Influence of botulinum toxin type A esthetic injections on facial expressions.

BACKGROUND: Botulinum toxin type A (BoNT-A) injection remains the leading medical cosmetic procedure worldwide, with a high rate of patient satisfaction. However, it still suffers from patients' fear of being unable to transmit their emotions and of looking frozen from unnatural results. AIM: This study aimed to determine whether BoNT-A can decrease the intensity of emotions in facial expressions. PATIENTS/METHODS: In this single-center prospective study, 42 patient investigators assessed four patients' facial expressions for six emotions and neutral faces, before and after injection of 36 IU or 48 IU of onabotulinumtoxinA, using photographs. Photographs were presented on a tablet to the investigators. RESULTS: There were no statistical differences between the before and after photographs for the intensity of emotions for all expressions (P > .05) except for the expression of surprise in the group of patients that received 48 IU of the injection (protocol with injection of the frontalis muscle). All patient investigators answered negatively to the question "Do you think that this patient has a 'frozen face'?". CONCLUSION: This study shows that esthetic injection of BoNT-A in the upper face has no negative effects on facial expressions and does not lead to the feared "frozen face" when it is injected with respect for best practice guidelines. This study can be used as an example for patients who have some reticences against BoNT-A injection.

High-Resolution Magnetic Resonance Imaging of Aging Upper Face Fat Compartments.

BACKGROUND: Age-related changes in fat compartments have yet to be fully characterized. Uncertainty remains in terms of volume gains/losses or shape fluctuations over time. The authors' aim was to determine the evolution of subcutaneous fat in the aging upper face, focusing on shifts in volume and dimension. METHODS: Over the course of 4.5 years, 100 faces of living female Caucasian patients were prospectively studied using high-resolution magnetic resonance imaging. Subjects were stratified by age as follows: group 1, 18 to 30 years; group 2, 30 to 60 years; and group 3, older than 60 years. Superficial temporal and central forehead compartments were delimited, analyzing respective volumes and dimensions by group. RESULTS: In 85 patients studied, superficial temporal fat (mean volume, 5.14 cm) increased 35.48 percent in total volume between youth and old age (p = 0.046). Overall height and magnitude of the lower one-third also increased with aging. Central forehead fat (mean volume, 2.56 cm), studied in 83 patients, showed a 209.75 percent volume gain in group 2 (versus group 1) and a 17.59 percent volume loss in group 3 (versus group 2) (p = 0.001). CONCLUSION: Subcutaneous facial fat fluctuates with aging, increasing in the upper face and promoting ptosis through basal compartmental expansion.

Coverage of Tendon Exposure after Radial Forearm Free Flap by the Dorsoulnar Artery Perforator Flap.

Objective This study was designed to assess the effectiveness of an alternative technique using a perforator flap to manage secondary tendon exposure after a radial forearm free flap in head and neck oncologic surgery. Study Design Prospective cohort study. Setting Plastic Reconstructive Surgery Unit, Nice University Hospital, Pasteur 2 Hospital, France. Subjects and Methods Despite its numerous advantages, the radial forearm free flap is associated with significant donor site morbidity and the risk of secondary tendon exposure. Conventional skin grafts for secondary tendon exposure can lead to diminished wrist range of motion and grip strength, with residual pain and cold intolerance. Between 2012 and 2015, we prospectively studied 20 patients with secondary tendon exposure after a forearm radial free flap for head and neck reconstruction. Two techniques of secondary coverage were compared: a reference technique with a secondary full skin graft (10 patients) and a dorsoulnar artery perforator (DUAP) flap (10 patients). Results Maximum wrist extension (100%) was observed for the DUAP group compared with only 87% for the skin graft (SG) group ( P = .001). An improvement in grip strength (+14 kg) ( P = .028) and a decrease in pain or cold intolerance ( P = .002) were also observed in the DUAP group, in addition to a better aesthetic appearance. Conclusion The perforator flap procedure is an interesting tool in reconstructive surgery. The DUAP flap is a reliable, useful flap for secondary tendon exposure coverage after a radial forearm free flap. Level of Evidence III (case-control analytic studies of 1 center).

Homeotic and Embryonic Gene Expression in Breast Adipose Tissue and in Adipose Tissues Used as Donor Sites in Plastic Surgery.

BACKGROUND: Autologous fat grafting has become an essential procedure in breast reconstructive surgery. However, molecular knowledge of different adipose donor sites remains inadequate. Tissue regeneration studies have shown that it is essential to match the Hox code of transplanted cells and host tissues to achieve correct repair. This study aims to provide a better molecular understanding of adipose tissue. METHODS: Over the course of 1 year, the authors prospectively included 15 patients and studied seven adipose areas: chin, breast, arm, abdomen, thigh, hip, and knee. The first step consisted of the surgical harvesting of adipose tissue. RNA was then extracted and converted into cDNA to study gene expression levels of 10 targeted genes by real-time polymerase chain reaction. RESULTS: Forty samples from Caucasian women with a mean age of 48 years were studied. The expression of PAX3, a marker of neuroectodermal origin, was significantly higher in the breast, with a decreasing gradient from the upper to lower areas of the body. An inverse gradient was found for the expression of HOXC10. This expression profile was statistically significant for the areas of the thigh and knee compared with the breast (p < 0.0083). CONCLUSIONS: Breast fat may have a specific embryologic origin compared with the knee and thigh. The reinjection of adipocytes from the infraumbilical area leads to the transfer of cells highly expressing HOXC10. This study raises questions about the safety of this procedure, and future studies will be required to examine molecular modifications of adipose cells transferred to a heterotopic location. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

Surgical treatment of secondary lymphedema of the upper limb by stepped microsurgical lymphaticovenous anastomoses.

OBJECTIVE: The incidence of lymphedema following treatment for breast cancer ranges between 10 and 50% after complete axillary dissection and gives rise to severe functional discomfort in patients. Results of lymphaticovenous anastomoses (LVA) in surgical treatment of lymphedema appear to be favorable. However, the available literature on this topic is scarce, often with short follow-up times. The aim of this study is to analyze the results of LVA on 31 patients and to review the existing literature. PATIENTS AND METHODS: This study comprised 31 female patients presenting lymphedema of the upper limb following treatment for breast cancer for which surgical treatment was given by microsurgery consisting of three stepped LVA performed in an outpatient setting. RESULTS: The post-LVA arm circumference was measured at three levels (wrist, forearm, and arm) in 31 female patients. Mean follow-up time was 12.8 months. Reduction in the circumference was 22.5, 21.32, and 30.2%, respectively, in the wrist, forearm, and arm. Functional improvement was observed in the majority (84%) of patients ranging from moderate to substantial. Only 2 patients had no result. The only patients to experience recurrence were those with a high level of lymphedema. CONCLUSION: The review of the current literature and the present study revealed modest results in terms of decreased excess volume, although a major improvement in function points to LVA as a useful technique in this indication. Progress in imaging techniques has enhanced the results achieved with this procedure, although further studies on recurrence rates are needed with a follow-up greater than 1 year.

Inferior Cubital Artery Perforator Flap for Soft-Tissue Coverage of the Elbow: Anatomical Study and Clinical Application.

BACKGROUND: Soft-tissue defects surrounding the elbow can be a challenging problem for the orthopaedic surgeon. Reliable reconstruction with use of muscular flaps or even perforator flaps derived from the surrounding vessels has been described. The inferior cubital artery (ICA) is an indirect septocutaneous perforator branch that most frequently arises from the lateral side of the radial artery. The purposes of the present study were to characterize the capillary cutaneous perforators of the ICA and to evaluate the potential of a local perforator flap procedure for soft-tissue coverage of the elbow. METHODS: Twenty fresh cadaveric forearms were dissected in order to describe the ICA anatomy, and in ten additional forearms the ICA was selectively injected with a red ink solution to detail the ICA vascular territory. For each artery, we recorded the site of origin, the diameter of the artery at its source, the course of the artery, and the number, type, and diameter of capillary cutaneous perforators. RESULTS: A total of seventy-eight ICA capillary perforators were analyzed from the twenty dissected forearms: forty-six were in-transit capillary perforators, nineteen were terminal capillary perforators, and thirteen were musculocutaneous capillary perforators. Of these seventy-eight perforators, sixteen (21%) had a caliber of <0.5 mm and sixty-two capillary perforators (79%) had a caliber of ≥0.5 mm. Ten ICAs were selectively injected, and the mean size of all stained skin areas was 30.9 ± 11.9 cm(2). A perforator pedicled flap was readily feasible for all dissections. We also describe the case of a patient with a medial soft-tissue defect of the elbow that was covered with a pedicled perforator flap based on an ICA. The patient had satisfactory healing at two months. CONCLUSIONS: The ICA flap is a reliable and useful flap for elbow soft-tissue reconstruction. CLINICAL RELEVANCE: The perforator flap procedure is a major advancement in reconstructive surgery. One potential application of the perforator flaps is the use of tissue adjacent to a defect as a perforator-based island flap. The use of this tissue allows for thinner flaps to be tailored for more accurate reconstruction. A flap that depends on a perforator branch of the radial artery called the inferior cubital artery seems to be an excellent solution for soft-tissue coverage of the elbow.

Facial artery perforator flap for reconstruction of perinasal defects: An anatomical study and clinical application.

BACKGROUND: The concept of the facial artery perforator flap was developed for improved freedom during the reconstruction of perioral and perinasal defects. This flap enables tailor-made reconstruction and a shift from the traditional two-stage procedure to a one-stage technique. In this cadaveric study, the authors quantify the number, length, and diameter of facial artery perforators (FAPs) and present their clinical experience with the FAP flap. METHODS: The authors performed 20 dissections of facial arteries (FAs). All FAPs greater than 0.5 mm were dissected to study the number, length, and diameter of FAPs. In addition, the authors report a case series of 15 perinasal defect reconstruction procedures performed using facial artery-based perforator flap. RESULTS: A total of 125 FAPs were dissected. We identified a mean of six FAPs per hemiface (range five to eight). The average length of all FAPs was 17.6 ± 1.9 mm, and the mean diameter of the FAPs was 0.91 ± 0.2. Fifteen patients underwent a perinasal defect reconstruction using a FAP flap with good aesthetic and functional results. CONCLUSIONS: The following study thus improves our understanding of FAP anatomy and clinical application and will enable the nasolabial fold to become the area where perinasal defect reconstruction using perforator flaps is performed.

Torsion of a huge pedunculated uterine leiomyoma.

Uterine leiomyoma in torsion is an uncommon emergency and mimics generalized peritonitis. We report the case of a 62-year-old woman with a huge subserous fibroid in torsion. The lesion was removed surgically with the uterus and ovaries. Imaging is an essential tool in the diagnosis of myomata and should serve to exclude other diseases, especially malignancy.