The efficacy of dermofat grafts from the groin for correction of acquired facial deformities.

BACKGROUND: Posttraumatic acquired facial deformities require surgical treatment, with options including scar revision, fat grafts, implant insertion, and flap coverage. However, each technique has specific advantages and disadvantages.
. METHODS: From 2016 to 2018, 13 patients (eight with scar contracture and five with a depressed scar) were treated using dermofat grafts from the groin. The harvested dermofat was then inserted into the undermined dead space after the contracture was released, and a bolster suture was done for fixation considering the patient's contour and asymmetry. A modified version of the Vancouver Scar Scale and satisfaction survey were used to compare deformity improvements before and after surgery.
. RESULTS: In most cases, effective volume correction and an aesthetically satisfactory contour were maintained well after dermofat grafting, without any major complications. In some cases, however, lipolysis proceeded rapidly when inflammation and infection were not completely eliminated. A significant difference was found in the modified Vancouver Scar Scale before and after surgery, with a p-value of 0.001. The average score on the satisfaction survey was 17.07 out of 20 points.
. CONCLUSION: A dermofat graft with the groin as the donor site can be considered as an effective surgical option that is the simplest and most cost-effective method for the treatment of acquired facial deformities with scar contracture.

Long-term postoperative satisfaction and complications in nasal bone fracture patients according to fracture type, site, and severity.

BACKGROUND: It is difficult to completely fix nasal bone fractures with closed reduction, as it is often accompanied by septal cartilage damage, and this often results in postoperative secondary deformities. Thus, patients are often reluctant to undergo closed reduction surgery. The present study aimed to evaluate aesthetic and functional satisfaction, as well as satisfaction with and complications of closed reduction, according to nasal bone fracture type. METHODS: The subjects were patients who underwent closed reduction under general anesthesia from January 2017 to December 2018. Based on the modified Murray classification, patients were classified into five groups according to the fracture site, septal fracture, and deviation. A total of 211 patients were sent a web-based survey on postoperative satisfaction and complications, as well as intention for revision and cosmetic surgery. Sixty-one patients (28.9%) responded. RESULTS: There were no significant differences in aesthetic and functional satisfaction or satisfaction with closed reduction according to the fracture type, site, or severity. Postoperative functional complications developed in 14 of 61 patients (22.95%). With 10 out of 24 (41.67%) patients (p = 0.044), the bilateral fracture with septal fracture or prominent septal deviation type had a higher incidence of complications than the other types. CONCLUSION: The incidence of complications is higher for bilateral fracture with septal fracture or prominent septal deviation compared to the other nasal bone fracture types. Therefore, long-term follow-up after closed reduction surgery for this fracture type can aid in establishing additional postoperative treatment plans and improving patient satisfaction.

Prediction of Lower Eyelid Malpositioning After Surgical Correction of Orbital Fracture Using the Subciliary Approach Through the Canthal Area and Orbital Vector Analysis.

A subciliary incision has been widely used not only for blepharoplasty but also for facial fracture surgery. However, lower eyelid malpositioning is one of the most common complications after fracture surgery. A limited number of studies have been conducted on the relationships among evaluation of the canthal area, orbital vector analysis, and lower eyelid malpositioning following the subciliary approach for surgical repair of fractures. The primary goal of this study was to identify and analyze the possible risk factors, including incidence of lower eyelid malpositioning and orbital vector after surgical correction of the orbital fracture. A total of 241 cases of orbital fracture surgery was retrospectively reviewed. Data related to the patient and surgery were collected. Orbital vector and angle that reflects the vector, distance between soft tissue and bone in the lateral canthal area were measured for orbital vector analysis. The relationship between the prevalence of the malpositioning of the lower eyelid and each factor was statistically analyzed. The distance between the soft tissue and bone at the lateral canthal area was statistically significant (P = 0.031). The distance between the soft tissue and bone at lateral canthal area illustrates the lateral side or periorbital anatomical morphology. It could be inferred that patients with a negative orbital vector were relatively more vulnerable to scar formation or lower eyelid malpositioning caused by iatrogenic factors. Therefore, it could be analyzed as a risk factor to predict the malpositioning of the lower eyelid postoperatively.

Differential Expression of Vascular Endothelial Growth Factor in the Cortex and Hippocampus upon Cerebral Hypoperfusion.

BACKGROUND/AIM: Vascular endothelial growth factor (VEGF) provides tolerance against ischemic brain injury, yet, the pattern of VEGF expression in the neurogenic zones following chronic cerebral hypoperfusion has not been studied. Here we evaluated the immunoreactivity of VEGF in a rat model of chronic cerebral hypoperfusion. MATERIALS AND METHODS: Chronic hypoperfusion was induced by bilateral common carotid artery ligation in rats. Immunohistochemistry was performed against hypoxia-inducible factor-1α (HIF-1α) and VEGF on brain sections. RESULTS: The density of HIF1α-positive cells in the hypoxia group was increased in the cerebral cortex and hippocampus. Further, the density of VEGF-positive cells was significantly higher in the hypoxia group compared to the control group in the cerebral cortex whereas it was similar in the subventricular zone, and in the dentate gyrus in the hippocampus between the two groups. CONCLUSION: The pattern of VEGF expression varies in different brain regions following chronic cerebral hypoperfusion.

Clinical usefulness of fixation of absorbable implants with cyanoacrylate in comminuted fractures of the maxilla.

BACKGROUND: The open reduction of craniofacial bone fractures requires internal fixation using metal plates and screws, which have been considered the gold standard. However, metal implants pose a risk of palpation, protrusion, and foreign body reaction, and they may require an additional operation for removal. Recently, good results have been reported for absorbable implants which complement the disadvantages of metal implants. This study presents the results of using absorbable mesh, plates, and screws with cyanoacrylate for more accurate and firmer fixation of comminuted fractures of the maxilla. METHODS: In total, 235 patients underwent operations for comminuted fractures of the maxilla. From January 2012 to December 2014, absorbable mesh and screws were used in 114 patients, while from January 2015 to December 2017, absorbable mesh, plates, and screws with cyanoacrylate were used in 121 patients. Open reduction of the bone fragments was performed, after which absorbable implants were accurately molded and fixed by screws. RESULTS: All patients underwent postoperative computed tomography scans, which showed highly accurate reduction and firm fixation in the patients who underwent procedures using absorbable implants, screws, and cyanoacrylate. There were no postoperative complications or cases of abnormal facial contour. CONCLUSION: When absorbable implants and screws are used for maxillary fractures, no additional surgery to remove the metal plate is required. In addition, the use of cyanoacrylate enables accurate and firm fixation of the tiny bone fragments that cannot be fixed with screws.

The efficacy of mobile application use on recall of surgical risks in nasal bone fracture reduction surgery.

BACKGROUND: The number of surgical risks recalled by a patient after surgery can be used as a parameter for assessing how well the patient has understood the informed consent process. No study has investigated the usefulness of a self-developed mobile application in the traditional informed consent process in patients with a nasal bone fracture. This study aimed to investigate whether delivery of information, such as surgical risks, through a mobile application is more effective than delivery of information through only verbal means and a paper. METHODS: This prospective, randomized study included 60 patients with a nasal bone fracture. The experimental group (n=30) received preoperative explanation with the traditional informed consent process in addition to a mobile application, while the control group (n=30) received preoperative explanation with only the traditional informed consent process. Four weeks after surgery, the number of recalled surgical risks was compared for analysis. The following six surgical risks were explained: pain, bleeding, nasal deformity, numbness, nasal obstruction, and nasal cartilage necrosis. RESULTS: The mean number of recalled surgical risks among all patients was 1.58±0.56. The most frequently recalled surgical risk was nasal deformity in both groups. The mean number of recalled surgical risks was 1.72±0.52 in the experimental group and 1.49±0.57 in the control group. There was a significant association between mobile application use and the mean number of recalled surgical risks (p=0.047). Age, sex, and the level of education were not significantly associated with the mean number of recalled surgical risks. CONCLUSION: This study found that a mobile application could contribute to the efficient delivery of information during the informed consent process. With further improvement, it could be used in other plastic surgeries and other surgeries, and such an application can potentially be used for explaining risks as well as delivering other types of information.

Use of Triamcinolone Acetonide to Treat Lower Eyelid Malposition after the Subciliary Approach.

BACKGROUND: The subciliary approach is commonly used for reconstruction of orbital wall or zygomaticomaxillary fractures. However, this approach is associated with postoperative complications, especially lower eyelid malposition. We report the experience of managing postoperative lower eyelid malposition with triamcinolone acetonide. METHODS: A retrospective review was performed for all traumatic facial fractures requiring surgery via the subciliary approach at Chosun University Hospital in 2014. For each patient meeting inclusion criteria, the medical chart was reviewed for demographic information and postoperative course, including the presence of postoperative eyelid malposition or scleral show. RESULTS: The review identified 189 cases in which the subciliary approach was used, and postoperative lower eyelid malposition was found in 7 cases (3.7%). For these 7 patients, the mean therapeutic period (interval to correction of the malposition) was 10.5 weeks (range, 8 to 14 weeks). On average, patients received 3 injections of triamcinolone. In all cases, degrees of the malposition were improved, and none of the patients required an operative intervention to correct the malposition. CONCLUSION: Triamcinolone injection is an appropriate treatment modality for lower eyelid malposition after subciliary approach. Treatment duration is relatively short, requiring fewer than 4 outpatient clinic visits, with relatively earlier recovery compared to conservative "wait-and-see" management.

The estimation of postoperative bleeding after reduction of blowout fracture: the effectiveness of negative-pressure drainage system.

BACKGROUND: Retrobulbar hemorrhage is a rare complication of midface injury, blepharoplasty, facial fracture surgery, periorbital surgery, and circumbulbar anesthesia. The incidence of postoperative retrobulbar hemorrhage is 0.3% to 4% after the reduction of facial bone fracture. The purpose of this study was to estimate the postoperative bleeding after the reduction of a blowout fracture and to demonstrate the effectiveness of a negative-pressure drainage system with a scalp vein set tube. METHODS: From January 2006 to July 2013, we handled a total of 1491 cases of blowout fractures. Two of them (0.13%) were diagnosed as retrobulbar hematoma in 2011. After experiencing 2 cases of retrobulbar hematoma, we have been routinely using a scalp vein set tube as a negative-pressure drainage system to check the postoperative blood volume. RESULTS: From January 2012 to July 2013, a total of 131 patients underwent blowout fracture repair and experienced application of a negative-pressure drainage system. Their mean total drained amount was 12.6 mL; maximum amount was 47.5 mL in the 2 days after the surgery. The maximum drained amount was 41.7 mL on the day of the surgery. All the patients had no cardinal signs or symptoms of retrobulbar hematoma and no complications. CONCLUSIONS: Retrobulbar hematoma is a rare but critical surgical complication that leads to permanent visual loss. Considering the limited orbital cavity and postoperative edema, the volume of postoperative bleeding is thought to be enough to compress the optic nerve if the blood is not drained. Thus, we recommended a simple negative-pressure drainage system to prevent retrobulbar hematoma.

Complex Correction of Complete Cleft Lip with Severe Prominent Premaxilla using Lip Adhesion and Nasoalveolar Molding Device.

Nasoalveolar molding (NAM) device is an effective treatment for protruding maxilla in infants with cleft palate. However, only a few studies have investigated the effect of NAM devices on the treatment of protruding maxilla in infants with cleft lip only. We have designed a combination treatment using NAM devices prior to cheiloplasy for cleft lip-only patients with severe anterior protrusion of the premaxilla. Three cleft lip-only infants with 1-cm or more of premaxilla protrusion were included. Definitive cheiloplasty was performed at 6 months of age without any preoperative correction in infant 1. Cheiloplasty was performed in conjunction with the use of NAM device and lip adhesion in infants 2 and 3. Postoperative columella length and anterior-posterior dimension of the protruding premaxilla were compared amongst the infants. We were able to obtain satisfactory postoperative columella length and general nasal appearance.

Direct Open Venous Drainage: An Alternative Choice for Flap Congestion Salvage.

In this report, we present a scalp defect reconstruction with lateral arm free flap. We highlight the difficulty in obtaining a recipient vein and the venous drainage managed through an open end of the donor vein. A 52-year-old woman presented with a pressure sore on the left scalp. A lateral arm free flap was transferred to cover this 8×6 cm defect. The arterial anastomosis was successful, but no recipient vein could be identified within the wound bed. Instead, we used a donor venous end for the direct open venous drainage. In order to keep this exposed venous end patent, we applied heparin-soaked gauze dressing to the wound. Also, the vein end was mechanically dilated and irrigated with heparin solution at two hour intervals. Along with fluid management and blood transfusion, this management was continued for the five days after the operation. The flap survived well without any complication. Through this case, we were able to demonstrate that venous congestion can be avoided by drainage of the venous blood through an open vessel without the use of leeches.

Aspiration pneumonitis due to povidone-iodine aspiration during a facial bone fracture reduction operation.

Aspiration pneumonitis caused by aspiration of an oral disinfectant such as povidone-iodine during general anesthesia is rare and presents from a simple cough to a potentially fatal reaction. We present the case of a 15-year-old woman who developed aspiration pneumonitis as a complication due to aspiration of povidone-iodine during reduction with a fracture in her left anterior maxillary wall and orbital floor while under general anesthesia. Operators should consider the risks of aspiration pneumonitis during oral cleansing while patients are under general anesthesia.

Clinical Follow-up on Sagittal Fracture at the Temporal Root of the Zygomatic Arch: Does It Need Open Reduction?

BACKGROUND: The zygoma is a major portion of the midfacial contour. When deformity occurs in this area, a reduction should be conducted to correct it. If a sagittal fracture at the temporal root of the zygomatic arch occurs, this also requires reduction, but it is difficult to approach due to its anatomical location, and the possibility of fixation is also limited. Thus, the authors attempted the reduction of sagittal fracture by two- or three-point fixation and the Gillies approach without direct manipulation. The preoperative and postoperative results of the patients were evaluated. Follow-up was performed to establish a treatment guideline. METHODS: A retrospective study was done with 40 patients who had sagittal fractures at the temporal root of the zygomatic arch from March 2009 to June 2012. Only two- or three-point fixation was performed for the accompanying zygomatic-orbital-maxillary fracture. The Gillies approach was used for complex fractures of the zygomatic arch, while the temporal root of the zygomatic arch was only observed without reduction. Preoperative and postoperative computed tomography and X-ray scans were performed to examine the results. RESULTS: The result of the paired t-test on preoperative and postoperative bone gap differences, the depression level, and the degree of temporal protrusion showed a marked decrease in the mean difference at a 95% confidence interval. The results were acceptable. CONCLUSIONS: In the treatment of sagittal fractures at the temporal root of the zygomatic arch, it is acceptable to use indirect reduction and non-fixation methods. This leads to a satisfactory aesthetic and functional outcome.

Retrobulbar hematoma in blow-out fracture after open reduction.

Retrobulbar hemorrhage, especially when associated with visual loss, is a rare but significant complication after facial bone reconstruction. In this article, two cases of retrobulbar hematoma after surgical repair of blow-out fracture are reported. In one patient, permanent loss of vision was involved, but with the other patient, we were able to prevent this by performing immediate decompression after definite diagnosis. We present our clinical experience with regard to the treatment process and method for prevention of retrobulbar hematoma using a scalp vein set tube and a negative pressure drainage system.