Zygomatic intraosseous haemangioma: Reconstruction with an alloplastic prosthesis based on a 3-D model

Surgical Navigation and CAD-CAM-Designed PEEK Prosthesis for the Surgical Treatment of Facial Intraosseous Vascular Anomalies

Background: Intraosseous vascular anomalies in the facial skeleton present significant diagnostic and therapeutic challenges due to complex anatomy. These anomalies represent about 0.5-1% of bony neoplastic and tumor-like lesions, usually presenting as a firm, painless mass. Most described intraosseous vascular malformations are venous malformations (VMs) and, more rarely, arteriovenous malformations. Objectives: The objectives of this work are to show our experience, protocol and the applications of computer planning, virtual surgery, CAD-CAM design, surgical navigation, and computer-assisted navigated piezoelectric surgery in the treatment of facial intraosseous vascular anomalies and to evaluate the advantages and disadvantages. Methods: Three females and one male with periorbital intraosseous vascular anomalies were treated using en-block resection and immediate reconstruction with a custom-made PEEK prosthesis. One lesion was in the supraorbital rim and orbital roof, one in the frontal bone and orbital roof, and two in the zygomatic region. We accomplished the resection and reconstruction of the lesion using virtual planning, CAD-CAM design, surgical navigation and piezoelectric device navigation. Results: There were no complications related to the surgery assisted with navigation. With an accuracy of less than 1 mm, the procedure may be carried out in accordance with the surgical plan. The surgeon's degree of uncertainty during deep osteotomies and in locations with low visibility was decreased by the use of the navigated piezoelectric device. Conclusions: Resection and reconstruction of facial intraosseous vascular anomalies benefit from this new surgical strategy using CAD-CAM technologies, computer-assisted navigated piezoelectric surgery, and surgical navigation.

Intraosseous Venous Malformation of the Zygomatic Bone: Comparison between Virtual Surgical Planning and Standard Surgery with Review of the Literature

Intraosseous venous malformations affecting the zygomatic bone are infrequent. Primary reconstruction is usually accomplished with calvarial grafts, although the use of virtual surgical planning, cutting guides and patient-specific implants (PSI) have had a major development in recent years. A retrospective study was designed and implemented in patients diagnosed with intraosseous venous malformation during 2006–2021, and a review of the scientific literature was also performed to clarify diagnostic terms. Eight patients were treated, differentiating two groups according to the technique: four patients were treated through standard surgery with resection and primary reconstruction of the defect with calvarial graft, and four patients underwent resection and primary reconstruction through virtual surgical planning (VSP), cutting guides, STL models developed with CAD-CAM technology and PSI (titanium or Polyether-ether-ketone). In the group treated with standard surgery, 75% of the patients developed sequelae or morbidity associated with this technique. The operation time ranged from 175 min to 210 min (average 188.7 min), the length of hospital ranged from 4 days to 6 days (average 4.75 days) and the postoperative CT scan showed a defect surface coverage of 79.75%. The aesthetic results were “excellent” in 25% of the patients, “good” in 50% and “poor” in 25%. In the VSP group, 25% presented sequelae associated with surgical treatment. The operation time ranged from 99 min to 143 min (average 121 min), the length of hospital stay ranged from 1 to 2 days (average of 1.75 days) and 75% of the patients reported “excellent” results. Postoperative CT scan showed 100% coverage of the defect surface in the VSP group. The multi-stage implementation of virtual surgical planning with cutting guides, STL models and patient-specific implants increases the reconstructive accuracy in the treatment of patients diagnosed with intraosseous venous malformation of the zygomatic bone, reducing sequelae, operation time and average hospital stay, providing a better cover of the defect, and improving the precision of the reconstruction and the aesthetic results compared to standard technique.

Intraosseous Venous Malformation of the Zygomatic Bone: Virtual Surgical Planning and Reconstruction With Customized CAD-CAM Titanium Implant

ABSTRACT

Zygomatic intraosseous vascular anomalies are uncommon. Most cases have been reported without a precise diagnosis. The prevalence is 3:1 women during the fourth decade of life. The study of these lesions includes clinical findings, radiological studies, such as computed tomography and magnetic resonance imaging scans, and a postoperative histological study of the specimen. Biopsy is not recommended because of the risk of bleeding. Complete surgical resection remains the gold standard elective treatment.The case of a patient with an intraosseous venous malformation of the zygomatic bone is presented, detailing the clinical, histological, and radiological characteristics and the surgical treatment with a primary reconstruction through Computer-Aided Design/Computer-Aided Manufacturing customized titanium implant guided by virtual surgical planning with a reduction of surgical time and morbidity in the donor area with optimal functional and aesthetic results.

Implications of Applying New Technology in Cosmetic and Reconstructive Facial Plastic Surgery

The field of facial plastic and reconstructive surgery is privy to a myriad of technological advancements. As innovation in areas such as imaging, computer applications, and biomaterials progresses at breakneck speed, the potential for clinical application is endless. This review of recent progress in the implementation of new technologies in facial plastic surgery highlights some of the most innovative and impactful developments in the past few years of literature. Patient-specific surgical modeling has become the gold standard for oncologic and posttraumatic reconstructive surgery, with demonstrated improvements in operative times, restoration of anatomical structure, and patient satisfaction. Similarly, reductions in revision rates with improvements in learner technical proficiency have been noted with the use of patient-specific models in free flap reconstruction. In the cosmetic realm, simulation-based rhinoplasty implants have drastically reduced operative times while concurrently raising patient postoperative ratings of cosmetic appearance. Intraoperative imaging has also seen recent expansion in its adoption driven largely by reports of eradication of postoperative imaging and secondary-often complicated-revision reconstructions. A burgeoning area likely to deliver many advances in years to come is the integration of bioprinting into reconstructive surgery. Although yet to clearly make the translational leap, the implications of easily generatable induced pluripotent stem cells in replacing autologous, cadaveric, or synthetic tissues in surgical reconstruction are remarkable.

Computer guided resection and reconstruction of intra-osseous zygomatic hemangioma: Case report and systematic review of literature

OBJECTIVES

to systemically integrate the available data on various published treatment strategies for intraosseous hemangioma of the zygoma in an updated comprehensive systematic review, and to present a new case of treated resection and immediate reconstruction using computer guided patient specific composite graft.

CASE PRESENTATION

A 29 years old female patient with intraosseos zygomatic hemangioma treated using computer guided resection and immediate reconstruction. The resection was performed using a resection template constructed based on preoperative 3D planning. The reconstruction was performed using ramus bone graft and titanium mesh. The patient was followed up for 3 years with no complications.

METHODS

An electronic search was performed on 3 data bases; additional hand search of bibliographies of selected articles was performed. Eligibility criteria include human studies presenting intraosseous zygomatico-orbital hemangioma with clearly reported therapeutic strategies.

RESULTS

53 articles with 73 cases were included. The lesion was highly prevalent in females compared to males (2.28:1). Fifth decade represents the highest prevalence with mean age of 44.1 ± 1.8 years. The main patient concern was swelling and facial deformity. Total tumor resection can assure no recurrence, while partial resection and curettage are associated with high recurrence rate.

Zygomatic Intraosseous Hemangioma: Case Report and Literature Review

Intraosseous hemangiomas are uncommon intrabony lesions, representing approximately 0.5 to 1% of all intraosseous tumors. Their description varies from "benign vasoformative neoplasms" to true hamartomatous proliferations of endothelial cells forming a vascular network with intermixed fibrous connective tissue stroma. These commonly present as a firm, painless swelling. Intraosseous hemangiomas present more commonly in females than in males and most likely occur in the fourth decade of life. The most common etiology of intraosseous hemangioma is believed to be prior trauma to the area. They have a tendency to bleed briskly upon removal or biopsy, making preoperative detection of the vascular nature of the lesion of significant importance. There are four variants: (1) capillary type, (2) cavernous type, (3) mixed variant, and (4) scirrhous type. Generally most common in the vertebral skeleton, they can also present in the calvarium and facial bones. In the head, the most common site is the parietal bone, followed by the mandible, and then malar and zygomatic regions. Intraosseous hemangiomas of the zygoma are rare entities with the first case reported in 1950 by Schoenfield. In this article, we review 49 case reports of intraosseous hemangioma of the zygoma, and also present a new case treated with excision followed by polyether-ether ketone implant placement for primary reconstruction.

Virtual Resection and Subsequent Design of a Patient-Specific Alloplastic Implant in the Preoperative Planning and Surgical Treatment of a Venous Malformation of the Zygoma

The authors present here the case of a 63-year-old female who developed a venous malformation of the left zygoma. These lesions are typically managed with nonoperative treatment, until or unless overt complicating symptoms require more aggressive surgical intervention. Reconstruction of the zygoma represents a challenge for the operating surgeon, considering its complex three-dimensional anatomy. Traditionally, the surgeon would estimate the appropriate margins of resection intraoperatively, and then design a construct to fit the defect using autologous bone grafts, allografts, or one of the various available alloplastic materials; however, for this patient preoperative virtual surgical planning was used. Using reconstructed three-dimensional images from the patient's maxillofacial computed tomography scan, the margins of the excision were virtually defined and the lesion "excised" during a preoperative planning session based on the specifications of the reconstructive surgeon. This process then allowed the design and production of custom osteotomy guides, and a patient-specific polyetheretherketone (PEEK) implant to match the resulting defect. The authors believe this methodology allows for a more efficient and precise overall procedural experience and reconstructive result, and has innumerable potential applications in the surgical treatment of craniofacial abnormality.

Management of Intraosseous Vascular Malformations of the Jaws in Children and Adolescents: Report of 6 Cases and Literature Review

Background

Intraosseous vascular malformations represent a rare clinical entity of the facial skeleton. The purpose of the current study was to present our experience in a Greek paediatric population and propose guidelines for the treatment of these jaws anomalies in children and adolescents.

Methods

A retrospective study (from 2009 to 2014) was performed to investigate the features and management of the intraosseous vascular anomalies in a Greek paediatric population.

Results

Six patients aged between 6 and 14 years were treated for intraosseous vascular malformations (4 venous and 2 arteriovenous) of the jaws. Five lesions were located in the mandible and one in the maxilla. In four lesions with pronounced vascularity superselective angiography, followed by embolization was performed. Individualized surgical treatment, depending on the size and vascularity of the lesions was applied in 4 patients.

Conclusions

The intraosseous vascular malformations of the jaws may escape diagnosis in paediatric patients. A multidisciplinary approach is important for their safe and efficient treatment. Embolization is recommended for extended high-flow lesions, either preoperatively or as a first-line treatment, when surgery is not feasible without significant morbidity.

Intraosseous haemangioma: semantic and medical confusion

The literature is rich in case reports of intraosseous haemangioma, although most of these are actually cases of venous or capillary malformations. To illustrate this confusion in terminology, we present three cases of slow-flow vascular malformations misnamed as intraosseous haemangioma. A retrospective study of children diagnosed with intraosseous haemangioma was conducted. Clinical and radiological data were evaluated. Histopathological examinations and immunohistochemical studies were redone by three independent pathologists to classify the lesions according to the International Society for the Study of Vascular Anomalies (ISSVA) and World Health Organization (WHO) classifications. Three children who had presented with jaw haemangiomas were identified. Computed tomography scan patterns were not specific. All tumours were GLUT-1-negative and D2-40-negative. The lesions were classified as central haemangiomas according to the WHO, and as slow-flow malformations according to the ISSVA. The classification of vascular anomalies is based on clinical, radiological, and histological differences between vascular tumours and malformations. Based on this classification, the evolution of the lesion can be predicted and adequate treatment applied. The binary ISSVA classification is widely accepted and should be applied for all vascular lesions.

Computer-aided three-dimensional reconstruction of main vessels in hemangiomas

This study aimed to investigate three-dimensional (3-D) morphological features of the main vessel architecture of human hemangioma. Serial sections of specimens from three cases of children hemangioma were stained with hematoxylin and eosin (HE) to visualize the vessels. Serial images were taken and processed with computer-assisted 3-D reconstruction. Partial 3-D structure reconstruction of vessel morphology in hemangioma revealed strange distribution and branching, which were different from normal vessels of the human skin. The 3-5 microvascular was most common in hemangioma. We observed respective characteristics of three cases: 1 case showed uniform artery vein distribution accompanied by running trend; 1 case showed main artery distribution and less vein distribution, and there were many blood sinus in the shallow surface close to the skin; another case showed vein distribution in the middle of antrum. In conclusion, digital vascular model of 3-D structure of main vessel hemangioma provides a new way for the diagnosis and treatment of hemangioma of children.

Primary Intraosseous Cavernous hemangioma of the Zygoma: A Case Report and Literature Review

Intraosseous hemangiomas are rare. We report the case of a 47-year-old man who presented with a gradually enlarging left zygomatic mass that had caused pain, deformity, and superficial soft-tissue swelling. Computed tomography revealed a well-circumscribed 2.0 × 2.5-cm mass with a ground-glass matrix in the left zygoma. Following surgical excision, the patient's symptoms resolved. Findings on pathologic examination of the excised tissue were consistent with an intraosseous cavernous hemangioma. We describe the features of this rare case, we discuss the pertinent radiologic features and pathophysiology of intraosseous hemangiomas, and we review the available literature.