Case Reports The Use of a Polyetheretherketone (PEEK) Implant to Reconstruct the Midface Region Rumana N. Hussain, M.B.B.S., M.A. Oxon., F.R.C.Ophth., Martin Clark, M.B.B.S., F.R.C.S., and Antonella Berry-Brincat, M.D., M.R.C.Ophth Abstract: A good functional and cosmetic result after midfacial reconstructive surgical procedures is of paramount importance. We describe the use of a Polyetheretherketone (PEEK) implant to reconstruct the midface area, after extensive mutilating surgery due to an infiltrative skin tumor. A 67-year-old male patient underwent multiple and extensive surgeries to the left cheek and lower lid because of a highly aggressive metatypical basal cell carcinoma. Complete resection of the recurrent tumor resulted in a cosmetically evident absent cheek contour and facial deformity. The PEEK implant was used to restore the bony cheek contour, with good aesthetic outcome and restoration of the facial symmetry. Preoperative planning with 3-dimensional CT scans allow for customization of the implant. PEEK implants have been scantily described in the periorbital region. The material has a very low reported morbidity and also has the advantage of improving intraoperative predictability and reducing surgical time in complex reconstructive procedures.
A
satisfactory cosmetic appearance is essential in midface reconstructions. The development of newer custom made computer-generated alloplastic implants mirroring the healthy side, have become more popular—not only by improving cosmesis but also by increasing predictability of outcomes and reducing surgical time and recovery.
CASE A 67-year-old male patient had undergone a complete excision of a lesion of his left cheek in 2009, the histology of which showed a metatypical basal cell carcinoma (BCC). A few years later, he developed a lower lid cicatricial ectropion with scar tissue inferiorly extending to the lateral canthus. The lid and cheek were firmly adherent to the underlying tissues and a punch biopsy revealed an infiltrative BCC. A subsequent CT showed involvement of the underlying bony structures. This necessitated the excision of the left cheek, lower eyelid, anterior maxilla, and anterior orbital floor. Reconstruction at the time involved a titanium plate to the orbital floor, a forearm skinfree flap as well as a Hughes flap. The histology of the excised tissues confirmed recurrence of the metatypical BCC invading the anterior maxillary wall into the sinus as well as extension to just below the orbital rim. Lymph node biopsies from the cervical region were also performed but these showed only reactive lymphoid hyperplasia. After the division of his Hughes flap, the patient had residual ptosis, lid hang up and lagophthalmos with 10-mm Lincoln County Hospital, Lincoln, United Kingdom Accepted for publication September 3, 2014. The authors have no financial or conflicts of interest to disclose. Address correspondence and reprint requests to Rumana Hussain, M.B.B.S., M.A. Oxon., F.R.C.Ophth., Department of ophthalmology, Leicester royal infirmary, Leicester LE1 5WW, United Kingdom. E-mail: [email protected] DOI: 10.1097/IOP.0000000000000345
Ophthal Plast Reconstr Surg, Vol. XX, No. XX, 2014
lower scleral show, but a good Bell’s phenomenon (Fig. 1A,B). In addition, he was left with marked facial deformity with loss of cheek volume (Fig. 1B). CT of the orbits and facial region with 3-dimensional (3D) reconstruction revealed the extent of bony loss (Fig. 1C). A Polyetheretherketone (PEEK) cheek implant was custom designed to recreate the zygomatic bone (Fig. 1D); the size and volume of the implant were similarly matched to the contralateral side based on the 3D images reconstruction (Fig. 1E–H). The implant was inserted under general anesthesia through an incision fashioned with a 10 blade along the free flap scar (Fig. 1I). A pocket within the zygomatic area was created by bluntly dissecting the tissues and exposing the underlying zygomatic bone remnant and periosteum, and the implant was placed within this pocket (Fig. 1I,J). Owing to the customized fit of the implant, there was no need for trimming or adjustment although the material could have been further shaped with a burr drill, if the need arose intraoperatively. Further manipulation is less easily done with a scalpel, as the material is hard and more difficult to cut. The maxillary remnant was less well exposed making it difficult to fix the PEEK implant to this end; the implant was therefore secured at 2 accessible points on the zygomatic bone remnants with 4 titanium screws (1.7 mm, Stryker) through two 2-hole straight titanium bone plates (Stryker). Owing to the smooth and impermeable nature of the implant, there was no need to presoak the implant in antibiotic solution. The previously inserted titanium plate to the orbital floor was left untouched and was not exposed. Closure of the cheek wound was with 4/0 vicryl (Polysorb Covieden) to the subcutaneous tissues and interrupted 5/0 nylon (Monosof Covieden) to the skin. A hard palate graft was harvested and a paramedian forehead flap was fashioned to reform his lower eyelid (Fig. 1J). Postoperatively, good contour and volume of the left midfacial region was evident, however, the lower lid flap developed an underlying hematoma and failed within a few days after surgery (Fig. 1K,L). He has subsequently undergone further surgery with a frickle flap and mucous membrane graft to augment his lower lid.
DISCUSSION PEEKs are a family of linear aromatic polymers containing ether and ketone linkages. The PEEK polymer is a semicrystalline material which has been advocated for a number of uses, predominantly to replace the use of other metal, ceramic, and plastic implants. The material has been promoted on the basis of robust qualities of strength, durability, resistance to a number of environmental insults, and the range of physical properties enabled.1 PEEK is classified as a high-performance engineering thermoplastic; its strength allows its use even to replace metallic implants, especially if reinforced with carbon fibres. Its strength withstands a wide range of temperatures and thereby a wide range of sterilization methods. The polymer has also shown resistance to radiation. A further advantage of these types of alloplastics over currently used alternative implant materials, are the enhanced properties of biocompatibility.2 The prostheses can be tailor made (CT imaging is utilized to match with the healthy contralateral side) resulting in a good cosmetic appearance. In addition, for the ongoing care of many patients, an important advantage is the lack of interference produced by these polymeric implants in all imaging modalities (CT, MRI). Although available since the 1980s, these biocompatible plastics have only recently been approved for use on a medical basis. It has been most studied in the field of orthopedics such as joint replacement surgery,3 but also for dental
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Copyright © 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc. Unauthorized reproduction of this article is prohibited.
Ophthal Plast Reconstr Surg, Vol. XX, No. XX, 2014
Case Reports
FIG. 1. A, Preoperative appearance showing marked left facial deformity with loss of cheek volume. B, Preoperative appearance showing extent of lagophthalmos and scleral show when eyelid closed. C, 3D CT image illustrating the outline of the orbital mesh in red and maxillary bone remnant in blue. D, Customized implant shape and structure before implantation. E, Superolateral 3D CT view showing the extent of the zygomatic/maxillary defect; the red outline illustrates the edge of the orbital floor mesh. F, Superolateral 3D CT view of the computer generated implant design superimposed on the defect. G, Frontal 3D CT view showing of the extent of the defect. H, Frontal 3D CT view of the computer generated implant design superimposed on the defect. I, Implant fitted into midfacial pocket prior being screwed to the neighboring bone. J, Intraoperative view with implant in situ and reformation of the left lower lid with paramedian forehead flap. K,L, Frontal and superolateral postoperative photos showing good facial contour and restoration of volume but a necrosed lower lid flap.
prostheses,4 (cranial vault reconstruction and cardiac implants (such as valves, pacemakers, or pumps).5 Their use has been scantily described in the orbital region including reconstructive surgery after orbital floor fractures and complex frontoorbital reconstructions.6,7 As far as we are aware, there has been only 1 report describing the use of this biosynthetic material in the maxillofacial region describing 2 cases of postsurgical unsatisfactory results following repair of trauma and long face syndrome.8 We describe a case of midfacial reconstruction after extensive soft tissue and bone excision because of a metatypical BCC. This is the first reported case of the use of a PEEK implant in the midfacial region after extensive surgery for a mutilating BCC affecting the cheek area. The reported case demonstrates the successful use of PEEK customized implants in complex maxillofacial and oculoplastic reconstructions. This alloplastic provides no interference to conventional radiological investigations, and if required, is able to withstand radiation therapy.2 Therefore, it not only gives a good cosmetic result, but it also
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does not interfere with the long-term care and follow-up of this patient after a diagnosis of metaplastic BCC. This method of 3D CT-guided customization of a PEEK implant allows reduced surgical time with very good aesthetic results and a more predictable surgical outcome in comparison to traditional implant methods. Certainly, further investigation is warranted with greater patient numbers and long-term followup to ascertain the implications of using such materials.
REFERENCES 1. May R. Polyetheretherketones. Encyclopedia of Polymer Science and Technology. New York: Wiley; 2008. 2. Williams DF, McNamara A, Turner RM. Potential of polyetheretherketone (PEEK) and carbon-fibre-reinforced PEEK in medical applications. J Mater Sci Lett 1987;6:188–190. 3. Kurtz SJ. PEEK Biomaterials in trauma, orthopedic, and spinal implants. Biomaterials 2007;28:4845–4869. 4. Schwitalla A, Müller W. PEEK dental implants: a review of the literature. J Oral Implantol 2013;13:743–749.
© 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
Copyright © 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc. Unauthorized reproduction of this article is prohibited.
Ophthal Plast Reconstr Surg, Vol. XX, No. XX, 2014
5. Camarini ET, Tomeh JK, Dias RR, da Silva EJ. Reconstruction of frontal bone using specific implant polyether-ether-ketone. J Craniofac Surg 2011;22:2205–2207. 6. Scolozzi P, Martinez A, Jaques B. Complex orbito-fronto-temporal reconstruction using computer-designed PEEK implant. J Craniofac Surg 2007;18:224–228.
Case Reports
7. Gerbino G, Bianchi F, Zavattero E, et al. Single-step resection and reconstruction using patient-specific implants in the treatment of benign cranio-orbital tumors. J Oral Maxillofac Surg 2013;7:1969–1982. 8. Scolozzi P. Maxillofacial reconstruction using polyetheretherketone patient-specific implants by “mirroring” computational planning. Aesthetic Plast Surg 2012;36:660–665.
© 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
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Copyright © 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc. Unauthorized reproduction of this article is prohibited.
A
satisfactory cosmetic appearance is essential in midface reconstructions. The development of newer custom made computer-generated alloplastic implants mirroring the healthy side, have become more popular—not only by improving cosmesis but also by increasing predictability of outcomes and reducing surgical time and recovery.
CASE A 67-year-old male patient had undergone a complete excision of a lesion of his left cheek in 2009, the histology of which showed a metatypical basal cell carcinoma (BCC). A few years later, he developed a lower lid cicatricial ectropion with scar tissue inferiorly extending to the lateral canthus. The lid and cheek were firmly adherent to the underlying tissues and a punch biopsy revealed an infiltrative BCC. A subsequent CT showed involvement of the underlying bony structures. This necessitated the excision of the left cheek, lower eyelid, anterior maxilla, and anterior orbital floor. Reconstruction at the time involved a titanium plate to the orbital floor, a forearm skinfree flap as well as a Hughes flap. The histology of the excised tissues confirmed recurrence of the metatypical BCC invading the anterior maxillary wall into the sinus as well as extension to just below the orbital rim. Lymph node biopsies from the cervical region were also performed but these showed only reactive lymphoid hyperplasia. After the division of his Hughes flap, the patient had residual ptosis, lid hang up and lagophthalmos with 10-mm Lincoln County Hospital, Lincoln, United Kingdom Accepted for publication September 3, 2014. The authors have no financial or conflicts of interest to disclose. Address correspondence and reprint requests to Rumana Hussain, M.B.B.S., M.A. Oxon., F.R.C.Ophth., Department of ophthalmology, Leicester royal infirmary, Leicester LE1 5WW, United Kingdom. E-mail: [email protected] DOI: 10.1097/IOP.0000000000000345
Ophthal Plast Reconstr Surg, Vol. XX, No. XX, 2014
lower scleral show, but a good Bell’s phenomenon (Fig. 1A,B). In addition, he was left with marked facial deformity with loss of cheek volume (Fig. 1B). CT of the orbits and facial region with 3-dimensional (3D) reconstruction revealed the extent of bony loss (Fig. 1C). A Polyetheretherketone (PEEK) cheek implant was custom designed to recreate the zygomatic bone (Fig. 1D); the size and volume of the implant were similarly matched to the contralateral side based on the 3D images reconstruction (Fig. 1E–H). The implant was inserted under general anesthesia through an incision fashioned with a 10 blade along the free flap scar (Fig. 1I). A pocket within the zygomatic area was created by bluntly dissecting the tissues and exposing the underlying zygomatic bone remnant and periosteum, and the implant was placed within this pocket (Fig. 1I,J). Owing to the customized fit of the implant, there was no need for trimming or adjustment although the material could have been further shaped with a burr drill, if the need arose intraoperatively. Further manipulation is less easily done with a scalpel, as the material is hard and more difficult to cut. The maxillary remnant was less well exposed making it difficult to fix the PEEK implant to this end; the implant was therefore secured at 2 accessible points on the zygomatic bone remnants with 4 titanium screws (1.7 mm, Stryker) through two 2-hole straight titanium bone plates (Stryker). Owing to the smooth and impermeable nature of the implant, there was no need to presoak the implant in antibiotic solution. The previously inserted titanium plate to the orbital floor was left untouched and was not exposed. Closure of the cheek wound was with 4/0 vicryl (Polysorb Covieden) to the subcutaneous tissues and interrupted 5/0 nylon (Monosof Covieden) to the skin. A hard palate graft was harvested and a paramedian forehead flap was fashioned to reform his lower eyelid (Fig. 1J). Postoperatively, good contour and volume of the left midfacial region was evident, however, the lower lid flap developed an underlying hematoma and failed within a few days after surgery (Fig. 1K,L). He has subsequently undergone further surgery with a frickle flap and mucous membrane graft to augment his lower lid.
DISCUSSION PEEKs are a family of linear aromatic polymers containing ether and ketone linkages. The PEEK polymer is a semicrystalline material which has been advocated for a number of uses, predominantly to replace the use of other metal, ceramic, and plastic implants. The material has been promoted on the basis of robust qualities of strength, durability, resistance to a number of environmental insults, and the range of physical properties enabled.1 PEEK is classified as a high-performance engineering thermoplastic; its strength allows its use even to replace metallic implants, especially if reinforced with carbon fibres. Its strength withstands a wide range of temperatures and thereby a wide range of sterilization methods. The polymer has also shown resistance to radiation. A further advantage of these types of alloplastics over currently used alternative implant materials, are the enhanced properties of biocompatibility.2 The prostheses can be tailor made (CT imaging is utilized to match with the healthy contralateral side) resulting in a good cosmetic appearance. In addition, for the ongoing care of many patients, an important advantage is the lack of interference produced by these polymeric implants in all imaging modalities (CT, MRI). Although available since the 1980s, these biocompatible plastics have only recently been approved for use on a medical basis. It has been most studied in the field of orthopedics such as joint replacement surgery,3 but also for dental
e1
Copyright © 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc. Unauthorized reproduction of this article is prohibited.
Ophthal Plast Reconstr Surg, Vol. XX, No. XX, 2014
Case Reports
FIG. 1. A, Preoperative appearance showing marked left facial deformity with loss of cheek volume. B, Preoperative appearance showing extent of lagophthalmos and scleral show when eyelid closed. C, 3D CT image illustrating the outline of the orbital mesh in red and maxillary bone remnant in blue. D, Customized implant shape and structure before implantation. E, Superolateral 3D CT view showing the extent of the zygomatic/maxillary defect; the red outline illustrates the edge of the orbital floor mesh. F, Superolateral 3D CT view of the computer generated implant design superimposed on the defect. G, Frontal 3D CT view showing of the extent of the defect. H, Frontal 3D CT view of the computer generated implant design superimposed on the defect. I, Implant fitted into midfacial pocket prior being screwed to the neighboring bone. J, Intraoperative view with implant in situ and reformation of the left lower lid with paramedian forehead flap. K,L, Frontal and superolateral postoperative photos showing good facial contour and restoration of volume but a necrosed lower lid flap.
prostheses,4 (cranial vault reconstruction and cardiac implants (such as valves, pacemakers, or pumps).5 Their use has been scantily described in the orbital region including reconstructive surgery after orbital floor fractures and complex frontoorbital reconstructions.6,7 As far as we are aware, there has been only 1 report describing the use of this biosynthetic material in the maxillofacial region describing 2 cases of postsurgical unsatisfactory results following repair of trauma and long face syndrome.8 We describe a case of midfacial reconstruction after extensive soft tissue and bone excision because of a metatypical BCC. This is the first reported case of the use of a PEEK implant in the midfacial region after extensive surgery for a mutilating BCC affecting the cheek area. The reported case demonstrates the successful use of PEEK customized implants in complex maxillofacial and oculoplastic reconstructions. This alloplastic provides no interference to conventional radiological investigations, and if required, is able to withstand radiation therapy.2 Therefore, it not only gives a good cosmetic result, but it also
e2
does not interfere with the long-term care and follow-up of this patient after a diagnosis of metaplastic BCC. This method of 3D CT-guided customization of a PEEK implant allows reduced surgical time with very good aesthetic results and a more predictable surgical outcome in comparison to traditional implant methods. Certainly, further investigation is warranted with greater patient numbers and long-term followup to ascertain the implications of using such materials.
REFERENCES 1. May R. Polyetheretherketones. Encyclopedia of Polymer Science and Technology. New York: Wiley; 2008. 2. Williams DF, McNamara A, Turner RM. Potential of polyetheretherketone (PEEK) and carbon-fibre-reinforced PEEK in medical applications. J Mater Sci Lett 1987;6:188–190. 3. Kurtz SJ. PEEK Biomaterials in trauma, orthopedic, and spinal implants. Biomaterials 2007;28:4845–4869. 4. Schwitalla A, Müller W. PEEK dental implants: a review of the literature. J Oral Implantol 2013;13:743–749.
© 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
Copyright © 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc. Unauthorized reproduction of this article is prohibited.
Ophthal Plast Reconstr Surg, Vol. XX, No. XX, 2014
5. Camarini ET, Tomeh JK, Dias RR, da Silva EJ. Reconstruction of frontal bone using specific implant polyether-ether-ketone. J Craniofac Surg 2011;22:2205–2207. 6. Scolozzi P, Martinez A, Jaques B. Complex orbito-fronto-temporal reconstruction using computer-designed PEEK implant. J Craniofac Surg 2007;18:224–228.
Case Reports
7. Gerbino G, Bianchi F, Zavattero E, et al. Single-step resection and reconstruction using patient-specific implants in the treatment of benign cranio-orbital tumors. J Oral Maxillofac Surg 2013;7:1969–1982. 8. Scolozzi P. Maxillofacial reconstruction using polyetheretherketone patient-specific implants by “mirroring” computational planning. Aesthetic Plast Surg 2012;36:660–665.
© 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
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Copyright © 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc. Unauthorized reproduction of this article is prohibited.
