Fatih Zor

Face, upper extremity, and concomitant transplantation: potential concerns and challenges ahead.

Summary: From its origination involving successful rat hind-limb allograft studies using cyclosporine, face and upper extremity composite tissue allotransplantation has since developed into an exciting and promising subset of reconstructive transplant surgery. Current surgical technique involving composite tissue allotransplantation has allowed optimal outcomes in patients with massive facial and/or upper extremity defects; however, with its coexisting immunologic barrier, obligatory lifelong immunosuppression commits each patient to a daily risk of transplant-related complications with many unanswered questions. Since 1998, nearly 50 hand transplantations in 40 patients have been performed around the world at various levels ranging from wrist level to shoulder level. However, the risk-to-benefit ratio remains controversial in bilateral versus unilateral transplantation and has yet to be determined. From recent experience, the two most important determinants of the success of each patients upper extremity transplant are patient compliance and intense rehabilitation. A total of nine face transplants have been performed since 2005. Multiple aesthetic subunits (i.e., nose, lips, eyelids) with or without underlying craniofacial skeletal defects (i.e., maxilla, mandible) have been successfully restored, thereby providing restoration of vital facial functions (i.e., smiling) in an unprecedented manner. As of today, face transplantation carries an estimated 2-year mortality of 20 percent. Concomitant composite tissue allotransplantation, which involves a variable combination of allograft subtypes, has been performed in two of the nine face transplant patients. These have included simultaneous bilateral hand transplants and tongue with mandible. Future study is warranted to investigate the potential advantages and disadvantages of using this approach versus a staged approach for reconstruction.

Pain relief during dressing changes of major adult burns: Ideal analgesic combination with ketamine

Pain management during burn dressing changes is a critical part of treatment in acute burn injuries. Although several treatment options have been suggested, it is still a challenge in a clinical setting. This study is aimed at finding out an ideal analgesic, sedative and/or anxiolytic combination that would minimise the unwanted effects of ketamine. A total of 24 patients, with burns up to 20-50% of total body surface area (TBSA), were included in the study and randomly divided into three groups. In group I, 2 mg kg(-1) ketamine was administered. In group II, 1 mg kg(-1) tramadol was administered and 30 min later, 1 microg kg(-1) dexmedetomidine and 2 mg kg(-1) ketamine was administered. In group III, 1 mg kg(-1) tramadol was applied and 30 min later, 0.05 mg kg(-1) midazolam and 2 mg kg(-1) ketamine was administered. The evaluation was performed with cardiopulmonary monitoring, sedation and visual analogue pain scores and overall patient satisfaction. Any adverse effects of ketamine were recorded. The results showed that group II had better outcomes with respect to pain management during dressing changes. As a conclusion, the use of the combination of ketamine, tramadol and dexmedetomidine was found to be a good treatment option for the prevention of the procedural pain suffered by adult patients during dressing changes.

Continuous brachial plexus blockade for digital replantations and toe-to-hand transfers.

Microsurgical operations of the hand are common procedures of reconstructive surgeons. Sympathetic blockade of the vessels provides increased blood flow to the injured extremity, which increases the success rate of the surgery. Moreover, postoperative pain management can be performed with continuous blockade of the nerves. In this article, the effect of continuous brachial plexus blockade on patients who underwent upper extremity microsurgical operation was evaluated. A total of 16 patients were operated on either for replantation or for toe-to-hand transfer. The first group (n = 9) received combined continuous brachial plexus blockade and general anesthesia, and postoperative pain management was performed with continuous brachial plexus blockade. The remaining 7 patients operated on general anesthesia and conventional pain management. All transplant and replants were followed by use of Doppler flowmeter. Pain was scored by visual analog scale every 4 hours postoperatively. Continuous brachial plexus blockade was found to be effective in both sympathetic blockade and postoperative pain management. Continuous brachial plexus blockade must be considered when microvascular anastomosis is performed at the upper extremity, especially at the digital vessels, which are very susceptible to vasospasm.

A new composite midface allotransplantation model with sensory and motor reinnervation

In this study, we extended application of face transplantation model in rat by incorporation of vascularized premaxilla, and nose with infraorbital and facial nerves for evaluation of allotransplanted sensory and motor nerve functional recovery. In group I (n = 3) the dissection technique is studied. In group II (n = 5) isotransplantations were performed. In group III (n = 5) allotransplantations were performed under Cyclosporin A monotherapy. Grafts; composed of nose, lower lip, and premaxilla; were dissected. Infraorbital nerve and facial nerve were included into the transplant. A heterotopic transplantation was performed to inguinal region of recipient. Nerve coaptations were performed between infraorbital‐sapheneous nerve and facial‐femoral nerve. CT scan, somatosensory‐evoked potential testing (SSEP), motor‐evoked potential testing (MEP), and microangiography were used for evaluation. All transplants survived indefinitely over 100 days. Microangiography showed preserved vascularization of the graft. Computed tomography revealed vital premaxillary bone segments. SSEP and MEP confirmed recovery of motor and sensory functions and latencies reached 67% of normal infraorbital nerve value and 70% of normal facial nerve value at 100 days post‐transplant. We have introduced new midface transplant model of composite midface allograft with sensory and motor units. In this model, motor and sensory functional recovery was confirmed at 100 days post‐transplant.

Multiple giant disseminated pyogenic granuloma in a burn lesion.

This case describes a 2-year-old boy who developed multiple giant pyogenic granulomas on his left upper extremity secondary to a burn injury caused by boiling milk. Here, we present multiple pyogenic granulomas in a burn patient and discuss the possible etiologies of the entity. The pyogenic granulomas were excised and wounds closed with sutures (primary repair) (primary closure). No pyogenic granulomas have recurred after 11 months of follow-up. Pyogenic granuloma with multiple dissemination in a burn scar is an extremely rare occurrence, and there have been no reports of pyogenic granulomas caused by flame and other type of scalding burns such as hot water and oil. The case presented here was a burn injury caused by hot milk. The burn etiology, not the burn injury itself, is important because all similar cases have the same etiology. We thought that this may not be a coincidence and that milk proteins or other components of the milk might cause the development of pyogenic granuloma.

An unusual complication of a Medpor implant in nasal reconstruction: a case report.

There are few implant materials which have been successfully used for nasal reconstruction. Of these, the medpor implant is the most accepted alloplastic material for reconstruction of the nasal framework. Here, an unusual complication of a medpor implant in nasal reconstruction is presented. A 24-year-old medical student suffering from a saddle nose deformity after a primary rhino plasty was admitted to our department. The medpor nasal implant was used to restore the nasal dorsum. The surgical result was appreciated by the patient. No problem was encountered during two years after surgery. Recently, the patient suffered from an asymmetry of the nasal dorsum. The physical examination revealed a step on the nasal dorsum with caudal mobility of the implant. The nasal implant was suspected to be broken. Multislice CT scan and ultrasonographicimaging of the implant were obtained. The radiologicevaluation of the region confirmed the fracture of the medpor nasal implant. Nasal reconstruction with a medpor implant is a good choice with low complication rates. This is the first case in the literature reporting a broken medpor nasal implant. Moreover, in this study a new method is described for imaging the medpor implant material.

The effect of platelet rich plasma on angiogenesis in ischemic flaps in VEGFR2-luc mice

To improve skin flap healing, one promising strategy in reconstructive surgery might be to optimize platelet rich plasma (PRP) bioactivity and the ischemia-altered expression of genes. We studied both the effect of PRP on ischemic flaps, and whether in vivo bioluminescence imaging (BLI) is a suitable method for the longitudinal monitoring of angiogenesis in surgical wounds. Axial murine skin flaps were created in four experimental groups. In vivo measurements of VEGFR2 expression levels were made every other day until the 14th day. The local VEGF level and microvessel density were quantified on the 14th day via ELISA and immunohistochemistry, and flap survival rates were measured. We demonstrated that PRP and induced ischemia have a beneficial influence on angiogenesis and flap healing. Combining the two resulted in a significantly robust increase in angiogenesis and flap survival rate that was corroborated by bioluminescence imaging of VEGFR2 activity. This study shows that angiogenic effects of PRP may be potentialized by the stimulus of induced ischemia during free flap harvesting, and thus the two procedures appear to have a synergistic effect on flap healing. This study further demonstrates that BLI of modulated genes in reconstructive surgery is a valuable model for longitudinal in vivo evaluation of angiogenesis.

Treatment of temporomandibular joint ankylosis and facial asymmetry with bidirectional transport distraction osteogenesis technique.

Transport distraction technique is a good treatment modality for unilateral temporomandibular joint ankylosis. However, with a unidirectional distraction, it is not possible to correct facial asymmetry that results from mandibular hypoplasia associated with early-onset unilateral temporomandibular joint ankylosis. For this purpose, gap arthroplasty and simultaneous bidirectional transport distraction was used to correct these deformities. Although vertical distraction corrects vertical deficiency of the ramus and creates a neocondyle, the simultaneous anteroposterior distraction of the transport segment corrects facial asymmetry resulting from horizontal shortness of mandible. Three patients, whose mean mouth opening was 8.6 mm, were successfully treated with this technique. Mean advancements in vertical and anteroposterior direction were 14.7 and 7.7 mm, respectively. Mean maximal mouth opening was 29.7 mm postoperatively. The average follow-up period was 13 months (range, 12-15 mo). During this period, reankylosis was not observed, and the interincisal distance did not decrease. Gap arthroplasty and bidirectional transport distraction of the mandibular ramus is a good and effective therapeutic option in treatment.

Burn injuries related to liquefied petroleum gas-powered cars.

Liquefied petroleum gas (LPG), which is used as a type of fuel, is stored as a liquid under high pressure in tanks. Immediate and sudden explosion of these tanks can release a large amount of gas and energy into the environment and can result in serious burns. In this study, the cases of 18 patients injured due to LPG burns in five incidents were examined, along with their epidemiologic features. The authors also investigated the causes of the LPG tank explosions. Inhalation injury was present in 11 cases with varying degrees of severity, and 7 patients subsequently required mechanical ventilation. The explosions resulted from weakening of the tank wall (n = 2), crash impact (n = 2), and gas leakage from the tank (n = 1). LPG-powered cars are becoming more popular because of their lower operational costs. However, LPG tanks can be hazardous in the event of a tank explosion. Burns caused by explosions of the LPG tanks in cars have significant mortality and morbidity. This danger must be taken into account and public awareness must be increased.

Imaging of porous polyethylene implant by using multidetector spiral computed tomography.

The porous polyethylene implant (Medpor; Porex Surgical, Inc., Newnan, GA) is one of the most usable implants in clinical practice. Because it is radiolucent on both direct radiography and conventional computed tomography, visualization of the implant becomes an important issue. In this clinical study, availability of multidetector spiral computed tomography for visualization of the implant was evaluated. The technique was used in 15 patients who had Medpor reconstructions on their faces, including frontal (seven), malar (five), and mandibular (five) regions. A 16-channel multislice computed tomography scanner was used in spiral scanning mode. Sagittal, coronal, and transverse multiplanar reformation and volume-rendered images were reformatted using a PC-based three-dimensional reconstruction program (Extended Brilliance Workspace, Release 1.0.1.1, Philips Medical Systems, Amsterdam, The Netherlands). The three-dimensional images along the course of the implant were additionally reformatted. Window width and level were adjusted for viewing the bone as respective values of 1100 HU and 450 HU in contrast to the values of 800 HU and 200 HU, respectively, for the implant. The detailed contour of the implants could be easily traced on the multidetector computed tomographic images, including either the concave or convex areas. The calcifications and cystic formations around the implants and the spatial relationship between the defects and the implants were also shown. We believe that the present multidetector computed tomographic technique offers direct visualization of the Medpor implant in the body. It has many advantages over the current magnetic resonance imaging techniques that need tissue in growth for visualization.