A Modified of Bilateral Sagittal Split Osteotomy: Technical Note and Proposal of a Nomenclature on the Osteotomy Lines.

Bilateral sagittal split osteotomy for orthognathic surgery is the most used technique for mandible advancement or setback and has been well documented and modified over the years since Trauner and Obwegeser described it. The improvement brought by each technique allowed the surgeons to perform safer osteotomies, shorten the operative time, and increased the flexibility of the programmed mandibular movements. The authors present a modification of the bilateral sagittal osteotomy technique with the aim of making the technique easier to perform and more comfortable for the surgeon for the purpose of positioning the osteosynthesis plates and screws. Finally, the authors describe a nomenclature on the osteotomy lines of the bilateral sagittal split osteotomy.

Transvascular Hydrolysis of Hyaluronic Acid Filler With Hyaluronidase: An Ex Vivo Study.

BACKGROUND: Despite the favorable safety profile of hyaluronic acid (HA) dermal fillers, side effects can occur. Skin necrosis is one of the most severe early-occurring complications resulting from accidental vascular impairment. Hyaluronidase (HYAL) is commonly used to degrade HA chains, allowing the degraded product to pass through vessels, and thus relieving the vascular obstruction. OBJECTIVE: The purpose of this study is to evaluate, in an ex vivo setting, the capability of HYAL to degrade crosslinked HA that was injected into human vessels. MATERIALS AND METHODS: During a neck dissection, a portion of the anterior jugular vein and facial artery was harvested. The vein and artery specimens were filled with 25 mg/mL of crosslinked HA filler. Each specimen was soaked in 0.5 mL of HYAL (300 IU/mL), in its own test tube, for 4 hours, after which the remaining HA was quantified. RESULTS: The remaining HA volume was found to be 0.02 mL in the vein segment and 0.002 mL in the artery segment. CONCLUSION: A single administration of HYAL may not be adequate to restore blood flow in the event of embolism, and relatively high doses of this enzyme must be injected hourly into the affected tissue until resolution is complete.

Anterior Cartilage Rasping During Otoplasty Performed With an Adson Brown Cartilage Forceps.

ABSTRACT: Protruding ears are a common occurrence and can affect the aesthetics and psychosocial aspects of patients. Hundreds of procedures have been described over the years to correct the 2 main deformities related to protruding ears: conchal hypertrophy and anti-helical fold absence.For the rasping technique, the rasp is inserted posteriorly, from the side where the skin is excised;The ending part of the forceps looks like a small rasp, it worked very well and the surgery was completed without problemsThe authors think this tip could be a useful "tool" for all the surgeons used to perform cartilage rasping "in case of necessity" when rasp is not available.

Cross-linked hyaluronic acid filler hydrolysis with hyaluronidase: Different settings to reproduce different clinical scenarios.

Skin necrosis is the most severe complication arising from hyaluronic acid (HA) injection. To avoid skin necrosis, hyaluronidase should be injected along the course of the involved artery, to allow blood flow restoration. We evaluated the ability of hyaluronidase to degrade a HA filler in two simulated clinical situations-a compression case and an embolization case-to identify differences in the hyaluronidase injection. In the compression case, a bolus of HA filler was directly soaked in hyaluronidase solution; in the embolization case, a vein harvested from a living patient was filled with the same HA filler and then soaked in hyaluronidase. We then evaluated the quantity of HA remaining after 2 hr. While we found hydrolysis of HA in both cases, in the compression case, we detected almost complete hydrolysis, whereas in the embolization case we observed a reduction of the 60%. Our results support the hypothesis that vessel compression can be resolved with only one injection of hyaluronidase, while in the case of vascular embolization, repeated perivascular injections should be performed owing to the reduction of hyaluronidase activity.

Hyaluronic Acid Injections to Correct Lips Deformity Following Surgical Removal of Permanent Implant.

One of the most attractive areas of the face are the lips, they are crucial for emotion and communication, both during animation and at rest. Throughout the years, several techniques to obtain permanent lip enhancement have been introduced, such as the use of nonresorbable fillers. The main problem related to permanent fillers is that undesirable results could not always be repaired; although lip sequelae can be addressed surgically, some surgeons will not perform this type of procedure due to its complexity and the lack of guidelines.In this paper, the authors present a case of a labial incompetence developed after lips implant removal performed elsewhere; after clinical examination the patient was planned for surgery, although during preoperative instrumental examination (chest X-ray) a solitary pulmonary nodule was noted; further investigation performed with needle biopsy revealed a lung cancer. For this reason, the surgical procedure planned for lip restoration was not performed; however, the patient asked for a minimally invasive procedure, thus to improve, although temporarily, her lips appearance.For the aforementioned reasons, the patient was treated just with hyaluronic acid injections achieving a pleasant result, solving also the labial incompetence at rest.To the best of the author's knowledge, this paper represents the first one describing the use of hyaluronic acid injections to restore lip competence following surgical removal of permanent implant.

Skin Necrosis and Vision Loss or Impairment After Facial Filler Injection.

Purpose of the present study is to objectively evaluate the number of severe vascular complications, represented by skin necrosis and vision loss or impairment, following facial filler injection. The investigators implemented a review of the literature including articles published on PubMed database without limitation about year of publication, including all reports concerning skin necrosis and vision loss or impairment related to the injection of fillers for cosmetic uses. The search highlighted 45 articles and a total of 164 cases of skin necrosis and vision loss or impairment after injection of different substances. The injection site most frequently associated with complications was the nose (44.5%), followed by glabella (21%), nasolabial fold (15%), and forehead (10%). Results of the present study suggest that injectable filler can cause severe complications even in expertized hands. Treatments in the new defined "Dangerous triangle" must be carefully carried out. Despite our expectations, the highest rates of sever adverse events have been associated with autologous fat transfer practice.

Surgical Lip Remodeling After Injection of Permanent Filler.

BACKGROUND: A major concern regarding permanent lip fillers is difficulty with revision should this be required. Currently, the only way to treat lip sequelae is by surgical remodeling. OBJECTIVES: Based on the senior author's 6-year experience, the authors collectively suggest a surgical method to correct lip deformity in such situations. METHODS: The records of 38 patients with lip deformity who underwent surgery between 2011 and 2017 after receiving permanent filler injections were analyzed retrospectively. A total of 38 consecutive patients (69 lips) with an average age of 38.8 years (range, 28-52 years) were treated surgically. RESULTS: All patients experienced postoperative swelling (average duration, 15 days), and no infections were recorded. In 3 cases, a 1-cm dehiscence was documented, which healed by secondary intention. In 1 case, a hematoma noted several days after surgery resolved spontaneously within 3 weeks. In 2 upper lips, a minor touchup procedure (with the patient under local anesthesia) was performed 9 months after the initial surgery. Overall, patients noted that it took at least 6 to 9 months to achieve natural lip movement. The average time until softening of the lip tissue was 4 months. CONCLUSIONS: This study emphasizes the importance of informing patients that complete removal of permanent filler is not always possible. However, most of the authors' patients were pleased with the results. This study also highlights the importance of paying strict attention when approaching the area adjacent to the oral commissures in order to avoid potential reductions in mouth opening that can occur from postoperative scarring.

Patients with high c-MYC-expressing squamous cell carcinomas of the tongue show better survival than those with low- and medium-expressing tumours.

BACKGROUND: c-MYC is a potent oncoprotein with roles in a wide range of cellular processes such as differentiation, apoptosis and growth control. Deregulation of the MYC gene is commonly seen in human tumours resulting in overexpression of the protein. Here we studied expression of c-MYC in correlation to clinical outcome in patients with primary squamous cell carcinoma of the mobile tongue. METHODS: Immunohistochemistry was used to identify c-MYC in a group of 104 tongue squamous cell carcinomas with an antibody directed against the N-terminal part of the protein. Staining was evaluated by multiplying the percentage of c-MYC-expressing cells with staining intensity, giving a quick score for each tumour. RESULTS: All 104 tumours expressed c-MYC at varying levels. Quantitation according to per cent of positive cells and staining intensity revealed that most (15/21; 71%) high-expressing tumours were seen in males. Within the group of high c-MYC-expressing tumours, the majority were alive 2 and 5 years after treatment. CONCLUSIONS: The present findings show that expression of c-MYC has prognostic value in squamous cell carcinoma of the tongue, and could be useful in choice of therapy.

Platelet Gel in a Non-Regenerating Cryosurgery-Induced Skin Wound in an Old Patient: A Case Report.

OBJECTIVE: To report on the clinical benefits of platelet gel application in a non-regenerating skin wound. CLINICAL PRESENTATION AND INTERVENTION: An 84-year-old man presented with a severe wound with a regular circumference in the frontal region which resulted in a complete loss of epidermis and dermis. The skin lesion, induced by cryosurgery used to remove a basal-cell carcinoma, had previously been treated with a dermal substitute application (Integra®). After the failure of the skin graft, the patient was treated using a platelet gel therapeutic protocol which achieved the complete healing of the injured area. CONCLUSION: This case showed the clinical efficacy of using platelet gel in this elderly patient in whom the dermal substitute graft had been ineffective.

Use of subepithelial connective tissue graft as a biological barrier: a human clinical and histologic case report.

The aim of the present study was to develop a method to study the healing process after gingival grafting and to observe the histologic results after use of the modified edentulous ridge expansion technique. A 47-year-old nonsmoking woman with a noncontributory past medical history affected by edentulism associated with a horizontal alveolar ridge defect was referred to the authors for surgical correction of the deficit to improve implant support and the final esthetics of an implant-borne prosthesis. At the 4-month follow-up visit, a biopsy was performed by a punch technique in the same sites of healing abutment connection. The tissue was elevated from the attached gingival. Clinically, the grafted tissues seemed to be attached to the bone surfaces. The histologic findings revealed dense grafted tissues, providing long-term stability to the area. No ligament or bone, characteristic for periodontal regeneration, were observed. The presence of thick attached keratinized tissue around implants may constitute a protective factor against marginal inflammation or trauma.

New generation vehicles: the impact of electric scooter trauma on the severity of facial fractures assessed by FISS score. A multicentre study.

With the increasing use of sustainable energy sources, the electric scooter has become a widely used vehicle. The aim of the study is to analyse the types of facial fracture related to road traffic accidents to outline the need for dedicated road rules. An observational, retrospective, multicentre study was carried out at the Maxillofacial Surgery Units of six Italian hospitals. Fifty patients (mean age was 34.76 years) from January 2020 to January 2024 were enrolled. The severity of trauma was evaluated by the Facial Injury Severity Scale (FISS) by Bagheri et al. Most of the accidents occurred during the day and the weekend in spring or summer; 24 drivers collided with infrastructures or pedestrians, while 26 involved other vehicles. A total of 33 vehicles were rented, and 17 were privately owned. A total of 43 subjects were not wearing helmets, five patients were drunk, and three patients took drugs. In order of frequency, the facial fractures involved: zygomatico-maxillary-orbital complex (ZMOC) (n = 16), mandibular condyle (n = 13), nasal bone (n = 11), orbit floor (n = 8), and mandibular body (n = 7). Fractures such as Le Fort I (n = 4), naso-orbito-ethmoidal NOE (n = 4) and mandibular ramus (n = 4) were less common. Other types of facial fracture were rare. Thirty patients reported multiple facial fractures. The vast majority of the cases showed a low severity grade FISS score. Fifteen patients suffered polytrauma. The mean hospitalisation time was 8.3 days. As accidents with electric scooters are increasing, it is important to characterise the most frequent facial fractures to improve patient management and encourage the introduction of new road rules.

Safety and efficacy of one-step rehabilitation of human immunodeficiency virus-related facial lipoatrophy using an injectable calcium hydroxylapatite dermal filler.

BACKGROUND: Human immunodeficiency virus (HIV)-related facial lipoatrophy seems to be the most distressing manifestation for individuals with HIV. It can be stigmatizing, severely affecting quality of life and self-esteem. Ever-increasing numbers of individuals with HIV receiving medication for HIV infection are presenting to plastic surgeons and requesting reconstructive surgery to counteract the unwanted side effects of their treatment protocols, for example facial lipoatrophy. The authors show their results with a one-step rehabilitation in cases of facial lipoatrophy using an injectable calcium hydroxylapatite dermal filler mixed with local anesthetic and adrenaline. MATERIALS AND METHODS: This study was conducted as a clinical prospective study; 26 individuals with HIV receiving antiretroviral therapy and with facial lipoatrophy received injections of an injectable calcium hydroxylapatite dermal filler mixed with local anesthetic and adrenaline. RESULTS: No major complications were registered. A stable result was observed in all the cases at the end of follow-up (3 months). High patient satisfaction was achieved in all cases. CONCLUSION: The outcomes of this study confirm that calcium hydroxylapatite dermal filler safely and effectively ameliorates the appearance of patients with HIV-related facial lipoatrophy, and mixing it with local anaesthetic and adrenaline can reduce pain during injection and ecchymosis.

Safety and Aesthetics of Autologous Dermis-Fat Graft after Parotidectomy: A Multidisciplinary Retrospective Study.

(1) Background: In surgical procedures for maxillofacial tumours, it is challenging to preserve functional and cosmetic properties in the affected patients. The use of fat grafting is considered as a valuable alternative to overcome postoperative aesthetic asymmetry problems. (2) Methods: In this study, we enrolled thirty patients with parotid gland tumours in which a partial or complete parotidectomy was performed with positioning in the parotid bed of autologous dermis-fat grafts. We evaluated the satisfaction rate of the patients and the objective efficacy in solving the deformity by comparing MRI data before and after surgery. (3) Results: Twenty-six patients showed a satisfying cosmetic result with proper facial symmetry between the affected side and the healthy one. Two patients presented mild postsurgical complications such as haematomas, and two patients reported temporary weakness of the facial nerve related to the parotidectomy. (4) Conclusions: Based on the imaging data obtained via MRI before and after surgery, we can assess that the employment of fat grafts in parotidectomy surgical procedures gives good cosmetic results and does not affect the post operative management and follow up of oncologic patients.

A facial marker in facial wasting rehabilitation.

BACKGROUND: Facial lipoatrophy is one of the most distressing manifestation for HIV patients. It can be stigmatizing, severely affecting quality of life and self-esteem, and it may result in reduced antiretroviral adherence. Several filling techniques have been proposed in facial wasting restoration, with different outcomes. The aim of this study is to present a triangular area that is useful to fill in facial wasting rehabilitation. METHODS: Twenty-eight HIV patients rehabilitated for facial wasting were enrolled in this study. Sixteen were rehabilitated with a non-resorbable filler and twelve with structural fat graft harvested from lipohypertrophied areas. A photographic pre-operative and post-operative evaluation was performed by the patients and by two plastic surgeons who were "blinded." The filled area, in both patients rehabilitated with structural fat grafts or non-resorbable filler, was a triangular area of depression identified between the nasolabial fold, the malar arch, and the line that connects these two anatomical landmarks. RESULTS: The cosmetic result was evaluated after three months after the last filling procedure in the non-resorbable filler group and after three months post-surgery in the structural fat graft group. The mean patient satisfaction score was 8.7 as assessed with a visual analogue scale. The mean score for blinded evaluators was 7.6. CONCLUSION: In this study the authors describe a triangular area of the face, between the nasolabial fold, the malar arch, and the line that connects these two anatomical landmarks, where a good aesthetic facial restoration in HIV patients with facial wasting may be achieved regardless of which filling technique is used.

Intraoral approach for nasal tip upturning.

BACKGROUND: The nose is an important landmark in facial beauty, and slight modifications lead to dramatic changes. The authors describe their surgical technique to upturn the tip of the nose with an intraoral approach sectioning the fibers of muscle depressor septi. METHODS: There were 14 patients (5 male and 9 female patients) in this study. All patients complained of nasal tip ptosis. The surgical procedure was explained to the patients, and the informed consent was obtained; preoperative frontal and lateral photographs were taken. The same surgical procedure was performed in all patients. RESULTS: No complications were observed. Tip upturning, with satisfaction of the patients, was observed in all cases and was confirmed comparing preoperative and 6-month postoperative photographs. CONCLUSIONS: From the outcomes of this short case series, the surgical technique described to upturn the tip of the nose with an intraoral approach sectioning the fibers of muscle depressor septi and with the skeletization of the premaxilla is an easy, safe, and inexpensive technique that can be easily performed at the office.

Solitary Extrapleural Fibrous Tumor in Salivary Glands: Our Experience-Case Series and Literature Review.

(1) Background: Extrapleural solitary fibrous tumors (ESFTs) are rare oncological entities occurring in the head and neck, and even more so in the salivary glands. The clinical presentation and histologic features are usually unspecific, resulting in frequent misclassification. As an unusual tumor, ESTFs have an unpredictable clinical behavior. (2) Methods: We present two clinical cases referred to our Maxillofacial Surgery Unit for the onset of a symptomless mass involving, in one case, the parotid gland, and in the other case, the sublingual gland. (3) Results: Solitary fibrous tumors could be considered as neoplasms with intermediate biological behavior that are not entirely predictable on the basis of morphological features, as these are mostly still unknown. However, a few histologic, immunohistochemical, and imaging features, such as a hypodense signal at the T1 sequence in an MRI, or positivity for CD34, bcl2, and CD99, and the NAB2-STATS6 fusion gene, could be useful for an early differential diagnosis of ESTFs. (4) Conclusions: All patients were alive at follow-up with no evidence of disease. Surgical management should always be considered as the first choice for oncological radicality, and clinical behavior should always be defined with the help of the study of radiological and anatomopathological features.

Botulinum toxin type A injections for masticatory muscles hypertrophy: A systematic review.

The aim of this study is to compare the efficacy of single-point injection of botulinum toxin A versus multi-point operative protocols found in the literature in reducing hypertrophy in patients with masticatory muscle hypertrophy. A systematic review was performed in accordance with the Park et al., 2018 guidelines, selecting articles from PubMed, Google Scholar, Web of Science and Ovid databases up to July 8, 2020.28 studies met the eligibility criteria. 748 patients were treated for masseter hypertrophy (MH) and 4 patients for temporal muscle hypertrophy. As for MH: in 45.2% of cases 3 injection sites (IS) were used, in 18.8% 1 IS, in 16.2% 2 IS, in 13% 5 IS, in 4.1% 6 IS, 2.7% 4 IS. At three months, the mean reduction in masseter muscle thickness is 26-31% when 1 IS was used, 28% in 2 IS, 12-27% in 3 IS and 22-30% in 6 IS. Heterogeneity of results, high bias level and selective reports led to a difficult efficacy comparison of the injection techniques described. Data suggest that the lowest number of IS possible should be used until stronger evidences are presented. Homogeneity in pre- and post-operative protocols is needed to establish a reliable setting for the condition under study.

An Italian Online Survey Regarding the Use of Hyaluronidase in Previously Hyaluronic Acid-Injected Noses Looking for Surgical Rhinoplasty.

Background: Nonsurgical nasal reshaping (nSNR) with hyaluronic acid (HA) filler is a well-established procedure performed to ameliorate nasal appearance and is considered a valid alternative to surgical rhinoplasty in selected patients. Objectives: The aim of our study is to evaluate the decision-making process and management of patients undergoing rhinoplasty, with previous HA filler injection, and evaluate if consensus could be achieved to recommend guidelines. Methods: Between April and May 2021, an online survey was sent to 402 Italian surgeons of different specialties. The survey collected information regarding the types of treatment of patients who have previously undergone nSNR, who should undergo surgical rhinoplasty. For those surgeons using hyaluronidase, an additional information was collected. Results: In a range of time of 2 months (April and May 2021), a total of 72 surgeons replied and completed the survey: out of the 402 questionnaires sent, the response rate was approximately 18%. The majority of respondents (61.5%) replied to inject hyaluronidase (HYAL) in patients who had to undergo a rhinoplasty but reported previous nSNR. Of the surgeons who use HYAL, 70% performed rhinoplasty after a waiting time of 3 to 4 weeks. Conclusions: Either direct surgical approach or hyaluronidase injection first seems to be a viable options. The use of HYAL before surgery is the choice with the broadest consensus in our survey. However, a larger case-control study with long follow-ups is necessary to understand if in patient seeking surgical rhinoplasty who already received nSNR, the injection of hyaluronidase before surgery is mandatory, recommended, or not.