Truth Lies in the Depths: Novel Insights into Facial Aesthetic Measurements from a U.S. Survey Panel.

BACKGROUND: Aesthetic facial bone surgery and facial implantology expand the boundaries of conventional facial surgery that focus on facial soft tissue. This study aimed to reveal novel aesthetic facial measurements to provide tailored treatment concepts and advance patient care. METHODS: A total of n=101 study participants (46 females and 55 males) were presented with 120 patient portraits (frontal images in natural head posture; 60 females and 60 males) and asked to assess the facial attractiveness (scale 0-10; "How attractive do you find the person in the image?") and the model capability score (MCS; scale 0-10; "How likely do you think the person in the image could pursue a modelling career?"). For each frontal photograph, defined facial measurements and ratios were taken to analyse their relationship with the perception of facial attractiveness and MCS. RESULTS: The overall attractiveness rating was 4.3 ± 1.1, while the mean MCS was 3.4 ± 1.1. In young males, there was a significant correlation between attractiveness and the zygoma-mandible angle (ZMA)2 (r= - 0.553; p= 0.011). In young and middle-aged females, MCS was significantly correlated with facial width (FW)1-FW2 ratio (r= 0.475; p= 0.034). For all male individuals, a ZMA1 value of 171.79 degrees (Y= 0.313; p= 0.024) was the most robust cut-off to determine facial attractiveness. The majority of human evaluators (n=62; 51.7%) considered facial implants a potential treatment to improve the patient's facial attractiveness. CONCLUSION: This study introduced novel metrics of facial attractiveness, focusing on the facial skeleton. Our findings emphasized the significance of zygomatic measurements and mandibular projections for facial aesthetics, with FI representing a promising surgical approach to optimize facial aesthetics. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Full facial retransplantation in a female patient-Technical, immunologic, and clinical considerations.

There is limited experience with facial retransplantation (fRT). We report on the management of facial retransplantation in a facial vascularized composite allotransplant recipient following irreversible allograft loss 88 months after the first transplant. Chronic antibody-mediated rejection and recurrent cellular rejection resulted in a deteriorated first allograft and the patient underwent retransplantation. We summarize the events between the two transplantations, focusing on the final rejection episode. We describe the surgical technique of facial retransplantation, the immunological and psychosocial management, and the 6-month postoperative outcomes. Removal of the old allograft and inset of the new transplant were done in one operation. The donor and recipient were a good immunological match. The procedure was technically complex, requiring more proximal arterial anastomoses and an interposition vein graft. During the first and second transplantation, the facial nerve was coapted at the level of the branches. There was no hyperacute rejection in the immediate postoperative phase. Outcomes 6 months postoperatively are promising. We provide proof-of-concept that facial retransplantation is a viable option for patients who suffer irreversible facial vascularized composite allograft loss.

The impact of the size of bone substitute granules on macrophage and osteoblast behaviors in vitro.

OBJECTIVE: Bone substitute (BS) size might influence the clinical outcomes of guided bone regeneration (GBR) procedures. The aim of the present study was to investigate the influence of BS size on macrophage (Mφ) and osteoblast behaviors in vitro. MATERIALS AND METHODS: Two different granule sizes (S and M/L) were assessed for four different commercial BSs: deproteinized bovine bone mineral (DBBM), biphasic calcium phosphate type 1 (BCP1), BCP type 2 (BCP2), and carbonate apatite (CO3Ap). The BSs were compared for their impacts on the cell viability and differentiation potential of THP-1-derived Mφs and human osteoblast-like Saos-2 cells. RESULTS: The smaller granules showed higher material volumes and surface areas than the larger granules. Significantly higher viability of Mφs and Saos-2 cells was observed with the DBBM_L-size granules than with the DBBM_S-size granules. Gene expression experiments in Mφs revealed few differences between the two sizes of each BS, although higher CD206 mRNA levels were observed in the BCP1_L group and the CO3Ap_M group than in the respective S-size groups on day 1. Only DBBM showed significantly higher mRNA levels of osteogenic markers, including Runx2 and osteocalcin, in Saos-2 cells in the S-size group than in the L-size group. CONCLUSIONS: The S-size and L-size DBBM granules exhibited clear differences in cell outcomes: cells cultured on the S-size granules exhibited lower cell viability, higher osteopromotive ability, and no noticeable Mφ polarization changes. CLINICAL RELEVANCE: A smaller granule size might be advantageous due to greater bone regeneration potential in the use of DBBM granules to treat defects.

Three-Dimensional Osteosynthesis Plates for the Surgical Treatment of Mandibular Fractures.

OBJECTIVES: Mandible fractures can be treated with different plate systems, that is, miniplates or three-dimensional (3D) plates. This systematic review describes the effectiveness and clinical outcomes of 3D plates used in fractures of the mandible and aims to critically evaluate its risks and benefits. MATERIALS AND METHODS: A comprehensive electronic search was conducted without date but with restriction to articles written in English. Studies in humans, including randomized or quasi-randomized controlled trials and retrospective studies, were included. The outcome parameters measured were number of patients, fracture classification, results, follow-up period, postoperative complications, and mean age of patients. Major complications were defined as those needing additional surgical intervention, for example, malocclusion, infection or plate fracture. Accordingly, complications not needing additional surgical intervention were defined as minor (ie, dehiscence, trismus). RESULTS: Guided by the PRISMA statement and the Cochrane Handbook for Systematic Reviews of Interventions, the authors identified 44 publications with a total of 1790 patients. Among the articles selected for the final review, there were 32 reported prospective studies, 12 reported retrospective studies. Regarding the evaluation of quality, 8 studies showed a low value of the risk of bias, 17 a moderate risk, and 19 a high risk. There were statistically significant advantages for 3D plates in mandibular fractures in terms of postoperative complications, for example, wound dehiscences or plate fracture. CONCLUSIONS: The 3D plate is an effective treatment modality for mandibular fractures, with low incidence of major complications, decreased length of operation time, and increased stability of osteosynthesis.

Volumetric Analysis of the Pterygopalatine Fossa by Semiautomatic Segmentation of Cone Beam Computed Tomography.

The aim of this study was to provide volumetric data of the pterygopalatine fossa by semiautomatic segmentation based upon cone beam computed tomography.Cone beam computed tomography (CBCT) images of 100 patients were analyzed. By using the open source software "ITK-Snap," the volumetric measurements of 200 pterygopalatine fossae were performed. For statistical investigations paired t test, and independent Student t test were performed. Also, the Pearsons chi-square test was applied. P values P < 0.05 were considered significant.The mean volume was 578.376 mm for the right and 560.979 mm for the left side. The results indicated statistically significant differences according to the right and the left pterygopalatine fossa, regardless of gender (P < 0.05). The analysis of differences between males and females did not show any significant results (P > 0.05), although males present a slightly larger volume than females. According to the median age (59 years), younger patients presented smaller volumes, whereas older patients presented larger volumes. Nevertheless, no statistically significant differences according to age (χ = 3.520; P > 0.05) could be found.Clinical intervention with the application of local anesthetics into the complex and vulnerable anatomy of the pterygopalatine fossa makes a thorough knowledge about the volumetric capacity indispensable. Therefore, the semiautomatic segmentation of CBCT images provides a useful, available and validated tool. Our results show that a final injected anesthetic volume larger than 1 ml exceeds the pterygopalatine fossa capacity considerably and could cause complications. To prevent this, volumetric analysis of this region can provide further information and enables an individualized patients' treatment.

Analysis of the Pterygomaxillary Fissure for Surgical Approach to Sphenopalatine Ganglion by Radiological Examination of Cone Beam Computed Tomography.

The pterygopalatine fossa (PPF) is a complex and paired anatomical structure located at the skull base. A clinically and surgically relevant structure located in the pterygopalatine fossa is the sphenopalatine ganglion. Electrical stimulation of the sphenopalatine ganglion is one possible method of treating cluster headache. The pterygomaxillary fissure (PMF) defines the pterygopalatine fossa laterally and determines the surgical approach. As part of preoperative surgical planning, each patient undergoes a preoperative head computed tomography or a cone beam computed tomography. In our study cone beam computed tomography images of 90 male and 110 female PMF were analyzed. Generally, males have a wider fissure than females. Moreover, a significant inter-subject difference could be shown between males and females. The analysis of the right and left PMF according to gender and age does not show any significant intra-subject differences. Following an established protocol for high-resolution CT images the measurements were classified into four fissure types and also analyzed according to gender and age. Fissure type I is significantly more often present in males, whereas the smaller fissure types (II, III, and IV) are significantly more often found in females. Older patients presented statistically significant more often with type I, whereas the younger patients showed more often the narrower types II and IV. Due to the fact that narrow fissures smaller than 2 mm could limit the insertion of neurostimulator implants in the PPF, special attention should be paid to females and younger patients during preoperative planning.

Osteotomy speed, heat development, and bone structure influence by various piezoelectric systems-an in vitro study.

OBJECTIVES: The aim of this in vitro study was to evaluate osteotomy speed, heat development, and bone structure influence from osteotomies performed by various piezoelectric devices and insert tips. These devices and tips were compared among each other with regard to conventional rotatory and oscillating systems with special focus on the insert tip design and thickness. MATERIAL AND METHODS: The osteotomies were conducted on porcine ribs utilizing 12 different insert tips (straight and angulated) and three conventional systems. After time and temperature measurements, histological analysis was carried out. Light microscopy was used to evaluate the roughness of the osteotomic surface and to search for indications of thermal bone necrosis. A special software analyzing tool was employed to determine cutting width (mm) and debris (%). RESULTS: All piezoelectric tips created smooth cuts. Cutting widths in general were wider than the actual insert tip size with a tendency for narrow straight insert tips producing relatively wide osteotomies, whereas narrow angulated inserts produced relatively small osteotomies. None of the samples demonstrated distinct indication of necrosis. Overall, there was only a small amount of debris in all osteotomy gaps. Conventional rotatory saws were faster and created less heat compared to all tested piezoelectric systems. Straight tips proved faster osteotomy speed than angulated tips. Thin insert tips indicated to have a positive correlation to osteotomy time and performed faster than conventional microsaw. The average temperature rise was lower when using conventional systems, but critical exceeding temperatures were only observed in short-time exceptional cases. In general, temperature rise was less when using angulated inserts. CONCLUSION: All tested tips are appropriate for bone surgery. Only small differences were found among the piezoelectric insert tips. Although conventional rotatory systems in general performed faster osteotomies, special designed and thin piezoelectric insert tips seem to have a positive influence on osteotomy speed. Ultimately, none of the tested devices or inserts combined all best features of speed, heat development, bone structure influence, and safety. CLINICAL RELEVANCE: Narrow and straight piezoelectric insert tips demonstrated reduced osteotomy times. Nevertheless, a combination of conventional and piezoelectric systems in clinical practice might be the best way to work time-efficient, patient-oriented, and safe. The choice of instrument should be based on clinical experience of the user and should be evaluated individually depending on the case.

A novel histopathological scoring system for patients with oral squamous cell carcinoma.

OBJECTIVES: Tumor invasion into blood and/or lymphatic vessels, perineural invasion, and histopathological grading are evaluated to assess the biological aggressiveness of oral squamous cell carcinoma (OSCC). We aim to assess the prognostic impact of a novel scoring system, based upon the aforementioned histological parameters. MATERIALS AND METHODS: Retrospective chart review of 334 patients with treatment-naive squamous cell carcinoma of the oral cavity. Statistical analysis was performed using univariate and multivariate analysis. Histological grade G1 or G2 were assigned 0 points and G3 or G4 1 point. Invasion of the lymphatic vessels, blood vessels, or perineural space was given 1 point. Zero points were given, when invasion was not detectable. The final score was conducted through addition of each parameter. Therefore, our scoring system ranged between 0 and 4 points. RESULTS: T-classification (p < 0.001), N-classification (p < 0.001), UICC stage (p < 0.001), extracapsular spread (p < 0.001), locoregional recurrence (p < 0.001), and overall survival (p < 0.001) were significantly associated with the OSCC-Histoscore. In multivariate analysis, T-classification (p = 0.001), N-classification (p = 0.039), resection margins (p = 0.038), and OSCC-Histoscore (p < 0.001) were independent prognostic markers for overall survival rate. CONCLUSION: Our presented OSCC-Histoscore serves as a strong independent prognostic parameter for 5-year overall survival (OS) and predicts OS better than T-classification, N-classification, and resection margins. CLINICAL RELEVANCE: Our presented histoscore improves prediction of the overall survival of patients with OSCC.

Does Meningioma Volume Correlate With Clinical Disease Manifestation Irrespective of Histopathologic Tumor Grade?

OBJECTIVES: The aim of the study was to investigate the association between meningioma volume and the occurrence of clinic-radiologic signs of tumor aggressiveness. For volumetric approximation, the authors evaluated the method of semiautomatic image segmentation at hand of high-resolution MRI-image sequences. METHODS: ITK-SNAP was utilized for semiautomatic image segmentation of 58 gadolinium-contrast enhanced T1-weighted thin-slice MRI datasets for volumetric analysis. Furthermore, multimodal imaging datasets (including T2, FLAIR, T1) were evaluated for radiological biomarkers of aggressiveness and growth potential. Thereby generated data was checked for association with retrospectively collected data points. RESULTS: Location (P = 0.001), clinical disease manifestation (P = 0.033), peritumoral edema (P = 0.038), tumor intrinsic cystic degeneration (P = 0.007), three-dimensional complexity (P = 0.022), and the presence of meningioma mass effect (P = 0.001) were statistically associated with higher tumor volumes. There was no association between higher tumor volumes and histopathological tumor grade. CONCLUSION: The size of a meningioma does not seem to reliably predict tumor grade. Growth potential seems to be influenced by tumor location. Higher tumor volumes were significantly associated with the occurrence of clinical symptoms.

Vein Graft Interposition: A Training Model Using Gradually Thawed Cryopreserved Vessels.

INTRODUCTION: Microsurgical interposition of vein grafts is an extraordinarily filigree surgical technique, which requires both sound theoretical knowledge and solid manual skills. Although there are a large number of training models, the majority of these are either relatively expensive, technically complex, or employ synthetic materials with poor resemblance to human tissue. The authors' model allows training of ex vivo vein graft interposition on gradually thawed cryopreserved vessels and it, therefore, is cost-efficient and readily available when needed. Furthermore, it respects the 3R-principle (Reduce-Refine-Replace), as it is based on rat cadaveric vessels. METHODS: Three trainees with basic microsurgical experience, but without prior performance of vein graft interpositioning, were chosen to perform 20 femoral vein graft (5 mm) interpositions into femoral artery defects. The patency and leakage rate served as qualitative variable and operation time as a quantitative variable for efficiency control. RESULTS: For the first half of trials, the trainees had a patency failure rate of 50% and for the second half a rate of 13.3%. The leakage rate noticeably decreased from 44.4% in the first half of trials to 10% in the second half. Although the trainees needed 60 minutes on average for their first 10 trials, they improved to 51 minutes for their last 10 anastomoses. CONCLUSION: The authors' microsurgical model offers a simple, low-cost simulation training, specifically designed for learning of vein graft interposition into arterial defects. The model is associated with a high learning curve, based on an objective control of the anastomoses by assessment of the patency, leakage, and operation time.

The Importance of Serological Procalcitonin Levels After Autologous Microsurgical Transplantation.

INTRODUCTION: Published data on procalcitonin (PCT) levels after microsurgical interventions are very scarce, although infection within these patients is not only associated with severe morbidity but also significantly higher mortality rates. MATERIAL AND METHODS: Retrospective study on 20 patients, who were operated on by a single experienced plastic and reconstructive surgeon within one year (June 2017-June 2018). The authors included all patients, who received microvascular transplants for reconstruction of soft tissue defects. Furthermore, age above 18 years and appropriate documentation allowing sufficient data collection were defined as inclusion criteria. The authors excluded all patients with perioperative systemic inflammation and transplant loss, as our aim was to solely determine and evaluate potential alterations of serological PCT levels after microsurgical interventions. RESULTS: The PCT cutoff level to differentiate physiological and pathological levels was defined as 0.1 µg/L. There was no detectable increase in procalcitonin in all of our 20 patients, for whom the authors performed microvascular transplantation to reconstruct soft tissue defects. CONCLUSION: Serological PCT levels remain stable after the considered surgical interventions and therefore PCT levels might be utilized to identify systemic inflammation, thus helping to reduce severe complications by early individualized antiinfective treatment strategies.

Epineurial Nerve Coaptation: A Biological Nonliving Training Model Using Gradually Thawed Cryopreserved Sciatic Nerves.

The authors present a novel biological nonliving epineurial nerve coaptation training model, which allows cost-efficient practicing on organic mammal nerves and offers an objective performance control on the basis of successful suturing and respecting the 3R model.Anatomic dissection of 40 rat cadavers was performed. Four residents without prior microneurosurgical experience were included. Each trainee performed 20 epineurial nerve coaptations. The number of successful sutures served as qualitative variable and operation time as a quantitative variable for efficiency control.The rate for successful sutures was 51.9% in the first half of trials and improved to 94.4% in the second half. Whereas, the trainees needed a mean time of 34 minutes for the first 10 coaptations, the last 10 coaptations were performed within 24.5 minutes.The authors' presented model is an easily accessible, low-cost microneurosurgical simulation model, allowing a realistic and instructive performance of epineurial nerve coaptation. Because cadaveric nerves are used, an approval of the local ethics committee is not needed. Furthermore, anatomic knowledge about the topography related to the harvest of the sciatic nerve of rats is provided in this study.

Rigid External Distractor-Aided Advancement After Simultaneously Performed LeFort-III Osteotomy and Fronto-Orbital Advancement.

Due to the complex development of the craniofacial skull, corrective surgery is a major challenge for patients with severe craniofaciostenosis. Although fronto-orbital advancement and simultaneous LeFort-III osteotomy in combination with distraction osteogenesis have been reported as a safe and successful method to obtain good esthetic and functional results, there is a lack of studies evaluating this method.Our retrospective study included 12 patients with syndromic craniofaciostenosis, who were primarily treated at our department in accordance with a standardized treatment protocol, consisting of a simultaneous fronto-orbital advancement with LeFort-III osteotomy in combination with a rigid external distractor (RED-II). Distraction distance, duration of operation, postoperative complications, perioperative hemoglobin concentration, esthetic outcome, and the subjective Whitaker Scale were used to evaluate the success of our surgical method.The esthetic outcome of all of our patients was assessed as good. Furthermore, the surgical outcome was assigned I for 11 patients and II for 1 patient, who suffered from wound healing disturbance at the left temporal site, which required revision 2 weeks postoperatively. The mean skeletal advancement of the midface was 16.4 mm, ranging from 12 to 20 mm.Our standardized treatment protocol, consisting of fronto-orbital advancement in combination with LeFort-III osteotomy and application of a rigid external distractor device (RED-III) for patients with severe syndromic craniofaciostenosis, goes along with low infection rates and more predictable and precise esthetic and functional outcomes than the conventional surgical technique without distraction osteogenesis.

Clinical Evaluation of Standardized Fronto-Orbital Advancement for Correction of Isolated Trigonocephaly.

Corrective surgery of trigonocephaly is a major challenge, owing to the complex development of the craniofacial skull. Although reports on the clinical success of standardized fronto-orbital advancement have been promising, there is a lack of studies, assessing this method. Hence, the aim of our study was to evaluate the clinical outcome of a standardized fronto-orbital advancement procedure for correction of isolated nonsyndromic trigonocephaly, in our patient cohort. The retrospective study included 30 patients from 2008 to 2015. Inclusion criteria were treatment-naive children with isolated nonsyndromic trigonocephaly, being treated with standardized frontoorbital advancement in our department. We considered postoperative complications and the Whitaker Score to evaluate the success of the clinical outcome. Surgery was performed at a mean age of 9.3 months. The mean operation time was 153 minutes. All patients were assigned I according to the Whitaker score. One patient suffered from a small inconsequential subdural hematoma. Another patient suffered from dural tears, which were identified and treated intraoperatively. No major complications occurred within our patient cohort. The standardized fronto-orbital advancement is a safe and successful method, as it is associated with a high morphological outcome and low complication rate.

Evaluation of Fronto-Orbital Advancement Using Titanium-Based Internal Fixation for Corrective Pediatric Craniofacial Surgery.

BACKGROUND: For successful reshaping of the cranial vault in terms of corrective fronto-orbital advancement (FOA) efficient and reliable internal fixation systems for stabilization of bone fragments are indispensable. The rate of complications and feasibility of corrective FOA with the usage of titanium-based rigid fixation systems is rarely analyzed and discussed. METHODS: The authors retrospectively reviewed the medical records of 42 patients who received corrective FOA with the implementation of titanium internal rigid fixation and consecutive secondary surgery for removal. The reliability of the fixation system was judged by the outcome of the FOA as evaluated by the Whitaker score, esthetic outcome as well as by the complication rate of the secondary intervention, necessary for removal of the fixation system. RESULTS: All patients were categorized as Whitaker I (no further treatment desirable). Esthetic outcome was excellent in all patients as judged by surgeon and parents. Mean age at the time of FOA was 9.3 months. Time to removal, duration of the second hospital stay for removal of the fixation system, and duration of surgical drains were on average 5 months, 2 days, and 1.7 days, respectively. Mean duration of the secondary surgery was 63 min. No complications occurred. CONCLUSION: Our investigation supports the usage of titanium internal rigid fixation systems in pediatric craniofacial surgery, thereby providing a reliable alternative to avoid the well-documented problems of bio-absorbable plate fixation systems.

Volumetric Analysis of 700 Mandibular Condyles Based Upon Cone Beam Computed Tomography.

The authors' aim was to provide volumetric data of mandibular condyles based upon cone beam computed tomography with the means of semiautomatic segmentation.Retrospective chart review of 350 patients (700 mandibular condyles) with cone beam computerized tomography between February 2007 and December 2016. Univariate analysis was performed to analyze associations between variables. P values <0.05 were considered significant. Volume measurement was performed in a semiautomatic segmentation method with the program "ITK-Snap."The mean volume was 2.443 cm for the right condyle and 2.278 cm for the left condyle. Bivariate analysis indicated a highly significant difference between the volume of the left and right condyles (P < 0.01). Female had a significant smaller condyle volume than male (P < 0.01 left condyle; P < 0.01 right condyle). Volume and age did not significantly correlate (P = 0.939 right condyle; P = 0.798 left condyle).A detailed assessment of the volume of mandibular condyles with cone beam computed tomography can help to assess pathophysiological alterations.Hence, the volumetric measurement may improve patient's individualized treatment.

Age-Related Volumetric Changes in Mandibular Condyles.

A precise knowledge of the condylar changes with advancing age may improve understanding of pathophysiological alterations of the mandibular condyles. However, the majority of studies focusses on morphological changes, although volumetric analysis based upon cone beam computerized tomography may provide important additional data to characterize mandibular condyles. Therefore, we aimed to provide and compare volumetric data of mandibular condyles of a young and old patient group. This is a retrospective chart review of 195 patients with cone beam computerized tomography between 2007 and 2016. Student t test, analysis of variance, and Pearson correlation test were performed to analyze associations between categorical and continuous variables. P values <0.05 were considered as significant. Volume measurement was performed in a semiautomatic segmentation method with the program 'ITK-Snap.' Side- and sex-specific significant differences between condylar volumes were found both in the young and old patient cohort. Age and posterior occlusal support did not significantly correlate with the condylar volume. Volumetric measurement of the mandibular condyles may serve as an important additional characteristic, derived from 3-dimensional imaging. Significant differences in volumetric measurement of mandibular condyles exist between sex and side, but not in relation to age and occlusal support.

The importance of early diagnosis in patients with maxillary sinus carcinoma.

There are two major challenges in the early diagnosis of maxillary sinus carcinoma: the maxillary sinus is not susceptible to direct inspection and palpation, and symptoms are uncharacteristic. The aim of this study was to assess the impact of the time interval between first symptoms noticed by the patient and the detection of the tumor on survival. 88 patients with maxillary sinus tumors were included in the retrospective study. Prognostic factors were identified through univariate analysis. Univariate analysis (p = 0.019) revealed a significant impact of the time interval from first symptom to diagnosis on overall survival. With increasing duration of the symptoms 5-year overall survival was reduced from 65 % for duration between 0 and 2 months to 24 % for duration of symptoms longer than 12 months. Furthermore, we found a significant association (p = 0.033) between local extension of the tumor and time interval from first symptom to diagnosis. Early diagnosis is often difficult because of uncharacteristic symptoms, which are identical with benign diseases of the maxillary sinus. The delay between the occurrence of the first symptom and diagnosis often makes a curative treatment impossible.

Surface modification of PEEK implants for craniofacial reconstruction and aesthetic augmentation-fiction or reality?

Facial implantology, a crucial facet of plastic and reconstructive surgery, focuses on optimizing implant materials for facial augmentation and reconstruction. This manuscript explores the use of Polyetheretherketone (PEEK) implants in craniofacial surgery, highlighting the challenges and advancements in this field. While PEEK offers mechanical resilience, durability, and compatibility with imaging modalities, its biologically inert nature hinders integration with the host tissue, which may lead to complications. In this systematic review, our aim was to assess the current state of knowledge regarding the clinical evaluation of Polyetheretherketone (PEEK) implants in facial implantology, with a focus on craniofacial augmentation and reconstruction in human studies. Additionally, we explore and discuss surface and structural modifications that may enhance bioreactivity and reduce complications in PEEK implants. A systematic review identified 32 articles detailing the use of PEEK Patient-Specific Implants (PSIs) in 194 patients for both reconstructive and aesthetic purposes. Complications, including infections and implant failures, were reported in 18% of cases, suggesting the need for improved implant materials. The discussion delves into the limitations of PEEK, prompting the exploration of surface and structural modifications to enhance its bioreactivity. Strategies, such as hydroxyapatite coating, titanium coating, and porous structures show promise in improving osseointegration and reducing complications. However, the literature review did not reveal reports of coated or modified PEEK in facial reconstructive or aesthetic surgery. In conclusion, although PEEK implants have been successfully used in craniofacial reconstruction, their biological inertness poses challenges. Surface modifications, particularly hydroxyapatite coatings, provide opportunities to promote osseointegration. Future research should focus on prospective long-term studies, especially in craniofacial surgery, to investigate the stability of uncoated PEEK implants and the potential benefits of surface modifications in clinical applications. Patient-specific PEEK implants hold promise for achieving durable craniofacial reconstruction and augmentation.

Early outcomes and risk factors for complications after facial alloplastic implant surgery: An ACS-NSQIP study.

BACKGROUND: Facial implantology (FI) is a growing field in facial surgery that focuses on harmonizing and balancing facial features. Despite its increasing popularity, larger-scale studies on FI outcomes and risks are scarce. METHODS: The ACS-NSQIP (2008-2021) was queried to identify patients who underwent combined/isolated alloplastic FI surgery of the malar/mandibular region. Based on CPT codes (21125; 21270), procedures were subdivided into combined or isolated FI surgery of the malar or the mandibular region. RESULTS: The study population included 84 patients, of which n = 19 (23%), n = 10 (12%), n = 33 (39%), and n = 22 (26%) underwent combined malar, isolated malar, combined mandibular, and isolated mandibular FI surgery, respectively. Isolated malar (total n = 10) and mandibular FI surgery (total n = 22) patients had relatively high comorbidity rates with up to n = 6 (60%) active smokers and n = 9 (41%) with hypertension, respectively. Combined malar (n = 19) and mandibular FI surgeries (n = 33) had the highest complication rates with n = 3 (16%) and n = 5 (15%) patients experiencing any complications. For both isolated malar and mandibular FI procedures, n = 1 (10% and 4.5%) patient reported any complications. CONCLUSION: In this study, we accessed the ACS-NSQIP database and found alloplastic augmentation for zygoma and mandible to be safe. Patients who underwent combined procedures and mandibular augmentation were more likely to show complications or require inpatient stay. Most alloplastic augmentations of mandible or zygoma were combined with other procedures (62%) which suggests that alloplastic facial implants (in the academic setting) are often used as an adjunct in the treatment of complex craniofacial disorders.