A Randomized, Placebo-Controlled Trial Evaluating the Single and Combined Efficacy of Radiofrequency and Hybrid Fractional Laser for Nonsurgical Aesthetic Genital Procedures in Post-Menopausal Women.

BACKGROUND: The efficacy of interventions that provide long-term relief of genitourinary symptoms of menopause has not been determined. OBJECTIVES: The authors sought to evaluate radiofrequency and hybrid fractional laser (HFL) treatments for menopausal vulvovaginal symptoms. METHODS: Thirty-one postmenopausal women completed all treatments and at least 1 follow-up. Outcomes included the Vulvovaginal Symptom Questionnaire (VSQ), Vaginal Laxity Questionnaire (VLQ), Urogenital Distress Short Form, Incontinence Impact Questionnaire (IIQ), Female Sexual Function Index (FSFI), laxity measurements via a vaginal biometric analyzer probe, and gene expression studies. RESULTS: Mean VSQ score decreased 2.93 (P = 0.0162), 4.07 (P = 0.0035), and 4.78 (P = 0.0089) among placebo, dual, and HFL groups 3 months posttreatment and decreased to 3.3 (P = 0.0215) for dual patients at 6 months. FSFI scores increased in the desire domain for placebo and dual groups and in arousal, lubrication, orgasm, satisfaction, and pain domains for the HFL group 3 and 6 months posttreatment. An increase of 1.14 in VLQ score (P = 0.0294) was noted 3 months and 2.2 (P = 0.002) 6 months following dual treatment. There was also a mean decrease of 15.3 (P = 0.0069) in IIQ score for HFL patients at 3 months. Dual, HFL, and RF treatments resulted in statistically significant decreases in collagen I, elastin, and lysyl oxidase expression. CONCLUSIONS: Several self-reported improvements were noted, particularly among HFL, dual, and placebo groups 3 and 6 months posttreatment. Objective biopsy analysis illustrated decreased gene expression, suggesting that treatments did not stimulate new extracellular matrix production.

A Single-Center Trial to Evaluate the Efficacy and Tolerability of Four Microneedling Treatments on Fine Lines and Wrinkles of Facial and Neck Skin in Subjects With Fitzpatrick Skin Types I-IV: An Objective Assessment Using Noninvasive Devices and 0.33-mm Microbiopsies.

BACKGROUND: Although ablative techniques are the standard of care for the treatment of fine lines and wrinkles, microneedling offers a minimally invasive alternative. OBJECTIVES: The purpose of this study was to assess the efficacy of microneedling on facial and neck fine lines and wrinkles. METHODS: Thirty-five subjects between 44 and 65 years old with Fitzpatrick skin types I to IV received 4 monthly microneedling treatments over the face and neck. Subjects returned 1 and 3 months posttreatment. At every visit, high-resolution ultrasonography and optical coherence tomography were performed, and transepidermal water loss and skin elasticity were measured. Microbiopsies (0.33 mm) were collected pretreatment, before the fourth treatment and 3 months posttreatment. RESULTS: Thirty-two subjects (30 females, 2 males) completed all 7 visits. Facial dermal and epidermal density increased 101.86% and 19.28%, respectively, from baseline at 3 months posttreatment. Facial elasticity increased 28.2% from baseline at 3 months posttreatment. Facial attenuation coefficient increased 15.65% and 17.33% at 1 and 3 months posttreatment, respectively. At study completion, blood flow at a depth of 300 µm decreased 25.8% in the face and 42.3% in the neck. Relative collagen type III and elastin gene expression was statistically higher 3 months posttreatment. However, total elastin protein levels were unchanged from baseline values. Dermal muscle formation was observed in 58% of biopsies extracted 3 months posttreatment compared with 15.3% at baseline. CONCLUSIONS: The results illustrate the effects of microneedling treatments. Noninvasive measurements and biopsy data showed changes in skin architecture and collagen/elastin gene expression, suggesting skin rejuvenation, with new extracellular matrix production and muscle formation.

Managing Alar Flare in Rhinoplasty.

Alar flare is a common feature that contributes to the width of the lower third of the nose. In the right patient, alar flare reduction can improve nasal harmony and facial aesthetic balance; however, it is also difficult to correct if conducted inappropriately or overzealously. The unique anatomy and diverse morphologies of the alar lobule, and the dynamic relationship between flare and changes in tip projection, must be considered. The authors provide guidelines for flare reduction: when it is appropriate and how to tailor the excision pattern to safely and effectively refine nasal width. Alar flare is classified into three types according to alar rim shape on basal view analysis. By designing the excision pattern based on specific flare type, the lower third of the nose is narrowed without creating an operated appearance. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

Preventing Soft-Tissue Triangle Collapse in Modern Rhinoplasty.

The unique anatomy of the soft-tissue triangle makes it prone to notching in primary, secondary, and reconstructive rhinoplasty. Understanding the anatomy of the region is critical to appropriate treatment. This article is meant to further clarify the anatomy of the soft-tissue triangle and to present the senior author's (R.J.R.) approach to proactive correction and prevention of soft-tissue triangle notching through five key steps: (1) precise dissection and incision placement, (2) providing internal support with cartilage grafting if needed, (3) closure of dead space, (4) avoiding undue tension during closure, and (5) providing external support postoperatively.

Cleft care in international adoption.

BACKGROUND: Standards of cleft care abroad differ from those in the United States, particularly in less developed countries, where international adoption rates are high. Children adopted from these countries present to plastic surgeons in the United States at various ages and states of repair. The operative and perioperative needs of these children are poorly understood. This study attempts to characterize the preadoption history, the postadoption course, and surgical outcomes of children adopted with cleft deformities. METHODS: The authors performed a retrospective review of all adopted cleft lip-cleft palate patients presenting to an academic craniofacial referral center and compared outcomes among adopted children who were repaired abroad, adopted children who underwent repair performed by the two senior authors (C.R.D. and S.B.B.), and children born in the United States who underwent repair performed by one of the senior authors (S.B.B.) RESULTS: : Between May of 1993 and August of 2010, 83 adopted children with cleft deformities were evaluated in the authors' craniofacial center. Average age at adoption was 30.5 months (range, 5.0 to 95.0 months). Comparing outcomes among adopted children repaired abroad, adopted children repaired by the senior authors, and children born in the United States who underwent repair in the United States, the authors found no statistically significant differences in lip revision rates, fistula rates, or velopharyngeal insufficiency. CONCLUSIONS: Adopted cleft patients constitute a complex and variable population with high rates of revision and delayed presentation. Internationally adopted children with orofacial clefts fared no better or worse after undergoing primary cleft repair abroad or in the United States.

Endocortical plating of the bandeau during fronto-orbital advancement provides safe and effective osseous stabilization.

BACKGROUND: Ectocortical resorbable plate fixation has become a standard method of fixation during fronto-orbital advancement (FOA) in young children. Plate hydrolysis occurs slowly and can cause visible prominences, sterile abscesses, and osseous depressions that can persist after complete resorption. Although endocortical placement avoids contour issues, the safety and effectiveness of this technique are undocumented. METHODS: A review of our prospectively collected craniofacial database was performed. All patients undergoing FOA by a single craniofacial team at a single institution from 1997 to 2011 were examined. Inclusion criteria were as follows: (1) unicoronal, bicoronal, or metopic synostosis; (2) resorbable endocortical fixation of the bandeau; and (3) follow-up for 1 year or longer. Evaluation included patient demographic data, postoperative clinical course, and computed tomography imaging when available. RESULTS: Seventy-three patients met the inclusion criteria. Fusion involved the unicoronal (n = 26), bicoronal (n = 19), and metopic (n = 28) sutures. Mean age at operation was 8.3 months (range, 2.7-35.5 mo), and follow-up was 4.5 years (range, 1.0-9.9 y). No endocortical or ectocortical sterile abscesses were documented in our series. Postoperative complications included hematoma (n = 2), infection (n = 2), wound breakdown (n = 3), cerebral contusion (n = 2), and cerebrospinal fluid leak (n = 1); none of these issues were related to endocortical absorbable fixation. Fifty-eight patients (80%) were categorized as Whitaker classification I/II; and 15 patients (20%), Whitaker classification III/IV. Postoperative computed tomography (mean follow-up, 4.6 y) was obtained in 34 patients (47%). All plates were completely resorbed, and there were no bone or soft tissue irregularities in the region where the plates were placed. CONCLUSIONS: Endocortical resorbable fixation is a safe and effective method of osseous stabilization during FOA for craniosynostosis in young children.

Analysis of routine intensive care unit admission following fronto-orbital advancement for craniosynostosis.

BACKGROUND: Intensive care unit admission following fronto-orbital advancement for craniosynostosis is routine at most institutions. The authors determined the frequency of postoperative events requiring intensive care unit care that justify this practice. METHODS: Infants with craniosynostosis who underwent primary fronto-orbital advancement at a single institution from 1997 to 2011 were included. Patient demographics, operative factors, and hemodynamic outcomes were recorded. Adverse postoperative events/interventions were graded as none (group I); minor (group II), easily managed on a surgical floor; or major (group III), requiring intensive care unit care. RESULTS: One hundred seven infants were included. Average length of hospitalization was 3.7 ± 1.6 days, with 1.3 ± 1.0 days in the intensive care unit and 2.4 ± 1.0 days on the floor. Seventy-eight patients (72.9 percent) were categorized into group I, 24 (22.4 percent) into group II, and five (4.7 percent) into group III. Major events/interventions included prolonged intubation (n = 2), reintubation (n = 2), and continuous positive airway pressure support (n = 1). Preexisting end-organ dysfunction was significantly associated with group III patients, who also had significantly higher intraoperative blood loss requiring greater resuscitation. Mean daily charges were $7652.33 (10.9 percent of total charges) for intensive care unit care and $2470.62 (6.9 percent of total charges) for floor care. CONCLUSIONS: In this study, 4.7 percent of patients had event/interventions requiring intensive care unit care after fronto-orbital advancement. Predictors included preexisting end-organ dysfunction and higher intraoperative blood loss requiring greater resuscitation. Financial savings from selective postoperative intensive care unit admission may not outweigh the potential cost of an emergent event on the surgical floor.

Multiple pregnancies following deep inferior epigastric perforator (DIEP) flap breast reconstruction.

Pregnancy following abdominal flap-based breast reconstruction may cause stress to the abdominal wall. These changes may result in weakness and hernia or bulge. We present two patients who previously underwent unilateral deep inferior epigastric perforator (DIEP) flap breast reconstruction and became pregnant twice. Both patients maintained abdominal contour without bulges or hernias. Subjectively, patients reported minor changes to abdominal strength. Therefore, these two patients had minimal abdominal morbidity following pregnancy after unilateral DIEP flap reconstruction.