Vascular Anatomy for the Prevention of Sublingual Hematomas: Life-Threatening Complication of Genioplasty.

After genioplasty, the occurrence of bleeding is rare; however, rapid enlargement or displacement of the tongue secondary to lingual or sublingual hematoma can lead to life-threatening airway obstruction, necessitating prompt recognition, and immediate management. Therefore, the investigators aimed to evaluate the underlying etiologies of sublingual hematoma and relevant anatomy to facilitate early recognition of the initial presentation of these hematomas and appropriate management. The authors conducted a literature review on cases of delayed sublingual hematoma after genioplasty. The authors also report a case of delayed hematoma after performing genioplasty. The anatomical structures involved with the development of rare and serious hematomas therein are the sublingual and submental arteries, which are located in the sublingual area, rendering them susceptible to injury during genioplasty. The results of this study suggest that submental artery ligation should be performed for proper management of airway obstruction, if symptoms of sublingual bleeding are observed during the surgical procedure. If there is continuous bleeding despite the submental artery ligation, sublingual artery ligation should be performed.

Clinical applications of the endoscopic transorbital approach for various lesions.

BACKGROUND: The endoscopic transorbital approach (ETOA) was recently added to the neurosurgical armamentarium. Although this approach could result in less injury to normal brain tissue, shorter operation times, and smaller scars, its clinical applications have not been fully investigated. We, therefore, sought to share our unique experiences of exploring the application of this approach in various diseases. METHODS: From June 2017 to March 2019, we conducted ETOAs via the superior eyelid crease in 22 patients for the treatment of lesions confined to the middle fossa with and without slight extension to the posterior fossa. These lesions included 5 gliomas, 11 meningiomas, 3 schwannomas, 1 lymphoma, 1 cavernous hemangioma in the orbital wall, and 1 hemangiopericytoma mimicking schwannoma. Perioperative radiologic findings and clinical outcomes were recorded. RESULTS: Gross total resection was accomplished in three (60%) patients with gliomas, nine (81.8%) with meningiomas, two (66.7%) with schwannomas, and one (33.3%) with another lesion. The mean bleeding count was 1051.4 ± 961.1 cc, and major complications were observed in only two (9.1%) cases (one major cerebral artery infarction and one reoperation due to a large amount of bleeding). A cerebrospinal fluid leak was reported in two (9.1%) patients, and transient eye movement palsy was noted in four (18.2%) patients without permanent disability. CONCLUSIONS: The endoscopic transorbital approach could be considered to be feasible for various lesions with different characteristics. After carefully considering the lesion anatomy, consistency, and vascular relationships, using this approach, we could achieve a satisfactory extent of resection without severe complications.

The effect of combination therapy on critical-size bone defects using non-activated platelet-rich plasma and adipose-derived stem cells.

PURPOSE: Non-activated platelet-rich plasma (nPRP) slowly releases growth factors that induce bone regeneration. Adipose tissue-derived stem cells (ASCs) are also known to induce osteoblast differentiation. In this study, we investigated the combined effect of nPRP and ASC treatment compared with single therapy on bone regeneration. METHODS: Thirty New Zealand white rabbits with 15 × 15 mm2 calvarial defects were randomly divided into four treatment groups: control, nPRP, ASC, or nPRP + ASC groups. For treatment, rabbits received a collagen sponge (Gelfoam®) saturated with 1 ml normal saline (controls), 1 ml non-activated PRP (nPRP group), 2 × 106 ASCs (ASCs group), or 2 × 106 ASCs plus l ml nPRP (nPRP + ASCs group). After 16 weeks, bone volume and new bone surface area were measured, using three-dimensional computed tomography and digital photography. Bone regeneration was also histologically analyzed. RESULTS: Bone surface area in the nPRP group was significantly higher than both the control and ASC groups (p < 0.001 and p < 0.01, respectively). The percentage of regenerated bone surface area in the nPRP + ASC group was also significantly higher than the corresponding ratios in the control group (p < 0.001). The volume of new bone in the nPRP group was increased compared to the controls (p < 0.05). CONCLUSION: Our results demonstrate that slow-releasing growth factors from nPRP did not influence ASC activation in this model of bone healing. PRP activation is important for the success of combination therapy using nPRP and ASCs.

Effects of Hat-Shaped Mortised Genioplasty with Genioglossus Muscle Advancement on Retrogenia and Snoring: Assessment of Esthetic, Functional, and Psychosocial Results.

BACKGROUND: An increasing number of patients undergo genioplasty for esthetic purposes to correct micrognathism or retrognathism. However, these conditions are considered an important risk factor for snoring. The purpose of this study was to evaluate both esthetic improvement and functional changes of snoring symptoms in patients who underwent hat-shaped mortised advancing genioplasty with genioglossus muscle advancement. MATERIALS AND METHODS: This retrospective study enrolled 25 patients. We evaluated scores for subjective snoring classification (Stanford scale) and questionnaire findings for esthetic results. RESULTS: Most people (96%) were satisfied with the esthetic improvement after surgery. The grade of subjective snoring classification (Stanford scale) improved from 8.68 (range 0-10) to 4.08 (range 0-10) after surgery. Twenty-four patients had an improved snoring grade. All patients reported a positive impact on their daily activity and self-confidence, and they were willing to recommend the same operation to someone with the same clinical problems. CONCLUSION: We conclude that hat-shaped mortised advancing genioplasty with genioglossus muscle advancement can relieve the symptoms of snoring for patients with hypoplastic chin or retrogenia. Patients were satisfied with the functional and esthetic 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 .

Cervical Spine Dysmorphism in Congenital Muscular Torticollis.

BACKGROUND: Congenital muscular torticollis is a common childhood musculoskeletal anomaly that might result in permanent craniofacial deformity, facial asymmetry, and changes in the cervical vertebrae, if not treated during early childhood. Although there have been many studies on cervical vertebral changes, their onset in children has not been previously studied. METHODS: Fifteen patients (aged <8 years) with a confirmed diagnosed of torticollis were included. Three-dimensional computed tomography scans were obtained, and segmentation of the cervical vertebrae was done. Division of the atlas and axis across the midsagittal plane was done to compare the anatomical changes. The volumes of each halves of the atlas and axis were measured. RESULTS: An apparent change was observed in the axis of the vertebral column when compared with that of the skull. There were progressive anatomical changes affecting the upper cervical vertebrae, which started to develop around the age of 8 months and became more evident in older children. The axis vertebra was the first to be affected. Rotational and bending deformities were the most likely changes to occur. Pearson correlation analysis showed a statistically significant trend in the volume and height changes for both halves of the atlas and axis (P < 0.001 and P < 0.001). CONCLUSIONS: Children with untreated congenital muscular torticollis show progressive anatomical changes of the cervical vertebrae which started at the age of 8 months. The severity of the deformity increased with the advance of age as well as with the severity of sternocleidomastoid tightness, which might result in permanent deformities.

Scaffold Free Bone Regeneration Using Platelet-Rich Fibrin in Calvarial Defect Model.

Bone regeneration is a complex process influenced by various physiological factors. Platelet-rich plasma (PRP) contains many growth factors and has shown osteogenic effects. The PRP is usually activated before use. However, the authors showed that nonactivated PRP (nPRP) and activated PRP have comparable osteogenic effects in the previous study. Generally, a scaffold has been needed for the application of PRP in the cranial defect model. In this study, the authors aimed to compare the performance of scaffold free platelet-rich fibrin (PRF) to nPRP as an adjuvant for bone regeneration.Twenty-four New Zealand White rabbits were randomly allocated into 3 groups: control, nPRP, and PRF. A 15 × 15 mm defect was created on each rabbit's cranium. Acellular collagen sponges (Gelfoam) were placed on the defects of the control group, Gelfoam with nPRP was used for the nPRP group, and PRF membrane was directly applied for the PRF group. nPRP and PRF were obtained from each subject's peripheral blood. Sixteen weeks later, the volume of regenerated bone was measured using 3-dimensional computed tomography. The surface area was measured via autopsy, and the samples were then obtained for histological analysis.Bone regeneration in the experimental groups was significantly greater than that in the control group. There were no significant differences in the area of regeneration or histological characteristics between the nPRP and PRF groups.In the calvarial defect of the rabbits, the use of PRF and scaffolded PRP showed comparable bone regeneration effects, which suggested that PRF might be a therapeutic alternative for bone grafts.

Complication of AQUAfilling® Gel Injection for Breast Augmentation: Case Report of One Case and Review of Literature.

INTRODUCTION: Augmentation mammoplasty is one of the most popular aesthetic operations in the world. In Korea, one of the fillers used for breast augmentation is AQUAfilling® gel (Biomedica. spol, s,r,o, Czech Republic). AQUAfilling® gel is a hydrophilic gel composed of 98% sodium chloride solution (0.9%) and 2% cation copolyamide. METHODS: This is a case report describing a patient that suffered complications after AQUAfilling® gel injection for breast augmentation. RESULTS: A 32-year-old female patient was referred to our plastic surgery department with a chief complaint of repeated wound dehiscence and fluid discharge involving both breasts. She was treated via surgical intervention for removal of necrotic infected tissue and filler, as well as massive irrigation three times. After the third surgery, there were no complications, including infection or dehiscence, during a 1-year follow-up period. CONCLUSIONS: Although AQUAfilling® gel is easy to inject and is natural looking, once a complication occurs, treatment is difficult. Also, there are concerns regarding toxicity of the gel material and its influence on surrounding tissues. Hence, sufficient evidences of long-term safety must be accumulated and proved, until which time the aesthetic use of the unapproved filler must be restricted. 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 .

Salvage of Ear Framework Exposure in Total Auricular Reconstruction.

BACKGROUND: One of the most common complications of total auricular reconstruction is delayed wound healing, which results in skin necrosis and exposure of the ear framework. Various options exist for salvage of the exposed ear framework. METHODS: From January 2009 to May 2014, 149 patients underwent total auricular reconstruction using an autogenous cartilage framework or porous polyethylene framework (Medpor; Stryker, USA). An autogenous cartilage framework was used in 48 patients, and a Medpor framework was used in 101 cases. Three cases of framework exposure (3/48, 6.3%) were observed among the patients treated with an autogenous cartilage framework. In contrast, framework exposure took place in 11 patients who were treated with a Medpor framework (11/101, 10.9%). Depending on the method of total ear reconstruction and the location of exposure, the authors used local skin flaps, temporoparietal fascia flaps, deep temporal fascia (DTF) flaps, or mastoid fascia (MF) flaps with skin grafting. RESULTS: Among the 11 patients who experienced framework exposure after being treated with a Medpor framework, a DTF flap with skin grafting was used in 6 patients and an MF flap with skin grafting in 6 patients; 1 patient was treated with both a DTF flap and an MF flap. All 3 cases of cartilage framework exposure were salvaged using a temporoparietal fascia flap with skin grafting, and a local skin flap was used in 1 case. In all 3 cases, the exposed framework was completely covered with the flap, and the reconstructed ears showed well-defined convolutions. CONCLUSIONS: Salvage of framework exposure remains a challenging issue in total auricular reconstruction. However, appropriate wound management using various flaps allows the reconstructed ear to be safely preserved.

Craniofacial Fibrous Dysplasia: Retrospective Study on the Relationship Between the Tumor Volume Changes and the Circulating Serum Calcitonin and Serum Alkaline Phosphatase.

BACKGROUND: The purpose of this study was to determine the usefulness of serum alkaline phosphatase (ALP) and calcitonin in the follow-up of tumor volume changes in patients with craniofacial fibrous dysplasia. METHODS: Twenty patients with isolated craniofacial fibrous dysplasia were included, who met our criteria for long-term follow-up. Three-dimensional computed tomography scans were obtained, and tumor segmentation was performed. The tumor volume was measured preoperatively, immediate postoperative and during long-term follow-up. Serum ALP and calcitonin levels were obtained at the same times to assess their correlation with tumor volumes. RESULTS: Preoperative calcitonin levels were correlated with the presence of tumor (P = 0.0442), whereas ALP levels were not (P = 0.1125). There were no significant associations between tumor volume and ALP or calcitonin levels in the preoperative or postoperative periods. During long-term follow-up, serum ALP was significantly associated with tumor recurrence (P = 0.0096), but serum calcitonin was not (P = 0.4760). However, serum levels of ALP did not reflect the tumor volume changes. CONCLUSIONS: Serum ALP may be useful as a laboratory test for follow-up of patients with isolated craniofacial fibrous dysplasia. However, it cannot represent the tumor's volume changes and 3-dimensional computed tomography scans with tumor volume measurement are mandatory for detecting significant volume changes during follow-up. Investigation of the serum calcitonin in the preoperative period is also recommended on a large scale because it was related to the presence of the tumor.

Comparative Skin Evaluation After Split-Thickness Skin Grafts Using 2 Different Acellular Dermal Matrices to Cover Composite Forearm Defects.

PURPOSE: The combination of acellular dermal matrix (ADM) and split-thickness skin graft (STSG) has been widely adopted to overcome functional and cosmetic limitations of conventional STSG. In this study, we evaluated the efficacy of this combination using 2 types of ADM: cadaveric acellular dermal matrix (CDM) and bovine acellular dermal matrix (BDM). METHODS: We recruited 72 patients undergoing autologous STSG to cover radial forearm free flap donor sites. They were included in 1 of 3 therapeutic groups: group 1, STSG using CDM (n = 29); group 2, STSG using BDM (n = 20); and group 3, STSG only (n = 23). Functional skin values for skin elasticity, humidification, transepidermal water loss, and color were determined. Values were compared between graft sites and adjacent normal (control) skin, and between grafted areas of each group. RESULTS: All skin defects were successfully reconstructed without graft loss. Groups 1 and 2 demonstrated better elasticity than did group 3, based on the analysis using the ratio of grafted area to control. Grafted areas in all 3 groups exhibited less moisture than did control normal skin. There was less transepidermal water loss in group 1 than in group 3, which implied that CDM application had better barrier capacity against water evaporation. Graft sites of groups 1 and 3 exhibited darker and redder color compared with control areas. CONCLUSIONS: Composite forearm defects were successfully restored and exhibited acceptable quality after treatment with an ADM plus STSG. Applying either CDM or BDM under a STSG was a suitable procedure, as verified by objective measurements. Elasticity was well preserved in CDM and BDM groups. However, both ADMs revealed functional impairment of humidification. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.