Increasing the viability of fat grafts by vascular endothelial growth factor.

OBJECTIVE: To increase the viability of fat grafts using vascular endothelial growth factor (VEGF) in a calcium alginate microsphere controlled release system. DESIGN: Twenty-four rats were divided into 4 groups of 6 rats each. Group 1 was the preconditioning group in which VEGF was applied prior to the fat grafting. In group 2,VEGF was given at the time of the grafting. In group 3, an empty microsphere was added to the grafting material. The fourth group, which received the fat graft only, was the control group. At the 90th day, samples of the fat grafts were weighed and compared with preimplantation weights. RESULTS: The graft viability ratios of the first 3 groups were significantly higher than those of the control group. The relative adipocyte index was significantly higher in the first and second groups compared with the control group and group 3. Consistent with the literature, VEGF used both in the preconditioning procedure and simultaneously with the grafting procedure increased the graft viability ratio and relative adipocyte index. CONCLUSION: This study suggests that VEGF-induced preconditioning of the recipient bed improves fat graft viability via increased revascularization.

Anatomy of gracilis muscle flap.

Gracilis muscle flap is commonly used in reconstructive surgery. The gracilis muscles of 15 formalin-fixed adult cadavers (30 cases) were dissected with 4× loupe magnification. The most proximal pedicle of gracilis muscle was the deep branch of the medial circumflex femoral artery. It was located 60 mm from the pubic tubercle and had a diameter of 0.9 m on the average. The second pedicle was the medial circumflex femoral artery. It was the dominant pedicle in 13% of the cases. The mean diameter of the artery was 1.2 mm, and it entered the muscle 98 mm from the pubic tubercle. The third artery that nourished the muscle was deep femoral artery. It was the dominant pedicle in 87% of the cases. It had a mean diameter of 1.6 mm with a length of 54 mm. The most distant pedicles originated from the superficial femoral artery. They were present in all cases and were double in 77% of the cases. Mean diameter and length of the artery were 1.4 and 52 mm, respectively. They entered the muscle 266 mm from the pubic tubercle. These distal pedicles seem to be large enough to elevate the middle part of the muscle as a free flap.

Anatomy of vastus lateralis muscle flap.

A vastus lateralis muscle flap is used as a pedicled and free flap. In this study, the vastus lateralis muscles of 15 adult formalin-fixed cadavers (30 cases) were dissected. The dominant pedicle was found to be descending branch of the lateral circumflex femoral artery. The mean diameter of the artery was found to be 2.1 mm. This pedicle was located 119.4 mm distal to the pubic symphysis. The mean length of the major pedicle was found to be 56.8 mm when the dominant pedicle was chosen to nourish the flap. The dominant pedicle entered the muscle 155.8 and 213.7 mm from the greater trochanter and the anterior superior iliac spine, respectively. The muscle had proximal minor pedicles from the ascending and transverse branches of lateral circumflex femoral artery. These arteries had mean diameters of 1.8 and 2.0 mm, respectively. The distal minor branches were present in all of the dissections. The distal branch had a mean diameter of 1.8 mm. The origin of this distal branch was located 83.7 mm proximal to the intercondylar line. The motor nerve of the vastus lateralis was found to be originating from femoral nerve. The nerve entered the muscle 194.6 mm from the anterior superior iliac spine.

Predictors of amputation in diabetics with foot ulcer: single center experience in a large Turkish cohort.

OBJECTIVE: Prediction of diabetic foot ulcer outcome may be helpful for clinicians in optimizing and individualizing management strategy. The aim of the present study was to examine the possibility of predicting the outcome of patients with diabetic foot ulcers by using easily assessed clinical and laboratory parameters at baseline. DESIGN: In this observational study, data were collected prospectively in 670 consecutive diabetic foot ulcer episodes in 510 patients examined between January 1999 and June 2008 and were used to evaluate potential predictors of amputation retrospectively. After exclusion of patients who did not come to the hospital for follow-up for a minimum of six months, data of 574 foot ulcer episodes were evaluated. RESULTS: Limb ischemia, osteomyelitis and presence of gangrene and ulcer depth, determined by the Wagner classification system, were the major independent predictors of overall and major amputations. Older age, presence of coronary artery disease, smoking and ulcer size were found to be associated with either overall or major amputations. Baseline levels of acute phase reactants (white blood cell count, polymorphonuclear leukocyte count, platelet count, erythrocyte sedimentation rate (ESR), serum C-reactive protein (CRP) and albumin) and decreased hemoglobin levels were associated with amputation risk. Multivariate analysis showed that one standard deviation increase in baseline CRP and ESR levels were independent predictors of overall and major amputations, respectively. CONCLUSIONS: The presence of limb ischemia, osteomyelitis, local and diffuse gangrene and ulcer depth were independent predictors of amputation. Baseline levels of ESR and CRP appeared to be helpful for clinicians in predicting amputation.

Dorsal nasal augmentation with rib cartilage graft: long-term results and patient satisfaction.

Various alloplastic and autogenous materials have been used for dorsal nasal augmentation. Bone and cartilage autografts commonly are used. We used rib cartilage graft for dorsal nasal augmentation. The aim of this study was to investigate the long-term outcomes and patient satisfaction of dorsal nasal augmentation with rib cartilage grafts. Thirty-eight patients who had been operated on for dorsal nasal augmentation with rib cartilage graft were included in this study. Operation times, postoperative complications, and revision surgery were investigated by using hospital records. Anthropometric measurements were used for determining the resorption rate of cartilage graft. A questionnaire was used for the evaluation of long-term patient satisfaction. Evaluation of the patients' records showed that average operation time was 116 minutes and there were no complications such aspleural damage. The mean follow-up period was 27.4 months. Nine patients required secondary nasal surgery, including soft tissue augmentation (n = 1), nasal tip revision (n = 3), and reshaping the cartilage graft (n = 5). Long-term anthropometric measurements, comparing preoperative and postoperative values, documented increases in both tip projection (4.2%) and nasal length (1.2%) and an increase in nasolabial angle of 8.2 degrees . Eighty-one percent of the patients who answered the questionnaire rated the nasal size as normal. Nasal symmetry and nasal shape were good in 75% and 66% of the patients, respectively. Results of the rib cartilage grafts that are used for dorsal nasal augmentation are satisfactory for the patients and resorption rates are not high enough to change the shape of the nose.

Repair of fractures of the orbital floor with porous polyethylene implants.

Our main aim was to evaluate the long-term results after reconstruction of the orbital floor with porous polyethylene implants. Twenty-six patients with fractures of the orbital floor were included in the study. The main cause of fractures was road crashes. They also complained of enophthalmos (n=19), diplopia (n=21), limited extrinsic ocular motility (n=17), impairment of the infraorbital nerve (n=18), and hypoglobus (n=9). All the fractures were reconstructed with thin and ultra-thin porous polyethylene sheets. No implants extruded and there were no signs of inflammatory reaction against the porous polyethylene. The symptoms were treated in 14 patients with enophthalmos, 18 with diplopia, 16 with limited extrinsic ocular motility, 14 with impairment of the infraorbital nerve and 8 with hypoglobus. Postoperative infections in four patients were treated with systemic antibiotics. Persistent ectropion was present in two patients. Porous polyethylene sheets are reliable, safe and effective implants and may be used for reconstruction of the orbital floor fracture with no donor site morbidity or need to fix implant.

The thickness and the lengths of the anterior wall of adult maxilla of the West Anatolian Turkish people.

The maxilla is the key structure on facial formation and stability. The knowledge about maxillary thickness and dimensions is crucial during facial reconstruction including this bone. In this study, anthropometric measurements of anterior wall of the maxilla on the dry human skulls were aimed. Sixty maxillae of 30 adult dry skulls of West Anatolian people were evaluated. Four vertical lines were drawn between the piriform aperture and lateral border of the bone and six horizontal lines between the infra-orbital margin and the inferior border of the piriform aperture. After establishing the lines, maxillary thicknesses on the intersection points of the vertical and horizontal lines and the lengths of the vertical lines from the infra-orbital margin to alveolar arch were measured by using a fine caliper. It was found that the thickest point of the anterior wall of the maxillae is on the lateral of the infra-orbital margin (5.17 +/- 2.27 mm), and thinnest one is on the inferior of the infra-orbital foramen (0.92 +/- 1.06 mm). The length of the vertical line tangent to piriform aperture (47.66 +/- 3.61 mm) is the longest. The corresponding data of the left and right maxillae were compared by Student's t test. There was no significant difference between both sides. After collecting the data, a thickness map of anterior wall of the maxilla was drawn. This data may be helpful in clinic during osteotomies, bone reconstructions, screw, or other reconstruction apparatus applications on the maxilla.

Management of close-range, high-energy shotgun and rifle wounds to the face.

Close-range, high-energy shotgun wounds of the face are life-threatening and devastating traumas of the face. Suicidal attempts are the main reason in the great majority of the patients in civilian life. There is no consensus on the timing of reconstruction for bone and soft tissue defects resulting from high-energy shotgun wounds. The conventional method is primary repair as soon as possible and serial debridements and definitive reconstruction in the delayed stage. An alternative to this approach is the immediate definitive surgical reconstruction of the patient during the first operation for acute management of trauma. We had 15 patients with close-range, high-energy shotgun wounds in 10 years. Six of 15 patients referred to our center for definitive reconstruction after the acute management of the patients were performed in another center and the rest were all admitted in the acute period. Either conventional approach with delayed reconstruction for 10 patients or immediate definitive surgical reconstruction for 5 patients was used. Immediate reconstruction eliminated disadvantages of the conventional method such as high infection and scarring rate and deformities resulting from contraction of tissues. The emotional conditions of the patients were evaluated and major depression signs were determined. Functional evaluation showed that there was great correlation between facial appearance after reconstruction and social activity level.

Anatomic study of the vasculature of the submental artery flap.

The submental artery island flap is a versatile option in head and neck reconstruction. This flap may be used for the coverage of perioral, intraoral, and other facial defects, leaving a relatively acceptable donor-site scar. In this study, the submental region of 13 formalin-fixed cadavers was dissected bilaterally. Comprehensive anatomical information regarding the pedicle of the flap and its relationship with the important adjacent structures is provided. The mean values of the measurements of the facial and submental arteries were as follows: the facial artery was 2.7 mm in diameter at the origin, and it crossed the mandibular border 26.6 mm from the mandibular angle. The origin of the submental artery was 27.5 mm from the origin of the facial artery, 5.0 mm from the mandibular border, and 23.8 mm from the mandibular angle. The diameter of the submental artery was 1.7 mm at the origin. The artery was found mostly to course superficial to the submandibular gland. In one case, the artery passed through the gland. The total length of the submental artery was 58.9 mm. The artery anastomosed with the contralateral artery in 92 percent of the cadavers. The submental artery was deep to the anterior belly of the digastric muscle in 81 percent of the cases. This study presents detailed anatomical data about the location, dimension, and relationship of the facial artery, the submental artery, and the submental vein that may be useful during dissection of the submental artery island flap.

Cadaveric study of the arterial anatomy of the upper lip.

Arterial distribution of the upper lip was investigated in this study. The location, course, length, and diameter of the superior labial artery and its alar and septal branches were determined on 14 preserved cadaver heads. Another cadaver head was used to show the arterial tree by the colored silicone injection technique. The superior labial artery was the main artery of the upper lip and always originated from the facial artery. The superior labial artery was 45.4 mm in length, with a range from 29 to 85 mm. The mean distance of the origin of the superior labial artery from the labial commissura was 12.1 mm. The superior labial artery was 1.3 mm in external diameter at its origin. The mean distance of origin of the superior labial artery from the lower border of the mandible was 46.4 mm. The alar division of the superior labial artery was mostly found as a single branch (82 percent). Its mean length was 14.8 mm and the mean diameter at the origin was 0.5 mm. The distance between the origins of the superior labial artery and the septal branch was 33.3 mm. The septal branch was single in most of the cases (90 percent). The mean length of the septal branch was 18.0 mm and the diameter at its origin was 0.9 mm. After all dissections, it was concluded that the arterial distribution of the upper lip was not constant. The superior labial artery can occur in different locations unilaterally and bilaterally, with the branches showing variability.

The effects of tumescent solutions containing lidocaine and epinephrine on skin flap survival in rats.

The effects of tumescent solutions consisting of lidocaine and epinephrine on skin flap survival in rats were studied. Dorsal skin flaps of rats were infiltrated using lidocaine (1%) with epinephrine in concentrations of 1:100,000, 1:200,000, 1:400,000, and 1:800,000 prior to elevating flaps of the different experimental groups. The solutions were applied intradermally or subcutaneously, and the flaps were raised "immediately" or "delayed" after injection in the different groups. Control flaps were infiltrated by lidocaine (1%) only. The survival of the flaps was assessed on the seventh day after the operation. As a result, the flaps showed higher necrosis rates in the groups injected by lidocaine with epinephrine in concentration of 1:100,000 and 1:200,000 than of the other experimental or all control groups (P < 0.01). In conclusion, lidocaine with epinephrine in concentrations of 1:400,000 and 1:800,000 was found safe on skin flap survival for tumescent technique in rats.

Arterial anatomy of the lower lip: a cadaveric study.

The aim of the study was to investigate the arterial anatomy of the lower lip. The location, course, length, and diameter of the inferior labial artery and the sublabial artery were revealed by bilateral meticulous anatomic dissections in 14 adult male preserved cadaver heads. Another cadaver head was used for silicone rubber injection to fill the regional arterial tree. The inferior labial artery was the main artery of the lower lip and in all cases branched off the facial artery. The mean length of the inferior labial artery was found to be 52.3 mm (range, 16 to 98 mm). The mean distance of the origin of the inferior labial artery from the labial commissura was 23.9 mm. The mean external diameter of the inferior labial artery at the origin was 1.2 mm. The sublabial artery was present in 10 (71 percent) of the cadavers. Mean measurements of this artery were 1 mm for diameter, 23.4 mm for length, and 27.6 mm for distance from the labial commissura. The sublabial artery may originate from the facial artery or the inferior labial artery. This study found that this region does not have a constant arterial distribution, the inferior labial artery and the sublabial artery (if it exists) can be in different locations unilaterally or bilaterally, and the diameter and the length may vary.

Callus stimulation in distraction osteogenesis.

Distraction osteogenesis has been described as in vivo tissue engineering. The ability to stimulate this process for the repair of bony defects or lengthening of congenitally shortened facial structures is likely to significantly impact the field of craniofacial surgery. The purpose of this study was to determine whether mechanical stimulation of the distracted rabbit mandible would accelerate the maturation of the bony callus when applied during the early consolidation period. Twenty adult New Zealand White rabbits underwent unilateral mandibular osteotomy. A uni-directional internal distractor device (Synthes, Paoli, Pa.) was positioned along a plane perpendicular to the line of osteotomy. After a 7-day latency period, distraction was commenced at a rate of 1.0 mm/day for 12 days in all animals. In a control group of 10 rabbits, a consolidation period of 8 weeks was observed before they were killed. In the experimental group of 10 rabbits, daily alternate compression and distraction of 1 mm (sequential compression and distraction) was performed for 3 weeks followed by a 5-week period of rigid fixation. Each animal received a dose of a fluorescent label at three different time points during the study: at the end of the distraction period, 3 weeks after the completion of the distraction phase, and 3 days before it was killed. All animals were killed 8 weeks after the completion of the distraction phase. Undecalcified histologic analysis and 3-point bending tests to failure were performed on the extracted mandibles. The results of the experimental and control groups were compared. Four animals in the control group and three animals in the experimental group were excluded from the study because of screw loosening resulting in distractor dislodgment or because of infection. On histologic analysis, cortical thickness at the center of the callus was found to be significantly greater in the experimental group compared with the control group when normalized to the contralateral hemimandible (83 percent versus 49 percent, respectively; p < 0.007). The ratio of cortical to cancellous bone in the distracted callus was uniformly found to be greater in the experimental specimens. The mineral apposition rate was calculated by using fluorescence microscopy and found to be significantly greater in the experimental group both during the period of sequential compression and distraction (3.2 microm/day versus 2.1 microm/day, p = 0.02) and after the period of sequential compression and distraction (1.4 microm/day versus 1.1 microm/day, p = 0.006). Mechanical testing revealed no significant differences in bending strength or stiffness between experimental or control groups (p = 0.54 and 0.47, respectively). This study has demonstrated that daily alternating compression and distraction of 1 mm amplitude during the early consolidation period has a stimulatory impact on callus formation with respect to osteoblastic activity, remodeling, and maturation of bone. Optimal timing and amplitude of sequential movement, long-term biomechanical differences, and molecular pathways have yet to be elucidated.