Virtual surgical planning and computer-aided surgery were used to treat a mono-ostotic fibrous dysplasia of the right zygoma. Mirroring of the contralateral zygoma sets the target for the contouring of the affected zygomatic bone. An optical system for computer-guided surgery was used. Instruments were calibrated and visualized in real time on screen. Achievement of the virtually set target for the orbitozygomatic anatomy was assessed during surgery. Postoperative computed tomography and clinical follow-up confirmed an excellent result with regard to facial symmetry and eye bulb position. The volume of the orbit was increased from 24.2 to 26.0 mL compared with a contralateral orbital volume of 25.7 mL. Computer-guided surgery may be a useful tool in the surgical reduction of craniofacial fibrous dysplasia.

ABSTRACT: Blowout fractures in the medial orbital wall may lead to enophthalmos, ocular dysmotility, and diplopia. Ten consecutive patients with unilateral, isolated fractures of the medial orbital wall were retrospectively studied. The radiologic accuracy of the medial orbital wall reconstructions and the long-term clinical outcomes were assessed. All cases were treated through a bicoronal approach and by use of porous polyethylene-titanium implants. The total fracture area and the orbital volume increase from the blowout were measured on computed tomographic scans. Next, we evaluated the reconstruction in the posterior part of the medial wall. This was done by calculating the ratio between the defect area and the implant area located behind the anterior ethmoidal canal. The patients were examined at least 1 year after the operation, and the rates of enophthalmos and diplopia were evaluated. The mean fracture defect area was 2.45 cm (range, 0.41-4.16 cm), and the mean volume increase from the blowout fractures was 1.82 cm (range, 0.53-2.76 cm). The orbital volume was accurately restored in all patients. However, the ratio of implant to defect area behind the anterior ethmoidal canal ranged from 0% to 100%(mean, 47.3%). None of the patients had enophthalmos or diplopia at the long-term follow-up. The results confirm that restoration of orbital volume is important to prevent postoperative enophthalmos in isolated medial orbital blowout fractures. Complete reconstruction of the most posterior part of the medial orbital wall seems to be of lesser importance.

ABSTRACT: This article presents a treatment strategy for early release of interalveolar synechiae, aiming to facilitate early oral feeding and prevent temporomandibular joint ankylosis.The treatment results of 2 patients with van der Woude syndrome were retrospectively studied. Both patients underwent early surgical release of interalveolar synechiae under general anesthesia through fiberscopic nasal intubation. The 2 patients were treated at the ages of 6 and 14 days, respectively. The interincisival distances increased from 5 and 6 mm preoperatively to 11 and 10 mm immediately after surgery. This was increased further to 25 and 20 mm at long-term follow-up (6 and 24 months).In conclusion, synechiae between the upper and lower jaws can be safely treated at a very early age under general anesthesia with fiberscopic nasotracheal intubation. The purpose of early intervention in these cases is to facilitate oral feeding and prevent temporomandibular joint ankylosis.

OBJECTIVES: The composition of tumor stroma and the activity of tumor associated fibroblasts are important for tumor growth. Interactions between carcinoma cells and fibroblasts regulate the turnover of extracellular matrix (ECM). Here, the in vitro effects of oral squamous cell carcinoma (SCC) cells (UT-SCC-30 and UT-SCC-87) on fibroblast expression of genes for ECM components and connective tissue growth factor (CTGF/CCN2), were compared to those of normal oral keratinocytes (NOK). MATERIALS AND METHODS: Cocultures with fibroblasts in collagen gels and keratinocytes with the two cell types separated by a semi permeable membrane were used, and relative gene expression was measured with real-time PCR. RESULTS: All investigated genes were regulated by NOK and the SCCs. The downregulation of pro-collagens α1(I) and α1(III) was more pronounced in cocultures with NOK, while the expression of CCN2 and fibronectin was downregulated by both NOK and the SCCs to a similar extent. UT-SCC-87, but not UT-SCC-30, secreted significantly more IL-1α than NOK. A recombinant interleukin-1 receptor antagonist reversed many of the observed effects on fibroblast gene expression suggesting involvement of IL-1 in cocultures with NOK as well as with SCCs. CONCLUSION: The observed differential effects on fibroblast gene expression suggest that NOK are more antifibrotic compared to UT-SCC-30 and UT-SCC-87. These findings may contribute to a better understanding of the mechanisms behind ECM turnover in tumors.

BACKGROUND The collected experience from facial allotransplantations has shown that the recovery of sensory function of the face graft is unpredictable. Unavailability of healthy donor nerves, especially in central face defects may contribute to this fact. Herein, the technical feasibility of transferring the supraorbitary nerve (SO) to the infraorbitary nerve (IO) in a model of central facial transplantation was investigated. METHODS Five heads from fresh cadavers were dissected with the aid of 3× loupe magnification. Measurements of the maximum length of dissection of the SO nerve through a supraciliary incision and the IO nerve from the skin of the facial flap to the infraorbital foramen were performed. The distance between supraorbital and infraorbital foramens and the calibers of both nerves were also measured. In all dissections, we simulated a central allotransplantation procedure and assessed the feasibility of directly transferring the SO to the IO nerve. RESULTS The average maximum length of dissection for the IO and SO nerve was 1.4 ± 0.3 cm and 4.5 ± 1.0 cm, respectively. The average distance between the infraorbital and supraorbital foramina was 4.6 ± 0.3 cm. The average calibers of the nerves were of 1.1 ± 0.2 mm for the SO nerve and 2.9 ± 0.4 mm for the IO nerve. We were able to perform tension-free SO to IO nerve coaptations in all specimens. CONCLUSION SO to IO nerve transfer is an anatomically feasible procedure in central facial allotransplantation. This technique could be used to improve the restoration of midfacial sensation by the use of a healthy recipient nerve in case of the recipient IO nerves are not available secondary to high-energy trauma. © 2012 Wiley Periodicals, Inc. Microsurgery, 2012.

To investigate the mechanisms behind the antifibrotic effect associated with epidermal regeneration, the expression of 12 fibroblast genes important for the modulation of the extracellular matrix (ECM), as well as α-smooth muscle actin, was studied in a keratinocyte-fibroblast organotypic skin culture model. The study was performed over time during epidermal generation and in the presence or absence of the profibrotic factor transforming growth factor-β. the Presence of epidermal differentiation markers in the model was essentially coherent with that of native skin. Fibroblast gene expression was analyzed with real-time polymerase chain reaction after removal of the epidermal layer. After 2 days of air-exposed culture, 11 out of the 13 genes studied were significantly regulated by keratinocytes in the absence or presence of transforming growth factor-β. The regulation of connective tissue growth factor, collagen I and III, fibronectin, plasmin system regulators, matrix metalloproteinases and their inhibitors as well as α-smooth muscle actin was consistent with a suppression of ECM formation or contraction. Overall, the results support a view that keratinocytes regulate fibroblasts to act catabolically on the ECM in epithelialization processes. This provides possible mechanisms for the clinical observations that reepithelialization and epidermal wound coverage counteract excessive scar formation.

ABSTRACT: Advances in biotechnology continue to introduce new materials for reconstruction of orbital floor fractures. Which material is best fit for orbital floor reconstruction has been a controversial topic. Individual surgeon preferences have been supported by inconsistent inconclusive data. The purpose of this study was to assess and analyze published evidence supporting various materials used for orbital floor reconstruction and to develop a decision-making algorithm for clinical application. A systematic literature review was performed from which 48 studies were selected after primary and secondary screening based on set inclusion and exclusion criteria. This cumulatively included 3475 separate orbital floor reconstructions. Results revealed risk and benefit profiles for all materials. Autologous calvarial bone grafts, porous polyethylene, and polydioxanone (PDS) were most widely used for orbital floor reconstruction. Increased infection rates were reported with polyglactin 910/PDS composites and silastic rubber. Ocular motility was reduced most with lyophilized dura and PDS. Preoperative and postoperative rates for diplopia and enophthalmos varied among the materials. In conclusion, our results revealed continued inadequate evidence to exclusively support the use of any one biomaterial/implant for orbital floor reconstruction. Results have served to create a decision-making algorithm for clinical application. Our authors propose certain parameters for future studies seeking to demonstrate a comparison between 2 or more materials for orbital floor reconstruction.

BACKGROUND : There are many approaches to the medial orbital wall. However, most of them have problems with limitation of exposure, scarring, and postoperative inflammatory symptoms related to the eye. The authors used an upper eyelid crease approach to overcome these problems and investigate the usefulness of this approach. METHODS : Between 2009 and 2011, the authors used this approach in 22 patients with medial orbital wall fractures. Incisions were performed on the medial one-third of the crease and a 2- to 3-mm superomedial extension along a relaxed skin tension line. RESULTS : Postoperative computed tomographic scans demonstrated complete reduction and accurate reconstitution of the bony defect in all cases. The initial two cases had revision to correct the implant position. Follow-up ranged from 8 to 28 months, with an average of 12 months. Complications related to the operation were not observed. Diplopia and limitation of eye movement resolved in most cases. Two patients had persistent diplopia for more than 6 months that decreased with time. Enophthalmos of more than 2 mm was not observed in any orbit. The operative scar was inconspicuous. CONCLUSIONS : This approach provides several advantages, including ease of exposure, and is more familiar to the plastic surgeon than the transconjunctival approach. There is little need to retract the globe laterally, thus minimizing postoperative inflammatory symptoms related to the eye. Therefore, the authors suggest that this method should be considered as a natural and useful surgical approach to medial orbital blowout fractures. CLINICAL QUESTION/LEVEL OF EVIDENCE : Therapeutic, IV.

ABSTRACT: Blowout fractures in the medial orbital wall may lead to enophthalmos, ocular dysmotility, and diplopia. Ten consecutive patients with unilateral, isolated fractures of the medial orbital wall were retrospectively studied. The radiologic accuracy of the medial orbital wall reconstructions and the long-term clinical outcomes were assessed. All cases were treated through a bicoronal approach and by use of porous polyethylene-titanium implants. The total fracture area and the orbital volume increase from the blowout were measured on computed tomographic scans. Next, we evaluated the reconstruction in the posterior part of the medial wall. This was done by calculating the ratio between the defect area and the implant area located behind the anterior ethmoidal canal. The patients were examined at least 1 year after the operation, and the rates of enophthalmos and diplopia were evaluated. The mean fracture defect area was 2.45 cm (range, 0.41-4.16 cm), and the mean volume increase from the blowout fractures was 1.82 cm (range, 0.53-2.76 cm). The orbital volume was accurately restored in all patients. However, the ratio of implant to defect area behind the anterior ethmoidal canal ranged from 0% to 100%(mean, 47.3%). None of the patients had enophthalmos or diplopia at the long-term follow-up. The results confirm that restoration of orbital volume is important to prevent postoperative enophthalmos in isolated medial orbital blowout fractures. Complete reconstruction of the most posterior part of the medial orbital wall seems to be of lesser importance.

The aim of this study was to evaluate the efficacy and safety of traumatic orbital defect reconstruction with titanium mesh. A retrospective study was made. Evaluations were made after a minimum postoperative follow-up of 12 months, looking for the main complications. Twenty-four patients were included in this evaluation; 19 were male (79.1%) and 5 (20.8%) were female. The main injury etiology was vehicle accidents (50%) followed by other causes. Fourteen patients (58.3%) presented orbital floor fractures, and 10 had more than one wall fractured (41.6%). Permanent infraorbital nerve hypoesthesia was observed in two patients (8.3%), enophthalmos occurred in five patients (20.8%), and exophthalmos was found in two patients (8.3%). Four patients (16.6%) still presented evidence of residual prolapsed intraorbital content, and one of those needed further surgical correction; sinusitis occurred in one patient (4.1%). Titanium mesh is a reliable option for orbital reconstruction, despite some complications found in this sample.

BACKGROUND Posttraumatic enophthalmos resulting from medial orbital wall fractures presents a complex challenge. Access to this area through traditional incisions is limited, making visualization of the fracture site difficult. This can be ameliorated by the transcaruncular approach, but with the potential for complications both with access and with reconstructive materials. The authors sought a new technique where enophthalmos correction would be based on augmenting soft tissue volume, rather than reducing the volume of the bony orbital cone. This was successfully accomplished using porous high-density polyethylene wedges. In an effort to increase overall knowledge of this technique, a retrospective review was undertaken. METHODS A retrospective chart review was undertaken to examine the senior authors'(J.F.T. and L.H.H.) experience using a lateral approach to address medial orbital fracture-related enophthalmos, aided by porous high-density polyethylene wedges to increase orbital volume. The relevant literature was reviewed and reported here. RESULTS Three patients with post-medial orbital wall fracture enophthalmos were treated using a lateral approach to place porous high-density polyethylene wedges; this technique adequately corrected enophthalmos in these patients. CONCLUSIONS Porous high-density polyethylene wedges can be placed into the orbit through a small lateral incision to reverse enophthalmos secondary to loss of volume after medial orbital wall fractures. Current techniques for orbital reconstruction typically focus on reduction of bony volume; this technique focuses on augmentation of soft tissue volume.

We review the literature on medial orbital wall fractures and perform a meta-analysis on outcomes with the transcaruncular approach. The reported incidence for this injury ranges widely, although diagnosis can be made effectively with clinical examination and computed tomography. Clinical sequelae can include rectus entrapment or herniation, enophthalmos, and diplopia. Local injuries occurring in high concordance include concomitant fractures of the orbital floor and nasal fractures, although anterior cranial fossa extension, ocular trauma, other craniofacial injuries, and polytrauma must be ruled out. Indications for operative intervention include large defects, early or persistent enophthalmos particularly if causing diplopia, and rectus muscle entrapment.Various surgical approaches to the medial orbit have been described; however, the transcaruncular approach offers direct, reliable access without creating a cutaneous scar on the central face. A meta-analysis was performed on all studies reporting outcomes of the transcaruncular approach. A total of 228 cases were pooled, finding a favorable overall complication rate of 2.6%. Half of these complications required surgical correction and half resolved nonoperatively.Medial orbital wall fractures are an increasingly appreciated injury requiring clinical and radiologic assessments. When indicated, reconstruction of the medial orbital wall can be safely and effectively performed with the transcaruncular approach. Additional prospective outcomes studies are required to elucidate (1) the incidence of medial orbital wall fractures,(2) indications for operative versus nonoperative management, and (3) outcomes analysis of the transcaruncular approach compared with other approaches.

PURPOSE This study aimed to illustrate the effectiveness of the combination of the transorbital and the endoscopic transnasal approach in the repair of medial wall and floor orbital fractures in Chinese patients. METHODS A retrospective study was carried out on 25 Chinese patients (18 men and 7 women) with orbital medial wall and floor fractures. All patients had enophthalmos more than 2 mm, 23 had diplopia, and 11 had eye movement restriction. Bone defect involving both medial and inferior walls was found with computed tomographic scans in all patients. In all 25 patients, surgery was done by 1 surgeon group using the transorbital and the endoscope-assisted transnasal approach. The endoscope was used to give a clear view of the posterior edge of the fracture. Titanium meshes were used to repair fractures of the orbital floor and the medial wall. Porous polyethylene sheet implants were used to recover the orbital volume. All patients were followed up 12 months after surgery. RESULTS Enophthalmos was corrected in all 25 patients immediately, diplopia disappeared or improved in 21 of 23 cases, and eye movement restriction was released or improved in all 11 patients. No significant complications occurred. The titanium mesh was completely covered by nasal mucosa at 1 month after surgery by an endoscopic check. CONCLUSIONS The endoscope-assisted transnasal approach allows for excellent visualization of the extent of the fracture, particularly in areas that are difficult to visualize by conventional methods. The combination of the transorbital and the endoscope-assisted transnasal approach is a good way to reconstruct a large orbital wall fracture involving the floor and the medial wall.

PURPOSE In many cases of trapdoor-type orbital blowout fracture, the bony segment has a stable hinge consisting of a greenstick fracture and the sinus mucoperiosteum that is attached to the intact orbital wall. If the displaced bony segment opposite the hinge will be reduced into its original position and will be fixed onto the unaffected bone, the orbital fracture may be reconstructed via the internal fixation of the bony segment itself rather than requiring substitution with an alloplastic implant or a bone graft. METHODS A retrospective study was conducted from January 2008 to February 2010 in 34 patients with blowout fracture, via retrospective chart review, including detailed preoperative and postoperative evaluations, age, sex, symptoms, and signs, and based on the postoperative complications. The subciliary, transconjunctival, and transcaruncular approaches were used to expose the orbital floor under general anesthesia. The herniated orbital soft tissue was carefully reduced. The displaced bony segment was carefully pulled up and placed in its original anatomic position with a skin hook. A small absorbable mesh plate was inserted between the normal orbital wall and the bony segment, tangential to the edge of the bony defect at the dependent portion. RESULTS Postoperative examinations such as the traction and forced duction tests showed no eye movement limitation and surgical complications. During the follow-up period, no complications occurred, and the orbital wall was accurately reconstructed in its original anatomic position, as confirmed by postoperative computed tomography scans. CONCLUSIONS The advantages of internal fixation include anatomic reconstruction of the orbital wall, preservation of the original orbital bone and the mucoperiosteum of the sinus resulting in rapid wound healing and normal mucus drainage function of the sinus, simplicity of the procedure, and the absence of surgery-related complications. This technique is presented as one of the preferred treatments for trapdoor-type orbital blowout fracture.

In the present article, the authors want to present the results of a retrospectively evaluated consecutive series of patients with surgically treated isolated orbital floor fractures (OFF;"blow-out fractures") concerning the functional outcome after OFF and give detailed recommendations based on the clinical and radiological findings. A series of 60 patients with isolated OFF over a 5-year period needing surgically repair at the same institution were evaluated. Patient data were analysed in terms of preoperative and postoperative clinical parameters and radiological findings. The analysed parameters were type of fracture, diplopia, gaze restriction, enophthalmos, materials used for repair, surgical approach and timing of the surgical intervention. Burst type fractures were more often found than punched-out fractures. The most frequently used surgical approach was a preseptal transconjunctival approach. An overall decrease of gaze restriction (93%), diplopia (89%) and enophthalmos (86%) was observed. According to the fracture size, we used Ethisorb® patches in smaller fractures and resorbable or titanium meshes or autologous bone in larger fractures in most cases. Patients who underwent surgery more than 7 days after the trauma showed better results with regard to an improvement of diplopia and motility disturbances than patients who were treated immediately. In indicated cases, the surgical repair of OFF leads to very good results if the anatomical and functional properties of the orbit and its contents are respected. The applied strategy and means presented in our study proved of value and can therefore be recommended.

PURPOSE: To evaluate the outcome of autologous bone grafts in the reconstruction of orbital floor fractures. A retrospective interventional case series was performed at a tertiary trauma center. MATERIALS AND METHODS: All patients with traumatic orbital floor fractures that had been reconstructed using calvarial or iliac autogenous bone grafts from August 2006 to January 2010 were included in the present study. The operations were performed by the same team of maxillofacial and oculoplastic surgeons. The patients were evaluated pre- and postoperatively for the presence of enophthalmus and diplopia. The surgical technique was tailored to best fit the patient's clinical characteristics, with attention to the cosmetic and functional outcomes and the preferred use of a sutureless transconjunctival technique, when applicable. The main outcome measures were residual enophthalmus, diplopia, and the complication rate. RESULTS: A total of 16 patients (11 males and 5 females), with an average age of 34.4 years, underwent orbital floor reconstruction using an autologous bone graft. Calvarial and iliac bone grafts were used in 11 and 5 patients, respectively. A transconjunctival approach was applied in 10 patients. All patients achieved good cosmetic and functional outcomes, with improvement in enophthalmus. Three patients had residual diplopia postoperatively that was probably due to traumatic muscular injury. No significant perioperative or long-term complications were noted during a mean follow-up of 12.5 months. CONCLUSION: Reconstruction of orbital floor fractures after trauma using autologous bone grafts is safe and associated with a low rate of complications. Combining the appropriate surgical approach with multidisciplinary teamwork results in excellent cosmetic and functional outcomes and allows for efficient and comprehensive postoperative management.