Printing in Time for Cranio-Maxillo-Facial Trauma Surgery: Key Parameters to Factor in.

Study Design: retrospective cohort study. Objective: 3D printing is used extensively in cranio-maxillo-facial (CMF) surgery, but difficulties remain for surgeons to implement it in an acute trauma setting because critical information is often omitted from reports. Therefore, we developed an in-house printing pipeline for a variety of cranio-maxillo-facial fractures and characterized each step required to print a model in time for surgery. Methods: All consecutive patients requiring in-house 3D printed models in a level 1 trauma center for acute trauma surgery between March and November 2019 were identified and analyzed. Results: Sixteen patients requiring the printing of 25 in-house models were identified. Virtual Surgical Planning time ranged from 0h 08min to 4h 41min (mean = 1h 46min). The overall printing phase per model (pre-processing, printing, and post-processing) ranged from 2h 54min to 27h 24min (mean = 9h 19min). The overall success rate of prints was 84%. Filament cost was between $0.20 and $5.00 per model (mean = $1.56). Conclusions: This study demonstrates that in-house 3D printing can be done reliably in a relatively short period of time, therefore allowing 3D printing usage for acute facial fracture treatment. When compared to outsourcing, in-house printing shortens the process by avoiding shipping delays and by having a better control over the printing process. For time-critical prints, other time-consuming steps need to be considered, such as virtual planning, pre-processing of 3D files, post-processing of prints, and print failure rate.

In-house 3D Model Printing for Acute Cranio-maxillo-facial Trauma Surgery: Process, Time, and Costs.

Three-dimensional (3D) printing is used extensively in cranio-maxillo-facial (CMF) surgery, but its usage is limited in the setting of acute trauma specifically, as delays in outsourcing are too great. Therefore, we developed an in-house printing solution. The purpose of this study was to describe this process for surgeons treating acute CMF trauma. This series describes the printing process, time required, and printing material costs involved for in-house printing applied to a variety of acute CMF trauma cases involving the upper, middle, and lower thirds of the face and skull. All consecutive patients requiring in-house 3D printed models in a level 1 trauma center for acute trauma surgery in mid-2019 were identified and analyzed. Nine patients requiring the printing of 12 in-house models were identified. The overall printing time per model ranged from 2 hours, 36 minutes to 26 hours, 54 minutes (mean = 7h 55 min). Filament cost was between $0.20 and $2.65 per model (mean = $0.95). This study demonstrates that in-house 3D printing can be done in a relatively short period of time, therefore allowing 3D printing usage for various acute facial fracture treatments. The rapid improvements in the usability of 3D software and printing technology will likely contribute to further adoption of these technologies by CMF-trauma surgeons.

Intraoperative Surgical Navigation Reduces the Surgical Time Required to Treat Acute Major Facial Fractures.

BACKGROUND: Assessing bone reduction and implant placement in facial fractures is time-consuming because of limited visibility. An intraoperative navigation system allows real-time confirmation of bone positioning and implant placement on the patient's computed tomographic scan. This circumvents the visibility problem and therefore appears to shorten the surgery time. The goal of this study was therefore to determine whether intraoperative navigation reduces the surgical time required to treat patients with acute major facial fractures. METHODS: In this retrospective quasi-experimental study, 50 patients with major facial fractures were identified and randomly assigned to treatment groups. Twenty-two were treated without the use of a navigation system, and 28 were treated using navigation. The Facial frActure Severity Score (FASS) was devised to better assess and control for complexity of cases and control for possible selection bias. RESULTS: The FASS was directly linked to surgery time, whether or not navigation was used. An analysis of covariance demonstrated that the surgical time required to treat major facial fractures, taking into account the FASS, was reduced by 36.1 percent (124.8 minutes) when navigation was used. CONCLUSIONS: This study compared the surgical time required to treat patients with major facial fractures, with and without a navigation system. The use of a navigation system reduced the surgical time by 36.1 percent. This is a significant improvement in reducing the length of craniomaxillofacial procedures. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Diced cartilage rhinoplasty technique for cleft lip patients.

BACKGROUND: Late warping of dorsal cartilage onlay grafts is a problematic complication of current secondary rhinoplasty techniques in cleft lip patients. MATERIAL AND METHODS: From May 2005 to December 2008, a total of 282 cleft patients had a secondary rhinoplasty performed at our center with a modified diced cartilage technique. Finely diced cartilage was injected over a cartilage framework, and no "sleeve" was used. Of those patients, 246 with a follow-up of more than 6 months were included in this retrospective study. RESULTS: The infection rate was 7.7%. In addition, 5.7% of patients complained of a bulbous tip. Cartilage warping, as seen with classic en bloc grafting of the dorsum, did not occur. Dorsal irregularity was seen in 8.5% of cases, and grafts were visible in 1.2% of cases. The reoperation rate was 8.1%. CONCLUSION: This technique has greatly reduced the late cartilage warping seen with the classic cartilage bloc dorsal augmentation. Complications are low, comparable in occurrence to other techniques, and are easily manageable, making it our technique of choice.

Craniofacial reconstruction of primary osteogenic sarcoma of the skull.

BACKGROUND: Osteosarcoma of the skull is an extremely rare tumour. Because it has few symptoms initially, it usually presents after signs and symptoms of local invasion are present. Obtaining negative surgical margins is one of few modifiable survival factors. Resection of these invasive tumours is often limited by the ability to perform a reconstruction that is adequate in form and function. Despite this critical limitation, there are no articles describing reconstructive techniques used after resection of osteosarcoma of the skull. The purpose of this article is, therefore, to describe the reconstructive methods that can be used in the treatment of osteosarcoma of the skull. METHODS: A retrospective chart, photographic and radiological study was conducted of cases performed between 1986 and 2007. Tumour characteristics and reconstructive methods were compiled. RESULTS: Six patients were operated for osteosarcoma of the skull. The mean age at surgery was 27 years. Resection margins were positive in three cases. Bony reconstructive methods were split calvarial bone, iliac bone grafts and bone cement. Dural repair was made with a variety of materials. Complex deficits were repaired with rotation and free flaps. CONCLUSION: This article presents reconstructive methods used for reconstruction of skull defects left after resection of osteosarcoma of the skull. A variety of methods are available to repair complex deficits. Obtaining negative surgical margins is critical for survival. The ability to completely resect an invasive tumour is often limited by advances in reconstructive methods. Thus, progress in craniofacial reconstruction techniques warrant further investigations.

Single-splint technique in orthognathic surgery: intraoperative checkpoints to control facial symmetry.

BACKGROUND: Despite the most meticulous preoperative planning and execution, intraoperative soft-tissue response to dentoskeletal changes is often different from those statistically predicted, especially when midline asymmetry is present. A "single-splint" technique for bimaxillary surgery, with intraoperative adjustments and checkpoints, was developed in an attempt to overcome these limitations. The purpose of this study was therefore to determine whether this technique can improve the midline symmetry of facial soft tissues. METHODS: Forty-five patients who underwent at least a Le Fort I and a bilateral sagittal split osteotomy of the mandible were identified in the authors' patient database. Standardized frontal photographs were used to measure the change in midfacial, intercommissural, chin to midface, and chin to ideal facial midline angles. The facial midline symmetry index, an overall score of facial symmetry, was also calculated. RESULTS: This study demonstrates that there is a statistically significant improvement of the four angles measured and of the facial midline symmetry index. CONCLUSIONS: These findings demonstrate that the single-splint technique with its intraoperative checkpoints can successfully maintain or improve facial midline symmetry. Thus, the single-splint technique is a useful alternative to the classic two-splint technique for bimaxillary surgery.

Asian rhinoplasty techniques.

Asian rhinoplasty is a broad term that refers to a set of rhinoplasty techniques commonly used in Asian populations. Although these techniques are well developed and documented in Asian languages, there are relatively few English-language articles on the subject, and even fewer on current debates and controversies among plastic surgeons. Knowledge of these different techniques is essential to perform an adequate rhinoplasty in Asians. For Western patients, reduction rhinoplasty with dorsal hump rasping and lower lateral cartilage resection is classic. In contrast, silicone implant augmentation rhinoplasty is the most commonly used technique in Orientals. This article focuses on current rhinoplasty practices and controversies in Asia. It reviews morphologic differences between the Oriental and Western noses, as well as common patient requests. Polytetrafluoroethylene (Gore-Tex) and silicone implant augmentation are discussed. A new augmentation rhinoplasty with diced cartilage is described in more detail.

Bimaxillary protrusion: an overview of the surgical-orthodontic treatment.

Bimaxillary protrusion is a commonly seen deformity in Asian populations. This condition is characterized by protrusive and proclined upper and lower incisors and an increased procumbency of the lips. It is usually combined with lip incompetence, gummy smile, mentalis strain, and anterior open bite. Facial aesthetics is the primary concern of these patients. Successful treatment depends on a thorough evaluation and understanding of this dentofacial deformity. Typical orthodontic treatment includes retraction and retroclination of maxillary and mandibular incisors after extraction of the four first premolars. Orthognathic surgery is required to correct significant skeletal problems. Anterior subapical osteotomies and extraction of premolars can correct sagittal excess of the jaw bones and relieve dental crowding. Segmental maxillary osteotomies are performed to treat patients with an associated exaggerated curve of Spee and vertical maxillary excess. Differential intrusion of anterior and posterior maxilla/maxillary segments with clockwise rotation of the occlusal plane is a useful technique for treatment of anterior open bite and creation of a consonant smile arc. Le Fort I osteotomy with setback sometimes provides an alternative to segmental maxillary osteotomies. Meticulous planning and execution of osteotomies in accordance with surgical planning are essential for aesthetic and functional outcome.

The asian face lift.

The face-lift procedure (rhytidectomy) is increasingly popular in Asia. There is extensive literature on different techniques in Western patients. Cultural and anthropomorphologic differences between Asian and Caucasians require the adaptation of current techniques to obtain a satisfactory outcome for both the patient and the surgeon. This article therefore attempts to define important differences between Asians and Caucasians in terms of signs of facial aging, perception of beauty, and surgical goals. Our face-lift technique, a modified deep-plane face lift for Asians, is detailed and cases are presented.

Single-splint technique for correction of severe facial asymmetry: correlation between intraoperative maxillomandibular complex roll and restoration of mouth symmetry.

BACKGROUND: One of the most difficult problems to treat is the patient presenting with severe facial asymmetry and malocclusion whose chief complaint is the need for facial improvement. A canted intercommissural plane appears to be a major contributor to the patient's perception of facial asymmetry, but little is known about its correction. The authors adjust the intercommissural plane intraoperatively by modifying the maxillomandibular roll. However, a correlation between maxillomandibular roll and intercommissural plane change has not been demonstrated. The purpose of this study was therefore to determine whether such a correlation exists. METHODS: A retrospective series of 18 patients with severe maxillomandibular asymmetry requiring differential maxillary impaction/extrusion (>2 mm difference in posterior maxillary vertical movement between the right and left sides) was studied. Preoperative and postoperative frontal photographs and lateral cephalometrics were studied to determine the effect of maxillomandibular complex roll on the intercommissural plane. Linear regression and statistical analysis were performed to determine the strength of the association between the two movements. RESULTS: A linear regression could be derived from the scatterplot tracing. A Pearson correlation demonstrated a significant positive relationship between vertical maxillomandibular complex change in roll and intercommissural plane changes (r = 0.8; p = 0.000, one-tailed). CONCLUSIONS: A correlation between maxillomandibular complex roll and intercommissural plane change has been demonstrated. This supports the usefulness of intraoperative change in maxillary roll to restore mouth symmetry in patients with severe facial asymmetry. It also identifies a major factor that can be modified to change mouth symmetry in the vertical plane during presurgical planning.

The superior and inferior gluteal artery perforator flaps.

BACKGROUND: Perforator flaps have allowed reconstruction of soft-tissue defects throughout the body. The superior and inferior gluteal artery perforator flaps have been used clinically, yet the published anatomical studies describing the blood supply to the gluteal skin are inadequate. This study comprehensively evaluated the anatomical basis of these flaps to present anatomical landmarks to facilitate flap dissection. METHODS: In six fresh cadavers, the integument of the gluteal region was dissected. Cutaneous perforators of the superior and inferior gluteal arteries were identified. Their course, size, location, and type (septocutaneous versus musculocutaneous) were recorded based on dissection, angiography, and photography. The surface areas of cutaneous territories and perforator zones were measured and calculated. RESULTS: The average number of superior and inferior cutaneous perforators greater than or equal to 0.5 mm in the gluteal region was 5 +/- 2 and 8 +/- 4, respectively, with all of the superior and 99 percent of the inferior gluteal artery perforators being musculocutaneous. Their average perforator internal diameter was 0.6 +/- 0.1 mm. The average superior and inferior gluteal artery cutaneous vascular territory was 69 +/- 56 cm and 177 +/- 38 cm, respectively. The superior gluteal perforators were found adjacent to the medial two-thirds of a line drawn from the posterior superior iliac spine to the greater trochanter. The inferior gluteal artery perforators were concentrated along a line in the middle third of the gluteal region above the gluteal crease. CONCLUSION: The reliable size and consistency of the superior and inferior gluteal artery perforators allow the use of pedicled and free superior and inferior gluteal artery perforator flaps in a variety of clinical situations.

Donor-site morbidity of the inferior gluteal musculocutaneous flap for breast reconstruction in teenagers.

The purpose of this study is to objectively evaluate donor-site morbidity of the inferior gluteal musculocutaneous flap in teenagers. All cases of breast reconstruction performed between 1996 and 2005 using an inferior gluteal flap were reviewed. Flap size, weight, and pedicle origin were noted. Donor-site morbidity was assessed for scarring, contour deformity, muscle function, and sensation. The charts of 15 patients were reviewed, and 6 patients were available for further investigation. The average flap size and weight were 17 cm x 7 cm and 430 g, respectively. All patients had a well-concealed scar with minimal buttock asymmetry. Sensory assessment showed some degree of hypoesthesia in the territory of the posterior femoral cutaneous nerve in all patients. There was no functional loss. Donor-site morbidity of the inferior gluteal musculocutaneous flap is largely related to posterior thigh hypoesthesia despite preservation of the posterior femoral cutaneous nerve.

The anatomical basis of the deep circumflex iliac artery perforator flap with iliac crest.

BACKGROUND: Perforator flaps are increasingly used because of advantages including reduced flap bulk, less donor-site morbidity, and more donor-site options. The deep circumflex iliac artery (DCIA) osteomusculocutaneous flap with iliac crest has been one of the most useful flaps used for mandibular reconstruction. However, its use has been limited by its bulkiness and added donor-site morbidity because of the inclusion of an "obligatory muscle cuff" of abdominal muscle. Early results at designing a DCIA perforator flap to circumvent this problem have been varied. Details regarding the location, number, and reliability of DCIA musculocutaneous perforators have been conflicting. The purpose of this study was to comprehensively document the anatomical basis of the DCIA perforator flap. METHODS: Six fresh bodies underwent whole-body lead oxide injection (n = 12 specimens). Landmarks were identified with radiopaque markers. Dissection, angiography, and photography were used to document the precise course of individual perforators in the flank region. Angiograms were assembled with Adobe Photoshop and analyzed with Scion Image Beta. RESULTS: An average of 1.6 DCIA perforators with a diameter of 0.7 mm was present in 92 percent of specimens. Perforators were located 5 to 11 cm posterior to the anterior superior iliac spine, 1 to 35 mm superior to the iliac crest, with a perforator zone of 31 cm. The DCIA perfused the medial aspect of the iliac crest. CONCLUSIONS: This article establishes the anatomical basis of the DCIA perforator flap with iliac crest. This perforator flap, along with a split iliac crest, will likely diminish donor-site morbidity and facilitate oromandibular reconstruction.

The posterior thigh perforator flap or profunda femoris artery perforator flap.

BACKGROUND: The thigh donor site has been used extensively for microsurgical tissue transfer; however, the posterior thigh has been neglected as a potential donor site. The perforators of the profunda femoris artery supply large cutaneous territories that could be useful for lower extremity coverage. The purpose of this article is to evaluate the anatomical basis of the posterior thigh perforator flap and to provide anatomical landmarks with which to facilitate flap dissection. METHODS: Six fresh cadavers underwent a whole-body, intraarterial injection of a lead oxide and gelatin preparation. The integument of the posterior thigh was dissected (n = 11), and perforators of the profunda femoris artery were identified. Their type (septocutaneous versus musculocutaneous), course, size, and location were documented by angiography and photography. Surface areas were measured with Scion Image Beta 4.02. Results are reported as mean +/- SD. RESULTS: The average number of profunda femoris cutaneous perforators in the posterior thigh was 5 +/- 2 (65 percent septocutaneous and 35 percent musculocutaneous), the average internal diameter was 0.8 +/- 0.3 mm, and the pedicle length was 29 +/- 14 mm from the deep fascia and 68 +/- 33 mm from the profunda femoris artery. The average profunda femoris cutaneous vascular territory was 229 +/- 72 cm, with a 46 +/- 13-cm perforator zone. Cutaneous perforators can be found on a line extending from the ischium to the lateral femoral condyle. CONCLUSIONS: The profunda femoris provides cutaneous perforators of large caliber supporting a substantial cutaneous territory. This flap will likely be clinically useful in lower extremity reconstruction as a free or pedicled flap.

A review of vascular injection techniques for the study of perforator flaps.

BACKGROUND: With a new era of flap surgery, additional anatomical information is required. The relatively recent interest in musculocutaneous perforator flaps has once again sparked interest in the vascular anatomy of surgical flaps. There are a variety of anatomical techniques available to define the vascular anatomy of tissues of interest. In this article, the authors review vascular injection techniques available and describe the technique currently used in their laboratory. METHODS: A comprehensive review of vascular injection techniques is summarized. Barium sulfate and lead oxide in particular are reviewed in detail. RESULTS: This article reviews the historical development of vascular injection techniques, outlines current investigative methods, and expands on a radiopaque lead oxide and gelatin injection method that provides high-quality angiograms. CONCLUSIONS: The standard method for the study of perforator flap is the lead oxide-gelatin technique. However, other methods can provide complementary information on vascular anatomy.

Treatment outcomes of unstable proximal phalangeal head fractures of the finger in children.

The authors reviewed 37 children presenting with closed, unstable fractures of the proximal phalangeal head. Fractures were classified as intra-articular (n = 15), including 14 unicondylar and 1 bicondylar, or extra-articular (n = 22), including 20 subcondylar and 2 comminuted subcondylar. Eighteen patients underwent closed reduction with K-wire fixation (n = 11) or dynamic skeletal traction (n = 7). Nineteen patients underwent open reduction with K-wire fixation (n = 14) or miniscrews (n = 5). Results were considered excellent when the active range of motion (ROM) of the proximal interphalangeal joint was > or = 90 degrees (n = 26); fair, active ROM, 70 to 89 degrees (n = 6); and poor, active ROM < 70 degrees (n = 5). The intra-articular fractures were rated 9 excellent, 5 fair, and 1 poor. The extra-articular fractures were rated 17 excellent, 1 fair, and 4 poor. The 18 closed reductions, K-wire fixation (n = 11) and traction (n = 7), were rated 16 excellent and 2 fair. The 19 open reductions, K-wire fixation (n = 14) and miniscrew fixation (n = 5), were rated 10 excellent, 4 fair, and 5 poor. Closed reduction showed better results than open reduction. Dynamic skeletal traction proved to be simple and effective in treating these injuries.