Impact of Geopolitical Unrest on Surgical Delays and Outcomes in Immigrant Populations With Cleft Lip and Palate.

BACKGROUND: Geopolitical conflicts in the Middle East have led to mass migrations, with Turkey becoming a major host country. This influx has strained the health care system, particularly regarding specialized care for conditions like cleft lip and palate (CLP). Timely intervention is crucial for optimal outcomes, but cultural, socioeconomic, and logistical barriers often cause delays, impacting physical, functional, and psychosocial development. METHODS: This retrospective study analyzed 72 immigrant pediatric CLP patients treated in Turkey between 2012 and 2022. Data on demographics, medical history, surgical interventions, complications, and treatment delays were collected. Surgical timing was compared with American Cleft Palate Craniofacial Association guidelines, and the impact of socioeconomic status on delays was assessed. RESULTS: Seventy-two patients underwent a total of 91 surgical interventions, including 29 cleft lip repairs, 22 cleft palate repairs, 6 pharyngeal flaps, 15 fistula closures, 8 corrections of secondary lip scars and whistling deformities, and 11 alveolar bone graftings. A majority (73.6%) had poor socioeconomic status. The average delays for cleft lip, cleft palate, and alveolar bone grafting surgeries were 5.3±4, 7.3±6.1, and 34.1±23.5 months, respectively, and were significantly longer for patients with poor socioeconomic status (P=0.00502, 0.030741, and 0.041878). The average delay for pharyngeal flap surgery, performed in patients with poor socioeconomic status (except for one), was 43.7±14.1 months. CONCLUSIONS: This study highlights the challenges and disparities in CLP care for immigrant children in Turkey due to geopolitical conflict. While surgical complication rates are similar to established data, delays in treatment, especially among those with lower socioeconomic status, are a significant concern. The findings emphasize the need for comprehensive, culturally sensitive care and systemic interventions to improve access and outcomes for this vulnerable population.

Velopharyngeal Insufficiency After Botox Injection for Persistent Bruxism.

Botulinum toxin type-A (BTX-A) injections have emerged as a promising treatment for bruxism and temporomandibular joint (TMJ) disorders. However, there is a need for further exploration of optimal dosage, injection techniques, and intervals to maximize treatment effectiveness. Complications, such as velopharyngeal insufficiency, can occur after BTX-A injections, emphasizing the importance of precautionary measures. The utilization of ultrasound guidance and electromyography assistance can aid in precise injections and minimize the risk of complications. In addition, patients should receive appropriate medication and adhere to post-treatment instructions to alleviate symptoms. Follow-up procedures are essential to monitor potential complications, and in some cases, professional mental health care may be required. Further research is warranted to establish the safety and efficacy of BTX-A injections for the treatment of bruxism and TMJ disorders. This case study presents the development velopharyngeal insufficiency in a patient with chronic bruxism 3 days after receiving a BTX-A injection.

A novel autologous dermal filler based on cultured fibroblasts and plasma gel for facial wrinkles: Long term results.

Autologous cultured fibroblasts combined with plasma gel (FibrogelTM) can be used as an injectable autologous soft tissue filler. Herein, we report the assessment of the long-term clinical efficacy and safety of Fibrogel for facial wrinkles. Ten healthy adults were treated for facial wrinkles with Fibrogel, an innovative autologous filler. Patients underwent three treatment sessions at 1-month intervals for the correction of infraorbital, nasolabial, and marionette folds. In each session, 6-8 mL of Fibrogel filler containing 4 million fibroblasts/mL, was injected into the deep dermis or subdermal plane. Three evaluators independently assessed the efficacy at 3, 6 and 12 months after the last treatment, using the validated Global Esthetic Improvement Scale at two different times in a blinded manner. Infraorbital area and lower face were evaluated separately. All patients showed immediate improvement after the first injection at the infraorbital area and lower face. Follow-ups at 3, 6 and 12 months revealed that the improvement was persistent. Adverse reactions were mild and the treatment was well tolerated. Delivering autologous cultured fibroblasts embedded in an autologous plasma gel (Fibrogel) to the skin can provide immediate volume effect and long-term improvement. Therefore, Fibrogel can be considered as a promising novel autologous filler.

Effectiveness of Different Surgical Flap Delay Methods and Their Systemic Toxicities.

OBJECTIVE: The surgical flap delaying has been shown to be effective in preventing partial flap loss or in preparing larger flaps. However, there is no gold standard flap delay method in the literature. In this study, the authors aimed to compare 3 types of surgical delay methods to determine which model would increase more flap survival. The authors also investigated the effect of delay methods on circulating mononuclear leukocytes as a parameter of DNA damage. METHODS: Twenty-four Sprague-Dawley male rats were divided into 4 groups. All subjects had a 10 × 3 cm modified McFarlane flap. Surface area measurements, biopsies, and blood samples were taken on the day of sacrification; 7th day for the control group and 14th day for delay groups. RESULTS: Between incisional surgery delay groups, a significant difference was found in necrosis and apoptosis in the bipedicled group, and only necrosis in the tripedicled group compared to the control. In terms of DNA damage, it was found higher in all experimental groups than in the control group. CONCLUSIONS: Both incisional surgical delay procedures' results were meaningfully effective when only incisions were made without the elevation of flaps. In conclusion, bipedicled incisional surgical delay seems to be the most effective method in McFarlane experimental flap model whereas two-staged surgeries may increase the risk of systemic toxicity.

Revisiting the Limberg flap for central midface reconstruction in elderly patients.

To present the use of Limberg flap in the central midface reconstruction as an useful flap in elderly patients. A retrospective review of a total of 13 cases who underwent Limberg flap procedure to reconstruct various sizes of midfacial defects. Etiology, size, location, surgical procedures, outcomes, and complications, final evaluation according to the tumor-free survival and patient satisfaction in terms of aesthetic appearance were analyzed, the latter was evaluated by visual analog scoring system. The mean follow-up period was 11.53 months (2-22 months). The mean age of cases was 68 years (between 49 and 81 years). Average defect size was 7.76 cm2 (between 2.25 and 25 cm2 ). All operations were performed under local infiltration anesthesia. All patients were discharged on the same day of the operation. All the flaps survived with uneventful wound healing according to the patient satisfaction scores that were reliable and high. No any early or late recurrence was detected. Limberg flap is a safe and rapid option that could be applied in small- and medium-sized cutaneous defects in the central midface reconstruction in elderly patients.

The Role of Staged Cryosurgery and Three-Dimensional Computed Tomography Integrated Navigation System in the Surgical Management of Severe Involvement of Craniofacial Polyostotic Fibrous Dysplasia.

Fibrous dysplasia (FD) is a developmental bone disorder caused by the hamartamatous proliferation of bone-forming cells. A 29-year-old male patient with diagnosis of FD was admitted to our clinic with the symptoms of severe craniomaxillofacial involvement of FD beginning from last year. Neurological examination revealed diplopia, horizontal nystagmus, conductive hearing loss, and partial vision loss. In his medical history, it was reported that he had undergone intramedullary nailing operation in his left femur due to a pathological fracture approximately 8 years ago in the orthopedics clinic of our institution. The patient underwent 3 consecutive surgeries by our plastic and neurosurgical team. The patient was followed-up in the neuro-intensive care unit between the surgical sessions and 1 week after the last operation. Afterwards, he was transferred to the neurosurgical department. No postoperative complication was detected. The preoperative signs were recovered. During his 6th month follow-up control-visit, all his preoperative symptoms were improved. In addition, the patient was satisfied with his postoperative cosmetic improvement. In conclusion, virtual surgical planning and intraoperative surgical navigation systems can make the challenging cases possible to operate with increasing the safety margin of the surgical procedures for polyostotic FD.

Recommendations for management of diabetic foot ulcers during COVID-19 outbreak.

COVID-19 pandemia began in Wuhan, China, in December 2019. A total of 1 878 489 people were infected and 119 044 people were lost because of the disease and its complications by 15 April. Severe morbidity and mortality complications are mostly seen in elderly and patients having comorbidities. Diabetic foot ulcers (DFUs) are one of severe complications of diabetes mellitus and it may require urgent surgical interventions. In this paper, we aimed to create a management algorithm to prevent the unexpected complications that may occur in the patients and health care workers during the evaluation of COVID-19 in DFU patients who require urgent surgical intervention. We advise the use of thorax computerised tomography for preoperative screening in all DFU patients with severe signs of infection and especially those requiring urgent surgery for both the detection of the possible undiagnosed COVID-19 in the patient for the need for close follow-up and protection of the surgical and anaesthesiology team.

Contribution of the Use of a Pen-Type Endoscope to Evaluate and Treat Ears Simultaneously During Cleft Palate Surgery in Late Presented Cases.

BACKGROUND: The prevalence of secretory otitis media is very high among the nonoperated cleft palate patients. METHODS: Ninety-one cleft palate operations were performed on late presented cases in Sudan, Africa. The surgeries were performed according to the Veau-Wardill-Kilner push-back technique. A laptop connected pen-type endoscopic camera was used to evaluate the tympanic membrane and address middle ear disease in all patients simultaneously. The procedure was performed after removing wax from the external auditory canal. A small incision was made with a myringotomy knife through the layers of the tympanic membrane if any sign of fluid collection was observed, after which the middle ear effusion was evacuated and the ventilation tube was inserted. RESULTS: This procedure was undertaken in 182 ears; 41 ears (22.5%) were healthy, 19 ears (10.5%) had chronic perforations, 122 ears (67%) underwent myringotomy procedures, and 54 (44.2%) were treated by inserting a ventilation tube. Despite the challenging work environment, standard monitoring facilities were available and all operations were completed with no early complications. CONCLUSION: The pen-type camera instead of an operating microscope was a tremendous contribution, as it was easy to handle and contributed to the good outcomes. The use of this technique is strongly recommended in surgical camps. LEVEL OF EVIDENCE: III.

Combination of Würinger's Horizontal Septum and Inferior Pedicle Techniques to Increase Nipple-Areolar Complex Viability During Breast Reduction Surgery.

BACKGROUND: Breast reduction techniques depend on the vascularity of the pedicle. Preserving vascularity of the nipple-areolar complex (NAC) is mandatory for reduction mammoplasties, as the NAC is the most important aesthetic and functional unit of the breast. The inferior pedicle technique is the most common method for breast reduction; however, pedicle length may increase after using this technique and cause problems related to NAC viability in gigantomastic and hypertrophic breasts. In this study, we present our technical approach to preserve NAC viability by combining Würinger's horizontal septum and inferior pedicle techniques. METHODS: This study included 60 women (mean age 39.71 ± 10.52 years) who underwent a breast reduction combining Würinger's horizontal septum and inferior pedicle procedures from April 2012 to January 2016. All patients were marked preoperatively in a standing upright position using a prefabricated Wise-pattern template. The base of the pedicle was marked at the level of the inframammary ridge at a width of 8 cm. RESULTS: The patients were followed up for a mean of 5.6 ± 3.3 months. The resection weights of the right and left sides were 1406 ± 566 and 1340 ± 563 g, respectively. Venous insufficiency was encountered in five cases (8.3%) and caused partial NAC necrosis in one case (1.6%). No cases of total NAC necrosis were encountered. Fifteen breasts (12.5%) were described as gigantomastic (resection weight >2000 g). CONCLUSIONS: This combined method may promote safer and more satisfying outcomes from inferior pedicle breast reduction. 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 .

A simple concept for covering pressure sores: wound edge-based propeller perforator flap.

We present a new surgical modification to allow propeller perforator flaps to cover pressure sores at various locations. We used a propeller perforator flap concept based on the detection of newly formed perforator vessels located 1 cm from the wound margin and stimulated by the chronic inflammation process. Between January 2009 and January 2017, 33 wound edge-based propeller perforator flaps were used to cover pressure sores at various locations in 28 patients. In four cases more than one flap was used on the same patient. The patients comprised 18 males and 10 females with a mean age of 41·25 (range, 16-70) years. All patients underwent follow-up for 0-12 months. The mean follow-up duration was 5·03 months. Venous congestion was observed in three flaps that were rotated by 180° (9·1%). However, there was a significant difference between flaps rotated by 90° and 180° according to the complication rate (P = 0·034). Out of 33 flaps, 29 flaps healed uneventfully. Patients were able to sit and lie on their flaps three weeks after surgery. In our study, we were able to obtain satisfying final results using these novel flaps.

Comparison of Cellular Alterations in Fat Cells Harvested With Laser-Assisted Liposuction and Suction-Assisted Liposuction.

OBJECTIVE: The aim of the present study was to evaluate the viability and proliferative capacity of adipose-derived stem cells obtained by laser-assisted liposuction (LAL). METHODS: Fat tissue was obtained from 7 male patients treated surgically for gynecomastia. On one side, harvesting was made before LAL, while it was implemented after LAL on the contralateral side. Viability, cell surface antigens, pluripotency, and apoptosis were assessed and compared in these samples. RESULTS: Cells harvested before and after LAL did not exhibit any significant difference in terms of surface cell markers. Number of viable stem cells was lower initially after exposure to laser, while this difference was reversed at the end of 72 hours. Genetic indicators of cellular differentiation were similar in both groups. Apoptosis indicators were increased remarkably after laser exposure in the first 24 hours, but this increase was absent 72 hours after LAL procedure. CONCLUSION: The authors' results have promising clinical relevance since mesenchymal stem cells harvested during LAL have maintained appropriate cellular features to be used for autologous fat transfer and fat grafting.

Asymptomatic intradiploic epidermoid cyst eroding frontal bone in a patient with craniosynostosis.

Epidermoid cyst located in cranium is uncommon and usually diagnosed with a growing mass leading to symptoms. Asymptomatic intradiploic epidermoid cyst has not been reported yet. In this study, incidental diagnosis of asymptomatic cyst and potential impact of that cyst on surgical planning of a patient with craniosynostosis are presented.

One-Stage Cleft Lip and Palate Repair in an Older Population.

BACKGROUND: In underdeveloped countries one-stage definitive repair of cleft lip and palate is considered for late-presenting patients. MATERIALS AND METHODS: A total of 25 patients with unoperated cleft lip and palate more than 2 years of age were enrolled in this study for one-stage simultaneous repair of cleft lip and palate. According to Veau-Wardill-Kilner push-back technique, 2 flap palatoplasties were performed for palatal repairs; all of the lips were repaired with the Millard II rotation-advancement technique. RESULTS: The authors experienced no perioperative or postoperative life-threatening complications. With respect to the registered operation periods, longer times were required to perform these double operations, but this elongation is shorter than the sum of the periods if the 2 operations had been performed separately. Although the authors were unable to evaluate the late postoperative results because the authors could not follow-up the patients after they were discharged the day after surgery, the early results related to the success of the operation without any surgical complication were prone to meet the parents' and patients' expectations. DISCUSSION: The authors presented their experiences with many volunteer cleft lip and palate trips to third world countries; however the structure of this article is not a new hypothesis and data based to support a scientific study, but observations are objective to get a conclusion. To perform one-stage definitive repair of the cleft lip and palate in late-presented patients was the reality that they had only 1 chance to undergo these operations. According to the terms and conditions of this challenging operation, one-stage simultaneous repair of cleft lip and palate is a more demanding and time-consuming procedure than is isolated cleft lip repair or cleft palate repair. Although technically challenging, single-stage repair of the whole deformity in late-presenting patients is a feasible, reliable, successful, and safe procedure in authors' experience.

Comparison of the flap survival with ischemic preconditioning on different pedicles under varied ischemic intervals in a rat bilateral pedicled flap model.

The study was undertaken to search whether pedicle selection for ischemic preconditioning (IP) and duration of global ischemia applied after IP influenced efficacy of IP on flap viability in epigastric adipocutaneous island flap with bilateral pedicles in rat model. In total, 159 rats were divided into one control and three (primary, secondary, or bilateral pedicle) IP treatment groups. IP was performed on different pedicles by three cycles of 10 minutes of pedicle clamping and 10 minutes of release. After IP procedure secondary pedicle was ligated in all groups, and flaps were exposed to 0, 1, 2, 4, or 6 hours of global ischemia by clamping primary pedicle. In control groups, after the perfusion of bipedicled flaps for 1 hour, left pedicle was ligated and flaps were exposed to global ischemia as in IP groups. On day 5 post-surgery, tissue samples and topographic measurements were taken. No significant differences in semi-quantitative scorings of polymorphonuclear leukocytes infiltration, chronic inflammation, interstitial edema, neovascularization, VEGF, and CD105 expression levels among groups were found (P > 0.05). Percentages of necrosis were consistently smaller in IP groups compared to controls for the same duration of global ischemia, with exception of the no-ischemia. Area of necrosis was significantly smaller in primary IP group versus secondary IP group in the absence of global ischemia (P < 0.01). In the presence of global ischemia, both primary and secondary pedicle IP groups had significantly smaller percentage of necrosis than controls (P < 0.05) and there was no significant difference between primary and secondary IP groups (P > 0.05). Thus, IP performed on different pedicles may ameliorate flap survival in a comparable fashion, depending on the duration of global ischemia. Secondary pedicle IP was as effective as primary pedicle IP and may be feasible in free flap transfers.

The multiple osteotomized free iliac osteocutaneous flap for reconstructions of complex maxillofacial and oromandibular defects.

The vascularized iliac osteocutaneous flap has been used successfully for jaw reconstruction. To obtain a better contour of the reconstructed area in large upper and lower jaw resections, the transferred bone actually needs to be osteotomized. Single closing-wedge osteotomy of the iliac flap for mandibular reconstruction has been previously described. In this article, the modified multiple osteotomized perforator-based versatile free iliac osteocutaneous flap is described. Eleven cases were enrolled. Seven patients had wide anterior mandibular resections due to oral cavity and mandibular tumors; 3 patients had a defect due to explosive injury and 1 patient had complicated orbitomaxillary defect due to blast injury. Skin paddle was based on the perforators. In 8 patients, the bony segment was divided into 3 segments by 2 osteotomies, whereas in 2 patients the bony segment was divided into 4 segments by 3 osteotomies. In 10 cases, the flap was used for anterior mandibular defects, whereas in 1 case the flap was customized to fit an L-shaped defect at the naso-orbito-maxillary region. The overall flap success rate was 100%. No resorption or morbidity related to the osteotomy of the bony segments was observed. The size of perforator skin paddle was 6 to 8 × 15 to 18 cm. Physical and radiologic examinations showed proper bone healing without any additional complications. The modified multiple osteotomized free osteocutaneous iliac flap can provide a safe and versatile bony segment to be arranged and adapted to reconstruct complex mandibular and maxillofacial defects.