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The spindle cell tumor is a variant of sarcomatoid carcinoma that mostly affects the oral cavity. Bone involvement in this tumor leads to a wide excision, which sometimes requires resection of both the maxilla and mandible. The maxilla and mandible are important bones that function to form the 3-dimensional dimensions of the facial bones. The fibular bone can be selected to replace the facial bone because of its strong structure with a skin paddle, long pedicle, and proper bone shape. The authors present the case of a 24-year-old female who underwent maxillectomy and total hemimandibulectomy after a spindle cell tumor resection. The free fibular flap was harvested and divided into several segments to close the mandible and maxilla. However, the vascularized bone was insufficient; thus, non-vascularized bone was used in combination to reconstruct the maxilla. Six months after bone reconstruction, a dermofat graft was placed to fill the cheek structure. During the 6 months of follow-up, the vascularized and non-vascularized fibular bones were well arranged. Intraoral placement of a skin paddle covering the maxilla and mandible was viable. Both functional and esthetic outcomes were attained in patients with high satisfaction rates. Although there are many reconstruction options for patients with post-wide tumor excision, the fibula free flap remains the main choice as a replacement for facial bones because it has a strong and firm bone structure that can resemble facial bones; thus, a non-vascularized bone graft can be used in combination to cover the defects., Competing Interests: The authors report no conflicts of interest., (Copyright © 2025 by Mutaz B. Habal, MD.)

Purpose: To evaluate the effect of diabetic retinopathy (DR) lesion type (hemorrhages and/or microaneurysms, intraretinal microvascular abnormalities, new vessels elsewhere, and venous beading), severity, and distribution on disease worsening based on the Early Treatment Diabetic Retinopathy Study Diabetic Retinopathy Severity Scale., Methods: Post hoc analysis of a multicenter observational study of 544 eyes with nonproliferative DR and an Early Treatment Diabetic Retinopathy Study Diabetic Retinopathy Severity Scale score of Level 35 to 53. Disease worsening was defined as Early Treatment Diabetic Retinopathy Study Diabetic Retinopathy Severity Scale worsening by ≥2 steps from baseline or receipt of DR treatment over 4 years. DR lesions were evaluated based on the entire visible area in the ultrawide field color (UWF-color) and UWF-fluorescein angiography images., Results: A significantly greater risk of disease worsening was associated with the presence of more severe lesion grades outside the Early Treatment Diabetic Retinopathy Study fields for hemorrhages and/or microaneurysms (hazard ratio: 1.74 [95% confidence interval, 1.28-2.36]) on UWF-color and for hemorrhages and/or microaneurysms (1.90 [1.38-2.61]), intraretinal microvascular abnormalities (1.68 [1.13-2.49]), and new vessels elsewhere (1.99 [1.36-2.93]) on UWF-fluorescein angiography., Conclusion: These results suggest that features on UWF-color and UWF-fluorescein angiography may provide additional prognostic value in determining the risk of disease worsening. The use of UWF-fluorescein angiography improves identification of DR lesions and disease progression. However, the optimal method of disease risk assessment on UWF imaging still needs to be determined.

Background/purpose: To define "strong" versus "weak" antivascular endothelial growth factor (anti-VEGF) treatment response in eyes with center-involved diabetic macular edema (CI-DME)., Methods: Exploratory analyses of three DRCR Retina Network randomized trials of eyes with CI-DME treated with aflibercept, bevacizumab, or ranibizumab. Thresholds of 5-, 10-, and 15-letter gain defined strong visual acuity (VA) response when baseline VA was 20/25-20/32, 20/40-20/63, or 20/80-20/320, respectively. Thresholds of 50, 100, or 200- µ m reduction defined strong anatomical response when baseline central subfield thickness (CST) was <75, ≥75 to <175, or ≥175- µ m above standard thresholds. Additional thresholds from regression equations were calculated., Results: At 24 weeks, outcomes for strong response were achieved by 476 of 958 eyes (50%) for VA and 505 eyes (53%) for CST. At 104 weeks among the 32% of eyes with strong VA and CST response at 24 weeks, 195 of 281 (69%) maintained strong VA and CST response, whereas 20 (7%) had neither strong VA nor strong CST response. Outcomes rates were similar across protocols and when defined using regression equations., Conclusion: These phenotypes are suitable for efforts to identify predictive biomarkers for response to anti-VEGF therapy for DME and might facilitate comparison of treatment response among diverse cohorts with DME.

Purpose: Evaluate association of retinal nonperfusion (NP) on ultrawide field (UWF) fluorescein angiography (FA) with diabetic retinopathy (DR) severity and predominantly peripheral lesions (PPL)., Methods: Multicenter observational study, 652 eyes (361 participants) having nonproliferative DR (NPDR) without center-involved diabetic macular edema in at least one eye. Baseline 200° UWF-color and UWF-FA images were graded by a central reading center for color-PPL and FA-PPL, respectively. UWF-FA was graded for NP index within concentric zones: posterior pole (<10 mm from fovea), midperiphery (10-15 mm), and far periphery (>15 mm)., Results: Baseline Early Treatment Diabetic Retinopathy Study DR severity was 31.7% no DR/mild NPDR, 24.1% moderate NPDR, 14.0% moderately severe NPDR, 25.6% severe/very severe NPDR, and 4.6% proliferative DR. Worse DR severity was associated with increased NP index overall (P = 0.002), in the posterior pole (P < 0.001), midperiphery (P < 0.001), and far periphery (P = 0.03). On average, 29.6% of imaged retinal NP was in the posterior pole, 33.7% in midperiphery, and 36.7% in far periphery. Increased NP index was associated with FA-PPL (P < 0.001) but not with color-PPL (P = 0.65)., Conclusion: Approximately, 70% of NP in diabetic eyes is located outside the posterior pole. Increased NP is associated with the presence of FA-PPL, suggesting UWF-FA may better predict future DR worsening than UWF-color alone.

Purpose: Among eyes with proliferative diabetic retinopathy, identify whether baseline characteristics impact the benefit of ranibizumab over panretinal photocoagulation (PRP) in DRCR.net Protocol S., Methods: Participants had proliferative diabetic retinopathy, visual acuity of 20/320 or better, and no previous PRP. Eyes were randomized to PRP or intravitreous 0.5-mg ranibizumab., Results: Ranibizumab was superior to PRP for change in visual acuity and development of vision-impairing central-involved diabetic macular edema over 2 years (P < 0.001). Among 25 characteristics, there were none in which participants assigned to PRP had superior outcomes relative to ranibizumab-assigned participants. The relative benefit of ranibizumab over PRP for change in visual acuity seemed greater in participants with higher mean arterial pressure (P = 0.03), without previous focal/grid laser (P = 0.03), with neovascularization of the disk and elsewhere on clinical examination (P = 0.04), and with more advanced proliferative diabetic retinopathy on photographs (P = 0.02). For development of vision-impairing central-involved diabetic macular edema, the relative benefit of ranibizumab over PRP seemed greater among nonwhite participants (P = 0.01) and those with higher mean arterial pressure (P = 0.01)., Conclusion: There were no characteristics identified in which outcomes were superior with PRP compared with ranibizumab. These exploratory analyses provide additional support that ranibizumab may be a reasonable alternative to PRP for proliferative diabetic retinopathy over a 2-year period.

Purpose: Compare changes in retinal nerve fiber layer (RNFL) thickness between eyes assigned to intravitreous ranibizumab or panretinal photocoagulation and assess correlations between changes in RNFL and visual field sensitivity and central subfield thickness., Methods: Eyes with proliferative diabetic retinopathy were randomly assigned to ranibizumab or panretinal photocoagulation. Baseline and annual follow-up spectral domain optical coherence tomography RNFL imaging, optical coherence tomography macular imaging, and automated static perimetry (Humphrey visual field 60-4 algorithm) were performed., Results: One hundred forty-six eyes from 120 participants were analyzed. At 2 years, for the ranibizumab (N = 74) and panretinal photocoagulation (N = 66) groups, respectively, mean change in average RNFL thickness was -10.9 ± 11.7 μm and -4.3 ± 11.6 μm (difference, -4.9 μm; 95% confidence interval [-7.2 μm to -2.6 μm]; P < 0.001); the correlation between change in RNFL thickness and 60-4 Humphrey visual field mean deviation was -0.27 (P = 0.07) and +0.33 (P = 0.035); the correlation between change in RNFL thickness and central subfield thickness was +0.63 (P < 0.001) and +0.34 (P = 0.005), respectively., Conclusion: At 2 years, eyes treated with ranibizumab had greater RNFL thinning than eyes treated with panretinal photocoagulation. Correlations between changes in RNFL thickness, visual field, and central subfield thickness suggest that the decrease in RNFL thickness with ranibizumab is likely due to decreased edema rather than loss of axons.

Purpose: To explore 5-year changes from baseline in diabetic retinopathy severity among eyes treated with ranibizumab for diabetic macular edema., Methods: Diabetic retinopathy severity was assessed from study visits and annual fundus photographs among participants in Protocol I (DRCR.net). The proportion of eyes that improved at annual examinations and the cumulative probability of worsening through 5 years were estimated., Results: Among 235 participants with nonproliferative diabetic retinopathy at baseline, there were 29%, 28%, and 32% of eyes with retinopathy improvement at 1, 3, and 5 years, respectively. Among 111 participants with proliferative diabetic retinopathy, corresponding improvement percentages were 38%, 35%, and 23%. The 5-year cumulative probability of worsening was 18% (95% CI: 14%-25%) among nonproliferative diabetic retinopathy eyes and 31% (95% CI: 23%-42%) among proliferative diabetic retinopathy eyes (P = 0.01). In Years 1, 3, and 5, the mean (SD) number of ranibizumab injections was 8.1 (2.5), 2.2 (2.6), and 1.8 (2.6) for nonproliferative diabetic retinopathy eyes, and 9.0 (2.8), 2.3 (2.9), and 1.7 (2.6) for proliferative diabetic retinopathy eyes, respectively. Proportions with improvement or rates of worsening did not change with time., Conclusion: Individuals receiving ranibizumab therapy for diabetic macular edema may have favorable changes in DR severity throughout a 5-year period concomitant with sequential reduction in anti-vascular endothelial growth factor therapy.

Rhinoplasty is one of the most delicate procedures in plastic and reconstructive surgery. Precision in every millimeter is vital in ensuring a better quality of surgical outcome. Many methods have been developed to fulfill this requirement. One such method is an implant, whether autogenous or artificial. Artificial implants involve several surgical complications, such as recipient rejection of implant material, infections, and rigid feel of the nasal tip. Hence, autogenous implants were eventually more widely applied, with material being obtained from the septum, concha, or rib cartilages. Therefore, the authors developed a new technique of rhinoplasty, using the osteochondral rib as an autogenous implant based on the ancient Chinese architectural technology called the DouGong method. The authors hereby present the results of 288 patients treated in our faculty wherein the data from the patients and the preoperative and postoperative 3-dimensional computed tomography scans were processed using Mimics software. The uniqueness of these implants is that the joint between the nasal dorsum and the columella strut is fixated without any screw, stitches, or K-wire. This procedure proved to be very useful as this technique not only minimized the application of fixation techniques, but also helped achieve a better nasofrontal angle, nasolabial angle, and columella length. After monitoring follow-ups of our patients, the authors hereby propose the use of this DouGong-based novel technique to improve the overall quality and outcome of corrective rhinoplasty.

Background: Large temporal plexiform neurofibroma (PNF) is an irritating problem that causes facial disfigurement. Surgical resection of PNF is the only effective way to remove the tumor as well as to improve the patient's facial appearance. However, temporal branch of the facial nerve (TBFN) in the tumor is prone to be destroyed during PNF removal. Thus, TBFN palsy is the inevitable complication after surgery and might induce other malformation and dysfunction. Therefore, the aim of this study is to reconstruct a nearly normal face contour while preserving the facial nerve function., Purpose: Selective PNF removal technique was designed to protect TBFN during PNF lesions resection in our patients., Methods: From May 2011 to June 2015, the authors had 10 patients who suffered from PNF in the temporal region with facial disfigurement and underwent selective PNF removal to correct the facial disfigurement while preserving TBFN as well., Result: All patients obtained the improvement of facial appearance after surgery. The temporal PNF was removed and the TBFN function successfully maintained. Plexiform neurofibroma recurrence has not been relapsed during 6 to 49 months' follow-up., Conclusions: In our initial exploration, TBFN function maintenance and facial appearance improvement can be achieved simultaneously by using PNF-selective removal surgery technique., Competing Interests: The authors report no conflicts of interest.

Background: The approach to managing diabetic macular edema in eyes with previous vitrectomy is based on limited evidence. Therefore, an exploratory post hoc assessment of 3-year data from eyes with and without vitrectomy before randomization in a DRCR.net trial that evaluated ranibizumab + prompt or deferred laser for diabetic macular edema is presented., Methods: Visual acuity and optical coherence tomography outcomes were compared between eyes with and without previous vitrectomy., Results: At baseline, eyes with previous vitrectomy (n = 25) had longer duration of diabetes, worse visual acuity, less thickened central subfield measurements on optical coherence tomography and were more apt to have worse diabetic retinopathy severity level or previous treatment for macular edema or cataract surgery than eyes without a history of vitrectomy (n = 335). Analyses adjusted for these baseline imbalances did not identify substantial differences between eyes with and without previous vitrectomy at each annual visit through 3 years for the favorable visual acuity, optical coherence tomography central subfield thickness, or volume outcomes, although optical coherence tomography improvement appeared slower in vitrectomy eyes during the first year., Conclusion: This study provides little evidence that the beneficial clinical outcomes for patients with center-involved diabetic macular edema treated with anti-vascular endothelial growth factor are affected in the long term by previous vitrectomy.

Background: As three-dimensional technology becomes more ubiquitous, many plastic surgical applications have emerged. The authors investigate a three-dimensional scanning and printing system for facial soft tissue reconstruction in conjunction with an anterolateral thigh dermal adipofascial flap for the treatment of Parry-Romberg syndrome., Methods: Seven patients with facial atrophy of the zygomatic, buccal, and mandibular areas were included. Three-dimensional scanning of each patient's face in conjunction was analyzed with computer-aided design (CAD) to quantify areas of facial asymmetry. Models were then created using three-dimensional printing to map areas of soft tissue deficiency. Free anterolateral thigh (ALT) dermal adipofascial flaps were designed based on the three-dimensional models of soft tissue deficiency., Results: All flaps survived. One case had a postoperative hematoma. Six patients had restored facial symmetry. One patient required fat injections to obtain symmetry. No patients required revision surgery of their healed flaps for contouring., Conclusions: Three-dimensional laser scanning and three-dimensional printing in combination with a free ALT dermal adipofascial flap offer surgeons a precise means to reconstruct facial contour deformities.

Purpose: To evaluate the effect of a topical, nonsteroidal antiinflammatory drug, nepafenac 0.1%, in eyes with noncentral diabetic macular edema., Methods: Multicenter, double-masked randomized trial. Individuals with good visual acuity and noncentral-involved diabetic macular edema were randomly assigned to nepafenac 0.1% (N = 61) or placebo (nepafenac vehicle, N = 64) 3 times a day for 12 months. The primary outcome was mean change in optical coherence tomography retinal volume at 12 months., Results: Mean baseline retinal volume was 7.8 mm. At 12 months, in the nepafenac and placebo groups respectively, mean change in retinal volume was -0.03 mm and -0.02 mm (treatment group difference: -0.02, 95% confidence interval: -0.27 to 0.23, P = 0.89). Central-involved diabetic macular edema was present in 7 eyes (11%) and 9 eyes (14%) at the 12-month visit (P = 0.79), respectively. No differences in visual acuity outcomes were identified. One study participant developed a corneal melt after using nepafenac in the nonstudy eye, which had a history of severe dry eye. No additional safety concerns were evident., Conclusion: In eyes with noncentral diabetic macular edema and good visual acuity, topical nepafenac 0.1% 3 times daily for 1 year likely does not have a meaningful effect on optical coherence tomography-measured retinal thickness.

Purpose: To review in a standardized fashion pre- and postoperative fluorescein angiographic characteristics in patients undergoing limited macular translocation (LMT) with scleral imbrication to treat subfoveal choroidal neovascularization (SFCNV) secondary to age-related macular degeneration (AMD). The current study was undertaken to assess any potential effects of the translocation procedure on altering the angiographic characteristics of SFCNV before laser photocoagulation., Methods: A consecutive series of patients undergoing LMT for AMD was identified retrospectively. The pre- and postoperative fluorescein angiograms were reviewed in a masked fashion. Angiographic characteristics evaluated included pre- and postoperative lesion components, stability of lesion, and the amount of retinal translocation obtained., Results: Eighty-eight patients (90 eyes) had angiograms of adequate quality to permit evaluation. Time between the preoperative and the prelaser angiogram ranged from 2 to 84 days (median 7.5 days). Neovascular complexes remained unchanged or decreased in size in 79% of patients. There was no statistically significant difference in lesion size between the pre- and postoperative periods (P = 0.34). Retinal movement ranged from 160 microm to 3,320 microm (median 960 microm), with 61% of cases undergoing effective translocation (i.e., the fovea was moved away from the neovascular complex). None of the lesion components or demographic factors evaluated affected the amount of translocation obtained. Larger lesions were more likely to remain subfoveal following translocation (P = 0.004)., Conclusion: The size and lesion characteristics appear relatively stable following translocation. Amount of retinal movement is not associated with angiographic lesion characteristics. Only size was associated with achievement of desired translocation in the final model, with large lesions being less likely to achieve desired translocation. In our study group, the amount of retinal translocation was variable with 61% of cases undergoing effective translocation.

Mesenteric traction syndrome consists of sudden tachycardia, hypotension, and cutaneous hyperemia, and frequently occurs during mesenteric traction in patients undergoing abdominal aortic aneurysm (AAA) reconstructive surgery. The etiology and clinical impact of this phenomenon are unknown, but the symptoms suggest a release of vasoactive materials from the mesenteric vascular bed. Thirty-one patients who underwent AAA surgery were studied. Mesenteric traction was accompanied by a decrease in systolic (p = 0.005) and diastolic (p less than 0.05) blood pressures, and in systemic vascular resistance (p less than 0.005), and was accompanied by an increase in heart rate (HR) (p less than 0.005), and cardiac output (p = 0.01). These hemodynamic changes coincided with an increase (p less than 0.001) in plasma concentrations of 6-keto-prostaglandin F1 (6-K-PGF1). No apparent change was found in prostaglandin E2, thromboxane B2, and histamine concentrations. The concentration of 6-K-PGF1 was correlated with diastolic blood pressure (r = -0.52, p less than 0.005) and HR (r = 0.65, p less than 0.001). Cutaneous hyperemia was observed in 58% of the patients. In an additional six patients, who had taken aspirin daily before AAA surgery, no significant changes were observed in the hemodynamic measurements or 6-K-PGF1 concentrations. These data suggest that mesenteric traction syndrome may be mediated at least in part by a selective release of prostacyclin.