Effect of navigation endoscopy combined with threedimensional printing technology in the treatment of orbital blowout fractures

●AIM:To explore the combined application of surgical navigation nasal endoscopy(NNE)and three-dimensional printing technology(3DPT)for the adjunctive treatment of orbital blowout fractures(OBF).●METHODS:Retrospective analysis was conducted on the data of patients with OBF who underwent surgical treatment at the Affiliated Eye Hospital of Nanchang University between July 2012 and November 2022.The control group consisted of patients who received traditional surgical treatment(n=43),while the new surgical group(n=52)consisted of patients who received NNE with 3DPT.The difference in therapeutic effects between the two groups was evaluated by comparing the duration of the operation,best corrected visual acuity(BCVA),enophthalmos difference,recovery rate of eye movement disorder,recovery rate of diplopia,and incidence of postoperative complications.●RESULTS:The study included 95 cases(95 eyes),with 63 men and 32 women.The patients’age ranged from 5 to 67y(35.21±15.75y).The new surgical group and the control group exhibited no statistically significant differences in the duration of the operation,BCVA and enophthalmos difference.The recovery rates of diplopia in the new surgical group were significantly higher than those in the control group at 1mo[OR=0.03,95%CI(0.01–0.15),P<0.0000]and 3mo[OR=0.11,95%CI(0.03–0.36),P<0.0000]postoperation.Additionally,the recovery rates of eye movement disorders at 1 and 3mo after surgery were OR=0.08,95%CI(0.03–0.24),P<0.0000;and OR=0.01,95%CI(0.00–0.18),P<0.0000.The incidence of postoperative complications was lower in the new surgical group compared to the control group[OR=4.86,95%CI(0.95–24.78),P<0.05].●CONCLUSION:The combination of NNE and 3DPT can shorten the recovery time of diplopia and eye movement disorder in patients with OBF.

Biomechanical analysis of an absorbable material for treating fractures of the inferior orbital wall

AIM:To investigate the biomechanical properties and practical application of absorbable materials in orbital fracture repair.METHODS:The three-dimensional(3D)model of orbital blowout fractures was reconstructed using Mimics21.0 software.The repair guide plate model for inferior orbital wall fracture was designed using 3-matic13.0 and Geomagic wrap 21.0 software.The finite element model of orbital blowout fracture and absorbable repair plate was established using 3-matic13.0 and ANSYS Workbench 21.0 software.The mechanical response of absorbable plates,with thicknesses of 0.6 and 1.2 mm,was modeled after their placement in the orbit.Two patients with inferior orbital wall fractures volunteered to receive single-layer and double-layer absorbable plates combined with 3D printing technology to facilitate surgical treatment of orbital wall fractures.RESULTS:The finite element models of orbital blowout fracture and absorbable plate were successfully established.Finite element analysis(FEA)showed that when the Young’s modulus of the absorbable plate decreases to 3.15 MPa,the repair material with a thickness of 0.6 mm was influenced by the gravitational forces of the orbital contents,resulting in a maximum total deformation of approximately 3.3 mm.Conversely,when the absorbable plate was 1.2 mm thick,the overall maximum total deformation was around 0.4 mm.The half-year follow-up results of the clinical cases confirmed that the absorbable plate with a thickness of 1.2 mm had smaller maximum total deformation and better clinical efficacy.CONCLUSION:The biomechanical analysis observations in this study are largely consistent with the clinical situation.The use of double-layer absorbable plates in conjunction with 3D printing technology is recommended to support surgical treatment of infraorbital wall blowout fractures.

Reconstruction of complex orbital fracture with titanium implants

AIM: To evaluate the effectiveness and safety of complex orbital fracture reconstruction with titanium implants. METHODS: A retrospective review of 46 patients treated with complex orbital fractures reconstruction using titanium implants from January 2005 to December 2008 was conducted. The following data were recorded: age, gender, mechanism of injury, preoperative and postoperative orbital CT, visual acuity, diplopia, ocular motility and Hertel exophthalmometer. RESULTS: The most common cause was motor vehicle accident (47.8%), followed by industrial injury (30.4%). All patients had improved appearance after operation and CT scan at one week after operation showed the fracture defects of orbit and neighboring areas had been reconstructed. Forty-six cases had various degrees of enophthalmos before operation. Among them, 32 cases were completely corrected, 11 cases improved obviously and 3 cases had no improvement after operation. Thirty-six patients with visual acuity =20/60 revealed diplopia of various degrees, including 26 patients had diplopia in right ahead and/or reading positions. At the sixth month after operation, diplopia disappeared in five patients, 7 patients still had diplopia in right ahead and/or reading positions, 14 patients had diplopia in positions rather than right ahead and reading positions (<20 degrees) and ten patients had diplopia only at peripheral gazing (>20 degrees). All patients had various degrees of ocular motility disorders before operation. At the sixth month after operation, eyeball movement disorder disappeared in 9 patients, 31 patients showed improvement and 6 patients had no improvement. Complications of implant infection, rejection and displacement were not reported after operation. CONCLUSION: The application of titanium implants in the repair of complex orbital fractures greatly improves the appearance and functional results, which is a favorable material for plastic surgery of complex orbital fracture.

Analysis of the effect of repair materials for orbital blowout fracture on complications

AIM: To investigate the effect of repair materials for orbital blowout fractures on the occurrence of postoperative complications. METHODS: The clinical data and follow-up data of 54 subjects with orbital blowout fractures were retrospectively analyzed. The study was divided into three groups according to the used repair materials: titanium mesh(16 cases), Medpor(12 cases), and Medpor titanium mesh(26 cases). All test data were analyzed using the SPSS version 23.0 statistical software. The mean age and duration of disease between the groups were compared through oneway analysis of variance. The Chi-square(χ~2) test was used to compare the number of males and females, different fracture types, and different surgical approaches among groups. The χ~2 test was used to compare the frequencies for complications in each group.RESULTS: The baseline characteristics of age and gender in each group were matched(F=1.763, P=0.172;χ~2=0.026, P=0.987). In addition, there was no difference in the type of fracture and surgical approach(χ~2=0.460, P=0.977;χ~2=0.691, P=0.952), or the incidence of complications(χ~2=0.081, P=0.960) between the three groups. CONCLUSION: Although there is no difference in effect of various repair materials on the incidence of complications, the effect of repair materials on postoperative complications of orbital blowout fractures should not be ignored.

Role of orthoptics and scoring system for orbital floor blowout fracture:surgical or conservative treatment

AIM:To assess the role of orthoptics in referring patients with orbital floor blowout fracture(OFBF)for conservative or surgical treatment and based on the results,to propose a scoring system for such decision making.METHODS:A retrospective analysis of 69 patients with OFBF was performed(35 treated conservatively,34 surgically).The role of orthoptics in referring to surgery or conservative treatment was retrospectively evaluated,the factors with the highest significance for decision making were identified,and a scoring system proposed using Logistic regression.RESULTS:According to defined criteria,the treatment was unsuccessful in 2(6%)surgically treated and only in one(3%)conservatively treated patient.The proposed scoring system includes the defect size and several values resulting from the orthoptic examination,the elevation of the eyebulb measured on Lancaster screen being the most significant.CONCLUSION:The study demonstrates the benefits of orthoptic examination when making decisions on conservative or surgical treatment and for diagnosing ocular motility disorder(with or without binocular diplopia)in OFBF patients.The proposed scoring system could,following verification in a prospective study,become a valuable adjunctive tool.

Temporary severe oculomotor nerve palsy after reconstruction of orbital medial wall fracture: a case report of nonfamiliar complication

Dear Editor, Commonly known complications following reconstruction of an orbital fracture include diplopia, hemorrhage, and displacement or infection of the orbital implant, and some studies have reported ptosis caused by temporary or permanent oculomotor nerve palsy after operation.

Repeated Hemorrhage after Repair of Orbital Floor Fracture with a Silicone Implant

A 16-year-old girl was accidentally kicked in her right eye by her cheerleading teammate in an exercise. Upward gaze ability of her right eye was severely impaired and computed tomography (CT) showed a trapdoor fracture of the right orbital floor. After surgical exploration, a silicone implant was inserted. No bleeding was confirmed at this time. The next day, CT detected a hematoma on the right orbital floor. The hematoma was drained and meticulous cautery was used to control any potential bleeding. The same silicone implant was re-inserted. Irrespective of attempts to avoid hemorrhage, this occurred twice after the respective evacuations. During a fourth operation, we removed the silicone implant simultaneously with hematoma evacuation. No hematoma has occurred since, and the patient’s ocular movement has dramatically improved to a normal binocular single vision field. When repeated hemorrhages occur after an orbital floor fracture repair with insertion of a silicone implant, removal of the implant is an effective strategy to resolve the hemorrhage.

Water balloon-induced orbital fracture in an aviator

Background:Orbital fractures are common injuries found in facial trauma.Typical etiologies of orbital fractures include motor vehicle collisions and assault.We report the case of a 32-year-old male who suffered an orbital fracture from a water balloon.Additionally,we describe the aeromedical complications that may result from this injury.Finally,we attempt to answer the question of when a patient may return to flying after sustaining such an injury through review of the literature.Case presentation:A 32-year-old male pilot with the United States Air Force was at an outdoor event with his unit when he was struck with a water balloon launched from a sling shot into his left orbit.Shortly afterwards,he had an onset of subcutaneous emphysema and was escorted to a nearby Emergency Department.Computed tomography identified an orbital fracture with associated orbital and subcutaneous emphysema.The patient was evaluated by a plastic surgeon and was determined not to be a surgical candidate.Four weeks later,he returned to flying status.Conclusions:Water balloons are thought to be safe and harmless toys.However,when coupled with sling shots,water balloons can become formidable projectiles capable of significant orbital injury including orbital fractures.These injuries are concerning to aviators,as the most common sites for fractures of the orbit are the thin ethmoid and maxillary bones adjacent to the sinuses.At altitude,gases in the sinuses may expand and enter the orbit through these fractures,which may suddenly incapacitate the flyer.It is important for flight surgeons to identify and assess these individuals to determine suitability for flying.

Ophthalmologic Repercussions of Orbital Fractures

Orbital fractures refer to all continuity solutions involving the wall of the orbit. They are responsible for serious complications, particularly ophthalmological. Objective: To identify the epidemiological, anatomical and clinical aspects as well as the possible ocular complications of orbital fractures in the Gbêkê region. Methods: Prospective study from July 1, 2020, to October 31, 2020, i.e., a duration of 4 months. It took place in the ophthalmology department of the University Hospital of Bouaké. Patients with orbital fractures with ocular repercussions received during the study period were included. Results: Out of 27 cases of orbital floor fracture received, 20 had ocular complications, i.e., a prevalence of 74.07%. The average age was 32 years with extremes of 18 and 48 years. The male gender predominated with 80%, i.e. a sex ratio of 4. Subconjunctival hemorrhage was the most frequent reason for consultation (70%). The etiology was dominated by road traffic accidents (85%). The average consultation time was 24 hours. 80% of the patients had a distance visual acuity (DVA) between 3/10 and 10/10.) Diplopia was observed in 60% of patients. Blow out fracture (70%) was the most prominent orbital lesion. At the paraclinical level, 80% of the patients had performed a CT scan of the orbit. Evisceration was the predominant ophthalmologic surgical management (4 patients). At the bone level, reconstruction of the orbital floor with a polydioxanone plate (PDS) was performed in 50% of patients. Conclusion: The risk of ocular injury in orbital fractures is frequent because of the close relationship between the orbit and the eyeball.

Orbital Floor Fractures: Epidemiological, Clinical and Therapeutical Study at Sylvanus Olympio University Teaching Hospital in Loméabout 51 Cases

Introduction: Orbital floor fractures are a significant pathology among maxillofacial injuries. They can cause oculomotor, sensory, and sometimes esthetic disorders. The goal of this study was to determine the epidemiological profile of orbital floor fractures and show their clinical and therapeutic approach in Lomé. Patients and method: This was a descriptive retrospective study of orbital floor fractures collected in the ENT and maxillofacial surgery department of Sylvanus Olympio University Hospital in Lomé over 8 years (January 1, 2011 to December 31, 2018). Results: We reviewed 63 cases of orbital floor fractures out of 552 cases of facial trauma. According to the inclusion and non-inclusion criteria, we retained 51 cases. The hospital frequency of orbital floor fractures was 9.24% of facial fractures. The average age of the patients was 35 ± 10.34 years. Males were predominant (ratio = 7.5). The main etiology was road accidents (92.16%). Ophthalmological signs were dominated by vertical diplopia (31.37%), limited eye movement (25.49%), and enophthalmia (29.41%). The sensory sign was dominated by suborbital hypoesthesia (13.73%). Surgical treatment was performed in 86.27% of patients. The average intervention time was 17.84 ± 12.69 days after the trauma. The main approach was the subciliary route (65.91%). The surgical procedures consisted of muscle and fat removal (20.45%) and orbital floor repair by mesh plate (50%). The average length of hospitalization was 9.63 ± 5.23 days. Surgical site infection was the main postoperative complication observed in 3.92% of patients. The main sequelae were diplopia (4.55%), suborbital hypoesthesia (4.55%), and enophthalmos (4.55%). Conclusion: Orbital floor fractures are mainly due to road accidents. Management must be multidisciplinary and adequate in order to avoid irreversible functional and/or morphological sequelae. Their prevention consists of effective combat of road accidents.

Eyelid malposition after orbital fracture surgery

Orbital fractures generally do not cause eyelid malposition.Studies have shown that mostly eyelid malposition is mainly due to the choice of surgical approaches of orbital fracture repair.Approaches are divided into transcutaneous and transconjunctival ones.The application of orbital fracture approaches depends on fractures’range and the surgeons’preferences.Eyelid malposition after orbital fracture surgery is not only an aesthetic concern but also a functional complication,which will cause eyes discomfort,such as corneal exposure and ocular irritation.Some patients may have multiple types of eyelid malposition.In this review,we summarized the surgical approaches of orbital fractures and the complications including scar,ectropion,retraction,entropion,flattening,laceration and lacrimal canaliculus avulsion and notch deformity that associated with eyelid,especially the lower eyelid.Reports revealed that the scar usually occurred in infraorbital incisions compared with subtarsal and subciliary incisions,and the transconjunctival approach had a higher incidence of entropion and flattening,and less ectropion than the transcutaneous approach.Meanwhile,pathogenesis of eyelid malposition after orbital fracture surgery are discussed.Furthermore,to prevent eyelid malposition complications,doctors should choose the appropriate orbital fracture approach according to the patient’s needs,and delicate tissue management,technical expertise,and meticulous hemostasis are necessary.Conservative treatment with taping,lubricating ointment,and steroid for eyelid malposition complications should be performed first,and then surgical intervention when the conservative treatment fails.

Intro-extro carnial approach treatment serious post fronto-orbital fracture deformities

Objective To explore the method of treating serious secondary fronto-orbital fracture deformities through intro-extra cranial approach. Methods The fronto-orbital fracture was divided into two types according to whether there were any large scale fronto-otbital bone defects; typeⅠ: Large scale fronto-orbital bone defect; type Ⅱ: Concave fronto-orbital fracture deformity without large scale bone defect. Both types were treated throuth intro-extra cranial approach to expose the fracture site. For typel deformity, the bone defects were repaired and reconstructed with outer table of cranial bone and artificial bone. For type Ⅱ, the deformity was repaired by osteotomy, bone reposition and internal rigid fixation. Results 18 cases were treated from June 1998 to October 2000, include typeⅠ, 12 cases, and typeⅡ, 6 cases. All the patients recovered well and the post-operative appearance were greatly improved. Conclusion Intro-extra cranial approach can June 2003 Vol12 No2 expose the fractured site better

Biocompatibility of polyetheretherketone for the treatment of orbital bone defects

AIM: To investigate the biocompatibility and therapeutic effects of polyetheretherketone(PEEK) on recovery of a rabbit orbital defect.METHODS: Totally 16 New Zealand rabbits were used to establish an orbital bone defect model and then randomly divided into two groups. PEEK was implanted in the experimental group. The control group was blank, and no substance was implanted. The model rabbits were sacrificed at 4 and 8 wk, and examined by general observations, histology, electron microscopy, Western blotting, and realtime polymerase chain reaction.RESULTS: No infection or rejection occurred after PEEK implantation, and biocompatibility was good. The relative expression of vascular endothelial growth factor(VEGF) protein in the experimental group was significantly higher than that in the control group postoperatively(P<0.05). Bone defect repair in the experimental group was significantly better than that in the control group in the same period and some osteogenesis was observed.CONCLUSION: PEEK has good biocompatibility and efficacy for the treatment of orbital bone defects in a rabbit model.

Frequency of Blindness Due to Zygomatic Fracture in Hazrat Fatemeh Hospital

Background: Zygomatic fracture is one of the most prevalent one among facial fractures caused by vehicle accident, motorcycle accident, fighting, fall and sport injuries. Materials & Methods: This study was a retrospective study of our patients during past 6 years. Results: We had 1277 facial fractures, of whom 9 patients had blindness. We had 193 patients with Zygomatic fracture. 98 patients had pure zygomatic fracture and other had complicated fractures. Frequency of blindness due to zygomatic fracture in a period of six years was 4.7% in all and in pure zygomatic fractures was 2.04%. Blindness was most prevalent in age group 20 - 29 years old (55.6%). The most prevalent cause of zygomatic fracture which causes blindness, was motor vehicle accident (77.8%). Blindness was more common in males (77.8%) than females (22.2%). Discussion and Conclusions: One of the most disastrous complication of zygomatic fracture is transection of optic nerve. Very careful examination of fractured bones careful examination of optic nerve and visual acuity and urgent operation and decompression of optic nerve must be performed. About 4% - 5% will have blindness purely due to fracture.

Facial and Periorbital Emphysemas Following a Violent Sneezing: An Atypical Clinical Situation

Introduction: Facial emphysema is the presence of air in the subcutaneous tissues of the facial region. They can be clinically recognized by the crackling sensation felt when the affected area is palpated. Observation: The authors describe left orbito-facial emphysema that occurred after a violent sneezing episode in a 36-year-old patient. He had significant edema of the left facial and ipsilateral periorbital region associated with major emphysema and complete closure of the left eye. Nasal cavities endoscopy revealed inflammation of the distal orifice of the nasolacrimal duct. The clinical ophthalmologic examination performed in emergency showed left chemosis, slight ocular hypertonia of mechanical origin, and a slight decrease in visual acuity. Pupillary reflexes and retinography were normal. A craniofacial computed tomography (CT) revealed a significant left orbital emphysema, a fracture of the left medial orbital wall (ethmoidal lamina papyracea) with intraconal fat incarceration without entrapment of the medial rectus and significant air infiltration of all the left hemifacial soft tissues. A broad-spectrum antibiotic and anti-inflammatory treatment were instituted, as well as practical advice to prevent a recurrence. We observed progressive resorption of the edema with a return to the normal of the soft tissues and the palpebral cleft in 15 days. Conclusion: These atypical cases can be serious. It is essential to exclude signs of visual deficit and ocular compression. Multidisciplinary management is important.

Isolated traumatic orbital floor fracture:An analysis of the National Trauma Data Bank

Objectives:To date,no study provides a comprehensive analysis of traumatic orbital floor fractures across the United States.We aimed to characterize patient demographics,injury-related variables,and operative management in this population.Method:The National Trauma Data Bank was queried for open or closed orbital floor fractures from 2008 to 2016.Clinical data were extracted.Results:Overall,148,592 orbital floor fractures were identified,with 142,577(95.9%)closed-and 6158(4.1%)open-type fractures.A total of 106,243(71.5%)patients were male and the median patient age was 41 years.The majority of patients(79.2%)had abbreviated injury scale scores of≤2,indicating minor/moderate injury.Fracture mechanism of injury(MOI)differed by gender,with the most frequent being unarmed fights in men(34.3%)and falls in women(14.0%).There were 29,600 patients(19.9%)with isolated orbital floor(I-OF)fractures.The MOI most strongly associated with operative intervention of with I-OF fractures were penetrating injuries caused by a firearm(odds ratio[OR]:2.91;95%confidence interval[CI]:1.62–5.20)and cuttings/piercings(OR:2.17;95%CI:1.29–3.65).Conclusion:This large epidemiological study reveals that orbital floor fractures tend to present with minor or moderate injuries and are more likely to require operative intervention in setting of firearm or cut/pierce injuries.

A retrospective study to compare the treatment outcomes with and without surgical navigation for fracture of the orbital wall

Purpose To evaluate the outcomes with and without aid of a computer-assisted surgical navigation system(CASNS)for treatment of unilateral orbital wall fracture(OWF).Methods Patients who came to our hospital for repairing unilateral traumatic OWF from 2014 to 2017 were included in this study.The patients were divided into the navigation group who accepted orbital wall reconstruction aided by CASNS and the conventional group.We evaluated the surgical precision in the navigation group by analyzing the difference between actual postoperative computed tomography data and preoperative virtual surgical plan through color order ratios.We also compared the duration of surgery,enophthalmos correction,restoration of orbital volumes,and improvement of clinical symptoms in both groups systemically.Quantitative data were presented as mean±SD.Significance was determined by the two-sample t-test using SPSS Version 19.0 A p<0.05 was considered statistically significant.Results Seventy patients with unilateral OWF were included in the study cohort.The mean difference between preoperative virtual planning and actual reconstruction outcome was(0.869±0.472)mm,which means the reconstruction result could match the navigation planning accurately.The mean duration of surgery in the navigation group was shorter than it is in the control group,but not significantly.Discrepancies between the reconstructed and unaffected orbital-cavity volume and eyeball projection in the navigation group were significantly less than that in the conventional group.One patient had remnant diplopia and two patients had enophthalmos after surgery in the navigation group;two patients had postoperative diplopia and four patients had postoperative enophthalmos in the conventional group.Conclusion Compare with the conventional treatment for OWF,the use of CASNS can provide a significantly better surgical precision,greater improvements in orbital-cavity volume and eyeball projection,and better clinical results,without increasing the duration of surgery.

Application of endoscopic techniques in orbital blowout fractures

Minimally invasive surgical techniques,particularly endoscopic techniques,have revolutionized otolaryngeal surgery.Endoscopic techniques have been gradually applied in orbital surgery through the sinus inferomedial to the orbit and the orbital subperiosteal space.Endoscopic techniques help surgeons observe fractures and soft tissue of the posterior orbit to precisely place implants and protect vital structures through accurate,safe,and minimally invasive approaches.We reviewed the development of endoscopic techniques,the composition of endoscopic systems for orbital surgery,and the problems and developmental prospects of endoscopic techniques for simple orbital wall fracture repair.

Clinical outcome after orbital floor fracture reduction with special regard to patient's satisfaction

Purpose: Primary reconstruction via transconjunctival approach is a standardized treatment option for orbital floor fractures. The aim of this study was to compare the findings of specific ophthalmologic assessment with the patient's complaints after fracture reduction. Methods: A retrospective medical chart analysis was performed on patients who had undergone transconjunctival orbital floor fracture reduction for fracture therapy with resorbable foil (ethisorb sheet or polydioxanone foil). A follow-up assessment including ophthalmological evaluation regarding visual acuity (eye chart projector), binocular visual field screening (Bagolini striated glasses test) and diplopia (cover test, Hess screen test) was conducted. Additionally, a questionnaire was performed to assess patients' satisfaction. Results: A total of 53 patients with a mean follow-up of 23 months (ranging from 11 to 72) after surgical therapy were included. Diplopia was present preoperatively in 23 (43.4%) and reduced in follow-up examination (n = 12, 22.6%). Limitations in ocular motility reduced from 37.7% to 7.5%. The questionnaire about the patient's satisfaction revealed excellent outcomes in relation to the functional and esthetical parameters. Conclusion: Transconjunctival approach is a safe approach for orbital fracture therapy. Postoperative diplopia is nearly never perceptible for the individual and differs to pathologic findings in the ophthalmic assessment.

Theoretical model of pediatric orbital trapdoor fractures and provisional personalized 3D printing-assisted surgical solution

Pediatric orbital trapdoor fractures are common in children and adolescents and usually require emergency surgical intervention.Herein,a personalized 3D printing-assisted approach to surgical treatment is proposed,serving to accurately and effectively repair pediatric orbital trapdoor fractures.We first investigated stress distribution in external force-induced orbital blowout fractures via numerical simulation,determining that maximum stresses on inferior and medial walls exceed those on superior and lateral walls and thus confer higher probability of fracture.We also examined 36 pediatric patients treated for orbital trapdoor fractures between 2014 and 2019 to verify our theoretical construct.Using 3D printing technique,we then created orbital models based on computed tomography(CT)studies of these patients.Absorbable implants were tailor-made,replicating those of 3D-printed models during surgical repairs of fractured orbital bones.As follow-up,we compared CT images and clinical parameters(extraocular movements,diplopia,enophthalmos)before and 12 months after operative procedures.There were only two patients with diplopia and six with enophthalmos>2 mm at 12 months,attesting to the efficacy of our novel 3D printing-assisted strategy.