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The broad trend toward minimally invasive methods in most surgical fields is contrasted by rhinoplasty: Extended open approaches, an increasing number of grafting techniques, donor site depletion, and extensive osteotomies seem to indicate a trend away from minimally invasive methodology for this particular procedure. This article intends to analyze which factors are involved in this and related developments in rhinoplasty.Evidence-based methodology sets the standards for scientific analysis. For rhinoplasty, however, limitations of established scientific methodology are identified. These include the relative lack of objective outcome measures and the impact of various systematic biases on reported results. These biases include operator dependence, interdependence of techniques, biased selection of outcome parameters, and orthodox treatment bias. Upon critical review, the importance of systematic biases may outweigh the impact of evidence-based study in rhinoplasty. Results should therefore be interpreted with caution. Strategies are suggested to identify and mitigate the impact of biases and to improve reporting and outcome analyses in rhinoplasty.

BACKGROUND Little is known about the incidence of narrowing and an operated appearance of the dorsum after hump resections if the dorsum is not reconstructed with spreader grafts or spreader flaps. METHODS Patients who had undergone a composite hump resection (n = 22) or a component hump resection (n = 25) were interviewed and photographed with a minimum follow-up of 12 months. Four expert rhinoplasty surgeons and four laypersons rated the appearance of the middle third of the dorsum on the preoperative and postoperative en face photographs. The quartile of the most surgical appearing outcomes was analyzed regarding potentially preventive surgical maneuvers. RESULTS No patient was dissatisfied with the frontal view of the nose. Agreement between expert and lay raters (Kendall's coefficient of concordance) was 0.51 (p < 0.01) and 0.34 (p = 0.06) for appearance and 0.55 (p < 0.01) and 0.46 (p < 0.01) for width, respectively. Expert raters found that a surgical appearance of the dorsum had both increased and decreased after surgery, with an average increase of 0.27 ± 1.05 and 0.21 ± 1.18 points on a five-point Likert scale for composite and component resection, respectively. Pearson correlation between the degree of dorsal lowering and surgical appearance on the anterior view was 0.31 (p = 0.026). Reconstruction of the middle third could potentially have improved the outcome in 15 percent of the patients. CONCLUSIONS Lowering of the dorsum without middle vault reconstruction on average increased an operated appearance to a small degree that was not noted by the patients. This effect was similar for composite and component hump resections. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.

Purpose of review To present criteria of minimally invasive surgery, which include minimal and hidden incision lines, reduced injury to tissue and application of endoscopic techniques, when feasible; to analyze techniques in rhinoplasty for their minimally invasive character - in light of recent publications; and to discuss the techniques that best meet the criteria of minimally invasive surgery. Recent findings The nose consists of about 60 percent soft tissue and 40 percent skeletal elements. Surgery causes injury to both tissue types through various mechanisms, including mechanical traction, separation, incision, heat, desiccation, and others. Multiple aspects including extent of approach and degree of tissue undermining determine the minimally invasive character of techniques and maneuvers in rhinoplasty. Summary A single incision endonasal approach, the subperichondrial and subperiosteal septal plane, the supraperichondrial plane over the cartilaginous dorsum, the subperiosteal plane over the bony dorsum, limited dorsal undermining with endoscopic visualization when feasible, conventional straight lateral osteotomy or percutaneous curved lateral osteotomy; percutaneous transverse osteotomy; conventional straight paramedian osteotomy; piezo and drill paramedian ostectomy; dorsal uncapping osteotomy; conventional rasp gross dorsal contouring; piezo or drill fine dorsal contouring; (cartilaginous) middle vault 'let down'; and minimal access subperiosteal turbinate bone resection were found to best fulfil the criteria of minimally invasive surgery. A classification system for the degree of minimally invasiveness of rhinoplasty techniques is proposed as a basis for discussion.

The nasal anatomy of Caucasian people includes thin skin, limited soft tissue volume, a high dorsum, strong cartilaginous framework, and narrow elliptical nasal inlets. A smooth dorsal contour, a well-defined tip, a naturally soft-feeling tip, and a functionally patent nasal valve constitute key objectives for Caucasian rhinoplasty. The author's focus on minimal-impact surgery has resulted in multiple novel techniques, embedded in a coherent algorithmic concept termed the S.O.F.T. (surgery and ongoing care free of trauma) concept. The foundation is the endonasal operation for the entire spectrum of primary and secondary deformities and maximal preservation of anatomic structures.

ZusammenfassungWährend einfache Defekte auch durch freie Hauttransplantate oder lokale Lappenplastiken rekonstruiert werden können, stellen komplexe dreischichtige Defekte eine Herausforderung für den rekonstruktiv tätigen Chirurgen dar. Diese bezieht sich in erster Linie auf eine suffiziente Wiederherstellung der inneren Nasenauskleidung, ohne die physiologischen Funktionen der Nasenschleimhaut zu kompromittieren. Die Autoren gehen auf verschiedene Rekonstruktionstechniken zur Wiederherstellung der inneren Nasenauskleidung ein. Eine besondere Bedeutung kommt hier dem epithelialen Kipplappen und dem kürzlich erst beschriebenen prälaminierten Stirnhautlappen bei (sub)totalen Nasendefekten zu. Beide haben sich in der Wiederherstellung der inneren Nasenauskleidung als sehr wertvolle und schleimhautschonende Alternativen zu herkömmlichen intranasalen Schleimhautlappen bewährt.

Background Recent research has indicated that botulinum toxin type A may have an inhibitory effect on the formation of fibroblasts and thus possibly decreases the severity of scar formation. Therefore, a trial was designed to assess the effects of botulinum toxin type A on scar formation after thyroid surgery. Methods A double-blind, randomized, controlled trial was designed. All patients underwent a preoperative survey to assess scar history. All patients underwent a total thyroidectomy, hemithyroidectomy, or parathyroidectomy through a standardized incision. At the conclusion of the case, one half of the incision was injected with botulinum toxin type A, and the other half was injected with saline (placebo). The scars were then evaluated at 4 weeks, 6 months, and 1 year postoperatively using subjective scar analysis scales. Results A total of 40 patients were enrolled. There was no significant difference in scarring at any of the time points between the botulinum toxin type A-treated and placebo sides of the incision. A subgroup analysis was performed that examined the effects of botulinum toxin type A on those with a severe scar history. This demonstrated a significant decrease in scarring at 6 months postoperatively on the botulinum toxin type A-treated side. Conclusions This study indicates that botulinum toxin type A administration immediately after surgical closure of a thyroid incision does not demonstrate a difference in scar outcomes compared with the control side. However, there was less scarring in subjects who had a severe scar history. This study found opposite results to a similarly designed study. Further study is required to determine the optimal use of botulinum toxin type A for wound healing. Clinical question/level of evidence Therapeutic, II.

Secondary cleft rhinoplasty represents a particular surgical challenge. The authors have identified the deficit in skeletal projection of the cleft-sided piriform rim as an important contributor to the pathology. A graft is described to augment the piriform crest on the cleft side. This foundation graft is suture fixated to the piriform crest after complete release of all soft tissue attachments to the alar base. The foundation graft is articulated with a long alar strut graft, which allows for powerful projection of the cleft-sided nasal tip. An advancement flap of vestibular skin is described to correct the vestibular stenosis. A transplant of diced cartilage in fascia is added to augment maxillary soft tissue volume. Subjective and objective measures of form and function are presented in a retrospective series of five cases, illustrating the efficacy of the techniques described.

BACKGROUND: Platelet-rich plasma (PRP) products are currently suggested in the treatment of chronic wounds due to possible pro-angiogenic effects. Microvascular compromise represents the major component in radiogenic wound healing complications. The effects of PRP on irradiated cells of the cutaneous wound healing process are still poorly understood. MATERIAL AND METHODS: Human dermal microvascular endothelial cells (HDMEC) and human adipose derived stem cells (hASC) were cultured and irradiated with doses of 2 to 12 Gy. PRP was activated, characterized and added to the incubation media in different concentrations after external radiation. Cell count was determined 48 h after radiation using a semi-automated cell counting system. Levels of interleukin-6 (IL-6), basic fibroblast growth factor (bFGF) and soluble intercellular adhesion molecule-1 (sICAM-1) in the supernatants of HDMEC and hASC co-cultures were determined by enzyme-linked immunosorbent assay (ELISA). Non-irradiated hASC and HDMEC served as controls. RESULTS: The employed PRP preparations were characterized and contained platelet derived growth factor (PDGF-AB), vascular endothelial growth factor (VEGF), bFGF and high levels of sICAM-1. Addition of PRP to irradiated cultures of HDMEC and hASC prevented profound radiation-induced decline in cell numbers. 10% PRP restored cell numbers to levels of untreated, non-irradiated cultures. Basic FGF expression was decreased significantly in hASC monocultures treated with 10% PRP without external radiation and after irradiation with 6 and 12 Gy. These inhibitory effects of PRP were also observed in HDMEC. In contrast, co-cultures of HDMEC-ASC showed a dose-dependent increase in bFGF expression when treated with 5 or 10% PRP. Doses of 6 and 12 Gy increased IL-6 expression in cultures stimulated with 5% PRP. CONCLUSIONS: Use of PRP in co-cultures of hASC and HDMEC restores proliferative defects caused by external radiation probably by induction of bFGF. Under irradiated conditions, PRP might induce pro-inflammatory stimuli which could be beneficial in treatment of chronic wounds where healing processes are defective. Combined use of hASC and PRP products might be helpful in the treatment of radiogenic wounds.

Minimal invasive Zugange zur vorderen Schadelbasis haben in den letzten Jahrzehnten einen wichtigen Stellenwert erlangt. Fur den HNO Bereich hat sich-in interdisziplinarer Kooperation-insbesondere das transnasal-endoskopische Vorgehen etabliert. Die jungere Technik des transorbital-endoskopischen Vorgehens kann durch ein differierendes Spektrum an Zugangskorridoren eine Erganzung des etablierten transnasal-endoskopischen Vorgehens darstellen. Ziel der vorliegenden Arbeit war die Bewertung der transorbital-endoskopischen Zugange anhand der aktuellen Literatur. Diese Zugange stellen eine wesentliche Erweiterung der minimal invasiven Zugange zur vorderen Schadelbasis dar. Wichtige Strukturen insbesondere der lateralen Aspekte der vorderen Schadelbasis einschlieslich der Stirnhohlenhinterwand lassen sich exzellent erreichen. Aufgrund ihrer geringen Morbiditat und der kosmetisch exzellenten Ergebnisse erganzen sie etablierte transnasale, transfaziale und transkranielle Zugange zur vorderen Schadelbasis. Ihre Durchfuhrung erfordert spezialisierte Kenntnisse okuloplastischer Operationstechniken des interdisziplinaren Teams.

Hintergrund Wundheilungsstorungen in bestrahlten Hautarealen stellen eine grose Herausforderung im klinischen Alltag dar. Die Pathophysiologie bestrahlter Wunden ist komplex und erfordert die Interaktion verschiedener Zellarten, Zytokine und Wachstumsfaktoren.

Wound healing complications in irradiated tissues represent a major clinical challenge. Fistula or even major vessel rupture may occur. The injection of adipose tissue derived stem cells seem to be a promising therapeutical strategy. The article describes the clinical case of a patient suffering from a pharyngo-cutaneous fistula after laryngectomy and radiotherapy. The patient was successfully treated by the injection of fat tissue.

Während einfache Defekte auch durch freie Hauttransplantate oder lokale Lappenplastiken rekonstruiert werden können, stellen komplexe dreischichtige Defekte eine Herausforderung für den rekonstruktiv tätigen Chirurgen dar. Diese bezieht sich in erster Linie auf eine suffiziente Wiederherstellung der inneren Nasenauskleidung, ohne die physiologischen Funktionen der Nasenschleimhaut zu kompromittieren. Die Autoren gehen auf verschiedene Rekonstruktionstechniken zur Wiederherstellung der inneren Nasenauskleidung ein. Eine besondere Bedeutung kommt hier dem epithelialen Kipplappen und dem kürzlich erst beschriebenen prälaminierten Stirnhautlappen bei (sub)totalen Nasendefekten zu. Beide haben sich in der Wiederherstellung der inneren Nasenauskleidung als sehr wertvolle und schleimhautschonende Alternativen zu herkömmlichen intranasalen Schleimhautlappen bewährt.

Summary Importance Nasal hump reduction is a frequent manoeuvre in rhinoplasty. Over the last years, composite hump reduction has been advocated in favour of component hump reduction. The latter allows a more controlled and stepwise approach in reducing the nasal dorsum by deprojecting the cartilaginous dorsum separately from the bony dorsum. This approach also preserves the upper lateral cartilages (ULCs) and their mucosa. Objective To analyse the intricacies of the anatomic transition zone between the ULCs, the rhinion and the nasal bones as they pertain to component hump reduction. Method Anatomical dissections with five fresh cadaveric heads were performed in this study. The cephalic extension of the ULCs beneath the nasal bones was modified and measured after component hump reduction on both sides of the rhinion. Results Central detachment of the ULCs from the bony dorsum and their release from the medial undersurface of the nasal bones allows for complete preservation of the ULCs. This is achieved by inferior-medial rotation of the cephalic ends of the ULCs against the septum. If not released completely during hump reduction, a substantial loss of the ULCs may be the consequence. Conclusions The described manoeuvre allows the preservation of the cephalic components of the ULCs underneath the bony dorsum during component hump reduction. The result is a smoother transition line at the keystone area and along the entire bony-cartilaginous dorsum with a straighter aesthetic dorsal profile and oblique view. The present findings allowed us to present an operative algorithm with implementation into clinical practice.

The stairstep graft is a novel method to modify the lateral anchoring point of lateral grafts for nasal valve correction.Eight consecutive patients with a diagnosis of nasal valve collapse were included in the study. The novel method of stairstep grafts was performed to reinforce the lateral crus and to widen the nasal valve. Postoperative evaluations were performed by using questionnaires and photographs. After a minimum follow-up of 3 months, all patients reported an improvement of nasal airway postoperatively. Persistent normalization of the preoperatively narrow alar base was noted.The stairstep graft introduces a new concept in nasal valve surgery by lateralization of the lateral anchoring point for the alar strut graft (or other lateral functional grafts). The concept seems logical, enhances an existing technique, and may be performed through a minimally invasive approach, and the potential for untoward effects seems to be low.

Bei richtiger Indikation und Durchfuhrung ist die Tranenwegschirurgie auserordentlich erfolgreich. Sowohl die externe Dacryocystorhinostomie als auch die endonasale Variante kann in uber 80 % der Falle die Tranenwege dauerhaft offen halten.

Introduction Meningiomas of the fronto-basal skull are difficult to manage as the treatment usually includes extensive resection of the lesion, consecutive reconstruction of the meninges and of the skull. Especially after removal of spheno-orbital and sphenoid-wing meningiomas, the cosmetic result is of utmost importance. In this technical note, we present our institutional approach in the treatment of skull base meningiomas, focussing on the reconstruction of the neurocranium with individually preformed titanium cranioplasty (CRANIOTOP ® , CL Instruments, Germany). Case report Two female patients (40 years, 64 years) are presented. Both patients presented with skull base lesions suggestive of meningiomas. The preoperative thin-sliced CT scan was processed to generate a 3D-model of the skull. On it, the resection was mapped and following a simulated resection, the cranioplasty was manufactured. Intra-operatively, the titanium plate served as a template for the skull resection and was implanted after microsurgical tumour removal, consecutively. The cosmetic result was excellent. Immediate postoperative CT scan revealed accurate fitting and complete tumour removal. Control Magnetic Resonance Imaging (MRI) within 12 weeks was possible without any artifacts. Discussion The comprehensive approach described indicates only one surgical procedure for tumour removal and for reconstruction of the skull. The titanium plate served as an exact template for complete resection of the osseous parts of the tumour. Cosmetic outcome was excellent and control MRI was possible post operatively. Conclusion CRANIOTOP ® cranioplasty is a safe and practical tool for reconstruction of the skull after meningioma surgery.

Objectives/Hypothesis To test whether therapeutic effects of botulinum toxin A on patient- specific keloid tissue can be reproduced on the cellular level. Specifically, effects on cell proliferation and expression of growth factors and cytokines relevant for wound healing were to be tested. Study Design Experimental study including patient specific cell cultures of keloids. Methods Patient-specific keloid tissue was tested in a cell culture model for effects of botulinum toxin incubation on cell proliferation and expression of the following cytokines and growth factors: IL-6 (interleukin-6), VEGF (vascular endothelial growth factor), TGF-β (transforming growth factor-β). Results None of the tested parameters of human keloid tissue were affected by botulinum toxin A incubation. Conclusion The present study does not add evidence to suggest a significant therapeutic role of botulinum toxin injections for the treatment of keloids. Level of Evidence N/A. Laryngoscope, 124:1344–1351, 2014

BACKGROUND Radiation-induced wound healing complications represent an important clinical problem. Microvascular compromise is an important component of its pathogenesis and the microvascular endothelial cell is the key representative affected at the cellular level. MATERIAL AND METHODS Human dermal microvascular endothelial cells (HDMEC) were cultured and irradiated with doses of 2 to 12 Gy. Cell density was determined 48 h after radiation using a semi-automated cell counting system. Levels of interleukin-6 (IL-6), basic fibroblast growth factor (FGF), intercellular adhesion molecule-1 (ICAM-1) and vascular cell adhesion molecule-1 (VCAM-1) in the supernatants of HDMEC were determined by polymerase chain reaction (PCR) and enzyme-linked immunosorbent assay (ELISA). Non irradiated HDMEC were used as controls. RESULTS Cell density was significantly impaired in irradiated cells compared to non irradiated controls. Radiation resulted in significant elevation of levels of IL-6, FGF, ICAM-1 and VCAM-1 in the supernatants of HDMEC in a dose dependent manner. CONCLUSION The inflammatory response observed clinically after radiation seems to correlate with elevated expression of cytokines and adhesion molecules by microvascula endothelial cells. The model of HDMEC documents the impairment of microcirculation. These in vitro changes may enhance our understanding of the pathomechanisms leading to radiation-induced vasculitis and associated wound healing problems.

Background Complete tumor removal and preservation of the facial nerve are essential in parotid gland surgery. A technical adjunct that potentially enhances the contrast between the facial nerve and the adherent tumor tissue and allows to identify residual tumor tissue could be Fluorescein Sodium. Methods Retrospective chart analysis on 7 patients with benign parotid gland lesions that were operated using Fluorescein Sodium intravenously and the application of the YELLOW 560 nm filter of the operating microscope. Safety and feasibility were evaluated. Results All tumors showed fluorescence and the rating ´contrast-enhancing´ was assigned in all cases. In 2 patients, satellite nodules were identified and resected meaning that the fluorescence staining of the tumor margins was significantly better than under white light. Conclusion The use of Fluorescein Sodium in parotidectomy is promising. In two cases residual tumor was detected that would have been left behind under white light. Further research in parotid gland surgery and other head and neck tumor procedures is warranted.

Minimally invasive approaches are becoming increasingly popular to access the anterior skull base. With interdisciplinary cooperation, in particular endonasal endoscopic approaches have seen an impressive expansion of indications over the past decades. The more recently described transorbital approaches represent minimally invasive alternatives with a differing spectrum of access corridors. The purpose of the present paper is to discuss transorbital approaches to the anterior skull base in the light of the current literature. The transorbital approaches allow excellent exposure of areas that are difficult to reach like the anterior and posterior wall of the frontal sinus; working angles may be more favorable and the paranasal sinus system can be preserved while exposing the skull base. Because of their minimal morbidity and the cosmetically excellent results, the transorbital approaches represent an important addition to established endonasal endoscopic and open approaches to the anterior skull base. Their execution requires an interdisciplinary team approach., GMS Current Topics in Otorhinolaryngology - Head and Neck Surgery; 14:Doc03

Objective To evaluate possible botulinum toxin A effects in a cell culture model. Methods In a cell culture model with dermal fibroblasts and microvascular endothelial cells, possible botulinum toxin A effects were evaluated. Cell proliferation and cytokine expression were analyzed using viability assays and enzyme-linked immunosorbent assay techniques. Results Neither cell proliferation nor cytokines and growth factors (interleukin 6, monocyte chemoattractant protein 2, fibroblast growth factor, macrophage colony-stimulating factor, and vascular endothelial growth factor) were affected by botulinum toxin A incubation. Conclusions The present data do not add evidence to suggest a significant therapeutic role of botulinum toxin A injections for cutaneous wound healing beyond chemoimmobilization. Further studies that include patient-specific cells of hypertrophic scars are required to better understand what role botulinum toxin A can play in the treatment of mature scar tissue.

Ein Parotistumor einer 62-jahrigen Patientin stellte sich intraoperativ als Malignom mit Infiltration des N. facialis dar. Schnellschnitthistologisch war eine Artdiagnose zunachst nicht moglich. Immunhistochemische Untersuchungen ergaben den seltenen Fall eines myoepithelialen Karzinoms der Gl. parotis. Es erfolgte die totale Parotidektomie einschlieslich Resektion der bukkalen Fazialisaste sowie eine Neck-Dissection der betroffenen Seite. Die Patientin wurde einer adjuvanten Radiatio zugefuhrt.

Botulinum toxin A is an effective and safe treatment for perioral rejuvenation. This article explores the application of this toxin for cosmetic use in the perioral region, facial asymmetry, and improved facial wound healing. This article also describes how the use of botulinum toxin A, which has traditionally been used on the upper one third of the face, has expanded to the lower two thirds with the advent of a new formulation that consists of botulinum toxin combined with an anesthetic agent and a vasoconstrictor. The new formula provides the injecting physician with immediate feedback on the eventual treatment effect and reduces local diffusion of the simultaneously injected agents, potentially limiting systemic absorption and diffusion to neighboring muscle groups and adding to an already remarkable safety profile.

To develop and evaluate a minimally invasive technique of lateral orbitotomy that provides improved orbital access with fewer complications.A cadaver study was undertaken to develop a technique of transconjunctival lateral orbitotomy that preserves the structural integrity of the eyelid support system and provides extended access to the orbit from floor to roof. We then evaluated the procedure in an outcome study of 30 consecutive patients.The cadaver investigations demonstrated that a transconjunctival lateral retrocanthal approach is technically possible and provides improved direct access to the lateral orbit. In the study of 30 consecutive procedures, there were no complications resulting from the surgical access. The wound healing was rapid, without tissue distortion or scars. The exposure was ample for all surgical interventions.Lateral retrocanthal orbitotomy is a new approach that provides extended access to the entire lateral orbit. The technique is rapid and can be extended in a single continuous incision to the medial orbit. The structural integrity of the lateral retinaculum is preserved, which appears to improve the postoperative cosmetic and functional result.

An algorithm was developed through an evolution of refinements in surgical technique with the goal to minimize risk and morbidity in otoplasty. Key principles were avoidance of cartilage incisions and transections and the use of multiple surgical techniques to distribute the "surgical load" evenly among these techniques. The present retrospective study was designed to test safety and efficacy of the concept in 100 consecutive patients and to discuss the results in light of the literature. Data detailing the surgery, preoperative, and postoperative period were extracted from the record and during patient interviews. Patients were contacted to complete a questionnaire to rate the postoperative pain and their satisfaction with the final outcome on a 6-point visual analog scale (VAS). An expert and a lay panel assessed preoperative and postoperative frontal-view photographs, using the same VAS. Pain in the postoperative was rated as minor (pain level VAS average score, 2.33) and patients' satisfaction was excellent (satisfaction level VAS average score, 1.82). The assessment by the panels of expert and lay evaluators paralleled these outcomes with a postoperative average VAS score of 1.69 and 1.87, respectively. Cartilage incision and transection can be effectively avoided in otoplasty. Even distribution of the surgical load among multiple techniques avoids the problems associated with "overload" of a single technique. The innovative technique of cortical mastoid drill-out is described. High satisfaction with the results, excellent patient comfort, and a favorable safety profile are associated with the present algorithm.

OBJECTIVE To test whether botulinum toxin-induced immobilization of facial lacerations enhances wound healing and results in less noticeable scars. PATIENTS AND METHODS In this blinded, prospective, randomized clinical trial, patients were randomized from February 1, 2002, until January 1, 2004, to botulinum toxin vs placebo injection into the musculature adjacent to the wound within 24 hours after wound closure. Blinded assessment of standardized photographs by experienced facial plastic surgeons using a 10-cm visual analog scale served as the main outcome measure. RESULTS Thirty-one patients presenting with traumatic forehead lacerations or undergoing elective excisions of forehead masses were included in the study. The overall median visual analog scale score for the botulinum toxin-treated group was 8.9 compared with 7.2 for the placebo group ( P =.003), indicating enhanced healing and improved cosmesis of the experimentally immobilized scars. CONCLUSIONS Botulinum toxin-induced immobilization of forehead wounds enhances healing and is suggested for use in selected patients to improve the eventual appearance of the scar.

Background The nasal muscles and their function are not clearly defined. The nasal muscles generally are thought to act synergistically to produce mimetic motion and affect the nasal airway. We proposed direct examination of the effects of the nasal muscles on the nasal airway. Methods Rhinomanometry was performed on volunteers. After paralysis of the nasal muscles with lidocaine, rhinomanometry was performed again to measure nasal airway function with the patient at rest and attempting to flare his/her nostrils. Each patient's rhinomanometric results (at rest and attempting to flare the nostrils) taken before injection of lidocaine served as the control for comparison of his/her results postinjection. The structural tension of the ala at rest and with active flaring of the nostril was measured also, and the results pre- and postparalysis with lidocaine were compared. Results The data from both the stiffness (structural tension) and the airflow portions, taken together, support the following conclusions. First, the paralysis was significant, although not complete. Clinical and stiffness data supported complete paralysis. Airflow data, which we think most sensitive, support a statistically significant affect of the injection, although incomplete paralysis. Conclusion All of the evidence supports an important role for the nasal muscles when actively used to increase nasal airflow. Second, the majority of the evidence supports an important resting nasal muscle tension that opens the nasal airway.

Illustrate long-term follow-up clinical and histologic data from a patient with unilateral multichannel cochlear implantation.Case report.Clinical history, evolution of audiometric findings, and results of temporal bone histopathology of a patient implanted with a Nucleus 22 system in the right ear were analysed and interpreted.Audiometry showed severe bilateral sensorineural hearing loss, which progressed in the non-implanted ear postoperatively. With the implanted ear, speech perception was excellent postoperatively and remained stable over 5 years. Histology showed a relatively small number of spiral ganglion cells bilaterally.Cochlear implantation can provide stable hearing in light of deteriorating hearing loss in the non-implanted ear. Only a small number of surviving ganglion cells were necessary for the implant.

Botulinum toxin injection has been used for a variety of indications in humans, including blepharospasm and hyperfunctional facial lines. This article describes a novel formulation of botulinum toxin, which supplies immediate feedback to the injecting physician. Additionally, recent findings are described that indicate the immediate injection of botulinum toxin into the muscles underlying a wound can improve the cosmetic outcome of the facial cutaneous scar. Future applications of these findings are discussed.

Direct transcutaneous resection has been a widely accepted standard for the removal of benign forehead lesions. In recent years, the endoscopic approach has become more prevalent because of its noninvasiveness. To date, only a few studies with limited case numbers have reported on this technique. We report our findings from one of the largest cohorts of patients undergoing tumor resection of the forehead via the endoscopic approach.To evaluate results of the endoscopic forehead approach for benign tumor excisions, to give a more nuanced insight into this procedure, and to discuss technical pearls and potential pitfalls from our experience.Multicenter, retrospective case study at 2 university centers and 1 private practice among 36 patients aged 18 to 72 years (mean age, 44 years) who underwent the endoscopic forehead approach for benign tumor resections.Symptoms at presentation, surgical procedure and duration, type of lesions, intraoperative and postoperative complications, recurrences, and patient satisfaction.In total, 34 patients had an asymptomatic forehead mass, while 2 patients reported discomfort and headache. Among all patients, complete tumor excision was achieved endoscopically. The mean operative time was 36 minutes. Histopathological examination revealed 18 lipomas, 13 osteomas, 2 dermoid cysts, and 1 bone fragment after previous rhinoplasty. In 2 patients, no specimen was submitted. No hematomas, infections, scalp numbness, contour irregularities, temporal branch paralysis, or tumor recurrences occurred. One patient had a prolonged area of alopecia, which resolved on its own. All patients attested to a high satisfaction rate.The endoscopic approach offers excellent aesthetic results and allows for safe tumor removal. It has proven to be an effective and minimally invasive alternative to the conventional open approach.4.

To develop a method to quantify nasal tissue resilience, to establish the normal range for persons without nasal obstruction, and to measure the changes in tissue resilience resulting from standard open rhinoplastic techniques.A new device is described that determines nasal tissue resilience. Measurements on the nasal tip were obtained in triplicate at 5 distinct anatomical sites. Normal values (N = 60) were stratified for both sexes into 3 different age groups. Preoperative and postoperative measurements were also obtained in 6 patients who underwent open rhinoplasty for airway obstruction. One patient who underwent intranasal valve repair was included for comparison. All operative patients underwent preoperative and postoperative rhinomanometric measurements.Across all age and sex groups the anterior septal angle is the firmest area of the nasal tip. The mean tissue resilience over the interdomal area and the midcolumella is significantly greater in men than in women. The resilience of the interdomal area exhibits an age effect, with decreasing stiffness over time. The postoperative changes seen correlate well with the placement of structural grafts during rhinoplasty.Nasal tip support can be quantified. Normative values have been established, which allow one to identify areas of inadequate tip support in persons with nasal obstruction. Alterations in tip support resulting from surgical intervention can be quantified. Open rhinoplasty techniques are an excellent tool to restore deficiencies in nasal tip support.

Correction of the protruded lobule in otoplasty continues to represent an important challenge. The lack of skeletal elements within the lobule makes a controlled lobule repositioning less predictable. OBJECTIVE To present a new surgical technique for lobule correction in otoplasty.Human cadaver studies were performed for detailed anatomical analysis of lobule deformities. In addition, we evaluated a novel algorithmic approach to correction of the lobule in 12 consecutive patients. INTERVENTIONS/EXPOSURES: Otoplasty with surgical correction of lobule using the fillet technique.The surgical outcome in the 12 most recent consecutive patients with at least 3 months of follow-up was assessed retrospectively. The postsurgical results were independently reviewed by a panel of noninvolved experts.The 3 major anatomic components of lobular deformities are the axial angular protrusion, the coronal angular protrusion, and the inherent shape. The fillet technique described in the present report addressed all 3 aspects in an effective way. Clinical data analysis revealed no immediate or long-term complications associated with this new surgical method. The patients' subjective rating and the panel's objective rating revealed "good" to "very good" postoperative results.This newly described fillet technique represents a safe and efficient method to correct protruded ear lobules in otoplasty. It allows precise and predictable positioning of the lobule with an excellent safety profile.4.

The reconstruction of internal lining in nasal reconstruction is critical to the final result. Most established techniques carry important drawbacks, which include limited available lining surface area, compromise of nasal physiologic function, or donor site morbidity. In this report, we demonstrate a technique that is reliable, technically facile, and allows for the reconstruction of large surface areas: the creation of a bilaminated forehead flap by in situ split-thickness skin grafting. The use of the bilaminated forehead flap in subsequent reconstructive steps allows for dependable reconstruction. All relevant technical steps are illustrated in detail.

Objectives:Determine modulatory effects of adipose-derived stem cells on irradiated fibroblasts. The inflammatory response clinically observed after radiation has been described to correlate with elevated expression of cytokines in fibroblasts. Therapeutic compensation for this compromise could be an important approach in the treatment of irradiated wounds. Clinical reports describe the potential of adipose-derived stem cells to enhance wound healing, but the underlying cellular mechanisms remain largely unclear.Methods:Normal human fibroblasts (NHF) and human adipose-derived stem cells (ASC) were cultured in a co-culture setting and irradiated with sequential doses of 2 to 12 Gy. Cell count was determined 48 h after radiation using a semi-automated cell counting system. Levels of interleukin-6 (IL-6) and vascular endothelial growth factor (VEGF) were determined in the supernatants using enzyme-linked immunosorbent assay (ELISA). Irradiated NHF and ASC as well as non-irradiated co-cultures, NHF, or ASC re...

Background: With decompressive craniectomy for ischemic stroke, traumatic brain injury, and skull-infiltrating tumors, the need for cranioplasty has increased. Different materials for custom-made cranioplasties have been evaluated, but a gold standard could not yet be established. We report our experience with the new custom-made titanium CRANIOTOP®cranioplasty (CL Instruments, Germany). Methods: A total of 50 consecutive patients received a CRANIOTOP cranioplasty within a 2 year interval. We reviewed the charts for time between initial surgery and cranioplasty, indication, complications, operative time, and cosmetic outcome. Postoperative imaging (computed tomography [CT] scan n = 48, magnetic resonance imaging (MRI) n = 5) was screened for fitting accuracy and for hemorrhages. Results: The most common indication for craniectomy were diffuse edema due to traumatic brain injury (n = 17, 34%) and ischemic stroke (n = 12, 24%). All patients were satisfied with the cosmetic result. In the postoperative CT scan accurate fitting was confirmed in all patients, the postoperative MRI was free of artifacts. Surgical revision was necessary in five patients because of empyema (n = 2), wound exposure (n = 2), and one cerebrospinal fluid fistula. Thus, the surgical morbidity was 10%. Conclusion: With due consideration of the limitations of this retrospective study, we feel the present data allow concluding that the custom-made titanium cranioplasty CRANIOTOP®is safe and feasible.

With the advent of the open structure rhinoplasty, a large number of grafts and suture techniques found widespread application. Among the many techniques available, those that allow for less invasive, more conservative, and longer-lasting results are increasingly preferred. When less invasive and more physiologic grafting and suture techniques are paired with the endonasal approach in rhinoplasty, naturally appearing results are frequently achieved.

Background The inflammatory response clinically observed after radiation has been described to correlate with elevated expression of cytokines and adhesion molecules by endothelial cells. Therapeutic compensation for this microvascular compromise could be an important approach in the treatment of irradiated wounds. Clinical reports describe the potential of adipose-derived stem cells to enhance wound healing, but the underlying cellular mechanisms remain largely unclear. Methods Human dermal microvascular endothelial cells (HDMEC) and human adipose-derived stem cells (ASC) were cultured in a co-culture setting and irradiated with sequential doses of 2 to 12 Gy. Cell count was determined 48 h after radiation using a semi-automated cell counting system. Levels of interleukin-6 (IL-6), basic fibroblast growth factor (FGF), intercellular adhesion molecule-1 (ICAM-1) and vascular cell adhesion molecule-1 (VCAM-1) were determined in the supernatants using enzyme-linked immunosorbent assay (ELISA). Irradiated HDMEC and ASC as well as non-irradiated co-cultures, HDMEC or ASC respectively were used as controls. Results Cell count was significantly reduced in irradiated co-cultures of HDMEC and ASC compared to non-irradiated controls. Levels of IL-6, FGF, ICAM-1 and VCAM-1 in the supernatants of the co-cultures were significantly less affected by external radiation in comparison to HDMEC. Conclusion The increased expression of cytokines and adhesion molecules by HDMEC after external radiation is mitigated in the co-culture setting with ASC. These in vitro changes seem to support the clinical observation that ASC may have a stabilizing effect when injected into irradiated wounds.

To delineate the anatomic architecture of the melolabial fold with surrounding structures and to elucidate potential implications for face-lift techniques.A total of 100 facial halves (from 50 cadaveric heads) were studied, including gross and microscopic dissection and histologic findings. Laboratory findings were correlated with intraoperative findings in more than 150 deep-plane face-lift dissections (300 facial halves) performed during the study period.In contrast to previous reports, the superficial musculoaponeurotic system (SMAS) was not found to form an investing layer in the midface. The SMAS, zygomatici muscles, and levator labii superioris alaeque nasi were found to be located in corresponding anatomic layers and to form a functional unit. Additional findings of the present study include the description of 3 structurally different portions of the melolabial fold, of an anatomic space below the levator labii superioris alaeque nasi (sublevator space), and of extensions of the buccal fat pad into the sublevator space and the middle third of the melolabial fold.The findings of the present study may contribute to augment our understanding of the complex anatomy of the midface and melolabial fold. Potential implications for modern face-lift techniques are discussed.

Surgery of the nasal valves is a challenging aspect of rhinoplasty surgery. The middle nasal vault assumes an important role in certain aspects of nasal valve collapse. Techniques that address pathologies of the middle vault include the placement of spreader grafts and the butterfly graft. We present an alternative technique of middle vault reconstruction that allows simultaneous repair of nasal valve collapse and creation of a smooth dorsal profile. The surgical technique is described in detail and representative cases are discussed.