Hyaluronic Acid Dermal Filler Promotes Cartilage Reshaping in Rabbit Ears.

BACKGROUND: Neonatal ear is more malleable and soft, allowing the correction of deformities by using external molding. This is mainly attributed to high concentration of the proteoglycan aggregate and hyaluronic acid. In this study, HA dermal filler was injected in rabbit ear as a long acting HA source to investigate the biological impact of HA in reshaping the ear cartilage. MATERIALS AND METHODS: Ears of twelve rabbits were divided into 4 groups. Control group was the left ears of 6 animals which were left intact. Group 2 was the right ears of the same animals, which received saline solution injection. Group 3 was the left ears of the other 6 animals, which were given 1 mL of HA. Group 4 was the right ears of them, which were given 2 mL of HA in both sites of the ear. All ears were folded and splinted for 4 weeks. Then, the angle of each ear was calculated. Following an additional 4 weeks, a cartilage biopsy was taken for histological examination. RESULTS: The ear angles did not show any statistical difference at week 4. There was a significant difference among the groups at the 8th week. In the 3rd and 4th groups, mean angles were higher than the group 1 and group 2. Thickening in the cartilage and ectopic cartilage formation was observed in the contact areas to hyaluronic acid. Significant difference was also found between the peak and mean cartilage thicknesses. CONCLUSION: HA dermal filler can stimulate cartilage regeneration by increasing the synthesis of extracellular matrix and chondrogenesis especially where it is in direct contact with the ear cartilage. 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 .

Three-Dimensional Tarsal Plate Reconstruction Using Lower Lateral Cartilage of the Nose.

BACKGROUND: Many types of graft tissue have been used to reconstruct the posterior lamella of the eyelids in cases of full-thickness defect, lid retraction, and loss of lower lid stability. In this study, lower lateral cartilage of the nose was used for the reconstruction of posterior lamella of the eyelids, which mimics the tarsal plate in shape, thickness, and size. MATERIAL AND METHODS: This study included 10 patients who underwent lid reconstruction to support tarsal plate strength and repair full-thickness defects of the eyelids due to tumor excision and trauma. While anterior lamella was reconstructed with local or regional flaps, posterior lamella was repaired by using either chondromucosal or chondral graft of the lower lateral cartilage of the nose. Graft harvesting was performed on the inner surface of the alar rim by turning it inside out. RESULTS: Cartilage grafts were sufficient to reconstruct the tarsal plate in all of the patients having eyelid defects of various sizes. In 3 patients, horizontal half of the eyelid was defective, in 3 patients 3/4, and in 2 patients 4/5 of the lids were missing. The inferior eyelid was totally reconstructed in 1 patient. Surgical outcomes provided good lid symmetry and esthetics, patient satisfaction, and proper lid function without any nasal deformity, incision scar, or discomfort. CONCLUSIONS: Ala graft provides a thin, pliable, and curved cartilage for the eyelid reconstruction. It has a high similarity with the anatomy of the tarsal plate, making it adaptable to the convex surface of the eyeball, and making 3 dimensional repair possible.

Reconstruction of Extensive Periorbital Defects With Pericranial Flap.

ABSTRACT: Wide excision of recurrent malignant tumors of periorbital region leaves deep and large composite defects, requiring a reconstruction to restore both the form and function of the eyelids. In this study, a pericranial flap was utilized in the reconstruction of large, complex defects of periorbital region.This study included 5 patients who underwent wide excision of recurrent large medial canthus and supraorbital rim malignant tumors. All defects involved the medial parts of eyelids including medial canthal ligaments, nasal walls, periosteum, and medial orbital walls. Defects were reconstructed via a pericranial flap, which was facilitated by the natural concavity and the acute angled nature of the medial canthus.The pericranial flap is not only a versatile alternative to the local or regional flaps in the reconstruction of periorbital defects, but also has the advantages of availability of abundant amount of flap tissue.

Lavage With Lidocaine and Adrenaline Mixture Reduces the Early Side Effects of Septorhinoplasty.

BACKGROUND: Pain, ecchymosis, and edema are well-known temporary consequences of septorhinoplasty procedure. They give rise to patient's complaints, discomfort, and dissatisfaction, increasing the patient's anxiety and recovery time in the early postoperative course. Several approaches have been described to reduce the level of these complaints.The aim of this clinical study was to determine the effect of nasal lavage with lidocaine and adrenaline mixture on early postoperative levels of pain, edema, and ecchymosis in 24 hours after a septorhinoplasty procedure. METHODS: This study included 40 consecutive patients who underwent septorhinoplasty procedure in which nasal septum was entirely dissected and corrected. Patients were randomly divided into 2 groups of 20 patients. At the end of the operation, incisions were closed with sutures, and both blood and seroma collections beneath the flaps were sufficiently drained by means of finger pressure, and then in patients of group A (control group), 5 mL of saline solution was given under the dorsal nasal flap to make lavage and in patients of group B (study group), 5 mL of 2% lidocaine with 1:100,000 adrenaline was given to the area under the dorsal nasal flaps. Five minutes later, nasal package and splint were applied and the operation was finished.Patients were evaluated for the level of pain sensation, degree of periorbital edema, and ecchymosis at the 1st, 3rd, 6th, 12th, and 24th hours postoperatively. Overall satisfaction scores were also determined at the 24th hour. RESULTS: A total of 40 patients (19 males and 21 females) between 18 and 42 years of age with a mean ± standard deviation of 24.5 ± 4.52 years were included in the study. Statistically significant differences were found between the A and B groups with regard to early postoperative pain, edema, ecchymosis, analgesic use, and satisfaction scores, suggesting the effectivity of the lavage with lidocaine-adrenaline mixture on the early postoperative pain, edema, and ecchymosis relief. CONCLUSIONS: Lavage of nasal flaps with lidocaine-adrenaline mixture seems an effective and simple way in the control of early postoperative pain, edema, and ecchymosis in septorhinoplasty patients. In addition, it considerably reduces total analgesic consumption and patients' discomfort, leading to high level of satisfaction.

A Rare Cause for Recurrent Implant-Related Inflammation of Orbit: Dacryocystitis.

Ultra-thin porous polyethylene has been widely preferred in orbital blow out fracture repair for many years as a safe and stable material. Delayed complications related to the implant in orbital blow out fracture repair are very rare and usually begin as a periorbital inflammation. Infections and tissue reaction to the foreign body are regarded as main causes for implant-related inflammation of which symptoms may vary among the patients and may involve subacute and chronic eyelid swelling, skin redness, pain, conjunctival injection, proptosis, and acute orbital inflammation.Presented here is a patient of recurrent periorbital inflammation who underwent orbital floor repair with ultra-thin porous polyethylene sheet which was complicated by dacryocystitis in the late follow-up period.

Otoplasty with an unusual cartilage scoring approach.

BACKGROUND: An ideal otoplasty procedure should minimise the possible risk of severe complications of otoplasty and provide a good aesthetic outcome; however, there is no standart technique to be applied to all types of auricular deformities in different populations. The aim of this study was to present an otoplasty technique with posterior approach in which small incomplete cartilage incisions and suture fixations were used to form the auricle without a need for anterior skin incision and dissection. METHODS: This study involved 42 patients who had bilateral prominent ears with unfurled antihelixes associated with or without conchal excess. The otoplasty procedure mainly consisted of a posterior skin excision, incomplete cartilage incisions in the shape of greater mark, ">", mattress sutures of the posterior cartilage, earlobe correction, and conchal reduction if necessary. RESULTS: This otoplasty technique consists of easy, simple, and rapid surgical steps without a need for anterior skin dissection and cartilage scoring, so it has a low rate of complications in both early and late postoperative periods. Follow-up time of patients ranged from 1-9 years, with an average of 3 years. No major complications such as haematomas, chondritis, wound infection, skin necrosis, asymmetry, recurrence, hypertrophic scars, granulomas, or irregularities developed in the early and late postoperative periods. A good symmetry and natural appearence were achieved with this otoplasty technique. Patients were satisfied with the results. All over complication rate in the postoperative period was 7%. CONCLUSION: The presented technique overcomes the drawbacks of anterior skin dissection and anterior scoring, and minimises the risk of severe complications such as anterior skin necrosis, cartilage necrosis or destruction, and ear irregularities. It also reduces the operation time, swelling, bruising, and possibility of suture extrusion and recurrence.

Repairing post burn scar contractures with a rare form of Z-plasty.

BACKGROUND: Although many precautions have been introduced into early burn management, post burn contractures are still significant problems in burn patients. In this study, a form of Z-plasty in combination with relaxing incision was used for the correction of contractures. METHODS: Preoperatively, a Z-advancement rotation flap combined with a relaxing incision was drawn on the contracture line. Relaxing incision created a skin defect like a rhomboid. Afterwards, both limbs of the Z flap were incised. After preparation of the flaps, advancement and rotation were made in order to cover the rhomboid defect. Besides subcutaneous tissue, skin edges were closely approximated with sutures. RESULTS: This study included sixteen patients treated successfully with this flap. It was used without encountering any major complications such as infection, hematoma, flap loss, suture dehiscence or flap necrosis. All rotated and advanced flaps healed uneventfully. In all but one patient, effective contracture release was achieved by means of using one or two Z-plasty. In one patient suffering severe left upper extremity contracture, a little residual contracture remained due to inadequate release. CONCLUSION: When dealing with this type of Z-plasty for mild contractures, it offers a new option for the correction of post burn contractures, which is safe, simple and effective.

An easy, rapid, and reproducible way to create a split-thickness wound for experimental purposes.

Partial-thickness wound models of rat skin have some difficulties in creating the wounds in equal size and depth. Moreover, making a split-thickness wound on the rat skin seems not to be simple and rapid. A new alternative method was presented here to overcome these obstacles, by using a waterjet device to create a split-thickness wound on rat skin. Twenty-four male Wistar rats were randomly divided into 3 groups. An area of 4 × 4 cm in diameter was marked on the center of the dorsal skin. Waterjet hydrosurgery system was used to create a wound on the dorsal rat skin, by removing the outer layers of the skin. In group 1, rat skin was wounded with setting 1 to create a superficial skin wound. In group 2, it was injured with setting 5 to make a deeper wound, and in group 3, skin wound was performed with setting 10 making the deepest wound in the experiment. After the wounds were created on the rat skin, a full-thickness skin biopsy was taken from the middle of the cranial margin of the wound, including both the wound surface and the healthy skin in a specimen. Healing time of the wounds of animals was recorded in the experiment groups. Then, the results were compared statistically between the groups. In the histologic assessment, both the thickness of the remnant of the epidermis in the wound surface and the thickness of the healthy epidermis were measured under light microscope. Thickness of the epidermis remaining after wounding was statistically compared among the groups and with the healthy epidermis. The mean thickness of the remaining epidermis was determined for each group. It was higher in the superficial wounds than in the deep wounds, because of the removal of the skin from its outer surface through the deep layers of the skin with waterjet device. The most superficial wound in the experiment was observed in group 1, which was statistically different from the wounds of group 3, whereas there was no difference between the wounds of groups 1 and 2. Compared with the wounds of groups 1 and 2, the wounds in group 3 were significantly deeper than the wounds of other groups, which was statistically significant. In all groups, mean thickness of epidermis in the wound surface showed statistically significant difference from that in the healthy skin. When compared with the healing times of the wounds in the groups, a statistically significant difference was found between them. Creation of a split-skin wound, by using the waterjet system, provides a wound in reproducible size and depth, also in a standardized and rapid manner. Moreover, it makes precise and controlled wound creation in the rat skin.

The effect of topical minoxidil pretreatment on nonsurgical delay of rat cutaneous flaps: further studies.

UNLABELLED: The purpose of this study was to determine the effectiveness of topically applied minoxidil in the pharmacological delay phenomenon and to demonstrate the comparable microscopic and macroscopic changes between minoxidil-pretreated flaps and surgically delayed flaps. A modified version of the McFarlane flap was used. Group 1 rats, in which a caudally based dorsal skin flap was raised and sutured back, were the control group. In group II, minoxidil solution was spread over the marked skin flap area for 7 days. On the 7th day, a caudally based dorsal skin flap was elevated and then sutured back. Group III rats underwent a surgical delay procedure alone. On the 7th day after flap elevation, evaluation was done by histologic examination and calculation of the flap survival areas in all groups. The lowest flap survival rate appeared in group I and was statistically different from groups II and III. The mean surviving skin flap area in the minoxidil-pretreated group was significantly larger than that in the control group. After histologic evaluation, moderate angiogenesis was also detected in group II. We also found that surgical delay significantly reduced flap necrosis when compared to the minoxidil pretreatment group. According to our study, minoxidil may be considered an effective vasoactive agent for the stimulation of angiogenesis in rat cutaneous flaps and capable of achieving pharmacological delay and increasing flap survival. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

A versatile modification of dermoglandular hammock flap for mastopexy: extended hammock.

Breast ptosis commonly develops in response to ageing and breastfeeding. Clinical studies now focus on both filling the upper pole of the breast with parenchymal flaps and long-term maintenance of the breast projection without recurrence of upper pole concavity and a significant change in breast shape over time. This study presents a modification for a well-known mastopexy technique, the dermoglandular hammock flap, which provides not only autoaugmentation for the breast but also suspension for the breast parenchyma. This technical modification involving a hammock flap extended in both width and length dimensions, was performed in 17 patients aged 28-43 years with an average age of 31 years. They had minimal, moderate, and severe ptosis. Of these, eight patients had mastopexy only without needing any resection of the breast tissue. In four patients, there was significant asymmetry, needing excision of the breast tissue. In five patients, it was necessary to resect less than 290 g of glandular tissue from both breasts to provide enough reduction of the breast volume. There were no severe complications either in the early or late postoperative period, such as nipple-areolar necrosis, haematoma, infection, or dehiscence of the suture line. However, in one patient, skin depression developed at the end of the vertical scar line in one breast. In the follow-up, medial and upper pole fullness of the breast maintained without recurrence of the ptosis, providing satisfactory shape and projection. With this modification, dermoglandular suspension flap turns to be a more effective procedure and suitable for all types of ptosis. As the sagged lower pole of the breast is used as a flap behind the nipple-areola complex and upper pole, it makes not only parenchymal reposition, but also autoaugmentation in the breast, leading to successful breast fullness.

Management of scar contractures of the hand using Z advancement rotation flap.

Functional consequences of hand contractures may lead to extreme impairment in hand functions so repair of the contractures can solve the problems related to hand functions. Different forms of z plasties have widely been used for the release of scar contractures. In this study, a useful z plasty technique, z advancement rotation flap (ZAR) was adapted for the release of hand contractures in the way of using only local tissues. Fourteen consecutive patients who had hand contractures, were treated successfully with z advancement rotation flap technique. They suffered from hand contractures for at least one year which were localized in wep spaces, flexor surfaces of the digits, first wep space, palmar area and extensor surface of the hand. Contractures are all in mild severity, restricting some of the hand motions moderately. In all patients, hand contractures released completely and clinically normal joint motions were achieved, improving extension, flexion and abduction ranges of fingers without any difficulty. All advanced and rotated flaps healed uneventfully. No major complications appeared such as infection, hematoma, suture dehiscence, flap congestion or necrosis. When dealing with this technique for release of hand contractures, it may offer a versatile alternative to well known z-plasty methods used particularly for hand contractures.

Effect of topically applied minoxidil on the survival of rat dorsal skin flap.

BACKGROUND: Flap necrosis still is a challenging problem in reconstructive surgery that results in irreversible tissue loss. This study evaluated the effect of topically applied minoxidil on angiogenesis and survival of a caudally based dorsal rat skin flap. METHODS: For this study, 24 male Wistar rats were randomly divided into three groups of eight each. A caudally based dorsal skin flap with the dimensions of 9 × 3 cm was raised. After elevation of the flaps, they were sutured back into their initial positions. In group 1 (control group), 1 ml of isotonic saline was applied topically to the flaps of all the animals for 14 days. In group 2, minoxidil solution was spread uniformly over the flap surface for 7 days after the flap elevation. In group 3, minoxidil solution was applied topically to the flap surface during a 14-day period. On day 7 after the flap elevation, the rats were killed. The average area of flap survival was determined for each rat. Subdermal vascular architecture and angiogenesis were evaluated under a light microscope after two full-thickness skin biopsy specimens had been obtained from the midline of the flaps. RESULTS: The lowest flap survival rate was observed in group 1, and no difference was observed between groups 1 and 2. Compared with groups 1 and 2, group 3 had a significantly increased percentage of flap survival (P < 0.05). Intense and moderate angiogenesis also was observed respectively at the proximal and distal areas of the flaps in group 3. CONCLUSIONS: The results of this experiment seem to show that the early effect of minoxidil is vasodilation and that prolonged use before flap elevation leads to angiogenesis, increasing flap viability. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Vascular pressure monitorization for necessity of vascular augmentation in a rat extended abdominal perforator flap model.

In case blood perfusion compromises, vascular enhancement with arterial supercharge or venous superdrainage can increase viability of the flap. In this study, vascular pressure monitorization was used in a rat extended abdominal perforator flap model to reveal intraoperative vascular compromise and the need for vascular augmentation. A rat abdominal perforator flap was designed, which was based on the right second cranial perforator of epigastric artery. Vascular pressures of the flap were monitored continuously for 60 min, by catheters placed in the right superficial inferior epigastric artery and vein. Forty rats were divided into four experimental groups, as follows: group 1 (n = 10, no vascular augmentation), group II (n = 10, arterial supercharge), group III (n = 10, venous superdrainage), and group IV (n = 10, arterial and venous augmentation). Arterial supercharge and/or venous superdrainage were performed by using the left superficial inferior epigastric artery and vein. After the rats were sacrificed on the 7th day, total flap area and necrotic regions were evaluated. Mean arterial blood pressure was found significantly lower (P < 0.05) and mean venous blood pressure was measured significantly higher (P < 0.05) in group I than the groups II, III, and IV. Flap survival area was also larger in the groups II, III, and IV than the group I (P < 0.05). The results of this experimental study demonstrate that arterial insufficiency and venous congestion are almost always present in the rat extended abdominal perforator flap model, similar to deep inferior epigastric perforator flap. When such an extended perforator flap is used, arterial and venous pressure monitorization may be considered as a tool to support intraoperative clinical findings to reveal the need of vascular augmentation and ascertain flap viability.

Difficulties with running V-Y plasty in releasing burn scar contracture.

BACKGROUND: Many approaches to the release of burn contracture have been described. Each offers some advantages for the treatment of contractures, but they have some limitations affecting their indications and outcomes. In this study, we attempt to describe clearly the difficulties with running V-Y plasty after our experience with this technique. METHODS: This study included 21 patients with scar contracture. Preoperatively, for marking the flaps, a zigzag line, the angles of which were kept in the range of 60-90°, was drawn over the contracture line. The incision was firstly made into the skin to avoid retraction of the flaps, and then deep through the fascia, making advancement of the V flap easy by sliding. The V flap was advanced along the long limb of the Y on the base of a subcutaneous pedicle. After meticulous hemostasis, all incisions were sutured. RESULTS: In most of the patients, successful release of the contracture was achieved without any complication. However, in a few cases, some challenging problems developed, suggesting possible limitations of the running V-Y plasty procedure. CONCLUSION: When considering running V-Y plasty for the release of contracture, awareness of the related difficulties will be helpful and will facilitate selection of the cases suitable for the procedure to achieve successful results and avoid possible complications.

Vacuum-assisted closure of perineal war wound related to rectum.

INTRODUCTION: Vacuum-assisted wound closure therapy has widely been used in various clinical applications with successful results and has considerably increased in popularity over the past decade. The patient who sustained a complex war wound to his perineum has been presented. METHODS: After the initial treatment he was discharged from the hospital in which he had been treated for 4 days in Iraq. On the examination, all wounds were deeply contaminated with foreign bodies and also involved significant volume of devitalized tissue. Perineal injury had not only caused a large skin defect but also left a deep wound leading to rectal perforation, so the wound and its borders were quite contaminated and infected by rectal contents. After improving his general condition with medical treatment, he underwent an immediate operation in which first a colostomy was performed and then the wound tract placed between perineum and rectum was sharply and extensively debrided to viable-appearing bleeding tissue to remove the whole necrotic tissues, foreign bodies, cloths, and debris. At the end of the intervention, a negative pressure dressing was applied and used during 12 days and then completed. RESULTS: The wound tract obliterated entirely without permitting any leakage of rectal contents, and wound bed appeared clean, granulated, contracted, and viable enough for definitive closure with flap mobilization. CONCLUSIONS: When dealing with this experience presenting an unusual wound that was in a very difficult area of the body for the treatment, perineum, caused from a challenging reason, war injury, and also was complicated with rectal injury, the technique seems to have a significant beneficial effect on the healing of complicated wounds such as in perineal wound and war wound, even if these are at risk of severe infection and progressive tissue necrosis.

A new sclerotherapy technique for the wrist ganglion: transcutaneous electrocauterization.

Ganglion, a cystic benign mass, most common soft tissue tumor of the hand, usually occurs in hand, wrist, and foot. In this study, we discuss a new sclerotherapy technique through which 17 patients with wrist ganglion were treated by using short bursts of high-frequency low voltage electrodessication delivered through a fine electrode that was inserted into the sac. Their ages varied from 28 to 52 with an average of 32.7 years. Two patients had volar wrist and 15 others had dorsal ganglia. In all patients, an ultrasound imaging was done for the discrimination of the other hand tumors. Under aseptic conditions, first ganglion was aspirated by using a large needle, which was commonly used for peripheric venous catheterization, and 0.5 mL of 1% xylocaine was injected into the cystic cavity, then electrocauterization was done. In the postoperative follow-up ranging from 6 to 29 months, 1 recurrence developed 3 months after the intervention, requiring the same procedure to overcome it. No complication occurred and all complaints of the patients resolved with this approach. The present technique is simple, safe, effective, and inexpensive for ganglion sclerotherapy, resulting in hopeful outcomes to become as an acceptable alternative to the open surgery.