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Abstract: In most cleft centers worldwide, nasal stents are routinely used in the postoperative period to prevent collapse of the lower lateral cartilage and maintain the shape of the nostrils as well as nasal alar. Prefabricated nasal stents are expensive and do not offer options for customization. In this paper, we introduce a cost-effective technique for manufacturing nasal stents using three-dimensional scanning and printing technology., Competing Interests: The authors report no conflicts of interest., (Copyright © 2021 by Mutaz B. Habal, MD.)

Background: One-third of infants have ear anomalies, and less than one-third self-correct. Correction of ear deformities by molding exploits the plasticity of the auricular cartilage because of circulating maternal estrogen during infancy. In this study, the authors assess the efficacy of the EarWell Infant Correction System in the correction of ear deformities and determine the factors that affect its outcome., Methods: The authors conducted a single-center prospective study over a 3-year period. Consecutive full-term infants who underwent ear molding with the EarWell system were recruited. Primary outcome was successful correction of ear anomaly. Secondary outcomes included complications and maintenance of ear shape. Factors identified included type of anomaly, age at application, duration of application, and breastfeeding., Results: Sixty-seven patients with a total of 105 ears were recruited. The anomalies were classified into deformations (66.7 percent) and malformations (33.3 percent). The median age group at presentation was 0 to 7 days (67 percent). Average duration of application was 4.1 weeks. Successful correction was achieved in 86 percent of patients. Ear deformations achieved a significantly higher rate of successful outcome (98 percent) compared with malformations (64 percent) (p < 0.001). Skin complications were common (46 percent) and attributed to our tropical climate. Patients with complications were of a higher mean age (22.1 days) compared with patients with no complications (10.6 days) (p = 0.037)., Conclusions: The EarWell system is an effective nonsurgical option for the treatment of ear anomalies. The type of anomaly was the only predictor of successful correction, whereas age at application, duration of molding, and breastfeeding were not. Complications were more common in older infants., Clinical Question/level of Evidence: Therapeutic, IV.

Background: This analysis presents patient-reported outcomes of breast augmentation procedures performed in Singapore using an inframammary fold incision and the "5 Ps" best practice principles for breast augmentation. These data are the first of their kind in Southeast Asian patients., Methods: Through a retrospective chart review, patients who underwent primary breast augmentation with anatomical form-stable silicone gel breast implants using an inframammary fold incision were followed for ≥6 months postoperatively. The BREAST-Q Augmentation Module (scores standardized to 0 [worst] - 100 [best]) and Patient and Observer Scar Assessment Scale (POSAS; 1 [normal skin] to 10 [worst scar imaginable]) were administered. Responses were summarized using descriptive statistics. Patient-reported events were collected., Results: Twenty-two Southeast Asian patients (mean age, 35.1 years) completed ≥1 postoperative BREAST-Q and POSAS assessment and were assessed 11 months to 5.5 years postoperatively. The mean postoperative BREAST-Q satisfaction with breasts and psychosocial well-being scores were 69.2 and 84.0, respectively. The mean POSAS score for their overall opinion of the scar was 4.2; the mean scores for all scar characteristics ranged from 1.2 to 4.2. Over 90% of patients (20/22) said that they would recommend the procedure. Patient complaints following surgery included anisomastia (possibly pre-existing; n=2), sensory loss at the nipple (n=2) or around the nipple (n=3), scarring (n=4), and slight capsular contracture (n=1). No patients required reoperation., Conclusions: Southeast Asian patients reported high long-term satisfaction scores on the BREAST-Q scale and with their scar characteristics following breast augmentation using an inframammary fold incision, and nearly all said they would recommend this procedure. No reoperations were necessary in patients assessed for up to 5.5 years postoperatively.

Excessive scar formation can form disabling contractures that result in a debilitating psychological outcome. Sustainable hydrophobic corticosteroid release in vivo is essential to regulate the wound healing process. Functional hydrogel particles are widely applied for sustainable release. However, due to the limited aqueous solubility of hydrophobic compounds, most of the corticosteroid is released from the hydrogels within seconds, causing undesirable scar formation and recurrence. In this study, a novel polymerization-induced phase separation is investigated to form well-defined polyethylene glycol diacrylate (PEGDA) core/alginate shell structured hydrogel particles using microfluidics without toxic organic solvents. Based on their wettability preference, hydrophobic corticosteroid-loaded poly(lactic-co-glycolic acid) (PLGA) nanoparticles are compartmentalized in the PEGDA core during polymerization to control the corticosteroid release. The distribution of the PLGA nanoparticles is precisely regulated by the phase separation boundary and characterized using a fluorescent dye. The thickness of the shell and partition coefficients are determined using the UV intensity and irradiation period. Upon encapsulation of the PLGA nanoparticles within the poly(PEGDA) core, a long-term corticosteroid treatment is developed and effective scar therapeutic outcomes are evaluated using both in vitro and in vivo models.

Purpose: To evaluate pharyngeal airway space (PAS; nasopharyngeal, oropharyngeal, and total airway) volume and the correlation of an obstructive sleep apnea (OSA) and hypopnea syndrome screening questionnaire (STOP-BANG) with various mandibular setbacks during bimaxillary surgery and compare these findings with an age- and gender-matched skeletal Class I control group., Patients and Methods: This retrospective cohort study was composed of patients with skeletal Class III discrepancy who underwent bimaxillary jaw surgery and were assessed with STOP-BANG score, cephalometry, and cone-beam computed tomography (of the PAS). The predictor variable was bimaxillary jaw surgery and included 4-, 6-, and 8-mm setbacks. The primary outcome variables were PAS volume, body mass index, and STOP-BANG score evaluated at 1 week before surgery and after comprehensive orthodontic treatment (11.25 ± 1.95 months). Other variables were grouped into the following categories: demographic and cephalometric parameters. Statistical intragroup and intergroup differences were assessed by paired t and independent t tests (P < .05), respectively., Results: The study sample was composed of 48 patients (18 to 25 yr old); group I received 4-mm setback (n = 16), group II received 6-mm setback (n = 16), and group III received 8-mm setback (n = 16) mandibular surgery, and all test groups received 4-mm maxillary advancement. The entire study group was compared with a skeletal Class I control group (n = 16). The total PAS volume after orthodontic treatment in groups I and II showed a significant decrease compared with the presurgical PAS (P < .001), but the decrease was not less than that in the control group (P > .05). In contrast, the total PAS volume in group III after orthodontic treatment (23,574 ± 1,394 mm 3 ) was less than that in the control group (23,884 ± 1,543 mm 3 )., Conclusion: After surgery, patients with Class III discrepancy exhibited a decrease in oropharynx volume; however, the STOP-BANG score showed no change in risk factors scores for OSA at 4- to 8-mm setback surgery of the mandible in bimaxillary jaw surgery., (Copyright © 2017 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.)

Recent studies have shown that infantile hemangiomas (IHs) undergo a rapid growth phase between 5.5 and 7.5 weeks of life and do not usually proliferate beyond 6 months; growth thereafter is usually proportionate to the child's growth. This review assesses the evidence for topical timolol as primary monotherapy for cutaneous facial IHs before 12 months of age, and to determine the differences in outcome between early (before 6 months) and late initiation (after 6 months) of timolol. A review of English language articles published up to November 2015 was performed using selected key words. Articles identified were further reviewed for relevance. The full text of studies included for final analysis was perused to include pertinent patient details, treatment protocol with timolol, complications (if any) reported, and response to treatment. Four studies met the inclusion criteria. In children before 12 months of age, the efficacy of topical timolol for the treatment of cutaneous facial IHs in achieving clinically significant improvement as defined by a standardized Global Assessment Score score of 3 and above ranged from 47% to 88%. One study also showed that IH regression was greater in patients started on timolol before 6 months of age compared with those started later (P <0.05). Topical timolol initiated in children before 12 months of age appears to be safe and clinically effective. There was insufficient data for detailed analysis of outcomes in patients who commenced treatment before and after 6 months of age.

Objective: We hypothesize that primary repair of submucous cleft palate (SMCP) with Furlow palatoplasty will not lead to significant differences in speech outcomes for syndromic and nonsyndromic children., Design: Retrospective analysis of patients with primary Furlow repair of SMCP between 2004 and 2012., Setting: Tertiary care center., Patients/participants: Thirty-four patients (15 boys; 44%) satisfied our inclusion criteria: multidisciplinary consensus on diagnosis of SMCP, failed trial of speech-language rehabilitation, at least 4 years old at the time of primary surgery, at least 6 months follow-up with a repeat set of postoperative speech assessments., Interventions: Primary Furlow palatoplasty for SMCP., Main Outcome Measures: Primary outcomes were based on postoperative perceptual speech assessments and the need for revision surgery. Secondary outcomes included improvement in nasalance scores, postoperative complications, and change in and time to normalization of velar closing ratios., Results: Mean age at surgery = 7.7 years. Of the patients, 17 (50%) were syndromic and 11 (32%) had associated hearing loss. Mean follow-up = 48 months. No patients had postoperative complications, such as wound dehiscence or fistula; however, two patients (one syndromic, one nonsyndromic) required secondary procedures. Velar closing ratios for all patients increased (P < .05) and approached normal at an average of 1.3 years postoperatively., Conclusions: Although the Furlow palatoplasty can correct anatomic anomalies, it cannot achieve normal perceptual resonance in syndromic patients, possibly because of inherent higher-order deficiencies that affect speech production. Further studies with greater patient numbers are necessary to achieve population statistical significance.

Background: Le Fort I maxillary distraction with the rigid external distraction (RED) device is performed to correct severe midface retrusion in cleft patients, but it may adversely affect velopharyngeal function., Objectives: This study aims to investigate the angular changes in the levator veli palatini (LVP) and its influence on velopharyngeal function after maxillary distraction using 3-dimensional computed tomography (3D CT) scan volume rendered images., Methods: This was a retrospective study of 12 patients. Group 1 had no velopharyngeal function deterioration and group 2 had velopharyngeal function deterioration. Preoperative and 1 year postoperative CT scans were analyzed with Mimics v10 software. Segmentation of the LVP and the nasopharyngeal airway was performed and volumetric images were obtained. Six measurements were made: (1) the angle between the levator plane and the Frankfort horizontal, (2) the angle between the levator plane and the soft palate plane, (3) the angle between the 2 LVP muscles, (4) the pharyngeal depth, and (5, 6) the movement of the inferior pharyngeal point with respect to the horizontal and vertical planes. The independent samples t test, Mann-Whitney test, and paired t tests were used for statistical analyses (P < 0.05)., Results: Group 2 had statistically significant reduction in the angle between the levator plane and Frankfort horizontal as well as the soft palate plane. Group 1 had a statistically significant increase in the pharyngeal depth and movement of the inferior pharyngeal point with respect to the horizontal plane., Conclusion: A decrease in the angle between the levator plane and the Frankfort horizontal or the soft palate plane was associated with velopharyngeal function deterioration.

The poor solubility of many newly discovered drugs has resulted in numerous challenges for the time-controlled release of therapeutics. In this study, an advanced drug delivery platform to encapsulate and deliver hydrophobic drugs, consisting of poly (lactic-co-glycolic acid) (PLGA) nanoparticles incorporated within poly (ethylene glycol) (PEG) microgels, was developed. PLGA nanoparticles were used as the hydrophobic drug carrier, while the PEG matrix functioned to slow down the drug release. Encapsulation of the hydrophobic agents was characterized by fluorescence detection of the hydrophobic dye Nile Red within the microgels. In addition, the microcomposites prepared via the droplet-based microfluidic technology showed size tunability and a monodisperse size distribution, along with improved release kinetics of the loaded cargo compared with bare PLGA nanoparticles. This composite system has potential as a universal delivery platform for a variety of hydrophobic molecules.

Background: The distally based sural artery flap is a reliable, local reconstructive option for small soft tissue defects of the distal third of the leg. The purpose of this study is to describe an adipofascial flap based on a single sural nerve branch without sacrificing the entire sural nerve, thereby preserving sensibility of the lateral foot., Methods: The posterior aspect of the lower limb was dissected in 15 cadaveric limbs. Four patients with soft tissue defects over the tendo-achilles and ankle underwent reconstruction using the adipofascial flap, which incorporated the distal peroneal perforator, short saphenous vein, and a single branch of the sural nerve., Results: From the anatomical study, the distal peroneal perforator was situated at an average of 6.2 cm (2.5-12 cm) from the distal tip of the lateral malleolus. The medial and lateral sural nerve branches ran subfascially and pierced the muscle fascia 16 cm (14-19 cm) proximal to the lateral malleolus to enter the subcutaneous plane. They merged 1-2 cm distal to the subcutaneous entry point to form the common sural nerve at a mean distance of 14.5 cm (11.5-18 cm) proximal to the lateral malleolus. This merging point determined the pivot point of the flap. In the clinical cases, all patients reported near complete recovery of sensation over the lateral foot six months after surgery. All donor sites healed well with a full range of motion over the foot and ankle., Conclusions: The distally based sural artery adipofascial flap allowed for minimal sensory loss, a good range of motion, an aesthetically acceptable outcome and can be performed by a single surgeon in under 2 hours.

Background: Vulvar defects result chiefly from oncologic resection of vulvar tumors. Reconstruction of vulvar defects restores form and function for the purpose of coitus, micturition, and defecation. Many surgical options exist for vulvar reconstruction. The purpose of this article is to present our experience with vulvar reconstruction., Methods: From 2007 to 2013, 43 women presented to us with vulvar defects for reconstruction. Their mean age at the time of reconstruction was 61.1 years. The most common cause of vulvar defect was from resection of vulvar carcinoma and extramammary Paget's disease of the vulva. Method s of reconstruction ranged from primary closure to skin grafting to the use of pedicled flaps., Results: The main complications were that of long term hypertrophic and/or unaesthetic scarring of the donor site in 4 patients. Twenty-two patients (51%) were able to resume sexual intercourse. There were no complications of flap loss, wound dehiscence, and urethral stenosis., Conclusions: We present a subunit algorithmic approach to vulvar reconstruction based on defect location within the vulva, dimension of the defect, and patient age and comorbidity. The gracilis and gluteal fold flaps are particularly versatile and aesthetically suited for reconstruction of a variety of vulvar defects. From an aesthetic viewpoint the gluteal fold flap was superior because of the well-concealed donor scar. We advocate the routine use of these 2 flaps for vulvar reconstruction.

Objective: To assess the results of maxillary distraction osteogenesis with the Rigid External Distraction System using three-dimensional computed tomography scan volume-rendered images with respect to stability and facial growth at three time frames: preoperative (T0), 1-year postoperative (T1), and 5-years postoperative (T2)., Design: Retrospective analysis., Setting: Tertiary., Patients: A total of 12 patients with severe cleft maxillary hypoplasia were treated between June 30, 1997, and July 15, 1998. The mean age at surgery was 11 years 1 month., Interventions: Le Fort I maxillary distraction osteogenesis. Distraction was started 2 to 5 days postsurgery at a rate of 1 mm per day. The consolidation period was 3 months. No face mask was used. A paired t test was used for statistical analysis., Main Outcome Measures: Overjet, ANB, and SNA and maxillary, pterygoid, and mandibular volumes., Results: From T0 to T1, there were statistically significant increments of overjet, ANB, and SNA and maxillary, pterygoid, and mandibular volumes. The T1 to T2 period demonstrated a reduction of overjet (30.07%) and ANB (54.42%). The maxilla showed a stable SNA and a small but statistically significant advancement of the ANS point. There was a significant increase in the mandibular volume. However, there was no significant change in the maxillary and pterygoid volumes., Conclusions: Maxillary distraction osteogenesis demonstrated linear and volumetric maxillary growth during the distraction phase without clinically significant continued growth thereafter. Overcorrection is required to take into account recurrence of midface retrusion over the long term.

Background: This study was the result of a constant evaluation of surgical techniques and results to obtain excellence in primary cleft rhinoplasty., Methods: This was a retrospective study from 1992 to 2003 comparing the long-term outcomes of four techniques of nasal reconstruction. There were 76 patients divided into four groups: group I (n = 23 patients), primary rhinoplasty alone; group II (n = 16 patients), nasoalveolar molding alone; group III (n = 14 patients), nasoalveolar molding plus primary rhinoplasty; and group IV (n = 23 patients), nasoalveolar molding plus primary rhinoplasty plus overcorrection. The surgical results were analyzed using photographic records obtained at 5 years of age. A ratio of six measurements was obtained comparing the cleft and noncleft sides. A panel assessment was obtained to grade the appearance of the surgical results. All surgery was performed by the senior author (P.K.T.C.)., Results: The results are given for groups I to IV, respectively. The nostril height ratio was 0.73, 0.77, 0.81, and 0.95. The nostril width ratio was 1.23, 1.36, 1.23, and 1.21. The one-fourth medial part of nostril height ratio was 0.70, 0.87, 0.92, and 1.00. The nasal sill height ratio was 0.75, 1.02, 1.07, and 1.07. The nostril area ratio was 0.86, 0.89, 0.95, and 1.08. The nostril height-to-width ratio was 0.58, 0.58, 0.71, and 0.92. Finally, group IV had the best panel assessment., Conclusions: The results revealed that group IV had the best overall result. Overcorrection of 20 percent was necessary to maintain the nostril height. Further technical modifications are necessary to minimize widening of the nostril width.

Palatal clefts in conjunction with space-occupying lesions of the oral or nasal cavities are of interest because they may represent a developmental etiology of palatal clefts. Epignathus is a rare space-occupying tumor of the nasopharynx that can arise from the upper jaw, palate, and sphenoid. It can protrude through the mouth, causing respiratory embarrassment and death. The pathogenesis of epignathus is unknown, but several theories have been proposed. Management depends on the size of the tumor and requires a multidisciplinary approach.

Head and neck reconstruction is an intensive multistep process that requires attention to detail to achieve a successful result. The knowledge and prevention of complications as well as their management is an essential part of the training of the surgeon participating in head and neck reconstruction. This article explores the general complications, including free flap failure, carotid artery blowout, hardware exposure, and ectropion, as well as regional complications relating to operations of the scalp, cranium, base of skull, midface, mandible, and pharyngoesophagus.

Flap coverage is ideal for wounds exposing bone and tendon, but technically less demanding and speedier options might be considered for small shallow wounds and for wounds with adjacent tissue loss precluding local flaps. We revisited the use of autologous dermal grafting-in combination with vacuum-assisted closure (VAC)-for such wounds.Five small- to medium-sized wounds exposing bone, joint, and/or tendon were each covered using an autologous meshed dermal graft followed by VAC application to induce granulation. Closure was completed at 2 weeks by split-thickness skin grafting over the granulating dermis graft.Complete and stable wound healing was achieved in all cases within 4 weeks of dermal grafting over exposed bone with excellent outcome at 1 year in terms of donor site healing and return to function. All healed wounds had a nearly flush profile with no bulkiness in the foot and toe region.Autologous dermal grafting with VAC is an integrated in vivo tissue engineering system in which the meshed dermis acts as an attractive scaffold for granulation within the conducive VAC-medium. As an alternative to flap surgery or dermal substitutes, the technique is simple, swift, and cost-effective for immediate closure of small shallow wounds and even multiple small wounds, exposing bone and tendon particularly in the lower legs, feet, and toes.

Background: Pharyngeal flaps are used to treat velopharyngeal insufficiency. Occasionally the flap exceeds its intended function and results in an obstructive airway. In this article, the results of management of these cases are analysed., Methods: This is a 39-year retrospective review of patients who had revision of pharyngeal flaps causing obstructive airway symptoms. Three methods of relieving the airway obstruction were used, and the patients were thus separated into three groups, namely group 1 (release and Z-plasty of the lateral ports), group 2 (division of the pharyngeal flap) and group 3 (division of the pharyngeal flap combined with Furlow palatoplasty). The results obtained were based on four parameters: symptomatic improvement, velopharyngeal sufficiency, the presence of re-attachment of the pharyngeal flap and the necessity for re-operation. These results were then pooled into two groups: 'good result' and 'bad result'. The respiratory disturbance index (RDI) was also obtained and analysed separately. Statistical analysis was performed with the Fisher's exact test and the paired t-test in SPSS v.11., Results: A total of 44 patients were included in the study. There were 20, 11 and 13 patients in groups 1, 2 and 3, respectively. The Pearson's chi-square test indicated that group 3 patients had a statistically significant proportion of 'good results' when compared to groups 1 (p=0.019) and 2 (p=0.004). There was a statistically significant reduction in RDI in group 3 (p=0.003). There was no statistically significant difference between the groups 1 and 2., Conclusions: Division of a pharyngeal flap for obstructive airway complications should be accompanied by a Furlow palatoplasty to reduce the myriad complications that arise from either a release+Z-plasty or a simple division of the pharyngeal flap., (Copyright 2009 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Background: Free fat grafts have an unpredictable survival rate, which may be dependent on host bed vascularity. Therefore, the authors hypothesized that the presence of growth factors in platelet-rich plasma (PRP), may enhance free fat graft survival., Methods: Free fat grafts and autologous PRP were harvested from a healthy female and processed using the Coleman technique and the Medtronic Magellan system respectively. The experiment comprised two groups of 12 nude mice each with injection of free fat grafts into the scalp. The experimental group comprised the combination of 0.8 ml of free fat graft and 0.2 ml of PRP. The control group comprised the combination of 0.8 ml of free fat graft and 0.2 ml of normal saline. The mice were euthanized after 16 weeks and the fat grafts explanted and measured for weight and volume. Histology was performed with Oil Red O stain. Statistical analysis of the weight and volume in between groups was performed using the independent samples T-test (SPSS v11). The Mann-Whitney test was used to compare the ranking of six histological parameters between the two groups., Results: The mean weight and volume for the experimental arm were 0.503 g and 0.545 ml respectively. The mean weight and volume for the control arm were 0.500 g and 0.541 ml respectively. The weight, volume and histological parameters between the two groups were not statistically significant. A mouse from each group died of unknown causes., Conclusion: PRP did not enhance free fat graft survival in the nude mouse.

Background: This review sought to determine the efficacy of tissue sealants such as fibrin tissue adhesives and platelet-rich plasma in reducing postoperative drainage, ecchymosis, and edema after face-lift surgery., Methods: The electronic databases MEDLINE (1966-May 2007) and EMBASE (1974-May 2007) and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched for human studies, randomized controlled trials, controlled clinical trials, metaanalyses, and reviews of randomized controlled trials using the key words "fibrin tissue adhesive," "tissue sealant," "platelet-rich plasma," "face-lift," "rhytidoplasty," "rhytidectomy," and "facial plastic surgery." The search yielded 10 articles, only 3 of which met our inclusion criteria. The three studies were within-patient comparisons (patients acted as their own controls)., Results: Although not statistically significant, the pooled results showed a strong trend toward reduction in postoperative drainage at 24 h and ecchymosis with the use of tissue sealants compared with the control arm of the study. No difference in outcomes was observed between the tissue sealant and control arms of the study in terms of postoperative edema measurement., Conclusion: There was no statistically significant benefit from the use of tissue sealants in face-lift surgery. However, tissue sealants may be useful for patients at a high risk for hematoma and ecchymosis formation.

Van der Woude syndrome is the most common cause of syndromic orofacial clefting. It is characterised by the presence of lip pits, cleft lip and/or cleft palate. It is transmitted in an autosomal dominant manner, with high penetrance and variable expressivity. Several mutations in the interferon regulatory factor 6 (IRF6) gene have been found in VWS families, suggesting that this gene is the primary locus. We screened for mutations in this gene in three families in our population. There was a recurrent nonsense mutation within exon 9 of the gene for a Malay family consisting of five affected members with different presentations. We also found a co-segregating rare polymorphism which would result in a non-synonymous change 23 bases downstream of the nonsense mutation. This polymorphism was present in <1% of the Malay subjects screened, but was not found among the Chinese and Indians in our population. For another family, a 396C-->T mutation (R45W in the DNA-binding domain) was found in the proband, although the possibility of a genetic defect elsewhere could not be excluded because his mother and twin sister (both unaffected) also had this variant. In the third case with complete absence of family history, a de novo deletion spanning the whole IRF6 gene was detected in the child with VWS. This case of haploinsufficiency caused disruption of orofacial development but not other organ systems as the child has no other medical or developmental abnormalities despite the deletion of at least five other genes.

This study was designed to investigate the optimal combination of known osteogenic biomaterials with shape conforming struts to achieve calvarial vault reconstruction, using a canine model. Eighteen adolescent beagles were divided equally into 6 groups. A critical-size defect of 6 x 2 cm traversed the sagittal suture. The biomaterials used for calvarial reconstruction were demineralized perforated bone matrix (DBM), recombinant human bone morphogenetic protein 2 (rhBMP2), and autogenous platelet-rich plasma (PRP). The struts used were cobalt chrome (metal) or resorbable plate. The groupings were as follows: 1) DBM + metal, 2) DBM + PRP + metal, 3) DBM + PRP + resorbable plate, 4) DBM + rhBMP2 + metal, 5) DBM + rhBMP2 + PRP + metal, and 6) DBM + rhBMP2 + resorbable plate. Animals were killed at 3 months after surgery. There was no mortality or major complications. Analysis was performed macroscopically and histologically and with computed tomography. There was complete bony regeneration in the rhBMP2 groups only. Non-rhBMP2 groups had minimal bony ingrowth from the defect edges and on the dural surface, a finding confirmed by computed tomographic scan and histology. Platelet-rich plasma did not enhance bone regeneration. Shape conformation was good with both metal and resorbable plate. rhBMP2, but not PRP, accelerated calvarial regeneration in 3 months. The DBMs in the rhBMP2 groups were substituted by new trabecular bone. Shape molding was good with both metal and resorbable plate.

The aim was to assess the stability of monobloc distraction osteogenesis using three-dimensional computed tomographic (CT) scan volume-rendered images with the "biporion-dorsum sellae" plane. This was a prospective study of patients undergoing monobloc internal distraction osteogenesis at the International Craniofacial Institute, Dallas, TX. Measurements were made of the perpendicular distance of 8 skeletal facial points to the static "biporion-dorsum sellae" plane. The statistical analyses were performed with the paired-samples t test in SPSS. Three male patients were included in the study. Of these patients, 2 had Apert syndrome (A, B) and 1 had Carpenter syndrome (C). The mean age was 73 (range 30-112) months, and the mean follow up was 14 (range 8-12) months. The consolidation period was 17, 23, and 28 weeks in each patient, respectively. In patient A, the paired-samples t test of matched points was P = 0.022. Further analysis of the three-dimensional lateral profile revealed an obvious relapse, and predistractor removal CT scans (at 17 weeks) also showed deficient bone growth across the distraction gaps at the anterior cranial fossae and the temporal bones. In contrast, patients B and C showed a stable outcome after distraction and after removal of distraction devices. On analysis of the predistractor removal three-dimensional CT scans (23 and 28 weeks, respectively), there was more bone growth across the distraction gaps at the anterior cranial fossa and temporal bones. The "biporion-dorsum sellae" plane was used to assess the results of monobloc distraction osteogenesis. Relapse was associated with inadequate bone growth across the anterior cranial fossa and temporal bone. The findings seem to point the way for an increased consolidation period and more detailed examination of the CT scans before removal of internal distraction devices.

Purpose: Cranial defect reconstruction presents 2 challenges: induction of new bone formation, and providing structural support during the healing process. This study compares quantity and quality of new bone formation based on various materials and support frameworks., Materials and Methods: Eighteen dogs underwent surgical removal of a significant portion of their cranial vault. Demineralized bone matrix was used to fill the defect in all animals. In 9 dogs, recombinant human bone morphogenetic protein-2 (rhBMP-2) was added, while the other 9 served as the non-rhBMP-2 group. In each group, 3 animals were fixed with cobalt chrome plates, 3 with adding platelet-rich plasma, and 3 fixed with a Lactosorb (Walter Lorenz Surgical, Inc, Jacksonville, FL) resorbable mesh. Necropsy was done at 12 weeks postoperative. Histomorphometry, density, and mechanical properties of the regenerate were analyzed., Results: The non-rhBMP-2 groups showed minimal substitution of demineralized bone matrix with new bone, while only sporadic remnants of demineralized bone matrix were present in the rhBMP-2 groups. The defect showed more new bone formation (P < .001) and density (P < .001) in the rhBMP-2 groups by Kruskal-Wallis test. The area of new bone was not significantly different among the rhBMP-2 subgroups. The resorbable mesh struts showed no sign of bone invasion or substitution. In the non-rhBMP-2 resorbable mesh group, demineralized bone matrix almost totally disintegrated without replacement by new bone., Conclusions: The addition of rhBMP-2 to demineralized bone matrix accelerated new bone formation in large cranial defects, regardless of the supporting framework or the addition of platelet-rich plasma. The use of a resorbable mesh in such defects is advisable only if rhBMP-2 is added.

The aim of this article was to present a retrospective audit on a single surgeon's experience with orthognathic surgery. This was a retrospective review of orthognathic cases performed from January 1, 2000, to January 1, 2006. There were 37 male and 65 female patients with a mean age of 20 years. Predisposing conditions included: unilateral cleft lip and palate (40), bilateral cleft lip and palate (15), cleft palate (three), hemifacial microsomia (three), posttraumatic (three), fibrous dysplasia (one), Romberg's disease (one), cavernous hemangioma (one), Crouzon's syndrome (one), and developmental deformities (34: 13 prognathism, 12 class III, six class II, three vertical maxillary excess). Indications for surgery included: class III malocclusion (89), class II malocclusion (six), facial asymmetry (three), vertical maxillary excess (three), crossbite (one). The majority of surgeries performed were Le Fort I osteotomy alone (33) and bimaxillary osteotomy (32). Overall median duration for all surgery was 2 hours 45 minutes (range, 1 hour 15 minutes to 8 hours 45 minutes), median blood loss was 720 mL (range, 100-6500 mL), and mean hospitalization stay was 4.3 days (range, 1-10 days). The mean duration of follow up was 24 months. Postoperatively, class I occlusion was obtained in 92 patients and class II occlusion in two patients. Relapse occurred in five (4.9%) patients (one had reoperation). Readjustment was done for three patients. Excessive bleeding occurred from the facial artery, maxillary artery, and pterygoid plexus separately in three patients. Readmission for secondary hemorrhage occurred twice and inferior alveolar nerve injury occurred once.

Objective: This study was designed to investigate the optimal combination of known osteogenic biomaterials with shape conforming struts to achieve calvarial vault reconstruction, using a canine model., Methods: Eighteen adolescent beagles were divided equally into 6 groups. A critical size defect of 6 x 2 cm traversed the sagittal suture. The biomaterials used for calvarial reconstruction were demineralised perforated bone matrix (DBM), recombinant human bone morphogenetic protein-2 (rhBMP2) and autogenous platelet-rich plasma (PRP). The struts used were cobalt chrome (metal) or resorbable plate. The groupings were as follows: 1) DBM + metal, 2) DBM + PRP + metal, 3) DBM + PRP + resorbable plate, 4) DBM + rhBMP2 + metal, 5) DBM + rhBMP2 + PRP + metal, and 6) DBM + rhBMP2 + resorbable plate. Animals were euthanised at 3 months post-surgery. There was no mortality or major complications. Analysis was performed macroscopically, histologically, and with computed tomography (CT)., Results: There was complete bony regeneration in the rhBMP2 groups only. Non-rhBMP2 groups had minimal bony ingrowth from the defect edges and on the dural surface, a finding confirmed by CT scan and histology. PRP did not enhance bone regeneration. Shape conformation was good with both metal and resorbable plate., Conclusion: rhBMP2 but not PRP accelerated calvarial regeneration in 3 months. The DBM in the rhBMP2 groups were substituted by new trabecular bone. Shape molding was good with both metal and resorbable plate.

Background: The aim of this study was to investigate the prevalence of abnormal preoperative screening prothrombin time and partial thromboplastin time in patients listed for primary cranial vault remodeling that required hematologic workup and their diagnoses and subsequent management., Methods: This retrospective analysis was performed from January of 2000 to December of 2003 at the International Craniofacial Institute, Dallas, Texas, on a total of 168 patients., Results: All patients had a normal prothrombin time. Abnormally raised partial thromboplastin time was found in six patients (prevalence of 3.57 percent), one who had factor XI deficiency, one who had a borderline factor XI deficiency and circulating inhibitor, one who had an intermittent factor XI deficiency and circulating inhibitor, one who had a borderline von Willebrand's disease with low factor XII, and the remaining two who had a circulating inhibitor of coagulation. Of these six patients, the perioperative management was altered in four of five patients, and one patient declined surgery out of fear of surgical morbidity. The surgery of one patient was aborted intraoperatively because of abnormal bleeding without clot formation after the calvarial burr holes had been drilled. The mean blood loss was 183 ml for the four patients with completed surgery and 100 ml for one patient., Conclusions: The authors conclude that even though the prevalence of abnormal screening partial thromboplastin time in these patients was low (3.57 percent), detection of an abnormal result required preoperative correction of coagulopathy in 80 percent of cases.

A case of total ischemia of the triquetrum after a crushing injury to the right wrist by a dumbbell is reported. He was treated conservatively with splinting and analgesia. There was complete clinical and radiological recovery after a follow-up of one year.

The results of craniofacial and orthognathic surgery have traditionally been monitored using lateral cephalometry. In the age of computed tomography (CT) and magnetic resonance imaging (MRI), newer methods of measuring surgical outcome have arisen. This has been further enhanced by the use of computer software to render CT images in a three-dimensional format. The authors present a novel method of measuring the outcome of monobloc distraction osteogenesis advancement using the biporion-dorsum sellae plane. The perpendicular distance of eight facial skeletal points to this plane were made automatically using the Vworks 4.0 program. A total of 10 measurements were made against six planes of reference. Planes 1, 2, 3, 1+2 degrees, and 1-2 degrees were constructed, and measurements were made by observer 1. Plane 6 was constructed and measurements were made by observer 2. Plane 1 was used as the denominator on which calculations were made. The results revealed a mean intra- and interobserver percentage difference from plane 1 of less than 5%. In addition, the overall mean intraobserver variance of all eight points from observer 1 was 0.91%, and the mean interobserver variance between observer 1 and 2 was 0.73%. In summary, based on the authors' method, repeated measurements made from the biporion-dorsum sellae plane have proven precision and reproducibility.

The psammomatoid ossifying fibroma is a rare and aggressive lesion that usually arises from the sinonasal region. The lesion is well circumscribed with the pathognomonic feature of concentric or laminated spherical ossicles that appear similar to psammoma bodies. The authors report a case of an extensive and neglected psammomatoid ossifying fibroma in a 10-year-old West African girl. She had a 5-year history of a slowly growing tumor, which at presentation was 15 cm in diameter and had resulted in left craniofacial deformity as well as left visual impairment. Due to the large tumor, the surgical resection plan necessitated a cranio-facial neurosurgical approach in combination with autogenous bone grafts for cranofacial reconstruction, and allogenous demineralized bone grafts for donor site coverage. In addition, preoperative embolization was utilized to reduce tumor vascularity. However, this embolization resulted in reduction of pericranial flap vascularity, leading to flap ischemia, infection and subsequent removal of necrotic autogenous bone graft. Ultimately, the objectives of large tumor resection and acceptable aesthetic outcome were met after controlling an episode of postoperative infection.

Wide excision of extramammary Paget's disease of the penoscrotal region may leave large defects that cannot be closed easily. The authors describe their experience with a series of 6 patients in whom reconstruction of the scrotal defect was undertaken using the scrotal remnant raised as a stretchable musculocutaneous flap. It was observed that as little as a third of the residual scrotum could be expanded to resurface the entire scrotum. All flaps survived completely. Severe scrotal edema and ecchymosis were observed in 1 patient but the symptoms resolved completely with Trendelenburg positioning. The penile defects were resurfaced individually with thick skin grafts. Good-quality take with no chordee was observed in all patients after initial reconstruction. One patient developed penile contracture after reexcision of recurrent disease. Mean follow-up was 22 months (range, 3-60 months). Large defects of as much as two thirds of the scrotum may be reconstructed successfully using the tissue-expanding scrotal musculocutaneous flap.

Extraarticular pigmented villonodular synovitis (PVNS) is very rare in the distal forearm. There has only been one previous case report of this disease in the extensor tendons of a child. We report a case of PVNS of the distal forearm that presented as two nodules over the radial aspect and a separate nodule on the ulnar aspect beneath the flexor carpi ulnaris tendon. Surgical exploration revealed an extensive extraarticular PVNS over the first and second dorsal compartment extensor tendons. On the anterior aspect it extended in the deep plane between the flexor tendons and the pronator quadratus and encased the radial artery completely. Complete excision of the tumour with the radial artery was done.

Introduction: Carotid body tumours are rare but are interesting in their manner of presentation and challenging with respect to surgical extirpation. They may present as a neck mass from which a bloody aspirate is obtained on fine needle aspiration. They are occasionally diagnosed only at the time of surgery, when one encounters the vascular tumour mass., Methods: We reviewed the results of 8 cases operated in our department over a 10-year period from 1989 to 1999. We evaluated in-hospital mortality and morbidity, as well as the long-term outcome especially with regards to functional disability., Results: Preoperative evaluation included angiography, computed tomography (CT) or magnetic resonance angiography. Operative technique involves good exposure, vascular control, identification and preservation of neurovascular structures and subadventitial tumour dissection. In all cases the vagus nerve was preserved, except in 1 case who had a malignant tumour and resection of the vagus nerve together with the accessory nerve and sympathetic chain. Two patients had unexpected hoarseness of voice postoperatively, 1 was due to permanent vagus nerve palsy and the other to transient vagus nerve palsy. One of them needed vocal cord medialisation and long-term tube feeding. One patient had bilateral tumours and developed a stroke after an operation on the second tumour. No patients exhibited local or metastatic disease during follow-up. There was no mortality in all cases., Conclusion: Although resection of the carotid body tumour is safe in experienced hands, long-term morbidity is still a significant problem and can be debilitating to the patient.

Surgery for constrictive pericarditis has become a rare entity now. Various non-cardiac surgical measures are sometimes tried to remove the calcific plaques on the surface without damaging the underlying cardiac structures. We report a case of severe calcific pericarditis in which the Midas Rex neurosurgical drill was successfully used to facilitate pericardiectomy. Such a case has not been previously reported in the literature.