Benefits of the Retrocaruncular Approach to the Medial Orbit: A Clinical And Anatomic Study.

BACKGROUND: Current trends in the management of medial orbital wall fractures are toward the development of transconjunctival incisions and the use of endoscopic-assisted methods. Different authors have suggested variations of the medial transconjunctival approach. METHODS: (1) In 30 fresh cadaver orbits, the classic transcaruncular approach was compared with the precaruncular and retrocaruncular approach under magnified dissection. (2) A retrospective analysis was conducted on a series of 20 consecutive patients that underwent primary repair of medial orbital wall fractures using a retrocaruncular approach without endoscopic assistance. Postoperative computed tomography scans were obtained for all patients and were evaluated by 3 experienced clinicians. RESULTS: (1) Anatomic dissections showed that all 3 approaches provided excellent exposure of the entire medial orbital wall. The transcaruncular and precaruncular approaches, however, (a) both resulted in exposure of the upper and lower tarsi when incisions greater than 10 mm were used; (b) both required a transition from the preseptal plane to the postseptal plane when combined with inferior fornix incisions. (2) A clinical study of 20 patients showed all reconstructions were possible without endoscopic assistance, resulting in no postoperative complications. Postoperative computed tomography scans showed anatomic orbital reconstruction in all patients judged as excellent by the clinicians. CONCLUSIONS: Medial orbital wall fractures can be successfully repaired using transconjunctival incisions without using endoscopes. The retrocaruncular approach surpasses the transcaruncular and precaruncular methods due to its decreased risk of postoperative lid complications and its ability to be directly carried to the inferior conjunctival fornix.

Evaluation of an ultra-lightweight, single-patient-use negative pressure wound therapy system over dermal regeneration template and skin grafts.

As the use of negative pressure wound therapy (NPWT) over skin grafts has increased, traditional methods of NPWT system reimbursement and application are increasingly being challenged. A simplified method of accessing and operating NPWT in the outpatient setting is needed, particularly in cases where immediate outpatient use of NPWT is optimal. We evaluated use of a new ultra-lightweight, off-the-shelf, disposable, single-patient-use NPWT system (SP-NPWT; V.A.C.Via™ Therapy, KCI USA, Inc., San Antonio, TX) over dermal regeneration template (DRT) and/or skin grafts. SP-NPWT was initiated over a DRT and/or skin graft in 33 patients with 41 graft procedures. Endpoints were recorded and compared to a historical control group of 25 patients with 28 grafts bolstered with traditional rental NPWT (V.A.C.® Therapy, KCI USA, Inc.). Average length of inpatient hospital stay was 0·0 days for the SP-NPWT group and 6·0 days for the control group (P < 0·0001). The average duration of SP-NPWT post-DRT or skin graft was 5·6 days for the SP-NPWT group and 7·0 days for the control (P < 0·0001). Preliminary data suggest that, compared to traditional NPWT, off-the-shelf SP-NPWT may provide a quicker, seamless transition to home, resulting in decreased hospital stay and potential cost savings.

Curvilinear mandibular distraction results and long-term stability effects in a group of 40 patients.

BACKGROUND: The mandibular internal curvilinear distractor design produces a curvilinear vector to provide ideal three-dimensional curvilinear movements compared with the limited straight unidirectional predecessor devices. In this manner, it corrects craniofacial deformities as anatomically as possible, allowing simultaneous bidirectional (rotational and translational) mandibular movement and multidirectional distraction. The aim of this study was to quantify the sagittal and vertical mandibular changes achieved through curvilinear distraction and to assess the long-term effect of this generated bone. METHODS: Forty patients (20 male and 20 female), with ages ranging from 5 to 55 years, who underwent mandibular distraction from December of 1999 to August of 2007 at Lucile Packard Children's Hospital in Stanford, California, were included. Preoperatively, postoperatively, and at follow-up (at least 2 years following distraction), panoramic and lateral cephalometric radiographs were traced by plotting different skeletal landmark points and were then analyzed. RESULTS: All patients tolerated the curvilinear distraction process well through completion. The average of the mandibular body elongation recorded was 8 to 9 mm and 6 to 8 mm in the panoramic and cephalometric radiographs, respectively; whereas the vertical change of the mandibular ramus achieved was 10 to 12 mm and 10 to 11 mm, respectively. The curvilinear distraction effect on the mandible was found to be significantly stable when the long-term follow-up measurements were compared with the postoperative data revealed in the panoramic and lateral cephalometric radiographs for the two dimensions. CONCLUSION: The internal curvilinear device is an effective tool that achieves a stable mandibular distraction, resulting in the correction of craniofacial deformities.

Principles of implant-based reconstruction and rehabilitation of craniofacial defects.

The final stages of reconstruction following craniofacial trauma or tumor resection often involve the fitting of prostheses. Development of osseointegrated implants for retention of prostheses has improved function and aesthetic outcome. Placement of osseointegrated implants requires coordinated care from multiple specialists and a lifetime commitment of the patient. The workup and surgical treatment algorithms for placement of intraoral compared with extraoral implants are discussed. The quality and quantity of bone available are the most important factors influencing design and placement. The long-term retention of implants is influenced by implant site, local tissue bed preparation, and hygiene. Osseointegrated implants are a part of the complete rehabilitation of patients with craniomaxillofacial defects. Although final fitting and maintenance of prostheses is completed by prosthodontists and patients, successful placement and preservation of implants is affected largely by the plan set forth by the reconstructive surgeon.