Depression Deformity Research Articles

Comparative analysis of free SMAS fold flap and ADM in facial depression after parotidectomy

BackgroundThis study aimed to analyze the effects of anterior descending mandible (ADM) and free superior mesenteric artery (SMAS) folding flaps on post-parotidectomy facial depression.MethodsThis retrospective study examined the effects of sex, age, surgical sample size, method, duration, and blood loss on postoperative complications in 65 patients.ResultsNo significant differences involving sex, age, or sample size for surgical resection were observed between the two groups. The incidence of Frey syndrome (P = 0.175) and the locations of facial nerve injuries and tumors were not significantly different between the two groups. However, a statistically significant difference was observed in postoperative facial depression between the groups (P = 0.045, P < 0.05). No significant difference was found between facial nerve injury and Frey’s sign in subgroup analysis of facial depression deformities. Within the facial depression group, tumor locations were significantly different (P = 0.021, P < 0.05). In the cases of facial depression after partial parotid resection, no significant difference was observed between ADM implantation and SMAS flap placement. A significant difference was noted between the ADM implantation and SMAS flap groups in the total parotidectomy group (P = 0.046 and P < 0.05, respectively).ConclusionWomen are more likely to experience facial depression after parotid surgery. Facial depression is most likely to occur after parotid resection if the tumor is located in the deep lobes of the parotid gland. The use of SMAS flaps can prevent facial depression, and both ADM and SMAS flaps can prevent Frey’s syndrome. Partial parotid resection reduces the risk of facial nerve injury and facial depression.

Effectiveness comparison of open reduction and hook plate fixation versus closed indirect reduction and dorsal extension blocking Kirschner wire fixation for bony mallet finger

To compare the effectiveness of open reduction and hook plate fixation versus closed indirect reduction and dorsal extension blocking Kirschner wire fixation for bony mallet fingers. The clinical data of 68 patients with bony mallet finger who admitted between May 2019 and June 2022 were retrospectively analyzed. Among them, 33 cases were in the open group (treated with open reduction and hook plate fixation) and 35 cases were in the closed group (treated with closed indirect reduction and dorsal extension blocking Kirschner wire fixation). There was no significant difference between the two groups in terms of gender, age, the affected side, the affected finger, cause of injury, time from injury to operation, and Wehbé-Schneider classification ( P>0.05). The operation time, intraoperative fluoroscopy frequency, fracture healing time, time of returning to work, and postoperative complications were recorded and compared between the two groups. At 12 months after operation, visual analogue scale (VAS) score was used to assess the pain of the injured finger, active flexion range of motion and extension deficit of the distal interphalangeal joint (DIP) were measured by goniometer, and the effectiveness was assessed by Crawford criteria. All patients in the two groups were followed up 12-26 months, with an average of 15 months. There was no significant difference in the follow-up time between the closed group and the open group ( P>0.05). The operation time in the closed group was shorter than that in the open group, and the intraoperative fluoroscopy times, the fracture healing time, and the time of returning to work in the closed group were more than those in the open group, and the differences were significant ( P<0.05). In the closed group, there were 5 cases of pinning tract infection and 3 cases of small area pressure ulcer skin necrosis on the dorsal side of the finger, which were cured after intensive nursing and dressing change. Local nail depression deformity occurred in 7 cases in the open group, and the deformity disappeared after removal of plate. The incisions of the other patients healed uneventfully without complications such as infection, skin necrosis, exposure of the internal fixation, or nail deformity. There was no significant difference in the incidence of skin necrosis between the two groups ( P>0.05), but the differences in the incidence of infection and nail deformity between the two groups were significant ( P<0.05). There was no significant difference in VAS score, DIP active flexion range of motion, DIP extension deficiency, or Crawford criteria evaluation between the two groups at 12 months after operation ( P>0.05). At last follow-up, there was no DIP osteoarthritis and joint degeneration in both groups. Open reduction and hook plate fixation versus closed indirect reduction and dorsal extension blocking Kirschner wire fixation have their own advantages and disadvantages, but both of them have good results in the treatment of bony mallet fingers. Open reduction and hook plate fixation is recommended for young patients with bony mallet fingers who are eager to return to work.

Poster 326: Near Complete Quadriceps Tendon Healing 2 Years Following Harvest in Anterior Cruciate Ligament Reconstruction

Objectives: The quadriceps tendon (QT) autograft has garnered popularity for anterior cruciate ligament (ACL) reconstruction (ACLR) in the last decade. However, as with other autograft choices, re-ruptures of QT autografts can occur especially in high-level athletes, with reported rates ranging from 2%-22%. ACL revision surgery is an option for these athletes, but it can be difficult for surgeons to decide what type of graft to select. Numerous studies have examined postoperative morphologic changes in the PT, and suggest the postoperative PT was thicker than the contralateral tendon at least 2 years postoperatively. However, there is a paucity of literature on postoperative morphologic changes in the QT, and the possibility of re-harvesting the QT remains unknown. Therefore, the purpose of this study was to reveal the postoperative morphologic changes in the QT harvest site at a minimum of 2 years following ACLR. The hypothesis was that the postoperative QT would remain the same in width but increase in thickness. Methods: Patients who underwent primary ACLR using QT autograft in our institution between January 2014 and March 2021 were retrospectively reviewed. Patients under 14 years of age and patients undergoing concomitant osteotomy, multi-ligament surgery, or ACL revision were excluded. Out of 493 patients meeting inclusion criteria, 30 patients who underwent magnetic resonance imaging (MRI) at a minimum of 2 years following ACLR were studied. The anterior-posterior (A-P) thickness, medial-lateral (M-L) width, and cross-sectional area (CSA) were measured at 5 mm, 15 mm, and 30 mm proximal to the superior pole of the patella (Figure 1). Since the axial plane was not perpendicular to the long axis of the QT, the CSA was adjusted by the angle between the QT and the plane of the axial cut based on a cosine function (adjusted CSA). Moreover, to obtain the signal/noise quotient (SNQ) of regions of interest (ROI) of the QT, the signal intensity of ROI with 10 mm2 was measured on the QT at 5 mm, 15 mm, and 30 mm proximal to the superior pole of the patella, the center of the PT, and the background on the same sagittal plane. SNQ of the QT was calculated using the following equation: SNQ = (mean signal value of the QT – mean signal value of the PT) / mean signal value of the background. In addition, the existence of defect or scar tissue formation at the harvest site was investigated by reviewing postoperative MRI. A defect was defined as a depression deformity at the harvest site, while a scar tissue formation was defined as a change in iso- to high-intensity signal at the harvested site on a fat suppression T2-weighted images compared to the preoperative tendon. To compare the A-P thickness, M-L width, adjusted CSA, and SNQ values between pre- and post-operative states, a Wilcoxon signed-rank test or paired t-test were used for non-normally and normally distributed data, respectively. Statistical significance was set at P &lt; 0.05. Results: Following all exclusion criteria, a total of 30 patients (mean age, 20.7 ± 5.5 years, 66.7% male) were included. The mean duration between primary ACLR and postoperative MRI was 2.8 ± 1.1 years. The axial plane of QTs at 30 mm proximal to the patella was included on both pre- and postoperative MRI in 8 patients. Compared with pre-surgery, the A-P thickness of the postoperative QT donor site was increased by 10.3% at 5 mm (8.7 ± 1.4 mm vs. 9.6 ± 1.6 mm, P &lt; 0.01), and 11.9% at 15 mm proximal to the patella (8.4 ± 1.1 mm vs. 9.4 ± 1.8 mm, P &lt; 0.05). Meanwhile, the M-L width was decreased by 7.3% at 5 mm (52.2 ± 6.9 mm vs. 48.4 ± 7.5 mm, P &lt; 0.01), and 6.5% at 15 mm proximal to the patella (43.0 ± 8.4 mm vs. 40.2 ± 8.0 mm, P &lt; 0.01). No difference in the CSA of the QT at each assessment location was observed between pre- and post-operative states. The SNQ of the QT was not significantly changed postoperatively at each assessment location (Figure 2). Defect and scar formation at the harvest site was observed in 4 (13.3%) cases, and 5 (16.6%) cases, respectively. Conclusions: At a minimum of 2 years following ACLR, the QT became slightly thicker and narrower, and defects or scar tissue formation were observed in only 30% of cases at the harvest site. Harvest thickness did not affect the postoperative morphologic change of the QT. Given the nearly normalized tendon morphology and post-surgical SNQ of the QT similar to pre-surgical state, re-harvesting the QT may be possible. [Figure: see text][Figure: see text]

Simultaneous Vertical Mastopexy During Aquafilling Removal: An Effective Way to Reshape the Breast with Ptosis.

Aquafilling was used to be a popular breast filler and was banned due to increasing reports of complications. Debridement surgery is the only available approach to treat complications caused by gel fillers, but it often leads to breast deformity and skin laxity. This study aims to present a new surgical strategy to reshape the breast immediately after Aquafilling removal. Twelve patients who underwent Aquafilling removal at our institution were included, with five patients receiving the combined vertical mastopexy in group I and seven patients receiving Aquafilling removal alone in group II. Surgical data, complications and satisfaction were compared between the two groups. Satisfaction was assessed by using the BREAST-Q at least 6months after surgery. The age range of the 12 patients was 41-56years. Although the duration of surgery in group I was longer than that in group II (p = 0.011), the drainage duration and postoperative hospitalization between the two groups were comparable. All patients recovered well. Scarring was the only complication in group I, but there was no difference compared to group II (p = 0.711). Group II had a significantly higher incidence of postoperative depression deformity than group I (p = 0.008). Regarding satisfaction, patients in group I had significantly higher scores in satisfaction with breasts, psychosocial well-being and sexual well-being than those in group II. Combining Aquafilling removal with vertical mastopexy is an effective method of reshaping the shape of the ptotic breasts, offering superior esthetic outcomes without delaying postoperative recovery or increasing the risk of complications. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Wang procedure for secondary thoracic deformity after simultaneous operation of sternal cleft with congenital heart disease

Sternal cleft is a rare thoracic deformity, often associated with congenital heart disease, which requires simultaneous treatment. There are many methods for treatment of sternal cleft, the early effect may be satisfactory, but the late effect is rarely reported. We performed a simultaneous operation on a patient with sternal cleft and ventricular septal defect, but the patient developed secondary depression deformity after the operation. We used Wang procedure to correct it and got satisfactory results.

Clinical application of microdissected thin thoracodorsal artery perforator flaps for repair of diabetic foot ulcers

To explore the effectiveness of microdissected thin thoracodorsal arterial perforator flap (TDAP) in repairing diabetic foot ulcers (DFUs). The clinical data of 11 patients with DFUs admitted between March 2020 and February 2021 were retrospectively analyzed, including 5 males and 6 females, aged from 22 to 67 years, with an average of 49.3 years. There were 10 cases of type 2 diabetes and 1 case of type 1 diabetes; the duration of diabetes ranged from 3 months to 25 years (median, 8 months). The duration of DFUs ranged from 6 days to 120 months (median, 1 month). There were 6 cases of grade 3 and 5 cases of grade 4 according to Wagner classification. The tissue necrosis and purulent secretions were found in all ulcer wounds, as well as different degrees of tendon and bone exposure; skin defects ranged from 5 cm×3 cm to 17 cm×6 cm. The DFUs were repaired by microdissected thin TDAP, including 6 cases of flaps (including 1 case of lobulated flap), ranging from 10.0 cm×4.5 cm to 26.0 cm×7.0 cm; 5 cases of chimeric perforator flaps, the range of the flap was 10.0 cm×4.5 cm to 16.0 cm×5.5 cm, and the range of the muscle flap was 6 cm×2 cm to 10 cm×3 cm. The donor site was sutured directly. The operation time ranged from 3.42 to 11.17 hours, with an average of 5.92 hours. All 11 flaps survived and no vascular crisis occurred; 1 patient had a sinus at the edge of the flap, and the surgical area healed well after dressing change. All 11 patients were followed up 6-12 months, with an average of 9 months. The flap texture was good, the recipient site was in good shape, and there was no swelling; the foot contour was good, the shoes were comfortable to wear, and the movement was good. The incision at the donor site healed by first intention, leaving only linear and concealed scar, without obvious depression deformity, and the shoulder joint function was good. On the premise of ensuring sufficient blood supply to the lower extremities and strengthening perioperative management, the microdissected thin TDAP to repair DFUs wounds can achieve better effectiveness and appearance; however, the prolonged operation time increases the probability of anesthesia and surgical risks in patients with DFUs.

Groove chest: An independent thoracic deformity

Thoracic deformity can be roughly divided into two categories, one is depression deformity the other is protrusion deformity. In general, depression deformity is called pectus excavatum. In the era of open surgery, there is no big problem with this nomenclature. However, in the era of minimally invasive surgery, because the general minimally invasive surgery cannot be used to treat some depression deformities, it is necessary to further classify these deformities. After a long time observations, we found that there was a type of deformity with distinct characteristics, which was the transverse groove in the anterior chest wall, and was significantly different from the hollow of the typical pectus excavatum. This deformity cannot be corrected with standard Nuss procedure. In order to better understand and treat this special deformity, we named it groove chest. We also made a special design for its operation, and finally designed an effective surgical method. Our experience shows that the surgery we designed is an effective technique, which also proves the necessity of treating groove chest as an independent deformity.

Application of Wenlin procedure in the treatment of thoracic deformity

Wenlin procedure is a minimally invasive surgery designed for pectus carinatum, which is similar to Abramson procedure to a certain extent, but their natures are completely different. Wenlin procedure is a typical template plastic surgery. This nature makes it possible to be used not only in protrusion deformities such as pectus carinatum, but also in a variety of complex deformities including depression deformities. With the progress of the concept of deformity treatment, the role of Wenlin procedure will become more and more significant.

Fat Graft with Allograft Adipose Matrix and Magnesium Hydroxide-Incorporated PLGA Microspheres for Effective Soft Tissue Reconstruction.

Autologous fat grafting is one of the most common procedures used in plastic surgery to correct soft tissue deficiency or depression deformity. However, its clinical outcomes are often suboptimal, and lack of metabolic and architectural support at recipient sites affect fat survival leading to complications such as cyst formation, calcification. Extracellular matrix-based scaffolds, such as allograft adipose matrix (AAM) and poly(lactic-co-glycolic) acid (PLGA), have shown exceptional clinical promise as regenerative scaffolds. Magnesium hydroxide (MH), an alkaline ceramic, has attracted attention as a potential additive to improve biocompatibility. We attempted to combine fat graft with regenerative scaffolds and analyzed the changes and viability of injected fat graft in relation to the effects of injectable natural, and synthetic (PLGA/MH microsphere) biomaterials. In vitro cell cytotoxicity, angiogenesis of the scaffolds, and wound healing were evaluated using human dermal fibroblast cells. Subcutaneous soft-tissue integration of harvested fat tissue was investigated in vivo in nude mouse with random fat transfer protocol Fat integrity and angiogenesis were identified by qRT-PCR and immunohistochemistry. In vitro cell cytotoxicity was not observed both in AAM and PLGA/MH with human dermal fibroblast. PLGA/MH and AAM showed excellent wound healing effect. In vivo, the AAM and PLGA/MH retained volume compared to that in the only fat group. And the PLGA/MH showed the highest angiogenesis and anti-inflammation. In this study, a comparison of the volume retention effect and angiogenic ability between autologous fat grafting, injectable natural, and synthetic biomaterials will provide a reasonable basis for fat grafting.

Chimeric Latissimus Dorsi Flap in One-Stage Reconstruction of Depressor Muscle Dysfunction and Depression Deformity in the Perimandibular Area.

Depression deformity and paralysis of depressor muscles (DMs) may occur following tumor resection in the perimandibular region. Obtaining satisfactory results is challenging. The authors report 3 cases of 1-stage reconstruction by transferring neurovascular chimeric latissimus dorsi (LD) musculo-adipose flaps, with satisfactory results. Three patients with depression deformity and DMs dysfunction after tumor resection in the perimandibular region underwent chimeric LD flap transfer. The flap comprised 1 portion with adipose tissue for augmentation, and the other contained muscle bellies with 1 or 2 neural pedicle (s) for DM reanimation. In case 1, the neural pedicle was sutured to the contralateral marginal mandibular branch. In case 2, the neural pedicle was sutured to the ipsilateral marginal mandibular branch. In case 3, the neural pedicle was sutured to both branches of the facial nerve. All patients were satisfied with the deformity corrections. However, contractions of the transferred muscles varied. Case 1 showed insufficient contraction. Case 2 had excessive muscle contraction. In case 3, the muscle had double innervation, and well-balanced contraction was maintained for 3 years. Neurovascular chimeric LD flaps are versatile and useful for secondary reconstruction after tumor resection for functional loss of mimetic muscles. The ipsilateral facial nerve may be an effective motor source.

Effect of human acellular dermal matrix (Megaderm™) on infra-auricular depressed deformities, Frey's syndrome, and first bite syndrome following parotidectomy: a multi-center prospective study.

Parotidectomy is the primary treatment for parotid gland tumors. However, complications may include a prominent facial scar or infra-auricular depressed deformity, Frey's syndrome, first bite syndrome, or other facial pain, numbness, and paralysis. Acellular dermal matrix (ADM) has been widely used to prevent these complications in parotid surgery, but there have been no prospective, multi-center trials documenting its efficacy. This study evaluates the effectiveness of ADM implantation in preventing infra-auricular depressed deformity, Frey's syndrome and first bite syndrome after parotidectomy. We analyzed 51 cases of standard parotidectomy and 58 cases of parotidectomy with implantation of Megaderm™ ADM through prospective multicenter trial. Acute complications including infection, seroma, hematoma, skin necrosis, and acute parotid area pain were evaluated 1 week postoperatively. Clinician grading of Frey's syndrome and blinded clinician evaluation of infra-auricular depressed deformities were conducted at 3, 6, and 12 months. Patients evaluated subjective satisfaction with neck appearance, Frey's syndrome quality, and acute parotid area pain at 3, 6, and 12 months. There was a higher incidence of seroma in the Megaderm™ group than in the control group at week 1. The incidence and total clinician-evaluated Frey's syndrome scores were significantly lower in the Megaderm™ group than in the control group at 3, 6, and 12 months. Both the objective and subjective evaluations of the facial contour showed a better outcome in the Megaderm™ group compared to the control group at 3, 6, and 12 months. There were no significant differences between the groups in the patient-reported Frey's syndrome quality scores at 3, 6, and 12 months, but the Megaderm™ group reported significantly less acute pain than the control group. ADM implantation can effectively reduce the occurrence of Frey's syndrome, infra-auricular depressed deformity, and first bite syndrome after parotidectomy. ADM may be especially advantageous in complex parotidectomy cases when significant complications are expected.

Pre-expanded Muscle-sparing Latissimus Dorsi Flaps for Reconstruction of Severe Scar Contractures on the Anterior Chest

ABSTRACT Objective To investigate the utility of pre-expanded muscle-sparing latissimus dorsi flaps in the reconstruction of deformities secondary to severe scar contractures on the anterior chest. Methods The function of the latissimus dorsi was preserved with blood supply from the main or lateral branch of the thoracodorsal artery. The entire treatment period was divided into two stages, during which segmental latissimus dorsi flaps were pre-expanded in stage I and anterior chest scar deformities were reconstructed in stage II. During stage I, the musculocutaneous perforators arising from the lateral branch of the thoracodorsal artery were determined by ultrasound preoperatively; the flap design included the anterior segment of the latissimus dorsi supplied by the musculocutaneous perforators from the lateral branch; and a tissue expander was placed following flap dissection and then infused with saline intermittently for 4–6 months. In stage II, the chest scars were excised, and breast tissues were repositioned; the continuity of the medial branch of the thoracodorsal nerve to the muscle was preserved when reconstruction was performed using the segmental latissimus dorsi flaps supplied by the main or lateral branch of the thoracodorsal artery. Results From October 2010 to October 2019, 21 patients (on 24 sides) underwent reconstructive procedures for extensive scar contractures on the anterior chest. All flaps survived, and their donor sites were sutured directly. During a follow-up of 3 months to 8 years, the flaps became soft and exhibited color similar to that of the adjacent tissues. The limited neck and shoulder movements improved, and postoperatively, all female patients were satisfied with the shape of their breasts. Additionally, neither apparent weakening on the adduction, internal rotation, or extension strength of the shoulder joint on the affected side nor marked depression deformity in the back was observed. Conclusion Pre-expanded muscle-sparing latissimus dorsi flaps with blood supply from the main or lateral branch of the thoracodorsal artery proved to be a desirable option for the reconstruction of extensive scar contractures on the anterior chest.

Autologous Free Fat Graft for Repair of Concave Deformity After Total Parotidectomy.

Resectioning of giant maxillofacial tumors has been shown to cause facial depression deformity, representing a persistent challenge for surgeons. Here, the authors review their experience using autologous free fat grafts to repair total parotidectomy defects. This review aims to encourage the surgical field to pay more attention to this century-old treatment technique. Patients were included who underwent free fat transfer for tissue reconstruction after total parotidectomy at the Affiliated Stomatology Hospital of China Medical University between 2012 and 2018. Patients with bleeding disease or postoperative follow-up less than 6 months were excluded. Twenty-three patients between the ages of 35 and 68 were included in this analysis. Ten patients (6 males, 4 females) underwent fat grafting at the time of total parotidectomy, and a control group of 13 patients (9 males, 4 females) underwent total parotidectomy without correction of concave deformities. There were significant differences between fat graft group and control group in terms of age (44.9 ± 9.0117 years versus 56.385 ± 8.9586 years; P = 0.006), Frey syndrome questionnaire score (1 ± 0 versus 2.385 ± 1.0439; P = 0.00), blood loss (195.7 ± 54.8777 mL versus 107.769 ± 22.8916 mL; P = 0.001), postoperative drainage (319.8 ± 103.1803 mL versus 230.385 ± 53.5701 mL; P = 0.027), duration of postoperative drainage (122.4 ± 23.8663 hours versus 90.462 ± 22.2434 hours; P = 0.003), and satisfaction questionnaire score (8.5 ± 0.8498 versus 3 ± 1.1547; P = 0.00). The difference in operation time between the fat graft group and control group was not significant (417 ± 108.0062 min versus 351.538 ± 91.7475 min; P = 0.131). Autologous free fat grafting resulted in more blood loss as well as an increased volume and duration of postoperative drainage. Remarkably, however, patients had superior satisfaction, lower Frey syndrome scores, and similar operation times with use of free fat grafting after parotidectomy. The authors recommend such grafting be utilized to repair concave deformities secondary to total parotidectomy.

Use propeller perforator flap to repair the skin malignancies wound on the back of the shoulder

Objective To discuss the therapeutic effect of free perforator flap of the humeral back and the healing of the wound after the removal of the malignant tumor. Methods From January, 2012 to June, 2016, 12 cases were treated as soft tissue tumors on shoulder, including 8 cases of skin juga fibrosarcoma, 3 cases of basal cell carcinoma, squamous cell carcinoma of the skin in 1 case. Preoperative using doppler ultrasound probe design perforator flap to expand resection, intraoperative cut edge basal tag frozen pathological examination without taking skin flap after the tumor invasion, according to the wound and wear the appropriate adjustment design of perforator flap. Followed-up to observe recurrence, flaps or ulcers, and the texture of the flap and the feel of the flap. All patients were followed-up regularly. Results All 12 patients were followed-up for 6-48 months. The flaps were all alive. The tumor did not relapse, and the flap was not swollen. The texture was consistent with the surrounding tissue. There was no ulceration of the flap. No obvious depression deformity. The outlook of flaps was satisfied, but the feeling was not.The doror sites were closed directly. Conclusion Adjacent using humeral back free perforators flap to repair the defect after tumor resection on shoulder is an easy operation. It is one of the ideal flaps to repair a malignant tumor on the back of the shoulder. Key words: Propeller flap, perforator flap; Wound repair; Malignant tumor; Back of the shoulder

Buccal Fat Pad: An Effective Option for Facial Reconstruction and Aesthetic Augmentation.

Autogenous grafting with lipoaspirate and dermo-fat grafting are popular techniques employed by plastic surgeons for correcting small volume facial defects and contour deformities. These techniques however present certain disadvantages. In this article, we present the use of the buccal fat pad graft as an alternative method of correcting such facial deformities. Free buccal fat pad grafting was carried out in 15 patients in our institution. All were harvested using an intraoral approach. The buccal fat pad graft was used to correct periorbital contour depressions, nasal tip deformities, as a camouflage graft over exposed silicon nasal implants and as a filler in the depression deformity after mass excision. All 15 patients demonstrated good contour deformity correction without a significant graft resorption up to 3years of follow-up. There were no donor site complications. The amount used ranged from 1 to 5cc in volume as a spacer or barrier for the moderate-sized volume defect or depression, even though more than 5cc of fat graft could be harvested if required. In conclusion, the buccal fat pad graft represents an easy, expedient and exceptional tool for the correction of contour deformities, volume replacement or for aesthetic augmentation. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Mixed Tumor in Deep Lobe and Versatility of Acellular Dermal Matrix.

Frey's syndrome and infra-auricular depressed deformities are the ones of the most common complications that can occur after total parotidectomy. We report 1 case of pleomorphic adenoma occurred in the deep lobe that obtained good results from using acellular dermal matrix (ADM) after total parotidectomy. A 24-year-old man visited the hospital with oval shape mass in right mandibular angle which of 4 cm in size was found in the deep lobe of right parotid gland from Magnetic resonance imaging scanning and a pleomorphic adenoma was suspected. A total parotidectomy was performed while preserving the facial nerve. The material known as ADM were placed in the depressed part from where the mass was removed, and the site was sutured. The surgery site was healed well without any complications such as Frey's syndrome or infra-auricular depressed deformities. The pathological result was confirmed as pleomorphic adenoma. In addition to these advantages, it does not have little potential of deformation by the gravity after the surgery, and there is no restraint on circulation, which makes fabrication free and each deformation into various shapes can be described as another advantage of the reconstruction using the ADM.

Application of modified coronal approach in treatment of craniomaxillofacial fractures

This study aimed to investigate clinical efficacy of a modified coronal approach in treatment of craniomaxillofacial fractures. Thirty-seven cases of craniomaxillofacial fractures underwent open reduction and rigid internal fixation through modified coronal approach. Clinical follow-up visits were conducted to evaluate facial nerve functional status, temporal shape, appearance restoration, and reduction of fracture and surgical area scars. During follow-up period of 6-36 months, appearance and function of all 37 patients recovered well without facial nerve injury and temporal depression deformity. All cases presented hidden scars, except for one case with hypertrophic scar. Applying modified coronal approach to craniomaxillofacial surgery effectively reduces incidence of temporal depression and facial nerve injury compared with traditional approach. The modified coronal approach produced more subtle scars compared with traditional approach and should be applied to treatment of craniomaxillofacial fractures.

Clinical application of orbital fat autograft for tear trough deformity through tranconjunctival approach

To discuss the orbital fat autograft for lower baggy eyelid with tear trough deformity and its therapeutic effect through tranconjunctival approach. The patients with lower eyelid bag and tear trough deformity were included into the study. The included 32 patients met the following criterias: ①less than 40 years old;②lower eyelid skin was not relaxed;③less than 1 s in Snap test; ④ Hirmand type Ⅰ and Ⅱ. They were treated with tranconjunctival lower blepharoplasty combined with the tears ligament relaxation. The orbital fat was repositioned on the depression site above orbital periosteum to correct tear trough deformity. The effect was evaluated through Tear Trough Rating Scale (TTRS) and satisfaction degree. Three cases with Hirmand type Ⅱ didn't have good effect. Among them, the baggy eyelid was corrected in 2 cases, while the tear trough deformity need additional hyaluronic acid injection. One patient underwent secondary lower blepharoplasty through cutaneous incision. Good effect was achieved in the other 29 cases with no depression deformity and eyelid withdrawal. The TTRS scores 6 months after operation was significantly improved(P ＜ 0.01).Satisfaction degree was 100％ (14/14) and 83.3％ (15/18) in type Ⅰ and Ⅱ patients. The technique can simultaneously improve lower eyelid bag and the tear trough deformity. It can be applied in periorbital rejuvenation for middle-aged and young patients.

The use of expanded polytetrafluoroethylene in depressed deformities of the face.

Expanded polytetrafluoroethylene (ePTFE) has been extensively used for facial soft tissue augmentation procedures, and is regarded as safe and reliable and suitable as a permanent implant. This implant is generally used in the lower third of the face for lips filling, nasal augmentation, nasolabial folds and chin augmentation, and rarely for congenital or acquired depressed deformities of the face. The aim of the present study was to assess the effects of ePTFE in congenital or acquired depressed deformities of the face. From September, 2008 to January, 2014, 26 patients were implanted with the material ePTFE to correct depressed deformities of the face. The average age at operation was 23.2 years, with a range of 17–45 years. The depressed deformities were lateralized. The follow-up period was 6–18 months (average 9 months). The etiologies of the depressed deformities included stable hemifacial atrophy (3 cases), craniofacial microsomia (13 cases), bony depression after trauma (8 cases), and other unclear reasons (2 cases). The operations were performed under local anesthesia. ePTFE was inserted in different tissue planes that varied among the different subanatomical areas in the face: beneath the superficial temporal fascia in the temporal area, and on the surface of the superficial musculoaponeurotic system in the zygomatic area, cheek and mandibular area. All of the patients were followed up. Most of the patients [25 of 26 patients (96.2%)] were satisfied with the results, while 1 patient (3.8%) was not satisfied for incomplete correction of the depressed deformity. In conclusion, aside from lipofilling and a free flap transfer, the results showed that ePTFE was an alternative treatment for facial depressed deformity.

Evaluation of Repairing Facial Depression Deformities Secondary to Lupus Erythematosus Panniculitis With Autologous Fat Grafting.

A facial depression deformity secondary to lupus erythematosus panniculitis results from fat necrosis, which seriously alters the patients' appearance and thus affects their psychological health. Few studies have discussed the repair of depression deformities. The authors repaired depression deformities due to atrophic lesions by using autologous fat grafting to obtain volumetric restoration of the facial skin, and the authors report our outcomes. In this series, 30 depression deformities in 18 patients were repaired. The authors suctioned fat grafts from the abdomen and centrifuged them at 500×g for 2 minutes. After discarding the upper oil and bottom liquid, the middle fat was injected into the depressed areas (ie, the cheek, temple, and zygoma) by using multiplane and multitunnel injections. The patients, plastic surgeons on staff, and laypersons evaluated the cosmetic outcome of each patient. No infection, subcutaneous nodules or cysts, cutaneous necrosis, blood vessel embolism, or other complications were found in any patient. Five patients had 1 injection, 5 had 2 injections, and 8 had 3 injections. All depression deformities improved. Regarding the cosmetic outcome, 33.3% of patients, 27.8% of laypersons, and 38.9% of doctors were satisfied with the results; 44.4% of patients, 55.6% of laypersons, and 50.0% of doctors were mostly satisfied. Autologous fat grafting can be a good choice for repairing facial depression deformities in patients with lupus erythematosus panniculitis, although 1 or more subsequent injections may be required to maintain the improved outcome.