Unilateral exophthalmos caused by an anterior ethmoidal meningoencephalocele.

A case of unilateral enophthalmos in a 1-year-old child is presented. This was caused by a meningoencephalocele that originated in the anterior cranial fossa and protruded into the orbit through a bony defect at the junction of the frontal and ethmoid bones at the site of the anterior ethmoid canal. This meningoencephalocele was reduced, and the dura was repaired with a temporalis fascia graft. A split calvarial bone graft was inserted into the floor of the orbit, and lateral canthal ligament elevation completed the operative correction.     

Surgical reconstruction of the contracted orbit

Anophthalmic patients and patients afflicted with retinoblastoma incur severe deformity of the orbit. Treatment of the severely contracted orbit is very difficult, and patient satisfaction is often poor. Since 1988, we have performed temporalis muscle transfer and surgical expansion of the contracted bony orbit in 26 patients. Satisfactory results were obtained. Gradual expansion of the orbit was performed in case of congenital anophthalmic patients. The treatment should be established in multiplicity, among many methods available for contracted eye sockets, according to the degree of orbital deformity and the amount of residual conjunctiva. In case of severe deformity, volume expansion surgery and temporalis muscle transfer are necessary. If augmentation is required in the periorbital region, rib bone onlay graft must be performed. We were able to shorten the operative time by modifying the three-wall orbital expansion technique of Tessier and Wolfe to a more simplified method. Our observations show that our procedures achieved symmetry in both eyes in all patients, and there have been no remarkable complications.     

Cyclopia-synotia: an unusual presentation

An infant showing an unusual combination of craniofacial abnormalities is described. Synotia, astomia, a rudimentary proboscis, and a central placode in the hairline were observed. Serial sections of the head were examined microscopically. The proboscis contained a mass of striated muscle, but no bony or nervous tissue. Cyclopia was suggested by the central placode, the latter consisting of a thin, stratified, squamous nonkeratinized epithelium attached to an incomplete orbit by a strand of connective tissue. The orbit consisted of a bony shelf with bundles of nerves, striated muscle, and degenerate retinal tissue. The central nervous system cranial to the hindbrain was poorly developed. The midbrain and diencephalon were rudimentary, and there was poor separation of the small cerebral hemispheres. The auditory system was well represented. The maxilla and mandible were present, but there was no evidence of tooth formation. The wide range of midline abnormalities and anodontia suggest that this is a case of cranial neural crest deficiency.     

The role of tissue expanders in an anophthalmic animal model

A study of orbital bony expansion using a custom tissue expander was performed in the anophthalmic cat model. Twelve 6-week-old kittens underwent right unilateral enucleations. Six kittens had immediate insertion of a tissue expander into the orbit. The remaining six served as controls. Every 2 weeks 0.5 cc saline was injected into the expander to a maximum of 5 cc. External horizontal and vertical orbital dimensions were obtained by palpation technique weekly. All animals had preoperative and study conclusion head CT scans with three-dimensional reconstructions performed. Dry skull preparations were done at the study conclusion at 24 weeks. Results demonstrated that tissue expanders were successful in maintaining normal orbital growth and size relative to the contralateral control orbit. The animals with enucleation only had an average difference in vertical and horizontal orbital measurements of -27 and -13 percent when compared with the contralateral normal orbit. In contrast, the enucleation and tissue-expansion animals had vertical and horizontal measurements of +4 and +2 percent (p less than 0.05) when compared with the contralateral orbit. Head CT scans with three-dimensional reconstructions demonstrated normal orbital geometry and volume for the animals with tissue expanders, whereas animals with enucleation only had small hypoplastic orbits. In conclusion, orbital tissue expanders offer a promising new technique in the treatment of anophthalmos.     

Function of the mammalian postorbital bar

Complete postorbital bars, bony arches that encompass the lateral aspect of the eye and form part of a circular orbit, have evolved homoplastically multiple times during mammalian evolution. Numerous functional hypotheses have been advanced for postorbital bars, the most promising being that postorbital bars function to stiffen the lateral orbit in taxa that have significant angular deviation between the temporal fossa and the bony orbit. Without a stiff lateral orbit the anterior temporalis muscle and fascia potentially would pull on the postorbital ligament, deform the orbit, and cause disruption of oculomotor precision. Morphometric data were collected on 1,329 specimens of 324 taxa from 16 orders of extant eutherian and metatherian mammals in order to test whether the orientation of the orbit relative to the temporal fossa is correlated with the replacement of the postorbital ligament with bone. The allometric and ecological influences on orbit orientation across mammals are also explored. The morphometric results corroborate the hypothesis: Shifts in orbit orientation relative to the temporal fossa are correlated with the size of the postorbital processes, which replace the ligament. The allometric and ecological factors that influence orbit orientation vary across taxa. Postorbital bars stiffen the lateral orbital wall. Muscle pulleys, ligaments, and other connective tissue attach to the lateral orbital wall, including the postorbital bar. Without a stiff lateral orbit, deformation due to temporalis contraction would displace soft tissues contributing to normal oculomotor function.     

Mandibular reconstruction with vascularized iliac crest: a 10-year experience

Since 1978, 35 patients have undergone mandibular reconstruction with vascularized iliac crest. During this time, the technique of raising and shaping the iliac crest has undergone a series of modifications. Initially, osteocutaneous segments based first on the superficial circumflex iliac system and later on the deep circumflex iliac system were used. More recently, only the inner table of the ilium has been employed, and where intraoral lining is required, an ulnar forearm free flap has been added. Thirty-two patients were reconstructed successfully. Of the three anastomotic failures, one bony segment was able to survive as a free graft. There were no donor-site complications. With continued experience, operative morbidity has been minimized, while the technique has been modified to tailor the reconstruction to the specific requirements of the patient. It is concluded that vascularized iliac crest provides the most appropriate mandibular reconstruction for a range of congenital and acquired defects.     

Vascularized rib for facial reconstruction

The reconstruction of maxillectomy defects is a complex problem encountered in plastic surgery. Defects can range in size and complexity from small defects requiring only soft tissue to complete maxillectomies requiring large tissue bulk, bone, and one or more skin paddles. The most difficult defects involve the skull base and orbit. The reconstructive surgeon is faced with the challenge of isolating the nasopharynx from the dura and globe while simultaneously restoring the bony framework of the maxilla and orbit to support the soft tissue of the cheek. The authors present a series of six reconstructions using a rectus abdominis muscle flap with associated vascularized rib for reconstruction of complex maxillectomy defects. This flap provides large soft-tissue bulk as well as bony support and a long vascular pedicle. A skin island can be taken with the flap, and the donor-site morbidity is comparable to that seen with a vertical rectus abdominis myocutaneous flap. Six flaps were used in five patients over a 20-month period. All patients had stable support of the orbit at follow-up with adequate soft-tissue coverage, and there were no incidences of visual changes.     

Midface fractures: advantages of immediate extended open reduction and bone grafting

Experience with 240 midface (Le Fort and zygoma) fractures in multiple trauma patients has emphasized that superior aesthetic results are obtained by immediate extended open reduction with primary bone grafting. Internal fixation of 110 zygomatic and 130 Le Fort fractures was performed in the lower midface (zygomaticomaxillary and nasomaxillary buttresses). Open reduction of the condyle was employed in five concomitant Le Fort and subcondylar fractures with a loss of ramus height to prevent superior and posterior displacement of the middle and lower face. Bone grafts were utilized in 74 patients. They were most frequently employed in the orbit and less frequently in the lower midface. Bone graft survival paralleled that observed under elective conditions, and a slightly higher infection rate was observed. Extended open reduction and immediate bone grafting adds a new dimension to the aesthetic results obtained from facial fracture treatment. Structural bony integrity and pre-injury facial architecture may be restored in the absence of soft-tissue contracture. Restoration of the pre-injury facial architecture (the essence of facial fracture treatment) is more accurately accomplished when these techniques are utilized.     

Surgical correction of the severely deviated nose by extramucosal excision of the osseocartilaginous septum and replacement as a free graft

Twenty-five patients with severe internal and external deviation of the nose characterized by deviation of the septum in several planes and almost total obstruction of the airway on one or both sides were operated on. The entire bony and cartilaginous septum was removed in each of these patients, preserving the mucoperichondrial and mucoperiosteal flaps. The extramucosal technique of septal dissection was used. A support graft was fashioned from cartilaginous remnants of the septal cartilage and placed between the mucoperichondrial flaps as a free graft. All patients were followed for a minimum of 1 year. The longest follow-up is 15 years. Aesthetic improvement of the nose was obtained in all patients. All patients experienced varying degrees of improvement in nasal blockade.     

Visual impairment from fibrous dysplasia in a middle-aged African man: a case report

Introduction

Fibrous dysplasia is a benign tumour of the bones and is a disease of unknown aetiology. This report discusses a case of proptosis and visual deterioration with associated bony mass involving the right orbit.

Case presentation

A 32-year-old Nigerian man of Yoruba ethnic origin presented to the eye clinic of our hospital with right-eye proptosis and visual deterioration of 7-year duration. Presentation was preceded by a history of trauma. Proptosis was preceded by trauma but was non-pulsatile with no thrill or bruit but was associated with bony orbital mass. The patient reported no weight loss. Examination of his right eye showed visual acuity of 6/60 with relative afferent pupillary defect. Fundal examination revealed optic atrophy. Computed tomography showed an expansile bony mass involving all the walls of the orbit. The bony orbital mass was diagnosed histologically as fibrous dysplasia. Treatment included orbital exploration and orbital shaping to create room for the globe and relieve pressure on the optic nerve.

Conclusion

Fibrous dysplasia should be considered in the differential diagnosis of slowly developing proptosis with associated visual loss in young adults.

     

Radiographic analysis of the midface of a stillborn infant with a unilateral cleft lip and palate

The midface of a full-term stillborn infant with a right complete unilateral cleft lip and palate was studied with plain-film radiography and tomography, xeroradiography, and computerized axial tomography. Gross skeletal and soft-tissue deficiencies on the cleft side were evident as compared to the noncleft side and involved the entire bony maxillary complex and antrum, the orbit, and the nasal pyramid and intranasal structures. The area on the cleft side was 19 percent less than the noncleft side, and the maximal anteroposterior dimension was 16 percent less. The cleft bony palatal shelf was 12.5 mm wide compared to 20 mm on the noncleft side. The findings demonstrate the deficient and abnormal functional matrix inherent in the cleft condition.     

Orbital volume measurements in enophthalmos using three-dimensional CT imaging

The purpose of this study was to investigate enophthalmos by measuring the volume of various orbital structures using off-line computer techniques on images generated by a CT scanner. Eleven patients with enophthalmos had CT scans of the orbits consisting of 30 to 40 adjacent 1.5-mm slices. The data from the scans were analyzed on a Nova 830 stand-alone computer system using software programs that allowed measurement of total bony orbital volume, total soft-tissue volume, globe volume, orbital fat volume, neuromuscular tissue volume, and apex-to-globe distance in the horizontal plane. These data were analyzed comparing the volumes in the normal eye with the volumes in the enophthalmic eye in each patient. The analysis demonstrated a statistically significant increase in bony orbital volume in the enophthalmic eye, but the total soft-tissue volume, fat volume, neuromuscular tissue volume, and globe volume were the same as in the normal eye. The apex-to-globe distance, a measure of the degree of enophthalmos, was less in the enophthalmic eye than in the normal eye. These results suggest that in the majority of patients, the cause of posttraumatic enophthalmos is increased bony orbital volume rather than by soft-tissue loss or fat necrosis. (Several patients showed no volume discrepancies, and it is likely that cicatricial contracture is responsible for the enophthalmos in these cases.) This study suggests that the objective of surgery for correction of enophthalmos in patients with a volume discrepancy should be to decrease the volume of the bony orbit and to increase the anterior projection of the globe.     

Temporal fossa bone grafts: a new technique in craniofacial surgery

The calvarium has become an increasingly popular bone-graft donor site. Previously described harvesting techniques are often difficult to perform and may produce unsatisfactory bone fragments. However, full-thickness bone grafts taken from the region of the temporal fossa, beneath the temporaiis muscle, have proven to be of high quality and technically easy to obtain. In our experience with eight patients, temporal fossa bone grafts were used primarily around the orbit, including reconstruction of the orbital floor, frontal bone, and zygoma. The procedure begins with a hemicoronal or bicoronal incision; the temporalis muscle is reflected, and an underlying bone plate up to 4 X 6 cm is removed. The resulting bone graft is consistently 3 to 4 mm in thickness. The cranial defect is packed with bone debris, and the muscle is replaced. This technique has proven to be safe, technically simple, consistently productive of high-quality bone grafts, and within discernible donor-site deformity.     

Fixation effects on membranous and endochondral onlay bone graft revascularization and bone deposition.

This paper investigates the relationship between bone resorption, the process of bone revascularization, and graft fixation. Vital staining techniques and microangiography were used to study the extent of graft revascularization of fixed and nonfixed endochondral (rib) and membranous (skull) onlay bone grafts in 20 adult sheep mandibles bilaterally. This assessment was carried out at 2 and 20 weeks postoperatively. Sequential fluorochrome staining was performed to examine the pattern of new bone deposition. Fixation was achieved using the lagscrew technique. At 2 weeks, membranous bone demonstrated a greater area of graft revascularization if fixed than if the graft was not fixed. The opposite result was seen for endochondral grafts, where nonfixed grafts showed a greater area of revascularization than fixed grafts. At 20 weeks, all bone that was present was fully vascularized. The inconsistencies in the results on the relationship between fixation and revascularization for membranous and endochondral grafts in the early stages of healing (2 weeks) suggest that although revascularization is a necessary precondition for bone resorption and deposition, biomechanical and structural factors may be a more satisfactory explanation for the differences observed in the maintenance of bony volume.     

Upper jaw in human cyclopia

In human cyclopia the upper jaw forms a solid bony mass between the median orbit and the oral cavity. The skeletal elements forming the upper jaw have been studied in serial sections through the median third of the head in 3 perinatal human specimens presenting with a median orbit and proboscis. One head was sectioned in the sagittal plane and 2 in the coronal plane. The upper jaw has also been studied in a dried cyclops skull and in a desiccated cyclops head in which the roof of the orbit had been removed. The data obtained demonstrate the particular contributions made by the lacrimal bones, the maxillae and the palatine bones to the upper jaw in human cyclopia. The effects of the absence of the frontonasal process contribution and of the absence of the nasal cavity on the upper jaw in cyclopia are considered.     

PARA-ARTICULAR FUSION OF THE PROXIMAL INTERPHALANGEAL JOINT OF THE HAND

The para-articular procedure for the arthrodesis of an interphalangeal joint is more reliable, rapid and simpler than intra-articular fusion. The position is easily maintained, and therefore one has no difficulty with approximating the flexion and rotational angles. Since a large dead space is not produced in carrying out the procedure, use of a compressing force for adequate surface contact is not necessary. Shortening of the finger is not a hazard. A Kirschner wire is used in the technique described, which gives good protection for the graft and keeps the joint in the desired position without distracting the surfaces during the bony resorption at the joint.     

Nasal cavity carcinosarcoma in a bonnet macaque (Macaca radiata)

An example of a rare, highly aggressive malignant intranasal neoplasm in a male Bonnet macaque is presented. The tumor invaded the bony orbit, distorted the position of the globe, and metastasized to regional lymph nodes and lungs. Histologically the tumor was composed of both mesenchymal and epithelial components and probably was of minor salivary gland origin.     

Repair of large defect of frontal bone with free graft of outer table of parietal bones.

We present a case with a full-thickness bony defect in the frontal area. It was corrected successfully by a free bone graft to the outer table from the parieto-occipital area, partly covered by a flap of periosteum from the same area.     

Treatment of infected tibial nonunion with bone defect using central bone grafting technique

Treatment of infected tibial nonunion with bone defect represents a challenge for every orthopaedic surgeon. Various methods of treatment have been described for nonunions with infection, bone loss or both. One of them is the central bone grafting technique, which is a safe and effective treatment for nonunions of the tibia. The technique involves placement of autogenous cancellous bone from the iliac crest on the anterior surface of the interosseous membrane with the aim of creating a tibiofibular synostosis. We present the results of uncontrolled, retrospective and continuous series of ten patients treated by a central bone grafting technique for infected tibial nonunion with bone loss. Mean follow-up period was 12 (10-15) years. Most injuries were a result of war injuries. Clinically and radiologically confirmed bony healing with total consolidation of the graft was achieved in all patients within a period of 10-12 months without further bone grafting. The newly-formed bone mass was able to fulfil the mechanical and functional demands of everyday life activities. Once again, the central bone grafting technique has shown to be a safe, reliable and effective method of treatment for infected tibial nonunion with bone defect.     

Firecracker eye exposure: experimental study and simulation

Understanding the mechanisms of traumatic ocular injury is helpful to make accurate diagnoses before the symptoms emerge and to develop specific eye protection. The comprehension of the dynamics of primary blast injury mechanisms is a challenging issue. The question is whether the pressure wave propagation and reflection alone could cause ocular damage. To date, there are dissenting opinions and no conclusive evidence thereupon. A previous numerical investigation of blast trauma highlighted the dynamic effect of pressure propagation and its amplification by the geometry of the bony orbit, inducing a resonance cavity effect and a standing wave hazardous for eye tissues. The objective of the current work is to find experimental evidence of the numerically identified phenomenon. Therefore, tests aimed at evaluating the response of porcine eyes to blast overpressure generated by firecrackers explosion were performed. The orbital cavity effect was considered mounting the enucleated eyes inside a dummy orbit. The experimental measurements obtained during the explosion tests presented in this paper corroborate the numerical evidence of a high-frequency pressure amplification, enhancing the loading on the ocular tissues, attributable to the orbital bony walls surrounding the eye.