Would you be a face transplant donor? A survey of the Turkish population about face allotransplantation.

With the technical advancement in face allotransplantation, we decided to survey the Turkish population to gain perspective into their thoughts and reactions toward face transplantation. A questionnaire was given to 1000 volunteers, regarding data about demographics, educational status, religious, and behavioral preferences. Their attitudes about donating their faces, knowledge about the pros and cons of this procedure, and personal desire for face transplantation if needed were inquired.The results of the survey demonstrated that knowing more about the procedure increases its acceptance but even so, the majority would rather undergo multiple operations with self-tissues before getting a facial transplantation (FT). When the risks of immunosuppression were exposed, less people agreed to FT, thinking it was not worth the risks.The cultural, ethnical, religious, and social background of different societies may influence the way FT is perceived and accepted. As this procedure is thought to challenge many ethical, physiological, and social points of views, we believe that it is important for a surgical team to have insight into their population's perception and general thoughts concerning the issue.

Effect of intraoperative platelet-rich plasma and fibrin glue application on skin flap survival.

The experiment was designed to compare the effect of intraoperative platelet-rich plasma (PRP) and fibrin glue application on skin flap survival. In this study, bilateral epigastric flaps were elevated in 24 rats. The right-side flaps were used as the control of the left-side flaps. Platelet-rich plasma, fibrin glue, and thrombin had been applied under the flap sites in groups 1, 2, and 3, respectively. Five days later, all flap pedicles were ligated. Necrotic area measurements, microangiography, and histologic and immunohistochemical evaluations were performed to compare the groups. Platelet-rich plasma reduced necrotic area percentages as compared with other groups. Histologically and microangiographically increased number of arterioles were observed in PRP groups. Thrombin when used alone increased flap necrosis. Vascular endothelial growth factor, platelet-derived growth factor, and transforming growth factor ß3 primary antibody staining showed increased neovascularization and reepithelialization in all PRP-applied flaps. This study demonstrated that PRP, when applied intraoperatively under the skin flap, may enhance flap survival. Thrombin used alone was found to be unsuitable in flap surgery.

Effect of preoperative subcutaneous platelet-rich plasma and fibrin glue application on skin flap survival.

BACKGROUND: The aim of this study was to compare the effects of preoperative subcutaneous platelet-rich plasma and fibrin glue administration on skin flap survival. METHODS: One week before surgery; saline, platelet-rich plasma, fibrin glue, and thrombin solutions were applied under rat skin flap areas in Groups I, II, III, and IV, respectively. Unipedicled epigastric flaps were elevated in the first three groups but could not be elevated in Group IV because of preoperative abdominal skin necrosis. Necrotic area measurements, microangiography, and histological and immunohistochemical evaluations were performed. RESULTS: Platelet-rich plasma reduced the percentage of necrotic area when compared to other groups. Histologically and microangiographically an increased number of arterioles were observed in the platelet-rich plasma group. Thrombin (when used alone) caused abdominal skin necrosis. Increased expression of VEGF and PDGF was found in all platelet-rich plasma-treated flaps. There was no significant difference between groups with respect to TGF-ß3 staining intensity. CONCLUSION: In this study preoperative administration of platelet-rich plasma mimicked the pharmacological delay effect and enhanced flap survival. Individual use of thrombin was found to be unsuitable in flap surgery. LEVEL OF EVIDENCE I: This journal requires that authors assign a level of evidence to each article.

A simple surgical technique for correction of macrotia with poorly defined helical fold.

Macrotia is a relatively rare auricular deformity and few techniques for treatment have been described, most of which include skin and cartilage excisions. Effacement of the helical fold may accompany this deformity and should be reconstructed for aesthetic integrity. The authors present their ear reduction technique that achieves ear reduction and helical fold reconstruction through a posterior approach. The method is a simple procedure performed by incising and overlapping the cartilage and should be indicated for selected mild macrotia cases.

Sliding alar cartilage (SAC) flap: a new technique for nasal tip surgery.

Congenital anatomic deformities or acquired weakness of the lateral crura of the lower lateral cartilages after rhinoplasty could cause alar rim deformities. As lower lateral cartilages are the structural cornerstone of the ala and tip support, deformities and weakness of the alar cartilages might lead to both functional and esthetic problems. In this article, we are introducing sliding alar cartilage flap as a new technique to reshape and support nasal tip. One hundred sixty consecutive patients between 18 and 55 years of age (mean age: 27.51) were included in the study between January 2007 and May 2008. Of the total number of patients 60 were male and 100 of them were female. None of the patients had rhinoplasty procedure including lower lateral cartilage excision previously. Sliding alar cartilage technique was used in an open rhinoplasty approach to shape the nasal tip in all patients. This technique necessitates about 2 to 3 minutes for suturing and undermining the alar cartilages. The follow-up period was between 4 and 18 months. In no patients any revision related to the sliding alar cartilage technique was required. Revision was applied in 3 patients due to thick nasal tip skin and in one patient due to unpleasant columellar scar. In this article, we are presenting the "sliding alar cartilage flap" as a new technique for creating natural looking nasal tip. This technique shapes and supports nasal tip by spontaneous sliding of the cephalic portion of the lower lateral cartilage beneath the caudal alar cartilage, with minimal manipulation, without any cartilage resection, or cartilage grafting.

Effect of platelet-rich plasma and fibrin glue on healing of critical-size calvarial bone defects.

Despite the insufficient number of experimental studies, platelet-rich plasma (PRP) including high amounts of growth factors is introduced to clinical use rapidly. The aim of this study was to compare the effects of PRP and platelet-poor plasma (PPP) on healing of critical-size bone defects.Bilateral full-thickness, critical-size bone defects were created in the parietal bones of 32 rabbits, which had been studied in 4 groups. Saline, thrombin solution, PPP, and PRP were applied to the created defects before closure. Radiologic defect area measurement results at 0, 4, and 16 weeks were compared between the groups. In addition, densities of the newly formed bones at 16th week were studied. Histologic parameters (primary and secondary bone trabecula, neovascularization, and bone marrow and connective tissue formation) were compared between 4- and 16-week groups.More rapid decrease in defect size was observed in groups 3 and 4 than in groups 1 and 2, both in the 4th and 16th weeks. Newly formed bone densities were also found to be higher in these 2 groups. New bone formation was detected to be more rapid considering histologic parameters, in groups 3 and 4 at 4th and 16th weeks.Study demonstrates that PRP and PPP might have favorable effects on bone healing. Although we cannot reveal any statistical difference between these 2 substances considering osteoinductive potential, PRP group has demonstrated superior results compared with fibrin glue group. Higher platelet concentrations may expose beneficial effects of PRP.

Upper lateral cartilage fold-in flap: a combined spreader and/or splay graft effect without cartilage grafts.

Dorsal hump reduction almost always breaks the internal nasal valve and nasal obstruction is likely to occur postoperatively, unless reconstructed. One hundred eighty patients were operated using both open and closed rhinoplasty approaches. Upper lateral cartilages were meticulously separated from their junction with septum. Following bony and septal cartilaginous hump removal, upper lateral cartilages were folded inward. Either transcartilaginous horizontal mattress/simple sutures or perichondrial sutures were used depending of the desired width of the middle vault and the necessity for a splay-graft effect. In 7 patients unilateral, and in 1 patient bilateral, nasal synechia occurred and they were all treated under local anesthesia. All patients but 9 stated significantly improved nasal breathing. There was no inverted-V deformity or middle-vault narrowing observed. This technique is simple and physiologic, might be applicable for almost all primary rhinoplasty patients. Although it is possible with closed rhinoplasty approaches, it is easier with an open approach.

Motor neurotization by segmental epineurectomy and implantation: lateral muscular neurotization.

In this study, we aimed to develop a new muscular neurotization technique, in which transection of the donor nerve is avoided. We investigated the outcome of insertion of the donor nerve within the denervated muscle following segmentary epineurectomy (lateral muscular neurotization). Thirty-five male Wistar rats were evaluated in five groups, including sham control, denervation control, denervation combined with segmentary epineurectomy, direct muscular neurotization, and lateral muscular neurotization. Electromyography, muscle weight measurements, and histological evaluations were performed at postoperative months 2 and 3. The denervation group was statistically successful for denervation as compared with the sham control group for all parameters. The lateral neurotization group was successful in preventing muscle atrophy and gaining reinnervation in electromyographic, histological, and weight parameters. The direct neurotization group was also successful in histological and weight parameters. Lateral muscular neurotization is promising because it does not interrupt the fascicular integrity and is successful in reinnervation; therefore, it seems to be a good alternative for direct muscular neurotization.

Effect of platelet-rich plasma on peripheral nerve regeneration.

Activated platelets release various growth factors, some of which are recognized to improve nerve regeneration. This study evaluated the effect of platelet-rich plasma (PRP) in end-to-end neurorrhaphy. A total of 45 Wistar rats were used, with the initial five used for PRP preparation. The right hind limbs were used as experimental, with the left as control. The animals were treated in five groups. Group A (n = 4): The right sciatic nerve was dissected only from the sciatic notch to the bifurcation. In all other groups, the nerve was sharply transected and repaired with: group B (n = 8): two sutures; group C (n = 8): six sutures; group D (n = 10): two sutures and PRP; and group E (n = 10): six sutures and PRP. Groups D and E were compared with groups B and C, respectively. Group E had a shorter latency time in electromyography ( P < 0.01) and a thicker myelin layer in the histological evaluation ( P < 0.003) in comparison with group C. These positive effects of PRP were not detected in the nerves were repaired with two sutures. In this animal model, the application of PRP to the repair site helped to improve remyelinization of the sciatic nerve in rats when the epineural repair was done with six sutures.

Impact of gradual blood flow increase on ischaemia-reperfusion injury in the rat cremaster microcirculation model.

INTRODUCTION: We aimed to evaluate the impact of gradual blood reperfusion on ischaemia-reperfusion injury and to explain the pathophysiology of reperfusion injury in a rat cremaster muscle microcirculation model. MATERIALS AND METHODS: Twenty-four Sprague-Dawley rats weighing 150-200 g were evaluated in three groups. Cremaster muscles were prepared for microcirculatory observations. Group I (n=8, control): no ischemia was induced. Group II (n=8, acute reperfusion): microclamps were applied to the right external iliac vessels for 150 min, then venous and arterial clamps were released at once. Group III (n=8, gradual reperfusion): microclamps were applied to the right external iliac vessels for 150 min, and then the first venous clamp was released; the arterial clamp was opened gradually by a specially designed microclamp holder (Sheey ossicle holding clamp). In all groups, following a wait of 150 min blood flow velocity was measured for 15 min and then the animals were reperfused freely for 1h. Next, red blood cell velocity, vessel diameters, functional capillary perfusion and endothelial oedema index were analysed, and rolling, migrating and adhesing leukocytes and lymphocytes were counted. All observations were videotaped for slow-motion replay. Muscle damage was evaluated histologically. RESULTS: In the acute clamp release group, blood velocities increased up to 600% of their pre-ischaemic values during the post-ischaemia-reperfusion period. The numbers of rolling, adhering and transmigrating leukocytes were significantly higher and histological evaluation revealed more tissue damage in the acute reperfusion group. CONCLUSION: Depending on histological and microcirculatory findings, gradual reperfusion was confirmed to reduce the intensity of reperfusion injury.

Reconstruction of traumatic orbital floor fractures with resorbable mesh plate.

Various materials such as autogenous bone, cartilage and alloplastic implants have been used to reconstruct orbital floor fractures. A new material is needed because of disadvantages of nonresorbable alloplastic materials and difficulties in harvesting autogenous tissues. In this study safety and value of the use of resorbable mesh plate in the treatment of orbital floor fractures are discussed. Between 2002 and 2004 a total of 17 maxillofacial trauma patients complicated with orbital floor fractures were treated with resorbable mesh plate through subciliary or transconjunctival incisions. Pure blow-out fractures were determined in 6 patients and 11 patients had accompanying maxillofacial fractures. Resorbable plate was easily shaped to fit to the orbital floor by cutting with scissors. Patients were evaluated clinically and with computed tomography scans preoperatively and at 3-, 6- and 12-month intervals postoperatively. Twelve patients had preoperative enophthalmos. Two patients had diplopia that was corrected postoperatively. In all 17 cases there was no evidence of infection, diplopia and gaze restriction postoperatively. Scleral show appeared in three patients by the second postoperative week but resolved totally within 3 to 6 weeks except one patient. In this patient anterior displacement of mesh was evident which caused ectropion and enophthalmos and required re-operation. No any other mesh related problems were seen at 15 months mean follow-up time. The advantage of the resorbable mesh system in orbital floor fracture is the maintenance of orbital contents against herniation forces during the initial phase of healing and then complete resorption through natural processes after its support is no longer needed. Our experience represents that resorbable mesh is a safe and effective material for reconstruction of the selected, non-extensive orbital floor fractures.

Scar tissue graft as a filler for soft tissue augmentation.

Soft tissue augmentation with autogenous tissue has been used to correct various defects during aesthetic facial contouring and reconstructive procedures. Although dermal grafts have longer survival rates, fat grafts always have been more popular because of the simple harvesting and grafting methods used. The authors aimed to use existing scar tissue as an injectable graft and to compare its effectiveness as a soft tissue filler substance with that of dermal grafts. In this study, scar tissue was created on 24 male Wistar rats. The created scar and normal healthy skin were removed from the rat dorsal scapular donor site. After depithelialization, the harvested tissues were minced until they were thin enough to pass through a 16-gauge needle. The grafts then were injected into the recipient site between the abdominal muscles. Volumetric analyses and histologic evaluation of the grafts were performed 1, 3, and 5 months after transplantation. The first month after the injection, the amount of remaining dermis graft was more than the scar graft, and this difference was statistically significant. However, at the end of months 3 and 5, there was no marked difference between the groups. The remaining volume of injected scar tissue graft was comparable with that of the dermis graft. The scar grafts were composed mainly of dense connective tissue during all the evaluation periods. In this study, scar tissue provided results comparable with those of dermal grafts up to 5 months when used as a soft tissue filler. It seems that neovascularization of the scar graft may be inadequate for maintenance of graft viability, as compared with dermis grafts. On the other hand, the scar graft formed fibrous tissue, which may be responsible for providing adequate volume as a filler. This may have clinical implications for the patient who needs both scar revision and soft tissue augmentation procedures simultaneously.

Selective percutaneous desiccation of the perforators with radiofrequency for strategic transfer of angiosomes in a sequential four-territory cutaneous island flap model.

BACKGROUND: Research in prevention of partial flap necrosis has recently concentrated on extending the safe length of a flap by ligating vessels of known territories. To advance this approach one step further, the authors decided to reveal the least invasive surgical strategy for transfer of angiosomes. METHODS: The study was arranged into three experiments. In the first experiment (n = 17 rabbits), a cutaneous island flap model spanning four adjacent vascular territories was developed. In the second experiment (n = 15 rabbits), the flap model was used to test the possibility of desiccating those vessels supplying the angiosomes to be captured percutaneously with radiofrequency. The delay procedures were performed by means of minimal skin incisions, and the flaps were elevated after a 2-week delay period. In the third experiment, the effectiveness of selective interference of these pedicles was compared to minimize the number of target vessels for successful transfer of angiosomes. RESULTS: The mean surviving area of the new flap model was 63 +/- 2 percent. The mean surviving flap area was 97 +/- 3 percent for the endoscopy equivalent technique and 94 +/- 4 percent for radiofrequency delay. The results were statistically insignificant between these two groups. In experiment 3, comparison of the results yielded a statistically insignificant difference for flap survival area among all four of the groups. CONCLUSIONS: An alternative flap model is introduced for future investigation of the vascular delay process. Percutaneous desiccation of the perforators with radiofrequency was found to be a reliable method, and selective desiccation of the perforator(s) was as efficient as destruction of all vascular sources other than the pedicle.

Fixation of the split calvarial graft in nasal reconstruction.

Reconstruction of nasal contour where skeletal support is deficient or absent has usually been achieved using autogenous bone. Membranous bone taken from the cranium is clearly superior to rib or iliac crest when used as autografting material to the craniofacial skeleton. Conventionally, the bone graft is rigidly fixated to the recipient nasal bone with either metal plate-screw systems or Kirschner wires. Reported here are the results of a single biodegradable screw fixation of the split calvarial graft that is used for nasal reconstruction. Ten patients with moderate to severe saddle nose deformity underwent reconstruction using the open rhinoplasty approach. The graft was harvested from the outer cortex of the parietal bone, shaped, and secured in place with a single bioresorbable screw. No significant resorption has been observed in the grafts and a favorable aesthetic result was achieved in all of the cases. Described modification in fixation of the bone graft in nasal reconstruction avoids some of the disadvantages of permanent materials while preserving the advantages of rigid fixation.