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.

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.

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.

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.

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.

Intracranial pseudoaneurysm associated with orbitozygomatic complex fracture.

Fractures of the orbitozygomatic complex are one of the most common facial fractures encountered by plastic surgeons. Many would consider this to be primarily a cosmetic deformity; however, these injuries can be associated with acute life-threatening complications. Intracranial pseudoaneurysm, although rare, is a well-documented complication of blunt facial trauma, which most plastic surgeons are unaware of. We present the case of a 20-year-old woman who developed an intracranial pseudoaneurysm after blunt facial trauma to illustrate the importance of (1) understanding this rare but highly morbid complication, (2) assessing high-risk patients for pseudoaneurysm, and (3) delaying reconstruction in high-risk patients.

Current applications of 3-d intraoperative navigation in craniomaxillofacial surgery: a retrospective clinical review.

Intraoperative navigation is a tool that provides surgeons with real-time, interactive access to their patient's diagnostic imaging studies while in the operating room. This modality allows for anatomic localization and facilitates intraoperative planning and diagnosis. The application of intraoperative navigation to neurosurgery, otolaryngology, and orthopedic surgery has been well documented; however, only isolated reports have analyzed its potential in the field of craniomaxillofacial surgery. Advancements in 3-dimensional navigational systems have greatly improved the accuracy of the technology, further broadening its scope. In this article, we evaluate a series of 101 craniomaxillofacial cases in which intraoperative navigation was used. The most common application was for intraorbital cases, such as enophthalmos and acute orbital fracture repairs. Other applications included tumor resection, osteotomy design, pathology localization, and craniotomy design. The major limitations of this technology have been its cost and the fact that it cannot reliably be used for soft-tissue reconstruction currently.

Advances in surgical approaches to the upper facial skeleton.

PURPOSE OF REVIEW: Surgical approaches to the upper facial skeleton comprise the coronal, lower eyelid and midface degloving approaches. These are routinely employed in both ablative and reconstructive craniofacial procedures. The ability to perform them in a well tolerated and predictable manner is predicated on knowledge of the indications and the exposure afforded by each approach, detailed appreciation of the anatomy and awareness of potential complications. This article reviews the literature for recent advancements and surgical refinements for each approach. RECENT FINDINGS: Multiple studies over the past 20 years have offered insight into many technical refinements in these surgical approaches. The choice of dissection plane in the lateral extension of the coronal approach affects the integrity of the frontal branch of the facial nerve and the temporal fat pad. A transcaruncular extension of the transconjunctival approach provides unprecedented access to the medial orbital wall and the midface degloving approach renders complex reconstructive procedures feasible. SUMMARY: These techniques continue to evolve and become more precise so that better results can be achieved and devastating complications can be avoided. This study reviews the literature and summarizes preferred options for craniofacial exposure, recent technical refinements, and our current preferred surgical approaches.

A new system for severity scoring of facial fractures: development and validation.

Facial fractures are often the result of high-velocity trauma, causing skeletal disruption affecting multiple anatomic sites to varying degrees. Although several widely accepted classification systems exist, these are mostly region-specific and differ in the classification criteria used, making it impossible to uniformly and comprehensively document facial fracture patterns. Furthermore, a widely accepted system that is able to provide a final summary measure of fracture severity does not exist, making it difficult to investigate the epidemiologic data surrounding facial fracture severity. In this study, a comprehensive method for panfacial fracture documentation and severity measurement is proposed and validated through a retrospective analysis of 63 patients operated on for acute facial fracture. The severity scale was validated through statistical analysis of correlation with surrogate markers of severity (operating room procedure time and number of implants). Spearman correlation coefficients were calculated, and a statistically significant correlation was found between severity score and both number of implants and operating room procedure time (R = 0.92790 and R = 0.68157, respectively). Intraclass correlation coefficients were calculated to assess intrarater and interrater reliabilities of the severity scale and were found to be high (0.97 and 0.99, respectively). This severity scale provides a valuable, validated research tool for the investigation of facial fracture severity across patient populations, allowing for systematic evaluation of facial fracture outcomes, cost-benefit analysis, and objective analysis of the effect of specific interventions.

Aesthetic eyelid reconstruction.

The eyelids are critical in the protection of the conjunctiva and sclera of the globe and, in turn, the preservation of vision. Aesthetically, the position and shape of the eyelids define a distinctive frame for the eyes, and disproportions in any given individual are immediately obvious. Reconstruction of the eyelids must address both functional and aesthetic requirements. This article emphasizes eyelid morphology and discusses the principles and key reconstructive methods used to achieve optimal results for upper and lower eyelid defects, defects of the medial and lateral canthi, and complex combined defects.

Biometric morphing: a novel technique for the analysis of morphologic outcomes after facial surgery.

The results of facial surgery are intuitively judged in terms of the visible changes in facial features or proportions. However, describing these morphologic outcomes objectively remains a challenge. Biometric morphing addresses this issue by merging statistical shape analysis and image processing. This study describes the implementation of biometric morphing in describing the average morphologic result of facial surgery. The biometric morphing protocol was applied to pre- and postoperative images of the following: (1) 40 dorsal hump reduction rhinoplasties and (2) 20 unilateral enophthalmos repairs. Pre- and postoperative average images (average morphs) were generated. The average morphs provided an objective rendering of nasal and periorbital morphology, which summarized the average features and extent of deformity in a population of patients. Subtle alterations in morphology after surgery, which would otherwise be difficult to identify or demonstrate, were clearly illustrated. Biometric morphing is an effective instrument for describing average facial morphology in a population of patients.

Graves' exophthalmos: Volumetric assessment of orbital expansion.

INTRODUCTION: Graves' ophthalmopathy is characterized by an increase in the volume of orbital soft tissue contents and an associated increase in intraorbital pressure. Surgical expansion of bony orbital volume is therefore an effective method of treating moderate to severe exophthalmos. Numerous correlations between specific decompression procedures and reduction of proptosis have been made. The main emphasis of the majority of these studies, however, appears to be of a qualitative nature rather than quantitative. OBJECTIVES: To quantitatively examine the consequences of surgical orbital decompression in the treatment of severe Graves' exophthalmos, with respect to changes in ocular globe projection and orbital soft tissue and bony volume. MATERIAL AND METHODS: A series of three patients (five orbits) with severe exophthalmos were evaluated. All patients were operated on by a single surgeon using a standard technique of orbitozygmatic osteotomy in conjunction with three-wall orbital decompression and release of periorbita. Data obtained from standardized preoperative and three-month postoperative computed tomography scans were transferred to an offline computer workstation. Scalar and volumetric parameters were quantitatively analyzed to determine changes in globe projection in relation to intraorbital volume differences. RESULTS: Following surgery, mean globe retrodisplacement from the lateral orbital rim and from the optic foramen were 6.7 mm and 3.3 mm, respectively. Osteotomy and decompression were effective in producing an 18.6% increase in bony orbital volume. However, the volume of intraorbital soft tissues increased substantially following surgery, with a 23.4% increase in orbital fat volume and a 12.2% increase in neurovascular tissue volume. CONCLUSIONS: The degree of globe retrodisplacement achieved by surgical expansion of the bony orbital cavity in patients with Graves' ophthalmopathy may be less than anticipated, due to a post-operative increase in the intraorbital soft tissue volumes.

INTRODUCTION: L'ophtalmopathie de Graves se caractérise par une augmentation de volume des tissus mous dans l'orbite et est associée à une augmentation de la pression intra-orbitale. L'expansion chirurgicale du volume osseux de l'orbite s'avère donc un moyen efficace de traiter l'exophtalmie modérée ou grave. De nombreuses corrélations ont été établies entre certaines techniques de décompression et la diminution de l'exophtalmie. Toutefois, dans la plupart des études, l'accent semble mis sur des critères qualitatifs plutôt que quantitatifs. OBJECTIF: Quantifier les effets de la décompression chirurgicale de l'orbite dans les cas d'exophtalmie marquée de Graves quant à la position du globe oculaire et au volume de tissu dur et de tissus mous dans l'orbite. MÉTHODE: Nous avons évalué trois patients (cinq orbites) atteints d'exophtalmie marquée. Tous ont été opérés par le même chirurgien, qui a procédé à une ostéotomie orbito-zygomatique classique, associée à une décompression triple des parois de l'orbite et au dégagement du périoste orbitaire. Des données obtenues par tomodensitométrie avant l'opération et trois mois après celle-ci ont été transférées dans un poste de travail autonome. Nous avons effectué une analyse quantitative de certains paramètres volumiques et scalaires pour déterminer les variations de position du globe oculaire en fonction des différences de volume intra-orbital. RÉSULTATS: Après l'opération, la rétro-redressement moyen du globe oculaire depuis le bord latéral de l'orbite et le foramen optique a été de 6,7 mm et de 3,3 mm respectivement. L'ostéotomie et la décompression ont permis une augmentation de 18,6 % du volume osseux de l'orbite. Toutefois, le volume intra-orbital de tissus mous a augmenté considérablement après l'intervention, soit une augmentation de 23,4 % du volume de tissu adipeux et de 12,2 % du volume de tissu neuro-vasculaire. CONCLUSION: Le degré de rétro-redressement du globe oculaire produit par la chirurgie d'expansion de la cavité orbitale osseuse dans les cas d'ophtalmopathie de Graves peut être moins important que prévu en raison de l'augmentation de volume des tissus mous intra-orbitaux en phase postopératoire.

Solitary fibrous tumor of the orbit.

Painless unilateral proptosis is a frequent manifestation of numerous orbital neoplastic and non-neoplastic processes. Various mesenchymal tumors of both fibrohistiocytic and vascular origin are well-described causes. Solitary fibrous tumors (SFTs) are rare spindle-cell neoplasms usually found associated with serosal surfaces, especially the pleura, but they have recently been described in a number of extrapleural sites including the orbit. The authors describe the case of an 18-year-old man who presented with a 6-month history of painless proptosis in the right eye. A visible nontender mass in the right supermedial orbit producing ptosis of the upper lid was present. Magnetic resonance imaging (MRI) showed a well-circumscribed soft tissue mass located above the right globe with no obvious invasion of adjacent orbital structures. Uneventful surgical excision through a right frontal-orbitotomy approach was performed. Histological evaluation showed a solid, highly vascular tumor mass composed of spindle cells arranged in short ill-defined fascicles. Intense immunohistochemistry staining for CD34 and B-cell lymphoma 2 (BCL-2) differentiated the lesion from the more common hemangiopericytoma. Though considered benign, local recurrence and extraorbital extension of orbital SFTs have been described. Malignant behavior, including distant metastases, has been documented in as many as 20% of pleural cases with mortality rates as high as 50%. The natural history of this tumor in the orbit is unclear. The authors report the 35th case of orbital solitary fibrous tumor and discuss the differential diagnosis, histopathology, radiological features, and clinical course.