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A simple technique for the correction of maxillonasal dysplasia using customized expanded polytetrafluoroethylene (ePTFE) implants
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Journal of Plastic, Reconstructive & Aesthetic Surgery (2017) xx, 1e6
A simple technique for the correction of maxillonasal dysplasia using customized expanded polytetrafluoroethylene (ePTFE) implants Jiao Wei a,e, Jiawen Luo b,e, Tanja Herrler c, Hua Xu a, Ning Deng d, Qingfeng Li a, Chuanchang Dai a,* a Department of Plastic and Reconstructive Surgery, Shanghai Jiaotong University Medical School, Ninth People’s Hospital, China b Department of Cardiovascular Surgery, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China c Plastic Surgery and Burn Center, Trauma Center Murnau, Murnau, Germany d Student of China Medical University, Shenyang, China
Received 9 July 2016; accepted 25 June 2017
KEYWORDS Binder’s syndrome; Midfacial retrusion; Flattened nose; ePTFE; Maxilla-nasal dysplasia
Summary Background: The treatment of maxillonasal dysplasia in Binder’s syndrome using autologous costal bone and cartilage is well established, but postoperative results may be compromised by scarring, unpredictable absorption of transferred autologous tissue, and donor site morbidity. Here, we propose a simple surgical technique to improve maxillonasal dysplasia using an expanded polytetrafluoroethylene (ePTFE) implant. Materials and methods: From February 1999 to May 2014, fifty-eight patients affected by maxillonasal dysplasia with different degrees of flattened nose and midfacial depression underwent surgical correction by augmentation of the nasal dorsum using an “L”-shaped ePTFE and subperiosteal implantation of an inverted “m”-shaped ePTFE at the base of the piriform aperture. The outcome was evaluated based on preoperative and postoperative patient pictures, 3D imaging technology for the assessment of nasolabial angle and facial convexity angle, and a postoperative patient satisfaction survey. Results: Postoperative results showed improved facial aesthetics with a significantly increased nasolabial angle from initially 74.1 8.9 to 93.7 6.1 at 6 months postoperatively (p < 0.05). Temporary discomfort involving upper lip numbness, foreign body sensation, and stiff smiling expression were complained during the first 3 months postoperatively, but
* Corresponding author. Department of Plastic and Reconstructive Surgery, The Ninth Hospital, Shanghai Jiaotong University School of Medicine, 639 Zhi Zao Ju Rd., Shanghai 200011, China. E-mail addresses: [email protected], [email protected] (C. Dai). e These authors contributed equally to this work. http://dx.doi.org/10.1016/j.bjps.2017.06.032 1748-6815/ª 2017 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Wei J, et al., A simple technique for the correction of maxillonasal dysplasia using customized expanded polytetrafluoroethylene (ePTFE) implants, Journal of Plastic, Reconstructive & Aesthetic Surgery (2017), http://dx.doi.org/ 10.1016/j.bjps.2017.06.032
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J. Wei et al. spontaneously resolved within 6 months. Complications included infection (2 cases), implant migration (2 cases), and implant exposure (1 case). The vast majority of patients (95.7%) rated their postoperative outcome as highly improved and improved. Conclusion: The present therapeutic strategy provides a simple and effective treatment for the correction of maxillonasal dysplasia with high patient acceptance in a single step approach. Further research is required to determine long-term outcomes. ª 2017 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Introduction
Surgical technique
Binder’s syndrome first described in 1934 is a congenital deformity of the maxillofacial area. The main clinical manifestations include midfacial depression, acute nasolabial angle, short columella, flat nasal dorsum and tip.1e3 A number of different surgical approaches for correction have been proposed including osteotomy of nasal base and maxilla and grafting of autologous tissue, i.e. bone and cartilage.4e7 Although effective in improving facial aesthetics, they often involve prolonged recovery time. Moreover, the transfer of autologous tissue is inevitably associated with donor site morbidity and unpredictable graft absorption which are unacceptable for many patients. This has directed the attention to the use of alloplastic material. In this study, we analyzed patients seeking treatment for maxillonasal dysplasia and propose a simple method for effective correction using ePTFE implants. We here describe the surgical technique, discuss complications, and demonstrate postoperative early and long-term outcomes.
Local anesthesia was applied alone or in combination with general anesthesia or intravenous sedation. The ePTFE material (Shanghai Suokang Medical Implants, Shanghai, People’s Republic of China) was carved into “L” and inverted “m”-shaped implants in consideration of the severity of maxilla-nasal dysplasia, nasal columella deficiency, maxillofacial symmetry, and the extent of midfacial and nasal depression in relation to ideal nasal length and height (Figure 2A, B). The “L”-shaped ePTFE implant was applied for nasal dorsal augmentation and adapted from a preformed shape. The “m”-shaped ePTFE implant was carved from a block and used to treat midfacial depression. Both implants were placed independent of each other. Regarding implant design, the horizontal extent of the inverted “m”-shaped ePTFE was determined by the width of both lateral alae, while the height was defined by the vertical extent of midface depression. The middle ridge of the inverted “m” was adjusted to fit the caudal anterior nasal spine. According to the degree of midfacial depression and nasal columella deficiency implant thickness was increased in more severe cases. Each lateral ridge of the inverted “m” was positioned at rim of the piriform aperture. An implant of greater thickness was applied in cases of increased vertical height of the maxillomandibular arch and/or severity of facial depression. A larger area of middle face depression was accommodated by increasing the width of the implant. The design of the “L”-shaped ePTFE was symmetrically rounded at the dorsal edge. Any deviation or twisting after implant insertion was meticulously avoided to ensure the esthetic outcome. A strictly aseptic technique during the surgical procedure was pursued to prevent infection. For implantation of the inverted “m”-shaped ePTFE a 3e4 cm horizontal incision of the mucosa 5 mm above the gingival sulcus was used. The submucous muscle was cranially dissected until the subperiosteal plane was reached. Using a periosteum elevator the maxillary periosteum was freed at the base of piriform aperture and laterally to the alae to create an implant pocket. The dimensions of the subperiosteal pocket were 2 cm laterally to the piriform aperture. In addition, the medial part of the periosteum was dissected towards the nasal cavity to increase the size of the subperiosteal pocket. The ePTFE implant was inserted under the periosteum with both lateral ridges extending laterally to the nasal ala. The
Material and methods From February 1999 to May 2014, fifty-eight (19 men and 39 women) presenting with different degrees of Binder’s syndrome characterized by flattened nose and midfacial depression were included in this study which was approved by the ethics committee of Shanghai Jiao Tong University Medical School. Patient age ranged from 17 to 51 years at the time of surgery with a mean age of 27.3 6.8 years. All patients were previously examined at the dental clinic to exclude severe malocclusion. To confirm the clinical diagnosis of Binder’s syndrome, patients underwent X-ray and 3D CT reconstruction. The surgical procedure was performed by the same surgeon after informed consent had been given by the patient. Standard patient pictures were taken before surgery and during postoperative follow-up at 3 and 6 months. At the same time points, the nasolabial angle determined by columella, subnasale, and labrale superius (CmeSneLs), and the angle of facial convexity based on glabella, subnasale, and pogonion (GeSnePog0 ) were calculated and compared using three-dimensional simulation technology and computer imaging (Figure 1A, B). Preoperatively, nasal skin quality and elasticity was by pulling the nasal tip forward to determine the maximum degree of maxillonasal augmentation.
Please cite this article in press as: Wei J, et al., A simple technique for the correction of maxillonasal dysplasia using customized expanded polytetrafluoroethylene (ePTFE) implants, Journal of Plastic, Reconstructive & Aesthetic Surgery (2017), http://dx.doi.org/ 10.1016/j.bjps.2017.06.032
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A technique to improve maxillonasal dysplasia using ePTFE
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Figure 1 Facial profile analysis: (A) In a patient with Binder’s syndrome (B) maxillonasal dysplasia was assessed based on the nasolabial angle (red lines) with columella, subnasale, and labrale superius (CmeSneLs) as landmarks and the angle of facial convexity defined by glabella, subnasale, and pogonion (GeSnePog0 ).
middle ridge of ePTFE was sutured to the anterior nasal spine. Intraoperatively, care was taken to protect the infraorbital neurovascular bundles and to keep the periosteum intact. A transcolumellar incision was applied for the placement of the “L”-shaped ePTFE. Bilateral soft tissue fiber connections between the lower lateral nasal cartilage middle crura and the upper lateral nasal cartilage were completely dissected using blunt dissection. Then, the prepared “L”shaped ePTFE was placed under the nasal dorsal fascia. The nasal lining was handled with care to keep it intact during in the entire procedure. Finally, submucous muscle and mucosa were primarily closed with layered sutures. Nasal tubes and a nasal splint were applied for three weeks to
support the stability of the septum and to prevent edema (Figure 2CeE). A postoperative patient satisfaction survey was performed at 6 and 12 months postoperatively to evaluate improvement of gingival exposure, aesthetics of the nasal profile, healing of the surgical incision, and adverse effects. A questionnaire was handed to the patients in the waiting room before the follow-up examination or sent by mail.
Statistical analysis All data were statistically analyzed by one-way analysis of variance for the comparison between preoperative status
Figure 2 Personalized implants (A, B) were sculptured and implanted in the nasal dorsum and at the base of the piriform aperture as seen in (C) the topographic illustration and (D, E) intraoperative views.
Please cite this article in press as: Wei J, et al., A simple technique for the correction of maxillonasal dysplasia using customized expanded polytetrafluoroethylene (ePTFE) implants, Journal of Plastic, Reconstructive & Aesthetic Surgery (2017), http://dx.doi.org/ 10.1016/j.bjps.2017.06.032
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J. Wei et al.
Figure 3 Preoperatively, considerable maxillonasal dysplasia was present (above). Follow-up at 32 months after surgery showed significant improvement regarding facial holistic profile (below).
and postoperative outcome using SPSS software (SPSS, Inc). p Values <0.05 were regarded as statistically significant.
Results A total of 58 patients with Binder’s syndrome underwent surgical correction of maxilla-nasal dysplasia. All patients were followed up for at least 10 months. The average follow-up period was 11 7.1 months ranging from 8 months to 7 years. Longer follow-up periods of more than 24 months exist for a number of 21 patients. In these patients, no significant changes were seen compared to their results after 18 months postoperatively. Postoperative outcomes with significantly improved facial aesthetics are demonstrated in Figure 3. Postoperative nasolabial angles showed significant improvement (Table 1). In particular, the preoperative nasolabial angle of 74.1 8.9 increased to 96.2 5.6 (p < 0.05) 1 month postoperatively, and 93.7 6.1 (p < 0.05) at 6 months. A significant increase in the angle of facial convexity was found from originally 160.0 9.7 to 173.9 8.6 and 171.6 6.2 after 3 and 6 months, respectively.
Table 1
The postoperative survey showed a high patient satisfaction regarding improvement of esthetic smile and facial holistic profile. The vast majority of patients (95.7%) rated their results as considerably improved/improved (Table 2). Temporary discomfort was reported 3 month postoperatively involving upper lip numbness (4 cases), foreign body sensation (1 case), and stiff smile (5 cases), but gradually resolved within 6 months. Complications included infection (2 cases), implant extrusion (1 case), implant migration and deviation (2 cases). No systemic complications and no other late recurrence or other adverse effects were observed.
Discussion Based on our study, we present a new treatment strategy to improve maxillonasal dysplasia in Binder’s syndrome by simply augmenting the base of the piriform aperture and the nasal region using an inverted “m”-shaped and an “L”shaped ePTFE, respectively. Importantly, our approach completely avoids any donor site morbidity, while providing effective correction with stable long-term outcomes and
Postoperative improvement of the maxillonasal profile based on nasolabial angle and angle of facial convexity.
Parameter
Before surgery
Nasolabial angle ( ) Angle of facial convexity ( )
85.3 6.21 160.20 79.7
Postoperatively 1 month
3 months
6 months
96.2 5.6* 173.2 4.7*
92.4 5.5* 173.9 8.6*
93.7 6.1* 171.6 6.2*
*p < 0.05 vs. preoperatively.
Please cite this article in press as: Wei J, et al., A simple technique for the correction of maxillonasal dysplasia using customized expanded polytetrafluoroethylene (ePTFE) implants, Journal of Plastic, Reconstructive & Aesthetic Surgery (2017), http://dx.doi.org/ 10.1016/j.bjps.2017.06.032
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A technique to improve maxillonasal dysplasia using ePTFE Table 2
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Patient satisfaction evaluation at 6 months postoperatively.
Type
No. of patients Self-assessment of postoperative outcome Much improved
Improved
No change
Worse
Nasal appearance Aesthetics of facial holistic profile
54 55
1 1
2 2
1 0
Percentage (mean)
95.7%
3.4%
0.9%
minimal surgical risk. Moreover, the surgical technique is easy to learn and apply. Expanded polytetrafluoroethylene (ePTFE) is an alloplastic implant material and has been successfully used as a substitute for autologous tissue in plastic and reconstructive procedures.8e12 Its excellent biocompatibility enables rapid integration into the recipient site, thus reducing implant mobility and foreign body reaction. Moreover, ePTFE may be carved to obtain customized implant size and shape. For patients unwilling to accept the limitations and adverse consequences of autologous reconstruction ePTFE therefore represents a suitable option with high patient acceptance. Importantly, the ePTFE implants required specific shapes of an “L” and inverted “m”, while size and thickness were individually adapted depending on the severity of maxillofacial dysplasia. A larger area and higher degree of midfacial depression demanded increased size and thickness of the inverted “m”-shaped ePTFE implant. The “L”-shaped implant was generally applied with increased thickness compared to regular nasal dorsum augmentation procedures. The present method for the correction of maxillonasal depression is technically simple and safe with a low risk for complications. Adverse effects including unnatural smile and edema were mostly temporary and resolved within 3e6 months postoperatively. Only two cases of infection were observed among which one was perioperative with implant exposure due to pressure of the nasal tubes against the implant. The other case of infection occurred 7 months postoperatively in a patient with overactive sebaceous glands. The nasal mucosa and nasal implant pocket were treated with iodine and the incision was closed with sutures. Perioperative prophylactic antibiotics were used for 3 days. Implant exposure (1 case), migration, and deviation (2 cases) were attributed to increased tension of nasal mucosa and skin. In this regard, a strictly aseptic procedure is essential as well as patient selection. However, there are some limitations of ePTFE implants. Due to an increased risk for complications including implant deviation the use of ePTFE is not recommended in patients with tight nasal skin. Preoperative testing of skin quality and elasticity by pulling the nasal skin forward helps to avoid this kind of pitfalls. In cases in which soft tissue characteristics are insufficient to provide satisfactory maxillonasal height, autologous graft material is rather recommended. Further contraindications include acne with or without overactive sebaceous glands in the nasal region. Binder’s syndrome involves a number of morphologic characteristics including arhinoid face, abnormal position
of nasal bone, atrophy of nasal mucosa, reduced or absent anterior nasal spine, and maxillary retrusion with associated malocclusion. Conventional techniques for surgical correction are rather invasive including complex osteotomy procedures and the application of autologous tissue grafts with resulting donor site morbidity. Previous work using Lshaped autologous bone grafts derived from the iliac crest to the nasal dorsum reported postoperative stiffness of the nasal region.13 Moreover, changes due to postoperative remodeling of the bone graft were observed over time. In contrast, ePTFE implants remained stable provided sufficient quality and elasticity of the overlying nasal skin and mucosa, while infection and implant exposure rates in the present study were comparable to previously published numbers for rhinoplasty using ePTFE.14,15 As a consequence, ePTFE represents a feasible therapeutic alternative for the correction of maxillonasal dysplasia.
Conclusion The present technique allows for effective improvement of varying degrees of maxillonasal dysplasia in Binder’s syndrome. This treatment option is reliable and safe. Moreover, it can be performed in a simple one-step procedure that is well-accepted by the patients. Follow-up studies are required to ensure long-term safety and stability of the postoperative outcome.
Conflict of interest There is no conflict of interest.
References 1. Watanabe T, Matsuo K. Augmentation with cartilage grafts around the pyriform aperture to improve the midface and profile in binder’s syndrome. Ann Plast Surg 1996;36(2): 206e11. 2. Dyer FM, Willmot DR. Maxillo-nasal dysplasia, Binder’s syndrome: review of the literature and case report. J Orthod 2002;29(1):15e21. 3. Carach B, Woods M, Scott P. Maxillonasal dysplasia (Binder syndrome): a lateral cephalometric assessment. Aust Orthod J 2002;18(2):82e91. 4. Guereschi P, Boudana D, Wolber A, Pellerin P. Maxillonasal osteochondral complex repair in maxillonasal dysplasia. J Craniofac Surg 2011;22(6):2375e81. 5. Chiang C, Xue K, Gu B, Li Q, Liu K. A novel single-rib recombination method in binder syndrome treatment. Ann Plast Surg 2013;70(6):659e62.
Please cite this article in press as: Wei J, et al., A simple technique for the correction of maxillonasal dysplasia using customized expanded polytetrafluoroethylene (ePTFE) implants, Journal of Plastic, Reconstructive & Aesthetic Surgery (2017), http://dx.doi.org/ 10.1016/j.bjps.2017.06.032
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6 6. Chummun S, McLean NR, Anderson PJ, David DJ. A long-term evaluation of 150 costochondral nasal grafts. J Plast Reconstr Aesthet Surg 2013;66(11):1477e81. 7. Morovic CG, Soto CA, Vidal C. Anteriorly based galeopericranial frontalis flap: a novel application in secondary rhinoplasty with atrophic skin. J Craniofac Surg 2016;27(2): 484e8. 8. Conrad K, Gillman G. A 6-year experience with the use of expanded polytetrafluoroethylene in rhinoplasty. Plast Reconstr Surg 1998;101(6):1675e83 [Discussion 1684]. 9. Sajjadian A, Naghshineh N, Rubinstein R. Current status of grafts and implants in rhinoplasty: part II. Homologous grafts and allogenic implants. Plast Reconstr Surg 2010;125(3): 99ee109e. 10. Peled ZM, Warren AG, Johnston P, Yaremchuk MJ. The use of alloplastic materials in rhinoplasty surgery: a meta-analysis. Plast Reconstr Surg 2008;121(3):85ee92e.
J. Wei et al. 11. Chen CT, Hu TL, Lai JB, Chen YC, Chen YR. Reconstruction of traumatic nasal deformity in Orientals. J Plast Reconstr Aesthet Surg 2010;63(2):257e64. 12. Lee MR, Unger JG, Rohrich RJ. Management of the nasal dorsum in rhinoplasty: a systematic review of the literature regarding technique, outcomes, and complications. Plast Reconstr Surg 2011;128(5):538ee50e. 13. Posnick JC, Tompson B. Binder syndrome: staging of reconstruction and skeletal stability and relapse patterns after LeFort I osteotomy using miniplate fixation. Plast Reconstr Surg 1997;99(4):961e73 [Discussion 974e5]. 14. Holmstrom H. Surgical correction of the nose and midface in maxillonasal dysplasia (Binder’s syndrome). Plast Reconstr Surg 1986;78(5):568e80. 15. Winkler AA, Soler ZM, Leong PL, Murphy A, Wang TD, Cook TA. Complications associated with alloplastic implants in rhinoplasty. Arch Facial Plast Surg 2012;14(6):437e41.
Please cite this article in press as: Wei J, et al., A simple technique for the correction of maxillonasal dysplasia using customized expanded polytetrafluoroethylene (ePTFE) implants, Journal of Plastic, Reconstructive & Aesthetic Surgery (2017), http://dx.doi.org/ 10.1016/j.bjps.2017.06.032
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Journal of Plastic, Reconstructive & Aesthetic Surgery (2017) xx, 1e6
A simple technique for the correction of maxillonasal dysplasia using customized expanded polytetrafluoroethylene (ePTFE) implants Jiao Wei a,e, Jiawen Luo b,e, Tanja Herrler c, Hua Xu a, Ning Deng d, Qingfeng Li a, Chuanchang Dai a,* a Department of Plastic and Reconstructive Surgery, Shanghai Jiaotong University Medical School, Ninth People’s Hospital, China b Department of Cardiovascular Surgery, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China c Plastic Surgery and Burn Center, Trauma Center Murnau, Murnau, Germany d Student of China Medical University, Shenyang, China
Received 9 July 2016; accepted 25 June 2017
KEYWORDS Binder’s syndrome; Midfacial retrusion; Flattened nose; ePTFE; Maxilla-nasal dysplasia
Summary Background: The treatment of maxillonasal dysplasia in Binder’s syndrome using autologous costal bone and cartilage is well established, but postoperative results may be compromised by scarring, unpredictable absorption of transferred autologous tissue, and donor site morbidity. Here, we propose a simple surgical technique to improve maxillonasal dysplasia using an expanded polytetrafluoroethylene (ePTFE) implant. Materials and methods: From February 1999 to May 2014, fifty-eight patients affected by maxillonasal dysplasia with different degrees of flattened nose and midfacial depression underwent surgical correction by augmentation of the nasal dorsum using an “L”-shaped ePTFE and subperiosteal implantation of an inverted “m”-shaped ePTFE at the base of the piriform aperture. The outcome was evaluated based on preoperative and postoperative patient pictures, 3D imaging technology for the assessment of nasolabial angle and facial convexity angle, and a postoperative patient satisfaction survey. Results: Postoperative results showed improved facial aesthetics with a significantly increased nasolabial angle from initially 74.1 8.9 to 93.7 6.1 at 6 months postoperatively (p < 0.05). Temporary discomfort involving upper lip numbness, foreign body sensation, and stiff smiling expression were complained during the first 3 months postoperatively, but
* Corresponding author. Department of Plastic and Reconstructive Surgery, The Ninth Hospital, Shanghai Jiaotong University School of Medicine, 639 Zhi Zao Ju Rd., Shanghai 200011, China. E-mail addresses: [email protected], [email protected] (C. Dai). e These authors contributed equally to this work. http://dx.doi.org/10.1016/j.bjps.2017.06.032 1748-6815/ª 2017 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Wei J, et al., A simple technique for the correction of maxillonasal dysplasia using customized expanded polytetrafluoroethylene (ePTFE) implants, Journal of Plastic, Reconstructive & Aesthetic Surgery (2017), http://dx.doi.org/ 10.1016/j.bjps.2017.06.032
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J. Wei et al. spontaneously resolved within 6 months. Complications included infection (2 cases), implant migration (2 cases), and implant exposure (1 case). The vast majority of patients (95.7%) rated their postoperative outcome as highly improved and improved. Conclusion: The present therapeutic strategy provides a simple and effective treatment for the correction of maxillonasal dysplasia with high patient acceptance in a single step approach. Further research is required to determine long-term outcomes. ª 2017 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Introduction
Surgical technique
Binder’s syndrome first described in 1934 is a congenital deformity of the maxillofacial area. The main clinical manifestations include midfacial depression, acute nasolabial angle, short columella, flat nasal dorsum and tip.1e3 A number of different surgical approaches for correction have been proposed including osteotomy of nasal base and maxilla and grafting of autologous tissue, i.e. bone and cartilage.4e7 Although effective in improving facial aesthetics, they often involve prolonged recovery time. Moreover, the transfer of autologous tissue is inevitably associated with donor site morbidity and unpredictable graft absorption which are unacceptable for many patients. This has directed the attention to the use of alloplastic material. In this study, we analyzed patients seeking treatment for maxillonasal dysplasia and propose a simple method for effective correction using ePTFE implants. We here describe the surgical technique, discuss complications, and demonstrate postoperative early and long-term outcomes.
Local anesthesia was applied alone or in combination with general anesthesia or intravenous sedation. The ePTFE material (Shanghai Suokang Medical Implants, Shanghai, People’s Republic of China) was carved into “L” and inverted “m”-shaped implants in consideration of the severity of maxilla-nasal dysplasia, nasal columella deficiency, maxillofacial symmetry, and the extent of midfacial and nasal depression in relation to ideal nasal length and height (Figure 2A, B). The “L”-shaped ePTFE implant was applied for nasal dorsal augmentation and adapted from a preformed shape. The “m”-shaped ePTFE implant was carved from a block and used to treat midfacial depression. Both implants were placed independent of each other. Regarding implant design, the horizontal extent of the inverted “m”-shaped ePTFE was determined by the width of both lateral alae, while the height was defined by the vertical extent of midface depression. The middle ridge of the inverted “m” was adjusted to fit the caudal anterior nasal spine. According to the degree of midfacial depression and nasal columella deficiency implant thickness was increased in more severe cases. Each lateral ridge of the inverted “m” was positioned at rim of the piriform aperture. An implant of greater thickness was applied in cases of increased vertical height of the maxillomandibular arch and/or severity of facial depression. A larger area of middle face depression was accommodated by increasing the width of the implant. The design of the “L”-shaped ePTFE was symmetrically rounded at the dorsal edge. Any deviation or twisting after implant insertion was meticulously avoided to ensure the esthetic outcome. A strictly aseptic technique during the surgical procedure was pursued to prevent infection. For implantation of the inverted “m”-shaped ePTFE a 3e4 cm horizontal incision of the mucosa 5 mm above the gingival sulcus was used. The submucous muscle was cranially dissected until the subperiosteal plane was reached. Using a periosteum elevator the maxillary periosteum was freed at the base of piriform aperture and laterally to the alae to create an implant pocket. The dimensions of the subperiosteal pocket were 2 cm laterally to the piriform aperture. In addition, the medial part of the periosteum was dissected towards the nasal cavity to increase the size of the subperiosteal pocket. The ePTFE implant was inserted under the periosteum with both lateral ridges extending laterally to the nasal ala. The
Material and methods From February 1999 to May 2014, fifty-eight (19 men and 39 women) presenting with different degrees of Binder’s syndrome characterized by flattened nose and midfacial depression were included in this study which was approved by the ethics committee of Shanghai Jiao Tong University Medical School. Patient age ranged from 17 to 51 years at the time of surgery with a mean age of 27.3 6.8 years. All patients were previously examined at the dental clinic to exclude severe malocclusion. To confirm the clinical diagnosis of Binder’s syndrome, patients underwent X-ray and 3D CT reconstruction. The surgical procedure was performed by the same surgeon after informed consent had been given by the patient. Standard patient pictures were taken before surgery and during postoperative follow-up at 3 and 6 months. At the same time points, the nasolabial angle determined by columella, subnasale, and labrale superius (CmeSneLs), and the angle of facial convexity based on glabella, subnasale, and pogonion (GeSnePog0 ) were calculated and compared using three-dimensional simulation technology and computer imaging (Figure 1A, B). Preoperatively, nasal skin quality and elasticity was by pulling the nasal tip forward to determine the maximum degree of maxillonasal augmentation.
Please cite this article in press as: Wei J, et al., A simple technique for the correction of maxillonasal dysplasia using customized expanded polytetrafluoroethylene (ePTFE) implants, Journal of Plastic, Reconstructive & Aesthetic Surgery (2017), http://dx.doi.org/ 10.1016/j.bjps.2017.06.032
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A technique to improve maxillonasal dysplasia using ePTFE
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Figure 1 Facial profile analysis: (A) In a patient with Binder’s syndrome (B) maxillonasal dysplasia was assessed based on the nasolabial angle (red lines) with columella, subnasale, and labrale superius (CmeSneLs) as landmarks and the angle of facial convexity defined by glabella, subnasale, and pogonion (GeSnePog0 ).
middle ridge of ePTFE was sutured to the anterior nasal spine. Intraoperatively, care was taken to protect the infraorbital neurovascular bundles and to keep the periosteum intact. A transcolumellar incision was applied for the placement of the “L”-shaped ePTFE. Bilateral soft tissue fiber connections between the lower lateral nasal cartilage middle crura and the upper lateral nasal cartilage were completely dissected using blunt dissection. Then, the prepared “L”shaped ePTFE was placed under the nasal dorsal fascia. The nasal lining was handled with care to keep it intact during in the entire procedure. Finally, submucous muscle and mucosa were primarily closed with layered sutures. Nasal tubes and a nasal splint were applied for three weeks to
support the stability of the septum and to prevent edema (Figure 2CeE). A postoperative patient satisfaction survey was performed at 6 and 12 months postoperatively to evaluate improvement of gingival exposure, aesthetics of the nasal profile, healing of the surgical incision, and adverse effects. A questionnaire was handed to the patients in the waiting room before the follow-up examination or sent by mail.
Statistical analysis All data were statistically analyzed by one-way analysis of variance for the comparison between preoperative status
Figure 2 Personalized implants (A, B) were sculptured and implanted in the nasal dorsum and at the base of the piriform aperture as seen in (C) the topographic illustration and (D, E) intraoperative views.
Please cite this article in press as: Wei J, et al., A simple technique for the correction of maxillonasal dysplasia using customized expanded polytetrafluoroethylene (ePTFE) implants, Journal of Plastic, Reconstructive & Aesthetic Surgery (2017), http://dx.doi.org/ 10.1016/j.bjps.2017.06.032
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Figure 3 Preoperatively, considerable maxillonasal dysplasia was present (above). Follow-up at 32 months after surgery showed significant improvement regarding facial holistic profile (below).
and postoperative outcome using SPSS software (SPSS, Inc). p Values <0.05 were regarded as statistically significant.
Results A total of 58 patients with Binder’s syndrome underwent surgical correction of maxilla-nasal dysplasia. All patients were followed up for at least 10 months. The average follow-up period was 11 7.1 months ranging from 8 months to 7 years. Longer follow-up periods of more than 24 months exist for a number of 21 patients. In these patients, no significant changes were seen compared to their results after 18 months postoperatively. Postoperative outcomes with significantly improved facial aesthetics are demonstrated in Figure 3. Postoperative nasolabial angles showed significant improvement (Table 1). In particular, the preoperative nasolabial angle of 74.1 8.9 increased to 96.2 5.6 (p < 0.05) 1 month postoperatively, and 93.7 6.1 (p < 0.05) at 6 months. A significant increase in the angle of facial convexity was found from originally 160.0 9.7 to 173.9 8.6 and 171.6 6.2 after 3 and 6 months, respectively.
Table 1
The postoperative survey showed a high patient satisfaction regarding improvement of esthetic smile and facial holistic profile. The vast majority of patients (95.7%) rated their results as considerably improved/improved (Table 2). Temporary discomfort was reported 3 month postoperatively involving upper lip numbness (4 cases), foreign body sensation (1 case), and stiff smile (5 cases), but gradually resolved within 6 months. Complications included infection (2 cases), implant extrusion (1 case), implant migration and deviation (2 cases). No systemic complications and no other late recurrence or other adverse effects were observed.
Discussion Based on our study, we present a new treatment strategy to improve maxillonasal dysplasia in Binder’s syndrome by simply augmenting the base of the piriform aperture and the nasal region using an inverted “m”-shaped and an “L”shaped ePTFE, respectively. Importantly, our approach completely avoids any donor site morbidity, while providing effective correction with stable long-term outcomes and
Postoperative improvement of the maxillonasal profile based on nasolabial angle and angle of facial convexity.
Parameter
Before surgery
Nasolabial angle ( ) Angle of facial convexity ( )
85.3 6.21 160.20 79.7
Postoperatively 1 month
3 months
6 months
96.2 5.6* 173.2 4.7*
92.4 5.5* 173.9 8.6*
93.7 6.1* 171.6 6.2*
*p < 0.05 vs. preoperatively.
Please cite this article in press as: Wei J, et al., A simple technique for the correction of maxillonasal dysplasia using customized expanded polytetrafluoroethylene (ePTFE) implants, Journal of Plastic, Reconstructive & Aesthetic Surgery (2017), http://dx.doi.org/ 10.1016/j.bjps.2017.06.032
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A technique to improve maxillonasal dysplasia using ePTFE Table 2
5
Patient satisfaction evaluation at 6 months postoperatively.
Type
No. of patients Self-assessment of postoperative outcome Much improved
Improved
No change
Worse
Nasal appearance Aesthetics of facial holistic profile
54 55
1 1
2 2
1 0
Percentage (mean)
95.7%
3.4%
0.9%
minimal surgical risk. Moreover, the surgical technique is easy to learn and apply. Expanded polytetrafluoroethylene (ePTFE) is an alloplastic implant material and has been successfully used as a substitute for autologous tissue in plastic and reconstructive procedures.8e12 Its excellent biocompatibility enables rapid integration into the recipient site, thus reducing implant mobility and foreign body reaction. Moreover, ePTFE may be carved to obtain customized implant size and shape. For patients unwilling to accept the limitations and adverse consequences of autologous reconstruction ePTFE therefore represents a suitable option with high patient acceptance. Importantly, the ePTFE implants required specific shapes of an “L” and inverted “m”, while size and thickness were individually adapted depending on the severity of maxillofacial dysplasia. A larger area and higher degree of midfacial depression demanded increased size and thickness of the inverted “m”-shaped ePTFE implant. The “L”-shaped implant was generally applied with increased thickness compared to regular nasal dorsum augmentation procedures. The present method for the correction of maxillonasal depression is technically simple and safe with a low risk for complications. Adverse effects including unnatural smile and edema were mostly temporary and resolved within 3e6 months postoperatively. Only two cases of infection were observed among which one was perioperative with implant exposure due to pressure of the nasal tubes against the implant. The other case of infection occurred 7 months postoperatively in a patient with overactive sebaceous glands. The nasal mucosa and nasal implant pocket were treated with iodine and the incision was closed with sutures. Perioperative prophylactic antibiotics were used for 3 days. Implant exposure (1 case), migration, and deviation (2 cases) were attributed to increased tension of nasal mucosa and skin. In this regard, a strictly aseptic procedure is essential as well as patient selection. However, there are some limitations of ePTFE implants. Due to an increased risk for complications including implant deviation the use of ePTFE is not recommended in patients with tight nasal skin. Preoperative testing of skin quality and elasticity by pulling the nasal skin forward helps to avoid this kind of pitfalls. In cases in which soft tissue characteristics are insufficient to provide satisfactory maxillonasal height, autologous graft material is rather recommended. Further contraindications include acne with or without overactive sebaceous glands in the nasal region. Binder’s syndrome involves a number of morphologic characteristics including arhinoid face, abnormal position
of nasal bone, atrophy of nasal mucosa, reduced or absent anterior nasal spine, and maxillary retrusion with associated malocclusion. Conventional techniques for surgical correction are rather invasive including complex osteotomy procedures and the application of autologous tissue grafts with resulting donor site morbidity. Previous work using Lshaped autologous bone grafts derived from the iliac crest to the nasal dorsum reported postoperative stiffness of the nasal region.13 Moreover, changes due to postoperative remodeling of the bone graft were observed over time. In contrast, ePTFE implants remained stable provided sufficient quality and elasticity of the overlying nasal skin and mucosa, while infection and implant exposure rates in the present study were comparable to previously published numbers for rhinoplasty using ePTFE.14,15 As a consequence, ePTFE represents a feasible therapeutic alternative for the correction of maxillonasal dysplasia.
Conclusion The present technique allows for effective improvement of varying degrees of maxillonasal dysplasia in Binder’s syndrome. This treatment option is reliable and safe. Moreover, it can be performed in a simple one-step procedure that is well-accepted by the patients. Follow-up studies are required to ensure long-term safety and stability of the postoperative outcome.
Conflict of interest There is no conflict of interest.
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Please cite this article in press as: Wei J, et al., A simple technique for the correction of maxillonasal dysplasia using customized expanded polytetrafluoroethylene (ePTFE) implants, Journal of Plastic, Reconstructive & Aesthetic Surgery (2017), http://dx.doi.org/ 10.1016/j.bjps.2017.06.032