Wound Healing Complications With Tranexamic Acid: Not the Silver Bullet After All.

Tranexamic acid (TXA) has been popularized as an adjunct to decrease the risk of bleeding and subsequent bruising and edema in aesthetic surgery. The most notable risks of TXA are thrombus and seizures, which are associated with higher plasma concentrations of the acid. In an effort to mitigate these risks, surgeons have begun using TXA locally, either as a topical irrigation or mixed into the local anesthetic. Although local use is thought to be safer from a side-effect standpoint, because there is decreased systemic absorption, its use is not without risk. We present 4 patients who developed wound healing complications thought to be related to locally administered TXA. One patient had TXA delivered topically, and 3 patients had TXA mixed into their local anesthetic. These adverse events have not been published in the literature previously. This case report serves as a warning to other surgeons about using locally administered TXA.

Complications of Polydioxanone Foil Use in Nasal Surgery: A Case Series.

Polydioxanone (PDS) foil is widely recognized as a septal cartilage replacement during rhinoplasties and is thought to be completely resorbable and biodegradable. Since its United States Food and Drug Administration approval in 2010, PDS foil has drawn significant enthusiasm and many surgeons consider it an ideal implantable biomaterial as reflected in numerous studies highlighting its benefits. However, scant literature exists highlighting relevant complications of PDS plates that may potentially lead to cavalier overuse. This descriptive case series assesses the outcomes of PDS foil usage in three patients seen for septoplasty at two independent institutions over the past 5 years. Our results demonstrate that PDS plate usage can lead to septal cartilage loss and resultant saddle nose deformity associated with prolonged postoperative edema and inflammation. To our knowledge, this is the largest case series of this reported phenomenon.

Modification of Chin Projection and Aesthetics With OnabotulinumtoxinA Injection.

IMPORTANCE: Because of the soft-tissue envelope and the dimensional complexity of the muscular contraction of the mentalis muscle, the projection and shape of the chin is not determined by only the bony projection. In a subset of patients with a seemingly underprojected chin, a hyperactive, high-riding mentalis muscle contributes to a blunted chin contour. OBJECTIVE: To evaluate the use of onabotulinumtoxinA (botulinum toxin A) for improving chin aesthetics in patients with an underprojected bony chin and a high-riding hyperactive mentalis muscle. DESIGN, SETTING, AND PARTICIPANTS: This case series and photographic analysis included 11 patients presenting with an underprojected bony chin and a high-riding hyperactive mentalis muscle at a private facial plastic surgery practice from August 25, 2006, to November 10, 2012. Data were analyzed from November 13, 2012, to April 9, 2013. INTERVENTIONS: Injection with 12 to 15 U of onabotulinumtoxinA into the mentalis muscle. MAIN OUTCOMES AND MEASURES: Photographic analysis of the vertical and horizontal positions of the pogonion relative to fixed facial points before and after injection. A patient satisfaction scale was also used to assess improvement in overall chin aesthetic. RESULTS: Eleven patients (3 men and 8 women; mean [SD] age, 46.3 [16.4] years) participated in the study, including 2 who had undergone prior chin implantation. The vertical position of the pogonion was more inferior after injection in 10 of 11 patients (mean [SD] vertical position, 1.36 [0.18] preinjection and 1.44 [0.18] postinjection; P = .005). Although the horizontal position of the pogonion changed in all patients, this change was not statistically significant (mean [SD] horizontal position, 0.11 [0.13] preinjection and 0.14 [0.13] postinjection; P = .32). All patients experienced improvement in their overall chin aesthetic and a subjective decrease in chin tension. Chin contour was improved, with soft-tissue volume overall displaced more inferiorly with a rounded rather than blunted appearance. No adverse effects were reported after injection. CONCLUSIONS AND RELEVANCE: OnabotulinumtoxinA is effective at improving chin aesthetics by altering the position of the pogonion. In this first photographic analysis to date of the influence of onabotulinumtoxinA treatment, patients demonstrated a measurable change in the position of the pogonion, in addition to improvements to the chin contour on profile. This nonsurgical mentoplasty may be used as an independent procedure or as an adjunct to optimize traditional chin augmentation in carefully selected patients. LEVEL OF EVIDENCE: 4.

An Analysis of Lateral Crural Repositioning and Its Effect on Alar Rim Position.

IMPORTANCE: Cephalically malpositioned lateral crura are a frequent cause of alar rim retraction during both primary and revision rhinoplasty. OBJECTIVE: To demonstrate the efficacy of lateral crural repositioning as an isolated maneuver as and combined with adjunctive grafts for lowering the alar rim. DESIGN, SETTING, AND PARTICIPANTS: From August through December 2014, we retrospectively reviewed the cases of 54 patients (102 hemi-noses) who had lateral crural repositioning performed by the same surgeon between 2007 and 2013. Only patients with standardized photographs taken preoperatively and at least 6 months postoperatively were included in the study. INTERVENTIONS: All primary and revision cases were completed via an open rhinoplasty approach and had lateral crural repositioning performed. MAIN OUTCOMES AND MEASURES: Preoperative and postoperative photographs were compared using Adobe Photoshop CS via a modified Gunter technique to measure the degree of alar rim retraction on lateral views. The change in angle was then calculated, and statistical analysis conducted using a paired t test. RESULTS: A total of 54 patients (102 hemi-noses) met inclusion criteria; 42 (79%) were women, and the average patient age was 41.3 years. Forty-five (83%) of the cases were revision rhinoplasties, and the average time to obtaining postoperative photographs was 11.3 months. The mean (SD) anterior nostril apex angles preoperatively (31.3° [8.9°]) and postoperatively (24.5° [6.8°]) indicated a net decrease of 6.8° (P < .001). Excluding patients who had other rim-lowering grafts (alar rim and/or composite grafts), we saw a similar result comparing preoperative (31.1° [8.2°]) and postoperative (24.5° [6.7°]) angles, with a net decrease of 6.6° degrees (P < .001). When examining patients who underwent lateral crural repositioning alone compared with those who also had lateral crural strut grafts, we saw a decrease of 6.9° (P < .001) and 6.7° degrees (P < .001), respectively. CONCLUSIONS AND RELEVANCE: Repositioning of the lower lateral cartilages results in a statistically significant lowering of the alar rim. Our data suggest that when combined with lateral crural repositioning, the addition of adjunctive grafts does not add significantly to the rim-lowering effect. LEVEL OF EVIDENCE: 3.

Accuracy of preoperative computer imaging in rhinoplasty.

OBJECTIVE: To quantitatively measure the accuracy of preoperative computer imaging (PCI) as a reflection of postoperative rhinoplasty results. METHODS: Thirty-eight patients underwent primary and revision rhinoplasty. Six-month postoperative photographs and "morphed" PCI images were graded on a 5-point Likert scale by 2 panels of judges, one composed of surgeons and the other of nonsurgeons. Twelve parameters were assessed. Results were stratified based on primary vs revision rhinoplasty and degree of difficulty of the rhinoplasties. Patient surveys were conducted to determine correlation between satisfaction and PCI accuracy. RESULTS: Mean overall accuracy was 2.98 by the expert panel, indicating moderate PCI accuracy. Supratip height was the lowest-rated parameter, while measurements of the upper third were most accurate. The accuracy in primary rhinoplasty was comparable to that found in revision surgery, although tougher cases were rated lower in overall accuracy and projection score. Satisfied patients had significantly higher PCI accuracy scores, and most patients found the PCI extremely useful. CONCLUSIONS: Preoperative computer imaging is a useful exercise, valued by patients during the rhinoplasty consultation. Accuracy is moderate in both primary and revision cases, although supratip edema is a limiting factor at the 6-month mark.

Cosmetic treatments and strategies for the upper face.

Botulinum toxin type A injection have become commonplace and are an essential part of the aesthetic management of the upper face. A through understanding of the interrelationships between relevant facial muscles allows clinicians to use Botox for a wide range of conditions in addition to those for which it was initially approved. This article provides an overview and strategy for using Botox to address various cosmetic issues in the upper face. The information provided serves as a practical guide for practitioners who wish to expand their everyday use of the neurotoxin.

Injected hyaluronidase reduces restylane-mediated cutaneous augmentation.

OBJECTIVE: To determine the effects of injected hyaluronidase in cutaneous areas previously augmented with Restylane (Q-Med AB, Uppsala, Sweden), a nonanimal, stabilized hyaluronic acid (NASHA) gel. METHODS: A prospective, randomized study was undertaken in 2 parts. First, the effects of hyaluronidase and saline were compared on post-NASHA dermal augmentation. Next, 3 different doses of hyaluronidase were evaluated after NASHA gel dermal augmentation. A blinded evaluator assigned postinjection skin scores. Each patient served as his or her own control. RESULTS: Hyaluronidase dramatically reduced the size of the augmentation created by injected Restylane in all of our subjects. A comparison of average scores of saline-injected sites vs hyaluronidase-injected sites revealed a statistically significant difference. By 4 to 7 days after hyaluronidase injection, skin scores were at 20% of baseline (P<.001). Dose-related response to injected hyaluronidase was also observed, although it was not statistically significant. A number of patients (25%) demonstrated localized, self-limiting hypersensitivity reactions to injected hyaluronidase. CONCLUSIONS: Intradermal hyaluronidase injections can be used to reduce dermal augmentation from previously injected Restylane. A small dose of hyaluronidase equivalent to 5 to 10 U may be injected initially.

Midfacial rejuvenation: personal experiences and philosophy.

Procedures to rejuvenate the face are constantly evolving. Elevating the midfacial tissues in a vertical direction has gained recent popularity, as it seems to enhance results achieved from more traditional rhytidectomy techniques. Many methods have been described for performing this operation, and the differences among them range from subtle to profound. This article describes my experiences with some of these techniques and explains my personal evolution to the present. It is hoped that the reader will gain insight into the advantages and disadvantages of these surgical techniques and that he or she will be encouraged to explore various methodologies for rejuvenating the midface. The preferred surgical technique that is described herein should also serve as a stepping stone for those readers whose efforts will continue to expand our surgical options and enhance results in the future.

Altering brow contour with botulinum toxin.

Brow position is determined by a dynamic interaction between depressor and elevator muscles. Botulinum toxin may be used to temporarily alter this equilibrium to result in a change in brow position. Knowledge of the anatomy of the brow depressors and elevators allows selective treatment of these muscles to effect a change in contour to elevate or depress a specific part of the brow. Botulinum toxin browlifting may result in an aesthetically pleasing, modest brow elevation; however, individuals who have significant brow ptosis would be better treated surgically.