Limited incision nonendoscopic brow lift.

BACKGROUND: The authors compared the nonendoscopic brow lift technique to the popular endoscopic procedure to determine whether it offers a less complex and less expensive but equally effective alternative. METHODS: A retrospective comparison of the senior author's experience with the endoscopic brow lift (100 patients; years 1999 to 2004) and the nonendoscopic brow lift (93 patients; years 2002 to 2005) was conducted. Using a three-incision approach for both procedures (one midline and two temporal), endoscopic visualization was used to assist in the last 2 cm of subperiosteal dissection over the superior orbital rim only in the endoscopic technique. In the nonendoscopic technique, this final dissection was performed without the endoscope, and the expected path of the supraorbital and supratrochlear neurovascular bundles through preoperative marking of their meridians was respected. Effective brow elevation, operative times, size of incisions, complications, and overall patient satisfaction were compared between groups. RESULTS: The authors found no significant difference in average brow elevation between the two brow lift groups (4 mm). However, the nonendoscopic brow lift was completed, on average, 20 minutes faster than the endoscopic brow lift (30 minutes versus 50 minutes) and required a smaller incision than the endoscopic brow lift (2 cm versus 2.5 cm). No nonendoscopic patient experienced permanent complications, but one endoscopic patient developed permanent paresthesias of the forehead secondary to supraorbital/supratrochlear nerve injury. Overall patient satisfaction was equivalent in both groups. CONCLUSIONS: The limited incision nonendoscopic brow lift is a safe and effective alternative to the endoscopic technique. With thorough anatomical knowledge of this region, it offers equivalent brow elevation, shorter operative times, smaller incisions, similarly low complications rates, and patient satisfaction and eliminates the need for costly and cumbersome endoscopic equipment.

Upper lip reconstruction with the alar crescent flap: A new approach.

PURPOSE: The alar crescent advancement flap technique has been widely used for repair of large central defects of the upper lip and base of the nose because of its 1-stage procedural simplicity and good results. Several more complicated and multiple staged procedures that respect either structure or function, often compromising one to achieve the other, have become popular and have recently taken its place. However, these procedures are more complex and in many cases require a staged approach. In this study, we present a series of 33 patients who underwent reconstruction of large upper lip defects utilizing alar crescent flaps between 1992 and 2002. PATIENTS AND METHODS: A series of 20 patients underwent reconstruction of large upper lip defects using alar crescent flaps between 1992 and 2002. Malignant etiologies were responsible for the defect in all patients. Reconstruction was performed as a 1-staged procedure in 19 cases. In 1 patient with a total upper lip defect, bilateral alar crescent flaps were used in conjunction with a cross lip flap that was later divided in a second stage procedure. RESULTS: All patients tolerated the procedure well with no major complications. Minor complications not requiring surgical intervention occurred in 5 patients. During the 12- to 60-month follow-up, all patients were found to be satisfied with the functional result. However, 7 patients underwent minor surgical procedures for esthetic improvement. There was no recurrence of disease in the 20 patients who underwent resection of malignancy. CONCLUSIONS: In these 20 cases, we have shown the utility of the alar crescent flap for varying length partial and full-thickness reconstruction of upper lip defects. This simple and straightforward technique provided good functional and esthetic results. The disadvantage of this procedure is the loss of philtral anatomic detail. Its primary advantage is that it is a single-stage procedure with a relatively low morbidity and patient inconvenience. As a single-stage technique it satisfies concerns over cost containment over more complex and staged procedures while still providing a good functional and cosmetic result. Furthermore, for those same reasons, this procedure is a good first choice in the elderly.

Correction of involutional entropion with suborbicularis septal and lateral canthal tightening.

BACKGROUND: Involutional entropion, or infolding of the margin of the eyelid, is a common eyelid malposition affecting the elderly that can lead to significant morbidity when not corrected. It is notable for both functional and cosmetic sequelae. Numerous surgical techniques have been described to correct this defect; however, because of its multifactorial pathophysiology, no single procedure has been entirely satisfactory. In this study, the authors present a simple and effective surgical procedure that addresses the salient pathophysiology and successfully corrects this defect with minimal morbidity or chance of recurrence. METHODS: Two hundred fifty-three patients (409 eyelids) with involutional entropion who underwent surgical repair from 1995 to 2004 were analyzed. All patients were symptomatic, ranging in age from 61 to 96 years (115 men and 138 women). All patients underwent lateral canthal lysis, suborbicularis and supraorbicularis undermining, canthoplasty, and lateral muscle suspension with septal tightening. RESULTS: All 409 eyelids with symptomatic involutional entropion were successfully corrected. All patients were satisfied with both the functional and cosmetic outcome and experienced a short recovery time. Objective examination revealed a marked improvement in static and dynamic lower eyelid position and alleviation of the herniated lateral orbital fat. There were no complications or entropion recurrences. CONCLUSIONS: Involutional entropion is frequently encountered in the elderly. Ideal treatment addresses horizontal lid laxity, improves vertical support, prevents preseptal orbicularis override, and reinserts the lower lid retractors. With the direct, easily executed and effective surgical procedure presented here, both functional and aesthetic improvements can be obtained. This procedure should be included among the techniques used by every surgeon who treats functional and cosmetic problems in the periocular region.

Nitric oxide modulation of low-density mononuclear cell transendothelial migration.

The blood-endothelial cell interface is a region of significant importance in many physiologic and pathologic processes. Blood-borne macromolecules and cells gain access to the subendothelial space and extravascular tissues by traversing the endothelium. Yet the various factors responsible for modulation of this process remain only partially elucidated. Several agents were found to be involved in this process, including nitric oxide (NO) and vascular endothelial growth factor (VEGF). It is known that under stress conditions (e.g., inflammation), NO can modulate the permeability of endothelial-cell monolayers to low-density mononuclear cells (LDMNCs). However, it is not known if NO can modulate such effects in the absence of inflammatory stimulation. In the present study, we utilized a Transwell chamber model to examine endothelial-cell monolayer permeability to LDMNCs in the absence of inflammatory stimuli. We noted that NO donor and L-arginine increased transendothelial-cell migration, whereas nitric oxide synthase (NOS) inhibition decreased migration. These effects were not significantly abrogated by VEGF antibody, suggesting that they were not VEGF-dependent.