Reconstructive Interventions Research Articles

ПРОБЛЕМЫ ВТОРИЧНОЙ РИНОПЛАСТИКИ

Every year, there has been a steady increase in the number of rhinoplasty. At the same time, the patient’s demands for these surgery are also increasing. Therefore, unsatisfactory functional and aesthetic results after rhinoplasty require repeated (revision) operations. The secondary rhinoplasty itself is more complex than the primary operation. Incorrectly performed rhinoplasty and iatrogenic tissue damage lead to deformities that require repeated reconstructive interventions. The reasons for the unsatisfactory results of rhinoplasty can be different. In assessing the results of rhinoplasty, the surgeon’s opinion may not be ambiguous with the patient. Often, when the surgeon considers the rhinoplasty result to be acceptable, the patient may be unhappy. In the postoperative period, deformities of the tissues of the nose may be due to the rough scars, and an infectious process. Еxcessive cartilage resection, insufficient or excessive osteotomy lead to deformities that require repeated reconstructive interventions. For secondary rhinoplasty, it is necessary to take into account all tissue deformations to eliminate them in one stage. Sometimes after the second, third or more operations performed, the result of revision rhinoplasty is difficult to predict, so the surgeon must predict the expected outcome result. Keywords: Secondary rhinoplasty, nasal meatus, nasal septum deviation, septoplasty.

Significance of the deep femoral ertery in repeat reconstructions

Atherosclerosis obliterans is managed by various reconstructions of lower-limb arteries, but despite this, in the immediate and remote postoperative period there appears the necessity to carry out repeat reconstructions, which might be caused by shunt thrombosis, progression of atherosclerosis, etc. One of the methods of solving this problem is revascularization of lower-limb arteries through the deep femoral vein with plasty thereof. In occlusive lesions of the superficial femoral artery, the deep femoral artery plays the key role in blood supply of the entire extremity. The article deals with the principles of repeat surgical treatment of lower-limb arteries with the use of the deep femoral artery, also discussing the problems concerning the frequency of occurrence of thromboses in various positions, and the role of the deep femoral artery in blood supply of the lower extremity. The problem of efficacy of redo operations on lower-limb arteries using the deep femoral artery is still important. Despite the possibility of revascularization of lower extremities through the deep femoral vein, a high percentage of amputations remains. The terms of patency of the reconstructed deep femoral artery has proved to be several times longer than those of femoropopliteal and femorotibial shunts in the remote postoperative period. Besides, there are no clear-cut criteria for prognosis of efficacy of reconstructive interventions on the deep femoral artery in patients with multi-segment lesions of arteries of lower extremities after primary interventions, therefore, no common surgical policy exists. The use of the deep femoral artery in patients with ischaemia of lower extremities is explained by the minimally traumatic nature and confirmed efficacy after a series of previously performed multilevel operations, severe lesions of the distal bed, as well as in patients with severe concomitant diseases.

Design of clinical prospective study: application of gene, cell therapy and indirect revascularization for treatment of patients with non-reconstructive chronic lower limb ischemia

The aim — to improve the results of surgical treatment of patients with chronic critical lower limb ischemia.Materials and methods. To organize the study, we chose the open controlled method of parallel groups. The study was planned and conducted as an open prospective randomized and controlled trial. The study was conducted in four stages: 1st (screening, up to 2 weeks) — evaluation of the possibility of involvement in the study. At this stage all examinations of patients were carried out; 2nd (2 days) — signing informed consent, distribution of the patients to the treatment groups; 3rd (1.5 months) — treatment; 4th (3 years) — observation. The study involved patients whose vascular bed surgical reconstruction was impossible due to: the presence of prolonged occlusion of the femoral artery with the transition to the distal bed; destruction of vessels of distal segments with unfavorable prognosis; previously performed reconstructive interventions on the arteries of the lower extremities, which did not eliminate chronic ischemia due to the impossibility of repeated surgery; decompensation of somatic pathology that could interfere with surgery.Results and discussion. 110 patients were selected for treatment. The patients were divided into three groups according to the treatment method: 1st — 48 patients who underwent revascularization osteotreopenia as an operation of indirect revascularization, 2nd — 21 patients who were administered endothelial cell growth factor drug for stimulation of their own angiogenesis, 3rd — 41 patients in whom subcutaneous fat sampling, cultivation and transplantation of autologous mesenchymal cells were performed according to proposed by us method. To compare the main endpoints of the study, we created a control group of patients, who had previously undergone the treatment by standard methods in the clinic. The criteria for inclusion in the treatment groups and control group did not differ. All patients in the treatment groups had a high level of pain (on average > 70 mm on a visual analog scale) in the affected limb. The most common associated pathologies were hypertension and coronary heart disease. There was no statistically significant difference in the anamnestic data. Many patients had a history of revascularization attempts (> 50 % had one attempt, 20 % had two or more), 42 % had previous amputations including 26.4 % of small amputations and 10.9 % of above‑knee amputations. The most common reason why patients in the treatment groups were not subject to the revascularization procedure was the technical impossibility of intervention (56.4 %), less common reason — the inappropriateness (33.6 %), which was evaluated on the Finnvasc scale.Conclusions. Critical lower limb ischemia is the most severe form of peripheral artery disease and is associated with a high risk of amputation of the affected limb and death. Three groups of patients, comparable in age, sex ratio, concomitant pathologies and clinical characteristics of the underlying disease, were selected for the prospective study. To compare the effectiveness of our treatment we selected a control group of patients retrospectively, by case histories, according to the inclusion criteria which were the same for all groups. This group was somewhat artificially created, as it consisted only of selected patients comparable to persons in treatment groups by age, comorbidities and underlying disease, as well as those patients whose treatment outcomes could be traced over a 3‑year follow‑up period.

Surgical treatment of a patient with stent restenosis in the mouth of the general carotid artery and the proximal department of the internal carotid artery

The results of surgical intervention on a patient with stent restenosis at the mouth of the common carotid artery (CCA) and proximal internal carotid artery (ICA) are presented herein. In 2013, the patient underwent stenting of the CCA and ICA. One month later, the aortic valve was replaced with a mechanical prosthesis MedEng-23 (MedEng, Penza, Russia) and mammarocoronary anastomosis with an envelope artery was performed under extracorporeal circulation. After the intervention, the patient regularly received 3.75 mg of warfarin, and was under the observation of a cardiologist. In 2018, the patient suffered a transient ischaemic attack. Subsequent examination of the patient revealed sub-occlusion of the left subclavian artery and signs of vertebral–subclavian steal syndrome on the left, and confirmed patency of the mammarocoronary shunt in envelope artery. The patient underwent carotid–subclavian shunting using the BASEX (A.N. Bakulev National Medical Research Center of Cardiovascular Surgery, Moscow, Russia) (8-mm prosthesis. Nine months after the patient underwent carotid–subclavian shunting, 85% restenosis was observed in the stent of the left ICA using control multi-spiral computed tomography with angiography (MSCT AG). The patient also exhibited up to 94% restenosis of the stent of the left ICA, occlusion of the right ICA, and up to 81% stenosis of the proximal anastomosis of the carotid–subclavian shunt. The patient underwent surgery for the removal of the following: the stent from the ICA with endarterectomy from the CCA, ICA with arterial plastic patches from the xenopericardium and prosthesis on the left (8-mm Vascutek prosthesis, Vascutek Ltd., UK). The brain was protected by raising the patient’s systemic blood pressure to 180/90 mm Hg. During the postoperative period, MSCT AG was performed to image the ICA. The MSCT AG images indicated that the prosthesis was passable. Presently, no clear standards exist for achieving revascularisation in this category of patients. The present clinical case emphasised the requirement for the detailed observation of patients after reconstructive interventions in different arteries as well as the possibility of surgically correcting the revealed lesions.Received 13 August 2019. Revised 8 November 2019. Accepted 9 November 2019.Funding: The study did not have sponsorship.Conflict of interest: Authors declare no conflict of interest.Author contributionsDrafting the article: A.N. KazantsevLiterature review: R.Yu. LiderIllustrations: A.R. Shabayev, A.N. VolkovCritical revision of the article: N.N. Burkov, A.I. AnufriyevPreoperative patient preparation: A.R. Shabayev, E.V. RubanPostoperative care: A.N. VolkovNeurological examination: E.V. RubanFinal approval of the version to be published: A.N. Kazantsev, N.N. Burkov, A.R. Shabayev, A.N. Volkov, E.V. Ruban, R.Yu. Lider, A.I. Anufriyev

Metabolic disorder and outcomes of reconstructive interventions in patients with peripheral arterial disease

The purpose of this study was to assess the effect of metabolic disorders on the effects of revascularization in patients with obliterating atherosclerosis.
 Materials and methods. The reconstruction was performed in 253 patients with femoral-tibial arterial segment lesion (98 open operations, 116 endovascular interventions and 39 patients were treated with hybrid technique).
 Results. Endovascular revascularization techniques are justified in case of disorders of carbohydrate metabolism. Conventional operations remain the method of choice in the case of those variants of atherosclerotic lesions, where minimally invasive techniques are impossible.
 Conclusions. Metabolic disorders in patients with peripheral atherosclerosis on the background of severe comorbid pathology may be the basis for choosing hybrid methods of revascularization.

Surgical Treatment Methods of Post-coarctation Aneurysms of Aorta

Introduction. Aortal coarctation is one of the most studied conditions of heart congenital defects, which comprises from 7% to 10% of all congenital heart defects.
 During many years the various treatment strategies were used. Open surgical reconstructive intervention was first de-scribed in 1945, and this was, as a rule, resection of aortal narrowed portion.
 Although the treatment of coarctation is usually successful in a short-term perspective, there is a well-known fact of de-velopment of complications at the later stages, especially after surgical reconstruction, such as post-coarctation aneurysms.
 Objective. To analyze surgical methods of correction of coarctation.
 Materials and methods.in the National Amosov Institute of Cardiovascular Surgery of the National Academy of Medical Sciences of Ukraine during the period 1960–2017, 4245 patients were operated with native coarctation of aorta.
 Selective patients’ choice for this work was restricted only by such cases of aneurysm of descending aorta, for which the data were reliable. Considering the above, we will be limited by the period of observation, starting from 1995.
 Totally, 91 cases with aneurysm of descending aorta were included in this work, 85 (93.4%) of patients were re-operated, 6 (6.6%) of patients were not operated due to various reasons. The patient distribution by age and gender at the moment of correction of aortal coarctation showed that they included 68 (74.7%) males and 23 (25.3%) females in the ratio 2.9:1. The average patient age by that time was 14.7, ranging from 1 to 38 years.
 By the moment of discovery of post-coarctation aneurysm the patients’ age increased to an average 38.1, ranging from 21 to 60 years. The average time interval between the surgery of aortal coarctation and diagnosis of aneurysm of descending aorta was 22 years, ranging from 1 month to 45 years.
 The frequency of complications of aneurysm of descending aorta after surgery of aortal coarctation was different for various surgical methods. Among the aneurysms, which developed after coarctation correction, the most frequent were aneurysms after implantation of synthetic patch – 61(88.5%). The less frequent were aneurysms in 6 (8.7%) patients after implantation of tubular prostheses, and in 2 (2.8%) patients – after end-to-end anastomosis.
 Results and discussion. Till recent time the standard treatment practice was open surgical operation with direct access to proximal part of descending aorta by left-sided lateral.
 In our Department 85 surgical interventions were performed, including 69 surgeries by the traditional surgical method. From these patients, 7(10.1%) were operated two times, and 2(2.9%) – three times. In all 69(81.2%) cases, operated by open traditional surgical method, we performed vascular prosthesis implantation.
 Such operations require highly qualified anesthetic support with obligatory differential endobronchial intubation, cor-rection of disorders of respiratory and kidney functions, and compensation of present and possible blood loss [4]. Consider-ing high probability of uncontrolled hemorrhage at the stage of aneurysm mobilization, we installed temporary bypass graft – 75.3% or CPB pump – 24.7%, from ascending aorta or left atrium to descending aorta or femoral artery.
 Hospital mortality in this patient cohort was 5.9%.The use of endovascular treatment of thoracic aorta aneurysm increased considerably since Dake et al. in 1994 implanted the first stent-graft into thoracic aorta.
 In our Department, we performed 16(18.8%) of the procedures under general anesthesia with spinal drainage. For the patients, who require the covering of the zone of going of left subclavian artery or left common carotid artery, we perform extra-anatomic shunting 9(10.5%), or even subtotal debranching 2(0.2%), if there is no possibility to use individually pre-pared scalped stent-graft. The most common access is through common femoral artery by operative access 15(17.6%), or, more recently, by transcutaneous access 1(1.1%).

AUTOVENOUS REVASCULARIZATION OF THE LOWER EXTREMITY ARTERIES IN PATIENTS WITH VARIANT ANATOMY OF THE PERIPHERAL BLOOD FLOW AND THE PROGRESSIVE ATHEROSCLEROTIC PROCESS

Obliterating diseases of the lower extremity arteries occupy a high proportion in the structure of cardiovascular morbidity in the population among the developed countries. The steadily progressing course of obliterating atherosclerosis leads to the critical lower limb ischemia and causes an unfavorable prognosis for preserving the extremity, as well as the patient's life. Nowadays, there are two ways of surgical management of this pathology: endovascular and open reconstructive interventions. The choice of the method is based on a comprehensive keeping of the patient-specific records, including the anatomical characterization of the arterial bed lesions. In case of extended occlusion of the superficial femoral artery, the open reconstructive surgery using a large saphenous vein as a transplant is recommended. This circumstance is confirmed by the autovein patency in the long term compared with a synthetic prosthesis according to the results of randomized clinical trials. Therefore, with the formation of a distal anastomosis below the gap of the knee joint, the patency of the autovein and synthetic prosthesis after 5 years is 71% and 44% respectively. In this article, we represent a clinical case of successful treatment of a patient with progression of atherosclerotic lesions of the infrainguinal segment arteries. A staged revascularization of the femoral-popliteal segment arteries using technique of a reversed vein on both lower extremities after attempts of the conservative treatment and x-ray endovascular intervention was performed. A feature of this case is the creation of a new bifurcation of the popliteal artery during the formation of a distal anastomosis below the fissure of the knee joint under the contitions of a high discharge of the anterior tibial artery.The given clinical case demonstrates the advantages of invasive surgical tactics with the aim of preserving the limb and improving the patient's quality of life.

Prognostic Model of Surgical Treatment of Severe Mitral Regurgitation at Mitral Valve Prolapse

The article presents a single-center experience of surgical treatment of patients with severe mitral regurgitation(MR) caused by mitral valve prolapse (MVP). The study is based on long-term results of reconstructive interventions on the mitral valve (MV) of the UCCC of the Ministry of Health of Ukraine. The purpose of this work is to determine the factors that influence the long-term results of surgical treatment of MR in prolapse of the mitral valve leaflets.
 Material and methods.From January 1, 2011, to January 1, 2018, 146 patients with severe MR were operated on the basis of the UCCC, which was conditioned by the prolapse of mitral valve leaflets.
 Results.Long-term results were analyzed in 95.2% of patients. The average postoperative follow-up period was 39.7 ± 19.8 months. The overall mortality rate was 1.4%. Freedom from moderate and severe MR in the remote postoperative period decreased to 94.2%, compared to the early postoperative period. Residual MR was absent in 17 (12.4%) patients. In 76 (55.5%) patients trivial MR was detected, in 36 (26.3%) there was a mild MR, in 3 (2.2%) a moderate MR. In 5 (3.6%) patients, a severe MR was detected during the observation. Using statistical methods, it was found that the anatomical variant of MVP influences the prognosis of treatment results in the long postoperative period with worse results in the group with isolated prolapse of the anterior leaflet. Also, the dependence of the results on the applied surgical techniques with better results in annuloplication using the annuloplasty rings and in the application of resection of the posterior mitral leaflet. On the basis of statistics, a prognostic model for the evaluation of MV repair results in the distant period was developed. The height of coaptation of mitral leaflets was determined as one of the indicators for predicting the results of surgical treatment of MR with MVP.
 Conclusions: 1. In most cases, a successful mitral valve repair is possible with the MVP. 2. A good immediate result does not mean keeping it in the long term. 3. The long-term results of MV reconstruction depend on the anatomical variant of the MVP, with worse results in patients with isolated prolapse of the anterior mitral leaflet. 4. The result of MV repair depends on the surgical techniques used, with better results when using the annuloplasty rings and resection of the posterior mitral leaflet. 5. The height of the coaptation of the MV leaflets is an indicator that allows predicting the outcome of surgical treatment in the long postoperative period.

Correction of persistent cloaca in children: experience and analysis of treatment results

Introduction. Cloaca is one of the most difficult to be corrected varieties of the pathology of the anorectal zone, occurring with a frequency of 1 case per 40 000–25 000 live births. Purpose: аnalysis of diagnostic methods and surgical correction, treatment outcomes of children with cloacal malformations. Materials and methods . The article analyzed 16 cases of surgical treatment of cloacal anomalies based on the Irkutsk Municipal Pediatric Clinical Hospital in Irkutsk for the period from 2008 to the present. Gender composition: girls – 14 (87,5%), genotype (46XX – 13; 46XX, del (6) – 1), boys – 2 (12,5%). Results. The most common cloacal anomaly was a persistent cloaca – 11 (68,8%), the extrophy of the cloaca was 4 – 25 (25%) and the posterior cloaca – 1 (6,25%) was much less common. Aggravated obstetric history was found in reliable data on the presence of teratogenic factors is associated with a lack of information on obstetric history. In 93,8% of cases, cloacal anomalies were combined with other congenital malformations. In 100% (11) of cases the posterior-sagittal anorectovaginourethroplasty was performed in its various modifications, including LAPassisted – 3 (27,3%). When evaluating long-term results, it was revealed that 3 (27,3%) patients developed chronic recurrent pyelonephritis, 2 (18,2%) had urinary incontinence and first-degree anal incontinence, 1 (9,1%) had sphincter-detrusor insufficiency and anal incontinence of 3 degrees. Conclusion. According to the authors, the issues of surgical strategy for the correction of cloacal anomalies remain unresolved. The morphology of blemish, the spectrum of concomitant pathology are important in the choice. The results of treatment in favorable cases should be considered quite satisfactory. However, in severe forms, poor functional results occur, which often requires repeated reconstructive interventions and long-term rehabilitation of patients.

Morphometric characteristics of competent proximal valves of the great saphenous vein and superficial femoral vein in vivo according to ultrasound angioscanning data

Introduction. It seems relevant to study the ultrasound anatomy and physiology of the proximal valve segments of the superficial femoral vein (SFV) and the great saphenous vein (GSV) to develop effective reconstructive surgical interventions on venous valves in chronic vein diseases.The aim of the survey was to study the ultrasound anatomy of the venous wall, the size and shape of the proximal SFV and GSV valves are normal at rest and during the functional test Valsalva.Material and methods. Proximal valve SFV studies were performed in 144 lower limbs in 115 people (mean age 51.1 ± 14.4 years, 60 women and 55 men), proximal GSV valves studies - in 82 lower limbs in 67 persons (average age 45, 1 ± 13.3 years, 33 women, 34 men). A longitudinal and transverse ultrasound scanning of the femoral vein bifurcation and safenofemoral junction areas were performed, the structures of the proximal SFV and GSV valves were visualized, the valve shape was measured and the diameter of the veins was measured at the level valves at the base of the valves (inlet diameter), at the point of maximum ectasia (diameter of ectasia), at the upper border of the valve (diameter of the outlet), as well as measuring the length of the valve a (length to ectasia, the total length of the valve). The degree of ectasia over the valve was judged by calculating the relative venous diameter change (RVDC).Results. the average diameter of the SFV at the level of the lower boundary of its first valve was 10.01 ± 1.44 mm. The average diameter of the SFV at the level of the maximum ectasia of its first valve was 13,1±2 mm. The average value of the index of RVDC for SFV was 31%±10,4%. An increase in the diameter of the vein in the zone of supravalvular ectasia up to 20% corresponded to the spindle-shaped valve, more than 20% - to the clavate form, which was noted in the majority of the examined. The change in the relative venous diameter of the SFV on the Valsalva test was 38,2%±12,4%. The average diameter of the GSV at the base of the first valves was 6,07±1,25 mm. The average diameter of the GSV at the level of the maximum ectasia of the osteal valve was 9,44±1,69 mm. The average RVDC for GSV was 58%±24%.Conclusion. the natural form of proximal SFV and GSV valves is clavate with presence of the significant supravalvular ectasia, which was noted in the majority of the subjects alone and in all during the performance of the Valsalva functional test.

Causes of unsatisfactory surgery results of gunshot extremity arterial injuries

The aim — to identify the characteristics of injured persons’ group with limb preservation failure, as well as the factors that led to the limb loss, despite the revascularization attempts, that allows the prognosis and outcome improvement in the injure treatment.Materials and methods. The data on 100 patients who were injured during an anti‑terrorist operation (Joint Forces Operation) in eastern Ukraine between 2014 and May 2019, underwent revascularization for main artery injuries on the extremities, were analysed. Among them were 28 patients with upper limb injuries and 72 patients with lower limb injuries. The amputation was performed in 5 (17.9 %) cases in the group of patients with upper limb injuries, in 12 (17.7 %) patients with lower extremities injuries in the next days or weeks. A cohort of patients with successful revascularization and one with limb loss were analysed. The analysis took into account such wounds’ features as the injury nature, the major soft tissues loss, the evacuation term, the term before specialized care, the accompanying damage to other anatomical structures in the wound area, the presence of combined trauma, the surgery type and condition severity on the moment of evacuation.Results and discussion. The number of prophylactic fasciotomies was lower in the amputee group compared to the group with preserved limbs (35 and 48 %, respectively). The total number of autovenous graft operations in both groups was 51. In 14 (27 %) cases, the amputation was further performed. After prostetic graft (n = 24), 3 (13 %) limb amputations were performed.Conclusions. The most significant factors that led to the unsatisfactory result of revascularization were a major soft tissues loss in the in the wound area, delayed evacuation to a specialized hospital, a severe general condition, concomitant damage to other anatomical structures in the wound area. The most unfavourable prognosis for a reconstructive intervention is a combination of the artery, vein, main nerves, and tubular bone damage («lost limb syndrome»). The choice of a synthetic alloprosthetic for revascularization in gunshot wounds does not increase the risk of further amputation.

A multidisciplinary approach to skin plastic of skull defects formed after implantation

At the present time in connection with the growth craniotomies interventions cranioplasties operations is widespread. The introduction of a significant number of heterogeneous implants to restore the integrity of the structures of the skull is accompanied by an increase in the frequency of complications in the area of their installation (up to 34 % of cases), which first and foremost must include the formation of ulcers of the skin and purulent inflammation. The basic principles of surgical treatment of such category of victims now provide implant removal, long-term conservative preparation of wounds and repeated reconstructive intervention in the long term. The article presents an analysis of four clinical observations of successful treatment of patients with defects of the skin of the skull over the implants using a number of methods of combined skin plastics. It is shown that surgical interventions using skin-fascial flaps and free split grafts can prevent implant removal, preserve foreign structures and avoid complications in the early postoperative period.

Reconstruction of lower limbs in old age-an interdisciplinary approach : Strategies for trauma surgery, vascular surgery and plastic surgery

The treatment of complex injuries of the lower extremities in geriatric and/or multimorbid patients requires optimized preoperative and perioperative management as well as differentiated and interdisciplinary surgical approaches. Timely and definitive treatment should be strived for to avoid longer periods of immobilization. Temporary external stabilization of complex fractures, when necessary, should be followed by permanent loading stable internal osteosynthesis as soon as possible. Accompanying soft tissue defects are reconstructed after wound débridement using the full armamentarium of plastic and reconstructive surgical procedures, including microvascular free flap. In the context of perfusion compromised soft tissue situations, negative pressure wound therapy can provide sterile temporary defect coverage and aid in preconditioning poorly vascularized tissue before definitive reconstruction. A clarification of the vascular status in geriatric patients is paramount and relevant perfusion disorders should be treated either by intervention or open surgery before complex reconstructive interventions. Close interdisciplinary coordination of the various surgical procedures is imperative in order to guarantee an optimized stable reconstructive outcome with acceptable patient risk. Taking these principles into account, the reconstruction of complex trauma to the extremities can be carried out even in geriatric or multimorbid patients in specialized interdisciplinary surgical centers with excellent functional results.

S8B-02 SESSION 8B: FACE RESEARCH - PART I TOWARD AN OBJECTIVE OUTCOME IN FACIAL REANIMATION SURGERY: AN EYETRACKING STUDY

Introduction: The availability of an objective outcome measure for facial reconstructive surgery remains elusive. Evaluations submitted by external raters or by patient self-report may be influenced by expert knowledge, emotional antecedent, or implicit attitude. These types of subjective ratings, or objective measures such as anthropometric analysis, may unreliably convey how one is perceived by others. We are interested in observers’ instantaneous, reflexive responses to the human face, and how those instinctive responses relate to subjective judgment of a given face. Methods: We explored the visual markers that lead to differential perception of patients before and after facial reanimation surgery. By examining the early stages of visual processing that occur, we intended to measure changes in the focus of impression formation, thereby helping surgeons and their patients prioritize areas for reconstruction. Pre and post operation (>3 months) photographs from 10 patients with unilateral facial nerve palsy who underwent cross facial nerve graft and free gracillis muscle transfer were obtained.40 observers examined each image while an infrared eye-tracking camera continuously recorded their eye movements. The observers were then asked to rate the image for character attributes (attractiveness, trustworthiness, sociability, healthy, and capability, 1–7 scale). Results: (i) The surgical intervention was found to decrease the observers’ attention to the upper lip on the unaffected (non palsy) side, thus equalizing attention to both sides of the lips. (ii) The surgical intervention was found to significantly increase the character ratings for all five attributes compared to pre op controls: (sociable 3.2 to 3.6, trustworthy 3.42 to 3.61, attractive 2.96 to 3.2, health 3.37 to 3.54, p<0.05. (iii) For those pre-operative images of facial palsy, observers’ attention was overwhelming drawn to the area of disproportion. (iv) Our eye tracking methodology clearly reflects a trend towards normalization of gaze attention following surgical intervention. This finding was associated with the improvement in character assessment of the images in the post-op cohort of images. Conclusion: We provide data illustrating a novel and objective technique to evaluate the effect of reconstructive intervention for facial palsy. This information may be used to inform patients about how these areas of facial difference/aging are perceived, and the potential effect that surgical intervention may have on others’ perception of them. This work may assist patients and their surgeons to more meaningfully focus their surgical decision-making priorities.

Objective Outcomes in Upper Blepharoplasty

GOALS/PURPOSE: The availability of objective outcome measures for facial reconstructive surgery remains lacking. Evaluations submitted by external raters or by patient self-report may be influenced by expert knowledge, emotional antecedent, or implicit attitude. Visual markers that lead to differential perception of patients before and after upper blepharoplasty were explored. By examining the early stages of visual processing that occur when an observer encounters images of affected individuals, we intended to reveal the focus of impression formation, thereby helping surgeons and their patients pinpoint the facial features that are most salient to viewers. METHODS/TECHNIQUE: Eighty images for 13 patients who underwent upper blepharoplasty, with and without lower blepharoplasty and brow lifts, were collected. Photographs were obtained before and after surgical correction (>3 months postoperative). Twenty lookzone regions were mapped onto each facial image, reflecting the esthetic units of the face. Eighty observers examined the images while an infrared eye tracking camera continuously recorded their eye movements. The observers were then asked to rate the image for character attributes (Attractiveness, Trustworthiness, Sociability, Healthy, and Capability, 17 scale). Factorial analysis of variance and Student’s t test analysis were performed to determine significance of differences between groups. Outcomes measured were the total number of eye fixations within different lookzone regions. Eye tracking data of pre- and postoperative images were analyzed and compared. RESULTS/COMPLICATIONS: Thirteen blepharoplasty patients were identified. (1) The surgical intervention was found to increase observers’ attention to the upper eyelid and periorbital area, and to decrease attention to the forehead, lower eyelid, and midcheek areas. (2) The surgical intervention was found to significantly increase the character ratings for all 5 attributes compared to preoperative controls: Sociable 3.66–4.01, Trustworthy 3.91–4.24, Attractive 3.39–3.75, Healthy 4.26–4.66, Capable 4.27–4.56; (P < 0.05) except for Attractive (P = 0.059). (3) For those preoperative images of brow and upper eyelid ptosis that resulted in clinical eyelid asymmetry, observers’ attention was overwhelming drawn to the area of disproportion. (4) Our eye tracking methodology clearly reflects a trend toward normalization of gaze attention following surgical intervention. This finding was associated with the improvement in character assessment of the images in the postoperative cohort of images. CONCLUSION: We provide data illustrating a novel and objective technique to evaluate the effect of reconstructive intervention for the upper eyelid and/or the brow. This information may be used to inform patients about how these areas of facial difference are perceived, and the potential effect that surgical intervention may have on others’ perception of them. This work may assist patients and their surgeons to more meaningfully focus their surgical decision-making priorities.

Quality of life in patients after cystectomy as the main aim while making a choice for the urine derivation procedure

Objective. To estimate a quality of life (QL) in the patients after radical cystectomy, depending upon the urine derivation method.&#x0D; Materials and methods. Clinical analysis and estimation of QL was conducted in 76 patients, to whom radical cystectomy was performed (the main group). For the urine derivation after radical cystectomy the orthotopic reconstruction of the bladder in accordance to Schtruder’s procedure was accomplished in 26 (34.2%) patients, while Brikker’s ileoplasty – in 50 (65.8%) patients. With the aim for objectivization and standardization of the QL estimation procedure after reconstructive operative intervention on the lower urinary ways in 1 and 12 mo a social-clinical method of the investigation, basing on questionnaire «Medical Outcomes Study – Short Form» (SF-36), was applied. Sexual function was estimated, using questionnaire IIEF-5 (International Index of Erectile Function).&#x0D; Results. Socio-clinical investigations of QL have revealed the best indices in 12 mo in the patients, to whom orthotopic reconstruction of the bladder in accordance to Schtuder’s procedure was done, what differs from the Brikker’s ileoplasty procedure, concerning social functioning, psychological health and vital activity on 18.1, 12.5 and 25% accordingly. All the QL indices in the groups investigated have improved in 12 mo postoperatively, what witnesses about progressing social rehabilitation, not depending upon the kind of the urine derivation. The method of the urine derivation do not influences erectile function, and the main significance is gaining the preservation of nervous and vascular elements of a small pelvis.&#x0D; Conclusion. The results obtained witnesses, that in a psychological way the patients, having a newcyst and with a continent derivation of the urine are accepting their state as a more physiological one. This makes possible the conduction of maximal socio-clinical rehabilitation and adaptation of the able-bodied contingent of patients.

Endovascular Treatment of Carotid Cavernous Fistulas in the Area of Cavernous Sinus

Background Assessment of endovascular methods possibilities in the treatment for carotid-cavernous fistulas. Material and Methods The results of endovascular treatment in 22 patients with carotid-cavernous fistulas in the period from 2008 to 2018 were evaluated. The number of male patients was 13 (59%), female patients – 9 (41%). Fifteen patients (68%) had traumatic damage, 7 patients developed a spontaneous disease. All patients had a specific clinical features of carotidcavernous fistula, confirmed by anamnesis and angiographic study. After verification of the diagnosis, all patients underwent permanent transcatheter embolization of the pathological connection using detachable balloons, microspirals and adhesive composition. Results Twenty-one patients (95.5%) underwent one-stage embolization of carotid-cavernous fistulas. One patient (4.5%) required three procedures: two embolization with detachable balloons, final embolization with detachable spirals, due to deflation of the balloons in the early postoperative period. Destructive embolization of carotid-cavernous fistulas was performed in 2 cases (9%), reconstructive interventions were performed in 20 cases (91%). The angiographic success of the procedure was 100%. All treated patients had regression of symptoms during their hospital stay. During this period, one complication was identified in the form of post puncture hematoma, which required conservative treatment. Conclusion Endovascular treatment is a modern, effective and safe method for treating carotid-cavernous fistulas. Destructive occlusion (if there is no possibility of performing reconstructive intervention) is also a safe and clinically justified method for treating this pathology.

Reverse Abdominoplasty Advancement Flap: An Innovative Option in Breast Reconstruction in Post-Massive Weight Loss Patients

Summary:With the increase in obesity in the world, we observe more and more bariatric surgeries. Simultaneously, the incidence of breast cancer increases. The reverse abdominoplasty has been essentially described to lift the upper part of the abdomen for the individual who has loose excess skin in the supraumbilical region. The application of reverse abdominoplasty flap has been extended beyond aesthetic procedures to breast reconstructive interventions. We present an innovative option of postbreast cancer reconstruction by reverse abdominoplasty advanced flap following massive weight loss.

Surgical treatment of children with hip dysplasia complicated with avascular necrosis of the femoral head

Introduction. Avascular necrosis of the femoral head complicates the surgical treatment of hip dysplasia and aggravates the prognosis.&#x0D; Aim. We studied the immediate and medium-term results of reconstructive treatment in 18 children with hip dysplasia complicated by avascular femoral head necrosis, which developed after closed repositioning of a congenitally dislocated femur.&#x0D; Material and methods. Average age at the time of operation was 4.2 0.2 years. The patients were divided into two groups. Group 1 included 12 children with hip subluxation who underwent extra-articular reconstructions on articular components, spinal tunneling of the neck and head, and hardware unloading of the joint and group 2 included six patients with hip dislocation in whom an additional open reduction was performed. Functional results were estimated using DAubigne-Postel classification, whereas X-ray results were evaluated using Kruczynski classification.&#x0D; Results. Duration of observation was 37 years (average, 4.2 0.3 years). Functional results were good (1518 points) in nine joints in group 1, satisfactory (1214 points) in three joints in group 1 and five in group 2, and unsatisfactory (11 points) in one joint in group 2. X-ray results were good in six joints in group 1, satisfactory in six joints in group 1 and five in group 2, and unsatisfactory in one joint in group 2.&#x0D; Conclusions. Extra-articular reconstructive and stimulatory interventions combined with hardware decompression helps improve the shape and structure of the femoral head, and formation of congruent articular surfaces in children with subluxation of the thigh complicated by avascular necrosis.

Recent advances in urologic surgical techniques for pyeloplasty.

Pyeloplasty is one of the most common urological reconstructive interventions. Since the presentation of the first open pyeloplasty by Anderson and Hynes in 1949, the management of ureteropelvic junction obstruction has dramatically developed. The most immense progress was made in the 1990s with the introduction of laparoscopy. A multitude of new minimal surgical techniques have been introduced since then. In the last few years, the innovations were based on refinement of already-existing techniques and technology. With this aim, single-port surgery, three-dimensional vision for laparoscopy, robotic technology, and alternative techniques for creating the anastomosis-like fibrin glue have been introduced. This unsystematic review is timely, and the scientific interest is to present and discuss some of the latest advances in surgical techniques and different approaches for the intra- and post-operative management in pyeloplasty. To the best of our knowledge, this is the only review looking at the recent advances in urological surgical techniques for pyeloplasty during the last few years with a focus on new technology and surgical techniques.