Background: Anthropometric measurements and proportions of the human body have made a significant contribution to the science of aesthetic and reconstructive plastic surgery.Objective: The present study was performed to measure anthropometric breast values in Turkish female students and compare them with those of women in other nations.Methods: The study included 385 female undergraduate student volunteers between the ages of 18 and 26 years with no physical or developmental deformity and with a body mass index between 20 and 26. A total of 19 parameters were measured in a standing position. The parameters measured were body weight, height, shoulder width, upper chest width, middle chest width, lower chest width, waist width, hip width, clavicle-nipple length, sternal notch-nipple length, nipple-nipple length, upper arm length, medial mammary radius, lateral mammary radius, nipple-inframammary fold length, nipple diameter, areola diameter, nipple projection, and mammary projection. Breast volume, breast ptosis, and retracted nipple rates were also assessed.Results: The mean breast volume was determined to be 407.2 +/- 263.6 cc. The mean values of the right and left breast volumes were calculated as 415.2 +/- 264.5 cc and 399.1 +/- 265.5 cc, respectively; the right breast volume was significantly greater than the left breast volume (P < .001). The ideal external view of the breasts with equal volume for both sides and no ptosis was observed in 35.1% of the volunteers. The percentage of women with unilateral or bilateral retracted nipple was 2.6%.Conclusions: The results of the present study will help in comparing the anthropometric breast values of young Turkish women with those of women in other countries. They may also be useful either in planning aesthetic and reconstructive breast surgery or in designing breast augmentation accessories and clothing.

Silicone is a material commonly used in reconstructive and aesthetic surgery, but capsular formation is a very frequent complication of silicone implants. This study aimed to investigate whether verapamil, a calcium-channel blocker, can reduce the thickness of the peri-implant capsule in rats when it is instilled into the subcutaneous pockets. For this study, 60 female Wistar albino rats were used, and cubes of silicone blocks (10 x 10 x 5 mm) were crafted. The rats were divided into five groups of 12 each, and the groups were distinguished according to the use of silicone and artificially created hematoma relevant to administration of a single dose of 5 mg verapamil (Isoptin). The control group was left without silicone. In two of the four silicone groups, hematoma was artificially created around the silicone by a 1-ml injection of blood. The implants were removed 6 months later, and capsulectomy was performed. Under light microscopic examination, no severe inflammation was observed in any of the capsule tissues. Additionally, the thickness of the capsule was measured and found to be significantly reduced statistically in all the verapamil-treated groups, including the groups with the artificially created hematoma. In conclusion, based on the statistically significant data obtained in this study, subcutaneous verapamil administration may be a useful adjunct for preventing formation of capsular contracture after silicone implantations. This preliminary work in rats should be confirmed with larger mammals before carefully controlled clinical trials are considered.

BACKGROUND:Free tissue transfer is a method of moving any tissue from a donor area of the body to a recipient site and re-attaching the arteries and veins to the blood vessels at the recipient site by microvascular surgery. Improved microsurgical techniques have resulted in a high percentage of successful free tissue transfers. Post-operative monitoring of tissue viability can detect early problems in free tissue transfer which may allow early intervention and salvage. Although many flap monitoring methods have been described, there is still no consensus on which of these techniques will become the standard accepted method for monitoring free muscle flaps. OBJECTIVE:In present study, we investigated the use of 99mTc sestamibi scintigraphy in determining free muscle flap viability and complications, and also in directing treatment. METHODS:Thirteen patients were examined prospectively during the post-operative period after free tissue transfer for foot defects. The cause of the defect was diabetic foot ulcer in 10 patients, dermatofibrosarcoma in one patient, squamous cell carcinoma in one patient and gunshot wound in one patient. Foot defect covering was carried out with a free latissimus dorsi muscle flap and skin graft (n=12) and a free gracilis muscle flap (n=1). All patients were examined with a monitoring system that consisted of visual inspection, hand-held Doppler ultrasonography and scintigraphic examinations. Scintigraphic imaging of all cases was performed routinely within the first 48 h post-operatively, and also on days 10 and 91 in two patients. RESULTS:There were four flap failures during the study. One of these patients had viable findings upon visual inspection and no evidence of vascular compromise on Doppler at the first examination. In the other patient, visual inspection of the flap showed that it was ischaemic in one region, but there was no vascular compromise on Doppler examination. Scintigraphic images of each of these patients showed a partial hypoperfused area in the flap region. Later, these two flaps showed positive clinical indications of hypoperfusion (colour of muscle and appearance of skin graft) and Doppler abnormalities. The remaining two patients had non-viable scintigraphic images as well as positive clinical indicators of hypoperfusion and evidence of vascular compromise on Doppler. Nine patients each had a viable flap. In these patients, all three examination tools demonstrated that the flaps were totally viable and there were no vascular complications. CONCLUSION:According to the results of this study, 99mTc sestamibi scintigraphy appears to be a feasible and promising method in the evaluation of free muscle flap viability and complications. On the other hand, to demonstrate any impact on management or patient outcome, further evaluation of 99mTc sestamibi imaging, including comparative studies with different established methods in a larger patient population, is highly recommended.

Spitzoid melanoma is a rare variant of melanoma. It has morphological features similar to those of Spitz's nevus. In this study, the histologic and immunohistochemical features of both Spitzoid melanoma and Spitz's nevus are emphasized. We report two cases of melanoma with spitzoid features occurring in the extremities of 9 and 8-year-old girls. Histologically both lesions had typical features of Spitzoid melanoma. We conclude that the differential diagnosis of Spitzoid melanoma and Spitz's nevus is at times problematic in childhood, in that distant metastasis may be the only diagnostic criteria for some cases to be distinguished from Spitz's nevus if strict criteria are followed. Spitzoid melanoma must be treated as other types of melanoma.

The treatment of venous ulcers of the leg often fails to heal because venous ulcers are mostly associated with severe lipodermatosclerosis. These complicated ulcers may require correction of local hemodynamics, excision of ulcer with surrounding lipodermatosclerotic skin, and replacement of the defect with healthy tissue. We present our experience with the use of the distally based sural flaps for the reconstruction of soft-tissue defects of the distal region of the lower limb in patients with chronic venous ulcer. Between 2001 and 2003, 12 patients with venous ulceration were treated with distally based sural flaps. At operation, the ulcer and its surrounding lipodermatosclerotic skin were excised. The defects after excision ranged from 3 x 3 to 11 x 17 cm. The distally based sural artery flap was inset within the defect. In all patients, the flap survived completely, and in only 1 patient, distal venous congestion was seen and was treated successfully with leeches. There was donor site skin graft loss in 2 patients. Two flaps had minor local complications that healed with local wound care. No recurrent ulcers were identified after average 19.7 months. In conclusion, the distally based sural flaps can be used reliably for treatment of venous ulcers. Our approach in treatment of chronic venous ulcers improves venous hemodynamics and provides local flap alternative that should be considered prior to a free-flap transfer for closure of the defect.

Objective. To review our experience with temporary arteriovenous (AV) fistula followed by free tissue transfer in the treatment of diabetic foot ulcers associated with peripheral arterial occlusion.Patients and method. From July 1997 to July 2002, 15 lower extremities were operated in 14 patients. An AV loop with its apex below the medial malleolus was created between popliteal artery and saphenous system. Three weeks later, the loop was divided to provide an artery and a vein end. Foot defect was covered with latissimus dorsi muscle flap followed by split thickness skin grafting.Results. Fistulas were patent in 12 extremities. Free tissue transfer was performed in 13 extremities. Two free flaps failed. After patent temporary arteriovenous fistula, free tissue transfer was successful in 11 of 12 extremities. One patient was amputated below knee due to ongoing infection despite successful free tissue transfer. Early mortality rate was 7%. Limb salvage was achieved in 11 of 13 extremities that staged operation was performed. Overall extremity loss was four of 15 lower extremities in 14 patients. Overall mortality was 21% for mean 20 follow-up period.Conclusion. Temporary AV fistula and free flap may provide stable wound coverage and high rate of limb salvage in treatment of diabetic foot ulcers with large tissue loss.

PURPOSE:Maxillary sinuses are the most frequently injured anatomic region of the facial skeleton in midfacial fractures. The purpose of this study was to evaluate the patients with maxillary sinus wall fractures using clinical examinations, maxillofacial computed tomography (CT), and cranial bone single-photon emission tomography (SPECT) and to interpret the results of these examinations to evaluate the indications of surgical intervention or drainage for maxillary sinus after maxillary sinus wall fractures. MATERIALS AND METHODS:The results of examinations of 15 patients with maxillary sinus fractures who were treated for midfacial fractures were evaluated. Follow-up examinations were performed in the range of 3 to 47 months after surgery (average, 19.8 months). The patients ranged in age from 10 to 45 years, with an average age of 31.6 years. There were 11 male and 4 female patients. Seven patients had Le Fort II fractures, 6 patients had tripod zygomatic fractures, 1 patient had infraorbital fracture, and 1 patient had zygomatic arch fracture. Operative procedure was performed in all cases. To evaluate maxillary sinus after surgery, maxillofacial computed tomography (CT), cranial bone SPECT, and maxillary sinusitis evaluation form were used in all patients. RESULTS:Maxillofacial CT scans were related to sinusitis in 9 patients who had positive complaints for sinusitis. The cranial bone SPECT showed positive uptake at the fractured sites in 8 patients, minimal uptake in 2 patients, and normal uptake in 5 patients. CONCLUSIONS:Clinical examination, maxillofacial CT, and cranial bone SPECT are the most reliable methods available today for the diagnosis and follow-up of complications of maxillary sinus fractures.

The appearance of superficial tissue is often an unreliable indicator of deep-tissue viability in cases of frostbite. We present a 34-year-old black man who was brought to the emergency department at fourth post-injury day with frostbite injury involving both lower extremities after prolonged exposure to subzero temperatures. In our previous experimental study, 99mTc sestamibi scintigraphy has been employed for evaluating frostbite injuries in rabbit hindlegs. In the case presented, 99mTc sestamibi scintigraphy, as a new diagnostic tool, was performed for detection of skeletal muscle perfusion on the fourth post-injury day. The scintigraphic images show diffusely reduced uptake in soft tissues of both calves and feet. It was thought that this hypoperfusion was due to viable but ischemic tissue. Five days after medical therapy, 99mTc sestamibi scan showed prominently increased uptake in both calves and feet and skin necrosis was observed. Debridement of necrotic skin and subcutaneous tissue was performed, and split-thickness skin graft was applied for coverage of the skin defect. Healing was good 15 days after grafting. We think 99mTc sestamibi scan can be used for assessment of soft-tissue perfusion and evaluation of treatment in frostbite injury.

During neoplastic development, several aspects of the regulation of polyamine synthesis undergo profound changes. In extrahepatic mammalian tissues in which the urea cycle is not functioning, arginase is believed to supply the cell with ornithine, a non-protein amino acid that is a precursor for biosynthesis of polyamines. Because the activity of ornithine decarboxylase and polyamine levels have been shown to be elevated during carcinogenesis, we decided to investigate the role of arginase in the development of malignant tumors of the human skin and to examine whether arginase activity and ornithine level can be used as biologic markers for distinguishing patients with squamous cell cancer from patients with basal cell cancer. For this purpose, we studied tissue arginase activity and ornithine level in tumor and adjacent normal tissues in 16 patients (55 +/- 10 years of age) with malignant skin tumors (8 of which were squamous cell cancers and 8 of which were basal cell cancers). The mean arginase activity and ornithine levels in tumor tissues (total) were 17.75 +/- 8.54 U/mg protein and 40.89 +/- 14.88 nmol/mg protein, respectively, versus 3.69 +/- 1.71 U/mg protein and 12.98 +/- 6.21 nmol/mg protein, respectively, for normal tissues. The mean specific arginase activity levels in squamous cell and basal cell cancers of the human skin were 18.49 +/- 10.47 U/mg protein and 16.63 +/- 6.00 U/mg protein, respectively. The mean ornithine levels in squamous cell and basal cell cancers of the human skin were 42.45 +/- 19.10 nmol/mg protein and 39.33 +/- 10.19 nmol/mg protein, respectively. Our results indicated that (1) arginase activity and ornithine levels are elevated in squamous cell and basal cell cancers of the human skin; (2) the increased activity of arginase and hence the elevated levels of ornithine may be important in the development of malignant tumors of the human skin; and (3) although arginase activity and ornithine level may be useful for distinguishing patients with malignant skin tumors from healthy subjects, they cannot be used as biologic markers for distinguishing patients with squamous cell cancer from patients with basal cell cancer.

In this study, the vascular responses of diabetic rat femoral arteries to epinephrine were investigated. The effects of lisinopril (ACE inhibitor) on vascular epinephrine sensitivity were also tested in a different group. This study was carried out in sodium pentobarbital-anesthetized rats 8 weeks after induction of diabetes with streptozotocin. After extensive dissection of the femoral arteries with adventitial stripping, epinephrine and chlorpromazine were applied to the vascular wall, and their vascular effects were compared in streptozotocin-diabetic (STZ-D), lisinopril-administered streptozotocin-diabetic (LASTZ-D), lisinopril-administered nondiabetic (LAND), and non-diabetic (ND) groups. Vasoconstriction was induced by epinephrine in all groups in a dose-response fashion. There were statistically significant differences in maximum percent constriction between STZ-D and LASTZ-D groups. There was also a significant increase in sensitivity to epinephrine in the STZ-D group. The vasoconstriction induced by epinephrine was relieved by chlorpromazine in all groups. Results suggest that there are important functional abnormalities in the responses of vessels to epinephrine in diabetics, and that the attenuation of vasoconstriction by ACE inhibitors may have beneficial effects in microsurgical procedures performed on diabetic patients. Topically-applied chlorpromazine appears to be effective in relieving vasospasm due to epinephrine, and may be a useful tool to resolve perioperative vascular spasm in microsurgical procedures for diabetic and non-diabetic patients.

Objective: A 13-day-old girl with a left transverse facial cleft and a median defect of the lower jaw is reported in detail. Left macrostomia was repaired using a W-plasty technique, and preauricular appendages were excised. The median defect of the mandible demonstrated by computed tomography scan on the first examination had disappeared at 1 year of age. Conclusion: Congenital clefts of the mandible can fuse at a later stage; thus, it is necessary to wait to treat the mandibular defect until the infant is slightly older.

Reconstruction of bone defects and contour irregularities in the craniofacial region is difficult and often requires complex solutions. This study investigated the tissue response, vascularization and bone ingrowth, in hydroxyapatite, porous polyethylene and silicone elastomer when used as bone graft substitutes. 24 albino rabbits (8 rabbits for each implant) were used in this investigation. Hydroxyapatite 500 particles, silicone rubber and porous high-density polyethylene were placed in the cavities formed with a drill in the rabbit frontal bones. As a part of a prospective study the vascularization rates of all implant materials were analyzed 10 days and 2 months after surgery using 99mTechnetium-MDP (Methylene diphosphonate) scintigraphy of the skull. The scintigraphic studies were performed 2 hours after intravenous injection of 4 mCi (148 MBq) 99mTc-MDP. The frontal bone was excised on the 10th and 60th days. All tissue specimens were placed first in 10% formalin and then in 10% nitric acid solution for decalcification. The vascularization, connective tissue ingrowth, foreign body reaction and bone regeneration around the implant were evaluated. Results of this study suggested that hydroxyapatite and porous polyethylene were stabilized in bone while as expected silicone was mobile, also hydroxyapatite implants are vascularized better and are more biocompatible than porous polyethylene.

A case of post-mastectomy lymphangiosarcoma is reported. Lymphangiosarcoma is an extremely rare but highly lethal complication of chronic lymphoedema. Our patient was treated by amputation and died 6 months later. Treatment of post-mastectomy lymphangiosarcoma is still unsatisfactory. Early recognition and radical ablative surgery seem to provide best chance for survival.

A case of malignant melanoma arising on the hyperkeratotic little finger of a 46-year-old patient with palmoplantar keratoderma is reported. A pigmented lesion had been present since childhood, over a period of two years it became larger and darker and had occasionally bled over the past two months. Histopathologic investigation revealed hyperkeratosis, hypergranulosis, and acanthosis on the left palm and malignant melanoma on the macule of the left little finger.

*Department of Plastic and Reconstructive Surgery, Edirne, Turkey †Department of Nuclear Medicine Trakya University Medical Faculty, Edirne, Turkey

An experimental study in rats was designed to determine the effects of z-plasty on the patency of microvascular anastomosis. Eighty Sprague-Dawley rats of mixed sex were divided into two groups. In all animals, the left carotid arteries were used. In the first group (n=40), a single z-plasty was done at the anterior side of the carotid artery before end-to-end anastomosis was performed. In the second group (n=40), end-to-end anastomosis with interrupted sutures was done. Patency and the appearance of the anastomosis were evaluated 1 hr later, on the seventh postoperative day, and at the end of the third postoperative week. There was no vasospasm demonstrated in the first group. Patency rates were 100 percent for both groups after 1 hr. On the seventh postoperative day, one anastomosis in the first group (patency rate, 97.5 percent) and two anastomoses in the second group had failed (patency rate, 95 percent). Patency rates were similar at the third week. The difference was not statistically significant (p=0.5). Histologic examinations demonstrated that z-plasty did not cause any adverse effects at the vessel wall or at the anastomosis.

Aygit, A. Cemal MD*; Onat, Ragip MD*; Aydin, Yağmur MD†; Orak, Fethi MD† Author Information

Various techniques have been used for reconstruction of extensive lower eyelid defects, but it is difficult to achieve results which are satisfactory, both from a functional and cosmetic viewpoint. In the past three years, ten patients have been reconstructed using a cheek flap over a chondromucosal graft, after extensive resection of lower eyelid tumors. As a modification of the classic method, the dermal layer of the cheek flap was sutured to the inferior orbital rim to prevent late sagging and ectropion. In addition, a tie-over pressure dressing on the inner aspect of the lid was used to give good contact between the chondromucosal graft and the flap. At a one year follow-up, the results were judged to be good, both aesthetically and functionally.