Fully Digitalized Workflow for One-Stage Mandibular Contouring and Orthognathic Surgery to Correct Severe Facial Asymmetry.

INTRODUCTION: Surgical correction of facial asymmetry is commonly performed in at least two stages. Recently, because of the long duration of a two-step procedure, the demand for a one-step procedure has increased. Our study aims to present a fully digitalized workflow for one-stage mandibular contouring (MC) and bimaxillary surgery to correct severe facial asymmetry using 3D technology. MATERIALS AND METHODS: A retrospective monocentric study was conducted for all patients affected by severe facial asymmetry who had undergone MC and orthognathic surgery between January 2018 and June 2020 at the Face Surgery Center, in Parma, Italy. RESULTS: The final study sample included 20 patients (12 women and 8 men). The mean age of the patients at the time of surgery was 20.8 years (range: 18-25 years). At the one-year follow-up, all patients had stable occlusion with a symmetric face. Mandibular angle degree (Ar-Go-Me) increased significantly from 113. 6° to 122.7° at the left side and from 113.3° to 122.7° at the right side (p < 0.05) (Table 1). The mandibular width (Go-Go) decreased from 116.5 to 106.4 mm (p < 0.05). CONCLUSION: A fully digitalized workflow for one-stage MC and bimaxillary surgery is a safe and valid option to correct facial asymmetry. CAD CAM technology is an indispensable tool to obtain predictable results. LEVEL OF EVIDENCE IV: 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 .

Advanced Facial Rejuvenation After Bimaxillary Surgery in Three Different Facial Types.

PURPOSE: Facial aging is the consequence of many mechanisms involving the bones and the "soft tissue" (skin, fat, ligaments, muscles, and periosteum) of the face such as downward migration of the soft tissue, adipose and muscular tissue atrophy, and skeletal resorption. The potential of orthognathic surgery (double jaw surgical advancement) of expanding the skeletal foundation to increase the facial drape support is now recognized and widely popularized by several authors. The aim of this study was to analyze the rejuvenation change of the face after bimaxillary advancement for orthognathic surgery, focusing on the previously mentioned stigmata of the middle and the lower third of the aging face. MATERIALS AND METHODS: A retrospective monocentric chart review was conducted for all patients affected by aging signs of the face who underwent orthognathic surgery between January 2015 and December 2019 at the Face Surgery Center (Parma, Italy). During the postoperative follow-up examination, all patients underwent anthropometric photographs and esthetic assessment to evaluate facial rejuvenation after double jaw surgical advancement. RESULTS: After application of the exclusion criteria, the final study sample included 85 patients (53 females, 32 males). Eighty-three patients (97%) showed a degree of rejuvenation after maxillo-mandibular advancement (MMA); the score of the postoperative face was less than the score of the preoperative face. Two patients reported no significant postoperative change; none reported a more aging face, with a successful "reverse face-lift" occurred in 97% of our cases. CONCLUSION: "Reverse face-lift" by bimaxillary advancement is a surgical procedure which is indicated for a selected group of middle-aged patients with a diagnosis of bimaxillary skeletal retrusion or posterior divergence very motivated to an extreme rejuvenation; this procedure provides support for the facial mask resulting in whole facial rejuvenation.

Algorithm to the treatment of Crouzon syndrome.

Clinical reports regarding the entire surgical sequence in Crouzon syndrome from the neonatal period to the adult age are rare. The purpose of this study is to trace an operative algorithm with a long term follow up in a homogenous group of patients affected by Crouzon syndrome. A retrospective review was conducted for all patients affected by Crouzon syndrome who completed the entire surgical sequence. 7 Crouzon patients (4 females, 3 males) completed the entire surgical sequence at different ages: fronto-orbital advancement (0.9 years), LF III distraction osteogenesis (11.5 years) and orthognathic surgery (18 years). The mean age at the last follow up was 19.3 years; normalization of the face was obtained in all cases with improvement of the respiratory problems. After orthognathic surgery, all patients had stable occlusion. A one-year postoperative CBCT scan revealed almost complete ossification of all osteotomy sites. Frontoorbital advancement and modified Le Fort III distraction osteogenesis are reliable surgical procedures. SARME and conventional orthognathic surgery with reductive genioplasty and fat grafting are performed at the end of the surgical sequence to enhance facial aesthetics.

"Surgery First" vs "Traditional Sequence" Surgery: A Qualitative Study of Health Experiences in 46 Bimaxillary Orthognathic Patients.

Introduction: Orthognathic patients are advocating an active role in selecting their appropriate ortho-surgical treatment, between the surgery first (SF) and the traditional sequence (TS) approaches. The aim of this study was to evaluate, through qualitative analysis, the subjective perceptions of the outcomes of each protocol. Methods: In-depth interviews were conducted with 46 (10 male and 36 female) orthognathic patients (23 SF and 23 TS) treated with bimaxillary orthognathic surgery by the same surgeon, between 2013 and 2015. Average treatment duration was 6.5 months for SF and 12 months for TS. Inclusion criteria were: the presence of Class III or Class II asymmetries and open bite. Patients were excluded if they refused interviews or stopped attending post-treatment follow-up. Investigated health experiences included overall satisfaction with appearance, self-confidence after surgery, perceived treatment time, functional recovery, and diet restrictions. Results: All SF and TS patients showed overall satisfaction with their appearance (though TS showed more enthusiastic tones) and approved their degree of functional recovery after surgery. Class III SF patients had earlier improvements in self-confidence after surgery. Orthodontics was considered enduring by both SF and TS patients. Conclusions: SF patients expressed a higher degree of satisfaction with the reduction in overall treatment time and with the early psychological benefit deriving therefrom. Both SF and TS patients completely approved of the aesthetic outcomes and the functional recovery from which they benefitted due to the entire procedure.

Vertical maxillary excess associated with altered passive eruption: a case report with an interdisciplinary approach.

A smile is a symbol of beauty and wellbeing in our modern society, human facial expression transcending language, culture, race, gender, time, and socioeconomic differences. An esthetic smile consists of three main components: the teeth, the lip framework, and the gingival scaffold. In some patients, the altered relationship between the teeth, the alveolar bone, and the soft tissue may result in the clinical condition known as gummy smile. A single factor or a combination of factors may be present in patients with this clinical condition, including altered passive eruption (APE), vertical maxillary excess, and a short or hyperactive upper lip. The present article reports on a 31-year-old female patient who presented for a consultation. The patient, who was in good general health with no significant medical history, was dissatisfied with her tooth esthetics. She had symmetric facial features with a long face appearance, retruded chin, protruded maxillary incisors, and excessive gingival display that indicated evident APE. In particular, the present case report aims to describe a multidisciplinary treatment involving a phase of orthodontics associated with maxillofacial surgery, and the periodontal surgical sequence of esthetic crown lengthening for the treatment of APE.

Interpositional collagenated cancellous bone blocks for nasal dorsum augmentation: A new technique for nasomaxillary hypoplasia treatment.

Nasomaxillary hypoplasia is a rare congenital malformation involving the middle third of the face. The present paper describes a novel technique for restoring the nasal projection in a patient with nasomaxillary hypoplasia, analyses its advantages and limitations, and discusses its potential applicability in other similar contexts. After orthognathic surgery, lateral osteotomies of the nasal bones were performed integrally with a piezoelectric device using a long cutting saw tip through the intraoral approach. The nasal bones were then projected by interpositioning two triangular-shaped collagenated cancellous bone graft blocks on each side in the osteotomies between the nasal and the frontal processes of the maxillary bones. Cone-beam computed tomography (CBCT) data was used to perform a morphometric analysis at one and 12 months of follow-up through image superimposition, which revealed a stable increased projection of the nasal dorsum and an anterior nasal spine (ANS) of 5.18 mm and 5.52 mm, respectively. The results of this case suggest that the technique affords satisfactory nasal dorsum augmentation while avoiding the use of permanent foreign materials, with minimal morbidity, no unsightly and visible scars, great patient satisfaction, and adequate stability at 12 months of follow-up.

How to Prevent Mandibular Lower Border Notching After Bilateral Sagittal Split Osteotomies for Major Advancements: Analysis of 168 Osteotomies.

PURPOSE: Mandibular ramus bilateral sagittal split osteotomy (BSSO) has been the most commonly used technique in orthognathic surgery for mandibular advancement. However, a common complication of BSSO has been the occurrence of visible and palpable osseous defects at the inferior border of the mandible. The aim of the present study was to determine whether bone grafting of the osseous defect at surgery would reduce the defect at 1 year postoperatively compared with no bone grafting. MATERIALS AND METHODS: The present retrospective cohort study evaluated patients who had undergone mandibular ramus BSSO for 10 mm or more of advancement. The primary predictor variable was BSSO surgery with bone grafting of the defect (graft group [GG]) versus no bone graft (no graft group [NGG]). The size of the mandibular ramus inferior border defect was the outcome variable considered within the framework of a 1-year postoperative cone beam computed tomography (CBCT) analysis. Gender, age, and the amount of advancement were also considered in the multilevel regression analyses. RESULTS: From January 2012 to November 2016, 84 patients (168 osteotomies) had undergone BSSO surgery with 10 mm or more of mandibular advancement at the Facesurgery Center (Parma, Italy). Their mean age was 27.4 years (range, 17 to 44 years). Of the 84 patients, 40 had undergone BSSO with bilateral bone grafts (GG). The monocortical block of the iliac crest bone was used as the bone homograft. The final residual defect was measured at 1 year postoperatively on CBCT scans. The GG and NGG had presented with a mean final defect of 0.7 mm (range, 0 to 4.5 mm) and 3.0 mm (range, 0 to 5.5 mm), respectively. Complete absence of the defect was achieved in 72% of the osteotomies in the GG and 9% of the osteotomies in the NGG. CONCLUSIONS: The use of an iliac crest bone allograft block in the gap between 2 segments during mandibular advancement of 10 mm or more substantially reduced the size and incidence of inferior border defects.

Mandibular ramus and condyle reconstruction with vascularized proximal fibular epiphyseal transfer in the pediatric patient: A case report.

Mandibular reconstruction in skeletally immature patients is challenging for the Plastic Surgeon. Indeed, it requires replacement of the bony defect with restoration of the growth capability and joint function, when condyle is involved. Vascularized transfer of the proximal epiphysis of the fibula meets all these reconstructive requirements providing an adequate bone stock which also contains a growth plate and an articular surface. The purpose of this article is to report a case of mandibular reconstruction in a 13-year-old boy who underwent resection of a high-grade osteosarcoma involving mandibular angle, ramus, and condyle. A fibular free flap including proximal epiphysis, with its growth plate and the articular surface, was harvested based on the anterior tibial vessels. The fibular head articular surface was placed facing the articular fossa of the temporal bone. A reverse-flow end-to-end anastomosis was performed with the facial vessels. Postoperatively, no infection nor anastomosis complications occurred. Surgical sites healed uneventfully. At latest follow-up, 1 year after surgery, no signs of recurrence were observed. The transferred bone survived and the growth plate was clearly open. Both functional and aesthetic outcomes were rated as good, with maximal mouth opening of more than 4 cm, neither impairment to mastication, deglutition nor phonation was observed. This technique may be a good option for pediatric reconstruction of large bony and articular mandibular defects, where functional restoration of temporomandibular joint and the growing capacity of the bone should be contemporary.

Evolution of Full Facial Feminization Surgery: Creating the Gendered Face With an All-in-one Procedure.

Facial feminization surgery (FFS) has recently gained popularity to enhance the female facial profile and promote a real transformation of the male to female face in transgender patients. The term involves overlapping of the surgical procedures devoted to feminization and represents a dual and reversible procedure unique in plastic and reconstructive surgery. Indeed, FFS envisages modifications of the hard and soft tissues and is both reductive and augmentative. For these reasons, full FFS (F-FFS) is used by surgeons with special expertise in FFS. This study describes a novel approach to F-FFS performed in a single surgery and thus renamed, de facto, all-in-one and representing its most recent evolution. Forty-nine consecutive nonrandomized patients underwent FFS at a private clinical practice (Face Surgery Center, Parma, Italy) between January 2003 and December 2017. Following a retrospective review according to specific inclusion criteria, the authors identified 9 patients aged 19 to 33 years (mean age, 21 years) who underwent all-in-one F-FFS. Patients were discharged the day after surgery with written postoperative care instructions. No reports of wound infection/dehiscence or nerve/vessel damage were recorded. Patients typically returned to work within 30 days following surgery. The mean operative time was 281 minutes (range, 245-305 minutes). The evolved all-in-one F-FFS provides a further step technically (overlapping several procedures) in terms of surgical outcome (higher satisfaction rate) and reduced overall costs and low morbidity.

A New Hybrid Technique for Performing a Safer Bilateral Sagittal Split Osteotomy: Combining Reciprocating Saw and Piezoelectric Devices.

The sagittal split osteotomy (SSO) is an indispensable tool in the correction of dentofacial abnormalities. In elective orthognathic surgery, it is important that surgeons inform patients about the risk of complications related to inferior alveolar nerve damage and unfavorable split. The purpose of this article is to describe a novel, hybrid technique to SSO by combining a reciprocating saw and piezoelectric devices with several advantages over traditional "pure" methods (osteotomies performed by reciprocating saw or piezoelectric devices only) in terms of precision, rapidity, easier splitting, and decreased complications related to inferior alveolar nerve damage and bad split with reduced overall morbidity. The level of evidence was Level IV, therapeutic study.

Orthognathic surgery "again" to correct aesthetic failure of primary surgery: Report on outcomes and patient satisfaction in 70 consecutive cases.

PURPOSE: An increasing number of patients complain about unsatisfactory aesthetic outcomes of orthognathic surgery, desiring reoperation to improve facial aesthetics. The aims of this article are to present a wide range of aesthetic reasons to justify a secondary orthognathic surgery and to report aesthetic outcomes and patient satisfaction after reoperation. MATERIAL AND METHODS: This research covers 70 consecutive patients who underwent a secondary bimaxillary orthognathic surgery with simultaneous facial lipofilling procedures between January 2006 and December 2015. The screening criteria are described for patient selection, the diagnostic process, surgical procedures, and outcomes. Pre- and postoperative facial appearances are compared. Postoperatively, patients were asked to state the improvements perceived in their facial appearance and their satisfaction with the aesthetic outcomes. RESULTS: After reoperation, all patients showed a full Class I occlusion. Major complications did not occur. According to the clinicians' evaluation, a postoperative evident aesthetic improvement was achieved in 65 patients (92.9%), and 64 patients (91.4%) were satisfied with the aesthetic outcomes achieved. CONCLUSION: Secondary orthognathic surgery performed in conjunction with facial lipofilling procedures in most cases led to satisfactory aesthetic outcomes. A very accurate selection of patients, a meticulous three-dimensional diagnostic process and planning, and appropriate intra-operative maneuvers are required.

Classification of tongue cancer resection and treatment algorithm.

BACKGROUND AND OBJECTIVES: Reconstruction of tongue cancer defects is challenging due to the complex anatomy and physiology of the tongue. Here, we classify patterns of tongue tissue loss and describe a treatment algorithm for achieving good functional and oncologic outcomes. METHODS: We retrospectively reviewed 50 tongue squamous-cell carcinomas surgically treated between January 2010-June 2015. Cancer resection and tongue reconstruction were stratified according to the missing anatomical subunits. RESULTS: A type 1 defect is a unilateral and marginal defect, not crossing the midline, and not extending to the posterior-third of the tongue. Type 2 involves the two-anterior-thirds of the mobile body, not crossing the midline, without posterior-third evolvement. Type 3 involves the two-anterior-thirds of the mobile body of the tongue with contralateral extension. Type 4 extends to the tongue base. Type 5 defect comprises any of the previous defects along with involvement of the floor of the mouth. Type 2 and 3 defects were the most common. Microvascular reconstruction was performed in 23 out of 50 patients. Complications included infection, partial necrosis, dehiscence, and microvascular thrombosis. CONCLUSIONS: Our classification system and treatment algorithm represent a reliable method of addressing management of tongue defects.

The role of bone marrow aspirate cells in the management of atrophic mandibular fractures by mini-invasive surgical approach: Single-institution experience.

PURPOSE: The treatment of fractures involves addressing the biology of fracture repair and the mechanical stability of fracture fixation. Traditionally it has included the addition of bone graft to enhance healing. New advances in the understanding of the cellular and molecular mechanisms of fracture repair have led to the use of growth factors to accelerate bone healing. This study aimed to assess the advantages of autologous stem cell use for atrophic mandibular fracture treatment in comparison to standard technique. MATERIALS AND METHODS: A total of 35 patients (14 male and 21 female) were treated for fractures of atrophic mandibles between January 2011 and December 2014. Surgical technique provided mini-invasive open reduction with or without immediate homologous bone graft, while selected patients received autologous bone marrow aspirate cell grafts in addition to the standard treatment. Demographic data and details of treatment and outcomes were recorded. RESULTS: Patients were categorized according to the use of autologous stem cells, leaving 17 patients treated with standard technique and autologous stem cells (Group A) and 18 treated with standard osteosynthesis only (Group B). Of the 35 patients, 26 had bilateral fractures; most patients had significant medical co-morbidities. Immediate bone graft was used in 37.1% of patients (7 in group A and 6 in group B). Complications occurred in 5 patients (14.3%). Two patients in group B (11.1%) showed non-union of the fracture. One patient in group A (5.8%) and one patient in group B (5.5%) showed wound dehiscence and were treated conservatively; one patient in group B had a local infection (5.5%), one out of 35 (2.8%), that was managed by prolonged antibiotic treatment. CONCLUSIONS: Despite the advanced age and medical co-morbidities of the vast majority of patients, mini-invasive open approach with autologous bone graft ensures a fast and excellent recovery. Moreover, the management of atrophic mandibular fractures by bone marrow aspirate cells is a safe and useful procedure which has a lower complication rate when compared to standard technique.

Surgical management of ankyloses of the temporomandibular joint by a piezoelectric device.

INTRODUCTION: Piezosurgery is commonly used in different field of craniomaxillofacial surgery; since its introduction it has become one of the widely adopted technique for performing osteotomies in orthognathic surgery, distraction osteogenesis and dentoalveolar surgery. Little has been written regarding ultrasonic system for temporomandibular joint surgery (TMJ). In this prospective study we describe the use of piezoelectric device for ankylosis of the TMJ. MATERIALS AND METHODS: We enrolled in this study 19 patients, 10 males and 9 females, mean (SD) age 24.6 (7.6) years, affected by unilateral ankylosis of TMJ who were surgically managed between January 2009 and December 2014 by interpositional arthroplasty with temporomyofascial muscle flap. We adopted in all cases a preauricular approach with temporal extension. The ankylotic block was removed with piezoelectric device in 9 patients and using traditional rotary bur in 10 cases. We investigated and compared the following parameters as surgical outcomes: intraoperative bleeding, duration of operation, incidence of infection, postoperative swelling and hematoma, mouth opening, nerve impairment and rate of recurrence. RESULTS: We noticed a substantial reduction in bleeding with the piezoelectric bone cutter when compared to traditional mechanical surgery (103 ml versus 117 ml; p < 0.05); however, we did not report any severe bleeding from the pterygoid plexus or maxillary artery. Operating time was longer in the piezo group (101 min versus 88 min; p < 0.05). There was a lower incidence of postoperative hematoma and swelling following piezoosteotomy. However, regarding postoperative nerve impairment and infection we did not observe any differences between the two groups. At one year follow-up mean (SD) mouth opening was 34 (4.3) mm. We did not report recurrence of the disease. CONCLUSION: Piezoelectric bone removal for the release of ankylosis of the TMJ is associated with minimal bleeding and few postoperative complications. We believe that piezosurgery allows surgeons to achieve better results compared to a traditional surgery. It is a possible alternative due to the clinical benefits demonstrated.

Three-Dimensional Analysis of Long-Term Stability After Bilateral Sagittal Split Ramus Osteotomy Fixed With a Single Miniplate With 4 Monocortical Screws and 1 Bicortical Screw: A Retrospective 2-Center Study.

PURPOSE: This study evaluated the long-term stability of bilateral sagittal split ramus osteotomy fixed with a single miniplate with 4 monocortical screws and 1 bicortical screw (hybrid technique [HT]) using 3-dimensional (3D) analysis and an objective measuring tool, cone-beam computed tomography (CBCT). MATERIALS AND METHODS: Sixty-four patients who underwent bimaxillary surgery with mandibular advancement fixed with the HT were selected from 2 different institutions and enrolled in this retrospective study. All patients underwent CBCT preoperatively, 1 month after surgery, and 12 months after surgery. To estimate the long-term stability of the HT, volumetric comparisons were performed using the following measurements: distance between the gonion and the B point in the sagittal plane; distance between the right and left gonion transversally; and the angle of the line connecting the mandibular notch and the gonion and the line connecting the gonion and the B point vertically. RESULTS: Statistical analysis showed no relevant relapse (<1 mm or <1°) when using the HT. However, a positive correlation between the amount of advancement and the amount of postoperative relapse was observed. CONCLUSION: The HT produces stable postoperative 3D results after 12 months.

The effect of a Le Fort I incision on nose and upper lip dynamics: Unraveling the mystery of the "Le Fort I lip".

INTRODUCTION: Postoperative flattening of the upper lip with loss of lip pout and down turning of the corners of the mouth is often seen after Le Fort I surgery. We aim to determine which facial muscles are involved in this phenomenon to update the literature on this subject. METHODS: In 6 cadavers, a unilateral Le Fort I incision was executed. After removal of the skin, all individual facial muscles were identified and submitted to bilateral tactile traction, comparing incised sides with non-incised sides. CONCLUSION: All the components of the deep layer of the modiolus alae nasi (transverse part of the nasalis muscle and the myrtiformis muscle) and the deep layer of the midface musculature (levator anguli oris muscle) were transected by the Le Fort I incision. After performing the incision, the majority of the depressor septi nasi is intact. Further, the superficial layer of the midface musculature is intact but it loses tension because of its connection to the deep layer. This study suggests the importance of correctly suturing the deep muscular layers to maintain the 3-dimensional facial contour. Moreover, in this cadaver study, we attempt to predict the functional consequences on the impairment of facial mimics related to the Le Fort I incision.