Advantages of simultaneous radial nerve and tendon reconstruction - a case report.

Transection of the radial nerve is frequently associated with humeral shaft fractures that are part of a very complex upper extremity injury. In the presented case, a 19-year-old man with a 10-cm radial nerve defect with a need for nerve grafting to recover complete sensory and motor deficit of the radial nerve. In our case, at the same time we provided the tendon transfer of musculus (m.) pronator teres to m. extensor carpi radialis brevis, m. flexor carpi ulnaris to m. extensor digitorum communis, m. palmaris longus to m. extensor pollicis longus, and long sural nerve graft because of an extensive zone of the injury. The assumption was that if these two procedures are performed in one surgery, it will accelerate overall recovery, restore the functionality of the upper limb more quickly, and thus enable a faster recovery.

Three-Stage Paramedian Forehead Flap Reconstruction of the Nose Using the Combination of Composite Septal Pivot Flap with The Turbinate Flap and L-Septal Cartilaginous Graft - a Case Report.

Nasal basal cell carcinomas are the most common malignant tumors of the facial skin, which predilectively affect areas exposed to sunlight, including the nasal area. After their radical removal, there is a variable complex defect of the affected area (defect of all 3 layers of the nose) or even a composite defect (it also occupies the adjacent soft tissues around the nose), which are usually used to reconstruct this area. A 73-year-old female patient with recurrent infiltrative basal cell carcinoma of the left nasal ala underwent four re-excisions before histologically verified free margins without the presence of the tumor. The result was a composite defect that occupied the top of the dome of the right nostril, the entire left half of the soft nose, including the base of the wing, part of the upper lip, and a defect of the adjacent face area of 9 × 5cm. In the first phase, the left cheek and upper lip were reconstructed by advancement French plasty and coverage of the two residual skin defects with full-thickness skin graft. One month later, during the second phase of reconstruction, the flap was re-elevated, shifted and rotated, and a three-stage nasal reconstruction was started using a composite septal pivotal flap and left turbinate flap for inner lining reconstruction, and the nasal skeleton was reconstructed with a cartilaginous L-graft from the 6th rib, septal and conchal cartilages. The skin cover of the nose was reconstructed with the left paramedian forehead flap, which was thinned during the second stage with the simultaneous widening of the bottom of the left nostril by the transposition flap, during the third stage the flap pedicle was removed. In the reconstruction of a complex defect of the nose and its surroundings, it is first necessary to create a stable platform on which the reconstruction of the nose itself will be performed. To achieve an excellent functional and aesthetic result of nose reconstruction, it is appropriate to use a three-stage forehead flap. In this paper, we describe a unique method of nasal reconstruction - a combination of a septal pivotal flap with a turbinate flap to reconstruct the inner lining in conjunction with an L-graft to ensure a stable nasal skeleton and forehead flap to reconstruct the skin cover.

Anterior open bite - diagnostics and therapy.

An anterior open bite (AOB) is an occlusal disorder that causes the patient both an aesthetic and functional handicap. The lower third of the face is disproportionately larger. Patients are unable to properly occlude with the anterior part of dental arch and occlusion only happens in the premolar and/or molar regions. An anterior open bite may be the result of anatomical anomalies. Long term stability as well as an immediate outcome of the surgery depends on the choice of a suitable treatment strategy. In this article, we review options of AOB treatment, from classical orthodontic treatment to current combined orthodontic and surgical approach with a benefit of an anchor system.

INDICATION AND IMPORTANCE OF RECONSTRUCTIVE SURGERIES OF FACIAL SKELETON IN MAXILLOFACIAL SURGERY: REVIEW.

Malignant head and neck tumors belong among common diseases and their incidence constantly rises. In the Czech Republic, the proportional representation of orofacial tumors ranges around 2% of the total number of malignancies. Rational treatment of these tumors is complex and long. In the course of therapeutic planning, you have to consider the age of the patient and the stage of the disease including the presence of distant metastases. Removal of the tumor with a sufficient safety margin and an eventual treatment of the relevant lymphatic system according to the type of the tumor is an important prerequisite for the success of the surgical therapy. Reconstructive procedures in maxillofacial oncosurgery presume good interdisciplinary cooperation and a high professional preparedness of the surgical and nursing team. Selection of the right patient is also very important with regard to the risks of both local and systemic postoperative complications. Use of the free flap techniques is currently the gold standard, but it is also necessary to master pedicled flap techniques, whose advantages lie in simpler technique and often better aesthetic results. At the same time, we have to realize that even traditional, classical reconstructive procedures using prosthetic replacements can still represent the ideal solution in many cases.

BILOBED FLAP IN FACIAL RECONSTRUCTION.

INTRODUCTION: The bilobed flap was first described by Esser in 1918. He used it to reconstruct the defects of the nose. It has been used in the reconstructions of trunk and feet defects by many authors since then. Its principle is also advantageous in reconstructions of larger facial defects. Successful reconstruction of problematic suborbital area using the bilobed flap was reported by Yenidunya in 2007. The design of the flap can be successfully used in other atypical facial defects. MATERIAL AND METHODS: The bilobed flap was used to cover facial defects of 199 patients who underwent 203 tissue reconstructions from 1st January 2007 to 31st December 2016 at the Department of Plastic and Aesthetic Surgery St. Anne´s University Hospital in Brno. RESULTS: The flaps were equally distributed between the genders, men 101 and women 98. Ages of patients ranged from 39 to 98 years (mean 76 years). It was used in the reconstruction of the tip and alars defects of the nose 159 times, in the reconstruction of periorbital defects 16 times and in other atypical facial areas 28 times. The excision of malignant tumours of the face (basal cell carcinoma, squamous cell carcinoma, SSM) were usually the causes of the defects (89.7%). There were 80 cases with defects of the nasal tip and ala in men and 79 cases in women. Complications occurred 41 times of all reconstructions (20.2%). The most common complication was abundance of the flap (4.9%). The postoperative results were favourable due to the preservation of colour, texture and function of the reconstructed areas. CONCLUSION: Bilobed flap in different modifications should always be considered in the reconstruction of extensive defects of the face, because unlike other techniques, it preserves good texture and colour of facial skin with minimal donor site morbidity.

USE OF MEDIAL FEMORAL CONDYLE FLAP AND ANTEROLATERAL THIGH FREE FLAP IN PROXIMAL TIBIAL POSTTRAUMATIC NON-UNION WITH MULTIPLE ANASTOMOSIS - CASE REPORT.

Fractures of the proximal tibia are high energy fractures. According to available literature, 3-4% of all fractures heal problematically with non-union or osteomyelitis. Usage of locking compression plating system as well as usage of hybrid fixator is associated with the risk of compartment syndrome, local infection and subsequent malunion, osteomyelitis or non-union. We present a case of 30-year-old male suffering from posttraumatic non-union. The medial femoral condyle flap was selected due to its favourable properties providing a highly vascularised osteogenic tissue in combination with anterolateral thigh flap and Corlett loop. Our case report describes a reconstruction of a long weight-bearing bone. Despite the amount of anastomoses and usage of vein graft, the selected method of reconstruction seems to be safe and with a long-lasting benefit for the patient.

HIRUDOTHERAPY IN RECONSTRUCTIVE SURGERY: CASE-REPORTS AND REVIEW.

Medicinal leeches (Hirudo medicinalis, Hirudo verbana) have been used in the field of medicine to treat various diseases for thousands of years. Popularity of their use changed over time and in Europe, it peaked at the beginning of the 19th century. In modern medicine, application of leeches on flaps with venous congestion was first used and described by Deganc and Zdravic in 1960. A certain renaissance of leech use is currently taking place, especially in the field of reconstructive surgery. In general, use of leeches is indicated during critical post-operative period, in which the microcirculation and veins are incapable of sufficient drainage of venous blood, which can lead to stagnation of circulation in tissues at all levels, clinically manifested as a change in color and turgor of the flap. If this venostasis is not recognized in time and treated adequately, tissue necrosis can develop. Medicinal leeches can be used in venous drainage disorders after a replantation of fingers, auricles, lips and parts of the nose. In head and neck reconstructive surgery, there are many studies that confirm the success rate of hirudotherapy in hematoma evacuation or in dealing with complications after scalp replantation and transfers of free and pedicled flaps. Leech application therapy can also be indicated as a part of non-surgical methods that improve conditions of the venous system.

SKIN SUBSTITUTES IN RECONSTRUCTION SURGERY: THE PRESENT AND FUTURE PERSPECTIVES.

The progress in critical and intensive care burn management in the 21st century has significantly reduced mortality in patients with critical burn injuries. This progress has moved the focus of burns care from simple survival to the quality of life after the burn trauma, in particular to healing of defects caused by full-thickness burns, subsequent maturation, characteristics and appearance of the scars. The benefits of the application of skin substitutes include elimination of excessive scarring, hypertrophic and keloid scar formation and subsequent contracture development. The authors of this article present the strategy of use, application and development of dermal scaffolds as well as the current trends in the use of dermal scaffolds in the treatment of full-thickness burns.

Pedicled pectoralis major flap in head and neck reconstruction - technique and overview.

The pedicled pectoralis major flap was the original workhorse flap for head and neck reconstruction. Over time, it became the secondary choice for oropharyngeal reconstruction with the implementation of free-soft tissue transfers. Nowadays, a polymorbid patient is primarily indicated for pedicled pectoralis major flap reconstruction, other indications include combinations of pedicled pectoralis major flap with free microvascular flap, salvage reconstruction due to complications, salvage reconstruction due to free flap failure and salvage reconstruction due to recurrent or extended primary disease. Pedicled pectoralis major flap can be successfully used for specific oropharyngeal defects, even primary resections, especially for less cooperative patients and patients after extensive neck dissection. Improving the flap harvesting techniques can reduce undesired complications in specific cases of oropharyngeal reconstruction. Flap morbidity in these cases remains comparable to morbidity of patients who had undergone free flap reconstruction. Pedicled pectoralis major flap remains valid reconstruction tool that should be included in the armamentarium of each surgeon dealing with reconstruction of the head and neck.

Pedicled pectoralis major flap in head and neck reconstruction - our experience.

INTRODUCTION: The pedicled pectoralis major flaps are still harvested and mainly indicated for reconstruction in the polymorbid patient. Other indications are combinations of pedicled pectoralis major flaps with free microvascular flap, salvage reconstruction following complications, free flap failure and recurrent or extended primary disease. MATERIALS AND METHODS: We describe the pedicled pectoralis major flap in 18 patients operated on at the Department of Oral and Maxillofacial Surgery, Olomouc from 1st January 2014 to 1st December 2016. RESULTS: Fifteen oropharyngeal defect reconstructions were performed using pedicled pectoralis major flap (including 1 submandibular defect of the neck). Indications were primary resection in polymorbid patients in 10 cases and recurrent diseases after previous neck dissection and radiotherapy in 5 cases. Pedicled pectoralis major flap was used for secondary reconstruction in 3 cases. Complications occurred in 50 % of patients, 28 % were major and 22 % minor. Major complications included a total flap failure (defect was successfully treated with free tissue transfer of latissimus dorsi myocutaneous flap) in 1 case, plate exposure in 2 cases, large dehiscence and large hemorrhage 1 case each. Minor complications included only small dehiscences (22 %). One was associated with fluidothorax after rib harvesting (6%). There were no cases of neck contracture or supraclavicular bulge. CONCLUSION: Even today, usage the pedicled pectoralis major flap in head and neck reconstruction surgery cannot be considered as an obsolete reconstructive procedure that has been completely replaced by a free microvascular flap. Innovations of flap harvesting techniques and high rate of flap survival are the main reasons why pedicled pectoralis major flap can still be primarily indicated for high-risk patients, non-cooperative patients and also for patients with extensive neck dissection. The pedicled pectoralis major flap has been the first choice in salvage surgery, in cases of a complication or free flap failure or a recurrence of a primary disease.

Lipomodelling - advanced technique for the correction of Congenital hypoplastic breast malformations and deformities.

A variety of surgical techniques has been used to correct hypoplastic breast malformations and deformities, including tissue expanders, breast implants, custom chest wall implants, mammary gland remodelling, as well as locoregional or free flap. Case series of successful breast reconstruction using lipomodelling technique in one patient with severe Polands syndrome and two patients with tuberous breasts are reported together with literature review. No surgical complications were observed and ultrasound examination did not reveal any pathology in breast tissue other than oil pseudocysts postoperatively. In both malformations, submammary fold was moved downwards. Moreover, the lower part of the breast and areolar herniation was corrected in tuberous breast, and in Polands syndrome, the areolar complex was significantly shifted downwards and laterally. In comparison with other reconstructive techniques, lipomodelling allows for the breast correction to begin in early adolescence. Further growth of the unaffected breast may be effectively corrected by subsequent lipomodelling session. This technique appears to change the overall approach to the management of hypoplastic breast and chest wall malformations.

TWISTED DISTAL LATERAL ARM FLAP FOR IMMEDIATE RECONSTRUCTION OF THUMB AVULSION INJURY.

BACKGROUND: Replantation is a complicated procedure in avulsion injuries in majority of the cases. When replantation of an avulsed thumb is not feasible, it is mandatory to find an appropriate reconstruction choice as soon as possible due to the importance of the thumb function in the dynamics of the handgrip. MATERIALS AND METHODS: Three patients with skin avulsion injury underwent immediate reconstruction by twisted lateral arm flap in our department since 2004. RESULTS: No infection, hematoma, partial or complete flap necrosis were observed after the procedure. All of the flaps healed without complications. CONCLUSION: Although the gold standard in reconstruction of these trauma defects is the use of local skin flaps or distant inguinal flap, these reconstructive choices have multiple drawbacks such as the loss of sensibility and they are thicker. In thispaper we propose a modification of distally planned lateral arm flap design and a new technique of its spiral shaping for immediate thumb reconstruction.

VASOSPASM OF THE FLAP PEDICLE--MAGNESIUM SULPHATE RELIEVES VASOSPASM OF AXIAL FLAP PEDICLE IN PORCINE MODEL.

BACKGROUND: The effect of magnesium sulphate on mechanically provoked vasospasm of the flap pedicle on porcine model was not studied yet. Positive effect of magnesium sulphate on vasospasm was proved in previous studies on rat. METHODS: The bilateral pedicled flaps based on the caudal superficial epigastric arteries were raised on 8 pigs. Flaps on the right side were the treatment group; flaps on the left side were the control group. The vasospasm was provoked by the tension applied on the pedicle in the axial direction using 160g weight. The blood perfusion of the flap was monitored using laser-Doppler. The duration of the vasospasm was defined as the time from the release of the tension until the blood flow began to rise. These times were detected using an automated computerized detection. In the treatment group, magnesium sulphate was given topically on the vessel; saline was used in the control group. RESULTS: The duration of the vasospasm in the treatment group was significantly shorter than in the control group (P = 0.024). CONCLUSION: Magnesium sulphate 10% shortened significantly the mechanically provoked vasospasm on caudal superficial epigastric flap in a porcine model. Further clinical studies are needed to prove the effect in humans.

The use of medicinal leeches in fingertip replantation without venous anastomosis - case report of a 4-year-old patient.

Replantation of amputated fingertip is a technical challenge to the microsurgeons. The success rate depends directly on the availability and the size of preserved vessels and on the degree of their damage. In distal digital amputations, veins are usually not easily recovered or even absent, and thus high number of replantation procedures fails because of the venous congestion. The use of medicinal leeches is a treatment option for venous congestion of replanted fingers. A case report of a 4-year-old patient after fingertip replantation without venous anastomosis when temporary venous drainage was provided by an application of medicinal leeches is reported together with literature review. We observed an unusually short duration of venous congestion (48 hours) and there was no need of blood transfusion.

[Treatment of a ruptured extensor policis longus tendon by extensor carpi radialis longus transfer]. / Vliv slachového transferu extensor carpi radialis longus - extensor pollicis longus na funkci ruky.

PURPOSE OF THE STUDY: Two tendons, i.e., the extensor indicis proprius (EIP) and the extensor carpi radialis longus (ECRL), are commonly used to reconstruct the function of a ruptured extensor pollicis longus (EPL) tendon. We reviewed a group of patients with EPL ruptures treated by ECRL tendon transfer to the EPL tendon, which was the method of choice. The aim was to evaluate the results and to assess the effect of ECRL detachment on hand function. MATERIAL AND METHODS: Twenty patients were treated surgically for a subcutaneous rupture of the EPL tendon between 2003 and 2007. Each patient was examined at 2 years after surgery. The range of motion (ROM) of both the injured and the contralateral hand was recorded and evaluated with a modified Geldmacher scoring system; a response to the DASH questionnaire was obtained. The mean follow-up was 24 months (19-31 months). RESULTS: For the ROM of the operated hand, the mean Total Active Motion (TAM) of 98.75 degrees (60-140, SD 22.74) was calculated. The mean extension lag at the interphalangeal (IP) joint was 5.42 degrees (0-25, SD 8.77) and the mean IP flexion was 65.8 degrees (40-80, SD 13.2). In order to evaluate body side differences, the ROM of the contralateral thumb was recorded. The values were as follows: mean TAM, 141.3 degrees (115-190, SD 20.43); mean IP extension lag, 0 degrees (0-0, SD 0); mean IP flexion, 68.8 degrees (50-80, SD 9.6). DISCUSSION: The extension lag at the IP joint was detected in both the operated and the contralateral hands. The patients examined at a longer interval after surgery showed an increase in extension lag. This may have been caused by undesired adaptation of the donor muscle, the presence of adhesions or suture loosening. CONCLUSIONS: The results showed increased adaptation of thumb motion to the extension lag at the IP joint, which had a mild effect on the patient's hand function. The difference in wrist extension between the operated and the contralateral hand corresponded to the pre-operative condition.

Evaluation of early dynamic splinting versus static splinting for patients with transposition of the extensor carpi radialis longus to the extensor pollicis longus.

We present a group of 20 patients who underwent transposition of the extensor carpi radialis longus to the extensor pollicis longus between April 2003 and September 2007. The group was divided into ten patients with an early dynamic splint and ten patients with a static plaster cast following the standard rehabilitation protocols. We compared these two rehabilitation protocols. The post-rehabilitation total range of motion was 87.5 degrees in the dynamic group and 58.75 degrees in the patients treated by the static protocol. The total time of rehabilitation was 10.2 weeks in the dynamic and 14.2 weeks in the static group. The overall mean follow-up was 12.2 weeks. We conclude that early dynamic splinting brings shorter recovery time, shorter time off work and significantly better movement of the thumb.

Conventional protein kinase C isoenzymes undergo dephosphorylation in neutrophil-like HL-60 cells treated by chelerythrine or sanguinarine.

The quaternary benzo[c]phenanthridine alkaloid chelerythrine is widely used as an inhibitor of protein kinase C (PKC). However, in biological systems chelerythrine interacts with an array of proteins. In this study, we examined the effects of chelerythrine and sanguinarine on conventional PKCs (cPKCs) and PKC upstream kinase, phosphoinositide-dependent protein kinase 1 (PDK1), under complete inhibition conditions of PKC-dependent oxidative burst. In neutrophil-like HL-60 cells, sanguinarine and chelerythrine inhibited N-formyl-Met-Leu-Phe, phorbol 12-myristate 13-acetate (PMA)-, and A23187-induced oxidative burst with IC(50) values not exceeding 4.6 micromol/L, but the inhibition of PMA-stimulated cPKC activity in intact cells required at least fivefold higher alkaloid concentrations. At concentrations below 10 micromol/L, sanguinarine and chelerythrine prevented phosphorylation of approximately 80 kDa protein and sequestered approximately 60 kDa phosphoprotein in cytosol. Moreover, neither sanguinarine nor chelerythrine impaired PMA-stimulated translocation of autophosphorylated PKCalpha/betaII isoenzymes, but both alkaloids induced dephosphorylation of the turn motif in PKCalpha/betaII. The dephosphorylation did not occur in unstimulated cells and it was not accompanied by PKC degradation. Furthermore, cell treatment with sanguinarine or chelerythrine resulted in phosphorylation of approximately 70 kDa protein by PDK1. We conclude that PKC-dependent cellular events are affected by chelerythrine primarily by multiple protein interactions rather than by inhibition of PKC activity.

An evidence for regulatory cross-talk between aryl hydrocarbon receptor and glucocorticoid receptor in HepG2 cells.

Aryl hydrocarbon receptor (AhR) and glucocorticoid receptor (GR) play crucial role in the regulation of drug metabolizing enzymes and in many essential physiological processes. Cellular signaling by these receptors shares several functional and regulatory features. Here we investigated regulatory cross-talk between these two receptors. Human hepatoma cells (HepG2) were the model of choice. We analyzed the effects of dexamethasone (DEX) and dioxin (TCDD) on i) expression of AhR and GRalpha mRNAs; ii) levels of AhR and GR proteins; iii) transcriptional activities of AhR and GR in reporter assays; iv) 7-ethoxyresorufin-O-deethylase activity (EROD). We found that both DEX and TCDD affected AhR and GR mRNAs expression, proteins levels and transcriptional activities in HepG2 cells. These effects on cellular signaling by AhR and GR comprised up-/down-regulation of gene expression and ligand-dependent protein degradation. We conclude that interactive regulatory cross-talk between GR and AhR receptors in HepG2 cells defines possible implications in physiology and drug metabolism. Future research should be focused on the investigation of AhR-GR cross-talk in various normal human cells and tissues both in vitro and in vivo.

Pharmacological inhibitors of JNK and ERK kinases SP600125 and U0126 are not appropriate tools for studies of drug metabolism because they activate aryl hydrocarbon receptor.

Mitogen-activated protein kinases (MAPKs) are important regulators of aryl hydrocarbon receptor (AhR). An immense progress in MAPKs' biochemistry was attained with the discovery of their specific pharmacological inhibitors. Unfortunately, the inhibitors of JNK and ERK MAPKs, i.e. SP600125 and U0126, respectively, affect AhR-CYP1A signaling pathway because they are partial agonists of AhR and induce CYP1A genes. This implies that SP600125 and U0126 are inappropriate tools for studies of the role of MAPKs in AhR regulation. The results from studies using SP600125 or U126, past or future, should be interpreted with prudence regarding their stimulatory effects on AhR-CYP1A pathway.

Metabolism of sanguinarine: the facts and the myths.

Sanguinarine, a quaternary benzo[c]phenanthridine alkaloid, exhibits antimicrobial and anti-inflammatory activities and for this reason it is used in dental hygiene products and feed additives. Its metabolism and disposition is the subject of constant scientific discourse. In this paper we summarize current knowledge on sanguinarine metabolism. We show in particular that: (i) Sanguinarine is not transformed to 3,4-benzacridine and that the literature reporting this compound as a metabolite of sanguinarine is based on artifacts and misinterpretations that in course of time have created a dogma; (ii) Sanguinarine is converted to dihydrosanguinarine in vivo, the conversion being tentatively a detoxication pathway; (iii) Aryl hydrocarbon receptor metabolic signaling pathways modulate sanguinarine biological activity.