Use of an Augmentation Spreader Graft for Management of Nasofacial Angle in Patients With Pseudo-Hump.

BACKGROUND: Correction of the hump nose entails more than just simple elimination of the dorsal hump. Recent trend is toward conservative reduction of the hump and appropriate adjustment of the radix height. East Asians often present with pseudo-hump due to underprojected radix or tip, which accentuates the height of the hump. This study introduces our method of pseudo-hump correction and achieving a balanced nasal profile with minimal reduction of the hump and augmentation of the dorsum and tip with a modified augmentation spreader graft. METHODS: A retrospective review was conducted of 97 consecutive cases of Korean patients undergoing hump reduction with simultaneous augmentation of the radix with resected hump fragments and augmentation of the nasal dorsum with augmentation spreader graft. No implants were used in any of the patients. Anthropometric analysis was performed, and patient satisfaction was evaluated at postoperative 1 year. RESULTS: Postoperatively, hump was eliminated, and the dorsum and tip were successfully elevated using only autologous septal cartilage. The radix was augmented without surface irregularity or graft visibility. Nasal dorsum, tip, and radix projection increased significantly after surgery. Subjective evaluation revealed a high level of satisfaction in 84%. CONCLUSIONS: Our multipurpose bilateral augmentation spreader graft positioned above the septal plane was effective in dorsal and tip augmentation without the need for alloplastic material. Conservative hump reduction combined with augmentation of the relatively deficient areas of the nose produces a balanced nasal profile.

Lateral Crural Reinforcement in Secondary Cleft Lip Nasal Deformity Through a Combined Lateral Crural Turn-over Flap and Strut Graft.

BACKGROUND: Secondary cleft lip nasal deformity is a complex deformity, and the variety of recommended techniques used to correct this deformity attests to it. Much of the nasal deformity can be attributed to an abnormal lower lateral cartilage. This study presents our experience with applying a lateral crural turnover flap with a sandwiched strut graft in adjunct with other procedures to correct unilateral secondary cleft lip nasal deformity. METHODS: A retrospective review was conducted of 20 cases of unilateral cleft lip patients undergoing secondary rhinoplasty with lateral crural turnover flap with strut graft. Nostril base augmentation, columellar strut, suture techniques, and alar base reduction were performed as needed. Anthropometric analysis and subjective grading of the postoperative results were performed to evaluate the effect of the procedure on nostril symmetry. RESULTS: At long-term follow-up of 1 year, the symmetry for cleft side and noncleft side nostril height, width, and angulation of long axis of nostril improved after surgery. Subjective evaluation revealed improved results for all patients. CONCLUSIONS: The lateral crural turnover flap with sandwiched strut graft is a useful technique for reinforcing, repositioning, and reshaping the lower lateral cartilage in cleft lip patients with hyperconcave lateral crus and hypoplastic pyriform margin. Combined with other techniques, the nostril is increased in height, decreased in width, and thus satisfactory symmetry is obtained.

Prevention of capsular contracture with Guardix-SG(®) after silicone implant insertion.

BACKGROUND: Capsular contracture is the most common side effect of breast implant insertion and the problem that breast surgeons seek to avoid the most. Previous animal studies have proved that an antiadhesive barrier solution (AABS) prevents peri-implant capsule formation. In this study, the authors sought to explore the effect that Guardix-SG(®), an AABS that can encapsulate implants in the form of a gel, can have on capsular contracture. METHOD: This study used 12 female New Zealand white rabbits weighing 2.5-3 kg. Implants were inserted into the subpanniculus carnosus plane through an incision in the bilateral midback area. Once the implant was inserted, 3 g of Guardix-SG(®) and normal saline were instilled into the left and right sides, respectively. The rabbits were killed 6 months after the procedure. The intracapsular pressure was measured using tonometry with a 38.2-g circular glass piece, and capsular thickness was measured by dyeing the biopsy specimen with hematoxylin and eosin and Masson's trichrome stain. The myofibroblasts were quantitatively analyzed through monoclonal anti-alpha smooth muscle actin antibody immunohistochemistry staining. RESULTS: The intracapsular pressure in the control group (4.51 ± 0.98 mmHg) was significantly higher (p = 0.002) than in the study group (3.51 ± 0.4 mmHg). The average capsular thickness was significantly greater in the control group (0.33 ± 0.15 mm; p = 0.015). In the analysis, the interrelation between capsular thickness and intracapsular pressure was insignificant in both groups, as was the number of myofibroblasts in both groups (p = 0.582). CONCLUSION: Through this study, the authors were able to demonstrate that capsular contracture can be suppressed in the rabbit model by instilling Guardix-SG(®) after insertion of cohesive gel implants in the subpanniculus carnosus plane. 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 .

Narrowing and lengthening genioplasty with pedicled bone graft in contouring of the short and wide lower face.

BACKGROUND: A short and wide lower face is perceived as unattractive and masculine. Simply contouring the mandibular body and angle is insufficient to make the lower face with short and wide features slimmer and more feminine. In many cases, vertical elongation of the chin together with a bone graft is necessary. This can cause infection, donor-site morbidity and height loss by resorption of the grafted bone. To prevent this problem, the authors performed a pedicled interpositional graft with the discarded bone from narrowing genioplasty, and the results were aesthetically satisfactory. METHODS: From March 2010 to September 2011, 32 patients who received chin narrowing and vertical lengthening surgery at the authors' clinic were included in this study. For all the patients, the remnant mandibular bone at the stepoff from the site of the genioplasty to the mandibular angle was reduced concurrently. RESULTS: No complications occurred, and all the patients were satisfied with their postoperative results. CONCLUSION: Harmonizing the vertical length and transverse width of the chin is essential to acquiring more favorable results in mandibular contouring. The authors recommend pedicled interpositional bone grafting in narrowing genioplasty as a safe and useful method for aesthetic chin lengthening. 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 .

Evaluation of the Structural, Physicochemical, and Biological Characteristics of SB11, as Lucentis® (Ranibizumab) Biosimilar.

INTRODUCTION: SB11 was recently approved as a ranibizumab biosimilar by the US Food and Drug Administration (FDA) and the European Commission (EC) as a therapy for retinal vascular disorders under the brand name Byooviz™. This study was performed to assess the analytical similarity between SB11 and reference products from the European Union (EU-ranibizumab) and United States (US-ranibizumab). METHODS: A comprehensive structural, physicochemical, and biological characterization was performed utilizing state-of-the-art analytical methods. Comparisons included the following: primary structure related to amino acid sequence and post-translational modifications; higher order structure; product-related substances and purity/impurity including size and charge variants. In addition, biological characterization included a series of mechanism of action (MoA)-related bioassays such as vascular endothelial growth factor (VEGF)-A binding assay (VEGF-A 165 and its isoforms), cell-based VEGF-A 165 neutralization assay, and anti-proliferation assay using human umbilical vein endothelial cells (HUVEC). RESULTS: The amino acid sequence of SB11 was identical to that of reference products, and post-translational modification profiles and higher order structures of SB11 were shown to be indistinguishable from the reference products. Product-related size and charge variants and aggregates were also similar. Using a broad range of VEGF-related functional assays, we demonstrated that SB11 has similar biological properties to reference products in VEGF-A binding activities (VEGF-A 165 and isoforms (VEGF-A 110, VEGF-A 121, and VEGF-A 189)), VEGF-A 165 neutralization, and HUVEC anti-proliferation. Overall, SB11 exhibits high similarity compared to EU/US-ranibizumab. CONCLUSION: Based on the comprehensive analytical similarity assessment, SB11 is highly similar to the EU/US-ranibizumab with respect to structural, physicochemical, and biological properties.

BellaGel breast implant: 4-year results of a prospective cohort study.

The demand for high-quality silicone breast implants is rising. This was the first clinical study on implantation of Asian company-made silicone breast implants into Asian women. The authors report 4-year study data for BellaGel implants. This study is an ongoing 10-year study with 103 subjects undergoing augmentation or primary reconstruction with BellaGel implants. To assess effectiveness, rupture and capsular contracture rates were measured and Kaplan-Meier analysis was performed. Paired t-test was used to determine significant changes in breast dimensions. Safety assessment included evaluation of all adverse reactions. Average follow-up period was 5.9 years. Implant rupture and capsular contracture rate through 4 years were 0 percent and 2.3 percent, respectively. Capsular contracture rate was lower in the augmentation group (0.8%) than in the reconstruction group (5.6%). Among the adverse events, procedural pain was the only complication considered device-related, apart from capsular contracture. These 4-year data from the ongoing implant study support the effectiveness and safety of BellaGel implants.

Correction of inverted nipples with the double-track sun-cross running suture technique.

Various techniques have been reported for correcting inverted nipples; however, problems such as incomplete correction, recurrence, scarring and nerve or duct injury persist. To minimise the recurrence rate and reliably attain a well-projected nipple, we developed a technique involving a single suture that runs through both the periphery and the core of the nipple. After the dissection and release of fibrotic connective tissue, an absorbable monofilament suture was passed through the periphery and core to leave double tracks of the suture at all locations, creating the final shape of a cross inside a circle (resembling the sun-cross symbol). Finally, the suture was tied in a purse-string manner to push the nipple outward. We performed this surgery on 34 congenital cases, comprising 29 patients with bilateral inverted nipples, 5 patients with a unilateral inverted nipple and 12 patients with an acquired deformity. During a mean follow-up period of 22.4 months, all of the corrected nipples remained everted without reinvagination. We successfully corrected inverted nipples with the double-track sun-cross running suture technique, which provided long-lasting eversion and created an aesthetically pleasing nipple contour.

The effect of age at surgery and compensatory articulation on speech outcome in submucous cleft palate patients treated with double-opposing Z-plasty: A 10-year experience.

BACKGROUND: Submucous cleft palate is a congenital deformity that may present as velopharyngeal insufficiency. The degree of anatomical abnormality varies widely among patients and does not predict severity of symptom. We present our 10-year experience treating submucous cleft palate patients with double opposing z-plasty and explore the effect of age at surgery and compensatory articulation on speech. METHODS: Preoperative assessment included intraoral examination, nasoendoscopy, and perceptual speech evaluation. Age, gap size, and severity of hypernasality were assessed to determine the timing and type of surgery. A retrospective study of 74 submucous cleft palate patients undergoing double-opposing z-plasty from 2005 to 2016 by a single surgeon (Baek RM) was conducted. Double opposing z-plasty was modified to fully release all abnormal insertions of the levator veli palatini muscle. Postoperative velopharyngeal function was measured and statistical analyses were performed. RESULTS: The ages of patients at surgery ranged from 11 months to 19 years. Postoperatively 87 percent of the patients achieved velopharyngeal competency and 13 percent had remaining mild hypernasality. Age was a significant factor in predicting speech outcome, and patients receiving surgery prior to the age of 5.5 years had a higher normalization rate. Compensatory articulation did not have an impact on postoperative hypernasality. There were no cases of postoperative hyponasality or airway problems. CONCLUSION: Satisfactory speech outcome was achieved with the authors' protocol and modification of the double-opposing z-plasty. A comprehensive assessment of patient age, intraoral findings, severity of hypernasality, and gap size, is necessary for proper treatment of submucous cleft palate patients.

Alveolar bone grafting with simultaneous cleft lip rhinoplasty.

BACKGROUND: Optimal timing for cleft lip rhinoplasty is controversial. Definitive rhinoplasty is deferred until facial skeletal growth is completed. Intermediate rhinoplasty is performed after stabilization of the grafted alveolar bone, because the grafted bone tends to be absorbed over several months postoperatively, distorting the nasal profile. Here, we report our experience with simultaneous rhinoplasty during alveolar bone grafting for indicated patients, describe our surgical technique that ensures long-term bone graft survival, and report graft take rates and nasal profile changes. METHODS: This retrospective chart review included a total of 54 patients; 44 underwent alveolar bone grafting only, and 10 underwent simultaneous cleft lip rhinoplasty. All surgeries were conducted with a judicious mucosal incision for tensionless wound closure. Bone graft take was evaluated with dental radiographs by the Bergland classification. Further, nasal aesthetic outcome was evaluated with medical photographs, based on nostril height and width and alar base width. RESULTS: In total, 96.3% of clefts showed graft success with Type I (66.7%) or Type II (27.8%) classifications; only 3.7% of clefts showed unfavorable results classified as Type III, and no clefts showed Type IV failure. The nasal shape was flatter with a decreased nostril height and increased nostril width after alveolar bone grafting, while nostril height was increased and nostril width was decreased in patients who underwent simultaneous rhinoplasty. CONCLUSION: With surgical techniques ensuring alveolar bone graft survival, simultaneous cleft lip rhinoplasty can result in nasal aesthetic improvement for patients with severe nasal deformities, decreasing the number of operations.

Acquired Palatal Fistula in Patients with Submucous and Incomplete Cleft Palate before Surgery.

It is uncommon for a palatal fistula to be detected in individuals who have not undergone surgery, and only sporadic cases have been reported. It is even more difficult to find cases of acquired palatal fistula in patients with submucous or incomplete cleft palate. Herein, we present 2 rare cases of this phenomenon. Case 1 was a patient with submucous cleft palate who acquired a palatal fistula after suffering from oral candidiasis at the age of 5 months. Case 2 was a patient with incomplete cleft palate who spontaneously, without trauma or infection, presented with a palatal fistula at the age of 9 months.

Medial and lateral canthal reconstruction with an orbicularis oculi myocutaneous island flap.

BACKGROUND: The eyelid and canthal areas are common locations for cutaneous tumors. The medial canthus includes, among many other apparatuses, the canthal tendon and lacrimal canaliculi, and its characteristic thin and supple skin is hard to mimic and restore using tissue from other regions. Accordingly, reconstruction of the canthal area can prove challenging for surgeons. Although various methods, such as skin grafts and local flaps from adjacent regions, have been utilized for reconstructive purposes, they present known disadvantages. However, we were able to successfully reconstruct both lateral and medial canthal area defects by using orbicularis oculi myocutaneous island flaps. METHODS: Our study included seven patients who underwent medial or lateral canthal region reconstruction, using orbicularis oculi myocutaneous island flaps, between 2011 and 2014, following either cutaneous tumor excision or traumatic avulsion injury. RESULTS: Five patients had basal cell carcinoma, one had squamous cell carcinoma of the eyelid, and one had sustained a traumatic avulsion injury of the eyelid and canthal area. Entire flap loss was not observed in any patient, but one-a heavy smoker-showed partial flap loss, which healed with secondary intention and yielded acceptable results. Donor site morbidity was not observed, and all patients were satisfied with their surgical outcomes. CONCLUSIONS: The canthal regions can be successfully reconstructed with orbicularis oculi myocutaneous island flaps. These flaps offer several key advantages, including similarity in texture, color, and thickness to the recipient site and a negligible incidence of donor site morbidity.

Onlay rib bone graft in elevation of reconstructed auricle: 17 years of experience.

BACKGROUND: A cartilage wedge block and covering flap are standard procedures for firm elevation of the ear in microtia correction. However, using costal cartilage for elevation of the reconstructed auricle can be insufficient, and the fixed cartilage wedge block may be absorbed or may slip out. Furthermore, elevating covering flaps is time-consuming and uses up fascia, a potential source of reconstruction material. Therefore, we propose an innovative method using autologous onlay rib bone graft for auricular elevation of microtia. METHODS: From February 1995 to August 2012, 77 patients received a first stage operation with a rib cartilage framework graft. In the second stage operation, a small full thickness of rib bone was harvested through the previous donor scar. The bihalved rib bone was inserted into the subperiosteal pocket beneath the cartilage framework. RESULTS: The follow-up time ranged from 1 month to 17 years, with a mean of 3 years. All of the patients sustained the elevation of their ears very well during the follow-up period. Donor site problems, except for hypertrophic scars, were not observed. Surgery-related complications, specifically skin necrosis, infection, or hematoma, occurred in 4 cases. CONCLUSIONS: Onlay rib bone graft used to elevate the reconstructed auricle is a more anatomically appropriate material than cartilage, due to the bone-to-bone contact between the bone graft and the temporal bone. Postoperative minor correction of the elevation degree is straightforward and the skin graft survives better. Therefore, reconstructed auricle elevation using onlay rib bone graft is a useful and valuable method.