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BACKGROUND: Craniofacial anomalies, although uncommon, can have considerable effects on the individual, their family and society.(1-4) They carry with them a large morbidity and require a highly specialized, multidisciplinary approach to treatment.(5) Facing the World (FTW), was founded in 2002, to offer facial reconstructive surgery to children with complex, craniofacial anomalies with no prospect of local treatment, from developing countries anywhere in the world. METHODS: We present an 8-year audit of the cases treated by FTW, where children are brought from their own countries to the UK for treatment. Patient selection takes place prior to their arrival in the UK by a multidisciplinary team. Specifically the condition has to be correctable to a degree that justifies the risks involved with the surgery, and the disruption to the child and their family. RESULTS: Since inception, FTW has evaluated more than 300 cases and provided treatment in the UK for over 24 cases from 18 different countries. We present our range of cases and complications. We discuss our complication rate of 28% and mortality rate of 4% (1 case). CONCLUSIONS: Key to the sustainability of FTW is the development of local healthcare infrastructure within the developing countries to facilitate eventual local management of the more straightforward cases and follow up of these patients by well-trained medical staff. By establishing these programs, FTW aims to not only change these children's lives but to raise awareness, and help to expand the global craniofacial network whereby in the future, satellite partners will be present to help manage these conditions locally. LEVEL OF EVIDENCE: III.

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Osseointegrated implant-fixated prostheses are useful for the reconstruction of the exenterated orbit. They provide good cosmesis, and are comfortable and light weight for the patient to wear. A retrospective review was performed of a series of twenty patients who had undergone orbital exenterations from 2003 to 2006, including complex cases with extraorbital and transcranial tumour excisions, nineteen of which were reconstructed with osseointegrated implant-fixated prostheses. For a successful outcome, decisions need to be made regarding the reconstruction of the orbital rim, periorbital soft tissues, indications for socket reconstruction and decisions regarding both one or two stage implantation and radiotherapy planning. Osseointegrated implants provide the optimal cosmetic and functional results in the rehabilitation of the exenterated orbit in our opinion. Close collaborative planning by both the surgeon and the prosthetist from the outset is essential.

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We present the case of a woman who had sustained pan-facial fractures in a road traffic accident 30 years previously, and describe the ensuing unusual problems with the orbital floor and maxillary sinus as a consequence of unrecognised misplacement of a dental periodontal dressing material into the sinus. The subsequent management is discussed.

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Since the first description of orbital blow-out fractures, there has been much confusion as to their aetiology. Two principal mechanisms have been proposed to explain these fractures, the buckling and hydraulic mechanisms, caused by trauma to the orbital rim and the globe of the eye, respectively. Previous experimental and clinical studies have aimed to support one or other of these two theories. However, these studies have failed to provide quantifiable data to objectively support their conclusions. We present the results of a study of these two proposed mechanisms under identical conditions, using quantifiable intraocular pressure, variable and quantifiable force, and quantifiable bone strain distribution with strain gauge analysis in fresh intact human post-mortem cadavers. Both qualitative and quantitative findings suggest that efforts to establish one theory over the other as the primary mechanism have been misplaced. Both mechanisms produce orbital floor fractures, although these fractures differ fundamentally in their size and location. We have objectively demonstrated that it is easier to fracture the orbital floor by the hydraulic mechanism than by the buckling mechanism, and provided quantitative data for the average force required to displace the orbital floor.

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This study set out to detect specific classes of potentially genotoxic aldehydes resulting from soybean-oil peroxidation in oil samples from 51 Trilucent implants in 26 patients and two factory-retained prostheses. The chemical analysis was performed independently of AEI inc. All of the implants showed evidence of shell deterioration suggestive of lipid absorption, and of lipid bleed throughout the implant shell. The mean implant weight loss was found to be almost 2% per year. Although none of the implants had actually ruptured in-situ, we identified specific problems with anterior and posterior patch delaminations, making the implant prone to rupture. Our data suggest that the soybean oil in all the explanted Trilucent implants and the two factory-retained prostheses had undergone peroxidation, yielding aldehyde by-products in millimolar concentrations. These concentrations are over 1000 times that thought to be potentially genotoxic. The clinical implications of these findings remain unclear. Capsular tissue was submitted to AEI Inc for histological and chemical analysis, but the data have not been forthcoming, which is disappointing as this may provide further evidence for the risks of long-term complications in these patients.

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Craniofacial units have a responsibility to collect data, to promote research and training and to carry out audit. We present a review of 114 consecutive transcranial procedures performed in 110 children in our unit over an 8 year period, with particular reference to complications. There were no deaths in this series. Complications included two cases of excessive intraoperative blood loss necessitating a delay in the procedure, and two postoperative infections that required aggressive antibiotic management. Minor complications, delaying hospital discharge, occurred in 13 patients. Within the range of paediatric transcranial procedures performed, the potential for complications is greater for complex osteotomies in syndromic conditions than for single sutural synostosis correction. The transcranial case mix included a relatively small number of craniofacial dysostoses, which contributes to the very low complication rate reported. This report demonstrates that multidisciplinary assessment and planning, adherence to craniofacial surgical principles, shorter operating times and avoidance of high-risk procedures contribute to a low complication rate, and confirms that paediatric transcranial procedures can be safely performed in dedicated centres where there is a multidisciplinary team with appropriate commitment and experience.

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