Aesthetic Deformity Research Articles

Aesthetic Subpectoral Placement of Implantable Cardioverter Defibrillators

The implantable cardioverter defibrillator (ICD) is the treatment of choice for life-threatening arrhythmias. Usually, the device is placed, by a subclavian access, on the upper portion of the pectoralis major muscle. As a result, the visibility of the device and the wide subclavian scar create an important aesthetic deformity, especially in young women, evolving in a relevant psychosocial distress. The authors report their experience with subpectoral ICD implantation. Between January 2001 and December 2011, approximately 30 consecutive female patients underwent submuscular ICD implantation or substitution, performed in collaboration with the cardiology team. No significant complications, except 1 case of wound dehiscence and 2 cases of caudal dislocation of the device, were observed. At 6 and 12 months' follow-up, no significant difference between preoperative and postoperative breast symmetry and volume was noticed. The combined approach aims at reducing the visible signs of the procedure and improving the psychological outcomes.

Zastosowanie propranololu w leczeniu naczyniaków dziecięcych

Infantile hemangiomas are the most common benign tumours in children. Although most hemangiomas can regress spontaneously in early childhood, some of them require treatment due to ulceration, bleeding, aesthetic deformity or impaired functions such as breathing or vision. Propranolol, a nonselective β-blocker, is currently first line therapy for treatment of head and neck hemangiomas that cause functional defects or significant disfigurement. The exact mechanism of propranolol action in hemangiomas treatment remains unclear. This paper presents review of current knowledge on propranolol in the treatment of infantile hemangiomas.

Fronto-orbital bone fracture: management and outcome

ObjectiveThe aim of this study was to review the effect of early and late surgical intervention and armamentarium used on the functional and esthetic outcome of fronto-orbital fracture repair.BackgroundOrbital roof fractures represent an important group of orbital fractures because of their close relation to the frontal lobe of the brain and also because of their relation to the eye. Management of orbital roof fractures requires good assessment, early reconstruction, if possible, and team management. Functional and esthetic outcomes should be assessed.Patients and methodsTwelve patients with orbital roof and frontal bone fractures were included in this study. Surgical treatment included open bone reduction alone, open reduction with fixation, and/or orbital reconstruction. Postoperative assessment of functional ocular deformities (limited eye movement and diplobia) and esthetic deformities (enophthalmos, dystopia, and proptosis) was carried out. Radiologic assessment for bone reduction and orbital volume was carried out.ResultsAll patients were males. They ranged in age from 16 to 61 years. Road traffic accidents were the cause of trauma in about 67% of patients. Early intervention was performed in 50% of patients, with 100% correction of functional deformities, 90% correction of esthetic deformities and accurate bone reduction in 95% of cases, and good patient satisfaction in 85% of cases. This was much better than late intervention. Titanium mesh was used in 50% of the cases, with accurate orbital volume reduction in 90% of the cases, which was only 50% with bone graft use.ConclusionEarly management of orbital roof and frontal bone fractures yields the best results. The use of titanium mesh leads to good functional and esthetic outcomes, with no donor-site morbidity, and saves time.

Clinical Application of the FACES Score for Face Transplantation

This study aimed to systematically evaluate all reported outcomes of facial allotransplantation (FT) using the previously described FACES scoring instrument. This was a retrospective study of all consecutive face transplants to date (January 2012). Candidates were identified using medical and general internet database searches. Medical literature and media reports were reviewed for details regarding demographic, operative, anatomic, and psychosocial data, which were then used to formulate FACES scores. Pre-transplant and post-transplant scores for "functional status", "aesthetic deformity", "co-morbidities", "exposed tissue", and "surgical history" were calculated. Scores were statistically compared using paired-samples analyses. Twenty consecutive patients were identified, with 18 surviving recipients. The sample was composed of 3 females and 17 males, with a mean age of 35.0 ± 11.0 years (range: 19-57 years). Overall, data reporting for functional parameters was poor. Six subjects had complete pre-transplant and post-transplant data available for all 5 FACES domains. The mean pre-transplant FACES score was 33.5 ± 8.8 (range: 23-44); the mean post-transplant score was 21.5 ± 5.9 (range: 14-32) and was statistically significantly lower than the pre-transplant score (P = 0.02). Among the individual domains, FT conferred a statistically significant improvement in aesthetic defect scores and exposed tissue scores (P ≤ 0.01) while, at the same time, it displayed no significant increases in co-morbidity (P = 0.17). There is a significant deficiency in functional outcome reports thus far. Moreover, FT resulted in improved overall FACES score, with the most dramatic improvements noted in aesthetic defect and exposed tissue scores.

Lower Lateral Crural Reverse Plasty

The lateral crus plays a significant role in the aesthetic appearance of the nose. Excessive concavities of the lower lateral crura can lead to heavy aesthetic disfigurement of the nasal tip and to insufficiencies of the external nasal valve. The lateral crus of the alar cartilage may also cause a concavity of the alar rim and even collapse of the alar rim in severe cases. Surgical techniques performed on the lateral crus help to treat both functional and aesthetic deformities of the lateral nasal tip. We present a reverse plasty technique for the lateral crus, and we evaluated the advantages and disadvantages of the technique.

The formetric TRACER index: a valid measure of aesthetic deformity in adolescent idiopathic scoliosis

Background The gold standard of scoliosis evaluation-Cobb angle measurement-is a valuable tool for assessing spinal deformity and making therapeutic decisions [1,2] but is not fully able to describe the trunk deformity (aesthetics), which is a main concern of patients. Posture, deformity of other bones and soft tissues could be other determinants of the aesthetic impairment due to scoliosis. We do not currently have a commonly accepted measurement of aesthetic impairment due to scoliosis. Purpose The goal of this study was to find a parametric measure to describe aesthetic impairment due to scoliosis. Design: Cross-sectional study. Population: 119 adolescent idiopathic scoliosis (AIS) patients (10.0% males, age 13.9±2.3, 25.4±10.9° Cobb). The sample was randomly divided into two subgroups. Methods Repeated formetric evaluations and simultaneous pictures of the back were performed. An online questionnaire with the photos was completed by 41 laypeople with no scoliosis experience (53.6% males, age 30.3±13.3), who judged the photos on a 0-3 Likert scale (0 normal, 3 highly asymmetric). Statistics: On the first subgroup, we performed a stepwise forward regression technique considering as dependent variable the median of the results of the questionnaire, and as independent variable formetric, clinical and radiological parameters. On the second group, we checked the correlation between the index found (TRACER) and the median of the results of the questionnaire (Spearman’s Rho). Finally, we checked the test-retest repeatability (Spearman’s Rho), concurrent (Spearman’s Rho) and diagnostic (T-test) validity of the index we found. Results The following formula was found: TRACER= [0.726+ (CobbMax*0,018)+(SurfaceRotation*0.037)]/3*100. This TRACER index (0-100) was well-correlated (Rho=0.414, p<0.01) with the median of the questionnaire results in the second group; it was also highly repeatable (Rho=0.922), strongly correlated to Cobb degrees (Rho=0.838), mildly correlated to TRACE index [3] (Rho=0.376) and distinguished pathological and healthy subjects (p<0.01). Conclusions and discussion The TRACER index could be used to measure aesthetic deformity in AIS patients; however, further studies are needed to investigate its role in the conservative and surgical treatment of scoliosis.

Restoration of Gingival and Esthetic Deformities Following Flap Advancement: The Physiologically Pigmented Gingival Graft—A Case Report

The coronal advancement of surgical flaps and subsequent shift of the mucogingival junction during bone augmentation procedures are common. These mucogingival alterations may become a challenge to manage in the maxillary anterior region among patients with a high lip line upon smiling or high esthetic demands. To further complicate matters, the presence of physiologic gingival pigmentation in the esthetic zone creates challenges of its own. In this case, a free gingival graft from the buccal gingiva of the maxillary molars was used to correct the mucogingival deformity created from a guided bone regeneration procedure.

Aesthetic Analysis of an Implant-Supported Denture at the Cleft Area

Objective : To evaluate the aesthetics of an implant-supported denture at the cleft area, comparing the peri-implant tissues and prosthetic crown with the contralateral tooth. Settings : Hospital for Rehabilitation of Craniofacial Anomalies, Bauru, São Paolo, Brazil. Patients : A total of 39 individuals of both genders, with complete unilateral cleft lip and palate, who received secondary alveolar bone graft and were rehabilitated with single implant-supported dentures at the area of the missing maxillary lateral incisor after completion of orthodontic treatment. Interventions : The following parameters were analyzed in follow-up sessions: length and width of prosthetic crown and contralateral tooth, characteristics of implants, filling of interproximal space by the papilla, and smile height of the patients. Results : The implant-supported prosthetic crowns were longer than the contralateral tooth (p < .001). Among the 78 papillae analyzed, 29 (37.17%) received a score of 3; 32 (41.02%) papillae had a score of 2; and 17 (21.79%) received a score of 1. Concerning the smile height, among the 39 patients analyzed, 23 (56.41%) had a medium smile, 15 (38.46%) had a high smile, and two (5.12%) presented a low smile. Conclusion : The use of dental implants to rehabilitate the edentulous cleft area is an excellent option. However, adequate evaluation of the bone quantity and quality, positioning and shape of adjacent teeth, smile height, and patient expectations should be considered to achieve success and avoid aesthetic deformities such as elongated teeth and absence of gingival papillae.

Touraine Solente Gole syndrome: The elephant skin disease

Touraine Solente Gole syndrome is a rare hereditary syndrome of primary pachydermoperiostosis, with the characteristic triad of pachydermia (or elephant like skin), periostosis and acropachia. A 27-year-old patient presented with aesthetic deformity of forehead due to deep skin folds and coarsening of facial features due to progressive thickening of skin. Associated palmoplantar hyperkeratosis with broadened of finger and toe tips and digital clubbing were noticed. Dermatologic evaluation revealed cutis verticis gyrata of scalp, seborrhoeic hyperplasia of face and hyperhidrosis. Natural history of the disease and aetiopathogenesis were reviewed. Aesthetic correction of forehead through frontal rhytidectomy was attempted.

Letter to the Editor Madelung’s disease in a patient with chronic alcohol abuse

A 47-year-old man with a history of chronic alcohol abuse was admitted to our hospital because of symmetrical face soft tissue enlargement for differential diagnosis. The lesions had appeared 4 years earlier and had been asymptomatic. Physical examination revealed painless, elastic tumors of the subcutaneous tissue in the mandibular angle region, with no clear relation to lymph nodes or salivary glands (Figure 1A). The laboratory tests showed elevated aspartate aminotransferase (ALT), 127 U/l; elevated alanine aminotransferase (ALT), 91 U/l, elevated γ-glutamyl transpeptidase (GGT), 643 U/l, and elevated lactate dehydrogenase (LDH) activity, 342 U/l. Test for antinuclear antibodies (ANA) was negative. HIV and HCV infections were excluded. Lipid profile results were within the normal range. An abdominal ultrasound revealed a fatty liver, but no other abnormality was noted. Ultrasonography of the parotid, submandibular and cervical region confirmed the correct size and structure of the salivary and thyroid glands and slight enlargement of the lymph nodes in both submandibular regions. In the place of visible symmetric thickening there was a tissue described as lipofibroma, 49 mm × 24 mm on the right side and 44 mm × 23 mm in size on the left side. Fine-needle biopsy revealed lipomatous tissue. A diagnosis of Madelung's disease was made. Figure 1 A – Frontal view of the patient at time of first hospitalization with visible symmetrical fatty masses. B, C – Frontal and lateral view of the patient at follow-up visit after 1 year; increase in the primary fatty deposit At the follow-up visit after 1 year, the patient had a computed tomography (CT) scan performed, which showed a slight increase in the primary fatty deposit and the appearance of another in the neck area (Figure 2A–C). Six months later the patient was disqualified from surgical treatment. The decision was motivated by the non-life-threatening condition and asymptomatic nature of the masses. Figure 2A–C Head and neck CT showing the symmetrical enhancement of the lipomatous tissue Madelung's disease (also known as benign symmetric lipomatosis or Launois-Bensaude syndrome) is a rare metabolic disorder of unknown etiology [1]. This disease usually affects men at the age of 30 to 60 years from the Mediterranean area. In reported cases, almost 90% of patients had a history of long-term alcohol abuse [2]. The disease is characterized by the presence of prominent, symmetrical deposits of non-encapsulated adipose tissue in the region of head, neck, nape and upper parts of the trunk [2, 3]. In contrast to other cases described in the literature, in our patient, the primary subcutaneous fat masses appeared in the parotid region, while the most common initial location is the neck. Although benign in nature, sometimes the fatty masses can reach very large sizes causing dyspnea, dysphagia, fatigue, and reduced neck movement ability [4]. The differential diagnosis includes familial multiple lipomatosis, simple obesity, Cushing's syndrome, angiolipoma, neurofibroma and liposarcoma [2, 4, 5]. The most effective treatment is surgery, especially in patients with esthetic deformity or compression of the aerodigestive tract [1, 3].

The Reconstruction of the Spheno-Orbital Region Using Latissimus Dorsi Flap and Costal Graft

To minimize complications in skull base surgery, it is necessary to separate intracranial structures from the upper aerodigestive tract with well-vascularized tissue. The majority of defects can be reconstructed using local flaps using pericranium, galea, or temporalis muscle. However, there are conditions that affect the suitability of the previously mentioned flaps, for example, previous surgical procedures or radiotherapy. Local flaps may also be inadequate to reconstruct particularly large defects. Extensive bony demolitions produce aesthetic deformities that need accurate reconstructions. Orbital wall defects have to be reconstructed to avoid complications such as the transmission of cerebral pulsation, bulbar dystopias, diplopia, and ophthalmoplegia. The microvascular latissimus dorsi flap is ideal in all these cases, and the use of a costal graft allows simultaneous reconstruction of bony defects. From January 2000 to January 2008, 17 patients have undergone surgical ablation of the spheno-orbital region and reconstruction with latissimus dorsi flap and costal grafts. The flap survival rate was 100%. One patient required revision of the venous anastomosis. No cerebrospinal fluid leak or intracranial infections have been detected. The only complications registered were dystopias in 6 patients and diplopia in 4; all of these spontaneously resolved within 2 months. The microvascular latissimus dorsi flap with costal graft is an effective method for the reconstruction of the spheno-orbital region when local flaps are not indicated. It has a negligible donor-site morbidity, an ideal vascular pedicle, and an easy harvesting technique. The costal graft allows the simultaneous reconstruction of the orbital walls, giving good results.

Aesthetic correction of isolated congenital absence of nasal lower lateral cartilages

Isolated congenital nasal anomalies that cause remarkable aesthetic deformities are extremely rare, and only a few cases have been reported in the literature. In this study, we present the case of a patient with nonsyndromic congenital isolated absence of the nasal lower lateral cartilage and the subsequent esthetic surgical correction. A satisfactory result was achieved.

Laser-assisted lipolysis for cankle remodelling: a prospective study in 30 patients

Cankles refer to the area where the calf and ankle meet. Unaesthetic fat cankles, where definition between the calf and ankle is impossible, are a frustrating aesthetic deformity, which are exacerbated by their genetic conditioning and special resistance to diet. This article reports our experience with laser-assisted lipolysis (LAL) in cankle remodelling. A total of 30 patients were treated for unaesthetic fat cankles with LAL. The 924/975-nm diode laser used in this study consisted of two lasers, one emitting at 924 nm, and the other at 975 nm. According to our mathematical models, we assumed that to destroy 1 ml of fat, 0.1 kJ was required in dual emission mode at 924/975 nm. Patients were asked to file a satisfaction questionnaire. Ultrasound was used to measure the fat thickness pre- and postoperatively. Oedema in both lateral sulcus of the Achilles tendon was seen in all patients. It subsided after 4 weeks in nine cases and 6 weeks in 21 cases. Only two patients developed mild hyperpigmentation that disappeared, respectively, after 4 and 10 weeks. Pain during the anaesthesia and discomfort after the procedure were low with this technique. Mean down time was 1.0 day. Of the 30 patients, 29 would recommend this treatment. Overall, high patient and investigator satisfaction was confirmed by the sonography used to measure decrease in fat thickness. LAL in cankle remodelling is a safe and reproducible technique that is particularly appreciated by the patient. The procedure allows homogenous reduction of fatty tissue together with skin tightening.

Management of frontal sinus fractures: A review of the literature

Aim: The aim of this paper is to conduct a literature review on the clinical anatomy of the frontal sinus as it relates to its implication in frontal sinus fractures (FSFs), as well as review the contemporary opinions on the management of these fractures. Materials and Methods: A computerized literature search of PubMed and Medline was conducted for publications on the clinical anatomy and management of FSFs. Search phrases were frontal sinus combined with management, treatment, and anatomy. The Boolean operator 'AND' was used to narrow the searches. Result: FSFs account for 5-15% of all maxillofacial injuries and are associated with 32% of panfacial and maxillary injuries. The FSFs may result from high-velocity impacts, such as motor vehicle accidents and assaults; blunt or penetrating force. The potential for intracranial injuries, esthetic deformities, and late mucocele formation is high. The treatment goals of FSFs are an accurate diagnosis, avoidance of short- and long-term complications, return of normal sinus function, and re-establishment of the premorbid facial contour. Recently, several treatment protocol with greater emphasis on the nasofrontal outflow tract (NFOT) injury are described in the literature, however, controversies still abound on effectiveness of these protocols in reducing the attending complications. Conclusion: The management of FSFs presents a unique and challenging problem for the contemporary surgeons. A clear understanding of corrective techniques is essential when approaching these challenging injuries. Each treatment method has its advocates, and controversies still abound regarding indications, applications, and ultimate success in given situations.

Atraumatic surgical extrusion using periotome in esthetic zone: A case series

Several techniques have been proposed for clinical crown lengthening procedures. Crown lengthening in esthetic zone can be classified in two basic types: Restorative and non-restorative cases after the crown lengthening is executed.Atraumatic surgical extrusion using a specially designed instrument called periotome was performed in four cases on isolated teeth in esthetic zone.The technique presented is an alternative approach to periodontal surgical procedures consisting orthodontic extrusion and osseous recontouring. It does not result in functional or esthetic deformities especially in the anterior esthetic zone.

Two-Stage Total Prosthetic Reconstruction of Temporomandibular Joint in Severe and Recurrent Ankylosis

Temporomandibular joint ankylosis is a devastating condition for the patient associated with both functional disability and aesthetic deformities. Various techniques have been described in the literature to overcome this problem; however, there is still a high risk of reankylosis in patients undergoing multiple temporomandibular joint operations, severe heterotopic ossification, and fibrosis of the soft tissues. This study includes 5 patients with severe and recurrent ankylosis. Two-stage reconstruction with excision of the bony mass and placement of a distraction device in the first stage, followed by gradual distraction of soft tissues, and placement of a total joint prosthesis in the second stage were performed in all patients. The 2-step approach helps to overcome the fibrosis and adhesions in the soft tissues and allows placing an implant with a higher ramus component. This approach seems to be a useful and effective technique for the management of such patients with high risk of reankylosis.

Combined prosthetic incisional hernioplasty and panniculectomy—a 5-year single-centre experience

Ventral incisional hernia patients develop limitation in physical activities as the hernia enlarges, leading to alteration in their lifestyle, quality of life, aesthetic deformities, and occasionally to complications. Cosmetic improvement of the abdomen, an important objective of hernia repair, can be achieved when hernia repair is combined with panniculectomy. The authors undertook this study to review their experience of the integration of hernia repair and panniculectomy to improve the understanding and treatment of this condition. A retrospective analysis of the records of patients who underwent abdominal hernia repair with panniculectomy from 2005 to 2010 was undertaken. The records were reviewed for patient demographics, hernia etiology, risk factors for recurrence, previous surgeries, previous approach, type of repair, incision approach, complications, length of hospital stay, and duration of follow-up. Surgical management included mesh hernia repair and pannus excision. Of the total 45 patients, mean age was 42.37 years and mean follow-up was 24.4 months. Twelve patients had recurrent hernias. Most of the patients underwent retrorectus underlay mesh repair [39 (86.67 %)], while 6 (13.33 %) underwent onlay mesh technique. Six (13.33 %) patients developed minor skin necrosis, while one (2.22 %) had skin flap necrosis requiring debridement and skin grafting, three (6.67 %) hernias recurred, one (2.22 %) had seroma formation, and one (2.22 %) developed sacral pressure sore. This technique provides both functional and aesthetic benefits and generally meets the needs of the patients. It is safe, with a low risk of postoperative complications. Level of Evidence: Level IV, therapeutic study.

Mise au point sur le traitement de l’hémangiome du nourrisson par bêta-bloquant

Hemangiomas are benign tumors most commonly encountered in infancy and early childhood. While most of them regress spontaneously, some require treatment due to a significant proliferation, which may be complicated by ulceration, deformation aesthetic deformation or worse impairment vital. Among the treatments used corticosteroids is the standard treatment but its use in high doses expose to potential risks. In 2008, the discovery by "chance" of the effectiveness of propranolol in the management of hemangioma revolutionizes the first line treatment. Its mechanism of action is not yet well understood and establishment of such treatment should be done by a hospital paediatrician in the absence of any contraindications. This article proposes focus on effectiveness and tolerance of β-blockers used as treatment of infantile hemangiomas.

Laser-assisted lipolysis for knee remodelling: A prospective study in 30 patients

Background: Unsightly fat knees are a frustrating aesthetic deformity exacerbated by genetic predisposition and resistance to diet. This article reports our experience with laser-assisted lipolysis (LAL) in knee remodelling. Methods: A total of 30 patients were treated for unsightly fat knees with LAL. The 924/975-nm diode laser used in this study consists of two lasers, one emitting at 924 nm and another at 975 nm. Previous mathematical modelling suggested that 0.1 kJ was required in order to destroy 1 ml of fat, in dual emission mode at 924/975 nm. Patients were asked to fill out a satisfaction questionnaire. Ultrasound was used to measure the fat thickness pre-and post-operatively. Results: Other than one patient who developed mild hyperpigmentation that disappeared after 2 months, there were no complications in the series. Pain during the anaesthesia and discomfort after the procedure were minimal. Return to normal activities never took longer than 2 days and mean downtime was 0.92 days. Of the 30 patients, 29 would recommend this treatment. Overall satisfaction was high with both patients and investigators and was validated by ultrasound measurements demonstrating a systematic decrease in fat thickness. Conclusion: LAL in knee remodelling is a safe and reproducible technique, particularly appreciated by patients. The procedure allows for a reduction in the amount of adipose deposits while providing concurrent skin contraction.

Full-mouth rehabilitation of a patient with severe attrition using the Hobo twin-stage procedure

Excessive occlusal wear can result in pulpal injury, occlusal disharmony, impaired function and aesthetic deformity. Loss of anterior guidance can result from severe wear of anterior teeth, which protects the posterior teeth during excursive movement. The collapse of posterior teeth also results in the loss of normal occlusal plane and the reduction of the vertical dimension. This clinical report describes the use of the Hobo twin-stage procedure for rehabilitation of a patient with severe tooth wear, resulting in reduced vertical dimension of occlusion.