Preauricular Aging: A Three-Point Grading System to Guide Treatment in Facial Rejuvenation

BACKGROUND

Aging affects the face in all its dimensions. However, more has been published about the improvement of the periocular, midface, and perioral aging changes. We believe the profile view, particularly the preauricular area, is of great value when assessing the need for facial contouring procedures, as well as their effectiveness.

OBJECTIVE

To develop and evaluate a classification based on the aging changes around the preauricular area, which aims to provide an objective direction to the appropriate treatment method.

METHODS AND MATERIALS

All patients who attended the clinic for different aesthetic procedures between June 2019 and January 2020 were photographed. Two non-treating dermatologists and two non-treating plastic surgeons were asked to evaluate the perceived aging of the preauricular area using a three-point grading system. The assessment of each photograph was made once by each evaluator, and the inter-rater correlation was calculated.

RESULTS

A total of 158 profile pictures of the preauricular area of 158 patients were evaluated by two non-treating dermatologists and two non-treating plastic surgeons. The inter-rater correlation was excellent at 0.942. The mean grading system of the patient samples was 1.42, with a standard deviation of 0.9 and a variance of 0.001.

CONCLUSIONS

The preauricular area is often overlooked and undertreated. Our results demonstrate an excellent inter-rater correlation between plastic surgeons and dermatologists at assessing the degree of aging in the area. This relatively hidden lateral area can serve as a test point, evaluating response to selected treatment before proceeding to full-face intervention. We suggest using a simple three-point scale to help guide treatment of the preauricular area and as part of our holistic approach to facial rejuvenation.

LEVEL OF EVIDENCE IV

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Cranial and ventricular size following shunting or endoscopic third ventriculostomy (ETV) in infants with aqueductal stenosis: further insights from the International Infant Hydrocephalus Study (IIHS)

PURPOSE

The craniometrics of head circumference (HC) and ventricular size are part of the clinical assessment of infants with hydrocephalus and are often utilized in conjunction with other clinical and radiological parameters to determine the success of treatment. We aimed to assess the effect of endoscopic third ventriculostomy (ETV) and shunting on craniometric measurements during the follow-up of a cohort of infants with symptomatic triventricular hydrocephalus secondary to aqueductal stenosis.

METHODS

We performed a post hoc analysis of data from the International Infant Hydrocephalus Study (IIHS)-a prospective, multicenter study of infants (< 24 months old) with hydrocephalus from aqueductal stenosis who were treated with either an ETV or shunt. During various stages of a 5-year follow-up period, the following craniometrics were measured: HC, HC centile, HC z-score, and frontal-occipital horn ratio (FOR). Data were compared in an analysis of covariance, adjusting for baseline variables including age at surgery and sex.

RESULTS

Of 158 enrolled patients, 115 underwent an ETV, while 43 received a shunt. Both procedures led to improvements in the mean HC centile position and z-score, a trend which continued until the 5-year assessment point. A similar trend was noted for FOR which was measured at 12 months and 3 years following initial treatment. Although the values were consistently higher for ETV compared with shunt, the differences in HC value, centile, and z-score were not significant. ETV was associated with a significantly higher FOR compared with shunting at 12 months (0.52 vs 0.44; p = 0.002) and 3 years (0.46 vs 0.38; p = 0.03) of follow-up.

CONCLUSION

ETV and shunting led to improvements in HC centile, z-score, and FOR measurements during long-term follow-up of infants with hydrocephalus secondary to aqueductal stenosis. Head size did not significantly differ between the treatment groups during follow-up, however ventricle size was greater in those undergoing ETV when measured at 1 and 3 years following treatment.

Rat Hindlimb Cryopreservation and Transplantation: A Step Toward "Organ Banking"

In 2016, over 5 million reconstructive procedures were performed in the United States. The recent successes of clinical vascularized composite allotransplantations, hand and face transplantations included, established the tremendous potential of these life-enhancing reconstructions. Nevertheless, due to limited availability and lifelong immunosuppression, application is limited. Long-term banking of composite transplants may increase the availability of esthetically compatible parts with partial or complete HLA matching, reducing the risk of rejection and the immunosuppressive burden. The study purpose was to develop efficient protocols for the cryopreservation and transplantation of a complete rodent limb. Directional freezing is a method in which a sample is cooled at a constant-velocity linear temperature gradient, enabling precise control of the process and ice crystal formation. Vitrification is an alternative cryopreservation method in which the sample solidifies without the formation of ice crystals. Testing both methods on a rat hindlimb composite tissue transplantation model, we found reliable, reproducible, and stable ways to preserve composite tissue. We believe that with further research and development, cryopreservation may lead to composite tissue "banks." This may lead to a paradigm shift from few and far apart emergent surgeries to wide-scale, well-planned, and better-controlled elective surgeries.

NOX1-induced accumulation of reactive oxygen species in abdominal fat-derived mesenchymal stromal cells impinges on long-term proliferation

Mesenchymal stromal cells (MSCs) are multipotent and can be derived from different adult tissues including fat. Our repeated attempts to produce long-term proliferative cultures of rat abdominal adipose stem cells (aASCs) under normal oxygen concentration (21%) were unsuccessful. We set to examine the events controlling this cytostasis of aASCs and found that it resulted from overproduction of reactive oxygen species (ROS) that led to apoptosis. ROS overproduction in aASCs was accompanied by increased expression of NOX1 but not of NOX2 or NOX4. NOX family members are an important source of intracellular ROS pointing to NOX1 involvement in ROS accumulation. This was verified when aASCs that were grown under 3% oxygen conditions expanded long term, displaying reduced NOX1 expression and decreased ROS accumulation. NOX1 involvement in aASC cytostasis was reaffirmed when cells that were expanded under normoxic conditions in the presence of a specific NOX1 inhibitor, ML171, demonstrated reduced ROS accumulation, reduced apoptosis and long-term expansion. aASC expansion arrest was accompanied also by a weak fat differentiation and migratory potential, which was enhanced by NOX1 inhibition. This suggests an inhibitory role for NOX1-induced ROS overproduction on aASCs, their fat differentiation and migratory potential. In contrast to aASCs, similar cells produced from subcutaneous fat were easily expanded in normoxic cultures, exhibiting low ROS concentrations, a low number of apoptotic cells and improved fat differentiation and migration. Taken together, our results show, for the first time, that NOX1-induced ROS accumulation halts ASC expansion and reduces their differentiation and migratory potential under normoxic conditions. Importantly, this phenotype comprises a tissue-specific signature as it was evident in aASCs but not in subcutaneous ASCs. NOX-induced ROS accumulation and cytokine production by fat are part of the metabolic syndrome. The similarity of this phenomenon to aASC phenotype may indicate that they arise from similar molecular mechanisms.

Catheter-directed clot fragmentation using the Cleaner™ device in a patient presenting with massive pulmonary embolism

Massive pulmonary embolism not amenable to systemic thrombolysis is a therapeutic challenge. Catheter directed clot fragmentation and thrombolysis have been efficacious in this setting. We describe successfully treating a massive pulmonary embolism with catheter-directed thrombolysis and clot fragmentation using local tPA, aspiration, and the Cleaner™ device in a patient with an absolute contraindication to systemic thrombolysis.

Sex differences in parental reaction to pediatric illness

The 'Tend-and Befriend' hypothesis claims that whereas the response of males to stress is Fight-or-Flight, females respond with Tend-and-Befriend. We tested this hypothesis with a sample of 110 couples whose children had undergone neurosurgery. Both mothers and fathers answered questionnaires measuring levels of tending, befriending, stress, anxiety, and depression. As hypothesized, mothers scored higher than fathers did on all measures. However, according to the Tend-and Befriend hypothesis, the sex difference in tending and befriending should be more pronounced in couples suffering from high-stress in comparison to couples suffering from low-stress. This hypothesis was not supported by the data. We suggest that the heightened tending and befriending of women is not a reaction to stress, instead it is a persistent maternal characteristic. Moreover, we suggest that maternal anxiety and depression result from a heightened maternal sensitivity, selected for caregiving. The study results imply that support interventions should be aimed mostly at mothers, since they experience more distress, in comparison to fathers.

Maternal adaptation to pediatric neurosurgical diagnosis: a growth curve analysis

OBJECTIVE

To describe trajectories of change in maternal adaptation to chronic pediatric neurosurgical diagnosis and to identify variables predicting the level and rate of adaptation.

METHODS

One hundred and thirty seven mothers of children diagnosed with neurosurgical illness participated. Mothers reported socio-demographic variables, neuroticism, optimism, spouse support, mental health, and personal growth. The coordinating nurse assessed illness variables. Data were collected from diagnosis to 32+months post-diagnosis.

RESULTS

Results showed poor maternal mental health at diagnosis, followed by a gradual improvement over the next 18 months, and then a slight regression. Optimism, spouse support and religiosity were identified as resistance factors, while neuroticism, treatment needs, maternal age, and maternal education were identified as risk factors. The rate of change in mental health was moderated by neuroticism.

CONCLUSIONS

Maternal adaptation to pediatric illness changes over time. The trajectories of adaptation vary in relation to personal, social and medical variables.

Parental Investment in Children with Chronic Disease: The Effect of Child's and Mother's Age

Parents do not invest their resources in their children equally. Three factors which elicit differential parental investment are the parent's reproductive value, the child's reproductive value (RV), and the impact of the investment on the child (II). As the child matures, his RV increases while the II may decrease. This raises a question regarding the favored strategy of investment by child age. It was hypothesized that different categories of parental investment generate different age-based strategies. Emotional investment, such as maternal worrying for the child's health, was hypothesized to increase with the child's age, while direct care was hypothesized to decrease with the child's age. Both categories were hypothesized to increase with the mother's age at childbirth. 137 Israeli mothers of children with chronic neurological conditions reported levels of worrying for their child and levels of change in direct care. Maternal worrying about the child's health was positively associated with the child's age at diagnosis and the severity of his illness, and negatively associated with the time from diagnosis. An increase in direct care was positively associated with maternal age at childbirth and illness severity, and negatively associated with the time from diagnosis, and the duration of the marriage. Contrary to the hypothesis, the child's age had no effect on changes in direct care. It appears that in mothers of children with adverse neurological conditions, child and maternal age effect parental investment differently. While the child's age is related to maternal worrying about his health, the mother's age at childbirth is related to changes in direct care.

Blood-brain barrier disruption results in delayed functional and structural alterations in the rat neocortex

Disruption of the blood-brain barrier (BBB) is a characteristic finding in common neurological disorders. Human data suggest BBB disruption may underlie cerebral dysfunction. Animal experiments show the development of epileptiform activity following BBB breakdown. In the present study we investigated the neurophysiological, structural and functional consequences of BBB disruption. Adult rats underwent focal BBB disruption in the rat sensory-motor cortex using the bile salt sodium deoxycholate (DOC). Magnetic resonance imaging in-vivo showed an early BBB disruption with delayed reduction in cortical volume. This was associated with a reduced number of neurons and an increased number of astrocytes. In-vitro experiments showed that the threshold for spreading depression and the propagation velocity of the evoked epileptic potentials were increased 1 month after treatment. Furthermore, animals' motor functions deteriorated during the first few weeks following BBB disruption. Treatment with serum albumin resulted in a similar cell loss confirming that the effect of DOC was due to opening of the BBB. Our findings suggest that delayed neurodegeneration and functional impairment occur following the development of the epileptic focus in the BBB-permeable cerebral cortex.

Acute and fatal hyponatraemia after resection of a craniopharyngioma: a preventable tragedy

Central diabetes insipidus developed for the first time in a 14-year-old female during the resection of a craniopharyngioma. The water diuresis persisted until a vasopressin analogue (dDAVP) was given. Professor McCance was asked to explain why hypernatraemia developed, to anticipate dangers that might develop in the salt and water area with therapy, and to provide insights into why this patient died, due to the subsequent development of hyponatraemia that caused a lethal rise in intracranial pressure. The team specifically wanted Professor McCance's opinions as to why a PNa of 124 mmol/l was uniquely dangerous for this patient, and this was a particularly challenging conundrum. Nevertheless, with the aid of a mini-experiment, a careful chart review, and creative thinking, he was able to offer a novel solution, and to suggest ways to prevent its occurrence in other patients.

[Folic acid use by pregnant women in Israel for preventing neural tube defects]

Spina bifida and anencephaly are the most common, serious malformations in neural tube defects (NTD). Randomized trials in the last 2 decades have demonstrated that folic acid, 0.4 mg/d, reduces the incidence of NTD by more than 50%. We investigated the use of folic acid and multivitamins containing folic acid in childbearing women. Of 221 women interviewed, 67 (30%) regularly took pills containing 0.4 mg folic acid. Women with higher educational levels were more likely to take multivitamins with folic acid than were the less educated (p = 0.05). Of the women who took folic acid, only 5 (7.5%) used separate folic acid tablets, before and during their pregnancy. The rest used multivitamins containing folic acid. The 5 women who took folic acid separately were college-educated and nonreligious, and they took multivitamins in addition (p > 0.05). Of the women interviewed, 58 (26.2%) were Bedouin of the Negev. 24 (41.4%) of them took pills containing folic acid on a regular basis. This percentage is higher than that in the Jewish women in the study who took folic acid for prevention of NTD (17%; p = 0.038). Most of the women took folic acid after the first trimester. Only a minority took daily periconceptional folic acid. Multivitamins containing 0.4 mg of folic acid were more popular than folic acid tablets alone. This study emphasizes the need for continuing efforts to increase consumption of folic acid and awareness of its benefits among women of childbearing age.

Xanthoma of the temporal bone: a unique case of this rare condition

Xanthoma of the temporal bone is extremely rare; we describe only the fourteenth reported case. Our case is further remarkable because it is the first report of such an occurrence in a patient with familial type III hyperlipoproteinemia. Moreover, while otalgia, infection, hearing loss, and tinnitus were the most common initial symptoms in the previous 13 cases, our patient reported only diplopia, vertigo, and unstable gait. The patient underwent a simple mastoidectomy and debulking, and his diplopia, vertigo, and unstable gait resolved.

Postoperative bilevel positive airway pressure ventilation after tonsillectomy and adenoidectomy in children--a preliminary report

Obstructive sleep apnea (OSA) in children, characterized by hypoventilation secondary to upper airway obstruction, often results from tonsil and adenoid hypertrophy. Adenotonsillectomy is the standard therapy in this patient population. The immediate postoperative period is complicated occasionally by respiratory difficulties that may require intubation and mechanical ventilation. Recently, physicians have provided temporary airway support using continuous and bilevel positive airway pressure (BiPAP) devices. Reported complications of positive airway pressure devices include local abrasions to the nose and mouth; dryness of the nose, eyes, and mouth; sneezing; nasal drip, bleeds, and congestion; sinusitis; increased intraocular pressure; non-compliance; and pneumocephalus. Subcutaneous emphysema following facial trauma, dental extractions, adenotonsillectomy, and sinus surgery has been reported. There is also a hypothetically increased risk of subcutaneous emphysema following the use of positive airway pressure ventilation in the tonsillectomy patient. Between January 1997 and July 1998, 1321 patients underwent tonsillectomy and/or adenoidectomy at our institution. In reviewing the records of all pediatric intensive care unit admissions during that time period, we identified nine patients, of the 1321, who required BiPAP postoperatively. Of these, four children were obese, four had preexisting neurological disorders, and one underwent endoscopic sinus surgery and adenoidectomy. Three children were asthmatic, and three were less than 3 years of age. Two obese children were discharged with home BiPAP, one of whom had been on BiPAP prior to surgery. All patients tolerated BiPAP without complications. This preliminary report suggests that BiPAP is a safe and effective method of respiratory assistance in the adenotonsillectomy patient with preexisting conditions who is predisposed to postoperative airway obstruction. Furthermore, with BiPAP, the risks of intubation and ventilator dependence are avoided.

Transcription control and neuronal differentiation by agents that activate the LXR nuclear receptor family

LXR and PPAR receptors belong to the nuclear receptor superfamily of transcriptional activating factors. Using ligand-dependent transcription assays, we found that 5-tetradecyloxy-2-furancarboxylic acid (TOFA) transactivates chimeric receptors composed of the glucocorticoid receptor DNA binding domain and the ligand binding regions of PPARalpha, PPARbeta (NUC-1) and LXRbeta (NER) receptors. In the same assays, ligands for PPARs (oleic acid, WY-14643 and L-631,033) and LXRs (hydroxycholesterols) maintain their respective receptor selectivity. TOFA and hydroxycholesterols also stimulate transcription from a minimal fibrinogen promoter that is under the control of AP-1 or NF-kappaB transcription factor binding sites. In addition to their effects on transcription, these LXRbeta activators induce neuronal differentiation in rat pheochromocytoma cells. TOFA and the natural LXR agonist, 22 (R)-hydroxycholesterol, stimulate neurite outgrowth in 55 and 28% of cells, respectively. No neurite outgrowth was induced by the related 22(S)-hydroxycholesterol, which does not activate the LXR family. These results suggest that the hydroxycholesterol signaling pathway has a complex effect on transcription that mediates the activity of TOFA and hydroxycholesterol on neuronal differentiation in pheochromocytoma cells.