QuickClot Saves Lives

Wolters Kluwer Health

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November/December 2019 Issue Highlights

In this prospective case series study of 104 patients who underwent cosmetic and/or functional rhinoplasty, Gadkaree and colleagues examined the association between patient-reported pain outcomes, objective opioid use, and perception of surgical success. They found a negative association between perception of pain and perception of outcome in purely functional rhinoplasty, but among patients who underwent rhinoplasty with cosmetic changes, no association between pain and perception of surgical success was found.

Govas et al conducted a randomized clinical trial including 87 patients to assess the efficacy of vibration during cutaneous anesthetic injection for dermatologic surgery for patients who catastrophize pain. They found that those who catastrophized pain reported significantly higher Numeric Rating Scale scores during local anesthetic injection than patients who did not. The addition of vibration resulted in a 25.5% reduction of Numeric Rating Scale scores during local anesthetic injection in patients who catastrophized pain and a 79.4% reduction in patients who did not catastrophize pain.

In this population-based cohort study of 294 039 adult patients, Olds and colleagues examine how frequently antibiotics are prescribed after nasal and oculoplastic procedures, and if antibiotic use was associated with reduced postoperative infection rates. Overall, 45.2% of patients filled antibiotic prescriptions after nasal and oculoplastic procedures; these patients were at significantly decreased risk of postoperative infections compared with those who did not fill antibiotic prescriptions.

Vincent and coinvestigators conducted a case series review of 7 patients who underwent masseter-to-facial nerve transfer with selective neurectomy for synkinesis. They found that these patients experienced a statistically significant improvement in multiple eFACE domains including smile, dynamic function, synkinesis, midface and smile function, and lower face and neck function at 1-year mean follow-up. Their findings suggest that masseteric-to-facial nerve transfer with selective neurectomy may provide significant smile improvement.

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Multimedia Assists Discharged Patients

Wolters Kluwer Health

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Entrepreneur Develops DIY Medical Imaging

Wolters Kluwer Health

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Association of Smoking and Other Factors With the Outcome of Mohs Reconstruction

Key Points

Question  Is smoking associated with an increased risk of acute and long-term postoperative complications after Mohs reconstruction with a flap or graft?

Findings  In this case-control study of 1008 patients undergoing Mohs reconstruction repaired by flap or graft, both current and former smoking were associated with an increased risk of acute complications. However, there was not a similar association between smoking status and long-term complications.

Meaning  This study suggests that smoking is an important lifestyle factor to consider for preoperative planning; these results may allow the surgeon to better quantify the magnitude of risk.

Importance  Smoking, a common lifestyle trait, is considered by many surgeons to be a major risk factor for postoperative complications. However, in the literature on local reconstruction, the association between smoking and the rate of postoperative complications after cutaneous tissue transfer is not well characterized.

Objective  To study the outcomes of flaps and grafts used in Mohs micrographic surgery reconstruction with respect to smoking status and patient-specific and surgery-specific variables.

Design, Setting, and Participants  This retrospective case-control study was conducted at a single tertiary referral center among 1008 patients who underwent Mohs reconstruction repaired by flap or graft between July 1, 2012, and June 30, 2016, and were selected via consecutive sampling. Cases with incomplete records or those in which a single flap or graft was used to repair multiple defects were excluded. Data analysis was performed from September 2017 to January 2018.

Main Outcomes and Measures  Postoperative acute and long-term complications. Acute complications included postsurgical infection, dehiscence, hematoma, uncontrolled bleeding, and tissue necrosis that required medical counseling or intervention. Long-term complications included functional or cosmetic outcomes that prompted the patient to request or the surgeon to offer additional intervention.

Results  Of the 1008 patients included in the study (396 women and 612 men), the median (SD) age was 70 (12) years (range, 21-90 years). A total of 128 patients (12.7%) were current smokers, 385 (38.2%) were former smokers, and 495 (49.1%) were never smokers. On multivariate logistic regression, current smoking (odds ratio [OR], 9.58; 95% CI, 3.63-25.3), former smoking (OR, 3.64; 95% CI, 1.41-9.38), larger defect size (OR, 2.25; 95% CI, 1.58-3.20), and the use of free cartilage graft (OR, 8.19; 95% CI, 2.02-33.1) were associated with increased risks of acute complications. For long-term complications, central face location (OR, 25.4; 95% CI, 6.16-106.5), use of interpolation flap or flap-graft combination (OR, 3.49; 95% CI, 1.81-6.74), larger flap size (OR, 1.42; 95% CI, 1.09-1.87), and basal cell carcinomas or other basaloid tumors (OR, 3.43; 95% CI, 1.03-11.5) were associated with an increased risk, whereas increased age (OR, 0.66 per 10-year interval; 95% CI, 0.54-0.80) was associated with decreased risk.

Conclusions and Relevance  This study suggests that both current and former smokers are at increased risk for acute postsurgical complications but that smoking status is not associated with long-term complications. These findings may allow the surgeon to better quantify the magnitude of risk and provide helpful information for patient counseling.

Level of Evidence  3.

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Best minimally invasive procedures to look your best for the holidays

best minimally invasive procedures to look your best for the holidays

Are you having trouble looking your best for holiday gatherings due to cold weather, dry skin, dull complexion and everything in between? Don’t fear, minimally invasive procedures are here!

Minimally invasive cosmetic procedures are a fantastic way to look rejuvenated and brighten up your look during the holidays with minimal to no downtime. An added perk is that most plastic surgeons offer holiday pricing or bundled packages to help save money while achieving glowing skin.

Skin rejuvenation

Winter can often dry out your skin, cause dullness and show more wrinkles. Improved skin quality can be quickly achieved with a chemical peel in the office, a microneedling procedure or even a laser treatment.

The best treatment for you depends on your skin type, previous treatments and other factors. Make sure to tell your plastic surgeon about your skin care goals, and they will help you pick a procedure that provides the best results with the least recovery time, allowing you to maximize your time off and enjoy the holidays looking refreshed.

Skin care products will help with overall skin health and make perfect gifts for you and others. Often, optimal skin care before and after any treatment will help you get better results and recover faster after any office treatment.

Botulinum toxin

Wrinkles caused by muscles, such as the crow’s feet area or the forehead, respond well to neuromodulators. The FDA-approved neuromodulators available in the US are Botox, Dysport, Jeuveau and Xeomin. Make sure to ask your plastic surgeon which one is best for you. Just a few days after the injections, your wrinkles will look substantially better.

Dermal fillers

Deeper wrinkles in the lower face or any loss of youthful facial features often respond well to dermal fillers. A quick injection in the office will give you immediate results and should last for months, and sometimes years, to help perfect your look for the holidays and beyond!

Common brands available in the US include Juvederm, Restylane, Radiesse, Sculptra, Versa, Belotero, Bellafill and even your own fat! These dermal fillers all have different factors for placement, how long they last, the need for allergy testing and other factors, so talk with your plastic surgeon about the best option for you.

Nonsurgical fat reduction

Your body doesn’t have to miss out on the fun! There are minimally invasive procedures that can help sculpt your body as well while offering quick recovery times.

Kybella is an injectable that melts fat, which is great for under the chin, as well as other areas such as the armpit fat and even the abdomen. Emsculpt can give you improved muscle tone in your abdomen and other areas of your body. Minimally invasive fat reduction can be achieved with CoolSculpting, SculpSure and other technologies.

Some of these technologies for your body may not give you very fast results or may require slightly longer recovery time compared to skin care, injectables and other facial treatments. Make sure you get educated to make the right choice for your timeframe.

Your board-certified plastic surgeon will be able to give you all minimally invasive and surgical treatments you need to look your best. Please check out other articles in the ASPS blog for more information about the surgical procedures and minimally invasive treatments that you are most interested in.

The views expressed in this blog are those of the author and do not necessarily reflect the opinions of the American Society of Plastic Surgeons.

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Weight-Calibrated Dosers

Wolters Kluwer Health

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Social Perception of the Nasal Dorsal Contour in Male Rhinoplasty

Key Points

Question  What are the social perception consequences of male rhinoplasty when specific modifications of the male nasal dorsal contour are carried out?

Findings  In this web-based survey study of 503 participants featuring 12 computer-simulated nasal dorsal contours of a male volunteer, the man in the photograph featuring the nose with the ski slope dorsal shape, nasofrontal angle of 130°, and nasolabial angle of 97° was deemed most attractive; this profile was also among the most frequently selected for other positive characteristics. Subset analyses also revealed statistically significant dorsal contour preferences by observers’ gender and age.

Meaning  This study’s results may potentially better inform rhinoplasty surgeons and their male patients on how changes to the nasal dorsal contour may not only affect the overall perception of a man’s social attributes, but also perception by observers’ sociodemographics.

Importance  The social perception of nasal dorsal modification for male rhinoplasty is poorly understood.

Objective  To investigate the association of modifying the male nasal dorsum with the perception of such social attributes as youth, approachability, healthiness, masculinity/femininity, intelligence, successfulness, and leadership.

Design, Setting, and Participants  Using computer simulation software, 12 images with varied combinations of the nasal dorsal shape, nasofrontal angle (NFA), and nasolabial angle (NLA) were generated from a photograph of a male volunteer’s face in profile. These photographs were then sent to participants at a university clinic who were English-speaking adult internet users who were masked to the purpose of the study, which asked them to value different social attributes regarding the face in the photograph in a 16-question survey. The study was conducted in September 2018 and the data were analyzed thereafter until March 2019.

Exposures  Twelve photographs embedded in a 16-question survey.

Main Outcomes and Measures  Population proportions of responses and χ2 test and graphical analysis based on 95% confidence intervals.

Results  Of 503 respondents (survey provision rate, 100%), 412 (81.9%) were women, 386 (76.7%) were white, 32 (6.4%) were Hispanic or Latinx, 63 (12.5%) were black/African American, 10 (2.0%) were Asian/Pacific Islander, and the median age was 46 years (interquartile range, 32-61 years). The man with ski slope–shaped nose with an NFA of 130° and NLA of 97° was often associated with frequently perceived positive characteristics; specifically, he was judged to be the most attractive (95% CI, 18%-26%; P < .001). Participants also often associated superlative youth (95% CI, 15%-24%; P < .001), approachability (95% CI, 13%-20%; P = .002), and femininity (95% CI, 14%-22%; P < .001) with dorsal contours that did not feature a dorsal hump. The man with a dorsal hump–shaped nose with an NFA of 140° and NLA of 105° was associated by the highest proportion of participants with being the oldest (95% CI, 35%-44%; P < .001), least approachable (95% CI, 27%-35%; P < .001), least attractive (95% CI, 37%-42%; P < .001), and least healthy (95% CI, 26%-34%; P < .001). Subset analyses also revealed statistically significant dorsal contour preferences by observers’ age, gender, and race/ethnicity.

Conclusions and Relevance  A reduced dorsal slope combined with more acute NFAs and NLAs was associated with positively perceived social attributes. The results may be of interest to rhinoplasty surgeons and their male patients when planning changes to the nasal dorsal contour.

Level of Evidence  NA.

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Two types of rhinoplasty explained – cosmetic vs functional

two types of rhinoplasty explained – cosmetic vs functional

When speaking about rhinoplasty, I explain to patients that the single term can refer to a wide range of elements. Nose surgery may involve altering the size and shape of the nostrils, bridge, nasal tip and/or other structures. The goal is harmonizing the shape and proportion of the nose with the entire face.

More broadly, rhinoplasty can be used to describe not only cosmetic procedures designed to impact the look of the nose, but also medical procedures to improve the function of the nose.

Why do patients choose rhinoplasty?

The two surgical focuses are closely linked because the form and function of the nose are intertwined. A visible asymmetry on the outside very likely indicates misaligned structures on the inside. Such irregularities can disrupt and impede the free flow of air, making breathing a more laborious task than it should be. In many cases, correcting the internal problem leads to a corresponding, aesthetically pleasing external shift, as well.

Functional rhinoplasty

Common problems seen in patients seeking functional rhinoplasty include nasal passages that are too narrow and a crooked (or “deviated”) line of cartilage known as the septum. A person’s septum may be misaligned due to its natural development, or it may have been pushed out of alignment due to trauma.

On its own, a procedure for straightening the septum is known as a septoplasty. Positioning the cartilage so that it sits properly vertical, instead of at an angle, can allow air to move more easily through each nostril.

Another common functional problem involves allergies, hormones or sinus infections causing turbinates to become enlarged. Also known as nasal conchae because of their shell-like shape, these structures warm and humidify the air as it moves through the nasal passages. Turbinates are made of bone, blood vessels and other tissue and come in three pairs: two superior, two middle and two inferior. If the inferior turbinates—which are the lowest and largest of the structures—become swollen, they can inhibit nasal airflow on both the right and left side of the nose.

Turbinate reduction can resolve this problem. The procedure involves removing tissue to provide more open space that allows air to pass by.

Cosmetic rhinoplasty

Patients pursuing cosmetic rhinoplasty also frequently cite asymmetry as a problem they want corrected. A nose that tilts, leans or points too far to the left or right can draw unwanted attention, especially when the rest of the features of the face are aligned symmetrically.

Other cosmetic issues nose surgery can address include overly wide nostrils, a nasal tip that is either pinched or bulbous and a pronounced bump or dip on the dorsum. Men and women who simply feel that their nose is “too large” often discover that there is one particular feature that is out of proportion.

Oftentimes, correcting a key area can yield results that make the entire nose appear to better balance with the eyes, mouth, forehead, and other parts of the face—including distance between these elements, their angles relative to each other and more.

What should you expect during your recovery?

No matter their procedural specifics, rhinoplasty patients should expect to wear a splint for approximately a week after their surgery. This will hold the nasal tissues in place and ensure that they properly heal in their new alignments.

Bruising and swelling are also to be expected, lasting for about two weeks. Once the skin returns to its typical color and the swelling goes down, the cosmetic results will be more apparent. Note, however, that the nose can take considerable time to heal, so full resolution may not happen for a matter of months, or perhaps even a year.

Is rhinoplasty right for you?

Rhinoplasty can be a life-changing procedure, and it’s no surprise that rhinoplasty is consistently among the top plastic surgery procedures performed every year. If you think rhinoplasty is right for you, be sure to use the ASPS Plastic Surgeon Match referral service to find a board-certified plastic surgeon in your area.

The views expressed in this blog are those of the author and do not necessarily reflect the opinions of the American Society of Plastic Surgeons.

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Improve ED Communication

Wolters Kluwer Health

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