A novel autologous dermal filler based on cultured fibroblasts and plasma gel for facial wrinkles: Long term results.

Autologous cultured fibroblasts combined with plasma gel (FibrogelTM) can be used as an injectable autologous soft tissue filler. Herein, we report the assessment of the long-term clinical efficacy and safety of Fibrogel for facial wrinkles. Ten healthy adults were treated for facial wrinkles with Fibrogel, an innovative autologous filler. Patients underwent three treatment sessions at 1-month intervals for the correction of infraorbital, nasolabial, and marionette folds. In each session, 6-8 mL of Fibrogel filler containing 4 million fibroblasts/mL, was injected into the deep dermis or subdermal plane. Three evaluators independently assessed the efficacy at 3, 6 and 12 months after the last treatment, using the validated Global Esthetic Improvement Scale at two different times in a blinded manner. Infraorbital area and lower face were evaluated separately. All patients showed immediate improvement after the first injection at the infraorbital area and lower face. Follow-ups at 3, 6 and 12 months revealed that the improvement was persistent. Adverse reactions were mild and the treatment was well tolerated. Delivering autologous cultured fibroblasts embedded in an autologous plasma gel (Fibrogel) to the skin can provide immediate volume effect and long-term improvement. Therefore, Fibrogel can be considered as a promising novel autologous filler.

Autologous Dermal Filler Derived from Cultured Dermal Fibroblasts and Plasma Gel (Fibrogel): One-year Follow-up of a Case.

In recent years, autologous fibroblast injections or plasma gel filler applications have been used in the treatment of facial contour deformities. In this case report, we describe a new method of autologous filler material derived from cultured dermal fibroblast and plasma gel. The plasma gel, which is the bioskeleton of the filler, is prepared from the patient's plasma, which provides a dense environment for a three-dimensional configuration of dermal fibroblasts. Although the plasma gel provides immediate volume effect, the fibroblasts synthesize extracelluar matrix proteins to promote skin rejuvenation. The filler effect occurs immediately after the first injection and persists 12 months after the third injection, without any complication. Long-term result of the presented case is promising for the concept of autologous filler development.

Defect closure with "8-shaped crisscross tensile suture" technique.

BACKGROUND: Sutures and suturing techniques compose the basis of the surgery. Although many surgical methods such as the skin grafts or flaps has been described for the closure of large defects, proper primary suturing may sometimes yield very successful results and decrease the need of complicated procedures. In this article, a new combined skin-subcutaneous tissue suturing technique called as "8-shaped crisscross tensile suture (8CTS)" designed for the closure of large skin defects is presented. PATIENTS AND METHODS: One hundred forty-nine patients with an age distribution between 14 and 65 y were operated for large skin defects by using the 8CTS technique. The most common etiology of the defects was free flap donor sites, and the most common defect localization was the anterolateral thigh region. The average defect width on the axis of primary closure was calculated as 14.6 cm. The 8CTS technique is a combination of both skin and subcutaneous layers suturation and may even involve deeper layers suturation according to the depth of the defect. RESULTS: Eight complications including wound dehiscence, early recurrence of pilonidal sinus disease, seroma formation, skin-edge necrosis, and incisional hernia were observed. The wounds of 141 patients were treated successfully. CONCLUSIONS: The 8CTS technique is a useful method for the closure of large defects eliminating the need of more complex procedures and providing acceptable cosmetic results while supporting both skin and subcutaneous tissue in one suture.

Microsurgical reconstruction in pediatric patients: a series of 30 patients.

BACKGROUND: Free flap surgery in the pediatric population has gained widespread acceptance regarding its technical utility and reliability. Initial concerns as to the feasibility and reliability of the procedure in children were resolved over time. METHODS: Thirty children (15 boys, 15 girls) were treated in Sisli Etfal Training and Research Hospital, Plastic and Reconstructive Surgery Clinic. Their mean age was 10.8 years. Defects were located on the lower extremity (n=22), head and neck (n=5) and upper extremity (n=3). The etiologies of the defects included vehicle accident, sequelae of burn, traumatic contractures, crush injury, epulis in the maxilla, and gunshot wound. RESULTS: The free flaps performed in our series were latissimus dorsi muscle flap, combined latissimus dorsi and serratus muscle flaps, serratus anterior muscle flap, cross latissimus dorsi muscle flap, scapular osteomyocutaneous flap, parascapular fasciocutaneous flap, fibular osteocutaneous flap, anterolateral thigh flap, medial circumflex femoral artery perforator flap, and crista iliaca osteocutaneous flap. CONCLUSION: The advantages of free flaps in children, which include better adaptation of the flap growth and better learning capacity of the children, provide the surgeon with more satisfactory functional and aesthetic results.

Computer-aided design and manufacture and rapid prototyped polymethylmethacrylate reconstruction.

UNLABELLED: This article discusses the application of computer-aided design and rapid prototyping techniques in polymethylmethacrylate reconstruction of craniofacial bone defects. This method avoids the probability of tissue damage due to exothermic reaction during the polymerization process and provides precise implants that exactly fit the defects. METHODS: A total of 11 patients who have various-sized craniofacial defects underwent polymethylmethacrylate reconstruction. We performed three-dimensional reconstruction and operative design using computer software. According to the design, we determined the shape and size of the implants and made individualized implants for craniofacial bone defects with the rapid prototyping technique. RESULTS: With the application of computer-aided design and a rapid prototyping technique, we could accurately determine the shape, size, and embedding location. Prefabricating the individual implant models is useful in improving the accuracy of treatment. No cases of infection, seroma, extrusion, or contour irregularity occurred as a complication, and all patients were satisfied with the results. During the follow-up period, ranging from 1 to 6 years, all patients remained satisfied, and no complications were sustained. CONCLUSIONS: In cases of various-sized cranial defects and complex maxillofacial defects that have enough soft tissue coverage and that do not have contact with a third space, prefabricated methyl methacrylate implants can be used safely. Patients will feel more comfortable if the postoperative shape resembles the original appearance, so the proposed algorithm effectively creates a customized implant.

Lower extremity soft tissue reconstruction with free flap based on subscapular artery.

OBJECTIVES: The purpose of our study was to evaluate the results of the reconstruction of the lower extremity defects with free flaps based on the subscapular artery. METHODS: Between January, 1998 and December, 2008, 51 patients (mean age 26 years; 16 female and 35 male) presenting with a lower extremity defect underwent a reconstructive surgery with flaps based on the subscapular vascular system. Thirty-seven percent of the defects were located in the crus, 19% in the sole, 16% in the heel, and 14% in the dorsum of the foot. Eighty and a half percent of the patients had traffic-accident-related and 13.5% had burn-related tissue defects. RESULTS: Fifty-three percent of the patients presenting with lower extremity defects underwent reconstruction with latissimus dorsi muscle flaps, 21% with free serratus muscle and/or fascia flaps, 14% with free parascapular fasciocutaneous flaps, and 12% with free combined latissimus muscle and serratus muscle and/or fascia flaps. Anastomoses of 80% of the patients were performed on their posterior tibial artery and accompanying veins and/or foot dorsal veins. End-to-end anastomosis was performed on 14 patients, while 35 patients received end-to-side anastomosis. Six patients were treated with cross free flaps, of which 4 received cross latissimus, 1 cross serratus, and 1 cross combined serratus and latissimus flaps. End-to-side anastomoses were performed on these patients on the cross-leg tibialis posterior artery. The cross-leg anastomosis was freed 4 weeks later. In the early period, venous occlusion was observed in 4 patients and arterial and venous occlusion was present in 1 patient. New anastomoses were performed in these patients. Partial necrosis was observed in 2 patients. The average follow-up period was 61 months. Pressure-related late ulcerative lesions developed in 4 patients. The lesions of these patients were repaired by debridement and primary suturing or partial thickness skin grafts. CONCLUSION: The subscapular vascular system based flaps have an optimal vascularity once they are prepared with adequate pedicles, causing minimal donor site morbidity. These flaps are a safe and effective alternative in lower extremity reconstruction. On the other hand, in the absence of appropriate recipient vessels, single or combined cross-leg free flaps may provide successful repair.

Repair of a wide lower extremity defect with cross-leg free transfer of latissimus dorsi and serratus anterior combined flap: a case report.

Composite tissue loss in extremities involving neurovascular structures has been a major challenge for reconstructive surgeons. Reconstruction of large defects can only be achieved with microsurgical procedures. The success of free flap operations depends on the presence of healthy recipient vessels. In cases with no suitable donor artery and vein or in which even the use of vein grafts would not be feasible, the lower limb can be salvaged with a cross-leg free flap procedure. We present a case with a large composite tissue loss that was reconstructed with cross-leg free transfer of a combined latissimus dorsi and serratus anterior muscle flap. This case indicates that this large muscle flap can survive with the cross-leg free flap method and this technique may be a viable alternative for large lower extremity defects that have no reliable recipient artery.

Nipple reconstruction with bipedicled dermal flap: a new and easy technique.

BACKGROUND: Nipple reconstruction is the last step in breast reconstruction. An entirely satisfying breast reconstruction can be achieved only with a symmetrically placed and ideally shaped nipple-areola complex. Several techniques and modifications have been described for nipple-areola reconstruction but long-term projection loss is still a problem in nipple reconstruction. METHODS: Between January 2005 and October 2008, 13 female patients underwent 19 nipple reconstructions in our department. Among these patients, seven underwent breast reconstruction with a DIEP flap following unilateral mastectomy, and six were diagnosed with gigantomasty and underwent bilateral breast reduction with a modification of free nipple grafting. Our method for nipple reconstruction relies on a vertically oriented bipedicled flap with horizontally oriented extensions from the mid-portion. RESULTS: Nineteen nipple reconstructions in 13 patients were evaluated and the mean follow-up period was 15 months. We did not see any necrosis or any significant projection loss in our cases. Patients' satisfaction was noted as high and the results were evaluated as pleasing. CONCLUSION: We present a new technique that uses a bipedicled flap, oriented vertically. A rich blood supply to the flap may be the principal cause for long-lasting nipple projection.

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.

A retrospective study on the epidemiology and treatment of maxillofacial fractures.

BACKGROUND: Maxillofacial injuries constitute a substantial proportion of cases of trauma. This descriptive analytical study assesses the cause, type, incidence, and demographic and treatment data of maxillofacial fractures. METHODS: A retrospective study on maxillofacial traumas was carried out in the Department of Plastic and Reconstructive Surgery at Sisli Etfal Hospital (Istanbul, Turkey) between January 1, 2000 and December 31, 2005. The study included 216 patients with a mean age of 29.8 years. Sex and age distribution of patients, etiology of trauma, localization of the fractures, treatment modalities, time to treatment after the trauma, and postoperative complications were recorded. RESULTS: The male predilection was 75.5%. Road traffic accident was the most common causative factor (67.1%), followed by interpersonal violence (19.4%), falls (12.5%), and work- and sport-related accidents (0.9%). A total of 50% of the patients suffered isolated mandibular fractures, 23.6% had isolated midface fractures, and 26.3% had combined midface and mandibular fractures. Regarding distribution of mandibular fractures, the majority (26.8%) occurred in the parasymphysis, 14.8% in the angulus, and 11.1% each in the symphysis and corpus. Complications occurred in 6% of patients, and the most common was malocclusion followed by infection and nonunion. CONCLUSION: The causes and pattern of maxillofacial fractures reflect trauma patterns within the community and, as such, can provide a guide for the design of programs geared toward prevention and treatment.

Use of rapid prototyping in prosthetic auricular restoration.

Reconstructing auricular defects is a challenging task for facial reconstructive surgeons. Although autologous reconstruction is the first choice for reconstruction, there may be circumstances of inconvenience such as previously attempted surgery, radiotherapy, systemic conditions, or patient's wish. Auricular restorations with facial prosthesis have produced promising results, but there are still problems to be tackled for improved results. Rapid prototyping in the production of an auricular prosthesis uses the mirror image of contralateral ear and produces excellent forms, eliminating the subjective perception of the prosthodontist. Rapid prototyping also lowers the production costs by reducing the need for several sessions in the process of producing the prostheses. Between 2004 and 2007, 10 patients applied to our department with the absence of an ear on a single side. All patients were male, with an average age of 23.1 years. The etiology for the loss of the ear was mostly tumors, followed by congenital deformities and trauma, respectively. In this study, we present our application of rapid prototyping technique and report our case series of 10 patients, two of which are presented in detail.

A new glabellar flap modification for the reconstruction of medial canthal and nasal dorsal defects: "flap in flap" technique.

BACKGROUND: In considering periorbital reconstructive options, the goals of reconstruction are to obtain functional and esthetic results. At the medial canthus, reconstruction should maintain the normal concavity of the canthus without distortion of the surrounding tissues and should maintain normal eyebrow contour and symmetry. The authors represent their flap in flap technique that provides normal concavity of the canthus and does not cause any complex and undesirable scars. METHODS: A new modification of conventional glabellar flap which was named "flap in flap technique" was raised to cover medial canthal defect. We designed an inverted V-shaped advancement flap (123Delta-A flap) that contains both B (145Delta flap) and C (2345) flaps. The B flap is designed in the glabellar region, which is at medial side of the defect and is transposed to defect, and the C flap is planned in V-Y fashion to release tension over the B flap. RESULTS: To date, we have used this technique successfully in 5 patients (4 women and 1 man), requiring a glabellar flap to reconstruct the medial canthus and proximal nasal dorsum. All defects were secondary to excision of basal cell carcinoma. All were satisfied with the cosmetic and functional results. CONCLUSIONS: Our glabellar flap in flap technique for the reconstruction of medial canthal defects has several advantages such as maintaining concavity of the canthus without distortion of the surrounding tissues and providing normal eyebrow contour and symmetry.

Reconstruction of complicated scalp defect via skin traction.

Management of an open wound is a problem frequently faced, with skin defects that cannot be closed primarily. Functional and aesthetic outcome could be improved if primary approximation of skin in these large defects were possible. Primary closure may be assisted using the viscoelastic properties of the skin. The viscoelastic properties of mechanical creep and stress relaxation in the skin were described more than 40 years ago. If skin is stretched with a constant force, it will expand with time as long as it is kept under tension, a phenomenon known as mechanical creep. In contrast, if the skin is stretched to a constant distance, it will expand and lead to a decrease in the force or tension on the skin with time, a phenomenon known as stress relaxation. We have recently applied these stretching properties to close the scalp because of a defect, which previously would have undergone pericranial flap and split-thickness graft. Because of the partial necrosis of the pericranial flap, skin grafting failed. In the second stage, we inserted only the wrist part of elastic latex gloves to the wound edges in full thickness. The skin margins were advanced slowly and gently.

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 new technique for medial canthal tendon fixation.

Traumas resulting from naso-orbitoethmoidal fractures and tumor surgery of the medial canthal region may cause orbital dystopia. A variety of techniques with many disadvantages, such as detachment and high cost, has been described for reattachment of medial canthal tendon. We present a new technique, namely, unitransnasal canthoplasty, which is easy to apply, cheap, and reliable. Two nonabsorbable sutures were passed through 2 drill holes to the nasal cavity, taken out from the nasal ostium, and were tied up. Upper and lower eyelids were fixed to the ipsilateral nasal bone.

Biomechanical comparison of a new technique of mandibular angle fractures: biplanar and bicortical superior proximal 3 holes and bicortical inferior plate fixation.

Miniplates have been used for mandibular angle fractures during the past 2 decades. The technique of placing single miniplate at the upper border based on the tension lines of the fracture was proposed by Michelet and Champy. The need for a second miniplate to be applied to the lower mandible has been discussed recently. Biomechanical comparison of biplanar and monoplanar dual-miniplate fixation techniques was investigated by Haug. Our hypothesis is in dual-miniplate fixation; the proximal 3 holes of superior border miniplate could be fixated by bicortical screws. The first 2 are at the proximal bone segment and are not related to the tooth and also superior to the alveolar nerve. Generally, the third molar tooth is extracted because it is at the fracture site. Hence, the proximal third hole could also be fixated by bicortical screws. We define a biplanar dual-miniplate technique in which the lower plate and the proximal 3 holes of the upper plate are fixated by bicortical screws. We have designed a study for biomechanical comparison of our method and popular types of mandibular fixation methods.