Perception of Nasal Aesthetics: Nose or Face?

BACKGROUND: Aesthetic assessment of the nose might not be limited to the nose as an isolated facial unit but might be the result of a broader perception of the whole facial image. The aim of this study was to investigate if the aesthetic evaluation of a nose is made by sole observation of the nose or influenced by the other features of the face. METHODS: Nose and face photographs of 20 voluntary models were taken from five different angles and merged into a single image of just the noses and whole faces of each model. First the nose and then the face photos were sent to a reviewer group consisting of 100 individuals from different professions to evaluate the nose's beauty on standard questionnaires with a four-week interval to complicate the recall process. RESULTS: Aesthetic evaluation of the isolated nose (Group 1) and the nose with the whole face (Group 2) were compared through Visual Analog Scale (VAS) scores ranging from 1 to 10 (1: the least, 10: the highest). The mean VAS score of the Whole Face Group (5.26 ± 1.28) was significantly higher than the score of the Isolated Nose Group (4.50 ± 1.32) (p 0.001). There was no significant difference between the scores of reviewers considering their gender, profession, or experience of having an aesthetic operation previously. CONCLUSION: Current study revealed that in the evaluation of the beauty of the nose, the holistic perception of the face is as important as the perfection of the angles and proportions within the nose itself. 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 .

The Efficacy of Hydrodilatation for the Prevention of Vasospasm following Microsurgical Anastomosis.

BACKGROUND: Vasospasm is a major problem following microsurgical reconstruction which can result in the partial or complete loss of the flap tissue. The aim of this study was to investigate the efficiency of hydrodilatation for the prevention of vasospasm. METHODS: Thirty male Wistar rats were used for this experimental study. Femoral arteries of were exposed, photographed, and transected. In group 1, group 2, and group 3 papaverine solution, hydrodilatation, and minimal mechanical dilatation (control group) was performed, respectively. The anastomosis was completed and the arteries were photographed again 10 minutes after completion of the anastomosis. Following 7-day period samples for transmission electron microscopy (TEM) and light microscopy were obtained. RESULTS: The mean vessel diameters prior to transection were 0.43, 0.45, and 0.52 mm in the papaverine, hydrodilatation, and control groups, respectively. The mean vessel diameter 10 minutes following the completion of anastomosis was 0.76, 0.75, and 0.51 mm in the papaverine, hydrodilatation, and control groups, respectively. Median score for papaverine group regarding histological parameters of regular endothelial lining and lumen, neutrophil infiltration, vascular congestion, and edema in tunica adventitia was 2, 3, 2, and 3 positive, respectively. Median score for the papaverine group regarding histological parameters of regular endothelial lining and lumen, neutrophil infiltration, vascular congestion, and edema in tunica adventitia was 3, 3, 3, and 3 positive, respectively. All the histological scores were negative in the control group. The difference between the control group and the experiment groups 1 and 2 was significant regarding all four histological parameters (p < 0.05). CONCLUSION: Hydrodilatation and papaverine application were both effective in preventing vasospasm following microsurgical intervention but papaverine caused slightly less damage to the endothelial lining and less edema in the tunica adventitia when compared with the hydrodilatation. Hydrodilatation group showed a vasodilatory effect that was statistically similar to that of papaverine, which has a proven efficacy.

Soft Tissue Thickness Variations of the Nose: A Radiological Study.

BACKGROUND: Soft tissue thickness (STT) is a major factor affecting the outcome in rhinoplasty. However, limited information is found in the literature on the age- and gender-related variations of the nasal STT. OBJECTIVES: The purpose of this study was to measure STT at various landmarks over the nasal framework and compare the age- and gender-related differences. METHODS: STT measurements were made at 11 landmarks in 325 patients by employing magnetic resonance imaging. Patients were divided into subgroups to compare the STT differences between female and male and between the age groups as young, middle age, and elderly. RESULTS: Soft tissue was thickest at the nasion and thinnest at the rhinion. The soft tissue coverage was significantly thicker in the male population at the supratip, tip, nasal bones, upper lateral cartilages, and alar lobules, whereas it is thicker in females at the rhinion. Average thickness of the soft tissues over the entire nasal framework increases with age except the rhinion. CONCLUSIONS: The STT is variable over different parts of the osteocartilaginous framework. Gender and age influence the STT. The soft tissue is thicker at the distal half of the nose in male patients, and these areas become gradually thicker with age, whereas the soft tissue over the midvault becomes thinner. Increasing age presents a particular challenge to achieve predictable results in rhinoplasty, and an understanding of the soft tissue envelope allows for improved aesthetic outcome.

Margin-Controlled, Staged Surgical Excision in the Treatment of High-Risk Basal Cell Carcinomas of the Head and Neck Region.

BACKGROUND: The most common skin cancer is basal cell carcinoma (BCC), and the gold-standard treatment for high-risk tumours is Mohs surgery. However, alternative methods are needed for high-risk tumours in countries where the performance rate of Mohs surgery is low. OBJECTIVES: The objective of this article is to investigate the feasibility, efficacy, and safety of margin-controlled, staged surgical excision (MCSSE) in high-risk tumours as a possible treatment alternative. METHODS: A retrospective cohort study, including patients diagnosed with high-risk BCC in the head and neck region and treated with MCSSE between 2003 and 2010, was conducted. RESULTS: During the study period 50 tumours in 47 patients were treated, with low adverse event rates and high patient satisfaction rates. Of the 50 tumours, 1 recurred at the 12-month follow-up. CONCLUSIONS: Despite the small sample size and relatively short follow-up period, the present study shows that MCSSE might be a feasible alternative for the treatment of high-risk BCCs in institutions where Mohs surgery is not performed. Future studies on long-term recurrence rates are needed.

Transection of the Nasal Base Muscles for the Correction of Plunging Tip: An Outcome Analysis.

BACKGROUND: The plunging-tip deformity has been attributed to the combined actions of nasal base muscles. However, there are no quantitative data in the literature to discuss the effect of muscle transections on the clinical outcome. OBJECTIVES: This study was designed to assess the actions of the nasal tip, nasal base, and upper lip in patients with plunging-tip deformity and to compare their preoperative and postoperative activities following multiple myotomies. METHODS: Patients were treated for nasal base animation deformity by the transection of the depressor septi nasalis, myrtiformis, nasalis, and levator labii superior alaeque nasi muscles. The profile views of preoperative and 12 months postoperative photographs were selected for measurements. Rest and smile images were overlaid to achieve alignment, and movements were measured with reference to the Frankfurt horizontal plane. RESULTS: Twenty-seven (27) patients were included in the study. Movements of the nasal tip and nasal base were significantly reduced postoperatively. The upper lip shortened significantly in smile poses postoperatively compared with preoperative measurements. The change in the tip angle during animation significantly decreased in the postoperative measurements. CONCLUSIONS: Movements of the nasal tip and the alar base contributed significantly to the hyperdynamic nasal tip deformity. Transection of the nasal base muscles is an effective treatment method with a weaker recovery of the muscle function in the long term. Dynamic upper lip shortening is an unexpected finding following surgery and should be investigated further.

Outcome After Breast Reduction Considering Body Mass Index and Resection Amount.

BACKGROUND: It is presumed that breast reduction improves patients' quality of life and promotes weight loss. Preoperative body mass index (BMI) and the amount of breast tissue (breast reduction amount [BRA]) in proportion to the patient's body weight are important variables to affect the breast reduction outcome. OBJECTIVE: This study was designed to evaluate the short and long-term effects of breast reduction from the perspective of BMI and BRA. METHODS: One hundred fifty-seven consecutive patients were invited to participate in the study. All clinical information was recorded on a breast surgery form. Patients completed a standardized questionnaire preoperatively, at postoperative year 1, and after postoperative year 5. Patients were grouped according to their BMI as "normal weight" and "overweight" and according to BRA as "minor/moderate reductions" and "major reductions." The differences in the BMI values and the life scores were compared between the BMI and BRA groups. RESULTS: Sixty-four patients were included in the study. Postoperative year 1 BMIs were significantly lower than both the preoperative BMIs and postoperative year 5+ BMIs. The year 1 BMI decrease in the major reduction group was higher than the decrease in the minor/moderate reduction group. The postoperative life scores of all subgroups were better than the preoperative life scores. CONCLUSIONS: Reduction mammaplasty has a significant effect on short-term weight loss and the improvement in lifestyle. Patients tend to return to their original body weight in the long term. BRA is a significant variable in short-term weight loss, but neither BMI nor BRA has any other significant effect on the outcome in any time section. LEVEL OF EVIDENCE: 4.

The role of botulinum toxin type a-induced motor endplates after peripheral nerve repair.

INTRODUCTION: The aim of this study was to test the hypothesis that the increased number of new motor endplates induced by botulinum toxin type A (BTX-A) injection before nerve injury would be reinnervated after nerve repair, resulting in greater force generation. METHODS: Thirty male Wistar rats were divided randomly into 3 groups: (1) controls; (2) a group with saline solution injection; and (3) a group with BTX-A injection into gastrocnemius muscle (BTX group). Thirty-six days after the injections the left sciatic nerve was divided and coapted in all groups. Eight weeks later, muscle forces were measured, and histological samples were collected. RESULTS: No differences in the number of innervated endplates were found between the groups, but the number of denervated endplates was higher in the BTX group, as was the muscle tissue degeneration score. The BTX group showed distal muscle force measurements of up to 25.8% less compared with the control group. CONCLUSION: Although BTX-A injection increases the number of motor endplates, they are not functional.

Comparison of bone prefabrication with vascularized periosteal flaps, hydroxyapatite, and bioactive glass in rats.

BACKGROUND: Periosteal flaps possess osteoprogenitor cells and an osteoinductive potential that can be further augmented by combination with a biodegradable scaffold; therefore, various osteoconductive and osteostimulative biomaterials are frequently combined with periosteal flaps in studies of bone prefabrication. An experimental study was designed to determine and compare the contribution of bioactive glass and hydroxyapatite to osteoneogenesis in rats when combined with a periosteal flap. MATERIALS AND METHODS: In 60 Sprague Dawley rats, saphenous artery periosto-fasciocutaneous island flaps were transposed to abdomen. In group 1, the flap was left alone, in group 2, an empty artificial pocket made of Gore-Tex (W. L. Gore & Associates, Inc.; Flagstaff, AZ) was sutured onto the periosteal layer, and in groups 3 and 4, the pocket was filled with bioactive glass and hydroxyapatite, respectively. Following sampling for histological analysis, a 4-point scoring system was used to grade inflammatory cell infiltration, osteogenesis, angiogenesis, and cell migration into the bioactive material. RESULTS: The combination of the periosteal flap with any of the bioactive materials resulted in significantly higher percentages of animals exhibiting osteogenesis (80% in hydroxyapatite group and 93.3% in the bioactive glass group; p = 0.0000528) and angiogenesis. Comparison of the bioactive material groups revealed that a significantly higher proportion of animals in the bioactive glass group exhibited moderate or severe inflammation (80 vs. 20%; p = 0.002814). CONCLUSION: Periosteal flaps prefabricated with hydroxyapatite or bioactive glass in rats exhibit osteogenic capacities that are not dependent on direct bone contact or proximity to vascular bony tissue. The innate capacity of the periosteal flap when utilized alone for osteoneogenesis was found to be rather insufficient.

Flap survival after previous vascular pedicle division and preexisting scar formation at the pedicle site: an experimental study.

BACKGROUND: We conducted an experimental study to investigate if it would be possible to re-elevate a flap at a standard flap site if its vascular pedicle was mutilated previously and there was a preexisting scar formation at the pedicle site. MATERIALS AND METHODS: Thirty-five male Sprague-Dawley rats were divided into 3 groups. In the control group (n = 5), animals received a procedure in which unilateral axial pattern abdominal flap was elevated, and then sutured to its original place. The remaining 2 groups underwent 2-stage procedures. In the first stage, scar tissue was created with either a skin incision (group 2, n = 15) or excision (group 3, n = 15) at the prospective pedicle site of the abdominal flap. In the second stage, abdominal flap was raised in 5 rats as a scar-pedicled flap at day 7, day 21, and day 42. Flaps were sutured in their places. Seven days later, flap survival was evaluated. RESULTS: Control flaps had complete survival (day 7, 95.5%; day 21, 94.8%; and day 42, 94.5%). Group 2 and group 3 flaps raised on day 7 (group 2, 65.4%; group 3, 63.9%) and on day 21 (group 2, 65.7%; group 3, 66.7%) showed decreased survival compared to control group flaps (P < 0.05). On day 42, group 1 flaps had better survival when compared to group 2 flaps (82.6% vs 70.0%, P < 0.05). Group 1 flaps showed progressive vascular network formation as evidenced by contrast medium first in the proximal two thirds of the flaps on day 7, and later via visualization of the axial pattern vascular tree on day 42. In group 3, approximately half of the flap was filled with barium contrast and no single pedicle was identified on day 42. CONCLUSIONS: Preexisting scar tissue and pedicle division in the pedicle site of a standard flap diminished dimensions of surviving flap when compared to control flaps. Incision-scar-pedicled flaps achieved better survival compared to excision-group flaps, particularly in the late postoperative period. The study findings showed that it may be possible to raise a flap from previously mutilated site secondary to scar formation and pedicle injury.

Surgical management of a congenital panda nevus with preexpanded triple forehead flaps and temporal island flap.

Congenital panda nevus or the divided nevus of the eyelids is a rare form of melanocytic nevus involving both upper and lower eyelids with the risk of future malignant transformation along with the patients' complaints about the cosmetic appearance. Delicate anatomic features of the eyelids and the limited skin redundancy of the periorbital region make the surgical removal and reconstruction difficult, even in mild cases with partial involvement of the eyelids. A case of congenital panda nevus involving upper and lower eyelids, the eyebrow, and part of the malar eminence and the nasal dorsum is presented. A multistaged surgical management of the lesion with staged excision and reconstruction with preexpanded forehead flaps, temporal island flap, and skin grafts is discussed.

A new experimental flap design: the saphenous artery periosto-fasciocutaneous flap of the rat.

Vascularized periosteal graft is a frequently applied flap model for bone prefabrication studies due to its inhabitance of osteoprogenitor cells and osteoinductive potential. Various bones such as rib and fibula are reported as a potential source for the harvest of the periosteal flap in experimental studies on higher species such as dogs and pigs, which necessitates a rather complicated and expensive experimental setting. Therefore a reliable and inexpensive small animal model on vascularized periosteal flaps is necessary for future research. A new saphenous artery based periosto-fasciocutaneous flap model in rats is described here, which is easily dissected and monitorized. In this experimental study, 15 male Sprague Dawley rats were operated and killed following a 3-month-long follow-up period . The histological analysis revealed heterotopic osteoneogenesis in 12 of 15 flaps (80%), whereas 14 flaps (93.3%) exhibited signs of angioneogenesis originating from the periostofasciocutaneous flap. The presented flap model promises to be an appropriate alternative for new studies where bone prefabrication methods are evaluated.

The central pillar technique: a new septum-based pedicle design for reduction mammaplasty.

BACKGROUND: Successful breast reduction involves remodeling the breast parenchyma and creating a pedicle to maintain blood supply to the nipple-areola complex (NAC). Although vascular compromise is generally venous in breast reduction surgery, clear anatomical descriptions of the breast veins are lacking in textbooks. OBJECTIVES: The author designed an NAC flap based on arterial and venous territories defined in a cadaver study and subsequently assessed the technique in a series of live patients. METHODS: Dynamic venous angiography was performed on hemithorax specimens from 6 fresh female cadavers. A new septum-based pedicle (the "central pillar") was designed, which protected the periareolar vein polygon along with the breast septum. Sixty-seven patients underwent breast reduction with this technique between 2005 and 2010. RESULTS: The patients were followed for an average of 26.4 months. Sixty-two of the 67 patients underwent bilateral reduction. The average reduction in tissue per breast was 910.7 g (range, 440-1935 g), and the average nipple transposition was 9.6 cm (range, 6-17 cm). The most common complications were delayed healing of the vertical "puckered" suture line (16 patients), seroma (7 patients), hematoma (2 patients), and unilateral deepithelialization of the NAC following transient venous congestion (2 patients). The patient satisfaction rate was high. CONCLUSIONS: The central pillar technique is a promising alternative for young patients with glandular breasts that require gross reduction and high-transposition NAC, who are not good candidates for the "free nipple graft" technique.

Sternocleidomastoid region restoration with lateral hemisoleus muscle incorporatied in free fibular flap for reconstruction of radical neck dissection and hemimandibulectomy.

In the treatment of head and neck carcinoma, radical cervical lymphadenectomy leaves the affected side of the neck devoid of the sternocleidomastoid muscle, thus more vulnerable to the unwanted side effects of the adjuvant radiotherapy. It also causes asymmetry and cosmetically unpleasant appearance of the cervical region. In the reported case with widely ulcerated squamous-cell carcinoma over mandible, hemimandibulectomy and radical neck dissection was performed. Following the mandibular reconstruction, the lateral hemisoleus muscle of the harvested osteomyocutaneous fibula flap was utilized to restore the ipsilateral sternocleidomastoid region. This new application promises to be a useful method, which can aid in the restoration of the aesthetic contour of the neck and provide protection against unwanted effects of the adjuvant radiotherapy on the ipsilateral carotid artery.

Isolated plexiform neurofibroma of the tongue.

A very rare case of isolated plexiform neurofibroma with a painless enlarging mass of the tongue of a 5-year-old girl is presented. This rare benign tumor has the potential for malignant transformation, and the diagnosis was difficult owing to the patient's age and to the insidious clinical presentation.

Microvascular reconstruction of composite cranial defects.

Microvascular reconstruction of composite cranium defects is challenging, and operative planning differs in various anatomic regions of the cranium. The aim of this article is to detail surgical strategies for microvascular reconstruction in different areas of the cranium. Fifty-eight free tissue transfers were performed in 54 patients with composite cranial defects between 1995 and 2009. The cranium was divided into six zones to classify the defects. Data on patient demographics, location and cause of the defects, technical details of surgical management, and complications were analyzed. Defects were secondary to ablative procedures in 45 patients. Eight patients had posttraumatic defects, and one patient had congenital defect. Nine different flap types were used in the series. Choice of recipient vessels and the use of interpositional vein grafts varied according to the site of the cranial defects. Microsurgical reconstruction of cranial defects can be performed safely with predictable outcome by methodic assessment of the problem and by careful attention to the details of the reconstructive plan. In this article, valid conclusions on the planning of microvascular reconstruction in different areas of the cranium have been determined.

Aberrant perfusion of the serratus anterior muscle flap: report of two cases and a review of the literature.

Free serratus anterior muscle flap, classified as Mathes-Nahai type III, is a versatile and frequently preferred choice for soft tissue coverage of small to moderate-sized defects owing to its reliable circulation pattern; however, some anatomic variations in the flap vascularity can result in partial flap loss. Here we present two cases with free serratus anterior muscle transfer where the distalmost portion of the flap was not perfused by the thoracodorsal pedicle. The most likely explanation seems to be the large flap size and the lack of distal interconnections between lateral thoracic artery and thoracodorsal artery branches. Our clinical experience suggests that anatomic variations of serratus anterior muscle circulation might end up with distal perfusion loss if a large flap is to be harvested.

Comparison of contraction rates of epigastric and extended dorsal island skin flaps in rats.

Flap surgery is a wide field in plastic and reconstructive surgery practice and experimental research is needed to improve surgical success. These research is often performed on rats. Rat is a loose-skinned animal and contraction of skin flaps on rats is an underestimated condition. Besides this variable contraction of survived and necrotic tissues may mislead calculations and results. In this study, contraction patterns of epigastric and dorsal island skin flaps were investigated to identify this phenomenon. Forty-two male Sprague-Dawley rats were divided into four groups. Eleven epigastric flaps with unilateral pedicles, 11 epigastric flaps with bilateral pedicles, 10 extended dorsal island skin flaps with unilateral pedicles, and 10 extended dorsal island skin flaps with bilateral pedicles were prepared. Total, necrotic and viable flap areas were calculated from standardized photographs which were taken daily. The animals were placed on marked papers and image processing software was used the calculate flap areas from the photographs. Respect to these daily flap areas, the contraction rates in epigastric flaps were highly significant. The area loss in necrotic tissues were faster than the viable areas. Compared to the epigastric flaps, the contraction was not significant in extended dorsal island skin flaps flap groups. In conclusion, the rat extended dorsal island skin flap is a more reliable model for experimental flap research, which is resistant to contraction, when compared to the epigastric skin flap model.