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1.
J Plast Reconstr Aesthet Surg ; 73(8): 1499-1505, 2020 Aug.
Artículo en Inglés | MEDLINE | ID: mdl-32546424

RESUMEN

BACKGROUND: Complex spine surgery in patients with major comorbidities leads to increased need for midline back wound reconstruction by plastic surgeons. Literature suggests that back wound reconstruction concurrent with high-risk immediate/index spine surgery may lead to fewer complication. This study aimed to validate this claim in a large cohort treated at a tertiary center. We hypothesize that immediate reconstruction may lead to fewer adverse events in comparison to delayed reconstruction. METHODS: This was a retrospective single-center review of 659 patients who underwent spinal surgery with/without reconstruction by plastic surgeons between November 2011 and December 2015. Three main cohorts were evaluated: patients who underwent spinal surgery with no reconstruction, patients with delayed reconstruction after spine surgery, and patients with immediate back wound reconstruction with index spine surgery. Demographic, clinical, and outcomes data were collected from electronic medical records. Primary endpoints were the incidence of any complications such as dehiscence, infection, seroma/hematoma, and exposed hardware. The secondary endpoint was return to the operating room and most recent follow-up. RESULTS: Forty-three patients underwent index reconstruction (follow-up 25.3 ± 12.7 months), 33 were delayed (follow-up 23.7 ± 12.5 months), and 583 had no reconstruction (follow-up 22.1 ± 15.2 months). Patients who underwent index reconstruction had more spinal levels involved than delayed reconstruction (7.8 ± 0.75 vs 5.6 ± 0.68; p = 0.03). The overall complications rate was 7.7%, most commonly wound dehiscence (2.7%), infections (0.9%), exposed hardware (2.0%), cerebrospinal fluid leaks (0.6%), and return to OR (3.8%). Patients who underwent index spinal wound reconstruction had a significantly lower complication rate (4.65%) than secondary spinal surgery patients (27.3%; p = 0.048). CONCLUSIONS: The data confirmed significantly decreased complication rates for index back wound reconstructions for high-risk patients compared to delayed spine wound reconstruction. Increased rates of wound dehiscence, exposed hardware, and revisions occurred with delayed reconstruction. Early employment of tension free, robust vascular flap closure may attribute to a decreased complication profile.

2.
J Craniofac Surg ; 31(3): 678-684, 2020.
Artículo en Inglés | MEDLINE | ID: mdl-32068731

RESUMEN

BACKGROUND: Patients with Crouzon syndrome develop various types of anatomic deformities due to different forms of craniosynostosis, yet they have similar craniofacial characteristics. However, exact homology is not evident. Different pathology then may be best treated by different forms of surgical technique. Therefore, precise classification of Crouzon syndrome, based on individual patterns of cranial suture involvement is needed. METHODS: Ninety-five computed tomography (CT) scans (Crouzon, n = 33; control, n = 62) were included in this study. All the CT scans are divided into 4 types based on premature closure of sutures: class I = coronal and lambdoidal synostosis; class II = sagittal synostosis; class III = pansynostosis; and class IV = "Others." The CT scan anatomy was measured by Materialise software. RESULTS: The class III, pansynostosis, is the most prevalent (63.6%). The classes I, III, and IV of Crouzon have significantly shortened entire anteroposterior cranial base length, with the shortest base length in class III. The external cranial measurements in class I show primarily a decreased posterior facial skeleton, while the class III presented with holistic facial skeleton reduction. Class II has the least severe craniofacial malformations, while class III had the most severe. CONCLUSION: The morphology of patients with Crouzon syndrome is not identical in both cranial base and facial characteristics, especially when they associated with different subtypes of cranial suture synostosis. The classification of Crouzon syndrome proposed in this study, summarizes the differences among each subgroup of craniosynostosis suture involvement, which, theoretically, may ultimately influence both the timing and type of surgical intervention.

3.
Plast Reconstr Surg ; 145(2): 518-521, 2020 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-31985651

RESUMEN

The mature bilateral cleft nasolabial deformity exhibits prolabial and vermilion deficiency, a broad depressed nasal tip, and short columella. Many strategies attempt to correct these stigmata, with varying degrees of success. The purpose of this communication is to describe a novel sequenced approach, staging an Abbe flap and rhinoplasty, with morphometric analysis of results. CLINICAL QUESTION/LEVEL OF EVIDENCE:: Therapeutic, IV.


Asunto(s)
Labio Leporino/cirugía , Rinoplastia/métodos , Colgajos Quirúrgicos , Adolescente , Adulto , Niño , Femenino , Humanos , Masculino , Satisfacción del Paciente , Resultado del Tratamiento , Adulto Joven
4.
Plast Reconstr Surg ; 145(1): 117e-125e, 2020 01.
Artículo en Inglés | MEDLINE | ID: mdl-31592950

RESUMEN

BACKGROUND: De novo or rare transmitted mutations in the SMAD6 gene affect 7 percent of midline nonsyndromic synostosis patients. This study aimed to determine the neurocognitive sequelae of SMAD6 synostosis. METHODS: Nonsyndromic synostosis patients 6 years or older with SMAD6 mutations and non-SMAD6 nonsyndromic synostosis controls were recruited. All patients completed a double-blinded neurodevelopmental battery (i.e., Wechsler Fundamentals, Wechsler Abbreviated Scale of Intelligence, Beery-Buktenica Developmental test), and parents/guardians completed behavioral surveys (Behavior Rating Inventory of Executive Function and Behavior Rating System for Children). RESULTS: Twenty-eight patients participated: 10 known SMAD6 patients (average age, 10 years; 1 female; eight metopic and two sagittal; nine treated with cranial vault remodeling and one treated with strip craniectomy) and 18 non-SMAD6 controls (age, 9.5 years; three female; 12 metopic and six sagittal; 17 treated with cranial vault remodeling and one treated with strip craniectomy). There were no differences between any demographics. Testing age, surgical age, parental education, and household income correlated with cognition (p < 0.05). After controlling for these factors, SMAD6 patients performed worse on numerical operations (p = 0.046), performance intelligence quotient (p = 0.018), full-scale intelligence quotient (p = 0.010), and motor coordination (p = 0.043) compared to age/race/gender/synostosis/operation-matched controls. On behavioral surveys, SMAD6 patients scored worse on 14 assessments, including aggression, communication, and behavior. CONCLUSIONS: This prospective double-blinded study revealed that neuropsychiatric development of nonsyndromic synostosis may be under genetic control. SMAD6 mutations led to poorer mathematics, performance intelligence quotient, full-scale intelligence quotient, and motor coordination, even after controlling for exogenous factors. Genetic testing may be critical for advocating early adjunctive neurodevelopmental therapy. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

5.
Plast Reconstr Surg ; 144(5): 772e-780e, 2019 11.
Artículo en Inglés | MEDLINE | ID: mdl-31373990

RESUMEN

BACKGROUND: Control and maintenance of nasal tip position are critical in rhinoplasty. Two frequent methods of exerting tip control are columellar strut and caudal septal extension graft. However, no quantitative data exist comparing the two methods over time. The purpose of this study was to analyze maintenance of tip projection and rotation following either columellar strut or septal extension graft. METHODS: A retrospective cohort study of patients undergoing rhinoplasty was reviewed. Three-dimensional photogrammetric evaluation of patients with either columellar strut or septal extension graft to increase tip projection was performed. Anthropometric points were analyzed in a blinded fashion. Outcome variables were tip projection, nasal length, the Goode ratio, and tip rotation. Results were stratified based on technique and compared statistically. RESULTS: One hundred six patients were included. Overall, 66 percent were female, with an average age of 34.5 years. A columellar strut was used in 42 percent of cases (n = 45), and a septal extension graft was used in 57 percent (n = 61). Analysis showed greater maintenance of tip rotation over time with the septal extension graft compared with the columellar strut [-1.01 percent change (p = not significant versus -5.08 percent change (p = 0.009)]. Tip projection, nasal length, and the Goode ratio decreased over time for both groups, but the differences were not statistically different. CONCLUSIONS: Nasal tip projection and rotation appear to decrease from the immediate postoperative position. In this study, both septal extension graft and columellar strut exhibit similar changes in tip projection with time; however, septal extension graft is better able to preserve tip rotation compared with the columellar strut. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.


Asunto(s)
Cartílagos Nasales/trasplante , Tabique Nasal/cirugía , Fotogrametría , Rinoplastia/métodos , Adulto , Estudios de Cohortes , Estética , Estudios de Evaluación como Asunto , Femenino , Humanos , Masculino , Persona de Mediana Edad , Prótesis e Implantes , Estudios Retrospectivos , Medición de Riesgo , Técnicas de Sutura , Resultado del Tratamiento
6.
J Craniofac Surg ; 30(5): 1488-1491, 2019 Jul.
Artículo en Inglés | MEDLINE | ID: mdl-31299750

RESUMEN

PURPOSE: Orthognathic surgery for dentofacial deformities is typically preceded and followed by orthodontic treatment. Traditionally, orthodontic hardware is secured to the dentition to allow dental movement and stabilization. Clear-aligner therapy (eg, Invisalign) provides an aesthetic alternative, consisting of a series of transparent trays. Its use has not been described in complex triple-jaw orthognathic surgery. The purpose of this study is to evaluate perioperative outcomes and 3-dimensionally quantify postoperative edema in Invisalign patients undergoing triple-jaw orthognathic procedures, comparing this to patients treated with conventional fixed appliances. The surgical approach to patients with clear-aligners is also outlined. METHODS: The authors conducted a retrospective chart review and 3-dimensional morphometric study of Invisalign patients undergoing triple-jaw surgery (LeFort I osteotomy, bilateral sagittal split osteotomy, and genioplasty). An identical assessment of demographically matched patients treated with conventional fixed appliances was performed and compared with the Invisalign group. RESULTS: Thirty-three patients, with a mean age of 19.99 years, were included: 13 with Invisalign and 20 with conventional fixed appliances. No significant difference was observed in operating time, concurrent extraction of teeth, fat grafting, duration of hospital stay, diet advancement, and use of narcotic analgesics between the 2 groups. Nine patients had sufficient 3-dimensional images for volumetric analysis (4 with Invisalign and 5 with conventional fixed appliances). Postoperative edema was not significantly different (P = 0.712) when comparing conventional fixed appliances (44.29 ±â€Š23.16 cm) to Invisalign (37.36 ±â€Š31.19 cm). CONCLUSION: The present study demonstrates that complex multiple-jaw orthognathic procedures can be successfully performed in Invisalign patients. Perioperative and short-term clinical outcomes are not compromised.


Asunto(s)
Aparatos Ortodóncicos Fijos , Cirugía Ortognática , Femenino , Mentoplastia , Humanos , Tempo Operativo , Aparatos Ortodóncicos Removibles , Osteotomía , Periodo Posoperatorio , Estudios Retrospectivos , Resultado del Tratamiento
7.
Plast Reconstr Surg ; 144(1): 89e-97e, 2019 07.
Artículo en Inglés | MEDLINE | ID: mdl-31246828

RESUMEN

BACKGROUND: Virtual surgical planning has facilitated preoperative planning, splint accuracy, and intraoperative efficiency in orthognathic surgery. The translation of the virtual surgical plan to the actual result has not been adequately examined. The authors examined the conformity of the virtual surgical plan to the postoperative result. They hypothesize that the greatest conformity exists in the anteroposterior dimensions. METHODS: The authors examined patients who underwent Le Fort I maxillary advancement, bilateral sagittal split osteotomy, and genioplasty. The preoperative virtual surgical planning file and postoperative cone beam computed tomographic scan were registered in Mimics using unchanged landmarks. The conformity to the virtual surgical plan was quantified using linear and angular measurements between bone surface landmarks. Results were compared using t tests, with p < 0.05 considered statistically significant RESULTS:: One hundred patients who underwent Le Fort I maxillary advancement, bilateral sagittal split osteotomy, and genioplasty were included. Three-dimensional analysis showed significant differences between the plan and outcome for the following landmarks: A point (y, p = 0.04; z, p = 0.04), B point (y, p = 0.02; z, p = 0.02), pogonion (y, p = 0.04), menton (x, p = 0.02; y, p = 0.01; z, p = 0.03), and anterior nasal spine (x, p = 0.04; y, p = 0.04; z, p = 0.01). Angular measurements sella-nasion-A point, sella-nasion-B point, and A point-nasion-B point were not statistically different. CONCLUSIONS: There is a high degree of conformity comparing the orthognathic virtual surgical plan to the actual postoperative result. However, some incongruency is seen vertically (maxilla) and sagittally (mandible, chin). Departures of the actual position compared with the plan could be the result of condylar position changes, osteotomy locations, aesthetic intraoperative decisions, and/or play in the system.


Asunto(s)
Registro de la Relación Maxilomandibular/métodos , Procedimientos Quirúrgicos Ortognáticos/métodos , Planificación de Atención al Paciente , Adolescente , Adulto , Puntos Anatómicos de Referencia , Femenino , Humanos , Procesamiento de Imagen Asistido por Computador/métodos , Imagenología Tridimensional/métodos , Masculino , Mandíbula/cirugía , Maxilar/cirugía , Persona de Mediana Edad , Cirugía Asistida por Computador/métodos , Adulto Joven
8.
Plast Reconstr Surg Glob Open ; 7(3): e2158, 2019 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-31044122

RESUMEN

Background: Apert syndrome patients are different in clinical pathology, including obstructive sleep apnea, cleft palate, and mental deficiency. These functional deficiencies may be due to anatomic deformities, which may be caused by different forms of associated suture fusion. Therefore, a classification system of Apert syndrome based on the type of craniosynostosis pattern might be helpful in determining treatment choices. Methods: CT scans of 31 unoperated Apert syndrome and 51 controls were included and subgrouped as: class I. Bilateral coronal synostosis; class II. Pansynostosis; and class III. Perpendicular combination synostosis: a. unilateral coronal and metopic synostosis; b. sagittal with bilateral/unilateral lambdoid synostosis; and c. others. Results: Class I is the most common (55%) subtype. The cranial base angulation of class I was normal; however, the cranial base angulation on the cranium side of the skull in class II increased 12.16 degrees (P = 0.006), whereas the facial side cranial base angle of class IIIa decreased 4.31 degrees (P = 0.035) over time. The external cranial base linear measurements of class I showed more evident reduction in anterior craniofacial structures than posterior, whereas other subtypes developed more severe shortening in the posterior aspects. Conclusions: Bicoronal synostosis is the most common subtype of Apert syndrome with the normalized cranial base angulation. Combined pansynostosis patients have flatter cranial base, whereas the combined unilateral coronal synostosis have a kyphotic cranial base. Class I has more significant nasopharyngeal airway compromise in a vertical direction, whereas classes II and III have more limited oropharyngeal space.

9.
Plast Reconstr Surg ; 143(6): 1233e-1243e, 2019 06.
Artículo en Inglés | MEDLINE | ID: mdl-31136487

RESUMEN

BACKGROUND: Considerable craniofacial features of Crouzon syndrome are attributed to the dysmorphology of the cranial base. As cephalometric studies have focused mainly on the facial deformity, rather than the cranial base, the underlying cause of deformity is not as well understood. Therefore, the authors compared the cranial base development of Crouzon syndrome to controls to trace the timing of deformity in the cranial base and face, to analyze their temporal correlation. METHODS: Ninety computed tomographic scans were included (Crouzon, n = 36; controls, n = 54) and divided into five age subgroups. Craniofacial cephalometric measurements were analyzed by Materialise software. RESULTS: The overall cranial base length in Crouzon syndrome compared with controls decreased 8 percent (p = 0.014) on average. The posterior cranial fossa shortening accounted for most of this reduction. The cranial base displaced with the distances from basion, sella, and ethmosphenoid to posterior nasal spine shortened by 21%, 18%, and 16%, respectively (all p < 0.01) during life. Although the cranial base angle on intracranial surface remains normal, the angles on facial surface narrowed were reduced. CONCLUSIONS: The cranial base deformity of Crouzon syndrome consists of the whole skull base and particularly anterior skull base shortening early, leading to a compensatory widened anterior skull base. However, when this widening did not compensate fully for the rapid enlargement of the brain, the posterior skull base displaced inferiorly and became kyphotic. The cranial base deformity develops sequentially anterior to posterior in a probable cascade of influence pattern. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.


Asunto(s)
Disostosis Craneofacial/patología , Base del Cráneo/anomalías , Adolescente , Adulto , Factores de Edad , Estudios de Casos y Controles , Niño , Preescolar , Disostosis Craneofacial/diagnóstico por imagen , Cara/anomalías , Asimetría Facial/diagnóstico por imagen , Asimetría Facial/patología , Femenino , Humanos , Lactante , Recién Nacido , Estudios Longitudinales , Masculino , Persona de Mediana Edad , Base del Cráneo/diagnóstico por imagen , Tomografía Computarizada por Rayos X , Adulto Joven
10.
Ann Plast Surg ; 83(5): 568-582, 2019 11.
Artículo en Inglés | MEDLINE | ID: mdl-31008788

RESUMEN

BACKGROUND: From infancy to adulthood, the mandible develops increased ramus height, prominence of the chin, and laterally widened gonial angles. In Crouzon and Apert syndromes, both relative retrognathia and prognathic jaws have been reported. Growth is influenced by a variety of factors, including the growth and relative position of the skull base, functional coordination, and the spatial influence of the laryngopharynx. Thus, this study aimed to explore in detail the evolution of the mandible in both syndromes and its relationship with the entire facial structure and skull base. METHODS: One hundred twenty-three preoperative computed tomographic scans (Crouzon, n = 36; Apert, n = 33; control, n = 54) were included and divided into 5 age subgroups. Computed tomographic scans were measured using Materialise software. Cephalometrics relating to the mandible, facial structures, and cranial base were collected. Statistical analyses were performed using t test and statistical power analysis. RESULTS: In Crouzon syndrome, the angle between the cranial base and gnathion was increased prior to 6 months of age by 10.29 degrees (P < 0.001) and by adulthood to 11.95 degrees (P = 0.003) compared with normal. After 6 months of age, the distance between bilateral mandibular condylions (COR-COL) was narrower by 15% (P < 0.001) in Crouzon syndrome compared with control subjects. Before 6 months of age, Apert COR-COL decreased 16% (P < 0.001) compared with control subjects and 13% (P = 0.006) narrower than Crouzon. During 2 to 6 years of age, Apert mandibular ramus height caught up to, and became longer than, Crouzon by 12% (P = 0.011). The nasion-sella-articulare angle of the Apert skull was 5.04 degrees (P < 0.001) less than Crouzon overall. CONCLUSIONS: In Crouzon syndrome, the changes of the spatial relationship of the mandible to the cranial base develop earlier than the mandibular shape deformity, whereas in Apert syndrome, the spatial and morphological changes are synchronous. The morphological changes of the mandible are disproportional in 3 directions, initially significant shortening of the mandibular width and length, and, subsequently, reduced height. Crouzon has more shortening in mandibular height compared with Apert, reflecting the more shortened posterior cranial base length. The narrowed angle between the mandible and the posterior cranial base in Apert skulls is consistent with the more limited nasopharyngeal and oropharyngeal airway space.

11.
J Craniofac Surg ; 2019 Apr 24.
Artículo en Inglés | MEDLINE | ID: mdl-31033684

RESUMEN

PURPOSE: Orthognathic surgery for dentofacial deformities is typically preceded and followed by orthodontic treatment. Traditionally, orthodontic hardware is secured to the dentition to allow dental movement and stabilization. Clear-aligner therapy (eg, Invisalign) provides an aesthetic alternative, consisting of a series of transparent trays. Its use has not been described in complex triple-jaw orthognathic surgery. The purpose of this study is to evaluate perioperative outcomes and 3-dimensionally quantify postoperative edema in Invisalign patients undergoing triple-jaw orthognathic procedures, comparing this to patients treated with conventional fixed appliances. The surgical approach to patients with clear-aligners is also outlined. METHODS: The authors conducted a retrospective chart review and 3-dimensional morphometric study of Invisalign patients undergoing triple-jaw surgery (LeFort I osteotomy, bilateral sagittal split osteotomy, and genioplasty). An identical assessment of demographically matched patients treated with conventional fixed appliances was performed and compared with the Invisalign group. RESULTS: Thirty-three patients, with a mean age of 19.99 years, were included: 13 with Invisalign and 20 with conventional fixed appliances. No significant difference was observed in operating time, concurrent extraction of teeth, fat grafting, duration of hospital stay, diet advancement, and use of narcotic analgesics between the 2 groups. Nine patients had sufficient 3-dimensional images for volumetric analysis (4 with Invisalign and 5 with conventional fixed appliances). Postoperative edema was not significantly different (P = 0.712) when comparing conventional fixed appliances (44.29 ±â€Š23.16 cm) to Invisalign (37.36 ±â€Š31.19 cm). CONCLUSION: The present study demonstrates that complex multiple-jaw orthognathic procedures can be successfully performed in Invisalign patients. Perioperative and short-term clinical outcomes are not compromised.

12.
Clin Plast Surg ; 46(2): 141-155, 2019 Apr.
Artículo en Inglés | MEDLINE | ID: mdl-30851747

RESUMEN

Management strategies for syndromic craniosynostosis patients require multidisciplinary subspecialty teams to provide optimal care for complex reconstructive approaches. The most common craniosynostosis syndromes include Apert (FGFR2), Crouzon (FGFR2), Muenke (FGFR3), Pfeiffer (FGFR1 and FGFR2), and Saethre-Chotzen (TWIST). Bicoronal craniosynostosis (turribrachycephaly) is most commonly associated with syndromic craniosynostosis. Disease presentation varies from mild sutural involvement to severe pansynostoses, with a spectrum of extracraniofacial dysmorphic manifestations. Understanding the multifaceted syndromic presentations while appreciating the panoply of variable presentations is central to delivering necessary individualized care. Cranial vault remodeling aims to relieve restriction of cranial development and elevated intracranial pressure and restore normal morphology.


Asunto(s)
Craneosinostosis/cirugía , Osteotomía/métodos , Procedimientos Quirúrgicos Reconstructivos/métodos , Cráneo/cirugía , Niño , Suturas Craneales/anomalías , Suturas Craneales/diagnóstico por imagen , Craneosinostosis/diagnóstico por imagen , Craneosinostosis/genética , Femenino , Humanos , Imagenología Tridimensional , Lactante , Masculino , Osteotomía Le Fort/métodos , Procedimientos Quirúrgicos Reconstructivos/efectos adversos , Cráneo/diagnóstico por imagen , Síndrome , Tomografía Computarizada por Rayos X
13.
J Craniofac Surg ; 30(3): 698-702, 2019.
Artículo en Inglés | MEDLINE | ID: mdl-30807474

RESUMEN

BACKGROUND: Autologous fat grafting concurrent with orthognathic surgery is a powerful adjunctive aesthetic tool, and has been shown to have anti-inflammatory properties in prior studies. The purpose of this study is to evaluate the effect of fat grafting on postoperative edema following orthognathic surgery, and also consider the impact of age and BMI. METHODS: A retrospective cohort study was performed. Three-dimensional photos (Canfield, Fairfield, NJ) from a series of postprocedure time-points were analyzed using Geomagic Studio 2013 (3D Systems, Morrisville, NC). An unstructured covariance linear mixed model was created to analyze the effect and extent of the effect of age, BMI, and fat using SPSS Statistics 24.0 (IBM, Armonk, NY). RESULTS: One hundred thirty postoperative three-dimensional pictures were analyzed, from 31 patients. The linear mixed model demonstrates that the fat injected (P<0.001), age (P=0.001), and BMI (P<0.001) are significant factors in the postoperative volume. Age and BMI increase postoperative edema by 3.63 cm per year and 14.60 cm per kg/m, respectively. Fat injected reduces postoperative edema by 8.72 cm per 1 cc injected. CONCLUSION: Increasing age and BMI lead to greater postoperative edema (3.88 cm per year and 14.60 cm per kg/m, respectively). Fat grafting concurrent with orthognathic surgery reduces postoperative edema by 8.72 cm per 1 cc injected, and hastens return to steady state. This impact is more profound in patients with a greater age and BMI.


Asunto(s)
Tejido Adiposo/trasplante , Edema/prevención & control , Procedimientos Quirúrgicos Ortognáticos/efectos adversos , Procedimientos Quirúrgicos Reconstructivos/efectos adversos , Adulto , Factores de Edad , Índice de Masa Corporal , Estética Dental , Femenino , Humanos , Masculino , Cuidados Posoperatorios , Complicaciones Posoperatorias/prevención & control , Estudios Retrospectivos
14.
J Plast Surg Hand Surg ; 53(3): 130-137, 2019 Jun.
Artículo en Inglés | MEDLINE | ID: mdl-30782083

RESUMEN

The dysplastic maxilla and retracted zygoma characterize Apert's syndrome. The relationship between the cranial base and facial development is believed to be influential and substantial. The purpose of this study is to explore the temporal relationships of maldevelopment of these structures to identify potential influence patterns. Fifty-four CT scans (unoperated Apert's, n = 18; control, n = 36) were included and divided into three age subgroups (0-6 months, 6 months-2 years, and 2-6 years). All measurements were analyzed by Materialize software. Cephalometrics relating to midface and cranial base were collected. In anteroposterior direction, prior to 6 months, the zygoma was markedly retruded by 12% in Apert's, followed by persistent retrusive shape into adulthood, averaging 17% shorter compared to controls. The maxillary anteroposterior dimension was 22% shorter than normal before 6 months of age, thereafter, it maintained at least an 18% deficiency into adulthood. In the horizontal direction, the transverse width of the zygoma increased 39% between 6 months and 2 years of age, and it was 14% wider on average overall into adulthood. The maxilla had normal growth in transverse and vertical directions. The zygoma is the most severely deformed anatomic facial structure in early infancy, in both positional relation and geometric shape in Apert's syndrome. This may develop as a 'bridge', influencing the structure, transmitting malformation stresses, caused by premature fused coronal and peri-zygomatic sutures, into facial structures and the maxilla.


Asunto(s)
Acrocefalosindactilia/complicaciones , Maxilar , Cigoma , Adolescente , Estudios de Casos y Controles , Cefalometría , Niño , Preescolar , Femenino , Humanos , Lactante , Recién Nacido , Masculino , Maxilar/anomalías , Maxilar/diagnóstico por imagen , Nariz/anomalías , Nariz/diagnóstico por imagen , Estudios Retrospectivos , Tomografía Computarizada por Rayos X , Adulto Joven , Cigoma/anomalías , Cigoma/diagnóstico por imagen
15.
J Oral Maxillofac Surg ; 77(4): 850.e1-850.e5, 2019 Apr.
Artículo en Inglés | MEDLINE | ID: mdl-30576673

RESUMEN

Wide alveolar clefts are challenging to treat and are often associated with a higher chance of failure requiring repeated bone grafts. Even if successful, an excessively large cleft leads to a wide edentulous space, and patients are faced with prolonged orthodontic treatment. We present a series of large alveolar clefts closed with the aid of segmental maxillary osteotomies. Cases of alveolar clefts treated by segmental maxillary osteotomy from 2014 to 2016 were reviewed. Preoperative and postoperative computed tomography scans were analyzed to assess the alveolar gap and bone filling. Demographic characteristics, diagnoses, and operative techniques were reviewed and described. A total of 10 alveolar fistulae were addressed, using 6 segmental osteotomies in 6 patients. Of the cases, 66% were bilateral. There were 4 female and 2 male patients with an average age of 12.6 years. The average preoperative cleft width was 14.2 mm on computed tomography scans. Postoperatively, all clefts were successfully closed and no adverse effects were observed. Segmental maxillary osteotomy with concurrent bone grafting and fistula closure is an effective approach to treat excessively wide alveolar clefts. This enables a prudent dental substitution or prosthodontic plan while minimizing prolonged orthodontia, in addition to achieving the traditional goals of alveolar bone grafting (stabilizing the maxillary arch, closing fistulae, and permitting canine eruption).

16.
J Oral Maxillofac Surg ; 77(4): 828-833, 2019 Apr.
Artículo en Inglés | MEDLINE | ID: mdl-30576675

RESUMEN

PURPOSE: Vertical changes in Le Fort I orthognathic surgery are critical to the overall esthetic result. Three-dimensional planning enables vertical measurements from the rendered computed tomographic (CT) scan, but intraoperative points are ascribed partially from soft tissues landmarks. This study compared intraoperative soft tissue vertical measurements with pre- and postoperative CT-based values and attempted to validate intraoperative soft tissue landmarks for vertical positioning. MATERIALS AND METHODS: In this retrospective single-cohort study, the authors examined orthognathic procedures performed by a single surgeon at their institution. Patients were excluded if measurements or pre- and postoperative CT scans were lacking. Demographic information and soft tissue perioperative data were tabulated. Clinical vertical measurements included the left medial canthus to the central incisor, the left medial canthus to the left canine, and the right medial canthus to the right canine. Bone measurements were calculated using pre- and postoperative cone-beam CT scans for the same clinical landmarks. Statistical analysis, including paired Student t test, was performed using SPSS. RESULTS: Forty-two patients were identified (mean age, 23 yr; 57% female). The change in pre- and postoperative measurements was analyzed. There was no significant difference in the absolute value pre- and postoperatively between the 2 modalities (P < .2, .1, .1), but there was a significant difference between bony and soft tissue measurements (P < .01). Subset analysis showed differences in postoperative values between Class II and III cases. CONCLUSIONS: These results show a nonlinear but predictable relation between intraoperative soft tissue (medial canthi and maxillary dentition) and CT-measured bony vertical measurements. Understanding this relation enables effective use of intraoperative measurements to reproducibly achieve the desired bony vertical position and allows adjustments to be made to optimize esthetics.

17.
J Craniofac Surg ; 30(2): 317-325, 2019.
Artículo en Inglés | MEDLINE | ID: mdl-30358751

RESUMEN

Complicated craniofacial malformations interfacing with multiple intracellular regulatory mechanisms, lead to ambiguous growth patterns in Apert syndrome. This study aims to explore the chronology and pathogenesis of the development of craniofacial anatomic relationships and to verify the positional correlates between skull and facial structures in Apert syndrome. Fifty-four computed tomography scans (Apert, n = 18; control, n = 36) were included and divided into 3 age subgroups. Craniofacial 3-dimensional cephalometries were analyzed by Materialize software. The angle between sella-nasion plane and maxillary plane widens 7.74° (P = 0.003) prior to 6 months of age; thereafter, this widening increases by 10.36° (P < 0.001) in 6 months to 2 years of age, and remains increased by 8.9° (P = 0.046) throughout childhood. The angle between Frankfort horizontal plane and maxillary plane widens 5.17° (P = 0.022) before 6 months. Angles SNA, SNB, and ANB showed decreases, averaging 12.23° (P < 0.001), 5.19° (P = 0.004), and 6.72° (P = 0.001), respectively. The linear measurements showed synchronicity and continuing deformity into adulthood. Between 6 months to 2 years of age, the distance from sella to nasion (S-N), anterior nasal spine (S-ANS), and posterior nasal spine (S-PNS) decreased 8% (P = 0.006), 16% (P < 0.001), and 19% (P = 0.002), respectively, and remained shortened into adulthood. The angulation changes occur earlier in development than linear distance reduction in Apert syndrome patients compared with controls. Angular adjustments were not sufficient to maintain normal cranial base length. Facial deformity of Apert syndrome temporally begins with the midface, and affects orbit and mandible later in life.


Asunto(s)
Acrocefalosindactilia , Cara , Cráneo , Acrocefalosindactilia/diagnóstico por imagen , Acrocefalosindactilia/patología , Cefalometría , Preescolar , Cara/diagnóstico por imagen , Cara/patología , Humanos , Lactante , Cráneo/diagnóstico por imagen , Cráneo/patología , Tomografía Computarizada por Rayos X
18.
Plast Reconstr Surg Glob Open ; 6(10): e1963, 2018 Oct.
Artículo en Inglés | MEDLINE | ID: mdl-30534503

RESUMEN

Background: In Crouzon's syndrome, cranial base deformities begin sequentially in the anterior cranial fossa initially, and later to the posterior cranial base. Facial characteristics are likely related to cranial base development. The temporal correlation between cranial base development and facial features is in need of clarification in Crouzon's patients, to clarify initial sites of deformity, which may impact surgical decision making. Methods: Thirty-six computed tomography scans of unoperated Crouzon's syndrome patients and 54 controls were included and divided into 5 age-subgroups. All the planes used for analysis were set as perpendicular to a defined "midplane" to offset the confounding factor caused by potential asymmetry. Results: The angle between Sella-Nasion plane and Frankfort horizontal plane was significantly increased before 6 months of age (P = 0.014), with an average 70% (P < 0.001) increase ultimately into adulthood. The angle between SN and maxillary plane and the angle between Sella-Nasion and occlusal planes increased consistently through infancy to adulthood (124% and 42%, respectively, both P < 0.001). The relative angle of mandibular plane to Frankfort horizontal plane increased before 6 months (28%, P = 0.007) with a peak timeframe from 2 to 18 years. Facial lateral curvature related measurements indicate the whole face is inclined posteriorly and inferiorly direction in relation to the anterior cranial base. Conclusion: Crouzon's facial malformation development is synchronous and positionally correlational with cranial base deformity. It transmitted from orbit to mandible, with the most evident morphologic changes are in the orbit and midface.

19.
J Craniomaxillofac Surg ; 46(12): 2042-2051, 2018 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-30391086

RESUMEN

Apert syndrome is characterized by the severe craniofacial deformities. The subsequent process of skeletal maldevelopment is likely to be influenced by multiple interactions at several levels, at a given time. In this study, we aimed to explore the evolution of cranial basal dysmorphology and the chronology of these deformities in Apert syndrome, by objectively analyzing three-dimensional measurements. Fifty-four CT scans from unoperated patients (Apert, n = 18; control, n = 36) were included in this study, with age range from 3 days to 24 years. Before 6 months of age, Apert's anterior cranial base was widened 60%. Between 6 months and 2 years of age, the whole cranial base length, anterior cranial base length and posterior cranial base length decreased 8%, 8% and 14%, respectively. The greater sphenoid wing angle was wider by 26.0°, and continued into adulthood. The cranial base angles did not produce significant changes throughout life. The extra cranial distances synchronously and almost proportionally shortened after later infancy. The anterior and posterior cranial base length shortened at an almost proportional rate. The malformations of the skull vault are additive effects with cranial base fusion on skull length restriction, but the angulation of the skull base is virtually normal.


Asunto(s)
Acrocefalosindactilia/patología , Base del Cráneo/anomalías , Acrocefalosindactilia/diagnóstico por imagen , Niño , Preescolar , Femenino , Humanos , Lactante , Estudios Longitudinales , Masculino , Base del Cráneo/diagnóstico por imagen , Tomografía Computarizada por Rayos X
20.
Plast Reconstr Surg ; 142(6): 1572-1581, 2018 12.
Artículo en Inglés | MEDLINE | ID: mdl-30188468

RESUMEN

BACKGROUND: Le Fort I maxillary advancements affect nasal proportions. However, there are no data on the three-dimensional nasal changes that occur with differential lateral plane adjustment (clockwise and counterclockwise movements) during Le Fort I maxillary advancements. This study analyzes and compares nasolabial soft-tissue changes after Le Fort I clockwise and counterclockwise repositioning. METHODS: Single-piece Le Fort I advancements were included. A retrospective study of patients split into clockwise and counterclockwise groups was performed. Preoperative and postoperative three-dimensional photographs (VECTRA 3D) were analyzed. Nasolabial anthropometric measurements were recorded using Mirror software. Statistical analysis involved paired t test to compare preoperative and postoperative measurements. RESULTS: Twenty-four patients were evaluated (12 per group), with 22 distinct nasolabial relationships measured. Counterclockwise movement showed a statistically significant increase in alar width (3.6 mm; p < 0.001), alar base width (1.6 mm; p = 0.009), oral width (3.2 mm; p = 0.02), and lip projection (3.4 mm; p = 0.04). Clockwise movement showed no statistically significant changes, with the largest position changes noted in alar width (2.7 mm; p = 0.07) and alar base width (1.7 mm; p = 0.09). CONCLUSIONS: Clockwise and counterclockwise Le Fort I advancements have a different effect on postoperative nasolabial morphology. Counterclockwise movements exhibit significant changes, widening the alar base and width and the oral and philtral widths. The impact on the nostril morphology and columella was similar between the groups. The differential impact on nasolabial appearance is important to recognize for treatment planning and patient counseling. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.


Asunto(s)
Cara/anomalías , Maxilar/cirugía , Surco Nasolabial/anatomía & histología , Osteotomía Le Fort , Adolescente , Cefalometría , Tejido Conectivo/anatomía & histología , Femenino , Humanos , Masculino , Movimiento , Estudios Retrospectivos , Rotación , Adulto Joven
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