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Three-dimensional CT-guided custom implant for the repair of facial defects.

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A 28-year-old man presented with chief complaints of epiphora, intermittent medial canthal swelling and pain, a left lower lid deformity, and poor facial cosmesis. One year earlier, he had been treated for a left maxillary sinus tumor with a subtotal maxillectomy and rectus abdominis free flap to the left malar region.

Findings on physical examination included left lower eyelid vertical shortening, chemosis, keratitis, dacryocystitis, and cicatricial ectropion secondary to atrophy of the rectus abdominis flap with skin tethering (figure 1, A). The workup included dacryocystography, an ophthalmologic consultation, and three-dimensional computed tomography (CT). The patient underwent an open dacryocystorhinostomy, lateral canthoplasty, and reconstruction of the left maxilla with a customized three-dimensional CT-guided implant created to precisely match the left maxillary defect. The surgery was successful in resolving the patient's ophthalmic symptoms and significantly improving his facial cosmesis (figure 1, B).

The restoration of craniofacial defects continues to pose a significant challenge to reconstructive surgeons. However, the advent of customized implants based on three-dimensional CT has improved precision, accuracy, and cosmetic outcomes (figure 2). Current indications for the use of custom implants include large, full-thickness defects in the craniofacial skeleton secondary to trauma, oncologic resection, or congenital deformity. Custom implants have also been useful in cheek augmentation for patients suffering from facial lipodystrophy secondary to human immunodeficiency virus infection. Custom implants are particularly effective in treating defects secondary to traumatic injuries and congenital anomalies. (1)

Three-dimensional CT-guided implants allow for preoperative production of an implant that precisely represents the anatomic defect (figure 3). These customized implants decrease operative time because they eliminate the need to hand-carve implants. They also minimize the removal of healthy bone, reduce or eliminate the need for bone grafting, and promote effective planning of implantation while improving surgical accuracy (figure 4). Three-dimensional modeling also allows for improved symmetry with the contralateral anatomic subunit, thereby enhancing postoperative cosmesis. Available materials include high-density polyethylene, expanded polytetrafluoroethylene, silicone, and combination materials such as polymethyl methacrylate and polyhydroxyethylmethacrylate with a calcium hydroxide coating. Complications associated with custom implants include sensitivity reactions, peripheral neuropathy, migration, extrusion, implant fracture, infection, prominence of the implant in the late postoperative period, and the need for revision procedures. (1-4)

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Postoperative surveys of patients undergoing surgery with custom implants have shown high patient satisfaction. Patients have specifically commented that their implants remain stable in position after implantation and retain their original size and structure. They are also pleased with their aesthetic outcomes. (1,2)

Three-dimensional CT-guided customized implants have revolutionized craniofacial reconstruction by improving precision, accuracy, and cosmetic outcomes for restoring facial defects. This technique should be added to every reconstructive surgeon's armamentarium.

References

(1.) Binder WJ, Bloom DC. The use of custom-designed midfacial and submalar implants in the treatment of facial wasting syndrome. Arch Facial Plast Surg 2004;6(6):394-7.

(2.) Eppley BL. Craniofacial reconstruction with computer-generated HTR patient-matched implants: Use in primary bony tumor excision. J Craniofac Surg 2002;13(5):650-7.

(3.) Lee MY, Chang CC, Lin CC, et al. Custom implant design for patients with cranial defects. IEEE Eng Med Biol Mag 2002;21 (2):38-44.

(4.) van Steenberghe D, Glauser R, Blomback U, et al. A computed tomographic scan-derived customized surgical template and fixed prosthesis for flapless surgery and immediate loading of implants in fully edentulous maxillae: A prospective multicenter study. Clin Implant Dent Relat Res 2005;7(Suppl 1):S111-S120.

Michelle Levian, BS; Hootan Zandifar, MD; Ryan F. Osborne, MD; Jason S. Hamilton, MD

From the Center for Facial Plastic and Reconstructive Surgery, Osborne Head and Neck Institute, Los Angeles.
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Title Annotation:HEAD AND NECK CLINIC; computed tomography
Author:Levian, Michelle; Zandifar, Hootan; Osborne, Ryan F.; Hamilton, Jason S.
Publication:Ear, Nose and Throat Journal
Article Type:Case study
Geographic Code:1USA
Date:Aug 1, 2010
Words:602
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