Effects of pulsed inhaled nitric oxide delivery on the distribution of pulmonary perfusion in spontaneously breathing and mechanically ventilated anesthetized ponies

OBJECTIVE To measure changes in pulmonary perfusion during pulsed inhaled nitric oxide (PiNO) delivery in anesthetized, spontaneously breathing and mechanically ventilated ponies positioned in dorsal recumbency. ANIMALS 6 adult ponies. PROCEDURES Ponies were anesthetized, positioned in dorsal recumbency in a CT gantry, and allowed to breathe spontaneously. Pulmonary artery, right atrial, and facial artery catheters were placed. Analysis time points were baseline, after 30 minutes of PiNO, and 30 minutes after discontinuation of PiNO. At each time point, iodinated contrast medium was injected, and CT angiography was used to measure pulmonary perfusion. Thermodilution was used to measure cardiac output, and arterial and mixed venous blood samples were collected simultaneously and analyzed. Analyses were repeated while ponies were mechanically ventilated. RESULTS During PiNO delivery, perfusion to aerated lung regions increased, perfusion to atelectatic lung regions decreased, arterial partial pressure of oxygen increased, and venous admixture and the alveolar-arterial difference in partial pressure of oxygen decreased. Changes in regional perfusion during PiNO delivery were more pronounced when ponies were spontaneously breathing than when they were mechanically ventilated. CLINICAL RELEVANCE In anesthetized, dorsally recumbent ponies, PiNO delivery resulted in redistribution of pulmonary perfusion from dependent, atelectatic lung regions to nondependent aerated lung regions, leading to improvements in oxygenation. PiNO may offer a treatment option for impaired oxygenation induced by recumbency.

Efficacy of Percutaneous Intraarterial Facial/Supratrochlear Arterial Hyaluronidase Injection for Treatment of Vascular Embolism Resulting From Hyaluronic Acid Filler Cosmetic Injection

Background Vascular embolism is a serious complication of hyaluronic acid (HA) filler cosmetic injection and hyaluronidase injection has been proposed as the treatment. Until now there is a lack of adequate clinical evidence regarding the benefits of treatment for HA filler-induced vascular embolism by percutaneous facial or supratrochlear arterial hyaluronidase injection. Objectives To evaluate the efficacy of percutaneous facial or supratrochlear arterial hyaluronidase injection as a rescue treatment for HA filler-induced vascular embolism. Methods We included 17 patients with vascular embolism after facial HA filler injection. Intraarterial injection of 1500 units hyaluronidase was performed via facial artery for thirteen cases with skin necrosis and via supratrochlear arterial for four cases with severe ptosis and skin necrosis but no visual impairment. Simultaneously, the general symptomatic treatment and nutritional therapy were performed. Results After hyaluronidase injection, the facial skin necrosis in all cases was restored and the ptosis in the four cases was also significantly relieved. Patients were subsequently followed for 1 month to 1 year. The skin necrosis in 16 patients were completely healed and only 1 patient had small, superficial scars. Conclusions It is effective to alleviate the skin necrosis and ptosis resulting from HA filler embolism via percutaneous facial or supratrochlear arterial hyaluronidase injection.

Reconstruction of medium-size defects of the oral cavity: radial forearm free flap vs facial artery musculo-mucosal flap

Background The radial forearm free flap (RFFF) is the most commonly used flap for defects of the oral cavity. The facial artery musculomucosal (FAMM) is a safe and effective method to reconstruct medium sized defects of the oral cavity. No comparison exists between the FAMM flap and RFFF. Methods 1) Retrospective chart review from 2007 to 2016. 2) Cost difference analysis. Results Thirteen FAMM flap cases and 18 RFFF met inclusion criteria. The FAMM flap showed a tendency to lower rates of return to the operating room (p = 0.065) as well as lower rates of complications not requiring return to the OR with 1 complication in 1 patient as opposed to 10 patients with 15 complications (p = 0.008). Also, FAMM flap had shorter operative times compared to the RFFF group (7.2HR and 8.9 HR respectively, p = 0.002). The average operative room related costs for a FAMM flap were 6510 CAD vs 10,703 CAD for RFFF (p < 0.0005). Speech and swallowing outcomes were similar (p > 0.05). Conclusion The FAMM flap can be used for reconstruction of medium-size defects of the oral cavity with functional outcomes similar to the RFFF while decreasing the associated costs and morbidity. Graphical Abstract

Role of the facial artery musculomucosal flap in the reconstruction of palatal defects

The facial artery musculomucosal flap (FAMM flap) is a convenient option for covering complicated palatal defects, as it is a local flap inside the oral cavity with good tissue quality and minimal drawbacks. The present prospective study included 17 patients, 7 males and 10 females. Most of the patients had palatal fistulae, after cleft palate surgical repair; only one had a post-traumatic palatal defect. Superiorly based FAMM flaps were used for eight patients, and inferiorly based FAMM flaps were used for nine patients. A speech specialist assessed all patients, postoperatively. The range of follow-up time was from two to four years. In the majority of cases, reconstruction was successful and uneventful. Patients were satisfied regarding oral function. Complications were minor, which include incomplete coverage, bulkiness, temporary hardness and dimpling. The FAMM flap is a very useful, versatile, and technically easy flap for covering difficult palatal defects.

Facial Arterial Variations in Asians: A Study on Computed Tomographic Angiography

Background A consensus on facial artery (FA) anatomy has not been established due to the discrepancies in previous studies. Objectives The purpose of this study was to assess the branches, course, and location of the FA in Asians utilizing computed tomographic angiography (CTA). Methods The CTA images of 300 FAs from 150 Asian patients were evaluated. According to the termination branch, the FA was classified as follows: type 1, FA terminates superior labial or inferior labial artery; type 2: FA terminates lateral nasal or inferior alar artery; type 3: FA terminates medial canthal artery; type 4: FA is divided into duplex branches with dominant medial canthal artery laterally. The relationship between nasolabial fold and FA was evaluated, and the distances from anatomical landmarks to FA were measured to position the course. Results 70 arteries (23.3%), 163 arteries (54.3%), 49 arteries (16.3%), and the other 18 arteries (6.0%) were classified as type 1, 2, 3 and 4, respectively. 72.3% of FAs were located medially to the nasolabial fold, and only 14.7% of arteries were lateral to the nasolabial fold. The vertical distance between FA and the inner canthus or the midpoint of inferior orbital rim decreased from type 1 to type 4 FA (P &lt; 0.0001). No significant difference was found among the four types of FA in the distances between the mandibular angle (P = 0.1226) or oral commissure (P = 0.1030) and the FA at inferior of mandible. Conclusions The detailed findings of facial artery will provide a valuable reference for filler injection in cosmetic procedures and flap design in reconstructive surgery.

1527 A Rare Case of Facial Skin Necrosis Following Subdermal Poly-L-Lactic Acid Injection

Introduction Non-surgical / minimally invasive aesthetic procedures are a growing trend in the UK. A range of devices are available for soft tissue augmentation, including injectable Poly-L-Lactic acid (PLLA). PLLA is used for soft tissue augmentation and is thought effective for the correction of contour deficiencies, facial wrinkles and in restoring subcutaneous volume in patients with HIV-associated lipoatrophy. Method In this case report, we present a rare but serious complication of subdermal injection of Poly-L-Lactic acid. A 45-year-old lady presented to our service approximately 24 hours after administration of self-sourced poly-L-Lactic acid. Results A 4cm ovaloid patch of full thickness skin necrosis over the zygomatic region was evident on presentation, with reactive/inflammatory changes in the adjacent skin. Vascular compromise is deemed the most likely cause, with loss of the transverse facial artery mapping to the area of necrosis. This patient was managed conservatively, with dressings and a prophylactic course of antibiotics. Conclusions Vascular compromise is a recognised and rare complication of subdermal injectable devices for facial soft tissue augmentation. The transverse facial artery branches from the superficial temporal artery within the substance of the parotid gland. Cadaveric and imaging studies alike demonstrate that the most common anatomical variant is a single TFA (70%), originating at the level of the temporofacial trunk of the facial nerve. It typically has a 5cm course, giving off on average 1.9 cutaneous perforators. This case highlights the importance of a detailed understanding of facial anatomy to ensure safe and effective placement of dermal fillers/devices.