A Cadaveric Study Comparing the Efficacy of the Sheen Spreader Graft and the Fulcrum Spreader Graft: Part 1.

BACKGROUND: Middle vault collapse is one of the common causes of airway obstruction. Several techniques have been described to alleviate this problem. The Sheen spreader graft is a well-established technique. The fulcrum spreader graft has been in use at the authors' institution for 10 years. No studies currently exist that have compared the efficacy of middle vault reconstruction methods. In this first part of their studies, the authors have compared the efficacy of the Sheen spreader graft technique to the fulcrum spreader graft technique under normal atmospheric conditions. METHODS: Twenty fresh unemblamed cadavers were used for the study. Outcome variables were cross-sectional area at three points within the nose, minimum cross-sectional area, resistance, volume, and minimum distance. Exposure variables were control, Sheen, and fulcrum. Data were acquired with the aid of an acoustic rhinometer. RESULTS: Analysis of the data showed that the fulcrum spreader graft technique provided statistically significant outcomes compared with control and the Sheen technique. CONCLUSION: The fulcrum spreader graft technique may be a more effective technique for middle vault reconstruction compared with the Sheen spreader graft technique.

Frontofacial advancement by distraction osteogenesis: a long-term review.

BACKGROUND: Frontofacial advancement by distraction osteogenesis is known to produce significant functional and aesthetic gains in the short and medium term. Little is known about the long-term effects of this technique. The authors present a long-term review of frontofacial advancement by distraction in patients with syndromic craniosynostosis. METHODS: In 2008, Witherow et al. presented functional outcomes in 20 consecutive patients who underwent frontofacial advancement by distraction osteogenesis using the rigid external distractor frame. This retrospective study has revisited the outcomes in these patients after a mean follow-up period of 10.2 years. RESULTS: Records for the original 20 patients were assessed. Cephalometric analysis demonstrated stable advancements over the long term. No patient achieved any anterior growth of the midface after frontofacial advancement. Long-term follow-up demonstrated a later deterioration of respiratory function in the younger group of patients (36.4 percent). Four patients required adenotonsillectomy. One patient has a persistent tracheostomy. Only one patient required further procedures to correct recurrent raised intracranial pressure. None of the patients in the older group experienced a deterioration of function. Other procedures included reduction of the supraorbital ridge, bimaxillary osteotomies, and rhinoplasties. CONCLUSIONS: Frontofacial distraction produced long-term stable advancement in all cases, and 15 of the 17 living patients (88.2 percent) achieved stable functional gains. Anterior growth of the midface does not occur following monobloc distraction. Deterioration in function is seen in those who undergo this procedure at a young age. The authors recommend regular follow-up of these patients. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

The Christmas tree foreheadplasty: a novel technique used in combination with a bandeau for fronto-orbital remodelling in craniosynostosis.

PURPOSE: Craniosynostosis of the coronal, metopic and frontosphenoidal sutures results in deformity of the forehead. This may cause both functional and psychological difficulties for patient and parent. We describe a novel surgical technique, the 'Christmas tree foreheadplasty', used in combination with a supraorbital bandeau to achieve fronto-orbital remodelling. METHODS: Between November 2008 and September 2011, 32 patients with craniosynostosis underwent fronto-orbital remodelling with a supraorbital bandeau in combination with Christmas tree foreheadplasty. Indications for surgery, age at surgery, blood transfusion requirements, length of hospital stay and perioperative complications were assessed. A 'blinded', independent reviewer, age-matched controlled, panel photograph study was also undertaken to review results of the surgery. A parental satisfaction survey by telephone questionnaire was undertaken. RESULTS: Mean age at surgery was 16 months. Average hospital stay was 3 days. Mean follow up time to this report was 19.5 months. Indications for the procedure included unicoronal, frontosphenoidal, metopic and bicoronal synostosis. Thirty of the 32 patients required a blood transfusion. One patient has required revision surgery following extrusion of prosthetic fixation plate. Surgical outcome measured by 'blinded' independent reviewers indicated that a significantly different preoperative score from normal was rendered to no significant difference from age-matched normal controls postoperatively. Parental satisfaction score of forehead appearance was significantly improved by the technique. CONCLUSION: The Christmas tree foreheadplasty is a commendable and reproducible technique for forehead remodelling in combination with supraorbital bandeau and is now used more widely for forehead reconstruction for congenital cases.

Facial transplantation revisited: findings from the very first public engagement exercise.

OBJECTIVES: Facial transplantation has emerged as a treatment option in facial reconstruction. In this pilot study, we investigate initial attitudes to this concept in relevant patient and health professional groups. METHOD: Attitudes towards facial transplantation as a procedure were examined among 200 participants, including 30 nurses, 30 doctors, 30 plastic surgeons, 30 renal transplant patients, 30 medical students, 30 members of the lay public and 20 patients with facial disfigurements through the use of a questionnaire. RESULTS: Identity was important for all participating groups with 83.5% positive about receiving a facial transplant provided no resemblance to donor. There was an inverse relationship between the side effects of the immunosuppressant regimen and organ rejection and the willingness to undergo facial transplantation when compared to other forms of organ transplantation. A relationship to the recipient and familiarity with a transplant programme were positively related to potential donation. CONCLUSION: This study identifies the key issues of altered identity and the understanding of immunosuppression and surgical risk as the focus for research and patient selection. The ethical aspects of facial transplantation are not addressed in this study, and have been addressed elsewhere.

A model for structuring the donor discussion in emergent transplant procedures.

OBJECTIVE: To investigate the potential for maximizing organ and tissue donation by identifying an empirical basis for structuring donor discussions. DESIGN: Intentions to donate organs and tissues were recorded in 2 separate samples of participants and analyzed separately by using Guttman scaling, the second sample providing a replication of the findings from the first. PARTICIPANTS: 304 participants were recruited from the Royal Society Summer Science Exhibition 2004, and 200 health professionals were recruited from the Royal Free Hospital. RESULTD: High coefficients of scalability and reproducibility in both samples indicate a one-dimensional scale for intentions to donate organs and tissues, with solid organs more likely to be donated than corneal, hand, and facial tissue. Thus donor discussions can be structured in a robust order, with the potential for reliable use of cutoff points once donation of a particular organ or tissue has been refused. CONCLUSIONS: This reliable pattern can be used to maximize organ and tissue donation rates and to underpin emergent transplant techniques.

Enhanced fibroblast contraction of 3D collagen lattices and integrin expression by TGF-beta1 and -beta3: mechanoregulatory growth factors?

Generation of contractile forces as fibroblasts attach and migrate through collagenous substrates is a fundamental behavior, yet its regulation and consequences are obscure. Although the transforming growth factor-betas (TGF-beta) are similarly important in fibrosis and tissue repair, their role in contraction is controversial. Using a quantitative, 3D collagen culture model we have measured the effects of TGF-beta1 and -beta3 on contractile forces generated by human dermal fibroblasts. Maximal stimulation was between 7.5 and 15 ng/ml of TGF-beta1. Higher doses were inhibitory (30 ng/ml), giving a bell-shaped dose response. The initial rate of force generation was increased sevenfold (15 ng/ml). A similar response pattern was seen with TGF-beta3 alone. However, the addition of both isoforms together stimulated a biphasic increase in force generation, suggesting that there was a distinct temporal cooperativity between the two isforms. This very early onset (10-20 min) of stimulation suggested that TGF-beta might act through cell attachment and integrin function and the effect of TFG-beta on expression of fibronectin (FnR) and vitronectin (VnR) integrin receptors was monitored over the same time scale. TGF-beta1 dramatically up-regulated VnR expression, relative to FnR, over time but the optimal time for this was 2-4 h later than that of force stimulation. It is concluded that TGF-beta1 and -beta3 behave here primarily as mechanoregulatory growth factors and that stimulation of integrin expression may be a consequence of the altered cell stress.