Simultaneous correction of scars and tissue deficiency with composite grafts in secondary cleft lip deformity.

PURPOSE: In secondary cleft lip deformities, repetitive surgeries lead to increased tension and deformities in the upper lip, ultimately resulting in new deformities such as wide scars and a tight lip. The simultaneous correction of a wide scar and tissue deficiency in the upper lip is paradoxical unless sufficient tissue is supplied to the scant upper lip. The authors describe a method to transfer composite tissue for the improvement of secondary cleft lip deformities and present an analysis of the outcomes. MATERIALS AND METHODS: Ninety-one patients with secondary cleft lip, a wide scar, and tight lip were enrolled. After complete excision of the scar, the defect was covered with a composite graft that included skin and subcutaneous fat. The results were rated by 2 investigators blinded to the image of the scar and the morphology of the upper lip. The skin color of the 25 grafts was analyzed using a narrowband spectrophotometer using the Commission International d'Eclairage L*a*b* color coordinates. RESULTS: All grafts survived without sequelae. The scores of the scar images and general morphology were 8.3/10 and 8.2/10, respectively. Spectrophotometric analysis displayed no differences between the composite tissues and normal upper lip skin in each color coordinate, indicating that the composite tissue had a good color match with a normal upper lip. CONCLUSIONS: The use of a composite graft on the upper lip can be a reliable option to correct a wide hypertrophic scar and tight lip simultaneously, resulting in a satisfactory scar image and an improvement of upper lip morphology.

Seven fundamental procedures for definitive correction of unilateral secondary cleft lip nasal deformity in soft tissue aspects.

PURPOSE: It is accepted that patients who undergo appropriate primary repair for cleft lip will have secondary deformities. Because these deformities are caused by complex and diverse patterns, the deformities were categorized to provide a standardized treatment for each category. PATIENTS AND METHODS: Pathologic characteristics of 1,170 patients were classified into 7 categories. Corrections were performed using 7 fundamental procedures corresponding to the surgical resolution of each deformity: 1) transposition of the caudal septum; 2) release of the septal-cartilaginous junction; 3) medial crus elevation; 4) lateral crus elevation; 5) release of the orbicularis oris muscle from the lip elevators; 6) anchoring of the orbicularis oris muscle to the anterior nasal spine; and 7) philtral column formation. A satisfaction survey was performed to evaluate the overall outcomes in 171 patients and an anthropometric analysis was performed in 38 patients. RESULTS: Satisfactory scores obtained through postoperative follow-up were higher than preoperative scores, and there was no difference between postoperative scores obtained over the short and long term. All preoperative anthropometric measurements were different from the postoperative measurements, indicating that the fundamental procedure achieved effective outcomes. CONCLUSIONS: These proposed 7 fundamental procedures can be used as guidelines that can always be applied for the correction of any secondary cleft lip nasal deformity to obtain ideal treatment outcomes.

Outcome of early rigid fixation and removal of rigid external distraction system after distraction osteogenesis of the midface.

After distraction osteogenesis of the midface using a rigid external distraction (RED) system, there is a high possibility that a relapse might occur due to an incomplete fixation during the consolidation period, and it is uncomfortable for the patients to wear a head frame for 2 to 3 months. There are also risks of trauma that are developing. To overcome these problems, we suggest the protocol of early rigid fixation, with excellent treatment outcomes and a review of literatures. Of 9 patients, Le Fort III osteotomy was completed in 2 patients with Crouzon disease, and a Le Fort I osteotomy was completed in 7 patients with a cleft lip and palate. Immediately after the distraction with RED was completed, the fixation was done using a miniplate. This was followed by the early removal of the RED system. In patients who underwent the current procedure, an analysis was performed for the degree and the duration of distraction and the period of use of the RED system. Then, the presence of relapse was examined. The mean degree of bone distraction was found to be 18.05 mm (range, 9-31.5 mm). The mean period of wearing RED system was 29.78 days (range, 21-43 days). Thereafter, the mean follow-up period was 13 months (range, 6 months to 3 years). The degree of accumulated relapse was found to be 1.7 mm (10%) on postoperative year 1, 2.4 mm (13.3%) on postoperative year 2, and 2.3 mm (14.6%) on postoperative year 3. With the concept of early rigid fixation, we were able to eliminate the disadvantages of distraction osteogenesis such as the long period of wearing a head frame, the delay of returning to society, and the inconvenience of patients. Moreover, early rigid fixation could decrease the need of overcorrection and the amount of relapses.

Transport disc distraction osteogenesis for the reconstruction of a calvarial defect.

PURPOSE: According to previous reports about the experimental study of transport disk distraction osteogenesis (TDDO) for the reconstruction of bone defects, TDDO showed great feasibility of successful bone regeneration. However, those studies had some limitations in their design and analysis of the results, either. In this report, we intended to verify the effect of TDDO in the reconstruction of skull defects with a combined result of distraction osteogenesis and bone graft of transported disk (TD). METHODS: Six female dogs were operated on and were given a 35×15-mm bilateral skull defect. In the experimental group, TDDO with internal distractors (7×14-mm TD) was performed. On the other side, in the control group, the bone defects were left to heal naturally. The distraction was performed from the postoperative fifth day at a rate of 1 mm/d. The distraction progressed for 14 days, and then the TD was maintained in the middle of the bone defect area. The 40% of the original bone defect area was left the same as the control side. The TD was expected to be survived as a bone graft during the consolidation period. After 3½ months of a consolidation period, the remained bone defects were measured by three-dimensional computed tomography. The solidity of the new bone was compared with the bone tissue of the normal skull bone. RESULTS: In the study group, the new bone formation was estimated to be 62.3% (SD, 25.1%) of the defect area, and in the control group, it was 44.8% (SD, 27.3%). The difference between the 2 groups was significant (P=0.04). The solidity of the newly generated bone by TDDO was not different from the normal skull (P=0.74). CONCLUSIONS: In this study, the concept of TDDO and bone graft seemed to promote new bone formation. The role of the TD could include bone regeneration from distraction osteogenesis as well as autogenous bone graft, although it needs more investigation. The relationship between the duration of distraction and the positive role of the TD as an autogenous bone graft in TDDO for better clinical application may be investigated.

First percutaneous reduction and next external suspension with Steinmann pin and Kirschner wire of isolated zygomatic fractures.

We have introduced a less invasive, simple, and effective method for zygomatic fractures using percutaneous reduction with a Steinmann pin (S-pin) and temporary external suspension with a Kirschner wire (K-wire).For 2 years, 51 patients underwent first percutaneous reductions and then fixations, which is a method that we developed. After the S-pin no. 1 was percutaneously inserted at the most prominent point of the zygoma, closed reduction was first attempted using lever movement and temporary external suspension with a K-wire. If required, 1-site rigid fixation was performed on the zygomaticomaxillary buttresses via gingivobuccal incisions. Only 13 patients received K-wire suspensions and 38 patients received K-wire suspensions and lateral buttress fixations. We evaluated the postoperative result in 4 aspects (flattening, symmetry, scar, and paresthesia) using the 4-point visual analog score after at least 6 months.The mean maintenance period of the S-pin and K-wire was 12.3 days, and the mean operation time was 33 minutes. No serious complications, such as infections or external wire instability, were observed. Excellent or good results were achieved in more than 95% of patients in all 4 aspects mentioned.We believe that our method, which is the first percutaneous reduction using S-pin and temporary external suspensions with a K-wire with or without a lateral buttress rigid fixation, is a simple and effective method for noncomminuted zygomatic fractures.

Skin color analysis using a spectrophotometer in Asians.

BACKGROUND/PURPOSE: To objectively describe skin color, the Commission International d'Eclairage (CIE) L*a*b* color coordinates and melanin and erythema indexes are used. However, it was difficult to understand the relationship among these parameters and to convert them into each other. We introduced a new technique to measure L*a*b* color coordinates and the melanin and erythema indexes at the same time. We analyzed the skin color of normal Asians using this method. METHODS: The skin color of the forehead, cheek, upper inner arm, dorsum of hand, and anterior chest of 148 volunteers was measured using a spectrophotometer. Using a computer analysis program, L*a*b* values and the melanin and erythema indexes were presented at the same time. The averages of these data were shown according to gender, age, body parts, and correlations among the melanin and erythema indexes and L*a*b* color coordinates, and then they were analyzed. RESULTS: The averages of the melanin and erythema indexes of 148 participants were 1.10 +/- 0.29 and 1.29 +/- 0.38, respectively. The averages of the L*, a*, and b* values were 64.15 +/- 4.86, 8.96 +/- 2.65, and 18.34 +/- 2.39, respectively. The melanin and erythema indexes were higher in males than in females. While the correlation of the melanin index with the L* value was negative, it was positively correlated with the a* and b* values. While the erythema index showed a weak correlation with the b* value, its correlation was negative with the L* value and positive with the a* value. CONCLUSION: Our method of skin color measurement is useful. We consider the data of this study valuable basic data for the evaluation of colors of pigmental skin diseases and scars in the future.

Vomopalatoplasty: a novel procedure to reduce velopharyngeal distance in cleft palate repair.

Despite numerous improvements in the palatoplasty procedure, speech dysfunction tends to develop in many patients, requiring another surgery. In addition, vomer flaps have been used in palatoplasty in various shapes and on purposes. Nonetheless, they have been used mostly to cover the defect in wide and complete type of cleft palate. We introduce the vomopalatoplasty procedure that uses a vomer flap to reduce the nasopharyngeal space in incomplete or submucous type of cleft palate patients.The mucoperiosteal flaps on the nasal and oral sides were elevated by the conventional palatoplasty procedure, which subsequently elevated the bilateral vomer flaps to the posterior edge of vomer. Then, the vomer flap was sutured with the mucoperiosteal flap of the nasal side to the anterior half of the soft palate, and thus, the soft palate was fixed in more posterosuperior direction than in conventional palatoplasty. For patients whose junction of vomer and hard palate had to be exposed, a part of the bone at the bifid posterior nasal spine of the hard palate may be removed sometimes.Ostectomy of the bifid posterior nasal spine or the posterior end of the hard palate was performed in 11 patients. Another 12 patients did not need ostectomy. After the surgery, the surgical wounds healed well in all patients without any major complications such as dehiscence or loss of flap.Our vomopalatoplasty is easy to perform, and the procedure could be combined to the conventional palatoplasty procedure. Thus, we consider vomopalatoplasty as a useful procedure that could reduce the nasopharyngeal space in patients with incomplete or submucous type of cleft palate.

Comparison of the soft tissue thickness of the midface in craniosynostosis.

Craniosynostosis is classified according to the included sutures as either symmetric, such as scaphocephaly and brachycephaly, or asymmetric, such as plagiocephaly. Asymmetric craniosynostosis has been known to exert asymmetric effects not only on the cranium but also on the facial skeleton. Nonetheless, the presence of asymmetry in soft tissues is only speculative and is based on the experience of plastic surgeons. In our study, after measuring the surface coordinates of soft and bone tissues from numerous positions on three-dimensional computed tomography (CT), the distance between the coordinates was calculated and the thickness of the soft tissues was obtained by objective measurements. The subjects included a control group of 8 symmetric craniosynostosis patients, and the study group consisted of 7 asymmetric craniosynostosis patients selected by computed tomographic data. In each patient, the thickness of the midfacial area was measured by dividing it into frontal and lateral views. The results show that in symmetric craniosynostosis, the thicknesses of the right and the left soft tissues were statistically identical. However, in asymmetric craniosynostosis, the thickness of soft tissues in the hypoplastic side was statistically significantly thin according to measurements taken at both the frontal and the lateral views (P = 0.048 and P = 0.034, respectively). This suggests that surgeons should pay attention to the asymmetry of soft tissues during follow-up and when correcting facial asymmetry in asymmetric craniosynostosis.

A comparative study of the medial crura of alar cartilages in unilateral secondary cleft nasal deformity: the validity of medial crus elevation.

The purpose of this study was to confirm whether the medial crus on the cleft side is primarily hypoplastic compared with the noncleft side and to evaluate the displacement of the medial crus on the cleft side presenting the validity of the "medial crus elevation" method. Thirty unilateral cleft lip nasal deformity patients underwent medial crus elevation. The thickness, width, and length of the medial crus on both sides were measured. The difference in the height of both foot plates was also measured. There were no significant differences between the cleft and noncleft sides in width, thickness, or length except proximal thickness. The foot plate on the cleft side was displaced downward. The medial crus on the cleft side is not hypoplastic, and it is merely displaced downward. These results show the validity of the medial crus elevation method for the correction of secondary nasal deformities in cleft patients.