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Background Carpal tunnel syndrome (CTS), 1 of the most common peripheral neuropathies of the upper extremity, has been studied for decades regarding its epidemiology and associated medical conditions. We conducted a large-scale, age- and gender-matched study from an Asian population database to investigate the relationship between the incidence and the demographic characteristics. Methods A retrospective cohort study using data of National Health Insurance Research Database was conducted. One million enrollees in Taiwan was used to identify 9442 patients with CTS and 37,768 randomly selected controls, in a control-case ratio of 4:1. Diagnoses of CTS were ascertained from January 1, 2003, to December 31, 2012. Sociodemographic and medical characteristics were evaluated to assess the correlation with CTS. Results Annual incidence of CTS was approximately 0.4% during the 10-year-period in Taiwan, with higher incidence rate in female sex and middle age of group (50-59 years). Among the medical conditions, previous wrist injuries, obesity, gout, and rheumatoid arthritis were associated with CTS most significantly. Conclusions Carpal tunnel syndrome has presented a relatively constant incidence in Taiwan. Female gender with middle age seemed to have the highest incident rate during a 10-year period from 2003 to 2012. Among the risk factors of CTS, previous wrist injuries, obesity, gout, and rheumatoid arthritis were demonstrated to be the most significantly correlated comorbidities.

Background Le Fort fractures with maxillary immobility are an uncommon presentation of facial trauma often associated with the disturbance of occlusion. Historically, cases involving high Le Fort fractures require a coronal extensive approach to mobilize the maxilla for occlusion restoration. Here, we review our institutional series of immobile Le Fort fractures and present their treatment approach, outcomes, classification, and then rationalize our treatment with a concept philosophy. Materials and methods We treated 12 consecutive patients with unilateral and bilateral immobile Le Fort fractures from 2010 to 2017. The mean age was 27.1 years. Ten patients had a unilateral greenstick Le Fort III fracture. Five patients also had associated mandible fractures. Intraoperative occlusions could only be restored after Le Fort I osteotomy was performed on the side of the immobile Le Fort fracture. The mean follow-up period was 1.6 years. Results All patients presented good long-term occlusion restoration. There were no cases of nonunion or significant complications. None of the patients complained of any malar or periorbital cosmetic issues during follow-up sessions. Conclusions We presented an institutional series and classification of unusual Le Fort fractures with maxillary immobility, including a previously unreported fracture configuration of greenstick unilateral Le Fort III fractures combined with complete contralateral Le Fort I fracture. Based on our moment concept to rationalize treatment, as well as a systematic review of published literature, we advocate the judicious use of Le Fort I osteotomy to efficiently and safely treat these unusual fractures.

Secondary post-traumatic orbital reconstructions are challenging. Portable computed tomography (CT) provides the option to acquire real-time, intraoperative images that help to detect the insufficient reconstruction of the orbit immediately. We retrospectively analyzed patients who received intraoperative CT imaging and analyzed the effect of intraoperative CT scans on revision rates and orbital volume changes before, during, and after surgery.From August 2014 to September 2016, eleven patients received intraoperative cone-beam CT scans to evaluate the results of secondary orbit reconstruction using Medpor + titanium implants. Patient demographics, surgical details, CT scanning protocol, and follow-up results were analyzed. 3D CT volumetry was used to analyze the orbital volume based on OsiriX MD software.Based on intraoperative CT findings, seven cases required intraoperative revision to further augment the orbital cavity or adjust implants. The mean preoperative measured enophthalmos was 3.41±1.4 mm (range: 2-6 mm), which decreased to 0.73±0.4 mm (range: 0-1 mm) at postop assessment (p0.0001). On the fracture side, there was a significant difference between preoperative vs. intraoperative and preoperative vs. postoperative volume measurements (p0.01 for both subsets), but no significant difference between intraoperative vs. postoperative measurements.Intraoperative CT is a valuable tool in secondary orbital reconstruction cases based on clinical enophthalmos evaluation and 3D CT volumetry. For these patients, the avoidance of another revision surgery may outweigh the disadvantage of increased operation time and additional radiation exposure.

Background Traumatic optic neuropathy (TON) is a rare cause of severe permanent visual impairment after injury. Traumatic optic neuropathy may occur due to sharp trauma (direct injury) that damages the optic nerve directly or due to damage from the transmitted forces after a concussive blow to the head or orbit (indirect injury). The management of indirect TON remains controversial. Either surgical decompression or mega dose corticosteroid is used for managing indirect TON. However, no consensus exists regarding the definitive treatment. Materials and methods We designed a randomized controlled trial study to investigate this issue. Only patients with indirect TON and normal vision before the injury were enrolled. The patients' data were recorded, and fine cut facial computed tomography scan was performed to exclude those with retrobulbar hematoma. All the study subjects were randomly allocated to either the mega dose steroid (30 mg/kg stat and 15 mg/kg every 6 hours for 3 days) group or the surgical decompression group. The patients were followed up at 1 week, 1 month, 3 months, 6 months, and 9 months. During each follow-up, the Snellen visual acuity (VA), visual field, color change, fundus findings, and intraocular pressure were evaluated. These data were compared and analyzed using the Mann-Whitney U test and odds ratio. The short form questionnaire was used to analyze the lift quality difference between the two groups. Results Thirty patients were enrolled, 12 in the surgical group and 18 in the steroid treatment group. There were no significant differences in the improvement rate, improvement degree, and life quality between the groups. However, the odds ratios are 5, 10, 2.5, and nonavailable in the cutoff points of no light perception (NLP), light perception (LP), hand movement, and counting finger in surgery group. In steroid group, they are 1, 1, 1, 1.83 in each cutoff points. Patients with better VA than NLP had better life quality than those with NLP VA (P = 0.005). Other cutoff point groups had no significant difference. Conclusions Patients with worse initial VA (eg, NLP and LP) had a higher chance of benefiting from surgical treatment and experiencing improvements in the life quality.

OBJECTIVE Maxillofacial fractures with concomitant laryngeal injuries put both the quality and maintenance of life in jeopardy. Because of its low incidence, it is often overlooked in the clinical setting. The purpose of this study is to review the incidence, clinical presentations, managements, and outcomes of these patients. METHODS A retrospective analysis of medical records from 2008 to 2015 was conducted at a single institute. A case series (n = 12, which contributed 22.2% of laryngeal injuries in our institute) of these patients was presented, and propensity score matching was applied for further statistical analysis. RESULTS When comparing patients who sustained maxillofacial fractures with concomitant laryngeal injuries with patients with only maxillofacial fractures and no laryngeal injuries, subcutaneous emphysema (83.3% vs 4.2%, P < 0.001), neck pain (75.0% vs 6.3%, P < 0.001), dyspnea (75.0% vs 0%, P < 0.001), hoarseness (41.7% vs 0%, P < 0.001), neck swelling (66.7% vs 4.2%, P = 0.012), stridor (16.7% vs 0%, P = 0.037), hemoptysis (16.7% vs 0%, P = 0.037), and thoracic trauma (58.3% vs 10.4%, P = 0.001) all showed significant differences. The length of intensive care unit stay (7.42 days vs 3.21 days, P = 0.008), ventilator use (66.7% vs 18.8%, P = 0.002), and tracheostomy (58.3% vs 0%, P < 0.001) were also significantly different. CONCLUSIONS A significant portion of laryngeal injuries is concurrent with maxillofacial fractures. As a craniofacial surgeon, we should be alert to the signs of laryngeal injury. Diagnosis of laryngeal injuries should be established before definitive surgery for maxillofacial fractures.

Objective To compare the surgical results of early treatment of zygomatic fractures with and without the use of the computer-assisted navigation system. Methods All patients with unilateral traumatic zygomatic fractures treated within 30 days after the injury at a single center between June 2012 and May 2017 were studied retrospectively. Primary outcome was defined by the displacement at 5 junctional sutures of zygomatic bone, the change at each point before and after the reconstruction, and the patient's subjective scoring of their appearance. Secondary outcome included the length of the operation and hospital stay, the number of incisional approaches, the fixation points, the maximal mouth opening, and the sequelae upon follow-up. Results Twenty-eight patients were enrolled in this study. Fourteen of them received surgery with the help of a computer-assisted navigation system (navigation group), and 14 patients were treated without its assistance (control group). Before the surgery, the mean displacement of each junctional suture and the mean total displacement between both groups were comparable. Postoperative computed tomography showed that the mean total displacement was significantly less for the navigation group than the control group (0.53 vs 2.93 mm, P = 0.001), and the displacement of zygomaticosphenoid suture was smaller (0 vs 0.9 mm, P = 0.009). Patients in the navigation group underwent surgery via the single buccal-gingival approach without the need for longer operation time. There were no significant differences in the length of hospital stay, maximal mouth opening, or cheek numbness. All patients recovered without major complications and were comparatively satisfied with their final appearance. Conclusions The navigation system has been demonstrated to be a useful tool for improving the symmetry in delayed or secondary reconstruction of zygomatic fractures. This study showed its effectiveness and safety in cases of early treatment as well, achieving a more accurate correction in a less invasive manner.

BACKGROUND/OBJECTIVES In recent years, a modified levator muscle resection using Putterman ptosis clamp was developed. We used a retrospective case-control study to compare the effects of the modified and traditional levator muscle resection methods. METHODS Patients with moderate-to-severe ptosis who underwent the traditional or modified method for levator muscle resection were divided into two groups: Group I received the traditional method in 2013 and Group II received the modified method using Putterman clamp in 2015. During each postoperative visit, in addition to imaging, changes in the margin reflex distance 1 (MRD 1), and adverse events were recorded. Surgical time and final result in the last follow-up were recorded. RESULTS Group I had 35 patients (54 eyes) and Group II had 33 patients (59 eyes). After the surgery, the MRD 1 in both groups was significantly improved at 1 week and at the final visit compared to baseline. Significant differences were observed in MRD 1 change at 1-week post-operation and the change at the final visit and the surgical time between Groups I and II (P

This study developed an anatomical thin titanium mesh (ATTM) plate for Asian orbital floor fracture based on the medical image database. The computer aided stamping analysis was performed on four hole/slot patterns included the control type without hole design, circular hole pattern, slot pattern and hole/slot hybrid patterns within the ATTM plate with upper/lower dies of averaged orbital cavity reconstruction models. The curved-fan ATTM plate with 0.4 mm thickness was manufactured and pre-bent using a patient matched stamping process to verify its feasibility and the interfacial fitness between the plate and bone on the orbital floor fracture model. The stamping analysis found that the hole/slot hybrid patterns design resulted in the most favorable performance among all designs owing to the lowest maximum von-Mises stress/strain and spring-back value. The interfacial adaption results test showed that the average patient-matched stamping bending gap size was only 0.821 mm and the operative time was about 8 s. This study concluded that the curved-fan ATTM plate with hole/slot hybrid pattern design and patient-matched pre-bent technique can fit the ATTM plate/orbital cavity interface well, decrease unstable fracture segment mobility and improve the overall reduction efficiency.

BACKGROUND Traumatic carotid-cavernous sinus fistula (tCCF) is infrequent but with high morbidity if delayed diagnosed or managed. Because of the lack of screening criteria and requirement of advanced and invasive radiological examinations, diagnosis is often delayed or underdiagnosed. METHODS A matched case-control study with univariate and multivariate analyses was conducted to predict tCCFs. Forty-six patients diagnosed with tCCFs were included and matched with 138 patients of craniofacial trauma without tCCF as control at a ratio of 1:3. RESULTS The diagnostic diameter of superior ophthalmic vein (SOV) in tCCF was 4 mm with area under curve of 0.89. In multivariate analysis, engorgement of SOV and cavernous sinus (odds ratio [OR], 35.39; 95% confidence interval [CI], 13.56-104.84; p < 0.001) and lateral impact (ipsilateral temporal and sphenoid sinus fractures) (OR, 3.96; 95% CI, 1.10-14.91; p = 0.028) were identified significant, whereas basilar skull fracture (OR, 1.58; 95% CI, 0.53-4.75; p = 0.300) and injuries to ocular nerves (cranial nerves III, IV, and VI) (OR, 1.77; 95% CI, 0.38-7.88; p = 0.055) were insignificant. CONCLUSION Presence of SOV or cavernous sinus engorgement on noncontrast computed tomography and lateral impact were demonstrated as independent predictors to tCCF and warrant further radiological evaluation. Injury to ocular nerves is not predictive but as an essential differential diagnosis with reversible outcome. LEVEL OF EVIDENCE Diagnostic, level III.

Sequelae of inadequate orbital reconstruction include enophthalmos, hypoglobus, and diplopia. Accuracy of orbital reconstruction is largely subjective and especially difficult to achieve because of anatomic distortion in secondary or late reconstruction and in extensive injury. We combined computer navigation and endoscopy to perform accurate, aesthetic, and safe minimal-access primary and secondary orbital reconstruction.From 2013 to 2014, 24 patients underwent unilateral primary and secondary or late minimally invasive orbital reconstruction with mainly Medpor and/or titanium mesh by navigation and endoscopic assistance through transantral, transconjunctival, or upper blepharoplasty approaches. Mean follow-up was 13.8 months (range, 6.2 months to 2.8 years).All orbital fractures were successfully reduced. Average enophthalmos among patients who underwent early reconstruction, late reconstruction, and multiorbital wall repair improved (p .001) to 0.2 mm from 1.6, 2.6, and 2.6 mm, respectively. Hypoglobus and diplopia resolved in all. In early reconstruction patients, mean interorbital volume difference improved from 1.72 ± 0.87 to 0.53 ± 0.83 ml (P = .03). For late reconstruction patients, this difference improved from 3.41 ± 1.23 to 0.56 ± 0.96 ml (p .001). There were no major complications during follow-up, and all were satisfied with their final appearance and function.Navigation sharpens reconstructive accuracy and avoids injury to vital structures. Combined with endoscopic assistance for minimal-access reconstruction of wide-ranging orbital defects from primary to secondary or late cases and to extensive multiwall fractures, navigation facilitates minimal cosmetic incision and synergistic endoscope use and clearly optimizes aesthetic and functional outcomes, all with enhanced safety and unparalleled intraoperative visualization.

Allogeneic bone-marrow mesenchymal stem cells (BMSCs) can promote bone regeneration and substitute for autologous BMSCs if autologous sources are unavailable, but the efficacy of bone regeneration by allogeneic BMSCs is still inconsistent. A Lewis rat cranium defect model was used to investigate the efficacy of bone regeneration between autologous and allogeneic BMSCs in gelatin-nanohydroxyapatite cryogel scaffolds. BMSCs from Wistar rats served as the allogeneic cell lineage. The full-thickness cranium defects were treated by either blank control, cryogel only, allogeneic BMSC-seeded cryogel, or autologous BMSC-seeded cryogel (n = 5). Bone regeneration was monitored by micro-computed tomography and examined histologically at week 12. In addition, we assessed the immune responses in vitro by mixed lymphocyte reaction (MLR) assay and CD4+ immunochemistry staining ex vivo. The MLR showed that allogeneic BSMCs elicited a weak immune response on day 14 that progressively attenuated by day 28. In vivo, the bone regeneration in allogeneic BMSCs was inferior at week 4, but progressively matched the autologous BMSCs by week 12. Our results suggest that allogeneic BMSCs can serve as an alternative source for bone regeneration.

The surgical indications of zygomatic fracture include aesthetic and functional impairment. No standard method exists for assessing the functional outcome nowadays, and traditional methods are subjective and inadequately quantitative for comprehensive analyses. This study was conducted to obtain a clinically applicable, reliable, quantitative, and noninvasive system for measuring the jaw function through kinematic, kinetic, and surface electromyography (sEMG) analysis. Because we previously established a model based on a healthy population, we applied the proposed system to patients with zygomatic fracture for this study. The study group comprised 20 young adults (18 male, 2 female) with simple zygomatic fracture. Twelve of them received open reduction and plate fixation (surgical group) and the other eight did not (nonsurgical group). We used a jaw motion analyzer to detect jaw movement, a sEMG instrument to evaluate the activity of the bilateral temporalis and masseter muscle, and an occlusal bite force system to measure the bite force. We compared jaw function over the affected side and sound side, and among the surgical group, nonsurgical group, and healthy population. In the surgical group, no functional difference was observed over the affected side and sound side 2 months after operation. However, the sEMG analysis revealed that the temporalis and masseter muscle and bite force exhibited less function over the affected side than over the sound side 3 months after the injury occurred in non-surgical group. Compared with the healthy population, the surgical group exhibited a shorter condylar path, narrower maximal mouth opening, less sEMG activity over masseter muscle, and less bite force over the affected side at 1 month after operation; however, their condition improved and did not differ from the control group at 2 months after operation. By contrast, the nonsurgical group continued to exhibit poorer jaw movement, less sEMG activity, and less bite force compared with the healthy population even 3 months after injury. Furthermore, the bite force was significantly lower in the nonsurgical group than in the surgical group at post-operative 3 month. (p = .002). We obtained a clinically applicable, quantitative, reliable, and noninvasive system for evaluating jaw and mastication function with biofeedback characteristics. For patients with a simple zygomatic fracture, the degree of jaw movement, sEMG activity, and bite force could return to normal by the second month after open reduction, stable fixation, and early rehabilitation.

Objective The study compares resorbable versus titanium fixation systems for their aesthetic and functional outcome in the treatment of zygomatic fractures. Methods Twenty-seven patients who required operative reduction and internal fixation for zygomatic fractures were studied in the period from April 2007 to March 2008. Fourteen patients who had fixation with resorbable plate/screws (group A) were compared with 13 patients fixed with titanium plates/screws (group B). The aesthetic outcome was evaluated by an overall self-satisfaction score at 2, 4, and 6 weeks and then at 6 months and 1 year postoperative interval, and the degree of displacement from computed tomographic facial bones were compared preoperatively and 1 year postoperatively. The functional outcome was evaluated by a self-satisfaction scoring system and maximum mouth opening during the same time intervals. Results The outcome showed that the 2 groups were matched in age, sex ratio, fracture severity, total displacement with 5 sutures, and aesthetic scores preoperatively (P > 0.05). The subjective evaluation by patients for functional satisfaction and overall satisfaction all showed lower satisfaction of absorbable group when compared to titanium group within a postoperative 4-week period, but the satisfaction was similar for both groups after 4 weeks. There was no significant difference between the 2 groups at each measured time period. Postoperative total displacement and aesthetic score demonstrated great improvement in fracture reduction and long-term stability in both groups. Conclusion There is no significant difference in the outcome between resorbable and titanium plates/screws in fixation of zygomatic fractures. These findings together with the advantages of biodegradable fixation validate its use in fixing these fractures with minimal morbidity.

BACKGROUND Orbital fractures and the concomitant soft tissue injuries within the bony orbit result in well-recognized complications such as diplopia and enophthalmos. Guidelines for timing and indications for surgery for achieving an optimal outcome remain elusive. This study examined the effects of timing and fracture type on the outcome of orbital fracture repair. MATERIAL AND METHODS Data on 255 patients treated for orbital fractures were retrospectively reviewed to determine the effects of the facial bones involved in the fractures, the types of orbital wall fracture, the timing of surgical repair, and diplopia evident before and after corrective surgery on surgical outcomes. RESULTS The incidence of posttraumatic diplopia increased with the number of orbital wall fractures (P < 0.001). The rate of diplopia resolution after corrective surgery was slow in the first 3 months irrespective of the severity of orbital wall fracture. The diplopia resolution rate for type I orbital wall fractures was significantly higher than that for type II and type III fractures. Patients treated within 2 weeks of sustaining an orbital fracture exhibited a higher diplopia resolution rate than did patients treated 2 to 4 weeks and more than 4 weeks after sustaining the fracture (58% vs 38.1%). CONCLUSIONS A higher number of orbital wall fractures are associated with a higher incidence of diplopia and a poorer long-term result. The timing of surgical repair influences the diplopia outcome. Performing corrective surgery for orbital fractures with diplopia after 2 weeks tends to result in a slower complete recovery rate.

Although recent evidence suggests a controversy effect of steroids in the management of indirect traumatic optic neuropathy (TON), steroid pulse therapy remains one of the reasonable treatments for patients with indirect TON. It is thought that microcirculatory spasms, edema, and nerve cell necrosis can be prevented or reduced by large doses of steroids. The aim of this study is to analyze the predisposing factors for the recovery of patients with indirect TON who were treated with steroid pulse therapy.In tracing the 2008 to 2014 data from the Trauma Center of Chang Gung Memorial Hospital, 20 consecutive cases of indirect TON were identified retrospectively. Twenty cases showed no light perception (NLP) under initial ophthalmologic examination. They all received steroid pulse therapy with methylprednisolone in IV form after examination by ophthalmologists, and they did not receive optic nerve decompression. The general data, fracture pattern from images, hospital courses, trauma-related data from ER record, and the initial and final visual data from ophthalmologic records are reviewed. The odds ratio (OR) and 95% confidence intervals (CI) are calculated. Fisher exact test is used for 2 variables to test differences between proportions. Nonparametric statistics are applied to compare the mean values of the data.The results show that for female patients (OR, 3.400; 95% CI, 1.628-7.101; P = 0.049), the administration of methylprednisolone in less than 24 hours from the injury (OR, 3.429; 0.297-39.637), lateral force fracture pattern (OR, 3.500; 0.313-39.153), age of 40 years or younger (OR, 2.333; 0.197-27.567), and pure facial trauma (OR, 3.667; 0.273-49.288) are the predisposing factors for improvement of visual acuity. Patients with orbital blowout fractures (OR, 9.800; 95% CI, 0.899-106.845; P = 0.070), initial free extraocular movement (EOM) (OR, 6.667; 0.809-54.597; P = 0.145), initial intraoptic pressure (IOP) greater than 25 mmHg (OR, 8.000; 0.598-106.936), and higher triage grade (OR, 3.000; 0.447-20.153) are at risk of showing no improvement.From this study, we might suggest to apply steroid pulse therapy on those patients without contraindication, with an incurring injury less than 24 hours previously. Factors such as sex, age, lateral force fracture pattern, and pure facial trauma revealed a better outcome for improvement of visual acuity. Orbital blowout fractures, initial free EOM, initial IOP greater than 25 mmHg, and higher triage grade suggested poor improvement of visual acuity.

SummaryBackground/introductionEnophthalmos, a common sequela following orbital trauma, may not be immediately evident, and it is often diagnosed late or inadequately treated. Managing orbital fractures with enophthalmos can be challenging and unpredictable.Purpose(s)/aim(s)This study evaluated the long-term enophthalmos outcome following surgical correction for different types of orbital fractures at various time intervals.MethodsMedical charts of 304 patients with orbital fractures were retrospectively reviewed. Several factors, including surgical timing, fracture zones, and orbital wall fractures, were analyzed. The improvement rate of enophthalmos following corrective surgery was compared with respect to the type of orbital wall fracture and surgical timing. Orbital wall fractures were classified into three types according to the number of walls involved: single-wall fracture (Type I orbital wall fracture), two-wall fracture (Type II orbital wall fracture), and three-to-four-wall fracture (Type III orbital wall fracture).ResultsThe most common pattern of facial injury is facial fracture involving the bony orbit and adjacent facial bones (Zone II). The overall incidence of enophthalmos in the present study was 56.9%. The incidence of residual enophthalmos following corrective surgery was 11.8% in Type I, 27.4% in Type II, and 16.4% in Type III orbital wall fractures (p ≤ 0.001). The improvement rates for enophthalmos at various time intervals, 4 weeks, were 65.6%, 80%, and 76.2%, respectively; however, a significant difference was not observed (p = 0.194).ConclusionOrbital fractures with enophthalmos can be corrected at various time intervals with a comparable improvement rate. Surgical indications and surgery timing for orbital fractures with enophthalmos should be individualized on the basis of the severity of injury and type of orbital wall fracture.

This study developed a zygomaticomaxillary complex (ZMC) patient-specific repairing thin (PSRT) implant based on the buttress theory by integrating topology optimization and finite element (FE) analysis. An intact facial skeletal (IFS) model was constructed to perform topology optimization to obtain a hollow skeleton (HS) model with the structure and volume optimized. The PSRT implant was designed based on the HS contour which represented similar trends as vertical buttress pillars. A biomechanical analysis was performed on a ZMC fracture fixation with the PSRT implant and two traditional mini-plates under uniform axial loads applied on posterior teeth with 250 N. Results indicated that the variation in maximum bone stress and model volume between the IFS and HS models was 15.4% and 75.1%, respectively. Small stress variations between the IFS model and repairing with a PSRT implant (2.75%&ndash, 26.78%) were found for compressive stress at frontal process and tensile stress at the zygomatic process. Comparatively, large stress variations (30.67%&ndash, 96.26%) with different distributions between the IFS model and mini-plate models were found at the corresponding areas. This study concluded that the main structure/contour design of the ZMC repair implant according to the buttress position and orientation can obtain a favorable mechanical behavior.

In this study, dissolving polymeric microneedle (MN) patches composed of gelatin and sodium carboxymethyl cellulose (CMC) were used to localize insulin. Their in vitro skin insertion capabilities were determined using tissue-marking dye to stain the skin after patches removal. Scanning electron microscopy (SEM) was used to determine changes in the MNs over time, and optical coherence tomography (OCT) was used to monitor their real-time penetration depth. Confocal microscopy images revealed that rhodamine 6G gradually diffuses from the puncture sites to deeper dermal tissue. Using an in vivo imaging system (IVIS), skin areas that received FITC-insulin-loaded MNs were found to present strong fluorescent signals that greatly decreased 1 h after application. Results show that dissolving MNs rapidly release FITC-insulin, and it then gradually diffuses into the skin. This study verifies that using a gelatin/CMC MN patch for insulin delivery achieves satisfactory relative bioavailability compared to a traditional hypodermic injection and can be a promising delivery device for poorly permeable protein drugs such as those used to treat diabetes. Insertion tests on human cadaveric skin demonstrate that dissolving MNs could serve as efficient devices for transdermal drug delivery in clinical practice and that the volar aspect of forearm skin is the ideal location for their applications.

Aging is associated with a function decline in tissue homeostasis and tissue repair. Aging is also associated with an increased incidence in osteopenia and osteoporosis, but whether these low bone mass diseases are a risk factor for delayed bone healing still remains controversial. Addressing this question is of direct clinical relevance for dental patients, since most implants are performed in older patients who are at risk of developing low bone mass conditions. The objective of this study was to assess how an osteopenic/osteoporotic phenotype affected the rate of new alveolar bone formation. Using an ovariectomized (OVX) rat model, the rates of tooth extraction socket and osteotomy healing were compared with age-matched controls. Imaging, along with molecular, cellular, and histologic analyses, demonstrated that OVX produced an overt osteoporotic phenotype in long bones, but only a subtle phenotype in alveolar bone. Nonetheless, the OVX group demonstrated significantly slower alveolar bone healing in both the extraction socket, and in the osteotomy produced in a healed extraction site. Most notably, osteotomy site preparation created a dramatically wider zone of dying and dead osteocytes in the OVX group, which was coupled with more extensive bone remodeling and a delay in the differentiation of osteoblasts. Collectively, these analyses demonstrate that the emergence of an osteoporotic phenotype delays new alveolar bone formation.

Bilateral mandibular condylar fractures accounts for 24% to 33% of condylar fractures but the indications of open reduction of bilateral condylar fracture are still controversial. It is generally accepted that displaced subcondylar fractures are indicated for open reduction, but the proper treatment of condylar head fractures are still variable. This retrospective study compares the radiographical and functional outcomes of bilateral condylar head fractures between open and closed reduction groups.From February 1994 to June 2012, a total of 85 patients with bilateral condylar head fractures were retrospectively reviewed. Among this group, 41 cases underwent open reductions while the other 44 cases had closed reductions. Only adult patients with adequate follow-up and complete radiographic study were included in this study: consisting of 20 patients in the open group and 18 patients in the closed group.The subjective symptoms including temporomandibular joints (TMJ) symptoms, complications or adverse sequelae, and functional results, such as maximal mouth opening, were recorded. The outcome of patient's satisfaction was individually assessed by an independent reviewer. The computed tomographic results after treatment were evaluated between both groups.The mean follow-up period was 25.5±13.3 months. The open reduction group had better postoperative chewing functions, less malocclusion rates, less degree of TMJ pain (p=0.046), better radiographic outcome (p=0.036), and an overall satisfaction rate (p=0.039).There were 4 cases of failure in the closed reduction group. Subsequent open reduction (n=2) and redo closed reduction with intermaxillary fixation (n=2) were performed. Eleven patients in the close reduction group presented persistent malocclusion through objective evaluation. The subsequent treatment included further orthognathic surgery (n=1) and orthodontic treatment (n=7). Three of the patients refused further treatment.Open reduction for bilateral condylar head fractures presented an overall better functional and radiographic outcome, with higher patient satisfaction if condylar fracture segments were still feasible for rigid fixation.

Background Zygomatic fractures are associated with functional and aesthetic problems. The purpose of this study was to evaluate the adequacy of management and the surgical satisfaction of patients with simple zygomatic fractures treated through a single buccal sulcus approach and fluoroscan assistance. Methods Between 2008 and 2012, 42 patients with simple zygomatic fractures were included in the study. The surgical procedure was performed through a single buccal sulcus incision. The fracture sites were aligned under direct vision and fluoroscan assistance and stabilized with rigid internal fixation. The adequacy of reduction was evaluated based on postoperative plain radiographic films and computed tomographic scans using mirror image analyses. The satisfaction of functional and aesthetic results was also evaluated subjectively using a visual analog scale during follow-up. Results Twenty-nine male and thirteen female patients with a mean age of 33.2 years were evaluated. Motorcycle crashes (78.6%) were the most common mechanism of trauma. Based on follow-up imaging studies, 2 patients had inadequate reduction of zygomatic body, and there was a slight depression of the zygomatic arch in one patient. Ninety-three percent (39/42) of patients had satisfactory results, although one patient complained of malar asymmetry and another felt a depression in the arch area. Two patients complained of persistent hypesthesia during follow-up at 6 months. Conclusions Our results suggest that a single buccal sulcus approach without lower eyelid or lateral eyebrow incision in the repair of simple fractures of the zygoma can be achieved with high patient satisfaction if the reduction and fixation are adequate and stable.

3D bio-model can assist surgeons to evaluate the size of the defect, design osteotomies tailored to the defect, and shaping of the titanium plate to fit the mandible pre-operatively, which shortens the operative time.

Surface modified porous polycaprolactone scaffolds fabricated via rapid prototyping techniques were evaluated for cartilage tissue engineering purposes. Polycaprolactone scaffolds manufactured by selective laser sintering (SLS) were surface modified through immersion coating with either gelatin or collagen. Three groups of scaffolds were created and compared for both mechanical and biological properties. Surface modification with collagen or gelatin improved the hydrophilicity, water uptake and mechanical strength of the pristine scaffold. From microscopic observations and biochemical analysis, collagen-modified scaffold was the best for cartilage tissue engineering in terms of cell proliferation and extracellular matrix production. Chondrocytes/collagen-modified scaffold constructs were implanted subdermally in the dorsal spaces of female nude mice. Histological and immunohistochemical staining of the retrieved implants after 8 weeks revealed enhanced cartilage tissue formation. We conclude that collagen surface modification through immersion coating on SLS-manufactured scaffolds is a feasible scaffold for cartilage tissue engineering in craniofacial reconstruction.

A desirable multi-functional nanofibrous membrane (NFM) for prevention of postoperative tendon adhesion should be endowed with abilities to prevent fibroblast attachment and penetration and exert anti-inflammation effects. To meet this need, hyaluronic acid (HA)/ibuprofen (IBU) (HAI) NFMs were prepared by electrospinning, followed by dual ionic crosslinking with FeCl3 (HAIF NFMs) and covalent crosslinking with 1,4-butanediol diglycidyl ether (BDDE) to produce HAIFB NFMs. It is expected that the multi-functional NFMs will act as a physical barrier to prevent fibroblast penetration, HA will reduce fibroblast attachment and impart a lubrication effect for tendon gliding, while IBU will function as an anti-inflammation drug. For this purpose, we successfully fabricated HAIFB NFMs containing 20% (HAI20FB), 30% (HAI30FB), and 40% (HAI40FB) IBU and characterized their physico-chemical properties by scanning electron microscopy, Fourier transformed infrared spectroscopy, thermal gravimetric analysis, and mechanical testing. In vitro cell culture studies revealed that all NFMs except HAI40FB possessed excellent effects in preventing fibroblast attachment and penetration while preserving high biocompatibility without influencing cell proliferation. Although showing significant improvement in mechanical properties over other NFMs, the HAI40FB NFM exhibited cytotoxicity towards fibroblasts due to the higher percentage and concentration of IBU released form the membrane. In vivo studies in a rabbit flexor tendon rupture model demonstrated the efficacy of IBU-loaded NFMs (HAI30FB) over Seprafilm&reg, and NFMs without IBU (HAFB) in reducing local inflammation and preventing tendon adhesion based on gross observation, histological analyses, and biomechanical functional assays. We concluded that an HAI30FB NFM will act as a multi-functional barrier membrane to prevent peritendinous adhesion after tendon surgery.

Objective: The aim of this study was to investigate the biomechanics of the facial skeletal for understanding the buttress after fixation with standard and modified anatomical thin titanium mesh (ATTM) plates by finite element (FE) analysis. Methods: Standard ATTM (SATTM) plate designed as the “L”-shape anticipated to be fixed in the ZMC anterior maxilla and lateral buttress to increase the fixation screw anchoring strength and another modified ATTM (MATTM) plate with a protrusion in the medial side and a slot and barb design in the lateral side to enhance the zygomaticomaxillary/nasomaxillary buttresses and provide precise positioning to the ZMC segments were studied by the FE analysis under masticatory forces with 250[Formula: see text]N. Result: The FE simulation results indicated that the total displacement distribution of the maxillary for ZMC fracture fixation with MATTM plate was smaller than that of SATTM plate. Stress concentration was found at the frontal and alveolar processes of the maxillary bone for SATTM plate fixation. Local vector plots of the first principal stress near the frontal process of the maxillary and zygomaticofacial formen of the zygomatic indicated that the stress flow for MATTM plate fixation was relatively close to nasomaxillary buttress, and the zygomaticomaxillary buttress, respectively. Conclusions: This study concluded that “L”-shape ATTM plate designed with a protrusion in the medial side and a slot and barb design in the lateral side can enhance the zygomaticomaxillary/nasomaxillary buttresses under uniform occlusal condition.

Our aim was to design a new bioresorbable fixation device for craniomaxillofacial surgery based on reinforcement of fibres between 2 different polymers. The final device, the 2.8 mm polyglycolide fibre-reinforced-poly-l-lactide screw (PGA FR-PLLA; PLLA/PGA: 70%:30%), was evaluated for its mechanical properties and compared with a commercial resorbable device that was not reinforced with fibre. To model clinical conditions, a unilateral sagittal split ramus osteotomy fixation model in pigs was then used to compare the clinical effectiveness of the resorbable screw with that of a titanium screw in vivo, followed by 3-dimensional reconstructive imaging and histological analysis. Finally, an ex vivo biomechanical test was completed to investigate the immediate fixation stability of the newly designed screws. The PGA FR-PLLA screw resulted in clinical healing that was comparable to that of the titanium screw and was mechanically superior to the commercial device, indicating that the newly-developed screws have a potential clinical application.

Most condylar process fractures can be managed conservatively with satisfactory outcome. However, unsuccessful treatment can result in malocclusion and facial asymmetry. We report our experience in surgical management of malunited condylar process fractures.This is a retrospective review of clinical records, photographs, imaging, and dental models of 12 consecutive patients who presented with malocclusion and facial asymmetry after nonoperative or failed treatment of condylar process fractures. Eight patients who presented relatively early (6 months) after the initial trauma were treated with subcondylar osteotomy (SCO), whereas 4 patients who presented relatively late (18 months) were treated with sagittal split osteotomy (SSO). These 2 groups were compared in terms of 3 parameters, namely, maximum mouth opening, aesthetic improvement, and patient satisfaction.The 2 groups were statistically similar in all 3 parameters, with the SCO group trending toward higher scores in all 3 parameters. The mean increase in maximal mouth opening in the SCO group was 21 versus 2.5 mm in the SSO group.Subcondylar osteotomy, performed at a relatively early time point, is at least as effective, if not more effective, than traditional SSO in the treatment of subcondylar malunions. Given this finding, a lower threshold should be adopted for the primary treatment of acute subcondylar fractures with open reduction and internal fixation, especially those with moderate displacement that may be at high risk for malunion.

Although the appropriate management of condylar process fractures after miniplate or microplate fixation has been described, there has been no comparative analysis of these plating systems. A retrospective review of patients who underwent open reduction and internal fixation (ORIF) of condylar head or neck fractures at our institution from January 2000 through August 2010 identified 70 patients. Of these, 38 were treated with microplates and 32 with miniplates. The primary functional and radiographic results were the maximal mouth opening and condylar bone resorption, respectively. The rates of complications, including malocclusion, chin deviation, temporomandibular joint complaints, and facial nerve palsy, were recorded. The maximal mouth opening was larger in the microplate group than in the miniplate group throughout the follow-up period; this difference was statistically significant 12 (P = 0.020), 18 (P = 0.026), and 24 (P = 0.032) months after ORIF. Similarly, the radiographic scores for bone resorption and condyle morphology were significantly better in the microplate group than in the miniplate group throughout the follow-up period [6 (P = 0.011), 12 (P = 0.035), 24 (P = 0.026), and 48 (P = 0.040) months after ORIF]. Moreover, patients who underwent miniplate fixation experienced a significantly higher incidence of temporomandibular joint click than those who underwent microplate fixation (P = 0.014). Microplates limit dissection, providing excellent fixation for intracapsular condylar head fractures, and also provide adequate rigidity for fixation of condylar neck fractures. Microplate fixation of condylar head and neck fractures yielded excellent functional and radiographic results. The rates of complications after microplate fixation were equal to or less than those in the miniplate group. Prospective studies are needed to confirm these findings.

In this report, we present our experience on the use of the reverse sural flap for traumatic foot and ankle reconstruction. The patient selection and surgical refinement are discussed. From 2007 to 2010, 11 consecutive patients underwent modified reverse sural flap at the Chang Gung Memorial Hospital. The defects were located at the ankle (three cases), foot (two cases), and heel (six cases). Particular attention was paid to precise patient selection and surgical refinements. Patient selection was based on the lower limb vascular status by palpable distal pedal pulses and ankle brachial index ranging from 0.9 to 1.2. Surgical techniques were refined as precisely locating the perforators of peroneal artery, placing the skin paddle in upper third of leg for a distal region coverage, designing a 7-cm-wide adipofascial pedicle with a 2 cm skin paddle on it, preserving the mesentery structure of sural nerve and concomitant artery with or without including gastrocnemius muscles cuff, no tunneling when inset this flap and supercharging with lesser saphenous vein whenever needed. All the flaps survived completely. Only one patient required immediate anastomosis of lesser saphenous vein to local vein around defect in order to relieve the venous congestion during operation. Patients felt diminished but adequate recovery of sense of touch and temperature at the flap. Following the precise patient selection and surgical refinements, the modified reverse sural flap seemed to be a reliable and effective local flap for reconstruction of the soft tissue defects on ankle and foot.

Background Replantation of amputated fingertips is a technical challenge, as many salvage procedures fail because no suitable vein in the fingertip is available for anastomosis. In this study, we examined our experience in fingertip replantation in cases without venous anastomosis with our established fingertip replantation treatment protocol. Methods Between August 2002 and August 2010, a retrospective study examined all patients who had undergone fingertip replantation at Chang-Gung Memorial Hospital. All the patients (n = 24) suffered from complete digital amputations at or distal to the interphalangeal joint of the thumb, or distal to distal interphalangeal joint of the fingers. A total of 30 fingertips that were salvaged by microsurgical anastomosis of the digital arteries but not of digital veins were included in this study. On satisfactory arterial anastomosis, a 2-mm incision was made over the fingertip with a number 11 Scalpel blade, and 0.1 to 0.2 mL heparin (5000 IU/mL) was injected subcutaneously around the incision immediately and once per day thereafter to ensure continuous blood drainage from the replanted fingertip. None of the replanted nail plate was removed, and no medical leeches were used. The perfusion of the replanted digits and patient's hemoglobin level were closely monitored. The wound bleeding was maintained until physiologic venous outflow was restored. Results Of 30 fingertips, 27 (90%) replanted fingertips survived. The average length needed for maintaining external bleeding by chemical leech was 6.8 days (range, 5-10 days). Twelve patients (including a 2-year-old child) received blood transfusions. The average amount of blood transfusion in the 23 adults was 4.0 units (range, 0-16 units) for each patient or 3.29 units (range, 0-14 units) for each digit. A 2-year-old child received 100 mL blood transfusion or 50 mL for each digit. Conclusions This study showed that a protocol that promotes controlled bleeding from the fingertip is essential to achieve consistent high success rates in fingertip replantation. The protocol is safe and reliable, as it avoids the use of medical leeches and the removal of nail plate from the replanted finger. However, full informed patient consent must include the potential need for transfusion and extended hospital stay.

Summary: Background: Zygoma fracture is of clinical importance because malar prominence plays an essential role in facial appearance. Traditionally, most maxillofacial surgeons perform osteosynthesis with titanium plates and screws for rigid fixation. However, this procedure has certain disadvantages that include the possibility of implant exposure, palpability or loosening of the screws, painful irritation, temperature sensitization, and radiographic artifacts. In this study, we compared the function and satisfaction outcome between Bonamates® bioabsorbable implant and Leibinger titanium implant. Method: Consecutively 53 patients with isolated unilateral zygomatic fracture that were treated with the Bonamates® bioabsorbable plate system, n = 53 were compared to patients with the titanium plate system, n = 55 in the period between 2009 and 2013. All patients were followed-up at least 6 months. Preoperative and postoperative facial computed tomography (CT) scans were performed and scored from 0 to 2 in the 5 areas of zygoma. A score of 2 indicated the most severely displaced fracture in one of the areas. A visual analogue scale ranging from 0 to 10 was used to assess the postoperative aesthetic and functional satisfactions. Result: The mean ages of the patients in the bioabsorbable and titanium plate groups were 33 years and 30 years, respectively. The male to female ratios were 1.2:1 (bioabsorbable plate group) and 1.1:1 (titanium plate group). The average preoperative CT scan scores of the bioabsorbable and titanium plate groups were 5.7 and 5.1, respectively. The postoperative CT scan scores of the bioabsorbable and titanium plate groups were 1.3 and 1.1, respectively. The implant cost of the bioabsorbable group was approximately 6-fold higher than that of the titanium plate group. The complication rate was similar in both groups and included complications such as palpable implant, skin irritation, and hypersensitive cheek. The patients in both groups attained similar mouth-opening function and a satisfactory score at 6 months after operation. Conclusion: This study revealed that the bioabsorbable plate outcome was similar to the titanium plate outcome for patients with isolated unilateral zygomatic fracture. The bioabsorbable implant system provides another option for internal fixation devices in the treatment of zygomatic fractures and avoids implant removal surgery; however, the implant cost of bioabsorbable plates is higher than that of titanium plates in Taiwan. Keywords: Bioabsorbable plate, Titanium plate, Comparison, Zygoma fracture

Purpose The aim of this study is to compare the 1-year functional outcomes and patient-reported satisfaction in treating mandibular fractures between resorbable and titanium fixation devices. Materials and methods A 1-year prospective study was conducted; 41 consecutive patients presenting with mandibular fractures were included. A resorbable system was used in 21 patients, while in 20 patients a titanium fixation device was used. Functional outcome was evaluated objectively at several time points (2, 4 and 6 weeks, 3 and 6 months, and 1 year after surgery). Bite forces over molars and incisors, mouth opening distance, occlusal status, operation time, fee for implants, bone healing and plate-associated complications were evaluated. Functional and overall satisfaction was measured by patients themselves subjectively. Results A statistical difference was found only in maximal mouth opening and molar bite force, both greater for the titanium group in the 2-week time point, achieving comparable measurements in subsequent ones. This coincides with the patient-reported statistically lower satisfaction rates. The cost of the resorbable device was nearly 3 times more expensive than the titanium devices. Conclusion Resorbable fixation can achieve stability of bone healing at 1 year postoperatively, with functional and satisfaction outcomes comparable to those associated with titanium hardware from the fourth week postoperatively, while yielding unique advantages.

Malar reduction is one of the most solicited aesthetic surgeries in Asia,1,2 where wide broad cheek bones and/or prominent anterior malar projection are considered masculine causing an aged appearance from illusory temporal and buccal hollowing. Most Asian women prefer a slim oval face with smooth malar-to-cheek transitioning.3,4 Increasingly, these patients desire minimally invasive malarplasty with short downtime to create the ideal profile. When evaluating for malar reduction it is vital to determine which specific areas of the zygoma are causing concern.5 Patients may specify the exact area of malar prominence that they want corrected. Some have facial widening due to an excessively curved zygomatic arch and many techniques can correct this.6-19 Conversely, if the malar body is anteriorly prominent, correction should entail re-positioning of the entire zygoma complex . Thus a technique versatile enough to correct any part of the malar anatomy is desirable. The earliest described reduction malarplasty was bone-shaving,3 and subsequent techniques entailed zygomatic arch resection, arch infracture,4 or osteotomy and repositioning of the entire zygomatic segment.20 Several effective malarplasty procedures – each with their pros and cons - can be categorized into intraoral approaches, external approaches, and a combination of both (Table 1). The technique we present avoids problems associated with previous methods2,9,21-23 through the major advantages of using a combined intraoral and external-endoscopic approach. View this table: Table 1. Pros and Cons of Different Malarplasty Approaches Any facial asymmetry, deviation or deformity was fully documented and communicated to the patient using preoperative photographs, since these may be corrected during the procedure or postoperatively become more obvious. Posterior-anterior and inverted Towne’s view cranial radiographs and 3D facial computed tomographic (CT) scanning were done - the latter particularly important for analyzing asymmetrical malar …

BACKGROUND The zygomaticomaxillary complex (ZMC) is frequently involved in craniofacial fractures. We propose an objective approach for defining the ZMC position on skeletal and soft tissue by using Amira to process 3-dimensional (3D) facial computed tomography (CT) images. AIM AND OBJECTIVES In this study, we aim to propose 1 anthropometric system, facilitated based on CT images, which can be used in quantitative analysis of ZMC position and examine the symmetry of skeletal and soft tissue of the ZMC with high reliability and validity. METHODS Twenty Taiwanese trauma patients with pure mandibular fracture but bilateral intact ZMCs were recruited to participate in this study. The head position was adjusted in 3D planes during the examinations. The distances between the zygion and nasion and maxillozygion and nasion were defined as the x plane. The y plane was defined as the distance between the maxillozygion to the vertex and orbitale to the vertex. The distance between the maxillozygion and opisthocranion was defined as the z plane. RESULTS The results indicated that the intrasubject variability was 0.7 to 1.6 and 0.1 to 1.8 mm in skeletal and soft tissue, respectively. The intersubject variability ranged from 3.1 to 9.2 and 1.8 to 9.3 mm in skeletal and soft tissue, respectively. The proposed anthropometric system demonstrated high validity and reliability in ZMC measurements. No significant difference was observed among bilateral ZMCs, indicating the feasibility of the mirroring technique during surgical processes. CONCLUSIONS We conclude that the anthropometric system for processing 3D facial CT images facilitated by Amira has potential implication in the assessment and reconstruction of the ZMC in both skeletal and soft tissue.

This study describes an injectable, thermo-responsive hyaluronic acid-g-chitosan-g-poly(N-isopropylacrylamide) (HA-CPN) copolymer for bone tissue engineering. The wettability, temperature-dependent change of water content, and volume of HA-CPN hydrogel were measured, together with its biocompatibility in vitro and in vivo. The dried hydrogel morphology shows a three-dimensional, porous structure with interconnected pores. Canine bone marrow-derived mesenchymal stem cells (cBMSCs) were encapsulated in HA-CPN hydrogel and osteoinduction was assessed by comparing samples with different osteogenic differentiation induction times but with the same total cell culture time. Cell proliferation and time-dependent osteogenic differentiation, evident from secretion of extracellular matrix and formation of mineral deposits, were observed. The cells showed better proliferation in HA-CPN hydrogel than on tissue culture polystyrene after osteo-induced for 21 days and higher alkaline phosphatase activity regardless of osteo-induction times. Mineralization extent of cBMSCs in HA-CPN followed by Alizarin red stains showed positive stained nodules after osteo-induced longer than 7 days. The cells/hydrogel construct also showed increased mechanical strength and elasticity after osteogenic differentiation, and the increase could be correlated with osteo-induction time. In vivo studies confirmed the biocompatibility and bioresorption of the HA-CPN hydrogel and ectopic bone formation when the hydrogel was used as a cell carrier for osteo-induced cBMSCs and implanted in nude mice subcutaneously. Taken together, the results indicate the feasibility and efficacy of HA-CPN hydrogel as an injectable bone tissue engineering scaffold with cBMSCs.

Background: This study examined whether a combination of autologous platelet-rich fibrin glue (PRFG) with mesenchymal stem cells (MSCs) and MEDPOR as guided tissue regeneration (GTR) could act as an osteogenic substitute and whether this treatment yields faster new bone formation than MEDPOR alone or PRFG plus MSC. Material: MSCs were harvested and isolated from the bone marrow of dog ilium. Full-thickness bony defects (1.5 × 1.5 cm) were created in the bilateral mandible angles of the dog. Treatments for bone defect in each group were as follows: group 1 (n = 4), MEDPOR sheet as GTR and autologous PRFG/MSCs admixtures; group II (n = 4), autologous PRFG/ MSCs admixtures; group III (n = 4), MEDPOR sheet as GTR; and group IV (n = 4), control (empty defect). The percentage of new bone regeneration in computerized tomography at 2 months and 4 months was calculated by Analyze version 7.0 software. The mandibles were harvested from all specimens at 4 months, and the grafted sites were evaluated by gross, histologic, and X-ray examination. Results: By radiographic analysis at 16 weeks posttransplantation, it was shown that an average of 72.8% ± 8.02% new bone formation in group I, 53.34% ± 6.87% in group II, 26.58% ± 6.41% in group III, and 15.14% ± 2.37% in group IV. Histologic examination revealed that the defect was repaired by typical bone tissue in groups I and II, whereas only minimal bone formation with fibrous connection was observed in the groups III and IV group. Besides, muscle incarceration was found in groups II and IV without MEDPOR as GTR. Conclusion: Autologous PRFG plus osteoinduced MSCs have good potential for bone regeneration. In combination with MEDPOR as GTR, bone regeneration is enhanced by preventing soft tissue ingrowth hindering bone regeneration.

Background Although closed reductions of nasal fractures and zygomatic arch fractures are considered minor procedures, improper reductions are not uncommon. Objectively evaluating reduction adequacy with imaging assistance during surgery is crucial. The authors used mobile Fluoroscan intraoperatively to assess the adequacy of closed reduction for nasal fractures and zygomatic arch fractures. Methods Patients with nasal fractures or zygomatic arch fractures who underwent surgery between 2000 and 2004 were enrolled. Results were reviewed according to postoperative photographs and radiography. Scoring systems were designed for objective assessment, with higher scores representing better outcome. Results One hundred eight patients with nasal fractures and 36 patients with zygomatic arch fractures were enrolled. Fifty-three patients underwent closed reduction of the nasal fracture with fluoroscopic assistance (group NF) and 55 patients underwent closed reduction without fluoroscopic assistance (group N). The mean scores for the fluoroscopic assistance group was 2.96 for radiography and 2.91 for photography, compared with 2.58 for radiography and 2.67 for photography for the group without fluoroscopic assistance. The difference was significant for radiography (p = 0.001) but not for photography (p = 0.068). Of the patients with zygomatic arch fractures, 16 were repaired with fluoroscopic assistance (group ZF) and 20 were repaired without fluoroscopic assistance (group Z). The average score for group ZF was 2.81 for radiography and 2.94 for photography, compared with 2.45 for radiography and 2.6 for photography in group Z. There were significantly higher scores for group ZF for both radiography and photography. Conclusion The mobile Fluoroscan provides direct visualization of the fracture site and instruments and improves the outcomes of closed reduction.

Ulusal, Betül Gözel (Balikesir Author), Microsurgical replantation is the standard method to treat penile amputation. The loss of variable area of skin is a common complication following penile replantation due to prolonged ischaemia time, postoperative venous congestion, oedema and wound infection. There is limited literature available on the management of complications following replantation. A skin graft is commonly used to resurface the denuded areas after skin necrosis. However, this simple and rapid approach has some inherent disadvantages, including paresthesia, contracture, mismatched skin colour and disfiguring donor site. In this report, we present the salvage of a replanted penis by a bipedicled scrotal flap in which the skin fragment was necrosed due to prolonged ischaemia time. Cosmetic and functional outcomes in the 1-year follow-up period were satisfactory.

Background Transantral endoscopic repair of orbital floor fracture minimizes the risk of implant misplacement and avoids complications associated with traditional lower eyelid approaches. Contrary to most publications, its application is not limited to early intervention of pure orbital blow-out fractures. The authors present their results of broad application of this technique, with longer-term patients' follow-up. Methods A retrospective review of 32 patients over a 10-year period (March of 1998 to June of 2008) was performed. The mean duration of follow-up was 27.5 months (range, 4 months to 10 years). Sixteen patients (50 percent) had associated zygoma, inferior orbital rim, and Le Fort I fractures. Twenty-five patients (78.1 percent) had enophthalmos, with 14 of these cases being 2 mm or more in severity. Diplopia was present in 15 patients (46.9 percent) preoperatively. Operations were performed within 2 weeks for 25 patients (78.1 percent). Twenty-eight patients required orbital floor reconstructions. Four of five patients with associated orbital medial wall fractures underwent simultaneous orbital medial wall reconstruction. Results All patients had successful reduction of orbital fractures. Two patients had residual enophthalmos of 1 mm postoperatively. Due to delay in surgery and the nature of injury, only 11 of the 15 patients with diplopia had complete resolution after surgery. One patient required drainage of recurrent sinusitis 1 year after surgery. Conclusions In suitably selected patients with orbital floor fractures, the transantral endoscopic approach is safe and reliable. Delayed surgery or associated zygomaticomaxillary complex fractures are not contraindications for the use of this technique. Long-term follow-up showed maintenance of the surgical results.

Summary Purpose The application of rhinoplasty in the treatment of traumatic nasal deformity remains one of the most challenging problems for surgeons. Not only is the skeletal structure severely deformed, but the soft tissue may also be disfigured by a previous injury. Although autogenous bone and cartilage have been the primary choice for nasal reconstruction, synthetic material is desirable for various reasons. This article presents our experiences in the reconstruction of traumatic nasal deformity by using porous polyethylene (Mdepor ® ) implant in Orientals. Materials and methods From May 1998 to January 2005, 32 patients, including 15 males and 17 females, underwent augmentation rhinoplasty for the correction of traumatic nasal deformity. Of these, 30 patients had experienced associated midfacial bone fractures. The surgical procedures employed consisted of the open-tip approach that was followed by implant carving, placement and fixation. Twenty patients received lateral nasal osteotomies, and septoplasty procedures were performed in nine patients, simultaneously. External taping was done, and nostril tampons were placed postoperatively and left in situ for 3 days. The outcome was assessed by an independent investigator and the patients themselves. Results The patients were, on average, 22 years old at the time of reconstruction and were followed up for an average period of 25.4 months. The interval from injury to the rhinoplasty procedure was 304 days, on average. The average length of dorsal grafts was 44.9mm. The overall aesthetic-improvement rate was 90.6%, and the patient-satisfaction rate was 84.4%. There were three complications, including an implant-tip exposure and two implant infections. Conclusion A porous polyethylene (Medpor ® ) implant is an effective alternative to autograft for correction of traumatic nasal deformity in Orientals to achieve a pleasing appearance of the nose without donor-site morbidity. A meticulous execution of concomitant procedures and impregnation of the implant by submerging it in an antibiotics solution prior to use were helpful in decreasing the complications.

Soft tissue reconstruction of the distal forefoot and toes poses a difficult problem. Skin grafts are not suitable when deep structures are exposed. Local flaps are not available, particularly for defects of the toes. Free flaps are spared for larger defects. Medial plantar flap has been widely used for plantar defects, especially weight-bearing surface of the heel. Distally based retrograde-flow design of this flap allows the transfer of the pedicled flap distally and provides coverage of soft tissue over the metatarsal heads. In this report, we further modified the retrograde-flow medial plantar island flap to extend its use for distal dorsal forefoot defects. The technique and outcomes of two patients are presented.

This paper examines links between institutional responses to legal crises and shareholder valuation. It explores whether the defendant firm's market performance upon the announcement of a filing varies according to the crisis response strategies applied. It also investigates the relationship between the legal issue and the type of crisis response strategy. It examines whether the type of legal issue affects the relationship between the use of crisis response strategies and the firm's performance upon the announcement of a filing. The findings indicate that using nonexistence and distance strategies instead of no response may mitigate negative market response. However, when firms face corporate governance suits, whether or not they implemented crisis response strategies has a significantly negative impact on firm value.

Retrobulbar hematoma is a rare complication after orbital surgery, with the potentially disastrous consequence of visual impairment and blindness. We report a female patient who was admitted for enophthalmos correction because of the unsatisfactory result of the primary repair of an orbital blowout fracture and who subsequently experienced the complication of retrobulbar hematoma after operation. The initial presentation of the patient was eye pain with vomiting, followed by proptosis and visual impairment. Retrobulbar hematoma was confirmed by computed tomography, and immediate medical and surgical treatments were instituted. The vision of the patient recovered gradually during outpatient follow-up.

Purpose Owing to the risk of facial nerve damage and the creation of visible scars, surgical treatment of condylar mandible fractures using an extraoral approach remains controversial. The transoral endoscopically assisted approach of condylar fractures has been reported to avoid these complications. A prospective, randomized controlled, multicenter trial was performed to quantify the patient benefit after open reduction and internal fixation of condylar mandible fractures using endoscopically assisted treatment compared with surgical treatment without endoscopic assistance. Patients and Methods Patients with dislocated uni-/bilateral condylar neck fractures were randomized to receive either nonendoscopic open reduction and internal fixation using an extraoral (submandibular, preauricular, retromandibular) approach or a transoral endoscopic procedure. The primary functional outcome measure was investigated using the asymmetric Helkimo dysfunction score at 8 to 12 weeks and 1 year after surgery. Results A total of 74 patients were recruited between 2003 and 2006; the nonendoscopic extraoral group included 34 patients and the endoscopically assisted open reduction group included 40 patients. Comparable functional results were noted in both groups without any statistical significance. Endoscope-assisted treatment proved to be more time consuming. For the extraoral group, visible scars were rated by most of these patients as being cosmetically acceptable; however, a greater number of facial nerve injuries were reported. Conclusions The treatment of condylar mandible fractures with a minimal invasive endoscopically assisted technique is reliable and may offer advantages for selected cases, particularly concerning the lower occurrence of facial nerve damage.