Artificial Dermis and Human Recombinant Epidermal Growth Factor Application for the Management of Critical Size Calvarial Defect.

Restoration of the 3-dimensional structure of the facial and calvarial skeleton after trauma or ablative oncologic surgeries serves as a framework for soft tissue reconstruction. In the present study, the authors aimed to evaluate the osteogenic effect of artificial dermis and epidermal growth factor treatment in critical-sized calvarial defects, which cannot be healed spontaneously. 8 mm calvarial defects were created in 28 male rats and filled with the artificial dermis, the artificial dermis and growth factor, growth factor or left untreated. Atomic absorption spectrometry was used to determine the amount of calcium, scanning electron microscopy was used to show the bone tissue in 3 dimensions, and immunohistochemistry was used to assess the bone formation and cell density. Histologic evaluation at 6 weeks showed incomplete bone regeneration in all groups. No statistical differences were found between the groups with regard to their scores for the following: inflammation, new bone formation, osteocyte density, resorption of bone at the edges of the defect, or fibrous tissue formation in the defect area. In conclusion, the predictability of bone formation in critical-size defects is not clear. Contrary to popular belief, the combined use of epidermal growth factor with artificial dermis or alone did not enhance the potential for osseous healing.

Comparison of The Thickness of Free Anterolateral Thigh Flap in Different Fascial Planes: Clinical Results of Subfascial and Superficial Fat Flap.

Background The anterolateral thigh (ALT) flap is a preferred option in the reconstruction of a wide variety of defects, enabling multiple tissue components and thicknesses. Methods This study was conducted to investigate the correlation of the thickness of the traditional subfascial ALT flap and superficial fat flap with age, gender, and body mass index (BMI). A total of 42 patients (28 males and 14 females) were included in the study. Results Mean age was 50.2 (range, 16-75) years and mean BMI was 24.68 ± 4.02 (range, 16.5-34.7) kg/m 2 . The subfascial flap thickness was significantly thinner in male patients (16.07 ± 2.77 mm) than in female patients (24.07 ± 3.93 mm; p < 0.05), whereas no significant difference was found between male (4.28 ± 1.15 mm) and female patients (4.85 ± 1.09 mm) regarding superficial fat flap thickness ( p = 0.13). The thickness of both flaps had a positive correlation with BMI, and the strongest correlation was found for subfascial ALT thickness in female patients ( r = 0.81). Age had no effect on both flap thickness measurements. The anterior thigh is thicker in women than in men, although it varies according to BMI. This shows that flap elevation is important in the superthin plane, especially if a thin flap is desired in female patients in defect reconstruction with the ALT flap. Thus, a single-stage reconstruction is achieved without the need for a defatting procedure after subfascial dissection or a second defatting procedure 3 to 6 months later. Conclusion The appropriate ALT flap plane should be selected considering the gender and BMI of the patient.

Histopathologic and Spectrometric Evaluation of Bony Components of Synostotic Suture and Parietal Bone in Children with Sagittal Synostosis.

AIM: To understand the characterization of the ossification process both in the synostotic suture, and the adjacent parietal bone. MATERIAL AND METHODS: The surgical procedure for the 28 patients diagnosed with sagittal synostosis consisted of removing the synostotic bone as a whole, if possible, "Barrel-Stave" relaxation osteotomies, and strip osteotomies to the parietal and temporal bones perpendicular to the synostotic suture. The synostotic (group I) and parietal (group II) bone segments are obtained during osteotomies. Atomic absorption spectrometry was used to determine the amount of calcium in both groups, which is an indicator of ossification. Scanning electron microscopy and immunohistochemistry were employed to assess trabecular bone formation, osteoblastic density, and osteopontin, which is one of the in vivo indicators of new bone formation. RESULTS: Histopathologically, trabecular bone formation scores did not indicate any significant difference between the groups. However, the osteoblastic density and calcium accumulation in group I were higher than those in group II, and the difference was significant. Osteopontin staining scores in cells showing membranous and cytoplasmic staining with osteopontin antibodies significantly increased in group II. CONCLUSION: In this study, we found reduced differentiation of osteoblasts despite their increase in number. Moreover, the osteoblastic maturation rate was low in synostotic sutures, bone resorption becomes slower than new bone formation, and the remodeling rate is low in sagittal synostosis.

Infections in Pediatric Patients With Burn Injury: 6 Years of Experience.

BACKGROUND: This study aimed to determine the frequency of bloodstream and wound infections and their possible risk factors in hospitalized children with burn injury. METHODS: We performed this retrospective descriptive study from 2015 to 2021. The study subjects consisted of all the pediatric patients hospitalized in the burn unit, from whom microorganisms were isolated either from blood or wound culture samples. RESULTS: We detected a total of 142 microorganisms from 97 blood culture samples and 45 wound culture samples. Among the 115 patients, 44 (38.3%) were females and 71 (61.7%) were males, with a median age of 21 months (interquartile range: 14-39 months). Gram-positive bacteria were the most common causative agents of bloodstream infections in patients with burns (54.6%), followed by Gram-negative bacteria (32.9%) and fungi (12.3%). Gram-negative bacteria were the most common causative agent of wound infections (86.7%). Prolonged hospitalization positively correlated with the extent of the burn surface area (P: 0.031), degree of burn (P: 0.001), use of central venous catheter (P: 0.028), and intensive care unit stay (P: 0.044). Independent risk factors for Gram-negative bacteremia and Gram-negative wound infections were the extent of the burn surface area (P: 0.018), degree of burn (P: 0.024) and intensive care unit stay (P: 0.023). The independent risk factor for fungemia was prolonged hospitalization (P: 0.026). CONCLUSIONS: To reduce infections, minimizing invasive procedures using a multidisciplinary approach would be beneficial, especially in patients who have a large burn surface area and are expected to have a long hospital stay.

The Effect of Ex-Vivo Hyaluronic Acid on Myofibroblast and Collagen in Dupuytren Disease.

Background: Dupuytren disease (DD) is characterised by increased myofibroblast/fibroblast activity and type3/type1 collagen ratios. Hyaluronic acid (HA) is major component of the extracellular matrix and some studies have showed that HA limits myofibroblast activity and decreases type3/type1 collagen ratio. The aim of this study is to determine the effect of the ex-vivo application of HA on cultured fibroblasts obtained from normal and diseased tissue from patients with DD. This is the initial step towards defining the use of HA as a new approach for medical treatment of DD. Methods: Tissue samples were obtained from both healthy forearm (C) and unhealthy palmar (D) fascia of patients undergoing surgery for DD. Tissue samples were cultured and divided into four groups depending on the addition of HA [C(HA-), C(HA+), D(HA-) and D(HA+)]. The tissues were evaluated using Western blot to detect effect of HA on myofibroblast (by measuring alpha smooth muscle actin [α-SMA) and on the ratio of type3/type1 collagen by measuring collagen type1 alpha 1 Chain (COL1A1) and collagen type3 alpha 1 Chain (COL3A1). Results: The rate of the average α-SMA value in the D(HA+) group was significantly lower compared to that of the D(HA-) group. The average ratio of type3/type1 collagen in the D(HA+) group was significantly lower compared to the D(HA-) group. Conclusions: The ex-vivo application of HA on cultured fibroblasts obtained from patients with DD resulted in a decrease in myofibroblast/fibroblast activity and type3/type1 collagen ratios. This may pave the way for clinical application of HA in the treatment of DD.

Reattachment of the Temporalis Muscle After Frontoorbital Advancement in Craniosynostosis Surgery.

Craniosynostosis surgery may result in temporal hollowing occasionally. Overexpansion of the normal side and undergrowth of the affected side exacerbate the problem in unilateral cases (like unicoronal synostosis). Temporalis muscle lies in the temporal fossa, and it is usually severed or detached from its origin in order to reach the lateral aspect of the fronto-orbital bar. Reattachment of the temporalis muscle is challenging especially when the orbital bar is moved forward. In this technical note, exposure of the lateral cranial vault with zigzag incision of the temporalis muscle in 35 nonsyndromic anterior plagiocephaly patients has been described in detail, and the ease of reattachment is demonstrated afterward.

Glomus tumors of the upper extremity.

BACKGROUND: Glomus tumors are uncommon and painful benign perivascular neoplasms. They usually occur in the subungual region of phalanx, and present with a classic clinical triad of localized tenderness, cold hypersensitivity, and excruciating paroxysmal pain. The aim of this study was to review 45 cases of glomus tumor according to the clinical, radiological and therapeutic characteristics, and the clinical and functional outcomes of surgical treatment. MATERIALS AND METHODS: A retrospective review was made of 45 glomus tumors of the upper extremity operated on between June 2005 and January 2019. Data were collected of demographic characteristics and the diagnostic, immunohistochemical, therapeutic and postoperative clinical findings. RESULTS: The patients comprised 69 % females and 31 % males with a median age of 41 years at the time of surgery. The most commonly affected anatomic location was the digits (87 %). Of the 39 cases with an affected digit, there was a predominance of the middle finger in 28 % and the peri-subungual area in 51 %. There was no recurrence or need for secondary surgical intervention in any patient in this study. The mean QuickDASH score was 1.47 at mean 66 months follow-up. CONCLUSIONS: Glomus tumor, which is usually seen in the middle finger of middle-aged women, presents with excruciating paroxysmal pain out of proportion to the tumor size. The long-term outcomes after surgical loupe-assisted surgery with a transungual approach were seen to be good, without local recurrence and an acceptable rate of postoperative nail dystrophy.

The use of autologous fat grafts in breast surgery: A literature review.

Autologous fat injection was first described roughly a century ago and has been used in surgery ever since. In addition to its use in many surgical fields, it is also frequently used for both aesthetic and reconstructive purposes in breast surgery. Since the application of fat grafting in breast surgery has steadily increased, studies investigating its reliability have simultaneously become increasingly common. Previous studies have reported that the use of fat grafting in breast surgery is reliable, but some pending questions remain about its routine use. In order to use fat grafts successfully in breast surgery, it is necessary to be familiar with the structure and content of adipose tissue, the efficacy of adipose stem cell-enriched fat grafts, the oncological safety of fat grafts, and the problems that may occur in the radiological follow-up of patients who undergo fat grafting procedures. In this literature review, we aim to discuss the use of fat grafts in breast surgery by investigating these common problems.

An unusual etiology in cold injury: Liquefied petroleum gas.

Cold injury is a condition that causes reversible and irreversible damage when tissues are exposed to cold. This injury occurs due to various etiologies, and the most commonly observed ones include contact with liquefied petroleum gas (LPG) used in households, vehicles, and industry. LPG is a type of gas stored in liquid state under high pressure within cylinders. LPG contains a mixture of propane and butane gases. Direct contact of these gases with the tissues has the potential to cause metabolic, toxic, and respiratory damage. In this study, we present the cases of four patients with cold injury in the face and upper extremity caused by a pressurized jet stream of liquid gas that escaped out of the valves of the LPG cylinders. The patients had bullous lesions in the upper extremities and the face and second- and third-degree cold injuries with fibrotic and necrotic areas. The superficial defects secondarily healed with minimal scarring, while the necrotic finger had to be amputated. Cold injury on the skin caused by high-pressure jet streams of liquid gas as in our study is a rare occurrence. Our patients are important cases due to the rare etiology of cold injury.

Stepwise Removal of the Fused Midline Parietal Bone to Avoid Superior Sagittal Sinus Injury in Infants with Sagittal Synostosis.

This work describes a simple technique for the safe removal of the midline parietal bone with the synostotic sagittal suture in infants with sagittal synostosis to avoid dural tearing and bleeding from the superior sagittal sinus. The technique consists of stepwise removal of the midline parietal bone in three pieces instead of one piece, starting with the anterior one-third midline bone being safely freed from the underlying dural sinus and then transversely cut using a craniotome. The step is repeated twice for the middle and distal one-third of the bone respectively. Once the midline bone is bilaterally cut along its entire length, the stepwise elevation of the superior sagittal sinus dura using an elevator and removal of the midline bone in three pieces allows a safer, controlled procedure minimizing the risk of tearing the underlying dural sinus and preventing sinus bleeding in infants with sagittal synostosis.

The Surgical Strategy for the Intraorbital Foreign Bodies.

PURPOSE: Four patients with intraorbital foreign bodies admitting to our clinic between 2001 and 2011 are presented. Their clinical and radiologic findings and surgical strategies are discussed. OBJECTIVE: The success of surgery for the intraorbital foreign bodies largely depends on the determination of the exact localization of them. Radiologic examination should follow clinical diagnosis. Computed tomographic views are especially required to demonstrate the foreign body. MATERIALS AND METHODS: Four patients with different etiologies of trauma are presented. Each had computed tomography views for foreign body localization. All but 1 had surgery for removal of the object under general anesthesia. RESULTS: No complications were observed postoperatively. Only 1 patient is followed up without an operation due to the risk of damaging delicate structures that the foreign body is close to. He has no loss of function. CONCLUSION: Early removal of foreign bodies in orbital region is usually preferred due to the risk of neurologic damage and other complications. Surgical removal is quite challenging for foreign bodies like wood. Magnets can be used for metallic bodies.

Increasing the survival of transverse rectus abdominis musculocutaneous flaps with a Botulinum toxin-A injection: A comparison of surgical and chemical flap delay methods.

BACKGROUND: Botulinum toxin type-A (Bot-A) is a commonly used drug for both cosmetic and therapeutic purposes. The effects of Bot-A on skin and muscle flaps and the related mechanisms have been described previously. In this study, we used a rat transverse rectus abdominis musculocutaneous (TRAM) flap model to examine the effects of Bot-A on the skin island, which is perfused by the rectus abdominis muscle according to the angiosome concept. METHODS: Forty female rats were divided into five groups, including control and sham groups. In the control group, a TRAM flap was raised and sutured back after inserting a silicone sheath underneath the flap. In the sham group, the flap was raised 1 month after injecting saline into the muscle. In the chemical delay group, the flap was raised 1 month after injecting 10 IU of Bot-A. In the surgical delay group, the flap was raised 2 weeks after ligating the cranial epigastric artery. In the surgical and chemical delay group, a Bot-A injection was performed initially, a cranial epigastric artery was ligated after 2 weeks, and a TRAM flap was raised after the first month. In all groups, laser Doppler examination, photographic documentation, and analysis of the flap survival rates were performed. In the histopathological evaluation, the diameter measurements of the caudal epigastric vessels, vascular density measurements using CD31 stain, and apoptotic rate estimation using the Tunnel method were performed. RESULTS: The necrosis ratios, arterial cross-sectional diameters, and microvascular density measurements were significantly superior compared to those of control and sham groups; however, there was no significant difference between the delay groups. There was also no difference in the laser Doppler measurements between the groups and the zones of the TRAM flaps. CONCLUSION: An injection of Bot-A increases muscular circulation and flap survival of TRAM flaps in rats.

Extradigital Glomus Tumor Revisited: Painful Subcutaneous Nodules Located in Various Parts of the Body.

BACKGROUND: Glomus tumor is a common lesion of the subungual area of the hand fingers. However, glomus tumors located outside the hand region are rare and the diagnosis is often difficult due to their low incidence and lack of distinct clinical features in the physical examination. The presented article contains five cases of extradigital glomus tumors with a short review of the literature. PATIENTS AND METHODS: Five cases of extradigital glomus tumor were included in the study. All lesions were purple colored subcutaneous nodules with sharp pain by digital palpation. All lesions were examined with ultrasound imaging were operated under local anesthesia using loupe magnification. RESULTS: Among five patients, only one patient was female with a mean age of 35. Two lesions were located at the arm region, two at the crural region and one at the sternal area. The smallest nodule was 0.5 cm and the biggest lesion was 2 cm in diameter. In all the cases, the early postoperative period was uneventful without any surgical complication or acute recurrence. The postoperative 1(st) year examination of all patients revealed complete resolution of the pain and no recurrence was encountered. CONCLUSIONS: Glomus tumor should be kept in mind in the differential diagnosis of all painful subcutaneous lesions especially for those with purple reflection on the skin surface. In this manner, patients with extradigital glomus tumors may be diagnosed earlier and unnecessary and wrong treatments may be prevented.

The effects of the centrifugation speed on the survival of autogenous fat grafts in a rat model.

Purpose The most important problem in fat transplantation is the durability, which is closely associated with the applied technique. This study includes the comparison of different centrifugation speeds on the survival of autogenous fat grafts in rats. Materials and methods Forty-nine Sprague-Dawley rats were divided into seven groups and the left inguinal fat pad was extracted and re-implanted under the scalp after performing appropriate preparation processes. In the first group the fatty tissue was re-implanted in en-bloc fashion and in the second group it was re-implanted after trimming. After trimming, centrifugation with a G-force of 111.8 (1000 rpm) was performed in the third group, 447.2 (2000 rpm) in the fourth group, 1006.2 (3000 rpm) in the fifth group, 1788.8 (4000 rpm) in the sixth group, and 2795 (5000 rpm) in the seventh group for 4 minutes. The fat grafts were taken after 3 months and histopathological and statistical evaluations were performed. Results The rate of viable fat grafts was significantly higher in the 4th and 5th groups comparing to the first three groups. Total weight and volume amounts of the 4th and 5th groups were also significantly higher comparing to the first three groups. Conclusion Maximal long-term durability and fat cell viability results were obtained in the groups with 2000 rpm or 447.2 G-force/4 minutes and 3000 rpm or 1006.2 G-force/4 minutes centrifugation speed, indicating that 4 minutes centrifugation with an average G-force of 698.75 or 2500 rpm provides the best results for the survival of autogenous fat grafts.

Effects of Different Concentrations of Injectable Collagenase Enzyme on Capsular Tissue Around Silicone Implants: A Preliminary Experimental Study for the Development of a New Treatment Strategy.

OBJECTIVES: In recent studies, collagen organization was blamed for the formation of capsular contracture which is still a challenging problem after silicone implant-based breast operations. In this study, effects of different concentrations of collagenase enzyme derived from Clostridium histolyticum on the capsular tissue formation around the silicone implants were investigated. The injectable form of collagenase has a routine clinical use in the treatment of both Dupuytren's and Peyronie's diseases. MATERIALS AND METHODS: Thirty-two Wistar albino rats were randomized into four groups. A 2 × 1 × 0.3-cm-sized silicone block was inserted inside a dorsal subcutaneous pocket in all groups. After 2 months of insertion, capsule thicknesses around the implants were detected under ultrasonography. This was followed by injection of isotonic saline, 150, 300, and 600 IU in Gr-1, 2, 3, and 4, respectively. All the animals were sacrificed at the end of the first week for histologic sampling to determine fibroblast proliferation, vessel density of the tissue, necrosis, edema, inflammation, and capsule thickness. All the data were statistically analyzed using Kruskal-Wallis and Mann-Whitney U tests and compared for significance of the results. RESULTS: There was no significant difference in terms of capsule thinning between the 300 and 600 IU groups but in both groups thinning was significantly higher than the sham group. In the 150 IU group there was no significant thinning as compared to the sham group (p > 0.05). However, complications such as skin necrosis, infection, and seroma formation were seen only in the 600 IU injection group. The optimal safe and effective dose of the enzyme was accepted as 300 IU. The 300 IU injection provided up to 89 % thinning in the capsule tissue. There was thinning of the collagen bundles parallel to capsule thickness. In the 600 IU group, micro-pores were encountered at the thinnest points. CONCLUSION: However, the late results and recurrence rates of capsular contracture were not included in this study; collagenase seemed effective for the reduction of capsular tissue around the implants. NO LEVEL ASSIGNED: This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. 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 Artery Perforator and Depressor Anguli Oris Muscle Chimeric Flap: A New Design of an Old Flap.

BACKGROUND: The aim of this study was to investigate the reliability and outcomes of the facial artery perforator and separately elevated depressor anguli oris (DAO) muscle chimeric flap for the reconstruction of partial or total lower lip defects. METHODS: Eleven patients with malignant skin tumors located at the lower lip were operated between 2013 and 2015. After the excision of the tumor with adequate clear margins using margin controlled excision technique, an appropriate flap fitting to the resultant defect based on the perforators of the facial artery and DAO muscle was prepared and placed into the defect. The DAO muscle activity was tested with electromyography in the postoperative first year examination. RESULTS: Besides 1 patient with transient venous insufficiency, all the flaps healed well without a partial or total flap loss. The mean follow-up period was 10 months. No new primary tumor or recurrence was observed. Although in 1 patient, transient asymmetric smiling and mild drooling was observed, the overall oral competence results were found to be quite satisfactory. The electromyography evaluation of DAO muscle of 5 patients who reached the postoperative first year examination showed action potential results in normal limits with a slight decrease. All patients were satisfied with the final esthetic and functional result. CONCLUSIONS: The facial artery perforator and depressor angel oris muscle chimeric flap is a valuable option for reconstruction of lower lip defects providing esthetically and functionally good results.