Reha Yavuzer

Effect of Platelet-Rich Plasma on Peripheral Nerve Regeneration

Activated platelets release various growth factors, some of which are recognized to improve nerve regeneration. This study evaluated the effect of platelet-rich plasma (PRP) in end-to-end neurorrhaphy. A total of 45 Wistar rats were used, with the initial five used for PRP preparation. The right hind limbs were used as experimental, with the left as control. The animals were treated in five groups. Group A (n = 4): The right sciatic nerve was dissected only from the sciatic notch to the bifurcation. In all other groups, the nerve was sharply transected and repaired with: group B (n = 8): two sutures; group C (n = 8): six sutures; group D (n = 10): two sutures and PRP; and group E (n = 10): six sutures and PRP. Groups D and E were compared with groups B and C, respectively. Group E had a shorter latency time in electromyography ( P < 0.01) and a thicker myelin layer in the histological evaluation ( P < 0.003) in comparison with group C. These positive effects of PRP were not detected in the nerves were repaired with two sutures. In this animal model, the application of PRP to the repair site helped to improve remyelinization of the sciatic nerve in rats when the epineural repair was done with six sutures.

Reconstruction of Traumatic Orbital Floor Fractures With Resorbable Mesh Plate

Various materials such as autogenous bone, cartilage and alloplastic implants have been used to reconstruct orbital floor fractures. A new material is needed because of disadvantages of nonresorbable alloplastic materials and difficulties in harvesting autogenous tissues. In this study safety and value of the use of resorbable mesh plate in the treatment of orbital floor fractures are discussed. Between 2002 and 2004 a total of 17 maxillofacial trauma patients complicated with orbital floor fractures were treated with resorbable mesh plate through subciliary or transconjunctival incisions. Pure blow-out fractures were determined in 6 patients and 11 patients had accompanying maxillofacial fractures. Resorbable plate was easily shaped to fit to the orbital floor by cutting with scissors. Patients were evaluated clinically and with computed tomography scans preoperatively and at 3-, 6- and 12-month intervals postoperatively. Twelve patients had preoperative enophthalmos. Two patients had diplopia that was corrected postoperatively. In all 17 cases there was no evidence of infection, diplopia and gaze restriction postoperatively. Scleral show appeared in three patients by the second postoperative week but resolved totally within 3 to 6 weeks except one patient. In this patient anterior displacement of mesh was evident which caused ectropion and enophthalmos and required re-operation. No any other mesh related problems were seen at 15 months mean follow-up time. The advantage of the resorbable mesh system in orbital floor fracture is the maintenance of orbital contents against herniation forces during the initial phase of healing and then complete resorption through natural processes after its support is no longer needed. Our experience represents that resorbable mesh is a safe and effective material for reconstruction of the selected, non-extensive orbital floor fractures.

Management of frontal sinus fractures.

Learning Objectives: After studying this article, the participant should be able to: 1. Understand the radiographic and clinical diagnosis of frontal sinus fractures. 2. Identify various management approaches to the frontal sinus fracture and the indications for each. 3. Understand the rationale behind the decision of sinus obliteration when needed. 4. Recognize the most common complications arising from frontal sinus fracture treatment and the methods of avoiding or managing these complications. Summary: Frontal sinus fracture management is still controversial and involves preserving function when feasible or obliterating the sinus and duct, depending on the fracture pattern. There is no single algorithm for the choice of management, but appropriate treatment depends on an accurate diagnosis using physical examination, computed tomography data, and the findings of intraoperative exploration. The amount and location of fixation and the need for frontonasal duct and sinus obliteration or elimination of the entire sinus depend on the anatomy of the fracture in general and the extent of involvement of the anterior wall of the sinus, the frontonasal duct, and the posterior wall in particular. This article discusses an algorithm for frontal sinus fractures that was obtained from the literature and modified according to the authors’ experience. The decision-making process presented by the authors has withstood the test of time over a period of more than 20 years in their practice and has been proven to be safe and efficacious in treating frontal sinus fractures of all types.

Guidelines for standard photography in plastic surgery.

Uniform patient photographs that create permanent records are essential for any visually oriented medical specialty. These images are valuable for any plastic surgeon’s practice for various reasons; thus, standards and recommendations for clinical photography should be well-known. There are several articles published on this issue, but it is still not uncommon to be exposed to medical publications and presentations that fail to satisfy clinical photography standards. This stimulated an interest in reviewing the important factors that are essential to achieve consistent, comparable clinical photographs with 35-mm single-lens reflex photography.

Cranial bone grafting for orbital reconstruction: is it still the best?

A variety of etiologies may result in functional and aesthetic deficiencies requiring orbital reconstruction. These are discussed, as are some of the possible repair techniques. In the current study, a randomized, retrospective chart review of one surgeons experience with orbital reconstruction using cranial bone grafts was performed. The results of the chart reviews are presented, including preoperative diagnosis, clinical signs and symptoms, and postoperative findings. This study allowed a comparison and contrast to be made between exogenous materials and autogenous bone for orbital reconstruction. The differences between cranial and iliac bone as autogenous sources of reconstructive material were examined. The study indicates that cranial bone grafting for reconstruction of the orbit remains the material of choice.

Surgical treatment of urethral fistulas following hypospadias repair.

&NA; Development of urethral fistulas is one of the most common late complications of hypospadias surgery. A total of 161 male patients who had 186 urethrocutaneous fistulas were first classified according to the fistula classification of Horton and colleagues and then treated with three types of procedures: simple closure, local rotation flaps, or tube graft reconstruction. With initial surgical intervention, 156 of 186 fistulas were treated successfully. The remaining 30 fistulas (16.1%) recurred during the follow‐up period. In the recurrent cases, immediate closure was not preferred, and an average of 6 months was waited before considering any additional surgical attempt. Distal cases had a higher failure rate, and the simple closure technique failed to show a success rate as high as local flap or tube graft repair. The high recurrence of distal cases was attributed mainly to the lack of adequate soft tissue adjacent to the fistula, which is vital for safe closure. In addition, the traction effect of erection on the skin and urethra, which is more prominent distally than proximally, is also believed to play an additive role. To increase success, the selection of appropriate treatment modality and customization of techniques for each patient cannot be overemphasized. However, the authors conclude that careful presurgical assessment of the patient, a 6‐month delay before any secondary surgical attempt, inversion of the urethral mucosa, avoidance of any overlapping suture lines, urinary diversion proximal to the repair site for 5 to 11 days, and usage of thin, absorbable suture materials are the main criteria that should be met for a satisfactory hypospadias fistula repair. Latifoğlu O, Yavuzer R, Ünal Ŝ, Çavuşoğlu T, Atabay K. Surgical treatment of urethral fistulas following hypospadias repair. Ann Plast Surg 2000;44: 381‐386

Reconstruction of orbital floor fracture using solvent-preserved bone graft

The orbital floor is one of the most frequently damaged parts of the maxillofacial skeleton during facial trauma. Unfavorable aesthetic and functional outcomes are frequent when it is treated inadequately. The treatment consists of spanning the floor defect with a material that can provide structural support and restore the orbital volume. This material should also be biocompatible with the surrounding tissues and easily reshaped to fit the orbital floor. Although various autografts or synthetic materials have been used, there is still no consensus on the ideal reconstruction method of orbital floor defects. This study evaluated the applicability of solvent-preserved cadaveric cranial bone graft and its preliminary results in the reconstruction of the orbital floor fractures. Twenty-five orbital floor fractures of 21 patients who underwent surgical repair with cadaveric bone graft during a 2-year period were included in this study. Pure blowout fractures were determined in nine patients, whereas 12 patients had other accompanying maxillofacial fractures. Of the 21 patients, 14 had clinically evident diplopia (66.7 percent), 12 of them had enophthalmos (57.1 percent), and two of them had gaze restriction preoperatively. Reconstruction of the floor of the orbit was performed following either the subciliary or the transconjunctival approach. A cranial allograft was placed over the defect after sufficient exposure. The mean follow-up period was 9 months. Postoperative diplopia, enophthalmos, eye motility, cosmetic appearance, and complications were documented. None of the patients had any evidence of diplopia, limited eye movement, inflammatory reactions in soft tissues, infection, or graft extrusion in the postoperative period. Providing sufficient orbital volume, no graft resorption was detected in computed tomography scan controls. None of the implants required removal for any reason. Enophthalmos was seen in one patient, and temporary scleral show lasting up to 3 to 6 weeks was detected in another three patients. Satisfactory cosmetic results were obtained in all patients. This study showed that solvent-preserved bone, which is a nonsynthetic, human-originated, processed bioimplant, can be safely used in orbital floor repair and can be considered as another reliable treatment alternative.

Tapia's syndrome following septorhinoplasty.

No surgery is free of complications varying from common minor problems to very unexpected and severe ones. In the case presented here, unilateral paralysis of the muscles of the tongue and ipsilateral vocal cord paralysis due to a lesion of the 10th and 12th cranial nerves occurred following a septorhinoplasty that was performed under endotracheal general anesthesia. This rare entity known as Tapia’s Syndrome is believed to be caused by pressure neuropathy of both nerves due to inflation of the cuff within the larynx. We remind surgeons of this unusual complication that can occur in any surgery under general anesthesia and discuss its diagnosis, treatment method, and the followup results in light of the literature.

Augmentation of the craniomaxillofacial region using porous hydroxyapatite granules

&NA; Augmentation of the craniomaxillofacial region is required for many aesthetic and reconstructive procedures. A variety of different materials and techniques have been used. Coralline hydroxyapatite has proved to have biocompatible properties as a bone graft substitute. This study further analyzes the use of porous coral‐derived hydroxyapatite granules in craniomaxillofacial augmentation for cosmetic and reconstructive purposes and evaluates the long‐term clinical result. This retrospective study reviewed the use of porous coral‐derived hydroxyapatite granules over a 20‐year period, between 1981 and 2001, in 180 patients, in whom 393 procedures were performed. The surgical technique is described and discussed. Statistical significance was evaluated by descriptive statistics and the correlation bivariate Spearmans test (p > 0.05). For 61.6 percent of the procedures, the surgical indication was reconstructive and in 38.4 percent, cosmetic. The maxilla was the most common site of surgery (44.3 percent), followed by the mandible (21.6 percent) and zygoma (15.4 percent). The complication rate was 5.6 percent (n = 22 of 393), with contour irregularities being responsible for 59 percent (n = 13 of 22). Both infection and granule extrusion were responsible for 1.3 percent of the complications. Good results were achieved in 96.4 percent of the procedures. Porous coral‐derived hydroxyapatite granules have shown considerable efficacy and versatility in craniofacial contour refinement and augmentation. They are stable, biocompatible, and safe. A sterile technique is advised, with care taken not to tear the periosteum in the pocket design and with subperiosteal placement of the granules, compaction of the granules at the site, overcorrection of 15 percent of the required total volume, watertight closure, and postoperative taping to prevent mobilization. The correct surgical indications and adherence to the principles stated above will result in a very satisfactory long‐term outcome. (Plast. Reconstr. Surg. 111: 1808, 2003.)

The effect of gradually increased blood flow on ischemia-reperfusion injury.

Even with excellent operative techniques, prolonged ischemic periods may cause unwanted results because of a complex mechanism called reperfusion injury. Various pharmacological and immunological agents have been used to prevent this type of injury. Another known way to diminish reperfusion injury is the gradual reperfusion of the ischemic tissues. In this study, the effect of a gradual increase in blood flow on ischemia-reperfusion injury of the skeletal muscle was investigated. The right hind limbs of 15 rats were partially amputated, leaving the femoral vessels intact. Preischemic femoral arterial blood flow was measured by using a transonic small-animal blood flowmeter (T106) in all animals. The rats were divided into three groups: Group I consisted of control rats; no ischemia was induced. Group II was the conventional clamp release group. Clamps were applied to the femoral vessels to induce 150 minutes of ischemia. The clamps were then released immediately and postischemic blood flow was measured. Group III was the gradual clamp release group. After 150 minutes of ischemia, clamps were released gradually at a rate so that the blood flow velocity would reach one fourth the mean preischemic value at 30 seconds, one half at 60 seconds, three fourths at 90 seconds, and would reach its preischemic value at 120 seconds. Total clamp release was allowed when blood flow was less than 1.5 fold of the preischemic values. Postoperatively the soleus muscles were evaluated histopathologically, and malonyldialdehyde and myeloperoxidase levels were measured. The mean preischemic blood flow was 13.6 ± 2.24 ml per kilogram per minute in all groups. In the conventional release group, postischemic flow reached four to five fold its preischemic values (61.06 ml per kilogram per minute). Histopathology revealed more tissue damage in the conventional release group. Malondialdehyde and myeloperoxidase levels were also significantly lower in the gradual release group. Depending on histological and biochemical findings, a gradual increase in blood flow was demonstrated to reduce the intensity of ischemia-reperfusion injury in the soleus muscle of this animal model.Ünal Ş, Özmen S, Demİr Y, et al. The effect of gradually increased blood flow on ischemia-reperfusion injury. Ann Plast Surg 2001;47:412–416