James Barrett Brown

Fractures of the bones of the face

F ACTORS of importance in extensive facial injuries may be listed as follows: (1) When a patient is examined, following a severe blow about the face, it is best to suspect a fracture and work from that point. If it is assumed that the possibility of fracture can be considered when the swelling has gone down, or, if soft tissue repairs are carried out with disregard for displaced bone fragments, the best chance for correct bone replacement has been missed. (2) Possibilities of good repair are present in almost all instances but must be met promptly and adequately. (3) Simple procedures of accurate replacement and holding of bone and soft parts, drainage and bandaging, should suffice; and, with relatively simple equipment, sound care usually can be afforded these patients. (4) The reverse is true if the full picture is not clear to those in charge and restorative measures are lax. (5) Although the lesions may be multiple, complicated splints and traction are seldom required and may actually be detrimental in some instances. It is important, however, to have available someone cognizant of the dental requirements and means of fixation, because one of the most important functions to be preserved is that of mastication, and this requires that the teeth come together in normal occlusion. (6) The problems presented by fractures about the upper part of the face require careful evaluation, and diagnosis ; if tissue has been completely lost, this point is of extreme importance in the final outcome, and the extent of loss should be recorded either in the original examination or at the time of operation. (7) Skull fracture and brain injury are so frequent that neurologic examination, including x-ray films, often must be made, and local repair delayed if there is any lesion that requires treatment or complete rest. Patients who receive (‘snap ” blows about the head may have damage to the cervical spine and, on the slightest indication, this region also should be checked with the x-ray. (8) Ocular damage is very frequent and is often the main indication for treatment. (9) Although good position and function may be obtained, final bony union may never occur in many instances. This may be due to the very thin edges of bone, that simply do not unite, and also to prolonged infection. In the lower jaw there may be solid union but with persistence of the fracture line on x-ray.

Double elongations of partially cleft palates and elongations of palates with complete clefts

A METHOD of elongating partially cleft palates was described in 1936,* the principle of which is that practically the entire soft tissue of the palate is freed from the bone, the major palatine arteries are loosened but not cut, and the entire mass of tissue is immediately set back-as a direct flap with preservation of its arterial supply-so that the anterior part, from just behind the incisors, is anchored all the way back at the posterior border of the bone. A gain in length is thus obtained equal to about as much as the expanse of denuded bone, the object being to have the longest possible functioning palate, to assist in nasopharyngeal closure in speaking and eating. Some of the original illustrations of the procedure in Figs. 1 to 4 show the complete freeing of the tissues from the bone, the preservation of the arteries and the anchoring of the palate to a little bridge of nasal mucosa that has been left behind for this purpose. The closure of the cleft itself is done usually at the same operation-as a preliminary step-in children, but may be done as a separate operation. In adults two stages are advisable because of excessive bleeding. The sequence of the elongation and the closure does not have to follow a definite rule; therefore, a field is opened for older children and even adults, who have had clefts closed many years before, to have their palates elongated in an effort to obtain better speech. Observations made or emphasized since the original publication may be summarized, as follows : 1. It is still thought that the direct flap, elevated and immediately set back, so that the least possible thickening will take place, is superior to the delayed flap method of elongation. 2. Preservation of the major palatine arteries (often called the posterior) is possible in nearly all patients, and freeing is effected by careful loosening of all tissue around the artery, gently stretching it from the foramen and, if necessary, carefully cutting it away from the palate flap. These methods have seemed better than trying to dislodge the artery from its bony canal by trying to remove the posterior wall of the canal. The palate may be gotten so free by this dissection plus complete separation of the aponeurosis from the bone that it may be easily “set-back,” practically against the posterior pharyngeal wall in most instances. This finding is in contradistinction to that of others who think that preservation of the arteries prevents elongation. This may seem somewhat of an equivocal point but it makes possible closure and elongation in a single stage, and it may give a less scarred and

Management of compound facial injuries

Abstract In summary, an attempt has been made to correlate and re-emphasize principles of care of severe facial injuries, borrowing some material directly from previous publications.

Skin homografts from postmortem sources; clinical application.

Abstract For this summary several previous publications have been drawn from and the clinical conclusion is included in the first paragraph.

The utilization of the temporal muscle and fascia in facial paralysis

T HE temporal muscle and fascia can be utilized to give anchorage for fascial strips in facial paralysis, and some degree of emotional expression may be developed, if the patient will train the newly substituted fifth nerve muscle and will avoid overactivity of the sound side of the face (Figs. 1, 2 and 3). Mechanical support, of course, should not be relied upon when nerve anasto-mosis is possible; but, where the distal branches of the nerve have been torn out-in partial paralysis where it is thought definitely best not to disturb the function already present-and in congenital paralysis, the operation outlined herein is applicable. Summary of Previous Work.-For direct nerve suture and free nerve transplant , the work of Ballance and Duel1 has developed much interest in the past few years. Anastomosis with other motor nerves has been effected by many surgeons, and the photographs of patients that showed excellent emotional expression have been recorded. used strips of temporal fascia turned downward over the zygoma to support the face. published the results of extensive work on the free transplantation of fascia, and the first report of free fascial strips to support the paralyzed face was made by Blair in 1926. Since this time, descriptions have been made of various methods of fixation of the fascial strips, of use of the opposite frontalis and of flaps of the ma,sseter and temporal muscles from the same side. Operation for Combining Temporal Muscle and Free Faha Support.-After consideration and observation of these different methods, a combination plan of operation was developed, in which free fascial strips are put subcutane-ously through the face and are anchored directly into the temporal muscle and fascia through an opening in the temporal region (hair-bearing area) (Figs, 1 and 2). Technic of Obtaining Pas&a.-Careful removal of very long strips of fascia lata is accomplished with the Masson or other suitable stripper. An incision is made above the knee about 6 cm. long, and the subcutaneous tissue is carefully separated from the fascia upward, the length of the dissecting scissors; this separation helps in getting the stripper started. At times there are a good many transverse fibers as a separate layer over the longitudinal fibers, and these can be opened through, as they are of no benefit and hinder the action of the stripper, Three or more strips about 1 cm. wide are removed, it being very advantageous to …

The prevention and correction of facial disfigurement

Abstract To recapitulate, all fractures should be reduced and the fragments held in their normal position before solidification commences. For those of the lower jaw and the tooth-bearing part of the upper jaw the reduction should be as early as possible. Compound fractures of the lower jaw should be drained by external incision. With most injuries of the soft tissue it is better practice to let the wound heal spontaneously than to indulge in early debridement, or run the risk of suture scars. Tattooed wounds, whether from road oil or gunpowder, should have the foreign matter removed early; the former by vigorous scrubbing with a stiff brush after anesthetizing the surface, the latter by cutting out each individual grain with a needle-pointed knife. It might be quite difficult to remove all coloring matter from incised wounds such as come from the edge of a stovepipe, but this can be excised and repaired later. In seeking gross foreign bodies in an open wound, the finger will sometimes detect what x-ray and vision will miss.

The Surgical Treatment of Post-radiation Keratosis1

Pathology WOLBACH (1) has reported clearly the pathologic findings of excessive X-ray exposure from clinical and experimental observations. Our own clinical pathologic findings bear out his conclusions, which he has summarized as follows: “1. Complete loss of appendages of the epidermis. “2. Replacement of the normal collagen (connective tissue constituent) by a peculiar dense hyaline collagen rich in elastic fibers and poor in cells. “3. Obliterative processes in blood vessels of the corium and subcutaneous tissues. “4. Necroses of varying sizes in the corium immediately beneath the epidermis. In the earlier stages these are usually in the region of thrombosed telangiectasis. In the later stages telangiectasis may be nearly entirely absent. “5. In response to necroses of the corium, reparative proliferation on the part of the epidermis,” which may extend beneath the telangiectasis or areas of necrosis. “These small necroses containing the thrombosed telangiectases become completely separated from the ski...

Repair of atomic, cathode-ray, cyclotron and x-ray burns of the hand: Long-term follow-up examinations and microscopic studies

Abstract Recorded experience in the treatment of radiation burns of the hands has directed efforts in the care of those burned by atomic, cyclotron and cathode-ray machine and x-ray sources. Results encourage continuance of this conservative management. Fingers have been saved and function of hands maintained by anticipating progressive breakdown, and carryout relative early resection and grafting.

Multiple internal wire fixation of facial fractures

Abstract Multiple wire pins have given simple, direct fixation adequate for solid union in severe compound facial injuries or crushes alone or in combination with other methods. Complicated, expensive, cumbersome external apparatus for traction or fixation is avoided.

LI. Observations on Sinus Abnormalities in Congenital Total and Hemi-Absence of the Nose

There is an occasional reference made in the literature to the condition shown in Fig. I. There is a woodcut in W. H. A. Jacobson’s “Operations of Surgery,” and we have recently seen a photograph of this condition in an adult, but we have never encountered any very plausible explanation of its “why” or “how.” Certain individual deviations that were found in all our cases suggest that a similar condition had at some earlier period been present in all congenital half-noses.