The Effect of Udenafil on Stasis Zone in an Experimental Burn Model.

BACKGROUND: Management of the burn injuries is still a problematic issue because the stasis zone may become necrotic. We hypothesized that udenafil, a potent phospodiesterase inhibitor, can be beneficial in burn treatment by enhancing the viability of the stasis zone. METHODS: Fifteen Wistar rats were randomly divided into 3 groups. Comb burn injury model was conducted bilaterally on the back of rats in each subject. Group 1 received 1 mL/d of saline orally for 7 days. Group 2 received 10 mg/kg per day of udenafil for 7 days. Group 3 received 20 mg/kg per day of udenafil for 7 days. At the end of seventh day, gross morphological and histopathological samples of stasis zone survival were evaluated. RESULTS: Histopathological examination of groups 2 and 3 revealed that the stasis zone was mostly viable. The mean necrotic area and severity of inflammation was significantly higher in the control group compared with the treatment groups. Significant differences were determined in treatment groups compared with control group in terms of vital stasis zone area and histopathological parameters. CONCLUSIONS: Udenafil treatment improved tissue survival on zone of stasis in. Future experimental studies should be conducted to develop zone of stasis treatment protocols combining udenafil with potent anti-inflammatory and antioxidant drugs.

Platelet-rich fibrin: An effective chronic wound healing accelerator.

BACKGROUND: Platelets are cells that play a central role in wound healing, and they are the main source of the growth factor complex that plays the main role in natural wound healing. It is aimed to present the beneficial effects of topical application of PRF on chronic ulcers that do not respond to standard wound care in cases of chronic ulcers that require a long treatment process and high costs. MATERIALS AND METHODS: The study included 16 patients between the dates of January 2017 and September 2019. The study was approved by the local ethics board and planned retrospectively. RESULTS: The mean number of PRF applications in the patients was 4.37 (range: 1-8), while the wounds of 10 patients were completely closed up to the mean number of applications, and at least 50% of the wounds of 4 patients were closed up to the mean number of applications. DISCUSSION: Choukroun's platelet-rich fibrin may be considered as a 2nd-generation platelet concentration. Its preparation protocol is reported to be highly simple and low-cost. CONCLUSION: PRF is a safe, practical, easy to use adjuvant treatment method which has a potential for closing chronic wounds.

Inferior and Central Mound Pedicle Breast Reduction in Gigantomastia: A Safe Alternative?

BACKGROUND: Gigantomastia has been described as excessive hypertrophy of the female breast, however, there is controversy about the weight of the excised tissue. In the literature, resected tissue amount between 1,000 g and 2,000 g per breast is reported as gigantomastia. Aims: The aim of this study is to evaluate the results of the patients who underwent reduction mammaplasty with a resection amount of at least 1,000 g or above via inferior pyramidal pedicle breast reduction technique retrospectively. Patients and methods: Between September 2015 and September 2018, 72 patients operated for gigantomastia were included in the study. All patients underwent reduction mammaplasty by inferior pyramidal pedicle and inverted Tscar technique. The pedicle base was not detached from the posterior region of the pectoralis fascia. Patient demographics, advantages, drawbacks and results of this technique were analyzed. All procedures were performed at a single institution by the senior author of this article. Results: The most common complication was hypertrophic scar (4.16%). At least 1-year follow-up revealed satisfactory results in terms of both esthetic and functional aspects. The average satisfaction rate was 88% (score: 4.38 = satisfied/very satisfied). Conclusion: Inferior pyramidal pedicle technique is a versatile reduction mammaplasty technique that can be applied in various breast sizes. It provides important advantages of preserving the nipple sensation and lactation potential with low complication rates.

Four Quadrant-Embedded Purse-String Closure for Defects of Benign Skin Tumors Post Circular Excision.

OBJECTIVE: Skin wounds after elliptical removal of benign tumors, are conventially sutured linearly for closure and often result in longer and undesirable scars. We aimed to evaluate the efficiency of four quadrant embedded intradermal purse-string suture closure technique for round defects in order to obtain satisfactory cosmetic outcomes and limited scar. MATERIALS AND METHODS: We analysed the features of 143 patients for whom a total of 208 four quadrant embedded purse string sutures were used to completely close their postoperative surgical defects. The location and histopathological types of the tumors removed were noted. Tumors were located in the cervicofacial region, thoracic region, back, lower and upper extremities. The patient and observer scar assessment scale (POSAS) questionairre was utilized to evaluate objective results of the ultimate scar. RESULTS: The defects of the lesions after excision were closed using intradermal four quadrant buried purse-string suture. The wounds showed good final healing without obvious adverse events postoperatively. Infection occurred only in three patients. The final cosmetic appearance of the healed wounds was satisfying as POSAS scores were 17.74 for patient scar assesment scale (PSAS) and 15.3 for observer scar assessment scale (OSAS). CONCLUSION: Four quadrant embedded purse string technique is a simple and useful method to close skin defects after circular resection of lesions. It provides minimal scarring and remarkable patient satisfaction.

Effects of dabigatran and fondaparinux on degloving injuries: An experimental study.

BACKGROUND: Management of the skin degloving injuries is still a problematic issue, and the avulsed part of the skin may become necrotic. We hypothesized that the anticoagulant pharmacological agents, fondaparinux and dabigatran may be beneficial in the treatment of degloving injuries by enhancing the viability of the reattached flap. METHODS: Twenty four Wistar rats were divided into three groups as follows: control group (Group 1), fondaparinux group (Group 2) and dabigatran group (Group 3). A model of a degloving injury on the tail of rats was developed in all groups. After 15 minutes, the avulsed flaps were sutured back. Group 1 received 1ml/day saline intraperitoneally for 10 days. Group 2 received 0.3 ml/kg/day fondaparinux intraperitoneally for 10 days. Group 3 received 30 mg/kg/day dabigatran orally for 10 days. At the end of the treatments, gross morphological and histopathological tail tissue survivals were evaluated. RESULTS: Histopathological examination of the fondaparinux and dabigatran groups revealed that the tail skin was mostly viable with mild inflammation. The mean necrotic length in tails and severity of inflammation was significantly higher in the control group compared to the fondaparinux and dabigatran groups (p<0.05). No statistically significant differences were noted between the fondaparinux and dabigatran groups in histopathologic evaluations. There was no significant difference in necrosis lengths and the other histopathological parameters between dabigatran and fondaparinux groups. CONCLUSION: Dabigatran and fondaparinux improved tissue survival in skin degloving injuries concerning gross morphological and histopathological findings. However, the findings of this study should be supported and improved by new experimental and especially clinical studies.

Preoperative estimation of breast resection weight in patients undergoing inferior pedicle reduction mammoplasty: the Bilgen formula

Background/aim: Symptomatic breast hypertrophy has a significant impact on the quality of life of women. The amount of tissue to be excised may be preoperatively estimated by an experienced surgeon. However, this remains a subjective assessment. Accurate quantification of the amount of breast tissue to be resected in the preoperative period will be a guide for both patient information and the surgeon during the operation. The aim of this study is to develop a new method based on simple measurements that can accurately estimate the resection weight in the preoperative period in a wide range of patients undergoing reduction mammoplasty. Materials and methods: The study was carried out between December 2016 and September 2018. With the determined drawing and measurement methods, a triangle was obtained by measuring the distances among the sternal notch (A) - right nipple areola midpoint (B), sternal notch (A) - left nipple areola midpoint (C) and both internipple areola (B-C). The height of this triangle (h) was found by measuring the distance between the sternal notch and the midpoint of both nipple areola levels. The amount of breast tissue to be resected for each breast was calculated by multiplying the distance between the sternal notch­nipple areola and the height of the large triangle. The formula may be expressed as AB × h for the right breast and AC × h for left breast. Results: When the t values and significance levels of the beta coefficients of the independent variables were examined, the preoperative values were determined to be in accordance with the actual values after surgery (P < 0.05). The values calculated before were calculated as the percentage of the actual values (91%). In other words, the R2 value showed that the calculated values were compatible with the actual values (R2 = 0.910). Conclusions: With the formula described herein, one may accurately estimate the amount of tissue to be resected in a wide range of patients undergoing reduction mammoplasty whose sternal notch­nipple distances are between 28­42 cm. Additionally, because measurements for each breast are performed separately, breast asymmetry does not affect the results. In conclusion, the formula we devised is simple, applicable, and has a high accuracy rate.

Disastrous Complications Following Rhinoplasty: Soft Tissue Defects.

BACKGROUND: Rhinoplasty has become one of the most frequently performed worldwide aesthetic procedures thanks to the successful results obtained by plastic surgeons. In this study, soft tissue defects, encountered as an undesirable and fearsome complication following rhinoplasty, its causes and precautions are presented by authors. MATERIALS AND METHODS: Eight patients operated between December 2015 and December 2018 were enrolled in this study. According to the causes of soft tissue defects observed following rhinoplasty; patients were examined in 5 groups consisting of excessive subcutaneous adipose tissue defatting, improper dissection plane, compression of cast, splint and strip materials, pressure applied to skin by cartilage grafts, and overresection. RESULTS: Herein, while subcutaneous excessive defatting and intense cigarette smoking was responsible of the necrosis in the first patient we defined, high pressure on skin due to tight bandaging or external splint materials lead to skin necrosis in our patients 2, 3, and 4. The 5th and 6th patients were candidates of a revision rhinoplasty; however, both resulted with necrosis probably by reason of inaccurate dissection and/or possible diminished vascularity by previous rhinoplasty operations. In the 8th patient, necrosis was observed due to the compression of the bulky autologous cartilage graft used in the skin. CONCLUSION: In conclusion, skin necrosis is a rare but bothersome complication of rhinoplasty. The importance of atraumatic techniques and appropriate dissection plane during the rhinoplasty operation as well as the importance of the effect and control of the postoperative applied splint and bandage materials is so obviously seen.

Our Treatment Approach in Pediatric Maxillofacial Traumas.

BACKGROUND: Maxillofacial injuries in children are rarer in proportion in comparison to adult facial injuries, and they constitute 1% to 15% of all facial bone fractures. The causes and incidence of maxillofacial injuries in children differ based on social, cultural, and environmental factors. AIM: The purpose of this study is to investigate the etiology, epidemiology, and type of injury in pediatric facial injuries, as well as analyzing types of fractures, related injuries, and treatment options. MATERIALS AND METHODS: The study obtained the approval of the local ethics board to include 55 pediatric patients in the age group of 0 to 18 years who received inpatient treatment or surgical interventions owing to maxillofacial trauma at an Esthetic, Plastic and Reconstructive Surgery Clinic between January 2016 and December 2018. The patients were examined under 5 groups based on their causes of injury: motorized vehicle accidents (MVA); bicycle; falls (from height or ground level); assault; firearm injuries. They were examined under 6 groups based on the location of their fractures: mandibula, maxilla, orbita, frontal bone, zygomatic arch, nasal bone. RESULTS: The study included 55 patients of the ages 0 to 18 with the mean age of 11.6 ±â€Š3.2 years. Thirty-seven of the patients (67.2%) were male, whereas 18 (32.7%) were female. Among the causes of injury, the highest number of patients was 25 (45.4%) with MVA. The most frequent location of the fractures was the mandible. CONCLUSIONS: Consequently, experiences regarding pediatric maxillofacial traumas are limited, and there is no complete consensus on treatment. In difference to the interventions in adults, the dental structure in pediatric patients need to be definitely considered, the least invasive intervention form should be preferred, and observation and follow-up should be practiced in minimally displaced fractures rather than surgical interventions.

The effect of oxidative stress and Raftlin levels on wound healing.

Reactive oxygen species (ROS) are crucial in all wound-healing processes. Raftlin also plays an important role in the induction of the autoimmune response and the vascular inflammatory response. Inflammatory mediators induce continuous synthesis and secretion. To the best of our knowledge, although there are studies in the literature on antioxidant enzyme levels (superoxide dismutase [SOD], catalase [CAT]) and oxidative stress markers, there are no studies on the comparison of these levels in wound patients with the activities of Raftlin, which is known to play a role in the vascular endothelial response. The aim of this study was to compare the levels of oxidative stress and antioxidant response between wound patients and a control group and to compare the levels of Raftlin between the two groups, which is a new biomarker in inflammatory diseases. Between January 2018 and September 2018, 30 healthy control patients and 30 patients with wounds were enrolled in the study as volunteers. Tissue samples were collected and were sent to the biochemistry laboratory to determine the levels of oxidative stress, antioxidant enzymes, and Raftlin, which play an important role in wound healing. The following were evaluated: SOD and CAT levels (as a measure of antioxidant enzymes); malondialdehyde (MDA) levels (as a measure of free oxygen radicals); and Raftlin, which is a lipid raft protein used in determining the level of inflammatory and autoimmune response. The analyses determined a statistically significant correlation between MDA, SOD, CAT, and Raftlin values in wound patients (p<0.05). Raftlin was a considerable parameter in determining the prognostic process of wound healing. The levels of tissue Raftlin were significantly higher in wounded patients. A significant increase in MDA, SOD, and CAT activities of the wounded patients also suggested that the oxidant and antioxidant effect was balanced and that external antioxidant supplementation was not required.

Van der Woude Syndrome With a Novel Mutation in the IRF6 Gene.

Van der Woude syndrome (VWS) is a rare autosomal dominant disease, first reported in the literature in 1845 by Demarquay and subsequently thoroughly described in 1954 by Van der Woude. Van der Woude Syndrome is the most common form of syndromic orofacial clefting and individuals with this syndrome account for 2% of all cleft cases. Van der Woude syndrome clinically presents with congenital lip pits. These lip pits occur on paramedian portion of the vermillion border of the lip. In VWS, congenital lip pits occur in concurrence with cleft lip and/or cleft palate and represent the most common clinical problem occurring in 80% of the patients. Lip pits result due to notching of the lips at an early stage of development with fixation of tissues at the base of the notch or they may result from a failure of complete union of embryonic lateral sulci of lip. Single lip sinuses without any cleft syndrome are rare; lower lip fistulas in VWS are generally asymptomatic, and surgical management is usually accomplished because of aesthetic concerns. However, in some cases, patients may complain of watery drainage or hypotonia of the lower lip. Herein, the authors report a novel frameshift mutation in IRF6 gene which may contribute to better understanding the genetic aspect of VWS.

Isolated Congenital Cleft of the Nose.

The intrauterine growth of the face is formed by appropriate fusion of frontonasal, maxillary, and mandibular protrusions. These anomalies are very rare and there may be differences between individuals according to cleft types. In this article, a very rare condition of isolated alar cleft and its treatment method were presented. A 14-year-old female patient applied to our clinic with complaint of congenital nasal deformity. On physical examination, a full thickness defect was observed on distal 1/3 of right alar wing, and the right alar cartilage was found as malpositioned of 2 cm more cranially than it should have supposed to be. The patient was diagnosed as isolated nasal cleft and repaired with rotation and transposition flaps. In the technique described earlier, it was observed that the rotation and transposition flaps not only correct the incomplete units but also facilitating the correction of the nostril malposition. One must consider full-layer repair to obtain a more acceptable image in terms of aesthetic and functional results. According to authors, this technique is advantageous as it provides both excellent color and texture harmony.

The effect of increasing the contact surface on tendon healing.

BACKGROUND: The most common complication after tendon repair is the development of adhesion, with subsequent rupture. METHODS: In this study, we present a new method in which the tendon healing contact surface is increased to reduce these complications. The tendons of chickens in groups 1, 3, and 5 were transversely cut and repaired with in the traditional fashion with double-modified Kessler method and 5/0 polypropylene. In the other groups, 3 mm of the tendon was removed from the proximal half of the upper end and from the distal half of the lower end of the tendon, and they were repaired with the modified Kessler method. The tendons of the chickens in groups 1 and 2 were evaluated immediatelly after surgery. Groups 3 and 4 were evaluated at 4 weeks after surgery. Groups 5 and 6 were evaluated at 6 weeks. RESULTS: Increases in transient inflammation and connective tissue formation were observed more clearly in the group treated with the new method in histopathological investigations at weeks 4 and 6. The stretching test showed statistically significant differences between groups 3 and 4 (P<0.05) and groups 5 and 6 (P<0.05). CONCLUSIONS: When repairing tendons with the new method, the healing surface increases and the direction of collagen fibers at the surface changes. Because of these effects, the strength of the tendon healing line increases; we therefore expect that this technique will enable patients to safely engage in early active exercise after the operation, with less risk of tendon rupture.

Setleis syndrome: clinical, molecular and structural studies of the first TWIST2 missense mutation.

Setleis syndrome is characterized by bitemporal scar-like lesions and other characteristic facial features. It results from recessive mutations that truncate critical functional domains in the basic helix-loop-helix (bHLH) transcription factor, TWIST2, which regulates expression of genes for facial development. To date, only four nonsense or small deletion mutations have been reported. In the current report, the clinical findings in a consanguineous Turkish family were characterized. Three affected siblings had the characteristic features of Setleis syndrome. Homozygosity for the first TWIST2 missense mutation, c.326T>C (p.Leu109Pro), was identified in the patients. In silico analyses predicted that the secondary structure of the mutant protein was sustained, but the empirical force field energy increased to an unfavorable level with the proline substitution (p.Leu109Pro). On a crystallographically generated dimer, p.Leu109 lies near the dimer interface, and the proline substitution is predicted to hinder dimer formation. Therefore, p.Leu109Pro-TWIST2 alters the three dimensional structure and is unable to dimerize, thereby hindering the binding of TWIST2 to its target genes involved in facial development.

[Closed reduction of zygoma tripod and isolated arch fractures with Volkmann bone hook]. / Zigoma tripod ve izole ark kiriklarinin Volkmann kemik kancasi ile kapali redüksiyonu.

OBJECTIVES: This study aims to investigate the effectiveness of closed reduction technique for the management of zygoma tripod or arch fractures without internal fixation. PATIENTS AND METHODS: Between June 2011 - December 2013, medical data of seven patients (2 females, 5 males; mean age 49.1 years; range 34 to 76 years) who were treated using closed reduction technique with Volkman bone hook due to zygoma tripod and isolated arch fractures were retrospectively analyzed. Symmetry and functional findings of the patients were assessed at three and six months postoperatively. RESULTS: No complication related to the closed reduction technique was observed. Inadequate reduction was seen in one patient with isolated zygoma arch fracture who was admitted in late-stage. CONCLUSION: Closed reduction using a bone hook can be safely applied in the management of isolated zygoma arch fractures and non-complicated zygoma tripod fractures without fixation.

An frontalis sling operation using an autogenous en-bloc, fan-shaped tensor fascia lata graft for blepharoptosis.

This article presents a modification of the frontalis sling operation for severe blepharoptosis with poor levator function. The fascia or other suspension materials are usually used in strip form to avoid a mass under the skin and lid-crease obliteration in the frontal sling operations. However, the 'strip-sling technique' carries the risk of some complications including irregular eyelid contour, unstable fixation and loss of elevating power in the follow-up period. To overcome these complications and to enhance elevating power transmission between the tars and the frontal muscle, the autogenous tensor fascia lata graft was designed to be en bloc and fan-shaped. This technique was used in nine patients (12 eyelids) who presented with different aetiologies. They had an average follow-up of 13.5 months. Although all the patients achieved favourable results with good eyelid opening, the patients who had traumatic ptosis were more prone to complications including lagophtalmos and pulling away problem. This modification appears to increase the surface contact area between the frontalis muscle, the fascia lata graft and the tarsus. This increased contact enhances tarsus elevation in ptotic eyelids and is associated with satisfactory results.

Reconstruction of large anterior scalp defects using advancement flaps.

Reconstruction of the scalp may be challenging for reconstructive surgeons because of the special anatomic structure of the scalp and underlying skeleton. Anterior scalp defects especially deserve special care for pleasant hairline re-creation and redirection of hair follicles. Local transposition or rotation flaps are the most common reconstruction methods for moderate or large anterior scalp defects. However, currently available techniques usually require multiple stages for completion of the reconstruction without alopecia.In this study, we report our experience with unilateral or bilateral advancement flaps for moderate or large anterior scalp defect reconstructions. Eight patients who had anterior scalp defect of varying etiology were presented. The defect size ranged between 3 × 5 and 8 × 12 cm. The average size of the defect was 53. 3 cm. The defects were located on the frontoparietal area of the scalp in 3 patients and frontal area in 5 patients. Unilateral advancement flap was used in four cases. All the flaps survived except in one patient who had partial flap loss. Based on our experience, we suggest that large scalp defects located especially on the frontal or frontoparietal area can be reconstructed with unilateral or bilateral scalp advancement flaps in one stage without the need for multiple surgeries.

Use of rotation flap in repair of cleft palate and velopharyngeal insufficiency.

Although cleft palate anomaly is frequent, the criterion standards in surgical treatment have not been determined yet. There are a few techniques described for cleft palate repair owing to the limited tissue in the palatal mucosa, the rigid structure of the palatal mucosa, and the limited vascularity of the hard palate. In this study, a novel cleft palate repair technique based on separating the soft palate from the hard palate as a musculomucosal flap and using it as a rotation flap has been described. The operation is evaluated individually for each anomaly because variations occur in the surgical technique according to the extension of the cleft toward the teeth in the palate. This operation was performed on a total of 28 patients (17 girls and 11 boys) aged between 1.5 and 16 years and presented to our clinic. Patients were assessed for speech analysis outcomes, tympanogram values, hearing functions, magnitude of palatal lengthening during the operation, and rate of fistulae. Statistically significant differences in values of the speech analysis and the audiometric assessment were determined between before and 6 months after surgery. Complete recovery of otitis was observed 1 month after surgery without another treatment in 9 (42.8%) of 21 patients who were detected to have serous otitis media preoperatively. Tension-free closure, lower risk of fistula, good restoration of velopharyngeal functions, ability to be performed on all types of cleft palate, ability to provide a good intraoperative exposure, and being a single stage seem to be the most important advantages of this technique.

The effects of exogenous melatonin on peripheral nerve regeneration and collagen formation in rats.

BACKGROUND: Peripheral nerve damage that requires surgical repair does not result in complete recovery because of collagen scar formation, ischemia, free oxygen radical damage, and other factors. To date, the best treatment method has not yet been determined. In this study, we designed an experimental peripheral nerve injury model, and researched the possible effects of melatonin hormone, based on evidence of its strong antioxidant and cell-protective effects via mimicking the effects of calcium channel blockers. MATERIALS AND METHODS: We randomized 24 healthy female albino rats into three groups: the pinealectomy group, melatonin group, and control group. In the pinealectomy group, craniotomy, pinealectomy, sciatic nerve transection, and coaptation were performed, and 0.9% NaCl was injected intraperitoneally. In the melatonin group, craniotomy (without pinealectomy), sciatic nerve dissection, and coaptation were performed, and melatonin was injected intraperitoneally, instead of NaCl. In the control group, craniotomy (without pinealectomy), sciatic nerve dissection and coaptation, and intraperitoneal NaCl injection were performed. In each group, nerve recovery was evaluated histologically, functionally, and electrophysiologically. Functional and electrophysiologic evaluations were conducted before surgery and at 4 and 12 wk. RESULTS: At 4 wk, no significant difference was observed between the groups. However, at 12 wk, significant electrophysiologic and functional improvement was observed only in the melatonin group. CONCLUSIONS: Melatonin seems to have a beneficial effect on nerve recovery. However, this effect is not effective at physiologic doses. Future comparative studies with melatonin versus other nerve-regenerating agents are necessary to determine the clinical utility of melatonin hormone.