Aesthetic Reconstruction of the Sequelae of Large Facial Involuted Infantile Hemangioma with Tissue Expanders.

BACKGROUND: Large involuted infantile hemangioma remains a challenge in facial reconstruction. The characteristic fibrofatty residuum and multiple subunits/tissues involvement contribute significantly to the difficulty of surgical management. Tissue expander plays an important role in facial reconstruction, allowing plastic surgeons to repair skin damaged by both congenital and acquired defects. METHODS: Between 2009 and 2021, 30 patients who underwent tissue expansion surgery were reviewed in a single hospital. The demographic data, lesion characteristics, surgical approaches, complication rate, and aesthetic outcomes were analyzed. RESULTS: Thirty patients (5 men and 25 women) with a mean age of 14.03 ± 7.25 years (range, 4-33 years) were included. The mean follow-up is 35.92 months, ranging from 9 to 75 months. Tissue expansion-related complications include closed infection, 2/30 (6.67%); skin ischemia, 2/30 (6.67%); hematoma, 1/30 (3.33%); flap necrosis, 1/30 (3.33%). CONCLUSION: Large facial involuted infantile hemangiomas have variable patterns of presentation and necessitate tailored therapy. Tissue expansion is a reproducible approach to achieving aesthetic reconstruction. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Temporoparietal Flap for Facial Reconstruction: Donor Site Morbidity.

Background: Temporoparietal flap (TPF) is recommended when thin delicate tissue for medium sized defect is needed. The most used form of this flap is for auricle reconstruction. In this article usage of this flap for facial reconstruction other than auricle is discussed, emphasing on donor site morbidity. Method: In this retrospective study, archived files of the Department of Oral and Maxillofacial Surgery, University of Medical Sciences, Mashhad, Iran were evaluated from 2016-2020. Patients whom TPF was used for facial reconstruction were included. Flap survival was checked and donor site morbidity was evaluated in the form of skin scar and frontal nerve branch injury. Results: This flap was used in 8 patients for facial reconstruction. All the cases had experienced Alopecia and this was the greatest when the skin of scalp was also included. All of the patients could elevate the eyebrow that means intact frontal branch of facial nerve. Conclusion: TPF is a versatile flap for facial reconstruction. However, alopecia is high in composite fasciocutaneous form of this flap.

Pediatric Facial Burn Reconstruction.

Contrary to prior pediatric burn treatment philosophies, we now know that early burn excision and grafting for non life-threatening burns can compromise future reconstruction. Extensive scar excision should be minimized and scar rehabilitation maximized, as secondary iatrogenic deformities can become even more difficult to fix. Scar remodeling with local tissue rearrangement can relieve tension and soften scars over time. The majority of facial burns often only involve skin and can be adequately treated without the need for complex flap reconstruction. Facial burn scars are a different problem than facial burn scar contracture. The former needs scar rehabilitation, whereas the latter needs the addition of skin. Laser therapy has transformed the treatment of burn scars and is an incredibly valuable adjunct to local tissue rearrangement and grafting. The most favorable functional, aesthetic, and psychological outcomes require a long-term multidisciplinary effort and customized protocol utilizing the vast armamentarium of reconstructive tools described below.

New Innovation: Custom Titanium Zygomaticomaxillary Complex (ZMC) Plate for Facial Reconstruction.

Zygomaticomaxillary complex (ZMC) fractures typically result from traumatic injuries, such as motor vehicle-related incidents, assaults, falls, and sports-related injuries. These fractures characteristically occur along suture lines where the zygomatic bone borders the frontal bone, maxilla, temporal bone, and sphenoid bone, resulting in a "tetrapod" fracture pattern that can be surgically fixated utilizing one, two, and three-point plate and screw fixation. However, fractures with complete loss of bone stock are less common, and standardized methods of fixation are not suitable for such complex fractures. Here, we present an interesting case of implantation of a custom-made alloplastic implant in a patient with complex ZMC fractures with loss of bone stock. A 52-year-old male sustained a traumatic gunshot wound to the face, resulting in significant destruction of bones involving the left orbital floor, left lateral orbital wall, and left zygomatic arch. Routine plating was not feasible, so a custom spanning plating system by DePuy Synthes (Synthes USA Products, LLC, West Chester, PA) was designed using the patient's CT scans. The patient recovered well with no complications. This case illustrates the successful application of patient-specific custom plates for complex ZMC fractures when standard plating methods are not suitable.

Craniofacial identification standards: A review of reliability, reproducibility, and implementation.

There are numerous anatomical and anthropometrical standards that can be utilised for craniofacial analysis and identification. These standards originate from a wide variety of sources, such as orthodontic, maxillofacial, surgical, anatomical, anthropological and forensic literature, and numerous media have been employed to collect data from living and deceased subjects. With the development of clinical imaging and the enhanced technology associated with this field, multiple methods of data collection have become accessible, including Computed Tomography, Cone-Beam Computed Tomography, Magnetic Resonance Imaging, Radiographs, Three-dimensional Scanning, Photogrammetry and Ultrasound, alongside the more traditional in vivo methods, such as palpation and direct measurement, and cadaveric human dissection. Practitioners often struggle to identify the most appropriate standards and research results are frequently inconsistent adding to the confusion. This paper aims to clarify how practitioners can choose optimal standards, which standards are the most reliable and when to apply these standards for craniofacial identification. This paper describes the advantages and disadvantages of each mode of data collection and collates published research to review standards across different populations for each facial feature. This paper does not aim to be a practical instruction paper; since this field encompasses a wide range of 2D and 3D approaches (e.g., clay sculpture, sketch, automated, computer-modelling), the implementation of these standards is left to the individual practitioner.

Ancient genome of the Chinese Emperor Wu of Northern Zhou.

Emperor Wu (, Wudi) of the Xianbei-led Northern Zhou dynasty, named Yuwen Yong (, 543-578 CE), was a highly influential emperor who reformed the system of regional troops, pacified the Turks, and unified the northern part of the country. His genetic profile and physical characteristics, including his appearance and potential diseases, have garnered significant interest from the academic community and the public. In this study, we have successfully generated a 0.343×-coverage genome of Wudi with 1,011,419 single-nucleotide polymorphisms (SNPs) on the 1240k panel. By analyzing pigmentation-relevant SNPs and conducting cranial CT-based facial reconstruction, we have determined that Wudi possessed a typical East or Northeast Asian appearance. Furthermore, pathogenic SNPs suggest Wudi faced an increased susceptibility to certain diseases, such as stroke. Wudi shared the closest genetic relationship with ancient Khitan and Heishui Mohe samples and modern Daur and Mongolian populations but also showed additional affinity with Yellow River (YR) farmers. We estimated that Wudi derived 61% of his ancestry from ancient Northeast Asians (ANAs) and nearly one-third from YR farmer-related groups. This can likely be attributed to continuous intermarriage between Xianbei royal families, and local Han aristocrats.1,2 Furthermore, our study has revealed genetic diversities among available ancient Xianbei individuals from different regions, suggesting that the formation of the Xianbei was a dynamic process influenced by admixture with surrounding populations.

Facial soft-tissue thickness in children: A study of a CTBC Brazilian sample.

As an auxiliary method in the process of human identification, forensic facial approximation (FFA) is an important tool for identifying unknown human bodies whose remains do not present the necessary traceability to any antemortem data collection. Specific characteristics are necessary when addressing children aged between 6 and 10 years, who have little sexual differentiation and a mixed dentition. Due to the chronology of eruption of the permanent second molars in this population, it is not possible to measure facial soft-tissue thickness (FSTT) from specific landmarks such as supra and infra M2. The objective of this research was to report the method for measuring the average FSTT of 32 landmarks adapting the method for adults replacing the landmarks at the upper and lower second molars (Supra M2 and Infra M2) in children up to 10 years of age for a measurement using the deciduous second molars as reference. We found statistical differences for some points, considering the variables of age and sex, but with a maximum difference of 2 mm, which allows the use of a single FSTT table. The deciduous teeth can replace the reference of the thicknesses at the supra and infra M2 landmarks. In addition to the new FSTT data for children in Brazil, we concluded that the proposed adaptation to the deciduous M2 points can be applied to obtain soft-tissue data for 32 facial points.

Identification of optimal flap types for color matching in free flap-based facial reconstruction in Asian population.

Large soft tissue defects of the face often require free flap-based reconstruction. To avoid a conspicuous patch-like appearance, choosing flaps with a color similar to that of the adjacent facial skin is crucial. This study aimed to identify the flap types that show the best color match via objective color evaluation. Patients who underwent free flap-based facial reconstruction between 2013 and 2023 were retrospectively reviewed. Based on standardized photographs, average color samples of the flap skin paddle and adjacent skin were obtained. The color differences were compared by flap type at two different time points, early (within 1-3 months, post-operative) and late (after 1 year, post-operative), using the delta E value. Fifty-eight free flaps were analyzed, including 22 thoracodorsal artery perforator (TDAP) flaps, 17 anterolateral thigh (ALT) flaps, nine superficial circumflex iliac artery perforator (SCIP) flaps, and eight radial forearm (RF) flaps. In the analysis of early outcomes, the RF flaps showed the least color difference, followed by the SCIP and TDAP flaps, and the ALT flaps showed the greatest difference, with the differences being significant. Most cases showed generally improved color matching over time. Time-dependent changes were significant in the ALT and TDAP flap groups. In the analysis of late outcomes, all flap types showed delta E values less than 10, with the RF flaps showing the least color difference, followed by the SCIP flap. The four workhorse flaps provided acceptable outcomes with long-term improvements. The RF flaps provided the best color matching in the long run.

Early outcomes and risk factors for complications after facial alloplastic implant surgery: An ACS-NSQIP study.

BACKGROUND: Facial implantology (FI) is a growing field in facial surgery that focuses on harmonizing and balancing facial features. Despite its increasing popularity, larger-scale studies on FI outcomes and risks are scarce. METHODS: The ACS-NSQIP (2008-2021) was queried to identify patients who underwent combined/isolated alloplastic FI surgery of the malar/mandibular region. Based on CPT codes (21125; 21270), procedures were subdivided into combined or isolated FI surgery of the malar or the mandibular region. RESULTS: The study population included 84 patients, of which n = 19 (23%), n = 10 (12%), n = 33 (39%), and n = 22 (26%) underwent combined malar, isolated malar, combined mandibular, and isolated mandibular FI surgery, respectively. Isolated malar (total n = 10) and mandibular FI surgery (total n = 22) patients had relatively high comorbidity rates with up to n = 6 (60%) active smokers and n = 9 (41%) with hypertension, respectively. Combined malar (n = 19) and mandibular FI surgeries (n = 33) had the highest complication rates with n = 3 (16%) and n = 5 (15%) patients experiencing any complications. For both isolated malar and mandibular FI procedures, n = 1 (10% and 4.5%) patient reported any complications. CONCLUSION: In this study, we accessed the ACS-NSQIP database and found alloplastic augmentation for zygoma and mandible to be safe. Patients who underwent combined procedures and mandibular augmentation were more likely to show complications or require inpatient stay. Most alloplastic augmentations of mandible or zygoma were combined with other procedures (62%) which suggests that alloplastic facial implants (in the academic setting) are often used as an adjunct in the treatment of complex craniofacial disorders.

Lower Lip Reconstruction after Skin Cancer Excision: A Tailored Algorithm for Elderly Patients.

BACKGROUND: Lower lip reconstruction is crucial to restore oral integrity post-cancer excision. A perfect balance between form and function should be achieved. With an aging demographic, adapting surgical methods to meet the unique needs of the elderly becomes imperative. Our study aims to introduce a specialized algorithm for lower lip reconstruction; it was tailored to geriatric patients and emphasized the use of "simpler flaps". Additionally, "Pearls and Pitfalls" were provided for surgeons approaching lower lip reconstruction. METHODS: Between January 2018 and June 2021, a retrospective study was carried out. Data collection included patient demographics, defect attributes, reconstructive approaches, flap viability assessment, wound healing, and complications. The follow-up was carried out for a period of a minimum of 6 months. RESULTS: Among 78 patients, squamous cell carcinoma predominated with a mean defect area of 3308 cm2. Postoperative complications were recorded in two patients. All patients reported sensory restoration and overall satisfaction at the 6-month follow-up; secondary procedures were not necessary. CONCLUSION: Our reconstructive algorithm, focused on elderly patients, prioritizes less invasive reconstructive techniques and introduces innovative modifications to the established methods to achieve both aesthetic and functional outcomes with a low complication rate. In patients undergoing lower lip reconstruction, the subjective microstomia was found to be less relevant than the objective microstomia.

Versatile Use of V-Y Advancement Flap for Facial Defect Reconstruction: A Case Series in Asian Patients.

BACKGROUND: V-Y advancement flap (VYAF) is a commonly used flap for facial reconstruction, but it is not popular in Asian society with limited aesthetic outcome evaluation. OBJECTIVE: To demonstrate our experience of facial VYAF with the quantitative aesthetic outcome assessment. METHODS AND MATERIALS: From January 2013 to December 2022, patients who underwent facial VYAF reconstruction were reviewed. Postoperative photographs were collected and independently graded by three plastic surgeons, three nurses, and six non-medical personnel using Manchester scar scale (MSS). The representative preoperative images were selected for surgeons' reconstruction preferences survey. RESULTS: Forty-eight patients (27 females and 21 males), with a mean age of 66.8 (23-97) years, were included in this study. All flaps survived with no flap necrosis. Only six patients (12.5%) developed minor postoperative complications, and they were treated conservatively and resolved uneventfully. The total MSS score was 7.8 ± 1.9 (scale of 4 [best scar] to 24 [worst scar]) and the overall scar VAS rating was 1.9 ± 1.1 (0 [best scar] to 10 [worst scar]), indicating satisfactory postoperative scar condition. From the survey of 22 plastic surgeons and 11 scenarios, VYAF was rarely chosen among other local flaps which only accounted for 8.7%. CONCLUSION: VYAF is an easy and safe method for facial reconstruction with low morbidity, but its usefulness is underappreciated. With a proper design and cautious dissection, we believe that good aesthetic and functional outcomes can be achieved with VYAF. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Regression analysis of nasal shape from juvenile to adult ages for forensic facial reconstruction.

The nose is a prominent feature for facial recognition and reconstruction. To investigate the relationship of the nasal shape with the piriform aperture in Korean adults and juveniles, we performed regression analysis. By regression analysis, prediction equations for nasal shape were obtained in relation to the shape of the piriform aperture considering sex and age groups. Three-dimensional skull and face models, rendered from computed tomography images, were assessed (331 males and 334 females). Juveniles (<20 years) were divided into three age groups according to the development of the dentition. Adults were divided into three age groups of two decades each, according to their age. To measure the nasal area, nine landmarks and nine measurements were chosen, while seven landmarks and five measurements were selected to measure the piriform aperture area. Four measurements were defined to explain the direct relationship between the nasal aperture and nasal shape. First, descriptive statistical analyses were performed according to sex and age groups. Subsequently, the correlation of nasal soft tissue measurements with piriform measurements was analyzed. Last, we performed a linear regression analysis of the measurements with higher correlations, considering sex and age groups as variables. Prediction equations were used to estimate the nasal bridge length, height, protrusion, and width. Equations considering sex and age groups showed better explanation ability. Measurements related to the height of the nasal bridge presented improvement. This study may assist in the more accurate approximation of nasal shape in facial reconstruction.

Surgical Treatment of Complex Craniofacial Fractures.

OBJECTIVE: Severe craniofacial fractures may present different needs in treating intracranial lesions over facial injuries. This paper examines the results of our strategy, consisting of a single-stage combined neurosurgical-maxillofacial treatment. METHODS: A retrospective review was conducted of 33 consecutive patients with complex fractures of the anterior cranial fossa and facial skeleton, who required elective surgery for craniofacial reconstruction. Patients who required emergency surgery for intracranial clots or penetrating wounds were excluded. In all cases, all or almost all the anterior skull-base was injured with compound fractures of the frontal sinus, the orbital roofs, the lamina cribrosa, and the planum sphenoidale. In all cases, the prioritization of treatment was carefully discussed, and surgical timing and strategy were agreed. RESULTS: There was 1 dead. Olfactory injuries were always found intraoperatively. There were no mucoceles, CSF-leak recurrences, cranial infections, or neurologic worsening. The functional and neurologic results were highly satisfactory. CONCLUSIONS: The one-stage surgical treatment of complex craniofacial fractures has numerous advantages, including the possibility of reducing facial fractures without the risk of CSF leaks. It also eliminates the need for repeated procedures in fragile patients, and the need to dismantle the facial reconstruction if the skull base repair is performed later. The main issue is the surgical timing, considering that the maxillofacial surgeon usually favors early facial repair, whereas the neurosurgeon generally prefers delayed manipulation of the contused frontal lobes. A timeframe of 10-14 days after trauma may be a good compromise for safe procedures with excellent neurologic and functional outcomes.

Virtual planning for corrections of hemifacial microsomia.

Objectives: This article describes the many anomalies within and outside the head and neck of hemifacial microsomia (HFM). Methods: The OMENS+ classification system is described with particular reference to the mandibular features classified by Pruzansky and modified by Kaban. The application of virtual surgical planning (VSP) to HFM, largely in children, is described and taken through to aspects indicated in maturity. Results: VSP is demonstrated with clinical cases examples in HFM patients for (1) grafts and flaps replacing missing parts of the zygomatic bone, temporo-mandibular joint and mandible, (2) distraction osteogenesis for lengthening of the mandibular ramus, advancement of the mandibular body, widening of the face and simultaneous mid-face and mandibular rotation, (3) implants and correction of microtia for bone anchored ear prostheses, (4) correction of microtia by autogenous ear construction, and (5) end stage rotational bimaxillary osteotomies. Conclusions: 3D virtual and physical planning is a valuable adjunct to the treatment of this complex condition.

Improving the oral function of patients with upper and lower lip tensor fascia lata slings for patients with flaccid facial nerve palsy.

BACKGROUND: Facial nerve paralysis (FNP) often causes decreased quality of life and may lead to significant facial dysfunction. Oral competence is frequently raised as a concern by patients as it impacts nutrition, hydration, social participation, and mental health. This can result in social isolation and reduced capacity to return to vocational roles. Despite its prevalence, it is incompletely understood and rarely described. This study prospectively evaluated the impact that facial nerve static and dynamic reanimation has on oral competence, with a specific focus on speech intelligibility and the oral phase of the swallow. MATERIALS AND METHODS: Patients who had a static or dynamic facial reanimation at Chris O'Brien Lifehouse due to facial nerve paralysis were recruited consecutively between September 2020 and October 2022. Their speech and swallow were analysed using patient reported outcome measures including the speech handicap index and the oral competence questionnaire, and speech intelligibility rated by the patient and their speech pathologist at baseline (up to 2-weeks prior to surgery), then at 6- and 12- months post-surgery. Outcomes were evaluated firstly by a paired analysis (pre- compared to post-operative oral competence outcomes), and secondly by a cohort analysis of static, compared to dynamic reanimation. RESULTS: 19 participants underwent a facial nerve reconstruction (10 static, 9 dynamic and static) due to pre-operative facial nerve paralysis. At 12-months improvements in both the oral competence questionnaire (OCQ) and the speech handicap index (SHI) (score reduced at a rate of 0.3 points per week and the 0.2 points respectively) and that this change met statistical significance (OCQ; p = p < 0.003, SHI; p < 0.001). Patient rated intelligibility increased 0.3 and clinician rated intelligibility increased 0.2 points per week which also significantly improved (p = 0.001 and p < 0.001 respectively). CONCLUSIONS: Both static and dynamic facial reanimation procedures significantly improved both speech and swallowing measures for oral competence at 6- and 12- months post-procedure. There was not a significant difference found between static and dynamic procedures.