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.

Nasal Dorsum Management Using Fragmented Cartilage Grafts.

Thinness of nasal dorsum skin and subcutaneous tissue underlying nasal dorsal skin are the major factors related to the visibility of small irregularities. Here, the authors discuss the use of bare fragmented cartilage grafts in managing nasal dorsum and the results obtained.Eight hundred fifty-six patients were operated for rhinoplasty between September 2009 and September 2014. Fragmented cartilage grafting over the nasal dorsum was performed in 781 of 856 patients. In total, 214 patients who were followed up regularly were evaluated. Nasal dorsum management of 182 out of 214 patients was performed as is described here and is included in this study. The authors fragmented the cartilage grafts with Kocher clamp until the fragmented cartilages do not exhibit resistance, which are then placed over the nasal dorsum and can be shaped easily by external manouevers.Follow-up period ranged from 6 to 36 months. There was no seroma formation, infection, or abscess formation during the postoperative follow-up period. Four patients required a secondary operation for nasal dorsum management. The irregularity was corrected by simple rasping. The rest of the patients were satisfied with their nasal dorsum appearance. Nasal dorsum management with fragmented crushed cartilages showed durable results during the follow-up period.The authors use fragmented cartilage grafts in nasal dorsum management and do not wrap them into endogenous or exogenous sleeve material thus preventing the delay for vascularization of cartilage grafts, which is directly related to obtain durable results. By this way, durable results and smooth nasal dorsum can be maintained.

Anatomic Variations in Paranasal Sinuses of Patients With Sinonasal Polyposis: Radiological Evaluation.

OBJECTIVE: Although sinonasal anatomic variations have been postulated as a risk factor for sinus disease, the role of anatomic abnormalities in the pathogenesis of nasal polyps is still unclear. This study was conducted to examine the association of sinonasal polyposis with anatomic variations. METHODS: The paranasal sinus computerized tomography scans of 155 patients with sinonasal polyposis were examined retrospectively from January 2012 to 2014 in a tertiary care hospital. Paranasal sinus computerized tomography of 100 patients without complaints and signs of sinus disease were also included to serve as control group. The incidence of anatomic variations was evaluated. The sinonasal polyposis and control group data was compared statistically. RESULTS: The incidence of the septal deviation, concha bullosa, Agger nasi, frontal sinus hypoplasiaand accessory sinus ostium in healthy subjects, and sinonasal polyposis patients revealed statistically significant difference. The mentioned variations were found significantly higher in sinonasal polyposis patients (P = 0.000, P = 0.000, P = 0.001, P = 0.002, and P = 0.035 respectively) and may be predisposing for this pathology. CONCLUSION: Considering the results obtained, the presence of septal deviation, concha bullosa, Agger nasi cell, frontal sinus hypoplasiaand accessory sinus ostium may play role in pathogenesis of sinonasal polyposis.

The Effect of Selenium on Ischemia-Reperfusion Injury: An Experimental Study on a Transverse Rectus Abdominis Musculocutaneous Flap Model.

BACKGROUND: The aim of this study is to investigate effects of selenium and enlighten the possible mechanism of action in a rat transverse musculocutaneous flap model following ischemia-reperfusion injury. MATERIALS AND METHODS: In this study, an experimental model, which mimicked free tissue transfer, was applied. Twenty-four male Wistar Albino rats were divided into a control group (N = 12), and a selenium treated group (N = 12). A superiorly based transverse rectus abdominis musculocutaneous (TRAM) flap was elevated and an ischemic insult for 4 hours was given. In selenium treated group (Group 2), sodium selenite (0.625 mg/kg) was injected intraperitoneally (i.p), 2 hours before the induction of ischemia. Six rats from each group were sacrificed at 24 hours after the operation and malonyldialdehyde (MDA), nitric oxide (NO), and glutathione (GSH) levels were measured biochemically, whereas the intensity of neutrophil infiltration was evaluated. For the rest of the rats in Group 2, sodium selenite was injected at the same dose everyday to the postoperative 10th day, in which the remaining 6 rats from each group were sacrificed. On postoperative 10th day, flap viability was assessed along with the evaluation of intensity of neovascularization. RESULTS: In Group 1, MDA levels were higher significantly (P < 0.05) when compared with Group 2. No statistical difference, however, was found for NO (P > 0.05), and GSH (P > 0.05) levels among Group 1 and 2. Neutrophil infiltration was more intense in Group 1, when compared with Group 2 whereas neovascularization was more abundant in samples of Group 2. Group 2 shows higher average flap surface areas when compared with Group 1 (P < 0.05). DISCUSSION: The results of this study demonstrated the preventive effect of selenium against ischemia-reperfusion injury by reducing tissue necrosis in muscle flaps possibly by decreasing MDA, increasing neovascularization, and decreasing neutrophil infiltration, thus suppressing inflammation.

Effects of verapamil, nifedipine, and daflon on the viability of reverse-flow island flaps in rats.

Reverse-flow flaps are preferable in reconstructive surgery due to their several advantages. However, they may have venous insufficiency and poor blood flow. In this study, effects of various pharmacological agents on the viability of reverse-flow flaps were investigated. Forty Sprague-Dawley rats were used. Superficial epigastric artery- and superficial epigastric vein-based reverse-flow island flaps were preferred. The rats were divided into 4 groups. Group 1 was considered as the control group. Group 2 was given verapamil 0.3 mg/kg per day, group 3 nifedipine 0.5 mg/kg per day, and group 4 Daflon 80 mg/kg per day for 7 days. On day 7, viable flap areas were measured, angiography was performed, serum nitric oxide levels were evaluated, and histopathological examination was done.The mean flap viability rate was 67.59% (±13.12259) in group 1, 77.38% (±4.12506) in group 2, 74.57% (±3.44780) in group 3, and 85.39% (±4.36125) in group 4 (P = 0.001). The mean nitric oxide level was 31.66 µmol/dL (±2.42212) in group 1, 51.00 µmol/dL (±2.96648) in group 2, 34.00 µmol/dL (±2.96648) in group 3, and 47.66 µmol/dL (±2.80476) in group 4 (P = 0.001). On angiography, there were vessel dilations and convolutions in group 2; capillaries became noticeable, and anastomotic vessels extended toward the more distal part of the flaps in group 4. Histological examinations showed severe inflammation in group 3 and minimal inflammation and venous vasodilatation in group 2.Verapamil and Daflon in therapeutic doses significantly increased the viability of reverse-flow island flaps. However, nifedipine did not make a significant contribution to the flap viability. The results of this study will contribute to the literature about the hemodynamics of reverse-flow island flaps and guide further studies on the issue.

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 .

Supraorbital artery island flap for periorbital defects.

The forehead skin has the same color and texture as the periorbital region as well as the other parts of the face. The forehead is a local flap donor area for the reconstruction of full-thickness periorbital defects. This report presents eight cases in which full-thickness defects resulting from tumor resection have been repaired with supraorbital artery island flaps. Of eight patients, one was female and the rest were male with a mean age of 72.8 years (range, 64-88 years). Defects were located in the medial canthal region, lateral canthal region, glabella, and lateral part of the orbita. The flaps ranged from 2 x 3 cm to 6 x 7 cm in size. The patients were followed for 7 to 18 months. No complications occurred, except for decreased sensation on the forehead, and trapdoor deformity was seen in one case. The outcome was functionally and aesthetically satisfactory in all cases and all patients were happy with the outcome. The supraorbital artery island flap is a good alternative for the repair of defects around the orbita in that the color and texture of this flap match up with the orbital region and that it is pliable, simple, safe, and sensorial and requires only a single-session procedure.

Reconstruction of saddle nose deformity with three-dimensional costal cartilage graft.

Saddle nose deformity is characterized by depression of the nasal bone and the cartilage dorsum associated with a collapse in the upper lateral and alar cartilages. Etiopathogenesis usually involves trauma or invasive excision of the bone and cartilage. Surgical treatment for functional and aesthetic recovery relies on the use of grafts. Options for grafting include autogenous tissue such as bone or cartilage and alloplastic augmentation. Nine patients with saddle nose deformity underwent surgical reconstruction with autogenous costal cartilage. The deformity was the result of trauma in seven patients and secondary to surgery in two patients. Cartilage obtained from the sixth and seventh ribs was used as the graft material to compensate for the low nasal dorsum. Cartilage was used as a single unit and shaped to cover the nasal dorsum and the lateral nasal walls completely. The upper lateral cartilages were fixed to shaped cartilage graft. Additional cartilage grafts into the columella and septum were also placed in all patients. Functional and aesthetic outcome was satisfactory in all patients. As a result, using costal cartilage graft, a single unit allowed more predictable and reliable reconstruction of the saddle nose deformity than the conventional dorsal grafts.

A comparative study on superior auricular artery island flaps with various pedicles for repair of periorbital defects.

Superior auricular artery (SAA) island flaps elevated from the retroauricular region have perfect color, thickness, and texture match with facial skin. In this article, reconstruction of periorbital defects with SAA island flaps is presented. Flaps were categorized into three types because they were elevated on three different pedicles. A type 1 flap was a superficial temporal vessel pedicled SAA island flap with antegrade blood flow. A type 2 flap was a reverse flow SAA island flap based on the frontal branch of the superficial temporal artery (STA). A type 3 flap was a reverse flow SAA island flap based on the parietal branch of STA. Fourteen patients (9 females and 5 males) aged between 31 years and 74 years were treated with these flaps. Two patients with lower eyelid, two patients with upper eyelid, three patients with malar, two patients with infraorbital, one patient with lateral canthal upper eyelid, and four patients with forehead defects underwent surgical intervention. Sizes of the flaps varied between 3x6 cm and 8x6 cm. Venous congestion was observed in all patients in the early postoperative period and lasted for 5 to 9 (mean, 6.6) days in type 1 flap, 5 to 9 (mean, 6.7) days in type 2 flap, and 2 to 5 (mean, 3.6) days in type 3 flap. Apart from distal necrosis of 1x1 cm in one patient and superficial dermal sloughing in two patients, no complications were encountered. Aesthetically and functionally successful results with minimal donor site morbidity were obtained in all patients during the 2 to 22 (mean 10.8) month follow-up period.

Reconstruction of orbital floor and maxilla with divided vascularised calvarial bone flap in one session.

We present four cases which underwent reconstruction of orbital floor and anterior maxillary wall with a vascularised bone flap following partial maxillectomy. After tumour resections, superficial temporal artery (STA) and vein based calvarial bone flaps from the outer tabula were prepared. Without disrupting the integrity of fascia and periosteum, the bone was separated into two segments in the same direction as the blood flow and one is 3 cm and the other 5 cm. The two bone segments were transferred as one single flap and one segment of the flap was used to reconstruct the orbital floor and the other for reconstruction of the anterior maxillary wall. Since two cases had large skin defects, lateral frontal skin to which the frontal branch of the STA supplies blood was incorporated into the flaps. Functional and aesthetic results were satisfactory at the end of 8-20 months follow-up. This technique allowed reconstruction of the orbital floor and anterior maxillary wall and even skin defects with a single pedicled flap in one session.

A novel flap to repair medial and lateral malleolar defects: anterior tibial artery perforator-based adipofascial flap.

Soft tissue coverage of the ankle is a difficult challenge. The adipofascial flap based on perforators of the anterior tibial artery was harvested from the dorsum of the foot and used for repairing of soft tissue defects either on the lateral or medial malleolar region in 7 patients. Two medial and 5 lateral malleolar defects were covered using the flap described. The size of flaps varied from 3.5 x 10 cm to 4.5 x 12 cm. All flaps had good perfusion and survived completely. Donor-site morbidity was minimal in all cases. Both functional and esthetical results were satisfactory. Because of thin and pliable features, this flap is suitable for repair of defects around the ankle region. In addition, donor-site morbidity of this flap is minimal, with an acceptable scar hidden in the shoe-wearing area.

A congenital isolated alar cleft.

Alar rim defects are mostly acquired, resulting from burns, traumas, or tumor excision. Sometimes they can accompany craniofacial clefts. However, isolated congenital alar defects are extremely rare. The authors present a case of congenital isolated alar cleft.

Effect of caffeic acid phenethyl ester on survival of axial pattern flaps in rats with ischaemia-reperfusion injuries.

Oxygen-derived free radicals have been implicated in the pathogenesis of tissue injury after ischaemia-reperfusion. Caffeic acid phenethyl ester (CAPE), an active ingredient of honeybee propolis, has been identified as having potent antioxidant and anti-inflammatory properties. We evaluated the ability of CAPE applied intraperitoneally in reducing tissue injury after ischaemia-reperfusion. To investigate whether treatment with CAPE modifies the concentrations of the endogenous indices of oxidant stress, we examined its effects on a model of flap ischaemia-reperfusion injury in rats. CAPE (10 micromol/kg) was given through the peritoneum before reperfusion. CAPE given intraperitoneally had an inhibitory effect on tissue injury after ischaemia-reperfusion comparable to that of a control group. The anti-inflammatory and antioxidant properties of CAPE may contribute to its suppression of tissue injury.

A new approach to retroauricular flap transfer: parietal branch-based reverse flow superior auricular artery island flap.

The retroauricular region provides adequate tissue of excellent color and texture match for the reconstruction of small- and medium-sized facial defects. In this study, parietal branch of the superficial temporal artery (STA) was used as the pedicle for the retroauricular island flap. Anastomoses between the parietal branch of STA, occipital artery, and contralateral STA were observed to deliver adequate nutritional blood supply to the flap. Total upper eyelid defect in 1 case, malar defect in 1 case, and forehead defects of various sizes in 4 cases were included in our study. Sizes of the flaps varied from 4 x 4.5 cm to 6 x 8 cm (mean 4.7 x 6.6 cm). All cases had venous congestion for 2-4 days (mean 3.4 days). Only 1 case experienced a superficial dermal necrosis of 1 x 3 cm in size in the distal part of the flap. Esthetic and functional results were satisfactory during the 1- to 14-month (mean 7) follow-up period. This flap is thought to be advantageous for the repair of defects and traumas of the forehead and upper eyelid as the pedicle does not develop torsion and dissection is easy.

Obstructive congenital gingival granular cell tumour.

Congenital gingival granular cell tumours (CGCT) are rare and always benign intraoral tumours originating from the alveolar ridge. They are also known as congenital epulis, congenital myoblastoma or Neumann's tumour. They are typically seen as a mass protruding out of a newborn child's mouth. In general, CGCT occurs as a solitary tumour. The main differential diagnosis is epignathus (oral teratoma). This report describes a newborn with a mass originating from lower alveolar ridge obtruding into the oral cavity. Clinical features, histiogenesis and necessity for early surgical treatment due to risk of airway obstruction and difficulty in feeding were discussed.