Three-dimensional computed tomographic scanning and major surgical reconstruction of the head and neck.

The major advantage of three-dimensional computed tomographic imaging is the ability to obtain accurate anatomic measurements of distance, area, and volume. This accuracy is possible because the three-dimensional relationships of soft tissue and skeleton are retained. This feature is particularly useful in reconstruction of the upper facial skeleton, where standard roentgenograms and computed tomographic scans are of limited value. Computer-interactive surgical procedures have been used for correction of congenital deformities and for removal of orbital neurofibromas and subsequent reconstruction. Because three-dimensional imaging is expensive and exposes the patient to high levels of irradiation, this approach is recommended only when a specific indication exists and when it can contribute to problem solving.

Infections in breast implants.

Infection following breast implants is an uncommon event. This is somewhat surprising, since the human breast is not a sterile anatomical structure. The flora found in the breast are derived from the nipple ducts and closely resemble those of normal skin. These organisms, predominantly S. epidermidis, may in some cases be responsible for firmness secondary to capsular contracture. Treatment of the periprosthetic infection usually involves implant removal, but salvage by systemic antibiotics is sometimes possible. Atypical mycobacteria are very rarely the cause of infection, but can be extremely difficult to eradicate when involved. Toxic shock syndrome has been reported to occur following breast implants and is a life-threatening problem requiring immediate removal of the implant. It may be significant that in some cases with effusion and infection occurring many months or years after implant placement, there has been a preceding event such as a laryngitis or flu-like illness. This suggests the possibility of a bacteremia being involved in the causation of the infection. If this were the case, then these patients should be handled in a fashion similar to those with prosthetic heart valves. Accordingly, in our own practice, we advise that penicillin "V" be given beforehand when a patient with breast implants is to have any dental procedure. It must be stressed that there is no statistical or scientific proof at the present time that this is of any value. In conclusion, when dealing with these large foreign bodies, absolute sterility is essential, and excellent surgical technique to obviate hematoma and the occurrence of tissue ischemia is mandatory. Evidence of severe infection necessitates implant removal, but in less severe cases a trial of intravenous antibiotics is permissible. Having removed an implant, further insertion should be deferred, preferably for 6 months. If the new implant can be placed in a different plane, that is, submuscular, this is desirable. Exposed implants can be salvaged but this requires considerable judgment and one should be prepared for re-exposure or frank infection.

Maxillary hypoplasia.

Maxillary hypoplasia and retrusion is complex. It may involve the dentoalveolar area, or it may involve the whole midface. It may be difficult to recognize, since the patient may come only with the complaint of nasal deformity, and the occlusion may be normal. It may be difficult to treat, as in the severe Binder's syndrome, where in addition to the bony deformity, the facial mask is deficient and obviously in the wrong position. To treat the condition the surgeon must have an aesthetic sense. It is not like the situation when only the maxilla is involved; this tends to be mechanical and is related to dental malocclusion. In these patients, an aesthetic appreciation of the nose and its relationship to the maxilla, infraorbital rims, and frontal area is paramount. Unless this complete approach is used, the patient will be undertreated and end up unhappy. Patients can readily appreciate the position and the contours of the nose, but they do not understand the subtleties of the lack of a bony foundation when there is maxillary hypoplasia. Not only does this involve a high degree of aesthetic appreciation on the part of the surgeon, it also necessitates a considerable ability to convey to the patients that the problem is not the simple one that they had first imagined. When all of these subtleties are appreciated, it is possible to develop a degree of sophistication in the treatment of these patients that will yield excellent results.

Complex craniofacial reconstruction using an implant-supported prosthesis: case report with long-term follow-up.

In complex craniofacial reconstruction involving an implant-supported prosthesis, problems such as tumor recurrence may require additional surgical resection. The solution to such recurrence may be autogenous bone grafting or additional implant placement or both (after resection of the tumor) and revision of the prosthesis. Tumor recurrence was seen during an 11-year, 8-month follow-up of a 58-year-old woman who had had an extensive mid-face defect. The various treatments, including extraoral and intraoral prostheses, provided the patient with an acceptable quality of life without interruption in use of the prostheses.

Ameloblastic carcinoma. Report of an aggressive case and review of the literature.

Odontogenic carcinomas of the jaws are classified as malignant ameloblastoma, ameloblastic carcinoma or primary intraosseous carcinoma. Because these lesions are extremely rare, microscopic diagnosis is difficult. An aggressive case of ameloblastic carcinoma of the mandible is presented. In spite of radical surgery and radiotherapy, the patient expired eight months following initial diagnosis. - A review of the literature seems to indicate that so called simple ameloblastomas rarely can dedifferentiate and metastasize following multiple inadequate surgical procedures. Although radical surgery is not necessary, local excision should be thorough. - Ameloblastic carcinoma and primary intraosseous carcinomas may be histogenetically similar. They are highly malignant tumours which should be treated aggressively. Metastasis is common and prognosis is poor.

Contouring of a solid silicone block: a new use for the Shaw scalpel.

The use of the Shaw hemostatic scalpel eliminates the frustration and physical fatigue formerly associated with the carving of solid silicone implants from blocks of silicone of all grades. It enables very accurate shaping and saves operating and anesthesia time. The smooth end product may, in many cases, eliminate the need for factory-made implants. This method of shaping silicone block is highly recommended. It is not suggested that the instrument should be purchased for this purpose alone, but if purchase of the scalpel is being considered for other purposes, this may be a significant factor in the decision.

Partial lip resection with orbicularis oris transposition for lower lip correction in unilateral facial paralysis.

Malfunction of the marginal mandibular nerve, either in combination with a generalized facial palsy or in isolation, can cause an unpleasant and disturbing appearance around the mouth. In total palsy, a cross-facial nerve graft combined with a free vascularized muscle transplant will usually deal with this problem successfully; however, all older procedures used in this situation are unpredictable. For the isolated palsy, procedures such as digastric muscle transfer or sling suspension are not uniformly successful. A method using the contralateral, nonaffected lower lip orbicularis muscle is described. A wedge is removed from the paralyzed lower lip and the orbicularis is advanced to the modiolus to provide a functional orbicularis all the way across the lower lip up to the angle of the mouth. This is a simple outpatient procedure that has produced satisfactory results in most cases.

Craniofacial and oral manifestations of fetal alcohol syndrome.

Six representative patients with fetal alcohol syndrome (FAS) were studied for craniofacial and oral anomalies, dental development, and long-term bodily growth patterns. The craniofacial features observed were reduction of total head size, increased head-body ratio, the existence of upper and middle craniofacial asymmetry and telecanthus in some instances, and the features of a long face syndrome with a large gonial angle. Dental development was mildly to moderately delayed, and enamel anomalies were present. Analysis of growth patterns demonstrated compensatory growth in stature, weight, or head circumference and a delayed bone age in some instances. It is suggested that the semiquantitative score system for fetal alcohol syndrome study may fail to diagnose individual cases and that craniofacial features are more important in diagnosis than seems to have been appreciated in the past.

Functional support for flap reconstruction of the lower lip and mandible.

A case of functional support for distant flap reconstruction of the entire lower lip and mandibular symphysis following resection of an aggressive recurrent basal cell carcinoma of the lip is presented. Resection of the entire lower lip and mandibular symphysis includes loss of the orbicularis oris and attached muscles of the modiolus as well as the buccinator and masseter muscles. Without the support of these muscles, control of saliva as well as solid and liquid food is lost and articulation is hampered. In this case, fasciae latae strips attached to distally transected temporalis muscle tendons were tunneled bilaterally into the lower lip and chin area, which had been previously reconstructed with deltopectoral and pectoralis major musculocutaneous flaps.

Primary veloplasty or primary palatoplasty: some preliminary findings.

Staged palatal closure was carried out in 30 children. The soft palate was closed at 9 months and the hard palate at 5 years. These patients were followed up for 7 years, and it was found that although the incidence of lateral crossbite was reduced in both unilateral and bilateral cases, the speech results were less satisfactory than those obtained with total palatal closure. In this series, there were two fistulae at the junction of the hard and soft palate. This was related to difficulty in closing this area in some patients at the time of the second operation. As a result, the procedure is not advised. An alternative palatal closure technique is described. This technique consists of nasal layer closure, careful dissection and reconstruction of the levator musculature, transverse division of the nasal layer, insertion of a buccal flap for lengthening, and closure of the oral layer with Veau flaps without dissection behind the tuberosities and with almost total closure of the lateral donor sites on the palatal shelves. In this way there is minimal scarring, particularly in the retrotuberosity area. This is felt to be important since it would seem from studies of facial growth that this is a much more significant area than the palatal shelves.

Vascular anatomy of the galeal occipitalis flap: a cadaver study.

The vascular anatomy of the galeal occipitalis flap was studied in 10 fresh cadavers by an intraarterial dye injection technique. The scalp flap was based posteriorly, incorporating both the occipital and posterior auricular arteries. A good transmidline anastomosis was demonstrated between the two occipital arteries in the full-thickness scalp flap. However, in the isolated galeal flap, although the axial distribution of the occipital artery was maintained, fewer transmidline connections were seen between the two occipital arteries. The posterior auricular artery was consistently visualized in all dissections, and it showed good connections with the ipsilateral occipital artery. However, there were very few anastomoses between the two posterior auricular arteries across the midline. The rich anastomotic network between the occipital artery and the posterior auricular artery extended well beyond the vertex. This study showed that a large flap can be raised if both the occipital artery and the posterior auricular artery are included in its base. The occipital artery is a vessel of satisfactory size and is potentially a good vascular source for a thin galeal free flap. It is recommended that the flap be raised at the subperiosteal level for ease of dissection and protection of the vessels, which are initially in the subgaleal plane and then arborize in the galea.

The use of Champy miniplates for osteosynthesis in craniofacial deformities and trauma.

Champy miniplates have been used in the treatment of craniofacial fractures and in osteotomies for correction of posttraumatic deformities, congenital craniofacial deformities, and secondary bony deformities due to pathologies such as hemangioma and neurofibroma. An additional use has been to stabilize free and vascularized bone grafts. The total number of cases reviewed were 50 (25 acute trauma, 4 vascularized mandible reconstruction, and 21 osteotomies of varied types). There were three infections, two in mandibular fractures that were comminuted and compound into the mouth and one in a compound comminuted fracture of the frontal and maxillary area that was judged to be infected when the plate was placed in position. Two plates have been obvious under the skin. No patient has requested plate removal. The advantages of plating in selected cases are decreased operating time, rigid fixation at surgery, good fixation of bone grafts, and the ability to remove intermaxillary fixation in children at the end of the procedure or within the first few postoperative days.

An anatomical classification of maxillary ameloblastoma as an aid to surgical treatment.

Maxillary ameloblastoma is a different entity from its mandibular counterpart. It is reported to behave more aggressively and have a poorer prognosis. Eleven maxillary ameloblastomas (three recurrent) are reported with a follow-up ranging from 1 month to 12 years with no recurrences. It is proposed that radical treatment of these tumours, with good reconstruction, can give satisfactory function and survival. To that end, the tumours have been classified as to their position in the maxilla and surgical resection related to this.

Distraction osteogenesis for lengthening of the hard palate: Part I. A possible new treatment concept for velopharyngeal incompetence. Experimental study in dogs.

Many procedures have been described to correct velopharyngeal incompetence. Significant complications can occur, and the results may not be satisfactory. If the short soft palate has satisfactory muscle function and if it could be moved toward the posterior pharyngeal wall by distraction osteogenesis of the hard palate, an entirely new concept of treatment for velopharyngeal incompetence would be available. The object of the present study was to explore the possibility of osteogenesis occurring in the hard palate in dogs after gradual distraction (callus distraction). Six adult, mix-bred dogs were anesthetized, and the palatal mucosa was elevated. A midpalatal transverse osteotomy and two lateral osteotomies were performed. Tantalum bone markers for cephalometric analysis were placed, and an individually fabricated, orthodontic-like distraction device with an expansion screw in the sagittal direction was inserted. The device was stabilized on the premolars and fixed to the palatal bone with titanium miniscrews. Gradual distraction began after a latency period of 10 to 18 days. The rate of the distraction varied from 0.25 to 0.75 mm per day. The device was left in place for 6 to 8 weeks after expansion to allow for bony consolidation. Assessment was by direct examination, cephalograms, computed tomography, and histology with bone labeling. Impressions of the jaws were taken preoperatively and after device removal to examine plaster cast changes in the dental occlusion. Cephalometric and computed tomographic scan analysis demonstrated a distraction of up to 8 mm. All gaps were filled with de novo osteogenesis. Comparison of the plaster casts revealed no change in the occlusion. At 1 month after distraction, the computed tomographic scan showed the first signs of ossification of the experimental gap from the anterior and posterior bone ends. After 4.5 months ossification was almost complete with a small translucent zone in the middle of the experimental gap. After 7 months ossification was complete.

Distraction osteogenesis for lengthening of the hard palate: Part II. Histological study of the hard and soft palate after distraction.

To correct velopharyngeal incompetence, a new treatment concept was proposed in Distraction Osteogenesis for Lengthening of the Hard Palate: Part I (using lengthening of the hard and soft palate by distraction osteogenesis). Cephalometry and computed tomography showed successful elongation of the posterior hard palate with gradual calcification. Here the sequential use of fluorochrome markers (oxytetracycline, xylenol orange, DCAF [2,4-bis-N-N'-dicarboxymethyl aminomethyl fluorescein], and alizarin complexone) during the distraction and retention period is reported together with the histologic investigations using light and laser scan microscopy without prior demineralization. The experimental gap showed de novo osteogenesis in all dogs. The new bone was always in continuity with the original anterior and posterior palatal bone margins. It either bridged the experimental gap fully or left a small central zone of fibrous tissue, in which eventual ossification occurred. Several distinct zones could be distinguished: A small central zone was found with parallel strains of collagen fibers, oriented longitudinally in the direction of the distraction. Next to this zone a layer of undifferentiated mesenchymal precursor cells was seen in direct contact to newly formed bone. The next zone was coarse woven bone, showing a transition to mature lamellar bone through remodeling. No evidence of endochondral bone formation was found, i.e., all dogs showed exclusively intramembranous bone formation. The soft tissues showed no signs of alteration: in particular, there was no necrosis or scar formation. The soft tissues were not thinned but appeared to have followed the longitudinal displacement. In conclusion, gradual distraction osteogenesis of the hard palate could be a possible method for lengthening the palate to treat velopharyngeal incompetence.

Assessment and treatment of facial deformity resulting from radiation to the orbital area in childhood.

Children who receive radiation for malignant tumors in the orbital area frequently develop widespread craniofacial deformities. These affect the skull, orbit, maxilla, and mandible. When these patients seek treatment at a later age, they require careful assessment using cephalometrics and three-dimensional imaging. It is recommended that the four levels of skeletal deformity be corrected in a single procedure, that is frontotemporal expansion with repositioning of the skull base area, orbital expansion and repositioning together with maxillary and mandibular surgery. Bone grafts should be inlay rather than onlay and soft tissue should be supplied by free-tissue transfer. This counteracts any residual ischemia related to the previous radiation therapy. The second surgical stage is designed to reconstruct the socket and the eyelids to allow more satisfactory rehabilitation with an ocular prosthesis. In patients who have a globe present, the usual enophthalmos can be corrected by repositioning of the eye as part of the first procedure by reducing the anteroposterior dimensions of the socket. In bilateral cases, the deformity is hourglass in nature and requires correction in the frontal and temporal area with lateral displacement of the orbits. A bimaxillary procedure is also indicated. It is emphasized that to formulate a satisfactory operative plan an in-depth three-dimensional analysis of the deformity is mandatory.

The management of intraosseous arteriovenous malformations in the head and neck area.

It is necessary that the treatment of arteriovenous malformations in general be undertaken by a team that consists of a radiologist who is experienced in angiography and embolization and a plastic surgeon. The latter should be well versed in angiographic techniques and should be able to comprehend the dynamics of these malformations. In this report, three patients with high-flow, high-shunt arteriovenous intraosseous malformations of the head are presented. Two of these presented as emergencies with almost uncontrollable bleeding and were initially treated with embolization and then mandibular resection and reconstruction within the first 48 hours. In one patient, a further reconstructive procedure using free vascularized tissue was carried out. A third patient with involvement of the maxilla, again presenting with bleeding, was treated with embolization and, because of the deformity that would be created by resection, was simply observed. However, this patient is to be reassessed in the future and may well come to maxillectomy. It is emphasized that the treatment of these patients requires careful assessment, embolization, and resection as indicated after discussion between radiologist and surgeon.

Surgical correction of the acromegalic face. A one stage procedure with a team approach.

The features of acromegaly are presented with special reference to facial deformity. A one-stage procedure with careful pre-operative planning is advocated. The operating team is composed of a plastic surgeon and an oral surgeon. The frontal protrusion is corrected by osteotomy, the vertical and anteroposterior facial disproportion by bimaxillary procedures, the nasal deformity by rhinoplasty or skull bone grafting, and the macroglossia by tongue resection. This results in an improvement of the patient's psyche and frequently improvement in speech.

The vascular anatomy of the galeal flap in the interparietal and midline regions.

The potential extension of the galeal flap in the interparietal area was studied on 17 fresh human cadaver heads by intravascular dye injection technique. It was demonstrated that an ipsilateral superficial temporal artery that supplies the galeal flap does not cross the midline or anastomose with the contralateral superficial temporal artery but ensures the survival of a flap extended up to 1 cm proximal to the sagittal suture line. The width of the temporoparietal flap can be extended up to 15 cm, depending on the vascular pattern of the superficial temporal artery. When required, the lateral extension may provide the required soft-tissue bulk despite the reduced flap length.

Full-thickness skin graft in the secondary repair of bilateral cleft lip. A case report.

A 13-week-old boy with bilateral complete cleft lip and palate is presented. He had three attempted repairs of his lip elsewhere over a period of four weeks, and all of these broke down. Consequently, a substantial amount of his prolabium became necrotic. After a preoperative orthodontic realignment of the cleft segments, a secondary lip/nose repair was performed. The mucosa was reconstructed by advancement flaps. The orbicularis muscle was dissected out from its abnormal insertion and reconstructed in the midline. The philtrum was reconstructed with a full-thickness skin graft from the right postauricular area. The six-month postoperative result was satisfactory. This technique could be considered as an alternative to primary Abbé flap in secondary reconstruction of the cleft lip, although long-term follow-up must be obtained.