A Novel Method of Neo-osseous Flap Prefabrication: Induction of Free Calvarial Periosteum with Bioactive Glass.

BACKGROUND: Reconstruction of craniofacial bone defects is a primary focus of craniofacial surgery. Although autogenous bone grafts remain as the gold standard, alloplastic materials have also gained widespread popularity due to their off-the-shelf availability, ease of use, and durability. In addition to replacing the missing bone, some of these alloplastic materials have also been found to induce new bone formation. OBJECTIVES: In this study, the phenomenon of neo-osseous induction with bioactive glass was investigated for different implant-soft tissue configurations. MATERIALS AND METHODS: Thirty-two male, Wistar albino rats were divided into four equally numbered study groups. In group 1 (FP), adipofascial groin flaps were prefabricated with free periosteal grafts. In group 2 (FPB), adipofascial groin flaps were prefabricated with free periosteal grafts and bioactive glass. In group 3 (FB), adipofascial groin flaps were prefabricated with bioactive glass. In group 4 (control), adipofascial groin flaps were not prefabricated. Morphometric analyses of the prefabricated structures were performed using micro-CT. The histologic properties of the ectopic ossification were assessed by using a modified scoring system. RESULTS: Group 1 (FP) showed the greatest rate of mature lamellar bone formation. Group 2 (FBP) showed the greatest amount of bone density and volume. However, the addition of bioactive glass in group 2 (FBP) decreased the rate of mature lamellar bone formation when compared with group 1 (FP). Ectopic ossification was not observed in the control group. CONCLUSION: Bioactive glass can be successfully used in the prefabrication of vascularized compound structures for the reconstruction of complex bone defects. However, interference with the periosteal induction of mature lamellar bone formation should be taken into consideration, especially in pediatric bone defects, which primarily rely on spontaneous osteogenesis through periosteal induction.

Modified Superior-Based Pharyngeal Flap Is Effective in Treatment of Velopharyngeal Insufficiency Regardless of the Preoperative Closure Pattern.

Velopharyngeal insufficiency (VPI) is certainly one of the most important problems confronted after cleft palate repairs. In this study, it was aimed to evaluate the preoperative and postoperative speaking results of patients who underwent modified superior-based pharyngeal flap. Sixty-six children who underwent modified superiorly based pharyngeal flap for treatment of VPI between 2005 and 2013 were retrospectively reviewed. The study population was evaluated in 2 distinctive groups depending on their preoperative velopharyngeal closure pattern as: coronal closure pattern or noncoronal closure patterns (ie, circular, sagittal with or without the presence of a Passavant ridge). The speech outcome of the patients was evaluated using the objective assessment tools of nasopharyngoscopy and nasometer. Coronal closure pattern was determined in 24 patients (36.4%) and noncoronal closure pattern in 42 patients (63.6%). The mean follow-up period was 14.67 ±â€Š3.90 and 13.74 ±â€Š3.53 months in the coronal and noncoronal groups, respectively. The results demonstrated that the postoperative nasalance scores of all syllables except (m) and (n) were found to be significantly lower compared to those of the preoperative period (P < 0.001). However, no significant difference between the preoperative and postoperative results was observed in means of closure pattern. The surgical approach of modified superior-based pharyngeal flap for treatment of VPI appears to be effective regardless of the preoperatively determined closure pattern.

Jejunum/DIEP Composite Flap: A Novel Rat Model of Viscerocutaneous Flap Prefabrication.

Background Reconstruction of complex pharyngoesophageal defects presents a major challenge, particularly in soft tissue deficient and previously scarred surgical sites. In recent years, the free jejunum flap method has emerged as a reliable means of esophageal reconstruction. However, it may require cutaneous coverage with an additional flap in extensively scarred, secondary reconstructions. Prefabrication of an intestinal/cutaneous composite flap can potentially solve this problem. Materials and Methods Total 28 Sprague Dawley rats were used in the study protocol. A vascularized jejunal segment was transposed beneath the deep inferior epigastric perforator (DIEP) flap. Contact with underlying abdominal fascia was prevented using a silicone sheet. Animals were distributed into five groups based on the timing of deep inferior epigastric vessel ligation to determine the time required for successful revascularization. The viability and the vascular anatomy of the prefabricated structures were analyzed using histology and microangiography. Results A jejunum/DIEP composite flap was successfully prefabricated based on mesenteric vessels. The skin component survived intact after 5 days of contact with serosal surface of the jejunal segment. Conclusion The clinical application of this technique can provide an alternative means of single-stage esophageal reconstruction, especially in patients with soft tissue deficiency and donor vessel unavailability.

Poly(L-Lactide)/Poly(ε-Caprolactone) and Collagen/ß-Tricalcium Phosphate Scaffolds for the Treatment of Critical-Sized Rat Alveolar Defects: A Microtomographic, Molecular-Biological, and Histological Study.

OBJECTIVE: To determine the efficacy of a newly developed scaffold (col/ß-TCP) in a preclinical rat model as compared with the gold standard treatment (autograft) and control scaffolds (PLLA/PCL). DESIGN: Fifty-six Sprague-Dawley rats were randomized into four experimental groups, and critical-sized alveolar defects (7 × 4 × 3 mm) were created in each animal. Group A was the blank defect group, group B received autograft, group C received col/ß-TCP scaffolds, and group D received PLLA/PCL blend scaffolds to fill the bone defects. New bone formation was assessed radiomorphometrically, histomorphometrically, and molecular-biologically at 1 and 4 months following surgery. RESULTS: Radiomorphometrically, the best new bone volume rate at 1 month (43.7%) and 4 months (45.4%) was observed in the autograft group, and the difference was significantly higher than in the other three groups (P < .005, P < .001, P < .001 for 1 month and P = .004, P < .001, P < .001 for 4 months). Even though the new bone volume rate in the col/ß-TCP group (21.5%) was higher than that of the PLLA/PCL group (18.2%), the difference was not significant (P = .08). Molecular-genetic analysis revealed significantly higher BSP and ALP gene expression levels in the autograft and col/ß-TCP groups than in the blank defect group (P = .002 and P = .004). CONCLUSION: The engineered tissue scaffolds described herein have great potential as an alternative treatment option when cost, donor region morbidity, and duration of hospitalization are considered.

Correction of Brachymetatarsia and Medial Angulation of the Great Toe of Apert Foot By Distraction Osteogenesis: A Review of 7 Years of Experience.

BACKGROUND: Apert foot anomalies may cause severe problems such as pain and development of callus formation related to weight redistribution, problems with footwear, and gait disturbances that may limit their daily activities. The main purpose of this study was to review our experience with distraction osteogenesis for the correction of brachymetatarsia and the great toe angulation of the patients with Apert syndrome. METHODS: This study retrospectively reviewed 7 patients (14 extremities) followed up for Apert syndrome who underwent distraction for the correction of bilateral congenital brachymetatarsia and angulation of the great toe between 2004 and 2008. Correction of the metatarsal inclination angle, the medial angulation of the great toe, the percentage of lengthening, and lengthening rates of distracted bones were evaluated. RESULTS: Patients ranged in age from 4 to 8 years at the distraction operation, with a mean age of 5.4±1.3 years, and the average length of follow-up was 86.6±21.0 months. The length of the first metatarsal bone increased significantly from the average length of 32.6±5.7 mm to an average of 46.7±6.5 mm (P<0.001). The mean lengthening rate and lengthening percentages of distracted bones were 0.4%±0.1%/month and 30.2%±6.4%/month, respectively. Preoperative and postoperative metatarsal inclination angles were at a mean of 43.8±5.12 and 32.6±3.8, respectively, and the correction of metatarsal inclination was considered as statistically significant (P<0.001). The mean angulation of the great toe reduced significantly from 49.8±11.76 to 13.2±8.5 degrees after distraction (P<0.001). Minor complications such as pin loosening, pin-tract infection, and early union that required reoperation were observed in 5 extremities (35.7%). CONCLUSIONS: Anatomic features of Apert foot may lead to complaints that may limit patients' daily activities and require as much attention as associated hand and craniofacial anomalies. Distraction appears to be an effective and safe approach for the simultaneous correction of the shortness of the first ray and medial angulation of the great toe. LEVEL OF EVIDENCE: Level IV.

Application of C-Shaped Osteotomy and Distraction Osteogenesis for Correction of Radial Angulation Deformities of the Hand in Children With Apert Syndrome: Review of 10 Years of Experience.

Apert syndrome is characterized by short, radially deviated thumbs, leading to difficulties in daily life such as holding a fork or a spoon and buttoning up. The main goal of surgery is to achieve thumb to index finger pinch to overcome these difficulties. Seven patients (14 extremities) followed up with Apert syndrome underwent distraction after a C-shaped osteotomy to simultaneously correct the brachydactyly and the angulation deformity of the bilateral thumbs. The patients ranged in age from 4 to 7 years at the distraction operation, with a mean (SD) of 4.7 (1.7) years, and the mean (SD) length of follow-up was 100.6 (14.95) months. The mean (SD) length of the phalanges at the beginning of distraction was 19.1 (3.26) mm, and the mean (SD) length of the distracted phalanx at long-term follow-up visit was 26.2 (5.63) mm. The mean (SD) correction of radial angulation was calculated as 42.6 (9.95) degrees, and the difference was considered as being statistically significant (P < 0.001). Minor complications such as pin loosening were observed in 6 extremities of 4 patients, and 2 patients were treated for pin tract infection. Index-to-thumb pinching was acquired by all the patients after distraction and correction of angulation. The hand features of Apert syndrome are as noteworthy as the craniofacial features and thus may lead to functional impairment and limitations in daily life. Distraction with a C-shaped osteotomy seems to be a promising method to correct both the shortness and the radial angulation of the thumb to achieve functional results.

Does contribution of extended vomer flap to palatoplasty affects speech results.

Development of normal speech is the primary goal of successful palatoplasty. The purpose of this study was to determine the importance of the contribution of vomer flap to palatoplasty procedure for speech function. Eighty-one children who underwent 2 flap palatoplasty procedures for cleft palate repair between 2002 and 2010 were retrospectively reviewed in 3 groups. Group 1 underwent palatoplasty without contribution of vomer flap. Group 2 underwent palatoplasty with standard dissection of vomer flap, whereas group 3 underwent palatoplasty with extended dissection of vomer flap. Speech function of the patients was evaluated using objective assessment tools such as nasopharyngoscopy and nasometer. Eighty-one children who underwent 2 flap palatoplasty were included in this study. The mean age at palatoplasty was 10.17 months, and mean length of follow-up was 72.33 months. For most syllables, patients repaired using extended vomer flap demonstrated lower nasalance scores. Nasopharyngoscopic examination revealed velopharyngeal motility in 24 patients (80%) in group 1 and in 20 (83.3%) and 23 (85.2%) patients in groups 2 and 3, respectively (P = 0.930). In velopharyngeal closure, there were only 5 patients (18.5%) in group 3, whereas there were 6 patients (25.0%) for group 2 and 10 patients (33.3%) for group 1 with no closure (P = 0.311). Although most optimum results were observed in the group with extended dissection of the vomer flap, contribution of the extended vomer flap to the repair of the soft palate did not lead to significantly better speech results.