• Archives of Craniofacial Surgery
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• v.24 no.2
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• pp.52-58
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• 2023

Background: Complex orbital fractures are impure orbital fractures because they involve the orbital walls and mid-facial bones. The author reported an orbital wall restoration technique in which the primary orbital wall fragments were restored to their prior position in complex orbital fractures in 2020. As a follow-up to a previous preliminary study, this study retrospectively reviewed the surgical results of complex orbital wall fractures over a 4-year period and compared the surgical outcomes by dividing them into groups with and without balloon restoration. Methods: Data of 939 patients with facial bone fractures between August 2018 and August 2022 were reviewed. Of these, 154 had complex orbital fractures. Among them, 44 and 110 underwent reduction with and without the balloon technique respectively. Pre- and postoperative Naugle exophthalmometer (Good-Lite Co.) scales were evaluated. The orbital volume and orbital volume ratio were calculated from preoperative and 6 months postoperative computed tomography images. Results: Among 154 patients with complex orbital fractures, 44 patients underwent restoration with the balloon technique, and 110 patients underwent restoration without it. The Naugle scale did not differ significantly between the two groups, but the orbital volume ratio significantly decreased by 3.32% and 2.39% in groups with and without the balloon technique and the difference in OVR was significantly greater in patients in the balloon restoration group compared with the control group. Postoperative balloon rupture occurred in six out of 44 cases (13.64%). None of the six patients with balloon rupture showed significant enophthalmos at 6 months of follow-up. Conclusion: The balloon rupture rate was 13.64% (6/44 cases) with marginal screw fixation, blunt screws, and extra protection with a resorbable foam dressing. Furthermore, we restored the orbital wall with primary orbital fragments using balloon support in complex orbital wall fractures.

• Archives of Craniofacial Surgery
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• v.24 no.4
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• pp.189-192
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• 2023

An intraosseous hemangioma of the frontal bone is typically removed via a coronal incision. This procedure, while effective, can be lengthy and may result in complications such as a prominent scar and hair loss. An alternative approach involves a direct incision in the forehead, which leaves a less noticeable scar and allows a quicker recovery. However, in this specific case, the patient declined both coronal surgery and surgery through a direct forehead incision due to cosmetic concerns. Therefore, we proposed an anterior hairline incision. A 35-year-old woman presented with a firm, non-mobile, palpable mass on her right forehead. Preoperative non-contrast computed tomography revealed a heterogeneous osteolytic lesion. We performed an excisional biopsy through the anterior hairline. Postoperative non-contrast computed tomography was conducted 2 and 6 months after surgery. The wound was clean and free of complications, and there was no local recurrence. Partial resection can reduce scarring for patients who are concerned about cosmetic outcomes. However, the potential for recurrence remains a significant concern. We present this case of an anterior hairline incision for a hemangioma located in the forehead, evaluated using serial computed tomography for both preoperative and postoperative imaging.

• Archives of Craniofacial Surgery
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• v.24 no.4
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• pp.167-173
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• 2023

Background: Mandibular split fractures, in which the fracture occurs exclusively in the posterior wall, are uncommon. This study aimed to enhance clinicians' understanding of mandibular split fractures and offer insights for future research. Methods: This study included six patients who visited our hospital between January 2020 and June 2023 and were diagnosed with mandibular split fractures. We retrospectively collected data from patients' medical records on their age, sex, symptoms, mechanism, impact site, associated injuries, and treatment method, as well as the location, pattern, and number of fractures observed on computed tomography (CT) and panoramic images. The frequency of split fractures among all mandibular fractures was calculated. Results: The six patients included three men (50%) and three women (50%), ranging in age from 20 to 71 years (mean age, 49.8 years). The split fractures were located in the symphysis in one patient (16.7%), symphysis to parasymphysis in two patients (33.3%), parasymphysis in one patient (16.7%), and parasymphysis to the body in two patients (33.3%). Four patients (66.7%) had condylar head fractures, while two patients (33.3%) had single split fractures. The mechanism of trauma was a slip-down incident in four cases (66.7%), while two cases (33.3%) were caused by motorcycle traffic accidents. Four patients (67%) underwent intermaxillary fixation, while two patients (33%) improved with conservative treatment. Split fractures were diagnosed in all six patients on CT, whereas the fracture line was not clearly visible on panoramic images. Mandibular split fractures accounted for 5.6% of all mandibular fractures. Conclusion: This study provides insights into the clinical characteristics of rare mandibular split fractures and the diagnostic imaging findings. Furthermore, CT scans and three-dimensional image synthesis-instead of panoramic images-may be essential for accurately diagnosing mandibular fractures, including mandibular split fractures, in the future.

• Archives of Craniofacial Surgery
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• v.24 no.1
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• pp.37-40
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• 2023

Penetrating wounds to the face are cosmetically devastating and can be life-threatening. If the foreign body causing the penetrating wound is a piece of wood, small remnants might be left behind after the initial treatment. A 33-year-old male patient presented to the emergency center after a piece of lumber pierced his face as a passenger in a traffic accident. The patient's vital signs were stable, and emergency surgery was performed to remove the foreign body and repair the soft tissue. No noteworthy complications were seen after open reduction and internal fixation of the facial bone fractures. Seven months after the accident, the patient underwent scar revision along with full-thickness skin grafting for post-traumatic scars. After the surgery, pus-like discharge which was not previously present was observed, and the graft did not take well. A residual foreign body, which was the cause of graft failure, was found on computed tomography and the remaining foreign body was removed through revision surgery. The patient is receiving outpatient follow-up without any complications 6 months after surgery. This case demonstrates the importance of performing a careful evaluation to avoid missing a residual foreign body, especially if it is of wooden nature.

• Archives of Craniofacial Surgery
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• v.24 no.1
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• pp.18-23
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• 2023

Background: When performing reduction of zygomatic arch fractures, locating the inward portion of the fracture can be difficult. Therefore, this study investigated the discrepancy between the locations of the depression on the soft tissue and bone and sought to identify how to determine the inward portion of the fracture on the patient's face. Methods: We conducted a retrospective review of chart with isolated zygomatic arch fractures of type V in the Nam and Jung classification from March 2013 to February 2022. For consistent measurements, a reference point (RP), at the intersection between a vertical line passing through the end point of the root of the ear helix in the patient's side-view photograph and a transverse line passing through the longest horizontal axis of the external meatus opening, was established. We then measured the distance between the RP and the soft tissue depression in a portrait and the bone depression on a computed tomography (CT) scan. The discrepancy between these distances was quantified. Results: Among the patients with isolated zygomatic arch fractures, only those with a fully visible ear on a side-view photograph were included. Twenty-four patients met the inclusion criteria. There were four types of discrepancies in the location of the soft tissue depression compared to the bone depression: type I, forward and upward discrepancy (7.45 and 3.28 mm), type II, backward and upward (4.29 and 4.21 mm), type III, forward and downward (10.06 and 5.15 mm), and type IV, backward and downward (2.61 and 3.27 mm). Conclusion: This study showed that discrepancy between the locations of the depressions on the soft tissue and bone exists in various directions. Therefore, applying the transverse and vertical distances measured from a bone image of the CT scan onto the patient's face at the indicated RP will be helpful for predicting the reduction location.

• Archives of Craniofacial Surgery
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• v.24 no.1
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• pp.24-27
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• 2023

Background: Osteomas are benign, slow-growing bone tumors that can be classified as central, peripheral, or extraskeletal. Central osteomas arise from the endosteum, peripheral osteomas from the periosteum, and extraskeletal osteomas within the muscle. Frontal peripheral osteomas are mainly encountered in plastic surgery. In this study, we retrospectively analyzed the clinical data of patients with frontal peripheral osteomas. Methods: We retrospectively reviewed the medical records of patients who visited our hospital with frontal peripheral osteomas between January 2014 and June 2022. We analyzed the following variables: age, sex, tumor type (sessile or pedunculated), single or multiple, size, history of head trauma, operation, and recurrence. Results: A total of 39 patients and 41 osteomas were analyzed, of which 29 osteomas (71%) were sessile and 12 osteomas (29%) were pedunculated. The size of the osteomas ranged from 4 to 30 mm, with an average size of 10 mm. The age of patients ranged from 4 to 78 years with a mean age of 52 years. There were seven men (18%) and 32 women (82%), and the man-to-woman ratio was 1:4.6. Two patients (5%) had multiple masses, with two osteomas in each, while only two patients (5%) had a history of head trauma. Twenty-nine patients (74%) underwent ostectomy by a direct approach, and none of the patients experienced recurrence. Conclusion: The epidemiologic data of our study will help plastic surgeons encounter frontal peripheral osteomas in the field to provide proper management for their patients.

• Archives of Craniofacial Surgery
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• v.24 no.2
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• pp.66-72
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• 2023

Background: During the coronavirus disease 2019 (COVID-19) pandemic, the everyday use of face masks massively increased to prevent the spread of infection. Many people complain of ear pain and erosion when wearing a mask for extended periods of time. If prolonged mask usage is uncomfortable for ordinary people, a question arises-how much more inconvenient must mask wearing be for patients with a full-thickness skin graft (FTSG) donor site in the retroauricular region? Herein, we evaluated complications related to face mask use in 27 patients with a retroauricular FTSG donor site, with the goal of clarifying whether the retroauricular region is still an appropriate FTSG donor site in the context of the COVID-19 pandemic. Methods: Complications in 27 patients treated by FTSGs harvested from the retroauricular region from 2019 to 2021 were investigated. A questionnaire comparing the normal and the operated sides was administered. Pain, itching, soreness, deformity, and symmetry were further investigated. Results: Pain and itching were the only observed complications. The operated side was slightly more painful than the normal side in four patients (14.8%), and four patients (14.8%) reported itching on the operated side. However, all patients who experienced complications stated that the pain or itching did not interfere with mask wearing. Most symptomatic patients were older than 60 years of age (23.8%, p= 0.185) and wore masks for longer periods of time (28.5%, p= 0.326). Conclusion: Few retroauricular donor site-related complications occurred, and none of these complications caused inconvenience in daily life. Therefore, in the COVID-19 pandemic, the use of the retroauricular region as an FTSG donor site remains appropriate.

• Archives of Craniofacial Surgery
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• v.24 no.2
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• pp.59-65
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• 2023

Background: Fibrous dysplasia (FD) is a localized bone disorder in which fibro-osseous tissue replaces the normal bone structure. Patients with craniofacial FD often present with gradual swelling, deformity, and compromised vision or hearing. We previously introduced "the core extirpation method," a novel surgical technique that is minimally invasive like traditional bone shaving but has longer-lasting effects. This study presents the long-term outcomes of our core extirpation method. Methods: We conducted a retrospective analysis of patients who underwent core extirpation for FD of the zygomaticomaxillary region from 2012 through 2021. Computed tomography (CT) scans were performed 6 to 12 months before the operation, immediately before and after the operation, and during follow-up visits. We performed all operations using the upper gingivobuccal approach, and we extirpated the core of the lesion while preserving the cortical structures of the zygoma and the maxilla to maintain symmetrical facial contour. Results: In 12 patients with lesions in the growth phase, anteroposterior/mediolateral (AP/ML) length discrepancies and the volume increased between preoperative and immediate postoperative CT scans. All patients' immediate postoperative AP/ML discrepancies were stable up to 12-17 months postoperatively. Postoperative volume showed continuous lesion growth; the median volume growth rate was 0.61 cc per month. Conclusion: In this article, we present our experiences managing FD using the minimally invasive core extirpation technique, which entails small expected blood loss and can be performed as day surgery. It provides similar cosmetic outcomes as traditional bone shaving but with longer-lasting results. Although there are some limitations with the study's retrospective nature and small sample size, our 4-year follow-up results show promising results of the core extirpation method in well-indicated patients.

• Archives of Craniofacial Surgery
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• v.24 no.2
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• pp.78-82
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• 2023

Blue nevi, which are characterized by collections of pigment-producing melanocytes in the dermis, have a variety of clinicopathological characteristics. Plaque-type blue nevus (PTBN) is a variant of blue nevi. PTBN presents at birth or arises in early childhood, and it shows a combination of the features found in common blue nevus and cellular blue nevus. It is typically found on the dorsal surface of the hands and feet or on the head and neck, and it is usually benign and stable over time. However, reports have occasionally described malignant melanomas developing in or associated with a PTBN. Malignant blue nevi are most commonly found on the scalp. We report the case of an 88-year-old woman with a malignant melanoma associated with a PTBN of the cheek.

• Archives of Craniofacial Surgery
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• v.24 no.3
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• pp.105-110
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• 2023

Background: Conventional radial forearm free flaps (RFFFs) are known to be safe, but can result in donor site complications. Based on our experiences with suprafascial and subfascial RFFFs, we evaluated the safety of flap survival and surgical outcomes. Methods: This was a retrospective study of head and neck reconstructions using RFFFs from 2006 to 2021. Thirty-two patients underwent procedures using either subfascial (group A) or suprafascial (group B) dissection for flap elevation. Data were collected on patient characteristics, flap size, and donor and recipient complications, and the two groups were compared. Results: Thirteen of the 32 patients were in group A and 19 were in group B. Group A included 10 men and three women, with a mean age of 56.15 years, and group B included 16 men and three women, with a mean age of 59.11 years. The mean defect areas were 42.83 cm² and 33.32 cm², and the mean flap sizes were 50.96 cm² and 44.54 cm² in groups A and B, respectively. There were 13 donor site complications: eight (61.5%) in group A and five (26.3%) in group B. Flexor tendon exposure occurred in three patients in group A and in none in group B. All flaps survived completely. A recipient site complication occurred in two patients (15.4%) in group A and three patients (15.8%) in group B. Conclusions: Complications and flap survival were similar between the two groups. However, tendon exposure at the donor site was less prevalent in the suprafascial group, and the treatment period was shorter. Based on our data, suprafascial RFFF is a reliable and safe procedure for reconstruction of the head and neck.