Simultaneous free flap and forehead flap for nasal reconstruction.

BACKGROUND: Reconstruction of total or near-total nasal defects is challenging and requires the re-creation of three nasal layers. Fasciocutaneous free flaps have been used effectively for restoring the vascularized nasal lining and staged forehead flap for nasal skin replacement, which is a long process. The aim of this study is to share our experience of combination of preliminary free tissue transfer with paramedian forehead flap reconstruction in the same stage of complex nasal reconstruction. METHODS: From December 2015 to July 2021, 10 patients underwent nasal reconstruction with free flaps including 4 medial sural artery perforator (MSAP) flaps, 5 anterolateral thigh (ALT) flaps and 1 radial forearm flap for lining and forehead flaps for skin coverage simultaneously for total or subtotal nasal defects. Nasal obstruction symptoms evaluation (NOSE) score was utilized to evaluate the functional outcome and the aesthetic results were evaluated with the last follow-up photos with score 1-5 by 5 plastic surgeon and 5 laypersons. RESULTS: The size of the free flaps ranged from 3 cm x 6 cm to 6 cm x 13 cm. After excluding one patient who expired before forehead flap division due to comorbidities, the average duration between combination surgery and the division of the forehead flap pedicle of the remaining patients was 5.7 months (range, 2-12). For patients without any postoperative events, the duration was 2.2 months (range, 2-3). One free flap had partial necrosis due to infection. The average follow-up duration was 29.6 months (range, 12-64). The NOSE score was 5.9 (range, 0-10) and the aesthetic score is 4.1 (range, 3-5) in average. CONCLUSIONS: The combination of preliminary free tissue transfer for nasal lining restoration with a paramedian forehead flap for nasal skin replacement in the same stage may shorten the long process and achieve satisfactory reconstruction in complex nasal reconstruction.

Forehead Flap Reconstruction in Different Nasal Defect: 58 Patients' Psychological Outcomes.

Forehead flap nasal reconstruction is a lengthy process; the final outcome requires multiple stages and several months to achieve. After flap transfer, the pedicle flap has to be kept attached to the face for weeks, which may lead to a variety of psychosocial distress and challenges for patients. From April 2011 to December 2016, 58 patients who underwent forehead flap reconstruction for nasal reconstruction were included. The general satisfaction questionnaire, Derriford Appearance Scale 19, and Brief Fear of Negative Evaluation Scale, were utilized to assess the change in psychosocial functioning over 4 time points: preoperative (time 1), 1 week after forehead flap transfer (time 2), 1 week after forehead flap division (time 3), and final outcome after refinement procedures (time 4). The patients were also divided into 3 groups based on the severity of nasal defects: defects involving only a single subunit (n=19), subtotal nasal defects (n=25), and total nasal defects (n=13). Between- and within-group comparisons were conducted. The vast majority of patients had the highest levels of postoperative distress and social avoidance immediately after flap transfer; these levels decreased after flap division and refinement procedures. The psychosocial functioning was more strongly affected by the stage time point than by the severity of the original nasal defects. The forehead flap nasal reconstruction can not only help patients gain a relatively normal nose but also restore their self-esteem and social confidence. The lengthy process is beneficial and worthwhile, even though it involves short-term psychosocial distress.

Upper Margin of the Forehead Flap and Its Correlation With Aesthetic Results in Nasal Reconstruction in Fitzpatrick Skin Type III and IV Chinese.

BACKGROUND: The forehead flap is one of the most commonly used methods for nose reconstruction. OBJECTIVE: To determine the ideal upper margin of the flap in nasal reconstruction and its correlation with aesthetic results. METHODS: From April 2013 to September 2017, 40 patients underwent nasal reconstruction involving the dorsum with a forehead flap. The authors hypothesized 5fdifferent levels as the position to place the upper margin of the forehead flap: (1) glabella, (2) level of the upper eyelid, (3) intercanthal line, (4) horizontal line between the keystone and intercanthal line, and (5) the keystone. Then they photoshopped the upper margins of the forehead flap at 5 different levels and designed a questionnaire. Nasal reconstructive plastic surgeons, medical practitioners, and people without medical backgrounds chose the most aesthetically pleasing photograph for every patient. RESULTS: The questionnaire showed that the most aesthetically pleasing positions were located at glabella (n = 0), level of upper eyelid (n = 9), intercanthal line (n = 24), the line between keystone and intercanthal line (n = 6), and keystone (n = 1). CONCLUSION: The authors suggest placing the upper margin of the forehead flap at the level of the intercanthal line in nasal reconstruction involving the dorsum to achieve the best aesthetic results.

Simultaneous Paramedian Pedicle Forehead and Free Medial Sural Artery Perforator Flap Reconstruction of a Composite Nasal Defect: A Case Report.

BACKGROUND: Extensive nasal defects after resection of a malignancy are a challenge for all plastic surgeons. Nasal composite tissue defects have to be reconstructed with multiple staging surgeries. A paramedian pedicled forehead flap and free tissue transfer can be used for lining and skin replacement at different stages. In general, free tissue transfer is used for nasal lining and nasal floor reconstruction at the preliminary stage. Several weeks or months later, a paramedian pedicled forehead flap is used to replace the skin. Intermediate stages will also be necessary, and therefore the total therapeutic course is very long. AIM AND OBJECTIVES: The aim of this study was to report the simultaneous use of a paramedian pedicle forehead flap and a free medial sural artery perforator (MSAP) flap to reconstruct a composite nasal defect after wide excision of squamous cell carcinoma. PATIENT: In 2015, a 57-year-old woman with squamous cell carcinoma of the nose underwent tumor wide excision, which caused a composite defect involving multiple nasal subunits (partial tip, dorsum, right sidewall, right ala subunits). She received both a pedicled paramedian forehead flap to replace the skin and an MSAP flap to reconstruct the lining during the same procedure. At the intermediate stage 4 weeks later, the pedicled forehead flap was elevated and tailored. Then, a further 4 weeks later, flap division was performed. RESULTS: The patient received a total of 3 surgical procedures to reconstruct the composite defects of multiple nasal subunits. Nasal reconstruction was done within 2 months. The patient was satisfied with the aesthetic appearance and functional outcome. CONCLUSIONS: Simultaneous paramedian pedicle forehead and free flap reconstruction can provide an effective solution for composite nasal defects. Satisfactory functional and aesthetic results can be achieved.

The Relationship Between Inter-canthal Distance and Implant Height in Asian Rhinoplasty.

Augmentation rhinoplasty is one of the top three anesthetic surgeries in Asia. I-shaped silicone-polytetrafluoroethylene composite implants are feasible for both primary and secondary augmentation rhinoplasty in Asians. This series was to analyze and evaluated the effect of the rhinoplasty to the intercanthal distance and to compare the height of the implantation with those differences in ICD before and after rhinoplasty. We retrospectively reviewed data from a single medical center via a single surgeon (Hsiao YC), at Chang Gung Memorial Hospital, between 2011 and 2017 with follow-up through 2018. There were 223 patients who received augmentation rhinoplasty with an I-shaped composite silicone-polytetrafluoroethylene ePTFE-lined silicone dorsal composite implant (Implantech, Ventura, CA) with a glabellar component (chimeric technique) or without a glabellar component. There were 169 patients with the height of the I-shaped composite implant over 3 mm, and 15 patients were less than 3 mm. There was no distribution significance between two groups even in gender, age, type of surgery, or indication. The paired difference of ICD/IPD ratio was statistically significant in the group with the height of composite implant over 3 mm (1.04% ± 0.11, p < 0.005, 95%). The normalized ratio of the ICD to IPD is estimated to decrease by 1-2%. Appropriate candidates including those with a wide ICD should be informed about these data during preoperative decision-making.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 .

Selection of Site for Harvesting Dermal Grafts as a Spacer in the Correction of Eyelid Retraction.

BACKGROUND: Several materials can serve as spacer grafts in the repair of retracted lower eyelids. However, previous studies did not reveal any of these to be superior to the others. From our perspective, autologous dermal grafts are ideal because they are biologically compatible and abundantly available. However, the absorption of these grafts is an issue, and the thickness of the dermal grafts is crucial. We evaluated the dermal thickness at five potential donor sites using ultrasonography and the efficacy and safety of the posterior neck dermis as a spacer graft in the correction of retracted lower eyelids. METHODS: In 20 healthy volunteers, the dermal thickness was assessed using ultrasonography and compared between the posterior neck, upper arm, inguinal area, intergluteal cleft, and gluteal sulcus. Between January 2018 and June 2021, eight retracted lower eyelids in eight patients were repaired using a posterior neck dermal graft. The surgical results of these grafts were also evaluated. RESULTS: The mean age of the volunteers was 37.8 years, and the mean body mass index was 24.45 kg/m2. The intergluteal cleft provided the thickest dermis followed by the posterior neck and gluteal sulcus, which were not significantly different. The upper arm and inguinal area had the thinnest dermis without significant differences between them. The mean marginal reflex distance 2/iris ratio decreased by 0.15 (p=0.008). The mean cosmetic score (0-10) for evaluation of lower eyelid reconstruction increased by 3.38 (p=0.011). The mean Vancouver Scar Scale score for evaluation of donor site scarring was 3.21. CONCLUSIONS: Although the posterior neck dermis is the second thickest, it is an ideal spacer graft in the reconstruction of retracted lower eyelids. Adequate thickness, uncomplicated methods, and a closer surgical field are its advantages. Additionally, donor site morbidity is minimal, with acceptable scarring. 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 .

A Combination of Three-Step Lower Blepharoplasty to Correct Four Types of Lower Eyelid Deformities in Asian People.

BACKGROUND: This study aimed to propose a novel four-type deformity and treatment-oriented classification of the lower eyelids that directs the therapeutic combination of three-step lower blepharoplasty for Asian populations. METHODS: We reviewed 183 patients who underwent a therapeutic combination of three steps of lower blepharoplasty after being diagnosed with four types of lower eyelid deformities between July 2018 and April 2021. The three-step lower blepharoplasty includes: (1) mid-face and lower eyelid augmentation, (2) transconjunctival eye bag removal, and (3) skin pinch removal. Consecutive digital images, detailed fat graft volume, fat removal amount, skin pinch removal amount, complications, and patient's satisfaction and aesthetic improvement score were recorded. RESULTS: The overall patient's satisfy score is 91. Aesthetic improvement score is 80.2 and 83.3 among lay persons and experts, respectively. The volume of the fat graft ranges from 2 to 3 mL per orbit according to the severity of the deformity. The amount of fat removed was 0.53 ± 0.36 and 0.61 ± 0.40 mL per orbit in types II and III patients, respectively. There is no lower lid malposition. Eleven patients had over-correction of fat grafting, and they need steroid injection; 20 patients had under-correction of fat grafting, and they need secondary fat grafting. Ten patients need secondary skin pinch excision due to post-op skin redundancy. Two patients had conjunctiva wound granuloma. CONCLUSIONS: The combination of three-step lower blepharoplasty according to the novel classification is a straightforward and effective method to correct lower eyelid deformities. The complication rate was low with high patient satisfaction. 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 .

Paranasal Augmentation With Composite Graft Transfer in Overresection of Alar Base and Nostril Contracture.

BACKGROUND: Many Asian patients desire a narrower nasal base with less flaring of the alar lobules. However, patients who underwent multiple rhinoplasty surgeries with nostril contracture or an overreduction of the alar base may experience nostril contracture and deformity, which may lead to further airway obstruction. We present a technique that combines paranasal augmentation with composite chondrocutaneous graft transfer to overcome this problem. METHODS: Nine patients underwent composite chondrocutaneous graft transfer to the soft triangle or alar base combined with paranasal augmentation using preshaped porous polyethylene implants to correct nostril contracture and airway obstruction between September of 2014 and May of 2018. Preoperative and postoperative alar base distances and cross-sectional areas of the nostrils were measured and compared. RESULTS: The average thickness of paranasal augmentation was 5.5 mm (range, 4.0-7.0 mm). Eighteen composite grafts were located over the soft triangle (n = 3) and the alar base (n = 15). The average number of composite grafts for each person was 2 (range, 1-4). All composite grafts survived totally or partially, and no graft failed. The average follow-up was 10.9 months (range, 3-28 months). The alar base increased 13.9% (range, 2.2%-23.9%), and the nostril area increased an average of 78.1% (range, 4.5%-316.8%) postoperatively. Patients had satisfactory aesthetic and functional outcomes. CONCLUSIONS: Combining paranasal augmentation and composite graft transfer increased the cross-sectional area of the external valve and improved nostril contracture and airway obstruction after the overresection of the alar base or nose contracture after multiple rhinoplasty surgeries.

Ideal Nasal Radix Position in Fluctuating Facial Asymmetry.

BACKGROUND: Augmentation rhinoplasty had become increasingly popular among Asians. Failure to recognize nasal deviation before surgery may engender unsatisfactory outcomes because the deviation becomes prominently visible after surgery due to the central position of the nose. Ideal nasal radix positioning has yet to be addressed. The head position affects facial asymmetry judgements; however, its effect on rhinoplasty has never been studied. This study determined the ideal nasal radix position in facial fluctuating asymmetry and investigated the effects of the natural head position (NHP) on nasal deviation perceptions. METHODS: A survey was conducted to compare different head and nasal radix horizontal positions using images of patients who underwent augmentation rhinoplasty. Images were retouched using editing software to adjust the head and nasal radix positions. The survey was performed using questionnaires involving 3 plastic surgeons and 3 laypersons, who were asked to determine the presence of nasal deviation and select the ideal nasal radix position among the retouched images. RESULTS: Twenty patients who underwent primary rhinoplasty were included in this study. The recognition of nasal deviation was significantly higher in the NHP than in the compensatory head position. The surgeons and the laypersons considered the midsagittal line the most appropriate position of the nasal radix. CONCLUSIONS: Facial analysis for augmentation rhinoplasty should be performed with the patient's head in the NHP to prevent nasal deviation masking. The preferred nasal radix position in facial fluctuating asymmetry is the midsagittal line.Level of Evidence: Level V, descriptive study.

The Upper Buccal Musculomucosal Flap for Nasal Lining and Columellar Defect Reconstruction.

ABSTRACT: Restoring the nasal lining is a great challenge in the reconstruction of nasal defects. In this series, the authors present our experience in using the upper buccal musculomucosal (UBMM) flap for the reconstruction of full thickness columellar or nasal lining defects. Ten patients who underwent UBMM flap reconstruction of columellar or nasal lining defects, with or without composite grafting, were identified between December of 2014 and February of 2017. The records were retrospectively reviewed to determine the demographics, nasal deformity etiology, surgical technique, complications, flap survival rate and duration of follow-up. Of these ten patients, three were men, and seven were women; the average age was 48.1 years (range, 34-66 years). Four patients underwent bilateral UBMM flaps, and 6 patients underwent unilateral UBMM flap reconstruction. All of the donor sites were closed without complications, except for one small granuloma that occurred 8 months later. Of the total 14 flaps, 7 healed well, 6 healed well after minimal debridement in the clinic, and one failed and was replaced with a contralateral UBMM flap. The average follow-up time was 20.1 months (range, 8-38 months). All patients had satisfactory aesthetic and functional outcomes. Due to the limited availability of healthy local tissue for nasal lining reconstruction after multiple surgeries, the UBMM flap serves as an applicable choice to restore columellar or nasal lining defects, with minimal donor site morbidity and no visible external scarring.

A Comparative Study Between Classic Derotation Graft and Novel Double V Cutting Folded Derotation Graft.

BACKGROUND: To introduce an innovative refinement, the "double V cutting folded derotation graft" (DVCFD graft), which is a method for nasal tip lengthening in aesthetic rhinoplasty with strong holding force and efficient cartilage use. METHODS: A retrospective study was conducted from January 2018 to July 2019 with 101 patients, including 11 males and 90 females with an average age of 36.87 ± 10.12 years, at Chang Gung Memorial Hospital; the patients received classic derotation grafts (n = 49, 17 of them were one layer and 32 of them were two layers) and DVCFD grafts (n = 52) for cosmetic tip plasty. The tip projection, columella labial angle and nasolabial angle were measured through clinical photography at three different times (T0: pre-operation, T1: two weeks post-operation and T2: five months post-operation). The differences between the original derotation graft and the DVCFD graft were identified using paired-t and independent-t tests. RESULTS: The final relapse ratios of the classic derotation graft and DVCFD graft were 36.78% versus 36.92% for tip projection, 40.65% versus 38.58% for columella labial angle and 45.00% versus 47.76% for nasal labial angle, respectively. The P values of the independent-t tests were 0.991, 0.564 and 0.439, respectively. CONCLUSIONS: Both the classic derotation graft and DVCFD graft possess similar stability in tip plasty. The novel modification of the DVCFD graft has more efficient cartilage usage and is a feasible and safe surgical option for patients with limited harvestable cartilage for tip lengthening. LEVEL OF EVIDENCE III: 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 .

Laser hair removal following forehead flap for nasal reconstruction.

The forehead flap is a dependable option for nasal reconstruction owing to its reliability and anatomic likeness to nasal skin. For patients with low hairlines, the vertical design of the paramedian forehead flap can intrude into the scalp, thus incorporating hair into the nasal reconstruction. The inadequate length of the forehead flap or shift to an oblique design may result in eyebrow elevation and asymmetry. Therefore, laser hair removal (epilation) on the forehead flap has been proposed to improve esthetic results. An alexandrite laser (755 nm, 10 to 20 ms, 18-mm spot size) with a Dynamic Cooling Device™ (DCD™) cooling system was used for hair removal in 22 patients (16 male and 6 female patients) after nasal reconstructions using forehead flaps from December 2011 to September 2016. All patients received cryogen spray cooling laser treatment (CSC-LT). The mean follow-up period was 24 months, with a range between 18 and 50 months. The average duration of treatment was 1.8 months (range, 1-5 months). The energy density ranged from 14 to 18 J/cm2 with an average of 17.2 J/cm2. The number of treatments ranged from 2 to 4 (mean 2.8). Patients had satisfactory esthetic results over 11.1 months (range, 8-18 months). Residual white hairs were observed in 3 patients, and 4 patients had tiny black residual hairs without deteriorating cosmesis. Using an alexandrite laser to remove hair on the forehead is safe and reliable in nasal reconstruction with superior recipient site cosmesis.

Upper Lip Reconstruction With Modification for Creating a Philtrum With Single-Stage Full-Thickness Skin Graft in Burned Face Injury.

BACKGROUND: The philtrum plays an important role in determining the shape and form of the upper lip and creates individual identity. Postburn scar contracture in this area often leads to severe functional and aesthetic disfigurement. In this report, we present a novel method of philtrum reconstruction using full-thickness skin grafts (FTSGs) after burn injury. METHODS: Between August 2011 and October 2017, 8 patients with postburn philtrum deformity who underwent FTSG for replacement of the whole upper lip unit with a silastic tube for creation of the philtral dimple were included. A review of photographic documentation was used to evaluate the aesthetic results. RESULTS: The size of FTSG ranged from 4 × 9 to 6 × 17 cm. No patient had immediate postoperative complications, such as hematoma, infection, or necrosis. The crests of the ridges preserved their height and length, and the dimple remained visible after an average follow-up of 30.4 months (range, 3-69 months). All patients were satisfied with both functional and aesthetic results. CONCLUSIONS: This technique of single-stage reconstruction of the upper lip and philtrum with FTSG and silastic tube produced favorable results in the formation of the philtral ridges and the dimple. Through thoughtful preoperative design, meticulous scar release, and skin grafting, satisfactory functional and aesthetic results are achievable.

Management of Major Burns in 37 Casualties of a Colored Powder Explosion: Experience of the Linkou Burn Center in Taiwan.

BACKGROUND: On June 27, 2015, a colored powder explosion occurred in Taiwan. As a result, 499 people were injured, and over 200 people were in critical condition because of severe burns. Forty-nine casualties were transported to the Chang Gung Memorial Hospital. METHODS: We undertook a single-center retrospective observational study using clinical data for 37 patients with major burns with more than 20% total burn surface area (TBSA). We describe the experience of managing patients with acute burn injuries in these patients. Patient-specific data were analyzed and expressed as mean ± standard deviation. RESULTS: Thirty-seven major burn patients were admitted to our hospital. The mean ± SD age was 22.5 ± 5 years. The mean ± SD TBSA was 48.9% ± 20%. All patients were stabilized within 6 hours after admission, and no patient experienced hypothermia or hypovolemia. We performed 95 debridement procedures and 88 skin grafts. A mean of 5.6 surgeries were performed for each patient. The mean ± SD hospital stay was 62 ± 32 days. The ratio for hospital days/%TBSA was 1.36, and hospital charges/hospital days ratio was US $973 a day for surviving patients. Two mortalities (2/37, 5.4%) were reported: one was related to cardiac insult, and another was caused by sepsis. CONCLUSIONS: We share our experience in managing 37 major burn patients in a colored powder explosion to improve the holistic care in modern mass burn casualties. Aggressive early debridement and skin grafting reduced hospital stay and costs.

Onlay Fascial Grafts to Silicone-Polytetrafluorethylene Composite Implants in Augmentation Rhinoplasty: A Retrospective Study of 241 Cases.

BACKGROUND: Silicone-polytetrafluoroethylene composite implants are fast gaining popularity in Asian rhinoplasty. Nonetheless, implant displacement, erythematous reactions, and infections still occur in the authors' patient group during long-term follow-up. OBJECTIVES: The authors reported successful experience of combining the utilization of silicone-polytetrafluoroethylene composite implants with onlay temporal fascial grafts to circumvent these complications. METHODS: Sixty-four patients of Asian ethnicity underwent augmentation rhinoplasty utilizing an I-shaped composite implant with an onlay fascial graft from January 2015 to June 2018, with a mean follow-up period of 13.5 months. This patient group was compared with a control group of 177 Asian patients who underwent augmentation rhinoplasty utilizing the same composite implant but without the addition of a fascial graft; the control group was treated from February 2012 to June 2015, with a mean follow-up of 42.0 months. Complications were compared between these 2 patient groups, specifically focusing on malposition/deviations, erythema, and infections. RESULTS: There was a marked decrease in complication rates with the addition of an onlay temporal fascial graft to cover the composite implant in augmentation rhinoplasty (7.8% vs 14.7%) as well as the rate of erythematous reactions (0% vs 6.2%, P = 0.04), infection (1.6% vs 1.1%), and implant malposition/deviation (0% vs 4.5%). Harvesting the temporal fascia and fashioning the onlay graft added an additional 33 minutes on average per procedure. No donor site morbidity was encountered. CONCLUSIONS: Although the operative time increased, the benefits of adding onlay fascial grafts to silicone-polytetrafluoroethylene implants in alloplastic augmentation rhinoplasty outweigh the drawbacks, as evidenced by the decrease in erythematous reactions.

Nose resurfacing with free fasciocutaneous flaps in burns patients.

BACKGROUND: Nasal reconstruction after burn injury can be challenging due to limited availability of local flaps. We present our experience of free flap reconstruction for full-thickness nasal defect after severe facial burn injury. METHODS: Between August 1998 and September 2015, six patients underwent nasal reconstruction with seven free flaps after burn injury. Among them, flame burn occurred in two patients, chemical burn in two, explosive burn in one, and contact thermal burn in one patient. The percentage of total body surface area ranged from 4% to 48%, and the face and forehead were involved in all patients. Their clinical and photographic records were retrospectively reviewed to evaluate the aesthetic results. RESULTS: Four ulnar forearm flaps, one radial forearm flap, one anterolateral thigh flap, and one medial sural artery perforator flap were used for nasal reconstruction. The nasal framework was constructed simultaneously using costal cartilage or conchal cartilage. The facial artery and vein were typically used as recipient vessels. One case each of partial necrosis and infection were noted during the average follow-up of 59 months (range, 16-126 months). Patients had satisfactory aesthetic and functional outcomes after 4.5 times (range, 2-7 times) refinement operation. CONCLUSIONS: Free flap is an applicable alternative to restore nasal skin envelope, with rebuilding the nasal framework performed in the same stage after severe facial burn injury. Through thoughtful planning and sufficient refinement, satisfactory aesthetic, and functional results are achievable.

The Influence of Paranasal Augmentation on the Measurement of the Nose for the Treatment of Midfacial Concavity.

BACKGROUND: A concave midface with its associated deep nasolabial folds is more aesthetically displeasing than a convex midface. Midfacial concavity may be addressed with autologous tissue and implants. OBJECTIVES: The aim of this study was to determine the effect of paranasal augmentation on photogrammetric parameters. METHODS: Between July 2013 and August 2016, 12 patients underwent paranasal augmentation to address midface concavity. Augmentation was performed with autologous rib cartilage, autologous mandibular bone, or preshaped porous polyethylene (PPE). All operations were performed through the upper gingivobuccal approach. Twelve patients who underwent malar reduction using the same approach acted as a control group to account for the influence of the approach on soft tissue change. Preoperative and postoperative measurements were made photogrammetrically. RESULTS: The average follow-up period was 12.8 months (range, 5-30 months) for both groups. The mean thickness of augmentation grafts was 5.18 mm (range, 3-7 mm). Alar width and alar base width increased 4.84% (P = 0.01) and 7.66% (P = 0.01), respectively. The nasolabial angle increased from 97.2°to 103.6° and the columellar inclination increased from 116.0° to 119.1° but neither were statistically significant. Photogrammetric parameters did not change significantly in the control group. Partial wound dehiscence occurred in one case. There was greater postoperative increase in alar width (P = 0.020), alar base width (P = 0.024), and nasolabial angle (P = 0.033) in the experimental group compared to the control group. CONCLUSIONS: Paranasal augmentation using PPE or autologous material generates measurable soft tissue changes designed to enhance paranasal aesthetics.

Aesthetic Multiple-Toe Reconstruction With Combined Iliac Bone Graft and Wraparound Free Anterolateral Thigh Flap-A Case Report and Literature Review.

Compared with upper extremity injuries, toe amputations and their replantations are rare because of the difficulty of their relatively thinner soft tissue envelope. Consequently, fewer reconstructive options are available for toes and they are rarely reported in the literature. In this study, we reported a case of right third to fifth toe amputations and their subsequent reconstruction with iliac bone grafts and a free anterolateral thigh flap. After serial debulking and division procedures, 3 toes were divided successfully. Ten months after the initial operation, the patient regained pain-free functional ambulation despite some bone resorption noted on follow-up radiographs. The patient showed high satisfaction on her new toes in terms of aesthetical and functional outcomes. She was able to stand for over 30 minutes without pain. At the 2-year follow-up, the Foot Function Index was 18.3%. Although toe reconstruction is frequently considered unnecessary because of its relative high demand of surgical techniques and little gain on gait; nonetheless, in selected cases, toe reconstruction may still be beneficial if the metatarsophalangeal joints were intact and there is a strong individual desire for aesthetical restoration.

Anterolateral Thigh Flap for Reconstruction in Postburn Axillary Contractures.

BACKGROUND: Reconstruction of postburn axillary contractures is difficult and particularly challenging without healthy adjacent soft tissue for axillary scar resurfacing. In this case, a free soft-tissue transfer is among the best treatment options. Here, we describe our experience with free anterolateral thigh (ALT) flap for reconstruction in postburn axillary contractures. METHODS: We enrolled 10 patients with postburn axillary contractures from August 2003 to July 2015. They all underwent wide scar contracture release through a transverse incision from the anterior axillary fold to the posterior axillary fold. The ALT flap was subfascially raised. The huge soft tissue defect after scar release was resurfaced with the ALT flap. RESULTS: Eight male patients and 2 female patients (age, 16-64 years; mean, 46 years) were included. The mean total burn surface area, follow-up time, duration between injury onset and free-flap transfer surgery, and flap size were 48%, 27 months, 7.7 months, and 12 × 23 cm, respectively. The most common recipient vessels were the thoracodorsal artery and vein (77%). The mean improvement in the range of motion of shoulder abduction was 86 degrees (range, 60-130 degrees). The mean operative time was 7 hours. All flaps survived without reexploration or failure. All but 1 donor site was managed by split-thickness skin grafting. No infection, hematoma, or deaths were noted postoperatively. Transient brachial palsy was noted in a 16-year-old male patient postoperatively, with full recovery 3 months after. CONCLUSIONS: For postburn axillary contractures without healthy adjacent soft tissue for scar resurfacing, ALT flap reconstruction represents a suitable treatment option. It allows simultaneous surgery on both the donor and recipient sites, without the need to change the patient's position. Furthermore, the ALT flap provides sufficient soft tissue and blood flow for reconstruction, leading to satisfactory functional outcomes.

The correlation between surface electromyography and bite force of mastication muscles in Asian young adults.

BACKGROUND: Mastication function is related to mandible movement, muscle strength, and bite force. No standard device for measuring bite force has been developed. A linear relationship between electromyographic activity and bite force has been reported by several investigators, but data on the reliability of this relationship remain limited in Asian young adults. AIM AND OBJECTIVES: The purpose of this study was to develop a clinically applicable, reliable, quantitative, and noninvasive system to measure the kinetic mastication function and observe the correlation between surface electromyography (sEMG) and bite force. MATERIALS AND METHODS: The study group consisted of 41 young healthy adults (24 men and 17 women). Surface electromyography was used to evaluate bilateral temporalis and masseter muscle activities, and an occlusal bite force system was used concurrently to measure the bite force during maximal voluntary biting. Bilateral symmetry was compared, and the correlation between EMG and bite force was calculated. RESULTS: The sEMG signals were 107.7±55.0 µV and 106.0±56.0 µV (P=0.699) on right and left temporalis muscles and 183.7±86.2 µV and 194.8±94.3 µV (P=0.121) on right and left masseter muscles, respectively. The bite force was 5.0±3.2 kg on the right side and 5.7±4.0 kg on the left side (P=0.974). A positive correlation between sEMG and bite force was observed. The correlation coefficient between the temporalis muscle and bite force was 0.512, and that between the masseter muscle and bite force was 0.360. CONCLUSION: No significant difference between the bilateral electromyographic activities of the temporalis and masseter muscles and bilateral bite force was observed in young healthy adults in Taiwan. A positive correlation between sEMG signals and bite force was noted. By combining sEMG and bite force, we developed a clinically applicable, quantitative, reliable, and noninvasive system for evaluating mastication function by using characteristics of biofeedback.