Vertical Dystopia Research Articles

A clinical prospective study on the surgical management of zygomatico-maxillary complex fractures using two-point fixation

The ZMC fractures are one of the most frequently occurring maxillofacial injuries due to its prominence and facial contour. The ZMC forms a principle buttress of face and helps transmit occlusal forces to skull base. Fracture of zygomatic bone leads aesthetic and functional deformity. Restoration to premorbid condition is most predictable by ORIF. In this study was to evaluate efficacy of two-point internal fixation using conventional miniplates and screws for ZMC fractures. 35 patients with established unilateral isolated ZMC fractures were operated using two-point fixation method i.e. the maxillary buttress and the fronto-zygomatic suture, followed up for 3 months. Patients were assessed clinically and radiographically at different follow up intervals. Charts of patients were reviewed for age, gender, etiology, malar height analysis and vertical dystopia. 35 patients in this study, underwent ORIF under GA with two-point fixation. Preoperatively, mean malar height of the patients recorded was 66.55 ± 3.02. There was a significant increase in malar height postoperatively (P < 0.0001). 70.24 ± 2.05, at 1st week, and 69.87 ± 1.98. in 3rd and 6th weeks. Preoperatively, mean vertical dystopia of patients was 2.24 ± 0.71. Postoperative resolution of vertical dystopia was statistically significant (P<0.0001), with value of 0.52 ± 0.52.Integrity of ZMC is important in maintenance of normal facial width and prominence of cheek. Two‑point fixation shows satisfactory results functionally, esthetically and also provides additional advantage by eliminating another surgical site. Thus we conclude that our study provides a basis for further research.

Sphenoid dysplasia in patients with neurofibromatosis type 1: Clinical features and imaging findings including cerebrospinal fluid alterations.

Neurofibromatosis Type 1 (NF-1) is a genetic disorder that occurs in 1:2500-3000 live births and may involve multiple organs. An uncommon but well-known phenomena is sphenoid dysplasia, which appears in 3-11% of the patients, and may result in significant lowering of the orbit. Understanding the cause and development of this process might predict its course and its treatment. The records of 29 patients with PNF in the head and neck region were searched for location of the PNF and type of surgery. Photographs were studied for facial disturbances, including vertical dystopia, hypertelorism, ptosis, exophthalmos and enophthalmos. MR and CT scans were studied for the presence of PNF, aspect of the sphenoid bone, alteration in the CSF circulation, and other tumour involvement. Fourteen of 29 patients with PNF in the head and neck presented with sphenoid dysplasia. All 14 patients had their PNF located in the periorbital region. Increased locoregional CSF collections were seen in almost all of these patients. Besides glioma of the optical nerve or hamartomas in the cerebrum and cerebellum, there were no other tumours found. Surgical treatment varies from simple excision to excessive debulking of the PNF, reconstruction of the orbit and even enucleation. Although sphenoid dysplasia is uncommon in NF-1 patients, early recognition is important to prevent facial disfigurement and vision loss. Clinicians should be aware that abnormalities in the periorbital region and especially vertical dystopia might be the first sign of sphenoid dysplasia. Performing a CT or black-bone MR scan would be the next step to confirm or exclude sphenoid dysplasia and abnormal CSF dynamics.

Extensive and Advanced Craniofacial Dysplasia

A 35-year-old Syrian patient presented to our department complaining of 7-year history of asymptomatic hard swelling in right side of the frontotemporal and naso-orbito-ethmoidal region, reaching the contralateral side (Panels A and B). Patient stated that from 1 year back his visual acuity has been decreased compared with the previous 6 years. Computed tomography (CT) with contrast (Panels C–F) showed diffuse bony expansion involving the frontal bones bilaterally. Bone expansion was more on the right side extending into the vertical plates as well as the horizontal plates forming the roof extending to involve the cribriform plates and into the crista galli extending posteriorly to involve the sphenoid bone including the body, greater and lesser wings of the sphenoid bone as well as the clinoid processes ends extending to the roots of the pterygoid plates. Multidisciplinary decision team meeting was done, with neurosurgery, anesthesiology, and maxillofacial surgery to decide the treatment. Under the general anesthesia the patient underwent remodeling and recontouring of the facial and cranial bones through bilateral occipital approach. Using the unilateral fronto-temporal extradural approach and retracting the dura and reaching the base of the skull the anterior clinoidectomy for optic nerve decompression was performed. Right clinoid process surgery reshaped the base of the skull releasing the bone which compressed the right orbital nerve. Affected bone which involved the frontotemporal area was removed and reconstruction was performed with cranioplasty fixed with osteosynthesis to the adjacent and healthy bony structures. The resected bone was submitted to Hamad general hospital histopathology laboratory which reported following fixation and decalcification irregular shaped trabeculae of immature woven bone scattered in a loosely hypercellular stroma histopathological diagnosed as fibrous dysplasia (Panels G and H: H&E staining). After 5 days of medical management as inpatient, the patient was discharge with close follow up. Patient was followed up in a weekly basis with a normal postoperative status. 5 months after the surgery (Panel I, photography on postoperative day 120 showed remanent dystopia but generalized acceptable craniofacial projection), patient stated to have improvement in his visual acuity compared to his base line as well as craniofacial projection with a remanent vertical dystopia. Panels J and K compare preoperative CT (Panel J) where anterior clinoid process involved with the pathology is noted and postoperative CT (Panel K) which reveals removal of anterior clinoid process for orbital nerve decompression.

Functional recovery of neurological deficit among patients with Orbital Fracture due to Craniofacial Traumas

Background: With recent development in imaging and bone fixation technology, the orbital fracture is now considered an emerging reconstruction technique for the fixation of even the most severe injuries. This study aims to explore the success rate of functional recovery through different orbital approaches in orbital fractures and reconstruction in patients having craniofacial injuries with clinical and neurological deficits.
 Methodology: This observational study was conducted from 2016 to 2018, at the Department of Neurosurgery, Liaquat University of Medical & Health Sciences (LUMHS). A total number of 30 patients were enrolled through consecutive sampling. The patients with any clinical and neurological deficit were included in this study, while the patients with craniofacial fractures with comorbidities were excluded. The evaluation of clinical and neurological deficits in the admitted patients was noted pre-operatively and re-assessment of the same deficit postoperatively was done during the tenure of 1-6 months. All orbital floor fractures were approached via a sub-ciliary or transconjunctival incision with a supraciliary approach used for all supra orbital injuries. The reconstruction of the fracture was done within 5 to 10 days of admission.
 Results: A total of 30 patients underwent surgery for the repair of an orbital floor fracture. The mean age observed was 32.09±10.36 years. The patient age range was 20-50 years. Among the patients 22 (73.3.0%) were male and 8(26.7%) patients were female. The improvement of symptoms observed after surgical intervention includes sub-ciliary approach that resides the recovery of diplopia (95%), paraesthesia (75%), enophthalmos (100%) and vertical Dystopia (100%). On the other hand, trans-conjuctival approach resides in the recovery of diplopia (95%), paraesthesia (100%), enophthalmos (100%) and vertical Dystopia (100%).
 Conclusion: It is concluded that the surgical treatment of orbital fracture shows promising results in the recovery of neurological deficit among patients with crani-o-facial injuries. Moreover, the trans-conjuctival approach holds much promising results in the improvement of infra-orbital para-aesthesia (100%) as compared to the sub-ciliary approach (75%).

Does initial reduction at infra-orbital rim first improve malar height and vertical dystopia in ZMC fractures?

To estimate the clinical and functional results of patients who underwent distinctive types of open reduction and internal fixation of ZMC fractures, with particular emphasis on malar height and vertical dystopia. A randomized clinical trial was conducted from August 2016 to October 2019 in which 40 adult patients with ZMC fractures of maxillofacial region were included. Patients were randomly allocated to group A (n = 20; frontozygomatic (F-Z) first 3-point reduction and fixation) or group B (n = 20; group B infra-orbital first 3-point reduction and fixation). All patients were evaluated objectively for malar height and vertical dystopia pre- and post-operatively at 3months. The data were scrutinized by applying mean and standard deviation and unpaired t test. Mean values of the malar height and vertical dystopia were statistically significant (P < .05) for group B compared with group A at all intervals. Data analyzed for other secondary variables showed a statistically non-significant difference between the groups (P > 0.05). The results showed improvement in the malar height and vertical dystopia for infra-orbital first three-point fixation (group B) compared with F-Z first approach for initial reduction and fixation (group A). Furthermore, group B was better in terms of malar width and antero-posterior projection of the zygomaticomaxillary complex.

Zygomaticomaxillary fracture fixation: a prospective comparative evaluation of two-point versus three-point fixation.

Zygomatic bone has a higher risk of sustaining injuries in the maxillofacial skeleton. On fracturing, zygomatic bone separates from the four neighbouring bones at its articulations. Treatment for zygomaticomaxillary fractures has evolved a long way since 3000BC. With the advent of miniplates for midface fracture, controversies still exist regarding the stability of zygoma following 1, 2, and 3 points for fixation. The study aims to compare and determine the most effective technique for the reduction of zygomaticomaxillary fractures and the ability to retain the fractured zygoma in a stable position. Hence, a study was conducted in our institute to compare 2 and 3-point fixation of zygomaticomaxillary fractures taking into account the clinical and radiographic parameters. Twenty-four patients were divided into 2 equal groups A and B, receiving 2- and 3-point fixation respectively. Fracture displacement and stability were assessed using coronal and axial CT scan tracings at preoperatively, immediate, and 5-week postoperatively. Group B showed a significant reduction in postoperative mean displacement at sphenozygomatic and infraorbital region when compared with group A. Patients in group A had an increase incidence in vertical dystopia and enophthalmos. There was no postoperative displacement at any site in both the groups. The fractured segment was held in place by both the fixation methods but 3-point fixation gave better stability in maintaining the fractured segment in desired reduced position.

Craniofacial Fronto-ethmoid ‘Ivory Osteoma’ Management and Outcomes

Introduction Fronto-ethmoid ‘Ivory Osteomas’ are rare, benign, slow growing tumours. They have a slight male preponderance (M:F ratio 1.5-2.0:1) with the frontal sinus the most common site for their development .Lesions are often identified as incidental findings on routine radiographic imaging. Surgical intervention is indicated for large, symptomatic lesions, which can present with symptoms such as facial pain, headache, diplopia, vertical dystopia and orbital proptosis.

Does Early Repair of Orbital Fractures Result in Superior Patient Outcomes? A Systematic Review and Meta-Analysis

To date, no clear evidence-based guidelines exist pertaining to the ideal timing to perform surgical treatment of orbital fractures. The purpose of this study was to determine if early treatment of orbital fractures resulted in better patient outcomes. We designed and implemented a systematic review and meta-analysis to test the null hypothesis of no difference in outcomes between different time intervals between orbital injury and surgical intervention. PubMed, Embase, the Cochrane Library, the Elsevier text mining tool database, and clinicaltrials.gov trial registry were queried. The quality of evidence was based on Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. The predictor variable was the timing of operative repair (early vs late). The outcome variable was complete recovery. Other variables of interest were diplopia, enophthalmos, and preoperative motility restriction. Meta-analyses were performed when definitions of active and control interventions and patient outcomes were deemed similar. In addition, χ2 tests were performed to determine differences in clinical outcomes between early and late operative repair. Of the 1,160 articles reviewed, 20 met the inclusion criteria. Surgery performed less than 2weeks after injury was significantly associated with greater odds of complete recovery of symptoms (odds ratio [OR], 6.9 [95% confidence interval (CI), 1.35-35.06]), as well as a lower incidence of postoperative diplopia (OR, 0.3 [95% CI, 0.1-0.9]) and enophthalmos (OR, 0.2 [95% CI, 0.1-0.9]).Repair performed less than 30days after injury was associated complete resolution of preoperative motility restriction (OR, 24.6 [95% CI, 1.30-462.34]) as well as diplopia. Differences in the timing of surgery and definition of patient outcomes, as well as variations in methods of evaluating postoperative outcomes, potentiate the risk of bias and warrant downgrading of the quality of evidence in a study. The timing of repair varied among 2, 4, and 8weeks after injury. However, a short time to surgical intervention was significantly associated with resolution of vertical dystopia, postoperative enophthalmos, and motility restriction.

Customized Titanium Mesh Based on the 3D Printed Model vs. Manual Intraoperative Bending of Titanium Mesh for Reconstructing of Orbital Bone Fracture: A Randomized Clinical Trial.

This study was aimed to compare the efficacy of customized patient-specific titanium mesh based on 3D printed model with intra-operative bending of titanium mesh for reconstructing of orbital floor fracture. This study was prospectively conducted on 10 patients with unilateral orbital floor fractures caused by accident or falls. In intervention group (n=5), the CT-scan slices were used for generating 3D reconstruction of both affected and unaffected orbits. Then, a 3D printed template of mirrored unaffected orbit was produced to mold the titanium mesh. The titanium mesh in conventional group (n=5) was bended only manually and intraoperatively by surgeon and positioned over the bony defect. All patients were followed-up within 1 week, 1 month and 4 months after surgery for assessing enophthalmos, diplopia and other complications. Of 10 patients of the study only two patients in intervention group had preoperative vertical dystopia or diplopia which had been resolved after intervention. The mean enophthalmos at baseline and 1 week, 1 month and 4 months after surgery in control group were 3.8±0.7, 2.4±0.8, 2.4±0.8, and 2.4±0.8 mm, respectively, and in intervention group were 2.6±0.8, 0.35 ± 0.4, 0.35 ± 0.4 and 0.35 ± 0.4 mm, respectively. The mean enophthalmos did not differ significantly at baseline between two groups, while two groups showed significant difference after surgery. Finally, we concluded that the placement of patient-specific titanium implant for reconstructing of orbital bone fracture led to better outcomes when compared to manual bending in terms of enophthalmos and other complications.

Orbital blowout fractures repair using porous polyethylene titanium mesh implants

Objective To observe the clinical efficacy of porous polyethylene titanium mesh implants for orbital blowout fractures. Methods The data of 20 eyes of 20 cases of blowout orbital fracture were retrospectively analyzed, including 6 cases of orbital medial wall fractures, 6 cases of orbital floor fractures, and 8 cases of orbital floor and medial wall fractures. There were 6 cases with diplopia, 6 cases with enophthalmos more than 3 mm, 2 cases with apparent downward globe dystopia, 6 cases of the fracture area over 20mm×20mm with herniation of large amount of orbital contents. Orbital fracture repair surgery was performed in all cases. The diorthosis of orbital fracture with an incision at inner canthus to implant porous polyethylene titanium mesh was performed in 6 cases of orbital medial wall fractures. Diorthosis of orbital fracture with an incision at lower palpebral margin to implant prefabricated mesh was performed in the rest 14 cases. Results All patients were followed up for 3 to 6 months.Diplopia was completely disappeared in 5 cases, and improved in 1 case. The 6 cases of enophthalmos was successfully corrected to less than 2 mm of enophthalmos. The vertical globe dystopia of the 2 cases disappeared. 6 cases of the fracture area more than 20 mm×20 mm had not showed enophthalmos. No visual acuity impairment was observed.No complications such as limited eyeball movement, rejection or migration of the implants occurred. Conclusion Porous polyethylene titanium mesh implants for orbital blowout fractures is safe, effective and stable. Key words: Fractures, orbital, blowout; Titanium mesh, porous polyethylene

Delayed Orbital Hemorrhage around Alloplastic Implants after Blowout Fracture Reduction.

Alloplastic implants have been used to repair orbital wall fractures in most cases. Orbital hemorrhage is a rare complication of these implants and has been reported rarely in Korea. The purpose of this article is to report a late complication case focusing on their etiology and management. A 20-year-old male patient underwent open reduction with Medpor (porous polyethylene) insertion for bilateral orbital floor fractures. The initial symptom occurred with proptosis in the right side as well as vertical dystopia, which had started 4 days earlier, 8 months after surgery. Any trauma history after the surgery was not present. We performed an exploration and removal of hematoma with Medpor titanium meshed alloplastic implant. A case of delayed orbital hematoma following alloplastic implant insertion was identified. It occurred within the pseudocapsule of the implant. One week after surgery, overall symptoms improved successfully, and no complications were reported during the 11-month follow-up period. Although rare, orbital hemorrhage is a potential complication of alloplastic orbital floor implants, which may present many years after surgery. As in the case presented, delayed hematoma should be included in the differential diagnosis of late proptosis or orbital dystopia.

Reconstruction of orbital floor fracture using porous polyethylene mesh

Objective: Treatment of traumatic orbital injury has long been a formidable challenge to maxillofacial and oculoplastic surgeon. Significant complication can occur as a result of these injuries including enopthalmus, persistent diplopia, vertical dystopia and restriction of gaze. Surgical techniques have been more aggressive with primary surgical repair directed at restoring bony orbital volume and contour while repositioning the herniated tissues. The study was undertaken to assess the treatment results with alloplastic graft for reconstruction of orbital floor. Material and methods: It is a prospective randomized study during the period of January 2010 to December 2012 including the follow up of six months on ten orbital floor fractures. Results: Eyeball movement restriction and infraorbital nerve paresthesia improved in all patients. One patient who also had associated head injury and the fracture of supraorbital rim, frontal and temporal bone had persistent enopthalmus, vertical dystopia and diplopia postoperatively. Conclusion: We conclude that early exploration of orbital floor minimizes the morbity associated with late reconstruction due to the fibrosis of tissues entrapped. Use of prolene mesh reduces the operating time and donor site morbidity.

Early treatment of coronal synostosis with endoscopy-assisted craniectomy and postoperative cranial orthosis therapy: 16-year experience

The objective of this study was to present the authors' 16-year experience treating coronal craniosynostosis in infants using endoscopy-assisted techniques and postoperative cranial orthoses. A total of 128 synostosed coronal sutures in 115 patients were treated between 1996 and 2012 by endoscopically resecting a strip of bone containing the stenosed suture via a 2-3 cm incision made at the ipsilateral stephanion. Data were obtained from a prospective database. Following surgery, patients were fitted with custom cranial orthoses to help correct preoperative craniofacial deformities. All patients were followed closely with cranial anthropometric measurements and photographs. The estimated mean blood loss was 20 ml (range 5-120 ml) and the estimated mean strip size was 0.6 cm × 10.7 cm. The mean surgical duration was 55 minutes (range 22-150 minutes). One patient underwent an intraoperative blood transfusion and 1 had a postoperative blood transfusion, for a total transfusion rate of 1.7%. Ninety-seven percent of patients were discharged on the first postoperative day. There were no deaths. Vertical dystopia correction of more than 80% from baseline was obtained in almost two-thirds of patients, with 51% achieving 100% correction. Nasal and sagittal craniofacial deviation (vertex-nasion-gnathion) correction greater than 80% was achieved in 80% of patients, with 77% achieving 100% correction. Supraorbital rim advancement of the ipsilateral eye was obtained in 98% of cases, with correction of frontal plagiocephaly the last deformity to achieve correction. Early treatment of coronal synostosis with endoscopy-assisted craniectomy and postoperative molding helmets leads to significant correction of craniofacial abnormalities, including vertical dystopia, nasal deviation, sagittal misalignment, and ipsilateral proptosis. This treatment method is associated with minimal trauma, blood loss, and transfusion rates, and typically only requires 1 overnight stay. This surgical approach is safe, effective, and associated with excellent results.

Endoscopic technique for coronal synostosis

This paper aims to present a 15-year experience treating coronal craniosynostosis with endoscopic-assisted techniques and postoperative cranial orthotic therapy. A total of 100 patients with coronal craniosynostosis were treated between 1996 and 2010. There were 36 males and 64 females. A single 2-cm incision was made halfway between anterior fontanelle and the squamosal on the affected side. Using endoscopic-assisted visualization, a strip of bone was removed between the aforementioned points. Following surgery, all patients were placed in cranial orthoses to assist in the correction of the craniofacial deformity. Mean estimated blood loss was 20 cm(3); only one patient required a transfusion. Mean length of stay was 1 day. Mean surgery time was 54 min. There were no mortalities. There was significant correction of vertical dystopia (66 % from baseline) and midsagittal plane deviation (80 % from baseline). Endoscopic-assisted craniectomy for treatment of coronal craniosynostosis in very young infants followed by cranial molding is associated with excellent long-lasting results and minimal morbidity and no mortality.

Reconstruction of unicoronal plagiocephaly with a hypercorrection surgical technique

OBJECT Successful surgical repair of unicoronal plagiocephaly remains a challenge for craniofacial surgeons. Many of the surgical techniques directed at correcting the stigmata associated with this craniofacial deformity (for example, ipsilateral supraorbital rim elevation [vertical dystopia], ipsilateral temporal constriction, C-shaped deformity of the face, and so on) are not long lasting and often result in deficient correction and the need for secondary revision surgery. The authors posit that the cause of this relapse was intrinsic deficiencies of the current surgical techniques. The aim of this study was to determine if correction of unilateral coronal plagiocephaly with a novel hypercorrection surgical technique could prevent the relapse of the characteristics associated with unicoronal plagiocephaly. METHODS The authors performed a retrospective analysis of 40 consecutive patients who underwent surgical repair of unicoronal plagiocephaly at their institution between 1999 and 2009. In all cases, the senior author (S.R.B.) used a hypercorrection technique for surgical reconstruction. Hypercorrection consisted of significant overcorrection of the affected ipsilateral frontal and anterior temporal areas in the sagittal and coronal planes. Demographic, perioperative, and follow-up data were collected for comparison. The postsurgical appearance of the forehead was documented clinically and photographically and then evaluated and scored by 2 independent graders using the expanded Whitaker scoring system. A relapse was defined as a recurrence of preoperative features that required secondary surgical correction. RESULTS The mean age of the patients at the time of the operation was 13 months (range 8-28 months). The mean follow-up duration was 57 months (range 3 months to 9.8 years). The postsurgical hypercorrection appearance persisted on average 6-8 months but gradually dissipated and normalized. No patients exhibited a relapse of unicoronal plagiocephalic characteristics that required surgical correction. In all cases the aesthetic results were excellent. Only 3 patients required reoperation for the management of persistent calvarial bone defects (2 cases) and removal of a symptomatic granuloma (1 case). CONCLUSIONS Our study demonstrates that patients who undergo unicoronal plagiocephaly repair with a hypercorrection surgical technique avoid long-term relapse. Our results suggest that the surgical technique used in the correction of unilateral coronal synostosis is strongly associated with the prevention of postsurgical relapse and that the use of this novel method decreases the need for surgical revision.

Long-term results after 40 years experience with treatment of rare facial clefts: Part 1-oblique and paramedian clefts

Oblique and paramedian rare facial clefts impose a major reconstructive challenge and long-term assessments of the outcomes remain scarce. This study provides new details regarding surgical techniques and timing, influence of growth, and difficulties of this pathology on the long-term; a guideline for surgical treatment is given. Twenty-nine adults with an oblique or paramedian facial cleft and surgically treated in the authors' unit between 1969 and 2009, were included. The long-term evaluation was based on series of photographs, 3D-CT's, X-rays, operation data, and was specified per facial area. The mean number of performed operations per patient was 10.6 (range: 1-26). Vertical dystopia is not caused by previous surgery, but by growth deficiencies of the maxilla. In all patients with vertical dystopia, its presence and severity were clear at the age of five, and it should ideally be treated shortly after that age. In mild cases grafting seems sufficient, but in more severe cases orbital translocation is necessary. Costochondral grafts showed the best long-term results in both orbital and nasal reconstructions. Major nose reconstruction is best delayed until adolescence. For an optimal final result in selected cases, correction of midface hypoplasia at adolescence is necessary. The three-dimensional underdevelopment of the midface region plays a central role in the deformities of most patients, but is complex and difficult to correct. The provided guideline should help to minimize the number of operations and ameliorate long-term results.

Multiple-suture nonsyndromic craniosynostosis: early and effective management using endoscopic techniques

Object The authors present the results of treating infants with multiple-suture nonsyndromic craniosynostosis in whom the authors used minimally invasive endoscopy-assisted techniques and postoperative cranial molding over an 11-year period. Methods A total of 21 patients who presented with multiple-suture (nonsyndromic) craniosynostosis were treated using minimally invasive endoscopy-assisted craniectomies. Surgery was followed by treatment with custommade cranial orthoses for up to 12 months. A total of 48 sutures were treated. The most common was the coronal suture (38 cases) and this was followed by the sagittal (11 cases), metopic (6 cases), and lambdoid (3 cases) sutures. There were 13 male and 8 female pediatric patients. Their ages ranged between 3 weeks and 9 months (mean 3.2 months, median 2.5 months). The sagittal suture was treated with a wide vertex craniotomy via 2 incisions located behind the anterior fontanel and in front of the lambda. The metopic suture underwent a suturectomy as did the coronal and lambdoid sutures. Results The mean follow-up duration was 61 months (range 3–135 months). There were no deaths. In patients with bicoronal synostosis, brachycephaly was corrected. Patients presenting with vertical dystopia or nasal deviation had these deformities corrected as well. The mean blood loss was 42 ml (range 10–120 ml). The mean hospital length of stay was 1 day. The intraoperative transfusion rate was 0%. The results indicate that nonsyndromic multiple-suture synostosis can be safely and effectively treated using endoscopic techniques. Conclusions Early treatment of complex multiple-suture synostosis with endoscopic techniques provides an excellent surgical alternative. The results of the present study indicate marked correction of skull base and craniofacial deformities. Endoscopy provides a safe and effective way to treat these patients.

Porous Polyethylene Implants in Orbital Blow-Out Fractures and Enophthalmos Reconstruction

To evaluate the efficacy of porous polyethylene sheet implants in reconstruction of orbital blow-out fractures. Sixty-eight patients with orbital blow-out fractures were admitted in our center from December 1996 to June 2005. Porous polyethylene sheet implants were used to repair the defects of orbital wall and to correct the enophthalmos. The clinical results of extrinsic eye movement, enophthalmos, hypoglobus (vertical dystopia), visual acuity, and infraorbital nerve anesthesia were analyzed preoperatively and postoperatively. Patients stayed in the hospital between 4 and 10 days. The enophthalmos and hypoglobus of all 68 patients was corrected except for one. The patient needs another surgery 6 months after operation to remove a piece of Medpor because the hypoglobus was overcorrected. Diplopia was resolved in 36 of 45 patients postoperatively. Persistent diplopia was found in 9 cases that were complicated orbitozygomaticomaxillary fractures. Visual acuity was improved in 13 of 45 patients, whereas no change was observed in the others. Infraorbital nerve hypoesthesia was resolved in 32 of 43 cases 6 months after operation. Only 1 patient developed postoperative ectropion, for which local suspending was required. No infections and Medpor outcrop were seen after operation. Porous polyethylene sheet implant is a very reliable material for reconstruction of the orbital blow-out fractures and restoration of the orbital volume. Overcorrection of 1 to 2 mm is necessary during operation to neutralize the tissue swelling or atrophy.

New Technique for Reconstructing the Affected Cranium and Orbital Rim in Unicoronal Craniosynostosis

Of the single-suture craniosynostoses, unicoronal synostosis (UCS) is widely acknowledged to represent the most varied and complex set of craniofacial deformities. This is attributed to the endocranial base being affected along with the coronal suture. This deformity may present with both coronal and frontosphenoidal synostosis and has been associated with elevated intracranial pressure; brain morphological abnormalities; vertical dystopia; ambylopia; malformations of the forehead, orbit, midface, and mandible; and behavioral, cognitive, and speech abnormalities. It is the variable structural presentation coupled with the long-term stability of the reconstruction that forms a complex reconstructive challenge. Our surgical technique concordantly addresses these associated structures beyond the isolated coronal suture. Although several surgical techniques have previously been described, there remains no consensus toward a preferred surgical approach to this dynamic and three-dimensional problem. We describe our technique of coronal and frontosphenoidal synostosis release as part of a frontotemporoparietal bone flap, release of the entire fronto-orbital rim, and use of the unaffected skull to reconstruct the affected half of the skull. The purpose of our study was to describe our surgical approach to UCS. It has been our experience that optimal correction of UCS must address the associated anomalies beyond the affected coronal suture and must be stable over time.

Pediatric orbital roof fractures

Isolated orbital roof fractures are rare. In the pediatric population, however, the lack of pneumatized frontal sinuses makes them more susceptible to such injuries. In evaluating these injuries, maxillofacial computed tomography is a necessary adjunct to a complete history and physical evaluation. Based on the relative position of bone fragments, orbital roof fractures can be classified as non-displaced, blowout, or blow-in. While many patients can be safely managed with careful observation. Symptoms such as extraocular entrapment, vertical dystopia, diplopia, or cerebrospinal fluid leak may require surgery. Many different approaches to the orbital roof are available; selection needs to be made based on surgeon experience and location of injury. Cooperation between neurosurgery, ophthalmology and head and neck surgery are essential to optimize the care for these patients.