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.

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.

Peritoneal contamination and associated post-operative infectious complications after natural orifice specimen extraction for laparoscopic colorectal surgery.

BACKGROUND: Peritoneal contamination is a major concern during natural orifice specimen extraction after laparoscopic colorectal resection (LCR-NOSE), but few data are available. We explored the prevalence, risk factors, and association between clinical outcomes and infectious complications in patients with positive peritoneal drain fluid culture (PDFC) after LCR-NOSE. METHOD: We retrospectively analyzed patient records in our prospectively maintained registry database who underwent LCR-NOSE between 2011and 2020. Peritoneal drain fluid was collected within 12 h post-operative and cultures for microorganisms were obtained. The relationships between PDFC, clinical variables, and infectious complications were examined by univariate and multivariable analysis. RESULTS: Of 241 consecutive patients who underwent LCR-NOSE and drainage fluid culture, 59 (24.5%) had PDFC. Anterior resection (Odds ratio OR 2.40) was identified as an independent predictor for PDFC. Twenty-eight patients (11.6%) developed infectious complications. Multivariable analysis identified low anterior resection (OR 2.74), prolonged operative time (OR 3.20), and PDFC (OR 5.14) as independent risk factors. Pseudomonas aeruginosa was the most frequently found microorganism (OR 5.19) responsible for infectious complications. CONCLUSIONS: Microorganisms are commonly present in the peritoneum after LCR-NOSE and play a critical role in the development of infectious complications and related morbidity. Specific caution is warranted in patients contaminated with specific types of microorganisms.

Natural orifice versus conventional mini-laparotomy for specimen extraction after reduced-port laparoscopic surgery for colorectal cancer: propensity score-matched comparative study.

BACKGROUND: Although reduced port laparoscopic surgery (RPLS), defined as laparoscopic surgery performed with the minimum possible number of ports and/or small-sized ports, is less invasive than conventional laparoscopic surgery by reducing the number of surgical wounds, an extension of the incision is still needed for specimen extraction, which can undermine the merits of RPLS. OBJECTIVE: To determine the impact of natural orifice specimen extraction (NOSE) in patients undergoing RPLS for colorectal cancer. The endpoints were perioperative outcome and oncologic safety at 3 years. SETTING: Single-center experience (2013-2019). PATIENTS: We retrospectively analyzed our prospectively collected patient records (American Joint Committee on Cancer (AJCC) stage I-III sigmoid or upper rectal cancer (tumor diameter ≤ 5 cm) who underwent curative anterior resection via RPLS. We excluded patients who did not undergo intestinal anastomosis. INTERVENTIONS: Perioperative and oncologic outcomes were compared between patients undergoing natural orifice (RPLS-NOSE) or conventional (mini-laparotomy) specimen extraction (RPLS-CSE). Patients were matched by propensity scores 1:1 for tumor diameter, AJCC stage, American Society of Anesthesiologists score and tumor location. RESULTS: Of 119 eligible patients, 104 were matched (52 RPLS-NOSE; 52 RPLS-CSE) by propensity scores. Compared with RPLS-CSE, RPLS-NOSE was associated with longer operative time (223.9 vs. 188.7 min; p = 0.003), decreased use of analgesics (morphine dose 33.9 vs. 43.4 mg; p = 0.011) and duration of hospital stay (4.2 vs. 5.1 days; p = 0.001). No statistically significant difference was found in morbidity or wound-related complication rates between the two groups. After a median follow-up of 34.3 months, no local recurrence was observed in RPLS-NOSE. The 3-year disease-free survival did not differ statistically significantly between groups (90.9 vs. 90.5%; p = 0.610). CONCLUSION: NOSE enhances the advantages of RPLS by avoiding the need for abdominal wall specimen extraction in patients with tumor diameter ≤ 5 cm. Surgical and oncologic safety are comparable to RPLS with CSE.

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 .

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 .

A Combination of Three-Step Lower Blepharoplasty to Correct Four Types of Lower Eyelid Deformities in Asian People.

BACKGROUND: This study aimed to propose a novel four-type deformity and treatment-oriented classification of the lower eyelids that directs the therapeutic combination of three-step lower blepharoplasty for Asian populations. METHODS: We reviewed 183 patients who underwent a therapeutic combination of three steps of lower blepharoplasty after being diagnosed with four types of lower eyelid deformities between July 2018 and April 2021. The three-step lower blepharoplasty includes: (1) mid-face and lower eyelid augmentation, (2) transconjunctival eye bag removal, and (3) skin pinch removal. Consecutive digital images, detailed fat graft volume, fat removal amount, skin pinch removal amount, complications, and patient's satisfaction and aesthetic improvement score were recorded. RESULTS: The overall patient's satisfy score is 91. Aesthetic improvement score is 80.2 and 83.3 among lay persons and experts, respectively. The volume of the fat graft ranges from 2 to 3 mL per orbit according to the severity of the deformity. The amount of fat removed was 0.53 ± 0.36 and 0.61 ± 0.40 mL per orbit in types II and III patients, respectively. There is no lower lid malposition. Eleven patients had over-correction of fat grafting, and they need steroid injection; 20 patients had under-correction of fat grafting, and they need secondary fat grafting. Ten patients need secondary skin pinch excision due to post-op skin redundancy. Two patients had conjunctiva wound granuloma. CONCLUSIONS: The combination of three-step lower blepharoplasty according to the novel classification is a straightforward and effective method to correct lower eyelid deformities. The complication rate was low with high patient satisfaction. 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 .

IL-7-dependent compositional changes within the γδ T cell pool in lymph nodes during ageing lead to an unbalanced anti-tumour response.

How the age-associated decline of immune function leads to increased cancer incidence is poorly understood. Here, we have characterised the cellular composition of the γδ T-cell pool in peripheral lymph nodes (pLNs) upon ageing. We find that ageing has minimal cell-intrinsic effects on function and global gene expression of γδ T cells, and γδTCR diversity remains stable. However, ageing alters TCRδ chain usage and clonal structure of γδ T-cell subsets. Importantly, IL-17-producing γδ17 T cells dominate the γδ T-cell pool of aged mice-mainly due to the selective expansion of Vγ6+ γδ17 T cells and augmented γδ17 polarisation of Vγ4+ T cells. Expansion of the γδ17 T-cell compartment is mediated by increased IL-7 expression in the T-cell zone of old mice. In a Lewis lung cancer model, pro-tumourigenic Vγ6+ γδ17 T cells are exclusively activated in the tumour-draining LN and their infiltration into the tumour correlates with increased tumour size in aged mice. Thus, upon ageing, substantial compositional changes in γδ T-cell pool in the pLN lead to an unbalanced γδ T-cell response in the tumour that is associated with accelerated tumour growth.

Paranasal Augmentation With Composite Graft Transfer in Overresection of Alar Base and Nostril Contracture.

BACKGROUND: Many Asian patients desire a narrower nasal base with less flaring of the alar lobules. However, patients who underwent multiple rhinoplasty surgeries with nostril contracture or an overreduction of the alar base may experience nostril contracture and deformity, which may lead to further airway obstruction. We present a technique that combines paranasal augmentation with composite chondrocutaneous graft transfer to overcome this problem. METHODS: Nine patients underwent composite chondrocutaneous graft transfer to the soft triangle or alar base combined with paranasal augmentation using preshaped porous polyethylene implants to correct nostril contracture and airway obstruction between September of 2014 and May of 2018. Preoperative and postoperative alar base distances and cross-sectional areas of the nostrils were measured and compared. RESULTS: The average thickness of paranasal augmentation was 5.5 mm (range, 4.0-7.0 mm). Eighteen composite grafts were located over the soft triangle (n = 3) and the alar base (n = 15). The average number of composite grafts for each person was 2 (range, 1-4). All composite grafts survived totally or partially, and no graft failed. The average follow-up was 10.9 months (range, 3-28 months). The alar base increased 13.9% (range, 2.2%-23.9%), and the nostril area increased an average of 78.1% (range, 4.5%-316.8%) postoperatively. Patients had satisfactory aesthetic and functional outcomes. CONCLUSIONS: Combining paranasal augmentation and composite graft transfer increased the cross-sectional area of the external valve and improved nostril contracture and airway obstruction after the overresection of the alar base or nose contracture after multiple rhinoplasty surgeries.

Tarsal Epithelial Cysts: Prevalence, Case Series, and Synthesis of Existing Literature.

PURPOSE: Tarsal epithelial cysts (TECs) are squamous epithelial-lined lesions of the eyelid that are often mistaken for chalazia or epidermal inclusion cysts. They remain poorly described in the literature. This study is designed to characterize the prevalence and clinical features of TEC. METHODS: We conducted a single-center retrospective review of adult patients with a diagnosis of eyelid neoplasm, eyelid cyst, hordeolum, stye, or chalazion between January 1, 2011 and July 1, 2017. Among this cohort, we identified patients with a histopathologic diagnosis of TEC. We also conducted a PubMed literature review and synthesis of existing clinical data of patients reported to have TEC, noting common clinical and histopathological features. RESULTS: Of 7,516 patients, we identified 6 patients with a histopathological diagnosis of TEC, amounting to a prevalence of 0.08% amongst patients with eyelid lesions. Average age was 49.7 years (range 18-76 years), with a 1:1 male to female ratio. The most common presenting symptom was a painless eyelid mass, and the majority (66.6%) had a preoperative diagnosis of chalazion. All but 1 patient had surgical excision from the posterior approach and there was 1 recurrence in the follow-up period. On review of the literature, we identified 68 prior cases of TEC from 18 clinical studies, with clinical features mirroring our case series. CONCLUSIONS: TEC has stereotypical clinical and histologic features that distinguish it from other tarsal lesions. Our review identified TEC as a relatively rare cause of eyelid lesions.

The Upper Buccal Musculomucosal Flap for Nasal Lining and Columellar Defect Reconstruction.

ABSTRACT: Restoring the nasal lining is a great challenge in the reconstruction of nasal defects. In this series, the authors present our experience in using the upper buccal musculomucosal (UBMM) flap for the reconstruction of full thickness columellar or nasal lining defects. Ten patients who underwent UBMM flap reconstruction of columellar or nasal lining defects, with or without composite grafting, were identified between December of 2014 and February of 2017. The records were retrospectively reviewed to determine the demographics, nasal deformity etiology, surgical technique, complications, flap survival rate and duration of follow-up. Of these ten patients, three were men, and seven were women; the average age was 48.1 years (range, 34-66 years). Four patients underwent bilateral UBMM flaps, and 6 patients underwent unilateral UBMM flap reconstruction. All of the donor sites were closed without complications, except for one small granuloma that occurred 8 months later. Of the total 14 flaps, 7 healed well, 6 healed well after minimal debridement in the clinic, and one failed and was replaced with a contralateral UBMM flap. The average follow-up time was 20.1 months (range, 8-38 months). All patients had satisfactory aesthetic and functional outcomes. Due to the limited availability of healthy local tissue for nasal lining reconstruction after multiple surgeries, the UBMM flap serves as an applicable choice to restore columellar or nasal lining defects, with minimal donor site morbidity and no visible external scarring.

A Comparative Study Between Classic Derotation Graft and Novel Double V Cutting Folded Derotation Graft.

BACKGROUND: To introduce an innovative refinement, the "double V cutting folded derotation graft" (DVCFD graft), which is a method for nasal tip lengthening in aesthetic rhinoplasty with strong holding force and efficient cartilage use. METHODS: A retrospective study was conducted from January 2018 to July 2019 with 101 patients, including 11 males and 90 females with an average age of 36.87 ± 10.12 years, at Chang Gung Memorial Hospital; the patients received classic derotation grafts (n = 49, 17 of them were one layer and 32 of them were two layers) and DVCFD grafts (n = 52) for cosmetic tip plasty. The tip projection, columella labial angle and nasolabial angle were measured through clinical photography at three different times (T0: pre-operation, T1: two weeks post-operation and T2: five months post-operation). The differences between the original derotation graft and the DVCFD graft were identified using paired-t and independent-t tests. RESULTS: The final relapse ratios of the classic derotation graft and DVCFD graft were 36.78% versus 36.92% for tip projection, 40.65% versus 38.58% for columella labial angle and 45.00% versus 47.76% for nasal labial angle, respectively. The P values of the independent-t tests were 0.991, 0.564 and 0.439, respectively. CONCLUSIONS: Both the classic derotation graft and DVCFD graft possess similar stability in tip plasty. The novel modification of the DVCFD graft has more efficient cartilage usage and is a feasible and safe surgical option for patients with limited harvestable cartilage for tip lengthening. LEVEL OF EVIDENCE III: 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 .

Long-term Oncologic Outcomes of Laparoscopic Anterior Resections for Cancer with Natural Orifice Versus Conventional Specimen Extraction: A Case-Control Study.

BACKGROUND: Although the short-term advantages of natural orifice specimen extraction are widely recognized, controversy exists concerning oncologic safety after laparoscopic surgery for colorectal cancer. OBJECTIVE: This study aimed to investigate the impact of natural orifice specimen extraction on local recurrence and long-term survival of patients undergoing colorectal cancer surgery. DESIGN: This is a propensity score-matched comparative study. SETTING: This study presents a single-center experience. PATIENTS: We retrospectively analyzed the records of patients who underwent curative laparoscopic anterior resection for American Joint Committee on Cancer stage I to III sigmoid or upper rectal cancer in 2011 to 2014, based on prospectively collected data. INTERVENTIONS: Oncologic outcomes were compared between patients undergoing natural orifice or conventional specimen extraction by minilaparotomy. Patients were matched 1:1 according to propensity scores calculated by logistic regression analysis with the following covariates: American Joint Committee on Cancer stage, tumor diameter, age, sex, BMI, and T stage. Cox proportional hazards regression analysis was performed to determine the impact on oncologic outcome. MAIN OUTCOME MEASURES: The primary outcomes measured were local recurrence and disease-free survival rates at 5 years. RESULTS: Of 392 eligible patients, 188 were matched (94 undergoing natural orifice specimen extraction and 94 undergoing conventional extraction by minilaparotomy). Median follow-up was 50.3 months. The cumulative local recurrence risk at 5 years was 2.3% and 3.5% (p = 0.632), whereas 5-year disease-free survival for all tumor stages combined was 87.3% and 82.0% (p = 0.383) in laparoscopic anterior resection with natural orifice specimen extraction and conventional extraction groups. T3 and T4 stages were the only variables independently associated with disease-free survival. LIMITATIONS: This study was limited because it focused on a single center, was a retrospective analysis, contained no long-term anorectal function testing, and had a small sample size. CONCLUSION: Long-term oncologic outcomes of patients undergoing laparoscopic anterior resection with natural orifice specimen extraction for sigmoid and upper rectal cancer do not differ from those undergoing conventional extraction. Thus, natural orifice specimen extraction could be a viable alternative to reduce abdominal wall insult in laparoscopic colorectal operations for malignancy in selected patients. See Video Abstract at http://links.lww.com/DCR/B241. RESULTADOS ONCOLÓGICOS A LARGO PLAZO DE RESECCIONES ANTERIORES LAPAROSCÓPICAS PARA CÁNCER A TRAVÉS DE ORIFICIO NATURAL FRENTE A EXTRACCIÓN CONVENCIONAL DEL ESPÉCIMEN: UN ESTUDIO DE CASOS Y CONTROLES: Si bien las ventajas a corto plazo de la extracción de especímenes por orificio natural son ampliamente reconocidas, existe controversia con respecto a la seguridad oncológica después de la cirugía laparoscópica para el cáncer colorrectal.Investigar el impacto de la extracción de especímenes por orificio natural en la recurrencia local y la supervivencia a largo plazo de pacientes sometidos a cirugía de cáncer colorrectal.Estudio comparativo con emparejamiento por puntuación de propensión.Experiencia en un centro único.Analizamos retrospectivamente los registros de pacientes que se sometieron a resección anterior laparoscópica curativa para cáncer sigmoideo o rectal superior AJCC en estadio I-III en 2011-2014, con base en datos recolectados prospectivamente.Los resultados oncológicos se compararon entre pacientes sometidos a extracción por orificio natural o convencional mediante minilaparotomía de especímenes. Los pacientes fueron emparejados 1:1 de acuerdo con los puntajes de propensión calculados por análisis de regresión logística con las siguientes covariables: estadio AJCC, diámetro del tumor, edad, sexo, índice de masa corporal y estadio T. Se realizó un análisis de regresión de riesgos proporcionales de Cox para determinar el impacto en el resultado oncológico.Recurrencia local y tasas de supervivencia libre de enfermedad a los 5 años.De 392 pacientes elegibles, 188 fueron emparejados (94 sometidos a extracción de espécimen por orificio natural y 94 a extracción convencional por minilaparotomía). La mediana de seguimiento fue de 50.3 meses. El riesgo cumulativo de recurrencia local a 5 años fue de 2.3% y 3.5% (p = 0.632), mientras que la supervivencia libre de enfermedad a 5 años para todas las etapas tumorales combinadas fue de 87.3% y 82.0% (p = 0.383) en los grupos de resección anterior laparoscópica con extracción de espécimen por orificio natural y extracción convencional, respectivamente. Las etapas T3 y T4 fueron las únicas variables asociadas independientemente con la supervivencia libre de enfermedad.Centro único, análisis retrospectivo, ausencia de pruebas de función anorrectal a largo plazo y tamaño de muestra pequeño.Los resultados oncológicos a largo plazo de los pacientes sometidos a resección anterior laparoscópica con extracción de espécimen por orificio natural para cáncer sigmoideo y rectal superior no difieren de los de aquellos sometidos a extracción convencional. Por lo tanto, la extracción de especímenes por orificio natural podría ser una alternativa viable para reducir el insulto a la pared abdominal en operaciones colorrectales laparoscópicas por malignidad en pacientes selectos. Consulte Video Resumen en http://links.lww.com/DCR/B241.

Laser hair removal following forehead flap for nasal reconstruction.

The forehead flap is a dependable option for nasal reconstruction owing to its reliability and anatomic likeness to nasal skin. For patients with low hairlines, the vertical design of the paramedian forehead flap can intrude into the scalp, thus incorporating hair into the nasal reconstruction. The inadequate length of the forehead flap or shift to an oblique design may result in eyebrow elevation and asymmetry. Therefore, laser hair removal (epilation) on the forehead flap has been proposed to improve esthetic results. An alexandrite laser (755 nm, 10 to 20 ms, 18-mm spot size) with a Dynamic Cooling Device™ (DCD™) cooling system was used for hair removal in 22 patients (16 male and 6 female patients) after nasal reconstructions using forehead flaps from December 2011 to September 2016. All patients received cryogen spray cooling laser treatment (CSC-LT). The mean follow-up period was 24 months, with a range between 18 and 50 months. The average duration of treatment was 1.8 months (range, 1-5 months). The energy density ranged from 14 to 18 J/cm2 with an average of 17.2 J/cm2. The number of treatments ranged from 2 to 4 (mean 2.8). Patients had satisfactory esthetic results over 11.1 months (range, 8-18 months). Residual white hairs were observed in 3 patients, and 4 patients had tiny black residual hairs without deteriorating cosmesis. Using an alexandrite laser to remove hair on the forehead is safe and reliable in nasal reconstruction with superior recipient site cosmesis.

Upper Lip Reconstruction With Modification for Creating a Philtrum With Single-Stage Full-Thickness Skin Graft in Burned Face Injury.

BACKGROUND: The philtrum plays an important role in determining the shape and form of the upper lip and creates individual identity. Postburn scar contracture in this area often leads to severe functional and aesthetic disfigurement. In this report, we present a novel method of philtrum reconstruction using full-thickness skin grafts (FTSGs) after burn injury. METHODS: Between August 2011 and October 2017, 8 patients with postburn philtrum deformity who underwent FTSG for replacement of the whole upper lip unit with a silastic tube for creation of the philtral dimple were included. A review of photographic documentation was used to evaluate the aesthetic results. RESULTS: The size of FTSG ranged from 4 × 9 to 6 × 17 cm. No patient had immediate postoperative complications, such as hematoma, infection, or necrosis. The crests of the ridges preserved their height and length, and the dimple remained visible after an average follow-up of 30.4 months (range, 3-69 months). All patients were satisfied with both functional and aesthetic results. CONCLUSIONS: This technique of single-stage reconstruction of the upper lip and philtrum with FTSG and silastic tube produced favorable results in the formation of the philtral ridges and the dimple. Through thoughtful preoperative design, meticulous scar release, and skin grafting, satisfactory functional and aesthetic results are achievable.

Management of Major Burns in 37 Casualties of a Colored Powder Explosion: Experience of the Linkou Burn Center in Taiwan.

BACKGROUND: On June 27, 2015, a colored powder explosion occurred in Taiwan. As a result, 499 people were injured, and over 200 people were in critical condition because of severe burns. Forty-nine casualties were transported to the Chang Gung Memorial Hospital. METHODS: We undertook a single-center retrospective observational study using clinical data for 37 patients with major burns with more than 20% total burn surface area (TBSA). We describe the experience of managing patients with acute burn injuries in these patients. Patient-specific data were analyzed and expressed as mean ± standard deviation. RESULTS: Thirty-seven major burn patients were admitted to our hospital. The mean ± SD age was 22.5 ± 5 years. The mean ± SD TBSA was 48.9% ± 20%. All patients were stabilized within 6 hours after admission, and no patient experienced hypothermia or hypovolemia. We performed 95 debridement procedures and 88 skin grafts. A mean of 5.6 surgeries were performed for each patient. The mean ± SD hospital stay was 62 ± 32 days. The ratio for hospital days/%TBSA was 1.36, and hospital charges/hospital days ratio was US $973 a day for surviving patients. Two mortalities (2/37, 5.4%) were reported: one was related to cardiac insult, and another was caused by sepsis. CONCLUSIONS: We share our experience in managing 37 major burn patients in a colored powder explosion to improve the holistic care in modern mass burn casualties. Aggressive early debridement and skin grafting reduced hospital stay and costs.

Onlay Fascial Grafts to Silicone-Polytetrafluorethylene Composite Implants in Augmentation Rhinoplasty: A Retrospective Study of 241 Cases.

BACKGROUND: Silicone-polytetrafluoroethylene composite implants are fast gaining popularity in Asian rhinoplasty. Nonetheless, implant displacement, erythematous reactions, and infections still occur in the authors' patient group during long-term follow-up. OBJECTIVES: The authors reported successful experience of combining the utilization of silicone-polytetrafluoroethylene composite implants with onlay temporal fascial grafts to circumvent these complications. METHODS: Sixty-four patients of Asian ethnicity underwent augmentation rhinoplasty utilizing an I-shaped composite implant with an onlay fascial graft from January 2015 to June 2018, with a mean follow-up period of 13.5 months. This patient group was compared with a control group of 177 Asian patients who underwent augmentation rhinoplasty utilizing the same composite implant but without the addition of a fascial graft; the control group was treated from February 2012 to June 2015, with a mean follow-up of 42.0 months. Complications were compared between these 2 patient groups, specifically focusing on malposition/deviations, erythema, and infections. RESULTS: There was a marked decrease in complication rates with the addition of an onlay temporal fascial graft to cover the composite implant in augmentation rhinoplasty (7.8% vs 14.7%) as well as the rate of erythematous reactions (0% vs 6.2%, P = 0.04), infection (1.6% vs 1.1%), and implant malposition/deviation (0% vs 4.5%). Harvesting the temporal fascia and fashioning the onlay graft added an additional 33 minutes on average per procedure. No donor site morbidity was encountered. CONCLUSIONS: Although the operative time increased, the benefits of adding onlay fascial grafts to silicone-polytetrafluoroethylene implants in alloplastic augmentation rhinoplasty outweigh the drawbacks, as evidenced by the decrease in erythematous reactions.

Similarity in Bilateral Isolated Internal Orbital Fractures.

PURPOSE: In evaluating patients sustaining bilateral isolated internal orbital fractures, the authors have observed both similar fracture locations and also similar expansion of orbital volumes. In this study, we aim to investigate if there is a propensity for the 2 orbits to fracture in symmetrically similar patterns when sustaining similar trauma. METHODS: A retrospective chart review was performed studying all cases at our institution of bilateral isolated internal orbital fractures involving the medial wall and/or the floor at the time of presentation. The similarity of the bilateral fracture locations was evaluated using the Fisher's exact test. The bilateral expanded orbital volumes were analyzed using the Wilcoxon signed-rank test to assess for orbital volume similarity. RESULTS: Twenty-four patients with bilateral internal orbital fractures were analyzed for fracture location similarity. Seventeen patients (70.8%) had 100% concordance in the orbital subregion fractured, and the association between the right and the left orbital fracture subregion locations was statistically significant (P < 0.0001). Fifteen patients were analyzed for orbital volume similarity. The average orbital cavity volume was 31.2 ± 3.8 cm on the right and 32.0 ± 3.7 cm on the left. There was a statistically significant difference between right and left orbital cavity volumes (P = 0.0026). CONCLUSIONS: The data from this study suggest that an individual who suffers isolated bilateral internal orbital fractures has a statistically significant similarity in the location of their orbital fractures. However, there does not appear to be statistically significant similarity in the expansion of the orbital volumes in these patients.

Nose resurfacing with free fasciocutaneous flaps in burns patients.

BACKGROUND: Nasal reconstruction after burn injury can be challenging due to limited availability of local flaps. We present our experience of free flap reconstruction for full-thickness nasal defect after severe facial burn injury. METHODS: Between August 1998 and September 2015, six patients underwent nasal reconstruction with seven free flaps after burn injury. Among them, flame burn occurred in two patients, chemical burn in two, explosive burn in one, and contact thermal burn in one patient. The percentage of total body surface area ranged from 4% to 48%, and the face and forehead were involved in all patients. Their clinical and photographic records were retrospectively reviewed to evaluate the aesthetic results. RESULTS: Four ulnar forearm flaps, one radial forearm flap, one anterolateral thigh flap, and one medial sural artery perforator flap were used for nasal reconstruction. The nasal framework was constructed simultaneously using costal cartilage or conchal cartilage. The facial artery and vein were typically used as recipient vessels. One case each of partial necrosis and infection were noted during the average follow-up of 59 months (range, 16-126 months). Patients had satisfactory aesthetic and functional outcomes after 4.5 times (range, 2-7 times) refinement operation. CONCLUSIONS: Free flap is an applicable alternative to restore nasal skin envelope, with rebuilding the nasal framework performed in the same stage after severe facial burn injury. Through thoughtful planning and sufficient refinement, satisfactory aesthetic, and functional results are achievable.