Raffi Gurunluoglu

Restoration of ovarian function after autotransplantation of intact frozen-thawed sheep ovaries with microvascular anastomosis

OBJECTIVE To test the feasibility of transplanting an intact frozen-thawed ovary with microvascular anastomosis of the ovarian vascular pedicle to the deep inferior epigastric vessels. DESIGN Chronic survival study. SETTING Biological Resources Unit, The Cleveland Clinic Foundation. ANIMAL(S) Adult merino ewes. INTERVENTION(S) Bilateral laparoscopic oophorectomy was performed on 17 synchronized ewes. In one group of animals (Group I, n = 11), both ovaries were cryopreserved intact with their vascular pedicles. In another group of animals (Group II, n = 6), ovarian cortical strips were prepared from each ovary and cryopreserved. After thawing, follicular viability and apoptosis rates were assessed using one ovary. The other ovary was transplanted to the abdominal wall with microvascular anastomosis (Group I). In Group II, the ovarian cortical strips were placed in the anterior abdominal wall. Ovaries were harvested after 8-10 days in situ and subjected to histological evaluation. MAIN OUTCOME MEASURE(S) Blood flow, apoptotic signals, follicular viability, serum estradiol (E(2)), follicle-stimulating hormone (FSH), and histology. RESULT(S) No significant differences were found in the mean values of apoptosis (mostly in the atretic and some secondary follicles) and follicular viability in both groups. In Group I, immediate and long-term patency were documented in 100% and 27% (3/11) of the grafts, respectively; and postoperative FSH levels were similar to preoperative values in animals with patent vessels. In Group II, postoperative FSH levels were significantly higher than the preoperative ones (P=.03). CONCLUSION(S) Transplantation of an intact frozen-thawed ovary is technically feasible. Using this approach, immediate restoration of vascular supply and ovarian hormonal functions is possible.

Current trends in breast reconstruction: survey of American Society of Plastic Surgeons 2010.

BackgroundWe conducted a retrospective survey of American Society of Plastic Surgeons to ascertain the current trends in breast reconstruction (BR). MethodsSurveys were sent to 2250 active American Society of Plastic Surgeons members by e-mail with a cover letter including the link using Survey Monkey for the year 2010. In all, 489 surveys (a response rate of 21.7%) were returned. Three hundred fifty-eight surveys from respondents performing BR in their practices were included in the study. The survey included questions on surgeon demographics, practice characteristics, BR after mastectomy, number of BR per year, type and timing of BR, use of acellular dermal matrix, reconstructive choices in the setting of previous irradiation and in patients requiring postmastectomy radiation therapy, timing of contralateral breast surgery, fat grafting, techniques used for nipple-areola reconstruction, the complications, and physician satisfaction and physician reported patient satisfaction. Returned responses were tabulated and assessed. ResultsAfter prophylactic mastectomy, 16% of BRs were performed. In all, 81.2% of plastic surgeons predominantly performed immediate BR. In patients requiring postmastectomy radiation therapy, 81% did not perform immediate BR. Regardless of practice setting and laterality of reconstruction, 82.7% of respondents predominantly performed implant-based BR. Half of the plastic surgeons performing prosthetic BR used acellular dermal matrix. Only 14% of plastic surgeons predominantly performed autologous BR. Surgeons in solo, plastic surgery group practices, and multispecialty group practices preferred implant-based BR for both unilateral and bilateral cases more frequently than those in academic practices (P < 0.05). Overall, plastic surgeons in academic settings preferred autologous BR more frequently than those in other practice locations (P < 0.05). Of total respondents, 64.8% did not perform microsurgical BR at all; 28% reported performing deep inferior epigastric perforator flap BR. Pedicled transverse rectus abdominis myocutaneous flap was the most often used option for unilateral autologous reconstruction, whereas deep inferior epigastric perforator flap was the most commonly used technique for bilateral BR. The overall complication rate reported by respondents was 11%. ConclusionThe survey provides an insight to the current trends in BR practice with respect to surgeon and practice setting characteristics. Although not necessarily the correct best practices, the survey does demonstrate a likely portrayal of what is being practiced in the United States in the area of BR.

Heterotopic autotransplantation of the ovary with microvascular anastomosis: A novel surgical technique

OBJECTIVE To test the feasibility of transplanting an entire ovary with anastomosis of the ovarian vascular pedicle. DESIGN Long-term survival study. SETTING Biological Resources Unit, Cleveland Clinic Foundation. ANIMAL(S) Five adult, nonpregnant ewes. INTERVENTION(S) Laparoscopic bilateral oophorectomy was performed. Ovaries were autotransplanted into the abdominal wall, and microsurgical vascular anastomosis of the ovarian to the inferior epigastric vessels was performed. The transplant was removed and evaluated after 7 +/- 1 days. MAIN OUTCOME MEASURE(S) Blood flow, serum E2 and FSH levels, and histologic characteristics. RESULT(S) At follow-up three transplants were viable; they showed no signs of necrosis, and patency of the vascular anastomosis was confirmed. Serum E2 levels did not change significantly after transplantation in the patent vessel group (155.3 +/- 46.1 vs. 125.7 +/- 44.6 pg/mL) or the nonpatent vessel group (99 vs. 158 pg/mL). Serum FSH level in the patent vessel group did not change significantly from before to after transplantation (70.6 +/- 37.2 ng/mL vs. 95.1 +/- 17.7 ng/mL), whereas a large increase in FSH level was observed in the nonpatent vessel group (52.3 ng/mL vs. 522 ng/mL). The patent vessel group had significantly more follicles after transplantation than did the nonpatent vessel group (6 +/- 1 vs. 1 +/- 1). CONCLUSION(S) In conjunction with improved protocols for cryopreservation, ovarian autotransplantation with vascular anastomosis may be superior to current ovarian tissue banking and grafting techniques.

Induction of tolerance to hind limb allografts in rats receiving cyclosporine A and antilymphocyte serum: effect of duration of the treatment.

Background. This study assessed the ability of antilymphocyte serum (ALS) and cyclosporine A (CsA) to induce tolerance for hind limb composite tissue allograft in rats without chronic immunosuppression. Methods. Hind limb transplantations were performed in Lewis-Brown-Norway (LBN, RT1l+n) and Lewis (LEW, RT1l) rats. Treatment consisted of ALS only (0.4 mL/kg), CsA only (16 mg/kg), and a combination of CsA and ALS, and it was administered 12 hr before surgery at three different intervals (7, 14, and 21 days). Long-term survivors were tested for tolerance by standard skin grafting from the recipient (LEW), the donor (LBN), and the third party (ACI, RT1a) 60 days after cessation of the treatment and by mixed lymphocyte reaction at 100 days. T-cell lines were analyzed with flow cytometry. Results. Single use of ALS in all treatment intervals did not prolong allograft survival. Single use of CsA extended survival up to 23 days in the 21-day protocol group. CsA and ALS caused indefinite survival in two of six rats in the 14-day protocol and in all six rats in the 21-day protocol (>420 days). The six long-term survivors in the 21-day protocol accepted the skin grafts from the donor (LBN) and the recipient (LEW) and rejected third-party grafts (ACI). Tolerant animals showed a donor-specific hematopoietic chimerism of 35% to 42% in the peripheral blood. Mixed lymphocyte reaction assay demonstrated tolerance to the host and donor alloantigens and increased response to the third party. Conclusions. Administration of CsA and ALS for 21 days induced donor-specific tolerance in the recipients of the rat hind limb composite tissue allografts. The mechanism of tolerance should be investigated further.

Gene therapy by adenovirus-mediated vascular endothelial growth factor and angiopoietin-1 promotes perfusion of muscle flaps.

An experimental study was conducted to investigate the potential use of intravascular gene therapy with adenovirus-mediated (Ad) vascular endothelial growth factor (VEGF) or angiopoietin-1 (Ang-1) for the enhancement of muscle flap perfusion and to evaluate the effect of therapy on microcirculatory hemodynamics and microvascular permeability in vivo by using a cremaster muscle flap model in the rat. The cremaster tube flap was left intact after isolation of the pudo-epigastric pedicle. A total of 90 male Sprague-Dawley rats were divided into five groups of 18 each, according to the type of intraarterial treatment. Control flaps received phosphate-buffered saline. Group 2 (the control gene encoding green fluorescent protein, Ad-GFP) served as the adenovirus control. In Groups 3, 4, and 5, flaps were pretreated with Ad-VEGF, Ad-Ang-1, and Ad-Ang-1 + Ad-VEGF, respectively. Flaps were preserved in a subcutaneous pocket in the hindlimb for evaluation of functional capillary density and microvascular permeability indices at 3, 7, and 14 days by intravital microscopy system. At day 7 and 14, Ad-VEGF, Ad-Ang-1, and combined treatment groups showed significantly higher numbers of capillary densities when compared with control and Ad-GFP groups (p < 0.05). At day 14, Ad-VEGF was the superior treatment group compared with Ad-Ang-1 and Ad-VEGF + Ad-Ang-1 (p < 0.05). Overall, there was a linear increase in the number of functional capillaries in all treatment groups (p < 0.05). At day 3 after Ad-Ang-1 therapy, a significantly lower permeability index was found when compared with Ad-VEGF + Ad-Ang-1 and Ad-VEGF alone treatment (p < 0.05). At day 7, the Ad-VEGF group had the highest score of permeability index compared with control, combined, and Ad-Ang-1 groups (p < 0.05). Histologic evaluation of muscle flaps demonstrated mild focal inflammation. There was evidence of mild vasculitis in all flaps except control muscles. Intravascular angiogenic therapy with Ad-VEGF or Ad-Ang-1 was technically feasible, as demonstrated by expression of the control gene, GFP, along the vascular tree. All treatment groups increased perfusion of the muscle flap over a period of 14 days, indicating a long-lasting effect of gene therapy. Ang-1 alone or in combination with VEGF was as effective as VEGF alone in augmenting muscle perfusion with more stable vessels 1 week after gene therapy.

Comparison of the effectiveness of gene therapy with transforming growth factor-β or extracorporal shock wave therapy to reduce ischemic necrosis in an epigastric skin flap model in rats

The induction of neoangiogenesis by exogenous growth factors in failing skin flaps has recently yielded promising results. Gene transfer with virus vectors has been introduced as a highly capable route of administration for growth factors, such as vascular endothelial growth factor or fibroblast growth factor. Extracorporal shock waves (ESW) deliver energy by means of high amplitudes of sound to the target tissue and have been shown to induce angiogenesis. We compared the effectiveness of gene therapy with adenovirus‐mediated transforming growth factor‐β (TGF‐β) and ESW therapy to treat ischemically challenged epigastric skin flaps in a rat model. Thirty male Sprague‐Dawley rats were divided into three groups of 10 each with an 8 × 8 cm epigastric skin flap. Rats received either subdermal injections of adenovirus (Ad) encoding TGF‐β (108 pfu) or ESW treatment with 750 impulses at 0.15 mJ/mm2. The third group received no treatment and served as a control group. Flap viability was evaluated after 7 days and digital images of the epigastric flaps were taken and areas of necrotic zones relative to total flap surface area calculated. Histologic evaluation and increased angiogenesis were confirmed by CD31 immunohistochemistry. Overall, there was a significant increase in mean percent surviving area in the Ad‐TGF‐β group and the ESW group compared to the control group (ESW group: 97.7 ± 1.8% vs. Ad‐TGF‐β: 90.3 ± 4.0% and control group: 82.6 ± 4.3%; p < 0.05). Furthermore, in the ESW group mean percent surviving areas were significantly larger than in the Ad‐TGF‐β group (ESW group: 97.7 ± 1.8% vs. Ad‐TGF‐β: 90.3 ± 4.0%; p < 0.05). Flap vascularization was increased by Ad‐TGF‐β and ESW with numerous vessels, however, there was no significant difference between the two treatment groups. We conclude that treatment with ESW enhances epigastric skin flap survival significantly more than Ad‐TGF‐β treatment and thus represents a modality that is feasible, cost‐effective, and less invasive compared to gene therapy with growth factors to improve blood supply to ischemic tissue.

Functional lower lip reconstruction with bilateral cheek advancement flaps: revisitation of Webster method with a minor modification in the technique.

Major defects of the lower lip have been repaired in many ways. Of these, some employed flaps from the chin, cheek or upper lip. Some of these procedures employed flaps without regard for the facial grooves or landmarks. Some methods required incisions through nerves supplying the orbicularis oris and the flaps used for the lower lip reconstruction. Of the many methods of reconstruction that have been reported, we believe that the Webster technique should be considered as the first choice for lower lip defects larger than 80% of the total. Because this technique interferes minimally with the sensation of the lower lip and a satisfactory cosmetic outcome with a functional lower lip is achieved, the sensation and muscle function of the upper lip are unaffected. In addition to discussing the advantages of the Webster method, in this paper we present a minor modification in the dissection of the orbicularis oris muscle in an attempt to improve the motor innervation and to provide adequate oral competence and labial functioning in expression and speaking. Motor function and innervation of the lips after reconstruction was documented by clinical findings as well as electrophysiological methods.

Reliability of primary vein grafts in lower extremity free tissue transfers.

Free flaps transferred to the lower extremity have a higher risk of failure, which may be expected to increase further with the use of vein grafts. The results of 103 consecutive free flaps to the lower extremities of 98 patients who were operated from March 1994 to December 1999 were evaluated to assess the reliability of vein grafts in lower extremity reconstruction. Five flaps were lost and the overall success rate was 95.1%. Eighty-four free tissue transfers in 79 patients were performed for the reconstruction of traumatic cases, and 81 of these flaps were performed in a delayed manner, between 1 week and 4 months after the injury. Interpositional vein grafts were used primarily in 22 flaps—all in traumatic cases—and 21 of them survived completely (95.4%). Primary vein grafts were used both for arteries and veins in 15 flaps and for arteries only in 7 flaps. The most common cause of tissue loss in these patients was a crush injury in earthquake survivors, followed by electrical injuries, gunshot injuries, motor vehicle accidents, and chronic infections. Free muscle flaps in 13 patients, skin flaps in 4 patients, osseous flaps in 2 patients, and temporal fascial flaps in 2 patients were the flaps of choice in vein graft reconstructions. Although a higher incidence of flap loss has been reported with the use of interpositional vein grafts than with regular transfers, and the technical and pathophysiological problems in flap transfers are also high in the lower extremity, the success rate in vein-grafted free flaps did not differ from that of the simple free flap transfers in the current series. This appears to be the result of meticulous preoperative planning and proper selection of recipient vessels during optimal operative conditions.

Dynamic Repair of Scapholunate Dissociation With Dorsal Extensor Carpi Radialis Longus Tenodesis

This study investigates the results of a technique using an extensor carpi radialis longus (ECRL) tenodesis for symptomatic scapholunate instability. Symptomatic scapholunate instability has been corrected so far either by limited wrist fusion or by various techniques of soft tissue repair. Limited wrist fusion greatly reduces wrist motion and increases the probability of osteoarthritis in the remaining mobile wrist segments. On the other hand, most types of soft tissue repair are technically difficult to perform and have disappointing results due to the inherent laxity. The presented dynamic approach was used in 20 wrists of 19 patients with static scapholunate instability. Preoperative evaluation included in all patients clinical examination, radiologic evaluation, and arthroscopy for establishing the diagnosis of static scapholunate instability. The technique involves the fixation of the ECRL tendon on the dorsal aspect of the scaphoid by means of a cancellous screw and a special washer. Dynamic ECRL tenodesis of the scaphoid is a safe and simple procedure that enhances the extension forces on the scaphoid in all wrist positions. The results of this preliminary report in 20 wrists showed dynamic ECRL tenodesis to be an effective treatment option for treating symptomatic static scapholunate instability.

Anterior neck reconstruction with pre-expanded free groin and scapular flaps

To improve aesthetic and functional outcomes in the reconstruction of severe anterior neck burn deformities and to reduce donor-site morbidity, pre-expansion of free-flap donor sites was performed in eight patients. In the first stage of reconstruction, the tissue expander was placed and gradually inflated over a period of 6 weeks. In the second stage, the anterior neck scar was resected up to the limits of the aesthetic unit of the neck, radical release of neck contracture was achieved by transection of contracted platysma muscle, and immediate coverage with a pre-expanded groin or scapular free flap was performed. The early postoperative course was uneventful. Physical therapy was started 1 week after the reconstruction. Long-term follow-up (mean, 4 years) of patients who underwent reconstruction of extensive neck burn deformities demonstrated good aesthetic and functional results. The advantages and drawbacks of using pre-expanded free flaps in the treatment of neck burn contractures are discussed.