Paramedian forehead flap pedicle division after 7 days using laser-assisted indocyanine green angiography.

The paramedian forehead flap is a major workhorse for reconstruction of medium- to large-sized nasal defects. The tissue bridge that results from the vascular pedicle results in significant cosmetic deformity, with associated social and occupational costs to the patient. This prospective cross-sectional study sought to assess efficacy and safety of takedown of the flap pedicle at 1 week using indocyanine green (ICG) angiography to assist in determining neovascularization of the flap. This study was performed at a tertiary care center from April 13, 2018 to March 22, 2019. Patients eligible for enrollment included those with defects appropriate for reconstruction with a paramedian forehead flap, partial-thickness defect, vascularized tissue in more than 50% of the recipient bed, and lack of nicotine use. Ten patients were included, and all underwent reconstructive surgery by a single surgeon. Laser-assisted ICG angiography was used during the first stage as well as at the second stage both immediately before and after flap division. Perfusion was in both time-independent and time-dependent analyses relative to a cheek reference point. Herein, we found successful 7-day flap takedown with no flap-related complications in all patients. There was an average of approximately 44% flap-to-cheek vascularity across all patients, and pre-division flap perfusion correlated well with post-division perfusion. In conclusion, in carefully selected patients with amenable defects, division of the pedicle at 1 week after initial flap transfer is safe and has the potential to limit the morbidity associated with the procedure.

Influence of the Topographic Vascular Distribution of the Face on Dermal Filler Accidents.

OBJECTIVE: Dermal fillers are an important tool in the field of aesthetic dermatology. Fillers are relatively noninvasive and easy to use but are not free of secondary complications. The main complications are vascular and are due to either the compression of an artery or the direct introduction of the product into the arterial lumen. The aim of this study is to provide an overview of the vascular territories of the face to avoid many possible complications when using facial fillings. Anatomical localization of the main arterial supply to the face has been described to assess the risk of vascular injury. METHODS: The authors dissected 17 hemifaces of embalmed adult cadavers that had previously been injected, through the common carotid artery, with latex containing a red dye. RESULTS: A topographic distribution was generated by facial regions following a clinical approach from where the facial fillings were placed and related to the pathways of the arteries. Following these criteria, we established 8 topographic regions (I-VIII) that indicate the main vascular problems of each of these regions. Detailed anatomical localizations of the main arteries in these topographic regions of the face and their relationships are described. CONCLUSIONS: The highest index of vascular lesions and especially visual alterations occurred for fillings of the upper third of the face. To prevent and avoid this type of lesion, it is advisable to avoid, as much as possible, treatments with filling materials in the upper third of the face, mainly including the glabellar and nasal region (III) and supraorbital region (VIII).

Lesions of the Parotid Gland and Buccal Artery After Buccal Fat Pad Reduction.

The significant increase in esthetic surgery, especially buccal fat pad reduction, has led to a corresponding increase in lesions and postoperatory after-effects from this surgical procedure. The aim of this study is to discuss the immediate and mediate risks of removing the Bichat ball, as well as describing a clinical study in which this surgical procedure resulted in lesions of the parotid gland and buccal artery, which was confirmed via nuclear magnetic resonance. The facial lesions were remedied via exploratory surgery by opening a new orifice of the glandular duct in the buccal cavity followed by drainage and compressive surgical bandages.

Distinctive vasculopathy with systemic involvement due to levamisole long-term therapy: a case report.

BACKGROUND: Levamisole belongs to the antihelminthic class of drugs that are sometimes administered to patients with frequently relapsing or steroid-dependent nephrotic syndrome, owing to its steroid-sparing effects. Neutropenia and skin lesions, compatible with vasculitis, have been reported as drug complications, but they are rarely associated with any systemic involvement. CASE PRESENTATION: We report a case of a 9-year-old Arab boy with steroid-dependent nephrotic syndrome who was treated with levamisole after his third relapse. The drug was initially well tolerated, but mild isolated neutropenia occurred 6 months after levamisole administration. This was followed by cutaneous vasculitis of both ears and the left cheek. The patient also developed hepatosplenomegaly and anemia. Levamisole was discontinued, and his disease remained in remission. All the systemic manifestations disappeared gradually over the course of 1 month. The patient remained in remission until 1 year after levamisole withdrawal, when clinical nephrosis recurred. CONCLUSIONS: Despite levamisole's being a useful drug for maintaining remission in steroid-dependent nephrotic syndrome, patients on long-term levamisole therapy should be monitored closely to prevent serious complications that can easily be resolved by simple drug withdrawal.

Effects of Selenium in the Microcirculation of Fructose-Fed Hamsters.

BACKGROUND AND AIMS: Fructose intake is directly related to vascular dysfunction and it is a risk factor for the development of metabolic and cardiovascular diseases, such as obesity, diabetes, and hypertension. Selenium, a component of antioxidant enzymes, improves hyperglycemia and vascular function in diabetic animals. The aim of this study was to evaluate the effects of dietary selenium supplementation on microcirculatory and metabolic parameters of fructose-fed hamsters. METHODS AND RESULTS: Male hamsters (Mesocricetus auratus) had their drinking water substituted or not by 10% fructose solution for 60 days, during which their microcirculatory function was evaluated in the cheek pouch preparation. Blood glucose and serum insulin levels were also tested. Microcirculatory responses to acetylcholine (an endothelium-dependent vasodilator) and to sodium nitroprusside (SNP, an endothelium-independent vasodilator), and macromolecular permeability increase induced by a 30-min ischemia/reperfusion (I/R) procedure, showed that endothelium-dependent and independent vasodilatation was significantly increased in animals that had high selenium supplementation, in both the control and fructose-fed groups. Selenium supplementation protected against plasma leakage induced by I/R in all control and fructose-fed groups. CONCLUSION: Our results indicate that dietary selenium supplementation reduces microvascular dysfunction by increasing endothelial-dependent and independent dilatation and reducing macromolecular permeability increase in fructose-fed animals.

Nitrosative stress uncovers potent ß2-adrenergic receptor-linked vasodilation further enhanced by blockade of clathrin endosome formation.

This study investigated the effect of sodium nitroprusside (SNP) preexposure on vasodilation via the ß-adrenergic receptor (BAR) system. SNP was used as a nitrosative/oxidative proinflammatory insult. Small arterioles were visualized by intravital microscopy in the hamster cheek pouch tissue (isoflurane, n = 45). Control dilation to isoproterenol (EC50: 10-7 mol/l) became biphasic as a function of concentration after 2 min of exposure to SNP (10-4 M), with increased potency at picomolar dilation uncovered and decreased efficacy at the micromolar dilation. Control dilation to curcumin was likewise altered after SNP, but only the increased potency at a low dose was uncovered, whereas micromolar dilation was eliminated. The picomolar dilations were blocked by the potent BAR-2 inverse agonist carazolol (10-9 mol/l). Dynamin inhibition with dynasore mimicked this effect, suggesting that SNP preexposure prevented BAR agonist internalization. Using HeLa cells transfected with BAR-2 tagged with monomeric red fluorescent protein, exposure to 10-8-10-6 mol/l curcumin resulted in internalization and colocalization of BAR-2 and curcumin (FRET) that was prevented by oxidative stress (10-3 mol/l CoCl2), supporting that stress prevented internalization of the BAR agonist with the micromolar agonist. This study presents novel data supporting that distinct pools of BARs are differentially available after inflammatory insult. NEW & NOTEWORTHY Preexposure to an oxidative/nitrosative proinflammatory insult provides a "protective preconditioning" against future oxidative damage. We examined immediate vasoactive and molecular consequences of a brief preexposure via ß-adrenergic receptor signaling in small arterioles. Blocked receptor internalization with elevated reactive oxygen levels coincides with a significant and unexpected vasodilation to ß-adrenergic agonists at picomolar doses.

Surgical Resection of Vascular Lesions Involving the Buccal Fat Pad.

Vascular abnormalities are localized structural irregularities, which are performed during vasculogenesis, angiogenesis, and lymphangiogenesis. The involvement of soft tissue in such vascular malformations is frequent; however, the compromising of the buccal fat pads (Bichat bags) is uncommon, even in specialized centers, such as the plastic clinic of our institution, in which very few patients have been reported in the literature. The purpose of this article is to present a series of 2 patients in which vascular malformations involving the buccal fat pads, which were extracted by intraoral approach.

A Minimally Invasive Endoscopic Approach to Midcheek Mass: Showcase for Technical Description.

BACKGROUND: Surgical approaches to the midcheek area are challenging. This area is included between the lower eyelid above, and the upper lip below. The peculiar anatomical location makes it really important for attractiveness, thus the need to obtain a correct balance between the operation's safety and minimally invasive aspect. To the authors' knowledge, this is the first showcase and technical description of a novel minimally invasive endoscopic approach for midcheek mass removal. METHODS: Making 3 incisions in concealed area an endoscopically aided facial dissection was performed to remove a solitary venus malformation of the left midcheek region. RESULTS: After the surgical procedure was performed, no hematoma, no edema, or facial nerve paralysis were observed. To date, during the follow-up period, no recurrence of the lesion has been observed, and the quality of life of the patient was good with a minimally scar outcome. Magnetic resonance imaging, performed 2 weeks postoperatively, demonstrated a complete removal of the mass CONCLUSION:: The authors' finding experience suggests that the minimally invasive approach provides an excellent surgical window that achieves greater exposure for the dissection of the midcheek area. Further clinical applications are required to assess advantages and/or limitations of this procedure.

Updated anatomy of the buccal space and its implications for plastic, reconstructive and aesthetic procedures.

BACKGROUND: The buccal space is an integral deep facial space which is involved in a variety of intra- and extra-oral pathologies and provides a good location for the harvest of the facial artery. The age-related anatomy of this space was investigated and compared to previous reports. METHODS: We conducted anatomic dissections in 102 fresh frozen human cephalic specimens (45 males, 57 females; age range 50-100 years) and performed additional computed tomographic, magnetic resonance and 3-D surface volumetric imaging studies to visualize the boundaries and the contents of the buccal space after injection of contrast enhancing material. RESULTS: The mean vertical extent of contrast agent injected into the buccal space was 25.2 ± 4.3 mm and did not significantly differ between individuals of different age (p = 0.77) or gender (p = 0.13). The maximal injected volume was 10.02 cc [range: 3.09-10.02] without significant influence of age (p = 0.13) or gender (p = 0.81). The change in surface volume was 3.64 ± 1.04 cc resulting in a mean surface-volume-coefficient of 0.87 ± 0.12 without being statistically significant influenced by age (p = 0.53) or gender (p = 0.78). CONCLUSIONS: The facial artery was constantly identified within the buccal space whereas the facial vein was found to course within its posterior boundary. The buccal space did not undergo age-related changes in volume or size which highlights this space is a reliable and predictable landmark for various plastic, reconstructive and aesthetic procedures.

Regional heterogeneity in the mechanisms of myogenic tone in hamster arterioles.

Myogenic tone is an important feature of arterioles and resistance arteries, but the mechanisms responsible for this hallmark characteristic remain unclear. We used pharmacological inhibitors to compare the roles played by phospholipase C (PLC; 10 µM U73122), inositol 1,4,5-trisphosphate receptors (IP3Rs; 100 µM 2-aminoethoxydiphenylborane), protein kinase C (10 µM bisindolylmaleimide I), angiotensin II type 1 receptors (1 µM losartan), Rho kinase (10 nM-30 µM Y27632 or 300 nM H1152), stretch-activated ion channels (10 nM-1 µM Gd3+ or 5 µM spider venom toxin GsMTx-4) and L-type voltage-gated Ca2+ channels (0.3-100 µM diltiazem) in myogenic tone of cannulated, pressurized (80 cmH2O), second-order hamster cremaster or cheek pouch arterioles. Effective inhibition of either PLC or IP3Rs dilated cremaster arterioles, inhibited Ca2+ waves, and reduced global Ca2+ levels. In contrast, cheek pouch arterioles did not display Ca2+ waves and inhibition of PLC or IP3Rs had no effect on myogenic tone or intracellular Ca2+ levels. Inhibition of Rho kinase dilated both cheek pouch and cremaster arterioles with equal efficacy and potency but also reduced intracellular Ca2+ signals in both arterioles. Similarly, inhibition of mechanosensitive ion channels with Gd2+ or GsMTx-4 produced comparable dilation in both arterioles. Inhibition of L-type Ca2+ channels with diltiazem was more effective in dilating cremaster (86 ± 5% dilation, n = 4) than cheek pouch arterioles (54 ± 4% dilation, n = 6, P < 0.05). Thus, there are substantial differences in the mechanisms underlying myogenic tone in hamster cremaster and cheek pouch arterioles. Regional heterogeneity in myogenic mechanisms could provide new targets for drug development to improve regional blood flow in a tissue-specific manner.NEW & NOTEWORTHY Regional heterogeneity in the mechanisms of pressure-induced myogenic tone implies that resistance vessels may be able to alter myogenic signaling pathways to adapt to their environment. A better understanding of the spectrum of myogenic mechanisms could provide new targets to treat diseases that affect resistance artery and arteriolar function.

Contribution of muscarinic receptors to in vitro and in vivo effects of Ruscus extract.

The objectives of this study were to evaluate, in vitro and in vivo, the contribution of muscarinic receptors to the effects of Ruscus extract. Ruscus extract was tested in competition binding experiments at recombinant human muscarinic receptors, heterologous expressed in Chinese Hamster Ovary (CHO) cells and in cellular assays measuring Ca2+ liberation and activator protein-1 (AP-1) reporter gene activation. The impact of muscarinic blockade on prolonged treatment outcome was evaluated using the hamster cheek pouch (HCP) microcirculation examining macromolecular permeability increase induced by histamine or ischemia/reperfusion (I/R), mean arteriolar and venular diameters, functional capillary density and I/R-induced leukocyte rolling and sticking. Ruscus extract exhibited affinities for muscarinic receptor subtypes at a range of 50-100µg/ml and behaved as partial agonist at human recombinant M1 and M3 receptors for Ca2+ liberation, confirmed in an AP-1 reporter gene assay. In the HCP model, topical application of atropine completely or partially blocked Ruscus extract-induced reductions of histamine- and I/R-induced increases of macromolecular permeability and leukocyte-endothelium interaction. Our results showed that Ruscus extract in vitro binds and activates different subtypes of muscarinic receptors and in vivo its anti-inflammatory effects are, at least partially, mediated via muscarinic receptors.

Direct Measurement of Tissue Oxygenation in Neonates via Resonance Raman Spectroscopy: A Pilot Study.

BACKGROUND: The ability to monitor tissue oxygenation in neonates remains a challenge due to limited blood supply and the reliance on invasive procedures. Resonance Raman spectroscopy noninvasively measures tissue oxygenation (RRS-StO2). Peripheral tissue oxygenation using this novel technology has not been described in neonates. OBJECTIVES: To examine the relationship between short-term RRS-StO2 measurements and central venous saturation (ScvO2) and pulse oximetry (SpO2) in preterm and term neonates. METHODS: Ninety-seven term neonates had buccal and plantar RRS-StO2 measurements performed. In 15 preterm neonates, similar measurements were obtained in conjunction with ScvO2 in the first week of life. Simultaneous SpO2 and heart rate were also recorded. RESULTS: In healthy neonates, buccal RRS-StO2 values negatively correlated with the day of life. No correlation existed between buccal and plantar RRS-StO2 values and ScvO2 or SpO2. Greater intra-patient plantar RRS-StO2 variability was seen in preterm neonates with increasing respiratory support. CONCLUSIONS: Neonatal RRS-StO2 measurements are feasible short term but do not correlate with ScvO2 and SpO2. Healthy neonates had greater differences and variability in RRS-StO2 values, illustrating an evolving microcirculation not detected with pulse oximetry. Greater RRS-StO2 variability in sick neonates requiring respiratory support may indicate microcirculatory instability despite being within target SpO2 ranges. Further study is needed to establish if RRS-StO2 monitoring is an accurate representation of tissue oxygenation.

Computer-aided quantification of microvascular networks: Application to alterations due to pathological angiogenesis in the hamster.

Angiogenesis is both a physiological and a pathological process of great complexity, which is difficult to measure objectively and automatically. The hamster cheek pouch (HCP) prepared for intravital-microscopy (IVM) has been used to characterize microvascular functions in many studies and was chosen to investigate microvascular characteristics observed in normal non-infected hamsters as compared to those HCPs parasitized by Trypanosoma cruzi. Images of HCPs captured at IVM were subjected to computer based measurements of angiogenesis and histamine-induced macromolecular (FITC-dextran) leakage with an image segmentation approach that has the capacity to discriminate between fluorescence emitted by macromolecular tracers inside the vasculature and in the extravascular space. We present such an automatic segmentation methodology using known tools from image processing field that, to our knowledge, have not been tested in IVM images. We have compared this methodology with a recently published segmentation strategy based on image intensity thresholding. Our method renders an accurate and robust segmentation of blood vessels for different microvascular scenarios, normal and pathological. Application of the proposed strategy for objective and automatic measurement of angiogenesis detection was explored in detail.

The Freestyle Facial Artery Perforator Flap for Reconstruction of Simultaneous Periorbital and Cheek Defects.

The reconstruction of defects involving the nasolabial, paranasal, and periorbital regions may be challenging, because they often involve more than one facial aesthetic unit, and can lead to functional problems. An average of 5 facial artery perforators of caliber >0.5 mm can be found above the mandible. A reference point for the location of the most constantly encountered perforator was suggested as being 1.5 cm lateral to the oral commissure, and at its same level in height or slightly inferior to the commissure. Based on injection studies, it is known that these perforators can supply an average area of 8 cm. The authors have extended the use of the freestyle perforator flap in a 87-year-old woman presented with an advanced melanoma of the paranasal area and nasolabial region (Breslow depth: 9 mm; Clark level V). Complete resection of the lesion with 3 cm oncological margins was performed. One-stage reconstruction with superior cosmetic results was achieved. The need for a perforator dissection is not necessarily a drawback, and classic concerns should be abandoned. The face is highly vascularized, and flap congestion is a rare event, usually a consequence of excessive pedicle trimming. Although technically more demanding, it should become one of the first reconstructive options when dealing with similar defects, if our results are confirmed in larger series.

Vascular Perfusion of the Facial Skin: Implications in Allotransplantation of Facial Aesthetic Subunits.

BACKGROUND: As the field of face transplantation develops, it may be possible to transplant segments of facial skin to replace facial aesthetic subunits in selected cases. The aim of this study was to identify the more reliable vascular pedicles of each facial aesthetic subunit for its use in transplantation METHODS:: Six full facial soft-tissue flaps were harvested, and the external carotid artery was identified and cannulated proximal to the facial artery. Next, radiopaque contrast was injected through the facial artery into three of the facial flaps and through the superficial temporal artery in the other three facial flaps. After vascular injections, three-dimensional computed tomographic arteriographs of the faces were obtained, allowing analysis of the arterial anatomy and perfusion in different facial aesthetic subunits. RESULTS: The chin, lower lip, upper lip, medial cheek, nose, and periorbital units were perfused in all facial flaps where the facial artery was injected and in none of those where the superficial temporal artery was injected. The lateral cheek was perfused in 100 percent of the superficial temporal artery flaps and in 67 percent of the facial artery flaps. The lateral forehead contained contrast in 100 percent of the superficial temporal artery-injected flaps and in none of the facial artery-injected flaps, and the medial foreheads contained contrast in 67 percent of the facial artery-injected flaps and in 67 percent of the superficial temporal artery-injected flaps. CONCLUSION: The majority of the facial subunits can be harvested based on the facial artery pedicle, with the exception of the lateral forehead, which is based on the superficial temporal artery.

Combined Intralesional Neodymium-Doped Yttrium Aluminium Garnet Laser and Intratumoral Ligation as Curative Treatment for Craniofacial Arteriovenous Malformations.

Craniofacial arteriovenous malformation (AVM), although very rare, has been a very difficult problem to treat especially when it is large and involves important structures. Surgical resection often results in unacceptable complications but still not curative. At our institution, treatment by combined intralesional neodymium-doped yttrium aluminium garnet laser and intratumoral ligation has been successful in venous malformation. This minimally invasive technique was then applied to more challenging AVM on the head and neck. Disease control was studied using clinical parameters and magnetic resonance imaging.Four patients with moderate-to-severe (Schobinger 2-4) craniofacial AVM were treated by this technique from 2001 to 2011. Patient age ranged from 2 to 51 years (mean: 25 years). After 2 to 4 treatments and follow-up period of 1456 days, 3 (75%) were cured. One of them was infant with huge mass and secondary pulmonary hypertension. Clinical cure was achieved after 3 treatments without residual cardiovascular compromise. The other patient (25%) had cheek mass with intraorbital involvement. The authors did not treat periorbital lesion so as to avoid triggering intraorbital spreading. The rest of the cheek lesion was clinically and radiologically cured.Laser energy setting, ablative technique, and skin cooling are the main factors determining the success. Individualized laser settings and properly set endpoints can increase treatment effectiveness in shorter period. In conclusion, this minimally invasive technique was successful in curing AVM without complication. With more clinical study and development of soft tissue monitoring tools, it is possible that intralesional laser could become the treatment of choice for all cutaneous AVM.

Cheek reconstruction following facial malignant melanoma surgery with the platysma myocutaneous flap.

The aim of this study was to evaluate the results of large cheek skin defect reconstruction using a superiorly based platysma myocutaneous flap accompanied by facial artery and vein preservation, following cutaneous head and neck melanoma surgery. This study offers new insight into a procedure that is a viable, but infrequently used reconstruction option. The authors report the cases of 13 consecutive patients with cheek skin defects following melanoma surgery who underwent reconstruction with a superiorly based platysma myocutaneous flap. The procedures were performed at a tertiary clinical centre and a national melanoma surgery referral centre between 2001 and 2008. According to the disease stage, eight patients underwent sentinel lymph node biopsy and five underwent comprehensive neck dissections. All of the patients were monitored for any complications related to the donor and recipient sites. Minor venous congestion of the flap was noted in two patients, with minor marginal skin necrosis in one patient. None of the patients had donor site complications. The superiorly based platysma flap proved to be a safe and reliable option for large cheek defect reconstruction, especially considering that it is a single-stage reconstruction procedure ensuring excellent colour-matching and low donor site morbidity.