Three-Part Analysis for Designing Nasal Alar Reduction Surgery in Asian Patients.

BACKGROUND: The external nasal alar reduction can be associated with many complications, such as nostril malformation and significant scarring. The authors proposed a 3-part analysis method for the design of nasal alar reduction surgery with the aim of improving nasal alar morphology more precisely. METHODS: The 3-part analysis was based on the patient's flared nose, wide nasal base, and drooping ala, respectively. We included 20 patients who underwent this surgery between January 2021 and January 2022. The visual analog scale (VAS) and the Stony Brook Scar Evaluation Scale (SBSES) were used to assess postoperative scar outcomes. The preoperative and postoperative ratios of the interalar distance to intercanthal distance and nostril shape were analyzed. Patient-reported satisfaction with the esthetic outcome was also assessed. RESULTS: All operations were successfully completed. There were no postoperative complications, such as wound infection or skin necrosis. Both VAS and SBSES assessment of postoperative scarring suggested keloid hyperplasia at 3 months postoperatively. At 12 months postoperatively, the scarring was insignificant and improved significantly over 3 months postoperatively. The mean ratio of the interalar distance to intercanthal distance decreased significantly from 1.15 preoperatively to 1.01 postoperatively (P<0.05). The shape of the patient's nostrils was also significantly improved after surgery compared with the preoperative period. Patient-reported satisfaction after surgery was high at long-term follow-up. CONCLUSIONS: The 3-part analysis to design an external nasal alar reduction procedure can accurately improve the morphology of nasal flaring, excessively wide nasal alar base, and nasal ptosis in Asian patients. LEVEL OF EVIDENCE: IV.

Scalp Composite Tissue Transplantation for Repairing Upper Lip Defect: A Feasible Clinical Study.

BACKGROUND: The repair of upper lip defects is difficult and can result in asymmetry. The authors have developed a postauricular scalp composite tissue for the repair of upper lip defects. Herein, the authors, present the feasibility of scalp composite tissue grafts for repairing of upper lip defects. METHODS: The authors conducted a retrospective study of 10 patients who underwent scalp composite tissue transplantation for upper lip repair. The surgical procedure consisted of the excision of skin lesions or scar tissue from the upper lip to prepare the recipient area, and then the scalp composite tissue was excised behind the ear and transplanted to the upper lip defect. The authors reviewed the photographs and clinical notes of these patients. The patients' self-reported satisfaction with the repair effect was assessed. Tissue sections and hematoxylin and eosin staining of the scalp composite tissues were performed. RESULTS: All patients successfully underwent lesion resection and scalp composite tissue transplantation to repair the wound. There was no necrosis of the scalp composite tissue in the early postoperative period. The lip wound healed completely within 2 weeks. The mean follow-up time was 16 months, ranging from 12 to 20 months. Histologic sections and hematoxylin and eosin staining showed that the scalp composite tissue had abundant capillaries and dense fibrous connective tissue. All 10 patients were satisfied with the clinical effect of the procedure. CONCLUSION: Scalp composite tissue transplantation is a viable method for repairing upper lip defects. The special histomorphological characteristics of the scalp provide the basis for clinical application. LEVEL OF EVIDENCE: IV.

Nasofacial Groove Pedicled Flap for the Reconstruction of Lateral Alar Defect.

BACKGROUND: The repair of nasal alar defects is challenging for plastic surgeons, and there is currently no standard operation. Herein, the authors reported the clinical outcomes of a nasofacial groove pedicled flap for the reconstruction of alar defect. METHODS: This retrospective study included patients who underwent the nasofacial groove pedicled flap for the reconstruction of alar defect between January 2018 and June 2020. Photographs of standard facial postures were taken before and after surgery to record the surgical results of the patients. The patient's medical history was reviewed retrospectively. Self-reported satisfaction of patients on scar morphology and reconstructive effect were evaluated with a questionnaire survey. RESULTS: There were 26 eligible patients enrolled, and all patients were followed up for more than 1 year after surgery. All flaps were free of ischemia and necrosis and healed well. No patient experienced restricted nostril ventilation. Eight patients underwent reoperation to trim the flap pedicle and the scar. Eight patients (8/26) reported "very satisfied," and 17 patients (17/26) reported "satisfied" with the repair effect and scar morphology. One patient went through multiple laser treatments to improve her scars but still remained visible hyperpigmentation. She was dissatisfied with postoperative flap pigmentation but was satisfied with the correction effect. CONCLUSIONS: The clinical results indicated that the nasal groove flap was safe for the treatment of the lateral alar defect, and the patients were satisfied with the clinical results. The authors believe that this flap can be used as an alternative method for repairing the lateral alar defect. LEVEL OF EVIDENCE: Level -IV, therapeutic study.

Dynamic Transcriptome Analysis of SFRP Family in Guided Bone Regeneration With Occlusive Periosteum in Swine Model.

BACKGROUND: A variety of congenital or acquired conditions can cause craniomaxillofacial bone defects, resulting in a heavy financial burden and psychological stress. Guided bone self-generation with periosteum-preserved has great potential for reconstructing large bone defects. METHODS: A swine model of guided bone regeneration with occlusive periosteum was established, the rib segment was removed, and the periosteum was sutured to form a closed regeneration chamber. Hematoxylin and eosin staining, Masson's staining, and Safranine O-Fast Green staining were done. Nine-time points were chosen for collecting the periosteum and regenerated bone tissue for gene sequencing. The expression level of each secreted frizzled-related protein (SFRP) member and the correlations among them were analyzed. RESULTS: The process of bone regeneration is almost complete 1 month after surgery, and up to 1 week after surgery is an important interval for initiating the process. The expression of each SFRP family member fluctuated greatly. The highest expression level of all members ranged from 3 days to 3 months after surgery. The expression level of SFRP2 was the highest, and the difference between 2 groups was the largest. Secreted frizzled-related protein 2 and SFRP4 showed a notable positive correlation between the control and model groups. Secreted frizzled-related protein 1, SFRP2, and SFRP4 had a significant spike in fold change at 1 month postoperatively. Secreted frizzled-related protein 1 and SFRP2 had the strongest correlation. CONCLUSIONS: This study revealed the dynamic expression of the SFRP family in guided bone regeneration with occlusive periosteum in a swine model, providing a possibility to advance the clinical application of bone defect repair.

Analysis of the Dynamic Expression of the SMAD Family in the Periosteum During Guided Bone Regeneration.

OBJECTIVE: The aim of this study was to investigate the dynamic expression of the SMAD family during guided bone regeneration for the reconstruction of cranio-maxillofacial bone defects. METHODS: A swine model of guided bone regeneration was established with one side of the rib as the trauma group and the contralateral as control group. Periosteal and regenerative tissue specimens were harvested at 9 time points in the early, middle, and late phases, and were subjected to gene sequencing and tissue staining. Expression data of each SMAD family were extracted for further analysis, in which the correlation of the expression of the respective members within and between groups and at different time points was analyzed. RESULTS: The expression of individual members of the SMAD family fluctuates greatly, especially during the first month. The SMAD3 and SMAD4 genes were the most highly expressed. The foldchange value of SMAD6 was the largest and remained above 1.5 throughout the process. The dynamic expression levels of SMAD2, SMAD4, SMAD5, SMAD6, and SMAD9 showed a significant positive correlation in both groups. The expression levels of each gene showed a positive correlation with other SMAD genes. Tissue staining showed that the overall contour of the regenerated bone tissue was basically formed within the first 1 month. CONCLUSION: The first month of guided bone regeneration is a critical period for bone regeneration and is an important period for the SMAD family to play a role. The SMAD6 may play an important role in the whole process of guided bone regeneration.

Two novel mutations within FREM1 gene in patients with bifid nose.

BACKGROUND: Bifid nose is a rare congenital deformity and the etiology is unknown. The purpose of this study was to report genetic variation in family of patients with bifid nose. METHODS: Twenty-three consecutive patients who were diagnosed with mild bifid nose were operated with z-plasty from 2009 to 2021. Three underage patients (a pair of twins and a girl) from two family lines, who came to our hospital for surgical treatment, were enrolled. Whole exome sequencing and Sanger sequencing were conducted. Z-shaped flaps were created and the cartilago alaris major were re-stitched. Photographs and CT scan before and after surgery were obtained. Clinical outcomes, complications and patients' satisfaction were evaluated and analyzed. The follow-up time ranges from 2 to 3 years (2.4 ± 1.2 years). RESULTS: Most patients were satisfied with the outcome (96.2%). The nasal deformities were corrected successfully with z-plasty technique in one-stage. FREM1 c.870_876del and c.2 T > C were detected with Whole exome sequencing, which have not been reported before. The results of Sanger sequencing were consistent with those of Whole exome sequencing. CONCLUSIONS: The newly detected mutations of FREM1 have a certain heritability, and are helpful to make an accurate diagnosis and provide a better understanding of bifid nose mechanism. Z-plasty technique can be an effective technical approach for correcting mild bifid nose deformity.

Repair of Scars and Tissue Deficiency With Free Grafts of Full-thickness Scalp in Secondary Unilateral Cleft Lip Deformity.

Although surgical techniques have developed, the incidence of secondary cleft lip deformities after the primary repair is still high. Asymmetry of Cupid's bow and philtrum is a common presentation and a technical challenge to reconstruct the upper lip. The authors introduce a technique to use the free grafts of the full-thickness scalp for the correction of scars and tissue deficiency in secondary unilateral cleft lip deformity. Thirty-seven patients with a prominent scar, tight upper lip, deformed Cupid's bow and philtrum, and irregular vermillion border were included in this study. The specific points of interest were assessed before and after surgery by independent examiners with both subjective and objective methods. All surgeries were successfully completed, and the assessment results were satisfactory. The rating scores of philtrum improvement was 1.6±0.4, the POSAS result of patient scales was 13.48±3.21, and the observer scale result was 11.98±3.88. The asymmetry of Cupid's bow was corrected ( P =0.004), the central tubercle of vermilion was more natural ( P =0.001), and the irregular vermillion border was improved ( P =0.015). The results presented significant differences before and after surgery. This method could be an optional treatment for repairing scars and tissue deficiency in secondary unilateral cleft lip deformity.

External Z-plasty Technique for Correction of Alar Retraction in Asian Patients.

BACKGROUND: Current strategies for correcting alar retraction mainly include cartilage grafting and composite grafting, which are relatively complicated and may produce injury to the donor site. Herein, we introduce a simple and effective external Z-plasty technique for correcting alar retraction in Asian patients with poor skin malleability. METHODS: Twenty-three patients were presented with alar retraction and poor skin malleability, and they were very concerned about the shape of the nose. These patients undergoing external Z-plasty surgery were analyzed retrospectively. In this surgery, no grafts were needed, and the location of the Z-plasty was according to the highest point of the retracted alar rim. We reviewed the clinical medical notes and photographs. During the postoperative follow-up period, patients' reported satisfaction with aesthetic outcome were also evaluated. RESULTS: The alar retraction of all the patients was successfully corrected. The postoperative mean follow-up period was 8 months (range: 5-28 mo). No incidents of flap loss, recurrence of alar retraction, or nasal obstruction were observed during postoperative follow-up. Within postoperative 3-8 weeks, minor red scarring was visible at the operative incisions in most patients. However, these scars turned unobvious after postoperative 6 months. There were 15 cases (15/23) being very satisfied with the aesthetic outcome of this procedure. Seven patients (7/23) were satisfied with the effect and the invisible scar of this operation. Only one patient was dissatisfied with the scar, but she was satisfied with the correction effect of the retraction. CONCLUSION: This external Z-plasty technique can be an alternative method for correction of alar retraction with no need of cartilage grafting, and the scar can be unobvious with fine surgical suture. However, the indications should be limited in patients with severe alar retraction and poor skin malleability, who should not particularly care about the scars.

Nasal Tip and Alar Groove Plasty Through External Nasal Cutting in Asians: A Clinical Study.

OBJECTIVE: Nasal tip hypertrophy is common in Asians, and its reshaping is very critical in rhinoplasty. For patients who refuse any implant placed in the nose, there are limited options for tip reshaping. Herein, we introduce a new procedure of nasal tip and alar groove plasty through external nasal cutting in Asians. METHODS: A total of 20 patients who had hypertrophic nasal tip and refused to have any implants were included in this study. They were performed this procedure of nasal tip and alar groove plasty through external nasal cutting. The authors carefully reviewed the patients' medical records and preoperative and postoperative photographs. Self-reported satisfactions of patients with the scar morphology and correction effect were assessed at postoperative every follow-up using a questionnaire survey. RESULTS: All of the patients' procedures were completely successful, and the hypertrophic nasal tip was improved. In the long-term postoperative follow-up, the patients' wound showed no abnormalities such as scar contracture deformity, scar bumps, and nasal deformation. In 1 patient, the nasal wound developed significant scarring, and we performed reoperation to remove the superficial scar tissue. Surgical scars in the remaining patients were not obvious. Eight patients (8/20) reported "very satisfied" with scar shape and nasal tip shape improvement results, and 10 patients (10/20) reported "satisfied" with the outcomes. CONCLUSIONS: This procedure of nasal tip and alar groove plasty could be an alternative for making the nasal tip more refined. However, the surgical indications for this procedure need to be strictly limited to specific patients. LEVEL OF EVIDENCE: Level IV.

Lateral Osteotomy for the Surgical Treatment of the Asian Wide Nose.

OBJECTIVE: Narrowing of the nasal dorsum allows for a more pleasing moderate width. We here introduce a lateral osteotomy technique that is less traumatic and easier to perform than commonly used procedures in Asian and share our experiences in the application. METHODS: After a blunt dissection of the periosteum at the mucosal side of the nasal bone, all patients who underwent treatment using nasal osteotomy at the level of the maxillary nasal process were retrospectively analyzed. The bony nasal width, height, and the nasal lateral wall slope of bone before and after surgery were measured. The postoperative outcomes, complications, and patient satisfaction were analyzed and evaluated. RESULTS: From January 2008 to January 2018, nasal dorsum narrowing was implemented in 106 patients. On average, nasal width was significantly decreased and no change in nose height after the nasal osteotomy. The nasal width was significantly reduced by 8.51 ± 2.16 mm compared with before surgery. The slope of the nasal lateral wall was reduced from the mean of 155.0 ± 7.63-degree preoperation to the mean of 135.25 ± 7.50-degree postoperation. The follow-up period ranged from 6 months to 4 years, with an average of 10.3 months. CONCLUSIONS: This type of nasal bone base osteotomy is a simple and feasible method for the treatment of wide Asian noses with a high patient acceptance and stable postoperative results. LEVEL OF EVIDENCE: Level IV.

An Innovative Stent Consisting of Expanded Polytetrafluoroethylene and Ear Cartilage in Rhinoplasty For Asians: Application I of Dai's Exogenous Extension Stent Concept.

BACKGROUND: Restricted ventilation is common after rhinoplasty with an endogenous extension stent. The authors proposed an exogenous extension stent concept for Asian rhinoplasty patients to avoid this problem. Herein, we introduce an innovative stent in rhinoplasty for Asians, which is an application of this concept. METHODS: An L-shaped expanded polytetrafluoroethylene is hand-carved, and the long arm is placed at the nose back to improve the flatness of the nose, while the short arm supports the nasal column to raise the nose tip. The prosthesis does not occupy nasal volume and therefore theoretically does not affect nasal ventilation. The fan-shaped ear cartilage was placed at the nasal tip to prevent visualization of the nasal tip. The safety and effectiveness of this method were verified through 20 years of clinical practice. The difficulty of learning and popularizing the method was tested through the course of rhinoplasty among 22 plastic surgeons. RESULTS: After 20 years of clinical practice, it was found that this stent could not only effectively improve the nasal dorsum and tip morphology, but also did not actually affect the nasal volume and thus did not affect the nasal ventilation of patients. Among the trainees in plastic surgery, we found that it was not difficult to learn this method of rhinoplasty and the trainees could complete the prosthesis carving well after standardized training. CONCLUSION: This stent consisting of expanded polytetrafluoroethylene and ear cartilage is suitable in rhinoplasty for Asians with significant advantages, one of which is that it has no risk of resulting in restricted nasal ventilation. LEVEL OF EVIDENCE: Level IV.

Alar Rim Triangular Flap for Congenital Nasal Cleft Repair in Pediatric Patients.

BACKGROUND: According to Tessier classification, number 1 and number 2 craniofacial clefts involve the nasal ala. Congenital nasal cleft is not common and is difficult for reconstruction. Notches in the medial one-third of either nasal ala are typical manifestations in these patients. Herein, we introduce a alar rim triangular flap, which is indeed a local flap, for the treatment of isolated nasal cleft due to congenital deformities in pediatric patients. METHODS: The authors conducted a retrospective cohort study including 10 consecutive pediatric patients undergoing this surgery. This alar rim triangular flap including 2 triangles was existing nasal tissue near the cleft. The alar rim defect was covered through local tissue re-arrangement. The authors reviewed the photographs and clinical medical notes of these patients carefully. Self-reported satisfactions of patients (or children's parents) with the scar morphology and correction effect of this procedure were evaluated as well at postoperative every follow-up. RESULTS: All the cases were followed up regularly, and the average follow-up time was 22 months (ranged from 13-38 months). All the nasal clefts were reconstructed successfully. The alar rim triangular flap survived with no flap loss. The wound created by this procedure healed primarily. No alar retraction, nasal obstruction or step-off deformities were observed during postoperative follow-up. There were no patients unsatisfied with the outcome of the scar morphology and correction effect of this operation. CONCLUSIONS: The newly designed alar rim triangular flap in this study can be an alternative treatment for correcting isolated congenital nasal cleft with optimal clinical outcome. LEVEL OF EVIDENCE: Level 4.

Correcting Wide Alar Base and Flare With Combined Sill and Alar Excision in Asian Patients.

BACKGROUND: Obvious scar and deformities are commonly observed with incision anterior to the alar-facial groove in alar excision surgery. The authors explored modified sill and alar excision to correct wide alar base and flare synchronously and decreased incident of unacceptable scar and deformities in Asian patients. METHODS: The authors conducted a retrospective cohort study including 52 consecutive patients undergoing this surgery. Contrary to previous studies, the incision for alar excision was located in the alar-facial groove and was closed by intracutaneous suture. Scars were assessed with visual analog scale and the Stony Brook Scar Evaluation Scale. Ratio of the interalar distance to intercanthal distance, nostril shape, and nostril symmetry was recorded. RESULTS: The mean follow-up time was 18 months. Visual analog scale results showed 50 patients (96.2%) reported unnoticeable scar and 2 noticeable but acceptable scar. Stony Brook Scar Evaluation Scale results indicated 49 patients (94.2%) with good scar outcomes and 3 (5.8%) with moderate scar outcomes. The mean ratio of interalar distance to intercanthal distance reduced significantly from preoperative 1.10 to postoperative 1.02. The frequency of horizon-shaped nostrils changed from preoperative 16 cases (30.8%) to postoperative 2 cases (3.8%). The frequency of the pear-shaped (preferred shape) nostrils improved from preoperative 15 cases (28.8%) to postoperative 26 cases (50.0%). The frequency of symmetrical nostril shape improved from preoperative 36 patients (69.2%) to 42 (80.8%). There were no patients with complications like alar deformities, and patients' dissatisfaction. CONCLUSIONS: When performing sill and alar excision in Asian patients, the authors recommended a modified approach with the incision for alar excision being placed in the alar-facial groove and closed by intracutaneous suture, which can avoid obvious scar and deformities in Asian patients.Level of evidence: Level 4.

Correction of Severe Short Nose Using a Costal Cartilage Extension Framework.

BACKGROUND: Various techniques for the aesthetic correction of short noses have been described, but the selection of the adequate graft material remains controversial. Previous reports have mainly focused on the application of septal cartilage or alloplastic materials for short nose elongation, but the lengthening effect is often unsatisfactory for severe short noses. We propose costal cartilage as an alternative treatment for short noses, describe the technique, and discuss outcomes, patient selection, and complications based on our 15-year experience. METHODS: From February 2004 to December 2018, 611 patients with varying degrees of short noses were included in this retrospective study. All patients underwent nose elongation surgery using a costal cartilage graft. Nasal length before and after surgery was measured based on a 3-dimensional simulation technology. Outcomes and complications including possible underlying reasons were analyzed. Patient satisfaction was evaluated using a self-assessment survey. RESULTS: Nasal elongation using costal cartilage was successfully achieved, with a mean increase in nasal length of 4.06 ±0.79 mm. Patients were followed up for a period of 8.5 months on average, ranging from 6 months to 8 years. Follow-up examinations demonstrated stable results. The overall complication rate was 3.8%. Complications included infection, implant extrusion, migration, deviation, visibility, prominence, and reddening of the nasal skin. Most patients (95.2%) rated their outcome as improved and much improved. CONCLUSION: Nasal elongation using costal cartilage grafting is an effective therapeutic approach for patients with severe short noses. Reliable outcomes and the use of autologous tissue along with minimal donor site morbidity contribute to the high patient acceptance. Meticulous surgical technique and careful patient selection are prerequisites for successful results.

Philtrum Reconstruction Using a Triangular-Frame Conchae Cartilage Graft in Secondary Cleft Lip Deformities.

BACKGROUND: The philtrum represents an essential feature in the architecture of the upper lip and over all facial appearance. A missing philtral ridge and dimple after cleft lip repair is associated with aesthetic impairment. The authors therefore developed a novel strategy for philtrum reconstruction using a triangular-frame conchae cartilage. The authors herein describe the surgical procedure and evaluate the postoperative outcomes. METHOD: In this study, 32 patients with a deficiency of the philtrum due to unilateral or bilateral cleft lip underwent reconstructive surgery based on a triangular-frame conchae cartilage graft. Preoperative and postoperative assessment of the convexity of the philtral ridge and dimpling was performed at rest and while puckering by standard patient photography and video technology. Postoperative outcome and complications were recorded during follow-up including a patient satisfaction survey. RESULTS: The follow-up period after philtrum reconstruction ranged from 6 months to 5.3 years. Postoperative evaluation showed satisfactory and stable results with an aesthetic philtral ridge and dimpling, even in the long term. The vast majority (31 patients) were satisfied with the postoperative outcome. Complications included acute infection (1 case), temporary stiffness of smile (1 case), and reddening of the scar (1 case). No systemic complications occurred. CONCLUSION: The authors here propose a simple, effective, and reliable surgical technique for secondary philtrum reconstruction in cleft lip deformity patients using a triangular-frame auricular cartilage graft. LEVEL OF EVIDENCE: 4.

The Use of Expanded Polytetrafluoroethylene in Short Nose Elongation: Fourteen Years of Clinical Experience.

BACKGROUND: Short nose elongation is a relatively common rhinoplasty procedure, especially in Asia. The selection of the adequate graft material is challenging. Previous reports have described the application of expanded polytetrafluoroethylene (ePTFE) for dorsal augmentation rhinoplasty, but studies using ePTFE for nose elongation are lacking. We propose ePTFE as an alternative treatment for short noses, describe the technique, and discuss outcomes, patient selection, and complications based on our 14-year experience. METHODS: From February 2003 to December 2016, 206 patients with varying degrees of short noses were included in this retrospective study. All patients underwent nose elongation surgery using an ePTFE implant. Nasal lengths before and after surgery were measured using a 3-dimensional simulation technology. Outcomes and complications including possible underlying reasons were analyzed. Patient satisfaction was evaluated using a self-assessment survey. RESULTS: Nasal elongation was successfully achieved using ePTFE. Mean increase in nasal length was 4.36 ± 0.85 mm. The mean follow-up period was 13.3 months, ranging from 6 months to 8 years. Follow-up examinations demonstrated stable results. The overall complication rate was 6.8%. Complications included infection, implant extrusion, migration, deviation, visibility, and/or prominence, tissue reaction, and reddening of the nasal skin. Most patients (93.6%) rated their outcome as improved and much improved. CONCLUSIONS: Nasal elongation using ePTFE implantation is a feasible therapeutic approach for patients with short noses. Reliable outcomes and the absence of donor site morbidity contribute to the high patient acceptance. Meticulous surgical technique and careful patient selection are prerequisites for successful results.

Large-Scale Skin Resurfacing of the Upper Extremity in Pediatric Patients Using a Pre-Expanded Intercostal Artery Perforator Flap.

BACKGROUND: The repair of extensive upper limb skin lesions in pediatric patients is extremely challenging due to substantial limitations of flap size and donor-site morbidity. We aimed to create an oversize preexpanded flap based on intercostal artery perforators for large-scale resurfacing of the upper extremity in children. METHOD: Between March 2013 and August 2016, 11 patients underwent reconstructive treatment for extensive skin lesions in the upper extremity using a preexpanded intercostal artery perforator flap. Preoperatively, 2 to 4 candidate perforators were selected as potential pedicle vessels based on duplex ultrasound examination. After tissue expander implantation in the thoracodorsal area, regular saline injections were performed until the expanded flap was sufficient in size. Then, a pedicled flap was formed to resurface the skin lesion of the upper limb. The pedicles were transected 3 weeks after flap transfer. Flap survival, complications, and long-term outcome were evaluated. RESULT: The average time of tissue expansion was 133 days with a mean final volume of 1713 mL. The thoracoabdominal flaps were based on 2 to 6 pedicles and used to resurface a mean skin defect area of 238 cm ranging from 180 to 357 cm. In all cases, primary donor-site closure was achieved. Marginal necrosis was seen in 5 cases. The reconstructed limbs showed satisfactory outcome in both aesthetic and functional aspects. CONCLUSION: The preexpanded intercostal artery perforator flap enables 1-block repair of extensive upper limb skin lesions. Due to limited donor-site morbidity and a pedicled technique, this resurfacing approach represents a useful tool especially in pediatric patients.

Double Composite Tissue Z-plasty Technique for Anatomical Restoration of Severe Nasal Deformity in Secondary Unilateral Cleft Lip.

BACKGROUND: Patients with secondary unilateral cleft lip are regularly affected by serious nasal deformities especially of the alar and nasal floor. A large number of techniques for correction have been published, but symmetrical restoration of severe nasal deformation is difficult to achieve. We propose an innovative approach for anatomical restoration for this entity of nasal deformities to achieve long-term symmetrical appearance and muscular function. METHODS: A total of 68 patients with severe nasal deformity due to secondary unilateral cleft lip underwent reconstructive surgery using a double composite tissue Z-plasty technique for anatomical restoration of cartilage, muscle, and soft tissue layers. Patient pictures were taken preoperatively and postoperatively to evaluate appearance and incisional wound healing. The surgical outcome was assessed based on a postoperative patient satisfaction survey. All occurring adverse effects were recorded. RESULTS: All patients were followed up for at least 7 months up to 8 years; mean follow-up period was 14.6 months. Patients were highly satisfied with the aesthetic result and improved facial profile (97.1%) and healing of the incision site (94.1%). There were 4 cases of implant deviation and 2 cases of impaired ventilation due to hypertrophic scarring of the upper lip (2 patients) and relatively decreased nostril size after augmentation rhinoplasty (1 patient), respectively, requiring surgical revision 1 year postoperatively. No other complications such as bleeding, infection, flap necrosis, and sensory dysfunction were recorded. CONCLUSIONS: The double composite tissue Z-plasty technique allows for thorough anatomical restoration of cartilage, muscle, and skin layers in unilateral cleft lip nasal deformities. This single-step approach is a safe and technically easy therapeutic option that is associated with high patient satisfaction and acceptance.

Correction of Midface Depression Using an Inverted m-shaped Expanded Polytetrafluoroethylene Implant Improves Gingival Exposure.

BACKGROUND: Current approaches for the treatment of gingival exposure are often time- and cost-consuming and/or rather invasive. We previously observed a strong correlation between the presence of gingival excess and midfacial depression and here propose an easy 1-step correction technique as a new strategy to improve gingival exposure. METHOD: From February 2004 to December 2012, 42 patients with gingival exposure associated with different degrees of midfacial depression, defined by Frankfort horizontal plane-labrale superius-subspinale angle and sella-nasion-A point angle, were treated by implantation of an inverted m-shaped expanded polytetrafluoroethylene at the base of the piriform aperture in a subperiosteal location. Patient pictures were taken preoperatively and postoperatively to assess gingival exposure at rest and fullest smile, as well as measurements of upper lip length, nasolabial angle, and facial convexity angle. A postoperative patient satisfaction survey was performed. RESULTS: The average maximum gingival exposure was 5.52 ± 1.64 mm preoperatively and significantly decreased to 1.79 ± 0.67 mm at 6 months after surgery (P < 0.05) along with a significantly improved nasolabial angle from initially 85.3° ± 6.21° to 95.2° ± 7.1° (P < 0.05). The majority of patients (90.5%) rated their postoperative outcome as highly improved and improved. Temporary discomfort involving upper lip numbness, foreign body sensation, and stiff smiling expression was complained at 1 month postoperatively and gradually returned to normal after 3 months. No late recurrence or other complications were seen in any of the patients. CONCLUSIONS: For cases involving midface depression, the present technique provides an effective and permanent treatment strategy to improve excessive gingival exposure. This single-step approach is a safe and technically easy therapeutic option which is associated with high patient acceptance.

Guided Self-Generation of Vascularized Neo-Bone for Autologous Reconstruction of Large Mandibular Defects.

Reconstruction of large mandibular defects is complex and challenging. The authors aimed to individually self-generate a large vascularized bone construct for autologous transplantation without the use of exogenous additives based on the concept of guided self-generation. Using computer-aided design and manufacturing a large size goat mandibular bone was reconstructed in 3 dimensions. Its negative mold printed from hydroxylapatite was temporarily embedded into the costal periosteum along with a contralateral demineralized bone matrix scaffold as control. After 3 months, a mandibular bone construct was obtained and used for autologous transplantation. Osteogenesis and angiogenesis were assessed by real-time imaging, histology, and biomechanical tests during neo-bone formation and up to 6 months after transplantation surgery. A total of 20 animals received implantation of a mandibular bone negative mold along with a contralateral demineralized bone matrix scaffold. Resulting negative mold mandibular bone constructs showed anatomically, histologically, and functionally similar characteristics compared with native controls. Only 1 goat presented partial fibrosis during construct generation with subsequent absorbtion after reconstruction. The absence of exogenous cells, growth factors, and scaffolds facilitated direct translation of this novel concept into clinical application. Further studies are needed to determine functional long-term outcomes and possible extensions to other tissues and organs.