Customizable, biocompatible implants for dorsal nasal augmentation: An in vivo pilot study of eight polylactic acid scaffold designs.

Augmentation of the nasal dorsum often requires implantation of structural material. Existing methods include autologous, cadaveric or alloplastic materials and injectable hydrogels. Each of these options is associated with considerable limitations. There is an ongoing need for precise and versatile implants that produce long-lasting craniofacial augmentation. Four separate polylactic acid (PLA) dorsal nasal implant designs were 3D-printed. Two implants had internal PLA rebar of differing porosities and two were designed as "shells" of differing porosities. Shell designs were implanted without infill or with either minced or zested processed decellularized ovine cartilage infill to serve as a "biologic rebar", yielding eight total treatment groups. Scaffolds were implanted heterotopically on rat dorsa (N = 4 implants per rat) for explant after 3, 6, and 12 months followed by volumetric, histopathologic, and biomechanical analysis. Low porosity implants with either minced cartilage or PLA rebar infill had superior volume retention across all timepoints. Overall, histopathologic and immunohistochemical analysis showed a resolving inflammatory response with an M1/M2 ratio consistently favoring tissue regeneration over the study course. However, xenograft cartilage showed areas of degradation and pro-inflammatory infiltrate contributing to volume and contour loss over time. Biomechanical analysis revealed all constructs had equilibrium and instantaneous moduli higher than human septal cartilage controls. Biocompatible, degradable polymer implants can induce healthy neotissue ingrowth resulting in guided soft tissue augmentation and offer a simple, customizable and clinically-translatable alternative to existing craniofacial soft tissue augmentation materials. PLA-only implants may be superior to combination PLA and xenograft implants due to contour irregularities associated with cartilage degradation.

Glomus tumor of the foot dorsum: A case report of a neglect podiatric entity.

Key Clinical Message: Podiatrists and orthopedists should be vigilant for chronically evolving, hyperalgic soft lumps in the foot with vascular radiological features, prompting early detection of glomus tumor, timely mass removal, providing pain relief and improving patient's quality of life. Abstract: Glomus tumors refers to a rare group of benign perivascular neoplasms that originate from a neuromyoarterial structure called a glomus body. These tumors are characterized by their painful nature and predominant distribution in the extremities mainly the fingers, the hands and the feet. Nonetheless, the diagnosis is usually made after several years of symptoms experience as the lesions are mostly small, not palpable, and have variable presentations. Radiological workup especially with magnetic resonance imaging is very useful for diagnosing the tumoral process, however, confirmation can only be obtained by histological analysis. The treatment is purely surgical, and it is successful in most cases. Herein, we describe a case of glomus tumor of the foot dorsal side among a middle age male patient.

Pneumatization types of the dorsum sellae: a computed tomography study.

PURPOSE: The present work aimed to classify the pneumatization of the dorsum sellae (DS) in subjects aged 1-90 years. METHODS: The study consisted of computed tomography images of 1080 subjects (582 males / 498 females), aged 1-90 years (mean age: 45.51 ± 26.06 years). Four different types regarding DS pneumatization were defined as follows: Type 0: no pneumatization, Type 1: pneumatization < 50%, Type 2: pneumatization > 50%, and Type 3: total pneumatization. RESULTS: DS pneumatization was identified in 354 (32.8%) subjects (189 males and 165 females). Its pneumatization was identified in 51 (21.2%) out of 241 children, and 303 (36.1%) out of 839 adults. The frequency of DS pneumatization types was found as follows: Type 0 (no pneumatization in 726 subjects, 67.2%) > Type 1 (pneumatization < 50% in 234 subjects, 21.6%) > Type 2 (pneumatization > 50% in 87 subjects, 8.1%) > Type 3 (total pneumatization in 33 subjects, 3.1%). DS pneumatization incidence was affected by ages (p < 0.001), but not sex (p = 0.818). The pneumatization degrees of DS (i.e., the distributions of Types 1-3) were not affected by ages (p = 0.637) or sex (p = 0.391). CONCLUSION: The pneumatization incidence of DS increased significantly with advancing adult ages (especially in elderly people). DS pneumatization should be taken into account by neurosurgeons and neuroradiologists to decrease the risk of complications such as cerebrospinal fluid fistula during surgeries such as posterior clinoidectomy.

[Application of three-dimensional ultrasound technique in repairing dorsal foot wounds with medial sural artery perforator flaps].

Objective: To investigate the accuracy of positioning perforator of medial sural artery with three-dimensional ultrasound technique guided by a wide band linear matrix array volume transducer probe before operation, and the effectiveness of the flap design based on this in repairing the dorsal foot wounds. Methods: Between January 2019 and December 2022, 30 patients with skin and soft tissue defects of the dorsal foot were treated. There were 19 males and 11 females, with an average age of 43.9 years (range, 22-63 years). There were 12 cases of traffic accident injury, 15 cases of heavy crushing injury, and 3 cases of machine injury. The time from injury to hospitalization was 1-8 hours (mean, 3.5 hours). The wounds in size of 5 cm×3 cm to 17 cm×5 cm were thorough debrided and covered with vacuum sealing drainage dressing. Then the wounds were repaired with the medial sural artery perforator flaps after no obvious infection observed. To obtain the complete three-dimensional image, the number and position of the medial sural artery perforator branches and the position of the main blood vessels in the muscle were detected and recorded by wide band linear matrix array volume transducer probe before operation. Suitable perforating branches were selected to design the flap and guide the flap incision on this basis. The size of the perforating flap ranged from 6 cm×4 cm to 18 cm×6 cm. The sensitivity and positive predictive value were calculated by comparing preoperative exploration with intraoperative observation of perforating branches, so as to evaluate the positioning accuracy of three-dimensional ultrasound technique. The donor sites were sutured directly in 25 cases and repaired with free skin grafting in 5 cases. Results: The 60 perforating branches of medial sural artery were found before operation and 58 during operation in 30 patients. Among them, pre- and intra-operative perforations were consistent with 56. The sensitivity was 93.3% and positive predictive value was 96.6%. The intramuscular position and route of the main blood vessels were basically consistent with the pre- and intra-operative observation. All flaps survived and wounds healed by first intention. All incisions at the donor sites healed by first intention, and all skin grafts survived. All patients were follow up 9-24 months (mean, 14.7 months). The appearance, color, and texture of the flaps were good, and no obvious effect on wearing shoes and walking. At last follow-up, the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hind score ranged from 80 to 92, with an average of 87.5. The patient satisfaction was excellent in 29 cases and good in 1 case. Conclusion: The three-dimensional ultrasound technique guided by the wide band linear matrix array volume transducer probe can accurately locate the perforating branch of the medial sural artery, and the three-dimensional imaging is more intuitive, which can be used to guide the design and incision of the medial sural artery perforator flap.

Squamous cell carcinoma initially occurring on the tongue dorsum: a case series report with molecular analysis.

BACKGROUND: Squamous cell carcinoma (SCC) of the dorsum of the tongue is extremely rare, and it clinically resembles various benign lesions. Somatic mutations in TP53 and some driver genes were implicated in the development of SCC; however, the somatic genetic characteristics of dorsal tongue SCC remain unknown. With a detailed analysis of gene mutations in dorsal tongue SCC, we aimed to better understand its biology. METHODS: Four cases of SCC initially occurring on the tongue dorsum were evaluated for clinical and histological findings and immunohistochemical expression of p53 and p16. Gene mutations were analyzed using next-generation sequencing with a custom panel of driver genes. RESULTS: We retrospectively investigated 557 cases of tongue SCC, and only four cases of SCC initially occurred on the tongue dorsum. The four patients (cases 1-4) were one woman and three men with a mean age of 53.75 years (range: 15-74 years). Histological analysis revealed well-differentiated SCC. Through molecular analysis, we identified pathogenic somatic mutations, namely, TP53 p.C176F (c.527G > T) in case 3 and TP53 p.R282W (c.844 C > T) in case 4. No pathogenic variants were identified in the PI3K/AKT or RAS/RAF pathways. The p53 immunohistochemical examination revealed a wild-type expression pattern in cases 1-3 and strong expression in case 4. The results of p16 immunostaining were negative in all cases. CONCLUSIONS: We described four previously unreported genetic characteristics of dorsal tongue SCC. Somatic TP53 mutations may contribute to the development of a subset of dorsal tongue SCC; however, more cases with genetic analysis need to be accumulated.

Topographic Anatomy and Pneumatization of the Posterior Clinoid Process in Chiari Type I Malformation.

OBJECTIVE: This study aimed to examine pneumatization and topographic location of the posterior clinoid process (PCP) in Chiari type I malformation (CIM) for skull base approaches. METHODS: Computed tomography images of 52 (23 males/29 females) CIM subjects aged 23.87 ± 16.09 years and 71 (26 males/45 females) healthy subjects aged 42.48 ± 21.48 years constituted the study universe. RESULTS: The distances of PCP to the foramen magnum (P = 0.037), superior orbital fissure (P < 0.001), foramen rotundum (P < 0.001), and foramen ovale (P < 0.001) were smaller, but the distance of PCP to the crista galli (P = 0.038) was greater in CIM patients, compared with normal subjects. In CIM, the fusion between PCP and the anterior clinoid process was observed in 9 sides (8.70%), while in controls it was observed in 12 sides (8.50%). PCP pneumatization was observed in 40 sides (38.50%) in CIM patients, while it was observed in 28 sides (19.70%) in normal subjects. These data displayed that PCP pneumatization was affected by CIM (P < 0.001). CONCLUSIONS: The distances of PCP to the crista galli and foramen magnum indicate the anterior fossa length and the posterior fossa depth, respectively; thus CIM patients have a longer anterior fossa and a shallow posterior fossa. In addition, the distances of PCP to the superior orbital fissure, foramen rotundum, and foramen ovale indicate the middle fossa width; hence CIM patients have less middle fossa width than normal individuals. CIM patients have an approximately 50% higher PCP pneumatization rate, and this may increase the risk of complications such as cerebrospinal fluid fistula during the application of posterior clinoidectomy.

Mapping lumbar efferent and afferent spinal circuitries via paddle array in a porcine model.

BACKGROUND: Preclinical models are essential for identifying changes occurring after neurologic injury and assessing therapeutic interventions. Yucatan miniature pigs (minipigs) have brain and spinal cord dimensions like humans and are useful for laboratory-to-clinic studies. Yet, little work has been done to map spinal sensorimotor distributions and identify similarities and differences between the porcine and human spinal cords. NEW METHODS: To characterize efferent and afferent signaling, we implanted a conventional 32-contact, four-column array into the dorsal epidural space over the lumbosacral spinal cord, spanning the L5-L6 vertebrae, in two Yucatan minipigs. Spinally evoked motor potentials were recorded bilaterally in four hindlimb muscles during stimulation delivered from different array locations. Then, cord dorsum potentials were recorded via the array by stimulating the left and right tibial nerves. RESULTS: Utilizing epidural spinal stimulation, we achieved selective left, right, proximal, and distal activation in the hindlimb muscles. We then determined the selectivity of each muscle as a function of stimulation location which relates to the distribution of the lumbar motor pools. COMPARISON WITH EXISTING METHODS: Mapping motoneuron distribution to hindlimb muscles and recording responses to peripheral nerve stimulation in the dorsal epidural space reveals insights into ascending and descending signal propagation in the lumbar spinal cord. Clinical-grade arrays have not been utilized in a porcine model. CONCLUSIONS: These results indicate that efferent and afferent spinal sensorimotor networks are spatially distinct, provide information about the organization of motor pools in the lumbar enlargement, and demonstrate the feasibility of using clinical-grade devices in large animal research.

The "Keystone Angle": Geometry in Preservation Rhinoplasty.

Rhinoplasty outcome may depend on different factors and bony dorsum shape has proven to significantly influence the lateral view result. The "Keystone angle" corresponds to the osseocartilaginous angle formed between bony and cartilaginous dorsum. Usually, the "V" shaped bony dorsum is characterized by a more acute "Keystone angle" compared to the "S" shaped bony dorsum. To achieve the ideal dorsum flatness, corresponding to a "Keystone angle" of 180°, different techniques may be used. Bearing these concepts in mind we suggest that preoperative assessment of the "Keystone angle" can guide the choice of the most appropriate technique for each patient. 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 .

Correction of nasal tip deformity using an island flap of nasal dorsum.

Bifid nose is a rare congenital malformation, and few cases have been reported due to its low incidence. Herein, we report a new surgical procedure to treat patients with excess dorsal nasal tissue and an underfilled tip. A total of 22 patients with bifid nose deformities underwent surgery at our institution between 2012 and 2022. They were characterized by a broad nasal dorsum and a missing or underdeveloped nasal tip. We designed an innovative island flap of nasal dorsum as a new surgical method for treating this bifid nose deformity. Nasal length, tip projection, and photographs of nose morphology were obtained before and after the surgery. Outcomes, complications, indications, and patient satisfaction were analyzed and interviewed. The follow-up time ranges from 6 to 33 months (8.7 ± 5.5 months). The deformity was successfully corrected with an improved nasal appearance. Nasal length increased from initially 4.2 ± 0.3 mm to 4.6 ± 0.3 mm. Tip projection reached 19.9 ± 4.0 mm, which was 15.7 ± 2.9 mm before surgery. No severe complications were observed except poor venous reflux within postoperative 72 hours in four cases. Six patients (27.3%) got moderate healing and acceptable scars, and 14 patients (63.6%) got good healing. Most patients were very satisfied with the outcome (93.9%). The newly designed nasal dorsum island flap is a safe and effective technical approach to correct nose deformity featured by broad nasal dorsum and a missing or underdeveloped nasal tip.

Rare Case of Squamous Cell Carcinoma of Midline Dorsum of Tongue: Diagnostic and Management Dilemma.

Squamous cell carcinoma is the most common carcinoma of the tongue. However, the majority of carcinoma originates in the lateral border of the tongue and midline dorsum only represents about 2-5% of tongue cancer patients. We present a rare case of squamous cell carcinoma in a 59 years old male patient originating in the midline dorsum of tongue and the management dilemma.

Electrodiagnostic testing in dogs with disorders of the spinal cord or cauda equina.

Electrodiagnostic (EDX) testing is uncommonly utilized in dogs other than for investigation of disorders of the neuromuscular system. In dogs with diseases affecting the spinal cord or cauda equina, EDX testing can provide functional data complementary to imaging information that together can guide therapeutic and management approaches. Additionally, in some clinical scenarios, EDX testing prior to advanced imaging is integral to identifying if there is spinal cord or cauda equina involvement and can aid in determining the appropriate diagnostic path. This review will outline EDX testing methods that have been reported in dogs relating to the diagnosis, monitoring or prognosis of various conditions affecting the spinal cord and cauda equina. The various tests will be briefly outlined regarding how they are performed and what information is provided. The main focus will be on clinical applications including highlighting situations where EDX testing is useful for differentiating between neurologic and non-neurologic presentations. Additional ways these EDX techniques could be incorporated in the management of diseases of the spinal cord and cauda equina in dogs will be presented.

Efficiency of Middle Vault Reconstruction with Dorsal Septal T Flap in Achieving Ideal Dorsal Aesthetic Lines and Regularity.

BACKGROUND: Dorsal aesthetic lines and irregularities are the most critical points that can be manipulated in rhinoplasty operations. Although spreader grafts and flaps have been used for this purpose in the reconstruction of the keystone area for a long time, dorsal irregularity is often inevitable. This study aims to evaluate the effectiveness of dorsal septal T flap and nasal dorsum reconstruction in achieving ideal dorsal aesthetic lines and regularity. METHODS: Thirty-four patients (30 women, 4 men) who underwent closed technique rhinoplasty between 2019 and 2021 were included in the study. The mean age of the patients was 25.4 years. Patients with crooked nose, severe deviation, and severe dorsal hump were also excluded. All patients included in the study underwent Rhinoplasty Outcome Evaluation (ROE) questionnaires preoperative and postoperative 1st year. RESULTS: The mean age of the patients was 25.4 years (range 18-40 years). A total of 34 patients, including 30 women and four men, were operated. The mean follow-up period was 13.2 months, ranging from 12 to 14 months. In the physical examinations performed at the control visits, no functional problem was encountered in any patients. Preoperative and postoperative mean ROE scores were 60.9 and 92.7, respectively. CONCLUSIONS: With the technique described in the study, dorsal hump recurrence is minimized compared to other preservation techniques. Since the keystone area transition can be fine-tuned, continuity is ensured, and ideal dorsal aesthetic lines are created. The stability of the upper lateral cartilages is provided, thus eliminating the need for spreader grafts. 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 Use of Posterior Auricular Fascia Graft (PAFG) for Slight Dorsal Augmentation and Irregular Dorsum Coverage in Primary and Revision Rhinoplasty: A Prospective Study.

INTRODUCTION: Augmentation and coverage of irregularities of the nasal dorsum remain a challenge in rhinoplasty. Different techniques have been described in the current literature for this purpose. The aim of this study is to assess and illustrate the author experience and outcomes using the posterior auricular fascia graft (PAFG) for dorsal camouflage and augmentation in primary and revision rhinoplasty. MATERIAL AND METHODS: A prospective bicentric study was conducted, including patients with slight dorsal deficiencies and/or with dorsal irregularities following hump resection, trauma or previous rhinoplasty receiving PAFG to improve the rhinoplasty outcome. To objectively assess the graft resorption rate, MRI was performed 2 weeks and 18 months after surgery. To investigate patient satisfaction, the preoperative and 1-year postoperative scores obtained using the rhinoplasty outcomes evaluation (ROE) scale were compared. The scores following a normal distribution obtained for each patient were compared using a paired t-test. RESULTS: Forty-five patients were enroled in this study. Average follow-up duration was 35.4 months. Patients' age ranged from 17 to 57 years. No cases of infection or major graft resorption were observed. No postoperative scars were visible at the donor site. All patients were satisfied after surgery, and a statistically significant difference between pre- and postoperative scores (p<0.0001) was observed. CONCLUSION: This study showed that PAFG is a reliable technique for dorsal camouflage and slight augmentation in primary and revision rhinoplasty. The procedure is safe, easy and quick and only requires a small learning curve. LEVEL OF EVIDENCE II: 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 .

Dynamic electrical stimulation enhances the recruitment of spinal interneurons by corticospinal input.

Highly varying patterns of electrostimulation (Dynamic Stimulation, DS) delivered to the dorsal cord through an epidural array with 18 independent electrodes transiently facilitate corticospinal motor responses, even after spinal injury. To partly unravel how corticospinal input are affected by DS, we introduced a corticospinal platform that allows selective cortical stimulation during the multisite acquisition of cord dorsum potentials (CDPs) and the simultaneous supply of DS. Firstly, the epidural interface was validated by the acquisition of the classical multisite distribution of CDPs and their input-output profile elicited by pulses delivered to peripheral nerves. Apart from increased EMGs, DS selectively increased excitability of the spinal interneurons that first process corticospinal input, without changing the magnitude of commands descending from the motor cortex, suggesting a novel correlation between muscle recruitment and components of cortically-evoked CDPs. Finally, DS increases excitability of post-synaptic spinal interneurons at the stimulation site and their responsiveness to any residual supraspinal control, thus supporting the use of electrical neuromodulation whenever the motor output is jeopardized by a weak volitional input, due to a partial disconnection from supraspinal structures and/or neuronal brain dysfunctions.

Case Report: Rare Presentation of Nodular Fasciitis over Dorsum of Wrist.

Introduction: Nodular fasciitis is a benign, reactive fibroblastic tumor that usually presents as a rapidly growing lesion with occasional involvement of the deep fascia and muscle. We present a case of nodular fasciitis over the dorsum of the wrist. In our knowledge, this is the first reported case of nodular fasciitis at this location in the literature. Case Report: A 33-year-old South Asian male with a desk job, presented with a rapidly growing lesion over the dorsum of the left wrist over 5 months, associated with pain and restriction of dorsiflexion of wrist. The X-ray, ultrasound, and magnetic resonance imaging images were inconclusive and excisional biopsy was done for definitive diagnosis. Conclusion: Nodular fasciitis is a relatively uncommon but important differential diagnosis for any rapid soft-tissue growth. It is a self-limiting proliferative fibroblastic lesion, with excisional biopsy as the gold standard for diagnosis of this condition.

The Use of Diode Laser for the Surgical Removal of Pyogenic Granuloma of the Dorsum of the Tongue: A Case Report.

Pyogenic granuloma (PG) is a common reactive oral lesion predominantly involving the gingiva and rarely occurring on the dorsum of the tongue. It can develop at any age but more commonly in the second decade with a female predilection. Numerous factors are associated with its development, and surgical removal is the standard treatment. Various surgical modalities have been used to excise it. Herein, we report a case of a female patient in her late 60s who presented with an exophytic lesion involving the dorsum of the tongue, which was excised using a 940 nm diode laser. In addition, it discusses the advantages of diode laser as a surgical modality and describes this lesion's clinical features and pathogenesis.

Use of hyaluronic acid matrix in dorsal augmentation rhinoplasty.

Augmentation rhinoplasty sometimes is required for patients with saddle nose deformity caused by failed rhinoplasty or facial trauma; finding appropriate grafting material remains a significant problem for this procedure. We investigated hyaluronic acid matrix as an allograft for dorsal augmentation rhinoplasty in a rabbit model. We performed an osteotomy on the nasal bones of eight rabbits. Four animals were sham operated as the control group and four were administered a mixture of saline-gelled hyaluronic acid matrix and sliced cartilage. Ultrasonography and three-dimensional reconstruction tomography were performed at the end of the experimental period. After sacrifice of the animals, nasal tissues were examined for histopathology, and both collagen scores and number of capillaries were compared between the two groups. Increased collagen and capillaries were apparent in the hyaluronic acid matrix group compared to controls. The median collagen score was significantly greater for the hyaluronic acid matrix group than for the control group. Although the number of capillaries for the hyaluronic acid matrix group was greater than for the control group, the difference was not statistically significant. Three weeks is sufficient for adhesion of ends of fractures in clinical practice; however, we found no ossification at this time in either group. A hyaluronic acid matrix may be a useful alternative supplement for dorsal augmentation rhinoplasty. Development of collagen was commensurate with membranous ossification; however, assessment of complete ossification requires a longer experimental period.

Spinal facilitation of descending motor input.

Highly varying patterns of electrostimulation (Dynamic Stimulation, DS) delivered to the dorsal cord through an epidural array with 18 independent electrodes transiently facilitate corticospinal motor responses, even after spinal injury. To partly unravel how corticospinal input are affected by DS, we introduced a corticospinal platform that allows selective cortical stimulation during the multisite acquisition of cord dorsum potentials (CDPs) and the simultaneous supply of DS. Firstly, the epidural interface was validated by the acquisition of the classical multisite distribution of CDPs on the dorsal cord and their input-output profile elicited by pulses delivered to peripheral nerves. Apart from increased EMGs, DS selectively increased excitability of the spinal interneurons that first process corticospinal input, without changing the magnitude of commands descending from the motor cortex, suggesting a novel correlation between muscle recruitment and components of cortically-evoked CDPs. Finally, DS increases excitability of post-synaptic spinal interneurons at the stimulation site and their responsiveness to any residual supraspinal control, thus supporting the use of electrical neuromodulation whenever the motor output is jeopardized by a weak volitional input, due to a partial disconnection from supraspinal structures and/or neuronal brain dysfunctions.

Common Dorsal Flaws Following Preservation Rhinoplasty: A Systemic Analysis.

BACKGROUND: There has recently been a resurgence of interest in preservation rhinoplasty (PR) for dorsal hump elimination or dorsal projection reduction. However, no studies have scrutinized aesthetic outcomes to identify common pattern of flaws seen in published images to aid those with ardent enthusiasm for this technique to become aware of the frequency of these flaws and find ways to reduce imperfections. METHODS: A systematic literature review was performed using search terms ("preservation" OR "let down", "push down") AND "rhinoplasty" on PubMed, Cochrane, SCOPUS, and EMBASE databases for studies between January 2000 and December 2022. Patient images from these studies were analyzed by three reviewers (MWW, IAC, and BG) for dorsal flaws. Raw interrater agreement percentage and Krippendorff's alpha were calculated to determine interrater reliability. A descriptive and comparative analysis with Fisher's exact test was performed for the aggregate data. RESULTS: There were 59 patient images with 464 views from 24 studies included for final analysis. Optimal dorsal aesthetic lines (DAL) were noted in 12 patients (20.3%), while optimal profile was observed in 15 patients (25.4%) (p = 0.66). Combined ideal front and profile view of dorsum was not observed on any patients. The most common flaws were DAL irregularities (n = 45; 78.0%), dorsal deviation (n = 32, 54.2%), and residual hump (n = 25, 42.4%). There was excellent interrater agreement. CONCLUSIONS: While PR may have some advantages, it has shortcomings in outcomes, particularly dorsal irregularities, dorsal deviation, and residual humps. Awareness of these imperfections may compel those performing this procedure to modify their techniques and improve their results. LEVEL OF EVIDENCE III: 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 .