Importance: Although conventional hump resections are a hallmark of rhinoplasty, there has been a rekindled interest in dorsal preservation (DP) techniques as a means for addressing the dorsal hump, with claims of superior functional and aesthetic results. As such, an understanding of DP, including technical considerations and outcomes, is imperative. Observations: DP allows for mobilization of the osseocartilaginous nasal vault as a single unit and thereby prevents disruption of the natural keystone area. The osseous nasal vault is managed with a transverse osteotomy and either a bilateral single lateral osteotomy (pushdown procedure) or bilateral bony wedge resections (letdown procedure) to allow for descent of the nasal dorsum. A variety of approaches to the septum exist, each differentiated by the location of cartilage resection: subdorsal, high-septal, midseptal, or inferior septum. These techniques result in pleasing dorsal aesthetic lines but may be limited by a higher rate of dorsal hump recurrence. Patency of the internal nasal valve (INV) is theoretically improved with DP. Robust series with patientreported outcomes are lacking, although several reports and early experience at our center with a newly described high-septal resection technique do suggest positive functional and cosmetic outcomes with DP. Conclusions and Relevance: With the recent revitalized interest in DP, an understanding of the potential benefits, techniques, and challenges associated with this surgery is helpful. Maintenance of the dorsum as a single unit has implications for maintaining structural integrity at the nasal keystone, pleasing dorsal aesthetic lines, and the patency of the INV. As surgeons continue to develop and employ these techniques, critical assessment of patient-reported outcomes and objective nasal measurements, with an emphasis on comparison with standard hump takedown techniques, will be valuable.

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Identifying factors affecting forehead flap neovascularization during nasal reconstruction surgical procedures using quantitative dynamics of fluorescence from indocyanine green angiography may be associated with reduced vascular complications.OBJECTIVES To identify quantifiable forehead flap perfusion measures using indocyanine green angiography during nasal reconstruction procedures and to evaluate clinical factors associated with neovascularization. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study of 71 patients at a tertiary referral center of Stanford University, Stanford, California, between January 1, 2010, and March 31, 2018, undergoing forehead flap nasal reconstruction surgery with flap perfusion assessed by indocyanine green angiography.EXPOSURES Indocyanine green angiography was performed intraoperatively to record forehead flap neovascularization during the second stage of nasal reconstruction surgery after temporary clamping of the pedicle. MAIN OUTCOMES AND MEASURESWith use of quantifiable data of fluorescence dynamics, flap perfusion in association with a reference point in the cheek after pedicle clamping was assessed by 2 methods: (1) ingress (arterial inflow) and egress (venous outflow) flap-to-cheek ratio and (2) flap-to-cheek perfusion (fluorescence) ratio at 3 time points (midpoint of indocyanine green flap inflow, maximum fluorescence [peak], and midpoint of indocyanine green flap outflow) and their calculated mean. Association of the perfusion measures with patient and procedural factors was performed using linear regression models. RESULTSOf the 71 patients included in the study, 43 (61%) were men; the mean (SD) age was 71.1 (11.0) years. The mean (SD) flap-to-cheek inflow ratio was 0.48 (0.40), peak fluorescence ratio was 0.59 (0.34), and outflow ratio was 0.88 (0.42). The calculated mean (SD) flap-to-cheek perfusion ratio of these measures was 0.65 (0.35). The mean (SD) flap-to-cheek ingress ratio was 0.54 (0.36) and egress ratio was 0.65 (0.98). With use of a multivariable regression model, the time between stages was positively associated with flap-to-cheek ingress ratio (β, 0.015; 95% CI, 0.001 to 0.030), and cartilage grafting was negatively associated with flap-to-cheek outflow ratio (β, -0.240; 95% CI, -0.472 to -0.008). CONCLUSIONS AND RELEVANCEThe findings suggest that indocyanine green angiography is an effective method to quantify relative neovascularization perfusion of forehead flaps. Future applications may include the use of this technology to aid in early flap division and ensure adequate perfusion among high-risk patients.LEVEL OF EVIDENCE NA.

Between 2002 and 2007, fifty elderly patients with displaced femoral neck fractures were treated with hip replacement at Emergency Hospital, Mansoura University. Patients were randomly selected, 25 patients had either cemented or cementless bipolar prosthesis, and another 25 patients had either cemented or cementless fixed-head prosthesis. There were 34 women and 16 men with an average age of 63.5 years (range between 55 and 72 years). All patients were followed up both clinically and radiologically for an average 4.4 years (range between 2 and 6 years). At the final follow-up, the average Harris hip score among the bipolar group was 92 points (range between 72 and 97 points), while the fixed-head group was 84 points (range between 65 and 95 points). Radiologically, joint space narrowing more than 2 mm was found in only 8% (2 patients) among the bipolar group, and in 28% (7 patients) of the fixed-head group. Through the follow-up period, total hip replacement was needed in two cases of the bipolar group and seven cases of the fixed-head group. Bipolar hemiarthroplasty offered a better range of movement with less pain and more stability than the fixed-head hemiarthroplasty in elderly patients with displaced femoral neck fractures.

BackgroundThe minimal clinically important difference (MCID) for the Standardized Cosmesis and Health Nasal Outcomes Survey (SCHNOS) has not been determined.ObjectivesThe authors sought to define the MCID for both domains of the SCHNOS questionnaire.MethodsThis prospective cohort study included patients who underwent functional, cosmetic, or combined rhinoplasty operation from June 2017 to June 2018 at a tertiary referral center. The average preoperative, postoperative, and change in scores were calculated for the nasal obstruction symptom evaluation scale (NOSE) and SCHNOS. Anchor-based MCIDs were estimated for both SCHNOS subscales to define change in obstruction and cosmesis perceived after the rhinoplasty.ResultsEighty-seven patients (69% women, 31% males) with a mean age (standard deviation [SD]) of 38 years (14.7) at the time of surgery were included. The mean postoperative follow-up period (SD) was 145 days (117). The mean preoperative score (SD) for the NOSE was 52 (32), SCHNOS for nasal obstruction (SCHNOS-O) score was 55 (33), and SCHNOS for nasal cosmesis (SCHNOS-C) score was 50 (26) points. Postoperatively, the NOSE score was 23 (22), SCHNOS-O score was 24 (23), and SCHNOS-C score was 13 (18) points. The mean change in scores (SD) for NOSE, SCHNOS-O, and SCHNOS-C was −29 (37), −31 (38), and −37 (28), respectively. The calculated MCID for SCHNOS-O was 26 (16) and for SCHNOS-C was 22 (15) points. The MCID for NOSE was 24 (13) points. A sensitivity test for the patients with a follow-up ≥3 months showed only slightly different MCID estimates: 28 (17) for SCHNOS-O, 18 (13) for SCHNOS-C, and 24 (15) points for NOSE.ConclusionsFor the obstruction domain SCHNOS-O, the MCID was 28 points. For the cosmetic domain SCHNOS-C, the MCID was 18 points.

The population in the East Nile Delta region of Egypt exhibits an unusually high rate of young-onset pancreatic cancer. Further studies to investigate the epidemiology of pancreatic cancer in this population may provide clues to its etiology.

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