The effects of thermal injury on immature rat ear cartilage.

The purpose of this study was to research regeneration and growing properties of an immature rat ear cartilage and its adjacent tissue after a thermal injury. Fifteen 30-day-old male Sprague-Dawley rats were used. Burn wounds were created by applying a heated plaque. All the rats, based on their tissue sampling day, were placed in two groups for histopathologic evaluation. In group I (n = 5), the burned right auricles were amputated on the first day,and the left auricles were amputated as a control at the same time. In group II (n = 10), the burned right auricles were amputated on the 30th day, and the left auricles were amputated as a control at the same time. Epithelization of skin was completed in period ranging between 12 and 15 days in all burned ears. The skin appendages were few throughout the affected area.Chondroid tissue regenerated from perichondrium and increased capillary vessels were observed.On the first day of the burn injury, electron microscopic findings were karyopyknosis, karyorrhexis, and karyolysis of the nucleus, and there were also signs of necrosis. New chondroblasts were formed around the collagen fibrils in the scar tissue on the 30th day. CD-31 immunohistochemical staining showed increased capillary vessels in the burned ear. The peripheral nerve fibers decreased and regenerative signs of nerves were shown with the use of S-100 immunohistochemical staining. Differentiation of chondroblasts to chondrocytes occurs in the burned immature ear, and new cartilage tissue regenerates from perichondrium. In addition, regenerative signs of nerves appear.

Reverse-flow retroauricular island flap in facial reconstruction.

BACKGROUND: Reconstruction of facial skin defects requires good-quality skin cover to satisfy aesthetic expectations of patient, especially when the skin defect is on the uncovered area of the face. Limitations in the available local tissue and donor-site morbidity restrict the options. OBJECTIVE: In an effort to solve these problems, we have begun to use a subcutaneous pedicled retroauricular reverse-flow flap. METHODS: Between January 1997 and December 2005, reverse-flow subcutaneous pedicled retroauricular island flap was used to cover facial defects in 12 patients who underwent surgical excision of skin tumor. The patients ranged in age from 44 to 81 years with a mean age of 58 years. RESULTS: Only one case experienced a superficial necrosis in the distal one-quarter part of the flap. The functional and aesthetic results were satisfactory for both patients and surgeons, and no tumor recurrence was observed during the 12 to 28 months (mean, 18.8 months) follow-up period. CONCLUSIONS: This flap can be used reliably for the reconstruction of facial skin defects of small and medium size. The preference of frontal branch pedicled flap enables more distal facial area defects to be covered, such as dorsal nasal, nasolabial, and upper lip, than flaps based on parietal branch.

Microvascular anastomosis with minimal suture and Arista: an experimental study.

BACKGROUND: The conventional technique of microvascular anastomosis may cause trauma to the vessel wall. In addition, the technique is difficult for beginners and is time consuming. The duration of ischemia is an important limiting factor for muscle transfer. In the case of multiple-digit replantations, fatigue developed in the surgeon may also result in suboptimal results. This study was performed to establish an easier and shorter method of microvascular anastomosis using the Arista hemostatic agent. METHODS: In this study, 20 carotid arteries obtained from rats were equally divided into two groups. The arteries were then divided and repaired using three simple interrupted stay sutures with Arista powder. Evaluations were performed using the following three methods: (1) clamping time during the vessel anastomosis, (2) patency test (after 1 hour, 24 hours, and 28 days), and (3) light microscopic findings. RESULTS: The clamping time in the conventional suture anastomosis group was 21+/-4 minutes, whereas that of the minimal suture in the Arista group was 12+/-2 minutes; the difference between the two groups was statistically significant (P<.001). There was no significant difference between the patency rates of the two groups (P= .474). It was observed that the Arista group showed qualitatively less perivascular foreign-body giant cell reaction than the control group. There was no evidence of vascular mural fibrinoid necrosis, indicating that Arista was nontoxic for the vessel walls. CONCLUSIONS: The Arista-assisted microvascular anastomosis is an alternative to the conventional suture-only method because it reduces the anastomosis time significantly and does not cause narrowing of the vessel wall. We believe that this technique has the potential for improving the performance of microvascular anastomosis in clinical practice.

The efficacy of linear polarized polychromatic light on burn wound healing: an experimental study on rats.

We aimed to investigate the questionable effect of linear polarized polychromatic light on burn wound healing in rats. Two deep second-degree burn wounds on the backside of each of 21 Sprague-Dawley rats were created with a standard burning procedure by applying a heated plaque. Burned regions located right dorsolaterally and classified as group I lesions were treated with linear polarized polychromatic light + open dressing + antibacterial pomade, whereas group II lesions were located left dorsolaterally and treated with only open dressing + antibacterial pomade. Macroscopic evaluation was performed for determination of the completed wound closure rate, measurement of burn wound area, and investigation of macroscopic edema, hyperemia, and epithelialization. Histopathological evaluation included monitoring of epithelialization, vascularization, origination of granulation tissue, inflammatory cell response, and total histopathological score on days 7, 14, and 21 after burn creation. Macroscopic evaluation revealed more obvious epithelialization in group I lesions between days 6 and 15. The number of completely closed wounds was higher in group I than in group II on days 16 and 21. The average area of burn wounds was lower from day 5, hyperemia was less on days 2 to 17, and edema was less from day 4 to day 13 in group I lesions. Histopathological evaluation revealed a higher rate of epithelialization on day 7 and higher vascularization occurrence on day 21 in group I lesions. Linear polarized polychromatic light seems to be effective in the treatment of burn wounds and in the promotion of healing. This may be related to linear polarized polychromatic light stimulation of epithelialization and vascularization.

Predictive value of 99mTc-sestamibi scintigraphy for healing of extremity amputation.

PURPOSE: Although various non-invasive procedures have been proposed to determine the optimal level of amputation of limbs in patients who have vascular disease, currently there are no consistent criteria that can be applied before surgery. The purpose of this study was to determine whether (99m)Tc-sestamibi imaging can accurately predict the healing of amputation sites. METHODS: In a prospective study in 26 patients (21 men, 5 women; age range 23-94 years) presenting with ulcers or gangrene of the foot and hand, (99m)Tc-sestamibi imaging was performed preoperatively. The indications for amputation included gangrene (23 patients), electrical injury (2 patients) and trauma (1 patient) of extremities. Although the amputation levels were chosen according to clinical criteria and scintigraphic results, the final amputation level was defined by scintigraphic results. Two below-knee, one above-knee, 12 toe, 11 transmetatarsal, two phalanx, one finger and one thumb amputations and one shoulder disarticulation were performed. In four cases, the amputation defect was not suitable for coverage using a local dermal flap; rather, it was covered with free tissue transfer. Patients had clinical follow-up for 6-36 months (mean 11.69 months) to assess healing of the stump. Scan results were compared with clinical outcome to assess prediction of healing. RESULTS: There was healing in all amputations at the end of the follow-up period. When evaluated regarding preoperative (99m)Tc-sestamibi uptake pattern, there was no perfusion to the lesion site in 21 patients and perfusion to an area smaller than the extent of skin necrosis in four patients; thus, in these 25 patients, (99m)Tc-sestamibi scintigraphy suggested non-viable tissue in the extremities with clear-cut edges of perfused muscle tissue. Diffusely decreased uptake was seen below the left knee in one case. How scintigraphy changed management was analysed. The amputation levels proposed before scintigraphy were divided into two groups, "definite" (n=14) and "indefinite" (n=12), based on visual examination and Doppler findings. In nine patients in the definite group, the proposed amputation level before scintigraphy was not altered by the scintigraphic data. However, (99m)Tc-sestamibi scan enabled unnecessarily high amputation levels to be avoided in 12 patients in the indefinite group and in five patients in the definite group. Therefore, there was change in management of 65% of cases based on scintigraphic findings. CONCLUSION: Since healing of the stump was seen in all cases, outcome was correctly predicted by scintigraphy. This preliminary study supports the use of (99m)Tc-sestamibi scan in selecting the optimal amputation level consistent with subsequent stump healing.

Spitzoid melanoma in childhood.

Spitzoid melanoma is a rare variant of melanoma. It has morphological features similar to those of Spitz's nevus. In this study, the histologic and immunohistochemical features of both Spitzoid melanoma and Spitz's nevus are emphasized. We report two cases of melanoma with spitzoid features occurring in the extremities of 9 and 8-year-old girls. Histologically both lesions had typical features of Spitzoid melanoma. We conclude that the differential diagnosis of Spitzoid melanoma and Spitz's nevus is at times problematic in childhood, in that distant metastasis may be the only diagnostic criteria for some cases to be distinguished from Spitz's nevus if strict criteria are followed. Spitzoid melanoma must be treated as other types of melanoma.

Management of the long nose: review of techniques for nasal tip supporting structures.

The long nose with a "plunging" tip is a deformity that involves an inferiorly rotated nasal tip, leading to an increase in the length of the nose. The anatomic basis of the long nose with a plunging tip may be divided into two types. Type 1 presents a normal alar-cartilage complex inferiorly displaced by a long nasal septum and long upper lateral cartilages. Type 2 is caused by a dislocation of the alar cartilages downward from the aponeurotic attachments to the septal angle. During the study period, the authors identified 60 patients with long noses and plunging tips. For 22 patients with type 1 long noses, the high septal incision technique was used in 12 cases and the step technique in 10 cases. The invagination procedure alone was used for 22 of 38 patients with type 2 plunging noses. Also, an extension graft with the invagination procedure was used for 6 patients, and a columellar strut graft was used for 10 patients. A high septal incision increased tip rotation without significantly changing the amount of tip projection. However, the step procedure, the invagination technique alone, septal extension graft with the invagination technique, and columellar strut grafts increased nasal tip rotation and projection. During the study period, 38 patients were identified as having a smiling deformity, which was improved using the authors' modification procedure. On the basis of the results, the authors recommend that the appropriate treatment for each patient with a long nose and a plunging tip must be determined by preoperative and intraoperative examination findings with the patient at rest and while smiling.

Review of monitoring free muscle flap transfers in reconstructive surgery: role of 99mTc sestamibi scintigraphy.

BACKGROUND: Free tissue transfer is a method of moving any tissue from a donor area of the body to a recipient site and re-attaching the arteries and veins to the blood vessels at the recipient site by microvascular surgery. Improved microsurgical techniques have resulted in a high percentage of successful free tissue transfers. Post-operative monitoring of tissue viability can detect early problems in free tissue transfer which may allow early intervention and salvage. Although many flap monitoring methods have been described, there is still no consensus on which of these techniques will become the standard accepted method for monitoring free muscle flaps. OBJECTIVE: In present study, we investigated the use of 99mTc sestamibi scintigraphy in determining free muscle flap viability and complications, and also in directing treatment. METHODS: Thirteen patients were examined prospectively during the post-operative period after free tissue transfer for foot defects. The cause of the defect was diabetic foot ulcer in 10 patients, dermatofibrosarcoma in one patient, squamous cell carcinoma in one patient and gunshot wound in one patient. Foot defect covering was carried out with a free latissimus dorsi muscle flap and skin graft (n=12) and a free gracilis muscle flap (n=1). All patients were examined with a monitoring system that consisted of visual inspection, hand-held Doppler ultrasonography and scintigraphic examinations. Scintigraphic imaging of all cases was performed routinely within the first 48 h post-operatively, and also on days 10 and 91 in two patients. RESULTS: There were four flap failures during the study. One of these patients had viable findings upon visual inspection and no evidence of vascular compromise on Doppler at the first examination. In the other patient, visual inspection of the flap showed that it was ischaemic in one region, but there was no vascular compromise on Doppler examination. Scintigraphic images of each of these patients showed a partial hypoperfused area in the flap region. Later, these two flaps showed positive clinical indications of hypoperfusion (colour of muscle and appearance of skin graft) and Doppler abnormalities. The remaining two patients had non-viable scintigraphic images as well as positive clinical indicators of hypoperfusion and evidence of vascular compromise on Doppler. Nine patients each had a viable flap. In these patients, all three examination tools demonstrated that the flaps were totally viable and there were no vascular complications. CONCLUSION: According to the results of this study, 99mTc sestamibi scintigraphy appears to be a feasible and promising method in the evaluation of free muscle flap viability and complications. On the other hand, to demonstrate any impact on management or patient outcome, further evaluation of 99mTc sestamibi imaging, including comparative studies with different established methods in a larger patient population, is highly recommended.

A new approach to smiling deformity: cutting of the superior part of the orbicularis oris.

A diagnosis of an aesthetic smiling deformity, which is functional rather than anatomic, is essential for provision of the best treatment in rhinoplasty. Smiling deformity consists of three elements: (a) the nasal tip tending to retrodisplace and rotate inferiorly; (b) the lower part of the upper lip moving superiorly; and (c) a horizontal groove occurring in the midphiltral area. An active depressor septi and orbicularis muscle can accentuate a drooping nasal tip and shorten the upper lip during smiling. Downward movement of the nasal tip and a sharper nasolabial angle usually are aesthetically unpleasant. During the study period (January 2000 to January 2004), the authors identified 38 patients with smiling deformities, 16 of whom underwent dissection and transposition of the paired depressor septi during rhinoplasty. The remaining 22 patients experienced hyperactivity of both the depressor septi and orbicularis muscles, as diagnosed by a descending nasal tip and a shortened upper lip at animation. These patients underwent a modification of the depressor septi and orbicularis muscles. No relapse was evident up to 2 years postoperatively. Repositioning of the depressor septi nasi muscle improved only mild cases. However, modification of the orbicularis and depressor septi muscles was a valuable adjunct to rhinoplasty for moderate and severe forms of smiling deformity. The new approach for smiling deformity provided an aesthetically pleasant appearance for the patient both at rest and when smiling.

Distally based sural flap in treatment of chronic venous ulcers.

The treatment of venous ulcers of the leg often fails to heal because venous ulcers are mostly associated with severe lipodermatosclerosis. These complicated ulcers may require correction of local hemodynamics, excision of ulcer with surrounding lipodermatosclerotic skin, and replacement of the defect with healthy tissue. We present our experience with the use of the distally based sural flaps for the reconstruction of soft-tissue defects of the distal region of the lower limb in patients with chronic venous ulcer. Between 2001 and 2003, 12 patients with venous ulceration were treated with distally based sural flaps. At operation, the ulcer and its surrounding lipodermatosclerotic skin were excised. The defects after excision ranged from 3 x 3 to 11 x 17 cm. The distally based sural artery flap was inset within the defect. In all patients, the flap survived completely, and in only 1 patient, distal venous congestion was seen and was treated successfully with leeches. There was donor site skin graft loss in 2 patients. Two flaps had minor local complications that healed with local wound care. No recurrent ulcers were identified after average 19.7 months. In conclusion, the distally based sural flaps can be used reliably for treatment of venous ulcers. Our approach in treatment of chronic venous ulcers improves venous hemodynamics and provides local flap alternative that should be considered prior to a free-flap transfer for closure of the defect.

Salivary duct carcinoma of the parotid gland metastasizing to the skin: a case report and review of the literature.

Salivary duct carcinomas of parotid gland are rare, as are the skin metastases from them. Four cases are reported with metastases to the skin. We present an additional case, with subcutaneous metastases of the back and leg. To our knowledge, this is the first case reported in the literature in which the nodule on an extremity was the metastasis of a salivary duct carcinoma of parotid gland.

The fate of intramuscularly injected fat autografts: an experimental study in rabbits.

An experimental study was designed to assess the viability and revascularization of intramuscularly injected fat autografts. For the study, 18 rabbits were divided into two groups. In the first group, fat was injected intramuscularly (12 rabbits). Autologous fat was obtained from the inguinal area and subsequently injected into the thigh muscle. In the second group, physiologic saline was injected intramuscularly to determine the effects of cannulation and pressure on muscle tissue (6 rabbits). Fat autografts were performed on the right side of the animal, and the left side was used as the control. Scintigraphic imaging and histopathologic examination of the limbs were performed after injection of adipose tissue on days 15, 30, 45, 60, 90, and 120. On the technetium-99m ((99m)Tc) hexamethylpropylene amine oxime scintigraphy, whereas similar activity distribution was observed between the left and right thigh on days 15, 30, and 45, there was increased uptake at the right thigh on days 60, 90, and 120. This increased uptake indicates that there is viable fat tissue in this region. Histopathologic evaluation showed that microcysts resulting from degeneration of some adipocytes and inflammatory changes on day 15 additionally increased vascularity and fibrosis in some animals on day 30, as well as fibrosis, microcysties, and focal calcification areas in adipose tissue on day 45 and later. It was observed that adipose tissue survived in more than 50% of the graft area in all the animals. These findings show that fat autografts can survive in muscle tissue with less than 50% fibrotic change.

Combined 99mTc MDP bone SPECT and 99mTc sestamibi muscle SPECT for assessment of bone regrowth and free muscle flap viability in an electrical burn of scalp.

A case of deep high energy electrical burn of the skull is presented. For assessment of bone regrowth and muscle flap viability after application of latissimus dorsi free flap, combined 99mTc MDP bone SPECT and 99mTc sestamibi muscle SPECT scintigraphy were used. Whereas 99mTc MDP bone SPECT showed absent uptake at the beginning, there was good uptake 3 months after flap application. 99mTc sestamibi SPECT revealed good uptake indicating normal perfusion of flap muscle tissue.

Molding the ears after anterior scoring and concha repositioning: a combined approach for protruding ear correction.

The goal of otoplasty for correction of prominent ears is normalization of shape and position of both pinnas with a certain symmetry. Recreating the antihelical fold and lowering the auriculocephalic angle are the basic processes for achieving a normal-looking ear. Various methods have been described to recreate the antihelical fold. In addition to anterior scoring or abrasion, many involve placement of permanent or absorbable sutures to reform the cartilage to proper shape to correct the deformity. In this study the use of a custom-made silicone mold was described after anterior scoring to recreate the antihelical fold, without using any suture material. Silicone molds provide good shaping of the antihelical fold, scapha, and helical rim while the tissue is healing. Fourteen patients underwent bilateral otoplasty for prominent ears in our clinic over a four-year period. The anthelical fold was created by anterior scoring and the concha-mastoid angle lowered and sutured. After completing the surgical procedure for both ears, custom-made silicone molds were worn by the patient for the first two weeks to maintain proper position. The third week, the patient wore the mold half a day. A head dressing was used for two days and the ears were subsequently supported using a headband. Follow-up ranged from fourteen months to four years. One patient developed a postoperative hematoma in one ear that resorbed spontaneously. Patient satisfaction with the procedure was generally high. Using a shape mold after a combination of anterior scoring and concha repositioning gives predictable results with a natural-looking ear.

Utility of 99mTc dextran scintigraphy in diabetic patients with suspected osteomyelitis of the foot.

PURPOSE: Osteomyelitis of the foot is a frequent complication of diabetes mellitus and its diagnosis is often difficult. The goal of this study was to demonstrate the utility of 99mTc dextran scintigraphy in suspected diabetic foot infections. MATERIALS AND METHODS: Twenty-six patients (20 males, 6 females, age range 18-80 years) with diabetes mellitus who had a total of 36 foot ulcers or necrosis were studied. All the patients underwent both three phase bone scan and 99mTc dextran scintigraphy. Final diagnosis was based upon either pathologic examination or clinical follow-up at least four months. RESULTS: On bone scan increased uptake was seen in 55 sites, and among these there were 11 lesions of proven osteomyelitis. There were 11 true-positive, 0 false negative, 0 true negative and 44 false positive results for bone scan. The sensitivity, specificity and accuracy of bone scan were 100%, 0% and 20%, respectively. With regard to 99mTc dextran scan, nine lesions produced true-positive results with two lesions indicating false negatives resulting in a sensitivity of 82%. Thirty-six true negative and eight false positive results produced a specificity of 82%, and an accuracy 82% from 99mTc dextran studies was obtained. Eight false-positive results were possibly due to neuroarthropathy, pressure points and deep penetrating ulcers. A patient with one false-negative result had angiopathy while other had neither neuropathy nor angiopathy. CONCLUSIONS: According to these results, 99mTc dextran scintigraphy seems to be a sensitive and specific diagnostic method, and because of its advantages over other radiopharmaceuticals (shorter preparation time, highly stability in vivo/in vitro, early diagnostic imaging and low cost), it may be a radiopharmaceutical of choice for diagnosing in diabetic foot infections.

Imaging of frostbite injury by technetium-99m-sestamibi scintigraphy: a case report.

The appearance of superficial tissue is often an unreliable indicator of deep-tissue viability in cases of frostbite. We present a 34-year-old black man who was brought to the emergency department at fourth post-injury day with frostbite injury involving both lower extremities after prolonged exposure to subzero temperatures. In our previous experimental study, 99mTc sestamibi scintigraphy has been employed for evaluating frostbite injuries in rabbit hindlegs. In the case presented, 99mTc sestamibi scintigraphy, as a new diagnostic tool, was performed for detection of skeletal muscle perfusion on the fourth post-injury day. The scintigraphic images show diffusely reduced uptake in soft tissues of both calves and feet. It was thought that this hypoperfusion was due to viable but ischemic tissue. Five days after medical therapy, 99mTc sestamibi scan showed prominently increased uptake in both calves and feet and skin necrosis was observed. Debridement of necrotic skin and subcutaneous tissue was performed, and split-thickness skin graft was applied for coverage of the skin defect. Healing was good 15 days after grafting. We think 99mTc sestamibi scan can be used for assessment of soft-tissue perfusion and evaluation of treatment in frostbite injury.