Chun-Shin Chang

Long-term comparison of four techniques for obtaining nasal symmetry in unilateral complete cleft lip patients: a single surgeon's experience.

Background: This study was the result of a constant evaluation of surgical techniques and results to obtain excellence in primary cleft rhinoplasty. Methods: This was a retrospective study from 1992 to 2003 comparing the long-term outcomes of four techniques of nasal reconstruction. There were 76 patients divided into four groups: group I (n = 23 patients), primary rhinoplasty alone; group II (n = 16 patients), nasoalveolar molding alone; group III (n = 14 patients), nasoalveolar molding plus primary rhinoplasty; and group IV (n = 23 patients), nasoalveolar molding plus primary rhinoplasty plus overcorrection. The surgical results were analyzed using photographic records obtained at 5 years of age. A ratio of six measurements was obtained comparing the cleft and noncleft sides. A panel assessment was obtained to grade the appearance of the surgical results. All surgery was performed by the senior author (P.K.T.C.). Results: The results are given for groups I to IV, respectively. The nostril height ratio was 0.73, 0.77, 0.81, and 0.95. The nostril width ratio was 1.23, 1.36, 1.23, and 1.21. The one-fourth medial part of nostril height ratio was 0.70, 0.87, 0.92, and 1.00. The nasal sill height ratio was 0.75, 1.02, 1.07, and 1.07. The nostril area ratio was 0.86, 0.89, 0.95, and 1.08. The nostril height-to-width ratio was 0.58, 0.58, 0.71, and 0.92. Finally, group IV had the best panel assessment. Conclusions: The results revealed that group IV had the best overall result. Overcorrection of 20 percent was necessary to maintain the nostril height. Further technical modifications are necessary to minimize widening of the nostril width.

Long-term comparison of the results of four techniques used for bilateral cleft nose repair: a single surgeon's experience.

Background: The purpose of this study was to evaluate progressive changes in surgical techniques and results, aiming for improved nasal shape in primary bilateral cleft rhinoplasty. Methods: This is an institutional review board–approved retrospective study. Ninety-one consecutive patients with bilateral complete cleft lip underwent primary cheiloplasty with four different techniques of nasal reconstruction from 1992 to 2007 as follows: group I, primary rhinoplasty alone; group II, nasoalveolar molding alone; group III, nasoalveolar molding plus primary rhinoplasty; group IV, nasoalveolar molding plus primary rhinoplasty with overcorrection; and group V, patients without cleft lip. The surgical results were analyzed using photographic records obtained at age 3 years. Four measurements and one angle measurement were obtained. A panel assessment was obtained to grade the appearance of the surgical results. Results: The results are expressed in order from groups I through V. The nostril height-to-width ratio was 0.49, 0.59, 0.62, 0.78, and 0.82, respectively. The nasal tip height–to–nasal width ratio was 0.29, 0.39, 0.49, 0.57, and 0.60. The columella height–to–nasal width ratio was 0.11, 0.18, 0.22, 0.27, and 0.28. The dome-to-columella ratio was 1.88, 1.25, 1.26, 1.14, and 1.10. The nostril area ratio was 1.2, 1.17, 1.13, 1.11, and 1.07. The nasolabial angle was 144.95, 143.98, 121.98, 120.99, and 100.88. Finally, group IV had the best panel assessment. Conclusions: The results revealed that group IV had the best overall result. Presurgical nasoalveolar molding followed by primary rhinoplasty with overcorrection resulted in a nasal appearance that was closer to the patients without cleft lip. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Botulinum toxin to improve results in cleft lip repair: a double-blinded, randomized, vehicle-controlled clinical trial.

Background Most patients with facial scarring would value even a slight improvement in scar quality. Botulinum toxin A is widely used to alleviate facial dynamic rhytides but is also believed to improve scar quality by reducing wound tension during healing. The main objective was to assess the effect of Botulinum toxin on scars resultant from standardized upper lip wounds. Methods In this double-blinded, randomized, vehicle-controlled, prospective clinical trial, 60 consecutive consenting adults undergoing cleft lip scar revision (CLSR) surgery between July 2010 and March 2012 were randomized to receive botulinum toxin A (n = 30) or vehicle (normal saline; n = 30) injections into the subjacent orbicularis oris muscle immediately after wound closure. Scars were independently assessed at 6-months follow-up in blinded fashion using: Vancouver Scar Scale (VSS), Visual Analogue Scale (VAS) and photographic plus ultrasound measurements of scar widths. Results 58 patients completed the trial. All scar assessment modalities revealed statistically significantly better scars in the experimental than the vehicle-control group. Conclusion Quality of surgical upper lip scars, which are oriented perpendicular to the direction of pull of the underlying orbicularis oris muscle, is significantly improved by its temporary paralysis during wound healing. Trial Registration ClinicalTrials.gov NCT01429402

Botulinum toxin to improve results in cleft lip repair.

Background: Upper lip wounds that lie perpendicular to the relaxed skin tension lines are subjected to repetitive dynamic tension caused by the orbicularis oris muscle and are susceptible to unsatisfactory scarring. Methods: In this double-blind, randomized, vehicle-controlled, prospective trial, 60 consecutive patients with unilateral cleft lip undergoing primary cheiloplasties between August of 2011 and June of 2012 were randomized to receive botulinum toxin type A or vehicle injections into the subjacent orbicularis oris muscle immediately after wound closure. Scars were assessed after 6 months using the Vancouver Scar Scale, photographic visual analogue scale, and photographic scar width measurements. Results: Fifty-nine patients completed the trial. Measurements of scar widths at two defined points revealed significantly better visual analogue scale scores and narrower scars in the experimental group. However, Vancouver Scar Scale assessments were similar between groups. Conclusions: Botulinum toxin injections into the subjacent orbicularis oris muscle produced better appearing and narrower cheiloplasty scars, but provided no additional benefits in terms of scar pigmentation, vascularity, pliability, or height. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Comparison of two nasoalveolar molding techniques in unilateral complete cleft lip patients: a randomized, prospective, single-blind trial to compare nasal outcomes.

Background: Nasoalveolar molding became increasingly popular in the 1990s as a means of easing surgery and improving nasal outcomes for cleft lip repairs. In the late 1990s, three orthodontists from our center underwent nasoalveolar molding training: two at the Rush Craniofacial Center, in Chicago; and one at New York University Craniofacial Center. They brought two different nasoalveolar molding techniques back to Chang Gung Craniofacial Center: the modified Figueroa and the modified Grayson techniques. Outcomes following use of these techniques have not previously been compared prospectively. Methods: Between May of 2010 and March of 2013, a randomized, prospective, single-blind trial was conducted to compare the number of clinical visits, total costs, complications, and nasal symmetry between the two nasoalveolar molding techniques in 30 patients with unilateral complete cleft lip. Results: There were no differences between nasoalveolar molding techniques in the number of clinical visits, total costs, nostril height, or nostril area ratio. Preoperatively but after nasoalveolar molding, the nostril width ratio was wider for the Figueroa group than for the Grayson group. Six months after surgical correction, there were no differences in nostril height, nostril width, nasal sill height, or nostril area ratio between nasoalveolar molding methods. Alveolar ulceration occurred more frequently in the Grayson group. Conclusions: The modified Grayson technique reduced nostril width more efficiently, but alveolar ulceration was more frequent and no differences in nostril width were found following surgery. Overall, the two nasoalveolar molding techniques produced similar nasal outcomes. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Chimeric autologous costal cartilage graft to prevent warping.

Background: Carved autologous costal cartilage is widely used in different rhinoplasty procedures because of its availability and proven advantages. However, the usefulness of rib grafts is limited by warping postoperatively. The chimeric autologous costal cartilage graft is proposed. “Chimeric” means the combining of two different tissues (bone and cartilage in this case) to make a single dorsal onlay graft. Methods: From October of 2010 to August of 2013, 31 patients underwent rhinoplasty or nasal reconstruction with costal cartilage graft using the chimeric autologous costal graft method. There were 14 men and 17 women, with ages ranging from 20 to 66 years (average, 33 years). Of the 31 patients, there were 12 with congenital nasal deformities, six with previous nasal trauma, eight with aesthetic rhinoplasty (four with primary rhinoplasty and four with secondary rhinoplasty), and five with nasal deformities after tumor extirpation. Patients’ profiles were documented and photographed. The outcomes were assessed by three plastic surgeons. Results: Follow-up for all patients was 4 to 30 months (average, 14 months). No cartilage warping was noted during the follow-up period. Two patients suffered from minor infection 2 weeks postoperatively. The average operative time for carving cartilage was 10 minutes. The overall average time of making a chimeric autologous costal onlay graft added approximately 20 minutes to the original method. Conclusion: From the clinical observation of all patients during the follow-up period, the chimeric autologous costal cartilage graft was shown to be effective for preventing cartilage warping. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Craniofacial reconstruction of primary osteogenic sarcoma of the skull

BACKGROUND Osteosarcoma of the skull is an extremely rare tumour. Because it has few symptoms initially, it usually presents after signs and symptoms of local invasion are present. Obtaining negative surgical margins is one of few modifiable survival factors. Resection of these invasive tumours is often limited by the ability to perform a reconstruction that is adequate in form and function. Despite this critical limitation, there are no articles describing reconstructive techniques used after resection of osteosarcoma of the skull. The purpose of this article is, therefore, to describe the reconstructive methods that can be used in the treatment of osteosarcoma of the skull. METHODS A retrospective chart, photographic and radiological study was conducted of cases performed between 1986 and 2007. Tumour characteristics and reconstructive methods were compiled. RESULTS Six patients were operated for osteosarcoma of the skull. The mean age at surgery was 27 years. Resection margins were positive in three cases. Bony reconstructive methods were split calvarial bone, iliac bone grafts and bone cement. Dural repair was made with a variety of materials. Complex deficits were repaired with rotation and free flaps. CONCLUSION This article presents reconstructive methods used for reconstruction of skull defects left after resection of osteosarcoma of the skull. A variety of methods are available to repair complex deficits. Obtaining negative surgical margins is critical for survival. The ability to completely resect an invasive tumour is often limited by advances in reconstructive methods. Thus, progress in craniofacial reconstruction techniques warrant further investigations.

Abstract: Pursuing Mirror Image Reconstruction in Unilateral Microtia: Customizing Auricular Framework by Application of Three-Dimensional Imaging and Three-Dimensional Printing

INTRODUCTION: The advances in three-dimensional imaging and three-dimensional printing technology have expanded the frontier of pre-surgical design for microtia reconstruction from two-dimensional curved lines to three-dimensional perspectives. This study presents the algorithm of combining three-dimensional surface imaging, computer-assisted design, and three-dimensional printing to create patient-specific auricular frameworks in unilateral microtia reconstruction.

Primary Septal Cartilage Graft for the Unilateral Cleft Rhinoplasty.

Background: Since 2006, the authors have explored the option of using septal cartilage as an alar rim graft on the cleft side during primary rhinoplasty to improve nasal symmetry. The aim of this study was to compare the nasal shape with or without rim graft. Methods: A total of 98 patients with unilateral complete cleft lip and palate were included; 39 patients had septal cartilage as the rim graft, and 59 patients did not. Measurements of the nostril height, nostril width, one-fourth medial part of nostril height, nostril area, nasal dome height, and nostril axis were obtained on the cleft and noncleft sides. Ratios of these measurements were calculated. These ratios were then compared between the graft and nongraft groups. The levels of asymmetry were categorized into four levels—less than 5 percent, 5 to 10 percent, 10 to 15 percent, and greater than 15 percent—based on the percentages deviated from perfect symmetry (100 percent). Panel assessment was also performed. Nasolabial angle and tip projection ratio were measured for the comparison of nasal growth. Results: The nostril height, height-to-width ratio, and nasal dome height were higher in the graft group (p = 0.003, p < 0.001, and p < 0.001, respectively). The graft group showed more consistency regarding the nostril shape and axis, and the differences were statistically significant (p < 0.05). The nasolabial angle and tip projection ratio showed no significant difference between the two groups. Conclusion: This preliminary study suggests that the use of a primary septal cartilage graft may offer better support at the alar rim and improve the long-term outcomes. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Orthognathic Surgery with Simultaneous Autologous Fat Transfer for Correction of Facial Asymmetry.

BACKGROUND Most patients treated with orthognathic surgery for facial asymmetry would value improvement in residual soft-tissue asymmetry. Autologous fat transfer is widely used to augment facial soft tissue. The authors assessed the effect of combining orthognathic surgery with autologous fat transfer for treating patients with facial asymmetry. METHODS In this retrospective study, 15 consecutive adults underwent combined orthognathic surgery and autologous fat transfer between January of 2013 and December of 2015. Lower facial profile symmetry was assessed using postoperative standard frontal photographs. RESULTS Lower facial symmetry was much improved by combining orthognathic surgery and autologous fat injection. CONCLUSION The combined use of orthognathic surgery and autologous fat transfer is a promising technique for improving facial symmetry in patients with facial asymmetry. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.BACKGROUND Most patients treated with orthognathic surgery for facial asymmetry would value improvement in residual soft tissue asymmetry. Autologous fat transfer is widely used to augment facial soft tissue. We assessed the effect of combining orthognathic surgery with autologous fat transfer for treating patients with facial asymmetry. METHODS In this retrospective study, 15 consecutive adults underwent combined orthognathic surgery and autologous fat transfer between January 2013 and December 2015. Lower facial profile symmetry was assessed using post-operative standard frontal photographs. RESULTS Lower facial symmetry was much improved by combining orthognathic surgery and autologous fat injection. CONCLUSION The combined use of orthognathic surgery and autologous fat transfer is a promising technique for improving facial symmetry in patients with facial asymmetry.