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The care and the management of the healing of difficult wounds at the level of the skull-facial face many problems related to patient compliance and the need to perform multiple dressings, with long periods of healing and, occasionally, a very long hospitalisation period. The introduction and evolution of negative pressure wound therapy (NPWT) in the treatment of difficult wounds has resulted in better healing, with a drastic reduction in terms of time and biological costs to the patient and cost to the health care system. The main aim of this study is to describe and discuss, using out our experience, the usefulness of NPWT in the cranial-facial-cervical region. We studied 16 patients with complex wounds of the cranial-facial-cervical region treated with NPWT. We divided clinical cases in four groups: cervicofacial infectious disease, healing complications in oncological-reconstructive surgery, healing complications of injury with exposure of bone and/or internal fixations and healing complications in traumatic injury with loss of substance. We evaluated complete or incomplete wound healing; application time, related also to hospitalisation time; days of intensive care unit (ICU) stay; management of the upper airways; timing of medication renewal; and patient comfort and compliance (on a scale of 1-5). Depression values were always between -75 and -125 mmHg in a continuous aspiration pattern. For every patient, we used the ActiVAC Therapy Unit, derived from the vacuum-assisted closure system (Kinetic Concepts Inc., San Antonio, TX). Medication renewals were performed every 48-72 hours. The NPWT application time ranged from 4 to 22 days (mean of 11·57 day). Therapy was effective to gain a complete restitutio ad integrum in every patient included in the group of cervicofacial infectious disease. Therapy has, however, been well tolerated in our series; this is probably due to the decreased number of applications, the ease of use and the comfort of the system relative to traditional dressing. Results were satisfactory for most of cases treated; faster and more effective wound healing was achieved. The lower number of NPWT applications, relating to standard dressings, led to an increase in patient comfort and compliance and a decrease in the use of medical, and in some cases economic, resources according to international literature.

Background: The aim of this study was to achieve a consensus on the minimum set of outcome measures and predictors to be used in the neurosurgical practice and on the timing of outcome assessment. Methods: A consensus building approach was employed. All neurosurgical departments in Lombardy (Italy) were invited to participate by the Carlo Besta Neurologic Institute IRCCS Foundation. Three workshops were organized during which a multidisciplinary group called Neurosurgical Outcome Network (NEON) was created and the methodology to select outcome measures, predictors, and timing of outcome assessment was established. Eight working groups were created for the different neurosurgical diseases (neuro-oncological, skull base, vascular, traumatic, spinal, peripheral nervous system, malformation, functional) and 8 workshops were organized to identify the outcome measures and predictors specific for each of the neurosurgical diseases based on the experts' clinical practice and the existing literature. Results: A total of 20 neurosurgical departments participated in this study. Specific outcome measures, predictors and the timing of outcome assessment were identified for each of the 8 neurosurgical diseases. Moreover, a list of variables common to all pathologies were identified by the NEON group as further data to be collected. Conclusions: A consensus on the minimum set of outcome measures and predictors and the timing of outcome assessments for 8 neurosurgical diseases was achieved by a group of neurosurgeons of the Lombardy region, called NEON. These sets could be used in future studies for a more homogeneous data collection and as a starting point to reach further agreement also at national and international level.

Cephalohematoma is a subperiosteal collection of blood above the skull. It is associated with operative and prolonged deliveries. In most cases the hematoma spontaneously resolves in a short span of time, usually within one month. In a few cases cephalohematoma can become ossified and require surgical treatment. Traditional belief that ossified cephalohematomas are an exclusively cosmetic issue has been called into question by recent description of EEG anomalies associated to a calcified cephalohematoma. We review relevant surgical literature, and we describe a novel variant of Wong's Radial Cap technique by foregoing healthy bone margin removal, removing the cephalohematoma lamellae in a stepwise fashion and using resorbable plaques for fixation. We furthermore review the rationale, timing and step-by-step execution of the procedure. An exemplary case description is discussed.

Supplemental Digital Content is available in the text., Background: It is anticipated that in due course the burden of emergency care due to COVID-19 infected patients will reduce sufficiently to permit elective surgical procedures to recommence. Prioritizing cleft/craniofacial surgery in the already overloaded medical system will then become an issue. The European Cleft Palate Craniofacial Association, together with the European Cleft and Craniofacial Initiative for Equality in Care, performed a brief survey to capture a current snapshot during a rapidly evolving pandemic. Methods: A questionnaire was sent to the 2242 participants who attended 1 of 3 recent international cleft/craniofacial meetings. Results: The respondents indicated that children with Robin sequence who were not responding to nonsurgical options should be treated as emergency cases. Over 70% of the respondents indicated that palate repair should be performed before the age of 15 months, an additional 22% stating the same be performed by 18 months. Placement of middle ear tubes, primary cleft lip surgery, alveolar bone grafting, and velopharyngeal insufficiency surgery also need prioritization. Children with craniofacial conditions such as craniosynostosis and increased intracranial pressure need immediate care, whilst children with craniosynostosis and associated obstructive sleep apnea syndrome or proptosis need surgical care within 3 months of the typical timing. Craniosynostosis without signs of increased intracranial pressure needs correction before the age of 18 months. Conclusions: This survey indicates several areas of cleft and craniofacial conditions that need prioritization, but also certain areas where intervention is less urgent. We acknowledge that there will be differences in the post COVID-19 response according to circumstances and policies in individual countries.

At the time of writing there is no measuring scale for the severity of facial trauma that can effectively summarize its clinical relevance, and can therefore be proposed as a definitive tool in trauma center decision making. This paper introduces a new, simple, comprehensive, and reproducible score for facial trauma, in which its severity is expressed in relation to the surgical duration necessary for definitive treatment. This parameter is identified as the most significant in expressing the commitment of care required. Statistical validation of this comprehensive facial injury (CFI) score involved a sample of 1050 patients, treated by the same team in two highly specialized trauma centers. It demonstrated a linear regression between CFI score and surgical duration, and a high degree of accuracy in forecasting overall surgical time for each type of facial injury. The descriptive capacity of CFI score, and its extremely simple use, make it a perfect tool for widespread application and for facilitating communication inside trauma centers. It also allows the classification of homogeneous groups of patients - a prerequisite for benchmarking and effective analysis of results. The CFI model is definitively proposed for the classification of facial injuries, and therefore for the integration of maxillofacial skills, within the trauma team.

Background We present a case of almost complete bifrontal dural ossification after decompressive craniectomy for severe traumatic brain injury. Case description A 6-year-old boy was brought to the emergency room after a severe traumatic brain injury (Glasgow Coma Scale/Score 7). Due to rapidly increasing intracranial pressure values (>20 mm Hg) refractory to conservative therapy and in the absence of focal lesions justifying the neurological status, a bicoronal decompressive craniectomy was performed. The patient underwent reconstructive bifrontal cranioplasty with autologous bone 110 days after surgery. Preoperative computed tomography scans showed an abnormal hyperdense layer surrounding both frontal lobes. During the procedure, widespread islets of eggshell-shaped bony tissue were found covering the pericranium and the dura mater. They were laboriously removed from the underlying tissues. Two months later computed tomography scans did not show evidence of calcification at the level of the frontal lobes or signs of bone reabsorption or epidural collections. Conclusions We focus on the clinical implications of this phenomenon, in terms of its surgical management and how it may influence the timing of cranioplasty. Furthermore, we discuss the main pathophysiologic models described in the literature.

Purpose: Autogenous bone represents the best material in pediatric reconstructive cranioplasty because of its compatibility with growth; however, its availability is limited. Alternative use of alloplastic materials would have the advantage of unlimited amount, but shows an increased risk of complications and incompatibility with growth. Fresh frozen banked cadaveric bones could be ideal for the reconstruction of large cranial defects in growing patients, because it offers unlimited amount of structural grafts with biomechanics properties quite similar to the autologous bones. Results: The authors report 2 cases of growing patients (13 months female and 9 years old male) undergoing the reconstruction of large (about 70 cm2 and 50 cm2 respectively) cranial vault defects, by using structural homologous banked bone grafts. Analytic main reconstruction materials risks/benefits evaluation, literature review of few previously reported pediatric cranioplasty with homologous bone, and both clinical cases satisfactory radiologic long-term results (beyond 4 years of F.U.) are reported. Conclusion: Structural homologous banked bone grafts appear as a valid solution for pediatric canioplasty reconstruction of wide defects, entailing the advantages of available without limitations and compatibility with future growth. The risk of transmissible infections seems minimal and is totally counterbalanced by the stability of long-term results.

Aim: Comparison of the long-term follow-up until the completion of growth of two homogeneous samples of children affected by hemifacial microsomia (HFM), one treated by mandibular distraction osteogenesis (DO) in the deciduous or early mixed dentition, the other not subjected to any treatment until adulthood. Material: Fourteen patients affected by vertically severe type I or II HFM were operated at an average age of 5.9 years with an average follow-up of 11.2 years. They were compared to a sample of eight patients who were never treated until the completion of growth. Methods: Mandibular vertical changes were measured on panoramic radiographs taken at different time points. Ratios between affected and non affected ramal heights were calculated and compared. Results: In the DO sample, after correction, mandibular vertical changes showed a gradual return of the asymmetry with growth in all patients. The ratio in the non treated sample was unchanged between the initial and the long term panoramic x-rays. Conclusion: The facial proportions of HFM patients are maintained, when not treated, throughout growth. The same proportions return to their original asymmetry after DO. Even though short term aesthetic and psychological advantages of distraction osteogenesis are well accepted, early surgery should only be applied after careful patient selection and honest clarification of the long term recurrence by genetically guided craniofacial growth pattern. © 2011 European Association for Cranio-Maxillo-Facial Surgery.

Summary Background Maxillary distraction osteogenesis (DO) in cleft lip and palate patients has been described by several authors, but most studies have a relatively short follow-up and do not clearly separate growing patients from non-growing patients. Method The records of 22 consecutive patients affected by cleft lip and palate, who underwent Le Fort I osteotomy and maxillary distraction with a rigid external distractor (RED), were reviewed. The sample was subdivided into a growing and a non-growing group. All patients had pre-DO cephalometric records, immediately post DO, 12 months post DO and long-term records with a long-term follow-up of >5 years (range 5–13 years). As a control sample for the growing group, cleft children with a negative overjet not subjected to distraction or any protraction treatment during growth were followed up until the completion of growth. Results The average maxillary advancement in the growing group was 22.2 ± 5.5 mm (range: 15–32 mm); in the non-growing group, it was 17.7 ± 6.6 mm (range: 6–25 mm). Excellent post-surgical stability was recorded in the adult sample. On the other hand, growing children had an average 16% relapse in the first year post DO and an additional 26% relapse in the long-term follow-up. Conclusions This study seems to point out that early Le Fort I DO allows for the correction of very severe deformities. It is followed by a relatively high amount of true skeletal relapse in children with cleft lip and palate. Prognosis should be discussed in depth with the family and true aesthetic and psychological needs assessed.

Purpose Correction of post traumatic orbital and zygomatic deformity is a challenge for maxillofacial surgeons. Integration of different technologies, such as software planning, surgical navigation and stereolithographic models, opens new horizons in terms of the surgeons' ability to tailor reconstruction to individual patients. The purpose of this study was to analyze surgical results, in order to verify the suitability, effectiveness and reproducibility of this new protocol. Methods Eleven patients were included in the study. Inclusion criteria were: unilateral orbital pathology; associated diplopia and enophthalmos or exophthalmos, and zygomatic deformities. Syndromic patients were excluded. Pre-surgical planning was performed with iPlan 3.0 CMF software and we used Vector Vision II (BrainLab, Feldkirchen, Germany) for surgical navigation. We used 1:1 skull stereolithographic models for all the patients. Orbital reconstructions were performed with a titanium orbital mesh. The results refer to: correction of the deformities, exophthalmos, enophthalmos and diplopia; correspondence between reconstruction mesh positioning and preoperative planning mirroring; and the difference between the reconstructed orbital volume and the healthy orbital volume. Results Correspondence between the post-operative reconstruction mesh position and the presurgical virtual planning has an average margin of error of less than 1.3 mm. In terms of en- and exophthalmos corrections, we have always had an adequate clinical outcome with a significant change in the projection of the eyeball. In all cases treated, there was a complete resolution of diplopia. The calculation of orbital volume highlighted that the volume of the reconstructed orbit, in most cases, was equal to the healthy orbital volume, with a positive or negative variation of less than 1 cm3. Conclusion The proposed protocol incorporates all the latest technologies to plan the virtual reconstruction surgery in detail. The results obtained from our experience are very encouraging and lead us to pursue this path.

Summary Background There is very few information regarding pain after craniotomy in children. Objectives This multicentre observational study assessed the incidence of pain after major craniotomy in children. Methods After IRB approval, 213 infants and children who were

Background: Midface distraction osteogenesis (DO) in craniofacial synostosis (CFS) patients has been described by several authors. However, very few cephalometric and computed tomography (CT) long-term follow-up studies are available. Method: A total of 40 consecutive patients affected by CFS subjected to Le Fort III and rigid external distraction (RED) were examined. All patients had pre-DO cephalometric records, immediately post-DO and 6-12 months post-DO. Twenty-seven patients had mid-term records (3 years post-DO) and 20 patients had long-term records (5-10 years post-DO). Fourteen patients had CT data within 1-year of DO, while 10 patients had long-term CT data (range 5-9 years). Results: Excellent post-surgical stability was recorded. Short- and long-term CT data demonstrated excellent ossification at the osteotomy sites post-DO. In the growing patients, surface resorption in the zygomatic-temporal and in the subspinal area (p < 0.05) was observed in the long-term follow-up, as well as a mild increment of the corrected exorbitism (p < 0.05), as only appositional and no sutural growth occurs post Le Fort III, whereby orbital volume does not increase after surgery. Conclusion: Significant advancement of the midface can be achieved and maintained through Le Fort III and RED. In the long term, in growing patients, in general a class III malocclusion does not re-occur, but physiological remodelling processes at the maxillary-zygomatic level, not coupled with sutural growth, tend to mildly re-express the original midfacial phenotype and the exorbitism. © 2011 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

An essential step in the navigation procedure is the recording of markers required for the triangulation of the intraoperative navigation system. The aim of this study was to describe the procedure and preliminary results of a simple methodology for the application of dental markers to achieve good triangulation of the navigation system in maxillofacial surgery, highlighting the indications, contraindications, and possible limitations. We analyzed results from a sample of 7 patients with orbital or orbitozygomatic fractures, who were subjected to surgical intervention for the reduction and synthesis of the zygomatic fracture and from 1 case of untreated orbital fracture with enophthalmos and diplopia. We used 2 different types of dental markers: in 3 patients, we used 4 or 5 ordinary orthodontic brackets, which we placed on their upper maxillary teeth, and in 1 patient, the hexagonal-headed screws used in osteosynthesis. The accuracy of the recording was assessed during surgery by checking healthy anatomic structures against computed tomographic images. By analyzing our clinical results in light of the most recent literature, we highlighted that the application of dental markers is comparable with the best recording systems requiring a discrepancy of less than 1 mm. From the preliminary clinical analysis of the results, we confirm that the introduction of this new and simple procedure enables the successful triangulation of the navigation system, which can be used whenever the use of a navigator is required.

Bilateral cleft lip and palate patients may present a vertical excess of the premaxilla, which is a severe aesthetic and functional problem. Early surgical correction may lead to secondary growth impairment. We present a suggested protocol based on the severity of the vertical excess and on the age of the patient, which includes orthopedic, orthodontic, and surgical corrections. Patients are presented to elucidate each different approach.

Aim The aim of this study is to analyze the transconjunctival approach in the treatment of orbital fractures and to evaluate the indications, the advantages of the surgical approach, and the occurrence of possible complications. Materials and methods From 2005 to September 2009 we used a transconjunctival approach on 53 patients for a total of 56 cases of orbital fractures (three cases with bilateral floor fractures), 54 cases of acute trauma, and two outcomes of previous fractures. We evaluated the incidence of intra or postoperative complications and in the postoperative follow-up we investigated the presence of: entropion, ectropion, scleral show, trichiasis, conjunctival granuloma, mobilization or exposure of orbital reconstruction material. Results In 56 cases we had four temporary postoperative complications and no long-term complications; two cases of trichiasis and two cases of partial entropion were treated only with medical therapy. All complications, as described in the literature, were transitory and did not require corrective surgery. Conclusion The transconjunctival approach is the most effective surgical access, not only to the medial orbital wall, but also to the orbital floor, as it does not interfere with the lachrymal drainage system and gives as wide a visualization of the orbital floor as does the palpebral approach. This surgical approach is simple to perform and gives good functional and aesthetic results.

Summary Aim After mandibular unilateral distraction osteogenesis (DO) a gradual reappearance of the vertical asymmetry during growth is observed. A pre- and post-surgical functional-orthodontic treatment was added to our distraction protocol in the attempt to increase long-term stability. In order to evaluate the actual efficacy of such a combined treatment, two samples of children affected by hemifacial microsomia were compared long-term. Material Ten children were treated by a combined orthodontic–distraction treatment, seven by distraction only. Method Only the vertical changes in the mandible and maxilla in the panoramic and postero-anterior cephalometric X-rays were measured. Results All of the patients showed a gradual return of the asymmetry with growth. Occlusal plane correction and, to a much lesser extent, mandibular vertical ramus height correction were better maintained over 5 years post-DO in the orthopaedic group. Conclusion Although orthopaedic treatment allows for a more stable occlusal plane and for a slower return of the mandibular vertical asymmetry, it has mainly a dento-alveolar effect. Therefore, the decision of applying an orthopaedic treatment associated with distraction, should be taken by surgeon and orthodontist together, considering both the advantages and the disadvantages of this treatment.

This is a longitudinal cephalometric study of patients with craniofacial synostosis (Crouzon's and Apert's) syndromes who underwent Le Fort III advancement during early childhood. The objectives of the study were to quantify presurgical growth, surgical results, and surgical stability as well as long-term postsurgical growth. Of the 31 patients operated on during their growth period (less than 10 years of age), 17 had sufficient records to be included in the study: at infancy, before the Le Fort III osteotomy (average age=7.3 years, range: 4.8-10 years), and immediately after surgery. Ten of the patients were followed radiographically long term for an average of 6.1+/-2.7 years (range: 4.5-10.8 years). The presurgical abnormal midfacial vertical growth pattern was accurately described with a progressive class III discrepancy and an increasing exophthalmos. Remarkable postoperative stability of the maxillary segment was observed. After surgery, growth of the midface was measured, together with minimal, if any, anterior growth, similar to the presurgical growth pattern and rate. No actual detrimental or beneficial effect of surgery on subsequent growth was seen. This study quantitatively confirms that the standard Le Fort III osteotomy is a stable and effective but generally not definitive procedure in childhood. This study might also serve as a control sample to compare with groups of patients undergoing distraction osteogenesis to verify the actual advantages and shortcomings of this alternative technique.

Summary Aim Prospective, longitudinal, clinical long-term follow-up study of a homogeneous sample of children affected by hemifacial microsomia and treated by mandibular distraction osteogenesis. Material Eight patients affected by types I and II hemifacial microsomia were operated on at an average age of 5.6 years with an average follow-up of 5.8 years. Methods Vertical changes were measured on postero-anterior cephalometric and panoramic radiographs taken sequentially. Results Angular changes of the infraorbital and nasal floor planes were not significant, showing that distraction osteogenesis starting after 5 years of age did not influence the maxillary skeletal base. Occlusal (plane) cant was reduced by 7° on average following distraction osteogenesis, showing good dentoalveolar plasticity. Mandibular vertical changes showed a gradual return of the asymmetry, with growth in all patients (the ratio between affected and non-affected rami returned by 77% of the correction obtained by means of distraction 5 years postoperatively). Conclusion Although aesthetic and psychological advantages of distraction osteogenesis are well accepted it should only be applied after careful patient selection and honest explanation of the long-term recurrence by genetically determined craniofacial growth patterns.