The Effect of Hyaluronic Acid Application on the Perisilicon Capsule Structure.

BACKGROUND: Silicon implants constitute a major part of plastic surgery practice. Although materials with high biocompatibility have been used around the implants, capsule formation still develops and progressive nature of this process results in capsule contraction. The aim of this study is to evaluate the effects of hyaluronic acid injected around the silicon block on the capsule structure. METHODS: Twenty Wistar albino rats were used in the study. Rats were divided into two main groups (group 1 and group 2) and two subgroups. Rats in group 1 were sacrificed in week 4 and rats in group 2 were sacrificed in week 8. A subcutaneous pouch was created in the dorsum of the rats and a silicon block was placed into the pouch in groups 1A and 2A. 0.2 ml of hyaluronic acid was injected around the silicon block in group 1B and group 2B. Rats were sacrificed and capsule structure and thickness were analyzed following macroscopic evaluation. Concentrations of transforming growth factor-ß1 (TGF-ß1) and heat shock protein-47 (HSP-47) were evaluated immunohistochemically, and statistical comparisons were made. RESULT: Capsule structure consisted of three layers in all the groups. A more intense collagen structure was observed in the middle layer. The capsule was thinnest in group 1A and thickest in group 2B; the difference between the groups was statistically significant. TGF-ß1 was most intense in group 2B and it was correlated with the amount of collagen. Involvement of HSP-47 was observed mainly in collagen and also in fibroblasts and vascular structures, and its concentration was found to be lower in groups 2A and 2B. CONCLUSION: Exogenously added cross-linked hyaluronic acid increased the capsular thickness and may increase the risk of developing capsular contracture around silicone implants. LEVEL OF EVIDENCE II: Evidence was obtained from the well-designed controlled trials without randomization.

The Effect of Subcutaneous Platelet-Rich Plasma Injection on Viability of Auricular Cartilage Grafts.

INTRODUCTION: Although cartilage grafts are frequently used for structural integrity and volume restoration, one of the main concerns dealing with cartilage grafting is gradual volume loss and unpredictable viability rates of cartilage grafts. Platelet-rich plasma (PRP) is a well known platelet concentrate reported to enhance cartilage repair and stimulates chondrocyte proliferation and matrix biosynthesis. The purpose of the current study was to investigate the effect of subcutaneous PRP injection on improving the viability of cartilage grafts. MATERIALS AND METHODS: Six circular cartilage grafts were obtained from auricular cartilages of 6 New Zealand white rabbits. Cartilage grafts were prepared in 3 forms: block, crushed, and crushed/wrapped with Surgicel (Surgical, Ethicon, Somerville, NJ). Grafts were placed to 6 dorsal subcutaneous pockets and pockets were closed. Autologous PRP was prepared and injected subcutaneously into the pockets of experiment groups. At the end of 8 weeks, cartilage grafts were removed. Cartilage mass reduction rates were measured. Resorption rates of cartilage grafts and formation of fibroelastic and bone tissue were microscopically evaluated. RESULTS: All of the cartilage grafts lost significant weight. Viability scores of block cartilages were higher than crushed cartilages. Although less weight loss rates and higher histopathologic scores were obtained in subcutaneously PRP injected cartilage graft groups, these results were not statistically significant. CONCLUSIONS: Although our study gives a new insight about increasing the viability of cartilage grafts, the subcutaneous PRP injection did not result in improving the viability of cartilage grafts in this experimental design.

A Social Evaluation of Perception on Body Contouring Surgery by Turkish Male Aesthetic Surgery Patients.

Although aesthetic procedures are known to have a higher impact on women, men are becoming more inclined toward such procedures since the last decade. To determine the reason behind the increase in demand for male aesthetic procedures and to learn about the expectations and inquietude related to body contouring surgery, a prospective questionnaire study was conducted on 200 Turkish males from January 1, 2011-May 31, 2012. Demographic information, previous aesthetic procedures and thoughts on body contouring procedures with given reasons were questioned. The results of the study showed that 53 % of all participants considered undergoing body contouring surgery with the given reason that they believed their current body structure required it. For those who did not consider contouring operations, 92.5 % said they felt that they did not need such a procedure. The results of the statistical analysis showed that BMI was a significant factor in the decision making process for wanting to undergo body contouring procedures. The results of the study showed that men's consideration for aesthetic operations depends mainly on necessity and that the most considered region was the abdominal zone in regard to contouring. We can conclude that men are becoming more interested in body contouring operations and therefore different surgical procedures should be refined and re-defined according to the expectations of this new patient group.

The quantitative effect of botulinum toxin A over brow height.

INTRODUCTION: Botulinum toxin type A (BTX-A) is currently used in temporal brow lifting. Reducing the activity of the superolateral portion of orbicularis oculi muscle causes lateral brow elevation. The objective of this study was to determine the quantitative brow elevation after paralysis of the superolateral portion of orbicularis oculi muscle. MATERIAL AND METHODS: This study includes 10 female patients. Six units of BTX-A were injected into the superolateral portion of the orbicularis oculi in a serial manner into 3 points, below the lateral half of the brow at each side. Bilateral measurements were obtained by using calipers, immediately before and 2 weeks after the treatment. The medial canthus to the medial brow margin (AB), the lateral brow margin to the lateral canthus (CD), the medial brow margin to the lateral brow margin (BC), the brow apex to upper lid margin at the level of the lateral limbus (EF), the brow apex to the medial brow margin (EB), the brow apex to the lateral brow margin (EC), and upper eyelid margin to lower eyelid margin at the level of the pupil (GH), were measured. RESULTS: There were no statistically significant differences found between pretreatment and posttreatment left and right measurements. There were statistically significant increases in CD, EF, and GH measurements, which are point out brow elevation. There were no statistically significant differences found in other measurements. CONCLUSIONS: Same doses of BTX-A application did not disrupt symmetry. Applications of 6U BTX-A to the superolateral portion of orbicularis oculi provide brow elevation and increased interpalbebral distance and upper eyelid distance. Our study has confirmed that BTX-A treatment of superolateral portion of the orbicularis oculi muscle produces quantitative temporal brow elevation.

Giant temporalis muscle metastasis of esophageal carcinoma.

Temporalis muscle metastasis of a tumor is a rare condition. Basaloid squamous cell carcinoma is an uncommon variant of squamous cell carcinoma, which often occurs in the aerodigestive tract. To the best of our knowledge, there have been no previous reports dealing with temporalis muscle metastasis from esophageal carcinoma in the literature.

An algorithmic approach for the management of hand deformities in dystrophic epidermolysis bullosa.

Treatment of hand deformities in epidermolysis bullosa patients represents a challenging field in hand surgery practice, thus a systematic approach by a team is mandatory for a successful result. A simple and practical algorithm for the surgical treatment of hand deformities in EB was employed by the authors where the deformities of each digit in EB patients was categorized according to pseudosyndactyly and interphalangeal joint contracture severity for guidance during the surgical treatment. The current study retrospectively reviewed the medical records and photographic data of 13 EB patients followed in our department, for whom a systematic approach to the management and treatment was used. Mild cases were treated by surgical release and secondary healing with non-adhesive dressing while moderate cases were treated with autologous dermal grafts harvested with a special technique that were fixed on denuded areas on the proximal interphalageal joints after release. The remaining areas were treated similarly to the mild group. Additional K-wires were applied for two weeks in severe cases. A total of 21 procedures were performed on 13 EB patients with hand deformities according to the proposed treatment strategy. Functional recovery was satisfactory for each patient and the outcomes were dependent upon the severity of deformity. A multidisciplinary and conscious approach followed by an algorithmic surgical treatment protocol described in the study has been beneficial in providing consistent and successful long-term results for these patients.

Resorbable plate-screw systems: clinical applications.

OBJECTIVE: To evaluate the results we obtained from 37 patients referred to our clinics with resorbable plate-screw systems which have been claimed as biodegradable fixation materials and used in craniofacial, maxillofacial and orthopedic reconstructive procedures owing to their advantages such as biocompatibility, adequate biomechanical resistance, longer dwelling time, elimination through physiological routes without causing any foreign body reaction and/or significant sequaleae. METHODS: Resorbable plate-screw systems used in 37 patients between 2000-2003 for various craniofacial reconstructive procedures were evaluated as for their efficacy, and biocompatibility. RESULTS: Adequate fixation was obtained in all patients, excluding one case operated for mandibula fracture whose reconstruction was completed with titanium plate-screw system. No serious complication was seen except a granuloma and sinus formation on subciliary incision in one patient. CONCLUSION: Owing to their improved polylactic acid/polyglycolic acid ratio resorbable plate-screw systems which contain varying compositions of polylactic acid and polyglycolic acid copolymers are ideal fixation materials used favourably in maxillofacial, craniofacial and orthopedic reconstructive surgery in that they make effective fixation and have further advantages such as biocompatibility, adequate biomechanical resistance against distraction and compression forces in the early postoperative period, longer dwelling time and elimination from the body through physiological routes without causing any foreign body reaction or significant sequaleae.

Reconstruction of orbital floor fracture using solvent-preserved bone graft.

The orbital floor is one of the most frequently damaged parts of the maxillofacial skeleton during facial trauma. Unfavorable aesthetic and functional outcomes are frequent when it is treated inadequately. The treatment consists of spanning the floor defect with a material that can provide structural support and restore the orbital volume. This material should also be biocompatible with the surrounding tissues and easily reshaped to fit the orbital floor. Although various autografts or synthetic materials have been used, there is still no consensus on the ideal reconstruction method of orbital floor defects. This study evaluated the applicability of solvent-preserved cadaveric cranial bone graft and its preliminary results in the reconstruction of the orbital floor fractures. Twenty-five orbital floor fractures of 21 patients who underwent surgical repair with cadaveric bone graft during a 2-year period were included in this study. Pure blowout fractures were determined in nine patients, whereas 12 patients had other accompanying maxillofacial fractures. Of the 21 patients, 14 had clinically evident diplopia (66.7 percent), 12 of them had enophthalmos (57.1 percent), and two of them had gaze restriction preoperatively. Reconstruction of the floor of the orbit was performed following either the subciliary or the transconjunctival approach. A cranial allograft was placed over the defect after sufficient exposure. The mean follow-up period was 9 months. Postoperative diplopia, enophthalmos, eye motility, cosmetic appearance, and complications were documented. None of the patients had any evidence of diplopia, limited eye movement, inflammatory reactions in soft tissues, infection, or graft extrusion in the postoperative period. Providing sufficient orbital volume, no graft resorption was detected in computed tomography scan controls. None of the implants required removal for any reason. Enophthalmos was seen in one patient, and temporary scleral show lasting up to 3 to 6 weeks was detected in another three patients. Satisfactory cosmetic results were obtained in all patients. This study showed that solvent-preserved bone, which is a nonsynthetic, human-originated, processed bioimplant, can be safely used in orbital floor repair and can be considered as another reliable treatment alternative.

Plastic surgeon's life: marvelous for mind, exhausting for body.

Surgery is accepted as one of the most demanding professions that create both physical and mental strain on the performers. Therefore, the authors aimed to elucidate the mental burden of surgeons, which is dedicated to operative stress. They also tested the hypotheses that participating in surgery creates mental stress on surgeons that leads to cardiovascular changes, and that this stress is more pronounced for actual operators than for first assistants. The method chosen for this purpose was an analysis of heart rate variability. Twelve surgeons (five plastic surgery staff and seven plastic surgery residents) were monitored by a digital ambulatory Holter recorder on at least two occasions. Half of the recordings were carried out on operating days and the other half on office days. Heart rate variability indices (low frequency, high frequency, high frequency/low frequency ratio, and heart rate) were analyzed from those recordings using computerized research tool software. The heart rate variability indices of the operators showed statistically significant differences between operating days and office hours in favor of an increased sympathetic and decreased parasympathetic activity for the former. For first assistants, three of the parameters, with the exception of heart rate, changed in favor of a sympathetic predominance over parasympathetic activity; these changes were also statistically significant. These results showed a sympathetic hyperactivity for both operators and first assistants during the operations. When the sympathovagal balance of the actual operators was compared with that of assistants, the former group showed a more pronounced sympathetic arousal. This difference is accepted as a proof for the mental stress of the surgery being the main factor responsible for the sympathetic hyperactivity that we detected during the operations. Surgeons continuously face a unique mental strain that other professions rarely bring forth, and these psychological stressors are associated with alterations in cardiac autonomic control that may contribute to the development of cardiac disease. Prolonged sympathetic hyperactivity could anticipate cardiac discomfort in more experienced surgeons with marginal cardiac reserve. Such cardiac diseases would be reconsidered as occupation-related illnesses, which might be reimbursed to the physician. In addition, the legal responsibility of surgeons concerning their unfavorable results might be assessed with more understanding with a realization of their undue working conditions.

Dirofilaria repens presenting as a premasseteric nodule.

Dirofilariasis is a rare zoonosis that is mainly seen with subcutaneous or pulmonary involvement. Natural hosts are dogs, cats, jackals, and raccoons; however, humans can rarely become an accidental host for the parasite. In the reported case, infection manifested as a subcutaneous nodule, representing a significant diagnostic challenge for both the surgeon and the pathologist. A case of a 62-year-old man with a premasseteric soft tissue mass caused by Dirofilaria repens is presented with histopathologic confirmation.

Reconstruction of traumatic orbital floor fractures with resorbable mesh plate.

Various materials such as autogenous bone, cartilage and alloplastic implants have been used to reconstruct orbital floor fractures. A new material is needed because of disadvantages of nonresorbable alloplastic materials and difficulties in harvesting autogenous tissues. In this study safety and value of the use of resorbable mesh plate in the treatment of orbital floor fractures are discussed. Between 2002 and 2004 a total of 17 maxillofacial trauma patients complicated with orbital floor fractures were treated with resorbable mesh plate through subciliary or transconjunctival incisions. Pure blow-out fractures were determined in 6 patients and 11 patients had accompanying maxillofacial fractures. Resorbable plate was easily shaped to fit to the orbital floor by cutting with scissors. Patients were evaluated clinically and with computed tomography scans preoperatively and at 3-, 6- and 12-month intervals postoperatively. Twelve patients had preoperative enophthalmos. Two patients had diplopia that was corrected postoperatively. In all 17 cases there was no evidence of infection, diplopia and gaze restriction postoperatively. Scleral show appeared in three patients by the second postoperative week but resolved totally within 3 to 6 weeks except one patient. In this patient anterior displacement of mesh was evident which caused ectropion and enophthalmos and required re-operation. No any other mesh related problems were seen at 15 months mean follow-up time. The advantage of the resorbable mesh system in orbital floor fracture is the maintenance of orbital contents against herniation forces during the initial phase of healing and then complete resorption through natural processes after its support is no longer needed. Our experience represents that resorbable mesh is a safe and effective material for reconstruction of the selected, non-extensive orbital floor fractures.

Distally based lateral and medial leg adipofascial flaps: need for caution with old, diabetic patients.

BACKGROUND: Reconstruction of defects around the ankle region has always been challenging for plastic surgeons. Distally based lateral and medial leg adipofascial flaps are among the flaps of choice for coverage of this difficult region. Presented here is the authors' clinical experience with these flaps, particularly emphasizing the complicated attempts in diabetic patients. METHODS: Seven skin defects around the ankle were reconstructed with lateral and medial leg adipofascial flaps. The lowermost perforators of the peroneal or posterior tibial artery were identified preoperatively, and a straight incision through skin only was made proximal to this perforator. With the skin flaps reflected, the adipofascial flap was than raised in the subfascial plane. The perforators to be retained in the base were located and the flap was then turned over to cover the defect, followed by application of a split-thickness skin graft over the flap. The donor site was closed primarily. RESULTS: The ages of the patients ranged from 25 to 80 years, and the size of the flaps ranged from 3 x 5 cm to 7 x 10 cm. Four defects were reconstructed with lateral leg adipofascial flaps, and medial leg adipofascial flaps were used in three. Two flaps healed uneventfully. Partial or total graft loss and partial flap necrosis were observed in five patients, four of whom were diabetic. CONCLUSIONS: Leg adipofascial flaps offer a valuable option for repair of defects around the ankle in many cases. However, adipofascial flaps should be used with caution in old, diabetic patients and, when performed, the probability of a second or third procedure should be considered.

What wrapped perichondrial and periosteal grafts offer as regenerators of new tissue.

The major goals in contour restoration procedures are to re-establish the desired contour with the use of resilient and durable materials that can be easily found and harvested. Cartilage grafts are commonly used for these purposes though they often possess a problem of donor site morbidity and shortage of quantity. The neo-cartilage formation capacities of both perichondrium and periosteum are well-known. We aimed to optimize both the amount and quality of the newly forming tissue from perichondrial and periosteal grafts. For this purpose the grafts were wrapped on themselves. Placement of oxidized regenerated cellulose (ORC) within graft layers was performed in two groups with the aim of giving support to the regenerating tissue, and increasing the connective tissue formation within the graft layers. Three-month-old New Zealand white rabbits were used. Group 1 ear perichondrial, and Group 2 calvarium periosteal grafts of 1.4 x 2.4 cm were harvested, folded on themselves, and sutured at the edges to create closed pockets. 0.8 x 0.8 cm sized ORC sheets were placed inside the pockets before wrapping in Group 3 perichondrial and Group 4 periosteal grafts. 0.2-mL autogenous blood was injected in each pocket. All grafts were transplanted under the abdominal muscle fascia, and harvested after 6 weeks. Volumes and weights of wrapped perichondrial grafts were higher than their periosteal counterparts either with or without the inclusion of ORC. Grafts with ORC (Groups 3 and 4) were heavier than the grafts lacking ORC (Groups 1 and 2), in a statistically significant manner (P

Homodigital reverse flow island flap for reconstruction of neuropathic great toe ulcers in diabetic patients.

Diabetic ulcers located in the plantar surface of the great toe resist conservative treatment modalities including skin grafts and usually require flap coverage for a stable reconstruction. Free tissue transfer is not feasible in these patients, because these defects are closely associated with peripheral vascular disease and local flap alternatives are extremely limited in this region. Reported here is the use of homodigital reverse flow island flap for reconstruction of neuropathic great toe ulcers in diabetic patients with encouraging results.

Management of frontal sinus fractures.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Understand the radiographic and clinical diagnosis of frontal sinus fractures. 2. Identify various management approaches to the frontal sinus fracture and the indications for each. 3. Understand the rationale behind the decision of sinus obliteration when needed. 4. Recognize the most common complications arising from frontal sinus fracture treatment and the methods of avoiding or managing these complications. SUMMARY: Frontal sinus fracture management is still controversial and involves preserving function when feasible or obliterating the sinus and duct, depending on the fracture pattern. There is no single algorithm for the choice of management, but appropriate treatment depends on an accurate diagnosis using physical examination, computed tomography data, and the findings of intraoperative exploration. The amount and location of fixation and the need for frontonasal duct and sinus obliteration or elimination of the entire sinus depend on the anatomy of the fracture in general and the extent of involvement of the anterior wall of the sinus, the frontonasal duct, and the posterior wall in particular. This article discusses an algorithm for frontal sinus fractures that was obtained from the literature and modified according to the authors' experience. The decision-making process presented by the authors has withstood the test of time over a period of more than 20 years in their practice and has been proven to be safe and efficacious in treating frontal sinus fractures of all types.