Long-term stability of limiting nasal alar base width changes with a cinch suture following Le Fort I osteotomy with submental intubation

Systematic mapping review of orthognathic surgery

STUDY DESIGN

Systematic mapping review AIM AND SCOPE: The objective of this mapping review was to identify, describe, and organize clinical research currently available from systematic reviews and primary studies regarding co-interventions and different surgical modalities used in orthognathic surgery (OS) and their outcomes.

METHODS

Systematic reviews (SRs), randomized controlled trials, and observational studies that evaluated perioperative OS co-interventions and surgical modalities were identified in an exhaustive search of MEDLINE, EMBASE, Epistemonikos, Lilacs, Web of Science, and CENTRAL. Grey literature was also screened.

RESULTS

Included were 35 SRs and 253 primary studies, 103 from SRs, and another 150 identified in our search. Overall, SR quality was rated as critically low, with only two SRs rated as of high quality. 19 questions on population, interventions, comparisons, and outcomes (PICO) extracted from the SRs focused on osteosynthesis methods, surgical cutting devices, and use of antibiotics, corticosteroids, and induced hypotension. Also identified were 15 research gaps. Evidence bubble maps were created to graphically depict the available evidence.

CONCLUSION

Future high-quality research, both primary and secondary, is needed to address the knowledge gaps identified in this systematic mapping review.

The Effect of Absorbable and Non-Absorbable Sutures on Nasal Width Following Cinch Sutures in Orthognathic Surgery

Background: Non-absorbable materials (nylon) are always used in cinch sutures to maintain nasal width and to improve harmonious facial symmetry in orthognathic surgery. However, a few drawbacks of nylon materials have been clinically reported following orthognathic surgery, such as nasal irritation and exposure of the sutures. An absorbable material (PDS) has been proposed in cinch sutures, not only to avoid the complications of nylon but also to stabilize the nasal width for a long-term follow-up. Methods: Fifty-seven patients with Angle’s malocclusion classification III receiving orthognathic surgery were enrolled in this study. A non-absorbable material (nylon) and an absorbable material (PDS) were utilized for the cinch sutures. Pre-operative (T1) and post-operative six-month (T2) craniofacial 3D images were collected for all patients to measure the alar curvature (Ac) width and the alar base (Al) width. A significance level of p < 0.05 was applied in the statistical analysis. Results: With the approval of IRB, cinch suturing was performed with nylon in 29 patients and with PDS in 28 patients. Pre-operative Ac and Al distances showed no significant difference between these two groups. There were also no significant differences between the suture materials in the peri-operative change in nasal width, including Ac (nylon: 1.999 ± 1.40; PDS: 1.484 ± 0.97; p = 0.112) and Al (nylon: 1.861 ± 1.66; PDS: 1.115 ± 0.92; p = 0.056). Conclusions: For cinch sutures in orthognathic surgery, PDS can maintain the peri-operative nasal width similarly to nylon; additionally, it can be absorbed in a timely manner without the drawbacks of non-absorbable materials.

Impact of the Different Types of Le Fort I Maxillary Surgical Movement on Nasal Width Changes: A Photogrammetric Analysis

BACKGROUND

Le Fort I maxillary movements affect nasal width, but nasal width changes with specific movement types have not been formally addressed to date.

OBJECTIVES

The purpose of this study was to analyze and compare the changes in nasal width with different maxillary movements.

METHODS

A retrospective study was performed among consecutive patients who underwent bimaxillary orthognathic surgery (n = 138) and who were grouped based on the type of maxillary movement (ie, maxillary advancement with intrusion [MAI], maxillary advancement with extrusion [MAE], and maxillary setback with intrusion [MSI]). Preoperative and 12-month postoperative nasal widths were analyzed photogrammetrically by 2 blinded evaluators.

RESULTS

Maxillary advancement with intrusion and MAE presented a significantly (P < 0.05) higher alar base widening than MSI did, with no significant (P > 0.05) differences between MAI and MAE. Maxillary advancement movements (MAI and MAE) showed significantly (P < 0.05) higher alar base widening than maxillary setback movement (MSI). However, no significant (P > 0.05) difference was observed between maxillary intrusion (MAI and MSI) and maxillary extrusion (MAE) movements.

CONCLUSIONS

This study shows that the nasal width varies distinctly depending on the type of Le Fort I maxillary surgical movement.

Catgut Versus Polypropylene Sutures for Transcolumellar Incision Closure in Open Rhinoplasty: A Retrospective Cohort Study

Background

Open rhinoplasty, including the transcolumellar approach, is commonly performed as it has fewer side effects and provides superior anatomical control to the surgeons compared to closed rhinoplasty. However, the postoperative scar outcomes, such as scar appearance, vary depending on the type of suture used in wound closure, and the optimal suture type is not firmly established.

Objective

To compare the impact of catgut versus polypropylene sutures on the postoperative transcolumellar scar outcomes and patient satisfaction following open rhinoplasty.

Methods

This retrospective cohort study, including 100 patients who underwent transcolumellar open rhinoplasty, was conducted at otolaryngology department of King Abdulaziz University Hospital, Riyadh, KSA. The patients were divided into two groups: the propylene suture group (group 1), which included 15 males and 35 females with a mean age of 31.5 years and underwent surgery using propylene sutures, and the catgut suture group (group 2), which included 10 males and 40 females with a mean age of 30.5 years and underwent surgery using catgut sutures. The postoperative transcolumellar scar outcomes, as determined by visual analogue scale (VAS) and Stony Brook Scar Evaluation Scale (SBSES) scores, and patient satisfaction, as assessed using a self-assessment scale, were compared between groups.

Results

The scars were unnoticeable in the majority of both groups: 88% in group 1 and 86% in group 2. The VAS and SBSES scores did not significantly differ between groups. Patients' satisfaction rates were also comparable and did not significantly differ between groups (p = 0.341).

Conclusion

Both catgut and polypropylene sutures lead to similar outcomes and patient satisfaction rates in terms of postoperative rhinoplasty transcolumellar scars. Thus, catgut may be the optimal suture for closing transcolumellar incisions following open rhinoplasty.

Nasolabial angle and nasal tip elevation changes in profile view following a Le Fort I osteotomy with or without the use of an alar base cinch suture: a long-term cohort study

OBJECTIVES

Cinch sutures attempt to counteract alar base widening but may lead to unintended increases in the nasolabial angle and nasal tip elevation. The aim of this investigation was to assess nasolabial angle changes after maxillary osteotomies with and without alar base cinch sutures in the short and long terms.

STUDY DESIGN

Seventy-eight patients were assessed, with 51 in the cinch group (38 females, 13 males; age range 16-39 years) and 27 in the no-cinch group (12 females, 15 males; age range 17-27 years). The upper component (nasal tip elevation), lower component (lower lip inclination), and the overall nasolabial angle were measured on preoperative, postoperative, and long-term follow-up lateral cephalometric radiographs.

RESULTS

The overall nasolabial angle (P = .006) and its upper component (P < .001) increased significantly in the cinch group immediately postoperatively but resolved by 6 to 12 months for the overall nasolabial angle and by 12+ months (up to 5.7 years) for the upper component. There were no significant changes in the no-cinch group.

CONCLUSIONS

In the short term, the alar base cinch suture increases nasal tip elevation and the overall nasolabial angle. In the long term, there was no significant difference, suggesting that the initial nasal tip elevation resolves over time and that the cinch suture may have a limited effect on nasal tip elevation in the longer term.

Patient- and 3D morphometry-based nose outcomes after skeletofacial reconstruction

Patient satisfaction with the shape and appearance of their nose after orthognathic surgery-based skeletofacial reconstruction is an important, but often overlooked, outcome. We assessed the nose-related outcomes through a recently developed patient-reported outcome instrument and a widely adopted 3D computer-based objective outcome instrument, to verify any correlation in the results produced by these tools. We collected FACE-Q nose appearance reports (2 scales) and 3D nasal morphometry (10 parameters) from patients with class III skeletal pattern and congenital cleft lip palate deformity (n = 23) or developmental dentofacial deformity (n = 23) after (>12 months) skeletofacial reconstruction. The cleft and dentofacial cohorts demonstrated significantly (p < 0.001) poorer satisfaction scores with regard to the FACE-Q nostrils scale than the normal age-, gender-, and ethnicity-matched subjects (n = 107), without any significant difference in FACE-Q nose scale. The cleft cohort had significantly (p < 0.001) smaller nasal length, nasal tip projection, and columellar angle and greater nasal protrusion, alar width, and columellar-labial angle values than the dentofacial and normal cohorts; however, there were no significant differences between the dentofacial versus normal cohorts. The FACE-Q nose and nostrils scales were significantly (p < 0.001; r = -0.26-0.27) correlated to the results of the 3D morphometric analysis, with regard to nasal length, alar width, columella angle, and columellar-labial angle parameters. This study revealed differences in satisfaction with the appearance of the nose according to the type of underlying deformity, and demonstrated a significant correlation (low correlation coefficients) between the patient-reports and 3D image-based outcome measure tools, which has implications for multidisciplinary-centered research, auditing, and clinical care.

Nasolabial soft tissue effects of segmented and non-segmented Le Fort I osteotomy using a modified alar cinch technique-a cone beam computed tomography evaluation

The aim of this study was to verify soft tissues changes and the effect of a minimally invasive surgical technique in the nasolabial region after segmented and non-segmented Le Fort I osteotomy, using cone beam computed tomography (CBCT) evaluation of three-dimensional (3D) volume surfaces. Two groups were evaluated: group 1, bimaxillary surgery with maxillary segmentation (n=40); group 2, bimaxillary surgery without maxillary segmentation (n=40). In both groups, a specific alar cinching technique was used to control nasal base broadening. CBCT evaluation was performed at three different treatment time points: T0, 1 month before surgery; T1, 1 month after surgery; T2, 1year after surgery. The results showed statistically significant differences in the nasolabial area (P<0.001). For group 1, the mean change in alar base width (Al_inf-Al_inf) was 1.31±1.40mm at T1 and 0.93±1.77mm at T2; for group 2 these values were 1.12±2.01mm at T1 and 0.54±1.54mm at T2. For group 1, the mean changes in inter-alar width (Al-Al) were 1.68±1.46mm at T1 and 1.49±1.33mm at T2; for group 2, they were 2.22±1.93mm at T1 and 1.34±1.79mm at T2. The alar cinch technique proposed here appears to be effective in controlling nasolabial soft tissue widening.

Clinical Anatomy of Submental Intubation: A Review of the Indications, Technique, and a Modified Approach

Since its original description in 1986 by Hernandez, submental intubation has been used in a wide variety of craniomaxillofacial cases as a way to satisfy both surgeon and anesthesiologist to provide access to necessary surgical sites and airway protection. Many modifications to the original technique have been described. There has been a paucity of plastic surgery literature over the last 10 years that have reviewed the anatomy, technique, and complications. In this article, the authors review the pertinent anatomy related to this method of intubation. A cadaver was used to enhance visualization of important structures and to show the modification used by our group. Submental intubation provides a useful alternative to tracheostomy in several craniomaxillofacial procedures. Our approach uses a reinforced endotracheal tube to prevent kinking and provide additional intraoperative protection of the airway. Submental intubation may be indicated in select patients undergoing craniomaxillofacial surgery. Therefore, it is pertinent to be aware of the important anatomy and the complications of this technique to appropriately counsel patients. Our modification provides safe airway control.

Review of nasal changes with maxillary orthognathic surgery

This article reviews the literature on nasal changes with maxillary orthognathic surgery. Understanding such changes is vital for surgical planning and for obtaining appropriate informed consent, and there are medico-legal implications. During orthognathic surgical planning a prediction of the effects of the different surgical movements is possible and this forms part of the basis of the planning stage. The predicted changes need to be identified and their desirability or not for each individual patient determined. Some techniques for managing undesirable nasal changes are discussed, including adjunct measures to minimize these potential effects (e.g. cinch sutures), and additional surgical procedures to manage the undesired nasal changes once they are produced.