Long-term Aesthetic Results Research Articles

Tongue reduction in Beckwith–Wiedemann syndrome: outcome and treatment algorithm

Beckwith–Wiedemann syndrome is a rare congenital overgrowth disorder with macroglossia being one of the cardinal symptoms. In pronounced cases, macroglossia can lead to airway obstruction, musculoskeletal alterations and functional deficits. Surgical tongue reduction is performed at varying ages and with different techniques. This study evaluated perioperative complications, as well as long-term aesthetic and functional outcomes, in a large cohort. A total of 68 patients, treated either surgically or conservatively, were included. Depending on the severity of macroglossia, patients were divided into three groups to determine the treatment algorithm. Complications after surgical tongue reduction were prolonged intubation and revision due to dehiscence or haematoma. In the long term, no patient suffered from impaired sense of taste or paresthesia, although the shape of the tongue was disproportional in 85%. With the present treatment algorithm, operative tongue reduction exerts a positive influence on skeletal, dentoalveolar and functional development with sufficient long-term outcome and high grade of satisfaction of the patients. Supportive therapy in an interdisciplinary centre is of fundamental importance for both surgical and conservative treatment.

Long-Term Esthetic Results of a Modified Technique of Bilateral Cleft Lip Repair

Purpose: To evaluate long-term esthetic results in the bilateral cleft lip repair by a modified technique characterized by prolabial self-elongation and orbicularis oris muscle reconstruction in one stage, using anthropometric measurements.Patients and Methods: Fourteen patients (8 were males and 6 were females) had their bilateral cleft lip and nasal deformity repaired simultaneously by modified technique characterized by prolabial self-elongation and orbicularis oris muscle reconstruction in one stage, during the period from 1999 to 2002. Direct and indirect anthropometry were applied to all patients to evaluate the long term esthetic results.Results: The long term esthetic results were satisfactory in all patients. There were no acute complications requiring re-surgery. In most patients, nasal length, nasal tip projection, columellar length, and upper lip shape were appropriate. Nasal tip protrusion, nasal width, upper lip height, and vermilion-mucosal height were within normal limit. The measurements were observed to be symmetrical; left and right measurement data were not significantly different. Conclusions: This modified technique is proved to be a valuable technique on the long term basis in repair of bilateral complete cleft lip which has its important impact on esthetic results.

Long-term outcomes of bilateral direct-to-implant breast reconstruction in women at high breast cancer risk

Introduction: Challenges of direct-to-implant breast reconstruction (BR) are to achieve sufficient implant coverage and lower pole projection. We assessed reoperation rates, long-term patient satisfaction and aesthetic outcome after direct-to-implant BR without acellular dermal matrix (ADM) in women with high breast cancer risk.Methods: Women who underwent bilateral skin or nipple-sparing mastectomy and immediate direct-to-implant BR between 1994 and 2006 completed a survey on reoperations and the Breast-Q Reconstruction questionnaire. Photographs taken during follow-up were rated for long-term aesthetic outcome (scale 1–10) by five plastic surgeons. Outcomes were compared between women who never underwent unanticipated reoperations after immediate BR and women who underwent one or more reoperations, adjusted for potential confounders using multivariable linear regression.Results: Of 143 women, 70 (49%) were never reoperated and 73 (51%) had undergone reoperations. Median follow-up was 12 years in both groups (range 7–17 and 6–19 years, respectively). Baseline characteristics were comparable except for history of prophylactic oophorectomy with 81% in the no-reoperations group versus 66% in the reoperated group (p = .03). Breast-Q scores were 59.7 ± 17.3 versus 58.0 ± 17.8 (p = .67) for ‘satisfaction with breasts’ and 71.1 ± 20.3 versus 68.1 ± 22.9 (p = .47) for ‘satisfaction with outcome’ in the no-reoperation versus reoperation group, respectively. Aesthetic outcome was scored 5.8 ± 1.1 in the no-reoperation group versus 5.3 ± 1.3 in the reoperation group (p = .01).Conclusions: The single-stage intent did not prevent unanticipated surgical reinterventions in 51% of the patients. Long-term patient satisfaction was reasonable and not affected by reoperations. Aesthetic outcome, however, was only poor to reasonable and scores were significantly lower in the reoperated group.

Objective assessment of flap volume changes and aesthetic results after adjuvant radiation therapy in patients undergoing immediate autologous breast reconstruction.

BackgroundThe use of immediate breast reconstruction and adjuvant radiation therapy is increasing in breast cancer patients. This study aimed to analyze the aesthetic outcome and changes in flap volume in patients with breast cancer undergoing radiation therapy of the surgical site after immediate autologous tissue reconstruction.MethodsImmediate abdominal free flap breast reconstruction following unilateral mastectomy was performed in 42 patients; 21 patients received adjuvant radiation (study group) and 21 patients did not (control group). To compare flap volume, three-dimensional computed tomography (CT) was performed before and after radiation. Also, aesthetic analysis was performed in both groups to evaluate shape changes.ResultsThere was a 12.3% flap volume reduction after the completion of radiation in the experimental group that was significantly greater than the 2.6% volume reduction observed in the non-radiation group (P<0.01). There was no significant difference in the short- and long-term aesthetic results between the groups.ConclusionsWhen performing immediate autologous breast reconstruction, 14% volume overcorrection is recommended for patients in whom adjuvant radiation therapy is anticipated to improve aesthetic outcomes.

Long-term esthetic outcomes of patients with cleft lip and palate have improved over time

Long-term esthetic outcomes of patients with cleft lip and palate have improved over time

The long-term esthetic results of two surgical methods for treating ingrown toenails

The long-term esthetic results of two surgical methods for treating ingrown toenails

Normal Tissue Complication Probability Modeling of Long-Term Aesthetic Outcome After Breast-Conserving Therapy

Normal Tissue Complication Probability Modeling of Long-Term Aesthetic Outcome After Breast-Conserving Therapy

Assessment of Aesthetic Results of 100 Patients Who Underwent Rhinoplasty-Rhinoplasty Outcome Evaluation.

Background:To assess the long-term aesthetic results of rhinoplasty and predict the final outcome.Methods:The sample was composed of 100 patients (34 men and 66 women) between 23 and 57 years old (mean, 34.8) operated on exclusively for aesthetic reasons. The time elapsed from the operation ranged from 3 to 13 years with a mean of 6.8 years. The study used Rhinoplasty Outcome Evaluation questionnaire, a simple, reliable, validated, and widely used inventory.Results:The vast majority of patients (93%) were satisfied postoperatively with scores > 50% (67 patients had scores > 80%). Only 7 patients had scores less than 50%. The mean score was 82.4 ± 1.7% with a median of 87%. In addition, it seems that the results of the operation remain high through time with a small decline along age groups and years elapsed. Women were found more satisfied than men (P = 0.03).Conclusions:The study concludes that the results of aesthetic rhinoplasty, if performed by skilled and experienced surgeons, are very satisfying and stable throughout time.

Nasal Reconstruction and Repair of Secondary Nasal Deformities Following Treatment of Nasal Hemangiomas

Secondary nasal deformities and retardation of development due to treatment of nasal hemangioma during infancy are a challenge when it comes to nasal reconstruction. In order to evaluate nasal repair and reconstruction in these patients, the authors compared the ease and outcomes of using expanded forehead, nasolabial sulcus, and medial upper arm tube flaps. According to the deformities and patients' wishes, flaps were selected; using autogeneic rib cartilage, auricle cartilage, or silica gel as a scaffold or without framework; the inner lining were made by the residual scar tissue or the distal end of transferred flap. The esthetical and functional scores were recorded by the Nasal Appearance and Function Evaluation Questionnaire score to evaluate the effectiveness of the methods. From January 2010 to December 2015, 34 patients were included. Postoperative follow-up went for 12 to 36 months. The expanded forehead flap was used in 28 patients, the nasolabial sulcus flap in 5 patients, and the medial upper arm tube flap in 1 patient. Regarding framework, 20 patients used rib cartilage, 8 patients used auricle cartilage, 1 patient used silicone, and 5 patients did not use any framework. All patients reported the increasing nasal appearance and function evaluation. Repair of secondary nasal defects following treatment of hemangiomas in infants and young children using an expanded frontal flap and autogenous cartilage framework is a reliable method with great long-term esthetic results. The nasolabial sulcus flap is a relatively simple method, especially for patients with a unilateral nasal alar defect. Supporting structure is needed and appropriate overcorrection is necessary.

Abstract P3-13-22: Should modified radical mastectomy be modified? A phase 1 study to evaluate infraradical mastectomy for invasive breast cancer

Abstract Background: Surgical procedures in breast cancer have become less aggressive. However, around one in three patients must undergo modified radical mastectomy (MRM). We evaluated if infraradical mastectomy (IFM), which preserves the skin and fat tissues surrounding the breast, is safe. IFM has the potential to preserve neck opening and by the way femininity of patients. Aesthetic results obtained after breast reconstruction are also expected to be improved. Objective: The primary objective of this phase 1 trial is to evaluate the feasibility and safety of IFM. Methods: Patients were recruited in two specialized breast clinics. We performed enucleation with a cold knife to the mammary gland after a water-assisted dissection of the periglandular space using a dedicated tool. In a second step we removed the peripheral skin and fat tissue which surrounded the gland to obtain a classical MRM. Fat tissue removed in the second step underwent a careful pathological examination (10 biopsies) in order to evaluate residual invasive or in situ breast cancer and atypical hyperplasia. We also evaluated which is the percentage of tissue and skin removed in the second step with regard to the global surgical specimen because that could be left in the future if the procedure is declared safe. Results: A total of 35 patients (43 to 80 years old) were prospectively recruited from March 2015 to March 2016. The distribution of tumor type was: pTis 2.9%, pT1 45.7%, pT2 45.7% and pT3 5.7%. Pathological analysis of the periglandular tissue removed in the second step revealed: 0% invasive carcinoma, 1% focal ductal carcinoma in situ (DCIS), and 0% atypical hyperplasia. On average, the weight of an IFM was 37% lower compared to the weight of a MRM. Skin resection was reduced by 48% with IFM. No serious adverse event was observed. Conclusions: Preliminary results are promising. Our phase 1 trial suggests that the procedure is safe concerning premalignant or malignant disease left after IFM. Moreover, a high quantity of skin and fat tissue is saved by IFM. We are now recruiting a second cohort of patients in order to confirm these results. In addition, we will also quantify the amount of mammary glands left around IFM compared to MRM by performing additional biopsies and quantitative evaluation by pathologists. Presurgical selection criteria have been modified for the second cohort in order to avoid residual DCIS left after IFM. After this second cohort, we plan to begin a large prospective randomized phase 3 trial with long-term disease-free survival and aesthetic results as the primary endpoints. Citation Format: Coibion M, Lifrange E, Jossa V, Mutijima E, Crevecoeur A, Olivier F, Di Bella J, Jerusalem G. Should modified radical mastectomy be modified? A phase 1 study to evaluate infraradical mastectomy for invasive breast cancer [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P3-13-22.

Orthodontic-surgical management of impacted maxillary central incisor

Maxillary incisors and canine, often referred to as the social six are most prominent teeth in an individual's teeth. Impaction of maxillary central incisors are less frequently than third molars and canines because of several contributing factors. Treatment of impacted teeth requires a combined orthodontic and surgical perspective. In the presented case we have used Closed-eruption technique combined with alteration in biomechanics and this had resulted in good long-term esthetic results. Keywords: Maxillary incisor; Impaction; Closed eruption technique; Modified biomechanics

CRYO-RADIOTHERAPY FOR LOCAL LYADVANCED RECURRENT SKIN CANCER OF THE FACE

The aim of the study was to improve the treatment outcomes for patients with locally advanced recurrent basal cell and squamous cell skin carcinomas of the face. Material and methods. A total of 26 patients with locally advanced recurrent basal cell (n=21) and squamous cell (n=5) skin carcinomas of the skin were treated with radiotherapy (2–2.5 Gy daily fractions to a total dose of 60–70 Gy, 5 days a week) in combination with local freezing of the tumor. Local cooling of the tumor to the temperature of tissue freezing was performed 10–15 minutes before each session of radiation therapy using liquid nitrogen cryo-preservation equipment. Patients with recurrent skin cancer who had received previously radiation therapy were not eligible for cryoradiotherapy. Results. Complete response was achieved in 23 (88.5 %) patients, residual tumors were removed by conventional surgery (n=2) and cryosurgery (n=1). At 2 to 14-year follow up, recurrences of skin cancer occurred in 3 (11.5 %) cases. Good aesthetic and functional results were observed. Conclusion. Cryo-radiotherapy was shown to be effective, providing long-term aesthetic and functional results.

Treatment of Rejection in Vascularized Composite Allotransplantation

Vascularized composite allotransplantation (VCA) has become an important modality to restore disfigured parts of the body that cannot be restored with conventional reconstructive techniques. Reported short- and long-term functional and esthetic outcomes have been excellent. However, acute rejection remains the most common complication associated with VCA. In addition, recent reports have linked the loss of some allografts to chronic rejections potentially fueled by insufficiently treated acute rejections. Here, we highlight recent diagnostic and therapeutic strategies for the prevention and treatment of acute and chronic rejections in VCA.

One-Step Salvage of Infected Prosthetic Breast Reconstructions Using Antibiotic-Impregnated Polymethylmethacrylate Plates and Concurrent Tissue Expander Exchange.

Periprosthetic infection represents a major complication in breast reconstruction, frequently leading to expander-implant loss. Recent studies report variable success in the salvage of infected breast prostheses through systemic antibiotic therapy and surgical intervention. There is currently no consensus regarding a management algorithm for attempted salvage. The purpose of this pilot study was to evaluate the early outcomes of a protocol using antibiotic-impregnated polymethylmethacrylate (PMMA) implant placement with expander device exchange. A retrospective database was queried to identify all patients with infected implant-based breast reconstruction who were treated by the study authors and who underwent attempted salvage under the study protocol. All patients received intravenous antibiotics followed by surgical debridement of the infected pocket, insertion of antibiotic-impregnated PMMA plates and/or beads, device exchange, and postoperative antibiotics. After clinical resolution of infection, tissue expansion was performed with the PMMA implants remaining in situ until exchanged to permanent implants. All patients with infected prosthetic breast reconstructions achieved implant pocket sterilization using this method. At a mean follow-up of 8.2 months (range, 1-19 months), none of these patients have required reoperation for capsular contracture. One patient, while under treatment with prednisone for a rash, developed recurrent infection, which led to explantation of her implant. Two patients underwent radiation therapy while an antibiotic plate and tissue expander were in place, with no observed exposure or infection recurrence. Sustained local antibiotic delivery using PMMA implants and expander device exchange can successfully salvage an infected breast implant. Perceived benefits include shorter time to completed reconstruction, preserved skin envelope integrity, and possibly improved long-term aesthetic outcomes.

Subtarsal Versus Transconjunctival Approach—Esthetic and Functional Long-Term Experience

In addition to the transconjunctival approach, the subtarsal incision is one of the most commonly used procedures for surgical exploration of the orbital floor and infraorbital rim. However, available data are limited regarding validity and long-term esthetic and functional outcomes. The aim of this study was to verify the favorable clinical results of the subtarsal approach and compare these results with the transconjunctival procedure. Forty-five patients (subtarsal group, n= 30; transconjunctival group, n= 15) were examined 6 to 30months after surgical intervention using a standardized follow-up. Clinically noted complications, such as paresthesia, epiphora, or ocular foreign body sensation, were scored. Postoperative scar formation was investigated using the modified Vancouver Scar Scale (mVSS) and recorded according to standardized photographic documentation procedures. Photographic images were evaluated in a blinded manner by experts and nonexperts according to fixed criteria. Concomitant photographic evaluation was performed by age- and gender-matched healthy controls. Recorded data analyzed by χ2 test and unrelated samples analyzed by the Wilcoxon-Mann-Whitney test were statistically significant (P= .05). Comparable complication rates were found for the 2 approaches without any significant differences (P= .29). Using the subtarsal approach, discrete scar formation was discerned in 7 of 30 cases. Moreover, categorization by the mVSS showed that, in 93.3% of cases, the scar was measured as unremarkable hyper- or hypotrophy (mean, 1.7 of 10 possible points). No statistically significant differences in conspicuous scars and asymmetries were observed between the 2 approaches in the nonexpert and expert groups (P > .05). The results of the present study confirm that the subtarsal approach is a safe and esthetically favorable method.

Immediate Restoration of Immediate Implants in the Esthetic Zone of the Maxilla Via the Copy-Abutment Technique: 5-Year Follow-Up of Pink Esthetic Scores.

Implant esthetics may benefit from individualized zirconia abutments copying the emergence profile of the natural tooth and delivered within days after immediate implant insertion. To investigate the esthetic outcome of the Copy-Abutment technique using the Pink Esthetic Score (PES). A total of 77 patients with single-tooth implants in the anterior maxilla restored at the day of immediate implant placement using Copy-Abutments and provisional crowns were followed-up after 1 week, 1 month, 4 months, 6 months, 1, 2, 3, 4, and 5 years to assess implant esthetics. PES ranged between 7 and 14 (median: 13) and improved significantly between the 6 month and 1 year follow-up (p < .001), then remained stable up to the fifth year. Significant improvement was seen for the variables PES-6 soft tissue color (p = .002) and PES-7 soft tissue texture (p < .001) up to the 1 year follow-up, while PES-5 alveolar process deficiency deteriorated (p = .016). Mean mucosal recession was 0.26 ± 0.86 mm (range: 0-1.6) after 5 years and not related to gingival biotype. Copy-Abutments for immediate restoration of implants in the esthetic zone show satisfactory long-term esthetic outcomes.

Principles for Management of Orbital Fractures in the Pediatric Population: A Cohort Study of 150 Patients.

Pediatric orbital fractures represent a challenging and sometimes controversial clinical problem. Patients may present with clear indications for surgery, but most require balancing benefits against intraoperative and late complications. The authors assessed these fractures at a state-designated ophthalmology referral center to develop criteria for surgery. Institutional review board approval was obtained to retrospectively analyze pediatric trauma registry patients with orbital fracture diagnoses at the Wilmer Eye Institute over 10 years. Patients were excluded if they did not undergo a full ophthalmologic examination, never followed up after their injury, or had significant facial fractures outside of the orbit. One hundred fifty patients met selection criteria; 116 patients (77 percent) completed all follow-up (average, 309 days). Two patients had 20/40 vision or worse at the end of follow-up. One hundred ten patients (71 percent) underwent surgery; 96 underwent acute repair (<3 weeks) and 11 underwent delayed repair (median, 49 days). Three patients required reoperation, two for plate infection and one for hyperglobus, with an overall complication rate of 4.7 percent. The authors analyzed the largest series of operative pediatric orbital fractures to propose criteria for surgical intervention. There are four potential indications: (1) rectus muscle entrapment; (2) early enophthalmos; (3) central-gaze diplopia or extraocular movement restriction after the resolution of swelling; and (4) loss of orbital support likely to produce secondary changes in globe position and/or binocular stereo vision. In our series, application of these principles offered excellent long-term aesthetic and ophthalmic outcomes with an acceptably low complication profile. Therapeutic, III.

Tripod suspension and stabilisation: an innovative splintage technique for closed reduction of comminuted and compound fractures of the nasal bones

Comminuted and compound fractures of the nose pose a surgical dilemma for the treating surgeon. There is a general belief that in such cases, a secondary septorhinoplasty is often required after a closed reduction and so there is a bias towards adopting an open or modified open reduction technique in the first instance. We, however, believe that a change in the splinting strategy after a closed reduction can make use of the innate advantages of the nasal structure and avoid a lot of major surgeries and consequent discomfort and expenses. Thirty-six patients with comminuted/compound fractures of the nose were enlisted in the study after due informed consent. After standard closed reduction, a new splintage technique developed by us, the ‘Tripod suspension and stabilisation technique’ was employed and kept for up to 3 weeks. The patients were then interviewed a minimum 8 weeks post splint removal to assess their levels of satisfaction regarding aesthetics and function of the nose post reduction on a visual analog scale. Thirty-six patients having comminuted or compound fracture nasal bone were splinted by this technique after closed reduction and followed up for subjective assessment at least 2 months later. While 95 % were quite satisfied with the aesthetic outcome and 97 % with the nasal function, only one felt the need for (and subsequently underwent) a septorhinoplasty. Tripod suspension and stabilisation is an effective and rational technique for splintage following closed reduction of comminuted/compound fractures of nasal bones. It is convenient for patients as they can breathe through their noses and do not restrict any activity while the splints are on. It is very stable and versatile and reduces hospitalisation as no packs are required and has shown excellent long-term functional and aesthetic results thereby reducing the need for open procedures. Level of Evidence: Level IV, therapeutic study.

The Modified Trap Door Flap for Reconstruction of Posterior Pinna and Concha Defects.

The Modified Trap Door Flap for Reconstruction of Posterior Pinna and Concha Defects.

Biplanar Contour-Oriented Approach to Lower Eyelid and Midface Rejuvenation.

Cosmetic rejuvenation of the lower eyelid-midface complex has evolved as our understanding of 3-dimensional midfacial aging and anatomy has become more sophisticated. Treating the lower eyelid and the midface as a single aesthetic unit leads to a more effective and natural-appearing rejuvenation. This is a review of midfacial anatomy and a 5-step approach to lower blepharoplasty and midface rejuvenation: (1) midfacial autologous fat transfer, (2) canthoplasty, (3) transconjunctival orbicularis-retaining ligament release and orbital fat manipulation, (4) transcutaneous midface-superficial muscular aponeurotic system elevation and orbicularis contouring, and (5) skin treatment. In addition, long-term aesthetic outcomes and complications are reviewed for 43 patients (86 eyelids) who underwent the 5-step biplanar approach lower blepharoplasty and midfacial rejuvenation (40 women and 3 men, with a mean age of 60 years). Follow-up averaged 10.8 months. Forty-one patients rated their outcome as "excellent," and 3 patients rated their outcome as "good." No patients rated their outcome as "fair," "no improvement," or "worsening." Seven patients (7 eyelids) had unilateral complications requiring postoperative intervention. The biplanar contour-oriented approach to lower blepharoplasty and midfacial rejuvenation is an option for treatment for aging of the lower eyelid-midface complex. The aesthetic outcomes appear natural owing to the synergy of reconstructing the aging changes of multiple lower eyelid and midface structures.