Comparison of the effects of PRP and hyaluronic acid in promoting peripheral nerve regeneration An experimental study with vascular conduit model in rats'.

AIM: Peripheral nerve defects generally occur due to mechanical, chemical, thermal and pathologic causes and the reconstruction is still a challenging problem. In the present study, we aimed to compare the effects of platelet rich plasma (PRP) that has high levels of growth factors and hyaluronic acid (HA) that is known to have positive effects on nerve regeneration by decreasing scar formation in a rat model where they were injected through allogeneic aorta graft in peripheral nerve defects using histopathologic and functional methods. MATERIAL AND METHODS: The study involved 20 Wistar Albino male rats that weighed 200 to 250 grams and aged about 1 year old. Of the rats, two were used as donor for PRP and aorta graft harvest. Three random groups of 6 rats were composed. In all of the groups, the left sciatic nerves were used and 1 cm of defects were created. The right sciatic nerves were used as control groups. Group 1 was the group repaired with autograft, Group 2 was the group repaired with HA injected through aorta graft and Group 3 was the group repaired with PRP injected through aorta graft. The findings were evaluated in terms of functional (electromyography and walk test analysis) and histopathologic parameters at 12 weeks. RESULTS: In all of the groups varying degrees of axonal regeneration was observed. Group 1 was the closest group to the control group showing highest rate of nerve regeneration followed by Group 3 where PRP was injected through aorta graft and group 2 where ha was used respectively. CONCLUSION: The study demonstrates that PRP enhances peripheral nerve regeneration more than HA when used in a vascular conduit model. KEY WORDS: Hyaluronic acid, Peripheral nerve regeneration, PRP.

The effect of addition of ketamine to lidocaine on postoperative pain in rhinoplasties.

BACKGROUND/AIM: The objective of this study was to examine the effect of addition of subanesthetic doses of ketamine to an epinephrine-lidocaine solution on postoperative pain, analgesic use, and patient comfort during rhinoplasties. MATERIALS AND METHODS: Ninety patients were randomly divided into three groups: Group L, lidocaine with epinephrine; Group K, lidocaine with epinephrine plus ketamine; and Group S (control group), physiological saline solution with epinephrine. The local anesthetic solution was injected as preincisionally with intranasal submucosal infiltration following induction of general anesthesia. We evaluated visual pain score, analgesic demand, Wilson sedation score, and antiemetic demand at 5, 15, and 30 min and 1, 2, 4, 6, 8, 16, and 24 h after the operation. The patient satisfaction score was checked 24 h after the operation. RESULTS: Visual pain score was significantly reduced in Group K in comparison with the other groups and this group did not need any rescue analgesics (P < 0.05). The postoperative patient satisfaction scores were highest in Group K compared with the other groups (P < 0.05). CONCLUSION: Addition of ketamine solution to lidocaine for infiltration block during rhinoplasty was successful in decreasing pain during postoperative periods and reducing analgesic consumption during the first 24 h after the operation.

Management of Composite Tissue Defect of the Midfoot With a Free Anterolateral Thigh Flap and Iliac Bone Graft: A Case Report.

Composite tissue defects of the midfoot with extensive bone and soft tissue loss represent a unique challenge because they can lead to primary amputation if not reconstructed. One should repair both the bone structure and the soft tissue to obtain satisfactory foot function for basic daily activities. In the present study, we report on a case in which we successfully reconstructed an extensive midfoot defect with iliac bone grafts for metatarsal reconstruction and an anterolateral thigh flap for soft tissue coverage. This technique is a safe, reliable, and functional method, offering single-stage reconstruction compared with other microsurgical techniques used for such defects.

Surgical management of immature teratoma involving the oral cavity and orbit in a neonate.

Teratomas are congenital germ cell tumors composed of elements from 1 or more of the embryonic germ layers and contain tissues usually foreign to the anatomic site of origin. In the head and neck region, these lesions are rare, and 90% of head and neck teratomas present during the neonatal and infantile periods. Besides, in neonates, it carries serious risk for respiratory distress as well as feeding problems due to oral cavity and airway obstruction.Here, an unusual case of intraoral teratoma involving the orbit in a newborn who underwent immediate surgical excision successfully is described.

Prelaminated calvarial osteofascial flap for palatal reconstruction.

Reconstruction of the hard palate defects is among the most challenging problems for plastic surgeons. Prosthetic obturations and local flaps for small defects have been used, whereas numerous regional and free flaps have been described for larger defects. The search for the ideal method offering a natural palatal structure is still ongoing. Five male patients with a mean age of 30.4 years experiencing hard palate defects due to congenital cleft palate or tumor excisions were repaired by prelaminated calvarial osteofascial flap. The mean defect size was 3.14 × 2.48 cm. Both of the surfaces of the calvarial bone elevated with superficial temporal fascia were wrapped with fascia and covered with split-thickness skin graft. The interval between the 2 sessions ranged from 3 to 6 weeks. In the second session, triple layered reconstruction involving the bony layer as well as the oral and nasal mucosa was performed. In 1 case, partial skin loss on the oral surface of the flap was seen in the second session but epithelialized spontaneously. The mean follow-up period was 21.8 months, and no complication such as wound detachment, infection, flap loss, as well as fistula or nasal regurgitation was encountered. A hard palatal reconstruction was performed, offering a natural anatomy in terms of structure and shape. This reliable technique, which is convenient for the three-dimensional reconstruction of the hard palate defects offering a near-normal anatomy owing to its triple layered structure, thickness, and the compatible shape of the calvarial bone to the palate, can be a good alternative against other regional and free flaps.

Comparison of nerve, vessel, and cartilage grafts in promoting peripheral nerve regeneration.

Peripheral nerve injury primarily occurs due to trauma as well as factors such as tumors, inflammatory diseases, congenital deformities, infections, and surgical interventions. The surgical procedure to be performed as treatment depends on the etiology, type of injury, and the anatomic region. The goal of treatment is to minimize loss of function due to motor and sensory nerve loss at the distal part of the injury. Regardless of the cause of the injury, the abnormal nerve regeneration due to incomplete nerve regeneration, optimal treatment of peripheral nerve injuries should provide adequate coaptation of proximal and distal sides without tension, preserving the neurotrophic factors within the repair line. The gold standard for the treatment of nerve defects is the autograft; however, due to denervation of the donor site, scarring, and neuroma formation, many studies have aimed to develop simpler methods, better functional results, and less morbidity. In this study, a defect 1 cm in length was created on the sciatic nerve of rats. The rats were treated with the following procedures: group 1, autograft; group 2, allogeneic aorta graft; group 3, diced cartilage graft in allogeneic aorta graft; and group 4, tubularized cartilage graft in allogeneic aorta graft. Group 5 was the control group. The effects of cartilage tissue in nerve regeneration were evaluated by functional and histomorphological methods.Group 1, for which the repair was performed with an autograft, was evaluated to be the most similar to the control group. There was not a statistically significant difference in myelination and Schwann cell rates between group 2, in which an allogeneic aorta graft was used, and group 3, in which diced cartilage in an allogeneic aorta graft was used. In group 4, myelination and Schwann cell formation were observed; however, they were scattered and irregular, likely due to increased fibrosis.In all of the groups, nerve regeneration at various rates was observed both functionally and histomorphologically. This study demonstrates that cartilage tissue has promoting effects in nerve regeneration.

A novel flap for the reconstruction of midcheek defects: "rabbit ear flap".

Cheek defects generally occur because of reasons such as trauma, burn, and tumor excisions. In the reconstruction of cheek defects, it is essential to cover the defects using the tissues with compatible color and similar texture. Although many techniques have been described for this purpose, local flaps are more likely to be used.In this study, we describe a new technique named "rabbit ear flap," which we used for the reconstruction of a 4.5 × 7-cm cheek defect due to basal cell carcinoma excision in a 71-year-old male patient. Two separate flaps on the extension of right facial artery with an inferior pedicle on the nasolabial region (hairless skin) and a superior pedicle flap that extended from right oral commissure to the submandibular region (hairy skin) were used. The hairy skin part of the defect was closed via the hairy skin flap, whereas the hairless region was closed with the hairless skin flap. The donor sites were closed primarily.No complication was encountered in the early or long-term follow-ups. In the 28-month follow-up of the patient, it was observed that the color and texture compatibility was fine, the natural beard integrity was obtained, the donor site scarring was minimal, and the scarring was camouflaged well in the anatomical lines.This technique is supposed to be an alternative method for reconstruction of medium-sized cheek defects because it is a simple, reliable, and single-session procedure, and because of its similar color and texture, it offers satisfactory aesthetic and functional outcomes due to natural beard restoration.

Correction of true hanging columella using medial crural tuck-up technique.

BACKGROUND: The nasal tip and columella are the two main key components that affect the results of a successful and aesthetically satisfactory rhinoplasty. A true hanging columella is a deformity in which the caudal border of the columella has a downward bowing appearance due to disproportion between the ala nasi and the columella, which is usually congenital. In the management of this challenging deformity, a thorough understanding and consideration of tip dynamics and the anatomical causes address the proper technique to be used. In this study we present our clinical experience with the medial crural tuck-up technique used on 53 consecutive patients with a true hanging columella. METHODS: A total of 1,421 patients underwent rhinoplasty between January 2005 and September 2011; 53 of those patients (age range=20-37 years; mean=27.3 years), who underwent this technique, were involved in the study. Thirty-eight patients were followed up for more than 1 year. RESULTS: The results were evaluated by comparing postoperative photos with preoperative photographic documentation. The appearance of the nasal tip and columella remained fine and stable over the 1 year of follow-up. CONCLUSION: Despite its limitation of applicability in secondary cases, the advantages of this technique are that it does not require conchal or costal cartilage and the desired tip rotation and projection can be done with ease. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Double-skin paddled superficial temporofascial flap for the reconstruction of full-thickness cheek defect.

The most common causes of cheek defects include trauma, burn, and tumor resections. In the reconstruction of the defects in this region, it is essential to use similar or adjacent tissue considering the aesthetic and functional properties. For this purpose, numerous local, regional, or distant free flaps were described. The local flaps harvested from the head and neck region are the most frequent methods because of the similar skin color, texture, and compatibility with cheek.In this study, the reconstruction in a 29-year-old male patient who had a full-thickness cheek defect due to tumor resection on the left side was performed, wherein a hairless skin island was carried through the frontal branch of superficial temporal artery for oral mucosa, and a hairy skin island through the parietal branch of the same pedicle was carried for the bearded skin defect. No complication occurred postoperatively and both aesthetic and functional satisfactory results were obtained, providing the oral mucosal and natural beard integrity. Donor-site scarring and temporal alopecia were recorded as the disadvantages of this method.This technique is a useful method for the reconstruction of full-thickness cheek defects because of its advantages including compatibility of color and texture, reliable blood supply, requiring single-session procedure, and being able to carry 2 different skin islands on the same pedicle.

ß-Glucan treatment prevents progressive burn ischaemia in the zone of stasis and improves burn healing: an experimental study in rats.

Saving the zone of stasis is one of the major goals of burn specialists. Increasing the tissue tolerance to ischaemia and inhibiting inflammation have been proposed to enable salvage of this zone. After a burn, excessive inflammation, including increased vascular permeability, local tissue oedema and neutrophil activation, causes local tissue damage by triggering vascular thrombosis and blocking capillaries, resulting in tissue ischaemia and necrosis. Oxygen radicals also contribute to tissue damage after a burn. However, macrophages play a pivotal role in the response to burn. We studied ß-glucan because of its many positive systemic effects that are beneficial to burn healing, including immunomodulatory effects, antioxidant effects (free-radical scavenging activity) and effects associated with the reduction of the inflammatory response. There were four test groups in this study with eight rats in each group. Group 1 was the control group, group 2 was administered a local pomade (bacitracin+neomycin sulphate), group 3 received ß-glucan (50 mg kg(-1), orally) + the local pomade and group 4 received ß-glucan. Burns were created using a brass comb model. Macroscopic, histopathological and statistical assessments were performed. Samples were harvested on the 3rd, 7th and 21 days for analysis. The neutrophilic infiltration into the zone of stasis was analysed on day 3. Macrophage infiltration, fibroblast proliferation, angiogenesis and re-epithelialisation ratios in the zone of stasis were analysed on days 7 and 21. The ß-glucan groups (groups 3 and 4) exhibited lower neutrophil counts on the 3rd day, and macrophage infiltration, fibroblast proliferation, angiogenesis and re-epithelialisation were very high in these groups on the 7th day. In particular, re-epithelialisation on the 21st day was significantly better in the ß-glucan groups. This study demonstrated that ß-glucan may prevent neutrophil-dependent tissue damage and burn-induced oxidative injury through its anti-inflammatory and antioxidant properties. We speculate that the inhibition of neutrophil activation preserves vascular patency by preventing capillary blockage. ß-Glucan is also a powerful macrophage stimulator, and is therefore very effective in saving the zone of stasis.

Management of extravasation injuries: a retrospective study.

The extravasation of many agents during administration by way of the peripheral veins can produce severe necrosis of the skin and subcutaneous tissue. The incidence of an extravasation injury is elevated in the populations prone to complications, including the younger age groups. The severity of the necrosis depends on properties of the extravasated agent (vinca alkaloids, antracyclines, catecholamines, cationic solutions, osmotically active chemicals) including the type, concentration, and the quantity injected. In general, the primary diseases were chronic diseases such as hepatic or ischaemic encephalopathies, cardiac or pulmonary diseases, diabetes mellitus, and oncological diseases. The aim of this article was to explore the prevention, diagnosis, and treatment of extravasation injuries with a review of the literature. From January 2009 to August 2011, 22 patients were reviewed. Ten patients were children, and the others were adults. The surgical interventions were delayed until the development of the necrosis. A topical boric acid 3% solution was applied to all wounds with repetitive debridement. Debridement was performed once every 2 days and was continued until healthy tissue was obtained. The wounds of eight patients were repaired with split-thickness skin grafts, the wounds of six patients were reconstructed with randomised fasciocutaneous flaps, and the wounds of five patients healed by secondary intention. The wounds of three patients with massive swelling of the forearms were treated with only conservative modalities and limb elevation for 24-48 hours. Boric acid was found to promote granulation tissue in the wounds. The extravasation injuries can be prevented by using appropriate measures, such as the avoidance of perfusion under pressure, patient participation in pain follow-up, wound management by experienced health professionals, and preference for large and suitable veins.

[Effectiveness of early fasciotomy in the management of snakebites]. / Erken fasyotominin yilan isiriklari tedavisindeki etkinligi.

BACKGROUND: The purpose of this study was to emphasize that early fasciotomy performed in the treatment of snakebites in the absence of the classic compartment syndrome criteria accelerates the clinical recovery and reduces the progressive tissue damage. METHODS: Fourteen patients with snakebite were examined retrospectively. Five of them healed with routine treatments. Six patients who did not respond to the treatment underwent early fasciotomy procedure in 48 hours. All of the patients had edema, pain, ecchymosis, bulla formation, and progressive skin necrosis over the extremity. Fasciotomy was performed in three patients who were referred in the late period with compartment syndrome. Fasciotomy incisions were closed after 4-6 days. RESULTS: After the early fasciotomy, edema diminished rapidly, the skin became more viable and local necrosis did not progress. Further, the toxic symptoms like local temperature increase and fever also diminished. The healing process in the three patients who underwent late fasciotomy was much slower compared with the early fasciotomy group. In particular, necrosis on the muscle and skin had deteriorated. CONCLUSION: Fasciotomy has a special place in snakebites. In cases of compartment syndrome, all necessary treatments including early fasciotomy should be performed before the full clinical symptoms develop or the compartment pressure reaches the threshold value.

An autoprosthesis technique for better breast projection in free nipple graft reduction mammaplasty.

BACKGROUND: Reduction mammaplasty for macromastia provides relief from uncomfortable symptoms and improves self-confidence and the ability to participate in sports activities. Reduction mammaplasty using the free nipple graft technique may result in bottoming-out deformity and a lack of upper-pole projection. We describe a modified breast reduction technique that combines the Graf and Thorek methods. METHODS: We operated on 26 patients with gigantomastia using this novel technique. Preoperative markings were planned according to the classic Thorek amputation technique using a Wise pattern. A 10-cm × 14-cm pyramidal inferior-based dermoglandular flap was prepared, passed under a transverse pectoral muscle loop, and then back-folded over the pectoral loop, thereby establishing an autoprosthesis to increase upper-pole fullness and prevent bottoming-out deformity. RESULTS: The average weight of the removed breast tissue was 1,634 g (range = 1,120-2,140 g) for the right breast and 1,630 g (range = 1,110-2,120 g) for the left breast. The average follow-up period was 22 months (range = 11-37 months). All samples were pathologically assessed. Minor complications included wound breakdown at the T-junction, fat necrosis, hypertrophic scarring, and partial necrosis of the nipple-areola complex (NAC). Loss of nipple projection and partial hypopigmentation of the NAC occurred in most patients. Mild glandular ptosis was observed in two patients, with no flattening or deflation, but no severe bottoming-out deformity was observed during long-term follow-up. CONCLUSIONS: All patients were happy with their new bra size, breast projection, and breast weight. Our combined autoprosthesis technique resulted in satisfactory long-term breast projection and upper-pole fullness. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Atypical presentation of skull metastasis from rectal adenocarcinoma as an initial symptom of recurrence.

Most malignant rectal tumors are histopathologically characterized as adenocarcinoma and generally metastasize to distant organs such as the lungs or the liver. Metastasis of rectal carcinomas to the skull is extremely rare. This study reports the initial diagnosis of rectal adenocarcinoma recurrence in a 65-year-old female with scalp metastasis. The patient's history indicated a colorectal adenocarcinoma that was resected five years earlier. A skull metastasis from a rectal adenocarcinoma has not yet been reported in the literature as an initial symptom for recurrence. This paper suggests that skull metastasis from any part of the body must be considered in the differential diagnosis of soft tissue tumors in the skull even in the absence of intestinal symptoms.

The influence of reduction mammaplasty on dermato-psychiatric disorders.

OBJECTIVE: Macromastia can cause psychiatric disorders, such as anxiety and depression, and decreases in self-esteem and self-confidence. These problems often externalize themselves on the skin, causing lesions characterized by various degrees of excoriations and lichenified plaques. Mammaplasty operations are very effective in the treatment of neurotic excoriations and similar skin lesions as well as any underlying psychiatric disorders. MATERIALS AND METHODS: This study included 17 patients with macromastia and neurotic excoriation lesions who underwent psychiatric treatment for various reasons. Follow ups were performed using routine photographs used in breast surgeries. RESULTS: During the postoperative follow ups, the excoriations for nearly every patient healed within 2 weeks. Some lesions healed with atrophic scars and some with permanent hyperpigmentation. Patients' physical complaints, such as backache, shoulder ache and submammary pruritic dermatitis, were also observed to heal. In addition, the patients stated that they felt better psychologically, and most also reported stopping psychiatric treatment. CONCLUSION: The psychological problems caused by macromastia include neurotic excoriation and similar skin problems, and aesthetic reduction mammaplasty surgeries are very effective in the treatment of these lesions. Body image perception comprises an important part of self-respect and self-esteem, and psychological-status cosmetic surgery can be evaluated as an alternative to psychological treatment.