Incorporation of titanium mesh in orbital and midface reconstruction

Several authors have demonstrated the safety and effectiveness of titanium in orbital reconstruction. One question posed by clinicians is what happens to large pieces of titanium in communication with the paranasal sinuses or nasal-oral-pharyngeal area. This question becomes increasingly relevant as titanium is used to reconstruct extensive defects for which the destruction of bony architecture requires the placement of mesh in proximity to these areas. The objective of this study was to examine the gross and histologic soft-tissue response to large segments of titanium mesh in the setting of orbital and midface reconstruction, particularly when exposed to the nasal-oral-pharyngeal area and paranasal sinuses. In this study, large segments of titanium mesh were used in eight patients to reconstruct orbital and midface defects, with direct communication between the mesh and nasal-oral-pharyngeal area and paranasal sinuses. Four patients had suffered self-inflicted gunshot wounds; as a result, much of their midface was missing, including the inferior and medial orbital floor, maxilla, nose, naso-orbital-ethmoid complex, and hard palate. Extensive sheets of titanium mesh were used to reconstruct their medial and inferior orbital walls, nasal bridge, and maxilla. In the fifth patient, titanium mesh was used to reconstruct the maxilla after resection of a squamous cell carcinoma of the nasolacrimal duct. In the sixth and seventh patients, mesh was used to reconstruct the nasal bridge after severely comminuted nasal fractures resulted in the loss of bone and mucosa. Finally, the eighth patient had titanium mesh used to replace cocaine-induced bone loss involving the left medial orbital floor and wall and part of the maxilla. On gross examination by either endoscopy or direct inspection, all eight patients had rapid soft-tissue incorporation of the titanium mesh. Initial examination typically revealed budding of soft tissue through mesh interstices, followed by progressive incorporation. One patient's mesh was covered in only 15 days. Two patients underwent biopsies of this newly formed soft tissue. One had biopsies performed at 3, 15, and 31 months after the original operation. Biopsy examination at 3 months revealed incorporation of the titanium with fibrous soft tissue covered by ciliated respiratory epithelium, goblet cells, and squamous epithelium with metaplasia. In addition, the dense, acute inflammation present at 3 months evolved into mild, chronic inflammation at 31 months. The second patient had a single biopsy 4 months after secondary orbital reconstruction for delayed enophthalmos. Biopsy examination revealed a fibrous soft-tissue sheath lined by squamous epithelium with metaplasia. Again, mild chronic inflammation was present within the soft tissue. This study provides evidence of titanium's compatibility with soft tissue. The mesh underwent progressive incorporation with soft tissue that was then resurfaced by indigenous cells, including respiratory epithelia and goblet cells. This phenomenon occurred despite communication with the nasal-oral-pharyngeal area and paranasal sinuses.     

Restoring facial shape in face lifting: the role of skeletal support in facial analysis and midface soft-tissue repositioning

Aesthetic analysis in facial rejuvenation has traditionally been subordinate to technical solutions. While concerns regarding correction of facial laxity, a reduction in the depth of the nasolabial fold, and improvement of both the jowl and the jawline are worthy goals in rhytidectomy, the aesthetic concept of restoring facial shape to a more youthful appearance is equally important. Restoring facial shape in face lifting requires an understanding of how the face ages and then the formulation of a treatment plan that is individualized for the patient. Re-establishment of facial contour is significantly influenced by the re-elevation of descended facial fat through superficial musculoaponeurotic system manipulation; it can be approached through a variety of technical solutions. Underlying skeletal support affects not only the appearance of the face in youth but also how the face ages and influences the operative plan in terms of the requirements for fat repositioning. Formulating a treatment plan that is patient specific and based on the artistic goals as influenced by skeletal support is the key element for consistency in restoring facial shape in face lifting.     

Achieving aesthetic balance in the brow,eyelids, and midface

An approach to the brow, eyelids, and midface emphasizing release and advancement of the orbicularis oculi muscle, conservative removal of orbital fat, preservation of the nerve supply to the orbicularis oculi muscle, and avoidance of canthal division was evaluated in 100 consecutive patients. The technique describes the selected release of three key retaining ligaments to the forehead, brow, and upper eyelid; mobilization of the lateral retinaculum and division of the lower lid retaining ligament; and division of the midface malar retaining ligament (zygomatic-cutaneous ligament). Preservation of motor branches to the lower lid orbicularis is stressed. Of significance to this series of patients is the inclusion of 50 patients with morphologically prone lower eyelids defined as atonic lower lids, exorbitism, and/or negative vector orbits. Three sites had failure of brow fixation, two patients had midface asymmetry requiring revision, and three patients failed to have complete correction of their preoperative lower lid retraction. There was zero incidence of scleral show or lower lid retraction that was not present preoperatively. No patients required division of the lateral commissure with canthoplasty, taping or suture suspension, massage, or steroid injections. Only two patients required division of the deep head of the lateral canthus, and these patients were noted to have had lateral canthal malposition preoperatively.     

Comparison of transcutaneous incisions used for exposure of the infraorbital rim and orbital floor: a retrospective study.

One hundred and five patients were investigated for functional and aesthetic impairments following treatment of orbital trauma through subciliary, mid-lower eyelid, or infraorbital incisions. The progress of impairments with time was assessed, and the merits and shortcomings of each of the three approaches were established. The results showed that impairments persisting up to 6 months postoperatively have virtually not receded even after 6 years. The infraorbital incision showed the highest frequency of impairments, followed by the subciliary incision. The mid-lower eyelid incision showed the best results, with an impairment frequency well below those of the other two approaches. This approach seems to combine the advantages of the infraorbital incision with the unnoticeable scar formation associated with the subciliary incision.     

Seeding of expanded polytetrafluoroethylene (ePTFE) vascular grafts. A morphological study of porcine endothelial and fibroblast cells.

The need to improve clinical results with small and medium calibre grafts has led to extensive research on cell seeding of prosthetic materials. Numerous problems remain regarding identification, seeding, adhesion and survival of the cells attached. We have studied the behaviour of seedings of endothelial and fibroblast cells on ePTFE grafts. Scanning electron microscopy allows us to observe the morphological characteristics and their interaction with the biopolymers. It has been possible to differentiate both cellular types by their characteristics and interactions with the ePTFE. At the same time, from this "in vitro" study it can be concluded that the time needed to obtain a stable and confluent monolayer on ePTFE pretreated with fibronectin is between 18 hours to 4 days for endothelial cells, and 24 hours for fibroblasts. These would be the optimal time periods for "in vivo" grafting of the seeded prostheses.     

Copper-containing mesoporous bioactive glass coatings on orbital implants for improving drug delivery capacity and antibacterial activity

Anophthalmic orbit restoration with artificial implants is usually accompanied with the risks of bacterial penetration and implant exposure. Here, we develop a facile evaporation-inducing self-assembly approach to modify the porous hydroxyapatite (pHA) orbital implants by using sol–gel derived CuO-containing mesoporous bioactive glass (Cu-MBG). The Cu-MBG coatings with 0–5 mol% CuO were prepared in the pore wall of pHA by immersion-evaporation-ageing route in the sol precursor of Cu-MBG. Brunauer–Emmett–Teller and Barrette-Joyner-Halenda analyses showed that the specific surface area and pore volume were slightly decreased with increasing CuO content, while the Cu-MBG-modified pHA maintained a sustained release of ofloxacin and significantly inhibited the bacterial viability (Staphylococcus aureus and Escherichia coli). These studies demonstrate that the Cu-MBG modification provides an effective and facile strategy to endow combined biological performances of pHA orbital implants and potentially reduce implant-related side effects.     

Nationalism,Aesthetic Redemption and Aboriginality

In this paper I analyse some contemporary cultural constructions of the Australian national psyche and how these involve constructions of the otherness of Aboriginality and of modernity. In particular, I am interested in analysing how the spiritualised otherness of Aboriginality is produced and employed within nationalist discourses which are concerned with establishing the cultural integrity and authenticity of Australian culture. Aborigines have became a cultural category to be used within discourses which assign themselves a redemptive function in relationship to curing the ravages inflicted by modernity.     

Face lifting: problems, solutions, and an outcome study

The superficial musculoaponeurotic system (SMAS) platysma rotation flap with platysmal transection from the deep surface has been the author's face-lift technique to correct jowls, submental laxity, and platysma bands since 1982. An outcome study of 10 consecutive face-lift operations is presented to demonstrate the efficacy of correction of lower face and neck aging and the duration of the improvement. Reappearance of platysma bands has been the earliest and most frequent sign of recurrent aging changes. A technique for directly dealing with platysma bands in the submental and cervicomental location is described, and follow-up results up to 3 years are shown.     

Mammary implants, diving, and altitude exposure

Mammary implants were exposed to various simulated dive profiles followed by altitude exposures to stimulate aircraft travel and then were observed for bubble formation and volume changes. Minimal volume changes occurred after each dive. Numerous bubbles formed, however, reaching their maximum size in 3 hours. By comparison, when implants were exposed to high altitude following a dive exposure, significant volume changes occurred. This in vitro study showed that bubble formation and volume expansion occur after exposing implants to diving and altitude, but the circumstances required to produce these changes in vivo are extremely unlikely to occur normally.     

Breast reconstruction with implants and expanders

Breast reconstruction with expanders and implants provides an excellent option in the properly selected patient. Techniques for reconstruction have evolved significantly over the past 30 years with the development of more sophisticated devices and improvement in surgical procedures. Several options exist, each with its own advantages and disadvantages. Two-stage breast reconstruction using a textured device with an anatomic shape and integrated valve seems to provide the most consistent and reproducible results in most patients. Those patients with small, minimally ptotic breasts may be candidates for either single-stage implant reconstruction or reconstruction with an adjustable device. Advantages of expander and implant reconstruction over other techniques include relative ease of the procedure; no distant donor-site morbidity; use of tissue of similar color, texture, and sensation; reduced operative time; and more rapid postoperative recovery.     

Advancement of the orbits and the midface in one piece, combined with frontal repositioning, for the correction of Crouzon's deformities

We describe the use of radical craniofacial osteotomies, to improve the correction of exorbitism and to obtain better esthetic results in children with Crouzon's syndrome. We suggest some minor modifications to improve the fixation and the mechanical stability of the mobilized segments of the skull. Our procedure consists, essentially, of advancement of both orbits and the midface in one piece, plus advancement and reshaping of the frontal area. The results obtained by this technique, in children with a Crouzon's deformity without open bite, have been most satisfactory. We believe the satisfactory resultant appearance will be maintained during and after growth of the face, although these children have not been followed long enough yet to ascertain this with certainty.