Kenneth E. Salyer

Combined report of problems and complications in 793 craniofacial operations.

We report the experiences in 6 major craniofacial centers, with similar teams but in different parts of the world, in a total of 793 craniofacial operations. The mortality rate was 1.6%. Complications developed in 16.5% of the cases (including infections in 4.4%). This surgery has many potential advantages, not least of which is its psychosocial effects on previously disfigured patients. Certain problems seem inherent, however, for there are not yet any satisfactory solutions to them. Some of the factors that reduce morbidity and improve results include the use of hypotensive anesthesia, a reduction in operating time, rigid stabilization of the mobilized bones at the end of the operation, a diminution in the number of incisions, and extensive antibiotic therapy.

Primary correction of the unilateral cleft lip nose: a 15-year experience.

This paper reviews a 15-year personal experience based on 400 unilateral cleft nasal deformities that were reconstructed using a method that repositions the alar cartilage by freeing it from the skin and lining and shifts it to a new position. The rotation-advancement lip procedure facilitates the exposure and approach to the nasal reconstruction. The nasal soft tissues are transected from the skeletal base, reshaped, repositioned, and secured by using temporary stent sutures that readapt the alar cartilage, skin, and lining. The nasal floor is closed and the ala base is positioned to match the normal side. Good subsequent growth with maintenance of the reconstruction has been noted in this series. The repair does not directly expose or suture the alar cartilage. Improvement in the cleft nasal deformity is noted in 80 percent of the cases. Twenty percent require additional techniques to achieve the desired symmetry. This method has been used by the author as his primary unilateral cleft nasal repair and has been taught to residents and fellows under his direction with good results. This technique eliminates the severe cleft nasal deformity seen in many secondary cases.

Porous hydroxyapatite as an onlay bone-graft substitute for maxillofacial surgery

This paper chronicles 3 years of a continuing study comparing porous hydroxyapatite to autogenous bone grafts as onlays in maxillofacial surgery. Twenty-five patients, seen from June of 1984 to May of 1985, underwent onlay augmentation on various maxillary and mandibular locations. A total of 68 onlay augmentation sites comparing Interpore porous hydroxyapatite and autogenous bone were followed for 2 years or more. This long-term study compares these substances in radiologic longevity, histologic incorporation, clinical function, and aesthetic appearance.

Two-flap palatoplasty: 20-year experience and evolution of surgical technique.

Background: The two-flap palatoplasty was described more than 30 years ago, but there are few reports of long-term results using this technique. There are also very few long-term series of a single method of palatoplasty from a single surgeon. Methods: The authors reviewed the technique of the two-flap palatoplasty, with emphasis on the senior author’s (K.E.S.) modifications. The authors also retrospectively reviewed 382 two-flap palatoplasties performed by the senior author in nonsyndromic patients over a 20-year period. The incidence of secondary velopharyngeal surgery was established. Detailed speech analysis was performed in a subset of 150 patients. Results: The proportion of patients with velopharyngeal insufficiency over 20 years was 8.92 percent, falling from 10.95 percent in the first decade to 6.43 percent in the second decade. There was no significant difference in velopharyngeal insufficiency between the cleft subtypes. Age at palatoplasty did not affect the development of velopharyngeal insufficiency, but it should be noted that most of the patients underwent palate repair before 12 months of age. Speech results were consistently good across the two decades. In the second decade, 91.14 percent had normal to mildly impaired resonance, 79.75 percent had no or inaudible nasal air emission, and 97.47 percent demonstrated no compensatory articulation errors. Conclusions: The two-flap palatoplasty is a reliable technique that has yielded excellent surgical and speech outcomes. Early and regular speech assessments and appropriate treatment when indicated are an integral part of the multidisciplinary approach to achieve good speech outcome.

Cranioplasty in the growing canine skull using demineralized perforated bone

This study was designed to test the hypothesis that demineralized perforated bone matrix implant from canine skull and tibia induces new bone formation within the calvarial defect comparable with the bone induced by autogenous graft. We also were interested in determining whether demineralized perforated bone matrix implants from membranous bone have greater osseoinductive capacity in the calvarial area than demineralized perforated bone matrix implants from endochondral bone. Forty 12-week-old purebred beagles were used. Group I consisted of animals with unrepaired surgically created calvarial defects healed by secondary intention (n = 10). Group II consisted of animals with surgically created calvarial defects in which the bone was removed and replaced with an autograft (n = 10). Group III consisted of animals with surgically created calvarial defects in which the bony defect was closed with a demineralized perforated bone matrix implant obtained from beagle calvaria (n = 10). Group IV consisted of animals with surgically created calvarial defects in which the bony defect was closed with a demineralized perforated bone matrix implant obtained from beagle tibia (n = 10). The two control groups (I and II) allowed us to isolate the inductive capacity of demineralized perforated bone matrix implants and compare it with the healing of the bone defects left unrepaired or repaired with calvarial autografts. Animals were sacrificed after 8 and 12 weeks. In the present study we were able to verify that demineralized perforated bone matrix implants are well accepted in the calvarial defects with little tissue reaction and remarkably little osteoclastic activity. In arguing for the osseoinductive potential of demineralized perforated bone, we must realize that it is likely that much of the bone consists of demineralized implant that has been invaded by host cells along with new bone in the area of the implant. This study revealed no statistically significant differences between new bone formation following the insertion of demineralized perforated bone matrix implants of the tibia or calvarium. (Plast. Reconstr. Surg. 96: 770, 1995.)

Distraction osteogenesis of costochondral neomandibles: A clinical experience

&NA; Distraction osteogenesis quickly has become a mainstay in the treatment of craniofacial syndromes with mandibular hypoplasia. We report on a series of eight patients undergoing distraction osteogenesis of neomandibles constructed with costochondral grafts. The length of distraction, resting phase between distraction and device removal, and complication rate were significantly greater in the rib‐graft distraction group when compared with our series of native mandibular distraction patients (n = 21 devices). Most complications were minor, including pintrack infection and hardware failure; however, major complications included fibrous union and facial nerve praxia. Secondary procedures have been able to be performed successfully on previously distracted rib grafts as well. (Plast. Reconstr. Surg. 100: 311, 1997.)

Long-term outcome of extensive skull reconstruction using demineralized perforated bone in Siamese twins joined at the skull vertex.

The successful use of cortical demineralized perforated bone in the treatment of extensive skeletal defects in children is exemplified by this case involving Siamese twins joined at the skull vertex. Four years following extensive skull reconstruction using demineralized perforated bone, an examination revealed successful calvarial reconstruction in one twin. The other twin required additional implants of demineralized perforated bone to fill in defects. However, a histologic examination taken following this additional procedure revealed that these implants neither caused tissue reaction over a 4-year period, nor showed signs of resorption. Bony remodeling and new bone formation were in progress. Compared with other bone substitutes, demineralized perforated bone has proven to be effective in the treatment of large skull defects in children.

Unilateral cleft lip-nose repair – long-term outcome

Good to excellent results have consistently been achieved by the authors in primary unilateral cleft lip-nose repair. Modifications and improvements in their original technique have led to better symmetry and balance, with less scarring. This technique, when performed by experienced surgeons, yields consistent, predictable, and achievable outcomes for all patients with unilateral cleft lip and nose, where normal appearance and function at conversational distance is the standard of care. The achievement of excellence in soft tissue and skeletal restoration optimizing each patients growth potential depends on a surgical-orthodontic-speech-oriented treatment plan. Long-term outcomes demonstrating consistently good to excellent results can be achieved using this primary technique if it is backed up with a dedicated, multidisciplinary ongoing treatment protocol.

The early vascularization of onlay bone grafts.

On the basis of this work, several conclusions may be drawn. (1) Autogenous iliac crest onlay bone grafts in the rat vascularize as early as 3 days. (2) The presence or absence of periosteum transferred with the graft has no significant effect on the rate of vascularization. Neither was a difference noted when grafts were placed above or below the host periosteum. (3) The onlay bone grafts in this study appeared to be revascularized by vessel ingrowth. (4) Factors other than the ones controlled in this experiment may influence rate, quantity, and quality of the vascularization of bone grafts.

Recombinant Human BMP-2 Enhances the Effects of Materials Used for Reconstruction of Large Cranial Defects

PURPOSE Cranial defect reconstruction presents 2 challenges: induction of new bone formation, and providing structural support during the healing process. This study compares quantity and quality of new bone formation based on various materials and support frameworks. MATERIALS AND METHODS Eighteen dogs underwent surgical removal of a significant portion of their cranial vault. Demineralized bone matrix was used to fill the defect in all animals. In 9 dogs, recombinant human bone morphogenetic protein-2 (rhBMP-2) was added, while the other 9 served as the non-rhBMP-2 group. In each group, 3 animals were fixed with cobalt chrome plates, 3 with adding platelet-rich plasma, and 3 fixed with a Lactosorb (Walter Lorenz Surgical, Inc, Jacksonville, FL) resorbable mesh. Necropsy was done at 12 weeks postoperative. Histomorphometry, density, and mechanical properties of the regenerate were analyzed. RESULTS The non-rhBMP-2 groups showed minimal substitution of demineralized bone matrix with new bone, while only sporadic remnants of demineralized bone matrix were present in the rhBMP-2 groups. The defect showed more new bone formation (P < .001) and density (P < .001) in the rhBMP-2 groups by Kruskal-Wallis test. The area of new bone was not significantly different among the rhBMP-2 subgroups. The resorbable mesh struts showed no sign of bone invasion or substitution. In the non-rhBMP-2 resorbable mesh group, demineralized bone matrix almost totally disintegrated without replacement by new bone. CONCLUSIONS The addition of rhBMP-2 to demineralized bone matrix accelerated new bone formation in large cranial defects, regardless of the supporting framework or the addition of platelet-rich plasma. The use of a resorbable mesh in such defects is advisable only if rhBMP-2 is added.