Facing The World in Vietnam: Feedback From Trainees on the Educational Value of Surgical Missions to Help Patients With Craniofacial Deformities.

BACKGROUND: Education and training of local healthcare staff is a crucial component of a surgical mission. Facing The World (FTW) is a UK-based craniofacial charity that provides facial reconstructive surgery to children with complex, craniofacial anomalies. As part of its global initiative, FTW has developed a training outreach program in Vietnam. The aim of this study was to analyze feedback data to evaluate the educational value of the training program and identify areas for improvement. METHODS: Feedback was obtained through both 5-point Likert scale and open-ended response questions on written questionnaires. Six postmission reports were reviewed, and used as a base for the content of the questionnaires. Selective sampling was used, with questionnaires distributed to all Vietnamese and UK trainees who have been part of the FTW training program. RESULTS: Seven Vietnamese trainee questionnaires were completed, a response rate of 87.5%. Twelve UK trainees completed the feedback questionnaire, giving a response rate of 85.7%. One hundred percent of local trainees and 83.3% of UK trainees found the training program to be useful or very useful, with no trainees deeming the training program not useful or of no use at all. CONCLUSION: The training missions offered by FTW have successfully provided education to both UK and Vietnamese surgeons in Craniofacial surgical techniques and patient care. No negative responses were identified in both questionnaires. The feedback provides evidence of FTW's effective training program, while allowing insight into where further improvements can be made.

Re-thinking 3D printing: A novel approach to guided facial contouring.

Rapid prototyped or three dimensional printed (3D printed) patient specific guides are of great use in many craniofacial and maxillofacial procedures and are extensively described in the literature. These guides are relatively easy to produce and cost effective. However existing designs are limited in that they are unable to be used in procedures requiring the 3D contouring of patient tissues. This paper presents a novel design and approach for the use of three dimensional printing in the production of a patient specific guide capable of fully guiding intraoperative 3D tissue contouring based on a pre-operative plan. We present a case where the technique was used on a patient suffering from an extensive osseous tumour as a result of fibrous dysplasia with encouraging results.

Recovery of Transplanted Eyebrow From Radiation-Induced Anagen Effluvium.

Ablative surgery for skin cancer of the face can often leave patients with significant deformities. These disfigurements can include loss of hair in conspicuous areas such as the eyebrows, leaving the patients with unsightly facial asymmetry. Eyebrow transplantation serves to address this issue; however, it has often been discouraged in patients who are destined to receive radiotherapy to the cutaneous area in question. This is due to the anagen effluvium effect of radiation therapy on hair follicles. We present a case in which the transplanted eyebrow hair follicles survived the deleterious effects of radiotherapy, leaving the patient with a symmetrical and aesthetically satisfactory eyebrow appearance.

A novel approach for successful closure of sinonasal fistulae.

UNLABELLED: Medial canthus sinonasal fistula is associated with troublesome aesthetic and functional issues. Corneal irritation and drying results from escape of both air and secretions from the nasal cavity across the ocular surface as well as misting of spectacles if worn. Reconstruction of such fistulae is associated with a high rate of recurrence and thus presents a difficult surgical challenge. METHODS: This paper describes the senior author's surgical approach to manage medial canthus sinonasal fistulae utilizing an interpolated forehead flap combined with extended galeafrontalis and pericranial flap for stepped closure. The technique of flap elevation and inset is discussed, with emphasis on key manoeuvres to prevent sinus recurrence. A retrospective review of consecutive cases is presented. RESULTS: Four patients were treated using this technique over 12 months. In all cases, fistulae developed following adjuvant radiotherapy for tumour resection. Flap elevation was performed in combination with a bicoronal approach in 2 patients and via direct forehead approach in 2 patients. No post-operative complications or recurrence of fistula have occurred over 12 months follow-up. CONCLUSION: The success of this technique is attributed to inclusion of a galeafrontalis and pericranial extension to the forehead flap. In addition, the fistula site must be prepared to accommodate the flap by dissection of a wide subcutaneous pocket. This stepped method of closure provides an effective barrier to air and nasal secretions and also achieves an excellent aesthetic outcome.

Rab11b mediates melanin transfer between donor melanocytes and acceptor keratinocytes via coupled exo/endocytosis.

The transfer of melanin from melanocytes to keratinocytes is a crucial process underlying maintenance of skin pigmentation and photoprotection against UV damage. Here, we present evidence supporting coupled exocytosis of the melanin core, or melanocore, by melanocytes and subsequent endocytosis by keratinocytes as a predominant mechanism of melanin transfer. Electron microscopy analysis of human skin samples revealed three lines of evidence supporting this: (1) the presence of melanocores in the extracellular space; (2) within keratinocytes, melanin was surrounded by a single membrane; and (3) this membrane lacked the melanosomal membrane protein tyrosinase-related protein 1 (TYRP1). Moreover, co-culture of melanocytes and keratinocytes suggests that melanin exocytosis is specifically induced by keratinocytes. Furthermore, depletion of Rab11b, but not Rab27a, caused a marked decrease in both keratinocyte-stimulated melanin exocytosis and transfer to keratinocytes. Thus, we propose that the predominant mechanism of melanin transfer is keratinocyte-induced exocytosis, mediated by Rab11b through remodeling of the melanosome membrane, followed by subsequent endocytosis by keratinocytes.

Complications of facial fillers: resource implications for NHS hospitals.

Facial rejuvenation seeks to reverse the negative sequelae of multiple factors but most importantly of genetic predisposition, sun damage and smoking. With the advent of the so-called 'non-surgical' techniques, and perhaps fuelled by these austere times, volumetric facial augmentation using dermal fillers has soared in popularity among both patients and practitioners. However, legislation has yet to keep pace with the change in clinical practices leaving patients poorly informed and with no protection against unscrupulous suppliers and unregulated practitioners. When things go wrong, patients often turn to the National Health Service (NHS) to rectify both the acute and chronic sequelae resulting in potentially difficult ethical and resource implications. Here, we report one of an increasing number of cases presenting to our NHS craniofacial service with acute filler-related complications.

Extracranial-intracranial bypass of the bilateral anterior cerebral circulation using a thoracodorsal axis artery-graft.

Bilateral extracranial-intracranial (EC-IC) bypass-grafting of the cerebral circulation is uncommon. We report a case of anterior cerebral artery EC-IC bypass using the thoracodorsal axis artery-graft. The bifurcation of the thoracodorsal axis allows bypass of both anterior hemispheres, while matching appropriate small-vessel dimensions.

Augmentation of temporal fossa hollowing with Mersilene mesh.

PURPOSE: Temporal fossa hollowing can represent a serious cosmetic concern to patients', whether congenital; part of a post-traumatic deformity; following oncological resection; or following orbital decompression procedures. Various methods have been described to augment the defect including high density polyethylene (HDPE) implants, methyl methylmethacrolate and lipotransfer, but all have their relative drawbacks. METHODS: We describe 13 temporal defects in 10 patients whose defects have been reconstructed with Mersilene mesh (Ethicon, Livingstone UK). When the temporalis muscle is still adequately suspended; folded mesh can be placed in a submuscular/subperiosteal plane. The mesh can be folded as many times as necessary to recreate the appropriate volume, thereby allowing fine control of temple width. If the temporalis is attenuated or displaced inferiorly by previous surgery, its insertion can be recreated using titanium screws to attach the mesh superiorly to the appropriate site on the cranium; the temporalis resuspended and the fascia sutured to the mesh. RESULTS: We report very pleasing cosmetic results with no associated complications such as implant, extrusion or exposure. One patient was complicated by infection requiring removal of the mesh as well as titanium cranioplasty, screws and plates. CONCLUSION: Mersilene mesh is easy to use, contours naturally to the defect and is considerably cheaper than alternatives like HDPE implants.

Giant hemifacial plexiform neurofibroma arising from trigeminal ganglion.

We present a case of a massive hemifacial plexiform neurofibroma. The tumor arose from the right trigeminal ganglion in the middle cranial fossa, involving the 3 divisions of the trigeminal nerve. This affected the whole right side of the face. The principles of management are discussed.

Buckling and hydraulic mechanisms in orbital blowout fractures: fact or fiction?

Since the first description of orbital blowout fractures, there has been much confusion as to their etiology. Two principal mechanisms have been proposed to explain their production, the buckling and the hydraulic mechanisms caused, respectively, by trauma to the orbital rim and the globe of the eye. The aim of this study was to evaluate both mechanisms qualitatively and quantitatively. Our protocol used intact cadavers, quantifiable intraocular pressure, variable and quantifiable force, and quantifiable bone strain distribution with strain gauge analysis. One orbit of each cadaver was used to simulate each of the two mechanisms, allowing direct comparison. Fractures produced by the buckling mechanism were limited to the anterior part of the orbital floor, with strain readings reaching up to 3756 microepsilon. Posteriorly, strain did not exceed 221 microepsilon. In contrast, hydraulic-type fractures were much larger, involving anterior and posterior parts of the floor as well as the medial wall of the orbit. Here, strain exceeded 3756 microepsilon in both parts of the floor. Furthermore, we have demonstrated that the average energy required to fracture the orbital floor by the buckling mechanism is 1.54 J, whereas an average energy of 1.22 J is needed to produce this fracture by the hydraulic mechanism. Our results suggest that efforts to establish one or another mechanism as the primary etiology are misplaced. Both mechanisms produce orbital blowout fractures, with different and specific characteristics. We believe this provides the basis for our reclassification of such fractures.

A novel technique of harvesting temporalis fascia autografts for correction of recurrent blepharoptosis.

Patients with poor levator function require ptosis correction by a sling procedure. A variety of synthetic materials are available for this suspension, but there is a recognized complication rate. Autografts are less prone to infection and extrusion than alloplastic materials. Harvesting temporalis fascia has a number of advantages over the use of fascia lata and outcomes have been effective. Although we recommend the use of autogenous material for slings whenever possible, if alloplastic materials are used and subsequently fail, then temporalis fascia is our preferred solution. We describe a novel technique of harvesting the temporalis fascia and present 4 patients (6 eyelids) with failed silicone slings who were managed with temporalis fascia autograft. Follow-up ranged from 5 to 32 months. The average improvement in palpebral aperture was 3.6 mm (78%).