Arterial Occlusion After Hyaluronic Acid Injection: Treatment With Hyaluronidase and Streptokinase.

ABSTRACT: The most feared complication of the hyaluronic acid injections in the periorbital region is embolism of the central retinal artery. The present study aimed to compare the effectiveness of hyaluronidase administered intravenously (systemically) alone or in combination with streptokinase with that of intra-arterial revascularization. Thirty rats were divided into 5 groups. The bilateral oblique groin flap of the rats was raised; the right side was the experiment group, and the left side was the sham control. The right superficial epigastric artery was occluded with a hyaluronic acid injection. After occlusion, no additional procedures were performed in group 1, whereas group 2 received systemic hyaluronidase, group 3 received intra-arterial hyaluronidase, group 4 received systemic hyaluronidase and streptokinase, and group 5 received intra-arterial hyaluronidase and streptokinase. On the seventh day, the rats were killed, flap necrosis rate was calculated, and histological examination was performed. There was no significant difference in the necrosis rates of the rats in groups 2, 3, 4, and 5 (P > 0.05). In histological evaluation, the histological view closest to normal arterial structure was observed in group 4. Immunohistochemical analysis revealed that the ischemia scores of systemic therapy were significantly lower than those of intra-arterial therapy. These results have shown that hyaluronidase and streptokinase administered systemically is as effective as intra-arterial revascularization and does not cause arterial wall degeneration. It has been shown that systemic administration of hyaluronidase and streptokinase is as successful as intra-arterial revascularization in the treatment of arterial embolism with hyaluronic acid.

Sparsity of dendritic cells and cytotoxic T cells in tumor microenvironment may lead to recurrence in basal cell carcinoma.

BACKGROUND: Antitumor immune response affects tumor growth. The effect of antitumor immune response on recurrence has been poorly studied in basal cell carcinoma (BCC). OBJECTIVES: To investigate the effects of the peritumoral immune infiltrate on BCC recurrence. METHODS: A total of 30 BCC patients without recurrence and 29 BCC patients with recurrence were included in this retrospective study. Non-recurrent tumor samples as well as primary and recurrent tumor samples from the recurrent group were stained immunohistochemically with anti-CD4, CD8, CD25, FOXP3, CD68, CD163, and CD1a antibodies. Immune infiltrates were semiquantitatively evaluated. RESULTS: BCC tumor microenvironment was rich in CD4+ cells. CD163 expression was higher than CD68. In primary tumors of the recurrent group, CD8 expression was significantly lower than CD4 expression. CD1a expression was lower in primary tumors of the recurrent group than in nonrecurrent tumors. CONCLUSIONS: Our results suggest the existence of an immunosuppressive microenvironment in BCC. Lower CD8+ T-cell numbers and sparsity of dendritic cells in primary tumors of recurrent patients suggest further immunosuppression in the tumor microenvironment and an increase in recurrence risk. This is the first study that evaluates and compares tumor immune microenvironments of primary and recurrent BCC lesions with several markers and investigates the role of antitumor immunity on BCC recurrence.

A Novel Stitching Technique: Adjustable Closed-Loop Sewing Machine Lock Stitching Technique to Bend or Unbend Cartilages.

This study aimed to evaluate the effect of a novel adjustable, closed-loop sewing machine lock stitching technique on cartilage shape. This study was performed on 18 rabbits that were divided into 3 groups to evaluate the short- (Group I), medium- (Group II), and long-term (Group III) effects of the technique on cartilage shape. Three cartilage grafts were obtained from the right and left ears of the rabbits and measured angularly. For the cartilage grafts obtained from the right ears, contours were corrected using the stitching technique proposed herein. The cartilage grafts obtained from the left ears were not stitched; these were maintained as the control group. Angular measurements were performed for the stitched cartilage grafts, and all the cartilages grafts obtained were finally embedded into the rabbits' backs. The rabbits in Groups I, II, and III were euthanized at week 2, 6, and 12, respectively, after which the cartilages were reevaluated for angular measurement and submitted for histopathological examination. A significant improvement from baseline was detected in the angular measurements of the stitched cartilage grafts obtained from the rabbits in each group. For the stitched cartilage grafts obtained from Group II and III rabbits, the angular measurements obtained immediately after stitching were found to be better than those obtained after euthanasia. In histopathological evaluation elevated collagen, perichondrium, and connective tissue levels were detected in grafts obtained from Group III rabbits. The novel stitching technique proposed herein appears to have beneficial long-term effects on the maintenance of cartilage contour.

The Effect of Minocycline on Fat Graft Survival and Apoptotic Pathway.

Variable absorption rate is one of the biggest problems of fat grafting and one of the most important causes of fat graft volume loss is apoptosis. Minocycline is a tetracycline derivative and besides its antibacterial capacity, it has been widely using for anti-apoptotic effects. This study was designed to investigate the effect of minocycline on fat graft survival and adipocyte apoptosis. A total of two main and eight subgroups were designed and a total of 48 experimental animals, 6 in each group, were used. Fat grafts are obtained from Wistar albino rats and implanted to dorsal area of rats. Local and systemic minocycline was applied in the study groups. On the 9th day, apoptotic cells were detected by the terminal deoxynucleotidyl transferase dUTP nick end labeling method and on the 90th day morphologic characteristics and viability of adipocytes were evaluated using histologic and immunohistochemical methods and statistically compared. This study revealed that the fat grafts were bigger, and they kept their structures better and they were more vascular in the minocycline groups and apoptosis was significantly lower in the minocycline groups. The authors demonstrated that minocycline increases fat graft survival and statistical improvement in apoptosis inhibition via using minocycline therapy has been shown.

The Effect of Albumin and Platelet-Poor Plasma Supplemented Botulinum A Toxin on Bioavaliability: An Experimental Rabbit Model.

Today, botulinum toxin is commonly used for cosmetic purposes throughout the world. Despite various agents reducing the efficiency of toxin are well defined, the studies related to increasing the bioavailability are limited. The purpose of our study is to assess the effect of the preparation of toxin by diluting with platelet-poor plasma (PPP) and/or albumin instead of standard dilution (saline) on bioavailability in cosmetic-purpose botulinum toxin applications.In the study, 24 New Zealand rabbits were used. Right anterior auricular muscle was preferred for toxin injections. Subjects were divided in 4 groups and in every group; botulinum A toxin (BTxA) that was prepared by different dilution methods was injected. 2.5 U saline-diluted BTxA was injected to the subjects in group 1, 2.5 U ready-to-use rabbit albumin-diluted BTxA was injected to group 2 and 2.5 U autologous PPP-diluted BTxA was injected to group 3 and pure saline was injected to group 4.Before the injection (0th week) and in the second, sixth, and 12th weeks after the injection, visual and electroneuromyographic evaluations of the ears of the subjects were performed.In the second week, median amplitude levels in group 2 were significantly found lower than other groups.In the sixth week, median amplitude levels in group 1 were significantly found lower than other groups.In 12th week, no significant difference was found among all the groups in terms of median amplitude levels.Visual findings were also correlated with electroneuromyographic findings.It was observed that the dilution of BTxA with albumin had caused a stronger paralysis when compared to dilution with saline or PPP at the beginning (second week); however, in the following weeks (sixth week), it was seen that dilution with saline had maintained paralysis better when compared with other dilution methods.In cosmetic BTxA applications, dilution of the toxin with albumin or PPP instead of standard dilution has no positive effect on bioavailability and such modifications regarding this kind of dilution are found unsuitable. Further studies are needed to directly relate the results with clinical applications.

The Inhibitory Effect of Platelet-Rich Plasma on Botulinum Toxin Type-A: An Experimental Study in Rabbits.

BACKGROUND: Combination treatments of botulinum toxin type-A and other rejuvenation agents or instruments are gradually becoming more popular. After observing a high incidence of therapy failure following simultaneous applications of botulinum toxin type-A and platelet-rich plasma mesotherapy, we aimed to investigate whether PRP has an inhibitory effect on botulinum toxin type-A. METHODS: Twenty-four New Zealand white rabbits were divided into 4 groups, and the anterior auricular muscle and overlying skin were used for injections. Groups I and II both received onabotulinumtoxinA intramuscular injections. In addition, autologous platelet-rich plasma mesotherapy was performed in Group I while Group II received saline mesotherapy. Group III was designed as the in vitro mixture group in which onabotulinumtoxinA and platelet-rich plasma were mixed and then administered intramuscularly. Group IV received saline within the mixture instead of platelet-rich plasma. The contralateral ears of all the rabbits served as control and were only treated with onabotulinumtoxinA. Visual evaluation of ear positions and electroneuromyographic studies were done prior to all procedures and at day 14. Anterior auricular muscles were harvested at day 14 and were evaluated with quantitative real-time PCR. RESULTS: Visual and electroneuromyographic studies revealed less onabotulinumtoxinA activity in Groups I and III. When platelet-rich plasma was administered through skin mesotherapy, onabotulinumtoxinA activity failure was more severe in comparison with direct contact. No significant difference in SNAP-25 mRNA expression through quantitative real-time PCR was observed between groups. CONCLUSION: Although we could not explain the exact mechanism underlying this interaction, platelet-rich plasma applications result in less onabotulinumtoxinA muscle paralysis activity.

The Effect of Microneedle Thickness on Pain During Minimally Invasive Facial Procedures: A Clinical Study.

BACKGROUND: Minimally invasive procedures are becoming increasingly popular because they require minimal downtime and are effective for achieving a more youthful appearance. The choice of needle for minimally invasive procedures can be a major factor in the patient's comfort level, which in turn affects the physician's comfort level. OBJECTIVES: In this comparative study, the authors assessed levels of pain and bruising after participants were injected with 30-gauge or 33-gauge (G) microneedles, which are commonly used for minimally invasive injection procedures. METHODS: Twenty healthy volunteers were recruited for this prospective study. Eight injection points (4 on each side of the face) were determined for each patient. All participants received injections of saline with both microneedles in a randomized, blinded fashion. Levels of pain and bruising were assessed and analyzed for significance. RESULTS: The highest level of pain was in the malar region, and the lowest level was in the glabella. Although all pain scores were lower for the 33-G microneedle, the difference was significant only for the forehead. Because most minimally invasive procedures require multiple injections during the same sitting, the overall procedure was evaluated as well. Assessment of the multiple-injection process demonstrated a significant difference in pain level, favoring the 33-G needle. Although the difference in bruising was not statistically significant between the 2 needles, the degree of bruising was lower with the 33-G needle. CONCLUSIONS: For procedures that involve multiple injections to the face (such as mesotherapy and injection of botulinum toxin A), thinner needles result in less pain, making the overall experience more comfortable for the patient and the physician. LEVEL OF EVIDENCE: 3.

Reconstruction of cranial bone defects using Struthio camelus eggshell.

BACKGROUND: There are many synthetic materials for the treatment of bone defects, which have their own advantages and disadvantages. We aimed to compare the efficacy of ostrich eggshell, which is cheap and easily available, and demineralized bone matrix in healing of cranial bone defects. METHODS: A full-thickness circular bone defect was created in the frontal bone of 40 Wistar rats. Group 1 was the operative control group. In group 2, demineralized bone matrix applied into the defects; in group 3, Struthio camelus (ostrich) eggshell implants (OSIs) were applied into the defects; and in group 4, ostrich eggshell powders were applied into the defects. Computed tomographic analysis was performed to evaluate the healing of bone defects, the bone density, the OSI area measurements, and the OSI volume and density. At the end of the 24th week, all rats were killed. New bone formation, infection, resorption, and tissue reactions were evaluated. RESULTS: Ostrich eggshell implants were slightly resorbed, integrated with bone, stable, and supplied good cranial completeness. Ostrich eggshell powders were totally resorbed at the sixth month. There were no significant differences between control and ostrich eggshell groups in new bone formation. CONCLUSIONS: Ostrich eggshell did not seem to be an osteoproductive material, but it has some important advantages as an implant. Ostrich eggshell has a strong structure, is cheap, is shaped easily, and does not cause tissue reaction or infection. Ostrich eggshell could be a good alternative graft material for craniomaxillofacial procedures. Further studies are required to find out the potential use of the ostrich eggshell in craniomaxillofacial reconstructions.

Distally based lateral and medial leg adipofascial flaps: need for caution with old, diabetic patients.

BACKGROUND: Reconstruction of defects around the ankle region has always been challenging for plastic surgeons. Distally based lateral and medial leg adipofascial flaps are among the flaps of choice for coverage of this difficult region. Presented here is the authors' clinical experience with these flaps, particularly emphasizing the complicated attempts in diabetic patients. METHODS: Seven skin defects around the ankle were reconstructed with lateral and medial leg adipofascial flaps. The lowermost perforators of the peroneal or posterior tibial artery were identified preoperatively, and a straight incision through skin only was made proximal to this perforator. With the skin flaps reflected, the adipofascial flap was than raised in the subfascial plane. The perforators to be retained in the base were located and the flap was then turned over to cover the defect, followed by application of a split-thickness skin graft over the flap. The donor site was closed primarily. RESULTS: The ages of the patients ranged from 25 to 80 years, and the size of the flaps ranged from 3 x 5 cm to 7 x 10 cm. Four defects were reconstructed with lateral leg adipofascial flaps, and medial leg adipofascial flaps were used in three. Two flaps healed uneventfully. Partial or total graft loss and partial flap necrosis were observed in five patients, four of whom were diabetic. CONCLUSIONS: Leg adipofascial flaps offer a valuable option for repair of defects around the ankle in many cases. However, adipofascial flaps should be used with caution in old, diabetic patients and, when performed, the probability of a second or third procedure should be considered.

Proper timing of breast reduction during the menstrual cycle.

Breasts are known to show cyclic changes in accordance with the menstrual cycle, and speculations have been made regarding the ideal timing of breast surgery in this extent, but the clinical evidence to support global acceptance and application is lacking. This study was designed to establish the relationship of intraoperative bleeding and postoperative drainage with the menstrual period of 35 reduction mammaplasty patients. The results indicate that both perioperative blood loss and postoperative drainage were significantly reduced when breast reduction is performed during the periovulatory phase compared with the perimenstrual phase. The authors strongly recommend the interval between days 8 and 20 of the menstrual cycle as a more convenient period to perform breast reduction. Drains may be avoided during this period, but they are preferred if the surgery is done during the perimenstrual phase.

Histologic profiles of breast reduction specimens.

Reduction mammaplasty is one of the most common procedures performed by plastic surgeons all around the world. This procedure is performed for aesthetic or reconstructive purposes, but also offers the opportunity to examine all resected breast tissue histopathologically. The purpose of this study was to evaluate the histologic diagnoses of the reduction mammaplasty specimens retrospectively and to determine the incidence of breast lesions in otherwise asymptomatic and healthy women. Therefore, 149 patients who had undergone reduction mammaplasty were reviewed with regard to their histologic diagnoses. We found that 61% of these women have pathologic alterations in at least one of their breasts, so each patient who requests a breast reduction surgery should be evaluated carefully and the specimens should be handled with particular care.