Which Quality Makes the Difference? - Cosmetic Rhinoplasty. / Welche Qualität macht den Unterschied?

There may be no field in which outcome is more obvious than in cosmetic nasal surgery. Both the quality of the procedure and the cosmetic quality of the result play an outstanding role in the arena of cosmetics. The expectations and interests of the surgeon are not always the same as those of the patient. Furthermore, with combination surgery, cost bearers focus independently on quality. This is often wrongly confused with economy. Objective criteria play a crucial role for the physician, but soft criteria are very important for patients. This is much more difficult, as everyone knows that beauty is in the eye of the beholder and must be compatible with functions such as breathing and smelling. There are many different quality standards, so that it is difficult for the patient to choose the right physician, particularly if he has to bear in mind the countless seals and certificates, and the influence of the internet and social media. But even the surgeon has to sift through a large number of congresses, courses, and symposia, if he is to achieve a minimum level of quality. Even though rhinosurgical techniques have greatly improved in recent decades, the patient always regards the quality of the outcome as being more important than the quality of the process. This paper presents a status report on the most objective quality indicators for cosmetic nasal surgery, as seen through the eyes of physicians, patients, and cost bearers, and in the context of changing surgical techniques.

Reconstruction of nasal tip support in primary, open approach septorhinoplasty : A retrospective analysis between the tongue-in-groove technique and the columellar strut.

The reconstruction of the nasal tip support is one of the most essential issues in septorhinoplasty. A comparison of the results after using the tongue-in-groove technique and the columellar strut technique was the target of this study. Thirty-three patients who underwent a primary, open approach septorhinoplasty using the above-mentioned techniques were retrospectively analyzed. The gain in tip rotation postoperatively, the sensitivity and the rigidity of the nasal tip and the aesthetic outcome after surgery were examined and evaluated. Both techniques led to an increase in nasal tip rotation postoperatively. The gain in rotation was higher in patients, treated with the tongue-in-groove technique (p = 0.0052). The sensitivity of the tip region in the tongue-in-groove group of patients was significantly lower than that in the columellar strut group of patients (p = 0.0424). Both techniques led to high percentages of tip rigidity after surgery with satisfactory aesthetic results though. The tongue-in-groove technique and the columellar strut technique are both reliable techniques for reconstructing the nasal tip support and correcting a droopy tip. Although the tongue-in-groove technique might result in a more significant increase in tip rotation, it leads to less sensitivity in the tip region.

Histological effect on the adipocutaneous flap in rats after preconditioning with 2-chloro-N(6) -cyclopentyladenosine.

BACKGROUND: 2-chloro-N(6) -cyclopentyladenosine (CCPA) was proven to be a protective factor in ischemic reperfusion injury. The purpose of this study was to determine how CCPA would affect the single tissue layers of the adipocutaneous flap. METHODS: Seventy male Wistar rats were divided into 5 experimental groups. Samples were taken of the area of flap necrosis and the wound margin after classical or pharmacological preconditioning on the fifth postoperative day. All samples were fixed in formaldehyde, embedded in paraplast, and analyzed in 3- to 4-µm sections (hemalaun-eosin stain and light microscopy). RESULTS: In general, wound healing was alike and remained unaffected by the experimental design. The most sensitive part of the flap during preconditioning is the subcutis. The number of neutrophils and of plasma cells is reduced significantly (p < .05). CONCLUSION: CCPA has an effect on each tissue layer of the flap. Subcutis became apparent as the most sensitive layer. CCPA influences complement pathway and neutrophils directly and indirectly.

Catecholamines reduce dose-dependent oedema formation and inflammatory reaction in an isolated rat lung model.

AIM: Since we detected that donor dopamine pre-treatment ameliorates lung function after hypothermia and ischaemia/reperfusion in an isolated rat lung model we studied, whether other catecholamines have beneficial effects on lungs. MATERIALS AND METHODS: Rats were treated with noradrenaline, adrenaline or dobutamine in different doses. Thereafter lungs were explanted, flushed with Perfadex® solution and stored at 4°C for different time periods. Oedema production was measured and inflammatory mediators were analysed after reperfusion and ventilation. RESULTS: Low-dose noradrenaline or dobutamine did not reduce tissue oedema after eight hours of hypothermia, whereas higher doses significantly reduced oedema formation. Low-dose catecholamines did not prevent the inflammatory response, whereas higher doses of beta-receptor-stimulating catecholamines significantly blunted inflammatory reaction. CONCLUSION: This study demonstrates that adrenergic-receptor-stimulating catecholamines have a protective dose-dependent effect on lungs after hypothermia and ischaemia/reperfusion. Although noradrenaline and dobutamine have similar dose-dependent organ-protective effects to dopamine, they have more side-effects.

Aesthetic rhinoplasty plus brow, eyelid and conchal surgery: pitfalls - complications - prevention.

Within the last years aesthetic surgery enjoys greater popularity and acceptance. One of the most frequently asked operations has been the aesthetic rhinoplasty. Hardly any other field of surgery is exposed to such a critical analysis than aesthetic rhinoplasty because the results are so obvious. According to the "International Society of Aesthetic Surgery" (ISAPS) over 980,000 cosmetic rhinoplasties have been performed in 2010. This corresponds to 10.4% of all registered aesthetic procedures worldwide. Complications can not be eliminated in such a large number of nasal operations. Five to 15% of all patients re-consult a doctor for a revision because they are much dissatisfied with their final rhinoplasty result. Findings of the tip followed by functional problems and irregularities of the nasal dorsum are named most frequently. The responsible rhinosurgeon has to take into account all anatomical and physiological details and to consider ethical and psychological aspects in the pre-selection and postoperative care of the patient. Aesthetic surgeons should be acquainted with terms and definitions like body image, dysmorphophobia or Thersites complex. Acronyms, like "SIMON" or "SYLVIA", support the physician additionally to analyze and assess the patient. The following article describes the most frequent faults, complications and pitfalls after aesthetic rhinoplasty listed by the anatomical structure. Results will be analyzed and strategies and techniques will be suggested to correct the faults and to prevent them in the future. Furthermore psychologic, social and psychiatric aspects will be discussed and handling with aesthetic patients explained.

Pyrrolidine dithiocarbamate as an effector and trigger in ischemia-reperfusion injury in adipocutaneous flaps in rats.

BACKGROUND: Immune and inflammatory responses and the regulation of cellular events seem to be major factors in ischemia-reperfusion (I/R) injury. The inhibition of nuclear transcription factor κB (NF-κB) by pyrrolidine dithiocarbamate (PDTC) shows beneficial effects in animal models in various diseases and tissues with respect to I/R injury. If these results from other tissues could be transferred to adipocutaneous flaps in rats, a new approach to pharmacologic preconditioning could be defined for tissue transfer, and PDTC could be a solution as a trigger and effector to ameliorate the aftermath of the I/R injury. METHODS: Fifty-six male WISTAR rats were divided into four experimental groups. An epigastric adipocutaneous flap was raised, and the average flap necrosis was assessed for all groups on the fifth postoperative day using planimetric software. RESULTS: The control group had a significantly lower flap necrosis than the ischemic control group (p < .05). The PDTC nonischemic group had a significantly lower flap necrosis than the ischemic control group (p  =  .005). The ischemic PDTC group had a 10% reduction in flap necrosis that was not significant. CONCLUSION: Our data show that a significant reduction in flap necrosis can be achieved by intravenous application of PDTC.

Highly selective A(1) -adenosine-agonist (2-chloro-N6-cyclopentyladenosine) and reduction of flap necrosis in adipocutaneous flaps in rats.

BACKGROUND: The 2-chloro-N6-cyclopentyladenosine (CCPA) was proven to be a protective factor in ischemic reperfusion injury in myocardium and to reduce the infarct size in the heart. The purpose of this study was to determine whether flap necrosis could be reduced by intravenous administration of CCPA. METHODS: Fifty-six male Wistar rats were divided into 4 experimental groups. An epigastric adipocutaneous flap was raised, and the area of flap necrosis was assessed for all groups on the fifth postoperative day with planimetry software. RESULTS: The control group had a significantly lower rate of flap necrosis than the ischemic control group (p < .05). The nonischemic CCPA group had a significantly lower rate of flap necrosis than the nonischemic control group (p < .05). The ischemic CCPA group had a highly significant (p < .0001) rate of lower flap necrosis than the ischemic control group. CONCLUSION: Our data show that reduction of flap necrosis can be achieved both with and without ischemic periods by intravenous administration of CCPA.

Reduction of oedema formation after preconditioning with dopamine in an isolated rat lung model is mediated by adrenergic receptors.

BACKGROUND: Donor treatment with dopamine (DA) is an effective modality to improve organ quality by reduction of hypothermic, ischemic and reperfusion (I/R) injury. It is unknown by which mechanism DA reduces oedema formation and inflammation. Therefore we tested the first time in an isolated rat lung model if dopaminergic or adrenergic receptors are involved. MATERIAL/METHODS: Rats were treated for 1 hr with NaCl, DA or simultaneously with DA alpha- beta- D1- or D2-receptor blockers. Thereafter lungs were explanted, flushed with Perfadex-solution and stored at 4°C. Peak inspiratory pressure (PIP), pulmonary arterial pressure (PAP) and lung weight were measured during reperfusion of 3 hrs. Inflammatory mediators and the expression of adhesion molecules were measured after perfusion. RESULTS: Up to 6 hours of hypothermia did not influence oedema formation or PIP and PAP during reperfusion time. However, hypothermia after 8 hrs significantly increased PIP, PAP and pulmonary oedema in NaCl, alpha- and beta-blocker treated lungs, but significantly not in DA, D1- or D2-blocker treated lungs. Perfusion and ventilation alone induced a strong upregulation of cytokine-induced neutrophil chemoattractant-1 and adhesion molecules in untreated, alpha- and beta-blocker treated lungs, while in DA, D1- and D2-blocker treated lungs significant lower levels were found. CONCLUSIONS: Our study suggests that dopamine mediated protective effects on I/R damage and inflammation in donor lungs are most likely mediated via adrenergic receptors. These findings are highly relevant because new strategies for organ preservation are necessary in terms of long donation waiting lists.

Comparison of proximal row carpectomy and midcarpal arthrodesis for the treatment of scaphoid nonunion advanced collapse (SNAC-wrist) and scapholunate advanced collapse (SLAC-wrist) in stage II.

BACKGROUND: Traumatic instability of the proximal carpal row is based either on a scaphoid fracture or a scapholunate dissociation. Long-standing scaphoid nonunion or scapholunate ligament insufficiency may lead to a carpal collapse and subsequent arthrosis. Controversy exists regarding the appropriate salvage procedure for patients with scapholunate advanced collapse (SLAC)- or scaphoid nonunion advanced collapse (SNAC)-wrist in stage II. Proximal row carpectomy (PRC) and midcarpal arthrodesis (MCA) are two commonly used options. The purpose of this retrospective study was to evaluate the functional outcome and pain relief in SNAC-SLAC-wrist stage II after MCA, compared to PRC in a long term follow up. METHODS: In the MCA group 17 patients, nine SLAC- and eight SNAC-wrists, with an average age of 47 years at surgery and a mean follow up of 42 months were examined. The PRC group consisted of 30 patients, seven SLAC- and 23 SNAC-wrists, with an average age of 39 years at surgery and a mean follow up of 27 months. Active range of motion (AROM) was verified with a goniometer, grip strength was measured with a JAMAR-Dynamometer II. Pain was evaluated by a visual analogue scale from zero to 100 (VAS 0-100) under resting and stress conditions. Patients' upper extremity disability was measured with the DASH questionnaire. Radiographic evaluation was carried out by conventional X-ray to verify bony consolidation. RESULTS: Mean values of postoperative AROM in extension/flexion was 61 degrees in MCA, and 75 degrees in PRC patients; radial/ulnar deviation was 32 degrees and 33 degrees, respectively. Mean DASH-score was 21 in the MCA and 25 in the PRC group. Pain relief was 54% in MCA and 77% in PRC during resting conditions and 22% and 42% during stress conditions. Static grip strength was significantly higher following MCA than PRC (72% to 50%). Among both the MCA and PRC groups three patients required further treatment with total arthrodesis due to persisting pain or absence of bony consolidation. CONCLUSION: Our data demonstrate that PRC is more favourable for patients who require less grip strength at work. For patients carrying out heavy manual work we recommend MCA due to the significantly better grip strength postoperatively.

Long-term results of midcarpal arthrodesis in the treatment of scaphoid nonunion advanced collapse (SNAC-Wrist) and scapholunate advanced collapse (SLAC-Wrist).

UNLABELLED: Outcome evaluation of midcarpal arthrodesis in the treatment of scaphoid nonunion advanced collapse (SNAC-wrist) and scapholunate advanced collapse (SLAC-wrist). PURPOSE: Scaphoid nonunion or scapholunate ligament instability results in carpal collapse and subsequent arthrosis. These conditions, termed SLAC-wrist and SNAC-wrist, are the most common patterns of arthrosis in the wrist. The purpose of this retrospective study was the evaluation of functional outcomes following midcarpal arthrodesis and of patients' satisfaction with these outcomes. METHODS: Forty-nine patients were reexamined at a mean follow-up time of 47 months. Active range of motion (AROM) was verified with a goniometer; grip strength was measured with a JAMAR-Dynamometer II. Pain was evaluated by a visual analogue scale from zero to 100 (VAS 0-100) for stress and under resting conditions. Patients' upper-extremity functioning was captured with the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire. Radiographic evaluation of bony consolidation was verified by conventional x-ray. RESULTS: Postoperative AROM was 56% and grip strength was 76% compared with the contralateral side. The DASH score was 29 points. Pain relief was 34% at rest and 31% after stress. Forty-five patients demonstrated bony consolidation in x-ray control. Six patients (12%) further required a total arthrodesis of the wrist because of pain or absence of bony consolidation. CONCLUSION: Our data demonstrate that midcarpal arthrodesis is a reliable procedure for treating SLAC- and SNAC-wrists in stages II and III and, furthermore, one which preserves some range of motion. Total wrist fusion should only be used in exceptional circumstances.

Transcardiopulmonary thermal dye versus single thermodilution methods for assessment of intrathoracic blood volume and extravascular lung water in major burn resuscitation.

The purpose of this study was to compare the approximated values for intrathoracic blood volume (ITBV) and extravascular lung water (EVLW) obtained from a single indicator dilution to the exact data measured by double-indicator dilution. Eighteen patients with an average TBSA of 46.3% (range, 26 to 67%) and an average abbreviated burn severity index of 8.7 (range, 7 to 11) were included into a intraindividual comparative prospective study over a 20-month period. The COLD Z-021 system (Pulsion Medical Systems, Munich, Germany) was used to obtain both the exact measurements, as well as the estimated values for ITBV and EVLW. Two hundred ninety intraindividually comparative measurements were performed during the first 4 days after the burn injury. A good correlation between both techniques was shown for ITBVI (0.77; P <.01) for the overall measurements. However, the overall bias demonstrated a standard deviation higher than the mean value (-87.4 +/- 136 ml/m2), and precision for the estimated values for ITBVI was poor (-491 to 783 ml/m2). Additional analyses demonstrated a poor but significant correlation for low states of ITBV (r =.37; P <.01), but no significant correlations were found between the techniques for normal and high ITBV states. Thus, the approximated ITBV obtained from single thermodilution should not be used to guide volume therapy in major burn resuscitation. Furthermore, the EVLW is neither suitable for diagnostic use nor for therapeutic decisions because it is calculated on the basis of the poorly estimated values for ITBV in single thermodilution. Transcardiopulmonary single thermodilution is not suitable to assess intrathoracic blood volume and extravascular lung water in burn shock. However, the method is suitable to assess cardiac output and its derived parameters in burn resuscitation as shown in previous studies. It still must be proven whether the exactly measured ITBV obtained from transcardiopulmonary double-indicator dilution is superior to the commonly used parameters to guide major burn resuscitation.

Effectiveness of a new perforated 0.15 mm poly-p-dioxanon-foil versus titanium-dynamic mesh in reconstruction of the orbital floor.

Introduction: In recent years a new perforated PDS (poly-p-dioxanon) foil (0.15 mm) has become available and has not yet been proven to be successful in reconstruction of the orbital floor after blow-out-fractures in randomized studies. The main aim of this clinical trial is to compare this new PDS foil with titanium dynamic mesh (0.3 mm) (TD), which is well established in reconstruction of the orbital floor. Patients and Methods: In a prospective multicentre randomized trial, conducted between 1997 and 1998, out of 42 patients with fractures of the orbital floor, 28 patients needing material for reconstruction were randomized to receive either PDS foil or TD. In a comprehensive preoperative and postoperative protocol patients were monitored by the surgeon, radiologist and ophthalmologist with a postoperative follow-up of least 6 months. Results: Maximum defects of the orbital floor were comparable in both groups (PDS group: 13.3 mm, TD group: 13.9 mm). In both groups the surgical procedure was well tolerated, and functional and cosmetic results were evaluated as satisfactory by all patients. Ophthalmological evaluation, performed up to 6 months postoperatively, revealed double vision or vertical strabismus in nine patients (five PDS group, four titanium group). This was not confirmed subjectively in each single patient. Also ex- or enophthalmos, registered in seven patients of the PDS and four of the TD group (mainly +/-1 mm) were not considered as relevant by the patients. Conclusion: The new 0.15 mm perforated PDS foil was comparable to 0.3 mm titanium mesh concerning functional and cosmetic outcome. Obviously, persisting ophthalmometric disorders were compensated very well in both groups. PDS foil is felt to be the preferred material since it is bioresorbable and more convenient to handle. Copyright 2001 European Association for Cranio-Maxillofacial Surgery.