Experimental Cranial Nerve Models in the Rat.

BACKGROUND: The intricacies of nerve regeneration following injury have prompted increased research efforts in recent years, with a primary focus on elucidating regeneration mechanisms and exploring various surgical techniques. While many experimental animals have been used for these investigations, the rat continues to remain the most widely used model due to its cost-effectiveness, accessibility, and resilience against diseases and surgical/anesthetic complications. A comprehensive evaluation of all the experimental rat models available in this context is currently lacking. METHODS: We summarize rat models of cranial nerves while furnishing descriptions of the intricacies of achieving optimal exposure. RESULTS: This review article provides an examination of the technical exposure, potential applications, and the advantages and disadvantages inherent to each cranial nerve model. CONCLUSION: Specifically in the context of cranial nerve injury, numerous studies have utilized different surgical techniques to expose and investigate the cranial nerves in the rat.

The effect of thymus transplantation on donor-specific chimerism in the rat model of composite osseomusculocutaneous sternum, ribs, thymus, pectoralis muscles, and skin allotransplantation.

INTRODUCTION: Research on tolerance has proven that development of donor-specific chimerism (DSC) may accompany tolerance induction in vascularized composite allotransplantation (VCA). In this study, we aimed to determine the effect of thymus transplantation on the induction of DSC in rat VCA model of osseomusculocutaneous sternum (OMCS) and osseomusculocutaneous sternum and thymus (OMCST) allotransplantation. MATERIALS AND METHODS: A total of 20 Lewis-Brown Norway and Lewis rats, 5-6 weeks old, weighting between 120 and 150 g, were used in the study. OMCS (n = 5) and OMCST (n = 5) allografts were harvested from Lewis-Brown Norway donors (RT1l + n ) based on the common carotid artery and external jugular vein, and a heterotopic transplantation was performed to the inguinal region of the Lewis (RT1l ) recipients under cyclosporine A monotherapy (16 mg/kg) protocol tapered to 2 mg/kg and maintained for the duration of the study. The peripheral blood chimerism levels (T-cell, B-cell, and monocyte/granulocyte/dendritic cell-MGDC populations) were evaluated at days 7, 14, 35, 63, 100, and 150 posttransplant by flow cytometry. At Day 150, thymus, spleen, and liver samples were assessed by polymerase chain reaction (PCR) in the presence of DSC. RESULTS: Total chimerism level increased in both OMCST and OMCS groups at all time points. At 150 days posttransplant, chimerism in OMCST group was significantly higher (12.91 ± 0.16%) than that in OMCS group (8.89 ± 0.53%%, p < .01), and PCR confirmed the presence of donor-derived cells in the liver and spleen of all OMCST recipients and in one liver sample and two spleen samples in OMCS recipients without thymus transplant. CONCLUSIONS: This study confirmed the direct effects of thymus transplantation on the induction and maintenance of DSC in T-cell, B-cell, and MGDC populations. These results confirm correlation between thymus transplantation and DSC induction.

Treatment of partial-thickness burns with a tulle-gras dressing and a hydrophilic polyurethane membrane: a comparative study.

OBJECTIVE: The purpose of this revisited study was to compare the clinical efficacy and long-term scar evaluation of a hydrophilic polyurethane membrane (HPM), Omiderm (Omikron Scientific Ltd., Rehovot, Israel) and an antimicrobial tulle-gras dressing (TGD), Bactigras (Smith & Nephew) in the management of partial-thickness burns. METHOD: Patients with partial-thickness burns were enrolled in this prospective study. Burn areas were divided into two areas and both dressings were applied to each field at the same time. Time to full re-epithelialisation and scar evaluation were compared using the Vancouver Scar Scale (VSS). RESULTS: A total of 21 patients, mean age 36.8 years, with 22 burns areas participated. The results showed that there is no statistically significant difference in terms of full epithelialisation time in the application of either dressing (p>0.05). However, with deep dermal burns, the HPM provided slightly faster epithelialisation (p>0.05). A VSS assessment showed no statistically significant difference (p>0.05) between applying either dressing materials. CONCLUSION: This study indicated that both dressings had the same effectiveness in treatment of partial-thickness burn wounds. However, the use of the HPM, especially in deep dermal second-degree burns, should be one of the first-line clinical choices, based on the advantages discerned by this study.

Adipogenesis for soft tissue reconstruction.

PURPOSE OF REVIEW: It has been increasingly common to use adipose tissue for regenerative and reconstructive purposes. Applications of autologous fat transfer and different stem cell therapies have significant limitations and adipose tissue engineering may have the potential to be an important strategy in the reconstruction of large tissue defects. A better understanding of adipogenesis will help to develop strategies to make adipose tissue more effective for repairing volumetric defects. RECENT FINDINGS: We provide an overview of the current applications of adipose tissue transfer and cellular therapy methods for soft tissue reconstruction, cellular physiology, and factors influencing adipogenesis, and adipose tissue engineering. Furthermore, we discuss mechanical properties and vascularization strategies of engineered adipose tissue, and its potential applications in the clinical settings. SUMMARY: Autologous fat tissue transfer is the standard of care technique for the majority of surgeons; however, high resorption rates, poor perfusion within a large volume fat graft and widely inconsistent graft survival are the main limitations. Adipose tissue engineering is a promising field to reach the first goal of producing adipose tissue which has more predictable survival and higher graft retention rates. Advancements of scaffold and vascularization strategies will contribute to metabolically and functionally more relevant adipose tissue engineering.

Immunological considerations and concerns as pertinent to whole eye transplantation.

PURPOSE OF REVIEW: The advent of clinical vascularized composite allotransplantation (VCA), offers hope for whole eye transplantation (WET) in patients with devastating vison loss that fails or defies current treatment options. Optic nerve regeneration and reintegration remain the overarching hurdles to WET. However, the realization of WET may indeed be limited by our lack of understanding of the singular immunological features of the eye as pertinent to graft survival and functional vision restoration in the setting of transplantation. RECENT FINDINGS: Like other VCA, such as the hand or face, the eye includes multiple tissues with distinct embryonic lineage and differential antigenicity. The ultimate goal of vision restoration through WET requires optimal immune modulation of the graft for successful optic nerve regeneration. Our team is exploring barriers to our understanding of the immunology of the eye in the context of WET including the role of immune privilege and lymphatic drainage on rejection, as well as the effects ischemia, reperfusion injury and rejection on optic nerve regeneration. SUMMARY: Elucidation of the unique immunological responses in the eye and adnexa after WET will provide foundational clues that will help inform therapies that prevent immune rejection without hindering optic nerve regeneration or reintegration.

Comparison of Neurosensory Assessment Methods in Plastic Surgery.

Sensory assessment of the skin is essential to document the function of the sensory fibers of the tested nerves. The Semmes-Weinstein monofilaments, disk-criminator, electrodiagnostic testing, and Pressure-Specified Sensory Device (PSSD) have been currently used to assess sensory function of peripheral nerves. None of these methods is optimal because of different drawbacks; however, an increasing number of articles, which recognize the reliability of PSSD, have been published during the last decade. In this review, following a short overview on basic physiology and assessment methods of the skin sensory receptors, we compared the sensory assessment methods and summarized the applications of the PSSD in the field of different clinical areas, mainly peripheral neuropathies, breast, and flap surgery.

A new total hemiface allotransplantation model in rats.

INTRODUCTION: Vascularized composite allotransplantation (VCA), a new reconstructive option for patients suffering from extensive facial defects leads to superior functional and aesthetic outcomes compared to the standard autologous reconstruction. Among VCA recipients, each case involves different facial structures and tissues depending on the patient's injury, thus drawing conclusions on the mechanism of immune interactions between the donor and recipient is challenging. This study introduces a new total hemiface VCA model, including scalp, external ear, mystacial pad, premaxilla, upper/lower lids, nose, and upper/lower lips to evaluate the effect of transplantation of multitissue VCA on the recipient's immune response. MATERIAL AND METHODS: Ten hemiface allotransplantations were performed in two groups between Lewis-Lewis (isograft) and LBN-Lewis (allograft) rats. Cyclosporine A (CsA) monotherapy was applied in the allograft group to prevent rejection. RESULTS: All flaps survived up to 100 days post-transplant. The mean warm ischemia time was 45 minutes. Histological analysis revealed normal bone, cartilage (ear and nose), conjunctiva, palpebra, and eyelashes. Flow cytometry confirmed donor-specific chimerism for T cells (CD4/RT1(n) and CD8/RT1(n)) and B cells (CD45RA/RT1(n)) in the peripheral blood of all rats in the allotransplantation group. At post-transplant day 7, chimerism levels were at 1.68% for CD4/RT1(n) , 0.46% for CD8/RT1(n) and 0.64% for CD45RA/RT1(n). However, chimerism levels for CD4/RT1(n), CD8/RT1(n), and CD45RA/RT1(n) populations decreased at long-term follow-up (at post-transplant day 100) to 0.08%, 0.04%, and 0.23%, respectively. CONCLUSION: The feasibility and long-term survival of the new hemiface VCA transplantation model was confirmed, donor-specific chimerism and post-transplant tissue changes were evaluated.

Targeted mesenchymal stem cell and vascular endothelial growth factor strategies for repair of nerve defects with nerve tissue implanted autogenous vein graft conduits.

Peripheral nerve gaps exceeding 1 cm require a bridging repair strategy. Clinical feasibility of autogenous nerve grafting is limited by donor site comorbidity. In this study we investigated neuroregenerative efficacy of autogenous vein grafts implanted with tissue fragments from distal nerve in combination with vascular endothelial growth factor (VEGF) or mesenchymal stem cells (MSCs) in repair of rat peripheral nerve defects. Six-groups of Sprague-Dawley rats (n = 8 each) were evaluated in the autogenous setting using a 1.6 cm long peroneal nerve defect: Empty vein graft (group 1), Nerve graft (group 2), Vein graft and nerve fragments (group 3), Vein graft and nerve fragments and blank microspheres (group 4), Vein graft and nerve fragments and VEGF microspheres (group 5), Vein graft and nerve fragments and MSCs (group 6). Nerve fragments were derived from distal segment. Walking track analysis, electrophysiology and nerve histomorphometry were performed for assessment. Peroneal function indices (PFI), electrophysiology (amplitude) and axon count results for group 2 were -9.12 ± 3.07, 12.81 ± 2.46 mV, and 1697.88 ± 166.18, whereas the results for group 5 were -9.35 ± 2.55, 12.68 ± 1.78, and 1566 ± 131.44, respectively. The assessment results did not reveal statistical difference between groups 2 and 5 (P > 0.05). The best outcomes were seen in group 2 and 5 followed by group 6. Compared to other groups, poorest outcomes were seen in group 1 (P ≤ 0.05). PFI, electrophysiology (amplitude) and axon count results for group 1 were -208.82 ± 110.69, 0.86 ± 0.52, and 444.50 ± 274.03, respectively. Vein conduits implanted with distal nerve-derived nerve fragments improved axonal regeneration. VEGF was superior to MSCs in facilitating nerve regeneration. © 2015 Wiley Periodicals, Inc. Microsurgery 36:578-585, 2016.

Reflectance confocal microscopy as a useful diagnostic tool for monitoring of skin containing vascularized composite allograft rejection: A preliminary study on rats.

Vascularized composite allografts can undergo immune-mediated rejection, and skin biopsies are needed for monitoring of the transplant. However it is an invasive method, and requires processing time and pathological assessment. The purpose of this study is to use a new noninvasive monitoring method of the reflectance confocal microscopy (RCM) to determine severity of the allograft rejection on rats. Five groin flap allotransplantation were performed between 10 male Sprague-Dawley rats. Immunosuppressive therapy with cyclosporine A was given to the recipients during 10 days after surgery and was ended at the 10th postoperative days to allow acute transplant rejection. Following cessation of CsA, concomitant RCM evaluation and skin biopsy was performed every other day from each animal until total rejection of the allograft. Complete rejection of the allograft took nearly about 10 days and 4 or 5 RCM evaluation and skin biopsy was performed from each rat during this period. A total of 17 specimens were evaluated. A scoring system was developed based on the RCM findings. Skin biopsies were evaluated according to the Banff 2007 working classification criteria. RCM evaluation revealed epidermal irregularity and collagen destruction, however mild perivascular inflammation and degeneration of the basal epidermal layer were observed in early and late rejection period respectively with histopathologic evaluation. High correlation was found between the RCM scores and histopathologic grading. The RCM may be the useful tool to reduce the need for skin biopsy for monitoring of the skin containing vascularized composite allograft.

Effect of Allogeneic Platelet Lysate and Cyanoacrylate Tissue Glue on the Fibrovascularization of the Porous Polyethylene Implant.

Because of limited autogenous tissue sources, donor site morbidity, and difficulty of shaping the autologous tissue, surgeons often need to use alloplastic frameworks in reconstruction of 3-dimensional tissue defects. Synthetic porous polyethylene (PP) implant is widely used in plastic surgery for 3-dimensional reconstruction of the lost or highly deformed tissues. One of the main factors of PP implant exposure is delayed fibrovascular ingrowth. In the present study, the authors investigated the effect allogeneic plateletlysate (PL) and cyanoacrylate tissue glue (CTG) (2-octyl cyanoacrylate) on the fibrovascularization of the PP implant.Twenty adult female Wistar rats were divided into 4 groups equally, according to the different surgical techniques and implanted materials used. Only PP implant was implanted subcutaneously through a skin incision on the chest wall skin of the rats in the control group; however, CTG was applied with PP implant in the cyanoacrylate group, PL was applied with PP implant in the platelet group, CTG and platelet was applied together with PP implant in the combination group. All of the implants in each group were histologically assessed at postoperative second week. Determination of the collagen density in the tissues, inflammation, and necrosis and vascularization status was assessed semiquantitatively.A denser collagen structure, low inflammation, and necrosis were found in PL groups. There was, however, a significant decrease in vascular density with PL-treated groups. PL treatment may have a potential to reduce complications related to PP implants.

Challenging Breast Augmentations: The Influence of Preoperative Anatomical Features on the Final Result.

BACKGROUND: Achieving satisfactory results may be difficult in augmentation mammaplasty patients in the presence of breast, chest wall, or vertebral deformities. These deformities have not been classified previously, and the impact of each deformity or combination of deformities has not been defined. OBJECTIVES: The aims of this study are to determine the complicating factors in augmentation mammaplasty, to classify these factors according to their influence on surgical outcome, and to develop an identification system for simplifying the recognition of challenging cases. METHODS: We retrospectively analyzed photographs and records of 100 consecutive patients who underwent augmentation mammaplasty. We observed suboptimal results in 18 cases. Preoperative deformities of the breast, chest wall, and vertebra were recorded in order to determine which factor or factors had complicated the surgeries. Eventually, the relationship between suboptimal surgical results and complicating factors was evaluated. RESULTS: We observed that some deformities alone caused suboptimal results, whereas others did not. Deformities that caused suboptimal results alone were called major complicating factors, and any others were called minor complicating factors. We observed that suboptimal results were also obtained in patients who had four minor complicating factors. Patients who had suboptimal results because of major or minor complicating factors were considered challenging cases. CONCLUSIONS: In this study, complicating factors for augmentation mammaplasty were defined and classified as major or minor depending on their effect on the surgical outcome. We suggest an identification system that simplifies the recognition of challenging cases in breast augmentation.

Fetal Cleft Lip/Palate Surgery: End of a Dream?

Recognition that a fetus can scarlessly heal in intrauterine life led to various animal studies in the mid 1980s exploring the possibility of fetal cleft lip/palate surgery. The idea of scarless cleft repair seemed like a possible dream after the promising results from the early animal studies. In this review, we analyze the progress made in the 30 years since our first experience with animal models.

Anatomy of the Anterior Deep Temporal Nerve: Implications for Neurotization in Blinking Restoration in Facial Paralysis.

Facial paralysis can lead to dysfunctions in eyelid closure, which is called lagophthalmos. A number of surgical procedures, both dynamic and static, have been described to restore the innervation of the orbicularis oculi muscle that closes the eyelids. This cadaver-based anatomical study aimed to evaluate the anatomy of the anterior, middle, and posterior deep temporal nerves; nerves to the temporalis muscle; and their availability for direct muscle neurotization of the orbicularis oculi. A total of 10 hemisectioned head specimens from 5 adult cadavers (2 men and 3 women) were used in this study. The adequacy of the length of the anterior deep temporal nerve was assessed for direct neorotization of the orbicularis oculi muscle. The mean distances between the originating point of the deep temporal nerves from the mandibular nerve in the infratemporal fossa and their terminal entry points into the muscle were 46.4 (42-51 mm), 42.2 (38-46 mm), and 33.4 mm (26-40 mm) for the anterior, middle and posterior branches of the nerves, respectively. We conclude that the anterior deep temporal nerve is a versatile nerve that can be used for direct muscle neurotization, nerve transfer, and babysitter procedures in selective blinking restoration. Before proceeding with any further clinical use, an anatomical study should be performed with fresh specimens from cadavers.

Comparison of Treatments With Local Mesenchymal Stem Cells and Mesenchymal Stem Cells With Increased Vascular Endothelial Growth Factor Expression on Irradiation Injury of Expanded Skin.

INTRODUCTION: Radiation injury results in chronically ischemic tissue. Radionecrosis can be encountered in severe cases. Mesenchymal stem cells (MSCs) have a therapeutic effect on ischemia-related lesions. In here, effects of bone-marrow derived MSC and vascular endothelial growth factor (VEGF) gene-transfected MSC (VEGF-MSC) treatment on expanded skin with irradiation injury is investigated. METHODS: Silicone tissue expander (50 cm) was placed subcutaneously and expanded weekly up to 60 cm in 24 Sprague Dawley rats. Single fraction (30 Gy) radiotherapy was applied to the 2 × 2 cm area of the expanded skin. Dulbecco modified Eagle medium without cell component, MSCs, and VEGF-MSCs were injected subcutaneously at the irradiation-expansion sites. Skin samples were evaluated by histomorphometry and immunohistochemistry. Perfusion rate of the samples was assessed by scintigraphy. RESULTS: Epidermal thickness of irradiated-expanded skin was increased after MSC and VEGF-MSC treatments, whereas dermal and capsule thicknesses did not change. The MSC and VEGF-MSC treatments were effective in preserving, respectively, CD31 and VEGF expressions at a similar level as expanded skin after irradiation injury. The VEGF-MSC treatment significantly elevated CD31 levels in the irradiated tissue. Skin perfusion results were consistent with the CD31 and VEGF expressions. The MSC and VEGF-MSC treatments were effective in increasing proliferating cell nuclear antigen (PCNA) expression in irradiation zone. The VEGF-MSC treatment was efficient in reducing both expansion- and irradiation-related apoptosis. CONCLUSION: Vascular impairment and dermal insufficiency due to tissue expansion and irradiation injury can easily result in a wound hard to repair. The MSCs and VEGF-MSCs can promote neovascularization, reverse the effect of irradiation, and provide more durable soft tissue for expansion/implant reconstruction.

The Future of Plastic Surgery: Surgeon's Perspective.

Since the days of Sushruta, innovation has shaped the history of plastic surgery. Plastic surgeons have always been known as innovators or close followers of innovations. With this descriptive international survey study, the authors aimed to evaluate the future of plastic surgeons by analyzing how plastic surgery and plastic surgeons will be affected by new trends in medicine. Aesthetic surgery is the main subclass of plastic surgery thought to be the one that will change the most in the future. Stem cell therapy is considered by plastic surgeons to be the most likely "game changer." Along with changes in surgery, plastic surgeons also expect changes in plastic surgery education. The most approved assumption for the future of plastic surgery is, "The number of cosmetic nonsurgical procedures will increase in the future." If surgeons want to have better outcomes in their practice, they must at least be open minded for innovations if they do not become innovators themselves. Besides the individual effort of each surgeon, international and local plastic surgery associations should develop new strategies to adopt these innovations in surgical practice and education.

Minced nerve tissue in vein grafts used as conduits in rat tibial nerves.

INTRODUCTION: Peripheral nerve injuries are encountered frequently in clinical practice. In nerve repair, an end-to-end suture is the preferable choice of treatment. However, where primary closure is not possible, the defect is to be repaired with a nerve graft. METHODS: A total of 21 female Wistar rats weighing 230 to 290 g were used in the study. They were classified into the following 3 groups: (I) nerve graft, (II) vein graft, and (III) minced nerve graft. In group I, after exposure of the tibial nerve, a 1-cm-long nerve gap was created on the tibial nerve, and the defect was repaired epineurally by using the autogenous nerve. In group II, the 1-cm tibial nerve defect was repaired by using an autogenous vein graft. In group III, a 1-cm nerve graft was divided to 3 equal parts, with one of the nerve parts being minced with microscissors and placed in the vein graft lumen. Thereafter, a 1-cm tibial nerve defect was repaired by the vein graft filled with minced nerve tissue. The tibial function indices (TFIs) were calculated for functional assessment using the Bain-Mackinnon-Hunter formula. Light and electron microscopic evaluations were performed for morphometric assessment. In addition, the myelinated fibers were counted in all groups. RESULTS: The TFIs of group II were found to be the lowest among all the groups after the sixth week, whereas the TFI of group I was found to be better than the other groups after the sixth week. There was no difference in TFIs between group I and group III. On the basis of the number of myelinated fibers, there was no statistically significant difference between group I and group III, whereas the difference was significant (P<0.05) between groups I/III and group II. Presence of peripheral nerves in light microscopic evaluation revealed normal characteristics of myelinated fibers in all groups. The myelinated axon profile was near normal in the nerve graft group in electron microscopic evaluation. However, there were more degenerated axons with disturbed contours and vacuolizations in the vein graft group compared to the minced nerve graft group. CONCLUSIONS: We can conclude that using minced nerve tissue in vein grafts as a conduit increases the regeneration of nerves (almost like the nerve graft group) and it may not be caused by donor-site morbidity. It can be used in the repair of nerve defects instead of autogenous nerve grafts after further experimental evidence and clinical trials.

Saddle-nose deformity repair with microplate-adapted costal cartilage.

UNLABELLED: Nasal deformities affecting the bone and lower two-thirds of the nose due to the loss of septal height and tip support are defined as "saddle-nose" deformity. Reconstruction of a saddle-nose deformity essentially necessitates structural grafting. This article presents an alternative approach for correction of saddle-nose deformity using a microplate and costal cartilage. The results are compared with those of the previously applied costal cartilage repair methods. Between 2004 and 2013, 16 patients were treated with costal cartilage autografts. Of these 16 patients, 7 were treated with a microplate and costal cartilage autograft combination, 4 were treated with a costal cartilage autograft and Kirschner (K)-wire, and 5 were treated with onlay costal cartilage grafts. The mean follow-up periods were 16 months for group treated with microplate-adapted autologous costal cartilage, 12 months for the group treated with K-wire and autologous costal cartilage, and 16 months for the group treated with onlay costal cartilage. The patients treated with K-wire inserted cartilages and the patients treated onlay dorsal costal cartilages encountered complications such as extrusion of the wire and warping, respectively. The seven patients treated with microplate and dorsal onlay costal cartilage graft did not experience any infection, warping, or extrusion complication. The warping tendency of the costal cartilage autograft can be efficiently prevented without a prominent complication risk by using microplate-adapted costal cartilage grafts. 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 .

Custom-made approach to a patient with post-burn breast deformity.

Second and third degree burns on breasts at preadolescent period may cause severe breast deformations. This deformation can be variable depending on severity and location of the burns, personal adolescent patterns, and treatment modality in acute burn period. A 21 year old female patient admitted to our department for her breast deformation due to burn contracture at the inferior pole of the right breast. On physical examination we defined that development of the volume of the right breast was equal to the left, and inferior pole of the right breast was flattened due to contracture, and nipple was projected to inferior. We found that inframammary crease of the right breast was 2 cm lower than that of left; andthe distance of nipple-inframamary crease was 4.7 cm while areola-inframmary crease was 2 cm. New nipple-areola complex level was identified according to left breast's level. Medial and lateral lines were planned to merge inferiorly at 2 cm above inframmary crease in a plan similar to vertical mammaplasty. Superior pedicle carrying nipple areola was desepitelised. Lower parenchymal V flap was transposed superiorly and attached to the pectoral muscle. Inferior parts of the lateral and medial glandular flaps were excised to form new inframammary crease. The desired laxity of skin at the lower pole was obtained by performing a new Z- plasty between lateral and medial skin flaps. Breast symmetry was confirmed by postoperative objective measurements between left and right breasts. Patient's satisfaction and aesthetic appearance levels were high. Breasts deformation patterns caused by burns, trauma and mass exsicion due to cancer could not be addressed with traditional defined techniques. Special deformations can be corrected by custom made plannings as we presented here.

Preoperative visualization of the greater occipital nerve with magnetic resonance imaging in candidates for occipital nerve decompression for headaches.

Occipital nerve decompression is effective in reducing headache symptoms in select patients with migraine and occipital neuralgia. Eligibility for surgery relies on subjective symptoms and responses to nerve blocks and Onabotulinum toxin A (Botox) injections. No validated objective method exists for detecting occipital headache pathologies. The purpose of the study is to explore the potential of high-resolution Magnetic Resolution Imaging (MRI) in identifying greater occipital nerve (GON) pathologies in chronic headache patients. The MRI protocol included three sequences targeting fat-suppressed fluid-sensitive T2-weighted signals. Visualization of the GON involved generating 2-D image slices with sequential rotation to track the nerve course. Twelve patients underwent pre-surgical MRI assessment. MRI identified four main pathologies that were validated against intra-operative examination: GON entanglement by the occipital artery, increased nerve thickness and hyperintensity suggesting inflammation compared to the non-symptomatic contralateral side, early GON branching with rejoining at a distal point, and a connection between the GON and the lesser occipital nerve. MRI possesses the ability to visualize the GON and identify suspected trigger points associated with headache symptoms. This case series highlights MRI's potential to provide objective evidence of nerve pathology. Further research is warranted to establish MRI as a gold standard for diagnosing extracranial contributors in headaches.

Definitive foot drop deformity repair with tensor fascia latae myocutaneous flap.

Tensor fascia latae (TFL) myocutaneous flap, utilized as a novel approach for the successful functional repair of the foot drop deformity is presented in this case report. A 21-year-old male patient was subjected to a close-range high-velocity gunshot injury and sustained comminuted Gustillo-type IIIB open fracture of his left tibia. A composite skin and soft tissue defect including tibialis anterior and extansor hallucis longus tendons was determined. The injury was managed in two stages. In the first stage, the immediate reconstruction of the open tibia fracture was provided by using a reverse flow sural flap and external fixation of the fracture. The functional restoration was achieved by vascular fascia latae in the second stage, 6 months after the initial skin, soft tissue, and bone defect repair. The functional recovery was successful, and the foot drop gait was almost totally ameliorated. Reconstruction with TFL flap should be retained in the armamentarium for the functional repair of the foot drop deformity, caused by composite skin and soft tissue defects of the pretibial region.