Jun Hee Byeon

An analysis of pure blowout fractures and associated ocular symptoms.

AbstractBlowout fractures are one of the commonly occurring facial bone fractures and clinically important, as they may cause serious complications such as diplopia, extraocular movement limitation, and enophthalmos. The purpose of this study was to evaluate the current patient demographics and surgical outcomes of 952 pure blowout fractures from 2 hospitals of the Catholic University of Korea, from 2003 to 2011. The medical records were reviewed according to the cause, fracture site, ocular symptoms, time of operation, and sequela. Male patients outnumbered female patients, and blowout fractures were most often seen in 21- to 30-year-old men. The most common cause was violent assault (40.7%). The medial orbital wall (45.8%) was the most common site, followed by floor (29.4%) and inferomedial wall (24.6%). The most common ocular injury was hyphema. Diplopia was presented in 27.6%; extraocular movement limitation was detected in 12.8% patients, and enophthalmos was encountered in 3.4% patients. Diplopia, extraocular movement limitation, and enophthalmos were significantly improved by surgical repair (P < 0.05). Postoperative complications were persistent diplopia (1.6%) and enophthalmos (0.4%). We surveyed a large series of blowout fracture in the Republic of Korea and recommend this study to serve as an important guideline in treating pure blowout fractures.

Anterior two-thirds calvarial remodelling: operative technique for the correction of metopic synostosis in toddlers.

BACKGROUND Premature closure of the metopic suture results in deformation of the anterior calvarium. Trigonocephaly is expressed in various forms--from a simple midline ridge of the forehead to a severe keel-shaped deformity--often requiring specific surgical correction for aesthetic improvement and cognitive and linguistic function advancement. This article presents a surgical technique used over 5 years to treat trigonocephalic toddlers in Korea. METHODS Retrospective analyses were performed on eight patients with metopic synostosis treated at St. Marys Hospital (Seoul) during 2002-2006. The study included reviews of preoperative and postoperative computed tomography scans, operative techniques, clinical outcomes and complications. Operative techniques included fronto-orbital bandeau tilting after expansion with a midline wedge-bone graft, detriangulation of foreheads with an inward bending at lateral orbital wall, multiple zigzag osteotomy of frontal bone, barrel-stave osteotomy of parietal bone and the occasional application of calcium phosphate cement (BoneSource, Leibinger Inc., Michigan, USA) to refine the forehead shape. RESULTS The average age of the patients at time of surgery--due to late referral to medical care--was 25.1 months. Two patients had concomitant bicoronal synostosis requiring coronal suture resection with anterior two-thirds calvarial reconstruction. The central angle measurements improved from a preoperative average of 118 degrees to 134 degrees ; interorbital distances widened from 18.8mm to 20.9 mm. Mean follow-up was 2.6 years, and no neurological sequelae or other significant complications were encountered. CONCLUSIONS Moderate-to-severe trigonocephaly requires surgical correction involving anterior two-thirds calvarial remodelling with fronto-orbital advancement and frontal-bone remodelling. The described operative approach, especially in toddlers, minimises bone defects by adopting multiple zigzag osteotomy of the frontal bone. This modality results in significant improvements in skull form and high patient/parent satisfaction.

Treatment of sagittal synostosis: Subtotal cranial vault remodelling with right-angled Z-osteotomies

INTRODUCTIONS Sagittal synostosis is the most common type of non-syndromic craniosynostosis with fusion of the sagittal suture. Various techniques have been introduced for the treatment of this irregular calvarial deformity. However, since these methods were not suitable for patients who were aged over 1 year when they were diagnosed with sagittal synostosis, a new approach should be undertaken. PATIENTS AND METHODS Between 2001 and 2005, five patients who were diagnosed with sagittal synostosis, after the age of 1 year, were treated with subtotal cranial vault remodelling. The procedure consisted of right-angled Z-osteotomies in the frontal and parieto-occipital bones, a shortening of the sagittal strut, and barrel-stave osteotomies in the temporal bone. They were undertaken to expand bitemporal diameter and to shorten anteroposterior diameter. RESULTS Cranial index increased from 68.2 to 77.8 immediately after surgery and to 78.4 post-surgery 36 months. Cranial morphologies were satisfactory during follow-up. The main advantage of the procedure is the easy control of fixation angle according to the surgeons preference. There were no major complications including infections or relapses. CONCLUSIONS The treatment goal of sagittal synostosis is to eliminate factors that may impede brain development by assuring an adequate cranial cavity and to maintain an aesthetically acceptable cranial morphology. We obtained functionally and aesthetically favourable results by right-angled Z-osteotomies. Further, our one-staged procedure is safe, especially in patients over the age of 1 year.

Two Cases of Cerebral Salt Wasting Syndrome Developing after Cranial Vault Remodeling in Craniosynostosis Children

Hyponatremia has been recognized as an important postoperative metabolic complication after central nervous system (CNS) operations in children. If not appropriately treated, the postoperative hyponatremia can cause several types of CNS and circulatory disorders such as cerebral edema, increased intracranial pressure. The postoperative hyponatremia after CNS surgery has been considered as one of the underlying causes of the syndrome of inappropriate secretion of antidiuretic hormone (SIADH). In some cases, however, the cerebral salt wasting (CSW) syndrome has been detected. CSW syndrome is far less well-known than SIADH and also different from SIADH in diagnosis and treatment. It causes an increase in urine output and urine sodium after a trauma of CNS and dehydration symptoms. The appropriate treatment of CSW syndrome is opposite the usual treatment of hyponatremia caused by SIADH. The latter is treated with fluid restriction because of the increased level of free water and its dilutional effect causing hyponatremia, whereas the former is treated with fluid and sodium resuscitation because of the unusual loss of high urinary sodium. Early diagnosis and treatment of CSW syndrome after CNS surgery are, therefore, essential. We made a diagnosis of CSW syndrome in two craniosynostosis children manifesting postoperative hyponatremia and supplied them an appropriate amount of water and sodium via intravenous route. The hyponatremia or natricuresis of the children improved and neurologic and circulatory sequelae could be prevented.

Posttraumatic delayed cranio-orbital cerebrospinal fluid leakage: Case report

A 56-year-old man sustained subarachnoid haemorrhage, skull base fracture and multiple facial fractures in a traffic accident. Two weeks later, the patient developed a subperiosteal fluid collection into the orbit of the right side presenting with a progressive proptosis and an increased intraocular pressure. We performed drainage of the fluid on the superior part of the right orbit, followed by a surgical reduction of the facial fractures. The patient had no exophthalmos any longer, whose intraocular pressure was normalised. In conclusion, our case indicates that careful monitoring of clinical signs and a follow-up radiography would be mandatory for patients with craniocerebral trauma despite a lack of the definite symptoms. Clinicians should consider the possibility that the cerebrospinal fluid (CSF) leakage into the orbit might occur in these patients.

Bioabsorbable plates and screws fixation in mandible fractures: clinical retrospective research during a 10-year period.

AbstractWe present the basic guidelines for the safe fixation of a mandible fracture using a bioabsorbable system with less strength than the metallic system based on our 10 years of experience.We conducted a retrospective review of 75 patients who had undergone fixation using a bioabsorbable system for a mandible fracture. We analyzed the method of fixation and the size and thickness of the plates and screws that were selected depending on the mandible’s fracture site.Minor complications including intraoral wound disruptions and infections occurred in 12 (16%) patients, and 2 (2.7%) patients among 10 patients who presented with infections had nonunion; therefore, they underwent replacement of the absorbable system with the titanium system. Bone resorption that was caused by the absorbable plate occurred in 12 (16%) patients.The bioabsorbable system also may be able to replace the metallic system in the fixation of comminuted mandible fractures if further research on the development of the system is supported.

Identifying preoperative factors associated with the postoperative nasal synechia in patients undergoing closed reduction of the nasal bone fracture.

AbstractWe conducted this study to identify preoperative factors that are associated with the postoperative nasal synechiae in patients with nasal bone fracture who underwent closed reduction.In the current single-center, retrospective study, we evaluated the fracture type, septal deviation angle (SDA), synechia scores (SSs) and visual analog scale (VAS) scores through a retrospective review of the medical records and computed tomography scans of 42 patients (n = 42) who had undergone closed reduction for nasal bone fracture at our medical institution during a period ranging from April to August 2013.The mean SS was significantly lower in the plane I group (n = 25) as compared with the plane II group (n = 17) (1.28 ± 1.77 vs 2.76 ± 1.89, P = 0.013). There was a significant positive correlation between the SDA and the SS with a formula of SS = 0.216SDA − 0.322 (r2 = 0.532, P < 0.001) and between the SS and the VAS with a formula of VAS = 1.280SS + 0.612 (r2 = 0.648, P < 0.001). Both the SS and VAS were significantly higher on the convex side as compared with the concave side of the nasal cavity.Our results indicate that patients with higher SDA or combined septal fractures might be at increased risks of developing the postoperative synechiae. Further large-scale, prospective studies are warranted to establish our results.

Orbital dystopia due to orbital roof defect.

Abstract We performed a retrospective review of patients who presented with delayed dystopia as a consequence of an orbital roof defect due to fractures and nontraumatic causes to search for a correlation between orbital roof defect size and surgical indications for the treatment thereof. Retrospective analyses were performed in 7 patients, all of whom presented with delayed dystopia due to orbital roof defects, between January 2001 and June 2011. The causes of orbital roof defects were displaced orbital roof fractures (5 cases), tumor (1 case), and congenital sphenoid dysplasia (1 case). All 7 patients had initially been treated conservatively and later presented with significant dystopia. The sizes of the defects were calculated on computed tomographic scans. Among the 7 patients, aspiration of cerebrospinal fluid, which caused ocular symptoms, in 1 patient with minimal displaced orbital roof and reconstruction with calvarial bone, titanium micromesh, or Medpor in 6 other patients were performed. The minimal size of the orbital roof in patients who underwent orbital roof reconstruction was 1.2 cm (defect height) × 1.0 cm (defect length), 0.94 cm2. For all patients with orbital dystopia, displacement of the globe was corrected without any complications, regardless of whether the patient was evaluated grossly or by radiology. In this retrospective study, continuous monitoring of clinical signs and active surgical management should be considered for cases in which an orbital roof defect is detected, even if no definite symptoms are noted, to prevent delayed sequelae.

Skeletal cavernous hemangiomas of the frontal bone with orbital roof and rim involvement

Skeletal cavernous hemangiomas are rare, benign tumors that may involve the supraorbital rim and orbital roof. However, such involvement is extremely rare. We report a case of skeletal cavernous hemangioma of the frontal bone involving the orbital roof and rim. En bloc excision and reconstruction, using a calvarial bone graft for the orbital roof and rim defect, was performed. It is important not only to perform total excision of skeletal cavernous hemangiomas, but to properly reconstruct the defects after the total excision since several complications can arise from an orbital roof and rim defect.

Endotine Midface for Soft Tissue Suspension in Zygoma Fracture.

Abstract Treatment of zygomatic fractures necessitates dissection beneath the soft tissues of the cheek. Inadequate resuspension may lead to deformities, including cheek ptosis, lower lid ectropion, and lateral canthal dystopia. The authors present their experience using a biodegradable suspension device for cheek flap resuspension. Patients who received open reduction for unilateral zygomatic fracture between January, 2006 and December, 2013 at a single center were included in the study. Patients could choose whether or not to have Endotine midface inserted. Patients rated satisfaction on facial symmetry. Computed tomography (CT) at 15 months was assessed for soft tissue thickness at the level of the midpoint of the nasolabial fold on each side. Photographs at 15 months were viewed by 3 blinded plastic surgeons and rated for cheek drooping. The results for all 3 parameters were compared between the Endotine group and the control group. A total of 83 patients were included (43 in the Endotine group and 39 in the control group). Patient satisfaction scores were statistically higher (P = 0.03) in the Endotine group (3.70 ± 0.76) than the control group (2.85 ± 0.96). Computed tomography soft tissue thickness score ratio between affected and unaffected side was significantly lower (P < 0.001) in the Endotine group than the ratio in the control group. Photography evaluation score difference between affected and unaffected side for the Endotine group (0.70 ± 0.77) was significantly (P = 0.041) smaller than the control group (1.92 ± 1.24). Endotine midface is easy to apply and effective in repositioning the elevated cheek flap in zygomatic fracture patients.