Effect of Tacrolimus on Peripheral Nerve Regeneration in Allograft Transplantation: A Light and Electron Microscopic Study.

OBJECTIVES: Peripheral nerve injuries are common in Europe; however, the treatment techniques may lead to disabilities. This study aimed to evaluate the effect of tacrolimus use on the capacity of the epineural sheath graft to improve its regeneration quality in rat sciatic nerves as a treatment option for nerve injuries. MATERIALS AND METHODS: In the experimental process, 30 male Sprague Dawley were used as recipients and 10 Wistar rats were used as donors. Under anesthesia, all rats were operated on to resect the sciatic nerve. The nerve tissue of Wistar rats was used as allograft. In the autograft group, the resected nerve was reversed and sutured, resulting in an epineural sheath graft. For the allograft groups, rats were randomly divided into 2 groups as the tacrolimus-treated group and the nontreated group after allograft transplant. Tacrolimus was administered intramuscularly at 0.1 mg/kg daily for 12 weeks. After the treatment period, rats were killed and evaluated histomorphologically with light and electron microscopy. RESULTS: Histological examination showed no remarkable differences between different regions of the sciatic nerves (distal, middle, and proximal). The axonal density was decreased in the allograft groups compared with the autograft group (P < .001). Results showed that the number of mast cells was increased in the allograft group without tacrolimus treatment (P < .05). Similarly, there was a mild increase in mast cell count in the tacrolimus-treated allograft group. CONCLUSIONS: Our results showed that tacrolimus use in rats with implanted epineural nerve sheath supported recovery in terms of morphological and physiological regeneration of the nerve.

68Ga-PSMA Uptake by Dermatofibroma in a Patient With Prostate Cancer.

Prostate-specific membrane antigen (PSMA) is a typ. 2 transmembrane protein that is highly expressed in prostate cancer cells. Ga-PSMA PET/CT imaging is a modality used to determine the extent of prostate cancer. Various other neoplasias may also express PSMA, which appears as Ga-PSMA uptake in PET/CT imaging. A 71-year-old man with prostate cancer underwent Ga-PSMA PET/CT imaging for restaging after having an elevated prostate-specific antigen level. Subcutaneous lesions showing focal PSMA uptake were detected, one of which was excised. The histopathologic diagnosis was dermatofibroma.

A new lateral thoracic artery perforator flap design with multiple vascular territories in rats.

BACKGROUND: To describe a new design for an extended lateral thoracic artery (LTA) perforator flap and investigate its anatomical, dynamic, and potential territories. MATERIALS AND METHODS: To assess vascular territories, rats were randomized according to LTA perforator flap type into the surgical groups A, hemidorsal island flap; B, entire dorsal island flap; and C, reduced-size dorsal island flap. RESULTS: On postsurgical day 7, the surviving flap areas were 95%, 92%, and 89% in groups A, B, and C, respectively. Necrosis most commonly occurred in the contralateral LTA territories in groups B and C. The immunoreactivities of intercellular adhesion molecule 1 and vascular endothelial growth factor receptor 2 in dynamic territories, as choke vessel markers, were increased. CONCLUSIONS: We clarified the LTA perforator flap nomenclature and defined its pedicle course and anastomosing patterns; furthermore, we demonstrated that the LTA perforator did not anastomose with its counterpart because of its unidirectional, oblique, and craniocaudal course. The LTA perforator flap was found to be a good model comprising multiple vascular territories and exhibiting continuous necrosis.

Circumflex scapular artery myocutaneous and/or vascularized scapular chimeric flap.

BACKGROUND: Chimeric osteomyocutaneous flaps harvested from the subscapular artery system have been used in clinical practice. We describe the use of a novel circumflex scapular artery myocutaneous and/or vascularized scapular chimeric flap in a rat model and demonstrate optimal skin flap dimensions. MATERIALS AND METHODS: An 8 × 4-cm-rectangular skin flap based on the circumflex scapular artery flap was harvested, and the mean percentage of the surviving flap area and the necrotic area were calculated to be 71% ± 17.9% and 29% ± 17.9%, respectively. Using flap dimensions determined in the first part of our study, a 4 × 3-cm quadrangular portion of skin was marked over the scapula, and the serratus anterior muscle and a portion of the scapular bone were included in our chimeric flap model. RESULTS: The mean percentages of the surviving flap and necrotic areas were 74% ± 6% and 25% ± 6%, respectively. Microangiographic and histologic studies revealed the vascularity of the skin island and identified the branches of the circumflex scapular artery that supplied the bone and muscle. CONCLUSIONS: The circumflex scapular artery myocutaneous and/or vascularized partial scapular chimeric flap may be considered a branch-based chimeric flap and can be an acceptable flap model due to its simplicity, reliability, and consistent vascularity. Furthermore, this flap may have potential applications in studying chimeric flap hemodynamics.

Reconstruction of midfoot bone and soft tissue loss with chimeric partial scapula and latissimus dorsi muscle flap and short perforator-based skin flap following gunshot injuries: Report of two cases.

INTRODUCTION: In this report we present two cases of gunshot injury related midfoot defects, reconstructed with a chimeric partial scapula and latissimus dorsi muscle flap and short perforator-based skin flap. The first case, a 14 years old male, had 10 × 8 cm medial plantar and 6 × 4 cm dorsal foot defects and the second case, a 55 years old female, had only 8 × 6 cm dorsal foot defect. In both cases the defects were associated with fractures, one with lateral cuneiform and cuboid with 90% bone loss and the other with navicular bone, respectively. After 6 months, the patients could walk well without support, and radiographs confirmed bony union. A chimeric partial scapula and latissimus dorsi muscle flap and short perforator-based skin flap may be used for the reconstruction of combined bony and soft tissue defects of the midfoot and to promote bone healing. © 2016 Wiley Periodicals, Inc. Microsurgery 36:598-603, 2016.

Combination of ischemic preconditioning and postconditioning can minimise skin flap loss: experimental study.

OBJECTIVES: Ischaemic preconditioning and postconditioning, which consist of one or a series of short ischaemic events. This study aimed to determine the efficiency of post-conditioning a flap in the minimisation of flap loss after a preconditioned skin flap. METHODS: The rats were divided into five groups: sham group, control group, pre-con group, post-con group, and pre + post-con group. On postoperative days 3 and 7, the entire flaps along with the margins of necrosis were traced onto transparent sheets. The areas of intact skin and tissue were recorded. RESULTS: The flap necrosis area and percentage of necrosis were calculated for each animal. The necrotic area percentage of the control group was found to be significantly higher than those of the other groups on Days 3 and 7 (p = 0.01 and p = 0.03, respectively). The necrotic area percentage of the pre-con group was significantly higher than the pre + post-con group on Day 7 (p = 0.01). VEGFR-3 expression was observed at a rate of more than 50% in the post-con group. The presence of a protective effect in the late period was separately investigated by immunohistochemical staining of VEGFR-3 in the proliferating vessels. The necrotic areas was reduced in the flaps of the pre-con, post-con, and pre + post-con groups and the combined preconditioning and postconditioning group has reduced necrotic area compared to preconditioning of the skin flap. CONCLUSION: The protective effect was observed on day 7 for combined ischaemic preconditioning and postconditioning. The presence of a protective effect in the late period was separately investigated by immunohistochemical staining of VEGFR-3 in the proliferating vessels.

Use of human nail for reconstruction of the orbital floor: an experimental study in rabbits.

The orbital floor is the thinnest part of the orbital wall, and in 20% of all maxillofacial injuries it is fractured. Autografts, allografts, and alloplastic materials are used in reconstruction, but there is no consensus about which material is the most appropriate. Nail is a semirigid material that is easy to reshape and is not antigenic. Alloplastic materials, which are used in reconstructions of the orbital floor, have various complications and are expensive. Autografts have donor-site problems, high rates of resorption, and take a long time to do. We created bilateral 10mm defects in the orbital floors in 18 New Zealand rabbits. We reconstructed the left orbital floors with double-ground human nail while the right orbital floors were left open as controls. The orbital floors were examined macroscopically and microscopically at 4, 8, and 12 weeks postoperatively, and there were no macroscopic signs of infection, inflammation, or extrusion. Forced duction tests showed that it was possible to induce movement of the eyeball for all 18 of the reconstructed sides throughout the observation period, and in 14 of the 18 rabbits on the control sides. Positive forced duction test shows us that orbital muscles are trapped in orbital floor defect and due to this movement of eyeball is restricted. Acute and chronic inflammation, fibrosis, vascularisation, and the presence of foreign body giant cells were evaluated microscopically. Acute inflammation and the presence of foreign body giant cells were recorded as mild, whereas fibrosis, chronic inflammation, and vascularisation were severe, as were epithelialisation on the maxillary sinus side of the nails, calcification, and progression of collagen. We found no signs of resorption of the nails.

Treating the Golden Implant Visibility on a Paralytic Eye by Using the Capsule Shield Technique.

Static upper eyelid weight loading is a well known treatment option for patients who suffer from paralytic lagophtalmus. Golden implants may cause some complications such as extrusion, postoperative ptosis, visibility of the implant from the skin, infection, or dislocation. Our patients applied to our clinic with discomfort of the implant's easily noticeable visibility in their daily life. They were scheduled the operation programme for reducing visibility of implant.In operation, capsule formation has seen and dissection begun preserving the capsule formation. The capsule has opened on its cranial edge and implant has been removed. By this maneuver, 2 layers of capsule were dissected from surrounding tissues without separating its caudal edges from the upper tarsal fold. These 2 layers were sutured to each other providing strong fibrous shield with the aim of preventing implant visibility. A new pocket has been created under this fibrous shield.Capsule shield technique is provided to replace the implant and prevent revisibilation by using forceful fibrous and highly vascular 2 layers of capsule. This technique seems 1 step ahead than autogenous grafts that require secondary surgical area and bring donor site complications with itself. It does not contain any risk of developing foreign body response and graft infection, unlikely nonautogenous/autogenous graft materials. Also, in the capsule shield technique, operation duration will be shorter and hospitalization period will be shorter compared with techniques using barrier materials because it does not require any additional surgical intervention in donor area. In addition, the authors keep the apeuneurosis in anatomical position and no other new incisions are required. Since no biomaterials are required, this technique also avoids donor site morbidity.

Defect closure with "8-shaped crisscross tensile suture" technique.

BACKGROUND: Sutures and suturing techniques compose the basis of the surgery. Although many surgical methods such as the skin grafts or flaps has been described for the closure of large defects, proper primary suturing may sometimes yield very successful results and decrease the need of complicated procedures. In this article, a new combined skin-subcutaneous tissue suturing technique called as "8-shaped crisscross tensile suture (8CTS)" designed for the closure of large skin defects is presented. PATIENTS AND METHODS: One hundred forty-nine patients with an age distribution between 14 and 65 y were operated for large skin defects by using the 8CTS technique. The most common etiology of the defects was free flap donor sites, and the most common defect localization was the anterolateral thigh region. The average defect width on the axis of primary closure was calculated as 14.6 cm. The 8CTS technique is a combination of both skin and subcutaneous layers suturation and may even involve deeper layers suturation according to the depth of the defect. RESULTS: Eight complications including wound dehiscence, early recurrence of pilonidal sinus disease, seroma formation, skin-edge necrosis, and incisional hernia were observed. The wounds of 141 patients were treated successfully. CONCLUSIONS: The 8CTS technique is a useful method for the closure of large defects eliminating the need of more complex procedures and providing acceptable cosmetic results while supporting both skin and subcutaneous tissue in one suture.

Beneficial effects of turnover orbicularis oculi muscle suspension flap for treating facial fractures via subciliary incision.

In patients with moderate lower lid laxity, the lower orbicularis oculi muscle becomes atonic or ptotic. Hence, in such patient populations, with periorbital fractures, additional vertical support endorsement either by lateral canthopexy or orbicularis oculi muscle suspension flap must accompany plate and screw fixations. In this report, we shared our experience in applying prophylactic suspension to the lower lid with turnover orbicularis oculi transposition muscle flap in zygomatic fractures treated by subciliary approach in 98 patients. Our results show that turnover orbicularis oculi muscle suspension flap avoids the rounding of the lateral canthal angle more successfully and prevents ectropion better than the resuspension orbicularis oculi muscle flap does. We advocate using this flap where zygomatic fractures are approached via the subciliary incision. We foresee that it is a reliable and easily executed technique especially in middle-aged patients with moderate lower lid laxity for the prevention of ectropion.

Human fingernail as interpositional graft material in the treatment of nasal septal perforations.

PURPOSE: The etiology of nasal septal perforations involves iatrogenic, traumatic, inflammatory, infectious, neoplastic, and caustic causes. To ensure successful closure, an appropriate interpositional graft material should be selected, and this graft material should be covered with healthy tissue. MATERIALS AND METHODS: The study included 18 New Zealand white rabbits weighing 2 to 2.5 kg. Nasal septal perforations were created in group 1. After the creation of defects in group 2, repair was performed with cartilage graft and bilateral mucoperichondrial advancement flaps. After septal nasal perforations in group 3, the defect was covered with fingernail and bilateral mucoperichondrial flaps. RESULTS: At week 12, the rabbits were sacrificed. The septum site that had been repaired with fingernail was intact. No nail exposition, wound site decomposition, or re-perforation was observed. No findings of a breach of the structural integrity of the fingernails or disintegration were encountered. CONCLUSION: Fingernails can be used as an interpositional graft material in place of cartilage in eligible cases for the repair of nasal septal perforations. Fingernails have several properties that enable their use in such cases, such as form preservation that is similar to cartilage, the lack of live cells, easy availability, and a lack of donor-site morbidity at removal.

Comparison of the flap survival with ischemic preconditioning on different pedicles under varied ischemic intervals in a rat bilateral pedicled flap model.

The study was undertaken to search whether pedicle selection for ischemic preconditioning (IP) and duration of global ischemia applied after IP influenced efficacy of IP on flap viability in epigastric adipocutaneous island flap with bilateral pedicles in rat model. In total, 159 rats were divided into one control and three (primary, secondary, or bilateral pedicle) IP treatment groups. IP was performed on different pedicles by three cycles of 10 minutes of pedicle clamping and 10 minutes of release. After IP procedure secondary pedicle was ligated in all groups, and flaps were exposed to 0, 1, 2, 4, or 6 hours of global ischemia by clamping primary pedicle. In control groups, after the perfusion of bipedicled flaps for 1 hour, left pedicle was ligated and flaps were exposed to global ischemia as in IP groups. On day 5 post-surgery, tissue samples and topographic measurements were taken. No significant differences in semi-quantitative scorings of polymorphonuclear leukocytes infiltration, chronic inflammation, interstitial edema, neovascularization, VEGF, and CD105 expression levels among groups were found (P > 0.05). Percentages of necrosis were consistently smaller in IP groups compared to controls for the same duration of global ischemia, with exception of the no-ischemia. Area of necrosis was significantly smaller in primary IP group versus secondary IP group in the absence of global ischemia (P < 0.01). In the presence of global ischemia, both primary and secondary pedicle IP groups had significantly smaller percentage of necrosis than controls (P < 0.05) and there was no significant difference between primary and secondary IP groups (P > 0.05). Thus, IP performed on different pedicles may ameliorate flap survival in a comparable fashion, depending on the duration of global ischemia. Secondary pedicle IP was as effective as primary pedicle IP and may be feasible in free flap transfers.

Microsurgical reconstruction in pediatric patients: a series of 30 patients.

BACKGROUND: Free flap surgery in the pediatric population has gained widespread acceptance regarding its technical utility and reliability. Initial concerns as to the feasibility and reliability of the procedure in children were resolved over time. METHODS: Thirty children (15 boys, 15 girls) were treated in Sisli Etfal Training and Research Hospital, Plastic and Reconstructive Surgery Clinic. Their mean age was 10.8 years. Defects were located on the lower extremity (n=22), head and neck (n=5) and upper extremity (n=3). The etiologies of the defects included vehicle accident, sequelae of burn, traumatic contractures, crush injury, epulis in the maxilla, and gunshot wound. RESULTS: The free flaps performed in our series were latissimus dorsi muscle flap, combined latissimus dorsi and serratus muscle flaps, serratus anterior muscle flap, cross latissimus dorsi muscle flap, scapular osteomyocutaneous flap, parascapular fasciocutaneous flap, fibular osteocutaneous flap, anterolateral thigh flap, medial circumflex femoral artery perforator flap, and crista iliaca osteocutaneous flap. CONCLUSION: The advantages of free flaps in children, which include better adaptation of the flap growth and better learning capacity of the children, provide the surgeon with more satisfactory functional and aesthetic results.

Modification of mandibular advancement osteotomy in a patient with Hanhart syndrome.

The oromandibular limb hypogenesis syndrome is a group of anomalies affecting the mandible, tongue, and maxilla with or without reductive limb anomalies. It was first described by Hanhart in 1950. In severe syndromic cases of mandibular hypoplasia, a number of techniques have been described for mandibular advancement including sagittal split osteotomies, segmental osteotomies, or distraction osteogenesis just to name a few. A 25-year-old male patient presented to our clinic with symptoms including difficulty in speech and eating, disability in opening the mouth, together with hand and foot abnormalities; we want to describe a modification in the technique of mandibular advancement and the patient's late postoperative results. The design of the step osteotomy is modified by softening the angles of the steps and elongating the horizontal segment of the step to approximately 25 mm to allow for a more efficient advancement of the mandible. The postoperative period was uneventful, with no signs of inferior alveolar nerve disturbance. The patient showed an increase of the mouth opening distance immediately after surgery. We believe that this tongue-in-groove-like modified mandibular step osteotomy technique is a good alternative in patients where advancement greater than 15 mm is required, preserving the nerve and achieving solid bony intact surfaces.

Marjolin ulcer: clinical experience with 34 patients over 15 years.

BACKGROUND: Malignancies that arise from scars are referred to as Marjolin ulcers. The association between chronic ulcers and squamous cell carcinomas is well established. There are many case reports in the literature regarding Marjolin ulcer; however, randomized controlled clinical series that describe a thorough evaluation of these patients are rarely encountered. OBJECTIVE: We present our clinic's 15 years of experience with 34 Marjolin ulcer patients and their treatment modalities. METHODS: A retrospective analysis of 302 squamous cell carcinoma patients who were treated in the plastic surgery department between 1997 and 2011 was performed. Thirty-four (10.3%) histopathologically confirmed Marjolin ulcer patients were further analyzed. RESULTS: Although burn scars represented 77% of the patients in the present study, unstable scars that formed following traffic accidents and fistula tracts are also among the commonly encountered etiologies. Based on our observations, squamous cell carcinoma, in addition to malignant melanoma and verrucous carcinoma, is frequently observed in cases of Marjolin ulcers. CONCLUSION: If the goal is to eradicate this clinical entity, all of the chronic ulcers that fail to heal require biopsies at regular intervals. Large excisional margins, lymphadenectomies in cases of palpable lymph nodes, and a well-defined oncology protocol are all essential in treating Marjolin ulcer.

The feasibility of tissue expansion in reconstruction of congenital and aquired deformities of pediatric patients.

Skin expansion is one of the major developments in reconstructive surgery. The use of tissue expansion has been popularized among plastic surgeons and has become the treatment method of choice for many congenital and acquired defects in a wide variety of diseases in adults and then later in children. The authors analyze their clinical experience in the treatment of burn scars and complex defects by tissue expansion in pediatric patients. The study included thirty five expansion procedures performed in 25 patients. Smooth surface expanders with a remote valve were used in the scalp (22), face (2), neck (3), hand (2), thorax (2), breast (1), palate (2), abdomen (1). Self-inflating osmotic tissue expanders were used in four patients, one of them had cleft palate and the other two of them had congenital hand anomalies and the last one had frontal scar and alopecia in the frontal hairline. In 19 out of 25 cases (76%) tissue expansion was achieved without complications. At the same time, in 1 cases minor complications and in 5 cases major complications occurred. The number of expanders per patient was only one in 16 cases. More than one expander was used to remove parts of the same injury in 9 cases. Our study may help to draw attention again on different aspects in tissue expansion and critically focus on each step of the tissue expansion both using self-filling tissue expanders and smooth surface tissue expanders with a remote valve.

Comparison of perivascular and intramuscular applied botulinum toxin a pretreatment on muscle flap ischemia-reperfusion injury and chemical delay.

BACKGROUND AND PURPOSE: Muscle flaps are known to be prone to local ischemia more than other flaps. The local and systemic injury that ensues after reperfusion of ischemic skeletal muscle is an important clinical problem in flap surgery. Flap delay may be applied chemically or sympathetically. Early use of botulinum toxin A (Btx-A) in muscle flap surgery relied on chemical denervation; however, in our study, we tried to emphasize a possible chemical delay mechanism of Btx-A, through the release of substance P and calcitonin gene-related peptide (CGRP) and vascular endothelial growth factor (VEGF). METHODS: Pretreatment with perivascular or intramuscular Btx-A was applied 1 week before the flap elevation, 3.5 units in 2 experimental groups each containing 8 Sprague-Dawley rats. The control groups (2 groups, each containing 8 rats) received 0.07 mL saline perivascularly and intramuscularly. The right gastrocnemius muscle flap was used as the experimental model. Ischemia-reperfusion cycle was applied to all groups. On the seventh day, the gastrocnemius flap was elevated, and perivascular tissues were observed macroscopically. Comparisons between perivascular Btx-A and intramuscular Btx-A groups were made, and the animals were killed. Muscle biopsies were taken. Damaged myocytes were counted using McCormack technique, and chemical delay was shown as angiogenesis, lymphocyte counts, and edema formation with VEGF3-R, CGRP, and substance P markers as immunohistochemical staining. RESULTS: The amount of muscle necrosis was the highest in intramuscular Btx-A admitted groups. The intramuscular and perivascular Btx-A groups showed significant angiogenesis scored blindly by the senior pathologist. CONCLUSIONS: Potential role of Btx-A in ischemic preconditioning of muscle flaps achieved through the release of substance P, CGRP, and VEGF was investigated. Chemical delay was shown objectively by Btx-applied groups.

Comparative analysis of the nail xenografts with cartilage autografts in eyelid reconstruction.

OBJECTIVE: The tarsal plate is the skeleton support system of the eyelids; therefore, repair during eyelid reconstruction is crucial. Many autogenous graft materials have been proposed for the tarsal reconstruction, such as nasal cartilage, palatal mucosa, upper eyelid tarsus, and auricular cartilage. Nail thickness and shape are similar to the tarsal plate with enough support for the eyelid. It also easily integrates with host tissues. The aim of this experimental study was to macroscopically and histopathologically compare nail xenografts with cartilage autografts when used in eyelid reconstruction in rabbits. METHODS: In total, 12 New Zealand rabbits were used in the experiment. Full-thickness defect with a 1-cm diameter was created in both upper eyelids. The right upper eyelids were used for cartilage autograft reconstruction, and the left upper eyelids were used for nail xenograft reconstruction. All animals were killed on week 12 after eyelid reconstruction. After the animals were killed, the upper eyelids of the rabbits were resected for macroscopic and histologic analysis. RESULTS: In histologic evaluation, moderate foreign body giant cell formation and moderate histiocytic, neutrophilic, basophilic, and lymphocytic infiltration were observed in both experimental group and control group. In addition, this marked fibrous capsule formation was observed around the nail xenograft, which was absent in the cartilage autograft group. CONCLUSIONS: Nail has some advantages such as being cost-effective, being easy to obtain, and having less rejection risk for being composed of dead cells. Nail xenografts can be taken into account instead of cartilage grafts in eyelid reconstruction.