Complex Scalp and Calvarium Defects After Giant Basal Cell Carcinoma Excision: Management, Challanges, Outcomes.

Giant basal cell carcinoma (GBCC) is defined as a tumor ≥5 cm in diameter. GBCC of scalp usually requires extended resection of soft tissues, calvarium, and dura. In this study, we present 5 patients with GBCC of head, who underwent a single-stage combined scalp, calvarium, and dural reconstruction. Herein, we aim to discuss reconstruction methods, cerebrospinal fluid (CSF) leakage, duration of hospital stay, and tumor recurrency. Peroperative and postoperative follow-ups, defect areas, and performed calvarium reconstruction methods of 5 patients, who underwent complex scalp and calvarium reconstruction after GBCC between year 2010 and 2017, were retrospectively maintained. We studied reconstruction methods, CSF leakage, duration of hospital stay, and tumor recurrency. All patients undergone single-stage reconstruction. Avarge duration of hospital stay was 15 days. Titanium mesh was used in 3 patients and methyl methacrylate was used in 2 patients for calvarium reconstruction. CSF leakage was seen in patients who underwent calvarium reconstruction with titanium mesh. Tumor recurrence occured next to calvarium in 1 patient who undergone calvarium reconstruction with methyl methacrylate. CSF leakage and duration of hospital stay may induce morbidity of this oncoplastic procedure. The fact of longer hospital stay of patients reconstructed with titanium mesh might be a new data presented in this study. These parameters can be related with the method of calvarium reconstruction.

No osteotomy rhinoplasty: indications and surgical details.

UNLABELLED: Lateral osteotomy is a particular step in rhinoplasty that aims to close an open roof deformity after hump reduction, narrow the lateral walls of the nose, and symmetrically align the nasal bony framework in cases with asymmetry. When the only reason for performing lateral osteotomy is to close an open roof, this can be avoided by using auto spreader flaps. In component hump reduction, the entire length of the upper lateral cartilage is preserved, including the portion under the nasal bone bilaterally. The basic principles involve suturing the flaps in the midline with a modified technique and supporting the lateral nasal walls with onlay cartilage grafts. This method was used for 34 patients. The lack of lateral wall support was obvious in one of the patients. With precise indications and a well-designed surgery, can be achieved. Further studies with more patients and a longer follow-up period are needed to determine the accuracy of this philosophy. 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 .

Effect of systemic carnitine therapy on serum fibronectin level in diabetic rats.

BACKGROUND: L-carnitine has been shown to enhance wound healing. There has, however, not been sufficient research on the effect carnitine has on diabetic wound healing. We investigated the relationship between the viability of full thickness skin grafts (FTSGs) and fibronectin (FN) serum levels in diabetic rats that were administered carnitine. MATERIALS AND METHODS: A total of 40 rats were divided into four groups of 10 rats each and operated on. The FTSG model was 10 × 3 cm, with the dorsal flap extending from the tip of the scapula to the hip joint. After surgery, group 1 (nondiabetic control, n = 10) and group 2 (diabetic control, n = 10) were given a sterile saline solution at 0.9% with a dose of 100 mg/kg/d intraperitoneally for 7 d after the surgery. Group 3 (diabetic sham, n = 10) contained diabetic rats and did not receive any agent after the surgery. The diabetic rats in group 4 (carnitine study diabetic, n = 10) were given carnitine with a dose of 100 mg/kg/d intraperitoneally for 7 d after the surgery. RESULTS: The percentages of viable areas in groups 1-4 were 70.38 ± 6.10%, 62.66 ± 1.55%, 62.59 ± 2.94%, and 73.48 ± 4.43%, respectively. The mean levels of FN, measured in milligram per deciliter, in groups-4 were 23.57 ± 3.27 mg/dL, 21.58 ± 2.35 mg/dL, 22.04 ± 2.71 mg/dL, and 27.11 ± 2.79 mg/dL, respectively. Furthermore, we found that there was a strong positive correlation (R = 0.509; P = 0.001) between FN and the viability of the FTSG. CONCLUSIONS: We demonstrated that administering carnitine leads to an increase in diabetic wound healing. Further increasing the levels of the FN serum might have a role in this process.

Reverse nasal SMAS-perichondrium flap to avoid supratip deformity in rhinoplasty.

BACKGROUND: Supratip deformity is an iatrogenic convexity that occurs cephalically to the nasal tip. This is also known as "parrot beak" deformity and causes an unnatural appearance of the nose. In the literature there are several explanations of the mechanism of the deformity and methods to correct it. One of the most accepted theories about the cause of supratip deformity is overresection of the caudal dorsum. Healing soft tissues fill in the gap created between the septum and the tip of the lower lateral cartilages, leading to fullness in the supratip area. The lower third and basically distal third of the middle third of the nose include several muscle groups, ligamentous structures, and perichondrium as the subcutaneous soft tissues. METHODS: With the idea of elevating a reverse-based flap basically from the lower third and the lower third of the middle third of the nose, including the perichondrium and SMAS tissue, we aimed to reduce this gap, which has the potential to accumulate soft tissues that cause supratip fullness. Between December 2008 and July 2010, the reverse nasal SMAS-perichondrium flap was used in 42 primary rhinoplasty patients. RESULTS: This flap was used in 42 patients. Follow-up ranged from 3 to 18 months. No early or late complications were noted, such as infection, excessive bleeding, or extended edema. Minor revisions were performed in only two patients with the aim of achieving a smoother nasal dorsum. CONCLUSIONS: The reverse nasal SMAS-perichondrium flap is a new flap. The results presented here are not long term; however, the preliminary results are promising. The flap should be avoided in cases of thin skin, or at least be used with caution, whereas in thick skin cases it is very safe. Further studies in larger groups are required to better define the advantages and disadvantages of this flap.

Curcumin protects against ischemia/reperfusion injury in rat skeletal muscle.

BACKGROUND: Curcumin has been shown to decrease ischemia-reperfusion (I/R) injury in kidney or brain tissues. In this study, the effects of curcumin were evaluated in skeletal muscle during I/R injury. MATERIALS AND METHODS: Hind limb ischemia was induced by clamping the common femoral artery and vein. After 4 h ischemia, the clamp of the femoral vessels of animals was taken off and the animal underwent 2 h reperfusion. We measured plasma concentrations of interleukin-1ß (IL-1ß) and tumor necrosis factor-α (TNF-α) using enzyme-linked immunosorbent assay (ELISA). The right gastrocnemius muscle was harvested and immediately stored at -30°C for the assessment of superoxide dismutase (SOD), catalase (CAT) activities, and measurement of glutathione (GSH), malondialdehyde (MDA), and protein oxidation (PO) levels. Curcumin (100 mg/kg), α-tocopherol, and normal saline (10 mL /kg1) were administered intraperitoneally 1 h prior reperfusion. RESULTS: Plasma TNF-α or IL-1ß levels increased significantly in I/R group. The plasma levels of these proinflammatory cytokines were reduced in curcumin group. Muscle tissues of I/R groups revealed significantly higher antioxidant enzyme (superoxide dismutase, glutathione peroxidase, catalase) activities, and increased levels of malondialdehyde, nitric oxide, and protein carbonyl content compared with the SHAM group. Levels of these parameters in muscle revealed significant reductions in the I/R + curcumin group compared witho the I/R group. Curcumin has more potent antioxidant activity than vitamin E in the skeletal muscle I/R. CONCLUSION: In this study, protective effects of curcumin against skeletal muscle ischemia-reperfusion injury have been revealed. We underscore the necessity of human studies with curcumin that would be hypothetically beneficial preventing skeletal muscle I/R injury.

Vacuum-assisted closure therapy leads to an increase in plasma fibronectin level.

An extensive research has been performed to investigate the mechanisms of action by which the application of subatmospheric pressure to wounds increases the rate of healing. Increased blood flow with vacuum-assisted closure (VAC) use is the most popular aspect. Fibronectin, which is an adhesion molecule, has several functional domains mediating chemotaxis, adhesion and migration. This is thereby involved in differentiation, proliferation, inflammation and thus in wound healing. In this study, plasma fibronectin levels were measured before and after VAC in patients with wounds. The results showed that there was an increase in pre- and post-VAC levels of plasma fibronectin. This statistically significant increase could be another explanation of how VAC therapy promotes wound healing.

Intraarticular hyaluronic acid injection for the treatment of reducing and nonreducing disc displacement of the temporomandibular joint.

Temporomandibular dysfunction (TMD) has been established as a therapeutic challenge in the plastic and maxillofacial clinics. The current treatment recommendations for TMD include resting the jaw, soft diet, and pain medication with nonsteroidal analgesic agents. If conservative and noninvasive techniques do not work, more invasive techniques may be considered. The main goal of this study was to assess the safety and clinical utility of intraarticular injection of sodium hyaluronate for the treatment of symptoms associated with internal derangement of the temporomandibular joint (TMJ). In this prospective study, 40 TMJs of 33 patients who have TMD were treated with intraarticular sodium hyaluronate injections at weekly intervals for 3 weeks. Pre- and postinjection pain intensity, the presence of joint sounds, and interincisial distance were documented. The follow-up period was 12 months. There was a statistically significant reduction of pain intensity (P < 0.01) and joint sound (P < 0.05) in all patients. This study shows that intraarticular hyaluronic acid injection for the treatment of reducing and nonreducing disc displacement of TMJ is an effective and safe management.

Biomechanical and histologic evaluation of the Norian craniofacial repair system and Norian Craniofacial Repair System Fast Set Putty in the long-term reconstruction of full-thickness skull defects in a sheep model.

BACKGROUND: The purpose of this study was to investigate the long-term (12 months) strength and osteoconductive properties of two forms of carbonated calcium phosphate cements (i.e., the Norian Craniofacial Repair System and Norian Craniofacial Repair System Fast Set Putty) and to compare these two bone cement forms to an autogenous cranial bone graft in a full-thickness skull defect adult sheep model. METHOD: Twenty-six sheep were assigned to one of eight groups (n = 3 per group). A 4.5-cm2 full-thickness defect was created in the right and left parietal bones. Reconstruction was performed with a full-thickness cranial bone autograft, the Craniofacial Repair System, or Fast Set Putty. Skull samples were harvested at day 1, 6 months, and 12 months. Biomechanical testing was performed using a vertical drop test. RESULTS: Although the Craniofacial Repair System and Fast Set Putty osseointegrated fully, there was little osteoconduction at 12 months. The Craniofacial Repair System was the weakest reconstruction, presenting the lowest peak force transmission and the highest displacement at 12 months. Fast Set Putty showed significantly higher values for peak force transmission and lower displacement when compared with the Craniofacial Repair System. CONCLUSIONS: The Craniofacial Repair System progressively lost strength over the course of this study. Fast Set Putty demonstrated greater strength and rigidity than the Craniofacial Repair System. Both implants had limited bone ingrowth from defect borders, but both cements osteointegrated completely. Bone grafts regained biostructural characteristics and strength similar to those of intact bone and clinically performed the same in this sheep model.

The role of larger osteotomy in long term success in external dacryocystorhinostomy.

AIM: This study aims to investigate whether it is possible to create a critical size bone defect in external dacryocystorhinostomy (DCR), and also at what size a defect can be considered as being critical for a successful surgical outcome. METHODS: Eighteen patients undergoing 19 external dacryocystorhinostomies, with the creation of wide osteotomies, were enrolled in this retrospective study. A 2 x 2 cm bone defect, which was considered as the critical size, was created. The postoperative structure of the bone gap was evaluated by computed tomography in axial and coronal planes at least two years after surgery. Functional patency of the ostium was confirmed with irrigation and nasal endoscopic examination. RESULTS: Thirteen female (72.2%) and five male (27.8%) patients underwent DCR. The patients were aged between 18 and 72 years old (mean+/-S.D.: 45.3+/-13.9). The follow-up time was between 24 and 48 months (mean 30.4 months). The areas of the gaps were between 1.21 and 4 cm(2) (mean+/-S.D.: 2.26+/-0.19). CONCLUSION: The critical size bone defect (2 x 2 cm) might prevent restenosis in long term follow ups.

Versatility of frontal island flaps in the reconstruction of periorbital soft tissue defects.

The reconstruction of large soft tissue defects in the orbital and maxillomalar region is a challenging task that necessitates the consideration of both functional and aesthetic outcomes. We used the frontal island skin flap in patients with full-thickness soft tissue defects of the periorbital and malar region. In the reconstruction of full-thickness defects of this particular region, the alternatives to this flap are other regional flaps or distant free flaps. Not every pedicled regional flap can be transferred to every defect and most of the time the application of distant free flaps increases the morbidity of the procedure. The surgeon must be capable of being able to select the most useful and comprehensive flap within a range of many alternatives. We present our experience in 10 patients with complex soft tissue defects in the maxillomalar and periorbital regions whose defects were reconstructed with frontal artery island skin flaps.

Upper lateral cartilage-sparing component dorsal hump reduction in primary rhinoplasty.

BACKGROUND: Dorsal hump reduction is a critical step in rhinoplasty. Most of the reasons behind revisional procedures are related to incorrect hump reduction. METHODS: The authors used a modified dorsal hump reduction method in their primary cases, the steps of which are as follows: 1) dissection of the nasal vault; 2) bilateral submucoperichondrial dissections to free the cartilaginous septum; 3) separation of the upper lateral cartilages from the cartilaginous septum; 4) partial dissection of the upper lateral cartilages from the inner surfaces of the nasal bones bilaterally; 5) separation of the bony septum from the nasal bones bilaterally; 6) reduction of the partially isolated nasal bones; 7) en bloc cartilaginous and bony septum removal. The authors have operated on 68 primary cases over a 2 year period (30 mo). RESULTS: In the great majority of cases, the results were satisfactory. No revisions were performed in this patient group. CONCLUSIONS: This method is a good alternative to traditional techniques in noses with a high and narrow roof, thin skin, and weak middle nasal vault. Revision could be performed more easily when required. Initially, wide noses may not seem good candidates for this procedure; however, careful case-based preoperative planning may overcome this difficulty.

The fate of diced cartilage grafts of traumatized versus nontraumatized origin.

BACKGROUND: Diced cartilage grafts have long been used in rhinoplasty. Along with their various reported advantages, they also have some disadvantages. The irregular resorption rate of the engrafted mass is one of the major issues noted with diced cartilage grafts. An explanation for the unpredictable resorption rate has not yet been elucidated. This study aimed to determine the role of traumatized versus nontraumatized cartilage as the source of diced cartilage grafts. METHODS: This study included the noses of 32 patients (19 traumatized noses and 13 nontraumatized noses) who underwent surgery using Surgicel-wrapped diced cartilage grafts. RESULTS: The most remarkable result noted in this study was that a Surgicel-wrapped diced cartilage graft, if prepared from traumatized cartilage (in 19 patients), failed to maintain a stable long-term volume. Partial volume loss was noted in 100% of these patients. However, the rate of this partial resorption was different for every individual and could not be predicted. The highest retention of cartilage graft volume was seen primarily over the nasal osseocartilaginous junction. In nontraumatized patients, however, the engrafted mass maintained long-term volume stability. These patients evidenced no visible external irregularities, and only a few very slight imperfections were noted with finger palpation. CONCLUSION: Diced cartilage of traumatic origin is not recommended for any purpose. In such cases, the authors' engrafting algorithm consists of autobone or ear conchal cartilage grafts for dorsal augmentation, columellar struts from the nontraumatized part of the septum, and spreader grafts from the nontraumatized part of the septum or ear concha.

The role of apoptosis in traumatic versus nontraumatic nasal septal cartilage.

BACKGROUND: Nasal surgery is occasionally performed to correct traumatic nasal deformity. Septal cartilage is the main tissue to be corrected and is a graft source when needed. A risk in engrafting with cartilage is the possibility of resorption as a result of either necrosis or apoptosis. The authors evaluated the rate of apoptosis in deviated and straight cartilage to investigate the cause of resorption of cartilage tissue. METHODS: Twenty-five patients with traumatic nasal septum deviation (group I) and 13 patients with nontraumatic nasal septum deviation (group II) were prospectively enrolled. After correction of the deviation, two small samples of cartilage were harvested, one from the deviated site (group Ia or IIa) and the other from the straight site (group Ib or IIb), immediately frozen at -70 masculineC, and evaluated for apoptosis using DNA agarose gel electrophoresis. RESULTS: Apoptosis was detected in 14 (56 percent) of the deviated and two (8 percent) of the straight cartilage samples in traumatic patients, whereas it was detected in only one deviated sample (7.7 percent) and none of the straight samples in nontraumatic patients. The apoptosis rates in group Ia were statistically significant when compared with groups Ib (p = 0.0007) and IIa (p = 0.0007). CONCLUSIONS: The present study demonstrates that apoptosis occurs in traumatized nasal septal cartilage. Apoptosis might be the factor leading to cartilage resorption, weakness, and warping when used as a graft. Thus, cartilage grafting materials should be taken from the nontraumatized portion of the septum and should not be traumatized either during harvesting or before placement.

Chimerism induction in vascularized bone marrow transplants augmented with bone marrow cells.

Composite tissue allografts (CTAs) are currently accepted in the clinic; however, long-term immunosuppression is still needed for allograft survival. The presence of donor-specific chimerism may induce tolerance. Thirty-six vascularized bone marrow transplantation (VBMT) allotransplantation were performed across MHC barrier under short-term protocol of 7-day alphabeta-TCRmAb and Cyclosporin A therapy to determine the efficacy of VBMT alone and VBMT augmented with donor bone marrow transplantation (BMT) in chimerism induction. Flow cytometry analysis revealed that VBMT supported with donor BMT directly into the bone resulted in chimerism augmentation and maintenance compared to VBMT. In vivo and in vitro tolerance testing showed prolonged survival of donor skin graft up to 35 days and moderate reactivity in MLR assay that suggests only tolerance induction. Transplantation of vascularized bone without chronic immunosuppression provides a substantial source of bone marrow cells, leading to the development of stable donor-specific chimerism.

Combined use of triple cartilage grafts in secondary rhinoplasty.

UNLABELLED: Secondary rhinoplasty on a patient with a middle vault deformity is one of the most challenging procedures for a plastic surgeon. In order to achieve proper nasal aesthetics and airway function, a surgeon most commonly chooses to engraft the nose with a spreader, dorsal onlay, or columellar graft. This paper examines the aforementioned techniques in the management of 25 patients who presented with a severe middle nasal vault deformity. METHODS: During the last 5 years, 25 patients received secondary rhinoplasty using triple cartilage grafts to repair severe middle vault deformities. Patients were then questioned at least 3 months postoperatively about both airway problems and cosmetic satisfaction. RESULTS: All the 25 patients indicated cosmetic satisfaction with 23 of the patients also achieving complete nasal airway function. Only two patients persisted to have an insufficient nasal airway. An endonasal examination revealed a slight nasal synechiae in one patient, while no anatomic problem was identified in the second patient. From a cosmetic standpoint, a straight dorsum with improved dorsal aesthetic lines and nasal profile, along with nasal-facial balance were achieved. When indicated, secondary rhinoplasty to repair a middle vault deformity using the combination of spreader, dorsal onlay, and columellar grafts to augment the nose has shown to have both functional and cosmetic benefits.

An algorithm for deciding alternative grafting materials used in secondary rhinoplasty.

Severe middle vault deformity with disturbed nasal form and function is one of the most challenging procedures to correct in a secondary rhinoplasty. Reconstructing the deformity with autologous septal cartilage would be the primary choice of most surgeons, if it were always available. However in certain cases the lack of a sufficient quantity of autologous cartilage has forced surgeons to explore other viable options. This paper discusses our experience with the combined use of spreader and dorsal onlay grafts from various materials in the reconstruction of severe middle vault deformity in 110 patients. In follow up, (between 6 and 42 months; mean 21 months) all patients were noted to have improved in both aesthetics and function with no major complications noted. In summary, this study proposes that any engrafting material can be used safely when the proper surgical principals and technique are employed.