Ali Totonchi

A randomized, controlled comparison between arnica and steroids in the management of postrhinoplasty ecchymosis and edema.

Background: Both arnica and corticosteroids have been suggested for reducing the postoperative edema and bruising associated with rhinoplasty. This study compared the efficacy of these products following rhinoplasty. Methods: Forty-eight primary rhinoplasty patients were randomized into three groups: group P received 10 mg of dexamethasone (intravenously) intraoperatively followed by a 6-day oral tapering dose of methyl-prednisone; group A received arnica three times a day for 4 days; and group C received neither agent and served as the control. Three blinded panelists rated the extent of ecchymosis, the intensity of the ecchymosis, and the severity of the edema. Results: On postoperative day 2, there were no significant differences in the ratings of extent and intensity of ecchymosis among the groups. There was a significant difference for the edema rating (p < 0.0001), with group C demonstrating more swelling compared with groups A and P. In addition, on postoperative day 8, group P demonstrated a significantly larger extent of ecchymosis (p < 0.05) and higher intensity of ecchymosis (p < 0.01) compared with groups A and C. There were no differences in the magnitude of edema by postoperative day 8 among the three groups. When the differences between day 2 and day 8 ratings were considered, groups A and C exhibited significantly more resolution of ecchymosis by day 8 compared with group P (p < 0.05). Conclusions: This study suggests that both arnica and corticosteroids may be effective in reducing edema during the early postoperative period. Arnica does not appear to provide any benefit with regard to extent and intensity of ecchymosis. The delay in resolution of ecchymosis for patients receiving corticosteroids may outweigh the benefit of reducing edema during the early postoperative period.

The zygomaticotemporal branch of the trigeminal nerve: an anatomical study.

This study was conducted to determine the site of emergence of the zygomaticotemporal branch of the trigeminal nerve from the temporalis muscle and to identify the number of its accessory branches and their locations. A pilot study, conducted on the same number of patients, concluded that the main zygomaticotemporal branch emerges from the deep temporal fascia at a point on average 17 mm lateral and 6 mm cephalad to the lateral palpebral commissure, commonly referred to as the lateral canthus. These measurements, however, were obtained after dissection of the temporal area, rendering the findings less reliable. The current study included 20 consecutive patients, 19 women and one man, between the ages of 26 and 85 years, with an average age of 47.6 years. Those who had a history of previous trauma or surgery in the temple area were excluded. Before the start of the endoscopic forehead procedure, the likely topographic site of the zygomaticotemporal branch was marked 17 mm lateral and 6 mm cephalad to the lateral orbital commissure on the basis of the information extrapolated from the pilot study. The surface mark was then transferred to the deeper layers using a 25-gauge needle stained with brilliant green. After endoscopic exposure of the marked site, the distance between the main branch of the trigeminal nerve or its accessory branches and the tattoo mark was measured in posterolateral and cephalocaudal directions. In addition, the number and locations of the accessory branches of the trigeminal nerve were recorded. On the left side, the average distance of the emergence site of the main zygomaticotemporal branch of the trigeminal nerve from the palpebral fissure was 16.8 mm (range, 12 to 31 mm) in the posterolateral direction and an average of 6.4 mm (range, 4 to 11 mm) in the cephalad direction. On the right side, the average measurements for the main branch were 17.1 mm (range, 15 to 21 mm) in the lateral direction and 6.65 mm (range, 5 to 11 mm) in the cephalic direction. Three types of accessory branches were found in relation to the main branch: (1) accessory branch cephalad, (2) accessory branch lateral, and (3) accessory branches in the immediate vicinity of the main branch. This anatomical information has proven colossally helpful in injection of botulinum toxin A in the temporalis muscle to eliminate the trigger sites in the parietotemporal region and surgical management of migraine headaches triggered from this zone.

An anatomical study of the lesser occipital nerve and its potential compression points: implications for surgical treatment of migraine headaches.

Background: This study maps the course of the lesser occipital nerve and its potential compression sites in the posterior scalp. Methods: Twenty sides of 10 fresh cadaveric heads were dissected. Two fixed anatomical landmarks were used: the y axis was the vertical midline in the posterior scalp through the midline of the cervical spine. The x axis was a horizontal line drawn between the most anterosuperior points of the external auditory meatus. A topographic map of the lesser occipital nerve and its potential compression points was created. Results: The lesser occipital nerve emerged from the posterior border of the sternocleidomastoid muscle at an average of 6.4 ± 1.4 cm lateral to the y axis and 7.5 ± 0.9 cm caudal to the x axis. Branches of the occipital artery were found to interact with the lesser occipital nerve in 11 of the 20 hemiheads (55 percent). The mean location of the artery-nerve interaction was 5.1 ± 0.9 cm lateral to the y axis and 2 ± 1.45 cm caudal to the x axis. Two patterns of artery-nerve interaction were seen: a single site of artery crossing over the nerve in nine of 20 hemiheads (45 percent) and a helical intertwining relationship in two of 20 of hemiheads (10 percent). A fascial band was identified to compress the lesser occipital nerve in four of 20 hemiheads (20 percent). Conclusion: This anatomical study traced the lesser occipital nerve as it courses through the posterior scalp and mapped its potential decompression sites.

The contribution of endogenous and exogenous factors to male alopecia: a study of identical twins.

Background: In this study, the authors investigated the potential contribution of environmental factors and testosterone levels on androgenic alopecia in women. Methods: Ninety-eight identical female twins were recruited from 2009 to 2011. Subjects were asked to complete a comprehensive questionnaire, provide a sputum sample for testosterone analysis, and pose for standardized digital photography. Frontal, temporal, and vertex hair loss were assessed from the photographs using Adobe Photoshop. Hair loss measures were then correlated with survey responses and testosterone levels between twin pairs. Two independent, blinded observers also rated the photographs for hair thinning. Results: Factors associated with increased frontal hair loss included multiple marriages (p = 0.043); longer sleep duration (p = 0.011); higher severity of stress (p = 0.034); positive smoking history (p = 0.021); higher income (p = 0.023); absence of hat use (p = 0.017); and history of diabetes mellitus (p = 0.023), polycystic ovarian syndrome (p = 0.002), and hypertension (p = 0.001). Factors associated with increased temporal hair loss included divorce or separation (p = 0.034), multiple marriages (p = 0.040), more children (p = 0.005), longer sleep duration (p = 0.006), and history of diabetes mellitus (p = 0.008) and hypertension (p = 0.027). Lack of sun protection (p = 0.020), consuming less caffeine (p = 0.040), history of skin disease (p = 0.048), and lack of exercise (p = 0.012) were associated with increased vertex hair loss. Higher testosterone levels were associated with increased temporal and vertex hair loss patterns (p < 0.039). Increased stress, increased smoking, having more children, and having a history of hypertension and cancer were all associated with increased hair thinning (p < 0.05). Conclusion: This study implicates several environmental risk factors in the pathophysiology of female alopecia.

Von Willebrand Disease: Screening, Diagnosis, and Management

Von Willebrand disease (vWD), a hemorrhagic disorder mimicking a defect in platelet function, is the most commonly inherited coagulopathy, resulting in a deficiency that may prolong bleeding time and increase risk for major bleeding complications during surgery. Von Willebrand factor (vWF) serves a dual role in hemostasis: mediating the initial platelet adhesion to damaged endothelium at the site of vessel injury and stabilizing coagulation factor VIII, an important cofactor in the generation of a fibrin clot. Although quantitative or qualitative defects in vWF protein can manifest as a mild to severe bleeding disorder, many cases of vWD remain subclinical, barring major invasive stimuli, and undetected by either patient or clinician. Nevertheless, the frequency of this coagulation disorder would almost ensure that every plastic surgeon will encounter affected patients, making a thorough understanding of vWD and its management absolutely necessary. Surprisingly, there is little information concerning vWD in the plastic surgery literature. Our goal is to familiarize the plastic surgeon with vWD, including physiology, diagnostic criteria, classification, and molecular basis for multiple vWD variants, and diagnosis and management.

Tranquilli-Leali or Atasoy flap: an anatomical cadaveric study

BACKGROUND The Tranquilli-Leali and Atasoy volar V-Y advancement flaps are considered workhorse flaps in the reconstruction of fingertip amputations. However, their description in the literature in terms of surgical dissection and blood supply is often indistinct. This study describes the differences between the two flaps and highlights their unique blood supply based on a thorough cadaveric study and review of the literature. METHODS Using 16 fresh cadaveric fingers, eight Tranquilli-Leali and eight Atasoy volar V-Y advancement flaps were dissected, mapping the arterial blood supply using an injectable blue resin. In addition, a thorough literature search on the subject was done. RESULTS In all eight fingertips dissected as decribed by Tranquilli-Leali, the flap was supplied by the anastomotic connections between the terminal branches of the palmar digital arteries and dorsal nail-bed arcades via the fibro-osseous hiatus. In contrast, in all eight fingertips which were dissected as described by Atasoy, the flaps were perfused through the terminal branches of the palmar digital arteries. CONCLUSIONS The Tranquilli-Leali and Atasoy volar V-Y advancement flaps, used to reconstruct fingertip amputations, are distinct from one another in several ways. The most obvious difference is their technique of flap dissection, which, in turn, dictates a unique blood supply. Through careful dissection and a review of the literature, this anatomical study has brought to light the specific vascular supply to each flap that was evaluated.

Modified temporal incision for facial rhytidectomy: an 18-year experience.

An 18-year experience with the senior author’s temporal incision is expounded. First, the existing sideburn is outlined with a marking pen. A sideburn is designed approximately 2 cm wide and 2 cm long, regardless of the extent of the existing sideburn providing the minimum sideburn. The posterocaudal portions of the newly designed sideburn will correspond to that of the existing dense portion of the sideburn. After dissection and removal of excess skin, the entire vertical portion of the scar will remain within the hair-bearing skin, eliminating the potential for visibility unless preoperatively the sideburn is less that 2 cm wide. There are several advantages to this approach. First, the configuration of the sideburn remains essentially unaltered. Second, the length of distribution for the redundant redraped facial skin is increased in comparison with most other incisions, thus avoiding a dog-ear regardless of the extent of the excess facial skin. Rhytidectomy is more effective because the distance from the incision to the nasolabial crease and the oral commissure is reduced, thereby effectively transmitting the traction forces to these sites compared with the conventional temporal incision that is placed above the ear. In addition, exposure of the surgical field is significantly enhanced by the added ability to rotate the skin flap medially. The potential disadvantage is that the operative time is increased to accommodate meticulous repair of the temporal incision. A slight modification of this incision has been implemented over the past 18 years, placing the anterior vertical incision farther posterior compared with the original report. The horizontal and posterior vertical portions of the incision are positioned at the hairline, resulting in an inconspicuous scar. None of the 125 patients in this latter group required a scar revision compared with 37 (4.28 percent) of 865 patients before this modification. This technique effectively achieves the goal of facial rhytidectomy and maintains a natural appearance without discernible scars for most patients. Patient and surgeon satisfaction with this method has been very high, and consequently, it has been used for almost all patients in the senior author’s (Guyuron’s) practice.

Effect of different suture materials on cartilage reshaping.

BACKGROUND Suturing techniques are one of the most commonly used means to reshape the nasal cartilage; however, no data exist regarding the optimal suture material and its long-term effect. OBJECTIVES The aim of the present study was to determine whether any absorbable materials will provide the same long-lasting effect on cartilage reshaping as permanent materials. METHODS Thirty-six New Zealand white rabbits were divided into three groups of 12. A 3 mm x 4 mm cartilaginous fold was created on a 5 mm x 10 mm in situ strip of cartilage on the posteromedial surface of each ear with different suture materials to simulate transdomal sutures. Nylon was used as a control suture material on the right ear of every rabbit, while plain catgut, monocryl, or polydioxanone (PDS) was used on the left ear, depending on the study group. At the end of 3 months, the folds were harvested and their dimensions and histology were compared. RESULTS The cartilaginous folds were graded on a scale of 1 to 4 based on the final fold height measurement. The mean grades were 3.51 for nylon, 3.50 for PDS, 2.08 for monocryl, and 1.83 for plain catgut. Nylon provided a significantly better fold grade compared to monocryl and plain catgut (P < .05 for both groups), whereas there was no difference between the fold created with nylon and PDS (P > .05). Among the pathologic factors examined, only the amount of adipose tissue between the fold correlates with a higher fold grade (P < .05). CONCLUSIONS Cartilaginous folds created using PDS are comparable to those created using nylon and are significantly better than monocryl and plain catgut materials. On this animal model, it appears that permanent suture material is not required to maintain a long lasting cartilaginous fold as long as the suture material holds the fold in shape for a certain period of time.

Cessation of hairline recession following open forehead rejuvenation.

Background: The senior author (B.G.) observed that patients who underwent forehead rejuvenation using a pretrichial incision did not experience hairline recession. The aim of this study was to objectively measure the effects of forehead rejuvenation on hairline recession. Methods: A 15-year retrospective review was performed in 31 forehead rejuvenation patients [17 endoscopic and 14 open (pretrichial incision) with adequate early (within 1 year) and late (≥8 years) postoperative photographs] and 11 age- and follow-up–matched cosmetic surgery patients who did not have forehead rejuvenation. Hair recession was measured using the Mirror program for Windows by averaging two successive perpendicular distances from bilateral medial canthi to the hairline and dividing by the intercanthal distance. In pretrichial incision patients, the distance from the incision to the anterior hairline was recorded. Results: The difference in short-term postoperative hairline measurements among groups was not significant (p = 0.445). Only the pretrichial group demonstrated significant stability between short-term and long-term hairline positions (p = 0.005). The pretrichial group demonstrated a stable or improved hairline position compared with either the endoscopic (p = 0.017) or control group (p = 0.006), whereas these patients demonstrated significant recession over time. Hairline measurements between early and late postoperative photographs in the endoscopic and control groups were not significant (p = 0.621). Conclusions: The pretrichial incision results in a stable hairline position over time compared with the endoscopic technique or matched controls. Pretrichial incision patients did not demonstrate separation between the scar and hairline, indicating no hair loss in this site. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Maxillary artery pseudoaneurysm after le fort i osteotomy: Treatment using transcatheter arterial embolization

Life-threatening hemorrhage is a rare complication after Le Fort I osteotomy. However, owing to the gravity of this complication, all surgeons who perform Le Fort I osteotomy should be aware of the potential for this complication and options for its resolution. The following case report describes an episode of subacute, life-threatening bleeding, after a Le Fort I osteotomy for the treatment of midface hypoplasia. Emergent angiographic evaluation demonstrated an internal maxillary artery pseudoaneurysm with fistulous drainage via the cavernous sinus. This was treated by arterial embolization in which the pseudoaneurysm was packed with microcoils. This report reaffirms the importance of maintaining a high clinical suspicion for pseudoaneurysm as a possible etiology of delayed postoperative bleeding in patients after craniomaxillofacial surgery.