Surgical planning using facial fracture 3D models: The role of cyanoacrylate glue and miniplating for anatomical reduction.

BACKGROUND: In comminuted facial fractures, peri-operative use of 3D-printed life size models is increasingly a useful adjunct. It allows for preoperative surgical rehearsal and plate bending, to achieve anatomical reduction with reduced operative time and cost. One problem encountered is difficulty contouring the fixation plate whilst maintaining the relative spatial orientation of comminuted fragments. This paper shares an effective method of overcoming this problem. METHODS: All comminuted facial fracture patients underwent counselling for 3D printing. Pre-printing thresholding and segmentation of each fragment (as directed by the surgeon) were done by the radiologist and the engineering team, using the multi-slice CT Face DICOM data. Life-size 3D-resin models of the fractures were printed. Fast-acting medium consistency cyanoacrylate glue (Zap-A-GapⓇ) and miniplates were used to assemble the printed model segments in 'anatomic reduction'. Aerosolized alcohol accelerator facilitated immediate glue curing, providing a stable model. The plates were adapted over this restored neonative 3D construct with bending inserts, sterilized and used intraoperatively. The 3D model was used to guide the operative sequence. Intraoperative CT was used in select cases to confirm anatomic reduction. RESULTS/COMPLICATIONS: All patients (n = 5) had comminuted fractures in at least one of the bony units (mandible, maxilla or orbits) and one was a pan-facial fracture case. 3D printed models aided fracture reduction and fixation, whilst avoiding the guesswork in ascertaining the contour of the mandibular arch. In addition, the pre-contoured mandible plates restored premorbid occlusion and projection, without the need for long-term archbars in all cases. Operative time was estimated to be reduced by 0.5-1 h. Resident teaching was enhanced by this approach. CONCLUSION: The application of medium consistency fast-acting cyanoacrylate glue and miniplates facilitated the creation of the premorbid facial skeletal model and allowed pre-bending of the plates, thus saving operative time and cost.

Surgical and oncological safety of nipple-sparing mastectomy in an Asian population.

BACKGROUND: Nipple-sparing mastectomy (NSM) allows for excellent postmastectomy reconstruction aesthetics and is used for both therapeutic and risk-reducing purposes. Reservations regarding the potential for locoregional recurrence and concerns about nipple-areolar complex (NAC) necrosis remain amongst many surgeons. We review the surgical and oncological outcomes after NSM in our institution. METHODS: All NSM cases at the National Cancer Centre Singapore and Singapore General Hospital between 2005 and 2015 were reviewed. Tumour characteristics, reconstruction methods, surgical and oncological outcomes are described. RESULTS: A total of 139 NSMs were performed for 130 patients. The median age was 46 years (range 21-66). The use of NSM increased from 2% of all breast reconstructions in 2005 to 37% in 2015. The majority (n = 119; 86%) were for cancer treatment and 20 (14%) for risk-reducing purposes. Among those performed for cancer, patients mainly had early stage breast cancer (n = 106, 89%). Autologous reconstruction (n = 111, 80%) was most common. Early complications requiring surgical intervention occurred in 24 (17%) NSMs, including 9 partial/complete flap loss and 2 complete NAC loss. Smoking, previous breast radiation and periareolar incision were all not associated with a higher re-intervention rate (p = 0.93, 0.41 and 0.91, respectively). Median follow-up was 43 months (range 5-145). Five patients (4%) developed local recurrence, including 2 NAC recurrences. The 2- and 5-year overall survival rate is 97 and 90%, respectively. CONCLUSION: NSM is an oncologically safe procedure in selected patients with acceptable low complication rates.

Immediate breast reconstruction following nipple-sparing mastectomy in an Asian population: Aesthetic outcomes and mitigating nipple-areolar complex necrosis.

BACKGROUND: Nipple-sparing mastectomies (NSMs) are increasingly performed to obtain the best aesthetic and psychological outcomes in breast cancer treatment. However, merely preserving the nipple-areolar complex (NAC) does not guarantee a good outcome. Darkly pigmented NACs and a tendency for poor scarring outcomes are particular challenges when treating Asian patients. Herein, we review the reconstructive outcomes following NSM at Singapore General Hospital. METHODS: All breasts reconstructed following NSM over an 11-year period from 2005 to 2015 were reviewed. Information was collected from the patients' records on mastectomy indications, operative details, and complications. Patient satisfaction, breast sensation, and aesthetic outcomes were evaluated in 15 patients. Sensation was quantified using the Semmes-Weinstein monofilament test. RESULTS: A total of 142 NSMs were performed in 133 patients for breast cancer (n=122, 85.9%) or risk reduction (n=20, 14.1%). Of the procedures, 114 (80.2%) were autologous reconstructions, while 27 (19.0%) were reconstructions with implants. Complications occurred in 28 breasts (19.7%), with the most common complication being NAC necrosis, which occurred in 17 breasts (12.0%). Four breasts (2.8%) had total NAC necrosis. The overall mean patient satisfaction score was 3.0 (good). The sensation scores were significantly diminished in the skin envelope, areola, and nipple of breasts that had undergone NSM compared to non-operated breasts (P<0.05). Half of the subset of 15 patients in whom aesthetic outcomes were evaluated had reduced nipple projection. CONCLUSIONS: Immediate reconstruction after NSM was performed with a low complication rate in this series, predominantly through autologous reconstruction. Patients should be informed of potential drawbacks, including NAC necrosis, reduced nipple projection, and diminished sensation.

The Rolling Earlobe Flap for Dilated Ear Holes Following Ear Gauging: A Novel Approach to Aesthetically Preserving Earlobe Soft Tissue Volume.

Patients are increasingly seeking repair of their earlobes following ear gauging. Research has shown that current repair techniques either excessively reduce the lobular volume or leave an obvious scar along the free edge of the earlobe. In our case series, we describe the use of a novel technique for repairing earlobes following ear gauging using a rolling earlobe flap that preserves the lobular volume and avoids leaving a scar on the free edge of the lobule. The procedure was performed on 3 patients (6 earlobes) who had defects from ear gauging that ranged from 3.0 to 6.5 cm. There were no postoperative complications of infection, wound dehiscence, flap necrosis, hypertrophic scars, or keloids, and all patients were highly satisfied with the postoperative results. This versatile technique allows for an aesthetically pleasing reconstruction of the lobule with the advantages of: the absence of a surgical scar on the free edge of the lobule, preserving the lobule volume, and presenting a highly customizable technique that allows lobules to be created with various shapes and volumes.