Danger Zones of the Gluteal Anatomy: Improving the Safety Profile of the Gluteal Fat Grafting.

INTRODUCTION: Knowledge of the vascular anatomy is critical to performing safe gluteal surgery. To date, only the course of the main blood vessels within the muscles has been outlined. These findings are based on MRI and CTA images that do not conform to a topographically standardized and normalized probability distribution. OBJECTIVES: The aim of this study was to develop a three-dimensional mapping of the gluteal zones of high vascular density in relation to anatomical landmarks. MATERIALS AND METHODS: This single-center retrospective cohort analysis comprised all consecutive patients who underwent cone-beam computed tomography (CBCT) scans between January 2016 and October 2021. The location of blood vessels in the gluteal region was allometrically normalized in relation to anatomical landmarks. Moreover, the caliber and area of the blood vessels were assessed. RESULTS: CBCT scans of 32 patients with an average age of 64 ± 12 years (range 34-87 years) were included. Fifty-three percent were female. The median [IQR] caliber of the intramuscular gluteal vessels was 1.47 [1.15-1.88] mm, significantly greater than that of the subcutaneous vessels 1.09 [0.72-1.44] mm (p < 0.001). Vascular density was higher intramuscularly, as 4.5% of the area of the muscle was occupied by blood vessels, as opposed to 0.3% in the adipose tissue. CONCLUSION: The analysis of the CBCT scans showed a higher vascular density and larger vessels intramuscularly. We, therefore, recommend the injection of autologous fat merely to the subcutaneous plane. LEVEL OF EVIDENCE II: 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 .

Deep learning-accelerated image reconstruction in MRI of the orbit to shorten acquisition time and enhance image quality.

BACKGROUND AND PURPOSE: This study explores the use of deep learning (DL) techniques in MRI of the orbit to enhance imaging. Standard protocols, although detailed, have lengthy acquisition times. We investigate DL-based methods for T2-weighted and T1-weighted, fat-saturated, contrast-enhanced turbo spin echo (TSE) sequences, aiming to improve image quality, reduce acquisition time, minimize artifacts, and enhance diagnostic confidence in orbital imaging. METHODS: In a 3-Tesla MRI study of 50 patients evaluating orbital diseases from March to July 2023, conventional (TSES ) and DL TSE sequences (TSEDL ) were used. Two neuroradiologists independently assessed the image datasets for image quality, diagnostic confidence, noise levels, artifacts, and image sharpness using a randomized and blinded 4-point Likert scale. RESULTS: TSEDL significantly reduced image noise and artifacts, enhanced image sharpness, and decreased scan time, outperforming TSES (p < .05). TSEDL showed superior overall image quality and diagnostic confidence, with relevant findings effectively detected in both DL-based and conventional images. In 94% of cases, readers preferred accelerated imaging. CONCLUSION: The study proved that using DL for MRI image reconstruction in orbital scans significantly cut acquisition time by 69%. This approach also enhanced image quality, reduced image noise, sharpened images, and boosted diagnostic confidence.

Enhanced Recovery After Surgery (ERAS) Pathways for Aesthetic Breast Surgery: A Prospective Cohort Study on Patient-Reported Outcomes.

BACKGROUND: Patients' expectations of an anticipated timeline of recovery and fear of anesthesia in aesthetic breast surgery have not been studied. OBJECTIVE: This study aims to assess patient anxiety, expectations, and satisfaction after Enhanced Recovery after Surgery (ERAS) pathways for aesthetic breast surgery and the progress of postoperative recovery. MATERIALS AND METHODS: All consecutive patients who underwent aesthetic breast surgery between April 2021 and August 2022 were included in this single-center prospective cohort study. The ERAS protocol consists of more than 20 individual measures in the pre-, intra-, and postoperative period. Epidemiological data, expectations, and recovery were systematically assessed with standardized self-assessment questionnaires, including the International Pain Outcome Questionnaire (IPO), the BREAST-Q or BODY-Q, and data collection forms. RESULTS: In total, 48 patients with a median of 30 years of age were included. Patients returned to most daily activities within 5 days. Eighty-eight percent of patients were able to accomplish daily activities sooner than expected. The time of return to normal daily activities was similar across all procedure types. There was no statistically significant difference regarding postoperative satisfaction between patients who recovered slower (12%) and patients who recovered as fast or faster (88%) than anticipated (p=0.180). Patients reporting fear of anesthesia in the form of conscious sedation significantly diminished from 17 to 4% postoperatively (p<0.001). CONCLUSION: Enhanced Recovery after Surgery (ERAS) pathways for aesthetic breast surgery are associated with rapid recovery and high patient satisfaction. This survey study provides valuable insight into patients' concerns and perspectives that may be implemented in patient education and consultations to improve patient satisfaction following aesthetic treatments. 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 .

Definitions of Abnormal Breast Size and Asymmetry: A Cohort Study of 400 Women.

BACKGROUND: Macromastia, micromastia and breast asymmetry have an impact on health and quality of life. However, there is scarce information addressing breast size and asymmetry frequency distribution in reference populations. OBJECTIVE: The current study aims to identify factors that influence breast size and symmetry and classifies abnormal breast sizes and breast asymmetries in an adult German population. METHODS: Breast base dimensions, breast volume, symmetry, and other breast anthropometric parameters of 400 German female patients were determined in a retrospective review of the MRI archives at our institution. Professional medical MRI-segmentation software was used for volume measurement. RESULTS: A total of 400 Patients were retrospectively enrolled. The patients had a mean age of 50 ± 12 years (min: 24; max: 82), mean BMI of 25.0 ± 5.0 (min: 14.7, max: 45.6), and a mean total breast volume of 976 ml (right: 973 ml, min: 64, max: 4777; left: 979 ml, min: 55, max: 4670). The strongest correlation of breast volume was observed with BMI (r = 0.834, p < 0.001), followed by breast base width (r = 0.799, p < 0.001). Smaller breasts have higher breast volume asymmetry ratios (r = - 0.124, p < 0.014). For a BMI between 18.5 and 24.9 kg/m2, micromastia is defined by breast volumes below 250 ml (5th percentile) and macromastia by volumes above 1250 ml (95th percentile). Abnormal breast volume asymmetry (< 5th and > 95th percentile) is equivalent to an absolute difference of approximately 25% relative to the smallest side (bidirectional asymmetry ratio 5th percentile - 19%; 95th percentile 26%). CONCLUSION: This study provides normative data of German women, as well as selected size-for-BMI percentiles and asymmetry ratio percentiles. The normative data may help to establish transparent and objective coverage criteria for health insurances. 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 .

Quantification of Facial Fat Compartment Variations: A Three-Dimensional Morphometric Analysis of the Cheek.

BACKGROUND: Cheek contour is a main determinant of facial attractiveness. The aim of this study was to evaluate the relationship between age, sex, and body mass index (BMI) and cheek fat volume in a large cohort to better understand and treat facial aging. METHODS: The authors performed a retrospective review of the archives of the Department of Diagnostic and Interventional Radiology, University Hospital of Tübingen. Epidemiologic data and medical history were assessed. Cheek superficial and deep fat compartment volumes were measured on magnetic resonance images. Statistical analyses were performed using SPSS and SAS statistical software. RESULTS: A total of 87 patients with a mean age of 46 years (range, 18 to 81 years) were included. The superficial and deep fat compartment volumes of the cheek increased with BMI ( P < 0.001 and P = 0.005), but there was no significant relationship between age and volume. The ratio of superficial versus deep fat did not change with age. No significant difference of the superficial or deep fat compartments was found between men and women in a regression analysis ( P = 0.931 and P = 0.057). CONCLUSIONS: Cheek fat volume measurements on magnetic resonance imaging scans using reconstruction software suggest that the fat volume of the cheek increases with BMI but does not change significantly with age. Further studies are needed to elucidate the role of age-related changes of bone structures or sagging of the fat compartments.

Enhanced Recovery After Aesthetic Breast Surgery Under Sedation, Intercostal Block and Tumescent Anaesthesia: A Prospective Cohort Study of the Early Postoperative Phase.

BACKGROUND: Comfort and recovery are major concerns of patients seeking aesthetic surgery. This study aimed to assess postoperative pain and recovery after outpatient breast surgery under sedation, intercostal block, and local anaesthesia. METHODS: This prospective cohort study included all consecutive patients who underwent aesthetic breast surgery between April 2021 and August 2022. Epidemiological data, anaesthesia, pain, and patients' satisfaction were systematically assessed with standardized self-assessment questionnaires. RESULTS: Altogether, 48 patients [median (IQR) age: 30 (36-25)] were included. The most frequent surgery was mastopexy. 69% of surgeries involved additional procedures. The mean intercostal block and local anaesthesia time was 15 min. Patients received a median (IQR) of 19 (34-2) mg/kg lidocaine and 2.3 (2.5-2.0) mg/kg ropivacaine. The median (IQR) consumption of propofol and alfentanil was, respectively, 4.89 (5.48-4.26) mg/kg/h and 0.27 (0.39-0.19) µg/kg/min. No conversion to general anaesthesia or unplanned hospital admission occurred. Patients were discharged after a median (IQR) of 2:40 (3:43-1:58) hours. Within the first 24 postoperative hours, 17% required once an antiemetic medication and 38% an opioid. Patients were very satisfied with the anaesthesia and 90% of the patients had not wished more analgesia in the first 24 h. CONCLUSIONS: Aesthetic breast surgery under sedation, intercostal block, and tumescent anaesthesia can safely be performed as an ambulatory procedure and is associated with minimal intra- and postoperative opioid consumption and high patient satisfaction. These data may be used to inform patients and clinicians and improve the overall quality of care. 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 .

Quantification of Breast Volume According to age and BMI: A Three-Dimensional MRI Analysis of 400 Women.

OBJECTIVE: Breast size alteration is the most common aesthetic surgical procedure worldwide. This study aimed to assess the correlation between breast volume and BMI or age. MATERIALS AND METHODS: The analyses were conducted utilizing 400 patients selected by a retrospective review of the archives at our institution. Epidemiological data and medical history were assessed. Adjusting for the age and BMI of patient from previously described cohorts, we calculated mean breast volumes per side and differences from the upper and lower percentiles to the mean volumes. RESULTS: The patients had a median BMI of 23.5 (range: 14.7-45.6) and a median age of 51 (range: 24-82). The average total breast volume increased strongly with BMI (r=0.834, p<0.01) and moderately with age (r=0.305, p<0.01). Within a BMI range of 18-24, breast volumes in the 8th and 18th percentile differ on average by about 50 ml. One BMI unit increase in women with breast sizes in the 10th percentile accounts for a breast volume difference of about 30 ml. CONCLUSION: BMI strongly correlates with breast size. To achieve natural results, preoperative consultation and planning of aesthetic and reconstructive breast surgery must recognize BMI as a major determinant of average breast size. 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 .

Reconstruction of the Fourth Metacarpal Using a Chimeric Medial Femoral Condyle Vascularized Osteochondral Cutaneous Graft: Case Report.

BACKGROUND: The medial femoral condyle has become a matter of great interest, thanks to the possibility of harvesting versatile chimeric flaps for reconstruction of metacarpal defects with minimal donor site morbidity. This case stands out because of the complete reconstruction of the metacarpal head, harvesting with a skin paddle for tension-free closure and monitoring, and the use of external fixation for better predictability of the reconstruction and early postoperative mobilization. CASE PRESENTATION: We report the case of a 20-year-old male patient who presented with an aneurysmal bone cyst involving the fourth metacarpal bone. The patient underwent resection en bloc of the metaphysis and distal epiphysis of the fourth metacarpal bone, and the bone defect was reconstructed using a 3.4-cm vascularized osteochondral cutaneous graft from the medial femoral condyle. RESULTS: At 1-year follow-up, the patient showed no impairment in hand range of motion and had a Disabilities of Arm, Shoulder and Hand score inferior to that of the male healthy population. Almost 5 years after the procedure, the radiographic examination did not reveal signs of arthrosis. This case report shows that the medial femoral condyle is an excellent and versatile source of vascularized osteochondral grafts for reconstruction of metacarpal defects.

CT-Guided Translumbar Placement of Permanent Catheters in the Inferior Vena Cava: Description of the Technique with Technical Success and Complications Data.

PURPOSE: To evaluate indications, technical success rate and complications of CT-guided translumbar catheter placement in the inferior vena cava for long-term central venous access (Port and Hickman catheters) as a bail-out approach in patients with no alternative options for permanent central venous access. MATERIALS AND METHODS: This retrospective study included 12 patients with a total of 17 interventions. All patients suffered from bilaterally chronically occluded venous vessels of their upper extremities, without patent internal jugular and/or subclavian veins. Catheter implantation was performed as a hybrid procedure with CT-guided translumbar access into the inferior vena cava with subsequent angiography-guided catheter placement of a Hickman-type catheter (7×) or a Port catheter (10×). RESULTS: All interventions were technically successful. The total 30-day complication rate was 11.8% (n = 2). The two detected complications were bleeding at the subcutaneous port hub and subcutaneous kinking of the venous tube. Mean follow-up time was 68.4 ± 41.4 months (range 3.4-160 months). Six patients (50%) died during follow-up from non-procedure-related complications associated with the underlying disease. Late complications occurred in 8/17 (47.1%) cases and were infections of the catheter system in 35.3% (n = 6), mechanical defect of the catheter system in 5.8% (n = 1) and dislocation of the catheter system in 5.8% (n = 1). The overall infection rate was 0.77 per 1000 catheter days. CONCLUSIONS: CT-guided translumbar placement of permanent catheters is a technically feasible and safe method for permanent central venous access as last resort in chronically occluded veins of the upper extremities.

Results of a prospective clinical study on the diagnostic performance of standard magnetic resonance imaging in comparison to a combination of 3T MRI and additional CT imaging in Kienböck's disease.

PURPOSE: This prospective clinical study examined standard wrist magnetic resonance imaging (MRI) examinations and the incremental value of computed tomography (CT) in the diagnosis of Kienböck's disease (KD) with regard to reliability and precision in the different diagnostic steps during diagnostic work-up. MATERIALS AND METHODS: Sixty-four consecutive patients referred between January 2009 and January 2014 with positive initial suspicion of KD according to external standard wrist MRI were prospectively included (step one). Institutional review board approval was obtained. Clinical examination by two handsurgeons were followed by wrist radiographs (step two), ultrathin-section CT, and 3T contrast-enhanced MRI (step three). Final diagnosis was established in a consensus conference involving all examiners and all examinations results available from step three. RESULTS: In 12/64 patients, initial suspicion was discarded at step two and in 34/64 patients, the initial suspicion of KD was finally discarded at step three. The final external MRI positive predictive value was 47%. The most common differential diagnoses at step three were intraosseous cysts (n=15), lunate pseudarthrosis (n=13), and ulnar impaction syndrome (n=5). A correlation between radiograph-based diagnoses (step two) with final diagnosis (step three) showed that initial suspicion of stage I KD had the lowest sensitivity for correct diagnosis (2/11). Technical factors associated with a false positive external MRI KD diagnosis were not found. CONCLUSION: Standard wrist MRI should be complemented with thin-section CT, and interdisciplinary interpretation of images and clinical data, to increase diagnostic accuracy in patients with suspected KD.

Comparison of short- with long-term regeneration results after digital nerve reconstruction with muscle-in-vein conduits.

Muscle-in-vein conduits are used alternatively to nerve grafts for bridging nerve defects. The purpose of this study was to examine short- and long-term regeneration results after digital nerve reconstruction with muscle-in-vein conduits. Static and moving two-point discriminations and Semmes-Weinstein Monofilaments were used to evaluate sensory recovery 6-12 months and 14-35 months after repair of digital nerves with muscle-in-vein in 7 cases. Both follow-ups were performed after clinical signs of progressing regeneration disappeared. In 4 of 7 cases, a further recovery of both two-point discriminations and in another case of only the static two-point discrimination of 1-3 mm could be found between the short-term and long-term follow-up examination. Moreover, a late recovery of both two-point discriminations was demonstrated in another case. Four of 7 cases showed a sensory improvement by one Semmes-Weinstein Monofilaments. This pilot study suggests that sensory recovery still takes place even when clinical signs of progressing regeneration disappear.

Aesthetic and Functional Outcomes of 2-Stage Versus 3-Stage Paramedian Forehead Flap Techniques: A 9-Year Comparative Study With Prospectively Collected Data.

BACKGROUND: The 3-stage forehead flap technique has been described as an aesthetic improvement after nasal reconstruction compared with the 2-stage technique. A standardized evaluation of aesthetic and functional outcomes of the 2-stage versus 3-stage paramedian forehead flap after nasal reconstruction was performed. METHODS: Between July 2003 and December 2012, 102 patients underwent either 2-stage or 3-stage paramedian forehead flap techniques. A standardized patient satisfaction questionnaire was used to assess resulting nasal appearance and function. Additionally, 2 plastic surgeons performed blinded assessments of the aesthetic outcome using a standardized photographic evaluation form. Together, these evaluations demonstrated functional and aesthetic outcomes (flap thickness, shape, color, flap hair growth, donor-site scars, and nasal symmetry). RESULTS: Functional and aesthetic outcomes according to the self-assessment questionnaire were similar between groups. On inclusion of the surgeon's evaluation, with a greater satisfaction was apparent from the reconstructed alar of the 2-stage group (Mann-Whitney U test, p = .03, Fisher exact test, p = .024, respectively). CONCLUSION: No clear evidence supported enhanced aesthetic results when the 3-stage forehead flap technique was used, especially in relation to flap thickness compared with the 2-stage technique. The 2-stage technique remains the state-of-the-art choice for nasal reconstruction, even in cases involving complex defects. LEVEL OF EVIDENCE: Therapy, Level III, and retrospective comparative study with prospectively collected data.

Treatment Algorithm and Clinical Outcome of Venous Malformations of the Limbs.

BACKGROUND: Venous malformations of the limbs are congenital low-flow vascular anomalies. A treatment is reasonable if they are symptomatic or if a progressive lesion may affect functional structures. OBJECTIVE: The purpose of this work is the presentation of clinical results after treatment of venous malformations of the limbs according to the standard algorithm used at the University Hospital of Tuebingen, Germany. PATIENTS AND METHODS: Between January 2008 and June 2015, patients with venous malformations of the limbs were subjected to either percutaneous sclerotherapy or surgical excision according to this treatment algorithm. Remaining symptoms such as pain level and disturbing appearance before and after treatment as well as overall satisfaction was assessed the earliest 3 months after last treatment. RESULTS: Thirty-nine patients with venous malformations of the limbs were subjected to either 1 or more percutaneous sclerotherapies (n = 19) or surgical excision (n = 21). There were no serious complications that needed surgical revision. There was a statistically significant reduction in the pain level and disturbing appearance after both sclerotherapy and surgical excision (p < .05) in 30 cases in total. The overall treatment satisfaction was rated 7.9/10 and 8.8/10 after sclerotherapy and surgical excision, respectively. CONCLUSION: A low complication rate with a high patient satisfaction could be achieved after this treatment algorithm for venous malformations of the limbs.

Improvement of Split Skin Graft Quality Using a Newly Developed Collagen Scaffold as an Underlayment in Full Thickness Wounds in a Rat Model.

INTRODUCTION: Frequently, full thickness skin defects were treated through split skin graft (SSG) transplantation. However, this is usually associated with a reduction of skin quality and scarring. In this context, a newly developed collagen cell carrier (CCC) has been evaluated as an underlayment in SSG transplantations in a rat model. MATERIALS AND METHODS: Twenty-eight standardized full thickness skin defects were generated on the back of 28 adult male Lewis rats. The wounds were randomized and treated with SSG transplantation solitarily (n = 14) or SSG transplantation using CCC as an underlayment (n = 14). For skin quality analysis, a histological evaluation was performed 3 months postoperative in regard to epidermal cell count and epidermal and dermal thickness. RESULTS: Wounds treated with SSG and CCC demonstrated a thicker epidermis and significantly higher epidermal cell count compared to SSG solitarily. At the time of evaluation, epidermal thickness of SSG and CCC was comparable to untreated, healthy skin (no statistically significant differences). DISCUSSION: As split skin grafting is frequently associated with skin quality reduction, the presented results reveal the beneficial effects of CCC in terms of skin graft quality improvement. This may offer unique opportunities in wound management and encourages further evaluation of CCC in surgical applications and regenerative medicine.

Comparison of clinical and radiologic treatment outcomes of Kienböck's disease.

PURPOSE: The clinical outcomes of scaphotrapeziotrapezoid (STT) arthrodesis were compared to radial shortening osteotomy (RSO) to determine if any of the treatment methods was superior. The impact of RSO and vascularized bone grafts (VBG) on disease progression were measured based on X-rays to evaluate if a difference in Kienböck's disease (KD) progression exists. METHODS: Out of 98 consecutive patients treated between 1991 and 2013, 46 had STT arthrodesis, 21 had RSO, 7 had VBG, and 3 had VBG and RSO. Patients treated with STT arthrodesis were compared to RSO regarding post-operative range of motion (ROM), wrist pain on the Numeric Rating Scale (NRS), grip strength, duration of incapacity for work, the Disabilities of the Arm, Shoulder, and Hand (DASH), and the Modified Mayo Wrist scores (MMWS). Radiographic assessment (Nattrass index, radioscaphoid angle, and Ståhl index) was performed to determine disease progression following RSO or VBG. Baseline patient characteristics were comparable in all treatment groups. RESULTS: There were no significant differences in post-operative ROM, wrist pain, grip strength, duration of incapacity, DASH score, or MMWS score following STT arthrodesis (n = 27) or RSO (n = 14). The Ståhl index, the Nattrass index, and the radioscaphoid angle suggested disease progression following RSO (n = 14) and/or VBG (n = 6) although the changes were not significant. CONCLUSIONS: The study failed to demonstrate clinically relevant differences between STT arthrodesis compared to RSO. No evidence was found that decompression or revascularization, or the combination of the two, can reverse or halt the course of the disease. LEVEL OF EVIDENCE: Therapy, level III, retrospective comparative study with prospectively collected data.

Work related etiology of de Quervain's tenosynovitis: a case-control study with prospectively collected data.

BACKGROUND: The etiology of de Quervain's tenosynovitis (dQ) has been based on conflicting small case series and cohort studies lacking methodological rigor. A prospective case-control study was conducted to analyze the most common risk factors for dQ. METHODS: Between January 2003 and May 2011, 189 patients surgically treated for dQ vs. 198 patients with wrist ganglia (WG) (controls) were identified in our clinic's electronic database. Sample characteristics, exertional, anatomical, and medical risk factors were compared between groups. RESULTS: dQ vs. WG differed by average age (52 vs. 43 years) and gender ratio (15/62 vs. 26/39). No significant difference between dQ vs. WG was found after subgrouping professional activities (manual labor: 18 % vs. 26 %, respectively, p = 0.23). No asymmetric distribution of comorbidities, wrist trauma, forceful or repetitive manual work, or medication was observed. CONCLUSIONS: Neither heavy manual labor nor trauma could be shown to be predisposing risk factors for dQ.

In vivo analysis of the vascular pattern of the superficial temporal artery based on digital subtraction angiography.

BACKGROUND: Existing anatomic descriptions of the superficial temporal artery (STA) are mainly based on cadaver studies and do not accurately reflect the in vivo situation. In this study, the anatomical course and branching pattern of the STA were analyzed with digital subtraction angiographies (DSAs). METHODS: DSAs of 93 Caucasian individuals between 16- and 79-years old were retrospectively analyzed regarding the course and branching pattern of the STA as well as surgically relevant inner diameters and lengths of its main branches. RESULTS: In total, 11 variations in the branching pattern of the terminal STA were found. About 89% of the examined individuals demonstrated the classic variation in which the main trunk of the STA bifurcates into a single frontal and parietal branch. In 60% of cases with an existing bifurcation, the division of the main trunk of the STA was located above the zygoma. The mean inner diameters of the STA main trunk, the frontal branch and the parietal branch were 2.4 ± 0.6 mm, 1.3 ± 0.6 mm and 1.2 ± 0.4 mm, respectively. The surgically relevant "working lengths" of the frontal and parietal branches above the upper margin of the zygoma up to an inner diameter of 1 mm were 106.4 ± 62.1mm and 99.7 ± 40.9 mm, respectively. CONCLUSIONS: The common variations of the branching pattern of the STA are described in this study. Furthermore, surgically relevant inner diameters and lengths of the main branches of the STA are determined. These findings should improve our understanding of the suitability and usefulness of the STA for various surgical procedures.

A Cohort Study of Paramedian Forehead Flap in 2 Stages (87 Flaps) and 3 Stages (100 Flaps).

BACKGROUND: In nasal reconstruction, the paramedian forehead flap is traditionally performed in 2 stages. To minimize the risk of flap necrosis, Millard described a 3-stage technique in a series of 5 cases in 1974. In this technique, an intermediate step of flap thinning is performed after flap transfer and before pedicle division. In this article, we compare the 2- and 3-stage techniques of paramedian forehead flaps for nasal reconstruction to determine the type and prevalence of complications related to each procedure. METHODS: Here, we present a retrospective review of a prospectively maintained database of paramedian forehead flaps for nasal reconstruction performed during a period of 6 years. We included all patients with 2- (n=87) and 3-stage (n=100) paramedian forehead flaps who had consistent and complete electronic patient records and followed them up for at least 6 months after pedicle division. We performed a regression analysis to adjust for the unequal distribution of complex cases. RESULTS: Demographic factors and the causes for the nasal defects were similar in both groups. Although the nasal reconstructions were significantly more complex in the 3-stage group, the rate of partial forehead flap necrosis was similar in both groups (2-stage, 3.4%; 3-stage, 5%; P=0.601). A regression analysis showed that the relative risk of partial flap necrosis in complex cases did not differ significantly between groups (relative risk, 0.80; P=0.705). CONCLUSIONS: To our knowledge, our study is the largest series published to date and the first one to compare the prevalence of forehead flap necrosis in the 2- versus the 3-stage technique for paramedian forehead flaps. We found no evidence that the use of a 3-stage forehead flap lowers the prevalence of necrosis. Until larger multicenter studies or meta-analyses can be conducted, smaller yet well-conducted studies such as the present one provide critical data and represent an important contribution to the field. Future research should investigate whether the 3-stage technique produces better aesthetic results than the 2-stage technique.