Management of the Nasal Dorsum: Construction and Maintenance of a Barrel Vault.

Rhinoplasty is not so much an art, but rather an architectural undertaking: a methodical approach to reconfiguring the nasal components to give a proportionate nose that both pleases the eye and satisfies functional requirements. The dorsum and dorsal esthetic lines are some of the most important components of the nose in terms of esthetics and function. The middle vault is the critical portion of the nose that will guide the management of the bony vault and the tip. The role of the spreader flap and its extension into the bony vault is stressed to re-create the barrel vaultlike nasal architecture.

Carbon Dioxide versus Saline Tissue Expanders: Does It Matter?

BACKGROUND: Implant-based breast reconstruction is the most common reconstructive technique in the United States. Despite its popularity, saline-based tissue expansion still has its limitations, including lengthy expansion times, large uncomfortable bolus dosing, and frequent percutaneous injections/expansion visits. Ideally, a novel technology would eliminate frequent, percutaneous saline injections and allow patients to perform expansion at home, reducing the disruptive experience of current tissue expansion. METHODS: Within the past 6 years, the AeroForm tissue expander system has used remotely activated carbon dioxide release as the fill medium instead of saline, eliminating many limitations of traditional tissue expanders. In this article, the authors first review the relevant literature concerning carbon dioxide-based tissue expansion in animal and human models. The authors then analyze the similarities and differences between two groundbreaking human trials (i.e., Patient Activated Controlled Expansion and AirXpanders Patient Activated Controlled Tissue Expander) with carbon dioxide-based expanders and discuss the risks and benefits associated with this new technology. RESULTS: At their site, the authors have enrolled 34 patients using 36 experimental devices in total, and have found significantly shorter expansion and overall reconstruction times in the patient-controlled tissue expander group. CONCLUSIONS: The authors believe that carbon dioxide-based devices may play a significant role in the future of implant-based breast reconstruction, and may be widely applicable to other areas of plastic surgery that also involve tissue expansion.

Desmopressin as a hemostatic agent to provide a dry intraoperative field in rhinoplasty.

BACKGROUND: Intraoperative bleeding during rhinoplasty makes it difficult to sculpt cartilages. Residual blood from a wet field can lead to induration, fibrosis, and definition loss. Recent studies with desmopressin (1-deamino-8-D-arginine vasopressin) to reduce blood loss in a variety of operations and minimize postoperative bleeding problems suggest using that drug routinely for elective rhinoplasty and not just for patients with coagulation issues. METHOD: Seventy-three consecutive rhinoplasty patients received desmopressin for the purpose of obtaining a dry operative field. The initial dose was 0.1 µg/kg. If the field was not as dry as desired, a second dose was given; if necessary, a third dose to a maximum of 0.3 µg/kg was given. All cases exhibited a satisfactorily dry field. There were no adverse effects. A retrospective comparison was made to 300 consecutive cases not receiving desmopressin. RESULTS: Thirty of the 73 patients received a starting dose of 0.1 µg/kg and nothing more. Fourteen received a second dose of 0.1 µg/kg because the field was not as dry as desired and 29 received a third dose of 0.1 µg/kg because the field was not as dry as desired. All 73 patients exhibited a satisfactorily dry field, in contrast to 9 percent in the group not receiving desmopressin. CONCLUSIONS: This study confirms the hemostatic effectiveness of desmopressin at lower than normally used doses in rhinoplasty. It also confirms its safety. It suggests its use in other procedures. A larger, carefully controlled study is indicated. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

AeroForm patient controlled tissue expansion and saline tissue expansion for breast reconstruction: a randomized controlled trial.

BACKGROUND: Prosthetic reconstruction of the breast, as a 2-staged procedure using tissue expanders followed by placement of permanent implants, offers favorable aesthetic results with minimal additional surgical intervention. However, the current outpatient process to fill saline expanders can be lengthy and onerous, involving months of office visits and discomfort from the bolus saline expansions. We present a new technology (AeroForm Tissue Expansion System), which has the potential to improve the process of breast tissue expansion by providing a method for low-volume incremental filling, eliminating the need for injections and directly involving the patient by allowing her some control over the expansion process. METHODS: The described study is a 2:1 randomized controlled trial of the investigational CO2 expansion system and saline expanders. Of the 82 women receiving expanders, 58 (39 bilateral and 19 unilateral; bilateral rate, 67%) were implanted with CO2 tissue expanders and 24 subjects (15 bilateral and 9 unilateral; bilateral rate, 63%) were implanted with saline expanders. RESULTS: Preliminary validated expansion results were available for 55 women. Available mean time for active expansion in the CO2 group was 18.2 (9.2) days (median, 14.0; range, 5-39; number of expanders, 53), which was less than the mean time for active expansion in the saline group: 57.4 (33.6) days (median, 55; range, 5-137; number of expanders, 33). Available mean time from implant placement to exchange for a permanent prosthesis in the CO2 group was shorter [106.3 (42.9) days; median, 99; range, 42-237; number of expanders, 53] than for the women in the control group [151.7 (62.6) days; median, 140; range, 69-433; number of expanders, 33]. After 2 events--underexpansion (n=1) and erosion (n=1)--in the CO2 group, the internal membrane was redesigned and the expander bulk was decreased to minimize the risk of underexpansion and erosion in subsequent patients. CONCLUSIONS: Preliminary evidence indicates that the CO2-based tissue expansion system performs the same function as saline expansion devices without significantly altering the risk to the patient and that the device has the potential to make the expansion process faster and more convenient for both the patient and the physician.

Pilot clinical study of a novel minimally invasive bipolar microneedle radiofrequency device.

BACKGROUND AND OBJECTIVES: Noninvasive bipolar and monopolar radiofrequency (RF) deep dermal heating devices have previously been described. A novel minimally invasive RF device employing a bipolar microneedle electrode system is introduced and its resultant thermal effects on human skin in vivo were characterized for the first time. STUDY DESIGN/MATERIALS AND METHODS: An investigational 35 W RF device was configured to operate in bipolar mode delivering energy directly within the dermis using 5 microneedle electrode pairs with real-time feedback of tissue temperature for treatment control. Superficial cooling was achieved using a Peltier device. A range of pulse durations between 1 and 25 seconds, and lesion temperatures between 60 and 80 degrees C were tested in vivo on 15 human subjects. Thermal effects were assessed histologically using either hematoxylin & eosin (H&E) or nitroblue-tetrazoliumchloride (NBTC) staining. Treatment effects and adverse events were also monitored clinically. RESULTS: The investigational bipolar RF device delivered controlled heating within dermal tissue. Histological staining with H&E revealed the presence of zones of denatured collagen within the reticular dermis. Lesions were generated at preselected temperatures between 60 and 80 degrees C. Fractional lesions separated by zones of sparing as well as contiguous lesion patterns were demonstrated. Histological staining with H&E and NBTC revealed sparing of adnexal structures and adipose tissue. No major adverse events were observed. CONCLUSIONS: A novel fractional RF device utilizing a minimally invasive bipolar microneedle delivery system for the treatment of human tissue was developed. Treatment of 15 human subjects illustrated the controlled creation of dermally located thermal coagulation zones, herein known as radiofrequency thermal zones. We discovered that varying the pulse length allowed for fractional sparing of dermal tissue. To our knowledge, this is the first report to describe use of a direct real-time temperature and impedance feedback system to control energy delivery during deep dermal heating.

Preliminary evaluation of a fast-absorbing multipoint fixation device.

BACKGROUND: Since the Endotine forehead fixation device (Coapt Systems, Palo Alto, CA) was introduced in 2003, a small percentage of surgeons and patients have complained of persistent palpability and sensitivity related to its 12- to 15-month absorption time. Therefore, a refinement of the original design, the Ultratine (Coapt Systems), consisting of a polymer blend altered for faster absorption and biodegradability, was introduced in 2006. OBJECTIVE: The authors report early results of fixation using the Ultratine with respect to permanence of elevation and the duration of visibility, palpability, and sensitivity of the implant. METHODS: The authors conducted a retrospective review of patients who had undergone brow lift with Ultratine forehead fixation, along with concomitant cosmetic procedures. RESULTS: Ten patients were available for follow-up at 14 months postoperatively. In many cases, the implant biodegraded and absorbed at the 3- to 6-month intervals, and symptoms of visibility, palpability, and sensitivity were markedly improved over the original Endotine device. CONCLUSIONS: The Ultratine degradation profile produces secure, permanent fixation and elevation for endoscopic brow lifts while diminishing the long-lasting side effects of visibility, palpability, and sensitivity exhibited by a small proportion of patients with the original Endotine device. It is an option particularly for those patients who have thin scalps or fine hair. The Endotine may still be the best choice for patients with heavier brows; tighter, more immobile brows; and for secondary cases. It may also be preferable in cases of reverse brow procedures intended to lower the hairline.

Brow fixation with the Endotine Forehead device in endoscopic brow lift.

BACKGROUND: The Endotine Forehead device (Coapt Systems, Inc., Palo Alto, Calif.) is an implantable bioabsorbable fixation device designed to provide intuitive, multipoint, distributed tension and repeatable and predictable brow fixation during endoscopic and open browplasty. The purpose of this study was to evaluate early results in a series of endoscopic brow lift cases using the Endotine Forehead device. METHODS: Two versions of the Endotine device were used in this study. One was composed of polylactic acid, and the other was a smaller version consisting of 82/18 L-lactide/glycolide). In a consecutive series of endoscopic brow lift cases, preoperative and postoperative standardized photographs were taken in the Frankfort horizontal plane and three measurements were compared: midpupil to superior brow, midpupil to hairline, and lateral canthus to superior brow. RESULTS: A total of 21 patients (19 women and two men) underwent endoscopic browplasty. Photographs were obtained preoperatively and 54 to 174 days postoperatively. Brow elevation measurements were obtained postoperatively. No significant adverse events were encountered in the follow-up period. CONCLUSION: The Endotine Forehead device provides significant and reproducible brow elevation, with no significant adverse events, as measured at three points in excess of 14 weeks postoperatively.

Midface lift technique with use of a biodegradable device for tissue elevation and fixation.

BACKGROUND: Aesthetic surgeons have become increasingly aware that elevation of the midface is a significant component of facial rejuvenation. However, adequate fixation remains a problem in midface lift procedures, regardless of the approach. OBJECTIVE: The purpose of this study was to evaluate the efficacy and ease of application of the Endotine midface device (Coapt Systems, Palo Alto, CA), as well as patient and surgeon satisfaction with the results of treatment. METHODS: The Endotine device consists of a polylactide polymer that incorporates 5 tines, each 4.5 mm long, to distribute tension over a wide area, maximizing fixation strength and holding power. After the cheek tissue is engaged, upward tension is applied to the anchoring leash, which is then sutured to the deep temporal fascia. Between October 2003 and October 2004, 31 patients underwent Endotine fixation for midface lift. The patient group comprised 7 men and 24 women ranging in age from 40 to 65 years (mean age, 49.25 years). Four patients had midface lifts as the sole procedure, and 27 had adjunctive facial cosmetic procedures. Results evaluated included ease of use/difficulty of insertion, postsurgical pain, adequacy and stability of fixation, side effects and complications, and patient and surgeon satisfaction. RESULTS: All patients were judged to have satisfactory cheek elevation and enhanced contour without evidence of recurrent midface ptosis or loss of elevation/fixation. There were no postoperative complications of infection, hematoma, or dehiscence. In a subset of 11 patients, "pain in the treated area" averaged 2.7 (0 = no pain, 10 = extreme pain) at one month follow-up. Surgeon satisfaction with the fixation result averaged 4.9 (1 = very dissatisfied, 5 = very satisfied) at one month follow-up. Patient self-assessment of aesthetic outcome averaged 3.8 (1 = worse than baseline, 4 = dramatic improvement from baseline) at one month follow-up, and patient satisfaction assessment averaged 3.9 (1 = very dissatisfied, 4 = very satisfied) at one month follow-up. CONCLUSIONS: The midface Endotine device provided rapid, secure fixation in our small patient study group without complications, and eliminated the complicated and awkward suture techniques that have been an impediment to midface surgery. Larger clinical studies are in progress.