Skeleton first in surgical treatment of facial disharmony.

PURPOSE: The aim of this study was to correct facial disharmony with or without occlusal dysfunction. METHODS: Based on computed tomography and presurgical design, restoration of normal skeleton relationship is a priority for selected facial deformities. Combination of different osteotomies for facial skeleton was chosen in 1-stage operation such as orthognathic surgery, zygomatic reduction, and mandibular angle reduction. Supplementary surgeries was considered in some cases as substitute implantation or autologous fat graft. RESULTS: All the 50 patients (hemifacial microsomia, Romberg syndrome, mandibular condyle hyperplasia, secondary cleft palate, and Crouzon syndrome) received surgeries, and their facial appearance improved significantly. Yearly follow-up shows that the symmetry and balance of the facial proportion approach normal, whereas most of their occlusal relationship has been significantly improved after the first stage of surgery. CONCLUSIONS: For most facial disharmony with or without occlusal dysfunction, skeleton-first surgery is a feasible strategy.

Reconstruction of fronto-orbital and nasal defects with compound epoxied maleic acrylate/hydroxyapatite implant prefabricated with a computer design program.

The repair of fronto-orbital nasal bone defects may be a troublesome problem to plastic surgeons. This report aims to present the results of reconstruction of fronto-orbital nasal bone defects with the prefabrication of epoxied maleic acrylate/hydroxyapatite compound (EH compound) using 3-dimensional (3D) imaging data and computer-assisted manufacturing techniques, sometimes combined with autogenous bone to repair nasal defect. Helical computed tomography data were used to create a 3D model of the patient's skull. On the basis of these data, the individual shape of the implant was created by a computer-aided design/computer-aided manufacturing program. A rapid prototyping system was applied for production of the physical models. A total of 12 patients with traumatic fronto-orbital nasal defects were included in this study. The patients followed up for 1 to 24 months. The satisfactory results, such as excellent symmetry, stability, and normal fronto-orbital contours were obtained for all patients. The operating time was short without any complications. The depression of the region of fronto-orbital nasal bone defects always achieved an attractive or satisfactory prominence that was in balance and harmony with other facial features of all the patients. This method allows accurate fabrication of the implant. It improves the surgical techniques and reduces the risk of a second intervention, with improved aesthetic outcomes.

Application of EH compound artificial bone material combined with computerized three-dimensional reconstruction in craniomaxillofacial surgery.

OBJECTIVE: To explore the application prospects of EH compound artificial bone material combined with computerized three-dimensional reconstruction in craniomaxillofacial surgery. METHODS: Computed tomographic scan, computer-aided design/computer-aided manufacturing three-dimensional reconstruction, and rapid prototyping were conducted on 39 patients during 2005 to 2008. An EH compound artificial bone material was made into the exact geometric shapes of the defect to be corrected and then implanted during surgical reconstruction. RESULTS: The EH compound artificial bone implants were perfectly matched with the facial areas needed for repair. The reconstructed faces were symmetric on the whole, and postoperative results were satisfying. CONCLUSIONS: The EH compound artificial bone material combined with computerized three-dimensional reconstruction offers a new method in craniomaxillofacial surgical practice. Aesthetic results after reconstruction surgery can therefore be effectively improved.

The assessment of midface distraction osteogenesis in treatment of upper airway obstruction.

Le Fort III osteotomy with midface distraction osteogenesis (Le Fort III DO) can improve the midface form and change the upper airway space. Some surgeons believe that midface advancement can improve respiratory outcome dramatically, but others think it does not predictably result in the cure of obstructive sleep apnea (OSA). In this study, we evaluated the structural and functional changes of the upper airway before and after Le Fort III DO; we hope these studies can improve future protocols for midface advancement. A retrospective study of 11 patients with severe midface retrusion who underwent Le Fort III osteotomy with midface external distractor system was undertaken. These patients had an average of 5.4 months of follow-up. Three-dimensional volumetric assessment of the upper airway was used before and after surgery. We also evaluated the two-dimensional cross-sectional area of the upper airway to show the changes in different airway levels. Two patients with preoperative evidence of OSA were evaluated both preoperatively and postoperatively by overnight polysomnography. The midface was distracted for an average of 20.27 +/- 8.04 mm. Comparison between preoperative and postoperative three-dimensional computed tomographic data showed an average 64.30% increase in upper airway volume, an improvement of 9.13 +/- 6.94 mL (P < 0.05). The two-dimensional measurement also showed that the cross-sectional area at the posterior nasal spine and uvula airway level increased (P < 0.05), but the cross-sectional area at the epiglottis level and the separation of airway and esophagus level did not increase (P > 0.05). Two patients with preoperative evidence of OSA had both preoperative and postoperative sleeping studies that showed improvement. Le Fort III DO can significantly improve the upper airway space in the cases of syndromic craniosynostosis. The upper airway space above the uvula level was significantly enlarged after Le Fort III DO according to two-dimensional and three-dimensional image measurements, and according to the polysomnography, the OSA was alleviated. Le Fort III DO is a promising procedure in the treatment of severe midface retrusion with OSA in young patients.

Flip-registration procedure of three-dimensional laser surface scanning images on quantitative evaluation of facial asymmetries.

UNLABELLED: The aim of the study was to find a proper method that may evaluate the severity of facial asymmetry quickly and accessibly in clinics. METHODS: The three-dimensional image data of facial asymmetry patients were collected with three-dimensional laser surface scanning, and the desired therapy outcomes were simulated in computers by flip-registration procedure. The discrepancy between desired results and initial images was calculated automatically, and a colored hypsography was printed. A questionnaire was given to both the patient and the craniofacial surgeon to examine the symmetry, accessibility, achievability, and helpfulness of these outcomes. RESULTS: The three-dimensional image data offered by laser surface scanning were accurate and convenient. The desired results were reliable and acceptable to the patients. The colored hypsography was clear and accessible and achieved high appreciations from the surgeons. CONCLUSION: Three-dimensional laser surface scanning together with flip registration procedure can evaluate the severity of facial asymmetry quickly, quantitatively, and effectively with an achievable outcome. It is welcomed by the craniofacial surgeons and has a great potential in clinic application.

Compared study of Asian reduction malarplasty: wedge-section osteotomy versus conventional procedures.

OBJECTIVE: The zygomatic body and arch are usually prominent in Asians; therefore, malar reduction is one of the most popular procedures for aesthetic facial contouring. The purpose of this study was to establish a new option for reduction malarplasty and analyze the merits and demerits of conventional operative techniques, thus searched for more effective and reliable surgical procedures. METHODS: Records of 570 patients who underwent reduction malarplasty in our center from 1988 to 2008 were reviewed in this study. Several introduced malar reduction techniques were used until an alternative wedge-section osteotomy technique was performed by the senior author (X.M.) in 2002. This new technique consisted wedge-section osteotomy of the lower zygomatic body via intraoral approach and greenstick infracture of the posterior zygomatic arch through a tiny sideburn stab incision. In this way, the prominent malar complex could be reduced by being pressed inward and stabilized by only surgical suture in moderation. The surgical indications, major complications, and patient satisfaction of different techniques were compared. RESULTS: In our experience, intraoral incision was better than coronal incision because of less iatrogenic scar formation and postoperative complications. Our wedge-section osteotomy was more effective and reliable as compared with other conventional methods. CONCLUSION: Recently, intraoral and minor preauricular incision for malar reduction was more likely acceptable by surgeon as a typical procedure. Our new method was proven to be a safe, effective, and easily handled technique for malar complex reduction and thus was an optimal strategy for aesthetic facial shaping in Asians.

Reconstruction of acquired orbital deformity characterized by volume change.

Acquired orbital deformity is a common disease in the practice of craniofacial surgery. Defective orbital volume and abnormality of eyeball position are the most important characteristics of pathologic changes. This study includes 87 cases of acquired orbital deformity, which received surgery for volume aberration from 2002 to present. Among them, 73 cases received orbital volume expansion surgery and 14 cases received reduction surgery. Coronal scalp, lower eyelid, or intraoral gingival-buccal incisions were carried out for the approach. In some patients, the original scar around the orbit was chosen for the incision. Operation aims were reduction of orbit and reconstruction of the orbital wall integrity. Operative methods were osteotomy for reduction and implantation of autologous bone or artificial materials. Orbital volume and eyeball position were restored to normal in all patients after the operation, and no serious complications occurred. Treatment of acquired orbital deformity should make restoration of orbital volume as the most important target of therapy. Autologous bone should be the material of first choice, and the selection and amount of implanted material should be decided by the specialty and experience of the physician.

[Experience of midfacial distraction osteogenesis in upper airway stenosis].

OBJECTIVE: To investigate the therapeutic effects of upper airway stenosis after Le Fort III osteotomy and midfacial distraction osteogenesis (DO). METHODS: Eleven cases (age, 5-16 yrs) with severe midface dysostosis complicated with exophthalmos, anterior crossbite and upper airway stenosis were treated by using Le Fort III osteotomy and midfacial DO from August 2000 to February 2007. The 3D reconstruction of the upper-airway from CT data was used to evaluate the upper airway volume before and after the operation. And meanwhile polysomnography was carried out to demonstrate the upper airway functional changes. RESULTS: There was a 64.3% mean increase [mean, (9.13 +/- 6.94) ml, P < 0.05] in upper airway volume in the 11 cases after the operations. It showed that there was significant improvements in the indexes of polysomnography after the operations, such as apnea and hypopnea index, average SaO2, minimum oxygen saturation and snore index. CONCLUSIONS: The Le Fort III osteotomy and midfacial distraction osteogenesis can efficiently relieve the symptoms of upper-airway stenosis in severe midfacial dysostosis.

[Surgical correction of craniofacial dysostosis with midface distraction osteogenesis].

OBJECTIVE: To investigate the effect of distraction osteogenesis on correction of craniofacial dysostosis. METHODS: Le Fort III osteotomy was applied through coronal route on patients with craniofacial dysostosis such as Crouzon and Apert syndrome. The procedures included disconnecting the skeletal midface from base of cranium, setting up a RED II distraction device, and directing the device bars. The distraction was started 5 days after the surgery, with a rate of 1 mm forward per day. When midface approaching the right position, i.e. a slightly over correction of occlusion was reached, stopped distraction and kept the device for 2 - 4 months. RESULTS: Eight cases completed all the therapy. The average blood lose was 300 ml and the average operation time was 3.5 hours. The midface had been moved averagely 9 mm forwardly and 1.5 mm downwards. The features had been improved obviously and the occlusion reached nearly normal. No serious complications occurred except for 1 case of seroma and 1 case of infection around pin on scalp. No recurrence was found in the 5 months of follow-up. CONCLUSIONS: Midface distraction osteogenesis is propitious to teenage or severe cases of craniofacial dysostosis.

[Surgical correction of exophthalmos in craniofacial synostosis].

OBJECTIVE: To analyze the efficacy and complications of the surgical correction of exophthalmos in craniofacial synostosis. METHODS: Three different procedures were used in exophthalmos patients with different ages. In patients aged 1 - 3 years old, the fronto-orbital advancing osteotomy to deepen the upper part of orbital cavity was employed. In patients aged 4 - 15 years old, Le Fort III osteotomy and distraction osteogenesis were selected. In patients aged 16 years old or more, Le Fort III osteotomy or monobloc craniofacial osteotomy with immediately advancement of the midface segments were selected. RESULTS: Good results were achieved for all 18 patients. The proptosis reduced 7.8 mm postoperatively. The depth of the skull base increased 8.2 mm and inferior orbit margin was advanced 7.8 mm as compared with the preoperative measurements. The angle between the maxilla and skull base (SNA) increased 9 degree. All of these measurements indicated that the proptosis and craniofacial contouring were approached to the normal situation after surgical intervention. CONCLUSION: Both immediate advancement and gradual distraction after frontal, orbital, and maxillar osteotomy to enlarge the orbital cavities are the best approaches for the treatment of exophthalmos in craniofacial synostosis.

Nasal measurements in Asians and high-density porous polyethylene implants in rhinoplasty.

OBJECTIVES: To understand Asian noses, set goals for rhinoplasty, and find the best alternative columellar strut. METHODS: Six values were used to evaluate the morphology of the nose: tip projection, alar-tip-columellar base angle, alar-columellar base-philtrum angle, nasolabial angle, nasofacial angle, and tip angle. One hundred average Chinese people (50 males and 50 females) were compared with 36 preoperative Chinese patients (13 males and 23 females). We presented an application of high-density porous polyethylene (Medpor) implant as a columellar strut for use in lengthening. We performed 3 surgical techniques: a single-plate strut, a double-plate strut, and a butterfly-shaped strut. Open rhinoplasty (transcolumella incision) was performed on 21 patients; closed rhinoplasty (marginal incision) was performed on 15 patients. RESULTS: Prominent changes in the 6 values were found in both male and female patients after rhinoplasty. CONCLUSIONS: An analysis of the Asian nose will help surgeons achieve better results. High-density porous polyethylene columellar strut grafts provide adequate support for refined tip definition and the shaping of the columellar-lobular angle.

Evaluation of dynamic morphologic changes in the masseter muscle in patients undergoing mandibular angle sagittal split osteotomy: a report of 130 cases.

OBJECTIVE: To evaluate the dynamic morphologic changes in the masseter muscle after mandibular angle sagittal split osteotomy (MASO). METHODS: Computed tomographic (CT) examinations were performed on 130 patients treated with MASO before surgery and at 3, 6, 12, and 18 months after surgery. These CT images were stored and a 3-dimensional reconstruction was made for calculating the volume of masseter muscle using Mimics 10.01 software. The cross-sectional area of masseter muscle was evaluated preoperatively and postoperatively using 3-dimensional CT images observed from 3 selected slice levels, which paralleled the Frankfurt horizontal plane. RESULTS: Following treatment, the reduction of the volume and cross-sectional area of masseter muscle were calculated. The volume of the masseter muscle was reduced by 28.18%, 39.58%, 33.37%, and 31.18% at 3, 6, 12, and 18 months postoperatively, respectively. The cross-sectional area of 3 slices were reduced, but the sectional area of the lower slice had the sharpest decline, with reductions of 79.27%, 84.39%, 84.02%, and 83.57% at 3, 6, 12, and 18 months postoperatively, respectively. CONCLUSIONS: The results showed that the masseter muscle undergoes significant atrophy after mandibular osteotomy, and these changes could be considered as a guide for the design and simulation of MASO before surgery.

Experience in East Asian facial recontouring: reduction malarplasty and mandibular reshaping.

OBJECTIVE: To review my experience in both malar reduction and mandibular reshaping techniques to establish optional, effective, and reliable surgical procedures. A square-shaped face is considered aesthetically unfavorable among East Asians; therefore, reduction malarplasty and mandibular reshaping are becoming more acceptable for aesthetic facial skeleton recontouring. METHODS: The techniques of zygoma arch infracture or mandibular angle reduction were used until 2 alternative techniques were introduced in 2002: the wedge-section osteotomy in the malar complex and inclined-fullness osteotomy in the mandibular angle and margin. Both osteotomies were selected according to personal experience and communication with patients. The wedge-section zygoma osteotomy was performed in the lower zygomatic body via an intraoral approach and greenstick infracture of the posterior zygomatic arch through a tiny preauricular incision. The prominent malar complex could be reduced by being pressed inward and was stabilized only by surgical suture or self-stabilization without any fixation, and the latter method was chosen in my recent cases. For the lower face, I designed an inclined-fullness osteotomy to address the mandibular angle and margin along the diagonal of marked projection of the mental foramen on the margin of the mandible and the projection of mandibular foramen on the ramus. The surgical indications, major complications, and levels of patient satisfaction for the different techniques were compared, and thus the pros and cons of wedge-section osteotomy and mandibular reshaping vs conventional procedures were analyzed. RESULTS: A total of 585 patients who had undergone either reduction malarplasty or mandibular reshaping in the craniofacial center at the Shanghai Ninth People's Hospital from May 1988 through December 2008 were reviewed in this study. Intraoral incision was the dominant method of access in both types of osteotomies. Wedge-section malarplasty osteotomy was more effective and reliable compared with other conventional methods. More than half of the patients in cases of the mandibular reshaping have undergone surgery that included both reduction of the mandibular angle and shaving of the mandibular margin. CONCLUSION: As optimal strategy for aesthetic facial contouring surgery in East Asians, reduction malarplasty and mandibular reshaping were proven to be safe, effective, and easily handled techniques for modifying the square-shaped face.

[Application of tunable guide device in prominent mandibular angle osteotomy].

OBJECTIVE: To discuss the application and therapeutic effect of tunable guide device in correction of prominent mandibular angle. METHODS: Since 2007, 50 cases with prominent mandible angle underwent mandible angle osteotomy with the tunable guide device. The patients were followed up for 3-6 months. RESULTS: No severe complication happened. Local seroma occurred in one case. Improved esthetic results were achieved at both frontal and oblique view. CONCLUSIONS: The mandibular angle osteotomy with the tunable guide device makes the procedure safe and easily performed.

[Reconstruction of the acquired orbital deformities].

OBJECTIVE: To investigate the reconstruction of acquired orbital deformities. METHODS: Through coronal incisions, subciliary incisions and buccal sulcus incisions, or periorbital wound, the displaced orbital walls were repositioned after osteotomy. And the mandibular outer cortex was used to repair the bone defect, so as to restore the orital integrity. RESULTS: From Sept. 2002 to Jun. 2006, 64 patients with acquired orbital deformities were treated. The integrity of orbit and eyeball location recovered very well. CONCLUSIONS: Restoration of the orbital integrity is the key to the treatment of acquired orbital deformities. The periorbital deformities should be corrected after osteotomy with mandibular outer cortex for bone defect.

[3-dimensional position changes of periorbital structures after midface distraction osteogenesis].

OBJECTIVE: To evaluate the 3-D position changes of periorbital structures after midface distraction osteogenesis in patients with Crouzon syndrome. METHODS: The CT data of 8 cases who had accepted the midface distraction osteogenesis following Le Fort III osteotomy were retrospectively analyzed. The patients were averagely 11.9 years old, and the CT was performed before and one year after operation. After 3-D image reconstruction, a right-hand coordinate system based on the preoperational Frankfurt Plane was then established. The pre- and post-operative positions of the superior orbit point (SOr), inferior orbit point (IOr), median orbit point (MOr), lateral orbit point (LOr), anterior ocularis point (AO), ocularis eyeball point (PO) and the four insertion ocularis rectus were documented and compared. The positions of these marked points in normal controls were also documented and compared with those in patients. RESULTS: After midface distraction osteogenesis, the position of AO was not changed significantly on the y-axis and z-axis, but the distance between two AO points on x-axis was reduced by 3.40 mm; IOr moved averagely 12.24 mm on y-axis and 4.25 mm on z-axis, MOr moved averagely 10.11 mm on y-axis and 2.80 mm on z-axis, LOr moved averagely 9.86 mm on y-axis and 2.31 mm on z-axis. The Inferior Rectus attachment moved averagely 3.63 mm on y-axis and 2.98 mm on z-axis. No other significant change was observed on other marked points. CONCLUSIONS: Midface distraction osteogenesis following Le Fort III osteotomy can significantly move the medial, lateral and inferior peri-orbital bone structure anteriorly and inferiorly. The eyeballs have no markedly sagittal position changes after distraction except slight medial, downwards movements and anterior-upwards rotations.

[Changes of different section area at different parts of upper-airway after Le Fort III osteotomy].

OBJECTIVE: To observe the therapeutic effects of Le Fort III osteotomy and midface distraction osteogenesis (DO) on the upper-airway narrow. METHODS: Since 2000, 11 cases (10 cases of Crouzon syndrome and 1 case of Apert syndrome) with severe midface deficiency were treated with Le Fort III osteotomy and midface DO. The section area of different parts of upper-airway were tested by computer assistants image measurement preoperatively and postoperatively. Some patients received sleep function monitoring. RESULTS: The face appearance and the function of upper-airway improved significantly after Le Fort III osteotomy and Midface DO. The section area at the level of posterior nasal spine and uvula increased obviously after treatment (P < 0.05), however the section area at the level of epiglottis and separation between airway and esophagus were not obviously enlarged (P > 0.05). CONCLUSIONS: Midface DO after Le Fort III osteotomy can effectively improve the upper-airway narrow, especially the upper part from uvula.

[Malar reconstruction in the patients with Treacher-Collin's syndrome].

OBJECTIVE: The key feature of Treacher-Collin's syndrome is malar dysostosis. The article focused on malar reconstruction for Treacher-Collin's syndrome and compared the implant materials. METHODS: From 1994 to 2002, a total of 55 patients with Treacher-Collin's syndrome were treated with malar reconstruction. In the operation, the lateral orbital rim and the mala were exposed by the bicoronal incision or the subciliary incision. The mala was augmented and reconstructed with implants of different materials, including autologous bone (rib, ilia or cranium). Medpor biomaterial or bone cement. RESULTS: The operations of the 55 patients were all successful without infection. The satisfactory rate in facial contour was 90%. Implant exclusion occurred in 2 cases using hone cement. CONCLUSION: Malar reconstruction is the most important treatment for Treacher-Collin's syndrome. Every implant material has advantages and shortcomings. Autologous hone is the best material for malar reconstruction. Medpor is the best artificial material, with good histocompatibility, without exclusion, absorption and donor injury.