Reconstruction of composite facial defects: the combined application of multiple reconstructive modalities

OBJECTIVE: To describe the combined use of craniofacial skeletal reconstruction, tissue expansion and microvascular free tissue transfer in the repair of major composite facial defects. DESIGN: Case series with an integrated team approach. SETTING: Craniofacial unit, university teaching hospital. PATIENTS: Three cases were selected to best illustrate the combined use of the three modalities in reconstruction of acute traumatic, congenital and post-traumatic facial defects. A 15-year-old boy had a shotgun wound to the face; a 23-year-old man had Treacher Collins syndrome; and a 55-year-old woman had a post-traumatic composite defect of the central midface. INTERVENTIONS: Preoperatively, complete neurologic, ophthalmologic and dental examinations, anthropometric analysis, prosthodontic assessment, computed tomography and computer graphics. Operatively, craniofacial exposure followed established surgical principles. Skeletal reconstruction was performed to provide accurate positioning of bony segments and three-dimensional stability. Bone grafting was used when necessary to restore bony continuity and increase stability. Tissue expansion was used to provide more locally available tissue for wound closure and resurfacing composite defects. Microsurgical free tissue transfer was used to provide functional replacement of deficient tissues. RESULTS: The results of the modalities used for reconstruction of these composite facial defects are illustrated for each case described. CONCLUSIONS: The use of multiple modalities, including craniofacial skeletal reconstruction, tissue expansion and free tissue transfer, allow the surgeon to address the specific functional and anatomical requirements associated with composite facial defects that are characterized by a combined deficiency of multiple tissues in the craniofacial region.     

Clinical use of bone allografts

Modern techniques of bone allograft surgery provide a treatment modality for management of difficult skeletal defects. In oncological limb-salvage surgery, allograft reconstructions permit re-establishment of skeletal continuity and function after a wide resection of bone tumour. Bone allografts are increasingly used in salvage of difficult bone stock deficiencies following failed total joint replacements. Union between the allograft and the host bone takes place slowly and the use of autogenous bone graft at the graft-host junction is recommended for induction of repair. Internal repair (revascularization and substitution of the original graft bone with new host bone) also progresses slowly and seems to be confined only to the superficial surface and the ends of the graft. Biomechanically, a massive allograft may serve a structural function in the absence of advanced revascularization and creeping substitution processes. Infection of an allograft is a disastrous complication, whereas non-union of the graft-host junction and fracture of the graft are amenable to surgical treatment. Osteochondral allografts tend to show gradual deterioration of the articular cartilage with time, necessitating occasionally late resurfacing arthroplasty. It is evident that there is more active immune response to osteochondral grafts than was thought previously. Bone allografts induce cell-mediated and antibody-mediated cytotoxicity specific for donor antigens similar to that seen after organ transplantations. Not only the basic mechanisms of bone allograft rejection but also the clinical features of bone allograft rejection are poorly characterized. Clinically, new non-invasive imaging techniques should be applied in determining the metabolic activity of bone in order to find the optimal loading of healing allografts. Although the clinical results of massive bone allografts are still not completely predictable, the method has proved to be a technically and biologically feasible alternative for non-biological skeletal reconstructions.     

Surgical treatment of children with brachial plexus paralysis

OBJECTIVE AND METHODS: A variety of surgical procedures exist for early repair of the nerve injury in obstetrical brachial plexus palsy, including neuroma excision and nerve grafting, neurolysis and neurotization. Secondary deformities of the shoulder, forearm, and hand can similarly be reconstructed using soft tissue and skeletal procedures. This review describes our surgical approach to maximize the ultimate functional outcome in infants and children with obstetrical brachial plexus palsy.     

"Primary" orthostatic tremor. 10 clinical electrophysiologic observations

Distraction osteogenesis has been shown to be an effective method of lengthening and augmenting endochondral bone. It has also been applied effectively in the reconstruction of the membranous bones of the craniofacial skeleton. With the accumulation of clinical experience in mandibular distraction, the differences between endochondral and membranous bone distraction have become apparent, especially in the limitations of uniplanar distraction for the three-dimensional reconstruction of the deficient mandible. Distraction of the mandible in a single plane cannot satisfy fully the functional and structural requirements of the patient with malocclusion as well as deficiency of the skeletal and soft tissue. This study reports the development and clinical use of a multiplanar mandibular distraction device with the ability to achieve linear distraction (Z-plane or sagittal), angular distraction (Y-plane or vertical), and transverse distraction (X-plane or coronal). The device contains two independent gear arrangements attached to two arms that extend from the central unit. Therefore, the trajectory of the regenerated bone may be changed during the distraction process. The device also allows manipulation of the various planes of movement independent of each other. Furthermore, the rotational points for the multiplanar distraction devices are located at a single point; therefore only a single osteotomy and two pin sites are required. The multiplanar distraction device allows the surgeon to customize and contour the dimensions of the distraction process by controlling the trajectory of the translation of the regenerated bone.     

Histological comparison of early wound healing following dense hydroxyapatite granule grafting and barrier placement in surgically-created bone defects neighboring implants

The purpose of this study was to examine early wound healing following grafting of dense hydroxyapatite granules (HA granules) and barrier placement in surgically-created bone defects surrounding implants. Eight healthy adult dogs with an average weight of 15 kg were used in this study. Thirty-two bone defects measuring 4 mm x 4 mm were removed with a surgical bur to form continuous bucco-lingual bone defects and 32 implants (16 titanium [Ti]) and 16 hydroxyapatite-coated [HA]) were then placed into the defects. Four implant groups were created: 1) grafting HA; 2) covering with an expanded polytetrafluoroethylene (ePTFE) membrane; 3) grafting HA and covering with ePTFE membrane; and 4) control (no treatment). Animals were sacrificed 28 days after surgery. Histological sections revealed large amounts of newly-formed bone in all bone defects surrounding the implants treated with ePTFE membranes alone. Fibrous encapsulation of HA granules was observed in the defects of the HA granules grafting group. In the group with grafting of HA granules and covering with ePTFE membranes, small amounts of bone tissue were observed among HA granules, but most HA granules were surrounded with fibrous tissue. Bone defects were completely filled with connective tissue in the control group. There were no differences in the histological findings between Ti and HA-coated implants in all cases. Histomorphometric data disclosed that the presence of HA granules in the bone defects significantly arrested bone formation. Our study suggests that the grafting of dense HA into bone defects surrounding implants will result in fibrous healing during the early healing stage.     

Repeated bone repositioning in the growing rabbit calvarium hampers bone segment incorporation

There has been concern among surgeons that multiple extended craniofacial procedures might be detrimental to the viability of the involved skeletal structures. This study aimed to explore the result of repeated bone repositionings in the growing rabbit calvaria. Seven immature rabbits were subjected to a three-stage surgical procedure, implying that four calvarial bone segments were originally harvested and repositioned according to a rotational scheme; after 6 weeks only three of the bone segments were harvested and repositioned and, finally, after an additional period of 6 weeks, two segments were repositioned. The results were evaluated by radiographic, histologic (with a special scoring system), and histomorphometric analysis. It was found that one or two cranioplasties did not markedly affect graft incorporation, but three procedures significantly reduced graft revascularization and integration. The findings are discussed with special reference to syndromic craniofacial disorders.     

UDP-GlcNAc:Galbeta1-->3GalNAc (GlcNAc to GalNAc) beta1-->6N-acetylglucosaminyltransferase holds a key role on the control of CD15s expression in human pre-B lymphoid cell lines

Distraction osteogenesis has become an important technique to treat craniofacial skeletal dysplasia. In this study, the technique of maxillary distraction with a rigid external distraction device is presented. Cephalometric results in the first 14 consecutive patients are analyzed. The study sample consisted of 14 patients with various cleft types and maxillary hypoplasia treated with the rigid external distraction technique. Analysis of the predistraction and postdistraction cephalometric radiographs revealed significant skeletal maxillary advancement. All patients had correction of the maxillary hypoplasia with positive skeletal convexity and dental overjet after maxillary distraction. The morbidity for the procedure was minimal. Surgical and orthodontic procedures are thoroughly described.     

Midfacial advancement by bone distraction for treatment of craniofacial deformities

Craniofaciostenosis is often associated with midfacial hypoplasia and has been treated traditionally using Le Fort advancement osteotomies and bone grafts. The surgical procedure requires a prolonged operating time, several osteotomies with a significant blood loss, and wide surgical exposure. According to the principles of bone lengthening, we performed midfacial advancement by bone distraction in 4 patients with midfacial hypoplasia to reduce the operative time and complication rate. In 2 patients with Crouzon's syndrome we performed a Le Fort III osteotomy and placed the distraction device behind the malar eminence and screwed it on the temporal bone bilaterally. In the other 2 children, with Apert's syndrome, we performed frontal advancement and remodeling before placing the device during the same surgery behind the malar bone without any midfacial osteotomy. It appears to us that patients with more severe deformities will need surgical procedures to offer more satisfactory results. In these patients, distraction is an initial therapy to reduce the severity of the deformity, making it possible to effect a better treatment afterward.     

Facial bone wound healing. An overview

Facial bone wound healing has practical importance not only in acute fracture repair, but also in head and neck surgery. Fundamental principles of fracture fixation are now understood, and the benefit of acute bone grafting has emerged. In the future, bone healing may be augmented with growth factors and implants incorporating cells grown in tissue culture.     

Histological identification of Lugaro cells in the cat cerebellum

Segmental loss of a peripheral nerve has been a challenging reconstructive problem. Management of the nerve gap has been accomplished classically with nerve grafting. However, autogenous nerve grafts are not always available for bridging large nerve gaps, and clinical results of large nerve cable grafts have been disappointing. Newer techniques concentrate on nerve lengthening with different methods. Tissue expansion of peripheral nerves has been producing promising results. Since the introduction of the Ilizarov external fixator, much attention has turned to limb-lengthening techniques and studies investigating the results of nerve and soft tissues lengthened during the course of this procedure. Primary nerve distraction may be an alternative to nerve elongation, by expansion or nerve grafting to repair the peripheral nerve gap. This study describes a device and a model for peripheral nerve distraction in a rat. Primary nerve distraction will need to be subjected to vigorous studies before clinical application.     

Modern imaging of craniofacial malformations

Due to progress in the field of medical imaging of craniofacial malformations, the place of these investigations in the assessment of these abnormalities needs to be revised. 3D CT scan currently remains the fundamental element of the assessment by providing a truly anatomical dissection of each bone. In the field of craniostenoses, the study of the base of the skull has allowed a new assessment of lesions of skull base and craniofacial sutures and the resulting skeletal deformities: they provide restrospective justification for an extensive approach to the surgery of this group of malformations and a basis for reflection concerning extension to direct skull base surgery. Craniofacial clefts constitute a heterogeneous groupe of anomalies in which Tessier's concepts have allowed a methodical approach. 3D CT allows better definition of certain subgroups of malformations within this group (midfacial clefts) and provides a clearer understanding of the skeletal defects of maxillary clefts, especially in the laterofacial region. This imaging is currently undergoing rapid development. Improvement of 3D CT scanning techniques (direct 3D image acquisition, improvement of the images obtained), development and combination of 3D MRI, after being superimposed onto the skeletal image, will allow total dissection of the malformation. Development of 3D cephalometric analysis techniques and growth analysis software will allow really predictive "image-assisted surgery". Finally, antenatal imaging (B-mode and 3D ultrasonography) makes a considerable contribution to this field of anomalies by allowing the diagnosis of serious or severely disabling anomalies and by elucidating the antenatal development of certain anomalies (especially craniostenoses) and their consequences.     

Content and predictors of the ethnic identity of Russian-speaking immigrant adolescents in Finland

Even though osteodistraction has been well established in the extremities, the parameters used in craniofacial distraction have been essentially borrowed from orthopaedic experience. Latency is widely practised but its relevance has not been fully investigated. The purpose of this study was to establish the role of latency in mandibular distraction osteogenesis. Twenty-two growing Wethers sheep were allocated to four experimental groups. Six animals were allocated to each of Groups A, B and C and underwent bilateral mandibular corticotomies and attachment of an external lengthening device. Latent periods of 0, 4 and 7 days respectively were observed prior to beginning distraction. The distraction protocol consisted of a rate of 0.5 mm twice daily for 20 days, followed by a consolidation phase of 20 days after which the sheep were killed. Histology, bone densitometry and 3-point mechanical testing were performed on the harvested mandibles. Group D formed the control group (n = 4). Histologically, the distracted bone exhibited bone formation primarily via intramembranous ossification with scattered islands of cartilage. The regenerated bone had mechanical properties significantly weaker than the undistracted control group (P < 0.05), but between the experimental groups no statistically significant differences were demonstrable either in mechanical strength or DEXA density. These data indicate that a change in latency does not alter the properties of the regenerated bone in mandibular distraction osteogenesis and indeed no latent interval may be necessary at all in craniofacial distraction. This has implications for the duration of device fixation in distraction procedures.     

Genetic analysis of the cap5 locus of Staphylococcus aureus

BACKGROUND: Fifteen patients with femoral shaft fractures complicated by infected nonunions were treated with a two-stage protocol. METHODS: In the first stage, radical debridement was performed along with antibiotic bead chains local therapy and external skeletal fixation. In the second stage, the debrided nonunion site was repaired with bone grafting and the external skeletal fixator was used until bony union was achieved. The time between the first and second stages of treatment was 2 to 6 weeks. The debrided bone defects ranged from 0.5 to 15 cm. Autogenous iliac cancellous bone grafting was performed in 11 patients, and microvascularized osteoseptocutaneous fibular transfer was performed in 4 patients. RESULTS: Wound healing and bone union were achieved in all 15 cases. The duration of external fixation of these patients ranged from 7 to 15 months, with an average of 9 months. Minor pin-track infection was seen in seven patients. Postoperative infection after the second-stage bone grafting occurred in three patients. These three infections were arrested by limited debridement along with 2 to 4 weeks of parenteral antibiotic therapy. In one case, stress fracture occurred at 11 months after microvascularized fibular transfer; this was managed with another 5 months of external skeletal fixation. With an aggressive physical therapy program, 10 patients achieved nearly full range of knee motion and 5 patients had relevant knee flexion deficits. The follow-up averaged 58 months (range, 40-76 months); no recurrence of osteomyelitis was observed even at 76 months. CONCLUSION: We have found that our two-stage treatment with antibiotic beads local therapy, definitive external skeletal fixation, and staged bone grafting is an acceptable treatment protocol for the management of femoral diaphyseal infected nonunion. It results in rapid recovery from osteomyelitis and a predictable recovery from nonunion.     

Osseous bridging of the distraction gap in leg lengthening procedures (author's transl)

The bony refill of the distraction-space in leg-lengthening operations is analysed by X-ray control and histological technic as well in animal experiments as clinical patients. Based on our observations a theory of the formation of bone is postulated: We figured out, that a) presumable besides the periosteal potentials of bone formation there are also other active mechanisms of bone growth to be found. b) frequently histological recognised formations of bones cannot yet be proved by X-ray, that means, that the X-ray changes follow the histological ones. c) optimal formation of callus needs most possible stability during the time of consolidation. d) most careful distraction prevents deformities.     

Acute peripheral neuropathy in adults. Guillain-Barré syndrome and related disorders

Wound healing in many tissue types is essentially the same as that which occurs in skin. The repair processes that occur in bone, tendon, the alimentary tract, skin grafts, and bone grafts are substantially different from cutaneous wound repair. Because surgeons frequently encounter these tissues, it is essential to understand how they heal.     

Management of craniofacial anomalies

Children with craniofacial anomalies comprise a diverse group of patients, with problems involving many organ systems. In the fairly recent past, no satisfactory treatment was available for many of these problems. Through the contributions of Tessier and many other innovators, however, multidisciplinary groups such as the Medical University of South Carolina's Craniofacial Team are now able to offer substantial improvement to many patients with congenital or acquired deformities of the craniofacial region. The best reconstruction for any given patient can be determined only after a careful analysis of the patient's problems and the patient's and family's wishes. Using this approach, we are able to help many patients significantly. As we treat today's patients, however, we must continue to critically assess our results and improve our methods, for only through this process will tomorrow's patients enjoy even better outcomes than today's.     

Comparative analysis of interleukin 15 and interleukin 2 for induction of killer activity and of type 2 cytokine production by mononuclear cells from lung cancer patients

Simple bone cyst (SBC) is a benign fluid-filled cavity found primarily at the proximal ends of long bones in children. Treatments proposed for SBC range from observation to intralesional curettage and bone grafting, which are all associated with uncertainty and complications. Because of these factors, a relatively noninvasive protocol with osteoinductive autogenic bone marrow was instituted. Twelve patients were identified with SBCs. Bone marrow was aspirated from the patient's iliac crests and injected into the cyst cavity. Follow-up ranged from 9 to 57 months. Eight (67%) patients demonstrated substantial healing, two (17%) showed partial healing, and two (17%) did not respond to bone marrow therapy. The advantages suggested by bone marrow injection over the currently practiced methods include a higher success rate with a single injection and earlier healing.     

The craniofacial dysostosis syndromes. Staging of reconstruction and management of secondary deformities

During the past several decades, since the introduction of craniofacial surgery by Dr. Tessier in 1967, craniomaxillofacial surgery has advanced in many ways. Craniosynostosis is a common craniofacial malformation and requires a thoughtful team approach to select the preferred timing and technical aspects of reconstruction. The current approach to the correction of the deformities associated with the craniofacial dysostosis syndromes is to stage the reconstruction to coincide with facial growth patterns, visceral function, and psychosocial development. Recognition of the need for a staged reconstructive approach serves to clarify the objectives of each phase of treatment both for the clinicians and family. By continuing to define our rationale for the timing, method, and extent of surgical intervention and then objectively evaluating both functional and morphologic outcomes, we will improve the outlook for patients affected by these disorders.     

Evaluation of the mechanical environment during distraction osteogenesis

Physical forces have been hypothesized to direct the process of bone regeneration during distraction osteogenesis. However, despite significant clinical experience, relatively little is known about how the mechanics of distraction influence bone formation. This study investigated net fixator forces and strains in the distraction callus during bilateral lengthening of tibiae in New Zealand White rabbits. Distractions yielded a classic viscoelastic response with a sharp increase in fixator force, followed immediately by significant relaxation. Tension acting on mesenchymal gap tissue caused by distraction was estimated to reach more than 30 N by the time full lengthening was achieved. Average maximum cyclic strains within the distraction zone during ambulation were estimated to be 14% to 15% and supported by the results of fluoroscopic imaging. Paradigms for fracture healing have hypothesized that such strains are incompatible with new bone formation. The documented clinical success of distraction osteogenesis at stimulating large volumes of new bone suggests that other mechanisms that warrant additional investigation may be at work during distraction.     

Visual and laser Doppler perfusion scanning assessments of Kathon CG patch test reactions

Metastases are the most common malignant tumors of the skeleton. Several imaging modalities can be engaged for the diagnosis of skeletal metastases. They may be combined, depending on the individual clinical setting. Plain films are used for evaluation of symptomatic regions of the skeleton. Sensitivity is low, but benign skeletal disorders causing clinical symptoms can usually be identified in plain films. Bone scintigraphy is employed for a survey of the entire skeleton with high sensitivity for the presence of metastases, but only poor specificity. Computed tomography (CT) and magnetic resonance imaging (MRI) are advanced diagnostic methods, essential particularly in the diagnosis of metastatic spinal disease. Using CT, additional percutaneous bone biopsies can be performed easily and safely. Of all imaging modalities, MRI has the highest sensitivity for skeletal metastases. Other advantages are the possibility of multidirectional slice positioning and excellent soft tissue contrast.