Effect of different obturation techniques on sealer penetration into dentinal tubules after final irrigation with XP-Endo finisher file

The first objective of this research was to evaluate the effectiveness of XP-Endo Finisher on dentinal tubule penetration of irrigation solution using confocal laser scanning microscopy. The main purpose of this research was to compare the effect of cold lateral condensation, continuous wave obturation and core-carrier based techniques on sealer penetration. Sixty mandibular premolars were prepared and allocated into two experimental groups (n=30) as the final irrigation technique and obturation technique experiment. In the final irrigation technique experiment, final irrigation was performed with XP-Endo Finisher, passive ultrasonic irrigation (PUI) and conventional needle irrigation (CNI) (n=10). The roots in the obturation technique experiment were also assigned into 3 groups and obturated with cold lateral condensation, continuous-wave obturation and core-carrier techniques (n=10). The most effective activation method, which emerged as a result of the first part of this study, was used as the final irrigation method in the obturation technique experiment. Then, all roots were sectioned in 1-mm-thick slices at 3mm from the apex for scanning. In terms of depth and percentage of material penetration, CNI exhibited significantly the lowest values and no significant difference was found between others. Also, there was no significant difference among obturation methods. In conclusion, XP-Endo Finisher and PUI are more effective than CNI on irrigant penetration. Sealer penetration into dentinal tubules is independent of obturation techniques.

El objetivo principal de esta investigación fue evaluar la eficacia de XP- Endo Finisher en la penetración de la solución de irrigación en los túbulos dentinarios mediante microscopía de láser confocal. Se prepararon sesenta premolares mandibulares y se distribuyeron en dos grupos experimentales (n=30) según el tipo de método de evaluación utilizado. En el experimento de la técnica de irrigación final, la irrigación final se realizó con XP-Endo Finisher, irrigación ultrasónica pasiva (PUI) e irrigación con aguja convencional (CNI) (n=10). Las raíces en el experimento de la técnica de obturación también se asignaron en 3 grupos y se obturaron con técnicas de condensación lateral fría, obturación de onda continua y portador de núcleo (n=10). El método de activación más eficaz, que surgió como resultado de la primera parte de este estudio, se utilizó como método de irrigación final en el experimento de la técnica de obturación. Luego, todas las raíces se seccionaron en muestras de 1mm de espesor. En términos de profundidad y porcentaje de penetración del material, CNI exhibió significativamente los valores más bajos y no se encontraron diferencias significativas entre los demás. Además, no hubo diferencias significativas entre los métodos de obturación. En conclusión, XP-Endo Finisher y PUI son más efectivos que CNI en la penetración del irrigante. La penetración del sellador en los túbulos dentinarios es independiente de las técnicas de obturación.

Characterization of Blue Light Treatment for Infected Wounds: Antibacterial Efficacy of 420, 455, and 480 nm Light-Emitting Diode Arrays Against Common Skin Pathogens Versus Blue Light-Induced Skin Cell Toxicity.

Objective: To determine effective treatment strategies against bacterial infections of chronic wounds, we tested different blue light (BL)-emitting light-emitting diode arrays (420, 455, and 480 nm) against wound pathogens and investigated in parallel BL-induced toxic effects on human dermal fibroblasts. Background: Wound infection is a major factor for delayed healing. Infections with Pseudomonas aeruginosa and Staphylococcus aureus are clinically relevant caused by their ability of biofilm formation and their quickly growing antibiotics resistance. BL has demonstrated antimicrobial properties against various microbes. Methods: Determination of antibacterial and cell toxic effects by colony-forming units (CFUs)/biofilm/cell viability assays, and live cell imaging. Results: A single BL irradiation (180 J/cm2), of P. aeruginosa at both 420 and 455 nm resulted in a bacterial reduction (>5 log10 CFU), whereas 480 nm revealed subantimicrobial effects (2 log10). All tested wavelengths of BL also revealed bacteria reducing effects on Staphylococcus epidermidis and Escherichia coli (maximum 1-2 log10 CFU) but not on S. aureus. Dealing with biofilms, all wavelengths using 180 J/cm2 were able to reduce significantly the number of P. aeruginosa, E. coli, and S. epidermidis. Here, BL420nm achieved reductions up to 99%, whereas BL455nm and BL480nm were less effective (60-83%). Biofilm-growing S. aureus was more BL sensitive than in the planktonic phase showing a reduction by 63-75%. A significant number of cell toxic events (>40%) could be found after applying doses (>30 J/cm2) of BL420nm. BL455nm showed only slight cell toxicity (180 J/cm2), whereas BL480nm was nontoxic at any dose. Conclusions: BL treatment can be effective against bacterial infections of chronic wounds. Nevertheless, using longer wavelengths >455 nm should be preferred to avoid possible toxic effects on skin and skin cells. To establish BL therapy for infected chronic wounds, further studies concerning biofilm formation and tissue compatibility are necessary.

The impact of non-toxic blue light (453 nm) on cellular antioxidative capacity, TGF-ß1 signaling, and myofibrogenesis of human skin fibroblasts.

Studies have demonstrated that blue light induces biological effects, such as cell death, and inhibition of proliferation and differentiation. Since blue light at longer wavelength (>440 nm) exerts less injurious effects on cells than at shorter wavelengths, (400-440 nm), we have investigated the impact of non-toxic (LED) blue light at 453 nm wavelength on human skin fibroblasts (hsFBs). We found that besides its decreasing effects on the proliferation rate, repeated blue light irradiations (80 J/cm2) also significantly reduced TGF-ß1-induced myofibrogenesis as shown by diminished α-SMA and EDA-FN expression accompanied by reduced protein expression and phosphorylation of ERK 1/2, SMAD 2/3, and p38-key players of TGF-ß1-induced myofibrogenesis. In parallel, catalase protein expression, intracellular FAD concentrations as well as NADP+/NADPH ratio were reduced, whereas intracellular reactive oxygen species (ROS) were increased. We postulate that as a molecular mechanism downregulation of catalase and photoreduction of FAD induce intracellular oxidative stress which, in turn, affects the signaling factors of myofibrogenesis leading to a lower rate of α-SMA and EDA-FN expression and, therefore, myofibroblast formation. In conclusion, blue light even at longer wavelengths shows antifibrotic activity and may represent a suitable and safe approach in the treatment of fibrotic skin diseases including hypertrophic scarring and scleroderma.

Vitamin D deficiency may stimulate fibroblasts in Dupuytren's disease via mitochondrial increased reactive oxygen species through upregulating transforming growth factor-ß1.

Dupuytren's disease, a benign fibroproliferative disorder of the palmar fascia, represents an ideal model to study tissue fibrosis. Transforming growth factor-ß1 (TGF-ß1) and its downstream Smad signaling system is well established as a keyplayer during fibrogenesis. Vitamin D has been extensively studied as an anti-fibrotic agent in malignant chronic diseases. A number of studies have shown that myofibroblasts are main target cells of 1,25(OH)2D3 inhibitory action. The myofibroblast in the palmar aponeurosis of patients in different stages of Dupuytren's disease was found by electron microscopy to contain a large number of mitochondria. Mitochondria play a critical role in cell metabolism being the major source of reactive oxygen species (ROS) in cells. TGF-ß1 has been shown to increase mitochondrial ROS production in different cell types, which mediate fibrosis related gene expression and myofibroblast differentiation. TGF-ß1 increases mitochondrial ROS production in patients with Dupuytren's contracture potentially in consequence of Vitamin D deficiency, leading to myofibroblast differentiation. Thus, targeting this basic pathomechanism seems suitable to establish new treatment strategies.

Efficacy of XP-Endo Finisher in the Removal of Triple Antibiotic Paste from Immature Root Canals.

INTRODUCTION: The aim of this study was to evaluate and compare the effectiveness of the XP-Endo Finisher (FKG Dentaire, La Chaux-de-Fonds, Switzerland) with passive ultrasonic irrigation (PUI) and needle irrigation in the removal of triple antibiotic paste (TAP) from the straight immature root canals of extracted teeth. METHODS: Thirty-four freshly extracted single-rooted teeth were used. All canals were prepared up to the ProTaper F5 file (Dentsply Maillefer, Ballaigues, Switzerland). Apices were drilled to simulate teeth with immature apices. The canals were filled with TAP, sealed, and incubated at 37°C and 100% humidity for 1 month. Samples were randomly assigned to 3 experimental groups according to the method used for TAP removal: XP-Endo Finisher, PUI, and needle irrigation (n = 10). Then, the roots were split into 2 halves. The amount of TAP residue in the apical portion of each segment was evaluated using a scanning electron microscopy and scored. RESULTS: The amount of remaining TAP was significantly lower in the XP-Endo Finisher group compared with the needle irrigation and PUI groups (P < .05). Between the needle irrigation and PUI groups, there were no statistically significant differences (P > .05). CONCLUSIONS: Within the limitations of this study, the XP-Endo Finisher removed significantly more TAP than needle irrigation and PUI.

Growth Differentiation Factor 5 Accelerates Wound Closure and Improves Skin Quality During Repair of Full-Thickness Skin Defects.

BACKGROUND: A fast and stable wound closure is important, especially for extended and unstable wounds found after burn injuries. Growth can regulate a variety of cellular processes, including those involved in wound healing. Growth differentiation factor 5 (GDF-5) can accelerate fibroblast cell migration, cell proliferation, and collagen synthesis, which are essential for wound healing. Nevertheless, no standardized evaluation of the effect of GDF-5 on the healing of full-thickness wounds has been published to date. METHODS: Five full-thickness skin defects were created on the backs of 6 minipigs. Three wounds were treated with GDF-5 in different concentrations with the help of a gelatin-collagen carrier, and 2 wounds served as control group. The first was treated with the gelatin carrier and an Opsite film (Smith & Nephew, Fort Worth, Texas), and the other was treated solely with an Opsite film that was placed above all wounds and renewed every second day. RESULTS: Growth differentiation factor 5 accelerates wound closure (10.91 [SD, 0.99] days) compared with treatment with the carrier alone (11.3 [SD, 1.49] days) and control wounds (13.3 [SD, 0.94] days). Epidermal cell count of wounds treated with GDF-5 revealed a higher number of cells compared with the control group. In addition, mean epidermal thickness was significantly increased in GDF-5-treated wounds compared with the control wounds. CONCLUSIONS: Because of its ability to improve skin quality, GDF-5 should be considered when developing composite biomaterials for wound healing.

Detection of Second Mesiobuccal Canals in Maxillary First Molars Using a New Angle of Cone Beam Computed Tomography.

BACKGROUND: The localization of the additional canal orifice is one of the primary factors influencing the success of endodontic treatment. To deal with this problem, several techniques that each have their own advantages and disadvantages have been discussed in the literature. OBJECTIVES: The aim of the present in vitro study was to review a new approach to localizing second mesiobuccal (MB2) canals in maxillary first molars using cone beam computed tomography (CBCT). PATIENTS AND METHODS: The CBCT scans of 296 patients who were referred to the department of dentomaxillofacial radiology were included in the study. The presence of MB2 canals, the angle formed by the mesiobuccal, distobuccal, and palatal root canal orifices (∠MDP), and the angle formed by the mesiobuccal, distobuccal, and MB2 canal orifices (∠MDMB2) were evaluated on the axial section. Pearson correlation and multiple linear regression methods were used for all predictions. All of the analyses were performed using SPSS for windows version 22.0. A two-sided P value < 0.05 was defined as statistically significant. RESULTS: Of the 468 first molars, MB2 canals were observed in 296 subjects (141 females and 155 males). There were no statistically significant differences between females and males (P = 0.300). The ∠MDP and ∠MDMB2 were detected and evaluated. A moderate positive correlation was found between the ∠MDP and the ∠MDMB2. To predict the ∠MDMB2 values, it was shown that the ∠MDMB2 increased by 0.420 degrees when the ∠MDP increased by 1 degree. If the ∠MDP was greater than 90.95 degrees, there was a 78% probability that MB2 canals could be found. CONCLUSION: The determination of the presence of MB2 in the maxillary first molars may be carried out using CBCT scans. If the ∠MDP was 91 degrees or greater, there was considered to be a higher probability that MB2 canals would be found in the endodontic cavity. Due to the positive correlation between the ∠MDP and the ∠MDMB2, the localization of MB2 canals may be easily performed in relation to the main MB canal.

Etiology, incidence and gender-specific patterns of severe burns in a German Burn Center - Insights of 25 years.

INTRODUCTION: Burns often require special treatment in specialized burn centers. One of the specialized German burn centers is located in Cologne-Merheim. Only little is known about the etiology of burns in Germany, their monthly distribution and changes over the past 25 years. METHODS: We therefore retrospectively analyzed the etiology for all patients treated at the burn intensive care unit (BICU) of Cologne in the last 25 years and categorized them into groups. Thereafter all groups were analyzed according to distribution of age, gender and occurrence. RESULTS: In this way we were able to show that the number of severe burns did not decrease over the time under evaluation and that it did not show seasonal variation. Injured females were older than males but fewer in number. The highest numbers of burns were related to fire, followed by electricity, hot liquids, chemicals and heat contact. Work-related burns occurred mostly with males. However, most of the burns were not work-related for either gender. CONCLUSION: The number of burns in Germany and in the world is still high, and prevention strategies do not always have the desired effect. This study aims to fill the gap in published burn knowledge in Germany by way of describing the gender differences and etiology characteristics. It can therefore help to identify risks and expand effective burn prevention strategies.

A prospective clinical trial comparing Biobrane(®) Dressilk(®) and PolyMem(®) dressings on partial-thickness skin graft donor sites.

INTRODUCTION: In a single-center, prospective, randomized clinical trial three different configured wound dressings Biobrane(®), Dressilk(®) and PolyMem(®) were compared with each other regarding objective and subjective healing parameters and cost efficiency. METHODS: 28 burn patients received surgical treatment with split-thickness skin grafting, while utilizing Biobrane(®), Dressilk(®) and PolyMem(®) as a single bound donor site wound dressing in all patients. Following a standardized case report form, we monitored several parameters such as pain, transparency of the dressing, active bleeding, exudation and inflammation by using the Verbal Rating Scale 1-10 through out. RESULTS: With regard to re-epithelialization, pain and acute bleeding all three dressings were equivalent. Dressilk(®) and Biobrane(®) presented clearly superior to PolyMem(®) in both wound assessment and in the reduction of mild inflammation and exudation. High subjective satisfaction rates were reported with Dressilk(®) and Biobrane(®) dressings in regard to comfort and mobility. During the continuous monitoring period Biobrane(®) outperformed Dressilk(®) by providing higher wound transparency rates and offering a better level of wound control during the entire study period. Regarding their cost efficiency, PolyMem(®) and Dressilk(®) are clearly superior to Biobrane(®). CONCLUSION: The "ideal" wound dressing maximizes patients' comfort while reducing pain and the risk of pulling off migrating epidermal cells from the wound surface. In addition reliable wound status evaluation (minimizing complications), an increase of treatment cost value efficacy, and reduced hospitalization rates should be provided. Dressilk(®) and Biobrane(®) were favored by patients and surgeons for providing an effective and safe healing environment, with overall low complication rates with respect to infection and exudation. Regarding cost-effectiveness PolyMem(®) and Dressilk(®) presented superior to Biobrane(®).

Non-Thermal Dielectric Barrier Discharge (DBD) Effects on Proliferation and Differentiation of Human Fibroblasts Are Primary Mediated by Hydrogen Peroxide.

The proliferation of fibroblasts and myofibroblast differentiation are crucial in wound healing and wound closure. Impaired wound healing is often correlated with chronic bacterial contamination of the wound area. A new promising approach to overcome wound contamination, particularly infection with antibiotic-resistant pathogens, is the topical treatment with non-thermal "cold" atmospheric plasma (CAP). Dielectric barrier discharge (DBD) devices generate CAP containing active and reactive species, which have antibacterial effects but also may affect treated tissue/cells. Moreover, DBD treatment acidifies wound fluids and leads to an accumulation of hydrogen peroxide (H2O2) and nitric oxide products, such as nitrite and nitrate, in the wound. Thus, in this paper, we addressed the question of whether DBD-induced chemical changes may interfere with wound healing-relevant cell parameters such as viability, proliferation and myofibroblast differentiation of primary human fibroblasts. DBD treatment of 250 µl buffered saline (PBS) led to a treatment time-dependent acidification (pH 6.7; 300 s) and coincidently accumulation of nitrite (~300 µM), nitrate (~1 mM) and H2O2 (~200 µM). Fibroblast viability was reduced by single DBD treatments (60-300 s; ~77-66%) or exposure to freshly DBD-treated PBS (60-300 s; ~75-55%), accompanied by prolonged proliferation inhibition of the remaining cells. In addition, the total number of myofibroblasts was reduced, whereas in contrast, the myofibroblast frequency was significantly increased 12 days after DBD treatment or exposure to DBD-treated PBS. Control experiments mimicking DBD treatment indicate that plasma-generated H2O2 was mainly responsible for the decreased proliferation and differentiation, but not for DBD-induced toxicity. In conclusion, apart from antibacterial effects, DBD/CAP may mediate biological processes, for example, wound healing by accumulation of H2O2. Therefore, a clinical DBD treatment must be well-balanced in order to avoid possible unwanted side effects such as a delayed healing process.

The topical use of non-thermal dielectric barrier discharge (DBD): nitric oxide related effects on human skin.

Dielectric barrier discharge (DBD) devices generate air plasma above the skin containing active and reactive species including nitric oxide (NO). Since NO plays an essential role in skin physiology, a topical application of NO by plasma may be useful in the treatment of skin infections, impaired microcirculation and wound healing. Thus, after safety assessments of plasma treatment using human skin specimen and substitutes, NO-penetration through the epidermis, the loading of skin tissue with NO-derivates in vitro and the effects on human skin in vivo were determined. After the plasma treatment (0-60 min) of skin specimen or reconstructed epidermis no damaging effects were found (TUNEL/MTT). By Franz diffusion cell experiments plasma-induced NO penetration through epidermis and dermal enrichment with NO related species (nitrite 6-fold, nitrate 7-fold, nitrosothiols 30-fold) were observed. Furthermore, skin surface was acidified (~pH 2.7) by plasma treatment (90 s). Plasma application on the forearms of volunteers increased microcirculation fourfold in 1-2 mm and twofold in 6-8 mm depth in the treated skin areas. Regarding the NO-loading effects, skin acidification and increase in dermal microcirculation, plasma devices represent promising tools against chronic/infected wounds. However, efficacy of plasma treatment needs to be quantified in further studies and clinical trials.

Intraalveolar TNF-α in combined burn and inhalation injury compared with intraalveolar interleukin-6.

The objective of this study was to evaluate the role of intraalveolar tumor necrosis factor-α (TNF-α) and interleukin-6 (IL-6) in a combination of skin burn and smoke inhalation injuries because this combined trauma is associated with an increased morbidity and mortality compared with either of these traumas alone. We used a standardized small animal model (rats n = 84) to investigate the early intraalveolar excretion of TNF-α during the first one, three, and six hours after a singular skin burn injury, singular smoke inhalation injury, and a combination involving both the traumas. The data were compared with the data from control rats that only received preparation and mechanical ventilation. The TNF-α serum levels and intraalveolar IL-6 concentrations were also measured. One hour after trauma, there was a significant difference in the TNF-α concentration between the controls and both the singular traumas (control vs burn P < .0444 and control vs smoke P < .005) and between the inhalation injury and the combined trauma (smoke vs burn + smoke P < .0084). After three and six hours, no significant differences among the groups were observed. Compared with the controls, both the singular skin burn and smoke inhalation injuries led to increased intraalveolar TNF-α excretion, whereas the combined trauma showed the least intraalveolar TNF-α levels at three and six hours post-trauma. These findings differed from the serum TNF-α levels. Compared with the IL-6 levels, we observed a negative correlation within the intraalveolar cytokine concentrations after one hour (r = -.809), three hours (r = -.627), and six hours (r = -.746). This study confirms the importance of the intraalveolar cytokine reaction in the early posttraumatic stage after a combined burn and inhalation injury. The differences between the combined and singular traumas indicate that TNF-α plays a role in the immunologic hyporesponsiveness of the lung and therefore in the systemic pathophysiological pathway, that often leads to patient mortality. In addition, an inverse correlation between TNF-α and IL-6, both classical markers of inflammation, in the intraalveolar space was observed.

A comparison of complications in 400 patients after native nail versus silicone nail splints for fingernail splinting after injuries.

BACKGROUND: The fingertip is the most commonly injured part of the hand and is an important aesthetic part of the hand. METHODS: In this retrospective study we analyzed data from 700 patients operated on between 1997 and 2008 for complications after nail splinting with native nail or silicone nail. Inclusion criteria were patients living in Bern/Berner Land, complete documentation, same surgical team, standard antibiotics, acute trauma, no nail bed transplantation, and no systemic diseases. Groups were analyzed for differences in age, gender, cause and extension of trauma, bony injury and extent, infection, infectious agent, and nail deformities. Statistical analysis was done using the χ (2) test, Fisher's exact test, and Pearson correlation coefficients. RESULTS: A total of 401 patients, with a median age of 39.5 years, were included. There were more men with injured nails. Two hundred forty native nails and 161 silicone splints were used. There were 344 compression injuries, 44 amputations, and 13 avulsion injuries. Forty-three patients had an infection, with gram-positive bacteria (Staphylococcus aureus) causing most infections. A total of 157 nail dystrophies were observed, split nails most often. The native nail splint group showed significantly (p < 0.015) fewer nail deformities than the silicone nail splint group; otherwise, there were no statistical differences. However, there were twice as many infections in the silicone nail group. CONCLUSION: It seems to be advantageous to use the native nail for splinting after trauma, when possible. In case of a destroyed and unusable nail plate, a nail substitute has to be used.

Blue light inhibits transforming growth factor-ß1-induced myofibroblast differentiation of human dermal fibroblasts.

Transforming growth factor-ß1 (TGF-ß1) is the major promoter of phenotypic shift between fibroblasts and myofibroblasts accompanied by the expression and incorporation of α-smooth muscle actin (α-SMA). This differentiation is crucial during normal wound healing and wound closure; however, myofibroblasts are considered as the main effecter cell type in fibrosis, for example in scleroderma and hypertrophic scarring. As blue light has exerted antiprolific and toxic effects in several cell types, we investigated whether blue light irradiations with a light-emitting diode array (420 nm) were able to affect proliferation and differentiation of human dermal fibroblasts (HDF). We found that repeated irradiation with non-toxic doses significantly inhibits TGF-ß1-induced differentiation of HDF into myofibroblasts shown by α-SMA immunocytochemistry and Western blotting. Additionally, used doses reduced proliferation and myofibroblast contractibility measured by resazurin and collagen gel contraction assays. It could be demonstrated that blue light mediates cell toxicity by oxidative stress due to the generation of singlet oxygen. We postulate that irradiations at non-toxic doses induce low-level oxidative stress and energy-consuming cellular responses, which both may effect proliferation stop and interfere with myofibroblast differentiation. Thus, targeting differentiation, proliferation and activity of myofibroblasts by blue light may represent a useful strategy to prevent or reduce pathological fibrotic conditions.

Micro-shear bond strength of adhesive resins to enamel at different relative humidity conditions.

This study tested whether exhaled humid conditions would affect the adhesion of etch-and-rinse, two-step and one-step self-etch adhesive resins to enamel. Enamel surfaces of human maxillary anterior teeth (N=240, n=20) were exposed to four humid conditions (H1: 63-68%, H2: 73-78%, H3: 93-98%, H4: 36-45% RH) during bonding with Adper Single Bond 2 (SB2), Clearfil SE Bond (CSE) and Adper Easy Bond (AEB). Specimens were stored in distilled water at 37 ºC for 24 h and tested to failure using micro-shear bond strength (µSBS) test. Data were analyzed using two-way ANOVA and Tukey's test (p<0.05). The µSBS to enamel with SB2, CSE and AEB was not significantly affected by humidity parameters. AEB resulted in significantly lower µSBS in all conditions. The frequency of adhesive failures was the highest at H2, H3 for SB2, H3 for CSE and H1-4 for AEB indicating that humidity conditions may decrease adhesion quality to enamel.

Adverse late reactions after cosmetic implantation of hydroxyethylmethacrylate particles suspended in hyaluronic acid: clinics and complication management.

BACKGROUND: The late-stage clinical course, histopathologic analysis, and surgical salvage procedures after eventful cosmetic injection of hydroxyethylmethacrylate particles suspended in hyaluronic acid (DermaLive, marketed through Dermatech, Paris, France and Novamedical GmbH, Langenfeld, Germany) have been studied. The study was designed to present modified treatment guidelines, report results, and draw conclusions regarding the future management of patients with late-stage DermaLive complications. METHODS: The study consulted and reviewed 21 patients with late-stage complications after facial implantation of DermaLive. Histology samples from excisional biopsies followed by radical surgical excision procedures were obtained and analyzed for nine patients. RESULTS: The treated zones included nasolabial folds, forehead and glabella, lips, and the perioral and zygoma regions. The late-onset period between injection and first symptoms averaged 17.5 months. Lesions were mostly symptomatic, with discomfort, pain, swelling, and edema. Clinical aspects included bulging, palpable nodules, erythema, and scar formation. A positive correlation between patient age and the delay period was found. All surgically treated patients recovered well. The initial conservative measures achieved only partial success, whereas all nine surgically treated patients (43 %) demonstrated complete relief of their clinical symptoms. CONCLUSIONS: Soft tissue augmentation with DermaLive led to a series of severe delayed adverse reactions. Sclerosing DermaLive granulomas demonstrated low success rates with conservative measures, whereas early radical surgical excision achieved good results. 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 .

Calciphylaxis - a challenging & solvable task for plastic surgery? A case report.

BACKGROUND: Calciphylaxis (calcific uremic arteriolopathy) is rare and its pathogenesis is not fully understood. Indeed, Calciphylaxis presents a challenge through the course of its management which involve different specialities but unfortunately this disease so far has a poor prognosis. We herein present, in this case report, a multidisciplinary approach involving plastic surgeons with special regards to reconstructive approach after debridement procedures. CASE PRESENTATION: We present a 21 years old male with a BMI of 38,2, who was transferred to our department from another hospital. Calciphylaxis has been diagnosed after receiving anticoagulation with phenprocoumon after a single event of pulmonary embolism. The INR on admission was 1,79. He had necrotic spots on both sides of the abdominal wall and on both thighs medially. During this time he underwent several reconstructive procedures in our department. CONCLUSION: It can be suggested that this agonizing disease needs indeed a multidisciplinary approach involving Nephrologists, Dermatologists, Intensive Care Physicians and Plastic Surgeons, taking into consideration that surgical correction can achieve further improvement in a specialized centre. Notwithstanding, further cohort studies should be approached clinically to insight the light on this disease with special regard to the prognosis after this approach.

High-pressure cornstarch inhalation--a rare but life-threatening occupational injury.

Cornstarch is a white, taste- and odorless powder widely used for food processing, papermaking, production of industrial adhesives, and is also a component of many cosmetic products. We herein report a case of severe cornstarch inhalation in a 49-year-old male who was exposed to high amounts of cornstarch powder while unloading a cornstarch transporter system. To our knowledge this is the first report on a high-pressure cornstarch inhalation during occupational activities. This report demonstrates the initial clinical situation, the patient's symptoms, and the severe clinical course. Finally the problems during the management of this rare but life-threatening accident are discussed.

The bivectorial full-thickness superiorly based NAC flap: a new option to increase plasticity and decrease tension in the superior pedicle vertical mammaplasty technique.

The standard split-thickness superior pedicle vertical mammaplasty technique sometimes suffers from tension on the nipple-areola complex (NAC). We suggest a bisected full-thickness superiorly based flap that offers two vectors for transposition within the context of superior pedicle vertical mammaplasty. The procedure increases both upper-pole fullness and projection of the breast while decreasing tension on the NAC. The surgical procedure presented contributes to a natural appearance of the breast. It should provide a useful and simple surgical option, increasing the versatility of the superior pedicle vertical mammaplasty technique.