Improved Neurotization in High Peripheral Nerve Injury: Side to Side H-shaped Nerve Graft at the Most Distal Part of an Injured Extremity in a Rabbit Model.

Background: We aimed to investigate the effects of nerve repair by setting a side-to-side (H-shaped) nerve graft on the most distal part of the damaged nerve to the adjacent intact nerve to accelerate its regeneration in the end organ. Methods: This pure experimental study was done on the lower extremities of two groups of rabbits in Animal Laboratory Department, 15 Khordad Hospital Tehran, Iran. In both groups, the sciatic nerve at the proximal part of the extremity below the superficial femoral branch was first cut and then repaired. In the investigation group, side-to-side H-shaped nerve grafts were applied between the sciatic and superficial femoral nerves (i.e., two branches) at the most distal to the cut site of the sciatic nerve below the superficial femoral branch at the lower extremity. The sciatic nerve was conventionally repaired in the control group. Results: None of the rabbits' feet in the control group respond to pain stimulation (were without senses) and had ulcers. They had numb legs and went lame. All had muscular atrophy and lacked nerve growth (regeneration) according to pathology. In the investigation group, 86.7% of the rabbits responded to pain stimulation and only 13.3% of them had ulcers. In addition, in pathology report, 13.3% had suffered muscular atrophy and lacked nerve regeneration. Therefore, nerve regeneration was successful in 86.7% of rabbits who underwent H-shaped nerve grafts. Conclusion: Side-to-side H-shaped nerve graft at the most distal part of an injured nerve may cause successful recovery of high (proximal) nerve injury.

The Road Less Traveled: The Marham National Health Institute's Journey on Cleft Lip and Palate Surgery Missions.

Congenital cleft lip and palate represent the prevailing craniofacial birth anomalies on a global scale. Notably, a substantial proportion of patients within remote regions of Iran defer corrective surgery until later stages of life, often in childhood or adulthood, primarily due to intricate financial and cultural constraints. In response to this pressing healthcare challenge, a dedicated collective of volunteer plastic surgeons was established in 2009 with the explicit aim of providing medical care to these underserved patients. Over the subsequent years, this compassionate team embarked on 31 meticulously planned missions to underprivileged areas scattered across the country. Through these organized endeavors, a remarkable total of 20,579 medical visits were conducted, coupled with the performance of 2,303 essential surgeries, thus offering a lifeline of healthcare to these disadvantaged individuals.

Introducing a New Technique for Correcting Nasal Soft Tissue Triangle Deformity Using a Modified Fine Graft (Cartilage Graft) and Evaluating Its Effect on Deformity Correction: A Prospective Study.

Background: The management of deformities of the nasal soft triangle (ST) is a difficult and very sensitive discussion in rhinoplasty. So far, the standard method for correcting these deformities has yet to be introduced. We aimed to introduce a new technique using modified fine graft (MMG) for correcting nasal ST triangle deformity and evaluate the effects of using this method. Methods: This prospective study was conducted on 20 rhinoplasty candidates who underwent surgery at 15 Khordad Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran between August 2021 to the February 2022 with the new technique of using an MMG to correct nasal ST triangle deformities. Follow-up was performed immediately after surgery, 3 and 6 months after surgery. Post-operative findings included ST deformity correction, graft exposure, graft visibility, recurrence rate, and the need for revision were evaluated by photography for all patients. Results: The mean age of patients was 33.65± 11.047 years, 85% of the cases were female and 90% of surgeries were primal rhinoplasties. The ST triangle deformity was not corrected in 2 cases (10%). Both patients were women with primary rhinoplasty, and cartilage was removed from the septum in both. Graft exposure, recurrence, and visibility were not reported in any cases. Conclusion: MFG was highly effective in correcting the deformity of the nasal ST triangle and did not cause serious complications in patients. This method is a suitable method with high efficiency for correcting nasal ST triangle deformity.

Two Forehead Flaps for Nasal Reconstruction of a Patient with Arhinia.

Complete or total arhinia, in which nasal soft tissue is absent, is an extremely rare disease. The embryological origin of the defect is thought to be the maldevelopment of paired nasal placodes. In this article, we introduce nasal reconstruction with two forehead flaps. The reconstruction was done with two forehead flaps in a 20-year-old male patient with arhinia. Using one frontal flap of the forehead as the inner layer and the other one as the outer layer. The postoperative care was uneventful. He was able to breathe through the nose. No chest pain or any difficulty was mentioned in daily activities. The principal advantage of this technique over previous techniques is that the operation is performed in two stages and at the end of the procedure the patient has the final shape of the nose and is able to breathe normally. Furthermore, this technique could be performed for all age groups.

Impact of COVID-19 pandemic on plastic surgery activities and residency programs in a tertiary referral centre in Iran.

Background: On March 11, 2020, the World Health Organization (WHO) announced the COVID-19 outbreak as a new pandemic. In the meantime, plastic surgeons postponed their appointments due to the fair and rational allocation of medical supplies. These limitations made all junior and senior residents perform operations only on traumatic patients rather than those needing reconstructive procedures. This study aims to determine the effects of the COVID-19 pandemic on plastic surgery training programs in Iran. Also, the number of canceled surgeries will be determined to see the effects of the pandemic on the patients. Methods: This retrospective case study considers a six-month timeframe in two consecutive years before and after the COVID-19 pandemic. For this purpose, the researchers evaluated the number of surgeries, types of procedures, age distribution, and gender distribution. The training program data of plastic surgery residents were collected from their logbooks and then analyzed in IBM SPSS Statistics 26. Differences were considered significant if p < 0.05 at a 95% confidence level. Results: The total number of surgeries decreased by 23.5% after the COVID-19 outbreak (p < 0.05). There was a 29.9% reduction in trauma cases, -78.9% in aesthetic surgeries, -17.7% in reconstructive surgeries, -51.8% in craniofacial surgeries, and -59.5%in microscopic surgeries for each resident. Conclusions: This study provides an insight into the severity of the pandemic effects on the plastic surgery training programs and the patients. The reduced number of surgeries led to a depletion in surgical skills training. These effects will not wear off immediately after the pandemic; therefore, it is necessary to observe whether the pandemic will have any lasting effects on this subspecialty.Level of evidence: Level IV, risk/prognostic study.

Survey on Hypothermia and Hyperthermia in Poisoned Patients in a Unique Referral Hospital, Tehran, Iran.

BACKGROUND: Body temperature is a critical criterion of health. Drugs and a variety of poisons can affect body temperature in poisoned patients, causing hyperthermia and hyperpyrexia. OBJECTIVES: Our previous study's findings in patients poisoned with organophosphate led us to the goal of this study: obtaining the initial tympanic temperature in patients poisoned by a variety of toxins. MATERIALS AND METHODS: A cross-sectional study reviewed the records of poisoned patients who were admitted to the toxicological intensive care unit (TICU) at Loghman Hakim hospital poison center (LHHPC) from February 2014 to February 2015. The data collected included gender, age, type of poisoning, the season during which poisoning occurred, vital signs, initial tympanic temperature (first four hours), presence of seizures, white blood cell (WBC) count, creatinine phosphokinase (CPK), length of stay and patient outcome. We determined the mean (SD) for normally distributed continuous variables, the median and interquartile range for non-normally distributed continuous variables, and the absolute and relative frequency (%) for categorical variables. All were determined using SPSS version 16. RESULTS: Data were collected from 310 eligible patients. The mean patient age was 32.65 (with a standard deviation of 14.40). Of the patients in the study, 183 (59%) were male. Intentional poisoning in an attempted suicide was documented in 253 (81.6%) patients. The most prevalent poisoning agent was aluminum phosphate (18.70%), followed by methadone (10%) and opium (10%). Seventy percent of the patients (n = 217) were diagnosed and classified with fever or hyperthermia. A temperature ≥ 40°C was detected in just three cases. The highest mean temperature was found in patients poisoned with amphetamine, organophosphate and tramadol. Patients with alcohol and phenobarbital poisoning were included in the sample, but these patients were not diagnosed with hypothermia. WBC ≥ 10,000 cells/mL and CPK ≥ 975 IU/L were recorded in 57.7% and 13.2% of subjects, respectively. CONCLUSIONS: Body temperature changes in human poisonings are a matter in need of special attention. A literature review did not reveal any controversy over hypothermia, but poisoning cases exhibit a variety of patterns of fever and hyperthermia. If there are no limits to the diagnosis of fever and hyperthermia, all cases with a poor prognosis which fail to respond to treatment could be categorized as drug-induced hyperthermia. Therefore, a different approach is needed for poisoning cases.

Central Nervous System Depressants Poisoning and Ventilator Associated Pneumonia: An Underrated Risk Factor at the Toxicological Intensive Care Unit.

BACKGROUND: Ventilator-Associated Pneumonia (VAP) is the main cause of nosocomial infection at intensive care units (ICUs), which causes high mortality and morbidity. OBJECTIVES: The objective of the present survey was to identify the VAP risk and prognostic factors among poisoned patients, who were admitted to the toxicological ICU (TICU), especially central nervous system (CNS) depressants due to their prevalence and importance. PATIENTS AND METHODS: A case-control study was conducted at the Loghman Hakim hospital between March 2013 and March 2014. Among 300 poisoned patients with mechanical ventilator ≥ 48 hours, 150 patients, who had developed microbiologically-confirmed VAP were considered as the VAP group and 150 without VAP were defined as the control group. The following data were collected; age, gender, type of poisoning, glasgow coma score, Acute physiology and chronic health evaluation (APACHE) II score, length of hospital stay, previous antibiotic use, microbial culture of the trachea, body temperature, leukocyte count, and patients' outcome. Based on the type of poisoning, patients were divided into three groups including: opioid, CNS depressants and others. All data were expressed as means (SD) for continuous variables and frequencies for categorical variables. Logistic regression was used to determine the relationship between risk factors and VAP. RESULTS: The mean age of the patients was 33.9 ± 14.3 years. The probable VAP incidence and mortality were 22% and 18.6%, respectively. The rate of CNS depressant versus opioid use (odds ratio, 3.74; P < 0.027), APACHE II (odds ratio, 1.28; P < 0.000) and length of hospital stay (odds ratio, 2.15; P < 0.000) were the independent risk factors for VAP. While, the APACHE II score (odds ratio, 1.12; P < 0.044) and length of hospital stay (odds ratio, 2.15; P < 0.000) were the independent predictors of VAP mortality among these patients. The most common microorganisms in VAP cases were Methicillin-Resistant Staphylococcus aureus (MRSA) and Acinetobacter sp. (56.7% and 12.7%, respectively). CONCLUSIONS: Central nervous system depressant was an important risk factor for VAP among poisoned patients. Hypoventilation due to CNS depression can lead to VAP. The APACHE II and length of hospital stay were shown as independent predictors of VAP and mortality among these patients.

Comparison of the Application of Allogeneic Fibroblast and Autologous Mesh Grafting With the Conventional Method in the Treatment of Third-Degree Burns.

Wound healing is a multipart process involving different cell types and growth factors. Third-degree burns are usually treated by early excision and skin grafting. Tissue engineering has been developed in this field in response to limitations associated with autografts. Allogeneic fibroblasts on meshed split thickness skin grafts (STSGs) are known to have useful properties in wound healing and can be used to construct a new model of living skin substitute. Fourteen patients were chosen from June 2009 until December 2010 as the sample for this study. After debridement and wound excision, meshed STSG was used to cover the entire wound. Alloskin (allofibroblasts cultured on a combination of silicone and glycosaminoglycan) was applied on one side and petroleum jelly-impregnated gauze (Iran Polymer and Petrochemical Institute) was applied on the other. The healing time, scar formation, and pigmentation score were assessed for the patients. All analyses were undertaken with SPSS 17 software. Alloskin demonstrated good properties compared to petroleum jelly-impregnated gauze. The average healing time and hypertrophic scar formation were significantly different between the two groups. In addition, the skin pigmentation score in the alloskin group was closer to normal. Alloskin grafting, including fibroblasts on meshed STSG, may be a useful method to reduce healing time and scar size and may require less autologous STSG in extensive burns where a high percentage of skin is burned and there is a lack of available donor sites.

Reconstructive surgery of extensive face and neck burn scars using tissue expanders.

BACKGROUND: Neck reconstruction is considered as one of the most important surgeries in cosmetic and reconstructive surgery. The present study aimed to assess the results of reconstructive surgery of extensive face and neck burning scars using tissue expanders. METHODS: This descriptive prospective study was conducted on 36 patients with extensive burning scars on the neck and face. Operation for tissue expander insertion was performed and tissue distension started two or three weeks later, depending on the patients' incisions. After sufficient time for tissue expansion, while removing the expander and excision of the lesion, the expanded flap was used to cover the lesion. Overall, 43 cosmetic surgeries were done. RESULTS: Rectangular expanders were employed in most patients (73.81%) and were located in the neck in most of them (60.78%). Complications were detected in five patients (13.89%), with exposure of the prosthesis being the most common one. Scar tissues at the reconstruction site and the flap donor site were acceptable in 94.44% and 98.18% of the cases, respectively. Overall, most of the patients (77.78%) were satisfied with the operation results.  CONCLUSION: Using tissue expanders in tissue reconstruction of extensive neck and facial burning scars results in highly desirable outcomes.

Parachute technique: a complimentary method in zone II tendon repair.

Flexor tendon lacerations still represent a challenging problem for the hand and the plastic surgeon, particularly in zone II. Many techniques have been devised accordingly to make the surgery of this zone easier. Hence, we too have devised an added complementary technique (ie, the parachute technique) to the common surgical techniques of the tendon repair to ease the repairing process and improve the outcomes. In this study, 79 patients, from whom 21 patients had 2 injured fingers, with flexor tendon injury in zone II (ie, 100 fingers) underwent this new technique. Finally, the results were hopeful. Thus, this complementary parachute technique combined with an early active mobilization with almost full range of flexion and extension, starting on the first postoperative day, resulted in improved outcomes compared with both passive mobilization and gentle active mobilization with a limited range of motion (ie, "controlled"). The Strickland formula (total active motion) system was used to evaluate the functional results of the flexor tendon repair. Finally, this technique is applicable for tendon repairs, and is shown to produce good results in their hands.

Comparisons of medicinal leech therapy with venous catheterization in the treatment of venous congestion of the sural flap.

INTRODUCTION: The originally described distally based sural flap technique has a risk of partial or total flap necrosis as high as 25%. The purpose of this study was to compare the medicinal leech therapy (MLT) with venous catheterization (VC) for blood volume removal, infection, wound dehiscence, and flap necrosis in the distally based sural flap with venous congestion. PATIENTS AND METHODS: Fifty-six conventional distally based sural flaps with venous congestion during reconstructive surgeries were randomly divided into two groups, MLT group and VC group. The results of comparisons were analyzed using SPSS software (SPSS for Windows Ver.11.5). RESULTS: There were significant differences in terms of the average volume of removed blood (53.6cc vs.172.2cc), infection (10.7% vs. 34.6%), wound dehiscence (10.7% vs. 42.3%), flap necrosis (3.6% vs. 19.2%), and nursing (7.8 vs. 5.19) and patient's satisfaction (8.03 vs. 5.6) in the VC group and MLT group, respectively. Although local heparin irrigation was performed in the VC group, the catheter was exchanged in 10 patients due to obstruction by clot. CONCLUSION: It is recommended that the VC be used for congested pedicled flaps instead of leech therapy, as VC is more effective, easy, and safe in blood removal, and it has less complication.

End-to-side anastomosis for limb salvage in the single artery of a traumatized extremity.

BACKGROUND: The purpose of this article is to describe and highlight our experience of end-to-side anastomosis technique in such cases for limbs salvage in the single artery of a traumatized extremity with free-flap transfer. METHODS: Thirty-two traumatized patients in need of free-flap transfer for their extremity reconstruction were referred to our hospital from March 2006 to November 2008. Angiography was performed in all patients. A single artery was confirmed in 11 cases (Gustilo IIIC). End-to-side anastomosis was applied for limb salvage in single-artery extremity reconstruction, such as preserving recipient's flow and preserving donor's flow in 11 patients. RESULTS: The anastomosis arteries included the popliteal artery (n=3), posterior tibial artery (n=2), peroneal artery (n=5) and radial artery (n=1). The mean time from the injury to the flap reconstruction was 34 days. All patients had severe fracture or bone deficit plus soft tissue defect. Postoperative hospital stay was 12-18 days. Time interval between the injury and referral was 27-45 days. Split thickness skin graft was performed in eight patients. CONCLUSION: Free-flap transfer by end-to-side anastomosis for limb salvage with a single artery is a safe procedure, so a vein graft and T and Y shape anastomosis are not necessary.

Adverse effects after use of polyacrylamide gel as a facial soft tissue filler.

BACKGROUND: Although the "perfect" filler material to correct soft tissue facial defects, wrinkles, and scars has not yet been found, ideal characteristics for such a substance may be considered as the following: permanent, inert, malleable, easily injectable, quick to metabolize, not prone to infection, affordable, removable, nonmigratory, and not associated with any disorder or disease state as shown by clinical and paraclinical studies. OBJECTIVE: The authors present an evaluation of patients undergoing treatment for facial wrinkles or soft tissue defects by injection of polyacrylamide hydrogel (PAAG) and analyze outcomes on the basis of the incidence of moderate to severe complications. METHODS: A retrospective study was performed, including history taking, physical examination, and follow-up of 542 patients who received facial injections of PAAG. RESULTS: Of 542 patients, 42 (7.7%) experienced complications such as swelling, abscess formation, lumpiness, change in facial appearance, change in gel location after injection, and sensitivity. CONCLUSION: The authors recommend that complications from treatment with PAAG be studied further before widespread use of this soft tissue filler.

The distally based neurocutaneous sural flap: a good choice for reconstruction of soft tissue defects of lower leg, foot and ankle due to fourth degree burn injury.

OBJECTIVE: Debridment of fourth degree burn wound usually leads to soft tissue loss. If these wound are on distal one-third of lower leg and ankle, a simple wound changes to a complex problem. Options are available for these conditions, but each of them have advantages and disadvantages. The distally based neurocutaneous sural flap is one recent flap available for this problem which has excellent results and decreased disadvantages. METHODS: Between 2000 and 2004, all patients with acute fourth degree burns or unstable scar on the distal third of lower leg, foot or ankle that referred to our hospital were scheduled for reconstruction by sural flap. The success rate and ability of the flap to create stable durable coverage at these sites were evaluated. RESULTS: Fifteen patients from 1.5 to 75 years old were included to this study. We had excellent result with this type of flap in 14, we had 100% success rate without necrosis. Only in one patient (a 75 years old man with a history of diabetes mellitus) we had a 0.5cm necrosis of distal margin of flap which healed completely after one session of debridement. All patients were completely satisfied with this flap. CONCLUSION: Because of few drawbacks of this flap and high success rate and relative simple operative technique, we recommend sural flap as a prime option for repair of fourth degree burn, at distal leg, foot and ankle.

Reconstruction of major forehead soft tissue defects with adjacent tissue and minimal scar formation.

Repair and reconstruction of soft tissue defects involving over 50% of the forehead using remaining forehead tissue has not been reported in the literature. The few existing reports mainly concern cases in which less than half of the forehead was involved. The forehead comprises one third of the face and with regard to its prominent position, it is one of the major contributing components to facial beauty. Considering the excellent color, thickness, and quality matching of the adjacent forehead skin, it is considered the ideal substitute for repair of forehead defects. Use of skin graft or free flaps for reconstruction of defects involving 50% or more of the forehead have not reported acceptable results because of the lack of similarity of the donor tissue with the remaining forehead tissue. In this study, we describe successful reconstruction of major forehead soft tissue defects of two thirds to three fourths of the forehead with use of a tissue expander and transverse supratrochlear pedicle flap in four patients who were diagnosed with giant hairy nevus. There were no serious complications such as hematoma, bleeding, infection, or flap necrosis. We recommend this technique for reconstruction of extensive forehead soft tissue defects.