Simultaneous Fat Injection for Nasal Contouring in Orthognathic Patients.

BACKGROUND: Augmentation rhinoplasty with autologous fat grafting is a useful procedure to meet the demand for facial harmonization in the Asian population. We used this procedure during orthognathic surgery to address inadequate dorsum projection. This prospective study was conducted to determine the fat retention rate in patients undergoing simultaneous autologous fat injection augmentation rhinoplasty and orthognathic surgery. METHODS: Nineteen patients were treated with simultaneous bimaxillary orthognathic surgery and autologous fat grafting of the nasal dorsum and tip. The paired t test was used to compare the nasal volumes before and at least 6 months after surgery measured by 3-dimensional computer tomography scans. All measurements were performed twice by the same evaluator at least 2 weeks apart for intrarater consistency. RESULTS: Seventeen patients completed the study. The volume means before and after surgery were 22.3 ± 4.6 cm3 and 23.3 ± 4.7 cm3, respectively, with a mean difference of 1.0 ± 0.3 cm3 (P < .001). The mean retention rate was calculated to be 50.5% ± 7.0% (range: 40.5%-64.7%). Intrarater consistency was high with a Cronbach α of .97 (P < .001) and .98 (P < .001), respectively. CONCLUSION: This prospective study provides objective graft retention measurements for fat injection augmentation rhinoplasty combined with orthognathic surgery. All patients were satisfied with the results and no complications or additional morbidity was noted in the postoperative course. We consider this procedure to be a safe, reliable, and powerful adjunct to improve the aesthetic results of orthognathic surgery.

Holistic reconstruction of mandible defect, lower lip and chin sensation, and smile reanimation in an advanced gum cancer patient: A case report.

Facial deformity, facial paralysis, and sensory loss are inevitable after some head and neck tumor resection and reconstruction, especially in high stage cancer. To overcome these obstacles, we present a case of T4a gum cancer patient (41-year-old) who received holistic reconstruction of the mandible defect via an osteo-peroneal-artery-perforator combined flap for defect coverage and cross-mental nerve graft for lower lip and chin sensation at the primary stage, followed by ipsilateral facial nerve (lower trunk) innervated gracilis functioning free muscle transplantation for facial reanimation and correction of the sunken face 3 years later. After 4.5 years of follow-up, the patient was satisfied with his appearance, and obtained a spontaneous and symmetrical smile without sensory deficit. This experience showed a possible solution to the reconstruction for complicated head and neck cancer patients.

Simultaneous Orthognathic Surgery With Asian Double Eyelid Suture Blepharoplasty.

BACKGROUND: The main objective of contemporary orthognathic surgery is to correct dentofacial deformities. Nonetheless, many adjunct procedures to enhance the esthetic outcome in orthognathic surgical cases have been successfully incorporated to improve patient satisfaction. The authors report our preliminary experience of performing simultaneous orthognathic surgery with Asian double eyelid suture method blepharoplasty in the same surgical setting. METHOD: This case series report includes all 19 consecutive cases presenting to the Chang Gung Craniofacial Center for combined orthognathic surgery with Asian double eyelid suture method blepharoplasty. The double eyelid crease height was measured as the vertical line between the upper eyelid margin (eyelid lash) and the upper eyelid crease, observed at the mid-pupillary line with the eyes in primary gaze. RESULTS: There were no complications or relapse reported within this time period. There was significant improvement in the left and right mid-pupillary double eyelid crease height postsurgery. There were no statistically significant differences between the left and right mid-pupillary double eyelid crease heights after surgery indicating good eyelid crease height symmetry bilaterally was obtained. CONCLUSIONS: Orthognathic surgery combined with suture method blepharoplasty can be safely performed in the same surgical setting without inappropriate rise in costs or operating room time. This case series demonstrates that excellent esthetic results can be obtained in simultaneous bimaxillary orthognathic surgery with suture method Asian blepharoplasty.

Identification of predisposing factors for osteonecrosis of the jaw after marginal mandibulectomy in the surgical management of oral squamous cell carcinoma.

BACKGROUND: The aim of this study is to evaluate osteonecrosis of the jaw (ONJ) with the extent of marginal mandibulectomy. METHODS: Between January 2006 and December 2012, 3087 patients undergoing ablative resection were consecutively enrolled. Among them, 345 cases undergoing marginal mandibulectomy were retrospectively reviewed. RESULTS: The occurrence of ONJ was 5.51% and associated with body mass index, overall stage, diabetes, concomitant mandibulotomy, and radiotherapy (P = 0.023, 0.033, 0.009, 0.016, and 0.006, respectively). As for bone parameters based on radiological measurements after marginal mandibulectomy, resected bone height, remaining bone height to original bone height ratio, and resected bone height to original bone height ratio were associated with ONJ. In multivariate logistic analyses, concomitant mandibulotomy, radiotherapy, diabetes, resected bone height of >14.5 mm, resected bone height to original bone height ratio of >49.5%, and remaining bone height to original bone height ratio of <53.5% indicated higher risks for ONJ (adjusted HR: 4.345, 4.152, 4.079, 3.402, 3.541, and 3.211; P = 0.018, 0.013, 0.009, 0.021, 0.018, and 0.043, respectively). CONCLUSIONS: This study demonstrated the predisposing factors and parameters associated with ONJ with marginal mandibulectomy; more caution is necessitated in performing marginal mandibulectomy in patients with multiple risks to prevent ONJ.

Minimizing osteoradionecrosis after mandibular reconstruction and radiation in advanced head and neck cancer patients.

BACKGROUND: Osteoradionecrosis may develop on the residual mandible or reconstructed fibula because of inadequate soft tissue coverage and compromised tissue perfusion post mandibular reconstruction, and radiation. This study was to investigate the incidence of osteoradionecrosis following class III mandibular defect reconstructions with an OPAC flap versus a fibula OSC flap. METHODS: A retrospective review of a consecutive series of mandibular reconstructions between 1999 and 2010 was performed. Mandibular defects and corresponding flap types were analyzed with emphasis on outcome, complications, and rates of osteoradionecrosis among the two subgroups. RESULTS: A total of 121 fibula flaps were performed, consisting of 53 OPAC and 68 fibula OSC flaps. Complications trended higher for OPAC flaps in partial and total flap loss rates as well as venous congestion when compared with the OSC flap cohort. The OPAC group had statistically significant lower rates of osteoradionecrosis and plate exposure than the OSC group (P = 0.04). CONCLUSION: The OPAC flap may be preferable to fibula OSC flap in mandibular reconstruction given its lower rates of osteoradionecrosis and plate exposure. This flap type may be the flap of choice for class III defects where additional vascularized tissue may be critical for addressing significant soft tissue deficiency. J. Surg. Oncol. 2016;114:399-404. © 2016 Wiley Periodicals, Inc.

Comparison of Facial Growth between Two Nasoalveolar Molding Techniques in Patients with Unilateral Complete Cleft Lip.

BACKGROUND: Nasoalveolar molding (NAM) has become standard treatment in the authors' craniofacial center. There are two types of presurgical NAM: the Grayson and Figueroa techniques. The Grayson method involves active alveolar molding, and the Figueroa method involves passive alveolar molding. The authors previously found no differences in number of clinic visits, costs, or 6-month postoperative outcome between the two techniques. The authors extended the previous study to evaluate facial growth between these two groups. METHODS: In this randomized single-blind study, conducted between May of 2010 and March of 2013, the authors recruited 30 patients with unilateral complete cleft lip and palate and randomized them for Grayson or Figueroa presurgical NAM. Standard lateral cephalometric measurements at 5 years were used to determine facial growth. RESULTS: Twenty-nine patients completed 5 years of follow-up. There were no statistically significant differences in facial cephalometric measurements between the two groups. CONCLUSION: Presurgical NAM using either a passive or active NAM technique produced similar facial growth patterns after unilateral cleft lip and palate repair. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

A nomogram to predict osteoradionecrosis in oral cancer after marginal mandibulectomy and radiotherapy.

OBJECTIVE: There is no useful tool to clinically predict the occurrence of osteoradionecrosis (ORN) of the mandible quantitatively. The aim was to investigate the risk factors, including different modalities of radiotherapy, for developing mandibular ORN in patients undergoing marginal mandibulectomy and postoperative radiotherapy. METHODS: Between January 2006 and December 2012, 167 subjects who underwent marginal mandibulectomy and postoperative radiotherapy with different modalities were enrolled. The association of ORN with mandibular bone measurements and patient variables was analyzed, and a nomogram was established. RESULTS: Fifteen (8.98%) of the 167 patients developed ORN during the follow-up period, and ORN was significantly associated with diabetes mellitus (DM), body mass index (BMI), remaining bone height, remaining bone height to original bone height ratio, resected bone height to original bone height ratio, and mandibular dose (P: < 0.001, 0.004, 0.042, 0.018, 0.010, 0.020, respectively). Interestingly, the risk of ORN had no significant difference between conformal and intensity modulation radiation therapy (P = 0.407). Multivariate analysis revealed that DM and resected bone height to original bone height ratio ≥ 50% were independent risk factors for postoperative ORN. A nomogram consisting of BMI, DM, resected bone height to original bone height ratio, mandibulotomy, and mandibular dose for predicting the ORN-free probability was established; and the c-index of the nomogram for ORN status was 0.803. CONCLUSION: A nomogram based on the risk factors was plotted to strengthen the prediction of ORN quantitatively. Surgeons should be more discrete regarding the treatment plan for patients with higher probability of ORN. LEVEL OF EVIDENCE: 3b Laryngoscope, 130:101-107, 2020.

Clinical evaluation of silicone gel in the treatment of cleft lip scars.

Upper lip scars are at risk of hypertrophy. Our center therefore uses microporous tape and silicone sheeting for postoperative scar care following cleft lip repair. However, some babies have previously ingested their silicone sheeting, which has the potential for respiratory compromise or gastrointestinal obstruction. Self-dry silicone gel is reportedly also effective for preventing hypertrophic scars. Hence, we sought to test whether silicone gel, which cannot be ingested whole, might be non-inferior to silicone sheeting for controlling against upper lip scar hypertrophy. This was a mixed prospective and retrospective case-controlled clinical trial involving patients undergoing unilateral cleft lip repair, 29 of whom received standard postoperative silicone sheeting (control group) and another 33 age-matched consecutive patients who received self-dry silicone instead. The Vancouver scar scale, visual analogue scale and photographically assessed scar width assessments were the same in both groups at six months after surgery. In conclusion, silicone gel appears to be non-inferior to silicone sheeting for postoperative care of upper lip scars as judged by scar quality at six months, but silicone sheeting has the safety disadvantage that it can be swallowed whole by babies. It is thus recommended that silicone gel be used for upper lip scar management in babies.

Simultaneous left maxillary and right mandibular reconstructions with a split osteomyocutaneous peroneal artery-based combined flap.

BACKGROUND: Traditionally, reconstruction of concurrent maxillary and mandibular defects on opposite sides of the facial skeleton often requires use of 2 free osseocutaneous flaps. A new technique of using a differentially split osteomyocutaneous peroneal artery-based combined (OPAC) flap for 1-stage reconstruction of left maxillary and right mandibular defects is presented. METHODS: An OPAC flap with 1 skin paddle and a cuff of soleus muscle was harvested. The fibula was split; the distal osseous flap was used for right mandibular reconstruction, and the proximal OPAC flap composing of proximal fibula, skin paddle, and soleus muscle was used for the maxillary reconstruction. Bilateral facial vessels were used as recipient vessels. RESULTS: No complications were encountered. The patient showed good functional and cosmetic outcomes at 1-year follow-up. CONCLUSION: The split OPAC flap allows for simultaneous reconstruction of bony defects that are spatially far apart without the need for a second free flap.

Anatomical basis and clinical application of the ulnar forearm free flap for head and neck reconstruction.

OBJECTIVES/HYPOTHESIS: This study was designed to investigate the anatomical features and applications of the ulnar forearm flap in head and neck reconstructive surgery. STUDY DESIGN: A prospective study was designed to include 50 ulnar forearm free flap transplants in 50 patients. Patient defects requiring reconstructive surgery involved the buccal mucosa, tongue, floor of the mouth, upper or lower gums, lips, soft palate, and scalp. Twenty ulnar forearm flaps were analyzed along the entire ulnar artery to determine the anatomy and distribution of the ulnar artery septocutaneous perforators. RESULTS: All 50 flaps were successfully transplanted into their respective sites. The mean diameters of the ulnar artery and vein were 2.3 ± 0.6 mm and 1.7 ± 0.6 mm, respectively. Arterial and venous size mismatch was experienced in 12 and 33 flaps, respectively. The mean number of sizable perforators was 4.3 ± 1.2, and most of the first perforators were located within 5 cm of the proximal wrist crease. None of the patients experienced long-term complications concerning the ulnar nerve. CONCLUSIONS: The ulnar forearm flap is a reliably consistent source of free flap transfer because it harbors constant septocutaneous perforators and produces minimal donor site morbidities for head and neck reconstructive surgery.

A strategic approach for tongue reconstruction to achieve predictable and improved functional and aesthetic outcomes.

BACKGROUND: Successful tongue reconstruction should restore swallowing, speech function, and cosmesis. The purpose of this prospective study was to evaluate the functional and aesthetic outcomes of tongue reconstruction using variable free flaps based on different tongue defects. METHODS: One hundred four patients with a mean age of 49±11 years underwent free tissue transfer following resection of T2 to T4 tongue cancers. The defects were classified prospectively into three groups: group A, hemiglossectomy defects (n=42) reconstructed with 33 radial forearm flaps and nine anterolateral thigh perforator flaps; group B, subtotal glossectomy defects (n=50) reconstructed with anterolateral thigh perforator (n=44) or anterolateral thigh myocutaneous flaps (n=6); and group C, total glossectomy defects (n=12) reconstructed with 12 pentagonal anterolateral thigh myocutaneous flaps. RESULTS: Two flaps failed, giving a success rate of 98.1 percent. Two patients developed partial flap loss. At a mean follow-up of 46.2 months, 33 patients were available for evaluation. Normal speech was found in 13 patients, intelligible speech was found in nine, and slurred speech was found in 11. Sixteen patients could eat a normal diet, eight could eat a soft diet, seven could eat a liquid diet, and two required tube feeding (p=0.28). The cosmetic results were rated as excellent in 19, good in nine, and fair in five patients (p=0.76). CONCLUSIONS: A strategic approach of variable flap selections based on different tongue defects may achieve predictably better functional and aesthetic outcomes. The innovative pentagonal anterolateral thigh myocutaneous flap for total tongue reconstruction creates a free neotongue tip with adequate volume, producing acceptable swallowing function and cosmesis.

Does ischemia time affect the outcome of free fibula flaps for head and neck reconstruction? A review of 116 cases.

BACKGROUND: The fibula osteoseptocutaneous flap is an excellent option for the reconstruction of segmental mandibular defects. This study was conducted to investigate the relationship between ischemia time and outcome of the fibula flap, thus establishing the critical ischemia time for this procedure. METHODS: Between February of 2003 and March of 2005, 114 patients who underwent 116 fibular osteoseptocutaneous flaps for head and neck reconstruction were reviewed retrospectively. Complications were classified as acute, subacute, or chronic based on the time at which they were detected postoperatively. Outcomes among different ischemia time groups were evaluated: group A, less than 3 hours; group B, 3 to 4 hours; group C, 4 to 5 hours; and group D, 5 to 7 hours. RESULTS: The mean success rate of the fibula osteoseptocutaneous flap was 98.3 percent. Mean flap ischemia time was 3.6±0.97 hours. Sixty-six patients (56.9 percent) experienced one or more complications at different stages (86 complications total). There were no statistically significant differences in acute, subacute, and chronic complications among the four groups (p=0.6, p=0.6, and p=0.2, chi-square test). The overall complication rate was significantly higher in group D (81.8 percent) (p=0.03, chi-square test). The partial flap loss rate was also statistically higher in group D (45.5 percent) compared with the other three groups (12.1, 12.2, and 8.7 percent) (p=0.02, chi-square test). CONCLUSIONS: : Using the fibula osteoseptocutaneous flap for head and neck reconstruction, ischemia times less than 5 hours do not increase complication rates in different postoperative stages. However, the critical ischemia time of the fibula osteoseptocutaneous flap should be limited to 5 hours to reduce partial skin paddle loss and overall complications.

Two small flaps from one anterolateral thigh donor site for bilateral buccal mucosa reconstruction after release of submucous fibrosis and/or contracture.

Oral submucous fibrosis causes health-related and social problems for affected patients. Free flap reconstruction has proved effective for maintaining mouth opening after release of fibrosis. Two independent free flaps from separate donor sites, such as bilateral forearm flaps or bilateral anterolateral thigh (ALT) flaps, were traditionally required for reconstruction. The former option sacrifices one of the two major arteries in the forearm. Both options are time consuming and required two donor sites. To eliminate these disadvantages, we developed a technical modification that allows harvesting of two independent flaps from one ALT thigh based on one descending branch of the lateral circumflex femoral artery (d-LCFA). Eighteen flaps from nine donor sites were harvested for post-release reconstruction of oral submucous fibrosis. Mean flap size was 4.1 x 7.5 cm, mean pedicle length was 7.6 cm, mean ischaemia time was 104 min and mean total operation time was 13 h and 19 min. All donor sites were closed primarily, with one exception. One flap failed and was replaced with a contralateral ALT flap. One patient developed a wound infection and another developed a seroma at the recipient site. Four flaps required secondary de-bulking in three patients. The improvement in mouth opening was evaluated by inter-incisor distance (IID): mean preoperative IID was 9.6mm (range: 0-20mm), mean follow-up time was 16.2 months (range: 10-33 months); mean postoperative IID was 23.8mm and mean improvement in IID was 15.3mm (range: 10-27 mm). In conclusion, two independent flaps can be harvested from d-LCFA of the same thigh, instead of from both thighs, to reconstruct bilateral buccal defects after release of submucous fibrosis and/or contracture.