Post-Traumatic Deformities in Ankara, Turkey

Post-traumatic deformities are shape abnormalities that develop as a result of injuries such as fractures, dislocations, tendon lacerations, or burns not being properly treated. They are common in the hand and fingers and can lead to both aesthetic and functional loss. Early diagnosis and an appropriate treatment process are important.

Among the most common deformities are malunion (healing in an incorrect position), nonunion (failure to heal), joint stiffness, and tendon adhesions. These conditions restrict finger movements, reduce grip strength, and make daily activities difficult. A multidisciplinary approach may be required.

The development of deformity is associated with factors such as the duration of immobilization after trauma, infection, and inappropriate surgical technique. Clinical evaluation is performed with functional tests and imaging methods. In necessary cases, dynamic splinting or neurological examination may be required.

Treatment is planned according to the type and severity of the deformity. Advanced techniques such as surgical corrections, tendon transfers, and bone reconstructions may be applied. The rehabilitation process is as important as surgery and plays a decisive role in restoring function.

What Are Post-Traumatic Deformities?

Post-traumatic deformities are disruptions of the normal anatomical alignment of bone and joint structures after fractures, dislocations, tendon, or soft tissue injuries. They may develop due to improper healing, incomplete treatment, or severe tissue damage. This can lead to loss of function, pain, and aesthetic problems. Treatment is planned with corrective osteotomy, soft tissue repair, or reconstructive surgical methods, aiming to improve the function and appearance of the hand.

Why Do Post-Traumatic Deformities Occur and Whom Do They Affect?

When we listen to the stories of patients who apply to plastic surgery clinics, we see that the way the trauma occurs is actually the most important factor that draws the roadmap of treatment. The mechanism of injury gives us critical clues about how much the tissue has been crushed, how contaminated it is, and what the healing potential may be. Our observations and statistical data reveal that the causes of trauma show significant differences among age groups and sexes.

When we look at the adult population, unfortunately, incidents of violence and assault stand out, especially in male patients. These traumas often target the face and can lead to comminuted fractures of the jaw bones. In female patients, the profile shifts somewhat, and domestic accidents or sharp-object injuries are more frequently encountered. In light of these data, the surgeon needs to adopt a holistic approach that manages not only physical repair but also the psychological effects of the traumatic event experienced by the patient.

In children, the situation is much more delicate. In the pediatric group, the vast majority of traumas result from domestic accidents and falls. Children’s curious nature and not-yet-fully developed balance mechanisms make them more prone to facial trauma and hand injuries. Since bone fractures or tissue losses in a growing child can lead to asymmetrical growth or developmental delay in the future, the principle of “repair without harm” is applied much more strictly in treatment. Occupational accidents are usually the main cause of hand injuries, and because they are contaminated, greasy, crush-type injuries, they require a serious struggle with the risk of infection.

Commonly encountered mechanisms in the etiology of trauma are:

• Traffic accidents
• Falls from height
• Occupational accidents
• Domestic accidents
• Assault and violent incidents
• Sharp and penetrating instrument injuries
• Firearm injuries
• Sports injuries
• Burns

How Are Fractures and Injuries in the Facial Region Treated?

The facial region is the most critical area in traumas because it is both the gateway for vital functions (breathing, vision, eating) and the source of our social identity. In facial injuries that we call maxillofacial trauma, the first rule for us is to ensure the continuity of life before aesthetics. Fractured bone fragments or intense swelling due to trauma can obstruct the patient’s airway. Especially in mandibular fractures, the tongue falling backward is an urgent situation that can cause the patient to suffocate. Therefore, our priority is always to secure the airway.

After the patient becomes stable, surgical planning begins. In the repair of facial bones, we have three main goals. The first is to ensure that the teeth come together fully and correctly. If a jaw fracture does not heal properly, the patient will have lifelong chewing difficulty, and this can lead to nutritional problems. Our second goal is to ensure that the jaw joint moves painlessly and without catching. The third goal—and the one the patient notices most when looking in the mirror—is to restore facial symmetry, the projection of the cheekbones, and the nasal line to their pre-trauma state.

To achieve these goals, we sometimes reach fracture lines through incisions made inside the mouth and sometimes through incisions within the scalp. We assemble the fractured pieces like a puzzle and fix them with titanium plates and screws. In soft tissue injuries, we repair while remaining faithful to anatomical layers (muscle, fat, skin). In pediatric patients, the use of plates and screws may inhibit bone growth, so different approaches, sometimes resorbable materials or more conservative methods, may be preferred.

Signs that require surgery in facial trauma include:

• Malocclusion (bite problems)
• Restricted mouth opening
• Double vision
• Facial numbness
• Significant facial asymmetry
• Nosebleed
• Bruising around the eyes
• Depression of the cheekbone

How Is Missing Bone Tissue Replaced by the Body’s Self-Repair?

Some severe traumas, firearm injuries, or infections due to untreated fractures can cause bone tissue loss. In the traditional method, it was necessary to take a piece from another part of the body (for example, the pelvic bone) and transplant it here. However, today, with a method we call “Distraction Osteogenesis,” we can enable the body to produce bone on its own. This method is actually one of the most successful applications of tissue engineering within the body.

The logic is quite simple, but its application requires great precision. The existing bone is surgically cut in a controlled manner and a special device is placed on both ends. After surgery, one waits for about a week; this is called the “latent period” and is necessary for the body to form healing tissue. Then, by turning the screws on the device, the bone ends are gradually separated by about 1 millimeter each day.

This stretching force signals to the body: “There is a gap here, you need to fill it.” In the gap between the two bone ends, the body begins to produce new, living bone tissue at an incredible rate. Moreover, not only bone but also the muscles, vessels, nerves, and skin surrounding the bone lengthen along with this stretching. In other words, all missing tissues are expanded simultaneously. Especially in jaw deficiencies or large bone gaps, this method provides results that are much higher quality and more permanent than bringing bone from outside.

Situations in which distraction osteogenesis is used include:

• Traumatic bone defects
• Mandibular deficiency
• Lengthening of short bones
• Non-healed fractures
• Skull deformities
• Alveolar bone insufficiencies

How Can Burn and Wound Scars Be Eliminated by Expanding Skin Tissue?

Extensive burn scars on the face, neck, or scalp, or large scars left after a traffic accident can isolate patients from social life. Technically, it is possible to take a skin graft from the leg or abdomen to repair these areas, but aesthetically the result can be disappointing. This is because the color, texture, and thickness of skin from other parts of the body do not match the face. This is where “tissue expander” applications come into play.

The basic philosophy of this method is “repair like with like.” A deflated balloon is surgically placed under the healthy skin right next to the damaged or scarred area. After the stitches heal, the balloon is inflated at weekly intervals by injecting saline from the outside. This process is very similar to how abdominal skin expands during pregnancy.

As the balloon inflates, the healthy skin over it stretches, expands, and increases in surface area. Once sufficient excess skin is obtained (which may take 2–3 months), a second surgery is performed. The balloon is removed, the unsightly scar or burn tissue next to it is excised, and the newly expanded healthy skin is advanced to cover the area. As a result, a repair is achieved with no color mismatch, excellent tissue harmony, and (if it is scalp) a hair-bearing reconstruction.

The advantages of using a tissue expander are:

• Excellent color match
• Similar tissue quality
• Hair follicle transfer
• Preservation of sensation
• Low donor-site morbidity

How Is Tissue Transfer (Microsurgery) Performed from Another Part of the Body?

Sometimes the traumas we encounter are so severe that there is not enough skin, muscle, or bone left in the area to repair. Simple tissue advancement or expanders are not sufficient to close these massive defects. In these seemingly “hopeless” situations, microsurgical methods come into play. Microsurgery is the transfer of a tissue block taken from one part of the body together with its vessels to the trauma area, and suturing these vessels to the local vessels under a microscope.

These operations are considered the pinnacle of plastic surgery. Using suture materials much thinner than a hair, vessels with a diameter of 1–2 millimeters are sutured to each other. During this procedure, the surgeon must have steady hands, be patient, and work with technical perfection. Because even a single suture error can cause the vessel to clot and the transferred tissue to die.

Tissue is commonly harvested from the thigh (ALT flap), the back (Latissimus Dorsi muscle), or the forearm. These tissues are called “free flaps.” For example, in a patient whose bone is exposed due to a major accident in the leg, muscle tissue harvested from the back can be transferred. This muscle tissue not only closes the defect but also fights infection and accelerates fracture healing thanks to the rich blood circulation it brings. Microsurgery has enabled the salvage of many limbs that previously would have required amputation.

Commonly used donor sites for microsurgical tissue transfer include:

• Anterior thigh
• Back region
• Inner forearm
• Abdominal region
• Fibula bone
• Pelvic bone

How Can Limb Loss Be Prevented in Lower Leg and Foot Injuries?

The lower extremity, namely the area below the knee and around the ankle, is one of the most challenging regions for plastic surgeons. This is due to its anatomical structure: on the anterior surface of the shin bone (tibia), there is almost no muscle or fat tissue under the skin. The skin lies directly over the bone. Therefore, in a high-energy trauma such as a motorcycle accident, the skin can easily tear and the bone comes into contact with the external environment.

In such open fractures, a race against time begins. When bone is exposed, it dries out and becomes vulnerable to infection. If infection settles in the bone (osteomyelitis), treatment can turn into a nightmare lasting months or even years. In reconstructions in this region, the priority is “saving the leg” and “preserving walking function,” rather than aesthetic concerns.

Bringing muscle tissue from another region with microsurgical methods is often the most reliable approach. Since muscle tissue has a very rich vascular structure, it facilitates antibiotics reaching the area and fills dead spaces. If there is tissue loss in the heel or sole, regaining sensation is also important, because an insensate sole can lead to recurrent wounds while walking.

The goals in lower extremity reconstruction are:

• Coverage of the bone
• Prevention of infection
• Restoration of walking function
• Ability to wear shoes
• Preservation of sensation

Can Functions Be Restored in Hand and Finger Injuries?

The hand is the most important organ for perceiving the world and performing daily tasks. A large proportion of occupational accidents affect the hands. In hand surgery, our criterion for success is whether the patient can button a shirt, hold a glass, or return to work. In other words, we work with a completely function-focused approach.

When the tendons that move the fingers are cut, it is not enough to suture them end to end. During healing, the tendons must not adhere to surrounding tissues and must glide comfortably within their sheath. Unfortunately, the body’s healing mechanism can sometimes lead to adhesions, and the finger may remain immobile. Therefore, as much as the surgery, the physical therapy process afterward is also critical.

Nerve injuries are a more complex process. When a nerve is cut, that area of the hand becomes numb. A numb hand is constantly prone to burns or cuts because protective reflexes do not function. With nerve repairs performed under a microscope, sensory recovery is targeted; however, nerves heal very slowly (approximately 1 mm per day) and require patience.

Common types of injuries encountered in hand surgery include:

• Tendon lacerations
• Nerve lacerations
• Finger amputations
• Nail bed injuries
• Hand bone fractures
• Skin defects

How Are Fractures Around the Eye and Orbital Floor Depression Corrected?

Hard impacts to the eye area such as a punch, ball strike, or traffic accident can cause fractures of the bony framework that protects the eyeball. The eyeball sits in a socket surrounded by strong bones; however, the floor and medial wall of this socket are as thin as paper. At the moment of impact, the eyeball is compressed and, due to pressure, it fractures these thin walls and herniates into the sinus cavities. This is called a “blow-out” fracture.

In this situation, the muscles that move the eye and the surrounding fat tissue can become trapped in the fracture line. The patient has difficulty looking upward and complains of double vision. In addition, due to herniated tissues, the eyeball sinks backward and downward (enophthalmos). This leads to a “dark, sunken, and smaller eye” appearance.

In treatment, we reach the fracture line through invisible incisions made from inside the eyelid or right along the lash line. We release the entrapped muscle and fat tissues and reposition them back into the orbit. We then reconstruct the bony defect with titanium meshes or special porous polyethylene implants, creating a new orbital floor. In this way, both eye movements improve and the eye regains its previous volume and position.

Findings that require surgical intervention include:

• Persistent double vision
• Sunken eyeball
• Restricted eye movements
• Large floor fractures
• Evidence of muscle entrapment

Which Treatments Are Used for Poorly Healing Scars and Keloids?

Every trauma and every surgical incision leaves a scar; “scarless surgery” is biologically impossible. However, the goal is for the scar to be barely noticeable. In some patients, due to genetic predisposition or wound infection, the healing process goes off track. Raised, firm, red, itchy, and painful tissues called “keloids” or “hypertrophic scars” may form. Keloids are structures that extend beyond the wound borders and tend to grow like a tumor, causing significant discomfort.

In the treatment of such problematic scars, performing surgery alone (cutting out the scar and re-suturing) is usually a mistake. Because keloids “like” trauma and can come back even larger with surgical trauma (recurrence). Therefore, the current approach is “multimodal,” meaning multiple treatments.

In our treatment protocol, we generally suppress elevation and itching by injecting corticosteroids into the scar at certain intervals. With laser technologies (Pulsed Dye Laser or Fractional Laser), we reduce vascularity and fade the color of the scar. Silicone gels and pressure garments are also essential. In highly resistant cases, applying low-dose radiotherapy immediately after surgical excision is one of the most effective methods to prevent recurrence.

Methods used in scar treatment include:

• Intralesional steroid injection
• Silicone gels and sheets
• Pressure garments
• Pulsed Dye Laser
• Fractional Laser
• Cryotherapy (freezing)
• Radiotherapy
• Surgical revision

How Are Depressions and Deformities Corrected with the Body’s Own Fat Tissue?

After post-traumatic healing is complete, there may sometimes be depressions, irregularities, or tethering due to scar tissue adhering to the underlying bone. These can create shadowing under light and make the deformity more noticeable. In treating such contour deformities, the patient’s own fat tissue (lipofilling) can be used as an excellent natural filler.

Fat harvested with fine cannulas from the abdomen, hips, or inner knee is processed and purified. This “liquid gold” is injected into the depressed areas using very fine cannulas. Fat tissue not only fills the defect; it also improves the quality of damaged, hardened, and discolored skin in that area thanks to the rich stem cells it contains. We call this a regenerative effect.

Fat injection is also very effective in releasing adhesions beneath traumatic scars and softening the skin. However, it should be known that part of the injected fat (between 30% and 50%) may be absorbed by the body over time. Therefore, to achieve permanent and complete fullness, the procedure may need to be repeated a few times at intervals of 3–6 months. Unlike synthetic fillers, the fat tissue that survives remains permanent for life, and since it is the person’s own tissue, it does not carry an allergy risk.

The benefits of fat injection include:

• Adding volume
• Improving skin quality
• Softening scar tissue
• Natural appearance
• No allergy risk
• Stem cell support

What Should the Postoperative Healing Process and Care Be Like?

A successful reconstructive surgery does not end with the last suture placed in the operating room; on the contrary, a new process begins. The healing period requires complete cooperation between the physician and the patient. No matter how perfectly the surgeon performs, if the patient does not follow postoperative instructions, the outcome can be disappointing.

Especially in patients who undergo microsurgery or tissue transfer, blood circulation is very delicate. Smoking is the greatest enemy of such surgeries because it constricts vessels and reduces blood flow. In a patient who smokes, wound healing is delayed, the risk of infection increases, and the likelihood of transferred tissue loss rises. Therefore, smoking must be stopped completely.

Nutrition also forms the building blocks of healing. The body needs protein, vitamins (especially vitamin C), and minerals (such as zinc) to produce new tissue. In addition, keeping the head or the affected limb above heart level for edema control and applying cold packs in the first days increases comfort. In hand or leg injuries that require physical therapy, the patient’s adherence to exercises is vital to prevent joint stiffness.

Postoperative points to pay attention to include:

• Stopping smoking
• Protein-rich nutrition
• Adequate water intake
• Protecting the area from trauma
• Regular use of prescribed medications
• Hygienic wound care
• Protection from the sun
• Physical therapy exercises