The use of hydroxyapatite cement in secondary craniofacial reconstruction.

Sixty-one patients underwent secondary craniofacial reconstruction for contour defects using hydroxyapatite cement over a 3-year period (20-month mean follow-up). There were 56 children, aged 2.2 to 18 years (mean, 10.7 years), 21 boys and 35 girls. This is the first series of pediatric patients in whom the use of hydroxyapatite cement has been reported. There were five adults aged 21 to 46 years (mean, 32 years), 3 men and 2 women. Thirty-one patients underwent reconstruction for secondary orbitocranial defects after surgery for synostosis, 7 after surgery for hypertelorism, 10 for posttraumatic skull defects, and 13 for a variety of other facial skeletal defects. There were seven complications (11 percent), ranging from a retained drain to postoperative seromas, all of which required reoperation without loss of the contour correction. All of the complications occurred in the first 18 months of our study. There has been excellent retention of implant volume with no recurrence of contour defects to date. We have not found any visible evidence of interference with craniofacial growth over the study period. We conclude that hydroxyapatite cement is a versatile and safe biomaterial when used for the correction of secondary craniofacial contour defects in children and adults. The coupling of antibiotics with this biomaterial may have applications in the treatment of osteomyelitis.     

Deep inferior epigastric perforator dermal-fat or adiposal flap for correction of craniofacial contour deformities

Craniofacial contour deformities are difficult to reconstruct. This article summarizes the authors' use of deep inferior epigastric perforator dermal-fat or adiposal flaps in eight patients with such deformities. Of these patients, three had traumatic craniofacial or facial deformities, one had congenital craniofacial deformity, two had hemifacial atrophy (one because of radiation), one had hemifacial microsomia, and one had localized frontonasal lipodystrophy. Stable restoration of the facial contour was achieved in all eight patients. The advantages of this flap are numerous. It has minimal donor-site morbidity, because the rectus abdominis muscle is preserved as a whole, and it accommodates pregnancy in female patients. Simultaneous elevation of this flap during preparation of the recipient site makes it possible to complete surgery in a shorter time than with the scapular flap. Furthermore, a considerable amount of the superficial or deep fatty layer can be removed primarily, making a bulky flap into a thinner one. This flap also allows the use of a large transverse abdominal ellipse of skin, fat, and Scarpa's fascia with abdominoplasty closure. Conversely, it requires a technically difficult dissection of the muscle perforator and skin grafting of donor defects in patients with a large dermal-fat flap. Also, additional minor operations may be necessary to reduce fat volume around the perforator. Ultimately, the deep inferior epigastric perforator adiposal flap seems to be suitable for craniofacial contouring surgery. It is especially indicated for use in children and female patients who are expecting to have children.     

The alar contour graft: correction and prevention of alar rim deformities in rhinoplasty

One of the most common problems affecting both the primary and secondary rhinoplasty patient is deformity of the alar rim. Typically, this deformity is caused by congenital malpositioning, hypoplasia, or surgical weakening of the lateral crura, with the potential for both functional and aesthetic ramifications. Successful correction and prevention of alar rim deformities requires precise preoperative diagnosis and planning. Multiple techniques of varying complexity have been described to treat this common and challenging problem.Over the past 6 years (1994 through 2000), the authors have employed a simple technique in 123 patients for alar retraction that involves the nonanatomic insertion of an autogenous cartilage buttress into an alar-vestibular pocket. Among the 53 patients who underwent primary rhinoplasty in this study, 91 percent experienced correction or prevention of alar notching or collapse. However, correction was achieved for only 73 percent of the patients who underwent secondary rhinoplasty; many of whom had alar retraction secondary to scarring or lining loss. In patients with moderate or significant lining loss or scarring, a lateral crural strut graft is recommended. The alar contour graft provides the foundation in the patient undergoing primary or secondary rhinoplasty for the reestablishment of a normally functioning external nasal valve and an aesthetically pleasing alar contour. This article discusses the anatomic and aesthetic considerations of alar rim deformities and the indications and the surgical technique for the alar contour graft.     

Mandibular retrusion, temporomandibular joint derangement, and orthognathic surgery planning.

One-hundred consecutive orthognathic surgery candidates with mandibular retrusion were selected for retrospective analysis. Patients had undergone imaging studies that included magnetic resonance imaging (MRI) of both temporomandibular joints to assess the presence or absence, stage, and activity of suspected internal derangement(s). Patients were divided into stable and unstable deformity groups based on the presence or absence of change in their facial contour and/or occlusal disturbances in the 24 months prior to evaluation. Each of the 58 unstable and 30 of 42 stable patients were found to have internal derangements of at least one temporomandibular joint. The degree of joint degeneration directly paralleled the severity of retrognathia in most cases. We concluded that temporomandibular joint internal derangement is common in cases of mandibular retrusion and leads to the facial morphology in a high percentage of patients. Preoperative temporomandibular joint imaging with MRI is recommended prior to orthognathic surgical correction of retrognathic deformities.     

Applications of a new carbonated calcium phosphate bone cement: early experience in pediatric and adult craniofacial reconstruction

Hydroxyapatite cements have recently been employed as bone substitutes in craniofacial reconstruction. They are easily applied, nonresorbable, available in unlimited quantity, and eliminate donor-site morbidity. Norian CRS (craniofacial repair system) is a new carbonated calcium phosphate paste that is unique in that it more closely resembles bone than do traditional hydroxyapatite pastes. Norian is a low-order crystalline apatite soluble at a low pH, facilitating its resorption and replacement by host bone. The cement was first used for craniofacial surgery in North America at the Children's Hospital of Philadelphia. This report presents the authors' experience with this bone substitute in both pediatric and adult craniofacial reconstruction. Sixteen adult and pediatric patients underwent craniofacial reconstruction involving the use of carbonated calcium phosphate paste for correction of defects that required from 5 to 110 g of carbonated calcium phosphate paste (mean, 28.5 g). The patients were all followed for a minimum of 14 months. Minor complications included one case of infection and two cases involving cement microfragmentation. In the authors' experience, carbonated calcium phosphate paste has proved to be an excellent alloplastic material for osseous augmentation and reconstruction in the craniofacial skeleton. Few problems were encountered using this material; no significant morbidity was encountered. Although this material seems to be promising as a bone substitute, further follow-up will be necessary to evaluate its potential role in craniofacial surgery.     

A contraindication for the use of hydroxyapatite cement in the pediatric population

The authors report on their experience with a particular hydroxyapatite cement in the pediatric population and review cases that elucidate potential limitations of its use in this population. In all patients, the implant was used for recontouring and augmenting the cranial vault. Seven of 15 patients had a direct communication between sinus mucosa and the implant at the time of surgery. Three of the seven patients developed late postoperative inflammatory reactions of the surgical site with delamination of the implant. Each patient required an aggressive irrigation and débridement with removal of the delaminated hydroxyapatite. Pathologic findings showed evidence of a foreign body inflammatory reaction in the tissue, and mixed bacterial flora were identified in all specimens. No late problems with the cement were seen in patients without a communication to the sinuses. Our findings suggest that the use of BoneSource, an essentially nonviable, nonvascularized implant, in areas exposed to bacterial contamination is contraindicated in the pediatric population. BoneSource and other similar hydroxyapatite biomaterials do have a role as implants in the craniofacial skeleton. The indications and contraindications of these substances will need to be further defined for wide acceptance to occur.     

A technique of brachioplasty

Various techniques for the management of upper extremity contour deformities have been suggested since aesthetic brachioplasty was first described. Such deformities are commonplace with aging, after normal weight loss, and especially after massive weight loss such as is seen following bariatric surgery. Despite the multiplicity of procedures described for the correction of these deformities, there are still problems associated with current brachioplasty techniques, including incorrectly placed incisions, widened hypertrophic scars, and postoperative contour deformities. In addition, postoperative skin laxity and ptosis in the axillary region are frequently encountered in the more extreme deformities. The authors present their technique for upper extremity brachioplasty. This technique is suitable for patients with severe brachial ptosis and skin laxity, with relatively little lipomatous tissue, which may extend from the olecranon to the chest wall. The described surgical approach provides excellent overall extremity contour with favorable scars while simultaneously addressing axillary contour deformities.     

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.     

CORRECTION OF ANOMALOUS VENOUS RETURN FROM THE RIGHT LUNG TO THE INFERIOR VENA CAVA (SCIMITAR DEFORMITY)

Anomalous pulmonary venous drainage to the inferior vena cava is a rare congenital cardiac defect. Oxygenated blood from the right lung enters the right atrium resulting in a left-to-right shunt. Because the radiographic shadow of the anomalous vein resembles a curved saber, this defect has been called the "scimitar" deformity. From 1958 through June 30, 1975, 11 patients underwent surgical correction of this anomaly at our institution with 10 survivors. Diagnosis was made by routine roentgenography of the chest in all but one patient. Eight patients had total correction which consisted of implanting the anomalous vein into the right atrium, opening the interatrial septum and applying a patch graft as a baffle to direct pulmonary venous blood into the left atrium. Five patients had associated cardiac defects which were also repaired. Three patients underwent pneumonectomy and all survived. The only operative death occurred in a 5-year-old female with an atrial septal defect and endocardial cushion defect. We believe the existence of a large left-to-right shunt justifies surgical intervention. The prognosis appears to depend upon the presence of other cardiac or pulmonary anomalies.     

Experimental hydroxyapatite cement cranioplasty.

Hydroxyapatite cement is a calcium phosphate-based material that when mixed with water forms a dense paste that sets within 15 minutes and isothermically converts in vivo to a microporous hydroxyapatite implant. This cement was used to reconstruct bilateral 2.5-cm-diameter full-thickness critical-sized parietal skull defects in six cats. One side was reconstructed with 100 percent hydroxyapatite cement, and the other with a mixture of 50 percent hydroxyapatite cement and 50 percent ground autogenous bone by weight. These animals were sacrificed at 6 and 12 months after implantation. Positive and negative controls also were prepared. The anatomic contour of the soft tissue overlying all hydroxyapatite cement implants was well maintained, there were no wound infections or structural failures, and the implants were well tolerated histologically. None of the negative (unreconstructed) control defects was completely filled with repair bone, and all positive (methyl methacrylate) controls demonstrated foreign-body giant-cell formation and fibrous encapsulation of the implants. Examination of decalcified and undecalcified sections revealed progressive but variable replacement of the cement by new bone and soft tissue without a change in the shape or volume of the hydroxyapatite cement-reconstructed areas. New bone comprised 77.3 and 64.7 percent of the tissue replacing the hydroxyapatite cement and hydroxyapatite cement-bone implants, respectively. Replacement of the hydroxyapatite cement implants by new bone is postulated to occur by a combination of osteoconduction and implant resorption. These results indicate that further experimental research leading to the possible application of hydroxyapatite cement for full-thickness calvarial defect reconstruction in humans is warranted.     

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.     

Three-dimensional surface imaging from CT scans for the study of craniofacial dysmorphology

Computer-assisted medical imaging technologies provide new tools for the study of congenital craniofacial deformities. Three-dimensional surface reconstructions have been developed to simplify the interpretation and improve the utility of CT scans of the head. While 3-D reconstructions initially were applied to assist clinical management of craniofacial deformities, these images now are finding utility in the study of unique anomalies, the definition of group characteristics for dysmorphic heads, the differentiation of similar phenotypes, and the documentation of the effects of cranial surgery on craniofacial growth. These findings should assist the formulation and evaluation of hypotheses regarding mechanisms of congenital malformation and deformation.     

Congenital nasal anomalies: a classification scheme

The purpose of this work was to develop a simple yet comprehensive classification scheme dedicated to congenital nasal anomalies. To date, no such classification system has been proposed and widely used. A 22-year retrospective review was performed. Two hundred sixty-one patients with congenital nasal anomalies were identified. From this extensive database, a systematic morphogenic classification system was devised. Congenital nasal deformities were classified into four categories. Type I, hypoplasia and atrophy, represents paucity, atrophy, or underdevelopments of skin, subcutaneous tissue, muscle, cartilage, and/or bone. Type II, hyperplasia and duplications, representing anomalies of excess tissue, ranging from duplications of parts to complete multiples, are categorized here. In the type III category, clefts, the comprehensive and widely utilized Tessier classification of craniofacial clefts is applied. Type IV deformities consist of neoplasms and vascular anomalies. Both benign and malignant neoplasms are found in this category.     

Nasal augmentation with Surgicel-wrapped diced cartilage: a review of 67 consecutive cases

Cartilage grafting has been used extensively to correct both the functional and aesthetic aspects of the nasal framework. The technique described by Erol ( 105: 2229, 2000) uses Surgicel-wrapped diced cartilage grafts in rhinoplasties. The advantages include its ease of preparation, the large volume of graft substrate available for use, and the avoidance of contour irregularities in the areas of placement. A retrospective case review of 67 consecutive patients who were treated with a Surgicel-wrapped diced cartilage graft as part of an aesthetic and/or functional rhinoplasty, in a 5-year period between 1995 and 2000, was performed in this study. All cases of congenital nasal deformities or deformities caused by trauma or tumors in which the technique was used were excluded. The charts were reviewed to determine demographic variables, the surgical procedures performed, prior operations, the rhinoplasty approach used, and the graft donor and recipient sites. Preoperative and postoperative photographs were examined, and the results were assessed. Data on the donor and recipient sites, complications, and the necessity for revisionary procedures were tabulated. There were two complications, namely, an infection, which resolved with aspiration and oral antibiotic therapy, and a recurrence of a dorsal depression, which necessitated repeated augmentation within 6 months. The technique of using Surgicel-wrapped diced cartilage proved to be effective for the augmentation of various areas of the nose. The complication and revision rates were acceptable and comparable to those of other techniques. Patient satisfaction with the aesthetic results was rated highly, with no reports of graft extrusion or contour irregularities. This technique is recommended for nasal augmentation and contouring for selected rhinoplasty patients.     

Anthropometric evaluation of dysmorphology in craniofacial anomalies: Treacher Collins syndrome

Advances in surgical techniques for correction of craniofacial anomalies have necessitated the development of objective pre- and postoperative quantitative assessments. Standard anthropometric techniques, supplemented by additional methods oriented to specific clinical problems, have proved useful in defining surface dysmorphology in craniofacial patients. A series of 77 surface measurements of the head and face and 41 proportions were determined in 20 preoperative patients with Treacher Collins syndrome, a rare congenital defect of the first and second branchial arches. To permit comparison with age- and sex-specific data for healthy North American children, the patient data were converted to standard (Z) scores. To test the hypothesis Z = 0, Student's t-test was performed on all variables. The anthropometric findings verified many of the clinical findings in this syndrome. In addition, a number of previously unreported defects were found. The cranium was low and short with a low, narrow forehead and a narrow cranial base. The face was narrow and shallow, the mandible long and narrow, and the lower face receding. The eye fissures were short with an antimongoloid inclination, but the orbits were hyperteloric. The nasal root was high and wide, the nasofrontal angle open, and the bridge inclination low. The labial fissure was narrow, and the ears were microtic. Except in the nasal root the defects were hypoplastic. Most of these defects were either horizontal or anteroposterior. Recognition of the defective areas and their contribution to disproportions of the head and face is important in the development of surgical strategies.     

Detection of gynecological cancer; use of fluorescence microscopy to show nucleic acids in malignant growth

Vitamin D resistant rickets is not a rare disorder. Increased awareness of this metabolic disorder during the examination of children with bowed legs, even infants receiving normal supplements of vitamin D, may lead to diagnosis oftener. Ten previously unrecorded cases of this disorder are included within this report. Three of the patients had associated congenital anomalies which also required treatment. Treatment of the vitamin D resistant rickets consists of the oral administration of large doses of vitamin D. Careful observation of patients during vitamin D therapy to prevent overdosage and resultant hypercalcemia is of utmost importance. Surgical correction of the bony deformities is rarely necessary. The cause of vitamin D resistant rickets is thought to be a defect of renal tubular mechanisms.     

VITAMIN D RESISTANT RICKETS

Vitamin D resistant rickets is not a rare disorder. Increased awareness of this metabolic disorder during the examination of children with bowed legs, even infants receiving normal supplements of vitamin D, may lead to diagnosis oftener. Ten previously unrecorded cases of this disorder are included within this report. Three of the patients had associated congenital anomalies which also required treatment. Treatment of the vitamin D resistant rickets consists of the oral administration of large doses of vitamin D. Careful observation of patients during vitamin D therapy to prevent overdosage and resultant hypercalcemia is of utmost importance.Surgical correction of the bony deformities is rarely necessary.The cause of vitamin D resistant rickets is thought to be a defect of renal tubular mechanisms.     

Lamellar split osteotomy: a new craniofacial technique

Craniofacial osteotomies have by convention been bilamellar translocations of the entire substance of the dysmorphic bone. This approach limits the surgeon by reducing the stable bone mass available for fixation, creating dependence on concave surfaces. Most important, it changes the bony topography that determines the preoperative plan. This paper presents a new craniofacial concept and technique used in 26 patients with various dysmorphic syndromes who were reconstructed by performing a lamellar split osteotomy. This technique maintains the internal lamella in its native position, thereby allowing it to act as a reference for the bony topography and providing a stable facial framework for rigid fixation. This interlamellar osteotomy has led to improved aesthetic results in the orthomorphic reconstructions of congenital and other deformities. It can be used in any aesthetic patient in whom contour changes or augmentation of form is desired. It is recommended as a preferred method for achieving quantitative contour improvement in patients over 3 years of age.     

A prosthesis to camouflage indented scars

Traditional silicone prostheses have been found to be inflexible, heavy, and of poor color match when used on the limbs. Ten patients distressed by contour deformities on their limbs after the wide excision of malignancies or following trauma were fitted with a light-weight prosthesis whose special features include a flexible foam backing, an outer tinted skin, and finely feathered edges that draw the eye away from the margins of the defect. The prosthesis sticks dependably to the skin and is particularly effective when worn under stockings or tights. When reviewed, all patients were continuing to use the device. It is a useful alternative to surgical reconstruction in such patients.