Cosmetic rhinoplasty: revision rates revisited.

BACKGROUND: Cosmetic rhinoplasty has great potential to change a patient's appearance. It also carries the very real risk of patient dissatisfaction and request for revision. Although there have been many published patient series studying various aspects of rhinoplasty, questions remain regarding revision rates, as well as risk factors for complications, dissatisfaction, and revision. OBJECTIVES: The authors investigate the rate of cosmetic rhinoplasty revision at a plastic surgery group practice and identify risk factors for revision. METHODS: Medical records were retrospectively reviewed for all patients who presented to a single multisurgeon practice for primary rhinoplasty, septorhinoplasty, and revision rhinoplasty between 1998 and 2008. Patient demographics, preoperative complaints, preoperative physical examination findings, detailed operative data, and postoperative outcomes were abstracted from the charts. Complication rates, revision rates, and postoperative patient satisfaction were calculated and analyzed for identifiable risk factors. RESULTS: Of 369 consecutive cosmetic rhinoplasties performed during the study period, 279 (72.7%) were conducted with an open approach. The overall complication, dissatisfaction, and revision rates were 7.9%, 15.4%, and 9.8%, respectively. Postoperatively, most patients (87%) were identified by their surgeons as having had successful anatomical correction of their nasal deformity. History of previous nasal operation or facial fracture, lack of anatomical correction, and occurrence of postoperative complications were associated with both revision and dissatisfaction (P < .05). Failure to address the nasal tip at the time of primary rhinoplasty was associated with a higher level of dissatisfaction. CONCLUSIONS: Cosmetic rhinoplasty is one of the most challenging procedures in plastic surgery; however, these data indicate that a high level of patient satisfaction is attainable within a plastic surgery group practice if certain factors are considered. Specifically, surgeons should be aware of risk factors that are potentially associated with dissatisfaction and revision. LEVEL OF EVIDENCE: 4.

Treatment of Pyogenic Flexor Tenosynovitis in the Emergency Department Setting With WALANT Technique.

BACKGROUND: The standard of care for treatment of pyogenic flexor tenosynovitis (PFT) involves antibiotic therapy and prompt irrigation of the flexor tendon sheath, traditionally performed in the operating room. With the acceptance of wide-awake local anesthesia no tourniquet (WALANT) hand surgery and its potential ability to minimize time to flexor tendon sheath irrigation, we sought to determine whether closed irrigation of the flexor tendon sheath could be safely and effectively performed in the emergency department setting with WALANT technique. METHODS: A retrospective review was conducted of the senior author's hand surgery consultations over a 12-month period. Six patients were identified who were diagnosed with PFT and subsequently underwent irrigation of the flexor tendon sheath using WALANT technique. Patient outcomes such as length of hospital stay, need for reoperation, infectious etiology, perioperative complications, and postprocedure range of motion (ROM) were identified. RESULTS: Six patients with diagnosis of PFT underwent irrigation of the flexor tendon sheath in the emergency department with local anesthesia only. The irrigation procedures were all well-tolerated. One patient required reoperation due to lack of appropriate clinical improvement following initial irrigation. Four of 6 patients regained their preinjury ROM while the remaining 2 patients had mild proximal interphalangeal joint extension lag. There were no complications associated with the procedures. CONCLUSIONS: Surgical treatment of PFT with closed irrigation of the flexor tendon sheath in the emergency department utilizing WALANT technique was safe, effective, and well-tolerated. Local anesthesia alone can be used effectively for irrigation procedures of the flexor tendon sheath.

Endogenous opioid peptides contribute to associative LTP in the hippocampal CA3 region.

The medial and lateral perforant path projections to the hippocampal CA3 region display distinct mechanisms of long-term potentiation (LTP) induction, N-methyl-d-aspartate (NMDA) and opioid receptor dependent, respectively. However, medial and lateral perforant path projections to the CA3 region display associative LTP with coactivation, suggesting that while they differ in receptors involved in LTP induction they may share common downstream mechanisms of LTP induction. Here we address this interaction of LTP induction mechanisms by evaluating the contribution of opioid receptors to the induction of associative LTP among the medial and lateral perforant path projections to the CA3 region in vivo. Local application of the opioid receptor antagonists naloxone or Cys2-Tyr3-Orn5-Pen7-amide (CTOP) normally block induction of lateral perforant path-CA3 LTP. However, these opioid receptor antagonists failed to block associative LTP in lateral perforant path-CA3 synapses when it was induced by strong coactivation of the medial perforant pathway which displays NMDAR-dependent LTP. Thus strong activation of non-opioidergic afferents can substitute for the opioid receptor activation required for lateral perforant path LTP induction. Conversely, medial perforant path-CA3 associative LTP was blocked by opioid receptor antagonists when induced by strong coactivation of the opioidergic lateral perforant path. These data indicate endogenous opioid peptides contribute to associative LTP at coactive synapses when induced by strong coactivation of an opioidergic afferent system. These data further suggest that associative LTP induction is regulated by the receptor mechanisms of the strongly stimulated pathway. Thus, while medial and lateral perforant path synapses differ in their mechanisms of LTP induction, associative LTP at these synapses share common downstream mechanisms of induction.

NMDA receptor antagonists block heterosynaptic long-term depression (LTD) but not long-term potentiation (LTP) in the CA3 region following lateral perforant path stimulation.

High-frequency stimulation of lateral perforant path is accompanied by a heterosynaptic long-term depression (LTD) of medial perforant path synaptic responses in both the dentate gyrus and the CA3 region of the hippocampus. We reported previously that LTP induction at lateral perforant path-CA3 synapses is unaffected by NMDA antagonists. However, it is not known if heterosynaptic LTD that is observed in the CA3 region following lateral perforant path stimulation also is independent from NMDA receptors. We address this question in anesthetized adult rats using systemic administration of the competitive NMDA receptor antagonist CPP. Induction of lateral perforant path-CA3 LTP produced a sustained heterosynaptic depression of medial perforant path-CA3 responses. Systemic administration of CPP (10 mg/kg) was ineffective in blocking the induction of LTP at lateral perforant path-CA3 responses. However, heterosynaptic LTD of medial perforant path-CA3 responses was blocked completely by CPP. These data indicate that NMDA receptors are not required for the induction of lateral perforant path-CA3 LTP, but are involved in the induction of heterosynaptic LTD that accompanies lateral perforant path activity. The requirement for NMDA receptors for heterosynaptic LTD suggests one functional role of NMDA receptors at termination fields of the lateral perforant path.

Associative long-term potentiation (LTP) among extrinsic afferents of the hippocampal CA3 region in vivo.

Monosynaptic perforant path projections to the CA3 region of the hippocampus are anatomically and physiologically substantial pathways that relay cortical input directly to the hippocampus proper. Despite the suggested relevance of these direct pathways in models of information processing within the CA3 region, surprisingly few studies have characterized synaptic plasticity in these direct cortical projections to the CA3 region. We assessed the ability of perforant path projections, and commissural/associational projections to the hippocampal CA3 region to both induce or display associative LTP in vivo. In pentobarbital-anesthetized adult rats, trains delivered to either the medial or lateral perforant pathway at current intensities normally insufficient to induce LTP displayed associative LTP when these same trains were delivered in conjunction with high-intensity trains to the alternate perforant pathway. Similarly, associative LTP is induced at intrinsic commissural/associational-CA3 (C/A-CA3) synapses when weak C/A trains were delivered in conjunction with high-intensity trains to either the medial or lateral perforant pathway. Associative LTP also was observed at medial and lateral perforant path-CA3 synapses when weak perforant path trains were tetanized in conjunction with high-intensity trains delivered to C/A-CA3 synapses. Thus direct perforant path-CA3 synapses and commissural/associational-CA3 synapses can modify and be modified by other CA3 afferents in an associative manner, verifying a requirement for synaptic plasticity explicit in models of autoassociative information processing in the CA3 region.

Outdoor recreational fires: a review of 329 adult and pediatric patients.

Outdoor recreational fires are a frequent occurrence during the summer months and can be associated with burns resulting in significant morbidity. Both pediatric and adult populations can be affected, and their mechanism of injury is often different. Understanding these mechanisms is important when designing prevention programs. It is the goal of this study to review our experience with outdoor recreational fires. All patients who presented to Spectrum Health Blodgett Regional Burn Unit for burns secondary to an outdoor recreational fire over an 8-year period were reviewed. Demographic data, mechanism of injury, body area involved, TBSA burned, treatments undertaken, and subsequent complications were recorded. Pediatric patients (aged 16 years and younger) were analyzed independently, and risk factors were determined. A total of 329 patients suffered burns secondary to outdoor recreational fires over the length of the study. More than 35% required inpatient treatment, with an average length of stay of 4.8 days. Hands were the most frequently affected body part, with the mean TBSA involved being 3.5%. Ninety-four patients (28.6%) required split-thickness skin grafting. The most common mechanism of injury in both adult and pediatric populations was falling into an ongoing fire. Wound infection was the most common complication. Alcohol intoxication was associated with a higher burn severity and complication rate. Pediatric patients represented 39.8% of the sample. Burns secondary to outdoor recreational fires are associated with significant morbidity. Adult prevention programs should target awareness with respect to alcohol consumption and campfires secondary to the morbidity associated with these injuries. Pediatric patients are particularly susceptible, and parents should remain diligent about campfire safety and be educated about the inherent dangers of both active and extinguished fires.

5-HT1a receptor antagonists block perforant path-dentate LTP induced in novel, but not familiar, environments.

Numerous studies suggest roles for monoamines in modulating long-term potentiation (LTP). Previously, we reported that both induction and maintenance of perforant path-dentate gyrus LTP is enhanced when induced while animals explore novel environments. Here we investigate the contribution of serotonin and 5-HT1a receptors to the novelty-mediated enhancement of LTP. In freely moving animals, systemic administration of the selective 5-HT1a antagonist WAY-100635 (WAY) attenuated LTP in a dose-dependent manner when LTP was induced while animals explored novel cages. In contrast, LTP was completely unaffected by WAY when induced in familiar environments. LTP was also blocked in anesthetized animals by direct application of WAY to the dentate gyrus, but not to the median raphe nucleus (MRN), suggesting the effect of systemic WAY is mediated by a block of dentate 5-HT1a receptors. Paradoxically, systemic administration of the 5-HT1a agonist 8-OH-DPAT also attenuated LTP. This attenuation was mimicked in anesthetized animals following application of 8-OH-DPAT to the MRN, but not the dentate gyrus. In addition, application of a 5-HT1a agonist to the dentate gyrus reduced somatic GABAergic inhibition. Because serotonergic projections from the MRN terminate on dentate inhibitory interneurons, these data suggest 5-HT1a receptors contribute to LTP induction via inhibition of GABAergic interneurons. Moreover, activation of raphe 5-HT1a autoreceptors, which inhibits serotonin release, attenuated LTP induction even in familiar environments. This suggests that serotonin normally contributes to dentate LTP induction in a variety of behavioral states. Together, these data suggest that serotonin and dentate 5-HT1a receptors play a permissive role in dentate LTP induction, particularly in novel conditions, and presumably, during the encoding of novel, hippocampus-relevant information.

Long-term potentiation in direct perforant path projections to the hippocampal CA3 region in vivo.

The perforant path constitutes the primary projection system relaying information from the neocortex to the hippocampal formation. Long-term synaptic potentiation (LTP) in the perforant path projections to the dentate gyrus is well characterized. However, surprisingly few studies have addressed the mechanisms underlying LTP induction in the direct perforant path projections to the hippocampus. Here we investigate the role of N-methyl-D-aspartate (NMDA) and opioid receptors in the induction of LTP in monosynaptic medial and lateral perforant path projections to the CA3 region in adult pentobarbital sodium-anesthetized rats. Similar to LTP observed at the medial perforant path-dentate gyrus synapse, medial perforant path-CA3 synapses display LTP that is blocked by both local and systemic administration of the competitive NMDA receptor antagonist (+/-)-3-(2-carboxypiperazin-4-yl) propyl-1-phosphonic acid [(+/-)-CPP]. By contrast, LTP induced at the lateral perforant path-CA3 synapses is not blocked by either local or systemic administration of this NMDA receptor antagonist. The induction of LTP at lateral perforant path-CA3 synapses, which is blocked by the opioid receptor antagonist naloxone, is also blocked by the selective mu opioid receptor antagonist Cys(2)-Tyr(3)-Orn(5)-Pen(7)-amide (CTOP), but not the selective delta opioid receptor antagonist naltrindole (NTI). CTOP was without effect on the induction of medial perforant path-CA3 LTP. The selective sensitivity of lateral perforant path-CA3 LTP to mu-opioid receptor antagonists corresponds with the distribution of mu-opioid receptors within the stratum lacunosum-moleculare of area CA3 where perforant path projections to CA3 terminate. These data indicate that both lateral and medial perforant path projections to the CA3 region display LTP, and that LTP induction in medial and lateral perforant path-CA3 synapses are differentially sensitive to NMDA receptor and mu-opioid receptor antagonists. This suggests a role for opioid, but not NMDA receptors in the induction of LTP at lateral perforant path projections to the hippocampal formation.