Billur Sezgin

Improving fat graft survival through preconditioning of the recipient site with microneedling

Although fat grafts are considered the ideal soft-tissue fillers, the main concern dealing with this technique is not being able to predict long-term graft survival due to high absorption rates. The purpose of this study was to investigate the angiogenic effects of preconditioning the recipient area with micro-needling and to determine its overall impact on fat graft survival. The study consisted of a sham, control and study group. The source of fat was the Wistar albino rat inguinal fat pad while the recipient area was a dorsal subcutaneous pouch. The dorsal area was preconditioned with standard technique micro-needling 1-week prior to fat graft transfer in the study group while the control group did not undergo micro-needling. At the end of 15 weeks, morphological, biochemical, histological and immunohistochemical evaluation was carried out. Fat grafts in the study group had better integrity and a higher level of vascularity compared to the control group. Volume analysis demonstrated higher graft survival in the study group in comparison to the control group. Histomorphometric and immunohistochemical evaluation showed better graft integrity and uniform adipocytes, less fibrosis, less vacuolisation and inflammation and better vascularisation in the study group. Although higher triglyceride concentrations were measured for the study group, the difference between the two groups was statistically insignificant. In conclusion, fat grafting performed in an area preconditioned with micro-needling results in higher graft volume, better integrity and vascularisation and an overall higher graft survival rate.

The Effect of Microneedle Thickness on Pain During Minimally Invasive Facial Procedures: A Clinical Study

BACKGROUND Minimally invasive procedures are becoming increasingly popular because they require minimal downtime and are effective for achieving a more youthful appearance. The choice of needle for minimally invasive procedures can be a major factor in the patients comfort level, which in turn affects the physicians comfort level. OBJECTIVES In this comparative study, the authors assessed levels of pain and bruising after participants were injected with 30-gauge or 33-gauge (G) microneedles, which are commonly used for minimally invasive injection procedures. METHODS Twenty healthy volunteers were recruited for this prospective study. Eight injection points (4 on each side of the face) were determined for each patient. All participants received injections of saline with both microneedles in a randomized, blinded fashion. Levels of pain and bruising were assessed and analyzed for significance. RESULTS The highest level of pain was in the malar region, and the lowest level was in the glabella. Although all pain scores were lower for the 33-G microneedle, the difference was significant only for the forehead. Because most minimally invasive procedures require multiple injections during the same sitting, the overall procedure was evaluated as well. Assessment of the multiple-injection process demonstrated a significant difference in pain level, favoring the 33-G needle. Although the difference in bruising was not statistically significant between the 2 needles, the degree of bruising was lower with the 33-G needle. CONCLUSIONS For procedures that involve multiple injections to the face (such as mesotherapy and injection of botulinum toxin A), thinner needles result in less pain, making the overall experience more comfortable for the patient and the physician. LEVEL OF EVIDENCE 3.

The impact of breast reduction surgery on the vertebral column.

BackgroundAlthough many studies have shown that breast reduction surgery is effective in reducing neck, back, and lumbar pain, most of these studies are subjective evaluations that usually provide data through pain scales. This study was undertaken to objectively evaluate the radiologic effects of breast reduction on the vertebral column. MethodsThirty patients who underwent breast reduction surgery were included in the study. A lateral thoracolumbar radiograph was taken before and 3 months after surgery for each patient. The thoracic kyphosis, lumbar lordosis, and sacral inclination angles were measured for each radiograph. The impact of breast reduction surgery on posture was evaluated according to the comparison of these angles before and after surgery. The effect of age, body mass index, and the total amount of removed tissue was also taken into account, and the relationship between these parameters and their effects on the change in preoperative and postoperative angle measurements were evaluated. ResultsThere was a significant decrease in all 3 angles after breast reduction surgery. A significant correlation was determined between body mass index and the total amount of removed tissue on the change in angle measurements, whereas a definite relationship was not observed between the angles and the patient’s age. ConclusionsThis study has shown the objective impact that breast reduction surgery has on the vertebral column. Although the symptomatic relief of breast reduction surgery on the musculoskeletal system is widely accepted, the objective assessment of this relief will be beneficial in persuading health insurance companies and those who think of this surgery as a purely aesthetic procedure.

The impact of the menstrual cycle on intra-operative and postoperative bleeding in abdominoplasty patients

BACKGROUND Hormonal changes that take place during the menstrual cycle may have an effect on perioperative bleeding. Previous studies have confirmed a relationship between the menstrual cycle and surgical bleeding in rhinoplasty and breast reduction surgery; yet both surgical sites display changes in accordance with sex hormone levels during the menstrual phase. AIM The aim of this study was to determine the effect of the menstrual cycle on perioperative bleeding when undergoing surgeries of sites not directly related to menstrual hormonal changes. MATERIALS AND METHODS Forty-one patients undergoing abdominoplasty were grouped as group A - perimenstrual (0-7, 21-28 days), group B - periovulatory (8-20 days) and group C - postmenopausal. Intra-operative blood loss was calculated during surgery while postoperative blood loss was determined by measuring the amount of drainage. All menstrual data were recorded. Age, body mass index and weight of the resected tissue were also considered as factors that can affect the amount of bleeding and therefore were also evaluated in terms of significance. RESULTS There was no significant difference between groups regarding intra-operative and postoperative blood loss. Body mass index and weight of the resected tissue had a strong influence on the time of drain removal and the amount of intra-operative and postoperative blood loss. CONCLUSION This study strongly suggests that the menstrual period does not affect perioperative blood loss for operations on areas less sensitive to sex hormone levels such as the abdomen. In light of the results, we can conclude that the patients menstrual date is not of vital importance regarding perioperative blood loss when planning surgery for areas with less sensitivity to menstrual hormonal changes.

Hypercoagulability in microvascular breast reconstruction: an algorithmic approach for an underestimated situation.

Despite appropriate surgical technique and follow-up, flap failures can be encountered for which no valid reason is evident. Current literature states that these unpredictable flap failures can be caused by unknown patient factors, such as undiagnosed hypercoagulability. Our approach and experience utilizing an algorithm to minimize unpredictable failures in microvascular breast reconstruction by predetermining hypercoagulation risk factors in preoperative patients is presented. A prospective assessment of microsurgical breast reconstruction candidates between October 2007 and December 2010 was conducted. Patients were questioned about their tendency toward hypercoagulation. A thrombophilia panel was requested for patients confirming any risk factors. Appropriate surgical planning was conducted according to results of the panel. Of the 60 patients thoroughly questioned about hypercoagulation tendency, 21 (35%) confirmed having prothrombotic tendency and were referred to the thrombophilia testing. The results indicated hypercoagulation in 9 (15%) patients. The primary reconstruction plan of utilizing free flaps was abandoned for these patients and pedicled flaps or implants were preferred for reconstruction. These percentages emphasize the value of questioning risk factors and testing for hypercoagulation in patients seeking microsurgical breast reconstruction. We believe that detailed preoperative questioning of risk factors and appropriate testing according to prothrombotic tendency is beneficial in minimizing unpredictable flap failures and increasing rates of success.

A Severe Acute Hypersensitivity Reaction after a Hyaluronic Acid with Lidocaine Filler Injection to the Lip

A 27-year-old woman requesting lip augmentation presented to our clinic (Figs. 1, ​,2).2). She had not been treated previously with any dermal filler. She was generally healthy and had no signs of active soft tissue infection, cheilitis, or herpes simplex lesions around her perioral area and face. She was not using any medication or herbal supplements (such as vitamin E, ginseng, ginger, or ginkgo biloba). Overall, she seemed to be an ideal candidate for lip augmentation using fillers. Before injection, written informed consent was obtained from the patient. According to standard procedure, EMLA (AstraZeneca PLC, London, UK) cream and cooling packs were applied to the perioral area ten minutes prior to injection. Mucosal and skin preparation was carried out with chlorhexidine gluconate. An Food and Drug Administration (FDA)-approved filler, consisting of 1 mL (0.5 mL per lip) of 24 mg/mL hyaluronic acid (HA) with 0.3% lidocaine (Juvederm Ultra Plus XC, Allergan, Irvine, CA, USA), was injected into the upper and lower vermilion border and vermilion. Retrograde fashion linear threading and serial puncture methods were used with a 30-gauge needle. The procedure was finished with a gentle massage to blend and smooth the region, and cooling packs were reapplied. Fig. 1 A twenty-seven-year old woman presented requesting lip augmentation. Fig. 2 A progressive lip edema occurred within minutes following injection with hyaluronic acid and lidocaine. Everything was normal upon the completion of the filler injection, but a progressive edema arose on the injection site within minutes. Lip volume increased 3-4 fold during the first hour, and swelling progressed during the first 12 hours after the injection (Fig. 3). The patient was monitored for approximately 2 hours and treated with intravenous antihistamines (a slow infusion of 2 mL of 45.5 mg/2 mL pheniramine maleate). She was closely followed for any sign of respiratory distress or systemic reaction until the reaction was clearly confined. Systemic findings such as hypotension, changes in consciousness, generalized rash, tongue and pharynx edema, dyspnea, or dysphagia were not observed. The edema did not spread outside the injection area and remained localized to the lips. After 3 hours follow-up, she was sent home with oral antihistamines (5 mg desloratadine 2 time/day). Ointments were applied for lubrication to avoid lip fissures and cold compression was continued. The edema started to resolve 48 hours after the start of the reaction and was completely resolved by the seventh day. The patient was worried about her lips after the initial treatment, but ultimately was satisfied enough that she requested another filler session. Before the first session, we examined the patient carefully and asked about her experiences with any previous lidocaine injections such as those that occur during dental treatments, but she did not mention any kind of allergic reaction. Likewise, she had an uneventful rhinoplasty operation one year before this procedure. Fig. 3 Edema was almost completely resolved at 7 days post-injection. HA fillers have a low hypersensitivity profile rate compared to other soft tissue fillers, ranging from 0.6% to 0.8% [1]. Generally, reactions are mild to moderate, self-limited, and continue for less than seven days. However, Leonhardt et al. [2] reported a rare case of severe local hypersensitivity. They observed a sudden swelling of the lips after a HA filler injection. Their patient was treated with steroids and valacyclovir for herpes prophylaxis and reaction was almost completely improved in four days. Recently, FDA-approved fillers containing HA and lidocaine have become available, with the goal of increasing patient comfort. Although there are only a few studies comparing pure HA fillers and fillers containing HA and lidocaine, the available results reveal no significant differences in the safety, efficacy, and longevity between the two treatments, while less procedural pain has been associated with the use of a filler containing HA and lidocaine [3]. The present report is the first case of a severe angioedema-type acute hypersensitivity reaction to a filler containing HA and lidocaine. In the present case, this acute reaction could be secondary to HA, lidocaine, EMLA cream, or simply due to the repeated punctures of the needle. Although no immunological tests were performed because the patient did not consent, the patients previous medical history indicates that HA hypersensitivity was more probable than other possible causes of the reaction. Although hypersensitivity reactions can often be treated by topical tacrolimus, intralesional steroids, systemic steroids, or antihistamines, the most commonly used drugs are steroids [4]. However, antihistamines are also frequently indicated in cases of hypersensitivity and they lead successful results. We preferred antihistamines in the treatment of this case and a satisfactory result was obtained. In light of our case and the similar cases in the literature, it seems that lips may have a greater tendency to swell and to show more severe reactions compared to other regions of the face. The high regional blood flow found in the lips may be the reason for this tendency. However, previous review articles about filler complications do not mention a higher possibility of hypersensitivity reactions following lip augmentation [5]. Once an allergic reaction has been observed after procedures involving artificial fillers, autologous lip augmentation options such as fat grafting become the first choice for future use in these patients.

The Inhibitory Effect of Platelet-Rich Plasma on Botulinum Toxin Type-A: An Experimental Study in Rabbits

BackgroundCombination treatments of botulinum toxin type-A and other rejuvenation agents or instruments are gradually becoming more popular. After observing a high incidence of therapy failure following simultaneous applications of botulinum toxin type-A and platelet-rich plasma mesotherapy, we aimed to investigate whether PRP has an inhibitory effect on botulinum toxin type-A.MethodsTwenty-four New Zealand white rabbits were divided into 4 groups, and the anterior auricular muscle and overlying skin were used for injections. Groups I and II both received onabotulinumtoxinA intramuscular injections. In addition, autologous platelet-rich plasma mesotherapy was performed in Group I while Group II received saline mesotherapy. Group III was designed as the in vitro mixture group in which onabotulinumtoxinA and platelet-rich plasma were mixed and then administered intramuscularly. Group IV received saline within the mixture instead of platelet-rich plasma. The contralateral ears of all the rabbits served as control and were only treated with onabotulinumtoxinA. Visual evaluation of ear positions and electroneuromyographic studies were done prior to all procedures and at day 14. Anterior auricular muscles were harvested at day 14 and were evaluated with quantitative real-time PCR.ResultsVisual and electroneuromyographic studies revealed less onabotulinumtoxinA activity in Groups I and III. When platelet-rich plasma was administered through skin mesotherapy, onabotulinumtoxinA activity failure was more severe in comparison with direct contact. No significant difference in SNAP-25 mRNA expression through quantitative real-time PCR was observed between groups.ConclusionAlthough we could not explain the exact mechanism underlying this interaction, platelet-rich plasma applications result in less onabotulinumtoxinA muscle paralysis activity.No Level AssignedThis journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors http://www.springer.com/00266.

Disulfiram Implantation for the Treatment of Alcoholism: Clinical Experiences from the Plastic Surgeon's Point of View

Background Disulfiram implantation is a widely used treatment alternative for alcohol abuse, yet reports on the surgical aspect of disulfiram implantation with respect to patient and drug-related treatment efficacy and wound complications are very limited. We present our clinical experiences with disulfiram implantation and discuss the surgical outcomes obtained with different anatomical planes for implantation. Methods Medical records of all patients referred to our clinic from the psychiatry department between 2007 and 2013 for disulfiram implantation were retrospectively analyzed. Implantation was carried out using 10 sterile Disulfiram tablets (WZF Polfa S.A.), each tablet containing 100 mg of disulfiram. The procedure was carried out by implanting the tablets randomly in either a subcutaneous or an intramuscular plane. The location and the plane of implantation and the complications were recorded for each patient and compared to determine the differences in the outcomes. Results A total of 32 implantation procedures were evaluated for this study. Twenty-five implants were placed in the intramuscular plane (78.2%), while seven implants were placed subcutaneously (21.8%). Exposure was encountered in three of the seven subcutaneous implants (42.9%), while no exposure was seen with the intramuscular implants. Incomplete absorption of the tablets was encountered in one patient with a previous subcutaneous implant who presented 1 year later for re-implantation as part of the continuation of therapy. Conclusions To overcome the issue of treatment continuation in the case of disulfiram therapy, which may be ceased due to frequently encountered wound complications, we believe that implantation in the subscapular intramuscular plane allows both uneventful healing and an out-of-reach implant location.

Would you be a face transplant donor? A survey of the Turkish population about face allotransplantation.

AbstractWith the technical advancement in face allotransplantation, we decided to survey the Turkish population to gain perspective into their thoughts and reactions toward face transplantation. A questionnaire was given to 1000 volunteers, regarding data about demographics, educational status, religious, and behavioral preferences. Their attitudes about donating their faces, knowledge about the pros and cons of this procedure, and personal desire for face transplantation if needed were inquired.The results of the survey demonstrated that knowing more about the procedure increases its acceptance but even so, the majority would rather undergo multiple operations with self-tissues before getting a facial transplantation (FT). When the risks of immunosuppression were exposed, less people agreed to FT, thinking it was not worth the risks.The cultural, ethnical, religious, and social background of different societies may influence the way FT is perceived and accepted. As this procedure is thought to challenge many ethical, physiological, and social points of views, we believe that it is important for a surgical team to have insight into their population’s perception and general thoughts concerning the issue.

External Mustarde suture technique in otoplasty revisited: A report of 82 cases

Abstract In otoplasty surgery the antihelical fold is frequently created using Mustarde sutures. When using the Mustarde suture technique it is important to insert the needle through the cartilage at right angles. This technical objective is easily achieved with an external Mustarde suture technique. A review of 82 patients who underwent otoplasty between 2005 and 2011 was conducted. All patients underwent external Mustarde suture otoplasty without conchal cartilage resection. The cartilage had been softened by rasping and conchomastoidal sutures had been used to correct conchal excess if necessary. In one patient, a secondary revision was performed for inadequate superior pole correction. In three patients sutures were visible after 1 year postoperatively and the sutures were removed under local anaesthesia without any recurrence. In one patient blister formation occurred due to inaccurate packing, but healed without any problem in a few days. No other complications, such as bowstringing of the internal sutures, haematoma, or infection, were observed. The patients expressed a high degree of satisfaction with their results. The risk of technical error is minimal. It is easy to perform and not time-consuming. Due to these advantages, this method is a reliable technique in otoplasty.