Effects of Osteotomy on Hemodynamic Parameters and Depth of Anesthesia in Rhinoplasty Operations.

BACKGROUND: Bleeding during rhinoplasty leads to many undesirable effects, such as loss of vision in the surgery area, complications during the procedure, and postoperative complications. The most important effect that increases bleeding is hemodynamic changes during surgery. Considering that osteotomy is the most challenging process in rhinoplasty, this study aimed to examine the hemodynamic changes during osteotomy and changes in the depth of anesthesia. METHODS: A total of 50 patients, aged 18 to 65 years with an ASA (American Society of Anesthesiology) score of 1 and 2, who underwent osteotomy during rhinoplasty under general anesthesia, were examined retrospectively. After routine monitoring, the patients underwent general anesthesia induction and endotracheal intubation. Before the surgery, they received remifentanil 1 µg/kg as an intravenous bolus followed by 0.5 µg/(kg·min) as intravenous infusion until the end of the surgery. The hemodynamic parameters and depth of anesthesia [bispectral index (BIS) values] of the patients were examined before anesthesia, 10 minutes before osteotomy, during osteotomy, and 10 minutes after osteotomy. RESULTS: A significant difference was found in heart rate (beats/min), systolic and diastolic blood pressures (mm Hg), and BIS values of the patients measured before, during, and after osteotomy (P < 0.001). The heart rate, systolic and diastolic blood pressures, and BIS values were significantly higher during osteotomy. Until the 10th minute after osteotomy, all 4 parameters nearly reached the values measured before osteotomy. CONCLUSIONS: Osteotomy directly affects hemodynamic parameters and depth of anesthesia. Hence, it is of utmost importance that the analgesic need and depth of anesthesia are adequately monitored and adjusted during osteotomy. By suppressing hemodynamic stress responses, the amount of bleeding can be reduced, thus increasing the surgical success and the patient's comfort.

Dexmedetomidine as an Alternative Anesthetic Agent for Flap Surgery: An Intravital Evaluation in the Cremaster Muscle Flap.

INTRODUCTION: Flap surgery is one of the most commonly used techniques of reconstructive surgery for effective repair of damaged tissue. Optimal anesthetic technique and anesthetic agent plays an important role in flap perfusion. This study aimed to evaluate the effects of dexmedetomidine infusion on the microcirculation in the cremaster muscle flap by direct in vivo monitoring. MATERIALS AND METHODS: We randomly divided 9 Wistar albino rats into 3 groups. The rats in the control group underwent the surgical procedure (isolation of the cremaster muscle) alone; the rats in the experimental groups 1 and 2 received an infusion of dexmedetomidine (10 and 30 min) after the surgical procedure. RESULTS: The means of vessel diameters, number of functional capillaries, and movements of leukocytes in all groups were evaluated using intravital microscopic examination. The diameters of the arterioles and venules of the cremaster muscle significantly increased in the dexmedetomidine groups. The number of functional capillaries was higher in the dexmedetomidine groups than in the control group. No difference was observed in the movements of leukocytes between the control and experimental groups. Dexmedetomidine significantly increased the diameters of the arterioles and venules of the cremaster flap and the number of functional capillaries. CONCLUSION: On the basis of the effects of dexmedetomidine on microcirculation, we suggest that dexmedetomidine continue to be used as an anesthetic agent, and may be considered also for reconstructive procedures, particularly flap surgery.

Hyaluronic acid viscoelastic medium as an aid for microsurgical venous anastomoses.

The thin-walled structure of veins leads them to stay collapsed during anastomoses, thereby the incidence of technical failures is more common than arterial anastomoses. In order to overcome this problem, we are introducing the use of viscoelastic material based on our experience on rats. Six rats were used in order to study the technical feasibility of the viscoelastic material during microsurgical vein anastomosis. End-to-end anastomoses were performed on rat jugular veins using 0.5-1 mL of the viscoelastic medium applied to the ends of the veins and surgical field under ×30 operating microscope magnification. Then 1.8% (n:3) and 3.0% (n:3) hyaluronic acid was used as a viscous medium in order to keep the vein lumens open during anastomosis. In conclusion, we have found that 3.0% hyaluronic acid viscoelastic medium facilitates microvenous anastomosis in rat. Studies involving human practice are needed for further evaluation of this technical refinement.

Intravital microscopic evaluation of cremasteric microcirculation in experimental testicular torsion.

AIM: Although absent cremasteric reflex is a significant clinical finding for testicular torsion (TT), there is limited information about microcirculation of the cremasteric muscle (CM) after TT. This experimental study was performed to evaluate CM microcirculation by intravital microscopy after TT. MATERIALS AND METHODS: Twelve Wistar rats were allocated into two equal groups: control (CG) and torsion (TG). After anesthetization of the CG rats, the CM flap was dissected through a left ventral inguinal incision with its vascular pedicle. In TG rats, TT was performed by rotating left testicles 720(°) in clockwise direction for 1 h. Then, the CM flap was dissected as in CG, and was placed under an intravital microscope. Vessel diameters, functional capillary perfusion and leukocyte activation in post-capillary venules were measured and evaluated statistically. RESULTS: There was a significant decrease in vessel diameter in TG compared to CG (p < 0.05). The median of perfused capillaries in CG and TG was 13 (11.75-14.30) and 5.5 (4.75-7.25), respectively (p < 0.05). Number of granulocytes (rolling, sticking, transmigrated) was greater in TG than CG (p < 0.05). CONCLUSION: Intravital microscopic evaluation of CM after TT showed decrease in vessel diameter and number of perfused capillaries, and increase in granulocyte activation. Clinical, electrophysiological alterations in CM after TT can be explained by deterioration of microcirculation of CM.

Meridian pedicle-based breast shaping in reduction mammaplasty: a technical modification.

BACKGROUND: We present a technical modification of vertical reduction mammaplasty which provides a reliable pedicle that can be used in large and highly ptotic breasts with confidence when compared to vertical mammaplasty techniques without sacrificing conical breast shape and projection, in contrast to Wise pattern reduction techniques. METHODS: Thirty-two patients under general anesthesia were operated on using this modification between 2008 and 2012. The surgical technique is as follows: after general anesthesia induction and local anesthetic infiltration, skin incisions are made according to preoperative drawings. The breast meridian is prepared by superior and inferior plication of the vertical pedicle, including two dermal and one central attachment to the chest wall. Lateral and medial tissue resections are performed, thus preparing medial and lateral pillars after skin undermining. The pillars are sutured to the meridian to reconstruct a projectile conical breast shape. Inverted-T scar (87.5%, n=28) and vertical scar (12.5%, n=4) were used for closure. RESULTS: All patients were satisfied with the outcome regarding breast projection, shape, and size at 12 (n=30) and 24 months (n=15) after surgery except for 12 cases that needed reoperations: 2 cases for bottoming out and lower pole deformity, 2 cases needed more reduction by liposuction or re-excision, and 8 scar revisions. CONCLUSION: Early and late results (up to 2 years) regarding breast shape and projection were found to be satisfactory while providing a reliable pedicle with less postoperative drainage. 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 .

Simultaneous reconstruction of medial canthal area and both eyelids with a single transverse split forehead island flap.

In this report, we are presenting a case in which we have split the paramedian forehead flap, thus providing 2 axially perfused skin flaps for simultaneous reconstruction of the upper and lower lid structures after resection of basal cell carcinoma from the left medial canthal area. We found that split forehead flap seems to be a favorable option for simultaneous reconstruction of the upper and lower eyelid defects by enabling nicely vascularized and abundant amount of regional skin.

Reconstruction of coup de sabre deformity (linear localized scleroderma) by using galeal frontalis muscle flap and demineralized bone matrix combination.

In this clinical report, we are presenting the combination of demineralized bone matrix combined with bilateral galea frontalis flaps. Based on our 6-month results, this seems to be a reasonable combination to accomplish long-lasting restoration of forehead defects related to en coup de sabre linear localized scleroderma.

Topographical anatomy of the dorsal branch of the ulnar nerve and artery: a cadaver study.

PURPOSE: The surgical anatomy of the dorsal branch of the ulnar nerve and artery on the dorsal aspect of the hand is important in design of neurocutaneous flaps for reconstructive surgery and serves as a donor site for nerve grafts. In this study, the course, location, and diameter of the dorsal branches of the ulnar nerve and artery were studied from anatomical and reconstructive perspectives. METHODS: Upper limbs of 14 (7 left and 7 right) and 22 formalin-preserved adult cadavers (15 left and 7 right) were dissected in two different centers. RESULTS: The diameters of the ulnar nerve, artery, and their dorsal branches were measured at selected reference points. The distances to specific anatomical landmarks were also measured, during their courses from the proximal forearm towards the middle phalanges of the 4th and 5th fingers. CONCLUSIONS: Our data may facilitate the design of neurocutaneous flaps nourished from the dorsal branches of the ulnar nerve and artery, and may aid in the harvesting of nerve grafts from the dorsal branch of the ulnar nerve, and provide a safe surgical approach to the dorsum of the hand.

Hypertrophic frontal sinus reduction by using anterior wall internalization and galeal frontalis flap obliteration.

In this article, we are introducing the use of galeal-frontalis flap to reduce hypertrophic sinus based on 1 case: a 25-year-old amateur boxer who had prominent frontal area due to hypertrophic frontal sinus. Three-dimensional reformatted computed tomography scans were obtained for evaluation of the hypertrophy and the morphology of the frontal sinus. Reduction of the hypertrophic frontal sinus was performed by resection and shaping of the anterior wall and obliteration of the frontal sinus by right-side galeal-frontalis flap excision via bicoronal approach. The trimmed anterior wall was inserted into the frontal sinus and secured with three 3.0 PDS sutures to the bone edges, and the incision was closed. The outcome was satisfactory without any complications during 1-year follow-up, and sixth-month computed tomography scans revealed no bone resorption. Here we are introducing a novel technique to reduce hypertrophic sinus based on a clinical report.

Reconstruction of orbital floor fractures using autologous nasal septal bone graft.

We describe herein a new technique for reconstruction of the orbital floor, using autologous nasal septal bone and report the surgical results achieved in maxillofacial trauma patients.Prior to its clinical surgical application, a cadaver practice was carried out on 5 formalin-fixed adult human cadavers to establish the feasibility and efficacy of the method. Fifteen patients with orbital floor fractures, operated between 2005 and 2008, using this technique, were included in the current study.Cadaveric practice revealed that an adequate and appropriate size of septal bone graft can be harvested for reconstruction of the orbital floor. All patients except one had satisfactory clinical and radiologic late results. One patient experienced persistent enophthalmos, possibly due to delayed repair and associated displaced zygomatic bone fracture.Autologous nasal septal bone as an orbital floor bone graft has many advantages, including low donor site morbidity, adequacy and appropriateness of size, and similarity of its bicortical morphology and histologic nature compared with the orbital floor bone. Our clinical results strongly support that this technique can become a satisfactory alternative to existing reconstruction methods.

Use of triangulation method in end-to-side arterial microvascular anastomosis.

In this article, we present the use of triangulation for end-to-side microvascular arterial anastomosis. The classic end-to-side anastomosis starts by putting 2 sutures 180 degrees apart to the lateral arteriotomy aperture that is parallel to the longitudinal axis. We are performing triangulation in end-to-side microvascular artery anastomoses by putting 3 stay sutures, securing 2 of them to visualize vascular lumen and reduce the risk of passing suture from the back wall. We have been using this method for the last 5 years and found that triangulation seems to be a safer technique to teach and practice end-to-side microvascular anastomosis.

Enophthalmos due to atelectasis of the maxillary sinus: silent sinus syndrome.

Silent sinus syndrome is a clinical entity with the constellation of progressive enophthalmos and hypoglobus due to gradual collapse of the orbital floor with opacification of the maxillary sinus, in the presence of subclinical maxillary sinusitis. It occurs secondary to maxillary sinus hypoventilation due to obstruction of the ostiomeatal unit. In this paper, a 35-year-old woman with a complaint of asymmetry in her left eye and denting of upper eyelid was reported. In the left eye, upper sulcus was deepened and there was 3-mm hypoglobus. There was no diplopia or restriction of eye movements in any gaze positions. Hertel exophthalmometry revealed a 4-mm enophthalmos on the left eye. Computed tomographic scan of the orbita and paranasal sinuses showed left maxillary sinusitis, air-fluid level, and collapse of left maxillary sinus walls. In addition, inferior bulging in the left orbital floor was also reported. The treatment was a 2-stage operation. In the first stage, she underwent endoscopic septoplasty plus left maxillary antrostomy, and in the second stage, she underwent a subciliary orbital floor repair of the iliac bone resulting in the improvement of the enophthalmos and her cosmetic appearance. Regarding this case, the literature is also reviewed in detail.

A rare complication of nasotracheal intubation: accidental middle turbinectomy.

In this paper, we are presenting a rare case of accidental middle turbinectomy, a complication of nasotracheal intubation. We have reviewed the literature and addressed important parameters on nasotracheal intubation to avoid damage to the turbinates and its possible serious complications.

Use of dental mirror in microsurgical practice.

In this article, we introduce the use of dental mirror during microsurgery. We have been using no. 4 dental mirror during microvascular anastomoses and nerve coaptations for the last 6 months successfully and found that, as a cheap and easily obtainable instrument, it has facilitated our practice. We are strongly recommending the use of dental mirrors in microsurgical practice and inclusion to every microsurgery instrument set.