Revisiting the "Puffed Cheek" Technique: Advantages, Fallacies, and Potential Solutions.

The "puffed cheek" technique is routinely performed during CT neck studies in patients with suspected oral cavity cancers. The insufflation of air within the oral vestibule helps in the detection of small buccal mucosal lesions, with better delineation of lesion origin, depth, and extent of spread. The pitfalls associated with this technique are often underrecognized and poorly understood. They can mimic actual lesions, forfeiting the technique's primary purpose. This review provides an overview of the puffed cheek technique and its associated pitfalls. These pitfalls include pneumoparotid, soft palate elevation that resembles a nasopharyngeal mass, various tongue displacements or distortions that obscure tongue lesions or mimic them, sublingual gland herniation, an apparent exacerbation of the airway edema, vocal cord adduction that hinders glottic evaluation, and false indications of osteochondronecrosis in laryngeal cartilage. Most stem from a common underlying mechanism of unintentional Valsalva maneuver engaged in by the patient while trying to perform a puffed cheek, creating a closed air column under positive pressure with resultant surrounding soft-tissue displacement. These pitfalls can thus be avoided by instructing the patient to maintain continuous nasal breathing while puffing out their cheek during image acquisition, preventing the formation of the closed air column. Keywords: CT, Head/Neck © RSNA, 2024.

Morphological Evaluation and Immunohistochemical Analysis of the Reparative Potential of the Buccal Fat Pad.

Background and Objectives: There are many surgical techniques for oroantral communication treatment, one of which is the buccal fat pad. Of particular interest is the high reparative potential of the buccal fat pad, which may be contributed to by the presence of mesenchymal stem cells. The purpose of this work is to evaluate the reparative potential of BFP cells using morphological and immunohistochemical examination. Materials and Methods: 30 BFP samples were provided by the Clinic of Maxillofacial and Plastic Surgery of the Russian University of Medicine (Moscow, Russia) from 28 patients. Morphological examination of 30 BFP samples was performed at the Institute of Clinical Morphology and Digital Pathology of Sechenov University. Hematoxylin-eosin, Masson trichrome staining and immunohistochemical examination were performed to detect MSCs using primary antibodies CD133, CD44 and CD10. Results: During staining with hematoxylin-eosin and Masson's trichrome, we detected adipocytes of white adipose tissue united into lobules separated by connective tissue layers, a large number of vessels of different calibers, as well as the general capsule of BFP. The thin connective tissue layers contained neurovascular bundles. Statistical processing of the results of the IHC examination of the samples using the Mann-Whitney criterion revealed that the total number of samples in which the expression of CD44, CD10 and CD133 antigens was confirmed was statistically significantly higher than the number of samples where the expression was not detected (p < 0.05). Conclusions: During the morphological study of the BFP samples, we revealed statistically significant signs of MSCs presence (p < 0.05), including in the brown fat tissue, which proves the high reparative potential of this type of tissue and can make the BFP a choice option among other autogenous donor materials when eliminating OAC and other surgical interventions in the maxillofacial region.

Trivial trauma to the cheek: significant complications in the chest.

A man in his 30s presented to the emergency department with a history of injury to the face with a crowbar. He was discharged from the department, in the absence of any facial bone fractures and given normal examination findings, except for a puncture wound on the mentum. The patient then re-presented within 24 hours with extensive cervical emphysema extending into the mediastinal cavity.He was referred to ear, nose and throat team for further management. CT scan of the chest and neck showed extensive surgical emphysema and a pneumomediastinum. The patient was managed conservatively and recovered well with no significant sequelae.Even in the absence of facial bone fractures, it is imperative to understand the force of impact which should prompt a consideration of imaging of the chest. Appropriate advice regarding avoidance of Valsalva manoeuvres will help prevent extensive propagation of air through the fascial planes that can result in a pneumomediastinum.

Efficacy and safety of fractional micro-needling radiofrequency for the treatment of enlarged pores on the cheeks of a chinese cohort: a retrospective study.

To explore the efficacy and safety of fractional micro-needling radiofrequency (FMRF) in the treatment of enlarged pores on the cheek in a Chinese cohort. Patients with enlarged facial pores who underwent FMRF between January 2020 and December 2022 were included in this study. Blinded clinical assessments were performed by two independent dermatologists using a six-grade photographic enlarged pore scale and a quartile grading scale. Patients were asked to rate the degree of pain related to treatment on a visual analog scale (VAS), with scores ranging from 0 (no pain) to 10 (worst pain ever). A paired t-test was used to analyze the six-grade photographic enlarged pore scores. A total of 22 patients received three consecutive sessions of FMRF treatment, with intervals of 1-3 months, and underwent follow-up as scheduled. The mean six-grade photographic enlarged score was 3.55 ± 0.96 at baseline, while the score decreased significantly to 2.59 ± 0.59 after three treatment sessions (P < 0.05). The improvement score of the patients, assessed by two independent dermatologists, was 2.31 ± 0.71, according to the quartile grading scale. The mean VAS score was 6.42 ± 1.44. FMRF is effective and safe for the treatment of enlarged facial pores after three sessions.

High-frequency Ultrasound in the Assessment before and after Applying HArmonyCa™.

AIM: To describe a clinical case of ultrasound (US) used to evaluate, before, post-immediately, and after 4 months, the facial application of a volumizing and biostimulating substance. BACKGROUND: Detecting the behavior of injected filler materials with high-frequency US-guided application is the future of natural facial rejuvenation with more predictable and satisfactory results. TECHNIQUE: A patient indicated for orofacial harmonization (OFH) procedures through volumizing and biostimulating material application was invited to participate. The technique was performed by applying HArmonyCa™ (Allergan Aesthetics, Irvine, CA, USA) in the gonial, preauricular, and bilateral lateral zygomatic angle regions. The first evaluations used the US images before and after product application with a Logiq e® high-frequency US device (GE Healthcare, Chicago, IL, USA) with a probe/linear transducer of 18 MHz. About 4 months after the procedure, a new assessment with the same initial acquisition pattern was performed. The first evaluation showed normal-looking anatomical structures without the esthetic material. Immediately after the procedure and 4 months later, the assessments presented semi-permanent esthetic fillers as dispersed lobulated hyperechogenic areas with a cloud aspect. CONCLUSION: High-frequency US was efficient in the static evaluation of HArmonyCa™ behavior on the facial skin. CLINICAL SIGNIFICANCE: The US-guided application of injectable products in specific areas has minimal side effects and contributes to more predictable and satisfactory results. How to cite this article: Gouveia RSA, Tostes LLL, Bezerra FV, et al. High-frequency Ultrasound in the Assessment before and after Applying HArmonyCa™. J Contemp Dent Pract 2024;25(1):10-14.

Use of the pedicle of previously harvested pectoral myocutaneous flap as a recipient for free flaps in head and neck reconstruction.

INTRODUCTION: The pectoral myocutaneous flap (PMF) is a workhorse regional reconstructive option for head and neck defects. It is commonly used for primary reconstructions due to its advantages or as a life-boat flap in the salvage of failed reconstructions of free flaps. However, it also has intrinsic drawbacks, such as perfusion problems and partial or complete flap loss. Although there are many studies about the advantages and use of PMF in the literature, the number of studies about salvage of this workhorse flap is inadequate. We aimed to present the use of the pedicle of previously performed PMF as a recipient for free flaps in head and neck reconstruction. METHODS: Between January 2022 and August 2023, 10 free flaps were used in nine patients (three females and six males) who had previously undergone head and neck reconstruction with PMF. The age of the patients ranged from 54 to 74 years. Seven out of the nine PMFs were previously performed by different surgical teams. Squamous cell carcinoma (SCC) was the reason for primary surgeries in all patients and the PMFs were used for right lower lip and right submandibular defect, left lower lip and mentum defect, lower lip defect, right lower lip and right submandibular defect, right retromolar trigone defect, right buccal defect, left anterolateral esophageal defect, right retromolar trigone defect and left anterolateral pharyngoesophageal defect reconstructions. The problems were partial skin island necrosis and wound dehiscence in six patients and total skin necrosis in three patients. The partial skin island necroses already showed that the pedicles were unproblematic. For patients with total skin island necrosis the muscle stalks so the pedicles were also unproblematic which were confirmed by physical examination and Doppler device. After complications, the finally defects were located in the lower lip, left lower lip and mentum, right lower lip and right submandibular area, left anterolateral esophageal area and left neck, right buccal area, right retromolar trigon, left anterolateral pharyngoesophageal fistula and left neck. The sizes of the defects were between 3 × 4 cm and 11 × 17 cm. For all patients, the pedicle of the previously harvested PMF was used as a recipient for free flaps. Since the PMF was flipped over the clavicula for the reconstruction previously, the pedicle was so close to skin or skin graft which was used for coverage of the muscle stalk. The Doppler device was used first over the clavicle where the PMF was flipped for vessel identification. After marking the vessels, a vertical zigzag incision was made on the skin or skin graft. The perivascular fatty tissue and the pedicle were encountered with minimal dissection by the guidance of Doppler. After meticulous microscopic dissection, the pedicle of PMF was prepared for anastomoses as usual. Six radial forearm free flap (RFFF) and four anterolateral thigh flap (ALT) flaps were used in the head and neck reconstructions for the nine patients. RESULTS: The sizes of the flaps were between 4 × 5 cm and 12 × 17 cm. The diameters of the recipient arteries were between 0.9 and 1.2 mm. Recipient veins were approximately the same diameter as the arteries. In one patient, two vein grafts were used for lengthening both the artery and vein to reach recipient vessels. End-to-end anastomoses without vein grafts were performed in the remaining patients. One arterial thrombosis that manifested on the first postoperative day was salvaged successfully. Hematoma was seen in two patients and wound dehiscence was seen in three patients. There was no partial or total flap necrosis and all flaps survived. The follow-up period ranged from 2 to 12 months. Despite successful reconstructions, two patients died during the follow-up period due to unrelated conditions. Functional results were acceptable in the remaining patients. CONCLUSION: The pedicle of previously used pectoral myocutaneous flaps may be a useful alternative option as the recipient for free flaps in head and neck reconstruction.

Melanotic Neuroectodermal Tumor of Infancy: A Case Image.

Melanotic neuroectodermal tumor of infancy (MNTI) is a rare benign neoplasm that can be mistaken for malignancies due to its unfamiliarity among clinicians and aggressive clinical appearance. We herein contributed by reporting an additional case of MNTI characterized by an extensive extraoral protrusion in a 2-month-old infant. The lesion involved the anterior maxilla, cheek, and infraorbital region, resulting the displacement of the nose to the contralateral side, and measuring approximately 10 cm in size. Surgical resection of the lesion was performed. After a 6-month follow-up, the patient has shown no evidence of recurrence. The rapid growth and aggressive behavior of MNTI emphasize the importance of an early diagnosis and prompt intervention in order to achieve favorable outcomes.

Characterization of the collagen network of human cheek skin using ultrasonic microscopy.

Dermal collagen is the most abundant component of human skin and has a network structure that regulates the mechanical properties of the skin. Therefore, non-invasive characterization of the collagen network would be beneficial for the evaluation of skin conditions. The microscopic substructures of the network, which are individual bundles and fibers, have been optically investigated. However, the macroscopic structure of the collagen network has not been assessed. To evaluate the dermal collagen network, we developed two new indicators, volume filling factor (VFF) and collagen fiber texture (CFT), to analyze three-dimensional echo intensity maps of high-frequency ultrasonic microscopy. By identifying the difference in the elastic modulus components of the dermal layer of facial skin, the density and texture of the collagen network were characterized using VFF and CFT, respectively. These new indicators revealed that the density decreased and the texture became fine with facial age. This study demonstrates that ultrasonic microscopy is useful for investigating skin conditions, paving the way for diagnostic applications in dermatology and aesthetic medicine.

Observation on efficacy and underlying mechanism of cheek acupuncture on ovulation induction for infertile women with PCOS: Case series.

RATIONALE: Polycystic ovary syndrome (PCOS) is the most common reproductive endocrine disorder among women of childbearing age and is the primary cause of anovulatory infertility, accounting for 70% to 80% of cases. Ovulation induction is the main treatment approach for infertile patients with PCOS. Commonly utilized medications for this purpose are clomiphene citrate (CC) and letrozole (LE). Clomiphene citrate administration results in an ovulation rate ranging from 60% to 85%, while the pregnancy rate is limited to 35% to 40%, and a further reduction is observed in live birth rates. Letrozole demonstrates a slightly higher pregnancy rate and live birth rate compared to clomiphene citrate, although challenges persist in terms of longer stimulation cycles, multiple pregnancies, and the risk of ovarian hyperstimulation syndrome (OHSS). Clinical reports indicate that acupuncture therapy shows promising efficacy in treating patients with PCOS-related infertility, despite a partially unclear understanding of its underlying mechanisms. PATIENT CONCERNS: In this study, one patient did not achieve pregnancy despite more than a year of ovulation induction using clomiphene citrate and letrozole. However, after 3 months of receiving cheek acupuncture therapy, she successfully conceived and gave birth to a liveborn baby. Another patient achieved natural conception and live birth after 2 months of exclusive cheek acupuncture therapy. DIAGNOSIS: PCOS. INTERVENTIONS: Cheek acupuncture therapy. OUTCOMES: Both of them successfully conceived and gave birth to a liveborn baby. LESSONS: These findings suggest that cheek acupuncture therapy can effectively stimulate follicle development and ovulation, potentially improving endometrial receptivity. According to holographic theory, there is a biologically holographic model within the cheek region that shares a homology with the human body structure. This model provides an explanation for the regulatory effects of cheek acupuncture point stimulation on the Hypothalamic-Pituitary-Ovarian axis (HPO), which subsequently influences follicle development and ovulation in patients. Consequently, when cheek acupuncture therapy is applied alone or in combination with ovulation induction medication, patients have the ability to achieve successful pregnancy and experience a smooth delivery.

Morphofunctional and histological patterns of blood vessels in the superficial cervicofacial musculoaponeurotic system in midlateral face regions.

OBJECTIVE: The superficial cervicofacial musculoaponeurotic system (SMAS) is a complex network formed by mimic muscles and conjunctive tissue of the superficial fascia of the face.This study aimed to introduce new anatomofunctional data on the importance of the trans-SMAS distribution pattern of the skin microperfusion of the face and to underline the role of SMAS in maintaining the homeostasis of the vascular network that crosses it. Considering the fibrous and muscular matrix of the SMAS, using COLIII and MyoH2 antibodies, together with endothelial immunohistochemistry(IHC)intercellular adhesion molecule 2 marker, we determined the correlation of these structures and their interaction. METHODS: This study included 33donors of SMAS tissues, which have been stained withregular hematoxylin and eosin (HE), and three different IHC markers have been used (collagen III, muscular tissue, and blood vessels). The samples were collected from parotid, masseteric, jugal, and zygomatic regions. Magnetic resonance angiography was used to identify the main vascular sources of the midlateral regions of the face of another 47 patients. RESULTS: Significant differences in topographic arrangement, density, and relations of the microsopic vasculature were observed between each of the four regions. Major differences were identified between the role of SMAS in each of these regions, from the parotid capsule to masseteric fascia, transition mobile part, and attaching manners in the zygomatic subunit. CONCLUSIONS: Blood vessel topography must be related with the surrounding conjunctive and muscular tissue, especially regarding facial SMAS. Intrinsic relations between these three components of the SMAS and nervous fibers can provide us important hints on the functionality of the whole system.

Revisiting the Anchor Flap for Nasal Defects: How It Fits in the Current Reconstruction Paradigm.

The anchor or Peng flap, first described in 1987, has not been comprehensively discussed in the literature since 2008. The anchor flap is worth revisiting as a useful advancement-rotation flap for medium-sized defects of the distal nose. More recent variations to the flap design incorporate medial cheek advancement and allow for versatility in its use for wide defects of the nasal tip, supratip, and dorsum. The anchor flap is a suitable reconstructive option for defects for which the bilobed/trilobed flap, dorsal nasal rotation flap, or interpolated flap would be considered. We review various designs of the anchor flap and discuss how it can be considered in the modern reconstructive paradigm.  J Drugs Dermatol. 2024;23(1):1271-1273.     doi:10.36849/JDD.7532.

Effectiveness and Safety of Sculptra Poly-L-Lactic Acid Injectable Implant in the Correction of Cheek Wrinkles.

BACKGROUND: The current study evaluated the effectiveness and safety of Sculptra injectable poly-L-lactic acid (PLLA-SCA) treatment in correcting cheek wrinkles compared with a no-treatment control. METHODS: Male/female immune-competent adults (aged >21 years) with moderate/severe cheek wrinkles, graded using the Galderma Cheek Wrinkle Scale (GCWS) at rest, were randomized 2:1 to receive PLLA-SCA injections (150 mg; 8 mL reconstitution in sterile water for injection) + 1 mL lidocaine hydrochloride (2%), administered immediately after reconstitution, or no treatment (control). Up to 3 additional treatments were allowed at monthly intervals, and follow-up was at months 7, 9, and 12. The primary endpoint was 1-grade or greater improvement in GCWS at rest for both cheeks at month 12. RESULTS: GCWS at rest responder rate was significantly higher with PLLA-SCA treatment versus the no-treatment control at months 7 (66.2% versus 38.6%; P=0.0043), 9 (70.6% versus 31.1%; P<0.0001), and 12 (71.6% versus 26.1%; P<0.0001). Treating investigators reported improvements in skin radiance (>95%), tighter appearance (>88%), and jawline contour (>85%). PLLA-SCA recipients reported high satisfaction levels regarding improvements in skin radiance (90% or greater), sagging (84% or greater), and firmness (91% or greater) as well as natural-looking results (85% or greater) and a desire for repeat treatment (84% or greater). Treatment-related adverse events were mostly mild in severity with no serious events related to PLLA-SCA injections. CONCLUSION: Injectable PLLA-SCA treatments were well tolerated and significantly reduced the severity of moderate/severe cheek lines and wrinkles, while improving skin quality. Effectiveness was durable over the 12-month study period with high subject-reported satisfaction, natural-looking appearance, and enthusiasm for repeat treatments. CLINICALTRIALS: gov registry number: NCT04124692J Drugs Dermatol. 2024;23(1):1297-1305.        doi:10.36849/JDD.7729.

Treatment for benign skin lesion in zygomatic-infraorbital region by the expanded multi-lobe cervicofacial advancement rotation flap in pediatric patients.

PURPOSE: Benign skin lesions in zygomatic-infraorbital regions severely influence pediatric patients' appearance as well as mental health. Treatments are difficult for the high requirements of patients' guardians in both function and aesthetics. The present study aims to introduce a surgical method, Expanded Multi-Lobe Cervicofacial Flap, which combines the advantages of the classical cervicofacial advancement rotation flap and the tissue expansion technique. METHODS: A total of 21 pediatric patients were enrolled. The treatment process included 2 stages: implantation of the skin tissue expander and flap transfer. The excessive skin created by tissue expansion extended the coverage area of the multi-lobe flap. RESULTS: In this retrospective study, follow-up periods were all more than 12 months (20.8 ± 6.7). In the last follow-ups, the flaps were all in good condition, and No facial organ displacement was observed. The patients' guardians were satisfied with the outcomes. CONCLUSIONS: Using the expanded multi-lobe cervicofacial flap for the zygomatic-infraorbital benign skin lesion repair is effective, and this method is especially applicable to the pediatric population.

Use of virtual monoenergetic images for reduction of extensive dental implant associated artifacts in photon-counting detector CT.

Aim of this study was to assess the impact of virtual monoenergetic images (VMI) on dental implant artifacts in photon-counting detector computed tomography (PCD-CT) compared to standard reconstructed polychromatic images (PI). 30 scans with extensive (≥ 5 dental implants) dental implant-associated artifacts were retrospectively analyzed. Scans were acquired during clinical routine on a PCD-CT. VMI were reconstructed for 100-190 keV (10 keV steps) and compared to PI. Artifact extent and assessment of adjacent soft tissue were rated using a 5-point Likert grading scale for qualitative assessment. Quantitative assessment was performed using ROIs in most pronounced hypodense and hyperdense artifacts, artifact-impaired soft tissue, artifact-free fat and muscle tissue. A corrected attenuation was calculated as difference between artifact-impaired tissue and tissue without artifacts. Qualitative assessment of soft palate and cheeks improved for all VMI compared to PI (Median PI: 1 (Range: 1-3) and 1 (1-3); e.g. VMI130 keV 2 (1-5); p < 0.0001 and 2 (1-4); p < 0.0001). In quantitative assessment, VMI130 keV showed best results with a corrected attenuation closest to 0 (PI: 30.48 ± 98.16; VMI130 keV: - 0.55 ± 73.38; p = 0.0026). Overall, photon-counting deducted VMI reduce the extent of dental implant-associated artifacts. VMI of 130 keV showed best results and are recommended to support head and neck CT scans.

Age-related changes in the fiber structure around adipocytes in the subcutaneous fat layer and their association with skin viscoelasticity.

OBJECTIVE: Age-related changes in the fiber structure around adipocytes were investigated via scanning electron microscopy (SEM) of excised skin tissues. In addition, the viscoelasticity of the subcutaneous fat layer was evaluated via elastography, and the association between the fiber structure and the viscoelastic properties was assessed. METHODS: Skin tissues excised from the facial cheek area were used. Then, SEM images of these tissues were obtained. The thickness and quantity of the fibers around adipocytes were assessed using a 5-point scale. The score was used to grade 18 tissue samples. Moreover, the viscoelasticity of the subcutaneous fat layer in the same samples was evaluated via ultrasound elastography. RESULTS: Based on the SEM image score, an association was observed between the fiber status score and age, thereby indicating a tendency toward age-related fibrosis. Fiber structures with high scores, which indicate fibrosis, had a significantly lower viscoelasticity based on ultrasound elastography. CONCLUSION: The thickness and quantity of fibrous structures around adipocytes in the subcutaneous fat layer increase with age, and these changes can be associated with decreased viscoelasticity in the subcutaneous fat layer.

The Buried Guide Suture Method: A Novel Technique to Correct Traumatic Facial Dimples.

SUMMARY: Facial dimpling, frequently occurring after blunt trauma, presents as soft-tissue depression, which is particularly apparent during facial expression. The displacement of subcutaneous tissue can be detected and measured by high-frequency ultrasound. Limited surgical methods have been applied in these closed-injury cases. Repositioning the subcutaneous tissue without incisions on unscarred skin is challenging. The authors propose a novel three-dimensional technique to suture and fix the subcutaneous tissue at a distance through a concealed incision. The buried guide suture method was used in the treatment of 22 patients with traumatic facial dimples on the cheek. All patients showed great improvement in their depressed deformity with minor complications. This technique provides an option to correct soft-tissue depression without leaving a visible scar, especially for mimetic rupture caused by blunt trauma.