International Microsurgery Journal (IMJ) is an open access journal with a comprehensive peer review policy and a rapid publication process. IMJ provides a global platform for scientists, clinicians, researchers and scholars to interact and share their latest research in all fields of microsurgery, including head and neck reconstruction, breast reconstruction, trunk and torso reconstruction, hand and upper extremities reconstruction, lower extremities reconstruction, lymphatic surgery, peripheral nerve, vascularized composite tissue allotransplantation, experimental microsurgery, microsurgical education, or other related topics.
IMJ is the official journal of International Microsurgery Club (IMC) and Internationl Course on Supermicrosurgery (国际超级显微外科学会, ICSM). International Microsurgery Club was created to facilitate discussion of complex cases and share knowledge of microsurgical techniques amongst experts around the world. Since its inauguration in May 2016, IMC now counts 5000 members and is one of the largest online educational platforms for microsurgery around the world. IMJ aims to make these educational case discussions available in written format to maximize the scholarly outreach and access to these valuable resources. IMJ welcomes submission of case reports, original articles, review papers, clinical studies, editorials, expert opinion and perspective articles, commentaries, and book reviews.
Dr. Tommy Nai-Jen Chang is an Assistant Professor in the Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Microsurgery, Chang-Gung Memorial Hospital, Linkou Medical Center, Taiwan. Dr. Chang finished his residency at Chang-Gung Memorial Hospital in 2011 and was appointed as staff of the department. Between March 2015 and January 2017, Dr. Chang completed a peripheral nerve research fellowship at the Hospital for Sick Children (SickKids) in Toronto, Canada, which was supervised by Dr. Gregory Borschel, Dr. Tessa Gordon and Dr. Ronald Zuker.
Clinically, Dr. Chang works with Professor David Chwei-Chin Chuang and Dr. Johnny Chuieng-Yi Lu for peripheral nerve reconstruction for adult and pediatric brachial plexus injury, facial paralysis, and reconstruction of upper and lower extremity defects. Dr. Chang also performs microvascular surgeries for Head and Neck reconstruction, perineal reconstruction, hand surgery and vascularized composite tissue allotranplantation. His research interests include peripheral nerve reconstruction, vascularized composite tissue allotransplantation, and the use of social media for surgical education such as online platform and questionnaire study.
Tommy Nai-Jen Chang, MD
International Microsurgery Journal
Professor David Chwei-Chin Chuang is the first plastic surgeon who concentrated on peripheral nerve science that incorporated injuries, reconstruction, and researches in Taiwan. It took him 30 years to be recognized as a world expert in the field of peripheral nerve injury and reconstruction. He started his microsurgical career in 1984 and became an academic professor in 2000. His phenomenal career was inspired largely by mentors namely: Dr. Samuel Noordhoff who motivated him to become a plastic surgeon, Dr. Fu-Chan Wei who influenced him to become a micro-surgeon; Dr. Julia K Terzis (USA), Dr. H. Millesi (Austria), Dr. A. Narakas (Switzerland), and Dr. Toru Kondo (Japan) - all four of whom had primed him to become a peripheral nerve microsurgeon.
In the process of aiming to make a solid contribution in the world of microsurgery, Prof. Chuang has developed many concepts and techniques related to the following: peripheral nerve reconstruction that deals with the classification level of brachial plexus injury; classification of level of radial nerve injury; classification of severity of post-paralysis facial synkinesis and strategy for treatment; the classification of traction avulsion amputation of the major limb; the technique of gracilis myocutaneous flap harvest; the technique revolution of FFMT for facial nerve reconstruction; the surgical treatment of thoracic outlet syndrome; the subfascial anterior transfer for cubital tunnel syndrome; the operative methods of nerve transfer for irreparable brachial plexus avulsion injury; the contralateral C7 transfer with free vascularized ulnar nerve graft; the intercostals nerve transfer to the musculocutaneous nerve, and other nerve transfer procedures.
Despite his already quite hectic schedule, he still found the time to get involved in many types of researches, which are related to peripheral nerve and free functioning muscle transplantation. Also, his numerous experimental types of research have been published in Plastic and Reconstructive Surgery, one of which is the research for arterialized venous flaps using vaso vasorum changes that he completed in 2015.
Because of his unique field of medical expertise, Prof. Chuang has been invited in countless local and worldwide meetings for special lectures, symposiums and panels in Japan, Korea, China, Thailand, Singapore, Indonesia, India, Argentina, Italy, Finland, Kuwait, Hong Kong, Mexico, Turkey, Germany and the USA. Furthermore, he also co-authored a chapter in three versions of the textbook entitled “Plastic Surgery” (2nd version 2006, third version 2013, and a new coming fourth version). Aside from these seemingly untiring achievements, he did several presentations locally and internationally, which were profiled in quite a number of publications for different medical journals.
Prof. Chuang has been similarly sought as the International Associate Editor of Plastic and Reconstructive Surgery from 2014 to 2016, and his term has been extended from 2016 to 2018. In relation to the foregoing, Professor Chuang has twice hosted the "Instructional Course" for adult brachial plexus injury in 2009, and facial paralysis reconstruction in 2011. The third part (adult brachial plexus injury) of which, is coming soon this 2017.
To make his career in micro surgery more fulfilling, Prof. Chuang engaged himself with the Fellow Training Program of Chang Gung Memorial Hospital as one of the teachers, for hundreds of international foreign fellows. Along with this, he has treated international patients (approximately 100) from 20 different countries around the world.
As an authority figure in the field of micro-surgery, Prof. Chuang held vital positions as follows: Chief of Department of Plastic Surgery, Chang Gung Memorial Hospital, Taipei-Linkou; 13th President of Taiwan Plastic Surgical Association (2006-2008); 10th President of Taiwan Society for Surgery of the Hand (2009-2010); and First (1st) President of Taiwan Society for Reconstructive Microsurgery (2014-2016). At present, he is the 9th President of World Society for Reconstructive Microsurgery (WSRM) from March 2015 to June 2017. Prof. Chuang is undertaking every workable means and ways to fortify the relationship between the WSRM central office and the four regional societies (ASRM, ALAM, EFSM and APFSRM).
Prof. Chuang’s high hope is for the International Microsurgery Club and the International Microsurgery Journal to truly become the “World Society.”
David Chwei-Chin Chuang, MD
International Microsurgery Journal
President Emeritus, World Society for Reconstructive Microsurgery
Prof. Koushima, president of World Society for Reconstructive Microsurgery from 2017 to 2019, graduated from Okayama Prefectural Tsuyama High School and Faculty of Medicine Tottori University in the 70s, finished his resident training as a plastic surgeon at Tokyo Women's Medical University Surgery department and The University of Tokyo Hospital Plastic surgery.
In 1983, he joined University of Tsukuba Plastic Surgery Faculty of Medicine as a lecturer. By the year of 1990, he became an associate professor at Kawasaki Medical School Plastic Surgery. He was then sent to Harvard University for further education in 1996 and became a professor at Okayama University Faculty of Medicine Plastic Reconstruction Surgery, The University of Tokyo Plastic Reconstruction Surgery, and National University of Singapore in the early 2000s. In 2010, he was the associate dean at The University of Tokyo Hospital and became emeritus professor at The University of Tokyo Hospital as well as distinguished professor at Hiroshima University International Lymphedema Treating Center in 2017.
Throughout his academic career, he performed live surgeries in 22 hospitals through invitations from international societies since 1997, including Ghent University Hospital, Belgium (twice), Louisiana State University, USA , Kuwait University hospital, München , Universidade de São Paulo hospital, Sant Pau Hospital, Barcelona, Ankara Medicine University, Turkey, China-Japan Friendship Hospital, Beijing (twice), National University of Singapore, Planas Hospital, Barcelona, Coimbatore city hospital, India, Versailles, France (2009/Feb), Utrecht University Hospital, Nederland (2009/May), Tomsk State University, Russia (2009/Sep), Planas Hospital, Barcelona(2010/Mar), University of Picardie Jules Verne, France (2010/Jul), Mahidol University, Thailand (2010/Aug), Hospital General Dr. Manuel Gea González (2010/Oct), The Chinese University of Hong Kong( 2010/Nov), National University of Singapore (2010/Dec), and Mumbai, India (2011/Mar).
Prof. Koushima’s contribution to the field can be divided into basic medical sciences and clinical medical sciences. He specializes in neuro-degeneration and neuro-regeneration, nerve grafting, tendon transplantation, and vascular pedicle nerve grafting. He is very well known in multiple clinical fields, such as perforator flap reconstruction, microvascular anastomosis, head and neck reconstruction, facial nerve palsy reconstruction, extremities’ reconstruction, lymphedema surgeries, as well as transgender surgeries for those with gender identity disorders. He has performed penis reconstruction, hand reconstruction, breast reconstruction, and aesthetic plastic surgery.
Prof. Koushima is affiliated with many societies as he is the reviewer of Plastic & Reconstructive Surgery Journal of American Society of Plastic Surgeons and Japanese Society of Plastic Reconstruction Surgery, and the founder and operator of International perforator flap conference 1997, Asia Pacific super micro conference in Singapore 2007, and Europe super micro conference in Barcelona 2010. He was the chairman of Japanese Society for Surgery of the Hand, Japanese Society of Reconstructive Microsurgery, and Japanese Society for Lymphoreticular Tissue. He is the supervisor of Japanese Society of Tissue Transplantation and members of Japan Society for Head and Neck Surgery and Japanese Research Society of Clinical Anatomy.
International Microsurgery Journal
Pesident, World Society for Reconstructive Microsurger
Prof. Wang is the world-famous microsurgeon in China. He is currently the chief of Shandong Provincial Hospital Extremities Surgery Department, professor and chief physician of Chinese Association of Microsurgery, vice chairman of Chinese Medical Association Branch of Microsurgery and Branch of Hand Surgery, and committee member of Shandong Province Society for Surgery of the Hand, committee member of Chief Shandong Province Society for Trauma surgery, vice chief physician of Shandong Province Society for Reconstruction Surgery, and editorial board member of Chinese Journal of Clinical Anatomy.
Prof. Zeng-Tao Wang’s work is filled with creativity, mainly focusing on a combination of clinical research and basic medical research. He has published several world-class original results based on innovative techniques in the clinical medical field. For instance, Dr. Wang’s research made great improvements regarding low temperature organ preservation. He successfully replanted three cases of low temperature-preserved severed finger at -196°C. Moreover, he created assembled digit reconstruction, a procedure that brought to light a whole new vision to the traditional procedure which has been used for thirty years in the world by replanting digits through cutting off the index toe. This new technique allows reconstructed fingers to resemble original digits instead of toes. His creativity and innovative visionary leads the field of reconstructive surgery into a new era.
Even more, Prof. Wang exceeded expectations as he placed extra hard work in reviewing and revising microsurgery anatomy, which helped clarify several anatomy structures related to microsurgery. His contribution has an exceptional impact on the improvement of the field of reconstructive microsurgery. He also has many literary works regarding such matters, for instance, the “Clinical Anatomy Atlas of Microsurgery”.
To include Prof. Wang as the honorary editor-in-chief of International Microsurgery Journal is the breakthrough of the global microsurgery since we successfully overcome the barrier of language and platform, so people can learn the masterpieces from Chinese microsurgery masters. In the future we will have more cooperation not only in the journal, but also the conference, and the online platform. Hope the knowledge pooling and exchange can benefit the global microsurgeons and the patients.
International Microsurgery Journal
Dr. Patel is an Assistant Professor of Plastic Surgery at the University of Southern California specializing in complex reconstructive surgery, particularly breast reconstruction, lymphedema surgery, and extremity reconstruction. He completed his Plastic Surgery training at Georgetown University following by advanced microsurgery training at Chang Gung Memorial Hospital in Taiwan.
Dr. Soo-Ha Kwon was born in Korea and moved to Taiwan at the age of 10. She graduated from National Yang-Ming University and currently is the resident of the Department of Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Taiwan. Her research interests have included peripheral nerve, microsurgery, aesthetic surgery and the questionnaire study. Dr. Kwon is currently the admin of International Microsurgery Club (IMC) and will continue working on IMJ, in order to push the new journal to the top of the filed of microsurgery.
Dr. Lee is a surgeon specializes in plastic and reconstructive surgery, served as a resident in Chang Gung Memorial Hospital, Linkou, Taiwan. The main focus of interests were reconstructive microsurgery of head and neck, nerve reconstruction, hand reconstruction, trauma reconstruction as well as evidence-based medicine. He attended the international meeting presentation of WSRM, ASRM and IFSSH as well as domestic department of plastic surgery and surgical concepts regarding to vulvar reconstruction, vascularized joint transfer, breast reconstruction, head and neck reconstruction and the prevention of its related complications. He also won the silver award of 16th Healthcare Quality Improve Campaign- National EMB competition- Clinical literature search group, 2015. Dr. Lee obtained his medical degree from China Medical University in Taichung, Taiwan. Currently, he is working on international journal articles in the field of plastic surgery. Dr. Lee have devoted the time in reconstructing and optimizing functional and aesthetic outcomes for over 2,000 patients in 4 years of resident training period.
Dr. Kevin Zuo is a resident in the Division of Plastic & Reconstructive Surgery, Department of Surgery at the University of Toronto. He completed medical school at the University of Alberta (Edmonton, Canada) and has worked as a Research Student at McGill University (Montreal, Canada). He is currently working towards a Master’s degree investigating peripheral nerve injury and regeneration under the supervision of Dr. Gregory Borschel at the Hospital for Sick Children, Toronto, Canada. Dr. Zuo is interested in all areas of reconstructive microsurgery and is honoured to serve as an Assistant Editor for IMJ.
Cheng-Feng Chu is a medical student from Chang Gung Medical College and Chang Gung University, Taoyuan, Taiwan. IMJ is a groundbreaking journal co-established by Dr. Tommy NJ Chang on 2017, associated with the biggest online microsurgery media—International Microsurgery Club (IMC). The educational open resource has become one of the most successful online discussion groups for surgeons around the world. Mr. Chu has made great contributions to the development of IMC by website construction, data analysis and cases organization; furthermore. Mr. Chu built a IMC Case Library, a digital reservoir commits to the long-term preservation of and access to IMC’s valuable collection. As an assistant editor pointed by the founder of IMC, the world’s largest microsurgeon community, Cheng-Feng Chu would like to contribute his comprehensive set of skills for International Microsurgery Journal to better spread knowledge, support research, assist collaboration, and facilitate learning networks in the field of microsurgery. Cheng-Feng Chu’s main interests are reconstructive surgery, craniofacial surgery, and hand surgery. He has wide range of research interests from basic laboratory research to meta-analysis. Cheng-Feng Chu is currently working on research studies and projects led by Dr. Tommy NJ Chang and Dr. Jung Ju Huang.
Angela Ting-Wei Hsu is a sixth-year medical student graduating in 2018 June from Mackay Medical College and currently doing the clerkship in Mackay Memorial Hospital, Taipei, Taiwan. Being interested in head and neck surgery, she has been to Massachusetts Eye and Ear Infirmary, Boston, the US for international clerkship exchange program in 2016. Her research interests from head and neck in otolaryngology to reconstruction via 3D-model, microsurgery, aesthetic surgery and questionnaire study in the plastic and reconstructive surgery department. During her student career, she has been to several international academic meetings for free paper presentations, including 2016 ASRM, TSA, and WSRM. Being a core member of International Microsurgery Club, she will continue working with other core members to make IMJ the top one journal in microsurgery.
Mark Shafarenko is currently a second-year medical student at the University of Toronto. Mark completed his undergraduate studies at the University of Western Ontario in Biomedical Sciences. Since beginning medical school, Mark has taken a keen interest in plastic and reconstructive surgery and microsurgery, conducting observerships and multiple research projects in the field. Mark hopes to be accepted into a plastic surgery training program in the near future.
Evelyn Ting-Hsuan Tang, is a 6th year medical student of Mackay Medical College ,New Taipei city, Taiwan. Between 2007 to 2011, she earned her bachelor’s degree in Pharmacy from National Taiwan University, Taipei City, Taiwan. Currently, she is receiving training in Mackay Memorial Hospital, Taipei City, Taiwan. After completing clerkship in the Department of Obstetrics and Gynecology, Pediatrics, Surgery, and Internal Medicine in Mackay Memorial Hospital, she went on observership in Department of Plastic Surgery of the Hospital for Sick Children, Toronto, Canada, which was supervised by Dr. Tommy Nai-Jen Chang and Dr. Gregory Borschel from July 2016 to August 2016. Also, she finishing short-term clerkship in the Department of Plastic Surgery in Chang Gung Memorial Hospital, Linkou Medical Center, Taiwan, which was supervised by Dr. Chih-Hung Lin in June, 2016. Evelyn Ting-Hsuan Tang’s medical and research interests focus on microsurgery, social media for surgical education and online questionnaire study. She serves as assistant manager of International Microsurgery Club(IMC) instructed by Dr. Tommy Nai-Jen Chang since May 2016 and investigates online medical consultation system via social media. She is going to attend the World Society of Reconstructive Microsurgery(WSRM) to present the successful experience of IMC in June 2017 and post a poster about negative pressure treatment which are instructed by Dr. Tommy Nai-Jen Chang. Also, she serves as staff of 2nd instructional course for adult brachial plexus injuries in November 2017. In addition, Evelyn enjoys online questionnaire study, including designing the model and analyzing the data. She had oral presentation experience in aesthetic surgery at annual conference of Taiwan Surgical Association and Taiwan Society of Plastic Surgery in December 2016 and March 2017, respectively. During medical school life, she received twice presidential award for academic excellence within top three grades in whole class in 2013 and 2016. She had publication in the field of medical chemistry, attended international carbohydrate symposium and was awarded undergraduate research grant while studying in Pharmacy. Besides, she dedicates to international health care and participated in medical mission team in Kiribati in March 2017. She is always enthusiastic about learning and is a highly motivated hard worker who is dedicated to discovering innovation in medical research and development.
Facial palsy affects both the functional and aesthetic aspects of the face. Many techniques for both static and dynamic facial reanimation have been described. Authors present their series of facial reanimation using the functioning free gracilis muscle flap innervated by the masseteric nerve.
The authors demonstrated the utility of hemi-intravascular stenting technique in a pediatric thumb replant.
Vessel-compromised neck is a challenge for the microvascular surgeon planning for a free tissue transfer. This study describes the authors’ experience regarding a successful free tissue transfer in a vessel-compromised neck. The authors also propose an algorithm for management of vessel-compromised neck.
Traditionally, suturing techniques have been the mainstay for microvascular anastomoses, but owing to its technical difficulty and labour intensity, considerable work has gone into the development of sutureless microvascular anastomoses. In this review, the authors take a brief look at the developments of this technology through the years, with a focus on the more recent developments of laser-assisted vascular anastomoses, the unilink system, vascular closure staples, tissue adhesives, and magnets. Their working principles, with what has been found concerning their advantages and disadvantages are discussed.
The authors proposed a new less invasive island flap, namely the first metatarsal artery capillary perforator flap. The advantages of this flap include the preservation of the first metatarsal artery and the adiposal tissue in the web space, thereby preventing compression around the remaining deep peroneal nerve.
The authors present a retrospective review of 7 patients who underwent wide excision of the malignant tumors around the clavicle. Patient demographics, clinical details, the arc of rotation, outcome, and complications were analyzed.
Patients with gynecological abdominal wall malignancies can benefit significantly from radical resection and autologous reconstruction. The pedicled anterolateral thigh flap is the preferred donor site, offering a reliable solution to abdominal wall reconstruction in this setting. The satisfactory results should prompt a more aggressive surgical approach for these patients. This article describes the authors' experiences with the abdominal reconstruction following surgical resection of gynecological abdominal wall malignancy using pedicled anterolateral thigh flap.
Prof. Koushima, president of World Society for Reconstructive Microsurgery, proposes an innovative concept and technique of the multi-stage ‘Orochi’ combined flaps (sequential flaps in parallel). The technique opens a new vista in reconstructive microsurgery.
Brachial plexus imaging is challenging due to its anatomical complexity. Multiple sequences of MRI may be performed pre-operatively for an accurate radiological diagnosis of brachial plexus injury. This image shows the useful role of MRI in localization of acute brachial plexus injury.
Our belief is: “Stronger microsurgeons for a better world.”
The progress of microsurgery in developing low-income countries.
Professor David Chwei-Chin Chuang sincerely welcomes you to join them for this instructional course on Nov. 13-16, 2017 at Chang-Gung Memorial Hospital.
A novel technique of sequential ETS micro-venous anastomoses using three vessel loops for IJV occlusion and a single vascular clamp to retract and hold the anastomoses sites in position.
A personal experience in robotic microsurgery.
A Fantastic platform for learning, professional development, and camaraderie. It's all just a few clicks away.
Division of the lateral plantar artery does not jeopardize the foot circulation because of anastomosis of the lateral plantar artery with the dorsalis pedis artery at the first intermetatarsal space. However, care should be taken with patients with peripheral artery occlusive disease and the flow of dorsalis pedis artery should be confirmed before surgery. Given the advantages of sizable vessel, easy dissection, and proximity to the defect, we believe that the lateral plantar artery might be a valuable option as recipient vessel for lateral plantar forefoot reconstruction.
Health care systems in many countries are confronted with increasing economic limitations. Thus, complex microsurgical procedures and extensive rehabilitation programs are poorly compensated. However, this case demonstrates a dramatic reduction of socioeconomic expenses by allowing a potential radiocarpal amputee to return to work for another estimated 30 years.
The 2nd instructional course for adult brachial plexus injuries is a fantastic opportunity to meet and learn from experts in the field. We cordially invite you to visit Chang Gung Memorial Hospital to participate in this unique learning experience.
Pedicled anterolateral thigh flap is a versatile option for reconstruction of complex soft tissue defects in varied anatomical regions. Its wide arc of rotation and less donor site morbidity are its added advantages.
The authors reviewed the MDCT images to show the number of lymph nodes superior to the saphenofemoral junction. In this study, on average, 3.67 nodes existed. However, there were 4 percent of cases with no countable nodes. This result indicates that appropriate preoperative screening is needed for this procedure.
The communication among international microsurgeons have switched from one direction (from paper, textbook) to multiway interactions through the internet. The authors believe the online platform will play an immensely important role in the learning and development in the field of microsurgery.
A 29-year-old male suffered from total loss of function of his left shoulder and upper limb after a traffic accident while riding a motorcycle. He was treated by a brachial plexus specialist at another hospital and managed surgically under the impression of total root avulsion.
The authors present a novel synthetic vascular model for microanastomosis training. This model is suitable for trainees with intermediate level of microsurgical skills, and useful as a bridging model between simple suturing exercise and in vivo rat vessel anastomosis during pre-clinical training.
Combining intraoperative ICG lymphography with NIR vein visualization can aid supermicrosurgeons in identifying lymphatic vessels and superficial venules to guide LVA incision placement. This guided approach significantly improves successful creation of LVAs when compared to the blind (anatomic) approach. In addition, the absence of linear ICG lymphographic patterns does not prevent formation of successful LVAs.
Authors present a case of combined proximal median and ulnar nerves extensive injury that was successfully managed using a novel safe strategy implemented.
Authors report a case of lower extremity lymphedema treated by LVA that preoperatively mapped not only lymphatic vessels by PDE, but also veins and venules using Veinsite™ .
Shoulder instability and lack of shoulder mobility are common and exhausting problems in adult patients with traumatic brachial plexus injury. Although primary nerve reconstruction remains the “gold standard” for brachial plexus management, secondary shoulder reconstruction by trapezius transfer is needed in neglected cases.
Immediate limb compression following the LVA procedure facilitates lymphatic drainage and increases the surgical efficacy by increasing the number of functioning anastomoses, and is a recommended postoperative practice.
Optimum operating conditions are an integral part of a successful microvascular surgery. We hereby introduce a new technique to make a low- cost microsuction cannula, which will be helpful for microvascular surgeons.
Improving efficiency of microvascular anastomosis by combination of open-loop and airborne suture techniques.
The authors describe various patient and breast-related factors that influence surgical outcomes while also addressing some techniques and principles for aesthetic microsurgical reconstruction.
Supraclavicular flap is an excellent fasciocutaneous flap for head and neck reconstruction due to its close color and texture match. In general, long flaps are required, but with the risk of distal necrosis. The aim of this study is to assess the relationship between the length and distal end necrosis of the supraclavicular flap.
This case report demonstrates an important supermicrosurgical technique for lymphedema, which was established by Isao Koshima in 1994. So far, over 2,000 cases of limb edema have been treated by this surgical method.
The authors present a revised application of the composite iliac crest bone free flap for hemimaxillectomy defects. This flap solely can give a support to the eye globe and the dental implants without osteotomies and titanium meshes. The upper ridge of the flap can be shaped to replicate the curvature of the orbital floor. The inner oblique muscle and the deep fascia can serve as an additional material for separation of the oral cavity from the nasal airway. Utilization of the Customized Contour Implants gives a surgeon a refining instrument for aesthetic correction of facial projection.