The Journal of Craniofacial Surgery • Volume 26, Number 2, March 2015
TABLE 3. Soft Tissue Facial Morphometry of Patients With Facial Contour Surgery
WM, mm WL, mm FH, mm WM/WL WM/FH WL/FH
Preoperative
2 Years Postoperative
144.92 ± 11.02 125.48 ± 10.06 117.74 ± 7.05 1.16 ± 0.12 1.24 ± 0.14 1.07 ± 0.09
141.15 ± 10.54 117.89 ± 8.07 118.11 ± 6.44 1.20 ± 0.12 1.20 ± 0.14 0.99 ± 0.07
Now, we could do the preoperative simulation of both reduction osteotomies from 3-dimensional CT. In the future, we may combine 3-D CT and stereo photogrammetry to generate a single 3D representation of facial contour and using the aforementioned postoperative ratio as template. Thus, we can do a more precise virtual surgical planning for the reduction facial contour surgery in Chinese people.
CONCLUSIONS Combined reduction malarplasty and reduction of mandibular angles with partial masseter muscle resection can achieve an ideal oval facial contour for Chinese patients. Furthermore, the relative proportion index can be referenced as the standard for digital preoperative design.
Brief Clinical Studies
16. Yuan J, Cho MY, Zhang Y, et al. Influence of the maxillary sinus exposure in reduction malarplasty with an L-shaped osteotomy. J Craniofac Surg 2011;22:1788–1790 17. Yuan J, Zhu QQ, Zhang Y, et al. Influence of partial masseter muscle resection along with reduction of mandibular angle. J Craniofac Surg 2013;24:1111–1113 18. Kim HJ, Yum KW, Lee SS, et al. Effects of botulinum toxin type A on bilateral masseteric hypertrophy evaluated with computed tomographic measurement. Dermatol Surg 2003;29:484–489 19. Kim NH, Chung JH, Park RH, et al. The use of botulinum toxin type A in aesthetic mandibular contouring. Plast Reconstr Surg 2005;115:919–930
Abducens Nerve Schwannoma in Cerebellopontine Angle Mimicking Acoustic Neuroma Ming Wang, MD, Hongguang Huang, MD, Yongqing Zhou, PhD, MD Abstract: The abducens nerve schwannoma is one kind of rare intracranial tumor. We report an interesting case of abducens nerve schwannoma in the right cerebellopontine angle in a 68-year-old male patient presenting only vertigo and headache, without any symptom of abducens nerve palsy. This is the oldest patient with abducens nerve schwannoma to date. The patient received a craniectomy via suboccipital retrosigmoid approach and had total surgical excision.
REFERENCES 1. Baek SM, Kim SS, Bindiger A. The prominent mandibular angle: preoperative management, operative technique, and results in 42 patients. Plast Reconstr Surg 1989;83:272–280 2. Ousterhout DK. Mandibular angle augmentation and reduction. ClinPlast Surg 1991;18:153–161 3. Yang DB, Park CG. Mandibular contouring surgery for purely aesthetic reasons. Aesth Plast Surg 1991;15:53–61 4. Lee Y, Kim JH. Mandibular contouring: a surgical technique for the asymmetrical lower face. Plast Reconstr Surg 1999;104:1165–1171 5. Min L, Lai G, Xin L. Changes in masseter muscle following curved ostectomy of the prominent mandibular angle: an initial study with real-time 3D ultrasonography. J Oral Maxillofac Surg 2008;66:2434–2443 6. Lo LJ, Mardini S, Chen YR. Volumetric change of the muscles of mastication following resection of mandibular angles: a long-term follow-up. Ann Plast Surg 2005;54:615–621 7. Pary A, Pary K. Masseteric hypertrophy: considerations regarding treatment planning decisions and introduction of a novel surgical technique. J Oral Maxillofac Surg 2011;69:944–949 8. Baek SM, Chung YD, Kim SS. Reduction malarplasty. Plast Reconstr Surg 1991;88:53–61 9. Cho BC. Reduction malarplasty using osteotomy and repositioning of the malar complex: clinical review and comparison of two techniques. J Craniofac Surg 2003;14:383–392 10. Mahatumarat C, Rojvachiranonda N. Reduction malarplasty without external incision: a simple technique. Aesthet Plast Surg 2003;27:167–171 11. Sumiya N, Ito Y, Ozumi K. Reduction malarplasty. Plast Reconstr Surg 2004;113:1497–1499 12. Yang X, Mu X, Yu Z, et al. Compared study of Asian reduction malarplasty: wedge-section osteotomy versus conventional procedures. J Craniofac Surg 2009;20:1856–1861 13. Lee KC, Ha SU, Park JM, et al. Reduction malarplasty by 3-mm percutaneous osteotomy. Aesthet Plast Surg 2006;30:333–341 14. Wang T, Gui L, Tang X, et al. Reduction malarplasty with a new L-shaped osteotomy through an intraoral approach: retrospective study of 418 cases. Plast Reconstr Surg 2009;124:1245–1253 15. Hahm JW, Baek RM, Oh KS, et al. 10-year experience on reduction malarplasty. J Korean Soc Plast Reconstr Surg 1997;24:1478–1485
Key Words: Abducens nerve, schwannoma, cerebellopontine angle
T
he abducens nerve schwannoma is one kind of rare schwannoma arising from motor nerves. Abducens nerve schwannoma was usually misdiagnosed preoperatively because it lacked specific imaging manifestations, and sometimes patients did not present symptom of abducens nerve palsy. We report the oldest patient with abducens nerve schwannoma in the cerebellopontine angle mimicking acoustic neuroma. The clinical features, diagnosis, and treatment of abducens nerve schwannomas are discussed within the context of a review of previous relative case reports.
CLINICAL REPORT A previously healthy 68-year-old man was admitted to our institute with vertigo and headache for more than 30 years and increasing in intensity for 2 months. Neurological examination did not reveal any nerve cranial disorder or muscle weakness. Magnetic resonance imaging showed a 20 16 15-mm heterogeneously enhancing tumor in the right cerebellopontine angle of which small portion extended into the right cavernous sinus, appearing as hypointense From the Department of Neurosurgery, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou Zhejiang Province, PR China, 310003. Received November 25, 2014. Accepted for publication December 23, 2014. Address correspondence and reprint requests to Dr. Yongqing Zhou, Department of Neurosurgery, the First Affiliated Hospital, College of Medicine, Zhejiang University, 79 Qingchun Rd, Hangzhou, Zhejiang 310003, PR China; E-mail: [email protected] The authors report no conflicts of interest. Copyright © 2015 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000001520
© 2015 Mutaz B. Habal, MD
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
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The Journal of Craniofacial Surgery • Volume 26, Number 2, March 2015
Brief Clinical Studies
FIGURE 1. Magnetic resonance images show the lesion as hypointense on T1-weighted imaging (A) and hyperintense on T2-weighted imaging (B) in the right cerebellopontine angle, with small a portion extended to the right cavernous sinus. T1-weighted imaging with contrast medium showing obvious inhomogeneous enhancement on transaxial (C) and coronal images (D).
on T1-weighted imaging and hyperintense on T2-weighted imaging. The brain stem was slightly compressed (Fig. 1). On computed tomography, the local bone anterior to the tumor was destroyed, but the internal acoustic meatus was normal in size (Fig. 2). The radiographic findings suggested the lesion as an acoustic neuroma. Therefore, the patient underwent craniectomy via suboccipital retrosigmoid approach. On opening the dura, the tumor was exposed and appeared as a solid gray mass, approximately 20 15 15 mm in size. It originated from the right abducens nerve and extended to the brain stem ventrolaterally. The trigeminal nerve and the facial and vestibulocochlear nerve complex attached to its dorsal surface superiorly and inferiorly. With the electrophysiological monitoring and ultrasonic surgical aspirator (CUSA), the tumor was debulked subtotally and the trigeminal nerve and the facial and vestibulocochlear nerve complex were identified and separated. For the tumor attached to the prepontine cisternal part of the abducens nerve firmly, we cut partial nerve at this point and excised the tumor completely (Fig. 3). The postoperative pathological examination confirmed the diagnosis of schwannoma (Fig. 4). The patient then recovered and was discharged with slightly abducens nerve palsy.
DISCUSSION Schwannomas are benign tumors of the peripheral nerve sheath, and most schwannomas arise from the sensory nerve. Abducens nerve schwannomas are extremely rare. To the best of our knowledge, only 24 cases of intracranial abducens nerve schwannomas have been published to date1–20; these are summarized in Table 1. After reviewing those cases, including the present one, the mean age at diagnosis of abducens nerve schwannomas was 45 years. No significant difference in the sex distribution was found. Clinically, most patients represented abducens nerve palsy, and other frequent symptoms or signs involved headache, facial numbness, hydrocephalus, hearing disturbance, and vertigo. Only 5 patients, including our patient, did not present symptoms of abducens nerve palsy. According to the site where the schwannoma arises and its predominant location along the course of the abducens nerve, Tung et al5 divided abducens nerve schwannomas into 2 categories: type I, schwannoma arises from the cavernous sinus, with the symptoms of abducens nerve palsy and with or without mild headache; type II, schwannoma arises from and predominantly occupies the prepontine area, with the presentation of obstructive hydrocephalus, abducens nerve palsy, and with or without other cranial nerve palsy. Half of the abducens nerve schwannomas reported was solid, but cystic
FIGURE 2. Computed tomographic scan of the tumor in the right cerebellopontine angle (A), and the local bone anterior to the tumor was destroyed (B).
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FIGURE 3. Intraoperative photomicrograph. A, The trigeminal nerve (V1) and the facial and vestibulocochlear nerve complex (V2) are seen on dorsal surface of the tumor (T) superiorly and inferiorly. V3: Posterior group cranial nerves. B, The abducens nerve (V4) was found to be attached to the tumor (T) posteriorly, and the tumor was debulked subtotally.
variant was found in 8 cases, and a few abducens schwannomas were mixed type. The patient we reported was a 68-year-old man, presenting only vertigo and headache, without the symptoms of abducens nerve palsy, and fell into the type II category. The tumor attached to the abducens nerve firmly but grew outward from the nerve sheath, without the invasion of the nerve fiber. Therefore, the patient did not present the abducens nerve palsy preoperatively. All but one case of abducens nerve schwannoma were misdiagnosed preoperatively. It is difficult to distinguish between trigeminal, vestibular, and abducens nerve schwannomas. Trigeminal nerve schwannomas could present abducens nerve palsy initially, whereas abducens nerve schwannomas could present only headache or other cranial nerve palsy, without abducens nerve palsy. In addition, preoperative computed tomography and magnetic resonance imaging showed no specific characteristics in abducens nerve schwannomas. Besides, intracranial schwannomas most frequently affect vestibular nerve, followed by the trigeminal nerve, but abducens nerve is rarely affected. Moses et al21 made the first case of correct preoperative diagnosis of abducens nerve schwannoma based on clinical and imaging features. When the patient presents isolated abducens nerve palsy and imaging tests reveal a mass located in the region of cavernous sinus or prepontine area, the diagnosis of abducens nerve schwannoma needs to be considered. Normal-appearing cisternal segment and ganglion of trigeminal nerve separate from the mass, and extension of the lesion along the course of abducens nerve in the region of Dorello canal on magnetic resonance imaging is valuable to make the diagnosis of abducens nerve schwannoma. Operation is the main treatment for abducens nerve schwannomas. Surgical approach depends on the location of the tumor. The patients with type I abducens nerve schwannomas were usually treated by frontotemporal approach,5,6,21 subtemporal approach,11,13 or their variations such as orbitozygomatic14 and zygomatic anterior transpetrosal approach.15 With type I abducens nerve schwannomas, it was hard to achieve total excision, and all patients but one had partial or complete abducens nerve palsy postoperatively.15 For type II abducens nerve schwannomas, the suboccipital approach was more appropriate; and lateral suboccipital approach or suboccipital retrosigmoid approach was a more common approach to access the tumor.1,2,7–10,12,19 Besides, Vachata and Sames18 excised an abducens nerve schwannoma at the right anterior pontomesencephalic junction totally via anterior transpetrosal approach, and the patient regained the abducens nerve function completely. Although the patients of type II abducens nerve schwannomas present more malignant clinical presentation, they get better opportunity for total surgical excision. Three cases of type II abducens nerve schwannomas had complete postoperative recovery of abducens nerve palsy.12,15,18 With the
FIGURE 4. Histological examination confirmed the diagnosis of a schwannoma with both cellular Antoni A and loosely textured Antoni B areas.
© 2015 Mutaz B. Habal, MD
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery • Volume 26, Number 2, March 2015
Brief Clinical Studies
TABLE 1. Reported Cases of Abducens Nerve Schwannoma Age (Years)
Reference Bing Huan,1 1981
46
Leunda et al,2 1982
10
Hansman et al,3 1986 Ginsberg et al,4 1988
58 47
Tung et al,5 1991
45 35
Lanotte et al,6 1992 Okada et al,7 1997
62 54
Beppu et al,8 1997
66
Ichimi et al,9 1997
61
Suetake et al,10 1998
31
11
Sex
Signs and Symptoms
Female VI palsy, headache, hydrocephalus Male VI palsy, facial pain, headache, hydrocephalus Male VI palsy Female VI palsy, facial weakness, difficulty swallowing, loss of balance, hydrocephalus Female VI palsy Male VI palsy Male VI palsy, headache Female VI palsy, facial numbness, headache Male VI palsy, tinnitus, hearing disturbance, vertigo, facial numbness Female VI palsy, facial numbness, hydrocephalus Female VI palsy, hearing disturbance, facial numbness Male VI palsy Male Headache, vertigo, hearing disturbance Female VI palsy
Lo et al, 2001 Nakamura et al,12 2002
19 42
Acharya et al,13 2003
40
Mascarenhas et al,14 2004
39
Nakagawwa et al,15 2004
38
Female VI palsy, headache, exophthalmos, chemosis Female VI palsy, facial numbness
Irace et al,16 2008 Erich et al,17 2009
55 26
Male VI palsy, painless proptosis Female VI palsy, nausea, headache
Vachata and Sames,18 2009
60
Male
36
Male
47 45 31 60 65 42 68
Male Female Female Female Male Male Male
Park et al,
19
2009
Hayashi et al,20 2010
Moses et al,21 2011 Rato et al,22 2011 Present case
Location
Consistency
Prepontine and CPA
Solid
Prepontine and middle fossa
Solid
CS and parasellar area Prepontine area with extension to CS
Solid Cystic
CS and parasellar area CS and parasellar area, extension to interpeduncular cistern Intracavernous Prepontine
Treatment (Surgical Approach) Craniotomy (suboccipital middle line) Craniotomy (suboccipital)
Total
Partial
Total
Palsy
? ?
Partial ?
Palsy ?
Mixed Cystic
Craniotomy (frontotemporal) Craniotomy (frontotemporal)
Subtotal Total
Palsy Palsy
Solid Mixed
Craniotomy (frontotemporal) Craniotomy (suboccipital and condylar) Craniotomy (lateral suboccipital)
Total Subtotal
Palsy Palsy
Partial
Palsy
Craniotomy (lateral suboccipital) Craniotomy (lateral suboccipital) Craniotomy (subtemporal) Craniotomy (lateral suboccipital) Craniotomy (subtemporal)
Total
Palsy
Subtotal
Partial
Subtotal Total
Palsy Complete
Subtotal
Palsy
Subtotal
Palsy
Total
Complete
Total Subtotal
Partial Palsy
Total
Complete
Total
Palsy
? ? ? ? Subtotal Total Total
Palsy Complete Partial Complete ? Complete Partial
CPA
Solid
CPA
Cystic
CPA and CS
Cystic
CS Prepontine area, with displacement of brain stem Parasellar and prepontine region, extends into posterior cranial fossa CS
Solid Solid
Cystic
Craniotomy (orbitozygomatic)
CS
Solid
Craniotomy (zygomatic anterior transpetrosal) Lateral orbitotomy Craniotomy (suboccipital) and radiation Craniotomy (anterior transpetrosal) Craniotomy (suboccipital retrosigmoid) GKS GKS GKS GKS Craniotomy (frontotemporal) Lateral orbitotomy Craniotomy (suboccipital retrosigmoid)
Solid
Solid Mixed
Vertigo, headache, falls, hearing loss, VI palsy VI palsy
orbit Right side of the pons and extend into CPA Right anterior pontomesencephalic junction CPA
Visual impairment None VI palsy None VI and VII palsy, headache VI palsy, painful proptosis Vertigo, headache
CS and orbit CS and prepontine CS CS CS and parasellar regions Orbit CPA with extension into CS
? ? ? ? ? Cystic Solid
abducens nerve schwannoma in the orbit, lateral orbitotomy approach is most advantageous.16,22 Gamma knife surgery (GKS) may be another effective treatment for abducens nerve schwannomas. Hayashi et al20 performed GKS in 4 intracavernous abducens nerve schwannomas and controlled the growth of tumor without acute complications or adverse effect. Conversional or stereotactic radiation is useful for recurrence or persistence of previously histologically verified abducens nerve schwannomas.
CONCLUSION Abducens schwannomas are rare and usually misdiagnosed as vestibular or trigeminal nerve schwannomas preoperatively. We
VI Removal Recovery
Cystic Cystic
reported the oldest patient with abducens nerve schwannoma to date without the symptoms of abducens nerve palsy. Operation and GKS were used as main treatments for primary abducens schwannomas. Further research is needed to improve the diagnosis and therapy for abducens schwannomas to have better postoperative recovery.
REFERENCES 1. Bing Huan C. Neurinoma of abducens nerves. Neurosurgery 1981;9:64–66 2. Leunda G, Vaquero J, Cabezudo J, et al. Schwannoma of occulomotor nerves: report of four cases. J Neurosurg 1982;57:563–566 3. Hansman ML, Hoover ED, Peyster RG. Sixth nerve neuroma in the cavernous sinus: CT features. J Comput Assist Tomorgr 1986;10:1030–1032
© 2015 Mutaz B. Habal, MD
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
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The Journal of Craniofacial Surgery • Volume 26, Number 2, March 2015
4. Ginsberg F, Peyster RG, Rose WS, et al. Sixth nerve schwannoma: MR and CT demonstration. J Comput Assist Tomorgr 1988;12:482–484 5. Tung H, Chen T, Weiss MH. Sixth nerve schwannomas: report of two cases. J Neurosurg 1991;75:638–641 6. Lanotte M, Giordana MT, Forni C, et al. Schwannoma of the cavernous sinus. Case report and review of the literature. J Neurosurg Sci 1992;36:233–238 7. Okada Y, Shima T, Nishida M, et al. Large sixth neuroma involving the prepontine region: case report. Neurosurgery 1997;40:608–610 8. Beppu T, Yoshida Y, Wada T, et al. Trochlear and abducens nerve neurinomas accompanied by a cerebellopontine angle meningioma—case report. Neurol Med Chir (Tokyo) 1997;37:416–421 9. Ichimi K, Yoshida J, Iano S, et al. Abducens nerve neurinoma—case report. Neurol Med Chir (Tokyo) 1997;37:197–200 10. Suetake K, Kurokawa Y, Ueda T, et al. A case of abducens neurinoma mimicking acoustic neurinoma. Comput Med Imaging Graph 1998;22:257–261 11. Lo PA, Harper CG, Besser M. Intracavernous schwannoma of the abducens nerve: a review of the clinical features, radiology and pathology of an unusual case. J Clin Neurosci 2001;8:357–360 12. Nakamura M, Cavalho GA, Samii M. Sixth nerve schwannoma: a case report with literature review. Surg Neurol 2002;57:183–189 13. Acharya R, Husain S, Chhabra SS, et al. Sixth nerve schwannoma: a case report with literature review. Neurol Sci 2003;24:74–79 14. Mascarenhas L, Magalhase Z, Honavar M, et al. Schwannoma of the abducens nerve in the cavernous sinus—case report. Actr Nerochir 2004;146:389–392 15. Nakagawa T, Uchida K, Ozveren MF, et al. Abducens schwannoma inside the cavernous sinus proper: case report. Surg Neurol 2004;61: 559–563 16. Irace C, Davi G, Corona C, et al. Isolated intraorbital schwannoma arising from the abducens nerve. Acta Neurochir (Wien) 2008;150: 1209–1210 17. Erlich SA, Tymianski M, Kiehl TR. Cellular schwannoma of the abducens nerve: case report and review of the literature. Clin Neurol Neurosurg 2009;111:467–471 18. Vachata P, Sames M. Abducens nerve schwannoma mimicking intrinsic brainstem tumor. Acta Neurochir 2009;151:1281–1287 19. Park JH, Cho YH, Kim JH, et al. Abducens nerve schwannoma: care report and review of the literature. Neurosurg Rev 2009;32:375–378 20. Hayashi M, Chernov M, Tamura N, et al. Gamma knife surgery for abducent nerve schwannoma. Report of 4 cases. J Neurosurg 2010;113 (suppl):136–143 21. Moses JE, Vermani N, Bansal SK. Preoperative clinico-radiological diagnosis of schwannoma arising from cavernous segment of abducens nerve. Neurol India 2011;59:471–472 22. Rato RM, Correia M, Cunha JP, et al. Intraorbital abducens nerve schwannoma. World Neurosurg 2012;78:375.e1–4
S267P Mutation in FGFR2: First Report in a Patient With Crouzon Syndrome Ronghu Ke, PhD,* Xianxian Yang, MD,† Min Ge, MD,* Tianyi Cai, BD,† Jiaqi Lei, BD,† Xiongzheng Mu, MD† Abstract: It has been known for several years that mutations in the fibroblast growth factor receptor (FGFR2) result in syndromic craniosynostosis including Apert, Crouzon, or Pfeiffer syndromes. Here, we report on a child with a clinically diagnosed Crouzon syndrome that shows the missense point mutation S267P in FGFR2 gene. The
592
mutation is firstly identified in Crouzon syndrome. Our observations expand the molecular spectrum of FGFR2 mutations in the syndrome. Key Words: Crouzon, craniosynostosis, FGFR2 mutation
C
raniosynostosis, the premature fusion of one or more cranial sutures, is a common malformation occurring in 1 of 2,500 live births. Although it frequently occurs as an isolated event resulting in nonsyndromic craniosynostosis, it is known to occur in conjunction with other anomalies in well-defined patterns that make up clinically recognized syndromes.1 There are more than 180 syndromic craniosynostoses. Among these syndromes, Crouzon syndrome (MIM 123500) is identified as one of the most common syndromic craniosynostoses, with a prevalence of approximately 1 in 60,000 births.2 The characteristic facial features are acrocephaly, exorbitism, maxillary hypoplasia, beaked nose, and prominent mandible. Other manifestations may include strabismus, atresia of the external auditory canals, premature calcification of stylohyoid ligament, Arnold–Chiari I malformation, hydrocephalus, and mental retardation. In contrast to Pfeiffer syndrome (MIM 101600), in which the first digits are characteristically broad and angulated, limb anomalies in Crouzon syndrome are milder or only apparent on radiological examination.3 Although this disorder was reported in 1912, its molecular genetic basis was firstly investigated more than 80 years later by Reardon et al who demonstrated exon 10 mutations of FGFR2 in nine unrelated individuals.4 Since then, many different mutations have been described in Crouzon syndrome, with approximately 95% of patients having mutations in just two exons of the gene (exon 8 and exon 10), which encode the extracellular immunoglobulin-like III (IgIII) domain of the protein.5 In this paper, we report on a young boy with a clinically diagnosed Crouzon syndrome that includes bicoronal craniosynostosis, proptosis, and maxillary hypoplasia but with normal digits. Subsequently, we analyzed FGFR2 mutation in the patient and identified a heterozygous Ser267Pro mutation in exon 8.
PATIENT AND METHODS Clinical and Radiological Findings A 6-year-old boy came to us for craniosynostosis. His family history was unremarkable and his parents were non-consanguineous. He showed a normal neuropsychiatric development. Physical examination showed a disproportionally wide head with flat occiput, underdeveloped midface with receding cheekbones (midfacial hypoplasia),
From the *Department of Plastic and Reconstructive Surgery, Huashan Hospital, Fudan University School of Medicine; and the †Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai Jaio Tong University School of Medicine, Shanghai, China. Received September 23, 2014. Accepted for publication December 23, 2014. Address correspondence and reprint requests to Xiongzheng Mu, MD, Department of Plastic and Reconstructive Surgery, Huashan Hospital, Fudan University School of Medicine, No. 12, Wu Lu Mu Qi Road (M), Shanghai 200040, China; E-mail: [email protected] The authors report no conflicts of interest. This work was supported by the National Natural Science Foundation of China (Grant No. 81171835, 81201483, 81372087). Copyright © 2015 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000001527
© 2015 Mutaz B. Habal, MD
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
TABLE 3. Soft Tissue Facial Morphometry of Patients With Facial Contour Surgery
WM, mm WL, mm FH, mm WM/WL WM/FH WL/FH
Preoperative
2 Years Postoperative
144.92 ± 11.02 125.48 ± 10.06 117.74 ± 7.05 1.16 ± 0.12 1.24 ± 0.14 1.07 ± 0.09
141.15 ± 10.54 117.89 ± 8.07 118.11 ± 6.44 1.20 ± 0.12 1.20 ± 0.14 0.99 ± 0.07
Now, we could do the preoperative simulation of both reduction osteotomies from 3-dimensional CT. In the future, we may combine 3-D CT and stereo photogrammetry to generate a single 3D representation of facial contour and using the aforementioned postoperative ratio as template. Thus, we can do a more precise virtual surgical planning for the reduction facial contour surgery in Chinese people.
CONCLUSIONS Combined reduction malarplasty and reduction of mandibular angles with partial masseter muscle resection can achieve an ideal oval facial contour for Chinese patients. Furthermore, the relative proportion index can be referenced as the standard for digital preoperative design.
Brief Clinical Studies
16. Yuan J, Cho MY, Zhang Y, et al. Influence of the maxillary sinus exposure in reduction malarplasty with an L-shaped osteotomy. J Craniofac Surg 2011;22:1788–1790 17. Yuan J, Zhu QQ, Zhang Y, et al. Influence of partial masseter muscle resection along with reduction of mandibular angle. J Craniofac Surg 2013;24:1111–1113 18. Kim HJ, Yum KW, Lee SS, et al. Effects of botulinum toxin type A on bilateral masseteric hypertrophy evaluated with computed tomographic measurement. Dermatol Surg 2003;29:484–489 19. Kim NH, Chung JH, Park RH, et al. The use of botulinum toxin type A in aesthetic mandibular contouring. Plast Reconstr Surg 2005;115:919–930
Abducens Nerve Schwannoma in Cerebellopontine Angle Mimicking Acoustic Neuroma Ming Wang, MD, Hongguang Huang, MD, Yongqing Zhou, PhD, MD Abstract: The abducens nerve schwannoma is one kind of rare intracranial tumor. We report an interesting case of abducens nerve schwannoma in the right cerebellopontine angle in a 68-year-old male patient presenting only vertigo and headache, without any symptom of abducens nerve palsy. This is the oldest patient with abducens nerve schwannoma to date. The patient received a craniectomy via suboccipital retrosigmoid approach and had total surgical excision.
REFERENCES 1. Baek SM, Kim SS, Bindiger A. The prominent mandibular angle: preoperative management, operative technique, and results in 42 patients. Plast Reconstr Surg 1989;83:272–280 2. Ousterhout DK. Mandibular angle augmentation and reduction. ClinPlast Surg 1991;18:153–161 3. Yang DB, Park CG. Mandibular contouring surgery for purely aesthetic reasons. Aesth Plast Surg 1991;15:53–61 4. Lee Y, Kim JH. Mandibular contouring: a surgical technique for the asymmetrical lower face. Plast Reconstr Surg 1999;104:1165–1171 5. Min L, Lai G, Xin L. Changes in masseter muscle following curved ostectomy of the prominent mandibular angle: an initial study with real-time 3D ultrasonography. J Oral Maxillofac Surg 2008;66:2434–2443 6. Lo LJ, Mardini S, Chen YR. Volumetric change of the muscles of mastication following resection of mandibular angles: a long-term follow-up. Ann Plast Surg 2005;54:615–621 7. Pary A, Pary K. Masseteric hypertrophy: considerations regarding treatment planning decisions and introduction of a novel surgical technique. J Oral Maxillofac Surg 2011;69:944–949 8. Baek SM, Chung YD, Kim SS. Reduction malarplasty. Plast Reconstr Surg 1991;88:53–61 9. Cho BC. Reduction malarplasty using osteotomy and repositioning of the malar complex: clinical review and comparison of two techniques. J Craniofac Surg 2003;14:383–392 10. Mahatumarat C, Rojvachiranonda N. Reduction malarplasty without external incision: a simple technique. Aesthet Plast Surg 2003;27:167–171 11. Sumiya N, Ito Y, Ozumi K. Reduction malarplasty. Plast Reconstr Surg 2004;113:1497–1499 12. Yang X, Mu X, Yu Z, et al. Compared study of Asian reduction malarplasty: wedge-section osteotomy versus conventional procedures. J Craniofac Surg 2009;20:1856–1861 13. Lee KC, Ha SU, Park JM, et al. Reduction malarplasty by 3-mm percutaneous osteotomy. Aesthet Plast Surg 2006;30:333–341 14. Wang T, Gui L, Tang X, et al. Reduction malarplasty with a new L-shaped osteotomy through an intraoral approach: retrospective study of 418 cases. Plast Reconstr Surg 2009;124:1245–1253 15. Hahm JW, Baek RM, Oh KS, et al. 10-year experience on reduction malarplasty. J Korean Soc Plast Reconstr Surg 1997;24:1478–1485
Key Words: Abducens nerve, schwannoma, cerebellopontine angle
T
he abducens nerve schwannoma is one kind of rare schwannoma arising from motor nerves. Abducens nerve schwannoma was usually misdiagnosed preoperatively because it lacked specific imaging manifestations, and sometimes patients did not present symptom of abducens nerve palsy. We report the oldest patient with abducens nerve schwannoma in the cerebellopontine angle mimicking acoustic neuroma. The clinical features, diagnosis, and treatment of abducens nerve schwannomas are discussed within the context of a review of previous relative case reports.
CLINICAL REPORT A previously healthy 68-year-old man was admitted to our institute with vertigo and headache for more than 30 years and increasing in intensity for 2 months. Neurological examination did not reveal any nerve cranial disorder or muscle weakness. Magnetic resonance imaging showed a 20 16 15-mm heterogeneously enhancing tumor in the right cerebellopontine angle of which small portion extended into the right cavernous sinus, appearing as hypointense From the Department of Neurosurgery, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou Zhejiang Province, PR China, 310003. Received November 25, 2014. Accepted for publication December 23, 2014. Address correspondence and reprint requests to Dr. Yongqing Zhou, Department of Neurosurgery, the First Affiliated Hospital, College of Medicine, Zhejiang University, 79 Qingchun Rd, Hangzhou, Zhejiang 310003, PR China; E-mail: [email protected] The authors report no conflicts of interest. Copyright © 2015 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000001520
© 2015 Mutaz B. Habal, MD
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
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FIGURE 1. Magnetic resonance images show the lesion as hypointense on T1-weighted imaging (A) and hyperintense on T2-weighted imaging (B) in the right cerebellopontine angle, with small a portion extended to the right cavernous sinus. T1-weighted imaging with contrast medium showing obvious inhomogeneous enhancement on transaxial (C) and coronal images (D).
on T1-weighted imaging and hyperintense on T2-weighted imaging. The brain stem was slightly compressed (Fig. 1). On computed tomography, the local bone anterior to the tumor was destroyed, but the internal acoustic meatus was normal in size (Fig. 2). The radiographic findings suggested the lesion as an acoustic neuroma. Therefore, the patient underwent craniectomy via suboccipital retrosigmoid approach. On opening the dura, the tumor was exposed and appeared as a solid gray mass, approximately 20 15 15 mm in size. It originated from the right abducens nerve and extended to the brain stem ventrolaterally. The trigeminal nerve and the facial and vestibulocochlear nerve complex attached to its dorsal surface superiorly and inferiorly. With the electrophysiological monitoring and ultrasonic surgical aspirator (CUSA), the tumor was debulked subtotally and the trigeminal nerve and the facial and vestibulocochlear nerve complex were identified and separated. For the tumor attached to the prepontine cisternal part of the abducens nerve firmly, we cut partial nerve at this point and excised the tumor completely (Fig. 3). The postoperative pathological examination confirmed the diagnosis of schwannoma (Fig. 4). The patient then recovered and was discharged with slightly abducens nerve palsy.
DISCUSSION Schwannomas are benign tumors of the peripheral nerve sheath, and most schwannomas arise from the sensory nerve. Abducens nerve schwannomas are extremely rare. To the best of our knowledge, only 24 cases of intracranial abducens nerve schwannomas have been published to date1–20; these are summarized in Table 1. After reviewing those cases, including the present one, the mean age at diagnosis of abducens nerve schwannomas was 45 years. No significant difference in the sex distribution was found. Clinically, most patients represented abducens nerve palsy, and other frequent symptoms or signs involved headache, facial numbness, hydrocephalus, hearing disturbance, and vertigo. Only 5 patients, including our patient, did not present symptoms of abducens nerve palsy. According to the site where the schwannoma arises and its predominant location along the course of the abducens nerve, Tung et al5 divided abducens nerve schwannomas into 2 categories: type I, schwannoma arises from the cavernous sinus, with the symptoms of abducens nerve palsy and with or without mild headache; type II, schwannoma arises from and predominantly occupies the prepontine area, with the presentation of obstructive hydrocephalus, abducens nerve palsy, and with or without other cranial nerve palsy. Half of the abducens nerve schwannomas reported was solid, but cystic
FIGURE 2. Computed tomographic scan of the tumor in the right cerebellopontine angle (A), and the local bone anterior to the tumor was destroyed (B).
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FIGURE 3. Intraoperative photomicrograph. A, The trigeminal nerve (V1) and the facial and vestibulocochlear nerve complex (V2) are seen on dorsal surface of the tumor (T) superiorly and inferiorly. V3: Posterior group cranial nerves. B, The abducens nerve (V4) was found to be attached to the tumor (T) posteriorly, and the tumor was debulked subtotally.
variant was found in 8 cases, and a few abducens schwannomas were mixed type. The patient we reported was a 68-year-old man, presenting only vertigo and headache, without the symptoms of abducens nerve palsy, and fell into the type II category. The tumor attached to the abducens nerve firmly but grew outward from the nerve sheath, without the invasion of the nerve fiber. Therefore, the patient did not present the abducens nerve palsy preoperatively. All but one case of abducens nerve schwannoma were misdiagnosed preoperatively. It is difficult to distinguish between trigeminal, vestibular, and abducens nerve schwannomas. Trigeminal nerve schwannomas could present abducens nerve palsy initially, whereas abducens nerve schwannomas could present only headache or other cranial nerve palsy, without abducens nerve palsy. In addition, preoperative computed tomography and magnetic resonance imaging showed no specific characteristics in abducens nerve schwannomas. Besides, intracranial schwannomas most frequently affect vestibular nerve, followed by the trigeminal nerve, but abducens nerve is rarely affected. Moses et al21 made the first case of correct preoperative diagnosis of abducens nerve schwannoma based on clinical and imaging features. When the patient presents isolated abducens nerve palsy and imaging tests reveal a mass located in the region of cavernous sinus or prepontine area, the diagnosis of abducens nerve schwannoma needs to be considered. Normal-appearing cisternal segment and ganglion of trigeminal nerve separate from the mass, and extension of the lesion along the course of abducens nerve in the region of Dorello canal on magnetic resonance imaging is valuable to make the diagnosis of abducens nerve schwannoma. Operation is the main treatment for abducens nerve schwannomas. Surgical approach depends on the location of the tumor. The patients with type I abducens nerve schwannomas were usually treated by frontotemporal approach,5,6,21 subtemporal approach,11,13 or their variations such as orbitozygomatic14 and zygomatic anterior transpetrosal approach.15 With type I abducens nerve schwannomas, it was hard to achieve total excision, and all patients but one had partial or complete abducens nerve palsy postoperatively.15 For type II abducens nerve schwannomas, the suboccipital approach was more appropriate; and lateral suboccipital approach or suboccipital retrosigmoid approach was a more common approach to access the tumor.1,2,7–10,12,19 Besides, Vachata and Sames18 excised an abducens nerve schwannoma at the right anterior pontomesencephalic junction totally via anterior transpetrosal approach, and the patient regained the abducens nerve function completely. Although the patients of type II abducens nerve schwannomas present more malignant clinical presentation, they get better opportunity for total surgical excision. Three cases of type II abducens nerve schwannomas had complete postoperative recovery of abducens nerve palsy.12,15,18 With the
FIGURE 4. Histological examination confirmed the diagnosis of a schwannoma with both cellular Antoni A and loosely textured Antoni B areas.
© 2015 Mutaz B. Habal, MD
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery • Volume 26, Number 2, March 2015
Brief Clinical Studies
TABLE 1. Reported Cases of Abducens Nerve Schwannoma Age (Years)
Reference Bing Huan,1 1981
46
Leunda et al,2 1982
10
Hansman et al,3 1986 Ginsberg et al,4 1988
58 47
Tung et al,5 1991
45 35
Lanotte et al,6 1992 Okada et al,7 1997
62 54
Beppu et al,8 1997
66
Ichimi et al,9 1997
61
Suetake et al,10 1998
31
11
Sex
Signs and Symptoms
Female VI palsy, headache, hydrocephalus Male VI palsy, facial pain, headache, hydrocephalus Male VI palsy Female VI palsy, facial weakness, difficulty swallowing, loss of balance, hydrocephalus Female VI palsy Male VI palsy Male VI palsy, headache Female VI palsy, facial numbness, headache Male VI palsy, tinnitus, hearing disturbance, vertigo, facial numbness Female VI palsy, facial numbness, hydrocephalus Female VI palsy, hearing disturbance, facial numbness Male VI palsy Male Headache, vertigo, hearing disturbance Female VI palsy
Lo et al, 2001 Nakamura et al,12 2002
19 42
Acharya et al,13 2003
40
Mascarenhas et al,14 2004
39
Nakagawwa et al,15 2004
38
Female VI palsy, headache, exophthalmos, chemosis Female VI palsy, facial numbness
Irace et al,16 2008 Erich et al,17 2009
55 26
Male VI palsy, painless proptosis Female VI palsy, nausea, headache
Vachata and Sames,18 2009
60
Male
36
Male
47 45 31 60 65 42 68
Male Female Female Female Male Male Male
Park et al,
19
2009
Hayashi et al,20 2010
Moses et al,21 2011 Rato et al,22 2011 Present case
Location
Consistency
Prepontine and CPA
Solid
Prepontine and middle fossa
Solid
CS and parasellar area Prepontine area with extension to CS
Solid Cystic
CS and parasellar area CS and parasellar area, extension to interpeduncular cistern Intracavernous Prepontine
Treatment (Surgical Approach) Craniotomy (suboccipital middle line) Craniotomy (suboccipital)
Total
Partial
Total
Palsy
? ?
Partial ?
Palsy ?
Mixed Cystic
Craniotomy (frontotemporal) Craniotomy (frontotemporal)
Subtotal Total
Palsy Palsy
Solid Mixed
Craniotomy (frontotemporal) Craniotomy (suboccipital and condylar) Craniotomy (lateral suboccipital)
Total Subtotal
Palsy Palsy
Partial
Palsy
Craniotomy (lateral suboccipital) Craniotomy (lateral suboccipital) Craniotomy (subtemporal) Craniotomy (lateral suboccipital) Craniotomy (subtemporal)
Total
Palsy
Subtotal
Partial
Subtotal Total
Palsy Complete
Subtotal
Palsy
Subtotal
Palsy
Total
Complete
Total Subtotal
Partial Palsy
Total
Complete
Total
Palsy
? ? ? ? Subtotal Total Total
Palsy Complete Partial Complete ? Complete Partial
CPA
Solid
CPA
Cystic
CPA and CS
Cystic
CS Prepontine area, with displacement of brain stem Parasellar and prepontine region, extends into posterior cranial fossa CS
Solid Solid
Cystic
Craniotomy (orbitozygomatic)
CS
Solid
Craniotomy (zygomatic anterior transpetrosal) Lateral orbitotomy Craniotomy (suboccipital) and radiation Craniotomy (anterior transpetrosal) Craniotomy (suboccipital retrosigmoid) GKS GKS GKS GKS Craniotomy (frontotemporal) Lateral orbitotomy Craniotomy (suboccipital retrosigmoid)
Solid
Solid Mixed
Vertigo, headache, falls, hearing loss, VI palsy VI palsy
orbit Right side of the pons and extend into CPA Right anterior pontomesencephalic junction CPA
Visual impairment None VI palsy None VI and VII palsy, headache VI palsy, painful proptosis Vertigo, headache
CS and orbit CS and prepontine CS CS CS and parasellar regions Orbit CPA with extension into CS
? ? ? ? ? Cystic Solid
abducens nerve schwannoma in the orbit, lateral orbitotomy approach is most advantageous.16,22 Gamma knife surgery (GKS) may be another effective treatment for abducens nerve schwannomas. Hayashi et al20 performed GKS in 4 intracavernous abducens nerve schwannomas and controlled the growth of tumor without acute complications or adverse effect. Conversional or stereotactic radiation is useful for recurrence or persistence of previously histologically verified abducens nerve schwannomas.
CONCLUSION Abducens schwannomas are rare and usually misdiagnosed as vestibular or trigeminal nerve schwannomas preoperatively. We
VI Removal Recovery
Cystic Cystic
reported the oldest patient with abducens nerve schwannoma to date without the symptoms of abducens nerve palsy. Operation and GKS were used as main treatments for primary abducens schwannomas. Further research is needed to improve the diagnosis and therapy for abducens schwannomas to have better postoperative recovery.
REFERENCES 1. Bing Huan C. Neurinoma of abducens nerves. Neurosurgery 1981;9:64–66 2. Leunda G, Vaquero J, Cabezudo J, et al. Schwannoma of occulomotor nerves: report of four cases. J Neurosurg 1982;57:563–566 3. Hansman ML, Hoover ED, Peyster RG. Sixth nerve neuroma in the cavernous sinus: CT features. J Comput Assist Tomorgr 1986;10:1030–1032
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Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
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4. Ginsberg F, Peyster RG, Rose WS, et al. Sixth nerve schwannoma: MR and CT demonstration. J Comput Assist Tomorgr 1988;12:482–484 5. Tung H, Chen T, Weiss MH. Sixth nerve schwannomas: report of two cases. J Neurosurg 1991;75:638–641 6. Lanotte M, Giordana MT, Forni C, et al. Schwannoma of the cavernous sinus. Case report and review of the literature. J Neurosurg Sci 1992;36:233–238 7. Okada Y, Shima T, Nishida M, et al. Large sixth neuroma involving the prepontine region: case report. Neurosurgery 1997;40:608–610 8. Beppu T, Yoshida Y, Wada T, et al. Trochlear and abducens nerve neurinomas accompanied by a cerebellopontine angle meningioma—case report. Neurol Med Chir (Tokyo) 1997;37:416–421 9. Ichimi K, Yoshida J, Iano S, et al. Abducens nerve neurinoma—case report. Neurol Med Chir (Tokyo) 1997;37:197–200 10. Suetake K, Kurokawa Y, Ueda T, et al. A case of abducens neurinoma mimicking acoustic neurinoma. Comput Med Imaging Graph 1998;22:257–261 11. Lo PA, Harper CG, Besser M. Intracavernous schwannoma of the abducens nerve: a review of the clinical features, radiology and pathology of an unusual case. J Clin Neurosci 2001;8:357–360 12. Nakamura M, Cavalho GA, Samii M. Sixth nerve schwannoma: a case report with literature review. Surg Neurol 2002;57:183–189 13. Acharya R, Husain S, Chhabra SS, et al. Sixth nerve schwannoma: a case report with literature review. Neurol Sci 2003;24:74–79 14. Mascarenhas L, Magalhase Z, Honavar M, et al. Schwannoma of the abducens nerve in the cavernous sinus—case report. Actr Nerochir 2004;146:389–392 15. Nakagawa T, Uchida K, Ozveren MF, et al. Abducens schwannoma inside the cavernous sinus proper: case report. Surg Neurol 2004;61: 559–563 16. Irace C, Davi G, Corona C, et al. Isolated intraorbital schwannoma arising from the abducens nerve. Acta Neurochir (Wien) 2008;150: 1209–1210 17. Erlich SA, Tymianski M, Kiehl TR. Cellular schwannoma of the abducens nerve: case report and review of the literature. Clin Neurol Neurosurg 2009;111:467–471 18. Vachata P, Sames M. Abducens nerve schwannoma mimicking intrinsic brainstem tumor. Acta Neurochir 2009;151:1281–1287 19. Park JH, Cho YH, Kim JH, et al. Abducens nerve schwannoma: care report and review of the literature. Neurosurg Rev 2009;32:375–378 20. Hayashi M, Chernov M, Tamura N, et al. Gamma knife surgery for abducent nerve schwannoma. Report of 4 cases. J Neurosurg 2010;113 (suppl):136–143 21. Moses JE, Vermani N, Bansal SK. Preoperative clinico-radiological diagnosis of schwannoma arising from cavernous segment of abducens nerve. Neurol India 2011;59:471–472 22. Rato RM, Correia M, Cunha JP, et al. Intraorbital abducens nerve schwannoma. World Neurosurg 2012;78:375.e1–4
S267P Mutation in FGFR2: First Report in a Patient With Crouzon Syndrome Ronghu Ke, PhD,* Xianxian Yang, MD,† Min Ge, MD,* Tianyi Cai, BD,† Jiaqi Lei, BD,† Xiongzheng Mu, MD† Abstract: It has been known for several years that mutations in the fibroblast growth factor receptor (FGFR2) result in syndromic craniosynostosis including Apert, Crouzon, or Pfeiffer syndromes. Here, we report on a child with a clinically diagnosed Crouzon syndrome that shows the missense point mutation S267P in FGFR2 gene. The
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mutation is firstly identified in Crouzon syndrome. Our observations expand the molecular spectrum of FGFR2 mutations in the syndrome. Key Words: Crouzon, craniosynostosis, FGFR2 mutation
C
raniosynostosis, the premature fusion of one or more cranial sutures, is a common malformation occurring in 1 of 2,500 live births. Although it frequently occurs as an isolated event resulting in nonsyndromic craniosynostosis, it is known to occur in conjunction with other anomalies in well-defined patterns that make up clinically recognized syndromes.1 There are more than 180 syndromic craniosynostoses. Among these syndromes, Crouzon syndrome (MIM 123500) is identified as one of the most common syndromic craniosynostoses, with a prevalence of approximately 1 in 60,000 births.2 The characteristic facial features are acrocephaly, exorbitism, maxillary hypoplasia, beaked nose, and prominent mandible. Other manifestations may include strabismus, atresia of the external auditory canals, premature calcification of stylohyoid ligament, Arnold–Chiari I malformation, hydrocephalus, and mental retardation. In contrast to Pfeiffer syndrome (MIM 101600), in which the first digits are characteristically broad and angulated, limb anomalies in Crouzon syndrome are milder or only apparent on radiological examination.3 Although this disorder was reported in 1912, its molecular genetic basis was firstly investigated more than 80 years later by Reardon et al who demonstrated exon 10 mutations of FGFR2 in nine unrelated individuals.4 Since then, many different mutations have been described in Crouzon syndrome, with approximately 95% of patients having mutations in just two exons of the gene (exon 8 and exon 10), which encode the extracellular immunoglobulin-like III (IgIII) domain of the protein.5 In this paper, we report on a young boy with a clinically diagnosed Crouzon syndrome that includes bicoronal craniosynostosis, proptosis, and maxillary hypoplasia but with normal digits. Subsequently, we analyzed FGFR2 mutation in the patient and identified a heterozygous Ser267Pro mutation in exon 8.
PATIENT AND METHODS Clinical and Radiological Findings A 6-year-old boy came to us for craniosynostosis. His family history was unremarkable and his parents were non-consanguineous. He showed a normal neuropsychiatric development. Physical examination showed a disproportionally wide head with flat occiput, underdeveloped midface with receding cheekbones (midfacial hypoplasia),
From the *Department of Plastic and Reconstructive Surgery, Huashan Hospital, Fudan University School of Medicine; and the †Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai Jaio Tong University School of Medicine, Shanghai, China. Received September 23, 2014. Accepted for publication December 23, 2014. Address correspondence and reprint requests to Xiongzheng Mu, MD, Department of Plastic and Reconstructive Surgery, Huashan Hospital, Fudan University School of Medicine, No. 12, Wu Lu Mu Qi Road (M), Shanghai 200040, China; E-mail: [email protected] The authors report no conflicts of interest. This work was supported by the National Natural Science Foundation of China (Grant No. 81171835, 81201483, 81372087). Copyright © 2015 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000001527
© 2015 Mutaz B. Habal, MD
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
