Aesthetic restoration of fronto-orbital deformity with prefabricated implant utilizing modeling clay and rapid-prototyping technology.

Skeletal deformity in the fronto-orbital region resulting from various problems can have significant aesthetic concerns. Restoring an aesthetically acceptable appearance relies most importantly on the restoration of a precise skeletal contour. Current surgical options for depression deformities or partial-thickness defects range from extensive corrective osteotomies to less complicated methods of onlay grafting with autogenous or alloplastic materials. Both methods have difficulties in providing a symmetric and smooth contour for predictable and reliable cosmetic results. Alloplastic implants provide another effective alternative and the success of the skeletal contouring correlates directly with the accuracy of the implant sculpture. Prefabricated methylmethacrylate implants, with the aid of modeling clay, computer imaging, and modern rapid-prototyping technologies, fits the depression deformity well and balances the skeletal contour. It provides plastic surgeons greater precision in customizing the implant, which ensures better predictability and reliability of cosmetic outcomes.

Surgical management of Binder's syndrome: lessons learned.

Maxillonasal dysplasia, commonly known as Binder's syndrome, is unmistakably characterized by midfacial hypoplasia and a retruded flat nose. The condition is variably expressed, and reconstruction must be tailored to the individual. Controversy still exists over the optimal age for surgery and the ideal treatment strategy. In a review of 24 patients with Binder's syndrome treated at the Chang Gung Craniofacial Centre over a period of 17 years, the authors examine the evolution of their experience treating patients with this condition. Maxillary osteotomies were rarely required and were reserved only for patients with severe and symptomatic class 3 malocclusion. Effective augmentation of the skeletal deficiencies in the midface was achieved with onlay bone or cartilage grafts. Nasal augmentation was performed with bone or cartilage grafts to the dorsum, columella, and tip. Cartilage is preferred over bone as graft material because it retains its volume and is less prone to resorption. Silastic implants can be a useful adjunct to cartilage in cases for which donor availability is limited. To minimize the risk of infection and extrusion, however, silastic implants are always limited to the nasal dorsum and always used in conjunction with cartilage grafts to the columella and tip. The authors prefer to defer surgery until midfacial growth is nearly complete, when the patient is in his or her mid-teenage years. Earlier surgery is indicated if the condition presents a significant psychological strain to the patient. In such cases, a silastic nasal implant can be used as a temporary corrective measure.

Facial nerve palsy after sagittal split ramus osteotomy of the mandible: mechanism and outcomes.

PURPOSE: Facial nerve palsy after sagittal split ramus osteotomy of the mandible (SSRO) is a rare, but serious, complication. The aim of the present study was to evaluate the incidence of this complication, the possible causative mechanisms, its subsequent management, and eventual outcomes. PATIENTS AND METHODS: All patients who underwent SSRO of the mandible at the Craniofacial Center, Chang Gung Memorial Hospital, Taiwan, from 1981 to 2008 were included in the present study. The patients reported as having postoperative facial nerve paralysis were identified and reviewed. RESULTS: A total of 3,105 patients had undergone bilateral SSRO (6,210 sagittal splits). Of these 3,105 patients, 6 were reported as having unilateral facial nerve palsy postoperatively, for an incidence of 0.1%. One case was diagnosed as Bell's palsy. None of the patients with postoperative facial nerve palsy required surgical intervention, but all received physical therapy and medications. Complete recovery was obtained without sequela in all but 1 patient, who had incomplete frontal branch recovery. CONCLUSIONS: Most facial nerve palsies that occur after SSRO of the mandible result from neurapraxia or axonotmesis, possibly from nerve compression or traction. Complete recovery can be expected in most cases, and conservative management without surgical exploration is recommended.

Surgical repair for macrostomia: significance of Z-plasty limb directions.

The objective of this study was to determine whether the direction of Z-plasty limbs incorporated into the surgical repair for macrostomia had a significant influence on the quality of the resultant scar. A total of 41 patients who underwent macrostomia repair by means of the same technique, and who had a follow up period of at least 2 years, were retrospectively reviewed through postoperative photographs and medical records. Quality of scar, lip symmetry, and commissure shape and thickness were recorded. Our results showed that a more favorable scar would be achieved in the medial limb of the Z-plasty if it was planned parallel to relaxed skin tension lines (P < 0.05). An unfavorable scar would be more likely if the medial limb of the Z-plasty was made in a horizontal direction or perpendicular to relaxed skin tension lines (P < 0.05). The quality of scar in both the central and lateral limbs of the Z-plasty was not significantly influenced by their direction.

Customised fabricated implants after previous failed cranioplasty.

Reconstruction of cranial defects can be reasonably considered a failure if an aesthetically obvious cranial contour deformity persists after surgery. Such unsatisfactory outcome often results from variable resorption of bone grafts or infection, requiring removal of implant. In considering further treatment for such failed cases, the use of alloplastic implants is frequently warned as imprudent due to their theoretically increased potential for infection; however, the validity of such caution has never been substantiated. We describe a user-friendly, time- and cost-effective method of producing prefabricated methyl methacrylate implants for the reconstruction of cranial defects, using readily available computer-aided design and computer-aided manufacture facilities. This method was carried out in 31 patients who presented with persistent cranial defects after previously failed cranioplasty. The efficacy of this technique and the clinical outcome of the patients in this series were analysed. All implants produced a precise fit, with a reduction in operating time and satisfactory cosmesis having been achieved. Infection that required removal of implant occurred in three patients (9.7%), and one patient developed a dural tear, requiring repair. Customised fabricated alloplastic implants provide a safe, accurate and efficient way of restoring normal cranial contours in patients with cranial defects who have had previous failed cranioplasties.

Negative pressure manoeuvre in microtia reconstruction with autologous rib cartilage.

In microtia reconstruction, maintaining a healthy contact between the skin and the fabricated cartilage framework is essential to attaining a smooth and accentuated contour of the reconstructed auricle. Conventional means to achieve this include bolster sutures and continuous suction drains, both of which have associated shortcomings. A new dressing method was developed and applied in 10 consecutive patients who underwent the first of a two-stage microtia reconstruction using the Nagata technique. A small catheter was introduced into the space between the skin and the cartilage framework. Negative pressure was applied through the catheter, drawing the skin onto the cartilage framework. This evens out the skin, accentuates the contour of the framework and concurrently eliminates potential dead space. Skin contact on the framework is maintained whilst the catheter is removed and an occlusive transparent dressing is applied to the ear. Of the 10 cases in which this manoeuvre was performed, one had to be converted to the bolster suture technique due to a persistent air leak from the wound. Overall results of the nine cases in which this technique was carried out successfully demonstrate smooth skin contour and excellent definition of the fabricated framework. This negative pressure manoeuvre provides a simple, safe and consistent approach to achieving a smooth and accentuated contour in auricular reconstruction.

Patient satisfaction after zygoma and mandible reduction surgery: an outcome assessment.

An ovoid and slender face is considered attractive in Oriental culture, and facial bony contouring is frequently performed in Asian countries to achieve this desired facial profile. Despite their popularity, critical analyses of patients' satisfaction after facial-bone contouring surgery is lacking in the current literature. Questionnaires were sent to 90 patients who had undergone zygoma and/or mandibular contouring by a single surgeon at the Craniofacial Center, Chang Gung Memorial Hospital, Taiwan. The number of patients who had mandibular angle reduction and zygoma reduction were 78 and 36, respectively. The questionnaire contained 20 questions, concerning aesthetic and surgical results, psychosocial benefits and general outcome. Medical records were also reviewed for correlation with the questionnaire findings. The survey response rate was 52.2% (47 patients). A total of 95.7% were satisfied with the symmetry of their face after surgery, and 97.9% felt that there was improvement in their final facial appearance. As many as 61.7% could not feel an objectionable new jaw line or bony step and 66.0% could not detect any visible deformity. A total of 87.2% could not detect bony regrowth after surgery. Complication after surgery was experienced by 17.0% of patients, but all of these recovered without long-term consequences. All patients noted a positive psychosocial influence, and 97.9% of patients said that they would undergo the same surgery again under similar circumstances and would recommend the same surgery to friends. The majority of patients with square face seeking facial bone contouring surgery are satisfied with their final appearance. Of equal importance is the ability for this type of surgery to have a positive influence on the patient's psychosocial environment.

A new method for the second-stage auricular projection of the Nagata method: ultra-delicate split-thickness skin graft in continuity with full-thickness skin.

BACKGROUND: Staged auricular reconstruction remains mainstream among the various techniques of microtia reconstruction using autogenous costal cartilage. The initial stage involves fabrication and implantation of the cartilage framework, followed by projection of the reconstructed auricle in the second stage. During the projection stage, the line of incision is usually made close to the helical rim, from the superoanterior margin of the helical rim to the region of the lobule. Generally, a fascial flap is raised and covered over a cartilage block to project the auricle, and a skin graft is inset over the raw surface of the newly created postauricular sulcus. METHODS: The authors developed a new refinement for the second-stage auricular projection, whereby the skin cover for the raw surface over the posterior aspect of the auricle and the postauricular sulcus is an ultra-delicate split-thickness skin graft raised in continuity with the full-thickness skin over the anterior aspect of the auricle. RESULTS: Incorporation of this new technique has minimized the visibility of suture lines and improved the appearance of the superior otobasion. In addition, the dimension of the skin cover required can be designed with greater precision. Postoperative outcomes using this new technique for auricular projection have been more than satisfactory. CONCLUSION: More favorable results that carry less surgical stigma can now be achieved in auricular reconstruction using this new modification of Nagata's two-stage method.

Strategies for achieving long-term effective outcome in cleft missions: the Noordhoff Craniofacial Foundation and Chang Gung Memorial Hospital.

The Noordhoff Craniofacial Foundation and Chang Gung Memorial Hospital have partnered to deliver cleft programs to developing nations still in need of adequate cleft care. The lessons learnt through the development of the Chang Gung Cleft and Craniofacial Center from humble beginnings to its current international standing have enabled insights into devising key strategies for achieving long-lasting and compounding outcome in cleft missions. Close collaboration with local governing and health authorities, as well as establishment of ongoing support from charitable organizations that share similar philosophies, is an essential component to creating growth and sustainability of a cleft program. Identification of local "seed" physicians and key personnel, and their subsequent training at a major cleft center, is pivotal to the establishment of local cleft centers and cleft foundations that would ultimately empower local health care providers' autonomy in delivering the highest standard of care to patients with cleft in their own country.