The Journal of Craniofacial Surgery
& Volume 25, Number 1, January 2014
The infection of the hematoma was a potential complication that could have led to a worsening of the case.27Y29 There were 2 reasons for the decision to drain the hematoma: the first was due to the continuous and gradual expansion of the hematoma,24 and the second was the potential risk of hematoma infection due to wound contamination.27Y29 The assessment of vascular lesions must be present in the initial care of patients with facial trauma and should be part of the routine of specialized trauma centers. Immediate and late complications of vascular lesions may put the patient in life-threatening situations and therefore should be diagnosed and treated as soon as possible. In this case, at the time of admission, the patient presented major respiratory distress requiring a surgical airway for life support. This case report demonstrates the importance of an accurate analysis of local vascularization.3 This analysis is critical and serves as a guide for the safe execution of the proposed treatment.30
CONCLUSIONS The authors presented a case of a huge hematoma of the tongue due to a stab wound and lingual artery injury. The bleeding lingual artery formed an expansive hematoma, which evolved into a high tongue and upper airway obstruction. The patient was initially treated with tracheotomy, followed by surgery for lingual artery ligation and drainage of the sublingual hematoma, using the findings of CT angiography as a surgical guide. The authors conclude that the surgical technique was an effective method of treatment and quite safe when driven by a precise analysis of the local circulation by CT angiography. Although rare, cases of lingual artery injury showing a similar trend can be resolved by this technique, which combines the advantages of a safe surgery, fast resolution of the case, and minimal complications. The authors argue that the demand for vascular lesions should be routine in patients who have facial trauma, and the assistant surgeon should be prepared for the correct diagnosis and treatment of these lesions.
REFERENCES 1. Offiah C, Hall E. Imaging assessment of penetrating injury of the neck and face. Insights Imaging 2012;3:419Y431 2. Mawaddah A, Goh BS, Kew TY, et al. Isolated blunt lingual artery injury secondary to a road traffic accident: diagnostic and therapeutic approach. Malays J Med Sci 2012;19:77Y81 3. Ribeiro ALR, Junior SMA, Pinheiro JJV. Traumatic pseudoaneurysm of the facial artery: late complication and effects on local blood flow. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2011;112:e4Ye9 4. Macpherson AK, Schull MJ. Penetrating trauma in Ontario emergency departments: a population-based study. Can J Emerg Med 2007;9:16Y20 5. Ribeiro AL, de Vasconcellos HG, Pinheiro JJ. Unusual fishing harpoon injury of the maxillofacial region in a child. Oral Maxillofac Surg 2009;13:243Y246 6. Homze EJ, Harn SD, Bavitz BJ. Extraoral ligation of the lingual artery: an anatomic study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1997;83:321Y324 7. Burke RH, Masch GL. Lingual artery hemorrhage. Oral Surg Oral Med Oral Pathol 1986;62:258Y261 8. Hing NR, Bowler MD, Byth PL, et al. Lingual haematoma leading to upper airway obstruction. Br J Oral Maxillofac Surg 1985;23:313Y321 9. van As AB, van Deurzen DF, Verleisdonk EJ. Gunshots to the neck: selective angiography as part of conservative management. Injury 2002;33:453Y456 10. Sagar S, Kumar N, Singhal M, et al. A rare case of life-threatening penetrating oropharyngeal trauma caused by toothcrush in a child. J Indian Soc Pedod Prev Dent 2010;28:134Y136 11. Meer M, Siddiqi A, Morkel JA, et al. Knife inflicted penetrating injuries of the maxillofacial region: a descriptive, record-based study. Injury 2010;41:77Y81
Brief Clinical Studies
12. Assenza M, Centonze L, Valesini L, et al. Traumatic subclavian arterial rupture: a case report and review of literature. World J Emerg Surg 2012;7:1Y6 13. Kaynar AM, Bhavani-Shankar K, Mushlin PS. Lingual hematoma as a potential cause of upper airway obstruction. Anesth Analg 1999;89:1573Y1575 14. Kattan B, Snyder HS. Lingual artery hematoma resulting in upper airway obstruction. J Emerg Med 1991;9:421Y424 15. DuBrul EL. Sicher and DuBrul’s Oral anatomy. 8th ed. Tokyo and New York: Ishiyaku Euro America, 1998 16. Mepani VN, Antscherl J. A tricky tracheotomy: airway management dilemma following unusual stab injury to the mouth. Ann R Coll Surg Engl 2012;94:e28Ye29 17. Lahiri S, Ghosh S, Sengupta G, et al. An unusual presentation of foreign body in the common carotid artery. Indian J Surg 2011;73:460Y462 18. Shaw RJ, McNaughton GW. Emergency airway management in a case of lingual haematoma. Emerg Med J 2001;18:408Y409 19. Song Z, Laggan B, Parulis A. Lingual hematoma treatment rationales: a case report. J Oral Maxillofac Surg 2008;66:535Y539 20. Ginzburg E, Evans WE, Smith W. Lingual infarction: a review of the literature. Ann Vasc Surg 1992;6:450Y452 ¨ zdal MP, Nal0acNog˘lu-Yu¨ksekkaya P, et al. 21. Subazi M, C ¸ akar-O Management of an orbitocranial knife injury: a case report. Turk J Pediatr 2012;54:184Y186 22. Schcepers A, Lownie M. The role of angiography in facial trauma: a case report. Br J Oral Maxillofac Surg 1994;32:109Y110 23. Arunkumar KV, Kumar S, Aggarwal R, et al. Management challenges in a short-range low-velocity gunshot injury. Ann Maxillofac Surg 2012;2:200Y203 24. Puri A, Nusrath MA, Harinathan D, et al. Massive sublingual hematoma secondary to anticoagulant therapy complicated by a traumatic denture: a case report. J Med Case Rep 2012;10:105 25. Yang R, Yu X, Ma L, et al. Emergency management of a patient with severe airway obstruction resulting from poorly differentiated thyroid carcinoma: a case report. Oncol Lett 2012;4:771Y774 26. Anielski R, Barczycski M. Postoperative wound infections II. Risk factors related to surgery. Przegl Lek 1998;55:109Y119 27. Grossman MD, Karlovitz A. Lingual trauma: the use of medicinal leeches in the treatment of massive lingual hematoma. J Trauma 1998;44:1084 28. Ames NJ, Sulima P, Ngo T, et al. A characterization of the oral microbiome in allogeneic stem cell transplant patients. PLoS One 2012;7:e47628 29. Chang CC, Lin HJ, Foo NP, et al. The hidden devil: unexpected retained knife in the chest wall. Ulus Travma Acil Cerrahi Derg 2012;18:453Y454 30. Ribeiro AL, de Melo Alves Junior S, de Jesus Viana Pinheiro J. True or false facial artery aneurysmVreply. Oral Surg Oral Med Oral Pathol Oral Radiol 2012;113:152Y153
Quantification of Facial Movements by Optical Instruments: Surface Laser Scanning and Optoelectronic Three-Dimensional Motion Analyzer Fernanda Vincia Sidequersky, MsST, PhD,* Laura Verze´, MD,Þ Andrea Mapelli, MBioEng, PhD,*þ Guglielmo Amedeo Ramieri, MD, DDS,§ Chiarella Sforza, MD, PhD* Abstract: The objective of this study was to assess the accuracy of displacements of tracing landmarks in standardized facial movements.
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
e65
Brief Clinical Studies
The Journal of Craniofacial Surgery
& Volume 25, Number 1, January 2014
Forty healthy persons were evaluated in 2 different groups (20 men and 20 women, aged 18Y30 years) with optoelectronic motion analyzer and surface laser scanning. The displacements of tracing landmarks in brow lift and smile were calculated, and the 2 methods (optoelectronic motion analyzer and surface laser scanning) were compared in healthy persons. Side-related differences were found in the tracing landmark (superciliare) during brow lift movements between both methods (the largest movements were found on the right side, P = 0.044), whereas in smile movements the tracing landmark cheilion did not show significant differences between the 2 sides. In both movements, the differences of the tracing landmark displacements between the 2 systems and sexes were on average less than 2 mm, without statistically significant differences (P 9 0.05). In conclusion, normal young adult men and women had similar standardized facial movements. The 2 analyzed movements can be measured by both optical instruments with comparable results.
noninvasive quantitative assessment of soft tissue facial movements without interfering with the subject.1,4,5,9,11,13,16,20,21,23,26Y31 The detection and quantitative analysis of facial movements are a key step in the description and grading of facial function and dysfunction, during diagnosis, treatment, and follow-up of their disorders.7,10,11,14,15,17,18,22,27,32 In our laboratories, we developed methods for the noninvasive, three-dimensional assessment of facial movements using either an optoelectronic motion analyzer or a laser scanner. These methods were found to be minimally disturbing and reliable and to accurately detect total and local motion during the performance of standardized facial animations.4,5,16,21,30,31,33 They offer a valuable support for the extraction of numeric values, which are very useful in the differential diagnosis.4,5,21,23,29,31 The aims of the current study were to assess the accuracy of displacements of tracing landmarks in standardized facial movements for optoelectronic motion analyzer and surface laser scanning, and to compare the 2 methods in healthy people.
Key Words: Three-dimensional imaging, motion analysis, mimics, human, asymmetry
MATERIALS AND METHODS
T
he human face has Xan important role not only in physiological activities, but also in social communication and interpersonal relationship; it continuously acts and reacts to internal and environmental stimuli, with the coordinated action of the facial muscles.1Y5 Facial expressions can be altered in various pathologic conditions and malformations, deriving from central nervous system diseases, neuromuscular and peripheral nerve paralysis (mostly, facial nerve paralysis), drug administration, dentofacial deformities and scars, and congenital anomalies.1,2,6Y16 Facial dysfunctions are usually assessed independently from their origin, and several clinical and instrumental evaluation can be used to grade both spontaneous and instructed facial movements.1,8,11,14,17Y23 Clinical assessments grade facial function using subjective methods.18,19 Whereas some methods use dichotomic indices (presence/absence of movement), more sophisticated scales allow some grading of the impairment. Nevertheless, the principal limitation of the clinical scales is their subjective nature, with a reduced interobserver agreement, lack of quantification, and some difficulties in data sharing among professionals and clinical centers.14,22,24,25 To overcome these limitations, quantitative methods for the assessment of facial movements have been proposed.7,10,11,17Y19 Nowadays, several three-dimensional motion analyzers allow a
From the *Functional Anatomy Research Center, Laboratory of Functional Anatomy of the Stomatognathic Apparatus, Dipartimento di Scienze Biomediche per la Salute, Faculty of Medicine, Universita` degli Studi di Milano, Milan; †Department of Science of Public Health and Pediatrics, Legal Medicine Section, University of Turin, Turin, Italy; ‡Department of Ophthalmology, Otorhinolaryngology, and Head and Neck Surgery, School of Medicine, Ribeira˜o Preto, University of Sa˜o Paulo, Sa˜o Paulo, Brazil; and §Department of Head and Neck Surgery, Division of Maxillofacial Surgery, San Giovanni Battista Hospital, University of Turin, Turin, Italy. Received January 25, 2013. Accepted for publication August 23, 2013. Address correspondence and reprint requests to Dr. Chiarella Sforza, Dipartimento di Scienze Biomediche per la Salute, Faculty of Medicine, Universita` degli Studi di Milano, Milano, Italy. Via Luigi Mangiagalli, 31 Milano, 20133, Italy; E-mail: [email protected] F.V.S. and L.V. equally contributed to the investigation. The authors report no conflicts of interest. Copyright * 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000000379
e66
Subjects Forty healthy adults (20 men and 20 women, aged 18Y30 years) participated in the study. They belonged to 2 different groups: in 1 group, facial movements were recorded by an optoelectronic motion analyzer; in the other group, a laser scanner was used. Each group comprised 10 men and 10 women. All subjects had a clinically normal facial function; no previous facial trauma, paralysis, or surgery; and no known neurological diseases. They had no current orthodontic treatment and no facial hair that would interfere with marker placement. Informed consent was obtained from each participant, and the protocol used in the current study was approved by the ethics committees of the Department of Biomedical Sciences for Health, University of Milan and Department of Public Health and Pediatrics, Legal Medicine Section, University of Turin, and it did not involve dangerous or painful activities.
Data Collection Facial movements were recorded using either an optoelectronic three-dimensional motion analyzer with a 60-Hz sampling rate (SMART System, BTS, Milano, Italy) or a Head and Face Colour 3D Scanner (3030RGB; Cyberware, Inc, Monterey, CA). For both acquisition protocols, a set of landmarks was chosen from classic anthropometry,34 and each subject performed 2 standardized facial animations: brow lift and smile. Each animation was explained and shown to the subjects who practiced before data acquisition. For each expression, each subject performed 3 standardized maximum facial animations from rest, without modifications of the marker positions. The positions of the markers were carefully controlled to avoid any interference of facial movements.
Optoelectronic Three-Dimensional Motion Analyzer For optoelectronic motion analysis, biadhesive plaster was used to position on the skin a set of reflective markers in correspondence of 21 anatomical landmarks: trichion (tr), nasion (n), superciliare (sci), exocanthion (ex), orbitale (or); pronasale (prn), nasal alar crest (ac), labiale superius (ls), sublabiale (sl), cheilion (ch), lower lip points halfway between cheilion and sublabiale (li); pogonion (pg), tragion (t); vertex (v) (Fig. 1). The 3 head markers (right and left t, and v) defined a head plane reference, used to mathematically eliminate head * 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
& Volume 25, Number 1, January 2014
Brief Clinical Studies
closed and teeth in occlusion (rest scan), and then after assuming facial expressions.
Data Analysis Optoelectronic Three-Dimensional Motion Analyzer The method had been described in detail by Sforza et al.4,30 For each subject, head and neck motion was subtracted from the raw facial movements using the 3 cranial (reference) markers, so only movements occurring in the face (activity of mimic muscles) were further considered. Subsequently, for each of the 15 facial markers, the three-dimensional movements during each facial animation were computed, and the modulus (intensity) of the three-dimensional vector of maximum displacement from rest was calculated. For each animation, the landmark (single or paired) with the largest displacement from rest was identified.
Surface Laser Scanning
FIGURE 2. Soft tissue landmarks used for the analysis of the facial movements using the laser scan.
movements during facial animations; this reference plane was also used to standardize head position within and between subjects.4,21,30 The optoelectronic three-dimensional motion analyzer uses 9 high-resolution infrared sensitive charge-coupled device video cameras coupled with a video processor that define a working volume of 44 (width) 44 (height) 44 (depth) cm3; metric calibration and correction of optical and electronic distortions were performed before each acquisition session using a 20-cm wand, with a resulting mean dynamic accuracy of 0.121 (SD, 0.086) mm, corresponding to 0.0158% of the diagonal of the working volume.30 Subjects sat on a stool inside the working volume and were asked to perform a series of standardized facial movements. During the execution of the movements, special software of each camera identified the two-dimensional coordinates of passive markers positioned on facial landmarks identified by a set of 2-mm round reflective markers.4,16,22,30,35 Subsequently, all the coordinates were converted to metric data, and a set of three-dimensional coordinates for each landmark in each frame that constituted each movement was obtained.
For each movement, the mimic scan was recorded on the rest scan, by use of a semiautomated regional registration on the unchanged areas; the method had been described in detail by Verze´ et al.5 Representation of the displacement of homologous points (clearance vector mapping) allowed evaluation of the symmetry and the direction of soft tissue displacement during movements. Areas identified as the most involved led to the selection of the study landmarks (one for each movement) among the landmarks positioned on the subjects’ faces during scanning. The data acquired were transferred to a graphics workstation for viewing and elaboration with Cyberware Echo software (Cyberware Inc). Facial surface reconstruction, multiple scan alignment and measurements were carried out using Rapid Form 2004 software (INUS Technologies Inc, Seoul, South Korea).
Surface Laser Scanning The scanning method took into consideration previous observations concerning the positioning of the subject and environmental conditions,33 to improve dimensional precision and repeatability of scanning models, increase interobserver consistency, and reduce artifacts. Before acquisitions, anatomical points of the face were marked with sticky paper labels bearing a central red spot (landmarks). The landmarks used for laser scanning method were trichion (tr), nasion (n), palpebrale superius (ps), superciliare (sci), endocanthium (ed), exocanthium (ex), pronasale (prn), alar curvature point (ac), labiale superius (ls), sublabiale (sl), cheilion (ch), pogonion (pg), and tragion (t). A further landmark, the midpoint of the tr-n axis, was also chosen (Fig. 2). All subjects were scanned several times. They were first scanned with the head in natural position (nhp), the eyes
FIGURE 1. Soft tissue landmarks used for the analysis of facial movements using the optoelectronic three-dimensional motion analyzer.
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
e67
The Journal of Craniofacial Surgery
Brief Clinical Studies
Method Error
& Volume 25, Number 1, January 2014 DISCUSSION
For the optoelectronic three-dimensional motion analyzer, withinand between-session repeatability was previously assessed in healthy subjects. Within session, the technical error of the measurement for single landmarks (random error) was, on average, 0.5 and 3.38 mm, showing good reproducibility. Between sessions, all facial movements had SDs lower than 1 mm.4,30 For laser scanning, the accuracy of scanning was T0.65 mm. The development of a specific protocol resulted in a mean scanning error of 1 to 1.2 mm on repeated scans of human subjects.33
Statistical Calculations For all healthy subjects, mean and SD values of the landmark displacement were calculated for each movement. The normal distribution of data was checked with the Kolmogorov-Smirnov test. For each facial expression (brow lift and smile), the landmark displacements for both optoelectronic and laser scanning systems were compared by a 3-way factorial analysis of variance (withinsubjects factor: side; between-subjects factors: system and sex; system and sex interaction was also computed). The level of significance was set at 5% (P G 0.05).
RESULTS The mean time required to accomplish all facial scanning or facial optoelectronic motion analysis in a single subject was 30 minutes, including explanation of the protocol for both optical methods, landmark positioning, and actual procedure. Careful analysis of the landmark displacements revealed that only a few of these were constantly involved in the considered movements in all subjects and for both imaging protocols. They were superciliare (sci) for brow lift and cheilion (ch) for smile. These were called ‘‘tracing landmarks,’’ and only their displacements are reported (Table 1). All data within each subgroup (men, women) were normally distributed (Kolmogorov-Smirnov tests, P 9 0.05). In both movements, the differences of the tracing landmark displacements between the 2 systems and sexes were on average less than 2 mm, without statistically significant differences (3-way factorial analysis of variance; all P 9 0.05). In smile movements, the tracing landmark ch did not show significant differences between the 2 sides. In contrast, significant side-related differences were found in the tracing landmark (sci) during brow lift movements (P = 0.044; 3-way factorial analysis of variance): the largest movements were found on the right side.
Accurate facial movement analysis is essential for precise diagnosis and preparation of a treatment plan in patients with dentofacial deformities and scars, peripheral nerve paralysis, and congenital anomalies, who present deficits in facial movements.1,8Y11,14Y16 In this study, we examined facial movements in normal subjects by optical instruments to determine the accuracy of displacements of tracing landmarks. Facial motion was investigated with marker displacements; this method had already been successfully used in several laboratories, without interfering with the movement.5,6,16,19,22,30,31,35,36 The different marking method depends on the kind of motion analyzer. In both approaches analyzed in this study, the markers have to be positioned on the face and subsequently semiautomatically tracked from the computerized recordings, whereas in other studies the facial characteristics were automatically singled out without previous marking.8,9 Previous studies examined the static accuracy and focused mainly on the concordance between direct and indirect measurement techniques, comparing traditional caliper-based anthropometry with standard twodimensional photogrammetry, cephalometry, three-dimensional stereophotogrammetry, or three-dimensional electromagnetic digitizer, in healthy subjects and patients.37Y41 Fourie et al42 compared the accuracy of standard anthropometric linear measurements made with laser surface scanning, cone-beam computed tomography, and threedimensional stereophotogrammetry in cadaver heads. Previous investigations developed standardized sequences of symmetric movements11,15,22,32 and reported asymmetric motions of paired landmarks of the face, even in healthy, normal subjects.10,17,20,27,32,43,44 In the current study, the symmetric facial movements were performed involving the middle and lower facial thirds (smile) and the upper facial third (brow raise).4,5,10,20,27,30,45 During the brow lift movements, the tracing landmark sci showed a significantly larger displacement on the right than on the left side. In contrast, in smile movements, the tracing landmark ch did not show any asymmetry. In literature, there are some theories regarding side dominance. In some studies, the movements were larger on the left than on the right side of the face during the execution of both instructed symmetric movement10,20,27 and emotional facial expressions,32,43,44 whereas in other studies the right-side movements were somewhat larger than the left-side ones in instructed symmetric movement.4,46Y49 Trotman et al17 reported a contrasting result, finding that some facial asymmetry was present in the evaluated healthy subjects, but there was no systematic side preference among subjects. The asymmetries found in some studies were explained by different information processing styles of 2 hemispheres; the right-side cerebral
TABLE 1. Descriptive Statistics of Tracing Landmark Displacement (in mm) During Execution of Standardized Movements in Males (M) and Females (F), on the Right and Left Facial Sides Brows Lift
Smile
Laser Scanning
M right M left F right F left MF right MF left M F Total
e68
Optoelectronic
Laser Scanning
Optoelectronic
Mean
SD
Mean
SD
Mean
SD
Mean
SD
6.94 6.06 6.60 6.58 6.77 6.32 6.50 6.59 6.54
2.71 3.57 2.80 1.60 2.69 2.71 3.12 2.22 2.67
9.17 8.08 7.44 7.21 8.31 7.65 8.63 7.33 7.98
3.70 4.11 4.92 4.75 4.33 4.35 3.85 4.71 4.30
10.96 10.09 10.20 10.33 10.58 10.21 10.52 10.27 10.39
4.97 4.04 4.06 3.95 4.43 3.89 4.43 3.90 4.12
10.89 11.24 12.11 12.33 11.47 11.75 11.07 12.22 11.61
3.90 3.22 1.91 3.54 3.10 3.32 3.48 2.76 3.17
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
& Volume 25, Number 1, January 2014
hemisphere exceeds the left-side one in processing emotional information, and it can control the left side of the face better.32,43,44 In addition, the different nervous supplies of the upper and lower parts of the face may explain the special asymmetry in mouth and lip movements. The lateral subnucleus, innervating the perioral muscles, primarily receives contralateral projections from the primary motor cortex, whereas the upper face muscles receive bilateral input from the supplementary and rostral cingulated cortex.32,50,51 Other hypotheses for facial asymmetries were a larger left side of the face and the influence of handedness.27 In conclusion, the only side-related difference was found in the sentinel landmark sci during brow lift, with some degree of asymmetry. The 2 analyzed movements can be measured by both optical instruments with comparable results, allowing an interchangeable use of data collected in the different laboratories.
REFERENCES 1. Nooreyazdan M, Trotman CA, Faraway JJ. Modeling facial movement: II. A dynamic analysis of differences caused by orthognathic surgery. J Oral Maxillofac Surg 2004;62:1380Y1386 2. Tarantili VV, Halazonetis DJ, Spyropoulos MN. The spontaneous smile in dynamic motion. Am J Orthod Dentofacial Orthop 2005;128:8Y15 3. Holberg C, Maier C, Steinha¨user S, et al. Inter-individual variability of the facial morphology during conscious smiling. J Orofac Orthop 2006;67:234Y243 4. Sforza C, Galante D, Shirai YF, et al. A three-dimensional study of facial mimicry in healthy young adults. J Craniomaxillofac Surg 2010; 38:409Y415 5. Verze´ L, Nasi A, Quaranta F, et al. Quantification of facial movements by surface laser scanning. J Craniofac Surg 2011;22:60Y65 6. Trotman CA, Stohler CS, Johnston LE Jr. Measurement of facial soft tissue mobility in man. Cleft Palate Craniofac J 1998;35:16Y25 7. Okada E. Three-dimensional facial simulations and measurements: changes in facial contour and units associated with facial expression. J Craniofac Surg 2001;12:167Y174 8. Wachtman GS, Cohn JF, van Swearingen JM, et al. Automated tracking of facial features in patients with facial neuromuscular dysfunction. Plast Reconstr Surg 2001;107:1124Y1133 9. Mishima K, Yamada T, Fujiwara K, et al. Development and clinical usage of a motion analysis system for the face: preliminary report. Cleft Palate Craniofac J 2004;41:559Y564 10. Tzou CH, Giovanoli P, Ploner M, et al. Are there ethnic differences of facial movements between Europeans and Asians? Br J Plast Surg 2005;58:183Y195 11. Proff P, Weinga¨rtner J, Rottner K, et al. Functional 3-D analysis of patients with unilateral cleft of lip, alveolus and palate (UCLAP) following lip repair. J Craniomaxillofac Surg 2006;34:26Y30 12. van der Werf F, Reits D, Smit AE, et al. Blink recovery in patients with Bell’s palsy: a neurophysiological and behavioral longitudinal study. Invest Ophthalmol Vis Sci 2007;48:203Y213 13. Agostino R, Bologna M, Dinapoli L, et al. Voluntary, spontaneous, and reflex blinking in Parkinson’s disease. Mov Disord 2008;23:669Y675 14. Mehta RP, Zhang S, Hadlock TA. Novel 3-D video for quantification of facial movement. Otolaryngol Head Neck Surg 2008;138:468Y472 15. Sawyer AR, See M, Nduka C. Quantitative analysis of normal smile with 3D stereophotogrammetry an aid to facial reanimation. J Plast Reconstr Aesthet Surg 2010;63:65Y72 16. Sforza C, Frigerio A, Mapelli A, et al. Facial movement before and after masseteric-facial nerves anastomosis: a three-dimensional optoelectronic pilot study. J Craniomaxillofac Surg 2012;40:473Y479 17. Trotman CA, Faraway JJ, Essick GK. Three-dimensional nasolabial displacement during movement in repaired cleft lip and palate patients. Plast Reconstr Surg 2000;105:1273Y1283 18. Kang TS, Vrabec JT, Giddings N, et al. Facial nerve grading systems (1985Y2002): beyond the House-Brackmann scale. Otol Neurotol 2002;23:767Y771
Brief Clinical Studies
19. Linstrom CJ, Silverman CA, Colson D. Facial motion analysis with a video and computer system after treatment of acoustic neuroma. Otol Neurotol 2002;23:572Y579 20. Giovanoli P, Tzou CH, Ploner M, et al. Three-dimensional video-analysis of facial movements in healthy volunteers. Br J Plast Surg 2003;56: 644Y652 21. Ferrario VF, Sforza C. Anatomy of emotion: a 3D study of facial mimicry. Eur J Histochem 2007;51:45Y52 22. Hontanilla B, Auba´ C. Automatic three-dimensional quantitative analysis for evaluation of facial movement. J Plast Reconstr Aesthet Surg 2008;61:18Y30 23. Popat H, Richmond S, Playle R, et al. Three- dimensional motion analysisVan exploratory study. Part I. Assessment of facial movement. Orthod Craniofac Res 2008;11:216Y223 24. Frey M, Giovanoli P, Gerber H, et al. Three-dimensional video analysis of facial movements: a new method to assess the quantity and quality of the smile. Plast Reconstr Surg 1999;104:2032Y2039 25. Reitzen SD, Babb JS, Lalwani AK. Significance and reliability of the House-Brackmann grading system for regional facial nerve function. Otolaryngol Head Neck Surg 2009;140:154Y158 26. Weeden JC, Trotman CA, Faraway JJ. Three dimensional analysis of facial movement in normal adults: influence of sex and facial shape. Angle Orthod 2001;71:132Y140 27. Coulson SE, Croxson GR, Gilleard WL. Three-dimensional quantification of the symmetry of normal facial movement. Otol Neurotol 2002;23:999Y1002 28. Johnston DJ, Millett DT, Ayoub AF, et al. Are facial expressions reproducible? Cleft Palate Craniofac J 2003;40:291Y296 29. Popat H, Richmond S, Playle R, et al. Three- dimensional motion analysisVan exploratory study. Part II. Reproducibility of facial movement. Orthod Craniofac Res 2008;11:224Y228 30. Sforza C, Mapelli A, Galante D, et al. The effect of age and sex on facial mimicry: a three-dimensional study in healthy adults. Int J Oral Maxillofac Surg 2010;39:990Y999 31. Verze´ L, Bianchi FA, Dell’Acqua A, et al. Facial mobility after bimaxillary surgery in class III patients: a three-dimensional study. J Craniofac Surg 2011;22:2304Y2307 32. Okamoto H, Haraguchi S, Takada K. Laterality of asymmetry in movements of the corners of the mouth during voluntary smile. Angle Orthod 2010;80:223Y239 33. Ramieri GA, Spada MC, Nasi A, et al. Reconstruction of facial morphology from laser scanned data. Part I: reliability of the technique. Dentomaxillofac Radiol 2006;35:158Y164 34. Farkas LG, Hreczko TA, et al. Craniofacial norms in North American Caucasians from birth (one year) to young adulthood. In: Farkas LG, ed. Anthropometry of the Head and Face. New York: Raven Press, 1994:302Y313 35. Trotman CA, Phillips C, Faraway JJ, et al. Association between subjective and objective measures of lip form and function: an exploratory analysis. Cleft Palate Craniofac J 2003;40:241Y248 36. Trotman CA, Faraway JJ, Silvester KT, et al. Sensitivity of a method for the analysis of facial mobility. I. Vector of displacement. Cleft Palate Craniofac J 1998;35:132Y141 37. Farkas LG, Tompson B, Phillips JH, et al. Comparison of anthropometric and cephalometric measurements of the adult face. J Craniofac Surg 1999;10:18Y25 38. Budai M, Farkas LG, Tompson B, et al. Relation between anthropometric and cephalometric measurements and proportions of the face of healthy young white adult men and women. J Craniofac Surg 2003;14:154Y161 39. Guyot L, Dubuc M, Richard O, et al. Comparison between direct clinical and digital photogrammetric measurements in patients with 22q11 microdeletion. Int J Oral Maxillofac Surg 2003;32:246Y252 40. Ghoddousi H, Edler R, Haers P, et al. Comparison of three methods of facial measurement. Int J Oral Maxillofac Surg 2007;36:250Y258 41. de Menezes M, Rosati R, Allievi C, et al. A photographic system for the three-dimensional study of facial morphology. Angle Orthod 2009;79:1070Y1077
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
e69
The Journal of Craniofacial Surgery
Brief Clinical Studies
42. Fourie Z, Damstra J, Gerrits PO, et al. Evaluation of anthropometric accuracy and reliability using different three-dimensional scanning systems. Forensic Sci Int 2011;207:127Y134 43. Borod JC, Koff E, Yecker S, et al. Facial asymmetry during emotional expression: gender, valence, and measurement technique. Neuropsychologia 1998;36:1209Y1215 44. Nicholls ME, Ellis BE, Clement JG, et al. Detecting hemifacial asymmetries in emotional expression with three-dimensional computerized image analysis. Proc Biol Sci 2004;271:663Y668 45. Coulson SE, Croxson GR, Gilleard WL. Quantification of the three-dimensional displacement of normal facial movement. Ann Otol Rhinol Laryngol 2000;109:478Y483 46. Farkas LG, Cheung G. Facial asymmetry in healthy North American Caucasians. An anthropometrical study. Angle Orthod 1981;51:70Y77 47. Ferrario VF, Sforza C, Poggio CE, et al. Distance from symmetry: a three-dimensional evaluation of facial asymmetry. J Oral Maxillofac Surg 1994;52:1126Y1132 48. Ferrario VF, Sforza C, Miani A Jr, et al. A three-dimensional evaluation of human facial asymmetry. J Anat 1995;186:103Y110 49. Shaner DJ, Peterson AE, Beattie OB, et al. Assessment of soft tissue facial asymmetry in medically normal and syndrome-affected individuals by analysis of landmarks and measurements. Am J Med Genet 2000;93:143Y154 50. Urban PP, Wicht S, Vucorevic G, et al. The course of corticofacial projections in the human brainstem. Brain 2001;124:1866Y1876 51. Ercan I, Ozdemir ST, Etoz A, et al. Facial asymmetry in young healthy subjects evaluated by statistical shape analysis. J Anat 2008;213:663Y669
Pediatric Acute External Laryngeal Trauma Ali Cemal Yumusakhuylu, MD, Muhammet Fatih Topuz, MD, Ceren Durgun, MD, Adem Binnetoglu, MD, Tekin Baglam, MD, Murat Sari, MD Abstract: Larynx and adjacent anatomical structures have complicated physiological functions and mechanical features. Traffic accidents, penetrating stab wounds and shot wounds, sports matches, and occupational accidents cause external laryngeal trauma. In the management of laryngeal trauma, maintenance of airway patency has priority. In this case report, we will mention of a 15-year-old male patient with a blunt laryngeal trauma and also the approach to laryngeal traumas.
& Volume 25, Number 1, January 2014
muscles at both sides. Ossification and calcification of the laryngeal cartilages increase with age, decreasing the elasticity and resistance. Larynx of children is located higher than in adults, so it is better protected by the mandibula. In addition, larynx of children is more flexible and soft, so the possibility of injury is lower than that of the adults.1 Motor vehicle accidents, sports injuries, and penetrating stab wounds may cause external laryngeal trauma. The most important condition in emergency approach to laryngeal trauma is to protect the vocal functions of the larynx and the airway. In this case report, we present a 15-year-old male patient with a blunt laryngeal trauma and also the approach to laryngeal traumas.
PATIENT A 15-year-old male patient admitted to our clinics with a complaint of neck injury resulting from the stinging of iron railings of the mosque while jumping over the mosque wall. The patient was conscious and cooperative, his blood pressure was 100/60 mm Hg, his pulse rate was 88, his respiration was normal, there was a 4-cm cut on his neck (Fig. 1), and a subcutaneous crepitation was felt with palpation. There was pain on talking and swallowing. Patient had hoarseness. Computed tomography (CT) of upper and lower airways was obtained in the emergency room. A defect was observed on the wall of the left side at the subglottic area in the neck CT (Fig. 2). A diffuse view of emphysema was present in fat planes on both sides of the neck extending to the skull base superiorly by starting from the thoracic inlet. IV fluid replacement and antibiotic, anti-inflammatory, analgesic, and bronchodilator treatments were started. Indirect laryngoscopic examination could not be performed because of pain. Direct laryngoscopy of the patient under sedation just before the entubation revealed left-sided vocal cord paralysis. In direct laryngoscopy, a hemorrhagic perforation on the left side was observed under the vocal cord (Fig. 3). A 0.2 0.2 cm perforation was seen through the exposed skin at the level of cricothyroid membrane. Thyroid cartilage was divided into 2 on the midline (Fig. 4). Cricoid cartilage was intact. Inner perichondrium of thyroid cartilage was peeled off. Perichondrium was sutured with 4-0 vicryl. Four stitches were put on the thyroid cartilage by 3-0 prolene sutures. Strap muscles were
Key Words: Pediatric laryngeal trauma, penetrating trauma, airway management
E
xternal laryngeal trauma, which is seen less than 1% of emergency trauma, is a rare condition but an emergency with high rates of mortality.1 The larynx is under protection of cartilaginous and bony structures. The larynx is protected by the vertebra behind, mandibula above, sternum below, and the sternocleidomastoid
From the Faculty of Medicine, Marmara University, Istanbul, Turkey. Received May 6, 2013. Accepted for publication August 26, 2013. Address correspondence and reprint requests to Dr Muhammet Fatih Topuz, Faculty of Medicine, Marmara University, Istanbul, Turkey; E-mail: [email protected] The authors report no conflicts of interest. Copyright * 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000000393
e70
FIGURE 1. A 4-cm cut on the neck.
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
& Volume 25, Number 1, January 2014
The infection of the hematoma was a potential complication that could have led to a worsening of the case.27Y29 There were 2 reasons for the decision to drain the hematoma: the first was due to the continuous and gradual expansion of the hematoma,24 and the second was the potential risk of hematoma infection due to wound contamination.27Y29 The assessment of vascular lesions must be present in the initial care of patients with facial trauma and should be part of the routine of specialized trauma centers. Immediate and late complications of vascular lesions may put the patient in life-threatening situations and therefore should be diagnosed and treated as soon as possible. In this case, at the time of admission, the patient presented major respiratory distress requiring a surgical airway for life support. This case report demonstrates the importance of an accurate analysis of local vascularization.3 This analysis is critical and serves as a guide for the safe execution of the proposed treatment.30
CONCLUSIONS The authors presented a case of a huge hematoma of the tongue due to a stab wound and lingual artery injury. The bleeding lingual artery formed an expansive hematoma, which evolved into a high tongue and upper airway obstruction. The patient was initially treated with tracheotomy, followed by surgery for lingual artery ligation and drainage of the sublingual hematoma, using the findings of CT angiography as a surgical guide. The authors conclude that the surgical technique was an effective method of treatment and quite safe when driven by a precise analysis of the local circulation by CT angiography. Although rare, cases of lingual artery injury showing a similar trend can be resolved by this technique, which combines the advantages of a safe surgery, fast resolution of the case, and minimal complications. The authors argue that the demand for vascular lesions should be routine in patients who have facial trauma, and the assistant surgeon should be prepared for the correct diagnosis and treatment of these lesions.
REFERENCES 1. Offiah C, Hall E. Imaging assessment of penetrating injury of the neck and face. Insights Imaging 2012;3:419Y431 2. Mawaddah A, Goh BS, Kew TY, et al. Isolated blunt lingual artery injury secondary to a road traffic accident: diagnostic and therapeutic approach. Malays J Med Sci 2012;19:77Y81 3. Ribeiro ALR, Junior SMA, Pinheiro JJV. Traumatic pseudoaneurysm of the facial artery: late complication and effects on local blood flow. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2011;112:e4Ye9 4. Macpherson AK, Schull MJ. Penetrating trauma in Ontario emergency departments: a population-based study. Can J Emerg Med 2007;9:16Y20 5. Ribeiro AL, de Vasconcellos HG, Pinheiro JJ. Unusual fishing harpoon injury of the maxillofacial region in a child. Oral Maxillofac Surg 2009;13:243Y246 6. Homze EJ, Harn SD, Bavitz BJ. Extraoral ligation of the lingual artery: an anatomic study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1997;83:321Y324 7. Burke RH, Masch GL. Lingual artery hemorrhage. Oral Surg Oral Med Oral Pathol 1986;62:258Y261 8. Hing NR, Bowler MD, Byth PL, et al. Lingual haematoma leading to upper airway obstruction. Br J Oral Maxillofac Surg 1985;23:313Y321 9. van As AB, van Deurzen DF, Verleisdonk EJ. Gunshots to the neck: selective angiography as part of conservative management. Injury 2002;33:453Y456 10. Sagar S, Kumar N, Singhal M, et al. A rare case of life-threatening penetrating oropharyngeal trauma caused by toothcrush in a child. J Indian Soc Pedod Prev Dent 2010;28:134Y136 11. Meer M, Siddiqi A, Morkel JA, et al. Knife inflicted penetrating injuries of the maxillofacial region: a descriptive, record-based study. Injury 2010;41:77Y81
Brief Clinical Studies
12. Assenza M, Centonze L, Valesini L, et al. Traumatic subclavian arterial rupture: a case report and review of literature. World J Emerg Surg 2012;7:1Y6 13. Kaynar AM, Bhavani-Shankar K, Mushlin PS. Lingual hematoma as a potential cause of upper airway obstruction. Anesth Analg 1999;89:1573Y1575 14. Kattan B, Snyder HS. Lingual artery hematoma resulting in upper airway obstruction. J Emerg Med 1991;9:421Y424 15. DuBrul EL. Sicher and DuBrul’s Oral anatomy. 8th ed. Tokyo and New York: Ishiyaku Euro America, 1998 16. Mepani VN, Antscherl J. A tricky tracheotomy: airway management dilemma following unusual stab injury to the mouth. Ann R Coll Surg Engl 2012;94:e28Ye29 17. Lahiri S, Ghosh S, Sengupta G, et al. An unusual presentation of foreign body in the common carotid artery. Indian J Surg 2011;73:460Y462 18. Shaw RJ, McNaughton GW. Emergency airway management in a case of lingual haematoma. Emerg Med J 2001;18:408Y409 19. Song Z, Laggan B, Parulis A. Lingual hematoma treatment rationales: a case report. J Oral Maxillofac Surg 2008;66:535Y539 20. Ginzburg E, Evans WE, Smith W. Lingual infarction: a review of the literature. Ann Vasc Surg 1992;6:450Y452 ¨ zdal MP, Nal0acNog˘lu-Yu¨ksekkaya P, et al. 21. Subazi M, C ¸ akar-O Management of an orbitocranial knife injury: a case report. Turk J Pediatr 2012;54:184Y186 22. Schcepers A, Lownie M. The role of angiography in facial trauma: a case report. Br J Oral Maxillofac Surg 1994;32:109Y110 23. Arunkumar KV, Kumar S, Aggarwal R, et al. Management challenges in a short-range low-velocity gunshot injury. Ann Maxillofac Surg 2012;2:200Y203 24. Puri A, Nusrath MA, Harinathan D, et al. Massive sublingual hematoma secondary to anticoagulant therapy complicated by a traumatic denture: a case report. J Med Case Rep 2012;10:105 25. Yang R, Yu X, Ma L, et al. Emergency management of a patient with severe airway obstruction resulting from poorly differentiated thyroid carcinoma: a case report. Oncol Lett 2012;4:771Y774 26. Anielski R, Barczycski M. Postoperative wound infections II. Risk factors related to surgery. Przegl Lek 1998;55:109Y119 27. Grossman MD, Karlovitz A. Lingual trauma: the use of medicinal leeches in the treatment of massive lingual hematoma. J Trauma 1998;44:1084 28. Ames NJ, Sulima P, Ngo T, et al. A characterization of the oral microbiome in allogeneic stem cell transplant patients. PLoS One 2012;7:e47628 29. Chang CC, Lin HJ, Foo NP, et al. The hidden devil: unexpected retained knife in the chest wall. Ulus Travma Acil Cerrahi Derg 2012;18:453Y454 30. Ribeiro AL, de Melo Alves Junior S, de Jesus Viana Pinheiro J. True or false facial artery aneurysmVreply. Oral Surg Oral Med Oral Pathol Oral Radiol 2012;113:152Y153
Quantification of Facial Movements by Optical Instruments: Surface Laser Scanning and Optoelectronic Three-Dimensional Motion Analyzer Fernanda Vincia Sidequersky, MsST, PhD,* Laura Verze´, MD,Þ Andrea Mapelli, MBioEng, PhD,*þ Guglielmo Amedeo Ramieri, MD, DDS,§ Chiarella Sforza, MD, PhD* Abstract: The objective of this study was to assess the accuracy of displacements of tracing landmarks in standardized facial movements.
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
e65
Brief Clinical Studies
The Journal of Craniofacial Surgery
& Volume 25, Number 1, January 2014
Forty healthy persons were evaluated in 2 different groups (20 men and 20 women, aged 18Y30 years) with optoelectronic motion analyzer and surface laser scanning. The displacements of tracing landmarks in brow lift and smile were calculated, and the 2 methods (optoelectronic motion analyzer and surface laser scanning) were compared in healthy persons. Side-related differences were found in the tracing landmark (superciliare) during brow lift movements between both methods (the largest movements were found on the right side, P = 0.044), whereas in smile movements the tracing landmark cheilion did not show significant differences between the 2 sides. In both movements, the differences of the tracing landmark displacements between the 2 systems and sexes were on average less than 2 mm, without statistically significant differences (P 9 0.05). In conclusion, normal young adult men and women had similar standardized facial movements. The 2 analyzed movements can be measured by both optical instruments with comparable results.
noninvasive quantitative assessment of soft tissue facial movements without interfering with the subject.1,4,5,9,11,13,16,20,21,23,26Y31 The detection and quantitative analysis of facial movements are a key step in the description and grading of facial function and dysfunction, during diagnosis, treatment, and follow-up of their disorders.7,10,11,14,15,17,18,22,27,32 In our laboratories, we developed methods for the noninvasive, three-dimensional assessment of facial movements using either an optoelectronic motion analyzer or a laser scanner. These methods were found to be minimally disturbing and reliable and to accurately detect total and local motion during the performance of standardized facial animations.4,5,16,21,30,31,33 They offer a valuable support for the extraction of numeric values, which are very useful in the differential diagnosis.4,5,21,23,29,31 The aims of the current study were to assess the accuracy of displacements of tracing landmarks in standardized facial movements for optoelectronic motion analyzer and surface laser scanning, and to compare the 2 methods in healthy people.
Key Words: Three-dimensional imaging, motion analysis, mimics, human, asymmetry
MATERIALS AND METHODS
T
he human face has Xan important role not only in physiological activities, but also in social communication and interpersonal relationship; it continuously acts and reacts to internal and environmental stimuli, with the coordinated action of the facial muscles.1Y5 Facial expressions can be altered in various pathologic conditions and malformations, deriving from central nervous system diseases, neuromuscular and peripheral nerve paralysis (mostly, facial nerve paralysis), drug administration, dentofacial deformities and scars, and congenital anomalies.1,2,6Y16 Facial dysfunctions are usually assessed independently from their origin, and several clinical and instrumental evaluation can be used to grade both spontaneous and instructed facial movements.1,8,11,14,17Y23 Clinical assessments grade facial function using subjective methods.18,19 Whereas some methods use dichotomic indices (presence/absence of movement), more sophisticated scales allow some grading of the impairment. Nevertheless, the principal limitation of the clinical scales is their subjective nature, with a reduced interobserver agreement, lack of quantification, and some difficulties in data sharing among professionals and clinical centers.14,22,24,25 To overcome these limitations, quantitative methods for the assessment of facial movements have been proposed.7,10,11,17Y19 Nowadays, several three-dimensional motion analyzers allow a
From the *Functional Anatomy Research Center, Laboratory of Functional Anatomy of the Stomatognathic Apparatus, Dipartimento di Scienze Biomediche per la Salute, Faculty of Medicine, Universita` degli Studi di Milano, Milan; †Department of Science of Public Health and Pediatrics, Legal Medicine Section, University of Turin, Turin, Italy; ‡Department of Ophthalmology, Otorhinolaryngology, and Head and Neck Surgery, School of Medicine, Ribeira˜o Preto, University of Sa˜o Paulo, Sa˜o Paulo, Brazil; and §Department of Head and Neck Surgery, Division of Maxillofacial Surgery, San Giovanni Battista Hospital, University of Turin, Turin, Italy. Received January 25, 2013. Accepted for publication August 23, 2013. Address correspondence and reprint requests to Dr. Chiarella Sforza, Dipartimento di Scienze Biomediche per la Salute, Faculty of Medicine, Universita` degli Studi di Milano, Milano, Italy. Via Luigi Mangiagalli, 31 Milano, 20133, Italy; E-mail: [email protected] F.V.S. and L.V. equally contributed to the investigation. The authors report no conflicts of interest. Copyright * 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000000379
e66
Subjects Forty healthy adults (20 men and 20 women, aged 18Y30 years) participated in the study. They belonged to 2 different groups: in 1 group, facial movements were recorded by an optoelectronic motion analyzer; in the other group, a laser scanner was used. Each group comprised 10 men and 10 women. All subjects had a clinically normal facial function; no previous facial trauma, paralysis, or surgery; and no known neurological diseases. They had no current orthodontic treatment and no facial hair that would interfere with marker placement. Informed consent was obtained from each participant, and the protocol used in the current study was approved by the ethics committees of the Department of Biomedical Sciences for Health, University of Milan and Department of Public Health and Pediatrics, Legal Medicine Section, University of Turin, and it did not involve dangerous or painful activities.
Data Collection Facial movements were recorded using either an optoelectronic three-dimensional motion analyzer with a 60-Hz sampling rate (SMART System, BTS, Milano, Italy) or a Head and Face Colour 3D Scanner (3030RGB; Cyberware, Inc, Monterey, CA). For both acquisition protocols, a set of landmarks was chosen from classic anthropometry,34 and each subject performed 2 standardized facial animations: brow lift and smile. Each animation was explained and shown to the subjects who practiced before data acquisition. For each expression, each subject performed 3 standardized maximum facial animations from rest, without modifications of the marker positions. The positions of the markers were carefully controlled to avoid any interference of facial movements.
Optoelectronic Three-Dimensional Motion Analyzer For optoelectronic motion analysis, biadhesive plaster was used to position on the skin a set of reflective markers in correspondence of 21 anatomical landmarks: trichion (tr), nasion (n), superciliare (sci), exocanthion (ex), orbitale (or); pronasale (prn), nasal alar crest (ac), labiale superius (ls), sublabiale (sl), cheilion (ch), lower lip points halfway between cheilion and sublabiale (li); pogonion (pg), tragion (t); vertex (v) (Fig. 1). The 3 head markers (right and left t, and v) defined a head plane reference, used to mathematically eliminate head * 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
& Volume 25, Number 1, January 2014
Brief Clinical Studies
closed and teeth in occlusion (rest scan), and then after assuming facial expressions.
Data Analysis Optoelectronic Three-Dimensional Motion Analyzer The method had been described in detail by Sforza et al.4,30 For each subject, head and neck motion was subtracted from the raw facial movements using the 3 cranial (reference) markers, so only movements occurring in the face (activity of mimic muscles) were further considered. Subsequently, for each of the 15 facial markers, the three-dimensional movements during each facial animation were computed, and the modulus (intensity) of the three-dimensional vector of maximum displacement from rest was calculated. For each animation, the landmark (single or paired) with the largest displacement from rest was identified.
Surface Laser Scanning
FIGURE 2. Soft tissue landmarks used for the analysis of the facial movements using the laser scan.
movements during facial animations; this reference plane was also used to standardize head position within and between subjects.4,21,30 The optoelectronic three-dimensional motion analyzer uses 9 high-resolution infrared sensitive charge-coupled device video cameras coupled with a video processor that define a working volume of 44 (width) 44 (height) 44 (depth) cm3; metric calibration and correction of optical and electronic distortions were performed before each acquisition session using a 20-cm wand, with a resulting mean dynamic accuracy of 0.121 (SD, 0.086) mm, corresponding to 0.0158% of the diagonal of the working volume.30 Subjects sat on a stool inside the working volume and were asked to perform a series of standardized facial movements. During the execution of the movements, special software of each camera identified the two-dimensional coordinates of passive markers positioned on facial landmarks identified by a set of 2-mm round reflective markers.4,16,22,30,35 Subsequently, all the coordinates were converted to metric data, and a set of three-dimensional coordinates for each landmark in each frame that constituted each movement was obtained.
For each movement, the mimic scan was recorded on the rest scan, by use of a semiautomated regional registration on the unchanged areas; the method had been described in detail by Verze´ et al.5 Representation of the displacement of homologous points (clearance vector mapping) allowed evaluation of the symmetry and the direction of soft tissue displacement during movements. Areas identified as the most involved led to the selection of the study landmarks (one for each movement) among the landmarks positioned on the subjects’ faces during scanning. The data acquired were transferred to a graphics workstation for viewing and elaboration with Cyberware Echo software (Cyberware Inc). Facial surface reconstruction, multiple scan alignment and measurements were carried out using Rapid Form 2004 software (INUS Technologies Inc, Seoul, South Korea).
Surface Laser Scanning The scanning method took into consideration previous observations concerning the positioning of the subject and environmental conditions,33 to improve dimensional precision and repeatability of scanning models, increase interobserver consistency, and reduce artifacts. Before acquisitions, anatomical points of the face were marked with sticky paper labels bearing a central red spot (landmarks). The landmarks used for laser scanning method were trichion (tr), nasion (n), palpebrale superius (ps), superciliare (sci), endocanthium (ed), exocanthium (ex), pronasale (prn), alar curvature point (ac), labiale superius (ls), sublabiale (sl), cheilion (ch), pogonion (pg), and tragion (t). A further landmark, the midpoint of the tr-n axis, was also chosen (Fig. 2). All subjects were scanned several times. They were first scanned with the head in natural position (nhp), the eyes
FIGURE 1. Soft tissue landmarks used for the analysis of facial movements using the optoelectronic three-dimensional motion analyzer.
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
e67
The Journal of Craniofacial Surgery
Brief Clinical Studies
Method Error
& Volume 25, Number 1, January 2014 DISCUSSION
For the optoelectronic three-dimensional motion analyzer, withinand between-session repeatability was previously assessed in healthy subjects. Within session, the technical error of the measurement for single landmarks (random error) was, on average, 0.5 and 3.38 mm, showing good reproducibility. Between sessions, all facial movements had SDs lower than 1 mm.4,30 For laser scanning, the accuracy of scanning was T0.65 mm. The development of a specific protocol resulted in a mean scanning error of 1 to 1.2 mm on repeated scans of human subjects.33
Statistical Calculations For all healthy subjects, mean and SD values of the landmark displacement were calculated for each movement. The normal distribution of data was checked with the Kolmogorov-Smirnov test. For each facial expression (brow lift and smile), the landmark displacements for both optoelectronic and laser scanning systems were compared by a 3-way factorial analysis of variance (withinsubjects factor: side; between-subjects factors: system and sex; system and sex interaction was also computed). The level of significance was set at 5% (P G 0.05).
RESULTS The mean time required to accomplish all facial scanning or facial optoelectronic motion analysis in a single subject was 30 minutes, including explanation of the protocol for both optical methods, landmark positioning, and actual procedure. Careful analysis of the landmark displacements revealed that only a few of these were constantly involved in the considered movements in all subjects and for both imaging protocols. They were superciliare (sci) for brow lift and cheilion (ch) for smile. These were called ‘‘tracing landmarks,’’ and only their displacements are reported (Table 1). All data within each subgroup (men, women) were normally distributed (Kolmogorov-Smirnov tests, P 9 0.05). In both movements, the differences of the tracing landmark displacements between the 2 systems and sexes were on average less than 2 mm, without statistically significant differences (3-way factorial analysis of variance; all P 9 0.05). In smile movements, the tracing landmark ch did not show significant differences between the 2 sides. In contrast, significant side-related differences were found in the tracing landmark (sci) during brow lift movements (P = 0.044; 3-way factorial analysis of variance): the largest movements were found on the right side.
Accurate facial movement analysis is essential for precise diagnosis and preparation of a treatment plan in patients with dentofacial deformities and scars, peripheral nerve paralysis, and congenital anomalies, who present deficits in facial movements.1,8Y11,14Y16 In this study, we examined facial movements in normal subjects by optical instruments to determine the accuracy of displacements of tracing landmarks. Facial motion was investigated with marker displacements; this method had already been successfully used in several laboratories, without interfering with the movement.5,6,16,19,22,30,31,35,36 The different marking method depends on the kind of motion analyzer. In both approaches analyzed in this study, the markers have to be positioned on the face and subsequently semiautomatically tracked from the computerized recordings, whereas in other studies the facial characteristics were automatically singled out without previous marking.8,9 Previous studies examined the static accuracy and focused mainly on the concordance between direct and indirect measurement techniques, comparing traditional caliper-based anthropometry with standard twodimensional photogrammetry, cephalometry, three-dimensional stereophotogrammetry, or three-dimensional electromagnetic digitizer, in healthy subjects and patients.37Y41 Fourie et al42 compared the accuracy of standard anthropometric linear measurements made with laser surface scanning, cone-beam computed tomography, and threedimensional stereophotogrammetry in cadaver heads. Previous investigations developed standardized sequences of symmetric movements11,15,22,32 and reported asymmetric motions of paired landmarks of the face, even in healthy, normal subjects.10,17,20,27,32,43,44 In the current study, the symmetric facial movements were performed involving the middle and lower facial thirds (smile) and the upper facial third (brow raise).4,5,10,20,27,30,45 During the brow lift movements, the tracing landmark sci showed a significantly larger displacement on the right than on the left side. In contrast, in smile movements, the tracing landmark ch did not show any asymmetry. In literature, there are some theories regarding side dominance. In some studies, the movements were larger on the left than on the right side of the face during the execution of both instructed symmetric movement10,20,27 and emotional facial expressions,32,43,44 whereas in other studies the right-side movements were somewhat larger than the left-side ones in instructed symmetric movement.4,46Y49 Trotman et al17 reported a contrasting result, finding that some facial asymmetry was present in the evaluated healthy subjects, but there was no systematic side preference among subjects. The asymmetries found in some studies were explained by different information processing styles of 2 hemispheres; the right-side cerebral
TABLE 1. Descriptive Statistics of Tracing Landmark Displacement (in mm) During Execution of Standardized Movements in Males (M) and Females (F), on the Right and Left Facial Sides Brows Lift
Smile
Laser Scanning
M right M left F right F left MF right MF left M F Total
e68
Optoelectronic
Laser Scanning
Optoelectronic
Mean
SD
Mean
SD
Mean
SD
Mean
SD
6.94 6.06 6.60 6.58 6.77 6.32 6.50 6.59 6.54
2.71 3.57 2.80 1.60 2.69 2.71 3.12 2.22 2.67
9.17 8.08 7.44 7.21 8.31 7.65 8.63 7.33 7.98
3.70 4.11 4.92 4.75 4.33 4.35 3.85 4.71 4.30
10.96 10.09 10.20 10.33 10.58 10.21 10.52 10.27 10.39
4.97 4.04 4.06 3.95 4.43 3.89 4.43 3.90 4.12
10.89 11.24 12.11 12.33 11.47 11.75 11.07 12.22 11.61
3.90 3.22 1.91 3.54 3.10 3.32 3.48 2.76 3.17
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
& Volume 25, Number 1, January 2014
hemisphere exceeds the left-side one in processing emotional information, and it can control the left side of the face better.32,43,44 In addition, the different nervous supplies of the upper and lower parts of the face may explain the special asymmetry in mouth and lip movements. The lateral subnucleus, innervating the perioral muscles, primarily receives contralateral projections from the primary motor cortex, whereas the upper face muscles receive bilateral input from the supplementary and rostral cingulated cortex.32,50,51 Other hypotheses for facial asymmetries were a larger left side of the face and the influence of handedness.27 In conclusion, the only side-related difference was found in the sentinel landmark sci during brow lift, with some degree of asymmetry. The 2 analyzed movements can be measured by both optical instruments with comparable results, allowing an interchangeable use of data collected in the different laboratories.
REFERENCES 1. Nooreyazdan M, Trotman CA, Faraway JJ. Modeling facial movement: II. A dynamic analysis of differences caused by orthognathic surgery. J Oral Maxillofac Surg 2004;62:1380Y1386 2. Tarantili VV, Halazonetis DJ, Spyropoulos MN. The spontaneous smile in dynamic motion. Am J Orthod Dentofacial Orthop 2005;128:8Y15 3. Holberg C, Maier C, Steinha¨user S, et al. Inter-individual variability of the facial morphology during conscious smiling. J Orofac Orthop 2006;67:234Y243 4. Sforza C, Galante D, Shirai YF, et al. A three-dimensional study of facial mimicry in healthy young adults. J Craniomaxillofac Surg 2010; 38:409Y415 5. Verze´ L, Nasi A, Quaranta F, et al. Quantification of facial movements by surface laser scanning. J Craniofac Surg 2011;22:60Y65 6. Trotman CA, Stohler CS, Johnston LE Jr. Measurement of facial soft tissue mobility in man. Cleft Palate Craniofac J 1998;35:16Y25 7. Okada E. Three-dimensional facial simulations and measurements: changes in facial contour and units associated with facial expression. J Craniofac Surg 2001;12:167Y174 8. Wachtman GS, Cohn JF, van Swearingen JM, et al. Automated tracking of facial features in patients with facial neuromuscular dysfunction. Plast Reconstr Surg 2001;107:1124Y1133 9. Mishima K, Yamada T, Fujiwara K, et al. Development and clinical usage of a motion analysis system for the face: preliminary report. Cleft Palate Craniofac J 2004;41:559Y564 10. Tzou CH, Giovanoli P, Ploner M, et al. Are there ethnic differences of facial movements between Europeans and Asians? Br J Plast Surg 2005;58:183Y195 11. Proff P, Weinga¨rtner J, Rottner K, et al. Functional 3-D analysis of patients with unilateral cleft of lip, alveolus and palate (UCLAP) following lip repair. J Craniomaxillofac Surg 2006;34:26Y30 12. van der Werf F, Reits D, Smit AE, et al. Blink recovery in patients with Bell’s palsy: a neurophysiological and behavioral longitudinal study. Invest Ophthalmol Vis Sci 2007;48:203Y213 13. Agostino R, Bologna M, Dinapoli L, et al. Voluntary, spontaneous, and reflex blinking in Parkinson’s disease. Mov Disord 2008;23:669Y675 14. Mehta RP, Zhang S, Hadlock TA. Novel 3-D video for quantification of facial movement. Otolaryngol Head Neck Surg 2008;138:468Y472 15. Sawyer AR, See M, Nduka C. Quantitative analysis of normal smile with 3D stereophotogrammetry an aid to facial reanimation. J Plast Reconstr Aesthet Surg 2010;63:65Y72 16. Sforza C, Frigerio A, Mapelli A, et al. Facial movement before and after masseteric-facial nerves anastomosis: a three-dimensional optoelectronic pilot study. J Craniomaxillofac Surg 2012;40:473Y479 17. Trotman CA, Faraway JJ, Essick GK. Three-dimensional nasolabial displacement during movement in repaired cleft lip and palate patients. Plast Reconstr Surg 2000;105:1273Y1283 18. Kang TS, Vrabec JT, Giddings N, et al. Facial nerve grading systems (1985Y2002): beyond the House-Brackmann scale. Otol Neurotol 2002;23:767Y771
Brief Clinical Studies
19. Linstrom CJ, Silverman CA, Colson D. Facial motion analysis with a video and computer system after treatment of acoustic neuroma. Otol Neurotol 2002;23:572Y579 20. Giovanoli P, Tzou CH, Ploner M, et al. Three-dimensional video-analysis of facial movements in healthy volunteers. Br J Plast Surg 2003;56: 644Y652 21. Ferrario VF, Sforza C. Anatomy of emotion: a 3D study of facial mimicry. Eur J Histochem 2007;51:45Y52 22. Hontanilla B, Auba´ C. Automatic three-dimensional quantitative analysis for evaluation of facial movement. J Plast Reconstr Aesthet Surg 2008;61:18Y30 23. Popat H, Richmond S, Playle R, et al. Three- dimensional motion analysisVan exploratory study. Part I. Assessment of facial movement. Orthod Craniofac Res 2008;11:216Y223 24. Frey M, Giovanoli P, Gerber H, et al. Three-dimensional video analysis of facial movements: a new method to assess the quantity and quality of the smile. Plast Reconstr Surg 1999;104:2032Y2039 25. Reitzen SD, Babb JS, Lalwani AK. Significance and reliability of the House-Brackmann grading system for regional facial nerve function. Otolaryngol Head Neck Surg 2009;140:154Y158 26. Weeden JC, Trotman CA, Faraway JJ. Three dimensional analysis of facial movement in normal adults: influence of sex and facial shape. Angle Orthod 2001;71:132Y140 27. Coulson SE, Croxson GR, Gilleard WL. Three-dimensional quantification of the symmetry of normal facial movement. Otol Neurotol 2002;23:999Y1002 28. Johnston DJ, Millett DT, Ayoub AF, et al. Are facial expressions reproducible? Cleft Palate Craniofac J 2003;40:291Y296 29. Popat H, Richmond S, Playle R, et al. Three- dimensional motion analysisVan exploratory study. Part II. Reproducibility of facial movement. Orthod Craniofac Res 2008;11:224Y228 30. Sforza C, Mapelli A, Galante D, et al. The effect of age and sex on facial mimicry: a three-dimensional study in healthy adults. Int J Oral Maxillofac Surg 2010;39:990Y999 31. Verze´ L, Bianchi FA, Dell’Acqua A, et al. Facial mobility after bimaxillary surgery in class III patients: a three-dimensional study. J Craniofac Surg 2011;22:2304Y2307 32. Okamoto H, Haraguchi S, Takada K. Laterality of asymmetry in movements of the corners of the mouth during voluntary smile. Angle Orthod 2010;80:223Y239 33. Ramieri GA, Spada MC, Nasi A, et al. Reconstruction of facial morphology from laser scanned data. Part I: reliability of the technique. Dentomaxillofac Radiol 2006;35:158Y164 34. Farkas LG, Hreczko TA, et al. Craniofacial norms in North American Caucasians from birth (one year) to young adulthood. In: Farkas LG, ed. Anthropometry of the Head and Face. New York: Raven Press, 1994:302Y313 35. Trotman CA, Phillips C, Faraway JJ, et al. Association between subjective and objective measures of lip form and function: an exploratory analysis. Cleft Palate Craniofac J 2003;40:241Y248 36. Trotman CA, Faraway JJ, Silvester KT, et al. Sensitivity of a method for the analysis of facial mobility. I. Vector of displacement. Cleft Palate Craniofac J 1998;35:132Y141 37. Farkas LG, Tompson B, Phillips JH, et al. Comparison of anthropometric and cephalometric measurements of the adult face. J Craniofac Surg 1999;10:18Y25 38. Budai M, Farkas LG, Tompson B, et al. Relation between anthropometric and cephalometric measurements and proportions of the face of healthy young white adult men and women. J Craniofac Surg 2003;14:154Y161 39. Guyot L, Dubuc M, Richard O, et al. Comparison between direct clinical and digital photogrammetric measurements in patients with 22q11 microdeletion. Int J Oral Maxillofac Surg 2003;32:246Y252 40. Ghoddousi H, Edler R, Haers P, et al. Comparison of three methods of facial measurement. Int J Oral Maxillofac Surg 2007;36:250Y258 41. de Menezes M, Rosati R, Allievi C, et al. A photographic system for the three-dimensional study of facial morphology. Angle Orthod 2009;79:1070Y1077
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
e69
The Journal of Craniofacial Surgery
Brief Clinical Studies
42. Fourie Z, Damstra J, Gerrits PO, et al. Evaluation of anthropometric accuracy and reliability using different three-dimensional scanning systems. Forensic Sci Int 2011;207:127Y134 43. Borod JC, Koff E, Yecker S, et al. Facial asymmetry during emotional expression: gender, valence, and measurement technique. Neuropsychologia 1998;36:1209Y1215 44. Nicholls ME, Ellis BE, Clement JG, et al. Detecting hemifacial asymmetries in emotional expression with three-dimensional computerized image analysis. Proc Biol Sci 2004;271:663Y668 45. Coulson SE, Croxson GR, Gilleard WL. Quantification of the three-dimensional displacement of normal facial movement. Ann Otol Rhinol Laryngol 2000;109:478Y483 46. Farkas LG, Cheung G. Facial asymmetry in healthy North American Caucasians. An anthropometrical study. Angle Orthod 1981;51:70Y77 47. Ferrario VF, Sforza C, Poggio CE, et al. Distance from symmetry: a three-dimensional evaluation of facial asymmetry. J Oral Maxillofac Surg 1994;52:1126Y1132 48. Ferrario VF, Sforza C, Miani A Jr, et al. A three-dimensional evaluation of human facial asymmetry. J Anat 1995;186:103Y110 49. Shaner DJ, Peterson AE, Beattie OB, et al. Assessment of soft tissue facial asymmetry in medically normal and syndrome-affected individuals by analysis of landmarks and measurements. Am J Med Genet 2000;93:143Y154 50. Urban PP, Wicht S, Vucorevic G, et al. The course of corticofacial projections in the human brainstem. Brain 2001;124:1866Y1876 51. Ercan I, Ozdemir ST, Etoz A, et al. Facial asymmetry in young healthy subjects evaluated by statistical shape analysis. J Anat 2008;213:663Y669
Pediatric Acute External Laryngeal Trauma Ali Cemal Yumusakhuylu, MD, Muhammet Fatih Topuz, MD, Ceren Durgun, MD, Adem Binnetoglu, MD, Tekin Baglam, MD, Murat Sari, MD Abstract: Larynx and adjacent anatomical structures have complicated physiological functions and mechanical features. Traffic accidents, penetrating stab wounds and shot wounds, sports matches, and occupational accidents cause external laryngeal trauma. In the management of laryngeal trauma, maintenance of airway patency has priority. In this case report, we will mention of a 15-year-old male patient with a blunt laryngeal trauma and also the approach to laryngeal traumas.
& Volume 25, Number 1, January 2014
muscles at both sides. Ossification and calcification of the laryngeal cartilages increase with age, decreasing the elasticity and resistance. Larynx of children is located higher than in adults, so it is better protected by the mandibula. In addition, larynx of children is more flexible and soft, so the possibility of injury is lower than that of the adults.1 Motor vehicle accidents, sports injuries, and penetrating stab wounds may cause external laryngeal trauma. The most important condition in emergency approach to laryngeal trauma is to protect the vocal functions of the larynx and the airway. In this case report, we present a 15-year-old male patient with a blunt laryngeal trauma and also the approach to laryngeal traumas.
PATIENT A 15-year-old male patient admitted to our clinics with a complaint of neck injury resulting from the stinging of iron railings of the mosque while jumping over the mosque wall. The patient was conscious and cooperative, his blood pressure was 100/60 mm Hg, his pulse rate was 88, his respiration was normal, there was a 4-cm cut on his neck (Fig. 1), and a subcutaneous crepitation was felt with palpation. There was pain on talking and swallowing. Patient had hoarseness. Computed tomography (CT) of upper and lower airways was obtained in the emergency room. A defect was observed on the wall of the left side at the subglottic area in the neck CT (Fig. 2). A diffuse view of emphysema was present in fat planes on both sides of the neck extending to the skull base superiorly by starting from the thoracic inlet. IV fluid replacement and antibiotic, anti-inflammatory, analgesic, and bronchodilator treatments were started. Indirect laryngoscopic examination could not be performed because of pain. Direct laryngoscopy of the patient under sedation just before the entubation revealed left-sided vocal cord paralysis. In direct laryngoscopy, a hemorrhagic perforation on the left side was observed under the vocal cord (Fig. 3). A 0.2 0.2 cm perforation was seen through the exposed skin at the level of cricothyroid membrane. Thyroid cartilage was divided into 2 on the midline (Fig. 4). Cricoid cartilage was intact. Inner perichondrium of thyroid cartilage was peeled off. Perichondrium was sutured with 4-0 vicryl. Four stitches were put on the thyroid cartilage by 3-0 prolene sutures. Strap muscles were
Key Words: Pediatric laryngeal trauma, penetrating trauma, airway management
E
xternal laryngeal trauma, which is seen less than 1% of emergency trauma, is a rare condition but an emergency with high rates of mortality.1 The larynx is under protection of cartilaginous and bony structures. The larynx is protected by the vertebra behind, mandibula above, sternum below, and the sternocleidomastoid
From the Faculty of Medicine, Marmara University, Istanbul, Turkey. Received May 6, 2013. Accepted for publication August 26, 2013. Address correspondence and reprint requests to Dr Muhammet Fatih Topuz, Faculty of Medicine, Marmara University, Istanbul, Turkey; E-mail: [email protected] The authors report no conflicts of interest. Copyright * 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000000393
e70
FIGURE 1. A 4-cm cut on the neck.
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
