Annette M. Pham

Computer modeling and intraoperative navigation in maxillofacial surgery

Objectives Recent advances in computer-modeling software allow reconstruction of facial symmetry in a virtual environment. This study evaluates the use of preoperative computer modeling and intraoperative navigation to guide reconstruction of the max-illofacial skeleton. Methods Three patients with traumatic maxillofacial deformities received preoperative, thin-cut axial CT scans. Three-dimensional reconstructions, virtual osteotomies, and bony reductions were performed using MIMICS planning software (Materialise, Ann Arbor, MI). The original and “repaired” virtual datasets were then imported into an intraoperative navigation system and used to guide the surgical repair. Results Postoperative CT scans and photographs reveal excellent correction of enophthalmos to within 1 mm in patient 1, significant improvement in symmetry of the nasoethmoid complex in patient 2, and reconstruction of the zygomaticomaxillary complex location to within 1 mm in patient 3. Conclusion Computer modeling and intraoperative navigation is a relatively new tool that can assist surgeons with reconstruction of the maxillofacial skeleton.

Comparison of 4 registration strategies for computer-aided maxillofacial surgery

PURPOSE: Surgeons have recently started to use computer-aided surgery (CAS) to assist with maxillofacial reconstructive surgery. This study evaluates four different CAS registration strategies in the maxillofacial skeleton. MATERIALS AND METHODS: Fifteen fiducial markers were placed on each of four cadaveric heads. Four registration protocols were used: 1) group 1—invasive markers, 2) group 2—skin surface, 3) group 3—bony landmark, 4) group 4—intraoral splint. Two observers registered each head twice with each of the four protocols and measured the target registration error (TRE). The process was repeated on two different navigation systems for confirmation. RESULTS: The mean TRE values were: invasive, 1.13 ± 0.05 mm (P < 0.05); skin, 2.03 ± 0.07 mm (P < 0.05); bone, 3.17 ± 0.10 mm (P < 0.05); and splint, 3.79 ± 0.13 mm (P < 0.05). The TRE values were consistent across CAS systems. CONCLUSION: Of the techniques tested for CAS registration, invasive fiducial markers are the most accurate. Skin surface landmarks, bony landmarks, and an intraoral splint are incrementally less accurate.

Endoscopic management of facial fractures.

Purpose of reviewEndoscopic applications in otolaryngology continue to expand, most recently in the area of maxillofacial trauma. Endoscopic management of orbital blow-out, frontal sinus, zygomatic arch, and subcondylar fractures has been described. This paper reviews the current literature including new techniques, indications, and outcomes in endoscopic management of facial fractures. Recent findingsVery few large studies of endoscopic fracture repair exist. The current literature, however, suggests that, when compared with an open approach, smaller endoscopic incisions result in reduced patient morbidity with similar outcomes. Dedicated endoscopic instrumentation and novel surgical approaches continue to be developed. SummaryEndoscopic repair of facial fractures is a new and evolving technique that offers the potential for reduced patient morbidity and operating time, as well as quicker patient recovery. Current applications include the management of orbital blow-out, frontal sinus, zygomatic arch, and subcondylar fractures. It should be emphasized that endoscopy augments, rather than replaces, the ‘time tested’ principles of adequate skeletal exposure, accurate fracture reduction, and appropriate internal fixation.

Efficacy of Crosseal Fibrin Sealant (Human) in Rhytidectomy

OBJECTIVE To examine the potential efficacy of Crosseal (the human protein, bovine component-free fibrin sealant) (OMRIX Biopharmaceuticals, Ltd, Brussels, Belgium) to reduce ecchymoses and hematoma formation in patients undergoing rhytidectomy. METHODS Before initiation of the study, approval was obtained from the US Food and Drug Administration for an Investigational New Drug Application and off-label use of Crosseal and from the Institutional Review Board of the University of California, Davis. Patients undergoing rhytidectomy with or without concomitant procedures were voluntarily enrolled without compensation in the study (N = 9). Patients were randomized according to which side of the rhytidectomy the tissue sealant was placed. In all patients in the study, 1 side of the rhytidectomy was treated with Crosseal; the other, untreated side was used as a control. Before closure of the skin, 2 mL of Crosseal was sprayed through a pressure regulator under the skin flap of the dissected area of the rhytidectomy only on 1 side. The skin was pretrimmed before placement and closed in standard fashion. A pressure dressing was left in place for 3 days before removal. Nine patients were originally enrolled in the study. On postoperative days 3 and 7, photographs were taken of the patients. The photographs were judged by 5 independent reviewers who were blinded as to which side had been treated with Crosseal. The judges rated the degree of ecchymoses on a scale of 1 (minimal) to 10 (severe) and were asked their opinion as to which side of the facelift had been treated with Crosseal. These results were compared using statistical analysis. Also on days 3 and 7, patients were examined for seroma or hematoma formation on each side of the face. RESULTS Our study demonstrated efficacy of Crosseal in reducing ecchymoses and swelling in all patients. The mean score for ecchymosis on the Crosseal-treated side was 4.5 and on the untreated (control) side was 6.2 (P < .01, Wilcoxon rank sum test). The rate of hematoma or seroma formation was 22% (2 of 9 patients) for the untreated side vs 0% (0 of 9 patients) for the treated side. This did not reach statistical significance (P = .43, Fisher exact test). Small hematomas developed in 2 patients on the control side, which were needle aspirated. There were no known long-term complications from either the use of Crosseal or the rhytidectomy. CONCLUSION Crosseal is efficacious in reducing ecchymoses after rhytidectomy.

Endoscopic removal of a giant fibrovascular polyp of the esophagus

Objectives: Giant fibrovascular polyps of the esophagus are rare benign tumors originating from the proximal esophagus. These pedunculated lesions can grow to “giant” proportions. Asphyxiation from aspiration of the regurgitated polyp is a well-described cause of death. Traditional excision has involved a transcervical vertical esophagotomy. This report describes the successful endoscopic removal of a giant fibrovascular polyp of the esophagus. Results: A 63-year-old man with dwarfism and obstructive sleep apnea was referred for evaluation of an esophageal mass that was intermittently regurgitated into the hypopharynx. Office esophagoscopy demonstrated a 10-cm giant fibrovascular polyp originating just below the cricoid cartilage. During endoscopic removal, the base of the lesion was exposed with a Weerda bivalved laryngoscope. Bipolar cautery combined with a snare was used to transect the base with excellent hemostasis. No esophageal leak was noted on an esophagogram on postoperative day 3. The patient then resumed a liquid diet and was discharged home, resuming a regular diet within a week. Conclusions: Giant fibrovascular polyps of the esophagus are life-threatening because of potential airway obstruction. This report describes the successful endoscopic removal of a giant fibrovascular polyp, avoiding the potential morbidity associated with a transcervical vertical esophagotomy.

Objective facial photograph analysis using imaging software.

Facial analysis is an integral part of the surgical planning process. Clinical photography has long been an invaluable tool in the surgeons practice not only for accurate facial analysis but also for enhancing communication between the patient and surgeon, for evaluating postoperative results, for medicolegal documentation, and for educational and teaching opportunities. From 35-mm slide film to the digital technology of today, clinical photography has benefited greatly from technological advances. With the development of computer imaging software, objective facial analysis becomes easier to perform and less time consuming. Thus, while the original purpose of facial analysis remains the same, the process becomes much more efficient and allows for some objectivity. Although clinical judgment and artistry of technique is never compromised, the ability to perform objective facial photograph analysis using imaging software may become the standard in facial plastic surgery practices in the future.

Management of bilateral cleft lip and nasal deformity.

Purpose of reviewManagement of bilateral cleft lip and nasal deformity can be a challenging task. This paper provides an overview of bilateral cleft lip and nasal deformity with an updated review of current management issues in the literature. Recent findingsThe Centers for Disease Control and Prevention recently reported that orofacial clefts are now the most common birth defect. While this statistic may be disheartening, the increased prevalence brings the problem to light at the forefront of the medical community, thus gaining more support and resources. Many techniques have been described for repair of bilateral cleft lip and nasal deformity. A recent advancement in presurgical orthopedics is the use of nasoalveolar molding to narrow wide clefts. SummarySurgical management of bilateral cleft lip and nasal deformity poses a challenge to the skill and judgment of the cleft surgeon. Although techniques continue to evolve over the decades, the basic principles of cleft surgery remain the same. The main principles are to achieve an appropriate philtral size and shape, to position the cartilages in a more optimal position, and to attain muscular continuity and symmetry for optimal appearance and function. Thus, while keeping the basic principles in mind, management of bilateral cleft lip and nasal deformity becomes a valuable and rewarding experience for the surgeon, patient and caregiver.

08:10: Comparing Registration Strategies for Computer-Aided Surgery

duration of stay, and time of onset of re-bleeding. RESULTS: One patient per 200 tonsillectomies was hospitalized and diagnosed with post-tonsillectomy hemorrhage during the six-year study period. Corresponding figure for re-operations requiring general anesthetics was less than 1 per 1,000 tonsillectomies. The latter group ranged from 8% (2003) to 36% (2000) of all re-hospitalized patients during the study period. The incidence of tonsillectomies increased 36% from 1999, and in-patient treatment became increasingly rarer. While there was in increase in the incidence of post-tonsillectomy bleeding during the study period, the re-bleeding surgery requiring general anesthetics remained stable and was performed in approximately 1 per 1,000 surgeries. CONCLUSIONS: Although posthemorrhage bleeding was rare and re-bleeding surgery applied in only one per thousand surgeries, a slight increase in surgery requiring general anesthetics was noted.