Our experience in the surgical management of craniofacial fibrous dysplasia: what has changed in the last 10 years?

Craniofacial Fibrous Dysplasia: Experience at San José Hospital, Bogotá, Colombia

INTRODUCTION

Fibrous dysplasia is a disorder in which normal bone is gradually replaced by immature fibro-osseous tissue, with an incidence of less than 7% of all benign bone tumors. The management of this disease is a challenge for plastic surgeons and neurosurgeons.

GOAL

To describe the diagnostic, therapeutic, and outcome approach of patients with craniofacial fibrous dysplasia seen at the Plastic Surgery Service of the Hospital San José in Bogotá, Colombia.

METHODS

This is a descriptive and retrospective case series study of patients diagnosed with monostotic and polyostotic fibrous dysplasia treated at the Plastic Surgery Department of Hospital San José during the period from January 1, 2010, to July 31, 2023.

RESULTS

All (n=10) of the patients had monostotic craniofacial fibrous dysplasia. The most affected bones in patients with monostotic fibrous dysplasia were zone I bones (n=10, 100%), followed by zone II bones (n=2, 20%). Patients with zone I and II involvement manifested throbbing headaches associated with phosphenes and tinnitus (n=8, 80%) and pain during occlusion associated with edema in the affected cheek (n=5, 50%). Physical examination showed that patients with orbital wall involvement (zone I bone) had ocular dystopia (n=7, 70%).Regarding the treatment received by the patients, 90% (n=9) of the patients received surgical management as primary treatment, with orbitotomy, replacement, and/or remodeling of the roof and lateral wall of the orbit with bone graft, drilling, canthoplasty, ciliary suspension being the most frequently performed procedure (n=6, 60%). Of the patients, 20% (n=2) required reintervention.

CONCLUSIONS

FD is a slowly progressive benign fibro-osseous disease that requires a timely, individualized, and multidisciplinary diagnosis and treatment to obtain favorable clinical and surgical results.The mainstay of treatment is surgery as a preventive measure since it is important to avoid future functional alterations that, depending on the location of the dysplasia, would cause a high risk of alteration of adjacent structures.

Functional outcomes and recurrence determinants in craniofacial fibrous dysplasia: Insights from 3D computed tomography and comprehensive clinical evaluation

BACKGROUND

This study aimed to identify risk factors for postoperative lesion regrowth and to assess functional outcomes in craniofacial fibrous dysplasia, using a three-dimensional computed tomographic volumetric analysis.

METHODS

A retrospective analysis was conducted on 47 patients with craniofacial fibrous dysplasia who were treated from July 2005 to December 2020. Patients were treated with either conservative shaving or radical excision followed by reconstruction. Demographic data, surgical details, lesion recurrence, and functional outcomes were assessed. Lesion volume changes and recurrence were evaluated clinically and through a computed tomographic volumetric analysis.

RESULTS

Among the patients, 16 underwent conservative treatment, whereas 31 received radical treatment. The radical group showed more significant improvements in functional outcomes, particularly in orbital dystopia and facial asymmetry. Postoperative lesion volume was notably lower in the radical group (41.94 ± 38.13 cm3) compared with the conservative group (78.3 ± 47.3 cm3, p = 0.008). This reduction was maintained over an average follow-up of 3 years. Lesion growth rates were similar between the groups (8.17 ± 5.85% in radical vs. 5.84 ± 6.43% in conservative, p = 0.268). Multivariate analysis indicated that patients aged ≤20 years and those with multifocal involvement had significantly higher risks of recurrence, with adjusted odds ratios of 11.269 (p = 0.039) and 6.914 (p = 0.046), respectively.

CONCLUSIONS

Our findings suggest that both conservative and radical treatments for craniofacial fibrous dysplasia provide benefits, with the radical approach notably enhancing functional outcomes. However, neither method definitively reduces lesion recurrence, highlighting the necessity for an individualized treatment strategy. This approach should balance functional enhancement with recurrence risks, tailored to each patient's specific clinical scenario.

Craniofacial fibrous dysplasia: Systematic review of facial management

Craniofacial fibrous dysplasia (CFD) may be associated with major cosmetic or functional consequences. However, management recommendations for CFD are currently unavailable. Therefore, this systematic literature review aimed to review the existing approaches for CFD management and propose a management algorithm. The focus question was "What are the different options for CFD treatment and their complication rates?" The MEDLINE database was searched, and 33 articles evaluating a total of 1154 patients were reviewed. The bias assessment showed that 20 of the 33 studies had a high or intermediate risk of bias, mainly because of retrospective data collection and small patient numbers. Radical surgery showed a lower recurrence rate than debulking, but its use should be weighed against the morbidity caused by the reconstruction performed in this technique. Orbital decompression using a radical technique or debulking is effective in cases showing exophthalmos or dystopia. Surveillance is a viable option for asymptomatic and/or non-progressive lesions. In cases showing optic nerve compression, prophylactic decompression should be avoided, and decompression should be performed only when patients show diminished visual acuity or visual field defect. Although bisphosphonates have shown efficacy in pain management, their posology requires further discussion. A management algorithm is presented.

Fibrous Dysplasia of the Jaw: Advances in Imaging and Treatment

A total of 7% of all benign bone lesions are diagnosed as fibrous dysplasia (FD). The symptoms of FD of the jaw range from asymptomatic to dental anomalies, pain and facial asymmetry. Due to its resemblance to other fibro-osseous bone lesions, misdiagnosis often occurs and can lead to inadequate treatment. Particularly in the jaw, this lesion does not become quiescent during puberty, making fundamental knowledge about the diagnosis and treatment of FD crucial. Mutational analysis and nonsurgical approaches offer new diagnostic and therapeutic options. In this review, we examine the advances and the difficulties of the diagnosis and the various treatment modalities of FD of the jaw in order to capture the current scientific knowledge on this bone disease.

Computer-guided contouring of craniofacial fibrous dysplasia involving fronto-orbital or fronto-cranial region using patient specific surgical depth guide: A prospective case series

The aim of this study was to introduce a new computer guided technique for debulking and contouring the craniofacial fibrous dysplasia involving the fronto-orbital and fronto-cranial regions. Computer-guided contouring was performed using a modified patient-specific surgical depth guide for six patients with craniofacial fibrous dysplasia involving the fronto-orbital and fronto-cranial regions. Virtual planning was performed to determine the desired amount of bone removal and construct the patient-specific surgical depth guide. Then, the guide was printed using rapid prototyping. In the surgical theatre, the guide was seated in position. Implant drills were inserted through the created depth holes according to the planned fixed depth to create depth holes. Finally, the bone in between the created holes was removed using cutting discs, bone chisels and surgical burs. Satisfaction with facial aesthetics was evaluated by the patients using a Likert scale, and by the surgeons using the Whitaker rating scale. The surgical procedures were uneventful for all the patients. All the patients were satisfied with the post-operative facial esthetics and categorized as category I Whitaker rating scale. Patient-specific surgical guide technique for recontouring of fronto-orbital and fronto-cranial fibrous dysplasia can be considered an accurate substitution technique that overcomes the drawbacks of the unpredictable conventional one. Further investigations are required.

Polyostotic Fibrous Dysplasia: A Case Report of Rarity

A skeletal condition known as fibrous dysplasia (FD) is characterized by the replacement of healthy bone with fibrous bone tissue. One bone (monostotic) or several bones could be involved (polyostotic). Any bone in the body might become affected by FD. The skull and face bones are the most typical locations. It is connected to a GNAS1 gene mutation (20q13.2). It begins during childhood and could continue far into adolescence and adulthood. In this case study, a 22-year-old woman was identified as having polyostotic FD based on her clinical, radiological, and histological characteristics.

Neurosurgical Treatment and Outcome of Pediatric Skull Base Lesions: A Case Series and Review of the Literature

INTRODUCTION

Pediatric skull base lesions occur rarely and are of various etiologies. Traditionally, open craniotomy has been the treatment of choice; however, nowadays, endoscopic approaches are increasingly applied. In this retrospective case series, we describe our experience in treating pediatric skull base lesions and provide a systematic overview of the literature on the treatment and outcome of pediatric skull base lesions.

METHODS

We conducted a retrospective data collection of all pediatric patients (<18 years) treated for a skull base lesion at the Division of Pediatric Neurosurgery, University Children's Hospital Basel, Switzerland, between 2015 and 2021. Descriptive statistics and a systematic review of the available literature were additionally conducted.

RESULTS

We included 17 patients with a mean age of 8.92 (±5.76) years and nine males (52.9%). The most common entity was sellar pathologies (n = 8 47.1%), with craniopharyngioma being the most common pathology (n = 4, 23.5%). Endoscopic approaches, either endonasal transsphenoidal or transventricular, were used in nine (52.9%) cases. Six patients (35.3%) suffered from transient postoperative complications, while in none of the patients these were permanent. Of the nine (52.9%) patients with preoperative deficits, two (11.8%) showed complete recovery and one (5.9%) partial recovery after surgery. After screening 363 articles, we included 16 studies with a total of 807 patients for the systematic review. The most common pathology reported in the literature confirmed our finding of craniopharyngioma (n = 142, 18.0%). The mean PFS amongst all the studies included was 37.73 (95% CI [36.2, 39.2]) months, and the overall weighted complication rate was 40% (95% CI [0.28 to 0.53] with a permanent complication rate of 15% (95% CI [0.08 to 0.27]. Only one study reported an overall survival of their cohort of 68% at five years.

CONCLUSION

This study highlights the rarity and heterogeneity of skull base lesions in the pediatric population. While these pathologies are often benign, achieving GTR is challenging due to the deep localization of the lesions and eloquent adjacent structures, leading to high complication rates. Therefore, skull base lesions in children require an experienced multidisciplinary team to provide optimal care.

Craniomaxillofacial Fibrous Dysplasia Improved Cosmetic and Occlusal Problem by Comprehensive Treatment: A Case Report and Review of Current Treatments

Fibrous dysplasia (FD) is a fibrous lesion of immature bone, with an incidence of 10–20% in the head and neck region. Most cases are monostotic, but when a lesion occurs on the maxillofacial region and spreads to the surrounding bone, it is classified as polyostotic, despite its localized occurrence. In some cases, surgical intervention is required to improve the cosmetic or functional disturbance of a FD in the maxillofacial region, but it is necessary to confirm symmetry of the maxillofacial region in real time, and a surgical support system is required to compensate. Furthermore, prosthetic intervention is considered when postoperative acquired defects occur or further cosmetic or occlusal function improvement is needed. A comprehensive approach by an oral surgeon and a maxillofacial prosthodontist is necessary for the successful treatment and rehabilitation of such patients. In this article, we describe the case of a craniomaxillofacial FD patient with facial asymmetry and denture incompatibility with improved quality of life measures by integrating surgical treatment using a navigation system and postoperative prosthetic rehabilitation. We also discuss recent diagnostic methods and treatment strategies for craniomaxillofacial FD in the literature.

Management Strategies of Fibrous Dysplasia Involving the Paranasal Sinus and the Adjacent Skull Base

OBJECTIVE

Current management of fibrous dysplasia (FD) involving the paranasal sinuses and the adjacent skull base is currently controversial. This study aims to present our experience in the management strategy of FD that involves the paranasal sinuses and the adjacent skull base.

METHODS

Twenty three patients from 2006 to 2019 with monostotic fibrous dysplasia (MFD), polyostotic fibrous dysplasia (PFD), or McCune-Albright syndrome (MAS) involving the paranasal sinuses and the adjacent skull base were retrospectively reviewed. This study series was divided into 3 groups based on management strategies: the observation group, the surgery group, and the optic nerve decompression group.

RESULTS

The observation group included 9 patients with asymptomatic MFD with stable condition during the follow-up period of 15 to 164 months. The surgery group included 10 symptomatic patients with MFD who had personalized endoscopic endonasal surgery. The symptoms of the patients were relieved after surgery. The optic nerve decompression group included 4 patients with visual loss, who underwent endonasal endoscopic optic nerve decompression (EOND) with the aid of image-guided navigation. Their vision improved after surgery.

CONCLUSIONS

Clinical observation and periodic computed tomography (CT) scan are adopted for asymptomatic patients. Surgery is indicated in symptomatic patients. Optic nerve decompression is recommended as soon as possible if the patient has visual loss, whereas prophylactic decompression is not recommended if the optic nerve is encroached by FD without visual loss. Navigation plays an important role in endoscopic surgery involving the paranasal sinuses and the adjacent skull base, especially in FD resection and optic nerve decompression.

Cranial fibrous dysplasia: An institutional experience and review of the literature

Background:

Cranial or craniofacial fibrous dysplasia (CFD) is a rare entity which most often presents with either incidental finding or with pain/cosmetic disfigurement or visual/hearing problems. Multidisciplinary treatment with close follow-up or medical management/surgery is options. Management of these lesions can often give satisfying results. There is a dearth of neurosurgical literature on this subject matter. Our objective was to review the clinical symptomatology and outcome of CFD patients managed in our institution.

Methods:

This is a retrospective observational study of CFD patients managed in our institution over a period of 5 years. Clinical and radiological data were collected from departmental database. Outcomes were evaluated immediately and on 1–4 years follow-up.

Results:

A total of 21 patients were managed over a period of 5 years with age ranging from 12 to 55 years and symptoms of cosmetic issues or visual disturbance. Preoperative computed tomography scan with 3D reconstruction with bone window was done in all patients. In most of the patients (16/20), immediate reconstruction was done following excision. Five patients were managed conservatively. Follow-up was obtained over a period ranging from 1 to 4 years and all (except one) patients are doing well. Only one patient had permanent visual impairment in spite of early intervention.

Conclusion:

Craniofacial dysplasia has various modalities of management. Careful selection of patients for surgical or conservative management is feasible with good results both in short and long term.

An Atypical Bilateral Presentation of Fibrous Dysplasia (FD) in the Mandible: Clinical, imaging and therapeutic characterization

Introduction and importance

Fibrous Dysplasia (FD) is a benign fibro-osseous lesion, characterized by replacement with fibrous connective tissue instead of normal bone. The best treatment option for the condition has not yet been established, although several therapeutic approaches have been reported. The present case report describes the clinical, imaging and therapeutic aspects of an atypical bilateral presentation of FD in the mandible.

Case presentation

A 26-year-old afro-descendent woman, who had previously undergone surgery to remove FD in the right hemimandible, complained of asymptomatic swelling in the left hemimandible. Imaging analysis showed an ipsilateral extensive multilocular mandibular lesion, with thinning of the cortical bone. After diagnosis of FD, complete surgical removal was performed, associated with immediate local reconstruction with xenograft and covering membrane, with primary wound closure.

Clinical discussion

Bilateral presentation of FD is uncommon, and its diagnosis by means of clinical data, imaging and histopathological analysis, is relevant in order to establish the correct therapy.

Conclusion

Complete surgical removal associated with immediate local bone reconstruction, has shown satisfactory clinical results, when adequate follow-up is performed.

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There are few reports based on the atypical bilateral presentation of FD.

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The bilateral presentation of FD in young non-syndromic patients is rare.

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There is a lack of consensus regarding the best treatment for FD.

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The surgical approach is still the best choice for avoiding recurrences.

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Bone grafting after the removal of FD lesions has shown clinical satisfactory results.

Middle Ear Implant in a Patient With Fibrous Dysplasia: An Alternative for Hearing Restoration

We propose middle ear implants (MEI) as alternative hearing restoration option for patients with fibrous dysplasia of the temporal bone (FDTB). A 60-year-old man presented with unilateral right-sided conductive hearing loss (CHL) and FDTB. The Vibrant Soundbridge (VSB) MEI was implanted in the right ear. Preoperatively, the right side had a pure tone average (PTA) threshold of 67 dB, speech reception threshold (SRT) = 75 dB HL, and speech discrimination score (SDS) = 54% at 80 dB HL presentation level. Postoperative aided PTA threshold of the right ear was 28 db, aided SRT = 30 db, and SDS = 96% at 65dB HL. After excluding cholesteatoma, VSB provides an alternative hearing restoration technique for adults with FDTB and CHL due to stenosis of the external auditory canal and/or ossicular crowding.

Secondary desmoplastic fibroma-like tissue changes in mandibular fibrous dysplasia: clinicopathological and molecular study of a case

Fibrous dysplasia may show locally aggressive behaviour reflecting secondary intralesional changes, extension to soft tissue, or malignant transformation. We report the case of a patient with polyostotic fibrous dysplasia who had a giant mandibular lesion consisting of histologically typical, genotypically-confirmed, fibrous dysplasia merged with a fibrotic and hypocellular desmoplastic fibroma-like tissue in which the same Gsα-R201H mutation was detected. The occurrence of the same mutation in both the fibrous dysplasia and areas of desmoplastic fibroma suggests that the fibroma-like tissue reflects an unusual secondary tissue change within an otherwise typical fibrous dysplasia. To the best of our knowledge, only four cases of fibrous dysplasia with desmoplastic fibroma-like tissue changes have been reported.

A rare case report of craniofacial fibrous dysplasia

Fibrous dysplasia (FD) is a fibro-osseous lesion of the osseous structures of the body. The exact cause is unknown; however, recently, the cause has been reported to be postzygomatic somatic mutation in guanine nucleotide-binding protein, alpha stimulating 1 gene located at chromosome 20q13.2. The three subtypes of FD are monostotic, polyostotic and craniofacial. The term craniofacial FD (CFD) is used to describe FD where the lesions are confined to contiguous bones of the craniofacial skeleton. This report describes the case of CFD of a 20-year-old male patient who had unusual presentation involving right maxilla and frontal bone of the left side of the face. The clinical features, radiological findings and treatment have been discussed.