Congenital Ossification Defects of the Frontal Bone: Description of a Novel Clinical Entity and the Management of Four Patients.

ABSTRACT: Embryologic development of the frontoorbital region is complex and is affected by a series of pathologies. These primarily represent failures of fusion at the interface between the frontal bones and the skull base or between the frontal bones themselves, or frontal bone defects in association with atypical craniofacial clefts or cutis aplasia. Isolated ossification defects in the frontal bones themselves are rare, with only 1 case having been previously reported. In that report, the defect was effectively managed with an alloplastic cranioplasty. However, long term results were not presented. Here, we describe 4 cases of isolated frontal bone aplasia their management using autologous bone.

An Integrated Approach to the Management of Meningoencephalocoeles.

ABSTRACT: Meningoencephalocoeles are congenital herniations of meningeal and cerebral tissues through a cranial defect. They occur most commonly in South-East Asia, and are relatively rare amongst European ancestry populations, with an estimated prevalence of 1/40,000 live births. The treatment of congenital meningoencephalocoeles is primarily surgical and are best managed by dedicated multi-disciplinary craniofacial teams. The authors performed a retrospective case review of all primary meningoencephalocoeles managed in the Oxford University Hospitals NHS Foundation Trust between 1986 and 2012. Twenty-nine cases (13 frontal, 9 occipital, 2 parietal, and 5 basal) were included in this study. The median age at presentation was 11 months (range 0-60 years). Twenty-five cases presented with an external mass; 3 with recurrent meningitis and 1 with otorrhoea. Twenty-six cases underwent surgery, and 17 of these were managed by an integrated approach between 2 or more surgical specialties. Twenty out of 26 operations were performed via a transcranial approach. The authors describe a particularly complex case in order to highlight the challenges associated with management of meningoencephalocoeles, the surgical technique employed, and the importance of a multidisciplinary surgical approach. This is the largest reported case series of meningoencephalocoeles managed in a single hospital in the United Kingdom. Designated craniofacial units with access to multidisciplinary surgical specialties provide a safe and optimal setting for the management of meningoencephalocoeles.

Central Retinal Artery Occlusion Following Prone Transcranial Surgery for Craniosynostosis and Discussion of Risk Factors.

Vision loss is a known rare complication of prone positioning during surgery. Vision loss following prone surgery is most commonly attributed to direct pressure on the eye but can also be caused by central retinal artery occlusion (CRAO) in the absence of pressure on the eye. Central retinal artery occlusion has not been previously described following prone transcranial surgery for craniosynostosis. We present two cases of monocular CRAO following prone calvarial expansion. A multidisciplinary root cause analysis suggested that raised intracranial pressure and intraoperative tranexamic acid may have been risk factors for the development of CRAO in these cases as no conventional risk factors for CRAO following prone surgery were present. Because of this, we retrospectively reviewed all prone transcranial procedures performed at the Oxford Craniofacial Unit for the presence of raised intracranial pressure and intraoperative tranexamic acid use. A total of 662 prone procedures have been performed between 1994 and March, 2019. Tranexamic acid has been used routinely in all transcranial procedures since 2012 and in the last 311 consecutive prone cases. Fifty-one (7.7%) prone procedures were performed for raised intracranial pressure, and tranexamic acid was used in the 33 most recent of these. Since the implementation of standard intraoperative administration of tranexamic acid there have been 2 cases of CRAO following prone surgery. The overall incidence of CRAO was 0.3% but was 6% in the context of raised intracranial pressure and tranexamic acid use. Prone positioning raised intracranial pressure and tranexamic acid use together may represent a potent combination of risk factors for CRAO.

Secretion of matrix metalloproteinase-3 by co-cultured pigmented and non-pigmented human trabecular meshwork cells following selective laser trabeculoplasty.

BACKGROUND: Matrix metalloproteinases (MMPs) are reported to contribute to the mechanism of argon laser trabeculoplasty, but it is unknown whether they are also secreted after selective laser trabeculoplasty (SLT). The aim of this study was to investigate whether human primary trabecular meshwork (HTM) cells secrete MMP-3 after stimulation by SLT. The relationship between SLT and the two principal forms of cell death, apoptosis and necrosis, was also examined. METHODS: Non-pigmented primary HTM cells were challenged with melanin granules to artificially introduce pigmentation. Isolated non-pigmented HTM cells and 1:1 co-cultures of pigmented and non-pigmented cells were treated with 0.5-1.5 mJ SLT. Cellular metabolic activity (CMA) was quantified using the 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide assay. Apoptosis and necrosis were measured using a cell death ELISA and a lactate dehydrogenase assay, respectively. MMP-3 secretion was measured by ELISA. RESULTS: Co-cultures exhibited a dose-dependent decline in CMA and a dose-dependent increase in necrosis 4 and 24 h after SLT. Non-pigmented cells did not undergo necrosis and displayed a trend towards increased CMA. Apoptosis was reduced in non-pigmented cells but elevated in co-cultures. Increased MMP-3 secretion was observed from co-cultures but not isolated non-pigmented cells. CONCLUSIONS: Pigmentation is necessary for both post-SLT cell death and MMP-3 secretion. SLT appears to have a hormetic effect on non-pigmented HTM cells.

Binocular visual training to promote recovery from monocular deprivation.

Abnormal early visual experience often leads to poor vision, a condition called amblyopia. Two recent approaches to treating amblyopia include binocular therapies and intensive visual training. These reflect the emerging view that amblyopia is a binocular deficit caused by increased neural noise and poor signal-in-noise integration. Most perceptual learning studies have used monocular training; however, a recent study has shown that binocular training is effective for improving acuity in adult human amblyopes. We used an animal model of amblyopia, based on monocular deprivation, to compare the effect of binocular training either during or after the critical period for ocular dominance plasticity (early binocular training vs. late binocular training). We used a high-contrast, orientation-in-noise stimulus to drive the visual cortex because neurophysiological findings suggest that binocular training may allow the nondeprived eye to teach the deprived eye's circuits to function. We found that both early and late binocular training promoted good visual recovery. Surprisingly, we found that monocular deprivation caused a permanent deficit in the vision of both eyes, which became evident only as a sleeper effect following many weeks of visual training.

Application of a Novel Semi-Automatic Technique for Determining the Bilateral Symmetry Plane of the Facial Skeleton of Normal Adult Males.

The accurate assessment of symmetry in the craniofacial skeleton is important for cosmetic and reconstructive craniofacial surgery. Although there have been several published attempts to develop an accurate system for determining the correct plane of symmetry, all are inaccurate and time consuming. Here, the authors applied a novel semi-automatic method for the calculation of craniofacial symmetry, based on principal component analysis and iterative corrective point computation, to a large sample of normal adult male facial computerized tomography scans obtained clinically (n = 32). The authors hypothesized that this method would generate planes of symmetry that would result in less error when one side of the face was compared to the other than a symmetry plane generated using a plane defined by cephalometric landmarks. When a three-dimensional model of one side of the face was reflected across the semi-automatic plane of symmetry there was less error than when reflected across the cephalometric plane. The semi-automatic plane was also more accurate when the locations of bilateral cephalometric landmarks (eg, frontozygomatic sutures) were compared across the face. The authors conclude that this method allows for accurate and fast measurements of craniofacial symmetry. This has important implications for studying the development of the facial skeleton, and clinical application for reconstruction.

The rule of thirds: Determining the ideal areolar proportions.

BACKGROUND: Breast surgery often requires changing the diameter of the areola. Recommended areolar size is commonly based on population averages, or surgical judgement. An ideal areola size has not been previously been described. We hypothesized that the ideal areolar diameter would be proportional to two breast measurements not commonly altered during breast surgery: the nipple diameter and breast base width. METHODS: 'The Sun' newspaper (London, UK) publishes photographs of topless models which are selected based on the aesthetic appeal of their non-operated breasts. The publication's archive, from March 2014 to January 2017, was independently reviewed by three authors to identify photographs that presented a clear anterior view of the breast. The base width, nipple diameter and areolar diameter were measured independently by each reviewer. Measurements were pooled, and the mean was included for analysis. Ratios of the areolar diameter to the base width and the nipple diameter were calculated. RESULTS: The photographs of 58 models were eligible for inclusion. The average areolar diameter to base width was 0.29 (SD = 0.05). The average nipple to areolar diameter was 0.29 (SD = 0.06). CONCLUSIONS: In aesthetically pleasing breasts, the areolar diameter is proportional to both the breast base width and nipple diameter. Breast base width is commonly measured preoperatively in aesthetic breast procedures, and is not typically modified. Breast base width can therefore be used to determine the ideal areolar size using the ratio of areola:base width ratio of 0.29 identified in this study.

Complementary and Alternative Medicines and Patients With Breast Cancer: A Case of Mortality and Systematic Review of Patterns of Use in Patients With Breast Cancer.

BACKGROUND: The use of complementary and alternative medicines (CAMs) is common among women being treated for breast cancer. A recent mortality associated with CAM at our center precipitated a systematic review of the Cochrane, EMBASE, and PubMed databases to identify English manuscripts including "CAM" and "breast cancer." METHODS: Papers included for review were selected based on predefined inclusion and exclusion criteria. The primary outcome was the use of CAM by women with breast cancer. Secondary outcomes included timing of use along disease trajectory, attitudes toward CAM by allopathic practitioners, and patient disclosure of CAM use to treating allopathic physicians. RESULTS: Of 701 titles identified by the search strategy, 36 met the inclusion criteria. The weighted average proportion of women with breast cancer who use CAM was 40% (standard deviation: 18%). The diagnosis of breast cancer also prompts the initiation or increase of CAM use. However, up to 84% of patients do not disclose the use of CAM to their allopathic practitioners. CONCLUSIONS: Although CAM is often dismissed as a harmless addition to allopathic therapy, significant complications and interactions can occur. Our review and the dramatic case example provided highlight the need for physicians to educate themselves regarding CAM and to engage with their patients regarding its use.

HISTORIQUE: Les femmes traitées pour un cancer du sein utilisent souvent des approches complémentaires et parallèles (ACP). Un récent décès lié à l'utilisation de telles approches, qui s'est produit au centre des chercheurs, a suscité une analyse systématique des bases de données Cochrane, EMBASE et PubMed pour en extraire les manuscrits anglophones incluant les termes complementary and alternative medicine et breast cancer. MÉTHODOLOGIE: Les chercheurs ont retenu les articles d'après des critères d'inclusion et d'exclusion prédéfinis. Les résultats primaires étaient l'utilisation d'ACP par des femmes atteintes du cancer du sein et les résultats secondaires, le moment de leur utilisation dans la trajectoire de la maladie, les attitudes des praticiens allopatiques envers les ACP et le fait que les patientes informaient ou non les médecins allopathiques qu'elles utilisaient des ACP. RÉSULTATS: Parmi les 701 articles obtenus par la stratégie de recherche, 36 respectaient les critères d'inclusion. La moyenne pondérée de femmes atteintes d'un cancer du sein qui utilisaient des ACP s'élevait à 40 % (ÉT 18 %). Le diagnostic de cancer du sein incite les patientes à utiliser des ACP ou à en accroître l'utilisation. Cependant, jusqu'à 84 % des patients n'informent pas leur praticien allopathique qu'elles utilisent des ACP. CONCLUSIONS: Les ACP sont souvent considérées comme des ajouts inoffensifs au traitement allopathique, mais des complications et des interactions importantes peuvent surgir. L'analyse des chercheurs et l'exemple d'un cas dramatique jettent la lumière sur la nécessité que les médecins s'informent des ACP et discutent de leur utilisation avec leurs patientes.

The Le Fort system revisited: Trauma velocity predicts the path of Le Fort I fractures through the lateral buttress.

OBJECTIVE: To examine the effect of trauma velocity on the pattern of Le Fort I facial fractures. METHOD: A retrospective medical record review was conducted on a consecutive cohort of craniofacial traumas surgically treated by a single surgeon between 2007 and 2011 (n=150). Of these cases, 39 Le Fort fractures were identified. Patient demographic information, method of trauma and velocity of impact were reviewed for these cases. Velocity of impact was expressed categorically as either 'high' or 'low': high-velocity fractures were those caused by a fall from >1 story or a motor vehicle collision; low-velocity fractures were the result of assaults with a blunt weapon, closed fist or falls from standing height. The vertical position of each fracture was measured at its point of entry on the lateral buttress and its point of exit on the piriform aperture. To allow for comparison across individuals, values were expressed as ratios based on their location on the face relative to these landmarks. A Wilcoxon rank-sum test was used to compare the fracture heights caused by high- and low-velocity trauma. RESULTS: The results revealed that high-velocity traumas to the face create Le Fort I fractures at a higher point in the lateral buttress compared with low-velocity traumas. There was no difference between heights at the piriform aperture. CONCLUSION: High-velocity trauma resulted in higher Le Fort I fracture patterns compared with low-velocity trauma.

OBJECTIF: Examiner l'effet de la vélocité du traumatisme sur le profil des fractures faciales de Le Fort I. MÉTHODOLOGIE: Les chercheurs ont effectué une analyse rétrospective des dossiers médicaux d'une cohorte consécutive de traumatisés craniofaciaux opérés par un même chirurgien entre 2007 et 2011 (n=150). De ce nombre, ils ont repéré 39 fractures de Le Fort. Ils ont extrait les caractéristiques démographiques des patients, le mode de traumatisme et la vélocité de l'impact, exprimée la vélocité deux catégories : « haute ¼ ou « faible ¼. Les fractures de haute vélocité étaient causées par des chutes de plus d'un étage ou un accident d'automobile. Les fractures de faible vélocité découlaient d'une agression à l'arme contondante ou au poing fermé ou de chutes à partir de la position debout. La position verticale de chaque fracture était mesurée à son point d'entrée sur la structure latérale et à son point de sortie dans l'orifice piriforme. Aux fins de comparaison, les valeurs étaient exprimées selon le ratio de l'endroit sur le visage par rapport à ces points de repère. Le test de Wilcoxon a été privilégié pour comparer la hauteur des fractures causées par des traumatismes à haute et à faible vélocité. RÉSULTATS: Les résultats ont démontré que les traumatismes faciaux à haute vélocité créaient des fractures de Le Fort I situées à un point plus élevé de la structure latérale que les traumatismes à faible vélocité. Il n'y avait pas de différences de hauteur à l'orifice piriforme. CONCLUSION: Les traumatismes à haute vélocité entraînaient des profils de fractures de Le Fort I situées à un point plus élevé que les traumatismes à faible vélocité.

Development and evaluation of a semi-automatic technique for determining the bilateral symmetry plane of the facial skeleton.

During reconstructive surgery of the face, one side may be used as a template for the other, exploiting assumed bilateral facial symmetry. The best method to calculate this plane, however, is debated. A new semi-automatic technique for calculating the symmetry plane of the facial skeleton is presented here that uses surface models reconstructed from computed tomography image data in conjunction with principal component analysis and an iterative closest point alignment method. This new technique was found to provide more accurate symmetry planes than traditional methods when applied to a set of 7 human craniofacial skeleton specimens, and showed little vulnerability to missing model data, usually deviating less than 1.5° and 2 mm from the intact model symmetry plane when 30 mm radius voids were present. This new technique will be used for subsequent studies measuring symmetry of the facial skeleton for different patient populations.