Importance of Stem Cell Transplantation in Cleft Lip and Palate Surgical Treatment Protocol.

Cleft lip and palate is a congenital malformation that requires a multidisciplinary treatment that evolves pediatrician, obstetrics, fetal medicine, genetics, plastic surgery, orthodontics, speech therapist, nursery, and psychology. Actually, the authors believe that it could be possible to ad protocols to use stem cells.The intrauterine diagnosis leads to preborn parental orientation and better parental collaboration to accept a precocious multidisciplinary treatment. After birth the authors' protocol is: orthodontic devices, phonoaudiology, and surgical procedures.The authors' cleft lip and palate reconstructive surgery protocol demands several steps and begins at 4 to 6-month old with rhinocheiloplasty and soft palate closure at the same moment. The treatment sequence involves the hard palate surgery (8-18 months after the first surgical step), alveoloplasty (after 10 years old), and secondary rhinoplasty (after 14 years old).New ideas to use stem cells and blood from the umbilical cord and also blood from placenta are discussed to improve final surgical results. Maternal stem cells are easy to collect, there are no damage to the patient and mother, it is autologous and it could be very useful in the authors' protocol.Nine patients with clef lip and palate were operated and had stem cells from umbilical cord blood and placenta blood injected into the bone and soft tissue during the primary procedure (rhinocheiloplasty).The stem cells activity into soft tissue and bone were evaluated. Preliminary results have shown no adverse results and improvement at the inflammatory response. A treatment protocol with stem cells was developed. It had a long time follow-up of 10 years.

End-to-side versus end-to-end neurorrhaphy at the peroneal nerve in rats.

PURPOSE: To evaluate three different kinds of neurorrhaphy of the peroneal nerve. METHODS: Eigthy rats were divided into 5 groups. Control: nerve had no intervention. End-to-end (EE): nerve was cut and elongated with a nerve graft with two end-to-end neurorrhaphies. End-to-side (ES): nerve was cut and sutured to the graft with at the lateral side of the nerve. Side-to-end (SE): the nerve was cut and sutured to the graft with end-to-end neurorrhaphy. Denervated: nerve was cut and both endings were buried into the muscle. The evaluation was done by walking track analysis, electrophysiology, body mass, cranial tibial muscle mass, nerve and muscle fibers morphometry. RESULTS: The EE, ES and SE have the same potential of reinnervation. CONCLUSION: There is no functional or histological difference between these different types of neurorrhaphy.

End-to-side versus end-to-end neurorrhaphy at the peroneal nerve in rats

Abstract Purpose: To evaluate three different kinds of neurorrhaphy of the peroneal nerve. Methods: Eigthy rats were divided into 5 groups. Control: nerve had no intervention. End-to-end (EE): nerve was cut and elongated with a nerve graft with two end-to-end neurorrhaphies. End-to-side (ES): nerve was cut and sutured to the graft with at the lateral side of the nerve. Side-to-end (SE): the nerve was cut and sutured to the graft with end-to-end neurorrhaphy. Denervated: nerve was cut and both endings were buried into the muscle. The evaluation was done by walking track analysis, electrophysiology, body mass, cranial tibial muscle mass, nerve and muscle fibers morphometry. Results: The EE, ES and SE have the same potential of reinnervation. Conclusion: There is no functional or histological difference between these different types of neurorrhaphy.

Osseous Flap of Galea and Periosteum Filled With Mesenchymal Stem Cells, Platelet-Rich Plasma, Bone Dust, and Hyaluronic Acid.

Reconstructive surgery to craniofacial deformities caused by tumor ressections, traumas or congenital malformation are frequent in medicine practice. It aims to provide the patients with better quality of life and functional improvement of speech, breathing, chewing, and swallowing. Many are the techniques described in the literature to recover bone defects. This study evaluated a vascularized galeal and periosteum flap in rabbits, which could possibly substitute the bone graft in reconstructive surgery, especially for facial defects. It involved rabbits, divided into 12 groups, submitted to a surgical procedure to construct the galea and periosteum cranial flap filled with fragments of cranial bone, platelet-rich plasma, mesenchimal stem cells, and hyaluronic acid. The evaluation methods included image examinations and histological analysis.The results demonstrated bone formation with the use of platelet-rich plasma, mesenchimal stem cells, and bone fragments. The use of several enrichment materials of osseous cellular stimulation improved the quality and bone tissue organization. The more enrichment factor used, the better the tissue quality result was.Much research should be done to improve the methods and to analyze if results in human have the same bone formation as it happened in rabbits.

Aesthetic and Non-aesthetic Indications for Orbicularis Oculi Myectomy.

INTRODUCTION: Crows' feet wrinkles are caused by the action of the orbicularis oculi muscle on overlying skin. Treatment options range from botulinum toxin to a multitude of surgical methods. We first described our technique in 2003 and refined it in 2006. We highlight the evolution of our technique and look at our results to assess the effectiveness of our technique. OBJECTIVE: The aim of this article is to show our experience of 13 years in 134 patients with our technique of orbicularis oculi myectomy. METHODS: From September 2000 to July 2013, we operated on 134 patients with an age range of 28-77 years. Of these patients, 104 had myectomies via lifting and 22 via a blepharoplasty approach. Five patients had myectomies for treatment of blepharospasm and a further three patients to restore symmetry in facial palsy. An evaluation of the results was performed by two medical students. RESULTS: Our results showed reduction of the wrinkles in all cases. For the statistical analysis the Wilcoxon test was performed. The p value was less than 0.001 showing a significant reduction of crows' feet wrinkles in both sides when the orbicularis myectomy was performed, via blepharoplasty or lifting. For myectomy performed for blepharospasm or facial palsy, the statistical analysis was not done due to the low numbers. CONCLUSION: In the appropriate patient, orbicularis oculi myectomy is an effective and long-term treatment for crows' feet wrinkles with a low risk of complications and high patient satisfaction. 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 .

Facial reanimation utilizing combined orthodromic temporalis muscle flap and end-to-side cross-face nerve grafts.

BACKGROUND: Individuals with facial paralysis of 6 months or more without evidence of clinical or electromyographic improvement have been successfully reanimated utilizing an orthodromic temporalis transfer in conjunction with end-to-side cross-face nerve grafts. The temporalis muscle insertion is released from the coronoid process of the mandible and sutured to a fascia lata graft that is secured distally to the commissure and paralyzed hemilip. The orthodromic transfer of the temporalis muscle overcomes the concave temporal deformity and zygomatic fullness produced by the turning down of the central third of the muscle (Gillies procedure) while yielding stronger muscle contraction and a more symmetric smile. The muscle flap is combined with cross-face sural nerve grafts utilizing end-to-side neurorrhaphies to import myelinated motor fibers to the paralyzed muscles of facial expression in the midface and perioral region. Cross-face nerve grafting provides the potential for true spontaneous facial motion. We feel that the synergy created by the combination of techniques can perhaps produce a more symmetrical and synchronized smile than either procedure in isolation. METHODS: Nineteen patients underwent an orthodromic temporalis muscle flap in conjunction with cross-face (buccal-buccal with end-to-side neurorrhaphy) nerve grafts. To evaluate the symmetry of the smile, we measured the length of the two hemilips (normal and affected) using the CorelDRAW X3 software. Measurements were obtained in the pre- and postoperative period and compared for symmetry. RESULTS: There was significant improvement in smile symmetry in 89.5 % of patients. CONCLUSION: Orthodromic temporalis muscle transfer in conjunction with cross face nerve grafts creates a synergistic effect frequently producing an aesthetic, symmetric smile. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors at www.springer.com/00266 .

Gliding mentoplasty: a new technique.

BACKGROUND: The goal of mentoplasty is to improve chin projection. Traditionally, this is accomplished by either mandibular osteotomy or alloplastic implants. However, these procedures are not free of complications. This report describes gliding mentoplasty, a novel, simple technique for chin projection. METHODS: The 12 patients in this study underwent gliding mentoplasty. By means of a 2-cm intraoral incision, a subcutaneous dissection was made in the caudal direction. The dissection then proceeded in the subperiosteal plane, leaving a 1-cm cuff of muscle attached to the bone, and advanced toward the lower border of the chin. Subsequently, the dissection was extended laterally, and the whole mental area was dissected from the surrounding tissue. Three 2-0 monofilament nylon sutures were placed in the submandibular periosteum and connected through the remaining muscle cuff to the periosteum. These key sutures allowed the submandibular region to slide forward, project the subcutaneous tissue and mentalis muscle, define the labiomental fold, and improve the pogonion projection. RESULTS: Gliding mentoplasty resulted in a symmetric projection of the chin in all cases. In two patients, a submandibular dimple developed, which spontaneously resolved in 1 month. No revision surgery was performed, and no tissue relapse was noted. The mean follow-up period was 24.7 ± 5.17 months (range 19-33 months). All the patients were satisfied with the result. CONCLUSION: Gliding mentoplasty is a simple, easy-to-perform, rapid surgical technique of chin projection that produces low pain, rapid recovery, and excellent cosmetic 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 .

Galea and periosteum flap filled with bone fragments in rabbits.

PURPOSE: To study the bone viability of a vascularized galea and periosteum flap filled with bone fragments, as a substitute of the bone graft in facial reconstructive surgery. METHODS: Forty rabbits were studied, and divided in two groups. One had a simple galea and periosteum flap done and the other had the same flap done and filled with bone fragments of the calvaria. The bone formation was evaluated by radiographies, macroscopic and microscopic analysis. RESULTS: The bone neoformation in both groups with differences in bone morphology and structure especially at histological analysis. CONCLUSION: This study demonstrated osseous formation in both groups of galea and periosteum flaps, with and without bone fragments.

Galea and periosteum flap filled with bone fragments in rabbits

PURPOSE: To study the bone viability of a vascularized galea and periosteum flap filled with bone fragments, as a substitute of the bone graft in facial reconstructive surgery. METHODS: Forty rabbits were studied, and divided in two groups. One had a simple galea and periosteum flap done and the other had the same flap done and filled with bone fragments of the calvaria. The bone formation was evaluated by radiographies, macroscopic and microscopic analysis. RESULTS: The bone neoformation in both groups with differences in bone morphology and structure especially at histological analysis. CONCLUSION: This study demonstrated osseous formation in both groups of galea and periosteum flaps, with and without bone fragments.