Keith L. Mutimer

Relative maxillary retrusion as a natural consequence of aging: Combining skeletal and soft-tissue changes into an integrated model of midfacial aging

The contribution of maxillary retrusion to the formation of the nasolabial fold is evaluated in the present study. Clinical observation of patients from the craniofacial unit with concomitant maxillary retrusion revealed prominent signs of midfacial aging: specifically these individuals displayed a prominent nasolabial fold at an early age. This observation led to the hypothesis that relative maxillary retrusion occurs as a normal feature of the aging process. Retrusion of the lower facial skeleton below the soft tissue of the nasolabial fold causes the nasolabial fold to appear more prominent. To test this hypothesis, computed tomographic data were assembled retrospectively and included both males and females, young and old. The age range of the males (n = 14) was 18 to 24 years (young) and 43 to 57 years (old); the age range of the females (n = 14) was 15 to 30 years (young) and 43 to 57 years (old). All individuals had complete upper dentition and had no bony facial injury. Computed tomographic data were reconstructed into three-dimensional images, and a technique was developed to create a standardized lateral view which eliminated rotational variance. Analysis of anterior-posterior changes showed that there is a tendency for the lower maxillary skeleton at pyriform to become retrusive with age relative to the upper face in individuals with complete dentition. Findings were very significant for both males and females (p = 0.0001 and p = 0.002, respectively). In both groups, a slight increase in vertical maxillary dimension was noted, consistent with previous studies. It is suggested that relative maxillary retrusion is a factor in the development of the nasolabial fold. The skeletal features of normal midfacial aging can be combined with the soft-tissue features such as ptosis and atrophy into an integrated model of midfacial aging. A model such as this has significance regarding both the timing and choice of procedure used to restore the aging midface.

Aplasia cutis congenita : failed conservative treatment

Large scalp defects in aplasia cutis congenita present a management dilemma. In these lesions, prolonged conservative treatment may cause as much risk as does operative treatment. As a result of our experience, we suggest that one should be prepared to undertake early surgical intervention, rather than prolonged conservative treatment, for larger defects. Decreasing the size of the defect should decrease the risk of complications, since these appear to be related. The management of this condition should be a compromise of both operative and conservative modalities.

The Reverse Lateral Upper Arm Flap for Elbow Coverage

Closure of soft tissue defects in the vicinity of the elbow has been attempted by numerous methods. The reverse lateral upper arm flap was conceived by applying concepts of previous work. Cadaver studies demonstrated the cutaneous territory and vascular anatomy of this region. The nature of the posterior recurrent radial artery and its perforators allows this fasciocutaneous flap to be perfused in a retrograde fashion. The flap can be used for covering various soft tissue defects around the elbow in a single stage with acceptable donor site morbidity. A case is presented in which the flap was used in a reverse flow fashion to cover an 8 X 11 cm acute cubital defect present after soft tissue release. Operative technique is discussed.

Tissue expansion for the treatment of complete syndactyly of the first web

Tissue expansion is a well-established technique for the management of soft tissue deficiencies. In congenital hand surgery the construction of an adequate first web is paramount. We used tissue expansion in four hands in three patients with complete complex syndactyly of the first web space. Two of these patients had Aperts syndrome and the other an isolated mitten hand anomaly. The expander is preferably placed early in life so that first web construction is completed in the first year. Tissue expander ports are left exposed. There have been no infections, flap or expander loss in our series.

Autologous fat grafting: current state of the art and critical review.

To the Editor: We read with interest the article entitled ‘‘Autologous fat grafting: current state of the art and critical review.’’1 We would like to congratulate Dr Richard J. Ross, Dr Mark W. Ashton, and colleagues for their publication, reviewing scientific databases to critically appraise the current body of literature in fat grafting, providing a framework to guide application and comparison. We believe that a systematic elaboration analyzing donor site, effect of infiltration solution, harvest method, effect of centrifugation, reinjection method, supplementation, role of adipose-derived stem cells, and scaffolding encourages a scientific debate. Considering all currently available reinjection methods listed in the article, we would like to add our personal experience using an 18-gauge angiographic sharp needle (Cordis Corp, Bridgewater, NJ) as published first time in 2008. Our studies gave evidence of better results in treatment of burn scars, surgical scars, hard-to-heal wounds, and radiodystrophic tissues. These conditions are all characterized by hard fibrous tissue. Performing fat grafting using the sharp angiographic cannula, compared with the blunt ones, we achieved better results. Because of needle cannula, we can overcome tissue resistance, thus obtaining better control in fat depositioning and ‘‘creating space’’ for fat transplant. Our technique has 2 key points, namely, multiple skin accesses breaking scar tissue and retrograde fat injection into the scar tissue. By multiple skin accesses, we obtain scar release, stimulating new collagen deposition and remodeling scar fibrous tissue as demonstrated in our studies. Histologic examination of scar tissue punch biopsies showed patterns of new collagen deposition, local hypervascularity, and dermal hyperplasia in the context of new tissue. Treated tissue magnetic resonance imaging showed optimal fat survival too. By retrograde fat replacement, we avoid intravascular fat injection, leading us to have low complications incidence, and we obtain lower cysts formation, increasing surface between graft and recipient bed. In conclusion, we believe that our technique can be considered in a systematic review about state of the art of fat grafting, our clinical results support autologous fat transplant using an 18-gauge angiographic sharp needle in selected cases as we demonstrated.

Adjustment of Mothers of Children With Obstetrical Brachial Plexus Injuries: Testing a Risk and Resistance Model

Objective: To investigate direct and moderating effects of risk and resistance factors on the adjustment of mothers of children with obstetrical brachial plexus injuries (OBPI). Participants: Fifty-three mothers of children with OBPI recruited from an OBPI clinic in an Australian pediatric hospital. Measures: OBPI Severity Scale, Parents of Children With Disabilities Inventory, Family APGAR, Short Form Social Support Questionnaire-6, Life Orientation Test—Revised, Perceived Control of Internal States Scale, General Health Questionnaire–12. Results: The factors explained 30% of maternal adjustment variation. Resistance factors explained a unique 18%. Optimism was the only significant moderator. Conclusions: Findings confirm the importance of risk and resistance factors in maternal adjustment and enhance understanding by identifying optimism as a moderator of the risk/adjustment relationship. Interventions promoting optimism may facilitate maternal adjustment. Obstetrical brachial plexus injuries (OBPI) are estimated to occur in 0.3 to 2.0 of every 1,000 live births. Damage to the nerves of the brachial plexus is thought to occur during birth when the infant’s neck and shoulders are stretched too far apart (Laurent & Lee, 1994). Children affected by OBPI are left with permanent deficits that range from subtle functional impairment to complete paralysis and lack of sensation in the affected arm (Michelow et al., 1994). Nerve damage can also extend to the face and cause pupil constriction, eyeball recession into the orbit, and lack of facial sweating on the injured side (Clarke & Curtis, 1995). Very little is known about the effects of this condition on the psychological adjustment of the children and their families. Parents of children with OBPI are confronted with a number of possible stressors associated with their child’s condition. These can include primary surgery (nerve graft surgery) on infants as young as 6 months old, secondary surgery (shoulder, hand, or

Correction of cryptotia using tissue expansion.

The anatomy and surgical correction of cryptotia are reviewed. Another technical procedure using retroauricular tissue expansion is presented. This method allows release of the auricle and construction of the auriculocephalic sulcus without the problems associated with older soft-tissue techniques, e.g., incomplete correction, multiple scars, poor color match of skin grafts, and donor-site morbidity.

Osseointegration in sinus-forming bone.

Osseointegration, using bone-anchored titanium fixtures, is a well-established technique for both intraoral and craniofacial prosthetic rehabilitation. The use of this technique in children can be complicated by craniofacial growth and sinus development. This study evaluates the effects of sinus formation and growth on the fate of osseointegrated titanium fixtures in the growing porcine model. At 3 weeks of age, six Landrace White cross male pigs had a 3.75 x 3.0 mm titanium fixture (Noblepharma) inserted into their right frontal bone where the right frontal sinus would subsequently develop. Preoperative CT scans with three-dimensional reconstructions were used to determine the insertion site. To follow the effects of growth and sinus formation, CT scans with three-dimensional reconstructions and cephalometric radiographs were taken at 1, 3, 6, and 9 weeks postoperatively and at sacrifice. The pigs were sacrificed serially, and direct osteometric measurements were taken to determine skull symmetry. All skulls were sectioned, and osseointegration was determined clinically, radiologically, and histologically with light and scanning electron microscopy. Five of the six fixtures osseointegrated. There were no apparent growth disturbances due to the fixtures. As growth progressed, the osseointegrated fixtures submerged into the frontal bone in a posteroinferior direction to become completely intraosseous 14 weeks after insertion. As the frontal sinus pneumatized, the fixtures remained osseointegrated, but progressive amounts of the fixtures became exposed in the sinus. From this study it would appear that osseointegrated titanium fixtures do not have any effect on calvarial growth and gradually submerge into the growing bone. As sinus development ensues, the fixtures remain integrated but become partially exposed within the sinus.(ABSTRACT TRUNCATED AT 250 WORDS)

Stress in mothers and fathers of children with obstetrical brachial plexus injuries

The stress load of 26 pairs of parents of children with obstetrical brachial plexus injuries (OBPI) was examined. Parents completed self-reports of condition-related stress, global stress, and psychological distress as well as medical and demographic questions. No significant differences were found between mean scores for mothers and fathers. Strong correlations were found between all study variables for mothers. Only global stress was related to psychological distress for fathers. Differences in the pattern of inter-relationships between maternal and paternal disability-related stress, global stress, and psychological distress should be taken into account when developing interventions to support families of children with OBPI.