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Purpose: The early detection and diagnosis of rare genetic diseases are crucial for maintaining patient health and well-being. However, the diagnosis of said diseases can be challenging owing to their rarity, limited clinical experience of physicians, and specialized facilities required for diagnosis. In recent years, deep learning algorithms have been investigated as a potential strategy for the efficient and accurate diagnosis of these diseases. Herein, we used the deep learning algorithm of multitask cascaded convolutional neural networks (MTCNN) to develop a face recognition model for the diagnosis of velocardiofacial syndrome (VCFS). Methods: We trained the model on a publicly available labeled face dataset and evaluated its performance. Subsequently, we analyzed the binary classification performance of diagnosing VCFS using the most efficient face recognition model. The facial images of 98 patients with VCFS and 91 non-VCFS controls who visited Seoul National University were used to create training and test sets. Moreover, we analyzed whether the classification results matched the known facial phenotype of patients with VCFS. Results: The facial recognition model showed high accuracy, ranging from 94.03% to 99.78%, depending on the training dataset. In contrast, the accuracy of the binary classification model for the diagnosis of VCFS varied from 80.82% to 88.02% when evaluating with photographs taken at various angles of the patient depending on the structure. When only evaluating frontal photographs, the accuracy was 95.00%. Moreover, the importance level analyzed through the gradient-weighted class activation mapping heatmap showed the characteristic parts of perinasal and periorbital area to be consistent with the conventional facial phenotypes of VCFS. Conclusion: We attempted to diagnose the patients' genetic syndrome using MTCNN-based deep learning algorithms only with the photos of the faces of patients with VCFS. We obtained high accuracy, and deep learning-based diagnosis has been conformed to be greatly helpful for medical staff in the early detection and diagnosis of children with rare genetic diseases, enabling them to provide treatment in a timely manner.

Background The vascularity of the nipple-areolar complex (NAC) is altered after reduction mammoplasty, increasing the risk of complications after repeat reduction or nipple-sparing mastectomy. Objectives The aim of this study was to evaluate angiogenesis of the NAC via serial analysis of magnetic resonance images. Methods Magnetic resonance images of breasts after reduction mammoplasty were analyzed for 35 patients (39 breasts) from 3-dimensional reconstructions of maximum-intensity projection images. All veins terminating at the NAC were classified as internal mammary, anterior intercostal, or lateral thoracic in origin. The vein with the largest diameter was considered the dominant vein. Images were classified based on the time since reduction: 2 years. Results The average number of veins increased over time: 1.17 (2 years). Within 6 months, the pedicle was the only vein. Veins from other sources began to appear at 6 to 12 months. In most patients, at least 2 veins were available after 1 year. After 1 year, the internal mammary vein was the most common dominant vein regardless of the pedicle used. Conclusions Repeat reduction mammoplasty or nipple-sparing mastectomy should be performed ≥1 year following the initial procedure. After 1 year, the superior or superomedial pedicle may represent the safest option when the previous pedicle is unknown.

Background: Lymphedema is a disease thatrefers to tissue swelling caused by an accumulation of protein-rich fluid that is usually drained through the lymphatic system. Detection of lymphedema is often based on expensive diagnoses such as bioimpedance spectroscopy, shear wave elastography, computed tomography, etc. Applications of data science and machine learning in predicting medical conditions offered support for medical doctors and patients in the early detection of diseases. Although current studies proposed machine learning models to predict lymphedema by using symptoms reported by patients, there might be uncertaintyinpatient-input data. In this study, we proposed to usemore reliable input data such as complete blood count, serum, and therapy data to develop predictive models for lymphedema. Methods: We collected data from 2137 patients, including 356 patients having lymphedema and 1781 patients not having lymphedema. The lymphedema status of each patient was confirmed by clinicians. Data of each patient includes: 1) complete blood count (CBC) test, 2) serum test, and 3) therapy information. We used machine learning algorithms (i.e., random forest, gradient boosting, support vector machine, decision tree and artificial neural network) to develop predictive models on training dataset (i.e., 80% of the data) and tested the models on the test dataset (i.e., 20% of the data). After choosing the best predictive models, we developed web application for medical doctors and clinicians to use our models for quick screening lymphedema patients. Results: A dataset of 2137 patients was collected from Seoul National University Bundang Hospital. Predictive models based on random forest algorithm showed satisfactory performance (balanced accuracy = 86.7 ± 0.9%, sensitivity = 84.3 ± 0.6%, specificity = 89.1 ± 1.5%, precision = 97.4 ± 0.4%, F1 score = 90.4 ± 0.4%, and AUC = 0.931 ± 0.007). A web application was made to assist medical doctors in quick screening lymphedema: https://snubhtxt.shinyapps.io/SNUBH_Lymphedema. Conclusions: Our study would provide a tool for the early detection of lymphedema and be the basement for future studies predicting lymphedema stages.

We report a case of adenocarcinoma originating in a urostomy site 35 years after bladder cancer operation and urostomy formation. While ileostomy adenocarcinoma has been reported as a rare complication after colectomy and ileostomy formation for inflammatory bowel disease or familial adenomatous polyposis, there were no previously published cases of parastomal carcinoma in patients with urostomy. In our case, a series of work-ups, including immunohistochemical staining (cytokeratin 7 and 20, p63), revealed no evidence of primary adenocarcinoma of the skin or any other primary tumor. The patient underwent surgical excision with urostomy reformation and the skin defect was successfully reconstructed using local flap and split-thickness skin graft. This case poses a diagnostic challenge for clinicians because skin primary adenocarcinoma (i.e., malignant adnexal tumor) is likely to be ruled out due to its low incidence, and the symptoms may be considered those of a rare subcutaneous metastasis from a visceral malignancy (e.g., colon cancer) in the patient with a history of a prior malignancy (bladder cancer). This underscores the need for a multidisciplinary approach and patient education for early diagnosis.

Background This is the first clinical study conducted among Asian women using breast implants manufactured by an Asian company. Four-year data regarding the safety and efficacy of BellaGel breast implants have already been published, and we now report 6-year data. Methods This study was designed to take place over 10 years. It included 103 patients who underwent breast reconstruction or augmentation using BellaGel breast implants. The rates of implant rupture and capsular contracture were measured and analyzed to evaluate the effectiveness of the breast implant. Results At patients’ 6-year postoperative visits, the implant rupture and capsular contracture rates were 1.15% and 2.30%, respectively. The implant rupture rate was 3.77% among reconstruction cases and 0% among augmentation cases. The capsular contracture rate was 5.66% among reconstruction cases and 0.83% among augmentation cases. Conclusions The 6-year data from this planned 10-year study suggest that the BellaGel cohesive silicone gel-filled breast implant is an effective and safe medical device that can be used in breast reconstruction and augmentation.

Implant-based reconstruction represents the most common form of breast reconstruction after mastectomy. Although the complication rate has lowered owing to the current advances, various implant-related complications are still a problem. There have been few reports discussing chest wall deformation following implant insertion. The aim of this study was to quantify chest wall depression (CWD) after breast implant insertion and identify possible risk factors.Patients who underwent unilateral direct-to-implant reconstruction were included in the study. We measured the pre- and postoperative antero-posterior length of the chest wall and used a CWD ratio to measure the change in length. Multivariate analysis was performed with factors with P values of0.2 in univariate analyses to identify factors associated with CWD.A total of 57 patients were included in this study. The pre- and postoperative difference of antero-posterior length was statistically significant using a pairedThis study showed the possibility of CWD following implant insertion. Surgeons and specialists should be aware of the possibility and risk factors of CWD following implant insertion to better inform patients.

Lymphedema is a progressive disease caused by lymphatic flow blockage in the lymphatic pathway. Primary (hereditary) lymphedema is caused by genetic mutations without secondary causes. However, the underlying cause of primary lymphedema remains obscure, and gene sequencing studies on a sizable patient cohort are lacking. We performed clinical profiling on Korean primary lymphedema patients based on their phenotypes and using lymphoscintigraphy and made genetic diagnoses using a next-generation sequencing panel consisting of 60 lymphedema-related genes. Of 27 patients, 21% had lymphedema of the upper extremities, 81% had lymphedema of the lower extremities, and two patients had lymphedema in both. Based on International Society of Lymphology staging, 14, 10, and 3 patients had stage 3, 2, and 1 lymphedema, respectively. Genetic abnormalities were identified in six patients: a pathogenic variant of CELSR1 in two patients, variants of uncertain significance (VUSs) of CELSR1 in two patients, a VUS of SOS1 in one patient, and a pathogenic variant of MPI and VUSs of TIE1, FLT4, and PIEZO1 in one patient. The clinical and genetic profile of hereditary lymphedema reported here is the first such data series reported in South Korea. Our study highlights the need for genetic screening in primary lymphedema diagnosis.

Lymphovenous anastomosis (LVA) is primarily used for treating early-stage lymphedema. Here, we aimed to investigate the relationship between lymphatic flow velocity and the efficacy of LVA in breast cancer-related lymphedema patients. To this end, we assessed the transit velocity of lymphatic fluid using indocyanine green (ICG) lymphography and radioisotope lymphoscintigraphy.We retrospectively examined patients diagnosed with breast cancer-related lymphedema who underwent LVA from January to December 2020. Patient data, including demographics, clinical stage, and postoperative surgical outcomes, were collected from electronic medical records. ICG lymphography results and dynamic lymphoscintigrams were analyzed to measure the lymphatic flow velocity and to determine the grade of the limb lymphedemas.Eighty patients (all female, mean age of 53.6 years) were included. The lymphatic flow velocity ranged between 0.58 and 21.5 cm/min (average, 7.61 cm/min); 37 (46.3%), 18 (22.5%), 15 (18.8%), and 10 (12.5%) arm lymphedemas were classified as lymphoscintigraphy grade 0, 1, 2, and 3, respectively. A significant association was observed between lymphatic flow velocity and lymphedema grade determined using lymphoscintigraphy and between the amount of volume reduction after LVA and preoperative lymphatic flow velocity (P 0.05).Our findings suggest that lymphatic flow velocity is positively correlated with surgical outcomes in patients undergoing LVA. Therefore, surgical treatment plans for lymphedema should not be based only on the International Society of Lymphedema stage, because advanced-stage lymphedema patients with high ICG velocities can benefit from LVA alone.

Intravenous ferric carboxymaltose (IV-FCM) can effectively correct perioperative anemia in patients undergoing major surgeries. However, its efficacy and side effects in patients undergoing free flap-based breast reconstruction are yet to be investigated. Starting from year 2020, patients with breast cancer undergoing abdominal free flap-based breast reconstruction were injected 500 mg of IV-FCM immediately post-operation. Propensity-matched 82 IV-FCM injected (study group) and 164 historical control group patients were analyzed for transfusion rates, changes in hematological parameters, and flap or donor-site related complications. The major and minor complication rates related to the operation site were similar between the two groups. There was no significant difference in the transfusion rate between the two groups (p = 0.71). However, the total amount of transfusion required was significantly higher in the historical control group (p = 0.02) than in the study group. Additionally, the historical control group showed a significantly higher drop in red blood cell count, hemoglobin, and hematocrit levels from postoperative days 1 to 2 and 2 to 3 compared to the study group. Immediate postoperative use of IV-FCM in free flap-based breast reconstruction was well tolerated by patients, reduced overall transfusion volume, and promoted faster postoperative recovery of hematological parameters.

BACKGROUND The pharyngeal flap is one of the most common secondary surgeries for the correction of velopharyngeal insufficiency (VPI) for patients with cleft palate and/or cleft lip and palate. This study aimed to demonstrate the effectiveness of the precision pharyngeal flap surgery performed by the senior author. MATERIALS AND METHODS Children with VPI, who underwent precision pharyngeal flap, were retrospectively examined. All surgical procedures were performed by the senior author. The flap size was individually configured based on the patients' preoperative nasopharyngoscopic analysis and speech function evaluation. Pre- and post-operative velopharyngeal functions were assessed using perceptual speech evaluation and nasometric analysis; factors affecting surgical outcomes were determined. RESULTS Of 138 patients, 112 (women: 53, men: 59) were included in analyses, according to the inclusion and exclusion criteria. The median follow-up period was 21 months (range: 9-120). Postoperative perceptual speech evaluation revealed improved velopharyngeal function in 108 (96.4%). There were no reports of postoperative hyponasality (preoperative, 1.8% versus postoperative, 0%; P = 0.053). Other parameters of perceptual speech evaluation (hypernasality, nasal emission, articulation error, and intelligibility) showed significant improvement postoperatively (P

Autologous reconstruction using abdominal flaps remains the most popular method for breast reconstruction worldwide. We aimed to evaluate a prediction model using machine-learning methods and to determine which factors increase abdominal flap donor site complications with logistic regression. We evaluated the predictive ability of different machine learning packages, reviewing a cohort of breast reconstruction patients who underwent abdominal flaps. We analyzed 13 treatment variables for effects on the abdominal donor site complication rates. To overcome data imbalances, random over sampling example (ROSE) method was used. Data were divided into training and testing sets. Prediction accuracy, sensitivity, specificity, and predictive power (AUC) were measured by applying neuralnet, nnet, and RSNNS machine learning packages. A total of 568 patients were analyzed. The supervised learning package that performed the most effective prediction was neuralnet. Factors that significantly affected donor-related complication was size of the fascial defect, history of diabetes, muscle sparing type, and presence or absence of adjuvant chemotherapy. The risk cutoff value for fascial defect was 37.5 cm2. High-risk group complication rates analyzed by statistical method were significant compared to the low-risk group (26% vs 1.7%). These results may help surgeons to achieve better surgical outcomes and reduce postoperative burden.

Background:. Deepening of the nasolabial fold with reduced malar highlight caused by sagging of the midface is one of the most important characteristics of facial aging. This report describes the use of 18-G polydioxanone (PDO) cog threads to improve midface soft tissue sagging and achieve satisfactory results through a minimally invasive procedure. Methods:. In total, 64 patients (all women; age, 33–60 years) underwent a midface thread lift from January 2017 to January 2018. After a stab incision was made through an 18-G needle over the lateral orbital rim, three 18-G precannulated PDO cog threads were inserted, targeting the deep medial fat pad and inner layer of the superficial muscular aponeurotic system. The threads were anchored to the periosteum of the lateral orbit, suspending the soft tissue to a more superior direction. Surgical results were evaluated subjectively (patient satisfaction ratings) and objectively (blinded physician ratings based on changes in the vertical position of the malar highlight). Results:. No major complications (postoperative hematoma, infection, or temporary sensory/motor decreases) were observed. The mean procedural time was 15 minutes, and all patients underwent local anesthesia. Patient satisfaction was the highest at 1 month postoperatively (mean, 4.7/5.0), decreasing at 1 year postoperatively (2.8/5.0). The scores on the objective assessment followed the same trend (4.5/5.0 at 1 month; 3.1/5.0 at 1 year). Conclusion:. Using PDO cog threads for midface lifting is simpler, quicker, and less invasive than using conventional surgical methods, and this method simultaneously achieves satisfactory results for at least 6 months.

Facial trauma, including panfacial fractures caused by high-impact trauma, is increasingly frequent in elderly patients. The purpose of this study was to investigate the effects of the particularly serious and challenging panfacial fractures on elderly adults.The authors retrospectively reviewed the files of all patients who were operated for panfacial fractures at our institution from December 2006 to December 2018. The definition of a panfacial fracture was a concurrent fracture in 2 or more locations, including nasoethmoid, frontozygomaticomaxillary, Le Fort I and II, and mandibular fractures. The authors reviewed in-hospital medical records to collect data on the medical history, cause of injury, fracture location, accompanying surgery, postoperative complications, duration of hospital stay, laboratory results, radiographic studies, and computed tomography scans.A total of 454 patients were enrolled. Among them, 57 (13%) were19 years old, 304 (72%) were 19 to 60 years old, and 62 (15%) were60 years old. Compared with younger patients, those aged older than 60 years were more likely to have underlying diseases including diabetes, hypertension, and antiplatelet, and showed a significantly higher proportion of brain hemorrhage, internal organ contusion, surgical site infection, and hematoma after surgery.The authors have analyzed the largest number of panfacial fractures in an elderly population so far. The pattern of injury and sequelae of severe facial trauma in elderly patients may be more serious, and the postoperative course more prone to complications than in younger patients. Therefore, more delicate treatment and a high degree of suspicion are needed.

Summary Background Only experienced surgeons can produce satisfactory results with most of the current surgical methods for bilateral cleft lip repair. The existing methods require not only preoperative orthodontic maneuvers but also accurate measurements for surgical design. We describe an easy-to-design and simple-to-execute general purpose surgical technique to repair most bilateral cleft lips. Methods A retrospective review was performed for the patients who underwent bilateral cleft lip repair using our novel method between 2003 and 2016. The authors collected data from medical records, and the aesthetic results were judged using the aesthetic result categories by three independent surgeons; indirect anthropometry was applied to patients over 9 years of age. In addition, we investigated the complications, the reoperation rate, and the reasons for reoperation. Results Bilateral cleft lip surgery was performed in 146 cases between 2003 and 2016. Seventy-eight patients had bilateral complete cleft lips, 47 patients had bilateral incomplete cleft lips, and 21 patients had bilateral complete and incomplete cleft lips (asymmetric patients). There were no acute complications requiring re-surgery, such as wound dehiscence, hematoma, and infection. According to aesthetic classification, 74 patients (51%) were classified into category I and 72 patients (49%) into category II; no patients were classified into categories III and IV. Seventy patients (48%) underwent secondary lip operations. In anthropometry, the measurements were observed to be symmetrical; left and right measurement data were not significantly different. The main purposes of the revision were excision of widened philtral scars (42 cases) and correction of lateral vermilion bulging (28 cases). Conclusions We have found our novel technique to be simple and capable of providing consistent, reproducible, and reliable results.

Background Numerous techniques have been used for lower blepharoplasty. The techniques can be classified into four principles: excision of excess fat, septal reset, orbital fat repositioning, and reinforcement of the attenuated orbital septum. Objectives We modified the conventional approach of septal reinforcement to utilize an inverted T-shaped plication with preservation of the orbital fat, repositioning the septum below the arcus marginalis to refine tear-trough deformity. Methods From April 2010 to September 2015, 93 individuals underwent bilateral lower blepharoplasty. Retrospective chart reviews were performed, and the results and complications during the follow-up period were recorded and photographed. Results The patients comprised 76 women and 17 men. Thirteen, 33, and 47 patients exhibited mild, moderate, and severe fat herniation, respectively, accompanied by tear-trough deformity. A total of 70 and 23 patients underwent lower blepharoplasty via subciliary and transconjunctival approaches, respectively. We performed inverted T-shaped plication of the orbital septum in mild and moderate cases and X-shaped plication in severe cases, and in moderate and severe cases, we performed septal repositioning simultaneously. The mean follow-up period was 25 months. When immediate mild lid retraction or lid malposition was observed, it recovered without specific treatment within 1 to 2 weeks. No permanent lid malposition or ectropion was observed in any of the patients. Conclusions Septal plication with inverted T-shape or X-shape can minimize the downward forces that affect postoperative eyelid malposition and ectropion. Further, these procedures provide sufficiently strong reinforcement of the orbital septum to restore infraorbital fat herniation.

Background. Fingertips are a common site for hand injuries. The ideal substitute for fingertip pulp is tissue that matches texturally with minimal donor site morbidity. We described anatomical findings from cadaveric studies and the reliability of the palmar ulnar artery perforator (PUAP) free flap techniques for the reconstruction of fingertips injuries. Methods. The cadaveric study involving 8 hands was conducted to illuminate the anatomy of the hypothenar region. We investigated the emerging point of perforators, diameter of the artery at the origin, and the length of the pedicle. Forty-four patients with fingertip injuries underwent fingertip reconstruction using PUAP free flaps. Data on the baseline patient demographics, hospital courses, and flap sizes were obtained retrospectively. The 6-month postoperative sensory capacity was determined using a 2-point discrimination test. Results. The cadaveric study found that the PUAP pedicles arose from the superficial palmar arch, the mean length of pedicles, and the diameter and location of perforators were also analyzed. The PUAP flap sizes varied from 2.0 × 2.3 cm to 2.5 × 3.5 cm, and the mean operative time was 124 min. In all cases, we performed neurorrhaphy for fingertip sensory restoration. All donor sites were closed primarily, and the 2-point discrimination test result was 5.7±0.87 mm 6 months after surgery. Conclusions. We confirmed the anatomical consistency of the PUAP. Among the numerous reconstruction options available for fingertip injuries, the PUAP free flap is a useful fingertip reconstruction option.

Background: Anatomical variation and deficits of velocardiofacial syndrome patients are related to unsatisfactory treatment results in surgical correction of speech abnormalities. The main purpose of the article is to investigate the clinical significance of thinned levator veli palatini muscle in VCFS patients. Methods: The authors reviewed medical records of all children with velocardiofacial syndrome who received pharyngeal flap surgery between March 2007 and September 2015. Data including thickness of levator veli palatini in magnetic resonance examination; preoperative velopharyngeal gap size from nasoendoscopy; and preoperative and postoperative speech outcomes were collected. Results: Total of 36 velocardiofacial syndrome patients with preoperative objective data and postoperative speech outcomes were identified. Preoperative velopharyngeal gap showed significant correlation with thickness of levator veli palatini (correlation coefficient: 0.297/0.397, P = .02/.03) and gap size showed correlation with postoperative speech improvement (0.347/0.413, P = .04/.02). However, muscle thickness showed no correlation with speech outcomes (0.046/0.037, P = .77/.86). Conclusion: Thinned levator veli palatini muscle in velocardiofacial syndrome patients are related to widened velopharyngeal gap and production of hypernasal speech, and can give negative impact on postoperative surgical outcome of pharyngeal flap surgery.

Common side effects during hyaluronic acid filler injections are typically mild and reversible, but several reports of blindness have received attention. The present study focused on orbital symptoms combined with blindness, aiming to classify affected patients and predict their disease course and prognosis. From September of 2012 to August of 2015, nine patients with vision loss after filler injection were retrospectively reviewed. Ptosis, ophthalmoplegia, and enophthalmos were recorded over a 6-month follow-up, and patients were classified into four types according to periocular symptom manifestation. Two patients were categorized as type I (blindness without ptosis or ophthalmoplegia), two patients as type II (blindness and ptosis without ophthalmoplegia), two patients as type III (blindness and ophthalmoplegia without ptosis), and three patients as type IV (blindness with ptosis and ophthalmoplegia). The present study includes previously unpublished information about orbital symptom manifestations and prognosis combined with blindness caused by retinal artery occlusion after cosmetic filler injection.Therapeutic, V.

Each year, thousands of patients, particularly Eastern Asians, receive reduction malarplasty to achieve a more feminine and slender facial appearance. To date, there lacks a systematic analysis regarding the postoperative complications related to this procedure. Hence, the authors performed a comprehensive literature review with meta-analysis.Articles were searched and reviewed using the MEDLINE and Embase databases. Among the studies regarding surgical outcomes after reduction malarplasty, articles with explicit reports and clear numbers of postoperative complications were selected for meta-analysis. Additionally, manual searches were made from references of selected articles.A total 14 retrospective review articles that represented 3149 cases were reviewed, and 7 different postoperative complications were analyzed. The complication that showed the highest weighted mean percentage of frequency was transient sensory weakness, with 5.8% (Z = -18.012; 95% confidence interval, 4.3-7.6%), followed by drooping (2.8%), nonunion (2.2%), asymmetry (1.8%), mouth opening restriction (1.8%), uncontrolled bleeding (1.3%), and facial nerve injury (0.9%).According to our meta-analysis of previous literatures, the aggregated rates of various complications related to reduction malarplasty were not high. Among the various complications, short-term sensory weakness was shown as the most frequent complication, emphasizing the necessity of patient warning and education before and after the operation. Moreover, soft tissue drooping and bone nonunion are also not rare and surgeons should be aware of these complications.

Background Achieving aesthetically favorable results in orthognathic surgery is equally as important as good postoperative occlusion and jaw function. Orthognathic surgery that only changes profile or proportion in the vertical dimension can often lead to patient's dissatisfaction and additional surgical revision. To achieve maximal aesthetic improvement and postoperative patient's satisfaction, the chin shape should be considered as important a component of orthognathic surgery as dental occlusion or jaw function. Methods From April 2010 to January 2014, 82 female patients with aesthetic complaints after previous orthognathic surgery visited our clinic for reevaluation and management. Among those 82 patients, 54 patients who were dissatisfied with their lower facial shape from the frontal view underwent revision surgery with narrowing genioplasty and contouring of the lower border of the mandible. Results Facial shapes, when viewed from the front in all patients, became more slender and balanced postoperatively, and there was no need for additional surgical revisions in this series. There were no significant complications caused by our surgical revisions. Conclusions Good aesthetic results were obtained after 54 secondary genioplasties for chin deformities after orthognathic surgery. These results suggest that surgeons should give more attention to managing chin shape when performing orthognathic surgery to meet the high aesthetic demands of patients and to avoid surgical revisions.