Abstract
Importance
Reconstruction of the midface remains a challenging task for even the most experienced surgeon, with a host of reconstructive options including free tissue transfer, allografts, or prosthetic implants. Presented here is a case of idiopathic bony destruction of the right midface in a 19 year old female, creating a unique defect requiring repair.
Objective
Demonstrate a unique case of severe maxillary degeneration and discuss the associated reconstructive challenges and final repair with a prosthetic implant.
Design
Case report.
Results
The patient presented with a 7 month history of an idiopathic progressive deformity of the right cheek. Computed tomography of the paranasal sinuses revealed extensive bone loss of the right midface and orbit. The patient underwent facial reconstruction using a customized Medpor (Stryker Corp, Kalamazoo, MI) implant. At 6 month follow-up the patient and physician were both pleased with the patient’s overall appearance. The patient did have some residual lower lid retraction present as well as some lateral pull at the lateral canthus outward from the orbit itself.
Conclusions
Preoperative planning for midface reconstruction requires a deep understanding of the aesthetic, functional, and supportive roles this structure holds. Computer assistance allows the creation of custom made implants, providing the reconstructive surgeon with innovative options for reconstruction with minimal morbidity to the patient. As the technology around the design and creation of the custom implants continues to improve, the role of computer assistance in reconstruction will become more prominent.
1
Introduction
The structural, functional, and aesthetic complications of loss of midface support resulting from maxillary defects are uniquely devastating. Structurally and functionally the maxilla serves as the principal separation of the nasal and oral cavities, it constitutes the anterior orbital floor, provides resistance to the forces of mastication, and serves as an anchor to the upper dentition and facial muscles. Aesthetically, this unique bone provides facial contour giving an individual a unique appearance. The etiologies of such defects are varied ranging from trauma to neoplastic causes (1–2).
Currently, there are a number of options available for major maxillary reconstructions. These options include the usage of microvascular free tissue transfer, prosthetic implants, allograft transplants, and tissue engineering. Given this complexity, the approach for reconstruction is often dictated by each patient’s unique defect. Some authors advocate for osteomyocutaneous free tissue transfer as the gold standard for large defects. However, not every deficit necessitates such extensive surgery with its associated comorbidities. Unfortunately, no single reconstructive technique accomplishes the goals of fully returning the premorbid structural, functional, and aesthetic roles of the maxilla, and it benefits the reconstructive surgeon to seek out the most appropriate method of repair on a case by case basis. (1–4).
This report illustrates a case of idiopathic extensive bone loss of the right midface in a 19-year-old female. The associated reconstruction with a Medpor (Stryker Corp., Kalamazoo, MI) implant and reconstructive challenges are discussed.
2
Case report
A 19-year-old female with an unremarkable past medical history and no antecedent facial trauma presented with a depression of the right maxillary eminence progressing over a 7 month period. She reported facial asymmetry arising shortly after a right maxillary dental extraction for severe periodontal disease. Axial high-resolution (0.4 mm slice) non contrast computed tomography of the paranasal sinuses with coronal and sagittal reconstructed images and 3D reconstruction demonstrated extensive bony loss of the right midface including absence of lateral, anterior, and inferior right maxillary sinus walls. Imaging also revealed absence of the right inferior orbital rim from the infraorbital foramen to the zygomatic arch ( Figs. 1, 2 ). She underwent an endoscopic nasal exam with right maxillary sinus biopsy and biopsy of the remnant maxilla at our institution, which was consistent with chronic sinusitis and normal bone.
Initial differential diagnosis for an indolent fibro-osseous destructive processes capable of causing hemifacial atrophy included Wegener granulomatosis, localized scleroderma, and osteolytic syndromes such as Gorham Stout or Perry Rhomberg. Workup with the assistance of rheumatology consultation was ultimately nondiagnostic. A plain film of the chest did not reveal pulmonary nodules and erythrocyte sedimentation rate (ESR), C-reactive protein, anti -nuclear antibody (ANA), rheumatoid factor (RF), cytoplasmic anti-neutrophil cytoplasmic antibodies (cANCA), and perinuclear anti-neutrophil cytoplasmic antibodies (pANCA) were all within normal limits. Biopsy of a minor salivary gland from the right alveolus was significant only for mild chronic inflammation.
A plan was made to reconstruct and restore facial contour and the integrity of the inferior orbital rim using a custom made Medpor implant.
2.1
Reconstruction
A resin model of the patient’s facial skeleton was created ( Fig. 3 ). Design of the custom made facial implant is based on high resolution, thin cut, computed tomographic scans with 3-dimensional reconstructions. The level of asymmetry is assessed between the right and left sides of the maxilla. With the unaffected side defining the normal side, a software analysis is performed to create dimensions for a 3-dimensional Medpor implant ( Fig. 4 ). Using this method, Medpor implants can be created in an infinite number of ways to contour to a patient’s unique facial skeleton.
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