Single Staged Resections and 3-D Reconstructions of the Nasion/Glabella/ Medial Orbital Wall/Frontal Sinus and Bone: Long-Term Outcome and Review of the Literature Oregon Health and Science University; The Permanente Medical Group

Backround We present the long-term follow up, technical aspects of single staged resection and 3-D reconstruction of the nasion/glabela/medial orbital wall/ frontal sinus/bone and orbital roofs. We provide a detailed review of the literature looking at the different types of implants used in reconstruction, the benefits of single-stage approaches, and novel developments in craniofacial reconstruction using biopolymers. Advances in technology are allowing neurosurgeons unprecedented opportunities to design complex yet feasible craniofacial reconstructions that improve a patient’s quality of life by enhancing facial contours and symmetry.

Methods: Each patient underwent single staged resection and 3-D reconstruction of an osteoma involving the nasion/glabela/medial orbital wall/frontal sinus/bone and orbital roofs.. Pre-operative planning of resection and reconstruction was performed. Online interactive meetings were performed to plan the 3-D reconstructive implant made of polymethylmethacrylate (PMMA). The patients were assessed for the restoration of normal skull and skin contour, accuracy of intra operative bone juxtaposition, aesthetic results, complications and overall long-term outomes.

Results: The patients are 4 and 3 years post-operative, respectively. Excellent cosmetic outcomes, restoration of normal skull and skin contour has been achieved. The first patient had an intra operative lumbar drain placed for brain relaxation and tumor resection. This patient required a blood patch for low pressure headache after lumbar drain removal . No CSF rhinorrhea occurred. Subjective outcomes were communicated as excellent by the patients and their families. Objective outcomes were considered excellent when the implant rested passively on the surrounding bone. An implant graft with less than 2 mm gap from the bone was termed good while satisfactory was had less than 3mm gap and poor if the gap was greater than 3 mm. The first patient underwent bi-frontal craniectomy and resection of an osteoma involving the nasion/glabelar/frontal sinus and medial orbital wall. The second patient underwent combined endoscopic endonasal resection nd disconnection from the medial orbital wall as well as bi-frontal craniectomy and resection of extensive osteoma involving the frontal bone/sinus/nasion/glabela/medial orbital wall and cribiform.

Conclusion: Reconstruction of the nasion/glabela/frontal sinus/bone, medial orbital wall and orbital roofs are highly complex. In these patients a “masquerade mask” 3-D reconstruction was performed in each patient providing excellent fit, symmetry and patient satisfaction. These cases highlight the importance of pre operative planning. This single staged resection and 3-D reconstruction approach also obviated the need for further hospitalizations and operations as is the case with the two–staged approach. Single staged approach is more cost effective and avoids the psychological and physical effects of living with a craniectomy defect. It also avoids surgical risks of redo surgery among them infection, necrosis and bleeding.