Evaluation of Anastomosis Efficiency in Arteriovenous Shunts Created by Using Hand-Sewn Microsurgery and Microvascular Anastomotic Coupler Device.

OBJECTIVE: Microsurgery has made great contributions to the advancement of surgery. In parallel with the developments in microsurgery, various techniques have been developed to perfect the technique. Microvascular anastomotic coupler device (MACD) is one of these techniques. The aim of the study was to evaluate the effectiveness of anastomoses created by using hand-sewn microsurgery (HSM) and MACD. METHODS: Twenty male Sprague-Dawley rats weighing 250 to 300 g were divided into 2 groups randomly. Arteriovenous shunt was performed between carotid artery and internal jugular vein with the principles of HSM in the first group (n=10) and by using the 1-mm anastomotic microvascular device in the second group (n=10). Groups were evaluated for anastomose time, success of anastomosis, thrombosis formation, color Doppler ultrasonography, and histopathological features. RESULTS: Anastomotic time was faster with the coupler device compared with HSM technique. Flow rates were found significantly higher in the MACD group. Endothelialization and wall integrity rates were better in MACD group. CONCLUSIONS: Microvascular anastomotic coupler device is faster than HSM. High quality and durability of vascularization, insignificant foreign body reactions are histopathological advantages of MACD.

Supraorbital Bone Shaving (S.O.S Procedure) in Restoration of Upper Lateral Convexity in Sunken Eyes.

BACKGROUND: Sunken eyes have become a most important target of periorbital area aesthetics. Throughout history, the aesthetics of the periorbital region have been emphasized, and various surgical techniques related to this region have been described. Most of these techniques provide only soft tissue solutions; therefore, additional surgical interventions may be required. The aim of our study was to introduce an endoscopic supraorbital shaving (SOS) technique for the treatment of individuals with sunken eyes. METHODS: Between 2020 and 2021, 34 patients (30 females, 4 males; mean age 36.2 years) with sunken eyes were treated with our described technique. All patients underwent an endoscopic SOS procedure under general anesthesia. RESULTS: A total of 34 patients (30 women and four men), aged 23-59 years old (mean = 36.2 years), underwent the endoscopic SOS procedure. The mean follow-up period was 13 months (range: 12-16 months). Postoperatively, significant improvement in lateral convexity was achieved in all patients. Physical examinations performed at the control visits revealed no functional problems in any patients and no visible or palpable irregularities or contour deformities. No complications were encountered regarding the SOS procedure. CONCLUSIONS: The technique described here provides significant improvement in lateral convexity compared to other techniques used in patients with sunken eyes. No additional eyelid intervention is needed. Unlike the techniques previously described in the literature, intervention is made in the bone structure, thereby providing more accurate results. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Trinity Lift: A Unique Technique for Endoscopic Midface and Lower Periorbital Unit Lift.

INTRODUCTION: A harmonious face is defined in terms of a balanced relationship among all facial tissues. This balance among skin, fat, muscle, and bone is lost with aging as progressive changes occur in their volume, shape, position, and consistency. Aging of the human face generally starts in the third decade of life, mainly in the midface and periorbital areas. Traditional face-lifting surgeries result in minimal improvements in the midface area. Various techniques have been developed using different dissection planes and vectors with different forms of incision, including endoscopic techniques. METHODS: We attempted to combine endoscopic subperiosteal dissection techniques with the percutaneous needle technique, especially in young- to middle-aged patients. We aim to share technical details of our preferred suspension and fixation method for an endoscopic midface lift with the aid of a percutaneous needle and to present the outcomes of this particular technique in 75 patients. RESULTS: Significant rejuvenation of the nasojugal groove was achieved, and patient satisfaction was high. All cases exhibited satisfactory, symmetrical, and stable elevation of the midface. None of the patients required a second surgery. CONCLUSION: Trinity lift allowed for stronger, easier, and faster application of sutures during endoscopic facial surgery without any other mucosal or transcutaneous incisions. 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 Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Challenges of Setting up a Lower Extremity Reconstruction Practice in a Constrained Environment.

BACKGROUND: Microsurgical lower extremity reconstruction remains challenging, especially when resources are limited such as lack of proper equipment, human resources, administrative support, and located in a remote area far from tertiary care. Nevertheless, reconstructive solutions are required, especially when in urgent trauma situations. In this article, we evaluate ways of overcoming challenges and issues that should be considered in a newly established unit by sharing our initial lower extremity reconstruction experience. METHODS: We report a local hospital's initial lower extremity reconstruction experience in February 2017 to January 2018. Through a total of seven patients, we tried to enhance the environment, instruments, nurses' contribution, and perspective of the peers and community in terms of factors related to the surgeon, hardware, environment, supporting faculty, reimbursement, and patients. RESULTS: Four patients underwent reconstruction with a freestyle propeller flap and three with an anterolateral thigh flap; in one case, a superficial circumflex iliac artery perforator flap was chosen to salvage partial flap necrosis. Increased experience of the surgeon, new equipment, continuing nurse/patient education, and collaborating with other departments allowed us to choose more challenging flaps and be more meticulous while decreasing the operation time and hospital stay. CONCLUSION: To start a lower extremity reconstruction practice in a resource-poor environment, the surgeon needs to evaluate the relevant factors; moreover, he or she should continuously improve them until a working methodology is achieved. Despite all the challenges, the adaptations learned at this center can be applied to other local hospitals around the world to set up a lower extremity reconstruction practice and improve its outcomes.

A New Perspective to the Periorbital Aesthetics: Bella Eyes.

INTRODUCTION: The term beautiful eyes can be defined as youthful, brilliant, vivid, and attractive eyes. The anthropometric findings about beautiful eyes may differ according to gender or race. In order to form such a beautiful eye, a variety of surgical, nonsurgical, or combination methods for periorbital region rejuvenation have been proposed. The surgical methods include coronal/peritrichial, endoscopic, upper and lower eyelid, or transconjunctival incisional procedures. Neuromodulators, fillers, and laser treatments are some of the nonsurgical approaches. Regardless of the method, while treating this particular area, the aesthetic unit concept should always be taken into consideration. METHODS: We attempted to combine an endoscopic dynamic canthopexy procedure with endoscopic temporal and brow lift, which we call "bella eyes" to achieve a more attractive look, especially in young people who desire a slanted eyelid. We aim to share our clinical experience from 35 patients and the technical details of the bella eyes procedure. RESULTS: Patient satisfaction was high, and the endoscopic technique eliminated all of the minor deformities and provided excellent harmony through each subunit of the periocular area with minimal discomfort and well-hidden scars. CONCLUSION: We believe that this procedure is a good way to achieve a beautiful eye in young women. 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.

Evaluation of the Retro-Orbital Fatty Tissue Volume in Delayed Orbital Blow-Out Fractures.

PURPOSE: In patients where diplopia and enophthalmia are manifest, surgical intervention is usually necessary. The pathogenesis of these symptoms usually includes the prolapse of orbital tissues into the sinus or compression by the surrounding bone structures. Although the retro-orbital fatty tissue, orbital fascia, and the muscle tissue can be reduced to the original place after being incarcerated into the maxillary space, it is obvious that the procedure can lead to significant fibrosis in these structures. The authors have aimed to carry out a quantitative evaluation of the fatty tissue volumes in patients with repair delayed for more than two weeks. METHODS: The preoperative and postoperative fatty tissue volumes and the changes in total orbital volume were evaluated by using CT on the patients (n = 9) who were consulted to the authors' clinic from other health centers. RESULTS: Although no significant correlation was observed between the prolapsed volume and the postoperative reduction in the fatty tissue, the reduction in the retro-orbital fatty tissue was statistically significant. CONCLUSION: Evaluating postoperative retro-orbital fatty tissue volumes may have implications for surgical intervention in the future.

The role of adenovirus 36 as a risk factor in obesity: the first clinical study made in the fatty tissues of adults in Turkey.

Obesity which developes due to multifactorial reasons, was associated recently with human Adenovirus-36 (Ad-36). The aim of this study was to investigate the prevalence of Ad-36 antibodies in obese adults and also to investigate the DNA of Ad-36 in their adipose tissue. In this cross-sectional and case-control based study, 49 obese adults, with BMI ≥ 30 kg/m(2), and 49 non-obese adults, with BMI ≤ 25 kg/m(2), applied for esthetic purposes and were included in this study as patient and control groups, respectively. Adipose tissue samples, obtained by the lipoaspiration method, were studied by single-step PCR and nested-PCR methods. Simultaneously, the presence of Ad-36 antibodies and serum leptin and adiponectin levels were assessed by serum neutralization assay (SNA) and ELISA, respectively. Serum samples which didn't cause a cytopathic effect at ≥ 1:8 were accepted as positive. Ad-36 antibody was detected in 6 (12.2%) of 49 patients by SNA and was statistically significant (p < 0.05). Ad-36 DNA was not detected in any of the adipose tissue samples of the patient or control groups. Mean BMI and leptin levels were higher in the Ad-36-positive group, while adiponectin levels were found to be lower in the Ad-36-positive group. Although no statistically significant difference was found in cholesterol and triglyceride levels between the two groups (p > 0.05), lower mean serum cholesterol and triglyceride levels were found in the Ad-36-positive patients. In conclusion, we couldn't detect Ad-36 DNA in adipose tissue; however, we detected significantly higher Ad-36 antibody levels in the obese group compared to the non-obese group, according to the both univariant and multivariant analyses, suggesting that Ad-36 may play a role in obesity. There is a need for new and extended serial, particularly cohort and human-based, studies in order to have a clear understanding of the Ad-36-obesity relationship.

Autologous fat injection into the pectoralis major as an adjunct to surgical correction of gynecomastia.

BACKGROUND: Correction of gynecomastia in males is a frequently performed aesthetic procedure. Various surgical options involving the removal of excess skin, fat, or glandular tissue have been described. However, poor aesthetic outcomes, including a flat or depressed pectoral area, limit the success of these techniques. OBJECTIVES: The authors sought to determine patient satisfaction with the results of upper chest augmentation by direct intrapectoral fat injection in conjunction with surgical correction of gynecomastia. METHODS: In this prospective study, 26 patients underwent liposuction and glandular excision, glandular excision alone, or Benelli-type skin excision. All patients received intramuscular fat injections in predetermined zones of the pectoralis major (PM). The mean volume of fat injected was 160 mL (range, 80-220 mL per breast) bilaterally. Patients were monitored for an average of 16 months (range, 8-24 months). RESULTS: Hematoma formation and consequent infraareolar depression was noted in 1 patient and was corrected by secondary lipografting. Mean patient satisfaction was rated as 8.4 on a scale of 1 (unsatisfactory) to 10 (highly satisfactory). CONCLUSIONS: Autologous intrapectoral fat injection performed simultaneously with gynecomastia correction can produce a masculine appearance. The long-term viability of fat cells injected into the PM needs to be determined. LEVEL OF EVIDENCE: 4 Therapeutic.

Is there a profit to use the lateral antebrachial cutaneous nerve as a graft source in digital nerve reconstruction?

BACKGROUND: The digital nerves are commonly injured in emergency hand surgery practice. Lateral antebrachial nerve is of the autologous graft options available in forearm for digital nerve reconstruction. In this report, we aimed the evaluation of this nerve as an autologous nerve source for digital nerve repair. PATIENTS AND METHODS: The overall sensorial results of the lateral antebrachial cutaneous nerve grafting and associated donor site morbidity in neglected digital nerve injuries of 15 patients in Zones 1 and 2 were evaluated Average length of the harvested lateral antebrachial cutaneous nerve grafts was 1.81 cm (0.75-3 cm.). RESULTS: Patients have been followed up for 20.7 months in average (range: 9.3-41 months). According to Highet and Sander criteria modified by Mackinnon and Dellon, nine patients were graded as S4, whereas six patients had S3+ values. According to modified ASSH guidelines for stratification of static 2PD results, excellent results were obtained in five patients, good results were achieved in eight patients and moderate results were obtained in two patients. Both the donor and recipient sites were evaluated with Semmes-Weinstein monofilament tests where satisfactory results have been obtained. Only two patients reported minimal cold intolerance at the donor site apart from the mild hypoesthesia noted at the anterolateral aspect of the middle forearm. CONCLUSION: Quite favorable clinical results with minimal donor site sensorial deficiency, anatomical and histomorphological similarity and being available in close location to surgical area brings up a matter to utilization of LABCN for digital nerve reconstruction.

"Three-suture technique" for estimation of the intraoperative maneuvers in rhinoplasty.

Rhinoplasty is one of the most challenging procedures to master in plastic surgery. A successful outcome almost always requires a detailed preoperative analysis. However, intraoperative assessment should not be underestimated as well. To give a rough idea about the changing positions of the basic landmarks of the nose, we would like to demonstrate the "3-point suture determination" test. With this simple method, surgeons might estimate the instant effects of certain maneuvers during surgery.

Functional outcomes of preauricular underparotid retrograde approach for mandibular condyle fractures.

Management of condyle fractures includes a wide spectrum of alternatives including analgesia alone, physiotherapy, intermaxillary fixation, and open reduction and internal fixation. Various approaches have been previously mentioned for the access to the mandibular condyle. The aim of this retrospective clinical study was to evaluate our clinical results on preauricular underparotid retrograde approach for condylar fractures. This retrospective study included 20 condylar fractures in 16 patients who were treated surgically using a preauricular transparotid retrograde approach between 2010 and 2013. Functional outcomes with this method were addressed in light of the results obtained in this clinical series. We suggest this method in the management of condylar fractures.

Large hydatid cyst of the maxillozygomatic region.

Hydatid cyst is a zoonotic infection caused by Echinococcus granulosus. Majorly affected body regions are the liver and the lungs. However, rare localizations of the neck region, mastoids, parotid glands, orbita, and the mandible have been reported in literature. In this case, we report a large hydatid cyst of the maxillozygomatic region presenting as a slowly growing mass.

"Roller coaster maneuver via lateral orbital approach" for reduction of isolated zygomatic arch fractures.

Numerous techniques have been reported for the reduction of zygomatic arch fractures. In this article, we aimed to describe a technique we named as "roller coaster maneuver via lateral orbital approach" to closed reduction of the isolated-type zygomatic arch fractures. Surgical outcomes of 14 patients treated with this method were outlined.

Use of acellular dermal matrix in peripheral nerve reconstruction: an experimental study on rat sciatic nerve defect.

BACKGROUND: In patients with nerve tissue defects, the use of autologous nerve grafts is the standard method of treatment. Alternatives to autologous, nerve grafts have attracted the attention of reconstructive surgeons. In this study, the results of nerve repairs using acellular dermal matrix (ADM) in an experimental rat sciatic nerve defect model are presented. METHODS: Thirty-six Sprague-Dawley rats were randomized into 5 groups: Group 1: control group, Group 2: negative control group (n = 6), Group 3: autologous nerve graft group (n = 10), Group 4: donor site entubulated with ADM group (n = 10); and Group 5: nerve graft entubulated with ADM group (n = 10). The animals in each group were evaluated for electrophysiologic functions, gastrocnemius muscle weight and histomorphology on the 3rd and 6th month. RESULTS: The compound muscle action potential was observed to be distinctly lower in Groups 3, 4 and 5 in comparison to the control group. In Group 4, the gastrocnemius ratio (GCR) values on the 6th month were statistically significantly lower than the GCR values in Group 3 and Group 5, The histological scores and myelinated axonal counts in Group 5 were statistically significantly higher than the values in Group 3 and Group 4. CONCLUSION: The results of this study showed that wrapping ADM around nerve grafts resulted in better outcomes with respect to nerve healing.

Use of outsized composite chondrocutaneous grafts in conjunction with dermal turnover flaps for reconstruction of full-thickness alar defects.

Chondrocutaneous (ChC) grafts have been used for nasal alar reconstruction for years. One of the consequences for using these grafts is the restriction in dimensions. In this study, we presented our results in which ChC grafts bigger than 20 mm in length have been used in conjunction with a dermal turnover flap for full-thickness alar subunit defects. Technical details and results of 8 alar subunits reconstructions in 8 patients were evaluated. Follow-up period ranged from 10 to 27 months, with a mean of 18.3 months. We achieved satisfactory results without partial or total graft failure. Finally, surgeons can safely use outsized ChC composite grafts with this type of design, for successful alar subunit reconstruction.

An uncommon complication of septorhinoplasty, acute dacryocystitis.

During septorhinoplasty procedures lacrimal drainage systems are susceptible to injury because of the close relationship of the nasal bones. Most of the injuries to the system remain asymptomatic. Here we report a case of septorhinoplasty which was complicated by acute dacryocystitis postoperatively. The patient was treated successfully with appropriate medical therapy.