Biomechanical properties of superficial musculoaponeurotic system tissue with vs without reinforcement with poly-4-hydroxybutyric acid absorbable mesh.

IMPORTANCE It is unknown whether poly-4-hydroxybutyric acid (P4HB)-reinforced superficial musculoaponeurotic system tissue (SMAS) plication techniques will support SMAS imbrication and plication and potentially improve outcomes in rhytidectomy. OBJECTIVES To evaluate the biomechanical properties (tissue breaking strength, suture tearing force, and stress relaxation) of the SMAS with vs without reinforcement with P4HB absorbable mesh and to correlate these results with potential clinical applications. DESIGN, SETTING, AND SAMPLES In a cadaver study at an academic setting, 12 fresh frozen cadaver heads were used. Rhytidectomy incisions were made, and the SMAS was harvested and prepared for strength and stress testing using an Instron device. MAIN OUTCOMES AND MEASURES Tissue breaking strength and suture tearing force were analyzed. Stress relaxation test results were also assessed. The results of the SMAS samples alone were compared with those reinforced with P4HB absorbable mesh. RESULTS Overall, there were significant differences noted in tissue breaking strength and suture tearing force between the 2 groups. When the SMAS was reinforced with absorbable mesh, significant improvements were observed in tissue breaking strength (P < .001) and suture tearing force (P < .003). In addition, less variability was demonstrated in the maximum tensile load-bearing quality of the SMAS when the repair was reinforced with P4HB. CONCLUSIONS AND RELEVANCE Reinforcement with P4HB absorbable mesh improves tissue breaking strength and suture tearing force in cadaveric SMAS. It also reduces the variability in load vs displacement seen among samples tested. These data suggest that P4HB-reinforced SMAS imbrication would support higher loads and provide more consistent, long-lasting SMAS support among patients undergoing rhytidectomy. Further studies are needed to correlate these data with clinical outcomes in rhytidectomy.

Contemporary review of rhinoplasty.

We conducted a contemporary review covering advances and trends in primary and functional rhinoplasty as published during the past decade. Specifically, we reviewed studies supporting the evidence for functional rhinoplasty, nasal valve surgery, and septal reconstruction. In addition, key articles discussing cephalic malpositioning of the lower lateral cartilages and tip contouring are reviewed. We also report studies involving lateral osteotomy techniques, computer imaging, and the use of homologous, alloplastic, and absorbable implants. When appropriate, we review outcomes data from key studies because these data are becoming increasingly important for evidence-based medicine, physician grading, and procedure reimbursement. Using evidence-based approaches whenever possible will help to ensure predictable patient outcomes.

Forehead lifting: state of the art.

Forehead lifting serves to restore a more youthful appearance as well as a more functional and aesthetically pleasing brow position. The purpose of this review is to describe the pertinent anatomy and forehead aesthetics, then to discuss the patient evaluation, surgical approaches, complications, and nonsurgical adjuncts. Anatomic features reviewed include the layers of the forehead and scalp, blood supply, innervation, musculature, and the temporal branch of the facial nerve anatomy. Forehead aesthetics described include the aging process, with its contributing factors and consequences, and the ideal brow position in women and men. Key aspects of the patient evaluation include assessment of skin type; ptosis; hairline, brow, and lid position; symmetry; and bony contours. Pertinent past medical/surgical history as well as family history are reviewed, and the need for ophthalmology evaluation is discussed. Surgical indications and approaches, including direct, coronal, mid-forehead, endoscopic, and trans-blepharoplasty, are reviewed. The advantages and disadvantages of each approach are discussed and techniques briefly described. Complications are mentioned, and the article concludes with a review of nonsurgical adjuncts.

Evaluating revascularization and flap survival using vascular endothelial growth factor in an irradiated rat model.

OBJECTIVE: To evaluate the role of vascular endothelial growth factor (VEGF) plasmid DNA (pDNA) in improving flap revascularization in a previously developed rat model. Our hypothesis was that the uptake and expression of VEGF pDNA in the wound bed would improve revascularization and flap viability. DESIGN: Twenty-eight male Sprague-Dawley rats received a total dose of 40 Gy electron beam radiation to the ventral abdominal wall. After a recovery period, they underwent a ventral fasciocutaneous flap procedure with a 2-hour ischemia period. Group 1 (n = 14) received topical VEGF pDNA, in vivo cationic polymer, and fibrin sealant. Group 2 (n = 14) received topical cationic polymer and fibrin sealant only. Seven of the rats from each group underwent pedicle ligation at 8 or 14 days. The primary outcome measure was percentage of flap revascularization 5 days after pedicle ligation. RESULTS: Rats receiving VEGF pDNA had a significantly higher rate of flap revascularization (90.8% vs 79.8%) after pedicle ligation at 14 days (P = .045). At 8 days, rats receiving VEGF pDNA (group 1) had an increased rate of flap revascularization (58.2% vs 42.8%) that approached significance (P = .11). CONCLUSION: This study demonstrates the potential of VEGF pDNA to improve revascularization and flap viability in previously irradiated tissue.

Methicillin-resistant Staphylococcus aureus infection in septorhinoplasty.

OBJECTIVES: Review the literature on methicillin-resistant Staphylococcus aureus (MRSA) infection following septorhinoplasty, identify patient groups at risk for MRSA complications following septorhinoplasty, and evaluate the need for antibiotic prophylaxis in these patients. DISCUSSION: Patients who are susceptible to MRSA infections may also be at higher risk for nasal colonization, and this includes elderly patients, patients recently hospitalized or treated in a rehabilitation center, and healthcare workers. Few cases of MRSA infection following septorhinoplasty have been reported in the literature. Prevention of nosocomial and postsurgical MRSA infections has been well studied, and it seems that elimination of nasal colonization is a major step in preventing these infections. CONCLUSIONS: Patients at increased risk for MRSA colonization should be screened prior to septorhinoplasty and if positive treated with antibiotic prophylaxis consisting of elimination of nasal carriage prior to surgery. Perioperative systemic antibiotic use should be considered, especially in revision cases.

Development of an irradiated rodent model to study flap revascularization.

OBJECTIVE: To develop a reproducible free-flap animal model to study the effects of irradiation on flap revascularization. DESIGN: After institutional animal care and use committee review and approval, 16 Sprague-Dawley rats were subjected to either 23- or 40-Gy electron beam irradiation to their ventral abdominal wall. After a recovery period, the animals then underwent a ventral fasciocutaneous flap pedicled on the inferior epigastric vessels with subsequent pedicle ligation at 10 days. An additional 16 rats were subjected to 40 Gy of irradiation and underwent pedicle ligation at 8 or 14 days postoperatively to determine if time to pedicle ligation affected percentage of flap viability. RESULTS: Rats receiving 23 Gy of irradiation had the same viability as rats undergoing no radiation. Rats receiving 40 Gy of irradiation had a significantly lower average percentage of flap viability (56.9%) than animals receiving 23 Gy (90.9%) (P < .001). Furthermore, the longer duration until pedicle ligation after 40 Gy of irradiation led to significant increases in flap viability (P < .001 for analysis of variance). CONCLUSIONS: This animal model establishes that external beam irradiation at a total dose of 40 Gy leads to significantly delayed flap revascularization over time compared with 23-Gy irradiation. This model will allow future investigators to study novel therapies to improve healing and flap revascularization.

Options for the management of forehead and scalp defects.

Forehead and scalp reconstruction comprises a diverse and complex set of defects. Repair must be performed with minimal disturbance to surrounding structures, such as the eyelid, eyebrow, and hairline. Care must be taken to maintain symmetry between sides. This article addresses the options for the management of forehead and scalp defects, including secondary intention healing, skin grafting, local flaps, free flaps, tissue expansion, and negative pressure treatment. When possible, special consideration is given to addressing the advantages and disadvantages of each repair option, while providing a framework from which to plan scalp and forehead reconstruction.

Laboratory versus portable sleep studies: a meta-analysis.

OBJECTIVE: The objective of this meta-analysis study was to compare the accuracy of home sleep studies with laboratory polysomnography in the diagnosis of obstructive sleep apnea (OSA). METHODS: Eligible studies included prospective cohort studies of portable and in-laboratory sleep studies performed on the same groups of patients. A comparison of respiratory disturbance index (RDI), mean low oxygen saturation levels, sleep time, rate of inadequate studies, and average cost per examination was made between portable and in-laboratory sleep studies. A total of 18 papers were identified in two independent Medline searches. RESULTS: RDI values on portable sleep studies were 10% lower on average compared with laboratory studies (odds ratio [OR], 0.90; 95% confidence interval [CI], 0.87-0.92). There was no significant difference in the mean low oxygen saturation on portable versus laboratory studies (OR, 1.0; 95% CI, 0.94-1.10). Recorded sleep time was significantly higher by 13% for laboratory compared with portable studies (OR, 0.87; 95% CI, 0.86-0.89), and portable studies were significantly more likely to give a poor recording when compared with laboratory examinations (P = .0001). The cost of home studies ranged from 35% to 88% lower than laboratory studies across a number of countries. CONCLUSION: Home sleep studies provide similar diagnostic information to laboratory polysomnograms in the evaluation of sleep-disordered breathing but may underestimate sleep apnea severity. The lower cost of home sleep studies makes it a viable screening tool for patients with suspected OSA; however, these lower costs are partially offset by the higher rate of inadequate examinations.