The Journal of craniofacial surgery
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Case Reports
Endoscopic endonasal anatomy and approaches to the anterior skull base: a neurosurgeon's viewpoint.
The objective of this study was to review the endoscopic anatomy of the anterior skull base, defining the pitfalls of endoscopic endonasal approaches to this region. Recently, these approaches are gaining popularity among neurosurgeons, and the details of the endoscopic anatomy and approaches are highlighted from the neurosurgeons' point of view, correlated with demonstrative cases. ⋯ This study showed that extended endoscopic endonasal approaches are sufficient in providing wide exposure of the bony structures, and the extradural and intradural components of the anterior skull base and the neighboring structures providing more controlled manipulation of pathologic lesions. These approaches need specific skill and learning curve to achieve more minimally invasive interventions and less postoperative complications.
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Case Reports
Chiari type 1 malformation in an infant with type 2 Pfeiffer syndrome: further evidence of acquired pathogenesis.
There seems to be an association between type 1 Chiari malformation (CM) and some congenital craniosynostosis syndromes. Type 2 Pfeiffer syndrome is a condition associated with premature fusion of multiple cranial sutures, cloverleaf skull (kleeblatschädel deformity), prominent ptosis, thumb and first toe abnormalities, variable syndactyly, and mutated genes for type 1 or 2 fibroblast growth factor receptor. These children generally do poorly because of significant often severe neurologic and cognitive defects, and many die very young. ⋯ Posterior fossa decompression yielded a good result. This patient provides further evidence to support the concept of acquired tonsillar herniation in patients with craniosynostosis syndromes. The etiology seems multifactorial and related to (1) the disproportionately slow growth of the skull relative to the brain, particularly in the posterior fossa, secondary to early fusion of skull sutures, in turn secondary to congenital deficiencies in fibroblast growth factor receptors; (2) impaired venous sinus drainage; (3) hydrocephalus; and (4) resultant elevations in intracranial pressure.
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Lower gingival squamous cell carcinoma (SCC) frequently invades the mandibular bone and buccal or lingual oral mucosa. In the concept of en bloc surgery of malignant tumors, it is advisable to prefer segmental mandibulectomy for T3-T4 lower gingival carcinoma that had radiologic bone involvement and resection of soft tissue on the buccal or lingual side with negative border of margin. Consequential defects of oral mucosa and mandible need immediate reconstruction to provide the maximum probability of cure and quality of life with minimal donor site morbidity. ⋯ Of 17 patients, 11 had with no evidence of disease with a mean follow-up period of 25 months. Our study results, together with literature findings, revealed that the fibula that had a long length of good-quality bone and sufficient blood supply were suitable for stable osteosynthesis, with the overlying skin suitable in thickness and without limitation of skin flap size for intraoral reconstruction especially after ablative surgery. This method provides oral and maxillofacial surgeons with a means to meet both hard and soft tissue needs in a one-stage procedure for extensive resection of gingival SCC.
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Case Reports Comparative Study
Simultaneous correction of hard- and soft-tissue facial asymmetry: combination of orthognathic surgery and face lift using a resorbable fixation device.
The purpose of this study was to evaluate outcomes of simultaneous correction of the hard- and soft-tissue facial asymmetry with face lift procedure using a resorbable fixation device (Endotine Ribbon; Coapt Systems, Palo Alto, CA) during bimaxillary orthognathic surgery in cases with severe facial asymmetry. The samples consisted of 8 patients (mean age, 23.3 [SD, 4.4] years; 8 skeletal class III and 2 class II malocclusion) who received bimaxillary orthognathic surgery and a face lift procedure using a resorbable fixation device. Preoperative cephalometric evaluation of the maxillary occlusal plane cant and chin point deviation and data on surgical movement, site, time, and difficulty of face lift procedure were collected at 1 week before operation and during operation procedure. ⋯ There were no severe complications such as hematoma, facial nerve injury, and postoperative scar. By the patients' and surgeon's view, all had satisfactory jowl elevation, lip canting correction, and achievement of the soft-tissue symmetry without evidence of recurrent asymmetry or loss of fixation. If the face lift procedure using a resorbable fixation device is done with proper vector control during orthognathic surgery, the hard- and soft-tissue facial asymmetry can be corrected simultaneously with satisfactory outcomes.
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Successful outcome in any surgery is dependent on unobstructed access. Management of patients with polytrauma of the face or those undergoing multiple/complex facial osteotomies has always been a challenge, not only to maxillofacial surgeons but also to the anesthetists, as both specialists fight for the same anatomic territory. ⋯ Since our first report in 1992, we have successfully avoided tracheostomy in 400 patients, by using this technique of transmylohyoid intubation. Experience of 20 years is put forward with critical analysis of problems and complications along with certain suggestions and refinements.