Four-step medial thighplasty: refined and reproducible.

BACKGROUND: The medial thigh remains a troublesome region for body contouring in both the aging patient and in the massive weight loss patient. Liposuction-assisted medial thighplasty is the next step in the series of medial thigh contouring refinements to improve complications and outcomes. METHODS: Forty-five patients are presented who underwent medial thigh contouring with liposuction-assisted medial thighplasty. After anatomical analysis of the medial thigh, noting skin and fat redundancy, patients were selected for either an upper/inner medial thighplasty or an extended medial thighplasty. Operative markings, liposuction, and the excisional technique are presented with intraoperative video footage. RESULTS: Twenty-nine patients (64 percent) presented with aging thigh lipodystrophy, whereas 16 patients (36 percent) were massive weight loss lipodystrophy patients. The patients' ages ranged from 30 to 67 years, with 0.5 month to 9.5 years of follow-up. Liposuction evacuation volumes ranged from 175 to 1950 ml per thigh. Ten patients had minor wound breakdown, which healed with conservative wound care. CONCLUSIONS: Liposuction-assisted medial thighplasty is a safe, efficient, and reproducible procedure that should follow a four-step algorithm: (1) L-shaped anterior markings, (2) superwet infiltration, (3) circumferential combined superficial ultrasound-assisted/suction-assisted liposuction, and (4) predesigned and patterned skin excision and layered closure. It simplifies the markings and resection, and the procedure preserves the lymphatics and nerves, minimizes blood loss, and maintains the saphenous vein system to prevent skin loss and wound breakdown. It produces reliable and predictable results, with optimal outcomes. This technique offers another refinement in the evolution of medial thigh contouring.

Propranolol induces regression of hemangioma cells through HIF-1α-mediated inhibition of VEGF-A.

OBJECTIVE: To investigate the mechanism of propranolol on regression of infantile hemangiomas. BACKGROUND: Propranolol has been found to be effective in treatment of severe hemangiomas of infancy. However, its mechanism of action is as yet unknown. METHODS: Cultured proliferating and involuting hemangioma endothelial cells were treated with varying concentrations of propranolol for up to 4 days. Analysis was performed using cell viability, migration, and tubulogenesis assays, as well as quantitative RT-PCR and flow cytometry. Western blots and ELISA assays were used to assess protein expression. RESULTS: Treatment with propranolol led to a dose dependent cytotoxic effect in hemangioma endothelial cells with decreased cell viability, migration, and tubulogenesis. This cytotoxic effect was VEGF (vascular endothelial growth factor) dependent, as demonstrated by decreased VEGF, VEGF-R1, and VEGF-R2 production. Decreased signaling through the VEGF pathway resulted in downregulation of PI3/Akt and p38/MAPK activity. Decreased VEGF activity was mediated through the hypoxia inducible factor (HIF)-1α pathway but not through NF-κß signaling. CONCLUSIONS: Collectively, these data suggest that propranolol exerts its suppressive effects on hemangiomas through the HIF-1α-VEGF-A angiogenesis axis, with effects mediated through the PI3/Akt and p38/MAPK pathways. These findings provide a plausible mechanism of action of propranolol on regression of infantile hemangiomas.

A comparison of outcome of surgical treatment of migraine headaches using a constellation of symptoms versus botulinum toxin type A to identify the trigger sites.

BACKGROUND: This study was designed to assess whether preoperative trigger-site confirmation using botulinum toxin type A injections significantly improved migraine surgery outcomes. METHODS: The medical charts of 335 migraine surgery patients were reviewed. Patients who received stepwise diagnostic botulinum toxin type A injections were placed in the botulinum toxin type A group (n = 245). Patients who did not receive botulinum toxin type A or received only therapeutic botulinum toxin type A were placed in the control group (n = 90). The preoperative and 12-month postoperative migraine headache frequency, duration, and intensity were compared to determine the success of the operations. RESULTS: Seventy-two of 90 control patients (80 percent) experienced a significant improvement (a decrease of at least 50 percent in migraine headache frequency, duration, or intensity) at 12 months after surgery, with 29 (32 percent) reporting complete elimination. Of the 245 botulinum toxin type A patients, 207 (84 percent) experienced a significant improvement, with 89 (36 percent) experiencing complete elimination. The surgical success rate of the botulinum toxin type A group was not significantly higher than that of the control group (p = 0.33). CONCLUSIONS: Confirmation of trigger sites using botulinum toxin type A does not significantly improve the outcome of migraine surgery. Although botulinum toxin type A can be a useful diagnostic tool, this study demonstrates that there is no statistically significant difference between the injection of botulinum toxin type A and the use of a constellation of symptoms to identify trigger sites. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Defining the ideal nasolabial angle.

BACKGROUND: The nasolabial angle is defined as the angle between the line drawn through the midpoint of the nostril aperture and a line drawn perpendicular to the Frankfurt horizontal while intersecting subnasale. An arbitrary range of 90 to 120 degrees for the nasolabial angle is usually stated in the literature. The purpose of this study was to objectively define the ideal nasolabial angle. METHODS: Life-sized, lateral photographs of 10 men and 10 women who had undergone rhinoplasty performed by the senior surgeon were selected. The photographs were electronically altered to change the nasolabial angle by 4 degrees. For men and women, these angles were 90, 94, 98, 102, 106, and 110 degrees. Sixteen raters, including plastic surgery attending staff, residents, and office staff, selected their most aesthetically pleasing nasolabial angle. RESULTS: Data analysis was done using the distribution of means of the first preference nasolabial angle values based on all 16 raters. The mean angle for ideal male nasolabial angle was 95.96 degrees ± 2.57 degrees (mean ± SD). The mean angle for women was 97.7 ± 2.32 degrees. Based on these standard deviations, the ideal nasolabial angle would be 93.4 to 98.5 degrees for men and 95.5 to 100.1 degrees for women. CONCLUSIONS: The authors' results indicate a much closer range of nasolabial angle between men and women than previously reported in the literature. This study is the first of its type to objectively define the ideal aesthetic nasolabial angle. In addition, the ideal nasolabial angle for women was found to be less obtuse than previously thought.

Tranquilli-Leali or Atasoy flap: an anatomical cadaveric study.

BACKGROUND: The Tranquilli-Leali and Atasoy volar V-Y advancement flaps are considered workhorse flaps in the reconstruction of fingertip amputations. However, their description in the literature in terms of surgical dissection and blood supply is often indistinct. This study describes the differences between the two flaps and highlights their unique blood supply based on a thorough cadaveric study and review of the literature. METHODS: Using 16 fresh cadaveric fingers, eight Tranquilli-Leali and eight Atasoy volar V-Y advancement flaps were dissected, mapping the arterial blood supply using an injectable blue resin. In addition, a thorough literature search on the subject was done. RESULTS: In all eight fingertips dissected as decribed by Tranquilli-Leali, the flap was supplied by the anastomotic connections between the terminal branches of the palmar digital arteries and dorsal nail-bed arcades via the fibro-osseous hiatus. In contrast, in all eight fingertips which were dissected as described by Atasoy, the flaps were perfused through the terminal branches of the palmar digital arteries. CONCLUSIONS: The Tranquilli-Leali and Atasoy volar V-Y advancement flaps, used to reconstruct fingertip amputations, are distinct from one another in several ways. The most obvious difference is their technique of flap dissection, which, in turn, dictates a unique blood supply. Through careful dissection and a review of the literature, this anatomical study has brought to light the specific vascular supply to each flap that was evaluated.