Feasibility and Safety of Superomedial Pedicle for Breast Reduction in Geriatric Patients.

INTRODUCTION:  Historically, inferior breast reduction is more commonly performed overall and this applies to the elder population. No study to this date has compared whether there is any difference in complications and overall safety between when using superomedial pedicle and inferior pedicle in geriatric patients and furthermore whether the safety profile of superomedial pedicle differs when compared to general population. METHODS: Patient files of women who had undergone breast reduction by a single surgeon over a 9 year period (2015-2023) was reviewed retrospectively. Patients over 65 years old at the time of surgery were selected as the main study group. Results were compared to a control group aged 65 years and younger consisting of 136 patients, who also had a breast reduction by the same surgeon. RESULTS: Fifty-four women met the inclusion criteria for the study group and they were further broken down into two subgroups; inferior and superomedial pedicle groups with 25 and 29 patients into each group, respectively. The mean age at the time of the operation was 67.8 years. Geriatric group had more significant comorbidities (37% vs. 9%, p<0.05). Looking solely on patients undergone superomedial pedicle breast reduction, OR times were similar between two age groups and hospital stay was slightly longer in the geriatric population albeit statistically insignificant. The average weight of specimens resected from each breast was 592.4 gr in geriatric population and slightly higher in the younger population with an average weight of 624 grams (p=0.27). Two women in the geriatric group and  six women in the  non-geriatric group developed major complications where superomedial pedicle was utilized, no meaningful difference was seen when major complications were compared (p=0.24). On the other hand, minor complications were significantly higher in the geriatric population compared to the younger cohort regarding superomedial pedicle reductions (p=0.02). 'Satisfaction with breasts' scores of BreastQ from the superomedial breast reduction subgroup was slightly higher than inferior pedicle breast reduction subgroup in geriatric population and it was statistically significant (0.032). CONCLUSION: Safety margins and satisfaction scores of superomedial pedicled breast reduction in geriatric patients seem similar to their younger counterparts. Furthermore, with similar complication rates and with its slightly higher 'Satisfaction with breasts'  scores  when compared to inferior pedicle, superomedial pedicled breast reduction technique can be utilized without reservation in geriatric candidates for breast reduction. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Neonatal cutaneous melanoma with cutaneous metastasis: a case report and review of literature.

Malignant melanoma, a rare skin cancer in children, primarily affects individuals over 10 years old. Giant congenital nevi, found in about 1% of newborns, increases the risk. However, the development of melanoma from a pre-existing giant congenital nevus diagnosed during the neonatal period is exceptionally rare. We present a case of congenital melanoma in a newborn, where nodules grew on an existing nevus on the baby's back. Literature on managing such cases was reviewed. This case highlights the importance of considering malignant transformation in congenital nevi and the challenges in their management. Due to limited reported cases over 80 years, conclusive findings on survival and treatment options are difficult to provide. Clinicians should report outcomes to develop a management algorithm for neonatal melanoma. Further studies are needed to enhance understanding of causes and treatment for patients with congenital giant hairy nevi and associated melanoma.

Investigation of prognostic factors for non-sentinel lymph node metastasis in patients undergoing sentinel lymph node biopsy for cutaneous malignant melanoma: Experience from a reference centre in Turkey.

BACKGROUND: In the light of the results of recent randomised controlled trials regarding the role of nodal observation and completion lymph node dissection (CLND), studies from different populations are needed. The aim of our study was to present our experience with sentinel lymph node biopsy (SLNB) and CLND and the clinical and histopathological factors associated with a positive non-sentinel node. METHODS: In this single-centre, retrospective study, we reviewed histopathological reports of patients with primary cutaneous melanoma who underwent SLNB and CLND over a period of 7 years. The primary outcomes were the positivity rates of SLNBs and CLNDs. Secondary outcomes were metastatic tumour burden in positive sentinel nodes and presence of perinodal invasion. RESULTS: Among the 110 participants who underwent SLNB (53 females, 57 males), the mean Breslow thickness of the primary tumour was 4.1 (0.3-41) mm. Ulceration appeared in 62.7% of lesions. The SLNBs were positive in 38 patients (34.5%), with 35 (92.1%) undergoing CLND, among which 9 (25.7%) showed metaNBstasis. Positive SLNB was linked to a higher Breslow thickness (p = 0.022), whereas CLND results lacked such an association (p = 0.76). Perinodal invasion (p = 0.006) and sentinel lymph node metastasis exceeding 1 mm (p = 0.017) was associated with a higher probability of non-sentinel node metastasis. CONCLUSION: To adapt the results of the new cohort study on SLNB and melanoma to different populations, studies with different patient groups highlighting the problems and suggested solutions are needed.

Post-Paretic Synkinesis: Objective & Subjective Comparisons of Depressor Anguli Oris (DAO) Myectomies vs DAO & Buccinator Myectomies.

BACKGROUND: Muscles affected by post-paretic synkinesis have imbalanced tonicity that limit peri-oral mimetic movement and inhibit the ability to smile. The depressor anguli oris (DAO) muscle has been a common myectomy target for the treatment of peri-oral synkinesis. While addition of buccinator myectomies to DAO myectomies has risen, no studies have analyzed the effects of buccinator myectomies. The goal of this study was to evaluate and compare the effects of a DAO myectomy with and without concomitant buccinator myectomy through objective facial metrics and subjective patient reported outcomes. METHODS: This study is a retrospective review of patients with post-paretic synkinesis who underwent DAO myectomy (DAO myectomy group) or DAO myectomy with buccinator myectomy (DAO+Buccinator myectomies group). Outcomes included post-operative differences in objective smile measures (smile angle, excursion, and dental show) using validated software, and patient reported outcomes using the Facial Disability Index (FDI) questionnaire and a myectomy-specific questionnaire. RESULTS: After chart review, 18 patients were included in the DAO myectomy group and 19 in the DAO+Buccinator myectomies group. There were no significant post-operative differences between the groups in 1. smile excursion, angle, or dental show at resting, closed smile, or open smile (p>.05), 2. FDI physical and social scores, p=.198 and p=.932, respectively, or 3. myectomy-specific questionnaire responses (p>.05). CONCLUSION: The addition of a buccinator myectomy to a DAO myectomy does not provide significant clinical benefit when compared with an isolated DAO myectomy, based on objective measures and subjective patient reported outcomes.

Investigation of the effects of clinical parameters on mortality in patients with necrotizing fasciitis.

BACKGROUND: Necrotizing fasciitis is a rapidly progressing, potentially fatal soft-tissue infection that spreads through the fascia. Due to the late onset of diagnostic signs during the disease's advanced stage and its rapid progression, it can be challenging to make a prompt diagnosis. However, with a rapid and accurate diagnosis, the progression of the disease can be halted through appropriate early surgical intervention. Even with correct and timely treatment, the mortality rate for necrotizing fasciitis is higher compared to other soft-tissue infections. This study aims to investigate the effects of clinical parameters in patients with necrotizing fasciitis on mortality. METHODS: The study included 37 patients with a necrotizing fasciitis diagnosis between 2009 and 2018. Demographic characteristics of the patients (age, gender, comorbid conditions), duration from diabetes diagnosis if present, blood glucose level at the time of diagnosis, microorganisms isolated from wound cultures, presence of positive blood cultures, administered antibiotic therapy, laboratory risk indicator for necrotizing fasciitis (LRINEC) score at presentation, number and types of surgical procedures performed, length of hospital stay, and mortality rates were retrospectively recorded. Statistical analysis of dependent and independent variables was conducted using t-tests, Mann-Whitney U test, Chi-square test, and Fisher's exact test. RESULTS: Age was found to be an average of 70 in the mortality group, and it is significantly higher compared to the non-mortality group. A high LRINEC score, the presence of comorbidity, and a positive blood culture were also found to be significant in the mortal-ity group. The low number of surgical procedures performed is significantly lower in the mortality group. CONCLUSION: This study highlights the conditions associated with high mortality in patients with necrotizing fasciitis, which is a treatable disease through timely and accurate diagnosis followed by appropriate antibiotic therapy and surgical intervention. It emphasizes the importance of updating the approach for high-risk group patients and aims to provide information that will help lower the threshold for diagnosing necrotizing fasciitis.

Bilateral Simultaneous LAP Flaps in Breast Reconstruction: Perioperative anesthetic outcomes addressing safety and feasibility.

INTRODUCTION: The lumbar artery perforator flap (LAP flap) has emerged as an excellent option for breast reconstruction, but its steep learning curve makes it less approachable. Furthermore, length of the operation, flap ischemia time, need for composite vascular grafts, complex microsurgery, multiple position changes, and general concern for safety has led experienced surgeons to stage bilateral reconstructions. In our experience, simultaneous bilateral LAP flaps are successfully feasible, but overall peri-operative safety has not been fully explored. METHODS: Thirty-one patients (62 flaps) underwent simultaneous bilateral LAP flaps and were included in the study (excluding stacked 4-flaps and unilateral flaps). Patients underwent two position changes in the OR: supine to prone and then supine again. A retrospective review of patient demographics, intraoperative details and complications was performed. RESULTS: Overall flap success rate was 96.8%. Five flaps were compromised postoperatively. Intra-operative anastomotic revision rate was 24.1% per flap (4.3% per anastomoses). Significant complication rate was 22.6%. The number of sustained hypothermic episodes and hypotensive episodes correlated with intra-operative arterial thrombosis (p<0.05). The number of hypotensive episodes and increased intra-operative fluid correlated with flap compromise (p<0.05). High BMI correlated with overall complications (p<0.05). The presence of diabetes correlated with intra-operative arterial thrombosis (p<0.05). CONCLUSION: Simultaneous bilateral LAP flaps can be safely performed with an experienced and trained microsurgical team. Hypothermia and hypotension negatively impact the initial anastomotic success. In this complex operation, a coordinated approach between the anesthesia and nursing team is paramount for patient safety.

Experience in reconstruction of esophagus, epiglottis, and upper trachea due to caustic injuries in pediatric patients and establishment of algorithm.

BACKGROUND: Unintentional swallowing of corrosive agents cause problems in the pediatric population. Swallowing dysfunction can be seen after injuring the pharynx and/or epiglottis which leads to the obstruction of esophagus. An algorithm was established taking into account the injury to the epiglottis and restoring gastrointestinal continuity with isolated or combine free and or supercharged jejunum flap, or supercharged colon transposition flap. METHODS: Seventeen patients between the ages of 3 and 16 (mean age: 7.7) were treated between 1985 and 2019. Three different procedures were performed based on endoscopic findings; for patients with no or minimal damage to epiglottis, pedicled colon transposition was done in 12 cases. For patients with epiglottic scarring or edema, a two-stage reconstruction was performed. In the first stage, free jejunum flap was implemented to the pharynx to facilitate food passage, followed by a pedicled jejunum in two cases, or a pedicled colon transposition in two cases to provide gastrointestinal continuity. For one patient with severe epiglottic scarring, a free jejunal flap was used as a diversion conduit in the first stage, followed by supercharged colon transposition to restore gastrointestinal continuity. RESULTS: Supercharged intestinal flaps were harvested with 3-4 cm of extra intestinal tissue than the measured thoracic portion in each individual in order to reach the hypopharyngeal region. The size of the free jejunal flaps were 10 cm. Oral feeding was initiated on the eighth postoperative day. Partial loss of the anterior wall of the jejunal flap was seen in one case, in which a free anterolateral thigh-vastus lateralis musculocutaneous flap was used for reconstruction. The mean follow-up time was 5.1 years and there was no stricture in the final outcome. CONCLUSION: A competent epiglottis is essential for proper swallowing reflex. Meticulous microsurgical dissection and performing supercharged intestinal flaps provide a complication-free end result.

The Efficacy of Hydrodilatation for the Prevention of Vasospasm following Microsurgical Anastomosis.

BACKGROUND: Vasospasm is a major problem following microsurgical reconstruction which can result in the partial or complete loss of the flap tissue. The aim of this study was to investigate the efficiency of hydrodilatation for the prevention of vasospasm. METHODS: Thirty male Wistar rats were used for this experimental study. Femoral arteries of were exposed, photographed, and transected. In group 1, group 2, and group 3 papaverine solution, hydrodilatation, and minimal mechanical dilatation (control group) was performed, respectively. The anastomosis was completed and the arteries were photographed again 10 minutes after completion of the anastomosis. Following 7-day period samples for transmission electron microscopy (TEM) and light microscopy were obtained. RESULTS: The mean vessel diameters prior to transection were 0.43, 0.45, and 0.52 mm in the papaverine, hydrodilatation, and control groups, respectively. The mean vessel diameter 10 minutes following the completion of anastomosis was 0.76, 0.75, and 0.51 mm in the papaverine, hydrodilatation, and control groups, respectively. Median score for papaverine group regarding histological parameters of regular endothelial lining and lumen, neutrophil infiltration, vascular congestion, and edema in tunica adventitia was 2, 3, 2, and 3 positive, respectively. Median score for the papaverine group regarding histological parameters of regular endothelial lining and lumen, neutrophil infiltration, vascular congestion, and edema in tunica adventitia was 3, 3, 3, and 3 positive, respectively. All the histological scores were negative in the control group. The difference between the control group and the experiment groups 1 and 2 was significant regarding all four histological parameters (p < 0.05). CONCLUSION: Hydrodilatation and papaverine application were both effective in preventing vasospasm following microsurgical intervention but papaverine caused slightly less damage to the endothelial lining and less edema in the tunica adventitia when compared with the hydrodilatation. Hydrodilatation group showed a vasodilatory effect that was statistically similar to that of papaverine, which has a proven efficacy.

Use of Dorsal Nasal Flap in Combination With Nasolabial Perforator Propeller Flap for Reconstruction of Nasal Skin Defects of Medium to Large Size; A Simpler Alternative to Frontal Flap.

ABSTRACT: Nasal reconstruction is one of the most challenging procedures in plastic surgery. To get optimal aesthetic and functional results, the surgeon should know all the options well. Forehead flap is the gold standard technique for closure of medium to large defects of the nose. Although it provides a very good color and texture match, it may become a difficult option in patients with poor condition. The aim of this study was to define a simpler technique for nasal reconstruction using combined local flaps.Twelve patients, operated using a dorsal nasal flap combined with a nasolabial perforator propeller flap, were presented in the study. Properties of the patients, defect size and locations, and complications were evaluated.The mean size of the reconstructed defects was 10.1 cm2. No flap loss was observed. Venous congestion was the most common complication and resolved spontaneously in all cases. Two cases had partial distal necrosis, which also healed spontaneously.Closure was achieved successfully in all cases with a medium to large nasal defect using a combined dorsal nasal flap and nasolabial perforator propeller flap. This method can be used as an alternative to forehead flap.

Three salvage strategies in microvascular fibula osteocutaneous flap for mandible reconstruction with vascular compromise and establishment of an algorithm.

BACKGROUND: Fibula osteocutaneous flap is associated with a higher rate of reexploration in mandible reconstruction due to limited space for the fixation of various tissue components on multiple segments of the fibula flap. To maintain optimal circulation to the flap and to prevent negative outcomes because of partial or total flap loss, we shared our experiences on salvaging the free fibula flap with vascular compromise in the first reexploration and we developed an algorithm. METHODS: From 1992 to 2018, 12 patients between the ages of 48 to 63 (mean: 52.5) who had presented with oral squamous cell carcinoma (n = 10) followed by osteoradionecrosis of the mandible (n = 2) were explored. The operative findings were; (1) occlusions of vein (3 cases); (2) occlusions of artery (4 cases); and (3) occlusions of both artery and vein (5 cases). After correcting the kinking or evacuating the hematoma, the arterial inflow was initially reestablished by anterograde flow. If this was nonfunctional, retrograde flow from the distal end of the peroneal artery was provided. For the vein, anterograde venous drainage was reestablished. If the thrombus extended deep into the peroneal vein, regular venous return was blocked on the anterograde side, and the flap remained congested therefore retrograde venous drainage was performed regardless of the valves in the vein. However, the two ends of the peroneal artery were anastomosed to prevent thrombosis of the artery. RESULTS: The success rate of revised cases was 75% (9/12). All failed cases had presented with both artery and vein occlusion (three cases). Pectoralis major musculocutaneous flap and anterolateral thigh flap were needed for the external surface in two cases. Skin graft was required for seven cases to restore intraoral lining. Six patients underwent dental rehabilitation with prosthetic implants. CONCLUSION: Immediate reexploration is mandatory to salvage the flap.

Comparison of Ischemic Preconditioning and Systemic Piracetam for Prevention of Ischemia-Reperfusion Injury in Musculocutaneous Flaps.

BACKGROUND: Ischemia-reperfusion injury plays an important role in flap failure. Ischemic preconditioning technique is the only proven method for preventing ischemia-reperfusion injury, but it is not used widely in daily practice because of difficulties such as prolonging the operation time, need for surgical experience, and increasing the risk of complications. This study has been performed with the assumption that piracetam may be a simple and inexpensive alternative to the preconditioning technique due to its antioxidant, antiaggregant, rheological, anti-inflammatory, antiapoptotic, cytoprotective, and immune modulating effects. METHODS: Thirty-two rats were divided into four groups and latissimus dorsi musculocutaneous flaps were raised. No extra procedure was applied, and no treatment was given to the control group. Four hours of ischemia was created by clamping the thoracodorsal pedicle in the second group. The animals in the third group were treated with 10 minutes of ischemia and reperfusion periods as a preconditioning procedure before the 4 hours of ischemia. Animals in the fourth group received systemic piracetam 30 minutes before and 6 days after reperfusion. Nitric oxide and myeloperoxidase levels in serum and tissue, acute inflammatory cell response, and vascular proliferation in tissue were examined at the postoperative 24th hour and 10th day. RESULTS: Myeloperoxidase activity in both preconditioning and piracetam groups, was significantly lower than the ischemia-reperfusion group. Acute inflammatory cell response was similarly decreased in both preconditioning and piracetam groups compared with ischemia-reperfusion group. Tissue measurements of nitric oxide were also significantly higher in both preconditioning and piracetam groups than in the ischemia-reperfusion group. However, vascular proliferation increased in the preconditioning group, while it did not show any significant change in the piracetam group. CONCLUSION: This study shows that systemic piracetam treatment provides protection against ischemia-reperfusion injury in musculocutaneous flaps and can offer a simple and inexpensive alternative to the preconditioning technique.

Nasolabial Perforator Flap: A Multi-Tool for Reconstruction of Facial Units.

BACKGROUND: Nasolabial flap is a work-horse flap for coverage of many facial units. However, these flaps have limited mobility and these limit their use in many instances. Facial artery with its numerous small cutaneous perforators can be a source for free-style skin flaps that can be islanded and have greater reach, one of which is nasolabial perforatory flap. METHODS: The authors present a case series of 35 patients with central facial unit defects reconstructed by a single flap harvested from the nasolabial sulcus. RESULTS: In our series, we did not encounter any significant flap loss and patient satisfaction was high both functionally and aesthetically. Main drawbacks were temporary venous congestion and hair bearing flaps in male patients. CONCLUSION: The authors think with its reliability and versatility nasolabial perforator flaps, based on the same donor area as the traditional nasolabial flap can be a valuable addition to our arsenal in reconstruction of central facial unit defects.

Correction of High-Grade Pseudogynecomastia After Massive Weight Loss: Modified Inferior Dermoglandular Pedicled Transverse Scar Reduction.

INTRODUCTION: Whereas body-contouring surgery after massive weight loss in women receives much attention, little attention has been devoted to accentuating the male physique. Male patients after massive weight loss often suffer from redundant skin and soft tissue in the anterior and lateral chest region, causing various deformities of pseudogynecomastia. The authors present their approach to high-grade pseudogynecomastia correction with preservation of the NAC on an inferior dermoglandular pedicle with transverse scar only closure and without any meaningful liposuction. MATERIALS AND METHODS: A description of comprehensive pseudogynecomastia correction with the aforementioned technique followed by review of 58 consecutive patients operated on in our clinic from January 2017 to June 2018. Epidemiological data such as age, weight, height, body mass index (BMI), weight loss, and the medical history of each patient were collected. All patients were photo-documented preoperatively and postoperatively in a standard manner. During the operation, weight of resected tissue and operative time were noted. RESULTS: Fifty-eight patients were operated on in a single stage. In our series, one patient had unilateral partial necrosis on nipple-areola complex, and two patients had minimal to moderate amounts of hematoma which were followed up without intervention. We did not encounter any infection-related complications or skin redundancy in our patients. Out of 58 patients, 55 of all the patients were highly satisfied with the aesthetic results. Three patients were mildly satisfied with the results, but they stress that moderate scar widening was the reason for the displeasure, not the definition of the chest which was deemed as satisfactory like the rest. CONCLUSION: Our technique obviates the need for skin resection in a second operation, allows immediate skin recontouring, and provides a viable nipple-areola complex at the desired location. The patient does not have to suffer prolonged stress while awaiting skin retraction and is protected from a second dose of anesthesia and hospitalization. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Effects of Cigarette Smoke on Fat Graft Survival in an Experimental Rat Model.

INTRODUCTION: A fat graft is the closest thing to being the ideal soft tissue filler. Although it has many advantages, reliability of late-term survival is a never-ending debate. Although there are observational studies that research the effect of cigarette smoke on fat graft take in clinical setting, there has not been an objective experimental animal study on the affect of smoking on fat graft survival. The aim of our study is to search if smoking has an affect on fat grafts. MATERIALS AND METHODS: Twenty-two Sprague-Dawley type rats were used. Exposure was maintained via a passive smoke exposure system. Rats were divided into three groups regarding their exposure period. At the end of the study, transferred fat grafts were extracted and weighed with a precision scale, an arterial blood sample was taken for biochemical analysis, and grafts were sent to the pathology laboratory for immunohistochemical assessment. RESULTS: There were meaningful differences between the control group and the other two groups in graft weight loss, serum cotinine, tissue MDA, adipose tissue/fibrosis ratio, stem cell counts, perilipin positive cell density and inflammation density. Furthermore, we detected meaningful correlations between serum cotinine, tissue MDA and graft weight loss. CONCLUSION: Fat graft takes with the same mechanisms as a wound heals. So like wound healing, cigarette smoke has a negative affect on fat graft survival. A fat graft is by its nature an elective procedure so to improve our late-term success, cigarette smoke exposure should be kept to a minimum for increased reliability. NO LEVEL ASSIGNED: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Nuclearity effects in supported, single-site Fe(ii) hydrogenation pre-catalysts.

Dimeric and monomeric supported single-site Fe(ii) pre-catalysts on SiO2 have been prepared via organometallic grafting and characterized with advanced spectroscopic techniques. Manipulation of the surface hydroxyl concentration on the support influences monomer/dimer formation. While both pre-catalysts are highly active in liquid-phase hydrogenation, the dimeric pre-catalyst is ∼3× faster than the monomer. Preliminary XAS experiments on the H2-activated samples suggest the active species are isolated Fe(ii) sites.

Vibrational Dynamics of Biological Molecules: Multi-quantum Contributions.

High-resolution X-ray measurements near a nuclear resonance reveal the complete vibrational spectrum of the probe nucleus. Because of this, nuclear resonance vibrational spectroscopy (NRVS) is a uniquely quantitative probe of the vibrational dynamics of reactive iron sites in proteins and other complex molecules. Our measurements of vibrational fundamentals have revealed both frequencies and amplitudes of (57)Fe vibrations in proteins and model compounds. Information on the direction of Fe motion has also been obtained from measurements on oriented single crystals, and provides an essential test of normal mode predictions. Here, we report the observation of weaker two-quantum vibrational excitations (overtones and combinations) for compounds that mimic the active site of heme proteins. The predicted intensities depend strongly on the direction of Fe motion. We compare the observed features with predictions based on the observed fundamentals, using information on the direction of Fe motion obtained either from DFT predictions or from single crystal measurements. Two-quantum excitations may become a useful tool to identify the directions of the Fe oscillations when single crystals are not available.

Iron normal mode dynamics in a porphyrin-imidazole model for deoxyheme proteins.

Iron vibrational modes of a deoxyheme protein model (2-methylimidazole)(tetraphenylporphinato)iron(II), [Fe(TPP)(2-MeImH)], have been studied by refining normal mode calculations to nuclear resonance vibrational spectroscopy (NRVS) data. The NRVS measurements give quantitative frequencies and iron amplitudes of all modes with significant Fe vibrational motion. Modes with in-plane displacement of iron are distinguished from those involving out-of-plane motion by measurements on oriented single-crystal samples. Normal modes having large overlaps with in-plane nu(42), nu(50), and nu(53) modes of the porphyrin core are identified, as well as several modes with large iron-imidazole stretch components. An out-of-plane mode at 78 cm(-1) shows significant doming of the porphyrin core, but the largest Fe doming motion arises from the coupling of phenyls and imidazole at 25 cm(-1).