Osseous genioplasty versus chin implants: early complications and patient satisfaction

Osseous genioplasty and chin augmentation with implants are the two main treatment options for retrognathia. This retrospective cohort study was performed to compare the prevalence of complications and patient satisfaction following osseous genioplasty and chin augmentation by implant. Eighty patients were included: 38 underwent advancement osseous genioplasty and 42 received chin implants (alloplastic, either Medpor or Silastic) intraorally or extraorally. The patients were assessed for complications 12 months after surgery, including neurosensory disturbances, infection or extrusion, wound dehiscence, and the need for reoperation. Patient satisfaction was evaluated using a visual analogue scale. The infection rate was significantly higher in the chin implant group than in the genioplasty group (P = 0.028). Moreover, dehiscence and the need for reoperation appeared to be more common following chin augmentation with implants. However, there was no significant difference in the prevalence of neurosensory disturbances between the two groups (P = 0.137). In the chin implants group, the extraoral approach resulted in a lower dehiscence rate than the intraoral approach. Patients in the genioplasty group had significantly higher satisfaction scores than those in the chin implant group (P = 0.001). Overall, the rates of the complications assessed were lower and patient satisfaction was higher after osseous genioplasty when compared to chin augmentation with implants.

Ischaemic preconditioning is related to decreasing levels of extracellular adenosine that may be metabolically useful in the at-risk myocardium: an experimental study in the pig

AIM

'Pre-treatment' with short repetitive periods of ischaemia (ischaemic preconditioning) has proved to be a powerful mechanism for modification of the extent of myocardial damage following acute coronary artery occlusion. The exact mechanism of protection induced by ischaemic preconditioning is not known. We herewith put forward a contributing component for protection with preconditioning involving a shift in the adenylate kinase (AK) equilibrium reaction in favour of adenosine triphosphate (ATP) formation.

METHODS

A coronary artery was occluded in anaesthetized thoracotomized pigs to induce ischaemic preconditioning as well as a longer period of ischaemia. Microdialysis probes were inserted in ischaemic and control myocardium and were infused with (14)C- adenosine with two different specific activities. (14)C-lactate was identified and measured in the effluent.

RESULTS

(14)C-adenosine was taken up by non-preconditioned and preconditioned myocardium during ischaemia. Significantly increased levels of (14)C-lactate were recovered in preconditioned myocardium. (14)C-adenosine with high specific activity resulted in a specific activity of lactate that was 2.7 times higher than that of lactate after administration of (14)C-adenosine with low specific activity. Mass spectrography verified the identity of (14)C-lactate.

CONCLUSIONS

Preconditioning up-regulates a new metabolic pathway (starting with 5'-nucleotidase and ending up with lactate) resulting in ATP formation in the micromolar range on top of another effect terminating in a useful shift in the AK equilibrium reaction in favour of ATP generation in the millimolar range. Although the up-regulation of the purine nucleoside phosphorylase pathway is clearly demonstrated, its biological relevance remains to be proved.

Validity of elevated interstitial levels of taurine as a predictor of myocardial ischemic injury

The microdialysis (MD) technique allows for continuous in vivo monitoring of dynamic changes in the interstitial levels of energy-related metabolites. The release of taurine from the myocyte has been suggested as a marker of ischemic injury. The relationship between (interstitial) taurine release and the degree of myocardial ischemic injury was evaluated following a 40 min long ischemia in a porcine heart-infarct-model. Different protocols of ischemia and reperfusion were used in order to achieve a graded level of myocardial injury. Both interstitial peak levels and the area under curve of taurine obtained during ischemia and reperfusion correlated with the degree of ischemic injury (assessed by developed infarct size estimation). The release of taurine in the myocardium measured by the MD-technique correlated with the degree of ischemic injury during ongoing ischemic insult. Hence, taurine determination in the MD-setting represents a powerful tool to follow the development of myocardial ischemic injury over time.

Validity of the microdialysis technique for experimental in vivo studies of myocardial energy metabolism

OBJECTIVES

The validity of the microdialysis technique for experimental in vivo studies of myocardial energy metabolism is not known. To address this question interstitial levels of energy-related metabolites (lactate, adenosine, inosine and hypoxanthine) obtained by the microdialysis technique were compared with corresponding metabolites from myocardial biopsies at given intervals in a porcine heart model using different protocols of ischaemia and reperfusion.

METHODS

In an open chest porcine heart model, interstitial levels of energy-related metabolites were monitored using the microdialysis technique. All animals (n = 23) were subjected to 120-min pretreatment followed by 40 min of regional ischaemia and 120 min of reperfusion. Tissue biopsies were obtained in the beginning, middle and at the end of the 40-min ischaemic period and at the end of the reperfusion period. Pretreatment consisted of either rest (group 1, n = 7), or rest for 90 min and one ischaemia/reperfusion (10 + 20 min) cycle (group 2, n = 9), or four ischaemia/reperfusion cycles (10 + 20 min each) (group 3, n = 7).

RESULTS

Interstitial levels of energy-related metabolites monitored by the microdialysis technique correlated with tissue biopsy levels of lactate (r = 0.90, P < 0.001), adenosine (r = 0.89, P < 0.001), inosine (r = 0.88, P < 0.001) and hypoxanthine (r = 0.91, P < 0.001), respectively, which were obtained by tissue biopsies at given time intervals. These significant correlations were valid regardless of the functional state of the myocardium.

CONCLUSION

We observed significant correlations between microdialysis probe levels and tissue biopsy levels of energy-related metabolites in both ischaemic and non-ischaemic tissue. These data assess the validity of the microdialysis technique (in the current setting) for studying dynamic changes of myocardial energy metabolism.

Ischaemic preconditioning alters the energy metabolism and protects the ischaemic myocardium in a stepwise fashion

AIMS AND METHODS

Recently it was suggested that ischaemic preconditioning (IP) protects the myocardium in a graded pattern as assessed by myocardial infarct size estimation. Using tissue biopsies we investigated the impact of the proposed graded pattern of protection on myocardial energy state in an open-chest porcine model of IP with either one (1xIP) or four (4xIP) episodes of preconditioning. Furthermore, we evaluated the relationship between interstitial energy-related metabolite levels obtained by the microdialysis technique and the degree of subsequent ischaemic insult.

RESULTS

During the long ischaemia the difference between pre-ischaemic and post-ischaemic total adenylate pools and the sum of adenylate breakdown products (adenosine, inosine and hypoxanthine) as well as tissue lactate levels appeared as follows: non-IP > 1xIP > 4xIP (P < 0.05). Moreover interstitial peak levels of lactate, hypoxanthine and taurine displayed a graded pattern analogous to the development of ischaemic damage, where non-IP > 1xIP > 4xIP.

CONCLUSIONS

We present for the first time concordant energy metabolic and morphometric data in support of IP being a stepwise phenomenon for protection of the ischaemic myocardium. Furthermore, IP resulted in proportionally higher levels of hypoxanthine (relative to inosine) in the ischaemic myocardium, suggesting a different handling of adenine nucleotide breakdown products in the IP myocardium.

Pre-conditioning activates adenosine utilization in a cost-effective way during myocardial ischaemia

During pre-conditioning the interstitial concentration of adenosine, in contrast to lactate, presents a die-away curve-pattern for every successive episode of ischaemia. This die-away pattern might not necessarily be attributed to diminished adenosine production. The present study was undertaken to investigate whether pre-conditioning alters the metabolic turnover of adenosine as observed by the lactate production during ischaemia. Interstitial levels of metabolites in pre-conditioned (n=21) and non-preconditioned (n=21) porcine hearts were monitored with microdialysis probes inserted in both ischaemic and non-ischaemic tissue in an open chest heart model. Three subgroups perturbated with either plain microdialysis buffer (control), buffer containing adenosine (375 microM), or buffer containing deoxyadenosine (375 microM) were studied. All animals were subjected to 90 min of equilibrium microdialysis before 40 min of regional myocardial ischaemia and 120 min of reperfusion. Pre-conditioning consisted of four repetitive episodes of 10 min of ischaemia and 20 min of reperfusion. Significantly higher levels of inosine and lactate were found in the ischaemic tissue of the pre-conditioned subgroup receiving adenosine (P < 0.05) compared with the other two subgroups receiving deoxyadenosine and plain buffer, respectively. This difference was only valid for pre-conditioned ischaemic myocardium, and hence equal amounts of inosine and lactate were produced in the non-preconditioned ischaemic myocardium regardless of the presence of adenosine or deoxyadenosine. In the non-ischaemic myocardium baseline levels of metabolites were measured in all subgroups. Pre-conditioning favoured degradation of exogenous adenosine to inosine successively ending up in enhanced lactate production. This was probably because of the involvement of the hexose monophosphate pathway in the pre-conditioned ischaemic myocardium. This route may therefore be supplementary in energy metabolism as a metabolic flow can be started by adenosine ending up in lactate without initial adenosine 5'-triphosphate (ATP) investment. Utilization of adenosine in this way may also explain the successive die-away pattern of adenosine seen in consecutive pre-conditioning cycles.