Upper Lip Fat Grafting Using the Anatomical Subunit and Fat Compartment Principles Improves Lip Cant and Symmetry in Patients With Unilateral Upper Lip Asymmetries.

BACKGROUND: Fat grafting is a widely adopted method for reconstructing upper lip asymmetries. However, most surgical techniques are difficult to reproduce, and none follow anatomical principles. OBJECTIVES: The aim of this study was to assess the clinical outcomes of upper lip contour asymmetry and lip cant correction by anatomical upper lip fat grafting using the subunit and fat compartment principles. METHODS: A prospective analysis was conducted of 113 consecutive patients who underwent anatomical upper lip fat grafting using the subunit and fat compartment principles for the management of lip cant and/or upper lip contour (volumetric) asymmetry. Quantitative photogrammetric upper lip symmetry and lip cant measurements were blindly performed preoperatively and at 3 and 12 months postoperatively. A panel assessment (by 8 blinded external plastic surgeons and 8 laypersons) was obtained to grade the qualitative upper lip symmetry. Bivariate and multivariate analyses were performed to identify independent variables associated with the 12-month postoperative lip cant change. RESULTS: There was significant (all P < 0.05) postoperative quantitative and qualitative upper lip symmetry and lip cant enhancement (preoperative < postoperative) after a single upper lip fat grafting procedure, and the outcomes were maintained (all P > 0.05) from 3 to 12 months postoperatively. Parry-Romberg syndrome was negatively associated (P < 0.05) with the 12-month postoperative lip cant change. CONCLUSIONS: Anatomical upper lip fat grafting, using the subunit and fat compartment principles, improves lip cant and symmetry in patients with unilateral upper lip asymmetries.

Outcomes of Surgical Management of Palatal Fistulae in Patients With Repaired Cleft Palate.

BACKGROUND: The palatal fistula is an important surgical challenge within the longitudinal follow-up of patients with repaired cleft palate as the success rate of palatal fistula reconstruction by adopting several surgical techniques is variable and often unsatisfactory. The purpose of this retrospective study was to report the clinical outcomes of an algorithm for the surgical management of palatal fistulae in patients with repaired cleft palate. METHODS: Consecutive patients (n = 101) with repaired cleft palate and palatal fistula-related symptoms who were treated according to a specific algorithm between 2009 and 2017 were included. Based on the anatomical location (Pittsburgh fistula types II-V), amount of scarring (minimal or severe scarred palate), and diameter of the fistula (≤5 mm or >5 mm), 1 of 3 approaches (local flaps [62.4%], buccinator myomucosal flaps [20.8%], or tongue flaps [16.8%]) was performed. For clinical outcome assessment, symptomatic and anatomical parameters (fistula-reported symptoms and residual fistula, respectively) were combined as follows: complete fistula closure with no symptoms; asymptomatic narrow fistula remained; or failure to repair the fistula ("good," "fair," or "poor" outcomes, respectively). Surgical-related complication data were also collected. RESULTS: Most patients (91.1%) presented "good" clinical outcomes, ranging from 86.2% to 100% (86.2%, 100%, and 100% for local flaps, buccinator flaps, and tongue flaps, respectively). All (8.9%) "fair" and "poor" outcomes were observed in fistulae reconstructed by local flaps. All "poor" (5%) outcomes were observed in borderline fistulae (4-5 mm). No surgical-related complications (dehiscence, infections, or necrosis) were observed, except for an episode of bleeding after the 1st stage of tongue flap-based reconstruction (1.0%). CONCLUSION: A high rate of fistula resolution was achieved using this algorithm for surgical management of palatal fistulae in patients with repaired cleft palate.

Predictors of Speech Outcome in Posterior Pharyngeal Fat Graft Surgery for Velopharyngeal Insufficiency Management.

BACKGROUND: The identification of variables potentially correlated with speech outcome, following posterior pharyngeal fat grafting for treatment of velopharyngeal insufficiency (VPI), can provide useful information to guide decision-making and preoperative counseling. This study assessed the predictors of speech outcome after posterior pharyngeal fat grafting for VPI management. METHODS: One hundred and sixty-seven consecutive patients with repaired cleft palate and VPI who underwent posterior pharyngeal fat grafting were retrospectively enrolled. Perceptual speech and nasendoscopic parameters were randomly rated by 3 blinded evaluators. Speech outcome was stratified based on previously published criteria. Bivariate and multivariate analyses were performed to identify independent predictors of 15-month postoperative speech outcomes. RESULTS: Large velopharyngeal gap, higher number of previous palatal surgical procedures, and referral pattern (ie, patients who underwent primary palatoplasty elsewhere) were independently negative (for all, P < 0.05) predictors of speech outcome, whereas small velopharyngeal gap size was positively (P < 0.05) correlated with this outcome. Age, sex, race, Veau hierarchy, syndromic diagnosis, Angle classification of malocclusion, type of primary palatoplasty, body mass index, obstructive sleep apnea-related scores, surgical period, donor site, grafted volume, recipient site-related complications, and preoperative status (velopharyngeal closure pattern, hypernasality, audible nasal emissions, and intraoral pressure) were not associated (for all, P > 0.05) with speech outcomes. CONCLUSION: Posterior pharyngeal fat grafting improves speech function in patients with VPI, whereas gap size, number of previous palatal surgeries, and referral pattern affect the speech outcome.

Tailored Posterior Pharyngeal Fat Grafting Outcomes in Velopharyngeal Insufficiency Managed According to a Simplified Algorithm.

BACKGROUND: This study aimed to evaluate the outcomes of posterior pharyngeal fat grafting for the management of velopharyngeal insufficiency using a simplified therapeutic algorithm and a tailored surgical technique. METHODS: This was a prospective study of consecutive nonsyndromic patients with repaired cleft palate and velopharyngeal insufficiency who were stratified according to a simplified algorithm (minimally scarred palate, transverse orientation of levator veli palatini, and pinhole-to-small velopharyngeal gaps) and who underwent tailored posterior pharyngeal fat grafting. The patients were screened for obstructive sleep apnea before and after surgery. Three blinded evaluators randomly rated perceptual speech (hypernasality, audible nasal emission, and intraoral pressure) and nasoendoscopic (velopharyngeal active gap size) characteristics using audio and video recordings. Successful speech outcome was defined as normal or borderline sufficient velopharyngeal function at 15 months after surgery. RESULTS: All included patients (n = 96) presented with a preoperative and postoperative low risk of obstructive sleep apnea. At 15 months after surgery, hypernasality (0.26 ± 0.53), audible nasal emissions (0.29 ± 0.48), intraoral pressure (0.1 ± 0.31), and velopharyngeal closure size (1.86 ± 0.34) were significantly decreased (all, P < 0.05) compared with the corresponding preoperative measurements (hypernasality, 2.17 ± 0.75; audible nasal emissions, 1.89 ± 0.82; intraoral pressure, 0.85 ± 0.35; and velopharyngeal closure size, 0.2 ± 0.49). In total, 84 (87.5%) patients showed successful speech outcomes. CONCLUSIONS: Tailored posterior pharyngeal fat grafting is an effective and safe surgical strategy for the management of velopharyngeal insufficiency in a selected cohort of patients with repaired cleft palate.

Brazilian-Portuguese Linguistic Validation of the Velopharyngeal Insufficiency Effects on Life Outcome Instrument.

BACKGROUND: The purpose of this study was to conduct a linguistic validation of the velopharyngeal insufficiency (VPI) Effects on Life Outcome (VELO) instrument for use in Brazilian-Portuguese patients with VPI. METHODS: The original English version of the VELO instrument was translated into Brazilian-Portuguese, back-translated, and adapted among the Brazilian patients (n = 21) with VPI and their parents, based on the standardized guidelines for the cross-culture adaption process. Discrepancies in the forward and backward translation steps were computed. Comprehension rates were captured for each debriefing interview. The content validity index (CVI) per item (I-CVI) and of the scale (S-CVI universal agreement [S-CVI/UA] and averaging [S-CVI/Ave]) were calculated. RESULTS: Reconciliation of the 2 forward translations and the comparison between the back translation and the original VELO version resulted in some item wordings with discrepancies which were reviewed by the research team (translators, expert committee, and original developers of instrument). Three rounds of cognitive interviews also led to some revisions of wording. Comprehension rates of patients and their parents were 60% to 100%, 80% to 100%, and 100% in the first, second, and third rounds of cognitive interviews, respectively. The I-CVI, S-CVI/AU, and SCI/Ave for the Brazilian-Portuguese VELO version were 0.83 (or higher), 0.83 (or higher), and 0.97, respectively. CONCLUSIONS: The linguistic validation process of the VELO instrument created a cross-culturally equivalent Brazilian-Portuguese version for use in Brazilian-Portuguese speaking patients with VPI.

Isolated Fat Grafting for Reconstruction of Lower Face Volumetric Asymmetry in Skeletally Immature Patients: A Clinical Outcome Study.

BACKGROUND: The purpose of this study was to assess the objective and subjective outcomes of lower face volumetric (contour) asymmetry correction with isolated fat grafting in skeletally immature patients. METHODS: A prospective analysis was conducted of skeletally immature patients (n = 73) with craniofacial microsomia and Parry-Romberg syndrome who underwent isolated fat grafting (with no previous or concomitant bone surgery) using anatomical surgical principles (facial subunits and fat compartments) for the reconstruction of lower face volumetric asymmetry. Objective ultrasound and photogrammetric lower face symmetry analyses were blindly performed preoperatively and at 3 and 12 months postoperatively. A panel assessment of blinded surgical professionals and laypersons was also obtained to grade the subjective lower face symmetry. RESULTS: There were significant (all P < 0.05) postoperative objective and subjective lower face symmetry enhancements (preoperative < postoperative) after isolated fat grafting, with no differences (all P > 0.05) between 3 versus 12 months' postoperative comparisons. CONCLUSIONS: Growing patients with unilateral lower face volumetric asymmetries presented with improvement of objective and subjective symmetry after a single isolated fat grafting procedure.

Measuring Patient-Reported Health-Related Quality of Life in Velopharyngeal Insufficiency: Reliability and Validity of the Brazilian Portuguese Version of the VELO Instrument.

OBJECTIVE: To test the Brazilian Portuguese velopharyngeal insufficiency (VPI) Effects on Life Outcome (VELO) instrument for reliability and validity. DESIGN: Cross-sectional methodological study. SETTING: Tertiary craniofacial medical center. PARTICIPANTS: Participants with VPI (VPI group, n = 60), with cleft and without VPI (no VPI/cleft group, n = 60), and with no cleft nor VPI (no VPI/no cleft group, n = 60) and their parents (n = 180). INTERVENTIONS: All patients with VPI 8+ years old and their parents completed the Brazilian-Portuguese VELO instrument and other questionnaires (Pediatric Quality of Life Inventory4.0, PedsQL4.0; Pediatric Voice-Related Quality of Life, PVRQOL; and Intelligibility in Context Scale, ICS) at baseline; patients with VPI and their parents completed the VELO instrument again 2 weeks later. MAIN OUTCOME MEASURES: The VELO instrument was tested for internal consistency, test-retest reliability, discriminant validity (participants with VPI against participants with no VPI), concurrent validity against other questionnaires, criterion validity against hypernasality severity, and construct validity against nasal air emission and overall velopharyngeal competence (speech construct) and velopharyngeal gap (anatomic construct). RESULTS: The VELO had excellent internal consistency (Cronbach α 0.99 for parents and 0.98 for participants with VPI) and test-retest reliability (all intraclass correlation coefficient > 0.87). The VELO discriminated well between VPI group and unaffected groups (all P < .05). The VELO was significantly correlated with the PedsQL4.0, PVRQOL, and ICS (-r > 0.75; P < .001). The VELO met criterion validity, speech construct validity, and anatomic construct validity (r > 0.7; P < .001). CONCLUSIONS: The Brazilian-Portuguese VELO instrument demonstrated reliability (internal consistency and test-retest) and validity (discriminant, concurrent, criterion, and construct).

Treinamento formal em documentação fotográfica bidimensional padronizada durante a residência em cirurgia plástica / Formal training in two-dimensional standardized photographic documentation during residency in Plastic Surgery

Introdução: A Cirurgia Plástica exige inúmeras habilidades, conhecimentos e competências, e seu escopo de atuação é amplo e desafiador. Dessa forma, todos os cirurgiões plásticos passam por uma extensa educação/formação, que se inicia durante a residência e continua ao longo da vida. O objetivo deste estudo foi delinear um treinamento formal em documentação fotográfica bidimensional padronizada para complementar o treinamento cirúrgico e científico durante a residência em Cirurgia Plástica. Métodos: Os componentes (as estratégias, os tópicos abordados e os processos de aquisição de habilidades e feedback) do treinamento em documentação fotográfica durante a residência em Cirurgia Plástica foram detalhados. Resultados: As atividades dos residentes, as interações entre os residentes o fotógrafo profissional e os cirurgiões/ preceptores e os tópicos abordados (estúdio fotográfico, câmeras fotográficas, objetivas, princípios fotográficos [exposição, abertura, velocidade, ISO e profundidade de campo], iluminação, preparo e posicionamento dos pacientes e da câmera fotográfica, situações fotográficas, vistas fotográficas, banco fotográfico, formatos de imagens, fotogrametria computadorizada e questões éticas e médico-legais) do programa de treinamento em documentação fotográfica foram delineados. Conclusão: O treinamento em documentação fotográfica complementa o arsenal de habilidades necessários aos residentes de Cirurgia Plástica em formação, com o intuito de melhor prepará-los para as carreiras futuras.

Introduction: Plastic surgery requires diverse skills, knowledge, and competencies, and its scope is broad and challenging. Thus, all plastic surgeons go through extensive education/training, which begins during residency and continues throughout their lives. This study aims to outline a formal training program in 2-dimensional standardized photographic documentation ("photodocumentation") to complement surgical and scientific training during residency in Plastic Surgery. Methods: The components (strategies, topics covered, skills acquisition, and feedback processes) of training in photodocumentation during residency in Plastic Surgery were detailed. Results: Topics in the photodocumentation training program included resident activities, interactions among residents, professional photographers, and surgeons/preceptors, studio settings, cameras, lenses, principles (exposure, aperture, speed, ISO, and depth of field), lighting, preparation and positioning of patients and the camera, photoshoot conditions, photo views, photo database, image formats, computerized photogrammetry, and ethical and medical-legal issues. Conclusion: Training in photodocumentation complements the arsenal of skills needed by residents in Plastic Surgery for continuing education, in order to better prepare them for future careers.

O treinamento formal em pesquisa científica aumenta a participação de residentes de Cirurgia Plástica em artigos revisados por pares / Formal training in scientific research increases the participation of plastic surgery residents in peer-reviewed articles

Introdução: Os objetivos deste estudo foram: (1) delinear um programa de treinamento em habilidades de pesquisa científica, (2) avaliar o perfil da participação dos residentes de Cirurgia Plástica em artigos, e (3) analisar o impacto da implementação do programa de treinamento sobre índices bibliométricos quantitativos. Métodos: Trata-se de uma análise bibliométrica da participação de residentes de Cirurgia Plástica de uma única instituição em artigos publicados em periódicos revisados por pares entre 2006 e 2014. Dados coletados: número de autores, posição dos residentes entre os autores, títulos, bases de indexação e fator de impacto dos periódicos, desenhos dos estudos e níveis de evidência. Dois períodos (janeiro/2006- janeiro/2010 [A] e fevereiro/2010-fevereiro/2014 [B]) foram criados para estudar o perfil evolutivo do impacto da implementação do programa de treinamento delineado neste estudo. Resultados: Houve predomínio significativo (p < 0,05) de artigos publicados em periódicos nacionais, em língua portuguesa, nas bases de dados SciELO e LILACS, artigos sem residentes como autor correspondente, sem fator de impacto, sem hipóteses e com nível de evidência III (estudos retrospectivos). A análise comparativa interperíodos revelou um aumento significativo (p < 0,05) de artigos publicados, de residentes com publicações ao término da residência, da participação de um ou mais residentes e de artigos publicados em inglês (período A < período B). Conclusão: A implementação do programa de treinamento em habilidades de pesquisa científica determinou um aumento da atividade de pesquisa (artigos revisados por pares) durante a residência.

Introduction: The objectives of this study were as follows: (1) to outline a scientific research skills training program, (2) to evaluate the profile of participation of plastic surgery residents in articles, and (3) to analyze the impact of the implementation of the training program on quantitative bibliometric indexes. Methods: This was a bibliometric analysis of the participation of plastic surgery residents of a single institution in articles published in peer-reviewed journals between 2006 and 2014. The data collected were the number of authors, position of residents among authors, article titles, indexing databases and impact factor of the journals, study design, and levels of evidence. Two periods (January 2006 to January 2010 [A] and February 2010 to February 2014 [B]) were created to study the evolutionary profile of the impact of the implementation of the training program outlined in this study. Results: A significant predominance (p < 0.05) was observed among articles published in national journals in the Portuguese language and in the SciELO and LILACS databases, and articles without residents as corresponding author, without impact factor, without assumptions, and with a level of evidence III (retrospective studies). The inter-period comparative analysis revealed a significant increase (p < 0.05) in the numbers of published articles and residents with publications at the end of their residency, in the involvement of one or more residents, and in the articles published in English (period A < period B). Conclusion: The implementation of a scientific research skills training program led to an increase in research activity of (peer-reviewed articles) during the residency.

Autologous Free Fat Grafting for Management of the Facial Contour Asymmetry.

BACKGROUND: The purposes of this study were to report autologous free fat grafting as the workhorse procedure to augment the facial soft-tissue envelope and restore facial contour symmetry of patients with asymmetric facial malformations; to detail the SOBRAPAR Hospital algorithm for soft-tissue reconstruction of patients with facial contour asymmetry; and to assess facial symmetry after fat grafting. METHODS: A retrospective analysis of consecutive patients (n = 178) who underwent fat grafting to restore the facial contour symmetry according to the SOBRAPAR Hospital algorithm between 2009 and 2016 was conducted. Computerized photogrammetric quantitative and qualitative facial symmetry analyses were performed. RESULTS: There were significant (all P < 0.05) postoperative quantitative facial symmetry enhancement and an overall qualitative facial symmetry enhancement, with a mean fat graft procedures per patient of 1.6 ±â€Š0.7, ranging of 1 to 3. CONCLUSION: A significant improvement of facial contour symmetry was obtained in a subset of patients using fat grafting according to the SOBRAPAR Hospital algorithm.

Surgical approach of hypertelorbitism in craniofrontonasal dysplasia. / Abordagem cirúrgica do hiperteleorbitismo na displasia craniofrontonasal.

OBJECTIVE: to present our experience in the hypertelorbitism surgical treatment in craniofrontonasal dysplasia. METHODS: retrospective analysis of craniofrontonasal dysplasia patients operated through orbital box osteotomy or facial bipartition between 1997 and 2015. Surgical data was obtained from medical records, complementary tests, photographs, and clinical interviews. Surgical results were classified based on the need for additional surgery and orbital relapse was calculated. RESULTS: seven female patients were included, of whom three (42.86%) underwent orbital box osteotomy and four (57.14%) underwent facial bipartition. There was orbital relapse in average of 3.71±3,73mm. Surgical result according to the need for further surgery was 2.43±0.53. CONCLUSION: surgical approach to hypertelorbitism in craniofrontonasal dysplasia should be individualized, respecting the age at surgery and preferences of patients, parents, and surgeons.

OBJETIVO: apresentar nossa experiência no tratamento cirúrgico do hiperteleorbitismo na displasia craniofrontonasal. MÉTODOS: análise retrospectiva dos pacientes com displasia craniofrontonasal operados por orbital box osteotomy ou por bipartição facial entre os anos de 1997 e 2015. Informações sobre as intervenções cirúrgicas foram obtidas dos prontuários médicos, exames complementares, fotografias e entrevistas clínicas. Os resultados cirúrgicos foram classificados com base na necessidade de cirurgia adicional, e a recidiva orbital foi calculada. RESULTADOS: sete pacientes do sexo feminino foram incluídas, três submetidas à orbital box osteotomy (42,86%) e quatro (57,14%) à bipartição facial. Houve uma recidiva orbital média de 3,71±3,73mm. A média global dos resultados cirúrgicos de acordo com a necessidade de novas cirurgias foi de 2,43±0,53. CONCLUSÃO: a abordagem cirúrgica do hiperteleorbitismo na displasia craniofrontonasal deve ser individualizada, respeitando, sempre que possível, a idade e as preferências dos pacientes, seus familiares e cirurgiões.

Abordagem cirúrgica do hiperteleorbitismo na displasia craniofrontonasal / Surgical approach of hypertelorbitism in craniofrontonasal dysplasia

RESUMO Objetivo: apresentar nossa experiência no tratamento cirúrgico do hiperteleorbitismo na displasia craniofrontonasal. Métodos: análise retrospectiva dos pacientes com displasia craniofrontonasal operados por orbital box osteotomy ou por bipartição facial entre os anos de 1997 e 2015. Informações sobre as intervenções cirúrgicas foram obtidas dos prontuários médicos, exames complementares, fotografias e entrevistas clínicas. Os resultados cirúrgicos foram classificados com base na necessidade de cirurgia adicional, e a recidiva orbital foi calculada. Resultados: sete pacientes do sexo feminino foram incluídas, três submetidas à orbital box osteotomy (42,86%) e quatro (57,14%) à bipartição facial. Houve uma recidiva orbital média de 3,71±3,73mm. A média global dos resultados cirúrgicos de acordo com a necessidade de novas cirurgias foi de 2,43±0,53. Conclusão: a abordagem cirúrgica do hiperteleorbitismo na displasia craniofrontonasal deve ser individualizada, respeitando, sempre que possível, a idade e as preferências dos pacientes, seus familiares e cirurgiões.

ABSTRACT Objective: to present our experience in the hypertelorbitism surgical treatment in craniofrontonasal dysplasia. Methods: retrospective analysis of craniofrontonasal dysplasia patients operated through orbital box osteotomy or facial bipartition between 1997 and 2015. Surgical data was obtained from medical records, complementary tests, photographs, and clinical interviews. Surgical results were classified based on the need for additional surgery and orbital relapse was calculated. Results: seven female patients were included, of whom three (42.86%) underwent orbital box osteotomy and four (57.14%) underwent facial bipartition. There was orbital relapse in average of 3.71±3,73mm. Surgical result according to the need for further surgery was 2.43±0.53. Conclusion: surgical approach to hypertelorbitism in craniofrontonasal dysplasia should be individualized, respecting the age at surgery and preferences of patients, parents, and surgeons.

Predictors of Autologous Free Fat Graft Retention in the Management of Craniofacial Contour Deformities.

BACKGROUND: Autologous free fat graft outcomes are not always predictable, and variables that can potentially influence fat graft retention are still not well understood or investigated. The purposes of this study were to assess fat graft retention in the management of craniofacial contour deformities and to identify possible predictive factors of this retention. METHODS: A prospective analysis was conducted using consecutive patients with unilateral craniofacial contour deformities who underwent autologous free fat grafting between 2012 and 2015. Standardized ultrasonographic craniofacial soft-tissue thickness measurements were adopted to determine the fat graft retention. Bivariate and multivariate analyses were performed to identify independent predictors of 12-month postoperative fat graft retention. RESULTS: One hundred forty-two patients were enrolled. There was significant (all p < 0.05) and progressive reduction in fat graft retention within the first 3 postoperative months, and the retained fat graft was maintained (all p > 0.05) from 3 to 12 months postoperatively, with a 12-month fat graft retention rate of 67.7 percent. Age, Parry-Romberg syndrome, previous craniofacial bone surgery, grafted volume, and forehead unit were independently negative (all p < 0.05) predictors of fat graft retention, whereas cheek unit was an independently positive (all p < 0.05) predictor of retention. CONCLUSION: Craniofacial fat graft retention is achievable but remains somewhat unpredictable, with age, Parry-Romberg syndrome, previous bone surgical intervention, grafted volume, and recipient sites affecting retention. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Customized acrylic implants for reconstruction of extensive skull defects: an exception approach for selected patients.

Objective: to present our experience in the surgical treatment of extensive skullcap defects with customized acrylic implants. Methods: we conducted a retrospective analysis of patients with extensive skull defects undergoing acrylic cranioplasties between 2004 and 2013. We carefully selected all patients and classified surgical results based on three scales (craniofacial esthetics, improvement of facial symmetry and need for additional surgery). Results: fifteen patients underwent cranioplasty with intraoperative acrylic implants, whether manually customized (46.67%) or made with prototyped three-dimensional biomodels (53.33%). There were two (13.33%) complications (one infection with implant withdrawal and one seroma). We considered the craniofacial aesthetics excellent (50%), the degree of improvement of craniofacial symmetry satisfactory (57.14%), and the overall mean of surgical results according to the need for new surgeries was 1.5±0.52. Conclusion: cranioplasties of patients with extensive skullcap defects should obey careful and predetermined criteria, both for selection and for the acrylic implant customization method.

Objetivo: apresentar nossa experiência no tratamento cirúrgico dos defeitos extensos da calota craniana com implantes de acrílico customizados. Métodos: análise retrospectiva de pacientes com defeitos extensos da calota craniana submetidos à cranioplastias com acrílico entre 2004 e 2013. Todos os pacientes foram criteriosamente selecionados e os resultados cirúrgicos foram classificados com base em três escalas (estética craniofacial, melhora da simetria facial e necessidade de cirurgia adicional). Resultados: Quinze pacientes foram submetidos à cranioplastia com implantes de acrílico customizados manualmente no intraoperatório (46,67%) e confeccionados com base em biomodelos tridimensionais prototipados (53,33%). Mesmo respeitando critérios de seleção, houve duas (13,33%) complicações (infecção com retirada do implante e seroma). A estética craniofacial foi considerada excelente (50%), o grau de melhora da simetria craniofacial foi considerado satisfatório (57,14%) e a média global dos resultados cirúrgicos de acordo com a necessidade de novas cirurgias foi 1,5±0,52. Conclusão: as cranioplastias dos pacientes com defeitos da calota craniana extensos devem ser criteriosamente indicadas, obedecendo a critérios pré-determinados de seleção dos pacientes, bem como, do método de customização do implante de acrílico.

Customized acrylic implants for reconstruction of extensive skull defects: an exception approach for selected patients / Implantes de acrílico customizados para a reconstrução de defeitos extensos da calota craniana: uma abordagem de exceção para pacientes selecionados

ABSTRACT Objective: to present our experience in the surgical treatment of extensive skullcap defects with customized acrylic implants. Methods: we conducted a retrospective analysis of patients with extensive skull defects undergoing acrylic cranioplasties between 2004 and 2013. We carefully selected all patients and classified surgical results based on three scales (craniofacial esthetics, improvement of facial symmetry and need for additional surgery). Results: fifteen patients underwent cranioplasty with intraoperative acrylic implants, whether manually customized (46.67%) or made with prototyped three-dimensional biomodels (53.33%). There were two (13.33%) complications (one infection with implant withdrawal and one seroma). We considered the craniofacial aesthetics excellent (50%), the degree of improvement of craniofacial symmetry satisfactory (57.14%), and the overall mean of surgical results according to the need for new surgeries was 1.5±0.52. Conclusion: cranioplasties of patients with extensive skullcap defects should obey careful and predetermined criteria, both for selection and for the acrylic implant customization method.

RESUMO Objetivo: apresentar nossa experiência no tratamento cirúrgico dos defeitos extensos da calota craniana com implantes de acrílico customizados. Métodos: análise retrospectiva de pacientes com defeitos extensos da calota craniana submetidos à cranioplastias com acrílico entre 2004 e 2013. Todos os pacientes foram criteriosamente selecionados e os resultados cirúrgicos foram classificados com base em três escalas (estética craniofacial, melhora da simetria facial e necessidade de cirurgia adicional). Resultados: Quinze pacientes foram submetidos à cranioplastia com implantes de acrílico customizados manualmente no intraoperatório (46,67%) e confeccionados com base em biomodelos tridimensionais prototipados (53,33%). Mesmo respeitando critérios de seleção, houve duas (13,33%) complicações (infecção com retirada do implante e seroma). A estética craniofacial foi considerada excelente (50%), o grau de melhora da simetria craniofacial foi considerado satisfatório (57,14%) e a média global dos resultados cirúrgicos de acordo com a necessidade de novas cirurgias foi 1,5±0,52. Conclusão: as cranioplastias dos pacientes com defeitos da calota craniana extensos devem ser criteriosamente indicadas, obedecendo a critérios pré-determinados de seleção dos pacientes, bem como, do método de customização do implante de acrílico.

Tratamento primário da deformidade labial e nasal nas fissuras labiais e labiopalatinas unilaterais / Primary treatment of lip and nasal deformity in unilateral cleft lip or cleft lip and palate

Introdução: A fissura labiopalatina é a deformidade congênita mais frequente dentre as malformações craniofaciais, afetando principalmente o lábio superior, nariz e palato. A realização da queiloplastia associada à rinoplastia primária em tempo único é uma tendência. Avaliamos a correlação entre a gravidade da fissura, a idade cirúrgica e a qualidade estética do resultado pós-operatório. Métodos: Foram avaliados 26 pacientes com fissuras labiais ou labiopalatinas unilaterais, com idades entre 3 e 12 meses, operados pela técnica de queilorrinoplastia de Göteborg/McComb. Foi feita uma avaliação fotográfica do pré e pós-operatório por cinco cirurgiões plásticos separadamente e os dados analisados. Resultados: A idade média de realização do procedimento foi de 6,5 ± 3,15 meses, sendo que somente sete pacientes (26,9%) foram operados na idade de 3 meses preconizada pelo protocolo. Foi encontrada correlação entre a gravidade da fissura e a qualidade dos resultados, ao mesmo tempo em que não foi encontrada associação entre a idade da cirurgia e os resultados. Todos os casos do estudo foram considerados ótimos ou satisfatórios. Conclusões: A utilização de uma técnica de queiloplastia que seja de fácil reprodutibilidade, com bons resultados estéticos, e que possa ser utilizada em conjunto com outras técnicas de tratamento primário do nariz é uma boa opção a ser adotada por centros de tratamentos deste tipo de paciente. A gravidade da fissura é um fator importante na qualidade dos resultados. Quanto mais grave a fissura os resultados tendem ser piores. A idade da cirurgia, neste estudo, não teve correlação com a qualidade nos resultados.

Introduction: Cleft lip and palate, the most frequent congenital craniofacial deformity, mainly affects the upper lip, nose, and palate. One possible treatment is single-stage lip repair with primary rhinoplasty. Here we assessed the correlations among cleft severity, surgical age, and aesthetic results. Methods: A total of 26 patients with unilateral cleft lip or cleft lip and palate aged 3-12 months underwent surgical lip repair associated with the Göteborg/McComb rhinoplasty technique. Steps before and after surgery were separately evaluated by five plastic surgeons using pictures and the data were analyzed. Results: The average patient age at surgery was 6.5 ± 3.15 months, and only seven patients (26.9%) underwent surgery at 3 months of age as recommended by the protocol. Cleft severity and results quality were associated, whereas surgical age and aesthetic results were not correlated. Results in all cases were considered optimal or satisfactory. Conclusions: The lip repair technique, which presents good reproducibility and aesthetic results and can be used with other primary treatment techniques for the nose, should be adopted by treatment centers managing cleft lip and palate. Cleft severity is an important factor in results quality; the greater the severity, the worse the results. In the present study, surgical age was not correlated with results quality.

Comprehensive and Global Approach of Soft-Tissue Deformities in Craniofacial Neurofibromatosis Type 1.

BACKGROUND: To present a single-institution experience in the comprehensive and global soft-tissue surgical approach of patients with craniofacial neurofibromatosis type 1 (NF-1). METHODS: A retrospective analysis of patients with craniofacial NF-1 (n = 20) who underwent craniofacial soft-tissue reconstruction between 1993 and 2014 was conducted. Surgical treatment was individualized according to age, functional and/or aesthetic impairment, neurofibroma types, anatomical location, size, and patient/family and surgical team preferences, regardless of previously published compartmental grading systems. The surgical results were classified based on 2 previously published outcome rating scales (craniofacial symmetry improvement and need for additional surgery). RESULTS: All patients underwent en bloc translesional surgical excisions, 12 facial suspension, 3 eyebrow suspension, 2 ear suspension, 9 lateral canthopexy, 5 horizontal shortening of the tarsus of lower eyelid, and 1 horizontal shortening of the tarsus of upper eyelid. The degree of craniofacial symmetry improvement was considered "mostly satisfactory" (75%), and the overall rate of surgical results ranked according to the need for additional surgery was 2.4 ± 0.50, with variations according to the spectrum of soft-tissue involvement. CONCLUSIONS: According to the experience and surgical outcomes presented in this study, the soft-tissue surgical approach of the craniofacial NF-1 should be global, comprehensive, and individualized.

Matthews device arthroplasty presents superior long-term mouth opening than interpositional arthroplasty in the management of temporomandibular joint ankylosis.

BACKGROUND: The aim of this study is to describe the surgical outcomes of a single-institution experience in the surgical management of temporomandibular joint ankylosis, comparing interpositional arthroplasty with autogenous tissue and Matthews device arthroplasty. METHODS: A retrospective analysis of temporomandibular joint ankylosis patients (n = 15), who underwent interpositional arthroplasty or Matthews device arthroplasty, was conducted. The surgical outcomes (preoperative, recent [4-6 weeks], intermediate [1 year], and late [3 years] postoperative maximal incisal opening, hospital stay, and complication, relapse, and reoperation rates) were compared. RESULTS: Significant (all p < 0.05) differences were recorded in temporomandibular joint ankylosis patients treated with interpositional arthroplasty with autogenous tissue (53.3%) versus Matthews device arthroplasty (46.7%) according to intermediate (25 ± 7 vs. 34 ± 5 mm) and late (19 ± 8 vs. 33 ± 5 mm) postoperative maximal incisal opening, intermediate (31% vs. 7%) and late (47% vs. 12%) postoperative relapse, and reoperation rate (38% vs. 0%). There was similarity (all p > 0.05) in preoperative (4.8 ± 2.9 vs. 4.9 ± 2.9 mm) and recent (35 ± 4 vs. 37 ± 4 mm) postoperative maximal incisal opening, hospital stay (3.5 ± 0.8 vs. 3.6 ± 0.8 days), and surgery-related complications (13% vs. 14%). CONCLUSION: Both surgical procedures evaluated were successful in initial management of temporomandibular joint ankylosis, but the Matthews device arthroplasty avoided postoperative relapse.