Comparison of the efficacy of fat, cartilage, and bone grafts in traumatic and asymmetric noses.

BACKGROUND: Correction of asymmetry and irregularity deformities with autologous grafts, without osteotomies, offers advantages to both plastic surgeons and patients with severe deviation. Various autologous tissues such as fat, bone, and cartilage grafts are viable options for this purpose. OBJECTIVES: This study aimed to compare the efficacy of 3 autologous filling materials in patients with bone asymmetry. METHODS: A retrospective evaluation was conducted on 297 patients seeking aesthetic nose surgery between 2015 and 2022. Only primary patients without prior surgery and those with bone asymmetry from trauma, with dorsum protrusion <3 mm, and without osteotomy were included. Patients were divided into fat, cartilage, and bone groups. Grafts were applied to the concave side during closed rhinoplasty, and evaluations were done 12 months after surgery by blinded plastic surgeons and patients using established assessment tools. RESULTS: Fat, cartilage, and bone grafts were utilized in 74, 127, and 96 patients, respectively, with a mean follow-up of 19 months. The mean graft volumes were 1.0 cc (bone), 1.3 cc (cartilage), and 1.6 cc (fat). The patient self-assessment scores were 75%, 84.9%, and 86.6%, respectively. The Asher-McDade averages were 77.2%, 86.7%, and 88.4%, respectively. Cartilage and bone graft results were statistically similar in patients' self-evaluation and significantly higher than those of fat grafts. Blinded assessments showed no significant difference between the cartilage and bone groups. CONCLUSION: Placing autologous grafts on the concave side for patients with minimal nasal bone protrusion (<3 mm) yields successful results. Cartilage grafts offer advantages in volume, result estimation, and preparation time, making them suitable for larger patient cohorts.

The effect of dobutamine treatment on salvage of digital replantation and revascularization.

PURPOSE: One of the most common causes of a failure after replantation and revascularization surgeries is 'no reflow' from proximal artery that occurs, especially following crush and avulsion injuries. In this study, we aimed to evaluate the effect of dobutamine treatment on salvage of replanted and revascularized digits. METHODS: The patients with no reflow phenomenon detected in the salvage operations of replanted/revascularized digits between the years 2017 and 2020 were included in the study. Dobutamine treatment was infused at a rate of 4 µg·kg-1·min-1 intraoperatively and of 2 µg·kg-1 min-1 postoperatively. Demographic data (age, sex), digit survival rate, ischemia time, and level of injury were retrospectively analysed. Pre-infusion, intraoperative and postoperative values of cardiac index (CI), mean arterial pressure (MAP), and heart rate (HR) were recorded. RESULTS: The phenomenon of 'no reflow' was encountered in 35 digits of 22 patients who underwent salvage surgery due to vascular compromise. The survival rate in the revascularization group was 75%, while it was 42.1% in the replanted digits. Metaphysis level of proximal phalanx was the most common localization for 'no reflow' phenomenon. The least values of CI, MAP and HR to obtain sufficient perfusion in salvaged digits were as follows: 4.2 l.min-1.m-2, 76 mm Hg, and 83 beat·min-1, respectively. CONCLUSIONS: It was demonstrated that dobutamine infusion at a rate of 4 µg·kg-1·min-1 intraoperatively and at 2 µg·kg-1·min-1 postoperatively has favorable effects on the vascular compromise derived from no reflow of proximal artery.

Reconstruction of nasal airway in patients of class IIId maxillary defect with vastus lateralis muscle-chimeric double skin paddle ALT flap.

BACKGROUND: A reconstructive challenge in patients with class IIId maxillary defect is how to obliterate the defect and restore a patent nasal airway. The current strategy using the single anterolateral thigh (ALT) fasciocutaneous flap for reconstruction may result in permanent mouth breathing. As the ALT flap was a common option in reconstruction processes, this study aimed to evaluate the benefits of vastus lateralis (VL) muscle-chimeric double skin paddle ALT flap in simultaneous defect and nasal airway reconstruction. METHODS: This study included 21 patients with class IIId maxillary defect who underwent free ALT flap reconstruction (n = 11, single ALT flap group; n = 10, VL muscle-chimeric double skin paddle ALT flap (chimeric ALT flap) group) at the China Medical University Hospital from August 2015 to September 2019. Associated parameters collected for analysis included gender, age, body mass index (BMI), operative time, hospitalization, clinical stage, preoperative treatment, flap/defect size, comorbidities, postoperative RT, mouth breathing and short/long term complications. RESULTS: No significant differences were observed in age, BMI, hospitalization, clinical stage, preoperative treatment, defect size, comorbidities, and postoperative RT between the two groups; however, the chimeric ALT flap group as dominated by male patients (p = 0.009), and had longer operative times (12.1 h vs. 10.1 h, p = 0.002) and larger flap sizes (180 cm2 vs. 96.7 cm2, p = 0.013). Compared with the chimeric ALT flap group, the single ALT flap group suffered from permanent mouth breathing. CONCLUSION: Nasal airway reconstruction should be considered in patients with class IIId maxillary defect. Compared to the single ALT flap, the chimeric ALT flap is a superior reconstructive option for patients with class IIId maxillary defect, although a longer surgical duration and larger flap size are required.

Reconstruction of axillary defects with propeller parascapular flap after resection in patients with advanced hidradenitis suppurativa.

INTRODUCTION: Wide excision of affected skin tissue and the apocrine glandular region is the standard treatment for advanced HS. Various flap types have been used for coverage. OBJECTIVE: This study was conducted to assess the use and outcomes of propeller parascapular flaps for unilateral or bilateral axillary defects after excision in patients with advanced axillary HS. MATERIALS AND METHODS: This retrospective case series reports on 11 patients with unilateral (7 patients) or bilateral (4 patients) advanced HS treated with propeller parascapular flap surgery between July 1, 2016, and December 31, 2018. Flap dimensions were measured. Patients were evaluated in terms of 2 main postoperative complications: postoperative recurrence and flap viability. In addition, other complications such as bleeding, infection, dehiscence, contracture, and hypertrophic scarring were noted. RESULTS: The average flap area was 160 cm2. One flap dehisced; no infection, partial necrosis, or total flap loss occurred, and no recurrence was observed. The mean follow-up period was 18 months. At final follow-up, no patient had contractures that caused restricted movement of the shoulder joint. CONCLUSION: Parascapular flaps should be the first choice in patients with advanced HS owing to low donor area morbidity, low recurrence rate, wide rotation arc, and sufficient flap size.

The effects of a combination treatment with mesenchymal stem cell and platelet-rich plasma on tendon healing: an experimental study.

BACKGROUND: The objective of this study was to investigate the effects that the application of mesenchymal stem cells (MSCs) and platelet-rich plasma (PRP) following tendon repair have on the strength and healing of the tendon and also to examine the possible mechanisms of action that take place. METHODS: The Achilles tendons of 80 rats were repaired and divided into eight groups. Following the repairs, MSCs obtained from humans were injected into the rat tendons in groups 1 and 2, a combination of MSCs from humans and PRP from rats was injected into the tendons in groups 3 and 4, and PRP from rats was injected into the tendons in groups 5 and 6. These procedures all took place simultaneously. Groups 7 and 8 did not receive any injections following the repairs. The rats were sacrificed at the end of the first and second months following the procedures, and biomechanical and histopathological analyses were performed. RESULTS: Inflammatory cell density increased most significantly in the combined group when compared to the first and second months. T he fibroblast density on the tendon repair region was significantly lower in the second-months groups of each intervention compared to their first-month groups (p = 0.001). For the analysis of the maximum tensile breaking force, the behaviors of the groups over time were significant when compared to the control groups (p = 0.0015). Also, the mean maximum breaking force in the combined group was statistically significantly higher at the end of the second month than at the end of the first month (p = 0.0008).

Acquired Constriction Band Syndrome Affecting Multiple Digits - A Case Report.

Rubber band syndrome is a condition that usually affects children because of wearing a rubber band on the wrist or the ankle. Depending on the degree of pressure caused by the band, patients may present acutely with ischemia and necrosis of the tissues distal to the bands or chronically with change in shape, oedema, loss of function, sensation and rarely amputation. This condition is very rare in adults and most reports in literature are in patients with cognitive impairment or psychiatric illness. We report 62-year-old lady with a background of a psychiatric illness who presented with an acquired constriction band syndrome affecting multiple digits of both hands. Level of Evidence: Level V (Therapeutic).

Evaluation of the effectiveness of the tuba uterina tubular flap in the peripheral nervous system regeneration in rats.

Nerve conduits could be used to provide a bridge between both nerve endings. In this study, the tuba uterina of female rats were prepared in a vascularized pedicled flap model and it used as a nerve conduit. The aim was to investigate the effectiveness of a vascularized pedicle nerve conduit and its ciliated epithelium in a sciatic nerve defect. The study was conducted between May and August 2018, and used a total of 60, 14-16-week-old female Wistar albino rats. Six groups were created; Cut and Unrepaired Group, Nerve Graft Group, Flap-Forward Group (Tuba uterina tubular flap, forward direction), Flap-Reversed Group (Tuba uterina tubular flap, reverse direction), Graft-Forward Group (Tuba uterina tubular graft, forward direction) and Graft-Reverse Group (Tuba uterina tubuler graft, reverse direction). Nerve regeneration was evaluated 3 months (90 days) after the surgery by the following methods: (1) Sciatic Functional Index (SFI) measurement, (2) Electromyographic (EMG) assessment, (3) Microscopic assessment with the light microscope and (4) Microscopic assessment with the electron microscope. According to the SFI, EMG and microscopic assessments with the light and electron microscope, it was observed that the transfer of tuba uterina tubular conduit as a graft was statistically better in its effect on nerve regeneration than flap transfer, but also indicated that the direction of the ciliated structures had no significant effect. We believe that as this model is improved with future studies, it will shed light on new models, ideas and innovations about nerve conduits.

A Rare Case: Primary Venous Malformation in Parietal Bone.

Primary intraosseous vascular malformations (PIVMs) are rare intraosseous lesions, accounting for approximately 0.5-1% of all intraosseous tumours. In this case report, we aimed to present a rare case of intraosseous vascular malformation causing a large lytic area in the parietal bone. A 25-year-old male patient was admitted to the clinic with a mass on the parietal bone. On physical examination, it was observed that the hair density on the mass was decreased, the mass had a soft consistency, and there was no pain on palpation. The patient was operated under local anaesthesia with a provisional diagnosis of a trichilemmal cyst. However, intraoperative diagnosis was a vascular malformation. There was a 3-cm full-thickness defect on the parietal bone caused by the lesion. The mass was excised completely while preserving the integrity of the dura. The resulting defect was reconstructed with bilateral rotation advancement flaps. The calvarial defect was not reconstructed due to equipment inadequacy. No complications were encountered in the postoperative period. Ninety-three PIVM cases have been reported in the skull since 1845. In very few of these cases, the mass is located in the parietal bone. The pathogenesis of PIVMs is not completely understood. The definitive diagnosis is made by histopathological examination. The therapeutic gold standard is surgery. Surgeons should keep in mind that radiological examination before the operation could prevent undesirable complications.

Midline Mandibular Cleft Treatment.

ABSTRACT: Tessier 30 cleft is a more rare anomaly comparing the other clefts and has variable clinical presentations. According to the literature, there were only 66 cases with Tessier 30 cleft reported since 2007. Furthermore, because of the rarity and variable clinical presentation of this condition, there is no consensus on the mode of management and timing of surgical procedures. In this case, we demonstrated the earlier treatment method of a newborn case with Tessier 30 cleft.

Assessment of Outcomes After Limberg Flap Reconstruction for Scrotal Defects in Patients With Fournier's Gangrene.

BACKGROUND: Fournier's gangrene (FG) is a rarely encountered necrotizing fasciitis principally affecting skin and subcutaneous tissues of the genital region, perineum, and abdominal wall. The overall incidence of FG is 1.6 cases per 100 000 per year; the incidence in males is higher. Management techniques described in the literature have both advantages and disadvantages, and there is no gold standard treatment technique. OBJECTIVE: This study evaluated whether the Limberg flap can be used reliably in scrotal defects with fewer complications than are seen with traditional techniques. The results of unilateral or bilateral Limberg flaps for scrotal reconstruction after FG were assessed. MATERIALS AND METHODS: This retrospective, single-center study analyzed records from 29 male patients with scrotal defects after multiple debridements who were treated from January 2013 to January 2018. Twenty-one patients (72.4%) with hemiscrotal defects and 8 patients (27.6%) with defects involving greater than 50% of the scrotal surface were included in this study. Demographic data that were analyzed included smoking history, comorbid conditions, time of surgery, and time of follow-up. Flap dimensions were measured. Patients were evaluated in terms of flap viability and postoperative complications. RESULTS: Mean age was 64 years (range, 47-80 years). The mean follow-up period was 16 months (range, 12-26 months). Dehiscence with seroma were detected in 4 patients (13.7%) on postoperative days 4 and 5. The average size of the flaps was 11 cm × 15 cm. Seroma and dehiscence were encountered in 4 patients (13.7%) during postoperative follow-ups. No postoperative infection was observed in any patient, and no partial or total flap loss was reported. CONCLUSIONS: These results suggest that use of the Limberg flap technique for scrotal reconstruction following FG has the important benefits of being easily harvested while providing tension-free repair and acceptable cosmetic results.

Assessment of sensory outcomes after successful fingertip replantation with or without nerve repair according to amputation level.

BACKGROUND: Good sensory outcome in fingertip replantation is a major part of the success of reconstruction and using the finger. Although some sensorial outcomes have been reported in various series in the literature, there is no controlled study, which demonstrates the anatomical levels where nerve repair should or should not be performed. We aimed to assess sensorial outcomes of fingertip amputations with or without nerve coaptation according to amputation level. METHODS: Between January 2013 and July 2018, patients with Tamai Zone 1 and Zone 2 amputations underwent replantation. The patients were divided two main groups. Patients underwent nerve coaptation were grouped as Group 1, and those coaptation not performed as Group 2. In addition, subgroups were designed according to level of the amputation. Tamai zone 1 amputations were grouped as groups 1a and 2a. Tamai zone 2 amputations were grouped as groups 1b and 2b. The mean age was 30.8 ± 30.8 years in Group 1a, 33.2 ± 12.6 years in Group 1b, 34.1 ± 13.6 years in Group 2a, 34.3 ± 11.1 years in Group 2b. Type of injury were evaluated as clean cut (with knife, saw etc.), moderately crushed, and severely crushed and/or avulsion. In Group 1a, one prominent branch of the nerve was repaired, and in Group 1b, the nerve in both side was repaired. The mean duration of replantation in Group 1a was 1 h and 40 min (1 h and 15 min-2 h), whereas this time was 1 h and 15 min (1 h - 1 h and 35 min) in Group 2a. Then, 2 h 15 min (1 h and 55 min-2 h and 50 min) in Group 1b, and 2 h (1 h and 45-2 h 25 min) in Group 2b. Mean age, type of injury and length of follow-up were statistically compared. Sensorial outcome was evaluated by 2-point discrimination test and the Semmes-Weinstein test. RESULTS: According to the Semmes-Weinstein test, 33% of the fingers tested were normal, 58% had diminished light touch, 8% had diminished protective sensation, and 0% had loss of protective sensation in Group 1a; In Group 1b, these values were 35% (7/20), 55% (11/20), 10% (2/20), 0%; in Group 2a, 38% (6/16), 56% (9/16), 6% (1/16), 0%; in Group 2b, 25% (4/16), 44% (7/16), %25 (4/16), 6% (1/16), respectively Mean static two-point discriminations in Groups 1a, 1b, 2a, and 2b were 4.17 ± 0.58, 4.55 ± 0.69, 4.25 ± 0.68, and 5.9 ± 1.26 mm, respectively. The mean follow-up duration was 24 months in Group 1a, 24 months in Group 1b, 26 months in Group 2a, 21 months in Group 2b. Then, 17 (3 in Group 1a, 6 in Group 1b, 4 in Group 2a, 4 in Group 2b) of the 64 fingers were clean cut amputation, 45 (9 in Group 1a, 14 in Group 1b, 11 in Group 2a, 11 in Group 2b) were moderately crushed amputation, and 2 (1 in Group 2a, 1 in Group 2b) were severely crushed and/or avulsion injury. There was no statistically significant difference between groups 1a and 2a (p = .71). On the other hand, there was a statistically significant increase in sensory outcomes of patients in Group 1b compared to Group 2b (p = .009). There was no statistically significant between the groups in terms of mean age, type of injury and length of follow-up. CONCLUSION: We think that nerve repair does not have a positive effect on sensorial recovery in Tamai Zone 1 amputations, but nerve coaptation should be performed in Tamai Zone 2 replantations if possible for better sensorial result.

Treatment of toes as an integrated part of infection control for advanced lower limb lymphedema.

The aim of this study was to compare the incidence of infection and verrucous hyperkeratosis in patients who underwent surgery for advanced lymphedema according to the algorithm designed by the senior author, and were treated concurrently with/without toe treatment. A case series (Between 2004-2015) of 46 patients with unilateral advanced lower limb lymphedema was reviewed. Lymphoscintigraphy was used for evaluation of lymphedema severity. The ICG lymphography was used for staging. Fibrosis and skin induration were reflected by the tonicity. They were divided into two groups: (1) patients who underwent further treatment of toes according to the algorithm, and (2) patients who did not have toe-related treatment. Infection episodes and verrucous hyperkeratosis were recorded. There were 21 and 25 patients in Groups 1 and 2, respectively. All lymphoscintigrams showed severe dermal backflow with severe stagnation by 2.5 h after injection of Tc-99 colloid. All patients were stage IV or V. Tonicity values of skin were <60. Group 1 was reduced to an average of 0.6 episodes per year in the past year of follow-up, and Group 2 was reduced to an average of 1.5 episodes per year in the past year of follow-up (p <0.001). The average frequency of preoperative cellulitis was 3.6 episodes per year. The occurrence of verrucous hyperkeratosis was observed in 14.3% and 32% of Groups 1 and 2, respectively. The incidences of cellulitis and verrucous hyperkeratosis were significantly lower in Group 1 than in Group 2 (p <0.001). To achieve successful control of infection, they should be treated carefully according to the strategy described above.

Histopathological evaluation of the effect of hyperbaric oxygen therapy on capsule occurrence around silicone breast prosthesis: an experimental study.

BACKGROUND: In general, capsular contracture is the underlying cause of complications such as pain, stiffening, breast asymmetry, and animation deformity that are seen in the late postoperative period due to the use of silicone breast prostheses. Considering the positive effects of HBO therapy on wound healing, the objective of this study was to investigate the effect of HBO therapy on capsule reaction occurring due to silicone implants. MATERIAL AND METHODS: Rats were divided into four groups. 1 cm × 1 cm silicone implants with rough surface were inserted in subcutaneous plane on the m spinotrapezius muscle fascia at just right of the dorsal region midline in rats in Group 1, while implants with same properties were inserted beneath m spinotrapezius muscle in rats in Group 2.Implants with the same properties were inserted in the subcutaneous area on the m spinotrapezius muscle in rats in Group 3 and into the area under the muscle in rats in Group 4. Beginning from the first postoperative day, rats in Groups 3 and 4 received HBO therapy for 90 min under 2.5 ATM pressure as one session a day over 15 days. RESULTS: The mean capsule thickness was statistically significantly lower in the groups treated with HBO compared to the control groups. Fibroblast, neutrophil and macrophage counts were statistically significantly lower in the groups treated with HBO compared to the control groups. CONCLUSION: We believe that HBO therapy can be used as an adjuvant treatment options to decrease capsule contraction occurring after silicone implant application.

Reconstruction of Below Knee Stump with Free Plantar Fillet Flap: A Case Report.

Here, we present a 45-year-old male patient who had right leg fracture in several pieces, arterial ischemia, multiple muscle, tendon losses and degloving injury on the distal thigh and knee undergoing emergency surgery due to a high-energy traffic accident and explain our experience with reconstruction of below knee stump using free plantar fillet flap in order to prevent above knee amputation in a patient with vascular injuries, multi-part fractures and soft tissue losses in the lower extremity.

Experience of Replantation and Reconstruction in Total Scalp, Partial Forehead, and Ear Avulsions.

In this study, the authors present the challenges of replantation and management of 2 patients who have total scalp, partial forehead and ear avulsion. A 39-year-old male farmer was admitted to the emergency room with the total scalp, forehead, partial right eyebrow and upper eyelid amputation after his hair was catched by an agricultural machine. Anastomoses of 2 arteries and 2 veins in the occipital region were done first. Anastomosis of the right and left superficial temporal arteries and veins were performed end to end by turning the operating table without moving the head, followed by 1 vein anastomoses in the frontal region. Although anastomotic blood flow was observed by Doppler ultrasonography, there were changes suggesting necrosis in the frontal and both temporoparietal regions and later in the occipital region. Necrotic tissues began to be debrided tangentially from the 10th day. During serial debridement, it was observed that the necrotic tissue includes skin and connective tissue. At the end of the post-operative second month, surgical treatment was completed and 12 months after the surgery, the patient lives with the wig because of hair loss, but the patient is cosmetically satisfied. An 18-year-old female gatherer was admitted to the emergency room with the total scalp, both eyebrows, right upper eyelid and partial right ear avulsion, after her hair was catched by an agricultural machine. Totally, anastomoses of 4 arteries and 3 veins were performed. On the 10th post-operative day, necrotic skin findings appeared and serial debridement were performed and it was revealed that aponeurosis was fully intact. The defect areas of skin and connective tissue were repaired with STSG. Intact partial temporal scalp tissue was present. Scalp replantation should always be considered as the first choice, according to the similar tissue principle of tissue repair in plastic surgery if there is no contraindication. Additionally, performing multiple arterial and vein anastomoses, evaluating the patient position in the post-operative period for anastomosis and hemodynamic follow-up, avoiding aggressive debridement and early reconstruction may give the patient the chance of skin grafting which is the basis of the reconstructive ladder.