Clinical evaluation of non-ablative radiofrequency facial rejuvenation.

OBJECTIVE: To evaluate the clinical efficacy of non-ablative cutaneous radiofrequency (RF) facial rejuvenation. DESIGN: Prospective study with longitudinal follow-up of a validation cohort set in an urban, private practice of an ambulatory facial plastic surgery center in southern California. METHODS: A consecutive sample was enrolled of 35 healthy adults with moderate facial aging, manifested by skin laxity, rhytids, and ptosis (brow, midface, jowls). Following intravenous sedation anesthesia, the study area was treated with 115-144 J/cm2 using the non-ablative RF device (ThermaCool TC). The main outcome measures were the objective measurement of brow height, investigator evaluation of skin parameters, a patient satisfaction questionnaire, and standardized photography, at fixed time intervals. RESULTS: At 12 weeks, a statistically significant increase in mean vertical brow height of 1.6-2.4 mm was observed in patients treated exclusively with the RF device (p<0.0001). All skin parameters (laxity, wrinkles, clarity, pore size) were improved. Complications and side effects were minimal. Patients were uniformly satisfied. CONCLUSIONS: The ThermaCool TC RF system represents a promising non-invasive method of obtaining moderate facial rejuvenation in the appropriately selected patient. Long-term results are pending.

Local administration of nitric oxide donor significantly impacts microvascular thrombosis.

OBJECTIVES/HYPOTHESIS: Clinical pharmacotherapy has demonstrated a role in preventing microvascular thrombosis in both experimental and clinical settings. Previous studies in the rabbit model have noted an increased rate of thrombosis with intravenous infusion of nitric oxide antagonists. The study assessed the effects of local application of nitric oxide agonists and antagonists on microvascular anastomotic patency rates. STUDY DESIGN: A randomized, prospective analysis. METHODS: An arterial inversion graft microvascular thrombosis model was used in New Zealand white rabbits. The rabbits were randomly assigned to nitric oxide agonist, antagonist, and control groups. In each rabbit, the common femoral artery was surgically exposed and a 2-mm arterial inversion graft was harvested. The anastomosis of the graft to the common femoral artery was performed in solutions of either 100 micromol/L spermine NONOate (nitric oxide donor), 100 micromol/L nitro-L-arginine-methyl ester (L-NAME) (nitric oxide synthase inhibitor), or 0.9% sodium chloride (control) solution. The contralateral common femoral artery also underwent arterial inversion graft testing with the use of the same solution. Arterial patency was assessed 1 hour after anastomosis. RESULTS: Sixteen of 22 arterial inversion grafts performed in the spermine NONOate solution remained patent, and 6 of 22 clotted. Eleven of 21 arterial inversion grafts performed in the control solution remained patent, and 10 clotted. Seven of 21 arterial inversion grafts performed in the L-NAME solution remained patent, and 14 clotted. These results were found to be statistically significant using the chi test with a value of less than.05. CONCLUSIONS: In the rabbit model, local application of nitric oxide agonists and antagonists can significantly impact anastomotic patency rates. Further studies may demonstrate a role for the clinical use of nitric oxide in microvascular surgery.

Myocardial infarction after microvascular head and neck reconstruction.

OBJECTIVE/HYPOTHESIS: Microvascular flap transfer is a popular method for immediate reconstruction of defects in the head and neck resulting after the treatment of head and neck cancer. Head and neck cancer occurs most commonly in elderly patients with a high prevalence of heavy smoking. Surgery in this patient population is frequently prolonged and is associated with significant intraoperative blood loss. The present study seeks to identify factors contributing to perioperative myocardial infarction and to determine the best course of management. STUDY DESIGN: Retrospective analysis of 193 consecutive free flap surgeries. METHODS A series of 193 microvascular free flaps performed over a 5-year period for reconstruction of defects in the head and neck was retrospectively analyzed to identify the incidence, management, and outcome of perioperative myocardial infarction in this patient population. RESULTS: Myocardial infarctions occurred in seven patients, for an overall incidence of 3.6%. Statistical analysis using logistic regression failed to demonstrate any significant relationship between age, sex, total operative time, operative blood loss, net intraoperative fluid shifts, tumor stage, American Society of Anesthesiology (ASA) preoperative classification, type of free flap, and the occurrence of perioperative myocardial infarction. Hemodynamic instability manifested by hypotension occurred in four patients who had perioperative myocardial infarction. Three of these patients underwent urgent coronary artery bypass surgery, whereas one patient underwent urgent endovascular therapy with subsequent stabilization of the hemodynamic instability. All free flaps survived despite myocardial infarction and hemodynamic instability. Two patients (29%) died after postoperative intervals of 74 and 99 days, never having left the hospital. CONCLUSIONS: Systemic hypotension is a well-recognized risk factor for free flap failure. Our experience suggests that aggressive intervention to reverse coronary ischemia associated with hemodynamic instability has a favorable outcome on free flap survival, and free flap thrombosis is not an inevitable outcome of the low-flow state associated with perioperative cardiopulmonary bypass. Although the overall incidence of perioperative myocardial infarction in patients undergoing microvascular head and neck reconstruction is low, patient mortality is high, so emphasis should be placed on preoperative identification of patients with coronary artery disease.

Adenotonsillar enlargement in pediatric organ transplant recipients: a cross-sectional analysis.

OBJECTIVE: Our goal was to statistically correlate adenotonsillar hypertrophy (ATH) in the pediatric posttransplant population with potential risk factors and to monitor the progression of ATH over time. STUDY DESIGN AND SETTING: Participants were evaluated for ATH through a standardized 65-point questionnaire and an 8-point physical examination. They were also evaluated for current age, age at time of transplantation, type of organ transplant, gender, tacrolimus use, history of transplant rejection, Epstein-Barr virus (EBV) serology, and cytomegalovirus (CMV) serology. We evaluated 243 pediatric solid organ transplant recipients, with 116 patients undergoing repeat evaluation. RESULTS: A statistically significant negative correlation was noted between age at time of transplantation and both questionnaire scores (P = 0.0075) and examination scores (P = 0.013). A significant negative correlation was also seen between age at time of evaluation and questionnaire score (P = 0.028) but not examination score (P = 0.49). Recipient EBV seronegativity significantly increased questionnaire score (P = 0.05). Liver transplant recipients also had a significantly higher questionnaire score than did kidney transplant recipients (P = 0.0048). Gender, CMV recipient status, and tacrolimus (immunosuppressant) use did not significantly impact questionnaire or examination scores. Repeat evaluation of 116 patients after a 2- to 9-month interval did not demonstrate any significant increases in questionnaire scores. A statistically significant drop in examination scores was noted (P = 0.003). CONCLUSIONS AND SIGNIFICANCE: These findings support previous reports in the literature that correlate EBV seronegativity, younger age at transplant, and liver versus kidney transplantation with increased incidence of PTLD.