Surgical scar management - an evaluation of surgical techniques.

The purpose of this narrative review is to analyze surgical techniques for removing scar tissue and minimizing them. A considerable proportion of the population have scars that are related to a traumatic event that they remember accurately, this being especially true for scars on the face, but also on the rest of the body if they are of significant size. The negative consequences of the esthetic damage are felt mainly in the family and at professional level, without losing sight of the fact that any person suffers as a result of the awareness of unsightly wounds or scars. To be successful, an aesthetic intervention must represent the optimal balance between science, the art of plastic surgery and the patient's expectations. Good communication between surgeon and patient is also needed. We must state that there is no method of total removal of scars; even in the case of complex surgical techniques, the scar cannot be completely excised, but a much more aesthetic appearance can be obtained. Scars cannot be completely removed from the skin, they can improve their appearance by fading or thinning, initially by conservative treatment, later, if necessary, by surgical scar reduction techniques. Improving the appearance of a scar depends on the type of scar, its severity, its surface and location, the causing factors, the time elapsed from production to the application of specialized treatment.

Successful management of chronic migraine through manual therapy. A case report.

Migraine is the second most debilitating condition affecting a significant portion of the general population, particularly young adults under 50. Despite extensive research, the etiology of migraine remains diverse and often multifactorial, with limited clarity on the specific underlying pathogenic processes. Consequently, the treatment of migraine lacks a mechanism-based approach. We present the case of a young female patient suffering for 8 years of chronic migraine and tension-type headaches. The manual therapy techniques successfully released the muscular tensions, considerably improving her quality of life in terms of pain and emotional well-being.

Can Vitamin D Levels Alter the Effectiveness of Short-Term Facelift Interventions?

Facelifting is increasingly popular among the population. It exceeded the limits of post-traumatic facia-reconstruction. Both the demand and the methods available are getting increasingly diverse. The minimally invasive technique revolutionized the facelift, although it took some time to completely comprehend the mechanics. The roles of vitamin D in numerous physiological processes in which it is involved have mostly been elucidated in the last decade. Our hypothesis is based on one of these roles, that is, vitamin D intervenes in changing the type of collagen by changing its location; therefore, collagen will have a supporting role for the subcutaneous tissue. A group of 156 patients with different facelifting methods was followed: 93 minimally invasive (NC), 49 classical surgery (C) and 14 with the combined technique (NC + C). The change in the subcutaneous tissue was monitored by an elastograph. The level of vitamin D was monitored in order to assess the immediate and long-term effects of vitamin D on the progression of subcutaneous fibrosis. It was proven that an optimal level of vitamin D has a beneficial effect in maintaining the volume of subcutaneous tissue in patients from the NC and NC + C groups, the best results being in the NC + C group. An increase in the subcutaneous volume was recorded, which leads to a decrease in elasticity (statistical significance p < 0.05) and the lowering of the subcutaneous tissue, and an increased amount of lowering corresponds to a lowering of vitamin D levels.

Cranioplasty after Two Giant Intraosseous Angiolipomas of the Cranium: Case Report and Literature Review.

Angiolipomas are rare, benign tumors resulting from the proliferation of adipose tissue and blood vessels, most frequently encountered subcutaneously at the upper limbs and trunk level. Due to their rarity, few cases of intraosseous angiolipomas are presented in the literature. The paper reports a 50-year-old female case with intracranial hypertension syndrome, frontal and parietal headache, nausea, and vomiting symptoms increasing in intensity. A CT exam revealed two hypodense expansive intraosseous formations/lesions. The first one was located in the projection of the frontal bone and the second one was placed on the left parietal bone. After further investigations, a two-stage procedure was considered. A frontal craniotomy with excision of the intraosseous tumor was performed in the first stage. In the second stage, a left parietal craniotomy was done with excision of the intraosseous tumor combined with a cranioplasty procedure. The patient had a favorable postoperative evolution with no symptoms or neurological deficits. This is among the few reported cases of intraosseous angiolipoma located at the cranium level and the first case report of two intraosseous angiolipomas situated on the same site. The medical recommendation was a complete surgical excision of the lesion followed by cranioplasty.

Combined distal median nerve block and local anesthesia with lidocaine:epinephrine for carpal tunnel release.

Aim: Evaluating patient comfort during full awake local anesthesia in carpal tunnel release surgery, without tourniquet use, by using epinephrine to obtain a completely dry surgical field. Methods: We included into the study 41 patients who underwent carpal tunnel syndrome surgery under full awake combined anesthesia, using a 9-point questionnaire. Pain and anxiety in all patients were evaluated through a Wang-Baker 0-5 scale. The injection solution consisted of 0.1cc of epinephrine and 10cc of 1% lidocaine (1:100.000); 5cc were used for local cutaneous anesthesia, and 5cc were used for distal median nerve block. All patients underwent a classic, open carpal tunnel release. Results: Anxiety scores during anesthesia and the post-operative period did not show a statistically significant difference (p > 0.01), with keeping their levels at low perception scores (average score of 1.68 ± 0.38 CI 95%, with a modal value of 2, compared to an average of 0.78 ± 0.29 CI 95% with a modal value of 0). Similar results were obtained for pain scores during anesthesia (1.73 ± 0.48 CI 95% with a most frequent modal score of 1). Our results also showed that the effects of combined anesthesia in carpal tunnel release surgery persisted well into the 6-hour post-operative moment, pain scores remaining low, statistically significant similar to recorded values during the anesthesia moment (p > 0.01), at an average of 2.29 ± 0.5 CI 95% with a modal value of 1. No serious complications were recorded. Conclusion: Combined distal median nerve block and local anesthesia with epinephrine:lidocaine provides a comfortable option for patients, with minimal risks of complications.

Vitamin D Implications and Effect of Supplementation in Endocrine Disorders: Autoimmune Thyroid Disorders (Hashimoto's Disease and Grave's Disease), Diabetes Mellitus and Obesity.

Background and Objectives: Vitamin D deficiency is involved in numerous pathologies, including endocrine pathology. The purpose of this review consists of presenting the role of vitamin D in the pathophysiology of certain endocrine disorders, autoimmune thyroid disorders (Hashimoto's disease and Grave's disease), diabetes mellitus, and obesity, and whether its supplementation can influence the outcome of these diseases. Materials and Methods: Review articles and original articles from the literature were consulted that corresponded with the thematic. Results: Vitamin D deficiency is frequently encountered in endocrine disorders and supplementation restores the normal values. In Hashimoto's disease, vitamin D deficiency appears to be correlated with a higher titer of anti-TPO antibodies and with thyroid volume, and supplementation was associated with reduction of antibodies in some studies. In other studies, supplementation appeared to reduce TSH levels. In Grave's disease, there was a significant correlation regarding vitamin D levels and thyroid volume respective to the degree of exophthalmos. In diabetes mellitus type 2 patients, supplementation led to some improvement of the HOMA-IR index and HbA1c, whereas obesity data from literature do not report significant beneficial findings. Conclusions: Vitamin D deficiency is highly prevalent in endocrine disorders and its supplementation appears to have numerous beneficial effects.

Aseptic Necrosis of Femoral Head - Clinical Study.

Femoral head osteonecrosis is a disease characterized by the decrease of blood vascularization in the femoral head, which leads to death of the osteocytes, demineralization and resorption of bone spans, change of trabecular architecture, with the reduction of the bone mechanical resistance and collapse of the articular surface in the femoral head. Left untreated, the disease may have a rapid progression, leading to severe symptoms, with significant articular dysfunction, functional impotence and a serious impact on the patient's quality of life. The prevalence of the disease is ever growing all over the world, affecting mainly people in their 30s, 40s or 50s. In the present study, we analyzed a number of 76 patients with femoral head osteonecrosis with severe symptoms that required a surgical treatment. There was observed that more than ¾ of the investigated patients were males, while 81.58% were younger than 60 years old. Among the identified risk factors, smoking came first, followed by alcohol intake, obesity and chronic administration of corticosteroids. A very high percentage of patients (84.21%) were diagnosed in stages III and IV of the disease.

CD4+ CD25+ regulatory T-cells role in tumor microenvironment of the squamous cell carcinoma.

INTRODUCTION: Squamous cell carcinoma (SCC) is the most common skin cancer with a high rate of death. Different lymphocyte populations play an important role in modulating the immune response in the tumor microenvironment. The increase in the proportion of cluster of differentiation (CD)4+ CD25+ regulatory T-cell (Treg) lymphocytes is associated, in different studies, with the increase of the cell multiplication rate. AIM: To analyze the Treg lymphocyte subpopulations and to correlate the results with the presence of the CD8+ cytotoxic T-cell (Tc) lymphocyte population. MATERIALS AND METHODS: Sixty primary skin SCC specimens were incubated with anti-CD8 (clone SP57) rabbit monoclonal antibody and anti-CD25 (clone 4C9) mouse monoclonal antibody. RESULTS: The ratio of the intratumoral∕peritumoral CD4+ CD25+ forkhead box protein p3 (Foxp3) lymphocytes was 0.46, emphasizing that at tumor margins, where tumor aggressiveness is higher, these lymphocytes subpopulations facilitate tumor progression. The comparative analysis of the tumor microenvironment profile revealed that in the case of intratumoral immune response, the number of Tc-type lymphocytes (CD8+) was 3.34 times higher compared to Treg lymphocytes (p<0001). In the peritumoral area, the number of Tc lymphocytes was 5.05 times higher compared to Treg lymphocytes (p<0001). CONCLUSIONS: Treg lymphocytes inhibition may cause the suppression of the antitumoral cell immune response in the tumor environment. We believe that Treg lymphocytes should represent a focus of interest for a new personalized therapy. New studies are needed to better understand the immune response in the tumor microenvironment.

The Behavior of Two Types of Upper Removable Retainers-Our Clinical Experience.

The Hawley retainer (HR) and the vacuum-formed retainer (VFR) are the most common removable retainers in orthodontic treatments. The aim of this retrospective study was to comparatively analyze the behavior of two types of removable retainers-HRs and VFRs-in terms of retainer damage, loss, and the rate of installation of mild or severe relapse that required recourse to certain therapeutic interventions. The study was performed on 618 orthodontic patients aged 11-17 years, average age 13.98 ± 1.51, out of which 57% were patients having VFRs and the remaining 43% having HRs in the upper arch. We performed an analysis of the two groups of patients-HRs group and VFRs group-at 6 months (T1) and at 12 months (T2) after the application of the retainer. The results showed that 6% of all the retainers were damaged, mostly at T2 (54.1%). Seven percent of all the retainers were lost, mostly at T1 (58.1%). Of all the patients, 9.1% presented mild relapse, mostly at T1 (58.9%), while 2.6% presented severe relapse. The VFRs were significantly more frequently associated with the occurrence of damage than the HRs (p < 0.001). Severe relapse was more frequently associated with the HRs rather than with VFRs (p < 0.05).

Nanoparticles and Nanostructured Surface Fabrication for Innovative Cranial and Maxillofacial Surgery.

A novel strategy to improve the success of soft and hard tissue integration of titanium implants is the use of nanoparticles coatings made from basically any type of biocompatible substance, which can advantageously enhance the properties of the material, as compared to its similar bulk material. So, most of the physical methods approaches involve the compaction of nanoparticles versus micron-level particles to yield surfaces with nanoscale grain boundaries, simultaneously preserving the chemistry of the surface among different topographies. At the same time, nanoparticles have been known as one of the most effective antibacterial agents and can be used as effective growth inhibitors of various microorganisms as an alternative to antibiotics. In this paper, based on literature research, we present a comprehensive review of the mechanical, physical, and chemical methods for creating nano-structured titanium surfaces along with the main nanoparticles used for the surface modification of titanium implants, the fabrication methods, their main features, and the purpose of use. We also present two patented solutions which involve nanoparticles to be used in cranioplasty, i.e., a cranial endoprosthesis with a sliding system to repair the traumatic defects of the skull, and a cranial implant based on titanium mesh with osteointegrating structures and functional nanoparticles. The main outcomes of the patented solutions are: (a) a novel geometry of the implant that allow both flexible adaptation of the implant to the specific anatomy of the patient and the promotion of regeneration of the bone tissue; (b) porous structure and favorable geometry for the absorption of impregnated active substances and cells proliferation; (c) the new implant model fit 100% on the structure of the cranial defect without inducing mechanical stress; (d) allows all kinds of radiological examinations and rapid osteointegration, along with the patient recover in a shorter time.

A rare case of schwannomatosis of the extremities.

A schwannoma is a benign tumor that arises from the myelin-producing Schwann cells that surround nerves. We herein report a case involving a 55-year-old man who first presented to our clinic with a schwannoma of the posterior tibial nerve and 5 years later with a schwannoma of the ulnar nerve. This is the first report of schwannomatosis of the ulnar and posterior tibial nerves.

Cardiac axis evaluation as a screening method for detecting cardiac abnormalities in the first trimester of pregnancy.

Congenital cardiac abnormalities refer to especially anatomic malformations of the heart that normally occur during fetal heart development, before eight weeks after conception. Aim: The aim is to investigate the association between cardiac axis and congenital heart abnormalities for a potential underline clinical application of cardiac axis evaluation during detection by abnormalities at the time of first trimester ultrasound. It is known that aneuploids can be associated in almost half of cases with cardiac abnormalities, so the angle of the cardiac axis could be a potential indirect marker for the detection of aneuploids in the first trimester of pregnancy. Being easy to obtain, from the cross-section at the chest level with the visualization of the four chambers, does not require additional sections to those provided in the current guides, we aim to prove its usefulness in diagnosing aneuploids and congenital cardiac abnormalities along with the translucent nuchal flow, at the level of the venous duct and the presence of tricuspid regurgitation. Conclusions: Cardiac axis has a higher value for the detection of congenital cardiac abnormalities with respect to the nuchal translucency, tricuspid regurgitation and inverted A wave at the level of the venous duct.

Histopathological and immunohistochemical aspects of bone tissue in aseptic necrosis of the femoral head.

Femoral head osteonecrosis, also known as avascular necrosis, is a disease with a multifactorial etiology, characterized by a profound change of bone architecture, which leads to the diminishing of bone resistance and femoral head collapse. The main causes that lead to femoral head necrosis are represented by the decrease of local blood perfusion and increase of intraosseous pressure, because of an excessive development of adipose tissue in the areolas of the trabecular bone tissue in the femoral head. The histopathological and immunohistochemical (IHC) study performed by us showed that most of bone trabeculae were damaged by necrotic-involutive processes, their sizes being reduced, both regarding their length and their diameter; generally, the spans were thin, fragmented, distanced among them, which led to the occurrence of some large areolar cavities, full of conjunctive tissue, rich in adipocytes. Some of the residual bone spans even presented microfractures. In the structure of the trabecular bone tissue, numerous cavities showed lack of content, which indicates the death of osteocytes inside, while the endosteum appeared very thin, with few osteoprogenitor, flattened, difficult to highlight cells. The IHC study showed a low reaction of the bone reparatory processes and a reduced multiplication capacity of bone cells involved in the remodeling and remake of the diseased bone tissue. Nevertheless, there were identified numerous young conjunctive cells (fibroblasts, myofibroblasts), positive to proliferating cell nuclear antigen (PCNA), cells that have a high capacity of multiplication, participating in the formation of a fibrous conjunctive tissue (sclerous) instead of the damaged bone trabeculae. The formation of fibrous conjunctive tissue causes the reduction of mechanical resistance of the femoral head and its collapse. The IHC study of the microvascularization in the femoral head damaged by aseptic osteonecrosis showed the presence of a very low vascular system, both in the residual bone trabeculae and in the sclerous conjunctive tissue. Of the inflammatory cells present in the spongy bone tissue of the femoral head affected by osteonecrosis, the most numerous ones were the macrophages. Both macrophages and T- and B-lymphocytes had a heterogenous distribution.

Topical Oxandrolone Reduces Ear Hypertrophic Scar Formation in Rabbits.

BACKGROUND: Wound healing is a complex process. Despite extensive studies, hypertrophic and keloid scars still occur, and can be functionally and cosmetically problematic. In an attempt to prevent hypertrophic scar formation, the effects of topical oxandrolone, using hyaluronic acid as a biomaterial, were studied on ear wounds in rabbits. METHODS: Deep second-degree burns were inflicted on each ear in 10 New Zealand rabbits. On the left ears, considered the control side, hyaluronic acid gel was applied, whereas on the right ears, the study side, a combination of oxandrolone and hyaluronic acid was applied. Dressings were changed every 2 days for 2 weeks. At week 10, biopsy specimens from the postburn scars were harvested for histologic and immunohistochemical examinations. RESULTS: Fourteen wounds were studied, half on the control side and half on the study side. Six hypertrophic scars were encountered on the control side and only one scar was encountered on the study side. In addition, an increased degree of inflammation, an increased amount of collagen and fibroblast cellularity, increased vascularization, and increased myofibroblast activity were observed on the control side. CONCLUSION: Topical administration of oxandrolone using hyaluronic acid as a biomaterial led to better healing and prevented hypertrophic scar formation.

Hemobilia by idiopathic aneurysm of cystic artery, fistulized in the biliary ways - clinical case.

Aneurysm of the cystic artery is not common, and it is a rare cause of hemobilia. Most of reported cases are pseudoaneurysms resulting from either an inflammatory process in the abdomen or abdominal trauma. We report a healthy individual who developed hemobilia associated with cystic artery aneurysm. Visceral artery aneurysms are rare and can rupture with potentially grave outcome due to excessive bleeding. The patient was managed with cholecystectomy and concomitant aneurysm repair.

The Use of Exosomes as Biomarkers for Evaluating and Monitoring Critically Ill Polytrauma Patients with Sepsis.

Regarding genetic biomarkers for early assessment and monitoring the clinical course in polytrauma patients with sepsis, in recent years a remarkable evolution has been highlighted. One of the main representatives is the exosome miRNAs. In this paper, we would like to present in more details the various methods of using exosome miRNAs as a biomarker for monitoring polytrauma patients with sepsis, as well as establishing a belated outcome by aggregating the entire clinical aspects. The use of exosome miRNAs for late evaluating and monitoring the clinical evolution of polytrauma patients can bring significant improvements in current clinical practice through the optimization and modulation of intensive care according to the needs of each patient individually.

Comparison of commercial fibrin sealants in facelift surgery: a prospective study.

BACKGROUND: The aim of this study was to compare the effects of two types of fibrin glue in patients undergoing facelift surgery. METHODS: A prospective, controlled "right-left side" study was carried out in 20 patients. The two fibrin sealants used were Quixil® and Tissucol®. The two sealants were used at the same time, ie, one on one side of the face and the other on the contralateral side. Comparisons were made with regard to rates of hematoma and seroma, degree of induration, edema, ecchymosis, pain levels, and patient satisfaction. RESULTS: The results were almost equivalent. The only exception was a significant (40 mL) hematoma in a patient treated with Quixil. Bleeding was most likely due to a sudden rise in blood pressure during the immediate postoperative period. However, it must be emphasized that, while Tissucol actually seals the undermined area, thus virtually eliminating the dead space, Quixil acts differently, in that its effectiveness in preventing hematoma is linked mainly to its hemostatic effect. CONCLUSION: The two fibrin sealants used were nearly identical with regard to patient safety and quality of the result. Nevertheless, it is noted that, while Tissucol has both hemostatic and "gluing" effects, Quixil is mainly effective in securing hemostasis.

A clinical trial in facial fat grafting: filtered and washed versus centrifuged fat.

BACKGROUND: Although the increasing trend is to rebuild facial soft-tissue volume with autologous fat transfer, there is no agreement concerning the best way of processing the harvested fat before reinjecting it. Among all the reported fat graft processing techniques, in the present study, the authors compared the clinical results obtained using simple filtered and washed fat with those achieved by means of pure centrifuged fat. METHODS: A prospective double-blind study was conducted on 25 healthy patients undergoing facial fat transplantation from January of 2006 to June of 2006. During the same session, half the face was injected with simple filtered and washed fat, and the other half was instead treated with centrifuged fat. Subjective and objective methods were used to evaluate the results. The subjective methods included a questionnaire, sent to all patients, accompanied by an explanatory letter. The objective method involved the evaluation of preoperative and postoperative photographs by a three-member jury. The average follow-up period was 12 months. RESULTS: The authors' experimental work demonstrates that there was no significant difference between the two fat-processing techniques. In the long term, the implanted hemifacial regions produced comparable results. CONCLUSION: The authors, following their personal experience based on the reported data, went back to using the simple filtered fat after some years of use of centrifuged fat.