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Although the cancellation of elective procedures due to the COVID-19 outbreak has been a vital precaution, it has resulted in the suspension of aesthetic procedures and surgeries worldwide. Consequently, this postponement and other factors might have a negative impact on patients planning to undergo aesthetic procedures. Understanding the changes in patient motivation and perception in comparison to the prepandemic period is imperative for proper adjustment of plastic surgery clinics.A prospective questionnaire study was conducted on patients with cancelled aesthetic surgeries or procedures to determine the effects that coronavirus disease 2019 (COVID-19) had on patient motivation regarding cosmetic surgery and procedures and to establish a relationship between patient characteristics and the overall effect of pandemia on the perception of cosmetic surgery.Although most patients felt angry or frustrated due to the cancellation of their surgeries or procedures, the majority accepted that it was a necessary precaution. Patients with a history of previous minimally invasive procedures had a significantly higher ratio of acceptance for cancellations, whereas single patients were more likely to want to have their treatments done if the decision were left up to them. A subset of patients considered undergoing additional cosmetic procedures in the setting of self-isolation, and all patients stated that they would reschedule once the pandemia was under control.Patients with established motivation for plastic surgery and minimally invasive procedures ultimately plan to resume their normal treatments alongside others after the pandemia subsides. Plastic surgeons must actively communicate with their patient population during this time to properly educate, embrace, and direct them under scientific guidelines.

Treatment of a sunken appearance of the temporal region using injectable fillers is a popular procedure. The temporal fossa has very complex anatomy due to multiple vessels running in the different tissue layers. A severe complication in the form of non-thrombotic pulmonary embolism (NTPE) can occur as a result of an inadvertent injection in the middle temporal vein (MTV) while performing temporal fossa filler procedures. Therefore, in-depth knowledge and understanding of the MTV anatomy are essential for successful and safer injectable procedures of the temporal fossa. While there have been many studies to describe the arteries in this region, there is limited information about the location and course of the middle temporal vein. This literature review is aimed at providing detailed information about the course, depth, and size of the MTV to help aesthetic practitioners in performing safer temporal fossa filler injections. This information is imperative to delineate the ‘venous danger zone’ in the temple region. The preferred reporting items for systematic reviews and meta-analyses guidelines were used for this review. A literature search was performed to find the articles providing details about the MTV anatomy and the measurements related to its course and size. A review of the literature showed that the MTV displays a consistent course and depth in the temporal region, with high variability in its diameter. The middle temporal vein width varied between 0.5 and 9.1 mm in various studies. The middle temporal vein receives many subfascial tributaries from the surface of the temporalis muscle, and for most of its course runs in the fat pad enclosed between superficial and deep layers of the deep temporal fascia. A ‘venous danger zone,’ in the interfascial planes of the temporal fossa, which contain the main part of the MTV and its tributaries, has been proposed in this paper. The temporal fossa filler procedures need great caution, and knowledge of the depth and course of the MTV is essential for avoiding NTPE. 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 .

BACKGROUND Although columellar strut grafts (CSGs) are considered among the fundamental steps for providing nasal tip support, a downward rotation of the nasal tip in patients with strut grafts can still be encountered. Patient-related factors such as nasal skin thickness can allow the plastic surgeon to anticipate certain drawbacks that can be encountered in the healing phase, but patient-based differences of nasal cartilage and the resulting impact have yet to be investigated. The purpose of this study was to evaluate the effect of the biomechanical properties of CSGs on late postoperative nasal tip position and support. METHODS The study was undertaken with the participation of 20 patients undergoing closed-technique primary rhinoplasty with CSGs. Each cartilage specimen was biomechanically analyzed to calculate the modulus of elasticity. Preoperative and postoperative images were obtained to determine nasal tip position and rotation with quantitative measurements. Postoperative 3- and 12-month measurements were evaluated according to their relationship with the elasticity modulus of the utilized cartilages. RESULTS The evaluation demonstrated that the elasticity modulus can impact the long-term support of the nasolabial angle in which an increase in the coefficient of elasticity can result in a decrease in long-term nasal tip support. CONCLUSION The results of the study reveal a new objective variable that can impact nasal tip dynamics and patient-related differences following rhinoplasty. This study not only brings forth a different perspective in the evaluation of nasal tip dynamics but can also provide data for determining ideal values for cartilage prefabrication.

Background Although the excision of the buccal fat pad has become very popular for achieving a slimmer midface, not all patients are good candidates for this procedure. Unfortunately, studies that provide guidelines by emphasizing volumetric and technical details are limited. Objectives The study compared preoperative and postoperative volumetric data to identify the amount of tissue that can safely be removed and important technical concepts involved in lower cheek contouring with buccal fat pad excision. Methods Patients complaining of cheek fullness were evaluated to determine if they were good candidates for the procedure. Eligible patients were screened with transbuccal ultrasound to determine tissue volumes and anatomical details. Intraoperative and postoperative, 6th-month volume measurements were undertaken and residual tissues and vascular pedicles reevaluated. Results Ultrasound imaging showed that the mean preoperative volume of the fat pads was 11.67 ± 1.44 mL, and the mean postoperative volume was 8.58 ± 1.07 mL. The mean volume of the excised tissues was 2.74 ± 0.69 mL. Postoperative buccal fat pad volume values correlated with the reported average in the literature for the same age group. Conclusions Buccal fat pad removal is an effective technique for refining the facial silhouette that should be reserved for patients with increased buccal fat pad volume. Removal of only the excessive portion of the fat pad is important because this structure provides significant volume in the midface that can be difficult to restore once aging affects the surrounding soft and bony tissue. Level of Evidence: 4

Background Lip augmentation procedures have increased drastically in the last years as patients seek to enhance the shape and size of their lips with dermal fillers. One of the main concerns faced with these procedures is the pain inflicted through injections. On the other hand, many different techniques have been introduced for the reduction of pain while performing office-based minimal invasive procedures. Objectives This study aims to determine the analgesic effect of vibration anesthesia during lip augmentation procedures and to evaluate its overall effect on the comfort of patients. Methods A split-lip study was designed in a randomized fashion for 25 lip augmentation patients who received hyaluronic acid fillers with or without with a concurrent vibration stimulus on either half of their lips. Patients were asked to score the pain that they felt during lip injections on a scale from 0 to 10 (0 being no pain and 10 being the worst pain ever felt) for either lip half. The pain scores were then analyzed for significance. Results The overall pain score on the vibration-assisted side was 3.82 ± 1.73 while the pain score for the side with no vibration was 5.6 ± 1.76 (P < 0.001). Twenty-three patients (92%) felt less pain with the addition of vibration while, interestingly, 2 patients (8%) stated that they felt an increase in pain levels on the vibration-treated side. Conclusions Vibration devices can be a safe and effective tool for lowering pain levels in patients undergoing lip augmentation with hyaluronic acid fillers. Level of Evidence 2.

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Objective: Several studies confirm the relationship between nasal surgery and the quality of sleep, but these surgical interventions are limited to septoplasty, turbinectomy and nasal polipectomy. Rhinoplasty is not limited to functional surgical interventions therefore the outcome of cosmetic surgical procedures should also be taken into consideration. Methods: A study was conducted to determine the effect of cosmetic rhinoplasty with or without additional septoplasty on the quality of sleep. The Pittsburgh Sleep Quality Index (PSQI) was used to determine sleep quality. A comparative analysis between preoperative and postoperative scores was performed along with a correlation analysis to test the relationship between sleep quality and nasal breathing. Results: Although both preoperative and postoperative values were consistent with “good” sleep quality, the increase of the quality of sleep was significant for cosmetic rhinoplasty. For patients who had additional septoplasty, the improvement in sleep quality was significant and sleep quality changed from “poor” to “good”. Septoplasty patients were then further evaluated according to the postoperative relief of their nasal breathing complaints. Patients who claimed they no longer had any breathing problems showed a significant change in score, while the change in score was insignificant for patients who still experienced nasal breathing problems. Conclusion: Previous studies have demonstrated the positive impact of septoplasty on the sleep quality, but this study also shows an increase of sleep quality with cosmetic rhinoplasty without septoplasty. Structural changes resulting from rhinoplasty alone can have a positive influence in increasing nasal airflow. (Gazi Med J 2012; 23: 59-64)

The aim of this study was to identify and quantify nasal profile changes following maxillary advancement (MA) and maxillary advancement with impaction (MAI) with Le Fort I osteotomies.The study consisted of preoperative and postoperative lateral cephalograms of 42 class III adult patients. The study sample was divided into 2 groups, with the first group composed of 22 patients who underwent MA surgery and the second group composed of 20 patients who underwent MAI surgery. In total, 7 skeletal parameters and 17 soft-tissue parameters related to nasal projection, hump, dorsal convexity, and the nasolabial region were evaluated on the cephalograms, and hard- and soft-tissue relationships were assessed.Nasal length, hump, nasal depths, distance from the most convex point of the Alar curvature to the most inferior point of the nostril, alar curvature-subnasale, and subnasale-pronasale measurements decreased postoperatively. In the MAI group, MA correlated with significant decreases in nasal length and hump. In the MA group, MA correlated with pronasale position (P0.05); significant decreases in nasal depth, columella convexity, and subnasale-pronasale length; and significant changes in subnasale position.There is little difference in the effects of the 2 different maxillary surgeries on the postoperative nasal profile.

Despite the insufficient number of experimental studies, platelet-rich plasma (PRP) including high amounts of growth factors is introduced to clinical use rapidly. The aim of this study was to compare the effects of PRP and platelet-poor plasma (PPP) on healing of critical-size bone defects.Bilateral full-thickness, critical-size bone defects were created in the parietal bones of 32 rabbits, which had been studied in 4 groups. Saline, thrombin solution, PPP, and PRP were applied to the created defects before closure. Radiologic defect area measurement results at 0, 4, and 16 weeks were compared between the groups. In addition, densities of the newly formed bones at 16th week were studied. Histologic parameters (primary and secondary bone trabecula, neovascularization, and bone marrow and connective tissue formation) were compared between 4- and 16-week groups.More rapid decrease in defect size was observed in groups 3 and 4 than in groups 1 and 2, both in the 4th and 16th weeks. Newly formed bone densities were also found to be higher in these 2 groups. New bone formation was detected to be more rapid considering histologic parameters, in groups 3 and 4 at 4th and 16th weeks.Study demonstrates that PRP and PPP might have favorable effects on bone healing. Although we cannot reveal any statistical difference between these 2 substances considering osteoinductive potential, PRP group has demonstrated superior results compared with fibrin glue group. Higher platelet concentrations may expose beneficial effects of PRP.

This study aimed to evaluate the effect of menstrual cycle phase on intraoperative bleeding in rhinoplasty patients. One hundred seven female patients grouped as G1 (perimenstrual) and G2 (periovulatory) according to menstrual cycle were included in this study. Intraoperative blood loss was compared using the t test. Fifty-two of the patients were in G1 and 49 were in G2 group. Operative surgeons, presence of additional interventions, and operation duration did not differ among the groups. Mean intraoperative blood loss was 69.0?±?24.6 ml in G1 and 80.4?±?27.7 ml in G2. The blood loss difference between the two groups was statistically significant. This study demonstrated that perioperative blood loss is higher in patients operated on during the periovulatory phase. This increase does not seem to create difficulty during the operation or to have an impact on the outcome. Nevertheless, this might be reflected in more pronounced ecchymosis in the early postoperative phase. © 2008 Springer-Verlag.

Yavuzer, Reha/0000-0002-8549-0875 WOS: 000268292700009 PubMed: 18972153 Prominent ear deformity is a common congenital ear deformity. Prominent ear deformity includes components such as valgus of concha, failure of scaphal folding, conchal hypertrophy, and prominent lobule. The deformity and the elastic properties of the ear cartilage determine the method of surgical correction in each case. Concha-mastoid suture, conchal excision, and posterior auricular muscle excision are different treatment options for mild to severe cases of conchal hypertrophy and valgus deformity. In this article we present a method of conchal excision, combined with a posterior auricular muscle flap, to repair severe conchal hypertrophy or valgus deformity. Six patients (11 ears) were operated on using this method. The results obtained were satisfactory. Postoperative results at 6 months were satisfactory in all patients. The smoothness and the natural appearance of the conchal bowls were notable in all patients. In contrast to the early methods of utilizing the posterior auricular muscle by transposing to the scapha or excising, its usage as a muscle flap for conchal hypertrophy and valgus deformity may be a promising option for the future.

Background: Gradually increased blood flow to the ischemic rat kidney was studied to assess the ability to diminish ischemia-reperfusion injury. Methods: The left renal artery and vein were isolated in 25 rats. Microclamps were applied for 45 minutes and were released at once (group II) or gradually (group III). Renal arterial blood flow and K+ activity were measured. Bilateral kidneys were harvested for histopathology and for malonyldealdehyde and myeloperoxidase levels. Results: Increased K+ activity returned to preischemic values faster in group III than in group II. No statistically significant difference existed in malonyldealdehyde and myeloperoxidase levels; histopathologic scoring showed less tissue damage in group III (P

Background: The technique of facial bipartition has been considered a great advance in achieving a more natural appearance in hypertelorism correction. Methods: Fourteen patients who had undergone hypertelorism correction by facial bipartition were retrospectively studied to analyze the role of three-dimensional computed tomographic reconstruction in the evaluation of the deformity and preoperative planning. The procedure and surgical details that can improve the outcome were described. A reproducible set of three-dimensional measurements that can help in preoperative patient evaluation was determined based on information obtained using the Analyze/AVW 3.1 system (Biomedical Imaging Resource, Mayo Foundation, Rochester, Minn.). Results: In this series, the most common diagnosis was frontonasal dysplasia (64.3 percent). Five patients had seconddegree (35.7 percent) and nine had third-degree hypertelorism (64.3 percent). The three-dimensional scans were shown to be highly accurate in predicting the degree of deformity. There was a significant difference in the preoperative and postoperative interdacryon distance and midface height (p < 0.05) but not in the bitemporal distance (p = 0.08). The simulation correlated significantly with the postoperative result when interdacryon distance and midface height were analyzed (0.736 and 0.999). Conclusions: Facial bipartition provided a three-dimensional correction of hypertelorism. Three-dimensional imaging can definitely be considered an extra tool for accurate surgical planning and helping the family understand the surgical procedure and the end result.

Background: Management of benign chronic frontal sinus disease is difficult. Patients are frequently seen by multiple specialties for medical treatment and endonasal procedures before they seek or require definitive treatment with frontal sinus obliteration. The progression of the disease may lead to serious or life-threatening conditions such as local bone destruction, periorbital abscess, osteomyelitis, meningitis, cranial epidural abscess, or septicemia. This study presents the use of the galeal-frontalis myofascial flap as part of the treatment of this disease. Methods: Thirty-one patients with chronic frontal sinus disease requiring obliteration were included in this study; all were approached through a coronal incision. The anterior wall of the frontal sinus was removed and the frontal sinus disease was evacuated. The sinus mucosa was completely removed, and the frontal sinus and nasofrontal duct were totally obliterated with either a unilateral flap or a bilateral galeal-frontalis flap. Results: All patients had failed medical therapy and many had failed endonasal and endoscopic procedures. The mean follow-up was 43.6 months (range, 1 to 125 months). There were two early complications, a seroma and a hematoma. Sinus infection recurred in one patient 3 months postoperatively. The recurrent infection was treated in the same manner, using the available and viable galeal-frontalis flap to obliterate the frontal sinus, with no recurrence after 40 months. Conclusions: The galeal-frontalis flap has been investigated by angiography and is based on the supratrochlear and supraorbital vessels. Its location and vascularity make it reliable and effective for frontal sinus obliteration. In the head and neck area and elsewhere, filling defects with vascularized tissue prevents infection. A further advantage is that any residual defects are usually well tolerated by patients, and those requesting correction can be easily accommodated. The risks and complications from using exogenous materials and from performing secondary procedures for graft harvest are avoided. Considering that most patients presented with complications from advanced disease and that after one revision no patients have had recurrence of disease, obliterative treatment with the galeal-frontalis myofascial flap should be contemplated earlier in treating patients with chronic frontal sinus disease.

A total of 18 patients with massive vascular malformations of the head and neck region were treated with compartmentalization using nonabsorbable sutures followed by injection of a sclerosant agent into each compartment. The indication for compartmentalization was either to stop potentially uncontrollable, life-threatening hemorrhage during the dissection of the lesion or to reduce its vascularity to allow a less dangerous subsequent resection. Compartmentalization was used in both high-flow and low-flow vascular malformations. In this technique, large nonabsorbable sutures are placed deeply in multiple areas within the lesion. The aim is to divide the malformation into multiple compartments by changing the direction of the suturing; in this way the sclerosing agent is provided with a more effective environment. The sclerosant used was either sodium tetradecyl sulfate 3%, absolute alcohol, or both. The total amount of infiltrate varied from 3 to 35 cc, according to the size of malformation. After compartmentalization, swelling was the most noticeable complication. With this technique, it was possible to treat what were considered untreatable malformations using standard techniques and to control the inevitable serious bleeding.

The medial canthus comprises three limbs and functions to maintain the shape of the eye and to assist in drainage of the lacrimal sac. Repair of the medial canthal tendon is often complicated by canthal drift, extrusion of wires or sutures, and in-fracture of the contralateral orbital bones from pressure by transnasal wires. A technique used successfully for more than 25 years with a low rate of complications is described in a stepwise manner. The long-term outcomes of using this technique are reviewed. Thirty-three patient charts were reviewed. The mean age of patients was 22.4 years (range, 3 to 59 years). The surgical indications were trauma, neoplasm, and congenital deformity. Only 2 cases of canthal drift were noted after this procedure and were corrected with the same technique without recurrence. Traditional methods of medial canthopexy frequently result in complications; the technique described eliminates most if not all of these.

Surgery is accepted as one of the most demanding professions that create both physical and mental strain on the performers. Therefore, the authors aimed to elucidate the mental burden of surgeons, which is dedicated to operative stress. They also tested the hypotheses that participating in surgery creates mental stress on surgeons that leads to cardiovascular changes, and that this stress is more pronounced for actual operators than for first assistants. The method chosen for this purpose was an analysis of heart rate variability. Twelve surgeons (five plastic surgery staff and seven plastic surgery residents) were monitored by a digital ambulatory Holter recorder on at least two occasions. Half of the recordings were carried out on operating days and the other half on office days. Heart rate variability indices (low frequency, high frequency, high frequency/low frequency ratio, and heart rate) were analyzed from those recordings using computerized research tool software. The heart rate variability indices of the operators showed statistically significant differences between operating days and office hours in favor of an increased sympathetic and decreased parasympathetic activity for the former. For first assistants, three of the parameters, with the exception of heart rate, changed in favor of a sympathetic predominance over parasympathetic activity; these changes were also statistically significant. These results showed a sympathetic hyperactivity for both operators and first assistants during the operations. When the sympathovagal balance of the actual operators was compared with that of assistants, the former group showed a more pronounced sympathetic arousal. This difference is accepted as a proof for the mental stress of the surgery being the main factor responsible for the sympathetic hyperactivity that we detected during the operations. Surgeons continuously face a unique mental strain that other professions rarely bring forth, and these psychological stressors are associated with alterations in cardiac autonomic control that may contribute to the development of cardiac disease. Prolonged sympathetic hyperactivity could anticipate cardiac discomfort in more experienced surgeons with marginal cardiac reserve. Such cardiac diseases would be reconsidered as occupation-related illnesses, which might be reimbursed to the physician. In addition, the legal responsibility of surgeons concerning their unfavorable results might be assessed with more understanding with a realization of their undue working conditions.

Background. Pseudocyst of the auricle is a rarely seen fluctuant swelling of the ear. Although various hypotheses on the etiology have been suggested, the exact cause still remains unclear. Chronic minor trauma, which is believed to create intracartilaginous cavity, is accepted to be the most probable cause. Several treatment methods have been used for this benign lesion, but higher recurrence rates can be seen if not properly treated. Objective. To discuss a new treatment modality for this rare disorder. Method. A 44-year-old man presented with a large pseudocyst of the auricle that had been treated several times previously with unsuccessful outcomes. For its treatment, we performed curettage and then used fibrin glue as a sealer between the two leaves of the cartilage. Results. At postoperative 6-months follow-up, there was no evidence of recurrence. The cosmetic outcome was excellent. Conclusion. The use of fibrin glue both to obliterate the pseudocyst space and to make the two leaves of the cartilage adhere to each other should be kept in mind in this rare disorder in order to avoid recurrences.

Augmentation of the craniomaxillofacial region is required for many aesthetic and reconstructive procedures. A variety of different materials and techniques have been used. Coralline hydroxyapatite has proved to have biocompatible properties as a bone graft substitute. This study further analyzes the use of porous coral-derived hydroxyapatite granules in craniomaxillofacial augmentation for cosmetic and reconstructive purposes and evaluates the long-term clinical result. This retrospective study reviewed the use of porous coral-derived hydroxyapatite granules over a 20-year period, between 1981 and 2001, in 180 patients, in whom 393 procedures were performed. The surgical technique is described and discussed. Statistical significance was evaluated by descriptive statistics and the correlation bivariate Spearman's test (p > 0.05). For 61.6 percent of the procedures, the surgical indication was reconstructive and in 38.4 percent, cosmetic. The maxilla was the most common site of surgery (44.3 percent), followed by the mandible (21.6 percent) and zygoma (15.4 percent). The complication rate was 5.6 percent (n = 22 of 393), with contour irregularities being responsible for 59 percent (n = 13 of 22). Both infection and granule extrusion were responsible for 1.3 percent of the complications. Good results were achieved in 96.4 percent of the procedures. Porous coral-derived hydroxyapatite granules have shown considerable efficacy and versatility in craniofacial contour refinement and augmentation. They are stable, biocompatible, and safe. A sterile technique is advised, with care taken not to tear the periosteum in the pocket design and with subperiosteal placement of the granules, compaction of the granules at the site, overcorrection of 15 percent of the required total volume, watertight closure, and postoperative taping to prevent mobilization. The correct surgical indications and adherence to the principles stated above will result in a very satisfactory long-term outcome.

Although, one out of every eight women has a risk of developing breast cancer. the reported incidence of breast carcinoma detection in reduction mammaplasty materials is rather low. To our knowledge, specimen radiography, which is used for breast biopsies has not been used for the assessment of breast reduction materials. We investigated the applicability of specimen radiography and its potential benefits in detection of the breast pathologies, especially malignancies in reduction mammaplasty materials. Forty patients scheduled for reduction mammaplasty operation were included. In all cases an inferior pedicle reduction technique was preferred and the radiographs of the resected breast tissues were taken immediately. The radiographs were evaluated for any possible pathologic appearance and all abnormal findings were marked. For the histopathologic evaluation, in addition to the random sampling of the pathologist, any marked areas were also microscopically examined. In two cases fibrocystic changes were found in radiographs and the same results were obtained in the histological examination. No false negative mammogram was seen. Specimen radiography. which is applicable for breast reduction materials is an easy and cheap method and does not cause any patient discomfort. It seems that the radiographs of reduction mammaplasty materials are useful to provide guidance to the pathologist during tissue sampling for microscopic examination especially when large a-mounts of breast tissue is excised.

Uniform patient photographs that create permanent records are essential for any visually oriented medical specialty. These images are valuable for any plastic surgeon's practice for various reasons; thus, standards and recommendations for clinical photography should be well-known. There are several articles published on this issue, but it is still not uncommon to be exposed to medical publications and presentations that fail to satisfy clinical photography standards. This stimulated an interest in reviewing the important factors that ate essential to achieve consistent, comparable clinical photographs with 35-mm single-lens reflex photography.

Fibrous dysplasia, which is characterized by a disorganized mixture of fibrous and osseous elements in the affected bones, is a non-neoplastic developmental anomaly caused by an activating mutation. Despite an identical histological pattern, the clinical behavior varies according to the site of involvement. Fronto-orbital lesions behave more aggressively and generally continue to grow during adulthood. During the last 20 years, 32 cases of fronto-orbital fibrous dysplasia have been treated and the results of treatment have been assessed. The indications for surgery were mainly visual deterioration due to optic nerve compression, globe malposition and widespread disease causing gross facial deformity. The treatment of these patients consisted of radical resection of the fibro-osseous tissue, decompression of the optic nerve canal and reconstruction of the resected fronto-orbital areas with either noninvolved bone grafts or with dysplastic bone which was contoured down or, in one case, heated in the sterilizer. Recently, Pamidronate, a bone resorption inhibitor, has been added to the treatment protocol. During follow-up there have been two recurrences, repeat optic nerve decompression has not been required and overall the esthetic results are satisfactory. Fronto-orbital fibrous dysplasia can have a devastating outcome with high recurrence rates and blindness, especially following incomplete resection. A radical and extensive approach to treatment is recommended; this seems to be the best choice as witnessed by the good results achieved in this series.

Hydroxyapatite cement is a calcium phosphate preparation composed of tetracalcium phosphate and dicalcium phosphate anhydrous powders. When mixed with water it isothermically forms a paste which can easily be shaped intraoperatively. This mixture sets in approximately 15-20 min and converts into water insoluble, nonceramic, microporous hydroxyapatite in 4 h. This biomaterial was used to correct either congenital or traumatic craniofacial contour irregularities or deficiencies in 20 patients. On follow-up there was only one patient who required repeat surgery for further correction, there were no other complications. The good cosmetic results, the ease of operation, the pliability of the cement paste allowing precise moulding during application, the short operation time and the avoidance of a donor site makes hydroxyapatite cement an attractive material for treating craniofacial contour defects. Careful long term follow-up is necessary to establish its safety and reliability.

Circumcision remains the most common operation performed on males. Although, not technically difficult, it is accompanied by a rate of morbidity and can result in complications ranging from trivial to tragic. The reported incidence of complications varies from 0.1% to 35% the most common being infection, bleeding and failure to remove the appropriate amount of foreskin. Forty patients suffering from different degrees of circumcision complications and their treatment are presented. In all patients satisfactory functional and cosmetic results were achieved. Whether it is done for ritualistic, religious or medical reasons circumcision should be performed by a fully trained surgeon using a proper technique as follows 1) adequate use of antiseptic agents; 2) complete separation of inner preputial epithelium from the glans; 3) marking the skin to be removed at the beginning of operation; 4) careful attention to the baby's voiding within the first 6 to 8 h after circumcision; 5) removal or replacement of the dressings on the day following circumcision.

Lymphangioma circumscriptum of the penis and scrotum is an unusual entity that may be indistinguishable from genital warts. After confirmation of the diagnosis, a treatment plan consisting of wide excision should be outlined. To lower the chance of recurrence, not only the affected skin but all the subjacent subcutaneous tissue, including the deeper components of the lymphatic malformation just above the deep fascia, should be removed.

Reconstruction of the exenterated orbit is a difficult problem with several advantages and disadvantages. Satisfactory reconstructive results for both the physician and the patient may need multistage operations that are time consuming and disfiguring. A simple and effective one-stage technique that combines two regional flaps is described for reconstruction of deformities of orbital exenteration. A temporalis muscle flap is transposed for orbital filling, and a prefabricated frontal island flap based on superficial temporal vessels is used for eye socket and eyelid reconstruction. For patients who oppose living with exenteration deformity and request quicker reconstruction, this new and simple technique may be used successfully.

INTRODUCTION Reconstruction of cranial bone defects is one of the most challenging problems in reconstructive surgery. The timing of reconstruction, the location of the defect, the materials to be used, and the medical history of the patient are parameters that have been mostly discussed in the literature. To the best of our knowledge, there has not been any published classification for the cranial bone defect reconstruction according to defect size. MATERIALS AND METHODS Twelve patients underwent reconstruction of cranial vault defects. Cranial bone defects were classified into 3 groups according to the size of the defect. The small-sized group included the defects smaller than 25 cm(2), the medium-sized group included the defects between 25 to 200 cm(2), and the large-sized group included the defects larger than 200 cm(2). The small-sized defects were reconstructed with split calvarial graft, demineralized bone matrix, or hydroxyapatite cement; the medium-sized defects were reconstructed with split calvarial graft or allogenic bone graft; and the large-sized defects were reconstructed with methyl methacrylate, autoclaved bone, or porous polyethylene. RESULTS Two patients needed revision for irregularities with demineralized bone matrix. Other patients had no skull defects or irregularities for which revision was suggested. CONCLUSIONS We believe that the size of the defect is important for the reconstruction of cranial vault defects and that using a standard algorithm can increase the success rate.

Introduction Botulinum toxin type A (BTX-A) is currently used in temporal brow lifting. Reducing the activity of the superolateral portion of orbicularis oculi muscle causes lateral brow elevation. The objective of this study was to determine the quantitative brow elevation after paralysis of the superolateral portion of orbicularis oculi muscle. Material and Methods This study includes 10 female patients. Six units of BTX-A were injected into the superolateral portion of the orbicularis oculi in a serial manner into 3 points, below the lateral half of the brow at each side. Bilateral measurements were obtained by using calipers, immediately before and 2 weeks after the treatment. The medial canthus to the medial brow margin (AB), the lateral brow margin to the lateral canthus (CD), the medial brow margin to the lateral brow margin (BC), the brow apex to upper lid margin at the level of the lateral limbus (EF), the brow apex to the medial brow margin (EB), the brow apex to the lateral brow margin (EC), and upper eyelid margin to lower eyelid margin at the level of the pupil (GH), were measured. Results There were no statistically significant differences found between pretreatment and posttreatment left and right measurements. There were statistically significant increases in CD, EF, and GH measurements, which are point out brow elevation. There were no statistically significant differences found in other measurements. Conclusions Same doses of BTX-A application did not disrupt symmetry. Applications of 6U BTX-A to the superolateral portion of orbicularis oculi provide brow elevation and increased interpalbebral distance and upper eyelid distance. Our study has confirmed that BTX-A treatment of superolateral portion of the orbicularis oculi muscle produces quantitative temporal brow elevation.

Yavuzer, Reha/0000-0002-8549-0875 WOS: 000316676300148 PubMed: 23524791 …

BACKGROUND: Bilateral coronal synostosis (brachycephaly) is the most common single-suture synostosis that may lead to functional deficits such as mental retardation. This increases the importance of volume gain during surgery. This study was designed to understand the differences in volume gain, cranial index (CI), and aesthetic outcomes when additional osteotomies or rotations are applied on the frontoparietal segment. METHODS: Acrylic brachycephaly models were prepared. Frontoparietal osteotomy was standard in all models. Frontoparietal segment was fixed: to the same position in surgical control model, after 1.2-cm advancement in advancement model, after 180-degree rotation without advancement in rotation model, after 180-degree rotation plus a horizontal osteotomy and 1.2-cm advancement in rotation plus angled advancement model, and after a horizontal osteotomy without rotation and 1.2-cm advancement and in angled advancement model. RESULTS: Intracranial volume changes (in milliliters) and CIs were as follows between groups: control group, 828/94.1; surgical control group, 830/93.8; advancement model, 900/84.5; rotation model, 834/89.1; rotation plus angled advancement model, 897/82.7; angled advancement model, 902/81.8. CONCLUSIONS: Advancement of the frontoparietal segment is the keystone of surgery in brachycephaly treatment. Making an additional horizontal osteotomy can angle this segment and may supply additional volume gain. Rotation of the frontoparietal segment does not provide additional volume or CI gain but increase better aesthetic outcomes.

Background: Facial aesthetic treatments are among the most popular cosmetic procedures worldwide, but the factors that motivate women to change their facial appearance are not fully understood. Objectives: The authors examine the relationships among the facial areas on which women focus most as they age, women’s general self-perception, and the effect of their personal focus on “beauty points” on their perception of other women’s faces. Methods: In this prospective study, 200 women who presented to a cosmetic surgery outpatient clinic for consultation between December 2009 and February 2010 completed a questionnaire. The 200 participants were grouped by age: 20–29 years, 30–39, 40–49, and 50 or older (50 women in each group). They were asked which part of their face they focus on most when looking in the mirror, which part they notice most in other women (of different age groups), what they like/dislike most about their own face, and whether they wished to change any facial feature. Results: A positive correlation was found between women’s focal points and the areas they dislike or desire to change. Younger women focused mainly on their nose and skin, while older women focused on their periorbital area and jawline. Women focus on their personal focal points when looking at other women in their 20s and 30s, but not when looking at older women. Conclusions: Women presenting for cosmetic surgery consultation focus on the areas that they dislike most, which leads to a desire to change those features. The plastic surgeon must fully understand patients’ expectations to select appropriate candidates and maximize satisfaction with the outcomes.

33rd National Congress of the Turkish-Society-of-Plastic-Reconstructive-and-Aesthetic-Surgery -- SEP 14-18, 2011 -- Cesme, TURKEY Findikcioglu, Kemal/0000-0002-8276-5730; Yavuzer, Reha/0000-0002-8549-0875 WOS: 000311682200003 PubMed: 23044350 Background: Hormonal changes that take place during the menstrual cycle may have an effect on perioperative bleeding. Previous studies have confirmed a relationship between the menstrual cycle and surgical bleeding in rhinoplasty and breast reduction surgery; yet both surgical sites display changes in accordance with sex hormone levels during the menstrual phase. Aim: The aim of this study was to determine the effect of the menstrual cycle on perioperative bleeding when undergoing surgeries of sites not directly related to menstrual hormonal changes. Materials and methods: Forty-one patients undergoing abdominoplasty were grouped as group A - perimenstrual (0-7, 21-28 days), group B - periovulatory (8-20 days) and group C - post-menopausal. Intra-operative blood loss was calculated during surgery while postoperative blood loss was determined by measuring the amount of drainage. All menstrual data were recorded. Age, body mass index and weight of the resected tissue were also considered as factors that can affect the amount of bleeding and therefore were also evaluated in terms of significance. Results: There was no significant difference between groups regarding intra-operative and postoperative blood loss. Body mass index and weight of the resected tissue had a strong influence on the time of drain removal and the amount of intra-operative and postoperative blood loss. Conclusion: This study strongly suggests that the menstrual period does not affect perioperative blood loss for operations on areas less sensitive to sex hormone levels such as the abdomen. In light of the results, we can conclude that the patient's menstrual date is not of vital importance regarding perioperative blood loss when planning surgery for areas with less sensitivity to menstrual hormonal changes. (C) 2012 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. Turkish Soc Plast Reconstruct & Aesthet Surg

The experiment was designed to compare the effect of intraoperative platelet-rich plasma (PRP) and fibrin glue application on skin flap survival. In this study, bilateral epigastric flaps were elevated in 24 rats. The right-side flaps were used as the control of the left-side flaps. Platelet-rich plasma, fibrin glue, and thrombin had been applied under the flap sites in groups 1, 2, and 3, respectively. Five days later, all flap pedicles were ligated. Necrotic area measurements, microangiography, and histologic and immunohistochemical evaluations were performed to compare the groups. Platelet-rich plasma reduced necrotic area percentages as compared with other groups. Histologically and microangiographically increased number of arterioles were observed in PRP groups. Thrombin when used alone increased flap necrosis. Vascular endothelial growth factor, platelet-derived growth factor, and transforming growth factor β3 primary antibody staining showed increased neovascularization and reepithelialization in all PRP-applied flaps. This study demonstrated that PRP, when applied intraoperatively under the skin flap, may enhance flap survival. Thrombin used alone was found to be unsuitable in flap surgery.

The aim of this study was to compare the effects of preoperative subcutaneous platelet-rich plasma and fibrin glue administration on skin flap survival. One week before surgery; saline, platelet-rich plasma, fibrin glue, and thrombin solutions were applied under rat skin flap areas in Groups I, II, III, and IV, respectively. Unipedicled epigastric flaps were elevated in the first three groups but could not be elevated in Group IV because of preoperative abdominal skin necrosis. Necrotic area measurements, microangiography, and histological and immunohistochemical evaluations were performed. Platelet-rich plasma reduced the percentage of necrotic area when compared to other groups. Histologically and microangiographically an increased number of arterioles were observed in the platelet-rich plasma group. Thrombin (when used alone) caused abdominal skin necrosis. Increased expression of VEGF and PDGF was found in all platelet-rich plasma-treated flaps. There was no significant difference between groups with respect to TGF-β3 staining intensity. In this study preoperative administration of platelet-rich plasma mimicked the pharmacological delay effect and enhanced flap survival. Individual use of thrombin was found to be unsuitable in flap surgery. 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 .

background. Microcystic adnexal carcinoma is a rare, slowly progressing, malignant tumor of sweat gland origin. objective. A case of microcystic adnexal carcinoma of the breast with a history of 20 years is presented. methods. On initial examination, the ulcerative cutaneous mass was fixed to the underlying breast tissue and chest wall. Both the macroscopic appearance of the tumor and its location suggested a glandular breast carcinoma. However, an incisional biopsy revealed the nature of the tumor as microcystic adnexal carcinoma of the breast skin. Following the diagnosis, a wide excision of the tumor was carried out for the final treatment. results. To our knowledge this is the first case of microcystic adnexal carcinoma arising in the breast skin presented in the literature. conclusion. This case demonstrates that microcystic adnexal carcinoma can occur on the breast skin and should be treated with wide excision due to its locally aggressive behavior.

background. Malherbe tumors, also known as pilomatricomas, are benign cutaneous tumors of hair matrix origin. objective. To discuss a rare case of multiple pilomatricoma of the head and neck region in a very young patient. methods. A 14-month-old baby presented with two lesions, one appearing on the preauricular region and the other on the nasolabial fold. One of the lesions showed significant ulceration. results. Excisional biopsy was performed for both of the lesions. Although the histopathologic examination suggested pilomatricoma as the diagnosis, the lesion with ulcerations exhibited increased mitosis which made us consider pilomatrix carcinoma in its differential diagnosis. conclusion. Increased mitoses, an uncommon unexpected feature for pilomatricoma, can be a marker for more aggressive biologic behavior.

Hydroxyapatite cement, which has several advantages when compared with other biomaterials, was used to reconstruct a cavity in the mandible resulting from extraction of two impacted teeth. The patient was followed up for 2 years and plain radiographs revealed no loss or resorption of the implant material. With the positive results of this clinical experience, hydroxyapatite cement now seems to be a good alternative for filling similar mandible defects.

The aim of this study was to emphasize the importance of preoperative surgical planning using 3D skull models in craniosynostosis surgery. By using 3D polymethyl methacrylate skull models manufactured using 3D tomography images, the authors previously showed that after fronto-parietal osteotomy, instead of fixing the fronto-parietal bone flap without rotation, angled advancement with horizontal osteotomy provides maximum increase in intracranial volume, in a bilateral coronal craniosynostosis model. After changing the operation technique using data gathered from previous studies, we reviewed two bilateral craniosynostosis patients operated with the new technique and compared it with two patients that were operated with the old technique. Comparing cranial indexes (CI), significant improvement was detected in both groups. The decrease in CI in the second group was slightly better than the first group. In the comparison of intracranial volume (ICV), there was an increase in ICV values in both groups. The percentage of increase between two groups was similar. The morphological outcome was satisfactory in all patients. There were no major or minor complications and morbidity. Current multislice tomography technology and stereolithographic procedures provide an excellent surgical simulation model to find new techniques and predict the outcome. These models should be used in all complex and syndromic craniosynostosis for both better results and reducing the operative time and associated blood loss.

Postoperative nausea and vomiting (PONV) are among the most common adverse events in the postoperative period. This is especially disastrous in aesthetic surgery; it may cause hematoma, wound dehiscence, and patient dissatisfaction. The purpose of this study was to evaluate the incidence of PONV after aesthetic surgery procedures, and to determine the risk factors for PONV. Two hundred and twelve patients undergoing the most common aesthetic surgical procedures were included into this study. Female gender, surgical site, and history of PONV were found to be significant risk factors, however, postoperative opiate use and history of motion sickness were not found to be significant risk factors for PONV. Those undergoing trunk surgery procedures appeared to be at higher risk than were those undergoing head and neck surgery procedures. Also, ondansetron was found to be more affective than metoclopramide. Risk factors for PONV must be questioned preoperatively. Patients with risk factors are good candidates for prophylaxis. As a result of the effective prevention of PONV, postoperative patient comfort and satisfaction should be more improved.

Activated platelets release various growth factors, some of which are recognized to improve nerve regeneration. This study evaluated the effect of platelet-rich plasma (PRP) in end-to-end neurorrhaphy. A total of 45 Wistar rats were used, with the initial five used for PRP preparation. The right hind limbs were used as experimental, with the left as control. The animals were treated in five groups. Group A (n = 4): The right sciatic nerve was dissected only from the sciatic notch to the bifurcation. In all other groups, the nerve was sharply transected and repaired with: group B (n = 8): two sutures; group C (n = 8): six sutures; group D (n = 10): two sutures and PRP; and group E (n = 10): six sutures and PRP. Groups D and E were compared with groups B and C, respectively. Group E had a shorter latency time in electromyography ( P < 0.01) and a thicker myelin layer in the histological evaluation ( P < 0.003) in comparison with group C. These positive effects of PRP were not detected in the nerves were repaired with two sutures. In this animal model, the application of PRP to the repair site helped to improve remyelinization of the sciatic nerve in rats when the epineural repair was done with six sutures.

For the past 15 years, a forehead flap with its pedicle based at or below the medial canthus has been used without any flap loss. This study describes the anatomical vascular relationships allowing this flap design to be successful.Nine fresh frozen cadaver heads were studied in three groups. Six heads were injected with red latex. In group I, the supraorbital, supratrochlear, and facial arteries of four heads were dissected out under the operating microscope. In group II, using two latex-injected heads, the median forehead flap was elevated in the extended fashion and the arteries within the flap were dissected. The distal portion of the flap was elevated supraperiosteally and the proximal portion was elevated subperiosteally. In group III, the arterial systems of three heads were injected with barium solution after the flaps had been elevated. Radiographic assessment was used to demonstrate the vascular pattern within the flap.Group I showed an anastomotic relationship between the supratrochlear and facial arteries and a consistent relationship between the infraorbital and facial arteries. Group II showed that the above-mentioned connections could be protected during the supraperiosteal and subperiosteal flap elevation. This was confirmed by radiographic assessment in group III. The vascular network of the flap was filled through the facial artery by means of the dorsal nasal and supratrochlear arteries.Within the paranasal and medial canthal region, there is an anastomotic relationship between the supratrochlear, infraorbital, and branches of the facial arteries, and branches from the contralateral side, creating a rich vascular arcade. This allows a median forehead flap to be narrowly based at the level of the medial canthus.

Soft tissue augmentation with autogenous tissue has been used to correct various defects during aesthetic facial contouring and reconstructive procedures. Although dermal grafts have longer survival rates, fat grafts always have been more popular because of the simple harvesting and grafting methods used. The authors aimed to use existing scar tissue as an injectable graft and to compare its effectiveness as a soft tissue filler substance with that of dermal grafts. In this study, scar tissue was created on 24 male Wistar rats. The created scar and normal healthy skin were removed from the rat dorsal scapular donor site. After depithelialization, the harvested tissues were minced until they were thin enough to pass through a 16-gauge needle. The grafts then were injected into the recipient site between the abdominal muscles. Volumetric analyses and histologic evaluation of the grafts were performed 1, 3, and 5 months after transplantation. The first month after the injection, the amount of remaining dermis graft was more than the scar graft, and this difference was statistically significant. However, at the end of months 3 and 5, there was no marked difference between the groups. The remaining volume of injected scar tissue graft was comparable with that of the dermis graft. The scar grafts were composed mainly of dense connective tissue during all the evaluation periods. In this study, scar tissue provided results comparable with those of dermal grafts up to 5 months when used as a soft tissue filler. It seems that neovascularization of the scar graft may be inadequate for maintenance of graft viability, as compared with dermis grafts. On the other hand, the scar graft formed fibrous tissue, which may be responsible for providing adequate volume as a filler. This may have clinical implications for the patient who needs both scar revision and soft tissue augmentation procedures simultaneously.

Yavuzer, Reha/0000-0002-8549-0875; AYHAN, MEHMET SUHAN/0000-0002-5067-6450; Findikcioglu, Kemal/0000-0002-8276-5730 WOS: 000246032200009 PubMed: 17440343 Background: Research in prevention of partial flap necrosis has recently concentrated on extending the safe length of a flap by ligating vessels of known territories. To advance this approach one step further, the authors decided to reveal the least invasive surgical strategy for transfer of angiosomes. Methods: The study was arranged into three experiments. In the first experiment (n = 17 rabbits), a cutaneous island flap model spanning four adjacent vascular territories was developed. In the second experiment (n = 15 rabbits), the flap model was used to test the possibility of desiccating those vessels supplying the angiosomes to be captured percutaneously with radiofrequency. The delay procedures were performed by means of minimal skin incisions, and the flaps were elevated after a 2-week delay period. In the third experiment, the effectiveness of selective interference of these pedicles was compared to minimize the number of target vessels for successful transfer of angiosomes. Results: The mean surviving area of the new flap model was 63 +/- 2 percent. The mean surviving flap area was 97 +/- 3 percent for the endoscopy equivalent technique and 94 +/- 4 percent for radiofrequency delay. The results were statistically insignificant between these two groups. In experiment 3, comparison of the results yielded a statistically insignificant difference for flap survival area among all four of the groups. Conclusions: An alternative flap model is introduced for future investigation of the vascular delay process. Percutaneous desiccation of the perforators with radiofrequency was found to be a reliable method, and selective desiccation of the perforator(s) was as efficient as destruction of all vascular sources other than the pedicle.