Change in nostril ratio after cleft rhinoplasty: correction of nostril stenosis with full-thickness skin graft

Background@#Patients with secondary deformities associated with unilateral cleft lip and nose might also suffer from nostril stenosis due to a lack of tissue volume in the nostril on the cleft side. Here, we used full-thickness skin grafts (FTSGs) to reduce nostril stenosis and various methods for skin volume augmentation. We compared the changes in the symmetry of both nostrils before and after surgery. @*Methods@#From February 2016 to January 2020, 34 patients underwent secondary cheiloplasty and open rhinoplasty for secondary deformities of the unilateral cleft lip and nose with nostril stenosis. FTSG was used on the nostril floor, nasal columella, and alar inner lining. The measured nasal profile included the nostril surface, nostril circumference, width of the nostril floor, and distance from the alar-facial groove to the nasal tip. The “overlap area,” which was defined as the largest overlapping area when the image of the cleft nostril was flipped to the left and right and overlaid on the image of the normal side nostril, was also calculated. The degree of symmetry was evaluated by dividing the value of the cleft side by that of the normal side of each measured profile and expressed as “ratios.” @*Results@#The results of all profile ratios, except for the nostril floor width, became significantly close to 1, which represents full symmetry. The overlap area ratio improved from 62.7% to 77.3%, meaning that the length and width of the nostril as well as the overall shape became similar (p< 0.05). @*Conclusion@#When performing cleft rhinoplasty with nostril stenosis, FTSG is useful to achieve symmetry in the nostril size and shape. Skin grafting is simpler to perform than the other types of local flap, and the results are generally satisfactory.

Change in nostril ratio after cleft rhinoplasty: correction of nostril stenosis with full-thickness skin graft

Background@#Patients with secondary deformities associated with unilateral cleft lip and nose might also suffer from nostril stenosis due to a lack of tissue volume in the nostril on the cleft side. Here, we used full-thickness skin grafts (FTSGs) to reduce nostril stenosis and various methods for skin volume augmentation. We compared the changes in the symmetry of both nostrils before and after surgery. @*Methods@#From February 2016 to January 2020, 34 patients underwent secondary cheiloplasty and open rhinoplasty for secondary deformities of the unilateral cleft lip and nose with nostril stenosis. FTSG was used on the nostril floor, nasal columella, and alar inner lining. The measured nasal profile included the nostril surface, nostril circumference, width of the nostril floor, and distance from the alar-facial groove to the nasal tip. The “overlap area,” which was defined as the largest overlapping area when the image of the cleft nostril was flipped to the left and right and overlaid on the image of the normal side nostril, was also calculated. The degree of symmetry was evaluated by dividing the value of the cleft side by that of the normal side of each measured profile and expressed as “ratios.” @*Results@#The results of all profile ratios, except for the nostril floor width, became significantly close to 1, which represents full symmetry. The overlap area ratio improved from 62.7% to 77.3%, meaning that the length and width of the nostril as well as the overall shape became similar (p< 0.05). @*Conclusion@#When performing cleft rhinoplasty with nostril stenosis, FTSG is useful to achieve symmetry in the nostril size and shape. Skin grafting is simpler to perform than the other types of local flap, and the results are generally satisfactory.

Delayed Methicillin-Resistant Staphylococcus aureus Infection on a Mandibular Angle Fracture with Absorbable Plates

No abstract available.

The Cheapest and Easiest Way to Make Platelet-rich Plasma Preparation

BACKGROUND: Platelet-rich plasma (PRP) has been advocated as a way to introduce increased concentrations of growth factors and other bioactive molecules to injured tissues in an attempt to optimize the local healing environment. Many methods for PRP preparation have been introduced. Despite variations in the volume of whole blood taken and the efficacy of the platelet concentration, the main objective of PRP preparation is to obtain sufficient platelet concentration in the finally processed autologous plasma. We have been making our own internal primitive PRP preparation, which is safe and aseptic, using simple tubes and a centrifugal separator at the outpatient department base. METHODS: Twenty cc of whole blood was collected and 10 cc of blood was added to each of two bottles, followed by addition of 1.5 cc adenosine-citrate-dextrose-acid solution to each bottle. Then, centrifugal separation was performed at 4,000 RPM for 15 minutes. Then, the buffy coat layer was aspirated using a 10 cc syringe equipped with a spinal needle. Platelet activation was initiated by addition of CaCl2 and botropase. RESULTS: We were successful in attaining PRP, which was three folds and six folds concentrated compared with the initial platelet count of whole blood. CONCLUSIONS: Our protocol is economical and only requires a few simple procedures for preparation of PRP. We expect the protocol to be applied to clinical trials without significant cost of time and money.

A Huge Neurofibroma of the Lower Back Invading the Spinal Cavity

No abstract available.

Columella Lengthening with a Full-Thickness Skin Graft for Secondary Bilateral Cleft Lip and Nose Repair

BACKGROUND: Various techniques for lengthening short columellae have been used for bilateral cleft nose repair. However, previous methods have not yielded satisfactory results. We performed a full-thickness skin graft to lengthen short columellae during secondary cleft nose repair in adult patients. METHODS: Ten bilateral cleft lip and nose patients underwent secondary cheiloplasty with open rhinoplasty between July 2008 and August 2014. The patients underwent a full-thickness skin graft on the medial crura to elongate the columella. The average age of the patients at the time of surgery was 22.2 years. Nasal profiles were evaluated before and after the operation using the photogrammetric method. RESULTS: The nasal profiles were improved in all patients, and all skin grafts were well taken, with the exception of one patient. Columellar height, nostril height, and columella-lip angle increased, and nasal width decreased significantly. The ratios of columellar height to nasal height, columellar height to nasal width, and nasal height to nasal width increased to a statistically significant extent. CONCLUSIONS: Columella lengthening with a full-thickness skin graft is a simple and effective method for the repair of severely short columellae in bilateral cleft nose patients. We had satisfactory outcomes, with good color matching and aesthetically pleasing contours.

Bone and Soft Tissue Changes after Two-Jaw Surgery in Cleft Patients

BACKGROUND: Orthognathic surgery is required in 25% to 35% of patients with a cleft lip and palate, for whom functional recovery and aesthetic improvement after surgery are important. The aim of this study was to examine maxillary and mandibular changes, along with concomitant soft tissue changes, in cleft patients who underwent LeFort I osteotomy and sagittal split ramus osteotomy (two-jaw surgery). METHODS: Twenty-eight cleft patients who underwent two-jaw surgery between August 2008 and November 2013 were included. Cephalometric analysis was conducted before and after surgery. Preoperative and postoperative measurements of the bone and soft tissue were compared. RESULTS: The mean horizontal advancement of the maxilla (point A) was 6.12 mm, while that of the mandible (point B) was -5.19 mm. The mean point A-nasion-point B angle was -4.1degrees before surgery, and increased to 2.5degrees after surgery. The mean nasolabial angle was 72.7degrees before surgery, and increased to 88.7degrees after surgery. The mean minimal distance between Rickett's E-line and the upper lip was 6.52 mm before surgery and 1.81 mm after surgery. The ratio of soft tissue change to bone change was 0.55 between point A and point A' and 0.93 between point B and point B'. CONCLUSIONS: Patients with cleft lip and palate who underwent two-jaw surgery showed optimal soft tissue changes. The position of the soft tissue (point A') was shifted by a distance equal to 55% of the change in the maxillary bone. Therefore, bone surgery without soft tissue correction can achieve good aesthetic results.

Subbrow Approach as a Minimally Invasive Reduction Technique in the Management of Frontal Sinus Fractures

BACKGROUND: Frontal sinus fractures, particularly anterior sinus fractures, are relatively common facial fractures. Many agree on the general principles of frontal fracture management; however, the optimal methods of reduction are still controversial. In this article, we suggest a simple reduction method using a subbrow incision as a treatment for isolated anterior sinus fractures. METHODS: Between March 2011 and March 2014, 13 patients with isolated frontal sinus fractures were treated by open reduction and internal fixation through a subbrow incision. The subbrow incision line was designed to be precisely at the lower margin of the brow in order to obtain an inconspicuous scar. A periosteal incision was made at 3 mm above the superior orbital rim. The fracture site of the frontal bone was reduced, and bone fixation was performed using an absorbable plate and screws. RESULTS: Contour deformities were completely restored in all patients, and all patients were satisfied with the results. Scars were barely visible in the long-term follow-up. No complications related to the procedure, such as infection, uncontrolled sinus bleeding, hematoma, paresthesia, mucocele, or posterior wall and brain injury were observed. CONCLUSIONS: The subbrow approach allowed for an accurate reduction and internal fixation of the fractures in the anterior table of the frontal sinus by providing a direct visualization of the fracture. Considering the surgical success of the reduction and the rigid fixation, patient satisfaction, and aesthetic problems, this transcutaneous approach through a subbrow incision is concluded to be superior to the other reduction techniques used in the case of an anterior table frontal sinus fracture.

Salvage of a Free Flap Using Postoperative Percutaneous Angioplasty in Patients with Diabetic Foot Ulcers

No abstract available.

Efficacy of Lateral Canthoplasty Combined with Transconjuctival Lower Blepharoplasty in Young Asian Patients

BACKGROUND: The lower eyelid bag associated with an old and tired appearance is not a rare aesthetic problem in young Asian people who have short palpebral fissures and an up-slanting appearance. Many patients want to make their eyes larger, brighter and more youthful at the same time. The purpose of the current study was to determine the feasibility of lateral canthoplasty combined with transconjunctival lower blepharoplasty in minimizing complications and maximizing aesthetic results. METHODS: From June 2011 to May 2014, 59 patients underwent inferior orbital fat removal and orbital septal resets through transconjunctival approaches and lateral canthoplasty. Simple inferolateral canthotomy incisions were used to provide a sufficient operative field for manipulation of the orbital septum, to lengthen the horizontal palpebral fissures and to lower the lateral canthal angle. Patients were evaluated to identify the presence of postoperative complications and to assess the need for additional operations. RESULTS: Most of the patients were satisfied with the aesthetic results during the 2-12-month postoperative follow-up period. There were no recurrences of lower eyelid bulging, postoperative asymmetry, or wound-related complications. Three cases of entropion and two cases of roundness of the lateral canthal angle occurred following the primary operation. However, there were no further complications after secondary operations to correct the tarsal-periosteal fixation position. CONCLUSIONS: Lateral canthoplasty combined with transconjunctival lower blepharoplasty using simple lateral canthotomy is a safe and effective method for maximizing aesthetic results in young Asian patients.

Open Reduction of Proximal Interphalangeal Fracture-Dislocation through a Midlateral Incision Using Absorbable Suture Materials

BACKGROUND: Fracture-dislocation of the proximal interphalangeal (PIP) joint is a relatively common injury. Various treatments for fracture-dislocation of the PIP joint have been reported. In the present study, we performed open reduction through a midlateral incision using absorbable sutures to reduce the small bone fragments and performed volar plate repair. METHODS: We treated nine patients with fracture-dislocation of the PIP joint with small fractured bone fragments too small for pinning or screw fixation. Patients with volar plate injury were treated with open reduction and volar plate repair at the periosteum of the middle phalangeal bone base by the modified Kessler method using absorbable sutures. All patients were placed in a dorsal aluminum extension block splint, which maintained the PIP joint in approximately 30 degrees of flexion to avoid excessive tension on the sutured volar plate. RESULTS: At a mean final follow-up of postoperative 9 months, all patients were evaluated radiographically and had adequate alignment of the PIP joint and reduction of the displaced bone fragments. Range of motion was improved and there were no complications. CONCLUSIONS: This technique is an excellent alternative to the current method of treating patients with fracture-dislocations that include small fragments that are too small for pinning or screw fixation. It is a less invasive surgical method and enables stable reduction and early exercise without noticeable complications.

Nostril Base Augmentation Effect of Alveolar Bone Graft

BACKGROUND: The aims of alveolar bone grafting are closure of the fistula, stabilization of the maxillary arch, support for the roots of the teeth adjacent to the cleft on each side. We observed nostril base augmentation in patients with alveolar clefts after alveolar bone grafting. The purpose of this study was to evaluate the nostril base augmentation effect of secondary alveolar bone grafting in patients with unilateral alveolar cleft. METHODS: Records of 15 children with alveolar clefts who underwent secondary alveolar bone grafting with autogenous iliac cancellous bone between March of 2011 and May of 2012 were reviewed. Preoperative and postoperative worm's-eye view photographs and reconstructed three-dimensional computed tomography (CT) scans were used for photogrammetry. The depression of the nostril base and thickness of the philtrum on the cleft side were measured in comparison to the normal side. The depression of the cleft side pyriform aperture was measured in comparison to the normal side on reconstructed three-dimensional CT. RESULTS: Significant changes were seen in the nostril base (P=0.005), the philtrum length (P=0.013), and the angle (P=0.006). The CT measurements showed significant changes in the pyriform aperture (P<0.001) and the angle (P<0.001). CONCLUSIONS: An alveolar bone graft not only fills the gap in the alveolar process but also augments the nostril base after surgery. In this study, only an alveolar bone graft was performed to prevent bias from other procedures. Nostril base augmentation can be achieved by performing alveolar bone grafts in children, in whom invasive methods are not advised.

Influence of the Alveolar Cleft Type on Preoperative Estimation Using 3D CT Assessment for Alveolar Cleft

BACKGROUND: The bone graft for the alveolar cleft has been accepted as one of the essential treatments for cleft lip patients. Precise preoperative measurement of the architecture and size of the bone defect in alveolar cleft has been considered helpful for increasing the success rate of bone grafting because those features may vary with the cleft type. Recently, some studies have reported on the usefulness of three-dimensional (3D) computed tomography (CT) assessment of alveolar bone defect; however, no study on the possible implication of the cleft type on the difference between the presumed and actual value has been conducted yet. We aimed to evaluate the clinical predictability of such measurement using 3D CT assessment according to the cleft type. METHODS: The study consisted of 47 pediatric patients. The subjects were divided according to the cleft type. CT was performed before the graft operation and assessed using image analysis software. The statistical significance of the difference between the preoperative estimation and intraoperative measurement was analyzed. RESULTS: The difference between the preoperative and intraoperative values were -0.1+/-0.3 cm3 (P=0.084). There was no significant intergroup difference, but the groups with a cleft palate showed a significant difference of -0.2+/-0.3 cm3 (P<0.05). CONCLUSIONS: Assessment of the alveolar cleft volume using 3D CT scan data and image analysis software can help in selecting the optimal graft procedure and extracting the correct volume of cancellous bone for grafting. Considering the cleft type, it would be helpful to extract an additional volume of 0.2 cm3 in the presence of a cleft palate.

Anthropometric Analysis of Mid-face; Senile Changes of Nasal Dimensions

The objective of this study is anthropometric analysis of nose and mid-face in Korean. This study was based on extensive sample size and variable measurement points. Total 3,000 healthy volunteers (18 to 79 years of age) were took two standardized photographs (frontal and lateral view). And 21 items were measured per person. Age groups were classified into three as young, middle-aged, and elderly. Average nasal length was around 4 cm and height was 5 cm. Female was 5~6% smaller than male. Facial width was 3.5 times larger than nasal length. Nasal length reduced by 5% as get older. Nasofrontal angle was 141degrees and nasolabial angle was 92degrees. Nasal width was 39mm and intercanthal distance was 35 mm. The significant age-related changes were eyeball depth (se-pu) and intercanthal distance. The characteristic senile change of male mid-face was downward deflection of soft tissue but female was soft tissue atrophy. The goal of augmentation rhinoplasty is not filling up sellion point depression but superior shifting of that point. Similarity between nasal length and width was another interesting finding of Korean nose. The results of this study will represent typical values of Korean nose and facilitate exact prediction of surgical results.

The Efficacy of Bioabsorbable Mesh as an Internal Splint in Primary Septoplasty

Nasal bone fractures are often accompanied by septal fractures or deformity. Posttraumatic nasal deformity is usually caused by septal fractures. Submucosal resection and septoplasty are commonly used surgical techniques for the correction of septal deviation. However, septal perforation or saddle nose deformity is a known complication of submucosal resection. Hence, we chose to perform septoplasty, which is a less invasive procedure, as the primary treatment for nasal bone fractures accompanied by septal fractures. During septoplasty, we used a bioabsorbable mesh as an internal splint. We used the endonasal approach and inserted the mesh bilaterally between the mucoperichondrial flap and the septal cartilage. The treatment outcomes were evaluated by computed tomography (CT) and the nasal obstruction symptom evaluation (NOSE) scale. The CT scans demonstrated a significant improvement in the septal deviation postoperatively. The symptomatic improvement rated by the NOSE scale was greater at 1 month and 6 months after surgery compared to the preoperative status. There were no cases of extrusion or infection of the implant. In cases of moderate or severe septal deviation without dislocation from the vomerine groove on the CT scan, our technique should be considered one of the treatments of choice.

The Efficacy of Bioabsorbable Mesh as an Internal Splint in Primary Septoplasty

Nasal bone fractures are often accompanied by septal fractures or deformity. Posttraumatic nasal deformity is usually caused by septal fractures. Submucosal resection and septoplasty are commonly used surgical techniques for the correction of septal deviation. However, septal perforation or saddle nose deformity is a known complication of submucosal resection. Hence, we chose to perform septoplasty, which is a less invasive procedure, as the primary treatment for nasal bone fractures accompanied by septal fractures. During septoplasty, we used a bioabsorbable mesh as an internal splint. We used the endonasal approach and inserted the mesh bilaterally between the mucoperichondrial flap and the septal cartilage. The treatment outcomes were evaluated by computed tomography (CT) and the nasal obstruction symptom evaluation (NOSE) scale. The CT scans demonstrated a significant improvement in the septal deviation postoperatively. The symptomatic improvement rated by the NOSE scale was greater at 1 month and 6 months after surgery compared to the preoperative status. There were no cases of extrusion or infection of the implant. In cases of moderate or severe septal deviation without dislocation from the vomerine groove on the CT scan, our technique should be considered one of the treatments of choice.

Correction of Retracted Ala Using Spacer Graft in Secondary Cleft Lip and Nose Deformity

PURPOSE: In patients with unilateral cleft lip and nose deformity, alar retraction is commonly seen on the non-cleft side after cleft side is corrected. Spacer graft was used to drag down the inferior border of the alar cartilage of the non-cleft side so as to match the cleft side. By performing spacer graft and septal extension graft together, symmetry and cosmetic improvements were achieved. METHODS: Seven unilateral cleft lip and nose deformity patients underwent surgery for alar retraction correction. The median age was 24 years (ranged from 15 to 34 years), and the median follow-up period was 7.4 months (ranged from 6 to 12 months). The perpendicular length from the longitudinal axis of the nostril to the alar rim, the nasolabial angle and the ala-labial angle were measured in the lateral view photo. The longest perpendicular length from the cephalic border of the alar rim to the parallel line of the alar base was measured in the frontal view photo. RESULTS: Improvement in alar retraction was seen after the surgery. There were no specific complications during the follow-up and the symmetry of both nostrils was satisfactory. No increase in the nasolabial angle or exposure of the nostrils was seen after the tip projection via tip plasty. CONCLUSION: The fundamental factor in correcting alar retraction with secondary cleft lip and nose deformity is repositioning the alar rim with spacer graft, which seems to be more physiologic than other methods. The method combining spacer graft with septal extension graft will bring symmetry as well as more cosmetic improvement in correction of alar retraction with secondary cleft lip and nose deformity.

Lower Blepharoplasty: In and Out Complementary Technique

PURPOSE: Traditional transcutaneous incision and transconjunctival incision methods are commonly used in the lower blepharoplasty. The transconjunctival method leaves no visible scars nor does it change the shape of lower eyelid contour and the surgical technique is not difficult. However removal of excess baggy skin is not possible through this method. Therefore, the transconjunctival incision method is useful only for patients who still have normal elasticity of the lower eyelids and fat that is protruding only anterocaudally. The Author will introduce a technique, which complements the limitations of these two methods mentioned above. METHODS: The author combined the transconjunctival approach and lower blepharoplasty with only the excised skin flap method. This method does not go beyond the previous methods but does apply the advantages of them. RESULTS: From March 2007 to October 2010, this new technique was performed in a total of 62 patients. Fat was removed and repositioned through transconjunctival incision. Drooped skin was excised as in the traditional blepharoplasty but only the skin flap was elevated. This prevents post-operative complications such as ectropion, sclera show, and deformation of the shape of the lower eyelids or under-resection of fat. All patients were satisfied with the post-operative appearance. CONCLUSION: The author was able to get satisfactory results while avoiding complications of traditional transcutaneous technique with this combined technique of the transconjunctival approach and the lower blepharoplasty method of skin flaps only.

Congenital Epulis with Feeding Difficulty: A Case Report

PURPOSE: The congenital epulis is a rare, benign tumor. It can protrude out of the newborn's mouth to prevent normal closure of the mouth and it can interfere with respiration or feeding. METHODS: An 11-day old female neonate presented with a 1.5x1.5x2.3cm sized mass in the gingival and anterior alveolar ridge of the mandible. We performed a simple excision. RESULTS: In our case, histologically, there was no pseudoepitheliomatous hyperplasia. The staining for S-100 protein, and actin was negative. After 8 months, the patient had normal teeth eruption and no recurrence of the tumor. CONCLUSION: With early detection and appropriate treatment, we were able to help the baby avoid developing any dyspnea. Nursing was possible after the mass had been removed.

Tip Plasty using Biodegradable Plate as a Columella Strut

PURPOSE: Most surgeons have used autogenous cartilage for columella strut graft. But the supply of autogenous cartilage is often limited. So, this study is to investigate the usefulness of biodegradable plate as columella strut material. METHODS: We studied 19 patients who have secondary cleft nasal deformity. Patients were divided into two groups. Group A patients who were not closed their growth plate underwent columella strut graft only with biodegradable plate through endonasal approach. The biodegradable plate was inserted between nasal tip and anterior nasal spine. Group B patients were closed their growth plate. They had an operation for columella strut graft with biodegradable plate fixed with autogenous conchal cartilage. If nasal tip projection was insufficient, we performed additionally onlay graft on nasal tip with autogenous soft tissue or remnant cartilage. RESULTS: As a result of mean 14 months follow-up, we achieved a good nasal tip projection, narrowing of interalar distance and symmetrical nostril shape. No specific complications were reported except 2 cases, which were the extrusion of biodegradable plate into the nasal cavity and Staphylococcus aureus infection. CONCLUSION: The columella strut graft using biodegradable plate is simple and effective method. Biodegradable plate can be a good substitute for columella strut in patients who can not use autogenous cartilages.