Craniofacial fractures. An algorithm to optimize results.

The aim of treatment of combined injuries of the cranium and face is the correct anatomic restoration of the maxilla in relation to the cranial base above and the mandible below and the reconstruction of any associated craniofacial, naso-orbitoethmoidal, and zygomatic fractures. The plethora of techniques described in this article for the management of these injuries attests to the controversy and confusion surrounding the management of these patients.

Hook nail deformity repaired using a composite toe graft.

The hook nail deformity is caused by loss of fingertip bone and soft tissue. Healing can result in a volarly displaced distal nailbed and a tight tip with inadequate padding and a poor cosmetic appearance. A composite graft from the second toe placed beneath the released nailbed gives good support and improved pulp substance. The technique of the composite toe graft has been performed in nine patients. All grafts were 100 percent viable, but one patient required a second graft for additional tip bulk. There has been no donor-site morbidity in the follow-up of 1 month to 2 years.

Treatment of the concrete scalp donor site.

The scalp has become a popular donor site for split-thickness skin, and few complications have been reported. However, we have been troubled by 5 patients in whom the donor site did not epithelialize but rather turned into dried granulation tissue with embedded growing hairs, a situation rather like concrete with steel reinforcing rods. The pathophysiology is not clear but seems to be related to thick grafts from hair-bearing areas. We treated the lesions by removing the granulation tissue, shaving the hair, and treating the wound as a new donor site. Four lesions healed with total or near total regrowth of hair, and one required a small skin graft.

Platelet-derived growth factor and wound contraction in the rat.

This experiment was undertaken for three purposes: (1) to determine a dose-response curve of acute steroid inhibition of wound contraction in the rat; (2) to confirm the results of our preliminary study that platelet-derived growth factor (PDGF) enhanced wound contraction in acutely steroid impaired rats; and (3) to examine the histology of the PDGF-treated wounds. To determine the dose-response of acute steroid inhibition of wound contraction, the rats were suppressed with daily doses of methylprednisolone and wound contraction was measured. Results demonstrated that significant glucocorticoid-induced inhibition of wound contraction begins with daily methylprednisolone doses of 2.0 mg/wound/day or 6.7 mg/kg/day. In an effort to confirm the results of our previous study of the effect of PDGF on wound contraction in acutely steroid-impaired rats and to study the histology of the PDGF-treated wounds, rats were suppressed with methylprednisolone or hydrocortisone and administered daily topical doses of rPDGF-BB. Wound contraction measurements revealed no improvement in the amount or rate of wound contraction. Histologically, the wounds were all very similar in the patterns of cellularity, granulation tissue maturity, collagen content, and epithelial migration. We have clarified the dose response of acute steroid inhibition of wound contraction in rats, data previously unavailable, and have concluded that PDGF in reasonable doses does not improve wound contraction in steroid-impaired rats nor does it alter the histology of the wounds.