Single-Splint, 2-Jaw Orthognathic Surgery for Correction of Facial Asymmetry: 3-Dimensional Planning and Surgical Execution.

Three-dimensional (3D) planning of orthognathic surgery (OGS) improves the treatment of facial asymmetry and malocclusion, but no consensus exists among clinicians regarding technical details. This study verified the consistency of authors' workflow and strategies between 3D planning and surgical execution for facial asymmetry. This retrospective study recruited consecutive patients (n=54) with nonsyndromic facial asymmetry associated with malocclusion. The stepwise workflow included orthodontic treatment, 3D imaging-based evaluation, planning, and transferring the virtual of single-splint 2-jaw OGS to actual surgery in all patients. Seven landmark-based measurements were selected for postoperative assessment of facial symmetry. Fifty patients had no anesthetic/surgical-related episode and procedure-related complications. Others experienced wound infection (n=1), transient TMJ discomfort (n=1), and facial numbness (n=3). Two cases had minor residual asymmetry (cheek and chin, respectively), but did not request revisionary bone or soft tissue surgery. Comparisons between the planned and postoperative 3D images with quantitative measurement revealed acceptable outcome data. The results showed a significant increase in facial symmetry at 7 landmark-based postoperative measurements for both male and female. This 3D-assisted pathway of OGS permitted achievement of consistent satisfactory results in managing facial asymmetry, with low rate of complications and secondary management.

Aesthetic Enhancement of the Vermilion Using Dermofat Graft in Patients With Cleft Lip Deformity.

BACKGROUND: There is an increasing patient expectation for better esthetics, manifesting through anatomical harmony, projection, and volume of the upper lip relative to the lower lip, in patients with cleft deformity. The aim of this study is to investigate the outcome of vermilion augmentation using autologous dermofat graft (DFG) to enhance the lip using both quantitative and qualitative assessment. METHODS: Patients with secondary cleft lip deformity who received the surgical treatment in our institution from 2015 to 2018 were recruited. Panel assessment was performed on standardized preoperative and postoperative digital photographs. A patient questionnaire was used for the reported outcome. Image processing and analyses were applied to measure the lip change. Statistical analyses were performed. RESULTS: A total of 91 patients were included. The mean age at operation was 22.7 years, and postoperative follow-up was 3.6 years. There were no complications in the study group. The panel assessment showed significant improvement (P < .00001) on upper lip vermilion in both frontal and lateral profile views. Ninety-five percent of patients reported improvement of the upper lip projection and volume. Quantitative image analysis showed an increase in the upper lip vermilion ratio in 97% of the cases in frontal views and improvement of the vermilion projection in 87% of the cases in the superimposed lateral views. CONCLUSIONS: The use of DFG is an effective and reproducible method for vermilion augmentation and aesthetic enhancement in patients presenting with upper lip insufficiency relative to the lower lip.

Strategic management of the minor-form and microform cleft lip: A long-term outcome assessment.

OBJECTIVE: The treatment of the lesser form cleft lip deformity (i.e., minor-form, microform, and mini-microform) is challenging to achieve patient satisfaction. There are no studies investigating how treatment outcomes balance patients' expectations and satisfaction with surgical or non-surgical care relative to the initial nasolabial findings. METHODS: Based on Mulliken's classification, consecutive records of patients with the lesser-form cleft lip from 1990 to 2015 were selected for analysis. Demographics, management, and revisions were reviewed. A panel analysis was performed based on the ratings from both professionals and non-professionals using patients' photographs. FACE-Q questionnaires were used to compare patient/parent-reported satisfaction to the normal controls. RESULTS: A total of 135 patients were included. All of the minor-form (23/23), 89% (58/65) of the microform, and 62% (29/47) of the mini-microform patients underwent surgery. Fifty-two percent (15/29) of the mini-microform patients, who underwent surgery, showed no significant improvement. Post-operative upper lip scars and remaining nasal asymmetry were the most common concerns in the treatment group. However, the FACE-Q results showed that patients experienced a statistically significant improvement in their overall facial appearance and social function in their respective groups. CONCLUSIONS: This study showed that differences exist in the perception of facial esthetics between the surgeon and the patient/parent. To achieve optimal individual treatment outcome and patient satisfaction, an awareness of the differences and treatment selection for patients are critical in surgical planning. This understanding and an open detailed discussion of overall long-term outcomes help in the management of patient expectations.

An Intraoperative Rescue Procedure for the Protruding Premaxilla in the Repair of Complete Bilateral Cleft Lip: Rapid Premaxillary Molding.

BACKGROUND: Primary reconstruction of complete bilateral cleft lip and palate (BCLP) with protruding premaxilla in one-stage surgery is challenging because of the tension on muscle repair. Such patients are also common in the developing countries. For this condition, we have applied intraoperative "rapid premaxillary molding (RPM)" technique and obtained satisfactory results. METHODS: We reviewed the data of patients with complete BCLP with protruding premaxilla applying intraoperative RPM including both our institution and cleft missions to developing countries in the past 20 years. Selection criteria were patients receiving either no or insufficient preoperative molding presenting with significant protruding premaxilla, had consecutive follow-ups after surgery. To perform this technique, the surgeon holds the patient's face with both hands and compresses the protruding premaxilla with both thumbs. An intermittent but stable backward pressure is applied to the premaxilla until the segment is gradually flexible. Repeated compression is performed prior to tying the muscle sutures, at which time the premaxilla is retro-positioned and aligned with the lateral maxillary segments. Pre- and postoperative data were evaluated. RESULTS: We have treated a total of 60 patients with complete BCLP with protruding premaxilla applying intraoperative RPM. All patients tolerated the operations and there were no major intra- and postoperative complications including lip dehiscence and vomer fracture. All of them had satisfactory results such as adequate muscle repair and symmetry of the lip and nostrils. CONCLUSION: The RPM is a reliable and valuable intraoperative adjunct procedure for patients with complete BCLP presenting the protrusive premaxilla.

A new technique for perioral muscle reconstruction and lip lengthening in complete unilateral cleft lip.

BACKGROUND: Adequate skin lengthening and symmetry may not be consistently obtained in unilateral cleft lip repair, especially in patients with complete cleft. The purpose of this study was to present the model of muscle dissection and approximation to facilitate lip lengthening and symmetry. METHODS: The design followed the rotation-advancement (RA) method without skin measurement. A curvilinear skin incision was made from subnasale to the Cupid's bow peak (CBP). Muscle dissection was continued to the contralateral nostril floor beneath the columellar base to facilitate downward rotation in the medial lip. Wide muscle dissection was performed in the lateral lip segment from the nasal mucosa passing the alar base. The lateral lip muscle was advanced and sutured to the medial lip muscle in a Z-plasty fashion. A small skin backcut was made above the CBP. Primary nasal correction was performed. A series of 138 patients with complete unilateral cleft lip and palate were included in this study. Standard photographs were collected for measurement in the nasolabial region. RESULTS: Adequate lengthening and symmetry of the lip was obtained. The ratio of vertical philtral height was 0.99±0.05 between the cleft and noncleft sides. The C flap was used for supplementary skin lengthening in 58% of cases. Postoperative lip retraction requiring massage occurred in 13%. Overall nasolabial appearance was satisfactory. CONCLUSION: The new technique of perioral muscle reconstruction facilitated to obtain lip lengthening and symmetry in the repair of complete unilateral cleft lip.

One-Stage versus Two-Stage Repair of Asymmetric Bilateral Cleft Lip: A 20-Year Retrospective Study of Clinical Outcome.

BACKGROUND: Both one- and two-stage approaches have been widely used for patients with asymmetric bilateral cleft lip. There are insufficient long-term outcome data for comparison of these two methods. The purpose of this retrospective study was to compare the clinical outcome over the past 20 years. METHODS: The senior author's (L.J.L.) database was searched for patients with asymmetric bilateral cleft lip from 1995 to 2015. Qualified patients were divided into two groups: one-stage and two-stage. The postoperative photographs of patients were evaluated subjectively by surgical professionals and laypersons. Ratios of the nasolabial region were calculated for objective analysis. Finally, the revision procedures in the nasolabial area were reviewed. Statistical analyses were performed. RESULTS: A total of 95 consecutive patients were qualified for evaluation. Average follow-up was 13.1 years. A two-stage method was used in 35 percent of the patients, and a one-stage approach was used in 65 percent. All underwent primary nasal reconstruction. Among the satisfaction rating scores, the one-stage repair was rated significantly higher than two-stage reconstruction (p = 0.0001). Long-term outcomes of the two-stage patients and the unrepaired mini-microform deformities were unsatisfactory according to both professional and nonprofessional evaluators. The revision rate was higher in patients with a greater-side complete cleft lip and palate as compared with those without palatal involvement. CONCLUSIONS: The results suggested that one-stage repair provided better results with regard to achieving a more symmetric and smooth lip and nose after primary reconstruction. The revision rate was slightly higher in the two-stage patient group. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

The pterygomaxillary junction: An imaging study for surgical information of LeFort I osteotomy.

Maxillary osteotomy is a common surgical procedure and often involves separation of the pterygomaxillary junction (PMJ), which is a "blinded" procedure with inherent risks. Knowledge of the PMJ structure is essential. It remains unclear whether patients with different facial types have different PMJ structures, or different surgical outcome. This study evaluated the computed tomographic images of 283 consecutive patients who received orthognathic surgery. Patients were classified into Angle class I, II, III and cleft lip/palate groups. The results showed that the PMJ was 5.1 ± 1.4 mm in thickness, 9.7 ± 1.7 mm in width, and 102.0 ± 4.0 degrees relative to the sagittal plane in the level of posterior nasal spine. There were no statistically significant differences in these measurements among the groups. The class III group demonstrated significantly smaller angle relative to the maxillary occlusal plane. The cleft group showed significantly longer vertical distance between the posterior nasal spine and the lower border of PMJ, shorter distance between the second molar and PMJ, and longer distance between the descending palatine artery and PMJ. With regard to postoperative outcome, the cleft group showed higher incidence of pterygoid plate fracture. The results in this study provide additional surgical anatomic information.

A New Method for Reconstruction of Vermilion Deficiency in Cleft Lip Deformity: The Bi-Winged Myomucosa Switch Flap.

BACKGROUND: This study reviewed the method of using the bi-winged myomucosa switch flap for correction of secondary cleft lip deformity in patients with vermilion mucosa deficiency, lack of the central tubercle, and disproportionate lip projection, obviating the conventional Abbe flap when the prolabium has acceptable philtrum and Cupid's bow definition. METHODS: The technique was applied to adult patients with secondary vermilion deficiency after primary bilateral cleft lip repair. The flap consisted of the transverse vermilion mucosa and the superior part of the orbicularis oris muscle from the lower lip. It was elevated, leaving a central cuff of muscle and mucosa tissue for blood supply, and tapered down bilaterally. The flap was transposed cephalically and inset to the deficient upper vermilion. Division of the pedicle was performed 2 weeks later. The preoperative and postoperative vermilion heights were measured, and the upper-to-lower vermilion ratios were calculated. RESULTS: All consecutive patients tolerated the operations without perioperative or flap complications. The vermilion discrepancy was corrected in all cases. The vermilion height and projection were improved in the upper lip and the prominent lower lip was reduced. The average vermilion ratio was 0.38 before and improved to 1.00 after surgery, as compared with the norm of 0.96. Adequate lip function and mobility were maintained. All patients expressed satisfaction after surgery. CONCLUSION: The described technique of bi-winged myomucosa switch flap is an effective method for reconstruction of upper lip vermilion deficiency with excellent aesthetic outcome.

Electronic structures of one-dimensional metal-molecule hybrid chains studied using scanning tunneling microscopy and density functional theory.

The electronic structures of self-assembled hybrid chains comprising Ag atoms and organic molecules were studied using scanning tunneling microscopy (STM) and spectroscopy (STS) in parallel with density functional theory (DFT). Hybrid chains were prepared by catalytic breaking of Br-C bonds in 4,4″-dibromo-p-terphenyl molecules, followed by spontaneous formation of Ag-C bonds on Ag(111). An atomic model was proposed for the observed hybrid chain structures. Four electronic states were resolved using STS measurements, and strong energy dependence was observed in STM images. These results were explained using first-principles calculations based on DFT.

Polymorphic porous supramolecular networks mediated by halogen bonds on Ag(111).

Intermolecular structures of porous two-dimensional supramolecular networks are studied using scanning tunnelling microscopy combined with density functional theory calculations. The local configurations of halogen bonds in polymorphic porous supramolecular networks are directly visualized in support of previous bulk crystal studies.

Achieving chiral resolution in self-assembled supramolecular structures through kinetic pathways.

Chiral phase transitions were studied in a self-assembled 2,6-dibromoanthraquinones supramolecular system prepared on Au(111) using scanning tunneling microscopy. As the molecules were deposited at about 150 K, they formed heterochiral chevron structures (a racemate) consisting of two alternating prochiral molecular rows. When the as-deposited sample was warmed to 300 K followed by cooling to 80 K, phase-separated homochiral structures (a conglomerate), as well as the chevron structures, were observed. We propose molecular models for the structures that are in good agreement with ab initio studies and can be explained by hydrogen bonds and halogen bonds. We found that heterochiral chevron structures were more stable than homochiral structures due to two additional [Formula: see text] halogen bonds per molecule. We considered kinetic pathways for the phase transitions that were made possible via a disordered liquid phase entropically stabilized at 300 K. We show how chiral resolution can be achieved by exploiting kinetic paths allowed in supramolecular systems.

Epitaxial Mn(5)Ge(3) nano-islands on a Ge(001) surface.

The growth behavior and atomic structure of Mn germanide, grown on Ge(001), is studied with x-ray diffraction and scanning probe microscopy. The amorphous clusters of as-deposited Mn are crystallized into Mn(5)Ge(3) nano-islands with a size of ∼100 nm by solid phase epitaxy. At low coverage, the shape of the nano-islands is plateau-like, while at increased coverage it becomes mound-like. At the flat top of the plateau-like nano-islands, the hexagonal atomic structure is resolved. It is interpreted, with the help of first-principles study, as a Mn-terminated Mn(5)Ge(3)(0001) structure.