Nasal Tip Flexibility and Stability: Comparison of Septal Extension Grafts and Columellar Strut Grafts in a Prospective Trial.

BACKGROUND: The stability of nasal tip rotation and projection, as well as providing a flexible nasal tip, are important elements in rhinoplasty. Two common options to provide these requirements are the septal extension graft (SEG) and the columellar strut graft (CSG). This study aims to compare the nasal tip stability and flexibility between the two graft options. METHODS: A prospective randomized study was carried out on sixty patients operated on with either the CSG or SEG. Tip rotation and projection stability were analyzed with photographic evaluation at the immediate postoperative period, the first month and the first year. Nasal tip flexibility was evaluated with a Newton meter at the preoperative period and postoperative first, third, and sixth months and the first year. RESULTS: The CSG showed a significant loss of projection and rotation, while the SEG showed better preservation of projection and rotation. However, both options showed a greater loss of projection and rotation in the first month and then a slight decrease in the following months. Although the SEG had lesser flexibility compared to the CSG anteroposteriorly, there was no flexibility difference between them in the lateral direction in the long term. CONCLUSION: The SEG provides better nasal tip stability compared to the CSG. The biggest downside of the SEG is decreased flexibility compared to the CSG. Surgeons should be aware of the loss of projection and rotation with both graft options and adjust their operation plan according to these points.

Tip Support in the Cleft Lip Rhinoplasty: A Comparison of Septal Extension Graft and Columellar Strut Graft.

BACKGROUND: We aimed to comparatively analyze nasal projection and rotation changes in patients that underwent secondary cleft rhinoplasty with a columellar strut graft (CSG) or septal extension graft (SEG). METHODS: Thirty-three patients were randomly divided into two groups. Preoperative, intraoperative (immediate postoperative), postoperative 1-, 6- and 12-month profile view pictures were analyzed. The nasion (N), alar base-cheek junction (A), tip defining point (T), columella (C), and lips (L) were marked. The AT/AN ratio, NAT angle, Goode ratio, and columellar-labial angle (CLA) were measured. RESULTS: Regarding tip projection, the AT/AN ratio was lower in CSG group compared to SEG group postoperatively. In CSG group, there was a significant progressive decrease in the AT/AN ratio, whereas in SEG group, it decreased until postoperative 6 month. Regarding tip rotation, the NAT angle was higher in CSG group postoperatively and increased progressively. In SEG group, the NAT angle was lower intraoperatively compared to the postoperative period, whereas it did not differ significantly in-between follow-ups. The Goode ratio was significantly lower in CSG group compared to SEG group postoperatively. In SEG group, the Goode ratio was significantly higher intraoperatively compared to the postoperative period, but it did not differ significantly in-between follow-ups. In CSG group, the Goode ratio decreased progressively. The CLA decreased in both groups, but there was no statistically significant difference between the groups. CONCLUSION: Secondary cleft lip rhinoplasty is a distinct subgroup of rhinoplasty that necessitates stable and strong tip support. SEG provides more reliable and predictable long-term results in secondary cleft lip rhinoplasty than CSG. LEVEL OF EVIDENCE I: 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 .

Sensory Changes in Nasal Subunits Following Open and Closed Rhinoplasty: A Randomized Controlled Trial.

BACKGROUND: Skin sensation changes are common after rhinoplasty and can be troublesome for patients postoperatively. The closed technique may be considered as causing less sensory loss compared to the open technique due to its conservative approach, minimal dissection and low tissue damage potential. A randomized study was planned to compare the sensory changes in the subunits of the nasal skin caused by the two main methods using objective and subjective parameters. METHODS: In the analysis of the patients, the nose was divided into seven subunits: nasion, rhinion, nasal tip, left alar wing, right alar wing, infratip lobule and columella base. Evaluations were done preoperatively and at the first, third, sixth and twelfth months postoperatively. Objective sensory evaluations were done using the Semmes-Weinstein monofilament test. The subjective sensory changes of each nasal unit were subjectively evaluated by the patients on a three-point Likert scale. RESULTS: Both objective and subjective evaluations showed a statistically significant decrease in sensation in the nasal tip and infratip lobule in the open group one month after surgery. In the closed group, no significant differences were observed between the preoperative and postoperative sensory values for nasal subunits across all periods. CONCLUSION: While a decrease in sensation was observed in the tip and infratip lobule in the open technique by the first month postoperatively, this loss of sensation returned to a normal level by the third month. In the closed technique, however, no significant loss of sensation was detected in the postoperative period. In light of our findings, surgeons can have a better insight into postoperative sensory changes in the subunits of nasal skin which makes them more confident and reassuring when there are concerns regarding altered sensation after rhinoplasty. Level of Evidence II 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 .

Comprehensive Assessment of the Functional Outcomes of Partial Turbinectomy: A Prospective Clinical Trial.

OBJECTIVES: The inferior and middle turbinates have crucial roles in nasal function, but their enlargement can cause obstructive effects, which can lead to breathing difficulties, sleep and smell disorders, and headaches. Partial turbinectomy is a common surgical technique used to address this issue during septorhinoplasty, but it carries risks such as empty nose syndrome. A clinical trial was designed to evaluate the functional outcomes of middle and inferior partial turbinectomy with a holistic approach. METHODS: Patients with NOSE questionnaire scores of 30 or higher, and grade 4 inferior turbinates and/or advanced middle concha bullosa were included. Patients completed questionnaires related to breathing, empty nose syndrome, headache, and olfaction preoperatively and at one-month, three-month, six-month, and first-year periods postoperatively. The partial excisions of the inferior and middle turbinates were carried out with serrated scissors while trying to preserve adequate turbinate size to maintain function. RESULTS: This study found that NOSE scores, headache frequency, and severity improved postoperatively. The olfactory-related quality of life of the patients with impairments in this area significantly improved found to be improved at all postoperative evaluations. None of the patients experienced prolonged bleeding requiring surgical intervention. No cases of anosmia and empty nose syndrome were reported. CONCLUSION: Partial turbinectomy of middle and inferior turbinates during septorhinoplasty can alleviate symptoms of turbinate hypertrophy, such as breathing issues, olfactory disorders, and headaches. It is an easy, reliable, and efficient surgical maneuver. Proper technique can minimize the risk of empty nose syndrome and other complications of turbinectomy surgery. 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 Systematic Review and Meta-Analysis of Early Relapse After Facelift.

BACKGROUND: Early relapse is an adverse outcome of facelift surgery. The rate of early relapse is an indirect measure of the longevity and efficacy of facelift techniques. However, early relapse after facelift is ill-defined, under-evaluated, and under-reported, and literature data on the subject are dispersed. In this systematic review, we aimed to analyze facelift studies using relapse-related outcomes (RROs). Our secondary aim was to highlight the importance of early relapse as an essential outcome measure. METHODS: The study design was a systematic review of the English literature and meta-analysis of RROs after facelift surgery. RROs that occurred within the first 2 years after surgery were considered "early". Performance, analysis, and reporting were performed in accordance with the PRISMA guidelines. The systematic search was conducted using the PubMed database as of February 2020. Initial screening was performed using the keywords "facelift", "rhytidectomy", "surgical rejuvenation", "face lift", "rhytidoplasty", and "facial rejuvenation". Articles were excluded by using a set of inclusion and exclusion criteria. RESULTS: RROs were reported only in 4.4% (19/433) of the papers that underwent full-text review. The frequency of RROs ranged between 0.2 and 50% among facelift papers. The weighted median rate of RROs after facelift surgery was found to be 2.4% in the meta-analysis. CONCLUSIONS: Future research on preventive measures will be successful upon acknowledgment of the actual prevalence of this problem. Consensus on its definition and objective criteria for its diagnosis are required for further progress. 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 .

Fine-Tuning of the Supratip in Rhinoplasty: An External Approach.

BACKGROUND: Supratip deformity, also known as the pollybeak deformity, accounts for one of the most common iatrogenic deformities requiring revision surgery in rhinoplasty. We aimed to present a novel technique to prevent supratip deformity and increase the tip definition, especially in patients with thick skin. METHODS: A total of eighty-three patients were included in the study. In control group, thirty-three consecutive patients with thick skin underwent structured primary rhinoplasty without any additional maneuvers. In study group, thirty-one consecutive patients with thick skin underwent the same operation with an additional "External supratip suture (ESS)." Nineteen patients with moderate skin were also operated using the ESS to accentuate the supratip break and control the soft tissue response. Patients' supratip regions were analyzed with reference to a tangent line from the tip defining point to the nasion. Two independent blinded plastic surgeons rated the supratip aesthetics on a 5-point scale. RESULTS: The ESS maneuver had better results in the supratip region according to the two parameters which were statistically significant (p < 0.05). No ischemic complications were observed. CONCLUSION: This simple and reliable external approach is a powerful maneuver which can be an effective technique not only in patients with thick skin, but also in moderate skin patients who requires better supratip definition. It enables surgeon to reduce the nasal volume efficiently in patients with noncompliant skin by controlling skin redraping by adhering to Auersvald's hemostatic net principles. We believe that this approach will find a place in the armamentarium of rhinosurgeons. LEVEL OF EVIDENCE IV: 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.

Evaluation of histopathological margin and other recurrence parameters in basal cell carcinoma: A retrospective analysis of 8821 lesions.

Basal cell carcinoma (BCC) is the most common skin cancer. Removing the lesion with wide surgical margins and obtaining a microscopically intact margin is considered sufficient in the treatment of BCC. However, it may not always be possible to provide wide and intact margins in cosmetically and functionally important areas. Although recurrence rates after BCC excision vary among studies, the recurrence rate at 5 years is considered to be 2%. BCC subtype, perineural invasion, and close margin are important factors in recurrence. The aims of this study are to investigate the other factors associated with recurrence in BCC treatment and reveal the value of the "histopathological surgical margin" which can help in making the decision for re-excision. A statistically significant correlation is observed between the increase in tumour size and recurrence(p<0.05). The recurrence rate after excision with a histopathologic margin of 1 mm or less is 19%. This rate is found to be 8% in patients with a histopathological margin greater than 1 mm and 3 mm or less. Reticular dermis and deeper tissue invasion statistically increase the recurrence rate. Multiple excision and the presence of residual tumour in the re-excision sample also increase the recurrence rate. In conclusion, recurrence in BCC patients is affected by more than one parameter. We highly recommend re-excision in patients with a histopathological margin of 1 mm or less. In tumours with histopathological margins between 1 mm and 3 mm, the decision for re-excision or "wait-and-see" approach should be made according to the characteristics of the tumours and patients.

A novel ultrasound-guided minimally invasive technique for the treatment of extracapsular condylar fractures.

The aim of this study was to present a novel ultrasound-guided minimally invasive technique for the treatment of extracapsular condylar fractures and evaluate its long-term outcomes. Seven patients with isolated extracapsular condylar fractures with a noncomminuted proximal segment were included in this study. Ultrasound was used for identification of the position of the bone segments and intraoperative confirmation of appropriate reduction. Reduction of the displaced segments was performed using threaded K-wires under ultrasonographic visualization. The bone segments were stabilized using an adjustable modified external fixator designed by us, which allows manipulation of the segments in three planes intraoperatively and postoperatively, if needed. The functional outcomes of patients were evaluated. Patients treated with ultrasound-guided percutaneous reduction and external fixation achieved normal occlusion with satisfactory mouth opening (>35 mm) and had no pain during mandibular movements at long-term follow-up. None of the patients had any signs of facial nerve injury. Within the limitations of the study it seems that the poposed approch might be an alternative to the open approach in selected cases.

Evaluation of versatility and outcomes of the first dorsal metacarpal artery flap in thumb defects.

BACKGROUND: It is clinically vital to determine the best technique to reconstruct thumb defects with satisfactory esthetic and functional outcomes. We aimed to quantitatively present the safety, versatility, limitations, advantages, and functional results of the first dorsal metacarpal artery flap (FDMAF) and evaluate its outcomes in thumb defect reconstruction by comparing it with the other current surgical options. METHODS: A total of 21 patients underwent thumb defect reconstruction. They were evaluated with the following parameters: Etiology, age, timing of reconstruction, flap vitality, Semmes-Weinstein monofilament (SWM) test, static two-point discrimination (2PD) test, pain, cortical reorientation, cold intolerance questionnaire, and Michigan hand outcomes questionnaire. Their functional outcomes were evaluated by comparing their scores with the other current surgical options published in the literature. RESULTS: The mean follow-up period was 22.3 months. The mean pain score of the flap was 0.4±0.6 and no patient had pain in the donor area (range, 0-10). The sensory outcome was 'good' (8.6 mm) based on the static 2PD test. The mean SWM test score was 4.02 g. Patient satisfaction was 4.6 according to the Michigan hand outcomes questionnaire (range, 0-5). The cold intolerance questionnaire scores showed that the patients had mild cold intolerance (mean, 10.5; range 0-100). Complete cortical reorientation was seen in 81% of the patients. CONCLUSION: Restoration of the innervation of thumb defects is possible with the FDMAF with high satisfaction rates based on our results. The absence of the microsurgical vessel or nerve repair facilitates the surgery, shortens its duration, and reduces morbidity, reserving the microsurgical options for more complicated cases. Therefore, it can be concluded that the FDMAF is an effective flap with great modifications for complicated thumb defects but surgeons should consider their clinical outcomes and prolonged surgery when choosing which technique to be used.

Temporomandibular joint innervation: Anatomical study and clinical implications.

BACKGROUND: Temporomandibular disorders and related pain are commonly seen in clinical practice. Due to its recurrent nature, they adversely affect a patient's social life. Current knowledge on the temporomandibular joint (TMJ) innervation is debatable and insufficient to ensure optimal treatment for the underlying pathology. This study aimed to elucidate the pathophysiology of temporomandibular pain by revealing the TMJ innervation topography, its variations, and its relationships with the surrounding anatomical structures. This will aid in creating a guide for temporomandibular, infratemporal, and preauricular interventions. METHODS: A total of 20 cadaver half heads, 10 fresh frozen and 10 embalmed, were used. The TMJ nerves were dissected together with the surrounding anatomical structures. RESULTS: We showed that the TMJ is mainly innervated by the auriculotemporal nerve posteriorly, the masseteric nerve anteriorly, the posterior deep temporal nerve anteromedially, and the TMJ branch originating directly from the mandibular nerve medially, and that there are variations in these innervation pathways. Additionally, we emphasized how these nerves might be affected in certain clinical conditions based on their anatomical relationships and pathophysiological mechanisms. To our knowledge, this is the first study showing the existence of a branch of the mandibular nerve directly innervating the TMJ. CONCLUSION: In light of our findings, elucidating TMJ pain based on the anatomical characteristics of the region will allow precise treatment algorithms and better clinical outcomes in these patients. Based on this study, new clinical studies and interventions can be designed to reduce healthcare costs and alleviate the burden of temporomandibular disorders.

ALX-Related Frontonasal Dysplasias: Clinical Characteristics and Surgical Management.

AIM: The term frontonasal dysplasia (FND) represents a spectrum of anomalies and its genetics have not been well defined. Recently, the critical role of the aristaless-like homeobox (ALX) gene family on the craniofacial development has been discovered. In the present study, we aimed to propose a systematic surgical treatment plan for the ALX-related FNDs according to the genotypic classification as well as demonstrating their clinical characteristics to help surgeons diagnose the underlying pathology accurately. DESIGN: Single-institution retrospective. SETTING: Tertiary health care. PATIENTS AND METHODS: Eighty-nine FND cases were evaluated. Eight of them had ALX1-related FND3, 3 had ALX3-related FND1, and 2 had ALX4-related FND2. Phenotype characteristics of ALX-related FNDs were evaluated, and relevant surgical interventions were assessed. RESULTS: The ALX1-related FND3 phenotype is striking due to the involvement of the eyes in addition to the presence of hypertelorism, facial clefts, and nasal deformities. A widened philtrum and prominent philtral columns are remarkable features of the ALX3-related FND1, whereas the ALX4-related FND2 has more severe deformities: severe hypertelorism, brachycephaly, large parietal bone defects, broad nasal dorsum, and alopecia. Facial bipartition, box osteotomies, eyelid coloboma repair, cleft lip and palate repair, nasal reconstruction, and fronto-orbital advancement can be performed in ALX-related FNDs based on the characteristics of each subtype. CONCLUSIONS: This genetic classification system will help surgeon diagnose patients with FND with unique features and draw a roadmap for their treatment with a better surgical perspective.

Photobiomodulation with polychromatic light (600-1200 nm) improves fat graft survival by increasing adipocyte viability, neovascularization, and reducing inflammation in a rat model.

OBJECTIVES: Unpredictability with the final volume and viability of the graft are the major concerns in fat grafting. An experimental study was conducted to increase graft retention using photobiomodulation (PBM) with polychromatic light in near-infrared region (600-1200 nm) by utilizing its stimulatory effects on angiogenesis, neovascularization, adipocyte viability, and anti-inflammatory properties. METHODS: A total of 24 rats were divided into four groups (n = 6) according to the applied polychromatic light protocol to the recipient site (none, before fat transfer, after fat transfer, and combined). In all groups, inguinal fat pad was excised, measured for volume and weight, and transferred to the dorsum of the rat. At the end of the experiment, fat grafts were harvested from the recipient site for volume and weight measurements, histological, and immunohistochemical evaluation. RESULTS: Intergroup comparison revealed that fat graft retention regarding weight and volume, was significantly superior in Group IV (p = 0.049 and p = 0.043, respectively), which polychromatic light was applied both before and after transfer of the graft. Hematoxylin-eosin and Masson's trichrome stained sections showed absence of necrosis, fibrosis, inflammation, cyst formation, and increased vascularization of both inner and outer zones of the grafts in Group IV. Also, immunohistochemical staining scores for perilipin (indicator for adipocyte viability), CD31 and VEGF (indicators for angiogenesis and neovascularization) were significantly higher (p < 0.001). Ki67 scores were significantly lower in this group because of anti-inflammatory environment (p < 0.001). CONCLUSIONS: Application of PBM to the recipient site before and after fat transfer improved outcomes in rats at 56 day after fat grafting by means of volume retention, increased neovascularization and adipocyte viability and reduced necrosis, fibrosis and inflammation.

A Novel Injection Technique to the Lateral Pterygoid Muscle for Temporomandibular Disorders: A Cadaveric Study.

BACKGROUND: Lateral pterygoid muscle activity is associated with the pathological mechanisms of some temporomandibular disorders. The authors aimed to define and demonstrate a novel, practical, and safe technique for botulinum toxin type A injection to the lateral pterygoid muscle based on their findings. Their secondary aims were to standardize the injection pattern according to the variations of the lateral pterygoid muscle and its surrounding anatomical structures, and to establish its advantages over intraoral injection. METHODS: Twenty cadaver heads were dissected. The lateral pterygoid muscle and its surrounding structures were investigated for anatomical variations. Based on these findings, a standardized extraoral injection protocol was defined and compared with the intraoral technique for accuracy and safety. RESULTS: The average depth of the lateral pterygoid plate from the skin surface was 49.9 ± 2.2 mm, and the mean width of the lateral pterygoid plate was 10.5 ± 3.9 mm. The extraoral injection approach based on the location of the maxillary tuberosity, tragus, and lateral pterygoid plate was consistent in all dissections for the accuracy of the intramuscular injection. In the intraoral approach, standardization of the entry point of the needle through the oral mucosa is difficult, which makes adjustment of the depth of the injection challenging while increasing the risk of neurovascular injury. CONCLUSIONS: The clinical significance of the lateral pterygoid muscle makes it worthwhile to implement minimally invasive treatments before considering more invasive options. The authors define a safe, accurate, and reliable approach with ease of administration in patients with temporomandibular disorders.

Posterior Cephalic Soft Triangle of the Nose: Surgical Implications.

BACKGROUND: The posterior cephalic soft triangle is formed between the posterior cephalic border of the lower lateral cartilage, posterior caudal border of the upper lateral cartilage, and the caudal edge of the nasal bone. PCST is an important component of the external nasal valve which provides resistance against dynamic collapse. OBJECTIVES: The objective of this study was to describe the anatomy of the PCST and to demonstrate its anatomic variations, dynamic interplays, and surgical implications. METHODS: A retrospective review was conducted of 310 primary and 42 secondary cases who underwent extended open approach rhinoplasty by the first author. The structures that create the PCST of the nose were preserved unless resection/displacement of them was absolutely necessary. Whenever an external nasal valve pathology was found, it was corrected with one or combination of the following maneuvers: triangular PCST onlay graft, caudal bone outfracture, alar rim graft, lateral crural strut graft. RESULTS: Twenty-four non-consecutive cases were identified in which PCST was intraoperatively confirmed to be weak or deformed. The most common pathology in the PCST was overresection of the posterior segments of the LLC during primary surgery (54.1%), followed by en bloc medialization of the PCST (33.3%). Triangular onlay grafting of the PCST was the most common corrective surgical intervention (83.3%), followed by corrective lateralization of caudal edge of nasal bone (29.1%). External valve function has been restored in 21 (87.5%) cases. CONCLUSIONS: PCST of the nose is an important anatomic landmark which has esthetic and functional significance in rhinoplasty. LEVEL OF EVIDENCE IV: 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 .

Defining a Preauricular Safe Zone: A Cadaveric Study of the Frontotemporal Branch of the Facial Nerve.

BACKGROUND: In the preauricular region, the frontotemporal branch of the facial nerve is vulnerable to injury, which can result in facial palsy and poor cosmesis after surgical interventions. OBJECTIVES: The purpose of this study was to describe variations in the branching patterns of the frontotemporal branch of the facial nerve and the relation between this branch and the surrounding anatomic landmarks. Based on our findings, we propose a Danger Zone and Safe Zones for preauricular interventions to avoid frontal branch injury. METHODS: Twenty cadaveric half-heads, 10 freshly frozen and 10 embalmed, were dissected. The anatomy of the auriculotemporal nerve, facial nerve, and variations of its branching pattern in the preauricular region were investigated. RESULTS: The mean [standard deviation] number of frontotemporal branches crossing the zygomatic arch was 2.05 [0.6]. Beginning from the X point at the apex of the intertragal notch, frontal branches ran over the zygomatic arch at a distance extending from 10 to 31 mm anterior to the tragus, which can be defined as the Danger Zone for frontal branches. Safe Zones A and B are triangular regions located behind and in front of the Danger Zone, respectively. CONCLUSIONS: Mapping of these Safety and Danger Zones is a reliable and simple approach in preauricular interventions to avoid frontal branch injury because the facial nerve typically has multiple frontal branches. This approach provides practical information for surgeons rather than estimating the trajectory of a single frontal branch from Pitanuy's line.

Assessment of Nutrition and Feeding Interventions in Turkish Infants with Cleft Lip and/or Palate.

PURPOSE: The present study aimed to highlight the feeding challenges of infants with cleft lip and/or palate (CLP) that caregivers encounter and analyze the alternative interventions they perform based on their experiences in the preoperative period. DESIGN AND METHODS: Parents of 200 infants with CLP were asked to complete our questionnaire. The prenatal feeding preparations, preoperative processes, and feeding challenges and modifications to overcome these difficulties were evaluated. RESULTS: One-third of the caregivers stated that they had received feeding education prenatally. Sixty-five percent of the parents stated that they were not successful in breastfeeding. Infants with isolated cleft lip had minor feeding difficulties, whereas the ones with cleft palate had some major challenges such as aspiration, choking, and inadequate growth. Parents also reported that 59.5% of the infants with cleft had stayed in the intensive care units following birth. Moreover, 42% of the infants were initially fed by nasogastric or orogastric tube. Out of the 166 infants with cleft palate, 31.9% used palatal obturators. CONCLUSIONS: We have reviewed the various feeding difficulties of the infants with clefts and highlighted the results of the interventions performed to overcome these difficulties for better nutrition and growth. PRACTICE IMPLICATIONS: In the light of our findings, further studies should be conducted and additional educational programs should be implemented for both healthcare providers and parents to increase families' awareness regarding cleft feeding, prevent unnecessary and improper feeding interventions in infants with clefts, and alleviate the burden of feeding difficulties for both parents and infants.

Endoscopic retrieval of retracted flexor tendons: An atraumatic technique.

BACKGROUND: The repair of retracted flexor tendons is a challenging problem for hand surgeons. The tendon stump should be handled in an atraumatic manner because any microtrauma to the sheath and tendon can lead to poor functional outcomes. METHODS: Twenty-three patients with flexor zone 2 injuries and intraoperative finding of retracted tendons were randomly divided into two groups: endoscopic retrieval group and proximal incision group. A flexible endoscope and a flexible grasping forceps were used for endoscopic retrieval of the retracted flexor tendons. The groups were compared in terms of infection rate, neurovascular complications, regional pain, total range of active motion (TAM) and functional outcomes. RESULTS: Age, gender, average preoperative pain and general pain perception scores were similar between the two groups. We found a significantly shorter duration of operation and better pain scores at 1-2 weeks in the endoscopic group than in the other group (p = 0.002 and p = 0.020, respectively). A significant difference in TAM was demonstrated between the groups at 3 to 5 weeks (p = 0.003). CONCLUSION: The surgical procedure presented here has the advantages of direct visibility of the proximal tendon end and retrieval in an atraumatic manner, with better results and decreased morbidity. It is a promising approach and can be used as a routine procedure in retracted tendon cases.

Assessment of Neurologic Disorders and Rare Intracranial Anomalies Associated With Cleft Lip and Palate.

Accompanying neurologic disorders directly affect psychosocial development of cleft lip and/or cleft palate (CLP) patients and make it difficult for their family to look after them properly. The aim of this study was to investigate the diversity and the incidence of additional neurologic malformations in children with CLP and to evaluate their effects on cleft care. All patients who applied to our Cleft and Craniofacial Center between July 2014 and July 2017 were included in the study. Demographic and perioperative data such as gender, cleft type, syndromic status of the patient, associated neurologic anomalies, timing and duration of operation, hospitalization period, and follow-up period in the intensive care unit are all recorded. All patients received an interdisciplinary evaluation including pediatric neurology specialists in terms of mental and/or motor developmental delay, epilepsy, and other neurologic disorders. After detailed neurologic examination, 83 (3.8%) out of 2190 were reported as having a neurologic defect. The most leading neurologic disorder was found to be mental-motor retardation in 57 children followed by epileptiform disorders detected in 36 children. In 22 patients, rare intracranial pathologies were detected on magnetic resonance imaging. According to our results, having a neurologic pathology increases the need for intensive care unit stay by 5 times in these patients. There was statistically significant relationship between hospitalization period, age of cleft surgery, and neurologic pathologies in these patients. Neurologic disorders could complicate cleft care, cause delays in the planned surgery schedule, and increase perioperative and postoperative morbidity.

Matrix metalloproteinases as potential targets in the venous dilation associated with varicose veins.

Varicose veins (VVs) are a common venous disease of the lower extremity characterized by incompetent valves, venous reflux, and dilated and tortuous veins. If untreated, VVs could lead to venous thrombosis, thrombophlebitis and chronic venous leg ulcers. Various genetic, hormonal and environmental factors may lead to structural changes in the vein valves and make them incompetent, leading to venous reflux, increased venous pressure and vein wall dilation. Prolonged increases in venous pressure and vein wall tension are thought to increase the expression/activity of matrix metalloproteinases (MMPs). Members of the MMPs family include collagenases, gelatinases, stromelysins, matrilysins, membrane- type MMPs and others. MMPs are known to degrade various components of the extracellular matrix (ECM). MMPs may also affect the endothelium and vascular smooth muscle, causing changes in the vein relaxation and contraction mechanisms. Endothelial cell injury also triggers leukocyte infiltration, activation and inflammation, which lead to further vein wall damage. The vein wall dilation and valve dysfunction, and the MMP activation and superimposed inflammation and fibrosis would lead to progressive venous dilation and VVs formation. Surgical ablation is an effective treatment for VVs, but may be associated with high recurrence rate, and other less invasive approaches that target the cause of the disease are needed. MMP inhibitors including endogenous tissue inhibitors (TIMPs) and pharmacological inhibitors such as zinc chelators, doxycycline, batimastat and marimastat, have been used as diagnostic and therapeutic tools in cancer, autoimmune and cardiovascular disease. However, MMP inhibitors may have side effects especially on the musculoskeletal system. With the advent of new genetic and pharmacological tools, specific MMP inhibitors with fewer undesirable effects could be useful to retard the progression and prevent the recurrence of VVs.