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Background Vasospasm is a major problem following microsurgical reconstruction which can result in the partial or complete loss of the flap tissue. The aim of this study was to investigate the efficiency of hydrodilatation for the prevention of vasospasm. Methods Thirty male Wistar rats were used for this experimental study. Femoral arteries of were exposed, photographed, and transected. In group 1, group 2, and group 3 papaverine solution, hydrodilatation, and minimal mechanical dilatation (control group) was performed, respectively. The anastomosis was completed and the arteries were photographed again 10 minutes after completion of the anastomosis. Following 7-day period samples for transmission electron microscopy (TEM) and light microscopy were obtained. Results The mean vessel diameters prior to transection were 0.43, 0.45, and 0.52 mm in the papaverine, hydrodilatation, and control groups, respectively. The mean vessel diameter 10 minutes following the completion of anastomosis was 0.76, 0.75, and 0.51 mm in the papaverine, hydrodilatation, and control groups, respectively. Median score for papaverine group regarding histological parameters of regular endothelial lining and lumen, neutrophil infiltration, vascular congestion, and edema in tunica adventitia was 2, 3, 2, and 3 positive, respectively. Median score for the papaverine group regarding histological parameters of regular endothelial lining and lumen, neutrophil infiltration, vascular congestion, and edema in tunica adventitia was 3, 3, 3, and 3 positive, respectively. All the histological scores were negative in the control group. The difference between the control group and the experiment groups 1 and 2 was significant regarding all four histological parameters (p Conclusion Hydrodilatation and papaverine application were both effective in preventing vasospasm following microsurgical intervention but papaverine caused slightly less damage to the endothelial lining and less edema in the tunica adventitia when compared with the hydrodilatation. Hydrodilatation group showed a vasodilatory effect that was statistically similar to that of papaverine, which has a proven efficacy.

Aesthetic assessment of the nose might not be limited to the nose as an isolated facial unit but might be the result of a broader perception of the whole facial image. The aim of this study was to investigate if the aesthetic evaluation of a nose is made by sole observation of the nose or influenced by the other features of the face.Nose and face photographs of 20 voluntary models were taken from five different angles and merged into a single image of just the noses and whole faces of each model. First the nose and then the face photos were sent to a reviewer group consisting of 100 individuals from different professions to evaluate the nose's beauty on standard questionnaires with a four-week interval to complicate the recall process.Aesthetic evaluation of the isolated nose (Group 1) and the nose with the whole face (Group 2) were compared through Visual Analog Scale (VAS) scores ranging from 1 to 10 (1: the least, 10: the highest). The mean VAS score of the Whole Face Group (5.26 ± 1.28) was significantly higher than the score of the Isolated Nose Group (4.50 ± 1.32) (p 0.001). There was no significant difference between the scores of reviewers considering their gender, profession, or experience of having an aesthetic operation previously.Current study revealed that in the evaluation of the beauty of the nose, the holistic perception of the face is as important as the perfection of the angles and proportions within the nose itself.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 .

Random skin flaps are essential tools in reconstructive surgery. In this study, we investigated the effect of subdermal nitrous oxide (N2O) application on random flap survival. In this experimental...

Skin-sparing and nipple-sparing mastectomies combined with immediate reconstruction and refinements in reconstructive techniques have shifted patients’ expectations of breast cancer management from surviving breast cancer to achieving aesthetically pleasing results. The primary aim of any breast reconstruction technique is to create natural-appearing breasts with maximum symmetry. Mastectomy and breast-conserving surgery (BCS) are two main surgical options for ablation of the affected breast. Several factors play a role in the decision making such as tumor size to breast ratio, indication for radiation, location and centricity of the lesion, and the patient’s motivation for a contralateral procedure. Post-oncological breast reconstruction is basicly conducted in two steps: replacement or restoration of volume and refinement of the breast sub-units. The reconstructive plan is mostly dictated by the oncological treatment plan. The choice of reconstruction depends on several different factors including the patient’s body habitus, need for adjuvant radiotherapy, and the patient’s personal preferences. Autologous tissue or implants can be used for primary augmentation of the effected breast, and lipofilling is a valuable instrument for secondary revisions. Delayed augmentation procedures may be more advantageous for contralateral breasts in achieving symmetry after adjuvant therapies are completed.

Objective: The aim of this study was to investigate the survival potential of the fat grafts inside the implant capsule in an experimentalsetting.Materials and Methods: Twenty male Wistar albino rats were used. A two-staged surgical procedure was performed. In the first stage,silicone sheets were placed in the subcutaneous plane on the left side of each rat. On day 60, fat grafts injected into the silicone capsuleeither by removing the silicone sheaths or leaving the silicone sheaths in their place. In both groups, the same amount of the fat graftswas injected into the right side of the dorsal subcutaneous plane of the rats and they served as their own controls. The findings wereevaluated according to the histopathological criteria.Results: There was no statistically significant difference in the inflammatory cell infiltration, fibrosis, and necrotic adipocytes amongthe groups. Although, the fat viability rate was higher in control groups, there was no statistically significant difference compared tothe capsule or silicone groups (p>0.05).Conclusion: Our study results suggest that implant capsule is a hospitable environment and resection of the capsule is unnecessary, ifsilicone implants are expected to be removed following fat injection.

Background Soft tissue thickness (STT) is a major factor affecting the outcome in rhinoplasty. However, limited information is found in the literature on the age- and gender-related variations of the nasal STT. Objectives The purpose of this study was to measure STT at various landmarks over the nasal framework and compare the age- and gender-related differences. Methods STT measurements were made at 11 landmarks in 325 patients by employing magnetic resonance imaging. Patients were divided into subgroups to compare the STT differences between female and male and between the age groups as young, middle age, and elderly. Results Soft tissue was thickest at the nasion and thinnest at the rhinion. The soft tissue coverage was significantly thicker in the male population at the supratip, tip, nasal bones, upper lateral cartilages, and alar lobules, whereas it is thicker in females at the rhinion. Average thickness of the soft tissues over the entire nasal framework increases with age except the rhinion. Conclusions The STT is variable over different parts of the osteocartilaginous framework. Gender and age influence the STT. The soft tissue is thicker at the distal half of the nose in male patients, and these areas become gradually thicker with age, whereas the soft tissue over the midvault becomes thinner. Increasing age presents a particular challenge to achieve predictable results in rhinoplasty, and an understanding of the soft tissue envelope allows for improved aesthetic outcome. Level of Evidence 2

Background It is presumed that breast reduction improves patients' quality of life and promotes weight loss. Preoperative body mass index (BMI) and the amount of breast tissue (breast reduction amount [BRA]) in proportion to the patient's body weight are important variables to affect the breast reduction outcome. Objective This study was designed to evaluate the short and long-term effects of breast reduction from the perspective of BMI and BRA. Methods One hundred fifty-seven consecutive patients were invited to participate in the study. All clinical information was recorded on a breast surgery form. Patients completed a standardized questionnaire preoperatively, at postoperative year 1, and after postoperative year 5. Patients were grouped according to their BMI as "normal weight" and "overweight" and according to BRA as "minor/moderate reductions" and "major reductions." The differences in the BMI values and the life scores were compared between the BMI and BRA groups. Results Sixty-four patients were included in the study. Postoperative year 1 BMIs were significantly lower than both the preoperative BMIs and postoperative year 5+ BMIs. The year 1 BMI decrease in the major reduction group was higher than the decrease in the minor/moderate reduction group. The postoperative life scores of all subgroups were better than the preoperative life scores. Conclusions Reduction mammaplasty has a significant effect on short-term weight loss and the improvement in lifestyle. Patients tend to return to their original body weight in the long term. BRA is a significant variable in short-term weight loss, but neither BMI nor BRA has any other significant effect on the outcome in any time section. Level of Evidence 4.

The impact of old scar tissue on the venous anatomy of a flap's pedicle is an important question in reconstructive surgery. This study tried to investigate the venous component in scar penetrating neovascularisation.Fifty Sprague-Dawley rats were used in this experimental study. Two experimental groups were designed. In the first group, incisions were performed over the epigastric flap pedicles. In the second group, 1 cm wide segments were excised over the pedicles. Ten weeks after the initial operations, angiographies and histological examinations were performed. A control group was used to demonstrate the normal arterial and venous anatomy of the pedicle.Arterial angiographies revealed that axial pattern arteries were visible in the incision group as opposed to the excision group. Although venous angiographies showed that there were more venous capillary formations in the incision group, none of the experimental groups had regenerated a vein with an axial pattern. Histological examinations revealed that venous vessel formations were significantly less in the distal samples of the experimental groups when compared to the control group (p 0.05).In this study, it has been observed that arterial pedicles do regenerate over old incision scars as opposed to veins. In the excision scars neither arterial or venous restoration of the axial pedicle was possible. In these cases, only a random type of limited circulation was restored.

Flap surgery is a wide field in plastic and reconstructive surgery practice and experimental research is needed to improve surgical success. These research is often performed on rats. Rat is a loose-skinned animal and contraction of skin flaps on rats is an underestimated condition. Besides this variable contraction of survived and necrotic tissues may mislead calculations and results. In this study, contraction patterns of epigastric and dorsal island skin flaps were investigated to identify this phenomenon. Forty-two male Sprague-Dawley rats were divided into four groups. Eleven epigastric flaps with unilateral pedicles, 11 epigastric flaps with bilateral pedicles, 10 extended dorsal island skin flaps with unilateral pedicles, and 10 extended dorsal island skin flaps with bilateral pedicles were prepared. Total, necrotic and viable flap areas were calculated from standardized photographs which were taken daily. The animals were placed on marked papers and image processing software was used the calculate flap areas from the photographs. Respect to these daily flap areas, the contraction rates in epigastric flaps were highly significant. The area loss in necrotic tissues were faster than the viable areas. Compared to the epigastric flaps, the contraction was not significant in extended dorsal island skin flaps flap groups. In conclusion, the rat extended dorsal island skin flap is a more reliable model for experimental flap research, which is resistant to contraction, when compared to the epigastric skin flap model.

Background: Anastomotic coupling device (ACD) has reached wide popularity, especially in venous anastomosis of free-tissue transfers. There are scant reviews in the literature about the reliability of these devices in venous anastomosis. We retrospectively analyzed our free flap cases to compare the thrombosis rates between ACDs and handsewn anastomosis and other possible risk factors that may contribute to venous thrombosis. Materials and Methods: Data of all microvascular free-tissue transfers performed between January 2015 and August 2019 were retrospectively reviewed. Patient characteristics were recorded. Reconstruction characteristics such as venous anastomosis type (hand-sewn vs. anastomotic coupler device), reconstruction site, and number of surgical interventions were also recorded. Results: A total of 385 consecutive-free microvascular reconstructions were identified. Total venous thrombosis rate was 4.7%. There was no statistically significant difference between hand-sewn anastomosis and anastomosis with coupler device (5.2% vs. 3.2%, P = 0.58). Only reconstruction site was found to be significantly associated with higher venous thrombosis (P = 0.03). Discussion: Our results involving different reconstruction sites and including multiple flap types demonstrated comparable revision rates between ACDs and hand-sewn anastomosis. This finding is consistent with the current literature.

Background: There is a need for a peripheral nerve model on which surgeons-intraining can simulate the repair of nerve injuries at their own pace. Although practicing on animal models/cadavers is considered the "gold standard" of microsurgical training, the proposed model aims to provide a platform for improving the technical skills of surgical trainees prior to their practice on cadaver/animal models. In addition, this model has the potential to serve as a standardized test medium for assessing the skill sets of surgeons. Methods: Several formulations of silicone were utilized for the design and fabrication of a model which realizes the hierarchical structure of peripheral nerves. The mechanical properties were characterized via the Universal Testing Machine; the damage caused by the needle on the entry sites was assessed through scanning electron microscopy (SEM). Results: Mechanical properties of the formulations of silicone were tested to mimic human peripheral nerves. A formulation with 83.3 wt% silicone oil and 0.1 wt% cotton fiber was chosen to be used as nerve fascicles. Both 83.3 wt% silicone oil with cotton fiber and 66.6 wt% silicone oil without fiber provided a microsuturing response similar to that of epineurium at a wall thickness of 1 mm. SEM also confirmed that the entry of the needle did not introduce significant holes at the microsuturing sites. Conclusions: The proposed peripheral nerve model mimicked human tissues mechanically and cosmetically, and a simulation of the repair of a fifth-degree nerve injury was achieved. (C) 2018 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

Introduction: The aim of this study was to test the hypothesis that the increased number of new motor endplates induced by botulinum toxin type A (BTX-A) injection before nerve injury would be reinnervated after nerve repair, resulting in greater force generation. Methods: Thirty male Wistar rats were divided randomly into 3 groups: (1) controls; (2) a group with saline solution injection; and (3) a group with BTX-A injec- tion into gastrocnemius muscle (BTX group). Thirty-six days after the injections the left sciatic nerve was divided and coapted in all groups. Eight weeks later, muscle forces were measured, and histological samples were collected. Results: No differences in the number of innervated endplates were found between the groups, but the number of denervated endplates was higher in the BTX group, as was the muscle tissue degen- eration score. The BTX group showed distal muscle force measurements of up to 25.8% less compared with the control group. Conclusion: Although BTX-A injection increases the number of motor endplates, they are not functional. Muscle Nerve 52: 412-418, 2015

The aim of this study is to investigate neovascularisation patterns in the presence of scar tissue and to compare the venous vs arterial components of the scar penetrating neovascularisation.Forty male Spraque-Dawley Rats, which were divided into four groups, were used for this study. At the beginning of the study a vertical midline abdominal incision was made to all animals. Six weeks after the incisions were made, epigastric flaps based on inferior epigastric vessels were raised. In the first group both left and right epigastric artery and veins were protected. In the second group only the right epigastric artery and vein was protected. In the third group, besides the right epigastric artery and vein, only the left epigastric artery was kept intact. In the fourth group, besides the right epigastric artery and vein, only the left epigastric vein was kept intact.The percentages of necrotic areas on the flaps were statistically evaluated. The percentages of the necrotic areas on the left side of the flaps were significantly higher in the second group (p = 0.0305). Total flap area necrosis was also significantly higher in the second group (p = 0.026). In each group, vessel formations were identified which were extending through the midline scar tissue in the angiographic evaluations.These results suggest that scar penetrating neovascularisation on an epigastric flap with one sided pedicle, which is supported by a vein or an artery on the contralateral side, can be enough to facilitate the flap circulation.

WOS: 000353366900008, PubMed ID: 25785651, Background Periosteal flaps possess osteoprogenitor cells and an osteoinductive potential that can be further augmented by combination with a biodegradable scaffold; therefore, various osteoconductive and osteostimulative biomaterials are frequently combined with periosteal flaps in studies of bone prefabrication. An experimental study was designed to determine and compare the contribution of bioactive glass and hydroxyapatite to osteoneogenesis in rats when combined with a periosteal flap. Materials and Methods In 60 Sprague Dawley rats, saphenous artery periosto-fasciocutaneous island flaps were transposed to abdomen. In group 1, the flap was left alone, in group 2, an empty artificial pocket made of Gore-Tex (W. L. Gore & Associates, Inc.; Flagstaff, AZ) was sutured onto the periosteal layer, and in groups 3 and 4, the pocket was filled with bioactive glass and hydroxyapatite, respectively. Following sampling for histological analysis, a 4-point scoring system was used to grade inflammatory cell infiltration, osteogenesis, angiogenesis, and cell migration into the bioactive material. Results The combination of the periosteal flap with any of the bioactive materials resulted in significantly higher percentages of animals exhibiting osteogenesis (80% in hydroxyapatite group and 93.3% in the bioactive glass group; p = 0.0000528) and angiogenesis. Comparison of the bioactive material groups revealed that a significantly higher proportion of animals in the bioactive glass group exhibited moderate or severe inflammation (80 vs. 20%; p = 0.002814). Conclusion Periosteal flaps prefabricated with hydroxyapatite or bioactive glass in rats exhibit osteogenic capacities that are not dependent on direct bone contact or proximity to vascular bony tissue. The innate capacity of the periosteal flap when utilized alone for osteoneogenesis was found to be rather insufficient.

BACKGROUND We conducted an experimental study to investigate if it would be possible to re-elevate a flap at a standard flap site if its vascular pedicle was mutilated previously and there was a preexisting scar formation at the pedicle site. MATERIALS AND METHODS Thirty-five male Sprague-Dawley rats were divided into 3 groups. In the control group (n = 5), animals received a procedure in which unilateral axial pattern abdominal flap was elevated, and then sutured to its original place. The remaining 2 groups underwent 2-stage procedures. In the first stage, scar tissue was created with either a skin incision (group 2, n = 15) or excision (group 3, n = 15) at the prospective pedicle site of the abdominal flap. In the second stage, abdominal flap was raised in 5 rats as a scar-pedicled flap at day 7, day 21, and day 42. Flaps were sutured in their places. Seven days later, flap survival was evaluated. RESULTS Control flaps had complete survival (day 7, 95.5%; day 21, 94.8%; and day 42, 94.5%). Group 2 and group 3 flaps raised on day 7 (group 2, 65.4%; group 3, 63.9%) and on day 21 (group 2, 65.7%; group 3, 66.7%) showed decreased survival compared to control group flaps (P < 0.05). On day 42, group 1 flaps had better survival when compared to group 2 flaps (82.6% vs 70.0%, P < 0.05). Group 1 flaps showed progressive vascular network formation as evidenced by contrast medium first in the proximal two thirds of the flaps on day 7, and later via visualization of the axial pattern vascular tree on day 42. In group 3, approximately half of the flap was filled with barium contrast and no single pedicle was identified on day 42. CONCLUSIONS Preexisting scar tissue and pedicle division in the pedicle site of a standard flap diminished dimensions of surviving flap when compared to control flaps. Incision-scar-pedicled flaps achieved better survival compared to excision-group flaps, particularly in the late postoperative period. The study findings showed that it may be possible to raise a flap from previously mutilated site secondary to scar formation and pedicle injury.

The objective of this study was to find out whether a compensatory increase in blood flow to the foot is observed after sacrifice of one of the tibial arteries. Eleven patients who had one of the tibial arteries as the recipient artery of free tissue transfer to their lower extremities were included. The arterial diameter, cross-sectional area, maximum flow velocity, minimum flow velocity, and flow rate were measured by a Doppler ultrasound in the nonrecipient tibial artery and perforating peroneal artery in the operated limb. The same parameters were measured in the anterior and posterior tibial arteries and the perforating peroneal artery in the contralateral limb. The arterial diameter, cross-sectional area, flow velocity, and flow rate were increased significantly in the nonrecipient tibial artery of the operated limb with respect to the same artery on the contralateral limb. The same changes were not demonstrated in the perforating branch of the peroneal artery. Total blood flow to the foot in the operated extremity was not different from that of the nonoperated foot. The results reveal that if a major feeder to the foot is sacrificed, the other tibial artery compensates for it, and resting blood supply to the foot is not altered.

Summary Upper lid loading for the treatment of lagophthalmos resulting from facial paralysis is a simple and effective procedure with relatively few side effects and complications. A detailed patient-based self assessment, focusing on subjective complaints after upper lid weight implantation is scarce. In this study, a population of facial palsy patients with lid weights is asked about their subjective complaints in order to find out the patients' point of view. Patients with upper lid weights were asked questions indicating the degree of soreness, tearing, redness, visual acuity, lid closing during the day, lid closing during sleep, aesthetic appearance, artificial tear utilisation and outdoor comfort. All questions were evaluated by an analogue scale in reference to the opposite eye, where a score of ‘10' corresponds to the best outcome (no symptoms at all or appearance comparable to the contralateral eye) and a score of ‘1' corresponds to the worst outcome. Thirty patients filled in the questionnaire and 22 of them were seen in the outpatient clinic. The most pleasing result was obtained in the lid closing during the day (score 8.8±1.9), during sleep (7.7±3.0) and in the aesthetic appearance of the eye (score 7.6±2.7), whereas visual acuity received the lowest score (score 5.7±1.5). Complication and re-operation rates were 23% and 13%, respectively. In conclusion, upper lid weights solve the problem they are used to address. They provide a satisfactory lid closure and aesthetic appearance in the patients' point of view. However, the ocular symptoms of facial paralysis still persist to some extent and the procedure is not without its complications.

Summary Computerised tomography (CT) is a useful adjunct in the diagnosis of cervical pathology in head and neck carcinoma. However, different criteria used in CT analysis make the comparison of outcome studies difficult. This study compares two different CT criteria (two different lymph node sizes) for detection of cervical lymph node pathology for head and neck tumours in the same patient population. A prospective study was performed on 55 patients, with minimum T2 intraoral squamous cell carcinoma and high risk extraoral malignancies, who underwent 65 neck dissections. Sensitivity, specificity and accuracy of clinical palpation, CT considering lymph nodes larger than 10mm as positive and CT considering lymph nodes larger than 15mm as positive are compared. The results are as follows: sensitivity, specificity and accuracy of clinical palpation are 86, 84 and 85%, respectively; sensitivity, specificity and accuracy of CT with lymph nodes exceeding 10mm are 95, 47 and 63%, respectively; sensitivity, specificity and accuracy of CT with lymph nodes exceeding 15mm are 86, 81 and 83%, respectively. The outcomes of the study reveal that CT evaluation of cervical lymph nodes with a cutoff value of 15mm should be preferred to a cutoff value of 10mm in order to prevent over-treatment in cervical management of head and neck tumours. When accuracy of the results is considered, CT alone does not have an advantage over clinical palpation in this study.

Glioblastoma multiforme is an aggressive neoplasm of the central nervous system and skin metastases are extremely rare. In this article, a patient who had rapidly developing scalp masses after surgery for glioblastoma multiforme is presented. The metastatic masses with ulceration were disturbing for the patient and his family, so he was operated on for palliative resection of the tumor. The resulting extensive defect was reconstructed with a free latissimus dorsi flap. Healing phase was uneventful and he was discharged from the hospital on the ninth postoperative day. A palliative surgery, even if it may necessitate a complex reconstruction, can be recommended in specific cases to improve quality of life and to ease patient care.

A new, comprehensive system for scoring and classification of nasal defects is proposed in this article. The soft tissue coverage of the nose is in continuity with the cheeks, glabella and upper lip and the osteocartilaginous infrastructure is in continuity with the two nasofrontal buttresses, the frontal bar and the palate. Soft tissues and the skeletal framework are divided into sub-units and these anatomic features are schematized on a logo. The sub-units are graded on the logo, depending on their gravity in reconstructive strategies. Any given nasal defect is described by shading the involved sub-units on the logo and the sum of the points appended each sub-unit gives the total score of defect. The severity of the tissue loss is assessed according to a "Classification System" which is derived from this scoring system. Nasal defects are classified into one of four main Types corresponding to their scores. One hundred twenty seven patients who were operated on for various nasal pathologies have been reviewed and nasal defects are scored and classified according to the proposed system. Application of this system to the spectrum of cases encountered in a 6 years period shows that it is based on anatomic grounds, easy to document and efficient transmission of objective information becomes possible. It also offers a useful algorithm to approach the reconstruction of nasal defects.

Surgery is a serious stressor and a cause of anxiety for the patients. Reconstructive surgery patients are mostly operated on because of certain functional impairment or disability; on the contrary, cosmetic surgery patients do not have any physical impairment and they are operated on because of mostly psychologic reasons. The aim of this study was to compare the anxiety levels in the reconstructive surgery patients and cosmetic surgery patients preoperatively. Thirty-two patients in the reconstructive surgery group and 30 patients in the cosmetic surgery group were included in the study. State Trait Anxiety Inventory was used to measure the anxiety levels in these 2 groups preoperatively. The 2 groups were similar in characteristics such as age, gender distribution, number of previous operations, and trait anxiety scores. Mean state anxiety scores obtained for the reconstructive surgery group was 38.0 +/- 8.7, while it was 44.2 +/- 10.79 for the cosmetic surgery group (t test, degrees of freedom = 60, P = 0.015). This study reveals that preoperative anxiety levels in the cosmetic surgery patients are higher than those of the reconstructive surgery patients. Therefore, adequate preoperative preparation for cosmetic surgery should include attempts to cope with anxiety. Anxiolytics may be used more liberally and professional psychologic assistance may be required.

High-pressure injection injuries to the upper extremity cause potentially severe complications that result in multiple operations, amputations, and permanent functional deficits. Early exploration and debridement are the mainstays of treatment for optimal functional recovery. We describe the late presentation of a high-pressure cement injection injury to the hand, its management, and long term course.

Neurotized fasciocutaneous flaps and split-skin grafted muscle flaps are the most frequently used free flap alternatives for the reconstruction of weight-bearing surfaces of the foot. An objective comparison of the innate characteristics of these two flap types, with respect to long-term stability, has not been possible because sensory reinnervation in the fasciocutaneous flaps has been a confounding factor. This study compares nonsensate fasciocutaneous flaps (n = 9) with nonsensate split-skin grafted muscle flaps (n = 11), with mean follow-up periods of 34.3 and 31.3 months, respectively. Patients completed a form that included questions regarding degree of pain at the operative site, presence of ulcers, ability to wear normal shoes, employment status, and time spent standing on foot. Touch and deep sensation were evaluated with Semmes-Weinstein and vibration tests, respectively. Significantly less pain and less ulceration (p < 0.05) were observed in the fasciocutaneous group. Semmes-Weinstein monofilament tests revealed poorer results with split-skin grafted muscle flaps, compared with fasciocutaneous flaps. These results indicate that even if the sensory protection of fasciocutaneous flaps is not considered, these flaps have superior properties, compared with split-skin grafted muscle flaps.

Free flaps transferred to the lower extremity have a higher risk of failure, which may be expected to increase further with the use of vein grafts. The results of 103 consecutive free flaps to the lower extremities of 98 patients who were operated from March 1994 to December 1999 were evaluated to assess the reliability of vein grafts in lower extremity reconstruction. Five flaps were lost and the overall success rate was 95.1%. Eighty-four free tissue transfers in 79 patients were performed for the reconstruction of traumatic cases, and 81 of these flaps were performed in a delayed manner, between 1 week and 4 months after the injury. Interpositional vein grafts were used primarily in 22 flaps--all in traumatic cases--and 21 of them survived completely (95.4%). Primary vein grafts were used both for arteries and veins in 15 flaps and for arteries only in 7 flaps. The most common cause of tissue loss in these patients was a crush injury in earthquake survivors, followed by electrical injuries, gunshot injuries, motor vehicle accidents, and chronic infections. Free muscle flaps in 13 patients, skin flaps in 4 patients, osseous flaps in 2 patients, and temporal fascial flaps in 2 patients were the flaps of choice in vein graft reconstructions. Although a higher incidence of flap loss has been reported with the use of interpositional vein grafts than with regular transfers, and the technical and pathophysiological problems in flap transfers are also high in the lower extremity, the success rate in vein-grafted free flaps did not differ from that of the simple free flap transfers in the current series. This appears to be the result of meticulous preoperative planning and proper selection of recipient vessels during optimal operative conditions.

In the treatment of head and neck carcinoma, radical cervical lymphadenectomy leaves the affected side of the neck devoid of the sternocleidomastoid muscle, thus more vulnerable to the unwanted side effects of the adjuvant radiotherapy. It also causes asymmetry and cosmetically unpleasant appearance of the cervical region. In the reported case with widely ulcerated squamous-cell carcinoma over mandible, hemimandibulectomy and radical neck dissection was performed. Following the mandibular reconstruction, the lateral hemisoleus muscle of the harvested osteomyocutaneous fibula flap was utilized to restore the ipsilateral sternocleidomastoid region. This new application promises to be a useful method, which can aid in the restoration of the aesthetic contour of the neck and provide protection against unwanted effects of the adjuvant radiotherapy on the ipsilateral carotid artery.

The effects of hyperbaric oxygen (HBO) and heparin on the survival of the rat inferior epigastric venous flap were investigated. Preliminary transcutaneous oxygen measurements showed that partial oxygen pressure values of venous flaps increased at 2.5 ATA pressure while inhaling 100% oxygen. During the experiment, 128 venous flaps of two different sizes and 50 composite grafts were prepared bilaterally in 89 rats. Perivenous areolar tissue was removed from the pedicle vein in all flaps. Half of the venous flaps were isolated from the wound bed. Initial flap perfusion was tested by fluorescein injection during flap elevation. Four treatment groups were created: control, heparin, HBO, and HBO+heparin. After 6 days of treatment, the mean surviving flap area was calculated for each group. Surviving flaps were reelevated, final flap perfusion was tested by fluorescein injection, and flaps were harvested for histological examination. The mean survival rates of the HBO (26.56%) and the HBO+heparin (36.87%) groups were significantly higher than the control (0%) and the heparin (0%) groups (p0.01). None of the composite grafts survived. Smaller flaps and nonisolated flaps survived better, although not significantly (p0.05). Veins were enlarged both clinically and histologically. Fluorescein uptake was delayed during initial flap elevation but was normal during reelevation. These findings imply that the rat inferior epigastric venous flap may be an ischemic flap with capillary circulation through a single venous pedicle, but it needs HBO treatment to survive, especially during the acute period. Heparin treatment, reducing the flap size, and presence of a vascular wound bed also improve survival rates.

Prefabrication of fat tissue using a fascial flap based on the superficial inferior epigastric artery was studied in rats. First, the superficial inferior epigastric fascia was transposed over the inguinal fat pad. Two weeks later fascia and fat were elevated together as a prefabricated composite flap. At this stage, a pilot study was done in ten rats and perfusion of the flaps was tested with fluorescein. After confirming fluorescein staining of the prefabricated flaps, the study continued with experimental and control groups of rats. In the experimental group, prefabricated flaps were transposed to the subcostal area. In the control group, the pedicles of the flaps were severed, creating composite grafts. These grafts were transferred to the subcostal area in the same manner as in the experimental group. One week later the flaps were re-elevated and grafts were exposed. Fluorescein tests and Indian ink microangiography were carried out. In the experimental group, the flaps were stained, while grafts in the control group were not stained. Fat and fascia were found to be viable in the experimental group, while they were necrotic in the control group on histopathological examination. Based on these findings, we can conclude that the prefabrication of fat by vascular fascia is successful and may have application in plastic surgery.

Skin grafts regain their sensory innervation from the graft bed by the regeneration of nerve endings. Although some clinical studies report sensory recovery in skin grafts implanted on free muscle flaps, the mechanism of recovery is obscure. The purpose of this study was to investigate nerve regeneration in experimental skin grafts on free muscle flaps to elucidate this phenomenon. Thirty-eight male Sprague-Dawley rats, weighing 450-550 g were used in the study. The rat gracilis muscle flap was the free flap model transferred from one groin to the other using microvascular anastomoses. Full-thickness skin grafts harvested from the abdomen were used to cover the free muscle flaps after transfer. Four study groups were formed: Group I (n = 10): Free muscle flaps were transferred without any nerve anastomosis; Group II (n = 10): Free flaps transferred with the anastomosis of the muscle's motor nerve to a sensory nerve at the recipient site; Group III (n = 10): Free flaps transferred with the anastomosis of the muscle's motor nerve to a motor nerve at the recipient site; Group IV (n = 8): Skin grafts were placed directly on the fascia layer over the medial hindlimb muscles and served as controls. The specimens were harvested for histologic examination after 12 weeks. Histologic examination was performed to visualise regenerating nerve endings using HE, S100, Luxol Fast Blue and tyrosine hydroxylase staining. The specimens were categorically scored according to the staining pattern of neural structures around pilosebaceous units and statistical comparisons were performed by using paired t-test. Skin grafts in both Group II and Group III markedly received tyrosine hydroxylase at the base of their pilosebaceous units in many of the specimens and functional nerve twigs could also be traced from the muscle layer to the overlying skin graft. In contrast, the skin grafts in Group I did not show any nerve function in the central parts. The overall staining scores of Groups II, III and IV were significantly higher than Group I (P0.05; P0.001; P0.05, respectively). There was no statistically significant difference between other groups. No myelinated nerve fibres could be detected in any of the skin grafts with Luxol Fast Blue technique. It was concluded in the present study that skin grafts over reinnervated free muscle flaps can develop significantly better innervation than skin grafts over non-innervated muscle flaps. However, the activity in skin appendages indicating nerve regeneration may only imply a gross sensation and in the absence of any myelinated nerve fibres transmission of finer sensation cannot be expected in any of the study groups.

Free serratus anterior muscle flap, classified as Mathes-Nahai type III, is a versatile and frequently preferred choice for soft tissue coverage of small to moderate-sized defects owing to its reliable circulation pattern; however, some anatomic variations in the flap vascularity can result in partial flap loss. Here we present two cases with free serratus anterior muscle transfer where the distalmost portion of the flap was not perfused by the thoracodorsal pedicle. The most likely explanation seems to be the large flap size and the lack of distal interconnections between lateral thoracic artery and thoracodorsal artery branches. Our clinical experience suggests that anatomic variations of serratus anterior muscle circulation might end up with distal perfusion loss if a large flap is to be harvested.

Contraction of experimental skin flaps in loose-skinned animals is a well-known but underestimated phenomenon that in fact may vary in different circumstances and complicate the calculations of survived and necrosed areas. A standard abdominal island skin flap design in the rat was used in this study to investigate the difference between the contraction rates of necrotic and survived tissues, and to determine its significance in the experimental models. The abdominal island skin flap was based on the inferior epigastric neurovascular bundles, and it extended from the pubis to the xiphoid and between the both midaxillary lines. The study was conducted in two steps. In the first step, contraction rates of completely necrosed (both pedicles severed) and completely survived (vascular pedicles were intact on both sides either with or without a nerve supply) flaps were assessed in 45 animals. After 1 week, area loss was highly significant in both necrosed and survived flaps (p0.001). The rate of contraction was significantly higher in necrosed tissues than in survived tissues (p0.001), and it was also significantly higher in the neurovascular flaps than in the denervated flaps (p0.05). The contraction of all flaps occurred in the vertical dimension, whereas the horizontal dimension stayed almost the same. In the second step of the study, a unilateral, pedicled abdominal flap was used, which had a constant necrotic zone on the nonpedicled half, either with or without a nerve supply in 30 animals. After 1 week the pedicled halves of all flaps were significantly larger than the nonpedicled halves (p0.001). Although the total area loss was higher in the neurovascular flaps than the denervated flaps, the difference was not significant statistically (p0.05). There was no statistically significant difference between the areas of necrosis seen in both groups when it was expressed as a proportion of the total flap area (p0.05). However, this insignificant difference became significant when the amount of necrosis was expressed as a proportion of only the nonpedicled flap half, favoring the denervated flaps (p0.005). It appears in this study that ultimate proportions of surviving and necrosed tissues may be inconsistent owing to the variable contraction rates of these tissues, and misleading conclusions may appear during the assessment of given treatment modalities.

An unusual variation of the extensor digitorum brevis manus in a male cadaver is presented. The band-shaped muscle was located at the ulnar side of the hand between the fourth and fifth extensors. It originated from the deep carpal fascia and inserted to the extensor tendons of the fourth and fifth fingers with a tendon and a slip, respectively. The origin, insertion, and location of the muscle differ from those previously reported; with these anatomic features, the muscle variation cannot be placed into the current classifications. The phylogenetic and ontogenetic implications of the muscle are reviewed.

Keloid formation on the penis is exceptionally rare even though the penis is frequently subjected to surgical manipulations such as circumcision. Review of the literature revealed a few reports of patients with penile keloids. A 13-year-old Caucasian boy who had a pronounced penile keloid after circumcision and a 56-year-old Caucasian male who had keloid formation on the dorsum of the shaft of the penis after several attacks of penoscrotal hidradenitis suppurativa are presented. They comprise the fifth and the sixth cases of keloid formation in the literature to our knowledge. Intralesional steroid injection and surgical excision are the treatment modalities for this malady. Surgical excision appears to be the choice of treatment for larger lesions that are disabling. Recurrence is still possible, of course.

Various flap procedures for the reconstruction of lower lip defects have been described to achieve the basic requirements of a functional repair, namely muscle function and sensation. Flaps elevated from the upper lip or the adjacent cheek may provide a solution, but for larger lower lip defects, preservation of function is difficult. In this article, a new functional lower lip reconstruction technique that includes the transfer of a myocutaneous flap based on the mental neurovascular bundle and on the branches of the facial artery is described. The principle of this reconstructive procedure is to advance the tissues from both sides of the chin as myocutaneous flaps upward to the lip defect, reorienting the muscles of the flap for sphincteric function, and preserving the mental nerve for sensation. The depressor anguli oris and remnants of the orbicularis muscle together with their motor nerve branches are included in the V-Y advancement flap.

Congenital panda nevus or the divided nevus of the eyelids is a rare form of melanocytic nevus involving both upper and lower eyelids with the risk of future malignant transformation along with the patients' complaints about the cosmetic appearance. Delicate anatomic features of the eyelids and the limited skin redundancy of the periorbital region make the surgical removal and reconstruction difficult, even in mild cases with partial involvement of the eyelids. A case of congenital panda nevus involving upper and lower eyelids, the eyebrow, and part of the malar eminence and the nasal dorsum is presented. A multistaged surgical management of the lesion with staged excision and reconstruction with preexpanded forehead flaps, temporal island flap, and skin grafts is discussed.

Background: Successful breast reduction involves remodeling the breast parenchyma and creating a pedicle to maintain blood supply to the nipple-areola complex (NAC). Although vascular compromise is generally venous in breast reduction surgery, clear anatomical descriptions of the breast veins are lacking in textbooks. Objectives: The author designed an NAC flap based on arterial and venous territories defined in a cadaver study and subsequently assessed the technique in a series of live patients. Methods: Dynamic venous angiography was performed on hemithorax specimens from 6 fresh female cadavers. A new septum-based pedicle (the “central pillar”) was designed, which protected the periareolar vein polygon along with the breast septum. Sixty-seven patients underwent breast reduction with this technique between 2005 and 2010. Results: The patients were followed for an average of 26.4 months. Sixty-two of the 67 patients underwent bilateral reduction. The average reduction in tissue per breast was 910.7 g (range, 440-1935 g), and the average nipple transposition was 9.6 cm (range, 6-17 cm). The most common complications were delayed healing of the vertical “puckered” suture line (16 patients), seroma (7 patients), hematoma (2 patients), and unilateral deepithelialization of the NAC following transient venous congestion (2 patients). The patient satisfaction rate was high. Conclusions: The central pillar technique is a promising alternative for young patients with glandular breasts that require gross reduction and high-transposition NAC, who are not good candidates for the “free nipple graft” technique.

Vascularized periosteal graft is a frequently applied flap model for bone prefabrication studies due to its inhabitance of osteoprogenitor cells and osteoinductive potential. Various bones such as rib and fibula are reported as a potential source for the harvest of the periosteal flap in experimental studies on higher species such as dogs and pigs, which necessitates a rather complicated and expensive experimental setting. Therefore a reliable and inexpensive small animal model on vascularized periosteal flaps is necessary for future research. A new saphenous artery based periosto-fasciocutaneous flap model in rats is described here, which is easily dissected and monitorized. In this experimental study, 15 male Sprague Dawley rats were operated and killed following a 3-month-long follow-up period . The histological analysis revealed heterotopic osteoneogenesis in 12 of 15 flaps (80%), whereas 14 flaps (93.3%) exhibited signs of angioneogenesis originating from the periostofasciocutaneous flap. The presented flap model promises to be an appropriate alternative for new studies where bone prefabrication methods are evaluated.

In the treatment of head and neck carcinoma, radical cervical lymphadenectomy leaves the affected side of the neck devoid of the sternocleidomastoid muscle, thus more vulnerable to the unwanted side effects of the adjuvant radiotherapy. It also causes asymmetry and cosmetically unpleasant appearance of the cervical region. In the reported case with widely ulcerated squamous-cell carcinoma over mandible, hemimandibulectomy and radical neck dissection was performed. Following the mandibular reconstruction, the lateral hemisoleus muscle of the harvested osteomyocutaneous fibula flap was utilized to restore the ipsilateral sternocleidomastoid region. This new application promises to be a useful method, which can aid in the restoration of the aesthetic contour of the neck and provide protection against unwanted effects of the adjuvant radiotherapy on the ipsilateral carotid artery.

Changes in protein turnover are among the dominant metabolic changes during aging. Of special importance is the maintenance of nuclear protein homeostasis to ensure a coordinated cellular metabolism. Therefore, in the nucleus a special PARP-1-mediated mechanism of proteasomal activation exists to ensure a rapid degradation of oxidized nuclear proteins. It was already demonstrated earlier that the cytosolic proteasomal system declines dramatically with aging, whereas the nuclear proteasome remains less affected. We demonstrate here that the stress-mediated proteasomal activation in the nucleus declines during replicative senescence of human fibroblasts. Furthermore, we clearly show that this decline in the PARP-1-mediated proteasomal activation is due to a decline in the expression and activity of PARP-1 in senescent fibroblasts. In a final study we show that this process also happens in vivo, because the protein expression level of PARP-1 is significantly lower in the skin of aged donors compared to that of young ones. Therefore, we conclude that the rate-limiting factor in poly(ADP-ribose)-mediated proteasomal activation in oxidative stress is PARP-1 and not the nuclear proteasome itself.

A competent knowledge of various microsurgical techniques is essential in various surgical specialities 1,2 and a microsurgical training program simulating basic technical maneuvers and difficult clinical situations is incorporated into regular residency training. 3 The end-to-end anastomosis of vessels with different luminal diameters is one of the most frequently faced technical problems in clinical microvascular surgery which is unexpectedly not considered in standard microsurgical training programs. In this letter, a new training model facing this important technical difficulty is presented which may be a useful addition to the basic microsurgical training program. The basis of the new training model for vessel size discrepancy is end-to-end anastomosis of rat femoral artery to the femoral vein by dividing them through different levels. Two different ratios of discrepancy (Moderate lumen discrepancy ratio 51:1.3‐1.5 and Severe lumen discrepancy ratio 51:1.8‐2) can be achieved in this model. The mean diameter of the vessels at a level cranial to the epigastric branches is 0.8‐0.9 mm for the artery and 1.3‐1.4 mm for the vein. Dividing the femoral artery and femoral vein at a level between the deep branches and the epigastric vessels creates a moderate lumen discrepancy of 1:1.3‐1.5 ratio for practicing endto-end anastomosis (Fig. 1). The oblique cut or spatulation of the smaller vessel end combined with closer placement of the sutures can be exercised in this situation. Saphenous artery is the continuation of the femoral artery after the epigastric branch and its most proximal part has a diameter of 0.7‐0.8 mm. In contrast, the diameter of the femoral vein at the level between the inguinal ligament and the deep branches is about 1.4‐1.5 mm. Dividing the proximal saphenous artery and cranial femoral vein and rotating the proximal cut edge of the saphenous artery cranially until reaching the proximal cut edge of the femoral vein for end-to-end anastomosis gives a severe discrepancy model with the mismatch ratio of 1:1.8‐2 (Fig. 1). End-to-end anastomosis after fishmouth incision 4 to the arterial end is exercised at this degree of discrepancy. The presented training model offers a standard and necessary exercise to overcome the problem of vessel diameter discrepancy faced in microsurgical end-to-end anastomosis in a range of 1:1.2 to 1:2. Vessel diameter discrepancy is an important clinical problem commonly faced in free tissue transfer and in our opinion, the addition of this easy and feasible model to the basic microsurgical training program may be helpful for the trainees by dealing with this important clinical problem.

Microvascular reconstruction of composite cranium defects is challenging, and operative planning differs in various anatomic regions of the cranium. The aim of this article is to detail surgical strategies for microvascular reconstruction in different areas of the cranium. Fifty-eight free tissue transfers were performed in 54 patients with composite cranial defects between 1995 and 2009. The cranium was divided into six zones to classify the defects. Data on patient demographics, location and cause of the defects, technical details of surgical management, and complications were analyzed. Defects were secondary to ablative procedures in 45 patients. Eight patients had posttraumatic defects, and one patient had congenital defect. Nine different flap types were used in the series. Choice of recipient vessels and the use of interpositional vein grafts varied according to the site of the cranial defects. Microsurgical reconstruction of cranial defects can be performed safely with predictable outcome by methodic assessment of the problem and by careful attention to the details of the reconstructive plan. In this article, valid conclusions on the planning of microvascular reconstruction in different areas of the cranium have been determined.

A simple method to take macrophotographs that show details even in the microsurgical field was discussed. The method uses any single lens up to 80 mm or any zoom lens in the reverse position with a single-lens reflex camera. In this manner, high reproduction ratios larger than the actual size of the object can be achieved.

The third part of the axillary artery unilaterally divides into two major arterial stems, named according to their localization as deep brachial artery and superficial brachial artery (brachial artery). The deep brachial artery gives off the posterior circumflex humeral artery, anterior circumflex humeral artery, subscapular artery, and profunda brachii artery. It continues its course in the arm lateral to the median nerve and terminates by giving a minute twig to the radial artery. The superficial brachial artery is larger in caliber than the deep brachial artery and gives no branches in the arm region. In the cubital fossa it gives the ulnar and the radial arteries. This case is a variant of the axillary artery that has been rarely (0.12-3.2%) documented in the literature. Accurate knowledge of the normal and variant arterial anatomy of the axillary artery is important for clinical procedures in this region. Clin. Anat. 13: 66-68, 2000.

Epithelioid sarcoma is a rare soft-tissue sarcoma which classically presents as a subcutaneous or deep dermal mass in distal extremities of adolescents and young adults. A more aggressive \"proximal\" or \"large-cell\" type has been described in rare cases to occur as a deep soft-tissue mass at proximal body sites which tends to recur and metastasize earlier than the conventional epithelioid sarcoma. The correct diagnosis of this type is essential since these lesions can easily be misdiagnosed as other epithelioid lesions. Its prognostic factors also have not yet been fully investigated. We herein report a case of metastatic proximal-type epithelioid sarcoma arising from the scrotum of a 50-year-old man managed by radical surgery and adjuvant chemotherapy.

Microvascular reconstruction of a cranial defect in a 10-week-old infant, which is the youngest case in the literature, is reported. A latissimus dorsi free muscle flap was transferred to cover the defect and a split thickness skin graft was placed over the muscle flap. Despite the successful flap transfer in this case, microvascular reconstruction in an infant has its own risks and infants should be discussed as a separate entity apart from the other pediatric patients.