Maxillary bone grafts for the repair of traumatic orbital floor defects.

PURPOSE: To present maxillary bone (MB) grafts as a viable option for repair of traumatic orbital floor (TOF) defects by comparing their use to titanium mesh (TM) looking at TOF defect size, operative time, and complication rate. METHODS: The senior author's surgical technique is described. Patients undergoing TOF repair using MB versus TM were assessed retrospectively, focusing on TOF defect size, operative time, and follow-up results. RESULTS: One hundred ninety-six patients with 212 TOF defects presented to a single surgeon between 2004 and 2008. One hundred sixty-five patients (178 TOF defects) were repaired with MB and 31 patients (34 TOF defects) with TM. The MB and TM groups were similar with respect to age, gender, time to repair, and other associated facial fractures. TOF defect size was similar between the two groups (MB: mean 1.7 cm2, range 0.32-2.82 cm2; TM: mean 1.9 cm2, range 0.5-2.83 cm2). Follow-up was slightly longer in the TM group; however, many patients were lost to follow-up. There were no donor-site complications in the MB group and no significant difference in postoperative complications in the MB group versus the TM group (11% vs 24%). The operative time in patients with TOF defects was slightly longer in the MB group versus the TM group (35 min vs 27 minutes, p = .02). CONCLUSIONS: This series is the largest published series to date. MB was used successfully to repair TOF defects, with no increased risk of complications and only a slightly longer operative time compared to TM. MB offers an autogenous bone graft source that is technically easy to harvest and in the same surgical field, obviating many of the complications associated with alloplastic materials and traditional bone graft choices. MB grafts should be considered a viable option when choosing material to repair TOF defects.

Cervical spine injury in association with craniomaxillofacial fractures.

BACKGROUND: The incidence of cervical spine injuries associated with facial fractures varies from study to study. There is general agreement that immediate management of cervical spine injuries is mandatory to prevent further neurologic injury. Nevertheless, disagreement exists as to the actual incidence of cervical spinal trauma in conjunction with various facial fracture patterns. The purpose of this study was to review the incidence of cervical spine injury associated with various types of facial fractures presenting to St. Michael's Hospital Regional Trauma Center, Toronto, Ontario, Canada. METHODS: The authors conducted a retrospective chart review of craniomaxillofacial fracture patients presenting to St. Michael's Hospital from January 1, 1994, to December 31, 2003, inclusive. RESULTS: The data from this 10-year time span revealed a total of 124 patients with cervical spine injuries drawn from a cohort of 3356 patients with craniomaxillofacial fractures. The overall incidence of cervical spine injury was 3.69 percent. Of these patients, 928 had isolated upper third facial or skull fractures, whereas isolated middle third facial fractures were seen in 716 patients and isolated lower third facial fractures were present in 798 patients. Combined facial fracture patterns, involving two or more facial thirds, accounted for the greatest number of cervical spine injuries, occurring in 8.86 percent (n = 914). CONCLUSIONS: The relationship between cervical spinal injuries and craniomaxillofacial trauma has been better defined as it relates to a regional trauma registry. The implications as related to the trauma assessment, diagnosis, and treatment of these injuries are reviewed.

Recalcitrant chest wall Aspergillus fumigatus osteomyelitis after coronary artery bypass grafting: successful radical surgical and medical management.

This report describes a 62-year-old male diabetic patient with persistent chest wall osteomyelitis that developed after repeat coronary artery bypass grafting. The chronic infection was localized to the right anterior chest wall and refractory to medical and surgical treatment including long-term antiobiotics, five separate intraoperative debridements, and reconstruction with vascularized omentum over a two-year period at outside institutions. Aggressive surgical debridement with flap reconstruction resulted in definitive management. The organism isolated from multiple intraoperative bone, cartilage, and tissue cultures yielded Aspergillus fumigatus; therapy with itraconazole was utilized for 6 months. Surgical management of osteomyelitis and costochondritis is reviewed accompanied by a literature review on this uncommon cause of chronic chest wall infection.

Frontal sinus obliteration with beta-tricalcium phosphate .

Autogenous materials are considered the gold standard when indicated for frontal sinus obliteration; however, alloplastic alternatives obviate the need for a second surgical site, eliminate donor site morbidity, and reduce operating room time. A variety of different alloplastic materials have been used for this purpose, but no report to date has described the use of pure beta -tricalcium phosphate synthetic bone. This case report describes the technique and successful use of this product for frontal sinus obliteration in a severely comminuted anterior table and nasofrontal duct injury. The product warrants consideration as a viable alternative to standard autogenous and alloplastic substrates for frontal sinus obliteration.

Composite plate and wire fixation for complicated sternal closure.

Many techniques have been described to achieve closure of complicated median sternotomy wounds. The standard method of closure uses stainless steel wiring of the sternal halves; however, in complicated sternal closures, sternal cut-through and wire failure can occur. Recent literature advocates the use of fixation plates that achieve bony union, with plating across the median sternal osteotomy site as a singular method. We describe a technique of composite closure using titanium fixation plates to buttress the sternum in combination with circumferential stainless steel wires. This composite technique has been used in 6 patients with complicated sternal closures. Successful wound closure without complication was achieved in all cases. The technique and the clinical series with an illustrative example are presented. The use of plate and wire fixation represents an alternate method to conventional techniques to achieve sternal closure, stability, and uncomplicated wound healing in these difficult-to-manage cases.

Bilateral frontozygomatic dermoid cysts.

A unique case of frontozygomatic dermoids in a 4-year-old child is presented. A bilateral, synchronous presentation in this location has not been reported previously in the literature. Both lesions were excised concurrently through upper eyelid crease incisions. The etiology, natural history, management, and prognosis of dermoids are reviewed.

Nasal augmentation with Surgicel-wrapped diced cartilage: a review of 67 consecutive cases.

Cartilage grafting has been used extensively to correct both the functional and aesthetic aspects of the nasal framework. The technique described by Erol ( 105: 2229, 2000) uses Surgicel-wrapped diced cartilage grafts in rhinoplasties. The advantages include its ease of preparation, the large volume of graft substrate available for use, and the avoidance of contour irregularities in the areas of placement. A retrospective case review of 67 consecutive patients who were treated with a Surgicel-wrapped diced cartilage graft as part of an aesthetic and/or functional rhinoplasty, in a 5-year period between 1995 and 2000, was performed in this study. All cases of congenital nasal deformities or deformities caused by trauma or tumors in which the technique was used were excluded. The charts were reviewed to determine demographic variables, the surgical procedures performed, prior operations, the rhinoplasty approach used, and the graft donor and recipient sites. Preoperative and postoperative photographs were examined, and the results were assessed. Data on the donor and recipient sites, complications, and the necessity for revisionary procedures were tabulated. There were two complications, namely, an infection, which resolved with aspiration and oral antibiotic therapy, and a recurrence of a dorsal depression, which necessitated repeated augmentation within 6 months. The technique of using Surgicel-wrapped diced cartilage proved to be effective for the augmentation of various areas of the nose. The complication and revision rates were acceptable and comparable to those of other techniques. Patient satisfaction with the aesthetic results was rated highly, with no reports of graft extrusion or contour irregularities. This technique is recommended for nasal augmentation and contouring for selected rhinoplasty patients.