A prospective study of psychological adjustment during and after forehead flap nasal reconstruction.

The psychological effects of staged nasal reconstruction with a forehead flap were prospectively investigated. Thirty-three patients underwent nasal reconstruction with forehead flaps between March 2017 and July 2020. Three questionnaires were used to assess psychosocial functioning before surgery (time 1), 1 week after forehead flap transfer (time 2), 1 week after forehead flap division (time 3), and after refinement procedures (time 4). The patients were categorized into three groups according to the severity of nasal defects. Between- and within-group comparisons were conducted. All patients reported increased satisfaction with their appearance during nasal reconstruction. For most patients, levels of distress and social avoidance were highest before reconstruction (time 1). Both levels decreased as reconstruction advanced, and were significantly improved by times 3 and 4. The stage of reconstruction had a greater effect on these levels than did severity of nasal defect. Nasal reconstruction with forehead flap is beneficial physically and psychologically. Psychological evaluation before and after surgery facilitates patient-surgeon interactions and further enhances outcomes.

Enhancing Philtrum Morphology Using Fat Grafting Combined with Percutaneous Rigottomy in Repaired Unilateral Cleft Lip.

BACKGROUND: Improving the philtrum morphology of patients with a secondary cleft lip deformity has been a challenge in cleft care. Combining fat grafting with percutaneous rigottomy has been advocated for treatment of volumetric deficiency associated with a scarred recipient site. This study assessed the outcome of synchronous fat grafting and rigottomy for improvement of cleft philtrum morphology. METHODS: Consecutive young adult patients ( n = 13) with a repaired unilateral cleft lip who underwent fat grafting combined with rigottomy expansion technique for enhancement of philtrum morphology were included. Preoperative and postoperative three-dimensional facial models were used for three-dimensional morphometric analyses including philtrum height, projection, and volume parameters. Lip scar was qualitatively judged by a panel composed by two blinded external plastic surgeons using a 10-point visual analogue scale. RESULTS: Three-dimensional morphometric analysis revealed a significant (all P < 0.05) postoperative increase of the lip height-related measurements for cleft philtrum height, noncleft philtrum height, and central lip length parameters, with no difference ( P > 0.05) between cleft and noncleft sides. The postoperative three-dimensional projection of the philtral ridges was significantly ( P < 0.001) larger in cleft (1.01 ± 0.43 mm) than in noncleft sides (0.51 ± 0.42 mm). The average philtrum volume change was 1.01 ± 0.68 cm 3 , with an average percentage fat graft retention of 43.36% ± 11.35%. The panel assessment revealed significant ( P < 0.001) postoperative scar enhancement for the qualitative rating scale, with mean preoperative and postoperative scores of 6.69 ± 0.93 and 7.88 ± 1.14, respectively. CONCLUSION: Synchronous fat grafting and rigottomy improved philtrum length, projection, and volume and lip scar in patients with repaired unilateral cleft lip. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Alar Crease Creation Suture in Nasal Reconstruction.

SUMMARY: The crescentic alar groove serves as a topographic landmark that frames the ala and separates this convex structure from the surrounding cosmetic subunits. This aesthetic landmark can be attenuated or even obliterated during wound repair in this area. Flaps spanning the alar crease are often noticeably bulky with a pin-cushioned appearance in nasal reconstruction, and it is challenging to reproduce a natural-appearing alar groove. The authors proposed a novel technique with a modified, interrupted inverted horizontal mattress suture to create an alar groove. From March of 2016 to May of 2021, 22 consecutive patients with alar defects who underwent nasal reconstruction with the paramedian forehead flap were identified. All patients underwent the authors' novel technique for the creation of the alar groove. The mean follow-up time was 3 years 7 months (range, 14 months to 5 years). A total of 32 alar crease creation suture operations were performed. All uneven wounds healed uneventfully within 2 weeks. Two cases of postoperative fading alar grooves required alar crease creation sutures to be redone. The authors' novel alar crease creation suture is a safe, straightforward, and reliable technique to create an aesthetic alar groove in forehead flap nasal reconstruction. It can create a medially shallow and laterally deep alar crease without apparent complications. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Clinical Efficacy, Safety, and Complications of the Arthroscopic Cartilage Shaving Procedure for Secondary Osmidrosis Treatment.

BACKGROUND: Axillary osmidrosis is a common disease with negative psychosocial impact on patients. Further, many treatment modalities are not sufficient and result in recurrence. OBJECTIVE: We aimed to evaluate the effectiveness and safety of using a cartilage shaver in patients with recurrent osmidrosis to remove tightly attached apocrine glands and subdermal scars. METHODS: We retrospectively evaluated 24 patients with secondary axillary osmidrosis who underwent cartilage shaving surgery between January 2013 and May 2022. We analyzed the incidence of complications, including seroma, infection, pigmentation, wound dehiscence, skin necrosis, scarring, shoulder movement limitation, comedones/sebaceous cysts, and nerve injury. Clinical effectiveness was also evaluated. RESULTS: Excellent or good efficacy with improved malodor was achieved in 24 patients (47 axillae [100%]). Complications were observed in 16 (36.17%) axillae, including hematomas (n = 2), pigmentation (n = 7), skin necrosis (n = 3), and comedones/sebaceous cysts (n = 4); one patient (2.13%) required local debridement. Mean Vancouver Scar Scale scores were markedly low (5.41 to 4.67). Scar tissue did not interfere with the shaving surgery, allowing for successful removal of the apocrine glands. CONCLUSIONS: Secondary osmidrosis treatment using a cartilage shaver system yielded satisfactory and better scar results than the patients' previous treatments.

Forehead Flap Reconstruction in Different Nasal Defect: 58 Patients' Psychological Outcomes.

Forehead flap nasal reconstruction is a lengthy process; the final outcome requires multiple stages and several months to achieve. After flap transfer, the pedicle flap has to be kept attached to the face for weeks, which may lead to a variety of psychosocial distress and challenges for patients. From April 2011 to December 2016, 58 patients who underwent forehead flap reconstruction for nasal reconstruction were included. The general satisfaction questionnaire, Derriford Appearance Scale 19, and Brief Fear of Negative Evaluation Scale, were utilized to assess the change in psychosocial functioning over 4 time points: preoperative (time 1), 1 week after forehead flap transfer (time 2), 1 week after forehead flap division (time 3), and final outcome after refinement procedures (time 4). The patients were also divided into 3 groups based on the severity of nasal defects: defects involving only a single subunit (n=19), subtotal nasal defects (n=25), and total nasal defects (n=13). Between- and within-group comparisons were conducted. The vast majority of patients had the highest levels of postoperative distress and social avoidance immediately after flap transfer; these levels decreased after flap division and refinement procedures. The psychosocial functioning was more strongly affected by the stage time point than by the severity of the original nasal defects. The forehead flap nasal reconstruction can not only help patients gain a relatively normal nose but also restore their self-esteem and social confidence. The lengthy process is beneficial and worthwhile, even though it involves short-term psychosocial distress.

A 10-year experience in microsurgical reconstruction of the nose with a lower extremity flap.

BACKGROUND: Traditionally, radial forearm free flaps are utilized for nasal lining reconstruction when local flaps cannot provide adequate coverage. However, according to our clinical observation, the skin of the forearm flap is relatively thin and prone to collapse. We present a series of nasal reconstructions using free flaps harvested from the lower extremities to determine if the thick flap could provide more support and decrease the tendency of airway collapse. METHODS: From March 2011 to July 2021, we identified 15 patients who underwent total or subtotal nasal reconstruction with free flap from the lower extremities (10 anterolateral thigh flap, 4 medial sural artery perforator flap, and 1 profunda artery perforator flap). We included 15 patients who underwent free forearm flap reconstruction as controls. The Nasal Obstruction Symptoms Evaluation (NOSE) score was utilized to subjectively evaluate the degree of nasal obstruction symptoms. RESULTS: The lower extremity group had a lower NOSE score than the forearm group (25.4 vs. 40). It took more time (6.5 vs. 4.2 months) and more surgeries (4.6 vs. 2.6) from the first free flap reconstruction till forehead flap reconstruction in the lower extremity group than in the forearm group, although the total number of surgeries was comparable between the 2 groups (7.2 vs. 8.1). CONCLUSIONS: Utilizing free flaps from the lower extremities in total or subtotal reconstruction of the nasal lining may decrease the tendency of flap collapse and alleviate airway obstruction symptoms and may also allow reconstruction of surrounding defects simultaneously compared with using forearm flaps.

Machine learning approach for predicting inhalation injury in patients with burns.

BACKGROUND: The coronavirus disease pandemic has had a tangible impact on bronchoscopy for burn inpatients due to isolation and triage measures. We utilised the machine-learning approach to identify risk factors for predicting mild and severe inhalation injury and whether patients with burns experienced inhalation injury. We also examined the ability of two dichotomous models to predict clinical outcomes including mortality, pneumonia, and duration of hospitalisation. METHODS: A retrospective 14-year single-centre dataset of 341 intubated patients with burns with suspected inhalation injury was established. The medical data on day one of admission and bronchoscopy-diagnosed inhalation injury grade were compiled using a gradient boosting-based machine-learning algorithm to create two prediction models: model 1, mild vs. severe inhalation injury; and model 2, no inhalation injury vs. inhalation injury. RESULTS: The area under the curve (AUC) for model 1 was 0·883, indicating excellent discrimination. The AUC for model 2 was 0·862, indicating acceptable discrimination. In model 1, the incidence of pneumonia (P < 0·001) and mortality rate (P < 0·001), but not duration of hospitalisation (P = 0·1052), were significantly higher in patients with severe inhalation injury. In model 2, the incidence of pneumonia (P < 0·001), mortality (P < 0·001), and duration of hospitalisation (P = 0·021) were significantly higher in patients with inhalation injury. CONCLUSIONS: We developed the first machine-learning tool for differentiating between mild and severe inhalation injury, and the absence/presence of inhalation injury in patients with burns, which is helpful when bronchoscopy is not available immediately. The dichotomous classification predicted by both models was associated with the clinical outcomes.

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.

Simultaneous free flap and forehead flap for nasal reconstruction.

BACKGROUND: Reconstruction of total or near-total nasal defects is challenging and requires the re-creation of three nasal layers. Fasciocutaneous free flaps have been used effectively for restoring the vascularized nasal lining and staged forehead flap for nasal skin replacement, which is a long process. The aim of this study is to share our experience of combination of preliminary free tissue transfer with paramedian forehead flap reconstruction in the same stage of complex nasal reconstruction. METHODS: From December 2015 to July 2021, 10 patients underwent nasal reconstruction with free flaps including 4 medial sural artery perforator (MSAP) flaps, 5 anterolateral thigh (ALT) flaps and 1 radial forearm flap for lining and forehead flaps for skin coverage simultaneously for total or subtotal nasal defects. Nasal obstruction symptoms evaluation (NOSE) score was utilized to evaluate the functional outcome and the aesthetic results were evaluated with the last follow-up photos with score 1-5 by 5 plastic surgeon and 5 laypersons. RESULTS: The size of the free flaps ranged from 3 cm x 6 cm to 6 cm x 13 cm. After excluding one patient who expired before forehead flap division due to comorbidities, the average duration between combination surgery and the division of the forehead flap pedicle of the remaining patients was 5.7 months (range, 2-12). For patients without any postoperative events, the duration was 2.2 months (range, 2-3). One free flap had partial necrosis due to infection. The average follow-up duration was 29.6 months (range, 12-64). The NOSE score was 5.9 (range, 0-10) and the aesthetic score is 4.1 (range, 3-5) in average. CONCLUSIONS: The combination of preliminary free tissue transfer for nasal lining restoration with a paramedian forehead flap for nasal skin replacement in the same stage may shorten the long process and achieve satisfactory reconstruction in complex nasal reconstruction.

Imaging and Histopathological Analysis of Microvascular Angiogenesis in Photodynamic Therapy for Oral Cancer.

The objective of this study is to use imaging and histopathological analysis to characterize and monitor microvascular responses to photodynamic therapy (PDT). In vivo chicken chorioallantoic membranes (CAMs) and a stimulated malignant oral lesions animal model were used to determine the blood flow and the biological activities of Photofrin® (2.5 mg/kg) exposed to different laser power densities at 630 nm. The vascular changes, the velocity of the blood flow, the speckle flow index (SFI) of fluorescence changes, and ultrastructure damage in the microvasculature before and after PDT were recorded. The subcellular localization of Photofrin® revealed satisfactory uptake throughout the cytoplasm of human red blood cells at 10 s and 20 s before PDT. The mean blood-flow velocities of the veins and arteries were 500 ± 40 and 1500 ± 100 µm/s, respectively. A significant decrease in the velocities of the blood flow in the veins and arteries was detected in the CAM model after PDT. The veins and arteries of CAMs, exposed to the power densities of 80, 100, and 120 mW/cm2, had average blood-flow velocities of 100 ± 20, 60 ± 10, and 0 µm/s and 300 ± 50, 150 ± 30, and 0 µm/s, respectively. In the stimulated malignant oral lesions animal model, the treated tumors exhibited hemorrhage and red blood cell extravasation after PDT. The oxyhemoglobin and total hemoglobin levels decreased, which resulted in a decrease in tissue oxygen saturation, while the deoxyhemoglobin levels increased. PDT using Photofrin® has the ability to cause the destruction of the targeted microvasculature under nonthermal mechanisms selectively.

Objective Comparison of Eyebrow Position after Internal and External Browpexy.

BACKGROUND: Several brow-lift techniques have been used to prevent brow ptosis after blepharoplasty. For example, both internal and external browpexies have been adopted worldwide. However, few studies have compared these two methods. The authors compared postoperative eyebrow position changes between upper eyelid skin excision, internal browpexy, and external browpexy. METHODS: The authors retrospectively reviewed the cases of 87 patients who underwent upper blepharoplasty performed by a single clinician at their institute between April of 2018 and June of 2020. Patients with routine outpatient photographs taken before and after surgery were enrolled in the study. ImageJ was used to measure brow height at eight points in each eye. Brow height changes were compared among the three groups. RESULTS: Routine photographs were available for 68 patients (133 eyes). Thirty-nine patients underwent internal browpexy (78 eyes), nine underwent external browpexy (17 eyes), and 20 underwent upper eyelid skin excisions (38 eyes). Three months after surgery, significant elevation was noted on the lateral side of the brow in the internal browpexy group and across the whole brow in the external browpexy group. In the upper eyelid skin excision group, whole brow ptosis was observed. Brow-lift outcomes were better in the external than in the internal browpexy group, whereas both browpexy groups showed better outcomes than the upper eyelid skin excision group. CONCLUSIONS: Within 3 months of surgery, both internal and external browpexy provided significant brow-lift effects, preventing brow ptosis caused by blepharoplasty with skin excision. External browpexy had better brow-lift outcomes than did internal browpexy. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Carbon Dioxide Laser Transconjunctival Lower Blepharoplasty: An Objective and Quantitative Comparison to Monopolar Electrosurgery.

BACKGROUND: The ability to simultaneously cut and perform hemostasis with low lateral thermal injury makes carbon dioxide laser a useful tool in blepharoplasty. Monopolar electrosurgery is another commonly used cutting tool that improves the quality of hemostasis and cutting speed. This study aimed to objectively and quantitatively assess the intraoperative and postoperative outcomes of transconjunctival lower blepharoplasty using either a carbon dioxide laser or monopolar electrosurgery. METHODS: Between August of 2018 and March of 2021, 78 patients who underwent transconjunctival lower blepharoplasty were assigned randomly to the carbon dioxide laser group or the monopolar electrosurgery group. Patient-related parameters were recorded. Periorbital bruises were assessed objectively and quantitatively using the ecchymosis evaluation score. Analyses were performed using the independent sample t test, the Mann-Whitney U test, the chi-square test, and the Fisher exact test. RESULTS: Sex, age, local anesthesia injection volume, and fat removal volume were not different between the groups. Patients' subjective intraoperative heat sensation was significantly higher in the monopolar electrosurgery group than in the carbon dioxide laser group. The carbon dioxide laser group had a significantly lower incidence of postoperative chemosis than the monopolar electrosurgery group. All patients had uncomplicated wound healing, except three (7.89%) patients in the monopolar electrosurgery group who developed conjunctival granuloma. Operation time, intraoperative pain sensation, intraoperative blood pressure, postoperative ecchymosis, conjunctivitis, and patients' aesthetic satisfaction did not differ between the groups. CONCLUSION: The authors' findings revealed that carbon dioxide laser is a useful technique for reducing intraoperative heat sensation and postoperative chemosis and may prevent conjunctival wound complications. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Biophotonic Effects of Low-Level Laser Therapy on Adipose-Derived Stem Cells for Soft Tissue Deficiency.

PURPOSES: The objectives of this study are to use diode lasers for low-level laser therapy (LLLT) and to assess its applicability and effects in adipose-derived stem cell (ADSC) growth processes. METHODS: Studies were conducted on the diode laser with wavelengths of 622.7, 527.1, and 467.3 nm. The mechanism of action of LLL illumination was studied on ADSCs, isolated from human tissue, and then cultured by examining different wavelengths to determine the relevant light parameters for optimal responses. We used enzyme-linked immunosorbent assay and real-time polymerase chain to determine the percentages of fibroblast-mediated procollagen type 1 and matrix metallopeptidase 1 (MMP-1), MMP-2, and MMP-9 production at different wavelengths. The levels of lactate dehydrogenase produced by ADSCs after LLL illumination were assessed as well. Clinical results from 20 patients treated for soft tissue deficiency were collected for assessment of ADSC-assisted lipotransfer. RESULTS: Low-level laser (622.7 nm) illumination on cell cultures in vitro increased ADSCs proliferation, type 1 procollagen expression, collagen production, as well as MMP-1, MMP-2, and MMP-9 relative expression. Statistical analysis demonstrated a significant difference in red light (622.7 nm) versus green light (527.1 nm) and blue light (467.3 nm, P < 0.05). No significant differences were noted between the effects of green and blue lights. In clinical application, all patients attained significant improvement with treatment in the final outcome assessment after 6 months. CONCLUSIONS: Low-level laser illumination may affect ADSCs growth processes and ADSC-assisted lipotransfer for soft tissue deformity, scar treatment, wound healing, and other reconstructive surgery.

The Relationship Between Inter-canthal Distance and Implant Height in Asian Rhinoplasty.

Augmentation rhinoplasty is one of the top three anesthetic surgeries in Asia. I-shaped silicone-polytetrafluoroethylene composite implants are feasible for both primary and secondary augmentation rhinoplasty in Asians. This series was to analyze and evaluated the effect of the rhinoplasty to the intercanthal distance and to compare the height of the implantation with those differences in ICD before and after rhinoplasty. We retrospectively reviewed data from a single medical center via a single surgeon (Hsiao YC), at Chang Gung Memorial Hospital, between 2011 and 2017 with follow-up through 2018. There were 223 patients who received augmentation rhinoplasty with an I-shaped composite silicone-polytetrafluoroethylene ePTFE-lined silicone dorsal composite implant (Implantech, Ventura, CA) with a glabellar component (chimeric technique) or without a glabellar component. There were 169 patients with the height of the I-shaped composite implant over 3 mm, and 15 patients were less than 3 mm. There was no distribution significance between two groups even in gender, age, type of surgery, or indication. The paired difference of ICD/IPD ratio was statistically significant in the group with the height of composite implant over 3 mm (1.04% ± 0.11, p < 0.005, 95%). The normalized ratio of the ICD to IPD is estimated to decrease by 1-2%. Appropriate candidates including those with a wide ICD should be informed about these data during preoperative decision-making.Level of Evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Positive signs on physical examination are not always indications for endotracheal tube intubation in patients with facial burn.

BACKGROUND: After clinical evaluation in the emergency department (ED), facial burn patients are usually intubated to protect their airways. However, the possibility of unnecessary intubation or delayed intubation after admission exists. Objective criteria for the evaluation of inhalation injury and the need for airway protection in facial burn patients are needed. METHODS: Facial burn patients between January 2013 and May 2016 were reviewed. Patients who were and were not intubated in the ED were compared. All the intubated patients received routine bronchoscopy and laboratory tests to evaluate whether they had inhalation injuries. The patients with and without confirmed inhalation injuries were compared. Multivariate logistic regression analysis was used to identify the independent risk factors for inhalation injuries in the facial burn patients. The reasons for intubation in the patients without inhalation injuries were also investigated. RESULTS: During the study period, 121 patients were intubated in the ED among a total of 335 facial burn patients. Only 73 (60.3%) patients were later confirmed to have inhalation injuries on bronchoscopy. The comparison between the patients with and without inhalation injuries showed that shortness of breath (odds ratio = 3.376, p = 0.027) and high total body surface area (TBSA) (odds ratio = 1.038, p = 0.001) were independent risk factors for inhalation injury. Other physical signs (e.g., hoarseness, burned nostril hair, etc.), laboratory examinations and chest X-ray findings were not predictive of inhalation injury in facial burn patients. All the patients with a TBSA over 60% were intubated in the ED even if they did not have inhalation injuries. CONCLUSIONS: In the management of facial burn patients, positive signs on conventional physical examinations may not always be predictive of inhalation injury and the need for endotracheal tube intubation in the ED. More attention should be given to facial burn patients with shortness of breath and a high TBSA. Airway protection is needed in facial burn patients without inhalation injuries because of their associated injuries and treatments.

Simultaneous Paramedian Pedicle Forehead and Free Medial Sural Artery Perforator Flap Reconstruction of a Composite Nasal Defect: A Case Report.

BACKGROUND: Extensive nasal defects after resection of a malignancy are a challenge for all plastic surgeons. Nasal composite tissue defects have to be reconstructed with multiple staging surgeries. A paramedian pedicled forehead flap and free tissue transfer can be used for lining and skin replacement at different stages. In general, free tissue transfer is used for nasal lining and nasal floor reconstruction at the preliminary stage. Several weeks or months later, a paramedian pedicled forehead flap is used to replace the skin. Intermediate stages will also be necessary, and therefore the total therapeutic course is very long. AIM AND OBJECTIVES: The aim of this study was to report the simultaneous use of a paramedian pedicle forehead flap and a free medial sural artery perforator (MSAP) flap to reconstruct a composite nasal defect after wide excision of squamous cell carcinoma. PATIENT: In 2015, a 57-year-old woman with squamous cell carcinoma of the nose underwent tumor wide excision, which caused a composite defect involving multiple nasal subunits (partial tip, dorsum, right sidewall, right ala subunits). She received both a pedicled paramedian forehead flap to replace the skin and an MSAP flap to reconstruct the lining during the same procedure. At the intermediate stage 4 weeks later, the pedicled forehead flap was elevated and tailored. Then, a further 4 weeks later, flap division was performed. RESULTS: The patient received a total of 3 surgical procedures to reconstruct the composite defects of multiple nasal subunits. Nasal reconstruction was done within 2 months. The patient was satisfied with the aesthetic appearance and functional outcome. CONCLUSIONS: Simultaneous paramedian pedicle forehead and free flap reconstruction can provide an effective solution for composite nasal defects. Satisfactory functional and aesthetic results can be achieved.

Upper Margin of the Forehead Flap and Its Correlation With Aesthetic Results in Nasal Reconstruction in Fitzpatrick Skin Type III and IV Chinese.

BACKGROUND: The forehead flap is one of the most commonly used methods for nose reconstruction. OBJECTIVE: To determine the ideal upper margin of the flap in nasal reconstruction and its correlation with aesthetic results. METHODS: From April 2013 to September 2017, 40 patients underwent nasal reconstruction involving the dorsum with a forehead flap. The authors hypothesized 5fdifferent levels as the position to place the upper margin of the forehead flap: (1) glabella, (2) level of the upper eyelid, (3) intercanthal line, (4) horizontal line between the keystone and intercanthal line, and (5) the keystone. Then they photoshopped the upper margins of the forehead flap at 5 different levels and designed a questionnaire. Nasal reconstructive plastic surgeons, medical practitioners, and people without medical backgrounds chose the most aesthetically pleasing photograph for every patient. RESULTS: The questionnaire showed that the most aesthetically pleasing positions were located at glabella (n = 0), level of upper eyelid (n = 9), intercanthal line (n = 24), the line between keystone and intercanthal line (n = 6), and keystone (n = 1). CONCLUSION: The authors suggest placing the upper margin of the forehead flap at the level of the intercanthal line in nasal reconstruction involving the dorsum to achieve the best aesthetic results.

Simultaneous Fat Injection for Nasal Contouring in Orthognathic Patients.

BACKGROUND: Augmentation rhinoplasty with autologous fat grafting is a useful procedure to meet the demand for facial harmonization in the Asian population. We used this procedure during orthognathic surgery to address inadequate dorsum projection. This prospective study was conducted to determine the fat retention rate in patients undergoing simultaneous autologous fat injection augmentation rhinoplasty and orthognathic surgery. METHODS: Nineteen patients were treated with simultaneous bimaxillary orthognathic surgery and autologous fat grafting of the nasal dorsum and tip. The paired t test was used to compare the nasal volumes before and at least 6 months after surgery measured by 3-dimensional computer tomography scans. All measurements were performed twice by the same evaluator at least 2 weeks apart for intrarater consistency. RESULTS: Seventeen patients completed the study. The volume means before and after surgery were 22.3 ± 4.6 cm3 and 23.3 ± 4.7 cm3, respectively, with a mean difference of 1.0 ± 0.3 cm3 (P < .001). The mean retention rate was calculated to be 50.5% ± 7.0% (range: 40.5%-64.7%). Intrarater consistency was high with a Cronbach α of .97 (P < .001) and .98 (P < .001), respectively. CONCLUSION: This prospective study provides objective graft retention measurements for fat injection augmentation rhinoplasty combined with orthognathic surgery. All patients were satisfied with the results and no complications or additional morbidity was noted in the postoperative course. We consider this procedure to be a safe, reliable, and powerful adjunct to improve the aesthetic results of orthognathic surgery.

Selection of Site for Harvesting Dermal Grafts as a Spacer in the Correction of Eyelid Retraction.

BACKGROUND: Several materials can serve as spacer grafts in the repair of retracted lower eyelids. However, previous studies did not reveal any of these to be superior to the others. From our perspective, autologous dermal grafts are ideal because they are biologically compatible and abundantly available. However, the absorption of these grafts is an issue, and the thickness of the dermal grafts is crucial. We evaluated the dermal thickness at five potential donor sites using ultrasonography and the efficacy and safety of the posterior neck dermis as a spacer graft in the correction of retracted lower eyelids. METHODS: In 20 healthy volunteers, the dermal thickness was assessed using ultrasonography and compared between the posterior neck, upper arm, inguinal area, intergluteal cleft, and gluteal sulcus. Between January 2018 and June 2021, eight retracted lower eyelids in eight patients were repaired using a posterior neck dermal graft. The surgical results of these grafts were also evaluated. RESULTS: The mean age of the volunteers was 37.8 years, and the mean body mass index was 24.45 kg/m2. The intergluteal cleft provided the thickest dermis followed by the posterior neck and gluteal sulcus, which were not significantly different. The upper arm and inguinal area had the thinnest dermis without significant differences between them. The mean marginal reflex distance 2/iris ratio decreased by 0.15 (p=0.008). The mean cosmetic score (0-10) for evaluation of lower eyelid reconstruction increased by 3.38 (p=0.011). The mean Vancouver Scar Scale score for evaluation of donor site scarring was 3.21. CONCLUSIONS: Although the posterior neck dermis is the second thickest, it is an ideal spacer graft in the reconstruction of retracted lower eyelids. Adequate thickness, uncomplicated methods, and a closer surgical field are its advantages. Additionally, donor site morbidity is minimal, with acceptable scarring. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .