Late postoperative massive bleeding in septorhinoplasty: A prospective study.

BACKGROUND: There are various complications that can occur in septorhinoplasty, most of which are related to postoperative failure to achieve the desired aesthetic result. However, there are also many other complications, including postoperative bleeding, which is one of the most common nonaesthetic-related complications. OBJECTIVE: The present study was a prospective analysis involving a total of 750 septorhinoplasty patients, and included individuals who experienced massive bleeding after postoperative day 8. RESULTS: The incidence of bleeding was 2% among all patients. One percent of cases with bleeding occurred between postoperative days 8 and 14. None of the patients exhibited an abnormality in preoperative or postoperative coagulation tests. Mean blood loss was approximately 1 unit. In all patients, clots in the nose were cleaned, bleeding was subsequently controlled by placement of a polyvinyl alcohol sponge tampon soaked in adrenalin and tranexamic acid, and intravenous administration of 250 mg tranexamic acid in isotonic saline solution. This treatment was sufficient for all cases. None of the patients expereinced recurrent bleeding nor did they require a blood transfusion. CONCLUSION: Late bleeding in septorhinoplasty is rare. It may be prevented by completely filling the nasal cavity so that there is no dead space between the septal mucosal membranes and the drainage opening. If bleeding occurs, it can be treated by placement of a tampon soaked in adrenalin and tranexamic acid plus intravenous administration of 250 mg tranexamic acid.

HISTORIQUE: Plusieurs complications peuvent survenir après une septorhinoplastie. La plupart sont liées à l'incapacité d'obtenir le résultat esthétique souhaité après l'opération. Il existe toutefois de nombreuses autres complications, y compris les hémorragies postopératoires, qui font partie des complications les plus courantes à ne pas être liées à l'esthétisme. OBJECTIF: La présente analyse prospective portait sur 750 patients ayant subi une septorhinoplastie et incluait des personnes qui avaient subi une hémorragie massive huit jours après l'opération. RÉSULTATS: L'incidence d'hémorragie s'élevait à 2 % pour l'ensemble des patients. Un pour cent des cas d'hémorragie se sont produits entre le huitième et le quatorzième jour suivant l'opération. Aucun patient ne présentait d'anomalie selon les tests de coagulation préopératoires ou postopératoires. La perte de sang moyenne s'élevait à environ une unité. Chez tous les patients, les caillots dans le nez ont été nettoyés, le saignement a été contrôlé par l'insertion d'un tampon d'alcool polyvinylique en éponge, imbibé d'adrénaline et d'acide tranexamique, et par l'administration intraveineuse de 250 mg d'acide tranexamique dans du sérum physiologique isotonique. Ce traitement a suffi dans tous les cas. Aucun des patients n'a souffert d'hémorragie récurrente ni n'a dû subir de transfusion. CONCLUSION: L'hémorragie tardive est rare après une septorhinoplastie. Pour l'éviter, on peut remplir complètement la cavité nasale, pour combler tout l'espace entre les muqueuses du cartilage triangulaire et l'ouverture de drainage. Pour traiter un saignement, on peut insérer un tampon imbibé d'adrénaline et d'acide tranexamique et administrer 250 mg d'acide tranexamique par voie intraveineuse.

The Effect of Patient Positioning on Amount of Intraoperative Bleeding in Rhinoplasty: A Randomized Controlled Trial.

BACKGROUND: There is a rich blood flow to the mucosa in the nasal region. In rhinoplasty, surgical procedures are performed in a narrow and confined space. So bleeding during surgery reduces visibility which can complicate the procedure. This study investigated the effects of the patient position on amount of intraoperative bleeding during surgical procedures. PATIENTS AND METHODS: This randomized controlled trial was conducted on 71 patients who underwent elective rhinoplasty. The patients were operated on in three groups. Group 1 consisted of 23 patients who were operated on in the supine position; Group 2 included 28 patients who were operated on using a 15° angle reverse Trendelenburg position; Group 3 consisted of 20 patients who were operated on at a 20° angle reverse Trendelenburg position. RESULTS: There were statistically significant differences between the groups in regard to surgeon satisfaction and the amount of intraoperative bleeding. The amount of intraoperative bleeding in Group 1 was significantly higher than those of Groups 2 and 3, and surgeon satisfaction was lower. CONCLUSIONS: Reverse Trendelenburg position reduces intraoperative bleeding in rhinoplasty patients while facilitating the procedure compared to the supine position. Surgery at a 15° angle reverse Trendelenburg position provides the optimum working conditions by both significantly reducing intraoperative bleeding and allowing for comfortable conditions for the surgeon. LEVEL OF EVIDENCE I: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Follicular Unit Extraction Hair Transplantation with Micromotor: Eight Years Experience.

OBJECTIVE: Follicular unit extraction (FUE) has been performed for over a decade. Our experience in the patients who underwent hair transplantation using only the FUE method was included in this study. METHODS: A total of 1000 patients had hair transplantation using the FUE method between 2005 and 2014 in our clinic. RESULTS: Manual punch was used in 32 and micromotor was used in 968 patients for graft harvesting. During the time that manual punch was used for graft harvesting, 1000-2000 grafts were transplanted in one session in 6-8 h. Following micromotor use, the average graft count was increased to 2500 and the operation time remained unchanged. Graft take was difficult in 11.1 %, easy in 52.2 %, and very easy in 36.7 % of our patients. CONCLUSIONS: The main purpose of hair transplantation is to restore the hair loss. During the process, obtaining a natural appearance and adequate hair intensity is important. In the FUE method, grafts can be taken without changing their natural structure, there is no need for magnification, and the grafts can be transplanted directly without using any other processes. Because there is no suture in the FUE method, patients do not experience these incision site problems and scar formation. The FUE method enables us to achieve a natural appearance with less morbidity.

Comparison of Various Rhinoplasty Techniques and Long-Term Results.

BACKGROUND: Various techniques are used in rhinoplasty. These techniques can be classified under transcolumellar approaches and endonasal procedures. Open rhinoplasty without transcolumellar incision (ORWTI) procedure can be described as a combination of these two techniques. METHODS: In this study, we present patients who underwent nasal surgery utilizing one of these three techniques between 1999 and 2013 and discuss some modifications to the techniques. RESULTS: Of a total of 1526 patients, 1131 were operated on with open rhinoplasty with transcolumellar incision, 219 were operated on with ORWTI, and 176 were operated on using the endonasal approach. With an average follow-up period of approximately 4 years, 4 % of the patients required revision. The patient satisfaction rate was more than 90 % for all of these techniques. CONCLUSIONS: The endonasal approach is an appropriate choice for select patients due to the lower chance of complications and a shorter procedure time. With open rhinoplasty with the transcolumellar incision technique, the type of surgery can be more easily controlled, however, extended nasal tip edema and columellar scar are some of the disadvantages of this method. ORWTI allows a patient to avoid these disadvantages and provides a more controlled procedure, similar to the open method.

Effect of sildenafil citrate in nicotine-induced ischemia: An experimental study using a rat model.

Recent experimental and clinical studies have demonstrated the negative effects of nicotine on the viability of skin flaps. Necrotic damage to skin flaps can result in significant complications including delayed wound healing, dehiscence and wound contraction. Phosphodiesterase type 5 inhibitors, such as sildenafil citrate, have a protective effect in ischemic injuries of the brain, kidney, myocardium, spinal cord, ileum and testes. In the present study, the authors evaluated the effect of sildenafil citrate on the viability of skin exposed to nicotine-induced ischemia in Sprague Dawley rats. In the preoperative period, the rats were divided into three groups of 10 rats each. Group C was treated with subcutaneous saline and group S and group N were treated with 2 mg/kg nicotine, administered subcutaneously twice per day for 28 days. McFarlane flaps were created in all experimental animals using an incision measuring 7 cm × 3 cm. Postoperative treatment varied among the groups: group S was treated with 20 mg/kg/day sildenafil citrate, while group C and group N were treated with equivalent doses of saline for seven days. A laser Doppler flow meter was used to monitor the microvasculature. Preoperative measurements of the microvasculature revealed decreased blood flow in group N and group S, both of which were treated with subcutaneous nicotine. During the postoperative evaluation, a trend toward increased blood flow was observed in group S compared with the group with nicotine-induced ischemia treated with saline alone postoperatively (group N). A visual fluorescein dye test was used to predict skin viability and demonstrated diminished skin viability in group N and group S (P<0.05) during the preoperative period. Following treatment with sildenafil for seven days, a statically significant improvement in skin viability was observed in group S (P<0.05). Nicotine decreased blood flow within the skin and impaired skin viability, while postoperative application of sildenafil significantly ameliorated the ischemic effects of nicotine and improved skin viability. Future studies will be required to evaluate the clinical use of sildenafil for the improvement of blood flow in ischemic injury of the skin.

De récentes études expérimentales et cliniques démontrent les effets négatifs de la nicotine sur la viabilité des lambeaux cutanés. Les dommages nécrotiques des lambeaux cutanés peuvent s'associer à d'importantes complications, y compris le délai de guérison de la plaie, la déhiscence et la contraction de la plaie. Les inhibiteurs de la phosphodiestérase de type 5, tels que le citrate de sildénafil, ont un effet protecteur sur les lésions ischémiques du cerveau, du rein, du myocarde, de la moelle épinière, de l'iléon et des testicules. Dans la présente étude, les auteurs ont évalué l'effet du citrate de sildénafil sur la viabilité de la peau exposée à une ischémie induite par la nicotine chez des rats de Sprague Dawley. Avant l'opération, les rats ont été divisés en trois groupes de dix rats. Le groupe C a reçu un traitement de solution physiologique par voie sous-cutanée, tandis qu'on a administré au groupe S et au groupe N un traitement de 2 mg/kg de nicotine par voie sous-cutanée deux fois par jour pendant 28 jours. Les chercheurs ont créé des lambeaux de McFarlane chez tous les animaux expérimentaux au moyen d'une incision de 7 cm × 3 cm. Le traitement postopératoire variait selon les groupes : le groupe S a reçu 20 mg/kg/jour de citrate de sildénafil, tandis que le groupe C et le groupe N ont reçu des doses équivalentes de solution physiologique pendant sept jours. Ils ont utilisé un débitmètre Doppler au laser pour surveiller les microvaisseaux. Les mesures préopératoires des microvaisseaux ont révélé une diminution du débit sanguin dans le groupe N et le groupe S, tous deux traités par de la nicotine sous-cutanée. Pendant l'évaluation postopératoire, les chercheurs ont observé une tendance vers l'augmentation du débit sanguin dans le groupe S par rapport au groupe N, qui avait subi une ischémie induite par la nicotine traitée au moyen d'une simple solution physiologique après l'opération. Un test visuel de coloration à la fluorescéine a permis de prédire la viabilité cutanée et d'en démontrer une diminution dans le groupe N et le groupe S (P<0,05) pendant la période préopératoire. Après le traitement au sildénafil pendant sept jours, les chercheurs ont observé une amélioration significative de la viabilité cutanée dans le groupe S (P<0,05). La nicotine réduisait le débit sanguin de la peau et nuisait à la viabilité cutanée, tandis que l'application postopératoire de sildénafil atténuait considérablement les effets ischémiques de la nicotine et améliorait la viabilité cutanée. De futures recherches s'imposent pour évaluer l'utilisation clinique du sildénafil pour améliorer le débit sanguin en cas de lésion ischémique de la peau.

Treatment of superficial cutaneous vascular lesions: experience with the long-pulsed 1064 nm Nd:YAG laser.

Recent published studies evaluating the long-pulsed 1064 nm Nd:YAG laser for superficial cutaneous vascular lesions have limited subjects and optimal treatment parameters have not been established. To determine the efficacy and safety of the long-pulsed 1064 nm Nd:YAG laser on superficial cutaneus vascular lesions and analyse retrospectively our experience of a 3-year period are the aims of this study. Over the 3-year period, 255 patients were treated [189 female and 66 male; median age 35 (range 7-65) years; Fitzpatrick skin types II-V]. Twenty-six patients with spider angioma, 130 with facial telangiectasia, and 99 with leg telangiectasia were treated. A long-pulsed 1064 nm Nd:YAG laser was used. A test dose was performed at the initial consultation and thereafter patients were reviewed and treated at 4-week intervals for 5 months. Of those patients who completed treatment and followup, 26/26 (100%) of spider angiomas, 125/130 (97%) of facial telangiectasia, and 80/99 (80,8%) of leg telangiectasia markedly improved or cleared. We suggest that the long pulsed Nd:YAG laser is a safe and effective treatment for common superficial cutaneous vascular lesions. However, it is not the first choise to use to treat superficial vessels on the face where depth is not the concern.

The relationship between insight and clinical features in bipolar disorder.

OBJECTIVE: The aim of this study is to examine the relationship between insight dimensions and clinical features in bipolar disorder. METHOD: One hundred and four inpatients with bipolar disorder( manic or mixed episodes) diagnosed according to DSM-IV criteria participated in the study. Patients were evaluated both during an acute episode and in remission, prior their discharge from the hospital by the Young Mania Rating Scale (YMRS), Montgomery-Asberg Depression Rating Scale (MADRS), Positive and Negative Syndrome Scale (PANSS), The Scale of Unawareness of Mental Disorders (SUMD), and a questionnaire regarding demographic and clinical characteristics. RESULTS: In remission, 57 patients (54.8%) had insight of their illness while 14 (13.5%)did not have insight. Besides %6.7 of patients did not have the Insight into the effects of medication. We also found that 27.9% of patients were unaware of the social consequences of their illness. Patients with psychotic symptoms had a significantly low level of awareness to the effects of their medication as well as the severeness of their manic episode. We found an unawareness of delusion in these patients. In terms of all SUMD items, female patients had significantly poorer insight compared to men. No correlation was found between the number of hospitalizations, the number of episodes or the first episode type and insight dimensions. CONCLUSION: Lack of insight in bipolar disorder is not rare. The assesment of insight addresses different components of the illness and the treatment awareness. The severity of illness, aggressive impulse control difficulties, psychotic symptoms especially the presence of delusions, female sex may be important predictors of impaired insight.

Nitric oxide in flow-through venous flaps and effects of L-arginine and nitro-L-arginine methyl ester (L-NAME) on nitric oxide and flap survival in rabbits.

OBJECT: Venous flaps are relatively recent practices in plastic surgery, and their life mechanisms are not known exactly. Partial necroses frequently occur in these flaps; therefore, their survival should be enhanced. Nitric oxide (NO) is an endogenous compound which has recently been dwelt upon frequently in flap pathophysiology, and its effect on viability in conventional flaps has been demonstrated. However, its role in venous flaps is unknown. The purpose of this study is to determine possible changes in the NO level in venous flaps and to investigate the possible effects of NO synthesis precursor and inhibitor on the venous flap NO level and flap survival. MATERIAL AND METHODS: Thirty white male rabbits of New Zealand type, aged 6 months, were divided into 3 groups as control (n = 10), L-arginine (n = 10), and nitro-L-arginine methyl ester (L-NAME) (n = 10). Blood and tissue samples were taken from one ear of 10 rabbits in the control group for the determination of NO basal levels 2 weeks before flap practice. The 3-x-5-cm flow-through venous flaps, which are sitting on the anterior branch of the central vein, were elevated on each ear of 10 rabbits in all groups. After flaps were sutured to their beds, 2 mL/d saline, 1 g/kg/d L-arginine (NO synthesis precursor), and 50 mg/kg/d L-NAME (NO synthesis inhibitor) were administered intraperitoneally in control, L-arginine, and L-NAME groups, respectively, for 3 days. At the 24th postoperative hour, blood and tissue samples were taken from all animals for biochemical analyses. At day 7, flap survivals were assessed. RESULTS: Mean NO levels in the blood following the flap elevation (129 +/- 76 micromol/mg protein) increased in comparison with basal levels (59 +/- 44 micromol/mg protein) (P < 0.06); however, the tissue level remained unchanged. NO levels in the blood in the L-arginine and L-NAME groups were alike compared with the control group. The tissue NO level in L-NAME group (0.08 +/- 0.03 micromol/mg protein) decreased significantly compared to the control group (0.46 +/- 0.36 micromol/mg protein) (P < 0.001). Mean flap survival in the L-arginine group (95% +/- 6) increased according to the control group (61% +/- 14) (P < 0.001), whereas it did not change in the L-NAME group (55% +/- 13). CONCLUSION: In our model of venous flap, NO level in the blood increased, while it did not change in the tissue; L-arginine significantly enhanced flap viability without affecting NO level. Additionally, L-NAME decreased NO level, but it did not affect flap survival. In light of these findings, NO increases in venous flaps; the change in its level does not affect flap survival, though. However, L-arginine enhances venous flap survival if not by virtue of NO.

A new proposal of classification of zygomatic arch fractures.

PURPOSE: Among facial fractures, zygomatic arch fractures occur rather frequently. Facial fractures have recently been classified in fine detail according to computed tomographic findings. Nevertheless, there exists no classification of the zygomatic arch fracture, which has a physiognomically important place, to provide guidance for treatment. We aimed to make a detailed classification of zygomatic fractures in various shapes, which does not exist in the literature, and to form an algorithm for treatment. PATIENTS AND METHODS: A total of 451 patients with zygomatic arch fractures treated in our clinic from 1987 through 2004 were assessed retrospectively from the treatment viewpoint together with radiological and clinical findings. RESULTS: At the end of this assessment, arch fractures were divided into 2 groups: 1) isolated fractures in which the zygomatic arch alone broke, and 2) combined fractures in which the zygomatic arch broke together with the other facial bones. Isolated fractures were also divided into 2 subgroups as A) 2 fractures in the arch, and B) more than 2. Isolated arch fractures with more than 2 fracture lines were also classified as V-shaped fractures where fragments are partially reduced and those where fragments are displaced. As for combined fractures, they were subgrouped as A) single fracture in the arch, and B) plural. Plural fractures were further classified within their own group, also according to whether fragments were displaced or not. CONCLUSION: In the 2 fractures and V-shaped fracture subgroups of isolated fractures, preservation of fragments in reduced position was satisfactory during the closed reduction and afterwards. As for those with more than 2 fractures of isolated arch fractures, they required open reduction and internal rigid fixation. The same treatment was used in combined zygomatic arch fractures where there were more than one displaced fractures. In addition to classification, we formed an algorithm to guide us in treatment based on our series.