Mert Calis

Revisiting the role of columellar strut graft in primary open approach rhinoplasty

Background: The effect of a columellar strut graft on final nasal tip position has been a subject of ongoing debate. The purpose of this study was to retrospectively analyze a series of 100 consecutive primary rhinoplasty cases performed without the use of columellar strut grafts, with a specific focus directed toward comparing preoperative, morphed, and actual postoperative changes in nasal tip position. Methods: Data were collected from patient charts and digital images of 100 consecutive primary open rhinoplasty patients. Preoperative, morphed, and actual postoperative digital images were quantitatively analyzed using image-processing software to compare various anatomical features, including nasal tip projection, nasolabial angle, and Goode ratio. Patient satisfaction regarding long-term postoperative results was also surveyed. Results: Primary rhinoplasty did not demonstrate a universal trend toward either an increase or a decrease in nasal tip projection. The planned changes in nasal tip projection, nasal tip rotation, and nasal profile proportions were obtained with statistically significant accuracy without the use of columellar strut grafts. The overall incidence of columellar contour irregularities was 3 percent. Conclusion: In primary open approach rhinoplasty, if native anatomical support structures of the nasal tip are preserved or reconstructed, preoperative goals regarding nasal tip projection, nasal profile proportions, and columellar integrity can be consistently achieved without using columellar strut grafts. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

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.

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.

Estrogen as a novel agent for induction of adipose-derived mesenchymal stem cells for osteogenic differentiation: in vivo bone tissue-engineering study.

Background: This study investigated whether the in vivo osteogenic differentiation potential of adipose-derived mesenchymal stem cells is enhanced by 17&bgr;-estradiol. Methods: Thirty Sprague-Dawley rats were randomized and divided into five experimental groups. For the surgical procedure, biparietal full-thickness bone defects (7 mm in diameter) were created. A chitosan-hydroxyapatite scaffold was used as the vehicle system for 17&bgr;-estradiol–loaded nanoparticles and adipose-derived mesenchymal stem cells. The first group, the blank defect group, was the control group. The defects were filled with either scaffold, estradiol, and scaffold; scaffold and adipose-derived mesenchymal stem cells; or estradiol, scaffold, and adipose-derived mesenchymal stem cells as experimental groups. The rats were killed at the end of weeks 4 and 12, and their calvariae were harvested for histologic and microtomographic evaluation. Results: Micro–computed tomographic evaluation of estradiol, scaffold, and adipose-derived mesenchymal stem cells revealed the highest median value (82.59 ± 17.17), and the difference was significant compared with the blank defect group (p = 0.004). Histologic samples demonstrated a significant difference between experimental groups for bone defect repair at the end of weeks 4 and 12 (p = 0.003 and p < 0.001). The estradiol, scaffold, and adipose-derived mesenchymal stem cell group had the highest median score (3.00 ± 0.0) at week 12, which was significantly higher than scores for the scaffold and adipose-derived mesenchymal stem cell group and the blank defect group. Conclusion: 17&bgr;-Estradiol appears to be a novel and promising agent for future cell-based bone tissue-engineering studies.

Unusual foreign body impaction in the palate: plastic screw cap.

To the Editor: W e would like to present a case of long-term impaction of a foreign body embedded in the hard palate, which was misdiagnosed initially as a mucosal tissue defect of the palatal tissue exposing the bone. Recently, a 2-year-old child was brought to the pediatric emergency department with the suspect of palatal lesion. The lesion was an incidental finding having been noticed initially by the mother. On examination, he was in no acute distress and had normal vital signs and normal oxygen saturation. After initial evaluation of the patient, he was referred to the department of plastic surgery because of a lesion with a diameter of 1 cm, which was diagnosed to be a mucosal defect of the palate exposing the bone underneath. Because the child was uncooperative, clinical examination had been difficult in zthe outpatient setting. However, examination revealed a smooth circular brown mass measuring approximately 1 cm in diameter and situated in the vault of the hard palate having a well-demarcated regular outline (Fig. 1). The clinical diagnosis of a possible foreign body impaction was made at the initial consultation, and with the head fully extended, the foreign body was removed with the aid of forceps in the outpatient setting. After removal of the object, it was noticed that, although an imprint of the object was left, the underneath palatal mucosa was intact. Further examination of the object after the removal and confirmation with the history by the parents showed it to be a plastic screw cover commonly found on ready to assemble furniture (Fig. 2). The child had no complications and was discharged. Palatal foreign bodies are relatively uncommon. Among the palatal foreign bodies discovered, plastic screw caps are even further surprising. There are only a few reported cases of screw caps in the literature. When considering a palatal lesion especially in infant population, foreign body ingestion should always be taken into consideration. Early discovery of foreign body impaction saves the child from further evaluation and probable radiologic examination, and even more important is that it saves from aspiration of the foreign body if secondarily dislodged.

Application of C-Shaped Osteotomy and Distraction Osteogenesis for Correction of Radial Angulation Deformities of the Hand in Children With Apert Syndrome: Review of 10 Years of Experience.

AbstractApert syndrome is characterized by short, radially deviated thumbs, leading to difficulties in daily life such as holding a fork or a spoon and buttoning up. The main goal of surgery is to achieve thumb to index finger pinch to overcome these difficulties. Seven patients (14 extremities) followed up with Apert syndrome underwent distraction after a C-shaped osteotomy to simultaneously correct the brachydactyly and the angulation deformity of the bilateral thumbs. The patients ranged in age from 4 to 7 years at the distraction operation, with a mean (SD) of 4.7 (1.7) years, and the mean (SD) length of follow-up was 100.6 (14.95) months. The mean (SD) length of the phalanges at the beginning of distraction was 19.1 (3.26) mm, and the mean (SD) length of the distracted phalanx at long-term follow-up visit was 26.2 (5.63) mm. The mean (SD) correction of radial angulation was calculated as 42.6 (9.95) degrees, and the difference was considered as being statistically significant (P < 0.001). Minor complications such as pin loosening were observed in 6 extremities of 4 patients, and 2 patients were treated for pin tract infection. Index-to-thumb pinching was acquired by all the patients after distraction and correction of angulation. The hand features of Apert syndrome are as noteworthy as the craniofacial features and thus may lead to functional impairment and limitations in daily life. Distraction with a C-shaped osteotomy seems to be a promising method to correct both the shortness and the radial angulation of the thumb to achieve functional results.

Does contribution of extended vomer flap to palatoplasty affects speech results.

Abstract Development of normal speech is the primary goal of successful palatoplasty. The purpose of this study was to determine the importance of the contribution of vomer flap to palatoplasty procedure for speech function. Eighty-one children who underwent 2 flap palatoplasty procedures for cleft palate repair between 2002 and 2010 were retrospectively reviewed in 3 groups. Group 1 underwent palatoplasty without contribution of vomer flap. Group 2 underwent palatoplasty with standard dissection of vomer flap, whereas group 3 underwent palatoplasty with extended dissection of vomer flap. Speech function of the patients was evaluated using objective assessment tools such as nasopharyngoscopy and nasometer. Eighty-one children who underwent 2 flap palatoplasty were included in this study. The mean age at palatoplasty was 10.17 months, and mean length of follow-up was 72.33 months. For most syllables, patients repaired using extended vomer flap demonstrated lower nasalance scores. Nasopharyngoscopic examination revealed velopharyngeal motility in 24 patients (80%) in group 1 and in 20 (83.3%) and 23 (85.2%) patients in groups 2 and 3, respectively (P = 0.930). In velopharyngeal closure, there were only 5 patients (18.5%) in group 3, whereas there were 6 patients (25.0%) for group 2 and 10 patients (33.3%) for group 1 with no closure (P = 0.311). Although most optimum results were observed in the group with extended dissection of the vomer flap, contribution of the extended vomer flap to the repair of the soft palate did not lead to significantly better speech results.

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.

Spontaneous lateral temporal encephalocele.

A spontaneous encephalocele is one that develops either because of embryological maldevelopment or from a poorly understood postnatal process that permits brain herniation to occur. We here report a rare case of lateral temporal encephalocele extending to the infratemporal fossa under the zygomatic arch. At birth, the infant was noted to have a large cystic mass in the right side of the face. After being operated on initially in another center in the newborn period, the patient was referred to our clinic with a diagnosis of temporal encephalocele. He was 6 months old at the time of admission. Computerized tomography scan and magnetic resonance imaging studies revealed a 8 × 9 cm fluid-filled, multiloculated cystic mass at the right infratemporal fossa. No intracranial pathology or connection is seen. The patient was operated on to reduce the distortion effect of the growing mass. The histopathological examination of the sac revealed well-differentiated mature glial tissue stained with glial fibrillary acid protein. This rare clinical presentation of encephaloceles should be taken into consideration during the evaluation of the lateral facial masses in the infancy period, and possible intracranial connection should be ruled out before surgery to avoid complications.