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The Le Fort I maxillary advancement and rotational movement have been adopted to treat patients with cleft-related skeletal Class III pattern and anteromedial cheek soft tissue deficiency, but cleft-specific cheek soft tissue prediction data are insufficient. This 3D imaging-based study addressed the issue.3D craniofacial soft tissue and bone models were created from 32 consecutive patients who received computer-aided two-jaw orthognathic surgery for the correction of cleft-related Class III deformity and cheek soft tissue deficiency. Using superimposed 3D models, the cheek volumetric change, the cheek sagittal movement, and the 3D cheek mass position were calculated. 3D data from orthognathic surgery-treated patients with no cleft (noncleft cohort) and individuals with no facial deformity (3D norm value) were retrieved for comparative analysis.Surgical maxillary advancement (p 0.001) but not maxillary clockwise rotation (p 0.05) had a significant impact on the cheek soft tissue change, with prediction models showing that maxillary advancement elucidated 77 and 79% of this change on the cleft and noncleft sides, respectively. Cleft cohort (0.46±0.12) had a significantly (p 0.001) smaller cheek soft-to-hard tissue ratio than that of the noncleft cohort (0.73±0.13). Cleft maxillary advancements4 mm resulted in a 3D cheek mass position (2.1±1.1 mm) similar (p 0.05) to the 3D norm value (2.2±1.2 mm), but different (p = 0.037) from the noncleft cohort (2.38±0.7 mm).This study showed that maxillary advancement but not the maxillary rotation affects the cheek soft tissue change, and the predictive values and comparative data could assist the orthodontist-surgeon interaction during preoperative planning and patient counseling.

Surgical mobilization of the maxillary segment affects nasal morphology. This study assessed the impact of the type of maxillary mobilization on the three-dimensional (3D) nasal morphometry.Pre- and postsurgery cone beam computed tomography-derived facial image datasets of consecutive patients who underwent two-jaw orthognathic surgery were reviewed. Using preoperative 3D facial models as the positional reference of the skeletal framework, 12-month postoperative 3D facial models were classified into four types of maxillary mobilizations (advancement [n = 83], setback [n = 24], intrusion [n = 55], and extrusion [n = 52]) and four types of final maxillary positions (anterosuperior [n = 44], anteroinferior [n = 39], posterosuperior [n = 11], and posteroinferior [n = 13]). Six 3D soft tissue nasal morphometric parameters were measured, with excellent intra- and interexaminer reliability scores (ICC0.897) for all the measurements. The 3D nasal change for each nasal parameter was computed as the difference between postoperative and preoperative measurement values.The intrusion maxillary mobilization resulted in a significantly (all p0.05) larger 3D nasal change in terms of alar width, alar base width, and nostril angle parameters, and a smaller change in terms of the nasal tip height parameter than the extrusion maxillary mobilization; however, no significant (all p0.05) difference was observed between advancement and setback maxillary mobilizations. The anterosuperior and posterosuperior maxillary positions had a significantly (all p0.05) larger 3D nasal change in terms of the alar base width and nostril angle than the anteroinferior and posteroinferior maxillary positions.The type of maxillary mobilization affects the 3D nasal morphometry.

Background Adequate skin lengthening and symmetry may not be consistently obtained in unilateral cleft lip repair, especially in patients with complete cleft. The purpose of this study was to present the model of muscle dissection and approximation to facilitate lip lengthening and symmetry. Methods The design followed the rotation-advancement (RA) method without skin measurement. A curvilinear skin incision was made from subnasale to the Cupid's bow peak (CBP). Muscle dissection was continued to the contralateral nostril floor beneath the columellar base to facilitate downward rotation in the medial lip. Wide muscle dissection was performed in the lateral lip segment from the nasal mucosa passing the alar base. The lateral lip muscle was advanced and sutured to the medial lip muscle in a Z-plasty fashion. A small skin backcut was made above the CBP. Primary nasal correction was performed. A series of 138 patients with complete unilateral cleft lip and palate were included in this study. Standard photographs were collected for measurement in the nasolabial region. Results Adequate lengthening and symmetry of the lip was obtained. The ratio of vertical philtral height was 0.99±0.05 between the cleft and noncleft sides. The C flap was used for supplementary skin lengthening in 58% of cases. Postoperative lip retraction requiring massage occurred in 13%. Overall nasolabial appearance was satisfactory. Conclusion The new technique of perioral muscle reconstruction facilitated to obtain lip lengthening and symmetry in the repair of complete unilateral cleft lip.

Summary Objective The treatment of the lesser form cleft lip deformity (i.e., minor-form, microform, and mini-microform) is challenging to achieve patient satisfaction. There are no studies investigating how treatment outcomes balance patients’ expectations and satisfaction with surgical or non-surgical care relative to the initial nasolabial findings. Methods Based on Mulliken's classification, consecutive records of patients with the lesser-form cleft lip from 1990 to 2015 were selected for analysis. Demographics, management, and revisions were reviewed. A panel analysis was performed based on the ratings from both professionals and non-professionals using patients’ photographs. FACE-Q questionnaires were used to compare patient/parent-reported satisfaction to the normal controls. Results A total of 135 patients were included. All of the minor-form (23/23), 89% (58/65) of the microform, and 62% (29/47) of the mini-microform patients underwent surgery. Fifty-two percent (15/29) of the mini-microform patients, who underwent surgery, showed no significant improvement. Post-operative upper lip scars and remaining nasal asymmetry were the most common concerns in the treatment group. However, the FACE-Q results showed that patients experienced a statistically significant improvement in their overall facial appearance and social function in their respective groups. Conclusions This study showed that differences exist in the perception of facial esthetics between the surgeon and the patient/parent. To achieve optimal individual treatment outcome and patient satisfaction, an awareness of the differences and treatment selection for patients are critical in surgical planning. This understanding and an open detailed discussion of overall long-term outcomes help in the management of patient expectations.

Summary Objective Double-opposing Z-plasty (DOZ) of the Furlow method has been successfully used for the correction of marginal velopharyngeal insufficiency (VPI) by reconstructing the levator muscle and lengthening the soft palate. For a recurrent or residual marginal VPI, it was questioned whether redo DOZ could be applied to correct the problem and minimize surgical morbidity. This study reported the outcome of the redo DOZ. Materials and methods The DOZ procedure was the method of choice for marginal VPI in the authors' center. To evaluate the effectiveness of the redo operation, patients with cleft palate with or without cleft lip treated from 2005 to 2014 were reviewed. Inclusion criteria were non-syndromic patients who underwent the second DOZ for the correction of marginal VPI. Clinical information, speech assessment, and nasopharyngoscopic findings were reviewed. Results The velopharyngeal function was improved from marginal to adequate in all 13 patients either subjectively or objectively. The resonance became normal in nine patients after the surgery, and the change was statistically significant. Preoperative audible nasal emission improved in four out of five patients. Complications were minor or transient including one patient with snoring. No patient complained of airway or sleep problems. Conclusion Although the levator muscle sling might be disturbed by the redo DOZ procedure, the surgery was effective in correcting the residual VPI with low morbidity.

Summary Purpose There is prominent lip asymmetry in patients with unilateral complete cleft lip and palate. Measurement of the lip on cleft and non-cleft sides provides appraisal of the lip deformity and information for planning of surgical correction. The purpose of this retrospective study is to evaluate the degree of lip deformity and to compare it with normative data. Materials and methods From 1983 to 1997, data from a total of 168 patients with unilateral complete cleft lip and palate were collected. There were no other associated craniofacial anomalies in this patient group. The measurement was performed under general anaesthesia by a senior surgeon using a calliper prior to the first lip repair. Corresponding normative data were collected from 2002 to 2003 on 50 patients who had normal facial appearance prior to hernia repair. The measurements included lip height, lip width, philtrum length and vermilion thickness. Comparisons were made between the cleft side and the non-cleft side, as well as between cleft patients and norms. Results Comparisons between the cleft and the non-cleft sides revealed significantly longer lip on the non-cleft side, including lip height from alar base to Cupid's bow, lip width from Cupid's bow to commissure and the vermilion thickness. The lip measurements on the norms were longer than those on the cleft side of the lip, but were similar to the non-cleft side. Conclusion A wide variety of tissue growth asymmetry is observed between the non-cleft and the cleft sides, indicating a deficiency of tissue development associated with the cleft deformity. These data can provide a fundamental basis for presurgical orthopaedic treatment, surgical planning, execution of surgery, postoperative assessment and may help to predict treatment outcome.

An ovoid and slender face is considered attractive in Oriental culture, and facial bony contouring is frequently performed in Asian countries to achieve this desired facial profile. Despite their popularity, critical analyses of patients' satisfaction after facial-bone contouring surgery is lacking in the current literature. Questionnaires were sent to 90 patients who had undergone zygoma and/or mandibular contouring by a single surgeon at the Craniofacial Center, Chang Gung Memorial Hospital, Taiwan. The number of patients who had mandibular angle reduction and zygoma reduction were 78 and 36, respectively. The questionnaire contained 20 questions, concerning aesthetic and surgical results, psychosocial benefits and general outcome. Medical records were also reviewed for correlation with the questionnaire findings. The survey response rate was 52.2% (47 patients). A total of 95.7% were satisfied with the symmetry of their face after surgery, and 97.9% felt that there was improvement in their final facial appearance. As many as 61.7% could not feel an objectionable new jaw line or bony step and 66.0% could not detect any visible deformity. A total of 87.2% could not detect bony regrowth after surgery. Complication after surgery was experienced by 17.0% of patients, but all of these recovered without long-term consequences. All patients noted a positive psychosocial influence, and 97.9% of patients said that they would undergo the same surgery again under similar circumstances and would recommend the same surgery to friends. The majority of patients with square face seeking facial bone contouring surgery are satisfied with their final appearance. Of equal importance is the ability for this type of surgery to have a positive influence on the patient's psychosocial environment.

Reconstruction of cranial defects can be reasonably considered a failure if an aesthetically obvious cranial contour deformity persists after surgery. Such unsatisfactory outcome often results from variable resorption of bone grafts or infection, requiring removal of implant. In considering further treatment for such failed cases, the use of alloplastic implants is frequently warned as imprudent due to their theoretically increased potential for infection; however, the validity of such caution has never been substantiated. We describe a user-friendly, time- and cost-effective method of producing prefabricated methyl methacrylate implants for the reconstruction of cranial defects, using readily available computer-aided design and computer-aided manufacture facilities. This method was carried out in 31 patients who presented with persistent cranial defects after previously failed cranioplasty. The efficacy of this technique and the clinical outcome of the patients in this series were analysed. All implants produced a precise fit, with a reduction in operating time and satisfactory cosmesis having been achieved. Infection that required removal of implant occurred in three patients (9.7%), and one patient developed a dural tear, requiring repair. Customised fabricated alloplastic implants provide a safe, accurate and efficient way of restoring normal cranial contours in patients with cranial defects who have had previous failed cranioplasties.

Summary Maxillary growth of adult patients with unoperated cleft has long been studied, but results varied between different studies. The objectives of this study were to determine the growth potential of adult patients with unoperated clefts compared to the normal population and to differentiate the growth potential among types of clefts. Methods Subjects were from the same ethnic group, were more than 16 years of age with non-syndromic cleft and no associated anomalies. The types of cleft included unilateral complete cleft lip and palate (UCLP), bilateral complete cleft lip and palate (BCLP), unilateral cleft lip (UCL) and isolated cleft palate (CP). The sella-nasion-A point (SNA) angle from the cephalometry was measured, and a dental cast study using a three-dimensional imaging system was performed. Results SNA measurements showed significant differences among different groups, the BCLP group having larger values and the CP group having smaller values when compared with normal values. Dental cast analysis measuring palatal surface area showed a significantly smaller area in patients with cleft as compared to normal controls, but no difference among the different types of cleft. From the linear measurement it was found that the interdental distance was significantly more narrow in the anterior part up to the first premolar region as compared to the control group, especially in the complete cleft groups (UCLP and BCLP). Dentoalveolar arch was also deeper and longer in these complete cleft groups. Conclusion There is an intrinsic tissue deficiency in all groups of patients with cleft; however, the sagittal development is still comparable to that of a normal population. Tissue deficiency mostly occurs in the anterior part. There is no difference in terms of the deficiencies among the different groups of cleft.