New directions in the management of cleft lip.

Advances in cleft lip and palate have included improved understanding of its etiopathogenesis, genetics, and the surgical evolution of technical refinements in the correction of this deformity.

Abdominal wall closure after intestinal transplantation.

Successful surgical closure of the abdominal wall after either combined or isolated intestinal transplantation may present a challenging dilemma for the plastic and reconstructive surgeon because of the following factors: restricted volume of the recipient abdominal cavity; donor-recipient size discrepancies as expressed by the donor to recipient weight ratio; and significant intraoperative edema. The purpose of this investigation is to present clinical experience with 51 consecutive patients who underwent a total of 57 sequential intestinal transplantations at the University of Miami-Jackson Memorial Hospital. A retrospective chart review of 36 pediatric (63 percent) and 21 adult (37 percent) transplantations was performed. Age of the pediatric population ranged from 1 month to 13 years (mean, 2.4 years) and of the adult population from 22 to 55 years (mean, 33.5 years). Several diagnostic classifications necessitated organ transplantation. Because of insufficient donor graft size for the recipient abdominal cavity in 19 transplantations (33 percent), several technical modifications were used to achieve anatomic and functional abdominal wall closure in all patients. In summary, the plastic and reconstructive surgeon should have a significant role in the comprehensive planning and management of abdominal wall closure in this challenging group of patients.

Priorities in the treatment of facial fractures for the millennium.

Although certain principles for management of facial fractures have not changed, new avenues reach this goal with greater precision and less morbidity. By reviewing these recent developments one can see the enormous potential for future developments in technology, techniques, and biomaterials. Development of tertiary care centers for the multiple trauma victim has improved management of facial trauma by bringing a large experience to a team of individuals where creativity flourishes. Major leaps in diagnostic skills and technology now allow us to answer some to the controversial treatment issues in facial trauma. This article hopes to review some old concepts and look at new approaches in managing facial fractures.

Patterns of maxillofacial injuries in powered watercraft collisions.

Because of the widespread popularity of water sports, plastic and reconstructive surgeons can expect to manage an increasing number of injuries associated with these activities, particularly those related to powered watercraft vehicles. Although seat belts for motorists and helmets for motorcyclists may be efficacious, such devices currently do not serve a similar role in powered watercraft sports. In this study, a retrospective chart review of 194 consecutive patients who presented to the University of Miami/Jackson Memorial Hospital (Level I trauma center) as a result of powered watercraft collisions is presented. The purpose of this investigation was to assess the incidence, cause, demographics, and available management options for head and neck injuries secondary to powered watercraft. Identified were 194 patients who presented because of watersports-related injuries during the period January 1, 1991, through December 31, 1996. From this group, 81 patients (41.8 percent) sustained injuries directly attributable to powered watercraft collisions, including 41 personal watercraft collisions (50.6 percent), 39 boat collisions (48.1 percent), and 1 airboat collision (1.2 percent). The patient population, as expected, tended to be young and male with an average age of 29 years (range, 8 to 64 years old). Interestingly, 41 of the patients (50.6 percent) who presented to this trauma center as a result of powered watercraft collisions also sustained associated head and neck trauma. Of 74 injuries 24 were facial fractures (32.4 percent), 18 were facial lacerations (24.3 percent), 14 were closed head injuries (18.9 percent), 8 were skull fractures (10.8 percent), 4 were scalp lacerations (5.4 percent), 4 were C-spine fractures (5.4 percent), 1 was an ear laceration (1.4 percent), and 1 was a fatality (1.4 percent). Le Fort fractures were the most commonly identified facial fracture in this series. The number of these injuries seen in hospital emergency rooms will most likely increase in the future as the popularity of water-related recreational activities becomes even more widespread. Based on these findings, it is strongly recommended that future efforts be directed toward the prevention of these injuries through patient education and the eventual development of efficacious and safe protective equipment.

Maxillofacial injuries in women.

Although maxillofacial injuries account for a large number of hospital admissions, there appear to be only a few reports detailing the etiology and pattern of facial injuries in women. To delineate this problem, we performed a retrospective chart review of all women admitted to University of California, Davis Medical Center with traumatic facial injuries from July 1, 1990, to June 30, 1992. Motor vehicle accidents were the primary etiology, followed by assaults. The mandible was the most commonly injured facial bone. In a closer evaluation of female patients injured by assault, we found inadequate documentation describing the circumstances surrounding their facial injuries. This indicates that domestic violence and other forms of assaults against women may be severely underreported and has important implications for health care professionals who must always suspect physical abuse in any woman who presents with maxillofacial injuries without an obvious, known etiology.

Complications of mandibular fractures.

Timely repair of mandibular fractures remains an effective means to reduce pain, restore function, and prevent complications. This study addresses the effect of the time interval between injury and treatment on the overall complication rate, the complication rate between various treatment modalities (mandibular-maxillary fixation [MMF] alone, MMF with intraosseous wire bone fixation, and MMF with rigid internal fixation), and the relationship of inpatient vs. outpatient management. Cost was also examined with respect to choice of management. We report a retrospective series of 308 consecutive patients managed at the University of Miami/Jackson Memorial Hospital. Patients who received treatment 3 to 10 days following injury were found to have a lower complication rate than earlier or later repair. We postulate that most patients with mandibular fractures may be managed on an outpatient basis, which represents a considerable savings in cost.

Effect of insulin-like growth factor type I on critical size calvarial bone defects in irradiated rats.

Irradiated wounds are characterized by a slow healing process. Insulin-like growth factor-1 (IGF-1), a somatomedin C, has been shown in previous studies to stimulate collagen synthesis and bony repair. The purpose of this investigation is to evaluate the potential beneficial effects of recombinant IGF-1 in the healing of critical size calvarial defects in previously irradiated adult male Sprague-Dawley rats.

Bregmatic masses in children.

Bregmatic masses often present a challenging diagnostic dilemma. We present two illustrative cases to demonstrate this clinical problem and present our recommendations for evaluation and treatment.

Bregmatic epidermoid inclusion cyst eroding both calvarial tables.

Dermoid and epidermoid cysts are uncommon masses in the head and neck region of children. Although the most common location of inclusion cysts in the head and neck is the bregma, masses in this region must be differentiated from midline hemangiomas, lipomas, hematomas, or encephaloceles. Inclusion cysts should be considered in the differential diagnosis of all midline cystic lesions in infants, because, if left untreated, it may lead to devastating complications. We present the case of a slowly enlarging midline mass in a female infant to illustrate the potential for serious sequelae from inclusion cysts.

Cranial bone grafting: biodegradable versus titanium fixation in a rabbit model.

Rigid internal fixation with miniplates and screws has enabled reconstructive surgeons to position bony segments precisely. Unfortunately, our present systems have been associated with a potential adverse effect on ultimate craniofacial growth and development. Also, they may be palpable, necessitating secondary procedures for removal of the hardware. We have been involved in an ongoing study evaluating the efficacy of a commercially developed biodegradable system. In this study, we compared biodegradable lag screw fixation with traditional titanium screw fixation in full-thickness, membranous bone grafts harvested from the zygomatic arches to the snout in a rabbit model. The results were compared with standard hematoxylin and eosin stains and laser densometry. Although this study adds further credence to the resorption of bone grafts, those secured with the polyglycolic acid screws demonstrated significantly less resorption than those maintained in position by traditional methods.

The residual cleft lip nasal deformity. An anatomic approach.

The cleft lip nasal deformity presents an extremely challenging problem for the reconstructive surgeon. Consistent satisfactory results have been difficult to attain. This article demonstrates that by obtaining sufficient exposure, each abnormal component can be identified and appropriately reconstructed.

Polyglyconate fixation successfully stabilizes zygomatic osteotomies in a nonhuman primate.

Investigators have reported problems with metal plates and screws, including restriction of craniofacial growth necessitating secondary removal; bone resorption secondary to stress shielding; increased incidence of infection, extrusion, and palpability, especially in regions with minimal soft-tissue coverage; and interference with radiological studies and postoperative radiation therapy. Biodegradable rigid fixation can easily eliminate a majority of these problems because the material provides adequate fixation for a finite interval corresponding to bony repair. For this reason, there has been increasing interest in developing satisfactory biodegradable plate and screw systems. We tested a commercially developed polyglyconate plate and screw system to stabilize zygomatic osteotomies in a nonhuman primate model before embarking on clinical trials. In this experimental model, the stabilized segments revealed satisfactory alignment; in the control animals, the bony fragments became significantly displaced. This polyglyconate plate and screw system appears to have a promising role in the surgical correction of craniomaxillofacial deformities in humans, and clinical testing should commence.

Staged repair of secondary cleft palate deformities.

Despite improvements in cleft palate surgery, residual oronasal fistulas remain a frustrating problem for plastic and reconstructive surgeons because of a high incidence of failure when scarred and immobile neighboring palatal mucoperiosteum is used for secondary closure. Therefore, my colleagues and I have found it necessary to introduce additional tissue from regional sites to close persistent oronasal fistulas. Although each technique may have its successes, no one method can be consistently depended on to repair large palatal fistulas. Even with regional flaps, dehiscence from a scarred surgical site is quite frequent. However, these flaps may still provide satisfactory coverage with staged reconstruction because they will frequently close a significant percentage of the overall defects, which then may be reused to close the remaining defect.

The effect of antenatal surgery on craniofacial growth in sheep model.

The purpose of this investigation was to evaluate the effect of antenatal palatal surgery in a sheep model. At 75 to 90 days of gestation, 20 fetuses underwent surgical in utero manipulation of their palates with the incision and elevation of bilateral bipedicled mucoperiosteal flaps. Sixteen of the 20 sheep (80 percent) went on to a normal full-term delivery. The palates and facial appearances were grossly evaluated, and detailed measurements were made of the palates. The data underwent statistical analysis. We were unable to discern any differences between the experimental group and the age-matched controls. Antenatal palatal surgery appeared to have no effect on craniofacial growth and development.

Biodegradable polyglyconate plates and screws: a histological evaluation in a rabbit model.

Within the zygomatic arch, bilateral osteotomies were performed on 20 adult male New Zealand white rabbits. These were stabilized in an anatomical position with polyglyconate acid plates and screws. At 3, 4, 6, 9, and 12 months, rabbits were killed and their zygomatic complexes removed en bloc. Specimens were serially sectioned for standard histological examination. Although no gross reactions were noted throughout the course of this investigation, histological reactions were brisk. At 3 months, particulate material was surrounded by a foreign body giant cell-type reaction. The quantity of foreign material appeared to decrease by 4 months, at which time the foreign body reaction was partially replaced by fibrous tissue. By 6 months, there was a thick periosteal scar at the osteotomy site with a few islands of persistent foreign material. These were primarily seen in small, irregular vesicular spaces surrounded by a large number of histiocytes with their characteristic foamy-cytoplasm. Although this foreign body reaction had subsided by 12 months, small foci of chronic inflammation still persisted.

Microform cleft lip associated with a complete cleft palate.

Clefting of the lip with or without an associated cleft palate may be present in varying degrees of severity. The so-called microform cleft lip or forme fruste has been characteristically described as having the appearance of a repaired cleft lip. The following case describes a patient with microform cleft lip and a complete cleft of the hard and soft palates. To the best of our knowledge, this is the first report of such an association.

Effect of insulin-like growth factor type 1 on critical-size defects in diabetic rats.

A number of investigators have reported on the clinically significant relationship between diabetes mellitus and impaired wound healing. Diabetic patients have an increased frequency of infection, delayed scar formation, and poor bony union. Investigations completed in our laboratory have demonstrated that insulin-like growth factor type 1 (IGF-1), a somatomedin C, has shown promise for accelerating bony repair. The purpose of this study was to examine the effects of recombinant IGF-1 on standardized, critical-size calvarial defects in 25 adult, male streptozocin-induced diabetic rats. From our study, it appears that IGF-1 exerts a potentiating effect on the repair of bony defects in diabetes-induced rats.

Repair of experimental calvarial defects with Bio-Oss particles and collagen sponges in a rabbit model.

Various materials have been used for reconstruction of both acquired and congenital calvarial defects. Unfortunately, each has its limitations. Autologous bone grafts have irregular rates of resorption that may require secondary corrective surgery, and individual harvest sites have limited stores that can necessitate additional donor locations. Alloplastic materials have unlimited quantities and volume stability but they may not become incorporated and are associated with a higher incidence of infection. The optimal bone substitute should stimulate new bone formation and permanently supplant the temporary space filler, thereby reconstituting the surgical defect. We evaluated 2 newly available bone substitutes, resorbable natural bone mineral (Bio-Oss particles) and a combination of collagen and natural bone mineral collagen combination (Bio-Oss sponges), to repair calvarial defects in an adult, male, New Zealand white rabbit model. We found that the particulate Bio-Oss material resorbed and then underwent the normal physiological stages of bone remodeling. The collagen and Bio-Oss combination was replaced by new bone ingrowth. These materials may have potential for use in the reconstruction of skull defects.

The use of pericranial flaps in frontal sinus fractures.

Although injuries to the frontal sinus are a reasonably common traumatic injury encountered by reconstructive surgeons, definitive indications for open exploration and the optimum method for handling the residual sinus cavity remain unsettled. During the last 3 years, we have accomplished frontal sinus obliteration with an "extended" pericranial flap in 14 consecutive patients. Thus far, we have not encountered any complications.