Longitudinal Follow-Up of Facial Growth of Patients With Unilateral Cleft Lip and Palate Following Modified Veau-Wardill-Kilner Palatoplasty.

OBJECTIVE: To evaluate facial growth after modified Veau-Wardill-Kilner/pushback (PB) palatoplasty from childhood to adulthood in patients with unilateral cleft lip and palate (UCLP). DESIGN: Retrospective longitudinal study. SETTING: Single center. PATIENTS: Sixty-two (29 males and 33 females) consecutive patients with nonsyndromic UCLP. INTERVENTIONS: Pushback palatoplasty and subsequent cleft palate treatment. MAIN OUTCOME MEASURES: Lateral and posterior-anterior cephalograms were taken at 3 different phases: phase 1 (before first-stage orthodontic treatment; N = 58; average age, 4.9 ± 1.1 years), phase 2 (before second-stage orthodontic treatment; N = 58; 15.9 ± 1.1 years), and phase 3 (after orthodontic retention; N = 51; 22.1 ± 3.2 years). RESULTS: The majority of patients had skeletal class III morphology in all 3 phases due to retrognathic maxilla. Maxillary growth did not improve in phase 2 despite first-stage orthodontic treatment in phase 1. Maxillary morphology improved in phase 3 but retardation occurred, although 77.42% of patients received orthognathic surgery during second-stage orthodontic treatment. Mandibular growth was slightly reduced in phases 1 and 2 and the mandible remained retrognathic in phase 3, following mandibular setback orthognathic surgery. The horizontal occlusal cant was slightly upward and toward the cleft side with respect to the reference plane, and the upper midline was deviated to the cleft side in phases 1 and 3. CONCLUSIONS: Patients with UCLP who undergo phased PB palatoplasty, orthodontic treatment, and orthognathic surgeries do not maintain skeletal class I facial morphology.

Change in Incisional Design in Primary Unilateral Cleft Lip Repair Under General Anesthesia.

Nasolabial features of infants with unilateral cleft lip (UCL) are different when they are under general anesthesia for lip repair compared to when they are awake. This study aimed to investigate changes in the incisional design of cheiloplasty according to patient position and anesthesia: upright and awake versus supine and under general anesthesia. Three-dimensional images of 20 infants with UCL were randomly selected. Two different incisional designs were drawn on the images captured while the infants were awake. Those incisional designs were anthropometrically compared to the designs drawn on the images captured while the infants were under general anesthesia. Under general anesthesia, vermillion height of both the medial and lateral sides of the cleft became significantly greater. In the rotation-advancement design, the incisional line of the rotation flap on the medial lip element became significantly shorter under general anesthesia, whereas the advancement flap on the lateral lip element was not significantly altered. In an anatomical subunit approximation, both lengths of the philtral ridge on the noncleft side and incisional line along the philtral ridge on the cleft side became significantly shorter under general anesthesia, but these alterations did not affect the calculation of the width of the small triangular flap on the lateral lip element. These changes in nasolabial features after general anesthesia may cause surgical error, which result in secondary cleft lip deformities. However, because these changes varied among infants, preoperative planning using three-dimensional facial images of infants who are awake may be able to avoid surgical error.

Three-Dimensional Measurement of the Lateral Lip Element Sacrificed in Primary Repair of a Unilateral Cleft Lip.

BACKGROUND: In most children with a unilateral cleft lip (UCL), because lateral lip tissue on the cleft side is congenitally short, the lateral lip element should be appropriately excised during primary cheiloplasty so that symmetric nasolabial features are obtained after surgery. The purpose of this study was to measure how much of the lateral lip element is removed during primary cheiloplasty and compare the amount of sacrifice between different incision designs. METHODS: Preoperative 3-dimensional images of 50 infants with UCL were randomly selected. The incision designs of 3 representative techniques (Millard, Onizuka, and Fisher) were drawn on the images that were obtained before the primary repair. The lateral lip tissue excised by each technique was estimated as a percentage of the surface area of the sacrificed lateral lip to the entire lateral lip of the cleft side. RESULTS: In the case of incomplete UCL, the median values (range) were 3.2% (1.1%-5.9%), 11.6% (8.3%-20.1%), and 27.2% (15.1%-42.3%) for the Millard, Onizuka, and Fisher repairs, respectively. In cases of complete UCL, no sacrifice was needed for the Millard repair, whereas the median values (range) were 10.6% (5.2%-28.9%) and 22.5% (11.5%-48.6%) for the Onizuka and Fisher repairs, respectively. In Millard repair, the median values (range) of the lateral lip element that was resected before skin closure according to the "cut-as-you-go" policy were 5.8% (2.2%-11.8%) in cases with an incomplete UCL and 4.9% (2.7%-9.1%) in cases with a complete UCL. CONCLUSIONS: Our study demonstrated that sacrifice of the lateral lip element was minimal in the Millard repair, whereas it could exceed 20% in the Fisher repair. However, additional sacrifice of the advancement flap was needed in the Millard-type repair. The ratio of the lateral lip sacrifice varied between patients. Although UCL repair techniques should not be evaluated with the sacrifice ratio, excessive sacrifice of the lateral lip tissue can complicate the secondary lip correction. We recommend that surgeons estimate preoperatively how much lateral lip element will be sacrificed with each incision design using a 3-dimensional image for each child with a UCL.

Incidence of Secondary Lip Correction for Children With Unilateral Cleft Lip: A Single-Center Retrospective Study.

BACKGROUND: Numerous reports have described the incidence of secondary lip correction for patients with cleft lip (CL), and this incidence broadly varies among centers. The purpose of this study was to determine this revision rate for a reasonably large number of patients in our center and identify the clinical factors that contribute to the revision rate. METHODS: A retrospective chart review was conducted for all infants with unilateral CL with or without cleft palate who underwent primary cheiloplasty at our cleft center from 2006 to 2012. Four surgeons were in charge of almost all operations. We investigated how many children underwent lip revisions by the end of 2017. RESULTS: In total, 490 infants underwent primary lip repair, and 47 underwent revision surgery by the age of 8 years. Half of them (24 children) underwent revisions at the age of 5 or 6 years. There was no significant difference in the revision rate by sex or cleft side. The revision rate in children with CL only tended to be lower than that in children with alveolar cleft or cleft palate, but it was not significantly associated with the cleft type. The revision rate ranged from 2.8% to 15.2% among surgeons. CONCLUSIONS: The overall revision rate was 9.6%, which is relatively lower than that in other cleft centers. However, the repair technique and cleft care program should not be evaluated using the revision rate only. Various factors, including surgeons' preference, contribute to the indications for revision, and these factors can change with age. We plan to follow up the patients until our completion of the cleft care program and report the final revision rate.

Association between three-dimensional measurements of the unilateral cleft lip nasal deformity and maxillary alveolar morphology: A retrospective study.

BACKGROUND: It is debatable whether rhinoplasty is necessary during a primary operation for cleft lip. However, many surgeons believe that rhinoplasty should be performed simultaneously for severe deformities. We investigated whether alveolar cleft severity is involved in nasal deformity. METHODS: Forty-three patients were assessed for alveolar cleft severity using maxillary plaster models prepared during primary cheiloplasty. We conducted morphological assessments of nasal deformities using three-dimensional photogrammetry. Patients were divided into two groups according to alveolar cleft severity: group A, overlap of the alveolar segments; group B, nonoverlap of the alveolar segments. Nasal asymmetry was assessed by measuring distances between landmarks around the nostrils and the columellar angle. These measurements were compared between the groups. The correlations between the columellar angle and the ratios of the five cleft side/non-cleft side distances and the correlation of each ratio were analyzed. RESULTS: Groups A and B included 21 and 22 patients, respectively. Group A demonstrated superior deviation of the alar base on the non-cleft side than that of the alar base on the cleft side (p < 0.05). No other statistically significant differences were observed. Group A had more severe nasal deformity. Columellar angle and nostril base width demonstrated correlation. CONCLUSION: In an uncorrected, unoperated unilateral cleft lip nasal deformity, alar base deformity is affected by deformity of the alveolar segments.

Longitudinal Follow-up of Individuals With Cleft Lip Using Three-Dimensional Stereophotogrammetry.

The usefulness of three-dimensional (3D) stereophotogrammetry for treating cleft lip (CL) has been well documented. However, there are only a few reliable anthropometric analyses in infants with CL because at this age they cannot assume a resting facial position. Since 2014, we have used a handheld 3D imaging system in the operating room to obtain optimal images of infants with CL and palate under general anesthesia. Currently, 168 infants with a unilateral cleft, 50 infants with bilateral clefts, and 47 infants with an isolated cleft palate are being followed up in this way for a maximum of 30 months. Most patients ≥3 years of age are cooperative and allow staff to obtain 3D images without sedation. We plan to follow them until adulthood, obtaining 3D images at every intervention. Each year, >150 infants can be added to this ongoing longitudinal study. Using an archive of these digital images, various retrospective studies can be attempted in the future, which include comparisons of the long-term outcomes of various surgical techniques and interventions at different time intervals. This is the first 2-year preliminary report of a 20-year longitudinal study.

Nasolabial Growth in Individuals With Unilateral Cleft Lip and Palate: A Preliminary Study of Longitudinal Observation Using Three-Dimensional Stereophotogrammetry.

There are limited numbers of studies comparing the preoperative and postoperative facial features of infants with unilateral cleft lip and palate (UCLP) using three-dimensional (3D) stereophotogrammetry. The authors attempted an anthropometric analysis of nasolabial asymmetry 1 year after primary lip repair using a handheld 3D imaging system. Five different nasolabial dimensions in 24 infants with UCLP were measured using 3D images captured during primary lip repair and again, 1 year after the repair. The nasal and upper-lip elements of the cleft side were significantly changed after primary lip repair, and nasolabial asymmetry was anthropometrically improved. This is a preliminary longitudinal observation of nasolabial growth in individuals with UCLP using 3D stereophotogrammetric technique. The authors would like to follow these children until adulthood, capturing 3D images at every intervention.

Chronic Expanding Hematoma Following Abdominoplasty.

Chronic expanding hematoma (CEH) is a relatively rare complication of trauma or surgery. We report a patient with CEH as a late complication of abdominoplasty. A 58-year-old woman underwent conventional abdominoplasty and thereafter refused to use a compression binder, citing discomfort. One month postoperatively, she presented with a gradually enlarging, painful abdominal mass. The results of ultrasonography and computed tomography were highly suspicious for CEH. The lesion was completely removed, together with surrounding fibrous tissue. Histopathology revealed a chronic hemorrhage collection with a fibrous capsule, consistent with CEH. This condition as a late complication of abdominoplasty has not previously been reported in the literature. However, an online medical consultation site features several abdominoplasty patients asking about persistent hematomas that sound suspicious for CEH. CEH might be underdiagnosed by surgeons. Although a postoperative binder may increase the risk of skin necrosis and deep vein thrombosis, appropriate compression treatment is necessary to prevent hematoma formation. Level of Evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Antitragicus muscle resection: A key to correction of prominent lobules.

The antitragicus muscle arises from the outer part of the antitragicus cartilage, and inserts into the helical tail and antihelix. Overdevelopment or malpositioning of the antitragicus muscle exerts an anterior pull on the helical tail, and it can cause prominent lobules. We attempted prominent lobule correction using antitragicus muscle resection and helical tail setback in combination with a Mustarde or Furnas suture technique. Seventeen children with prominent lobules underwent this technique, and all had satisfactory outcomes. Resection of the antitragicus muscle is minimally invasive and easy to perform. This procedure is a key to successful lobular setback.

Excision of Large Lipomas Using Tumescent Local Anesthesia.

BACKGROUND: Many large lipomas are removed under general anesthesia, because more local anesthesia than is safe to inject may be required for complete excision of such large tumors. METHODS: The authors performed total excision using tumescent local anesthesia in an outpatient clinic for 23 patients with solitary large lipomas. RESULTS: The longest diameter of the lesions on magnetic resonance imaging ranged from 10 to 22 cm. Mean length of the skin incision was 4.8 cm, and 56 mL of the tumescent solution on average was used for each patient. The postoperative courses of all patients, except for 1 patient who developed a hematoma, were uneventful. CONCLUSIONS: With judicious patient selection after physical examination and magnetic resonance imaging findings, total excision of large lipomas under tumescent local anesthesia can be performed safely in an outpatient setting.

Difference in nasolabial features between awake and asleep infants with unilateral cleft lip: Anthropometric measurements using three-dimensional stereophotogrammetry.

PURPOSE: Cleft lip repair is performed in the supine position, tilting the head back under general anesthesia. However, postoperative results are evaluated in the upright position while patients are awake. The purpose of this study was to anthropometrically assess whether nasolabial features of infants with unilateral cleft lip are influenced by posture and anesthesia. MATERIAL AND METHODS: Three-dimensional facial images in a preoperative upright position and operating supine position under general anesthesia were captured from 51 consecutive infants with unilateral cleft lip. Twenty-four indirect anthropometric measurements (11 for the nose and 13 for the lip elements) were considered on each infant. RESULTS: In the supine position under general anesthesia, alar surface distance was significantly shorter (p < 0.001). Regarding lip measurements, medial lip height of the cleft side and philtrum height were significantly smaller (p < 0.05 and p < 0.05, respectively), whereas vermilion height was greater (p < 0.01). In addition, the cleft width and lip width were significantly broader (p < 0.001 and p < 0.001, respectively) after general anesthesia. CONCLUSIONS: Several nasolabial alteration patterns are found after general anesthesia that are presumably attributable to cessation of nasal breathing and the action of muscle relaxation. Surgeons should take these nasolabial changes into account during preoperative planning and postoperative assessment.

Borderline personality disorder and aesthetic plastic surgery.

UNLABELLED: Borderline personality disorder (BPD) is a common axis II disorder associated with a high risk of impulsivity and self-injury. Several authors have suggested that individuals with BPD are poor candidates for plastic surgery. Recent changes in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria for BPD may be confusing to surgeons. This article reviews the literature on BPD and discusses how important it is to recognize this condition and how difficult it is to treat patients, highlighting features and signs of this condition in plastic surgery settings. Illustrative case examples from our experience are also described. Our careful search of the literature revealed that individuals with BPD may seek treatment from plastic surgeons in two different patterns: as treatment for self-injury or as insatiable requests for aesthetic procedures. Individuals with BPD tend to request corrections of multiple body parts to avoid abandonment by the surgeon or due to their impulsivity, but such preoccupation with appearance is less profound and shifts from one body part to another over time. While flexible and individualized psychological approaches are required to minimize the patient's impulsivity and abandonment fears, surgeons should be inflexible to any unrealistic requests. It is best to avoid surgery on patients with BPD. Surgeons should be aware of the nuances of this condition so as not to miss the proper timing for a psychiatric referral. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Self-mutilation by a patient with borderline personality disorder.

UNLABELLED: We present an unusual insatiable aesthetic/plastic surgery patient with borderline personality disorder (BPD) who removed her upper eyelids by herself after we rejected her request for revision blepharoplasty. This impulsive self-injury was attributed to anxiety from what the patient considered to be abandonment by the surgeon. Even after the eyelid defects were successfully treated, the patient requested several other revisions, including tattoo removal. Compared with other mental disorders, including body dysmorphic disorder, preoccupation with appearance in BPD is less profound and shifts from one body part to another. In an aesthetic and plastic surgery practice, a different psychiatric approach should be used for individuals with BPD, and the proper timing for a psychiatric referral should be established. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Chronic expanding hematoma, ruptured through the skin 53 years after buttock contusion.

INTRODUCTION: Chronic expanding hematoma is a relatively rare complication of soft tissue trauma and often clinically mistaken for a malignant neoplasm. PRESENTATION OF CASE: A 71-year-old female presented with a chronic expanding hematoma that ruptured through the buttock skin 53 years after the original contusion. The diagnosis of CEH was made based on the results of the biopsy, physical examination, and CT. The tumor was completely excised, and the defect was covered with a rhomboid flap. DISCUSSION: There are no reports of lesions rupturing through the skin. Almost all instances of chronic expanding hematoma previously reported in the English literature have a history ranging from 1 month to 20 years. There is a report of a thorax CEH that ruptured into the lung parenchyma after 24 years, so it is conceivable that other subcutaneous CEHs could break through the skin several decades after their inception. CONCLUSION: Once this lesion has ruptured, its differentiation from other entities becomes more complicated.

Clinical features of axillary osmidrosis: a retrospective chart review of 723 Japanese patients.

Axillary osmidrosis often disturbs a person's social life, particularly in Asian countries. However, the clinical aspects of this condition have not been well documented in the English-language published work. This study aimed to provide information on the features of axillary osmidrosis, with a particular focus on sex differences. A retrospective review was made of the charts for 723 Japanese patients (492 female, 231 male). The mean age at initial presentation (29.1 years) was nearly the same for males and females. Almost all patients (96.1%) had wet earwax, which was extremely high compared to its frequency in the general Japanese population. An association with hyperhidrosis was seen in 61.8% of these patients. Subjective odor levels in female patients were significantly lower than those in males (P < 0.001). A positive family history was more frequent for females than for males (P < 0.001), and prior treatment history was also more frequent for females than for males (P < 0.015). Most patients (86.6%) had received some treatments in our clinic. There were significantly fewer females who underwent surgical treatments compared to males (P = 0.026), as females preferred less invasive techniques (P < 0.001). Several features, including male/female ratios, and associations of wet earwax and hyperhidrosis, corresponded to previously reported data on axillary osmidrosis. Female patients were more concerned with axillary odor than males, and females had a tendency for polysurgery.

Palatoplasty and growth of the temporal bone mastoid air cells.

OBJECTIVES: The present study was undertaken to analyze the relationship between the method used for manipulation of the levator veli palatini muscle and the area of the mastoid air cells in patients with cleft palate. DESIGN: Retrospective study. PATIENTS: The subjects were 50 patients seen for surgical treatment of cleft palate. INTERVENTIONS: Palatoplasty was carried out using the mucosal flap method in 25 patients and the mucoperiosteal flap method in 25 patients. In the mucosal flap method, the levator veli palatini muscle was overlapped and sutured, followed by posterior movement of the muscle bundle (the posterior relocation group). In the mucoperiosteal flap method (the control group), the mucoperiosteal flap was pushed back, followed by end-to-end suturing of the muscle. The area of the mastoid air cells was measured on X-rays when patients were 5 years old. RESULTS: The mastoid air cell area did not differ significantly between the posterior relocation group (mean, 5.00 cm(2); range, 1.66 to 19.7 cm(2)) and the control group (mean, 5.3 cm(2); range, 2.29 to 15.9 cm(2)). CONCLUSION: No significant growth of mastoid air cells was noted following posterior relocation of the levator veli palatini muscle. Thus, in cases of cleft palate in which significant growth of mastoid air cells is not expected following reconstruction of the levator veli palatini muscle, the results confirm the view that tympanic ventilation tube insertion is the most suitable method for the treatment of otitis media.

Hair growth stimulated by conditioned medium of adipose-derived stem cells is enhanced by hypoxia: evidence of increased growth factor secretion.

Adipose-derived stem cells (ADSCs) and their secretomes mediate diverse skin-regeneration effects, such as wound-healing and antioxidant protection, that are enhanced by hypoxia. We investigated the hair-growth-promoting effect of conditioned medium (CM) of ADSCs to determine if ADSCs and their secretomes regenerate hair and if hypoxia enhances hair regeneration. If so, we wanted to identify the factors responsible for hypoxia-enhanced hair-regeneration. We found that ADSC-CM administrated subcutaneously induced the anagen phase and increased hair regeneration in C(3)H/NeH mice. In addition, ADSC-CM increased the proliferation of human follicle dermal papilla cells (HFDPCs) and human epithelial keratinocytes (HEKs), which are derived from two major cell types present in hair follicles. We investigated the effect of hypoxia on ADSC function using the same animal model in which hypoxia increased hair regrowth. Forty-one growth factors in ADSC-CM from cells cultured under hypoxic or normoxic conditions were analyzed. The secretion of insulin-like growth factor binding protein (IGFBP)-1, IGFBP-2, macrophage colony-stimulating factor (M-CSF), M-CSF receptor, platelet-derived growth factor receptor-beta, and vascular endothelial growth factor was significantly increased by hypoxia, while the secretion of epithelial growth factor production was decreased. It is reasonable to conclude that ADSCs promote hair growth via a paracrine mechanism that is enhanced by hypoxia.

Primary repair in adult patients with untreated cleft lip-cleft palate.

BACKGROUND: The authors have volunteered their services as plastic surgeons in several countries, such as Nepal and Cambodia. In these programs, the authors saw many adults with cleft lips or palates who could not have primary repair at the proper time. The purpose of this report is to discuss the primary repair of untreated cleft lips or palates in adult patients. METHODS: Subjects were older than 17 years. In Nepal, primary repairs were performed in 129 adults with untreated clefts over the past 11 years. Unilateral cleft lips were repaired by rotation advancement with the small triangular flap method or the straight method with a small triangular flap. Bilateral clefts were repaired using a one-stage repair method. Cleft palates were repaired by a mucoperiosteal push-back or Furlow technique. RESULTS: Differences between primary cleft repair for infants and for adults were as follows: (1) in adults, aggressive correction was possible, as maxillary growth was not a consideration; (2) correction of the anterior part of the nasal deformity was more difficult than in infants, as adults showed less elasticity and a more severe deformity of the nasal cartilages; (3) simultaneous palatoplasty should be chosen judiciously, as it is more invasive and results in higher morbidity; and (4) cheiloplasty under local anesthesia can reduce cost, time, and manpower. CONCLUSIONS: These observations should be useful for the local and foreign surgeons who treat clefts in developing regions.