Deep-Plane Lipoabdominoplasty in East Asians

BACKGROUND: The objective of this study was to develop a new surgical technique by combining traditional abdominoplasty with liposuction. This combination of operations permits simpler and more accurate management of various abdominal deformities. In lipoabdominoplasty, the combination of techniques is of paramount concern. Herein, we introduce a new combination of liposuction and abdominoplasty using deep-plane flap sliding to maximize the benefits of both techniques. METHODS: Deep-plane lipoabdominoplasty was performed in 143 patients between January 2007 and May 2014. We applied extensive liposuction on the entire abdomen followed by a sliding flap through the deep plane after repairing the diastasis recti. The abdominal wound closure was completed with repair of Scarpa's fascia. RESULTS: The average amount of liposuction aspirate was 1,400 mL (700-3,100 mL), and the size of the average excised skin ellipse was 21.78×12.81 cm (from 15×10 to 25×15 cm). There were no major complications such as deep-vein thrombosis or pulmonary embolism. We encountered 22 cases of minor complications: one wound infection, one case of skin necrosis, two cases of undercorrection, nine hypertrophic scars, and nine seromas. These complications were solved by conservative management or simple revision. CONCLUSIONS: The use of deep-plane lipoabdominoplasty can correct abdominal deformities more effectively and with fewer complications than traditional abdominoplasty.

Deep-Plane Lipoabdominoplasty in East Asians

BACKGROUND: The objective of this study was to develop a new surgical technique by combining traditional abdominoplasty with liposuction. This combination of operations permits simpler and more accurate management of various abdominal deformities. In lipoabdominoplasty, the combination of techniques is of paramount concern. Herein, we introduce a new combination of liposuction and abdominoplasty using deep-plane flap sliding to maximize the benefits of both techniques. METHODS: Deep-plane lipoabdominoplasty was performed in 143 patients between January 2007 and May 2014. We applied extensive liposuction on the entire abdomen followed by a sliding flap through the deep plane after repairing the diastasis recti. The abdominal wound closure was completed with repair of Scarpa's fascia. RESULTS: The average amount of liposuction aspirate was 1,400 mL (700-3,100 mL), and the size of the average excised skin ellipse was 21.78×12.81 cm (from 15×10 to 25×15 cm). There were no major complications such as deep-vein thrombosis or pulmonary embolism. We encountered 22 cases of minor complications: one wound infection, one case of skin necrosis, two cases of undercorrection, nine hypertrophic scars, and nine seromas. These complications were solved by conservative management or simple revision. CONCLUSIONS: The use of deep-plane lipoabdominoplasty can correct abdominal deformities more effectively and with fewer complications than traditional abdominoplasty.

Breast Reduction through an Inframammary Incision

PURPOSE: Reduction mammaplasty is a procedure with a relatively high patient satisfaction rate, however, associated scarring around the areola can be a serious problem. This study proposes a new modification of the breast reduction procedure by means of an inframammary incision alone. METHODS: The breast is marked out preoperatively with standing position. Under the general anesthesia, an inframammary incision of approximately 7-8cm is done. The subcutaneous plane is made in the lower pole of the breast, then the subglandular plane is entered and a sharp dissection is made up to 2cm below the areola. The breast is mobilized from the chest wall and a cone-shaped parenchyme is removed in en-block except from the retroareolar central part. The remaining both pillars are gathered together with absorbable sutures and the base of the gland is narrowed to project the breast forward. The wound is closed in a layered fashion and taping of the breast mound is applied to redistribute the breast skin. RESULTS: 21 patients(36 breasts) underwent this procedure from December 2004 to December 2009. Average follow up was 9 months(ranged from 6 months to 12 months). No major complication occurred. Most patients were pleased with the breast size, shape, and scars. However, 2 patients complained their hypertrophic scars which were corrected by revision. CONCLUSION: This technique is a simple approach to mild to moderate breast reduction through an inframammary incision alone. And, this technique provides an option with minimal complications and invisible scarring, which is especially important in the young patient group.

Nipple Reduction with a Pentahedral Excision Technique

PURPOSE: Several methods of the nipple reduction have been reported. However, the methods described previously are difficult or have some demerits. This study proposes a simple technique for reduction of the nipple height as well as diameter. METHODS: The purposed nipple height is marked. A pentahedral design of excision was marked around thenipple. Local anesthetic solution was infiltrated and a 4- 0 Nylon traction suture was applied at the nipple apex. Excision of the nipple inside both two triangles and a rectangle was made. Remaining two flaps were approximated using 5-0 Nylon simple interrupted sutures. However, a part of wound closure was not done in the central area of the nipple. RESULTS: Eighty-three patients (166 nipples) underwent this procedure from December 1999 to December 2008. Follow-up period ranged from 6 months to 2 years with a mean of 10 months. Seventy-eight patients were female and 5 patients were male. No major complications occurred and remaining scars were very inconspicuous. CONCLUSION: This simple technique has the advantage of nipple reduction in both height and diameter, and provides good aesthetic outcomes.

A Correction of Inverted Nipple by Partial Ductal Division and V-Y Advancement of Parenchyma

The pathophysiology of the inverted nipple is characterized by less connective tissue beneath the nipple, dense fibrous tissue at nipple-areola junction and shortened fewer functional lactiferous ducts. For grade I and II nipple inversion, the dissection of dense fibrous tissue at nipple-areola junction is sometimes not enough to completely bring out the nipple and also the recurrence rate is high. These findings suggest that the shortened hypoplastic ducts might play a considerable role in grade I and II nipple inversion. The purpose of this study was to prove the effectiveness of partial ductal division and V-Y advancement of glandular tissue to correct the inverted nipple. Through a 3mm slit incision around the nipple base, partial division of lactiferous ducts was performed and V-Y advancement of parenchyma was followed. The extent of ductal division was limited only to the central portion until the nipple protrusion persisted without any support. A deep purse-string with a 4-0 permanent suture reinforced the advancement of glandular tissue to add bulk beneath the nipple, and a superficial purse-string was applied at the subcutaneous layer to avoid instability of the nipple. 168 female patients(309 nipples) underwent this procedure from April 2000 to June 2008. 37 nipples were grade I and 272 nipples were grade II. No major complication occurred. Overall recurrence rate was 4.2%(13/309). Among 17 women who had breast-fed after correction of inverted nipples, 2 women failed to breast- feed. This safe and simple technique can correct almost all pathologic factors of nipple inversion, and it can also be easily applied to reoperation cases.

Endoscopic Transaxillary Dual Plane Breast Augmentation

PURPOSE: The transaxillary approach for breast augmentation has been advocated for patients and surgeons for several decades. However, this blind technique had many disadvantages including, traumatic dissection, difficult hemostasis, displacement of implants, and ill-defined asymmetrical location of inframammary crease. In the present study, the precise endoscopic electrocautery dissection was applied to eliminate the limits of blunt dissection throughout the procedures. METHODS: From December 2006 to December 2007, a total of 103 patients with an average age of 29.5 years underwent endoscopic assisted transaxillary dual plane augmentation mammoplasty. The mean implant size was 243 cc with the range between 150 and 350cc. Through a 4cm axillary incision, electrocautery dissection for submuscular pockets was carried out under the endoscopic control. The costal origin of pectoralis muscle was completely divided to expose subcutaneous tissue and to make type I dual plane. RESULTS: Using the endoscopic dissection, we achieved good aesthetic results including a short recovery period, less morbidity, and symmetrical well-defined inframammary crease. Type I dual plane procedure could support the consistent inframammary fold shape and be applied to most patients without breast ptosis. Minor complications did not occur, however, four major complications of capsular contracture occurred. CONCLUSION: In contrast to the era of the blind techniques, endoscopic assisted transaxillary dual plane breast augmentation can now be performed effectively and reproducibly. With Its advantage, the axillary application of endoscopy for augmentation mammaplasty is useful to achieve the optimal cosmetic outcomes.

Early Metabolic Changes and Its Considerations after Liposuction

PURPOSE: Advanced techniques now make it possible to remove considerable amounts of subcutaneous adipose tissue more safely with minimum blood loss. However, few have analyzed the metabolic consequences of liposuction. The purpose of this study was to identify the early effects of the surgical removal of subcutaneous fat on metabolic changes in patients who have undergone liposuction. METHODS: Nineteen patients were evaluated from June 2005 to December 2005. Preoperative body weight, serums levels of lipids, apolipoprotein A1, dehydroepiandrosterone(DHEA), uric acid, insulin, and glucose were evaluated. Insulin resistance was determined using the homeostasis model assessment of insulin resistance (HOMA-IR), which is based on fasting glucose and insulin concentrations. All of these data were remeasured in 1 and 4 weeks postoperatively. Tumescent fluid was infiltrated using the superwet technique. The liposuction device used was a Liposlim(R) power-assisted unit. RESULTS: Average volumes of infiltrate and aspirate were 3,268mL and 2,892mL, respectively. Results in 1 week postoperatively demonstrated a significant difference in high-density lipoprotein(HDL) cholesterol, apolipoprotein A1, insulin, and HOMA-IR levels. However, all values were within normal limits and returned to baseline in 4 weeks postoperatively. CONCLUSION: This study provides little to support the presumed therapeutic effect of liposuction. And, it is unclear whether liposuction can prevent or be used to treat the metabolic complications of obesity. However, the results of the present study lead us to believe that liposuction is a metabolically safe procedure.

Endoscope-Assisted Transaxillary Approach in Gynecomastia Correction

Various approaches for gynecomastia correction have been described to remove glandular tissue. In recent years, standard and ultrasound-assisted liposuction became popular methods. However, these methods cannot meet all their needs in some patients who do not want to have scars on their breast's esthetic units and are known to have a tendency to form keloid. The purpose of this study is to introduce the usefulness of endoscope-assisted transaxillary removal of breast tissue in selected patients. Through a stab incision in the axilla, the entire surgical area was infiltrated using the tumescent technique. Ultrasoundassisted liposuction(UAL) was initially performed, followed by power-assisted liposuction(PAL). Then, the endoscope was introduced through a 3 cm axillary incision, and endoscopic electrocautery dissection of glandular tissue was performed under direct vision throughout the procedures. Adjuvant subcutaneous dissection around areola was done via 1 cm subareolar incision. Twelve male patients(22 breasts), whose age ranged from 19 to 38 years, underwent this technique from April 2007 to July 2008. Follow-up ranged from 2 to 16 months with a mean of 9 months. Average volume of aspirate was 290 mL, and mean amount of glandular tissue removed was 35g. No major complications occurred. The resulting scar in the axilla was inconspicuous, and patients were satisfied with postoperative breast contour. These results show that the combined use of an endoscope with the subareolar technique enables an effective treatment of gynecomastia and provides a smooth masculine breast contour without stigma of breast surgery.

Treatment of Various Auricular Diseases Using Magnetic Disks

PURPOSE: The earlobe is one of the areas which are most vulnerable to trauma. Various auricular diseases need compression treatment. We report a new compression method using magnetic disks. METHODS: Seventeen patients with auricular diseases were treated from October 2002 to September 2006. The mean age was 29.1 years. The diseases details were osteochondroma in 2 patients; cauliflower's ears in 2 patients; acute otohematoma in 1 patient; and hypertrophic scars in 11 patients. The most common cause of their disease was ear piercing. The mean follow-up period was 8.9 months. All surgical procedures were performed under local anesthesia. To compress immediately, a pair of magnetic disks was applied to the anterior and posterior surface of the earlobe. RESULTS: The results were generally good. Major complications, such as recurrence, necrosis, dehiscence, or infection, did not occur. CONCLUSION: A pair of magnetic disks are useful compression tool in various auricular diseases.

Treatment of Partial Thickness Skin Defect with Cultured Allogenic Keratinocytes (Kaloderm.)

PURPOSE: Grafting with autograft skin remains the most effective method for treating skin defects. When insufficient donor sites are present or patients are afraid of the operation, a skin graft is impossible. Cultured allogenic keratinocytes speed wound healing by providing cover and by producing growth factors and extracellular matrix protein. We report an application of cultured allogenic keratinocytes (Kaloderm., Tegoscience, Seoul, Korea) in the treatment of an acute partial thickness skin defect. METHODS: From March 2005 to January 2006, 20 patients with a partial thickness skin defect were treated with cultured allogenic keratinocytes. The wound was covered with a sheet of cultured allogenic keratinocytes and ointment with Bactigras. gauze. The wound was inspected every two or three days. We regarded completion of epithelialization as wound healing. RESULTS: The mean period between time of injury and time of Kaloderm. application was 7.5 days. The time taken from application of Kaloderm. to complete closure of the wounds was 7.2 days. CONCLUSION: In view of the favorable outcome, cultured allogenic keratinocytes are safe and effective biologic dressing materials for use in the treatment of open wounds.

Reconstruction of Scarred Umbilicus Using an Inverted C-V Flap: A Case Report

PURPOSE: The umbilicus is an important aesthetic component of the abdomen. Its absence is both cosmetically and psychologically distressing to the patient. Umbilical reconstruction should always be aimed at creating an umbilicus of sufficient depth and good morphology with less scarring. The C-V flap developed for nipple reconstruction was used in an inverted fashion in case of umbilical reconstruction. The aim of this article is to report our experience of scarred umbilical reconstruction using inverted C-V flap. METHODS: A 22-year-old woman presented with contracted scar tissue in the umbilical region because she had undergone surgical correction of an umbilical hernia at 5 year of age. Pedicle of the inverted C-V flap was based cephalically. For enhancing depth of the umbilicus, three anchoring sutures to linea alba were done at both lateral and caudal aspects of the umbilical tube. Primary closures were done at donor sites of the V flaps and bolster sutures were done in the caudal direction of the inverted umbilical tube. RESULTS: The patient was satisfied with the appearance of umbilicus. Major complications such as dehiscence, infection, and delayed healing did not occur. CONCLUSION: The inverted C-V flap is easy and simple technique, and it can produce a satisfactory reconstruction of umbilical structure.

Comparison of the Usefulness of MDCT (Multidetective Computed Tomogram) in Facial Bone Fractures

PURPOSE: In maxillofacial surgery, proper preoperative diagnosis is very important in achieving good postoperative results. Although conventional CT scans are useful for visual representations of fractures, they cannot provide direct guidance for reconstructing facial bone fractures. However, the recent technology of multislice scanning has brought many clinical benefits to CT images. Direct correlations can be made between preoperative imaging data and operative planning. The aim of the current study is to evaluate the differences between conventional CT and multidetective three-dimensional CT(3D MDCT) measurements in craniofacial deformities. METHODS: From January 2005 to November 2005, MDCT scans of 41 patients were evaluated by comparing them with conventional CT scans. The 3D MDCT images were assessed and reviewed by using a simple scoring system. RESULTS: The 3D MDCT scans offered easy interpretation, facilitated surgical planning, and clarified postoperative results in malar complex fractures, mandibular fractures, and extensive maxillofacial fractures and cranioplasty. However, 3D MDCT images were not superior to conventional CT scans in the diagnosis of blowout fractures. CONCLUSION: In spite of its limitations, the 3D MDCT provided additional and more comprehensive information than the conventional CT for preoperative assessment of craniofacial deformities. Therefore, the 3D MDCT can be a useful tool for diagnosis and systematic treatment planning in craniofacial skeletal deformities.

ROM(Reducing Opposed Multilobed) Flap Repair for the Treatment of Medium Sized Skin Lesion

PURPOSE: Circular skin lesions between 10 and 35 mm in diameter generate problems often. Direct closure of the lesion risks excessive wound tension or wound dehiscence. Skin grafts heal slowly and often remain unsightly. Traditional skin flaps have a limited role. We treated this circular medium-sized skin lesion(10 - 35 mm sized) by reducing opposed multilobed(ROM) flap. METHODS: ROM flap involves a series of semicircular lobes extending both cephalic and caudal from the defect. Direction of the semicircular multilobed flap is set parallel to relaxed skin tension line(RSTL) to minimize scar formation. First semicircle is drawn 60% in diameter of the defect. Second semicircles are drawn at the cephalic and caudal aspects of the original semicircles. These semicircles are 60% in diameter of the first semicircle. Additional semicircles are repeatedly drawn until the tension of skin flaps becomes free. ROM flap has a length-to-base ratio of 0.5 resulting in lower theoretical risk of end flap necrosis than a random pattern flap with a large ratio. The technique involves lobes most distant from the primary defect being transposed in turn closer to the defect. RESULTS: The ROM flap reduces skin tension concerns, lowers the risk of flap necrosis and allows for quicker and more aesthetic healing. Results were generally good and major complications, such as dehiscence, infection, or delayed healing, did not occur. CONCLUSION: ROM flap repair allows the plastic surgeon an additional option when faced with a circular medium-sized skin lesion.

Simultaneous Correction of Depressed Scar Using Dermofat Graft Harvested during Scar Revision

While no scar can be completely erased, most linear facial scars can result in a relatively good scar after revision. However, in case of round shaped depressed scar, the scar is often lengthened following an incisional technique. This study focuses on the technique of dermofat graft harvested from the adjacent scars for correction of depressed scars. 18 patients having multiple facial scars with a depressed scar among 375 patients who had undergone scar revision were treated from June 2003 to May 2004. Dermofat was harvested from the adjacent linear scar, then it was deepithelialized, reshaped, and grafted to the depressed scar through a small incision. Cosmetic results were generally good. Complications were overcorrection in 4 patients; hyperpigmentation occured in 1 patient. However, 13 patients were satisfied with the results. The advantages of our technique are as follows: it does not require additional operation; dermofat graft has low absorbable rate; it can maintain the volume with an adequate texture.

Correction of Unilateral Ptosis of the Gluteal Fold after Liposuction: A Case Report

A 37-year-old woman complained of unilateral ptotic gluteal fold in her left gluteal area. She had undergone two times of liposuction procedures on her buttocks, thighs, and flanks five years and two years ago. Initially, we marked a 16x5cm2 elliptical design over the ptotic gluteal skin on her standing position. The elliptical area was deepithelialized and two 6cm long separate transverse incisions were made on the dermis of the deepithelialized skin flaps. Through these incisions, blunt dissections down to the gluteal fascia were carried out. Using 2-0 PDS sutures, the edges of the incisions were anchored to the gluteal fascia at the predetermined level corresponding to the inferior border of the gluteus muscle. Upper and lower dermal flaps were incorporated in a layered fashion(3-0 and 4-0 PDS) and the remaining skin was approximated with 5-0 nylon sutures in a continuous manner. Symmetry was achieved postoperatively and the scar was negligible because it was concealed in the gluteal crease. In conclusion, the anchoring technique of deepithelialized skin flaps to the gluteal fascia is very useful for correction of the buttock ptosis, especially resulting from closed degloving injuries, and applicable for the patients who have lost their natural infragluteal fold.

Clinical Experiences and Considerations of Large-Volume Liposuction

A review of recent reports showed that many surgeons define large-volume liposuction as the removal of over 5000ml of total aspirate. However, no clinical reports of single procedures in Korean involving aspirate volume of 5000 ml or greater have been presented. From May 2002 to December 2004, 59 patients with age averaging 31.2 years old underwent large-volume liposuction. Liposuction was performed using the superwet technique and a Lipomatic(R) vibropneumatic system. Clinical data, which included; body weight changes and BMIs at a postoperative 2 months, hemoglobin and hematocrit at a postoperative 2 days, operative time, and volume of infiltrate and aspirate, were evaluated. The average volumes of infiltrate and aspirate were 6916.7+/-1665.8ml and 6549.6+/-1787.2ml, respectively. Mean patient weight had decreased from 62.96+/-14.21 to 58.61+/-13.43kg with an average weight loss of 4.35kg, and mean body mass index from 23.84+/-3.91 to 22.17+/-3.70kg/m2 with an average drop of 1.67kg/m2; equivalent to a fall in weight per liter of aspirated volume of 0.66+/-0.09kg/L. Falls in hemoglobin and hematocrit per liter of aspirate volume were 0.46+/-0.07g/dl/L and 1.70+/-0.35%/L, respectively. Mean operative time per liter of aspirate was 39.6+/-2.1min/L. Complications were palpable skin irregularity in 5 patients; hyperpigmentation scars occurred in 5 patients; 2 of the heaviest women required blood transfusions; and 1 patient experienced prolonged edema. One major complication of subclinical fat embolism occurred. Cosmetic results were generally good. In conclusion, if patients are properly selected and fluid resuscitations are performed adequately, single stage liposuction involving aspirations of greater than 5000ml can be undertaken safely in Korean.

Treatment of Axillary Osmidrosis with Power- Assisted Lipoplasty(PAL)

Axillary osmidrosis is caused by excessive apocrine gland secretion, which causes an unpleasant odor. Axillary osmidrosis causes difficulty in social activities and personal handicap. Many surgical procedures have been introduced for treatment of axillary osmidrosis. Most of them are based on the surgical excision of subcutaneous tissue including apocrine glands. However, these methods also have complications such as wide surgical scar, skin necrosis, hematoma, seroma. For this reason, developing a new treatment that is as effective as surgery but causes fewer complications is reasonable. We have used the technique of power-assisted lipoplasty(PAL) as a method of treatment for axillary osmidrosis. From July 2003 to June 2004, a total of 45 patients(26 men and 19 women) had been treated with this procedure for axillary osmidrosis. Forty patients(88.89 percent) had good results, and 2 patients(4.47 percent) had poor results. The power-assisted lipoplasty(PAL) for axillary osmidrosis has the advantages of a high success rate with minimal complications and rapid recovery for daily activity. Therefore, power-assisted lipoplasty(PAL) is a viable option for treatment of axillary osmidrosis.

A Study on the Knowledge about the Plastic Surgery(II)

The authors presented 'A study on the knowledge about the field of plastic surgery(I)' decade ago. Since then, the cognition toward a plastic surgery might be altered by the evolution of internet and social atmosphere taking count of outward appearance. Therefore the authors studied again about the cognition to the plastic surgery. The subjects were total 1812 of high school and college students residing in Seoul, Korea from October through December in 2003 and 1812 students are consisted of 839 male and 973 female. The contents of questionnaire are as follows: 1. The cognition to the plastic surgery. 2. The cognition to the difference between plastic surgery and orthopedic surgery. 3. The cognition to the operation performing in the filed of plastic surgery. 4. The known operation kinds of plastic surgery. 5. The experience of plastic surgery operation. We compared the results of this survey with that in 1992. The results of research showed 15.1% increase in the cognition to the plastic surgery, 5.6% increase in the cognition to the difference between plastic surgery and orthopedic surgery and 9% increase in the cognition to the operation performing in the filed of plastic surgery. In the known operation kinds of plastic surgery, a double-eyelid operation was the most well known and followed by rhinoplasty and augmentation mammoplasty, but in 1992, a double-eyelid operation was followed by rhinoplasty and rhytidectomy. In the experience of plastic surgery operation, the result showed 6.3 %, which has more than doubled in the last 10 years. Increase of the cognition to the plastic surgery is inspired, but that results is localized to aesthetic field.

Configuration of Upper Lip in Newborn

Millard presented the concept of rotation advancement for unilateral cleft lip repair, and today this method of cleft lip closure is acknowledged by most as optimal in principle. However, it has been noted that this procedure occasionally can produce a scar that is symmetrical on the lower two-thirds of philtral column. The scar crosses the upper one third of the philtrum obliquely. The purpose of our study is to determine the configuration of the philtrum. 200 newborn infants were examined from June 1998 to September 1998. Mean gestational ages were 39 weeks and 5 days. Mean birth weight was 3226 gm. Multiple parameters such as philtral shape, nostril sill shape, vermilion shape, curvature of Cupid's bow, mean philtral length, mean white roll length, mean Cupid's bow length, and mean distance between both commissures were applied. An arbitrary classification of the philtrum was established to divide these infants into five groups. As a result, the parallel philtral column from nostril base to vermilion border(Type lla) was found to be the most popular type. Most common vermilion shape was protrusion type. Normal curve of Cupid's was most common. Mean values of philtral length, white roll length, Cupid's length, and distance between commissures were 8.3+/-1.1 mm, 13.9+/-1.3 mm, 5.7+/-1.0 mm, 24.7+/-2.3 mm, respectively. We believe this classification system will be useful for newborn infants evaluation and analysis, systemic planning and application of proper cleft lip repair procedure.

The application of cranofacial osteotomies to surgical exposure of crantofacial tumors

Access to the craniofacial skeleton and skull base requires osteotomies. An adequate exposure of neoplasms occupying the skull base and the oral cavity and oropharynx, especially retromolar trigone, is very important for precise tumor ablation. The demonstration by Tessier of the capacity for large segments of bone to survive removal and replacement has enabled skull base tumor surgery to grow into a subspeciality. Through the refined craniofacial exposure osteotomies, the surgery is safer, the operation shorter, and the result better both oncologically and reconstructively. We experienced 24 cases of exposure osteotomies consisting of 12 cases transzygomatic approaches, 1 case tranglabellar osteotomy, 1 case lateral transmaxillary approach, 1 case Le Fort II & midline splitting, and 9 cases mandibulotomy. There was no significant complication except a local wound infection in transzygomatic approach and one case of minimal malocclusion after parasymphyseal mandibulotomy. The orthotopic bone graft and the rigid fixation enables the postoperative morbidity to decrease. It seems that the previously inaccessible craniofacial tumors can be treated through the various exposure osteotomies.