A new concept for mandible reconstruction after oncological resection: Multisegment virtual surgical planning.

PURPOSE: Virtual surgical planning (VSP) is good for three dimensional reconstructions in maxillofacial surgery, but it is not problem-free completely especially when the resection margins cannot be affirmed in preoperative period. We aimed to obtain an ideal reconstruction with elaborating VSP to be prepared for adverse conditions during surgery and to proceed the oncological resections step- by- step with A, B, and C resection planes. PATIENTS AND METHODS: Four patients undergoing multisegment VSP for the primary mandible malignancies were included in the study. The first resection margin was detected as plan A in VSP, and plans of B and C were also prepared considering the tumor- positive result of intraoperative frozen section procedure. RESULTS: Following the tumor resection, margins were extended to the plan B in two patients, and plan C in one patient in accordance with the results of the frozen section procedure.Histogram comparison of the localizations of osteotomies in mandible and fibula, and positions of the implants were calculated at a confidence level of 95 % (p > 0.95) and mean difference was found -0.55 mm, while standard deviation was 1.76 mm. CONCLUSION: Multisegment virtual surgical planning seems to achieve the optimal reconstruction with the staged resection preventing redundant removal of tumor- free structures like bone and teeth.

A Distinct Technique of Intermaxillary Fixation Screw Application to Condylar Process to Fracture Reduction in Open Approach of Condylar Fracture Treatment.

ABSTRACT: The aim of this letter is to present the surgical experience obtained from a patient, in whom the proximal segment was better manipulated for precise alignment after application of the intermaxillary fixation screw.

Effects of Platelet Rich Plasma and Amniotic Cell Culture Medium on Wound Healing Following Experimental Animal Tracheal Injury Model: A Comparative Study.

INTRODUCTION: Prolonged inflammation after tracheal injury invariably results in a degree of stenosis. The topical application of platelet-rich plasma (PRP) and human amniotic fluid-derived cell culture medium (ACCM) have been shown to promote wound healing. The effects of PRP and amniotic cell culture medium (Gibco AmnioMAX - II ) were investigated in a rat model through morphometric, histological, and biochemical parameters. MATERIAL METHODS: Thirty-two male Sprague Dawley rats were included in the study: 4 rats provided for the preparation of PRP. Three groups of 7 rats were divided into PRP and ACCM groups, a control and a sham group respectively. A transverse incision on the ventral aspect of the third trachea spanning half of the tracheal circumference was performed. The incision was repaired with 7/0 polypropylene in the sham group. In the control group, 0.5 ml saline solution was applied on to the repaired injury site. In the other two groups, 0.5 mL PRP or ACCM were applied topically on the tracheal repair. Tissue samples were harvested 30 days after surgery for morphometric measurements and biochemical analyses for oxidative stress markers, IL-1beta, IL-6, and VEGF. Connective tissue thickness was evaluated histologically. Statistical analysis included the Mann-Whitney U and Kruskal Wallis tests. RESULTS: A notable difference was detected (P = 0,025) in cartilage segment length measurements of the trachea between the ACCM group and the sham and control groups (P < 0.03). A significant difference was found in the analysis of TAS, TOS, and OSI values between the study groups and the control and sham groups (P < 0.005). There were also differences in IL1-beta and IL-6 levels between ACCM and PRP groups (P < 0.05). For the same parameters, the differences were significant between the PRP and, sham and control groups (P = 0,004 and P = 0,002 respectively), and between the ACCM and, sham and control groups (P = 0,003 and P = 0,002 respectively).VEGF values demonstrated a significant difference between the PRP and sham group (P = 0,002), and between ACCM and sham/control groups (p=0,002 for both), the highest VEGF value was in ACCM group while the lowest value was in the sham group. In the histological assessment of connective tissue, a significant difference was observed between ACCM and the other groups. CONCLUSION: Amniotic fluid-derived cell culture medium shows less oxidative stress status than the other applications. ACCM is more effective on inflammatory and angiogenetic processes. Connective tissue thickness results were consistent with those biochemical and morphologic results. Additionally, a significant difference was observed in histological data between ACCM and PRP. Overall, ACCM proved to be efficient on tracheal healing. These effects can be attributed to the abundance of growth factors in both PRP and amniotic fluid-derived cell culture medium (ACCM).

Effectiveness of Different Surgical Flap Delay Methods and Their Systemic Toxicities.

OBJECTIVE: The surgical flap delaying has been shown to be effective in preventing partial flap loss or in preparing larger flaps. However, there is no gold standard flap delay method in the literature. In this study, the authors aimed to compare 3 types of surgical delay methods to determine which model would increase more flap survival. The authors also investigated the effect of delay methods on circulating mononuclear leukocytes as a parameter of DNA damage. METHODS: Twenty-four Sprague-Dawley male rats were divided into 4 groups. All subjects had a 10 × 3 cm modified McFarlane flap. Surface area measurements, biopsies, and blood samples were taken on the day of sacrification; 7th day for the control group and 14th day for delay groups. RESULTS: Between incisional surgery delay groups, a significant difference was found in necrosis and apoptosis in the bipedicled group, and only necrosis in the tripedicled group compared to the control. In terms of DNA damage, it was found higher in all experimental groups than in the control group. CONCLUSIONS: Both incisional surgical delay procedures' results were meaningfully effective when only incisions were made without the elevation of flaps. In conclusion, bipedicled incisional surgical delay seems to be the most effective method in McFarlane experimental flap model whereas two-staged surgeries may increase the risk of systemic toxicity.

Hybrid reconstruction of distal nasal defects.

We present hybrid reconstruction of distal lateral "through-and-through" nasal defects (skin, cartilage, and mucosa) due to resection of tumor and/or infection. Retrospective descriptive study. The study was performed in multicenter clinics between July 2011 and September 2016. 13 patients with full thickness distal nasal defects secondary to tumor and/or infection were included. Defects included dorsal and/or caudal septum, upper lateral cartilage, or inner/outer nasal valve. Caudal-based turn-in flaps were planned and used to repair inner lining of nasal cavity. Conchal and septal cartilages were used as cartilage grafts. Skin defects were reconstructed with lateral nasal artery perforator flaps. All flaps healed uneventfully, without flap loss. Nasal passage collapse, adhesion, or difficulty in breathing were not seen. No hematoma, infection, and deformity at cartilage graft donor areas was observed. During nasal reconstruction, it is mandatory to consider 3D complex and functional structure of nose. The repair of skin defects may not be enough for functional restoration. We believe that single step reconstruction of full thickness nasal defects through hybrid reconstruction may lead to anticipated successful results.

Neutrophil Elastase Inhibitor Increases Flap Survival in Experimental Degloving Injuries.

OBJECTIVES: Degloving hand injuries have generally been viewed as among the most difficult of injuries to manage due to the extensive nature of associated damage. The traditional approach to the circumferentially degloved segment of problematic flap viability has been to resuture the flap and to wait and see. However, the waiting period or the specific hemorheological protocol remains uncertain. This study aims to acknowledge if Sivelestat, known to ameliorate ischemia-reperfusion injury, enhances the survival of avulsed flaps in a hind limb degloving model of rats and to compare Sivelestat's effects to Pentoxifylline. METHODS: In this study, total flap area (cm2), area of necrosis in the flap (cm2), and the ratio between the necrotic and total areas (percentage) were determined. Angiogenesis among the groups was documented with CD31, anti-PECAM staining. TUNEL assay was performed to allow the visualization of cell nuclei containing fragmented DNA, a typical feature of apoptosis. RESULTS: The findings obtained in this study showed that Sivelestat administered at 10 mg/kg/hour dosage will inhibit the ischemia-reperfusion injury more pertinently than Pentoxifylline, which exerts only hemorheological effects. CONCLUSION: The anti-inflammatory effects of Sivelestat will be beneficial for decreasing the early complications of degloving injury, such as inflammation, sepsis, and edema, better than Pentoxifylline, which exerts only hemorheological effects.

The Role of Staged Cryosurgery and Three-Dimensional Computed Tomography Integrated Navigation System in the Surgical Management of Severe Involvement of Craniofacial Polyostotic Fibrous Dysplasia.

Fibrous dysplasia (FD) is a developmental bone disorder caused by the hamartamatous proliferation of bone-forming cells. A 29-year-old male patient with diagnosis of FD was admitted to our clinic with the symptoms of severe craniomaxillofacial involvement of FD beginning from last year. Neurological examination revealed diplopia, horizontal nystagmus, conductive hearing loss, and partial vision loss. In his medical history, it was reported that he had undergone intramedullary nailing operation in his left femur due to a pathological fracture approximately 8 years ago in the orthopedics clinic of our institution. The patient underwent 3 consecutive surgeries by our plastic and neurosurgical team. The patient was followed-up in the neuro-intensive care unit between the surgical sessions and 1 week after the last operation. Afterwards, he was transferred to the neurosurgical department. No postoperative complication was detected. The preoperative signs were recovered. During his 6th month follow-up control-visit, all his preoperative symptoms were improved. In addition, the patient was satisfied with his postoperative cosmetic improvement. In conclusion, virtual surgical planning and intraoperative surgical navigation systems can make the challenging cases possible to operate with increasing the safety margin of the surgical procedures for polyostotic FD.

Recommendations for management of diabetic foot ulcers during COVID-19 outbreak.

COVID-19 pandemia began in Wuhan, China, in December 2019. A total of 1 878 489 people were infected and 119 044 people were lost because of the disease and its complications by 15 April. Severe morbidity and mortality complications are mostly seen in elderly and patients having comorbidities. Diabetic foot ulcers (DFUs) are one of severe complications of diabetes mellitus and it may require urgent surgical interventions. In this paper, we aimed to create a management algorithm to prevent the unexpected complications that may occur in the patients and health care workers during the evaluation of COVID-19 in DFU patients who require urgent surgical intervention. We advise the use of thorax computerised tomography for preoperative screening in all DFU patients with severe signs of infection and especially those requiring urgent surgery for both the detection of the possible undiagnosed COVID-19 in the patient for the need for close follow-up and protection of the surgical and anaesthesiology team.

Combination of Würinger's Horizontal Septum and Inferior Pedicle Techniques to Increase Nipple-Areolar Complex Viability During Breast Reduction Surgery.

BACKGROUND: Breast reduction techniques depend on the vascularity of the pedicle. Preserving vascularity of the nipple-areolar complex (NAC) is mandatory for reduction mammoplasties, as the NAC is the most important aesthetic and functional unit of the breast. The inferior pedicle technique is the most common method for breast reduction; however, pedicle length may increase after using this technique and cause problems related to NAC viability in gigantomastic and hypertrophic breasts. In this study, we present our technical approach to preserve NAC viability by combining Würinger's horizontal septum and inferior pedicle techniques. METHODS: This study included 60 women (mean age 39.71 ± 10.52 years) who underwent a breast reduction combining Würinger's horizontal septum and inferior pedicle procedures from April 2012 to January 2016. All patients were marked preoperatively in a standing upright position using a prefabricated Wise-pattern template. The base of the pedicle was marked at the level of the inframammary ridge at a width of 8 cm. RESULTS: The patients were followed up for a mean of 5.6 ± 3.3 months. The resection weights of the right and left sides were 1406 ± 566 and 1340 ± 563 g, respectively. Venous insufficiency was encountered in five cases (8.3%) and caused partial NAC necrosis in one case (1.6%). No cases of total NAC necrosis were encountered. Fifteen breasts (12.5%) were described as gigantomastic (resection weight >2000 g). CONCLUSIONS: This combined method may promote safer and more satisfying outcomes from inferior pedicle breast reduction. 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 .

Histogram Planimetry Method for the Measurement of Irregular Wounds.

INTRODUCTION: Irregularly shaped wounds or flap borders usually require specified software or devices to measure their area and follow-up wound healing. In this study, an easy way of area measurement called histogram planimetry (HP) for wounds with irregular geometric shapes is defined and compared to conventional millimetric wound measurement. MATERIALS AND METHODS: Ten irregularly bordered geometric shapes were measured by 4 different individuals working as surgical assistants using both HP and manual millimetric measurement tools. The amount of time for each wound shape calculation as well as the measurements of the wound areas were noted. All measurements were compared for each method and between each individual using the Wilcoxon signed-rank test. RESULTS: There was no statistically significant difference between 2 measurement methods by means of measured areas; however, measurement time was significantly lower when the HP method was used. There also was no significant difference between the individuals' measurements and calculation times. These results indicated that HP is useful as a conventional millimetric square wound measurement technique with significantly lower measurement times. CONCLUSION: Due to the development of photo-editor software technologies, measurements in the surgical field have become more accurate and rapid than conventional manual methods without consuming the time and energy needed for other studies. A future study including comparisons between the presented method and complex computerized measurement methods, in terms of duration and accuracy, may provide additional supportive data for the authors' method.

Comparison of Cellular Alterations in Fat Cells Harvested With Laser-Assisted Liposuction and Suction-Assisted Liposuction.

OBJECTIVE: The aim of the present study was to evaluate the viability and proliferative capacity of adipose-derived stem cells obtained by laser-assisted liposuction (LAL). METHODS: Fat tissue was obtained from 7 male patients treated surgically for gynecomastia. On one side, harvesting was made before LAL, while it was implemented after LAL on the contralateral side. Viability, cell surface antigens, pluripotency, and apoptosis were assessed and compared in these samples. RESULTS: Cells harvested before and after LAL did not exhibit any significant difference in terms of surface cell markers. Number of viable stem cells was lower initially after exposure to laser, while this difference was reversed at the end of 72 hours. Genetic indicators of cellular differentiation were similar in both groups. Apoptosis indicators were increased remarkably after laser exposure in the first 24 hours, but this increase was absent 72 hours after LAL procedure. CONCLUSION: The authors' results have promising clinical relevance since mesenchymal stem cells harvested during LAL have maintained appropriate cellular features to be used for autologous fat transfer and fat grafting.

Effects of Different Concentrations of Injectable Collagenase Enzyme on Capsular Tissue Around Silicone Implants: A Preliminary Experimental Study for the Development of a New Treatment Strategy.

OBJECTIVES: In recent studies, collagen organization was blamed for the formation of capsular contracture which is still a challenging problem after silicone implant-based breast operations. In this study, effects of different concentrations of collagenase enzyme derived from Clostridium histolyticum on the capsular tissue formation around the silicone implants were investigated. The injectable form of collagenase has a routine clinical use in the treatment of both Dupuytren's and Peyronie's diseases. MATERIALS AND METHODS: Thirty-two Wistar albino rats were randomized into four groups. A 2 × 1 × 0.3-cm-sized silicone block was inserted inside a dorsal subcutaneous pocket in all groups. After 2 months of insertion, capsule thicknesses around the implants were detected under ultrasonography. This was followed by injection of isotonic saline, 150, 300, and 600 IU in Gr-1, 2, 3, and 4, respectively. All the animals were sacrificed at the end of the first week for histologic sampling to determine fibroblast proliferation, vessel density of the tissue, necrosis, edema, inflammation, and capsule thickness. All the data were statistically analyzed using Kruskal-Wallis and Mann-Whitney U tests and compared for significance of the results. RESULTS: There was no significant difference in terms of capsule thinning between the 300 and 600 IU groups but in both groups thinning was significantly higher than the sham group. In the 150 IU group there was no significant thinning as compared to the sham group (p > 0.05). However, complications such as skin necrosis, infection, and seroma formation were seen only in the 600 IU injection group. The optimal safe and effective dose of the enzyme was accepted as 300 IU. The 300 IU injection provided up to 89 % thinning in the capsule tissue. There was thinning of the collagen bundles parallel to capsule thickness. In the 600 IU group, micro-pores were encountered at the thinnest points. CONCLUSION: However, the late results and recurrence rates of capsular contracture were not included in this study; collagenase seemed effective for the reduction of capsular tissue around the implants. NO LEVEL ASSIGNED: This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. 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.

One-Stage Cleft Lip and Palate Repair in an Older Population.

BACKGROUND: In underdeveloped countries one-stage definitive repair of cleft lip and palate is considered for late-presenting patients. MATERIALS AND METHODS: A total of 25 patients with unoperated cleft lip and palate more than 2 years of age were enrolled in this study for one-stage simultaneous repair of cleft lip and palate. According to Veau-Wardill-Kilner push-back technique, 2 flap palatoplasties were performed for palatal repairs; all of the lips were repaired with the Millard II rotation-advancement technique. RESULTS: The authors experienced no perioperative or postoperative life-threatening complications. With respect to the registered operation periods, longer times were required to perform these double operations, but this elongation is shorter than the sum of the periods if the 2 operations had been performed separately. Although the authors were unable to evaluate the late postoperative results because the authors could not follow-up the patients after they were discharged the day after surgery, the early results related to the success of the operation without any surgical complication were prone to meet the parents' and patients' expectations. DISCUSSION: The authors presented their experiences with many volunteer cleft lip and palate trips to third world countries; however the structure of this article is not a new hypothesis and data based to support a scientific study, but observations are objective to get a conclusion. To perform one-stage definitive repair of the cleft lip and palate in late-presented patients was the reality that they had only 1 chance to undergo these operations. According to the terms and conditions of this challenging operation, one-stage simultaneous repair of cleft lip and palate is a more demanding and time-consuming procedure than is isolated cleft lip repair or cleft palate repair. Although technically challenging, single-stage repair of the whole deformity in late-presenting patients is a feasible, reliable, successful, and safe procedure in authors' experience.

Asymptomatic intradiploic epidermoid cyst eroding frontal bone in a patient with craniosynostosis.

Epidermoid cyst located in cranium is uncommon and usually diagnosed with a growing mass leading to symptoms. Asymptomatic intradiploic epidermoid cyst has not been reported yet. In this study, incidental diagnosis of asymptomatic cyst and potential impact of that cyst on surgical planning of a patient with craniosynostosis are presented.

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

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

Hezarfen wings: a lower lateral cartilage-based cartilage suspension technique for the adjustment of nasal tip rotation and projection and the correction of supratip deformity.

Nasal tip surgery is one of the most important parts of rhinoplasty to achieve an attractive nose. There are numerous techniques focusing on the correction of nasal tip rotation and projection. In this article, a new cartilage support derived from the cephalic border of lower lateral cartilages is used for the adjustment of tip rotation and projection, whereas improving supratip fullness is presented. Bilaterally harvested cartilage extensions are resembled as bird's wings and dedicated to the wings that were created by the world's first scientist who flew from one continent to another: Hezarfen Ahmed Çelebi. Thirty-two patients who underwent open-approach rhinoplasty operation including the abovementioned method were evaluated retrospectively. After performing conventional steps of open approach rhinoplasty, a wing is created by making a cephalic incision parallel to the lateral crural axis leaving the medial attachment intact and then undermined. Then, the cartilage is turned over the midline bilaterally as it acts like a curb by pulling or releasing the wings to adjust to the desired tip rotation and projection and sutured to the repaired upper lateral cartilage roof. Other 2 types of using these wings were asymmetric suturing one of the wings to help in the redirection of deviated nasal tip (n = 12) and suturing each other at midline to support the overlying skin like a tent with supratip deficiency (n = 7). The authors presented here both esthetic and functional outcomes of Hezarfen wings' method that was used for both nasal tip adjustments and supratip support.