Dong Hee Kang

Change of the Orbital Volume Ratio in Pure Blow-out Fractures Depending on Fracture Location

AbstractThe purposes of this study were to observe bony orbital volume (OV) changes in pure blow-out fractures according to fracture location using a facial computed tomographic scan and to investigate whether the OV measurements can be used as a quantitative value for the evaluation of the surgical results of the acute blow-out fracture.Forty-five patients with unilateral pure blow-out fracture were divided into 3 groups: inferior (group I), inferior medial (group IM), and medial (group M) orbital wall fracture. The OV and the orbital volume ratio (OVR) were prospectively measured before and 6 months after surgery with the use of 3-dimensional computed tomographic scans, and the Hertel scale was measured with a Hertel exothalmometer.The preoperative OVR increased to the greatest extent in group IM, and the mean preoperative OVR was 121.46. The mean preoperative OVR in group I was significantly higher than that of group M (P = 0.005). The OV and OVR revealed a statistically significant decrease after the surgery (P = 0.000). The Hertel scale improved from −1.04 mm before the surgery to −0.78 mm after the surgery, but no significant difference was observed (P = 0.051).The OVR was useful as a quantitative value to evaluate pure blow-out fractures, compared with that of the Hertel scale. Fracture location–associated OVR studies are needed to make volume guidelines of blow-out fracture surgery.

Delayed Foreign Body Reaction Caused by Bioabsorbable Plates Used for Maxillofacial Fractures.

Background Bioabsorbable plates and screws are commonly used to reduce maxillofacial bones, particularly in pediatric patients because they degrade completely without complications after bone healing. In this study, we encountered eight cases of a delayed foreign body reaction after surgical fixation with bioabsorbable plates and screws. Methods A total of 234 patients with a maxillofacial fracture underwent surgical treatment from March 2006 to October 2013, in which rigid fixation was achieved with the Inion CPS (Inion, Tampere, Finland) plating system in 173 patients and Rapidsorb (Synthes, West Chester, PA, USA) in 61 patients. Their mean age was 35.2 years (range, 15-84 years). Most patients were stabilized with two- or three-point fixation at the frontozygomatic suture, infraorbital rim, and anterior wall of the maxilla. Results Complications occurred in eight (3.4%) of 234 patients, including palpable, fixed masses in six patients and focal swelling in two patients. The period from surgical fixation to the onset of symptoms was 9-23 months. Six patients with a mass underwent secondary surgery for mass removal. The masses contained fibrous tissue with a yellow, grainy, cloudy fluid and remnants of an incompletely degraded bioabsorbable plate and screws. Their histological findings demonstrated a foreign body reaction. Conclusions Inadequate degradation of bioabsorbable plates caused a delayed inflammatory foreign body reaction requiring secondary surgery. Therefore, it is prudent to consider the possibility of delayed complications when using bioabsorbable plates and surgeons must conduct longer and closer follow-up observations.

The Correlation between the Orbital Volume Ratio and Enophthalmos in Unoperated Blowout Fractures

Background Enophthalmos may not appear immediately after trauma due to periorbital swelling in a blowout fracture, and preoperative measurements of enophthalmos cannot be used as a reliable guideline. It is important to predict the eventual final extent of enophthalmos in order to determine whether to perform surgery, and there have been several attempts to predict the degree of late enophthalmos using preoperative orbital volume. The purpose of this study is to investigate the correlation between the orbital volume ratio (OVR) with final enophthalmos and the palpebral fissure, and to find the OVR that induced 2 mm of enophthalmos in unilateral unoperated blowout fractures. Methods We retrospectively reviewed the medical records of 38 patients and divided them into 3 groups, determined by the fracture location. The relationships between the OVR and both the degree of enophthalmos and the palpebral fissure ratio (PFR) were assessed and, in particular, the OVR that induced 2 mm of enophthalmos was sought. Results Enophthalmos increased in proportion to the OVR, and there was a highly significant correlation between the increase in the OVR and the degree of enophthalmos (P<0.05). On the other hand, there was no correlation between OVR and PFR (P>0.05). The OVR that induced 2-mm enophthalmos was 112.18%. Conclusions The final degree of enophthalmos can be estimated by the preoperative measurement of OVR. Preoperative measurements of OVR can be used as quantitative values to predict the final degree of enophthalmos in pure blowout fractures.

Orbital Wall Restoring Surgery in Pure Blowout Fractures

Background Restoring orbital volume in large blowout fractures is still a technically challenge to the orbital surgeon. In this study, we restored the orbital wall using the combination of transorbital and transnasal approach with additional supports from the paranasal sinuses, and we compared the surgical outcome to that of a conventional transorbital method. Methods A retrospective review of all patients with pure unilateral blowout fractures between March 2007 and March 2013 was conducted. 150 patients were classified into two groups according to the surgical method: conventional transorbital method (group A, 75 patients, control group), and the combination of transorbital and transnasal approach with additional supports from the paranasal sinuses (group B, 75 patients, experimental group). Each group was subdivided depending on fracture location: group I (inferior wall), group IM (inferomedial wall), and group M (medial wall). The surgical results were assessed by the Hertel scale and a comparison of preoperative and postoperative orbital volume ratio (OVR) values. Results In the volumetric analysis, the OVR decreased more by the experimental groups than each corresponding control groups (P<0.05). Upon ophthalmic examination, neither the differences among the groups in the perioperative Hertel scale nor the preoperative and postoperative Hertel scales were statistically significant (P>0.05). Conclusions Our surgical results suggest that orbital volume was more effectively restored by the combination of transorbital and transnasal approach with additional supports from the paranasal sinuses than the conventional method, regardless of the type of fracture.

Retiform hemangioendothelioma on the finger.

Retiform hemangioendothelioma was differentiated from low-grade cutaneous angiosarcoma by Calonje et al. [1] in 1994; retiform hemangioendothelioma is a very rare tumor of the blood vessels, with less than 30 cases reported throughout the world [2]. The causes of retiform hemangioendothelioma are unknown [2]. Clinically, this tumor occurs mainly in the limbs of young adults, with greater occurrence in the lower limbs, but occasional cases in the trunk, head, and penis [1,3]. Although metastasis or malignancy is rare, retiform hemangioendothelioma is known to recur in approximately 50% of cases [3]. No cases of retiform hemangioendothelioma have previously been reported in Korea. The authors describe the case of a Korean patient diagnosed with retiform hemangioendothelioma. A 20-year-old male patient without any medical history of interest visited the department of plastic and reconstructive surgery of Dankook University Hospital with a mass on the middle phalanx of the left index finger (Fig. 1). The mass began to form about 6 years ago and was gradually enlarged; the patient did not have any history of a wound or a mass in the same region. A soft and compressible protruding mass, with a dimension of 1.5×1×1 cm, was observed. Although there was no open wound, the patient complained of pain when pressed. The finger distal to the mass had normal circulation and sensation. Angiography carried out prior to surgery revealed that the mass corresponded to an angioma (Fig. 2). Fig. 1 Clinical photograph of retiform hemangioendothelioma on left index finger. Fig. 2 Arteriography showing increased focal vascularity on the left index finger during the capillary phase. The patient was administered general anesthesia since the mass was located below the dermis and its boundary was not clear; skin was incised vertically over the mass and 3 mm of normal surrounding soft tissue was excised with the mass. During the excision, the mass did not present any signs of infection or inflammation. Following the excision, the size of the mass was 0.5×0.4 cm, which was considerably smaller than the size prior to excision. Histologically, the lesion was not well demarcated and was composed of elongated and branching blood vessels arranged in a retiform pattern (Fig. 3). The blood vessels were lined with hobnail endothelial cells with focal papillary projections. The endothelial cells revealed enlarged nuclei with vesicular chromatin and rare mitosis. Some lymphocytic infiltrate was observed. Immunohistochemically, the endothelial cells were diffusely positive for factor VIII-related antigen (Fig. 4). Fig. 3 (A) Microscopic findings of retiform hemangioendothelioma (H&E, ×200). (B) Diagrammatic representation of the branching blood vessels lined with hobnail endothelial cells with focal papillary projections. RBC, red blood cell. Fig. 4 Microscopic findings of retiform hemangioendothelioma. Endothelial cells were immunoreactive to factor VIII-related antigen (Immunohistochemistry, ×200). The patient was diagnosed with retiform hemangioendothelioma and recovered without complications. However, 2 months after surgery, the tumor had recurred, and the patient was lost to follow-up. Retiform hemangioendothelioma was first considered to be a disease entity separate from low-grade cutaneous angiosarcoma in 1994 [1]. Cutaneous angiosarcoma has a dismal prognosis, with a high incidence of recurrence and metastasis and a high mortality rate [1]. Retiform hemangioendothelioma also has a high local recurrence rate; however, this tumor rarely metastasizes, and no tumor-related deaths have been reported to date [2,3]. Although retiform hemangioendothelioma occurs across a diverse age range, it is most common in young or middle-aged adults, with a greater frequency in females [1,3]. It mostly occurs in the limbs, with a higher incidence in the lower limbs [1,3]. But in the trunk, head, and penis, cases occasionally occur [1,3]. Retiform hemangioendothelioma mostly occurs as an asymptomatic, slow-growing single lesion [3]. However multiple, rapid-growing cases have been reported [3,4]. The duration of lesion varies between 2 months to several years [3]. Most cases are presented as exophytic, dermal, or subcutaneous nodules or plaques with a size range of 1 to 30 cm [3]. The etiology of retiform hemangioendothelioma remains unknown. However several reports have proposed its association with human herpesvirus-8, lymphedema, previous radiation treatment, and non-epidermal malignant tumors [1,2]. Local recurrence is observed in almost half of all cases of retiform hemangioendothelioma [3]. A single case of localized lymph node metastasis and one case of soft tissue metastasis have been described, but there have been no reports of remote metastasis or death clearly related to the mass [2,3]. As there is no characteristic clinical symptom helpful in diagnosing retiform hemangioendothelioma, biopsy is the only diagnostic method available at present [1,3,5]. The differential diagnosis of retiform hemangioendothelioma includes Dabskas tumor, malignant lymphoma, dermatofibrosarcoma protuberans, bacillary angiomatosis, Kaposis sarcoma, targetoid hemosiderotic hemangioma, and cutaneous angiosarcoma [1-3]. Histologically, retiform hemangioendothelioma is characterized by long arborizing vascular channels lined with hobnail endothelial cells. The vascular channels are arranged in a retiform pattern, which mimics normal rete testis. Prominent stromal lymphocytic infiltrates are often observed. Immunohistochemically, the endothelial cells express endothelial markers such as CD31, CD34, factor VIII, and Ulex europaeus agglutinin-1 [1]. Due to its high incidence of local recurrence, the treatment of choice for retiform hemangioendothelioma is a wide surgical excision with histopathologically tumor-free margins and long-term follow-up is essential. In cases with lymph node metastasis, radiation therapy has been reported to be successful [1]. In addition, in unresectable retiform hemangioendothelioma was successfully treated with low-dose cisplatin and moderate radiotherapy in one case [2]. In summary, retiform hemangioendothelioma is a rare vascular neoplasm of low malignant potential with a high recurrence rate, most often occurring on the extremities of young adults. To our knowledge, this is the first case of retiform hemangioendothelioma reported in Korea.

Orthodromic Transfer of the Temporalis Muscle in Incomplete Facial Nerve Palsy

Background Temporalis muscle transfer produces prompt surgical results with a one-stage operation in facial palsy patients. The orthodromic method is surgically simple, and the vector of muscle action is similar to the temporalis muscle action direction. This article describes transferring temporalis muscle insertion to reconstruct incomplete facial nerve palsy patients. Methods Between August 2009 and November 2011, 6 unilateral incomplete facial nerve palsy patients underwent surgery for orthodromic temporalis muscle transfer. A preauricular incision was performed to expose the mandibular coronoid process. Using a saw, the coronoid process was transected. Three strips of the fascia lata were anchored to the muscle of the nasolabial fold through subcutaneous tunneling. The tension of the strips was adjusted by observing the shape of the nasolabial fold. When optimal tension was achieved, the temporalis muscle was sutured to the strips. The surgical results were assessed by comparing pre- and postoperative photographs. Three independent observers evaluated the photographs. Results The symmetry of the mouth corner was improved in the resting state, and movement of the oral commissure was enhanced in facial animation after surgery. Conclusions The orthodromic transfer of temporalis muscle technique can produce prompt results by applying the natural temporalis muscle vector. This technique preserves residual facial nerve function in incomplete facial nerve palsy patients and produces satisfying cosmetic outcomes without malar muscle bulging, which often occurs in the turn-over technique.

Surgical Management of a Mandible Subcondylar Fracture

Open reduction and anatomic reduction can create better function for the temporomandibular joint, compared with closed treatment in mandible fracture surgery. Therefore, the double miniplate fixation technique via mini-retromandibular incision was used in order to make the most stable fixation when performing subcondylar fracture surgery. Those approaches provide good visualization of the subcondyle from the posterior edge of the ramus, allow the surgeon to work perpendicularly to the fracture, and enable direct fracture management. Understanding the biomechanical load in the fixation of subcondylar fractures is also necessary in order to optimize fixation methods. Therefore, we measured the biomechanical loads of four different plate fixation techniques in the experimental model regarding mandibular subcondylar fractures. It was found that the loads measured in the two-plate fixation group with one dynamic compression plate (DCP) and one adaption plate showed the highest deformation and failure loads among the four fixation groups. The loads measured in the one DCP plate fixation group showed higher deformation and failure loads than the loads measured in the two adaption plate fixation group. Therefore, we conclude that the selection of the high profile plate (DCP) is also important in order to create a stable load in the subcondylar fracture.

Comparative Study of Naugle and Hertel Exophthalmometry in Orbitozygomatic Fracture.

AbstractAccurate perioperative evaluation of enophthalmos is important to determine the adequacy of surgical repair in orbitozygomatic fracture. In this study, the authors evaluated the degree of enophthalmos using Hertel and Naugle exophthalmometry in patients with pure blowout fracture and orbitozygomatic fracture, and compared the results. Fifty patients were divided into 2 groups: pure blowout fracture (Group A: control group, 25 patients) and orbitozygomatic fracture with displaced lateral orbital rim (Group B: experimental group, 25 patients). Hertel and Naugle scales were measured before and 6 months after surgery. The degree of lateral orbital rim advancement was assessed by comparing the difference between the perioperative change of the Hertel and Naugle scales. In Group A, the difference between the pre- and postoperative scales in the 2 exophthalmometry was statistically significant (P < 0.05). In Group B, the Hertel scale increased from −0.20 to −0.16 mm, with an insignificant difference between pre- and postoperative values (P > 0.05) and the Naugle scale increased from −0.88 to −0.20 mm, with a significant difference (P < 0.05). The &Dgr; Hertel scale differed from the &Dgr; Naugle scale by a mean of −0.64 mm, which represents the degree of lateral orbital rim advancement. Naugle exophthalmometry is a more reliable method for evaluation of enophthalmos in lateral orbital rim displaced orbitozygomatic fractures than Hertel exophthalmometry. The degree of lateral orbital rim advancement can be assessed by combined use of the Hertel and Naugle exophthalmometry in orbitozygomatic fractures.

Orbital Wall Restoring Surgery for Inferomedial Blowout Fracture.

AbstractRepairing a large inferomedial blowout fracture remains a challenge to orbital surgeon. The authors restored the fracture using combined transnasal and transorbital approaches using support of both paranasal sinuses. The authors compared surgical results of this novel method with those of the traditional procedure. Of 106 inferomedial blowout fracture patients who underwent surgical treatment between March 2007 and July 2013, 50 patients were selected in our study: 25 patients underwent the traditional procedure as controls, and the other 25 patients underwent orbital wall restoring surgery by our combined approach. Outcomes were evaluated in terms of the orbital volume ratio (OVR) and changes in Hertel scale. The OVR in the experimental group (7.19%) decreased more significantly than in the control group (2.71%) (P < 0.05). In conclusion, the orbit was restored more successfully following orbital wall restoring surgery with dual support than by using the traditional inferomedial blowout fracture procedure.

Orbital wall restoring surgery with resorbable mesh plate

Background Orbital resorbable mesh plates are adequate to use for isolated floor and medial wall fractures with an intact bony buttress, but are not recommended to use for large orbital wall fractures that need load bearing support. The author previously reported an orbital wall restoring surgery that restored the orbital floor to its prior position through the transnasal approach and maintained temporary extraorbital support with a balloon in the maxillary sinus. Extraorbital support could reduce the load applied on the orbital implants in orbital wall restoring surgery and the use of resorbable implants was considered appropriate for the author’s orbital wall restoring technique. Methods A retrospective review was conducted of 31 patients with pure unilateral orbital floor fractures between May 2014 and May 2018. The patients underwent transnasal restoration of the orbital floor through insertion of a resorbable mesh plate and maintenance of temporary balloon support. The surgical results were evaluated by the Hertel scale and a comparison of preoperative and postoperative orbital volume ratio (OVR) values. Results The OVR decreased significantly, by an average of 6.01% (p< 0.05) and the preoperative and postoperative Hertel scale measurements decreased by an average of 0.34 mm with statistical significance (p< 0.05). No complications such as buckling or sagging of the implant occurred among the 31 patients. Conclusion The use of resorbable mesh plate in orbital floor restoration surgery is an effective and safe technique that can reduce implant deformation or complications deriving from the residual permanent implant.