Mesenchymal Stem Cells: a Potential Treatment Approach for Refractory Chronic Spontaneous Urticaria.

The etiopathogenesis of chronic spontaneous urticaria (CSU) is not fully elucidated, and almost 30-40% of patients are resistant to treatments; therefore, there is still a need for the development of new and effective treatments. This study aimed to develop experimental cellular therapy for CSU patients resistant to current treatment options. Autologous adipose tissue mesenchymal stem cells (MSC) were administered to 10 refractory CSU patients who were then followed up for six months. The efficacy of treatment was evaluated according to the weekly urticaria activity scores (UAS7) and drug use scores (DUS7). To observe the effect of treatment on immune cells, CD4+ T cell subsets were analyzed by flow cytometry, and the serum IFN-γ, TNF-α, IL2, IL-4, IL-5, IL-6, IL-10, IL-13, IL-17a, IL-21, IL-22, TGF-ß1, PGE2, IDO and anti-FcεRI levels were measured using the Luminex and ELISA methods. The values obtained were compared with 10 control refractory CSU patients and five healthy controls. We found that the T cell subsets and inflammatory molecules were not affected by MSC treatment during the follow-up period. In control patients, a significant decrease was detected only at the Th2 subset, TGF-ß1, PGE2, IDO and anti-FcεRI levels on the 14th day of treatment. The UAS7 and DUS7 values of the MSC-treated patients significantly decreased during the follow-up period, but in control patients, a significant but temporary decrease was seen. According to our findings, unlike conventional treatment, MSC therapy resulted in longer and more effective recovery. Our data indicate that MSCs may be an alternative and effective approach for treatment-resistant CSU patients. Graphical Abstract.

Cranially-based nasolabial flaps for the reconstruction of nasal surgical defects.

BACKGROUND: Cranially-based nasolabial flaps are a good alternative for the reconstruction of nasal defects. METHODS: A cranially-based nasolabial flap was used in 18 patients to reconstruct defects of the nose from 2010 to 2016, and the long-term results are presented in this report. RESULTS: Fifteen of the flaps completely survived. All the patients had a bulky appearance, but they did not want to undergo a second operation for cosmesis. The dissection of the flap took approximately 20 minutes, and the total operation lasted for 1 hour. The patients were hospitalized for 1-7 days, and the postoperative follow-up period was 1-28 months (mean, 17 months). CONCLUSIONS: The cranially-based nasolabial flap possesses all the advantages of the traditional forehead flap, and can safely be used in selected cases.

Malignant tumor of outer root sheath epithelium, trichilemmal carcinoma. Clinical presentations, treatments and outcomes.

OBJECTIVES: To emphasize different clinical features of tumor that can be misdiagnosed clinically. METHODS: A total of 8 cases operated between September 2009 and 2016 at the Celal Bayar University, Faculty of Medicine were included in the study. Patients' clinicopathological features, type of surgery and follow up information were evaluated. Results: Six patients were male. The average age was 75.50. The lesions were located on the head and neck, and chest wall. Six patients had a history of the rapid growth of lesion. There was no metastasis at the time of diagnosis. None of the patients needed adjuvant therapy. Mean follow up time was 19.37 months. None of the patients developed recurrence or metastasis. Conclusion: This tumor resembles basal or squamous cell carcinoma. The histopathological evaluation may lead to misdiagnosis. Regional or distant metastasis is very rare. There is no consensus about adjuvant therapy. Screening for metastasis and close follow up are mandatory.

The cranially based contralateral nasolabial flap for reconstruction of paranasal and periorbital surgical defects.

The importance of the paranasal and periorbital regions on the aesthetics of the face presents a variety of reconstructive challenges for surgical and traumatic defects of those regions. We used the cranially based nasolabial flap in patients with full-thickness soft-tissue defects of the paranasal and periorbital regions harvested from the contralateral side of the present defect. We present our experience in 25 patients of geriatric population (13 females and 12 males with a mean age of 76) with complex soft-tissue defects in the paranasal and periorbital regions whose defects were reconstructed with contralateral nasolabial skin flaps. Sizes of the defects changed between 2 × 3 cm and 6 × 7 cm. The flap sizes varied from a width of 2 to 5 cm (average 3 cm) and a length of 7 to 11 cm (average 8 cm). Primary closure of the donor sites of the flaps was possible in 24 of the patients in this series. Twenty-one flaps of this series (84%) healed without any necrosis and completely survived. The contralateral nasolabial flap is a very convenient, safe and reliable flap that can be used in medium to large paranasal and periorbital defects. Optimal aesthetic results for a variety of central facial defects could be obtained with this flap, especially when the ipsilateral nasolabial flap cannot be used due to various reasons.

The effect of melatonin on a dorsal skin flap model.

BACKGROUND: Melatonin (Mel) has a very potent antioxidant activity, depending mainly on its capacity to act as an electron donor. Recently, the antioxidant property of Mel has been much emphasized. In this study, the dorsal skin flap model was used to investigate the effect of Mel in flap viability in rats. MATERIAL AND METHODS: Totally 28 Wistar Albino rats were divided into four groups: control group (C) (n = 7), local treatment group (L) (n = 7), systemic low-dose melatonin treatment group (LT) (n = 7), and systemic high-dose melatonin treatment group (HT) (n = 7). The necrosis rate of the skin flaps was observed seven days after the operation by a blinded observer. Oxidative stress was assessed by determining malondialdehyde (MDA) level, and effects of melatonin on antioxidant enzymes such as superoxide dismutase (SOD) and catalase (CAT) were measured. Vascularity, epithelial thickness, and fibroblast proliferation of dorsal skin flaps were assessed histologically. RESULTS: Amount of MDA were found significantly lower (p < .05), and the flap viability, CAT, SOD, vascularity, fibroblast proliferation, and epithelial thickness were found significantly higher (p < .05) in groups HT than in groups C, L, and LT statistically. CONCLUSION: Our results showed that the usage on different doses of melatonin could play an important role in the process of flap viability and further studies will focus on these areas of interest.

The double scalpel flap: a new technique for the closure of circular skin defects.

Reconstruction needs to be designed attentively to obtain a functional and a good aesthetic consequence for closing skin defects. Numerous local flaps have been defined to conceal skin defects. However, new techniques are still required, especially for circular type of skin defects.This study describes a new technique that has been well defined to repair the circular type of skin defects. The technique basically uses extra skin relaxation provided with 2 opposing flaps' rotation maneuver in favor of the defect closure. The objective of this technique is for the flaps to start from one border of the defect and extend just to the other border, not invading beyond the defect borders. This enables us to apply the procedure on defects that are close to important anatomical structures because it is sufficient to use only the opposing 2 sides of the defect for its closure.With this method, 2 opposing flaps that resemble the tip of a scalpel were rotated to the existing circular defect; and by suturing these 2 flaps at the midline, the defect was closed. This technique was applied to 17 patients between the ages of 48 and 83 years. Defect sizes were between 2.5 × 2.5 and 5 × 5 cm.With the use of opposing flaps designed narrower than half-width of the defect, a tension-free closure could be achieved on both the donor and the recipient site. No flap necrosis was detected on any patients. After a mean follow-up of 11 months (3-26 months), it was realized that a good aesthetic appearance could be achieved in all the patients about 2 to 3 months postoperatively.

The role of upper lateral cartilage in correcting dorsal irregularities: section 2. The suture bridging cephalic extension of upper lateral cartilages.

BACKGROUND: Dorsal irregularity after hump reduction is one of the most annoying problems in aesthetic nasal surgery. Spreader grafts, cartilaginous autogenous thin (CATS) grafts, Skoog-type dorsal grafts, cartilage grafts, bone grafts, fascia grafts, dermal grafts and nonbiologic products such as silicon and polytetrafluoroethylene are used to overcome this problem. In cases managed with spreader flaps rather than graft procedures, problems may persist in the area of the nasal bones, whereas irregularities in the cartilage dorsum can be minimized. More specifically, the surgically treated surface of the dorsum's upper third and the rhinion area [nasal bone and upper lateral cartilage (ULC) junction], which has the thinnest nasal soft tissue, present the greatest challenge for hiding irregularities and call for special attention. METHODS: The ULC has a cephalic extension with varying lengths under the nasal bone. When these pieces of cartilage are protected during hump excision and sutured to each other, a strong, smooth, and a single-unit structure can be obtained. This technique was applied to 76 patients between 2009 and 2010. RESULTS: Manual examination during the postoperative period showed no irregularities in 60 patients. In the remaining 16 patients, minimal irregularities in the bony region were encountered. In 4 of these patients, the irregularities were visible in the profile view, and in the remaining 12 patients, they were felt only by manual examination. CONCLUSION: The bridging suture technique using cephalic extensions of the ULC is an improvement of the spreader flap technique to obtain a straight, smooth, and single-unit dorsum in rhinoplasty patients. LEVEL OF EVIDENCE IV: 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 .

The use of titanium clips in septal surgery for correction and strengthening.

Permanent correction of septal deformities is one of the most difficult and controversial subjects in aesthetic nasal surgery. The main reasons for failure in most of the corrective procedures are either not to weaken the septal cartilage enough to straighten it, or to treat the septum too radically causing iatrogenic deformities or predisposing it to new deformities postoperatively. Our approach to correct septal deformities relies on the principle of strengthening/reinforcing the septal cartilage (with or without some weakening maneuvers to correct the deformities beforehand) with application of titanium hemoclips at some critical locations in septum. Eighty-seven patients operated on between 2007 and 2009 are included in this study. Thirty-six of these patients had combined septo-nasal deformities while the remaining 51 had solely septal deformities. In 30 patients with septo-nasal deformity the technique was proven to be successful. The remaining 6 patients of this group had axial nasal deformity (rather than intrinsic septal problems) and did not respond to our technique successfully. Within four years of follow up, we did not encounter any recurrences, infections, ulcerations or exposure in the mucosa covering the titanium clips. None of the titanium clips were required to be removed for any reasons.

Comparison of clinical outcomes between single- and multiple-perforator-based free thoracodorsal artery perforator flaps: clinical experience in 87 patients.

BACKGROUND: Although thoracodorsal artery perforator flaps have not gained popularity in the reconstructive era, the results of recent studies regarding the vascularity of thoracodorsal artery perforator flaps are promising. In the present study, the authors aimed to determine the clinical outcomes of free multiple-perforator versus single-perforator thoracodorsal artery perforator flaps. METHODS: Eighty-seven patients with various defects underwent reconstruction with free thoracodorsal artery perforator flaps. The flap was used for upper extremity reconstruction in 43 patients (49.4 percent), for head and neck reconstruction in 16 patients (18.4 percent), and for lower extremity reconstruction in 28 patients (32.2 percent). Of the 87 flaps, 48 (55.2 percent) were based on a single perforator, whereas 39 flaps (44.8 percent) were based on multiple perforators. The single- and multiple-perforator-based thoracodorsal artery perforator flaps were compared regarding clinical outcomes and morbidity. RESULTS: The morbidity rate was found to be significantly higher in the single-perforator-based group. Of the patients in the single-perforator group, seven patients had transient venous congestion, five were heparinized and treated with leeches for permanent venous congestion, six had partial necrosis, and one had total necrosis. In the multiple-perforator-based group, two patients had transient venous congestion, and no partial or total necrosis was observed. CONCLUSION: Despite the fact that dominant perforators may often be absent, this study showed that a multiple-perforator-based thoracodorsal artery perforator flap may be more reliable with safe vascularity compared with a single-perforator-based flap.

Remodeling of a nontreated displaced parasymphyseal fracture of a child.

There have been considerable advances in the management of craniomaxillofacial injuries in children. Conservative approaches such as close observation, a liquid-to-soft diet, and analgesics can be used for the management of mandibular fractures without displacement and malocclusion. However, displaced fractures need to be an anatomic reduction and immobilization. The basic principle of displaced mandibular fractures in both children and adults is the stabilization of fracture fragments forming the pretraumatic contour and occlusion state until osteosynthesis occurs. The major differences of pediatric fractures from adults are the flexibility of bones and very rapid healing pattern. Therefore, reduction in pediatric age group must be accomplished earlier. This case was an 11-year-old boy presented with a severely displaced parasymphyseal mandibular fracture resulting from a fall. He was given a soft diet and analgesic, given anti-inflammatory treatment of edema, and scheduled for operation. Subsequently, it was surprisingly observed that there was a significant improvement in the fracture line on the 12th posttraumatic day. The comparison of maxillofacial computed tomographic scans of the first and 12th posttraumatic days revealed a noteworthy remodeling and a remarkable approximation of the fracture lines. It can be concluded that bone remodelization in the pediatric age groups is perfect and very rapid, even in severely displaced fractures.

Alopecia treatment with scalp expansion: some surgical fine points and a simple modification to improve the results.

In the current study, authors present their clinical experience with the esthetic reconstruction of alopecia by means of a tissue expansion technique in 74 consecutive patients who were treated between May 1986 and June 2002 in the Department of Plastic and Reconstructive Surgery. The principles of the conventional technique are mentioned briefly, but the authors essentially tried to explain a number of surgical fine points together with some simple modifications so as to get the maximum profit from the expanded tissue and to decrease the complication rate. In the first 39 patients of this study, who were treated with a conventional tissue expansion technique, the major complication rate was found to be 15.4%. In the last 35 patients, this rate was found to be decreased to 5.7%. The improvement in the major complication rate is attributed to the authors' surgical modifications compared with the conventional technique. The article provides a supplement to the existing literature, underscoring the importance of some surgical fine points and outlining a systematic way of planning expander placement and tissue expansion.

Comparing the osteogenic capacities of bone substitutes: hydroxyapatite, high-density porous polyethylene, and bone collagen: a biochemical and histological analysis.

Several inorganic materials have been shown previously to hold some osteogenic capacity. The purpose of this study is to compare the bone-forming abilities of hydroxyapatite ceramic, high-density porous polyethylene, and bone collagen within the periosteal island flap of rabbit tibia using histological and biochemical analysis. With this goal, four discrete experimental groups were formed, each comprising 22 New Zealand male rabbits. A sac was created on each rabbit tibial periosteum flap in each of the groups, and each of the previously mentioned materials was placed within this sac separately. One of these groups was thought as a control group without any material being placed inside the periosteal sac. Biopsies were taken at weeks 1, 2, 4, and 8 for biochemical analysis and at weeks 2 and 8 for histological evaluation. Neo-osteogenesis was evaluated quantitatively by determination of alkaline phosphatase and osteocalcin levels biochemically as well as by the percentage of new bone formation inside the periosteal sac histologically. Results show statistically that the osteogenic effect of high-density porous polyethylene is greater than that of the other materials used in this study (P < 0.05).

Management of lower lip cancer: a retrospective analysis of 118 patients and review of the literature.

In this current study, the clinical data and postoperative follow-up findings of 118 patients with a primary lower lip carcinoma who were treated between 1983 and 1999 in the Department of Plastic and Reconstructive Surgery are presented. Medical records were reviewed retrospectively and data were collected concerning age, gender, followup period, location of lesion on the lip, cervical metastasis at presentation, preoperative biopsy results, histological grade, initial treatment, reconstruction type, pathological outcome, local recurrence, regional lymph node metastasis, treatment of local recurrence and regional lymph node metastasis, and postoperative treatment. The prognostic value of clinical stages in relation with recurrence and mortality from disease was investigated. The overall rate of recurrence was calculated as being 39.8%, and the determinate survival rate was found to be 72.9% at 5-year follow-up. The data concerning the above-mentioned parameters, together with risk factors that might play a role in the development of lip cancer, are discussed in light of the current literature.