Successful replantation of an avulsed frontal scalp through microvascular anastomoses of only one artery and one vein: a case report

Scalp avulsion is a devastating injury. The best possible procedure is replantation. Several successful scalp replantations with anastomoses of several vessels in large defects have been reported. In this report, we present a case of replantation of a large scalp avulsion using revascularizing with only one artery and vein. Despite the initial signs of flap congestion, we could predict the survival of the replanted scalp and terminate the procedure after detecting good perfusion and washout with indocyanine green fluorescence imaging. The procedure was successful following the patient's recovery of sensory and sweating functions without complications such as flap necrosis or infection. Several important factors for successful scalp replantation with positive esthetic and functional outcomes were considered.

Application of augmented reality using automatic markerless registration for facial plastic and reconstructive surgery

This study aimed to present a novel markerless augmented reality (AR) system using automatic registration based on machine-learning algorithms that visualize the facial region and provide an intraoperative guide for facial plastic and reconstructive surgeries. This study prospectively enrolled 20 patients scheduled for facial plastic and reconstructive surgeries. The AR system visualizes computed tomographic data in three-dimensional (3D) space by aligning with the point clouds captured by a 3D camera. Point cloud registration consists of two stages: the preliminary registration gives an initial estimate of the transformation using landmark detection, followed by the precise registration using Iterative Closest Point algorithms. Computed Tomography (CT) data can be visualized as two-dimensional slice images or 3D images by the AR system. The AR registration error was defined as the cloud-to-cloud distance between the surface data obtained from the CT and 3D camera. The error was calculated in each facial territory, including the upper, middle, and lower face, while patients were awake and orally intubated, respectively. The mean registration errors were 1.490 ± 0.384 mm and 1.948 ± 0.638 mm while patients were awake and orally intubated, respectively. There was a significant difference in the errors in the lower face between patients while they were awake (1.502 ± 0.480 mm) and orally intubated (2.325 ± 0.971 mm) when stratified by facial territories (p = 0.006). The markerless AR can accurately visualize the facial region with a mean overall registration error of 1-2 mm, with a slight increase in the lower face due to errors arising from tube intubation.

Effect of Therapeutic Radiation on Polycaprolactone/Hydroxyapatite Biomaterials in a Calvarial Model

Bone defects caused by cancer resection often require postoperative radiotherapy. Although various synthetic polymers have been introduced as graft materials, their biological behavior after radiation exposure remains unclear. Here, we investigated how polycaprolactone/hydroxyapatite (PCL/HA) implants respond to therapeutic radiation exposure (in terms of volume and bone regeneration). Four 8 mm diameter calvaria defects were surgically created on the parietal bone of 6 rabbits. PCL/HA implants made of porous, solid, and hybrid polymers were grafted by random placement in each defect. The fourth defect was left untreated. Four weeks after surgery, radiation exposure was conducted weekly for 6 weeks (total: 48 Gy). Micro-computed tomography and histologic analysis were performed at 3 and 6 months, and 6 months postradiation, respectively. The total augmented volumes of all implants showed no significant differences between 3- and 6-months postradiation computed tomography images. In histologic analysis, new bone areas were 0.45±0.11 mm2, 2.02±0.34 mm2, and 3.60±0.77 mm2 in solid, hybrid, and porous polymer grafts, respectively. Bone regeneration was limited to the periphery of the defect in the hybrid and porous polymer grafts, whereas new bone formed inside the porous implant. The total augmented volume of the defect was maintained without significant absorption even after radiation exposure. The PCL/HA implant maintained its structure despite radiation exposure. The porous PCL/HA implant demonstrated excellent bone regeneration, followed by the hybrid and solid implants. The PCL/HA implant is a promising candidate for bone defect reconstruction.

The Volumetric Effect of Botulinum Toxin Type A Injection on the Parotid Gland: A Randomized Controlled Trial

BACKGROUND

Botulinum neurotoxin type A (BTX-A) to the masseter muscle is a useful tool for the aesthetic narrowing of the width of the lower face. The administration of BTX-A to visible parotid glands is also effective to reduce lower facial width. However, no studies have quantitatively analyzed the effect of BTX-A on the parotid glands.

METHODS

The purpose of this study was to confirm the impact of BTX-A injection on the parotid gland and to suggest the effective dosage of BTX-A in facial slimming. This study was conducted by selecting patients who desired facial slimming from among patients who required surgery for a facial bone fracture. Patients undergoing BTX-A injection were randomized to high-dose, low-dose, and placebo groups, and different doses of BTX-A for each group were injected into both parotid glands during facial bone surgery.

RESULTS

A total of 30 patients were enrolled in this study. Ten patients in the high-dose group, eight in the low-dose group, and nine in the control group completed the clinical trial. There were significant changes in both the high- and low-dose groups compared with the control group ( P < 0.001, P < 0.001), and in interaction of time and group ( P < 0.001). Volume recovery after 3 months was found in 7.6% in the high-dose group and in 4.8% in the low-dose group.

CONCLUSION

BTX-A injection into parotid glands can be an effective treatment option in managing salivary gland enlargement for lower face contouring.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, II.

Effect of neck extension on intraocular pressure in paediatric patients undergoing palatoplasty

BACKGROUND

Intraocular pressure (IOP) can increase with postural changes, which can cause ocular complications. Neck extension is commonly used during palatoplasty to improve surgical angulation. This study evaluates whether neck extension affects IOP during palatoplasty.

METHODS

In this prospective observational study, IOP was measured using a rebound tonometer at four specific time points: T1, 10 min after anaesthesia while in the supine position; T2, 5 min after neck extension; T3, at completion of palatoplasty with neck extended; and T4, 5 min after returning to the supine position. The primary outcome was the IOP at T2, and the secondary outcomes were the IOPs at T3 and T4. Haemodynamic and respiratory variables were also measured at each time point.

RESULTS

Thirty-seven patients were included. IOP at T2 was significantly higher than at T1 (15.8 ± 3.4 mmHg vs 10.5 ± 2.8 mmHg, P < 0.001), and IOPs at T3 and T4 were also significantly higher than at T1 (T3 vs T1: 18.9 ± 3.6 mmHg vs 10.5 ± 2.8 mmHg, P < 0.001; T4 vs T1: 13.3 ± 3.7 mmHg vs 10.5 ± 2.8 mmHg, P < 0.001). However, no significant differences were observed for the haemodynamic and respiratory variables at any time point.

CONCLUSION

Our findings indicate that the intraoperative neck extension position during palatoplasty significantly increases IOP in paediatric cleft palate patients undergoing a palatoplasty.

Neck Extension and Intraocular Pressure Elevation During Palatoplasty in a Patient with Patau Syndrome and Congenital Glaucoma: A Case Report

Patau syndrome (trisomy 13) is a severe disorder associated with multiple systemic defects. Patau syndrome is commonly associated with ocular abnormalities but rarely associated with congenital glaucoma. To obtain a better surgical view, palatoplasty requires neck extension during surgery. The intraocular pressure (IOP) of patients with Patau syndrome can increase owing to the neck extension position while undergoing palatoplasty, particularly in those with congenital glaucoma. Here, we describe a case with increased IOP measured using a rebound tonometer during palatoplasty in a pediatric patient with Patau syndrome and congenital glaucoma. This case shows that it may be important to reduce the degree of neck extension and shorten the operation time to minimize any increase in the IOP during palatoplasty in pediatric patients with Patau syndrome accompanied by congenital glaucoma.

Three-Dimensional Analysis of Flap Volume Change in Total Tongue Reconstruction: Focus on Reinnervated Dynamic Tongue Reconstruction

In general, flap volume decreases over time and further in the case of a denervated muscle flap. In our institution, dynamic reconstruction, including functional muscle flaps, has been used to aid functional recovery in the past 6 years. This study aimed to determine the effect of volume change of the fat and muscular sections of reconstructed tongue flaps after motor nerve reinnervation in dynamic total tongue reconstruction using 3-dimensional measurement and analysis. A retrospective chart review was performed on 21 patients who underwent total tongue reconstruction using an anterolateral thigh free flap from 2015 to 2020. The fat and muscle volumes of the flap were measured using computed tomography data obtained before surgery (T0), 2 weeks after surgery (T1), and 6 months after surgery (T2) using a 3-dimensional rendering software. Among the 21 patients that underwent tongue reconstruction, 10 underwent dynamic reconstruction, whereas 11 underwent conventional reconstruction using a fasciocutaneous flap. T2 volume compared with T1 was 69.08% in the conventional reconstruction group, and the fat and muscle portions in the dynamic reconstruction group were 77.04% and 69.06%, respectively. No significant difference was noted in the volume change between the 2 groups. After dynamic tongue reconstruction, the muscular volume of the flap had similar volume reduction rate as the fat volume. The dynamic reconstruction was effective not only for functional muscle transfer but also for maintaining the volume of the reconstructed muscle flap.

Impact of Dynamic Tongue Reconstruction on Sequential Changes of Swallowing Function in Patients Undergoing Total or Near-Total Glossectomy

PURPOSE

This study aimed to compare the effects of motor-innervated free flap on sequential changes of swallowing function in patients undergoing total or near-total glossectomy with laryngeal preservation.

MATERIALS AND METHODS

The medical charts of 21 patients who underwent tongue reconstruction after total or near-total glossectomy between April 2015 and December 2020 were retrospectively reviewed. Patients were divided into groups by reconstruction type: conventional, reconstruction using an anterolateral thigh free flap (n = 11), and dynamic, reconstruction using an anterolateral thigh with innervated vastus lateralis flap (n = 10). Demographics, surgical details, and survival outcomes were investigated. A videofluoroscopic penetration-aspiration scale and functional outcome swallowing scale were analyzed according to postoperative time courses, classified as within 6 months, 6 to 12 months, and after 12 months postoperative. A time-to-event analysis was performed for gastrostomy tube status.

RESULTS

The dynamic group showed improved swallowing outcomes at 6 to 12 months postoperative (dynamic vs conventional group, penetration-aspiration scale: 3 ± 1.51 vs 6 ± 1.63, P = 0.024; functional outcome swallowing scale: 1.89 ± 1.36 vs 4 ± 1.41, P = 0.009). In the multivariate analysis, the dynamic group showed a decreased probability of decompensated swallowing function at 6 to 12 months postoperative (odds ratio, 0.062; 95% confidence interval, 0.004-1.084; P = 0.057). A time-to-event analysis revealed no significant difference in gastrostomy tube status between the dynamic and the conventional group.

CONCLUSIONS

Considering higher mortality in patients subjected to total or near-total glossectomy, dynamic reconstruction with motor-innervated free flap is worth to perform in terms of enhancing the swallowing function within 1-year postoperative period, thereby improving the quality of life.

Current concepts of vascular anomalies

Vascular anomalies encompass a variety of malformations and tumors that can result in severe morbidity and mortality in both adults and children. Advances have been made in the classification and diagnosis of these anomalies, with the International Society for the Study of Vascular Anomalies establishing a widely recognized classification system. In recent years, notable progress has been made in genetic testing and imaging techniques, enhancing our ability to diagnose these conditions. The increasing sophistication of genetic testing has facilitated the identification of specific genetic mutations that help treatment decisions. Furthermore, imaging techniques such as magnetic resonance imaging and computed tomography have greatly improved our capacity to visualize and detect vascular abnormalities, enabling more accurate diagnoses. When considering reconstructive surgery for facial vascular anomalies, it is important to consider both functional and cosmetic results of the procedure. Therefore, a comprehensive multidisciplinary approach involving specialists from dermatology, radiology, and genetics is often required to ensure effective management of these conditions. Overall, the treatment approach for facial vascular anomalies depends on the type, size, location, and severity of the anomaly. A thorough evaluation by a team of specialists can determine the most appropriate and effective treatment plan.

Swallowing analysis in hemi-tongue reconstruction using motor-innervated free flaps: A cine-magnetic resonance imaging study

BACKGROUND

This study aimed to explore the outcomes of motor-innervated free flaps in hemi-tongue reconstruction by assessing the tongue mobility through midsagittal images from cine-magnetic resonance imaging.

METHODS

In this retrospective study, 47 patients who underwent tongue reconstruction following hemi-glossectomy and 10 control subjects without any surgical history were included. Patients were classified into two groups: the motor and no-motor innervation group. Various spatial parameters related to tongue mobility that were acquired from midsagittal sections were compared during consecutive swallowing phases.

RESULTS

Overall, the motor group showed improved functional swallowing scale compared with the no-motor group. In case of tongue base resection, the motor group showed improved mobility of the tongue base during pharyngeal phase, whereas the no-motor group showed increased laryngeal elevation for compensatory movement.

CONCLUSION

The tongue reconstruction with motor-innervated free flaps may facilitate swallowing capacity in patients with a hemi-tongue defect combined with tongue base resection.

Efficacy and safety of equine cartilage for rhinoplasty: a multicenter double-blind non-inferiority randomized confirmatory clinical trial

Background

The efficacy and safety of equine cartilage as a competent xenograft material for rhinoplasty were evaluated and compared to the outcomes of rhinoplasty using silicone implants.

Methods

We performed a multicenter, double-blind, non-inferiority, and randomized confirmatory study. Fifty-six patients were randomized 1:1 to the study group (using MegaCartilage-E) and control group (using silicone implants). The Rhinoplasty Outcome Evaluation (ROE) score, photo documentation, Global Aesthetic Improvement Scale (GAIS), and adverse event data were obtained until 12 months after surgery. The primary efficacy, which is the change in ROE score 6 months after surgery, was assessed in the modified intention-to-treat set. The secondary efficacy was evaluated in the per-protocol set by assessing the change in ROE score 6 and 12 months after surgery and nasofrontal angle, the height of the nasion, and GAIS 1, 6, and 12 months after surgery.

Results

The change in ROE score of the study group was non-inferior to that of the control group; it increased by 24.26±17.24 in the study group and 18.27±17.60 in the control group (p=0.213). In both groups, all secondary outcome measures increased, but there was no statistical difference. In the safety set, treatment-emergent adverse events occurred in 10 patients (35.71%) in the study group and six patients (21.43%) in the control group (p=0.237). There were 13 adverse device events in the study group and six adverse device events in the control group (p=0.515).

Conclusion

Processed equine cartilage can be used effectively and safely as xenograft material for rhinoplasty.

Clinical Application of Three-Dimensional Printing of Polycaprolactone/Beta-Tricalcium Phosphate Implants for Cranial Reconstruction

Polycaprolactone (PCL) implants are a biodegradable polymeric material with appropriate mechanical strength and durability for use in cranioplasty. They can be manufactured as patient- customized implants using a three-dimensional (3D) printer. Herein, the authors aimed to share our experience in cranioplasty of patients with deformed and asymmetric skulls using PCL/beta- tricalcium phosphate (ß-TCP) implants.

Seven patients underwent cranioplasty using patient-specific PCL/ß-TCP implants. Cranial computed tomography images were converted to a 3D model and mirrored to design a patient-specific implant. Based on the 3D simulation, an implant was 3D printed using PCL/ß-TCP. A 6-month follow-up was conducted with periodic visits and computed tomography scans. Symmetry after surgery and complications were evaluated.

Postoperatively, the soft tissue volumes increased to 15.8 ± 17.2 cm³ and 14.9 ± 15.7 cm³ at 2 weeks and 6 months of follow-up, respectively. The volume change from 2 weeks to 6 months was —4.4 ± 2.5%. Six patients achieved complete symmetry after cranioplasty, whereas 1 patient noticed partial symmetry. The symmetry remained unchanged at 6 months of follow-up. Upon palpation to assess smoothness, 6 patients exhibited a smooth edge interface, whereas 1 patient had a slightly irregular edge.

Based on these findings, 3D-printed PCL/ß-TCP implants are an excellent material for cranioplasty, and a favorable cosmetic outcome can be achieved. Specifically, these novel PCL/ß-TCP implants have good biocompatibility and mechanical strength without any postoperative foreign body reaction.

Counterclockwise Rotational Orthognathic Surgery for the Obstructive Sleep Apnea in Class II Dentofacial Deformity: Polysomnography and 3D Computed Tomographic Analysis

ABSTRACT

Traditionally, maxillomandibular advancement is an orthognathic surgical procedure that has been used to manage obstructive sleep apnea in patients not able or willing to maintain adherence to continuous positive airway pressure therapy or for patient who are not able to adhere to treatment. However, maxillomandibular advancement often leads to unsatisfactory cosmetic results.This prospective study investigated functional and esthetic outcomes using polysomnography and 3-dimensional computed tomography, after counterclockwise rotational orthognathic surgery. We enrolled 17 patients with obstructive sleep apnea, who underwent orthognathic surgery at single institution between March 2013 and December 2018.After 12 months, the patients' mean self-rated score for facial appearance, using a 10-step visual analog scale, was 7.36. The preoperative apnea-hypopnea index and respiratory disturbance index were 34.70 and 37.45, respectively; postoperative indices were 11.60 and to 12.69, respectively (P = 0.003, 0.003). The mean posterior pharyngeal airway space increased from 5357.88 mm3 preoperatively to 8481.94 mm3 after 6 postoperative months.Counterclockwise rotational orthognathic surgery for the correction of obstructive sleep apnea turned out to be the ideal solution not only in the correction of the sleep apnea, but also in the facial esthetics.

Dynamic Hemitongue Defect Reconstruction With Functional Gracilis Muscle Free Transfer

BACKGROUND

Because the tongue consists of 26 intrinsic and extrinsic muscles, even hemiglossectomy, which preserves some of the tongue and its muscles, leads to functional morbidity in speech and swallowing. Subsequent reconstruction using a conventional fasciocutaneous flap results in limited functional recovery. This study compared the functional recovery of patients who underwent hemiglossectomy based on the fasciocutaneous free flap with or without dynamic gracilis muscle flap reconstruction.

METHODS

Twenty-three patients were included in the study. Reconstruction was achieved using radial forearm and gracilis conjoined flaps (n = 7), gracilis flaps (n = 7), and radial forearm flaps (RFFFs) (n = 9) between 2014 and 2019. Functional outcome data were collected via videofluoroscopic swallowing, speech analysis, and a tongue movement scale.

RESULTS

In the conjoined flap group, the lingual range of motion in terms of elevation and defect-side lateralization was superior to that of the RFFF group. Furthermore, the conjoined flap was associated with superior protrusion, elevation, and lateralization (on both sides) than the gracilis-only flap. Patients who underwent conjoined-flap reconstruction had better articulation, intelligence, and dysphagia outcomes than patients who underwent reconstruction with RFFFs or gracilis-only flaps.

CONCLUSIONS

Although this was a preliminary study, the findings suggest that using a conjoined free flap with an RFFF and a functional gracilis muscle flap for dynamic hemitongue reconstructions could improve postoperative tongue function.

Dynamic Oromandibular Reconstructions Using Chimeric Fibular and Gracilis or Vastus Lateralis Free Flaps

Background Despite efforts of head and neck functional reconstruction, anatomic restoration has been used until now. This article describes our experience of using a chimeric free fibular osteocutaneous flap conjoined with a functional muscle free flap, defined as dynamic oromandibular reconstruction.

Methods Through a retrospective chart review, four consecutive patients who underwent reconstruction with a total fibular free flap were included. The former two patients underwent reconstruction using a conventional osteocutaneous free fibular flap. The latter two patients had an oromandibular defect after cancer resection and underwent dynamic oromandibular reconstruction with a chimeric free fibular flap conjoined with a gracilis free flap or vastus lateralis muscle free flap.

Results In the speech analysis, the dynamic group revealed a satisfactory tongue movement. Protrusion and lateralization were the most different movement changes. The tongue range of motion score was 62.5 in the dynamic group and 25.0 in the control group. On the dynamic magnetic resonance imaging, the contact of the soft palate with the tongue was excellent, and the epiglottis closure during deglutition was complete. In the three-dimensional volumetric analysis of mandibular aesthetic contouring, the dynamic group showed a much smaller difference in hemifacial volume, with a difference of 73.7 mL in the dynamic group and 101.76 mL in the control group.

Conclusion This study is a preliminary trial of dynamic oromandibular reconstruction using chimeric free fibular flaps with functional muscle transfer. We demonstrated the possibility of dynamic oromandibular reconstruction, which enhanced more functional aspects in the patients in this study.

Analysis of Speech and Functional Outcomes in Tongue Reconstruction after Hemiglossectomy

Background Reconstruction in tongue cancer to restore the shape and function of the tongue without airway obstruction in the narrow oral cavity is challenging for reconstructive surgeons. Herein, the authors retrospectively analyzed flaps to reveal the factors that affect the functional outcome of tongue reconstruction.

Methods Herein, we retrospectively reviewed 30 patients (men, 16; women, 14; mean age, 50.3 years) who underwent the hemi-tongue reconstruction followed by speech therapy between 2009 and 2017. Data about postoperative chemotherapy and radiotherapy were collected. The dimensions (width and length) of the flaps were measured. Speech outcomes were assessed under the conditions of varying distances of the tongue tip from lower incisors when it was protruded, retracted, and elevated. Lateralization was evaluated based on the count of teeth reached by the tip of the tongue from the midline.

Results Preoperative chemotherapy and radiotherapy significantly influenced tongue retraction, tongue articulation, and intelligibility (p = 0.006, 0.002, 0.048, respectively). Postoperative chemotherapy did not statistically significantly influence any outcome measure. Contralateralization of the tongue was significantly decreased in the postoperative radiotherapy group (p = 0.029). The length of the flap showed highly negative correlation with articulation and intelligibility (p = 0.009, p< 0.001, respectively). The width of the flap was not correlated with the outcomes.

Conclusion We proved that unlike chemotherapy, postoperative radiotherapy influences the functional outcome of tongue reconstruction. The dimensions, particularly the length of the flap, were also important for restoring the reconstructed tongue function.

Impact of Recipient Vein Selection on Venous Patency and Free Flap Survival in 652 Head and Neck Reconstructions

Background This study was conducted to evaluate the impact of choosing a particular recipient venous system on venous patency and flap survival in 652 head and neck free flap reconstructions.

Methods A retrospective review was performed. Patient factors investigated included: age, sex, type of flap, tumor location, history of radiation, presence of previous neck dissection, tumor stage, and any underlying disease. Data related with recipient vein including the number of anastomosis, the repair technique, the type of recipient vein, and the configuration of selected venous system were examined. The impact of patient factors and parameters related with recipient vein on the venous patency and flap survival were analyzed using bivariate and multivariate analyses.

Results Of 652 free flaps, 36 flaps (5.5%) were re-explored due to venous congestion and 28 flaps (77.8%) were salvaged. The overall survival rate of total free flaps was 98.8%. The type of recipient venous system was found to be an insignificant factor with respect to venous congestion and flap survival in multivariate analysis. A history of radiation treatments was the only factor associated with a higher risk of venous compromise (odds ratio [OR] = 13.138, p < 0.001) and a lower rate of flap survival (OR = 20.182, p = 0.002).

Conclusion The selection of recipient venous systems has no impact on venous patency and flap survival. History of radiation treatment was the only factor associated with venous congestion and flap failure. Since no single method can ensure a successful reconstructive result, selecting the optimal recipient vein should be based on individual patient factors and the surgeon's experience.

Three-dimensional orbital wall modeling using paranasal sinus segmentation

PURPOSE

Three-dimensional orbital wall modeling is a time-consuming process because of the presence of pseudoforamina. We developed an automated three-dimensional modeling software to characterize the orbital wall, and evaluated it using data from fracture patients.

METHODS

We first characterized the air and face regions using multiphase segmentation; the sinuses were segmented by applying morphological operations to air regions. Pseudoforamina of the orbital wall were offset with the segmented sinuses. Finally, the three-dimensional facial bone model, with orbital wall, was reconstructed from the segmented images.

RESULTS

Ten computed tomography data sets were used to evaluate the proposed method. Results were compared with those obtained using the active contour model and manual segmentation. The process took 31.7 ± 8.0 s, which was 30-60 times faster than other methods. The average distances between surfaces obtained with the proposed method and those obtained with manual segmentation (normal side: 0.20 ± 0.06 mm; fractured side: 0.28 ± 0.10 mm) were approximately half those obtained using the active contour model.

CONCLUSIONS

Three-dimensional orbital wall models, which were very similar to the manually segmented models, were archived within 1 min using the developed software, regardless of fracture presence. The proposed method might improve the safety and accuracy of surgical procedures.

Comparison of Periorbital Anthropometry Between Beauty Pageant Contestants and Ordinary Young Women with Korean Ethnicity: A Three-Dimensional Photogrammetric Analysis

BACKGROUND

The purpose of this study is to investigate the differences in the periorbital anthropometry between national Beauty Pageant Contestants and Ordinary Young Women with Korean ethnicity.

METHODS

Forty-three Beauty Pageant Contestants who were elected for the national beauty contest and forty-eight Ordinary Young Women underwent 3D photography. The authors analyzed 3D photogrammetric measures regarding periorbital soft tissue.

RESULTS

The palpebral fissure width was significantly higher in the Beauty Pageant Contestants than the Ordinary Young Women (27.7 ± 1.2 vs. 26.3 ± 1.6 mm) (p < 0.001). The palpebral fissure height was also significantly higher in the Beauty Pageant Contestants (11.5. ± 1.0 vs. 9.1 ± 1.2 mm) (p < 0.001). The intercanthal width and upper eyelid height were smaller for the Beauty Pageant Contestants (intercanthal width, 34.3 ± 1.86 mm vs. 36.7 ± 3.1 mm; upper eyelid height, 11.5 ± 1.4 mm vs. 13.4 ± 2.3 mm) (p < 0.05). The nasal width and midfacial width were significantly smaller in the Beauty Pageant Contestants (nasal width, 38.0 ± 1.8 vs. 39.5 ± 2.2 mm; midfacial width 144.5 ± 3.9 vs. 146.9 ± 5.2 mm) (p < 0.05). The eyebrow showed significantly different features between the two groups in terms of vertical position in the upper face and the shape of the brow apex. The interpupillary distance, binocular distance, slant of palpebral fissure and width of pretarsal crease showed no significant difference between the two groups.

CONCLUSION

Periorbital features in Beauty Pageant Contestants are wide-set eyes, larger palpebral fissure in width and height, relatively small upper eyelid height and intercanthal width, and relatively small nose and facial width compared to normal women. Our anthropometric results can be referable values for Asian eyelid surgery and help surgeons to establish individualized surgical planning.

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 .

Patient-specific puzzle implant preformed with 3D-printed rapid prototype model for combined orbital floor and medial wall fracture

BACKGROUND

The management of combined orbital floor and medial wall fractures involving the inferomedial strut is challenging due to absence of stable cornerstone. In this article, we proposed surgical strategies using customized 3D puzzle implant preformed with Rapid Prototype (RP) skull model.

METHODS

Retrospective review was done in 28 patients diagnosed with combined orbital floor and medial wall fracture. Using preoperative CT scans, original and mirror-imaged RP skull models for each patient were prepared and sterilized. In all patients, porous polyethylene-coated titanium mesh was premolded onto RP skull model in two ways; Customized 3D jigsaw puzzle technique was used in 15 patients with comminuted inferomedial strut, whereas individual 3D implant technique was used in each fracture for 13 patients with intact inferomedial strut. Outcomes including enophthalmos, visual acuity, and presence of diplopia were assessed and orbital volume was measured using OsiriX software preoperatively and postoperatively.

RESULTS

Satisfactory results were achieved in both groups in terms of clinical improvements. Of 10 patients with preoperative diplopia, 9 improved in 6 months, except one with persistent symptom who underwent extraocular muscle rupture. 18 patients who had moderate to severe enophthalmos preoperatively improved, and one remained with mild degree. Orbital volume ratio, defined as volumetric ratio between affected and control orbit, decreased from 127.6% to 99.79% (p < 0.05) in comminuted group, and that in intact group decreased from 117.03% to 101.3% (p < 0.05).

CONCLUSION

Our surgical strategies using the jigsaw puzzle and individual reconstruction technique provide accurate restoration of combined orbital floor and medial wall fractures.

Comparison of endocranial morphology according to age in one-piece fronto-orbital advancement using a distraction in craniosynostotic plagiocephaly

The capacity for cranial remodelling is known to be better at younger ages. The timing of cranioplasty could affect the axis of the skull base. We investigated whether age at the time of distraction is related to the outcome of endocranial morphology correction. In this retrospective study, we investigated the surgical outcome of 14 patients with unilateral craniosynostotic plagiocephaly who underwent one-piece fronto-orbital advancement without bandeau by using a distraction technique between April 2005 and December 2015. Satisfactory results were achieved in all 14 patients with unilateral coronal suture craniosynostosis. An average distraction of 27.3 mm was obtained without detachment from the dura mater. The endocranial angulation of the anteroposterior axis was reduced from 165.4° to 173.5° on average, and the average total change was 8.1°. Between patients aged <1 year and those >1 year, there was a statistically significant difference in the postoperative endocranial angulation of the anteroposterior axis after 3 months (p = 0.003). The distraction techniques resulted in better correction of endocranial morphology. This indicates that the changes in the skull base axis after one-piece fronto-orbital advancement without bandeau are related to the remodelling capacity of the skull base in growing children based on the dura mater.

3D Photogrammetric Analysis of the Nasal Tip Projection and Derotation Based on the Nasal Tip Quadripod Concept

BACKGROUND

Regarding septal fixation in nasal tip plasty, the nasal tip tripod theory may require modification. We performed three-dimensional (3D) photogrammetric analysis of the "Skiff graft," which is a quadripod method involving folded conchal cartilages fixated on the caudal septal angle, paired lateral crura reinforced by a derotational conchal cartilage graft, and conjoined medial crus on the columella base. We assessed the efficacy of the Skiff graft in maintaining tip projection and preventing cephalic rotation of the nasal tip.

METHODS

In total, 39 patients who underwent nasal tip plasty with the Skiff graft during 2012-2015 and underwent 3D photogrammetry before (T0), immediately postoperatively (T1, average of 1 week postoperatively), and an average of 215 days postoperatively (T2) were included. Nasal tip projection was objectively measured from images using a software program.

RESULTS

The average differences between the T0 and T1, T0 and T2, and T1 and T2 lengths were 4.81, 3.57, and 0.85 mm, respectively. Thus, 81% of the change in tip projection length that had been achieved immediately postoperatively was maintained at T2 based on 3D photogrammetry (P < 0.001). The relapse ratio of the examined technique was 19.26% (mean, 0.85 mm; P < 0.001).

CONCLUSIONS

Nasal tip plasty with the Skiff graft preserves septal support and is an effective primary and revision rhinoplasty technique in Asian patients. This approach may be suitable as an alternative to nasal tip plasty with the septal extension graft in terms of maintaining nasal tip projection, rotational controllability, and nasal mobility.

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 .

Comparison of Aesthetic Outcomes Between Vertical and Horizontal Flap Insets in Breast Reconstruction with the TRAM or DIEP Flaps

BACKGROUND

Tissue transfer, such as use of the transverse rectus abdominis myocutaneous (TRAM) or deep inferior epigastric artery perforator (DIEP) free flaps, is considered a standard method. However, outcomes may vary among inset methods. Here we compared the aesthetic outcomes of breast reconstructions using vertical and horizontal flap inset methods.

METHODS

We, respectively, reviewed 274 patients who underwent unilateral post-mastectomy breast reconstruction using TRAM or DIEP free flaps between April 2006 and December 2013. Photographs (frontal and bilateral oblique views) obtained 6 months post-operatively were evaluated. Symmetry scores and regional volume discrepancy scores were compared between the vertical and horizontal inset groups. Symmetry scores were adjusted for 11 potential confounding factors on multivariate regression analysis.

RESULTS

The vertical inset method was associated with higher total symmetry scores, projection, and ptotic naturalness scores. On multivariate regression analysis, the inset method was an independent predictor of outcomes. Regional volume discrepancy score analysis showed a greater tendency for more symmetrical volumes in the upper, medial, and lateral poles with the vertical inset.

CONCLUSION

The flap inset method is one of the key determinants of aesthetic breast reconstruction outcomes. The vertical inset method was associated with superior aesthetic outcomes and enabled balanced distribution of flap volume to the four poles of the breast.

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 .

Free-flap reconstruction for the management of life-threatening hereditary hemorrhagic telangiectasia

Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant multi-systemic disease that exhibits increasing penetrance with age. Some patients present with severe life-threatening epistaxis which is intractable to all common treatment modalities. A 63-year-old female patient with hereditary hemorrhagic telangiectasia (HHT) presented with recurrent life-threatening epistaxis that required repeated transfusions despite multiple embolizations and septodermoplasty. Previous septodermoplasty failed due to septal perforation. Resurfacing of the nasal lining with a free flap was planned. Total removal of the nasal mucosa and remaining septum was conducted to make the nasal cavity into one common cavity. Nasal passages were resurfaced with a radial forearm free flap. Following surgery, the patient experienced no further significant epistaxis. Fasciocutaneous free-flap resurfacing might represent a curative solution for cases of HHT intractable to conservative treatment and septodermoplasty, especially for patients with large septal perforation.

Oral and Oropharyngeal Reconstruction with a Free Flap

Extensive surgical resection of the aerodigestive track can result in a large and complex defect of the oropharynx, which represents a significant reconstructive challenge for the plastic surgery. Development of microsurgical techniques has allowed for free flap reconstruction of oropharyngeal defects, with superior outcomes as well as decreases in postoperative complications. The reconstructive goals for oral and oropharyngeal defects are to restore the anatomy, to maintain continuity of the intraoral surface and oropharynx, to protect vital structures such as carotid arteries, to cover exposed portions of internal organs in preparation for adjuvant radiation, and to preserve complex functions of the oral cavity and oropharynx. Oral and oropharyngeal cancers should be treated with consideration of functional recovery. Multidisciplinary treatment strategies are necessary for maximizing disease control and preserving the natural form and function of the oropharynx.

Histologic comparison between the internal mammary artery and the deep inferior epigastric artery and clinical implications for microsurgical breast reconstruction

BACKGROUND

The internal mammary artery (IMA) is one of the most popular recipients for microsurgical breast reconstruction. However, it is often separated into sleeve-like layers when it is handled. This study tried to explain this unique behaviour of the IMA through histologic observation.

METHODS

Nine pairs of IMAs and DIEAs were harvested and subject for haematoxylin-eosin and Verhoeff's elastic staining. Thickness of the tunica media and the number of elastic lamellae were compared. Samples of the IMA, the DIEA, and the thoracodorsal artery from another patient were observed through the transmission electron microscope to further show the structural differences.

RESULTS

The most notable difference was presence of multiple elastic lamellae in tunica media in the IMAs, which was barely present in the DIEAs. The mean number of elastic lamellae was 9.2 in the IMA group and 1.0 in the DIEA group (p < 10(-9)). A transmission electron microscope showed that the tunica media of the DIEA and the TDA was densely packed with smooth muscle cells, while the muscle cells distributed sparsely in the IMA.

CONCLUSIONS

The IMA is an elastic artery which is characterised by multiple layers of elastic lamellae while relatively lacking in smooth muscle cells. The wall of the IMA is easily dissected between the tunica media and the adventitia, or at the outer 1/3 of the tunica media. The inner structure is easily torn if microsutures do not engage the tunica adventitia.

Adjuvant chemotherapy reduces the incidence of abdominal hypertrophic scarring following immediate TRAM breast reconstruction

Among the many factors that affect the degree of completion and satisfaction of breast reconstruction, the scarring is one issue that a surgeon cannot completely control. We hypothesized that the administration of cytotoxic drugs following the immediate breast reconstruction using transverse rectus abdominis musculocutaneous (TRAM) flap might affect the process of scarring, thus resulting in reduced incidence of hypertrophic scarring at the donor site. Data have been collected from 1,000 consecutive patients between July 2001 and December 2009. The relationship between the adjuvant chemotherapy and the incidence of hypertrophic scarring was studied, and the influence of other presumed risk factors was analyzed. The incidence of hypertrophic scarring was 18.6 % (75 of 404) in the non-CTX group and 3.8 % (20 of 530) in the CTX group. Univariate analysis using logistic regression modeling confirmed the statistical significance of the reducing effect of chemotherapy on the incidence of hypertrophic scarring (p < 0.001; OR: 0.172). The incidence of donor-site hypertrophic scarring following immediate TRAM breast reconstruction was found in nearly 20 % of the patients without chemotherapy, showing a significant difference from the patients with chemotherapy. We believe that Asian patients who undergo immediate TRAM breast reconstruction without chemotherapy are a high-risk group that is prone to hypertrophic scarring, requiring active preventive measures.

Cloning, sequencing, and expression of porcine interleukin-18 in Escherichia coli

IL-18 is the new name of a novel cytokine that plays an important role in T(H1) response, primarily by its ability to induce IFN-gamma production in T cells and natural killer cells. The porcine IL-18 gene was isolated using RT-PCR from porcine alveolar macrophages. Sequence analysis of the porcine IL-18 gene has demonstrated an open reading frame of 579 base pairs encoding 192 amino acids precursor protein with a predicted molecular mass of 22 kDa. The porcine IL-18 gene shares 84% and 89% similarity to the human and canine equivalents, respectively, at the nucleotide level. The cloned IL-18 was expressed in Escherichia coli and its expression was confirmed by SDS-PAGE and Western blotting.

Clothing selection behavior of the aged women for thermal comfort

Wearing behavior and thermoregulatory responses of five young women (YG; 20 +/- 1 yr) and five aged women (AG; 65 +/- 3 yr) to indoor cold in summer were investigated in this study. The subjects were exposed to 21.0 +/- 0.5 degrees C and 55 +/- 5% RH while seated during a 90-minute experiment. The subjects were allowed to select and wear for thermal comfort clothing whenever they needed additional clothing during the experiment. Rectal temperature (Tre) and temperatures of 7 sites (head, chest, forearm, hand, thigh, leg, foot) of the skin of the subjects were measured every 10 minutes. Mean skin temperature (Tsk) of the subject was obtained every 10 minutes. First selection time of additional clothing was monitored and weight of selected total clothing was calculated. The results for this study were as follows: Tre and Tsk gradually decreased in YG and AG, however Tre decreased less than Tsk which decreased greater in AG than YG (p < 0.01). AG's first selection of additional clothing and thermal sensation response were slower than YG's. Furthermore, total clothing weight was less in AG than YG. It was concluded that clothing selection behavior would modify the intrinsic thermoregulatory responses of the aged women to the cold stress in the summer.

[Rapid detection of Theileria sergenti by polymerase chain reaction]

Four separate pairs of oligonucleotide primers within the coding region in a T. sergenti 33-kDa surface protein gene were selected to detect T. sergenti by PCR. The specificity of PCR-amplified DNA was examined by digestion with restriction enzyme and Southern blot hybridization using T. sergenti p33 DNA probe. PCR appears to be specific for T. sergenti, without detectable signals from uninfected erythrocytes, uninfected bovine leukocytes and other hemoparasites, including A. marginale and B. ovata. Although 46 of 71 specimens (64.8%) from grazing cattle were microscopically positive, PCR in this study showed that 64 specimens (88.7%) were positive. Therefore, PCR proves a useful diagnostic tool for detecting T. sergenti-infected cattle. In addition, it is also revealed that PCR was significantly more sensitive than traditional microscopic examination using Giemsa's stain.

Different thermal conditions of the extremities affect thermoregulation in clothed man

The effects of different types of clothing on human deep body temperature were studied with six healthy male subjects in a supine posture. Two clothing ensembles were employed for the present study: A covered the whole body area with garments except the face (1.97 clo) and B covered only the trunk and the upper half of the extremities with garments (1.53 clo). The experiment was carried out in a climatic chamber at 55% +/- 5% relative humidity under cooling and warming temperatures: the temperature was changed from 22 degrees C to 10 degrees C (cooling) and returned to 22 degrees C again (warming). The major findings were: rectal temperature (T(re)) continued to decrease gradually in A throughout the experiment, whereas in B it increased during cooling, and returned to previous levels during warming. As a result, T(re) and chest skin temperature were maintained at a higher level in B than in A. Internal tissue conductances were greater in A than in B both during cooling and during warming. Thermal comfort appeared to have been influenced more by the rate of skin temperature change than by the level of skin temperature per se. It was concluded that peripheral vasoconstriction in B induced less heat flow from core to shell, and, thus, the core temperature was maintained at a higher level in B than in A.

Circadian rhythm of rectal temperature in man with two different types of clothing

We compared the circadian rhythm of human rectal temperature with two different types of clothing at an ambient temperature of 27.5 degrees +/- 0.5 degrees C and a relative humidity of 40 +/- 10%. One clothing covered the whole body area except for the head, hands and feet (Type A, weight 475 g, 0.98 clo), the other covered the trunk, upper arms and thighs (Type B, weight 366 g, 0.93 clo). Major findings are summarized as follows: (1) Late evening fall after retiring and a morning rise after rising in the rectal temperature rhythm were significantly quicker in Type B than in Type A. (2) Late evening rise after retiring and a morning fall after rising in the skin temperatures of the extremities were quicker in Type B than in Type A. (3) A range of oscillation in the circadian rectal temperature rhythm was significantly larger in Type B than in Type A. It was suggested that the quicker late evening rise and morning fall of the skin temperatures in the extremities after retiring and rising, respectively, might be responsible for the quicker late evening fall and morning rise of the circadian rectal temperature.

Effects of wearing two different forms of garment on thermoregulation in men resting at 10 degrees C

We have compared the human thermoregulatory responses and clothing microclimate temperature when the body core-shell ratio was changed by wearing two different forms of garment. Each was worn for 160 min at an ambient temperature of 10 degrees C and a relative humidity of 50% by six healthy males in the supine posture. One garment covered the whole body area except for the face (long-sleeves: L-S), the other covered the central body area alone (half-sleeves: H-S). Major findings are summarized as follows: 1) Rectal temperature was kept higher by H-S than L-S even though L-S showed higher thermal resistance values. 2) The standard deviation of rectal temperature was smaller in H-S. 3) Trunk skin and clothing microclimate temperatures were also kept higher by H-S. We suggest that the reduced level of rectal temperature in L-S might be ascribed to a different pattern of venous return originating in the mechanisms of the counter-current heat exchange system: the venous return from the periphery into the thoracic and abdominal areas being cooler in L-S than in H-S.