Khatib Baber, Cuddy Karl, Cheng Allen, Patel Ashish, Sim Felix, Amundson Melissa, Gelesko Savannah, Bui Tuan, Dierks Eric J, Bell R Bryan
Fellow, Advanced Craniomaxillofacial and Trauma Surgery/Head and Neck Oncologic and Microvascular Reconstructive Surgery, Department of Surgery, Legacy Emanuel Hospital, Portland, OR; Head and Neck Surgical Associates, Portland, OR.
Fellow, Advanced Craniomaxillofacial Surgery and Trauma, Legacy Emanuel Medical Center, The Head and Neck Institute, Portland, OR.
J Oral Maxillofac Surg. 2018 Mar;76(3):580-594. doi: 10.1016/j.joms.2017.10.017. Epub 2017 Oct 14.
Virtual surgical planning (VSP) is an indispensable aid in craniomaxillofacial reconstruction, yet no protocol is established in facial gunshot wounds. We review our experience with computer-aided reconstruction of self-inflicted facial gunshot wounds (SIGSW'S) and propose a protocol for the staged repair.
A retrospective case series enrolling patients with SIGSW's managed with the Functional Anatomic Computer Engineered Surgical protocol (FACES) was implemented. Subjects were evaluated at least one month postoperatively. Outcome variables were jaw position, facial projection, oro-nasal communication, lip competence, feeding tube and tracheostomy dependence, descriptive statistics were computed. The FACES protocol implemented during the initial hospitalization is as follows 1) damage control; 2) selective debridement; 3) VSP reconstruction back converted into navigation software 4) navigation assisted midfacial skeletal reconstruction; 5) computer aided oro-mandibular reconstruction with or without microvascular free flaps using custom cutting guides/hardware; 6) navigation assisted, computer aided palatomaxillary reconstruction with or without microvascular free flaps using cutting guides/hardware; 7) navigation assisted reconstruction of the internal orbit; 8) and confirmation of accurate reconstruction using intraoperative CT.
The sample was composed of 10 patients, mean age of 43 years (range, 28 - 62 years, 70% M), 100% with SIGSW's to the submental/submandibular region. All had satisfactory facial projection (n=10), nine had satisfactory jaw position, were decannulated by one month's follow up and were feeding tube independent (90%). All traumatic oro-antral communications were closed (n=8, 7 surgical, 1 obturator), seven had adequate lip competence (70%). Complications included fibula malunion (n=1), plate exposure (n=2) infection (n=2), intracranial abscess (n=1) and microstomia (n=2).
Computer-aided surgery is an indispensable tool in the reconstruction of SIGSW's. Successfully implemented, it proved to be a useful adjunct for: the restoration of orbital volume, facial projection and symmetry; the inset of composite tissue, and the facilitation of dental implant supported prosthetic rehabilitation.
虚拟手术规划（VSP）在颅颌面重建中是不可或缺的辅助手段，但面部枪伤尚无既定方案。我们回顾了计算机辅助重建自伤性面部枪伤（SIGSW）的经验，并提出了分期修复方案。
实施一项回顾性病例系列研究，纳入采用功能性解剖计算机工程手术方案（FACES）治疗的SIGSW患者。术后至少1个月对受试者进行评估。结果变量包括颌骨位置、面部突出度、口鼻相通情况、唇部功能、饲管和气管切开依赖情况，并计算描述性统计数据。初次住院期间实施的FACES方案如下：1）损害控制；2）选择性清创；3）将VSP重建转换回导航软件；4）导航辅助面中部骨骼重建；5）使用定制切割导板/硬件进行计算机辅助下颌骨重建，可带或不带游离微血管皮瓣；6）使用切割导板/硬件进行导航辅助、计算机辅助腭上颌重建，可带或不带游离微血管皮瓣；7）导航辅助眶内重建；8）术中CT确认准确重建。
样本包括10例患者，平均年龄43岁（范围28 - 62岁，70%为男性），100%为颏下/下颌下区域的SIGSW。所有患者面部突出度均令人满意（n = 10），9例颌骨位置满意，随访1个月时拔除气管套管，90%患者无需饲管。所有创伤性口鼻窦相通均已闭合（n = 8，7例手术闭合，1例使用闭孔器），7例唇部功能良好（70%）。并发症包括腓骨畸形愈合（n = 1）、钢板外露（n = 2）、感染（n = 2）、颅内脓肿（n = 1）和小口畸形（n = 2）。
计算机辅助手术是SIGSW重建中不可或缺的工具。成功实施后，它被证明是一种有用的辅助手段，可用于：恢复眶容积、面部突出度和对称性；复合组织植入；以及促进牙种植体支持的修复康复。
