Isolated Medial Maxillary Buttress Displacement in Naso-Orbito-Ethmoid Fractures: A Surgical Indication to Resolve Nasal Airway Obstruction.

PURPOSE: The aim of this study was to present a case series emphasizing low medial maxillary (pyriform) buttress displacement in naso-orbito-ethmoid (NOE) fractures as an operative indication, in the absence of the typical NOE surgical indications (medial canthus displacement, midface bony comminution, nasal bone collapse, and orbital indications), to prevent nasal airway obstruction. METHODS: Five cases of minor NOE fractures are reviewed, where only the low medial maxillary buttress was displaced. The typical surgical indications for NOE repair were absent. RESULTS: In each case, the pyriform buttress was medially and posteriorly displaced, creating nasal airway obstruction in each patient. The medial canthal tendons were all nondisplaced, there was no diplopia, and the other 2 cardinal buttresses (infraorbital rim and nasofrontal junction) were minimally displaced or greensticked. In the acute setting, patients were treated with open reduction and internal fixation. With delayed presentation, septorhinoplasty or osteotomy and fixation were used. Among the patients who had adequate follow-up, nasal airway obstruction was resolved. CONCLUSIONS: This series suggests that, in NOE fractures with isolated displacement at the medial maxillary buttress, nasal airway obstruction should be considered an operative indication (independent of the classical indications) in order to prevent or resolve nasal airway obstruction.

Biologic TNF-α inhibitors reduce microgliosis, neuronal loss, and tau phosphorylation in a transgenic mouse model of tauopathy.

BACKGROUND: Tumor necrosis factor-α (TNF-α) plays a central role in Alzheimer's disease (AD) pathology, making biologic TNF-α inhibitors (TNFIs), including etanercept, viable therapeutics for AD. The protective effects of biologic TNFIs on AD hallmark pathology (Aß deposition and tau pathology) have been demonstrated. However, the effects of biologic TNFIs on Aß-independent tau pathology have not been reported. Existing biologic TNFIs do not cross the blood-brain barrier (BBB), therefore we engineered a BBB-penetrating biologic TNFI by fusing the extracellular domain of the type-II human TNF-α receptor (TNFR) to a transferrin receptor antibody (TfRMAb) that ferries the TNFR into the brain via receptor-mediated transcytosis. The present study aimed to investigate the effects of TfRMAb-TNFR (BBB-penetrating TNFI) and etanercept (non-BBB-penetrating TNFI) in the PS19 transgenic mouse model of tauopathy. METHODS: Six-month-old male and female PS19 mice were injected intraperitoneally with saline (n = 12), TfRMAb-TNFR (1.75 mg/kg, n = 10) or etanercept (0.875 mg/kg, equimolar dose of TNFR, n = 10) 3 days/week for 8 weeks. Age-matched littermate wild-type mice served as additional controls. Blood was collected at baseline and 8 weeks for a complete blood count. Locomotion hyperactivity was assessed by the open-field paradigm. Brains were examined for phosphorylated tau lesions (Ser202, Thr205), microgliosis, and neuronal health. The plasma pharmacokinetics were evaluated following a single intraperitoneal injection of 0.875 mg/kg etanercept or 1.75 mg/kg TfRMAb-TNFR or 1.75 mg/kg chronic TfRMAb-TNFR dosing for 4 weeks. RESULTS: Etanercept significantly reduced phosphorylated tau and microgliosis in the PS19 mouse brains of both sexes, while TfRMAb-TNFR significantly reduced these parameters in the female PS19 mice. Both TfRMAb-TNFR and etanercept treatment improved neuronal health by significantly increasing PSD95 expression and attenuating hippocampal neuron loss in the PS19 mice. The locomotion hyperactivity in the male PS19 mice was suppressed by chronic etanercept treatment. Equimolar dosing resulted in eightfold lower plasma exposure of the TfRMAb-TNFR compared with etanercept. The hematological profiles remained largely stable following chronic biologic TNFI dosing except for a significant increase in platelets with etanercept. CONCLUSION: Both TfRMAb-TNFR (BBB-penetrating) and non-BBB-penetrating (etanercept) biologic TNFIs showed therapeutic effects in the PS19 mouse model of tauopathy.

Managing postoperative pain in adult outpatients: a systematic review and meta-analysis comparing codeine with NSAIDs.

BACKGROUND: Analgesics that contain codeine are commonly prescribed for postoperative pain, but it is unclear how they compare with nonopioid alternatives. We sought to compare the effectiveness of codeine and nonsteroidal anti-inflammatory drugs (NSAIDs) for adults who underwent outpatient surgery. METHODS: We conducted a systematic review and meta-analysis of randomized controlled trials comparing codeine and NSAIDs for postoperative pain in outpatient surgery. We searched MEDLINE and Embase from inception to October 2019 for eligible studies. Our primary outcome was the patient pain score, converted to a standard 10-point intensity scale. Our secondary outcomes were patient-reported global assessments and adverse effects. We used random-effects models and grading of recommendations assessment, development and evaluation (GRADE) to assess the quality of evidence. RESULTS: Forty studies, including 102 trial arms and 5116 patients, met inclusion criteria. The studies had low risk of bias and low-to-moderate heterogeneity. Compared with codeine, NSAIDs were associated with better pain scores at 6 hours (weighted mean difference [WMD] 0.93 points, 95% confidence interval [CI] 0.71 to 1.15) and at 12 hours (WMD 0.79, 95% CI 0.38 to 1.19). Stronger NSAID superiority at 6 hours was observed among trials where acetaminophen was coadministered at equivalent doses between groups (WMD 1.18, 95% CI 0.87 to 1.48). NSAIDs were associated with better global assessments at 6 hours (WMD -0.88, 95% CI -1.04 to -0.72) and at 24 hours (WMD -0.67, 95% CI -0.95 to -0.40), and were associated with fewer adverse effects, including bleeding events. INTERPRETATION: We found that adult outpatients report better pain scores, better global assessments and fewer adverse effects when their postoperative pain is treated with NSAIDs than with codeine. Clinicians across all specialties can use this information to improve both pain management and opioid stewardship.

Adjunctive Dorsal Scapular Nerve Transfer to Suprascapular Nerve for Brachial Plexus Birth Injuries: Case Series.

PURPOSE: Brachial plexus birth injury (BPBI) may result in permanent functional deficits. Brachial plexus birth injury involving the suprascapular nerve (SSN) is conventionally treated using accessory nerve transfer or excision and nerve grafting. This study analyzed shoulder function in patients with BPBI undergoing dorsal scapular nerve (DSN) to SSN transfer. METHODS: We performed a retrospective review of all infants referred to the McMaster University Children's Hospital for BPBI between 1999 and 2012. Patients were included if they underwent SSN reconstruction with DSN transfer and functional outcomes were recorded as measured by the active movement scale (AMS). RESULTS: Of the 266 patients referred, 16 met inclusion criteria. From the initial assessment to final follow-up, average AMS scores improved by 4.1 and 4.4 points for shoulder abduction and external rotation, respectively. In addition, 50% of patients had shoulder abduction greater than half of full range of motion and 43% had external rotation greater than half of full range of motion (AMS scores of 6 or greater). No patient had a secondary surgery; however, 9 of 16 had subsequent botulinum toxin injections. CONCLUSIONS: Although DSN to SSN nerve transfers were combined with other interventions and the outcomes cannot be attributed solely to this nerve transfer alone, it presents an alternative approach to SSN reinnervation under circumstances in which the accessory nerve is unavailable, damaged, or suboptimal. Successful results were achieved; thus, further exploration and study are warranted. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Surgical correction in orbitotemporal neurofibromatosis with dystopia.

BACKGROUND: Orbitotemporal neurofibromatosis is a challenging disease for orbital surgeons. Ptosis correction may be needed following correction of orbital dystopia. CASE PRESENTATION: A 34-year-old man, who underwent excision of a neurofibroma on the right eyelid in our clinic, returned to our clinic four years later complaining of dystopia and bulkiness of the protruding mass in the right eyelid and eyebrow. Computed tomographic imaging showed dysplasia and deformity in the sphenoid bone and orbit. A large mass was found in the superior portion of the orbit, protruding towards the temporal lobe, which in turn displaced the orbit downwards. A bicoronary incision and transcranial approach were performed, followed by the excision of the superior orbital space and temporal lobe mass by uncovering certain portions of the frontal, temporal, and zygomatic bones. After the excision of the mass, a calvarial bone graft was used to remodel the longitudinal widened orbit to correct the dystopia. While primary surgery was successful in the correction of dystopia, secondary surgery was performed to correct the exacerbated ptosis by levator muscle resection. CONCLUSIONS: Correction of orbitotemporal neurofibromatosis with dystopia involves three steps: removal of the mass in the orbit to eliminate the effect of downward dislocation of the orbit, placement of a bone graft in the orbit floor after repositioning the orbit for suspension and remodeling of the orbit, and following the correction of dystopia, ptosis may be corrected if needed.

Aplasia Cutis Congenita Associated With Aplasia of the Superficial Temporal Artery.

Aplasia cutis congenita with or without congenital anomalies is a rare congenital disorder most commonly involving the skin of the scalp, as well as the skull and dura.The etiology is uncertain, and several theories, including vascular accident intrauterine period, vascular anomaly, intrauterine infection, teratogen, and aminiotic adhesion, have been proposed. One theory is that lesions of the scalp are usually caused by vascular anomalies.The authors report on a patient with aplasia cutis congenita presenting with a huge skin and skull defect combined with aplasia of the superficial temporal artery, which was thought to be the etiology.

Correction of deep static glabellar lines with acellular dermal matrix insertion.

The glabellar rhytid has not only dynamic but also static cause, which is usually achieved by injection of filler. Deep glabellar rhytides, however, are difficult to correct with filler. Therefore, the authors introduce a novel method of inserting a small strip of acellular dermal matrix (ADM) underneath the wrinkle line. From May 2009 to March 2012, 30 patients were treated for deep glabellar wrinkles with ADM augmentation by the senior author. The surgical outcomes were evaluated by the physician using the Lemperle scale and questionnaires filled out by the patients. The deep rhytides were significantly improved after the procedure, as evaluated by objective and subjective measurements, and their improvement lasted for a long period. No complications such as hematomas or infection were seen on postoperative follow-up. Augmentation with ADM provides a simple, easy, and minimally invasive option for the treatment of deep glabellar wrinkles. In cases of deep glabellar lines that cannot be corrected by filler injection, this procedure can be recommended as another option.

Measuring surgical competency in facial trauma: the Arch Bar Placement Assessment Scale.

BACKGROUND: Surgical education is in a period of significant change. Assessment of surgical competency is imprecise compared with cognitive knowledge and judgment. A surgical competency measurement tool may be useful for plastic surgery training programs and certification societies. We present a validation study of a novel measurement instrument for arch bar placement and dental wire handling. METHODS: An Arch Bar Placement Assessment Scale (ABPAS) was created via consensus by 2 craniofacial and 2 maxillofacial surgeons. Residents and faculty members of plastic and maxillofacial surgery (n = 20) then placed an arch bar on the lower jaw of a skull model. Performances were video recorded without revealing identities. Two study groups were created based on subjects experience level: group 1 (n = 10) previously placed fewer than 25 arch bars; group 2 (n = 10) previously placed more than 25 arch bars. Two craniofacial surgeons used the ABPAS to blindly grade surgical performance. RESULTS: The ABPAS consisted of a 48-point rating scale that included a 23-point task-specific work list and a 25-point global rating scale. Pearson coefficient showed limited intraobserver (P = 0.97) and interobserver (P = 0.95) variance of test scores. The ABPAS demonstrated superior performance in group 2 in the task-specific work list [12.6 (5.5) vs 17.6 (1.5), P = 0.02], global rating scale [17.4 (4.4) vs 22 (2.1), P = 0.01], and ABPAS score [30 (9.8) and 39.6 (3.2), P = 0.01]. CONCLUSIONS: The ABPAS is a novel measurement tool which assesses technical surgical skill and can identify surgical competency in arch bar placement and dental wire handling. This tool may have future use in residency training and continuing education.

Predictive factors for successful limb salvage surgery in diabetic foot patients.

BACKGROUND: The goal of salvage surgery in the diabetic foot is maximal preservation of the limb, but it is also important to resect unviable tissue sufficiently to avoid reamputation. This study aims to provide information on determining the optimal amputation level that allows preservation of as much limb length as possible without the risk of further reamputation by analyzing several predictive factors. METHODS: Between April 2004 and July 2013, 154 patients underwent limb salvage surgery for distal diabetic foot gangrene. According to the final level of amputation, the patients were divided into two groups: Patients with primary success of the limb salvage, and patients that failed to heal after the primary limb salvage surgery. The factors predictive of success, including comorbidity, laboratory findings, and radiologic findings were evaluated by a retrospective chart review. RESULTS: The mean age of the study population was 63.9 years, with a male-to-female ratio of approximately 2:1. The mean follow-up duration was 30 months. Statistical analysis showed that underlying renal disease, limited activity before surgery, a low hemoglobin level, a high white blood cell count, a high C-reactive protein level, and damage to two or more vessels on preoperative computed tomography (CT) angiogram were significantly associated with the success or failure of limb salvage. The five-year survival rate was 81.6% for the limb salvage success group and 36.4% for the limb salvage failure group. CONCLUSION: This study evaluated the factors predictive of the success of limb salvage surgery and identified indicators for preserving as much as possible of the leg of a patient with diabetic foot. This should help surgeons to establish the appropriate amputation level for a case of diabetic foot and help prevent consecutive operations.

Avulsion Fracture of the Extensor Carpi Ulnaris: A Report of Two Cases.

Background Avulsion fracture of the extensor carpi ulnaris (ECU) bony insertion at fifth metacarpal base is a rare injury that may preclude recognition on radiographs. Case Description We report two cases of ECU avulsion fracture, both of which were successfully treated surgically by open reduction and fixation (ORIF). Literature Review Only two cases of ECU avulsion fracture have previously been reported in the literature. Forced motion of the wrist into a position of hyperflexion and/or radial deviation appears to be a common mechanism. Clinical Relevance Clinicians should be aware that ECU avulsion fractures can occur in isolation or in association with other fractures of the hand or wrist. ORIF is warranted due to the prospect of impaired wrist range of motion as well as persistent pain caused by the avulsed fragment.

Highly selective intramolecular carbene insertion into primary C-H bond of α-diazoacetamides mediated by a (p-cymene)ruthenium(II) carboxylate complex.

Complex [(p-cymene)Ru(η(1)-O(2)CCF(3))(2)(OH(2))] mediated transformation of α-diazoacetamides ArCH(2)N(C(CH(3))(3))C(O)CHN(2) to result in carbene insertion into the primary C-H bond exclusively, with the γ-lactam products being isolated in up to 98% yield. This unexpected reaction is striking in view of the presence of usually more reactive sites such as secondary C-H bonds in the substrates. DFT calculations based on proposed Ru-carbene species provide insight into this unique selectivity.

Medial orbital wall fractures and the transcaruncular approach.

We review the literature on medial orbital wall fractures and perform a meta-analysis on outcomes with the transcaruncular approach. The reported incidence for this injury ranges widely, although diagnosis can be made effectively with clinical examination and computed tomography. Clinical sequelae can include rectus entrapment or herniation, enophthalmos, and diplopia. Local injuries occurring in high concordance include concomitant fractures of the orbital floor and nasal fractures, although anterior cranial fossa extension, ocular trauma, other craniofacial injuries, and polytrauma must be ruled out. Indications for operative intervention include large defects, early or persistent enophthalmos particularly if causing diplopia, and rectus muscle entrapment.Various surgical approaches to the medial orbit have been described; however, the transcaruncular approach offers direct, reliable access without creating a cutaneous scar on the central face. A meta-analysis was performed on all studies reporting outcomes of the transcaruncular approach. A total of 228 cases were pooled, finding a favorable overall complication rate of 2.6%. Half of these complications required surgical correction and half resolved nonoperatively.Medial orbital wall fractures are an increasingly appreciated injury requiring clinical and radiologic assessments. When indicated, reconstruction of the medial orbital wall can be safely and effectively performed with the transcaruncular approach. Additional prospective outcomes studies are required to elucidate (1) the incidence of medial orbital wall fractures, (2) indications for operative versus nonoperative management, and (3) outcomes analysis of the transcaruncular approach compared with other approaches.

Volumetric analysis of anterior versus posterior cranial vault expansion in patients with syndromic craniosynostosis.

BACKGROUND: Syndromic craniosynostosis is associated with a high incidence of elevated intracranial pressure. The most common treatment paradigm is to perform anterior cranial vault reconstruction in infancy followed later by possible expansion of the posterior cranial vault and midface advancement. Recently, however, posterior cranial vault expansion has been advocated as an initial step in treatment. We sought to quantify volumetric changes with anterior versus posterior cranial vault surgery in these patients. MATERIALS AND METHODS: We reviewed patients with syndromic brachycephalic craniosynostosis treated in our unit from 2002 to 2009 with existing preoperative fine-cut computed tomographic scans. Using computer software (Analyze; Mayo Clinic, Rochester, MN) and computed tomographic data, the senior author simulated both anterior and posterior cranial vault expansions. Expansion was simulated with a series of translational advancements of the separated segments. Volumetric data were compared for each simulated procedure. RESULTS: Thirteen patients underwent simulated cranial vault reconstructions. At 2, 10, and 20 mm of anterior advancement, the mean increase in intracranial volume was 1.8%, 8.8%, and 17.7%, respectively, whereas posterior advancements achieved 2.4%, 11.9%, and 23.9%, respectively. On average, posterior cranial vault reconstruction created 35% more relative expansion than anterior expansion at equivalent degrees of advancement (P < 0.001). In all simulations, posterior cranial vault reconstruction created greater intracranial volume changes than anterior reconstructions. CONCLUSIONS: This simulation demonstrates that, in syndromic brachycephalic craniosynostosis, posterior cranial vault advancement achieves approximately 35% greater intracranial volume expansion compared with equivalent degrees of anterior cranial vault advancement. This may help guide decisions in treatment sequencing of patients with syndromic craniosynostosis.

Concomitant open reduction of a nasal bone fracture combined with a zygomatic fracture through a subciliary incision.

Nasal bone fracture is the most common of the fractures of the facial skeleton. For centuries, these injuries have been managed with closed reduction, but because of low surgeon satisfaction rates and high revision rates, open reduction is advocated in cases involving severe deviation of the nasal dorsum associated with septal fractures. There are many surgical approaches that can be used to expose the nasal bones, but we present a case where the subciliary incision was used to reduce and fixate the fracture in a patient with combined zygomatic fractures. Owing to the abundance of other concomitant facial fractures with nasal bone fractures, this approach can be used in patients with combined injuries to the facial skeleton, in whom an open reduction of the nasal bones is also required.

Full- versus Sub-Regional Quantification of Amyloid-Beta Load on Mouse Brain Sections.

Extracellular accumulation of amyloid-beta (Aß) plaques is one of the major pathological hallmarks of Alzheimer's disease (AD), and is the target of the only FDA-approved disease-modifying treatment for AD. Accordingly, the use of transgenic mouse models that overexpress the amyloid precursor protein and thereby accumulate cerebral Aß plaques are widely used to model human AD in mice. Therefore, immunoassays, including enzyme-linked immunosorbent assay (ELISA) and immunostaining, commonly measure the Aß load in brain tissues derived from AD transgenic mice. Though the methods for Aß detection and quantification have been well established and documented, the impact of the size of the region of interest selected in the brain tissue on Aß load measurements following immunostaining has not been reported. Therefore, the current protocol aimed to compare the Aß load measurements across the full- and sub-regions of interest using an image analysis software. The steps involved in brain tissue preparation, free-floating brain section immunostaining, imaging, and quantification of Aß load in full- versus sub-regions of interest are described using brain sections derived from 13-month-old APP/PS1 double transgenic male mice. The current protocol and the results provide valuable information about the impact of the size of the region of interest on Aß-positive area quantification, and show a strong correlation between the Aß-positive area obtained using the full- and sub-regions of interest analyses for brain sections derived from 13-month-old male APP/PS1 mice that show widespread Aß deposition.

Quantification metrics for telangiectasia using optical coherence tomography.

Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant disorder that causes vascular malformations throughout the body. The most prevalent and accessible of these lesions are found throughout the skin and mucosa, and often rupture causing bleeding and anemia. A recent increase in potential HHT treatments have created a demand for quantitative metrics that can objectively measure the efficacy of new and developing treatments. We employ optical coherence tomography (OCT)-a high resolution, non-invasive imaging modality in a novel pipeline to image and quantitatively characterize dermal HHT lesion behavior over time or throughout the course of treatment. This study is aimed at detecting detailed morphological changes of dermal HHT lesions to understand the underlying dynamic processes of the disease. We present refined metrics tailored for HHT, developed from a pilot study using 3 HHT patients and 6 lesions over the course of multiple imaging dates, totalling to 26 lesion images. Preliminary results from these lesions are presented in this paper alongside representative OCT images. This study provides a new objective method to analyse and understand HHT lesions using a minimally invasive, accessible, cost-effective, and efficient imaging modality with quantitative metrics describing morphology and blood flow.

Delayed infection after a zygoma fracture fixation with absorbable plates.

A 48-year-old man who had received a bioresorbable plate fixation for a zygomatic bone fracture 13 months earlier visited our clinic complaining of sudden facial swelling. The facial computed tomographic scan showed the soft tissue swelling without any bony abnormality, and the symptoms did not improve after 1 week of antibacterial therapy. The patient had a diagnosis of a late infection caused by unresorbed plates, and exploratory surgery was performed. Partially resorbed plates and screws were seen, and we removed the remnants of such completely. The symptoms were relieved after the operation, and there was no recurrence during 8 months of follow-up.

Preliminary cone-beam computed tomography study evaluating dental and skeletal changes after treatment with a mandibular Schwarz appliance.

INTRODUCTION: The purpose of this study was to evaluate the efficacy of the Schwarz appliance with a new method of superimposing detailed cone-beam computed tomography (CBCT) images. METHODS: The subjects were 28 patients with Angle Class I molar relationships and crowding; they were randomly divided into 2 groups: 14 expanded and 14 nonexpanded patients. Three-dimensional Rugle CBCT software (Medic Engineering, Kyoto, Japan) was used to measure 10 reference points before treatment (T0) and during the retention period of approximately 9 months after 6 to 12 months of expansion (T1). Cephalometric and cast measurements were used to evaluate the treatments in both groups. Also, the mandibular widths of both groups were measured along an axial plane at 2 levels below the cementoenamel junction from a CBCT scan. Differences between the 2 groups at T0 and T1 were analyzed by using the Mann-Whitney U test. RESULTS: The dental arch (including tooth root apices) had expanded; however, alveolar bone expansion was only up to 2 mm below the cementoenamel junction. There was a statistically significant (P <0.05) difference between the groups in terms of crown, cementoenamel junction, root, and upper alveolar process. However, no significant (P >0.05) differences were observed in the interwidths of the mandibular body, zygomatic bones, condylar heads, or mandibular antegonial notches. In the mandibular cast measurements, arch crowding and arch perimeter showed statistically significant changes in the expanded group. The buccal mandibular width and lingual mandibular width values had significant changes as measured from a point 2 mm below the cementoenamel junction. CONCLUSIONS: The findings suggest that the Schwarz appliance primarily affected the dentoalveolar complex, but it had little effect on either the mandibular body or any associated structures. In addition, the molar center of rotation was observed to be below the root apex.

Early surgical correction of microstomia following Stevens-Johnson syndrome.

Stevens-Johnson syndrome (SJS) is a rare disease in which extensive toxic epidermolysis occurs after medication. Skin and mucous membranes are involved in about 90% of SJS cases, and webbing of mouth corners (microstomia) may occur when they are affected. Few reports have been issued on microstomia in SJS, and no consensus has been reached regarding treatment methods, timings, or results. We encountered a case of microstomia following SJS after ofloxacin medication in a 22-year-old woman treated by commissuroplasty using a lozenge-shaped excision. We present an appropriate correction method and surgical timing for microstomia following SJS.

Reconstruction of microstomia considering their functional status.

BACKGROUND: Microstomia is defined as a condition with a small sized-mouth that results in functional impairment such as difficulty with food intake, pronunciation, and poor oral hygiene and cosmetic problems. Several treatment methods for microstomia have been proposed. None of them are universally applicable. This study aims at analyzing the cases treated at our institution critically reviewing the pertinent literature. METHODS: The medical records of all microstomia patients treated in our hospital from November 2015 to April 2018 were reviewed retrospectively. Of these, all patients who received surgical treatment for microstomia were included in the study and analyzed for etiology, chief complaint, surgical method, and outcomes. The functional outcomes of mouth opening and intercommissure distance before and after the surgery were evaluated. The cosmetic results were assessed according to the patients' satisfaction. RESULTS: Five patients with microstomia were corrected. Two cases were due to scar contracture after chemical burn, two cases derived from repeated excision of skin cancer, and one patient suffered sequela of Stevens-Johnson syndrome. The following surgical methods were applied: one full-thickness skin graft on the buccal mucosa, three buccal mucosal advancement flaps after triangular excision of the mouth corner, and one local buccal mucosal flap. Mouth opening was increased by 6.0 mm, and the intercommissure distance improved by 7.2 mm on average. Follow-up was 9.6 months (range, 5-14 months). Cosmetic assessment was as follows: two patients found the results excellent, three judged it as good. CONCLUSION: Microstomia has several causes. In order to achieve optimal functional recovery and aesthetic improvement it is important to precisely evaluate the etiologic factors and the severity of the impairment and to carefully choose the appropriate surgical method.