Supraciliary Incision as a New Double-Eyelid Approach for Asian Patients: Clinical Experience of 528 Cases.

BACKGROUND: The double-eyelid operation is the most requested cosmetic surgery in Asians. The incision is usually located at the pretarsal skin 6 mm to 8 mm above palpebral margin. The purpose of this paper is to report a novel approach of double-eyelid operation through a supraciliary incision (SCI). METHODS: Three transverse curved lines were drawn on the upper lid skin. The location of line 1 (SCI) was 1.5 mm above the eyelash, line 2 according to the amount of redundant skin excised and line 3 at 3 mm to 4 mm above line 2. After the incisions were made between line 1 and line 2, the subcutaneous dissection is carried out over 5 mm the line 3. Then, the redundant skin and a strip orbicularis oculi muscle were removed to open the orbital septum and to explore underside levator aponeurosis. Along the line 3, the internal buried fixation sutures between dermal tissue and the fusion line of the orbital septum and levator aponeurosis were placed. Finally, the wounds were closed between line 2 and line 1. RESULTS: There were 528 patients who underwent the double-eyelid operation through the supraciliary approach. In long-term follow-up, 288 patients were evaluated at 6 months to 78 months postoperatively. Of those, 266 patients were satisfactory for the result (92.36%) with natural shape and invisible surgical scar. In another 22 patients (7.63%), a revised blepharoplasty was performed in 22 eyelids. CONCLUSION: The double-eyelid surgery using the SCI has several advantages including less visibility of the incision, the protected subdermal vascular network, the intact continuity of the upper eyelid skin, the combination of the SCI and internal dermal buried suture method. The approach can be considered an efficient technique for Asian patients. 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 .

Late hematoma, seroma, and galactocele in breasts injected with polyacrylamide gel.

Late hematoma or seroma and galactocele caused by augmentation mammaplasty have been reported in patients with silicon breast prostheses but are extremely rare in patients injected with polyacrylamide gel (PAAG). In a retrospective survey, the incidence, clinical manifestations, and management of late hematoma, seroma, and galactocele in 28 of 2,610 patients who underwent breast augmentation with PAAG injection were investigated, and 5 typical cases are presented. The diagnostic and managing methods for this complication have been assessed. The incidence of late hematoma or seroma was 0.65% and that of galactocele was 0.35% among patients with PAAG-injected breast augmentations. The clinical onsets of such late PAAG complications were of two types: rapid enlargement in 17 patients and progressive expansion in another 11 patients. Aspiration, ultrasound, and magnetic resonance imaging (MRI) are useful and sensitive tools for diagnosis. Foreign body reaction, PAAG-related tissue necrosis and fibrosis, and granuloma were shown, and the bacterial cultures in all 12 cases were negative. Needle aspiration with pressure dressing has been advocated as a reliable method for small diseases, and surgical exploration with irrigation-vacuum drainage and evacuation with capsulectomy have been considered more effective for recurrent, large, and long-term cases. In conclusion, these late complications rarely present after large-volume injections of PAAG for breast augmentation. The PAAG-related pathologic inflammatory tissue changes are suggested as the pathogenesis for the complication. Trauma and breastfeeding are considered to be stimulating factors.

Our strategy in complication management of augmentation mammaplasty with polyacrylamide hydrogel injection in 235 patients.

Polyacrylamide hydrogel (PAAG) was once widely used in breast augmentation in China. Although it had been banned for augmentation mammaplasty in 2006, a large number of patients whose breasts were augmented with the gel injection have continued to seek medical advice because of its complications. The clinical management of these complications has never been standardised. The data of a total of 235 patients with complications following PAAG-injected breast augmentation have been summarised and the types and causations analysed. Magnetic resonance imaging (MRI) was undertaken in 228 patients with palpable masses, breast pain or tenderness, asymmetry or deformity and functional or psychological problems to eliminate neoplasm, infection and to delineate the diseases. The surgical gel evacuation via periareolar incisions was performed for all patients and immediate silicone breast prostheses were implanted in 108 patients and were delayed in 28 cases by 6 months. Most patients (214/235) of the group were satisfied with the treatment, and symptoms disappeared after removal of the gel. The gel distribution and involved tissue were well defined and neoplasm was ruled out by MRI. Postoperative MRI in 68 patients revealed that no obvious PAAG remaining. In either immediate or delayed reconstructive patients with silicone breast implants, good breast contour presented. A diagnosis and management strategy for these complications is proposed. In conclusion, the breast masses, pain and deformity are major complications after PAAG-injected breast augmentation. Psychological problems should be paid attention to. MRI is a sensitive and accurate method for diagnosis and treatment evaluation. Surgical removal of injected gel is the preferred method for complication management. The implantation of silicone prostheses for breast contour restoration after PAAG evacuation is effective for patients under strict selection. Our strategy for treating PAAG-related complications proved useful.

[The nasal development after one-staged correction of nose deformity and unilateral complete cleft lip in infancy].

OBJECTIVE: To introduce one-staged correction of nasal deformity and unilateral complete cleft lip in infancy and to observe the nasal development after the operation. METHODS: The unilateral complete cleft lip and nasal deformity were corrected in one stage in27 cases. They were followed up for several years. With post-operative photos, the anthropometric method was used to analyze the nasal development. RESULTS: The long-term results were excellent in 10 cases, good in 14 cases, and poor in 3 cases. CONCLUSIONS: Based on the anatomic findings of nasal blood supply, one-staged correction of nasal deformity and unilateral complete cleft lip in infancy can be performed with no obvious interference with nasal development. The secondary nasal deformity before school age can be alleviated or avoided.

Breast cancer following augmentation mammaplasty with polyacrylamide hydrogel (PAAG) injection.

Polyacrylamide hydrogel (PAAG) as an implanted material for augmentation mammaplasty has been used for years in China. Many kinds of complications associated with PAAG use have been reported in the clinical literature. This report presents two cases of breast cancer occurring after injection of PAAG in augmented breasts. The delayed diagnosis and more aggressive disease due to PAAG injection should be cause for concern. It is very important to detect breast cancer early when it is covered by the induration of the injected gel and inflammation reaction after PAAG injection. PAAG injection for augmentation mammaplasty may affect the outcome of breast cancer diagnosis and prognosis.

[Nasendoscopic comparison for cleft palate repair after velopharyngeal muscle reconstruction].

OBJECTIVE: To find out the nasendoscopic changes of velopharyngeal configuration and movement after palatoplasty with or without velopharyngeal muscle reconstruction. METHODS: The nasendoscopy was taken in forty-one patients with palatoplasty, 22 repaired by velopharyngeal muscle reconstruction and 19 with modified von Langenbeck's procedure (non-reconstructive group). RESULTS: In patients with velopharyngeal muscle reconstruction, the velopharyngeal ports are smooth and full with a definite reduction in size than patients without velopharyngeal muscle reconstruction. During phonation, the complete and marginal velopharyngeal competence rate in reconstructive group (90.91%) is higher than the group of non-reconstruction (37.31%) The major velopharyngeal closure is circular movement in reconstructive group, otherwise coronal closure in nonconstructive group. CONCLUSIONS: Based the observation of nasendoscopy, the velopharyngeal muscle reconstruction in palatoplasty has more definite improvement to velopharyngeal closure than non-reconstructive procedure. Palatoplasty with velopharyngeal muscle reconstruction could reduce the size of velopharyngeal port and make the complete velopharyngeal closure easier.

A modified procedure for velopharyngeal sphincteroplasty in primary cleft palate repair and secondary velopharyngeal incompetence treatment and its preliminary results.

During cleft repair, velopharyngeal sphincter reconstruction is still a challenge to plastic surgeons. To improve the surgical treatment for cleft palate and secondary velopharyngeal incompetence (VPI), a carefully designed modified procedure for primary palatoplasty and secondary VPI was presented. Fifty-six patients (48 for primary cleft palate repair and eight for secondary VPI of previously repaired clefts) underwent this procedure from 1988 to 2001. The modified procedure is a combination of the tunnelled palatopharyngeus myomucosal flap for dynamic circular reconstruction of the pharyngeal element of the velopharyngeal sphincter and the double-reversing Z-plasty with levator velo palatini muscles reposition in the velar element of the sphincter. The satisfactory velopharyngeal competence (complete velopharyngeal closure and marginal velopharyngeal closure) was achieved in 23 of 25 patients with primary cleft palate repair examined by nasendoscopy and the nasality, speech articulation and intelligibility are also assessed in 25 primary cleft palate repaired patients with 92% satisfactory result (normal speech and speech with mild VPI) in single word test and 88% in continuous speech evaluation. Based on our experience, we believe that this modified procedure is a reasonable choice for primary cleft repair and secondary VPI treatment because it is in accord with normal physiology and anatomy of the velopharyngeal sphincter, can lengthen the soft palate, decrease the enlarged velopharynx, augment the posterior pharyngeal wall, and enhance the relationship between the muscles of velopharyngeal sphincter which results in a dynamic neo-sphincter in palatopharyngoplasty. Further study of the procedure is needed. The theoretical basis, operative highlights, velopharyngeal function, advantages and disadvantages of the modified procedure were discussed.

[Lateral radiographic comparison for velar movement between palatoplasty with velopharyngeal muscular reconstruction and modified Von Langenbeck's procedure].

OBJECTIVE: To verify the effect of palatoplasty with or without velopharyngeal muscular reconstruction on the velar movement through the lateral radiography. METHODS: From October 1988 to October 2000, 62 patients with cleft palate and velopharyngeal insufficiency were treated. Of them, 32 were repaired by velopharyngeal muscular reconstruction (group A) and 30 by modified von Langenbeck's procedure (group B). The lateral radiographs and cephalometric analysis were taken. The velopharyngeal closure, velar extensibility, the angle changes of velar elevation, the distance changes of velar levator eminence based on anatomy (LEA) to velopharyngeal closure line (VCL), the varieties in LEA, the comparison of LEA and velar levator eminence based on phonation (LEP), the distance comparison between posterior nasal spine (PNS) to LEA and LEP through soft palate line (SPL) were measured. RESULTS: During the phonation, group A was significantly greater than group B in the velopharyngeal closure rate (P<0.01), the velar extensibility (P<0.05) and the location comparison between LEA and LEP (P<0.01); group B was significantly greater than group A in velar elevation angle (P<0.05), the varieties in LEA (P<0.05). In velar rest position, the distance of LEA to VCL was greater in B group than in A group(P<0.01). There was significant difference in the distance comparison between LEA and LEP(P<0.05), difference between LEA and LEP (P<0.01) and the distance PNS-SPL-LEA and PNS-SPL-LEP(P<0.05) within group B; contrary to the results within group A (P>0.05). CONCLUSION: The velopharyngeal muscular reconstruction in palatoplasty can result in a near normalization of anatomic measurement of velar levator muscles and improve the velar function and velopharyngeal competence. Repositioning of velar muscles in a more anatomic correct, transverse position is more important to improve the velar length and accordant velar movement with velopharyngeal muscles in functional palatoplasty. The velar angle change and velar elevation during phonation are not determinative factors for velopharyngeal competence.

Migration of implants: a problem with injectable polyacrylamide gel in aesthetic plastic surgery.

Polyacrylamide gel (PAAG) has been used as a soft tissue filler material for cosmetic purposes in Europe and China since 1997. The various complications of PAAG have been reported. A total of 15 patients who received PAAG injections at other institutions were treated for gel migration in the authors' hospitals. During treatment, the authors found that the injected PAAG had not formed capsules within the muscle and was encapsulated only by thin fibrous tissue in skin and mammary glands. Consequently, the filler material migrated easily because of muscular activity or the influence of gravity, especially when the capsule was broken by incorrect massage or incidental force. It is suggested that PAAG should not be injected into muscular tissue or subcutaneous areas with active movement, such as joints and muscles involved in facial expression with thin skin. After years of gel implantation, the thinned capsule may result in an increasing incidence of this complication. Management and some clinical findings in relation to the complication also are discussed.

[A comparison of the velopharyngeal closure after palatoplasty between with or without velopharyngeal muscular reconstruction].

OBJECTIVE: To evaluate the effect of palatoplasty with or without velopharyngeal muscular reconstruction on the velopharyngeal closure under the lateral radiography. METHODS: The lateral radiographs and cephalometric analysis were taken in sixty-two patients with cleft palate and velopharyngeal insufficiency, 32 repaired with velopharyngeal muscular reconstruction and 30 with modified von Langenbeck's procedure (non-reconstructive group). RESULTS: In patients with velopharyngeal muscular reconstruction, the velopharyngeal competence, the reductive rate of nasopharynx, the distance reduction in lower part of the mobile nasopharynx during phonation and the distance in middle part of mobile nasopharyngo in rest were superior to that without velopharyngeal muscular reconstruction, and there were variform PPW eminence-soft palate contact in velopharyngeal closure. The patients with complete or good velopharyngeal closure had a definite reduction in nasopharynx, compared to the patients with velopharyngeal insufficiency in the non-reconstructive group. CONCLUSIONS: The functional area for velopharyngeal closure after palatoplasty might be located in the middle part of mobile nasopharynx. The velopharyngeal muscular reconstruction in palatoplasty could reduce the size of nasopharynx and improve the coordination movement of velopharyngeal closure.

[The applied anatomic study of palatopharyngeus muscle].

OBJECTIVE: The aim of this investigation was to examine the anatomic basis of palatopharyngeus and clinical implications for sphincter pharyngoplasty. METHODS: Detailed dissections were performed on 17 sides of adult human head and neck specimens. The eight sides newborns' head and neck cadavers were also used in the study (4 normal and 4 cleft lip and palate). The observations of histologic serial sections were undertaken in six fetus head and neck specimens on coronal, transverse and sagittal direction. RESULTS: The palatopharyngeus with three components of pharyngeal origins and two heads of velar insertions contributes the continuity between the velum and lateral pharyngeal wall and the bulk of muscle fibers were extended to the posterior tonsilar pillars with (27.58 +/- 6.73) mm length and (34.1 +/- 10.50) mm2 section area. The muscles were supplied dominantly from the branches of ascending pharyngeal artery and tonsilar artery and partly from the branches of ascending palatine artery and dorsal lingual artery. The muscles were innervated by the branches of pharyngeal plexus which focus on the level 10 mm to 25 mm below the hard palate and at the level of 15 mm below the hard palate there was at least one of the nerve branch entered the muscle. CONCLUSION: The palatopharyngeus muscle is not only a major musculature of lateral pharyngeal wall but also an important portion of the soft palate, participating the middle and posterior velum, which means that the muscle may play a significant effect in the velar function and pharyngeal wall movements. It is also a good donor site for palatopharyngeus flap. The sphincter pharyngoplasty has some influence to the blood supply and innervation of the muscles, which may result to blood reversion and denervation for the distal component of palatopharyngeal flap.

[Regeneration of autologous tissue-engineered cartilage by using basic-fibroblast growth factor in vitro culture].

OBJECTIVE: To investigate the effect of the basic fibroblast growth factor (b-FGF) to regenerate an autologous tissue-engineered cartilage in vitro. METHODS: The Cells were harvested from the elastic auricular cartilage of swine,and were plated at the concentration of 1 x 10(4) cells/cm2 , studied in vitro at two different media enviroments: Group I contained Ham's F-12 with supplements and b-FGF, Group II contained Ham's F-12 only with supplements. The passage 2 cells (after 12.75 +/- 1.26 days) were harvested and mixed with 30% pluronic F-127/Ham's F-12 at the concentration of 50 x 10(6) cells/ml. It was injected subcutaneously at 0.5 ml per implant. The implants were harvested 8 weeks after the vivo culture and examined with the histological stains. RESULTS: The chondrocytes displayed morphologically similar to the fibroblasts in the media containing basic-FGF. The number of cell doublings (after 12.75 +/- 1.26 days) in vitro culture was as the following: Group I, 70; Group II, 5.4. Eight 8 weeks after the vivo autologous implantation, the average weight (g) and volume (cm3) in each group was as the following: Group I, 0.371 g/0.370 cm3 Group II, 0.179 g/0.173 cm3 (P < 0.01). With the b-FGF in vitro culture, the cells were expanded by 70 times after 2 weeks. Histologically, all of the engineered cartilage in the two groups were similar to the native elastic cartilage. CONCLUSION: These results indicate that the basic-FGF could be used positively to enhance the quality and quantity of the seeding cells for the generation of the well-engineered cartilage.

Complications of breast augmentation with injected hydrophilic polyacrylamide gel.

Since 1997, the hydrophilic polyacrylamide gel (PAAG), an injectable alloplastic biomaterial, imported from the Ukraine has been used for augmentation mammaplasty in China. There were twelve patients with various complications visiting our hospitals after breast augmentation with injected hydrophilic polyacrylamide gel by other clinics, even though such procedures are not performed in our clinical practices. The complications included four cases of PAAG-induced multiple induration and lumps, and one with lactation, three cases of hematoma, two cases of inflammation (infection), and persistent mastodymia, unsatisfactory contour results and abnormal skin sensations in each case. All patients have been treated by removing the injected gel and giving antibiotics. Other procedures included replacement by silicon breast prostheses, mammotomy, and segmental mastectomy. We suggest that the injectable hydrophilic polyacrylamide gel be contraindications for breast augmentation in any young female who is not married, or without a child, with a tendency to hemorrhage, and with little mammary tissue. Some considerations to prevent and manage these complications are discussed.

[Simultaneous repair of complete cleft lip and palatein infancy-preliminary observation (271 cases report)].

OBJECTIVE: To Verify the safety and reliability of one-stage repair of complete cleft Lip and palate in infancy and to obtain the primary result. METHODS: The simultaneous repair of complete cleft Lip and palate in infants 3 to 12 months of age were performed in 271 cases. The deformities include 185 cases of typical complete unilateral clefts and 75 cases of complete bilateral clefts, and other 11 atypical cleft infants. The preoperative orthopedic treatment for wide alveolar cleft was undertaken in 24 infants and the lip appearance and speech outcome were evaluated in 116 children by 1 to 4 years' postoperative follow-up. RESULTS: All infants, except for dyspnea in 2 babies, palatal fistula formation in 6 cases and temporary wound hemorrhage in 5 infants, were recovered without complications. After orthopedic treatment, the width of the alveolar cleft was reduced 6.1 mm in average. The evaluation showed that 93.1% of children had got good or excellent lip appearance. And the acceptable or excellent speech was found in 94.8% children. CONCLUSIONS: Simultaneous repair of complete cleft lip and palate in infancy is safety and reliable. The preoperative orthopedic procedure is able to reduce the wide alveolar cleft and to achieve alignment of alveolar segments. The acceptable and or excellent lip appearance and speech function could be obtained in this one-stage operative procedure in infants.