The Effect of Liquid Nitrogen on Bone Graft Survival.

Liquid nitrogen is used in medicine for cancer treatment and tissue preservation; however, bone viability after its application is controversial. This study aims to evaluate both the tissue viability and the clinical and histopathologic findings following liquid nitrogen application with different thawing techniques in rats. Mandibular bone grafts were taken from 45 Wistar rats and freezed in liquid nitrogen for 20 minutes. In the rapid-thawing technique (Rapid Thawing-1, Rapid Thawing-2), the grafts were held for 20 minutes in room temperature; in the slow-thawing technique (Slow Thawing-1, Slow Thawing-2), 20 minutes in -20°C, 20 minutes in +4°C, and 20 minutes in room temperature, respectively. In Rapid Thawing-2 and Slow Thawing-2 groups, autografts were implanted to their origin for 3 weeks and bone staining with India ink was performed and samples taken for histologic examination. The amount of cells and blood vessels and the density of bone canaliculi were significantly reduced in Rapid Thawing-1 and Slow Thawing-1 groups comparing to the Control group. However, the reduction rate was more significant in the Slow Thawing-1 group. Histomorphometric evaluation of the healing autografts after 3 weeks revealed that the decreased amounts of canaliculi were not changed in Slow Thawing-2 group. The study results demonstrated that bone tissue survives after liquid nitrogen treatment regardless of the performed thawing technique; however, slow thawing causes more tissue damage and metabolism impairment.

Comparison of bone prefabrication with vascularized periosteal flaps, hydroxyapatite, and bioactive glass in rats.

BACKGROUND: Periosteal flaps possess osteoprogenitor cells and an osteoinductive potential that can be further augmented by combination with a biodegradable scaffold; therefore, various osteoconductive and osteostimulative biomaterials are frequently combined with periosteal flaps in studies of bone prefabrication. An experimental study was designed to determine and compare the contribution of bioactive glass and hydroxyapatite to osteoneogenesis in rats when combined with a periosteal flap. MATERIALS AND METHODS: In 60 Sprague Dawley rats, saphenous artery periosto-fasciocutaneous island flaps were transposed to abdomen. In group 1, the flap was left alone, in group 2, an empty artificial pocket made of Gore-Tex (W. L. Gore & Associates, Inc.; Flagstaff, AZ) was sutured onto the periosteal layer, and in groups 3 and 4, the pocket was filled with bioactive glass and hydroxyapatite, respectively. Following sampling for histological analysis, a 4-point scoring system was used to grade inflammatory cell infiltration, osteogenesis, angiogenesis, and cell migration into the bioactive material. RESULTS: The combination of the periosteal flap with any of the bioactive materials resulted in significantly higher percentages of animals exhibiting osteogenesis (80% in hydroxyapatite group and 93.3% in the bioactive glass group; p = 0.0000528) and angiogenesis. Comparison of the bioactive material groups revealed that a significantly higher proportion of animals in the bioactive glass group exhibited moderate or severe inflammation (80 vs. 20%; p = 0.002814). CONCLUSION: Periosteal flaps prefabricated with hydroxyapatite or bioactive glass in rats exhibit osteogenic capacities that are not dependent on direct bone contact or proximity to vascular bony tissue. The innate capacity of the periosteal flap when utilized alone for osteoneogenesis was found to be rather insufficient.

Microvascular anastomosis using Ankaferd blood stopper: demonstration of long-term histopathologic effects on vascular tissue.

Ankaferd blood stopper (ABS) (Ankaferd Ilaç Kozmetik A.S., Turkey) is a medicinal plant extract, which is used in Turkish traditional medicine as a haemostatic agent. The aim of this study was to investigate the haemostatic effect of ABS in preventing microvascular leakage on an anastomosis site and to look into its long-term impact on vascular tissue. Twenty-one Wistar albino rats were randomly divided into three groups. The animals in the second and third groups were pretreated with acetylsalicylic acid. All of the right femoral arteries were divided and anastomosed in an end-to-end fashion. Following microvascular anastomosis, saline-soaked gauze tampons were applied in the first and second groups. In the third group, ABS-soaked tampons were applied to the anastomosis sites. The mean bleeding time of group 3 was significantly shorter than group 2 and group 1. Three weeks after the operation, there were aneurysms on all of the anastomosis sites in group 3 and none of the anastomoses were patent. Histologic examination demonstrated increased inflammatory cell infiltration, tunica media degeneration and contraction of tunica intima in group 3. This is the first study reporting the long-term effects of ABS on microvascular anastomosis. Contrary to previously reported studies, this agent is not appropriate for use on injured or anastomosed vessels.

Delayed reduction of a displaced zygomatic arch fracture by external traction.

An easy and useful method designed for the reduction of delayed and displaced zygomatic arch fractures used by the treatment of a 33-year-old female patient is presented.

Superficial musculoaponeurotic system flap for reconstruction of the intraoral defects.

Intraoral tumors are the main causes of the intraoral and maxillofacial defects. Skin grafts and several soft tissue flaps can be used to reconstruct the intraoral defects including local, regional, and free flaps. Here we present a case of intraoral adenocystic carcinoma treated with segmental maxillectomy, resection of the parotid gland, and the buccal mucosa leaving a full-thickness intraoral defect. The defect was covered with a superficial musculoaponeurotic system (SMAS) flap elevated using the preauricular incision. Reconstruction with SMAS flap for temporal defects and parotidectomy defects has been described in the literature. To our knowledge, the use of this flap for intraoral defects has not been reported. The proximity of the flap to the defect and ease of harvest in cases including total parotidectomy are few of the reasons we use and recommend this flap in reconstruction of intraoral defects.

Duplication of the mandible in Klippel-Feil syndrome.

The duplication of the mandible is an extremely rare case, which was first described by McLaughlin in 1948 as a case report of duplication of the mouth, the tongue and the mandible. Betty in 1956 and Davies in 1973 reported similar cases. The duplication of the mandible may be associated with the Klippel-Feil syndrome (KFS). A low hairline, short neck with cervical vertebral fusion and painless limitation of the head movement are the characteristic findings of this syndrome. The incidence of the syndrome varies from 1/30,000 to 1/40,000. Although autosomal recessive inheritance was suggested, no familial inheritance was found in some cases. A very rare case of mandibular duplication in association with KFS, whose duplicated mass was removed following distraction, has been reported.

Anterior pillarplasty: a modification in cleft palate repair.

After the primary repair of cleft palate, surgeons are frequently confronted with a short soft palate and a wide velopharyngeal space, both of which are known to diminish the quality of speech. We introduce a new modification of the primary repair of cleft palate that lengthens the soft palate and helps to reduce the volume of the velopharyngeal space. Ten patients younger than 12 months with nonsyndromic cleft palate were operated on with this technique. The incision at the cleft margin extended behind the uvula as a modification to the classic design of mucoperiosteal flaps. The sagittally divided mucosal layers of each anterior tonsillar pillar are sutured at the midline 1 cm posterior to the new uvula. The rate of postoperative fistula formation and other complications were evaluated postoperatively. One patient had a uvular and partly pillar detachment at the postoperative period. All other clefts healed without complication. The primary repair of the cleft palate with the anterior pillarplasty technique is a safe and easy-to-perform procedure. This modification can effectively reduce the transverse diameter of the velopharyngeal space and increase the anteroposterior length of the palate.

Injury patterns and psychological traits of patients with self-inflicted wounds produced by punching glass.

BACKGROUND: Self-inflicted injuries are among the preventable forms of hand injury. Psychologic factors underlying these injuries have not been studied sufficiently. This study aims to reveal the extent of injury and the morbidity as well as the psychologic factors in a population of patients who intentionally injured themselves by punching glass. METHODS: Patients seen and treated for glass punching injuries during a 4.5-year period were reviewed. The demographic data included the extent of injury, postoperative hospitalization time, and full recovery time. Their psychologic traits were analyzed by two questionnaires (Symptom Distress Check List and State-Trait Anger Expression Inventory) and through a psychiatric interview. The results were compared with a sex- and age-matched control group with accidental hand injuries. RESULTS: The study group consisted of 36 patients. Mean age was 24.7 years. Most were men (n = 28), not married (n = 28), and living with their families. Half of them were unemployed. Twelve had only skin lacerations. The remaining 24 patients had a total of 45 tendon, 15 nerve, and 9 artery injuries. On an average, 46 days were required for full recovery. A second attempt of self-infliction was not reported. Twenty-one patients underwent questionnaires and psychiatric interview. The study group felt significantly higher levels of psychologic distress and hostility (p = 0.018 and p = 0.002, respectively). They also had higher levels of anger in daily life (p = 0.002). Clinical psychiatric evaluation failed to reveal any significant psychiatric disorder. CONCLUSION: Self-inflicted hand injuries increase the workload of emergency services and clinics involved in the treatment. Prevention is very difficult, especially when alcohol is not an underlying cause. A typical patient has hostile and disobedient characteristics and who easily expresses his anger. Happily, having suffered enough during their treatment these patients do not attempt a second self-infliction.

Lipofibromatous hamartoma of the median nerve.

Lipofibromatous hamartoma is a rare tumor-like overgrowth of fibroadipose tissue surrounding the nerves. Most commonly, it involves the median nerve. The tumor is usually present at birth and grows very slowly. The expected age of clinical presentation is the third or fourth decades of life. The case reported here had a rapid overgrowth and presented at the age of eight. Our case is the first reported case of lipofibromatous hamartoma of the median nerve in the pediatric age group.

A new alternative for reconstruction of soft triangle defects secondary to burn injury: superiorly based columellar flap.

Nasal reconstruction following severe burn injury remains a challenge in plastic surgery. In burn patients, the external nares and the soft triangle are commonly affected subunits of the nose where local tissue deficit and scar contraction during the recovery period contribute to soft triangle deformity and alar stenosis. These patients usually have associated facial burns with varying severity, which significantly limit the availability of local flaps. Reconstruction with skin grafts often yields unsatisfactory results because of the mismatch in colour and texture in addition to the primary and secondary contraction phenomena. The use of superiorly based columellar flap, which has yielded satisfactory results on a female patient, would be a new and reliable option for reconstruction of the soft triangle deficit with alar stenosis.

A rare complication after septoplasty procedure in a misdiagnosed submucous cleft palate case: palatal fistula.

Nasal septoplasty is a common and low-risk procedure performed very frequently in plastic surgery as well as in otorhinolaryngology. The development of a palatal perforation following a nasal septoplasty procedure is a very rare event with only a few cases reported in the literature. A patient with palatal fistula formation after septoplasty procedure is presented here, who was later on diagnosed with submucous cleft palate during the repair of the palatal fistula.

The effects of the size of liposuction cannula on adipocyte survival and the optimum temperature for fat graft storage: an experimental study.

BACKGROUND: Determining the most advantageous size of liposuction cannula and injection needles in terms of adipocyte viability could help to increase fat graft survival. When recurrent injections are necessary, storing fat tissue which is harvested during the first operation could be a practical solution if it is stored at an appropriate temperature providing the highest amount of viable fat cells. METHODS: Fat tissue was removed from the abdomen of 10 consecutive female patients by 6-, 4- and 2-mm-diameter liposuction cannulas. Fat tissue harvested with the 6mm cannula was injected through 14, 16 and 20 g needles and collected in separate tubes. An additional three tubes of fat samples were prepared from fat tissue obtained with the 6mm cannula to be stored at +4, -20 and -80 degrees C for 2 weeks. Viability of the fat grafts was evaluated by fat cell isolation with collagenase digestion and staining with supravital dye and counting adipocytes with a haemocytometer. RESULTS: The viability of fat grafts harvested with the 6mm cannula was higher than grafts obtained with smaller cannulas. The viability of fat grafts injected through 14, 16 and 20 g needles were similar to each other. The viability of fat grafts stored at +4 degrees C was similar to fresh tissue whereas freezing fat grafts caused significant loss of viable adipocytes compared to fresh tissue. CONCLUSIONS: The use of larger liposuction cannulas for fat tissue harvesting provides more viable fat grafts. A temperature of +4 degrees C could be proposed as an effective and easily available way of storing fat grafts for at least 2 weeks.

Computed tomography in the management of cervical lymph node pathology.

Computerised tomography (CT) is a useful adjunct in the diagnosis of cervical pathology in head and neck carcinoma. However, different criteria used in CT analysis make the comparison of outcome studies difficult. This study compares two different CT criteria (two different lymph node sizes) for detection of cervical lymph node pathology for head and neck tumours in the same patient population. A prospective study was performed on 55 patients, with minimum T2 intraoral squamous cell carcinoma and high risk extraoral malignancies, who underwent 65 neck dissections. Sensitivity, specificity and accuracy of clinical palpation, CT considering lymph nodes larger than 10mm as positive and CT considering lymph nodes larger than 15 mm as positive are compared. The results are as follows: sensitivity, specificity and accuracy of clinical palpation are 86, 84 and 85%, respectively; sensitivity, specificity and accuracy of CT with lymph nodes exceeding 10 mm are 95, 47 and 63%, respectively; sensitivity, specificity and accuracy of CT with lymph nodes exceeding 15 mm are 86, 81 and 83%, respectively. The outcomes of the study reveal that CT evaluation of cervical lymph nodes with a cutoff value of 15 mm should be preferred to a cutoff value of 10mm in order to prevent over-treatment in cervical management of head and neck tumours. When accuracy of the results is considered, CT alone does not have an advantage over clinical palpation in this study.

Patients' perspectives on the ocular symptoms of facial paralysis after gold weight implantation.

SUMMARY: Upper lid loading for the treatment of lagophthalmos resulting from facial paralysis is a simple and effective procedure with relatively few side effects and complications. A detailed patient-based self assessment, focusing on subjective complaints after upper lid weight implantation is scarce. In this study, a population of facial palsy patients with lid weights is asked about their subjective complaints in order to find out the patients' point of view. Patients with upper lid weights were asked questions indicating the degree of soreness, tearing, redness, visual acuity, lid closing during the day, lid closing during sleep, aesthetic appearance, artificial tear utilisation and outdoor comfort. All questions were evaluated by an analogue scale in reference to the opposite eye, where a score of '10' corresponds to the best outcome (no symptoms at all or appearance comparable to the contralateral eye) and a score of '1' corresponds to the worst outcome. Thirty patients filled in the questionnaire and 22 of them were seen in the outpatient clinic. The most pleasing result was obtained in the lid closing during the day (score 8.8+/-1.9), during sleep (7.7+/-3.0) and in the aesthetic appearance of the eye (score 7.6+/-2.7), whereas visual acuity received the lowest score (score 5.7+/-1.5). Complication and re-operation rates were 23% and 13%, respectively. In conclusion, upper lid weights solve the problem they are used to address. They provide a satisfactory lid closure and aesthetic appearance in the patients' point of view. However, the ocular symptoms of facial paralysis still persist to some extent and the procedure is not without its complications.

Septocolumellar suture in closed rhinoplasty.

Several surgeons advise a variety of tip sutures and describe their own techniques in open approach. Septocolumellar suture is one of them and can be described as a loop suture between the medial crura and caudal septum. Although some of the articles mention that it can be applied in closed rhinoplasty, there is no description of the technical details. This paper presents indications, technical steps, and advantages of the septocolumellar suture in closed rhinoplasty. After completing the classic sequence of the endonasal extramucous technique, the medial crural cartilages are dissected from the overlying skin at the midcolumellar level, keeping the distal fibrous attachments between the anterior columellar skin and these cartilages intact. A 5/0 or 4/0 Prolene (Ethicon Ltd, UK) with a round needle is passed, penetrating both the medial crura and then the caudal septum. Depending on the penetration level of this suture, the tip projection can be increased or decreased, the tip can be rotated, and columellar show can be corrected. This suture also makes the medial crura of the alar cartilages and septum rigidly fixed together, thus providing stability. Depending on the experience gained in 433 primary and 62 secondary rhinoplasty cases since 2000, it can be claimed that this technique, presenting an alternative to the open approach in many cases and expanding the borders of closed approach, allows one to manipulate the tip and columella easily with closed rhinoplasty and provides a significant decrease in the suboptimal results and number of complications.

Atypical midline cleft with duplication of the metopic suture.

INTRODUCTION: In contrast to the common clefts of the lip, alveolus and palate, the atypical clefts of the face may come in myriad patterns of clinical expression and are often not easy to define. PURPOSE: In this report, a case of median craniofacial dysraphia is described. PATIENT: At presentation, the 3-month-old male patient had a bilateral complete cleft of the lip, alveolus and palate. The nose was wide and a horn was present on the nasal dorsum. 3-D CT AND MRI REVEALED: Duplication of the metopic suture ending at the wide anterior fontanel; orbital hypertelorism; midline cranial cleft ending just superior to the nasal dorsum; frontoethmoidal encephalocoele and holoprosencephaly. The presence of two metopic sutures was confirmed during surgery. CONCLUSION: The presented case carries the characteristics of the median cleft face syndrome. However, it differs from similar cases in two respects. First, the patient had two metopic sutures, one on either side of the cranial extension of the median cleft. Second, the patient had a bilateral cleft lip in contrast to the expected median cleft lip deformity.

Patients' and surgeons' perspectives on the scar components after inferior pedicle breast reduction surgery.

BACKGROUND: Scarring is the most frequent cause of dissatisfaction both for the surgeons and for the patients in breast reduction surgery. Some of the techniques used today use the classic inverted T scar. An inverted T scar is a combination of three separate scars (periareolar, vertical, and inframammary). To the authors' knowledge, no study has investigated the cosmetic outcome of these three scar components separately. The aim of this study was to determine the surgeons' and patients' perspectives on the cosmetic outcome of these three scar components. METHODS: A total of 19 patients who had inferior pedicle reduction mammaplasties were included in the study. The patients' perspectives on their reduction mammaplasty scars and the surgeons' evaluations of scar hypertrophy, widening, and color match were assessed by Likert scales. RESULTS: Patient evaluations revealed that periareolar scars were the most pleasing, whereas the inframammary scars were the least pleasing. Surgeon evaluations revealed no significant difference in scar hypertrophy, color match, or widening for the three scar components. However, the vertical scar had a tendency to widen and the inframammary scar color tended to match poorly. CONCLUSIONS: In this study, patients were most pleased with the periareolar scars and least pleased with the inframammary scars. Surgeons need to find ways of getting rid of the inframammary scar and should also deal with vertical scar widening. Scar hypertrophy was not a problem in this patient population.