Follow-up Photographs Research Articles

Measured Gain in Projection With the Extended Columellar Strut-Tip Graft in Endonasal Rhinoplasty

The extended columellar strut-tip graft was designed to improve nasal tip projection and tip definition in patients undergoing rhinoplasty. To determine whether the extended columellar tip graft leads to a true and measurable increase in nasal tip projection or simply gives the illusion of an increase in projection. Retrospective case review. The mean time of follow-up photographs was 32 months after surgery (range, 8 months to 10 years). The study population comprised 15 patients who underwent primary or revision rhinoplasty during the last 10 years. Primary or revision rhinoplasty. The outcome measure was the long-term gain in nasal tip projection. Preoperative and postoperative images were cropped and sized equally for accurate comparison. All measurements were made from the alar-facial crease to the tip defining point. In all 15 patients, an increase in tip projection was obtained. The mean increase in projection was 19% compared with the preoperative projection. After applying a paired t test for analysis, there was a statistically significant increase in nasal projection (P < .05). The extended columellar strut-tip graft effectively corrected poor nasal tip projection. The effect is maintained years later. The extended columellar strut-tip graft is an excellent choice in endonasal rhinoplasty to improve poor tip projection and definition. 4.

Abdominoplasty Revision Using Tissue Expansion

Postoperative revision after abdominoplasty may be necessary at times to improve contour, remove asymmetries, revise the umbilicus, or improve the scar. This report describes the case of an abdominoplasty performed outside the United States that resulted in an inappropriately high and unattractive scar with an elevated pubic hairline. The patient presented to our clinic 2 years after her initial surgery, and a scar-lowering procedure was performed with the assistance of tissue expansion. The reconstructive effort was staged over a period of 4 months, with an initial procedure to repair several hernias, bury the umbilicus, and place a tissue expander. Over several months, 3.5 L of expansion was performed. During a subsequent surgery, the tissue expander was removed, and the scar was successfully lowered and improved. The healing was uneventful, and the patient was satisfied with the outcome. The final result is exhibited in 1-month follow-up photographs. 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 .

Refreshing Labioplasty Techniques for Plastic Surgeons

Level of Evidence V This journal requires that authorsassign a level of evidence to each article. For a fulldescription of these Evidence-Based Medicine ratings,please refer to the Table of Contents or the onlineInstructions to Authors www.springer.com/00266.We comment on the review of labioplasty by Drs. Tri-ana and Robeldo [1] The authors studied 74 patients andreviewed them during an average follow-up period of 6months according to a prescribed follow-up protocol ofseven postoperative visits.Although we have not been informed how many of theirpatients returned for follow-up, their experience seems tobe at odds with ours because less than 5 % of our labio-plasty patients keep their second postoperative follow-upappointment. We wonder whether the authors have anexplanation for why satisfied patients would return seventimes for a follow-up evaluation and whether the authorsenjoy a special cultural advantage.Also, the authors state that their patients ranged in agefrom 23 to 47 years and that two of their photographedpatients were ages 52 and 58 years, respectively. Weassume this was an error. Finally we commend the authorsfor their accumulated experience and their excellent pho-tographic follow-up evaluation.Reference

Prospective Multicenter Clinical Trial of a Minimally Invasive Temperature-Controlled Bipolar Fractional Radiofrequency System for Rhytid and Laxity Treatment

A minimally invasive fractional bipolar radiofrequency (FRF) was developed. To evaluate safety and efficacy of FRF in reducing face and neck rhytides and laxity. This prospective, open-label, multicenter clinical trial enrolled 100 subjects with mild to severe facial and neck rhytides and laxity at seven centers in a per-protocol analysis. One single-pass FRF treatment was administered through five 32g-needle electrode pairs at a preselected real-time fixed temperature of 62 to 78°C, energy duration for 3 to 5seconds, and impedance restrictions of 200 to 3,000Ohms, ensuring intradermal delivery. Five blinded dermatologists and plastic surgeons graded randomized standardized baseline and follow-up photographs of 53 and 42 subjects at 3- and 6-month follow-up intervals, respectively, using the Fitzpatrick wrinkle and Alexiades-Armenakas laxity scales. Subject assessments and adverse events were recorded in 100 subjects. Blinded evaluations revealed correct pre- and post-treatment identification in 100% of scored cases, mean improvement of 25.6% on the Fitzpatrick Wrinkle Scale and 24.1% on the Alexiades-Armenakas laxity scale at 6months, and 100% response rate for rhytides and 95% for laxity. Subgroup analysis revealed maximal rhytid reduction in the mean target temperature of 66.7, energy duration of 4.2seconds, and volume of denatured collagen ofmm(3) denatured collagen group. Adverse events included transient erythema, edema, and ecchymoses, resolving within 1 to 5days, and two incidents of temporary pinpoint depressions. More than 90% of subjects were satisfied or very satisfied. Real-time temperature-controlled FRF is a highly reproducible, safe, effective nonsurgical treatment of face and neck rhytides and laxity and provides important insights into neocollagenesis, neoelastogenesis, and clinical outcomes.

Non-instrumented correction of cervicothoracic kyphosis in ankylosing spondylitis: a critical analysis on the results of open-wedge osteotomy C7-T1 with gradual Halo-Thoracic-Cast based correction

With progression of cervicothoracic kyphosis (CTK), ankylosing spondylitis (AS) patients suffer functional disability. Surgical correction still poses neurologic risks, while evidence of an ideal technique preventing its complications is weak. We report our results with non-instrumented correction in perspective of a review of literature, serving as an important historical control. Database review identified 18 AS patients with CTK correction. After application of a Halo-Thoracic-Cast (HTC) patients underwent posterior non-instrumented open-wedge osteotomy at C7/T1 and osteotomy closure by threaded HTC-rod adjustments. Postoperative gradual HTC correction was continued for 2-4 weeks. Patients were invited for follow-up and medical charts were reviewed for demographics, surgical details, complications and outcomes. The patients' preoperative, postoperative, before HTC removal and follow-up photographs were analyzed for the Chin-Brow-Vertical-Angle (CBVA), radiographs for the CTK angle. Patients' age was 50 ± 11 years, follow-up was 37 ± 47 months and CBVA correction was 25° ± 9° (p < 0.000001). The final radiographic correction at follow-up was 20° ± 11° (p = 0.00002). At the latest follow-up, three patients judged their outcome as excellent, nine good, three moderate and one poor. Upon invitation, seven patients appeared with follow-up averaging 87 months. Neck-pain disability index was 8 ± 14 %. Two patients died, three were lost, one had revision elsewhere and five just had a routine follow-up. Six patients sustained a minor and ten a major complication. Revisions were indicated in five patients including infection, C8-radiculopathy and neurologic events by translation at the osteotomy. A total of 44 % of patients showed translation at the osteotomy indicating acute surgery with instrumentation twice after osteotomy closure, three patients had a revision posterior decompression and instrumented fusion for sequels related to translation. With the non-instrumented HTC-based technique, average CBVA correction of 25° was achieved and all patients were ambulatory at follow-up. However, regarding translation at the osteotomy, loss of correction, morbidity of the HTC and lack of control at the osteotomy instrumentation-based correction and instrumented fusion seem to be preferable.

Reflections on my first year as Oral Pathology Section Editor: “the good, the less than ideal, and the downright ugly”

Reflections on my first year as Oral Pathology Section Editor: “the good, the less than ideal, and the downright ugly”

Re: End-of-Skin Grafts in Syndactyly Release: Description of a New Flap for Web Space Resurfacing and Primary Closure of Finger Defects

Sir, I read with great interest the article “End-of-skin grafts in syndactyly release; description of a new flap for web space resurfacing and primary closure of finger defects” by Sharma et al. published in Hand in 2009 [7]. The method of using an islanded dorsal flap without additional skin grafts for syndactyly release was first described by Sherif et al. in 1998 [8], being subsequently reported and modified by many authors [1, 3, 5, 9, 11]. While they all agree that this method of web space reconstruction provides an excellent basis for a long-lasting good result, most of them also admit that it is not suitable for all syndactyly types, and that releasing complete and complex syndactylies most often still requires the use of skin grafts and local flaps [3, 5, 9, 11]. The authors described a method of closing the middle and distal phalangeal defects that result from syndactyly release through direct closure or secondary intention healing following defatting of skin flaps. This technique produces a linear scar in the mid-lateral line of the digit, which will, with time, lead to contracture and finger and nail deformity. Although the authors reported one patient in their series having had complex syndactyly, they did not report any additional procedures performed to reconstruct the fingertip in this patient. The reconstruction of the lateral nail fold in complex syndactyly release usually requires some form of pulp flap method to cover exposed bone, of which the technique described by Buck-Gramcko is probably the best known [2]. Previously used methods of nail plate, matrix and pulp fat reduction to achieve the direct closure have failed the test of time, very often resulting in cosmetically unacceptable fingertips with deformed nails and absent or deformed lateral nail folds [4]. Indeed, taking a closer look at the follow-up photograph of one of the released digits in the article (Fig. 1), it is clearly visible that there is extensive scarring and notching of the lateral nail fold and deformation of the nail plate, which the authors did not consider as a problem. Fig. 1 Close-up of the follow-up photographs of one of the released digits (with kind permission from Springer Science+Business Media [7]) Considering the relatively small number of patients reported, various syndactyly types included in the study group and relatively short follow-up time, it is difficult to accept conclusions about the long-term outcomes. Unfortunately the authors also failed to quantify their results using parameters traditionally used in syndactyly release outcome reports [6], such as joint ROM, web creep, as described by Withey [10], and scar evaluation by the Vancouver Scar Scale or some other scar score. A normal sensation is reported, although it is admitted that sensory testing can be challenging in this age group (10 months to 3 years plus 1–3 years follow-up). Although many reports provide ample evidence that dorsal island flap techniques can provide long-lasting good result in incomplete syndactylies, thus avoiding the need to use skin grafts and shortening the operation time, complete and especially complex syndactylies necessitate the use of skin grafts and local flaps if a cosmetically pleasing fingertip is to be achieved.

Craniofacial neurofibromatosis and tissue expansion: Long-term results

The role of tissue expansion for coverage of soft-tissue defects of the face following neurofibroma resection has been briefly described previously with good results but limited follow-up. Recent scientific evidence has arisen that neurofibromas adversely affect the rheological properties of normal surrounding skin resulting in hyper-extensibility of dermal elements. In this context, we believe that long-term outcomes of tissue expansion for treatment of soft-tissue defects in patients with craniofacial neurofibromatosis would demonstrate suboptimal results because of loss of contour. Between June 1981 and June 2011, two patients underwent five tissue expander placements during the course of treatment for craniofacial neurofibromatosis at our institution. In both patients, tissue expansion was used to recruit tissue for fascio-cutaneous flaps following radical excision of adjacent neurofibromas. Three cervical expansions were performed for cheek and lateral face recontouring. One forehead expansion was used for nasal reconstruction and a second forehead expansion was performed for temporo-orbital recontouring. No perioperative complications occurred related to the tissue expander placement, expansions or radical excisions. Photographic follow-up of 15 years is available in each case. Cervical tissue expanded to provide cheek coverage demonstrated early loss of contour. Loss of lateral cheek contour resulted in increased morbidity from lateral and caudal displacement of the mid-face and orbital tissues requiring multiple revisional procedures. Tissue expansion of the forehead for both nasal reconstruction and temporo-orbital reconstruction demonstrated excellent long-lasting results.

Experience with non-ablative fractional photothermolysis with a dual-mode laser device (1,440/1,320 nm): no considerable clinical effect on hypertrophic/acne scars and facial wrinkles

In the literature, non-ablative fractionated photothermolysis (nFP) is accredited with improvement of wrinkles and scars combined with a reduced downtime. The purpose of this work was to evaluate the impact of a combination laser (1,320/1,440nm) for nFP on hypertrophic scars, acne scars, and facial wrinkles. Thirty-six patients suffering from hypertrophic scars (n = 7), acne scars (n = 9), and wrinkles (n = 20) were treated using a combination Nd:YAG laser [λ(em) = 1,320 and 1,440nm, pulse duration: 3-ms single pulse, fluence: 8.0-9.0J/cm(2) (1,320nm); 2.0-2.5J/cm(2) (1,440nm)]. The appearance of the treated condition was evaluated in a retrospective study by two blinded investigators based on follow-up photographs and by patient self-assessment. The frequency of side-effects was also assessed. Both patients and blinded observers rated the treatment results for hypertrophic scars and acne scars as slight improvement, and for wrinkles as equal as compared to baseline. No serious side-effects were reported. The light device used did not lead to a considerable clinical improvement of hypertrophic scars, acne scars, or wrinkles in this study.

Automated alternation flicker for the detection of optic disc haemorrhages

Optic disc haemorrhages are associated with active glaucomatous neurodegeneration and ongoing visual field loss. We sought to determine whether automated alternation flicker enhances the detection of disc haemorrhages in serial images from patients with glaucoma when compared to side-by-side photographic evaluation and single-image display. Serial sets of optic nerve photographs of 394 eyes from 234 patients followed for glaucoma at the authors' institutions were included in this study. Eyes with disc haemorrhages were graded for difficulty level and randomized along with nondisc haemorrhage control images into one of three presentation groups (automated alternation flicker, side-by-side or single image). Seven graders viewed all images and assessed for the presence or absence of disc haemorrhages. The sensitivity of automated alternation flicker for disc haemorrhage detection (0.878) was higher than side-by-side (0.705; p = 0.002) and single photographs (0.757; p = 0.01). There was no specificity difference between pairs of presentation groups (all p ≥ 0.7). Automated alternation flicker was a more sensitive method for disc haemorrhage detection than the current clinical standards and may have an important role in the management of glaucoma.

Reply

Sir: Thank you for the opportunity to reply to the letter by Dr. Acartürk. We reported in the March 2010 issue of Plastic and Reconstructive Surgery a case of banking a hemiabdominal deep inferior epigastric perforator (DIEP) flap for “high-risk patients.”1 We sought to describe this as a unique and original technique for preserving a perforator flap while awaiting oncologic clearance of a tumor that was being primarily reconstructed at a single recipient site. The title of the article and the indication for the procedure certainly demonstrated this, and clearly differed from the planned staging of a bilateral breast reconstruction, in which two separate defects were reconstructed, as reported by Dr. Acartürk.2 Although Dr. Acartürk's case was reported in 2008, we performed our reported case in November of 2004, with the original photograph and dates from the camera shown in Figure 1. We have actually performed a series of these procedures since 1999, with the first procedure performed in February of 1999 and the original photograph and date from the camera of the first such procedure shown in Figure 2 (this is a 12-month follow-up photograph). However, where the concern appears to have arisen is the time between Dr. Acartürk's 2008 publication and our March of 2010 publication. We would like to point out that in fact we wrote our article before Dr. Acartürk's publication (in early 2008), and our article was submitted, accepted, and has been in press since 2008. He also claims that we referenced a 2009 article in our article—we certainly did not, and there is no mention of this reference in our article,3 given that our submission was well before that. There were certainly no “intentional” omissions from the literature, and a thorough literature review was indeed performed at the time of initial writing, before Dr. Acartürk's case was published or presented.Fig. 1.: Original photograph of the published case example of a “surplus,” banked DIEP flap performed in November of 2004, in which chest wall reconstruction with a right-sided hemiabdominal DIEP flap was performed for locally advanced lymphangiosarcoma, and closure of the abdominal wall was performed with a left DIEP advancement flap for subsequent use in the case of local recurrence.Fig. 2.: Original photograph of our first case of a “surplus,” banked DIEP flap performed in February of 1999 for unilateral breast reconstruction, demonstrating the 12-month postoperative results.This must of course be taken in the context of the Plastic and Reconstructive Surgery Viewpoints section, which offers the ability to provide broad access to many ideas and techniques by limiting submissions to five references and 500 words, but which in turn can serve to limit the extent of literature review. However, given the nature of the different case reports in the current discussion, this is not highly relevant here. In addition, the dates of submission and acceptance are not listed in the Viewpoints section, which can confound the interpretation of dates. Finally, in terms of Dr. Acartürk's presentation of the case report at the European Federation of Societies for Microsurgery meeting, the presentation was not seen by any of the authors, and again the article was written well before this. We commend Dr. Acartürk for his earliest publication of such a technique, one which we have clearly found useful ourselves for some time, in a range of different clinical settings. Rafael Acosta, M.D. Department of Plastic Surgery Uppsala Clinic Hospital Uppsala, Sweden Warren M. Rozen, M.B.B.S., B.Med.Sc., P.G.Dip.Surg.Anat., Ph.D. Brockhoff Reconstructive Plastic Surgery Research Unit Department of Anatomy and Cell Biology University of Melbourne Parkville, Victoria, Australia Iain S. Whitaker, B.A.(Hons.), M.A.(Cantab.), M.R.C.S. Department of Plastic, Reconstructive, and Burns Surgery Welsh National Plastic Surgery Unit Morriston Hospital Swansea, United Kingdom

Split‐face comparison of intense pulsed light with short‐ and long‐pulsed dye lasers for the treatment of port‐wine stains

So far, pulsed dye lasers have been regarded as the gold standard in the treatment of port-wine stains (PWS). Recently, intense pulsed light (IPL) has been reported to achieve more pronounced fading in some patients. To evaluate the efficacy and the side effects of IPL treatment of PWS in a direct comparison to the short-pulsed dye laser (SPDL) and the long-pulsed dye laser (LPDL). Test spots (n = 158) were applied with IPL (λ(em) = 555-950 nm, pulse duration: 8-14 milliseconds (single pulse), fluence: 11-17.3 J/cm(2)), the SPDL (λ(em) = 585 nm, pulse duration: 0.45 milliseconds, fluence: 6 J/cm(2)), and the LPDL (λ(em) = 585/590/595/600 nm, pulse duration: 1.5 milliseconds, fluence: 12/14/16/18 J/cm(2)) in a side-by-side modus in untreated (n = 11) and previously treated (n = 14) patients with PWS. Lesion clearance was evaluated by three blinded investigators based on follow-up photographs 6 weeks after treatment. Incidence of side effects was assessed. In previously untreated PWS as well as in pretreated PWS, IPL treatments were rated significantly (P<0.05) better than treatments with the SPDL. In both groups, IPL and LPDL treatments did not differ significantly. Side effects were few in all settings. In PWS resistant to dye laser therapy, IPL showed additional lesion clearance. The use of IPL increases the therapeutic possibilities in PWS.

Slow Enlargement of Choroidal Nevi: A Long-Term Follow-Up Study

Choroidal nevi are generally considered to be stable lesions, and growth of a choroidal nevus is usually believed to be a sign of malignant transformation. We performed this study to determine whether choroidal nevi enlarge over a long period of follow-up without undergoing malignant transformation. Retrospective observational case series. A total of 278 patients with 284 nevi who had at least 7 years of photographic follow-up without clinical signs of transformation into melanoma were included in the study. Data on demographic and clinical information were extracted from patients' charts. Detailed fundus drawings and color fundus photographs were reviewed and compared for evidence of enlargement. Nevus enlargement without clinical evidence of transformation into melanoma. Of the 278 patients, 69% were female and more than 99% were White with a median age at presentation of 57 years (range, 4-87 years). The largest nevus basal diameter was a median of 5 mm (range, 0.5-14 mm), and the median thickness was 1.5 mm (range, 0.1-3.6 mm). Only 14 nevi (5%) had subretinal fluid outside the nevus, and 6% showed overlying orange pigment. Overlying retinal pigment epithelial alterations included drusen (61%), atrophy (6%), hyperplasia (10%), and fibrous metaplasia (6%). Of 284 nevi, 31% showed slight enlargement over a mean follow-up of 15 years. The median increase in diameter was 1 mm (mean, 0.9 mm; range, 0.2-3.0 mm), and the median rate of enlargement was 0.06 mm/yr (mean, 0.06 mm/yr; range, 0.01-0.36 mm/yr). None of the lesions that enlarged developed new risk factors that are generally associated with malignant transformation. Frequency of enlargement was 54% in patients aged less than 40 years and 19% in patients aged more than 60 years. On multivariate analysis, younger patient age was the only factor predictive of nevus enlargement (P<0.001). With long-term follow up, 31% of choroidal nevi showed slight enlargement without clinical evidence of transformation into melanoma. The frequency of enlargement was inversely related to patient age.

Glaucomatous Progression in Series of Stereoscopic Photographs and Heidelberg Retina Tomograph Images

To compare optic disc changes using automated analysis of Heidelberg retina tomograph (HRT) images with assessments, by glaucoma specialists, of change in stereoscopic photographs. Baseline and follow-up stereophotographs and corresponding HRT I series of 91 eyes from 56 patients were selected. The selection criteria were sufficiently long, good-quality HRT series (7 visits in > or =70 months of follow-up) and follow-up photographs contemporaneous with the final HRT image. Topographic change analysis (TCA), statistic image mapping (SIM), and linear regression of rim area (RALR) across time were applied to HRT series. Glaucomatous change determined from stereophotographs by expert observers was used as the reference standard. Expert observers identified 33 eyes (36%) as exhibiting glaucomatous change. Altering HRT progression criteria such that 36% of eyes progressed according to each method resulted in concordance between HRT methods and stereophotograph assessment of 54% for TCA, 65% for SIM, and 67% for RALR (Cohen kappa = 0.05, 0.23, and 0.30, respectively). Receiver operating characteristic curves of the HRT analyses revealed poor precision of HRT analyses to predict stereophotograph-assessed change: areas under the curve were 0.61 for TCA, 0.62 for SIM, and 0.66 for RALR. Statistical methods for detecting structural changes in HRT images exhibit only moderate agreement with each other and have poor agreement with expert-assessed change in optic disc stereophotographs.

Morphologic Features and Natural History of Scalp Nevi in Children

To characterize the clinical changes in clinically distinctive scalp nevi over time in children to help guide management and avoid misdiagnosis as melanoma. Cohort study. Washington University School of Medicine pediatric dermatology clinics. Patients Of 93 patients younger than 18 years with photographically documented, clinically distinctive scalp nevi, 28 (30%) consented to participate. Minimum follow-up from the initial visit was 1 year. Collectively, these patients had 44 scalp nevi at the initial visit. No patient had a personal diagnosis of melanoma or dysplastic nevus syndrome. Clinical changes in scalp nevi as determined using the ABCDE scoring system (ie, asymmetry, border irregularity, color variegation, diameter >6 mm, and evolution/elevation from initial to follow-up images) on initial and follow-up photographs of scalp nevi. Overall, 77% of the clinically distinctive scalp nevi (34 of 44) showed clinical signs of change during mean follow-up of 2.8 years. Of those with changes, 18 (53%) became more atypical and 16 (47%) became less atypical since the initial examination. None of the changes were concerning for melanoma. The mean total scalp nevus count was 2.6. Scalp nevi represented approximately 6% of total-body nevi. The number of scalp nevi increased with age. Boys had 1.5 times the number of scalp nevi as girls (P = .03). Scalp nevi are clinically dynamic in childhood. These changes include an increase or a decrease in atypical features and occur in all age groups. This preliminary study does not support excisional biopsies but does support physician evaluation of scalp nevi evolution and serial photography of clinically distinctive lesions.

Blinded, Randomized, Quantitative Grading Comparison of Minimally Invasive, Fractional Radiofrequency and Surgical Face-lift to Treat Skin Laxity

To quantify the improvements in laxity from the surgical face-lift and to perform a randomized, blinded comparison with the clinical effects of a novel, minimally invasive fractional radiofrequency (FRF) system. Randomized, blinded, comparative trial. Fifteen sequential patients with facial skin laxity enrolled in the trial and completed FRF treatment and follow-up. Baseline and follow-up digital photographs of patients undergoing FRF were randomly mixed with 6 sets of baseline and follow-up images of patients undergoing surgical face-lift with equivalent baseline facial laxity grades. Five independent blinded evaluators graded randomized baseline and 3- to 6-month follow-up photographs using a comprehensive quantitative 4-point laxity grading scale. Quantitative changes in laxity grades were calculated and compared statistically for FRF treatment vs surgical face-lifts. Patient satisfaction and adverse events were also evaluated. Blinded grading of unmarked, randomized baseline and follow-up photographs of patients undergoing FRF treatment randomized with baseline and follow-up photographs of patients undergoing surgical face-lift demonstrated statistically significant improvement in facial laxity, with a mean grade improvement of 1.20 for patients in the surgical face-lift group and of 0.44 for FRF-treated patients on a 4-point laxity grading scale (P < .001). The improvements relative to baseline were 16% for FRF treatment compared with 49% for the surgical face-lift. The mean laxity improvement from a single FRF treatment was 37% that of the surgical face-lift. Patient satisfaction was high (dissatisfied, 0%; neutral, 7%; satisfied, 60%; and very satisfied, 33%). All participants in the FRF treatment group experienced transient erythema, mild edema, and mild to moderate purpura that resolved in 5 to 10 days, and they returned to normal activities within 24 hours. There were no adverse events or complications in the FRF group. All patients in the surgical face-lift group experienced scarring at surgical margins, erythema, edema, and ecchymosis, and they returned to normal activities on suture removal at 7 to 10 days. This randomized, blinded, quantitative assessment using a validated grading scale of skin laxity improvement from the gold standard treatment, the surgical face-lift, and comparative analysis to a novel, minimally invasive FRF treatment has demonstrated 49% improvement in skin laxity relative to baseline for the surgical face-lift, compared with 16% for FRF. The surgical face-lift resulted in a mean 1.20-grade improvement on the 4-point laxity grading scale. In comparison, a single, minimally invasive FRF treatment demonstrated a 0.44-laxity grade improvement, or 37% that of the surgical face-lift, without the adverse effects and complications of surgical procedures. This study provides a basis for quantifying cosmetic outcomes from novel treatments with comparative analysis to the gold standard. It also suggests that minimally invasive FRF treatment may provide an important nonsurgical option for the treatment of facial skin laxity.

Description of the Age-Related Eye Disease Study 9-Step Severity Scale Applied to Participants in the Complications of Age-related Macular Degeneration Prevention Trial

To describe characteristics of the Age-Related Eye Disease Study (AREDS) 9-step severity scale applied to participants in the Complications of Age-related Macular Degeneration Prevention Trial (CAPT). Eligibility criteria for CAPT required 10 or more large (>or=125 microm) drusen in each eye. Readers graded baseline photographs from all participants and all follow-up photographs from 402 untreated eyes. Drusen and pigment characteristics were used to assign the AREDS scale score. Choroidal neovascularization was identified from fluorescein angiograms. Geographic atrophy involving the macular center was identified from color photographs. Among 1001 untreated eyes, 90% were at steps 5 to 7 at baseline. The 5-year incidence of advanced age-related macular degeneration (AMD) increased with each step from 8% (step 4) to 40% (steps 8 and 9 combined). These rates were similar to those reported in AREDS. Among 261 eyes with all 5 annual photograph gradings available and without progression to advanced AMD, 55% of eyes had scores that indicated improvement at least once. Before progression to advanced AMD, only 32% of 141 eyes either went through step 8 or 9 or had an increase of 2 or more steps from baseline. The AREDS 9-step severity scale was predictive of development of advanced AMD. The AREDS scale has deficiencies as a surrogate outcome for progression to advanced AMD.

Free Tissue Transfer in a Head and Neck Cancer Patient with Polycythemia Vera

Sir: Hematologic disorders are rarely seen in patients with free flap reconstruction for head and neck defects. We report a patient with polycythemia vera who underwent successful free flap reconstruction. A 50-year-old man with known polycythemia vera presented with a T2N0M0 squamous cell carcinoma of the floor of the mouth. Bilateral selective neck dissections, a marginal mandibulectomy, and resection of floor of mouth were performed. A titanium plate was used to reinforce the remaining mandible. A left anteromedial thigh flap with a segment of the rectus femoris muscle was harvested because of the lack of perforators in the anterolateral thigh territories. The muscle was used to fill the floor-of-mouth defect and cover the anterior mandible. The skin portion of the flap resurfaced the intraoral mucosal defect. The recipient vessels were the lingual artery and common facial vein. The patient’s preoperative hemoglobin level was 18.5 g/dl and his hematocrit level was 52.7 percent. After phlebotomy preoperatively, his hemoglobin level dropped to 15.9 g/dl (Fig. 1). Intraoperatively, the patient was well hydrated and his hemoglobin level was monitored carefully. The patient lost approximately 400 ml of blood, and no blood transfusion was given intraoperatively. No intraoperative anticoagulation was given.Fig. 1.: The patient’s hemoglobin (Hb) and hematocrit (Hct) levels before surgery (Pre1 and Pre2), during surgery (OR), and after surgery up to postoperative day 5.The patient had an uneventful recovery. His postoperative hemoglobin level was monitored daily and remained relatively stable (Fig. 1). Postoperatively, the patient received a daily baby aspirin, with no other anticoagulatory therapy. No thrombotic events occurred, and the flap survived in its entirety. He was discharged on postoperative day 6 and started on an oral diet following a negative modified barium swallow study on postoperative day 8. At 1 year, he showed excellent oral function, with a regular diet and normal speech, and near-normal appearance of the face and neck. A follow-up intraoral photograph is shown in Figure 2.Fig. 2.: A follow-up photograph at 6 weeks shows a well-healed anteromedial thigh flap for floor-of-mouth reconstruction, without excessive bulk.Free flap reconstruction in patients with polycythemia vera therefore seems a viable option, provided that necessary precautions are taken. With increased hematocrit levels and blood viscosity in polycythemia vera, microvascular thrombotic events exist.1 Thrombotic events are present in 20 to 50 percent of patients with polycythemia vera associated with essential thrombocythemia.2 Medical management for polycythemia vera involves primarily cytoreduction with phlebotomy. Interferon alfa, hydroxyurea, and low-dose aspirin are other treatment options.3 Low-dose aspirin helps prevent microvascular thrombosis. The “safe” hemoglobin/hematocrit level for microvascular surgery is unknown. However, it is imperative that hemoglobin and hematocrit levels be reduced to normal range perioperatively, using phlebotomy and/or myelosuppressive agents.4 With an estimated 400 ml of intraoperative blood loss and hemodilution in the perioperative period, the patient’s hemoglobin level gradually dropped to 10 g/dl on postoperative day 4 before it started to climb. This gave us a “safe” time period for the free flap to survive. The need for intraoperative anticoagulation is somewhat controversial. The senior author does not routinely give anticoagulation agents during the perioperative period. Because this patient’s hemoglobin level was within the normal range, no anticoagulation was given intraoperatively. Postoperatively, aspirin therapy is practical for patients with polycythemia vera, even if, as in the present case, there is no associated essential thrombocythemia. Samuel J. Lin, M.D. Division of Plastic Surgery Beth Israel Deaconess Medical Center Boston, Mass. Peirong Yu, M.D. Department of Plastic Surgery University of Texas M. D. Anderson Cancer Center Houston, Texas

Graduated Approach to Refinement of the Nasal Lobule

To present a graduated approach to refining the nasal lobule (a frequent complaint during consultations for rhinoplasty) based on anatomic features and to discuss the casuistics of this procedure since we began performing it. A retrospective evaluation of the medical charts of 1152 patients who underwent rhinoplasty from 2003 to 2006; 641 patients fulfilled the criteria for our study (55.6%). Outcomes were assessed by comparing preoperative and last follow-up photographs and considering the width, symmetry, and contour of the nasal lobule. Cases were allocated into 7 groups: (1) no surgery on nasal tip; (2) interdomal breakup; (3) cephalic trim; (4) domal suture; (5) shield-shaped graft; (6) vertical dome division; and (7) replacement of lower lateral cartilages. Of the 641 patients enrolled in the study, 435 were women and 206 were men. Mean follow-up period was 1.5 years. An asymmetric tip was present in 28 patients (4.4%), and a persistent width of interdomal space in 34 (5.3%). None presented overnarrowing of interdomal space. Surgical revision rate to enhance refinement of the lobule was 5.6%. Our graduated approach has shown excellent outcomes, a high rate of patient satisfaction, and a low rate of revision.

Nonsurgical Management of Congenital Eyelid Malpositions Using Hyaluronic Acid Gel

To report our preliminary experience using hyaluronic acid gel fillers as a nonsurgical alternative in the management of congenital eyelid malpositions. In this retrospective interventional case series, 5 patients (10 eyes) with congenital eyelid malpositions, including eyelid retraction, ectropion, euryblepharon, epiblepharon, and abnormalities associated with a shallow orbit, with resultant lagophthalmos and/or keratopathy and tearing were evaluated before and after injection with hyaluronic acid gel (Restylane) in the pretarsal and/or septal regions of the affected eyelid(s). Pretreatment, posttreatment, and follow-up photographs were analyzed for eyelid position and degree of eyelid closure and lagophthalmos, and slit-lamp evaluation of the degree of keratopathy. All 5 patients demonstrated significant improvement of eyelid position and degree of keratopathy. The mean improvement in lagophthalmos was 4.5 mm (range, 2-7 mm). The average volume of hyaluronic acid gel used was 0.5 ml per eyelid. Complications were minor, including transient edema and ecchymosis at the sites of injection. Of the 10 eyelids injected, only one had increased astigmatism after injection. Hyaluronic acid gel shows promise as a safe and effective nonsurgical treatment for the management of certain eyelid malpositions, disorders traditionally requiring surgical intervention if aggressive ocular lubrication fails. This treatment is particularly useful in such patients who are commonly premature with poor general health and serves as a temporizing measure by allowing the much needed tissue expansion to take effect over time.