IMPORTANCE Recovery from facial nerve transection is typically poor, but daily mechanical stimulation of the face in rats has been reported to remarkably enhance functional recovery after facial nerve transection and suture repair. This phenomenon needs additional investigation because of its important clinical implications. OBJECTIVE To determine whether automated mechanical stimulation of the whisker pad improves whisking recovery after facial nerve transection and repair in a rat model. DESIGN AND SETTING Sixty-one rats underwent unilateral facial nerve transection and suture repair and were randomized into 8 groups. Six groups received daily automated whisker or whisker pad mechanical stimulation including 0.5-, 1.5-, and 8.0-Hz patterns. Two control groups received restraint without stimulation. Treatment started on postoperative day 8, occurred 5 days per week, and lasted throughout 15 weeks of recovery. Whisking amplitude, velocity, and acceleration were quantified weekly for 15 weeks. INTERVENTIONS Unilateral facial nerve transection, suture repair, and, for 6 groups, daily automated whisker or whisker pad mechanical stimulation. MAIN OUTCOMES AND MEASURES Quantification of whisking amplitude, velocity, and acceleration. RESULTS Rats receiving the low frequencies of stimulation of the whiskers or whisker pad did not demonstrate enhanced whisking recovery, and rats receiving stimulation at 8.0 Hz showed significantly worse whisking recovery compared with controls and previously published groups receiving lower dose manual stimulation. CONCLUSIONS AND RELEVANCE Although daily manual whisker pad stimulation has been shown to enhance whisking recovery, rats in this study did not demonstrate improved whisking recovery after automated mechanical stimulation across a wide range of driving frequencies. Moreover, faster stimulation (8.0 Hz) was actually detrimental to recovery. Further work is needed to understand the relationship between stimulation patterns and the physiologic mechanisms underlying improved or worsened functional outcomes after facial nerve transection and repair.
IMPORTANCE Cable grafting is widely considered to be the preferred alternative to primary repair of the injured facial nerve; however, quantitative comparison of the 2 techniques has not been previously undertaken in a rodent model. OBJECTIVE To establish functional recovery parameters after interposition autografting in a rodent facial nerve model. DESIGN, SETTING, AND PARTICIPANTS Prospective randomized animal study at a tertiary care facial nerve center using 16 female Wistar Hannover rats. INTERVENTION The experimental group received reversed autograft reconstruction of a 20-mm neural gap, and the control group received facial nerve transection and primary repair. MAIN OUTCOME AND MEASURE Whisker excursion was measured weekly for 70 postoperative days using laser micrometers. RESULTS The control group exhibited the most rapid recovery, with substantial return of whisker movement occurring during the third postoperative week. The experimental group demonstrated return of function beginning in the fourth postoperative week, eventually achieving a degree of function comparable to that of the control group by the sixth postoperative week (P = .68). CONCLUSIONS AND RELEVANCE Recovery of facial function after cable grafting seems to be slower than, but eventually similar to, recovery after primary neurorrhaphy in a rodent model. In the present study we have established a benchmark for recovery of whisker movement across a 20-mm rodent facial nerve gap, which will be used for comparison of different facial nerve gap bridging materials in future studies. LEVEL OF EVIDENCE NA.
IMPORTANCE:Long-term follow-up reference for experienced clinicians dedicated to profileplasty. OBJECTIVE:To evaluate the long-term results and complications of combined rhinoplasty and genioplasty. DESIGN:Retrospective study including objective and subjective evaluation before and after 3 years of undergoing simultaneous open rhinoplasty and genioplasty among a cohort of 90 patients. SETTING Academic medical center. PATIENTS:A total of 90 cases of combined rhinoplasty and genioplasty performed from January 2002 through January 2004 were reviewed to evaluate the stability of the esthetic result. MAIN OUTCOME MEASURE:Long-term stability of the esthetic outcome of the simultaneous open rhinoplasty and genioplasty. RESULTS:Soft-tissue Pogonion projection to the true vertical line and mandibular height (mandibular incisor tip to menton) were recorded. As far as reduction genioplasty patients are concerned, 45.6% of the patient population had a 100% stability after 3 years (<0.25 mm resorption measured at the menton). On the other hand, if augmentation genioplasty patients are considered, 52.4% (22 patients with a vertical augmentation range from 4-6 mm; mean, 5.3 mm; and 25 patients with a sagittal augmentation from 6-8 mm; mean, 7.2 mm) had 100% stability after 3 years. The chin was stable with no more than 1 mm of recurrence. CONCLUSIONS AND RELEVANCE:The results of the study indicate that the combined approach in correcting the facial profile is an effective procedure to achieve a more harmonic and consistent clinical outcome. The recurrence rate of less than 1 mm on the chin bone measurements is relevant to support this statement. An aesthetically proportionate face is strongly determined by the nasal-cervical relationship when observing the patient's profile. Even after a successful rhinoplasty, the patient's face can lack aesthetic attractiveness. Combined rhinoplasty-genioplasty is usually the best solution, particularly for patients with microgenia. It provides optimum patient satisfaction with a low incidence of recurrence. LEVEL OF EVIDENCE:4.
OBJECTIVE To quantify the degree of perceived age change after aesthetic facial surgical procedures to provide an objective measure of surgical success. METHODS Sixty patients undergoing various aging face surgical procedures were randomly chosen for analysis. Preoperative and postoperative photographs were evaluated. Raters were presented with photographs in a random assortment and were asked to estimate the age of the patient. Perceived age difference was defined as the difference between the chronological age and the estimated age, and the change in this value after surgery was the chief outcome of interest. Statistical models were designed to account for any effects of interrater differences, preoperative chronological age, rater group, photograph order, or surgical procedure performed. RESULTS Our patient population was divided into the following 3 groups based on the surgical procedure performed: group 1 (face- and neck-lift [22 patients]), group 2 (face- and neck-lift and upper and lower blepharoplasty [17 patients]), and group 3 (face- and neck-lift, upper and lower blepharoplasty, and forehead-lift [21 patients]). Adjusted means demonstrated that patient ages were estimated to be 1.7 years younger than their chronological age before surgery and 8.9 years younger than their chronological age after surgery. The effect was less substantial for group 1 patients and was most dramatic for group 3 patients, who had undergone all 3 aging face surgical procedures. CONCLUSIONS Our study is novel in that it quantifies the degree of perceived age change after aging face surgical procedures and demonstrates a significant and consistent reduction in perceived age after aesthetic facial surgery. This effect is more substantial when the number of surgical procedures is increased, an effect unrelated to the preoperative age of a patient and unaffected by other variables that we investigated. The ability to perceive age correctly is accurate and consistent.
OBJECTIVES To define (1) at-risk structures during the orthodromic temporalis tendon transfer and (2) achievable tendon length without temporal releasing incisions or perioral lengthening materials. METHODS Ten fresh cadavers provided 20 hemifaces for dissection. Measurements and photographic documentation were used to examine the parotid duct, masseteric artery, inferior alveolar nerve, internal maxillary artery, and mobilized tendon relative to adjacent landmarks. RESULTS The parotid duct was found in a reproducible region posterior to the melolabial crease and inferior to a parotid duct reference line. The masseteric artery was found posterior to the posterior-most attachment of the tendon at its exit from the sigmoid notch (mean, 14.5 mm). The inferior alveolar nerve was found posterior to the anterior edge of the ascending ramus (mean, 18.3 mm). The internal maxillary artery coursed superiorly from posterior to anterior along the medial mandible near the coronoidectomy site. The tendon reached beyond the melolabial crease in 17 of 20 hemifaces (85%). CONCLUSIONS The parotid duct reference line and the melolabial crease allow estimation of the parotid duct location. Anatomical relationships between the tendon, parotid duct, neurovasculature, and anatomical landmarks underscore the importance of deliberate soft-tissue retraction and subperiostial elevation to minimize injury. The tendon alone usually provides adequate length for orthodromic suspension.
In this article, we contend that publically available, mass digitization projects, such as Google Books, present faculty, regardless of their specific institutional context, with an exciting opportunity to promote meaningful undergraduate research in the humanities. By providing a classroom case study and by proposing an institutional model, we suggest that the Google Books archive can be a powerful tool in helping to establish research in the humanities as a regular and expected component of the undergraduate experience.
In this article, we contend that publically available, mass digitization projects, such as Google Books, present faculty, regardless of their specific institutional context, with an exciting opportunity to promote meaningful undergraduate research in the humanities. By providing a classroom case study and by proposing an institutional model, we suggest that the Google Books archive can be a powerful tool in helping to establish research in the humanities as a regular and expected component of the undergraduate experience.
OBJECTIVE To describe how severe ear deformities after otoplasty can be corrected. METHODS The correction of creases is possible through readaptation of the cartilage edges followed by revision otoplasty using suture techniques in the reconstructed cartilage. In the case of defect formation or extreme thinning of the cartilage, an appealing auricular shape is achieved by the use of porous polyethylene implants. RESULTS We have treated 12 severe ear deformities in the past 2 years with the procedures described herein. In 11 cases, there were no complications, nor was it necessary to make further corrections for cosmetic reasons. CONCLUSIONS Reconstructing the cartilaginous skeleton and redoing otoplasty is a recommendable procedure with a longer lasting effect than just covering creases with fascia or preserved materials. In the case of a missing ear cartilage skeleton, the use of porous polyethylene implants instead of autogenous cartilage should be considered for reconstruction.
BACKGROUND Current management of permanent facial paralysis centers on nerve grafting and muscle transfer; however, limitations of those procedures call for other options. OBJECTIVES To determine the durability and biocompatibility of implanted artificial muscle in a gerbil model and the degree of inflammation and fibrosis at the host tissue-artificial muscle interface. METHODS Electroactive polymer artificial muscle (EPAM) devices engineered in medical-grade silicone were implanted subcutaneously in 13 gerbils. The implanted units were stimulated with 1 kV at 1 Hz, 24 h/d via a function generator. Electrical signal input/output was recorded up to 40 days after implantation. The animals were euthanized between 23 and 65 days after implantation, and the host tissue-implant interface was evaluated histologically. RESULTS The animals tolerated implantation of the EPAM devices well, with no perioperative deaths. The muscle devices created motion for a mean of 30.3 days (range, 19-40 days), with a mean of 2.6 × 106 cycles (range, 1.6 × 106 to 3.5 × 106 cycles). Histologic examination of the explanted devices revealed the development of a minimal fibrous capsule surrounding the implants, with no evidence of bacterial infection or inflammatory infiltrate. No evidence of device compromise, corrosion, or silicone breakdown was noted. CONCLUSIONS Artificial muscle implanted in this short-term animal model was safe and functional in this preliminary study. We believe that EPAM devices will be a safe and viable option for restoration of facial motions in patients with irreversible facial paralysis.
W E ARE LIVING THROUGH AN EXCITing era in facial plastic surgery. Innovations and scientific advancements abound in all directions of the globe. We can celebrate the advent of science without borders. Facial plastic surgery is simultaneously a very focused specialty, centered on reconstructive and aesthetic surgery of the face, and one of the more expansive and connected. Our specialty interfaces with dermatology, ophthalmology, oral maxillofacial surgery, surgery, and more; in addition, it is integral to both otolaryngology–head and neck surgery and plastic surgery. The primary basic science of facial plastic surgery is wound healing encompassing areas from flap physiology to peripheral nerve regeneration; our research, however, embraces technologies from disciplines as diverse as lasers, biomaterials, computer simulation, biomechanics, outcomes research, and many more. Facial plastic surgery will benefit in numerous ways from The JAMA Network. It will allow us to access and share information with the many medical and surgical specialties with which we interface. In addition to the website’s ease of navigation and enhanced content, it will allow us to search for important information with semantic tagging on The JAMA Network, whether the subject is the neurosciences or epidemiology. The website platform brings creative new possibilities to our visual and technical specialty. The Archives of Facial Plastic Surgery—soon to be JAMA Facial Plastic Surgery—was founded as a global journal. From the beginning years we have been the official journal of both the American Academy of Facial Plastic and Reconstructive Surgery and the International Federation of Facial Plastic Surgery Societies (the Federation). The Federation’s recent scientific meeting in Rome, Italy, was the largest such international meeting ever held, thanks to the expertise and hard work of its leaders Pietro Palma, MD, Paolo Castelnuovo, MD, and Abel-Jan Tasman, MD. As president of the Federation, it was my pleasure to welcome 2 JAMA Network staff, Elizabeth Solaro and Sara Nagy, to Rome to help present the many opportunities our new family of journals will provide. Interest in both manuscript submission and subscriptions was intense, and there is little doubt we will see impressive growth outside North America in coming years. The smartphone/tablet app provides a unique opportunity to introduce our global colleagues to the best resource possible to stay abreast of the latest information and to improve care for their patients. Medical publishing is transforming rapidly and its future is unclear. We do know, however, that facial plastic surgery will be well positioned to communicate our scientific advances in both print and web on the new, forward-looking JAMA Network. As a specialty we are a global family and will benefit immensely by joining The JAMA Network family.
The overarching imperative for patient care when a physician volunteers to treat patients in another country is to respect the dignity of the individuals. Because of cultural differences and language barriers, the typical patient-physician relationship will likely not be possible in its fullest extent. Therefore, the physician must make an effort to gain the trust of the patient through nonverbal communication as well as verbal (likely through a translator). A pleasant, attentive approach to patients, with appropriate friendliness, interest, and respect, will be helpful in putting them at ease. One must be cautious, however, not to cross a boundary that lies within the cultural and/or religious fabric of the population. It is very important for the volunteer physician to be adequately prepared for interacting with patients by first studying the cultural and religious customs of the country and its people. Good intentions can be marginalized and future missions jeopardized through unwittingly inappropriate interactions with patients and their families. Often the host organization or host physicians can be helpful in providing advice and understanding on what can or cannot be done in this regard.
Archives of Facial Plastic SurgeryVol. 14, No. 1 Free AccessRetrospective Review of Resorbable Plate Fixation in Pediatric Craniofacial SurgeryLong-term OutcomeSherard A. TatumIIISherard A. TatumIIICorrespondence: Sherard A. Tatum III, Division of Facial Plastic and Reconstructive Surgery, Departments of Otolaryngology and Pediatrics, State University of New York, Upstate Medical University, 750 E Adams St, Syracuse, NY 13210 (E-mail Address: tatums@upstate.edu).Search for more papers by this authorPublished Online:2 Jan 2012AboutSectionsPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail Resorbable Plate Fixation in Pediatric Craniofacial Surgery: Long-term Outcome. Imola MJ, Hamlar DD, Shao W, Chowdhury K, Tatum S Arch Facial Plast Surg. 2001;3(2):79-90Objective: To determine the long-term efficacy of resorbable plate fixation in pediatric patients undergoing craniofacial surgery for congenital anomalies, traumatic deformities, or skull base tumors.Design: Retrospective case review.Materials and Methods: Medical records of 57 consecutive cases using resorbable plates and screws for craniofacial fixation in patients younger than 18 years were analyzed.Main Outcome Measures: The status of bone healing postoperatively (anatomical union, malunion, delayed union, or nonunion) and any complications or adverse effects (hardware visibility or palpability, plate extrusion, or infection) were noted.Results: In midfacial and upper face procedures (54 patients) anatomical union and uncomplicated bone healing occurred in 52 (96%) of the patients. In this same group, complications (plate extrusion) occurred in 2 patients (3.7%) and were resolved using conservative treatment without untoward sequelae. These outcomes are comparable to results using metal osteosynthesis in similar situations. Costs of resorbable hardware are similar to existing metal fixation systems.Conclusions: Our data support the use of bioresorbable plate fixation in pediatric craniofacial surgery as a means of avoiding the potential and well-documented problems with rigid metal fixation. Indications include fractures and segmental repositioning in low-stress non-load-bearing areas of the middle and upper craniofacial skeleton. Although there is an initial learning curve in using this technology, we believe the benefits are well worth the effort and represent a major advance in pediatric craniofacial surgery.COMMENTIn April 2001, the Archives of Facial Plastic Surgery published an article by Imola et al titled “Resorbable Plate Fixation in Pediatric Craniofacial Surgery.” This article is a multicenter review of a nearly 3-year period of the use of resorbable plate fixation in patients younger than 18 years who underwent craniofacial skeletal surgery for a mixture of congenital and acquired disorders. There were 55 patients who underwent 57 procedures. In some of the early cases, the authors used metal plates in locations thought to require added strength. Most of the cases were primary synostosis repairs in children younger than 7 years. The balance consisted of congenital revision, skull base tumor, and trauma cases.Nearly all of the cases involved the Lactosorb (Walter Lorenz Surgical Inc) absorbable plating system because it was the only readily available system during the study period. The reasons stated for desirability of absorbable plating systems include the theoretical or real problems associated with metal plates: visibility, palpability, tenderness, thermal sensitivity, bone atrophy or weakness from stress shielding in all patients, and interference with growth and intracranial migration in pediatric patients. These systems have been developed primarily from (co-) polymers of glycolic and/or L- or DL-lactic acid. Their strength degradation and resorption profiles are related to the ratios of the different monomers. These plates and screws range in strength retention from about 3 to 9 months, and in complete resorption from 6 to 36 months. They have mechanical strength profiles similar to metal plates, but they have to be bulkier to achieve this parity.Complications in the study included visible and/or palpable hardware, hardware extrusion, delayed union or malunion, and infection. The authors noted that the resorbable systems were more labor intensive and technically sensitive than metal systems and that there was a steep learning curve. The screw holes had to be tapped after drilling, and screws easily became cross-threaded, causing binding and screw failure. The plates had to be heated to be contoured, and they cooled quickly out of their thermoplastic range. Resorption of the materials was found at times to be associated with an inflammatory response. The authors concluded that the problems with resorbable fixation were outweighed by the benefits in growing patients. In nongrowing patients, the ease of use and lack of an inflammatory response of metal plates remains superior.Resorbable fixation remains an important topic in craniomaxillofacial surgery. Since this study was published, there have been about 150 more articles published on the subject. This is in part because there are several different systems available now, and their use has become quite common. The indications have expanded to more traumatic and orthognathic applications. There are even resorbable distraction devices.Many of the studies test the strength of resorbable material relative to that of titanium and evaluate its clinical reliability for maintaining bony segment position stability for trauma and orthognathic surgery. Overall, the resorbable systems have (nearly) equivalent performance to similarly tasked titanium. There are, however, notable exceptions. While these systems are in wide use, there is still significant controversy over their role in adults,1 even as their use has expanded in the last decade to mandibular applications.2,3 It is not clear that they offer a significant benefit over titanium systems relative to their detriments. Areas where questions remain include mandibular angle fractures,4,5 orthognathic procedures,6 and postablative reconstruction.7 In these areas the superior strength of titanium retains an important edge vs resorbable materials. In children, the benefit of resorbable materials is still clear. They avoid the risks of intracranial migration and growth interference as the pediatric craniofacial skeleton expands.In their article, Imola et al mention technical challenges in application of the resorbable plates. In the past 10 years there have been technical refinements in the materials and application systems. The plates and screws still have a higher profile than titanium with similar strength, but the differences are decreasing. New manufacturing techniques are increasing material strength. There are systems approved for mandibular applications, including positioning screws for sagittal split mandibular ramus osteotomies. Plate and screw handling has also improved in the last decade. There are torque-limiting screwdrivers to reduce screw failure. There are tack and pin systems to avoid the tapping step. There are heating in situ plate-bending tools to facilitate contouring.8 In addition, with experience have come technique refinements that have reduced complications. It has been demonstrated that too much bending during plate contouring significantly weakens the material, as does leaving a plate too long in the water bath used to heat the plate for bending in the first place.9With regard to personal experience, I use resorbable plates in more cases in my pediatric practice than I did 10 years ago, but I use fewer plates. The advantages of reduced risks of intracranial migration and growth interference remain. The handling and application of the plates has certainly become more streamlined, but some patients have developed scalp fluid collections in the 6- to 18-month range, when the materials are hydrolyzing and breaking down. These have been self-limited but disconcerting. Also, even though they are told the problem will go resolve, parents tend to be concerned about the palpability and visibility of the higher-profile resorbable plates. Because of these problems I tend to use lower-profile (and consequently weaker) mesh in thin-skinned areas. I use absorbable sutures where the rigidity of plates is not required, and when I need a thick plate, I try to position it under thicker soft tissue such as deep to the temporalis muscle in the temporal fossa. I also am more likely to try to maintain large bone flaps for cranial vault remodeling to minimize the amount of hardware required for stability. The plates tend to function better in tension situations rather than under compression, torsion, or angular stress. Plates with a single row of screws usually are fine in a tension zone. Strut plates, lattice plates, or pieces of mesh work better in the other situations. The mesh also works well to shield graft material from dural pulsations during cranioplasty (Figure).Figure. Intraoperative cranioplasty images. A, Resorbable mesh underlay for cranioplasty. B, Calcium phosphate cement cranioplasty completed.In conclusion the findings of the featured article hold true today. The resorbable systems provide adequate strength for most pediatric craniofacial applications. The production processes and techniques for use of these systems have improved in the past decade and reduced the inherent problems with them. They are still a little more difficult to apply than titanium, but the learning curve has become less steep. The visibility and palpability of the plates through the skin when unavoidable requires good family education. The occasional inflammation associated with plate degradation usually responds to expectant management, although sometimes I have felt compelled to treat the associated fluid collections with antibiotics when the patient was febrile.With regard to expanding applications for resorbable systems, it should be remembered that they are not as strong as titanium, and more demanding areas where greater strength is required should be approached cautiously. Applications where large biomechanical forces must be overcome such as mandibular angle fractures, orthognathic procedures with large movements, and postablative mandibular reconstruction are currently at the limit of what can be reliably achieved with resorbable fixation. The future promises to provide stronger, more easily applied materials with more precise degradation profiles and little or no inflammation with resorption.Financial Disclosure: None reported.Departments of Otolaryngology and Pediatrics, State University of New York Upstate Medical University, SyracuseREFERENCESDorri M, Nasser M, Oliver R. Resorbable versus titanium plates for facial fractures.. Cochrane Database Syst Rev. 2009;1CD007158 19160326 Google ScholarYlikontiola L, Sundqvuist K, Sàndor GK, Törmälä P, Ashammakhi N. Self-reinforced bioresorbable poly-L/DL-lactide [SR-P(L/DL)LA] 70/30 miniplates and miniscrews are reliable for fixation of anterior mandibular fractures: a pilot study.. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2004;97(3):312–317 15024352 Google ScholarGaball C, Lovald S, Baack B, Olson G. Minimally invasive bioabsorbable bone plates for rigid internal fixation of mandible fractures.. Arch Facial Plast Surg. 2011;13(1):31–35 21242429 Abstract, Google ScholarBayram B, Araz K, Uckan S, Balcik C. Comparison of fixation stability of resorbable versus titanium plate and screws in mandibular angle fractures.. J Oral Maxillofac Surg. 2009;67(8):1644–1648 19615576 Google ScholarEsen A, Ataoğlu H, Gemi L. Comparison of stability of titanium and absorbable plate and screw fixation for mandibular angle fractures.. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2008;106(6):806–811 18718777 Google ScholarUckan S, Veziroglu F, Soydan SS, Uckan E. Comparison of stability of resorbable and titanium fixation systems by finite element analysis after maxillary advancement surgery.. J Craniofac Surg. 2009;20(3):775–779 19480039 Google ScholarKetola-Kinnula T, Suuronen R, Kontio R, Laine P, Lindqvist C. Bioabsorbable plates and screws for fixation of mandibulotomies in ablative oral cancer surgery.. J Oral Maxillofac Surg. 2010;68(8):1753–1762 20018418 Google ScholarPietrzak WS. Heat adaptation of bioabsorbable craniofacial plates: a critical review of science and technology.. J Craniofac Surg. 2009;20(6):2180–2184 19934672 Google ScholarBallard TN, Kelly KJ, Zaydfudim V, et al.. Absorbable plate strength loss during molding.. J Craniofac Surg. 2010;21(3):644–647 20485022 Google ScholarFiguresReferencesRelatedDetails Volume 14Issue 1Jan 2012 InformationCopyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.To cite this article:Sherard A. TatumIII.Retrospective Review of Resorbable Plate Fixation in Pediatric Craniofacial Surgery.Archives of Facial Plastic Surgery.Jan 2012.11-13.http://doi.org/10.1001/archfaci.2011.1280Published in Volume: 14 Issue 1: January 2, 2012PDF download
Tissue sealants exist in 2 forms: platelet-rich plasma (PRP) and platelet-rich fibrin matrix (PRFM). They both result in activation of fibrinogen to fibrin, but PRFM contains a higher concentration of fibrinogen. PRFM products, otherwise known as fibrin sealants, make use of pooled human donor fibrinogen, factor XIII, and fibronectin. When they are mixed with thrombin, calcium chloride, and aprotinin, a fibrin clot is formed. Fibrin sealants are available as single-use kits. As an example, Evicel (Ethicon 360) comes in a triluminal catheter. One lumen contains the fibrinogen solution; one contains the thrombin solution; and one is filled with air to allow the spray application. On spraying, the fibrinogen and thrombin solutions are mixed, and a fibrin clot is created within seconds. In 2001, our facility compared the severity of edema and ecchymosis with and without the use of autologous PRP in 8 healthy women after standard deep-plane rhytidectomy. Unilateral application of the PRP was performed on closure of the superficial musculoaponeurotic system and skin flaps (Figure). The conclusion from this prospective, randomized, controlled pilot study was that there was a trend toward decreased postoperative ecchymosis and edema on the side of PRP application. The trend was more apparent early in the postoperative period (days 3-12) and more so for ecchymosis than edema. Because of the limited power of the study, however, a statistically significant difference could not be elucidated. In 2009, Lee et al published their results using the fibrin sealant Crosseal (Ethicon Inc) in 9 patients who were undergoing rhytidectomy. The sealant was applied unilaterally at random, and the contralateral side served as the control. The severity of ecchymosis for each side was scored 1 (minimal) to 10 (severe) by 5 blinded observers at postoperative days 3 and 7. The authors found a statistically lower level of ecchymosis for the fibrin sealant side (4.5) as compared with the control (6.2). Zoumalan and Rizk investigated hematoma occurrence with fibrin glue in both deep-plane and lateral superficial musculoaponeurotic system rhytidectomies. In their study, 459 patients underwent skin flap closure with fibrin glue, and 146 patients underwent standard closure. The authors concluded that there was a statistically significant reduction in hematoma rate when fibrin glue was applied to the skin flap. The hematoma rate was 3.4% in the control group and 0.4% in the fibrin sealant group (P=.01). Based on these studies, it seems likely that tissue sealants reduce the severity of ecchymosis in the acute postoperative period and may also minimize hematoma occurrence. It should be noted, however, that many other studies have not been able to corroborate these findings. Perhaps one of the more important and less frequently discussed advantages of fibrin sealants is the reduced operative time to achieve hemostasis and wound closure. Clearly, patients stand to benefit from reduced anesthesia time. However, the reduced facility and anesthesia fees must be weighed against the product expense. The unit cost for 2 mL of fibrin sealant plus the applicator is $200. In our experience, the use of fibrin sealants saves approximately 5 minutes of operative time during rhytidectomy. Because the product costs exceed the reduced facility costs, our facility no longer uses PRP or PRFM. Unfortunately, in our opinion, the potential benefits of these sealants have not been adequately substantiated to justify their costs in rhytidectomy. Figure. Application of platelet-rich plasma to the skin flap during closure of a deep-plane face-lift (reprinted with permission from Powell et al2).
Objectives: To understand Asian noses, set goals for rhinoplasty, and find the best alternative columellar strut.Methods: Six values were used to evaluate the morphology of the nose: tip projection, alar-tip-columellar base angle, alar-columellar base-philtrum angle, nasolabial angle, nasofacial angle, and tip angle. One hundred average Chinese people (50 males and 50 females) were compared with 36 preoperative Chinese patients (13 males and 23 females). We presented an application of high-density porous polyethylene (Medpor) implant as a columellar strut for use in lengthening. We performed 3 surgical techniques: a single-plate strut, a double-plate strut, and a butterfly-shaped strut. Open rhinoplasty (transcolumella incision) was performed on 21 patients; closed rhinoplasty (marginal incision) was performed on 15 patients.Results: Prominent changes in the 6 values were found in both male and female patients after rhinoplasty.Conclusions: An analysis of the Asian nose will help surgeons achieve better results. High-density porous polyethylene columellar strut grafts provide adequate support for refined tip definition and the shaping of the columellar-lobular angle.
OBJECTIVE To determine the rate of post-face-lift hematoma among users of serotonin reuptake inhibitors (SSRIs) vs non-SSRI users. Selective serotonin reuptake inhibitors have come under recent scrutiny because of possible bleeding risks. However, cessation of SSRIs carries inherent risks. METHODS The medical charts for 250 consecutive patients who underwent a modified deep-plane face-lift and 13 patients who underwent neck-lift from January 2010 to May 2011 were reviewed for the incidence of postoperative hematoma. Patients' medical records were examined for medical comorbidities, coagulopathy, and medication list, with particular attention to any usage of SSRIs or serotonin norepinephrine reuptake inhibitors (SNRIs). RESULTS Twenty-two percent of patients were taking SSRIs or SNRIs. We observed a total hematoma (major + minor) rate of 1.95% for non-SSRI/SNRI users vs 1.72% for SSRI/SNRI users. The minor hematoma rate was 1.95% among nonusers vs 0% for users. The major hematoma rate was 0% among nonusers vs 1.72% for users. CONCLUSIONS Usage of SSRIs was more common in this large series of face-lift patients than in the general population. In these patients, SSRIs in the perioperative period are found to be safe and did not seem to adversely affect outcome. We found no evidence to support discontinuing SSRIs perioperatively.
Background: Facial laser resurfacing and chemodenervation with botulinum toxin type A are used independently as means of nonsurgical facial rejuvenation. Recent reports in the literature have described combining these 2 therapies, claiming improved and longer-lasting laser resurfacing results. To date, no scientific investigation has been undertaken to prove or disprove this theory. Design: Institutional review board–approved, prospective, randomized, blinded study at university-affiliated outpatient cosmetic surgery offices. Intervention: Patients had one side of their face injected, at specific anatomic subsites (crow’s feet, horizontal forehead furrows, and glabellar frown lines), with botulinum toxin 1 week before laser resurfacing. After receiving an injection, patients underwent cutaneous laser exfoliation on both sides of the face with either a carbon dioxide or an erbium dual-mode laser. Main Outcome Measures: Patients’ injected (experimental) and noninjected (control) sides were compared after laser resurfacing. Follow-up was documented at 6 weeks, 3 months, and 6 months after laser resurfacing. Subjective evaluation, based on a visual analog scale, was performed in person by a blinded observer. Furthermore, a blinded panel of 3 expert judges (1 facial plastic surgeon, 1 oculoplastic surgeon, and 1 cosmetic dermatologist) graded 35-mm photographs taken during postoperative follow-up visits. Results: Ten female patients were enrolled in the study. A 2-tailed t test showed that all sites that were pretreated with botulinum toxin showed statistically significant improvement (P .05) over the nontreated side, with the crow’s feet region showing the greatest improvement. Comparing results between the carbon dioxide and erbium lasers did not result in any statistically significant differences. Conclusions: Hyperdynamic facial lines, pretreated with botulinum toxin before laser resurfacing, heal in a smoother rhytid-diminished fashion. These results were clinically most significant in the crow’s feet region. We recommend pretreatment of movement-associated rhytids with botulinum toxin before laser resurfacing. For optimum results, we further recommend continued maintenance therapy with botulinum toxin postoperatively.
Archives of Facial Plastic SurgeryVol. 14, No. 6 Free AccessLeonardo da Vinci's Aesthetic Analysis of Nasal Tip ProminenceFarhad B. NainiFarhad B. NainiCorrespondence: Dr Naini, Department of Orthodontics, St George's Hospital and Medical School, Blackshaw Road, London, SW17 0QT, England, UK (E-mail Address: farhad.naini@yahoo.co.uk).Search for more papers by this authorPublished Online:1 Nov 2012AboutSectionsPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail Aesthetic nasal evaluation requires the nose to be analyzed both as an independent facial unit and in terms of its size, morphologic characteristics, and position relative to its neighboring facial structures and the entire craniofacial complex. Nasal tip projection describes an actual change in the distance from nasal ala to tip, that is, the alar-tip distance. If there is increased tip projection, the nasal tip extends an excessive distance from the face and is perceived as disproportionately prominent.A number of methods have been described to evaluate sagittal nasal tip projection in profile view, each having its limitations.1 These include the nasofacial angle, described by Jacques Joseph (1865-1934), one of the pioneers of modern rhinoplasty, using a drawing of Leonardo da Vinci's to describe what he termed the “profile angle.”2,3 Tip projection has also been analyzed in relation to upper lip height (Simons method4), as nasal height to projection ratio (Goode method1; Baum method5), as a triangle method (Crumley and Lanser method6), as tip projection to nasal length ratio (Byrd and Hobar method7) and as tip projection relative to sagittal upper lip position.1In addition, Baud8 described the “facial circle” method for analyzing nasal tip projection in relation to the sagittal projection of the forehead and chin (Figure 1). The midpoint of the anterior semicircle was taken as the midpoint of the external auditory canal, but an alternative landmark is the tragion, which is the notch on the superior border of the tragus (Behrbohm modification1). A line from tragion to pronasale forms the radius of a circular arc; ideally, the trichion (hairline) and soft-tissue pogonion (the anterior projection of the chin) should be located on the path of this arc. Assuming normal forehead and chin position, if the nasal tip falls outside this circle it is considered to be overprojected. Interestingly, a strikingly similar aesthetic analysis has now been identified in the notebooks of Leonardo da Vinci (Figure 2).Figure 1. Baud's “facial circle.”8 A line from the tragion to the pronasale forms the radius of a circular arc; ideally, the trichion (hairline) and soft-tissue pogonion (anterior projection of the chin) should be located on the path of this arc. Assuming normal forehead and chin position, if the nasal tip falls outside this circle it is considered to be overprojected. Reprinted with permission. Copyright 2011 Farhad B. Naini and Wiley-Blackwell.Figure 2. The facial circle method as depicted by Leonardo da Vinci (1452-1519). Folio 2 (back) and folio 3 (front) from Manuscript A (circa 1490-1492); detail from folio 2 (“profile of human head”) highlighted. Interestingly, as well as the arc from the ear to the nasal tip, there is also a fainter arc from the ear to the glabellar region. 21.3 × 14.8 cm. Bibliothèque de l'Institut de France, Paris, France. Reproduced with kind permission from Reunion des Musees Nationaux, Bibliothèque de l'Institut de France. Copyright 2012 Bibliothèque de l'Institut de France.The study of the proportions of the human figure was of special interest to the ancient Greeks, particularly in relation to sculpture, and to the Romans, mainly in relation to architecture. The existing works from antiquity became available in the Renaissance, leading to a revival of interest. Leonardo would have studied what was available, but following from and advancing Leon Battista Alberti's methods, he took his own anthropometric measurements in order to find “ideal” proportional relationships.Twelve manuscripts, donated by Count Galeazzo Arconati to the Biblioteca Ambrosiana in the 17th century, were removed in 1796 at the express order of Napoleon Bonaparte, then commanding the French troops who had just entered Milan. They were taken to Paris, to the Institut de France, where they were assigned identifying letters ranging alphabetically from A to M. These manuscripts have various formats, ranging from rapid sketches and quickly jotted notes to accurate text and drawings. Manuscript A originally consisted of 114 folios, of which only 63 remain. (The missing pages were removed in the 19th century by Guglielmo Libri, who fled to England and sold a volume he had put together from these sheets together with others from Manuscript B, to Lord Ashburnham.)The image depicted is from Manuscript A and in the original occurs on a page with unrelated text on matters of natural history (Figure 2). Leonardo did not provide any explanatory text to accompany the image. The image is, as far as we know, a one-off. It is a relatively early drawing (circa 1490-1492) and probably corresponds to a stage when Leonardo was working out how best to tackle the proportions of the body. There are no other drawings that use this method, and it was unusual for Leonardo to make use of circles in his study of the proportions of the human head.9 Yet, the image appears to depict the facial circle method and predates Baud by nearly 5 centuries.This image provides another example of this Renaissance polymath—a man clearly ahead of his time whose mark of genius was an incessant activity of mind and insatiable curiosity for understanding the natural world.Conflict of Interest Disclosures: None reported.REFERENCESNaini FB. Facial regional analysis: the nose.. In: Naini FB, ed. Facial Aesthetics: Concepts and Clinical Diagnosis. Oxford, England: Wiley-Blackwell; 2011:214-237 Google ScholarJoseph J. Nasenplastik und sonstige Gesichtsplastik nebst einem Anhang über Mammaplastik und einige wietere Operationen aus dem Gebiete der äusseren Körperplastik.. Leipzig, Germany: Curt Kabitzsch; 1931 Google ScholarNaini FB. Leonardo da Vinci's Portrait of a Young Woman in Profile: studies of beauty and “ideal” proportions.. Arch Facial Plast Surg. 2012;14(2):148–149 22431818 Abstract, Google ScholarSimons RL. Nasal tip projection, ptosis, and supratip thickening.. Ear Nose Throat J. 1982;61(8):452–455 Google ScholarBaum SJ. Introduction.. Ear Nose Throat J. 1982;61(8):426–428 Google ScholarCrumley RL, Lanser M. Quantitative analysis of nasal tip projection.. Laryngoscope. 1988;98(2):202–208 3339933 Google ScholarByrd HS, Hobar PC. Rhinoplasty: a practical guide for surgical planning.. Plast Reconstr Surg. 1993;91(4):642–656 8446718 Google ScholarBaud C. A new way of measuring the profile.. SSO Schweiz Monatsschr Zahnheilkd. 1966;76(9):741–748 5225830 Google ScholarNaini FB. Facial proportions: classical canons to modern craniofacial anthropometry.. In: Naini FB, ed. Facial Aesthetics: Concepts and Clinical Diagnosis. Oxford, England: Wiley-Blackwell; 2011:18-44 Google ScholarFiguresReferencesRelatedDetails Volume 14Issue 6Nov 2012 InformationCopyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.To cite this article:Farhad B. Naini.Leonardo da Vinci's Aesthetic Analysis of Nasal Tip Prominence.Archives of Facial Plastic Surgery.Nov 2012.463-464.http://doi.org/10.1001/archfaci.2012.855Published in Volume: 14 Issue 6: November 1, 2012PDF download
