Oleh M. Antonyshyn

Advanced technology in the management of fibrous dysplasia.

BACKGROUNDnThe aim of this paper is to describe the applications of advanced imaging technology in optimising the surgical management of complex craniofacial fibrous dysplasia (FD).nnnMETHODSnPreoperative planning involved a number of advanced technologies. Haptic modelling was used to simulate tumour excision and the design of the osteotomies, on a virtual 3D computerised tomographic (CT) scan. Rapid prototyping was employed in fabricating a physical prototype of the skull, featuring the ideal, symmetrical reconstruction. Tumour extirpation was carried out with the aid of stereotactic navigation. Intraoperatively, resorbable mesh is moulded precisely to the shape of the skull prototype, thereby transferring the surgical simulation to the patient in the operating room. The resorbable mesh serves as a template which guides the shape and spatial orientation of an autologous bone graft reconstruction. Pre- and postoperative volumetric differences were assessed to determine the accuracy of the final results.nnnRESULTSnShort and long term follow-up examinations show excellent cosmetic outcome, with significant restoration of volumetric symmetry.nnnCONCLUSIONSnThe added complexity of using the new technologies increases preoperative planning time, but we believe that this is offset by the improved safety during the resection of the tumours as well as the excellent aesthetic outcomes.

Optimizing Craniofacial Osteotomies: Applications of Haptic and Rapid Prototyping Technology

Craniofacial reconstruction frequently relies on the osteotomy and transposition of skeletal segments. Preplanning of the osteotomies has been greatly simplified with the development of more accurate imaging techniques including 3-dimensional (3D) computed tomographic (CT) scans. More recently the use of rapid prototyping (RP) and the construction of a physical prototype with stereolithography (SL) has allowed the craniofacial surgeon to remotely plan the osteotomy site and position. 1-6 Despite the increased sophistication of preoperative planning, accurate intraoperative implementation of the osteotomy design remains problematic. Precise determination of the optimal spatial position and orientation of the osteotomy segment is difficult, particularly when visualization is restricted or when adjacent anatomical landmarks are unreliable. This problem is addressed very effectively in orthognathic surgery by the use of intraoral splints, which provide a means of transferring the preoperative plan from the dental models to the patient and in guiding osteotomy segment positioning. There is no analogous technique in the zygoma or upper face. This report introduces a simple, reliable system to guide the intraoperative positioning and fixation of osteotomy segments in the upper craniofacial skeleton. It requires initial haptic simulation of the desired reconstruction based on 3D CT images, followed by the fabrication of a custom made resorbable polylactic-co-glycolic acid (PLGA) (Stryker Leibinger Co, Kalamazoo, MI) template to guide osteotomy segment transfer and positioning. This template is constructed on a physical model produced by RP using a 3D printing system.

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.

Acute management of complex midface fractures

Midface fractures rarely occur in isolation and are often a component of a panfacial or maxillary-mandibular fracture pattern. The evolution of open reduction and internal fixation techniques in the treatment of facial fractures over the past 2 decades has supplanted the need for prolonged periods of intermaxillary fixation and facilitated early functional rehabilitation. Appropriate application of the following general principles will minimized morbidity and ensure a return to premorbid facial appearance and occlusion: (1) preoperative imaging with 3-mm axial computed tomography (CT) scans and/or 3-dimensional reconstructions for accurate diagnosis of fracture patterns, (2) adequate surgical exposure, (3) maxillary disimpaction and restoration of premorbid occlusion with intermaxillary fixation, (4) completion of cranial base repair, (5) restoration of midface width and projection by using the zygomatic arch and mandibular dental arch as reference points, (6) restoration of lower facial vertical height, (7) conversion of complex midface fracture into a Le Fort I, (8) bone healing supplemented by primary bone grafting for reconstruction of missing or comminuted buttresses, (9) controlled soft-tissue redraping, and (10) postoperative functional rehabilitation.

Computer Planning for Craniofacial Surgery

The design and execution of reconstructive craniofacial procedures has been greatly enhanced by the application of three-dimensional modeling and rapid prototyping technologies. This chapter discusses the methods and applications of preoperative three-dimensional facial surface simulation and quantitative analysis, rapid prototyping for the generation of patient-specific implants, or molds which allow intraoperative shaping of custom implants in a variety of materials.

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.