PyroCarbon implant hemiarthroplasty for trapeziometacarpal arthritis.

The trapeziometacarpal joint is commonly affected by degenerative arthritis, presenting with pain, stiffness, and swelling at the base of the thumb. When conservative treatment fails, surgical intervention may be warranted based on clinical and radiologic staging as well as patient demand. The concept of replacing the trapeziometacarpal joint remains attractive because of the decreased pain and stiffness, prevention of thumb shortening, and earlier recovery of strength seen with implant arthroplasty. A technique of using a cementless PyroCarbon hemiarthroplasty implant that allows excellent range of motion and decreased postoperative stiffness and pain is presented, with a focus on dorsal capsular reconstruction to prevent subluxation of the implant.

Anatomy of the supratrochlear nerve: implications for the surgical treatment of migraine headaches.

BACKGROUND: Migraine headaches have been linked to compression, irritation, or entrapment of peripheral nerves in the head and neck at muscular, fascial, and vascular sites. The frontal region is a trigger for many patients' symptoms, and the possibility for compression of the supratrochlear nerve by the corrugator muscle has been indirectly implied. To further delineate their relationship, a fresh tissue anatomical study was designed. METHODS: Dissection of the brow region was undertaken in 25 fresh cadaveric heads. The corrugator muscle was identified on both sides, and its relationship with the supratrochlear nerve was investigated. RESULTS: The supratrochlear nerve was found in all 50 hemifaces. Three potential points of compression were uncovered in this investigation: the nerve entrance into the brow through the frontal notch or foramen, the entrance of the nerve into the corrugator muscle, and the exit of the nerve from the corrugator muscle. The nerve generally bifurcates within the retro-orbicularis oculi fat pad, and these branches enter into one of four relationships with the corrugator muscle: both branches enter the muscle, one branch enters the muscle and one remains deep, both branches remain deep, and the branches further branch into ever smaller filaments that cannot be identified cranially. CONCLUSIONS: Some patients are nonresponders to migraine decompression techniques that address the supraorbital nerve. The supratrochlear nerve may be compressed in these patients. A standard corrugator resection that comes more medially within 1.8 cm of the midline may be beneficial. The morphology of the frontal notch/foramen must be examined and addressed if necessary.

Social networks uncovered: 10 tips every plastic surgeon should know.

Understanding online social networks is of critical importance to the plastic surgeon. With knowledge, it becomes apparent that the numerous networks available are similar in their structure, usage, and function. The key is communication between Internet media such that one maximizes exposure to patients. This article focuses on 2 social networking platforms that we feel provide the most utility to plastic surgeons. Ten tips are provided for incorporation of Facebook and Twitter into your practice.

Asymmetric class III malocclusion: association with cranial base deformation and occult torticollis.

The etiology of Angle class III malocclusion with facial asymmetry has not been fully elucidated. To investigate the etiology, patients with asymmetric prognathism (n = 30) from a single institution were assessed for previously undiagnosed torticollis and cranial base asymmetry. Presence of torticollis was determined by measuring restricted head movement when turning the head against a wall and cranial base tilt with upward gaze. Cranial base asymmetry was evaluated by preoperative three-dimensional computed tomography scans. Thirty-one percent of patients with prognathism presented with concurrent facial asymmetry. In patients with asymmetric prognathism, cranial base tilt was present on upward gaze in all patients; mean angle between head and wall was 31 degrees greater than that in control patients, and a 22% to 36% difference in the angle was present when comparing one side with the other. Based on these findings, all patients with asymmetric prognathism were found to be affected by torticollis. By computed tomography scan, 85% of these torticollis patients showed slight anteromedial displacement of the glenoid fossa ipsilateral to torticollis, and 73% demonstrated temporal fossa shift of 4 mm or greater. The current study demonstrates a strong association between asymmetric class III malocclusion, torticollis, and cranial base asymmetry. We conclude that undiagnosed torticollis is a likely etiology for otherwise idiopathic cranial base asymmetry and that cranial base asymmetry in turn causes facial asymmetry and malocclusion. This study highlights the importance of evaluating cranial base asymmetry and torticollis in patients with class III malocclusion to allow for earlier treatment and improved outcomes.

Outcome analysis of combined lipoabdominoplasty versus conventional abdominoplasty.

BACKGROUND: Abdominoplasty and liposuction have traditionally been separate procedures. The authors performed a retrospective cohort study to evaluate the outcomes of a novel single-stage approach combining extensive lipoplasty with a modified transverse abdominoplasty. METHODS: One hundred fourteen patients were evaluated for abdominal contouring. Patients were categorized into four groups: group I (n = 20) received abdominal liposuction only, group II (n = 33) traditional W-pattern incision line abdominoplasty, group III (n = 30) modified transverse incision abdominoplasty, and group IV (n = 31) combined procedure involving widely distributed abdominal liposuction accompanied by inverted V-pattern dissection abdominoplasty. Wound complications, patient satisfaction, and revision rates were compared statistically. RESULTS: Group I (liposuction alone) experienced an overall complication rate of 5 percent; two patients were dissatisfied (10 percent) and underwent further revision with full abdominoplasties. Group II (traditional W-pattern abdominoplasty) had a complication rate of 42 percent, a dissatisfaction rate of 42 percent, and a revision rate of 39 percent. By comparison, group III (modified low transverse abdominoplasty) had a complication rate of 17 percent, a dissatisfaction rate of 37 percent, and a revision rate of 33 percent. Group IV (combined liposuction plus abdominoplasty) had significantly lower complication, dissatisfaction, and revision rates (9, 3, and 3 percent, respectively). CONCLUSIONS: Modified transverse abdominoplasty combined with extensive liposuction and limited paramedian supraumbilical dissection produced fewer complications and less dissatisfaction than did traditional abdominoplasty. This may be attributable to a reduced tension midline closure in the suprapubic region, less lateral undermining in the upper abdomen, and greater preservation of intercostal artery blood flow to the flap.

Intracranial volume and cephalic index outcomes for total calvarial reconstruction among nonsyndromic sagittal synostosis patients.

BACKGROUND: Controversy abounds as to how craniosynostosis affects intracranial volume and whether more extensive procedures achieve superior results. Intracranial volume and cephalic index were evaluated among nonsyndromic sagittal synostosis patients undergoing cranioplasty. METHODS: Twenty-four children with isolated nonsyndromic sagittal synostosis underwent a total calvarial reconstruction. Volume and cephalic index measurements were taken 1 month preoperatively, 1 month postoperatively, and at 1-year follow-up. Data obtained were compared against normative value curves, and interval shifts between curve SD ranges were noted. The absolute percentage difference between the observed intracranial volume or cephalic index and the correlated normative mean value (absolute mean percentages) was calculated for each scan. RESULTS: Preoperatively, intracranial volume for patients younger than 30 months (n = 19) was within the normal range (+/-1 SD), whereas it exceeded 1 SD in all patients older than 30 months (n = 5). Postoperatively and at follow-up, intracranial volume range was unchanged for patients younger than 30 months but was decreased to normal for 60 percent of those older than 30 months. Absolute mean volume percentage showed a small increase from preoperatively for patients younger than 12 months (p < 0.05), no change for patients aged 12 and 30 months, and decreased for patients older than 30 months (p < 0.05). Postoperatively, all patients demonstrated a normal intracranial volume growth rate. As for cephalic index, preoperatively, 92 percent of patients fell below the minimum normal values. At follow-up, 100 percent had a cephalic index in the normal range (p < 0.05). CONCLUSIONS: Nonsyndromic sagittal synostosis results in an age-dependent increased intracranial volume and decreased cephalic index. Total calvarial reconstruction (1) appears to allow for the expansile forces of the growing brain to be distributed and may relieve an underlying abnormality; (2) does not affect postoperative intracranial volume growth rate; and (3) enables normalization of cephalic index.

Reduced morbidity and improved healing with bone morphogenic protein-2 in older patients with alveolar cleft defects.

BACKGROUND: In older cleft patients, alveolar bone grafting may be associated with poor wound healing, graft exposure, recurrent fistula, and failure of tooth eruption. A new procedure using a resorbable collagen matrix with bone morphogenetic protein (BMP)-2 was compared with traditional iliac crest bone graft to close alveolar defects in older patients. METHODS: Skeletally mature patients with an alveolar cleft defect undergoing alveolar cleft repair were divided into either group 1 (BMP-2, experimental) or group 2 (traditional iliac graft, control) (n = 21). Bone healing was assessed with intraoral examination and NewTom scans (three-dimensional, Panorex, periapical films). Donor-site morbidity was determined with pain surveys. Overall cost and length of hospital stay were used to examine economic differences. RESULTS: Preoperative and follow-up (1 year) intraoral examinations revealed fewer complications (11 percent versus 50 percent) and better estimated bone graft take in group 1 compared with group 2. Panorex and three-dimensional computed tomographic scans showed enhanced mineralization in group 1 compared with group 2. Volumetric analysis showed group 1 had a larger percentage alveolar defect filled with new bone (95 percent) compared with group 2 (63 percent). Donor-site pain intensity and frequency were significant in group 2 but not group 1. The mean length of stay was greater for group 2 compared with group 1. In addition, the mean overall cost of the procedure was greater in group 2 ($21,800) compared with group 1 ($11,100). CONCLUSIONS: For this select group of late-presenting alveolar cleft patients, the BMP-2 procedure resulted in improved bone healing and reduced morbidity compared with traditional iliac bone grafting.

Craniofrontonasal dysplasia: a surgical treatment algorithm.

BACKGROUND: Craniofrontonasal dysplasia is a rare, familial X-linked syndrome with coronal synostosis (brachycephaly or plagiocephaly), hypertelorbitism (frequently asymmetric), and extracranial anomalies. Details of the timing and technique of the craniofacial correction have not been well described. The largest series of patients with craniofrontonasal dysplasia treated at a single institution was used for review. METHODS: A review of patients at the University of California, Los Angeles Craniofacial Clinic with the diagnosis of craniofrontonasal dysplasia was performed (n = 21). Data included office, hospital, and operative records; photographs; lateral cephalograms; and three-dimensional computed tomographic scans. Based on surgical outcomes, a treatment algorithm was created. RESULTS: Fourteen patients were female, seven were male, and five had a family history of craniofrontonasal dysplasia (24 percent). Eight patients had unilateral coronal synostosis (plagiocephaly) and 13 had bilateral coronal synostosis (brachycephaly). Eleven patients had asymmetric hypertelorbitism and 10 had symmetric hypertelorbitism. Patients also had cleft lip-cleft palate (10 percent), ear deformities (19 percent), strabismus or esotropia (81 percent), dry frizzy hair (100 percent), syndactyly (14 percent), and nail (100 percent) or other anomalies. After fronto-orbital advancement, no patients had increased intracranial pressure problems or difficulty related to resynostosis. After hypertelorbitism correction, three patients relapsed. Because of this, correction in later patients was delayed until after eruption of permanent maxillary incisors. The mean anterior interorbital distance was reduced in patients from 184 percent to 98 percent of sex-matched controls. CONCLUSIONS: The phenotypic expression of craniofrontonasal dysplasia is described to recognize patients early. A treatment algorithm for craniofrontonasal dysplasia based on timing and technique is offered to decrease the need for revision and improve outcomes.

Delayed closure of the hard palate leads to speech problems and deleterious maxillary growth.

BACKGROUND: Hard palate cleft closure has been associated with maxillary hypoplasia. The Schweckendiek procedure offers delayed hard palate closure to avoid early subperiosteal dissection and palatal scarring. This study sought to compare single-stage versus delayed hard palate closure for speech outcome and maxillary growth. METHODS: A retrospective outcome study was performed of unilateral cleft lip and palate patients with either delayed hard palate repair with a pinned-retained speech prosthesis (Schweckendiek repair) (group 1, delayed hard palate repair, 1978 to 1983) or single-stage cleft palate repair (group 2, single-stage repair, 1983 to 1988). Patients with complete records to maturity at the University of Pittsburgh Cleft Palate Craniofacial Center (n = 82, two equal groups of 41 patients) were studied. Comparative data were collected from multidisciplinary evaluations, perceptual speech scores, speech tests, and cephalometric analysis. RESULTS: Single-stage cleft palate repair had a lower fistulization rate (11 percent) compared with delayed hard palate repair (58 percent). It also had better speech outcomes compared with delayed hard palate repair: mean speech score, 3.1 versus 7.8; final speech score, 0.9 versus 2.9; velopharyngeal incompetency, 21 percent versus 66 percent; failed video fluoroscopy or nasoendoscopy, 18 percent versus 52 percent; and need for secondary speech procedure, 20 percent versus 63 percent. Single-stage repair showed less maxillary growth disturbance, with class III malocclusion, 31 percent versus 66 percent; cephalometric SNA, 78.2 versus 74.8; need for Le Fort I advancement, 24 percent versus 42 percent; and amount of maxillary advancement required, 6 mm versus 9 mm. CONCLUSION: The delayed cleft palate repair led to worse speech outcomes; thus, the authors' center abandoned this technique in favor of single-stage repair. In addition, their data showed that the delayed cleft palate repair led to deleterious maxillary growth.

Cranial suture response to stress: expression patterns of Noggin and Runx2.

BACKGROUND: Current theory on normal cranial suture fusion entrusts the dura with the regulatory role. Studies suggest that the dura responds to stress with changes in gene expression. Noggin (bone morphogenetic protein inhibitor) expression is decreased in normal (rat and mouse) cranial suture fusion, but its role in craniosynostosis and the response to stress has not been studied. METHODS: Posterior frontal (fusing) and sagittal (patent) rat cranial sutures were held static, oscillated, or distracted for 10 days in an organ culture microdistraction device beginning at 5 days of age (n = 30 sutures, or 10 sutures per group). The percentage of fusion equaled the score received for bony closure. Noggin, Runx2, and alkaline phosphatase expression was localized by immunohistochemistry for all groups. RESULTS: Both the posterior frontal and sagittal sutures demonstrated a significant (p < 0.05) increase in fusion percentage with oscillation relative to the static control. Noggin was not expressed in the fusing posterior frontal suture but was expressed in the normally patent sagittal suture. Conversely, Runx2 was expressed in the posterior frontal suture but not in the sagittal suture. However, when a mechanical stress was applied, both the posterior frontal and sagittal sutures expressed Runx2 but not Noggin, as in the static fusing suture. CONCLUSIONS: The application of mechanical stress to cranial sutures results in fusion of both the posterior frontal suture and the normally patent sagittal suture. Runx2 is expressed but Noggin is not expressed. Thus, mechanical stress influences sutural fusion and may play a role in craniosynostosis.

Posterior cranial fossa box expansion leads to resolution of symptomatic cerebellar ptosis following Chiari I malformation repair.

Chiari I malformation occurs when the cerebellar tonsils herniate downward through the foramen magnum into the upper cervical spinal canal. If the posterior fossa craniectomy during corrective surgery leads to excessive enlargement of the foramen magnum, the complication of cerebellar ptosis may result. To treat this difficult problem a posterior cranial fossa box expansion was devised and studied. Patients who developed symptomatic cerebellar ptosis (confirmed by MRI) following cranial vault decompression for Chiari I malformations underwent a posterior fossa box expansion (n=7). This procedure involved coverage of posterior aspect of the enlarged foramen magnum with a split-thickness calvarial bone graft box. The box reconstruction provided separation between the neck musculature, soft tissues from the neural tissue; prevention of cerebellar prolapse; and expansion of the posterior cranial vault. Patients had a mean of 12+/-1 months between initial suboccipital craniectomy and confirmation of symptomatic cerebellar ptosis. Mean age at the time of posterior fossa box reconstruction was 31+/-9 years (range of 14 to 44 years). Preoperative symptoms of headache (7/7, 100%), upper extremity numbness (5/7, 71%) or paresthesias (3/7, 43%), respiratory disturbance (2/7, 29%) and inability to walk (2/7, 29%) improved in all patients postoperatively. At more than 12 month follow-up 6/7 patients (86%) were both disease-free (MRI confirmation) and symptom-free. One out of seven patients had return of headache in a more mild form. Thus, in our patient group the posterior fossa box reconstruction led to resolution of symptomatic cerebellar ptosis following Chiari I malformation repair.

Autologous fat transfer national consensus survey: trends in techniques for harvest, preparation, and application, and perception of short- and long-term results.

BACKGROUND: Despite a perceived interest in autologous fat transfer, there is no consensus as to the best technique or the level of success. The purpose of the present study was to determine the national trends in techniques for harvest, preparation, and application of autologous fat, as well as the success perceived by practitioners. METHODS: Comprehensive surveys were sent to 650 randomly selected members of the American Society for Aesthetic Plastic Surgery. The survey was aimed at determining whether autologous fat transfer is a commonly performed procedure and, if so, the specific methods involved and the subjective perception of short- and long-term results. RESULTS: The results of the national consensus survey from 508 surgeons (78 percent return rate) showed the following: (1) autologous fat transfer is a relatively common procedure (57 percent perform >10 annually), but few perform it in high volume (only 23 percent perform >30 annually); (2) techniques for harvest, preparation, and injection rarely deviate from methods discussed in the literature (microcannula, 54 percent; centrifugation, 75 percent; injection in nasolabial fold > lips > nasojugal folds); (3) most physicians believe that at least some graft survival is clinically evident (93 percent); and (4) patients are pleased with the short-term results (good to excellent, 84 percent), despite a lower rate of long-term patient satisfaction (fair to good, 80 percent). CONCLUSION: Currently, plastic surgeons across the country report a uniformity of autologous fat grafting techniques with acceptable patient satisfaction.

Monobloc advancement by distraction osteogenesis decreases morbidity and relapse.

BACKGROUND: Treatment of midface hypoplasia and forehead retrusion with monobloc advancement is associated with significant complications, including meningitis, prolonged intubation, and frontal bone flap necrosis. To see whether distraction of the monobloc segment offered decreased morbidity, the authors compared clinical outcomes of patients who underwent conventional monobloc advancement with those of patients who underwent monobloc distraction. METHODS: Group 1 (conventional monobloc; n = 12) underwent traditional monobloc advancement with bone grafting. Group 2 (modified monobloc; n = 11) did not receive ventriculoperitoneal shunts and underwent the above procedures with placement of a pericranial flap and fibrin glue over the midline defect. Group 3 (monobloc distraction; n = 24) underwent advancement of the monobloc segment by distraction osteogenesis using internal distraction devices. Complications included meningitis, cerebrospinal fluid leak, frontal bone flap loss, and wound infection. Preoperative, postoperative, and follow-up lateral cephalograms were used to assess horizontal changes of the forehead, midface, and maxilla. RESULTS: Group 3 (distraction monobloc) had the lowest complication rate (8 percent), followed by groups 2 (modified monobloc; 43 percent) and 1 (conventional monobloc; 61 percent) (p < 0.05). Group 3 achieved greater advancement (12.6 mm) than did group 2 (9.4 mm) or group 1 (9.1 mm) (p < 0.05). Relapse was least in group 3 (8 percent) compared with groups 2 (67 percent) and 1 (45 percent). CONCLUSIONS: Monobloc advancement by distraction osteogenesis had less morbidity and achieved greater advancement with less relapse compared with conventional methods of acute monobloc advancement with bone grafting. Monobloc distraction is superior to conventional methods of acute monobloc advancement and is an alternative to staged fronto-orbital advancement followed by Le Fort III advancement.

Genioplasty distraction osteogenesis and hyoid advancement for correction of upper airway obstruction in patients with Treacher Collins and Nager syndromes.

BACKGROUND: Treacher Collins and Nager syndromes may present with mandibular hypoplasia that causes posterior collapse of the tongue base and a decreased oropharyngeal airway. Mandibular distraction and orthognathic advancement are effective treatments to correct the airway, but failure may occur despite achieving class I occlusion. For this select population, the authors propose a novel procedure of genioplasty distraction and hyoid advancement to optimize epiglottal positioning. METHODS: Patients diagnosed with Treacher Collins (n = 5) or Nager syndrome (n = 3) with obstructive sleep apnea or tracheostomy dependency (n = 8) underwent genioplasty distraction and hyoid advancement. Airway outcome was assessed by preoperative and 1-year follow-up comparison of (1) laryngobronchoscopy, (2) sleep studies, and (3) tracheostomy dependency. For genioplasty outcome, three groups were used: group I (distraction genioplasty, syndromic) (n = 8), group II (acute genioplasty, syndromic) (n = 7), and group III (acute genioplasty, nonsyndromic) (n = 10). Lateral cephalogram measurements were used in the preoperative, postoperative, and follow-up periods to assess horizontal and vertical advancement and relapse. RESULTS: Epiglottal position was optimized by the procedure in all patients based on direct endoscopic assessment. All five patients with obstructive sleep apnea had resolution of symptoms, and two of three patients achieved removal of their tracheostomy. Mean advancement for groups I, II, and III was 25, 14, and 8 mm, respectively. Follow-up horizontal advancement for groups I, II, and III were 18, 4, and 6 mm, respectively. Cephalometric measurements showed a horizontal relapse for groups I, II, and III of 10, 62, and 11 percent, respectively. CONCLUSIONS: Data suggest that genioplasty distraction allows for a greater advancement and decreased relapse rate than acute procedures alone; and genioplasty distraction with hyoid advancement is a useful technique for resolution of obstructive sleep apnea or to achieve tracheostomy removal in those syndromic patients who have already undergone mandibular advancement into a class I occlusion.

Temporomandibular joint bony ankylosis: comparison of treatment with transport distraction osteogenesis or the matthews device arthroplasty.

Temporomandibular joint (TMJ) bony ankylosis with micrognathia is a rare congenital condition that is difficult to treat and may result in recurrence. In a series of affected patients, we compared two new methods of treatment: transport distraction osteogenesis and Matthews Device arthroplasty. All patients had computed tomography scan documented bilateral TMJ bony ankylosis. Group I (transport distraction osteogenesis) underwent distraction advancement of the mandible (for micrognathia) followed by resection of the condyles, recontouring of the glenoid fossas with interposition temporoparietal-fascial flaps, and transport distraction osteogenesis of mandibular rami segments. Group II (Matthews Device arthroplasty) underwent all of the above procedures except for transport distraction osteogenesis. Instead, the Matthews Devices were anchored to the temporal bone and mandibular rami. Hinged arms allowed for motion at the reconstructed TMJ. In both groups, patients underwent extensive postoperative therapy. Preoperative, postoperative, and follow-up lateral cephalograms were obtained, and incisor opening distances were recorded. All patients but one had severe micrognathia (n = 9). For group I (transport distraction osteogenesis), mean age was 6.8 years. and mean advancement was 28.5 mm. For group II (Matthews Device arthroplasty) mean age was 8.2 years, and mean advancement was 23.5 mm. In group I (transport distraction osteogenesis), mean incisor opening was 1 mm preoperatively and 27.5 mm postoperatively; however, it relapsed to 14.3 mm by 12.5 months follow-up (48% relapse). Mean incisor opening in group II (Matthews Device arthroplasty) was 3.9 mm preoperatively and 33.4 mm postoperatively and remained at 30.6 mm after 11.1 months follow-up (8% relapse). One patient in group I (transport distraction osteogenesis) underwent surgical revision because of relapse. Our data showed that for congenital TMJ bony ankylosis both transport distraction osteogenesis and Matthews Device arthroplasty techniques were successful initially; however, the Matthews Device arthroplasty avoided long-term relapse.

Osteogenic potentiation of human adipose-derived stem cells in a 3-dimensional matrix.

Adipose-derived stem cells (ADSCs) hold promise for use in tissue engineering. Despite growing enthusiasm for use of ADSCs, there is limited research that has examined their behavior in different in vitro and in vivo systems. The purpose of our study was to evaluate the effect of the extracellular matrix structure and composition on osteogenic differentiation by comparing the osteogenic marker expression of ADSCs grown under 2-dimensional or 3-dimensional cell culture conditions. Group 1 (2-D) included ADSCs raised under conventional cell culture conditions (cells in a 2-D monolayer configuration) (n = 24), and group 2 (3-dimensional) included ADSCs seeded in a collagen gel (cells within a 3-dimensional, biologically active environment) (n = 24). Comparison of ADSC behavior between the 2 groups was analyzed during a 14-day time frame. Osteogenic marker expression (CBFA-1, alkaline phosphatase, osteonectin, osteopontin, Collagen I, and JNK2) was quantified by real-time PCR, and histologic analysis was performed. Histologically, group 1 (2-D) showed cell spreading and deposition of a calcified extracellular matrix. Group 2 (3-dimensional) assumed a disorganized state in the collagen gel, with extension of pseudopodia throughout the matrix. Expression of CBFA-1 was up-regulated immediately in both groups. However, cells in group 2 (3-dimensional) had a more rapid and greater overall expression compared with cells in group 1 (2-D) (250-fold greater at 4 days). At day 14, cells in group 2 (3-dimensional) showed greater expression of all other osteogenic markers than cells in group 1 (2-D) (2.3-fold greater expression of alkaline phosphatase [P < 0.05], 8.4-fold greater expression of osteonectin [P < 0.05], 6.4-fold greater expression of osteopontin [P < 0.05], 2.9-fold greater expression of collagen I [P < 0.05], and 2.5-fold greater expression of JNK2 [P < 0.05]). Our data showed there was a progressive stimulatory effect on ADSCs with regard to osteogenesis when cultured in a 3-dimensional gel compared with a 2-D monolayer.

Improved outcomes in cleft patients with severe maxillary deficiency after Le Fort I internal distraction.

BACKGROUND: Correction of severe maxillary deficiency in cleft lip-cleft palate patients often results in undercorrection, relapse, and need for secondary corrective procedures. Le Fort I internal distraction osteogenesis offers an alternative to one-step orthognathic advancement, with advantages of gradual lengthening through scar and earlier treatment in growing patients. METHODS: Patients with cleft lip-cleft palate deformities and maxillary deficiency were divided into three groups treated by Le Fort I advancement: group 1, mild to moderate deficiency (< 10 mm) with conventional orthognathic procedure; group 2, severe deficiency (> or = 10 mm) with conventional orthognathic procedure; and group 3, distraction procedure for severe deficiency (> or = 10 mm) (n = 51). Preoperative, postoperative, and follow-up (> 1 year) lateral cephalogram measurements were compared including angular (SNA and SNB) and linear (Deltax = horizontal and Deltay = vertical) changes. The Pittsburgh Speech Score was used to assess for velopharyngeal insufficiency (score > 3). RESULTS: Results demonstrated that group 1 patients had a mean SNA change from preoperatively (78.7) to postoperatively (83.8), and a horizontal change of 5.0 mm, with no relapse. Group 2 patients had a mean SNA change from preoperatively (76.3) to postoperatively (82.0) and a horizontal change of 7.2 mm, with 63 percent relapse. Group 3 patients had a mean SNA change from preoperatively (74.1) to postoperatively (84.9) and a horizontal change of 16.5 mm, with 15 percent relapse. Thus, for severe maxillary deficiency, the distraction group had 48 percent less relapse than the conventional Le Fort I group. Postoperative speech evaluation showed velopharyngeal insufficiency in the following: group 1, four of 20 patients (20 percent); group 2, nine of 11 patients (82 percent); and group 3, nine of 20 patients (45 percent). CONCLUSION: These data suggest that Le Fort I internal distraction for severe cleft maxillary deficiency leads to better dental occlusion, less relapse, and better speech results.

Favorable morphologic change of preosteoblasts in a three-dimensional matrix with in vitro microdistraction.

BACKGROUND: Distraction osteogenesis has been used to correct hypoplastic and asymmetric bony deformities in the growing patient, yet its underlying cellular mechanisms are poorly understood. Using a new in vitro model, the microdistractor, morphologic properties of preosteoblasts under mechanical strain were studied. METHODS: Mouse calvarial MC3T3 cells were suspended in a polymerized three-dimensional collagen gel and stressed for 14 days as one of three groups (n = 30): (1) distraction (0.5 mm/day); (2) oscillation (1 mm/day for 2 days alternated with 1 mm/day for 2 days); and (3) control (no force). A computer modeling system, KS-300, was used to record cell shape (aspect ratio) and orientation (deviance from axis of stress). RESULTS: In part I of the study, morphologic cellular changes were found to be even throughout different regions of the gel (central versus peripheral, versus different vertical layers), suggesting the force was evenly applied to all cells in the gel. In addition, when linear distraction forces were applied, morphologic change occurred over time, suggesting a morphologic response to the applied stress. In part II of the study, with different forces applied, morphologic changes occurred over time such that linear distraction forces caused cells to elongate and align in a parallel direction to the force, whereas oscillation caused cells to switch from parallel (with distraction) to perpendicular (with compression) orientation relative to the force applied. CONCLUSION: The authors' data suggest that the microdistractor device is an effective in vitro model for studying the cellular response to distraction stresses. It may be used in future studies to optimize clinical methods of distraction.

Repair of large nasal septal perforations using facial artery musculomucosal (FAMM) flap.

BACKGROUND: Nasal septum perforations from surgical submucous resection, septoplasty, blunt trauma, and substance abuse may cause epistaxis, nasal obstruction, discharge, crusting, dryness, pain, and whistling. While small symptomatic perforations are closed with local mucosal flaps, options for closure of large symptomatic perforations are limited. A local pedicled flap, the facial artery musculomucosal (FAMM) flap was studied in patients with large symptomatic nasal septal defects. METHODS: Patients included in the study had (1) a nasal septal defect measuring at least 20 mm in greatest dimension; and (2) related symptoms of nasal crusting, discharge, dryness, obstruction, epistaxis, pain, or whistling. Six patients (3 males; 3 females) met these criteria and received FAMM flap repair. Outcomes were assessed based on comparison of preoperative versus last follow-up (range, 10-30 months; mean 17 months) assessment of perforation size and symptomatology. Overall discomfort was rated at each time point on a 1-10 scale. RESULTS: Age at time of operation ranged from 21 to 44 years, with a mean of 34 years of age. Causes of septal perforation included blunt trauma (50%), cocaine abuse (33%), and submucous resection (17%). Preoperatively, maximal recorded dimensions of septal perforations ranged from 3.1 to 4.0 cm with a mean of 3.5 +/- 0.4 cm. Symptoms included pain (83%), dryness (67%), crusting (50%), discharge (33%), epistaxis (33%), and obstruction (33%). Three or more symptoms were experienced by 5 patients (83%). Overall discomfort ranged from 6-10, with a mean of 8.4. Postoperatively at last follow-up, all 6 patients (100%) achieved closure of their septal defect (P < 0.001). Overall discomfort score was zero for all 6 patients (100%) (P < 0.0001). Complete symptomatic resolution was also noted among all 6 patients (100%) (P < 0.01). CONCLUSIONS: In summary, the advantages of the FAMM flap closure technique were (1) no visible external scar, with minimal donor site morbidity; (2) successful closure of large septal defects (>2 cm) with vascularized tissue in a single stage; and (3) resolution of patient symptomatology.