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Posts Tagged ‘cranial bone grafts’

Case Study – Secondary Brow Bone Reconstruction with Cranial Bone Grafts

Monday, April 27th, 2015

 

Background: Most frontal sinus problems can be successfully managed with an endoscopic approach. But if frontal sinus drainage can not be successfully established, an open approach for its treatment may be needed to eliminate the entire frontal sinus.. The osteplastic bone flap approach for frontal sinus obliteration has been around for a long time  to treat such problems as chronic frontal sinusitis, mucopyoceles frontal sinus tumors and frontal sinus fractures that involve the posterior table.

In frontal sinus obliteration there are three key manuevers, complete removal of all sinus lining, sealing of the frontonasal duct and filling in of the entire frontal sinus. The only variable historically has been what material to opacify the frontal sinus. Historically it has been the use of autologous fat. But hydroxyapatite cement was introduced in the 1990s and offered an off the shelf material that did not require a fat graft harvest. Hydroxyapatite cement has the potential to osteointegrate into the surrounding bone and provides a stable contour to the frontal forehead area.

Regardless of the material used, the key to success in frontal sinus obliteration is the complete removal of mucosa and obliteration of the frontonasal duct. No implanted material will be successfully of residual mucosa remains which can ultimately become a source of chronic pain and/or a mucoceole.

Case Study: This 35 year-old female had a history of frontal sinus obliteration which was needed because of infection that developed after an open brow bone reduction procedure. She had chronic pain over the central sinus area that persisted for several years. A CT scan showed a radiolucent cystic area under the brow bone area where her pain was. She requested that the hydroxyapatite cement be removed and replaced with cranial bone grafts.

Frontal Sinus HA Removal with Central Nasal Communication Dr Barry Eppley IndianapolisUnder general anesthesia, her original hairline incision was used for access to the brow bone area where the hydroxyapatite cement was immediately obvious. Using a handpiece and burr the cement was drilled out of all four frontal sinus sections. On its removal a large central cavity was encountered in the midline. It communicated directly into the nose. The mucosal lining was removed and a temporalis fascia was initially packed into it and covered with fibrin glue. Multiple split thickness cranial bone grafts were harvested from the posterior frontal bone area on both sides. Multiple layers of bone grafts were layered into the defect.

Nasofrontal Communication Obliteration Ddr Barry Eppley IndianapolisFrontal Sinus Reconstruction with Cranial Bone Grafts Dr Barry Eppley IndianapolisThe remaining frontal sinus areas were filled with demineralized bone and the outer brow bone area reconstructed with cranial bone grafts stabilized with small plates and screws. The cranial bone graft harvest sites were contoured to the surrounding bone level with hydroxyapatite cement.

Secondary frontal sinus obliteration can be done using cranial bone grafts after removal of hydroxyapatite cement. A smooth outer brow bone contour can be obtained with careful shaping and adaptation of monocortical cranial bone grafts. Any small defects in the gaps can be filled with demineralized bone paste.

Case Highlights:

1) Obliteration of the frontal sinus with hydroxyapatite cement is an alloplastic method that is historically very successful.

2) Hydroxyapatite cement can be removed from the frontal sinus and replaced with autogenous bone grafts

3) Reconstruction of split thickness cranial bone graft sites can be done with hydroxyapatite cement.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study: Craniofacial Reconstruction of a Severe Zygomatico-Maxillary Complex (ZMC) Fracture

Wednesday, August 1st, 2012

Background:  Facial fractures occur from a wide variety of mechanisms, most commonly blunt trauma. The cheekbone or zygomatico-maxillary complex (ZMC) is one of the facial bones that is commonly broken due to its prominence on the face. Usually blunt trauma such as being hit by a sporting ball or a fist causes the cheekbone to be knocked out of place, down and into the maxillary sinus. The legs or attachments of the cheek bone behind its frontal prominence are fourfold, being attached superiorly to the tail end of the brow, medially to the lower rim of the eye socket, inferiorly to the maxilla and out laterally to the arch process/temporal bone. To displace the cheekbone, all four legs must be fractured.

Gunshot injuries to facial bones are unique because they have a blast effect, similar to the forces of blunt trauma, but also have a penetrating disruptive force of a high-velocity bullet. The path of the bullet slices the bones creating a wedge effect in its path. When bullets penetrate the face, they are frequently deflected from their path by the initial bone that they hit. This creates non-straight line bullet paths that can be completely unpredictable. The facial fracture pattern of each bullet wound injury is unique.

Case Study: This 39 year-old female has sustained a severe facial injury from a gunshot wound. The bullet entered her right temple and angled through her cheekbone area downward, incredulously exiting out her mouth. She retained her right eye but became blind due to optic nerve impingement from the blast effect and bony displacement. When seen for reconstruction four months after her injury, she had a severely displaced ZMC fracture pattern with impingement and fibrosis to the coronoid process of the lower jaw and temporalis muscle. As a result she had more than a centimeter of orbital dystopia, very significant facial asymmetry and she could not open her mouth.

A 3-D model made from a CT scan shows the severe amount of ZMC bony displacement.

She subsequently underwent a craniofacial reconstructive procedure that was done through a combined coronal (scalp), lower eyelid and intraoral incisions. The entire ZMC complex (or what remained of it, was displaced downward into the maxillary sinus and well scarred into the temporalis muscle. It was osteotomized and repositioned along the lateral orbital rim, zygomatic arch and the underlying maxilla. The bones were stabilized with titanium plates and bone gaps repaired with split-thickness cranial bone grafts. The orbital floor was also built up with cranial bone grafts in layers until the eye position was at the same level as the normal size. Her lower jaw was remobilized by removing the coronoid process and releasing it from the scarred muscle.

After six weeks of healing, she could be seen to have substantial improvement in her facial symmetry with better eye position and cheek projection. Equally important she could open her mouth to almost a normal amount. While she will need further refinements, such as temporal augmentation, the underlying facial skeleton has been anatomically restored.

Case Highlights:

1) ZMC facial fractures can affect the position of the eye and eyelid, the prominence of the cheek bone, opening of the lower jaw and the integrity of the maxillary sinus.

2) Severe ZMC fractures require extensive osteotomies using a multiple incisional approach, cranial bone grafts and rigid titanium plate and screw fixation.

3) Orbito-zygomatic bone and eye symmetry is a main objective of extensive ZMC reconstruction.

Dr. Barry Eppley

Indianapolis, Indiana


Dr. Barry EppleyDr. Barry Eppley

Dr. Barry Eppley is an extensively trained plastic and cosmetic surgeon with more than 20 years of surgical experience. He is both a licensed physician and dentist as well as double board-certified in both Plastic and Reconstructive Surgery and Oral and Maxillofacial Surgery. This training allows him to perform the most complex surgical procedures from cosmetic changes to the face and body to craniofacial surgery. Dr. Eppley has made extensive contributions to plastic surgery starting with the development of several advanced surgical techniques. He is a revered author, lecturer and educator in the field of plastic and cosmetic surgery.

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