Libyan freedom fighter. Injury sustained 3 weeks prior to admission. Entrance wound of missile at R medial canthal area, repaired elsewhere.

Trajectory of missile crosses the L orbit, thereby blinding the patient. Exit wound at L temple.

Extensive comminution of naso-orbito-ethmoidal area results in traumatic telecanthus.

Frontal skull defect was caused by older road traffic

accident. Stereolithographic model of

skull defect constructed from CT data.

Access to nasofrontal area, supraorbital rims bilaterally, L zygomaticofrontal area and L zygomatic arch via coronal flap.

Laterally-based pericranial flap raised on the L independently to be used for reconstructive purposes or for dural repair, if needed.

Frontal skull defect dissected after full development of the coronal flap down to the supraorbital bar.

Frontal skull defect dissected after full development of the coronal flap down to the supraorbital bar.

Development of coronal flap down to L zygomatic arch, which is extensively comminuted, like the L lateral orbital rim (exit wound of

missile)

Reduction and wire fixation of L frontozygomatic suture area.

Anterior skull base, as viewed from above. 3 dural tears repaired with Vicryl sutures. Additional sealing effect obtained with application of

large collagen membrane and tissue glue.

Reconstruction of frontal skull defect (frontal cranioplasty) with titanium-reinforced porous polyethylene sheet and multiple

microscrews.

Frontal bar reconstruction with multiple microplates. “T”-shaped plate holds porous polythelene implant for management of saddle nose

deformity.

Reconstruction of L orbital floor with porous polyethylene implant supported by microplate. L zygoma body fracture fixed with miniplate.

Medial inferior orbital rim fracture fixed with wire. The remains of the L eye globe were enucleated and a porous polyethylene sphere was

inserted.

Immediately postoperative. No attempt was made to revise skin lacerations to minimize risk of exposure of nasal dorsum implant. A left

medial canthopexy has been performed to address traumatic telecanthus.

Postoperative skull films

2-months postoperative / The L eye globe is prosthetic.

1.5-years postoperative

Duration of surgery: 14 hours Surgical team: George Vilos, Oral & Maxillofacial Surgeon Harry Apostolidis, Oral & Maxillofacial Surgeon Athanasios Roumeliotis, Oculoplastic Surgeon Stavros Tombris, Oral & Maxillofacial Surgeon