Reduction malarplasty

Reduction malarplasty is one of the common aesthetic procedures performed in the Orient, although it is rarely performed in the West. Previously described techniques for malar reduction include shaving the prominent portion and contouring the outer surface of the malar complex utilizing a variety of surgical approaches. We describe a technique for malar reduction involving a coronal approach followed by either an in situ transposition osteoplasty or the removal of the malar complex and contouring of the bone with replacement as a free bone graft. We have performed this procedure on 94 patients with good results.     

Angle-splitting ostectomy followed by face lift for elderly patients with prominent mandibular angles

A prominent mandibular angle is a relatively common aesthetic problem among Asians, and the reduction angle-splitting ostectomy is now becoming a very popular procedure in Asian countries. Although this operation is usually performed on young patients, the same aesthetic demands are also seen in the elderly. In this report, the authors describe their experience with angle-splitting ostectomies followed by face lifts in three patients older than 50 years. The angle-splitting procedure was the same as that performed in young patients, and clinical results were assessed with photographs and three-dimensional computed tomographic scans. The facial contours after angle-splitting ostectomy were satisfactory, but the patients showed postoperative redundancy of the skin, especially along the jaw line, because of the loss of bony protrusion laterally. Therefore, the patients underwent subsequent superficial musculoaponeurotic system cheek lifts. The final aesthetic results were satisfactory in all cases. When surgeons want to perform the angle-splitting ostectomy safely and effectively on the elderly, they should be aware of the risks and indications specific for elderly patients, and a multidisciplinary support system should be available. Subsequent face lifts can improve skin redundancy and lead to better cosmetic results.     

The dorsalis pedis free flap: technique of elevation, foot closure, and flap application

The dorsalis pedis free flap is an excellent reconstructive tool for thin remote mucosal defects, for heel and hand defects where innervation is critical, and as an osteocutaneous flap with unique application to mandibular and floor of mouth reconstruction. The major criticism with this flap is related to its uncertain vascularity and the donor defect. We have found in our series of 45 cases that the vascular anatomy is exceedingly reliable. Problems with the donor defects are all related to technique. With care in flap elevation and foot closure, which we describe in detail, an acceptable donor site with minimal complications can be achieved. The clinical applications of this flap are illustrated by three case reports. Our experience with the donor site has not been problem-free. However, we do believe that with meticulous technique primary healing will occur without functional disability and with minimal cosmetic deformity.     

The use of botulinum toxin type A in aesthetic mandibular contouring

The lower third of Asian faces is wider than that of Caucasians and it is determined by the size and width of the mandibular bone and the thickness of muscles and subcutaneous fat tissues surrounding it. Efforts to create an aesthetically slim and smooth facial contour line in nonobese people have led the authors to focus on two approaches: surgical resection of the masseteric muscle and modeling ostectomy of the square-angled mandibular bone. Because these procedures present some problems, the authors adopted a nonsurgical concept that chemically denervates muscles and reduces the bulk of the muscle. The authors have conducted a total of 1021 clinical cases from March of 2001 through September of 2002, in which patients were treated with botulinum toxin type A (Dysport; Ipsen Ltd, Slough, United Kingdom) for remodeling the lower facial contour line; 383 of those cases were followed up for at least 3 months after the initial injection. A database was made by measuring the change in the thickness of the injected muscle with an ultrasonogram. Eleven patients underwent resection of the mandibular angle before injection. The preinjection ostectomy group was involved in the study as a result of their dissatisfaction with the surgical results; they had a rather thick masseter muscle and not a bone problem. Some had both bone problems and a thick masseter muscle. Three months after the botulinum toxin injection, the thickness of the muscle was reduced by 31 percent on average. The atrophic effect of injection was observed after 2 to 4 weeks for most patients. Seventy percent of the 383 patients tracked were greatly satisfied with the result, with another 23 percent generally satisfied. No long-term side effects were reported. Masseteric hypertrophy is frequent in Asians because of racial characteristics and dietary habits. Botulinum toxin type A has made a new epoch in facial contouring for Asians. Considering that Asians have a prominent malar and a prominent mandible angle, the reduction in the thickness of the masseter can provoke relative prominence of the malar and mandible angle. Therefore, precise indication and anatomy of the facial muscle should be thoroughly understood, which will decrease the incidence of side effects and problems. Botulinum toxin type A (Dysport) injection is simple in technique, has few side effects, and promises a rapid return to daily life. The authors conclude that the injection of botulinum toxin type A can replace surgical masseter resection.     

A Correlational Study of Scoliosis and Trunk Balance in Adult Patients with Mandibular Deviation

Previous studies have confirmed that patients with mandibular deviation often have abnormal morphology of their cervical vertebrae. However, the relationship between mandibular deviation, scoliosis, and trunk balance has not been studied. Currently, mandibular deviation is usually treated as a single pathology, which leads to poor clinical efficiency. We investigated the relationship of spine coronal morphology and trunk balance in adult patients with mandibular deviation, and compared the finding to those in healthy volunteers. 35 adult patients with skeletal mandibular deviation and 10 healthy volunteers underwent anterior X-ray films of the head and posteroanterior X-ray films of the spine. Landmarks and lines were drawn and measured on these films. The axis distance method was used to measure the degree of scoliosis and the balance angle method was used to measure trunk balance. The relationship of mandibular deviation, spine coronal morphology and trunk balance was evaluated with the Pearson correlation method. The spine coronal morphology of patients with mandibular deviation demonstrated an “S” type curve, while a straight line parallel with the gravity line was found in the control group (significant difference, p<0.01). The trunk balance of patients with mandibular deviation was disturbed (imbalance angle >1°), while the control group had a normal trunk balance (imbalance angle <1°). There was a significant difference between the two groups (p<0.01). The degree of scoliosis and shoulder imbalance correlated with the degree of mandibular deviation, and presented a linear trend. The direction of mandibular deviation was the same as that of the lateral bending of thoracolumbar vertebrae, which was opposite to the direction of lateral bending of cervical vertebrae. Our study shows the degree of mandibular deviation has a high correlation with the degree of scoliosis and trunk imbalance, all the three deformities should be clinically evaluated in the management of mandibular deviation.     

Risk factors contributing to symptomatic plate removal in maxillofacial trauma patients

This study analyzed the fate of plates used to correct maxillofacial injuries and defined risk factors that eventually resulted in plate removal. The outpatient clinic files of 108 patients treated with rigid internal fixation after maxillofacial trauma were reviewed. Study variables included age, sex, trauma circumstances, diagnosis, type of fracture, approach to the facial skeleton, presence of teeth in the line of fracture, plate material, site of plates, and reasons for plate removal. Of 204 plates used for fixation, 44 plates (22 percent) were removed. When all factors were considered together, only fracture diagnosis (mandibular body and angle) and plate location (mandibular body and angle) were statistically significant. Only when each factor was considered separately, the approach to the facial skeleton (intraoral) and the type of fracture (comminuted and compound fractures) were statistically associated with plate removal. Selection of favorable plate location, the extraoral approach, and vigilant infection control may reduce plate removal in patients with maxillofacial injuries. Special attention should be given to compound and comminuted fractures of the mandibular body and angle.     

Mandibular retrusion, temporomandibular joint derangement, and orthognathic surgery planning.

One-hundred consecutive orthognathic surgery candidates with mandibular retrusion were selected for retrospective analysis. Patients had undergone imaging studies that included magnetic resonance imaging (MRI) of both temporomandibular joints to assess the presence or absence, stage, and activity of suspected internal derangement(s). Patients were divided into stable and unstable deformity groups based on the presence or absence of change in their facial contour and/or occlusal disturbances in the 24 months prior to evaluation. Each of the 58 unstable and 30 of 42 stable patients were found to have internal derangements of at least one temporomandibular joint. The degree of joint degeneration directly paralleled the severity of retrognathia in most cases. We concluded that temporomandibular joint internal derangement is common in cases of mandibular retrusion and leads to the facial morphology in a high percentage of patients. Preoperative temporomandibular joint imaging with MRI is recommended prior to orthognathic surgical correction of retrognathic deformities.     

Breast reconstruction in women treated with radiation therapy for breast cancer: cosmesis, complications, and tumor control.

The records of 55 patients who had breast cancer treated by mastectomy, irradiation, and breast reconstruction were reviewed for cosmetic outcome, complications, and tumor control. Median follow-up was 35 months. Local control rates were 95 percent in patients treated for high risk factors or breast conservation and 85 percent in patients treated for recurrent breast cancer. Acceptable cosmetic results were obtained in only 42 percent of patients. The incidence of complications was 55 percent. Transverse rectus abdominis muscle (TRAM) reconstructions gave superior cosmetic results compared with all other types of reconstructions. The timing of reconstruction in relation to mastectomy or radiation therapy did not significantly influence cosmetic outcome, although other factors suggest that delayed reconstruction may give better results. A majority of patients were satisfied with cosmetic outcome.     

Implant prosthetic rehabilitation of the patients with mandibular resection following oral malignoma surgery

Patient underwent mandibular resection due to surgical therapy of oropharingeal malignoma. Facial asymmetry and cosmetic distortion are frequent consequences of such interventions, which may also include deviation and intrusion of the mandible, motor and sensory disorders, abnormal intermaxillary relations and malocclusion. Implant-supported prosthesis could be an optimal solution to prosthodontic treatment of such patients. However, there is a problem in determination of stable (interocclusal) intermaxillary relations. This article describes the choice of therapy and procedures undertaken in prosthetic rehabilitation of a patient who underwent mandibular resection and radiotherapy with supported prosthesis retained with four implants.     

The influence of age,sex, population group,and dentition on the mandibular angle as measured on a South African sample

The mandibular angle is measured in physical anthropological assessments of human remains to possibly assist with the determination of sex and population affinity. The purpose of this investigation was to establish how the mandibular angle changes with age and loss of teeth among the sexes in South African population groups. The angles of 653 dried adult mandibles from the Pretoria Bone Collection were measured with a mandibulometer. Males and females of both South African whites and blacks were included. To compensate for imbalances in numbers among subgroups, type IV ANOVA testing was applied. No association was found between age and angle within either of the populations, within sexes, or within dentition groups. The angle was the most obtuse in individuals without molars and with an uneven distribution of molars, and most acute in the group with an even distribution of molars on both sides. Statistically significant differences (P < 0.001) were found in the angle between the two population groups and sexes in the overall sample as well as in the subgroup with absent molar teeth (P = 0.003 for sex, males more acute angle, and P = 0.001 for population group, blacks more acute angle), although a very large overlap existed. No significant differences could be demonstrated between the sexes or populations within the subgroups with molars. We concluded that the loss of molars, especially if complete or uneven, has a considerable effect on the mandibular angle. In the assessment of human remains, the mandibular angle is not very usable in determining sex. Am J Phys Anthropol, 2009. © 2009 Wiley‐Liss, Inc.     

Breast reconstruction following lumpectomy and irradiation

The traditional approach to breast cancer has been the surgical mastectomy. The cosmetic deformity resulting from this procedure has led to the development of our current methods of breast reconstruction. The inherent attraction of lumpectomy and radiotherapy has been its equation with improved cosmesis. This procedure may be an effective alternative to surgery from the cancer perspective and does produce, in the majority of patients, an acceptable cosmetic result. However, this paper demonstrates that it may produce a result that is less optimal than mastectomy with postoperative breast reconstruction. The etiology of the increased deformity can either be the localized lumpectomy with marked internal derangement of breast volume or the radiation therapy itself. In addition, those who develop a combination require a solution to both. We describe three patients who illustrate these problems and believe that a greater awareness of these potential complications should be available to aid patients in choosing their cancer treatment.     

拔除下颌第三磨牙对下颌角区形态影响的CBCT 研究

目的:探讨下颌第三磨牙的拔除会否造成下颌角区骨骼形态的变化以及这种变化对面型的影响。方法:30例因矫治需要拔除下颌第三磨牙的成人正畸患者,在拔牙前和拔牙后6个月拍摄CBCT片,采用三维测量软件mimics10.01测量下颌第三磨牙所在的下颌角区牙槽骨骨质的宽度、高度和长度,利用SPSS18.0统计软件分析前后数值有无差异。结果:下颌第三磨牙拔除前后下颌角区骨质宽度和高度减小,差异有统计学意义(P<0.05),下颌角区骨质前后向长度未见明显差异。结论:拔除下颌第三磨牙能从一定程度上减小下颌角区骨质高度和宽度,但是前后向长度度基本没有变化。     

Mandibular symphysis of large-bodied hominoids

The hominoid mandibular symphysis has received a great deal of attention from anatomists, human biologists, and paleontologists. Much of this research has focused on functional interpretations of symphyseal shape variation. Here, we examine the two-dimensional cross-sectional shape of the adult mandibular symphysis for 45 humans, 42 chimpanzees, 37 gorillas, and 51 orangutans using eigenshape analysis, an outline-based morphometric approach. Our results demonstrate that a large proportion of the variation described by the first eigenshape correlates with proposed functional adaptations to counteract stresses at the mandibular midline during mastication. Subsequent eigenshapes describe subtle aspects of shape variation in the mandibular symphysis. The morphology associated with these eigenshapes does not conform with functional predictions, nor does it show a relationship with sexual dimorphism. However, eigenshapes provide for considerable taxonomic discrimination between the four taxa studied and may consequently prove useful in the analysis of fossil material. Comparison with elliptical Fourier analysis of the mandibular symphysis identifies eigenshape analysis as providing superior taxonomic discrimination. The results presented here demonstrate that the cross-sectional shape of the mandibular symphysis results from a complex interplay of functional and nonfunctional influences and for the first time identifies and quantifies the specific aspects of variation attributable to these factors.     

中国汉族男性不同年龄阶段面貌特征的编码

推断年龄一直是法医人类学重点研究的内容。目前,最主要的年龄推断方法就是骨龄鉴定,但是成本较高。本文开拓新思路,利用照片推断年龄范围。将面部结构分成上中下三个区域,按区域进行观察和测量。实验选取12项指标,包括8项测量指标和4项观察指标。面部上1/3选取外眼角间距、内眼角间距、额纹和眉弓突出度;面部中间1/3选择容貌上面高、颧间距、鼻宽和鼻翼沟可见度;面部下1/3选择下颌长度、下颌角间距、口裂长度和口周皱褶。每项指标根据程度不同按数量级划分,统计出面部不同区域数字编码组合出现的频率。在面部上1/3处,20岁-组到60岁-组出现频率最高的组合分别为2311、3311、2311、1321和1333;在面中部1/3处,20岁-组到60岁-组出现频率最高的组合分别是1111、2311、2111、1212和3232;在面部下1/3处,20岁-组到60岁-组出现频率最高的组合分别是1111、1111、2211、2331和3332。     

Maxillary advancement for mandibular prognathism: indications and rationale

The surgical correction of mandibular prognathism has traditionally involved posterior repositioning of the mandibular body. This treatment approach corrects the skeletal disproportion at the expense of reducing facial skeletal volume and can unpredictably result in inadequately supported soft tissues with loss of skeletal definition. In an effort to avoid these sequelae of mandibular reduction, 18 patients diagnosed as having mandibular prognathism were treated with maxillary advancement surgery at the Le Fort I level. Mean patient SNB angle was 85.2 degrees, as compared with a normal 79 +/- 3 degrees. Maxillae were documented to be in normal position relative to both cranial base and Frankfort horizontal. The mean maxillary advancement was 6.9 mm, with a range of 4.5 to 8.8 mm. All patients required genioplasty to reduce vertical chin height and/or to laterally shift the chin. At the time of follow-up (mean 16.2 months), all patients retained cephalometric data suggestive of enlarged mandibles and excessive anterior facial divergence. However, maxillomandibular harmony and facial convexity had been restored without sacrificing skeletal volume. Treatment results demonstrated these faces to be skeletally well proportioned despite lower face protrusion that was beyond "normal." Postoperative appearances were characterized by a well-supported soft-tissue envelope and a highlighted skeletal foundation, creating angular, well-defined lower faces. These findings support the credibility of maxillary advancement as the procedure of choice in selected individuals with mandibular prognathism. Indications and an aesthetic rationale for this surgical approach are presented.     

Manipulation of callus after linear distraction: a "lifeboat" or an alternative to multivectorial distraction osteogenesis of the mandible?

Despite impressive results, distraction osteogenesis of the mandible is still compromised by difficulties with vector control. Because of the action of the masticatory muscles, the gonion angle has the tendency to open, resulting in an open bite. We report two patients, aged 10 and 12 years, who developed a severe open bite during mandibular distraction. As a salvage procedure, manual shaping of the soft regenerate was done immediately after distraction. Uneventful bony consolidation was observed, which resulted in anatomically shaped gonion angles. The fact that a regenerate created by distraction osteogenesis can be molded to virtually any shape offers interesting perspectives for the correction of complex mandibular deformities.     

A randomized, evaluator-blind, multicenter comparison of the efficacy and tolerability of Perlane versus Zyplast in the correction of nasolabial folds

Bovine collagen is widely used as a dermal filler for facial soft-tissue augmentation, but it provides only temporary cosmetic improvement. Nonanimal stabilized hyaluronic acid has reduced potential for immunogenicity and hypersensitivity and may provide a more durable aesthetic result. Sixty-eight patients with prominent nasolabial folds were randomized to intradermal treatment with nonanimal stabilized hyaluronic acid gel (Perlane) and bovine collagen (Zyplast) on contralateral sides of the face. On achievement of "optimal cosmetic result" (baseline), patients were followed up for 6 months; bilateral retreatment with Perlane was offered at 6 or 9 months after baseline. Responses were evaluated at 2, 4, 6, 9, and 12 months after baseline. Investigator-based and patient-based ratings indicated that Perlane was more effective than Zyplast in maintaining cosmetic correction. According to investigator-based Wrinkle Severity Rating Scale assessments at 6 and 9 months after baseline, Perlane was superior in 50.0 percent and 48.8 percent of patients, respectively, whereas Zyplast was superior in 10.3 percent and 14.0 percent of patients, respectively (p < 0.0004). Investigator-based Global Aesthetic Improvement Scale assessment at 9 months after baseline indicated that Perlane was superior in 48.8 percent of patients, whereas Zyplast was superior in 14.0 percent of patients (p = 0.0025). "Optimal cosmetic result" was achieved with a smaller volume of Perlane than Zyplast (mean, 1.2 ml versus 2.1 ml). Local injection-site reactions (redness, swelling, pruritus, and induration) were less frequent with Perlane than with Zyplast. Delayed-onset reactions were rare and did not reoccur after Perlane retreatment. Perlane has acceptable long-term safety and offers a longer-lasting aesthetic improvement than Zyplast.     

Multiplane face lift with the subperiosteal dissection for orientals

A subperiosteal face lift rejuvenates the midface and periorbital region by restoring facial muscle tone. Since 1993, the authors have performed this procedure on Oriental patients who have their own distinct facial contours: the brachycephalic cranium and a prominent zygoma and mandibular angle. Although it was thought that these protuberances might disturb the subperiosteal procedure, especially in the anterior midface, the procedure could be performed easily by adopting the ancillary upper buccovestibular and subciliary incisions; the authors found that the protuberances actually act as fulcrums to keep up the lifting vectors reliably. For older patients, the procedure was combined with a deep subcutaneous dissection. A simple lift of the periosteum would not improve a severe nasolabial fold deformity and prominent wrinkles adequately because of "lag-lifting" of the superficial layer. It was concluded that the multiplane face lift, consisting of the subperiosteal and the deep subcutaneous approaches, achieves a natural-appearing rejuvenation of the Oriental aging face.     

Prospective comparison of panoramic tomography (zonography) and helical computed tomography in the diagnosis and operative management of mandibular fractures

This prospective study compared the sensitivity of panoramic tomography (zonography) and helical computed tomography (CT) in diagnosing 73 mandibular fractures in 42 consecutive patients and correlated the results with known surgical findings. The purpose of the study was to determine the optimal radiologic examination for the diagnosis and operative management of mandibular fractures. The attending surgeons' interpretations of panoramic tomograms and helical CT images in the axial plane were compared with the patients' known surgical findings. A series of questions assessed the relative contribution of these two radiologic examinations in formulating an optimal operative plan for each patient. In the 42 patients studied, the sensitivity of helical CT was 100 percent in diagnosing mandibular fractures; this compared with 86 percent (36 of 42) for panoramic tomography, in which significantly more fractures were missed (p = 0.0412). In the six patients with fractures not visualized, the operative management was altered because of the new fracture visualized on helical CT. Of the seven missed fractures, six were in the posterior portion of the mandible. Comparing fracture detection by region, seven fractures found on helical CT were not visualized on panoramic tomography. Helical CT improved the understanding of the nature of mandibular fractures by providing additional information regarding fracture displacement and comminution and by locating injuries missed using panoramic tomography. This study suggests that helical CT alone may be more diagnostic than panoramic tomography alone in evaluating mandibular fractures. Helical CT sufficiently demonstrated details of fractures in 41 of 42 patients; in one patient, the nature of a dental root fracture was better delineated by panoramic tomography.     

Cloning and expression of Ventrhoid, a novel vertebrate homologue of the Drosophila EGF pathway gene rhomboid

In Drosophila melanogaster, the seven-pass transmembrane protein Rhomboid (Rho) is a crucial positive modulator of EGF signaling playing a substantial role in patterning of the ventral neuroectoderm and fate specification of neuroblasts. Here, we describe the cloning and expression pattern of Ventrhoid (Vrho), the novel evolutionarily conserved vertebrate cDNA related to fruit fly rho. Most importantly, like rho in Drosophila, Vrho is also expressed in a spatially restricted manner. Vrho expression is most prominent along the developing ventral neural tube, and is also detectable in the ventral forebrain, prospective diencephalon, otic vesicles, mandibular arches, cranial sensory placodes, last formed pair of somites and hindgut in midgestational mouse embryos.