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Flap surgery is widely performed in reconstructive surgery. Experimental research is vital to improve flap viability. However, the number of flap models for animals is still limited. In this study, we define a new adipofascial flap in rats that can be used to investigate pedicled flap and/or adipofascial flap physiology.Eight Wistar male rats were used. Under deep anesthesia, paraepididymal adipofascial flaps were harvested. Flap perfusion was assessed using a near-infrared fluorescence imaging system. The length of the flap and the diameter of the flap pedicle were measured.All animals (n = 8) had sufficient sizes of paraepididymal fat pad, and no animals were lost. The only postoperative complication was testicular hematoma, which was observed in 2 animals. The maximum length of the harvested paraepididymal adipofascial flap was 9.7 cm with a mean of 6.6 cm. The maximum width of the flap was 3.3 cm with a mean of 2.6 cm. The mean pedicle diameter of the paraepididymal adipofascial flap was 1.1 mm. Near-infrared fluorescence imaging revealed adequate perfusion in all flaps.The number of reported adipofascial flap models in animals is low, and they are mostly limited to flaps based on epigastric vessels. Superior epididymal artery-based paraepididymal adipofascial flap can be used as a pedicled flap model for studies focusing on adipofascial and/or pedicled flap physiology. Uncomplicated surgical technique and short operative time make this flap a valuable alternative to other flap models.

Background: Palatal defects are still challenging for the reconstructive surgeon since the palate carries important functional roles in swallowing and articulating while providing an adequate airway. The aim of this article is to discuss the preferred free flap types for palatal reconstruction and present the functional outcome. Material and Methods: Records of patients who underwent microsurgical palatal reconstruction between 2012 and 2017 were reviewed for demographic properties, defect properties, flap of choice, and complication rates. A questionnaire was applied to the patients for assessment of speech, swallowing, regurgitation, snoring, and overall satisfaction. Results: Four patients were operated for palatal defects with a mean size of 23.25 cm2. The most commonly used free flap was the radial forearm flap in our four patient series. All patients reported improvement for every functional criterion in the questionnaire. Conclusion: Free flaps are an acceptable method for restoring palatal function. Radial forearm free flap was the flap of choice for reconstruction of large palatal defects in this retrospective review.

Radiation-induced wounds are extremely difficult to treat. They may lead to severe infections and can even be life-threatening. Wound dressings, negative pressure wound treatment, hyperbaric oxygen therapy, and antibiotics are the main treatment modalities for radiation-induced wounds. Amniotic membrane is the innermost surface of the placenta. It has been shown that amniotic membrane induces re-epithelization, regulates angiogenesis, and decreases inflammation and fibrosis. Our proposed theory was that amniotic membrane can have a role in treating radiation-induced wounds by inducing epithelization and increasing wound tensile strength. Out of 24 rats, 3 groups were composed. In group A, 21 days after one session of radiotherapy, a 2-cm incision was made on the gluteal region then an amniotic membrane was placed under the skin flaps. In group B, 21 days after one session of radiotherapy, a 2-cm incision made on the gluteal region and wound is sutured back after 2 × 2 cm of area was undermined. In group C, no radiotherapy is given. We just made an incision and sutured it back again with the same size of area undermined. Three weeks after these surgeries, wound regions were excised en bloc and taken out for biomechanical and histopathological assessments. The end results in amniotic membrane group (group A) were statistically higher than those in the other groups in the terms of wound healing and biomechanical measurements. After biomechanical and histopathological evaluation, amniotic membrane, with its antimicrobial, anti-inflammatory, angiogenic, and epithelial-inductive effects, was found to be affective in post-radiation wound treatment. Due to the features of amniotic membrane mentioned above, it can be an option in treatment of patients which received neoadjuvant radiotherapy to prevent future wounds. It can also be used for the care and treatment of post-radiation wounds. Level of Evidence: Not ratable

Background: The unique anatomy of the orbita and the different behavior of each malignant tumor cause us to perform the various types of orbital exenteration that yields to varying defect each of which has own specific demands in terms of the reconstruction. Current classification of orbital exenteration defects seems not to be adequate to provide detailed description. This study reviews 50 exenteration defects to offer a more effective anatomical classification system. Methods: Over a 15 years period, 50 orbital exenteration defects in 47 patients were reconstructed. Defects were categorized according to the resected orbital wall, dura, and ethmoid resection. If the maxillectomy was performed, A or B was added to define the type of maxillectomy as partial (intact palate) or total maxillectomy, respectively. According to these criteria, 4 types of defect patterns were determined including Type 0 (n = 5) with intact orbital wall, Type I (n = 9) with sino-orbital fistula, Type II (n = 4) with crania-orbital fistula with intact dura, Type III (n = 6) with crania-orbital fistula associated with dura defect, and Type IV (n = 8) with cranio-nasal-orbital fistula. There were 12 partial (A) and 6 total maxillectomy (B) defects along with the orbital exenteration. Results: There was no major complication except one. The minor wound-healing problems occurred in 7 patients. Nine patients (19%) used prosthesis. Twenty-two (46.8%) patients chose a patch to cover the area. The remaining 16 patients were not able to use any type of prosthesis because of the reconstruction methods. Conclusion: The authors believe that the authors' anatomical classification system provides more precise description of the defect which eventually enhances the success rate of both reconstruction and resection. © 2017 by Mutaz B. Habal, MD.

A fat graft is the closest thing to being the ideal soft tissue filler. Although it has many advantages, reliability of late-term survival is a never-ending debate. Although there are observational studies that research the effect of cigarette smoke on fat graft take in clinical setting, there has not been an objective experimental animal study on the affect of smoking on fat graft survival. The aim of our study is to search if smoking has an affect on fat grafts. Twenty-two Sprague-Dawley type rats were used. Exposure was maintained via a passive smoke exposure system. Rats were divided into three groups regarding their exposure period. At the end of the study, transferred fat grafts were extracted and weighed with a precision scale, an arterial blood sample was taken for biochemical analysis, and grafts were sent to the pathology laboratory for immunohistochemical assessment. There were meaningful differences between the control group and the other two groups in graft weight loss, serum cotinine, tissue MDA, adipose tissue/fibrosis ratio, stem cell counts, perilipin positive cell density and inflammation density. Furthermore, we detected meaningful correlations between serum cotinine, tissue MDA and graft weight loss. Fat graft takes with the same mechanisms as a wound heals. So like wound healing, cigarette smoke has a negative affect on fat graft survival. A fat graft is by its nature an elective procedure so to improve our late-term success, cigarette smoke exposure should be kept to a minimum for increased reliability. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The literature contains confusing and opposing views about the naming, prevalence, anatomic structure, and clinical significance of the arcade of Struthers. The conflicting rates of arcade (between 0% and 100%) prevalence found in the literature may be due to the varying definition of the arcade among the authors, as well as the dissection method. The present study aims to examine the structure to determine whether or not the arcade of Struthers exists through an anatomic dissection study of a fresh human cadaver and seeks to compare its findings with those in the literature. Twenty arms from fresh frozen cadavers were dissected. An arcade of Struthers was not found in any specimen. Study concluded that its existence is unproven, and the arcade of Struthers does not exist.

Free radicals were first mentioned by Healey about the hematoma under skin flaps, trying to explain the blood itself has different effect beyond its space-occupying effect or infection. The aim of this study was to determine whether hematoma would have any effect on neutrophil behavior in muscle flap microcirculation. Rat cremaster muscle flap model was used for measuring intravital different parameters. We used the rat cremaster muscle flap model for direct observation and measurement of rolling and adhesion. The rats were randomized into 6 groups. Groups I and IV: only the cremaster muscle was turned to the abdominal wall (n = 4 and n = 4). Groups II and V: saline was injected under the muscle flap (n = 3 and n = 4). Group III and VI: blood was injected under the muscle flap (n = 4 and n = 5). Two sets of microcirculatory measurements were taken in each group. For the comparisons of the groups, the measurements that were taken at the second hour and at the sixth hour were standardized according to the baseline values of the same groups in the same postcapillary venules. Comparisons within the groups were made by Student t test. Between the groups, analysis of variance (ANOVA) independent test was used. Within groups, the number of adherent neutrophils in the second and sixth hour in hematoma groups were found significantly increased according to the baseline measurements, and the number of rolling neutrophils in the second hour in hematoma group was found increased according to the baseline measurements. Between groups, the number of rolling neutrophils in the second hour was found significantly increased between hematoma and sham/hematoma and control groups and the number of adherent neutrophils in the second and sixth hour was found significantly increased between hematoma and sham/hematoma and control groups.

An experimental study was designed to examine whether the blood supply of the muscle would be maintained by a reverse flow from the random pattern skin flap through the musculocutaneous perforators. A flap model containing rat rectus abdominis muscle and randomly based overlying abdominal skin was designed. Sixty rats were divided into four experimental groups as follows. In group I, scintigraphy and microangiography were performed in 10 and 6 rats, respectively, immediately after flap elevation. In group II, scintigraphy and microangiography were performed in 10 and 6 rats, respectively, 2 days after flap elevation. In group III, surviving skin paddle area was evaluated in 16 rats 7 days after flap elevation. After evaluation of surviving skin paddle area, the same animals were used for microangiographic (n=6) and scintigraphic (n=10) studies at the same day. In group IV, histopathologic examination was done in six flap muscles each 2 and 6 weeks after flap elevation (n=12). The mean percentage of surviving skin paddle area was 95.6 +/- 6.5% on postoperative day 7. Microangiography showed progressively developed blood flow from the skin to muscle through the musculocutaneous perforators in groups II and III, respectively. The radioisotope uptake of the operated muscle was 40.9 +/- 12.8% immediately after flap elevation (group I), 58.3 +/- 15.6% on postoperative day 2 (group II), and 70.7 +/- 25.6% on postoperative day 7 (group III). There was a significant difference only between group I and group III ( P0.05, analysis of variance). Histopathologically prominent atrophy, lipomatoses, and fibroses were revealed at week 6. The poor circulation and viability outcomes of the muscle revealed in the study are because of immediately insufficient blood microcirculation at the distal part of the random pattern skin flap.

The literature contains confusing and opposing views about the naming, prevalence, anatomic structure, and clinical significance of the arcade of Struthers. The conflicting rates of arcade (between 0% and 100%) prevalence found in the literature may be due to the varying definition of the arcade among the authors, as well as the dissection method. The present study aims to examine the structure to determine whether or not the arcade of Struthers exists through an anatomic dissection study of a fresh human cadaver and seeks to compare its findings with those in the literature. Twenty arms from fresh frozen cadavers were dissected. An arcade of Struthers was not found in any specimen. Study concluded that its existence is unproven, and the arcade of Struthers does not exist.

Background: Fournier's gangrene, first described by Dr Jean Alfred Fournier in 1883, still has a high mortality rate. The prognosis and outcome of such patients were analysed. Methods: Forty-one patients with Fournier's gangrene were reviewed on the parameters of age, sex, aetiological agents, predisposing factors, treatment modalities and outcomes. Results: Although early intervention and careful treatment was carried out, nine of 41 patients (21.9%) died as a result of complications of septicemia. Among the treatment modalities, there were extensive debridement, drainage, excisions of the skin and fascia, colostomy procedure, extensive antibiotic treatment and hyperbaric oxygen therapy. Although a combination of different treatment modalities were used, the mortality rate was 21.9%. Conclusions: Fournier's gangrene is still a severe disease. Today, hyperbaric oxygen treatment is very effective in the treatment of this disease.

Background Surgical techniques have recently been introduced for patients with vitiligo. Randomized controlled trials have not been performed. Aim To compare the efficacy and side-effects of two surgical methods (suction blister vs. thin split-thickness graft technique) for the treatment of vitiligo. Methods Three suction blisters, approximately 0.8 cm in diameter, made with a special tool attached to a vacuum extractor, which were converted to erosions by removal of the roofs of the bullae, and one round erosion of approximately the same diameter, made using a silver knife, were created. One roof of a blister and two cutaneous thin split-thickness grafts taken from the gluteal region were transferred onto recipient vitiliginous areas; one was left alone. The results were evaluated by one non-blind and two blind observers bimonthly during the 3-month follow-up period. Results Repigmentation rates were 25-65% in the suction blister technique and 90% in the thin split-thickness graft technique (P < 0.001). Conclusions The thin split-thickness graft technique is superior to the suction blister technique in treating vitiligo.

An experimental study was planned to examine whether the blood supply of muscle would be maintained by reverse flow from the cutaneous arteriolar microcirculatory system via the musculocutaneous perforators. A flap model containing both muscle and skin based on the inferior superficial epigastric vessels was designed with the blood supplied directly from the cutaneous arteriolar microcirculatory system. A total of 154 male Wistar Albino rats were divided into three groups. Group I included the standard vertical rectus abdominis musculocutaneous flap based on the superior deep epigastric vessels (N = 48). Group II included the acute cutaneous muscle flap (N = 53). Group III contained the delayed cutaneous muscle flap (N = 53). Skin flap survival area, muscle scintigraphy with technetium-99m-methoxy-isobutyl-isonitrile, microangiography, and histopathological examination of the flaps were conducted. The mean percentage of surviving skin paddle area was 96.4 +/- 5.2%, 84.9 +/- 21.6%, and 91.0 +/- 16.8% in groups I, II, and III respectively. There was no significant difference between groups. Microangiography revealed the blood flow from skin to muscle through the musculocutaneous perforators. The radioisotope uptake of the muscle flap was expressed as A percentage of the intact contralateral muscle. Mean uptake in group I was 90.1 +/- 4.9% immediately after flap elevation, 62.5 +/- 13.5% on day 2, and 88.3 +/- 12.0% on day 7. These values were 53.7 +/- 7.1%, 63.6 +/- 14.1%, and 89.2 +/- 18.1% in group II, and 64 +/- 7.8%, 75.5 +/- 9.8%, and 92.8 +/- 40.1% in group III. Radioisotope uptake in group I was significantly higher than groups II and III immediately after flap elevation (p < 0.05, analysis of variance), whereas there was no significant difference on days 2 and 7. Histopathological examination revealed surviving muscle tissue without marked atrophy. There was no marked difference between groups histopathologically. These results indicate that muscle tissue may survive by reverse flow through the musculocutaneous perforators when elevated with an axial skin flap.

Increased production of oxygen free radicals and infiltration of neutrophils into tissue subjected to ischemia-reperfusion have emphasized that neutrophils play a direct role in the development of injury. The present study was designed to elucidate the effect of FK506, a new immunosuppressive drug, on 11 hours of complete ischemia and reperfusion of the inguinal island skin flaps in rats. Group 1 (n = 10) control animals underwent ischemia and reperfusion and no treatment. Group 2 (n = 10) animals received FK 506 0.3 mg/kg/day, and group 3 (n = 9) animals received 0.5 mg/kg/day intramuscularly for 3 days before the ischemia. The effect of the drug was evaluated by measuring flap survival and tissue malondialdehyde content and myeloperoxidase activity and also by histopathologic examination of the skin specimens taken at the 1st and 24th hour after reperfusion. The survival of flaps controlled for 7 days was found to be significantly improved in group 2 (65.0 +/- 10.93 percent) and group 3 (93 +/- 6.25 percent) when compared with the control group (14 +/- 10.12 percent) (p < 0.04 and p < 0.0001). The tissue contents of malondialdehyde and activities of myeloperoxidase were significantly lower in groups 2 and 3 than in the control group. Three days of pretreatment with FK506 significantly reduced neutrophil infiltration in groups treated with either of the doses. These results showed that neutrophils play an important role in island flap survival associated with ischemia-reperfusion injury. Increased neutrophil infiltration was found related with increased levels of malondialdehyde and myeloperoxidase. Flap necrosis and the increase in malondialdehyde, myeloperoxidase, and neutrophil infiltration were improved by FK506 pretreatment, a neutrophil modulating agent.

The purpose of this study was to investigate the role of neutrophils in ischemic tissue injury and the possible inhibition by pretreatment with FK506, a neutrophilic modulating agent. A dorsal caudally based skin flap (3 x 9 cm) was used as an ischemic injury model in experimental groups. Prior to flap elevation, FK506 at doses of 0.3 mg per kilogram (group 2), 0.5 mg per kilogram (group 3), and 1.0 mg per kilogram (group 4) was given for 3 days intramuscularly. The relationship among neutrophil accumulation (histopathologically), myeloperoxidase (MPO) activity, malondialdehyde (MDA) content (biochemically) of the flap tissue, and flap survival were studied. Skin flaps showed reduced necrosis in the FK506-treated groups (p < 0.08, p < 0.0001, and p < 0.0001 respectively). The increase in accumulation of neutrophils, and MDA and MPO levels (which were induced by ischemia) observed 1 and 24 hours after flap elevation was diminished by FK506 pretreatment. The increased neutrophilic infiltration, and raised tissue MDA content and MPO activity revealed involvement of both free radical production and neutrophils in ischemia. This injury was decreased by FK506, probably by inhibition of neutrophilic chemotaxis, infiltration, and releasing factors.

Oxygen free radicals are produced and play an important role in ischemic injury. We therefore wished to investigate the role of free radicals on ischemic skin wound healing. For this purpose, H-shaped flaps, where the test ischemic wound is the horizontal line in the H, were created on the dorsum of the rat. To inhibit the probable hazards of free radicals, allopurinol and superoxide dismutase (SOD) were given to the animals. Most of the studied wound-healing parameters were impaired in the ischemic group. In the allopurinol-treated group, breaking strength was increased by 52% by day 7 and by 109% by day 14 (p < 0.0002 and p < 0.001), and in the SOD-treated group the increase was 69% both by days 7 and 14 of healing when compared with the ischemic control group (p < 0.003 and p < 0.002). Hydroxyproline content was increased 75% with allopurinol and 113% with SOD in the wound by day 7 (p < 0.03 and p < 0.001 respectively). SOD treatment caused a significant decrease in wound edema by day 7 of healing (p < 0.05). Histopathological evaluation revealed that in the SOD- and allopurinol-treated groups, the amount of collagen and its organization were more prominent when compared with the ischemic controls. These results show that oxygen free radicals play an important role in the failure of ischemic wound healing, and antioxidants partly improve the healing in ischemic skin wounds.

To understand the alterations in lipid metabolism following burn injury, 29 patients with burns, 18 survivors for the first 15 days and 11 non-survivors until death, were studied for total fatty acid (FA) profiles. No specific dietary fat was given. The plasma total FA profile was determined by capillary gas chromatography. The main observations of this survey were that: arachidonic acid decreased by 55.7 per cent (P < 0.0002), and linoleic acid decreased by 31.6 per cent (P < 0.004), more immunosuppressive mediators were probably produced. The elevated levels of both palmitic (12.1 per cent increase, P < 0.02) and oleic acids (63.0 per cent increase, P < 0.0001) in the plasma of burned patients suggested increased lipolysis from depot triglycerides. Eicosatrienoic acid showed decreased levels (49.5 per cent decrease, P < 0.005) at 3-4 days. Docosahexaenoic acid reached its lowest level at postburn days 7-9 (32.1 per cent decrease, P < 0.04). The significant changes of FA profile in patients could be related to the increased activity of fat metabolism. The results of this study have revealed the basic FA changes and requirements. Overfeeding and unnecessary intake of the source of immunosuppressive mediators would be avoided.

This experiment was designed to study the reactions in the surrounding area of burn injury that may lead to further necrosis in 24 h. To prevent extension of burn size into the tissue adjacent to burn injury, it was attempted to reduce progressive microvascular damage by different drugs (ibuprofen, allopurincl or cyclosporin A (CyA)) in a rat model. The burn model consisted of a row of four 10 × 20 mm burn areas separated by three unburned 5 × 20 mm skin bridges (interspaces). To evaluate microcirculation and perfusion of panniculus carnosus muscle which is beneath the burned area of skin, the radioactive agent, technetium-99m methoxyisobutylisonitrile ( 99 Tc m -MIBI) was used 24 h after the burn. Capillary permeability of injured tissue was assessed by the wet and dry weight technique. In all study groups, interspaces showed higher uptakes of 99 Tc m -MIBI between 40 and 95 per cent, in comparison with burn sites in the first 24 h following burn. Among the treated rats better results were obtained by allopurinol and CyA treatment that commenced before burn than ibuprofen. Wet and dry ratios were found to be significantly lower in interspaces in rats pretreated with allopurinol and CyA. Results of this experiment showed that neutrophils and free radical-mediated injury may be involved in the pathogenesis of local response to thermal injury, and allopurinol and CyA have some effects to prevent progressive ischaemia, capillary compromise and oedema.

Many burns that occur in the first two decades of life are accidental and preventable. The aim of this study was to determine the demographic features, mortality, and other factors associated with pediatric burns in Istanbul, Turkey.Our retrospective study included 375 hospitalized pediatric patients (225 male, 150 female; mean age 4.07±3.79; range 0.2 to 16 years) aged 16 years or less admitted between January 2005 and January 2009. Each child's medical record was reviewed and demographic features, mechanism of burn, place of residence, total body surface area (TBSA), surgical treatment, duration of hospital stay and mortality rates were analyzed.Scalding was the predominant cause among all pediatric age groups. There were no differences between the age groups with respect to mean TBSA. Length of hospital stay in infants and toddler age group was significantly lower than in other age groups (p0.005). Sixteen (4.3%) patients died during the study period. Mortality rates associated with scalding, flame and electrical burns were 3.1%, 13.9% and 10%, respectively. Electrical burns and flame resulted in significantly higher mortality rates than scalding (p0.05).Scalding was found to be the most important cause of burns and flame-related mechanisms resulted in the highest mortality rate among children. Only a specific preventive program for changing the traditional habits of Turkish parents would reduce burn injuries among children.

A 30% burn injury was found highly immunosuppressive in mice by means of two in vivo measurements of cell-mediated immunity, and this immunosuppression could be prevented by early excision and grafting. FK506, a new immunosuppressive agent, was given at different doses for 12 days after early excision and grafting following burn and all doses prolonged the acceptance time of allografts from 14 to 20 days. Allograft rejection was not seen when animals were on the drug. Higher doses prolonged the rejection more, even after the cessation of the drug, and they caused some degree of immunodepression. Immunosuppressive treatment with FK506 when used following burn injury affected cell-mediated immunity minimally to moderately when compared to burned control groups.

Accessory breast tissue is a remnant persisting after normal embryological development of the breast. Although accessory breasts may be asymptomatic, they can cause discomfort during menstruation, anxiety, cosmetic problems, pain, or restriction of arm movement. The data of all patients who presented with axillary accessory breasts between January 2000 and September 2008 were recruited from a computer database. Medical charts, outpatient records, operative notes, and pathology reports were reviewed. A total of 29 patients underwent surgical treatment of axillary accessory breasts in the Department of Breast Surgery and Department of Plastic, Reconstructive and Aesthetic Surgery. The ages of the patients at the time of surgery ranged from 19 to 54 years. The mean age was 28.8 years. All patients were female. Sixteen patients had unilateral accessory breast and 13 patients had bilateral accessory breasts. Fourteen patients had breast hypertrophy. Twenty-one patients had excision, five patients had liposuction, and three patients had both. Axillary accessory breasts can be satisfactorily treated with excision, liposuction, or both. In patients with concomitant macromastia, reduction mammaplasty and removal of accessory breasts can be performed at the same time with no additional morbidity.

Background: Bilateral traumatic amputation and limb-threatening injury of the lower extremities is more challenging than the unilateral amputation. Successful replantation of both lower extremities has been reported previously. However, orthotopic implantations may not be possible when amputation of both lower limbs with different levels of section and degrees of damage to surrounding tissues occurs. It was reported that the crossover replanted foot in combination with prosthetic limb is better than 2 artificial limbs. Hence, crossover replantation should be considered when anatomic replantation of both lower extremities is not possible as a result of bilateral total or subtotal amputation. To our knowledge, there are few reports about the crossover replantation of the lower extremity in the literature. Case Report: A 30-year-old engineer being run over by the train had crushed the bilateral lower limbs in different anatomic levels. We decided to perform the crossover replantation of the right foot to the stump of the left leg to provide the patient with at least 1 weight-bearing sensate extremity. At the latest follow-up examination, 30 months after the operation, he had mild pain, especially in toes of the replanted foot. There was no ulceration in both the replanted extremity and the right amputation stump. The sole has maintained complete protective sensation. The patient described the functional result of the reimplanted leg as satisfying and better than the prosthesis that has caused much more problems than the replanted extremity. He had no complaint about the cosmetic result. He stated that he would have the crossover replantation again under the same condition. He was able to return to his previous job. Moreover, he affirmed that he is able to carry on his all social activities as he had done before the accident except for playing football. In conclusion, the possibility of the crossover replantation should be considered while evaluating the patient with bilateral lower limb injuries to allow the patient to stand on their own foot and still touch ground.

Thermal injury initiates systemic inflammatory reactions producing burn toxins, an inflammatory response, oxygen radicals and finally peroxidation. The relationship between the amount of products of oxidative metabolism and natural scavengers of free radicals determines the outcome of local and distant tissue damage, and further organ failure in burn injury. To determine the relationship between the level of total natural scavengers of the body, the place of superoxide dismutase in this capacity, and its relation with lipid peroxidation, malondialdehyde, superoxide dismutase levels and total antioxidant status were measured in plasma. Animals were subjected to 30 per cent full thickness body surface area burn, and their blood was collected at 24 h postburn. Plasma malondialdehyde levels were significantly elevated above the level of controls (P0.02). Burn injury caused a remarkable decrease in superoxide dismutase (45 per cent decrease, P0.0001) and total antioxidant status (14 per cent decrease, P0.01) when compared to control.

The short distance of the nasal tip from the alar crease indicates inadequate projection. Tip grafts are commonly used for the management of this problem. In addition to tip grafts, labiocolumellar augmentation by cartilage grafts also provides further elevation of the tip complex for patients with poor tip definition, excessive alar base width, inadequate tip projection, or plunging nasal tip. In addition to standard rhinoplasty procedure and tip grafting for nasal tip augmentation, a linear cartilage graft was inserted centrally just behind the labiocolumellar angle for further tip elevation. The graft was placed in the subdermal plane just anterior to the orbicularis oris muscle to prevent graft displacement and clicking during muscle motion. This procedure was performed for 45 rhinoplasty patients, only three of whom underwent tip plasty procedures alone. During 1 year, 43 patients were followed up. Most of the patients (75%) were satisfied with the results of the procedure. Tip graft combined with labiocolumellar graft is an effective technique for obtaining satisfactory tip projection and correcting the acute labiocolumellar angle.

Suppression of cellular immunity following thermal injury may contribute to the high incidence of postburn sepsis. Early excision and skin grafting may remove deleterious local wound factors and prevent immunosuppression. The effect on cellular immunity of early burn wound excision and skin grafting was investigated in an animal model using female Wistar rats. The development of immunosuppression shortly after burn injury was shown by popliteal lymph node assay and a 2,4-dinitrofluorobenzene skin reaction test. Excision and skin grafting 2 days after burn trauma restored parameters to normal. Burned tissue suppresses cellular immunity; this effect is preventable by early excision and skin grafting.

Seventy cases with malignant tumors requiring maxillary resection in the past 10 years were reviewed, retrospectively. The primary site of tumor was adjacent skin in 53%, maxillary sinus or maxilla in 20%, palate and alveolar arch in 13%, lip and buccal mucosa in 13%, and mandible in 1% of the cases. The most common histopathological diagnoses was squamous cell carcinoma (54%), followed by basal cell carcinoma (20%). Most of the patients had advanced tumors, either neglected or recurred. Orbital exenteration was performed in 28 cases, mandibulectomy in six cases, combined craniofacial resection in seven cases, and radical neck dissection in 18 cases. Major skin loss was present in majority of the patients. Postsurgical defects were reconstructed with pedicled flaps in 37 cases and free flaps in 12 cases. Lining of the maxillary sinus defects was provided with split-thickness skin grafts. Patients with palatal defects were encouraged to use prosthetic obturators. Postoperative radiotherapy was performed in 32 patients and combined radiotherapy and chemotherapy in 12 patients. Communication could be established with only 52 patients. Sixty-three percent of them have survived without recurrence and distant metastasis. Resection of the tumor with free surgical margins and appropriate evaluation of the surgical defect for the most suitable reconstruction are the mainstays of treatment of the midfacial tumors.

Secondary venous ischemia caused by anastomotic failure is one of the major causes of failure after free tissue transfers and replantations. The effects of cyclosporin A (CsA) on secondary ischemic injury associated with neutrophil infiltration and lipid peroxidation were evaluated in a rat inferior epigastric island skin flap model. Primary ischemia was produced by arteriovenous occlusion for 2 hours. Twenty-four hours later, secondary venous ischemia was produced by 5 hours of venous occlusion. Nonischemic (n = 5), primary ischemic (n = 5), and secondary ischemic control groups (n = 10), and four treatment groups (n = 10) were created. Treatment groups received either 15 or 30 mg per kilogram per day oral CsA for 3 days before flap elevation, or 15 or 30 mg per kilogram intravenous CsA at 4 hours of secondary venous ischemia. Flap survival area, malondialdehyde (MDA) content, and myeloperoxidase (MPO) activity were assayed for each group. The mean flap survival area of the high-dose posttreatment group was significantly higher than the secondary ischemic control group (29% +/- 39% vs. 3% +/- 8%; p < 0.05, Student's t-test). The MDA and MPO levels of each treatment group were significantly lower than the secondary ischemic control group at hours 1 and 24 (p < 0.0001, Student's t-test). The lowest MDA and MPO levels were achieved in the high-dose posttreatment group. Results suggest that CsA may improve flap survival after secondary venous ischemia by attenuating neutrophil infiltration and by reducing lipid peroxidation.

Although antioxidant therapy has been introduced into early post burn protocols to prevent oxidative injury, it is still not known how they effect the cellular immunity which was already depressed due to thermal injury. To investigate the effect of antioxidant therapy on postburn immunosuppression following burn injury in a rat model, well known antioxidants: allopurinol (50 mg/kg/day), desferrioxamine (15 mg/kg/day), PEG-catalase (PEG-CAT) (1200 U/kg/day), N-acetylcysteine (NAS) (1 mg/kg/day) and vitamin-C (Vit-C) (0.5 mg/kg/day) were given for 7 days following thermal injury. The immunologic status of the rat was studied using two in vivo measures at seventh day following (30% TBSA) full-thickness burn injury. The contact hypersensitivity response (CHR) of rats, and their ability to induce a host versus graft reaction (HVGR) in the popliteal node were used to assess immune system as in vivo measures. The use of mentioned antioxidants resulted in significant improvement (between P < 0.05 and P < 0.001) of burn induced immunosuppression as reflected by CHR. The treatment with allopurinol and PEG-CAT (P < 0.01) significantly improved, while desferrioxamine, NAS and Vit-C improved, but not significantly, HVG reaction in burned rats. This study demonstrated that a large burn was profoundly immunosuppressive and early intervention of antioxidant therapy was able to significantly restore cell-mediated immunity as reflected by two in vivo assays.

Neutrophils diffusely invade lung, liver, kidney, intestine, muscle and burned skin following burn injury. To ameliorate this invasion and minimize its effects, neutrophils can be modulated by giving neutrophil inhibitors and modulators. In this study, FK506 was used to decrease neutrophil infiltration and lipid peroxidation in remote organs (lung, liver, kidney and intestine) in a burned rat model. FK506 is a new major immunosuppressive agent that is known to modulate neutrophils during inflammation. Neutrophil infiltration was assessed indirectly by measuring myeloperoxidase (MPO) activity biochemically in remote organs following 30% full thickness burn injury. Malondialdehyde (MDA), the end product of lipid peroxidation, was measured biochemically in remote organs and plasma to determine if there is a relationship between neutrophil infiltration and lipid peroxidation after burn injury. FK506 was given intramuscularly at the dose of 0.5 and 1.0 mg/kg for three days before burn injury. Thermal trauma to the skin caused a statistically significant increase in MPO activity and MDA content in remote organs. FK506 was effective in reducing lipid peroxidation and neutrophil infiltration especially at 24 h postinjury in lung, liver and kidney. FK506 may have some benefit (prophylactic) in reducing systemic neutrophilic injury and related lipid peroxidation in burns.

This study was designed to determine the effect of N-acetylcysteine (NAC, a natural hydroxyl radical scavenger) treatment on levels of pulmonary malondialdehyde (MDA, the end product of lipid peroxidation) and glutathione (GSH, a natural antioxidant) in thermally injured rats. Severe skin scald injury (30 percent TBSA) caused a significant decrease in GSH levels, and a significant increase in MDA levels in lung tissue both at 1 h and 1 day postburn injury. Treatment of rats with NAC (15 mg/kg intraperitoneally, 15 min and 12 h following the burn) significantly improved GSH levels, and decreased ongoing lipid peroxidation at 1 day. This study showed that thermal injury resulted in increased pulmonary lipid peroxidation, and this remote organ injury was decreased by treatment with NAC. In addition NAC, a scavenger of hydroxyl radicals, improved GSH levels in the lungs. The higher level of GSH in the lungs of the burned rats treated with NAC could be due to either a decrease in the rate of degradation of GSH or to an increase in its synthesis. No data about these possibilities are provided.

The behavior, under burn scars, of three different alloplastic materials, silicone, Medpor and Proplast, was compared in an animal model. A standard burn wound was created in rats, and 3 months later silicone, medpor and proplast alloplasts were placed under the burn scar. The rats were followed for another 3 months and ulceration and/or alloplast exposure rates were evaluated. At the end of this period specimens were examined histologically for the thickness of the fibrous capsule around the implant, thickness of the overlying tissue, tissue ingrowth and vascularization of the implants. Ulceration and exposure occurred in 2 of the 12 Medpor, 2 of the 12 Proplast and none of the 12 silicone implants. Fibrous capsule was significantly thicker around the silicone implants. Tissue ingrowth and vascularization were most prominent in Medpor implants while thickness of the overlying tissue was maximum in Proplast implants. These findings suggest that complications with silicone implants may be less than with other porous implants when used under burn scarred tissue.

The role of neutrophils, their presence, and their degree of infiltration was examined in ischemic skin flaps. In a rat model, caudally based dorsal flaps were studied and neutrophils were manipulated by giving cyclosporine at two different doses (15 and 30 mg per kilogram), administrated either for 5 days as a pretreatment or 15 minutes before flap elevation. The presence of neutrophils and lymphocytes in both intravascular and extravascular space was assessed at 15, 30, and 60 minutes by skin biopsies, taken after elevation of the flap, by direct quantitative counting under the light microscope. The correlation between the counts and localization of the neutrophils, but not the lymphocytes, and the percentage of necrosis showed an early and definite role of neutrophils on skin flap survival during ischemic insult. Cyclosporine-treated flaps showed a 24% to 37% increase in viability when compared to control flaps. These data suggest that neutrophils, probably their interactions and/or products, play an important role in ischemic flap survival, and cyclosporine A is able to inhibit neutrophil accumulation and sequestration.

A method for obtaining large amounts of epidermal (split thickness) and dermal skin allografts is described. Animals are inflated with air subcutaneously after killing, and both grafts are taken by Watson knife consecutively.

A woman with very extensive burns (of over 75 per cent TBSA and 45 per cent full skin thickness) received cyclosporin to extend the survival of skin allografts obtained from several unmatched donors. The patients' wounds appeared completely healed after 3 months when the cyclosporin was discontinued. During the immunosuppressive treatment with cyclosporin there was no evidence of graft rejection or any side effects related to cyclosporin. Twelve days after discontinuing the drug rejection started. The burns were then successfully covered with autografts during two operations. The late functional results were excellent.

BACKGROUND Reconstruction of facial skin defects requires good-quality skin cover to satisfy aesthetic expectations of patient, especially when the skin defect is on the uncovered area of the face. Limitations in the available local tissue and donor-site morbidity restrict the options. OBJECTIVE In an effort to solve these problems, we have begun to use a subcutaneous pedicled retroauricular reverse-flow flap. METHODS Between January 1997 and December 2005, reverse-flow subcutaneous pedicled retroauricular island flap was used to cover facial defects in 12 patients who underwent surgical excision of skin tumor. The patients ranged in age from 44 to 81 years with a mean age of 58 years. RESULTS Only one case experienced a superficial necrosis in the distal one-quarter part of the flap. The functional and aesthetic results were satisfactory for both patients and surgeons, and no tumor recurrence was observed during the 12 to 28 months (mean, 18.8 months) follow-up period. CONCLUSIONS This flap can be used reliably for the reconstruction of facial skin defects of small and medium size. The preference of frontal branch pedicled flap enables more distal facial area defects to be covered, such as dorsal nasal, nasolabial, and upper lip, than flaps based on parietal branch.