Thickness and design features of clinical cranial implants-what should automated methods strive to replicate?

PURPOSE: New deep learning and statistical shape modelling approaches aim to automate the design process for patient-specific cranial implants, as highlighted by the MICCAI AutoImplant Challenges. To ensure applicability, it is important to determine if the training data used in developing these algorithms represent the geometry of implants designed for clinical use. METHODS: Calavera Surgical Design provided a dataset of 206 post-craniectomy skull geometries and their clinically used implants. The MUG500+ dataset includes 29 post-craniectomy skull geometries and implants designed for automating design. For both implant and skull shapes, the inner and outer cortical surfaces were segmented, and the thickness between them was measured. For the implants, a 'rim' was defined that transitions from the repaired defect to the surrounding skull. For unilateral defect cases, skull implants were mirrored to the contra-lateral side and thickness differences were quantified. RESULTS: The average thickness of the clinically used implants was 6.0 ± 0.5 mm, which approximates the thickness on the contra-lateral side of the skull (relative difference of -0.3 ± 1.4 mm). The average thickness of the MUG500+ implants was 2.9 ± 1.0 mm, significantly thinner than the intact skull thickness (relative difference of 2.9 ± 1.2 mm). Rim transitions in the clinical implants (average width of 8.3 ± 3.4 mm) were used to cap and create a smooth boundary with the skull. CONCLUSIONS: For implant modelers or manufacturers, this shape analysis quantified differences of cranial implants (thickness, rim width, surface area, and volume) to help guide future automated design algorithms. After skull completion, a thicker implant can be more versatile for cases involving muscle hollowing or thin skulls, and wider rims can smooth over the defect margins to provide more stability. For clinicians, the differing measurements and implant designs can help inform the options available for their patient specific treatment.

A Computed Tomography Scan Near Miss of an Intraorbital Wooden Foreign Body.

When intraorbital wooden foreign bodies are missed, the consequences can be devastating. While the gold standard diagnostic imaging is computed tomography (CT), it has low sensitivity. We present a 61-year-old man with a bamboo injury to his right eye. He underwent two CT scans that failed to raise the possibility of intraorbital foreign bodies. Upon additional review, a rectangular-shaped pocket of air was identified in the orbit which was most consistent with wooden foreign bodies based on the clinical history. A combined mid-lid approach followed by a transconjunctival and transcaruncular extension were employed to remove several wooden splinters. Postoperatively, due to recurrent orbital compartment syndrome, he required a second decompression with an inferior rim osteotomy. He had good recovery at 3 months follow-up. Overall, intraorbital wooden foreign bodies are challenging to diagnose due to imaging limitations. Providing a clear history and suspected diagnosis to radiology is critical for diagnosis.

Manquer des corps étrangers intraorbitaires en bois peut avoir des conséquences désastreuses. L'imagerie diagnostique de référence est la tomodensitométrie (TDM) mais sa sensibilité est faible. Nous présentons le cas d'un homme de 61 ans ayant une plaie par morceau de bambou dans son œil droit. Il a bénéficié de deux tomodensitométrie qui n'ont pas réussi à donner l'alarme sur la possibilité de corps étrangers intraorbitaires. Lors d'un réexamen supplémentaire, une poche d'air de forme rectangulaire a été identifiée dans l'orbite; cette poche était très compatible avec des corps étrangers en bois, selon l'histoire clinique. Un abord combiné à mi-paupière, suivi d'une extension transconjonctivale et transcaronculaire, a été employé pour retirer plusieurs échardes en bois. En postopératoire, le patient a nécessité une deuxième décompression avec ostéotomie du bord inférieur en raison d'un syndrome du compartiment orbitaire récidivant. La récupération a été bonne au suivi de trois mois. Globalement, les corps étrangers intraorbitaires en bois sont difficiles à diagnostiquer en raison des limites de l'imagerie. Fournir au radiologue une histoire claire et un diagnostic suspecté est essentiel au diagnostic.

Five-Segment Mandibular Osteotomy: A Novel Approach to the Correction of Complex Post-Traumatic Mandibular Deformities.

BACKGROUND: Post-traumatic mandibular malocclusion is a complex condition that poses a significant challenge to reconstructive surgeons. The malocclusion that ensues from bilateral condylar and parasymphseal fractures presents a particular challenge as it leads to bilateral posterior shortening and lingual tilting of dental arch leading to a combination of open anterior bite, crossbite, overbite, underbite, and/or facial asymmetry. The complexity of such malocclusion requires intricate freedom of movement of the mandibular arch that can be achieved by performing a 5-segment mandibular osteotomy. METHOD: This is a case series of 9 adult patients with significant post-traumatic mandibular malocclusion who were treated with 5-segment mandibular osteotomy technique. This article details the demographics, surgical technique and outcomes in this cohort of patients. RESULTS: All 9 patients in this series had condylar fracture as part of the index mandibular trauma. They have a common post-traumatic deformity of the mandibular arch due to shortening of the vertical mandibular height in the fracture site and variable degrees of lingual tilting leading to crossbite. The 5-segment mandibular osteotomy provided an adequate correction of dental and facial deformities in all 9 patients. One patient had a relapse of the dental malocclusion that required postoperative rescue orthodontics. Furthermore, one patient had a significant postoperative hemorrhage that required a facial artery ligation. CONCLUSION: Post-traumatic mandibular malocclusion is a complex deformity that poses a great challenge to practicing surgeons. Five-segment mandibular osteotomy is a technique that provides ample degrees of movement of mandibular segments that is necessary to correct such deformity.

Accuracy of Orbital Shape Reconstruction-Comparative Analysis of Errors in Implant Shape Versus Implant Positioning: A Cadaveric Study.

INTRODUCTION: Orbital blowout fractures are commonly reconstructed with implants shaped to repair orbital cavity defects, restore ocular position and projection, and correct diplopia. Orbital implant shaping has traditionally been performed manually by surgeons, with more recent use of computer-assisted design (CAD). Accuracy of implant placement is also key to reconstruction. This study compares the placement accuracy of orbital implants, testing the hypothesis that CAD-shaped implants indexed to patient anatomy will better restore orbit geometry compared with manually shaped implants and manually placed implants. METHODS: The placement accuracy of orbital implants was assessed within a cadaveric blowout fracture model (3 skulls, 6 orbits) via 3-dimensional CT analysis. Defects were repaired with 4 different techniques: manually placed-manually shaped composite (titanium-reinforced porous polyethylene), manually placed CAD composite, indexed placed CAD composite, and indexed placed CAD titanium mesh. RESULTS: Implant placement accuracy differed significantly with the implant preparation method ( P =0.01). Indexing significantly improved the placement accuracy ( P =0.002). Indexed placed titanium mesh CAD implants (1.42±0.33 mm) were positioned significantly closer to the intact surface versus manually placed-manually shaped composite implants (2.12±0.39 mm). DISCUSSION: Computer-assisted design implants indexed to patient geometry yielded average errors below the acceptable threshold (2 mm) for enophthalmos and diplopia. This study highlights the importance of adequately indexing CAD-designed implants to patient geometry to ensure accurate orbital reconstructions.

Worth Syndrome-Patient Report, Diagnostic Work-Up, and Surgical Management of a Rare Craniofacial Entity.

Worth syndrome is a rare genetic bone disorder that often presents with cortical thickening of the mandible and an increase in mandibular width. The authors report the preoperative considerations in a young female with Worth syndrome, operative planning, and successful mandibular reduction using cutting guides.

Current Management of Late Posttraumatic Enophthalmos.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Describe the orbital anatomy and completely understand the important components relevant to surgical correction of enophthalmos, including oculo-orbito relations. 2. Understand the pathophysiology and predictive factors for posttraumatic enophthalmos and identify the challenges associated with correction of enophthalmos in the late setting. 3. Develop a surgical plan for late enophthalmos repair and understand the value and utility of osteotomies, intraoperative navigation, and patient-specific implants. 4. Discuss the expected outcomes, possible complications, and adjunctive surgery as related to late enophthalmos repair. SUMMARY: This article addresses the current management of late posttraumatic enophthalmos. In this article, the authors describe surgically relevant orbital anatomy and oculo-orbital relations, the pathophysiology of enophthalmos, clinical and radiologic findings, decision-making in management, and surgical treatment. The authors attempt to cover some of the main challenges and recent advances in the management of late posttraumatic enophthalmos, including intraoperative navigation and patient-specific implants.

Decision-Making in Adult Cranial Vault Reconstruction.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Define and classify different types of cranial defects 2. Compare both autologous and alloplastic options for reconstruction 3. Develop an optimal approach for cranial vault reconstruction in various clinical scenarios. SUMMARY: Defects of the cranium result from various causes, including traumatic loss, neurosurgical intervention, skull tumors, and infection. Cranial vault reconstruction aims to restore both the structural integrity and surface morphology of the skull. To ensure a successful outcome, the choice of appropriate cranioplasty reconstruction will vary primarily based on the cause, location, and size of the defect. Other relevant factors that must be considered include adequacy of soft-tissue coverage, presence of infection, and previous or planned radiation therapy. This article presents an algorithm for the reconstruction of various cranial defects using both autologous and alloplastic techniques, with a comparison of their advantages and disadvantages.

Surgical Sparing and Pairing Endovascular Interventions for Carotid-Cavernous Fistula: Case Series and Review of the Literature.

BACKGROUND: Carotid-cavernous fistulas (CCFs) are abnormal communications between the arterial and venous circulation within the cavernous sinus, manifesting in myriad neurological and ophthalmological sequalae. In rare circumstances patients' unique vascular anatomies preclude standard endovascular treatment for this pathology, warranting combined surgical and endovascular approaches wherein the cavernous sinus is accessed via superior ophthalmic vein (SOV) exposure, cutdown, and cannulation. CASE DESCRIPTION: We describe 3 cases of CCF treated at our quaternary neurovascular referral center between 2017 and 2019. The first is a 35-year-old man with symptomatic, traumatic, right-sided CCF, treated with endovascular therapy (transarterial detachable balloon placement). The other cases were treated with contrasting surgical and endovascular combined approaches because of unique vascular challenges. The second is a 71-year-old woman with spontaneous right-sided CCF whose carotid sinus was accessed and embolized through a transpalpebral cutdown of the SOV. The third case is a 70-year-old man with symptomatic, spontaneous bilateral CCF. After unsuccessful transarterial and transvenous endovascular approaches, transorbital (intracranial) SOV cutdown and cannulation were performed to embolize the shunting fistula. CONCLUSIONS: Endovascular approaches are well described as the mainstay of treatment for CCF but are not possible for all patients. In circumstances where individual vascular anatomy is not amenable to transarterial or transvenous access or embolization, a combined surgical and endovascular approach may be appropriate. We describe 3 cases that illustrate the spectrum of interventions for CCF, as well as the technical aspects of treatment for 2 patients with complex, direct CCF, using an embolization approach reliant on SOV cutdown and cannulation.

Best Practice Guidelines for the Management of Acute Craniomaxillofacial Trauma During the COVID-19 Pandemic.

Coronavirus disease 2019 (COVID-19) is an infectious disease that is caused by severe respiratory syndrome coronavirus 2. Although elective surgical procedures are being cancelled in many parts of the world during the COVID-19 pandemic, acute craniomaxillofacial (CMF) trauma will continue to occur and will need to be appropriately managed. Surgical procedures involving the nasal, oral, or pharyngeal mucosa carry a high risk of transmission due to aerosolization of the virus which is known to be in high concentration in these areas. Intraoperative exposure to high viral loads through aerosolization carries a very high risk of transmission, and the severity of the disease contracted in this manner is worse than that transmitted through regular community transmission. This places surgeons operating in the CMF region at particularly high risk during the pandemic. There is currently a paucity of information to delineate the best practice for the management of acute CMF trauma during the COVID-19 pandemic. In particular, a clear protocol describing optimal screening, timing of intervention and choice of personal protective equipment, is needed. The authors have proposed an algorithm for management of CMF trauma during the COVID-19 pandemic to ensure that urgent and emergent CMF injuries are addressed appropriately while optimizing the safety of surgeons and other healthcare providers. The algorithm is based on available evidence at the time of writing. As the COVID-19 pandemic continues to evolve and more evidence and better testing becomes available, the algorithm should be modified accordingly.

Comparative Cost-Effectiveness of Cranioplasty Implants.

PURPOSE: The aim of this study was to compare operative duration and total hospital costs incurred for patients undergoing elective cranioplasty with a variety of materials, including manually shaped autogenous bone graft and titanium mesh, custom patient-specific titanium mesh, polymethyl methacrylate (PMMA) acrylic, and polyetheretherketone (PEEK) implants. METHODS: A single-centre retrospective chart review was used. Patient demographics, defect characteristics, total operative time, and length of hospital stay were obtained. Total costs were sourced from Sunnybrook and standardized to the 2014 to 2015 year. Bivariate and age-controlled multivariate analyses were performed with (n = 119) and without (n = 101) outliers. RESULTS: When outliers were removed, an age-controlled analysis revealed that autogenous implants resulted in an operative time of 178 ± 37 minutes longer than manually shaped titanium implants (P < .01). The average cost of cranioplasty was CAD$18 335 ± CAD$10 265 for manually shaped titanium implants, CAD$31 956 ± CAD$31 206 for custom patient-specific titanium implants, CAD$20 786 ± CAD$13 075 for PMMA, CAD$14 291 ± CAD$5562 for autogenous implants, and CAD$27 379 ± CAD$4945 for PEEK implants (P = .013). When outliers were removed, cranioplasty with PMMA and PEEK incurred greater costs, CAD$4442 ± CAD$2100 and CAD$13 372 ± CAD$2728, respectively, more than manually shaped titanium implants (P < .01). CONCLUSIONS: Manually shaped titanium mesh is the most cost-effective implant choice for small cranial defects. Large unknown defects and frontal paranasal sinus defects are most effectively treated with autogenous bone or titanium mesh. Despite prolonged operative duration and inpatient admission, total costs were not significantly increased. Both PMMA and PEEK implants were significantly more costly, which may be a result of higher complications necessitating reoperation.

OBJECTIF: La présente étude visait à comparer la durée de l'opération et les coûts hospitaliers totaux engagés pour les patients qui subissaient une cranioplastie non urgente faisant appel à divers matériaux : greffon osseux autologue et treillis de titane façonnés à la main, implant PMMA et implant PEEK. MÉTHODOLOGIE: Les chercheurs ont réalisé une analyse rétrospective monocentrique des dossiers. Ils ont colligé les renseignements démographiques sur les patients, les caractéristiques de l'anomalie, la durée totale de l'opération et la durée du séjour hospitalier. Ils ont extrait les coûts totaux de Sunnybrook et les ont standardisés pour l'année 2014-2015. Ils ont effectué des analyses bivariées et multivariées contrôlées selon l'âge en incluant (n=119) et en excluant (n=101) les valeurs aberrantes. RÉSULTATS: Après l'élimination des valeurs aberrantes, une analyse contrôlée selon l'âge a révélé que les implants autologues s'associaient à une opération plus longue de 178 ± 37 min que les implants de titane façonnés à la main (p<0,01). Le coût moyen de la cranioplastie s'élevait à 18 335 CAD$ ± 10 265 CAD$ pour les implants de titane façonnés à la main, à 31 956 CAD$ ± 31 206 CAD$ pour les implants de titane adaptés aux patients, à 20 786 CAD$ ± 13 075 CAD$ pour les implants en PMMA, à 14 291 CAD$ ± 5 562 CAD$ pour les implants autologues et à 27 379 CAD$ ± 4 945 CAD$ pour les implants en PEEK (p=0,013). Une fois les valeurs aberrantes éliminées, la cranioplastie par PMMA ou PEEK étaient les plus coûteuses, à 4 442 CAD$ ± 2 100 CAD$ et 13 372 CAD$ ± 2 728 CAD$ de plus que les implants de titane façonnés à la main (p<0,01). CONCLUSIONS: Les treillis de titane façonnés à la main présentent le meilleur rapport coût-efficacité en cas d'anomalies crâniennes bénignes. Le traitement des graves anomalies d'origine inconnue et des anomalies des sinus paranasaux frontaux les plus efficaces sont l'os autologue ou le treillis de titane. Malgré une opération et un séjour hospitalier prolongés, les coûts totaux n'augmentaient pas de manière significative. Les implants de PMMA et de PEEK étaient considérablement plus cher, peut-être à cause du plus fort taux de complications donnant lieu à une réopération.

Radiation for below the knee skin cancers: a single institution experience.

Background: Historically, radiation to skin cancers for the lower legs has been avoided due to the perceived increased risk of radiation toxicity (poor wound healing, radiation necrosis). However, there is a paucity of published data regarding this perceived risk.Purpose: The objective was to review the risk of poor wound healing/radiation necrosis occurring post radiation and to determine rates of complete response (CR), partial response (PR), and progressive disease after radiation therapyMaterials and methods: A retrospective review of patients treated with radiation for skin cancer below the knee was undertaken from January 1, 2013 to May 31, 2018.Results: A total of 25 patients with 39 below the knee skin sites were treated with radiation. Mean follow-up time was 19 months (range 3 months-7.2 years). Crude CR, PR and progression rates for the treated lesions were 65%, 19%, and 16% respectively. Four out of 23 (17%) patients developed Grade 3 skin toxicity. There were no grades 4 or 5 toxicities.Conclusions: For patients not eligible for surgery, radiation therapy is an option with a moderate chance of complete response (65%) and a 17% risk of poor wound healing/radiation necrosis.

Functional Outcomes of Late Posttraumatic Enophthalmos Correction.

BACKGROUND: Posttraumatic enophthalmos has debilitating functional consequences, resulting in restriction of ocular motility and diplopia. Surgical correction aims to restore the globe position and ultimately improve function. This study evaluates the functional outcome of posttraumatic enophthalmos repair. METHODS: Patients included in this study had posttraumatic enophthalmos and diplopia requiring enophthalmos repair. Diplopia was graded from 0 (no diplopia) to 4 (constant diplopia) based on the Functional Diplopia Grading Scale. Limitations of eye movements were recorded in the vertical, horizontal, and torsional directions. Data were gathered prospectively at preoperative assessment, postenophthalmos repair, and final follow-up. RESULTS: Between 2002 and 2014, 41 patients fulfilled inclusion criteria. Substantial functional improvement, defined as a decrease of greater than or equal to 1 grade of diplopia, was achieved in 65.9 percent of patients (27 of 41) after all surgical interventions. Patients with residual diplopia (34 of 41) after enophthalmos surgery were managed with secondary strabismus surgery (10 of 34) and/or prism glasses (four of 34). After all interventions, vertical restrictions improved from -1.95 ± 1.13 to -1.06 ± 0.98. Horizontal restrictions improved from -0.88 ± 0.62 to 0.59 ± 0.6. Adequate clinical correction of enophthalmos to within 2 mm of the contralateral globe was achieved in 37 of 41. CONCLUSIONS: This is the largest case series evaluating functional outcomes of patients undergoing posttraumatic delayed enophthalmos repair. A multidisciplinary care approach resulted in improved globe position and eye movement, and improvement of diplopia. Further studies with larger sample sizes are needed to better understand and treat this important and challenging problem. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Risk Factors for Titanium Mesh Implant Exposure Following Cranioplasty.

PURPOSE: Titanium mesh is used to reconstruct the neurocranium in cranioplasties. Though it is generally well-tolerated, erosion of the overlying soft tissue with exposure of the implant is a complication that adversely affects patient outcomes. The purpose of this study is to investigate potential risk factors for titanium mesh exposure. METHODS: This study comprises all consecutive patients who underwent titanium mesh cranioplasty between January 2000 and July 2016. A retrospective chart review was conducted to extract demographics, details of management, and outcome. Latest postoperative computed tomography scans were reviewed to document the thickness of soft tissue coverage over the implant and the presence of significant extradural dead space deep to it. RESULTS: Fifty patients were included. Implant exposure occurred in 7 (14%), while threatened exposure was observed in 1 additional patient, for a total complication count of 8 (16%).Four (50%) exposure and 3 (7.1%) nonexposure patients underwent preoperative radiotherapy (odds ratio [OR] = 19.67, P = 0.018). Similarly, 4 (50%) exposure and 5 (11.9%) nonexposure patients had a free flap tissue transfer for implant coverage (OR = 6.50, P = 0.046). Postoperative computed tomography scans revealed significant thinning of soft tissues over titanium mesh in 7 (87.5%) exposure and 15 (35.7%) nonexposure patients (OR = 10.71 P = 0.040). No significant association was found between transposition/rotation flap, postoperative radiotherapy, or the presence of significant extradural dead space, and exposure (P = 0.595, P = 0.999, P = 0.44). CONCLUSION: Preoperative radiotherapy, free flap coverage, and soft tissue atrophy resulted in greater odds of titanium mesh exposure. The findings of this study provide important considerations for reconstructive surgeons using titanium mesh for cranioplasty.

An Algorithm for Managing Intraosseous Vascular Anomalies of the Craniofacial Skeleton.

BACKGROUND: Intraosseous vascular anomalies (IOVA) are rare in the craniofacial skeleton and present a diagnostic and therapeutic challenge. This study aims to describe the clinical management based on a large case series. METHODS: A retrospective chart review was performed and 9 IOVA were identified over a 15-year period. Data on demographics, diagnostic features, clinical management, and outcomes were reviewed. RESULTS: Five frontal bone IOVA and 4 orbital IOVA were identified. The postoperative follow-up ranged from 4 months to 4 years. All 9 lesions were diagnosed with computed tomography (CT) imaging. Magnetic resonance imaging (MRI) was used to delineate soft tissue involvement in 2 patients presenting with oculo-orbital dystopia and ophthalmoplegia. En bloc excision was performed in all patients. Preoperative interventional embolization was critical in the successful resection of an orbital IOVA following 2 previously failed attempts that were aborted secondary to hemorrhage. Intraoperative 3-dimensional stereotactic navigation was used for the accurate en bloc excision of a frontal IOVA to prevent injury to the frontal sinus. Reconstruction of esthetic and functional deformities was successfully accomplished. CONCLUSION: The diagnosis of IOVA relies primarily on clinical assessment and CT imaging. Further interpretation of the involvement of periorbital, facial, and intracranial soft tissue is best defined by MRI. Multidisciplinary care with interventional radiology and neurosurgery must be considered for ensuring the safe and adequate en bloc excision of craniofacial IOVA.

Analyzing the Cost of Autogenous Cranioplasty Versus Custom-Made Patient-Specific Alloplastic Cranioplasty.

PURPOSE: Comparing expenses related to autogenous cranial vault reconstruction versus custom-made patient-specific alloplastic cranioplasty. METHODS: The authors retrospectively reviewed charts of a group of patients who underwent autogenous cranioplasty and poly-ether-ether ketone (PEEK) cranioplasty. The data collected from the patient files included demographic information, details of the surgery, postoperative recovery data, and also duration of surgery. The authors also added costs related to the length of surgery, utilization of intensive care unit, length of hospital stay, amount and seriousness of complications, and hardware cost. The outcomes were studied in terms of skull form maintenance and complications.Eleven of our patients had PEEK cranioplasty at Sunnybrook Hospital, Toronto, ON, in the period from July 2009 to June 2011. The authors identified 11 patients who had split skull autogenous bone graft cranioplasty. They were matched for age and skull defect size.Comparable information was collected for both patient groups. The information was examined to compare costs of custom-made patient-specific alloplastic implants and costs of autogenous cranioplasty. RESULTS: Conclusions made from this paper will hopefully serve as guidance for allocation of hospital funding and resources at the Ministry of Health level.

Radiation therapy for the treatment of skin Kaposi sarcoma.

OBJECTIVE: Kaposi sarcoma (KS) lesions are purplish, reddish blue or dark brown/black macules, plaques or nodules which involve the skin and occasionally internal organs. Most patients with KS have a long indolent chronic course. METHODS: A retrospective review was undertaken for all KS skin patients treated with radiotherapy at a tertiary cancer centre from Jan. 2, 1999 to Dec. 31, 2014 (inclusive). RESULTS: A total of 47 patients with KS (43 classical, 0 African, 1 iatrogenic, 3 AIDS related) were seen in the multidisciplinary clinic. Out of this group, 17 patients (5 females and 12 males, 14 classical, 0 African, 0 iatrogenic, 3 AIDS related) with 97 KS skin sites were treated with local external beam radiotherapy. An additional 18 skin sites were treated with repeat radiotherapy. The radiotherapy dose ranged from 6 Gy in 1 fraction to 30 Gy in 10 fractions with the most common dose fractionation scheme being 8 Gy in 1 fraction or 20 Gy in 5 daily fractions. For the previously untreated KS sites, 87% responded to radiation [30% complete response (CR) and 57% partial response (PR)]. Thirteen percent of KS sites treated with radiation progressed. For the skin sites which were treated with repeat radiotherapy, 0% showed CRs, 50% PRs and 50% had continued progression. CONCLUSIONS: The majority of KS skin lesions (87%) responded to radiotherapy. Patients experience minimal side effects from the palliative radiation regimens used. KS skin lesions which progress despite radiation are unlikely to show CR with repeat radiotherapy. In our experience 50% of skin KS will have partial regression with repeat radiotherapy and 50% will have continued progression.

Use of the Derriford Appearance Scale 59 to assess patient-reported outcomes in secondary cleft surgery.

BACKGROUND: Secondary rhinoplasty, one of the final procedures in addressing the stigma of the cleft lip and palate (CLP), has both functional and aesthetic objectives. The way in which physicians evaluate outcomes in surgery concerning aesthetics is changing. Well-designed patient-reported outcome measures to assess health-related quality of life improvements attributable to surgery are increasingly being used. The Derriford Appearance Scale 59 (DAS-59) is currently the only available validated patient-reported outcome measure that assesses concern about physical appearance. METHODS: Twenty patients with CLP presenting between May 2009 and May 2013 for secondary rhinoplasty to Sunnybrook Health Sciences Centre (Toronto, Ontario) were recruited. DAS-59 measures were administered both preoperatively and at least six months after surgery. Pre- and postoperative measures were scored and compared. Item-by-item analysis of the measure was also performed. RESULTS: Total scores for this CLP group indicated greater concern about appearance than the general population. Across all subscales of the measure, there was a reduction in scores after secondary rhinoplasty suggesting less patient concern with appearance and a positive effect of surgery on patient quality of life. Item-by-item analysis suggested relatively few items in the measure were driving overall change in total scores. CONCLUSION: Comparison of pre- and postoperative scores with the DAS-59 in secondary cleft rhinoplasty suggests there is less concern with appearance after surgery. However, a small number of items within this generic scale contributing to this difference may suggest the need for a more patient specific measure for assessment of surgical outcomes in the cleft population.

HISTORIQUE: La rhinoplastie secondaire, l'une des dernières interventions pour corriger une fente labio-palatine (FLP), a des objectifs à la fois fonctionnels et esthétiques. La manière dont les médecins évaluent les résultats esthétiques après une chirurgie est en évolution. Ils utilisent de plus en plus des mesures de résultats bien conçues faites par les patients pour évaluer les améliorations à la qualité de vie liée à la santé découlant de l'opération. L'échelle d'apparence Derriford en 59 éléments (DAS-59) est la seule mesure validée de résultats déclarés par le patient pour évaluer les préoccupations relatives à l'apparence physique. MÉTHODOLOGIE: Les chercheurs ont recruté 20 patients ayant une FLP qui ont consulté au Sunnybrook Health Sciences Centre de Toronto, en Ontario, entre mai 2009 et mai 2013 pour subir une rhinoplastie secondaire. Ils ont administré les mesures de DAS-59 avant et au moins six mois après l'opération. Ils ont établi les scores des mesures préopératoires et postopératoires et les ont comparées. Ils ont également analysé chaque élément de la mesure. RÉSULTATS: Le score total de ce groupe de FLP s'associait à une plus grande préoccupation relative à l'apparence qu'au sein de la population générale. Dans toutes les sous-échelles de la mesure, les scores diminuaient après la rhinoplastie secondaire, ce qui laisse supposer que les patients se préoccupaient moins de leur apparence et que l'opération avait eu un effet positif sur leur qualité de vie. L'analyse de chaque élément indiquait que relativement peu d'éléments de la mesure suscitaient le changement des scores totaux. CONCLUSION: La comparaison des scores de la DAS-59 avant et après une rhinoplastie secondaire de la FLP indique une moindre préoccupation de l'apparence après l'opération. Cependant, peu d'éléments de cette échelle générique contribuent à cette différence, ce qui laisse croire à la nécessité d'utiliser une mesure plus précise pour évaluer les résultats chirurgicaux au sein de cette population.

Facial Fractures.

LEARNING OBJECTIVES: After reading this article, the participant should be able to: 1. Demonstrate an understanding of some of the changes in aspects of facial fracture management. 2. Assess a patient presenting with facial fractures. 3. Understand indications and timing of surgery. 4. Recognize exposures of the craniomaxillofacial skeleton. 5. Identify methods for repair of typical facial fracture patterns. 6. Discuss the common complications seen with facial fractures. SUMMARY: Restoration of the facial skeleton and associated soft tissues after trauma involves accurate clinical and radiologic assessment to effectively plan a management approach for these injuries. When surgical intervention is necessary, timing, exposure, sequencing, and execution of repair are all integral to achieving the best long-term outcomes for these patients.

Patient-Specific Orbital Implants: Development and Implementation of Technology for More Accurate Orbital Reconstruction.

Fracture of the orbital floor is commonly seen in facial trauma. Accurate anatomical reconstruction of the orbital floor contour is challenging. The authors demonstrate a novel method to more precisely reconstruct the orbital floor on a 50-year-old female who sustained an orbital floor fracture following a fall. Results of the reconstruction show excellent reapproximation of the native orbital floor contour and complete resolution of her enopthalmos and facial asymmetry.

A Three-Dimensional Statistical Average Skull: Application of Biometric Morphing in Generating Missing Anatomy.

PURPOSE: The utilization of three-dimensional modeling technology in craniomaxillofacial surgery has grown exponentially during the last decade. Future development, however, is hindered by the lack of a normative three-dimensional anatomic dataset and a statistical mean three-dimensional virtual model. The purpose of this study is to develop and validate a protocol to generate a statistical three-dimensional virtual model based on a normative dataset of adult skulls. METHOD: Two hundred adult skull CT images were reviewed. The average three-dimensional skull was computed by processing each CT image in the series using thin-plate spline geometric morphometric protocol. Our statistical average three-dimensional skull was validated by reconstructing patient-specific topography in cranial defects. The experiment was repeated 4 times. In each case, computer-generated cranioplasties were compared directly to the original intact skull. The errors describing the difference between the prediction and the original were calculated. RESULTS: A normative database of 33 adult human skulls was collected. Using 21 anthropometric landmark points, a protocol for three-dimensional skull landmarking and data reduction was developed and a statistical average three-dimensional skull was generated. Our results show the root mean square error (RMSE) for restoration of a known defect using the native best match skull, our statistical average skull, and worst match skull was 0.58, 0.74, and 4.4  mm, respectively. CONCLUSIONS: The ability to statistically average craniofacial surface topography will be a valuable instrument for deriving missing anatomy in complex craniofacial defects and deficiencies as well as in evaluating morphologic results of surgery.