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A frontoorbitozygomaticomaxillary fracture, also known as a complex midface fracture or "quadripod fracture," is a type of facial fracture involving multiple midface region bones. This includes the frontal bone (forehead), orbitozygomatic complex (which includes the zygomatic bone or cheekbone and the orbital bones around the eye), and the maxillary bone (upper jaw). These complex midface fractures associated with temporoparietal bone fractures can occur in clinical practice. However, a single-piece fracture of these has not been reported before. This study reports a 44-year-old male patient with a significant frontoorbitozygomaticomaxillary fracture associated with a temporoparietal bone fracture combined with epidural hematoma at the superior aspect of unilateral frontoparietotemporal convexity. Surgical treatment was performed 3 weeks after the traumatic event. Despite craniotomy of the parietal bone fragment, the reduction was not possible. The facial bone reduction was finally achieved following an additional single osteotomy at the unilateral zygomaticomaxillary buttress. The follow-up CT scan taken immediately and 3 weeks postoperatively showed successful realignment of craniofacial bone fracture. In conclusion, a single-piece fracture of frontoorbitozygomaticomaxillary bone connected to a temporoparietal bone can require additional osteotomy to achieve successful outcomes in an acute setting., Competing Interests: The authors declare no conflicts of interests., (Copyright © 2023 by Mutaz B. Habal, MD.)

Background: To approach isolated anterior frontal bone fracture, coronal incision is the common surgical access of choice. This approach has complications such as aesthetically undesirable scarring and alopecia along the incision line. An alternative approach to these fractures is through a supratarsal incision. The aim of the present study was to correct the frontal bone fracture, through supratarsal approach., Methods: Six consecutive patients with frontal bone fracture were operated through supratarsal incision and evaluated regarding: patient cosmetic satisfaction, forehead contour, scarring, sensibility and motility in forehead and upper eyelids., Results: Seven months (6-12) postoperatively, all the patients had normal mobility in the forehead and the upper eyelids and 17% (n = 1) had hypoesthesia of superior orbital nerve. The forehead contour was excellent in all patients. About 83% (n = 5) of the patients were very satisfied and 17% (n = 1) were satisfied with the surgical result., Conclusion: Correction of anterior frontal bone fracture through a supratarsal approach appears to be safe and offers a sufficient exposure to the frontal bone fracture correction with excellent contouring results and no noticeable scarring.

Purpose: Fracture of the frontal bone can be accompanied by damage to the optic canal. The present study uses finite element analysis to identify fracture patterns, suggesting the involvement of the optic canal., Methods: Ten finite-element skull models were generated from computer tomography data of 10 persons. Then, dynamic analyses simulating collision of a 2-cm-radius brass ball to 6 regions on the frontal bone in the 10 models were performed. Fracture patterns presented by the frontal bone in the 60 experiments were observed, and all those involving the optic canal were selected. Commonalities of the selected fracture patterns were identified., Results: Fracture of the optic canal was observed in 9 of the 60 patients. In all 9 patients, fracture existed on the anterior and posterior walls of the frontal sinus and on the superior orbital wall., Conclusion: When the anterior and posterior walls of the frontal sinus and the superior orbital wall are all broken, the optic canal is highly likely to be involved in the damage. When this pattern is observed in emergency examination, preventive decompression of the optic nerve should be considered to avoid potential occurrence of blindness.

The frontal bone fractures occur very often in service units in oral and maxillofacial surgery. Bicoronal access is the most common for the surgical treatment of frontal bone fractures. However, patients are surprised when they receive notice that such invasive access will be made. This approach allows adequate visualization of the fracture site, but may be associated with complications, which can be avoided by the use of less invasive techniques. We describe an alternative approach that aims to minimize the complications of a coronal incision.

A 34-year-old woman with severe craniofacial trauma, which included eversion of the entire frontal bone, survived with high-quality functional and cosmetic results as a consequence of efficient and aggressive action by emergency technicians and physicians. Early preliminary steps of craniofacial reconstruction provided a structural foundation that facilitated this outcome.

The deep layers of the nasoethmoid region comprise a thin-walled lacrimal bone, a paper-thin ethmoid plate, and ethmoidal cells, forming an extremely fragile and easily crushed structure. In a nasoethmoid complex fracture where the support structure itself is destroyed, epithesis and immobilization are difficult and can lead to residual saddle nose deformities. Therefore, bone grafts are often necessary at a later date. Recently, the authors occasionally see reports of nasoethmoid complex fractures that are treated with Halo distraction devices. Advantages of this device are that it applies constant traction to maintain the shape of the structures until the ruptured nasoethmoid bone and mucosa are repaired, thus minimizing relapse. There is no need for rigid fixation with a plate, no limitations on how much distraction is possible, and no major skin incisions are required for the approach. The authors treated a 30-year-old man who suffered a severe and widespread depressed facial deformation due to a nasoethmoid fracture that included a midface comminuted fracture using a Halo-type distraction device. A gentle traction was maintained on the nasoethmoid bone and part of the maxilla pulling it forward, and resulted in an extremely good outcome both esthetically and functionally. This method is believed to be extremely useful and effective, requiring only minimally invasive surgery for comminuted midface fractures involving a nasoethmoid fracture with a depressed frontal process of the maxilla. Below, the authors provide a detailed description of their experience with this device.

An anterolateral thigh myo-adipofascial flap was used in the definitive management of a patient presented with chronic infective process associated with a large fronto-nasal defect. Unfortunately, the risk of free flap transfer failure emerged when intraoperative dissection showed absence of a reliable ipsilateral superficial temporal artery as the recipient artery. This rare incident happened at the stage whereby the anterolateral thigh flap was nearly completely raised with a distal perforator in situ. In this article, the authors presented an innovative strategy to salvage the flap by transforming the flap into a modified composite flap based on the retrograde blood flow principle. To the best of our knowledge, this is the first report of using such a technique in reconstructive microsurgery. This successful salvage strategy has clinical application and could potentially minimize free flap transfer failure.

Background: Pediatric cranial vault fractures are a unique subset of injuries that pose distinct management and treatment challenges. They are anatomically distinct from their adult counterparts with potential implications on the development of the brain and craniofacial skeleton, and require unique considerations for management and treatment outcomes.A detailed analysis of the characteristics and outcomes of pediatric cranial vault fractures remains understudied in this population. Thus, the aim of this study was to characterize the demographics, injury patterns, operative interventions, concomitant injuries, and factors predictive of mortality in pediatric patients sustaining cranial vault fractures., Methods: A retrospective review of patients less than 18 years of age presenting to the emergency department of a pediatric level I trauma center between 2000 and 2005 with skull fractures was performed. All patients were included regardless of treating specialty, treatment modality, or inpatient status. Patients were stratified into 3 groups (age < = 5 yrs, 5.1-11 yrs, and >11 yrs). ZIP codes were mapped using ArcGIS 10.2 Software (ESRI Inc, Redlands, CA) with ZIP code shapefiles from ESRI's ArcGIS Online. Socioeconomic and demographic variables at the ZIP code level were linked to each geocoded location using the United States Census Bureau summary files, and spatial clusters of injury were performed using GeoDa to conduct a test of local indicator of spatial autocorrelation. Statistical analysis was performed using the SPSS version 17 (SPSS Inc, Chicago, IL)., Results: A total of 923 consecutive patients met the inclusion criteria for the study. Caucasian (P < 0.001) males (P = 0.055) were most likely to sustain cranial vault fractures. The average age at injury was 5.97 years. Falls (53.7%) were the most common cause of injury across all age groups, followed by collisions (20.8%), with falls being more common in the youngest age group (< = 5 yrs), and collisions being more common in the older age groups. Direct objects to the head had the highest rate of surgical intervention (P < 0.001). Parietal bone fractures were more frequent in the youngest age group, while frontal and temporal bone fractures were more common in the older age groups. Increasing age was an independent predictor of the need for surgical intervention (P < 0.0001). The overall incidence of blindness and hearing loss was low, and increased with increasing age. Patients with fractures as a result of violent mechanisms were more likely to come from highly impoverished zip codes, compared with patients with nonviolent mechanisms of injury (19.6% versus 8%). Overall mortality was low (2.9%). Temporal bone fractures had the greatest risk of mortality (P < 0.001) with age > = 5 years being an independent predictor of mortality (P < 0.001). Victims of falls, and patients with associated gastrointestinal or musculoskeletal injuries, had a statistically significant increased chance of survival, whereas victims of collisions and patients with concomitant cervical spine, cardiothoracic, or respiratory injuries had a significantly increased risk of death., Conclusions: Pediatric cranial vault fracture injury patterns are significantly correlated with demographics, mechanisms of injury, presence and type of concomitant injuries, need for surgical intervention, and mortality. Although the need for operative intervention and overall mortality is low, these variables play significant roles in portending prognosis, and an understanding of the metrics presented herein will enable practitioners optimize management and treatment in this unique patient population.

Craniofacial trauma can lead to several complications. The combined fractures of anterior and posterior walls of the frontal bone are almost always followed by lesions in nasofrontal orifices and disruption of nasofrontal ostia or ducts, a significant factor for the development of early and late complications after sinus fractures. This article reports a case of trauma patient, who underwent neurological evaluation and at first showed good general condition. Computed tomography noted fracture of the anterior and posterior walls of the frontal sinus and small foci of pneumocephalus in the cerebral cortex. The patient was monitored periodically and 9 days after trauma showed increased areas of pneumocephalus in prefrontal cortex, cerebrospinal fluid draining, and large dura mater lesion, with signs of necrosis and inflammation (meningitis). The necrotic tissues were removed, and dura mater was repaired through the approximation with resorbable wire polyglactin 910 5-0, oxidized cellulose application, and bonding with human fibrin sealant (fibrinogen, thrombin, and calcium chloride). Sinusectomy, frontal sinus, and nasofrontal duct obliteration with pedicled pericranium flap were performed. Tomographically, a reanatomization was noted in frontal region, and a 12-month follow-up showed no complication. The use of fibrin glue to repair dura mater lacerations, as well as the pedicle pericranium flap for frontal sinus and nasofrontal duct obliteration, is an efficient method for treating fractures of the frontal bone.

Aneurysmal bone cysts (ABCs) rarely occur in the cranial bone. Surgical resection can lead to bone defects, deformities, functional abnormalities, and so on. This article describes a frontal ABC in a 73-year-old man who has a rapidly increasing swelling in the frontal bone preceded by an accidental trauma. In this case, we use percutaneous sclerotherapy with absolute alcohol under the guidance of fluoroscopy to treat the ABC instead of traditional surgical resection. When analyzed the follow-up imaging, bone reconstruction happened after using absolute alcohol. It is a feasible alternative treatment for ABC arising from the cranial bone.

The objective of this study was to investigate the diagnosis and surgical treatment of central brain herniations caused by traumatic bifrontal contusions. A total of 63 patients (45 men and 18 women; mean age of 43 years with a range from 20 to 72 years) who suffered from traumatic bifrontal contusions between January 2007 and December 2012 were inspected. The clinical and imaging results were studied for all patients, and we found that swelling of the mesencephalon and a downward shift of the bilateral red nucleus were significant signs of central brain herniation in the image of magnetic resonance imaging. All patients were given a simultaneous bilateral craniotomy for balanced decompressive surgery. The Glasgow Outcome Scale was used to monitor the patients during the follow-up period, which lasted from 6 to 52 months with a mean of 22 months. At the termination of the follow-up period, the following Glasgow Outcome Scale scores were obtained: 14 patients scored 5 points, 22 patients scored 4 points, 7 patients scored 3 points, 13 patients scored 2 points, and 7 patients scored 1 point. Therefore, our study suggested that an early magnetic resonance imaging scan could result in a more timely diagnosis of central brain herniation, and simultaneous bilateral craniotomy was found to be one of the best treatments for central brain herniation to improve patient outcomes.

The reconstruction of calvarial defect is a challenging treat for any craniofacial surgeon. The split calvarial bone graft reconstruction is a well-described method of reconstruction and gives very good results. Here, we present a 14-year-old girl who presented with a frontal cranial bone defect with a size of 5 × 3 cm for which the reconstruction was done with a split calvarial bone graft taken from the parietal bone. The method of reconstruction resembled keeping a lid of a jar, and we named this procedure lid cranioplasty. We were able to come out with very good cosmetic and functional outcome.

The aim of this retrospective study was to evaluate the epidemiology, treatment, and complications of frontal bone fractures associated, or not, with other facial fractures. This evaluation also sought to minimize the influence of the surgeon's skills and the preference for any rigid internal fixation system. The files from 3758 patients who attended the Oral and Maxillofacial Surgery Department of the School of Dentistry of Ribeirao Preto, University of Sao Paulo, from March 2004 to November 2011 and presented with facial trauma were scanned, and 52 files were chosen for the review. Eleven (21.15%) of these patients had pure fractures of the frontal bone, and trauma incidence was more prevalent in men (92.3%), whites (61.53%), and adults (50%). Despite the use of helmets at the moment of the trauma, motorcycle crashes were the most common etiological factor (32.69%). Fracture of the anterior wall of the frontal sinus with displacement was the main injury observed (54.9%), and the most common treatment was internal fixation with a plate and screws (45.09%). Postoperative complications were observed in 35.29% of the cases. The therapy applied was effective in handling this type of fracture, and the success rate was comparable to that reported in other published studies.

The management of frontal bone injury is an important issue, and inappropriate management of such injuries may give rise to serious complications. Piezosurgery is a technique used to perform safe and effective osteotomies using piezoelectric ultrasonic vibrations. This instrument allows a safe method for osteotomy of the cranial vault in close proximity to extremely injury-sensitive tissue such as the brain. After a wide review of the literature, the authors present this technical report, introduce the use of piezosurgery to perform a safe "slim-osteotomies" for treatment of posttraumatic frontal bone deformities, and suggest the use of this instrument for aesthetic recontouring of the craniofacial skeleton.

Fractures of the orbitozygomatic complex are one of the most common facial fractures encountered by plastic surgeons. Many would consider this to be primarily a cosmetic deformity; however, these injuries can be associated with acute life-threatening complications. Intracranial pseudoaneurysm, although rare, is a well-documented complication of blunt facial trauma, which most plastic surgeons are unaware of. We present the case of a 20-year-old woman who developed an intracranial pseudoaneurysm after blunt facial trauma to illustrate the importance of (1) understanding this rare but highly morbid complication, (2) assessing high-risk patients for pseudoaneurysm, and (3) delaying reconstruction in high-risk patients.

Object: Promising clinical results were reported in watertight closure of anterior skull base defects (ASBDs) with bisphenol-a-glycidyl-dimethacrylate (bis-GMA)-based materials to prevent the cerebrospinal fluid leaks. However, interrelation of these materials with surrounding bones in histologic level, referred to as the osteointegration, has not been reported in the anterior skull base. In addition, an illustrative case with an ASBD that was repaired using a bis-GMA composite has been presented., Methods: Twenty New Zealand rabbits were divided into 4 groups: control and sham groups consisted of 2 and 6 rabbits, respectively. The "skull base defect" group (n = 6) underwent a unifrontal craniectomy and an iatrogenic ASBD followed by creating a dural defect to obtain a cerebrospinal fluid leak. Similar bony and dural defects were acquired in the "repair with bis-GMA based allograft" group (n = 6), but the bony defect was closed with bis-GMA-based allograft., Results: All animals in the "skull base defect" group died in 3 weeks after surgery. There were no animal losses in the "repair with bis-GMA based allograft" group at the sixth month. Histologic evaluation revealed complete osteointegration of bis-GMA composite with surrounding bones., Conclusions: bis-GMA based allograft achieved a watertight repair of the ASBD. Histologic findings of this study showed that bis-GMA composite is a reliable material to be used in the closure of anterior skull base bony defects.

Reconstruction of craniofacial defects in children presents several challenges that are not encountered in the adult population. Autologous bone grafts have long been the criterion standard for repairing these defects. Recently, several new materials and techniques have expanded our arsenal of reconstructive options. In this clinical report, we describe the use of both particulate bone grafting and demineralized bone matrix together to repair craniofacial defects encountered in pediatric patients.

Temporal hollowing is most frequently an acquired defect and can be caused by a volumetric deficiency of bone, soft tissue, or both. Given high-density porous polyethylene's ease of use, customizability, long-term strength and resiliency, and successful application in other areas of the craniofacial skeleton, the authors have used it as the first-line material for reconstruction of temporal hollowing. Herein, we present 4 illustrative cases demonstrating this technique and further describe subtypes of the temporal defect with appropriate means of reconstruction. The cases were reviewed for comorbidities, intraoperative details, and the postoperative course. There were no complications, and all patients were pleased with their final result. High-density porous polyethylene is a safe, well-studied, and easily handled biomaterial that is useful for the treatment of temporal hollowing.

The purpose of this study was to compare the osteogenic potential of a synthetic and a demineralized bone matrix (DBM) putty using a cranial defect model in New Zealand white rabbits. Paired, bilateral critical-size defects (10 mm) were prepared in the frontal bones of 12 rabbits and filled with either OsteoSelect DBM Putty or NovaBone calcium-phosphosilicate putty. At days 43 and 91, 6 rabbits were killed and examined via semiquantitative histology and quantitative histomorphometry. Defects filled with the DBM putty were histologically associated with less inflammation and fibrous tissue in the defect and more new bone than the synthetic counterpart at both time points. Histomorphometric analysis revealed that the defects filled with DBM putty were associated with significantly more bone formation at day 43 (70.7% vs 40.7%, P = 0.043) and at day 91 (70.4% vs 39.9%, P = 0.0044). The amount of residual implant was similar for both test groups at each time point.

Facial fractures resulting from blunt-mechanism trauma, although common, have been infrequently evaluated in large studies that do not include confirmation of fractures based on author review of available patient radiographic studies. An 8-year review (1998-2006) of the R Adams Cowley Shock Trauma Registry was performed with institutional review board approval. Patients diagnosed with blunt-mechanism facial fractures were identified by the International Classification of Diseases, Ninth Revision (ICD-9) codes and their facial fractures confirmed by author review of computed tomographic scans. Individual fractures were classified and grouped according to the facial thirds. Intra- and interreader variability was calculated, and confirmed fracture patterns were compared to fracture patterns listed by ICD-9 codes. Concomitant injuries and demographic data were additionally evaluated. Four thousand three hundred ninety-eight patients with 8127 fractures were identified. Intra- and interreader variability was 2% and 7%, respectively. ICD-9 coding misdiagnosed 12.5% of all fractures. Eighty-two percent of patients sustained associated injuries, including basilar skull fractures (7.6%) and cervical spine fractures (6.6%). 1.1% had at least one fracture in each facial third (panfacial fracture pattern). Significant relationships were found between demographic parameters, concomitant injuries, specific fractures, and fracture patterns. Studies investigating facial fractures should report fracture patterns confirmed by author review of available radiographic imaging. Large retrospective data sets containing confirmed fractures and capable of addressing rare fracture patterns can be compiled with low inter- and intrauser variability, and are useful for generating mechanistic hypotheses suitable for evaluation in prospective series or by directed biomechanical studies.

Cranioplasty is a medical technique to correct cranial bone defects. Depending on the size and location of the defect, a bone substitute can be used to replace the missing bone. Frontal bone defects are important to patients in terms of cosmetics because they are visible. Advances in computer design allow the production of customized implants with improved cosmetic and functional results. This report describes hybrid optimization of three-dimensional technological methods along with traditional methods toward the manufacture of deep-buried titanium implants, restoring frontal skull defects for 4 patients. A three-dimensional model was produced from the computed tomographic scan data of 3 patients using an in-house three-dimensional printer. A new approach was followed in treating the fourth patient. The defect was restored using preoperative scan before cranioplasty. These data were transported digitally into the defect skull to recreate the bone contour required, and a three-dimensional model was produced from the "new" digital model using the three-dimensional printer. Defect areas of the patients were large and measured 101.21 × 123.35 (vertical × horizontal) in average (mm). Conventional wax-up of the defect was carried to restore normal conformity. A titanium sheet (0.5 mm) was swaged into the desired shape; however, convexity of the defect area makes titanium swaging challenging, especially at the deep lateral undercuts. Making side flanges at reasonable lengths made it easy to swage without creasing. Three-dimensional models aided to produce accurately fitting plates. Finally, the sequential method of using both digital and manual procedures is a low-cost, reliable, accurate, and reproducible method.

Background: Subperiosteal hematoma is the accumulation of blood between the periosteum and the skull, which commonly occurs in the neonatal period but rarely in other ages. Subperiosteal hematoma can be self-absorbed in most cases and occasionally may cause ossification., Materials and Methods: This study reports a case of subperiosteal hematoma formed in a 16-year-old adolescent boy after a minor trauma. Because the hematoma did not disappear for more than a month after the trauma, the patient was treated with multiple hematoma punctures. However, the hematoma recurred and led to ossification. Finally, the patient underwent surgical treatment., Results: Finally, the ossification associated with the hematoma was treated through surgery. The head contour recovered normally., Conclusions: The occurrence of hematoma ossification in the 16-year-old patient suggests that the periosteum has great potential for osteogenesis. This is likely caused by the joint action of some active factors in the blood and a certain tension of the hematoma on the local periosteum. This case provides the following thoughts. (1) A subperiosteal hematoma that has not been absorbed after 1 month should be treated promptly to avoid ossification. Once ossification has occurred, the hematoma should be treated surgically. (2) The potential for periosteal osteogenesis is great, which may provide a new thought for cranioplasty.

Computer-aided design has gained increasing popularity in clinical practice, and the advent of rapid prototyping technology has further enhanced the quality and predictability of surgical outcomes. It provides target guides for complex bony reconstruction during surgery. Therefore, surgeons can efficiently and precisely target fracture restorations. Based on three-dimensional models generated from a computed tomographic scan, precise preoperative planning simulation on a computer is possible. Combining the interdisciplinary knowledge of surgeons and engineers, this study proposes a novel surgical guidance method that incorporates a built-in occlusal wafer that serves as the positioning reference.Two patients with complex facial deformity suffering from severe facial asymmetry problems were recruited. In vitro facial reconstruction was first rehearsed on physical models, where a customized surgical guide incorporating a built-in occlusal stent as the positioning reference was designed to implement the surgery plan. This study is intended to present the authors' preliminary experience in a complex facial reconstruction procedure. It suggests that in regions with less information, where intraoperative computed tomographic scans or navigation systems are not available, our approach could be an effective, expedient, straightforward aid to enhance surgical outcome in a complex facial repair.

Intracranial epidermoid cysts constitute about 1% of all intracranial tumors. They are usually congenital in origin and are thought to derive from ectodermal cell inclusions occurring during closure of the neural tube. Twenty-five percent of these are found in the skull as intradiploic epidermoid cysts. These intradiploic cysts are usually congenital, slow growing, and can grow to large size without causing symptoms. We present a case of intradiploic epidermoid cyst of frontal bone developed due to childhood trauma. The cyst expanded and eroded the walls of the frontal sinus causing proptosis, diplopia, and restricted eye movements with frontal headache. The bicoronal flap approach was used for complete removal of the cyst. Complete removal of the cyst wall is necessary to avoid recurrence.

Subperiosteal orbital hematoma occurs rarely after blunt trauma. However, this is of importance, as this condition may cause ocular symptoms. The major characteristics of subperiosteal orbital hematomas are painful proptosis, downward displacement of the globe, absence of lid ecchymosis, chemosis without subconjunctival hemorrhage, and motility impairment. Visual impairment is known as a rarely presenting symptom. A 22-year-old male patient presented with right periorbital ecchymosis, swelling, and diplopia with upper lateral gaze limitation. Besides, the patient complained of lower visual field disturbance. Radiologic evaluation revealed traumatic subperiosteal orbital hematoma. The hematoma was evacuated through a lacerated wound on the right lateral eyebrow with additional incision. After the hematoma evacuation, the orbital symptoms are restored. Postoperative computed tomographic scans showed normally restored orbital space without any evidence of remnant hematoma or rebleeding. In case of subperiosteal hematoma, early detection and complete surgical evacuation is crucial for preventing possible complications and sequelae.

Defects on the craniofacial complex may result in aesthetic defects, functional damage, and psychologic consequences. Previously, surgeons showed no interest in reconstructing the operated area, but in the treatment of the problem, leaving bone contour is a secondary issue. Nowadays, area reconstruction with post-reestablishment of contour and local shape has become one of the surgeon's priorities. The use of alloplastic implants with specific digital design has been stated to be an effective technique on the treatment of craniofacial defects, reducing the need for manipulation in the intraoperative period and decreasing surgery time. Polyether ether ketone (PEEK) is a potential candidate because it is a linear polyaromatic semicrystalline polymer that combines strength, stiffness, durability, and resistance. Polyether ether ketone biocompatibility has been supported in literature, and subsequent medical applications of the material have been observed. The aim of this study was to describe a case of frontal bone defect reconstruction in which the PEEK was used as polymer material in a specific implant for the Synthes (PEEK-PSI) patient.

A resorbable fixation system has many advantages, but there are complicated procedures to be accomplished to fix a resorbable plate. The complicated procedures in the fixation of a resorbable plate make the operation for facial fractures more difficult and can result in extended operation time and incomplete reduction or fixation. For these reasons, we suggest a new way of using a tapper that can make the surgery more simple and accurate than before. After the resorbable plate is properly located above the fractured site, a hole on the fracture fragment is made by drill, and the tapper is inserted into the hole. When the tapper is inserted at the proper depth, the fracture fragment can be reduced to right place by handling the inserted tapper. Then, the tapper is inserted to the end, and the handle is split. While the inserted tapper acting as a temporary metal screw is placed, another hole is made at nearby site and the screw is inserted. Next, the inserted tapper acting as a temporary metal screw is removed, and another screw is inserted into the hole from which the tapper was removed. From October 2006 to April 2008, we applied this procedure to 106 facial bone fractures in 68 patients, and no major complications were noted. In conclusion, we tried to make the operation more simple and accurate by using the tapper as an instrument for reduction and fixation of fracture fragment.

Facial injuries with the retention of foreign bodies inside the tissues, both in soft and hard ones, can cause major functional and aesthetic damage. Among the different etiological agents, cutting tools, fragments of a firearm, the splinter of wood, steel, or iron, launched by misuse, or even caused by defects in equipment, are the main cause of these injuries. The aim of this study was to discuss the peculiarity of the multidisciplinary approach in caring of a 33-year-old man, victim of an accident at work, by the rupture of an emery disc and consequent penetration of the fragments in violation of the tissues in the orbital and zygomatic region of the left side, with perforation of the eyeball and orbital-zygomatic fracture. Urgent treatment consisted of debridement of wounds, bleeding control, removal of foreign bodies, fracture reduction with rigid internal fixation, and suture, performed by the oral and maxillofacial surgical team. Reconstruction of orbital tissues by the ophthalmology team consisted of suture of the injuries. About 1 month after the trauma, phthisis bulbi was noted, and the patient underwent a new procedure under general anesthesia for eye evisceration and installation of an alloplastic prosthesis associated with the homogenous sclera. Facial harmony was restored, especially in aesthetics and function of the zygomatic-orbital complex.

As part of the trauma of the upper third of the massive face, the fronto-orbito-zygomatic arch is the most frequent and is often associated with eyelid involvement. From 2001 to 2008, 135 patients with fronto-orbital eyelid complex alterations occurred at our center; the patients were included in clinical follow-ups until 2010. Most patients (80%) came to our observation in a state of emergency due to automobile accidents, sports injuries, or assaults, whereas a smaller proportion (20%) was because of previous trauma or surgery. Among the urgent patients, 28 patients present bone lesions without soft-tissue involvement, 62 present bone lesions with soft-tissue involvement, and 16 present only soft-tissue lesions. Among the patients who came as outcomes, in 16 patients, a bone review was necessary; in 15 patients, only soft-tissue review was necessary; and 8 patients needed only scar outcome review. Soft-tissue treatment was more difficult, especially the eyelid. The eyelid must be treated as soon as possible to avoid corneal lesions and major complications like total vision lost. The surgical design must satisfy even the aesthetic profile to guarantee functional success and aesthetic too.

We describe the resolution of persistent diabetes insipidus after cranioplasty with autogenous bone and bone morphogentic protein 2-infused collagen matrix in a patient who had large bilateral craniectomies for trauma. A potential pathogenic mechanism is presented.

Mucoceles of the frontal sinus are expansive cysts filled of the mucus secreted by goblet cells interspersed in the ciliated mucosa. The aim of this article was to present a case of a frontal mucocele that was developed in a 31-year-old man 19 years after having had a frontal sinus fracture. This is a rare entity. Frontal sinus fractures must be treated by a multidisciplinary team to avoid all possible sequelae. An adequate primary management of frontal sinus fractures is essential to prevent complications. This may include conservative attitude, reduction and fixation with miniplates, obliteration, cranialization, or grafting. Removal of any rest of epithelium is mandatory in this sense.

Background: Using conventional complex facial fracture management principles, confirmation of adequate facial fracture reduction can be achieved only by obtaining a postoperative computed tomography (CT) scan. If the CT scan revealed any discrepancy in fracture alignment, additional procedures for correction may be required. The concept of intraoperative CT scanning provides immediate postreduction or intraoperative information that orients the surgeon to the potential need for additional maneuvers for improved fracture reduction and osseous fixation. We assessed the early technical feasibility of real-time intraoperative CT scanning using the xCAT ENT (Xoran Technologies, Inc, Ann Arbor, MI), for monitoring of fracture reduction with the possibility of immediate intraoperative revision if needed, potentially obviating the need for revision procedures., Methods: Three adult patients were studied who were admitted from the emergency department. During their respective reconstructive procedures, the xCAT ENT was used to provide images: Axial, coronal, sagittal, and three-dimensional reformatted images with segmentation of the CT data set and mirroring of the reconstructed side to the unaffected side were used for precise measurement and comparison of the reconstruction. The scans were examined by the operating surgeon and an intraoperative decision was made as to whether immediate revision was required., Results: Facial fracture management with intraoperative CT monitoring was changed in 2 of the 3 cases. One patient who underwent immediate revision had an open reduction-internal fixation after cranialization. The second patient who had a revision had a persistent subcondylar fracture that was found not amenable to closed reduction., Conclusions: The intraoperative CT scan may positively change the outcome of facial fracture reduction especially when dealing with complex fractures. Additional studies are needed for studying its potential impact in monitoring reduction of facial fractures.

The purpose of this study was to evaluate the natural history of zygomatic fractures in 469 cases over 14 years. The medical records of patients seeking treatment for zygomatic fractures were reviewed. The zygomatic fractures were classified as monopod, dipod, or tripod fractures for most patients. The monopod fractures included (1) zygomaticofrontal, (2) zygomaticomaxillary, and (3) zygomatic arch fractures. The dipod fractures were subclassified into 3 types according to combination of the previously mentioned 3 sites, which were 1 and 2, 1 and 3, and 2 and 3. Tripod fracture included all 1, 2, and 3. Among 469 cases of zygomatic fractures, tripod fractures (n = 238, 50.7%), zygomaticomaxillary fracture (n = 121, 25.8%), and isolated fracture of the zygomatic arch (n = 98 20.9%) formed most of the cases (n = 457, 97.4%). About one-half cases were tripod fractures (n = 238, 50.7%), and another half cases were monopod fractures (n = 220, 46.9%). Only 11 cases (2.4%) were dipod fractures. Most of the monopod fractures were zygomaticomaxillary (n = 121, 25.8%) and zygomatic arch fractures (n = 98, 20.9%). Among the dipod fractures, no cases of zygomaticofrontal and zygomatic arch fractures were reported. An open reduction was performed in 73.8% (346 cases), closed reduction in 24.5% (115 cases), and conservative treatment in only 1.7%. In tripod fracture (n = 238), an open reduction and internal fixation was performed for most of the cases (n = 225, 94.5%), and closed reduction was performed in only 11 cases (4.6%). In monopod zygomaticomaxillary fracture (n = 121), internal fixation was performed for most of the cases (n = 108, 89.3%), and closed reduction was performed in only 9 cases (7.7%). However, in monopod fracture of the zygomatic arch (n = 98), most of the cases (n = 95, 96.9%) were treated with closed reduction; open reduction was performed in only 1 case (1.0%). At zygomaticofrontal area (n = 241), internal fixation was performed in most of the cases (n = 198, 82.2%). At the infraorbital rim (n = 364), internal fixation was carried out in most cases (n = 257, 70.6%). At the zygomaticomaxillary buttress (n = 279), internal fixation was performed in about one third of the cases (n = 91, 32.6%). At the zygomatic arch (n = 339), only 1 case (0.3%) was fixed internally. The postoperative complication rate occurred in 88 cases (19.1%) among 461 cases operated. The most common complication was hypesthesia (50 cases, 56.8%), followed by diplopia (15 cases, 17.0%), limitation of mouth opening or closure (11 cases, 12.5%), infection (6.8%), and hematoma (4.5%). Most patients with hypesthesia improved at 2 months. About 90% of the patients with diplopia improved within 2 months. Limitation of mouth opening was improved immediately after operation in most of the cases. Our findings demonstrate significant differences in the demographics and clinical presentation that will enable a more accurate diagnosis and prediction of concomitant injuries and sequelae.

Traumatic injuries treatment of the fronto-naso-orbito-ethmoidal region has been one of the most challenging treatments within maxillofacial surgery, particularly of extensive orbital defects, very common in this type of pathologic condition. A 48-year-old man involved in a car collision presented an extensive bilateral fracture of the orbit medial wall, nasal bones, the nasal septum, and the frontal anterior table. The clinical and tomographic findings concluded the diagnosis of a maxilla and fronto-naso-orbito-ethmoidal fracture. Among the variety of biomaterials, the titanium mesh was elected because of the extension and magnitude of the bone defect, obtaining this way esthetic and functional results with better prognosis.

Bilateral orbital roof fractures are rare events usually associated with high-energy impact trauma. The clinical picture is often multiple because of involvement of cranial, cerebral, and facial injuries. The primary diagnostic and therapeutic approaches aim to safeguard the cerebral state and to intercept the consequences of severe orbital trauma. The latter may present dramatic events and determine permanent ocular bulb or optic nerve damage, even vision impairment and blindness. Immediate intraorbital decompression decreases the pressure exerting directly or indirectly on the optic nerve. Surgical decompression of the orbit was performed in a young man showing almost complete blindness after bilateral orbital roof fracture. The final result showed good recovery of vision and functional motility of the bulbs.

Head injuries are one of the most common causes of treatment in the emergency and accidents ward. The first causes of head traumatology are still car or motorcycle accidents, followed by personal aggressions. The authors here present a case of forehead trauma outcome after a severe injury in growing age. The interesting aspect is the triple challenge of cerebral, bone, and soft tissue restoration. The main goal was to restore functionality of the brain and to re-establish the integrity of cranial vault. Excision of pathologic cerebral cortex and well-known surgical techniques have been adopted to achieve this result. Moreover, the peculiar technique that led to the good result was to create a barrier between bone layer and soft tissues. The authors present their personal suggestions for the best functional and aesthetic outcome.

According to the result of retrospective studies for patients who have not taken medical treatment, most patients experience late enophthalmos and perceive their facial asymmetry. Thus, correct diagnosis method and concrete operative indication were required for medial orbital wall fracture. Retrospective investigation on all patients with facial trauma, who had visited the emergency room between January 1, 2000 and December 31, 2006, was made. Height and longitudinal length of the defect were obtained, and computed tomographic scan of the defect area was obtained. The degree of enophthalmos was measured, and investigation on enophthalmos and presence of facial asymmetry perceived by the patients was made. When the defect area of medial orbital wall fracture was 0.55 cm, late enophthalmos of 1 mm occurred, and patients with late enophthalmos of 1 mm or more perceived their enophthalmos and facial asymmetry. In conclusion, medial orbital wall fracture whose defect area is 0.55 cm or more requires operation.

In cases of soft tissue defects in which the calvaria is exposed, the use of flap is generally considered. However, in cases in which patients' general status is poor or vascular insufficiency is present, the use of flap becomes difficult. A 90-year-old male patient visited our outpatient clinic with a chief complaint of scalp defect accompanied by calvarial exposure after falling from an escalator. The patients' systemic status was poor, and the soft tissue defect was accompanied by calvarial exposure. Treatment involved removal of the outer table of the skull and application of acellular human dermis (AlloDerm). Then split-thickness skin graft was performed in a single phase. This shortened the treatment period and produced excellent outcomes. Here, we report our case with a review of literatures.

The frontalis musculocutaneous island flap offers advantages of immediate repair for small to medium-sized forehead defects (0.5-5 x 0.5-5 cm). Based on the supraorbital artery, the flap is both adaptable and dependable. Advantages of this flap include the ability to perform the procedure immediately and in one stage, rapid aesthetic restoration, minor donor-site morbidity, and technical ease. A clinical report demonstrating the use of this flap for repair of an electrothermal injury to the glabella is presented.

Fractures of the nasofrontal orbital complex account for 5% of all facial fractures. Mean hospitalization is usually longer than for other types of facial lesions, independent of the trauma responsible (road accidents, sport, falls, firearm wounds, and so on). The choice of treatment, usually dictated by the site and extent of the damage, is important because inadequate treatment may lead to immediate or subsequent complications. A conservative surgical technique for use in the treatment of non-comminuted frontal lesions is described, which consists of the closed reduction of the depressed fragments by means of a small percutaneous approach. Before surgery, a computed tomography scan is carried out with 2-mm slices both in the axial and coronal projections, mandatory to evaluate the orbital roof and frontal region. The peripheral limits of the frontal region fracture are marked on the skin, a punctiform incision made in the area of maximum depression, and a calibrated drill inserted. Two small holes are created in the center of the depressed fragment and two pins screwed in, both of a length to allow the surgeon an easy reduction maneuver. A radiographic evaluation is then performed to check the correct alignment of the previously depressed fragment, the two percutaneous pins removed, and two sutures applied, if necessary. This technique avoids the scarring often observed after the open reduction technique and, in selected cases, treatment may be carried out in neuroleptanalgesia reducing operating as well as hospitalization times and healthcare costs.

Cosmetic and functional reconstruction of large and complex calvarial defects remains a challenge for craniofacial surgeons. Computer-designed alloplastic implants have revolutionized the conceptualization and approach to these reconstructions and have become a reliable and irreplaceable part of the surgical armamentarium. We are reporting a case of complex orbito-fronto-temporal reconstruction using a computer-designed PEEK (polyetheretherketones)-Patient Specific Implant (PSI). To the best of our knowledge, no other similar cases regarding the use of these implants in cranial reconstruction have been reported previously.

Cranioplasty of cranial bone defects can generally be accomplished with autogeneous bones as well as with nonbiological materials. Autologous living-bone grafts are ideal but require sacrifice of donor bone, and synthetic materials might have possible exposure of the materials, delayed infection, and/or allergic reaction. The authors report cranioplasty with a bone graft after auto-purification by subcutaneous preservation of the contaminated bone fragment. A 47-year-old man was given a frontal cranioplasty with a split parietal bone and rib. Epidural abscess ensued, and debridement was performed to control the infection. The largest bone fragment was subcutaneously preserved in the chest wall and reused for cranioplasty. Subcutaneous preservation of bone is a promising strategy for cranioplasty after neurosurgery. The condition of the bone fragment can be inferred from the condition of the site at which it is preserved. If the bone flap is contaminated, it can be purified by the patient's immune system.

Craniofacial traumas are one of the most common clinical events of the 21st century. The possibility of associated injuries of the head and neck may also determine functional and cosmetic problems in these patients. The most frequent pathologic conditions observed are contusions, lacerations, abrasions, avulsions, and the inclusion of foreign bodies. In particular, penetrating injuries represent a rare but complex variety of craniofacial trauma. Generally, the penetrating material is stiff enough to cross through different anatomic structures during a particularly violent collision caused by a road or work accident or during an attack. The therapeutic strategy adopted for this type of patient depends mainly on diagnostic procedures such as skull radiograms in different projections, computerized tomography, magnetic resonance imaging, and, occasionally, echotomography. However, on arrival at the emergency department, the clinical conditions of the patient will determine the type of investigation to be carried out. Last, to prevent any postoperative infections, wide spectrum antibiotic therapy is advisable. Ideally, imaging should be repeated postoperatively to confirm resolution of the initial clinical condition. In this article, the authors describe three unusual clinical cases of patients with penetrating injuries of the head and face together with the protocol adopted for treatment of such complex craniofacial injuries. The three cases described demonstrate that, despite the initial appearance of penetrating wounds, a correct diagnostic assessment followed by a suitable therapeutic protocol can reduce cosmetic and functional defects to a minimum.

Gas within the brain parenchyma, known as intracerebral pneumocephalus, has been infrequently reported. Head trauma is the most common cause. A case of intracerebral pneumocephalus resulting from a golf club injury and a review of the literature are presented.

The authors report two cases of closed reduction of the anterior wall of the frontal bone. In the first case, the fractured segment was successfully reduced with a small periosteal elevator. In the second case, a tip of the periosteal elevator was broken during maneuvering the fractured bone and lost into the sinus cavity. The sinus was opened to retrieve the broken piece and repaired by internal fixation. The technique has a few merits: (1) the procedure is simple; (2) the operation time is short; and (3) only a small incision is needed.

Recent advances in bioabsorbable devices have introduced tacks that do not require tapping. This may help to reduce operative time and, consequently, costs. The goal of this study was to demonstrate the feasibility of a new method of cranial bone osteofixation using novel bioabsorbable tacks and plates instead of screws. A 36-year-old man presented for elective cranioplasty to reconstruct a large frontal cranial bone defect that followed a decompression operation performed because of a head injury sustained 6 months previously. Cranioplasty was performed using split parietal bone grafts to reconstruct the defect. Bone grafts were fixed together and to the skull using self-reinforced (SR) poly(L/DL)lactide [SR-poly(L/DL)lactide] (70/30) (Biosorb FX) plates (n = 10) and tacks (n = 98). The plates were 0.6 mm thick, 102 mm long, and 12 mm wide. The tacks had a maximum thread diameter of 2 mm and a length of 6 mm. The tacks used did not require any tapping procedure, and they were applied using a special applicator gun. Stable and secure fixation was obtained during surgery. The postoperative period was uneventful, except for delayed epithelialization of a small area (1 x 0.5 cm) over the frontal skin that healed later. One year after surgery, the cosmetic result was excellent, and no complications were detected. Stabilization of large cranial bone pieces can be achieved using bioabsorbable SR-poly(L/DL)lactide plates and tacks, with excellent cosmetic results. The method is thought to be reliable and may help to reduce operative time.

We devised a technique to fix the temporalis muscle to the transplanted hydroxyapatite implant by using a titanium plate, which is fixed to the hydroxyapatite ceramic implant by screws and achieves good clinical results. The size, shape, and curvature of the hydroxyapatite ceramic implants were determined according to full-scale models fabricated using the laser lithographic modeling method from computed tomography data. A titanium plate was then fixed with screws on the implant before implantation, and then the temporalis muscle was refixed to the holes at both ends of the plate. The application of this technique reduced the hospitalization time and achieved good results esthetically.

In 1998, 28 patients with craniofacial fractures have been under observation at the Emergency Room of the Policlinico Umberto I of Rome. Twenty-six patients have undergone reduction and contention surgery of the fractures. The diagnosis of the fractures has been achieved through CT axial scanning and coronal reconstruction as well as with three-dimensional CT. The CT spiral was used in those cases that required more rapid intervention, whereas the MRI was used to evaluate the condition of the eyeball. Twenty of such patients underwent surgical treatment a few hours after the trauma and, in such cases, excellent aesthetic and functional results were achieved. The general and neurological conditions of six patients did not permit prematurely proceeding with surgery. Two patients died a few hours after the trauma of the injuries sustained. Of the six patients who underwent delayed treatment, acceptable functional and aesthetic results were achieved in four, whereas the remaining two patients had inadequate results. The results we have obtained show that it is possible to achieve the best results, both aesthetic and functional, through immediate treatment. Delayed treatment is carried out at least 2 weeks after the trauma because of the patient's condition and presents reconstruction difficulties that do not guarantee a satisfactory aesthetic reconstruction as well as, in some cases, an effective functional restoration.

The authors report a successful reconstruction of an extensive frontotemporal bone defect after craniotomy, which was complicated with infection and necessitated removal of frontal and temporal bones. The large frontotemporal bone defect was reconstructed using prefabricated hydroxyapatite blocks in combination with the free vastus lateralis muscle flap. The patient's functional and cosmetic restoration has been maintained for 10 months' follow-up.