Clockwise and Counterclockwise Le Fort I Movements Influence Nasolabial Morphology Differently.

BACKGROUND: Le Fort I maxillary advancements affect nasal proportions. However, there are no data on the three-dimensional nasal changes that occur with differential lateral plane adjustment (clockwise and counterclockwise movements) during Le Fort I maxillary advancements. This study analyzes and compares nasolabial soft-tissue changes after Le Fort I clockwise and counterclockwise repositioning. METHODS: Single-piece Le Fort I advancements were included. A retrospective study of patients split into clockwise and counterclockwise groups was performed. Preoperative and postoperative three-dimensional photographs (VECTRA 3D) were analyzed. Nasolabial anthropometric measurements were recorded using Mirror software. Statistical analysis involved paired t test to compare preoperative and postoperative measurements. RESULTS: Twenty-four patients were evaluated (12 per group), with 22 distinct nasolabial relationships measured. Counterclockwise movement showed a statistically significant increase in alar width (3.6 mm; p < 0.001), alar base width (1.6 mm; p = 0.009), oral width (3.2 mm; p = 0.02), and lip projection (3.4 mm; p = 0.04). Clockwise movement showed no statistically significant changes, with the largest position changes noted in alar width (2.7 mm; p = 0.07) and alar base width (1.7 mm; p = 0.09). CONCLUSIONS: Clockwise and counterclockwise Le Fort I advancements have a different effect on postoperative nasolabial morphology. Counterclockwise movements exhibit significant changes, widening the alar base and width and the oral and philtral widths. The impact on the nostril morphology and columella was similar between the groups. The differential impact on nasolabial appearance is important to recognize for treatment planning and patient counseling. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Does Fat Grafting Influence Postoperative Edema in Orthognathic Surgery?

PURPOSE: Autologous fat grafting is a useful adjunctive procedure to orthognathic surgery and may also confer anti-inflammatory properties. The purpose of this study is to answer the clinical question: among patients undergoing orthognathic operations, what are the effects of fat grafting on facial edema (magnitude, duration, and rate of decrease)? METHODS: A retrospective cohort study was performed. Three-dimensional photos (Canfield, Fairfield, NJ) from preoperative and a series of postprocedure time-points were analyzed. The data set was divided into a fat-grafted cohort and a non-fat-grafted cohort and later analyzed using paired and unpaired t tests and linear regressions to determine significant correlations. RESULTS: One hundred sixteen pre- and postoperative three-dimensional photo data sets were included. The sample included 29 subjects. The facial volume was analyzed both overall and comparing each subgroup (orthognathic vs. orthognathic + fat grafting group). Postoperative facial volume increase averaged 23.7% for the entire cohort (FG and nFG). By week 12, the swelling decreased about 62% from baseline. In all patients, there was a statistically significant decrease in facial volume with time. In the fat-grafted group, despite adding volume, the facial volume was equal to the non-fat-grafted group at week 1, yet the rate of decrease was faster through week 12. CONCLUSION: The majority of postoperative facial edema decreases by 12 weeks following orthognathic surgery. In this cohort of patients, despite the addition of volume, concurrent fat grafting lessened postoperative edema, and led to a greater magnitude and speed of resolution.

Three-dimensional Nasolabial Morphologic Alterations Following Le Fort I.

BACKGROUND: Le Fort I osteotomy imparts significant changes to the nasolabial region. Past studies have relied on 2-dimensional data and have not delineated differences among various Le Fort I subtypes. The purpose of this study is to 3-dimensionally analyze Le Fort I-induced nasal and lip changes comparing advancement alone versus widening alone [surgically assisted maxillary expansion (SAME)] versus advancement and widening. We hypothesize that the combination of maxillary advancement with widening will result in the most profound changes. METHODS: A retrospective cohort study was performed. Included Le Fort I patients were grouped as: (1) nonsegmental straight advancement, (2) widening without advancement, and (3) segmental advancement and widening. Pre- and postoperative 3-dimensional photogrammetry (Canfield) were analyzed. Anthropometric landmarks were placed and measured by 2 independent observers. Statistics involved both paired and unpaired t tests (significance = P < 0.05). RESULTS: One hundred eight photogrammetric data sets were analyzed, including 46 single-piece, 26 SAME, and 36 segmental. Significant postoperative nasal changes were observed within each intragroup analysis. The most dramatic changes were seen after segmental Le Fort I with advancement and widening, which included alar base width, alar width, nostril width, and soft triangle angle, all P < 0.05. CONCLUSIONS: Le Fort I osteotomy results in significant alteration of the nasolabial morphology. This is the first study to 3-dimensionally analyze nasal changes that occur comparing maxillary advancement alone versus widening alone (SAME) versus advancement with widening. These objective data permit improved patient counseling and surgical planning.

Osteonecrosis of the Jaw in Association With Chemotherapy in the Setting of Cutaneous T-Cell Lymphoma.

T-cell lymphomas (TCLs) account for approximately 15 to 20% of all non-Hodgkin lymphomas in the United States. The most common form of TCL is cutaneous TCL (CTCL), with Sézary syndrome and mycosis fungoides being the most prevalent subtypes. Sézary syndrome is the more aggressive form and often is referred to as a late-stage variant of mycosis fungoides. Clinically, it is characterized by diffuse erythroderma, cutaneous edema, pruritus, nonhealing cutaneous ulcers, and lymphadenopathy. Patients also can present with changes to their nails, hyperpigmentation, alopecia, palmoplantar keratoderma, ectropion, and hepatosplenomegaly. The overall prognosis for patients with Sézary syndrome is poor. The literature regarding oral manifestations of CTCL mostly report those of mycosis fungoides because it is the most common subtype of CTCL. Currently, there are only 2 reports in the scientific literature of intraoral manifestations of Sézary syndrome. This case report describes a patient with Sézary syndrome who presented with rapidly progressing erythematous lesions of the gingiva and multifocal osteonecrosis of the maxilla and mandible. This is the third reported case of an intraoral manifestation of Sézary syndrome and the first reported case of osteonecrosis in the setting of CTCL.

Sulfur-containing malodorant vapors enhance responsiveness to the sensory irritant capsaicin.

The nose is innervated with both odor responsive olfactory (cranial nerve I) and irritant responsive trigeminal (cranial nerve V) nerves. The nature and extent of any interactions between these two nerves is poorly understood. The aim of the current study was to determine if two sulfur-containing malodorants, ethyl sulfide and t-butyl sulfide, modulated responsiveness to the trigeminal C fiber stimulant capsaicin using female C57Bl/6J mice as an experimental model. Cessation or marked slowing of flow at the onset of each expiration (termed braking) was used as a biomarker for trigeminal nerve stimulation. Aerosolized capsaicin solution (100 microg/ml) increased the time of braking from baseline levels of 8 ms to an average of 69 ms. At an exposure concentration of 100 ppm the malodorants induced only a minimal time of braking response (< 35 ms); the time of braking response in animals exposed to either malodorant plus capsaicin was 2.5-fold greater than in animals exposed to capsaicin alone (p < 0.01). In a subsequent experiment the time of breaking response to capsaicin was doubled (281 vs. 146 ms) by concomitant exposure to a no effect level of ethyl sulfide (11 ppm) and the modulation of capsaicin responsiveness was nearly abolished by inclusion of the adenosine antagonist theophylline in the aerosol formulation (time of braking 184 ms, p > or = 0.05 compared with capsaicin alone). These results suggest trigeminal nerve responsiveness is enhanced by exposure to malodorants through a theophylline-sensitive paracrine signaling pathway between olfactory and trigeminal nerves.

Adenosine sensory transduction pathways contribute to activation of the sensory irritation response to inspired irritant vapors.

The molecular mechanisms through which sensory irritants stimulate nasal trigeminal nerves are poorly understood. The current study was aimed at evaluating the potential contribution of purinergic sensory transduction pathways in this process. Aerosols of 4-36 mM adenosine 5'-triphosphate (ATP) and adenosine both acted as sensory irritants. Large dose capsaicin pretreatment to induce degeneration of transient receptor potential vanilloid type-1 (TRPV1)-expressing C fibers greatly reduced, but did not abolish, the sensory irritation response to ATP aerosol and was without effect on the response to adenosine aerosol, indicating that ATP acts largely on capsaicin-sensitive (primarily C fibers) and adenosine acts on capsaicin-insensitive (primarily Adelta fibers) nerves. The response to adenosine was diminished by pretreatment with the broad-based adenosine receptor antagonist theophylline (20 mg/kg) and A1-selective antagonist 8-cyclopentyl-1,3-dipropylxanthine (0.1 mg/kg), providing evidence that adenosine stimulates capsaicin-insensitive nerves via the A1 receptor. The sensory irritation responses to 275 ppm styrene and 110 ppm acetic acid vapors were significantly reduced by theophylline pretreatment suggesting a role for adenosine signaling pathways in activation of the sensory irritant response by these vapors. If sensory nerves are activated by mediators that are released from injured airway mucosal cells, then nasal sensory nerve activation may be a reflection of irritant-induced alterations in airway cell integrity.