Perception of Nasal Aesthetics: Nose or Face?

BACKGROUND: Aesthetic assessment of the nose might not be limited to the nose as an isolated facial unit but might be the result of a broader perception of the whole facial image. The aim of this study was to investigate if the aesthetic evaluation of a nose is made by sole observation of the nose or influenced by the other features of the face. METHODS: Nose and face photographs of 20 voluntary models were taken from five different angles and merged into a single image of just the noses and whole faces of each model. First the nose and then the face photos were sent to a reviewer group consisting of 100 individuals from different professions to evaluate the nose's beauty on standard questionnaires with a four-week interval to complicate the recall process. RESULTS: Aesthetic evaluation of the isolated nose (Group 1) and the nose with the whole face (Group 2) were compared through Visual Analog Scale (VAS) scores ranging from 1 to 10 (1: the least, 10: the highest). The mean VAS score of the Whole Face Group (5.26 ± 1.28) was significantly higher than the score of the Isolated Nose Group (4.50 ± 1.32) (p 0.001). There was no significant difference between the scores of reviewers considering their gender, profession, or experience of having an aesthetic operation previously. CONCLUSION: Current study revealed that in the evaluation of the beauty of the nose, the holistic perception of the face is as important as the perfection of the angles and proportions within the nose itself. 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 Efficacy of Hydrodilatation for the Prevention of Vasospasm following Microsurgical Anastomosis.

BACKGROUND: Vasospasm is a major problem following microsurgical reconstruction which can result in the partial or complete loss of the flap tissue. The aim of this study was to investigate the efficiency of hydrodilatation for the prevention of vasospasm. METHODS: Thirty male Wistar rats were used for this experimental study. Femoral arteries of were exposed, photographed, and transected. In group 1, group 2, and group 3 papaverine solution, hydrodilatation, and minimal mechanical dilatation (control group) was performed, respectively. The anastomosis was completed and the arteries were photographed again 10 minutes after completion of the anastomosis. Following 7-day period samples for transmission electron microscopy (TEM) and light microscopy were obtained. RESULTS: The mean vessel diameters prior to transection were 0.43, 0.45, and 0.52 mm in the papaverine, hydrodilatation, and control groups, respectively. The mean vessel diameter 10 minutes following the completion of anastomosis was 0.76, 0.75, and 0.51 mm in the papaverine, hydrodilatation, and control groups, respectively. Median score for papaverine group regarding histological parameters of regular endothelial lining and lumen, neutrophil infiltration, vascular congestion, and edema in tunica adventitia was 2, 3, 2, and 3 positive, respectively. Median score for the papaverine group regarding histological parameters of regular endothelial lining and lumen, neutrophil infiltration, vascular congestion, and edema in tunica adventitia was 3, 3, 3, and 3 positive, respectively. All the histological scores were negative in the control group. The difference between the control group and the experiment groups 1 and 2 was significant regarding all four histological parameters (p < 0.05). CONCLUSION: Hydrodilatation and papaverine application were both effective in preventing vasospasm following microsurgical intervention but papaverine caused slightly less damage to the endothelial lining and less edema in the tunica adventitia when compared with the hydrodilatation. Hydrodilatation group showed a vasodilatory effect that was statistically similar to that of papaverine, which has a proven efficacy.

Soft Tissue Thickness Variations of the Nose: A Radiological Study.

BACKGROUND: Soft tissue thickness (STT) is a major factor affecting the outcome in rhinoplasty. However, limited information is found in the literature on the age- and gender-related variations of the nasal STT. OBJECTIVES: The purpose of this study was to measure STT at various landmarks over the nasal framework and compare the age- and gender-related differences. METHODS: STT measurements were made at 11 landmarks in 325 patients by employing magnetic resonance imaging. Patients were divided into subgroups to compare the STT differences between female and male and between the age groups as young, middle age, and elderly. RESULTS: Soft tissue was thickest at the nasion and thinnest at the rhinion. The soft tissue coverage was significantly thicker in the male population at the supratip, tip, nasal bones, upper lateral cartilages, and alar lobules, whereas it is thicker in females at the rhinion. Average thickness of the soft tissues over the entire nasal framework increases with age except the rhinion. CONCLUSIONS: The STT is variable over different parts of the osteocartilaginous framework. Gender and age influence the STT. The soft tissue is thicker at the distal half of the nose in male patients, and these areas become gradually thicker with age, whereas the soft tissue over the midvault becomes thinner. Increasing age presents a particular challenge to achieve predictable results in rhinoplasty, and an understanding of the soft tissue envelope allows for improved aesthetic outcome.

Comparison of contraction rates of epigastric and extended dorsal island skin flaps in rats.

Flap surgery is a wide field in plastic and reconstructive surgery practice and experimental research is needed to improve surgical success. These research is often performed on rats. Rat is a loose-skinned animal and contraction of skin flaps on rats is an underestimated condition. Besides this variable contraction of survived and necrotic tissues may mislead calculations and results. In this study, contraction patterns of epigastric and dorsal island skin flaps were investigated to identify this phenomenon. Forty-two male Sprague-Dawley rats were divided into four groups. Eleven epigastric flaps with unilateral pedicles, 11 epigastric flaps with bilateral pedicles, 10 extended dorsal island skin flaps with unilateral pedicles, and 10 extended dorsal island skin flaps with bilateral pedicles were prepared. Total, necrotic and viable flap areas were calculated from standardized photographs which were taken daily. The animals were placed on marked papers and image processing software was used the calculate flap areas from the photographs. Respect to these daily flap areas, the contraction rates in epigastric flaps were highly significant. The area loss in necrotic tissues were faster than the viable areas. Compared to the epigastric flaps, the contraction was not significant in extended dorsal island skin flaps flap groups. In conclusion, the rat extended dorsal island skin flap is a more reliable model for experimental flap research, which is resistant to contraction, when compared to the epigastric skin flap model.

Subdermal nitrous oxide delivery increases skin microcirculation and random flap survival in rats.

Random skin flaps are essential tools in reconstructive surgery. In this study, we investigated the effect of subdermal nitrous oxide (N2O) application on random flap survival. In this experimental study, we used 21 female rats in three groups. In the N2O and air groups, gases were administrated under the proposed dorsal flap areas daily for seven days. Following the treatment period, flaps were raised and inserted back into their place from the dorsal skin. In the control group, the flaps were elevated and inserted back to their place without any pretreatment. Calculation of necrotic flap areas, histological examination and microangiography was performed to evaluate the results 7 days after the flap surgery. The average of necrotic flap area in the N2O, air and control group was 13.45%, 37.67% and 46.43%, respectively. (N2O vs air p = .044; N2O vs control p = .003). The average number of capillary formations identified in the histological analysis was 7.0 ± 1.58, 3.75 ± 2.36 and 4.4 ± 0.54 in the N2O, air and control group, respectively. (N2O vs air p = .017; N2O vs control p = .037). The average number of capillary structures identified in the angiography images were 6.3 ± 1.52, 1.6 ± 1.15 and 1.3 ± 0.57 in the N2O, air and control group, respectively. (N2O vs air p = .04; N2O vs control p = .02). We conclude that subdermal N2O application increases random flap survival through an increase in the skin microcirculation and could be promising for future clinical applications.

Silicone-based simulation models for peripheral nerve microsurgery.

BACKGROUND: There is a need for a peripheral nerve model on which surgeons-in-training can simulate the repair of nerve injuries at their own pace. Although practicing on animal models/cadavers is considered the "gold standard" of microsurgical training, the proposed model aims to provide a platform for improving the technical skills of surgical trainees prior to their practice on cadaver/animal models. In addition, this model has the potential to serve as a standardized test medium for assessing the skill sets of surgeons. METHODS: Several formulations of silicone were utilized for the design and fabrication of a model which realizes the hierarchical structure of peripheral nerves. The mechanical properties were characterized via the Universal Testing Machine; the damage caused by the needle on the entry sites was assessed through scanning electron microscopy (SEM). RESULTS: Mechanical properties of the formulations of silicone were tested to mimic human peripheral nerves. A formulation with 83.3 wt% silicone oil and 0.1 wt% cotton fiber was chosen to be used as nerve fascicles. Both 83.3 wt% silicone oil with cotton fiber and 66.6 wt% silicone oil without fiber provided a microsuturing response similar to that of epineurium at a wall thickness of 1 mm. SEM also confirmed that the entry of the needle did not introduce significant holes at the microsuturing sites. CONCLUSIONS: The proposed peripheral nerve model mimicked human tissues mechanically and cosmetically, and a simulation of the repair of a fifth-degree nerve injury was achieved.

Margin-Controlled, Staged Surgical Excision in the Treatment of High-Risk Basal Cell Carcinomas of the Head and Neck Region.

BACKGROUND: The most common skin cancer is basal cell carcinoma (BCC), and the gold-standard treatment for high-risk tumours is Mohs surgery. However, alternative methods are needed for high-risk tumours in countries where the performance rate of Mohs surgery is low. OBJECTIVES: The objective of this article is to investigate the feasibility, efficacy, and safety of margin-controlled, staged surgical excision (MCSSE) in high-risk tumours as a possible treatment alternative. METHODS: A retrospective cohort study, including patients diagnosed with high-risk BCC in the head and neck region and treated with MCSSE between 2003 and 2010, was conducted. RESULTS: During the study period 50 tumours in 47 patients were treated, with low adverse event rates and high patient satisfaction rates. Of the 50 tumours, 1 recurred at the 12-month follow-up. CONCLUSIONS: Despite the small sample size and relatively short follow-up period, the present study shows that MCSSE might be a feasible alternative for the treatment of high-risk BCCs in institutions where Mohs surgery is not performed. Future studies on long-term recurrence rates are needed.

Transection of the Nasal Base Muscles for the Correction of Plunging Tip: An Outcome Analysis.

BACKGROUND: The plunging-tip deformity has been attributed to the combined actions of nasal base muscles. However, there are no quantitative data in the literature to discuss the effect of muscle transections on the clinical outcome. OBJECTIVES: This study was designed to assess the actions of the nasal tip, nasal base, and upper lip in patients with plunging-tip deformity and to compare their preoperative and postoperative activities following multiple myotomies. METHODS: Patients were treated for nasal base animation deformity by the transection of the depressor septi nasalis, myrtiformis, nasalis, and levator labii superior alaeque nasi muscles. The profile views of preoperative and 12 months postoperative photographs were selected for measurements. Rest and smile images were overlaid to achieve alignment, and movements were measured with reference to the Frankfurt horizontal plane. RESULTS: Twenty-seven (27) patients were included in the study. Movements of the nasal tip and nasal base were significantly reduced postoperatively. The upper lip shortened significantly in smile poses postoperatively compared with preoperative measurements. The change in the tip angle during animation significantly decreased in the postoperative measurements. CONCLUSIONS: Movements of the nasal tip and the alar base contributed significantly to the hyperdynamic nasal tip deformity. Transection of the nasal base muscles is an effective treatment method with a weaker recovery of the muscle function in the long term. Dynamic upper lip shortening is an unexpected finding following surgery and should be investigated further.

Venous component in scar penetrating neovascularisation.

BACKGROUND: The impact of old scar tissue on the venous anatomy of a flap's pedicle is an important question in reconstructive surgery. This study tried to investigate the venous component in scar penetrating neovascularisation. METHODS: Fifty Sprague-Dawley rats were used in this experimental study. Two experimental groups were designed. In the first group, incisions were performed over the epigastric flap pedicles. In the second group, 1 cm wide segments were excised over the pedicles. Ten weeks after the initial operations, angiographies and histological examinations were performed. A control group was used to demonstrate the normal arterial and venous anatomy of the pedicle. RESULTS: Arterial angiographies revealed that axial pattern arteries were visible in the incision group as opposed to the excision group. Although venous angiographies showed that there were more venous capillary formations in the incision group, none of the experimental groups had regenerated a vein with an axial pattern. Histological examinations revealed that venous vessel formations were significantly less in the distal samples of the experimental groups when compared to the control group (p < 0.05). CONCLUSIONS: In this study, it has been observed that arterial pedicles do regenerate over old incision scars as opposed to veins. In the excision scars neither arterial or venous restoration of the axial pedicle was possible. In these cases, only a random type of limited circulation was restored.

Outcome After Breast Reduction Considering Body Mass Index and Resection Amount.

BACKGROUND: It is presumed that breast reduction improves patients' quality of life and promotes weight loss. Preoperative body mass index (BMI) and the amount of breast tissue (breast reduction amount [BRA]) in proportion to the patient's body weight are important variables to affect the breast reduction outcome. OBJECTIVE: This study was designed to evaluate the short and long-term effects of breast reduction from the perspective of BMI and BRA. METHODS: One hundred fifty-seven consecutive patients were invited to participate in the study. All clinical information was recorded on a breast surgery form. Patients completed a standardized questionnaire preoperatively, at postoperative year 1, and after postoperative year 5. Patients were grouped according to their BMI as "normal weight" and "overweight" and according to BRA as "minor/moderate reductions" and "major reductions." The differences in the BMI values and the life scores were compared between the BMI and BRA groups. RESULTS: Sixty-four patients were included in the study. Postoperative year 1 BMIs were significantly lower than both the preoperative BMIs and postoperative year 5+ BMIs. The year 1 BMI decrease in the major reduction group was higher than the decrease in the minor/moderate reduction group. The postoperative life scores of all subgroups were better than the preoperative life scores. CONCLUSIONS: Reduction mammaplasty has a significant effect on short-term weight loss and the improvement in lifestyle. Patients tend to return to their original body weight in the long term. BRA is a significant variable in short-term weight loss, but neither BMI nor BRA has any other significant effect on the outcome in any time section. LEVEL OF EVIDENCE: 4.

Calculation of contraction patterns in rat skin flap model.

INTRODUCTION: In this study rat abdominal skin flaps were observed daily to explain their contraction behavior and a mathematical formula has been developed. METHODS: 24 male rats were used for the study. Abdominal skin flaps based on the inferior epigastric neurovascular bundles were raised. In the first group all flaps were sutured to their donor area without any extra physical or chemical interference. In the second groups steroid was applied under the flaps to change the contraction rate. RESULTS: Contraction rate was significantly higher in necrotic tissues in both groups. A formula was used to correct for the contraction. The corrected results for the seventh day necrotic area percentage measurements were significantly higher than actual measurements. (p = 0.0001). CONCLUSIONS: By using the mathematical formula developed in this study, pre-contraction value of the experimental skin flaps can be achieved and the results can be interpreted more accurately.

Evaluation of scar penetrating neovascularisation in a rat epigastric flap model.

AIM: The aim of this study is to investigate neovascularisation patterns in the presence of scar tissue and to compare the venous vs arterial components of the scar penetrating neovascularisation. METHODS: Forty male Spraque-Dawley Rats, which were divided into four groups, were used for this study. At the beginning of the study a vertical midline abdominal incision was made to all animals. Six weeks after the incisions were made, epigastric flaps based on inferior epigastric vessels were raised. In the first group both left and right epigastric artery and veins were protected. In the second group only the right epigastric artery and vein was protected. In the third group, besides the right epigastric artery and vein, only the left epigastric artery was kept intact. In the fourth group, besides the right epigastric artery and vein, only the left epigastric vein was kept intact. RESULTS: The percentages of necrotic areas on the flaps were statistically evaluated. The percentages of the necrotic areas on the left side of the flaps were significantly higher in the second group (p = 0.0305). Total flap area necrosis was also significantly higher in the second group (p = 0.026). In each group, vessel formations were identified which were extending through the midline scar tissue in the angiographic evaluations. CONCLUSIONS: These results suggest that scar penetrating neovascularisation on an epigastric flap with one sided pedicle, which is supported by a vein or an artery on the contralateral side, can be enough to facilitate the flap circulation.

Comparison of bone prefabrication with vascularized periosteal flaps, hydroxyapatite, and bioactive glass in rats.

BACKGROUND: Periosteal flaps possess osteoprogenitor cells and an osteoinductive potential that can be further augmented by combination with a biodegradable scaffold; therefore, various osteoconductive and osteostimulative biomaterials are frequently combined with periosteal flaps in studies of bone prefabrication. An experimental study was designed to determine and compare the contribution of bioactive glass and hydroxyapatite to osteoneogenesis in rats when combined with a periosteal flap. MATERIALS AND METHODS: In 60 Sprague Dawley rats, saphenous artery periosto-fasciocutaneous island flaps were transposed to abdomen. In group 1, the flap was left alone, in group 2, an empty artificial pocket made of Gore-Tex (W. L. Gore & Associates, Inc.; Flagstaff, AZ) was sutured onto the periosteal layer, and in groups 3 and 4, the pocket was filled with bioactive glass and hydroxyapatite, respectively. Following sampling for histological analysis, a 4-point scoring system was used to grade inflammatory cell infiltration, osteogenesis, angiogenesis, and cell migration into the bioactive material. RESULTS: The combination of the periosteal flap with any of the bioactive materials resulted in significantly higher percentages of animals exhibiting osteogenesis (80% in hydroxyapatite group and 93.3% in the bioactive glass group; p = 0.0000528) and angiogenesis. Comparison of the bioactive material groups revealed that a significantly higher proportion of animals in the bioactive glass group exhibited moderate or severe inflammation (80 vs. 20%; p = 0.002814). CONCLUSION: Periosteal flaps prefabricated with hydroxyapatite or bioactive glass in rats exhibit osteogenic capacities that are not dependent on direct bone contact or proximity to vascular bony tissue. The innate capacity of the periosteal flap when utilized alone for osteoneogenesis was found to be rather insufficient.

The role of botulinum toxin type a-induced motor endplates after peripheral nerve repair.

INTRODUCTION: The aim of this study was to test the hypothesis that the increased number of new motor endplates induced by botulinum toxin type A (BTX-A) injection before nerve injury would be reinnervated after nerve repair, resulting in greater force generation. METHODS: Thirty male Wistar rats were divided randomly into 3 groups: (1) controls; (2) a group with saline solution injection; and (3) a group with BTX-A injection into gastrocnemius muscle (BTX group). Thirty-six days after the injections the left sciatic nerve was divided and coapted in all groups. Eight weeks later, muscle forces were measured, and histological samples were collected. RESULTS: No differences in the number of innervated endplates were found between the groups, but the number of denervated endplates was higher in the BTX group, as was the muscle tissue degeneration score. The BTX group showed distal muscle force measurements of up to 25.8% less compared with the control group. CONCLUSION: Although BTX-A injection increases the number of motor endplates, they are not functional.

Flap survival after previous vascular pedicle division and preexisting scar formation at the pedicle site: an experimental study.

BACKGROUND: We conducted an experimental study to investigate if it would be possible to re-elevate a flap at a standard flap site if its vascular pedicle was mutilated previously and there was a preexisting scar formation at the pedicle site. MATERIALS AND METHODS: Thirty-five male Sprague-Dawley rats were divided into 3 groups. In the control group (n = 5), animals received a procedure in which unilateral axial pattern abdominal flap was elevated, and then sutured to its original place. The remaining 2 groups underwent 2-stage procedures. In the first stage, scar tissue was created with either a skin incision (group 2, n = 15) or excision (group 3, n = 15) at the prospective pedicle site of the abdominal flap. In the second stage, abdominal flap was raised in 5 rats as a scar-pedicled flap at day 7, day 21, and day 42. Flaps were sutured in their places. Seven days later, flap survival was evaluated. RESULTS: Control flaps had complete survival (day 7, 95.5%; day 21, 94.8%; and day 42, 94.5%). Group 2 and group 3 flaps raised on day 7 (group 2, 65.4%; group 3, 63.9%) and on day 21 (group 2, 65.7%; group 3, 66.7%) showed decreased survival compared to control group flaps (P < 0.05). On day 42, group 1 flaps had better survival when compared to group 2 flaps (82.6% vs 70.0%, P < 0.05). Group 1 flaps showed progressive vascular network formation as evidenced by contrast medium first in the proximal two thirds of the flaps on day 7, and later via visualization of the axial pattern vascular tree on day 42. In group 3, approximately half of the flap was filled with barium contrast and no single pedicle was identified on day 42. CONCLUSIONS: Preexisting scar tissue and pedicle division in the pedicle site of a standard flap diminished dimensions of surviving flap when compared to control flaps. Incision-scar-pedicled flaps achieved better survival compared to excision-group flaps, particularly in the late postoperative period. The study findings showed that it may be possible to raise a flap from previously mutilated site secondary to scar formation and pedicle injury.