Ali Emre Aksu

Co-infusion of donor bone marrow with host mesenchymal stem cells treats GVHD and promotes vascularized skin allograft survival in rats.

We investigated the effect of autologous mesenchymal stem cells (MSC) on multiple unmodified donor bone marrow (BM) infusions and vascularized skin graft outcome. BM-derived rat MSC were examined for phenotype and function. MSC/MSC-conditioned-medium suppressed IFN-gamma production by T cells and modified DC function. Infusions of MSC with one-time BM improved vascularized skin graft survival, while with one-two-times BM reversed graft versus host disease (GVHD). Mixed chimerism was enhanced in recipients given two-four-times BM with MSC infusions. Interestingly, four-times BM infusions with MSC delayed GVHD onset, reduced host tissue damage and enhanced vascularized skin allograft survival compared to four-times BM alone. These data demonstrate that, the co-infusion of MSC with unmodified BM limit the toxicity of allogeneic BM transplantation, enhance mixed chimerism and improve vascularized skin graft survival. These findings provide insights for the development of autologous MSC-based BM transplantation and prevention of graft rejection or treatment of autoimmunity.

Extracorporal Shock Wave Therapy as a Delay Procedure to Improve Viability of Zone 4: An Experimental Study in a Rat TRAM Flap Model.

BackgroundThe purpose of this study was to test our hypothesis that preoperative application of radial extracorporeal shock wave therapy (rESWT) as a delay procedure would improve the survival of zone 4 of transverse rectus abdominis musculocutaneous (TRAM) flap and reduce the resulting necrotic area. MethodsTwenty-four Wistar rats were randomized and divided into 3 experimental groups (n = 8 each). Caudally based TRAM flap model, with the right rectus abdominis muscle as the carrier and right inferior epigastric vessels as the vascular pedicle, was used in this study. In group 1 (control), after being raised, the TRAM flap was sutured back to its bed without any further intervention. In group 2, the TRAM flap was raised, and rESWT was administered immediately after the flap was sutured back to its bed. In group 3, rESWT was applied 7 days before the elevation of the flap, as a delay procedure. Seven days after the administration of rESWT, TRAM flap was raised and then sutured back to its bed. ResultsAt postoperative day 5, the mean percentage of skin flap survival was 61.82 ± 12.22 for group 1, 77.65 ± 4.62 for group 2, and 79.89 ± 5.86 for group 3. Groups 2 and 3 revealed higher survival areas when compared with control group (P = 0.02). In rESWT applied groups 2 and 3, the increase in capillary density and dilatation of microvessels in the skin flap survival areas were obvious. Histologic analysis revealed significantly higher neovascularization and less inflammation in zone 4 of rESWT applied groups (P < 0.001 and P = 0.042, respectively). ConclusionsESWT appears to be a cheap, practical, and promising option for improving the viability of zone 4 of TRAM flap and may also be used as a delay procedure in the clinical setting.

The systematic review and meta-analysis of free flap safety in the elderly patients: ÜSTÜN et al .

Prolonged mean life expectancy gives rise to a more populated and older patient group. With increasing number of cases during the past decades, older patients are regarded as candidates for microsurgical interventions. Whether advanced patient age is an independent risk factor for microsurgical reconstruction is still an ongoing matter of debate.

Intraoral use of extraoral implants for oral rehabilitation of a pediatric patient after resection of ewing sarcoma of the mandible and reconstruction with iliac osteocutaneous free flap.

Large osseous defects secondary to resection of the mandibular segment may lead to significant facial deformity, functional disabilities, and associated psychologic problems. The therapeutic approach is more complicated in pediatric patients because it must not interfere with normal craniofacial growth process. Here, we present a clinical report to emphasize the application of extraoral short implants with magnetic abutments used for mandible of a growing patient reconstructed with free iliac flap after resection of Ewing sarcoma. A 5-year-old boy, complaining of an ulcerated mass of the anterior mandibular area and floor of the mouth, was referred to our clinic. Incisional biopsy from the lesion confirmed the diagnosis of Ewing sarcoma. After resection, free iliac osteocutaneous flap, with a 6.5 × 4.0-cm skin paddle and based on the deep circumflex iliac vessels, was used to reconstruct the mandibular integrity and to cover the floor of the mouth simultaneously. Nine months after the operation, the patient was referred for oral rehabilitation. Prosthodontic plan included the placement of 5 extraoral implants with magnetic abutment and fabrication of an implant-retained overdenture. Magnetic abutment was preferred not to interfere with the expected craniofacial growth. During a follow-up period, radiographic images showed no pathologic signs with consideration of overall bone loss and recurrence of the tumor; 12 months after the initiation of prosthetic loading, no peri-implant bone loss was observed. In conclusion, this reported case would be an example for the management of challenging pediatric mandibular tumor cases in terms of resection, reconstruction and dental rehabilitation.

Which instrument should we use to assess hand function after digital replantation

The functional recovery of a replanted body part is as important as its viability. We compared four instruments frequently used for the evaluation of hand function after digital replantation. The functional results of 17 patients at least one year after replantation of a total digital amputation between 2004 and 2007 were evaluated according to the Tamai, Ipsen, Chen and Disabilities of the Arm, Shoulder and Hand questionnaires. Scores of each patient for each test were calculated and intra-individual comparisons were made. Correlation was significant at the 0.05 level (two tailed) for all tests. A high correlation (>0.71) was found between the Ipsen, Tamai and DASH tests. The Chen test had a moderate correlation with the other tests. We determined that Ipsen, Tamai and DASH tests have similar effectiveness in assessing hand function after replantation.

A rare poland syndrome deformity: humero-pectoral band.

Since Dr. Lallemand has defined isolated pectoral muscle absence in 1826 [1], many articles have been published about Poland Syndrome. Ipsilateral syndactyly with pectoralis major muscle agenesis has been defined by Dr.Froriep in 1839 [1]. Dr. Alfred Poland has defined same entity in 1841 while he was a medical student [1]. Agenesis of the pectoralis major muscle’s sternal head is the major finding in diagnosis of Poland Syndrome. Additionally, scoliosis, lung, rib cage (two to four or three to five costal cartilages), breast and nipple-areolar hypoplasia, ipsilateral brachysynphalangism, serratus, pectoralis minor, latissimus dorsi and external oblique muscles hypoplasia, absence of axillary hairs and sweet glands and decreased subcutaneous tissue would be seen together in Poland Syndrome [1, 2].

Abdominal amniotic band associated with fenestrated syndactyly: a rare amniotic band syndrome presentation.

Amniotic band syndrome (ABS) is characterized by the attachment of amniotic and placental remnants and encircling the fetus leading to malformations and even amputations. Its incidence is estimated at 1/1200 to 1/15,000 live births. ABS is a heterogenous condition with broad spectrum of anomalies ranging from simple ring constrictions to major craniofacial and visceral anomalies. We would like to share a rare presentation of ABS as circumferential abdominal constriction band with fenestrated syndactyly. 13-year-old girl was referred to our clinic. Delay in the admission was due to the lack of socioeconomic status of the family. The infant has been delivered at term by vaginal delivery to a 37-year-old G3P3 mother. Both parents were non-smokers with no history of drug or heavy alcohol intake of the mother during pregnancy. There was no family history of congenital anomalies. The antenatal and postnatal course was uncomplicated and psychomotor development was normal. The patient was presenting with a nearly circumferential abdominal band along the anterior abdominal wall extending to bilateral flank region with minimal posterior sparing (Figure 1). In addition, symbrachydactyly of 4th and 5th digits of the right hand and fenestrated syndactyly between them was remarkable. Preoperative CT scan revealed no anterior abdominal wall anomalies and defect. As the patient was having social adaptation problems because of her striking physical appearance, surgery was planned. Surgically, abdominal amniotic band was excised with lazy S incisions. Abdominal flaps were elevated in a limited fashion and in order to restore the contour, layer to layer closure of Scarpa’s fascia, subcutaneous layer and skin is achieved. Syndactyly repair and correction of the flexion contractures of the fingers are simultaneously done at the same operative stage. Postoperative period was

Reconstruction of external auditory canal with a laterocervical twisted (snail) flap.

There are several different causes of the deformities of the external auditory canal requiring reconstruction such as tumors, burns, trauma, and malformations. Many surgical approaches with varying success for the reconstruction of the external auditory canal (EAC) have been favored, including secondary healing, skin grafting, and a variety of local skin flaps. Unfortunately, the major drawback of the previously defined techniques is the resulting stenosis of the EAC. A 73-year-old white man was admitted to our clinic because of an unhealing ulcerated lesion at the superior and posterior one third of the left external auditory canal, involving the most internal part of the concha. Preserving the superior one third of the helix, left auricle and the EAC was surgically removed en bloc. To reconstruct the surgical defect, a snail flap was designed on the ipsilateral cervical region and based posteriorly on the left mastoid region. Twisting the flap on its main axis, as mentioned, created a final shape resembling a snail and a tube with epithelium-lined canal inside. At the postoperative first-year visit, the patients endoscopic examination showed no sign of recurrence, tympanoplasty graft was intact, and the EAC was patent without signs of stenosis. Our experience with the laterocervical flap supports the fact that this flap does not cause stenosis, hearing loss, and therefore should be concerned as one of the first choices of treatment for the reconstruction of EAC.

Report of multidisciplinary treatment of an extensive mandibular ameloblastoma with free iliac crest bone flap, dental implants, and acellular dermal matrix graft.

A meloblastomas are benign odontogenic tumors, constituting 1% and 9%–11% of all oral and odontogenic tumors, respectively. Presenting an aggressive nature in progression, ameloblastomas can cause orofacial swelling, sensitivity, occlusal disorders, and periodontal attachment loss. Although the literature reports various treatment alternatives for ameloblastomas based on the extent of the lesion, more radical procedures including radical resection and hemimandibulectomy are performed for extensive tumors. To overcome esthetic and functional disabilities caused by radical resective treatment of extensive tumors, several surgical techniques for reconstruction of the orofacial region have been proposed. Recently, free bone flaps, in which bone grafts can be adapted to the deficient site with sufficient intact blood supply, have been shown to be superior in bone volume gain and resistance when compared with other techniques. Although free bone flaps resolve the bone deficiencies caused by resective surgeries, for complete restoration of the life quality, problems associated with loss of dentition have to be managed. Conventional prosthesis presents a low success rate due to the disrupted morphology of bone and soft tissues, diminished salivary flow rate, and adverse effects of radiotherapy. By providing accurate rehabilitation of the supporting bone and dentition, dental implants allow stabilization of prosthesis and thereby have a considerable place in restoring functional deformities and esthetics in patients with maxillofacial defects. This case presents the multidisciplinary rehabilitation of a patient diagnosed with extensive ameloblastoma using dental implants and acellular dermal matrix grafts following reconstruction with free iliac crest bone flap.

Microvascular tissue transfers in the elderly: safety analysis for a challenging area

BACKGROUND/AIM Due to increased average life expectancy, the number of elderly patients requiring complex reconstructive microsurgical procedures is rising. Age, comorbid conditions, and location of operation are all possible risk factors. The aim of this study is to evaluate surgical outcomes to set the right criteria. MATERIALS AND METHODS Between 1996 and 2014, the data of 30 patients over the age of 70, who were treated with microsurgical techniques in our clinic, were extracted from patient records and analyzed retrospectively. RESULTS In this patient population, flap success rate was 94%. Systemic and surgical complication rates were 40% and 48%, respectively. Complication rates were higher in head and neck cases but there was no statistically significant difference compared to reconstructions in other areas. Loss of oral lining, as a serious complication, had no effect on complications in head and neck reconstruction patients in our series. Conclusions: Flap success is comparable to younger age groups but procedures are associated with a high rate of complications Evaluating and controlling comorbid conditions is important. The American Society of Anesthesiologists scoring system is reliable in this patient population. Although complications are more common, these procedures can be performed safely in elderly populations with careful patient selection.