Background Reduction malarplasty presents challenges in terms of postoperative complications, particularly limited mouth opening. Excessive inward displacement of the zygomatic complex can impinge on the coronoid process resulting in restricted mouth opening. This study aimed to assess the spatial relationship between the coronoid process and the zygomatic complex after reduction malarplasty. Methods A retrospective study was conducted, including consecutive patients underwent reduction malarplasty. Radiological measurements were performed before surgery and during the final follow-up, including the coronoid-condylar index, distance between the coronoid process and zygomatic complex, and thickness and density of the temporal and masseter muscles. Clinical and radiographic data were recorded and analyzed. Results A total of 159 female patients were included with an average age of 28.1 years and a mean follow-up of 6.7 months. The mean coronoid-condylar index was 1:1.4, ranging from 1:0.6 to 1:2.6. Following surgery, the distances between the coronoid process and the anterior zygoma decreased by approximately 1 mm. Additionally, the postoperative distance between the highest point of the coronoid process and the zygomatic arch decreased by around 4 mm horizontally and changed approximately 1 mm vertically. No significant changes were observed in the thickness and density of the temporal and masseter muscles after surgery. Conclusions Reduction malarplasty led to a slight decrease in the distance between the coronoid process and the zygoma. The operation generally resulted in proximity between the highest point of the coronoid process and the zygomatic arch. However, we believe that common reduction malarplasty rarely leads to osseous impingement. Level of Evidence IV 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

Objective: A flat superciliary arch is relatively common in East Asian women. Superciliary arch augmentation aims to increase the facial three-dimensionality of the upper face. However, there are few reports in the literature specifically introducing the surgery. In this study, the authors present the clinical outcomes after a series of superciliary arch augmentation with silicone implants. Methods: From May 2020 to December 2022, 54 patients underwent superciliary arch augmentation with silicone implants. Silicone implants generally have a length of 50 to 60 mm, a width of 13 to 14 mm, and an arc of 170 degrees. The thickness was 2 to 7 mm. The implant was placed subperiosteal at the lower edges of the eyebrows through a 7 mm incision below the brow tail. All patients evaluated the outcome according to the Global Esthetic Improvement Scale. Four plastic surgeons evaluated postsurgery results with a 5-point Likert Scale (5 = excellent, 4 = good, 3 = fair, 2 = no change, and 1 = worse). Results: Fifty-four patients were successfully enrolled. The mean follow-up period was 12.02 ± 3.38 months. The mean thickness was 4.55 ± 0.67 mm for the thickest part of the implant. The minor complication rate was 44.44%. They all subsided within 1 month without treatment. Patients’ outcome ratings were 4.45 ± 0.55 (3 mo), 4.51 ± 0.48 (6 mo), and 4.51 ± 0.45 (1 y). The surgeons’ outcome scoring was 4.49 ± 0.31. Conclusions: Superciliary arch augmentation with silicone implants is a quite simple, effective, inexpensive, and safe strategy to improve the three-dimensionality and contour of the upper face in East Asians.

Objective:To preliminarily verify the effectiveness of self-designed artificial condyle-mandibular distraction (AC-MD) complex in the treatment of Pruzansky type ⅡB and Ⅲ hemifacial microsomia (HFM) through model test. Methods:Five children with Pruzansky type ⅡB and Ⅲ HFM who were treated with mandibular distraction osteogenesis (MDO) between December 2016 and December 2021 were selected as the subjects. There were 3 boys and 2 girls wih an average age of 8.4 years (range, 6-10 years). Virtual surgery and model test of AC-MD complex were performed according to preoperative skull CT of children. The model was obtained by three-dimensional (3D) printing according to the children's CT data at a ratio of 1∶1. The occlusal guide plate was designed and 3D printed according to the children's toothpaste model. The results of the model test and the virtual surgery were matched in three dimensions to calculate the error of the residual condyle on the affected side, and the model test was matched with the actual skull CT after MDO to measure and compare the inclination rotation of the mandible, the distance between the condylar of the healthy side and the residual condyle of the affected side, and the lengthening length of the mandible. Results:The error of residual condyle was (1.07±0.78) mm. The inclination rotation of the mandible, the distance between the condylar of the healthy side and the residual condyle of the affected side, and the lengthening length of the mandible after 3D printing model test were significantly larger than those after MDO ( P<0.05). Conclusion:In the model test, the implantation of AC-MD complex can immediately rotate the mandible to the horizontal position and improve facial symmetry, and the residual condyle segment can be guided close to the articular fossa or the preset pseudoarticular position of the skull base after operation.

Background Traditional middle and lower facelifts are not suitable for patients with mild skin laxity or who wish to avoid incision scars. Objective We present the stab access fascia suspension lift (SAFS-lift) technique, which does not require regular skin incisions, as a reliable surgical facelift strategy for the lower and middle face. Methods From September 2020 to September 2021, 38 patients underwent SAFS-lift. SAFS-lift involved (1) incomplete subcutaneous undermining with hydrodissection-assisted tunneling; (2) complete subcutaneous undermining with a dissecting cannula in the zygomatic buccal groove area and hollow below zygomatic arch; and (3) maximal firm superficial musculoaponeurotic system suspension with polydioxanone barbed threads in loops. All patients evaluated the outcome according to the Global Aesthetic Improvement Scale. Four plastic surgeons evaluated postsurgery result with a five-point Likert scale (5 = excellent, 4 = good, 3 = fair, 2 = no change, and 1 = worse). Results Thirty-six patients were successfully enrolled. The mean follow-up period was 14.72 +/- 3.89 months. No patients showed visible scarring 6 months after surgery. The minor complication rate was 19.4%. They all subsided within 1-6 weeks without treatment. No infection, hematoma, seroma, or facial nerve injury was observed. Patients' outcome ratings were 4.22 +/- 0.58 (3 months), 4.69 +/- 0.46 (6 months), and 4.69 +/- 0.54 (1 year). Surgeons' outcome scoring was 3.98 +/- 0.95. Conclusions Stab access fascia suspension-lift is a predictable, effective, and safe facelift technique that can be performed without making noticeable incisions and resecting the skin.

BackgroundMandibular sagittal split ramus osteotomy (SSRO) is a routine surgery to correct mandibular deformities, such as mandibular retrusion, protrusion, deficiency, and asymmetry. However, nonunion/malunion of the fragments and relapse caused by fixation failure after SSRO are major concerns. Rigid fixation to maintain postosteotomy segmental stabilization is critical for success. Additionally, understanding the biomechanical characteristics of different fixation methods in SSRO with large advancements is extremely important for clinical guidance. Therefore, the aim of the present study was to evaluate the biomechanical characteristics of different SSRO methods by finite element analysis.MethodsSSRO finite element models with 5-, 10-, 15-, and 20-mm advancements were developed. Seven fixation methods, namely, two types of bicortical screws, single miniplate, dual miniplates, grid plate, dual L-shaped plates, and hybrid fixation, were positioned into the SSRO models. Molar and incisal biomechanical loads were applied to all models to simulate bite forces. We then investigated the immediate postoperative stability from four aspects, namely, the stability of the distal osteotomy segment, osteotomy regional stability, stress distribution on the mandible, and implant stress performance.ResultsThe stability of the distal osteotomy segment and osteotomy region decreased when the advancement increased. All seven fixation methods displayed favorable biomechanical stability under minor advancement (5 mm). With large advancements, bicortical screws, dual miniplates, and grid plates provided better stability. The von Mises stress was concentrated around the screws close to the osteotomy region for the proximal segment for all fixation methods, and the von Mises stress on implants increased with larger advancements. With small advancements, five fixation methods endured tolerable maximum stresses of <880 MPa. A single miniplate and dual L-shaped plates generally suffered high stresses using larger advancements. The biomechanical characteristics were similar under molar and incisal loads.ConclusionsThe current study investigated the biomechanical properties of seven fixation devices after SSRO under molar and incisal loads. Generally, bicortical screws, grid plates, and dual miniplates provided better biomechanical stability using finite element analysis.

BACKGROUND:Digital technology has been widely used in mandibular curved osteotomy to improve accuracy. However, the planning process still highly dependent on the experience and judgement of the surgeon. This study describes an automatic method to design the new gonion and osteotomy line based on the aesthetic standards in attractive women, and assesses its clinical outcomes.METHODS:An automatic surgical planning method for mandibular curved osteotomy was developed based on our previous research of mandibular angle aesthetics. A prospective clinical study was conducted from April 2016 to April 2018. Twenty-five female patients with prominent mandibular angle were enrolled. Pre- and postoperative skull computed tomography (CT) was performed. Three-dimensional (3D) CT data were obtained and processed by Mimics 18.0. Surgical templates were designed according to the automatic surgical planning method and 3D printed for the surgery. Preoperative measurements, surgical simulation and postoperative measurements were taken to evaluate the surgical outcomes.RESULTS:There were significant differences between the preoperative and the postoperative groups' results (p < 0.01). There was no difference between the surgical simulation and the postoperative results. All postoperative measurements were consistent with aesthetic features of mandibles. Patients were satisfied with their outcomes in terms of outline, symmetry and lower facial width.CONCLUSIONS:Our study developed an automatic method to position the new aesthetic gonion and osteotomy line for prominent mandibular angle patients. We proved that this method is safe, effective and reliable.

Background: The mandibular sagittal split ramus osteotomy (SSRO) is a routine operation performed to correct mandibular deformity including mandibular retrusion, protrusion, deficiency, and asymmetry. The SSRO remains a challenging procedure for junior surgeons due to a lack of adequate morphological knowledge necessary for success in clinical practice. Virtual reality (VR) and three-dimensional printed (3DP) models have been widely applied in anatomy education. The present randomized, controlled study was performed to evaluate the effect of traditional educational instruments, VR models, and 3DP models on junior surgeons learning the morphological information required to perform SSRO. Methods: Eighty-one participants were randomly assigned to three learning groups: Control, VR, and 3DP. Objective and subjective tests were used to evaluate the learning effectiveness of each learning instrument. In the objective test, participants were asked to identify 10 anatomical landmarks on normal and deformed models, draw the osteotomy line, and determine the description of SSRO. In the subjective test, participants were asked to provide feedback regarding their subjective feelings about the learning instrument used in their group. Results: The objective test results showed that the VR and 3DP groups achieved better accuracy in drawing the osteotomy line (p = 0.027) and determining the description of SSRO (p = 0.023) than the Control group. However, there was no significant difference among the three groups regarding the identification of anatomical landmarks. The VR and 3DP groups gave satisfactory subjective feedback about the usefulness in learning, good presentation, and enjoyment. The Control and 3DP groups reported positive feelings about ease of use. Conclusion: The current findings suggest that VR and 3DP models were effective instruments that assisted in the morphological understanding of SSRO-related anatomical structures. Furthermore, 3DP models may be a promising supplementary instrument to bridge the gap between conventional learning and clinical practice.

Objective:To study the clinical effect of dynamic reconstruction of lower lip defect after squamous cell cancer resection by using unilateral Gillies fan flap and perioral muscle restoration.Methods:From Feburary 2017 to January 2020, 8 patients (6 female and 2 male, aged 55-81, 62.9 in average)diagnosed lower lip squamous cell carcinoma were accepted treatment in the Department of Otolaryngology Head & Neck Surgery, the First Affiliated Hospital of Xiamen University. All the moderate lower lip defect after cancer resection were repaired with unilateral Gillies fan flap with perioral muscle restoration under general anesthesia. The length of the vermilion of the upper lip in the Gillies fan flap was designed to be 1/3 of the length of the vermilion of the lower lip defect. The composite axial flap was prepared with the blood supply from contralateral upper lip artery-ipsilateral upper lip artery-mouth corner part of facial artery-ipsilateral lower lip artery.The end of all the perioral muscles were also prepared. After reconstruction of the continuity of the orbicularis oris, the ends of these perioral radiation muscles were restored in the position where they should be in the reconstructed lip.These perioral muscles training were undergone for 6 months after operation. After the reconstructed lip tend to be stable, measurement and calculation were carried out to evaluate the appearance, opening and closing functions of the mouth.Results:In our series of 8 cases, the length of the vermilion of the upper/lower lip was 52.4 mm(46.0-60.0 mm) in average; the circumference of the vermilion was 104.8 mm(92-120 mm)in average; the length of the defect of lower lip was 27.6 mm (21.0-35.0 mm)in average, 52.5% (42.0-67.3%) of the vermilion of lower lip. Six cases were using the right-side flap, and the other 2 cases were left. The length of the vermilion of the upper lip in the Gillies fan flap was 9.5 mm(7.0-12.0 mm)in average.All cases healed well with inconspicuous scar. No infection, hematoma or other surgical complications.No local or distant recurrence of cancer was observed during the follow-up period. Numbness of the lower lip happened posto-peration, and gradually disappeared 6 months later.Evaluation was conducted according to the measurement result preoperatively and 6 months postoperatively. (1) Appearance: the reconstructed lips were naturally symmetrical. Both side of the mouth corner were in the same horizontal level. The upper lip was lengthened with average increase of 6.8 mm and average increase rate of 15.9%. The lower lip was lengthened with average increase of 15.4 mm and average increase rate of 45.3%. In the rest situation, the circumference of the lips decreased by 5.5 mm in average compared with that preoperatively, which was 94.9% of the lip preoperatively, basically rehabilitate to the shape preoperatively.(2) Mouth-opening function: 1 week postoperation, the opening shape of mouth in all the cases was skewed with an about 1.5 fingers mouth-opening. Six months later, the opening shape of mouth was basically symmetrical round with a 3 fingers mouth-opening; in maximum mouth opening situation, the circumference of the lips decreased by 46.5 mm in average compared with that preoperatively, which was 73.1% of the lip in maximum mouth opening situation preoperatively, basically meeting physiological needs. (3) Mouth-closing function: All patient shave complete mouth-closing function and speech function.No leakage when making closed lip sound and whistling. All patients were satisfied with the oral appearance and the function of opening and closing mouth.Conclusions:Unilateral Gillies fan flap with perioral muscle restoration is a reliable method to repair the moderate full-thickness defect of the lower lip after cancer resection. After dynamic reconstruction of the perioral muscle group, the insufficient tissue of lips can be extended to obtain sufficient mouth opening, natural corner of the mouth and symmetrical lip appearance.

PURPOSE:Although body image disturbance (BID), anxiety, depression, and obsessive-compulsive disorder (OCD) are the most common comorbid psychological conditions among patients presenting for orthognathic surgery (OS), little is known about whether psychological symptoms relate to facial deformity or how symptoms change after OS. To fill these knowledge gaps, this study investigated preoperative and postoperative psychological symptoms and preoperative baseline facial deformity in patients who underwent OS. PATIENTS AND METHODS:This study included 49 patients who underwent OS by a single surgeon between 2011 and 2018. The patients completed validated psychological tests to assess symptoms of anxiety (Beck Anxiety Inventory), depression (Patient Health Questionnaire-9), BID (BID Questionnaire, BIDQ), and OCD (Florida Obsessive-Compulsive Inventory). In addition, we measured severity of preoperative facial deformity with the Facial Aesthetic Index (FAI). We compared preoperative and postoperative symptoms using univariate nonparametric Wilcoxon signed rank tests. We tested associations between the 4 types of preoperative psychological symptoms and baseline Facial Aesthetic Index category using Spearman's rank correlations. RESULTS:Postoperatively, both BIDQ scores (median 2 to 1.2, P < .001) and Florida Obsessive-Compulsive Inventory scores (median number of OCD symptoms 1 to 0, P < .001) decreased, whereas anxiety and depression symptoms showed no change (P > .45). Preoperative BIDQ was significantly associated with the severity of the facial deformity (ρ = 0.32, P = .025; median BIDQ: mild FAI = 1.0, severe FAI = 2.1). CONCLUSIONS:Our results show that patients with more severe facial deformity have a higher BID preoperatively and that both BID and OCD improve after OS. Interestingly, anxiety and depression symptoms did not change after OS.

Objective To discuss the efficacy of computer aided design ( CAD) and computer aided manufacturing ( CAM) in the treatment of microgenia by osseous genioplasty. Methods From July 2015 to January 2018, 17 cases (Male, n=5, Female, n=12), aged from 17 to 32 years, with the meanage of 24 years, were enrolled. All patients had microgenia, and underwent osseous genioplasty. Computed tomography ( CT) was performed preoperatively and 7-10 days postoperatively for all cases. Based on preoperative CT data, CAD was applied to make individualized surgical plan, surgery simulation, todetermine the movement of mentum. CAM was used to prefabricate the individualized surgical templates and transfer the CAD into intraoperative guidance. The registration of CAD and postoperative CT were performed to evaluate the surgical accuracy.Results All patients were satisfied with the surgical outcomes. The deformity of microgenia was significantly corrected. The Pg error was (0. 24±0. 08) mm, and the Me error was ( 0. 15 ± 0. 17) mm. Conclusions The application of CAD increases the accuracy of surgical planning, and CAM provides areliable guidance with individualized template. Anoptimal surgical outcome can be achieved.

Introduction: The multidimensional atrophy of progressive hemifacial atrophy(PHA) makes quantitative analyses complicated. In mild to moderate PHA, plastic surgeons have mainly focused on the restoration of soft tissue deficiencies. While, bone deficits are easily overlooked. This study aims to introduce a symmetric classification with quantitative references for PHA patients and to develop a computer-assisted sequential treatment combines the autologous mandibular outer cortex(MOC) grafting with fat grafting to improve the surgical outcomes. Methods: 37 patients with PHA were enrolled. The soft and bony symmetric values included the Asymmetry Index(AI), the Asymmetry Rate(AR), the Volume Deficiency Rate(VDR) and the Midline Deformation Rate(MDR) were calculated respectively on the established 3D coordinate system. According to the proportion of soft tissue and bone from AI,AR,VDR,MDR with relationship with “1”, we classified PHA into 2 types: type I, all 4 proportions were greater than 1, the soft tissue deficiency primarily lead to the facial asymmetry and should firstly be repaired; type IIa, 4 proportions were either greater or less than 1, the deficiency involved both soft tissue and bone, the treatment combined bony reconstruction with soft tissue restoration was recommended; type IIb, all 4 proportions were less than 1, the deficiency involved both soft tissue and bone, the bony atrophy should firstly be repaired. From 2015 to 2018, 15 patients with PHA were enrolled and classified into the 2 types. All 15 patients received computer-assisted sequential surgical procedure combined autologous MOC grafting with fat grafting simultaneously or 6 months later. The accuracy and the absorption rate of MOC grafting, and the percentage volume maintenance(PVM) of fat grafting were assessed. Surgeons’ attitude towards the practicability of surgical templates and patients’ satisfaction were evaluated with Likert scale. Results: All 15 patients achieved significant symmetry and high satisfaction. The MOC thickness(MOC-T) accuracy was 5.91±2.91% and the MOC volume(MOC-V) accuracy was 2.59±1.49%. The MOC-V absorption rate was 19.09±3.61% at 6 months follow up. The first and second PVM of fat grafting was 55.82±9.7% and 58.58±5.86% respectively. The good symmetry and high stabilization can be seen at long term follow ups. Conclusion: The symmetric classification of PHA can guide the treatment principle and can also be a supplement of other classifications. The computer-assisted sequential treatment combines MOC grafting with fat grafting based on the symmetric classification of PHA significantly improved the facial symmetry.

The AO CMF has recently launched the first comprehensive classification system for craniomaxillofacial (CMF) fractures. The AO CMF classification system uses a hierarchical framework with three levels of growing complexity (levels 1, 2, and 3). Level 1 of the system identifies the presence of fractures in four anatomic areas (mandible, midface, skull base, and cranial vault). Level 2 variables describe the location of the fractures within those defined areas. Level 3 variables describe details of fracture morphology such as fragmentation, displacement, and dislocation. This multiplanar radiographic image-based AO CMF trauma classification system is constantly evolving and beginning to enter worldwide application. A validation of the system is mandatory prior to a reliable communication and data processing in clinical and research environments. This interobserver reliability and accuracy study is aiming to validate the three current modules of the AO CMF classification system for mandible trauma in adults. To assess the performance of the system at the different precision levels, it focuses on the fracture location within the mandibular regions and condylar process subregions as core components giving only secondary attention to morphologic variables. A total of 15 subjects individually assigned the location and features of mandibular fractures in 200 CT scans using the AO CMF classification system. The results of these ratings were then statistically evaluated for interobserver reliability by Fleiss' kappa and accuracy by percentage agreement with an experienced reference assessor. The scores were used to determine if the variables of levels 2 and 3 were appropriate tools for valid classification. Interobserver reliability and accuracy were compared by hierarchy of variables (level 2 vs. level 3), by anatomical region and subregion, and by assessor experience level using Kruskal-Wallis and Wilcoxon's rank-sum tests. The AO CMF classification system was determined to be reliable and accurate for classifying mandibular fractures for most levels 2 and 3 variables. Level 2 variables had significantly higher interobserver reliability than level 3 variables (median kappa: 0.69 vs. 0.59, p < 0.001) as well as higher accuracy (median agreement: 94 vs. 91%, p < 0.001). Accuracy was adequate for most variables, but lower reliability was observed for condylar head fractures, fragmentation of condylar neck fractures, displacement types and direction of the condylar process overall, as well as the condylar neck and base fractures. Assessors with more clinical experience demonstrated higher reliability (median kappa high experience 0.66 vs. medium 0.59 vs. low 0.48, p < 0.001). Assessors with experience using the classification software also had higher reliability than their less experienced counterparts (median kappa: 0.76 vs. 0.57, p < 0.001). At present, the AO CMF classification system for mandibular fractures is suited for both clinical and research settings for level 2 variables. Accuracy and reliability decrease for level 3 variables specifically concerning fractures and displacement of condylar process fractures. This will require further investigation into why these fractures were characterized unreliably, which would guide modifications of the system and future instructions for its usage.

Key PointsQuestionCan use of a novel intraoral training model and surgical templates improve mandibular contour surgery (MCS) training and surgical results? FindingsThis prospective, observational study including 90 patients and 15 fellow physicians, compared the use of (A) an intraoral MCS training system including intraoral MCS training models and surgical templates; (B) the intraoral MCS training models without surgical templates; and (C) standard training as a control group. Use of both interventions decreased clinical surgery time, improved surgical accuracy, and shortened the learning curve compared with the control group, but the use of templates with the intraoral MCS training models was associated with the best results among the 3 groups. MeaningThe intraoral MCS training system improved MCS training among fellow physicians and surgical outcomes for patients; the optimal intraoral MCS training system included intraoral MCS training models and surgical templates. This study compared the use of an intraoral mandibular contour surgeries (MCS) training system including intraoral MCS training models and surgical templates, the intraoral MCS training models without surgical templates, and standard training as a control group. ImportanceMandibular contour surgeries (MCS) involving reduction gonioplasty and genioplasty are rewarding for patients with square faces; however, the procedure has inherently difficult clinician learning curves and unpredictable skill acquisitions. To our knowledge, there has been no effective, validated training model that might improve training and surgical outcomes for MCS. ObjectiveTo establish and evaluate a standardized intraoral MCS training system. Design, Setting, and ParticipantsIntraoral MCS training models were constructed by 3-dimensional (3D) skull models covered with elastic head cloths. From April 2016 to April 2018, 90 consecutive MCS patients (30 per group) and 15 craniofacial surgery fellow physicians (5 per group) were enrolled in the prospective observational study. They were randomly divided into intervention groups (A and B) and a control group (C). Intervention groups A and B completed 5 training sessions on the intraoral MCS training models before each clinical case. Group A performed both the model training sessions and clinical surgeries with surgical templates. Control group C had no extra training before clinical surgeries. All groups completed clinical surgery under supervision on 6 patients. The duration of follow-up was at least 3 months postoperatively. InterventionsIntraoral MCS training models were provided to intervention groups (A and B) before clinical surgeries. Surgical templates were provided to intervention group A both in training sessions and clinical surgeries. Main Outcomes and MeasuresThe completion time, surgical accuracy, learning curves, operating confidence, surgical skill, and outcome satisfaction of each procedure were recorded and analyzed with paired t test and 1-way analysis of variance test by blinded observers. ResultsAll 90 patients (14 men, 76 women; mean [SD] age, 26 [5] years) were satisfied with their postoperative mandible contours. The intervention groups (A and B), especially the group with surgical templates (A) showed improvements in clinical surgery time (mean [SD], group A 147.2 [24.71] min; group B, 184.47 [16.28] min; group C, 219.3 [35.3] min; P=.001), surgical accuracy (mean [SD], group A, 0.68 [0.22] mm; group B, 1.22 [0.38] mm; group C, 1.88 [0.54] mm; P<.001), learning curves, and operators' confidence and surgical skill. Conclusions and RelevanceThe intraoral MCS training model was effective and practical. The optimal intraoral MCS training system included intraoral MCS training models and surgical templates. The system significantly decreased clinical surgery time, improved surgical accuracy, shortened the learning curve, boosted operators' confidence, and was associated with better acquisition of surgical skills. Level of EvidenceNA.

Introduction: In East Asia, a square face with a short, receding chin is regarded as unattractive. Mandibular contour surgeries (MCS) involving reduction gonioplasty and genioplasty are extremely rewarding for patients with square faces. MCS have inherently difficult learning curves and unpredictable skill acquisitions. An effective training model might improve the training and surgical outcome. However, there is no effective training model for MCS. Therefore, we established and evaluated a standardized intraoral-MCS-training system. Methods: Intraoral-MCS-training models were constructed by three-dimensional(3D)-skull models covered with elastic head cloths. From April 2016 to April 2018, 90 consecutive MCS patients(30 per group) and 15 craniofacial surgery fellows(5 per group) were enrolled in the prospective observational study. They were randomly divided into experimental groups (A, B) and control group C. Experimental groups A and B completed 5 training sessions on the intraoral-MCS-training models before each clinical case. Group A performed both the model training sessions and clinical surgeries with surgical templates. Control group C had no extra training before clinical surgeries. All groups completed clinical surgery under supervision on 6 patients. The duration of follow-up was 3 months at least postoperatively. The completion time, the surgical accuracy, learning curves, operating confidence, surgical skill and outcome satisfaction of each procedure were recorded and analyzed with paired sample t-testing and 1-way ANOVA testing by blinded observers. Results: All 90 patients (14 males, 76 females; mean± SD age at surgery, 26.33±5.24) were satisfied with their postoperative mandible contours. Experimental groups(A, B), especially with surgical templates(A) showed great improvements in clinical surgery time(mean± SD, group A 147.2±24.71min, group B 184.47± 16.28min, group C 219.3± 35.3 min, P<0.001), surgical accuracy(mean± SD, group A 0.68±0.22 mm, group B 1.22±0.38mm, group C 1.88±0.54mm, P<0.001), the learning curves, operators’ confidence and surgical skill. Conclusion: The intraoral-MCS-training model is effective and practical. The optimal intraoral-MCS-training system includes intraoral-MCS-training models and surgical templates. The system significantly decreased the clinical surgery time, improved the surgical accuracy, shortened the learning curve, boosted operators’ confidence and achieved better acquisition of surgical skills.

Keloid is a dermal tumor with high recurrence rate. The immune system plays a critical role in preventing pathogen infiltration, inducing inflammation, initiating downstream processes, and recruiting fibrocytes in keloids. Interestingly, we observed a local, but not systemic, enrichment of Treg cells and Treg-associated gene expression at the keloid lesions compared to non-keloid tissues. Concurrently, keloid tissues presented significantly elevated expression of type I and type III collagen. Moreover, the level of collagen III and the collagen III-to-collagen I ratio were positively correlated with the level of FOXP3. To investigate whether Treg cells could directly promote the expression of collagen, fibrocytes were cocultured with autologous Treg cells. Activated Treg cells, but not quiescent Treg cells, were capable of promoting collagen expression. This response was more pronounced in keloid patients than in non-keloid controls, and required the secretion of TGF-β. Overall, these findings demonstrated a connection between collagen overexpression and imbalance and Treg dysregulation in keloid tissues.

Intraoral facial contour surgery is one of the most popular craniofacial cosmetic surgeries in China, in spite of its challenging surgical technique and serious complication, such as fracture and bleeding. In addition, the key point, such as inadequate tissue exposure and high soft tissue tension cannot be simulated using traditional three-dimensional model. Consequently, craniomaxillofacial surgery requires a long learning curve for young surgeons. This article describes the establishment and application of a new model for intraoral facial contour surgery. Compared to young surgeons trained using traditional three-dimensional model, the authors confirmed this new surgical model is more reliable and effective. Therefore, it is worthy of being popularized.

Reduction malarplasty is a popular facial skeletal contour surgery in East Asia. Zygomatic nonunion is a reported complication. However, it is often misunderstood and misdiagnosed. Here we present typical misdiagnosed zygomatic nonunion cases, propose and preliminarily clarify 4 major misunderstandings of zygomatic nonunion: diagnostic standard, the cause, the incidence, and the prognosis of zygomatic nonunion.

Background Reduction gonioplasty is very popular in East Asia. However, there has been little quantitative criteria for mandibular angle classification or aesthetics. The aim of this study was to investigate the quantitative differences of mandibular angle types and determine the morphologic features of mandibular angle in attractive women. Methods We created a database of skull computed tomography and standardized frontal and lateral photographs of 96 Chinese female adults. Mandibular angle was classified into 3 groups, namely, extraversion, introversion, and healthy group, based on the position of gonion. We used a 5-point Likert scale to quantify attractiveness based on photographs. Those who scored 4 or higher were defined as attractive women. Three types of computed tomography measurements of the mandible were taken, including 4 distances, 4 angles, and 3 proportions. Discriminant analysis was applied to establish a mathematic model for mandibular angle aesthetics evaluation. Results Significant differences were observed between the different types of mandibular angle in lower facial width (Go(l)-Go(r)), mandibular angle (Co-Go-Me), and gonion divergence angle (Go(l)-Me-Go(r)) (P < 0.01). Chinese attractive women had a mandibular angle of 123.913 2.989 degrees, a FH-MP of 27.033 +/- 2.695 degrees, and a Go-Me/Co-Go index of 2.0. The healthy women had a mandibular angle of 116.402 +/- 5.373 degrees, a FH-MP of 19.556 +/- 5.999 degrees, and a Go-Me/Co-Go index of 1.6. The estimated Fisher linear discriminant function for the identification of attractive women was as follows: Y = -0.1516X(1)(Co-Go) + 0.128X(2)(Go-Me) + 0.04936X(3)(Co-Go-Me) +0.0218X(4)(FH-MP). Conclusions Our study quantified the differences of mandibular angle types and identified the morphological features of mandibular angle in attractive Chinese female adults. Our results could assist plastic surgeons in presurgical designing of new aesthetic gonion and help to evaluate lower face aesthetics.

Background: Interpositional arthroplasty (IPA) with temporalis fascia flap has been one of the most frequently performed procedures to treat temporomandibular joint (TMJ) ankylosis. However, recurrence often occurs when the flap lacks bulk or atrophies. Whether to perform IPA or distraction osteogenesis (DO) first has long been a controversial issue when patients presented mandibular dysplasia (MD). This study provided IPA a new graft material sufficient to prevent recurrence, combined the modified protocol of performing DO 6 months after IPA, and evaluated its efficacy in treating TMJ ankylosis patients with MD. Methods: Six patients with unilateral TMJ ankylosis and MD were treated in the authors’ study. The temporalis fascia flap and part of adjacent galea aponeurotica were filled the space after surgical release. Mouth-opening exercises started immediately post-IPA. Distraction osteogenesis was performed 6 months after IPA and had a 4-month consolidation. The maximum interincisal distance at preoperative, immediately post-IPA and the latest follow-up were recorded, as was the distraction length. The body mass index was measured at each patient's postoperative visit. Result: All patients had significant improvements in facial aesthetic, mouth-opening, and occlusion. No major complication or recurrence was observed at 3 to 4 years’ follow-up. The mean maximum interincisal distance was 4.83 ± 2.79 mm preoperative and 35.67 ± 3.39 mm at the latest follow-up. The mean distraction distance was 16.17 ± 5.98 mm. The body mass index improved from 17.33 ± 0.64 kg/m2 preoperative to 18.75 ± 0.60 kg/m2 before DO. Conclusions: Temporalis fascia flap and adjacent galea aponeurotica as new graft materials are recommended for IPA. The modified staged treatment proved to be reliable and effective to prevent recurrence, improve mandibular length and final occlusion.

Objective To observe the clinical effect of osteotomy of the outer mandibular cortex combined with CHA implantation for mandibular hypoplasia caused by hemifacial microsomia. To evaluate the postoperative effect of the method and analyse the range of application and the advantage of the method of the surgery may exist. Methods There were 5 patients of Pruzansky -Kaban type Ⅰ or type Ⅱa hemifacial microsomia treated with the method of osteotomy of the outer mandibular cortex combined with coralline hydroxyapatite implantation. Follow-up visits were conducted for 6 to 24 months to monitor. To observe the postoperative effect by the imaging and three-dimensional CT reconstruction. Results With the thickness of mandibular increased significantly after 6 months, significant improvements in the asymmetry of the mandible as well as in the aesthetic appearance of all the patients were observed. Conclusion On account of lower complications and bone absorption rate, the osteotomy of the outer mandibular cortex combined with CHA implantation is a useful method for hemifacial microsomia.