The Use of Three-Dimensional Printed Technology for Mandibular Reconstruction in a Rare Case of Giant Odontogenic Myxofibroma.

ABSTRACT: Odontogenic myxofibroma is a benign odontogenic tumor of mesenchymal tissue that generally originates from the mandible. It is an extremely rare tumor accounting for approximately 2% of all odontogenic tumors. In this report, the authors presented a giant right mandibular mass that extends to the angle of the mandible and displacing the tongue laterally caused significant malocclusion, pain, and impaired oral intake. The tumoral involvement of the mandibula required a partial mandibulectomy with the resection of right mandibular ramus, body, and bilateral parasymphysis. Right mandibular condyle was preserved. The mandibular defect was reconstructed with a fibula free flap. Three-dimensional printed maxillofacial bone model of the patient was used as contour modeling and guide. Histopathologic examination confirmed the diagnosis as odontogenic myxofibroma.The purpose of the report is to present a very rare case of odontogenic myxofibroma and its general characteristics, radiological features, differential diagnosis, surgical management, and the use of three-dimensional printing technology in the field of mandibular reconstruction.

Effects of Open Technique Rhinoplasty on Mimicry: Electroneurographic Evaluation.

OBJECTIVE: This study was designed to investigate the effects of open technique rhinoplasty on facial nerve terminal branches more concerned with mimicry via electroneurography (ENoG). METHODS: Twenty patients ages between 24 and 36 years were included in the study. Five nasal mimicry muscles were used to evaluate axonal loss of the facial nerve: bilateral transverse nasal, levator labii superioris alaeque nasi (LLSAN), and procerus muscles of all patients were evaluated preoperatively and postoperative third month by ENoG. The patients that have abnormalities regarding the amplitude and latency at third month were reevaluated at sixth month postoperatively. RESULTS: Mean latencies of the facial nerve were calculated to be increased for all muscles at third postoperative month, but this increase was significant only for left LLSAN (P = 0.002). Amplitudes of the facial nerve decreased in all of the groups, but this decrease was not significant (P > 0.05). Two patients with exceptionally long latency facial nerve response of transverse nasal muscle and 11 muscle recordings with abnormal low amplitudes of the facial nerve at the third month was reevaluated at sixth postoperative month and the values were improved. CONCLUSIONS: This study demonstrated that facial nerve integrity is minimally affected after rhinoplasty, yet all affected muscles were recovered on the long term.

Lessons learned from the first quadruple extremity transplantation in the world.

BACKGROUND: Limb transplantation is emerging as a promising area of surgery and is an indispensable alternative for prosthetic rehabilitation of amputees, the severity of which is increasing because of combat-related injuries. Successful unilateral and bilateral limb transplantations have already been performed before this operation. METHODS: We performed the first ever quadruple limb transplantation in February 2012. The limbs procured from a 40-year-old man heart-beating donor were transplanted to a 27-year-old male patient who was a quadruple amputee for the last 14 years because of an electrical injury. RESULTS: To shorten the ischemic period to a minimum, 3 separate microsurgery teams worked simultaneously. All extremities were reperfused within 8 hours of procurement, and the operation lasted for 12 hours. Metabolic load was managed by hemodialysis. One hour after the completion of the operation, cardiac arrest developed, resuscitation of which necessitated median sternotomy and temporary partial cardiopulmonary support. Despite the removal of the transplanted limbs and all efforts including continuous hemodialysis, plasmapheresis, and extracorporeal membrane oxygenation, the patient died on the fourth day after transplantation in a clinical condition of severe systemic inflammation. CONCLUSIONS: The problems we faced were difficulty of vascular access for invasive monitoring and fluid replacement, and the severe systemic inflammation effects of which could not be dealt with, despite aggressive supportive treatment. We hope that our experience will enlighten the surgeons who are willing to extend the limits of limb transplantation and serve the success of future operations.

The double scalpel flap: a new technique for the closure of circular skin defects.

Reconstruction needs to be designed attentively to obtain a functional and a good aesthetic consequence for closing skin defects. Numerous local flaps have been defined to conceal skin defects. However, new techniques are still required, especially for circular type of skin defects.This study describes a new technique that has been well defined to repair the circular type of skin defects. The technique basically uses extra skin relaxation provided with 2 opposing flaps' rotation maneuver in favor of the defect closure. The objective of this technique is for the flaps to start from one border of the defect and extend just to the other border, not invading beyond the defect borders. This enables us to apply the procedure on defects that are close to important anatomical structures because it is sufficient to use only the opposing 2 sides of the defect for its closure.With this method, 2 opposing flaps that resemble the tip of a scalpel were rotated to the existing circular defect; and by suturing these 2 flaps at the midline, the defect was closed. This technique was applied to 17 patients between the ages of 48 and 83 years. Defect sizes were between 2.5 × 2.5 and 5 × 5 cm.With the use of opposing flaps designed narrower than half-width of the defect, a tension-free closure could be achieved on both the donor and the recipient site. No flap necrosis was detected on any patients. After a mean follow-up of 11 months (3-26 months), it was realized that a good aesthetic appearance could be achieved in all the patients about 2 to 3 months postoperatively.

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.

Subgaleal-subperiosteal flap for forehead and scalp reconstruction.

Forehead soft tissue defects are most usually associated with motor vehicle accident and less commonly with physically assault, trauma resulting from falls, malignant tumor resection, and burn injury. These kinds of defects incorporate only the soft tissue in general but sometimes there are accompanying bone defects. Different reconstruction alternatives can be preferred depending on the defect type and the amount of tissue loss. In this report, a patient who underwent surgery for tumor excision is presented. After surgical excision, denuded frontal bones were covered with subgaleal-subperiosteal flap. Split thickness skin graft harvested from the medial upper arm was used for skin resurfacing. Optimal healing and cosmetic outcome were obtained using 1-step surgical procedure.

Reconstruction of internal nasal valve, septum, dorsum, and anterior structures of the nose in a single procedure with a molded bone graft: the sail graft.

Excessive surgical removal or traumatic loss of the tissues supporting the nasal roof can result in the "saddle nose" deformity. It involves both cartilage and bone deficiencies. Two main resources are used to reconstruct this difficult deformity: autogenous bone and cartilage grafts and alloplastic materials. This study presents the reconstruction of the dorsum, septum, internal nasal valve, and anterior structures and the tip of the nose using a block of molded autogenous bone graft. We called it the "sail graft," because it looks like a sail from a lateral view. The mast of the sail is oriented in a superior-to-inferior direction, beginning in the frontonasal region to the tip of the nose to form a straight, well-rounded dorsum. The longest postoperative follow-up of 13 cases is now 10 years; the median follow-up is 2 years. The results have been satisfactory.

Treatment of "en coup de sabre" deformity with adipose-derived regenerative cell-enriched fat graft.

Linear scleroderma "en coup de sabre" is characterized by atrophy and furrowing of the skin of the front parietal region above the level of the eyebrow. In most cases, it occurs as a single paramedian line that may be associated with hypoplasia of underlying structures and hemiatrophy of the face. The affected region is a depression that may be associated with hypoplasia of the underlying soft tissues and bone that results in facial hemiatrophy. If the lesion is narrow, it can be resected and directly sutured; in the case of a wide lesion, many different reconstructive techniques, directed at augmentation of deficient soft tissue volume, have been proposed such as autologous tissue grafts, biomaterials, pedicled flaps, and free flaps. Adipose-derived regenerative cells (ADRCs) can be easily processed from lipoaspirated fat and can provide a significant quantity of multipotent cells for a variety of therapeutic regenerative medicine therapies. There is an increasing interest in a possible therapeutic role of ADRCs from processed lipoaspirate for many applications, including their use as soft-tissue fillers. We introduce the application of a successful ADRC therapy for a linear scleroderma en coup de sabre deformity.

Autologous fascia lata graft for contour restoration and camouflage in tertiary rhinoplasty.

Tertiary rhinoplasty is a surgical procedure to correct nasal deformities that have been developed after prior unsuccessful surgeries. Such surgery requires complicated manipulations and tissue grafting for proper restoration. In the current study, we report the use of fascia lata graft combined with cartilage grafts for contour restoring and camouflage. Twenty-three patients who had severe nasal deformities were included, of whom 14 were men and 9 were women. Their ages ranged between 24 and 34 years (mean, 29 y). All patients were twice previously operated on by surgeons other than the authors. An informed consent was obtained from all patients. After harvesting the costal cartilage, the fascia lata graft (mean size, 2-3 cm) was uniformly harvested from the right lateral thigh. Application of the fascia lata and the cartilage graft was achieved through the open rhinoplasty incision. The fascia lata was applied over the cartilage in the dorsal region in 20 patients (86.9%), applied over the reconstructed alar and dome area in the nasal tip in 8 patients (34.7%), and applied over both areas simultaneously in 4 patients (17.3%). Postoperative follow-up was between 14 and 35 months (mean, 24.5 mo); clinical evaluation, photographic documentation, and a questionnaire form related to donor-site morbidity and patient satisfaction were applied after 12 months of the follow-up period. Results showed that all patients had an improved aesthetic result, and no apparent irregularities were observed in the integument of the aesthetic lines. No complications or no requirement for revision surgery was observed later on. In conclusion, refinements of the nasal dorsum and the nasal tip in tertiary rhinoplasty are indeed important and difficult to be managed. Placing the fascia lata over the applied cartilage grafts provide a good cover that conceals the possible irregularities or distortions that may appear in the late postoperative period.

Adipose Derived Regenerative Cell Therapy for Treating a Diabetic Wound: A Case Report.

BACKGROUND: Recent studies have reported on the use of adipose derived regenerative cells (ADRC) as a therapeutic method in wound healing. The present study introduces the first application of successful ADRC therapy for a diabetic foot wound. CASE REPORT: A 63-year-old woman with diabetes mellitus complaining of an opened necrotic wound in the plantar aspect of the right foot was admitted by another surgeon for debridement surgery. Despite multiple efforts, a Chopart's amputation was performed to salvage rest of the foot. In the early postoperative period, a 2 cm x 2 cm circular ulcer at the heel region and a 1 cm x 2 cm unhealed wound at the previous incision site had formed. Due to resistant diabetic ulcers, the patient was introduced to ARDC therapy (informed consent was obtained). The Celusion SystemTM (Cytori Therapeutics, Inc, San Diego, CA) was used for autologous generation of ARDC cells-1 cc of the ARDC was mixed with 40 cc of fat graft. Afterward, the ARDC-enriched fat graft was introduced to the heel and plantar region to restore the deficient glabrous tissue. The remaining 4 cc of ARDC were equally injected in a radial fashion to the wound edges. RESULTS: In the postoperative follow-up, accelerated wound healing was observed and the ulcers were completely healed after 4 weeks of ARDC treatment. CONCLUSION: ARDC therapy has the potential to be a promising new therapeutic modality for treating diabetic wounds.

Pre-auricular and ascending helical free composite flap in reconstructing an alar defect resulting from a human bite: a case report.

Full-thickness defects of the nose result in severe aesthetic and functional problems. Nasal alar defects are frequently caused by trauma, surgical resection or congenital deformities, yet an alar defect due to a human bite is quite rarely seen. For a successful alar reconstruction, selected tissue must be similar to nasal structures in texture, color and thickness. The structural similarities between the nasal alae and auricular helices have allowed the use of free helical composite flaps for the repair of nasal defects. In this article, we report a 36-year-old male patient who had a right alar defect caused by a human bite. The defect was successfully reconstructed with a reverse flow superficial temporal vessel based pre-auricular and ascending helical free composite flap. Since the color and the texture of the flap was compatible with the nose integuments, this flap enjoyed of an optimal integration in the central facial area.

Tracheal paraganglioma: a case report.

Paragangliomas are neuroendocrine tumors that originate from extra-adrenal chromaffin cells. The trachea is an unusual site for paragangliomas. A 29-years-old female was admitted to our clinic with complaints of recurrent hemoptysis and dyspnea, and a 1.5x1.3 cm mass in the posterior wall of the trachea, which was subsequently diagnosed as a paraganglioma. In this report, we presented the 11th case of tracheal paraganglioma, a rare benign tracheal tumor, and reviewed the medical literature.

The bipedicled latissimus dorsi myocutaneous free flap: clinical experience with 53 patients.

The Latissimus dorsi musculocutaneous flap is a valuable workhorse of the microsurgeon, especially in closing large body defects. One of the pitfalls in harvesting the flap, is particularly in its inferior aspect which may be unreliable. Here we report a series of 53 patients who were undergone bipedicled free latissimus dorsi musculocutaneous free flaps for extensive tissue defects. The age of patients were between 5 and 64 and all of them were males. The wound sizes in these patients ranged between 31-35 x 10-12 cm and flap dimensions were between 38-48 x 6-8 cm. Perforator branches of the 10th intercostal vessels were dissected and supercharged to the flaps to reduce the risk of ischemia of the inferior cutaneous extensions. The secondary pedicles were anastomosed to recipient vessels other than the primary pedicles. Recipient areas were consisted of lower extremities. Four patients suffered of early arterial failure in the major pedicle and all revisions were successfully attempted. Neither sign of venous congestion nor arterial insufficiency were observed at the inferior cutaneous extensions of the flaps, and all defects were reconstructed successfully. All donor sites were primarily closed, only two patients suffered from a minor area of superficial epidermal loss at the donor site, without suffering any adjunct complications. In conclusion coverage of large defects can be safely performed with extending the skin paddle of latissimus dorsi flap as a bipedicled free flap.

Adenolipoma of the nose: a case report.

Adenolipoma is a rare benign neoplasm composed of both mature adipose tissue and glandular elements. In this article we report a case of 19-year-old woman, who had nasal blockage and deformity. On examination, a round, soft, nonpulsatile submucosal mass in the cartilagenous vault of the right nasal cavity was found. There was also alar rim notching, nostril asymmetry on the right side and septal deviation towards the opposite side. Computed tomography revealed a clearly demarcated dense mass located at the right submucopericondrial level obstructing the nasal passage. An open septorhinoplasty approach was preferred to remove the mass and also to correct the deformities caused by the mass. The histopathologic examination was reported as an adenolipoma. No recurrence was observed during postoperative two year follow-up. To our knowledge, this is the first case report of an adenolipoma of the nose in the English literature.

Generation of Skin Tissue Using Adipose Tissue-Derived Stem Cells.

BACKGROUND: The aim of this study was to generate skin tissue using adipose tissue-derived mesenchymal stem cells. METHODS: Thirty Wistar albino rats were used. A 2-cm-diameter full-thickness skin defect on the back of each rat was formed. A secondary wound healing model was constituted in group 1, fibrin matrix only was applied in group 2, a keratinocyte-coated fibrin matrix was applied in group 3, an adipose tissue-derived mesenchymal stem cell-seeded fibrin matrix was applied in group 4, and a keratinocyte-coated and adipose tissue-derived mesenchymal stem cell-seeded fibrin matrix was applied to the defects in group 5. RESULTS: A similar form of wound healing, with contraction from the edges and ulceration at the center, was observed in groups 1, 2, and 3. The wound contraction was reduced in group 4, and the epidermis was creeping from the surrounding tissue but with some ulcerations in the central part of the wounds. In group 5, the defect area was almost totally epithelialized, with minimal wound contraction. By microscopic analysis, significant increases in the collagen volume ratios and vascular volume ratios were determined in groups 4 and 5. From the fluorescent micrographs, fibroblastic differentiation and extracellular matrix synthesis, endothelial differentiation of stem cells, and neoangiogenesis and epithelium derived from marked keratinocytes were observed in group 5. CONCLUSION: Formation of the adipose tissue-derived mesenchymal stem cell-seeded and keratinocyte-coated autologous fibrin scaffold leads to significant skin replacement.

Human olfactory stem cells for injured facial nerve reconstruction in a rat model.

BACKGROUND: The purpose of this study was to show the efficacy of olfactory stem cells for injured facial nerve reconstruction in a rat model. METHODS: Olfactory stem cells were isolated from the olfactory mucosa of human participants. A 2-mm excision was performed on the right facial nerve of all rats. Reconstruction was performed with a conduit in group 1 (n = 9); a conduit and phosphate-buffered saline in group 2 (n = 9); and a conduit and labeled olfactory stem cell in group 3 (n = 9). Rats were followed for whisker movements and electroneuronography (ENoG) analyses. RESULTS: The whisker-movement scores for group 3 were significantly different from other groups (p < .001). ENoG showed that the amplitude values for group 3 were significantly different from group 1 and group 2 (p = .030; p < .001). Group 3 showed marked olfactory stem cell under a fluorescence microscope. CONCLUSION: This study suggests that olfactory stem cells may be used as a potent cellular therapy for accelerating the regeneration of peripheral nerve injuries. © 2016 Wiley Periodicals, Inc. Head Neck 38: E2011-E2020, 2016.

In vivo tissue-engineered allogenic trachea transplantation in rabbits: a preliminary report.

Conventional tracheal reconstruction techniques are not successful at restoring functional units in situations with extensive damage involving more than half the length of the trachea. For the first time, we investigated in vivo tissue-engineered trachea regeneration from a decellularized cadaveric trachea matrix with seeded adult adipose tissue-derived mesenchymal stem cells (MSCs) and investigated the integration of the matrix into the recipient tracheal side. For the procedure, 1.8-cm grafts were prepared from 3.5-cm tracheas of three donor rabbits. Then, tracheal grafts were rendered nonimmunogenic using a decellularization technique. MSCs isolated from recipient rabbit adipose tissue were cultured and marked before being seeded in the decellularized matrix. A total of 1.8 cm of the recipient tracheas was replaced with either a decellularized tracheal matrix (group 1) or tracheal matrix-seeded MSCs (group 2). Rabbits survived 17 ± 2 days in the first group, and the causes of death were separation in the anastomosis region, airway obstruction, and infection. In the second group, animals were sacrificed on the 30th, 60th, and 90th days of follow-up. Histopathological analysis revealed the integration of MSCs seeded-decellularized cadaveric tracheas to the recipient tracheal sides and increased angiogenesis. The MSCs were traced by fluorescence microscopy in the ciliated epithelium, under the epithelium, and in the cartilage of the integrated new trachea. Tracheas generated by autologous cells and tissue-engineering techniques will be a great source for the treatment of life-threatening tracheal injuries after the completion of related studies.

Comparative clinicoanatomical study of ilium and fibula as two commonly used bony donor sites for maxillofacial reconstruction.

We assessed the morphological characteristics and dimensions of the ilium and fibula to evaluate the suitability of particular areas of bone for use as donor sites for dental reconstructions that carry implants. We measured the dimensions of 130 bilaterally harvested ilium and fibula bones from 65 adult cadavers using osteometric methods, and analysed the effects of age, sex, and side. Dimensions at measuring points, overall suitability for implantation, and relations among age, sex, and side, were evaluated statistically. We report observations of bone morphology involving cross-sections, and clinical relevance. Although the mean dimensions of the fibula and iliac crest were adequate, some segments would not support an implant 10 mm long and 3.5 mm wide. The overall suitability of parts of the iliac block fell to 30%. Fibular morphology is characterised by constant height and width, and relation of cortical and cancellous bone. Bony dimensions on the iliac fossa and fibula were significantly greater in men than in women. Age had a negative impact in one area of the iliac fossa, but nowhere on the iliac crest. Side was not significant. We found differences in dimensions and morphology between measuring points on the same bone. Precise knowledge about which areas of the donor sites can reliably provide sufficient bone to carry implants after reconstructions will allow greater flexibility and safety when reconstructions are designed.