Cosmetic Open Rhinoplasty in Acute Nasal Bone Fracture With Pre-Existing Deformity.

The simultaneous reduction of nasal bone fracture and cosmetic rhinoplasty is a challenging procedure, because of fracture severity and skeletal instability. Our aim was to investigate the surgical strategy and outcomes of cosmetic rhinoplasty according to the pre-existing nasal deformity when performing simultaneous reduction of nasal bone fracture and cosmetic rhinoplasty. In total, 71 patients who underwent cosmetic rhinoplasty were included. All patients were categorized according to pre-existing deformity, dorsal hump and irregularities, and deviation of the nose, wide nose, and flat nasal dorsum. The authors performed individual maneuvers to correct each deformity. Autologous tissue was used in all maneuvers for graft. Photoanalysis was performed to measure the deviation, nasal length, radix height, dorsal height, tip projection, nasofrontal angle, and nasolabial angle. Subjective evaluation of the functional and esthetic problems was confirmed through rhinoplasty outcome evaluation. In the analysis of the photographs, most patients presented improved scores ( P <0.05). The scores of satisfaction were significantly higher in the postoperative state ( P <0.05). As a postoperative complication, 2 cases of deviated tip occurred due to septal instability and were successfully revised with septoplasty and columellar strut graft. The authors created a harmonious face by evaluating, categorizing, and treating each deformity of the nose in patients with nasal fractures according to our algorithm.

Post-traumatic Telecanthus Induced by a Missed Diagnosis of Avulsion Fracture of the Medial Canthal Tendon.

Telecanthus is commonly accompanied by severe naso-orbito-ethmoid fractures. If there is only an avulsion fracture of the medial canthal tendon (MCT), the initial diagnosis may be missed, and post-traumatic telecanthus may follow. To avoid misdiagnosis of post-traumatic telecanthus, the following should be considered: avulsion fracture of the MCT should be suspected in the presence of an injury or edema of the medial canthal area; the facial computed tomography images should be carefully analyzed to confirm the presence of bone segment caused by the avulsion fracture of the MCT; physical examinations, such as the bowstring test and bimanual palpation, also provide essential data for early diagnosis. And even if early diagnosis is delayed, post-traumatic telecanthus can be improved through aggressive surgical correction.

Multiple Delayed Complications at Different Time Points After AQUAfilling Filler Injection for Facial Rejuvenation.

ABSTRACT: Delayed inflammatory and infectious complications occurred in a 63-year-old woman after receiving AQUAfilling filler injection in the forehead and nasolabial folds. The complications were idiopathic and occurred at different time points at different sites. Her condition improved after the removal of the injected materials and capsule, and administration of intravenous antibiotics. Although injection sites differ, inflammation can occur at any site at different time points. The possibility of inflammation at other injection sites should always be considered during periodic follow-up, even if the filler injection site initially shows no signs of complications.Level of Evidence: Level IV.

The Incidence of Traumatic Optic Neuropathy Associated With Subtypes of Orbital Wall Fracture.

BACKGROUND: Traumatic optic neuropathy (TON) is a rare disease but leaves critical sequelae to patient. Purpose of this study is to evaluate the incidence of TON in each orbital wall fracture. MATERIALS AND METHODS: Retrospective review of 2629 patients with orbital wall fracture was performed in from January 2010 to March 2019, based on diagnostic code, Korean Standard Classification of Diseases, 7th Revision. The orbital wall fractures were divided into 4 subtypes: superior, medial, inferior, and lateral wall. Incidence of TON is analyzed according to subtypes, single and multiple wall fracture. RESULTS: Among 2629 patients with orbital wall fractures, 27 patients were diagnosed with TON with an incidence of 1.02%. In single wall fracture, only lateral wall showed significantly high TON incidence, which only zygomatic fracture was included in single lateral wall fracture. In multiple wall fracture, it was statistically significant in the superior wall. CONCLUSIONS: Fracture on lateral and superior orbital wall showed a tendency to increase the incidence of TON. Based on the above results, radiologic evaluation and physical examination is necessary for patient who has lateral and superior orbital wall fracture.

Analysis of Complication in Mandibular Angle Fracture: Champy Technique Versus Rigid Fixation.

INTRODUCTION: The mandibular angle endures tension and compression during mastication, and proper internal fixation is essential when a fracture occurs. The authors analyzed the complication rate between Champy technique and rigid fixation, used in the treatment of mandibular angle fracture. METHODS: The retrospective study included patients with mandibular angle fracture in single center, from January 2003 to December 2019. The patients were categorized into 2 groups by fixation method of angle fracture: Champy technique which uses single miniplate and rigid fixation which uses multiple miniplate, reconstruction plate, compression plate, lag screw, and wire. Pearson chi-square test was used to analyze the complication rates. RESULTS: A total of 64 patients met inclusion criteria. Thirty-four patients had isolated angle fractures and 30 patients had multiple mandibular fractures. In isolated angle fracture, there were no significant differences in all complications between the Champy technique group and rigid fixation group. In multiple mandibular fractures, there were no significant differences in all complications between 2 groups. CONCLUSIONS: For isolated angle fractures, Champy technique is a reliable treatment method. Additionally, in case of multiple mandibular fractures, Champy technique is an effective fixation method in angle fractures when proper rigid fixation is performed for accompanying fractures.

Mealworm Oil (MWO) Enhances Wound Healing Potential through the Activation of Fibroblast and Endothelial Cells.

Mealworm and mealworm oil (MWO) have been reported to affect antioxidant, anti-coagulation, anti-adipogenic and anti-inflammatory activities. However, the function of MWO in wound healing is still unclear. In this study, we found that MWO induced the migration of fibroblast cells and mRNA expressions of wound healing factors such as alpha-smooth muscle actin (α-SMA), collagen-1 (COL-1) and vascular endothelial growth factor (VEGF) in fibroblast cells. The tube formation and migration of endothelial cells were promoted through the activation of VEGF/VEGF receptor-2 (VEGFR-2)-mediated downstream signals including AKT, extracellular signal-regulated kinase (ERK) and p38 by MWO-stimulated fibroblasts for angiogenesis. Moreover, we confirmed that MWO promoted skin wound repair by collagen synthesis, re-epithelialization and angiogenesis in an in vivo excisional wound model. These results demonstrate that MWO might have potential as a therapeutic agent for the treatment of skin wounds.

Big Data Statistical Analysis of Facial Fractures in Korea.

BACKGROUND: The big data provided by Health Insurance Review and Assessment (HIRA) contains data from nearly all Korean populations enrolled in the National Health Insurance Service. We aimed to identify the incidence of facial fractures and its trends in Korea using this big data from HIRA. METHODS: We used the Korean Standard Classification of Disease and Cause of Death 6, 7 for diagnosis codes. A total of 582,318 patients were included in the final analysis. All statistical analyses were performed using SAS software and SPSS software. RESULTS: The incidence of facial fractures consistently declined, from 107,695 cases in 2011 to 87,306 cases in 2016. The incidence of facial fractures was the highest in June 2011 (n = 26,423) and lowest in January 2014 (n = 10,282). Nasal bone fractures were the most common, followed by orbit and frontal sinus fractures. The percentage of nasal bone fractures declined, whereas those of orbital fractures increased from 2011 to 2016 (P < 0.001). Among orbital fractures, inferior wall fractures were the most common, followed by medial wall fractures. Among mandibular fractures, angle fractures were the most common, followed by condylar process and symphysis fractures. Although it was difficult to predict the most common type of zygomatic and maxilla fractures, their incidence consistently declined since 2011. CONCLUSION: We observed trends in facial fractures in Korea using big data including information for nearly all nations in Korea. Therefore, it is possible to predict the incidence of facial fractures. This study is meaningful in that it is the first study that investigated the incidence of facial fractures by specific type.

A Comparative Analysis of Outcomes After Reduction of Zygomatic Fractures Using the Carroll-Girard T-bar Screw.

PURPOSE: Several approaches are available for managing zygomatic fractures; however, each approach has its complications. Use of the Carroll-Girard T-bar screw (CGTS) can reduce complications because it reduces the number of approaches needed for reduction. This study aimed to analyze the efficiency of the CGTS compared with the 3-point approach. METHODS: A retrospective study was conducted by reviewing the computed tomography scans of 204 patients who underwent reduction surgery of Knight and North type 3, 4, or 5 zygomatic fractures from March 2009 to August 2017. Facial asymmetry, operative time, and complications were evaluated to compare 2 groups of patients: those who underwent CGTS and those who did not. Bilateral differences in the distance from the reference plane to the malar eminence in 3 dimensions based on computed tomography scans were used to calculate facial asymmetry. RESULTS: Among 204 patients, 91 were treated with CGTS whereas 113 patients underwent a 3-point approach. Bilateral differences in the position of the malar eminence and facial asymmetry were not statistically different in both groups. Operative time was not different in both groups. However, when patients with type 4 fracture were independently compared, the mean operative time was significantly shorter for the CGTS group. Wound dehiscence occurred in 11 patients (9.7%) in the 3-point approach group, compared with none in the CGTS group. None of the patients in the CGTS group complained of postoperative cheek scars over their incision sites. CONCLUSIONS: This study revealed that CGTS is a useful and feasible instrument that can reduce the number of approaches for zygomatic bone reduction and help clinicians achieve satisfactory outcomes.

Relationship Between Nasal Fracture and Blowout Fracture: Can Nasal Fracture Be a Predictor of Blowout Fracture?

PURPOSE: Nasal and blowout fractures are the most common injuries from craniomaxillofacial trauma. Nasal fractures are easily diagnosed by clinical signs, such as pain and crepitus. However, blowout fractures are frequently asymptomatic and are easy to miss without computed tomographic (CT) scanning. This study analyzed the relation between the 2 fracture types to determine whether nasal fracture could be used as a predictor of blowout fracture. MATERIALS AND METHODS: CT scans of 1,368 patients who underwent reduction surgery for nasal fracture were retrospectively reviewed. The pattern of nasal fractures (n = 1,368) was classified as frontal or lateral according to the direction of impact. Blowout fractures (n = 297) were classified into 3 types according to the position of the fracture: medial, inferior, or inferomedial wall. After calculating the number of patients in each group, the relation between nasal and blowout fracture types was statistically analyzed. RESULTS: Of 305 patients with frontal-type nasal fractures, the incidence of medial, inferior, and inferomedial wall fracture was 26, 7, and 9, respectively. Of 1,063 patients with lateral-type nasal fractures, the incidence of medial, inferior, and inferomedial wall fracture was 118, 75, and 62, respectively. Medial wall fracture was most common in the 2 nasal fracture groups and showed a higher frequency in the lateral-type group. CONCLUSIONS: This study showed a strong relation between nasal fractures and medial wall blowout fractures. If nasal fracture is suspected, especially the lateral type, then thorough examination for medial wall blowout fracture, with a high index of suspicion, should be performed.

Ischemic Time in Free-Flap Surgery With Arteriovenous Bundle Interposition Graft: Comparison of Two Anastomosis Sequences.

BACKGROUND: During free-tissue transfer for scalp reconstruction, pedicle lengthening may be required when finding a recipient vessel is difficult because of defects from previous surgery. Arteriovenous (AV) bundle interposition grafting is a good option. This study compared 2 sequences of AV bundle interposition grafting when flap pedicle lengthening is needed. METHODS: Two anastomosis methods were used. In the recipient lengthening type (R type), the flap was harvested and the AV bundle was harvested from a donor vessel for lengthening. In the flap lengthening type (F type), the flap was harvested first. Next, in contrast to that in the R type method, the authors performed anastomosis with a flap pedicle and bundle before the AV bundle was harvested. RESULTS: The mean flap pedicle length was 8.75 cm (range, 5-11 cm). The AV bundle had a mean length of 9.25 cm (range, 6-13 cm), meaning that 13 cm of additional pedicle length can be added. The mean length of the extended vascular pedicle was 18 cm (range, 14-23 cm). CONCLUSION: This study compared the results of F type and R type AV bundle interposition grafting. The F type allowed easy monitoring of the anastomosis of the flap pedicle and ensured flap stability by reducing continuous ischemic time. Finally, this study confirmed the efficacy and safety of the AV bundle interposition graft in scalp reconstruction.

Schwannoma of the Membranous Nasal Septum: a Clinical Report With Aesthetic Approach.

Schwannoma is an uncommon tumor of nerve sheath that arises from any peripheral, cranial, or autonomic nerve. Only 4% of head and neck schwannomas originate from the sinonasal tract, and a finding of a schwannoma in the nasal septum is exceedingly rare. The authors experienced nasal septal schwannoma with the functional and aesthetic consideration of nasal contour. The authors present an open rhinoplasty approach for nasal septal schwannoma which has not been reported in the previous literature yet.

Repair of Lower Canalicular Laceration Using the Mini-Monoka Stent: Primary and Revisional Repairs.

BACKGROUND: We present our results of primary repair of lower canalicular injury using the Mini-Monoka stent and report our experience with revisional repair of canalicular blocks to treat epiphora following primary repair METHODS:: We performed primary repair in 169 canalicular laceration patients using Mini-Monoka. The primary repair was defined as the first operation proceeded within 48 hours after injury. Revisional repairs were performed in patients who underwent primary repair of canalicular laceration and subsequently complained of epiphora with canalicular block owing to peripheral scarring. In revisional repair, a Mini-Monoka stent was reinserted to maintain the realigned lacrimal pathway. RESULTS: The primary repair achieved functional success in 94.7% of patients. After primary repair, nine patients complained of epiphora. Two of 9 patients underwent CDCR and 5 underwent revisional repair of canalicular blockage. The revisional repair achieved functional success in 4 of 5 patients. After revisional repair, scar contracture and asymmetry of the medial canthus or malposition of the lower lacrimal punctum were corrected. Cosmetically, all 5 patients were satisfied with the results. Functionally, one patient complained persistent epiphora and was treated with CDCR. CONCLUSIONS: We were able to experience simple, safe, and successful primary repair of lower canalicular injuries using the Mini-Monoka stent. If epiphora owing to canalicular block after primary repair and asymmetry of the medial canthus owing to scar contracture or malposition of lacrimal punctum are present, scar release and realignment of the canaliculus with Mini-Monoka insertion at the time of revisional repair are recommended.

Clinical Outcomes Between Atrophic and Nonatrophic Mandibular Fracture in Elderly Patients.

The number of elderly patients with mandibular fracture is rapidly increasing. To improve outcome, it is important to understand the age-related characteristics of mandibular fracture. Thus, the aim of this study is to analyze the impact of atrophic change on mandibular fracture in elderly patients. The retrospective study was conducted in patients aged ≥65 years old, who underwent surgery for the treatment of mandibular fracture in our hospital from March 2006 until March 2015. Patient characteristics, such as age and gender, causes of injury, anatomic location of fracture, height of mandibular body, extent of atrophy, location of surgical sites, postoperative outcomes, and the follow-up period, were examined. Descriptive statistics were compared between atrophic and nonatrophic mandibles. The patients included 17 males and 12 females and the mean age was 71.9 years old. The average follow-up period was 6.06 months. Regarding occlusion and complications, there were no statistical differences between the atrophic and nonatrophic mandibular fractures. As major complications, nonunion occurred in 2 patients and malunion in 1 patient. There was no mortality associated with anesthesia or surgery. Atrophic and nonatrophic mandibular fractures in elderly patients can be treated successfully with surgery. There was no significant difference with respect to major complications between patients with atrophic and nonatrophic mandibular fractures.

A Systematized Strategy in Corrective Rhinoplasty for the Asian Deviated Nose.

BACKGROUND: A deviated nose is a common deformity encountered in rhinoplasty. Over the past several decades, a variety of rhinoplasty techniques have been described focusing on the classification of bony and cartilaginous deviation. Nevertheless, corrective rhinoplasty is still a challenging procedure even for experienced surgeons because of the high recurrence rate of deviation. In attempt to reduce the recurrence rate, the author systematized the complex procedures by using a single technique regardless of the classification of a deviation. MATERIALS AND METHODS: Forty patients who underwent corrective rhinoplasty between June 2009 and December 2014 were reviewed retrospectively. All the patients were operated using 4 main surgical procedures: anterior approach septal correction, unilateral osteotomy, and medialization of the deviated complex to the contralateral intact side, and dorsal augmentation with a dermofat graft. Assessment of improvement was based on photo standardization. The degree of nasal deviation, nasofrontal angle, tip projection-to-nasal length ratio, vertical line of the upper lip-to-tip projection ratio, and columellar-labial angle were measured. RESULTS: Preoperative and postoperative anthropometric measurements revealed that the mean degree of deviation changed from 10.19° to 3.43° (P < 0.01), and the degree of nasofrontal angle changed from 131.55° to 133.14° (P < 0.01). All patients responded to both the preoperative and postoperative questionnaires. The questionnaires revealed a significant functional and cosmetic improvement from 36.84° to 76.95° and 39.45° to 79.41°, respectively (P < 0.0001). CONCLUSIONS: This systematized strategy to correct the Asian deviated nose provided reproducible and consistent results It also resulted in low recurrence rates and high postoperative satisfaction among patients.

Fat Graft Survival After Recipient Site Pretreatment With Fractional Carbon Dioxide Laser.

BACKGROUND: Fat grafting is a commonly performed procedure not only for augmenting the soft tissue but also for regeneration in esthetic and reconstructive plastic surgery.However, unpredictable fat survival rate because of high resorption rate is remained as the main problem. The purpose of this study was to investigate the effect of pretreatment of the recipient site to the fat survival using fractional carbon dioxide (CO2) laser. METHODS: The rats were divided to 2 groups. Inguinal fat pads of rats were transplanted to the dorsum without pretreatment in the control group. The study group was preconditioned by fractional CO2 laser to the recipient site 1 week before fat graft.The pulse energy was set to 100 mJ. Transplanted fat tissues were harvested at postoperative days 1, 3, 7, 14, and 28 and were analyzed morphologically, histologically, and immunohistochemically. RESULTS: Weight and volume in the control group was more decreased than in the study group at postoperative day 28. Histological evaluation showed less inflammation, less fibrosis, less vacuolization, and better integrity of adipocytes. Immunohistologically, microvessel density in the study group was higher than in the control group (P < 0.05) at postoperative day 1. Survival rate in the study group was higher than in the control group at postoperative days 1, 3, 7, and 14 (P < 0.05). CONCLUSIONS: Pretreatment of recipient site using fractional CO2 laser helped vascularization in the early stage in fat graft and solved the ischemic condition, so it improved fat survival rate.

Correction of Lying Ears by Augmentation of the Conchoscaphal Angle.

Lying ears are defined as ears that protrude less from the head, and in frontal view, are characterized by lateral positioning of antihelical contour relative to the helical rim. These aesthetically displeasing ears require correction in accord with the goals of otoplasty stated by McDowell. The authors present a case of lying ears treated by correcting the conchomastoid angle using Z-plasty, resection of posterior auricular muscle, and correction of the conchoscaphal angle by releasing cartilage using 2 full-thickness incisions and grafting of a conchal cartilage spacer. By combining these techniques, the authors efficiently corrected lying ears and produced aesthetically pleasing results.

Axillary Advancement Suture to Minimize Post-Implantation Deformity in Implant-Based Breast Reconstruction.

Patients who have undergone implant-based breast reconstruction after skin-sparing mastectomy often complain about bulging on the upper flank or inferior axillary area. This is most likely because the subcutaneous tissue layer of the upper flank, which is continuous with the breast tissue, tends to show inferolateral drooping once the subcutaneous tissue becomes loose after eliminating the breast parenchyma. In addition, one of the weaknesses of implant surgery is that implants cannot completely replace the tissue removed during skin-sparing mastectomy (SSM). This leads to the formation of a depression and a stepping effect superior and lateral to the implant on both sides. Notably, because the pectoralis major muscle is quite thin, when there is a depression around the superolateral area of the implant, it acts as a band, which then leads to tissue bulging and serious aesthetic problems. Here, we describe a simple advancement suture technique that can be used to resolve these two aesthetic problems in direct-to-implant breast reconstruction. The advancement sutures are performed after the implant and drains are inserted following SSM and before closing the incision. First, the surgeon confirms the depression in the superolateral area of the implant insertion site by redraping a skin flap lateral to the margin. If a depression is suspected, the surgeon uses forceps to pull the subcutaneous tissue in the lateral flank pocket over to the lateral border of the pectoralis major muscle, superolateral to the implant. At this point, correction of the lateral flank bulging and depression on the superolateral border is verified. If the result is not satisfactory, the surgeon may attempt advancing the subcutaneous fat from different areas; the more posterior the tissue is advanced, the better it eliminates the lateral bulging and superolateral depression. However, too much advancement may cause extra tension, potentially resulting in tearing of the tissue. A round needle is used to suture two to three stitches, before completing wound closure. By performing this simple advancement suture, we were able to successfully minimize post-implantation deformity-bulging on the lateral flank and depression at the superolateral implant margin. Level of Evidence IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Simvastatin Reduces Capsular Fibrosis around Silicone Implants.

Capsular fibrosis and contracture occurs in most breast reconstruction patients who undergo radiotherapy, and there is no definitive solution for its prevention. Simvastatin was effective at reducing fibrosis in various models. Peri-implant capsular formation is the result of tissue fibrosis development in irradiated breasts. The purpose of this study was to examine the effect of simvastatin on peri-implant fibrosis in rats. Eighteen male Sprague-Dawley rats were allocated to an experimental group (9 rats, 18 implants) or a control group (9 rats, 18 implants). Two hemispherical silicone implants, 10 mm in diameter, were inserted in subpanniculus pockets in each rat. The next day, 10-Gy of radiation from a clinical accelerator was targeted at the implants. Simvastatin (15 mg/kg/day) was administered by oral gavage in the experimental group, while animals in the control group received water. At 12 weeks post-implantation, peri-implant capsules were harvested and examined histologically and by real-time polymerase chain reaction. The average capsular thickness was 371.2 µm in the simvastatin group and 491.2 µm in the control group. The fibrosis ratio was significantly different, with 32.33% in the simvastatin group and 58.44% in the control group (P < 0.001). Connective tissue growth factor (CTGF) and transforming growth factor (TGF)-ß1 gene expression decreased significantly in the simvastatin group compared to the control group (P < 0.001). This study shows that simvastatin reduces radiation-induced capsular fibrosis around silicone implants in rats. This finding offers an alternative therapeutic strategy for reducing capsular fibrosis and contracture after implant-based breast reconstruction.

Erratum: Correction of Figure: Simvastatin Reduces Capsular Fibrosis around Silicone Implants.

This corrects the article on p. 1273 in vol. 31, PMID: 27478339.

Correction of Medial Blowout Fractures According to the Fracture Types.

BACKGROUND: Regarding the issue of blowout fracture, a variety of approaches and surgical techniques have been reported to improve postoperative results. However, there are no extant guidelines for the selection of these various methods. The current authors classified the medial blowout fracture into 3 different types and adapted to suitable surgical techniques. METHODS: Between October 2010 and March 2013, 89 patients who had medial blowout fracture were included in this study. We classified the study patients into 3 different categories: greenstick, simple, and complex. The greenstick type used the transnasal endoscopic approach and was reduced with packing after applying a silastic sheet. The simple type used an onlay covering technique. The complex type was treated using the transcaruncular approach and inlay implanting technique. After surgery, the continuity of orbital wall was checked by computed tomography. Patients were then examined for the following conditions: diplopia, eyeball movement, and enophthalmos. RESULTS: The greenstick category consisted of 12 cases, most cases were satisfied. One case relapsed after removal of the packing. In the simple category, a total of 9 cases were treated by onlay covering technique. In all 68 cases of the complex type, we could obtain suitable anatomical reconstruction with inlay implanting technique. Only 2 cases complained of transient diplopia and moderate enophthalmos. CONCLUSIONS: Appropriate clinical classification, depending on the type of fracture and selection of optimal treatment methods, could obtain the satisfactory result and improve the treatment outcomes in the correction of medial orbital wall fracture.