Refining reconstructive arsenal: Free omental flap with autologous bone graft for complex craniofacial defects after tumor resection and frontal osteoradionecrosis

Skull osteoradionecrosis may happen after radiation therapy for head and neck cancer. Here in, the authors present a case of intracranial carcinoma with osteoradionecrosis and exposure of frontal bone with a large communication between nasal cavity and anterior fossa associated. The patient was successfully treated with resection of the tumor and reconstruction omentum free flap wrapped around autologous bone graft.

The Efficacy of Intercostal Nerve Block in the Management of Postoperative Pain After Costal Cartilage Harvest for Craniofacial Reconstruction Systematic Review and Meta-analysis

INTRODUCTION

Autologous costal cartilage harvest is a common procedure in craniofacial reconstruction due to its stability, dependability, and diversity. However, such a procedure is associated with severe donor-site pain postoperatively. Therefore, we aim through this study to compare the efficacy of intercostal nerve block in the management of postoperative pain in patients undergoing costal cartilage harvest for craniofacial reconstruction.

METHOD

This systematic review was reported according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines. The study systematically reviewed MEDLINE, Cochrane, and EMBASE databases without time-limitation.

RESULTS

As a result of reviewing the literature, 33 articles were screened by full-text resulting in 14 articles which met our inclusion/exclusion criteria. However, only four high-quality RCT articles were included in the quantitative synthesis (meta-analysis). The findings of this study suggest that there is no significant difference in pain scores between ICNB and control groups at 12, 24, and 48 h postoperatively, both at rest and with coughing. Therefore, both techniques are considered safe and effective.

CONCLUSION

Our results show evidence of favorable outcome of preventive donor-site analgesia with ICNB for harvesting autologous costal cartilage in multiple studies. However, the overall outcomes were insignificant between the two arms.

NO LEVEL ASSIGNED

This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Use of supermicrosurgery in craniofacial and head and neck soft tissue reconstruction: a systematic review of the literature and meta-analysis

Supermicrosurgery is an evolving approach in the reconstruction of head and neck (HN) and craniofacial (CF) defects. This systematic review aims to evaluate the use of supermicrosurgery for arterial or combined arterial and venous anastomoses in the reconstruction of HN and CF soft tissue defects, and the associated success, total complication, and reoperation rates. A literature search was conducted on PubMed, Dynamed, DARE, EMBASE, Cochrane, and British Medical Journal (BMJ) electronic databases (PROSPERO ID: CRD42023476825). Nine studies fulfilled the inclusion criteria with 35 patients who underwent soft tissue reconstructive procedures using supermicrosurgery. Twenty-one flaps were performed on 20 patients (57.1%) with the remaining 15 patients (42.9%) undergoing supermicrosurgical replantation. The most common pathology requiring reconstruction was HN trauma (n = 16, 45.7%) followed by malignancy (n = 15, 42.9%). The pooled success rate for supermicrosurgery was 98% (95% CI 90 to 100, p = 1.00; I2 = 0%). The cumulative complication rate across all the studies was 46% (95% CI 13 to 80, p < 0.01; I2 = 0%), and the pooled rate of reoperation was 1% (95% CI 0 to 8, p = 0.23; I2 = 24%). The use of supermicrosurgery for HN and CF soft tissue reconstruction has an overall success rate of 98%, which is commensurate with traditional microsurgery for HN reconstruction. Complication and reoperation rates are comparable to previous literature. This study confirms the feasibility of supermicrosurgery as a safe and reliable reconstructive option for HN and CF defects.

Pedicled Radial Forearm Flap in Reconstruction of Complex Defects in the Craniofacial Region

The radial forearm flap is a fasciocutaneous flap that has been used for reconstructing defects in the craniofacial region, either as a free flap or a pedicled flap. The pedicled radial forearm flap is a reliable option for reconstructing scalp defects. Microvascular free tissue transfer has, however, remained the preferred choice in the reconstruction of most complex scalp defects in the craniofacial region. We present the cases of a 37-year-old woman with an ulcerated malignant lesion on the forehead and a 40-year-old woman with a large malignant tumor on the scalp. Excision of both lesions, which turned out to be squamous cell carcinomas, resulted in complex defects that were reconstructed with pedicled radial forearm flaps. Both patients had satisfactory results and were counseled for radiotherapy.

Systematic review on forensic craniofacial reconstruction. I. facial soft-tissue thickness

Forensic anthropologists are traditionally interested in facial approximations and reconstruction of physiognomies of individuals from past populations and creation of lifelike features onto unknown skulls retrieved from forensic or bioarchaeological contexts. Present review article examines the significance of facial soft-tissue thickness (FSTT) in craniofacial reconstruction by revisiting the studies published in the recent past decade (2010-21). The searches for published articles mentioning the FSTT and related topics over these years were performed using the following search engines: PubMed, ScienceDirect, Web of Science, and Scopus. A total of 325 research articles were identified using different keywords, out of which 84 studies were found relevant for systematic review presented in this article. The selected studies were further analyzed based on the adopted study design, radiographic modality used for estimating FSTT, and generated databases and their advantages and limitations. Out of 84 relevant articles, 30 articles presented databases for sex, age, and ethnicity-dependent variations in soft tissue thickness measurements. Finally, 17 studies reporting sexual dimorphic variations in FSTT values estimated in supine or upright postured individuals (aged 18-90 years and above) were considered for meta-analysis. This article gives a decisive outlook on research trends in FSTT estimations, its contributions in refining craniofacial reconstruction technology, and identifying where we lack and where we can improve.

A portrait drawing of the 17th century Korean scholar based on craniofacial reconstruction

As a technique mainly hiring in forensic investigation field to identify the descents, craniofacial reconstruction (CFR) is also used in archaeology to create the faces from ancient or medieval human remains, when there is little information about his/her appearance. Eung-Cheok Ko (1531-1605) was a writer and scholar in the mid Joseon period. In January of 2019, His mummified body was found at Gumi, Kyeonsangbuk-do, Korea. The remains were anthropologically examined, and archaeological CFR was also requested for this case. This report reveals the case's facial reconstruction process and his portrait that is drawn based on the 3-dimensional CFR result.

Augmented reality-assisted craniofacial reconstruction in skull base lesions - an innovative technique for single-step resection and cranioplasty in neurosurgery

Defects of the cranial vault often require cosmetic reconstruction with patient-specific implants, particularly in cases of craniofacial involvement. However, fabrication takes time and is expensive; therefore, efforts must be made to develop more rapidly available and more cost-effective alternatives. The current study investigated the feasibility of an augmented reality (AR)-assisted single-step procedure for repairing bony defects involving the facial skeleton and the skull base. In an experimental setting, nine neurosurgeons fabricated AR-assisted and conventionally shaped ("freehand") implants from polymethylmethacrylate (PMMA) on a skull model with a craniofacial bony defect. Deviations of the surface profile in comparison with the original model were quantified by means of volumetry, and the cosmetic results were evaluated using a multicomponent scoring system, each by two blinded neurosurgeons. Handling the AR equipment proved to be quite comfortable. The median volume deviating from the surface profile of the original model was low in the AR-assisted implants (6.40 cm³) and significantly reduced in comparison with the conventionally shaped implants (13.48 cm³). The cosmetic appearance of the AR-assisted implants was rated as very good (median 25.00 out of 30 points) and significantly improved in comparison with the conventionally shaped implants (median 14.75 out of 30 points). Our experiments showed outstanding results regarding the possibilities of AR-assisted procedures for single-step reconstruction of craniofacial defects. Although patient-specific implants still represent the gold standard in esthetic aspects, AR-assisted procedures hold high potential for an immediately and widely available, cost-effective alternative providing excellent cosmetic outcomes.

Orbital reconstruction - applied materials, therapeutic agents and clinical problems of restoration of defects

Reconstruction of large cavities in the skull and facial regions is important not only to restore health but also for the correction of facial distortions. Every visible deformity in the facial region of the patient affects their mental wellness and perception by society, entailing both, deterioration of health, but also a decrease in the performance in society, which translates into its productivity. With the progressive degradation of the natural environment, cancer, in the coming years, will be on the leading causes of morbidity and mortality. The review focuses on two main aspects: (i) the causes of injuries leading to the necessity of removal of orbital cavities occupied by the tumor and then their reconstruction, with the focus on the anatomical structure of the orbital cavity, (ii) the materials used to reconstruct the orbital cavities and analyze their advantages and disadvantages. The manuscript also underlines the not yet fully met challenges in the area of facial- and craniofacial reconstruction in people affected by cancer.

Innovations and Future Directions in Head and Neck Microsurgical Reconstruction

Head and neck reconstructive microsurgery is constantly innovating because of a combination of multidisciplinary advances. This article examines recent innovations that have affected the field as well as presenting research leading to future advancement. Innovations include the use of virtual surgical planning and three-dimensional printing in craniofacial reconstruction, advances in intraoperative navigation and imaging, as well as postoperative monitoring, development of minimally invasive reconstructive microsurgery techniques, integration of regenerative medicine and stem cell biology with reconstruction, and the dramatic advancement of face transplant.

Three-dimensional prediction of nose morphology in Chinese young adults: a pilot study combining cone-beam computed tomography and 3dMD photogrammetry system

The nose is the most prominent part of the face and is a crucial factor for facial esthetics as well as facial reconstruction. Although some studies have explored the features of external nose and predicted the relationships between skeletal structures and soft tissues in the nasal region, the reliability and applicability of methods used in previous studies have not been reproduced. In addition, the majority of previous studies have focused on the sagittal direction, whereas the thickness of the soft tissues was rarely analyzed in three dimensions. A few studies have explained the specific characteristics of the nose of Chinese individuals. The aim of this study was to investigate the relationship between the hard nasal structures and soft external nose in three dimensions and to predict the morphology of the nose based on hard-tissue measurements. To eliminate the influence of low resolution of CBCT and increase the accuracy of measurement, three-dimensional (3D) images captured by cone-beam computed tomography (CBCT) and 3dMD photogrammetry system were used in this study. Twenty-six measurements (15 measurements for hard tissue and 11 measurements for soft tissue) based on 5 craniometric and 5 capulometric landmarks of the nose of 120 males and 120 females were obtained. All of the subjects were randomly divided into an experimental group (180 subjects consisting of 90 males and 90 females) and a test group (60 subjects consisting of 30 males and 30 females). Correlation coefficients between hard- and soft-tissue measurements were analyzed, and regression equations were obtained based on the experimental group and served as predictors to estimate nasal morphology in the test group. Most hard- and soft-tissue measurements appeared significantly different between genders. The strongest correlation was found between basis nasi protrusion and nasospinale protrusion (0.499) in males, and nasal height and nTr-nsTr (0.593) in females. For the regression equations, the highest value of R² was observed in the nasal bridge length in males (0.257) and nasal tip protrusion in females (0.389). The proportion of subjects with predicted errors < 10% was over 86.7% in males and 70.0% in females. Our study proved that a combined CBCT and 3dMD photogrammetry system is a reliable method for nasal morphology estimation. Further research should investigate other influencing factors such as age, skeletal types, facial proportions, or population variance in nasal morphology estimation.

Facial average soft tissue depth variation based on skeletal classes in Indonesian adult population: A retrospective lateral cephalometric study

OBJECTIVE

To understand the influence of three types of skeletal classes (Class I, Class II and Class III) on midline average soft tissue depth (ASTD).

METHODS

Lateral cephalograms of 335 pre-treatment orthodontic patients were obtained from the archive of Radiology Clinic Universitas Padjadjaran Dental Hospital Bandung Indonesia. The linear measurements of 10 midline facial landmarks ASTD and angular measurement of ANB were extracted and analysed statistically.

RESULTS

A database of ASTD grouped by skeletal classes, specific for the Indonesian population, within the South East Asian ancestry group was obtained.

CONCLUSIONS

A generic pattern of deeper upper lip than lower lip in class III compared to class II and conversely, deeper lower lip than upper lip in class II compared to class III, was visible in both male and female groups.

Assessment of nasal profiles for forensic facial approximation in a modern Korean population of known age and sex

The nose is a valuable facial feature for facial recognition and approximation. We propose the use of regression functions to predict nasal profiles comprising the structures around the piriform aperture using CT-based 3D models. We examined craniofacial reconstruction models acquired from computed tomographic images of Korean adults (188 males and 201 females). Eighteen measurements using 16 craniometric landmarks were measured on 3D craniofacial models. We conducted a descriptive analysis with comparisons according to sex, and simple linear regression analyses to obtain regression functions. Using multiple regression analyses with sex and age as independent variables, multiple regression equations were developed with coefficient of determination R² ranging from 0.314 to 0.724, meaning that the equations for known sex and age were better for the prediction of nasal profiles than equations that assumed only known sex. These equations are useful and practical for reconstructing nasal profiles in forensic analyses.

Craniofacial reconstruction of the Indus Valley Civilization individuals found at 4500-year-old Rakhigarhi cemetery

Despite academic efforts to study the Indus Valley Civilization (IVC), there have as yet been no successful attempts to unveil the IVC people's craniofacial appearance. We investigated the IVC cemetery area of Rakhigarhi site, which was estimated to be of 2273 ± 38 and 2616 ± 73 years BCE. By craniofacial reconstruction (CFR) procedure using computed tomography (CT) data of two Rakhigarhi skulls (A1 BR02 and A2 BR36), we successfully reconstructed the faces of the IVC individuals who were buried about 4500 years ago. This is the first attempt to unveil scientifically accurate representations of IVC people's actual facial morphology.

Complications after craniofacial reconstruction with calcium phosphate cements: a case report and review of the literature

Among different graft materials for craniofacial reconstruction, calcium phosphate cements have the advantages of alloplastic grafts and wide use. The authors report a case of foreign body reaction following frontal reconstruction with JectOS (an injectable calcium orthophosphate cement; Kasios) and reviewed the literature on complications of this material after craniofacial reconstruction from 2002 to 2017. Complications were categorized into two groups: immunologic reactions (consisting of seroma collection, chronic sinus mucosa swelling, and foreign body reaction) and non-immune events (infection, fragmentation, and ejection). It is wise to use calcium phosphate-based material only in selected cases with small defects, and long-term follow-up is needed to observe their consequences.

Use of omental free flap for craniofacial reconstruction in unfavorable wound bed: A case report

INTRODUCTION

The omental free flap is an effective tool for craniofacial reconstruction. However it is generally under-utilised by a large number of practitioners. This paper's goal is to increase awareness of this free flap's accessibility and to demonstrate that it can be an attractive option for reconstructive surgery.

CLINICAL REPORT

This article outlines the details of a 57-year-old patient who required coverage of a fronto-parietal wound with dura mater exposure. After previous failed conventional free flap attempts, a procedure using the omental free flap was finally performed on this severe wound. The omentum was harvested via a 8cm laparotomy and anastomosed to the temporal vessels. The final result was successful, with a favorable aesthetic result.

DISCUSSION

The omental free flap has many advantages: the pedicle length is long, it allows coverage of a large wound, it can be applied to a wound bed previously irradiated and infected, it has a low morbidity rate to the donor site, the surgical technique of harvesting is easy, the aesthetic result is satisfactory. However, the absence of skin slice is a disadvantage of the omental free flap because it makes monitoring difficult and it requires a skin graft in a second procedure. Laparoscopic harvest of omentum free flaps is a safe and effective tool in the reconstructive armamentarium. Every maxillofacial and plastic surgeon should aim to master and use this method as a legitimate option in some infrequent but appropriated cases.

Nose profile morphology and accuracy study of nose profile estimation method in Scottish subadult and Indonesian adult populations

This study investigated nose profile morphology and its relationship to the skull in Scottish subadult and Indonesian adult populations, with the aim of improving the accuracy of forensic craniofacial reconstruction. Samples of 86 lateral head cephalograms from Dundee Dental School (mean age, 11.8 years) and 335 lateral head cephalograms from the Universitas Padjadjaran Dental Hospital, Bandung, Indonesia (mean age 24.2 years), were measured. The method of nose profile estimation based on skull morphology previously proposed by Rynn and colleagues in 2010 (FSMP 6:20–34) was tested in this study. Following this method, three nasal aperture-related craniometrics and six nose profile dimensions were measured from the cephalograms. To assess the accuracy of the method, six nose profile dimensions were estimated from the three craniometric parameters using the published method and then compared to the actual nose profile dimensions.

In the Scottish subadult population, no sexual dimorphism was evident in the measured dimensions. In contrast, sexual dimorphism of the Indonesian adult population was evident in all craniometric and nose profile dimensions; notably, males exhibited statistically significant larger values than females. The published method by Rynn and colleagues (FSMP 6:20–34, 2010) performed better in the Scottish subadult population (mean difference of maximum, 2.35 mm) compared to the Indonesian adult population (mean difference of maximum, 5.42 mm in males and 4.89 mm in females).

In addition, regression formulae were derived to estimate nose profile dimensions based on the craniometric measurements for the Indonesian adult population. The published method is not sufficiently accurate for use on the Indonesian population, so the derived method should be used. The accuracy of the published method by Rynn and colleagues (FSMP 6:20–34, 2010) was sufficiently reliable to be applied in Scottish subadult population.

The unfamiliar face effect on forensic craniofacial reconstruction and recognition

Previous research into the reliability of forensic craniofacial reconstruction (CFR) has focused primarily on the accuracy of reconstructed faces from European or African ancestry skulls. Moreover, the recognition of CFR in relation to the experience and ancestry of the practitioners and the assessors has not been previously considered. The cross-race effect is a recognised phenomenon in psychology studies, where familiar ancestry faces are recognised more readily than unfamiliar ancestry faces, but there is a paucity of research addressing the relationship between the accuracy of reconstructed faces and the familiarity with this ancestry by the practitioners/assessors. The aims of this research were to investigate whether 'unfamiliar-race effect' has any influence on the accuracy of CFR and to evaluate how much the correct recognition rate of CFR is affected by the cross-race effect. Eight CFRs from three ancestry groups were produced by experienced practitioners in order to explore the aims. The results demonstrated that practitioners produced more recognisable CFRs using skulls from a familiar ancestry than skulls from unfamiliar ancestries.

Densely calculated facial soft tissue thickness for craniofacial reconstruction in Chinese adults

Craniofacial reconstruction (CFR) is used to recreate a likeness of original facial appearance for an unidentified skull; this technique has been applied in both forensics and archeology. Many CFR techniques rely on the average facial soft tissue thickness (FSTT) of anatomical landmarks, related to ethnicity, age, sex, body mass index (BMI), etc. Previous studies typically employed FSTT at sparsely distributed anatomical landmarks, where different landmark definitions may affect the contrasting results. In the present study, a total of 90,198 one-to-one correspondence skull vertices are established on 171 head CT-scans and the FSTT of each corresponding vertex is calculated (hereafter referred to as densely calculated FSTT) for statistical analysis and CFR. Basic descriptive statistics (i.e., mean and standard deviation) for densely calculated FSTT are reported separately according to sex and age. Results show that 76.12% of overall vertices indicate that the FSTT is greater in males than females, with the exception of vertices around the zygoma, zygomatic arch and mid-lateral orbit. These sex-related significant differences are found at 55.12% of all vertices and the statistically age-related significant differences are depicted between the three age groups at a majority of all vertices (73.31% for males and 63.43% for females). Five non-overlapping categories are given and the descriptive statistics (i.e., mean, standard deviation, local standard deviation and percentage) are reported. Multiple appearances are produced using the densely calculated FSTT of various age and sex groups, and a quantitative assessment is provided to examine how relevant the choice of FSTT is to increasing the accuracy of CFR. In conclusion, this study provides a new perspective in understanding the distribution of FSTT and the construction of a new densely calculated FSTT database for craniofacial reconstruction.

Retrospective study of experience of craniofacial reconstruction

Reconstruction is a basic task in craniofacial plastic surgery. Different methods must be used to meet the aspirations of surgeons and patients with different defects and deformities. We make a retrospective study of our experience of craniofacial reconstruction. In accordance with 10 years' clinical experience, direct suturing, skin graft transfer, nerve anastomosis, expanded pedicled or random flaps, facial local random flaps, reduction of mandibular fracture and correction of congenital craniofacial deformities were included in this case series. These types of treatment were applied to reconstruct facial defects or deformities according to different circumstances of patients. Directed by rational design and treatment, reconstructive surgery can be executed to treat different cases with different circumstances. A total of 891 different cases with different facial circumstances were treated with different methods: direct suturing (n = 93), skin graft transfer(n = 104), nerve anastomosis (n = 38), expanded pedicled or random flaps(n = 310), facial local random or pedicled flaps(n = 231), reduction of mandibular fracture(n = 112) and correction of congenital craniofacial deformities(n = 13). Reconstructive technique must be directed by reliable methods and special guidelines in Plastic Surgery. Three guidelines are summarised: reconstruction in the first stage and returning injured tissue to its origin site as far as possible for traumatic events; adjacent tissue must be prior to other distant tissue for reconstructive choice; and reconstruction at different stages after careful design.

A regional method for craniofacial reconstruction based on coordinate adjustments and a new fusion strategy

Craniofacial reconstruction recreates a facial outlook from the cranium based on the relationship between the face and the skull to assist identification. But craniofacial structures are very complex, and this relationship is not the same in different craniofacial regions. Several regional methods have recently been proposed, these methods segmented the face and skull into regions, and the relationship of each region is then learned independently, after that, facial regions for a given skull are estimated and finally glued together to generate a face. Most of these regional methods use vertex coordinates to represent the regions, and they define a uniform coordinate system for all of the regions. Consequently, the inconsistence in the positions of regions between different individuals is not eliminated before learning the relationships between the face and skull regions, and this reduces the accuracy of the craniofacial reconstruction. In order to solve this problem, an improved regional method is proposed in this paper involving two types of coordinate adjustments. One is the global coordinate adjustment performed on the skulls and faces with the purpose to eliminate the inconsistence of position and pose of the heads; the other is the local coordinate adjustment performed on the skull and face regions with the purpose to eliminate the inconsistence of position of these regions. After these two coordinate adjustments, partial least squares regression (PLSR) is used to estimate the relationship between the face region and the skull region. In order to obtain a more accurate reconstruction, a new fusion strategy is also proposed in the paper to maintain the reconstructed feature regions when gluing the facial regions together. This is based on the observation that the feature regions usually have less reconstruction errors compared to rest of the face. The results demonstrate that the coordinate adjustments and the new fusion strategy can significantly improve the craniofacial reconstructions.

Designing patient-specific 3D printed craniofacial implants using a novel topology optimization method

Large craniofacial defects require efficient bone replacements which should not only provide good aesthetics but also possess stable structural function. The proposed work uses a novel multiresolution topology optimization method to achieve the task. Using a compliance minimization objective, patient-specific bone replacement shapes can be designed for different clinical cases that ensure revival of efficient load transfer mechanisms in the mid-face. In this work, four clinical cases are introduced and their respective patient-specific designs are obtained using the proposed method. The optimized designs are then virtually inserted into the defect to visually inspect the viability of the design . Further, once the design is verified by the reconstructive surgeon, prototypes are fabricated using a 3D printer for validation. The robustness of the designs are mechanically tested by subjecting them to a physiological loading condition which mimics the masticatory activity. The full-field strain result through 3D image correlation and the finite element analysis implies that the solution can survive the maximum mastication of 120 lb. Also, the designs have the potential to restore the buttress system and provide the structural integrity. Using the topology optimization framework in designing the bone replacement shapes would deliver surgeons new alternatives for rather complicated mid-face reconstruction.

Facial soft tissue thickness among various vertical facial patterns in adult Pakistani subjects

Facial reconstruction techniques are used to obtain an approximation of an individual's appearance thus helping identification of unidentified decedents from their dried skeletal remains. Many of these techniques rely on the sets of average facial soft tissue thickness (FST) values at different anatomical landmarks provided by the previous studies. FST is influenced by the age, sex, ethnicity and the body mass index of the individual. Recent literature has shown that the anthropological variations of the skull may also affect FST at certain points. This study was designed to evaluate the effect of such variations in vertical skull morphology on FST as around one third of different population groups have either a long or short facial pattern as compared to the average facial pattern. Moreover, this study also provides a FST database for the adult Pakistani subjects that may have potential implications in the facial reconstruction of the local subjects. A retrospective analysis of 276 lateral cephalograms of adult subjects having normal sagittal facial pattern was performed. Subjects were categorized into three vertical facial patterns (long face=95, average face=102, short face=79) according to the vertical dimensions of the skull and the FST was measured at 11 midline points. To compare the FST between males and females Mann-Whitney U test was used. Kruskal-Wallis test was applied to compare FST among three vertical facial patterns. The results of our study revealed significant differences in FST at nine landmarks between males and females. These sex-based differences were more pronounced in the long and short facial patterns as compared to the average facial pattern. FST at stomion, pogonion, gnathion and menton was significantly greater in the short facial pattern as compared to the long facial pattern in both the sexes. The results of the present study highlight the importance of anthropological analysis of the skull and taking the vertical skeletal dimension into consideration while performing facial reconstruction.

Porous polyethylene implants in facial reconstruction: Outcome and complications

The aim of the present study was to assess the indications, results and complications of patients treated with porous polyethylene (Medpor(®)) implants in the Department of Oral and Maxillofacial Surgery of VU Medical Centre, Amsterdam over 17 years. A total of 69 high-density porous polyethylene implants (Medpor(®) Biomaterial; Porex Surgical, Newman, GA) were used in forty patients (22 males, 18 females). All patients were analysed for gender, age, diagnosis, indications for surgery, follow-up period and postoperative complications. A mean age of 34.1 years was observed. The main reason for implant surgery was post-traumatic functional impairment (27.5%). Most implants were placed at the mandibular angel and the orbital floor. Unsatisfactory appearance scored the highest in postoperative complications (10.1%) followed by infection rate (7.2%). Comparing the number of implants placed over the years and the incidence of complications, makes the overall complications rate of porous polyethylene very low. A consensus about antibiotic prophylaxis is needed. The objective measurements in patient satisfaction and proper implant design would be of great use.

Impact of body mass index, gender, and smoking on thickness of free soft tissue flaps used for orofacial reconstruction

Donor-site selection may play an important role in the reconstruction of large orofacial defects. The thickness and structure of transplanted tissue has to fit those of the recipient site to achieve a satisfactory outcome. To evaluate the thickness of free flaps that are frequently used for orofacial reconstruction and its association with body mass index (BMI), gender, and smoking, a prospective study was conducted. A total of 122 volunteers were included in the study, and their data regarding BMI, gender, and tobacco use were documented. Ultrasonography was used to evaluate the thickness of the radial and ulnar forearm flaps (RFFF and UFFF, respectively), the scapular and parascapular flaps (SF and PSF, respectively), the anterolateral thigh flap (ALT), and the free fibular flap (FF). Correlation and regression analysis were performed to assess any relationship among parameters and to investigate their effect on flap thickness. The UFFF showed the lowest thickness (0.65 ± 0.16 cm), followed by the RFFF (0.83 ± 0.20 cm). The FF showed a comparable thickness (0.82 ± 0.26 cm), followed by the SF (0.99 ± 0.13 cm) and the PSF (1 ± 0.14 cm). The ALT flap displayed the greatest thickness (1.42 ± 0.42 cm) and correlated especially with BMI and gender, whereas the UFFF was the thinnest with relatively constant values, regardless of potential influential factors.

Patient-specific reconstruction plates are the missing link in computer-assisted mandibular reconstruction: A showcase for technical description

INTRODUCTION

Preoperative planning of mandibular reconstruction has moved from mechanical simulation by dental model casts or stereolithographic models into an almost completely virtual environment. CAD/CAM applications allow a high level of accuracy by providing a custom template-assisted contouring approach for bone flaps. However, the clinical accuracy of CAD reconstruction is limited by the use of prebent reconstruction plates, an analogue step in an otherwise digital workstream.

TECHNICAL REPORT

In this paper the integration of computerized, numerically-controlled (CNC) milled, patient-specific mandibular plates (PSMP) within the virtual workflow of computer-assisted mandibular free fibula flap reconstruction is illustrated in a clinical case. Intraoperatively, the bone segments as well as the plate arms showed a very good fit. Postoperative CT imaging demonstrated close approximation of the PSMP and fibular segments, and good alignment of native mandible and fibular segments and intersegmentally. Over a follow-up period of 12 months, there was an uneventful course of healing with good bony consolidation.

CONCLUSION

The virtual design and automated fabrication of patient-specific mandibular reconstruction plates provide the missing link in the virtual workflow of computer-assisted mandibular free fibula flap reconstruction.

Utility of high density porous polyethylene implants in maxillofacial surgery

The aim of this paper was to determine the utility of high density porous polyethylene implants (HDPE) in a variety of facial skeletal deformities. Sixteen patients (age range 14-28 years) with facial deformities requiring skeletal defect reconstruction or augmentation, treated between January 2008 and December 2010. The follow-up of the patients ranged from 6 months to 2 years.The types of deformities and defects treated include: one patient each with hemifacial microsomia and nasal tip correction, two patients each with malar deformities and orbital floor reconstruction, three patients with paranasal deformities and mandibular hypoplasia and four patients with chin augmentation. A total of 24 implants were placed. The complications included infection and wound dehiscence in one patient. The implants were palpable extraorally in two patients. It is concluded that HDPE is an excellent alternative to autogenous grafts for facial skeletal augmentation. Its porous nature, excellent soft tissue growth and coverage are the advantages and disadvantages include its rigidity and sometimes it is palpable extraorally.

Evaluation of antibiotic releasing porous polymethylmethacrylate space maintainers in an infected composite tissue defect model

This study evaluated the in vitro and in vivo performance of antibiotic-releasing porous polymethylmethacrylate (PMMA)-based space maintainers comprising a gelatin hydrogel porogen and a poly(dl-lactic-co-glycolic acid) (PLGA) particulate carrier for antibiotic delivery. Colistin was released in vitro from either gelatin or PLGA microparticle loaded PMMA constructs, with gelatin-loaded constructs releasing colistin over approximately 7 days and PLGA microparticle-loaded constructs releasing colistin for up to 8 weeks. Three formulations with either burst release or extended release at different doses were tested in a rabbit mandibular defect inoculated with Acinetobacter baumannii (2×10(7) colony forming units ml(-1)). In addition, one material control that released antibiotic but was not inoculated with A. baumannii was tested. A. baumannii was not detectable in any animal after 12 weeks on culture of the defect, saliva, or blood. Defects with high dose extended release implants had greater soft tissue healing compared with defects with burst release implants, with 8 of 10 animals showing healed mucosae compared with 2 of 10 respectively. Extended release of locally delivered colistin via a PLGA microparticle carrier improved soft tissue healing compared with implants with burst release of colistin from a gelatin carrier.

A spatially-dense regression study of facial form and tissue depth: towards an interactive tool for craniofacial reconstruction

Forensic Craniofacial Reconstruction (CFR) is an investigative technique used to illicit recognition of a deceased person by reconstructing the most likely face starting from the skull. A key component in most CFR methods are estimates of facial soft tissue depths (TD) at particular points (landmarks) on the skull based on averages from databases of TD recordings. These databases vary in their method of extraction, number and position of landmarks (usually sparse <100), condition of the body, population studied, and sub-categorization of the data. In this work a new dataset is presented in a novel manner based on 156 CT scans using a spatially-dense set (∼7500) of TD recordings to allow for a complete understanding of TD variation interpolating between typical landmarks. Furthermore, to unravel the interplay between soft-tissue layers, skull and facial morphology, TD and Facial Form (FF) are investigated both separately and combined. Using a partial least squares regression (PLSR) analysis, which allows for working with multivariate and spatially-dense data, on metadata of Sex, Age and BMI, different significant patterns on TD and FF variation were found. A similar, but with TD and FF combined, PLSR generated a model useful to report on both, in function of Sex, Age and BMI. In contrast to other datasets and due to the continuous nature of the regression there is no need for data sub-categorization. In further contrast, previous datasets have been presented in tabulated form, which is impractical for spatially-dense data. Instead an interactive tool was built to visualize the regression model in an accessible way for CFR practitioners as well as anatomists. The tool is free to the community and forms a base for data contributions to augment the model and its future use in practice.

The promotion of mandibular defect healing by the targeting of S1P receptors and the recruitment of alternatively activated macrophages

Endogenous signals originating at the site of injury are involved in the paracrine recruitment, proliferation, and differentiation of circulating progenitor and diverse inflammatory cell types. Here, we investigate a strategy to exploit endogenous cell recruitment mechanisms to regenerate injured bone by local targeting and activation of sphingosine-1-phosphate (S1P) receptors. A mandibular defect model was selected for evaluating regeneration of bone following trauma or congenital disease. The particular challenges of mandibular reconstruction are inherent in the complex anatomy and function of the bone given that the area is highly vascularized and in close proximity to muscle. Nanofibers composed of poly(DL-lactide-co-glycolide) (PLAGA) and polycaprolactone (PCL) were used to delivery FTY720, a targeted agonist of S1P receptors 1 and 3. In vitro culture of bone progenitor cells on drug-loaded constructs significantly enhanced SDF1α mediated chemotaxis of bone marrow mononuclear cells. In vivo results show that local delivery of FTY720 from composite nanofibers enhanced blood vessel ingrowth and increased recruitment of M2 alternatively activated macrophages, leading to significant osseous tissue ingrowth into critical sized defects after 12 weeks of treatment. These results demonstrate that local activation of S1P receptors is a regenerative cue resulting in recruitment of wound healing or anti-inflammatory macrophages and bone healing. Use of such small molecule therapy can provide an alternative to biological factors for the clinical treatment of critical size craniofacial defects.