Chen Lee

Endoscopic subcondylar fracture repair : Functional, aesthetic, and radiographic outcomes

An endoscopic method of mandibular subcondylar fracture repair has been described recently. To determine the effectiveness of this new technique, we longitudinally studied functional, aesthetic, and radiographic parameters following endoscopic repair of 22 subcondylar frac-tures in 20 patients. Restoration of mandibular function was achieved without postoperative maxillomandibular fixation. Premorbid occlusion was restored. Clinical jaw motion was found to progressively increase with a mean interincisal jaw opening of 43 mm achieved after the eighth postoperative week. Patients were pleased with the aesthetic restoration of their chin projection, jaw line, and the symmetric midline movement of the chin point on jaw opening. Anatomic fracture reduction with rigid plate fixation was confirmed on early postsurgical radiographs. Late radiographs showed fracture union without remodeling of the condylar head. Endoscopic subcondylar fracture repair was efficacious at functional, aesthetic, and radiographic restoration of the mandible.

A cadaveric and clinical evaluation of endoscopically assisted zygomatic fracture repair.

&NA; An endoscopic method of malar arch repair without a bicoronal incision has been recently described. To determine the effectiveness of this new technique, a cadaver study was performed to evaluate the capacity of this technique to (1) restore the anatomic position of a fractured malar arch, (2) rigidly fixate the arch, and (3) avoid injury to the frontal branch of the facial nerve. The technique of endoscopically assisted fracture repair was then applied to a clinical series of consecutive patients presenting with displaced zygomatic fractures with comminution at the malar arch. All cadaveric specimens repaired with this endoscopic technique demonstrated anatomic reduction and rigid fixation of the arch without disruption of the frontal branch of the facial nerve. In all clinical cases, four‐point rigid plate fixation (zygomaticofrontal, infraorbital, malar arch, and zygomaticomaxillary buttress) was achieved endoscopically with limited access incisions. All clinical cases demonstrated excellent skeletal restoration of the zygoma on postoperative computed tomography scans. On clinical examination, facial symmetry and normal facial nerve function were observed in all patients after operation. (Plast. Reconstr. Surg. 101: 333, 1998.)

Endoscopic Repair of a Complex Midfacial Fracture

Inadequate treatment of complex midfacial fractures involving the orbit and zygomatic arch can result in important functional and aesthetic deformity. Accurate repair of fractures at the zygomatic arch and orbital floor has traditionally necessitated coronal scalp and lower eyelid incisions respectively. Complications such as facial nerve injury, alopecia, external scarring, ectropion, and eyelid edema have been associated with these traditionally open surgical techniques. We report an endoscopic-assisted technique of open reduction and rigid fixation of a complex midfacial fracture. The endoscopic-assisted technique facilitated the anatomic repair of associated zygomatic arch and orbital floor fractures. The technique minimized ocular globe manipulation and eliminated the need for coronal scalp and lower eyelid incisions.

Intraorbital squamous epithelial cyst : an unusual complication of silastic implantation

Thin Silastic sheet alloplasts (Dow Corning, Midland, MI, U.S.A) are commonly used to reconstruct posttraumatic orbital floor defects. Complications associated with orbital Silastic implantation include infection, migration, and extrusion. The authors report an unusual case of an intraorbital, squamous, epithelial-lined cyst appearing as progressive vertical globe dystopia and proptosis occurring after Silastic reconstruction of a traumatic orbital floor defect.

Objective interpretation of surgical outcomes: is there a need for standardizing digital images in the plastic surgery literature?

Background: Subjective interpretation of preoperative and postoperative photographs is heavily relied on for evaluating standards of care. For preoperative and postoperative digital images to accurately reflect surgical outcomes, image characteristics, other than acquisition, must be rigidly standardized. The authors investigated, using objective methodology, the consistency of published images within the plastic surgery literature. Methods: A panel reviewed four plastic surgery journals (Aesthetic Plastic Surgery, Aesthetic Surgery Journal, Plastic and Reconstructive Surgery, and the British Journal of Plastic Surgery), with 100 consecutive, color, digital, paired preoperative and postoperative images per journal compared. Image characteristics, including color, brightness, contrast, resolution, view, zoom, size, image labeling, background, patient clothing, accessories, makeup/tan, facial expression, and hairstyle, were objectively assessed using a five-point Likert scale; mean values were tabulated and compared among journals; and statistical significance was determined (p < 0.05). Results: The most consistent characteristics among journals included labeling (4.782) and size (4.867), in contrast to clothing (3.097) and hairstyle (3.724) (p < 0.001). Much variability was also present in color, brightness, and view. Plastic and Reconstructive Surgery and American Aesthetic Plastic Surgery were the two most consistent journals when all image characteristics were combined, scoring 4.6 and 4.5, respectively (p ≤ 0.01). Conclusions: Standardization of photographic images is essential in plastic surgery for validity of results. Overall, the authors have demonstrated that much variability exists for all image characteristics between preoperative and postoperative images. Many are crucial to the evaluation of the surgical outcome depicted. In a specialty with a dramatically increasing trend toward communication by means of digital imaging, an effort toward standardization is essential.

The disappearing “melanoma”

Editor,—Uveal melanoma is the most common primary intraocular malignancy in adults. Accurate diagnosis relies upon evaluation by indirect ophthalmoscopy as well as on characteristic features present on ancillary tests such as ultrasonography and angiography. Masquerading lesions can occasionally provide diagnostic challenges. Common simulating lesions include choroidal naevi, metastases, haemangioma, osteoma, CHRPE, and disciform scar.1 We report the case of a patient with a lesion simulating an intraocular melanoma which resulted from the development of an orbital cyst that indented the globe. ### CASE REPORT A 49 year old white male was referred with a diagnosis of an intraocular melanoma. He complained of progressively decreasing vision in his right eye over the previous 1.5 years. His medical history was …

First carpal-metacarpal joint dislocation and trapezial fracture treated with external fixation in an adolescent.

The intrinsic joint stability of the first carpal-metacarpal joint (CMC) makes dislocation a rare injury with fewer than 40 cases described. The degree to which supporting ligaments have been disrupted is reflected clinically by a spectrum of joint stability. Close review of radiographs and an attentive physical examination are necessary to make the diagnosis. Acute treatment has consisted of closed or open reduction with K-wires for stabilization or casting with failures leading to chronic joint instability and the need for soft tissue tendon suspension to maintain joint alignment. We present the case of a 12-year-old boy with a complete first CMC dislocation and trapezial fracture treated with closed reduction and external fixation. At a 3-year follow-up, our patient demonstrates excellent range of motion, strength, and no joint instability without functional limitations. We suggest that external fixation be added to the armamentarium for managing these difficult injuries especially in the pediatric population where interference with growth plates is not ideal.

Applications of the endoscope in facial fracture management.

The aesthetic necessity to preserve an undisturbed facial appearance and function has led to the progressive adoption of less-conspicuous incisions and decreasingly aggressive exposure in the treatment of facial injuries. The goals of proper anatomic reduction and stable fixation, however, must not be omitted. The introduction of endoscopic techniques has allowed a harmonious union of these two seemingly competing objectives. In condylar injuries, the endoscope may be used to restore preinjury condylar height and angulation, avoiding the feared risks of facial nerve injury and visible scarring. Treatment of complex zygoma and LeFort III fracture cases may be facilitated by repairing the zygomatic arch through remote stab incisions, obviating the need for an extensive coronal exposure. Endoscopically assisted treatment and diagnosis of orbital floor fractures decreases the risks of lower eyelid malpositioning without predisposing to the development of enophthalmos or hypoophthalmos. Similarly, depressed frontal sinus injuries may be reduced or camouflaged via hidden incisions, significantly reducing stigmata of surgical entry. In the overview to follow, the application of endoscope-assisted techniques to the treatment of the above fractures will be presented. The rationale for use, specific operative indications, bailout strategies, and outcome studies will be discussed.