Combining Patient-specific Implant With Malar Reduction to Repair Mid-facial Asymmetry Caused by Craniofacial Fractures in Asians.

Mid-facial asymmetry caused by bone defect or deformation resulted from craniofacial fracture was a common secondary complication needed to repair. Patient-specific implant (PSI) designed with the unaffected side as a template is a good choice to repair this kind of facial asymmetry. However, in Asians, the broad and prominent zygomatic bone in unaffected side is not an optimal template, because the oval facial shape was considered as a more attractive appearance in Asian esthetic concept. To repair the mid-facial asymmetry and to improve the facial contour, the authors combined PSI implantation with malar reduction in one-stage surgery. The authors referred the facial proportion index (the optimal ratio of mid and lower face was 1.27) as a basis for preoperative precise design to determine the ideal facial shape of unaffected side, and used mirror image overlay technique with the ideal shape of unaffected side as a template to design the PSI. With this surgical strategy, patients not only can repair facial asymmetry but also can get a more attractive appearance.

Risk factors for postoperative infection after bilateral sagittal split ramus osteotomy: A retrospective analysis.

BACKGROUND: This retrospective clinical study investigated risk factors for infection following bilateral sagittal split ramus osteotomy (BSSO) as orthognathic surgery, including the patients' general condition, local factors, and surgical factors. PATIENTS AND METHODS: The cases of 160 mandibular sites of 80 Japanese patients (26 males, 54 females; mean ± SD age: 25.3 ± 7.7 years, range 16-55 yrs) with a jaw deformity who underwent BSSO orthognathic surgery at our Department of Oral and Maxillofacial Surgery between Jan. 2017 and Dec. 2022 were analyzed. Potential risk factors were classified as clinical predictive variables. Descriptive and univariate statistics were computed. A multivariate analysis was performed with logistic regression. RESULTS: Fifteen mandibular sites (9.4 %) were complicated with postoperative infection. The multivariate analysis revealed significant differences in facial asymmetry (OR 24.0, p = 0.0002) and the amount of mandibular movement (OR 0.664, p = 0.011) between the sites with and without infection. CONCLUSIONS: Among clinical variables, facial asymmetry was the strongest risk factor for post-BSSO infection, followed by the amount of mandibular movement.

The effect of sex and age on facial shape directional asymmetry in adults: A 3D landmarks-based method study.

OBJECTIVES: Facial directional asymmetry research, including age-related changes, is crucial for the evaluation of treatment of craniofacial malformations/trauma in orthodontics, facial surgery and forensic sciences. The aim was to describe facial directional asymmetry (DA) in different age categories of adults using 3D methods. According to our hypothesis, facial shape DA (1) depends on sex; (2) differs among age groups; and (3) has wider variability in older age. MATERIAL AND METHODS: A cross-sectional sample of healthy Czech adults without craniofacial trauma or anomalies consisted of 300 3D facial models (151 females). The age-range in the study was between 20-80 years. The shape asymmetry of 28 3D landmarks was evaluated using geometric morphometrics and multivariate statistics. RESULTS: The manifestation of DA was similar in both sexes and in each age category; however, there were some statistical differences. In contrast to the ideal symmetrical face, the mean asymmetrical faces tended to create a slightly bent "C" shape of the midline. Therefore, the upper face was rotated slightly clockwise and the lower face counter-clockwise. The right eye was located slightly higher, with the nasal tip and mandibular region tilting to the left. Sex differences in facial DA were significant before the age of 40. DA was more significant in the youngest males than in the oldest, while the women's DA did not change. CONCLUSIONS: The DA patterns were similar in both sexes and in all age categories (a slightly bent C shape of the midline); however, some significant local differences between male age groups were found. A significantly more pronounced asymmetry compared to other age groups was found only in the youngest males from 20 to 40 years. Moreover, significant sexual dimorphism of DA rapidly decreased after middle age, likely caused by the same age-related changes of the face during aging.

Changes in Facial Symmetry Following Computer-Assisted Secondary Correction of Craniofacial Fractures.

OBJECTIVE: For patients without dysfunctions, the main purpose of secondary correction for craniofacial fractures is restoring facial symmetry. Computer-assisted surgery techniques including virtual surgical planning and intraoperative navigation provide the help to restore the bony symmetry as much as possible. The authors retrospectively quantitatively analyzed patients who received computer-assisted secondary correction for craniofacial fractures on facial symmetry pre and postoperation. METHODS: This observational study reviewed the medical records of 17 patients requiring secondary correction for craniofacial fractures. Pre and postoperative computed tomography data were used to quantitatively analyze the changes in facial symmetry and enophthalmos. RESULT: All patients enrolled in this study showed mid-facial asymmetry but without dysfunctions except for enophthalmos, and 5 patients had bone defects in the frontal-temporal area. The corrective surgical techniques were different for each patient according to their specific condition. Virtual surgical planning with or without intraoperative navigation was performed for all patients. Compared with the preoperative condition, their facial symmetry was significantly improved. The maximum discrepancy value between the affected side and the mirrored unaffected side decreased from 8.10 ± 2.69 to 3.74 ± 2.02 mm postoperatively, and the mean discrepancy value decreased from 3.58 ± 1.29 to 1.57 ± 0.68 mm. In addition, the Enophthalmos Index decreased from 2.65 to 0.35 mm. CONCLUSION: This observational study objectively demonstrated that computer-assisted secondary correction for craniofacial fractures can significantly improve facial symmetry. And the authors recommend that virtual surgical planning and intraoperative navigation should be a must step in craniofacial fracture correction.

Facial and Cranial Symmetry after One-Piece Fronto-Orbital Advancement with Distraction for Isolated Unilateral Coronal Synostosis.

BACKGROUND: The surgical correction of unilateral coronal synostosis (UCS) aims to achieve longstanding facial and cranial symmetry. The authors hypothesized that endocranial morphology correction achieved by one-piece fronto-orbital advancement with distraction osteogenesis (FODO) could alleviate facial asymmetry because endocranial morphology is thought to be its major determinant. This study aimed to quantitatively analyze the changes in supraorbital and midfacial symmetry after FODO. METHODS: The authors included 27 patients with UCS who underwent FODO between May of 2008 and November of 2019. The supraorbital, midfacial, and orbital symmetry ratios and the endocranial and midface angles were measured using computed tomography images. RESULTS: The mean follow-up period was 3.7 ± 1.9 years. The supraorbital shape became symmetric after FODO; the supraorbital distance ratio changed from 0.88 ± 0.04 to 0.98 ± 0.03 ( P < 0.001). The endocranial angulation improved from 167.5 ± 5.0 degrees to 174.4 ± 3.4 degrees ( P < 0.001) and the midface angulation decreased from 6.6 ± 2.2 degrees to 2.6 ± 1.9 degrees ( P < 0.001). In the long-term follow-up analysis (5.9 years), the endocranial angle experienced a slight relapse (-1.4% ± 0.9%) and supraorbital symmetry experienced a -2.0% ± 3.9% relapse. The midface angle continued to improve over the follow-up periods, but it was not statistically significant ( P = 0.121). CONCLUSIONS: The authors' observations indicate that FODO produced satisfactory outcomes in correcting supraorbital retrusion and midface asymmetry. In addition, FODO may allow anterior cranial base remodeling and help relieve midface and skull base angulation. Therefore, FODO can be a good therapeutic strategy for correcting supraorbital and facial asymmetry in patients with UCS. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

The etiology, clinical features, and treatment options of hemifacial microsomia.

The second most frequent craniomaxillofacial congenital deformity is hemifacial microsomia (HFM). Patients often accompany short mandible, ear dysplasia, facial nerve, and soft tissue dysplasia. The etiology of HFM is not fully understood. To organize the possible up-to-date information on the etiology, craniofacial phenotypes, and therapeutic alternatives in order to fully comprehend the HFM. Reviewing the potential causes, exploring the clinical features of HFM and summarizing the available treatment options. Vascular malformation, Meckel's cartilage abnormalities, and cranial neural crest cells (CNCCs) abnormalities are three potential etiology hypotheses. The commonly used clinical classification for HFM is OMENS, OMENS-plus, and SAT. Other craniofacial anomalies, like dental defects, and zygomatic deformities, are still not precisely documented in the classification. Patients with moderate phenotypes may not need any treatment from infancy through adulthood. However, patients with severe HFM require to undergo multiple surgeries to address facial asymmetries, such as mandibular distraction osteogenesis (MDO), autologous costochondral rib graft (CCG), orthodontic and orthognathic treatment, and facial soft tissue reconstruction. It is anticipated that etiology research will examine the pathogenic mechanism of HFM. A precise treatment for HFM may be possible with thoroughly documented phenotypes and a pathogenic diagnosis.

Facial asymmetry in children with either unilateral lambdoid craniosynostosis or positional posterior plagiocephaly.

BACKGROUND: In unilateral lambdoid craniosynostosis (ULC), the posteriorly situated lambdoid suture of the cranial vault fuses prematurely. Positional posterior plagiocephaly (PPP) causes flattening of the posterior side of the head, either through external forces or through underlying differences in brain development. Both conditions cause occipital flattening of the head, but the aetiology is different. MATERIALS AND METHODS: Eight ULC children were compared with 16 sex- and age-matched PPP children. 3D computer tomography scans of all 24 children were analysed with Dolphin imaging software. The location and symmetry of the temporomandibular joint (Co), and the symmetry of the maxillary anterior nasal spine (ANS) and the mandibular symphysis (Pgn) were analysed. Furthermore, the mandibular bone (Co-Pgn) length, corpus length, ramus height, positional changes in the external acoustic meatus (PoL) and the distance from the orbital margin to the articular fossa were measured. RESULTS: In all eight ULC children, the Co was anteriorly displaced on the affected side compared with the unaffected side. In all ULC and PPP children, the ANS, which is considered the bony maxillary midpoint, was shifted towards the affected side. In all ULC children, the mandibular bone (Co-Pgn) was shorter on the affected side. The PoL was antero-inferiorly positioned in all ULC children on the affected side compared with the unaffected side. CONCLUSIONS: Our results show that both types of posterior plagiocephaly are associated with an asymmetric position of the Co and asymmetry of the mandible and maxilla. Facial asymmetry was more frequently seen in ULC than PPP children.

Micro-computed tomography evaluation of bone architecture in various forms of unilateral condylar hyperplasia.

Condylar hyperplasia is one of the causes of facial asymmetry and malocclusion, characterized by enlargement of the lower jaw due to excessive condyle growth activity. The aim of this study was to use micro-computed tomography (micro-CT) to evaluate the bone architecture of the condylar head and determine whether there are differences between patients with various forms of unilateral condylar hyperplasia (UCH): hemimandibular hyperplasia, elongation, and mixed form. The cohort consisted of 28 patients with a mean age of 21.9 years. All patients underwent surgical treatment (condylar shaving) for active pathological growth activity. The portion of the condylar head removed was imaged by micro-CT and subsequently evaluated. Micro-CT imaging and semiquantitative and quantitative evaluation of the bone structure (percentage bone volume, surface density, trabecular thickness, trabecular separation, degree of anisotropy, and porosity of the subchondral bone) did not reveal significant differences between the individual types of condylar hyperplasia (P > 0.05). There were no significant differences in bone structure between the anterior and posterior portions of the condylar head. No statistically significant differences between individual groups of UCH were found in the micro-CT evaluation of the condylar head bone architecture.

[A case report of the first and second branchial arch syndrome with torticollis].

A 54-month-old female patient presented to the department of ophthalmology with abnormal head posture and facial asymmetry for two years. The patient's facial development was asymmetrical, with the middle 1/3 of the left side shorter than the right side. The left ear is less malformed than the right. There was no obvious abnormality in corneal light reflex and eye movement. Head tilt test ( -). So, paralysis of the superior oblique muscle was excluded. In consultation with the department of maxillofacial surgery, the patient was confirmed as the first and second branchial arch syndrome and torticollis.

Innovation of new clinical concepts in the correction of facial deformity of patients with post-traumatic condylar hyperplasia condition.

Post traumatic condylar hyperplasia condition is an increase in the total number of cells due to increased activity, which exist only as long as the activity or the stimulus is applied. When it is removed, the tissue returns to the normal state; however, a secondary structural alteration in the general architecture due to accompanying degeneration may render a complete return to the normal state impossible. Mandibular asymmetry following condylar injury is poorly documented as a cause of facial asymmetry. leFort1 (low-level fracture) osteotomies and bilateral sagittal mandibular osteotomies, which are comprehensive surgical plans, correct the facial deformity together with the occlusion. An innovation of new clinical concepts has been used in the correction of facial deformity in 11 patients with post-traumatic condylar hyperplasia condition (syndrome) by applying a new modified allo plastic material (subperiosteal acrylic implant).

Multi-Staged Surgeries for Coexisting Facial Asymmetry and Strabismus in Parry-Romberg Syndrome.

ABSTRACT: Parry-Romberg syndrome (PRS) is a rare disorder resulting in disfiguring facial asymmetry. Ocular manifestations can result in complex strabismus. There were limited reports on the treatment of PRS with coexisting strabismus. We present a multistaged surgical approach to manage the facial asymmetry and strabismus.

Evaluation of the relationship between nasal septal deviation and development of facial asymmetry with anthropometric measurements depending on age.

AIM: It was aimed to determine the change of facial asymmetry resulting from nasal septal deviation (SD) depending on age, gender, degree of deviation and the affected area besides the effect of SD on somatotype and craniofacial morphology. MATERIALS AND METHODS: 171 volunteers (90 males, 81 females), 27 individuals aged 9-13, 44 individuals aged 14-18, 44 individuals aged 19-23 and 56 individuals in control group participated in the study conducted in otorhinolaryngology polyclinic.11 photometric, 16 anthropometric measurements were taken from the participants. RESULTS: SD affects facial asymmetry formation, although not statistically significant compared to healthy individuals asymmetry rates (p˃0.05). It was determined that the degree of SD affected asymmetry only between the ages of 14-18 (in adolescence) and the development of asymmetry in all SD patients was not statistically dependent on age and gender (p˃0.05). Photometric measurements demonstrated asymmetries in horizontally-extending parameters of 1/3 middle part of face. There was no statistically significant difference in the cranial anthropometric measurements of the upper and lower 1/3 of the face compared to the control group (p˃0.05). The order of the most asymmetrical parameters is Alare-Zygion, Alare-Subnasale, Cheilion-Gonion, Exocanthion-Cheilion, Midsagittal plane-Zygion, Zygion-Cheilion, Zygion-Gonion, Subalare-Cheilion, Glabella-Exocanthion. In all participants were determined that endomorph somatotype was dominant in female and mesomorph somatotype was dominant in male besides SD did not affect somatotype and somatotype did not alter with age. CONCLUSION: The development of facial asymmetry due to SD is not affected by age and gender furthermore SD does not affect craniofacial asymmetry and somatotype.

Torticollis, Facial Asymmetry, Local Pain, and Barré-Liéou Syndrome in Connection with One-Sided Ponticulus Posticus: A Case Report and Review of the Literature.

BACKGROUND: Ponticulus posticus (PP) occurs frequently and may cause symptom series, including vertebrobasilar insufficiency, migraine, hearing loss, and Barré-Liéou syndrome. However, few studies to date have described surgical treatment of PP. We report a rare case of a patient who suffered from torticollis, facial asymmetry, localized pain, and Barré-Liéou syndrome in connection with PP. We also review the pertinent literature, focusing on surgical treatment for symptoms due to PP. CASE PRESENTATION: A 23-year-old male presented with the chief complaint of continuous significant dizziness to the point of losing consciousness while rotating his head to the right. Plain radiographs and computed tomography (CT) scans of the cervical spine showed a С1 anomaly with the formation of complete PP on the left (dominant) side, with acute-angled, С-shaped kinking of the vertebral artery. Resection of PP via the posterior midline was performed successfully. The patient had satisfactory postoperative relief from localized pain and Barré-Liéou syndrome, but there were no obvious changes in the torticollis and facial asymmetry observed during the 3-month follow-up period. CONCLUSIONS: This case is a rare presentation of torticollis, facial asymmetry, localized pain, and Barré-Liéou syndrome in connection with one-sided complete PP. This tetrad indicates that PP may affect the patient earlier than expected. In such situations, early diagnosis and timely surgical treatment may significantly improve patients' quality of life and avoid the development of torticollis and face asymmetry.

Airway challenges in an adult with hemifacial microsomia along with neglected cleft palate: what to expect?

A female patient in her early 20s, with a known diagnosis of hemifacial microsomia (unilateral microtia and mandibular hypoplasia) accompanied with an unoperated cleft palate, came for an infected mandibular distraction plate removal. The anticipated difficult airway and lack of enough literature about what to expect in such a scenario, along with the psychological impact on the patient, made this case challenging and thought-provoking. Inability to perform the awake tracheal intubation because of the uncooperative patient, along with the difficult fibreoptic owing to narrowed nostrils, offered an extra set of challenges.

Facial Asymmetry in Children With Unilateral Congenital Ptosis.

PURPOSE: To analyze facial asymmetry in children with unilateral congenital ptosis. METHODS: This is a retrospective review of pediatric patients undergoing ptosis repair between January 1, 2017, and December 31, 2020. Charts were reviewed to ensure a diagnosis of idiopathic unilateral congenital ptosis. Sex, age, laterality, margin to reflex distance 1, levator function, and surgical intervention were collected.Clear preoperative photos without head turn were included. Using the ImageJ software ( nih.gov ), landmarks of the periorbital region, midface, and lower face were marked, and measurements between these landmarks were taken.Two-tailed Student t tests were used to compare measurements between the ptotic and non-ptotic sides. Relationships between different measurements on the same side of the face were analyzed using paired-variable regressions. RESULTS: Forty-four patients with unilateral congenital ptosis were included. The surgical management consisted of Mullerectomy in 9 of 44 (20%), levator resection in 15 of 44 (34%), and frontalis suspension in 20 of 44 (46%) patients. The side of the face with blepharoptosis was found to more often have smaller margin to reflex distance 1 ( p < 0.001), smaller margin to reflex distance 2 ( p < 0.005), smaller horizontal palpebral fissure ( p < 0.05), shorter midface height ( p < 0.001), and a more inferiorly displaced lateral canthus (canthal angle, p < 0.001) relative to the non-ptotic side of the face. The mean head tilt of patients with right sided ptosis (1.37° right tilt) was statistically significantly different from those with left sided ptosis (0.85° left tilt; p = 0.04). CONCLUSIONS: In children with unilateral congenital ptosis, the ptotic side of the face was found to be the nondominant side of the face. Patients were also found to have ipsilateral head tilt.

New method to evaluate sequelae of static facial asymmetry in patients with facial palsy using three-dimensional scanning analysis.

OBJECTIVE: During the process of neural recovery after facial palsy, distressing sequelae of static and dynamic facial asymmetry develop in patients with facial palsy. A pronounced nasolabial fold is mainly responsible for static facial asymmetry, which leads to many psychological and social problems in patients. Objective and qualitative assessment of facial appearance is critical to determine the severity of sequelae of static facial asymmetry and whether an intervention is effective for treatment. In the present study, an attempt was made to develop three-dimensional analysis method to assess sequelae of static facial asymmetry after facial palsy. METHODS: Eight patients with sequelae of facial asymmetry after facial palsy and ten healthy volunteers were enrolled. We used three-dimensional scanning analysis with a portable non-contact optical scanner to obtain three-dimensional surface data from a patient's face and produced a three-dimensional digital model of the face. We then identified a reference plane fixed with the patient's face, and measured the depth of the nasolabial fold of the face. RESULTS: The nasolabial fold of the face on the affected side was significantly deeper than that on the unaffected side in patients with sequelae of static facial asymmetry after facial palsy. However, the depth of the facial nasolabial fold on the right side was not different from that on the left side in healthy volunteers. Affected-unaffected side differences in the depth of the nasolabial fold in patients with sequelae of static facial asymmetry after facial palsy were significantly larger than left-right differences in the depth of the nasolabial fold in healthy volunteers. Two weeks after treatment with botulinum toxin injection to the affected zygomaticus muscles, affected-unaffected side differences in the depth of the nasolabial fold were significantly decreased in the patients. In the patients who received botulinum toxin, the absolute values of affected-unaffected side differences in the depth of the nasolabial fold measured using the three-dimensional scanning analysis showed a significant positive correlation with the visual analog scale scores of facial asymmetry marked by independent doctors. CONCLUSION: The present findings suggest that affected-unaffected side differences in the depth of the nasolabial fold of the measured using three-dimensional scanning analysis can be used as an index of sequelae of static facial asymmetry. It is also suggested that the index can evaluate whether interventions are effective for the treatment of sequelae.

Hemifacial hypertrophy - Report of 2 cases.

Hemifacial hyperplasia (HH) is a rare congenital condition involving enlargement of one or more tissues of the face. The treatment is surgically challenging and requires expertise. This manuscript aims to report two similar appearing HH but warranting different surgical treatment. A 19-year-old female and a 14-year-old boy presented with right facial asymmetry since birth and sought correction of the same. Surgical treatment was planned. Based on clinical history, diagnosis and imaging, HH was diagnosed. The first case was entirely a soft tissue abnormality that was treated with debulking while the second case had involvement of facial bones, necessitating surgical recontouring. The facial asymmetry was addressed. Healing was uneventful. Though the aesthetical concern and appearance of the two cases of HH were same, the treatment vastly differed. This was based on the source of asymmetry. Proper diagnosis and informed decision are a key for successful surgical outcome.

Three-Dimensional Quantification of Facial Asymmetry in Children with Positional Cranial Deformity.

BACKGROUND: The extent of facial involvement in positional plagiocephaly is only little investigated so far. Investigation methods that take into account the challenging anatomical conditions and growth of infants' faces are desirable. In this study, the authors established a new three-dimensional photogrammetry quantification method evaluating pretherapeutic and posttherapeutic facial asymmetry in positional plagiocephaly. Furthermore, a facial asymmetry index was established and evaluated. METHODS: Three-dimensional photographs of 100 children undergoing treatment with head orthoses were analyzed by constructing a standardized interindividual coordinate system. Defining landmarks, section planes, and point coordinates with a computer-aided design software, both sides of the faces were compared. Facial asymmetry was quantified by measuring differences between left and right sides and pretherapeutic and posttherapeutic changes in each patient. The facial asymmetry index was calculated by putting the absolute differences in relation with the coordinates of the nonaffected side. RESULTS: Present results indicate that positional plagiocephaly results in a distinct facial asymmetry (range, -3.8 to 9.6 mm) in nearly all spatial directions and facial regions. Helmet therapy led to a significant reduction (p < 0.05) of intraindividual facial asymmetry (median change in facial asymmetry index, -1.9 to 3.1 percent). However, no correlation of the Cranial Vault Asymmetry Index and facial asymmetry (Spearman rank correlation coefficient, ρ = -0.09 to 0.47) has been seen. According to these results, severe occipital deformation does not necessarily provoke distinct facial asymmetry. CONCLUSIONS: Present three-dimensional photogrammetry method allows the longitudinal quantification of facial involvement in positional plagiocephaly. Asymmetry has been determined in all facial regions. The facial asymmetry decreased through helmet therapy but was not eliminated completely.