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Background : The objective of this study was to determine the applicability and reliability of the medial sural artery perforator (MSAP) flap in patients with diabetes with peripheral arterial disease (PAD) for lower extremity defects and to assess the effects of sacrificing the MSA on distal circulation. Patients and Methods: A radiologic and clinical study has been utilized to assess safety and applicability of MSA perforator flap in diabetics. Five diabetic patients operated for complex lower extremity defects were analyzed and radiological findings from 43 lower limbs of patients with diabetes previously subjected to angiography for PAD were analyzed. Age, duration of diabetes, concomitant complications and occluded vessel type, the diameter of MSA at the popliteal junction, the branching pattern, and the number of sizeable perforators were documented. Results: One total flap loss occurred, one donor side dehiscence occurred. All other flaps survived, and defects were successfully closed. Radiologically MSA was present in unoccluded form in all 43 diabetic patients. At least one sizeable perforator was observed in all patients. There was a statistically significant, but negative, correlation between the size of MSA and the occlusion of the popliteal artery. Conclusions: Diabetes solely is not a contraindication of MSAP flap usage, as MSA is not affected by PAD. However, perigenicular collateral hypertrophy through arteriogenesis can be an issue in patients with severe occlusion at the level of the popliteal artery, since MSA enlarges. Cases of MSA hypertrophy in the presence of PAD constitute a high risk; therefore, selection of another flap is recommended.

Purpose Volumetric or multiplane defects of the upper and midface remain a challenge for reconstruction because of limited regional flap options. In this study, the authors harvested the reverse temporalis muscle flap and pericranial flap (RTMP flap) based on the same vascular pedicle, the superficial temporal artery, in a chimeric manner to obtain double-layer closure of deep facial defects. Materials and Methods This study was a prospective case series performed in the Department of Plastic Surgery of Ataturk University (Erzurum, Turkey). The outcomes, including flap survival, postoperative complications, reconstructive success, esthetic appearance, and donor site morbidity, were clinically evaluated. Results Fourteen patients (10 male and 4 female) with deep defects of the middle third of the face underwent reconstruction using the chimeric RTMP flap. All chimeric RTMP flaps survived without postoperative complications. All defects were successfully repaired and covered with chimeric RTMP flaps. Patients were satisfied with the esthetic results. Conclusion The chimeric RTMP flap is a good reconstruction option and can be used safely for moderate to large 3-dimensional defects of the middle and upper face. Smooth and durable coverage over the bulky muscle flap used to fill the volume defect and a larger flap for larger volume defects can be obtained by including the pericranial segment of the chimeric RTMP flap.

The aim of the study was to evaluate postburn contracture reconstructions caused by high temperature such as tandir. The records of our 58 patients who were operated for burn contracture between 2008 and 2018 were retrospectively reviewed. Duration elapsed after the burn, localization of contracture, surgery applied, and the recurrence rates were recorded. McCauley classification was used to evaluate the severity of hand contractures. One hundred and thirty-seven contracture release operations were performed in 45 hands in 40 cases. Five patients had bilateral hand contractures. One hundred and sixty-three (84.9%) surgeries out of total 192 contracture release surgery were applied to the hand and foot region. FTSG alone was the most common method of treatment. Z-plasty was used the most frequently by our team as the flap surgery. Tissue damage is more severe due to very high temperature of the tandir and as a result, more frequent and heavier burn contracture occurs on hands and feet than other burn etiologies develops, and reconstructive operations are needed more frequently.

Flaps are the workhorse of plastic surgery practice. The delay procedures have been defined to prevent flap necrosis. The golden standard method of delay is a surgical delay. On the other hand, a major drawback of surgical delay is two sessions of surgery. Efforts have been made to omit one session and increase the patient safety and decrease the costs. The writer's aim was to evaluate the effects of topical negative pressure, applied prior to flap elevation, on flap survival, perfusion and compare the results with the surgical delay. In a rabbit random flap model, prior to elevation, the writers used a topical negative pressure system on the lateral thoracic region of, for induction of delay and compared the results with surgical delay and the control group. The total and necrotic flap areas, necrosis ratio, histomorphometric vascular density, immunohistochemical evaluation of neovascularization (CD31/CD34), Laser Doppler images and computerized tomography contrast uptake were used to compare the groups. In all of the parameters, the vacuum assisted flap delay was equivalent to surgical delay. Both were superior to non-delayed flaps. Control group had 65.56 ± 18.02% flap necrosis rate, while Surgical Delay group had 37.31 ± 30.74% and Vacuum Assisted Flap Delay group had 19.58 ± 27.35%. Vacuum Assisted Flap Delay did not require an extra operation for the delay procedure. The mechanism of action in the vacuum-assisted flap delay is unclear. The clinical significance should be studied further. However, vacuum assisted flap delay seems to be a promising method in the clinical setting.

Medial sural artery perforator (MSAP) flap is a relatively new flap which is a modification of medial gastrocnemius myocutaneous flap. Both radial forearm flap and MSAP has common benefits, such as thinness, long pedicle and pliability; however, MSAP has lower donor site morbidity when compared with radial forearm flap. Because of this reason, the MSAP flap has gained popularity during the last decade. The objective of this study was to determine clinical application results of this flap in reconstruction of post-oncologic defects in the head and neck region. 11 patients operated for head and neck post oncologic defects and reconstructed with MSAP between June 2014 and Dec 2015 were included in the study. Age, gender, histopathology, area of reconstruction, flap size, number of perforators were reviewed. Postoperatively recipient and donor site complications, hospital stay and additional surgical procedures were also analyzed. We had seven uncomplicated cases; one total flap failure due to arterial problem, in three cases due fistula formation and local wound healing problems additional surgeries were performed. All venous anastomosis were performed with 9/0 sutures, nine arterial anastomosis were performed with 9/0 and two arterial anastomosis were performed with 10/0 nylon sutures. Medial sural artery perforator flap is a good alternative in head and neck reconstruction, with the advantages of thin and pliable skin, a reliable vascular pedicle, straightforward intramuscular dissection. But there are certain drawbacks like tedious pedicle and perforator dissection, small arterial pedicle size which complicates anastomosis and obscurities of anatomy. Surgical team must always be ready for a difficult micro anastomosis and an alternative flap choice must be prepared and counseled with the patient in case of inadequate perforators.

Heel reconstruction after tumor ablative surgery or trauma presents the patient and the clinician with difficult treatment choices1-3. The heel region has complex osseous interactions, ligamentous slings, and unique skin coverage that provides sufficient cushion, all of which are crucial for normal gait4. Although there are regional pedicle flap options, reconstruction of these complex tissue defects usually requires free flaps. Regional fasciocutaneous flaps can resurface the defect efficiently. However, when there is a complex tissue defect that includes the calcaneus, more complex treatment options are needed5. In this case report, we describe how we reconstructed the heel region in a patient with an extensive plantar defect, with simultaneous use of free iliac crest and latissimus dorsi muscle flaps. The patient was informed that data concerning the case would be submitted for publication, and he provided consent. A forty-nine year-old man presented with a Marjolin ulcer on the right heel. He had an ulcerated and vegetating mass that measured 14 × 7 cm (Fig. 1). An incisional biopsy revealed squamous-cell cancer. Physical examination and preoperative computed tomography (CT) demonstrated calcaneal invasion and excluded lymph node involvement. He had difficulty walking and had moderate pain. The American Orthopaedic Foot & Ankle Society (AOFAS) Ankle Hindfoot Score was 626. The tumor was stage III, which necessitated amputation of the foot. However, because the patient would not consent to amputation, the surgical team formulated an alternative plan. Fig. 1 Preoperative photograph of the ulcerated mass, which covered nearly the entire sole region. The calcaneus, the flexor hallucis longus tendon, the posterior tibial tendon, and the flexor digitorum longus tendon were resected along with two-thirds of the sole of the foot. The Achilles tendon was stripped off of the calcaneus. After wide resection of the tumor and …

Aim: Unique pattern of the pediatric facial skeleton and its fractures confers a special issue to take into account. Conservative management, occlusal splints and wiring techniques are popular among pediatric facial fractures. As titanium plates require plate removal after the fracture healing, resorbable plates have gained popularity. However, they are expensive and it may not be possible to obtain resorbable plates in some medical facilities. This led us to question the mechanical stability and functional outcome after fracture fixation using polydioxanone (PDS) sutures.Material and Methods: Seven children with maxillofacial fractures were included in this study. After limited sufficient dissection and periosteal striping the fracture lines were reduced and four holes were made with a drill on preoperatively planned sites where no tooth buds were projected. After that a number 2 PDS loop suture was passed through these holes in a figure of eight fashion and tied to stitches after sufficient stability and anatomic reduction.Results: No complication occurred, except for two cases that had tooth extractions.Conclusion: To sum up, PDS suture fixation in a figure of eight fashion is a feasible and cheap alternative to titanium and resorbable plate systems.

The Internal Mammary Artery (IMA) and its perforators play an important role in coronary bypass grafting and reconstructive breast, head, and neck surgery. This study aimed to obtain anatomic data pertaining to these vessels using Multi Detector Computed Tomography Angiography (MDCTA) and to demonstrate that the MDCTA could be a considerable assessment tool prior to surgery. In 50 outpatients (27 males and 23 females), the above-mentioned arteries were bilaterally evaluated with a 16-detector spiral computed tomography scanner. Based on the obtained images, diameters of the bilateral IMAs were separately measured in each intercostal spaces from 1 to 5 through their traces. IMAPs greater than 0.5 mm in diameter were bilaterally evaluated in terms of distance from the sternal border to the ramification point under the muscular layer, maximal external diameter at ramification from the IMA, and the length between the ramification point from the IMA and enter point to the subcutaneous fat tissue. Mean diameters of the left and right IMAs were 2.05 ± 0.50 mm and 2.20 ± 0.57 mm, respectively. Mean diameters, distances, and lengths of the perforators were 1.30 ± 0.30 mm, 6.80 ± 3.40 mm, 17.05 ± 6.07 mm on the left side and 1.32 ± 0.25 mm, 6.71 ± 3.43 mm, 17.35 ± 3.48 mm on the right side, respectively. No statistically difference was found between the sides (P > 0.05). About 20 of 36 perforators appeared in the second intercostal space, whereas there were eight in the first and eight in the third intercostal space. MDCTA, as a non-invasive vascular imaging method, can be a valuable tool for investigating the anatomic characteristics of the IMA and its perforators before planning an operation. © 2013 Wiley Periodicals, Inc. Microsurgery 34:277–282, 2014.

Objective To increase the viability of fat grafts using vascular endothelial growth factor (VEGF) in a calcium alginate microsphere controlled release system. Design Twenty-four rats were divided into 4 groups of 6 rats each. Group 1 was the preconditioning group in which VEGF was applied prior to the fat grafting. In group 2, VEGF was given at the time of the grafting. In group 3, an empty microsphere was added to the grafting material. The fourth group, which received the fat graft only, was the control group. At the 90th day, samples of the fat grafts were weighed and compared with preimplantation weights. Results The graft viability ratios of the first 3 groups were significantly higher than those of the control group. The relative adipocyte index was significantly higher in the first and second groups compared with the control group and group 3. Consistent with the literature, VEGF used both in the preconditioning procedure and simultaneously with the grafting procedure increased the graft viability ratio and relative adipocyte index. Conclusion This study suggests that VEGF-induced preconditioning of the recipient bed improves fat graft viability via increased revascularization.

The management of soft-tissue defects in the ankle and foot area is a challenging task. Distally based sural flap is widely used, however it leaves donor area paresthesia. For this purpose, the sural nerve was dissected and preserved in the distally based sural flap in five cases of ankle and foot soft tissue reconstruction. This modification did not cause any compromise in flap circulation. All flaps survived with one partial distal necrosis. We suggest that, the distally based nerve sparing sural flap can be securely elevated with only a 3-4 cm wide subcutaneous pedicle without any compromise in flap circulation.

The aim of this study is to present our clinical experience with rhomboid flaps.Twenty-four patients who were operated on between January 2006 and October 2010 were included in the study. All defects were reconstructed using rhomboid flaps.Twenty-four patients were operated on for various reasons, and 26 rhomboid flaps were performed. Eleven of the 24 cases were male, and the median age of participants was 47.5 years. Eight cases were operated on under general anesthesia, and 13 were locally anesthetized; the remaining cases were operated on under regional anesthesia. In 17 cases, the defect was due to a benign or malignant tumor excision, and five cases were operated on due to burn contracture. There were no occurrences of partial or total flap necrosis or hematoma in our series.Our series indicates that rhomboid flaps can be safely used to reconstruct small to moderately sized skin defects.Çalışmanın amacı rhomboid fleplerle elde ettiğimiz deneyimlerin sunulmasıdır.Ocak 2006 ve Ekim 2010 arasında opere edilen 24 hasta çalışmaya dahil edildi. Tüm defektler rhomboid fleple rekonstrükte edilmişti.Çeşitli nedenlerle opera edilen hastalarda 26 romboid flep uygulandı. 24 hastanın 11’I erkekti. Medyan yaş 47.5 idi. 8 hastada genel, 13 hastada lokal anestezi kullanılırken diğer hastalara bölgesel anestezi verilmişti. 17 hastada benign ya da malign tumor eksizyonu nedeniyle rekonstrüksiyon yapıldı. 5 olgu yanık kontraktürüne bağlı opera edilmişti. Seride kısmi ya da tam flep nekrozu ve hematom görülmedi.Serimizden elde edilen sonuçlar, orta veya küçük boy cilt defektlerin rekonstrüksiyonunda romboid fleplerin güvenle kullanılabileceğini göstermektedir.

Aim: Children are prone to burn injury. Burns can be seen as a part of child abuse. The aim of this study was to investigate the factors affecting adherence to the treatment of burn patients, and to emphasize the role of the physician in identifying children's non-accidental burn injuries. Materials and Methods: Children who were hospitalized in the burn unit were analyzed retrospectively. Results were assessed for significance using the Chi-square test. Results: A total of 189 patients were included. Some patients (n = 52; 27.5%) were discharged against medical advice (DAMA) before completion of treatment. Although we could not demonstrate a relationship between non-accidental etiology and DAMA group, it was significant that these patients did not contact the outpatient clinic after discharge. It was evident from records that two of these cases were abused. The reasoning of the parents in the DAMA group for the early discharge was siblings at home, financial and accommodation problems. Conclusion: Although burns in children commonly occur due to an accident, each burn case should be examined for a non-accidental etiology and findings suggesting abuse should be noted. Physicians should be alert for the detection of signs of burn related child abuse.

Objectives: Adequate coverage of traumatic complex lower extremity wounds is often challenging for reconstructive surgeons. Local perforator flaps have gained wide acceptance as an alternative in soft tissue coverage of complex lower extremity defects over the last decade. Here, we report our experience with distal lower extremity reconstructions performed either with free or local perforator flaps. In the literature, no studies have been conducted that directly compare free flaps to propeller flaps; our aim here was to compare non-microvascular microsurgical flaps with free flaps for coverage of traumatic lower extremity wounds. Methods: 28 patients operated on for lower extremity defects and reconstructed either with free or local perforator flaps between February 2011 to June 2015 were included in the study. Age, gender, defect sizes, etiologies, and operation times were reviewed. Postoperative recipient and donor site complications, hospital stay, and additional surgical procedures were also analyzed. Results: There were 24 male and four female patients. Mean age was 43.11 years (range: 30 to 65 years) in the free perforator flap group and mean age was 44 years (range: 30 to 70 years) in the local perforator flap group. Hospital stay and overall operation time was significantly higher in the free flap group. There was no statistically significant difference in complication rates between either group. Conclusions: Concerning many advantages, like decreased operative time, avoiding micro anastomosis, and reconstruction with like tissues, we suggest that propeller perforator flaps can be the first-line reconstructive choice. These flaps can be used successfully by reconstructive surgeons in small clinics and they may prevent unnecessary tertiary medical center referrals as well as extended hospitalizations, long operation times, and increased costs. [Hand Microsurg 2017; 6(3.000): 102-109]

The Internal Mammary Artery (IMA) and its perforators play an important role in coronary bypass grafting and reconstructive breast, head, and neck surgery. This study aimed to obtain anatomic data pertaining to these vessels using Multi Detector Computed Tomography Angiography (MDCTA) and to demonstrate that the MDCTA could be a considerable assessment tool prior to surgery. In 50 outpatients (27 males and 23 females), the above-mentioned arteries were bilaterally evaluated with a 16-detector spiral computed tomography scanner. Based on the obtained images, diameters of the bilateral IMAs were separately measured in each intercostal spaces from 1 to 5 through their traces. IMAPs greater than 0.5 mm in diameter were bilaterally evaluated in terms of distance from the sternal border to the ramification point under the muscular layer, maximal external diameter at ramification from the IMA, and the length between the ramification point from the IMA and enter point to the subcutaneous fat tissue. Mean diameters of the left and right IMAs were 2.05 ± 0.50 mm and 2.20 ± 0.57 mm, respectively. Mean diameters, distances, and lengths of the perforators were 1.30 ± 0.30 mm, 6.80 ± 3.40 mm, 17.05 ± 6.07 mm on the left side and 1.32 ± 0.25 mm, 6.71 ± 3.43 mm, 17.35 ± 3.48 mm on the right side, respectively. No statistically difference was found between the sides (P0.05). About 20 of 36 perforators appeared in the second intercostal space, whereas there were eight in the first and eight in the third intercostal space. MDCTA, as a non-invasive vascular imaging method, can be a valuable tool for investigating the anatomic characteristics of the IMA and its perforators before planning an operation.

Silicon rods initially advocated by Hunter have been widely used in two-stage flexor tendon reconstruction. Two-stage tendoplasty is an expensive procedure; with the addition of the high cost of rods, it is still more expensive. An experimental study investigated cheaper alternatives to silicon rods, but no clinical studies seem to have been reported so far. This study involved 17 patients undergoing two stage flexor tendon grafting. In all fingers, silicon urinary catheters were used as tendon prosthesis. The Wehbe et al modification of the Boyes and Stark classification was used for preoperative classification and Strickland formulation and Buck-Gramcko criteria for postoperative analysis. This clinical study showed that comparable clinical results and proper pseudosheaths for tendon grafting with similar histological and physical features can be obtained using a silicon urinary catheter which is fifty times less costly than Hunter's rod.

The fractures of facial structures lead to great morbidity. Cross-sectional studies are needed to evaluate the current state of maxillofacial traumas. Thus, this study aims to evaluate these experiences and to compare these results with the current literature.The medical records of the maxillofacial fracture cases hospitalized between January 2004 and November 2011 were examined. The age, sex, etiology, fracture localization and treatment method for each case were documented. The affected facial bones were grouped as mandible, maxilla, zygoma, naso-orbitoethmoid complex (NOEC) and blow-out. Nasal fractures were excluded. The cases were assigned to 3 groups with respect to age (below 16, above 65 and between 17 and 64). The chi Square test was used to assess the significance of the difference in mandibular fracture rates in the pediatric population compared to others.The total number of cases was 152. The total number of fractures was 185. Of the 152 cases, 117 were male and 35 were female. The average age was 31.4 (±18.3), ranging between 2 and 81. Thirty-one cases were 16 years old or less. Nine cases were 65 years old or more. Mandibular and zygomatic fractures were the most prevalent fractures in the adult group. Mandibular fractures were significantly more common in the pediatric age group compared to rest of the population (X(2), p0.05). Traffic accidents were the most common etiological factor, with a 55.3% ratio. Open reduction and internal fixation was the most frequently conducted treatment modality in all age groups.Retrospective studies are important for the projection of future prospects. In summary, our results indicate that pediatric fractures are mostly in the lower face and usually affect the condylar region, which is consistent with the literature.Yüz kemiği kırıkları büyük morbidite nedenidir. Maksillofasyal travmalarda güncel durumun değerlendirilmesi ve buna yönelik değerlendirmeler için kesitsel çalışmalar gereklidir. Bu nedenle bu çalışmada, deneyimlerin değerlendirilmesi ve mevcut literatürle karşılaştırılması amaçlanmıştır.Ocak 2004-Kasım 2011 arasında kliniğimizde yatırılarak izlenen hastaların tıbbi kayıtları geriye dönük olarak incelenmiştir. Yaş, cinsiyet, etiyoloji, kırık yeri ve tedavi yöntemi her hasta için belirlenmiştir. Kırık yerleşimleri, mandibula, maksilla, zigoma, nazoorbitoetmoid kompleks ve blow-out kırıkları şeklinde sınıflandırıldı. Burun kırıkları dahil edilmedi. Seri, yaşa göre 3 gruba bölündü. Pediatrik grup 16 yaş altı, erişkin grup 17–64 arası ve geriatrik grup 65 yaş ve üzeri şeklinde sınıflandırıldı. Pediatrik grup ve pediatrik olmayan gruplar arasında mandibula kırıkları açısından fark olup olmadığı Chi Kare testi ile değerlendirildi.Toplam 152 hasta incelendi. Toplam kırık sayısı 185 olarak saptandı. Hastaların 117’si erkek 35’i kadındı. Yaş ortalaması 31.4 (±18.3) ve yaş aralığı 2 ve 81 arasındaydı. Otuz bir olgu pediatrik, 9 olgu geriatrik gruptaydı. Mandibula kırıkları pediatrik grupta diğer yaşlara göre anlamlı düzeyde daha fazla görülmekteydi (XRetrospektif çalışmalar geleceğin projeksiyonu için önemlidir. Sonuçlarımız, literatürle uyumlu şekilde, alt yüz kırıklarının pediatrik yaş grubunda daha fazla görüldüğünü ortaya koymuştur.