Correction of Crow's Feet by the Expansion of Orbicularis Oculi Muscle Flap

As people grow older, many aging phenomena occur in the facial skin and soft tissues, including crow's feet, glabellar frown lines, jowls, depression of malar fat pads, brow ptosis, Marionette lines, and more. Among these results, the authors focused on crow's feet(Lateral. periorbital wrinkles), which are one of the major causes of facial rejuvenation in the periorbital area. Upper & lower blepharoplasty do not always improve crow's feet to one's satisfaction, and above that, surgery sometimes accentuates rather than improves these wrinkles. Consequently, the authors proposed a new operative method for lateral. periorbital wrinkle correction, which could be summarized as dissection of the orbicularis oculi muscle, below the subcutaneous tissue above the temporal fascia, elevation of the muscle flap, advancement of the flap to the upper-lateral direction, and excision of redundant skin. After laying the patient down on the operation table and exposing both ears, the whole face was cleansed with an antiseptic solution. Incision lines were designed as temporal W-shaped. After dissecting through the subcutaneous fat layer and elevating the flap from the temporal fascia, the orbicularis oculi muscle was incised at the lateral margin of orbicularis muscle. The orbicularis oculi muscle flap was then elevated, and pulled into the upper- lateral direction with smooth forceps to find the point which would make the patient's eyes look the most natural. The lateral margin of orbicularis muscle was fixed to the deep temporal fascia of temporal hairline. with 4-0 Nylon suture. Redundant skin was excised and wound was closed with 6-0 Black silk by W- plasty technique. Between 2001 and 2006, 63 patients were operated on using the technique mentioned above, with favorable aesthetic and functional results. Several patients complained about the W-plasty scar but those were aesthetically accepted. Crow's feet are not always corrected with satisfactory results, and sometimes are accentuated, by upper & lower blepharoplasty. In order to solve these problems, an operative technique was conceived that dissects the orbicularis oculi muscle, elevates and advances the muscle flap, and then excises the redundant skin. This technique showed favorable patient satisfaction scores in both functional and aesthetic aspects, with satisfactory results even in long-term follow up, and also had the effect of a central- facial face lift.

Comparative Study of the Latissimus Dorsi and Gracilis Muscle Reconstruction for Reanimation of a Paralyzed Face

PURPOSE: The most accepted method for the reanimation of a paralyzed face is the two-stage method that combines cross-face nerve grafting with free-muscle transfer. Although the results of reconstruction with this method are satisfactory, there is an excessive delay between the stages, which prolongs the period of rehabilitation. In order to overcome this drawback, a one- stage, neurovascular free-flap reconstruction method using free neurovascular muscle flaps is introduced. METHODS: From 1994 to 2004, 35 patients with longstanding facial palsy were treated. Fifteen patients underwent the single-stage reconstruction with the latissimus dorsi muscle, and 20 patients underwent the two-stage reconstruction method with the gracilis muscle. We compared the long-term results of the two methods of reconstruction. The mean follow-up period was 28.7 months for one-stage reconstruction, and 35.2 months for the two-stage, respectively. RESULTS: In the patient group of the single stage reconstruction, both mouth corner excursion and animation grade were markedly improved at the final postoperative visit. Moreover, the first muscle contraction occurred earlier in this group, than in the two-stage reconstruction group. However, four patients in the single stage group never achieved a first muscle contraction or mouth corner excursion. CONCLUSION: Facial palsy is a very challenging condition for cosmetic surgeons to deal with. Traditional methods for treatment of chronic facial palsy use a two- stage muscle flap which is time-consuming and burdensome to patients, many of whom are averse to waiting 8 to 12 months to complete the two stages. The one- stage reconstruction method described herein uses a atissimus dorsi free-flap and has demonstrated consistent positive outcomes in clinical assessments.

The Removal of Plates after Craniomaxillofacial Surgery: A Retrospective Study

PURPOSE: Plate systems have been used for osteosynthesis of cranial and oromaxillofacial fracture. However, there is no consensus on the need for routine removal of plate and the question about indications of removal. Therefore, we present the retrospective study to clarify the indications and consensus of removal. METHODS: The medical records of patients who were treated with rigid internal fixation using plates after craniofacial trauma were reviewed. Study variables included age, gender, type of fracture, type of plate, seniority of the operator, causes of removal, and time between insertion and removal. All results amendable to statistics were analyzed using SPSS 10.0 to determine which set of variables might affect the fate of the plates. RESULTS: For a period of 10 years (March 1, 1994 through July 31, 2004), total of 41 plates(6.7%) were removed among 609 plates inserted into 419 patients; 27 plates were removed from 15 patients for infection, which is the most common cause of removal accounting for 65.8%. Mean time between insertion and removal is 35.2 months and mean age is 41.4 years. Most plates were removed from combined fracture(14.92%) and facial fracture(8.47%) and these were statistically significant. The age, gender, seniority of the operator and other variables were not statistically associated with plate removal. CONCLUSION: This retrospective study shows that routine removal does not appear to be clinically indicated due to respectively low removal rate and that the commonest indications for removal were infection.

Measurement Analytical Study of Computed Tomography of the Orbital Structure in Acute Blow-out Fracture

PURPOSE: Blow-out fracture is one of the most common fractures in facial trauma. It is diagnosed by Computed Tomography(CT) scan, which is considered as the most effective diagnostic tool. Since, the Picture Archiving Communication System(PACS) has been provided recently to many hospitals, doctors are more familiar with imaging software of PACS. Because this software has many useful measuring tools, doctors can measure orbital structure easily and make a plan for treatment with its data. Therefore, authors intended to analyze the data of orbital structure measured with PACS imaging software and evaluate its usefulness. METHODS: The charts and CT images of 100 patients, which were 50 patients with medial wall fracture and 50 patients with floor fracture, were reviewed. Patients were selected by pre-determined criteria and their CT images were measured with image software of PACS. 'Extraocular muscle thickness', 'Defect ratio'(ratio of defect area to normal area) and 'Globe position index' were measured and analyzed statistically. RESULTS: The thickness of inferior rectus muscle and medial rectus muscle was simultaneously increased in acute-stage of blow-out fracture. The medial rectus muscle was more thickened in medial wall fracture and inferior rectus was more thickened in floor fracture, respectively. In acute blow-out fracture, globe position is exophthalmic rather than enophthalmic. Especially in floor fracture, numerical value summed up thickness of all extraocular muscle is correlated to the defect ratio and globe position index. CONCLUSION: Clinicians can decide globe position or presume defect ratio in inferior wall fracture by measurement of CT image in acute blow-out fracture using PACS.

Measurement Analytical Study of Computed Tomography of the Orbital Structure in Acute Blow-out Fracture

PURPOSE: Blow-out fracture is one of the most common fractures in facial trauma. It is diagnosed by Computed Tomography(CT) scan, which is considered as the most effective diagnostic tool. Since, the Picture Archiving Communication System(PACS) has been provided recently to many hospitals, doctors are more familiar with imaging software of PACS. Because this software has many useful measuring tools, doctors can measure orbital structure easily and make a plan for treatment with its data. Therefore, authors intended to analyze the data of orbital structure measured with PACS imaging software and evaluate its usefulness. METHODS: The charts and CT images of 100 patients, which were 50 patients with medial wall fracture and 50 patients with floor fracture, were reviewed. Patients were selected by pre-determined criteria and their CT images were measured with image software of PACS. 'Extraocular muscle thickness', 'Defect ratio'(ratio of defect area to normal area) and 'Globe position index' were measured and analyzed statistically. RESULTS: The thickness of inferior rectus muscle and medial rectus muscle was simultaneously increased in acute-stage of blow-out fracture. The medial rectus muscle was more thickened in medial wall fracture and inferior rectus was more thickened in floor fracture, respectively. In acute blow-out fracture, globe position is exophthalmic rather than enophthalmic. Especially in floor fracture, numerical value summed up thickness of all extraocular muscle is correlated to the defect ratio and globe position index. CONCLUSION: Clinicians can decide globe position or presume defect ratio in inferior wall fracture by measurement of CT image in acute blow-out fracture using PACS.

The Effect of Platelet-Rich Plasma(PRP) on the Survival of the Autologous Fat Graft

PURPOSE: Platelet-rich plasma(PRP) contains protein growth factors, which are actively secreted by platelets to promote wound healing. However, it is not clear whether the injection of PRP into the autologous fat grafts increases the survival rate and the degree of angiogenesis. METHODS: New Zealand White rabbit ears were injected fat with PRP, saline, insulin or isoproterenol (n=8/each group) for observation of the survival and degree of angiogenesis of the injected fat. The volume of the harvested fat and the degree of angiogenesis from dorsum of rabbit ears were evaluated 4, 8, and 12 weeks after the autologous fat graft. The degree of angiogenesis was measured with microvascular density (MVD) counts. RESULTS: The volume of harvested fat decreased in a time-dependent manner after autologous fat grafts, but the decrease rate in volume of harvested fat was slower in PRP-injected group compared to that of other control groups. The difference in the volume of the harvested fat between PRP-injected group and other control groups became significant from 4 weeks after the autologous fat graft, and was maintained up to 12 weeks. However, there was no significant difference between PRP-injected group and insulin-injected group 8 and 12 weeks after the autologous fat graft. On the contrary, MVD counts increased in a time-dependent manner after autologous fat grafts. The MVD counts were significantly higher in PRP-and insulin-injected groups than in other control groups from 4 weeks after the autologous fat graft, and these differences were maintained up to 12 weeks. There was no correlation between mean platelet numbers and the volume of harvested fat. CONCLUSION: The present study demonstrates that PRP-injection into autologous fat grafts increases the survival rate and the degree of angiogenesis. Thus, PRP injection with autologous fat grafts would be a promising tool for maintaining the volume of the grafted fat.

The Effect of Platelet-Rich Plasma(PRP) on the Survival of the Autologous Fat Graft

PURPOSE: Platelet-rich plasma(PRP) contains protein growth factors, which are actively secreted by platelets to promote wound healing. However, it is not clear whether the injection of PRP into the autologous fat grafts increases the survival rate and the degree of angiogenesis. METHODS: New Zealand White rabbit ears were injected fat with PRP, saline, insulin or isoproterenol (n=8/each group) for observation of the survival and degree of angiogenesis of the injected fat. The volume of the harvested fat and the degree of angiogenesis from dorsum of rabbit ears were evaluated 4, 8, and 12 weeks after the autologous fat graft. The degree of angiogenesis was measured with microvascular density (MVD) counts. RESULTS: The volume of harvested fat decreased in a time-dependent manner after autologous fat grafts, but the decrease rate in volume of harvested fat was slower in PRP-injected group compared to that of other control groups. The difference in the volume of the harvested fat between PRP-injected group and other control groups became significant from 4 weeks after the autologous fat graft, and was maintained up to 12 weeks. However, there was no significant difference between PRP-injected group and insulin-injected group 8 and 12 weeks after the autologous fat graft. On the contrary, MVD counts increased in a time-dependent manner after autologous fat grafts. The MVD counts were significantly higher in PRP-and insulin-injected groups than in other control groups from 4 weeks after the autologous fat graft, and these differences were maintained up to 12 weeks. There was no correlation between mean platelet numbers and the volume of harvested fat. CONCLUSION: The present study demonstrates that PRP-injection into autologous fat grafts increases the survival rate and the degree of angiogenesis. Thus, PRP injection with autologous fat grafts would be a promising tool for maintaining the volume of the grafted fat.

Histologic Changes and Photographic Analysis of AlloDerm(R) at Tip Plasty of the Nose

AlloDerm(R) is human cadaveric dermis that has been decellularized. It is easy to handle and simple to use, and has superb tissue compatibility; hence it has been used in several fields. But studies about the effect and the histologic changes of AlloDerm(R) in soft tissue augmentation are lacking. We measured the heights of pronasale and supretip breakpoint through Pre-and post- operative photographs in 13 patients who had undertaken AlloDerm(R) tip plasty surgery from April 2004 to July 2005. Histologic changes were investigated by H&E and CD34 immunochemistry staining of tissue samples from 10 patients who had AlloDerm(R) removed by re-operative procedures from January 2005 to March 2006. The result of photographic analysis is as follows supratip breakpoint heights were 2.43+/-0.36, 2.64+/-38, 2.52+/-0.38mm in the pre-operative(T1), early post-operative(T2) and late post-operative(T3) periods, respectively. Pronasale heights were 2.68+/-0.33, 2.93+/-0.44, and 2.79+/-0.38mm, respectively. Statistical analysis of corrective value of T1-T2, T2-T3 and T1-T3 revealed a statistically significant difference in both pronasale and supratip breakpoint heights. Histological analysis showed chronic inflammatory signs with foreign body reactions around grafted AlloDerm(R). We concluded that AlloDerm(R) neovascularization and fibroblast ingrowth were also noted. AlloDerm(R) is effective in raising the nasal tip, but considering the late-term partial absorption, an overcorrection of about 50% is recommended.

Analysis of Free Flap Reconstruction of the Tongue

PURPOSE: Advanced carcinoma of the tongue is a devastating disease which may cause severe speech or swallowing dysfunction. But, none to date has provided all of the complex functions of the tongue. The purpose of this study is to review our experiences with individuals who underwent glossectomy followed by reconstruction using free tissue transfer. METHODS: Between February 1998 and February 2005, twenty-four patients underwent glossectomy followed by free tissue transfer reconstruction. The defects of tongue caused by partial or subtotal glossectomy were reconstructed by means of radial forearm or lateral thigh free flap with nerve innervation. Especially for the patients who underwent total glossectomy, we reconstructed deglutition muscles anatomically with nerve reinnervation, a procedure that allows the grafted muscle to maintain good tongue bulk without obvious atrophy. RESULTS: Patients were reviewed to determine their functional outcome as it related to speech, deglutition, and aspiration. All patients achieved oral intake of a soft diet and acceptable speech. CONCLUSION: Although reconstruction following glossectomy using free tissue transfer is not ideal, this procedure is safe and reliable, and provides predictable results. A future challenge is the development of a surgical procedure for reconstruction of a tongue that maintains mobility and sensation using neurotized flaps.

Outcome of Open Reduction Via Retromandibular Approach for Mandibular Subcondyle Fracture

Subcondylar fractures have generally been treated by intermaxillary fixation except in cases where there is an absolute indication for open reduction. The reason behind a less aggressive surgical approach lies on the inherent difficulties in manipulating fragments in such a small area at the risk of damaging facial nerves or vessels such as the internal maxillary artery. However, long-term follow-up studies showed that conservative treatment of subcondylar fractures results in disturbances of occlusal function, deviation of the mandible, internal derangement of the temporomandibular joint, and ankylosis of the joint. We carried out open reduction of dislocated subcondylar fractures in 14 patients from 2000 to 2004 by a retromandibular approach. After the reduction of fractured bone, two H-shaped miniplates with 6 holes were fixed with screws at the anterior and posterior surfaces of the subcondyle. The retromandibular approach allowed good access and easy manipulation of the subcondyle. Immediate relief from malocclusion and correction of mandibular midline shifting were observed in all patients. Late temporomandibular dysfunction and ankylosis were not observed. Open reduction with plate osteosynthesis made it possible to avoid IMF in 7 of the 14 patients. The present study shows that open reduction through this retromandibular approach can produce good outcome in adult patients with subcondylar fracture.

A Survey of Korean College Students' Cognition of Cosmetic Operation

Throughout the ages, mankind has always been in pursuit of enhanced personal beauty. Thanks to the power of mass media, interest in one's own personal appearance and the ability to make enhancements through cosmetic operation has skyrocketed. The purpose of this study is to examine the cognition that Korean college students have of cosmetic operation and how it relates to their own personal appearance. From December, 2002 through February, 2003, a total of 402 college students attending school on campuses in Seoul, South Korea were surveyed. The survey population consisted of 218 men and 184 women. Eighteen questions were included in the survey, falling into 5 basic categories; their personal concept of appearance, the need for cosmetic operation, the operative regions they are most concerned with, the means be which they gather information about aesthetic surgery, and their understanding of board certification. Wilcoxon rank sum test(SPSS version 10.1 for window) was used to analyze the data and show the statistical results. The survey revealed that both male and female students consider appearance as important as intelligence. 93% of all respondents feel that they will need some kind of cosmetic operation at some point in their future. Of the desired operative regions, men as well as women gave higher priority to skin surgery than to rhinoplasty, eye surgery, and facial bone contouring surgery. When asked why they might hesitate to undergo an operative procedure, the fear of side effects ranked highest. The results also showed that these students get most of their information on cosmetic operation from the Internet. When asked about their understanding of board certification, only 24% of the respondents could distinguish between board certified plastic surgeons and general physicians. The results of our survey highlight the high amount of interest Korean college students have in maintaining their personal appearance and the positive understanding they have of cosmetic operation. Even though many of the respondents expressed a desire to have cosmetic operation, most of them were apprehensive of the possible side effects. The results also showed that most of the students were unable to correctly identify board certified plastic surgeons. Therefore, the results of this study suggest that the general public is in need of more information on specialized cosmetic operation and board certification.

The Effect of the Injectable Bovine Collagens (Zyderm(R)) on the Repair of Critical-Size Defect in Rat Calvaria

This study was designed to examine the capacity of injectable bovine collagen(Zyderm(R)) to mediate the repair of critical size defects of rat calvaria. Thirty-six rats were randomized into six groups(n=6) and an 8-mm circular calvarial defect was made in each rat. In Group I, defects were left untreated. Defects in Groups II and III were implanted with Zyderm I(R) and Zyderm II(R), respectively. These three groups were evaluated in the 6th week after the operation. The defects in Groups IV, V, and VI received the same treatment as in Groups I, II, and III, respectively and were evaluated at postoperative 12th week. Results were examined by gross and histologic findings, simple radiographic study, and radiodensitometric analysis for bony density quantitatively. By gross and simple radiographic findings, defects with Zyderm(R) implantation showed thick coverage and focal radioopacity within defect area, but non-treated animals showed only fibrous healing. Histologically collagen pocket and woven bone were coexisted over the defect at postoperative 6th week, but the regenerating bone appeared much robust in Group III. At postoperative 12th week, there was a well-organized lamellar pattern of new bone formation, especially on the periosteal side of the defect. In the radiodensitometric analysis, all groups of Zyderm(R) implantation showed significant bony healing. There was also statistically significant difference between Group II and Group III at 6th week. Compared with Group V, however, Group VI did not show significant bony healing at 12th week. Additionally, prolonged implantation period allowed more complete healing of the defects with the same concentration of collagen. In conclusion, Zyderm(R) appeared to be an effective mediator of bone regeneration in this critical size calvarial defect model and its concentration had an effect on bone healing in the early period.

The Effect of Doxorubicin and Allopurinol in Chemomyectomy

This study was designed to identify doxorubicin as a permanent chemomyectomy agent that overcomes reversible effect of botulinum toxin A. Doxorubicin was assessed for its ability to bring about a permanent chemomyectomy and the effects of pretreatment were observed to assess its ability to prevent any complications brought about by doxorubicin. A total of thirteen rabbits were assigned to the control group(n=3) and two experimental groups(n=5 for each group). To investigate the myopathic changes following the injections of the agent, both orbicularis oculi muscles of the lower eyelids of each rabbit in the control group were directly injected with single dose of 0.2ml normal saline. Group I were injected with 0.5mg/0.2ml of doxorubicin into the right eyelid and 1.0 mg/0.2 ml of doxorubicin into the left. Group II were given an intravenous injection of 35mg/kg of allopurinol as the pretreatment, then 30minutes later injected with 0.5mg/0.2ml of doxorubicin into the right and 1.0mg/ 0.2ml of doxorubicin into the left. The rabbits were examined daily to monitor the onset, duration and size of skin necrosis and histologically examined two and four months after initial injections. The myopathic change after doxorubicin injection was persistent and irreversible. The dose related effects of doxorubicin chemomyectomy were confirmed by the histologic finding. Skin necrosis occurred in all cases of doxorubicin injection(both 0.5mg and 1.0mg), however the allopurinol pretreatment decreased the size of the skin necrosis in case of the high dose(1.0mg) of doxorubicin. The combined use of allopurinol and doxorubicin reduced the myopathic change more effectively than doxorubicin use alone. Further study is needed to determine optimal dose and administration method, which we feel will contribute to safer and permanent chemomyectomy.

The Repair of Critical-Size Defect with Fibrin Sealant in Rat Calvaria

This study was designed to evaluate the capacity of fibrin sealant to mediate the repair of critical size defects of rat calvaria. Twenty-four rats were randomized into four groups(n=6) and an 8-mm circular calvarial defect was made in each rat. In Group I and II, as control groups, defects were left untreated and evaluated at postoperative 6th and 12th week, respectively. In Group III and IV, defects were treated with fibrin sealant implantation and evaluated at the same point of time as in Group I and II, respectively. Results were examined by gross and histologic findings, simple radiographic study, and radiodensitometric analysis for bony density quantitatively. By gross and simple radiographic findings, animals with fibrin sealant implantation generally showed thick coverage of defects and focal radioopacity within defect area, but non-treated animals showed only fibrous healing. Histologically, small amount of new appositional bone growth was only seen at the edge of the defect at 6th week in Group III, but in Group IV, there are substantial amounts of new immature bone with well-organized patterns within the defect at 12th week postoperatively. In the radiodensitometric analysis, there was no statistically significant difference between Group I and Group III at 6th week. Compared with Group II, however, Group IV showed significant bony healing (p=0.0225) at 12th week. In conclusion, the fibrin sealant appeared to be an effective mediator in bone regeneration of this critical-sized calvarial defect model, but long-term implantation period should be needed for optimal results.

Epitheloid Sarcoma in the Hand: A Case Report

Epitheloid sarcoma is rare malignant tumor of the skin, connective tissue, subcutaneous tissue and tendon sheath, which was first described by Enzinger in 1970. It is usually located in the extremities. We treated a 30-years-old man who developed an epitheloid sarcoma in the radial side of the left palm. The tumor was 2x1.6x1 cm sized, arose from the thenar muscle, and histologically the mass was composed of epitheloid cells. It was treated by wide local excision. However, after 2 months of initial operation, second operation and radiotheraphy was performed because of local recurrence. Because of its harmless appearance and similarity to an inflammatory response, it is often mistaken for a benign lesion.Even though it is a rare tumor, clinicians and pathologists should be aware of this malignant nature. Metastasis can be local or may involve draining lymph node and other distant organs, mostly the lung. Diagnosis is made on pathologic evaluation. Aggressive surgical approach is required in order to prevent recurrence, and radiotherapy and chemotherapy should be considered in all cases.

Orbital Reconstruction via Extended Transconjuctival and Transpalpebral Approach

In case of blow-out fracture involving floor or inferomedial wall, the fracture site can be accessed by methods such as subcilliary incision, mid-lower eyelid incision, infra-orbital incision and transconjunctival incision. Meanwhile, in case of orbital fracture involving supero-medial wall or roof, above-mentioned methods have the limitation of fracture site exposure, and bicoronal incision is required to overcome the difficult approach. The authors exposed fracture site widely and executed accurate reduction through extended transconjunctival approach and transpalpebral approach, instead of the approach by bicoronal incision. We executed 118 cases of orbital reconstruction by above method among 96 patients who consulted doctors to reconstruct blow-out fracture and enophthalmos from September 1997 to May 2001. Among the 118 cases were 50 cases of orbital floor fracture, 4 cases of orbital roof fracture, 48 cases of orbital medial wall fracture, 13 cases of complex type and 3 cases of enophthalmos. The authors made wide dissection of antero-superial medial wall of orbit and roof fracture of orbit enabled by above methods, which allowed enough exposure and approach to orbital fracture site and prevented side effects such as post operative lower eyelid scar or ectropion and scleral show.

Arterialized venous flap

Paget-Schroetter syndrome is synonymous with spontaneous or effort-induced thrombosis of the axillosubclavian vein that is characterized by swelling and pain on upper extremity. Though axillosubclavian thrombosis represents only 1 - 2%, its frequency of diagnosis has increased over the past years due to improvement of ultrasonography. Although the cause of catheter and drug-related cases is clear, several studies have invested the etiology of Paget- Schroetter syndrome, a condition more commonly seen in the young and otherwise healthy individual. Factors often cited include compression of the vein by the anatomic structure, stress, or excessive effort to the extremity, and repetitive shoulder-arm motion. In the view of treatment, thrombolysis by direct infusion of urokinase has proven to be superior to surgical thrombectomy and is now treatment of choice. We successfully treated a 30-year-old man who suffered from swelling and pain on the right upper extremity by using direct urokinase infusion on thrombosis of subclavian vein. This is very rare disease in plastic and reconstructive surgery, thus diagnosis will seldom be made on clinical evaluation. It should be included in the differential diagnosis of upper extremity swelling compared with lymphedema.

New Tension-free Suture Method in the Forehead Reduction and Scalp Reduction

A variety of treatments has been used to correct long forehead and frontal alopecia. These include forehead reduction (scalp reduction), hair graft and flap transfer. Among these procedures, forehead reduction (scalp reduction) is the most simple and effective method. In this procedure, various fixation techniques of scalp flap to cranial bone are used to prevent retraction of the scalp. We used Sherlock (or Piranha) screw to anchor the scalp flap to cranial bone. Between August 1998 and May 2000, this technique had been performed for 37 patients. Average follow-up period was 15 months. For forehead reduction (scalp reduction), the scalp was elevated back to the occipital region through a pretrichial incision, and relaxation incisions of galea was made at a right angle to the vector of advancement. The Sherlock (or Piranha) screw was fixed to the cranial bone. The entire scalp was then repositioned anteriorly, advancing the hairline caudally and shortening the forehead. Retraction of the scalp was prevented by anchoring the galeal fascia to the cranial bone using Sherlock (or Piranha) screws. This technique allows sufficient advancement of the scalp and a tension-free closure. Postoperatively scar widening was less than that of other methods. There were not any infection, hematoma, hair loss nor permanent paresthesia on scalp. In 2 cases, screws were palpable and we removed a screw for 1 case. Advantages of using Sherlock (or Piranha) screw are that the procedure is easy and simple, and sufficient advancement of the scalp, tension-free closure, and less scar widening can be achieved. Disadvantages of this procedure include cost of screw and palpability of screw. In conclusion, by using Sherlock (or Piranha) screw, the procedure was simple and we could get aesthetically good results.

Cranioplasty with Absorbable Plates for Craniosynostosis

With the introduction of smaller metallic plating systems, many surgeons have adopted their use for craniofacial procedures in infants and small children. However, this metallic plating system had problems associated with the use of plates and screw in infants and children. These problems include intracranial migration of material, cranial growth restriction, foreign body reaction and infection. Absorbable plating system has been used as solution of these problems. In this study, absorbable plates (BioSorbFX, BIONX IMPLANTS inc.) composed of a copolymer of polylactic and polyglycolic acid were used in the reconstruction of pediatric craniofacial deformities. In 4 patients who were diagnosed with craniosynostosis between 10 and 36 months of age, absorbable plates were implanted. Follow-up periods were from 6 months to 18 months. Postoperatively, circumferential length of head was increased and cranial bone growth was symmetric. No complications were seen with this use, including infection, overlying soft tissue reaction, reconstructive instability, or underlying osteolysis around the screws. In secondary reconstructive surgery of patient with Crouzon's disease, we found out that no residual traces of polymer were evident visually and all osteotomy sites were healed completely without underlying osteolysis. These results demonstrate the safety and effectiveness of this copolymeric material for pediatric craniofacial applications.

Stability and Efficacy of Titanium in Osteointegration in a Rabbit Model

Osteointegration with titanium implant has become a highlight having titanium implant tightly fixed in the bone with prosthesis attaching over it. The procedure is relatively simple with no morbidity of donor site and ensues superior shape aesthetically. However, the stability of it has been in question, therefore an experiment was performed to study the actual stability and periosteal formation around the implant. This study presents a histomorphometric and biomechanical comparison of bone response between titanium and stainless steel placed in the tibia of 5 rabbits. Two implants were placed in tibia of rabbit; titanium implant in left and stainless steel implant as a control in right. As a titanium implant, Brnemark implant with depth of 4 mm and diameter of 3.75 mm which has actually been used in the reconstruction of ears was used, and the stainless steel was manufactured in the same way as titanium implant. After a healing period of 3 months, the average removal torque was 8.2 Ncm for the stainless steel implants and 26.5 Ncm for the titanium implant. Histomorphometric study revealed that the stainless steel screw demonstrated rough and irregular contact surface with partial formation of new bone and the titanium implant demonstrated smooth contact surface with a good formation of new bone. In conclusion, the results indicated that titanium surfaces achieved greater periosteal bone formation over stainless steel surfaces and provided enhanced mechanical interlocking.