Combination of ischemic preconditioning and postconditioning can minimise skin flap loss: experimental study.

OBJECTIVES: Ischaemic preconditioning and postconditioning, which consist of one or a series of short ischaemic events. This study aimed to determine the efficiency of post-conditioning a flap in the minimisation of flap loss after a preconditioned skin flap. METHODS: The rats were divided into five groups: sham group, control group, pre-con group, post-con group, and pre + post-con group. On postoperative days 3 and 7, the entire flaps along with the margins of necrosis were traced onto transparent sheets. The areas of intact skin and tissue were recorded. RESULTS: The flap necrosis area and percentage of necrosis were calculated for each animal. The necrotic area percentage of the control group was found to be significantly higher than those of the other groups on Days 3 and 7 (p = 0.01 and p = 0.03, respectively). The necrotic area percentage of the pre-con group was significantly higher than the pre + post-con group on Day 7 (p = 0.01). VEGFR-3 expression was observed at a rate of more than 50% in the post-con group. The presence of a protective effect in the late period was separately investigated by immunohistochemical staining of VEGFR-3 in the proliferating vessels. The necrotic areas was reduced in the flaps of the pre-con, post-con, and pre + post-con groups and the combined preconditioning and postconditioning group has reduced necrotic area compared to preconditioning of the skin flap. CONCLUSION: The protective effect was observed on day 7 for combined ischaemic preconditioning and postconditioning. The presence of a protective effect in the late period was separately investigated by immunohistochemical staining of VEGFR-3 in the proliferating vessels.

Does vitamin B alter the efficacy of botulinum toxin?

Botulinum toxin prevents acetylcholine release at motor nerve terminals. Group B vitamins (B-vit) are essential for proper nerve function. The present study addresses the question of whether B-vit accelerate recovery in rat skeletal muscle after botulinum toxin A (Btx-A) injection. Forty-four adult male Wistar albino rats were used in this experimental study. Rats were divided into three groups: group 1 rats were given Btx-A injection only, group 2 rats were given B-vit supplementation before Btx-A injection, and group 3 rats were given Btx-A and B-vit injections together. During the experiment, compound muscle action potential (CMAP) of the gastrocnemius muscle was recorded before Btx-A injection and sequentially ten times after toxin injection. The statistical significance of the CMAP amplitude change among the groups was analyzed. All groups showed similar amplitude change between consecutive measurement points. In conclusion, combining Btx-A injection with B-vit supplement does not decrease the efficacy of the toxin.

Witch nose: an embarassing metaphor for nasal tip dermoid cysts.

Nasal dermoid cysts are one of the most frequent congenital pathologic lesions of the nasal area. These lesions may have intracranial extensions without any clinical evidence, which can be explained by the pathophysiologic development of the lesion, thought to be related to a delay or pause during the separation period of the dura and skin during embryogenesis. This factor is independent from the location and size of the lesion and may lead surgeons to misdiagnoses or inadequate treatments.In this article, 2 cases of nasal dermoid cysts localized at the tip of the nose are presented. Although these lesions can be seen anywhere from the root to the columella, nasal tip location is rare in previously published series. In the cases presented in this study, both patients are school-aged and are faced with social and psychologic problems, as their friends call them "witch nose," in reference to the lesion at the tip of the nose. Vertical tip incision for complete excision of these lesions was performed after accurate radiologic imaging of the brain and possible intracranial extension. No complications or recurrence was seen in either patient.Although the treatment of dermoid cysts is surgical, operative planning should be made after complete physical and radiologic examinations. As the lesion may lead to psychologic and social problems because of its appearance, especially in children, therapy should not be delayed.

Combination of stromal cell-derived factor-1 and collagen-glycosaminoglycan scaffold delays contraction and accelerates reepithelialization of dermal wounds in wild-type mice.

While dermal substitutes can mitigate scarring and wound contraction, a significant drawback of current dermal replacement technologies is the apparent delay in vascular ingrowth compared with conventional skin grafts. Herein, we examined the effect of the chemokine stromal cell-derived factor-1 (SDF-1) on the performance of a porous collagen-glycosaminoglycan dermal analog in excisional wounds in mice. C57BL/6 mice with 1 cm × 1 cm dorsal full-thickness wounds were covered with a collagen-glycosaminoglycan scaffold, followed by four daily topical applications of 1 µg SDF-1 or phosphate-buffered saline vehicle. Some animals were also pretreated with five daily doses of 300 mg/kg granulocyte colony-stimulating factor. Animals treated with SDF-1 and no granulocyte colony-stimulating factor reepithelialized 36% faster than vehicle controls (16 vs. 25 days), and exhibited less wound contraction on postwounding day 18 (∼ 35% greater wound area) plus three-fold longer neoepidermis formed than controls. Conversely, granulocyte colony-stimulating factor promoted contraction and no epidermal regeneration. Early (postwounding Day 3) inflammatory cell infiltration in the SDF-1-treated group was 86% less, while the fraction of proliferating cells (positive Ki67 staining) was 32% more, when compared with controls. These results suggest that SDF-1 simultaneously delays contraction and promotes reepithelialization and may improve the wound-healing performance of skin substitutes.

Effects of vinblastine on microvascular anastomosis healing in diabetic rats.

OBJECTIVE: Diabetes mellitus and chemotherapy use are well-known factors that can affect success after microvascular repair. Although many studies have investigated each factor individually, no study exists on their combined effect. The aim of our study was to investigate the effects of preoperative vinblastine, a vinca alkaloid, on the healing of microvascular anastomosis in diabetic and non-diabetic rats. METHODS: In this study, 144 Sprague Dawley rats were assigned randomly and equally into experimental or control groups. The experimental group consisted of 72 rats which were made diabetic by alloxan injections. Diabetes was confirmed by glycosuria (>2%) and elevated plasma glucose (>300 mg/100 ml) after three days of alloxan injections. The experimental group then received a single dose of intraperitoneal vinblastine. After applying the medication, the two main groups were divided into three subgroups. For each group, we performed end-to-end femoral artery anastomosis on Day 7, 14, and 21, respectively. We further divided each subgroup equally into three smaller groups to test patency and took biopsies at Day 7, 14 and 21, respectively. Histopathologic evaluation was carried out. RESULTS: The comparison of patency tests and pathologic examination indicated that there was no statistically significant difference between the two groups. CONCLUSION: The negative effects of diabetes and the administration of vinblastine did not significantly influence anastomosis healing.

Stereolithographic volume evaluation of healing and shaping after rhinoplasty operations.

Nasal edema and volume changes are unavoidable processes during the healing period after rhinoplasty. Various applications were reported regarding the prevention of early edema; however, the literature shows no study focused on the course of the nasal edema and volume changes up-to-date. We aimed to study the nasal volume changes during the first year of postoperative healing period and to form a recovery and volume change diagram with the obtained data. We prepared standard frames and nasal molds of 7 rhinoplasty patients at regular time intervals (preoperative period and at the postoperative 1st, 2nd, 4th, 8th, 12th, 24th, and 52nd weeks). Plaster nasal models were created by using these molds. Volumes of models were measured by computed tomographic scanning and three-dimensional image processing programs. According to our results, the nasal edema reaches its maximum level at the postoperative fourth week and then rapidly decreases until its minimum level at the eighth week. In contrast with the general opinion, the nasal volume begins to increase smoothly reaching to a level minimally below the preoperative value by the end of the first year.

Improved survival of murine island skin flaps by prevention of reperfusion injury.

BACKGROUND: Studies have demonstrated that blocking a single specificity of self-reactive immunoglobulin M with a 12-amino acid peptide mimic of the antigen of immunoglobulin M can attenuate murine intestinal and skeletal muscle injury following ischemia and reperfusion. The aim of this study was to ascertain whether peptide (P8) had protective effects in an axial island skin flap model, where tissue loss is attributed to ischemia-reperfusion injury. METHODS: Dorsal lateral thoracic artery island skin flaps (3.5 x 1.5 cm) were elevated in 82 male C57BL/6 mice and rendered ischemic for 10 hours by placing a 7-mm microclamp on the vascular pedicle followed by 7 days of reperfusion. Group I (n = 7), the sham group, had no clamp placed. Group II (n = 21) had clamp placement but no other treatment. Thirty minutes before clamp placement, group III (n = 18) received 0.25 cc of saline intravenously, group IV (n = 18) received 25 microg/0.25 cc P8 peptide, and group V (n = 7) received 25 microg/0.25 cc random 12-mer peptide. Animals in group VI (n = 11) underwent two cycles of 20 minutes of ischemic preconditioning before 10 hours of ischemia. After 1 week of reperfusion, percent necrosis was measured and results were compared using analysis of variance and an unpaired t test. RESULTS: In animals treated with P8 peptide, flap necrosis was 14.61 +/- 2.77 percent. This represents a statistically significant, 56 percent reduction in flap necrosis compared with controls (p < 0.001). CONCLUSION: These data demonstrate that prevention of ischemia-reperfusion injury with P8 peptide produces a significant reduction in necrosis of treated flaps.

A novel murine island skin flap for ischemic preconditioning.

BACKGROUND: Ischemia reperfusion injury is a well-known phenomenon affecting skin flap viability. One method to improve flap viability is ischemic preconditioning. Previous murine flap models used random flaps. We developed a single pedicle island skin flap which allows us to create true ischemia by clamping the single pedicle. Our first aim was to describe a novel murine skin flap model with a definable, reproducible injury. Our second aim was to test the usefulness of this model by demonstrating mitigation of injury via ischemic preconditioning. MATERIALS AND METHODS: Dorsal lateral thoracic artery pedicle island skin flaps (3.5 x 1.5 cm) were elevated in 39 male C57/BL6 mice: a Control group (n = 7), 10 h of ischemia (n = 21), and Preconditioning (2 cycles of 20 min ischemia: 20 minutes reperfusion) + 10-h ischemia (n = 11). After flap elevation, a silicon sheet barrier was placed. The axial pedicles were occluded, and the flaps were inset with 6-0 prolene. In all mice, ischemia was followed by 1 wk of reperfusion. At 1 wk, percent necrosis was measured and an analysis of variance was performed. RESULTS: The percent of flap necrosis was 1.1% +/- 1.11% in controls. Animals that were subjected to 10 h of ischemia developed 33.14% +/- 7.23% necrosis. Preconditioned animals that underwent 10 h of ischemia demonstrated a 43% reduction in necrosis (18.82% +/- 5.68%). There was a statistically significant difference among all groups (P < or = 0.001). CONCLUSION: Rat models have been the standard for skin flap experiments. We have developed a novel murine single pedicle island skin flap model with reproducible injury. This model has numerous advantages, including ease of handling, low cost, appropriateness for biomedical studies, and the availability of genetically altered animals. We also confirmed this model's usefulness in a study of mitigation of ischemia reperfusion injury through ischemic preconditioning.

Lower lip reconstruction with local neuromusculocutaneous advancement flap.

Various reconstruction techniques, using the remaining lip or the adjacent cheek tissue, have been described for the repair of lower lip defects. With these techniques, microstomia, commissural distortion, functional insufficiency, and sensorial loss might be observed. The authors describe a technique of lower lip reconstruction with preservation of neuromuscular tissue as a single-stage procedure. Lip sensation and orbicularis oris muscle function are preserved. Fifteen patients with lower lip defects, after tumour ablation or after traumatic loss, were treated by this technique. The only prerequisite for the application of this technique is the availability of at least 20% of the remaining lip tissue. Satisfactory functional, aesthetical, and sensational results were obtained.

A useful tool for intraoperative photography: underwater camera case.

The use of cameras in the operating room is increasing. However, there is not always a free person or an assistant who is familiar with your camera. In order to take faster and high quality photographs in the operating room, we use under water camera cases. These cases are produced for each type of camera and can be gas sterilized prior to operation.

A new technique in nipple reconstruction: dome technique with double pedicle.

BACKGROUND: One of the main steps for satisfactory breast reconstruction is symmetrical nipple reconstruction in an ideal position and projection. Various techniques, using cartilage, bone, fat, and even hydroxyapatite crystals, have been proposed to overcome projection loss in late term. METHOD: We present a new nipple reconstruction technique performed in 6 cases. In this technique, the nipple dome is nourished by a double pedicle and supported by lateral flaps. Nipple projection is secured with 4/0 nylon sutures, which are applied between pedicles. Skin excess is advanced to the donor areas of nipple flaps. RESULTS: All patients were discharged the day after the operation, and nipple flaps healed well. No projection loss was noted in the 8- to 12-month follow-up period. Areola shape and consistency were acceptable. CONCLUSION: Due to the presence of a double pedicle, this technique is especially helpful for patients with possible circulatory problems. Tension-free closure and rich blood supply to the nipple dome prevent loss of projection in the late term.

A new nerve-muscle unit model for peripheral nerve studies in rats.

Ischiatic, femoral and tibial nerves are commonly utilized in the studies of peripheral nerve surgery in rats. The authors present a new nerve-muscle unit model in which the nerve is distal enough to minimize morbidity and the muscle is convenient for all electromyographic studies. Twenty-five Wistar-Albino rats were used. In the control group; normal electromyography and histology were demonstrated in the lateral tibial nerve (LTN) and in the flexor digiti quinti brevis (FDQB) muscle. In experimental group I; a 0.5 cm nerve gap was made in the LT nerve and the proximal end was buried in the muscle in order to prevent reinnervation. In experimental group II, the LTN was cut and repaired primarily. In both groups I and II, electromyographic and histologic studies were performed at 6 and 12 weeks. In study group I, atrophic and degenerative findings were observed and in study group II, only regenerative findings were observed. The authors concluded that the LT nerve-FDQB muscle unit is a convenient model for peripheral nerve studies, with the advantages of easy dissection, wide exposure, and minimal morbidity. This model is also convenient for electromyographic and histologic evaluation.

Sialoblastoma: a congenital epithelial tumor of the salivary gland.

Sialoblastoma is a rare congenital epithelial tumor of the salivary gland that is diagnosed at birth or shortly thereafter with significant variability in histologic range and clinical course; hence, for an individual case, it may be difficult to predict the most appropriate therapy [Cancer 1972;30:459-69; Pediatr Pathol 1988;8:447-52; Br J Plast Surg 2000;53(8):697-699]. We report the case of a 4-year-old girl who had a widely spreading sialoblastoma of the left cheek. We were obligated to widely resect the tumor including the trunk of the facial nerve, superior part of the left maxilla, and the zygoma. Although the patient was operated 3 times in 4 years, invasion of the tumor could not be stopped. The patient died because of respiratory insufficiency and deterioration of her general health.

Martius repair in urethrovaginal defects.

AIM: To repair a urethrovaginal defect in childhood is a challenge for a pediatric surgeon. Martius fat-pad flap repair is being used in women successfully. Here, we report 2 girls who had Martius repair for their urethrovaginal defects. METHOD: Topical estriol and asiaticoside perineally were administered for preoperative 3 weeks to reinforce the tissues. Martius repair was done using 1-sided labial fat-pad flap. Urethral and bladder catheters were inserted. Urethral catheter was removed on postoperative day 14 and bladder catheter on day 21 after controlling residual urine. PATIENTS: Patient 1, a 6-year-old girl, had lipomeningocele repair at the age of 18 months and had an iatrogenic urethrovaginal fistula that is caused by catheter insertion. She developed urinary incontinence, and 3 primary repair attempts were unsuccessful. Patient 2 is a 5-year-old girl who had pouch colon with persistent cloacal malformation and had posterior anorectovaginourethroplasty. The urethrovaginal septum did not heal, and she was incontinent. One attempt of primary repair was unsuccessful. The urethrovaginal wall was completely open at the time of Martius repair in both patients. RESULTS: Urethral wall was completely healed after Martius repair in both patients. CONCLUSION: Martius fat-pad flap repair can be used to repair urethrovaginal fistulas in girls. It has both functionally and cosmetically good results, and neourethra is easily catheterizable.

Hair removal with the long-pulse alexandrite laser.

BACKGROUND: Although laser depilation has been performed for removal or reduction of unwanted and dark-colored hair in recent years, techniques including the appropriate approaches for different skin types and body areas have not yet been optimized. OBJECTIVE: We review the principles of laser hair removal and report a retrospective study of 322 patients who received long-pulse alexandrite laser hair removal for 3 or more sessions between January 2000 and December 2002. METHODS: Prior to treatment, patients were evaluated by a physician and informed of the mechanism, efficacy, and possible side effects of treatment. Patients were classified by skin type according to the Fitzpatrick classification. Those patients with systemic disease, a history of sun sensitivity, or who had used drugs known to cause photosensitivity were excluded from laser treatment. All treatments were performed with a long-pulse alexandrite laser with a constant spot size (18 mm) and 3-ms pulse width that applied energy of 755 nm. Sessions were repeated at different intervals depending on the body parts to be treated. RESULTS: The overall hair reduction rate for all patients, independent of skin type, was estimated as 80.8%. There were 2 cases of hypopigmentation and 8 cases of hyperpigmentation post-treatment. No other complications were reported. CONCLUSIONS: Treatment with the long-pulse alexandrite laser can meet the expectations of patients who desire permanent hair removal. Careful examination of patients prior to therapy, as well as thorough patient education, are essential to patient compliance and success with this technique.