Patient with Severe Skeletal Class II Malocclusion: Double Jaw Surgery with Multipiece Le Fort I.

A 22-year-old woman with severe skeletal Class II malocclusion was referred to our clinic. A clinical examination revealed a convex soft tissue profile and increased teeth and gingiva exposure both while smiling and in the natural rest position. She had Class II molar and canine relationship with increased overjet, moderate crowding in both upper and lower jaws, and proclined upper and lower incisors. Skeletally, she showed transverse maxillary deficiency, maxillary vertical excess, and mandibular retrognathia. We planned orthodontic-orthognathic surgery with multipiece Le Fort I osteotomy and bilateral sagittal split osteotomy (BSSO) to achieve ideal occlusion, stability, and facial esthetics. During orthodontic decompensation to relieve the crowding and to gain an ideal incisor inclination, four bicuspid extractions were performed. Because we used continuous mechanics, at the end of the decompensation period, we cut the maxillary arch wire distal to the lateral incisors into three pieces and waited for 3 months for vertical and transversal dental relapse. During the double jaw surgical procedure, the maxilla expanded and impacted with multisegmented Le Fort I osteotomy and the mandible advanced with BSSO. After the orthodontic and orthognathic surgical treatment, the skeletal and dental imbalance was corrected, and functional occlusion and dental and skeletal Class I relationship were achieved. The treatment results were stable at the 1-year follow-up.

Targeted mesenchymal stem cell and vascular endothelial growth factor strategies for repair of nerve defects with nerve tissue implanted autogenous vein graft conduits.

Peripheral nerve gaps exceeding 1 cm require a bridging repair strategy. Clinical feasibility of autogenous nerve grafting is limited by donor site comorbidity. In this study we investigated neuroregenerative efficacy of autogenous vein grafts implanted with tissue fragments from distal nerve in combination with vascular endothelial growth factor (VEGF) or mesenchymal stem cells (MSCs) in repair of rat peripheral nerve defects. Six-groups of Sprague-Dawley rats (n = 8 each) were evaluated in the autogenous setting using a 1.6 cm long peroneal nerve defect: Empty vein graft (group 1), Nerve graft (group 2), Vein graft and nerve fragments (group 3), Vein graft and nerve fragments and blank microspheres (group 4), Vein graft and nerve fragments and VEGF microspheres (group 5), Vein graft and nerve fragments and MSCs (group 6). Nerve fragments were derived from distal segment. Walking track analysis, electrophysiology and nerve histomorphometry were performed for assessment. Peroneal function indices (PFI), electrophysiology (amplitude) and axon count results for group 2 were -9.12 ± 3.07, 12.81 ± 2.46 mV, and 1697.88 ± 166.18, whereas the results for group 5 were -9.35 ± 2.55, 12.68 ± 1.78, and 1566 ± 131.44, respectively. The assessment results did not reveal statistical difference between groups 2 and 5 (P > 0.05). The best outcomes were seen in group 2 and 5 followed by group 6. Compared to other groups, poorest outcomes were seen in group 1 (P ≤ 0.05). PFI, electrophysiology (amplitude) and axon count results for group 1 were -208.82 ± 110.69, 0.86 ± 0.52, and 444.50 ± 274.03, respectively. Vein conduits implanted with distal nerve-derived nerve fragments improved axonal regeneration. VEGF was superior to MSCs in facilitating nerve regeneration. © 2015 Wiley Periodicals, Inc. Microsurgery 36:578-585, 2016.

Recalcitrant caustic burn wound and definitive treatment with medial plantar flap.

Caustic chemicals cause destruction in tissues even long after the initial exposure. This study reported a case of recurrent graft lysis encountered throughout the treatment of a sodium hydroxide burn. A caustic burn on the ankle of a patient was reconstructed with split thickness skin grafts thrice in a period of four months. The burn site healed uneventfully after each skin grafting. However, weeks after each successful graft take, even though the patient did not experience any trauma at his operated ankle, an eczematous blistering at the skin graft site was observed. Thereafter, skin grafts almost totally sloughed over time even after each successful graft take. Six months after the initial burn and recurrent skin graft lysis, the defect site was reconstructed with medial plantar flap. At the postoperative ninth month follow-up, there was no sign of the blistering or skin loss at the burn area after definitive flap surgery. Recurrent graft lysis, in a few weeks after total skin graft take is an unusual complication for most of the burn cases. Caustic burns may have a deceptively superficial appearance concealing the chemical reactions that further damage the tissue. Therefore, early surgical interventions such as deep debridement and graft surgery should be kept in mind as primary treatment options.

Changing the Donor Site Selection Concept of Facial Skin Expansion from Pure Healthy Tissue to Defect and Healthy Tissue Combination.

UNLABELLED: Facial defect reconstruction is a challenge for plastic surgeons due to unique esthetic and functional properties of the region. Facial tissue expansion provides an ideal reconstruction resource. However, the donor site is limited in the facial region. Thus, a cost-effective expansion management is crucial for an efficient reconstruction. In this article, the evolution of our donor site preference for tissue expansion from pure healthy tissue to a defect-healthy tissue combination is presented. Fifteen patients underwent skin reconstruction with local tissue expansion for facial and cervical defects. The full facial or cervical region including the defect and healthy tissue combination was determined as the donor expansion site. The donor site was not limited only to pure healthy tissue. The largest size rectangular expander suitable for the combined expandable donor site size was placed under the defect and healthy tissue border, paying attention to carry the expander far beneath the defect site. The defect site and most adjacent healthy tissue were expanded simultaneously. Major complications such as infection, hematoma, rupture, or flap necrosis were not observed. The expansion of defect-healthy tissue border presented successful reconstruction results with acceptable scars. In the traditional tissue expansion concept, using a large size expander to provide more abundant flap gain does not comply with the limited size of healthy donor site in the face. Expanding the whole facial region, without restriction of the defect, supplies excess donor tissue area for larger size expander use. Eventually, defect-healthy tissue border expansion with large expanders results in minimum final scar and less tissue loss in flap relocation and enables optimal flap gain. This method can easily be adapted to any tissue expansion site of the body. 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 .

Avoiding Extended Scar in Skin Expansion: Alagoz Technique.

The principal aim of skin expansion is to provide additional donor tissue without extra donor-site morbidity. Most of the reports about tissue expansion are focused on the properties of expander. Donor-site decision is usually underestimated. Here, we offer to use the defect area and surrounding healthy tissue as the donor site.In 4 cases, expanders were placed just under the defect in a fashion to extend 1 to 2 cm more laterally toward the encircling healthy tissue. The expanded tissue was not mobilized for longer distances; thus, there was no loss in flap gain. The resulting final scar was linear or crescentic. In the Alagoz technique, tissue gain similar in size to the defect is sufficient for reconstruction. The simpler the flap, the best the resulting scar.

Superior Pedicle Reduction Mammoplasty Supported with Inferior Pedicle Chest Wall-Based Flap: Refinements to the Technique.

Breast reduction techniques strive to obtain a final aesthetic breast shape. The most difficult issues to address after breast surgery are providing consistent upper pole fullness and preventing recurrent ptosis. Our surgical approach is a superior pedicle vertical scar breast reduction with an inferior pedicle chest wall-based flap to enhance the projection of the breast. We describe our refinements to the previously described similar techniques to provide upper pole fullness with long-lasting breast shape and prevent the bottoming out deformity. Twenty-five patients underwent reduction mammoplasty and/or mastopexy (15 mastopexy, 10 reduction mammoplasty) using modified superior pedicle reduction mammoplasty supported with inferior pedicle chest wall-based flaps between 2009 and 2013. Medical records and follow-up outcomes were retrospectively analyzed. Scar widening was acceptable even for larger reduction cases. The aesthetic results of both reduction and mastopexy cases were satisfying. Upper pole fullness was maintained in the long-term follow-up. Significant bottoming out was not observed. No skin excess was noted at the inferior fold region in any of the cases. In our modified technique, tissue is excised in a beveled fashion under the superior pedicle and pillars, particularly from the lateral; hence, the chest wall flap does not cause tissue excess at the upper infra-areolar site of the vertical scar. Flexibility in choosing the location from which to remove the breast tissue provides a custom-made approach to shape each breast. The long-term results of our technique demonstrate minimal breast descent and sufficient upper pole fullness.

Saddle-nose deformity repair with microplate-adapted costal cartilage.

UNLABELLED: Nasal deformities affecting the bone and lower two-thirds of the nose due to the loss of septal height and tip support are defined as "saddle-nose" deformity. Reconstruction of a saddle-nose deformity essentially necessitates structural grafting. This article presents an alternative approach for correction of saddle-nose deformity using a microplate and costal cartilage. The results are compared with those of the previously applied costal cartilage repair methods. Between 2004 and 2013, 16 patients were treated with costal cartilage autografts. Of these 16 patients, 7 were treated with a microplate and costal cartilage autograft combination, 4 were treated with a costal cartilage autograft and Kirschner (K)-wire, and 5 were treated with onlay costal cartilage grafts. The mean follow-up periods were 16 months for group treated with microplate-adapted autologous costal cartilage, 12 months for the group treated with K-wire and autologous costal cartilage, and 16 months for the group treated with onlay costal cartilage. The patients treated with K-wire inserted cartilages and the patients treated onlay dorsal costal cartilages encountered complications such as extrusion of the wire and warping, respectively. The seven patients treated with microplate and dorsal onlay costal cartilage graft did not experience any infection, warping, or extrusion complication. The warping tendency of the costal cartilage autograft can be efficiently prevented without a prominent complication risk by using microplate-adapted costal cartilage grafts. 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 .

Minced nerve tissue in vein grafts used as conduits in rat tibial nerves.

INTRODUCTION: Peripheral nerve injuries are encountered frequently in clinical practice. In nerve repair, an end-to-end suture is the preferable choice of treatment. However, where primary closure is not possible, the defect is to be repaired with a nerve graft. METHODS: A total of 21 female Wistar rats weighing 230 to 290 g were used in the study. They were classified into the following 3 groups: (I) nerve graft, (II) vein graft, and (III) minced nerve graft. In group I, after exposure of the tibial nerve, a 1-cm-long nerve gap was created on the tibial nerve, and the defect was repaired epineurally by using the autogenous nerve. In group II, the 1-cm tibial nerve defect was repaired by using an autogenous vein graft. In group III, a 1-cm nerve graft was divided to 3 equal parts, with one of the nerve parts being minced with microscissors and placed in the vein graft lumen. Thereafter, a 1-cm tibial nerve defect was repaired by the vein graft filled with minced nerve tissue. The tibial function indices (TFIs) were calculated for functional assessment using the Bain-Mackinnon-Hunter formula. Light and electron microscopic evaluations were performed for morphometric assessment. In addition, the myelinated fibers were counted in all groups. RESULTS: The TFIs of group II were found to be the lowest among all the groups after the sixth week, whereas the TFI of group I was found to be better than the other groups after the sixth week. There was no difference in TFIs between group I and group III. On the basis of the number of myelinated fibers, there was no statistically significant difference between group I and group III, whereas the difference was significant (P<0.05) between groups I/III and group II. Presence of peripheral nerves in light microscopic evaluation revealed normal characteristics of myelinated fibers in all groups. The myelinated axon profile was near normal in the nerve graft group in electron microscopic evaluation. However, there were more degenerated axons with disturbed contours and vacuolizations in the vein graft group compared to the minced nerve graft group. CONCLUSIONS: We can conclude that using minced nerve tissue in vein grafts as a conduit increases the regeneration of nerves (almost like the nerve graft group) and it may not be caused by donor-site morbidity. It can be used in the repair of nerve defects instead of autogenous nerve grafts after further experimental evidence and clinical trials.

Bilobed flap for web reconstruction in adult syndactyly release: a new technique that can avoid the use of skin graft.

AIM: The aim of the study was to describe the use of a bilobed flap for web formation of syndactyly release, which decreases the need for graft and also avoids the use of skin grafting in syndactyly cases. METHODS: A retrospective review of this procedure was performed for 15 web space reconstructions. Patients were aged 20-23 years. The mean follow-up period was 7-12 months (mean 7 + 3.2). The operations were performed for the beneficial use of the dorsal hand skin by lowering the need for a skin graft. The flap was on the dorsum of the hand and proximal phalanx and was used for web formation. RESULTS: Surgery was completed without skin grafting in nine cases of 14 web spaces; two of them were complex/complete syndactylies, and two of them were simple/complete syndactylies. We used a skin graft in one patient because of triangular flap necrosis in a second operation. The use of a bilobed flap allowed the construction of web spaces, providing satisfactory cosmetic outcomes. No partial necrosis or complications was observed in bilobed flaps. No secondary correction was needed during the follow-up period. CONCLUSION: The present surgical technique could be a new surgical option for web formation and reconstruction in primary and secondary cases, especially in an adult population in which the skin on the dorsum of the hand is more pliable. LEVEL OF EVIDENCE: IV.

Nosocomial infection characteristics in a burn intensive care unit: analysis of an eleven-year active surveillance.

AIMS: The objective of this study was to describe nosocomial infection (NI) rates, risk factors, etiologic agents, antibiotic susceptibility, invasive device utilization and invasive device associated infection rates in a burn intensive care unit (ICU) in Turkey. METHODS: Prospective surveillance of nosocomial infections was performed according to Centers for Disease Control and Prevention (CDC) and National Healthcare Safety Network (NHSN) criteria between 2001 and 2012. The data was analyzed retrospectively. RESULTS: During the study period 658 burn patients were admitted to our burn ICU. 469 cases acquired 602 NI for an overall NI rate of 23.1 per 1000 patient days. 109 of all the cases (16.5%) died. Pseudomonas aeruginosa (241), Acinetobacter baumannii (186) and Staphylococcus aureus (69) were the most common identified bacteria in 547 strains. CONCLUSION: Total burn surface area, full thickness burn, older age, presence of inhalation injury were determined to be the significant risk factors for acquisition of NI. Determining the NI profile at a certain burn ICU can lead the medical staff apply the appropriate treatment regimen and limit the drug resistance. Eleven years surveillance report presented here provides a recent data about the risk factors of NI in a Turkish burn ICU.

Long-term follow-up results of a pediatric brachial plexus laceration.

A rare case of pediatric brachial plexus laceration is presented. A five-year-old boy who sustained a sharp laceration on his right axillary region was immediately operated. The axillary artery, radial, ulnar and musculocutaneous nerve branches of the brachial plexus, and the lateral root of the median nerve were totally lacerated. The medial root of the median nerve was partially transected. All of the lacerated brachial plexus elements and axillary artery were immediately repaired. Significant functional recovery was determined even six months after the repair. Motor and sensory functions of the affected extremity were almost totally restored at the postoperative 21st month, except for the ulnar nerve motor functions. There was no cold intolerance or trophic change at the injured extremity. Primary repair of a brachial plexus laceration injury in the pediatric population can be expected to produce successful functional recovery results, even in a relatively short period after the repair.

The effect of subcutaneous mesenchymal stem cell injection on statis zone and apoptosis in an experimental burn model.

BACKGROUND: In an acute burn injury the zone of stasis is initially vital but may progress to coagulation necrosis with time. In this study, salvage of the zone of stasis was aimed at by subcutaneous mesenchymal stem cell injection. METHODS: Mesenchymal stem cells were obtained from the bone marrow of Sprague-Dawley rats (n = 10). Twenty Sprague-Dawley rats received thermal injury on the back according to the previously described "comb burn" model. Thirty minutes after the burn injury, mesenchymal stem cells were injected subcutaneously to the stasis zone of the experimental group (n = 10). Animals in the control group (n = 10) were given the same amount of saline without mesenchymal stem cells. Animals in the sham group (n = 6) did not receive any thermal trauma. Seventy-two hours after the burn injury, scintigraphic examination was applied to determine average vital tissue at the stasis zone. Thereafter, skin samples were assessed by immunohistochemistry assay for apoptosis count. The blood samples drawn before and 72 hours after the burn injury were analyzed to determine systemic cytokine levels. RESULTS: The apoptosis count of the control group was found to be significantly higher than that of the experimental group. Vital tissue percentage of the stasis zone was significantly higher for the experimental group than for the control group. The cytokine levels did not reveal any statistically significant difference between the groups. CONCLUSION: Apoptosis count and scintigraphic results of this study confirm that mesenchymal stem cell treatment has a statistically significant benefit for the survival of the stasis zone in acute burn.

One-and-a-half-barrel vascularized free fibular flap for the reconstruction of segmental mandibular defect.

We designed one-and-a-half-barrel vascularized free fibular flap which is a further modification of the double-barrel technique, and we tried to overcome the discrepancy between mandible and fibula flap. We used this flap in case of a segmental mandibular defect that occurred as a result of a giant cell reparative granuloma excision. This new modification eliminated volume insufficiency of the classical technique and volume excess of the double-barrel technique.A segmental mandibular defect that occurred as a result of giant cell reparative granuloma excision was reconstructed using one-and-a-half-barrel vascularized free fibular flap. The size discrepancy between mandible and free fibula flap is a well-known problem, and this new modification of free fibular flap eliminated volume insufficiency or excess problems of the other techniques.

Reconstruction of the great toe tip defect with a pedicled heterodigital artery flap.

UNLABELLED: Reconstruction of the foot's distal portion has always been a difficult problem in plastic surgery. Moreover, isolated soft tissue defects of the hallux are not common in daily practice. In the case of tissue loss over the hallux, it is common practice to treat the soft tissue defect conservatively or to apply a skin graft. But the loss of tissue leaves a shortened, hypersensitive, and deformed toe. A method for reconstruction of a soft tissue defect on the tip of the hallux by means of a pedicled heterodigital artery flap from the second toe is presented, and alternative flap choices for this challenging area of the distal foot are discussed. To the best of the authors' knowledge, this surgical approach for reconstruction of hallux tip defects has not been reported previously. 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 .

Definitive foot drop deformity repair with tensor fascia latae myocutaneous flap.

Tensor fascia latae (TFL) myocutaneous flap, utilized as a novel approach for the successful functional repair of the foot drop deformity is presented in this case report. A 21-year-old male patient was subjected to a close-range high-velocity gunshot injury and sustained comminuted Gustillo-type IIIB open fracture of his left tibia. A composite skin and soft tissue defect including tibialis anterior and extansor hallucis longus tendons was determined. The injury was managed in two stages. In the first stage, the immediate reconstruction of the open tibia fracture was provided by using a reverse flow sural flap and external fixation of the fracture. The functional restoration was achieved by vascular fascia latae in the second stage, 6 months after the initial skin, soft tissue, and bone defect repair. The functional recovery was successful, and the foot drop gait was almost totally ameliorated. Reconstruction with TFL flap should be retained in the armamentarium for the functional repair of the foot drop deformity, caused by composite skin and soft tissue defects of the pretibial region.

Elbow reconstruction with a pedicled thoracodorsal artery perforator flap after excision of an upper-extremity giant hairy nevus.

The complexity of managing large soft-tissue defects at the elbow region by conventional techniques arises from the difficulty of providing sufficient tissue with adequate elasticity and durability. Reconstruction options that allow early mobilisation and avoid the risk of functional loss should be considered to achieve defect closure at the elbow region. A 21-year-old man presented with a congenital giant hairy nevus on his left upper extremity. The nevus was excised and the resulting raw surface after the excision was covered with a split-thickness skin graft except for the elbow region. The elbow was covered in one stage with an ipsilateral 24 cm long pedicled thoracodorsal artery perforator (TDAP) flap. The follow-up examination 3 years after total reconstruction demonstrated durable elbow support provided by the TDAP flap. The patient revealed no complaint considering pain or sensitivity even when exposed to mechanical stress. Split-thickness skin grafting of the large superficial defects is almost always possible; however, impairment of the function on joint areas due to gradual contraction and skin graft propensity to ulcers under mechanical stresses can be devastating. The elbow is a weight-bearing area of the body. Elbow defects require durable and thin soft-tissue coverage and the tissue cover must possess excellent elastic properties to re-establish elbow mobility. The TDAP flap is an ideal choice for elbow soft-tissue defects. The longest pedicle length reported for the TDAP flap is 23 cm. In our case, the pedicle length was 24 cm and it was possible to transfer this flap to the elbow on its pedicle. A pedicled TDAP skin flap so as to provide elbow coverage in one stage is a useful choice to retain in one's armamentarium.

The effect of perineurotomy on nerve regeneration in diabetic rats.

BACKGROUND: One of the main causes of diabetic neuropathy is endoneurial edema, which increases the internal pressure of the perineurium, which has a tight structure. The treatment used to reduce internal pressure is perineurotomy, in which a surgical incision is made into the perineurium. METHODS: Forty male Sprague-Dawley rats were used in the study. They were classified into four groups. Streptozotocin-induced diabetes was created in groups III and IV. The sciatic nerve was transected and repaired epineurally in all groups. Perineurotomy was performed additionally in group II and IV to the sciatic, peroneal, tibial, and sural nerves from the most proximal side to their most distal ends. The sciatic function indices were calculated for functional assessment. Light and electron microscopic evaluations were performed for morphometric assessment. In addition, the myelinated and degenerated fibers were counted in all groups. RESULTS: The sciatic function indices of the diabetic perineurotomy group were found to be significantly higher than those of the other groups (p < 0.05). Based on the myelinated fiber counts, there was insignificant difference between group I and group II, whereas the difference was significant (p < 0.05) between group III and group IV. Presence of peripheric nerves in light microscopic evaluation revealed normal characteristics of myelinated fibers in group I and group II. The myelinated axon profile in group IV was similar to that of groups I and II in electron microscopic evaluation. CONCLUSION: It is concluded that perineurotomy may be established as a useful adjunctive procedure for nerve repair in diabetic patients.