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& Volume 25, Number 2, March 2014

2. Papadopoulos O, Konofaos P, Chrisostomidis C, et al. Nonmelanoma skin tumors involving the craniofacial region: our 22 years of experience. J Craniofac Surg 2007;18:1021Y1033 3. Menick FJ. Nasal reconstruction: forehead flap. Plast Reconstr Surg 2004;113:100Y111 4. Reece EM, Schaverien M, Rohrich RJ. The paramedian forehead flap: a dynamic anatomical vascular study verifying safety and clinical implications. Plast Reconstr Surg 2008;121:1956Y1963 5. Isik D, Faruk K, Isik Y, et al. Clinical outcomes of suture delay in forehead flap. J Craniofac Surg 2012;23:75Y77

FIGURE 4. Postoperative 1-year result.

flaps without the risk for distortion of important anatomic regions. When local flap options are not available or suitable, the best choice of regional reconstruction method is the forehead flap.1 The skin of the forehead has perfect color and tissue match with the nose, lips, as well as the medial canthal and malar regions. Paramedian forehead flap is widely accepted as the workhorse flap for nasal reconstruction.1Y3 The paramedian forehead flap is an axial flap that is perfused by the supratrochlear artery as major and the supraorbital artery as minor pedicle.4 Vertical paramedian flap length is limited with hairline. Obliquely oriented flap can be used to increase the length.5 In our case, local flaps from the malar region were not reliable because of a previously performed surgery. We preferred deepithelialized modification of paramedian forehead flap instead of standard fashion because of the thickness heterogeneity of the cavity. The distal portion of the flap was folded to fill the deeper caudal part of the defect. The fullthickness skin graft obtained from the flap was used to cover the defect. Thus, the cavitary defect was filled and no additional morbidity was formed for skin graft harvesting. Being a 2-stage procedure is the most important disadvantage of forehead flap. The perfect color and tissue match with the infraorbital region makes this disadvantage negligible. With our modification, a cavitary infraorbital defect could be reconstructed, preserving the contour of the cheek and also achieving color and tissue match. Cemil Ozerk Demiralp, MD Department of Plastic Reconstructive and Aesthetic Surgery Ataturk Training and Research Hospital Ankara, Turkey Duriye Deniz Demirseren, MD Department of Dermatology, Ataturk Training and Research Hospital, Ankara, Turkey Ersin Aksam, MD Department of Plastic Reconstructive and Aesthetic Surgery Ataturk Training and Research Hospital Ankara, Turkey [email protected] Candemir Ceran, MD Berrak Aksam, MD Mustafa Erol Demirseren, MD Department of Plastic Reconstructive and Aesthetic Surgery Ataturk Training and Research Hospital Ankara, Turkey

REFERENCES 1. Menick FJ. Defects of the nose, lip, and cheek: rebuilding the composite defect. Plast Reconstr Surg 2007;120:887Y898

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Reconstruction of Extensive Frontal Fracture With Titanium Mesh To the Editor: Frontal traumas correspond to 5% to 15% of all fractures from the maxillofacial complex and are frequently associated with neurologic lesions, orbital injuries, and other facial fractures.1Y3 The etiology of frontal fractures is based on high-impact traumas, such as vehicular and industrial accidents, and physical aggression.4 Patients traumatized in the frontal bone region may present lacerations, facial sinking,5 edema, laceration of the dura, and fistulation of the cerebrospinal fluid in more severe cases.6 The decision for surgical treatment is based on the protection and prevention of intracranial contents against ascending infections and the reestablishment of the facial superior contour.7Y10 The diagnosis consists of anamneses as well as clinical and ophthalmic examination to discard eye lesions.2 The image examinations by computed tomography are primordial for the visualization of the level of anatomic structures involvement.1,7 The classification of frontal bone fractures allows the surgeon to identify the level of anatomic structures commitment so that the correct treatment can be determined as soon as possible. The intervention must be precise to avoid postsurgical complications, such as ascending infections, bleeding, and/or cranialization.7 When fractures in this region are complex or comminuted and associated with loss of bone tissue, which may lead to considerable critical defects, the use of alloplastic materials, such as porous polyethylene,11,12 methacrylate orthopedic cement13 that fell in disuse, and titanium mesh, is necessary to anatomic reconstruction. The latter is malleable, simple to use, and biocompatible.14Y16 Hence, the aim of this study was to describe a case report of a patient traumatized in the frontal bone region, which resulted in a complex fracture with several bone tissue loss, leading to a greater aesthetic defect by loss of facial contour volume. The titanium mesh was chosen for patient rehabilitation, highlighting advantages with its clinical use.

CLINICAL REPORT A 51-year-old man was found unconscious next to a railway line in Andradina, Sao Paulo, and driven to the emergency room of Santa Casa de Miserico´rdia in Ara0atuba, Sao Paulo. According to the information collected, the patient was a victim of a physical attack with wood sticks and kicks. In the physical examination, the patient had a score of 3 in the Glasgow coma scale and absence of ocular opening as well as verbal and motor response was observed. Three-dimensional computed tomography for hard and soft tissues was performed, allowing the identification of a frontal sinus fracture extended to the temporal right region with displacement of the bone table, complex bilateral supraorbital fractures, and additional fractures in the nasal and maxillary region characterized by a half Le Fort I on * 2014 Mutaz B. Habal, MD

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

The Journal of Craniofacial Surgery

& Volume 25, Number 2, March 2014

the left side (Fig. 1). The help of the neurosurgeon team was requested, and the team diagnosed the fracture in the anterior wall, posterior sinus, and frontal sinus as well as subdural bleeding. Initially, the neurosurgeons performed a coronal incision, drained the subdural bleeding, and repaired the dura with polyglactin 910 suture and fibrin glue. Afterward, the team of bucomaxillofacial surgery and traumatology realized the fractures reduction and fixation of bone fragments. A pericranial flap was performed to obliterate the nasofrontal duct. The bone fragments were set with titanium mesh and screws (1.5-mm system). After the fixation, the region of supraorbital archs showed a greater aesthetic defect because of the complex fractures, not allowing the reconstruction with plates and screws. Hence, the team decided to use a titanium mesh (1.5-mm system), which was molded and reanatomized according to necessities. The mesh was fixed in the remaining frontal bone, in the orbital roof, and in the frontozygomatic suture, reestablishing immediately the harmonic contour of the face and supporting soft tissues, improving the aesthetics of the patient. A Portovac drain was inserted for edema and hematoma draining. Then, the reduction of the nasal fracture was conducted. The remaining fractures will be fixed in a second surgical time, after neurologic healing. Both in the immediate postsurgical time and 30 days of follow up, results of computed tomography showed the correct bone fragments and titanium mesh placement (Fig. 2). The neurologic and ophthalmological examinations confirmed that, because of the highintensity trauma in the ocular region, the patient presented amaurosis in both eyes.

DISCUSSION The high-intensity trauma of vehicular and industrial accidents and physical aggressions3 may cause frontal bone fractures, resulting in severe aesthetic defects by facial sinking, as described in this case report. To obtain a correct diagnosis, the three-dimensional computed tomography is extremely important because it will provide to the surgeon all the necessary information regarding the localization and extension of the fracture and additional fractures.9,17 The classification of frontal sinus fractures is based on isolated fractures in the anterior cortical bone with or without displacement, fractures of anterior and posterior table bones with or without displacement, isolated posterior fractures, and any fracture that affects the nasofrontal duct and results in the rupture of the dura associated with cerebrospinal fluid draining with or without subjacent brain lesion.4,5,7,18 With the information of the three-dimensional computed tomography and the identification of the type of fracture, the treatment should be based on the protection of the intracranial content against infections

FIGURE 1. Three-dimensional computed tomographic scans. A, An extensive frontal fracture extending to the right temporal region, complex bilateral supraorbital fracture, and nasal fracture can be observed. B, The complexity of fractures in the superior third of the face can be observed (inferosuperior view).

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FIGURE 2. Final three-dimensional computed tomographic scans showing the correct adaptation of the titanium mesh. A, Lateral view. B, Frontal view.

and promote the reestablishment of the facial superior contour.7Y10 According to Tiwari et al,19 when the nasofrontal duct is involved and its permeability is affected, the obliteration of the latter should be performed in association with the complete removal of the sinus mucosa. The cavity can be filled with pericranial flaps, bone graft free from adipose tissue, medullary autogenous bone, or muscles. This part of the treatment is performed to avoid postsurgical complications, which may occur just after the surgical intervention or afteryears. Manolidis and Hollier18 reported many levels of complications, such as pain, bleeding, sinusitis, meningitis, mucocele, and brain abscess. The aesthetic defect caused by the loss of bone integrity can be repaired with a titanium mesh, which is characterized as a good material for this application. Mara˜o et al,20 Mokal and Desai,15 and Zavattero et al14 showed the advantages of titanium mesh, such as easy manipulation and modeling, favorable stability with enough rigidity to maintain the tissues in position, thin, not reabsorbable, slightly susceptible to infections, able to drain internal liquids, growth of internal tissues, low inflammatory response, and a minimum of artifacts on the three-dimensional computed tomography, promoting an excellent frontal bone contour. Lazaridis et al16 reported 6 cases of facial fractures treated with titanium mesh and showed satisfactory results. These findings corroborate with the current study because the reconstruction of the frontal bone fracture and supraorbital margins was satisfactory with titanium mesh, which is easily modeled in the interested region, decreasing the surgical time and the costs for a healthy system.

CONCLUSIONS The interdisciplinarity in the treatment of patients with trauma is important because it creates a quick service for brain protection, preventing late complications and promoting the appropriate repair of anatomic structures, which can lead to aesthetics defects when lost by sinking, allowing the facial reconstruction because of the titanium mesh’s applicability and characteristics. Cristian Statkievicz, DDS Department of Surgery and Integrated Clinic, Universidade Estadual Paulista, Dental School of Aracatuba, Sa˜o Paulo, Brazil [email protected] Leonardo Perez Faverani, DDS, MSc Gabriel Ramalho-Ferreira, DDS, MSc Giovana Barbosa Francisconi, DDS, MSc Lamis Meorin Nogueira, DDS, MSc Sabrina Ferreira, DDS, MSc Idelmo Rangel Garcia Ju´nior, DDS, Msc Department of Surgery and Integrated Clinic, Universidade Estadual Paulista, Dental School of Aracatuba, Sa˜o Paulo, Brazil

* 2014 Mutaz B. Habal, MD

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

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REFERENCES 1. Molendijk J, Van Der Wal KG, Koudstaal MJ. Surgical treatment of frontal sinus fractures: the simple percutaneous reduction revised. Int J Oral Maxillofac Surg 2012;41:1192Y1194 2. Thiagarajan B. Fracture frontal bone and its management. Online J Otolaryngol 2013;3:1Y16. Available at: www.scopemed.org/?mno=34021. Accessed August 15, 2013 3. Piccolino P, Vetrano S, Mundula P, et al. Frontal bone fractures: new technique of closed reduction. J Craniofac Surg 2007;18:695Y698 4. Gerbino G, Roccia F, Benech A, et al. Analysis of 158 frontal sinus fractures: current surgical management and complications. J Craniomaxillofac Surg 2000;28:133Y139 5. Doonquah L, Brown P, Mullings W. Management of frontal sinus fractures. Oral Maxillofac Surg Clin North Am 2012;24:265Y274 6. Strong EB. Frontal sinus fractures: current concepts. Craniomaxillofac Trauma Reconstr 2009;2:161Y175 7. Ioannides C. Fractures of the frontal sinus: classification and its implications for surgical treatment. Am J Otolaryngol 1999;20:273Y280 8. Gabrielli MF, Gabrielli MA, Hochuli-Vieira E, et al. Immediate reconstruction of frontal sinus fractures: review of 26 cases. J Oral Maxillofac Surg 2004;62:582Y586 9. Bell RB. Management of frontal sinus fractures. Oral Maxillofac Surg Clin North Am 2009;21:227Y242 10. Jardim ECG, Santiago-Ju´nior JF, Guastaldi FPS, et al. Fratura do seio frontal: relato de caso. Revista Odontolo´gica de Ara0atuba 2010;31:35Y39 11. Gazio?lu N, Ulu MO, Ozlen F, et al. Acute traumatic orbital encephalocele related to orbital roof fracture: reconstruction by using porous polyethylene. Ulus Travma Acil Cerrahi Derg 2008;14:247Y252 12. Rubin PA, Bilyk JR, Shore JW. Orbital reconstruction using porous polyethylene sheets. Ophthalmology 1994;101:1697Y1708 13. Da Silva JJ, Neto RA, Pereira AM, et al. Fratura tardia de seio frontal: relato de caso clı´nico. Rev cir Traumatol buco-maxilo-fac 2005;5:51Y56 14. Zavattero E, Boffano P, Bianchi FA, et al. The use of titanium mesh for the reconstruction of defects of the anterior wall of the frontal sinus. J Craniofac Surg 2013;24:690Y691 15. Mokal NJ, Desai MF. Titanium mesh reconstruction of orbital roof fracture with traumatic encephalocele: a case report and review of literature. Craniomaxillofac Trauma Reconstr 2012;5:11Y18 16. Lazaridis N, Makos C, Iordanidis S, et al. The use of titanium mesh sheet in the fronto-zygomatico-orbital region. Case reports. Aust Dent J 1998;43:223Y228 17. Manson PN, Markowitz B, Mirvis S, et al. Toward CT-based facial fracture treatment. Plast Reconstr Surg 1990;85:202Y212 18. Manolidis S, Hollier LH Jr. Management of frontal sinus fractures. Plast Reconstr Surg 2007;120:32Y48 19. Tiwari P, Higuera S, Thornton J, et al. The management of frontal sinus fractures. J Oral Maxillofac Surg 2005;63: 1354Y1360 20. Mara˜o HF, Gulinelli JL, Pereira CC, et al. Use of titanium mesh for reconstruction of extensive defects in fronto-orbito-ethmoidal fracture. J Craniofac Surg 2010;21:748Y750

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in skull shape. The occurrence is È1 in 2100 to 2500 births, which makes it a fairly common pediatric anomaly.1,2 The most commonly involved suture seems to be the sagittal with male preponderance (3:1),3,4 but there is much less information about rarely expected synostotic patterns, such as closure of the squamosal suture.5,6 Two cases of nonsyndromic craniosynostosis were found in a late seventh- to eighth-century cemetery at Dunaszentgyo¨rgy-Kasza´sTanya of the so-called Avar population, situated in central Hungary.7 Anthropological examination and pathological observation were conducted on the fragmented remains. The interest of this presentation can be not only the presence of other pathological alterations on the skeletons and their possible linkage with cranial suture closure, but also even the rarity of archaeological infant findings with craniosynostosis.8 In the fragmentary skeletal remains of an infant, approximately 4 to 5 years of age, except the bregma area, whole fusion of the sagittal suture can be seen, whereas other sutures remain patent (Fig. 1). No signs of ridging, frontal bossing, or metabolic diseases were found on the strongly fragmentary remains, but signs of artificial cranial modification can be seen on the skull vault (Fig. 1). This practice was noted in the Carpathian Basin from as early as the second century9 to the eighth century,10 and several deformed crania had been excavated from cemeteries of the Avar population from the sixth to eighth centuries.10 The suggestion for the sutural effects of fronto-occipital cranial modification is based on the fact that the tensile forces created by the deforming apparatus can influence suture patency and cause a significantly higher incidence in sagittal suture closure.11 However, no significant literatures have given any additional confirmation to this theory yet, and the child in this case was at such a young age when, in our opinion, the slight modification did not explain the suture synostosis. In a moderately preserved remains of a 13- to 14-year-old child, the whole left temporal area was obliterated, including the squamosal, the sphenosquamosal and the parietomastoid sutures (Fig. 2). No signs of endocranial lesion, porotic hyperostosis, or enamel hypoplasia were observable on the skull, but there was significant deformity especially of the femur, which suggests disturbances in bone mineralization due to a possible inefficiency in vitamin D metabolism. Bending of the diaphysis of both femurs can be seen, with a remarkable difference in the diameter: the right femur was significantly more robust than the left one because of build-up of bone (Fig. 2). The pathological findings in this case suggest a link between craniosynostosis and the signs of some kind of metabolic disturbance, probably rickets disease. However, although most of the cases in clinical diagnoses report the preferential involvement of the

Two Suture Craniosynostoses: A Presentation That Needs to Be Noted To the Editor: Craniosynostosis is the premature fusion of the cranial sutures, which occurs in early childhood and can cause severe alterations in craniofacial development and even mental retardation, or can go almost unnoticed, causing only a slight deformity

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FIGURE 1. Sagittal synostosis with open coronal and lambdoid sutures and signs of artificial cranial modification on the frontal bone. The arrows show the presumed margins of the bandage used (Obj. nr. 349, S-355).

* 2014 Mutaz B. Habal, MD

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

Reconstruction of extensive frontal fracture with titanium mesh.

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