Influence of Lip Revision Surgery on Facial Growth in Patients With A Cleft Lip.

Although patients with cleft lip and palate often present with poor maxillary growth because of intrinsic and iatrogenic factors, the surgical influence of lip revision surgery, palatal fistula repair, and pharyngeal flap procedures remains uncertain in contrast to that of primary cleft lip repair and palatoplasty. Therefore, this study aimed to reveal factors inhibiting maxillary growth and inducing later orthognathic surgery. A retrospective analysis was conducted on the data of patients with cleft lip and palate who underwent a series of treatments at Keio University Hospital from 1990 to 2000. We collected data on patient sex, cleft type, number and timing of lip revision surgery, the incidence of palatal fistulae, history of pharyngeal flap procedures, and timing of a repeat bone graft, and reviewed whether these patients underwent orthognathic surgery later in life. Multivariate analysis was conducted using binary logistic regression to extract factors affecting later orthognathic surgery. A total of 52 patients were included in this study. Results showed that revision surgery conducted more than twice was the highest statistically significant predictor of later orthognathic surgery in patients with a cleft lip and palate ( P <0.05, odds ratio=43.3), followed by palatal fistula occurrence after cleft palate repair ( P <0.05, odds ratio=22.3). Therefore, primary surgical procedure is most important for these patients.

The role of surgeon's learning on the outcomes of alveolar bone graft for cleft repair.

BACKGROUND AND PURPOSE: Teaching cleft repair in the operating room may not sufficiently prepare craniofacial residents to perform the procedure self-reliantly. This study aimed to assess the influence of surgeons' experience level on the operative time and graft survival ratio after alveolar bone grafts for cleft repair. SUBJECTS AND METHODS: This was a retrospective review of 100 consecutive alveolar bone graft patients treated for unilateral alveolar cleft by one craniofacial surgeon between 2012 and 2019. An alveolar bone graft from the iliac bone was performed using the lateral sliding flap. Sex, age, cleft width, cleft defect volume, and operative time were recorded, and the 1-year postoperative graft survival ratio was calculated. Multiple regression analysis was performed to identify factors that affect the operative time and survival ratio. RESULTS: Factors affecting the operative time were the experience level of the surgeon and the presence of a cleft palate. Factors affecting the graft survival ratio were the cleft defect volume and experience level of the surgeon. In cleft lip and alveolus, the survival ratio was constant, and the operative time stabilised after approximately 20 cases. In cleft lip and palate, more experience was required to master the technique, and the operative time and survival ratio were stabilised only after approximately 40 cases. CONCLUSION: Surgeons' experience level influenced the outcomes of alveolar bone grafting. Although surgical training is currently undergoing a paradigm shift from on-the-job training to simulation-based training, clinical experience is critical to be self-sufficient.

Three-dimensional Coordinate System for Hemifacial Microsomia.

BACKGROUND: Hemifacial microsomia (HFM) is a congenital disorder characterized by facial asymmetry, but no midline reference has been established for evaluating facial morphology in patients with HFM. The purpose of this study was to develop a 3-dimensional coordinate system unaffected by the deformity of the external acoustic aperture or orbital circumference and to quantitatively evaluate craniofacial morphology in such patients. METHODS: We quantitatively evaluated craniofacial morphology using 3-dimensional measurements with the skull base as a reference. Using computed tomography data from 15 patients with HFM and 15 controls, a coordinate system was created for each patient, and left-right differences between measurement points were compared. RESULTS: When mandibular deformity was severe, the deformity of the posterior part of the palatine bone and lateral part of the orbit increased, but this trend was not evident for other measurement points. Thus, craniofacial deformity in HFM was not always related to mandibular deformity. Moreover, no difference was evident in the position of the hypoglossal canal between controls and patients with HFM. CONCLUSIONS: Quantitative assessments are possible using the coordinate system devised in this study, irrespective of the severity of HFM. The degree of mandibular deformity detailed in the Pruzansky classification was associated with the superoinferior deformity of the posterior part of the palatine bone and anteroposterior deformity of the lateral part of the orbit.

Clinical Application of the Internal Mammary Artery Perforator Adipofascial Flap.

BACKGROUND: Skin ulcers on the anterior chest wall are caused mainly by radiation therapy for breast cancer and anterior mediastinitis after thoracotomy, and they are often refractory. Some muscle flaps are commonly used for anterior chest wall reconstruction, but muscle flaps accompany high invasion. We used the internal mammary artery perforator (IMAP) adipofascial flap and IMAP skin flap for the anterior chest wall reconstruction. METHODS: We examined the IMAPs using a handheld Doppler device and contrast-enhanced computerized tomography preoperatively. Each flap was designed based on the location of the IMAP and the size of the flap was dependent on the coverage required by the size and location of the skin ulcer. The location of the IMAPs functioned as the pivot point of the flap and the flap was flipped or swung on the defect. RESULTS: We used IMAP adipofascial flap for 2 cases and IMAP skin flap for 1 case. In those 3 cases, we could elevate the flap with no complications even after the internal mammary artery had been harvested. There was no recurrence of the skin ulcer or wound infection after the operation. CONCLUSIONS: In this study, we reported 3 cases of skin ulcer on the anterior chest wall reconstructed with the IMAP adipofascial and skin flap. To our knowledge, this is the first report of the use of the IMAP flap as an adipofascial flap. The IMAP adipofascial flap accompanies less invasion than muscle flaps and the surgical procedure is relatively easy. The IMAP adopofascial flap is considered as one of the effective means for anterior chest wall reconstruction.

Cleft Palate Repair without Lateral Relaxing Incision.

BACKGROUND: The goals of successful palate repair include optimization of speech and feeding, avoidance of fistula formation, and mitigation of adverse maxillary growth. However, the effects of scar formation on maxillary growth have not been discussed in detail. METHODS: Between November 2010 and December 2011, the palateplasty was performed for 24 patients with cleft palate (median age, 12 months; range, 11-18 months). In the velum, a symmetrical intravelar veloplasty with mucosal Z-plasty was performed on both the nasal and oral sides. In the hard palate, instead of lateral relaxing incisions, a 1-line mucoperiosteal incision along the cleft margins was designed with subperiosteal undermining in the entire palatine bone. The palatal mucoperiosteum was sutured together in the middle of the cleft, and the cleft was directly closed without lateral relaxing incisions. The patients were monitored for 6 months to 1.6 years. RESULTS: None of the cases had issues concerning flap viability, and all palate repairs healed well. Postoperative results were satisfactory, without any complications such as dehiscence, perforation, or palatal fistula. CONCLUSIONS: The method presented in this article was effective, with successful palatal closure and without scar formation or mucosal defects along the alveolus. We conclude that minimum contracture of the hard palate was useful for not only mitigating adverse maxillary growth but also for orthodontics.

Effect of Platelet-Rich Plasma on Bone Grafting of Alveolar Clefts.

The purpose of this study was to evaluate the effectiveness of platelet-rich plasma (PRP) on the absorption of the bone graft in the alveolar cleft.Twenty-nine patients with alveolar clefts in unilateral cleft lip were examined; 6 were the control group and received iliac cancellous bone and marrow grafts without PRP, while the remaining 23 comprised the PRP group and received grafts with PRP. Quantitative evaluation of remaining bone was made by the computer-aided engineering with multidetector row computed tomography at 1 month and 1 year after surgery.Satisfactory bone bridging formation was observed in all patients. Two patients in control group and 1 patient in PRP group developed wound dehiscence with minor bone exposure. One year postoperatively, the canine was exposed and orthodontically guided into an ideal arch relation in all patients. The mean resorption ratio was 49.9 ±â€Š17.2% and 44.9 ±â€Š14.4% with no significant difference (P = 0.60).In conclusion, there is currently no evidence to suggest that autologous PRP is of value for effect on the bone resorption for alveolar bone graft.

A biomechanical study of relationship between sternum defect patterns and thoracic respiration.

BACKGROUND: Various types of sternum defects are produced after the removal of thoracic tumors involving the sternum. The present study aims to elucidate the relationship between the defect patterns and their effects on thoracic respiration. METHODS: Ten sets of finite element models were produced simulating thoraces of 10 persons and termed normal models. With each of the 10 normal models, the sternum was removed in six different ways to produce new models termed defect models. Defect models were categorized into hemi-superior (H-S), hemi-inferior (H-I), hemi-whole length (H-W), bilateral-superior (B-S), bilateral-inferior (B-I), and bilateral-whole length (B-W) defect types, depending on the locations of the defects. Respiratory movement was dynamically simulated with these models. The volume change the thoraces present during respiration was measured to evaluate the effectiveness of thoracic respiration. This value - defined as ΔV - was calculated and was compared between normal and defect models. RESULTS: With H-W and B-W type models, ΔV dropped to around 20% of normal values. With H-S and B-S type models, ΔV dropped to around 50% of normal values. With H-I and B-I type models, ΔV presented values almost equivalent to those of normal models. CONCLUSION: Effectiveness of thoracic respiration is seriously impaired when the whole length of the sternum is absent. Reconstruction of the defect is essential for these cases. However, since the upper part of the sternum is most important for effective thoracic respiration, priority should be placed on the upper part in performing reconstruction.

Salt as a new colored solid model for simulation surgery.

BACKGROUND: Simulated craniomaxillofacial surgery is critical for planning the procedure, shortening operative time, and practicing the procedure. However, typical models are expensive, given their solid materials, and the surgical sensations do not accurately reflect the procedure performed using human bone. To solve these problems, a new solid salt model has been developed. METHOD: Stereolithography data was generated using computed tomography data, and a salt model was created using a 3D inkjet printer. By extracting specific data for elements such as the teeth and mandibular canal, these elements were highlighted in the solid model using different colored material. Also, we compared the maximum load and plastic deformation of the salt model, a stereolithographic resin model, and a pig limb. RESULT: The salt model had similar tenacity to bone, and the risk of damage to the teeth and inferior alveolar nerve was easily confirmed. CONCLUSION: The material cost of the salt model is extremely low, and the salt model may provide a more accurate sensation of cutting human bone. Thus, this model is useful for both simulated operation and practice for inexperienced surgeons.

Evaluation of velopharyngeal closure by 4D imaging using 320-detector-row computed tomography.

OBJECTIVE: Current imaging techniques for velopharyngeal closure (VPC) evaluation are two-dimensional, static, or distressing, thus necessitating multiple procedures to understand this three-dimensional and dynamic area. We validated the use of a novel four-dimensional (4D) computed tomography (CT) technique for the morphological and kinematic evaluation of VPC in cleft palate patients based on dynamic volume scanning with 320-detector-row CT. METHODS: Five patients aged 4-10 years (40% males) with persistent velopharyngeal insufficiency post palatoplasty underwent conventional tests (cephalometry and video-nasal endoscopy) and 4D-CT. For each patient, complete multiplanar reconstruction, 4D airway CT, and 4D-CT endoscopy data for all scanning phases were compared with cephalometric and video-nasal endoscopy data. The movements of the velum and posterior pharyngeal walls were graded by each modality. RESULTS: 4D airway CT revealed higher anatomical detail than cephalometry, additionally providing dynamic images. 4D-CT endoscopy and video-nasal endoscopy were in agreement for all patients regarding the patterns of VPC, with complete visualization of VPC in five versus one patient, respectively. 4D airway CT and cephalometry showed a discrepancy in one case, wherein grading by cephalometry was overestimated. 4D-CT was also useful in determining the width and length of a proposed pharyngeal flap. The examination time (mean ± standard deviation (SD), seconds), including patient preparation time, was 224 ± 73, 492 ± 145, and 718 ± 123 for cephalometric radiographs, CT, and video-nasal endoscopy, respectively. The mean estimated radiation dose during 4D-CT was 4.44 ± 1.64 mSv. CONCLUSIONS: 4D-CT provides detailed morphological and kinematic analysis of VPC and may offer advantages over conventional procedures.

Surgical treatment for medically refractory myasthenic blepharoptosis.

PURPOSE: Currently, only a few reports have recommended surgery as a suitable treatment for blepharoptosis associated with myasthenia gravis. The present study aims to introduce our surgical criteria, surgical options, outcomes, and precautions for medically refractory myasthenic blepharoptosis. PATIENTS AND METHODS: Eight patients who failed to respond to at least 2 years of medical treatment and who underwent blepharoptosis surgery, from January 2008 to December 2011, were enrolled in this study. Medical records, photographs, and questionnaire results regarding postoperative status were evaluated. Of the eleven procedures performed, four involved frontal suspension, four involved external levator advancement, one involved nonincisional transconjunctival levator advancement, and two involved subbrow blepharoplasty with orbicularis oculi muscle tucking. The margin reflex distance improved postoperatively in seven patients. RESULTS: Seven patients had very minimal scarring, and one had minimal scarring. Five patients showed no eyelid asymmetry, one had subtle asymmetry, and two had obvious asymmetry. Seven patients were very satisfied, and one patient was satisfied with the overall result. Postoperative complications included mild lid lag with incomplete eyelid closure, prolonged scar redness, and worsened heterophoria. No patient experienced postoperative exposure keratitis or recurrent blepharoptosis during the study period. CONCLUSION: Our results indicate that blepharoptosis surgery is effective for patients with myasthenia gravis, especially those with residual blepharoptosis despite multiple sessions of medical treatments. We recommend that neurologists and surgeons collaborate more systematically and discuss comprehensive treatment plans to increase the quality of life for patients with myasthenia gravis.

Evaluation of bone volume after secondary bone grafting in unilateral alveolar cleft using computer-aided engineering.

The purpose of this study was to evaluate the initial defect and the outcome of bone grafts for unilateral alveolar cleft. To determine the absorption of the bone graft in patients with unilateral cleft, computer-aided engineering (CAE) with multi-detector row computed tomography (MDCT) was used. MDCT scans of 29 patients were taken immediately preoperatively and at 1 month and 6 months postoperatively. The patients underwent bone grafting between 8 and 14 years of age using iliac crest bone grafts. Three-dimensional models were created in each period, and the defect at the alveolar cleft and volume of the bone graft were determined in each patient using CAE. Cleft volume and success of alveolar bone grafting were significantly correlated (P < .01). Alveolar clefts with cleft palate required more bone volume than those without cleft palate (P < .01), but the resorption rate did not significantly differ between alveolar clefts with and without cleft palate (0.48 ± 0.14 and 0.49 ± 0.18, respectively; P = .93). In conclusion, three-dimensional reconstruction of bone grafts using CAE based on MDCT provides a valuable objective assessment of graft volume.

3-D analysis of dislocation in zygoma fractures.

OBJECTIVE: When fractured, zygomas rotate and dislocate. The present study quantitatively elucidates the pattern of the rotation. METHODS: 50 patients with tri-pod-type zygoma fractures were involved in this study. After defining a 3-dimensional coordinate system--consisting of the M-L axis (the axis directed from the medial to lateral side of the skull), I-S axis (directed from the inferior to superior side), and P-A axis (directed from the posterior to anterior side), the degree with which the fractured zygomas rotated around each of these axes was measured using 3-dimensional graphic software. Thereafter, the tendency of the rotation was compared between the three rotational axes. RESULTS: Rotation around the I-S axis was the most frequent with a 96% incidence, followed by a substantial margin by rotation around the M-L axis with a 26% incidence; rotation around the P-A axis was rare, with an incidence of 10%. Furthermore, the degree of P-A axis rotation was minor compared to I-S and M-L axis rotations. CONCLUSION: The main factor of zygoma dislocation in zygoma fracture is rotation around the I-S axis. This finding is helpful for effective performance to reposition fractured zygomas.

The use of mandibular body distraction in hemifacial microsomia.

OBJECTIVE: The goals of treatment for hemifacial microsomia include horizontalization of occlusal plane and acquisition of facial symmetry. Although horizontalization of occlusal plane can be easily achieved, facial symmetry, particularly in relation to mandibular contour, can be difficult to attain. Soft tissue is generally reconstructed to correct facial asymmetry, and no studies have described correction of facial asymmetry through skeletal reconstruction. CASE: A 12-year-old girl presented with grade IIb right-sided hemifacial microsomia. She was treated using Nakajima's angle-variable internal distraction (NAVID) system for mandibular body distraction. RESULTS: Following treatment, appropriate facial symmetry was achieved, and the patient was extremely satisfied with the results. CONCLUSIONS: Thus, we successfully treated the present patient by our novel method involving distraction osteogenesis. This method was effective and useful for several reasons including; the changes were not accompanied by postoperative tissue absorption, donor sites were not involved, and the treatment outcome could be reevaluated by adjusting distraction while the patient's appearance was being remodeled.

Not only "nurture", but also "nature", influence the outcome of zygoma repair.

The present study aims to elucidate the relationship between preoperative deviation patterns of fractured zygomas and treatment outcomes. Forty-five randomly selected patients with tri-pod type zygoma fractures were classified into a medial rotation group and a lateral rotation group, depending on preoperative deviation patterns. A minimum of 6 months after the operation, symmetry of the cheek was evaluated by three plastic surgeons using a VAS system. The evaluated scores were compared between the two groups. Furthermore, simulation of postoperative secondary deformity was performed by applying hypothetically defined relapse forces on CAD models produced by referring to the CT data of 20 patients. The deviation values obtained by the simulation were compared between the two groups. The results demonstrate that VAS scores were higher for the lateral rotation group than for the medial rotation group and that the deviation values were higher for the medial rotation group than for the lateral rotation group. It is concluded that treatment outcomes of zygoma fractures are affected by preoperative deviation patterns. Cases with medial rotation are likely to present poorer outcomes than those with lateral rotation.

A 25-year review of cases with submucous cleft palate.

OBJECTIVES: To evaluate the effect of diagnostic and operative time on velopharyngeal closure in submucosal cleft palate (SMCP). METHODS: SMCP patients treated at the Keio University School of Medicine from 1986 to 2011 were enrolled as subjects. Clinical data were obtained, including patient sex, age at diagnosis, and operative age, occasion of diagnosis, accompanying deformities, speech test results before and 6 months after palatoplasty, and pharyngeal flap usage after palatoplasty. RESULTS: Data were available for 16 patients, with a mean diagnostic age of 51.1 months (range: 0-132 months). The clinical presentations were bifid uvula in 4 patients and speech dysfunction in 11. The cases suspected from bifid uvula were diagnosed significantly earlier than those with speech dysfunction (19.5 versus 56.8 months, p<0.01). Velopharyngeal closure was improved in 6 cases, and the average age of these patients at surgery was significantly lower than that of the other patients (46.7 versus 79.8 months, p<0.05). A pharyngeal flap was performed in 7 cases (43.8%). The pharyngeal flap usage rate in cleft palate patients other than those with SMCP was significantly lower than that of SMCP patients (3.5% versus 43.8%, p<0.01). CONCLUSIONS: Early discovery and surgical correction is vital for improving postoperative speech outcomes in SMCP patients. This requires educating physicians about SMCP and future studies regarding simple and effective SMCP screening methods.

Evaluation of maxillary sinus volume in cleft alveolus patients using 3-dimensional computed tomography.

OBJECTIVE: The aim of the study was to evaluate the volume of the maxillary sinus in patients with cleft alveolus. STUDY DESIGN: This is a retrospective, descriptive study. PATIENTS AND METHODS: The 3-dimensional computed tomographic data of 218 maxillary sinuses of 109 patients with cleft alveolus were compared with those of 100 sinuses of 50 healthy individuals. RESULTS: No significant difference in the maxillary sinus volume was found between the patients with cleft alveolus and the noncleft individuals. In the patients with cleft palate and alveolus, the maxillary sinus volume was significantly larger on the right side, but no significant difference was found between the cleft and noncleft sides. CONCLUSIONS: The volume of the maxillary sinus in the patients with cleft alveolus is not different from that of the noncleft individuals. The information about the maxillary sinus is clinically important in executing such operations as endoscopic sinus surgery.

Role of solid model simulation surgery for hemifacial microsomia.

Distraction osteogenesis is now a standard procedure for hemifacial microsomia, and various methods have been described. However, it is sometimes difficult to obtain the horizontal occlusal plane and facial symmetry. This brief communication describes and discusses the usefulness of solid model simulation surgery for hemifacial microsomia.