Lip augmentation using the palmaris longus tendon

Iatrogenic Injury to the Median Nerve During Palmaris Longus Harvest: An Overview of Safe Harvesting Techniques

Background: A rare and disastrous complication of harvesting a tendon graft is the misidentification of the median nerve for the palmaris longus. Methods: The authors report a referred case in which the median nerve was harvested as a free tendon graft. Results: Few reports of this complication are found in the literature despite the frequency of palmaris longus tendon grafting and the proximity of the palmaris tendon to the median nerve. Given the obvious medicolegal implications, the true incidence of this complication is difficult to assess. Discussion: Safe harvesting of the palmaris longus mandates a thorough understanding of the relevant anatomy, in particular the proper differentiation between nerve and tendon and recognition of when the palmaris longus tendon is absent. Techniques to facilitate proper identification of the palmaris longus are outlined.

Anatomic variation of palmaris longus and flexor digitorum superficialis of little finger in Indian population

INTRODUCTION

Palmaris longus and flexor digitorum superficialis of the little finger are highly variable anatomically. The tendons vary in different parts of the globe and different regions of the same country. Many studies have negated an association between the tendons. However, most of the studies have a sample size of less than 500 subjects.

AIMS AND OBJECTIVES

The aim was to study the tendons in the Indian population and study the association, if any between the tendons and to test functional significance of the tendons using the Michigan Hand Outcomes Questionnaire.

METHODS AND MATERIAL

It was a single centre cross-sectional study with a sample size of 1500 in the age group of 20-60 years. The subjects were tested for the presence of the tendons and their functionality was assessed by Michigan Hand Outcomes Questionnaire. The data was tabulated and was assessed using SPSS 13.0 software.

RESULTS

Palmaris longus was bilaterally absent in 10.9% and flexor digitorum superficialis of the little finger was bilaterally absent in 42% of the cases. There was a statistically significant association between the tendons when considered bilaterally. The tendons did not have any bearing on the functionality as assessed by the Michigan Hand Outcomes Questionnaire.

CONCLUSIONS

There is significant variability in the palmaris longus and flexor digitorum superficialis tendon to the little finger not only in the different countries but in different regions of the same country. However despite the various clinical and medicolegal aspects concerning both the tendons, they do not have much bearing on the functionality of the hand.

Systematic review of "filling" procedures for lip augmentation regarding types of material, outcomes and complications

BACKGROUND

The ideal lip augmentation technique provides the longest period of efficacy, lowest complication rate, and best aesthetic results. A myriad of techniques have been described for lip augmentation, but the optimal approach has not yet been established. This systematic review with meta-regression will focus on the various filling procedures for lip augmentation (FPLA), with the goal of determining the optimal approach.

METHODS

A systematic search for all English, French, Spanish, German, Italian, Portuguese and Dutch language studies involving FPLA was performed using these databases: Elsevier Science Direct, PubMed, Highwire Press, Springer Standard Collection, SAGE, DOAJ, Sweetswise, Free E-Journals, Ovid Lippincott Williams & Wilkins, Willey Online Library Journals, and Cochrane Plus. The reference section of every study selected through this database search was subsequently examined to identify additional relevant studies.

RESULTS

The database search yielded 29 studies. Nine more studies were retrieved from the reference sections of these 29 studies. The level of evidence ratings of these 38 studies were as follows: level Ib, four studies; level IIb, four studies; level IIIb, one study; and level IV, 29 studies. Ten studies were prospective.

CONCLUSIONS

This systematic review sought to highlight all the quality data currently available regarding FPLA. Because of the considerable diversity of procedures, no definitive comparisons or conclusions were possible. Additional prospective studies and clinical trials are required to more conclusively determine the most appropriate approach for this procedure.

LEVEL OF EVIDENCE

IV.

Palmaris longus absence in six largest Indonesian ethnicities and its relationship with gender, ethnicity, and hand dominance

Background: Palmaris longus (PL) tendon is often used as graft in tendon or ligament reconstruction. PL absence is a normal variation in human body. Its prevalence was different in various population. Serbian population had an absence rate of 42.4%, but in the Korean population it was only 4.0%. This study aimed to determine the prevalence of PL absence in various ethnic of Indonesian population and its relationship with gender and side of hand dominance. Methods: We conducted a cross-sectional study in 1230 people from six ethnicities in Indonesia. The absence of PL was determined by Schaeffer test and confirmed with Mishra and Thompson test. Data collection was performed by a single examiner in various cities in Indonesia. The relationship between PL absence with ethnicity, gender, and hand dominance were determined by Chi-square test. Results: Prevalence of PL absence in overall Indonesian population was 10.4% (bilateral 37.5% and unilateral 62.5%). The highest were in Batak and Madura ethnicities (15.5%), followed by Sunda (11.8%), Java (10.0%), Betawi (6.0%), and the lowest was Minang ethnicity (4.1%) (p = 0.008). Prevalence of PL absence in female and male were 10.7% 10.2%, respectively, p > 0.05).Conclusion: Compared to range of prevalence in other countries in the world, prevalence of PL absence in Indonesian population was moderate (10.4%). There was significant difference found between ethnicity, but not in gender. Surgeon should consider this data when planning for reconstruction procedures using PL graft in Indonesian population.

Versatile but temperamental: a morphological study of palmaris longus in the cadaver

INTRODUCTION

Palmaris longus (PL) is one of the most variable muscles in our body and is vestigial functionally. Its long tendon and its superficial location make it an ideal source for tendon harvesting. Variations such as absence, duplication and reversal have far reaching clinical impact. The aim of this study is to estimate the presence, variants and nerve supply of the PL.

MATERIALS AND METHODS

Upper extremity of 24 cadavers was dissected and PL was examined. The results were compared to other studies on the PL and literature survey was carried out.

RESULTS

Thirty nine specimens showed normal morphology and four showed complete agenesis. Other morphological variations seen included - reversed, hybrid, fusiform, fleshy and bifurcated tendon of insertion.

CONCLUSION

Every surgeon must be aware of the variations of the versatile but temperamental PL. Prior knowledge of the layout of the muscle helps in planning intricate surgeries to which this tendon is put use to.

Constructing the philtral column in the secondary cleft lip deformity: utilizing the palmaris longus graft

BACKGROUND

The philtrum and the Cupid's bow are the most prominent features of the upper lip and are crucial for normal appearance. Unfortunately, projection of the philtral column is a common deficiency of the repaired cleft lip. Although a multitude of methods for constructing the philtral dimple and ridge have been described, no single procedure has achieved complete satisfactory results. The authors describe their technique for construction of the philtral column using palmaris longus tendon.

METHODS

Between 1998 and 2009, a retrospective study was performed for identifying patients with depression of the philtral scar following cleft lip repair. Pre- and postoperative photographs were taken with at least 6 months follow-up. Postoperative patient satisfaction and occurrence of complications are reported.

RESULTS

In all, 17 patients who developed depression of the philtral ridge following cleft lip repair underwent philtral reconstruction utilizing palmaris longus tendon grafts by the senior author (H.K.K.). At the time of surgery, average age for 11 females and 6 males was 18.5 years. The follow-up period ranged from 6 to 126 months, with an average of 42.3 months. In the early postoperative period, 2 complications in the form of graft exposure occurred. However, both cases were successfully managed with preservation of the graft. All patients were satisfied with their long-term results, and none required further surgery.

CONCLUSIONS

The use of palmaris longus tendon graft is an effective, reproducible, and safe method by which to construct the philtral column in the secondary cleft lip deformity.

Incidence of agenesis of palmaris longus in the Andhra population of India

BACKGROUND

The knowledge of Palmaris longus (PL) is a growing interest for its wide role in reconstructive plastic surgeries as a donor tendon for transfer or transplant. The prevalence of the PL agenesis has been well-documented by many authors in different ethnic groups or populations. Many conventional tests for determining the presence of the PL has been described, but lamentably there are many discrepancies in confirming its presence or absence. Slight modifications of the prevailing methods can still give authenticate results.

AIM

This prospective study was conducted to determine the incidence of unilateral and bilateral agenesis of PL and its association with sex and side of the limb in the Andhra population of India.

MATERIALS AND METHODS

A total of 942 subjects of both sexes belonging to 18-23 years were used to access the PL using various tendon examination techniques including our modified Schaeffer's test. The data collected were analyzed by Pearsons χ(2) test using SPSS software.

RESULTS

Overall agenesis of muscle in both sexes was 264 (28.0%), out of which 40.2% was seen in females and 14.7% in males with the ratio of 3:1. The unilateral agenesis was seen in 70.5% and bilateral agenesis in 29.5% subjects. The left side agenesis was seen in 51.6% and right side in 48.4% subjects.

CONCLUSIONS

The prevalence of bilateral and unilateral agenesis was more common on left side with a greater likelihood in the female subjects. The proposed technique could bring better results in all subjects and can be implemented in manual examination of PL.

Temporalis fascia for lip augmentation

BACKGROUND

The pervasiveness of the desire for beautiful lips persists today, with women in the United States spending almost 2.9 billion dollars annually on cosmetics and lip products. The lips occupy the central feature of the lower third of the face and are of paramount importance to facial beauty. Various surgical approaches and methods are used in lip augmentation.

METHODS

We reviewed the charts of 7 patients who underwent temporalis fascia lip augmentation to evaluate the temporalis fascia as a safe and effective means for lip augmentation.

RESULTS

The average follow-up was 5 years (range, 4-6 years). All patients who underwent lip augmentation were female. The average age of the patients was 47 years old with a range of 36 to 67 years. All patients were very satisfied with the results of their surgical lip augmentation postoperatively and no patients required any revision operations.

CONCLUSION

Temporalis fascia is a safe method of lip augmentation and is durable and long lasting. Lip augmentation with temporalis fascia can easily be performed in conjunction with other procedures.

Upper-lip augmentation by graft of preseptal orbicularis oculi muscle through blepharoplasty

BACKGROUND

Upper-lip augmentation is used to enhance a thin upper lip or correct lip deficiencies or senile hypotrophy. We describe an easy, effective, and reproducible technique.

METHODS

We use two preseptal orbicularis oculi muscle grafts that provide a reliable option for soft-tissue upper-lip augmentation, with improved vertical lip height and lateral lip projection and reappearance of the Cupid's bow. Muscle grafts are harvested from a blepharoplasty done at the same time.

RESULTS

The advantages of this procedure include the creation of an anatomically natural upper lip through preserving the continuity and function of the labial structure, good augmentation, no donor-site morbidity, no visible scars on the vermilion, and successful rejuvenation with the associated blepharoplasty.

CONCLUSION

Both patients and surgeons were satisfied with the results because the muscle grafts produce a youthful appearance by adding natural, soft roundness and fullness to the upper lip without an artificial look or the use of synthetic material, providing long-term augmentation.

Autologous fat transfer national consensus survey: trends in techniques for harvest, preparation, and application, and perception of short- and long-term results

BACKGROUND

Despite a perceived interest in autologous fat transfer, there is no consensus as to the best technique or the level of success. The purpose of the present study was to determine the national trends in techniques for harvest, preparation, and application of autologous fat, as well as the success perceived by practitioners.

METHODS

Comprehensive surveys were sent to 650 randomly selected members of the American Society for Aesthetic Plastic Surgery. The survey was aimed at determining whether autologous fat transfer is a commonly performed procedure and, if so, the specific methods involved and the subjective perception of short- and long-term results.

RESULTS

The results of the national consensus survey from 508 surgeons (78 percent return rate) showed the following: (1) autologous fat transfer is a relatively common procedure (57 percent perform >10 annually), but few perform it in high volume (only 23 percent perform >30 annually); (2) techniques for harvest, preparation, and injection rarely deviate from methods discussed in the literature (microcannula, 54 percent; centrifugation, 75 percent; injection in nasolabial fold > lips > nasojugal folds); (3) most physicians believe that at least some graft survival is clinically evident (93 percent); and (4) patients are pleased with the short-term results (good to excellent, 84 percent), despite a lower rate of long-term patient satisfaction (fair to good, 80 percent).

CONCLUSION

Currently, plastic surgeons across the country report a uniformity of autologous fat grafting techniques with acceptable patient satisfaction.

Augmentation Rhinoplasty Using Injectable Tissue-Engineered Soft Tissue

In a previous animal study, the authors reported that cultured human fibroblasts suspended in Restylane, which is a modified hyaluronic acid, can produce human dermal matrices with extended in vivo stability. This study was undertaken to evaluate the clinical efficacy of this method, particularly for augmentation rhinoplasty cases. Between January 2002 and June 2003, 11 patients were treated with subcutaneous implants of Restylane mixed with autologous fibroblasts for augmentation rhinoplasty. Of these 11 patients, a long-term follow-up for more than 1 year was possible in 6 patients. Appearance of reconstructed noses, degree and time of resorption, occurrence of complications, and patients' satisfaction were investigated. The injected implants remained in situ without evidence of significant resorption or loss of correction. All patients were satisfied with the achieved long-term results, and no complication occurred. The results obtained indicate that this method is well tolerated and may have a potential to be an effective means of performing augmentation rhinoplasty.

The fate of transplanted fibrous capsule as an autogenous graft

BACKGROUND

In reconstructive and aesthetic surgery, several autogenous graft materials and biomaterials are available for soft-tissue augmentation, but none has all the properties of the ideal filler material. The common problem is that heterogeneous material is reactive, and the problem for the autogenous grafts is resorption.

METHODS

In this experimental study, the authors examined the transformation that the autogenous graft undergoes in a different location when it is used as a capsule tissue in place of silicone. Whole/diced capsule and fat grafts were evaluated at 3, 6, 9, and 12 months for their volume, weight, and histopathologic and statistical bases.

RESULTS

The capsule graft was observed at month 12 as a dense collagen bulk. When it had decreased by 25.6 percent in volume at the end of the 12-month period, the decrease in weight was found to be 20 percent. The resorption rates in diced capsule grafts were 14 percent of volume and 8.6 percent of weight. The volume-based rate of resorption was even lower (63 percent) for the capsule than for the fat, and the weight-based rate of resorption was even lower (70 percent) for the capsule.

CONCLUSIONS

The low rate of resorption in capsule grafts was attributed to the environmental conditions that triggered the potential cause of resorption, such as inflammation in the localization conditions when it is was carried from the region where it was formed. The results indicate that in the new localization of the capsule tissue that is developed against silicone, it behaves as an autogenous graft that it is resorbed at a lower rate.

Advantages of the Presence of Living Dermal Fibroblasts Within Restylane for Soft Tissue Augmentation

For the elimination of facial wrinkles and skin contour defects, injectable filler substances composed of commercially prepared nonanimal stabilized hyaluronic acid (Restylane) are now widely used. Although this method of suspension has been shown to be relatively safe and convenient, varying degrees of resorption have required repeated percutaneous injections. This study was undertaken to evaluate the feasibility of Restylane, which is a modified hyaluronic acid, combined with cultured human dermal fibroblasts, to enhance the longevity of injected implants. The histologic changes of the injected implants were also evaluated. For the test group, fibroblasts from the dermis of healthy adults were isolated and cultivated. The cultured fibroblasts were measured with a hemocytometer. Five x 105 fibroblasts suspended in 200 microl of Dulbecco phosphate-buffered saline (DPBS) were then dispersed in 200 microl of Restylane to form a 400-microl human fibroblast-Restylane mix. For the control group, 200 microl of DPBS without fibroblasts were mixed with 200 microl of Restylane. These implants were subcutaneously injected into the back of an athymic nude mouse at 6 sites, the 3 left sites composing the control group and the 3 right sites composing the test group. Twelve nude mice were injected for a total of 36 injections per group. The nodular swellings that resulted from the injections were excised to include skin beyond the swelling points down to the panniculus carnosus layer using 5-mm punches, and the weights were measured at 1, 2, 4, 8, 12, and 16 weeks after the injections. Histologic comparisons were also performed to confirm the presence of human collagen in the fibroblast-mixed Restylane group using immunohistochemical study with antihuman collagen type I polyclonal antibody. The mean weight of the control group nodules decreased throughout the examination period. The mean weight at the 16th week was 60% of the weight at the first week. On the other hand, the mean weight of the test-group nodules decreased only over the first 2 weeks. Beyond 2 weeks, there was no further significant weight change. The mean weight at the 16th week was 91% of the weight measured at the first week. Histologic examinations of the control group exhibited negative immunohistochemical staining for human collagen at each examination period. The test group exhibited positive staining after 2 weeks, indicating the presence of human collagen. These results indicate that Restylane mixed with cultured human dermal fibroblasts may be successfully injected as living grafts for long-term retention of implants.

Lip augmentation using an alloderm graft

A wide variety of surgical procedures and implant materials have been used to satisfy the growing demand of patients for lip augmentation. The authors describe our experience with Alloderm (LifeCell Corp, The Woodlands, TX). It has proven to be a safe and effective means of offering mild to moderate augmentation of the lips.