The Journal of Craniofacial Surgery • Volume 26, Number 1, January 2015

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residues of the target protein to activate the transcription factors, interacted with DNA-binding proteins resulting in gene transcripts to bring about biologic effects.21 Based on the above evidences, the mechanisms for PRP-induced bone healing during distraction osteogenesis are complex and should be further investigated. Tie-Lou Chen, MD Department of Periodontology Oral Research Center of CPLA Hospital 411 of CPLA Shanghai, China [email protected], [email protected] Hui-Jie Lu, PhD Department of Psychology Aerospace Engineering Medical College Fourth Military Medical University Xi’an, China Shi-Feng Wang, MD Department of Hyperbaric Medicine and Physiology Naval Medical Research Institute Shanghai, China Shu-Guang Li Department of Medical Support Hospital 411 of CPLA Shanghai, China ACKNOWLEDGMENTS This study was supported by Nanjing Command Science & Technology Program (06MA08) and General Logistics Department Science Research Program of CPLA(CHJ13J035). This study was also supported by Scientific Research Subject Foundation of Shanghai Municipal Health Bureau (2013-418) and the Board of Health of Hong Kou District Foundation of Science & Technology Program of Shanghai (1203-15).

REFERENCES 1. Xu H, Ke K, Zhang Z, et al. Effects of platelet-rich plasma and recombinant human bone morphogenetic protein-2 on suture distraction osteogenesis. J Craniofac Surg 2013;24:645–650 2. Chen TL, Lu HJ, Liu GQ, et al. Effect of autologous platelet-rich plasma in combination with bovine porous bone mineral and Bio-guide membrane on bone regeneration in mandible bicortical bony defects. J Craniofac Surg 2014;25:215–223 3. Latalski M, Elbatrawy YA, Thabet AM, et al. Enhancing bone healing during distraction osteogenesis with platelet-rich plasma. Injury 2011;42:821–824 4. De Leonardis D, Pecora GE. Prospective study on the augmentation of the maxillary sinus with calcium sulfate: histological results. J Periodontol 2000;71:940–947 5. Kearns AE, Khosla S, Kostenuik PJ. Receptor activator of nuclear factor kappa B ligand and osteoprotegerin regulation of bone remodeling in health and disease. Endocr Rev 2008;29:155–192 6. Boyce BF, Xing L. Functions of RANKL/RANK/OPG in bone modeling and remodeling. Arch Biochem Biophys 2008;473:139–146 7. Idris AI, Krishnan M, Simic P, et al. Small molecule inhibitors of kappa B kinase signaling inhibit osteoclast formation in vitro and prevent ovariectomy-induced bone loss in vivo. FASEB J 2010;24:4545–4555 8. Wada T, Nakashima T, Hiroshi N, et al. RANKL-RANK signaling in osteoclastogenesis and bone disease. Trends Mol Med 2006;12:17–25 9. Perez-Sayans M, Somoza-Martın JM, Barros-Angueira F, et al. RANK/RANKL/OPG role in distraction osteogenesis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010;109:679–686

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10. Ignatius A, Schoengraf P, Kreja L, et al. Complement C3a and C5a modulate osteoclast formation and inflammatory response of osteoblasts in synergism with IL-1β. J Cell Biochem 2011;112: 2594–2605 11. Blann A, Cain G, Bareford D. Vascular endothelial growth factor and platelets in primary thrombocythaemia. Br J Haematol 2006;132:530–531 12. Grunewald M, Avraham I, Dor Y, et al. VEGF-induced adult neovascularization recruitment, retention, and role of accessory cells. Cell 2006;13:175–189 13. Maes C, Goossens S, Bartunkova S, et al. Increased skeletal VEGF enhances beta-catenin activity and results in excessively ossified bones. EMBO J 2010;29:424–441 14. Liu N, Shi S, Deng M, et al. High levels of β-catenin signaling reduce osteogenic differentiation of stem cells in inflammatory microenvironments through inhibition of the noncanonical Wnt pathway. J Bone Miner Res 2011;26:2082–2095 15. Paoloni J, De Vos RJ, Hamilton B, et al. Platelet-rich plasma treatment for ligament and tendon injuries. Clin J Sport Med 2011;21:37–45 16. Thorwarth M, Wehrhan F, Schultze-Mosgau S, et al. PRP modulates expression of bone matrix proteins in vivo without long-term effects on bone formation. Bone 2006;38:30–40 17. Kawasumi M, Kitoh H, Siwicka KA, et al. The effect of the platelet concentration in platelet-rich plasma gel on the regeneration of bone. J Bone Joint Surg Br 2008;90:966–972 18. Fang TD, Salim A, Xia W, et al. Angiogenesis is required for successful bone induction during distraction osteogenesis. J Bone Miner Res 2005;20:1114–1124 19. Welsh WJ. Autologous platelet gel: clinical function and usage in plastic surgery. Cosmetic Derm 2000;80:13–18 20. Andrae J, Gallini R, Betsholtz C. Role of platelet-derived growth factors in physiology and medicine. Genes Dev 2008;22: 1276–1312 21. Attisano L, Wrana JL. Signal transduction by the TGF-β superfamily. Science 2002;296:1646–1647

Late Treatment of Ocular Globe Displacement to the Maxillary Sinus After an Orbital Floor Fracture

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he complete displacement of the ocular globe to the maxillary sinus after an extensive orbital floor fracture is an extremely uncommon event resulting from traumatic impact directly on the orbital content.1 Despite ample descriptions in the literature on the treatment of facial fractures, the diagnosis and treatment of displacement of the ocular globe constitute a challenge to oralmaxillofacial surgeons.2,3 This article describes a case of a patient who had undergone surgery for an extensive orbital floor fracture followed by a late diagnosis of displacement of the ocular globe to the maxillary sinus. A 25-year-old white man presented to the Oral-Maxillofacial Trauma and Surgery Residency Service of the Cariacica Hospital Complex (Brazil) complaining of intense pain in the region of the right orbit. The patient reported having undergone a surgical procedure at a different hospital service 2 months earlier for the correction of a fracture of the right zygomatic-orbital complex stemming from a rodeo accident. The patient was unable to remember the exact circumstances of the accident but reported the complete loss of vision on the side corresponding to the fracture. © 2014 Mutaz B. Habal, MD

Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.

The Journal of Craniofacial Surgery • Volume 26, Number 1, January 2015

The initial physical examination of the face revealed an absence of edema and periorbital ecchymosis. The ocular examination revealed the absence of light perception, absence of the right ocular globe, and ocular globe atrophy giving the appearance of postenucleation syndrome (Figs. 1A, B). Computerized tomography (CT) revealed an extensive fracture of the orbital floor, titanium mesh used for the reconstruction, and the ocular globe displaced to the right maxillary sinus, which was filled with the orbital content (Figs. 1C, D). Surgical exploration of the orbital floor was performed through a subtarsal access, and the titanium mesh was removed. A periosteal elevator was inserted through the maxillary antrostomy, superoinferior pressure was imposed to reposition the ocular globe in the orbital cavity, and the ocular globe was enucleated (Fig. 2A). The orbital floor was reconstructed with high-density porous polyethylene (Medpor), and the ophthalmologic team placed an orbital implant composed of an acrylic sphere and human sclera obtained from an eye bank and then placed scleral prosthesis. Six months later, the patient was submitted to further surgery to correct the eyelid, reestablish facial harmony, and achieve better retention of the scleral prosthesis (Figs. 2B–D). Changes in the position of the ocular globe in the orbital cavity are classified as luxation, displacement, and avulsion. Luxation consists of protrusion of the ocular globe outside the orbital cavity with spastic closure of the eyelid. In most cases, this occurs spontaneously in individuals with shallow orbits. Displacement is the migration of the ocular globe to the paranasal or nasal cavities due to trauma. Avulsion consists of protrusion of the ocular globe together with the breakage of the extraocular muscles and optic nerve, leading to the complete dislocation of the eye from its socket.4 The diagnosis of orbital floor fracture with displacement of the ocular globe to the paranasal sinuses is based on clinical characteristics and imaging examinations (CT scan and/or magnetic resonance).5 The ischemia resulting from the herniation of these structures determines the need for immediate surgery or surgery within 48 hours. Late treatment increases the risk for complications such as edema as well as compression of the optic nerve and central artery of the retina, which increases the likelihood of an irreversible loss of vision.6

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FIGURE 2. A, Clinical aspect after ocular globe enucleation. B, Acrylic sphere and human sclera for reconstruction of orbital volume. C, Acruylic sphere and human sclera adapted in the orbital cavity. D, Clinical aspect after installation of the prosthesis and 6 months after the surgery to correct the eyelid.

The installation of the orbital implant allows the reestablishment of the orbital volume, and then scleral prosthesis can be placed. However, enophthalmia, eyelid contraction, and a deep fold in the upper eyelid can be observed, characterizing postnucleation socket syndrome, so other esthetic surgeries may be necessary.7 Ana Paula Simões Corrrêa, DDS, MSc Araçatuba School of Dentistry University of Estadual Paulista Araçatuba Sao Paulo, Brazil [email protected]

FIGURE 1. A, The ocular examination revealing the absence of the right ocular globe. B, Clinical aspect with orbital atrophy giving the appearance of postenucleation syndrome. C, The CT scan also revealing titanium mesh used for the reconstruction of the fracture orbital floor. D, CT scan revealing displacement of the ocular globe.

Carlos Alberto Timóteo, DDS, MSc Araçatuba School of Dentistry Univ. Estadual Paulista Araçatuba Sao Paulo, Brazil Elio Hitoshi Shinohara, DDS, MSc Department of Surgery and Integrated Clinics Araçatuba School of Dentistry University of Estadual Paulista Araçatuba Sao Paulo, Brazil

© 2014 Mutaz B. Habal, MD

Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.

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Alessandra Marcondes Aranega, DDS, MSc Rodrigo dos Santos Pereira, DDS, MSc Department of Surgery and Integrated Clinics Araçatuba School of Dentistry University of Estadual Paulista Araçatuba Sao Paulo, Brazil

REFERENCES 1. Kohlhof JK, Driemel O, Müller-Richter UD. Traumatic dislocation of the globe into the maxillary sinus—is a rehabilitation possible? Klin Monbl Augenheilkd 2005;224:867–870 2. Magarakis M, Mundinger GS, Kelamis JA, et al. Ocular injury, visual impairment, and blindness associated with facial fractures: a systematic literature review. Plast Reconstr Surg 2012;129:227–233 3. Guly CM, Guly HR, Bouamra O, et al. Ocular injuries in patients with major trauma. Emerg Med J 2006;23:915–917 4. Flower JG. Spontaneous luxation of the eyeballs. JAMA 1941;116:1206–1208 5. Xu B, Xu XL, Yan J. Treatment of traumatic globe dislocated completely into the maxillary sinus. Int J Ophthalmol 2013;6:106–107 6. Haggerty CJ, Roman P. Repositioning of a traumatically displaced globe with maxillary antrostomy: review of the literature and treatment recommendations. J Oral Maxillofac Surg 2013;71:1915–1922 7. Tyers AG, Collin JRO. Orbital implants and postenucleation socket syndrome. Trans Ophthalmol Soc 1982;102:90–92

Malignant Peripheral Nerve Sheath Tumor of the Forehead To the Editor: Malignant peripheral nerve sheath tumor (MPNST) originates from the peripheral nerves or their sheaths, and it has replaced the previous confusing terminologies of a neurogenic sarcoma, neurofibrosarcoma, or malignant schwannoma.1–5 The estimated frequency of MPNSTs in the population is 0.001%; on the other hand, it can increase from 2 to 5% to 42% in patients with neurofibromatosis type 1 (NF1) with an aggressive course.3 The highest incidences of these tumors occur about the ages of 20 to 50 years.1 Malignant peripheral nerve sheath tumors derive from the peripheral nerve root trunk, extremities, and the head and neck area.6 Malignant peripheral nerve sheath tumor is extremely occasional tumor with an incidence of 1 per 100,000 population, which is between 3% and 10% of all the soft tissue sarcomas. So, this entity is often managed as a subgroup of soft tissue sarcomas.1,7 Here, we are reporting a case of a sporadic, malignant, peripheral nerve sheath tumor of the forehead in a 65-year-old man. In our case, there was no clinical sign of NF1, and NF1-independent MPNSTs are extremely infrequent.

FIGURE 2. Postoperative view of the patient.

and examined in another clinic. The excision margins were tumor positive, and the defect was reconstructed with a full-thickness skin graft, which was taken from the supraclavicular area (Fig. 1).There was blunt sensitive pain over the graft area. There was a previous history of trauma that was triggered by a blunt object to the forehead 3 years ago. There were no clinical data that were indicative of NF1 and no family history of any NF1 lesion. On physical inspection, the scarring and swelling were found to be on the forehead area, which measured 2.52.0 cm in the middle one third of the forehead (Fig. 1). The swelling was soft and painful, and it was fixed to the overlying skin, soft tissue, and the muscle, but it was free from bone. The swelling was nonpulsatile, with normal temperature. The laboratory results, which included blood count, urine analysis, and chest x-ray/ultrasonography of the abdomen were all unremarkable. Computed tomography and magnetic resonance imaging were suggestive of a 2.0  1.8 cm soft tissue mass that was free from bone. The patient underwent a wide local excision of the lesion. Ther defect was reconstructed with a scalping flap, and the donor site of the flap was reconstructed with split-thickness skin graft (Fig. 2). The wide excised mass (6.6  3.2  0.8) was solid and cystic in nature, and it was adherent to the supraorbital nerve (Fig. 3). By gently detaching it from the nerve, the lesion was excised, and it was sent for histopathologic analyses. The postoperative interval was uneventful.

GROSS FINDING We took the excised mass of the forehead, which completely measured 6.6  3.2  0.8 cm (Fig. 3). Its outer surface was well restricted, nodular, and irregular, with crowded vessels. On cutting it open, a gray-white mass with a spotted form, with an area of a hemorrhage, necrosis, and cystic alterations, was observed.

LIGHT MICROSCOPY

A 65-year-old male patient was referred to our clinic with a diagnosis of malign peripheral nerve sheets tumor that was excised

Multiple slices, which were explored, showed a well-demarcated tumor with hypercellular and hypocellular parts. The hypercellular parts were arranged in fascicles, sheets, and nodules. The specific tumor cells were spindle formed, with curly cores and buckling. The hypocellular parts were composed of large centers of necrosis with a standard palisading look and with myxoid extents. Focal regions of hemorrhage and necrosis were noticed. Multiple nerves like curls were also distinguished (Fig. 4A). The underlying muscle was free from tumor. An absolute histopathologic conclusion of a malignant soft tissue tumor, a malignant peripheral nerve sheet tumor,

FIGURE 1. Preoperative view of the patients.

FIGURE 3. Excised material.

CLINICAL REPORT

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© 2014 Mutaz B. Habal, MD

Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.

Late treatment of ocular globe displacement to the maxillary sinus after an orbital floor fracture.

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