The Logical Sequence of Primary Open Rhinoplasty Founded on the Principles of Rhinoplasty Dynamics.

Rhinoplasty is a perplexing procedure due to the variety of complex interplays between anatomical structures of the nose and the maneuvers used to accomplish the intended objective. Although every rhinoplasty is individualized, having a systematic order and an algorithm is crucial to achieve the designed aesthetic goals and a superior outcome, considering the interactions between maneuvers. Otherwise, the accumulated, unanticipated effects will result in displeasing outcomes due to over or under correction. In this report, we describe the sequential steps of rhinoplasty based on knowledge that the senior author has garnered over four decades of experience and having studied the rhinoplasty dynamics continually. Furthermore, we explain the detailed reasoning for each maneuver based on surgical indications and the resulting interplays.Level of Evidence IV 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 http://www.springer.com/00266.

First Report of Testicular Replantation Following Wrong-Site Surgery.

Testicular replantation represents a unique circumstance. There are very few reports documenting their experience with testicle replantation and to the best of the authors' knowledge, this is the first case that has been reported in the peer-reviewed literature following a wrong site surgery. Therefore, we detail our technique and outcome when faced with such a rare event. In addition we review the literature, in order to compare and report the experience of others. This case highlights the value of applied microsurgical knowledge and the importance of cross-disciplinary efforts to improve patient outcomes.

Reflecting on Your Reflection: Examining the Effect of a Non-Reversing Mirror on Self-Perception.

BACKGROUND: Photographic images can clash markedly with patients' self-perception. Individuals are more familiar with their mirror image, where their facial asymmetries are reversed. A non-reversing mirror (NRM) allows patients to see their dynamic non-reversed image and familiarize themselves with how they appear in photographs and to others. OBJECTIVES: The aim of this study was to explore the effect that a NRM has on facial self-perception and investigate whether a NRM changes an individual's goals when considering cosmetic surgery. METHODS: Individuals (n = 30) filled out portions of the FACE-Q questionnaire after inspecting their reflections in a NRM and in a standard mirror for 30 seconds each. After these two inspections had been completed, investigators asked qualitative questions comparing the 2 mirrors. Wilcoxon signed-rank test, Mann-Whitney U test, and Pearson's chi-squared test were used to analyze the differences. RESULTS: Participants scored significantly better on the FACE-Q Age Appraisal and Appearance-Related Psychosocial Distress scales when looking in a standard mirror vs a NRM (P = 0.007 and 0.001, respectively). Qualitatively, most reported that their faces seemed less symmetric and less balanced (73% and 53%, respectively) in the NRM. Overall, 83.3% reported seeing a qualitative difference in their appearance, with 30% endorsing that looking in the NRM had changed their facial aesthetic goals. CONCLUSIONS: A NRM can bridge between the familiarity of the patient's reversed reflection and their less-familiar, non-reversed true image. It may serve as a useful physician-patient communication tool when discussing goals and expectations for facial aesthetic procedures.

The Use of Eye Tracking Technology in Aesthetic Surgery: Analyzing Changes in Facial Attention Following Surgery.

BACKGROUND: The ability to quantitatively analyze how we look at a face and determine if this changes following facial surgery should be of interest to the plastic surgeon. Eye tracking technology (ETT) provides the ability to record where observers fixate when viewing a facial image, enabling quantitative data to be obtained comparing pre- and postoperative changes. OBJECTIVES: The authors sought to investigate ETT as a novel outcome assessment tool, determining if facial rejuvenation surgery shifts attention away from the prominent signs of aging, and if so, where this attention shifts. METHODS: Twenty-five volunteers viewed 32 randomized frontal, oblique, and lateral images of 11 patients pre- and post-facelift. An eye movement monitoring system recorded the observer's eye position, net dwell time, fixation count, fixation time, and revisits into predefined areas of interest. Data were grouped and analyzed by angle and areas of interest. Paired t tests were employed to detect significant differences in pre- and post-images. RESULTS: On frontal images, less dwell time, fixations, and revisits were noted on the bottom third, forehead, perioral region, and neck (P < 0.05). On the lateral view, less visual attention was given to the neck, upper third, and perioral region, with more time in the cheek, nose, and middle third (P < 0.05). On oblique images, less attention was given to the neck and upper lid with more aimed at the middle third of the face (P < 0.05). CONCLUSIONS: ETT provides quantitative data post-facial rejuvenation. Facial aesthetic surgery does alter where observers look when viewing a face, decreasing the time spent inspecting the prominent signs of aging.

Reconstruction of Secondary Calvarial Defects with Ex Situ Split Calvarial Bone Grafts: Long-Term Evaluation of Outcomes.

BACKGROUND: Autologous bone continues to represent the first choice for reconstruction of calvarial defects. However, unanswered questions remain on the natural history of the graft and the influence of patient-related risk factors. This study investigated the outcomes of skull reconstruction with split calvarial bone graft, examining the natural history and stratifying the risk of unfavorable results. METHODS: Patients who underwent cranioplasty with split calvarial bone graft between 1982 and 2016 at the Cleveland Clinic were analyzed, recording demographics, comorbidities, indications, size and location of defect, and outcomes including complications and reoperations. Changes in graft thickness were analyzed using computed tomographic and magnetic resonance imaging scans. RESULTS: Forty-one patients with an average age of 33.2 years, cranial defect size of 68 cm, and mean follow-up of 28 months were included. The majority of patients (85 percent) had significant risk factors, with 43 percent suffering prior infection. Seventy-three percent of patients experienced successful restoration. A major complication was recorded in 26.8 percent; resorption occurred in 19.5 percent of patients (in 75 percent only at the recipient site), with 9.8 percent requiring reoperation. Patients with one or more risk factors or a smoking history were more likely to experience a complication. The mean ratio of the graft to the bicortical donor bone thickness was 0.48 ± 0.17 for the recipient site and 0.57 ± 0.10 for the donor site at an average radiographic follow-up of 11.9 ± 10.9 years. CONCLUSIONS: This study demonstrated a 73.2 percent first-attempt success rate in a high-risk population. The grafts maintain thickness over time, with no evidence of bone hypertrophy. Defect characteristics and patient systemic factors appear to be important variables influencing success. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Apparent Age is a Reliable Assessment Tool in 20 Facelift Patients.

BACKGROUND: Although the literature is replete with favorable facelift results, there are few validated facial rejuvenation outcome measures. Apparent age (AA), a visual estimate of age by objective observers, has been utilized in several studies; although attractive, AA lacks validation. OBJECTIVE: The aim of this study is to examine the reliability of AA, highlighting the importance of the exclusive use of validated outcome measures in future studies. METHODS: Ten blinded reviewers assessed pre- and postoperative photographs of 32 patients who underwent facelift. Each reviewer completed 3 surveys at 3-month intervals composed of 40 randomly ordered photos; totaling 1200 photographs assigned an AA. The intra-class correlation coefficient was classified as "excellent," "good," "fair," or "poor." The accuracy of assigned AA, agreement within 5 years, and reduction in AA were also evaluated. RESULTS: The mean difference of preoperative true age from assigned AA was 2.74 ± 4.36 years. Forty-three percent of raters were within 5-years (±2.5) of the mean. Intra-rater reliability preoperatively and postoperatively were 0.77 (95% CI, 0.82-0.72) and 0.75 (95% CI, 0.79-0.71), respectively. Inter-rater reliability preoperatively was 0.98 (95% CI, 0.99-0.96), while postoperatively was 0.95 (95% CI, 0.99-0.95). Mean AA reduction was 5.23 ± 2.81, with an intra-rater reliability 0.15 (95% CI, 0.03-0.34) and inter-rater reliability 0.65 (95% CI, 0.84-0.38). CONCLUSION: Using current statistical measures and analysis, AA is an acceptable tool for pre- and postoperative facial evaluation when assessed by a group of 10 reviewers. Therefore, apparent age represents a reliable and valid objective observer assigned measure for evaluation of facelift outcomes.

The Cardioplastic Approach to the Treatment of Infected Aortic Grafts.

BACKGROUND: Aortic graft infection (AGI) is a rare complication following reconstructive aortic surgery, yet it represents a significant source of morbidity and mortality. There is no consensus regarding the optimal surgical management, due in part to the small cohorts of patient reports. Pedicled muscle or omental flap coverage of AGI has been shown to improve outcomes, making them a valuable consideration in the treatment algorithm. Thus, we aim to compile and evaluate cases of autologous vascularized tissue (AVT) in the treatment of infected aortic grafts, summarizing location specific trends, treatments, and outcomes. METHODS: A comprehensive review of peer-reviewed literature regarding the management of AGI was performed. Data collected included patient characteristics, original procedure, pathogen, infection location, tissue utilized, technique of tissue isolation and delivery, staging, outcome, length of follow-up, and level of evidence. RESULTS: Ninety-four cases of AGI managed with AVT transfer were identified. Infection of ascending aorta grafts accounted for 59% of cases, followed by a combination of ascending aorta and aortic arch (21%), the descending thoracic aorta (18%), and the thoracoabdominal aorta (2%). The infected graft was preserved in 81% of cases, followed by debridement and AVT coverage. The omentum was the most commonly applied flap (69%) for all divisions of the aorta followed by the pectoralis major (19%), the rectus abdominis (5%), and latissimus dorsi (4%). Mortality was limited, and the Powered by Editorial Manager and ProduXion Manager from Aries Systems Corporation overall survival was 93% (7 deaths), with a mean follow-up of 33.5 months. CONCLUSIONS: Autologous vascularized tissue coverage has proven to be a successful approach for treatment of infected aortic grafts. Although the incidence of AGI is rare, it represents an area of scarce evidence-based literature that warrants increased attention and surgical refinement. These results, which show a remarkably low infection-related mortality rate (3%), should encourage interdisciplinary collaboration with the plastic surgeon, cardiothoracic surgeon, and infectious disease specialists with the goal of improving outcomes in the treatment of infected aortic grafts.

Watershed Areas in Face Transplantation.

BACKGROUND: The maxillary artery has traditionally been considered the main blood supply of the facial skeleton. However, the deep and concealed location makes the harvest of facial allografts based on this artery challenging, giving preference to the facial artery. There is growing evidence that the junction between the hard and soft palate may represent a watershed area in facial artery-based allografts. The aim of this study was to review the occurrence of partial allograft necrosis and modify the available craniofacial techniques, allowing for a reliable harvest of maxillary artery-based facial allografts. METHODS: PubMed/MEDLINE databases were searched for articles presenting allograft perfusion details and the occurrence of partial flap necrosis. Next, 25 fresh cadaver heads were used: eight allografts were harvested by means of a traditional Le Fort III approach, in six the maxillary artery was injected with latex, in three cadaver heads lead oxide gel was injected in the maxillary artery, and eight full facial allografts were harvested through a modified approach. RESULTS: Seven patients developed palatal fistulas or palatal necrosis (41 percent) when allograft was perfused through the facial artery. The traditional Le Fort III approach demonstrated consistent injury to maxillary artery/branches. The modified approach allowed for preservation of the maxillary artery under direct vision. CONCLUSIONS: Current facial transplantation outcomes indicate that facial artery-based allografts containing Le Fort III bony components can experience compromised palate perfusion. The described modified Le Fort III approach allowed safe dissection of the maxillary artery, preserving the arterial blood supply to the facial skeleton. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

Current Evidence for Clinical Efficacy of Platelet Rich Plasma in Aesthetic Surgery: A Systematic Review.

Background: Platelet rich plasma (PRP) has attracted attention in a number of surgical fields due to a wide variety of potential clinical benefits. Yet PRP has not gained wide popularity in aesthetic surgery as a result of uncertainty surrounding objective clinical evidence. Objectives: We aim to describe the current applications, define preparation and activation, explore effectiveness, and propose a classification system to facilitate comparisons across studies. Methods: A comprehensive review of the literature regarding the use of platelet rich plasma in aesthetic surgery was performed. Data gathered included: PRP application, study type, subject number, centrifugation, anticoagulation, activation, PRP composition, and outcomes. Results: Thirty-eight reports were identified. Applications included injection into aging skin (29%), scalp alopecia (26%), lipofilling (21%), fractional laser (13%), and facial surgery (11%). The majority of studies (53%) were case series without controls. Leucocytes were sparsely defined (32%). The concentration of injected and/or baseline platelets was rarely clarified (18%). The mechanism of activation was described in 27 studies (71%), while anticoagulation was uncommonly elucidated (47%). While most studies (95%) claim effectiveness, objective measures were only utilized in 17 studies (47%). Conclusions: Current studies produce context-dependent results with a lack of consistent reporting of PRP preparation, composition, and activation in aesthetic applications, making meaningful meta-analysis unrealistic. Thus the method of PRP preparation warrants increased attention. We recommend a set of descriptors, FIT PAAW (described below), to produce scientifically grounded conclusions, facilitating a clearer understanding of the situations in which PRP is effective. Level of Evidence: 4

Pterygopalatine Fossa Anatomy for a Surgical Approach to Sphenopalatine Ganglion.

The sphenopalatine ganglion is an extracranial neural structure within the pterygopalatine fossa. Modulation of this region via implantation of a neuromodulatory device presents a novel therapy for the treatment of facial and head pain. Yet sex, race, and genetic factors contribute to morphological variations between individuals. This study defines the standards and variations of the bony landmarks surrounding the pterygopalatine fossa. One hundred dry skulls were analyzed from the Hamann-Todd osteological collection. Ten anatomical dimensions were measured on each side of the face for each specimen (vidian foramen, zygomatic buttress, zygomatic maxillary suture, pyriform rim, infraorbital rim, pterygoid maxillary suture, greater palatine foramen, auditory canal, and pterygoid fossa). A statistical analysis was performed for both sides of the face based on sex and race. When stratified by sex, 7 of the 10 measurements revealed a statistically significant difference bilaterally. When stratified by race, 5 of the 10 measurements demonstrated a statistically significant difference bilaterally. Both male and African American skulls showed greater hemifacial values bilaterally when compared with their respective counterparts. The only statistically significant measurement on both the left and right sides of all skulls was the length from the vidian foramen to the infraorbital rim. Defining the anatomical mean distance between skull landmarks and highlighting differences between sex and race not only provides further insight into relative skull anatomy, but also sets the stage for device innovation.