Case Report 4

(Malunion of Fractured Cheek Bone)
(Malar)

Figure 1 Figure 2 Patient referred 1 year following surgery (Craniofacial Injury - Road Traffic Accident) The Cheekbone (Malar) was incorrectly positioned. Nasal Bones are deviated to the patient's right side. Biomodel planning was not an established technique at time of initial surgery. A silastic implant, used to reconstruct the orbit, is extruding through the skin. Surgical Plan Mission Accurate Treatment Planning with Engineering Assisted Surgery™ Figure 3 Customised Positioning Jig® and Customised Orbit Biomodel Surgery Malar and nasal bones are sectioned and repositioned using a custom jig® Biomodel is reassembled in the correct anatomical position (Figure 5) Figure 4 Figure 5 Deformity Planned Position Normal contour of orbit achieved Malar has been lifted upwards and inwards  Figure 6 vertex view Note the correct anterior projection of malar the jig achieves precise anatomical position Figure 7 Simulation of Jig Positioning at Surgery Figure 8 Figure 9 Figure 10 Figure 11 Computer simulation of desired aesthetics Figure 11 Actual outcome 3 months post operation Technical Aspects of Surgery Surgery was carried (28th July 1998) out through an incision over the top of the head (bicoronal flap), through an old facial scar below the left orbit (eye socket), and through the mouth in a nine hour operation, filmed by ITN. No bone grafts were required. The stereoscopic model with attached bone plates, and cheekbone in the correct position, (figure 5), was sterilised as a single unit. To avoid any error of surgical judgment, the re-fractured cheek bone was correctly positioned using a metal jig® temporarily screwed onto the forehead during the operation. The orbit was reconstructed with a customised CNC engineered implant. The facial symmetry produced was within 0.5mm of the unaffected side, as measured on post operative x-rays. Post operative facial skeletal contour is now normal for this patient, and this is illustrated in Figure 11. Case Summary 1. Reconstruction stable @ 46 months (May 2002). 2. Major Surgery - with increased margins of safety / accuracy. 3. No second donor surgical site required to effect primary reconstruction. 4. Surgery time - 8 hours in the operating theatre. 5. No post operative intensive care required. 6. Enhanced rehabilitation - no bone grafting. 7. Unexplained restoration of sight in left eye (6/6 vision) 8. Good aesthetics related to skeletal contour 9. Residual weakness of facial nerve with paralysis of upper left eyelid, which could not close. 10. Lid paralysis treated with a gold weight implanted under the skin. (see patient comment below). 11. Significant Cost Savings for Purchasers of Health Care. Comment This patient's quality of life has been transformed by the introduction of precision engineering to a surgical procedure, and it is argued that as experience is gained in this technology, this method of treatment planning will become the Gold Standard. This technology has important implications with respect to "Duty of Care" and the reader is referred to our Medicolegal section, where this subject has been tested in litigation. Mpg file 474KB please wait - file below downloading...... Patient Comment @ 36 Months Note: Facial Nerve Paralysis (patient's left side) Gold weight insertion permits closure of the upper eyelid Further reading related to this case "Face of a Medical Miracle" © Photograph by permission of Reader's Digest by David Moller Readers Digest (U.K. Edition) August 2000