Reconstruction of the palatal aponeurosis with autogenous fascia lata in secondary radical intravelar veloplasty: a new method.

Velopharyngeal insufficiency in cleft patients with muscular insufficiency detected by nasendoscopy is commonly treated by secondary radical intravelar veloplasty, in which the palatal muscles are reoriented and positioned backwards. The dead space between the retro-displaced musculature and the posterior borders of the palatal bone remains problematic. Postoperatively, the surgically achieved lengthening of the soft palate often diminishes due to scar tissue formation in the dead space, leading to reattachment of the reoriented muscles to the palatal bone and to decreased mobility of the soft palate. To avoid this, the dead space should be restored by a structure imitating the function of the missing palatal aponeurosis. The entire dead space was covered using a double layer of autogenous fascia lata harvested from the lateral thigh, which should allow sufficient and permanent sliding of the retro-positioned musculature. A clinical case of a 9-year-old boy who underwent the operation is reported. Postoperatively, marked functional improvements were observable in speech assessment, nasendoscopy and nasometry. The case reported here suggests that the restoration of the dead space may be beneficial for effective secondary palatal repair. Fascia lata seems to be a suitable graft for this purpose.

Short- and long-term skeletal relapse after mandibular advancement surgery.

This study analyzes short- and long-term skeletal relapse after mandibular advancement surgery and determines its contributing factors. Thirty-two consecutive patients were treated for skeletal Class II malocclusion during the period between 1986 and 1989. They all had combined orthodontic and surgical treatment with BSSO and rigid fixation excluding other surgery. Of these, 15 patients (47%) were available for a long-term cephalography in 2000. The measurement was performed based on the serial cephalograms taken preoperatively; 1 week, 6 months and 14 months postoperatively; and at the final evaluation after an average of 12 years. Mean mandibular advancement was 4.1 mm at B-point and 4.9 mm at pogonion. Representing surgical mandibular ramus displacement, gonion moved downwards 2 mm immediately after surgery. During the short-term postoperative period, mandibular corpus length decreased only 0.5 mm, indicating that there was no osteotomy slippage. After the first year of observation, skeletal relapse was 1.3 mm at B-point and pogonion. The relapse continued, reaching a total of 2.3 mm after 12 years, corresponding to 50% of the mandibular advancement. Mandibular ramus length continuously decreased 1 mm during the same observation period, indicating progressive condylar resorption. No significant relationship between the amount of initial surgical advancement and skeletal relapse was found. Preoperative high mandibulo-nasal plane (ML-NL) angle appears to be associated with long-term skeletal relapse.

Calcium pyrophosphate dihydrate crystal deposition disease of the temporomandibular joint.

A case of a 74-year-old woman with calcium pyrophosphate dihydrate crystal deposition disease of the temporomandibular joint (TMJ) is presented. This disease rarely involves the TMJ and is not usually considered in the differential diagnosis of TMJ disorders. To our knowledge, only 23 cases have been reported in the literature and only four without any destructive changes of the condyle as in the present case.

Sports related maxillofacial injuries: the first maxillofacial trauma database in Switzerland.

BACKGROUND: With the increase in the amount of medical data handled by emergency units, advances in computerisation have become necessary. New computer technology should have a major influence on accident analysis and prevention and the quality of research in the future. OBJECTIVES: To investigate the occurrence of sports related maxillofacial injuries using a newly installed relational database. To establish the first sports trauma database in Switzerland. METHODS: The Qualicare databank was used to prospectively review 57 248 case histories of patients treated in the Department of Emergency Medicine between January 2000 and December 2002. Pre-defined key words were used to collect data on sports related maxillofacial injuries. RESULTS: A total of 750 patients with maxillofacial injuries were identified. Ninety (12%) were sports related maxillofacial fractures. Most (27%) were sustained during skiing and snowboarding, 22% during team sports such as soccer or ice hockey, and 21% were from cycling accidents. Sixty eight per cent of the cyclists, 50% of the ice hockey players and soccer players, and 48% of the skiers and snowboarders had isolated fractures of the midface. Fractures of the mandible were noted predominantly in contact sports. CONCLUSIONS: Computerisation of trauma and emergency units and the introduction of customised software can significantly reduce the workload of researchers and doctors. The effective use of new computer technology should have a considerable influence on research and the quality of future prospective and retrospective studies.

Effects of unprocessed and processed cardiopulmonary bypass blood retransfused into patients after cardiac surgery.

BACKGROUND: The aim of this prospective study was to compare the effect of autologous unprocessed to processed residual cardiopulmonary bypass blood (CPB) on patients' laboratory and clinical parameters and outcome. METHODS: 20 patients undergoing elective coronary artery bypass surgery were randomized to receive either unprocessed CPB blood (control group) or processed CPB blood employing the Continuous AutoTransfusion System (CATS; Fresenius, Bad Homburg, Germany). We have shown that this method eliminated >93% of activated mediators. Serial laboratory parameters including complement activation, coagulation factors and the stimulation of IL-6 and IL-8 were compared with clinical side effects and patients' outcome. RESULTS: Compared to control patients, retransfusion of unprocessed CBP blood significantly increased heparin, free plasma hemoglobin and D-Dimers. Postoperatively, three patients in the control group and two patients in the CATS group required prolonged mechanical ventilation or developed infections associated respectively with elevated C3a (desArg) or IL-6 concentration. CONCLUSIONS: CATS-processing of CPB blood provided a high-quality red blood cell concentrate, resulting in a reduced load of retransfused activated mediators.

Qualitative assessment of blood washing with the continuous autologous transfusion system (CATS)

A number of different blood-processing methods can be used at the end of cardiopulmonary bypass (CPB) to improve the quality of autologous blood. They include centrifugation, hemofiltration and cell-washing. They differ in processing time required, cost of disposables and the quality of the processed autologous blood product. The newly developed continuous auto-transfusion system (CATS: Fresenius AG, Bad Homburg) uses a continuous cell-washing method. In a prospective study, the oxygenator blood of 10 patients was processed at the end of cardiac surgery with CATS and the quality of autologous blood before and after processing was compared. The processing volumes and the time required were recorded. The concentrations and elimination rates of blood parameters and waste products such as activated coagulation and complement products were measured. At the end of CPB a mean volume of 1,010 +/- 174 ml diluted oxygenator blood was processed and concentrated to 310 +/- 88 ml in 11.0 +/- 2.2 mins. Cellular elements such as erythrocytes and leucocytes were mostly retained and their concentration showed a significant increase after processing (250% and 210% respectively; p < 0.01). Thus, the blood processing with CATS resulted in an excellent hemoconcentration (hematocrit 62 +/- 3 vs. 24 +/- 4% before processing) with a consistent reproducibility. On the other hand, the CATS concentrate showed a significant loss of autologous plasma proteins. Likewise, all water soluble elements such as waste products are significantly lower in concentration after processing and, if calculated by quantity, they show a high elimination rate (> 93%). In conclusion, the continuous autologous transfusion system permits an automated, rapid and continuous processing of autologous blood yielding a standardised high quality erythrocyte concentrate.