Linton A. Whitaker

Membranous versus endochondral bone: implications for craniofacial reconstruction.

Based on observations in the human suggesting improved membranous bone graft take, an experimental study was undertaken in 15 rabbits and 7 monkeys to evaluate the differences in take between membranous and endochondral bone grafts. Using vital stains, serial cephalograms, direct measurements, and point-counting techniques, the grafts were compared. In both types of experimental animals, membranous bone maintained its volume to a significantly greater extent than endochondral bone when autografted in the craniofacial region. The loss of volume with endochondral grafts was at the end of the experiment more than three times that of membranous grafts in the rabbit (65 percent endochondral loss versus 19.5 percent membranous loss) and more than four times volume loss in the monkey (17.2 percent membranous volume loss versus 88 percent endochondral loss). The uptake of vital stains (tetracycline and alizarin) was greater with membranous bone, and point counting demonstrated more living membranous bone (40.5 percent membranous versus 28.1 percent endochondral) at the end of the experiment. These studies confirm the increased resorption of endochondral bone grafts when compared with membranous grafts and substantiate clinical impressions that cranial donor sites are preferable for craniofacial recipient areas when clinically feasible.

THE PSYCHOLOGY OF COSMETIC SURGERY: A REVIEW AND RECONCEPTUALIZATION

This article discusses the psychology of cosmetic surgery. A review of the research on the psychological characteristics of individuals who seek cosmetic surgery yielded contradictory findings. Interview-based investigations revealed high levels of psychopathology in cosmetic surgery patients, whereas studies that used standardized measurements reported far less disturbance. It is difficult to fully resolve the discrepancy between these two sets of findings. We believe that investigating the construct of body image in cosmetic surgery patients will yield more useful findings. Thus, we propose a model of the relationship between body image dissatisfaction and cosmetic surgery and outline a research agenda based upon the model. Such research will generate information that is useful to the medical and mental health communities and, ultimately, the patients themselves.

body Image Dissatisfaction and Body Dysmorphic Disorder in 100 Cosmetic Surgery Patients

This study was the first empirical investigation of body image dissatisfaction and body dysmorphic disorder in cosmetic surgery patients. Of 132 women, 100 women (response rate, 76 percent) completed two body image measures prior to surgery, the Multidimensional Body-Self Relations Questionnaire and the Body Dysmorphic Disorder Examination Self-Report. Cosmetic surgery patients did not demonstrate greater dissatisfaction with their overall appearance compared with the reported normal values of the measures. However, when asked about the specific bodily feature they were considering for cosmetic surgery, they reported significantly greater dissatisfaction than a normative sample. In addition, 7 percent of the sample met diagnostic criteria for body dysmorphic disorder, a potential psychiatric contraindication to cosmetic surgery. Implications of these findings are discussed with respect to the nature of body image dissatisfaction and the prevalence of body dysmorphic disorder in cosmetic surgery populations.

Craniosynostosis: an analysis of the timing, treatment, and complications in 164 consecutive patients.

Treatment options for the craniosynostoses vary from conservative observation until completion of growth to radical remodeling in infancy. To further define the timing and type of treatment necessary in these complex disorders, we have retrospectively analyzed all patients operated on for this deformity during the past 12 years. One-hundred and sixty-four patients with craniosynostosis were analyzed and subgrouped into asymmetrical (predominantly unilateral) and symmetrical (bilateral) deformities, in addition to segregation by age and type of procedure performed. This was done recognizing that no deformity, like no normal human face, is truly symmetrical. Results of treatment were categorized on the basis of the need for additional surgery and varied from no refinements necessary (category I) to major reduplication of the initial procedure (category IV). Analysis of the data led us to conclude that excellent results can be expected in the asymmetrical deformities group treated in infancy by a unilateral approach. Similarly, for the mild symmetrical deformities, treatment at this time by bilateral orbital advancement gives satisfactory results in the majority of patients. By contrast, the more severe symmetrical groups treated in childhood have a high incidence of requiring secondary major reconstructions, and consideration should be given to delaying craniofacial surgery until age 7 or older, although earlier cranial surgery may be advisable.

The early revascularization of membranous bone.

The experimental finding that membranous onlay bone grafts maintain volume and viability to a greater extent than do endochondral grafts may be related to the more rapid vascularization of membranous bone. Microangiographic techniques were used to study the rates of vascularization of membranous and endochondral bone grafts in adult white New Zealand rabbits at 1, 3, 7, 14, and 21 days after bone grafting. Vascularization patterns were quantified microscopically using a modified point-counting technique. At 3 days, membranous bone grafts demonstrated vessel ingrowth from both soft tissue and host bone. Little ingrowth was seen in endochondral grafts. By day 7, 2.5 vessels per square were indentified entering membranous grafts, while an average of 0.6 vessels per square were counted for endochondral bone grafts. At day 14, there was an average of greater than 20 vessels per square for membranous grafts versus 1.8 for their endochondral counterparts. At 21 days, the endochondral grafts demonstrated persistent avascular central areas not seen in membranous grafts. Membranous onlay bone grafts in the rabbit are more rapidly vascularized than endochondral grafts. This factor may affect the greater volume maintenance seen in experimental membranous grafts.

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.

The effect of rigid fixation on the survival of onlay bone grafts: an experimental study.

Much attention has recently been focused on rigid fixation as a method of improving fracture healing. Whether such fixation, when applied to onlay grafting, improves graft take and volume is unknown. To examine this question, we compared survival of both endochondral and membranous grafts fixed rigidly and nonrigidly in areas of low motion (snout) and high motion (femur) in a rabbit model. Gross morphology, histologic analysis, and graft volume kinetics were evaluated. Findings demonstrate that in areas of high motion, the application of rigid fixation improves graft survival, whereas in a low-motion region, no differences in graft volume retention as a function of fixation were observed. Histologically, no differences with the method of fixation employed were seen, and similar revascularization patterns were noted. By kinetic analysis, rigid fixation appears to exert its most profound effect early in the postgraft period. Membranous bone grafts remain superior to endochondral grafts under all circumstances. From these studies, we conclude that rigid fixation is the method of choice in all circumstances where onlay bone grafts may be exposed to motion, shear, and torsional forces.

Body image concerns of breast augmentation patients

This study investigated the body image concerns of women who sought cosmetic breast augmentation. Thirty breast augmentation candidates completed several measures of body image before their initial surgical consultation. Thirty physically similar women who were not interested in breast augmentation were recruited from the medical center and university community and also completed the measures. Breast augmentation candidates, as compared with women not seeking augmentation, reported greater dissatisfaction with their breasts. Augmentation candidates rated their ideal breast size, as well as the breast size preferred by women, as significantly larger than did controls. In addition, women interested in breast augmentation reported greater investment in their appearance, greater distress about their appearance in a variety of situations, and more frequent teasing about their appearance. Finally, breast augmentation candidates also reported more frequent use of psychotherapy in the year before the operation as compared with women not seeking augmentation. These results replicate and extend previous studies of body image in cosmetic surgery patients.

Age-related Changes of the Craniofacial Skeleton: An Anthropometric and Histologic Analysis

With the development of increasingly sophisticated methods for the alteration of bony facial form consequent to age, it is imperative that the surgeon have a fundamental knowledge of the age-related changes the skeleton may undergo. To understand these changes better, a detailed anthropometric and histomorphic analysis of the craniofacial skeleton as a function of age was undertaken. The study consisted of a detailed craniometric analysis of 160 skulls selected randomly from a Caucasian population of skeletal remains totaling 1500 specimens. Additionally, a histologic analysis of the supraorbital ridge in a separate preserved cadaver population was performed. Although the results showed individual variation as expected, definite changes in craniofacial morphology were observed. These included (1) appreciable reduction of facial height, most marked in the maxilla and mandible, and strongly correlated with loss of teeth, (2) modest increase in facial width, (3) modest increase in facial depth, except in those regions associated with tooth loss, and (4) general coarsening of bony prominences. Histomorphic analysis demonstrated increasing porosity with age, more marked in the female population. Although these changes represent population trends, in any given patient, any or all of them may be present to varying degrees. Surgeons should be aware of these possibilities and consider selective alterations of the skeletal foundation, either separately or in concert with the overlying soft-tissue envelope, in order to optimize the results of surgery for the aging face. (Plast. Reconstr. Surg. 90: 592, 1992.)

Metopic synostosis: Defining the temporal sequence of normal suture fusion and differentiating it from synostosis on the basis of computed tomography images.

Only the metopic suture normally fuses during early childhood; all other cranial sutures normally fuse much later in life. Despite this, metopic synostosis is one of the least common forms of craniosynostosis. The temporal sequence of normal physiologic metopic suture fusion remains undefined and controversial. Therefore, diagnosis of metopic synostosis on the basis of computed tomography images alone can prove misleading. The present study sought to determine the normal sequence of metopic suture fusion and characterize both endocranial and ectocranial suture morphology. An analysis of computed tomography scans of 76 trauma patients, ranging in age from 10 days to 18 months, provided normative craniofacial data that could be compared to similar data obtained from the preoperative computed tomography scans of 30 patients who had undergone surgical treatment for metopic synostosis. Metopic suture fusion was complete by 6 to 8 months in all nonsynostotic patients, with initiation of suture fusion evident as early as 3 months of age. Fusion was found to commence at the nasion, proceed superiorly in progressive fashion, and conclude at the anterior fontanelle. Although an endocranial ridge was not commonly seen in synostotic patients, an endocranial metopic notch was virtually diagnostic of premature suture fusion and was seen in 93 percent of synostotic patients. A metopic notch was not seen in any nonsynostotic patient. The morphologic and normative craniofacial data presented permit diagnosis of metopic synostosis based on computed tomography images obtained beyond the normal fusion period.