Cosmetic Standpoint Research Articles

Body Composition in Chronic Liver Disease.

Body composition has recently been attracting people's attention, not only from a cosmetic standpoint but also from the perspective of health and longevity. The body is classified into three components: fat, bone, and lean soft tissue, and it is common to see an increase in body fat and a decrease in total body muscle mass with aging. Aging-related loss of muscle mass and muscle function is referred to as primary sarcopenia, while sarcopenia caused by disease-specific conditions is referred to as secondary sarcopenia. On the other hand, the liver-muscle axis has been attracting attention in recent years, and it has become clear that the liver and the skeletal muscles interact with each other. In particular, patients with cirrhosis are prone to secondary sarcopenia due to protein-energy malnutrition, which is a characteristic pathophysiology of the disease, suggesting the importance of the organ-organ network. In this review, we would like to outline the latest findings in this field, with a focus on body composition in liver diseases such as liver cirrhosis, fatty liver disease, alcoholic liver disease, and hepatocellular carcinoma.

Enchanting smile with laminate veneers (Contact lens of teeth) – A case report

From a purely cosmetic standpoint, the value of the appearance of one's teeth has taken on greater importance in today’s society. Various multiple options are available to serve the problem arising in esthetic zone. Porcelain laminate veneers are considered as most conventional and esthetic restoration that can be used to augment esthetics. The use of laminate veneers has been shown a feasible treatment option in the anterior esthetic zone. This case report discusses a patient having spacing in anterior region with discolored and old composite restorations in interdental region. The patient was then treated with porcelain laminate veneers in the maxillary arch for the same. Keywords: conservative preparation, Esthetic, Etched enamel, laminate veneer, Porcelain

Evaluation of Neurotized Hypothenar Free Perforator Flaps Used for Fingertip Reconstruction

In reconstruction of digital amputations of the upper extremity, composite tissue alternatives with similar features are limited for finger tip reconstruction. Among these alternatives, free perforator flaps elevated from the hypothenar region (HFPFs) are defined, but reluctancy goes on for utilization of these flaps.In this study, we aimed to highlight the sensory results of HFPFs when a neural repair is incorporated to the flap and also to justify their usage by presenting functional and aesthetic outcomes of the reconstructions performed with HFPFs. This clinical study was conducted from June 2015 to June 2017. Twelve patients with acute finger tip amputations were examined. Distal amputation levels were subgrouped according to Ishikawa classification. Patient demographics and amputation etiology were listed. All fingertip defects were reconstructed with a neurotized HFPF. All perforator anastomoses were performed in an end-to-end fashion. During follow-up, 2-point discrimination and dynamometric test were conducted. In addition, the Michigan Hand Outcomes Questionnaire was carried out. Evaluation of the results from a cosmetic standpoint was also conducted, with 4 blinded, independent surgeons using the visual analog scale. Of 12 digital amputations reconstructed with neurotized HFPFs, 10 were totally viable during follow-up, whereas partial loss was observed in 2 flaps. The mean age was 38.8 ± 11.8 years. Most of the amputations were classified as Ishikawa subgroup 2 (50%). The mean dynamic 2-point discrimination was 3.2 ± 0.11 mm and slightly greater compared with contralateral digit (P = 0.003). Also minor decreases were measured in forced grip and pulp-to-pulp grip strengths (P = 0.003). Overall satisfaction was 92.7% in Michigan Hand Outcomes Questionnaire. Average visual analog scale score was 7.25 out of 10. Hypothenar free perforator flaps, with incorporation of neural repair, give promising results for reconstruction of the fingertip. In addition to superior sensorial outcomes, HFPFs yield satisfying results from aesthetic and functional perspectives.

The “Sea” should not be operated on in scar revision for “Island-Like” scars

Scars developing on body surfaces not only restrict body movement, but are also problematic from a cosmetic standpoint. Hence, revision is conducted by removing the scar and re-suturing the resultant defects. In performing scar revision, care should be taken to prevent the re-sutured wounds from developing hypertrophy again. Scars often present a pattern where hard, red parts are separated by soft parts in between. As the hard and soft parts may be analogized as islands and seas respectively, we call this the “Island-Like” scar.Two strategies can be taken to treat scars of this type. The first is to remove the entire scar—including both hard and soft parts; the second is to remove only the hard parts and leave the soft parts untouched. The authors conducted a biomechanical study using finite element analyses and found that as a body moves, greater stresses occur in the peri-wound regions with the first strategy than with the second strategy. A wound’s likelihood to develop hypertrophy increases as the stresses working on it increase. Hence, it is hypothesized that the second strategy carries less risk of the operated wounds developing re-hypertrophy than the first strategy. Based on this logic, in performing scar revision for scars consisting of hard and soft parts, it is recommended only to remove only hard parts and not to operate on soft parts in between.

Application of Mini-abdominoplasty after Conservative Excision of Extensive Cesarean Scar Endometriosis

Endometriosis is defined as the presence of functioning endometrial tissue outside the uterine cavity, and the standard treatment is extensive surgical excision. Cesarean scar endometriosis is a type of cutaneous endometriosis arising on or near a Cesarean section scar. A 44-year-old woman presented with a 9×6 cm sized dark-brown, stony-hard, irregular, lower abdominal mass of four years duration. The patient had a history of two Cesarean deliveries, 14 and 16 years ago. Suspecting endometriosis, we excised the tumor conservatively rather than extensively to prevent incisional hernia considering the benign nature of the tumor and the low possibility of recurrence because the patient's age was near menopause, along with simultaneous bilateral salpingo-oophorectomy that was performed in this case. On reconstruction, mini-abdominoplasty was adopted to avoid possible wound complications and cosmetic deformities. The patient was satisfied with the cosmetic results, and neither recurrence nor functional problems occurred during the 1-year follow-up period. Plastic surgeons should keep in mind the possibility of cutaneous endometriosis in an abdominal mass of a female of reproductive age with a previous history of pelvic or intra-abdominal surgery. An optimal result from oncological, functional, and cosmetic standpoints can be achieved with conservative excision followed by mini-abdominoplasty of extensive Cesarean scar endometriosis.

Implantation Site of a Pacemaker Generator

Background: We reported that as for the placement parts of generator, to place the generator at left axillary fossa with axillary vein puncture was thought to be useful from the mental, functional and cosmetic standpoint. But objective assessment was different. Purpose: The purpose of this study is to make comparative study of mental, functional and cosmetic situation by the generator planting part of pacemaker. Method and Patients: The questioner investigation concerning impact shock from out side of body, electromagnetic wave interference, cosmetic condition and satisfaction rating to present pacemaker planting part was performed to 10 patients at left axillary fossa (F) and 119 patients at the anterior chest (A). Result: 1) There were 66% worry in A for the impact shock to pacemaker planting part from the outside, and 90% in F had the sense of security. 2) 42.3% thought pacemaker to be remarkable and 57.1% was not satisfied in A but 90% was satisfied in F with the placement parts of generator. Conclusion: Though A was 119 and F was 10, and comparative study is difficult. F is giving a good effect as a tendency in the function, the mental and cosmetic aspect compared with A. It is scheduled that the more cases are examined in the future.

PPARγ Agonists, Modulation of Ion Transporters, and Fluid Retention

Peroxisome proliferator-activated receptor γ (PPARγ) agonists, also known as thiazolidinediones (TZDs), are used as insulin-sensitizing agents to treat type 2 diabetes. Examples include pioglitazone (Actos®), rosiglitazone (Avandia®), and others such as troglitazone, farglitazar (GI262570), and GW7845. Side effects of TZD therapy include fluid retention and peripheral edema. The weight gain from fluid retention is undesirable from a cosmetic standpoint but more seriously can adversely affect comorbidity in the diabetic state.1 Reported effects of PPARγ agonists on cardiovascular function are mixed. One recent high-profile study found that rosiglitazone increases the risk of death from cardiovascular disease,2 although other studies observe beneficial effects of pioglitazone on major cardiovascular events in humans3 and protection against ischemia–reperfusion injury and reduction of myocardial infarct size in animal models.4 Regardless of the risk–benefit relationships of PPARγ agonist therapy, it is clear that fluid retention exacerbates compromised cardiac function and lessens patient compliance with drug treatment. Unfortunately, PPARγ-agonist-induced fluid retention is refractory to most first-line diuretic therapies.5 The nature of PPARγ-agonist-induced fluid retention suggests an integrated physiologic response that includes a primary effect on renal regulation of salt and water balance. PPARγ is expressed in the collecting duct, suggesting that ligands for this receptor modulate salt and water homeostasis through ion transport systems in this nephron segment. The epithelial Na+ channel (ENaC) expressed in collecting duct principal cells is regulated by steroid (aldosterone) and peptide hormones (insulin, IGF-1, and vasopressin) and represents a key control point for the modulation of salt reabsorption and, consequently, BP. It is logical, therefore, to postulate that ENaC is a likely target of a PPARγ agonist effect. Unfortunately, studies performed to substantiate this relationship are contradictory, and it is difficult to establish a consensus as to potential mechanisms. Two different collecting-duct-specific PPARγ null mouse models showed …

Lower Island Trapezius Flap Reconstruction of Lateral Skull Base Defects

Introduction: Reconstruction of soft tissue defects after temporal bone resection can vary from simple overclosure of the external auditory canal to complex flap closure. Large defects typically require reconstruction with locoregional pedicled myocutaneous or distant free myocutanaeous flaps. While microvascular free tissue transfer is an excellent option from a functional and cosmetic standpoint, patients often have significant comorbidities that increase perioperative risk during extended procedures. The pedicled lower island trapezius flap provides a reliable, cosmetically acceptable coverage in this patient population.

Combined use of triple cartilage grafts in secondary rhinoplasty

Secondary rhinoplasty on a patient with a middle vault deformity is one of the most challenging procedures for a plastic surgeon. In order to achieve proper nasal aesthetics and airway function, a surgeon most commonly chooses to engraft the nose with a spreader, dorsal onlay, or columellar graft. This paper examines the aforementioned techniques in the management of 25 patients who presented with a severe middle nasal vault deformity. During the last 5 years, 25 patients received secondary rhinoplasty using triple cartilage grafts to repair severe middle vault deformities. Patients were then questioned at least 3 months postoperatively about both airway problems and cosmetic satisfaction. All the 25 patients indicated cosmetic satisfaction with 23 of the patients also achieving complete nasal airway function. Only two patients persisted to have an insufficient nasal airway. An endonasal examination revealed a slight nasal synechiae in one patient, while no anatomic problem was identified in the second patient. From a cosmetic standpoint, a straight dorsum with improved dorsal aesthetic lines and nasal profile, along with nasal-facial balance were achieved. When indicated, secondary rhinoplasty to repair a middle vault deformity using the combination of spreader, dorsal onlay, and columellar grafts to augment the nose has shown to have both functional and cosmetic benefits.

Minimizing impairment in laborers with finger losses distal to the proximal interphalangeal joint by second toe transfer.

Traditionally, toe-to-hand transfers have been reserved for thumb amputations or for use after severe mutilating injuries. The authors report their experience with the use of second toe-for-finger amputations with preserved or reconstructible proximal interphalangeal joints in manual workers. The aim of the procedure was to reduce impairment and to upgrade the hand from a functional and cosmetic standpoint. Fifteen second-toe wrap-around or variations were carried out on 11 adults (18 to 41 years old). Four patients with two or more finger amputations received two sequential second toes; four patients with two finger amputations received one toe; and each of three patients with single-digit amputation received a single toe. All but one amputation were performed less than 3 weeks after the accident. All toes survived. Range of motion at the native proximal interphalangeal joint was more than 90 percent in all patients but one; however, it was minimal at the transplanted joints. Patient satisfaction was high from a cosmetic and functional standpoint. Ten of 11 laborers resumed their previous activity. On the basis of this experience, a classification with aesthetic and functional implications is proposed to help in the decision-making process when dealing with multidigital injuries. It is concluded that second-toe transfer is an excellent choice for finger amputation distal to the proximal interphalangeal joint in laborers. Its prime indication is for amputations of two fingers where at least one toe should be transferred, as required, to achieve an "acceptable hand" (three-fingered hand). Early transfer allows salvage of critical structures from the damaged finger, such as joints, tendons, and bone, that otherwise would be lost. Early transplantation is highly recommended.

Surgical creation of a Cupid's bow using W-plasty in patients after cleft lip surgery

The three-dimensional contour of the Cupid's bow is extremely important from a cosmetic standpoint, and many patients with bilateral or unilateral cleft lip require revision or reconstruction of the Cupid's bow. A number of surgical techniques have been reported for creating the Cupid's bow, among which the methods of Gillies and Onizuka are the most widely known. In the methods of Gillies and Onizuka, the dog-ear can result in excessive volume in the vermilion notch, raising the trough in the Cupid's bow and leading to regression during the post-surgical period. We have improved upon these techniques using the W-plasty and have obtained satisfactory results that preserve the white skin roll. In our method, the left and right prominence of the Cupid's bow is created through an incision of the white lip, while the central trough is created through a curvilinear incision of the vermilion mucosa. At the two sites of the white lip tissue and the curvilinear incision of the central vermilion tissue, the white skin roll is preserved as much as possible. In patients where the Gillies method had been used, the Cupid's bow tended to be flattened gradually after surgery. We report on the details of our method and the case reports using the technique.

Étude des répercussions psychologiques de deux modalités de traitement chez des adolescents atteints de maladie de Crohn

No study has yet compared the respective psychological impact of corticotherapy and enteral nutrition in the treatment of Crohn’s disease, and especially, the psychological problems linked to the wearing of a nasogastric tube 24 hours a day. The goal of this study was to collect comparative information regarding the real-life experience and the feeling of these two treatments. Patients and methods. – From September 1997 to February 1998 at the clinic of inflammatory bowel diseases of the hospital Necker–Enfants malades, 51 patients aged 12 to 18 (average 15) participated in this study. Thirty 〚15 on corticotherapy (CT) ; 15 on enteral nutrition (EN)〛 answered a questionnaire inspired by a similar Canadian questionnaire (Inflammatory Bowel Disease Questionnaire), and 21 passed Spielberger’s anxiety tests, Beck’s depression tests and a psychological interview. Results. – Treatment : According to the 30 questionnaires the appreciation of the therapeutic results was similar in the two treatments, the majority of patients respected their treatment (only one patient on EN ate secretly and two on CT stopped their corticotherapy). Of the 15 EN questionnaires : nine out of 15 patients responded well to the suspension of oral feeding, two were hungry, nine experienced cravings and ten avoided meals during their treatment. From a cosmetic point of view, six/14 (43 %) found it difficult putting up with the nasogastric tube 24 hours a day, and eight/15 (53 %) on CT found the facial swelling difficult to bear. According to the 21 psychological interviews, eight patients deemed EN efficient, while only four felt the same about CT. Of the 11 EN psychological interview, no adolescent patients were hungry, eight had cravings and nine avoided meals during their treatment, seven mentioned they felt different and seven described how EN had upset the family’s routine. Nine (82 %) talked about how difficult it was to put up with the nasogastric tube 24 hours a day from a cosmetic standpoint while eight/ten (80 %) on CT found the facial swelling difficult to live with. Seven complained that they had been the victims of verbal abuse. Quality of life : According to the 30 questionnaires, eight/15 patients on EN missed an average of 15 days of school against five/15 patients on CT, ten patients judged that EN restricted their daily lives and nine mentioned the daily difficulties to wear a tube 24 hours a day. Tests : Spielberger’s test of anxiety revealed that on average, the 11 patients on EN who were interviewed suffered the first level of anxiety, while the ten patients on CT felt the second level. As for the Beck's depression test, the 11 patients on NE suffered the first level of depression on average, while those on CT were subject to the second level. Conclusion. – This study demonstrated that EN was perceived as being more disruptive to patients daily lives than CT and defines the difficulties linked to the suspension of oral feeding and the wearing of a naso-gastric tube. The study also describes the difficulties involved in coping with the side effects of CT, one example being facial swelling which can be as unpleasant from a cosmetic point of view as wearing of a naso-gastric tube.

Management of Congenital Venous Malformations of the Vulva

In Brief OBJECTIVE To discuss the differential diagnosis and the management of venous malformations of the vulva. METHODS Five symptomatic patients were treated. The degree of pain and discomfort was self-assessed by using a horizontal visual analog scale before and after treatment. Preoperative evaluation included Doppler ultrasound scanning in all patients and magnetic resonance imaging (MRI) in one. All patients had direct-injection venography and sclerotherapy during the same session. Ethanol was used in two cases and polidocanol in three. Patients were followed-up by means of Doppler ultrasound scanning and office visits. RESULTS All patients experienced marked swelling after the injection, and one developed cutaneous necrosis that healed within 2 weeks. Transient hemoglobinuria was observed in two cases. No early or late major complications occurred. At a mean follow-up of 23 months (range 5–43), all patients experienced complete relief from symptoms and currently have normal vulvar sensation. Four patients had complete ablation of the treated lesion. In one patient the procedure resulted in a significant, albeit incomplete, occlusion of the lesion, and no further treatment was deemed necessary. From a cosmetic standpoint, both patients and physicians considered the results successful. CONCLUSION Vulvar venous malformations should be distinguished from vulvar varicosities, hematomas, soft-tissue neoplasms, and other vascular anomalies. Doppler ultrasound, MRI, and direct-injection venography are the most accurate diagnostic modalities. Sclerotherapy can successfully treat this condition. The procedure should be monitored with an imaging modality, preferably direct-injection venography with digital subtraction serial imaging. Vulvar venous malformations are rare congenital lesions that, when symptomatic, can be successfully treated with sclerotherapy.

Part II: Delayed reconstruction of continuity defects of the mandible after tumor surgery

Reconstruction of the mandible is particularly challenging because of its complexity and unique characteristics. The mandible is a unique bone for many reasons. It has significant impact on facial harmony from a cosmetic standpoint and is extremely diverse in function. The mandible not only bears half of the dentition, but it also is responsible for mastication, it contributes to speech and swallowing, and it supports the tongue base to maintain a patent airway. During function, the arch form expands or contracts, varying with the degree of opening and the influence of the muscles of mastication.

Management of congenital venous malformations of the vulva

OBJECTIVE: To discuss the differential diagnosis and the management of venous malformations of the vulva. METHODS: Five symptomatic patients were treated. The degree of pain and discomfort was self-assessed by using a horizontal visual analog scale before and after treatment. Preoperative evaluation included Doppler ultrasound scanning in all patients and magnetic resonance imaging (MRI) in one. All patients had direct-injection venography and sclerotherapy during the same session. Ethanol was used in two cases and polidocanol in three. Patients were followed-up by means of Doppler ultrasound scanning and office visits. RESULTS: All patients experienced marked swelling after the injection, and one developed cutaneous necrosis that healed within 2 weeks. Transient hemoglobinuria was observed in two cases. No early or late major complications occurred. At a mean follow-up of 23 months (range 5–43), all patients experienced complete relief from symptoms and currently have normal vulvar sensation. Four patients had complete ablation of the treated lesion. In one patient the procedure resulted in a significant, albeit incomplete, occlusion of the lesion, and no further treatment was deemed necessary. From a cosmetic standpoint, both patients and physicians considered the results successful. CONCLUSION: Vulvar venous malformations should be distinguished from vulvar varicosities, hematomas, soft-tissue neoplasms, and other vascular anomalies. Doppler ultrasound, MRI, and direct-injection venography are the most accurate diagnostic modalities. Sclerotherapy can successfully treat this condition. The procedure should be monitored with an imaging modality, preferably direct-injection venography with digital subtraction serial imaging.

Microvascular Reconstruction of the Head and Neck After Tumor Ablation

Microvascular reconstruction of the head and neck in cancer patients after surgical ablation has significantly improved the quality of life of these patients from both a functional and cosmetic standpoint. Successful management and reconstruction of these patients requires a well-coordinated team approach. Operating room times and hospital stays have significantly decreased with coordination and experience of the team members.

The free fibula bone graft for salvaging failed mandibular reconstructions

Drs Anthony, Foster, and Pogrel present useful information for the surgeon faced with the dilemma of salvaging failed attempts at mandibular reconstruction. While tackling large soft and hard tissue defects, the reconstructions performed by these authors were reportedly uniformly successful from anastomotic, functional, and cosmetic standpoints, although only seven cases constitute the study. This notwithstanding, the authors adequately address the purpose of their study, which was to determine the efficacy of the vascularized free fibula bone graft for mandibular salvage reconstruction. The surgical histories of the patients requiring these bone grafts is quite intriguing in several instances, and the reader is quickly reminded of the great controversies associated with the management of such patients when reviewing the discussion section of the article. Of particular interest is that four of the seven patients in the study had received radiation therapy, and indeed, three patients were reconstructed because of osteoradionecrosis. Interestingly, none of these patients received hyperbaric oxygen therapy (HBO) at any time during their treatment, either as part of the original or salvage reconstmctions.

Reconstructive surgery in the head-neck area with regional and free tissue transfer

Operative treatment of head and neck cancer requires radical resection of the tumor with not only severe impairment of important functions like swallowing speech, and respiration but also aesthetic mutilation because of the exposed character of the head and neck region. Therefore the rehabilitation from a functional and cosmetic standpoint is an essential goal of treatment in addition to control of the malignant disease. Fortunately regional plastic surgery offers a variety of options for reconstruction of the defects to receive a solution tailored to each individual patient. Between the years 1986 and 1996, 107 patients with advanced head and neck cancer were treated surgically by radical resection of the tumor and plastic reconstruction. In this study we made a retrospective analysis of the functional and aesthetic outcome of the techniques of reconstructive surgery we used for rehabilitation. The sex ratio was 79 males to 28 females. Average age was 59.4 years (ranging from 39 to 78 years). Most of the patients suffered from squamous cell carcinoma of the upper digestive tract (97 cases). The others included an adenocarcinoma of the paranasal sinuses (three cases), adenoid cystic cancer of the palate (two cases), squamous cell carcinoma of the temporal bone (two cases), two deep infiltrating basaliomas in the area of the nose and forehead and one chondrosarcoma of the neck. Our oncological concept includes a radical resection of the tumor and a onestep reconstruction of the defect, if the patient's general condition enables this approach. The surgical techniques we used include the approved pedicled myocutaneous flaps like the pectoralis major flap, latissimus dorsi flap (which can be also applied as a free microvascular tissue graft), temporalis muscle flap, and the free radial forearm flap. In previous years, the pedicled myocutaneous pectoralis-major- and latissimus-dorsi-flaps were used for reconstruction (n = 67), but the arc of rotation and the huge bulk of the graft are limiting factors for the indication of these techniques. The free forearm flap has increasingly been used to provide an excellent closure of large pharyngeal defects (n = 16), whereas the temporalis flap is useful for restoration after limited resection of the palate (n = 18). Beside these rather invasive procedures, aesthetic rehabilitation may be achieved with bone-anchored epithesis especially after exenteration of the orbit and ablation of the external ear in case of elderly patients with multiple morbidities (n = 5). In most cases, sufficient rehabilitation from the anatomical and functional point of view was possible even after large tumor resections. A main problem can be longstanding aspiration after resection of large areas of the pharyngeal mucosa (n = 8). Complications included eight cases of necrosis of the flaps and seven patients who developed significant seromas at the donor site. The potential of modern regional reconstructive surgery enables the surgeon to achieve anatomically and functionally rehabilitation in a one-step procedure in most cases, even after extended resection for head and neck cancer. One should be aware of the fact that these techniques do not offer a significant improvement of prognosis. As such, the aggressiveness of surgical therapy should remain in reasonable relation to the prognosis of the malignant disease.

Skin Approximation Using Nd:YAG Laser in Head and Neck Surgery

Laser is useful for surgery to cut, coagulate, vaporize and weld the tissue. Recently, low power laser was utilized for the treatment of ulcer, pain and vascular anastomosis. We applied low power Nd: YAG laser irradiation for skin approximation. An experimental study was carried out by using the Nd: YAG laser in approximating the surgically cut skin wound of guinea pigs. Healing of the wound was observed on post operative days of 3, 7 and 21, respectively. Laser approximation for the incised skin showed less scaring and faster healing than conventional suture technique. This laser technique will be beneficial as one of the new procedures of skin suture in clinical practice. The results were discussed from either technical or cosmetic standpoint.

低出力Ｎｄ：ＹＡＧレーザーによる皮膚接合

Laser is useful for surgery to cut, coagulate, vaporize and weld the tissue. Recently, low power laser was utilized for the treatment of ulcer, pain and vascular anastomosis. We applied low power Nd: YAG laser irradiation for skin approximation. An experimental study was carried out by using the Nd: YAG laser in approximating the surgically cut skin wound of guinea pigs. Healing of the wound was observed on post operative days of 3, 7 and 21, respectively. Laser approximation for the incised skin showed less scaring and faster healing than conventional suture technique. This laser technique will be beneficial as one of the new procedures of skin suture in clinical practice. The results were discussed from either technical or cosmetic standpoint.