In Vitro and In Vivo Evaluation of Metformin Hydrochloride Hydrogels Developed with Experimental Design in the Treatment of Burns.

Burns alter the normal skin barrier and affect various host defense processes that help prevent infections. An ineffective repair process can lead to serious damage, such as the onset of an infection or skin loss, which can then harm the surrounding tissues and ultimately the entire organism. This study aims to prepare in situ gels containing metformin hydrochloride, a compound known for its wound healing properties. To achieve this, in situ gels were prepared using three different gelling agents (Poloxamer 407®, Carbopol 934®, and sodium carboxymethyl cellulose (Na-CMC)) and three different concentrations of metformin hydrochloride (4 mg/g, 6 mg/g, and 8 mg/g), which were optimized through experimental design. Metformin concentration and gelling agent type were independent variables, and the loaded amount and the percentage of metformin released after 150 min were chosen as dependent variables in the optimization process. After determining the optimum values of the dependent variables according to the ANOVA analysis results, in vivo studies were conducted with optimized hydrogel formulations. Two groups, each consisting of seven Wistar rats with a burn model, were treated with metformin-poloxamer 407® gels at doses of 4 mg/g and 8 mg/g for 29 days. The results were then compared to untreated and placebo gel groups. Rats treated with in situ Poloxamer 407® hydrogels containing metformin hydrochloride showed a significant reduction in the size of the burned area after 29 days of treatment. However, for a comprehensive understanding of the wound healing mechanism, further studies such as immuno-histochemical and cell culture studies are needed.

Reconstruction of Orbital Floor With Auricular Concha.

Orbital floor fractures of varying sizes commonly occur after orbital injuries and remain a serious challenge. Serious complications of such fractures include enopthalmos, restriction of extraocular movement, and diplopia. There is a dearth of literature that can be applied widely, easily, and successfully in all such situations, and therefore there is no consensus on the treatment protocol of this pathology yet. Autogenous grafts and alloplastic and allogenic materials with a wide variety of advantages and disadvantages have been discussed. The value of preoperative and postoperative ophthalmological examination should be standard of care in all orbital fracture patients. An ideal reconstructed orbital floor fracture should accelerate the restoration of orbital function with acceptable cosmetic results. Management parameters of orbital fractures such as timing of surgery, incision type, and implant materials, though widely discussed, remain controversial. In this study, 55 patients with orbital floor fractures surgically reconstructed with conchal cartilage grafts between 2008 and 2014 were retrospectively evaluated. Complications and long-time follow-up visit results have been reported with clinical and radiographic findings. The aim of this study was to present the authors' clinical experiences of reconstruction of blow-out fractures with auricular conchal graft and to evaluate the other materials available for use.

A rare type of burn injury due to butane gas inhalation.

BACKGROUND: Abusive inhalation of butane gas is becoming a serious public health problem among teenagers and young adult population; however, there has been little reporting on explosion burns associated with abuse of butane cigarette lighter fluid. METHODS: Retrospective study was conducted of 22 patients who were burned in last 2 years in explosion of butane gas, a flammable, odorless, and colorless aliphatic hydrocarbon. RESULTS: Details of sociodemographic profile of the patients, any underlying psychiatric illness, alcohol abuse, depth of burn injury, any associated injury, duration of hospitalization, and percentage of burned area were recorded and analyzed. CONCLUSION: All of the patients were young men, and most had superficial burn injury. Hospital stay ranged from 0 to 11 days. All of the patients were treated with conservative management.

A New Surgical Approach for Tessier No. 4 Facial Cleft Reconstruction: Lip-Rescue Flap.

Craniofacial clefts are rare, severe challenges for surgeons about which there is limited literature. Tessier Number 4 (No. 4) clefts are one of the most complex craniofacial anomalies and present difficulties in surgical treatment. The most-common deformities associated with Tessier No. 4 clefts are displacements of the lower eyelids, medial canthus, and ala and decreased distance between the lower eyelids and lips. In surgery to correct these deformities, the greatest challenges are the design and the placement of the landmarks and incisions. Because of its relative rarity and wide range of severity, no definitive operative methods have been accepted for Tessier No. 4 facial cleft. The present study presents a new lip-rescue flap technique as an alternative approach for reconstructing Tessier No. 4 facial clefts.

Intranasal Extramucosal Access: A New Access for Lateral Osteotomy in Open Rhinoplasty.

BACKGROUND AND OBJECTIVE: Different accesses have been used to perform lateral osteotomies in rhinoplasty. All of them have some disadvantages. The aim of this paper was to report a new access to overcome drawbacks of the other techniques in lateral osteotomy during open rhinoplasty. METHODS: An anatomical study was designed to search possibility of intranasal extramucosal access (open sky access) for the lateral osteotomy in open rhinoplasty. It was performed directly on the lateral wall of piriform aperture, and then possible advantages of this technique were investigated. Five fixed cadavers were used for this purpose. No drawbacks were observed during procedure in cadavers. Then the same procedure was performed in 23 consecutive rhinoplasty patients. Nineteen operations were primary and 4 operations were secondary. Median oblique osteotomies were added to the procedure in all patients. The mean follow-up was 17 months. RESULTS: Intranasal extramucosal access during lateral osteotomy was easily performed in all patients. Hemorrhage due to angular vessel injury was not occurred during intraoperative period. Edema and ecchymosis was minimal. Intranasal examination did not show any sign for nasal mucosal tearing in all patients. Residual bone spurs or bone irregularities were not observed in any patients. CONCLUSION: Intranasal extramucosal access that produces precise, predictable, and reproducible aesthetic and functional results could also provide better exposure during lateral osteotomy. Additionally, open sky access minimizes scars because it does not need additional incisions on the skin and mucosa. Protection of the internal periosteum of the nasal bones may be the main advantages of this technique.

Repair of Full-Thickness Nasal Alar Defects Using Nasolabial Perforator Flaps.

BACKGROUND: The repair of full-thickness nasal alar defects presents difficulties because of their complex 3-dimensional structure. Reconstructions using inappropriate methods may lead to asymmetries and dissatisfying functional results. In this study, our aim was to present the repairs of full-thickness alar defects performed using cartilage-supported nasolabial perforator flaps. MATERIALS AND METHODS: Eight patients who presented to our clinic between January 2011 and April 2014 with full-thickness defects in the alar wings were included in this study. The nasolabial perforator flap was prepared on the basis of the closest perforator to the defect area and in a way to include 2 to 3 mm of subcutaneous adipose tissue. The medial section of the flap was adapted to form the nasal lining. In the 7 patients in whom cartilage support was used, the cartilage graft was obtained from the septum nasi. After the cartilage was placed on the flap, the lateral section of the flap was folded over the medial section and the defect was repaired. In 1 patient in whom cartilage support was not required, the flap was folded over itself before the repair was performed. The flap donor area was primarily repaired. RESULTS: No detachment around the suture lines, infection, venous insufficiency in the flap, or partial or total flap losses were observed in any of the patients. Retraction developed in 1 patient in whom no cartilage support was used. No retraction was observed in any of the patients in whom cartilage support was used. The results were functionally and esthetically satisfying in all the patients. CONCLUSIONS: The greatest advantage of perforator-based nasolabial flaps is the greater mobilization achieved in comparison with the other nasolabial flaps. Thus, full-thickness defects can be repaired in 1 session in some patients, no revision is required around the flap pedicle, and much less donor area morbidity occurs. Nasal alar reconstructions performed using this type of flap lead to both esthetically and functionally satisfying results.

Comparison of Subciliary Approaches in Orbito-Zygomatic Fractures: Skin Flap Versus Skin-Muscle Flap.

BACKGROUND: Because of the complications of classical subciliary incision, some modified subciliary approaches have been described in recent literature. OBJECTIVES: The aim of this study was to compare 2 commonly used subciliary approaches according to development of postoperative complications (scar formation, and ectropion). MATERIALS AND METHODS: Ninety patients were included in this retrospective study. Subciliary skin flap technique (SF group) was performed to 39 patients, while the others were operated by using skin-muscle (stepped) flap technique (SMF group). Fitzpatrick skin types, genders, ages, scar scores, and ectropion scores of the patients also were recorded. RESULTS: The mean age of the patients was 39.3 (18-99) years, and the mean follow-up period was 2.1 (1-6) years. Fitzpatrick skin-type levels were between 2 and 4 (median = 3). No difference was found between 2 groups in terms of age, follow-up period, and Fitzpatrick skin-type levels. However, the scar values of the SMF group were significantly lower than the SF group statistically. Also, there was no significant difference between males and females in SF and SMF groups in terms of scar and ectropion formation. On the other hand, scar values were lower in SMF groups rather than SF group in males. Although ectropion values were not different between SF and SMF groups in females, ectropion values of SMF group were significantly lower than SF group in males statistically. CONCLUSION: Subciliary skin-muscle (stepped) flap technique can be more reliable than subciliary skin flap technique for approach to orbitozygomatic fractures.

The Versatile Facial Artery Perforator-Based Nasolabial Flap in Midface Reconstruction.

INTRODUCTION: Defects in the lower two thirds of the face occur due to trauma, tumoral masses, or infections. In this study, repairs of various defects located in the midface using facial artery perforator-based nasolabial flaps are presented. PATIENTS AND METHODS: Between January 2009 and June 2013, 15 patients with defects in the lower two thirds of the face or the intraoral region underwent repairs with facial artery perforator-based nasolabial flaps. The etiology was malignant skin tumor excisions in 11 patients, infection in 2 patients, and trauma in 2 patients. Among the patients, 10 were male and 5 were female. Their mean age was 65.1 (range: 20-86) years. The mean duration of follow-up was 14 (7-24) months. The defects were located at the upper lip, cheek, lower lip, intraoral region, and the nasal area. The size of the defects varied between 10 × 10 mm and 40 × 50 mm. All the flaps were prepared as perforator flaps. The flap donor area was primarily closed. RESULTS: No partial or total flap loss was observed in any of the flaps. The flap donor areas healed without problem. Full patient satisfaction was achieved both aesthetically and functionally. CONCLUSION: The nasolabial perforator flap has certain advantages such as the 1-stage application, repair using a similar tissue, a wider rotation arc around the pedicle compared to the other regional flaps, and the primary closure of the donor area. Based on these characteristics, it is an ideal alternative for the repairs of the defects located in the lower two thirds of the face or the intraoral region.

Combination of rhomboid flap and double Z-plasty technique for reconstruction of palmar and dorsal web space burn contractures.

BACKGROUND: Web space contractures after a burn can cause severe impairments in hand function along with esthetic deformities. In this study we present our experience with the combined treatment technique consisted of rhomboid flap and double Z-plasty for palmar and dorsal web space contractures. MATERIALS AND METHODS: Combined rhomboid flap and double Z-plasty was performed in eight patients with eleven web space contractures occurred after burn. The average follow-up was 10.9 months. RESULTS: The average age of 8 patients was 16.3 years. The average duration of burn contractures was 6 years (range 1-13 years). The right third web of the patients was the most common contracted web space. In the postoperative period hematoma, infection, partial or total flap loss was not observed in any patient. Web and hand function and esthetic appearance of web spaces were satisfactory in the late postoperative period. CONCLUSION: Rhomboid flap combined with a double Z-plasty technique was an effective choice for the treatment of palmar and dorsal web space contracture after burn.

Fujimori gate flap: an old flap for reconstruction of lower lip defects due to lower lip carcinoma resection.

OBJECTIVES: This study aims to present our clinic experiences on the Fujimori gate flap used for reconstruction of lower lip defect due to lower lip carcinoma. PATIENTS AND METHODS: This retrospective study included 19 patients (7 females, 12 males; mean age 60.3 years; range 41 to 79 years) who underwent reconstruction with the Fujimori-gate flap between January 2006 and March 2011. Demographic features of all patients and postoperative long-term functional and aesthetic results were reviewed. RESULTS: The mean size of the defects was 34.2 mm (range, 10 to 60 mm). Totally 27 flaps were elevated. No complication was observed after surgical procedure. In the long-term, nine patients underwent minor revisions. None of the patients showed local recurrence. CONCLUSION: Fujimori gate flap may be used for the reconstruction of the soft tissue loss after tumor surgery at lower lip.

Inverted nipple correction with dermal flaps and traction.

BACKGROUND: Inverted nipple occurs when part of or the entire nipple is abnormally located below the areola. Surgical repair of severe cases involves suture or flap techniques. Complications include recurrence, lactation problems, hypopigmented scar formation in the areola, and loss of sensation. We describe an alternative repair technique using a dermal flap and traction, which leads to less apparent scarring and preserves lactation function and sensation. METHODS: Between January 2010 and January 2013, we treated 28 inverted nipples in 16 patients using two areola-based triangular dermal flaps and traction. The scar was aligned with the junction of the nipple and the areola. Postoperatively, traction was applied through an apparatus prepared from a 50-cc syringe. Patients were followed up for 8-24 months (mean = 16.5 months). RESULTS: Adequate projection was achieved in all patients and no wound dehiscence or complications such as infection occurred. Unilateral recurrence occurred in one patient on the 10th postoperative day. This patient was reoperated on successfully using the same method. No loss of sensation was observed in any of the patients during the postoperative period. CONCLUSIONS: This dermal flap technique for treating inverted nipple was effective and preserved lactation function. The alignment of the scar with the junction of the nipple and the areola led to a more aesthetic appearance with no apparent scarring. The traction method helped maintain traction for a longer period, which in our opinion increased the success rate of the surgery. 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.

Correction of hyperpigmented palmar grafts with full-thickness skin grafts from the lateral aspect of the foot.

The palmar surface of the hand possesses special features when compared with the hair-bearing parts of the body. The same quality of skin has to be used in reconstruction of the palmar skin defects to restore normal function. The lateral aspect of the foot has similar features with the palmar region histologically and can be used for palmar reconstruction. Seventeen patients who had hyperpigmentation after skin graft in the palmar region were treated. Scar contracture was combined in seven patients. The hyperpigmented grafts were excised and then the defects were full-thickness skin grafted from the lateral aspect of the foot. The mean follow-up period was 13.7 (4-22) months. Engraftment was successful in 16 patients, but one failed due to haematoma. The colour of the graft was initially reddish, and then became similar to the palmar area. The donor site healed without any problem within 3 weeks. At follow-up these grafts had good colour and texture match with adjacent palmar skin. There was no hyperpigmentation. Minimal marginal scarring and scar hypertrophy occurred in four patients (24%). The skin of the lateral aspect of the foot is a good choice for palmar skin defects, because of the similarities in their characteristics. Results are acceptable in terms of minimal recurrence of scar contracture, no hyperpigmentation, adequate colour and texture match, and minimal marginal scarring and scar hypertrophy.

A case of syngnathia, cleft palate and hypospadias: an isolated case or syndromic syngnathism?

Syngnathia occurs when an ectopic membrane forms a fibrous or bony adhesion between the maxillary and mandibular alveolar processes. A case of congenital syngnathia is presented.

Importance of the levator labii alaeque nasi muscle in dorsal septal deviations.

Deviated cartilages structures of the nose can be affected by nasal muscles, and deviation becomes conspicuous when the patient smiles. This condition depends on activity of nasal muscles, particularly the levator labii alaeque nasi muscle. A total of 124 septorhinoplasty operations were performed to correct dorsal concave septal deviation between 2005 and 2009 years. The 70 women and 54 men included in the study had an average age of 28 years. The average follow-up period was 12 months. Open septorhinoplasty was preferred in all cases. The medial part of the levator labii alaeque nasi muscle was extensively dissected from the lateral crus and surrounding tissues. The lateral crura of the alar cartilages were separated from the upper lateral cartilages in the scroll area. The dorsal septal deviation was corrected by combination of bilateral spreader grafts, which reinforced cartilage with horizontal control sutures. Early postoperative period was uneventful. Nasal obstruction was reduced after surgery, and significant subjective postoperative improvements were observed in all patients. Comparison of preoperative and postoperative photographs demonstrated improved dorsal nasal contour. Revision operation was performed in 3 cases. The corrected septal cartilage was in a good position in all revised cases; therefore, septal surgery was not performed in the revision operations. In conclusion, surgical disruption of the anatomic relationship between the muscle with the dorsal septal cartilage and reinforcement of the dorsal septal cartilage with spreader grafts and horizontal control sutures can decrease risk of recurrence.

A "modified-flying wing" procedure for the treatment of saddle nose and supratip pathologies.

OBJECTIVES: In this report, we present the usage of a "modified flying wing" procedure for different indications such as correction of primary supratip depression and saddle nose deformity due to prior septal surgery or prior trauma, and also for prevention of possible supratip deformity. PATIENTS AND METHODS: Between April 2004 and January 2008, the "modified flying wing" procedure was used in a total of 11 patients; for the correction of primary supratip depression deformities in three patients, for the saddle nose deformities due to prior trauma or septal surgery in four patients, and for the prevention of future supratip deformity in four patients (3 males, 8 females; mean age 25.3 years; range 19 to 35 years). The "modified-flying wing" procedure was performed as described by Jugo. Hump removal and medial or lateral osteotomy were considered based on patient status. In all patients a symmetric, balanced nose was achieved with an adequately projected tip and an esthetically satisfactory dorsum extending from the brows to the tip of the nose. No patient required a secondary rhinoplasty. RESULTS: In all patients the postoperative periods were without any complication and the long-term results were satisfactory. CONCLUSION: Using a "modified flying wing" procedure for the correction of saddle nose deformity avoids some disadvantages of autografts, such as the tendency of the autograft to warp and curl. Use of this procedure for primary rhinoplasty patients with a risk of developing future supratip deformity prevents this deformity. This combination approach in selected primary rhinoplasty cases provides an esthetically pleasing nose while preventing some complications of classical reduction rhinoplasty. We performed this procedure in 11 patients with good long-term functional and esthetic results.