Psychosocial outcome of craniofacial surgery in children

Thirty-four children between the ages of 7 and 15 years with congenital craniofacial anomalies underwent psychosocial evaluation before and 12 to 18 months after surgery. Also evaluated were healthy children matched to the craniofacial subjects by sex, age, intelligence, and economic background. Preoperative assessment revealed the craniofacial group to have multiple but not severe psychosocial limitations. At follow-up, only a measure of social functioning still differentiated the groups, with the craniofacial subjects experiencing more negative social encounters. Comparison of initial and follow-up scores for the craniofacial group revealed a significant reduction in trait anxiety and trends toward reduction in parent-reported inhibited and hyperactive behavior. Scores on measures of extraversion and social functioning tended to be positively correlated with age for the comparison subjects only. Results suggest a modest improvement in psychological adjustment following surgery with a residual, possibly increasing, deficit in social functioning.     

Blepharo-canthal deformities in patients following craniofacial surgery

Functional problems and deformities of the eyes have become a major concern in the surgical treatment of ortital hypertelorism and craniofacial dysostosis, as experience with skeletal relocation for these disorders has been gained. Comprehensive preoperative and postoperative study and measurements of the bony orbits, the globes, the lids, the canthi, and the nose are necessary for the evaluation of present techniques and the design of alternative procedures. Some of the deformities of the blepharo-canthal complex are part of the congenital malformation. Other distortions, seen only postoperatively, are secondary to specific surgical maneuvers. Awareness of these primary and secondary factors has led to better soft tissue reconstruction at the time of the bony orbital translocations or the craniofacial disjunction. We describe the techniques which we have found especially useful in avoiding and correcting these postoperative blepharocanthal deformities.     

Inappropriate antidiuretic hormone syndrome in craniofacial surgery

Three instances of inappropriate ADH syndrome following craniofacial operations are reported. The cornerstone to diagnosis is careful fluid and electrolyte monitoring. Treatment consists of fluid restrictions in the acute phase and demeclocycline for refractory cases. Seizures should be symptomatically treated. Surgeons involved in the care of craniofacial anomalies must be aware of this syndrome because the symptoms closely mimic those commonly observed following intracranial procedures. If unrecognized, the consequence is potentially lethal.     

The "third" dimension in craniofacial surgery

A new method for reconstruction of a three-dimensional surface from a sequence of high-resolution axial CT scans has been developed. This algorithm is realized as a set of computer programs that can operate on commercially available CT scanners or evaluation consoles. The program is both efficient and easy to implement. No operator intervention is required. The images produced simulate photographs of the skull. Frontal, lateral, oblique, bird's eye, worm's eye, and rear views are generated. As with photographs and conventional radiographs, each of these projections uniquely displays specific anatomic details. This method of osseous surface reconstruction is now routinely applied to all patients evaluated for major craniofacial reconstruction at our institution. The images are useful in defining aberrant anatomy, planning surgical procedures, and evaluating the results of such operations. This method replaces an inexact concept in the surgeon's imagination with a three-dimensional image of the craniofacial skeleton.     

Projection geometry and stress-reduction techniques in craniofacial surgery

Since 1981, we have been able to modify the mathematical patterns of projection geometry to reshape the skull in craniofacial surgery. Unlike burring, morcellization, rotation, and plate switching, this technique actually changes the shape of individual sections of the skull by changing their radius of curvature. The technique is an adaptation of the principles used by engineers to build complex structures such as ships' hulls, airfoils, and domes. The result is a rigid form of the desired shape that becomes permanent with healing. This has several advantages: 1. An increase in the level of safety of craniofacial procedures for remodeling the skull. This is so because there is no need to dissect normal areas as in the standard plate-switching techniques. 2. Decreased operating room time. 3. An increased range of surgical manipulations. No longer is the surgeon limited to the shape of the material present. 4. Relief of edge pressure on the frontal lobes during scalp closure. 5. Creation of a solid bony form over which the pericranial scalp flap can be draped to form new layers of bone.     

Blood supply of the upper craniofacial skeleton: the search for composite calvarial bone flaps

This study investigated the blood supply of the upper craniofacial skeleton by injection studies. The major supply to the calvaria is provided by the middle meningeal artery and its branches. This vessel is difficult for the plastic surgeon to exploit in composite bone-flap design. The majority of the outer surface of the craniofacial skeleton is supplied by tiny perforators from the overlying periosteum. The vascular interconnections within the periosteum are poorly developed. For this reason, the galea and the overlying vascular network (derived from the superficial temporal, occipital, supraorbital, and supratrochlear vessels) should be left broadly attached to the bone when transferring a vascularized calvarial bone flap. Dissection of the scalp away from this vascular network should be carried out just below the hair follicles. By observing these principles, vascularized calvarial bone can be transferred on the superficial temporal, deep temporal, supraorbital, supratrochlear, or occipital vessels. Details of the use of each are discussed.     

The use of venous allografts in vascular surgery

Biochemical, morphological and biomechanic study of various veins which were taken from 54 patients without trophic disorders during phlebectomy and kept for 7 days was made. 2% solution of neutral formalin and isotonic buffer solution (Henx solution) was used; results of the study show, that conserved veins can be used for grafting in arterial reconstructive surgery in cases of absence of autogenous vein material. Optimal period of conservation is 1 day.     

Use of the galeal frontalis myofascial flap in craniofacial surgery

The anatomy and the technique of raising the galeal frontalis myofascial flap is described. In 38 patients with various pathologies, congenital anomalies, tumors, and trauma, this technique was employed. There were no extradural infections. The applications and complications of the flap are discussed. It is highly recommended wherever there is a possibility of direct intracranial nasopharyngeal communication.     

Temporal fossa bone grafts: a new technique in craniofacial surgery

The calvarium has become an increasingly popular bone-graft donor site. Previously described harvesting techniques are often difficult to perform and may produce unsatisfactory bone fragments. However, full-thickness bone grafts taken from the region of the temporal fossa, beneath the temporaiis muscle, have proven to be of high quality and technically easy to obtain. In our experience with eight patients, temporal fossa bone grafts were used primarily around the orbit, including reconstruction of the orbital floor, frontal bone, and zygoma. The procedure begins with a hemicoronal or bicoronal incision; the temporalis muscle is reflected, and an underlying bone plate up to 4 X 6 cm is removed. The resulting bone graft is consistently 3 to 4 mm in thickness. The cranial defect is packed with bone debris, and the muscle is replaced. This technique has proven to be safe, technically simple, consistently productive of high-quality bone grafts, and within discernible donor-site deformity.     

Pseudomeningocele: an unusual complication of craniofacial surgery.

A previously unreported complication of pseudomeningocele following monoblock frontofacial advancement is described. The defect was repaired by means of an extracranial approach with a satisfactory outcome.     

Evaluation of safety and efficacy of radiation-sterilized bone allografts in reconstructive oral surgery

Bone grafting allows reconstruction of the atrophied or destroyed alveolar process. In orthopaedics and traumatology allogeneic grafting has been used to restore defects of osseous tissue for over 60 years. In order to improve safety of the graft recipient, sterilized allogeneic grafts have been use. The aim of the study was to assess the direct and long-term outcomes following augmentation of atrophied alveolar processes with the use of radiation-sterilized allogeneic bone grafts. Sixty-eight patients were surgically treated between 2004 and 2011: 29 underwent open sinus floor elevation, post-extraction alveoli augmentation was performed in 16 subjects and 23 underwent reconstruction of the atrophied alveolar process. Augmentation of bone defects used bone granulate in 63 patients and bone blocks stabilized with titanium screws in 5 patients. PRF membranes collected from the patient’s blood were also used in all the procedures. In each of the cases optimal dimensions of the alveolar process were obtained allowing embedment of BIOMET 3I dental implant/-s. In all the patients the defects were successfully restored with implant-supported prostheses. Radiation-sterilized allogeneic bone grafts proved to be safe and effective for the patients and manageable for the surgeon constituting a good alternative to autogeneic material.