Active Tobacco Use in Patients with Claudication Does Not Affect Outcomes after Endovascular Interventions.

BACKGROUND: With the advent of endovascular procedures, the indications for intervention in claudicants have become less strict. Many interventionalists, however, will not intervene in patients with lifestyle-limiting claudication unless they have discontinued tobacco use. Many patients are unable to comply with this goal, and there is little published evidence to suggest that continued tobacco use results in poorer outcomes. We sought to determine if it is justified to deny this group of patients endovascular, potentially lifestyle-improving, procedures based on their outcomes. METHODS: A retrospective chart review was performed between 2007 and 2011 at a midsize community teaching hospital. Patients included had documented lifestyle-limiting claudication, underwent endovascular therapy, and had no previous vascular intervention. Patients were divided into 2 groups: active smokers (AS) and nonsmokers (NS) including former and never smokers. The primary outcome was the need for reintervention and the secondary outcomes were the need for surgical revascularization, limb loss, myocardial infarction (MI), stroke, and death. RESULTS: One hundred thirty-eight patients met inclusion criteria with 89 being male (64.5%). Forty-seven (34%) were active smokers versus 91 (66%) who were nonsmokers. Mean age at initial intervention for all 138 subjects was 66.34 years (standard deviation 10.7) and was not statistically different between the AS and NS groups. Mean follow-up was 3.6 years and was not significantly different between the two groups. Between the two groups (AS vs NS), there was no statistically significant difference between the rate of reintervention, surgical bypass, and limb loss. We also did not observe any significant difference in the rate of MI, stroke, or death during our follow-up period. CONCLUSIONS: Although tobacco use has been shown to negatively impact bypass patency, our data show that it does not appear to increase the need for reintervention, conversion to open surgical revascularization, limb loss, or other morbidities in patients undergoing endovascular interventions for claudication. We continue to strongly recommend all our patients who smoke to discontinue tobacco use. Our results, however, do not support the notion that those patients who are unable to quit should be denied the potential benefit of an endovascular intervention. The most important limitation of our study is the small numbers of patients available for review. Larger studies will be necessary to confirm our findings.

A Novel Method for Smooth Contouring of Nasal Tip: Camouflaging Alar Tip Graft.

The aim of this article is to define a tip graft that provides camouflage for a smoothly contoured, natural-looking tip and that prevents long-term graft visibility. When traditional grafts are used to substantially increase tip projection, there is a possibility for thinning of the skin and subsequent graft visibility. To avoid such unwanted results, the authors have developed a novel graft: the camouflaging alar tip (CAT) graft. In this study, the authors provide a retrospective analysis of the long-term follow-up of 742 patients from 2003 to 2013 in whom a CAT graft was placed. This article is a synopsis of the authors' 10 years experience in nasal tip surgery.

The Soft Triangle: An Often Neglected Area in Rhinoplasty.

BACKGROUND: This study aims to focus on one of the lesser mentioned topics in discussions of aesthetic nose operations, the soft triangle. In addition to outlining the characteristics of the area, the various complications specific to the soft triangle are discussed along with methods and techniques utilized by the authors to avoid such complications. METHODS: One hundred twenty-seven of 841 (15 %) patients who were assessed both preoperatively and intraoperatively for the presence of an anatomical issue of the soft triangle were included in the study. Patients were divided into three groups according to their anatomical features that were identified intraoperatively. The preoperative and postoperative photographs of all patients were compared to assess the effects of the respective soft triangle grafts on both nostril length and the nostril/lobule harmony. RESULTS: The average follow-up time of the patients was 27 months (6-60). Postoperative notching (of various degrees) was found in six (6/127) total patients: one (1/31) patient in the first group, two (2/24) patients in the second group, and three (3/72) patients in the third group. CONCLUSION: Neglecting the soft triangle area might yield grim results in terms of cosmetic and functional aspects. To avoid these problems, incisions should be planned purposefully, and patients who have anatomically weak support should be identified so that additional precautions should be taken for these cases. LEVEL OF EVIDENCE V: 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 .

Secondary Improvement in Static Facial Reanimation Surgeries: Increase of Nasal Function.

OBJECTIVE: The aim of this study was to measure the effect of the static reanimation operation administered to patients with facial paralysis on nasal function area by comparing patients' preoperative and postoperative subjective perception of the nasal airflow. MATERIALS AND METHOD: We applied the Nasal Obstruction Symptom Evaluation (NOSE) scale to 13 patients who underwent static reanimation because of facial palsies, both preoperatively and postoperatively, and results were compared statistically. The changes in nasal base angulation were recorded and compared based on the photographs of patients taken before and after the surgery. RESULTS: Following the static reanimation operation, 76% (10/13) of the patients reported a subjective improvement in the nasal airflow, whereas 24% (3/13) did not report any change. Mean preoperative and postoperative NOSE scale scores were 66.92 ± 9.90 and 36.15 ± 9.61, respectively. The change in mean NOSE scale score was statistically significant (P < 0.001). In the preoperative and postoperative comparison of the photographs taken from the front view of the patients, a decreased nasal base angulation compared with preoperative period was detected in 8 (61.6%) patients. CONCLUSIONS: A statistically significant increase in subjective perception about nasal function was observed after the static facial reanimation; however, it is not certain whether this effect can be considered persistent. Long-term studies conducted on a larger patient population will provide beneficial results.

A novel method for reconstruction of severe caudal nasal septal deviation: Marionette septoplasty.

We conducted a retrospective study to compare open and endonasal (closed) approaches to extracorporeal reconstruction of severe caudal septal deviations. From January 1, 2010, through December 31, 2013, 78 patients with severe caudal septal deviation underwent corrective surgery at our hospital. Of this group, 33 patients (mean age: 32 yr) underwent extracorporeal septoplasty via an open approach, and 45 patients (mean age: 35 yr) underwent treatment with a new procedure that we developed: subtotal extracorporeal septoplasty through a closed approach, which we call "marionette septoplasty." In addition to demographic data, we compiled information on surgical time, the duration of postoperative edema, the degree of postoperative pain, and differences between pre- and postoperative nasal function and tip support in both groups. We found that our marionette septoplasty procedure required significantly less surgical time and resulted in a significantly shorter duration of postoperative edema than did open septoplasty, while there was no statistically significant difference between the two procedures in the degree of pain. Following surgery, nasal function in both groups improved significantly, without any significant difference between the two. Finally, we documented improved tip support in all 78 patients. Our results show that marionette septoplasty produces the same functional results as does open septoplasty while requiring less surgical time and shortening the healing period.

A novel method for nasal dorsal reconstruction: permanent fixation using Kirschner wire-guided hidden sutures.

BACKGROUND: In this study, we aimed to present a novel application and use of Kirschner wire-guided suturing that is less invasive and allows permanent fixation for nasal dorsal reconstruction. METHODS: A total of 23 patients, who underwent surgery between 2009 and 2013, were included in this study: 19 with saddle nose deformity and 4 patients with keystone area damage, or collapse of the dorsal nasal support during primary septoplasty or rhinoplasty. The patients were asked to fill out a nasal obstruction symptom evaluation (NOSE) scale preoperatively and at the postoperative sixth month to assess breathing quality. The patients were followed up for complications such as nasal dorsal contour irregularity, dorsal collapse, as well as graft malposition and infections. The results of the surgeries were assessed on the basis of preoperative and postoperative examinations, septal support test, NOSE scale results, and photographic comparison. RESULTS: The mean (SD) NOSE scales were 78.91 (10.09) and 30.48 (10.71) in the preoperative and postoperative periods, respectively. The difference of mean NOSE scale was statistically significant (P < 0.001). None of the patients experienced nasal dorsal collapse or graft malposition. Two patients had nasal dorsal irregularity complaints owing to inadequate costal cartilage edge beveling. None of the patients had complications of suture reaction, suture visibility, or suture extrusion. All of the patients stated that they were happy with the cosmetic outcome. CONCLUSIONS: Permanent sutures introduced through channels made with the Kirschner wire provide a less invasive, cosmetically pleasing, and functional solution, promising more reliable results in the long term.

A novel flap technique for repairing large lower lip defects.

UNLABELLED: There are many well-established methods for the reconstruction of the lower lip. The selection of a particular method generally relies on the amount of lip resected and the amount of lip remaining. In cases of large defects (>50% of the lip length) where direct closure and lip-switch techniques are inadequate, a perioral flap is used. All techniques for perioral flaps described until now result in an unwanted decrease in circumoral opening. The only available method that keeps the circumoral opening the same is a distant or regional free flap, and this technique is usually reserved for more extreme defects because it is more radical, technically demanding, and can pose a greater risk of complications. In this study, we describe a novel technique for reconstruction of the lower lip using a perioral flap in which the circumoral opening is kept the same. LEVEL OF EVIDENCE V: 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.

An Unexpected Otoplasty Complication: Temporal Nerve Paresis.

Otoplasty, for prominent ear correction, is the most common aesthetic surgery procedure done in children. While the outcome often has a positive impact on the psychological state of the patient, the procedure itself does have associated complications that must be considered. Common complications include hematomas, infection, necrosis, outer ear canal stenosis, extrusion of sutures, insufficient correction, overcorrection, keloids, and hypertrophic scars. This is the first case report of facial nerve palsy as a complication following otoplasty.

A retrospective analysis of the relationship between rhinosinusitis and sinus lift dental implantation.

INTRODUCTION: Dental implants have been associated with the occurrence of postoperative rhinosinusitis. In some patients, preoperative sinus lifting must be performed to increase the chances of successful implant placement. This retrospective study examines the relationship of dental implants after sinus lifting with the occurrence of postoperative rhinosinusitis. METHODS: A total of 268 dental implants were inserted in 94 patients (62 Males, 32 Females) between 2011-2013. The ages ranged from 29-71 (in males) and 33-64 (in females). Additionally, bilateral sinus lifing was performed in 51 patients, and unilateral sinus lifting was performed in 43 of the patients. Patients were evaluated for sinus pathology for a period of 5-47 months postoperatively using a satisfaction questionnaire, conventional radiographic examination, and nasal endoscopic examination. RESULTS: Four of the patients (4.2%) had a complication of postoperative sinusitis and were treated medically. In one patient, the implant was unsuccessful (even after treatment) and was removed. None of the patients needed surgery due to the sinusitis or any associated complications. CONCLUSION: The risk for postoperative rhinosinusitis was found to be higher in patients who suffer from chronic sinusitis and in cases in which a large amount of graft was utilized for sinus lifting. These predisposing factors need to be considered when evaluating patients for dental implants and sinus lift procedures.

The lateral thoracic artery revisited.

BACKGROUND: Although the variations in the origin of the branches of the axillary and subclavian arteries have been well documented, little information regarding the highly variable lateral thoracic artery (LTA) is available. Descriptions of the LTA variations may prove useful during procedures of the lateral aspects of the thorax such as reconstructive plastic surgery and modified radical mastectomy. PURPOSE: The aim of this study was to examine the anatomy of the LTA and offer an accurate account of its variability. METHODS: The entire course and distribution of the LTA was examined in 420 formalin-fixed adult human cadavers. RESULTS: The LTA was found in 96.7 % of the specimens, showing great morphological variability and classified into six types according to its origin. The most common type was where the LTA arose from the thoracoacromial artery (Type I 67.62 %). In decreasing order of incidence were origins from: the axillary artery (Type II 17.02 %), the thoracodorsal artery (Type III 5 %), and the subscapular artery (Type IV 3.93 %). Additionally, multiple LTAs were present (Type V 3.09 %) and complete absence of LTA (Type VI 3.33 %) was observed. CONCLUSION: Despite variations in origin of the vessels, our dissections demonstrated that the ultimate tissue distribution of the LTA remained typical in the vast majority of the specimens and descended on the lateral border of the pectoralis minor. Our results illustrate the need for re-evaluation of the branches of the thoracoacromial artery with possible consideration that the LTA arises from it, instead of directly from the axillary artery. We hope that the information supplied by this study will provide useful information to anatomists and surgeons alike.

Facilitated anastomosis using a reverse thermo-sensitive polymer for temporary coronary occlusion in off-pump minimally invasive direct coronary artery bypass surgery.

To evaluate the safety and efficacy of a novel, reverse thermo-sensitive polymer (LeGoo™) for its ability to provide temporary coronary occlusion and hemostasis during minimally invasive direct coronary artery bypass (MIDCAB) surgery. Between January 2009 and March 2009, 20 consecutive MIDCAB patients were studied. Ten patients received a conventional MIDCAB procedure using proximal vessel loops and CO2 blower (control group). The following 10 patients were operated by an otherwise identical procedure, except that intracoronary administration of LeGoo™ was used instead of vessel snares (LeGoo™ group). Left internal mammary artery (LIMA) bypass flow, peri- and postoperative events and perioperative creatinine kinase-MB fraction (CK-MB) release were prospectively analyzed. CO2-blower use was required in three of 10 of the LeGoo™ patients. Procedural time was identical, with a trend of shorter anastomosis time in the LeGoo™ group (12.3 vs. 10.7 min, P=0.11). LIMA-LAD flow was also not different (control 35.8 vs. LeGoo™ 42.5 ml/min, P=0.541). CK-MB values were not statistically different on postoperative days 1 and 2. However, the level of CK-MB 4 h postoperatively was lower in LeGoo™ patients (18.3±6.1 vs. 13.2±2.9 U/l, P=0.006). No major adverse cerebral or cardiovascular event occurred postoperatively and during follow-up of 317±21 days. Using LeGoo™ to achieve temporary coronary artery occlusion is easier to work with during MIDCAB due to the absence of vessel snares and less need of blowing to eliminate blood from the operative field. There were no negative postoperative events associated with the use of LeGoo™.

Update on the medical treatment of allergic rhinitis.

Allergic rhinitis is a global health problem affecting at least 10 to 25 % of the population. So far, numerous classifications and treatment modalities have been described. In the treatment of allergic disorders Pharmacotherapy is the most used therapeutic modality, especially in allergic rhinitis. The first step to successful management is the accurate diagnosis of the type of AR (intermittent or persistent) and assessment of its severity (mild or moderate to severe). Although objective measurements of the nasal airway have great value to evaluate and follow up the cases, in most centers they are not done in routine clinical practice. Allergen avoidance should be the initial step in the management of AR. Oral antihistamines are the first-line therapy for mild to moderate intermittent and mild persistent rhinitis. They are also recommended for moderate/severe persistent rhinitis cases which are uncontrolled on topical intranasal corticosteroids alone. Corticosteroids are well known for their antiinflammatory and anti allergic effects. Topical usage provides topical efficacy while avoiding systemic side effects. Meta-analysis shows that intranasal corticosteroids are superior to antihistamines. They act by suppression of inflammation at multiple points in the inflammatory cascade and reduce all symptoms of rhinitis. A meta-analysis demonstrated that Montelukast was better than placebo, as effective as antihistamines, but less effective than nasal corticosteroids in improving symptoms and QOL in patients with SAR. Good results were reported with subcutaneous and sublingual immunotherapy. Further investigations are promising.