Craniofacial Tumors Research Articles

Application of intraoperative CT in oral and maxillofacial surgery

With the introduction of the concept of precision surgery and the development of modern compound operating rooms, intraoperative computerized tomography (ICT) came into being. Due to the multidisciplinary nature of ICT, its use in oral and maxillofacial surgery has also been increasing in recent years. This article describes the application of ICT in oral and maxillofacial trauma, orthognathic surgery, and craniofacial tumor treatment, and analyzes its advantages and limitations.

Risk factors for metastasis at presentation with conventional chondrosarcoma: a population-based study

The aim of the study was to investigate risk factors for metastasis at diagnosis. We collected patients diagnosed with conventional chondrosarcoma between 1983 and 2014 from the Surveillance, Epidemiology, and End Results (SEER) database. Each patient was classified as having metastatic or localized disease. Univariate and multivariate logistic regression analyses were applied to determine which characteristics were risk factors for metastasis at diagnosis. Two thousand three hundred forty-nine patients were collected and 180 patients had metastasis at presentation. Data on age, gender, primary site, grade, and tumour size were enrolled into the multivariate logistic analysis. Greater age (60years or older: OR = 1.872, 95% CI, 1.206 to 2.904), axial or craniofacial location (spine: OR = 1.775, 95% CI, 1.188 to 2.651; thoracic cage: OR = 2.034, 95% CI, 1.321 to 3.134; craniofacial bones: OR = 5.507, 95% CI, 3.001 to 10.107), higher grade (grade II: OR = 1.849, 95%CI, 1.181 to 2.895; grade III: OR = 4.016, 95%CI, 2.513 to 6.418), and larger tumour size (size over 10cm: OR = 7.135, 95%CI, 2.130 to 23.893) were associated with an increased risk of metastasis at presentation. Conventional chondrosarcoma patients with greater age, axial or craniofacial tumour location, higher grade, and larger tumor size were more likely to have metastasis at diagnosis.

Anterior Skull Base Tumors: The Role of Transfacial Approaches in the Endoscopic Era.

The basis of craniofacial tumor surgery is complete surgical extirpation, preferably en bloc or with free borders. Craniofacial techniques are the gold standard and primary strategies in the treatment of anterior skull base tumors. In the last decade, the reports favoring results of endoscopic techniques have increased. One could conclude that the classical transfacial approaches might become useless, but, in fact, there is little research comparing these techniques.In this article, the authors present their experience with combined craniofacial resection of anterior craniofacial skull base tumors in 9 consecutive patients between January 2013 and July 2015. This article aims to review some of the traditional transfacial approaches, illustrating them with this series of surgical patients. Benefits and drawbacks of these approaches are discussed.

Erratum to: Long-term success of dental implant-supported dentures in postirradiated patients treated for neoplasms of the maxillofacial skeleton: a retrospective study.

The reconstruction of oral function in irradiated patients with craniofacial tumors is a significant challenge. The aim of this study was to detect long-term success of dental implant-supported dentures in postirradiated patients treated for neoplasms of the maxillofacial skeleton. From 2004 to 2011, 36 irradiated patients underwent oral function reconstruction using implant-supported prostheses. Bone augmentation was completed using vascularized bone grafts in 22 patients. Fourteen patients were treated by hyperbaric oxygen therapy (HBO). A total of 198 dental implants were used in jaw rehabilitation. After loading, implant success rates, biological and prosthetic complications, patient satisfaction, and psychological changes were recorded. Bone augmentation of the jaw was successful and vascularized grafts provided an additional vascular supply in compromised irradiated tissue. Rehabilitation was successful in all of the patients after loading. Thirty-eight dental implants failed, and 35 implants were removed. The success rate of the implants was 93.6 % for 10 years after loading. It was not a significant difference in implant success rate between the HBO group and the other groups. The prosthodontic maintenance results and complication rates showed that patients required intervention 0.19 times per year. All patients were satisfied with the oral restoration results. The restoration of oral function in radiotherapy patients with tumor resection using implant-supported prostheses is a viable treatment option. Either alone or in combination with HBO, dental implant-supported prostheses can be used an effective therapeutic approach for irradiated patients with oral function reconstruction.

Coronal Incision: An Approach to Facial Fractures

Background: The coronal incision with its various modifications provides the most versatile approach to various areas in the cranio-maxillofacial region coupled with excellent exposure. The aesthetic advantage of a hidden scar in the hairline, accounts for its continued popularity. In maxillofacial it can be used for fractures in the frontal bone, nasal bone and extensive fractures involving zygomatic arch and complex Methods: In this clinical and observational study, we operated 5 patients with complex cranio-maxillofacial injuries involving frontal bone, zygomatic arch and zygomatic complex, nasal bone and supra-orbital region. All the five cases were trauma cases between ages of 20 to 60 years with no facial nerve injury per-operatively. These cases for followed for post-operative complications namely sensory and motor nerve deficits, haematoma, wound dehiscence and ptosis Result: Two patients each had sensory and motor nerve deficits and one patient had minimal wound dehiscence, all settled conservatively Conclusion: The incision provides excellent access, has reduced complications and produces an acceptable scar. This incision is advised in treating complex cranio-facial trauma, tumors and le-fort esthetic surgeries. DOI: 10.21276/AABS.1430

Indication for and Limitation of the Facial Dismasking Flap Approach for Skull Base Surgery to Achieve the Best Esthetical and Functional Results.

The facial dismasking flap (FDF) approach to operations on the deep skull base region consists of a coronal incision and a circumpalpebral incision. This approach provides a wide surgical field for extirpation of deep extended craniofacial tumors without leaving any undesirable scars on the face. Therefore, the FDF approach can provide satisfactory esthetical and functional results. Meanwhile, in some cases, especially in patients with a history of skull base surgery or orbital extension, patients are not fully satisfied even when the FDF approach is used. In this study, we evaluated the indication for and limitation of the FDF approach. We reviewed 26 patients who underwent the FDF approach for skull base surgery. The patients were 16 men and 10 women, and average age was 37 years. Of these patients, 21 were treated using a hemi-FDF approach, and the remaining 5 were subjected to a bilateral FDF approach. Patients were divided into 2 groups in this study: group A (11 patients), patients with no history of skull base surgery and orbital extension; and group B (15 patients), patients with a history of skull base surgery and/or orbital extension. There was no FDF loss or facial palsy in either group A or group B. In group A, there was no lagophthalmos or scar contracture of the eyelid. In group B, there were 5 cases (33%) of ectropion and lagophthalmos and 7 of eyelid scar contracture (46%). As for esthetical evaluation, group B showed a significantly higher rate of facial asymmetry than group A. Moreover, in group A, the total ratings for above average reached 90.9%, whereas in group B, nearly half of the patients (48.9%) gave ratings of fair and poor. The FDF approach could be a good option for skull base surgery. In particular, patients without a history of skull base surgery and orbital extension could obtain satisfactory esthetical and functional outcomes. However, the procedure had limited effectiveness for patients with a history of skull base surgery or orbital extension because esthetical and functional outcomes inevitably became worse.

Closure of Large, Secondary Skull Base Defect following Craniofacial Tumor Resection and Adjuvant Chemoradiation Therapy Using a Free, Microvascularly Anastomosed Radial Forearm Fascial Graft: A Case Report

Objective: Secondary skull base defects with persistent CSF leak following ablative surgery and tissue irradiation pose a major threat to the patients concerned, as well as a true challenge for the treating surgical team.

Melanotic neuroectodermal tumor of infancy

Melanotic neuroectodermal tumor of infancy (MNTI) is a rare pigmented craniofacial tumor of newborns and infants. We report the imaging findings of a 3-month old male patient with a maxillary MNTI. Detailed discussion on imaging features on various magnetic resonance sequences and CT scan are included. Characteristic radiographic appearance is also described. MNTI, of neural crest origin, display a biphasic population of melanin containing cells and neuroblastic cells, within a moderately vascularized fibrous stroma. The child underwent complete surgical excision with no evidence of recurrence at one year follow up. MNTI is an unusual tumor occurring in early childhood with a predilection for the maxilla. Clinical findings, CT scan and MRI may allow a preoperative diagnosis.

Fontal Sinus Osteoma: A Huge Craniofacial Tumor Preoperative Planning and Strategy of Surgical Excision and Reconstruction

Osteomas are the most common fibro-osseous lesions in the paranasal sinus. They are benign tumors characterized by slow growth and are often asymptomatic. Treatment is indicated in sphenoid osteomas that threaten the optic canal or orbital apex and in symptomatic cases. We report a case of a giant frontal sinus osteoma with orbital invasion treated by a combined open craniofacial approach with reconstruction of the anterior cranial base and orbital walls. Immediate reconstruction allows aesthetic and functional restoration of neighboring structures, which should one of the goals in the treatment of this benign entity. The literature is reviewed and aetiopathogenic theories, diagnostic procedures and surgical approaches are discussed. The choice of surgical management depends on the location, size and experience of the surgeon. An open approach allows tumor removal with direct visual control and remains the best option in large tumors, but the continued progression in endoscopic approaches is responsible for new indications in closed techniques.

Long-term success of dental implant-supported dentures in postirradiated patients treated for neoplasms of the maxillofacial skeleton: a retrospective study.

The reconstruction of oral function in irradiated patients with craniofacial tumors is a significant challenge. The aim of this study was to detect long-term success of dental implant-supported dentures in postirradiated patients treated for neoplasms of the maxillofacial skeleton. From 2004 to 2011, 36 irradiated patients underwent oral function reconstruction using implant-supported prostheses. Bone augmentation was completed using vascularized bone grafts in 22 patients. Fourteen patients were treated by hyperbaric oxygen therapy (HBO). A total of 198 dental implants were used in jaw rehabilitation. After loading, implant success rates, biological and prosthetic complications, patient satisfaction, and psychological changes were recorded. Bone augmentation of the jaw was successful and vascularized grafts provided an additional vascular supply in compromised irradiated tissue. Rehabilitation was successful in all of the patients after loading. Thirty-eight dental implants failed, and 35 implants were removed. The success rate of the implants was 93.6% for 10years after loading. It was not a significant difference in implant success rate between the HBO group and the other groups. The prosthodontic maintenance results and complication rates showed that patients required intervention 0.19 times per year. All patients were satisfied with the oral restoration results. The restoration of oral function in radiotherapy patients with tumor resection using implant-supported prostheses is a viable treatment option. Either alone or in combination with HBO, dental implant-supported prostheses can be used an effective therapeutic approach for irradiated patients with oral function reconstruction.

Extended orbital exenteration for sinonasal malignancy with orbital apex extension: surgical technique and clinical analysis.

The majority of sinonasal malignancies present with advanced disease, and cure rates are generally poor. Surgical extirpation remains the mainstay of treatment. In cases of sinonasal malignancy with orbital apex extension, gross-total tumor resection requires orbital exenteration and bony skull base resection around the orbital apex to provide sufficient margins. In this retrospective study, the authors describe their surgical strategy in and technique for orbital exenteration with orbital apex resection in patients at Tokyo Medical and Dental University who had sinonasal malignancy with orbital apex extension. They also analyzed the clinical features of and the results in these patients. Between February 2001 and August 2012 at the authors' institution, sinonasal malignancy with orbital apex extension was treated using craniofacial tumor resection with orbital exenteration including skull base bone around the orbital apex. The authors describe this technique and analyze the surgical indications, extent of resection, primary tumor location, outcome, pathological findings, and neoadjuvant and adjuvant therapies of the patients who underwent the technique. The patients consisted of 12 men and 3 women with a mean age of 47.7 years (range 14-79 years). The longest postoperative follow-up was 9.5 years, and the shortest was 0.67 year (mean 3.0 years). Tumor originated at the ethmoid sinus in 6 patients (40%), maxillary sinus in 5 (33%), nasal cavity in 2 (13%), and orbital cavity and maxillary bone in 1 patient each (7%). Histological analysis of tumor specimens revealed squamous cell carcinoma in 9 patients (60%), rhabdomyosarcoma in 2 (13%), and small cell carcinoma, mucoepidermoid carcinoma, adenoid cystic carcinoma, and Ewing sarcoma in 1 patient each (7%). Two patients experienced recurrences at 1 and 5 months after treatment; these patients died at 5 and 10 months after surgery, respectively. Estimated 5-year recurrence-free survival (RFS) was 86.7%, and estimated 5-year overall survival (OS) was 86.2%; there was no perioperative mortality. None of the patients had new neurological deficits as a result of the surgery, but 5 patients suffered infectious complications from the graft transplanted into the cavity after resection. There were no other perioperative complications. These authors are the first to describe a technique for extended orbital exenteration with orbital apex skull base resection. The technique provided sufficient margins for gross-total resection of the sinonasal malignancy with orbital apex extension. The estimated 5-year OS and RFS rates were high, and the perioperative complication rate was acceptably low, demonstrating the safety and efficacy of this technique.

The role of evaluation of craniofacial tumor blood supply in the planning of surgical treatment

The role of evaluation of craniofacial tumor blood supply in the planning of surgical treatment

Prognostic criteria of patients’ survival at malignant craniofacial tumors

Introduction. Taking into account that malignant tumors often recur, determining prognostically significant criteria makes it possible to improve the treatment strategy, justify the indications for surgery, and to increase the overall patients’ survival. Materials and methods. In a period from 2002 to 2012 treatment results of 133 patients with malignant craniofacial tumors were analyzed. Results. Study of intracranial or sometimes intracerebral spread of malignancies, dura mater invasion or concretion, as well as resection are the basis of prognostic factors in surgery of craniofacial tumors. It was found that the patients’ survival rates did not depend on these factors and the histological type of the tumor. They depend upon such factors as disease duration, patient’s age, tumor invasion, growth of tumor tissue around the eye hole. 3 years survival was 53%, 5 years — 38%. After surgery all patients were alive. Complications occurred in 19 (14%) patients. Conclusion. Accounting for prognostic factors gives an opportunity to increase overall survival rates, to reduce the incidence of postoperative complications, avoid postoperative mortality.

Primary dural closure and anterior cranial base reconstruction using pericranial and nasoseptal multi-layered flaps in endoscopic-assisted skull base surgery.

Dural and anterior cranial base reconstruction is essential in the surgical resection of a craniofacial tumor that extends from the paranasal sinuses to the subdural space. Watertight reconstruction of vascularized tissue is essential to prevent postoperative liquorrhea, especially under conditions that prevent wound healing (e.g., postoperative irradiation therapy). We successfully treated two cases of olfactory neuroblastoma by endoscopic-assisted craniotomy with primary dural closure and anterior cranial base reconstruction using a multi-layered flap technique. Dural defects were closed using temporal fascia or fascia lata in a conventional fashion, immediately after detaching the subdural tumor, in order to isolate and prevent contamination of subdural components and cerebrospinal fluid (CSF) from the tumor and nasal sinuses. Tumor removal and anterior cranial base reconstruction were performed without any concern of CSF contamination after dural closure by craniotomy and endoscopic endonasal approach (EEA). Vascularized pericranial flaps (PCF) and nasoseptal flaps (NSF) were used simultaneously as doubled-over layers for reconstruction. The tumor was completely removed macroscopically and the anterior cranial base was reconstructed in both cases. CSF leak and postoperative meningitis were absent. Postoperative and irradiation therapy courses were successful and uneventful. This multi-layered anterior cranial base reconstruction consisted of three layers: a fascia for dural plasty and double-layered PCF and NSF. This surgical reconstruction technique is suitable to treat craniofacial tumors extending into the subdural space through the anterior cranial base dura mater.

Neuroimaging of Langerhans cell histiocytosis: a radiological review

The neuroimaging of Langerhans cell histiocytosis (LCH), in most of the cases, is nonspecific and can vary depending on the location, especially as shown on magnetic resonance imaging (MRI). In the absence of a clinical history of LCH, isolated central nervous system (CNS) lesion presents a diagnostic challenge. LCH should be considered in the differential diagnosis of craniofacial tumors and neurodegenerative (ND) lesions of the brain. MRI is the modality of choice for investigating the CNS-LCH. Long-term follow-up with MRI is indicated in patients with ND-LCH. This retrospective study provides a comprehensive description of the spectrum of neuroimaging findings in patients with LCH, the underlying neuropathology, and follow-up study of the disease.

Surgery minimizing at median craniofacial tumors

Introduction. For surgery minimizing at median craniofacial tumors subcranial surgery is used, in particular endoscopic endonasal surgery or subcranial approach (via frontal sinus).Materials and methods. In 93 patients with malignant craniofacial tumors anterior craniofacial resections was performed: in 63 patients — bifrontal, in 30 — subcranial approach. Histological form and intracranial spread of the tumors was identical in both groups.Results. Total removal when applying subcranial and bifrontal approach differed slightly (respectively 63 and 68%). Indexes of cancer survival do not show significant differences depending on surgical approach (P>0.0500). Postoperative complications were observed more often after bifrontal approach — in 15% patients than after subcranial approach — in 8%. General condition improving was observed in both groups, but after subcranial approach it was significant.Conclusions. Effectiveness of the subcranial approach is similar to that of bifrontal one by surgery radicalism and indexes of overall survival in patients been operated because of malignant craniofacial tumors. At the same time, subcranial surgery of skull base malignant neoplasm is associated with lower frequency of postoperative complications (in our study, twice) and best patients’ state (according to Karnofsky scale).

Fibrous Dysplasia of the Zygomaticomaxillary Region

Fibrous dysplasia is the most common craniofacial tumor, presenting in both monostotic and polyostotic forms with varying degrees of severity. No consensus exists regarding the surgical management of craniofacial fibrous dysplasia, particularly in the zygomaticomaxillary region. The present study compared long-term outcomes of limited reduction burring versus radical resection of zygomaticomaxillary fibrous dysplasia. Patients with craniofacial fibrous dysplasia at the University of California, Los Angeles, Craniofacial Center from 1982 to 2008 were studied based on demographics, treatment, and follow-up data, including examinations, computed tomographic scans, photographs, physician Whitaker scoring, and patient surveys (n=97). Outcomes were compared for zygomaticomaxillary disease treated with radical resection with cranial bone graft reconstruction or limited reduction burring (n=58). Thirty-four percent of patients had monostotic disease, 66 percent had polyostotic disease, 3 percent had McCune-Albright syndrome, and 2.1 percent had malignant degeneration into osteosarcoma. Most patients had surgical treatment (84.5 percent). Of the patients that required optic nerve decompression for vision changes (11.4 percent), most (75 percent) had vision stabilization postoperatively. Differences were recorded in zygomaticomaxillary disease treated with radical resection (63.8 percent) versus reduction burring (36.2 percent) according to age (19.6 versus 14.2 years), complications (13.5 percent versus 4.8 percent), recurrence (66.7 percent versus 24.3 percent), and number of subsequent procedures (2.8 versus 4.0). There were similarities in Whitaker outcome score (1.3±0.3 versus 1.5±0.6) and patient satisfaction (2.7±0.4 versus 2.8±0.3). Although different approaches have been advocated to treat fibrous dysplasia, the authors' data support a more aggressive management for zygomaticomaxillary disease with radical resection and cranial bone graft reconstruction, especially for more involved disease. CLINICAL QUESTION OF EVIDENCE: Therapeutic, III.

Double flap technique for reconstruction of anterior skull base defects after craniofacial tumor resection: technical note

Successful reconstruction of large anterior skull base (ASB) defects after craniofacial resection of malignant skull base tumors is paramount for preventing cerebrospinal fluid (CSF) fistulas. The vascularized pedicled pericranial flap (PCF) has been the gold standard for repairing ASB defects after transbasal transcranial approaches. However, flap necrosis and delayed CSF leaks can occur after adjuvant radiation therapy. We describe a "double flap" reconstruction technique in which the PCF is augmented inferiorly by a secondary vascularized pedicled nasoseptal flap (NSF) that is harvested and rotated using an endoscopic endonasal approach. This technique is illustrated in 2 patients who underwent a combined cranionasal (transbasal and endoscopic endonasal) approach for large sinonasal malignancies with significant intracranial extension (1 esthesioneuroblastoma, 1 sinonasal teratocarcinosarcoma). After tumor removal via a combined cranionasal approach, primary repair of the ASB dural defect was performed with a free patch graft. The ASB defect was then repaired using the double flap technique with a vascularized PCF from above and augmented with a vascularized NSF from below. Postoperatively, there were no complications of CSF leakage, meningitis, or tension pneumocephalus in both patients. After subsequent radiation therapy, the double flap repair remained intact at 2 years postoperatively in both patients. The double flap skull base reconstruction technique provides an additional barrier of vascularized tissue to prevent CSF leakage, meningitis, tension pneumocephalus, and postradiation necrosis. This technique is a viable option if a combined transcranial and transnasal endoscopic tumor resection is performed and postoperative radiation is anticipated.

Free Anterolateral Thigh Flap for Reconstruction of Complex Craniofacial Defects After Resection of Tumors of the Fronto-Orbitomaxillary Complex

Tumors of the fronto-orbitomaxillary segment are complex and pose a significant challenge for radical resection and subsequent reconstruction. With evolution in surgical reconstructive techniques, better reconstruction of these complex defects is now possible and facilitates more aggressive surgical management. The anterolateral thigh (ALT) flap has features particularly suited for this reconstruction. We review our single institutional experience with this technique. Sixteen consecutive patients with defects of the fronto-orbitomaxillary segment (from radical resection of craniofacial tumors of this region) were reconstructed using the free ALT flap. The demographic features, radiology, histology, and surgical technique as well as the perioperative events were reviewed retrospectively from a prospective database of all craniofacial resections performed. There were 9 males and 7 females with a mean age of 35 years. Eleven had previously undergone surgery. Dura was resected in 6 and inadvertently breached in another 2. Gross total resection was achieved in 14 (87.5%) of the 16 patients, of which 8 had microscopically negative margins. Thirteen musculocutaneous flaps and 3 chimeric flaps were performed. The mean duration of surgery was 9.4 hours. The average total blood loss was 2000 mL. There was no perioperative mortality. Major complications occurred in 2 patients in the form of venous thrombosis on the next day of surgery. These were detected and salvaged promptly by urgent re-exploration and redo of venous anastomosis, ultimately requiring skin grafting for partial flap loss. In our experience, the free ALT flap is a suitable reconstructive choice for complex craniofacial defects and has favorable results.

Advances and Innovations in Computer-Assisted Head and Neck Oncologic Surgery

Over the past years, computer-assisted surgery has gained more importance in craniomaxillofacial surgery, especially in primary and secondary treatment of head and neck malignancies. The basis for oncologic treatment of the head and neck region requires detailed planning using computed tomography, cone-beam computed tomography, or magnetic resonance imaging in combination with computer-assisted, infrared-based navigation system. These techniques allow a preplanned image-guided path to the tumor region for taking biopsies, resection, or reconstruction. The aim of this work was to show the advances and technical benefits for tumor surgery in a daily clinical routine from the view of the craniomaxillofacial surgeon. The target of our working group was to develop and clinically evaluate a novel three-dimensional planning and navigation software solution for treatment of craniofacial tumors. This work was carried out on 5 categories for oncologic surgical procedures in which computer-assisted surgery was applied from 2005 to 2011: preplanned trajectorial-guided tumor biopsy, intraoperative image-controlled tumor resection, tumor mapping, reconstruction after tumor surgery (true to original), and oral rehabilitation (backward planning). Successful preoperative planning, import of image data suitable for navigation, and intraoperative precise infrared-based navigation were obtained for all 5 categories without any complications. Image-guided navigation technique for head and neck oncologic surgery provides a precise, safe surgical method with real-time excellent anatomic orientation. Regarding the advantages of computer-assisted surgery, this technique will play a major part in craniofacial reconstructive surgery and will address widespread general methodologic solutions that are of great interest in multidisciplinary oncologic treatment.