Autogenous Calvarial Particulate Bone Grafting in Craniosynostosis

PURPOSE: Autogenous particulate bone grafting is a type of autogenous bone graft that consists of small particles of cortical and cancellous bone. Autogenous particulate bone grafting has been used for calvarial bone defect after calvarial defect of craniosynostosis and prevention of temporal depression after fronto-orbital advancement. The results were followed up and studied for effectiveness of autogenous calvarial particulate bone grafting. METHODS: Cranial vault remodeling and fronto-orbital advancement was performed for six craniosynostosis patient from August 2005 to October 2007. Autogenous particulate bone grafting was harvested from endocortex of separated cranial vault and if insufficient, from extocortex of occipital region using Hudson brace & D'Errico craniotomy bit and was grafted on the calvarial bone defect of cranial vault and temporal hollow. Fibrin glues were added to the harvested particulated bone for adherence and shaping of paticles. RESULTS: Autogenous particulate bone grafting was followed-up at least longer than I year. The calvarial bony defects following primary cranial remodeling were successfully covered and postoperative temporal depressions after fronto-orbital advancement were also well prevented by grafted particulated bone. CONCLUSION: Autogenous calvarial particulate bone graft can be harvested in infants and young children with minimal donor site morbidity. It effectively heals cranial defects in children and during fronto-orbital advancement reduces the prevalence of osseous defects independent of patient age. It's easy and effective method of reconstruction of calvarial defect.

Subungual Squamous Cell Carcinoma of the Left Fifth Toe: A Case Report

PURPOSE: Subungual squamous cell carcinoma is a very rare malignant tumor of the digitus especially in toe making it very difficult to differentiate from tinea unguium, verruca vulgaris, eczema, pyogenic granuloma, and malignant melanoma due to their clinical similarities. Therefore this article reports on subungual squamous cell carcinoma of left 5th toe. METHODS: A patient visited at our hospital due to pain and incurable inflammation on left 5th toe with no improvement for four months. Despite of antibiotics and dressing for a week, treatment was ineffective. After excisional biopsy, he was diagnosed with subungual squamous cell carcinoma. And ray amputation and prophylactic inguinal lymph node dissection was done. RESULTS: The biopsy was showed irregular cells made up of anaplastic and squamous cells in the dermis and epidermis. And the inguinal lymph node showed no metastasis. The patient had been treated without significant complications or recurrence for a year. CONCLUSION: This article emphasizes the need of diagnostic biopsy on the subungual lesions that have resistance to the conventional treatments. And if that is subungual squamous cell carcinoma, complete resection of the lesion and prophylactic inguinal lymph node dissection is essential.

A Case of Simultaneous Correction of Frontoethmoidal Meningoencephalocele and Hypertelorism

PURPOSE: A meningoencephalocele is a congenital malformation involving herniation of the meninges and cerebral tissue through a defect in the skull. For the patient with frontoethmoidal meningoencephalocele with hypertelorism, the removal of the meningoencephalocele without correction of the combined hypertelorism is not enough for getting a good cosmetic appearance. Correction of the hypertelorism is needed for cosmetic problem. We experienced a case of simultaneous correction of frontoethmoidal meningoencephalocele with hypertelorism. METHODS: The meningoencephalocele was removed and the hypertelorism was corrected by central segment technique. The bone defects were filled with autogenous bone dusts. And the nose was reconstructed by a calvarial bone graft. RESULTS: The patient had a good cosmetic appearance without any neurological complications without serious complications. CONCLUSION: We experienced a case of simultaneous correction of frontoethmoidal meningoencephalocele with hypertelorism. And a brief review of related literatures is given.

Large Vulvar Lipoma in an Adolescent: A Case Report

Lipomas are the most common benign tumors of soft tissues. However, conventional lipomas have been reported only rarely as presenting in the vulva. We present a case of vulvar lipoma in a 17-yr-old woman, possibly caused by chronic intermittent irritation.

Clinical Usefulness of Titanium Mesh in Reconstruction of the Craniofacial Bone Defects

PURPOSE: Reconstruction of the craniofacial defects can be carried out with autogenous tissues, allogenic implants, or alloplastic materials. Titanium mesh systems have been used for bony reconstruction in non load- bearing areas. They offer several advantages: immediate availibility without any donor site morbidity, easy handling, stable 3-D reconstruction, and low susceptibility to infection. The aim of this study is to evaluate the usefulness and complications of titanium mesh system in the reconstruction of the craniofacial defects. METHODS: From Jan. 2000, to Dec. 2004, we performed reconstruction of craniofacial bone defects in 21 patients who had benign or malignant tumor and fracture events in the cranium, orbit, nasal bone, maxilla, zygoma and the mandible. The size of the defects ranged from 1.0 X 1.5 cm to 12 X 10 cm. Two different mesh systems, micro-titanium augmentation mesh and dynamic mesh was used for bony reconstruction in non load-bearing areas. The patients were evaluated from 1 to 4 yrs clinically and radiographically with a mean follow up period of 1.5 yrs. RESULTS: There were no serious complications, including wound infection, foreign body reaction, exposures or loos of the mesh, central infection and pathologic findings of bone around mesh exception of one patient, who had expired of skull base tumor recurrence. Long-term stability of the reconstructions and the overall functional and aesthetic outcome was excellent. CONCLUSION: Our experiences demonstrate that the Titanium mesh system is a relatively safe and efficient method in the craniofacial reconstruction and have broadens our choices of therapeutic procedures in the craniomaxillofacial surgery.

Clinical Usefulness of Titanium Mesh in Reconstruction of the Craniofacial Bone Defects

PURPOSE: Reconstruction of the craniofacial defects can be carried out with autogenous tissues, allogenic implants, or alloplastic materials. Titanium mesh systems have been used for bony reconstruction in non load- bearing areas. They offer several advantages: immediate availibility without any donor site morbidity, easy handling, stable 3-D reconstruction, and low susceptibility to infection. The aim of this study is to evaluate the usefulness and complications of titanium mesh system in the reconstruction of the craniofacial defects. METHODS: From Jan. 2000, to Dec. 2004, we performed reconstruction of craniofacial bone defects in 21 patients who had benign or malignant tumor and fracture events in the cranium, orbit, nasal bone, maxilla, zygoma and the mandible. The size of the defects ranged from 1.0 X 1.5 cm to 12 X 10 cm. Two different mesh systems, micro-titanium augmentation mesh and dynamic mesh was used for bony reconstruction in non load-bearing areas. The patients were evaluated from 1 to 4 yrs clinically and radiographically with a mean follow up period of 1.5 yrs. RESULTS: There were no serious complications, including wound infection, foreign body reaction, exposures or loos of the mesh, central infection and pathologic findings of bone around mesh exception of one patient, who had expired of skull base tumor recurrence. Long-term stability of the reconstructions and the overall functional and aesthetic outcome was excellent. CONCLUSION: Our experiences demonstrate that the Titanium mesh system is a relatively safe and efficient method in the craniofacial reconstruction and have broadens our choices of therapeutic procedures in the craniomaxillofacial surgery.

Contribution of the Dura & the Pericranium in Absorption of Cranial Bone

Many craniofacial and neurosurgical procedures rely on cranial bone as a bone graft. In the majority of instances, the bone heals and gives good results. But we found that if either the dura or the pericranium were missing adjacent to the cranial bone, bone absorption would be increased. We studied a single animal model, investigating the contribution of the dura and the pericranium in the process of cranial bone absorption. The animals were divided into four groups of each five animals depending on the differential blockade of the dura and/or the pericranium by silastic sheet. Bilateral 100-mm2, parietal bone flaps were harvested from mature rabbits. Animals were humanely killed after 12 weeks, and histomorphometric analysis was performed. The volume maintenance is as follows; Group I; 89.0%, Group II; 80.0%, Group III; 63.3%, Group IV; 52.4%. The weight maintenance; Group I; 87.1%, Group II; 79.4%, Group III; 61.6%, Group IV; 51.1%. The histological contribution of living bone; Group I; 92.9%, Group II; 85.6%, Group III; 71.1%, Group IV; 56.2%. Significantly increased bone absorption occurred in Group II, III, IV compared with Group I. Conclusions are: 1. Cranial bone absorption is effected by both the dura and the pericranium. 2. The dura is more important than the pericranium in preventing cranial bone absorption. 3. The dura to be the source of central cranial bone and the pericranium to be the source of peripheral cranial bone.

Clinical Application of Cranialization of the Frontal Sinus

Both frontal sinus ablation and osteoplastic frontal surgery with obliteration have limitations in treatment of injury to the frontal sinus that extends into the posterior wall and frontal lobes of the brain. In these problematic cases, cranialization of the frontal sinus is the method of choice. The purpose of the cranialization of the frontal sinus was as follows: (1) ablation of the sinus, precluding later infection or mucocele, mucopyocele formation (2) restoration of a normal aesthetic frontal bony contour (3) protection of frontal lobe by allowing space for the expansion of the edematous brain. From May 1999 to December 2003, we performed cranialization of involved frontal sinus in 23 patients who had malignant tumor, fibrous dysplasia, osteoma, mucoele, and fracture event in the frontal sinus on each other. After the frontal sinus was exposed through a bicoronal incision, the excision of posterior wall and removal of mucosa remaining on the floor of the sinus and residual anterior wall were done. The nasofrontal ducts were occluded with pericranial flap or/and bone source(R), or bone graft. Reconstruction of anterior wall was done with autogenous bone or/and bone source(R), or mesh plate, bone graft, and mesh plate with bone source(R).The average follow-up period was one and half years (from 1 year to 4 years).There were no serious complications including CNS infections, mucocele formation and CSF leakage, with an exception of one person who was expired of recurrence of skull base tumor. Also, the overall functional and aesthetic outcome was excellent except one case in which there was irregularity in the frontal area. The cranialization of the frontal sinus is a safe surgical procedure without complications if prevented.

The Role of Transfacial Approach in Skull Base Surgery

Even though there are diverse tumors invading skull base, it is impossible to completely remove the tumor only by transcranial approach due to its anatomical complexity. Therefore we operated by transfacial approach as well which allows to have a good vision and remove the tumor from different directions. Transfacial approach is to approach tp the skull base for the tumor located on the margin of skull and face through exposing such as nasal cavity, paranasal cavity, nasopharyngeal cavity, etc. after separating facial bone. In 1990 Janecka introduced it, dividing the face into 4 groups: mini, standard, expanded, and bilateral facial translocation, based on neurovascular and aesthetic line. Transfacial approach makes it possible to do three dimensional tumor resection, remove the tumor, check its margin directly, and have functionally and aesthetically satisfactory reconstruction. In such cases that tumor invades lower part of skull base, the tumor can be removed only by transcanial approach. Although tumor can be removed by transcranial approach to find the location three dimensionally, transfacial approach can be used as adjunctive means which allow to get a good vision and remove the remnant completely. For 36 months, we have executed 16 cases of tranfacial approach, removing tumors located at the skull base. We classify and suggest the role of tranfacial approach based on our documents.

Surgical Correction of the False Oxycephaly in Adult Patient: A Case Report

Oxycephaly, which is a frontal deformity in which the forehead is recessed and tilted backwards, is usually caused by the premature fusion of mainly the coronal and sagittal suture. In 1926, David M. Greig proposed to classify oxycephaly into three different forms; true oxycephaly, delayed oxycephaly and false oxycephaly. False oxycephaly is a simple morphotype of the skull without any clinical symptoms which does not affect the brain in any way. Surgical repair of oxycephaly for adults can include cosmetic considerations and the prevention or possible improvement of functional symptoms such as headaches, vomiting and visual disturbance. Furthermore, in adults who does not have any functional problems, cosmetic surgery can be done. But oxycephaly of adult patients need more complex and extensive surgical interventions than that of infant patients. A-21-year-old male who had a retroverted forehead, pointed head and a flat fronto-nasal angle, without any functional problems, was treated by a fronto- orbital advancement and a transposition between the frontal and fronto-parietal bone. This method provided us with a good frontonasal angle and a gently backward sloping forehead above the supraorbital bar. An acceptable aesthetic appearance was achieved 6 months after the operation. This remodeling technique is adequate for resolving the aesthetic problems of adult false oxycephalic patients who does not have any functional problems.

Clinical Experience in Treatment of the Giant Frontal Sinus Osteoma using Cranialization

Frontal sinus osteoma is one of the rare diseases and is diagnosed incidentally by skull X-ray. After the disease is confirmed, long term follow-up is necessary. The etiology of the disease is usually unknown and almost all of the patients has any kind of symptoms or signs. The most of the symptoms of this disease are pain, headache, swelling and lagophthalmos. Frontal sinus osteoma has characteristic features such as radiopaque, mass like lesion in the frontal sinus. Operation of the frontal sinus osteoma is not necessary unless it has symptoms or infection sign. We experienced one case and operated the osteoma and reconstructed frontal sinus by cranialization and bihalving calvarial bone graft. The result is satisfactory without complication.

Clinical Experience in Treatment of the Giant Frontal Sinus Osteoma using Cranialization

Frontal sinus osteoma is one of the rare diseases and is diagnosed incidentally by skull X-ray. After the disease is confirmed, long term follow-up is necessary. The etiology of the disease is usually unknown and almost all of the patients has any kind of symptoms or signs. The most of the symptoms of this disease are pain, headache, swelling and lagophthalmos. Frontal sinus osteoma has characteristic features such as radiopaque, mass like lesion in the frontal sinus. Operation of the frontal sinus osteoma is not necessary unless it has symptoms or infection sign. We experienced one case and operated the osteoma and reconstructed frontal sinus by cranialization and bihalving calvarial bone graft. The result is satisfactory without complication.

Limited Bilateral Facial Translocation with Le Fort I and Modified Le Fort II For Removal of Basal Sphenoidal Meningocele: A Case Report

Surgical treatment of skull base tumors are a challenge because of their location. These lesions were considered nonoperable for surgical morbidity and mortality and in many cases radical removal of the tumor was not possible because satisfactory surgical access to these areas was difficult to achieve. However, the facial translocation access to this area meets the current underlying principle of skull base approaches, minimizes brain retraction while maximizing skull base visualization. We completely exposed this area by approaching with limited bilateral facial translocation with Le Fort I and modified Le Fort II in basal sphenoidal meningocele patient. This provides direct access, excellent visualization of the ethmoid, sphenoid, nasopharynx and practically all surgical margins. Through this panoramic approach, one can easily expose the skull base lesions and operate on this area under direct visual and manual control. It also makes possible functional reassembly of soft tissue and the skeleton, plays an important role in producing a subsequent excellent facial appearance.

Role of Bioabsorbable Plates and Screws in Genioplasty

The use of bioabsorbable fixation system for the craniomaxillofacial surgeon has become available for prevention of intracranial migration, growth restriction by metal implants in pediatric patients as well as palpability in patients of all of ages. Recently, the field of bioabsorbable fixation system was expanded and the bioabsorbable screws were used successfully in endoscopic brow lift surgery. We reviewed 6 cases in which bioabsorbable plates and screws were used in aesthetic genioplasty: one male and 5 female patients between 17 and 38 years of age. The fixation of repositioned bone segment in genioplasty was obtained by using plates composed of a copolymer, polyglycolic acid and polylactic acid(LactoSorb, Walter Lorenz Surgical, Jacksonville, Fla.). The fixation devices were evaluated with regard to satisfactorily rigid fixation at the time of procedure. The postoperative follow-up procedure evaluated clinical wound healing, infection, palpability of plates through the skin and its visibility on imaging technique. Our experience with bioabsorbable fixation system in aesthetic surgery has been very favorable and reliable, although prospective studies with a longer follow-up of a larger number of patients are desirable to confirm these findings.

Clinical Experience in Reconstruction of the Posterior Lingual Mandibular Bony Defect

Posterior lingual mandibular bony defect is rare disease entity. Diagnosis of this entity is almost incidental because it has neither symptoms nor signs. However, it has characteritic features in radiologic images that radiolucent defect located near the mandibular angle. Many of this defects are filled with sublingual salivary gland tissues and some includes fat tissue. Various terms such as aberrant salivary gland defect, mandibular embryonic defect, developmental submandibular bone defect, are available for this disease entity bacause cause of this entity is controversal. Operation for reconstruction of the defect is not necessary except this entity has symptoms or diagnosis of this is unclear. Authors experienced one case of this entity incidentally, and operated for defect reconstruction by osteotomy and filled the defect with hydroxyapatite. The result is satisfactory without any complications.

Reconstruction of Pharyngocutaneous Fistula with Radial Forearm Free Flap: A Case Report

Pharyngocutaneous fistula formation is a serious complication after total laryngectomy and its incidence varies from 7.6% to 50%. It leads to a prolonged hospitalization and complicated rehabilitation. Although many reconstruction methods have been introduced, each has its own merit and demerit and there is no single perfect answer. In our study, the fistula was reconstructed with inner lining using hinge method and radial forearm free flap. The operation was performed in 5 patients who underwent pharyngocuatneous fistula after total laryngectormy. We obtained a satisfactory reconstruction of the fistula and natural neck contouring using this method in all cases. Only 1 patient had complication of wound infection. However, the patient was healed with conservative antibiotics therapy. We believe the radial forearm free flap with hinge flap is the optimal method for circumferential reconstruction of pharyngocutaneous fistula. In comparison with other reconstructive techniques, the radial forearm free flap offers the best combination of flap reliability and low donor site morbidity. This method also allows patients to shorten the hospitalization and meet their cosmetic needs.

4 Cases of Treatment of Growing Skull Fracture

A fracture of the skull occurred during the infancy and childhood ordinarily heals without difficulty. Rarely, however, such a fracture enlarges progressively to form a permanent cranial defect with pulsating mass. Patients usually have a history of head trauma and skull fracture and show pulsating soft mass with underlying bony defect. Pulsation of the brain is transmitted through the cysts to the inner table of the skull, and erosion of the bone ordinarily occurs in a localized area overlying the cysts. Enlargement of skull fractures has been reported at least 4 months after the accident. The existence of a dura defect in this syndrome has been amply verified by operative and autopsy observation, and appears to be a requisite for enlargement of the fracture. Ideal is early diagnosis and preventive treatment before it develops into a growing skull fractrue. Repeated simple radiology and color doppler sonography are very useful for evaluation of growing skull fracture. Also an early and aggressive operation is strongly recommended in young children. We experienced 4 cases of the growing skull fracture, which were reconstructed with cranioplasty and duraplasty. Clinical findings and management of the growing skull fracture are discussed, a review of the relevant literature is presented.