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AIM: To investigate the utility of two different interpositional materials (muscle graft vs. fascia flap) for preventing the osseous reunion of skull bone defect including the coronal suture line in rats. MATERIAL AND METHODS: A total of 32 male Sprague-Dawley rats were divided into 2 groups (n=16 for each) after the formation of bilateral coronal bone defect, based on the interpositional materials used to prevent re-ossification; the rats were divided into the muscle graft (MG) group and the fascial flap (FF) group. In each group, the other side of the coronal suture served as the control. The rats were sacrificed at postoperative 4 weeks or 8 weeks for histopathological, radiological, and microbiologic investigations. RESULTS: At postoperative 8 weeks, there was partial reunion in the defects with bony tissue in both the groups; no obvious differences were noted between the groups on radiological examination.The defect content involved bone and fibrous tissue in the MG group and bony bridges and loose connective tissue in the FF group. New bone formation was moderate, marked, and extreme and the reduction in defect size was marked, moderate, and extreme in the MG, FF, and control groups, respectively. CONCLUSION: Our findings revealed that neither the temporal MG nor the temporal FF were able to achieve complete prevention of re-ossification of the skull bone defects including the coronal suture line; further, neither material was superior to the other.

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OBJECTIVE: The intralesional injection of recombinant human epidermal growth factor (EGF-IL), a new therapy, has been claimed to prevent major amputations in advanced diabetic foot lesions. In this study, the efficacy of EGF-IL on advanced diabetic foot ulcers (DFU) was reviewed. METHODS: Intralesional 75 µg EGF application (Heberprot-P® 75, Heber Biotec, Havana, Cuba) to 12 diabetic foot lesions in 11 patients (8 males, 3 females; mean age: 62.2±10.6 years) was evaluated. Most of the patients had undergone revascularization and received hyperbaric oxygen therapy (HBOT) and negative pressure wound therapy (NPWT), along with standard care, but failed to heal. After amputation was offered as the final option, EGF-IL was applied to evaluate its effects. RESULTS: Two patients underwent amputation, while 10 lesions of the remaining 9 patients healed completely. CONCLUSION: Our results prove that intralesional application of EGF can prevent amputations in advanced diabetic foot cases with an ischemic component. However, evidence in the literature supporting its use remains lacking, and its high cost presents an additional problem. Thus, we believe that intralesional application of EGF should be an option for ischemic wounds only after vascular evaluation (and intervention when possible), HBOT, NPWT, and standard care have proven insufficient.

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Free vascularized fibular autograft transfer to the defect area after wide resection of bone sarcoma is one of many biological reconstruction methods. We report on an 8-year-old girl with 7 years of follow-up treated for right femur osteosarcoma. A 26 cm long tumor was resected with clear margins. Because the length of one fibular autograft was shorter than the defect length, bilateral free vascularized fibular autografts were used in a vertical array on top of one another, and placed inside a fresh-frozen femoral allograft. The original length of the femur was maintained by this technique.

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A microanastomosis might tolerate a torsion up to 360°, but the effects of arterial microanastomosis torsion on the survival of the flap it supplies are unclear. The aim of this study was to investigate the consequences of microarterial anastomosis torsion on the groin flap in rats. Forty Sprague-Dawley rats were divided into five groups. An oblique groin flap was harvested as an island flap and a patch-to-side arterial anastomosis was performed with torsion angles of 0°, 90°, 180°, 270°, and 360°. Six of eight flaps in Group I (0° torsion), six of eight flaps in Group II (90°), three of eight flaps in Group III (180°), and none of the flaps in Groups IV and V (270° and 360°) were found to be viable after 1 week. The patency and flap survival rates observed in Groups II, III, IV, and V were compared with those in Group I using Fisher's exact test. The patency rates and flap survival rates in Groups IV and V were significantly lower compared with those in Group I. Our data show that skin flaps can survive even if their arterial pedicle is anastomosed with a torsion of up to 180°.

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Malignant foot tumours are often treated with amputations due to anatomical difficulties. Limb salvage techniques are difficult to perform, as a stable, sensible and plantigrade foot should be obtained to prevent further problems.In this report, we present a midfoot reconstruction with a vascularized free fibula, osteomized in a V-shape after wide resection of a midfoot synovial sarcoma. We describe the reconstruction of both longitudinal arches in which using a vascularized autograft facilitated union, remodeling of the bone, and obtaining a functional foot.

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Because the extremities are dependent on a single vascular supply, namely the brachial and femoral arteries, injuries around the girdles are challenging, and may contribute to high morbidity rates such as extremity loss, or even mortality due to bleeding, sepsis or vascular compromise. The reconstruction or aided closure of these regions may present additional technical difficulties in the presence of a vascular injury that complicates the use of a microvascular-free transfer, which sometimes may be needed to cover the exposed vessels, bones, tendons, and cartilages whenever the neighboring skin and subcutaneous tissue are inadequate or demised. In these circumstances, pedicled regional flaps of muscular or musculocutaneous consistency (especially if a bulk or rich vascular tissue is needed) would be an alternative. In this report, we present two cases that underwent femoral artery repair via saphenous vein grafting in the vascular surgery clinic followed by our inferiorly based pedicled rectus abdominis muscle flap coverage procedure.

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OBJECTIVES: The aim of this study was to evaluate surgical treatment and follow-up results of patients who presented to our department with sciatic nerve injuries. METHODS: The study included 13 patients (12 males, 1 female; mean age 23 years; range 11 to 35 years) who underwent surgical treatment for sciatic nerve injuries. The etiologies of sciatic nerve injuries were penetrating trauma in five patients, firearm injuries in four patients, and motor vehicle accidents in four patients. Injuries involved the knee level in five patients, and above-the-knee level in eight patients. Peroneal nerve involvement was seen in all the patients, and the tibial nerve was involved in 11 patients. Primary repair was performed in six patients, neurolysis in three patients, and nerve grafting in three patients. One patient underwent neurolysis for the peroneal portion, and nerve grafting for the tibial portion. Muscle strength and reflex changes were recorded at every stage of the treatment. Muscle strength was assessed according to the British Medical Research Council scale. The Semmes-Weinstein monofilament test was used for sensory evaluation. The mean follow-up period was 4 years (range 1 to 6 years). RESULTS: In 11 patients with tibial nerve injuries, the soleus/gastrocnemius strength was measured as follows: M1 in one patient, M3 in four patients, M4 in four patients, and M5 in two patients. Plantar sensation was absent in four patients, while seven patients had at least adequate protective sensation. In 13 patients with a peroneal nerve injury, the strength of the anterior tibial muscle was measured as follows: M0 in three patients, M2 in three patients, M3 in one patient, M4 in three patients, and M5 in three patients. Of these, four patients had persistent insensitivity in the dorsum of the foot, while six patients had protective sensation, and three patients had normal sensation. Two patients with inadequate anterior tibial muscle strength following nerve repair underwent posterior tibial tendon transfer for restoration of foot dorsiflexion. The greatest functional improvement was obtained in cases in which neurolysis was performed; patients undergoing primary repair had better outcomes compared to those where nerve grafts were used. The results were better in thigh level injuries than those in the gluteal region. CONCLUSION: Low expectations after sciatic nerve repair in the past are now being rapidly replaced by a more optimistic approach. Advances in microsurgery and use of treatment algorithms based on scientific research account for this significant improvement in outcomes after sciatic nerve surgery. Tendon transfers can enhance the success rate and be combined with nerve repair in selected cases.

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BACKGROUND: Severe facial burn sequelae present a great challenge and maximally test the principles of reconstructive surgery. Three of these basic principles--free tissue transfer, flap prefabrication, and tissue expansion--are combined to achieve superior reconstructive outcomes. This approach evolved into the prefabricated induced expanded flap, which refers to the staged transfer of expanded supraclavicular skin with an antebrachial fascial free flap used as the carrier. METHODS: In the first surgical stage, the radial artery and corresponding vein in antebrachial fascia were transferred to a subcutaneous pocket in the supraclavicular fossa over a large skin expander, with anastomoses to the neck vessels. During the second stage, after adequate expansion lasting 2 to 3 months, the total scarred hemiface was excised, and the prefabricated induced expanded flap was dissected and then transferred as an island to cover the skin defect. RESULTS: Twenty-six patients with severe hemifacial burn sequelae and three more with other large hemifacial lesions underwent successful facial resurfacing with the described technique in the last 7 years. Twenty patients were male and nine were female, with a mean age of 23. Mean follow-up was 3.4 years. All of the flaps survived after transfer, and no major complication was observed. CONCLUSIONS: The supraclavicular prefabricated induced expanded flap can provide ample amounts of vascularized, thin, and desirable skin with perfect color match for resurfacing major facial defects. The aesthetic and functional results were encouraging and progressively improved during follow-up.

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INTRODUCTION: Reconstruction of the lower leg commonly requires a free tissue transfer after Gustillo grade IIIB-IIIC injuries and severe postoncological resections, where, free musculocutaneous flaps (MCF) are preferred for their size and robust blood supply. The anastomoses are performed at more proximal levels to keep them away from the trauma zone. This reasonable maneuver causes the distal of the flap to cover the most critical part of the defect. Any marginal necrosis, then, ends in exposure of the bone or implant. Reported here is the use of a perforator flap derived from a previously transferred free MCF as a backup tissue. PATIENTS AND METHODS: Distal marginal necrosis exposing vital structures were encountered after six free MCF transfers during the last 6 years. These were highly complicated cases in which no regional flap options were available and a second free flap was unfeasible due to recipient vessel problems. A perforator flap was elevated on the perforator vessel(s) penetrating the underlying muscle of the previous MCF and either advanced or transposed to cover the defect. Donor sites on MCF were closed primarily. RESULTS: Wound dehiscence that healed secondarily was observed in two cases. The knee prosthesis was removed in one case due to uncontrolled osteomyelitis. No complications were detected in other three cases. CONCLUSION: The described flap can be a leg saver whenever a previously transferred free MCF fails to cover the distal site of the defect. The flap can be advanced for 3-5 cm and allows more than 90 degrees of rotation.

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Although some authors previously stated that microlymphatic surgery does not have application to primary lymphedema, opposite views are reported based on the observations that the lymphatics were not hypoplastic in majority of these patients and microlymphatic surgery yielded significant improvement. The aim of this study was to compare the intraoperative findings and outcomes of primary and secondary lower-extremity lymphedema cases treated with lymphaticovenous shunts. Between December 2006 and April 2009, microlymphatic surgery was performed in 80 lower extremities with primary and 21 with secondary lymphedema. These two groups of extremities are compared according to the morphology of the lymphatic vessels and possibility of precise anastomoses, their response to the treatment, and final outcomes based on volumetric measurements during the follow-up period. The morphology of the lymphatics in secondary lymphedema was more consistent, and at least one collector larger than 0.3 mm was available for anastomosis in 20 of 21 extremities. In the primary lymphedema group, the lymphatics were smaller than 0.3 mm in 13 of 80 extremities. It was, therefore, possible to perform supermicrosurgical lymphaticovenous anastomosis in 84% of extremities with primary lymphedema and 95% of extremities with secondary lymphedema. Reduction of the edema occurred earlier in the secondary lymphedema group, but the mean reduction in the edema volume was comparable between the two groups. Microlymphatic surgery, although more effective and offered as the treatment of choice for secondary lymphedema, would also be a valuable and relevant treatment of primary lymphedema.

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Recent supermicrosurgical techniques have developed the possibility for vascular anastomosis of smaller vessels and it is now safe and sound to perform precise anastomoses between lymphatics and venules. Reported here is the 2 years experience on supermicrosurgical lymphaticovenular anastomosis and/or lymphaticovenous implantation combined with a nonoperative physical therapy for treatment of lower extremity lymphedema. Microlymphatic surgery was performed in 42 patients with unilateral lower extremity lymphedema. Thirty patients were women and 12 were men with a mean age of 34. Lymphaticovenular anastomoses were performed in 37 patients with an average of 2.5 anastomoses per patient, and lymphaticovenous implantations were made in 36 patients with an average of 2.4 implantations per patient. The lymphatics that were larger than 0.3 mm were anastomosed to venules with supermicrosurgical technique. Lymphaticovenous implantation technique was used for thinner lymphatics in a particular incision. Postoperatively, 18 patients used continuous compressive garments, 9 patients used garments but discontinued after 6 months, and no compression was used in 9 patients. The results of surgery were assessed both clinically with volume measurements and by lymphoscintigraphy and were classified as good, moderate, or ineffective. The mean decrease in the volume of the edema was 59.3% at an average follow-up of 11.8 months. Six outcomes were classified as ineffective, eight outcomes as moderate, and 28 outcomes as good. Supermicrosurgical lymphaticovenular anastomosis and/or lymphaticovenous implantation seems to be highly beneficial, especially in the early stages of peripheral lymphedema and may be offered as the treatment of choice in selected patients.

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We report a patient who was diagnosed as fat embolism syndrome after replantation surgery of left amputated foot. This diagnosis was based on the presence of a long bone fracture with an amputation of a major extremity, supported by the signs of pulmonary and cerebral dysfunction and confirmed by the demonstration of arterial hypoxemia in the absence of other disorders.

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The higher rate of anastomotic failure in avulsion injuries has been attributed mostly to the uncertainty in determining the uninjured vessel segment suitable for anastomosis and resection past a proximal branch that has been proposed to achieve good arterial flow. A graded, longitudinal, microarterial traction model in rats has been used to examine the histopathologic aspects of the extent of vascular injury and its association with the proximal side branch. Additionally, anastomoses were performed following traction, and thromboses rates were determined. Results indicated a more proximal vessel injury with increasing rates of traction and, although the vessel segment proximal to the side branch was spared, up to a certain degree of traction, the injury extended beyond this point with more aggressive traction force. Consistently increasing rates of thromboses, significantly higher than the control group, were demonstrated. This model may be of use in further studies on the efficacy of various antithrombotic agents.

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Mutilation of the hand as a result of hot press injury, the common characteristics of which are extensive soft tissue and extensor tendon loss, metacarpal and phalangeal necrosis, exposition of multiple joints, and infection, presents a serious challenge to the hand surgeon. Free transfer of the inferior three slips of the serratus anterior muscle is a useful surgical option for the reconstruction of dorsal-side defects in the hand. The versatility of the three separate slips, which are easily divisible for contouring, enables individual reconstruction of the different digits. Long vascular pedicle, low donor-site morbidity, and durability are other advantages. Four male patients with hot press injury of the dorsal side of the hand were treated with free transfer of serratus anterior muscle slips and split-thickness skin grafts. Follow-up period ranged between 5 and 12 years. Late functional and cosmetic results are presented.

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OBJECTIVES: We evaluated tendon reconstruction with one-stage tendon grafting in flexor tendon injuries in which primary repair was not considered because of delay in treatment or of inappropriate circumstances on the part of the wound and the patient. METHODS: Thirty-seven patients (29 males, 8 females; mean age 20.5 years; range 4 to 52 years) underwent single-stage flexor tendoplasty involving 41 fingers. Twenty-eight patients had zone II injuries. The mean duration from trauma to surgery was one month (range 3 to 6 weeks). Tendon grafts were obtained from the palmaris longus in 26 repairs, flexor digitorum superficialis in 14 repairs, and flexor carpi radialis in one repair. Early passive rehabilitation was administered after surgery. Improvement in the flexion motion was calculated using the Strickland formula. The results were compared with respect to the tendon graft used, associated nerve injuries, and the age of the patients (equal to or below 10 years/above 10 years). The mean follow-up was 35 months (range 4 to 83 months). RESULTS: Functional results were excellent in 12 fingers (29.3%), good in 13 fingers (31.7%), moderate in 14 fingers (34.2%), and poor in two fingers (4.9%). Overall, the mean total active movement was 57% (range 22 to 88%). No significant differences were found between the functional results with respect to the tendon graft used, associated nerve injuries, and the age of the patients (ANOVA, p>0.05). CONCLUSION: Single-stage flexor tendoplasty seems to be an appropriate choice of treatment for flexor tendon injuries where local wound conditions and decreased tendon length prevent primary repair, provided that the pulley system remains intact.

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Torsion at the microanastomosis site is a basic fault and should be avoided. In this study, we investigate the effects of different degrees of microvenous torsion on patency and its physical changes on anastomoses in a rat model. One hundred anastomoses were performed at different degrees of torsion, using femoral veins of Sprague-Dawley rats. Anastomoses were performed at 0 degrees, 45 degrees, 90 degrees, 135 degrees, and 180 degrees of torsion randomly. Patency tests immediately, 1 h, and 1 week after the anastomoses were checked, using the refill test. Measurements of external diameter were recorded at three points: one at the anastomosis site, and the others 2 mm proximal and distal to the anastomotic site. Finally, histopathologic and scanning electron microscopy studies were performed. Subsequently, because of the peculiar phenomenon of early recannulation of the thrombosed vessels, 20 vessels were also explored on the first and the third days postoperatively. The data demonstrate that torsion at 180 degrees, compared with 0 degrees, 45 degrees, and 90 degrees, impaired patency significantly (P < 0.005). In the subsequent study of 20 veins that were thrombosed on the first day, all became patent on the third day and remained so. In conclusion, rotation of a microvenous anastomosis begins to affect the patency rate at 90 degrees of torsion, and at 180 degrees has a patency rate of only 25%. However, all become patent again from the third day onwards. Thrombosis of rat femoral veins without chronic obstruction results in rapid lysis of thrombus and transient proliferative changes.

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All kinds of technical faults must be prevented in microvascular anastomosis for successful reconstructive microsurgery. Torsion at the anastomosis site is one of the most basic technical errors. In this study, we investigate the effect of different degrees of microarterial torsion on patency and its physical changes on anastomosis in a rat model. A total of 144 microanastomosis were performed in 72 Sprague-Dawley rats. They were divided into 9 groups. The anastomosis was performed at 0 degrees, 45 degrees, 90 degrees, 135 degrees, 180 degrees, 225 degrees, 270 degrees, 315 degrees, and 360 degrees of torsion randomly. Patency rates and the narrowest point of the artery after the anastomosis were recorded after 1 hour for each group. In the second stage of the study, the 9 groups were divided into 2 groups for patency rates and histopathological sampling at the second and seventh days postoperatively. The femoral arteries in all groups were all patent at the end of 1 hour. Only 5 microanastomosis were thrombosed (one in the 45 degrees group, one in the 225 degrees group, one in the 270 degrees group, and two in the 315 degrees group) at the second day of exploration. Only two arteries were thrombosed (one in the 45 degrees group and one in the 315 degrees group) at the seventh day of exploration. The patency rate was 96.8% in experimental groups excluding the control group. Different degrees of torsion had no statistically significant effect on the patency rates of microvascular anastomosis. Torsional repair of the femoral artery in the rat has no significant histopathologic changes, but alternately, endothelial integrity was affected by excessive degrees of torsion. Different degrees of torsion at the anastomosis site do not affect patency rates and cross sectional histology of rat femoral arteries. In clinical practice, minor torsion can be tolerated, however, factors affecting patency such as tension, diameter disproportion, and tight closure can affect the final result of anastomosis. We observed that torsional force of the vessel is distributed along the artery to the weakest point.

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