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BACKGROUND The objective of this trial is to evaluate the flexibility of the cartilaginous component of the cleft nose after diced cartilage rhinoplasty by determining the degree of possible bending in relation to the vertical nasal dorsum axis and to compare with to a control group of the unaffected population. PATIENTS AND METHODS Fifteen cleft nose patients with diced cartilage rhinoplasty were included in this study, as well as a control group of 15 unaffected individuals. The angle of maximum nasal bending is measured between the basic and maximum bending axis and performed by the same rater twice at least 2 weeks apart to account for intrarater reliability. Study groups were compared with Fisher and independent t test. RESULTS The maximum bending to the left side was 16.10 ± 5.03 degrees for the study group and 23.95 ± 6.54 degrees for the control group (P = 0.001). The maximum bending to the right side were 16.54 ± 6.73 degrees for the study group and 23.00 ± 8.88 degrees for the control group (P = 0.034). CONCLUSION Diced cartilage graft injection for dorsal augmentation yields reproducible and esthetically pleasing outcomes with good flexibility and natural feel of the nasal tip. Although there is a significant difference compared with a nonaffected control group in maximum bending capacity, all patients in this study were satisfied with the results.

Purpose An objective and quantitative assessment of facial symmetry is essential for the surgical planning and evaluation of treatment outcomes in orthognathic surgery (OGS). This study applied the transfer learning model with a convolutional neural network based on 3-dimensional (3D) contour line features to evaluate the facial symmetry before and after OGS. Methods A total of 158 patients were recruited in a retrospective cohort study for the assessment and comparison of facial symmetry before and after OGS from January 2018 to March 2020. Three-dimensional facial photographs were captured by the 3dMD face system in a natural head position, with eyes looking forward, relaxed facial muscles, and habitual dental occlusion before and at least 6 months after surgery. Three-dimensional contour images were extracted from 3D facial images for the subsequent Web-based automatic assessment of facial symmetry by using the transfer learning with a convolutional neural network model. Results The mean score of postoperative facial symmetry showed significant improvements from 2.74 to 3.52, and the improvement degree of facial symmetry (in percentage) after surgery was 21% using the constructed machine learning model. A Web-based system provided a user-friendly interface and quick assessment results for clinicians and was an effective doctor-patient communication tool. Conclusions This work was the first attempt to automatically assess the facial symmetry before and after surgery in an objective and quantitative value by using a machine learning model based on the 3D contour feature map.

BACKGROUND The evolving 3-dimensional computer-based technology revolutionized the field of orthognathic surgery (OGS). Digital occlusion setup for OGS may provide advantages in the planning comparing with the conventional approach based on the manual setup using dental casts, but we are not aware of any study focusing on digital occlusion setup for cleft OGS. The purposes of this study were to compare the conventional and digital occlusion setup approaches and to propose a protocol for digital occlusion setup in unilateral cleft OGS. METHODS Thirty consecutive patients with unilateral cleft lip/palate who underwent orthodontic treatment by a single orthodontist and 2-jaw OGS by a single surgeon using 3-dimensional surgical simulation were adopted for analysis. Quantitative data were collected from the dental cast occlusion setup approach (conventional group). A multidisciplinary team combined this quantitative data and established a protocol for digital occlusion setup in cleft OGS. Digital occlusions were set according to this protocol using the images of the 30 patients, and quantitative data were collected accordingly (digital group). The results of 2 groups were compared. All information was reviewed to refine the protocol and define the final guidelines. RESULTS There were no significant differences (all P > 0.05) for all parameters, except midline discrepancy (conventional group > digital group, P < 0.001). The root-mean-square deviation (0.46 ± 0.26 mm) indicated acceptable relationship between the conventional and digital groups. A 6-step protocol for digital occlusion setup in cleft OGS was established: dental midline, overjet/overbite, yaw rotation, pitch rotation, roll rotation, and overall facial skeletal appearance. CONCLUSIONS This study shows that digital occlusion setup is quantitatively comparable with the conventional dental model approach and contributes for cleft OGS by establishing a protocol for surgical occlusion setup using digital approach.

Skeletofacial reconstruction in skeletally mature patients with cleft lip/palate can be challenging because of multifaceted condition-specific anatomical features in addition to several repercussions from surgical intervention during the growing period. This surgical report presents the history and evolving philosophy of cleft-skeletofacial reconstruction at the Chang Gung Craniofacial Center, a referral center for cleft care in Taiwan. The maximization of satisfactory function and the appearance outcome-burden ratio have been the fundamental aims for this team to develop and upgrade cleft-skeletofacial reconstruction over the past 4 decades, with more than 10,000 mature patients treated. The study highlights key lessons learned in outcome-based and patient-oriented changes over time until the current approach, which focuses on patient-centered care with a comprehensive, multidisciplinary, and team-based model. Substantial advances in surgical, orthodontic, anesthetic, and computer imaging aspects have contributed to improving and optimizing the correction of a broad spectrum of facial and occlusal deformities while ensuring safety, predictability, efficiency, and stability in outcomes. Understanding the development and refinement of cleft-skeletofacial reconstruction over the time and transferring these time-tested and scientifically validated protocols and principles to clinical practice may serve as a reliable foundation to continue the advancement and enhancement of the delivery of surgical cleft care worldwide.

Background Cleft lip/palate is a congenital craniofacial anomaly affecting patients physically and psychosocially and has contributed to the global burden of surgical disease, especially in underprivileged areas. For 20 years, Noordhoff Craniofacial Foundation (NCF) and the Chang Gung Craniofacial Center (CGCFC) have carried out missions to these areas. Rather than implementing short-term missions that lack proper follow-up care, the team has provided an effective, long-term, and multidisciplinary approach for the treatment of patients with cleft lip/palate. In this study, we evaluate the sustainability and effectiveness of the cleft mission model implemented by NCF and CGCFC. Methods Data from the years 1998-2017 were retrieved from the NCF database. All local centers were evaluated by a 3-stage categorization, levels 1 to 3, based on 4 criteria: (1) capacity to carry out independent missions, (2) diversity of cleft-care professionals, (3) diversity of surgical service offered, and (4) collaboration with local hospitals. Support and training of personnel were provided based on deficiency in these criteria. Noordhoff Craniofacial Foundation made close collaborations and partnerships with several organizations that shared its mission for comprehensive cleft care in developing countries. Results In all, 19 partner cleft teams in 9 different countries were established. In coordination with these teams, NCF and CGCFC have treated 1846 patients across 78 mission trips. To date, 158 personnel from 19 different countries have been successfully trained to provide cleft care in local centers. Most partner cleft teams centers have progressively reached category level 3, including those in the Philippines, Cambodia, and Mongolia. Conclusions In order to establish and maintain sustainable cleft care in developing regions, commitment and compassion toward those who lack essential resources are necessary. Noordhoff Craniofacial Foundation and CGCFC have achieved a successful and practicable model through seeding medical personnel in order to provide effective and sustainable cleft care to the regions in need.

Three-dimensional (3D) computer-aided planning has truly revolutionized orthognathic surgery (OGS) treatment, but no study has compared the traditional hybrid and full 3D digital planning models. This study compared these virtual planning models in the treatment of asymmetric maxillomandibular disharmony.Young adult patients with an asymmetric skeletal class III deformity who underwent 3D computer-aided 2-jaw OGS using hybrid (alginate dental impression, 2D cephalometric tracings, manual-guided stone model surgery, occlusion setup, and splint fabrication; n = 30) or full digital (laser-scanned dentition, 3D cephalometric tracings, virtual-based occlusion setup and surgery, and computer-generated surgical splint; n = 30) planning models were consecutively recruited. Preoperative and postoperative 3D cephalometric analyses (dental relation, skeletal assessments based on sagittal and frontal views, and soft tissue evaluations) were adopted for intragroup and intergroup comparisons. Postoperative patient-perceived satisfaction with facial appearance was also recorded.Both hybrid and full digital planning groups had significant (all P0.05) improvements after surgery with respect to facial convexity, incisor overjet, and frontal symmetry parameters. The full 3D digital planning-based OGS treatment had similar (all P0.05) 3D cephalometric-derived outcomes (preoperative, postoperative, and treatment-induced change data) and patient-perceived outcomes compared with the traditional hybrid 3D planning method.For the decision-making process in selecting the planning model, multidisciplinary teams could consider additional parameters such as patient comfort, storage needs, convenience for data reuse, overall planning time, availability, and costs.

PURPOSE Autologous fat injection is a widely used, simple, and less invasive technique to correct volume deficiency. This study developed a treatment method by using a 3-dimensional (3D) simulation to plan and implement fat injection in patients with an extensive facial deficiency and then validated the accuracy of the method and treatment outcomes. METHODS Seven patients with a large unilateral facial deficiency receiving autologous fat grafts between 2015 and 2017 were recruited. One patient received repeated treatment. Furthermore, 3D surgical simulation was used to measure the difference between the mirrored image and lesion side. An extra 20% to 30% of fat graft was added. A color map was provided, and contour lines 2 mm deep marked the location of the fat injection. Outcome assessments were then performed, and a 3D symmetry index was defined using the contour lines on the facial surface. RESULTS No significant difference was noted between the predicted volume and postoperative fat graft retention (35.7 ± 7.4 and 31.6 ± 9.7 mL, respectively; P = 0.176). A comparison of preoperative (79.5% ± 4.3%) and postoperative (89.0% ± 3.3%) 3D symmetry indexes indicated significantly improved facial symmetry (P = 0.018). Patient-reported outcomes of satisfaction on FACE-Q questionnaires yielded an average score of 62.73, higher than the control score (59.83). CONCLUSIONS By using the proposed method, we could predict the required fat graft volume; moreover, the contoured map aided accurate surgical implementation. Thus, this method is useful for planning and guiding fat grafting treatment in patients with major unilateral facial deficiency.

OBJECTIVE Although several methods of note have been reported for the repair of cleft palate, wound separation and oronasal fistula can still occur. This study reports a useful technique of dissection in the pyramidal space for adequate release of tension and the prevention of palatal fistula. METHODS A total of 404 consecutive patients with cleft palate with or without cleft lip who had received standard surgical repair were evaluated. The mucoperiosteal flaps were raised from the hard palate. Dissection was performed in the pyramidal space to expose the greater palatine foramen, neurovascular pedicle, pyramidal process of the palatine bone, opening to the space of Ernst, and hamulus with tensor veli palatini aponeurosis. The restricting ligamentous fibers lateral and posterior to the pedicle were released. The hamulus process was divided at its root and pushed medially for further relief and medial mobilization of the flap. Closure of the flaps was achieved with minimal tension in the midline. The patients received regular postoperative follow-ups. RESULTS Only 1 case was found to have postoperative palatal fistula, resulting in a fistula rate of 0.25% during the 11-year study period. CONCLUSION Adequate dissection in the pyramidal space helped to close the palatal flaps with minimal tension and prevent the formation of palatal fistula.

Botulinum neurotoxin A (BoNT-A) is a minimally invasive and technically straightforward treatment of masseter muscle (MM) volume reduction and facial contouring, but the literature on its long-term effect on MM volume remains unclear.This study aimed to assess quantitatively for progressive volume changes of lower facial contour after 3 BoNT-A injections in patients with bilateral MM hypertrophy causing square facial morphology using 3-dimensional computed tomographic scans.Ten female patients with square facial morphology due to bilateral MM hypertrophy were recruited to, and 6 completed, this clinical study. Each received 24 U of BoNT-A into the inferior portion of each MM on both sides, repeated 6 monthly to complete 3 treatments. Masseter muscle volume changes were assessed using 3-dimensional computed tomography at pretreatment (before injections) and posttreatment (1 year after the third injection).Mean MM volume significantly reduced from 26.39 ± 4.18 cm before treatment to 23.26 ± 4.31 cm 1 year after treatment (P = 0.002).Three consecutive 6-monthly BoNT-A injections into the MMs reduced their volume by 12% when assessed 1 year after completion of treatment.

Objective Lip cant is a feature of facial deformity and commonly seen in patients with facial asymmetry. Because of its importance in aesthetic assessment, it is necessary to define the perceptions of lip cant and investigate differences in perception between laypersons and professionals. These data were insufficient in the literature. Methods Photographs of 30 male and 30 female individuals with normal faces were collected, and the lip line angles were measured. A composite facial photograph was generated from superimpositions of the normal faces. Lip line angles from 0° to 9° were made, with other facial features remaining unchanged. The test photographs were arranged in random fashion and evaluated by 64 laypersons and 30 professionals. Comparisons and cumulative frequency were performed. Results The lip line angle from the 60 normal persons was 1.20° ± 0.94°. From the composite test photographs, the average first perception of lip cant was 3.25° 1± 1.36° in the laypersons and 1.70° ± 0.69° in the professionals. The average first perception of unacceptable lip cant was 6.40° ± 1.79° in the laypersons and 4.40°1. ± 1.65° in the professionals. Significant differences were found between the first perception and perception as unacceptable lip cant, as well as between the laypersons and the professionals. Cumulative data showed that 82.8% of the laypersons perceived lip cant at 4°, and 17.2% of them felt it aesthetically unacceptable. Few laypersons (1.6%) considered less than 4° unacceptable. Conclusions The data in this study provide helpful information in the evaluation of lip cant. A lip cant of 4° or more could be considered an indication for clinical management.

Background Because primary nasal correction by the time of lip repair has been incorporated into the treatment approach, many patients have benefitted from this combined procedure. However, primary nasal correction cannot guarantee an excellent result. Although overcorrection has been mentioned as a treatment rationale of the unilateral cleft lip nasal deformity, a detailed approach and quantitative evidence of the rationale are rare. This study evaluates whether overcorrection in the primary repair results in a quantitative improvement in nasal appearance. Patients and methods In this retrospective study, the inclusion criteria were patients with complete unilateral cleft lip and palate who underwent primary lip and nose repair by the age of 3 to 4 months. Primary nasal overcorrection was achieved by application of muscle to septal base suture, alar cinching suture and Tajima reversed U incision method. Patients were further divided into an overcorrected (n = 19) and nonovercorrected group (n = 19). The following parameters were identified on basilar photos of all patients taken at least 12 months after repair, ratios of cleft to noncleft side in each patient were taken and the mean for each parameter calculated: Ac angle (ACA/ACA'), alar height (AH/AH'), alar width (AW/AW'), nostril height (NH/NH`), nostril width (NW/NW'), and columellar deviation from the midline (CD/NW). The means of the overcorrected and nonovercorrected groups were then compared using the t test. Results From all investigated measuremens, Alar height (AH/AH': overcorrected, 0.983 to nonovercorrected, 0.941; P = 0.03) and nostril height ratio (NH/NH') (NH/NH': covercorrected, 0.897 to nonovercorrected, 0.680; P = 0.003) showed statistically significant differences favoring the overcorrected group at least 12 months after surgery. Conclusions Primary nasal overcorrection including muscle to columella base suture, alar cinch suture, and Tajima method resulted in quantitatively more long-term symmetric alae and nostril height compared to nonovercorrected patients.

Objective Asymmetry of median facial structures is a major concern for patients with unilateral cleft lip and palate, and the principal goal of its treatment is to restore symmetry. Unilateral complete cleft of lip and primary palate (UCCLPP) is an uncommon subgroup and rarely reported. Patients with UCCLPP have protruding and deviating premaxilla, rendering a primary repair difficult. This study evaluated consecutive patients with UCCLPP and presented their treatment outcome. Methods We assessed 36 patients with UCCLPP and collected clinical information. Surgical repair was performed at 3 months of age by using a modified rotation-advancement method and primary nasal reconstruction. A single surgeon performed all surgical procedures. A postoperative nasal stent was used for 6 months. Follow-up standardized photographs were collected. Landmarks were identified, and nose and lip dimensions measured. The ratios of the corresponding parameters (cleft vs noncleft side) were obtained for evaluating nose and lip symmetry. Results No surgical complication was noted in any patient. The overall lip and nose outcome after the primary repair were adequate, and all ratios were close to 1. The nostril width was slightly wider on the cleft side, but the alar width and height were acceptable. The lip heights were balanced between the 2 sides. Patients who received presurgical nasoalveolar molding did not show more favorable lip and nose dimensions, except for the medial philtral height. Conclusion Even in the presence of protruding and deviating premaxilla, our patients with UCCLPP obtained adequate lip and nose outcome after undergoing primary lip repair and nasal reconstruction.

Three-dimensional computer-assisted orthognathic surgery has been applied to improve planning and outcome. This study presents our experience with this promising modality for simulation of surgery, prefabrication of positioning guides, and navigation of the surgery.Thirty-seven patients who received surgical simulation and intraoperative navigation for 2-jaw orthognathic surgery were recruited. Preoperative 3-dimensional cone-beam computed tomographic images were used for surgical simulation and design of intraoperative guidance. An initial surgical plan was developed and transferred for 3-dimensional virtual surgery. Modification of the surgical plan was made if facial symmetry and skeletal harmony or collision of ramus segments were concerned. The result of virtual surgery was used to design and manufacture positioning guides and perform preoperative navigation planning. During the operation, the positioning guides were used to transfer the virtual planning to actual surgery, and a real-time navigation system was used to confirm the predetermined position of the maxillomandibular complex. For assessment of the computer-assisted surgical system, the simulation image was superimposed to the postoperative image for comparison.The computer-assisted orthognathic surgery was successfully carried out in all patients. The initial surgical plan was modified in 17 patients in whom the position of maxillomandibular complex was changed. The positioning guides were helpful in controlling the spatial position of the maxillomandibular complex. The BrainLabTR navigation system was useful to further confirm the position of the facial bone. Superimposition of the simulation and postoperative images revealed satisfactory result with acceptable errors. The difference ranged from 0.05 to 1.46 mm, with a mean value of 0.66 mm, for patients using the positioning guides; and the difference ranged from 0.07 to 2.30 mm, with a mean value of 1.20 mm, for patients using the navigation system. Overall, patient and doctor satisfaction was high.This computer-assisted orthognathic surgery system helps to improve surgical planning, reduce surgical difficulty, facilitate positioning and fixation of the maxillomandibular complex, and improve outcome.

BACKGROUND This study aims to demonstrate the reliability of our proposed facial reference system in the horizontal axis using 3-dimensional photogrammetry and to find a correlation between this plane and the Frankfurt horizontal (FH) plane. METHODS Forty-one patients were enrolled. Three-dimensional facial images were taken before and 6 months after orthognathic surgery. Superimposition was carried out, and differences in landmark position were evaluated. Two constant landmarks were selected to construct a reference system within a standardized reference frame. Cone-beam computed tomography and 3-dimensional facial images were superimposed. Two reference lines were identified, and the angle between these lines was calculated. RESULTS For landmark reliability, 5 landmarks [gnathion, nasion, exocanthion (Ex), endocanthion, and tragion (T)] were constant. Two landmarks (Ex and T) were selected to construct a reference system within a standardized reference frame. For angular measurement, the mean angle between this reference plane and the skeletal FH plane was 17.6 ± 2.0 degrees. There was no statistical difference between sex, side, and preoperative/postoperative timing of photography. CONCLUSIONS Our proposed reference plane is constructed from reliable facial Ex and T landmarks. This plane is consistent and crosses the FH plane at 17.6 degrees.

Postoperative functional impairment of the inferior alveolar nerve (IAN) has been a common and well-recognized complication. Our study introduced a modified Obwegeser-Dal Pont bilateral sagittal split osteotomy (BSSO) technique and evaluated the subsequent incidence of postoperative neurosensory disturbance of IAN.In this prospective cohort study, 57 patients receiving our modified BSSO during orthognathic surgery were enrolled. The technique contained opening the 2 ramus cortices and inserting the osteotome bypassing the IAN to avoid nerve injury. A 5-point scale self-assessment questionnaire was used to evaluate IAN neurosensory disturbance one week, six months and 12 months postoperatively. Differences between groups were analyzed using χ test for categorical and Wilcoxon signed-rank test for pairwise categorical data.Complete ramus splitting could be achieved in 109 (95.6%) sides. Lower lip or chin neurosensory disturbances presented in 72 (63.2%) sides 1 week postoperatively and gradually reduced to 9 (7.9%), and 4 (3.5%) at postoperative months 6 and 12, respectively.This BSSO technique could be safely performed with low rates of IAN exposure and injury and a low incidence of persistent neurosensory disturbance in 3.5% of patients 12 months postoperatively.

The objective of this prospective, double-blind, randomized clinical trial was to compare the effect of 2 dexamethasone dosages on reducing facial swelling after orthognathic surgery through 3-dimensional (3D) photogrammetry.Patients were classified into group 1 (control group) and group 2 (study group), depending on the administered dexamethasone dosage (5 and 15 mg, respectively). Three-dimensional images were recorded at 5 time points: preoperative (T0) and postoperative at 48 ± 6 hours (T1), 1 week (T2), 1 month (T3), and 6 months (T4). A preliminary study was performed on 5 patients, in whom 3D images were captured at 24, 36, 48, and 60 hours postoperatively to record serial changes in facial swelling. Facial swelling at T1, T2, and T3 and the reduction in swelling at T2 and T3 compared with that at the baseline (T4) were calculated. Possible complications, namely, adrenal suppression, wound dehiscence, wound infection, and postoperative nausea and vomiting were evaluated.In total, 68 patients were enrolled, of whom 25 patients in group 1 and 31 patients in group 2 were eligible for final evaluation. No significant differences were found between the 2 groups at any period. On average, the swelling subsided by 86% at 1 month after the orthognathic surgery. Facial swelling peaked approximately 48 hours after the surgery. The incidence of nausea and vomiting did not differ significantly between the groups.The effect of 5 and 15 mg of dexamethasone on facial swelling reduction as well as on nausea and vomiting after orthognathic surgery was not significantly different.

For auricular reconstruction of external auricle, the goals of the surgery are (1) in the fabrication of the morphologically complete 3-dimensional costal cartilage framework (3-dimensional frame) of the auricle, and (2) in the attainment of ample skin surface area to cover the grafted 3-dimensional frame, so that more than satisfactory results can be achieved. In review of the published literature, the cartilage framework used for auricular reconstruction is either insufficient or incomplete in the fabrication of the anatomic structures or inappropriate in proportion. We herein introduce the 3-dimensional resin template model (3-dimensional template model) and 3-dimensional frame used in our daily surgical practice. The 3-dimensional template model is proportionally fabricated with all the essential morphologic structures of the auricle. It can be used intraoperatively for reference in fabricating the 3-dimensional frame and simulation of the surgery. The 3-dimensional template model is very useful as an adjuvant tool in adjusting the skin flaps, prevention of mistake in fabrication of the 3-dimensional frame, and for educational purposes of junior resident surgeons.

The purpose of this study was to use three-dimensional imaging methods to measure the palatal surface of unrepaired cleft patients. The surface area of the palate was defined and measured on three-dimensional computed tomography images of dental plaster models in four different groups of cleft patients at 3 months of age. There were 30 unilateral complete cleft lips and palates (UCLP), 27 bilateral complete cleft lips and palates (BCLP), 23 isolated cleft palates of incomplete form (CP), and 19 unilateral cleft lips without cleft palates (UCL). These patients were nonsyndromic, unoperated, and without other major deformities. The dental casts were scanned, and the computed tomography data were transferred to an imaging laboratory for processing and reconstruction of three-dimensional images. Surface area of the palate was delineated, which was defined as within the alveolar crest and the line connecting both tuberosities. In UCLP and BCLP, the edge of cleft formed the medial boundary of the area for each palatal shelf, and the palatal surface area was the combination of both palatal shelves and the premaxillary area in BCLP group. The surface area was measured. Repeated definition and measurement tasks were performed for calculation of errors. The imaging data management and measurement were performed using the Analyze program (Biomedical Imaging Resource, Mayo Foundation, MN). In addition, linear distances were measured between the canine points on the alveolar crest (line C) and the tuberosity points (line T). The measurements were compared among the different groups. Analysis of variance and multiple comparisons were used for statistical analyses. The results showed that the mean error between repeated area definitions and measurements in this study was 1.86%. The bilateral complete cleft lip and palate (BCLP) and unilateral complete cleft lip and palate (UCLP) groups had significantly smaller palatal surface area than the unilateral cleft lip without cleft palate (UCL) and isolated cleft palate of incomplete form (CP) groups. There was no significant difference between the BCLP and UCLP groups. Line C and line T distances were significantly longer in BCLP and UCLP groups than in UCL and CP groups. The findings suggest that compared with UCL and CP patients, there is an intrinsic tissue deficiency in the palate/maxilla of BCLP and UCLP patients.

It is frequently reported that early repair of the soft palate induces narrowing of the remaining palatal cleft and thus facilitates later hard palate closure. However, to the best of our knowledge, there have been no comparative studies to test this hypothesis. The purpose of this retrospective study was to evaluate the change of palatoalveolar morphology following primary lip repair and posterior palatoplasty. Dental plaster models of patients with complete unilateral cleft of lip and palate (UCLP) were used to measure the width of the cleft and palatal arch. Twenty-six patients received simple posterior palatoplasty (PP group) simultaneous with primary lip repair, and 20 patients did not (NPP group). The dental models included one preoperative cast at 2 months (T1) and two or three casts at 6 (T2), 12 (T3), and 18 (T4) months before final palate closure. The linear measurements performed were width of alveolar cleft (Ca); width of palatal cleft between the canines (Cc), molars (Cm), and tuberosities (Ct); the palatal arch distance between the canines (Dc); the widest distance between molars (Dm) and the tuberosities (Dt); and the palatal height between the canines (Hc) and tuberosities (Ht). The raw measurements and the calculated cleft-to-arch ratios of Cc/Dc, Cm/Dm, and Ct/Dt were compared between the two groups. The results showed gradual narrowing of the width of cleft from T1 to T4. Narrowing of alveolar cleft width (Ca) from T1 to T2 was dramatic. The palatal arch (Dc, Dm, Dt) showed no change to mild increase in width. The cleft-to-arch ratios decreased with time. The palatal height remained the same or slightly increased over time. There were no significant differences observed between the PP and NPP groups among these measurements except for the Ct and Ct/Dt at T4. In conclusion, after initial lip repair, there was a decrease of the width of cleft in patients with complete UCLP during the 18-month period, and simple posterior palatoplasty did not further narrow the cleft nor influence palatal arch development.

Infantile myofibromatosis is a rare disease characterized by myofibroblastic proliferation, and typically occurs in early infancy. There is a wide spectrum of clinical presentation, which may involve various kinds of tissues in the body. Skin and subcutaneous lesions were the types of tissue most often seen. Although a multicentric form may behave aggressively, a solitary form of the tumor is benign with the possibility of spontaneous regression. Conservative management is justified after proper pathological diagnosis if the tumor involves an aesthetically important area. A case of solitary infantile myofibromatosis involving the upper lip is presented. Partial excision for biopsy was performed and long-term observation was undertaken. The tumor disappeared 3 years postoperatively.

Avulsion injury of the leg may result in exposure of the anterior surface of the tibia in addition to skin loss. This exposed bone should be covered by a soft tissue flap to facilitate healing and provide durability. The split anterior tibial muscle flap is ideal in this situation because of its adjacent location, reliability, and simplicity. A cadaveric study demonstrated rich intramuscle vascular anastomoses between the segmental branches from the anterior tibial artery that provide safety in partial transfer. The technique of split anterior tibial muscle flap was applied successfully in 4 patients with leg avulsion injury associated with tibial bone exposure. The cosmetic result was good and the function of the muscle was preserved.

Superiorly based pharyngeal flaps (PFs) are commonly used for the treatment of velopharyngeal insufficiency (VPI) in patients with cleft palate. However, failure may occur with recurrence of hypernasality and surgical revision may be necessary. Hemisphincter pharyngoplasty using either unilateral or bilateral posterior tonsillar pillars with the underlying palatopharyngeus muscle can be used to narrow the incompetent lateral portals. We retrospectively reviewed 22 patients diagnosed with VPI after PF surgery, who underwent hemisphincter pharyngoplasty from 1995 to 2007. Seventeen patients with complete speech assessment records were evaluated for the surgical outcome. Overall velopharyngeal function improvement was 88.2%. Symptoms of airway obstruction developed in 41% of the patients perioperatively. All of them improved gradually except 1 patient who needed continuous positive airway pressure mask treatment for obstructive sleep apnea. It is concluded that hemisphincter pharyngoplasty for narrowing of the incompetent portals is an effective treatment of VPI after PF.

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 (P0.05). 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 (P0.05). The quality of scar in both the central and lateral limbs of the Z-plasty was not significantly influenced by their direction.

Mandibular angle resection is an accepted procedure for the correction of square face appearance due to mandibular angle prominence. Long-term follow-up of the changes in volume that occurs in the muscles of mastication and osseous structures has been inadequate in the literature. In this study, 3-dimensional computed tomography data were used to extract the mandible, masseter, medial pterygoid, and lateral pterygoid muscles for assessment of the volumetric changes that took place after angle reduction in 7 patients (14 hemimandibles) with an average age of 24.9 years and a mean follow-up time of 4.5 years. All measurements were performed twice to assure accuracy, with a difference of 1.2 +/- 1.1% noted. The hemimandible volume was reduced by 12.6% immediately after the reduction procedure and 8.2% at final follow-up. Osseous regeneration was observed as thickening of the bone and partial regrowth of the angles. None of the 14 hemimandibles had a complete return of the preoperative angular shape. The volumetric changes that occurred in the muscles of mastication were inconsistent among the patients. The masseter muscle was reduced by 5.2%, the medial pterygoid muscle was reduced by 14.4%, and the lateral pterygoid muscle was increased by 5.7% at final follow-up. The medial pterygoid muscle change was more significant than that of the masseter muscle (P = 0.00361). The objective findings of this study were not in agreement with the conventional thought and clinical impression that the masseter muscle becomes atrophic after mandibular angle resection. Only a slight reduction occurred in some patients in the volume of the muscles, with some actually displaying a slight increase. The end result was a satisfactory esthetic outcome for the patients in the long term despite the minor changes in muscle volume and slight bony regeneration that occurred.

Mandibular angle reduction is a popular contouring surgery in Asia. Avoidance of injury to the inferior alveolar nerve is crucial during these procedures. Anatomic data regarding the position of the nerve in the mandibular angle area are sparse. The purpose of this study was to use 3-dimensional computed tomographic data to evaluate the nerve in patients with prominent mandibular angles and to compare the nerve position with a normative group. A total of 28 female and 5 male adult patients who presented with a complaint of prominent angles or a "square-face" look, as well as 20 female and 22 male adult normal subjects were included, for a total of 150 hemimandibles for extraction of the inferior alveolar nerve. The nerve and the mandible were displayed. Point O was defined on the oblique line along the anterior cortex of ramus, where it intersected with a line extending from the alveolar arch. From the O point, linear distances were defined, including horizontal distances to the posterior cortex, oblique distances to the gonion, and the vertical distances to the inferior cortex. Mandibular width was defined as the distance between the 2 gonion points. Results demonstrated significant differences mainly in the oblique distances (ie, from the O point to the nerve [O1], from the nerve to the gonion [O2], and from the O point to the gonion [O1-O2]) in both female and male patients. The O2 distance was 23.69 mm versus 20.66 mm in women and 27.30 mm versus 23.28 mm in men (square face vs norm). The mandibular width was significantly larger in the male square-face patients, but the difference was not significant between the female groups. These results provide useful information for surgeons planning mandibular angle reduction. These findings suggest that the mandibular contouring procedure should be aimed at correcting regional osseous dysmorphology in the angle area and improving the relationship to the chin, rather than merely reducing the mandibular width.

Airway obstruction is frequent in patients with severe syndromic craniosynostosis, and must be treated for successful, complete care. The purpose of this study was to evaluate the incidence and the management of airway obstruction in patients with severe craniosynostosis. All patients with complex syndromic craniosynostosis at Chang Gung Craniofacial Center were evaluated retrospectively. Criteria for inclusion of patients were the presence of adequate follow-up and documentation. A total of 40 patients were included, of whom 13 had Apert's syndrome and 27 had Crouzon's disease. Clinical symptoms and signs related to airway obstruction and its treatment were evaluated carefully, and were verified further by telephone inquiry. The status of the airway was categorized into one of three groups: no obstruction; mild obstruction, for which positioning and medical treatment were needed; and severe obstruction, for which surgical intervention was needed. The results showed that 24 patients (60%) did not have airway obstruction, 11 patients (27.5%) had mild obstruction, and 5 patients (12.5%) had severe obstruction. There was no significant difference in the distribution of airway status between patients with Apert's syndrome and Crouzon's disease. Causes for the 5 patients with severe obstruction were midface hypoplasia, lower airway obstruction, tonsillar and adenoid hypertrophy, and choanal atresia. Tracheostomy was performed to control airway in 3 patients, and 1 patient died. Midface anterior distraction helped to decannulate 1 patient. In conclusion, airway obstruction was observed in 40% of patients with severe craniosynostotic syndromes. Most of them could be managed successfully with conservative or medical treatment, and surgical intervention should be considered on the basis of each patient's individual condition.

A patient with Wolf-Hirschhorn syndrome had multiple congenital anomalies and a right cleft lip. Hemangioma involved the full thickness of the upper medial lip segment at the age of 2 months, which caused lip repair to be very difficult. The first attempt at adhesion cheiloplasty resulted in complete separation. The tumor did not respond to steroid treatment. A subsequent trial of lip repair with the assistance of a tension-relieving suture tied to the nasal septum was successful. This type of tension suture is helpful to prevent dehiscence when security of lip closure is questionable or cannot be achieved.