Chang Gung Forum: An Exemplary Strategy for Implementing a Multidisciplinary Network of Experts in Craniofacial Anomalies.

INTRODUCTION: The Chang Gung Forum has been dedicated to the care of craniofacial anomalies since 2000. This annual continuing medical education program focuses on orofacial cleft and surgery-first orthognathic surgery by providing up-to-date information and management guidelines. This study explored how the Chang Gung Forum has influenced medical perspectives, decisions, and practices in a multidisciplinary craniofacial team. METHODS: Between 2000 and 2022, 20 Chang Gung Forums have been held. A questionnaire was distributed among 170 attendees who had participated in the forum more than once. The questionnaire collected information on the participants' experiences and levels of satisfaction with the educational program and whether or how it had influenced their clinical practice. RESULTS: Valid responses from 86 attendees (response rate, 50.6%) who had participated more than once were collected and analyzed. The overall satisfaction rate of the Chang Gung Forum based on the respondents' most recent visits was 4.28 ± 0.63 out of 5. Of the respondents, 90.9% acknowledged changes in their clinical practice, with modifications in surgery plans and decisions being the most notable (48.5%). In addition, comprehension increased throughout years of attending the annual forum (P < 0.001). CONCLUSION: The Chang Gung Forum has contributed markedly to the community of congenital craniofacial anomalies. The program will continue providing updated information and influencing the clinical decision-making of health care professionals.

Comparison of Facial Growth between Two Nasoalveolar Molding Techniques in Patients with Unilateral Complete Cleft Lip.

BACKGROUND: Nasoalveolar molding (NAM) has become standard treatment in the authors' craniofacial center. There are two types of presurgical NAM: the Grayson and Figueroa techniques. The Grayson method involves active alveolar molding, and the Figueroa method involves passive alveolar molding. The authors previously found no differences in number of clinic visits, costs, or 6-month postoperative outcome between the two techniques. The authors extended the previous study to evaluate facial growth between these two groups. METHODS: In this randomized single-blind study, conducted between May of 2010 and March of 2013, the authors recruited 30 patients with unilateral complete cleft lip and palate and randomized them for Grayson or Figueroa presurgical NAM. Standard lateral cephalometric measurements at 5 years were used to determine facial growth. RESULTS: Twenty-nine patients completed 5 years of follow-up. There were no statistically significant differences in facial cephalometric measurements between the two groups. CONCLUSION: Presurgical NAM using either a passive or active NAM technique produced similar facial growth patterns after unilateral cleft lip and palate repair. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Botulinum Toxin to Improve Lower Blepharoplasty Scar: A Double-Blinded, Randomized, Vehicle-Controlled Clinical Trial.

BACKGROUND: Lower blepharoplasty is a common cosmetic operation that relies on minimal postoperative scarring, but Asian patients are at higher risk than Caucasians for hypertrophic and/or widened scars. Botulinum toxin type A (BTX) injections are widely employed to alleviate dynamic facial rhytids and also can improve scar quality by reducing scar tension. The authors assessed whether simultaneous transcutaneous lower blepharoplasty and BTX injections could improve subciliary scar quality. OBJECTIVES: The objective of this study was to assess whether simultaneous transcutaneous lower blepharoplasty and BTX injections could improve subciliary scar quality. METHODS: This is a prospective, randomized, vehicle-controlled, double-blinded clinical trial. Between May 2015 and May 2018, 40 adults who underwent bilateral transcutaneous lower blepharoplasties were randomized to receive BTX (n = 20) or vehicle (normal saline; n = 20) injections into the lateral orbicularis oculi muscle immediately after wound closure. Vancouver Scar Scale, Visual Analogue Scale, and photographic scar width measurements at 3 reference points were recorded at the final clinical follow-up. RESULTS: Thirty-seven patients completed the trial. Vancouver Scar Scale and Visual Analogue Scale scores in the experimental and vehicle control groups were similar, but scar widths in the experimental group at all measured points were significantly narrower than in the vehicle control group (P < 0.001, P = 0.027, and P < 0.001 at each measured point, respectively). CONCLUSIONS: Transcutaneous lower blepharoplasty scars in Asians can be significantly narrowed by simultaneous BTX injections without additional complications.

Simultaneous Orthognathic Surgery With Asian Double Eyelid Suture Blepharoplasty.

BACKGROUND: The main objective of contemporary orthognathic surgery is to correct dentofacial deformities. Nonetheless, many adjunct procedures to enhance the esthetic outcome in orthognathic surgical cases have been successfully incorporated to improve patient satisfaction. The authors report our preliminary experience of performing simultaneous orthognathic surgery with Asian double eyelid suture method blepharoplasty in the same surgical setting. METHOD: This case series report includes all 19 consecutive cases presenting to the Chang Gung Craniofacial Center for combined orthognathic surgery with Asian double eyelid suture method blepharoplasty. The double eyelid crease height was measured as the vertical line between the upper eyelid margin (eyelid lash) and the upper eyelid crease, observed at the mid-pupillary line with the eyes in primary gaze. RESULTS: There were no complications or relapse reported within this time period. There was significant improvement in the left and right mid-pupillary double eyelid crease height postsurgery. There were no statistically significant differences between the left and right mid-pupillary double eyelid crease heights after surgery indicating good eyelid crease height symmetry bilaterally was obtained. CONCLUSIONS: Orthognathic surgery combined with suture method blepharoplasty can be safely performed in the same surgical setting without inappropriate rise in costs or operating room time. This case series demonstrates that excellent esthetic results can be obtained in simultaneous bimaxillary orthognathic surgery with suture method Asian blepharoplasty.

Patients With Cleft Lip and Palate Associated With Intraoral Fibrous Bands: A Report of 3 Cases and Review of Literature.

In rare instances, cleft lip and palate occur in association with synechia, intraoral fibrous bands connecting the maxilla and mandible. The main concern in synechia is a restricted mouth opening that leads to airway and feeding problems. This study reports our experience in the treatment of 3 cases and includes a review of the literature. Three patients with intraoral fibrous bands received treatment and follow-ups in our center. Division of the bands and reconstruction of the lip and palate were successfully performed. All reported cases in the literature were collected for a summary of clinical presentations and as references for management. Early management of the synechia improves the mouth opening and facilitates the treatment of associated anomalies.

Simultaneous auricular reconstruction and transcutaneous bone conduction device implantation in patients with microtia.

BACKGROUND/PURPOSE: The Bonebridge (BB) is a newly designed transcutaneous bone conduction hearing implant. We describe, for the first time, simultaneous BB implantation and different surgical techniques of auricular reconstruction for microtia patients with aural atresia/stenosis. METHODS: Ten patients with unilateral or bilateral microtia underwent BB implantation combined simultaneously with either total auricular reconstruction using bespoke hand-carved Medpor framework or second stage auricular projection using autologous costal cartilage framework. Auditory aided and unaided sound fields were evaluated using (1) a pure-tone average (PTA4), (2) a speech reception threshold (SRT), and (3) a Speech Discrimination Score (SDS) at a sound level of 65 dB SPL. RESULTS: All patients and their families were satisfied with the aesthetic outcome of their constructed ears with no requests for further revision. No major complications were encountered. One patient developed minor partial skin graft epidermolysis that healed uneventfully, and another patient had a three month period of auditory acclimatization to the BB device that resolved. Postoperatively, the mean aided PTA4 decreased by 35.35 dB, while the SRT was 54.5 dB HL unaided and 28 dB HL with use of a BB sound processor. The SDS increased by 16.4%-65 dB SPL. CONCLUSION: Simultaneous BB implantation during either total auricular reconstruction or framework projection for microtia patients who have aural atresia/stenosis is feasible and safe. This approach reduces operative stages, thereby minimizing schooling/occupational disruption and time to total microtia reconstruction and auditory rehabilitation.

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.

A modified supra-auricular approach with helix cartilage suture for surgical treatment of the preauricular sinus.

OBJECTIVE: Several surgical techniques and modifications have been described to reduce the high recurrence rate after excision of preauricular sinus (PAS). This study was designed to evaluate the surgical outcomes of PAS excision using a new modified supra-auricular approach (SAA) and to assess the predisposing factors for recurrence. METHODS: A total of 175 (158 patients) PAS excision procedures were performed from 2007 to 2016 in a single institute using this modified SAA with helix cartilage suture to obliterate the dead space. The specimens were assessed to measure the closest distance between the squamous tract and the excised auricular cartilage (sinocartilaginous distance). We also evaluated the surgical outcomes and investigated the predisposing factors for recurrence, including gender, lesion laterality, etiology (primary or revised), anesthesia methods (general or local), history of infection, and history of incision and drainage (I&D) for abscess. RESULTS: Patients were followed up for a median duration of 45 months (range from 6 months to 10 years). There was a 2.3% (4 ears) recurrence rate and a 1.7% (3 ears) complication rate in our series. The average sinocartilaginous distance was 0.44 mm (median distance, 0.3 mm) and this value was less than 0.5 mm in 66% of cases. Recurrence was not significantly affected by gender, lesion laterality, etiology of surgery, anesthesia method, or a history of infection or preoperative I&D for abscess. CONCLUSIONS: Surgical PAS excision using the modified SAA with cartilage suture of dead space yielded low overall recurrence and complication rates in this series. Cosmesis was maintained due to a smaller incision. No significant predisposing factors for recurrence were identified. Thus, the modified technique described in the present study can be regarded as a simple, effective and reproducible surgical treatment for PAS.

Clinical evaluation of silicone gel in the treatment of cleft lip scars.

Upper lip scars are at risk of hypertrophy. Our center therefore uses microporous tape and silicone sheeting for postoperative scar care following cleft lip repair. However, some babies have previously ingested their silicone sheeting, which has the potential for respiratory compromise or gastrointestinal obstruction. Self-dry silicone gel is reportedly also effective for preventing hypertrophic scars. Hence, we sought to test whether silicone gel, which cannot be ingested whole, might be non-inferior to silicone sheeting for controlling against upper lip scar hypertrophy. This was a mixed prospective and retrospective case-controlled clinical trial involving patients undergoing unilateral cleft lip repair, 29 of whom received standard postoperative silicone sheeting (control group) and another 33 age-matched consecutive patients who received self-dry silicone instead. The Vancouver scar scale, visual analogue scale and photographically assessed scar width assessments were the same in both groups at six months after surgery. In conclusion, silicone gel appears to be non-inferior to silicone sheeting for postoperative care of upper lip scars as judged by scar quality at six months, but silicone sheeting has the safety disadvantage that it can be swallowed whole by babies. It is thus recommended that silicone gel be used for upper lip scar management in babies.

Pursuing Mirror Image Reconstruction in Unilateral Microtia: Customizing Auricular Framework by Application of Three-Dimensional Imaging and Three-Dimensional Printing.

BACKGROUND: Advances in three-dimensional imaging and three-dimensional printing technology have expanded the frontier of presurgical design for microtia reconstruction from two-dimensional curved lines to three-dimensional perspectives. This study presents an algorithm for combining three-dimensional surface imaging, computer-assisted design, and three-dimensional printing to create patient-specific auricular frameworks in unilateral microtia reconstruction. METHODS: Between January of 2015 and January of 2016, six patients with unilateral microtia were enrolled. The average age of the patients was 7.6 years. A three-dimensional image of the patient's head was captured by 3dMDcranial, and virtual sculpture carried out using Geomagic Freeform software and a Touch X Haptic device for fabrication of the auricular template. Each template was tailored according to the patient's unique auricular morphology. The final construct was mirrored onto the defective side and printed out with biocompatible acrylic material. RESULTS: During the surgery, the prefabricated customized template served as a three-dimensional guide for surgical simulation and sculpture of the MEDPOR framework. Average follow-up was 10.3 months. Symmetric and good aesthetic results with regard to auricular shape, projection, and orientation were obtained. One case with severe implant exposure was salvaged with free temporoparietal fascia transfer and skin grafting. CONCLUSIONS: The combination of three-dimensional imaging and manufacturing technology with the malleability of MEDPOR has surpassed existing limitations resulting from the use of autologous materials and the ambiguity of two-dimensional planning. This approach allows surgeons to customize the auricular framework in a highly precise and sophisticated manner, taking a big step closer to the goal of mirror-image reconstruction for unilateral microtia patients. CLINCIAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

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.

Precision of three-dimensional stereo-photogrammetry (3dMD™) in anthropometry of the auricle and its application in microtia reconstruction.

BACKGROUND: The advent of three-dimensional stereo-photogrammetry in recent years has vastly helped the craniomaxillofacial field improve in terms of preoperative and intraoperative decision making. With regard to the auricle though, there is paucity of research as to the application of this promising technology. METHODS: A total of 20 normal adult ears were included in this study. Thirteen anthropometric measurements were taken, twice by two plastic surgeons using direct measurement (DM) and through images captured via 3dMD™. The purpose was to compare the reliability of measurements involving the two instruments. RESULTS: The overall mean absolute differences (MADs) of all ear anthropometries of DM and 3dMD™ were 0.52 mm (range: 0.28-0.72 mm) and 0.27 mm (range: 0.15-0.53 mm), respectively, and the grand mean relative error magnitudes (REMs) were 2.85% (range: 1.01-5.99%) and 1.57% (range: 0.48-3.62%), respectively, across observers. Thus, the precision of all ear anthropometries across observers was high in both methods, but the precision of 3dMD was better than DM irrespective of observers. In addition, the MADs were less than a millimeter across all measurements. CONCLUSION: The application of three-dimensional technology in microtia surgery for both template production and soft tissue analysis leads to improved planning and satisfactory results with fewer complications. We believe that with further refinement and enhancement, the use of this innovation will pave the way for prefabricated, individualized autologous or biocompatible alloplastic implantable frameworks based on an accurate mirror image of each patient's normal ear in unilateral cases and in bilateral cases, appropriately sized.

Three-dimensional computed tomography reveals different donor-site deformities in adult and growing microtia patients despite total subperichondrial costal cartilage harvest and donor-site reconstruction.

BACKGROUND: Donor-site deformity may complicate autologous costal cartilage harvest for microtia reconstruction. This is reportedly prevented by total subperichondrial costal cartilage harvest, costochondral growth center preservation, donor-site reconstitution with morselized leftover costal cartilage, and perichondrial repair (Kawanabe-Nagata method). However, no quantitative assessment of preoperative versus postoperative thoracic morphology exists following use of this method. METHODS: Twenty-five consecutive patients (11 adult and 14 growing patients) who received radiographic donor-site evaluation for autologous unilateral primary microtia reconstruction were studied. Each underwent thoracic three-dimensional computed tomography preoperatively and 6 months postoperatively. The authors quantified (1) donor-site skeletal deformation with respect to the sixth to ninth costochondral junctions (2) and distortion in thoracic/hemithoracic Haller indices. The contralateral unoperated hemithorax provided intrapatient control data. RESULTS: Statistically significant deformations occurred in the sagittal and transverse planes in growing patients and in the transverse plane in adults, with respect to most costochondral junctions on operated versus unoperated sides. Importantly, in growing patients, the sixth to ninth costochondral junctions on the operated side failed to descend postoperatively with normal growth in the vertical plane, unlike on the unoperated side. However, no gross distortions in thoracic/hemithoracic proportions occurred according to Haller indices. CONCLUSIONS: Despite meticulous donor-site management and reconstruction according to the Kawanabe-Nagata method, patients sustained significant localized skeletal deformations, as quantified by three-dimensional computed tomography, the configurations of which differed according to whether patients were adult or growing when operated on. Whether these improve or worsen in the long term, particularly in growing patients, requires confirmation. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

A cross-sectional study of lung volume development in pectus excavatum patients: estimating the total lung volume from chest computed tomograph using 3-dimensional volumetric reconstruction.

BACKGROUND/PURPOSE: This study quantified the lung volume development of pectus excavatum (PE) patients using chest computed tomography (CT) 3-dimensional volumetric reconstructions. The technique permits current and retrospective analyses of data from different institutions. PATIENTS AND METHODS: We analyzed the records of PE patients who underwent chest CT preoperatively between 2005 and 2009 at 3 institutions. All patients were Chinese. A window of -992 to -198 Hounsfield units was chosen for calculating the CT total lung volume (TLV). The data were compared with the data for 73 microtia and other chest-wall tumor patients studied during the same period as a control group. RESULTS: In total, 377 PE patients with Haller pectus index (PI) of at least 3.2 were identified for this study. Compared with the reported TLV data for 1050 healthy children and our control group, we found little evidence of a decreased TLV in PE patients at any age for either sex. The mean PI did not change significantly between the ages of 3 and 27 years. The PI was inversely correlated with the TLV (P < .001). CONCLUSION: Our cross-sectional study provides evidence that the TLV of PE patients is within the reference range in children and adolescents.

Negative pressure manoeuvre in microtia reconstruction with autologous rib cartilage.

In microtia reconstruction, maintaining a healthy contact between the skin and the fabricated cartilage framework is essential to attaining a smooth and accentuated contour of the reconstructed auricle. Conventional means to achieve this include bolster sutures and continuous suction drains, both of which have associated shortcomings. A new dressing method was developed and applied in 10 consecutive patients who underwent the first of a two-stage microtia reconstruction using the Nagata technique. A small catheter was introduced into the space between the skin and the cartilage framework. Negative pressure was applied through the catheter, drawing the skin onto the cartilage framework. This evens out the skin, accentuates the contour of the framework and concurrently eliminates potential dead space. Skin contact on the framework is maintained whilst the catheter is removed and an occlusive transparent dressing is applied to the ear. Of the 10 cases in which this manoeuvre was performed, one had to be converted to the bolster suture technique due to a persistent air leak from the wound. Overall results of the nine cases in which this technique was carried out successfully demonstrate smooth skin contour and excellent definition of the fabricated framework. This negative pressure manoeuvre provides a simple, safe and consistent approach to achieving a smooth and accentuated contour in auricular reconstruction.

A new method for the second-stage auricular projection of the Nagata method: ultra-delicate split-thickness skin graft in continuity with full-thickness skin.

BACKGROUND: Staged auricular reconstruction remains mainstream among the various techniques of microtia reconstruction using autogenous costal cartilage. The initial stage involves fabrication and implantation of the cartilage framework, followed by projection of the reconstructed auricle in the second stage. During the projection stage, the line of incision is usually made close to the helical rim, from the superoanterior margin of the helical rim to the region of the lobule. Generally, a fascial flap is raised and covered over a cartilage block to project the auricle, and a skin graft is inset over the raw surface of the newly created postauricular sulcus. METHODS: The authors developed a new refinement for the second-stage auricular projection, whereby the skin cover for the raw surface over the posterior aspect of the auricle and the postauricular sulcus is an ultra-delicate split-thickness skin graft raised in continuity with the full-thickness skin over the anterior aspect of the auricle. RESULTS: Incorporation of this new technique has minimized the visibility of suture lines and improved the appearance of the superior otobasion. In addition, the dimension of the skin cover required can be designed with greater precision. Postoperative outcomes using this new technique for auricular projection have been more than satisfactory. CONCLUSION: More favorable results that carry less surgical stigma can now be achieved in auricular reconstruction using this new modification of Nagata's two-stage method.

Free radial forearm flap in an adult with hypospadias.

A 22-year-old man presented with a scarred neophallus and complex hypospadias. The local penile skin was inadequate for urethral repair. A 16 cm free radial forearm flap was used for urethral replacement. Microvascular anastomosis allowed this flap to remain viable and functional. One year postoperatively, the patient had satisfactory functional and cosmetic outcomes. A small fistula developed in the course of the proximal anastomosis, and it was successfully repaired. Our case describes the successful use of a free radial forearm flap for urethral reconstruction.

Microtia reconstruction with adjuvant 3-dimensional template model.

For auricular reconstruction of external auricle, the goals of the surgery are (1) in the fabrication of the morphologically complete 3-dimensional costal cartilage framework (3-dimensional frame) of the auricle, and (2) in the attainment of ample skin surface area to cover the grafted 3-dimensional frame, so that more than satisfactory results can be achieved. In review of the published literature, the cartilage framework used for auricular reconstruction is either insufficient or incomplete in the fabrication of the anatomic structures or inappropriate in proportion. We herein introduce the 3-dimensional resin template model (3-dimensional template model) and 3-dimensional frame used in our daily surgical practice. The 3-dimensional template model is proportionally fabricated with all the essential morphologic structures of the auricle. It can be used intraoperatively for reference in fabricating the 3-dimensional frame and simulation of the surgery. The 3-dimensional template model is very useful as an adjuvant tool in adjusting the skin flaps, prevention of mistake in fabrication of the 3-dimensional frame, and for educational purposes of junior resident surgeons.