Postoperative Nerve Injury Research Articles

Lateral versus crossed wire fixation for displaced extension supracondylar humeral fractures in children

Reduction and percutaneous pin fixation is widely accepted treatment for displaced humeral supracondylar fractures in children, but the best pin configuration is still debatable. This study examined the outcome for crossed and lateral pins placement in type IIB and III supracondylar humeral fractures. Clinical notes and radiographs of 131 children with an average age of 6 years were retrospectively reviewed. Lateral pins fixation was used in 66 children and crossed wires in 65. The groups were similar with regard to gender, age, follow-up, severity of displacement and number of closed/open reductions. There was no statistical difference between the two groups either clinically or radiologically in the quality of outcome. However, postoperative ulnar nerve injuries occurred in 6% of patients treated with crossed wire fixation, whilst none of the group with pins inserted laterally suffered this complication. We recommend fixation of displaced humeral supracondylar fractures with two or three lateral pins inserted parallel or in a divergent fashion. This method of fixation gives similar results to crossed wires but prevents iatrogenic ulnar nerve injuries.

A Retrospective Study of the Incidence of Neurological Injury after Axillary Brachial Plexus Block

It has been suggested that performing a nerve block under general anesthesia, as customary in pediatric population, may predispose to nerve injury. However, few clinical data exist to either support or refute this assertion. We retrospectively reviewed data on all patients who received an axillary block for upper extremity surgery in our institution during an eight-year period. The blocks were performed under sedation or general anesthesia, without using a nerve stimulator. Perioperative records from the Hand Surgery Unit Clinic were reviewed for postoperative complaints and complications. In the eight-year period of the review, 336 patients had axillary block. In total, 230 received the block with sedation and 106 during general anesthesia. All the sedated patients were older than 14 years (mean age 45.2), while of the general anesthesia patients 48 were older than 14 years (mean age 13.9 years). There were six cases of postoperative nerve injury in sedated patients (2.6%) vs. eight cases (7.5%) in the general anesthesia patients. Most patients recovered fully within several weeks. One patient had permanent nerve injury. Definitive conclusions cannot be drawn because of disparities in patient group demographics (majority of pediatric patients were in the general anesthesia group) and the retrospective nature of this study. Nevertheless, the findings suggest that the conduct of axillary block under general anesthesia in pediatric patients holds a greater potential for nerve injury than when the block is performed under sedation in adults.

Was the Postoperative Nerve Injury Really Related to the Performance of the Block?

Was the Postoperative Nerve Injury Really Related to the Performance of the Block?

Was the Postoperative Nerve Injury Really Related to the Performance of the Block?

Was the Postoperative Nerve Injury Really Related to the Performance of the Block?

Mini skin incision for carotid endarterectomy (CEA): A new and safe alternative to the standard approach

Patients requiring surgery are naturally attracted to shorter incisions because they tend to cause less pain and are esthetically more appeasing. To substantially shorten the length of standard skin incisions (4 to 7 inches) for carotid endarterectomy (CEA), we used preoperative duplex scanning to outline the carotid bifurcation as well as to determine the extent of disease in both the internal and common carotid arteries. During the last 21 months, 265 consecutive primary CEAs were performed in 253 patients (mean age 72 +/- 10 years) at a single institution. Of these, 142 were men (56%). Hypertension, coronary artery disease, diabetes mellitus, smoking, and chronic renal failure were present in 81%, 44%, 43%, 28%, and 19% of the patients, respectively. Neurologically asymptomatic patients accounted for 71% of the cases. All patients received general anesthesia. Duplex-assisted skin markings of the diseased carotid artery were performed after proper patient positioning on the operating table. Synthetic patches were routinely used, and intraluminal shunts were deemed necessary by low stump pressures in 64 cases (24%). Completion duplex scanning was performed in all cases. The length of the longitudinal skin incision varied from 0.8 to 3.5 inches (average 1.4 +/- 0.5 inches). It was < or = 1 inch in 56 cases (21%), 1.1 to 1.5 inches in 110 (42%), 1.6 to 2 inches in 85 (32%), and 2.1 to 3.5 inches in the remaining 14 cases (5%). Intraluminal shunts were required in 9 (16%), 18 (16%), 29 (34%), and 8 (57%) of the cases, respectively. Incisions were longer in cases requiring an indwelling shunt (1.6 +/- 0.6 inches vs 1.4 +/- 0.4 inches) (P < .0001). The average patch length was 1.3 +/- 0.3 inches (range, 0.7 to 2.6 inches). The skin incision averaged 1.54 +/- 0.45 inches for the first 133 cases and 1.35 +/- 0.45 inches for the remaining 132 cases (P < .0001). Technical defects occurred in 10 cases (3.8%). The overall incidence of ipsilateral stroke and death was 1.9% and 0%. There were no technical defects or strokes in patients with the shortest incisions (< or = 1 inch). Overall, there were three transitory peripheral nerve injuries (1.1%). A comparative analysis with 265 consecutive CEAs performed immediately before this series without duplex-assisted skin markings revealed no significant differences in age (71 +/- 11 years), incidence of neurologically symptomatic patients (26%), sex (60% men), shunt use (24%), and major technical defects (3%). Also, postoperative transitory peripheral nerve injury (0.8%), stroke (0%), and death (0%) were not significantly different from the duplex-assisted group. It is of interest to note that none of the former cases was performed with a skin incision < or = 2 inches. Most CEAs (95%) can safely be performed with < or = 2-inch skin incisions. Pre-CEA duplex-assisted skin marking is a novel approach that confirms the side of the operation, localizes the disease, and minimizes the magnitude of the operation via shorter, more esthetically pleasing incisions.

Diagnostic and Therapeutic Considerations: Third Molar Teeth

Numerous non-controversial indications for removal of third molar teeth exist. Nevertheless, recent costcontainment efforts by third party payers and government agencies have focused on the asymptomatic third molar as a public health policy issue. These efforts have led, in turn, to current research aimed at establishing specific treatment criteria. Ongoing studies on the bacteriology of the periodontium surrounding the partially erupted third molar have found microorganisms characteristic of periodontal disease. Non-intervention outcome studies, while in their infancy, have provided some data regarding the longterm fate of third molars that are not extracted. Economic analyses and statistical modeling to assess costeffectiveness of extraction versus non-extraction are themselves controversial. Although the data are not yet conclusive, this lecture will attempt to present the available evidence, both pro and con, regarding specific conditions affecting third molars, with emphasis on periodontal disease, orthodontic requirements, and the truly non-pathologic third molar. Implicit in the decision in favor of extraction is knowledge of the potential complications of this surgical procedure. The discussion of complications will provide in-depth information on postoperative infection, alveolar osteitis, nerve injury, and mandibular fracture.

Nerve Injury and Small Saphenous Vein Surgery

ObjectiveTo assess nerve injuries in small (short) saphenous vein surgery. DesignProspective study. MethodsDuring a five and a half year period, 272 small saphenous vein operations were studied in 217 consecutive unselected patients, to assess postoperative nerve injuries. Patients with nerve injuries were treated and followed-up by an independent peripheral nerve surgeon. ResultsA peripheral nerve injury occurred three times in 272 procedures: two sural nerve injuries and one common peroneal nerve injury. There was a full recovery of all three nerve injuries, the latest after 18 months. ConclusionsNerve injuries following small saphenous vein surgery are rare and may have a good recovery.

Nerve Injury and Small Saphenous Vein Surgery

ObjectiveTo assess nerve injuries in small (short) saphenous vein surgery. DesignProspective study. MethodsDuring a five and a half year period, 272 small saphenous vein operations were studied in 217 consecutive unselected patients, to assess postoperative nerve injuries. Patients with nerve injuries were treated and followed-up by an independent peripheral nerve surgeon. ResultsA peripheral nerve injury occurred three times in 272 procedures: two sural nerve injuries and one common peroneal nerve injury. There was a full recovery of all three nerve injuries, the latest after 18 months. ConclusionsNerve injuries following small saphenous vein surgery are rare and may have a good recovery.

Clinical characteristics and treatment outcome for nonvestibular schwannomas of the head and neck

Purpose Studies involving head and neck schwannomas have focused predominantly on involvement of the vestibulocochlear nerve complex (acoustic neuroma) because of the associated morbidity related to lesions involving that region. However, the majority of head and neck schwannomas are not of vestibular nerve origin and may also produce significant morbidity due to involvement of the orbit, skull base, and cranial nerves. The purpose of this study is to examine the presenting signs and symptoms, location, nerve of origin, and outcome after treatment of patients with nonvestibular schwannomas of the head and neck. Materials and methods The medical and pathological records of all patients with nonvestibular head and neck schwannomas treated at a single institution between 1979 and 1999 were retrospectively reviewed. Results Eighteen (69%) of 26 patients presented with symptoms secondary to mass effect or nerve deficit. The parapharyngeal space was the most common site of tumor origin occurring in 8 patients (31%). The nerve of origin was identified in 16 patients (62%). Twenty-three patients (88%) had complete surgical excision, and 3 patients (12%) had subtotal resection. Postoperative nerve injury occurred in 16 patients (62%) with resolution in 7 patients (44%). Conclusions Nonvestibular head and neck schwannomas occur most commonly in the parapharyngeal space, and presenting signs or symptoms are usually related to mass effect or neural deficit. Complete tumor removal is often achieved, but subtotal or near-total resection may be indicated for patients with extensive skull base, middle ear, or facial nerve involvement. Postoperative morbidity is associated with nerve injury from the surgical approach and/or resection of the involved nerve.

Continuous laryngeal nerve integrity monitoring during thyroidectomy: Does it reduce risk of injury?

To determine if continuous laryngeal nerve integrity monitoring (NIM) during thyroidectomy is associated with a decreased risk of postoperative recurrent laryngeal nerve (RLN) injury. Retrospective cohort study of 165 patients who underwent thyroidectomy at a resident teaching institution between 1999 and 2002. The control group had 120 nerves at risk (NAR) whereas the NIM group consisted of 116 NAR. Primary outcome measures included postoperative RLN paralysis, paresis, and total injury rates. RLN paralysis occurred in 2.54% NAR in the control group and 0.86% in the NIM group [relative risk (RR) = 0.34, 95% confidence interval (CI95) = 0.04-3.27, P = 0.62]. Temporary RLN paresis occurred in 4.24% NAR in the control group and 3.45% in the NIM group (RR = 0.9, CI95 = 0.23-3.55, P = 0.89). Total RLN injury occurred in 6.78% NAR in the control group and 4.31% in the NIM group (RR = 0.66, CI95 = 0.21-2.09, P = 0.48). When compared to all other NAR, advanced T-stage malignancy was associated with a significantly increased risk of RLN paresis (T4 RR = 9.0, CI95 = 2.56-31.67, P = 0.0006; T3+T4 RR = 7.5, CI95 = 2.17-25.86, P = 0.0001) but not paralysis. NIM did not significantly reduce the risk of RLN paresis in the advanced T-stage subset (T3+T4 RR = 0.36, CI95 = 0.04-3.0, P = 0.59). There were no statistically significant differences in RLN paralysis, paresis, or total injury rates between control and NIM groups, even in subsets with advanced T-stage and increased baseline risk. Advanced T-stage is a significant predictor of RLN paresis in this cohort.

Continuous laryngeal nerve monitoring during thyroidectomy: Does it reduce the injury rate?

Problem: To determine if continuous laryngeal nerve integrity monitoring (NIM) during thyroidectomy is associated with a decreased risk of postoperative recurrent laryngeal nerve (RLN) injury. Methods: This was a cohort study of 165 patients who underwent thyroidectomy at a resident teaching institution between 1999 and 2002. The control group had 120 nerves at risk (NAR) while the NIM group consisted of 116 NAR. Primary outcome measures included postoperative RLN paralysis, paresis, and total injury rates. Results: RLN paralysis occurred in 2.54% of NAR in the control group and 0.86% in the NIM group (RR = 0.34, CI95 = 0.04–3.27, P = 0.62). Temporary RLN paresis occurred in 4.24% of NAR in the control group and 3.45% in the NIM group (RR = 0.9, CI95 = 0.23–3.55, P = 0.89). Total RLN injury occurred in 6.78% of NAR in the control group and 4.31% in the NIM group (RR = 0.66, CI95 = 0.21–2.09, P = 0.48). When compared to all other NAR, advanced T-stage malignancy was associated with a significantly increased risk of RLN paresis (T4 RR = 9.0, CI95 = 2.56–31.67, P = 0.0006; T3+T4 RR = 7.5, CI95 = 2.17–25.86, P = 0.0001) but not paralysis. NIM use did not significantly reduce risk of RLN paresis in the advanced T-stage subset (T3+T4 RR = 0.36, CI95 = 0.04–3.0, P = 0.59). Conclusion: There were no statistically significant differences in RLN paralysis, paresis, or total injury rates between control and NIM groups, even in subsets with advanced T-stage and increased baseline risk. Advanced T-stage is a significant predictor of RLN paresis in this cohort. Significance: NIM does not appear necessary in routine thyroidectomy, although it may be considered in patients with T3 and T4 tumors given an increased risk of RLN injury in these patients. Support: None reported.

Effect of obesity on postoperative complications in dentoalveolar surgery

Statement of the Problem: Obesity is a disease that affects approximately 51 million Americans. Another 69 million Americans are considered to be overweight including at least one in five children. Morbid obesity has been associated with increased pulmonary atelectasis after general anesthesia. Obesity is considered a risk factor for increased complications in cardiothoracic, orthopedic, reconstructive, and transplant surgery. Overweight and obesity as risk factors for complications associated with dentoalveolar surgery have not been extensively studied. The purpose of this study was to investigate the frequency and the nature of postoperative complications in obese patients receiving ambulatory dentoalveolar surgery. Materials and Methods: Patients presenting for outpatient dentoalveolar surgery over a six month period were included in the study if their weight and a final disposition were recorded in the chart. Weight groups by procedure comparisons were made for all patients. Eight surgical procedure categories were established based on the number of teeth removed, impacted teeth and other adjunctive surgical procedures. Unfavorable outcomes studied were postoperative visits, infections, nerve injury, alveolar osteitis, bone sequestrum, revision alveoplasty, facial fracture follow-up, redundant tissue requiring excision, ulcerations associated with immediate dentures, wound dehiscence, excessive bleeding, and maxillary sinus exposure. Because height was not routinely recorded, body mass index could not be determined. Thus patients were assigned to one of five weight groups: less than 150 lb; 150 to less than 200 lb; 200 to less than 250 lb; 250 to less than 300 lb; and greater than 300 lb. Method of Data Analysis: Data were analyzed by chi square tests and analysis of variance. Results: Fifteen hundred fifty-six charts were reviewed and 693 patients were included in the study. Fifty-seven percent of the patients were females and 47% were males. Seventy-four patients had complications or multiple postoperative visits that occurred equally in all weight groups. There were no procedure differences between patients less than or equal to 200 lb and patients greater than 200 lb. The five weight groups showed no significant differences in rate of postoperative complications or need for multiple postoperative visits. Postoperative infections (21), pain (19), and nerve injury (13) were the most frequently recorded complications. Seventy-eight percent (15) of the infections occurred in females, as did 92% (12) of the nerve injuries and 68% (13) of the postoperative visits for pain. There were no significant differences in the complication frequency between the genders. Conclusion: Excess weight and obesity do not appear to be risk factors for postoperative complications following dentoalveolar surgery. References Eichenberger AS, Proietti S, Wicky S, et al: Morbid obesity and postoperative pulmonary atelectasis: An underestimated problem. Anesth Analg 95:1788, 2002 Berg EE: Knee joint arthroscopy in the morbidly obese. Arthroscopy 15:321, 1999

Mandibular angle fractures: two-miniplate fixation and complications.

Noncompression monocortical miniplate fixation of the mandibular angle is an accepted and reliable method for providing rigid internal fixation. High complication rates have been reported for internal fixation of angle fractures. To analyze the outcome and complications in cases in which patients were treated with 2-miniplate fixation at the mandibular angle. A retrospective analysis of outcomes for a case series. Treatment performed at a level 1 trauma-rated teaching hospital. From May 1992 to September 2001, a total of 88 patients with angle fractures of the mandible were treated with 2-miniplate fixation. Sixty-eight of the 88 patients, with 70 angle fractures, were included in the study; 13 were unavailable for follow-up and 7 had less than the minimum follow-up of 6 weeks. The time of trauma to treatment, cause of injury, and associated fractures were recorded. Postoperative complications, including infection, malunion, nonunion, dehiscence, osteomyelitis, and nerve injury due to surgical manipulation, were tabulated. Follow-up examinations were performed up to 12 weeks after surgery, with additional examinations if necessary. Postreduction panoramic radiographs were obtained in most cases. No patients treated with monocortical 2-miniplate fixation had malunion, nonunion, or osteomyelitis. Twelve (17.6%) of the 68 patients were identified as having at least 1 postoperative complication. Postoperative infection occurred in 2 patients (2.9%). Infection was controlled with oral antibiotic therapy. One patient required removal of miniplates after the acute phase resolved. Occlusal disturbances were noted in 4 patients (5.9%) (2 with a slight anterior open bite, 1 with a crossbite, and 1 with premature contact of a molar) after surgery. Three of the 4 patients had associated midfacial or multiple mandibular fractures. None required further surgery. Wound dehiscence, with exposure of an underlying plate, occurred in 4 patients (5.9%); the wounds were treated conservatively and subsequently resolved. Nerve injury due to surgical manipulation occurred in 3 patients (4.4%). Monocortical 2-miniplate fixation of the mandibular angle is a reliable and effective technique for providing rigid fixation. The complications were minimal in our study, and the infection rate was 2.9%, which is comparable to or better than the infection rate reported with the use of a single miniplate fixation technique in other studies. Disturbances of occlusion were associated with midfacial or additional mandibular fractures. In view of the contradictory published results, further studies are needed to determine the ideal approach for noncompression monocortical plate fixation of angle fractures.

A Contemporary Assessment of Carotid Body Tumor Surgery

Carotid body tumor resection remains a surgical challenge traditionally associated with a 15-30% incidence of cranial nerve injury. The authors reviewed their experience with carotid body tumor surgery to determine whether contemporary awareness of carotid body tumors is leading to earlier detection and operation, resulting in a lower incidence of postoperative cranial nerve injury. Twenty-seven carotid body tumors were resected in 25 patients between 1990 and 2000. No patient died and no patient had postoperative baroreflex failure syndrome. There was 1 stroke (4%) in a patient who required ligation of the internal carotid artery. There were 9 cranial nerve injuries (33%), most commonly to the vagus or hypoglossal nerves, which was not significantly different from the rate of cranial nerve injury (44%) in the 9 patients operated upon between 1984 and 1989 (p=0.37, Fisher's exact test). Multivariate analysis demonstrated that tumor size was the only significant factor predicting cranial nerve injury (p=0.045, logistic regression). Since carotid body tumors with large size or higher Shamblin grades had predictably high operative blood loss and rates of postoperative cranial nerve injury, a high index of suspicion and aggressive surgical management may lead to earlier detection and operation on smaller tumors, ultimately reducing the risk of nerve injury. Nevertheless, carotid body tumor surgery appears to be relatively free of mortality and major morbidity in contemporary practice.

Transtympanic stimulation of the facial nerve to assess nerve integrity in iatrogenic facial nerve paralysis

Facial nerve paralysis is a well-described complication of head and neck surgical procedures. When the nerve is purposefully transected, the clinical approach is often clear, involving nerve repair, grafting, or substitution. In cases where the extent of facial nerve injury is not obvious, the potential for recovery is often uncertain. 1 We present a case of complete ipsilateral facial paralysis after resection of a parapharyngeal space tumor in a child. We used transtympanic stimulation of the tympanic segment of the facial nerve to assess anatomic integrity of the nerve. More experience with this technique may provide valuable information in guiding the management of postoperative facial nerve injury.

Eliciting Paresthesias for Peripheral Nerve Block: A Harmful Clinical Standard?

Eliciting Paresthesias for Peripheral Nerve Block: A Harmful Clinical Standard?

Peripheral nerve injuries during cardiac surgery: risk factors, diagnosis, prognosis, and prevention.

Neuropathies involving the brachial plexus, phrenic, recurrent laryngeal, and saphenous nerves, as well as the sympathetic chain are complications of cardiac surgery. The reported frequency of nerve injuries varies from 1.5% to 24% for the brachial plexus and 10% to 60",,6 for the phrenic nerve (1-5). Neuropathies of the recurrent laryngeal, lower limb (saphenous) nerves, and the sympathetic chain are less frequent.

Cranial and cervical nerve injuries after repeat carotid endarterectomy

Background and Purpose: The incidence of cranial and/or cervical nerve injuries after primary carotid endarterectomy (CEA) ranges from 3% to 48%; however, the clinical outcome of these injuries after repeat CEA has not been thoroughly analyzed in the English-language medical literature. This prospective study analyzes the incidence and outcome of cranial nerve injuries after repeat CEA. Patients And Methods: This study includes 89 consecutive patients who had repeat CEAs. Preoperative and postoperative cranial nerve evaluations were performed, including clinical examinations (neurologic) and direct laryngoscopy. Patients with vagal or glossopharyngeal nerve injuries also underwent comprehensive speech evaluations, video stroboscopy, fluoroscopy, and methylene blue testing for aspiration. Patients with postoperative cranial nerve injuries were followed up for a long time to assess their recovery. Results: Twenty-five cranial and/or cervical nerve injuries were identified in 19 patients (21%). They included 8 hypoglossal nerves (9%), 11 vagal nerves or branches (12%) (6 recurrent laryngeal nerves [7%], 3 superior laryngeal nerves [3%], and 2 complex vagal nerves (2%]), 3 marginal mandibular nerves (3%), 2 greater auricular nerves (2%), and 1 glossopharyngeal nerve (1%). Twenty-two (88%) of these injuries were transient with a complete healing time ranging from 2 weeks to 28 months (18 of 22 injuries healed within 12 months). The remaining three injuries (12%) were permanent (1 recurrent laryngeal nerve, 1 glossopharyngeal nerve, and 1 complex vagal nerve injury). The recurrent laryngeal nerve injury had a longer healing time than the other cranial nerve injuries. Conclusions: Repeat CEA is associated with a high incidence of cranial and/or cervical nerve injuries, most of which are transient. However, some of these have a long healing time, and a few can be permanent with significant disability. (J Vasc Surg 2000;32:649-54.)

Tracheobronchial ruptures from blunt thoracic trauma in children

Background/Purpose: Tracheobronchial ruptures in blunt thoracic trauma in children are rare. The aim of this study was to suggest the means of an early diagnosis and a conservative management as often as possible. Methods: Sixteen cases of tracheobronchial ruptures by blunt thoracic trauma were observed over 26 years in 9 regional pediatric centers. Results: There were 12 boys and 4 girls, from ages 1 hour to 17 years. Nine children presented with associated lesions. Fibroscopy established the following diagnosis: 8 tracheal wounds and 8 bronchial wounds. Six children were operated on within 18 hours (on average) after installation of a thoracic drainage. Two lobectomies, 3 ideal tracheal sutures, and 1 bronchial suture were performed. Seven children were treated exclusively by thoracic drainage. Two of them were intubated through the lesion, leading to a transitory endoprothesis accompanied or not by an external thoracic drainage. One infant recovered spontaneously. There were no deaths in this series. Two recurrent postoperative nerve injuries were noted, one of which was a transitory spontaneously resolutive scar bud and one a granuloma treated by laser. Three times, a stenosis occurred after a conservative management. Two were operated on. Conclusions: Tracheobronchial ruptures in children are rare. An early fibroscopy holds an important place in the approach of this pathology. Treatment is variable, based on thoracic lesions, their tolerance by the child, and associated lesions. Surgery is not the only therapy because conservative treatment by simple thoracic drainage or lesion intubation has proved effective.

Tumescent Cervicofacial Rhytidectomy

A modification of the tumescent technique for body contouring has been adapted for patients undergoing face lift. Thirty women, average age 56 years, were prospectively studied, with a 1-year follow-up. All surgery was performed in a private ambulatory operating room facility. The patients were under intravenous sedation with a board-certified anesthesiologist in attendance at all times. The preferred solution was 0.3% lidocaine 1/250,000 epinephrine (average volume injected 500 mL). The solution was a mixture of Ringer’s lactate 400 mL plus 2% lidocaine 50 mL and 1% lidocaine 50 mL plus 1:1000 epinephrine 2 mL. The average lidocaine dose per patient was 29.4 mg/kg. Serum lidocaine levels demonstrated a 1-hour peak at 2.7 μg/mL (no value exceeded 3.3 μg/mL). The technique began with superficial liposculpture followed by independent skin-lateral superficial musculoaponeurotic system-ectomy/platysmaplasty with wide skin undermining. Average operating time was 1 hour and 48 minutes. No operative complications were encountered. Excellent anesthetization was achieved in all patients without postoperative hematomas or nerve injuries. Tumescent cervicofacial rhytidectomy has been found to be a safe and effective rhytidectomy procedure that offers several advantages when compared with nontumescent techniques: avoidance of general inhalational agents, reduced operative bleeding and operative time, improved technical ease of superficial liposculpture and surgical dissection, and minimal postoperative bruising and swelling.