Hakan Bulam

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.

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.

Cosmetic Outcome and Percentage of Breast Volume Excision in Oncoplastic Breast-Conserving Surgery: A Proposal

During our research on breast shape and estimating the breast volume to be excised, we came across the article entitled ‘‘Cosmetic Outcome and Percentage of Breast Volume Excision in Oncoplastic Breast Conserving Surgery’’ [1]. The importance of cosmetic outcomes and patient satisfaction in oncologic surgery is increasing, and we are very much interested in this concept. We have taken advantage of this article for our recent studies. In our opinion, there is only one problem in the article. Preoperative breast measurements were performed based on mammographic findings, and the final amount was determined in units of volume (cubic centimeters, cm); however, intraoperative excised material was weighed and calculated as units of weight (grams, g). The percentage of breast volume excision is then calculated by dividing the weight of the excised tissue by the estimated breast volume (g/cm). This might cause confusion when determining cosmetic outcomes depending on the described percentage. In our opinion, if the researchers measured the volume of excised material by Archimedes principle (water displacement method) or another technique [2], the result would be more consistent and reliable. As we all know, some breast tissue is more glandular, and some has more fat; even in the same breast the distribution of glandular and fatty tissue varies. Therefore, the weight/volume ratio of the breast changes with these conditions. The authors noted that, ‘‘The application of the [sic] oncoplastic technique allows large-volume excision with satisfaction remaining high when the [sic] breast volume excision was [sic] less than 20%, regardless of different tumor location and tumor distance from the [sic] nipple.’’ If all results were calculated in units of volume, the stated cutoff point of 20% would be changed, which directly affects the point of the research.

A 1-Year-Old Boy With Paraspinal Elastofibroma: The Youngest Diagnosed Elastofibroma

Elastofibroma is a benign and slow-growing soft tissue tumor that classically presents as an ill-defined solitary mass at the inferior pole of the scapula in the fifth and sixth decades of life for women. This tumor can be rarely seen in childhood, but it has not been reported in the infantile age group to date. To our knowledge, this case represents the first report of elastofibroma in the infantile age group. The aim of this report is to present a paravertebral elastofibroma in a 14-month-old patient and discuss the clinical features and treatment modalities.

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.

Iatrogenic pressure sores: primum non nocere.

Dear Editors, An iatrogenic wound can be defined as a wound that is attained during or as a result of medical treatment provided by a health care giver. A study by Lee et al. reported that the most common iatrogenic injuries that are referred to plastic surgeons are extravasation injuries, followed by cast-induced injuries and vasopressor-induced necrosis (1). Pressure sores can also be identified within the iatrogenic wound spectrum, as a majority of such wounds occur during treatment in a medical facility and is regarded as a serious complication of hospitalisation (2). Stationary positioning and the subsequent altered tissue perfusion along with a compromised nutritional status are among the main factors that lead to decubitus ulcers, and universal precautions are taken in order to minimise the risk (3). Several iatrogenic wounds have been referred to us, mainly unconventional pressure sores in patients undergoing medical treatment in different branches. We believe that the main reason behind the occurrence of these wounds in the wards is the lack of attention given to areas distant to the area of primary pathology. One dramatic case of an iatrogenic pressure sore was a 61-year-old male patient who presented with circumferential penile necrosis following the rigorous taping of an external urinary catheter after colon surgery (Figure 1). However, the necrosis was superficial, and the patient was treated with debridement followed by skin grafting. Another unusual case of an iatrogenic pressure sore was a 42-year-old female patient who presented with a linear ulcer in her left popliteal area due to thromboembolic sock compression following gastric surgery (Figure 2). Her wounds were also treated with debridement and local wound care.