Facial deformation following treatment for pediatric head and neck rhabdomyosarcoma; the difference between treatment modalities. Results of a trans-Atlantic, multicenter cross-sectional cohort study

Background: The four different local therapy strategies used for head and neck rhabdomyosarcoma (HNRMS) include proton therapy (PT), photon therapy (RT), surgery with radiotherapy (Paris-method), and surgery with brachytherapy (AMORE). Local control and survival is comparable; however, the impact of these different treatments on facial deformation is still poorly understood. This study aims to quantify facial deformation and investigates the differences in facial deformation between treatment modalities. Methods: Across four European and North American institutions, HNRMS survivors treated between 1990 and 2017, more than 2 years post treatment, had a 3D photograph taken. Using dense surface modeling, we computed facial signatures for each survivor to show facial deformation relative to 35 age–sex–ethnicity-matched controls. Additionally, we computed individual facial asymmetry. Findings: A total of 173 HNRMS survivors were included, survivors showed significantly reduced facial growth (p <.001) compared to healthy controls. Partitioned by tumor site, there was reduced facial growth in survivors with nonparameningeal primaries (p =.002), and parameningeal primaries (p ≤.001), but not for orbital primaries (p =.080) All patients were significantly more asymmetric than healthy controls, independent of treatment modality (p ≤.001). There was significantly more facial deformation in orbital patients when comparing RT to AMORE (p =.046). In survivors with a parameningeal tumor, there was significantly less facial deformation in PT when compared to RT (p =.009) and Paris-method (p =.007). Interpretation: When selecting optimal treatment, musculoskeletal facial outcomes are an expected difference between treatment options. These anticipated differences are currently based on clinicians’ bias, expertise, and experience. These data supplement clinician judgment with an objective analysis highlighting the impact of patient age and tumor site between existing treatment options

Quantitative analysis of planar bone scintigraphy in patients with unilateral condylar hyperplasia

This study compares quantitative analysis of planar bone scintigrams with visual interpretation in patients having unilateral condylar hyperplasia (UCH) and normal control subjects. The possibility of using a bony structure in a region near the condyle as an objective measurement of bone activity is assessed. Planar bone scintigrams from 20 subjects suspected of having active UCH were analyzed both qualitatively and quantitatively. Bone activity was assessed in both condyles as well as in reference sites in the cervical spine and the skull. Percentile activities for both condyle regions and ratios using condyle activity versus reference regions were assessed. All UCH patients had unilateral increased activity on qualitative visual interpretation of the bone scan. The mean percentile activities of the affected and unaffected condyles in the UCH group were significantly different at 55.3% and 44.7%, respectively (P <.001). No significant difference was found in the control group, with the ratios between left and right condyle being 49.5% and 50.5%, respectively (P = .46). In the ratios between the region of interest (ROI) in the condyles versus the ROIs selected for the cervical spine and the skull, a significant difference was noticed in the UCH group; however, there was a considerable overlap between condyle and reference ROI ratios. Symmetrical uptake of diphosphonate reliably excluded continued asymmetrical growth of the condyles. Quantitative analysis of planar scintigrams in unilateral condylar hyperplasia patients was not found to be superior to qualitative visual interpretation of the scans. Because of a considerable overlap in condyle/reference ROI ratios, quantified ratios did not seem to be clinically helpful in the differentiation of a hyperplastic condyle from a normal condyle. In the case of unilateral increased condylar uptake of diphosphonate, clinical assessment is mandator

The surgical management of post-traumatic malocclusion

Facial skeleton fractures should be reduced as early as possible to restore optimal function and minimize skeletal and soft-tissue deformity. With unsatisfactory outcome from delayed treatment because of comorbidity, or despite optimal management, late reconstruction can succeed with conventional orthognathic surgical procedures. Management follows well-established principles of correcting dentofacial deformities, coordinated with orthodontic and prosthodontic support. Planning should include dental records when available, and clinical photographs. The late deformity of midfacial fractures can be corrected by following initial fracture lines; condylar fracture patients can be treated by remote osteotomies. Before surgical intervention, diminished temporomandibular joint (TMJ) mobility should be managed with aggressive physiotherapy to maximize stomal opening. Additionally, successful outcome will depend on a stable TMJ relation without ongoing remodelin

Intraoral distraction osteogenesis to lengthen the ascending ramus. Experience with seven patients

Seven children with facial asymmetry, mean age 12 years (range 11-14.5) were treated by intraoral distraction osteogenesis to lengthen the hypoplastic ramus. We achieved a mean increase in length of the ramus of 13mm (range 10-16). In only one patient did we achieve a posterior open bite on the distraction side. All patients ended with a symmetrical chin. It was helpful to place an orthodontic bite block on the opposite side either preoperatively or postoperatively to cant the plane of occlusion. The duration of follow-up was too short to allow conclusions to be drawn about the future requirement for bimaxillary osteotomie

The orbit first! A novel surgical treatment protocol for secondary orbitozygomatic reconstruction

A novel surgical treatment sequence for secondary orbitozygomatic complex (OZC) reconstruction is described. Orbital reconstruction is performed before OZC repositioning. A surgical plan is made: the affected OZC is virtually osteotomized and aligned with a mirrored model of the unaffected OZC. A patient-specific implant (PSI) is designed for orbital reconstruction. Screw holes from the primary reconstruction are used for fixation. Primary screw hole positions at the repositioned OZC are embedded in the design, to guide OZC repositioning. A second patient-specific design is made for guidance at the zygomaticomaxillary buttress. The workflow was utilized in two patients. The PSI was positioned using navigation feedback. After repositioning of the zygomatic complex, the screw hole positions at the infraorbital rim and zygomaticomaxillary buttress seemed to align perfectly: no screw hole adjustments were necessary. Minor deviations were seen between planned and acquired PSI position; the mean errors between planned and acquired OZC position were 1.5 and 1.2 mm. Orbital reconstruction with a PSI before OZC repositioning ensures true-to-original orbital reconstruction. The use of old screw hole positions enables the PSI to be used as a static guide for ON repositioning. The combination of static and dynamic guidance increases predictability in secondary OZC reconstruction. (C) 2017 Published by Elsevier Ltd on behalf of European Association for Cranio-Maiillo-Facial Surger

Transgender feminization of the facial skeleton

In transsexualism, there is a strong and ongoing cross-gender identification, and a desire to live and be accepted as a member of the opposite gender; thus there is a wish for somatic treatment to make one's body as congruent as possible with gender identity. Makeup and change in hairstyle and accessories further feminize the face, and in time, most persons became more adapted to their life as a member of the opposite gender. There is a need for more objective standardization of the differences in the facial features of the two sexes, to facilitate surgical treatment planning and more objectively assess the outcome of the facial surgery on psychosocial functioning and appearanc