Craniofacial Measurements: A History of Scientific Racism, Rethinking Anthropometric Norms.

ABSTRACT: Craniofacial measurements have been used in attempt to create racial categories. This article discusses the history of this practice and the potential implications this has for patients.

The use of negative-pressure wound therapy over a cultured epithelial autograft for full-thickness wounds secondary to purpura fulminans in an infant.

Purpura fulminans is a serious condition that can result in severe morbidity in the pediatric population. Although autologous skin grafts remain the gold standard for the coverage of partial- to full-thickness wounds, they have several limitations in pediatric patients, including the lack of planar donor sites, the risk of hemodynamic instability, and the limited graft thickness. In Singapore, an in-house skin culture laboratory has been available since 2005 for the use of cultured epithelial autografts (CEAs), especially in burn wounds. However, due to the fragility of CEAs, negative-pressure wound therapy (NPWT) dressings have been rarely used with CEAs. With several modifications, we report a successful case of NPWT applied over a CEA in an infant who sustained 30% total body surface area full-thickness wounds over the anterior abdomen, flank, and upper thigh secondary to purpura fulminans. We also describe the advantages of using NPWT dressing over a CEA, particularly in pediatric patients.

Aesthetic Durable Forehead Contouring in Asians With Fat Grafting and Botulinum Toxin.

BACKGROUND: Augmentative forehead contouring to create a full rounded smooth forehead is increasingly popular worldwide especially in East Asia where a flat and/or concave irregular forehead is considered unaesthetic. We present our outcomes performing fat transfer to the forehead in combination with botulinum toxin (Botox) corrugator-frontalis injection where indicated in East Asians. METHODS: From 2013 to 2017, 62 consecutive patients with flat and/or concave irregular unaesthetic foreheads underwent forehead fat transfer using a microautologous fat transplantation gun. Concomitant Botox injection to minimize corrugator and frontalis contraction-mediated fat displacement was indicated in 23 patients (thin forehead skin and/or excessive forehead animation or rhytides) to prevent forehead vertical crease formation. Thirty-nine subjects with a mean follow-up of 16 months (range = 3-44 months) had their pregraft and postgraft forehead contours assessed on an aesthetic grading scale. Of these 39, 17 completed forehead fat graft volumetric analysis using preoperative and postoperative 3D photography. RESULTS: Aesthetic results were durable at latest follow-up, and all patients were satisfied with their final appearance. The mean amount of fat transferred was 7.72 mL (range = 1.5-33 mL). One subject required a repeat fat grafting (with Botox) because of vertical crease formation after the index procedure (without Botox). Another 12 needed a second fat-grafting session to optimize the contour. All who received Botox did not develop vertical creases. The mean ± SD forehead contour grade improved from 2.29 ± 0.77 to 3.24 ± 0.67 (P < 0.001). The percentage mean ± SD retention of grafted fat was 46.71% ± 5.77% with Botox versus 39.12% ± 5.24% without Botox (P = 0.006). CONCLUSIONS: Fat grafting to the forehead using our technique with selective Botox administration is an effective, simple, fast, inexpensive, and safe strategy for aesthetic forehead contouring especially for flat and/or concave foreheads. Forehead fat survival rate is objectively improved with simultaneous Botox injection. There is minimum downtime and long-lasting results with high patient satisfaction rates.

Masseter Muscle Volume Changes Evaluated by 3-Dimensional Computed Tomography After Repeated Botulinum Toxin A Injections in Patients With Square Facial Morphology.

INTRODUCTION: Botulinum neurotoxin A (BoNT-A) is a minimally invasive and technically straightforward treatment of masseter muscle (MM) volume reduction and facial contouring, but the literature on its long-term effect on MM volume remains unclear. OBJECTIVE: This study aimed to assess quantitatively for progressive volume changes of lower facial contour after 3 BoNT-A injections in patients with bilateral MM hypertrophy causing square facial morphology using 3-dimensional computed tomographic scans. MATERIALS AND METHODS: Ten female patients with square facial morphology due to bilateral MM hypertrophy were recruited to, and 6 completed, this clinical study. Each received 24 U of BoNT-A into the inferior portion of each MM on both sides, repeated 6 monthly to complete 3 treatments. Masseter muscle volume changes were assessed using 3-dimensional computed tomography at pretreatment (before injections) and posttreatment (1 year after the third injection). RESULTS: Mean MM volume significantly reduced from 26.39 ± 4.18 cm before treatment to 23.26 ± 4.31 cm 1 year after treatment (P = 0.002). CONCLUSION: Three consecutive 6-monthly BoNT-A injections into the MMs reduced their volume by 12% when assessed 1 year after completion of treatment.

Clinical outcomes for minimally invasive primary and secondary orbital reconstruction using an advanced synergistic combination of navigation and endoscopy.

BACKGROUND: Sequelae of inadequate orbital reconstruction include enophthalmos, hypoglobus, and diplopia. Accuracy of orbital reconstruction is largely subjective and especially difficult to achieve because of anatomic distortion in secondary or late reconstruction and in extensive injury. We combined computer navigation and endoscopy to perform accurate, aesthetic, and safe minimal-access primary and secondary orbital reconstruction. METHODS: From 2013 to 2014, 24 patients underwent unilateral primary and secondary or late minimally invasive orbital reconstruction with mainly Medpor and/or titanium mesh by navigation and endoscopic assistance through transantral, transconjunctival, or upper blepharoplasty approaches. Mean follow-up was 13.8 months (range, 6.2 months to 2.8 years). RESULTS: All orbital fractures were successfully reduced. Average enophthalmos among patients who underwent early reconstruction, late reconstruction, and multiorbital wall repair improved (p < .001) to 0.2 mm from 1.6, 2.6, and 2.6 mm, respectively. Hypoglobus and diplopia resolved in all. In early reconstruction patients, mean interorbital volume difference improved from 1.72 ± 0.87 to 0.53 ± 0.83 ml (P = .03). For late reconstruction patients, this difference improved from 3.41 ± 1.23 to 0.56 ± 0.96 ml (p < .001). There were no major complications during follow-up, and all were satisfied with their final appearance and function. CONCLUSION: Navigation sharpens reconstructive accuracy and avoids injury to vital structures. Combined with endoscopic assistance for minimal-access reconstruction of wide-ranging orbital defects from primary to secondary or late cases and to extensive multiwall fractures, navigation facilitates minimal cosmetic incision and synergistic endoscope use and clearly optimizes aesthetic and functional outcomes, all with enhanced safety and unparalleled intraoperative visualization.

Simultaneous maxillo-mandibular distraction in early adolescence as a single treatment modality for durable correction of type II unilateral hemifacial microsomia: Follow-up till completion of growth.

BACKGROUND: Timing of surgical intervention in hemifacial microsomia (HFM) is controversial. Although mandibular osteodistraction in childhood for HFM is popular, recent data for single-stage distraction in growing HFM patients demonstrated long-term relapse. Literature suggests that adolescents in the late mixed dentition age or permanent dentition age (11-16-year-old) had more stable outcomes post-distraction than younger children. We present favorable experience using single-treatment simultaneous maxillo-mandibular distraction in early adolescent Pruzansky-Kaban type II HFM patients. METHODS: This was a retrospective longitudinal study of seven consecutive type IIa/b HFM growing patients (12-16-year-old) treated with simultaneous maxillo-mandibular distraction. Oral commissure cant was photographically measured preoperatively and at 6 months and annually ranging 3-7 years post-distraction. Ramus height and chin deviation were measured from radiographs done preoperatively and at distractor-removal, 1 year, 2 years, and 4 years post-distraction. RESULTS: Average age at osteodistraction and at latest follow-up was 13.7 and 18.6 years, respectively. Improvement was significant (p < 0.05) and sustained for mean oral commissure cant (5.1°-0.41°), mean ramus height ratio (0.59-0.86), and average chin deviation (15.9 mm-1.2 mm). Two subjects had mandibular branch palsy and one had mild pin-tract infection - all resolved. All were satisfied with their facial appearance. CONCLUSION: We have demonstrated good lasting outcomes at completion of growth with single-stage simultaneous maxillo-mandibular distraction for type II HFM adolescents in the late mixed-dentition or older age, and advocate this as an alternative to osteodistraction or orthognathic surgery upon skeletal maturity.

Efficacy of Topical Timolol as Primary Monotherapy in Cutaneous Facial Infantile Hemangiomas.

Recent studies have shown that infantile hemangiomas (IHs) undergo a rapid growth phase between 5.5 and 7.5 weeks of life and do not usually proliferate beyond 6 months; growth thereafter is usually proportionate to the child's growth. This review assesses the evidence for topical timolol as primary monotherapy for cutaneous facial IHs before 12 months of age, and to determine the differences in outcome between early (before 6 months) and late initiation (after 6 months) of timolol. A review of English language articles published up to November 2015 was performed using selected key words. Articles identified were further reviewed for relevance. The full text of studies included for final analysis was perused to include pertinent patient details, treatment protocol with timolol, complications (if any) reported, and response to treatment. Four studies met the inclusion criteria. In children before 12 months of age, the efficacy of topical timolol for the treatment of cutaneous facial IHs in achieving clinically significant improvement as defined by a standardized Global Assessment Score score of 3 and above ranged from 47% to 88%. One study also showed that IH regression was greater in patients started on timolol before 6 months of age compared with those started later (P <0.05). Topical timolol initiated in children before 12 months of age appears to be safe and clinically effective. There was insufficient data for detailed analysis of outcomes in patients who commenced treatment before and after 6 months of age.

Achieving Ideal Lower Face Aesthetic Contours: Combination of Tridimensional Fat Grafting to the Chin with Masseter Botulinum Toxin Injection.

BACKGROUND: Lower face aesthetic contouring is in high demand among Asians with wide and short faces desiring a slim lower face. For this purpose invasive mandible angle reduction and genioplasty are complex procedures with significant risks and downtime. Non-invasive botulinum toxin A injection into bilateral masseters - while popular for lower face contouring - does not address facial length deficiency in wide and short faces. Autologous chin fat grafting is a simple minimally-invasive technique for facial lengthening. OBJECTIVES: We present our experience pairing chin fat grafting and masseteric botulinum toxin injection for effective lower face contouring. METHODS: Thirteen consecutive patients with relatively wide and short faces underwent chin fat grafting and 1 to 3 serial masseteric botulinum toxin A injections. Mean follow up after final intervention was 20 months (range, 6 months to 3 years). RESULTS: The postoperative mean ratio of bigonial distance to total facial height improved from 0.599 to 0.569 (P < .01), closer to the ideal ratio of 0.561. The mean ratio of upper lip length to lower lip and chin length improved from 0.611 to 0.560 (P < .01), nearing the ideal 0.542. Postoperative lateral profile in all was ideal. There were no complications at follow up. Results were durable at latest follow up and most were satisfied with their final appearance. CONCLUSIONS: Combined tridimensional chin fat grafting and botulinum toxin masseteric injection is an effective, simple, fast, inexpensive, safe, and minimally-invasive strategy for aesthetic lower face contouring of short and wide faces, with short downtime, long-lasting results, and high patient satisfaction. LEVEL OF EVIDENCE: 4 Therapeutic.

Efficacious Healing of Ulcerated Infantile Hemangiomas Using Topical Timolol.

Infantile hemangiomas (IHs) are the most common benign pediatric soft-tissue tumors. Ulceration-the most frequent complication of IH-tends to heal poorly and is associated with pain, bleeding, infection, and scarring. Mainstay treatment modalities include propranolol (ß-blocker) and corticosteroids, whose effectiveness is countered by a need for long-term medication and risk of systemic adverse effects and ulcer recurrence. A 3-month-old infant presented to us with a large, medial thigh-ulcerated IH that progressed despite 2 prior months of dressings and topical antimicrobials. Topical timolol 0.5% thrice daily was initiated, and significant healing was evident at 1 week, with complete healing at 1 month. Timolol was stopped after 3 months, and at 18 months after cessation of timolol, there was no ulcer recurrence. This novel therapy for ulcerated IH seems to have many advantages such as rapid efficacy with easy application, no systemic adverse effects and no long-term recurrence, and current literature describing similar advantages justifies the use of this treatment modality in infants.

Subunit principle of vulvar reconstruction: algorithm and outcomes.

BACKGROUND: Vulvar defects result chiefly from oncologic resection of vulvar tumors. Reconstruction of vulvar defects restores form and function for the purpose of coitus, micturition, and defecation. Many surgical options exist for vulvar reconstruction. The purpose of this article is to present our experience with vulvar reconstruction. METHODS: From 2007 to 2013, 43 women presented to us with vulvar defects for reconstruction. Their mean age at the time of reconstruction was 61.1 years. The most common cause of vulvar defect was from resection of vulvar carcinoma and extramammary Paget's disease of the vulva. Method s of reconstruction ranged from primary closure to skin grafting to the use of pedicled flaps. RESULTS: The main complications were that of long term hypertrophic and/or unaesthetic scarring of the donor site in 4 patients. Twenty-two patients (51%) were able to resume sexual intercourse. There were no complications of flap loss, wound dehiscence, and urethral stenosis. CONCLUSIONS: We present a subunit algorithmic approach to vulvar reconstruction based on defect location within the vulva, dimension of the defect, and patient age and comorbidity. The gracilis and gluteal fold flaps are particularly versatile and aesthetically suited for reconstruction of a variety of vulvar defects. From an aesthetic viewpoint the gluteal fold flap was superior because of the well-concealed donor scar. We advocate the routine use of these 2 flaps for vulvar reconstruction.

Reconstructing a large helical rim defect: synergy of a postauricular perforator flap, diced cartilage, and otoplasty technique.

Large full thickness helical ear defects are a challenge to reconstruct. A 25-year-old woman presented to us with loss of a large portion of the helical rim after an assault. A successful 2-stage reconstruction was performed, incorporating the principles of perforator flaps, otoplasty techniques, and use of diced cartilage more commonly used for rhinoplasty. There was a 5 × 0.5-cm central helical defect of the right ear. In the first stage, the original defect was recreated and a 7 × 1.5-cm inferiorly based postauricular artery perforator flap was raised from the right postauricular sulcus. Diced cartilage was harvested from the adjacent conchal bowl and conchomastoid sutures were used to set the relatively prominent ear back so as to facilitate tension-free donor-site closure. Diced cartilage was wrapped in the deep fascia of the perforator flap and the edges of the deep fascia were sutured to the perichondrium of the exposed cartilage. The pedicle was divided at a second stage. At 1-year postoperation, the reconstructed ear maintained good form and symmetry, and the patient was satisfied with the outcome. This is a novel efficient technique of reconstructing large ear helical defects combining a postauricular artery perforator flap with wrapped diced cartilage augmentation, and incorporating classical otoplasty technique for virtually scarless donor-site closure.

The hook plate technique for fixation of phalangeal avulsion fractures.

BACKGROUND: Avulsion fractures of the phalanges involve small osseous fragments that are usually attached to structures that are necessary for stability or movement of the joint. Satisfactory healing of the fracture to preserve joint function may require open reduction and internal fixation, which can be difficult because of the small size of the fragments. METHODS: We used a hook plate fashioned from a 1.3-mm Synthes titanium plate in thirteen patients with a phalangeal avulsion fracture. Four patients had an avulsion fracture of the volar plate with dorsal proximal interphalangeal joint dislocation, four had a dorsal avulsion fracture of the extensor central slip from the middle phalanx, three had a flexor digitorum profundus avulsion fracture from the distal phalanx, and two had an avulsion fracture of the phalangeal insertion of the collateral ligament. RESULTS: Union without complications was achieved in all cases. After an average duration of follow-up of seventeen months, all patients had a good to excellent result and the average total interphalangeal motion was 149°. CONCLUSIONS: This indirect fixation technique produces stable fixation allowing early active finger motion.

Large unilateral breast autoinflation after breastfeeding linked to polyacrylamide hydrogel injection augmentation mammaplasty.

Augmentation mammaplasty using polyacrylamide hydrogel (PAAG) injection is associated with myriad complications. A patient treated by the authors had bilateral breast augmentation with PAAG injection and experienced large unilateral right breast autoinflation after breastfeeding, which required surgical clearance of a likely galactocele or sterile pus collection that resulted in deformity. Patients with PAAG filler injection-augmented breasts should avoid breastfeeding. The authors recommend against using PAAG injection for augmentation mammaplasty, especially in women intending to breastfeed. Physicians and patients must be aware of the complications associated with PAAG before gel administration.

In vivo tissue engineering over wounds with exposed bone and tendon: Autologous dermal grafting and vacuum-assisted closure.

Flap coverage is ideal for wounds exposing bone and tendon, but technically less demanding and speedier options might be considered for small shallow wounds and for wounds with adjacent tissue loss precluding local flaps. We revisited the use of autologous dermal grafting-in combination with vacuum-assisted closure (VAC)-for such wounds.Five small- to medium-sized wounds exposing bone, joint, and/or tendon were each covered using an autologous meshed dermal graft followed by VAC application to induce granulation. Closure was completed at 2 weeks by split-thickness skin grafting over the granulating dermis graft.Complete and stable wound healing was achieved in all cases within 4 weeks of dermal grafting over exposed bone with excellent outcome at 1 year in terms of donor site healing and return to function. All healed wounds had a nearly flush profile with no bulkiness in the foot and toe region.Autologous dermal grafting with VAC is an integrated in vivo tissue engineering system in which the meshed dermis acts as an attractive scaffold for granulation within the conducive VAC-medium. As an alternative to flap surgery or dermal substitutes, the technique is simple, swift, and cost-effective for immediate closure of small shallow wounds and even multiple small wounds, exposing bone and tendon particularly in the lower legs, feet, and toes.