Rescue of vision in burn patients with total eyelid loss.

OBJECTIVE: For severe burn victims suffering from total loss of upper and lower eyelids, skin graft or skin flap is normally used to cover the lesion and to protect the cornea, preventing corneal ulcer and simultaneously preparing for corneal transplantation. However, a new problem arises after the formation of the new palpebral fissure, that is, the reconstructed eyelids cannot open and close like the normal eyelids and the eyeball movement is limited, which exposes the cornea to dry air resulting in ulceration. In this article, we present a simple technique to partially solve this problem. METHODS: Five burn victims who lost their eyelids received treatment: stumps of upper and lower eyelids bulbar conjunctiva were dissected and pulled together as the lining of the conjunctival sac. Intermediate split-thickness skin was then immediately grafted as the new eyelids' skin. After 3 months, a 2-cm transverse incision was made 5mm below the normal palpebral fissure to open the conjunctival sac and new 'eyelids' were formed. RESULTS: The patients were followed for 2-9 years. No lagophthalmos and xerophthalmia were found. When the patients raised their heads in the supine position, they could see outside. When they bowed their heads, the cornea was protected. Their remaining vision was rescued and an average 0.4 vision recovered. Most of the patients went back to work. CONCLUSION: The opening and closing function of the eyelids can partially be replaced by movements of the head and neck using this technique. It seems to be a reliable option to rescue the vision in these types of challenging situations.

[Experience of midfacial distraction osteogenesis in upper airway stenosis].

OBJECTIVE: To investigate the therapeutic effects of upper airway stenosis after Le Fort III osteotomy and midfacial distraction osteogenesis (DO). METHODS: Eleven cases (age, 5-16 yrs) with severe midface dysostosis complicated with exophthalmos, anterior crossbite and upper airway stenosis were treated by using Le Fort III osteotomy and midfacial DO from August 2000 to February 2007. The 3D reconstruction of the upper-airway from CT data was used to evaluate the upper airway volume before and after the operation. And meanwhile polysomnography was carried out to demonstrate the upper airway functional changes. RESULTS: There was a 64.3% mean increase [mean, (9.13 +/- 6.94) ml, P < 0.05] in upper airway volume in the 11 cases after the operations. It showed that there was significant improvements in the indexes of polysomnography after the operations, such as apnea and hypopnea index, average SaO2, minimum oxygen saturation and snore index. CONCLUSIONS: The Le Fort III osteotomy and midfacial distraction osteogenesis can efficiently relieve the symptoms of upper-airway stenosis in severe midfacial dysostosis.

[Changes of different section area at different parts of upper-airway after Le Fort III osteotomy].

OBJECTIVE: To observe the therapeutic effects of Le Fort III osteotomy and midface distraction osteogenesis (DO) on the upper-airway narrow. METHODS: Since 2000, 11 cases (10 cases of Crouzon syndrome and 1 case of Apert syndrome) with severe midface deficiency were treated with Le Fort III osteotomy and midface DO. The section area of different parts of upper-airway were tested by computer assistants image measurement preoperatively and postoperatively. Some patients received sleep function monitoring. RESULTS: The face appearance and the function of upper-airway improved significantly after Le Fort III osteotomy and Midface DO. The section area at the level of posterior nasal spine and uvula increased obviously after treatment (P < 0.05), however the section area at the level of epiglottis and separation between airway and esophagus were not obviously enlarged (P > 0.05). CONCLUSIONS: Midface DO after Le Fort III osteotomy can effectively improve the upper-airway narrow, especially the upper part from uvula.

[Surgical correction of craniofacial dysostosis with midface distraction osteogenesis].

OBJECTIVE: To investigate the effect of distraction osteogenesis on correction of craniofacial dysostosis. METHODS: Le Fort III osteotomy was applied through coronal route on patients with craniofacial dysostosis such as Crouzon and Apert syndrome. The procedures included disconnecting the skeletal midface from base of cranium, setting up a RED II distraction device, and directing the device bars. The distraction was started 5 days after the surgery, with a rate of 1 mm forward per day. When midface approaching the right position, i.e. a slightly over correction of occlusion was reached, stopped distraction and kept the device for 2 - 4 months. RESULTS: Eight cases completed all the therapy. The average blood lose was 300 ml and the average operation time was 3.5 hours. The midface had been moved averagely 9 mm forwardly and 1.5 mm downwards. The features had been improved obviously and the occlusion reached nearly normal. No serious complications occurred except for 1 case of seroma and 1 case of infection around pin on scalp. No recurrence was found in the 5 months of follow-up. CONCLUSIONS: Midface distraction osteogenesis is propitious to teenage or severe cases of craniofacial dysostosis.

[Surgical correction of craniofacial dysostosis with midface distraction osteotogenesis].

OBJECTIVE: Correction of craniofacial dysostosis with midface distraction osteotogenesis. METHODS: Le Fort III osteotomy has been employed through coronal route on patients with midface craniofacial dysostosis such as Crouzon and Apert syndrome. Then a REDII distraction device was set up, and the device bars directed. The distraction begins 6.4 days after the surgery, with a rate of 1 mm per day. When midface approaching the right position, i.e. an slightly over correction of occlusion is reached, the distraction stops and the device is held for the next 2-4 months. RESULTS: There are 8 cases completed all the therapy with an average age of 11.9 years old. The midface had been moved averagely 9.7 mm forwards and 1.6 mm downwards. The features had been improved obviously and the occlusions reach nearly normal. The exophthalmos reduced from 20.3 mm to 11.9 mm. In cephalometry, SNA was averagely enlarged 9 degrees, and ANB enlarged 8.8 degrees. The snore during sleeping was also improved in 87.5% cases. No serious complication had occurred except minor one such as 1 case of seroma and 1 case of infection around pin on scalp. According to 5 months averagely follow-up, there is no recurrence in our list. CONCLUSIONS: Midface distraction osteotogenesis is propitious to teenage or severe cases of craniofacial dysostosis.

[Anatomic study of supratrochlear artery and its application in nasal reconstruction].

OBJECTIVE: To study the anatomy of the cutaneous branch (CB) of supratrochlear artery and its relevance to the design of frontal flap in nasal reconstruction. METHODS: 10 fresh cadavers were dissected to study the position and course of the CB of supratrochlear artery (supraorbital rim and facial midline as landmark). The communication between the CB and supraorbital artery was also studied. 5 cases of ultra-thin frontal flaps and 11 cases of bi-flap( cutaneous flap and muscular flap) were designed on anatomic basis. The survival rate of flap, the stability and aesthetic appearance of the reconstructed nose were followed up. RESULTS: The supratrochlear artery gave off constant CB (1.18 +/- 0.36) cm from upper orbital rim and (1.35 +/- 0.34) cm from the midline of face. The CB passed in a subcutaneous plane and communicated with the bilateral muscular branch, CB of the opposite side and bilateral supraorbital artery. The supratrochlear artery only had CB with no muscular branch in 3 cases. All the flaps survived completely except one with blister on the nose tip which healed spontaneously. The postoperative aesthetic appearance was very satisfactory. CONCLUSIONS: The supratrochlear artery has constant CB. The frontal ultra-thin flap pedicled with the CB can improve the therapeutic effect of nasal reconstruction.

[Experimental study of gene therapy with human vascular endothelial growth factor-c in lymphedema].

OBJECTIVE: To study the efficacy of gene therapy with human vascular endothelial growth factor-c (VEGF-C) on obstructive lymphedema. METHODS: Two animal models of lymphedema were created: one in the right hind limb of adult New Zealand white rabbits and the other in SD mouse tail. Each model was randomly divided into two groups to receive intradermal injection of either VEGF-C gene (experimental group), or saline(control group). In rabbit model, the volume change of affected limb was measured. In mouse model, biopsy was performed after 3 weeks treatment to detect the expression of VEGF-C mRNA and proteins. The lymphagenesis was evaluated by immunohistochemical examination with lymphatic endothelium hyaluronan receptor antibody. RESULTS: The volume of the affect rabbit limb decreased by (24.40 +/- 1.08) ml in experimental group, compared with (5.80 +/- 1.92) ml in control group (P = 0.0001). The expression of VEGF-C mRNA and protein increased markedly in experiment group, but not in controls. More lymphatic vessels with large caliber were seen in experiment group (P = 0.0004). CONCLUSIONS: VEGF-C gene therapy may alleviate or treat lymphedema by inducing lyphmangiogenesis.

[Strategy study of harvesting total facial flap and donor choice for allograft transplantation in cadaver].

OBJECTIVE: To explore the operational strategy of harvesting total facial allograft by autopsy. METHODS: Twelve fresh human cadavers were dissected. They were divided into two groups randomly. The total facial-scalp flap of the group I was elevated by the bi-pedicle method, the group II was operated with single-pedicle method. Both were dissected at the deep plane of the SMAS. : the time of facial flap harvesting, length of the artery vein and nerve pedicles of the donor were measured and marked, after operation, in each group we transferred one facial allograft to another. Then the free graft of group I was poured through artery by methylthioninium chloride to study vascular territories. RESULTS: Mean harvesting time of the group I (46 +/- 11) minutes, group II (111 +/- 7) minutes, P < 0.01. Perfusion result shows that unilateral superficial temporal artery and the opposite side of the facial artery can supply blood for whole face. The pedicle was long enough for anastomosis. Post-operation appearance: the face looks like neither the donor nor the recipient primarily, It's mainly due to the characteristics of the skeleton and the soft tissues. CONCLUSIONS: The bi-pedicle method of the harvesting total facial allograft is concise, fast, safe can be widely applied in clinical.

[Research of the preservation of the composite facial allograft].

OBJECTIVE: To investigate the effective method of preserving composite facial allograft so as to attenuate ischemic injury. METHODS: The composite facial allografts were harvested from dog, perfused and preserved with 4 degrees C physiological sodium chloride and UW solution respectively. Immediately after the removal of the flap, after 12, 24, 48 h of preservation, MTT assay was used to determine the viability of several kinds of tissue, including skin, mucosa, muscle, bleed vessel, nerve and gland. The results of the two groups were compared in term of viability percentage. The pathology of several tissues were observed after 24 and 48 h of storage. RESULTS: The viability percentage of every tissue conserved in UW solution for 48 hours was more than 75%. There was significant difference between physiological sodium chloride group and UW group (P < 0.05). Some changes, including Porous arrangement of fibers in connective tissue of skin and mucosa, hyalinization of tissue around the hair follicle and edema of cell in hair follicle, enlargement of space between muscle bundles and unclearness of boundary of acinus could be seen in physiological sodium chloride group while no significant change in UW group. CONCLUSIONS: UW solution could be considered as preservation solution for composite facial allograft.

[Treatment of primary lower limb lymphedema with ultrasonic assisted liposuction].

OBJECTIVE: To observe treatment effects of primary lower limb lymphedema using ultrasonic assisted liposuction. METHODS: Internal ultrasonic liposculpture system combined postoperative continual elastic stockings or bandages were used for reducing lymphatic burdens of the affected limbs by partly removal of lymphedematous tissues. RESULTS: Edema regression in the affected limbs were obvious at 2 weeks postoperative and kept to stable without recurrence during 1 year follow-up. CONCLUSIONS: Ultrasonic assisted liposuction combined with elastic compression is safe and effective for the treatment of primary limb lymphedema.

[Establishment of composite facial and scalp allograft transplantation model in canine].

OBJECTIVE: To develop an experimental model of composite facial and scalp allograft in canine in order to investigate technical and immunological aspects and functional recovery of facial muscles of this new approach to facial reconstruction. METHODS: (1) Anatomic study: Four mongrel dogs were used for anatomical dissection of the head and neck region and for harvesting flap experiment. (2) Autologous transplantation (group I): Three types composite facial and scalp autologous transplantation were performed in five mongrel dogs. Type I composite tissue flap (group I a n = 2) included bilateral external ear and orbicularis oculi muscle. Type II (group I b n = 1) included single-lateral external ear, orbicularis oculi muscle, external nose upper and lower lip. Type III (group I c n = 2) included single - lateral external ear and orbicularis oculi muscle. (3) Allograft transplantation (group II): In group II a (n = 2), two allograft transplantation were performed with type III composite facial and scalp . In group II b (n = 4), four allograft transplantation were performed with the modified type III composite facial and scalp which included single - lateral external ear, orbicularis oculi muscle and one third of inferior tarsal plate and palpebral conjunctiva. To prevent allograft rejection, Cyclosporin A (CsA) and Methylprednisolone (MP) or Prednisone (PS ) were combined used as immunosuppressive protocol . Dose of CsA was adjusted depending on its blood drug level. Electromyogram (EMG) of orbicularis oculi muscle was carried out at 4 weeks, 6 weeks, 12 weeks and 6 months postoperation. RESULTS: (1) The facial anatomic characteristic of dog is similar to that of human being, external carotid artery and external jugular vein afford good blood supply to composite facial and scalp. (2) The dogs in group I c were long-term surviving with leakage of salivary juice. (3) In group II a (n = 2), one dog presented rejection reaction at 28th day postoperation, the reversal of rejection was achieved by increasing the dose of CsA and prednisone and with topical clobetasol for 2 weeks, the dog survived indefinitely( > 309 days). In group II b (n = 4), there were three dogs survived indefinitely ( > 159 days, > 129 days, > 108 days) without complication, EMG showed the function of orbicularis oculi muscle was gradually improving. CONCLUSION: The modified type III composite facial and scalp allograft transplantation model is an ideal model for facial allograft transplantation study.

[Malar reconstruction in the patients with Treacher-Collin's syndrome].

OBJECTIVE: The key feature of Treacher-Collin's syndrome is malar dysostosis. The article focused on malar reconstruction for Treacher-Collin's syndrome and compared the implant materials. METHODS: From 1994 to 2002, a total of 55 patients with Treacher-Collin's syndrome were treated with malar reconstruction. In the operation, the lateral orbital rim and the mala were exposed by the bicoronal incision or the subciliary incision. The mala was augmented and reconstructed with implants of different materials, including autologous bone (rib, ilia or cranium). Medpor biomaterial or bone cement. RESULTS: The operations of the 55 patients were all successful without infection. The satisfactory rate in facial contour was 90%. Implant exclusion occurred in 2 cases using hone cement. CONCLUSION: Malar reconstruction is the most important treatment for Treacher-Collin's syndrome. Every implant material has advantages and shortcomings. Autologous hone is the best material for malar reconstruction. Medpor is the best artificial material, with good histocompatibility, without exclusion, absorption and donor injury.

[Metabolism of hyaluronic acid and extremity lymphedema].

OBJECTIVE: To investigate the possible influence of the impairment of lymph fluid on the metabolism of hyaluronic acid (HA) in the lymphedematous skin tissue. METHODS: Tissue fluid was collected in lymphedematous limbs and the contralateral healthy limbs of 39 patients and HA content was measured with radioimmunoassay. The protein contents were also measured. RESULTS: The HA contents in interstitial fluid of lymphedematous limb were significantly (8 fold) higher than that of normal limb. The protein concentration in the tissue fluid did not show significant differences between lymphedema and those with normal tissue. CONCLUSION: The result suggests blockage of regional draining lymphatics may impairs breakdown of HA and the stagnation of HA in the limb may exert a deleterious effect on the interstitium.

[Surgical correction of exophthalmos in craniofacial synostosis].

OBJECTIVE: To analyze the efficacy and complications of the surgical correction of exophthalmos in craniofacial synostosis. METHODS: Three different procedures were used in exophthalmos patients with different ages. In patients aged 1 - 3 years old, the fronto-orbital advancing osteotomy to deepen the upper part of orbital cavity was employed. In patients aged 4 - 15 years old, Le Fort III osteotomy and distraction osteogenesis were selected. In patients aged 16 years old or more, Le Fort III osteotomy or monobloc craniofacial osteotomy with immediately advancement of the midface segments were selected. RESULTS: Good results were achieved for all 18 patients. The proptosis reduced 7.8 mm postoperatively. The depth of the skull base increased 8.2 mm and inferior orbit margin was advanced 7.8 mm as compared with the preoperative measurements. The angle between the maxilla and skull base (SNA) increased 9 degree. All of these measurements indicated that the proptosis and craniofacial contouring were approached to the normal situation after surgical intervention. CONCLUSION: Both immediate advancement and gradual distraction after frontal, orbital, and maxillar osteotomy to enlarge the orbital cavities are the best approaches for the treatment of exophthalmos in craniofacial synostosis.

[The effect of insulin-like growth factor 1 on the fusion of cranial suture].

OBJECTIVE: To evaluate the effect of insulin-like growth factor 1 for the bone induction and the regulation for the fusion of the sagittal cranial sutures. METHODS: The cells, derived from cranial sutures in the newborn SD rats and the sagittal suture from the mice, were cultured with a serum-free medium and treated with and without insulin-like growth factor 1. The osteoblast phetotypes (osteocalcin, alkaline, osteoponcin and type-1 collagen) were measured with the RT-PCR and ELISA, and the explanted sagittal sutures were then evaluated under light microscopy. RESULTS: The cells, treated with the insulin-like growth factor 1, significantly produced more osteocalcin, alkaline, osteoponcin and type-1 collagen than those without insulin-like growth factor 1. The fusion of the sagittal suture explants will delay till to 30 days when it was not treated with IGF1. However, in the group with IGF1 the fusion was observed to start in 8 days, and a small amount of the sagittal suture fusion was found at the 20th day while a large amount was at the 30th day. CONCLUSION: The IGF1 has a direct effect on the fusion of cranial suture due to enhancing bone induction of cranial suture cell.

[Repair of whole auricular defects with implant-plasty and prosthesis].

OBJECTIVE: To repair the whole auricular defects with implant-plasty and prosthesis technique. The indications, complications and implant sites of this method were discussed. METHODS: In reconstruction of the whole auricular defect, the self-developed pure titanium implants, specialized for plastic surgery, were used for intra-osseous fixation for retaining the artificial ear. 10 cases were treated with this method. RESULTS: Follow-up of three years demonstrated that this implant system, with stable function, could generate osseointegration and be used as an abutment of intra-osseous fixation to retain the auricular prosthesis for a long time. CONCLUSION: The operation is simple and convenient with little trauma and short-term of treatment. The artificial ear has lifelike appearance, proper color and satisfactory effects. This technique has wide indications and is worth popularization.

[An experiment study on repair of peripheral nerve defects by GDNF gene modified Schwann cells].

OBJECTIVE: To investigate an effective treatment of peripheral nerve injuries by means of gene transference. METHODS: 48 adult Wister rats were divided evenly into 3 groups. A 10 mm sciatic nerve gap was created and bridged with a silicone chamber. The silicone chamber was filled with glial cell-line derived neurotrophic factor(GDNF) gene modified Schwann cells(SCs) (group 1), the normal SCs(group 2) and nothing(the control). At 4, 8, 12, and 16 weeks after the operation, the general and histological observations, the electromyographic and immunohistochemical examinations were performed to the regenerated nerves. RESULTS: The GDNF-SCs group was significantly better than the SCs and the control groups in nerve conduction velocity, the number and density of reinnervation, the area of regenerated nerve and the thickness of myelin sheath of the regenerated nerves. CONCLUSION: GDNF gene modified SCs secrete higher levels of neurotrophic factors for a prolonged time, which are more effective in peripheral nerve repair than the normal SCs.

[Surgical correction of orbital and periorbital deformities using lamella and complex osteotomies].

OBJECTIVE: To investigate surgical correction of orbital and periorbital deformities in orbital and periorbital region. METHODS: In order to reconstruct orbital deformities such as orbital hypertelorism, orbital dystopia, radiated orbit, and secondary deformities of traumatic orbit, lamella osteotomies of either orbital rim and wall or complex osteotomies of both adjacent orbital rims and walls using bicoronal or galea aponeurotica incision were employed. The reconstructed complex was placed in new position with rigid fixation. Clinic evaluations were performed before and after operative osteotomies such as cephalometry (measurement of interorbital distance, IOD), exophthalmos (measurement with Hetel exophthalmometer), the angle (between orbital horizontal level and bilateral tragus linkage, A-OT), and the linear distance (between lateral canthus and tragus, LC-T), then the gap differences were analyzed before and after operation. RESULTS: Nearly normal orbital volumes, better contour of orbit and midface, improved eyelids and visions were achieved in total 44 cases. There were 5 cases of supraorbital osteotomy (intracranial routine), 8 cases of medial orbital osteotomy, 3 cases of inferior orbital osteotomy, and 28 cases of both lateral and inferior orbital osteotomy in these series. No complications were found after surgery. The orbital and midfacial appearances were improved significantly. CONCLUSIONS: Lamella and complex osteotomies of orbital rim and wall are proved to be safe and effective to correct most deformities of orbital and periorbital region and various kinds of orbital malposition.