Novel classification system for adult Asian secondary bilateral cleft lip with nasal deformity that guides surgical strategy.

BACKGROUND: Bilateral cleft lip is a congenital defect often accompanied by secondary lip and nose deformity. The current classification system for secondary cleft lip deformity has limitations in guiding surgical planning. In this article, we report a method for secondary bilateral cleft lip classification that can guide surgery on the basis of the pathological anatomy of the columellar and upper lip. METHODS: Photographs of patients were retrospectively classified into four types on the basis of the ratio of columellar height to alar base width (CH/AW) and upper lip protrusion (UP) to lower lip, as follows: type I - with CH/AW ≥ 0.2 and UP ≥ 0; type II - with CH/AW ≥ 0.2 and UP <0; type III - with CH/AW < 0.2 and UP ≥0; type IV - with CH/AW < 0.2 and UP < 0. Surgical treatments and the change of the nasal profile were documented. RESULTS: A total of 105 patients from January 2008 to December 2018 were included in this study. The nasal profile was significantly improved in type III and IV patients with postoperative CH/AW values close to normal. The upper lip was distinctively retruded in type II and IV patients before treatment, and the postoperative view revealed improved upper lip protrusion with UP values close to normal. Ninety-eight patients reported satisfactory outcomes after treatment. CONCLUSIONS: The new classification method described provides key information regarding the deformity of different types of secondary bilateral cleft lip patients and provides clear guidance for surgical planning on the basis of the anatomical defect of each type.

A reinforced framework construction technique using unilateral auricular cartilage in Asian rhinoplasty to prevent long-term nasal tip drooping.

BACKGROUND: Enhancing nasal tip projection is an important objective in Asian rhinoplasty. Nasal tip enhancement using auricular cartilage is simple and suitable for Asian patients. However, the long-term retraction problem of the auricular framework still needs to be solved for optimal results. OBJECTIVES: The authors propose a modified auricular cartilage framework construction technique that provides stronger long-term support to the nasal tip and columellar base. METHODS: Eighty-one patients underwent augmentation rhinoplasty between January 2016 and December 2019. The cymba and cavum conchae were harvested from one ear in all cases. The cymba concha was carved and folded to form a caudal septal extension graft (CSEG). The cavum concha was divided into an integrated cap/shield graft and a columella base graft. The columella base graft was diced into particles in size of 1 mm3, and inserted into the gap between CSEG, anterior nasal spine, and the medial crus to strengthen the foundation. The nasal profile was analyzed before the operation and at least 12 months after the operation. The patient satisfaction score was assessed 12 months after surgery. RESULTS: Patients were followed up for 12-36 months. The nasal tip projection from both the lateral and basal views was significantly improved. The columella-labial angle was increased from 83.15° (6.20°) to 96.50° (7.40°) (p < 0.05). The nostril tip proportion increased from 0.83 (0.14) to 1.17(0.16) (p < 0.01). A stable long-term outcome was achieved. CONCLUSIONS: With the modified framework construction technique, long-term nasal tip drooping can be prevented. This method can be a practical choice for Asian patients seeking augmentation rhinoplasty.

Domino Flaps for Repairing of Secondary Bilateral Cleft Lip With Severe Columella Deformity.

The patients with secondary bilateral cleft lip and nasal deformity always suffer from a serious part of the horizontal and vertical soft tissue deficiencies in the upper lip and nose, especially the columella. Normally, the Abbe flap is used to increase the soft tissue volume of upper lip. However, how to reconstruct the sever columella deficient, how to make full use of the Abbe flap and the remaining soft tissue of the upper lip, are always the problems that need to be solved by plastic surgeons. Twenty-nine patients with secondary bilateral cleft lip and severe columella deficiency were simultaneously reconstructed with several local flaps like dominos that was called "Domino sliding flaps." Six of the patients had their nasal tip and dorsum or collumella augmented and modified with autologous costal cartilage at the same time. The other 23 patients underwent the autologous auricular cartilage augmentation. The patients were followed from 15 months to 50 months. No secondary deformation occurred in any of the patients. 93.1% patients were satisfied with the aesthetics postoperatively, 89.7% patients were satisfied with the incision and donor site scar. Among them, 3 of the patients got hypertrophic scar on the upper lip and were modified 1 year after their first operations. The operational technique of the domino sliding flaps could better play the role of the Abbe flap. It also gave plastic surgeons an effective method to modify the severe deformities of bilateral cleft lip in 1 stage.

Autologous Stem Cell Transplantation Promotes Mechanical Stretch Induced Skin Regeneration: A Randomized Phase I/II Clinical Trial.

BACKGROUND: Mechanical stretch, in term of skin expansion, can induce effective but limited in vivo skin regeneration for complex skin defect reconstruction. We propose a strategy to obtain regenerated skin by combining autologous stem cell transplantation with mechanical stretch. METHODS: This randomized, blinded placebo-controlled trial enrolled 38 adult patients undergoing skin expansion presenting with signs of exhausted regenerative capacity. Patients randomly received autologous bone marrow mononuclear cell (MNC) or placebo injections intradermally. Follow-up examinations were at 4, 8weeks and 2years. The primary endpoint was the volume achieved in relation to the designed size of the expander (expansion index, EI). Secondary endpoints were surface area, thickness and texture of expanded skin. This trial is registered with ClinicalTrial.gov, NCT01209611. FINDINGS: The MNC group had a significantly higher EI at 4weeks (mean difference 0.59 [95% CI, 0.03-1.16]; p=0.039) and 8weeks (1.05 [95% CI, 0.45-1.66]; p=0.001) versus controls. At 8weeks, the MNC group had significantly thicker skin (epidermis: p<0.001, dermis: p<0.001) and higher subjective scores for skin quality/texture (24.8 [95% CI, 17.6-32.1]; p<0.001). The MNC group had more skin surface area (70.34cm2 [95% CI, 39.75-100.92]; p<0.001). Patients in the MNC group gained up to the quadrupled surface area of expanded skin compared to pre-expansion at the end of expansion. No severe adverse events occurred. INTERPRETATION: Intradermal transplantation of autologous stem cells represents a safe and effective strategy to promote in vivo mechanical stretch induced skin regeneration, which can provide complex skin defect reconstruction with plentiful of tissue.

A Randomized Clinical Trial of Comparing Monophasic Monodensified and Biphasic Nonanimal Stabilized Hyaluronic Acid Dermal Fillers in Treatment of Asian Nasolabial Folds.

BACKGROUND: Cross-linked hyaluronic acids (HAs) with varying characteristics and formulations are available. Despite the popularity of HA, limited studies compared the effectiveness of monophasic monodensified hyaluronic acid (MMHA) and biphasic nonanimal stabilized hyaluronic acid (BHA) products in correcting nasolabial folds (NLFs) in the Asian population. OBJECTIVE: This double-blinded, randomized research aimed at evaluating the outcomes of MMHA and BHA products in treating Asian NLFs. MATERIALS AND METHODS: Subjects aged between 18 and 65 years with moderate-to-severe NLFs were randomized to receive MMHA or BHA treatment. A touch-up treatment with the same product was performed at the 4-week follow-up, if needed. The effectiveness was evaluated for 24 weeks by masked investigators. All adverse events were recorded for safety evaluation. RESULTS: Twenty-five subjects in the MMHA Group and twenty-four subjects in the BHA Group finished 24-week follow-up. Results showed that subjects from both groups obtained satisfactory outcome in NLF correction. A lower amount of MMHA was required to achieve a similar result as that of BHA (p < .01). Both HA products maintained the effectiveness at the end of the 24-week follow-up. CONCLUSION: Both MMHA and BHA are effective for correcting NLF in Asian patients, producing satisfactory results. Monophasic monodensified hyaluronic acid provides similar satisfaction to BHA while requiring less injection volume.

In vivo bioimaging analysis of stromal vascular fraction-assisted fat grafting: the interaction and mutualism of cells and grafted fat.

BACKGROUND: Unpredictable survival rate of transplanted fat is an obstacle in application of fat grafting. Although recent researches have suggested that adipose-derived stromal vascular fraction (SVF) could promote grafted fat survival, there has been seldom reports on tracing the dynamic change of grafted fat in vivo and on discussing interaction between transplanted SVFs and surrounding fat graft. METHODS: Fat tissue and SVF separated from luciferase (Luc)-transgenic rats were applied for bioimaging analysis. The Luc-fat (0.2 mL) was subcutaneously injected into the back of nude mice with or without SVFs from 0.2 mL wild type rat fat, with bioimaging at 63 days. Immunohistochemical staining was performed to evaluate the structural integrity. Moreover, to evaluate the influence of surrounding fat tissue to transplanted SVFs, Luc-SVFs separated from 0.2 mL luciferase fat were transplanted to evaluate the influence of surrounding fat tissue to transplanted SVFs. RESULTS: The bioimaging results showed that fat tissues transplanted with SVFs had higher survival ratio than those transplanted without SVFs (49.99(5.38)% vs. 32.78(3.32)%; P < 0.001). Stromal vascular fraction-assisted fat grafts had more integral structure and less necrosis cysts. The results showed that, with the existence of grafted fat, transplanted SVF survived for a significantly longer time and could contribute to fat graft survival and regeneration by differentiating into structural cells. CONCLUSION: The results showed that SVF-assisted fat graft had significantly higher survival rate than that transplanted alone. Moreover, our research demonstrated that interaction between grafted fat and SVFs was important in SVF's long-term living and differentiation.

Mechanical stretch upregulates SDF-1α in skin tissue and induces migration of circulating bone marrow-derived stem cells into the expanded skin.

BACKGROUND: Skin and soft tissue expansion is a procedure that stimulates skin regeneration by applying continuous mechanical stretching of normal donor skin for reconstruction purposes. We have reported that topical transplantation of bone marrow-derived mesenchymal stem cells (MSCs) can accelerate mechanical stretch induced skin regeneration. However, it is unclear how circulating MSCs respond to mechanical stretch in skin tissue. METHODS: MSCs from luciferase-Tg Lewis rats were transplanted into a rat tissue expansion model and tracked in vivo by luminescence imaging. Expression levels of chemokines including macrophage inflammatory protein-1α, thymus and activation-regulated chemokine, secondary lymphoid tissue chemokine, cutaneous T-cell attracting chemokine, and stromal-derived factor-1α (SDF-1α) were elevated in mechanically stretched tissues, as were their related chemokine receptors in MSCs. Chemotactic assays were conducted in vitro and in vivo to assess the impact of chemokine expression on MSC migration. RESULTS: MSC migration was observed in mechanically stretched skin. Mechanical stretching induced temporal upregulation of chemokine expression. Among all the tested chemokines, SDF-1α showed the most significant increase in stretched skin, suggesting a strong connection to migration of MSCs. The in vitro chemotactic assay showed that conditioned medium from mechanically stretched cells induced MSC migration, which could be blocked with the CXCR4 antagonist AMD3100, as effectively as medium containing 50 ng/ml rat recombinant SDF-1α. Results from in vivo study also showed that MSC migration to mechanically stretched skin was significantly blocked by AMD3100. Moreover, migrating MSCs expressed differentiation markers, suggesting a contribution of MSCs to skin regeneration through differentiation. CONCLUSION: Mechanical stretching can upregulate SDF-1α in skin and recruit circulating MSCs through the SDF-1α/CXCR4 pathway.

Rescue of vision in burn patients with total eyelid loss.

OBJECTIVE: For severe burn victims suffering from total loss of upper and lower eyelids, skin graft or skin flap is normally used to cover the lesion and to protect the cornea, preventing corneal ulcer and simultaneously preparing for corneal transplantation. However, a new problem arises after the formation of the new palpebral fissure, that is, the reconstructed eyelids cannot open and close like the normal eyelids and the eyeball movement is limited, which exposes the cornea to dry air resulting in ulceration. In this article, we present a simple technique to partially solve this problem. METHODS: Five burn victims who lost their eyelids received treatment: stumps of upper and lower eyelids bulbar conjunctiva were dissected and pulled together as the lining of the conjunctival sac. Intermediate split-thickness skin was then immediately grafted as the new eyelids' skin. After 3 months, a 2-cm transverse incision was made 5mm below the normal palpebral fissure to open the conjunctival sac and new 'eyelids' were formed. RESULTS: The patients were followed for 2-9 years. No lagophthalmos and xerophthalmia were found. When the patients raised their heads in the supine position, they could see outside. When they bowed their heads, the cornea was protected. Their remaining vision was rescued and an average 0.4 vision recovered. Most of the patients went back to work. CONCLUSION: The opening and closing function of the eyelids can partially be replaced by movements of the head and neck using this technique. It seems to be a reliable option to rescue the vision in these types of challenging situations.