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Study Design: A retrospective radiographical study of pre- and postoperative anterior chest wall shape in thoracic adolescent idiopathic scoliosis. Objective: To assess the anterior chest wall deformity and define its relationship with other deformed components in adolescent idiopathic scoliosis. The surgical influence on the deformed chest wall contour was also evaluated to improve the clinical recognition of the risk factors associated with aggravated chest wall shape postoperatively. Summary Of Background Data: Anterior chest wall deformity is one of the major cosmetic concerns that may be attributable to rotational coupling in adolescent idiopathic scoliosis. Patients could be quite different in their anterior chest wall appearance with similar spinal angulation. The surgical improvement of this deformed chest wall shape is also quite elusive and the reverse could also happen despite excellent correction in Cobb angle. We investigated whether or not the anterior chest wall deformity was independent in the severity from the codevelopment of spinal curvature, translation, and vertebral rotation. Methods: In this retrospective study, 110 sets of computed tomographic scans, 70 of which had both pre- and postoperative images, were retrieved and analyzed. The ImageJ software (National Institutes of Health, Bethesda, MD) was used to manipulate formatted computed tomographic scans into 3-dimensional anterior chest wall reconstructions. Multiple anterior and posterior deformity parameters were evaluated, correlated, and compared. Results: The preoperative Cobb angle of major thoracic curve, chest wall angle (CWA), rib hump (RH), angle of the sternum relative to the apical vertebral body (α), sternum-rib ratio (S-R ratio), apical vertebral rotation (AVR), and angle of trunk rotation (ATR) averaged 54.4° ± 15.2°, 5.4° ± 3.9°, 14.7° ± 5.4°, 80.5° ± 7.8°, 1.3° ± 0.2, 12.3° ± 6.5°, and 8.8° ± 4.6°, respectively. The thoracic Cobb angle demonstrated moderate correlation with CWA, RH, α, S-R ratio, AVR, and ATR (r = 0.377, 0.604, -0.401, 0.514, 0.530, and 0.517, respectively, P < 0.001). The RH demonstrated moderate correlation with AVR (r = 0.546, P < 0.001). No statistically significant relationships between CWA and RH, AVR, and ATR were detected (r = 0.129, 0.043, -0.039, P > 0.05). The AVR demonstrated significant correlation with α and S-R ratio (r = -0.757, P < 0.001; r = 0.213, P < 0.05). Averaged CWA with different curve apex showed a normal distribution shape, with the highest at T9 level. The postoperative thoracic Cobb angle, S-R ratio, AVR, and ATR improved significantly (P < 0.05), with the exception of the postoperative CWA and α (P > 0.05). Postoperative |CWA| aggravated in 52.8% of the patients, with 38.6% beyond 5°, which showed a significantly lower average preoperative CWA (3.0° ± 2.8°) compared with the rest of patients with decreased CWA (7.9° ± 3.1°) (P < 0.001). Conclusion: Idiopathic scoliosis is associated with distinctive anterior chest wall deformity, with its variations partially attributable to Cobb angle and apex location, but not directly correlated with AVR. Incidence of aggravated postoperative anterior chest wall shape is notable in our study, and patients should be informed of this risk beforehand. Small preoperative CWA and apical vertebra located above T9 were associated with relatively higher risk of postoperative chest wall shape aggravation. [ABSTRACT FROM AUTHOR]

Background: The ability to simultaneously cut and perform hemostasis with low lateral thermal injury makes carbon dioxide laser a useful tool in blepharoplasty. Monopolar electrosurgery is another commonly used cutting tool that improves the quality of hemostasis and cutting speed. This study aimed to objectively and quantitatively assess the intraoperative and postoperative outcomes of transconjunctival lower blepharoplasty using either a carbon dioxide laser or monopolar electrosurgery., Methods: Between August of 2018 and March of 2021, 78 patients who underwent transconjunctival lower blepharoplasty were assigned randomly to the carbon dioxide laser group or the monopolar electrosurgery group. Patient-related parameters were recorded. Periorbital bruises were assessed objectively and quantitatively using the ecchymosis evaluation score. Analyses were performed using the independent sample t test, the Mann-Whitney U test, the chi-square test, and the Fisher exact test., Results: Sex, age, local anesthesia injection volume, and fat removal volume were not different between the groups. Patients' subjective intraoperative heat sensation was significantly higher in the monopolar electrosurgery group than in the carbon dioxide laser group. The carbon dioxide laser group had a significantly lower incidence of postoperative chemosis than the monopolar electrosurgery group. All patients had uncomplicated wound healing, except three (7.89%) patients in the monopolar electrosurgery group who developed conjunctival granuloma. Operation time, intraoperative pain sensation, intraoperative blood pressure, postoperative ecchymosis, conjunctivitis, and patients' aesthetic satisfaction did not differ between the groups., Conclusion: The authors' findings revealed that carbon dioxide laser is a useful technique for reducing intraoperative heat sensation and postoperative chemosis and may prevent conjunctival wound complications., Clinical Question/level of Evidence: Therapeutic, II., (Copyright © 2023 by the American Society of Plastic Surgeons.)

Background: Several brow-lift techniques have been used to prevent brow ptosis after blepharoplasty. For example, both internal and external browpexies have been adopted worldwide. However, few studies have compared these two methods. The authors compared postoperative eyebrow position changes between upper eyelid skin excision, internal browpexy, and external browpexy., Methods: The authors retrospectively reviewed the cases of 87 patients who underwent upper blepharoplasty performed by a single clinician at their institute between April of 2018 and June of 2020. Patients with routine outpatient photographs taken before and after surgery were enrolled in the study. ImageJ was used to measure brow height at eight points in each eye. Brow height changes were compared among the three groups., Results: Routine photographs were available for 68 patients (133 eyes). Thirty-nine patients underwent internal browpexy (78 eyes), nine underwent external browpexy (17 eyes), and 20 underwent upper eyelid skin excisions (38 eyes). Three months after surgery, significant elevation was noted on the lateral side of the brow in the internal browpexy group and across the whole brow in the external browpexy group. In the upper eyelid skin excision group, whole brow ptosis was observed. Brow-lift outcomes were better in the external than in the internal browpexy group, whereas both browpexy groups showed better outcomes than the upper eyelid skin excision group., Conclusions: Within 3 months of surgery, both internal and external browpexy provided significant brow-lift effects, preventing brow ptosis caused by blepharoplasty with skin excision. External browpexy had better brow-lift outcomes than did internal browpexy., Clinical Question/level of Evidence: Therapeutic, III., (Copyright © 2023 by the American Society of Plastic Surgeons.)

Study Design: A retrospective study., Objective: To analyze the mechanisms, predisposing factors, and prognosis of the intraoperative vertebral subluxation (VS) during pedicle subtraction osteotomy (PSO) for thoracolumbar kyphosis secondary to ankylosing spondylitis (AS)., Summary of Background Data: VS is one of the most daunting challenges that surgeons encounter during PSO closure, especially in patients with AS with ankylosed and mostly osteoporotic spine. Unfortunately, there is a paucity of research designed to conceptualize the mechanisms, predisposing factors, and discuss the complication-avoidance strategies and prognosis., Methods: A retrospective single-center review was performed for a consecutive series of 153 patients with AS with rigid thoracolumbar kyphosis who underwent one-level PSO from April 2000 to December 2013. The incidence of the VS at the level of PSO during correction was analyzed and the potential causative factors were investigated., Results: VS occurred in six patients with the incidence being 3.9% in this patient cohort. The predisposing factors were (1) early fracture of the anterior cortex of the osteotomized vertebra (OV); (2) excessive decancellation from vertebral body causing parallel collapse of the vertebral column with significant loss of the ability to create local lordosis; (3) improper manual osteoclasis due to insufficient decancellation of the OV; and (4) inappropriate application of cantilever technique and concomitant long instrumentation. The early surgical complication involved one patient with cerebrospinal fluid leakage at the osteotomized site, but no devastating neurological deficits. During follow-up, bone healing and adaptive vertebral remodeling with no rod breakage were observed for all these six patients., Conclusion: Intraoperative VS was a rare occurrence associated with inappropriate manual manipulation of osteotomy, gap closure, and rod insertion. Neurological complication was a potential risk, but could be well prevented with extensive laminectomy and emergency actions favoring partial subluxation reduction. Moreover, adaptive bone remodeling and fusion at the level of VS ensured the maintenance of kyphosis correction and avoidance of instrumentation failure., Level of Evidence: 4.

Study Design: A prospective magnetic resonance imaging (MRI) study., Objective: To investigate the change in aortic traversing length in patients with thoracolumbar kyphosis secondary to ankylosing spondylitis (AS) after closing wedge osteotomy (CWO)., Summary of Background Data: The CWO has been widely adopted for the correction of thoracolumbar kyphosis caused by AS. During this procedure, the aorta may be elongated in the instrumented area, which implies a potential risk of the aortic injury. To date, no reports have been specifically published using MRI to investigate the alteration in aortic traversing length in patients with AS undergoing CWO., Methods: From June 2013 to July 2015, 24 patients with AS with thoracolumbar kyphosis with a mean age of 38.1 years were recruited in the present study. All patients underwent single-level CWO. MRI examinations were performed before and 2 weeks after surgery. For each subject, the aortic diameter and length were measured on the MRI. Radiographic measurements included the global kyphosis, thoracic kyphosis, lumbar lordosis, local kyhosis, angle of fusion levels, and anterior height of the osteotomized vertebra. The height of these patients was also recorded., Results: The aortic traversing length significantly increased by an average of 2.0 cm after surgery. Significant changes in height, global kyphosis, lumbar lordosis, local kyphosis, and angle of fusion levels were observed (P < 0.01), whereas the anterior height of the osteotomized vertebra was comparable before and after surgery (P > 0.05). In addition, the correlation analysis revealed a significant correlation between the aortic traversing length and changes in global kyphosis, lumbar lordosis, local kyphosis, angle of fusion levels, and height (P < 0.01)., Conclusion: The stretch of the aorta after CWO for the correction of thoracolumbar kyphosis was quantitatively verified by MRI investigation in the present study. Spine surgeons should be aware of the potential vulnerability of aortic injury in patients with AS undergoing CWO., Level of Evidence: 4.

Study Design: An immunohistochemical analysis., Objective: The aim of this study was to systematically and extensively evaluate the immunopathology of the facet joints in patients with thoracolumbar kyphosis secondary to ankylosing spondylitis (AS)., Summary of Background Data: The facet joints may be predominantly involved in the process of spinal inflammation in AS. Thus, a detailed investigation of the immunopathology at sites of facet joints is of crucial importance in understanding the pathogenesis of AS., Methods: The facet joints were obtained from 30 AS patients and 23 age- and gender-matched controls (patients with fresh thoracolumbar fracture). The facet joints were assessed immunohistochemically by analyzing the number of infiltrating T cells (CD3, CD4, CD8), B cells (CD20), microvessel density (CD34), osteoblasts (CD56), bone marrow macrophages (CD68), and osteoclasts (CD68) per high-power field (hpf). According to the presence or absence of persistent inflammation, AS patients were divided into 2 groups: A (patients with persistent inflammation) and B (patients without persistent inflammation). Lumbar spinal mobility was assessed using the modified Schober index (MSI)., Results: Two or more CD3+ T cell aggregates were found in the facet joints from 18 of 30 AS patients, whereas 1 CD3+ T cell aggregate was noted in 5 of 23 patients with thoracolumbar fracture. The levels of T cells (CD4+ and CD8+), CD20+B cells, CD56+ osteoblasts, and CD34+ microvessel density were significantly higher in AS patients than in the controls (all P < 0.01). Notably, the MSI score in group A was significantly higher than that in group B (P < 0.01)., Conclusion: Active spinal inflammation is frequently observed in AS patients with thoracolumbar kyphosis. In addition, persistent inflammation in facet joints may further contribute to the loss of spinal mobility in the later stages of AS. These findings indicate that careful monitoring of disease activity is mandatory for AS patients in its advanced stage., Level of Evidence: 4.

Study Design: A computed tomographic study., Objective: To investigate the change in abdominal morphology in surgically treated patients with ankylosing spondylitis (AS) and thoracolumbar kyphosis., Summary of Background Data: Severe thoracolumbar kyphosis in patients with AS exerts pressure on the abdominal cavity and subsequently causes intra-abdominal complications. Several spinal osteotomy techniques have been widely used to correct AS-related thoracolumbar kyphosis. To date, the changed abdominal morphology in patients with AS undergoing surgical correction of thoracolumbar kyphosis has not been addressed., Methods: A total of 29 patients with AS undergoing lumbar pedicle subtraction osteotomy for correction of thoracolumbar kyphosis were retrospectively reviewed. Computed tomographic scans of the spine were used to measure the longitudinal, transverse, and anterior-posterior diameters of the abdominal cavity. Furthermore, the abdominal cavity was considered as an ellipsoid structure, thereby allowing calculation of its volume. Radiographical evaluations included global kyphosis (GK), thoracic kyphosis, lumbar lordosis (LL), and angle of fusion levels (AFL)., Results: The longitudinal diameter of abdominal cavity significantly increased (P < 0.01), whereas the transverse and anterior-posterior diameters of the abdominal cavity did not change, postoperatively (P > 0.05). Significant changes in GK, LL, and AFL were observed (P < 0.01). The abdominal cavity volume (ACV) increased by an average of 652  mL. The change in ACV was significantly correlated with the changes in GK (r = 0.453, P = 0.014), LL (r = 0.42, P = 0.023), and AFL (r = 0.388, P = 0.037)., Conclusion: The increased ACV after correction of thoracolumbar kyphosis was quantitatively confirmed by this study. Thus, the improvement in digestive function after correction of thoracolumbar kyphosis secondary to AS, which has been previously documented, may be because of an increase in ACV. Moreover, spine surgeons should be aware of the potential risk for the development of abdominal complications caused by the lengthening of longitudinal diameter of the abdominal cavity., Level of Evidence: 3.

Study Design: A computed tomography study., Objective: To identify the best scoliotic deformity components that show impact upon the spontaneous postoperative modulation of the deformed anterior chest wall contour in right convex thoracic adolescent idiopathic scoliosis., Summary of Background Data: Spontaneous postoperative aggravation of the anterior concave costal projection was a common occurrence in adolescent idiopathic scoliosis, yet the risk factors that effectively bridged the gap between what the surgeons did in the interior and how the rib cages reacted on the exterior were still open to debate., Methods: Pre- and postoperative computed tomographic scans of 77 patients with right convex thoracic adolescent idiopathic scoliosis were retrieved and analyzed. According to the postoperative variation of anterior chest wall angle (CWA), the patients were divided into 2 groups with either aggravated or improved CWA. Multiple scoliotic deformity parameters and their surgical correction rates were evaluated, correlated, and then compared between the 2 groups. Moreover, patients with apex located at T9 were isolated and evaluated independently. A logistic regression analysis was used to determine the independent predictors of the spontaneous postoperative modulation of the anterior chest wall contour., Results: The surgical correction rate of Cobb angle (supine), the rotational angle with respect to the sagittal plane (RAsag angle), the rotational angle with respect to the anterior midline of the body (RAml angle), the angle of lateral deviation of the apical vertebrae from the midline (MLdev angle), the posterior hemithorax ratio, the vertebral translation (VT), and the thoracic rotation averaged 64.6%, 19.5%, 30.8%, 39.2%, 15.0%, 41.2%, and 28.7%, respectively. Ratio of aggravated anterior chest wall contour was the highest at the T7 apex group (84.6%) as compared with T8 apex group (47.1%), T9 apex group (19.5%), and T10 apex group (0.0%). The preoperative CWA was significantly lower in the aggravated CWA group when compared with the improved group (2.1 ± 1.8°vs. 6.6 ± 2.4°, P < 0.001). Besides, in the aggravated CWA group, significantly greater surgical correction of VT and lesser correction of RAsag angle were demonstrated when compared with the improved CWA group (VT: 53.0% vs. 34.8%, P = 0.001; RAsag: 2.5% vs. 28.7%, P = 0.000). In the T9 subgroup, remarkably different correction rate of VT and RAsag were similarly observed (VT: 54.9% vs. 35.3%, P = 0.046; RAsag: 4.9% vs. 23.5%, P = 0.034). In terms of other deformity parameters, no significantly different correction rate was consistently detected. In the logistic regression analysis, apex location, CWA, and correction rate of RAsag were demonstrated to be independent factors predictive of the alteration of chest wall contour., Conclusion: In addition to the smaller preoperative CWA and higher apex location, lesser correction of vertebral rotation, if accompanied by great surgical correction of apical VT, could also largely result in a poor postoperative anterior chest wall contour.

Study Design: A genetic association study to comprehensively investigate variations of neurotrophin 3 (NTF3) gene polymorphisms in a Chinese Han population., Objective: To explore whether the NTF3 gene polymorphisms are associated with the susceptibility, curve severity, or bracing effectiveness of adolescent idiopathic scoliosis (AIS)., Summary of Background Data: Scoliosis has developed in mice with NTF3 deficiency in previous studies. Increased expression of NTF3 mRNA was detected in the paravertebral muscle in AIS. Moreover, linkage study has defined a novel AIS locus on chromosome 12p while NTF3 gene is located exactly in this interval. All evidence indicates a potential role of NTF3 in the pathogenesis of AIS. As for brace treatment of AIS, continuous sensory stimulation caused by an orthosis could help awareness of body misalignment and trigger curve correction through postural reflex. While NTF3 gene is tightly associated with proprioceptive feedback mechanism to adjust postural control, we hypothesized NTF3 as a potential candidate gene associated with the bracing effectiveness., Methods: A total of 362 AIS patients and 377 age-matched healthy controls were recruited. Two single-nucleotide polymorphisms (SNPs) were selected on the basis of the Chinese data from the HapMap project, and genotyping was carried out by polymerase chain reaction-restriction fragment length polymorphism for each SNP, respectively. Case-control study and case-only study were performed to define the contribution of NTF3 gene polymorphisms to predisposition and disease severity of AIS. Another subgroup of 120 skeletally immature AIS patients who received continuous brace treatment for minimal 2 years was genotyped, and bracing effectiveness was assessed to determine its association with NTF3 gene polymorphisms., Results: The genotype and allele frequency distribution were similar between AIS and normal control for these 2 SNPs (χ² test: P > 0.05). For SNP rs11063714 in the promoter region of NTF3 gene, AIS patients with AA genotype showed significantly lower mean maximum Cobb angle than the patients with AG or GG genotypes (analysis of variance: P = 0.008). In addition, skeletally immature bracing AIS patients with AA genotype possessed significantly higher successful ratio of brace treatment compared with GG genotype (χ² test: P = 0.043). For SNP rs1805149, no significant association with predisposition or curve severity was detected., Conclusion: The NTF3 gene polymorphisms are not associated with the occurrence of AIS, but the promoter polymorphism (rs11063714) is associated with the curve severity, implicating an alleviating role of NTF3 in the curve progression of AIS. In addition, the promoter polymorphism is also associated with brace responsiveness. These findings indicated that NTF3 gene might be a disease-modifying gene of AIS.