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.

NAM-help or burden? Intercultural evaluation of parental stress caused by nasoalveolar molding: a retrospective multi-center study.

OBJECTIVES: Nasoalveolar molding (NAM) was developed to facilitate easier treatment and better outcomes for cleft lip and palate (CLP) patients. The aim of this study was to investigate the parental burden and possible intercultural differences of this treatment modality, which is often argued to burden parents to an extraordinary amount. MATERIALS AND METHODS: Standardized questionnaires (available in English, Mandarin, and German) with 15 non-specific and 14 NAM-specific items to be retrospectively answered by Likert scales by parents of unilateral CLP patients with completed NAM treatment. RESULTS: The parents of 117 patients from two treatment centers in Taiwan and Germany were included. A very high level of overall satisfaction was found in both countries with significant intercultural differences in prenatal parent information, feeding problems, dealing with 3rd party's perception, and experienced personal effort. CONCLUSION: NAM is an effective treatment tool for children's CLP deformities and their caregivers in overcoming the feeling of helplessness. Intercultural differences may be due to infrastructural reasons, cultural attitudes and habits, or different public medical education. CLINICAL RELEVANCE: In addition to facilitating easier surgical treatment, NAM can be seen as a powerful coping strategy for parents dealing with a CLP deformity of their child and does not seem to burden them extraordinarily.

Primary Repair in Patients With Unilateral Complete Cleft of Lip and Primary Palate: Assessment of Outcomes.

OBJECTIVE: Asymmetry of median facial structures is a major concern for patients with unilateral cleft lip and palate, and the principal goal of its treatment is to restore symmetry. Unilateral complete cleft of lip and primary palate (UCCLPP) is an uncommon subgroup and rarely reported. Patients with UCCLPP have protruding and deviating premaxilla, rendering a primary repair difficult. This study evaluated consecutive patients with UCCLPP and presented their treatment outcome. METHODS: We assessed 36 patients with UCCLPP and collected clinical information. Surgical repair was performed at 3 months of age by using a modified rotation-advancement method and primary nasal reconstruction. A single surgeon performed all surgical procedures. A postoperative nasal stent was used for 6 months. Follow-up standardized photographs were collected. Landmarks were identified, and nose and lip dimensions measured. The ratios of the corresponding parameters (cleft vs noncleft side) were obtained for evaluating nose and lip symmetry. RESULTS: No surgical complication was noted in any patient. The overall lip and nose outcome after the primary repair were adequate, and all ratios were close to 1. The nostril width was slightly wider on the cleft side, but the alar width and height were acceptable. The lip heights were balanced between the 2 sides. Patients who received presurgical nasoalveolar molding did not show more favorable lip and nose dimensions, except for the medial philtral height. CONCLUSION: Even in the presence of protruding and deviating premaxilla, our patients with UCCLPP obtained adequate lip and nose outcome after undergoing primary lip repair and nasal reconstruction.

3D printing in orthognathic surgery - A literature review.

With the recent advances in three-dimensional (3D) imaging, computer-assisted surgical planning and simulation are now regularly used for analysis of craniofacial structures and improved prediction of surgical outcomes in orthognathic surgery. A variety of patient-specific surgical guides and devices have been designed and manufactured using 3D printing technology, which rapidly gained widespread popularity to improve the outcomes. The article presents an overview of 3D printing technology for state-of-the-art application in orthognathic surgery and discusses the impacts on treatment feasibility and patient outcome. The current available literature regarding the use of 3D printing methods in orthognathic surgery including 3D computer-aided design/computer-aided manufacturing, rapid prototyping, additive manufacturing, 3D printing, 3D printed models, surgical occlusal splints, custom-made guides, templates and fixation plates is reviewed. A Medline, PubMed, ProQuest and ScienceDirect search was performed to find relevant articles over the past 10 years. A total of 318 articles were found, out of which 69 were publications addressing the topic of this study. An additional 9 hand-searched articles were added. From the review, we can conclude that the use of 3D printing methods in orthognathic surgery provide the benefit of optimal functional and aesthetic results, patient satisfaction, and precise translation of the treatment plan.

Establishment of a Reliable Horizontal Reference Plane for 3-Dimensional Facial Soft Tissue Evaluation Before and After Orthognathic Surgery.

BACKGROUND: This study aims to demonstrate the reliability of our proposed facial reference system in the horizontal axis using 3-dimensional photogrammetry and to find a correlation between this plane and the Frankfurt horizontal (FH) plane. METHODS: Forty-one patients were enrolled. Three-dimensional facial images were taken before and 6 months after orthognathic surgery. Superimposition was carried out, and differences in landmark position were evaluated. Two constant landmarks were selected to construct a reference system within a standardized reference frame. Cone-beam computed tomography and 3-dimensional facial images were superimposed. Two reference lines were identified, and the angle between these lines was calculated. RESULTS: For landmark reliability, 5 landmarks [gnathion, nasion, exocanthion (Ex), endocanthion, and tragion (T)] were constant. Two landmarks (Ex and T) were selected to construct a reference system within a standardized reference frame. For angular measurement, the mean angle between this reference plane and the skeletal FH plane was 17.6 ± 2.0 degrees. There was no statistical difference between sex, side, and preoperative/postoperative timing of photography. CONCLUSIONS: Our proposed reference plane is constructed from reliable facial Ex and T landmarks. This plane is consistent and crosses the FH plane at 17.6 degrees.

A Modified Technique of Mandibular Ramus Sagittal Split Osteotomy for Prevention of Inferior Alveolar Nerve Injury: A Prospective Cohort Study and Outcome Assessment.

BACKGROUND: Postoperative functional impairment of the inferior alveolar nerve (IAN) has been a common and well-recognized complication. Our study introduced a modified Obwegeser-Dal Pont bilateral sagittal split osteotomy (BSSO) technique and evaluated the subsequent incidence of postoperative neurosensory disturbance of IAN. METHODS: In this prospective cohort study, 57 patients receiving our modified BSSO during orthognathic surgery were enrolled. The technique contained opening the 2 ramus cortices and inserting the osteotome bypassing the IAN to avoid nerve injury. A 5-point scale self-assessment questionnaire was used to evaluate IAN neurosensory disturbance one week, six months and 12 months postoperatively. Differences between groups were analyzed using χ test for categorical and Wilcoxon signed-rank test for pairwise categorical data. RESULTS: Complete ramus splitting could be achieved in 109 (95.6%) sides. Lower lip or chin neurosensory disturbances presented in 72 (63.2%) sides 1 week postoperatively and gradually reduced to 9 (7.9%), and 4 (3.5%) at postoperative months 6 and 12, respectively. CONCLUSIONS: This BSSO technique could be safely performed with low rates of IAN exposure and injury and a low incidence of persistent neurosensory disturbance in 3.5% of patients 12 months postoperatively.

Complications following orthognathic surgery for patients with cleft lip/palate: A systematic review.

BACKGROUND/PURPOSE: The purpose of this systematic review is to update the available data for complications following orthognathic surgery in cleft lip and/or palate patients. METHODS: Three electronic databases (Medline, Embase, and Cochrane) were searched for publications from 1990 to 2014. RESULTS: A total of 26 articles were selected including 1003 patients (male: 391, female: 353, 259: not mentioned) who underwent maxillary osteotomies for cleft lip/palate. Mean age at surgery was 19.3 years (range: 8.5-60 years). Overall perioperative complications were reported in 126 cases (12.76%). The most common complication was closure failure of pre-existing palatal fistula (28.57%), followed by velopharyngeal impairment (16.79%), closure failure of pre-existing alveolar fistula (10.74%), gingival recession (4.55%), and failure of premaxilla stabilization in bilateral cases (4.55%). Severe vascular complications included one arteriovenous fistula (0.10%), one maxillary aneurysm (0.10%), and one cavernous sinus thrombosis (0.10%). Mean horizontal relapse rate was 17.9% (range: -20.0% to 37.2%), and mean vertical relapse rate was 35.4% (range: -25.9% to 162.5%). Reoperation rate was 12.2% (range: 0.0-64.0%). Prospective studies or randomized trials were rare. CONCLUSION: To obtain a dataset with higher evidence, a prospective multicenter study should be conducted with clearly defined criteria for each complication.

Three-Dimensional Analyses of Postoperative Effects of Surgically Assisted Rapid Palatal Expansion (SARPE) on the Soft Tissue of the Midface Region and the Upper Airway Space Using Stereophotogrammetry and Cone Beam Computed Tomography (CBCT).

BACKGROUND: Surgically assisted rapid palatal expansion (SARPE) is an established method to treat transverse maxillary hypoplasia in skeletally mature adult patients. SARPE affects the surrounding soft tissue. In addition, effects on the airway and breathing have been described. Aim of this study was to assess the effects of SARPE on the nasal soft tissue and the upper airway by means of three-dimensional stereophotogrammetry and cone beam computed tomography (CBCT). METHODS: This retrospective study used preoperative and postoperative cone beam computed tomography (CBCT) scans and three-dimensional stereophotogrammetry. Ten skeletally adult patients (4 male, 6 female; mean age 27.68 years) with transverse maxillary hypoplasia were included. Patients had undergone SARPE procedure, performed by the same surgical team using the same technique. Nasal soft tissue changes were analyzed, using three-dimensional stereophotogrammetry records taken preoperatively (t0) and at the postoperative checkup appointment (t1). The upper airway was assessed using CBCT scans for surgical planning (t0) and the first scan taken after SARPE (t1). RESULTS: In stereophotogrammetry, it was shown that only a few soft tissue nasal parameters increased significantly and SARPE leads to mainly clinically irrelevant changes in nasal soft tissue. In CBCT, only a significant increase in nasopharyngeal airway volume was found. DISCUSSION: Results were in alignment with literature. The effects of SARPE on the nasal soft tissue are mostly statistically insignificant and clinically irrelevant. Airway volume significantly increased in the nasopharyngeal area. Further research on SARPE effects should be conducted to reinforce SARPE as a treatment option for sleep apnea patients.

Patient- and 3D morphometry-based nose outcomes after skeletofacial reconstruction.

Patient satisfaction with the shape and appearance of their nose after orthognathic surgery-based skeletofacial reconstruction is an important, but often overlooked, outcome. We assessed the nose-related outcomes through a recently developed patient-reported outcome instrument and a widely adopted 3D computer-based objective outcome instrument, to verify any correlation in the results produced by these tools. We collected FACE-Q nose appearance reports (2 scales) and 3D nasal morphometry (10 parameters) from patients with class III skeletal pattern and congenital cleft lip palate deformity (n = 23) or developmental dentofacial deformity (n = 23) after (>12 months) skeletofacial reconstruction. The cleft and dentofacial cohorts demonstrated significantly (p < 0.001) poorer satisfaction scores with regard to the FACE-Q nostrils scale than the normal age-, gender-, and ethnicity-matched subjects (n = 107), without any significant difference in FACE-Q nose scale. The cleft cohort had significantly (p < 0.001) smaller nasal length, nasal tip projection, and columellar angle and greater nasal protrusion, alar width, and columellar-labial angle values than the dentofacial and normal cohorts; however, there were no significant differences between the dentofacial versus normal cohorts. The FACE-Q nose and nostrils scales were significantly (p < 0.001; r = -0.26-0.27) correlated to the results of the 3D morphometric analysis, with regard to nasal length, alar width, columella angle, and columellar-labial angle parameters. This study revealed differences in satisfaction with the appearance of the nose according to the type of underlying deformity, and demonstrated a significant correlation (low correlation coefficients) between the patient-reports and 3D image-based outcome measure tools, which has implications for multidisciplinary-centered research, auditing, and clinical care.

Reinforcing the Mucoperiosteal Pocket with the Scarpa Fascia Graft in Secondary Alveolar Bone Grafting: A Retrospective Controlled Outcome Study.

BACKGROUND: Secondary alveolar bone grafting is the gold standard for the treatment of alveolar clefts in cleft lip and palate patients. The authors present a modified method using a Scarpa fascia graft that is placed deep into the mucoperiosteal pocket for watertight sealing of the bone graft chamber and limiting the graft position to the alveolar region for bony stability and tooth support. The outcome was assessed for clinical success in terms of bone graft stability and infection rate. METHODS: Seventy-four unilateral complete cleft lip and palate patients were enrolled in this retrospective study consisting of equal-size Scarpa fascia and control groups of consecutive unilateral complete cleft lip and palate patients undergoing secondary alveolar bone grafting. Occlusal radiographs of the alveolar cleft taken at least 1 year postoperatively were evaluated for Spearman correlated Bergland and Witherow scales. Statistical evaluation was conducted using t test, chi-square test, and odds ratio. RESULTS: The clinical success rate (Bergland types I and II) of the Scarpa fascia procedure was significantly higher (67.6 versus 94.6 percent, respectively), with a significantly lower infection rate (16.2 versus 2.7 percent, respectively) and a high correlation of Bergland and Witherow scales (0.964; p < 0.001). There was no wound dehiscence, fistula, bone graft exposure, or additional donor-site morbidity in the Scarpa fascia group. CONCLUSION: The authors' new method of alveolar bone grafting with the Scarpa fascia graft is safe and effective, and has one of the highest documented success rates. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

An integrated surgical protocol for adult patients with hemifacial microsomia: Methods and outcome.

BACKGROUND: Hemifacial microsomia (HFM) features hypoplasia and asymmetry in skeletal as well as soft tissue, and correction of the deformity is difficult in terms of aesthetic outcome. The purpose of this study is to examine the validity of an integrated treatment protocol for correction of this facial deformity. PATIENTS AND METHODS: A retrospective study was performed on adult HFM patients who received two-jaw orthognathic surgery combined with facial contouring procedures in the first stage, and fat injection for the residual facial deficiency in the second stage. Inclusion criteria were patients treated by the same surgeon and follow-up at least 6 months. The demographic, perioperative, and follow-up data were collected. We defined a facial surface area discrepancy index (FDI) for objective assessment of the symmetry between the affected and non-affected side, and utilized visual analogue scale (VAS) for subjective evaluation of facial asymmetry before and after surgical treatment. RESULTS: A total of 14 patients were included. The mean age at orthognathic surgery was 21.7 years. Four patients were categorized as Pruzansky-Kaban type I, while the remaining 10 patients were type II (7 patients type IIA, 3 patients type IIB). Fat injection as a secondary procedure was performed in eleven cases (79%). The mean pre- and postoperative FDI was 87.6±6.3 and 95.4±5.2 with a significant advance for symmetry (p < 0.001). The pre- and postoperative VAS for asymmetry was 7.2±1.7 and 3.8±2.4 respectively, with a significant improvement (p = 0.002). CONCLUSION: Our integrated approach using orthognathic surgery, facial contouring surgery and subsequent fat injection is satisfactory and obtain significant improvement of the facial deformity considering the complexity of HFM.

Selection of a horizontal reference plane in 3D evaluation: Identifying facial asymmetry and occlusal cant in orthognathic surgery planning.

Facial asymmetry and dental occlusal cant have been detected in two-dimensional cephalometry using different horizontal reference lines, but equivalent 3-dimensional (3D) reference planes have not been thoroughly investigated. In this study, 3D cone-beam computed tomography scans of 83 consecutive patients were evaluated using a standardized 3D frame and three horizontal reference planes, Supraorbitale (Sor), Frontozygomatic (Z), and Frankfurt horizontal (FH) for cant detection. Canting was defined as a vertical difference between left and right sides of 2 mm or more, and in at least two investigated planes. Concordance for negative canting was found in 38 patients, and for positive canting in 22 patients. Discordance in cant detection was found in 23 patients (28%). 29 patients were found to have canting in at least 2 planes. The FH plane was discordant to the other two planes in 4 patients, the Sor plane in 7 patients and the Z plane in 12 patients. Youden's index showed the highest performance for FH (0.878), followed by Sor (0.823) and Z plane (0.762). This study revealed that the FH plane was the best method for cant detection in 3D imaging. The FH plane and Sor plane can be combined if orbital asymmetry is suspected.

Correction of Facial Deformity in Sturge-Weber Syndrome.

BACKGROUND: Although previous studies have reported soft-tissue management in surgical treatment of Sturge-Weber syndrome (SWS), there are few reports describing facial bone surgery in this patient group. The purpose of this study is to examine the validity of our multidisciplinary algorithm for correcting facial deformities associated with SWS. To the best of our knowledge, this is the first study on orthognathic surgery for SWS patients. METHODS: A retrospective chart review included 2 SWS patients who completed the surgical treatment algorithm. Radiographic and clinical data were recorded, and a treatment algorithm was derived. RESULTS: According to the Roach classification, the first patient was classified as type I presenting with both facial and leptomeningeal vascular anomalies without glaucoma and the second patient as type II presenting only with a hemifacial capillary malformation. Considering positive findings in seizure history and intracranial vascular anomalies in the first case, the anesthetic management was modified to omit hypotensive anesthesia because of the potential risk of intracranial pressure elevation. Primarily, both patients underwent 2-jaw orthognathic surgery and facial bone contouring including genioplasty, zygomatic reduction, buccal fat pad removal, and masseter reduction without major complications. In the second step, the volume and distribution of facial soft tissues were altered by surgical resection and reposition. Both patients were satisfied with the surgical result. CONCLUSIONS: Our multidisciplinary algorithm can systematically detect potential risk factors. Correction of the asymmetric face by successive bone and soft-tissue surgery enables the patients to reduce their psychosocial burden and increase their quality of life.

Modified Furlow Palatoplasty Using Small Double-Opposing Z-Plasty: Surgical Technique and Outcome.

BACKGROUND: A smaller Z-plasty is applied in a modified Furlow palatoplasty. The purpose of this study was to assess its surgical and functional outcome. METHODS: The surgical technique included mucoperiosteal flap elevation in the hard palate, complete pedicle dissection and release, double-opposing Z-plasty using 5-mm limbs and muscle dissection in the soft palate, and the buccal fat pad covering lateral relaxing wounds. A retrospective chart review was conducted for 231 consecutive nonsyndromic patients undergoing modified palatoplasty from May of 2007 to December of 2014. The demographic, postoperative, and follow-up data were collected. Statistical analyses were performed. RESULTS: Average age at palatoplasty was 8.3 months. The overall oronasal fistula rate was 0.4 percent; oronasal fistula occurred in only one case with bilateral cleft. Other complications included postoperative bleeding in two cases (0.8 percent), postoperative airway obstruction in one case (0.4 percent), obstructive sleep apnea in one case (0.4 percent), stitch abscess in one case (0.4 percent), and distal uvula dehiscence in two cases (0.8 percent). One hundred twenty-seven patients had full speech evaluation, and seven (5.5 percent) were diagnosed with velopharyngeal insufficiency requiring surgical correction. CONCLUSION: This modified palatoplasty using a small double-opposing Z-plasty provided adequate cleft palate closure, with a low fistula rate and satisfactory speech outcome. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Computer-Assisted Orthognathic Surgery for Patients with Cleft Lip/Palate: From Traditional Planning to Three-Dimensional Surgical Simulation.

BACKGROUND: Although conventional two-dimensional (2D) methods for orthognathic surgery planning are still popular, the use of three-dimensional (3D) simulation is steadily increasing. In facial asymmetry cases such as in cleft lip/palate patients, the additional information can dramatically improve planning accuracy and outcome. The purpose of this study is to investigate which parameters are changed most frequently in transferring a traditional 2D plan to 3D simulation, and what planning parameters can be better adjusted by this method. PATIENTS AND METHODS: This prospective study enrolled 30 consecutive patients with cleft lip and/or cleft palate (mean age 18.6±2.9 years, range 15 to 32 years). All patients received two-jaw single-splint orthognathic surgery. 2D orthodontic surgery plans were transferred into a 3D setting. Severe bony collisions in the ramus area after 2D plan transfer were noted. The position of the maxillo-mandibular complex was evaluated and eventually adjusted. Position changes of roll, midline, pitch, yaw, genioplasty and their frequency within the patient group were recorded as an alternation of the initial 2D plan. Patients were divided in groups of no change from the original 2D plan and changes in one, two, three and four of the aforementioned parameters as well as subgroups of unilateral, bilateral cleft lip/palate and isolated cleft palate cases. Postoperative OQLQ scores were obtained for 20 patients who finished orthodontic treatment. RESULTS: 83.3% of 2D plans were modified, mostly concerning yaw (63.3%) and midline (36.7%) adjustments. Yaw adjustments had the highest mean values in total and in all subgroups. Severe bony collisions as a result of 2D planning were seen in 46.7% of patients. Possible asymmetry was regularly foreseen and corrected in the 3D simulation. CONCLUSION: Based on our findings, 3D simulation renders important information for accurate planning in complex cleft lip/palate cases involving facial asymmetry that is regularly missed in conventional 2D planning.

The ideal split-thickness skin graft donor-site dressing: a clinical comparative trial of a modified polyurethane dressing and aquacel.

BACKGROUND: The almost single disadvantage of conventional polyurethane film dressings, uncontrolled leakage, is probably as often described as its numerous advantages for split-thickness skin graft donor sites. This shortcoming can be overcome by perforating the polyurethane dressing, which permits controlled leakage into a secondary absorbent dressing. The study was conducted to compare the polyurethane dressing system and Aquacel, a hydrofiber wound dressing, which also seems to fulfill all criteria of an ideal donor-site dressing. METHODS: This prospective, randomized, double-blind clinical trial included 50 adult patients. Skin graft donor sites were divided equally for the application of Aquacel and polyurethane dressing. The dressings were kept unchanged for 10 days. After removal of the dressing at day 10, the epithelialization rate of both sites was evaluated. Pain scores were assessed according to a 0 to 5 numeric pain scale every postoperative day and during dressing removal. RESULTS: On postoperative day 10, 86.4 percent of the polyurethane dressing donor sites showed complete reepithelialization compared with 54.5 percent of the Aquacel-treated donor sites (p<0.001). Polyurethane dressing was significantly less painful until and during removal of the dressing (p<0.001). There was no significant difference with respect to scar formation. CONCLUSIONS: Overall, polyurethane dressing was superior to Aquacel. Further attributes of the polyurethane dressing such as ease of application, low labor input, high patient comfort, and protection against secondary wound infection qualify this dressing system as an ideal wound covering for donor sites. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.