Nonsurgical Rhinoplasty With the Novel Hyaluronic Acid Filler VYC-25L: Results Using a Nasal Grid Approach

BACKGROUND

Nonsurgical aesthetic treatment of the nose is becoming increasingly popular. VYC-25L is a novel hyaluronic acid product with the high G' and cohesivity required of a nasal filler.

OBJECTIVES

The authors sought to assess the safety and efficacy of VYC-25L for treatment of the nose utilizing a previously published, grid-based protocol.

METHODS

This was a retrospective, single-center analysis of data from adult patients undergoing treatment of the nose with VYC-25L between February and April 2019 utilizing the grid system as the reference for injection quantity and sequencing. Specific procedures included correction of inadequate projection, deep glabella treatment, correction of a nasal hump, and adjustment of the nasolabial angle and columella. Patients were followed-up for 6 to 9 months.

RESULTS

A total of 61 patients were included in the analysis (mean age, 32 ± 3 years; n = 45 females [74%]). At 2 weeks posttreatment, a high degree of defect correction was confirmed based on independent evaluation, with all patients scoring 9 or 10 on a 10-point visual analog scale. Fifty-nine of 61 patients (97%) self-assessed the degree of correction as "adequate." Results were stable at 3- and 6-month follow-up visits. Complications recorded were bruising (n = 15, 25%), asymmetry (n = 2, 3%), and hematoma (n = 1, 2%). All resolved rapidly. There were no cases of infection, bumps, or skin necrosis.

CONCLUSIONS

VYC-25L is safe and efficacious for treatment of the nose, with high levels of patient satisfaction. It has potential to be a valuable tool in nonsurgical rhinoplasty.

LEVEL OF EVIDENCE: 4

"Dynamic Canthopexy" Drill Hole Canthal Repositioning

BACKGROUND

Canthopexies can be performed to modify the eye slant, both when the lateral canthus is lower than the medial one (congenital defect) or in case the patient asks for an almond-shaped eye (cosmetic indication).

OBJECTIVES

This peculiar type of canthopexy can be defined as "dynamic canthopexy," meaning that the lateral canthus is released from its original insertion and raised to a higher position. The goal of this study is to demonstrate the differences and the efficacy of the dynamic cantoplasty.

METHODS

The authors reviewed 30 patients treated with a "dynamic canthopexy" between January 2005 and March 2015. Eighteen patients were affected by true downslanting palpebral fissure, and 12 patients had a normal eye shape but were wishing for a more "Asian" look. Dynamic canthopexy involves a total modification of the canthal suspension system and its careful reconstruction at a higher level inside the orbital rim. To obtain a permanent result, canthal ligament and tendon had to be anchored to drill holes in the orbital rim bone with nonabsorbable sutures. Symmetry was very carefully assessed. The average surgical time was 1 hour.

RESULTS

This surgery proved extremely effective in all cases. Patients must be warned, though, that an initial hypercorrection is necessary to achieve the desired canthal position. About 6 months after surgery the result of this operation can be considered permanent. Severe complications are rare.

CONCLUSIONS

Dynamic canthopexy can provide stable correction of anti-Mongolian slant. It can also be effectively employed to obtain permanent slant eyes when required by purely cosmetic patients. If precisely carried out, this technique can yield very rewarding outcomes.

LEVEL OF EVIDENCE: 4

Face Treatment Using Nonsurgical Mini-Invasive Techniques as Postsurgical Procedure for Traumatic Injury

BACKGROUND

Facial trauma can cause major psychological damage and compromise a patient's quality of life. Unfortunately, surgery cannot always solve this problem or provide an acceptable result.

OBJECTIVES

Treatment with injectables may provide a solution that is minimally invasive and better accepted by patients as a means to improve poor outcomes after facial trauma.

METHODS

This retrospective study involved 50 patients (29 men, 21 women) who underwent primary surgery to treat facial trauma between January 2015 and January 2017. Based on the facial area affected by poor outcomes (upper face, midface, and lower face), patients underwent ≥1 aesthetic medicine treatments with hyaluronic acid dermal fillers and botulinum toxin injections. To evaluate patient satisfaction and the effect of the treatment on quality of life, patients were asked to complete 2 questionnaires, POSAS and FACE-Q, prior to treatment and 90 days after the last treatment session.

RESULTS

Questionnaire scores indicated improvements in aesthetic and psychological metrics, perceived both by the patient and the observer.

CONCLUSIONS

Minimally invasive aesthetic treatments represent a valuable adjunct to surgical procedures for improving facial aesthetics after injury and consequently the quality of life of patients affected by facial trauma.

LEVEL OF EVIDENCE: 4

Regenerative potential of the Bichat fat pad determined by the quantification of multilineage differentiating stress enduring cells

Published studies regarding Bichat fat pad focused, quite exclusively, on the implant of this adipose depot for different facial portions reconstruction. The regenerative components of Bichat fat pad were poorly investigated. The present study aimed to describe by an ultrastructural approach the Bichat fat pad, providing novel data at the ultrastructural and cellular level. This data sets improve the knowledge about the usefulness of the Bichat fat pad in regenerative and reconstructive surgery.

Bichat fat pads were harvested form eight patients subjected to maxillofacial, dental and aesthetic surgeries. Biopsies were used for the isolation of mesenchymal cell compartment and for ultrastructural analysis. Respectively, Bichat fat pads were either digested and placed in culture for the characterization of mesenchymal stem cells (MSCs) or were fixed in 2% glutaraldehyde and processed for transmission or scanning electron microscopy. Collected data showed very interesting features regarding the cellular composition of the Bichat fat pad and, in particular, experiments aimed to characterized the MSCs showed the presence of a sub-population of MSCs characterized by the expression of specific markers that allow to classify them as multilineage differentiating stress enduring cells. This data set allows to collect novel information about regenerative potential of Bichat fat pad that could explain the success of its employment in reconstructive and regenerative medicine.

Variations of the profile of the nose of the upper lip

BACKGROUND

The aim of this study is to analyze the path needed to achieve a good aesthetic and functional result in patients treated with orthognathic surgery.

METHODS

Seventy-three patients with only III class malocclusion were treated with sagittal split ramus osteotomy and with Le Fort I in only one piece. Through the analysis of anatomical cephalometric tracings, changes in the skeletal base, upper incisor and nose's shape were evaluated. The statistical analysis measurements were calculated for each length and for each angle at T0 (preoperative value) and at T1 (postoperative value).

RESULTS

A significant statistical correlation was found mainly between forward movement of the upper maxilla and the outline of the nose, the nasal projection, and the naso-labial angle (NLA). The upper incisor in movements of verticality and inclination did not show any significant correlations with modifications of the NLA.

CONCLUSIONS

A significant correlation can be seen between the forward movements of the upper maxilla with the outline of the nose, the nasal projection and the Naso-Labial Angle.

Osteoconductivity of Complex Biomaterials Assayed by Fluorescent-Engineered Osteoblast-like Cells

Biomaterials employed for the bone regeneration can be assayed for specific features such as osteoconductivity and gene expression. In this study, the composite HA/collagen/chondroitin-sulfate biomaterial was investigated using an engineered human cell line, named Saos-eGFP. This cell line, a green fluorescent engineered human osteoblast-like cell, was employed as a cellular model for the in vitro study of biomaterial characteristics. The cytotoxicity was indirectly evaluated by fluorescence detection, osteoconductivity was assayed both by fluorescence and electron microscope analysis as well as cell morphology, whereas the RT-PCR technique was employed to assay gene expression. Saos-eGFP cells viability detection after 24 and 96 h of incubation showed that biomaterial enables the adhesion and proliferation of seeded cells as well as that of the plastic surface, the control. Fluorescence and scanning electron microscopy (SEM) analyses indicated that Saos-eGFP cells were homogeneously distributed on the HA granule surfaces, exhibiting cytoplasmic bridges, and were localized on the collagen-chondroitin sulfate extra-cellular matrix. An expression analysis of specific genes encoding for differentiation markers, showed that biomaterial assayed did not alter the osteogenic pathway of the Saos-eGFP cell line. Our assays confirm the cytocompatibility of this biomaterial, suggesting an osteoconductive capacity mediated by its chemical contents. We showed that the Saos-eGFP cellular model is suitable for in vitro biomaterial assays, and more specifically for assessing osteoconductivity. This result suggests that the cytocompatibility and osteoconductive features of the biomaterial assayed as bone substitute, could have a positive downstream effect on implant osteo-integration.

Surgical management of ocular symptoms in spheno-orbital meningiomas. Is orbital reconstruction really necessary?

Spheno-orbital meningioma (SOM) is an intriguing tumor because of the many different factors that can influence clinical and oncological outcome after treatment. Reasoning that outcome indicator measurement is key to improving therapy, we retrospectively evaluated the management of proptosis and other ocular symptoms in 47 patients surgically treated for SOM at our department in the last 10 years. This patient series was characterized by a high rate of tumor infiltration of the extradural cranial base. Clinical outcome was assessed by comparing preoperative and postoperative ophthalmological and neurological signs. Acute postoperative complications were reported, and clinical and radiological outcome was assessed at 4-6 months, 12 months, and the last follow-up. Proptosis (measured by Hertel exophthalmometry), visual acuity, visual field defect (measured by Goldmann perimetry), diplopia (measured by the Hess-Lancaster test), and other disturbances were rated as normalized, improved, or unchanged/worsened. The most common presenting symptoms were proptosis (95.7%), visual impairment (51%), and cranial nerve deficit (38.2%). Surgery via the frontotemporal approach was performed in all 47 cases, with the primary aim to relieve symptoms/signs and maximize tumor resection. Bony orbital reconstruction was never performed. Complete resection was achieved in 51% of cases (Simpson grades I and II) with minimal morbidity. At a mean follow-up of 52 months (range, 12-112), proptosis normalized in 90.9% and improved in the remaining patients, visual acuity normalized in 20.8% and improved in 45.8% patients, cranial nerve deficit subsided in all but two cases. The recurrence rate was 29.7%. One of the gold standards of surgical treatment, normalization of proptosis, can be achieved by accurate resection of the superior and lateral orbital walls. In this setting, careful reconstruction of the frontobasal dura is far superior to bony reconstruction. Complete tumor resection should not be pursued at the expense of increased morbidity.

Delayed progressive haematoma after Le Fort I osteotomy: A possible severe complication in orthognatic surgery

Although the Le Fort I osteotomy is a safe surgical technique, many complications have been reported. We present a case of an extended cervico-facial haematoma due to delayed bleeding from the terminal branches of the maxillary artery after orthognatic surgery. A 23-year-old man was referred to our observation for the surgical correction of a class III asymmetric malocclusion. The patient underwent a Le Fort I osteotomy, with impaction of the maxilla, associated with an Epker mandibular bilateral sagittal split osteotomy, with maxillary advancement and rigid internal fixation of the mandible with four miniplates and another four for the upper maxilla as well. The first post-surgery day, the patient developed a gradual dispnea together with neck swelling. By second postoperative day, the patient's general condition improved with a progressive normalization of laboratory tests values. The Computerised Axial Tomography (CAT) scan confirmed a decrease in the parapharyngeal thickening. Total recovery was achieved within two months, the final clinical check showed a healthy appearance with good occlusion. An increased knowledge of the basic biology of the Le Fort I osteotomy, the development of instruments specially designed for the Le Fort I procedure and the use of hypotensive anaesthesia could reduce the morbidity and duration of this procedure.

Bilateral pneumothorax after orthognatic surgery

Among complications in orthognathic surgery, the insurgence of pneumothorax is very rare. Pneumothorax is the presence of air or gas in the pleural cavity and it is rare complications in the postoperative oral and maxillofacial surgery patient. The clinical results are dependent on the degree of collapse of the lung on the affected side. Pneumothorax can impair oxygenation and/or ventilation. If the pneumothorax is significant, it can cause a shift of the mediastinum and compromise haemodynamic stability. While 10% of pneumothoraces are asymptomatic, patients often complain of acute chest pain and difficulty breathing. There is a reduction in vital capacity, tachycardia, tachypnoea and a decrease in partial pressure of oxygen with an inability to maintain oxygen saturations. We observed this unusual surgical consequence in a 28-year-old female with negative clinical history and instrumental evaluation after Le Fort I osteotomy and bilateral sagittal split osteotomy (BSSO). No further consequences, no neurological sequelae, no infections and no other osteotomies sequelae were seen. Sudden post-surgical dispnea associated to sub-cutaneous emphysema of the neck and of the thorax must be adequately observed with the aim of monitoring further severe sequelae. The anaesthetic management of the emergency difficult airway in any post-surgical orthognatic treatment can be extremely difficult requiring a multi-disciplinary approach.

Primary non-Hodgkin's lymphoma of the jaws: immunohistochemical and genetic review of 10 cases

PURPOSE

Non-Hodgkin's lymphoma (NHL) comprises a group of malignant lymphoproliferative diseases characterized by clonal expansion of lymphocytes at various levels of ontogenetic development. The aim of this study was to review the immunohistochemical and cytogenetic features of 10 cases of NLH of the jaws to determine their respective derivation.

PATIENTS AND METHODS

Histopathologic and immunohistochemical review of 10 cases of large-cell lymphomas of the jaws, together with Southern blot analysis of 2 of the cases, was performed and results compared with the findings in the literature.

RESULTS

In the 10 cases studied, the average age of onset of the NHL was 51 years, with a male-to-female ratio of 3:2. Tumefaction was the first clinical sign of disease. Eight of 10 cases were high-grade, large-cell NHLs, centroblastic type. Two cases were high-grade, large-cell NHL, immunoblastic type.

CONCLUSION

The immunohistochemical and Southern blot data remain the principal laboratory aids in the diagnosis and characterization of NHL, and they provide critical information for guiding clinicians to the appropriate treatment protocol for these malignancies.

Immunocytochemical detection of hMSH2 and hMLH1 expression in oral melanoma

BACKGROUND

The DNA mismatch repair system (MMR) plays an important role in the maintenance of genomic stability. To date few studies have been performed on hMSH2 and hMLH1 expression and melanoma of the head and neck region. A study of two cases revealed no mutations of the mismatch repair genes hMSH2 and hMLH1.

MATERIALS AND METHODS

To verify the possibility of implication of hMSH2 and hMLH1 alterations in melanocytic cancerogenesis, the authors examined the protein expression pattern of hMSH2 and hMLH1 by immunohistochemistry in 9 paraffin-embedded oral melanoma.

RESULTS

One case (11%) showed nuclear positivity for hMSH2, 3 cases (33%) showed cytoplasmic positivity, and five cases (55%) showed no staining in the tumoral cells, even if normal squamous epithelium available in this section showed a nuclear positivity. Four cases (44%) showed no hMLH1 staining in the tumoral cells, even if normal squamous epithelium available in this section showed a nuclear positivity. Two cases (22%) showed nuclear positivity, and three cases (33%) showed cytoplasmic positivity.

CONCLUSIONS

The analysis of mismatch repair genes can be a new molecular diagnostic tools for the detection of patients at high risk of developing melanoma and other neoplasia, or metastasis and recurrences.

Early diagnosis of nevoid basal cell carcinoma syndrome

BACKGROUND

Nevoid basal cell carcinoma syndrome, or NBCCS, is a hereditary condition characterized by basal cell carcinomas, or BCCs; odontogenic keratocysts, or OKCs; and skeletal abnormalities. The authors conducted this study to determine the early signs of NBCCS.

METHODS

The authors reviewed files from two Italian dental schools from January 1980 to January 1995 to determine the early signs of NBCCS and the age at which patients were first examined. They re-examined all of the patients, using the diagnostic criteria for NBCCS.

RESULTS

The authors found 14 patients who fulfilled the criteria for diagnosis of NBCCS in five families. All of the patients were 16 years of age or younger. In 11 cases (78 percent), the first sign of NBCCS in the patients was an OKC. The OKCs diagnosed in patients older than 13 years of age were large and characterized by widespread bone resorption. One 11-year-old patient had six large OKCs. The authors also found a case of multiple OKCs in an 8-year-old patient. Only one patient showed BCCs.

CONCLUSIONS

OKCs are often the first signs of NBCCS and can be detected in patients younger than 10 years of age. Our data suggest that OKCs arise earlier in patients who have NBCCS than in patients who do not have NBCCS. The patients' young ages explain the low incidence of BCCs in this study.

CLINICAL IMPLICATIONS

The presence of multiple OKCs in a child or onset of BCC in a patient younger than 20 years of age should alert dentists to the possibility of the patient's having NBCCS.

Immunocytochemical detection of hMSH2 and hMLH1 expression in oral SCC

BACKGROUND

The loss of DNA mismatch repair system was reported in hereditary non-poliposis colon cancer and in other tumours. The aim of this study was to detect the protein expression pattern of hMSH2 and hMLH1 in oral squamous cell carcinoma (SCC) by immunohistochemistry in paraffin-embedded tissues.

MATERIALS AND METHODS

5 specimens, obtained from healthy oral mucosa, and 20 from oral SCC were tested with anti-hMSH2 and anti-hMLH1 monoclonal antibodies.

RESULTS

Six cases (30%) showed nuclear positivity in differentiated areas (G1) and cytoplasmic positivity in areas with a lower degree of differentiation, four cases (20%) showed only cytoplasmic positivity, and only one (5%) no staining. One case of oral SCC (5%) showed no hMLH1 staining in the tumoral cells, even if normal squamous epithelium available in this section showed a nuclear positivity; six cases (30%) showed nuclear positivity in differentiated areas (G1) and cytoplasmic positivity in areas with a lower degree of differentiation, three cases (15%) showed only cytoplasmic positivity.

CONCLUSIONS

These data suggest that examination of hMSH2 and hMLH1 protein expression by immunohistochemistry is important in oral SCC. The analysis of mismatches expression in these cases of oral SCC might suggest that an absent nuclear staining for both hMSH2 and hML1 could constitute a hallmark of potential phenotype mutator for this type of neoplasia.

Odontogenic myxoma of the jaws: a clinical, radiologic, immunohistochemical, and ultrastructural study

Ten cases of odontogenic myxoma were evaluated radiologically, histologically, and histochemically. Ultrastructural examination was performed in five cases. Stellate cells with branching processes were seen in an abundant acid mucopolysaccharide background. Occasionally macrophages were found in the tumors. In two cases islands of inactive odontogenic epithelium were identified. The ultrastructural features suggest that many lesional cells are very similar to a myofibroblast. With the avidin-biotin complex immunohistochemical technique, the lesions were tested with antibodies to S- 100 protein, neuron-specific enolase, neurofilaments, glial fibrillary acid protein, keratin, desmin, muscle-specific actin, and vimentin. All the lesions were found to be positive for vimentin and muscle-specific actin, and negative for the rest. The results of our study seem to confirm the muscle-specific actin-positivity of odontogenic myxomas as previously reported.

Cavernous sinus-carotid fistula: a complication of maxillofacial injury

A case of traumatic carotid-cavernous sinus fistula (CCSF) is presented. The patient sustained an undisplaced fracture of his right mandibular condyle and a zygoma fracture after a motor vehicle accident. Five months later, all the classic signs and symptoms of a CCSF had appeared except ophthalmoplegia. These symptoms were preceded by a tiring auditive homolateral sensation. A carotid angiography confirmed the presence of a large CCSF. Successful management was achieved intravascularly by balloon embolization.