Publications by authors named "Kemal Ugurlu"

36 Publications

Is Counterclockwise Rotation With Double Jaw Orthognathic Surgery Stable in the Long-Term in Hyperdivergent Class III Patients?

J Oral Maxillofac Surg 2018 09 15;76(9):1983-1990. Epub 2018 Mar 15.

Professor Dr, Plastic Surgeon, Private Practice, Istanbul, Turkey.

Purpose: To evaluate the long-term postsurgical stability of counterclockwise rotation of the occlusal plane (OP) in double-jaw orthognathic surgery in patients with hyperdivergent Class III malocclusion.

Materials And Methods: This retrospective cohort study evaluated the postsurgical stability of orthognathic surgery in patients with skeletal Class III malocclusion and counterclockwise rotation of the maxillomandibular complex with an OP change of at least -2°. Patients were evaluated with lateral cephalometric analysis before surgery, immediately after surgery, and at longest follow-up. The primary predictor variable was the change in angle of the OP and the Frankfort horizontal (FH) after surgery. The primary outcome variable was stability of the OP at longest follow-up. Other study variables were age, gender, and the following cephalometric measurements: mandibular plane angle; gonial angle; angle formed by the sella, nasion, and B point; maxillary height; angle of the palatal plane to the line connecting the sella and nasion; and distances of the posterior nasal spine and A point to the FH and of the A point to the vertical line passing from the nasion. The Mann-Whitney U test was used to compare stability between groups because the variables were not normally distributed. Bonferroni correction was used to evaluate P values. The χ test and Fisher exact test, where appropriate, were used to compare the proportions of groups. A P value less than .05 was accepted as statistically significant.

Results: The sample was composed of 15 adult patients (mean age at surgery, 23.5 yr; 40% men). The median duration of follow-up was 48 months (interquartile range, 36 to 60 months). The groups had similar demographic properties and similar surgical changes. Ten patients showed very stable results with an OP-FH change no greater than 1°. Four patients showed unstable results with an OP-FH change of 2.25 ± 0.5° during the follow-up period. The change in the mandibular plane angle was notable between patients with stability and those with instability, which was the variable most affected by relapse of the OP.

Conclusion: This study found long-term postsurgical skeletal stability of counterclockwise rotation of the OP during double-jaw orthognathic surgery in patients with high angle Class III malocclusion after a median follow-up of 48 months.
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http://dx.doi.org/10.1016/j.joms.2018.03.005DOI Listing
September 2018

Use of human nail for reconstruction of the orbital floor: an experimental study in rabbits.

Br J Oral Maxillofac Surg 2016 Jul 16;54(6):664-8. Epub 2016 Apr 16.

Private Practice, Turkey.

The orbital floor is the thinnest part of the orbital wall, and in 20% of all maxillofacial injuries it is fractured. Autografts, allografts, and alloplastic materials are used in reconstruction, but there is no consensus about which material is the most appropriate. Nail is a semirigid material that is easy to reshape and is not antigenic. Alloplastic materials, which are used in reconstructions of the orbital floor, have various complications and are expensive. Autografts have donor-site problems, high rates of resorption, and take a long time to do. We created bilateral 10mm defects in the orbital floors in 18 New Zealand rabbits. We reconstructed the left orbital floors with double-ground human nail while the right orbital floors were left open as controls. The orbital floors were examined macroscopically and microscopically at 4, 8, and 12 weeks postoperatively, and there were no macroscopic signs of infection, inflammation, or extrusion. Forced duction tests showed that it was possible to induce movement of the eyeball for all 18 of the reconstructed sides throughout the observation period, and in 14 of the 18 rabbits on the control sides. Positive forced duction test shows us that orbital muscles are trapped in orbital floor defect and due to this movement of eyeball is restricted. Acute and chronic inflammation, fibrosis, vascularisation, and the presence of foreign body giant cells were evaluated microscopically. Acute inflammation and the presence of foreign body giant cells were recorded as mild, whereas fibrosis, chronic inflammation, and vascularisation were severe, as were epithelialisation on the maxillary sinus side of the nails, calcification, and progression of collagen. We found no signs of resorption of the nails.
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http://dx.doi.org/10.1016/j.bjoms.2016.03.031DOI Listing
July 2016

Microvascular anastomosis using fibrin glue and venous cuff in rat carotid artery.

J Plast Surg Hand Surg 2015 Apr 22;49(2):72-6. Epub 2014 Dec 22.

Department of Plastic Reconstructive and Aesthetic Surgery, Marmara University School of Medicine , Istanbul , Turkey.

Conventional anastomosis with interrupted sutures can be time-consuming, can cause vessel narrowing, and can lead to thrombosis at the site of repair. The amount of suture material inside the lumen can impair the endothelium of the vessel, triggering thrombosis. In microsurgery, fibrin sealants have the potential beneficial effects of reducing anastomosis time and promoting accurate haemostasis at the anastomotic site. However, there has been a general reluctance to use fibrin glue for microvascular anastomoses because the fibrin polymer is highly thrombogenic and may not provide adequate strength. To overcome these problems, a novel technique was defined for microvascular anastomosis with fibrin glue and a venous cuff. Sixty-four rats in two groups are included in the study. In the experimental group (n = 32), end-to-end arterial anastomosis was performed with two stay sutures, fibrin glue, and a venous cuff. In the control group (n = 32), conventional end-to-end arterial anastomosis was performed. Fibrin glue assisted anastomosis with a venous cuff took less time, caused less bleeding at the anastomotic site, and achieved a patency rate comparable to that provided by the conventional technique. Fibrin sealant assisted microvascular anastomosis with venous cuff is a rapid, easy, and reliable technique compared to the end-to-end arterial anastomosis.
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http://dx.doi.org/10.3109/2000656X.2013.800528DOI Listing
April 2015

Modification of mandibular advancement osteotomy in a patient with Hanhart syndrome.

J Craniofac Surg 2013 Nov;24(6):2162-6

From the *Department of Plastic and Reconstructive Surgery, Medistate Hospital; and †Department of Plastic and Reconstructive Surgery, Sisli Etfal Research and Training Hospital, Istanbul; and ‡Department of Plastic and Reconstructive Surgery, Akdeniz University Faculty of Medicine, Antalya, Turkey.

The oromandibular limb hypogenesis syndrome is a group of anomalies affecting the mandible, tongue, and maxilla with or without reductive limb anomalies. It was first described by Hanhart in 1950. In severe syndromic cases of mandibular hypoplasia, a number of techniques have been described for mandibular advancement including sagittal split osteotomies, segmental osteotomies, or distraction osteogenesis just to name a few. A 25-year-old male patient presented to our clinic with symptoms including difficulty in speech and eating, disability in opening the mouth, together with hand and foot abnormalities; we want to describe a modification in the technique of mandibular advancement and the patient's late postoperative results. The design of the step osteotomy is modified by softening the angles of the steps and elongating the horizontal segment of the step to approximately 25 mm to allow for a more efficient advancement of the mandible. The postoperative period was uneventful, with no signs of inferior alveolar nerve disturbance. The patient showed an increase of the mouth opening distance immediately after surgery. We believe that this tongue-in-groove-like modified mandibular step osteotomy technique is a good alternative in patients where advancement greater than 15 mm is required, preserving the nerve and achieving solid bony intact surfaces.
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http://dx.doi.org/10.1097/SCS.0b013e3182a2b80eDOI Listing
November 2013

Microsurgical reconstruction in pediatric patients: a series of 30 patients.

Ulus Travma Acil Cerrahi Derg 2013 Sep;19(5):411-6

Deparment of Plastic and Reconstructive Surgery, Akdeniz University Faculty of Medicine, Antalya, Turkey.

Background: Free flap surgery in the pediatric population has gained widespread acceptance regarding its technical utility and reliability. Initial concerns as to the feasibility and reliability of the procedure in children were resolved over time.

Methods: Thirty children (15 boys, 15 girls) were treated in Sisli Etfal Training and Research Hospital, Plastic and Reconstructive Surgery Clinic. Their mean age was 10.8 years. Defects were located on the lower extremity (n=22), head and neck (n=5) and upper extremity (n=3). The etiologies of the defects included vehicle accident, sequelae of burn, traumatic contractures, crush injury, epulis in the maxilla, and gunshot wound.

Results: The free flaps performed in our series were latissimus dorsi muscle flap, combined latissimus dorsi and serratus muscle flaps, serratus anterior muscle flap, cross latissimus dorsi muscle flap, scapular osteomyocutaneous flap, parascapular fasciocutaneous flap, fibular osteocutaneous flap, anterolateral thigh flap, medial circumflex femoral artery perforator flap, and crista iliaca osteocutaneous flap.

Conclusion: The advantages of free flaps in children, which include better adaptation of the flap growth and better learning capacity of the children, provide the surgeon with more satisfactory functional and aesthetic results.
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http://dx.doi.org/10.5505/tjtes.2013.09515DOI Listing
September 2013

Comparison of the flap survival with ischemic preconditioning on different pedicles under varied ischemic intervals in a rat bilateral pedicled flap model.

Microsurgery 2014 Feb 4;34(2):129-35. Epub 2013 Oct 4.

Department of Plastic, Reconstructive and Aesthetic Surgery, Bezmialem Medical School, Bezmialem Vakıf University, Istanbul, Turkey.

The study was undertaken to search whether pedicle selection for ischemic preconditioning (IP) and duration of global ischemia applied after IP influenced efficacy of IP on flap viability in epigastric adipocutaneous island flap with bilateral pedicles in rat model. In total, 159 rats were divided into one control and three (primary, secondary, or bilateral pedicle) IP treatment groups. IP was performed on different pedicles by three cycles of 10 minutes of pedicle clamping and 10 minutes of release. After IP procedure secondary pedicle was ligated in all groups, and flaps were exposed to 0, 1, 2, 4, or 6 hours of global ischemia by clamping primary pedicle. In control groups, after the perfusion of bipedicled flaps for 1 hour, left pedicle was ligated and flaps were exposed to global ischemia as in IP groups. On day 5 post-surgery, tissue samples and topographic measurements were taken. No significant differences in semi-quantitative scorings of polymorphonuclear leukocytes infiltration, chronic inflammation, interstitial edema, neovascularization, VEGF, and CD105 expression levels among groups were found (P > 0.05). Percentages of necrosis were consistently smaller in IP groups compared to controls for the same duration of global ischemia, with exception of the no-ischemia. Area of necrosis was significantly smaller in primary IP group versus secondary IP group in the absence of global ischemia (P < 0.01). In the presence of global ischemia, both primary and secondary pedicle IP groups had significantly smaller percentage of necrosis than controls (P < 0.05) and there was no significant difference between primary and secondary IP groups (P > 0.05). Thus, IP performed on different pedicles may ameliorate flap survival in a comparable fashion, depending on the duration of global ischemia. Secondary pedicle IP was as effective as primary pedicle IP and may be feasible in free flap transfers.
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http://dx.doi.org/10.1002/micr.22192DOI Listing
February 2014

Simultaneous alveolar cleft closure and dental midline correction with curvilinear intraoral distraction.

Cleft Palate Craniofac J 2014 May 11;51(3):344-9. Epub 2013 Sep 11.

This article describes a new method that enables vector control during alveolar distraction osteogenesis in the treatment of a cleft palate patient. The patient presented with unilateral complete cleft lip and palate, and the alveolar part of the defect was covered by a mobile buccal flap. The distraction was performed by sliding the surgically released tooth segment with the help of an intraoral distractor over 1.5-mm stainless steel archwires held by metal crowns. This vector-controlled method enabled new bone and attached gingiva formation in harmony with the proper alveolar shape.
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http://dx.doi.org/10.1597/12-279DOI Listing
May 2014

Two-suture fish-mouth end-to-side microvascular anastomosis with fibrin glue.

J Craniofac Surg 2012 Jul;23(4):1120-4

Department of Plastic, Reconstructive and Aesthetic Surgery, Bagcilar Training and Research Hospital, Bagcilar, Istanbul, Turkey.

The most decisive step during free tissue transfers and replantation surgery may be respected as microvascular anastomosis. The conventional end-to-side anastomosis technique with simple interrupted sutures is well established and proven to be successful. On the other hand, conventional technique can be time consuming and can cause vascular thrombosis, vessel narrowing, and foreign-body reactions. Search for a more rapid and secure alternative to conventional technique is carried on. In this study, we defined a new technique for end-to-side anastomosis with fish-mouth incisions and application of fibrin glue and compared our results with those we obtained with conventional end-to-side anastomosis. We evaluated end-to-side anastomosis of carotid arteries of a total number of 64 Wistar-Albino rats. In control group (n = 32), conventional anastomoses with 8 to 10 sutures were performed. In experimental group (n = 32), fish-mouth incisions were applied first on the recipient artery, followed by performing anastomosis with only 2 corner sutures and applying commercially available fibrin glue. Time taken to perform the anastomosis was significantly shorter with the experimental group (P = 0.001), whereas early and late patency and aneurysm rates were comparable to those achieved with control group. Histological evaluation did not point out any significant differences between the groups. We have defined a rapid and safe alternative technique of end-to-side anastomosis with the use of fibrin glue. This method may be an alternative especially where multiple anastomoses are required or where it is difficult to approach anastomotic line, as it is easily performed, rapid, safe, and not involving any complex equipments.
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http://dx.doi.org/10.1097/SCS.0b013e31824e2a39DOI Listing
July 2012

The effect of nonpreserved human amniotic membrane on the survival of ischaemic skin flaps in rats.

J Plast Reconstr Aesthet Surg 2012 Dec 6;65(12):1700-5. Epub 2012 Jul 6.

Okmeydanı Training and Research Hospital, Department of Plastic, Reconstructive and Aesthetic Surgery, Darülaceze Caddesi, Ana Bina Kat:2, Sisli, Istanbul, Turkey.

Objective: Random-pattern skin flaps are used widely in plastic surgery, but necrosis resulting from ischaemia in the distal sections of the flap is a serious problem. Free oxygen radicals and the accumulation of increased neutrophil granulocytes play important roles in tissue injury and may lead to partial or complete necrosis of the flap. Amniotic membrane is a biomaterial used widely in clinical settings to prevent the infiltration and activation of leucocytes. The aim of this study was to test the effects of amniotic membrane on the survival of ischaemic skin flaps in rats.

Methods: A total of 32 male rats were divided randomly into four groups of eight, according to the procedure to be tested: flap-only (F), flap-amniotic membrane (FA), flap-Tegaderm(®) (FT) and flap-amniotic membrane-Tegaderm(®) (FAT). Rectangular, random-pattern, caudally based modified McFarlane skin flaps were elevated at the dorsum of the rats in all four groups. The flap-only group was also the control group; in this group, the flaps were elevated and sutured to their native position. In the FA group, after the flaps were elevated, the amniotic membrane was inserted underneath the undersurface of the flap. In the FT group, after the flaps were elevated, a piece of Tegaderm was inserted underneath the undersurface of the flap. In the FAT group, the amniotic membrane was inserted underneath the undersurface of the flap and the Tegaderm(®) was inserted in the flap donor area. The survival rate of the skin flaps was measured on day 7, and histologic assessments were performed.

Results: The survival rate of the skin flaps was significantly improved in the FA and FAT groups (67-69%, p < 0.05) compared with the F and FT groups (46-48%, p < 0.05). Histologic analysis showed many more blood vessels and fewer neutrophils in the FA and FAT groups than in the F and FT groups.

Conclusion: This study showed that amniotic membrane could improve the survival rate of ischaemic skin flaps.
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http://dx.doi.org/10.1016/j.bjps.2012.06.013DOI Listing
December 2012

Bare dorsal thoracic fascial flap for esophageal defects: an experimental study with dogs.

Surg Endosc 2012 Jun 17;26(6):1682-9. Epub 2011 Dec 17.

Plastic and Reconstructive Surgery Clinic, Sisli Etfal Research and Training Hospital, Gazi Berkay Cd. No: 13/9 Sisli, Istanbul, Turkey.

Background: Reconstruction of esophageal defects has challenged reconstructive surgeons for a long time. Problems that affect the continuity of the orogastic tract influence the patient's quality of life and general health. Bare free fascial flaps are used to restore soft tissue defects of the oral cavity because they provide thin, pliable tissues with a high capacity for epithelialization to preserve the local anatomy. An experimental study was planned to investigate reconstruction of anterior cervical esophageal defects using a pedicled dorsal thoracic fascial flap.

Methods: Eight hybrid dogs were used in the study. All operations were planned in three steps and performed with the animals under general anesthesia. For the two-layered reconstruction, the bare dorsal thoracic fascial flap was harvested and adapted like a patch to the defect.

Results: No partial or total flap loss was observed. On postoperative day 20 surgery, a complete epithelial lining on the same plane as the esophageal mucosa was observed over the flap tissue. A 4- to 5-mm longitudinal scar that did not form even a minimal stricture in any dog also was observed. No significant changes from postoperative day 20 to postoperative days 40 and 60 were observed.

Conclusion: Bare fascial flaps in the oral cavity heal with spontaneous epithelialization and with no need for skin and mucosal grafts. Fascial flaps are easy to harvest and do not cause any functional loss because they are nonfunctional units. Their thin constitution helps the surgeon to shape the tissue and even form tubed flaps.
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http://dx.doi.org/10.1007/s00464-011-2093-3DOI Listing
June 2012

Lower extremity soft tissue reconstruction with free flap based on subscapular artery.

Acta Orthop Traumatol Turc 2011 ;45(2):100-8

Department of Plastic and Reconstructive Surgery, Şişli Etfal Training and Research Hospital, İstanbul, Turkey.

Objectives: The purpose of our study was to evaluate the results of the reconstruction of the lower extremity defects with free flaps based on the subscapular artery.

Methods: Between January, 1998 and December, 2008, 51 patients (mean age 26 years; 16 female and 35 male) presenting with a lower extremity defect underwent a reconstructive surgery with flaps based on the subscapular vascular system. Thirty-seven percent of the defects were located in the crus, 19% in the sole, 16% in the heel, and 14% in the dorsum of the foot. Eighty and a half percent of the patients had traffic-accident-related and 13.5% had burn-related tissue defects.

Results: Fifty-three percent of the patients presenting with lower extremity defects underwent reconstruction with latissimus dorsi muscle flaps, 21% with free serratus muscle and/or fascia flaps, 14% with free parascapular fasciocutaneous flaps, and 12% with free combined latissimus muscle and serratus muscle and/or fascia flaps. Anastomoses of 80% of the patients were performed on their posterior tibial artery and accompanying veins and/or foot dorsal veins. End-to-end anastomosis was performed on 14 patients, while 35 patients received end-to-side anastomosis. Six patients were treated with cross free flaps, of which 4 received cross latissimus, 1 cross serratus, and 1 cross combined serratus and latissimus flaps. End-to-side anastomoses were performed on these patients on the cross-leg tibialis posterior artery. The cross-leg anastomosis was freed 4 weeks later. In the early period, venous occlusion was observed in 4 patients and arterial and venous occlusion was present in 1 patient. New anastomoses were performed in these patients. Partial necrosis was observed in 2 patients. The average follow-up period was 61 months. Pressure-related late ulcerative lesions developed in 4 patients. The lesions of these patients were repaired by debridement and primary suturing or partial thickness skin grafts.

Conclusion: The subscapular vascular system based flaps have an optimal vascularity once they are prepared with adequate pedicles, causing minimal donor site morbidity. These flaps are a safe and effective alternative in lower extremity reconstruction. On the other hand, in the absence of appropriate recipient vessels, single or combined cross-leg free flaps may provide successful repair.
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http://dx.doi.org/10.3944/AOTT.2011.2261DOI Listing
November 2011

Bare serratus anterior free flap in the reconstruction of the partial pharyngoesophageal defect.

J Craniofac Surg 2011 May;22(3):1010-2

Department of Plastic, Reconstructive and Aesthetic Surgery, Sisli Etfal Training and Research Hospital, Istanbul, Turkey.

Reconstruction of defects of the cervical esophagus is a challenge in head and neck surgery. Several methods have been used: flaps with local tissues, pharyngogastric anastomosis, deltopectoral skin flaps, skin muscle transplant from the pectoralis major, and microvascularized free skin fascial and small intestine flaps. A 81-year-old patient who has a partial pharyngoesophageal defect after resection of laryngeal carcinoma underwent reconstruction with bare serratus anterior fascial free flap. The subscapular artery and vein were anastomosed to the superior thyroid artery and vein. The patient's postoperative recovery went uneventfully. In the endoscopic examination, the defect was completely covered with native mucosa 8 weeks after surgery, and also, there were no stricture and fistula tract in the reconstructed area.Serratus fascial flap is a thin and pliable flap with good and reliable vascularity; it can be used in the reconstruction of partial cervical esophageal defect with its long pedicle. Serratus fascial flap can provide significant epithelialization that cannot be differentiated from native esophagus. We propose that serratus fascial free flap is an important alternative in esophageal reconstructions because it creates minimal donor-site morbidity and it can easily adapt to the defect.
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http://dx.doi.org/10.1097/SCS.0b013e3182101567DOI Listing
May 2011

Anastomosis with fish-mouth technique using fibrin glue.

J Craniofac Surg 2011 May;22(3):1047-51

Plastic and Reconstructive Surgery Clinic, Okmeydani Education Research Hospital, Istanbul, Turkey.

Researchers have made numerous attempts to shorten anastomosis duration since Jacobson first used the term microvascular surgery in 1960. However, none of these alternatives has its combination of facility, low cost, reliability, durability, and high success rate. This study aimed to shorten the anastomosis duration, especially in operations that require multiple anastomoses, and the authors performed experimental anastomoses with the fish-mouth technique using fibrin glue. This technique first involves 2 longitudinal incisions made 180 degrees apart in the shape of a fish mouth at each vessel end, thus creating a pair of equal-sized, full-thickness flaps on both vessels. These incisions, equal in length, were as long as the radius of the vessel. Two simple stay-sutures placed on the corners of the flap bases and vessels were approximated. Then, the anastomosis site was sealed with fibrin glue. Both control and experimental groups are consisted of 32 rats. This study assessed and statistically evaluated the groups with biopsies on days 3, 7, 14, and 21 and also assessed patency rates, microaneurysm formation, histologic healing patterns, and operation duration. The present study concluded that anastomosis with fish-mouth technique using fibrin glue takes less time, requires fewer sutures, decreases the amount of foreign materials in direct contact with the blood stream, creates less foreign-body reaction in the vessel wall, and everts contact surfaces. With these advantages, this technique provides a reliable and successful alternative, especially in operations requiring multiple anastomoses.
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http://dx.doi.org/10.1097/SCS.0b013e3182135f39DOI Listing
May 2011

The practice of plastic surgery in emergency trauma surgery: a retrospective glance at 10,732 patients.

Ulus Travma Acil Cerrahi Derg 2011 Jan;17(1):33-40

Department of Plastic Reconstructive and Aesthetic Surgery, Şişli Etfal Training and Research Hospital, Istanbul, Turkey.

Background: The number of patients applying to the emergency Plastic and Reconstructive Surgery outpatient clinic varies considerably depending on the sociocultural profiles of societies. Due to the abundance of anatomic regions comprising the targets of this field of specialization, plastic surgery is continuously gaining in importance in emergency traumatology.

Methods: In this study, 10,732 patients admitted to the outpatient clinic of Emergency Plastic Surgery in Şişli Etfal Training and Research Hospital were evaluated retrospectively regarding etiology, sex, age distribution, injury characteristics, and treatment.

Results: While 64% of all patients had forearm and hand injuries, 28% had maxillofacial injuries, and 8% had tissue defects. There was a male: female ratio of 4: 1, and the mean age of all patients was 22.9 years. The mean age of patients (males 81%) admitted with upper extremity injuries was 22.3 years. Most of the upper extremity injuries were due to glassware cuts (33%). The mean age of patients admitted with maxillofacial trauma was 23.2 years. Among the patients with head-and-neck injuries, the most frequent cause of trauma was traffic accidents (38%).

Conclusion: Regarding the frequency and characteristics of the patients treated, we suggest that plastic surgery shows a progressively increasing significance and widening field of practice in emergency traumatology and, as no similar study currently exists, ours will contribute significantly to the literature.
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January 2011

Transfacial approach, pedicled rhinotomy for a clival chordoma: a technical report.

Turk Neurosurg 2011 Jan;21(1):86-9

Sisli Etfal Education and Research Hospital, Department of Neurosurgery, Istanbul, Turkey.

Clival chordomas are frequently midline structures. Due to their critical location, invasive nature and aggressive recurrences, skull base chordomas are difficult to manage surgically. We present a case operated on with the pedicled transnasal and transfacial approach. The case presented with neurological deficits as cranial nerve palsy and findings of brainstem compression. The lesion was removed without any neurological deficit. Her deficits related to brainstem compression regressed after surgery. In our case, a large exposure was achieved through a lateral nasal incision in order to excise the tumor totally with acceptable cosmetic results, and a successful outcome was observed during the postoperative follow-up period with the surgical procedure applied.
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January 2011

Perineoscrotal reconstruction using a medial circumflex femoral artery perforator flap.

Microsurgery 2011 Feb 25;31(2):116-21. Epub 2011 Jan 25.

Department of Plastic and Reconstructive Surgery, Sisli Etfal Training and Research Hospital, Istanbul, Turkey.

Major scrotal defects may result from infection due to Fournier's gangrene, excision of scrotal skin diseases, traumatic avulsion of scrotal and penile skin, and genital burns. The wide spectrum of bacterial flora of the perineum, difficulty in providing immobilisation, and obtaining a natural contour of the testes make testicular cover very difficult. Various methods have been reported to cover the penoscrotal area, including skin grafting, transposing them to medial thigh skin, and use of local fasciocutaneous or musculocutaneous flaps. In this report, reconstruction using six local medial circumflex femoral artery perforator (MCFAP) flaps was undertaken in five male patients (mean age, 47 years) with complex penoscrotal or perineal wounds. The cause of the wounds in four patients was Fournier's gangrene, and was a wide papillomateous lesion in the other patient. Flap width was 6-10 cm and flap length was 10-18 cm. The results showed that a MCFAP flap provided the testes with a pliable local flap without being bulky and also protected the testicle without increasing the temperature. The other advantage of the MCFAP flap was that the donor-site scar could be concealed in the gluteal crease. Our results demonstrated that the MCFAP flap is an ideal local flap for covering penoscrotal defects.
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http://dx.doi.org/10.1002/micr.20839DOI Listing
February 2011

Single-stage ala nasi reconstruction: lateral nasal artery perforator flap.

J Craniofac Surg 2010 Nov;21(6):1887-9

Sisli Etfal Training and Research Hospital, Plastic and Reconstructive Surgery Clinic, Istanbul, Turkey.

Since its first description, the nasolabial flap is one of the most preferred methods for the ala nasi reconstruction. Because of its similarity in skin color and texture to the nose, completely concealed scar in the nasolabial sulcus makes it a better choice. The major drawback of this flap is that it necessitates a 2-stage procedure. To gain more freedom in the reconstruction of alar defects, we planned to harvest a perforator flap around the nasolabial fold, which was the one of fixed areas, and included perforators from the lateral nasal artery that is a branch of the facial artery. Lateral nasal artery perforator flap was obtained from 8 patients who have them in the perialar region. Mean age was 64 years. Mean follow-up time was 18 months. In all patients, defects occurred after excision of basal cell carcinoma. All of them were verified histopathologically. In all patients, we identified a suitable lateral nasal artery perforator to meet our reconstructive demand. All defects that occurred were not suitable for primary closure, and sizes of all flaps were bigger than 1.5 cm in width and 1.5 cm in length. All of the flaps survived, and venous congestion was seen in the first 24 hours after operation, but this resolved without any partial or complete necrosis in 3 flaps. As another perforator flap, lateral nasal artery perforator flap can be adopted for defects in any fashion without any mobilizing restrictions. The lateral nasal artery perforator flap can be rotated 90 and 180 degrees as a propeller flap or can be transposed or advanced.
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http://dx.doi.org/10.1097/SCS.0b013e3181f4af27DOI Listing
November 2010

Preliminary study on durability of nail as xenograft.

J Craniofac Surg 2010 Nov;21(6):1843-7

Department of Plastic Reconstructive and Aesthetic Surgery, Şişli Etfal Training and Research Hospital, Istanbul, Turkey.

In reconstructive surgery, many autograft/allograft/xenograft and synthetic materials are being used for repairing congenital or acquired tissue and skeletal deformities. Compatibility of the graft or the material to the tissue, the risk or rejection, toxicity, and morbidity affect the preference. With the aim of searching the usability of human cadaver nail being used as xenograft instead of cartilage graft on small and composite defects, 60 rats were separated into 3 groups, each of which was composed of 20 rats. One hundred twenty nail samples of 1 × 1-cm size, whose epithelium tissue was shaved 2-sided, were prepared for the purpose of placing 2 of them into the back of rats. They were placed under the dorsal skin of rats as naked in the first group, as fascia-wrapped in the second group, and as amnion membrane-wrapped in the third group. It has been stated as a result of the pathologic surveys performed in 2, 4, 12, and 24 weeks from rats in all groups that all the nails were available; acute and chronic inflammatory signs that were observed in early stages regressed, and in late stages, histopathologic signs of all groups were similar. Nail has some advantages such as being cost-effective, being easy to obtain, and having less rejection risk for being composed of dead cells. Application of nail xenograft eroded 2-sided can be taken into account instead of cartilage graft in small-size areas needing support tissue.
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http://dx.doi.org/10.1097/SCS.0b013e3181f43e9fDOI Listing
November 2010

Reduction mammaplasty using the free-nipple-graft vertical technique for severe breast hypertrophy: improved outcomes with the superior dermaglandular flap.

Aesthetic Plast Surg 2011 Apr 8;35(2):254-61. Epub 2010 Oct 8.

Plastic and Reconstructive Surgery Clinic, Sisli Etfal Training and Research Hospital, Istanbul, Turkey.

Background: Management of severe mammary hypertrophy is a challenge. The limitations of most dermal pedicle techniques include insufficient breast projection with severe hypertrophy. The authors have designed a free-nipple-graft vertical technique with a superior demaglandular flap to provide acceptable breast projection and an attractive, smooth breast contour for patients with severe hypertrophy and gigantomastia who are not suitable for pedicle breast reduction techniques.

Methods: Reduction was performed for 24 patients with severe mammary hypertrophy between 2003 and 2009. This study evaluated patient age, cup size, mean distances from sternal notch to nipple and from nipple to inframammary fold, amount of resection, complications, and postoperative breast shape.

Results: All 24 patients were followed regularly to 1 year postoperatively. The inclusion criteria for the reported technique specified gigantomastia larger than 1,000 g per side, grade 4 breast ptosis, and increased sternal notch-to-nipple distance. The mean distance from the sternal notch to the nipple was 48.5 cm, and the mean distance from the nipple to the inframammary fold was 19.5 cm. The new nipple was positioned at a mean of 23.5 cm. The tissue excised per breast was 1,670 g. All the patients had long-lasting, pronounced nipple and adequate breast mound projection with attractive, smooth breast contours.

Conclusion: A free-nipple graft with a superior dermaglandular flap yields a conical breast with adequate projection and fullness. Parenchyma sutures to the pectoral fascia provide long lasting results. Plastic surgeons experienced in superior pedicle breast reduction can adopt this technique easily.
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http://dx.doi.org/10.1007/s00266-010-9592-9DOI Listing
April 2011

Use of wide bipedicled pericranial flap in anterior scalp reconstruction.

J Craniofac Surg 2009 Nov;20(6):2248-51

Plastic, Reconstructive and Aesthetic Surgery Clinic, Sisli Etfal Training and Research Hospital, Istanbul, Turkey.

Pericranial flap is a composite flap involving the periosteum of the skull with its overlying loose areolar tissue termed subgaleal fascia. The multiple blood supply of the pericranial tissue enables this versatility, with a rich, anastomosing arterial supply from the supraorbital, supratrochlear, superficial temporal, posterior auricular, and occipital vessels. Thus, the shape, size, and location of the pericranial flap could be altered as long as a sufficient pedicle width could be fashioned to maintain a blood supply. In our study, we have performed wide bipedicled pericranial flap in scalp reconstruction in 2 cases. After tumor excision was completed, a pericranial flap was planned on the caudal side of the defect. A bipedicle-based pericranial flap was outlined with the use of a sharp dissection; this flap was elevated in a submusculoaponeurotic plane. The bipedicled pericranial flap, whose arterial supply was from the superficial and posterior auricular arteries, was transposed to the frontal defect.We preferred a bipedicled flap, whose arterial supply is from the superficial temporal and posterior auricular arteries to augment vascular supply. If a large, long pericranial flap is required, making the flap pedicled ensures stable blood supply.
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http://dx.doi.org/10.1097/SCS.0b013e3181bf871bDOI Listing
November 2009

A retrospective study on the epidemiology and treatment of maxillofacial fractures.

Ulus Travma Acil Cerrahi Derg 2009 May;15(3):262-6

Department of Plastic Aesthetic and Reconstructive Surgery, Sişli Etfal Training and Research Hospital, Istanbul, Turkey.

Background: Maxillofacial injuries constitute a substantial proportion of cases of trauma. This descriptive analytical study assesses the cause, type, incidence, and demographic and treatment data of maxillofacial fractures.

Methods: A retrospective study on maxillofacial traumas was carried out in the Department of Plastic and Reconstructive Surgery at Sişli Etfal Hospital (Istanbul, Turkey) between January 1, 2000 and December 31, 2005. The study included 216 patients with a mean age of 29.8 years. Sex and age distribution of patients, etiology of trauma, localization of the fractures, treatment modalities, time to treatment after the trauma, and postoperative complications were recorded.

Results: The male predilection was 75.5%. Road traffic accident was the most common causative factor (67.1%), followed by interpersonal violence (19.4%), falls (12.5%), and work- and sport-related accidents (0.9%). A total of 50% of the patients suffered isolated mandibular fractures, 23.6% had isolated midface fractures, and 26.3% had combined midface and mandibular fractures. Regarding distribution of mandibular fractures, the majority (26.8%) occurred in the parasymphysis, 14.8% in the angulus, and 11.1% each in the symphysis and corpus. Complications occurred in 6% of patients, and the most common was malocclusion followed by infection and nonunion.

Conclusion: The causes and pattern of maxillofacial fractures reflect trauma patterns within the community and, as such, can provide a guide for the design of programs geared toward prevention and treatment.
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May 2009

A novel approach for the reconstruction of medial canthal and nasal dorsal defects: frontal hairline island flap.

J Craniofac Surg 2008 Nov;19(6):1653-7

Plastic, Reconstructive and Esthetic Surgery Department, Sisli Etfal Education and Research Hospital, Istanbul, Turkey.

Medial canthal and dorsal nasal defects after surgery have been a challenging problem for surgeons and patients. The main purpose in reconstruction is not solely covering the defects with similar skin and soft tissue, but also causing minimal donor-area morbidity. The authors described an elliptical fashioned frontal island flap at the level of the frontal hairline, nourished by the vascular network composed of supraorbital and supratrochlear arteries, then carried subcutaneously to the defect area at medial canthus and upper nose. Any extra incisions above the eyebrow to control the pedicles were not necessary. Donor region was closed primarily; thus, scarring was hidden at the hairline. We present our frontal hairline island flap design and results in our series of 10 patients.In our study, we aimed to reduce scarring at donor area by planning a forehead island flap in an elliptical fashion at the frontal hairline. There are no more incisions than the elliptical incision over the hairline. Primary closure of skin flaps at the donor ensures a final scar that is hidden at the frontal hairline border. Forehead hairline island flap is an important flap for small- and medium-size defects as an alternative to conventional paramedian forehead flap.
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http://dx.doi.org/10.1097/SCS.0b013e31818ac1b2DOI Listing
November 2008

[Electrophysiologic and histopathologic evaluation of peripheral nerve regeneration at different nerve segments and with different repair techniques].

Acta Orthop Traumatol Turc 2008 Aug-Oct;42(4):278-83

Department of Plastic and Reconstructive Surgery, Sişi Etfal Training and Research Hospital, Istanbul, Turkey.

Objectives: We compared the electrophysiologic and histopathologic results of early primary nerve repair and grafting of transections made at different levels.

Methods: Twenty-two male Sprague-Dawley rats were divided into three groups. In one group (distal group, n=8), the right sciatic nerve was transected near the proximal segment of, and in another (proximal group, n=7) at 15 mm proximal to, its branching. In the graft group (n=7), the nerve was resected from 5 mm to 15 mm proximal to its branching and the defect was repaired with the removed segment. All the nerves were repaired using the epiperineural technique. Electrophysiologic studies were performed before and after surgery. In the third month, bilateral biopsies were taken from the L4-5 dorsal root ganglion and from distal nerve segments for histopathologic examination and neuron and axon counts.

Results: At two months, the distal group exhibited significantly shorter latency (p=0.001) and higher amplitude (p=0.05) values. However, at three months, all the groups had similar values of latency, amplitude, and conduction velocity. At three months, the number of the dorsal root ganglion neurons was significantly greater in the distal group compared to the graft group (p<0.001), but this did not differ from the proximal group (p>0.05). Axon counts per square millimeter were similar (p>0.05), but axon diameter was greater in the distal group (p<0.05). In correlation analyses, increases in the number of L4-5 dorsal root ganglion neurons were significantly associated with increases in the percent changes in distal latency (p<0.05) and conduction velocity (p=0.018).

Conclusion: Our findings suggest that distal injuries and primary repair of the sciatic nerve result in a faster and better recovery.
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http://dx.doi.org/10.3944/aott.2008.278DOI Listing
May 2009

Reconstruction of the urethral defects with autologous fascial tube graft in a rabbit model.

Asian J Androl 2007 Nov;9(6):835-42

Department of Plastic, Reconstructive and Esthetic Surgery, Sişli Etfal State Hospital, Istanbul 34377, Turkey.

Aim: To investigate the feasibility of the autologous fascia graft in urethra defect reconstruction.

Methods: In 24 adult male rabbits, a standardized defect (17 mm) was created within the midportion of each urethra. Two-cm long fascial tube grafts were interposed between the cut ends of the urethra. Twenty-four rabbits were divided into 12 groups. At 0, 3, 10, 15, 21, 30, 45, 60, 90, 120, 150, and 180 days postoperatively, one group was killed. In the first four groups, rabbits were killed and specimens were obtained for histological examination. After 21 postoperative days, in the subsequent eight groups, retrograde urethrograms were carried out to evaluate urethral patency and caliber, then rabbits were killed and specimens were obtained.

Results: In the histological study, advancement of the urethral transitional epithelium along scaffold provided by the fascial graft was determined. At the 30th day, the new urethra was completely covered with the transitional epithelium. Fistula formation was observed in two of 24 rabbits. In urethrograms, narrowing was determined in three of 16 rabbits.

Conclusion: For segmental urethral reconstruction, fascial graft is a good urethral substitute because of its rapid epithelization capacity, low contraction degree and thinness. We therefore propose the use of fascial grafts for reconstruction of male-urethra defects in humans.
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http://dx.doi.org/10.1111/j.1745-7262.2007.00271.xDOI Listing
November 2007

Reconstructing wide palatomaxillary defects using free flaps combining bare serratus anterior muscle fascia and scapular bone.

J Oral Maxillofac Surg 2007 Apr;65(4):621-9

Department of Plastic and Reconstructive Surgery, Sisli Etfal State Hospital, Istanbul, Turkey.

Purpose: Wide palatomaxillary defects, mostly after tumor resections, can cause severe functional and esthetic problems. Although prosthetic obturator devices or local flaps are mostly adequate for uncomplicated small-size defects, free flaps are preferred for a 3-dimensional multitissue reconstruction of more complicated defects. Regarding the anatomical structure of the palatomaxillary region, the flap must be thin enough to separate the oral and nasal cavities while not compromising palatal function, yet rigid enough for adequate dental restoration. This goal is usually accomplished with a combined or complex free flap. Numerous free flaps containing both soft tissues and bone have been described in the literature. In this study, we present a novel use of the free scapular bone flap combined with serratus anterior fascia and its functional and esthetic results.

Patients And Methods: Nine cases are presented whose wide composite palatomaxillary defects were repaired with free angular scapular bone flap combined with serratus anterior fascia based on the subscapular vascular system, between 1999 and 2003. Scapular bone wrapped with the naked serratus anterior fascia, like a sandwich, was used to repair the palate.

Results: The naked fascia was epithelialized with the help of the surrounding mucosa in 4 to 6 weeks. Results were satisfying with regard to breathing, eating, speech, and facial contour after follow-ups for 2 months to 6 years.

Conclusion: For the reconstruction of wide palatomaxillary defects, a combined flap of angular scapular bone wrapped with naked serratus anterior fascia was conceived useful for obtaining satisfactory functional and esthetic results.
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http://dx.doi.org/10.1016/j.joms.2005.12.075DOI Listing
April 2007

Sialoblastoma: a congenital epithelial tumor of the salivary gland.

J Pediatr Surg 2006 Jul;41(7):1322-5

Department of Plastic and Reconstructive Surgery, Sisli Etfal Research and Educational Hospital, 34360 Istanbul, Turkey.

Sialoblastoma is a rare congenital epithelial tumor of the salivary gland that is diagnosed at birth or shortly thereafter with significant variability in histologic range and clinical course; hence, for an individual case, it may be difficult to predict the most appropriate therapy [Cancer 1972;30:459-69; Pediatr Pathol 1988;8:447-52; Br J Plast Surg 2000;53(8):697-699]. We report the case of a 4-year-old girl who had a widely spreading sialoblastoma of the left cheek. We were obligated to widely resect the tumor including the trunk of the facial nerve, superior part of the left maxilla, and the zygoma. Although the patient was operated 3 times in 4 years, invasion of the tumor could not be stopped. The patient died because of respiratory insufficiency and deterioration of her general health.
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http://dx.doi.org/10.1016/j.jpedsurg.2006.03.040DOI Listing
July 2006

Repair of proboscis lateralis.

Scand J Plast Reconstr Surg Hand Surg 2005 ;39(3):184-7

Department of Plastic and Reconstructive Surgery, Sisli Etfal Research and Education Hospital, Istanbul, Turkey.

We report an 8-year-old girl presented with a proboscis on the right nasal nostril, right heminasal hypoplasia, hypertelorism, and cleft lip and palate on the other side. After repair of the cleft lip and palate and the hypertelorism, we successfully reconstructed the heminose with a V-Y advancement flap containing the proboscis tube.
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http://dx.doi.org/10.1080/02844310510006169DOI Listing
November 2005

Congenital fusion of the maxilla and mandible.

J Craniofac Surg 2005 Mar;16(2):287-91

Sisli Etfal Research and Educational Hospital, Department of Plastic and Reconstructive Surgery, Istanbul, Turkey.

Congenital fusion of the maxilla and mandible (syngnathia) is rare and can present in a wide range of severity from single mucosal bands (synechiae) to complete bony fusion (synostosis). Congenital synostosis of the mandible and maxilla is even less common than synechiae, with only 25 cases reported in the literature. Most of them presented as an incomplete, unilateral fusion. A 4-year-old boy was referred to the authors' emergency unit with asphyxia after vomiting. The authors found the child could not open his mouth. His upper and lower jaws were fused, with only a 2- to 3-mm gap in the anterior part. X-rays and computed tomography scans showed that there was a bony fusion of the ramus of the mandible to the zygomatic complex and the posterior part of the maxilla. In addition, there was significant mandible hypoplasia. After performing an osteotomy (to treat the fusion between the bilateral ramus mandible, maxilla, and zygoma), the authors performed a temporomandibular joint reconstruction using a silicon block. After the completion of these procedures, they observed that the mouth could be opened 32 mm. After 2 years of mandibular lengthening performed with an external distracter, the patient's facial appearance and occlusion became more acceptable. An extremely rare case is described, and the existing literature is reviewed.
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http://dx.doi.org/10.1097/00001665-200503000-00016DOI Listing
March 2005

Extended vertical trapezius myocutaneous flap in head and neck reconstruction as a salvage procedure.

Plast Reconstr Surg 2004 Aug;114(2):339-50

Department of Plastic and Reconstructive Surgery, Sişli Etfal State Hospital, Istanbul, Turkey.

In surgical treatment of head and neck cancer, when local tumor recurrence or failure of the previous reconstruction method occurs, reoperation for reconstruction of complicated soft-tissue defects can become a challenge for the plastic surgeon. This article describes the authors' experience with the extended vertical trapezius myocutaneous flap for head and neck complicated soft-tissue defects in nine patients ranging in age from 17 to 72 years. The causes of the defects were squamous cell carcinoma of the external ear (n = 2), lip (n = 2), larynx (n = 1), and oral cavity floor (n = 1); congenital hemifacial atrophy-temporomandibular joint ankylosis (n = 1); synovial sarcoma at the mandibular ramus (n = 1); and malignant fibrous histiocytoma at the posterior cranial fossa (n = 1). Eight of the nine patients had previously been operated on using other flap procedures, including free flaps and/or distant pedicled flaps (pectoralis major and deltopectoral flaps). One patient had been operated on using a graft procedure. After failure of the previous flap procedures in four patients and tumor recurrence in five patients, the extended vertical trapezius myocutaneous pedicled flap was used as a salvage procedure. The mean flap size was 7 x 34 cm. The flap was based solely on the transverse cervical artery. Superior muscle fibers of the trapezius were preserved and the caudal end of the flap was extended from 10 to 13 cm beyond the caudal end of the trapezius muscle. Three weeks postoperatively, the pedicle was separated. No flap failure occurred. The donor sites were closed primarily. There were no disabilities with regard to shoulder motion. Tumor recurrence was observed in two patients. In conclusion, for complicated soft-tissue defects of the head and neck, the extended vertical trapezius flap can be preferred as a salvage procedure because it is a simple, reliable, large flap that is located far enough from the damaged area.
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http://dx.doi.org/10.1097/01.prs.0000131984.55825.9dDOI Listing
August 2004