Remote Monitoring Service

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Original Article

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Investigation of the Longevity of the Endoscopic Midface Lift

Key Points

Question  Is the endoscopic preperiosteal midface lift an effective technique, and do the results last?

Findings  In this retrospective review, there was a significant, objective improvement (decrease) in midfacial height after the endoscopic preperiosteal midface lift that persisted for at least 5 years and up to 15 years. Validated regional and global aesthetic scales demonstrated lasting improvement in midface appearance over time.

Meaning  There is a persistent improvement in midfacial height after the endoscopic preperiosteal midface lift that is achieved without complete disruption of the midfacial ligaments.

Importance  To our knowledge, until now, the efficacy and durability of the transtemporal endoscopic preperiosteal midface lift has not been reported in the literature.

Objective  To determine the efficacy and longevity of the endoscopic preperiosteal midface lift using objective measurements and validated aesthetic scales.

Design, Setting, and Participants  This retrospective review included patients 18 years or older who were treated for aging midface by endoscopic midface lift by the senior author (A.E.W.) between June 2000 and August 2016. Patients were categorized based on length of follow-up into 3 groups: (1) short-term (1-3 years), (2) intermediate-term (3-5 years), and (3) long-term (>5 years).

Interventions or Exposures  Endoscopic preperiosteal midface lift.

Main Outcomes and Measures  (1) Objective measurements of midfacial height (the width of the interzygomatic distance of the midface to the medial canthus [WIZDOM-MC]), (2) validated regional aesthetic scales, and (3) global aesthetic scoring systems measured preoperatively, 3 to 6 months postoperatively, and at the most recent follow-up visit.

Results  Adult patients 18 years or older (median [range] age, 59 [31-79] years) who were treated for aging midface by undergoing an endoscopic midface lift were included in this study. The medical records of 143 patients were reviewed (135 women and 8 men). The endoscopic midface lift resulted in objective improvement in midfacial height. The median WIZDOM-MC decreased by 3.4 mm after the endoscopic midface lift (interquartile range [IQR], 2.3-4.4 mm; P < .001), thus shortening the elongated lower eyelid. At 5 to 15 years after surgery, there was a sustained decrease in median WIZDOM-MC of 2.1 mm (IQR, 0.8-3.1 mm; P < .001). Improvement in the infraorbital hollow was also sustained in patients at more than 5 years’ follow-up (IQR, 0-1.0; P < .001). Improvements in upper cheek fullness and lower cheek fullness were maintained at 3 to 5 years and tended to be at baseline at more than 5 years. Global aesthetic improvement scores remained significantly improved at 5 to 15 years’ follow-up.

Conclusions and Relevance  There is a significant, objective improvement in midfacial height after the endoscopic midface lift that persists for up to 15 years. Validated midfacial scales and global aesthetic scoring systems demonstrate sustained improvement in midface appearance over time. Surgery that minimally disrupts the zygomatic and orbicularis retaining ligaments can provide long-lasting aesthetic improvements.

Level of Evidence  4.

Original Article

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Gauze Stops Bleeding

Wolters Kluwer Health

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Original Article

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Outcomes of Extracorporeal Septoplasty and Its Modifications for L-Strut Septal Deviation

Key Points

Question  Is extracorporeal septoplasty (including modified techniques) effective in the treatment of severe L-strut septal deviation?

Findings  In this meta-analysis of 31 studies, 5 reporting change in Nasal Obstruction Symptom Evaluation scores indicate both a clinical and statistically significant improvement of nasal obstruction, but heterogeneity was high.

Meaning  Although extracorporeal septoplasty and its modifications may be effective methods to reduce nasal airway obstruction for deviations of the septal L-strut, standardized reporting of outcomes and sound methodology of study design is needed.

Importance  While extracorporeal septoplasty (ECS) and its modifications have been previously studied, to our knowledge, no systematic review of surgical outcomes and complications of this technique has been performed.

Objective  To evaluate the evidence of surgical outcomes and complications of ECS (including modified techniques) to treat severe L-strut septal deviation defined as deviation within 1.0 cm of the caudal or dorsal septum.

Data Sources  MEDLINE, Embase, CINAHL, CENTRAL, Scopus, and Web of Science databases and reference lists were searched from inception to April 2018 for clinical and observational studies. Search terms included extracorporeal, septoplasty, and septum.

Study Selection  Selection criteria were defined according to the population, intervention, comparison, and outcome framework. Relevant studies were selected by 2 independent reviewers based on abstracts and full texts.

Data Extraction and Synthesis  Data were extracted using standardized lists chosen by the authors according to Cochrane Collaboration guidelines. Data were collected and synthesized with ranges reported, as well as assessment of bias and heterogeneity when applicable. Analysis started in February 2019.

Main Outcomes and Measures  Outcomes assessed included functional nasal airway improvement by objective measurements and subjective measurements (Nasal Obstruction Symptom Evaluation [NOSE] and visual analog scale scores); complications including bleeding, infection, dorsal irregularities, and other functional or cosmetic deficits; and as revision surgery rates.

Results  Of 291 records initially obtained, 31 were considered relevant after review according to PRISMA guidelines. All studies except 1 randomized clinical trial (3.2%) were observational in nature, with 21 retrospective studies (67.7%) and 9 prospective studies (29.0%). Conventional ECS was performed in 16 studies (51.6%), and modified ECS was performed in 15 studies (48.4%). The sample size varied from 10 to 567, and the mean age varied from 22.5 to 46 years. Of 31 studies, 14 (45%) were of good methodology. Meta-analysis was performed on 5 studies reporting change in NOSE scores, with pooled effect of −60.0 (95% CI, −67.8 to −52.2) points, but heterogeneity was high, with I2 = 96%. When comparing complications between modified and conventional ECS, the relative risk for infections was 0.95 (95% CI, 0.34-2.7); for bleeding, 0; for nasal dorsal irregularities, 0.29 (95% CI, 0.16-0.53); for other cosmetic complications, 4.3 (95% CI, 0.87-21.1); for other functional complications, 0.47 (95% CI, 0.20-1.1); and for revision operations, 1.4 (95% CI, 0.83-2.3).

Conclusions and Relevance  Of the 31 studies included in this systematic review, less than half were of good methodology, and a significant level of heterogeneity was found regarding type of outcome measure used and reporting of complications. To improve the level of evidence, better study methodology, standardization of surgical outcomes measures, and reporting of complications are needed.

Original Article

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Seeing Clearly

Wolters Kluwer Health

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Original Article

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A Practical Precaution Relevant to Facial Injections

To the Editor We read with interest the case report by Sebaratnam et al.1 Recently a new type of white adipose tissue (WAT), dermal WAT (dWAT), has been identified and is recognized as playing a role in skin processes such as hair follicle growth, thermoregulation, wound healing, and signal transmission.2 This layer lies in the reticular dermis encasing mature hair follicles.3 In addition this fat compartment is associated with specific adipose stem cell phenotypes (CD24+), distinctly different from subcutaneous WAT, suggesting unique functions of this fat depot.2 Dermal WAT is organized in cone-like structures (often identified in deeper skin graft donor areas) and is particularly associated with scarring when exposed at that depth.4 Importantly, dWAT appears to have a unique relationship with the hair follicle and dynamic reciprocity is seen between these 2 anatomic regions through WNT signaling pathway and its major mediator cadherin-associated protein β 1 (CTNNB1 or β-catenin).5 Research of this signaling has revealed that dWAT is directly stimulated in unison with anagen and regresses through telogen.5 This is a logical relationship when one considers the evolutionary function both regions serve in relation to thermoregulation.

Original Article

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AxoTrack Named One of 2012’s Best Innovations

Wolters Kluwer Health

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Original Article

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A Practical Precaution Relevant to Facial Injections—Reply

In Reply We greatly appreciate the insights provided by Widgerow regarding a potential mechanism through which deoxycholic acid treatment could lead to a telogen effluvium.1 The hair follicle unit intimately interacts with dermal white adipose tissue (dWAT). As the hair follicle moves through the anagen, catagen, and telogen phases, there is progressive rearrangement of dermal adipocytes as well as variation in the thickness of the dWAT.2 The expansion of the dWAT follows the burgeoning of anagen hair follicles mediated by multiple signaling pathways including hedgehog, Shh, bone morphogenetic proteins, and WNT. Similarly, catagen causes regression of the dWAT, in part through lipolysis.3 Defects in the generation of immature adipocytes in the dWAT have previously been proposed to block follicle stem cell activation.4 The inflammatory response induced by deoxycholic acid may cause such a defect, with the panniculitis at the injection site leading to a reduction in the availability of immature adipocytes. This, in turn, could potentially deplete the signals propelling hair follicle units into the anagen phase, with a relative preponderance of follicles in catagen and telogen. Arresting this transition through the hair follicle cycle could lead to the telogen effluvium observed clinically. As the panniculitis abates over a period of weeks, adipocytes may be able to regain their physiological functioning, which would account for the reversal of the telogen effluvium that is observed in most patients. Our hypothesis is speculative, but offers a biologically plausible mechanism to account for the clinical changes observed in this emerging therapy.

Original Article

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Panasonic Introduces 32″ 3D Monitor for Surgical Suite

Wolters Kluwer Health

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Original Article

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The Tripod Concept of the Upper Nasal Third

Key Points

Question  Can we describe a concept related to the well-known tripod theory with extrapolation to the upper nasal third as it pertains to cosmetic rhinoplasty?

Findings  In this study of 10 lay individuals and 10 rhinoplasty-trained individuals who evaluated manipulated photographs of 3 women who had not had surgery, lay individuals were more likely to choose an ideal nasal profile based on surrounding facial architecture, while individuals with rhinoplasty training tended to separate the ideal nose from the surrounding face (statistically significant). Projection was recognized as being altered by both rhinoplasty-trained and lay individuals (although not statistically significant), whereas subjective changes in rotation were significantly more elusive to the lay individual (statistically significant).

Meaning  Simple alteration of the upper nasal third can result in an improved nasal profile without specific alteration of tip architecture.

Importance  The tripod theory of the upper nasal third parallels the concept of the well-known nasal tip tripod. We are evaluating the idea that one can simply alter the upper nasal angles reliably without the complex physics associated with the nasal tip to achieve a pleasing cosmetic result.

Objective  To describe a concept related to the well-known tripod theory with extrapolation to the upper nasal third as it pertains to cosmetic rhinoplasty.

Design, Setting, and Participants  This is a prospective study in which lateral photographs of 3 women who had not undergone surgery (age range, 20-50 years) were selected for digital manipulation of the nasal radix with subsequent alteration of the nasofrontal and nasofacial angles via imaging software. The altered images were analyzed by 20 blinded individuals between July 2009 and June 2017 to assess how changes in the height of the nasal dorsum and radix alone affect nasal appearance and the perception of ideal nasal angles. The study took place at a tertiary center, and the patients chosen for evaluation had nasal architecture that only required subtle changes rather than structure that demonstrated glaringly obvious overprojection or underprojection and rotation or a large dorsal bony hump. Analysis began June 2018.

Main Outcomes and Measures  Overall trend in recognition of objective and subjective alterations in projection and rotation for the rhinoplasty- and non–rhinoplasty-trained evaluators.

Results  Ten medically trained and 10 lay individuals (13 women [65%]; mean [SD] age, 38 [8.6] years) analyzed digitally manipulated photographs of 3 women (age range, 20-50 years) who had not undergone surgery. Lay individuals were more likely to choose an ideal nasal profile based on surrounding facial architecture (28 of 30 [93%]), while individuals with rhinoplasty training tended to separate the ideal nose from the surrounding face (18 of 30 [60%]) (P < .001). Projection was consistently and accurately recognized as being altered by both rhinoplasty-trained and lay individuals (95% CI, −0.18 to 0.38; P = .60 and 95% CI, −0.26 to 0.33; P > .99 for most and least projected), whereas subjective changes in rotation were significantly more elusive to the lay individual (95% CI, −0.04 to 0.52; P = .12 and 95% CI, 0.11 to 0.65; P = .01 for most and least rotated).

Conclusions and Relevance  Predictable and consistent aesthetic results are the primary aim in rhinoplasty. Alterations in the upper nasal tripod are more reliable with extrapolated healing than with the tripod of the nasal tip. Ultimately, simple alteration of the upper nasal third can result in an improved nasal profile without specific alteration of tip architecture.

Level of Evidence  NA.

Original Article

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