Preoperative Simulation in Planning Rhinoplasty: Evaluation from Patients' and Surgeons' Perspectives.

Among aesthetic surgery procedures, rhinoplasty is one of the most common. Preoperative simulations have become increasingly commonplace through the recent years along with a controversy regarding their use. Although capable of building a solid rapport between the surgeon and the patient by visualizing the end result, it can also prove to be a liability for a surgeon who is not confident about delivering the result which has been put on screen. The objective of this study is to evaluate the outlook of the surgeons and patients on preoperative simulations. Plastic surgeons who perform rhinoplasty and individuals who consider rhinoplasty were surveyed via an online questionnaire system. Their opinions about the practice of simulation were questioned and they were asked to distinguish between simulated and actual postoperative results. Statistical analyses were performed using SPSS software. Major factors influencing the decision-making process of patients were the availability of preoperative simulation, being shown appealing results of the surgeon's previous work and a personal reference from a patient with an appealing result. Within the health care professionals, it has been observed that experienced surgeons are more confident about using simulations, while inexperienced ones are daunted by being bound with a visual contract (p < 0.05). However, it has been noted that the preference of withholding the simulation or providing a copy to the patient was similar in all experience levels (p > 0.05). In conclusion, our findings suggest that the patients' self-consciousness regarding preoperative simulations seem to grow faster than the surgeons' confidence in their use. Level of evidence is Level V.

Reconstruction of Extensive Orbital Exenteration Defects Using an Anterolateral Thigh/Vastus Lateralis Chimeric Flap.

Neglected malignant tumors within the orbital region can invade the eyeball, extraocular muscles, and bone substance surrounding the eye. Such patients require orbital exenteration, which may involve extraocular skeletal structures (even exposing paranasal sinuses), resulting in 3-dimensional defects requiring reconstruction. This study presents our experience with anterolateral thigh vastus lateralis (ALT/VL) chimeric free flaps for the reconstruction of extensive orbital exenteration defects involving various paranasal sinuses.Between 2012 and 2016, 4 patients with extensive 3-dimensional orbital defects with sinus involvement were treated using the ALT/VL chimeric flap. The ALT component (117-170 cm) was used to resurface the cutaneous defect while the VL component (105-243 cm) was used to obliterate the cavitary defect. The flaps were all based on the common descending pedicle, and branches to separate components were individually dissected. Recipient vessels were in the neck region, to which the donor pedicles were passed through a tunnel for anastomosis.All cavitary and surface defects were simultaneously reconstructed via the ALT/VL chimeric flap. Within an average of 17 months, no complications associated with flap surgery were observed. One patient received postoperative adjuvant radiotherapy with no complications. With its separate components supplied by a common vascular pedicle, the ALT/VL chimeric free flap allows the surgeon to conveniently reconstruct separate spatial and volumetric defects resulting from extensive orbital exenteration.

Columellar Scar Perception in Open Rhinoplasty. Interplay of Scar Awareness, Body Cathexis and Patient Satisfaction.

INTRODUCTION: Open and closed approaches for rhinoplasty have individual advantages and disadvantages; however, the resultant columellar scar of the open approach is directly considered as a disadvantage. This study focuses on the columellar scar awareness and its implications on overall satisfaction of the patients after open rhinoplasty. PATIENTS AND METHODS: A total of 91 patients who have undergone open rhinoplasty were included in this study. A written questionnaire algorithm consisting of 4 sequential questions was applied. Except for the first question [Do you have any scar(s) caused by any trauma, operation or any other reason on your face?], every question was answered on a scale from 1 to 5. The respondents were given the 25-question "Modified Body Cathexis Scale (MBCS)"and their scars graded using the "Columellar Scar Assessment Scale" (CSAS). The data were statistically interpreted. RESULTS: Of the 91 open rhinoplasty patients, 12 of them responded with a "yes" to the first question reporting their columellar scars. There was no significant difference with regards to patient satisfaction regarding these patients (p > 0.05). However, those who reported the scar yielded a significantly lower MBCS scores. 9 patients declared that they exerted effort to conceal their scars. Those who concealed their scars and those who did not yielded a significant difference in patient satisfaction. The CSAS scores of those who reported the columellar scar were significantly higher than those who did not. CONCLUSION: Our study suggests that MBSC can be a valuable tool for determining the impact of outcomes from the patient's standpoint, and awareness of the columellar scar is not related to patient satisfaction but with bodily perception. 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 www.springer.com/00266 .

Caudal Septal Support Versus Strut Graft in Achieving the Desired Lateral Profile in Rhinoplasty.

Nasal tip support is critical to achieve a lasting result in rhinoplasty. In this article, the authors compared the effects of strut grafts (SG) and caudal septum-based nasal tip supporting techniques (CSB-T) in terms of reaching the desired tip projection.Included in this study were 40 patients (24 women and 16 men) who underwent primary open rhinoplasty via transcolumellar incision between January and June 2012. To achieve a good nasal projection, SG and CSB-T were used for 15 and 25 of these patients, respectively.Certain anatomic landmarks were identified on preoperative, simulative, and 1-year follow-up photos. With these landmarks, certain angular and proportional values were calculated.In the SG, the authors found no statistically significant difference in between simulative goals and postoperative results regarding bending angle. Postoperative nasolabial angle (NLA), tip angle, subnasal-tip/subnasal-radix (SnT/SnR) ratios were significantly lower than the simulation values; radix angle and supratip index values were significantly higher.In the CSB-T group, the authors found no statistically significant difference in between preoperative values and postoperative results regarding NLA, tip angle, bending angle, (SnT/SnR) ratio values. Postoperative supratip index and radix angle measurements were found to be significantly higher than the simulation values.With these findings, the authors concluded that CSB-T support is superior than the SG for supporting the nasal tip in noses that also need shortening in caudal length. In noses that do not need caudal shortening, nasal tip projection can again be supported by the caudal septum by just forming a bridge between lower lateral cartilage and quadrangular septum using a wider SG that mimics septal extension grafts.

Accordion-style pedicle suspension in inferocentral pedicled mammoplasty.

OBJECTIVE: In breast reduction surgery, while the primary objective may appear to be decreasing the breast volume, the ultimate goal is to achieve symmetrical, appealing, and sustainable breast cosmesis. To circumvent late-term ptosis following inferior pedicle mammoplasty, methods such as pedicle suspension to the ribs, support with dermal flaps and grafts, and the use of some alloplastic materials have been proposed. This paper presents a method of folding and fixing the inferocentral pedicle on itself and the underlying pectoral fascia. METHODS: Inferocentral pedicled, inverted T-scar reduction mammoplasties were performed on 50 patients from June 2009 to June 2014. The inferocentral pedicle, which was kept narrow and long, instead of the conventional inferior-based pyramidal design, was folded over its de-epithelialised surfaces in an accordion fashion and sutured. The confection was then sutured to the pectoral fascia by its lateral and superior borders for long-term preservation of breast moulding. RESULTS: In inferocentral breast reduction, the quest for a method that achieves appealing and lasting pyramidal breast shape continues. CONCLUSIONS: This technique is regarded as a simple and effective method for achieving good short- and long-term results for patients being considered for moderate and advanced breast reduction.

Comparison of the effects of different vasoactive and antiplatelet drugs on perforator flap viability. An experimental study.

Perforator flaps are very popular in the reconstruction of soft tissue defects. As these flaps generally depend on a single perforator, drugs that increase the perfusion of the flap and/or prevent vascular complications may increase flap survival. In this study, we compared the effects of systemically administered hydralazine (arterial vasodilator via potassium channels), nifedipine (arterial vasodilator via calcium channels), piracetam (antiplatelet and regulator of microcirculation) and alprostadil (vasodilator, antiplatelet, rheological and cytoprotective) on flap survival in a rat epigastric artery perforator flap model. The percentage of necrosis was measured on each flap and evaluated using one-way analysis of variance (Anova). Histopathological analyses were also performed. Mean flap survival area was 3.85 cm(2) in the control group. Mean flap survival area was 4.88 cm(2) in the nifedipine group, 4.69 cm(2) in the hydralazine group, 10.55 cm(2) in the piracetam group and 11.3 cm(2) in the alprostadil group. When compared with the control group, all drugs except hydralazine improved flap survival; piracetam and alprostadil yielded significantly better results than nifedipine. Only the alprostadil group showed signs of improved vascularity in the histological analysis. As far as perforator flap survival is concerned, drugs that regulate the microcirculation by a combination of different antiaggregation mechanisms appear more beneficial than single action vasodilators. Alprostadil, a synthetic PGE-1 analogue, has combined antiplatelet and vasoactive effects that further increase flap survival.

The Effect of Epigallocatechin Gallate on Flap Viability of Rat Perforator Abdominal Flaps.

Background Epigallocatechin gallate (EGCG) is a substance abundant in green tea. In this study, the effects of EGCG on perforator flap viability were investigated. Methods A total of 40 rats were assigned to four groups of 10 each. In each subject, a 4 × 6 cm abdominal skin flap was raised and adapted back onto its place. In the control group, no further procedures were taken. In the flap group, 40 mg/kg/d EGCG was injected into the flap. In the gavage group, 100 mg/kg/d EGCG was given through a feeding tube. In the intraperitoneal group, 50 mg/kg/d EGCG was injected intraperitoneally. On the 7th postoperative day, flaps were photographed and the viable areas were measured and compared via a one-way analysis of variance. Results The ratios of viable and contracted flap area were 9.15/12.01, 4.59/16.46, 11.56/11.20, and 11.65/10.77 cm(2) for the control, flap group, gavage group, and intraperitoneal group, respectively. While the flap group yielded the worst results in the sense of flap contraction and viability (p < 0.001), the gavage and intraperitoneal groups were significantly better than those of the control group (p = 0.03). Histologically, epidermal, papillary dermal, and capillary tissue volumes were evaluated. In comparison to the control group, the flap group yielded significantly increased epidermal and dermal volumes (p = 0.03), however, these values were significantly decreased (p = 0.04) in the gavage and intraperitoneal groups. Capillary volumes were significantly decreased in EGCG treatment groups (p < 0.01). Conclusion Our experiment has shown that oral and intraperitoneal administration of EGCG increases the perforator flap viability when compared with controls, while direct injection decreases the viability.

The Effect of Chemodenervation by Botulinum Neurotoxin on the Degradation of Hyaluronic Acid Fillers: An Experimental Study.

BACKGROUND: Early degradation is a common complaint for hyaluronic acid fillers. Although the combination of hyaluronic acid fillers with botulinum neurotoxin type A presented improved clinical results, objective measurement of hyaluronic acid volumes has not been previously assessed. METHODS: In this study, the authors have split the calvaria of the rabbit to mimic the glabellar region in humans. In this model, the authors applied hyaluronic acid alone to one side and hyaluronic acid combined with botulinum neurotoxin type A to the contralateral side. Two days and 3 months after the filler injection, magnetic resonance imaging was performed to assess the filler volumes. RESULTS: Average initial volume of filler only and filler combined with botulinum neurotoxin type A was 0.61 cm on both sides, and there was no difference between initial volumes of the two sides (p = 0.735). At the end of 3 months, average degraded volumes of filler-only and filler combined with botulinum neurotoxin sides were 0.33 cm and 0.19 cm, respectively, and the degradation difference was significant between the two groups (p = 0.001). End volumes for the filler-only and filler combined with botulinum neurotoxin sides were 0.28 cm and 0.42 cm, respectively, and end volumes between two sides were also statistically significant (p < 0.001). CONCLUSION: This study showed that hyaluronic acid filler application in combination with botulinum neurotoxin type A significantly decreases the degradation process and increases the remaining volume of the hyaluronic acid fillers at the end of the paralyzed period.

Heterotopic Transarticular Replantation: A Functional Reconstruction Design for a Mutilated Hand with Multiple Digit Involvement.

CASE: A patient sustained a high-energy trauma that resulted in amputation of the middle and ring fingers, along with injuries to the thumb and the index finger. The amputations were not clean; therefore, heterotopic replantation of the best amputated part of the finger to the most functional stump was undertaken. Transarticular replantation was done at the level of the proximal interphalangeal joint without osseous fixation. Early active motion was initiated the next day. The replanted finger had excellent function. CONCLUSION: Whenever possible, designing a heterotopic transarticular replantation can minimize the functional drawbacks resulting from the prolonged immobilization often associated with fracture fixation.

A rare complication of rhinoplasty: periorbital emphysema.

UNLABELLED: Subcutaneous emphysema is a clinical entity that may be associated with trauma. Rhinoplasty is not an atraumatic procedure. This report presents a case of acute periorbital emphysema after cosmetic rhinoplasty. 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 .

Comparison of oversized artery and vein grafts for interpositional pedicle lengthening in rat femoral artery.

Vessel grafting is commonly used for revascularization or pedicle lengthening. Although veins are more commonly used, they can form aneurysms when bridging an arterial gap. This can lead to thrombosis, and the risk is increased when there is a size discrepancy. This study reports the long-term results of arterial lengthening via size discrepant carotid artery and femoral vein grafts in a rat femoral artery model (1:1.5 ratio). A total of 28 rats were used in this study, divided into two groups of 14. By the 21st day, one anastomosis in each group has been found to be thrombosed. Long-term patency rates were the same for both groups (93.3%). Radiologic imaging showed that size match in the carotid artery grafts was excellent despite of slightly fusiform dilatation, but in the vein groups, pronounced aneurismal deformation and distortion in the anastomosis was seen. Histologic analysis revealed that in the arterial grafts, endothelial continuity was smooth and mural inflammation was less than that of the vein grafts. Organized or recanalized mural thrombi were seen in 38.5% in the vein grafts, whereas in arterial grafts there were none.

Moist heat postconditioning to increase flap survival.

One of the areas of interest within the discipline of reconstructive microsurgery is increasing the amount of tissue harvested along with a given pedicle and sustaining it. The aim of this study is to introduce moist heat postconditioning as a means to increase skin flap survival and evaluate its effectiveness. Eight white New Zealand rabbits weighing 2500 to 3000 g were separated into two groups. In both groups, the truncal flaps spanning four consecutive angiosomes were elevated bilaterally. Flaps were inset back afterwards, and to the flaps in the trial group moist heat was applied for 30 minutes. After 2 weeks, the flaps were photographed and flap survival ratios were calculated via ImageTool© software (University of Texas Health Science Center, San Antonio, Texas, USA). With an average necrosis ratio of 4.91% versus 37.31%, the flaps treated with moist heat displayed a significantly better survival rate (p = 0.000). This study presenting our new method demonstrates that application of moderate moist heat right after the flap inset provides a significant increase in flap survival and introduces a noninvasive, cost-effective, and safe method for clinical use.

The effect of "minimally invasive transfer of angiosomes" on vascularization of prefabricated/prelaminated tissues.

Prefabrication and prelamination are experimental and clinical applications of reconstructive surgery and inspired the vascularization challenge of engineered tissues. The purpose of this study is to test the efficiency of "minimally invasive transfer of angiosomes" to enhance the vascularization of the final construct during prefabrication and prelamination. Fifteen rabbits were used for this study. Three of the animals were used in a pilot study to develop the protocol. During the study, thoracodorsal and lateral thoracic vascular pedicles on each side constituted 4 study groups. The pedicles were prepared to simulate prelamination with and without transfer of angiosomes, and prefabrication with and without transfer of angiosomes. In all of the groups, a 10 x 15 mm auricular cartilage graft was used as the construct to be vascularized. After 2 weeks, vascularization of the grafts was evaluated by means of microangiography and histology. Results indicate that both prelamination and prefabrication with transfer of angiosomes displayed better vascularization, both qualitatively and quantitatively. However, prelamination with transfer of angiosomes group displayed distinct statistical superiority. The results suggest that minimally invasive transfer of angiosomes coupled with the procedure significantly increases the induction of angiogenesis during prelamination and prefabrication.