Alireza Ghassemi

Anatomy of the SMAS Revisited

Despite the relevance of the superficial musculoaponeurotic system (SMAS) in facial rejuvenation a clear anatomic definition of the SMAS is still lacking. Therefore, the morphology of the SMAS in 18 cadavers was investigated using different macroscopic and microscopic techniques. The region-specific anatomy of the SMAS is described in the forehead, parotid, zygomatic, and infraorbital regions, the nasolabial fold, and the lower lip. The SMAS is one continuous, organized fibrous network connecting the facial muscles with the dermis. It consists of a three-dimensional scaffold of collagen fibers, elastic fibers, and fat cells. Two different types of SMAS morphology were demonstrated: type 1 SMAS architecture is located lateral to the nasolabial fold with relatively small fibrous septa enclosing lobules of fat cells, whereas type 2 architecture is located medial to the nasolabial fold, where the SMAS consists of a dense collagen–muscle fiber meshwork. Overall, it was demonstrated that different facial regions show specific morphological characteristics, and thus region-specific surgical interventions may be necessary in facial rejuvenation.

Evaluation of computer‐assisted jaw reconstruction with free vascularized fibular flap compared to conventional surgery: a clinical pilot study

The introduction of computer‐assisted surgery was a milestone in functional reconstructions of facial skeletal defects.

Arthroscopy or ultrasound in undergraduate anatomy education: a randomized cross-over controlled trial

BackgroundThe exponential growth of image-based diagnostic and minimally invasive interventions requires a detailed three-dimensional anatomical knowledge and increases the demand towards the undergraduate anatomical curriculum. This randomized controlled trial investigates whether musculoskeletal ultrasound (MSUS) or arthroscopic methods can increase the anatomical knowledge uptake.MethodsSecond-year medical students were randomly allocated to three groups. In addition to the compulsory dissection course, the ultrasound group (MSUS) was taught by eight, didactically and professionally trained, experienced student-teachers and the arthroscopy group (ASK) was taught by eight experienced physicians. The control group (CON) acquired the anatomical knowledge only via the dissection course. Exposure (MSUS and ASK) took place in two separate lessons (75 minutes each, shoulder and knee joint) and introduced standard scan planes using a 10-MHz ultrasound system as well as arthroscopy tutorials at a simulator combined with video tutorials. The theoretical anatomic learning outcomes were tested using a multiple-choice questionnaire (MCQ), and after cross-over an objective structured clinical examination (OSCE). Differences in student’s perceptions were evaluated using Likert scale-based items.ResultsThe ASK-group (n = 70, age 23.4 (20–36) yrs.) performed moderately better in the anatomical MC exam in comparison to the MSUS-group (n = 84, age 24.2 (20–53) yrs.) and the CON-group (n = 88, 22.8 (20–33) yrs.; p = 0.019). After an additional arthroscopy teaching 1% of students failed the MC exam, in contrast to 10% in the MSUS- or CON-group, respectively. The benefit of the ASK module was limited to the shoulder area (p < 0.001). The final examination (OSCE) showed no significant differences between any of the groups with good overall performances. In the evaluation, the students certified the arthroscopic tutorial a greater advantage concerning anatomical skills with higher spatial imagination in comparison to the ultrasound tutorial (p = 0.002; p < 0.001).ConclusionsThe additional implementation of arthroscopy tutorials to the dissection course during the undergraduate anatomy training is profitable and attractive to students with respect to complex joint anatomy. Simultaneous teaching of basic-skills in musculoskeletal ultrasound should be performed by medical experts, but seems to be inferior to the arthroscopic 2D-3D-transformation, and is regarded by students as more difficult to learn. Although arthroscopy and ultrasound teaching do not have a major effect on learning joint anatomy, they have the potency to raise the interest in surgery.

Microsurgical Free Flap Reconstructions of Head and Neck Region in 406 Cases: A 13-Year Experience

PURPOSE The reconstruction of extended soft tissue and bony defects in the maxillofacial region with microsurgical flaps is considered to be the therapy of first choice. The aim of this retrospective study was to detect different influencing factors concerning flap survival. MATERIALS AND METHODS We examined the data of 406 patient cases (121 female and 285 male cases; mean age, 57 years) undergoing reconstruction with a microsurgical flap in our facility between 1998 and 2010. In these cases 326 soft tissue flaps (radial forearm flap, scapula flap, latissimus dorsi flap, anterolateral thigh flap, lateral arm flap, and jejunum flap) and 80 bony flaps (fibula flap and deep circumflex iliac artery flap) were examined. Evaluated parameters were, among others, the timing of reconstruction, defect localization, and recipient vessels used (external vs internal jugular system), as well as anticoagulative management. We statistically analyzed data by means of a χ(2) test, taking account of the odds ratio with P < .05, which was deemed significant. RESULTS The overall flap survival rate was approximately 92%, without any gender- or age-specific differences. Primary reconstructions proceeded distinctly more successfully than secondary reconstructions (P < .01). Likewise, the defect localization exerted a significant effect on the survival rate (P = .01), with a more caudal localization affecting flap survival positively. Finally, neither the anticoagulation regimen nor the choice of recipient vein system exercised an influence on the survival rate. CONCLUSIONS Microsurgical tissue transfer is a convenient and reliable method in maxillofacial surgery, provided that one is aware of the determining factors for success.

Comparison of donor-site engraftment after harvesting vascularized and nonvascularized iliac bone grafts.

PURPOSE The objective of this study is to characterize the donor-site morbidity after harvesting of nonvascularized and vascularized iliac bone grafts. PATIENTS AND METHODS Clinical data of 353 patients were collected for analysis. In addition, a questionnaire was sent to all patients asking about their perceptions of different parameters. In an individual age-matched layout, we compared 34 patients with nonvascularized iliac bone grafts with 34 patients with vascularized iliac bone grafts. RESULTS Transplantation of vascularized bone grafts has been increasingly performed at our institution. The mean age was 41.5 years in the nonvascularized group and 48.6 years in the vascularized group. The main reason for the bony defect in the vascularized group was malignancy. The majority of postoperative functional problems were observed in obese patients. No patient had serious or long-term complications at the donor site. The amount of bone graft taken affected postoperative sensitivity disturbance and caused postoperative functional problems and pain. CONCLUSIONS We conclude that the iliac crest is a suitable site for harvesting both vascularized and nonvascularized bone grafts measuring up to 10 x 3 cm. For larger defects that require a larger bone graft, a vascularized bone graft is more suitable with a better predictable healing capability. No significant differences in donor-site morbidity were found between the vascularized and nonvascularized bone grafts if a similar amount of bone was taken for transplant.

3D evaluation of postoperative swelling in treatment of bilateral mandibular fractures using 2 different cooling therapy methods: A randomized observer blind prospective study

Surgical treatment and complications in patients with mandibular fractures leads to a significant degree of tissue trauma resulting in common postoperative symptoms and signs of pain, facial swelling, mandible dysfunction and limited mouth opening (trismus). Beneficial effects of local cold treatment on postoperative swelling, oedema, pain, inflammation and haemorrhage, as well as the reduction of metabolism, bleeding and haematomas have been described. The aim of this study was to compare postoperative cooling therapy by cooling compresses with the water-circulating cooling face mask by Hilotherm(®) in terms of beneficial effects on postoperative facial swelling, pain, mandible dysfunction, trismus and neurological complaints. Thirty-two patients were assigned for treatment of bilateral mandibular fractures and were divided randomly into treatment either with the Hilotherm(®) cooling face mask or with conventional cooling with cooling compresses. Cooling was initiated as soon as possible after surgery until postoperative day 3 continuously for 12h daily. Facial swelling was quantified by a 3D optical scanning technique. Pain, neurological complaints, mandibular dysfunction and the degree of mouth opening were measured for each patient. Patients receiving cooling therapy by Hilotherm(®) demonstrated less facial swelling, less pain, a tendency to fewer neurological complaints and were more satisfied when compared to conventional cooling. Hilotherm(®) is more superior in the management of postoperative swelling and pain after treatment of bilateral mandibular fractures when compared to conventional cooling.

The accuracy of computer-assisted primary mandibular reconstruction with vascularized bone flaps: iliac crest bone flap versus osteomyocutaneous fibula flap.

Background The intention of mandibular reconstruction is to restore the complex anatomy with maximum possible functionality and high accuracy. The aim of this study was to evaluate the accuracy of computer-assisted surgery in primary mandibular reconstruction with an iliac crest bone flap compared with an osteomyocutaneous fibula flap. Materials and methods Preoperative computed tomography data of the mandible and the iliac crest or fibula donor site were imported into a specific surgical planning software program. Surgical guides were manufactured using a rapid prototyping technique for translating the virtual plan, including information on the transplant dimensions and shape, into real-time surgery. Using postoperative computed tomography scans and an automatic surface-comparison algorithm, the actual postoperative situation was compared with the preoperative virtual simulation. Results The actual flap position showed a mean difference from the virtual plan of 2.43 mm (standard deviation [SD] ±1.26) and a surface deviation of 39% <2 mm and 15% <1 mm for the iliac crest bone flap, and a mean difference of 2.18 mm (SD ±1.93) and a surface deviation of 60% <2 mm and 37% <1 mm for the osteomyocutaneous fibula flap. The position of the neomandible reconstructed with an osteomyocutaneous fibula flap indicated a mean difference from the virtual plan of 1.25 mm (SD ±1.31) and a surface deviation of 82% <2 mm and 57% <1 mm, in contrast to a mean difference of 1.68 mm (SD ±1.25) and a surface deviation of 63% <2 mm and 38% <1 mm for the neomandible after reconstruction with an iliac crest bone flap. For shape analysis, a similarly high accuracy could be calculated for both flaps. Conclusion Virtual surgical planning is an effective method for mandibular reconstruction with vascularized bone flaps, and can help to restore the anatomy of the mandible with high accuracy in position and shape. It seems that primary mandibular reconstruction with the osteomyocutaneous fibula flap is more accurate compared with the vascularized iliac crest bone flap.

Three-Dimensional Evaluation of Postoperative Swelling After Third Molar Surgery Using 2 Different Cooling Therapy Methods: A Randomized Observer-Blind Prospective Study

PURPOSE In most cases, the removal of third molars leads to a significant degree of tissue trauma, resulting in common postoperative symptoms and signs of pain, facial swelling, dysfunction, and limited mouth opening (trismus). The beneficial effects of cold treatment on postoperative swelling, edema, pain, and inflammation, as well as the reduction in bleeding and hematomas, have been described. The aim of the present study was to compare postoperative cooling therapy using cooling compresses with that using the water-circulating cooling face mask by Hilotherm. We recorded the beneficial effects on postoperative facial swelling, pain, trismus, and neurologic complaints. PATIENTS AND METHODS A total of 30 patients were scheduled to undergo third molar surgery and were divided randomly into 2 groups for treatment with either the Hilotherm or conventional cooling with cooling compresses. Cooling was performed one time for 45 minutes immediately after surgery. Facial swelling was quantified using a 3-dimensional optical scanning technique. The pain and neurologic scores and the degree of mouth opening were observed for each patient. RESULTS Patients receiving cooling therapy using Hilotherm demonstrated less facial swelling, less pain, a tendency toward fewer neurologic complaints, and were more satisfied than the patients who had received conventional cooling. CONCLUSION The results of our study have shown that the Hilotherm is more efficient for managing postoperative swelling and pain after the removal of third molars than conventional cooling using compresses.

Tibial versus iliac bone grafts: a comparative examination in 15 freshly preserved adult cadavers.

PURPOSE We compared autogenous bone grafts from the proximal tibia and the anterior iliac crest under standardized conditions with regard to the attainable bone amount and the histological bone density. MATERIAL AND METHODS In 15 freshly preserved adult cadavers, a corticocancellous block graft from the anterior iliac crest and a purely cancellous transplant from the tibia of the homolateral side were harvested respectively, with the length of the skin incision set at 6 cm for the iliac and at 3.5 cm for the tibial approach. The size of the iliac graft was defined to be between 1/3 and 1/4 of the total iliac length. At the medial tibia the maximum possible amount of cancellous bone was collected after preparation of a cortical lid. For volume determination grafts were cautiously cut up and then put in a water-filled measuring cylinder. In addition, bone density was measured by histomorphometry. The received data were statistically evaluated using the t-test for related samples at P=0.05 and Pearsons correlation analysis. RESULTS From both donor sites approximately equal amounts of bone were available. This result is neither dependent on age nor on gender. In contrast, bone density turned out significantly higher in the iliac graft, with the difference showing a significant age dependence (r=-0.556). CONCLUSIONS Provided that no cortical transplants are needed, cancellous tibial bone grafts offer an appropriate alternative to the classic iliac bone graft, especially in elderly patients.

Enoxaparin Prevents Steroid-Related Avascular Necrosis of the Femoral Head

Nontraumatic osteonecrosis of the femoral head is still a challenging problem in orthopedic surgery. It is responsible for 10% of the 500,000 hip replacement surgeries in the USA and affects relatively young, active patients in particular. Main reasons for nontraumatic osteonecrosis are glucocorticoid use, alcoholism, thrombophilia, and hypofibrinolysis (Glueck et al., 1997; Orth and Anagnostakos, 2013). One pathomechanism of steroid-induced osteonecrosis is thought to be impaired blood flow to the femoral head caused by increased thrombus formation and vasoconstriction. To investigate the preventive effect of enoxaparin on steroid-related osteonecrosis, we used male New Zealand white rabbits. Osteonecrosis was induced by methylprednisolone-injection (1 × 20 mg/kg body weight). Control animals were treated with phosphate-buffered saline. Treatment consisted of an injection of 11.7 mg/kg body weight of enoxaparin per day (Clexane) in addition to methylprednisolone. Four weeks after methylprednisolone-injection the animals were sacrificed. Histology (hematoxylin-eosin and Ladewig staining) was performed, and empty lacunae and histological signs of osteonecrosis were quantified. Histomorphometry revealed a significant increase in empty lacunae and necrotic changed osteocytes in glucocorticoid-treated animals as compared with the glucocorticoid- and Clexane-treated animals and with the control group. No significant difference was detected between the glucocorticoid and Clexane group and the control group. This finding suggests that cotreatment with enoxaparin has the potential to prevent steroid-associated osteonecrosis.