The Effect of Astaxanthin on Random Pattern Skin Flaps.

BACKGROUND: Skin flaps are the first-line treatment modality for skin defect reconstruction. With the increased importance and use of flap surgery, a growing number of studies have investigated the ways for the prevention of ischemia-reperfusion injury. The aim of this study was to investigate the effect of astaxanthin, which is an antioxidant molecule from the xanthophyll family, on the survival of random pattern skin flaps. METHODS: Thirty-two Sprague-Dawley rats with a caudally based random pattern skin flap (3 × 9 cm) were divided into 4 groups: group A (astaxanthin orally 1 mg/kg per day), group B (astaxanthin orally 4 mg/kg per day), group C (astaxanthin orally 16 mg/kg per day), and the control group. On postoperative day 7, the flaps were evaluated by photographic, scintigraphic, and histological methods. Photographs were taken to investigate the total flap, necrotic flap, and surviving flap areas. A scintigraphic evaluation was undertaken to analyze the surviving area. The flaps were evaluated histopathologically for vascularization, acute inflammation, and chronic inflammation. RESULTS: The rate of surviving flap areas was observed to increase in parallel to the increase in the astaxanthin dose. Surviving flap areas and flap perfusion values were higher in group C compared with the control group and group A (P < 0.05). The values were also significantly higher in group B compared with control group (P < 0.05). All study groups were shown to have statistically significantly higher vascular density than the control group (P < 0.05), whereas lymphocyte and neutrophil densities were similar among all groups (P > 0.05). The photographic and scintigraphic evaluations for the viable area percentages of the flaps correlated with each other (rs = 0.913, P < 0.001). CONCLUSIONS: Orally administered astaxanthin, if given at doses higher than 4 mg/kg, increases flap viability rates and vascularization and can be used as an adjunctive agent.

The Impact of Duration and Force of Centrifugation on Platelet Content and Mass in the Preparation of Platelet-Rich Plasma.

PURPOSE: Platelet-rich plasma (PRP) is an autologous prepared plasma enriched with platelets and obtained after a centrifugal separation and aggregation procedure. However, the optimized preparation protocol for PRP is still controversial and there are no standardized preparation protocols. The aim of this study is to show the effect of time and force of the centrifugation on the concentrations of platelets and to optimize the effective PRP preparation protocol. METHODS: For the study, whole blood was drawn into 24 different 6-ml standard tubes containing 0.6 ml anticoagulant citrate dextrose solution-formula A. The samples were centrifuged separately at forces of 45×g, 180×g, 400×g, 725×g, 1130×g and 1630×g for 5, 10, 15 and 20 min. Every sample was analyzed, and a comparison was made between all groups. RESULTS: No significant difference was observed in terms of platelet concentration, mean platelet volume or platelet mass between all groups (p > 0.05). The mean ± SD of platelet mass in baseline is 1890 ± 134 × 103 fL/µL. The mean ± SD of platelet mass in the high centrifugal force of 1630×g was 3395 ± 564 × 103 fL/µL, 2638 ± 425 × 103 fL/µL, 2355 ± 449 × 103 fL/µL and 2109 ± 41 × 103 fL/µL over times of 5, 10, 15 and 20 min, respectively. The mean ± SD of platelet mass in the low centrifugal force of 45×g was 2002 ± 1623 × 103 fL/µL, 2491 ± 1591 × 103 fL/µL, 2611 ± 876 × 103 fL/µL and 3003 ± 511 × 103/µL over times of 5, 10, 15 and 20 min, respectively. CONCLUSIONS: Platelets should be evaluated with platelet mass not including platelet concentrations alone, but also with mean platelet volume, which symbolizes the size of platelets while comparing platelet-rich plasma preparation protocols and kits. This could be a new starting point for comparison of PRP for all applications in the literature. All centrifugation forces and times could produce biologically reactive PRP. It may be only suggested that if high acceleration force is used, low durations should be selected, or if low acceleration force is used, long time of centrifugation should be selected. NO LEVEL ASSIGNED: 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 .

Analysis of Fractured Mandible Over Two Decades.

Mandible fractures have a special place within the injuries of the other bones of the maxillofacial system. In their management, cosmetic issues and functional aspects such as chewing, speaking, and swallowing become very important.In this study, a retrospective analysis of 419 mandible fractures in 283 patients was performed in relation to epidemiologic factors, treatment strategies, and complications. The average age was 32.14 years (4-69 years). The male/female ratio was 4/1. The most frequent etiologic factor was interpersonal violence (104 patients, 36.7%). The parasymphysis region was the mostly affected site (28.4%). A total of 157 patients (55.5%) were presented with single fracture and the rest with 2, 3, or 4 fracture lines on the mandible. The most common fracture combination was angulus-parasymphysis fracture combination (24.6%). Open reduction and fixation with mini plates and screws was the most preferred treatment strategy (48.2%). Transient short arch bars were not used intraoperatively for any of the patients. There was not any difference in terms of complications between the patients treated with plating systems and plating systems plus intermaxillary fixation.In conclusion, proper treatment of mandible fractures is critical. Except certain fracture types, the usage of intermaxillary fixation as an adjunct to fixation with plating systems is not necessary.

A local flap that never disappoints: V-Y rotation advancement flap.

BACKGROUND: There are lots of ways to close a defect according to the reconstruction ladder. In this article, we would like to share our experience with V-Y rotation advancement flap on different parts of the body. PATIENTS AND METHODS: Between 2006 and 2009, we performed V-Y rotation advancement flap on 68 patients (average age, 50 years). We performed this flap for decubitus and neuropathic ulcer on 33 patients, for defect reconstruction after tumor removal on 29 patients, and for trauma on 6 patients. RESULTS: The sizes of the defects ranged between 2 × 2 and 26 × 16 cm. All flaps survived without any major complications. Patients were satisfied with their scar appearance, and no sensory impairment was seen. CONCLUSIONS: V-Y rotation advancement flap restores the defect with a perfect color match and leaves an aesthetically acceptable scar. With its surgical flexibility and durability, this flap disappoints neither the surgeon nor the patient.

The effect of reduction mammaplasty on the vertebral column: a radiologic study.

Some studies emphasized that anatomic mechanisms of vertebral aberrations could be associated with large breasts. The effect of mammaplasty operation on the vertebral column and body posture seems to be beneficial; in this trial, it was planned to investigate the objective radiologic effect of reduction mammaplasty on the posture of the vertebral column in a group of patients operated due to the large breasts. Thirty-four white women with large breasts were enrolled in this study. The patients were divided into three groups according to their breast cup sizes. Anteroposterior and lateral radiographs of the lumbosacral and thoracic spine were taken at baseline preoperatively, and the same radiographic images were taken in an average of 12 months later than the reduction mammaplasty operation. All were evaluated and compared for thoracic kyphosis angle and lumbar lordosis angle both preoperatively and postoperatively. The mean thoracic kyphosis angle was 40,53 preoperatively and 39,38 postoperatively. However, there was no statistically significant difference between the preoperative and postoperative measurements in all groups (P > 0,05). The mean lumbar lordosis angle was 54,71 preoperatively and 53,18 postoperatively. Regarding the preoperative and postoperative measurements of lumbar lordosis angles, no statistically significant difference was found between the groups (P > 0,05). Although breast size may be an important factor that affects body posture, reduction mammaplasty operations have little or no radiologic effect on the vertebral column.

Scintigraphic and histopathologic evaluation of combined bone grafts.

OBJECTIVES: We aimed to assess various bone grafts on bone formation using bone scintigraphy and histology, especially the first study that evaluated the demineralized bone matrix (DBM) + tricalcium phosphate (TCP) + hyaluronic acid (HA) combination. MATERIALS AND METHODS: A total of 44 pieces in groups of autogenous bone graft, TCP, DBM, DBM + TCP combination, and DBM + TCP + HA combination were applied to parietal bones of 24 New Zealand rabbits. Bone scintigraphies of the rabbits were performed at 2, 6, and 12 weeks. The uptake ratios were compared for the different types of grafts. In addition, in 2, 6, and 12 weeks, the graft areas were taken from the sacrificed rabbits and examined histologically. RESULTS: In the 2-week evaluation, DBM + TCP combination and DBM + TCP + HA combination had more osteoblastic activity accumulation than the TCP and DBM groups. These findings supported that the DBM + TCP combination group showed new bone formation earlier in the histopathological evaluation. The DBM + TCP + HA combination had more uptake than the TCP and DBM groups on bone scintigraphy at 2 weeks, and this uptake ratio decreased in the following weeks. It was thought that the increased uptake in DBM + TCP + HA combination at 2 weeks was due to severe inflammation seen in the histopathological evaluation. CONCLUSION: The DBM + TCP + HA combination should not be used for graft repair, although it was thought to be a good combination in the early weeks.

Monitorization of asymmetric dimethylarginine (ADMA) levels in an experimental ischemia-reperfusion flap model: a preliminary report.

One of the most important endothelium-derived vasoactive mediators is nitric oxide (NO). Endothelial dysfunction by the loss of NO is a critical event during ischemia. Asymmetric dimethylarginine (ADMA) is a competitive inhibitor of NO synthase (NOS) that inhibits vascular endothelial NO production in concentrations found in pathophysiological conditions. The goal of this study was to monitorize overexpression of ADMA in an experimental ischemia-reperfusion flap model. This study was performed using 20 rats. The baseline ADMA levels were measured preoperatively. In Group I (n = 10, control) abdominal flaps were harvested and replaced in situ without creating ischemia. The plasma ADMA levels were measured at 1, 12, and 24 hours postoperatively. In Group II (n = 10, study) abdominal flaps were harvested, and clamping the vascular pedicle created a subsequent 8-hour period of warm ischemia. Clamps were removed and provided tissue reperfusion. The ADMA levels were taken after 1 hour of reperfusion, and at 12th and 24th hours. The mean preoperative ADMA levels in group I and group II were calculated to be 0.37 ± 0.06 (µmol/L) and 0.40 ± 0.06 (µmol/L), respectively. The differences between the preoperative ADMA levels were not statistically significant (p > 0.05). The mean postoperative ADMA levels in group I (control) were calculated to be 0.39 ± 0.09 (µmol/L) at the first hour, 0.42 ± 0.07 (µmol/L) at the 12th hour, and 0.40 ± 0.08 (µmol/L) at the 24th hour. Respectively, the mean postoperative ADMA levels in group II were calculated to be 0.68 ± 0.14 (µmol/L) after 1 hour of reperfusion, 0.62 ± 0.09 (µmol/L) at the 12th hour, and 0.60 ± 0.12 (µmol/L) at the 24th hour. All postoperative ADMA levels were significantly higher in Group II (p < 0.05). These experimental results suggest that systemic production of ADMA is greater in animals having ischemia reperfusion injury of the skin flaps. The strategy of decreasing levels of ADMA may be beneficial to prevent ischemia-reperfusion injury of flaps or composite transplants; thus, ADMA might be an important candidate of therapeutic target in flap or transplantation surgeries.

First report of surgery for anencephaly in twin pregnancies: Technical notes and postoperative management.

Anencephaly, the most severe form of neural tube defect, has no known cure, and in most cases, patients die before or shortly after birth. To date, no surgical intervention has been reported in the management of anencephaly. This study presents a case of dichorionic-diamniotic twin pregnancy in which 1 twin was anencephalic and describes the surgical management of this complex case. We aimed to share the problems experienced during the follow up of a patient who survived for a long time after surgery. We also aimed to highlight several clinical issues, including the challenges of managing anencephaly in twin pregnancies, problems experienced during the follow up process in our case, diagnosis of brain death in anencephaly cases, and ethical dilemmas related to organ donation. This case is notable because of the challenging nature of the surgical procedure and complexity of postoperative care. By highlighting the difficulties encountered during the follow up period, we hope to provide insights to health professionals that can inform the management of similar cases in the future.

Calcaneal osteomyelitis due to Achromobacter xylosoxidans: a case report.

Achromobacter xylosoxidans (A. xylosoxidans) has been described as an opportunistic pathogen causing infection. The case we describe is that of an elderly man who had osteomyelitis of calcaneal bone caused by A. xylosoxidans. As far as we are aware there are only 5 cases of osteomyelitis with A. xylosoxidans in the literature. Impaired defensive mechanism of the foot in direct contact with this waterborne bacterium can cause this disease. Because of the high level of antibiotic resistance of this bacterium, clinically more attention should be paid to patients who have impaired defensive mechanisms in their extremities, for example free flaps.

Scintigraphic and tomographic evaluation of biological activities of prefabricated free and vascularized bone allografts.

BACKGROUND: We performed an experimental study on rabbits to compare the biologic activities of free and vascularized cortical and corticocancellous solvent-dehydrated bone allografts by scintigraphy and three-dimensional computed tomography (CT). METHODS: Twenty New Zealand white rabbits (2500-3000 g) were divided into 2 groups each consisting 10 animals. In group 1, solvent-dehydrated human cadaveric cranium allografts (corticocancellous bone) were used. The grafts were divided into 20 pieces, approximately 10 × 10 × 5 mm. On the right ears, grafts were placed on dissected vascular bundles. On their left ears, allografts were implanted into subcutaneous pockets without dissecting any vascular bundle. The same procedure was performed in group 2 with solvent-dehydrated human cadaveric fibula bone allografts (cortical bone). No infection or any animal death occurred during 12 months of observation. At the end of the 12th month, implanted bone allografts were evaluated by 3-phase bone scintigraphy to observe the circulation and viability of the grafts and three-dimensional CT scans to measure their dimensions. RESULTS: Radioactive uptake by scintigraphy of grafts placed on vascular bundle was higher than grafts placed in pockets. t-Test was calculated for region of interest of right ear (vascularized) to left ear rate (nonvascularized) according to graft type. Rate for corticocancellous bone graft was 1.187 ± 0.179 (P = 0.038) and cortical bone graft was 1.055 ± 0.052 (P = 0.038). There was correlation between region of interest generated from arm and neck regions and graft regions (P = 0.001). Regarding the dimension measurement made by three-dimensional CT, all the grafts grew whether they were on vascular bundle or not. Mann-Whitney test was used to determine whether differences between preoperative and postoperative volumes of grafts and growth of all grafts were significant (P = 0.007 for vascularized cortical bone and P = 0.005 for others). Kolmogorov-Smirnov test was performed to evaluate the distribution of growth rate. Vascularized medullar-cortical and nonvascularized medullar bone grafts expanded more than nonvascularized cortical bone (P = 0.001, P = 0.005, P = 0.001, respectively). CONCLUSIONS: Vascularized bone allograft combines the advantages of autogenous and allogenous grafts. Both scintigraphic and tomographic results overlapped that corticocancellous and cortical bones developed more on vascular bundle. Even though radioactive uptake was statistically higher in vascularized bone allografts, we determined that this small difference did not affect the overall late vascularity of the bone allografts. In conclusion, regardless their types or placement on vascular bundle, prefabricated bone allografts had similar metabolic function after 1 year of integration.

An important and overlooked parameter in platelet rich plasma preparation: The mean platelet volume.

BACKGROUND: The platelets are the most heterogeneous cellular elements of the blood in size whereas larger platelets have more granules that make them more reactive rather than their smaller counterparts. OBJECTIVES: The aim of this study is to report the distribution of platelets in the plasma after centrifugation steps. METHODS: Twelve healthy male subjects were enrolled.5.4 mL of whole blood samples were collected for each tube containing 0.6 mL of acid citrate dextrose. Four samples were centrifuged at the force of 180 × g for 15 minutes. Then, 0.6 mL buffy coat was drawn from one of the four centrifuged tubes and 1/3 of the lower layer of the plasma (1.0 mL) from the second centrifuged tube; 1/3 of the middle(1.0 mL) and 1/3 of the upper layer (1.0 mL) of the plasma from third and fourth ones were drawn for blood analysis. RESULTS: Blood analysis including MPV and platelet concentrations were significantly different between the layers (P < .05). Together buffy coat and lower third of plasma layers contain 87% of the entire platelet mass. CONCLUSIONS: Platelets should not be argued only with their concentration, but it would be appropriate to evaluate with their yielded concentration and volume with MPV together while comparing PRP preparation protocols and kits.

Barbed sutures versus conventional tenorrhaphy in flexor tendon repair: An ex vivo biomechanical analysis.

BACKGROUND: The management of flexor tendon injuries has evolved in recent years through industrial improvements in suture materials, refinements of repair methods, and early rehabilitation protocols. However, there is no consensus on the ideal suture material and technique. This study was conducted to compare the tensile strength, repair time, and characteristics of 4-strand cruciate, modified Kessler, and 4-strand horizontal intrafiber barbed sutures for flexor tenorrhaphy with a 12-mm suture purchase length in an animal model. METHODS: The right third deep flexors of 60 adult Leghorn chicken feet were isolated and repaired with a 12-mm suture purchase length. The tendons were randomly assigned to three groups of equal number (n=20 each). Groups 1 and 2 received 4-strand cruciate and modified Kessler repair with conventional suture materials, respectively. A 4-strand horizontal intrafiber barbed suture technique was used in group 3. The repaired tendons were biomechanically tested for tensile strength, 2-mm gap resistance, and mode of failure. Repair times were also recorded. RESULTS: The maximum tensile strength until failure was 44.6±4.3 N in group 1, 35.7±5.2 N in group 2, and 56.7±17.3 N in group 3. The barbed sutures were superior to the other sutures in terms of the load needed for 2-mm gap formation (P<0.05). Furthermore, the barbed sutures showed the shortest repair time (P<0.05). CONCLUSIONS: This study found that 4-strand horizontal intrafiber barbed suture repair with a 12-mm purchase length in a chicken flexor tendon injury model showed promising biomechanical properties and took less time to perform than other options.

Pulley reconstruction with different materials: experimental study.

The digital fibroosseous pulley system is essential for optimum function of the flexor tendons and the continuation of normal hand functions. Different materials have been used for pulley reconstruction in the literature but the ideal material is still controversial. In this study, after the excision of the A2 pulley, pulley reconstructions were performed by using acellular dermal matrix, solvent dehydrated bovine pericardium, fascia lata, and free tendon graft in the rabbit model. The animals were killed at the 8th and 12th weeks and subjected to biomechanical testing. Tendon excursion and work of flexion values were calculated for each digit of the rabbits. As a result, all the reconstructed pulleys were functioning well without a statistically significant difference between the experimental groups. Pulleys reconstructed with acellular dermal matrix and solvent-dehydrated bovine pericardium appear to have the potential to function as effective pulley substitutes.

Dealing with the venous congestion of free flaps: venous catheterization.

For head and neck reconstruction after tumor ablation surgery, free flaps are mostly the chosen treatment modality for most of the centers. Coping with venous insufficiency and increasing venous outflow of the flap during this process increases the success rate. To increase venous outflow, triple-lumen central venous catheter is inserted to one of the donor veins of the flap that has venous insufficiency and one intact vein anastomosis.

Eight years of clinical experience with digit replantation: Demographic characteristics and outcomes.

BACKGROUND: Despite surgical and technical advances in microsurgery, it is still difficult to obtain satisfactory results after replantation of finger amputation. The aim of the present study was to discuss some of the many factors that can affect the success rate of replantation. METHODS: A retrospective analysis of 60 patients with 85 finger replantations was performed. Revascularizations and replantations proximal to the metacarpophalangeal joint were excluded. Demographic characteristics of the patients, place of injury, mechanism of injury, level of amputation, and success rate were examined. RESULTS: A total of 53 male and 7 female patients with mean age of 31 years were included in the study. Index finger (27%) was the most commonly replanted digit. Left side was the more affected, with 62%. Mechanism of injury was crush in 56%, guillotine in 23%, and avulsion in 21% of replanted digits. Success rate was 81%, 53%, and 36% in guillotine, crush, and avulsion injuries, respectively. CONCLUSION: In conclusion, the injury type and personal variables are very important in the rate of replantation success. Knowledge about the effects of different factors on the results of replantation surgery will provide guidance to hand surgeons in order to inform patients and their relatives properly.

Clinicopathological evaluation of Marjolin ulcers over two decades.

Malignant changes arising on the previously traumatized or chronically inflamed skin are defined as Marjolin ulcers. They can develop on many different lesions but frequently they are detected on burn scars. Histopathologically, Marjolin ulcers are mostly diagnosed as squamous cell carcinoma and they need special attention when especially located on the lower extremities. In this study, 63 patients treated for Marjolin ulcers between January 2000 and March 2015 were evaluated according to etiology, histological differentiation, primary tumor size, patient age and anatomical localization. Medical records of these patients were reviewed retrospectively. Mean age was 49.7 years. Average interval between the first injury and carcinoma development was 37.9 years. Most frequent etiologic factor was burn scars with 82.5%. Foot was the most frequently affected site with 28.6% and scalp was the second most frequent localization with 25.4%. Squamous cell carcinomas were detected in 88.9% of the patients and basal cell carcinomas were detected in 11.1% of the patients. For treatment, excision and grafting was performed for 48 patients (76.2%), excision and local flaps were used for 10 patients (15.9%) and excision and free flaps were used for five patients (7.9%). Regional lymph node dissection was performed for 12 patients (19%). Average follow up period was 46.5 months. Local recurrences were detected in nine patients (14.3%). In conclusion, Marjolin ulcers are aggressive tumors that require special care. In order to prevent life threatening sequelas of this entity, it is important to know basic aspects of clinical progress, prognostic factors and treatment modalities.

Does crossover innervation really affect the clinical outcome? A comparison of outcome between unilateral and bilateral digital nerve repair.

Digital nerve injuries are the mostly detected nerve injury in the upper extremity. However, since the clinical phenomenon of crossover innervation at some degree from uninjured digital nerve to the injured side occurs after digital nerve injuries is sustained, one could argue that this concept might even result in the overestimation of the outcome of the digital nerve repair. With this knowledge in mind, this study aimed to present novel, pure, focused and valuable clinical data by comparing the outcomes of bilateral and unilateral digital nerve repair. A retrospective review of 28 fingers with unilateral or bilateral digital nerve repair using end-to-end technique in 19 patients within 2 years was performed. Weber's two-point discrimination, sharp/dull discrimination, warm/cold sensation and Visual Analog Scale scoring were measured at final 12-month follow ups in all patients. There was no significant difference in recovery of sensibility after unilateral and bilateral digital nerve repairs. Though there is crossover innervation microscopically, it is not important in the clinical evaluation period. According to clinical findings from this study, crossover innervations appear to be negligible in the estimation of outcomes of digital neurorrhaphy.