Delayed degradation according to the location of fixation with using an absorbable plate.

BACKGROUND: The ideal absorbable plating system should provide sufficient rigidity and then be absorbed within a timely manner. The Resorb-X has been recently developed as a plating system with a mixture ratio of 50:50 poly(D, L-lactide). METHODS: We present seven of 121 patients who experienced delayed degradation with this absorbable plate. One hundred twenty-one patients with facial bone fracture underwent surgical treatment from March 2011 to March 2015, and rigid fixation was achieved with the Resorb-X. RESULTS: Of 121 patients, seven (5.8%) developed complications at the surgical sites. Six of 102 cases underwent fixation of the infraorbital rim and one of 73 underwent fixation of the frontozygomatic buttress; the other sites of fixation did not develop delayed degradation. Foreign body granuloma developed at the earliest by postoperative 20 months and at the latest by postoperative 28 months (average, 23.5 months). CONCLUSION: We observed that the use of absorbable plates in incision sites or areas with thin skin can increase the possibility of delayed degradation. When performing surgery in these areas, the normal skin above the fixed location should be covered sufficiently.

Usefulness of indirect open reduction via a transconjunctival approach for the treatment of nasal bone fracture associated with orbital blowout fracture.

BACKGROUND: Nasal fracture and orbital blowout fracture often occur concurrently in cases of midface blunt trauma. Generally, these multiple fractures treatment is surgery, and typically, the nasal bone and orbit are operated on separately. However, we have found that utilizing a transconjunctival approach in patients with concurrent nasal bone fracture and orbital blowout fracture is a useful method. METHODS: The participants in the present study included 33 patients who visited the Plastic Surgery outpatient department between March 2014 and March 2017 and underwent surgery for nasal fracture and orbital blowout fracture. We assessed patients' and doctors' satisfaction with surgical outcomes after indirect open reduction via a transconjunctival approach for the treatment of nasal bone fracture with associated orbital blowout fracture. RESULTS: According to the satisfaction scores, both patients and doctors were satisfied with transconjunctival approach. CONCLUSION: We presented here that our method enables simultaneous operation of nasal fracture accompanied by orbital blowout fracture, rather than treating the two fractures separately, and it allows precise reduction of the nasal fracture by direct visualization of the fracture site without any additional incisions or difficult surgical techniques. Also, by preventing the use of excessive force during reduction, this method can minimize damage to the nasal mucosa, thereby reducing the incidence of nasal bleeding.

Simultaneous Development of Three Different Neoplasms of Trichilemmoma, Desmoplastic Trichilemmoma and Basal Cell Carcinoma Arising from Nevus Sebaceus.

Nevus sebaceus is a hamartoma of the sebaceous gland that occurs congenitally, from which various secondary tumors can arise with a prevalence of 5%-6%. Benign neoplasms commonly arise from nevus sebaceous, but they have a very low malignant potential. Two neoplasms may occasionally arise within the same lesion, but it is rare for three or more neoplasms to occur in a nevus sebaceus simultaneously. A 61-year-old male patient was admitted to our hospital for a 4 cm×2.5 cm growing tumor in a verrucous form arising within a periauricular nevus sebaceus in the post auricle of the left ear that had developed 30 years earlier. The nodule was diagnosed as 3 different types of tumors: trichilemmoma, desmoplastic trichilemmoma, and basal cell carcinoma. To our knowledge, this is the first report of the coexistence of three different tumors arising from nevus sebaceous. It contain malignant neoplasm also. Surgeons should be aware of the need for close monitoring and early complete surgical excision of sebaceous nevus in order to improve patient outcomes.

Late Complication of a Silicone Implant Thirty Years after Orbital Fracture Reconstruction.

Alloplastic materials used for orbital fracture reconstruction can induce complications, such as infection, migration, extrusion, intraorbital hemorrhage, and residual diplopia. Silicone is one of the alloplastic materials that has been widely used for decades. The author reports a rare case of spontaneous extrusion of a silicone implant that was used for orbital fracture reconstruction 30 years earlier. A 50-year-old man was admitted to the emergency room for an exposed substance in the lower eyelid area of the left eye, which began as a palpable hard nodule a week earlier. The exposed material was considered to be implant used for previous surgery. Under general anesthesia, the implant and parts of the fibrous capsule tissue were removed. Several factors hinder the diagnosis of implant extrusions that occur a long period after the surgery. So, surgeons must be aware that complications with implants can still arise several decades following orbital fracture reconstruction, even without specific causes.

Skin Necrosis with Oculomotor Nerve Palsy Due to a Hyaluronic Acid Filler Injection.

Performing rhinoplasty using filler injections, which improve facial wrinkles or soft tissues, is relatively inexpensive. However, intravascular filler injections can cause severe complications, such as skin necrosis and visual loss. We describe a case of blepharoptosis and skin necrosis caused by augmentation rhinoplasty and we discuss the patient's clinical progress. We describe the case of a 25-year-old female patient who experienced severe pain, blepharoptosis, and decreased visual acuity immediately after receiving a filler injection. Our case suggests that surgeons should be aware of nasal vascularity before performing an operation, and that they should avoid injecting fillers at a high pressure and/or in excessive amounts. Additionally, filler injections should be stopped if the patient complains of severe pain, and appropriate measures should be taken to prevent complications caused by intravascular filler injections.

Cephalometric Angular Measurements of the Mandible Using Three-Dimensional Computed Tomography Scans in Koreans.

BACKGROUND: We conducted this study to analyze the values of the key cephalometric angular measurements of the mandible using 3-dimensional (3D) computed tomography scans. METHODS: In the 106 enrolled patients, a 3D cephalometric analysis was performed to measure the angular variables of the mandible. These values were compared between the two sides and between the two sexes. RESULTS: The frontal measurements revealed that the mandibular body curve angle was larger on the left (Lt) side (right [Rt], 141.24±7.54; Lt, 142.68±6.94; P=0.002) and the gonial angle was larger on the right side (Rt, 134.37±8.44; Lt, 131.54±7.14; P<0.001). The sagittal measurements showed that the gonial angle was larger on the right side (Rt, 134.37±8.44; Lt, 131.54±7.14; P>0.05). Further, the transverse measurements revealed that the mandibular body curve angle was larger on the right side (Rt, 140.28±7.05; Lt, 137.56±6.23; P<0.001). CONCLUSIONS: These results provide an average of the mandibular angular measurements for the Korean population, establishing a standard for determining surgical patient groups and outcome evaluations in the field of mandible contour surgery.

Transient Anisocoria during Medial Blowout Fracture Surgery.

Transient anisocoria is rare during blowout fracture reconstruction. We report a case of transient anisocoria occurring during medial blowout fracture reconstruction and review the relevant literature. A 54-year-old woman was struck in the face and was admitted for a medial blowout fracture of the left eye. During the operation, persistent bleeding occurred. To control this bleeding, a 1% lidocaine solution with 1:200,000 epinephrine was applied to the orbital wall with cotton pledgets. In total, 40 mL of local anesthetic was used for the duration of the operation. After approximately three hours of the surgery, the ipsilateral pupil was observed to be dilated, with sluggish response to light. By 3 hours after the operation, the mydriasis had resolved with normal light reflex. In conclusion, neurological and ophthalmologic evaluation must be performed prior to blowout fracture surgery. Preoperative ophthalmic evaluation is simple and essential in ruling out any preexisting neurologic condition. Moreover, surgeons must be aware of the fact that excessive injection of lidocaine with epinephrine for hemostasis during orbital wall surgery can result in intraoperative anisocoria. Anisocoria-related situations must be addressed in a proficient manner through sufficient understanding of the mechanism controlling the pupillary response to various stimuli.

Stafne Bone Cavity of the Mandible.

Stafne bone cavity is a rare mandibular defect that was first reported by Edward C. Stafne in 1942. It commonly presents with a well-demarcated, asymptomatic, unilateral radiolucency that indicates lingual invagination of the cortical bone. A 52-year-old female patient who with nasal bone fracture, visited the hospital. During facial bone computed tomography (CT) for facial area evaluation, a well-shaped cystic lesion was accidentally detected on the right side of the mandible. Compared to the left side, no swelling or deformity was observed in the right side of the oral lesion, and no signs of deformity caused by mucosal inflammation. 3D CT scans, and mandible series x-rays were performed, which showed a well-ossified radiolucent oval lesion. Axial CT image revealed a cortical defect containing soft tissue lesion, which has similar density as the submandibular gland on the lingual surface of the mandible. The fact that Stafne cavity is completely surrounded by the bone is the evidence to support the hypothesis that embryonic salivary gland is entrapped by the bone. In most cases, Stafne bone cavity does not require surgical treatment. We believe that the mechanical pressure from the salivary gland could have caused the defect.

The Hydraulic Mechanism in the Orbital Blowout Fracture Because of a High-Pressure Air Gun Injury.

There are 2 predominant mechanisms that are used to explain the pathogenesis of orbital blowout fracture; these include hydraulic and buckling mechanisms. Still, however, its pathophysiology remains uncertain. To date, studies in this series have been conducted using dry skulls, cadavers, or animals. But few clinical studies have been conducted to examine whether the hydraulic mechanism is involved in the occurrence of pure orbital blowout fracture. The authors experienced a case of a 52-year-old man who had a pure medial blowout fracture after sustaining an eye injury because of a high-pressure air gun. Our case suggests that surgeons should be aware of the possibility that the hydraulic mechanism might be involved in the blowout fracture in patients presenting with complications, such as limitation of eye movement, diplopia, and enophthalmos.

A Novel and Easy Approach for Contouring Surgery in Patients With Craniofacial Fibrous Dysplasia.

Although the bone-shaving procedure is the optimal alternative treatment of craniofacial fibrous dysplasia affecting the maxilla and zygoma, it is difficult to determine the appropriate amount of bone to be removed. The authors therefore developed a novel method for bone shaving using three-dimensional printing technology on computed tomography (CT) scans and screws as a guide. In our method, we implanted screws of predetermined lengths into surgical sites and then performed a burring within the visual field. By using screws, the exact amount of bone could be removed, as determined preoperatively. Thus, the operation time was shorted and the method was less effort intensive. Moreover, this procedure had reduced risk of radiation exposure owing to frequent use of CT, and had a low cost. This simple new method is more precise and effective, and shows satisfactory cosmetic outcomes than those with current bone-shaving practices.

Benefits of the Modified Forced Duction Test in Medial Orbital Wall Fracture With Ocular Motility Disturbance.

PURPOSE: The forced duction test (FDT) is important during the surgical treatment of ocular motility disturbance due to orbital wall fracture, but the lack of objective standards yields various test results based on individual examiners' subjective assessments. METHODS: Medial limbus abduction values of the affected eye were measured during preoperative and postoperative FDT, and the values were compared with those of the normal eye. RESULTS: More accurate results were obtained using the modification of the FDT in the surgical repair of medial orbital wall fracture with entrapments. CONCLUSIONS: The modified FDT used here in medial orbital wall fracture with limited ocular motility can contribute to more effective and positive surgical outcomes by providing an objective reference point.

Simple Aesthetic Correction for Patients with Acute Auriculocephalic Angle.

BACKGROUND: Acute auriculocephalic angle refers to an ear with helix that is spaced closely to the cranium. An increasing number of patients with acute auriculocephalic angle wish to undergo corrective operation for aesthetic purposes. However, there is a paucity of data regarding acute auriculocephalic angle. This paper proposes a treatment protocol for patients with acute auriculocephalic angle. METHODS: We performed a retrospective analysis of patients undergoing acute auriculocephalic angle (4 patients, 6 ears). Patient records were reviewed for demographic data as well as auricular measurements at preoperative, immediate postoperative and final follow-up evaluations. RESULTS: All of the patients were men with a mean age of 36.5 years (range, 23-52 years). The mean follow-up period was 47.5 months (range, 28-60 months). Postoperative auriculocephalic angle was close to the normal auriculocephalic angle (25°-30°) without notable scars. Moreover, the patients had minimal contractions of the skin flaps without any hematoma or relapse. CONCLUSION: We propose the following three treatment protocols for patients with acute auriculocephalic angle: the posterior auricular muscle should be sufficiently released, the mastoid area should be augmented using implants, the skin should be repositioned with a superior auricular flap.

Correlation between the Time to Surgery and That to Recovery from Postoperative Diplopia Based on a Single-Center, Retrospective Experience: A Case Series of 11 Patients.

BACKGROUND: We conducted this study to identify the correlation between the time to surgery and that to recovery from postoperative diplopia. METHODS: In the current single-center, retrospective study, we enrolled a total of 11 patients (n=11) who were diagnosed with white-eyed blowout fracture and underwent surgical operation at our institution between January 2009 and January 2013. To identify the correlation between the time to surgery and that to recovery from postoperative diplopia, we divided our patients into the three groups: the group A (time to surgery, <2 days) (n=4), the group B (time to surgery, 3-7 days) (n=4) and the group C (n=3) (time to surgery, 8-60 days). Then, we compared such variables as sex, age, signs of soft tissue injury, preoperative nausea/vomiting, the degree of preoperative diplopia and the side of the fracture on computed tomography scans between the three groups. RESULTS: In our series, mean age at the onset of trauma was nine years (range, 5-16 years); the mean time to surgery was 30 days (range, 2-60 days); and the mean follow-up period was one year (range, 6 months-2 years). Our results showed that the time to recovery was shorter in the patients with a shorter time to surgery. CONCLUSIONS: We found that the degree of recovery from impaired ocular motility and diplopia was the highest in the patients undergoing surgical operations within 48 hours of the onset of trauma with the reconstruction of the fracture sites using implant materials.

Severe visual loss and cerebral infarction after injection of hyaluronic acid gel.

We report a case of a 23-year-old man with cerebral infarction and permanent visual loss after injection of a hyaluronic acid gel filler for augmentation rhinoplasty. The patient was admitted to the hospital with complaints of loss of vision in the right eye, facial paralysis on the right side, and paralysis of the left limbs with severe pain during augmentation rhinoplasty with filler injection. Brain magnetic resonance imaging and computed tomography showed ophthalmic artery obstruction and right middle cerebral artery infarction. Acute thrombolysis was performed to treat the infarction; however, the patient's condition did not improve. Intracerebral hemorrhage in the right temporal/frontal/occipital/parietal lobe, subarachnoid hemorrhage, and midline shifting were observed on brain computed tomography after 24 hours after thrombolysis. Emergency decompressive craniectomy was performed. After the surgery, the patient continued to experience drowsiness, with no improvement in visual loss and motor weakness. Three months later, he could walk with cane. This case indicates that surgeons who administer filler injections should be familiar with the possibility of accidental intravascular injection and should explain the adverse effects of fillers to patients before surgery.

A simple aesthetic approach for correction of frontal sinus fracture.

PURPOSE: Frontal sinus fracture management remains controversial and involves preserving function whenever possible or obliterating the sinus and duct as required by the fracture pattern. The purpose of this study was to introduce the simple and effective method in the surgical treatment of the anterior wall of frontal sinus fractures. METHODS: All 11 patients who presented with anterior wall fractures of the frontal sinus between 2009 and 2013 were included in this study. Two 7-mm stab incisions were made on each side of the fracture, a titanium screw with an attached wire was fixed to the fractured fragment, and an elevator was used to apply force in the opposite vector. One titanium screw was also fixed to the firm normal frontal bone, and the reduction was conducted by observing the C-arm until the fractured fragment reached the height of the normal side. RESULTS: No patients showed any recurrent displacement or infection during the follow-up period, nor did any patient complain of or demonstrate forehead paresthesia. The surgical scar was less than 3 cm in all 11 patients, and all of them reported satisfaction with the results. CONCLUSION: We obtained the results of an open reduction while using a less invasive method in the surgical treatment of the anterior wall of frontal sinus fractures.

Aesthetic correction of hypertrophic frontal sinus with beveled osteotomy.

The authors performed aesthetic correction of hypertrophic frontal sinus in 3 patients with protruded supraorbital region by using beveled osteotomy. Under general anesthesia, a bicoronal incision was performed followed by dissection through the subgaleal plane to the supraorbital ridge. Subsequently, the anterior wall of the frontal sinus was sectioned with a reciprocating saw and an osteotome by using the beveled osteotomy technique. Beveled osteotomy is a technique applied during sectioning of the anterior wall of the frontal sinus whereby the upper portion of the sinus remains intact and the lower portion of the sinus is changed. The technique used by the authors differed from the conventional method in that the existing shape of the outer wall of the frontal sinus was preserved when osteotomy was performed. This technique therefore preserves a more natural contour of the forehead and is advantageous in that it does not require additional interventions.