Efficacy and Pain Tolerance of Alexandrite Laser Hair Removal at Different Stages of the Menstrual Cycle.

BACKGROUND: Several different parameters play a role in the transition of hair follicles to the anagen phase, with the role of androgens, progesterone, estrogen hormones, and receptors being significant. OBJECTIVES: The effectiveness of Laser Hair Removal (LHR) and pain tolerance during application were investigated during three different phases of the menstrual cycle. METHODS: 48 axillae were randomly divided into three groups: menstruation, ovulation, and luteal. Three laser sessions were performed on each axilla at a one-month interval. Blood hormone levels were measured in the patients. Alexandrite laser was used during LHR sessions, before each LHR session and one month after the third session, hair follicles in 4 cm2 areas in the center of the axillae were counted. Patients self-assessed the pain they felt during the laser application in each session using visual pain scale. RESULTS: The average values for hair counting in the groups were as follows: MO = 47.6, M1 = 27.4, M2 = 16.1, M3 = 9.9, O0 = 41.8, O1 = 21.1, O2 = 13.8, O3 = 8.6, L0 = 49.4, L1 = 27.1, L2 = 15.1, L3 = 9.8. The average values for Visual Analog Scale (VAS) scores in the groups were: M1 = 3.94, M2 = 3.06, M3 = 1.94, O1 = 3.50, O2 = 3.06, O3 = 1.69, L1 = 3.63, L2 = 2.50, and L3 = 1.56. Statistical analysis was conducted using Tukey post hoc analysis after ANOVA. CONCLUSIONS: The results of LHR are not affected by changes in hormone levels during the menstrual cycle in women. Although not statistically significant, it has been observed that pain tolerance during laser application is lower during the menstruation cycle.

Reply: Comparison of Two Anticoagulants for Pain Associated with Platelet-Rich Plasma Injections.

We read the letter titled "Comparison of Two Anticoagulants for Pain Associated with Platelet-Rich Plasma Injections" authored by Pensato et al. in Aesthetic Plastic Surgery. The authors emphasized an important point. PRP treatments have a lot of variables; preparation method, application, amount of PRP injections, and content (such as number of platelet concentration, presence of leucocytes, and pH). However, in our study, we focused on the pain of injections. We showed that there is a pain difference by using different anticoagulants during PRP preparation, but we did not investigate for possible reason of this pain difference. The use of different anticoagulants may have caused changes in the content, and these alterations could be responsible for the variation in pain. Researches could be done to investigate the reason and the physiology of this effect.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 measurement of wound tensile strength and the effect of PRP on wound tensile force: an experimental investigation on rabbits.

Platelets in PRP are used for their functions in the initiation and regulation of the wound healing process and are used for the repair of injured tissues and the rejuvenation of healthy tissues. In this study, we evaluated the effect of a single dose platelet-rich plasma on skin wound healing and we demonstrated the effect of platelet-rich plasma on skin wound healing by measuring changes in the wound tensile strength.Material and methods: A total of 8 incisions, each 3 cm long, were made on the back skin on both sides of the vertebral column of 12 rabbits. After suturing their backs with staples, platelet rich plasma (PRP) was injected into the edges of the wounds on the left side and saline solution (saline) was injected into the edges of the wounds on the right side. The tensile force that causes wounds to rupture by applying tension was measured on the 7th, 14th, 21st, and 28th days with the help of a special home-designed device.Results: The mean PRP enrichment was 3.19 fold over peripheral blood. The saline to PRP tensile strength ratios on the 7th, 14th, 21st, and 28th days were calculated as 75.7%, 104.0%, 105.3% and 86.5%, respectively. Overall, the difference in the tensile strength for wounds that had received saline or PRP was in-significant.Conclusion: The application of PRP increases the tensile strength of the wound in the early period. It is possible to measure the tensile strength precisely in in vivo studies with economical home-designed devices.

Does the use of Dermojet affect the concentration of platelet-rich plasma? An in vitro experimental investigation.

Needle-free injection systems with high jet pressure have been used for seven decades for drug or vaccine administration via intradermal, subcutaneous, and intramuscular routes. These systems are used for the application of mesotherapy drugs in plastic surgery and dermatology. Platelet-rich plasma (PRP) tissue regeneration is applied intradermally by a needle for different indications, such as wound healing and scar revision. To prevent complaints such as pain, erythema, and ecchymosis by patients during this application, PRP was applied using Dermojet, a jet injector system with a spring-loaded system. In this study, after measuring the average platelet count in PRP preparations obtained from 18 volunteers, a 2.5 cc PRP shot into an empty tube was performed with Dermojet. The mean platelet count was measured in a homogenized tube. The same procedures were performed for platelet-poor plasma (PPP). The platelet loss rates for PRP and PPP were compared. In addition, the amount of PRP in each shot of the Dermojet was calculated. When PRP and PPP were applied using the Dermojet, platelet loss was 8.41% and 8.33%, respectively. The difference in the number of platelets formed in PRP and PPP when applied with Dermojet was not statistically significant. PRP application with needle-free injection systems, such as Dermojet, may be an alternative because of patient comfort and the negligible platelet loss compared with the PRP application with the standard needle injection.

What Is the Adequate PRP Dose for an Effective Treatment? An In Vitro Experimental Study on the Skin.

BACKGROUND: The clinical results of many studies on platelet-rich plasma (PRP) differ due to a lack of standardization in PRP preparation and administration as well as many variables such as PRP preparation methods, platelet concentration, and platelet activation. OBJECTIVES: The authors sought to investigate a different variable that will affect PRP application results. How much PRP should be injected into the unit area of tissue for an effective PRP treatment? METHODS: The study was performed on fresh surplus tissues of 20 patients that were discarded in abdominoplasty and mammoplasty operations. Nine areas of 4 cm2 were marked on the skin. Fluorescein-stained PRP was injected intradermally with 3 different gauge needles at 3 different doses (0.01, 0.03, and 0.05 mL). After injections, spreads of the fluorescent dye-covered areas in horizontal and vertical planes were measured and compared. For the horizontal plane measurements, the dye spread was measured first from the surface of the skin and second from the dermal surface of the skin. In addition, the width and depth of the dye spread in the dermis were measured from vertical sections. RESULTS: Changing the needle diameter does not affect the width or depth (thickness) of the PRP spread in the dermis. Increasing the applied dose to 0.03 mL increases the spread to the width and depth (thickness). CONCLUSIONS: In research evaluating the effectiveness of PRP treatments, it is necessary to report the volume of PRP to be applied per unit of tissue.

Treatment of scalp defects with a combination of trephination and platelet-rich plasma.

In cases of complete scalp loss where the calvarium is exposed and reconstruction cannot be achieved using replantation, or local or far flaps, using trephination to create holes to the depth of the spongeous layer followed by grafting once granulation has covered all defects is an important reconstruction alternative. However, growth of the granulation after trephination and waiting for the entire defect to be covered is a slow process. Since the introduction of platelet-rich plasma (PRP), several researchers have investigated the efficacy of different bone healing and grafting procedures. We present a case with full-thickness partial scalp defect in which we support the development of granulation through holes drilled to the spongeous layer by trephination with PRP.

Platelet-Rich Plasma for Skin Graft Storage: An Experimental Study Using Rabbit Ears.

BACKGROUND: Storage of surplus grafts for later use is one of the standard procedures used in plastic surgery. For the delayed use of skin grafts, various methods and media have been investigated for short-term storage. This study aimed to investigate the effect of platelet-rich plasma (PRP) skin graft storage on the survival of skin grafts obtained from rabbit ears. MATERIALS AND METHODS: Twelve rabbits were used in this study. A total of 12 skin grafts measuring 1 × 1 cm were obtained from the inner surfaces of the rabbits' ears. The grafts were stored at +4°C in saline, Hartmann's, and PRP media. On days 3, 7, 10, and 14, the grafts were implanted into the ears in areas measuring 1 × 1 cm where the skin, cartilage, and perichondria were excised. After the implantation of the grafts, the survival rates were evaluated by measuring the graft areas on day 0, day 10, and day 30. RESULTS: The graft survival rate decreased as the storage period increased in all 3 of the media. The decrease in survival rate was higher in the grafts that were stored in the Hartmann's media in comparison with the saline and PRP media, and the difference was statistically significant. The decrease in graft survival was similar between the storage in saline and PRP media; however, the differences were statistically insignificant. CONCLUSIONS: Although in vitro criteria are important for evaluating graft survival, in vivo studies showing the graft take rate in the recipient area are required. When the in vivo criteria are evaluated, the use of PRP is not superior to the use of saline for graft storage. However, additional studies are required to evaluate the effects of PRP media on graft quality.

Skin graft storage in platelet rich plasma (PRP).

Storage of skin grafts for later use is one of the standard applications in surgery. It is the most preferred method to maintain at +4°C in refrigeration after wrapping the surplus grafts into sterile gauze pad moistened with saline. Although there are many studies on the storage of skin grafts, less is known about storing skin grafts with PRP. Twenty-five pieces of 1 × 1 cm2 partial thickness skin graft were harvested from 12 patients during the reduction mammoplasty operation. Twenty-four grafts were divided into 4 groups, and each group consisted of 6 grafts, 1 graft was analyzed as Day 0. Grafts in Group 1, 2, and 3 were wrapped by sterile gauze pad moistened by either saline (Group 1) or Hartman (Group 2) or PRP (Group 3). Grafts were analyzed macroscopically and microscopically. There were no significant differences between media for the first 10 days. Decrease in viability was less in saline and PRP wrapped grafts at 20 day, viability decreased significantly in all environments after 20 days. Although there was no significant difference in saline or PRP storage, it was observed macroscopically that the grafts stored in the PRP appeared better.

Comparison of Two Anticoagulants for Pain Associated with Platelet-Rich Plasma Injections.

BACKGROUND AND AIM: Platelet-rich plasma (PRP) has long been used in skin rejuvenation and hair loss treatment. Some patients require multiple intradermal injections into the face and scalp, and the way in which these patients process and experience pain differs, depending on the patient. Minimizing pain and discomfort during nonsurgical procedures is essential for patient satisfaction. In our experience, the use of acid citrate dextrose-A (ACD-A) as an anticoagulant caused more patient discomfort than did sodium citrate (Na-citrate) among patients who underwent facial rejuvenation with PRP. The aim of the present study was to evaluate patient-related discomfort in PRP sessions using two different anticoagulants. MATERIALS AND METHODS: This clinical trial included 10 patients who received facial PRP injections for facial rejuvenation and 10 patients who received PRP injections in their scalps for hair loss. On the application area, half the surface was treated with Na-citrate PRP injections, and the other half was treated with the same amount of ACD-A PRP injections. Neither the doctors who applied the treatment nor the patients were given information about which anticoagulant was used in each area. Immediately after the procedure, the patients were asked to score their pain on each side of the application area on a scale of 1-10 using a visual analog scale (VAS). RESULTS: PRP injections using Na-citrate as an anticoagulant caused less discomfort on both the face and scalp as compared with that of ACD-A. The outcome was statistically significant. CONCLUSION: Anticoagulants used in PRP preparation affected patients' pain perceptions during the injections. The sensation of pain with PRP prepared with Na-citrate as an anticoagulant was lower than that of PRP prepared with ACD-A. Further studies are required to evaluate the correlation between anticoagulants used for PRP preparation and pain feelings during injections. LEVEL OF EVIDENCE III: 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.

Effects of device variables to radiofrequency (RF) applications.

RF devices have frequency, power and duration setting options, it is important to make sure that the device meets the targeted values at the head output. This study was made to evaluate the RF device output value accuracy and the effects of different frequencies on the tissue heat levels. RF was applied to invitro tissues obtained from surgical operations, and invivo tissues during operations. Heat differences and depth were measured by laser/IR thermometer and thermal infrared camera. First, the output frequency and power values provided by the device were approved. Then, three three heads (monopolar, bipolar and tripolar) with three different frequencies (1,7, 20 MHz) were used. Depth of heat increase was evaluated in millimeters. The results showed that temperature increase varied between 10°C and 30°C at different depths using different frequencies. Heating of the skin with a radiofrequency device in a therapeutic dose is possible if the appropriate frequency and adequate power values are applied. Because the therapeutic temperature is close to the complication limit, the practitioner should be an expert using the device, well-knowledgeable about the regional skin structure and thickness, as well as be able to properly adjust the application doses in order to get therapeutic results.

Effects of omentin on flap viability: an experimental research on rats.

Background: Viability decreases at the distal parts with an increase in the length of flaps. In this study, we evaluated the effects of subcutaneously administered omentin on flap viability, where it is applied to distal one-third part of McFarlane flaps elevated from the rat's dorsal skin.Materials and methods: Twenty-four adult, female, Sprague-Dawley rats were used. Subjects were divided into three groups; group 1 is the control group, group 2 received omentin 1 week before flap elevation, and group 3 received omentin 2 d before and at the day of flap elevation. About 1 cc (300 nanogram/cc) omentin applied by subcutaneous injections to the distal one-third flap. Photos are taken daily for macroscopic evaluations. The 3-mm full thickness punch biopsies at the third day and 1-cm2 biopsies at the seventh day from the middle of the one-third distal third of the flaps were taken. Necrotic and viable areas were measured. Neutrophil counting, epidermis thickness, inflammation, edema, and vascular endothelial growth factor (VEGF) immune staining were evaluated using histopathological analyses. Endothelial Nitric Oxide Synthase (eNOS) expression was performed by ELISA.Results: Omentin increased the percentage of the viable areas of flaps, epidermal thickness, number of newly formed blood vessels, and eNOS expression levels. The results showed statistical significance.Conclusions: Omentin human increases the viable areas of flaps and may be used for enhancement of flap survival.

The Effects of Colchicine-Impregnated Oxidized Regenerated Cellulose on Capsular Contracture.

Capsular contracture is the most common complication of breast augmentation. Oxidized regenerated cellulose can be used as a matrix for drug transport. Colchicine is an antimitotic drug that interferes with various steps of wound healing. The aim of this study was to evaluate the effects of oxidized regenerated cellulose alone or in combination with colchicine on capsular contracture. Twenty-one adult female Wistar-Albino rats were divided into 3 groups. In group 1 silicone blocks only, in group 2 oxidized regenerated cellulose-wrapped silicone blocks, and in group 3 colchicine-impregnated oxidized regenerated cellulose-wrapped silicone blocks were inserted in the dorsal region. Four weeks later, implants were removed and histopathological examination was performed. Capsular thickness, inflammatory infiltrate degree, collagen fiber organization, and myofibroblast density were evaluated. Macroscopic examination revealed a distinct capsule formation only in group 1 animals, with average measurement being 134.65 µm on histopathological examination. In groups 2 and 3 animals, no distinct capsule formation was seen. Inflammatory infiltrate degree was found to be less in groups 2 and 3 animals than in group 1 animals. Collagen fiber organization around the implants was found to be parallel and organized in group 1 animals, whereas it was random and disorganized in animals in both groups 2 and 3. High myofibroblast density was observed in animals in groups 1 and 2, while no myofibroblast was found in animals in group 3. The results of our study suggest that coating silicone implants with oxidized regenerated cellulose or with colchicine-impregnated oxidized regenerated cellulose may be effective in preventing capsular contracture.

Does reduction mammaplasty revert skeletal disturbances in the vertebral column of patients with macromastia? A preliminary study.

BACKGROUND: Enlarged breasts are associated with many physical and psychological symptoms. It is important to use objective criteria in documenting physical changes of a patient's body due to enlarged breasts and the benefits of surgery. This preliminary study aimed to determine whether the reduction mammaplasty procedure changes the angles of cervical lordosis, thoracic kyphosis, and lumbar lordosis. METHODS: The study population consisted of 22 patients who underwent breast reduction surgery. All the patients had lateral cervicothoracolumbar radiographs taken preoperatively and at least 2 months postoperatively. Cervical lordosis, thoracic kyphosis, and lumbar lordosis angles, as well as sagittal balance, were examined. The body mass index (BMI), breast tissue volume, and excised tissue amount of each patient were recorded. RESULTS: All the patients had increased cervical lordosis and thoracic kyphosis angles preoperatively, and the angles were significantly decreased postoperatively. Of the 22 patients, 7 had decreased and 8 had increased lumbar lordosis angles. All the lordosis angles showed significant improvement at the last examination. Seven patients had disturbed sagittal balance preoperatively, and all had normal sagittal balance postoperatively. Preoperative total breast tissue volume was positively correlated with the differences in cervical lordosis angles, BMI, preoperative cervical lordosis angles, and cervical lordosis angles. CONCLUSION: Hypertrophic breasts are not only a cosmetic but also a functional problem complicated by pathologic conditions in the vertebral column such as increased cervical lordosis, thoracic kyphosis, and increased or decreased lumbar lordosis. Breast reduction may improve these pathologic angles. Reducing the nonphysiologic weight of enlarged breasts located anterior to the main axis of the body may correct pathologic angulation and disturbed sagittal balance of the vertebral column. 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 .

Treatment modalities in severe mento-sternal synechia.

OBJECTIVE: Scar contracture of the neck after a burn-injury can cause both functional and aesthetic problems, and still presents a challenge for plastic surgeons. The anatomic area and adjacent structures such as the lower lip, trachea and neuro-vascular structures which are affected by the scar make treatment diffucult. Scarring and contracture of the neck region may severely limit function, cause alterations of normal posture and make intubation for surgery difficult. When a burn scar extends toward the face, eating and swallowing may be restricted and facial distortion may develop as the scar pulls the mouthdownwards even the lower eyelids. METHOD: Following the upper extremity, the neck is the most common site affected by burn contracture. The method chosen for contracture release, depends on the severity of scarring and extent of involvement. If the contracture area is limited, z-plasties, skin grafts or local skin flaps are adequate for the treatment but when the whole anterior neck is affected, the treatment modalities are limited and mostly skin grafts either meshed or unmeshed are used. RESULTS: In this study we evaluated the usage of alternative teatment methods involving skin grafts and local flaps for severe neck contractures and tried to discuss oftenly encounered difficulties in treating these group of patients. CONCLUSION: Many techniques have been described for correction of neck contractures, including skin grafting, expanders, local regional flaps and free flaps. The treatment of choice should be modified for every patient.

Sensory recovery with innervated and noninnervated flaps after total lower lip reconstruction: a comparative study.

This study compares sensory recovery after total lower lip reconstruction in a wide variety of flaps including bilateral depressor anguli oris flap, submental island flap, bilateral fan flaps, radial forearm flap, and pectoralis major myocutaneous flaps in a large number of patients. Spontaneous return of flap sensation was documented by clinical testing in the majority (3%) of patients who underwent total lower lip reconstruction. Sensory recovery occurred more often in patients with fasciocutaneous free flaps than in those with musculocutaneous flaps. Flap sensation to touch, two-point discrimination, and temperature perception was correlated with age, smoking, and radiation treated patients. We conclude that reasonable sensory recovery may be expected in noninnervated flaps, provided that the major regional sensorial nerve has not been sacrificed, and also provided that the patients age is relatively young and that enough surface contact area of the recipient bed is present without marked scarring. This trial was regestered with Chinese Clinical Trial Registry (Chi CTR) with ChiCTR-ONC-13003656.

Short-term vasculoprotective effects of imatinib mesylate on intimal hyperplasia of arterial anastomosis: An experimental study using a rabbit model.

BACKGROUND: Since the beginning of the 'microvascular era', the success rates of microvascular procedures have increased to more than 90% in most series. The main reason for failure, however, is the healing of microarterial anastomosis, which is dependent on the status of endothelial cells and affects the rate of arterial thrombosis. In 80% of arterial thrombosis cases, complications are primarily observed during the first 72 h after surgery. Healing of arterial anastomosis results in intimal hyperplasia in which myofibroblasts comprise the predominant cell type. Intimal hyperplasia has been described previously as an adaptive process that occurs in response to hemodynamic stress or injuries to the vascular bed. During wound healing, fibroblasts proliferate, migrate and differentiate into myofibroblasts - a process that takes one to three days. Imatinib mesylate (ST1571-Gleevec, Novartis, Germany) is a specific platelet-derived growth factor receptor blocker that has found use as an adjunct to sirolimus in cardiovascular surgery for restenosis. However, its potential utility in preventing arterial thrombosis in microvascular surgery has not been evaluated in routine plastic surgery practice. METHODS: Twenty-four randomly selected, male, white New Zealand rabbits were divided into six groups (A to F), and the femoral artery model was used for arterial anastomosis. Following anastomosis, groups A, B and C received phosphate-buffered saline orogastrically. In groups D, E and F, imatinib mesylate was administered via an orogastric tube twice per day at a dose of 10 mg/kg starting two days before arterial anastomosis. Following anastomosis, imatinib mesylate was administered for one, three and seven days, and the regression of intimal hyperplasia was recorded. RESULTS: In groups administered imatinib mesylate (ie, groups D, E and F), intimal hyperplasia decreased by up to 50%, which represented a statistically significant difference. Histological analysis confirmed smooth muscle cell migration from the tunica intima to media on days 3 and 7 in groups E and F. CONCLUSION: The present study revealed that imatinib mesylate, which was initiated as a prophylactic, systemic pretreatment and continued for seven days, gradually decreased intimal hyperplasia at the anastomosis site.

HISTORIQUE: Depuis le début de « l'ère microvasculaire ¼, le taux de réussite des interventions microvasculaires a augmenté pour atteindre plus de 90 % dans la plupart des séries. Cependant, la principale raison des échecs provient de la guérison de l'anastomose microartérielle, qui dépend de l'état des cellules endothéliales et influe sur le taux de thromboses artérielles. Dans 80 % des cas de thrombose artérielle, on observe surtout les complications pendant les 72 heures suivant l'opération. La guérison de l'anastomose artérielle produit une hyperplasie de l'intima dont le principal type de cellules est le myofibroblaste. L'hyperplasie de l'intima a déjà été décrite comme un processus adaptatif qui se produit en réponse à un stress hémodynamique ou à des blessures au lit vasculaire. Pendant la guérison de la plaie, les fibroblastes prolifèrent, migrent et se différencient en myofibroblastes, dans un processus d'une durée de un à trois jours. Le mésylate d'imatinib (ST1571-Gleevec, Novartis, Allemagne) est un antagoniste des récepteurs du facteur de croissance dérivé des plaquettes, utile comme complément au sirolimus en cas de chirurgie cardiovasculaire pour soigner une resténose. Cependant, son utilité potentielle pour prévenir la thrombose artérielle en cas de chirurgie microvasculaire n'a pas été évaluée dans le cadre des chirurgies plastiques habituelles. MÉTHODOLOGIE: Vingt-quatre lapins blancs mâles néo-zélandais choisis au hasard ont été divisés en six groupes (A à F), et les chercheurs ont retenu le modèle d'artère fémoral pour effectuer une anastomose artérielle. Après l'anastomose, les chercheurs ont administré une solution de tampon phosphate salin par voie orogastrique aux groupes A, B et C, et du mésylate d'imatinib aux groupes D, E et F par sonde orogastrique deux fois par jour, à une dose de 10 mg/kg, à compter de deux jours avant l'anastomose artérielle. Après l'anastomose, ils leur ont administré du mésylate d'imatinib pendant un, trois et sept jours, et ont consigné la régression de l'hyperplasie de l'intima. RÉSULTATS: Dans les groupes à qui on avait administré du mésylate d'imatinib (c'est-à-dire les groupes D, E et F), la diminution de l'hyperplasie de l'intima a atteint jusqu'à 50 %, ce qui représentait une différence statistiquement significative. L'analyse histologique a confirmé une migration des cellules des muscles lisses de l'intima à la tunique moyenne les jours 3 et 7 dans les groupes E et F. CONCLUSION: La présente étude a révélé que le mésylate d'imatinib, amorcé comme prétraitement systémique prophylactique et maintenu pendant sept jours, réduisait graduellement l'hyperplasie de l'intima au foyer de l'anastomose.

Results of transmasseteric anteroparotid approach for mandibular condylar fractures.

Management of condylar fractures has been the subject of much disagreement and debate. There is no general consensus for definitive treatment. Although there is a growing tendency for open reduction and internal fixation technique, risks and morbidity of the surgical procedure are still a point of concern for maxillofacial surgeons. To reduce potential complications and improve surgical exposure, the transmasseteric anteroparotid approach was introduced. Since 2008, we have operated on 6 patients (7 fractures) using this approach. The technique is easy to learn, provides adequate surgical exposure for open reduction internal fixation, and has few complication rates.

Reconstruction of congenital and acquired columellar defects: clinical review of 38 patients.

Reconstruction of columella presents certain difficulties and includes reconstruction of the cartilaginous strut and the overlying skin to obtain good results. We conducted a retrospective clinical review of 38 patients presenting with congenital and acquired columellar defects. Anatomic characteristics to be considered were defined and a classification method is proposed to more fully describe columellar defects. The columellar defects of the patients were classified into three groups as follows: type I, skin defect of columella and absence of medial crura of lower lateral cartilage; type II, type II + partial absence of caudal part of septal cartilage; and type III, complex defect of columella accompanying with the other nasal subunit defects. The patients chosen in this study were designed to describe a common approach for the choice of the reconstruction method that provides excellent aesthetic result while minimizing the extent of the surgery and maximizing patient acceptance.

Comparison of aesthetic outcomes and morbidity of nasal reconstruction with forehead flaps and free flaps.

The most common etiology of nasal defects that require reconstruction is skin cancer, particularly basal cell carcinoma, the most common nasal skin cancer, as well as squamous cell carcinoma, and melanoma. Reconstruction of extensive nasal defects including nasal bone, septum, and esthetically defined units of the nose always represent with certain difficulties. Forehead flaps and free flaps can be utilized for reconstruction of extensive nasal defects. The forehead flap is a reliable and well-established reconstructive option for management of extensive nasal defects. We aimed to compare the esthetic and functional results of forehead flaps and free flaps for reconstruction of extensive nasal defects.

Maximizing breast projection with combined free nipple graft reduction mammaplasty and back-folded dermaglandular inferior pedicle.

Standard technique for free nipple reduction mammoplasty was described by Thorek in 1922. In contrast to its effectiveness, late postoperative results included insufficient projection of the breast and the nipple-areola region. We describe a modification of this well recognized technique in order to increase central mound projection and improve nipple-areola projection by suturing the dermaglandular flap to the pectoralis major muscle by back-folding the pedicle. Twenty macromastia patients were subjected to free-nipple-graft reduction mammoplasty in combination with inferior pedicled dermaglandular reduction mammaplasty of a total of 40 breasts with this technique between years 2000 and 2004. Preoperative planning for inferior pedicled dermaglandular flap was made using the "Wise" pattern for large breasts. The variation of the technique comes from using the back-folded deepithelialized inferior pedicled dermaglandular flap for increasing the breast mound projection by fixating the demaglandular flap with absorbable sutures to the underlying pectoralis major muscle fascia and the costal cartilage pericondrium. By applying this technique, increased projection during the early preoperative and late postoperative periods are achieved, compared with patients who only underwent free-nipple- graft reduction mammoplasty.