Role of Membranous Septum in the Alar-Columellar Relationship: Strategies in Closed-Approach Rhinoplasty.

A normal alar-columellar relationship is crucial for lower third finesse in rhinoplasty. Hanging columella is a common complaint in the alar-columellar relationship and membranous septum excision is frequently recommended for its correction. This paper focuses on the role of the membranous septum in achieving a normal alar-columellar relationship. It was aimed to present an algorithm that could be used for aberrancies in the alar-columellar relationship.Ninety-seven patients who underwent closed-approach rhinoplasty between January and December 2022 were included in this retrospective study. Routine tip plasty maneuvers were performed on all patients. Membrane septum excision was not performed in any of the cases. Standardized preoperative and postoperative 12-month lateral view photographs were scanned for hanging or retracted columella.Hanging columella was observed in seven patients preoperatively (n = 97). No hanging or retracted columella was observed postoperatively.Hanging columella can be successfully corrected with alternative surgical maneuvers without excision of the membranous septum in closed-approach rhinoplasty in appropriate cases. Complete preservation of the membranous septum does not cause hanging columella in the postoperative period.

Comparison of Different Suture Techniques on Nasal Soft Tissue Envelope to Prevent Supratip Deformity: A Histologic Study.

BACKGROUND: Studies have described various surgical maneuvers in rhinoplasty to limit thickening from excessive scarring in the supratip region. This study aimed to compare the effectiveness of three maneuvers-a simple suture, a U suture, and bolster dressing-used to avoid supratip deformity in a rabbit model. METHODS: Thirty-two male New Zealand white rabbits were included. The animals were divided into four groups, and dissection was performed in the supra-perichondrial plane up to the supratip region through an open rhinoplasty incision. After dissection, the following approaches were applied to the supratip region: Group 1, simple approximation suture; Group 2, U suture; Group 3, bolster dressing; and Group 4 (control group), no suture. All animals were sacrificed after 12 weeks. Histological analysis was performed. RESULTS: In Group 4, scar thickness was significantly greater than in the other groups (p < 0.05). Group 3 had greater scar thickness than Group 2 (p < 0.05). The ratio of scar thickness to skin thickness was higher in Group 4 compared with the other groups (p < 0.05). Finally, there was no difference in the ratio of scar thickness to skin thickness between Groups 1, 2, and 3 (p > 0.05). CONCLUSIONS: In this study, it was concluded that surgical methods using sutures in the supratip region reduced scar thickness in a rabbit model, and these surgical methods had similar levels of effectiveness. NO LEVEL ASSIGNED: This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. 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 .

Comparison of Polypropylene and Polydioxanone in the Hemitransdomal Suture: A Novel Rabbit Ear Cartilage Model.

BACKGROUND: Lower lateral cartilage reshaping is one of the basic steps in rhinoplasty. Hemitransdomal suture is frequently used for dome narrowing. Different suture materials can be used for hemitransdomal suture. In this study, we investigated the effectiveness of polypropylene and polydioxanone in hemitransdomal suture by designing a new experimental model in the rabbit ear cartilage. METHODS: Twelve young adult male New Zealand White rabbits were used. The bipedicled inverted-U-shaped cartilage was elevated in each ear of the rabbits. Two hemitransdomal sutures were applied using 5-0 polypropylene on one ear and 5-0 polydioxanone on the other ear randomly. A 5 mm high cartilage mound was created with two hemitransdomal sutures on each side. The sample size was twelve both in the polypropylene group and the polydioxanone group (n = 12). All animals were sacrificed after three months. Cartilage mound heights were measured. The samples were examined histologically regarding fibroadipose tissue, inflammation, foreign body granuloma, cartilage degeneration, and the presence of inclusion cyst. RESULTS: Cartilage mound height was significantly higher in the polypropylene group than in the polydioxanone group at the end of the third month [3.75 mm (± 0.68) vs. 3.03 mm (± 0.69); p < 0.05]. There was no significant difference between the two groups in histological analysis (p > 0.05). CONCLUSIONS: Polypropylene suture may be more effective in maintaining the shape given to the dome by hemitransdomal sutures in rhinoplasty. No Level Assigned This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to Table of Contents or the online Instructions to Authors www.springer.com/00266.

Progressive Contouring of the Platysma With Barbed Sutures.

BACKGROUND: As the prevalence of neck lift surgeries increases, the field is continually enriched by evolving techniques for enhancing neck aesthetics. While many recent publications focus on deep neck procedures, it is essential not to overlook the significance of platysmal contouring as an integral aspect of neck rejuvenation surgery. Accordingly, we would like to elucidate our unique approach to contouring the platysma. OBJECTIVES: This study was designed to assess the efficacy of the progressive contouring concept, a technique in which the neck is reshaped with barbed sutures synergistically with other treatment strategies. METHODS: Our study encompassed 337 patients who received neck rejuvenation treatment with the progressive contouring technique from 2014 to 2021. We conducted a retrospective review to evaluate the change in cervicomental angle (CMA) with Mirror software during the preoperative and postoperative stages. RESULTS: The study sample predominantly comprised females (304 out of 337), with a median age of 61 years (24-88). Most patients (95%) underwent deep cervicoplasty, with a surgical net applied in all cases for skin adaptation. After a median follow-up of 14 months, significant improvements were observed in CMA values (reduced from 149.8° to 106.7°). This demonstrated statistically significant differences when comparing preoperative and postoperative outcomes. CONCLUSIONS: Progressive shaping of the neck with barbed sutures is an effective technique in neck rejuvenation. It utilizes multipoint and multivector plication, particularly when integrated with other adjunctive surgical maneuvers.

Simplified Septal Stabilization in Closed-Approach Low-Septal-Resection Dorsal Preservation Rhinoplasty.

BACKGROUND: Septal fixation is a basic step in low-septal-resection dorsal preservation rhinoplasty. Inadequate septal stabilization can lead to supratip depression or more severe saddle nose deformity. This paper presents a simple surgical maneuver to stabilize quadrangular septal cartilage instead of suture fixation to the anterior nasal spine. METHODS: Thirty patients who underwent closed-approach low-septal-resection dorsal preservation rhinoplasty between July and December 2021 were included in this retrospective study. Depending on the surgical maneuver performed to stabilize quadrangular septal cartilage, the patients were divided into 2 groups as follows: (1) a group in which the septum was stabilized with transfixion sutures (the transfixion suture group) and (2) a group in which the septum was fixed to the anterior nasal spine with suture (the anterior nasal spine suture fixation group). Standardized postoperative 12-month lateral-view photographs were scanned for the presence of supratip depression or saddle nose deformity that may indicate insufficient septum stabilization. RESULTS: Supratip depression was observed in 1 patient in the transfixion suture group (n = 16) and in 1 patient in the anterior nasal spine suture fixation group (n = 14; P > 0.05). No saddle nose deformity was observed in either group. CONCLUSIONS: Transfixion sutures seem effective in providing septal stabilization to prevent supratip depression or saddle nose deformity in closed-approach low-septal-resection dorsal preservation rhinoplasty. Transfixion sutures can be used for septal stabilization in closed-approach rhinoplasty, allowing the surgeon to take advantage of the ease of placement.

Lateral Crural Turn-Up Flap for Increasing the Volume of Cartilaginous Nasal Sidewall in Closed-Approach Dorsal Preservation Rhinoplasty.

BACKGROUND: Dorsal preservation rhinoplasty can also be applied in crooked nose cases. This article describes a lower lateral cartilage-based flap (lateral crural turn-up flap) used to correct cartilaginous nasal sidewall asymmetries. It was aimed to introduce a flap to be used in crooked nose cases operated with dorsal preservation rhinoplasty and to show possible modifications of this flap. METHODS: Eight patients who had lateral crural turn-up flap due to crooked nose between July and December 2021 were included in this retrospective study. Standardized preoperative and postoperative 12-month front-view photographs were analyzed and scored for correction of midvault nasal sidewall asymmetries by 2 plastic surgeons. The Rhinoplasty Outcome Evaluation (ROE) scale was applied at 12 months. RESULTS: The mean score given by the surgeons for correction of midvault nasal sidewall asymmetries was 4.18. The mean ROE score was 89, and all patients were satisfied according to their ROE scores. There were no major complications. CONCLUSIONS: Unilateral lateral crural turn-up flap seems to be effective in correcting cartilaginous nasal sidewall asymmetries in crooked nose cases operated with dorsal preservation rhinoplasty.

First Composite Woman-to-Woman Facial Transplantation in Turkey: Challenges and Lessons to Be Learned.

ABSTRACT: After the first face transplantation from woman to woman we performed in our clinic, it was aimed to eliminate the lack of knowledge about the subject in the literature by transferring our experiences and long-term results to the problems we had with the patient. A 20-year-old patient underwent partial osteomyocutaneous facial transplant (22nd facial transplant), which included 2 functional units of the face. The patient had no major problems in the early period and had a good aesthetic appearance. In the postoperative period, the patient ended her social isolation and adopted the transplanted face.In the late period, secondary surgical interventions, management of the problems caused by immunosuppression, and the patient's living in a remote location to our clinic were the difficulties encountered. Six revision surgeries were performed after the transplantation. Due to immunosuppression, opportunistic infections and metabolic problems required intermittent hospitalization. The patient died at the end of 56 months because of complications secondary to immunosuppression.A successful transplant involves the management of long-term problems rather than a successful tissue transfer in the early period. In today's conditions, long-term success can be achieved with a good patient compliance, as well as each team member should take an active role in the team at the transplantation centers. More case series are needed to adapt the standard treatment and follow-up protocols for solid organ transplantations for composite tissue allotransplantations. This will be possible by sharing the results and experiences transparently in the centers where face transplantation is performed worldwide.

Inferior and Medially Based Breast Parenchymal Rotation Flap: A New Mastopexy Technique for Replacing Breast Volume After Breast Implant Explantation.

BACKGROUND: Recently, a growing number of patients have been opting for the removal of breast implants. This often results in a degree of volume loss that can vary from mild to substantial, contingent on the size of the implant, with many patients requiring a mastopexy. Although autoaugmentation mastopexy serves as the primary surgical approach to restore shape and fill the void left by the implant, the fullness attained with the implant cannot be replicated through autoaugmentation. OBJECTIVES: Our goal was to present the technical details and utilization of an inferomedial pedicle-based breast parenchymal flap, without rotational restriction from the parenchyma, for autoaugmentation after explantation. METHODS: A retrospective chart review was performed of 12 patients who underwent surgery with this technique between the years of 2019 to 2022, with emphasis on reasons for explantation, early and late complications, and satisfaction scores on a Likert scale. RESULTS: Capsular contracture was the most common reason for explantation, and only 2 patients experienced minor wound dehiscence in the early postoperative period. With a mean follow-up of nearly 2 years, no bottoming out was encountered in any of the patients, and satisfactory breast shape was obtained. Further, postoperative satisfaction was significantly higher than preoperative satisfaction. CONCLUSIONS: The inferomedial-based parenchymal rotation flap is a new procedure that can be applied in this patient group because of its wide rotation arc and reliable vascularity. It is also an effective option for creating the desired conical breast shape in patients who do not want breast implants over the long term.

Comparison of the Results of Suture and Resorbable Plate-Screw Fixation in Craniosynostosis.

BACKGROUND: Although many fixation methods are used alone or in combination for craniosynostosis, only few studies have compared the effectiveness and long-term results of these methods. METHOD: In this study, patients in whom suture or resorbable plate-screw system was used for fixation were evaluated in terms of postoperative results and complications. The data of patients who underwent surgery for craniosynostosis between 2002 and 2019 were retrospectively reviewed and evaluated. RESULTS: A total of 70 patients, 41 in the suture group and 29 in the resorbable plate-screw group, were included in the study. Whitaker classification was used for head shape evaluation, and anthropometric head circumference measurements were performed in all patients in the preoperative and postoperative periods. In the postoperative period, all patients were compared in terms of the operation time, transfusion requirement, discharge, follow-up period, and complications according to the chosen fixation method.The mean age, postoperative complication rates, anthropometric head circumference measurements, and Whitaker scores of both groups were found to be statistically similar. Although the resorbable plate-screw group had a longer follow-up period, the operation time was longer in the suture group. Furthermore, the suture group had lower transfusion requirement and earlier discharge from the hospital than the resorbable plate-screw group. CONCLUSIONS: If fixation with suture is chosen in suitable patients, in addition to the low patient cost, this method can be safely applied in centers with limited logistical possibilities, because of the results and complication rates being similar to fixation with resorbable plate-screws.

Evaluation of Orbitomalar Region Projection in Patients With Operated Cleft Lip and Palate (Cephalometric Study).

OBJECTIVE: The aim of this study was to compare the orbitomalar region projection in patients with cleft lip and palate (CLP) with skeletal class 1 cases. DESIGN: Retrospective. SETTING: Single center. PATIENTS: Cephalometric data of 52 cases with unilateral CLP, 25 cases with bilateral CLP, and 60 healthy participants in skeletal class 1 without CLP were included. MAIN OUTCOME MEASURE(S): A total of 5 parameters, 3 in the orbital and 2 in the suborbital region, that determine the projection of the orbitomalar region on lateral cephalograms, and 13 parameters of the craniofacial region were evaluated. RESULTS: Lateral, inferior, and anterior orbital parameters were similar between groups, while suborbital parameters were in a retrusive position in the CLP groups compared to the control group (P < .05). No significant difference was found between the CLP groups in terms of suborbital parameters. A moderate positive correlation was found between orbitomalar parameters and the anteroposterior positions of the maxilla and mandible. The lateral orbital region had a moderate negative correlation with anterior maxillary height, and the suborbital region had a negative moderate correlation with maxillary inclination. CONCLUSION: Suborbital projection was more retrusive in CLP compared to the control group, but no difference was found between the CLP groups. On the other hand, the correlation between orbitomalar projection and maxillary and mandibular development was significant. The results show that there is a need for alternative treatment modalities for the suborbital region in patients with CLP.

Arterial Occlusion After Hyaluronic Acid Injection: Treatment With Hyaluronidase and Streptokinase.

ABSTRACT: The most feared complication of the hyaluronic acid injections in the periorbital region is embolism of the central retinal artery. The present study aimed to compare the effectiveness of hyaluronidase administered intravenously (systemically) alone or in combination with streptokinase with that of intra-arterial revascularization. Thirty rats were divided into 5 groups. The bilateral oblique groin flap of the rats was raised; the right side was the experiment group, and the left side was the sham control. The right superficial epigastric artery was occluded with a hyaluronic acid injection. After occlusion, no additional procedures were performed in group 1, whereas group 2 received systemic hyaluronidase, group 3 received intra-arterial hyaluronidase, group 4 received systemic hyaluronidase and streptokinase, and group 5 received intra-arterial hyaluronidase and streptokinase. On the seventh day, the rats were killed, flap necrosis rate was calculated, and histological examination was performed. There was no significant difference in the necrosis rates of the rats in groups 2, 3, 4, and 5 (P > 0.05). In histological evaluation, the histological view closest to normal arterial structure was observed in group 4. Immunohistochemical analysis revealed that the ischemia scores of systemic therapy were significantly lower than those of intra-arterial therapy. These results have shown that hyaluronidase and streptokinase administered systemically is as effective as intra-arterial revascularization and does not cause arterial wall degeneration. It has been shown that systemic administration of hyaluronidase and streptokinase is as successful as intra-arterial revascularization in the treatment of arterial embolism with hyaluronic acid.

Endoscopic Orbital Reconstruction With Temporalis Muscle Flap.

ABSTRACT: Temporalis muscle flap is one of the most commonly used flaps in orbital reconstruction. Although multiple case series in the literature have reported elevation of the flap with an open incision and a retrograde approach from the periorbital region, to the best of the authors' knowledge, no studies have reported the use of an endoscopic method. Therefore, the authors' study presents endoscopy-assisted temporalis muscle reconstruction of a defect that occurred in the periorbital region following orbital exenteration. Minimal scarring and morbidity are some of the advantages of endoscopic methods, and healing without complications was achieved in our patient during the postoperative period. To the authors' knowledge, their study is the first to report the use of temporalis muscle flap in endoscopy-assisted periorbital reconstruction, which is a preferred method for endoscopic surgery.

Before and After: What Has Changed in the Attitude of Turkish Society Regarding Face Transplantations?

Face transplantation is one of the most popular and controversial subjects of plastic surgery today. Although there are various surveys on the subject, there is no study comparing the past and the present social viewpoint and behavioral preferences for face transplantations across the world. In this study, we aimed to investigate the changes in the views of the Turkish society with respect to face transplantation from past to present. For this purpose, 1000 volunteer participants were questioned in terms of demographics and their perspective and preferences on organ and face transplantation. The results of the study were compared with the past data, and based on the results, the level of consciousness and awareness of the Turkish society about the subject has increased; the rate risk taking for immunosuppression has decreased, and instead, the rate of having an undecided stance has increased, and this attitude continues even if the risk is resolved. With these results, we can conclude that the greatest handicap for face transplantation in the Turkish society today is immunosuppression and the associated risks. We believe that new drug protocols and monitoring of patient outcomes for longer periods as well as more extensive clinical applications may be beneficial in addressing this issue.

The Relationship Between Ocular Protrusion and Craniofacial Structures.

OBJECTIVE: This study aimed to evaluate the relationships between ocular protrusion and other craniofacial structures. METHODS: The lateral cephalograms of 124 nonsyndromic white adults were assessed. Two orbital and 13 craniofacial parameters were measured. Subgroups were constructed according to sex, anteroposterior position of maxilla, and mandibular plane angle values.Anatomical parameters and their relationships were statistically analyzed by analysis of variance and multivariate stepwise regression analysis. RESULTS: There were no significant differences in ocular protrusion distances between sexes, and between individuals with different maxillary anteroposterior position and mandibular plane angle values. Ocular protrusion distances, the distance between the eyeball apex and the lateral orbital margin (Eyeball apex-LOr: OP1) and inferior orbital margin (Eyeball apex-IOr: OP2), were found to be 20.6 ±â€Š2.8 and 16.5 ±â€Š3.1, respectively. However, regression analysis showed that the ocular protrusion distances had weak correlation with a few craniofacial structures. The OP1 had a low negative relationship with the maxillary anteroposterior position (N-Aperp) (r: -0.289) (P < 0.05). The OP2 had a low negative relationship with the palatal plane angle (FH/PP) (r: -0.291) (P < 0.01) but had a positive relationship with the cranial base angle (BSN) (r: 0.304) (P < 0.01) and posterior facial height (SGo) (r: 0.299) (P < 0.01). CONCLUSIONS: Ocular protrusion distances did not differ by sex, maxillary anteroposterior position, and amount of mandibular plane angle and showed weak correlation with a few craniofacial structures. Ocular protrusion amounts can be used for diagnosis and treatment plan in craniofacial syndromic or nonsyndromic anomalies.

A Novel Stitching Technique: Adjustable Closed-Loop Sewing Machine Lock Stitching Technique to Bend or Unbend Cartilages.

This study aimed to evaluate the effect of a novel adjustable, closed-loop sewing machine lock stitching technique on cartilage shape. This study was performed on 18 rabbits that were divided into 3 groups to evaluate the short- (Group I), medium- (Group II), and long-term (Group III) effects of the technique on cartilage shape. Three cartilage grafts were obtained from the right and left ears of the rabbits and measured angularly. For the cartilage grafts obtained from the right ears, contours were corrected using the stitching technique proposed herein. The cartilage grafts obtained from the left ears were not stitched; these were maintained as the control group. Angular measurements were performed for the stitched cartilage grafts, and all the cartilages grafts obtained were finally embedded into the rabbits' backs. The rabbits in Groups I, II, and III were euthanized at week 2, 6, and 12, respectively, after which the cartilages were reevaluated for angular measurement and submitted for histopathological examination. A significant improvement from baseline was detected in the angular measurements of the stitched cartilage grafts obtained from the rabbits in each group. For the stitched cartilage grafts obtained from Group II and III rabbits, the angular measurements obtained immediately after stitching were found to be better than those obtained after euthanasia. In histopathological evaluation elevated collagen, perichondrium, and connective tissue levels were detected in grafts obtained from Group III rabbits. The novel stitching technique proposed herein appears to have beneficial long-term effects on the maintenance of cartilage contour.

Treatment Approach to Severe Microgenia Cases: Combined Use of Osseous and Implant Genioplasty.

INTRODUCTION: As well as the chin is an important esthetic unit of the facial structure, it is also the region having a key role in the appearance of the face. Correction of cosmetic and functional deformities that may occur in this region because of serious hypoplasia (microgenia) is performed by chin augmentation. Chin augmentation is most frequently performed via implant or osseous genioplasty in the literature. Both 2 techniques have their own advantages and disadvantages. In the literature, various studies comparing these 2 techniques and their long-term results are present, but in some severe microgenia cases, these techniques can be insufficient only for augmentation. In such cases, combined use of implant and osseous genioplasty techniques can come up and data and experiences regarding such combined uses are limited in the literature. In our study, we aim to report our experiences and long-term results regarding 3 cases to whom chin augmentation combined with implant and osseous method is applied because of serious chin hypoplasia (microgenia). METHOD: Three patients to whom chin augmentation combined with osseous and implant genioplasty was applied because of severe microgenia between 2011 and 2016 are included in our study. Before the chin restoration, orthognathic surgery or maxillomandibular distraction applications owing to existing obstructive sleep apnea, malocclusion, or facial asymmetry, are performed in the patients. In preoperative period, chin augmentation amount required is planned for all the patients via cephalometric analysis and the operations of all the patients are performed under general anesthesia via intraoral access. RESULTS: Among 3 patients, 2 were male and 1 was female and their mean age was 27.3 years (22-33). In all the patients, primarily horizontal subapical sliding osteotomy was performed and advancement was performed. After osteotomy, mean 8-mm osseous advancement was obtained and Medpor implant was placed in the chin at the same session for additional augmentation. Mean advancement amount obtained by the Medpor implants was 9 mm. A total average of 17-mm augmentation was obtained in the patients via osseous and implant genioplasty. The reflection of this advancement amount on the soft tissue was measured as 13 mm. Mean follow-up period is 24 months and the patients did not encounter with a major complication in the postoperative period. In the postoperative period, early-period band application was performed at the chin of the patients to reduce edema and to support immobilization. CONCLUSIONS: Chin contour is an important part of facial aesthetics and osseous genioplasty is the ideal treatment option for the correction of most chin deformities. However, in some serious microgenia cases, osseous genioplasty may be insufficient to correct the existing deformity. In such cases, it is seen that the combined correction procedures to be applied together with the implant use can be applicable in terms of the safety and its long-term results.

The Effect of Albumin and Platelet-Poor Plasma Supplemented Botulinum A Toxin on Bioavaliability: An Experimental Rabbit Model.

Today, botulinum toxin is commonly used for cosmetic purposes throughout the world. Despite various agents reducing the efficiency of toxin are well defined, the studies related to increasing the bioavailability are limited. The purpose of our study is to assess the effect of the preparation of toxin by diluting with platelet-poor plasma (PPP) and/or albumin instead of standard dilution (saline) on bioavailability in cosmetic-purpose botulinum toxin applications.In the study, 24 New Zealand rabbits were used. Right anterior auricular muscle was preferred for toxin injections. Subjects were divided in 4 groups and in every group; botulinum A toxin (BTxA) that was prepared by different dilution methods was injected. 2.5 U saline-diluted BTxA was injected to the subjects in group 1, 2.5 U ready-to-use rabbit albumin-diluted BTxA was injected to group 2 and 2.5 U autologous PPP-diluted BTxA was injected to group 3 and pure saline was injected to group 4.Before the injection (0th week) and in the second, sixth, and 12th weeks after the injection, visual and electroneuromyographic evaluations of the ears of the subjects were performed.In the second week, median amplitude levels in group 2 were significantly found lower than other groups.In the sixth week, median amplitude levels in group 1 were significantly found lower than other groups.In 12th week, no significant difference was found among all the groups in terms of median amplitude levels.Visual findings were also correlated with electroneuromyographic findings.It was observed that the dilution of BTxA with albumin had caused a stronger paralysis when compared to dilution with saline or PPP at the beginning (second week); however, in the following weeks (sixth week), it was seen that dilution with saline had maintained paralysis better when compared with other dilution methods.In cosmetic BTxA applications, dilution of the toxin with albumin or PPP instead of standard dilution has no positive effect on bioavailability and such modifications regarding this kind of dilution are found unsuitable. Further studies are needed to directly relate the results with clinical applications.