An Oncoplastic Approach to Primary Pediatric Pterygomaxillary Osteosarcoma

Osteosarcomas arising within the pterygomaxillary/infratemporal fossa region are rare among the pediatric population. Survival rates are most influenced by tumor resection with negative margins, which can be dependent on surgical accessibility of the tumor site. The pterygomaxillary/infratemporal fossa location poses several challenges to safe and adequate tumor resection, including proximity of the facial nerve and great vessels and scarring associated with traditional transfacial approaches. In this article, we present the case of a 6-year-old boy with an osteosarcoma of the left pterygomaxillary/infratemporal fossa region successfully managed with an "oncoplastic" approach, incorporating the use of CAD/CAM and mixed reality technologies.

"A Simplified Approach for Surgical Correction of Vertical Orbital Dystopia: A 45-year Retrospective Cohort Study."

INTRODUCTION

Vertical Orbital Dystopia (VOD) results in significant facial asymmetry, psychological distress, and poor quality of life in affected patients. The traditional approach (TA) for surgical correction has entailed a standard frontal craniotomy along with circumferential orbital osteotomy, vertical translocation of the orbit, and bone grafting to the lower maxilla. Caution has been expressed regarding its invasive transcranial nature. In this report, we describe the limited approach (LA) for simplified surgical correction of VOD, which obviates the need for a standard frontal craniotomy.

METHODS

A 45-year retrospective review was conducted of all patients that underwent surgical correction of VOD, as performed by a single surgeon. Demographic details, procedural characteristics, and complications were compared between patients who were corrected by the TA and those who were corrected by the LA. Complications were defined as CSF leak, infection of the frontal bone, permanent diplopia, permanent ptosis, sudden-onset vision loss, persistent asymmetry, and surgical revision.

RESULTS

Forty patients met inclusion criteria for correction of true VOD, of which 18 underwent the TA and 22 underwent the LA. Mean length of hospital stay was 5.3±2.3 days and 4.0±1.5 days for the TA and LA cohorts, respectively. Mean follow-up time was 4.9±7.5 years for the TA and 2.6±3.3 years for the LA. The only reported complications were persistent asymmetry in 2 patients in the TA cohort with one patient requiring surgical revision due to undercorrection, while the LA cohort exhibited no postoperative asymmetry or need for surgical revision.

CONCLUSIONS

Both the TA and LA are effective for surgical correction of VOD. The limited craniotomy of the LA reduces exposure of intracranial structures and adequately achieves postoperative symmetry.

Surgical Management of a Mild Case of Frontonasal Dysplasia: A Case Report and Review of Literature

Frontonasal dysplasia (FND) is a rare congenital craniofacial cleft syndrome associated with a spectrum of midline facial bone and soft-tissue malformations. When present, the physical features of FND are often obvious and classified at birth. The resultant facial deformities have the potential to negatively influence psychosocial health and quality of life. Reconstructive surgical intervention in early childhood can serve to restore facial contour and alleviate psychological stress. In this report, a case of a 14-year-old female with previously undiagnosed mild form of FND presented for reconstructive surgery evaluation and underwent several procedures including sliding advanced genioplasty, submucosal resection of the nasal turbinates, open rhinoplasty, and bilateral transnasal medial canthopexies. The patient had subsequent nasal tip recontouring for persistent supratip fullness. The patient achieved an acceptable esthetic outcome and was satisfied with her physical appearance. This case emphasizes the subtle presentation and reconstructive surgical options of a mild case of FND that was diagnosed at a later age, unlike the more severe phenotypes of the syndrome and other common craniofacial anomalies that are usually diagnosed and treated in early childhood. Multidisciplinary craniofacial care teams should be able to correctly diagnose and implement the appropriate surgical interventions in patients with milder forms of FND.

Surgical Management of Facial Port-Wine Stain in Sturge Weber Syndrome

Sturge Weber Syndrome is characterized by the classic triad of a facial port-wine stain, leptomeningeal angiomatosis, and glaucoma. The resultant facial vascular anomaly can lead to soft tissue and bone irregularities, causing psychosocial distress and mental health morbidity. When severe, patients can opt for multi-staged surgical intervention by reconstructive surgeons to restore normal symmetry and improve the aesthetic appearance of the face. This study reports a case of surgical correction for severe facial vascular malformation resulting in poor outcomes due to the associated mental comorbidities seen in Sturge Weber Syndrome. A 37-year-old male with previously diagnosed Sturge Weber Syndrome presented to the outpatient craniofacial clinic for surgical evaluation of a large facial tuberous hemangioma. The patient underwent multiple operations for facial reconstruction including a staged full-thickness skin graft, facial recontouring, and extracranial correction of vertical orbital dystopia. The case was complicated by the patient's poorly controlled seizure disorder and psychosocial illness, resulting in self-mutilation of the repair and poor follow-up. Over the span of 10 years, the patient's mental illness caused him to fail numerous attempts at facial restoration and ultimately led to a poor final result. The psychosocial distress seen in patients with Sturge Weber Syndrome can adversely affect surgical outcomes. Physicians should be mindful of the possible complications that can arise in these patients and have the clinical means to address them.

Fibrous dysplasia: management of the optic canal

BACKGROUND

Fibrous dysplasia is an abnormal growth of bone that can lead to severe facial disfigurement. A dreaded outcome is compression of the optic nerve, leading to blindness. Controversy has surrounded the role of optic nerve unroofing for circumferential involvement of the optic canal. At present, many neurosurgeons unroof the nerve therapeutically in the setting of optic nerve dysfunction. Prophylactic unroofing (i.e., unroofing the nerve prior to the development of visual symptoms) has been previously proposed, although reported outcomes have been mixed. The authors present their long-term results of patients who have undergone optic nerve unroofing.

METHODS

From 1975 to 2012, patients with fibrous dysplasia were investigated. Their age, demographics, operative procedure, optic nerve involvement (radiologically and clinically), and long-term outcomes and complications were recorded.

RESULTS

Over 37 years, the senior author (S.A.W.) operated on 32 patients with fibrous dysplasia. Average follow-up was 5 years. Nine patients underwent optic nerve unroofing. Two patients had bilateral unroofing. Three patients who underwent therapeutic optic nerve unroofing ultimately went on to complete vision loss. The remaining seven patients who underwent prophylactic unroofing had no immediate postoperative visual compromise.

CONCLUSIONS

Therapeutic optic nerve unroofing is advocated in fibrous dysplasia patients with continuous deterioration of vision. However, the authors believe prophylactic unroofing is safe, and it should be performed not necessarily as a primary surgical procedure, but as a procedure along with excision of fibrous dysplasia in the anterior skull base during the same operation performed for orbitocranial deformity.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Paul Tessier facial reconstruction in 1970 Iran, a series of post-noma defects

BACKGROUND

Paul Tessier was a pioneering plastic surgeon who founded craniofacial surgery and had an international influence in the field of reconstructive surgery. We reviewed his techniques in the reconstruction of post-noma defects in Iran in the late 1970s.

PATIENTS AND METHODS

We studied a series of 23 patients operated on by Tessier from 1974 to 1978 in Iran (property of Association Française des Chirurgiens de la Face). They all suffered from noma in childhood with major facial defects.

RESULTS

Ten suffered from simple lip and cheek defects, nine also from nose defects and four from extensive facial defects. Abbe flaps were used in 15 patients to reconstruct the lips completed by commissuroplasty in six patients. Nose defects were reconstructed with nasofrontal flaps (ten cases). The outer cheek was reconstructed with a rotation flap (four cases), or with a frontotemporal flap (six cases). The inner cheek was reconstructed using a Barron-Tessier myocutaneous flap (ten cases). Of the 23 patients, partial flap necrosis occurred in five cases.

CONCLUSIONS

Tessier was a pioneering plastic surgeon who used local flaps to reconstruct these important facial defects. He had a high rate of success, although nowadays local flaps are commonly replaced by free flaps.

Two extraordinarily severe cases of Treacher Collins syndrome

Here, we report two extraordinarily severe cases of Teacher Collins syndrome. Initially, amniotic bands and plical fold disruption were considered, but downslanting eyes made us consider severe Treacher Collins syndrome. A TCOF1 mutation in exon 24 was identified in Patient 1 (c.4355_4356ins14, resulting in p.1456Thrfs*18). Patient 2, who expired on day 4, is so similar to Patient 1 that severe Treacher Collins syndrome may be inferred in this instance. Neither the TCOF1 mutation nor the well-known variability in the expression in affected families with Treacher Collins syndrome (∼40% of reported cases) can explain the severity of these cases; otherwise, we would be aware of such cases within families from time to time. We are unaware of any recent sporadic cases (∼60% of reported cases) exactly like ours either with a single exception in the case reported by Writzl et al. [2008] with a TCOF1 mutation. The case described by Otto in 1841 is spectacular. We propose several hypotheses to be considered in explaining this developmental amplification, including some promoter effect on the gene, some position effect on the gene, a polymorphism elsewhere in the gene, a point mutation elsewhere in the gene, a polymorphism in another gene, or a point mutation in another gene, such as POLR1C (which maps to 6p21.1) or POLR1D (which maps to13q12.2). We also review the etiology and pathogenesis of Treacher Collins syndrome, and discuss several other severe cases from the past.

Special considerations in vascular anomalies: operative management of craniofacial osseous lesions

The treatment of vascular anomalies of the head and neck typically focuses on restoration of abnormal structures of the soft tissues. However, vascular anomalies can affect the craniofacial skeleton, and osseous reconstruction may be indicated. Osseous involvement occurs as either a primary or secondary phenomenon. In primary osseous involvement, the vascular anomaly expands the bone from within. Secondary osseous involvement occurs when bony hypertrophy develops because of increased flow of the surrounding soft tissue. This article focuses on the management of the osseous deformities associated with vascular anomalies.

The Arrhinias

The Arrhinias consist of three groups of malformations: the Total Arrhinias (T-AR), the Hemi-Arrhinias (H-AR, often called Hemi-Nasal Ageneses) and the Proboscis Lateralis (P.L.) This work deals with 51 cases of Arrhinias gathered within 35 years (8 T-AR, 25 H-AR, and 18 P.L): their anatomy, clinical signs, and some indications for treatment; but it does not extend to a discussion for their etiopathology. However, the T-AR and the H-AR represent ageneses, whereas the P.L represents a dysgenesis. The anomalies common to the three groups of Arrhinias are many: the agenesis of the nasal bones, the telecanthus which is often in contrast to the hypo-telorbitism, the obstruction of the naso-lacrimal passage, the ectasia of the lacrimal sac with an erosion of the inferomedial angle of the orbit, the hypopneumatization of the maxillary sinus and a small maxilla, the unerrupted canines, the flattened fronto-nasal process, the obliteration of the cribriform plate, the dysplasia in the root of the eyebrows, the transverse hypoplasia of the upper lip, the frequency of microphthalmia, colobomas of the iris and nystagmus. Cleft lip and palate are frequently associated with the Arrhinias (see Table I) and also other facial malformations, but in different proportions, according to groups. They are: cryptophtalmias, eyelid coloboma, fronto-orbital encephalocele, agenesis of the premaxilla or prolabium, microtia. (See Table II) The basic principles of the treatment are the following: In the T-AR, a nasal passage should initially be bored through the maxilla, or there should be a displacement of the two halves of the mid-face by a procedure known as "facial bipartition". This nasal passage should be epithelialized and maintained wide open to the pharynx until the nasal construction. In the H-AR, it is sufficient to create an epithelialized passage through the curtain of bone where one would expect the pyriform rim to be and carry this passage through the septum into the contralateral nasal airway. Then, regardless of the type of arrhinia, the nasal construction is carried out with a forehead flap and bone grafts. The first grafts are either iliac or tibial, and subsequent ones are generally outer table calvarial grafts harvested from the parietal region. Later, there are further procedures: a maxillary advancement, a lengthening of the central midface, the final stages of the nasal construction, the elevation of the medial canthus, and the restoration of the infero-medial angle of the orbit (but rarely an efficient lacrimal drainage). The earliest stage for surgery can be debated. A strategy for treatment is suggested. Finally, 20 brief comments are made, which are as much questions asked concerning the three groups of arrhinia and their relationship with other centro-facial and latero-facial malformations.

Cleft lip and palate: review

The most common craniofacial malformation in the newborn is the orofacial cleft, consisting of cleft lip with or without cleft palate and isolated cleft palate. Given its prevalence it is important to understand the etiology of the deformity, medical management prior to surgical correction, surgical techniques and timing.

Chin deformities

Facial analysis for chin deformities evaluates the perioral structures independently and their relationship to the entire face. Chin deformities in the absence of malocclusion can be treated by a genioplasty. Patient evaluation and preoperative planning and the operative technique for an osseogenioplasty are outlined with clinical reports to illustrate.

The Osseous Genioplasty

Despite its existence for nearly half a century and its versatility in solving a complex range of chin deformities, osseous genioplasty through an intraoral approach remains a rusty tool in many surgeons' armamentarium. The osseous genioplasty is not solely within the domain of the maxillofacial or craniofacial surgeon; it is well within the reach of any surgeon whose practice involves facial aesthetics. The surgeon who masters this relatively simple procedure can solve a broad range of chin deformities that an implant cannot solve: a chin that is too long, too short, or asymmetric.

Posterior Movements of the Maxilla

A wide range of facial proportions of the profile are considered normal, but extreme bimaxillary protrusion and retrusion are very unattractive. Maxillary setback in the right occlusal setting represents a good option that should be part of the armamentarium of the orthognathic surgeon. The surgical technique for one-piece maxilla repositioning is outlined and representative cases described.

Melanocytic Neuroectodermal Tumor of Infancy

Melanocytic neuroectodermal tumor of infancy is a rare pigmented tumor generally occurring in the head and neck region in children 12 months of age or younger. The true incidence is unknown and fewer than 200 clinical case reports have been reported to date in the literature. The tumor itself is locally aggressive. It does not have a tendency to metastasize but carries a high risk of local recurrence. This report describes one patient's care, including primary palate reconstruction, and provides a review of the literature. A 7-month-old boy was found in a Haitian orphanage with a growing, very large mass originating from his right maxilla.

High-flow Orbital Arteriovenous Malformation in a Child

Vascular malformations of the orbit cause significant morbidity such as chronic pain, diplopia, amblyopia, and cosmetic disfigurement. They are rare lesions which require multidisciplinary care, and in the modern era results of treatment have been greatly improved with the assistance of endovascular therapy. Other treatment options include laser therapy, percutaneous embolization, open surgery, or a combination of these modalities. Nevertheless some patients suffer poor results despite modern medical advances. A case of an orbital arteriovenous malformation (AVM) initially treated independently by a dermatologist, a plastic surgeon, and a neuroendovascular interventionalist is presented. When treating patients with these rare but disabling lesions it is of the highest importance to coordinate efforts between all pertinent specialists in order to promote the best possible result.

The Genioplasty and Beyond: An End-Game Strategy for the Multiply Operated Chin

BACKGROUND

Genioplasty has been a useful and frequently employed technique. In previous publications, the authors discussed the benefits and versatility of the genioplasty. Here, they briefly examine the entire experience of the senior author, from 1975 to the present.

METHODS

The authors examined a series of 580 genioplasties performed in 567 patients over a 28-year period by the senior author. This was done by chart review, which involved collection of demographic data and tabulation of the number of operations and type of genioplasty, as well as inspection of operative notes and clinical photographs. The focus was on the subgroup of patients who required multiple procedures to obtain a final satisfactory result. In one subgroup of patients, largely those with severe developmental or syndromic retrogenia, staged procedures were part of the original plan. A second subgroup included patients who had had problems with alloplastic chin implants; for these patients, further operations were not part of the original plan. RESULTSIn the first group of patients, with severe developmental or syndromic retrogenia, an osseous genioplasty was often associated with orthognathic surgery and could be repeated later as a staged procedure. In the second group of patients, who had multiple problems with alloplastic chin implants, an osseous genioplasty often provided the solution to difficult problems.

CONCLUSIONS

In both groups of patients, an autogenous costal cartilage graft may be of great help after one has accomplished as much as one can with an osseous genioplasty. In rare cases, microsurgical free tissue transfer may be required.

Prophylactic antibiotics in aesthetic surgery

According to the authors, prophylactic antibiotics should not be used routinely in aesthetic surgery, but only when indicated by empirically-based criteria. Here they provide literature-based guidelines, advocate for new double-blinded studies, and advise aesthetic surgeons to decide on prophylactic antibiotic treatment by considering the relative risks and benefits in each individual case.

Autogenous Bone Grafts and Bone Substitutes???Tools and Techniques: I. A 20,000-Case Experience in Maxillofacial and Craniofacial Surgery

Alloplastic bone substitutes can be used to alter facial contour. In contrast, autogenous bone grafts have a successful 80-year history of restoring facial contour as well as the basic functional support of the craniofacial skeleton. The traditional procedures for harvesting and using autogenous bone grafts are not obsolete. During the past 30 years, the techniques have been refined and new sources have been found, such as calvarial grafts. New tools were required and have been designed to make harvesting of grafts easier and faster for the surgeon and safer and less expensive for the patient. Four short articles under the heading of "Techniques and Tools" are presented addressing the harvesting of (1) iliac, (2) costal, (3) tibial, and (4) calvarial grafts. These articles are based on the experience of six surgeons using the same technique and instruments in more than 20,000 autogenous bone grafting procedures. (These figures represent the group experience as of 2001. Since then, one of the junior coauthors has retired, but the remaining five continue to harvest autogenous bone grafts on a regular basis. So, the group experience as of 2004 is in the range of 23,000 procedures). The-senior surgeon's experience of 9500 procedures spans a period of 50 years (from 1946 to 1996). For the other surgeons (10,500 procedures combined), the collection period was 25 years (from 1975 to 2000).

A pastiche for the cleft lip nose

An approach to primary and secondary repair for the cleft lip nasal deformity is presented in a brief form. The approach borrows from a large number of sources, hence the use of the term "pastiche." The sources include Millard, McComb, Anderl, Mulliken, and Cutting; Gunther, Rohrich, and Tebbetts; and Burget and Menick. A single case from each of the following cleft categories is presented and discussed: primary complete unilateral cleft, primary incomplete asymmetric bilateral cleft, primary complete bilateral cleft, and a secondary bilateral cleft. A description of the treatment method, its rationale, and a discussion are given for each category. There are a great number of varieties of the cleft lip malformation, but the principles presented can be applied to all of them.

Use of skin substitutes in pediatric patients

There are various artificial skin substitutes available commercially. The authors have used Integra, cultured epithelium, and Apligraf in their clinic. In the present report, they present their experiences based on two case reports. The first patient was a 12-year-old boy with widespread skin defects and left axillary contracture due to epidermolysis bullosa (EB). Apligraf was used to cover the skin defects on the trunk and face and to manage ectropion and axillary contracture. The second patient was a 6-year-old boy who suffered neurocutaneous melanosis. Partial excision of a pigmented lesion on the back created a large defect. Integra application followed by repair with cultured autologous skin was accomplished, and the results were satisfactory. Skin substitute products 1) are commercially immediately available; 2) are effective for management of contractures, chronic wounds, and chronic skin illnesses; 3) decrease or avoid the risk of donor area morbidity, which is more difficult to treat in children; 4) provide long-term coverage of the wound; and 5) can be used in conjunction with autologous tissue (e.g., Integra followed by cultured epithelium applications).

Transcriptional control of the testis-specific histone H1t gene

The mammalian testis-specific linker histone H1t is synthesized only in pachytene primary spermatocytes during spermatogenesis. In this review we summarize some of the progress made in our laboratory and in other laboratories in understanding transcriptional regulation of this gene. The gene is transcriptionally active in pachytene primary spermatocytes and is repressed in all other germinal and non-germinal cell types. To place the transcriptional control of the testis-specific histone H1t gene in the proper context, we briefly review recent literature concerning mammalian linker histone genes in general and we compare and contrast these with the testis-specific histone H1t gene.

Use of the radial forearm flap for deep, central, midfacial defects

Six cases that required soft-tissue replacement in the central midface are presented. The greatest number of flaps were used for large defects in patients with cleft palates who had undergone multiple previous operations. Several were for palatal defects attributable to cocaine abuse, and one was used for lining in a nasal reconstruction. There were no flap losses and, on the basis of these experiences, it is concluded that this is an excellent method for providing soft tissue in these difficult situations.

Special report: lengthening the nose: thoughts on correction with a reexamination of some basic principles

BACKGROUND AND OBJECTIVES

Providing thin, well-vascularized lining flaps is still the most elusive achievement in corrective nasal surgery. The purpose of this article is to reexamine some of the principles of correction.

METHODS AND MATERIALS

To demonstrate the importance of releasing or sectioning nasal lining, the authors review the principles of lengthening the nose, illustrated with seven clinical cases from their surgical experience and a detailed 12-drawing presentation of the surgical approach by Tessier--the senior surgeon.

RESULTS AND/OR CONCLUSIONS

The nose is the center of the face and a major determinant of facial appearance. The short nose has been one of the more difficult conditions to treat in rhinoplastic surgery. To optimize the result, procedures developed from experience in craniofacial surgery should be combined with the existing methods, developed primarily by rhinoplastic surgery and confined to the nasal tip.

Beyond the "recognition code": structures of two Cys2His2 zinc finger/TATA box complexes

BACKGROUND

Several methods have been developed for creating Cys2His2 zinc finger proteins that recognize novel DNA sequences, and these proteins may have important applications in biological research and gene therapy. In spite of this progress with design/selection methodology, fundamental questions remain about the principles that govern DNA recognition. One hypothesis suggests that recognition can be described by a simple set of rules--essentially a "recognition code"--but careful assessment of this proposal has been difficult because there have been few structural studies of selected zinc finger proteins.

RESULTS

We report the high-resolution cocrystal structures of two zinc finger proteins that had been selected (as variants of Zif268) to recognize a eukaryotic TATA box sequence. The overall docking arrangement of the fingers within the major groove of the DNA is similar to that observed in the Zif268 complex. Nevertheless, comparison of Zif268 and the selected variants reveal significant differences in the pattern of side chain-base interactions. The new structures also reveal side chain-side chain interactions (both within and between fingers) that are important in stabilizing the protein-DNA interface and appear to play substantial roles in recognition.

CONCLUSIONS

These new structures highlight the surprising complexity of zinc finger-DNA interactions. The diversity of interactions observed at the protein-DNA interface, which is especially striking for proteins that were all derived from Zif268, challenges fundamental concepts about zinc finger-DNA recognition and underscores the difficulty in developing any meaningful recognition code.