World Journal of Plastic Surgery
Volume:9 Issue: 3, Sep 2020

From discussing the etiologies of post-mastectomy pain syndrome and potential methods of prevention, the next step is to create specific methods of prevention and to identify ways to measure their effects. With the increase in breast cancer related surgeries and increased survival after breast cancer patients, efforts must be made to prevent chronic pain and improve quality of life for these patients after surgery. The plastic surgeon, skilled in breast reconstruction and peripheral nerve reconstruction, may play a significant role in eliminating chronic pain after breast cancer related surgery.

Hypospadias repair is a challenging type of urogenital reconstructive surgery for which different techniques are currently used. The purpose of this study is to determine the outcomes of distal, mid-shaft and proximal hypospadias repair using two new variations of tubularized incised plate (TIP) urethroplasty (TIP-δ and TIP-ελ) and to compare their complication rates with other already known operative techniques made from the same surgical team.

This study included 269 boys with hypospadias. The preoperative meatal site was distal in 179 patients, mid-shaft in 44 and proximal in 46. The average age at the operation was 17 months. The technique applied in distal hypospadias was Mathieu in 77 patients, Snodgrass in 28 and (TIP)-δ in 74. The technique applied in mid-shaft hypospadias was a tubularized island flap (TIF) in 12 patients, onlay island flap (OIF) in 5 and TIP-ελ in 27. The operative technique for proximal hypospadias was TIF in 15 patients, OIF in 10 and TIP-ελ in 21. TIP-δ and TIP-ελ are two new variants of TIP operation that we have used in our clinic since 2010. Postoperative complications were recorded, and we compared the outcomes obtained by applying the techniques.

The use of TIP-δ in the distal hypospadias and long TIP-ελ in the mid-shaft and proximal hypospadias resulted in significantly fewer complications than the other surgical methods across all cases of hypospadias (p<0.05).

The type of tissue used for neourethral coverage seems to play an important role in the outcome of hypospadias surgery.

BACKGROUND 

Grafting split-thickness (STSGs) and full-thickness skin grafts (FTSGs) are common techniques to replace missing skin and to restore the skin barrier in burn, trauma and remaining skin defects after tumor resections. The defect coverage with skin grafts offer many advantages, but also disadvantages such as donor site morbidity like possible sensory disturbances, scarring, risk of infection, contour changes and pigment disorders. We aimed to assess the preferred distribution of donor site for STSGs and FTSGs in patient’s skin grafting for plastic-surgical defect coverage.

METHODS 

Patients and their accompany persons referred to the Department of Plastic Surgery were interviewed for defect coverage with STSGs or FTSGs, the preference in donor site was investigated and the detailed advantages and disadvantages were clarified. 

RESULTS 

We evaluated 85 participants (male=43, female=42) with a median age of 42 years (mean=46 years). The definition of the donor site (n=188 markings) was mainly based on the physicians recommendation (32.98%), mobility (23.40%), aesthetic results (22.34%) and pain (21.28%). Feared complications (n=152) were mainly wound healing disorders (32.24%), circulation disorders (28.29%), scars (20.39%) and bleeding risks (19.08%). Among all participants, 79 split-skin graft preferences were specified, while 32% favored the scalp as a donor site, as well as 29% the frontal part of the left thigh and 10% the frontal part of the right thigh. 

There were preferred anatomical donor sites for skin grafting. Nevertheless, in conscious patients, the donor site has to be selected in a consent talk and joint approval, preoperatively. The options of taking STSGs from the occipital region with all its advantages should be discussed intensively as it is an attractive graft donor site.

Covering burn wounds, especially high surface area burns has been always a challenge for surgeons. The Meek technique has been introduced to increase the covering area. There is paucity of clinical trials comparing the Meek technique and mesh in the same individuals to assess it efficacy.

METHODS 

In a case-control study, 20 patients with grade III burns who underwent the Meek technique and mesh in different areas/limbs were enrolled. Expansion rate, re-epithelization, operation time, wound infection, graft failure, etc. were compared between the two groups. 

Among patients, 18 were males and 2 were females. The mean of total body surface area (TBSA) was 36.9±16.6%. Mean time of re-epithelialization in the Meek group was 2.8±2.5 months and in the mesh group was 5.0±2.1 months (p=0.01). Operation time was shorter in modified Meek technique (p=0.04). Expansion ratio was higher in modified Meek technique (p=0.04). Local wound infection rates were slightly different without a statistically significant difference.

Meek technique provided higher surface area coverage in comparison to mesh; in addition to faster re-epithelization. Therefore, it is recommended to consider the Meek technique as a routine procedure, especially those with high surface area burns.

Augmentation of facial components is an acceptable approach in facial aesthetics. The best filler material and the optimal technique for facial soft tissue augmentation still remain to be determined. This study has assessed the lip augmentation using post-auricular fibroareolar tissue as a new autogenous filler.

This prospective study enrolled patients who were candidate for lip augmentation. Loose fibroareolar tissue was harvested from post-auricular region and was inserted in the prepared lip pocket. Standard digital photography was used for lip analysis in each patient before and 6 months after surgery (the height and projection of the upper lip and lower lip).

At a mean follow-up period of 6 months, average upper and lower lip height increased from 5.27 to 8.72 mm (p<0.001), and the average upper and lower lip projection increased from 3.97 to 7.75 mm (p<0.001).

Our technique was minimally invasive and a safe method, in which post-auricular loose fibroareolar tissue was applied for lip augmentation with minimum donor site morbidity and long-term results. On the follow-up, all patients were satisfied with the results and no patients required any revision operation. Moreover, the complication rate was negligible.

BACKGROUND 

Since aesthetic issues are the most important causes of referring skeletal class III patients to surgeons, investigating the impact of orthognathic surgeries on improving patient profiles increases the quality of treatment and quality of life. 

METHODS 

In a retrospective observational-analytical study, 25 patients older than 18 years with class III skeletal malocclusion who had gone under both orthodontic and double-jaw orthognathic treatment were enrolled. Cephalometric imaging interval was before and at least 6 months after surgery. By defining a number of points and coordinate axes (X-Y), a criterion for comparing hard and soft tissue changes was obtained. These measurements were coordinated, linear and angular. The quantitative data were compared with data obtained using the Likert Scale Questionnaire by means of electronic “Google Forms” that was completed by orthodontists (n=5) and maxillofacial surgeons (n=5) to rank improvement in post-surgical profiles for both cephalometry and photography from poor to pleasant. Spearman Correlation Analysis was conducted between the quantitative and qualitative data.

Vertical changes of point B and horizontal changes of point PNS showed correlation with improvement of patient profile. Changes in N-Pog line (R=-0.4), mandibular plane angle (R=-0.4) and nasolabial angle (NLA) (R=0.38) were significantly correlated with improvement of profiles. 

In orthognathic double-jaw surgery on patients with skeletal Class III, forward movement of maxilla, upward positioning of mandible (decreasing anterior facial height), decreasing mandibular plane angle and increasing nasolabial angle would result in a better profile.

Several methods have been introduced to correct crooked nose during rhinoplasty. This study aimed to compare the final shape of nasal pyramid as well as patients’ satisfaction of the outcomes in two different rhinoplasty techniques. 

METHODS 

Participants in this study underwent rhinoplasty with two different techniques of double lateral osteotomy in comparison with asymmetric dorsal hump reduction using rasp. Ninety patients were allocated in two groups by a quadruple block randomization. Patients were compared for the correction of nasal deviation 6 and 12 months after surgery. Their self-rated satisfaction with rhinoplasty outcome was also assessed using a researcher-made questionnaire.

RESULTS 

Crooked nose correction was performed in 45 patients in each surgery group. Primarily, the mean of nasal deviation in two study groups were relatively similar (159.83±22.37 degree in C-shaped group vs. 11.79±4.98 degree in I-shaped group). The changes in degree of deviation after rhinoplasty were statistically significant in both intervention groups. However, based on the shape of nasal curvature, double lateral osteotomy was superior in long term follow up in I-shaped curvatures. Patients’ post-operative satisfaction with their nasal appearance was higher in the group of double lateral osteotomy and they were less interested in re-surgery.

The two rhinoplasty techniques were not statistically different in terms of changes in nasal deviations correction after the surgery. However, long term changes in I-shaped curvatures were more desirable in group of double lateral osteotomy.  Use of double lateral osteotomy was associated with better satisfactory aesthetic outcomes among study participants.

Cutaneous melanomas (CMs) account for only a small proportion of skin cancers, however these are responsible for most skin cancer deaths. There has been a consistently increasing trend in their incidence across the globe.

This prospective case series study spanned over a period of three years. All patients with histologically confirmed CMs were included.

There were 31 patients including 28 males and 3 females with the mean age of 58.25±11.33 years. The histological subtypes included 13 cases (41.93%) of nodular melanoma (NM), 11 patients (35.5%) of acral lentiginous melanoma (ALM), 3 cases (9.67%) of superficial spreading melanoma (SSM) and lentigo maligna melanoma (LMM) and one case (3.22%) of desmoplastic melanoma. Two patients (6.45%) presented with stage II, whereas 21 patients had (67.74%) stage III melanoma. There were 8 patients (25.80%) with stage IV. Time interval between onset of the lesion and first presentation to hospital ranged from 6 to 17 weeks with a mean of 12.45±3.2 weeks. The overall median survival for patients with stage III and IV was 8.75 months. The overall survival for stage II at one year was 100%.

CMs more frequently affected males aged ≥58 years. Feet, face, trunk, hands and scalp were the affected anatomical body parts in decreasing order of frequency. NM and ALM were the more common histological subtypes. Majority of patients presented late and advanced stages of melanoma. Awareness about the sinister course of the disease will ensure early presentation with better treatment outcome.

Scalp arteriovenous malformations (SAVMs) are seen in young individuals and skin involvement is common in large SAVMs. They are commonly seen in younger age group too. Pre-operative embolization followed by surgical excision and hair bearing scalp reconstruction with tissue expansion are the treatment of choice. Therefore, proper selection of tissue expander for reconstruction of hair bearing scalp, seems essential. This study evaluated excision of large SAVMs with aesthetic scalp reconstruction.

We described management of 10 patients of large SAVMs with cutaneous involvement. All patients underwent pre-op embolization followed by surgical excision and hair bearing scalp reconstruction with tissue expansion. 

All cases of large SAVMs healed well with minor complications.

While complete surgical excision with extirpation of the nidus is considered as the gold standard treatment, aesthetic hair bearing scalp restoration is also of paramount importance for the patient. This is done by using scalp tissue expansion after proper selection of the expander.

Epinephrine is commonly used in plastic and reconstructive surgeries to reduce the blood loss, and to achieveing the lowest and the most effective dosage of epinephrine can improve the results of the surgery.

Thirty two rats were divided in four groups. Local injection of epinephrine solution (3 mL) with concentrations of 1:200,000, 1:400,000 and 1:1,000,000 was undertaken in three different groups; and the fourth group was the control in which 3 mL of normal saline was administered 15 minutes before making the incision. The bleeding amount was compared in these groups.

A significant difference in blood loss was noted between the control and other groups, but no significant difference was present between epinephrine concentrations of 1:200,000, 1:400,000 and 1:1,000,000.

Local injection of epinephrine solution was shown to reduce bleeding from surgical incisions, but the difference between various pinephrine concentrations was not significant. The use of the lowest concentration (1:1,000,000) was suggested to decrease epinephrine side effects.

Feijoa is widely used in medicine due to their anti-inflammatory, antioxidant, antimicrobial and antitumor properties. The current investigation studied the proliferative and regenerative effect of acetonic extract of Feijoa sellowiana on stem cells.

Acetone extract of Feijoa was prepared using percolator and rotary machines. Human bone marrow stem cells (hBMSCs) were used as experimental in vitro model and characterized morphologically, by flowcytometry, and differentiation properties. The toxicity of the extract on hBMSCs was determined by MTT assay. The viability and growth kinetics of hBMSCs treated to Feijoa was determined. Real time PCR was used for changes in expression of proliferative and apoptotic genes on day 7th.  

RESULTS 

MTT assay demondtrated that Feijoa at doses less than 200 ng/ml did not show any cytotoxic effect on hBMSCs and increased the cell proliferation until day 3rd followed by a non-significant slow decreasing trend until day 7th. Population doubling time (PDT) showed a decline until day 3rd followed by an increase until day 7th. A significant rise in expression of Bax and decline in Bcl-2 expression were noted on day 7th.

The modulatory activity of Feijoa may be responsible for its increasing effect on cell proliferation till day 3rd. Therefore, when faster proliferation during a shorter time period is targeted, Feijoa can be safely added to the culture media in the first three days.

Hand Zone 2 flexor injuries are among the most important tendon lesions and its prognosis is poorer than the other hand zones. Limited incisions prevent multiple skin flaps. The present study aimed to determine the location of palmar flexor tendons using surface anatomical markers to provide a simple and easy guide for hand surgeons assisting them in minimal incisions.

Patients with hand injuries in Zone 2 were taken to the operating room for surgery. The skin and subcutaneous tissue over the flexor tendons sheath were incised. After finding the flexor tendons in the palm, their exact position was located with a blue needle (23G) over the palm crease and marked relative to the finger borders.

Thirty-eight patients with the mean age of 27±3.6 years were operated. Totally, 57 fingers and 38 palms were dissected. The flexor tendons were located under the proximal and distal palm creases between two parallel lines extended from finger borders and mid-axial axis of the fingers. The average distance from finger print to distal palmar crease was 25, 32 and 24 mm for little, ring and long finger, respectively and 32 mm from index finger print to mid palmar crease.

The precise position of flexor tendons can be easily determined in the palm according to surface anatomical markers and plan for limited incisions.

With the advent of parenteral, intravenous infusion for various purposes like chemotherapy, parenteral nutrition, radiocontrast intravenous injection for imaging studies, extravasation injuries are emerging as a serious problem with often disastrous complications, if not recognized early. Fortunately, if treated early, the affected extremities can be salvaged and hence the role of plastic surgeons cannot be over-emphasized, especially when it comes to the reconstruction of necrotic and ischemic wounds as a result of these injuries. Proper monitoring and immediate intervention will go a long way in minimizing the morbidity associated with these injuries. However, if there is a delay in recognition and treatment, it can lead to complications like skin necrosis, gangrene, extensive soft tissue defects and contractures. Treatment in these circumstances needs an individualized approach and entails wound debridement followed by skin grafts and flap cover. Documentation and prompt intervention can avoid medicolegal issues for the physician and the hospital.

Despite the whole world’s effort for controlling an ongoing global outbreak caused by new corona virus; it is still a major public health issue. Any hospitalized patient or outpatient in burn departments should be considered as a potential infectious source of COVID-19, which may cause an overwhelming of disease. However, there are no previous experiences about COVID-19 in burn patients all over the world, and here we reported two burn cases at Amir-al-Momenin Burn Hospital Affiliated to Shiraz University of Medical Sciences, Shiraz, Iran with skin manifestations, which were detected as a rarely COVID-19 symptom. A 13-year-old girl [total body surface area (TBSA): 18%] and a 37-year-old woman (TBSA: 30%) who had burn injuries by gas explosion and car accident, respectively were enrolled. After admission, some vesicular injuries were visible in burn area. To confirm, skin biopsy specimens were either sent for histopathology examination or for real time polymerase chain reaction (PCR) as follow: Herpes Simplex Virus (HSV), chicken pox, and potassium hydroxide (KOH) for fungal infections. All test results were negative. Although they had no symptoms of COVID-19, two swabs from nasopharyngeal and oropharyngeal samplings were taken, the result was negative either. Specimens were obtained from vesicular lesions for qRT-PCR assay of COVID-19. According to the molecular results for vesicular samples, all the results were positive for COVID-19. Unlike all other COVID-19 patients who have respiratory symptoms, SARS-COV-2 appeared by cutaneous vesicular and blisters in two burn cases.

Here, we present a 45-year-old male patient who had right leg fracture in several pieces, arterial ischemia, multiple muscle, tendon losses and degloving injury on the distal thigh and knee undergoing emergency surgery due to a high-energy traffic accident and explain our experience with reconstruction of below knee stump using free plantar fillet flap in order to prevent above knee amputation in a patient with vascular injuries, multi-part fractures and soft tissue losses in the lower extremity.

We described a rare case of arteriovenous (AV) fistula after mandibular fracture in a 64-year-old man with chronic schizophrenia. The diagnosis was made by CT angiography. The patient suffered two episodes of mandibular fracture 3 months and 12 months ago. He was found to have a large AV fistula in left side of his neck. So the patient was scheduled for operation to correct fistula.

Trigeminal trophic syndrome is an unusual cause of facial ulcers that affects the sensitive area of the trigeminal nerve. Trigeminal trophic syndrome (TTS) is an unusual condition characterized by anesthesia, paraesthesias and ala nasi ulceration, following peripheral or central damage to the trigeminal nerve. We reported a 27-year-old man who presented with a left ala nasi ulcer accompanied by pruritus and paraesthesia for two months and one month before admission, he was a case of car accident that was admitted in ICU due to diffuse axonal injury (DAI). An underlying infectious, malignant and vasculitic cause for the ulcer was excluded by a skin biopsy. So awareness of the predisposing factors and clinical presentations of this important disfiguring condition seems to be necessary to ensure prompt diagnosis and treatment.