Richard C. Schultz

The acute effects of cigarette smoke exposure on experimental skin flaps.

Random vascular patterned caudally based McFarlane-type skin flaps were elevated in groups of Fischer 344 rats. Groups of rats were then acutely exposed on an intermittent basis to smoke generated from well-characterized research filter cigarettes. Previously developed smoke inhalation exposure protocols were employed using a Maddox-ORNL inhalation exposure system. Rats that continued smoke exposure following surgery showed a significantly greater mean percent area of flap necrosis compared with sham-exposed groups or control groups not exposed. The possible pathogenesis of this observation as well as considerations and correlations with chronic human smokers are discussed. Increased risks of flap necrosis by smoking in the perioperative period are suggested by this study.

Management and timing of cleft palate fistula repair.

&NA; This study reviewed 199 cleft palate repairs resulting in 22 percent fistula formation. Of these, 49 percent were judged to be symptomatic. Of 44 fistulas, 21 required treatment, of which 14 had conventional type surgical closure with an overall success rate of 35 percent. Good surgical technique and good surgical judgment were felt to be important factors both in preventing postoperative fistula and in the success of their repair. Conventional methods of surgical repair of hard palate fistulas were seen to result in a very poor success rate. Orthodontic movement of maxillary segments was seen to contribute to late postoperative fistula formation. Therefore, orthodontic movement should be completed before undertaking surgical repair of anterior palatal fistulas. Finally, the success rate of anterior fistula repair has been dramatically improved by the addition of free periosteal grafts and cancellous bone grafts.

Congenital Arteriovenous Malformation of the Face and Scalp

A case of congenital arteriovenous fistula of the forehead and scalp is presented. A review of the embryology, incidence, clinical findings, and diagnostic techniques is discussed along with the various modes of therapy. The ideal treatment of congenital arteriovenous malformation is early, total removal of the tissue involved.

Immediate and long-term management of gunshot wounds to the lower face.

The steadily increasing level of urban violence and attempted suicides in the recent past has resulted in large numbers of gunshot injuries to the face from small-caliber weapons. Our experience with 35 consecutive cases of civilian gunshot wounds involving primarily the lower face is presented. Initial management included securing of the airway, control of bleeding, and treatment of coexisting injuries. After clinical and radiologic evaluation and conservative debridement of all devitalized tissues, the mandibular fractures were reduced and stabilized appropriately. Large bony defects were treated by stabilization of the mandibular segments followed by secondary bone grafting. Intraoral soft tissues were then repaired with local mucosal flaps or tongue flaps when necessary. Finally, the soft tissues were repaired by primary closure or local flaps. Distant flaps were used only as a secondary procedure. Our results are presented, the differences between civilian and military injuries are discussed, and the principles of gunshot ballistics are described. We conclude that most of these wounds can be treated in a relatively conservative manner immediately after the injury with good functional and cosmetic results.

Free Periosteal graft repair of maxillary clefts in adolescents

Free periosteal grafting of the maxillary cleft in adolescents is an alternative, simplified method of reconstructing secondary maxillary cleft deformities, particularly the sunken nostril sill. The historical background of bone grafting, periosteal flaps, and free periosteal grafts in infants, along with recent studies of adolescent growth patterns of the maxilla and cleft side dentition, provides the rationale for our protocol. Fourteen patients were operated on ranging in age from 9 to 30. They were studied clinically by Panorex x-rays and some by CT scans. New bone bridging the maxillary cleft with resultant improvement in the cleft deformities was found routinely in patients under 15 years of age. Some patients exhibited greater cosmetic improvement than others.

Medial thigh lift.

A simple procedure has been developed to correct this laxity of the upper, inner thighs. This consists of symmetrical resection of a crescent-shaped segment of skin and subcutaneous tissue having the distribution of an L1 embryological dermatome, just inferior to the inguinal crease. Despite temporary sensory loss and spreading of scars in some patients, the procedure has been gratifying to both patient and surgeon. Patients must be carefully selected, as the procedure does not correct either trochanteric lipodystrophy or ptosis, or lipodystrophy medial to and just superior to the knee.

Cleft palate fistula repair. Improved results by the addition of bone.

A retrospective study of cleft palate repairs showed a 22% fistula incidence. Of these 49% were judged to be symptomatic. Of the fistulae, approximately half required treatment. Of the conventional type surgical closures, there was only a 35% success rate. Conventional methods of surgical repair of anterior hard palate fistulae were seen to result in the very poorest permanent closure. As a result of this study, a new protocol was developed which has resulted in marked improvement in the surgical repair of anterior fistulae. We now close these fistulae in early adolescence following completion of orthodontic expansion using gingival and palatal flaps after the addition of free periosteal grafts or cancellous bone grafts.

Reconstruction of facial deformities with alloplastic material

The two most ideal and versatile foreign materials for reconstruction of facial bone deformities are silicone rubber and methyl methacrylate. Their biomechanical characteristics are uniquely suited to facial implantation for reconstruction of complex, irregular bony defects. The advantages and disadvantages of each are discussed, along with specific indications for their use. Surgical approaches and various methods of fabrication and fixation are presented and illustrated. The hazards and potential disappointments in the use of these and other alloplastic implants are reviewed.

Restoration of frontal contour with methyl methacrylate.

Of the various materials currently available for reconstruction of bony frontal deformities, bone cement (methyl methacrylate) has been judged to be superior in its simplicity, reliability, and aesthetic potential. It is uniquely suited to reconstruction of irregular defects of the forehead. Its biological characteristics, advantages, and hazards are presented along with the techniques of its use. Clinical examples illustrate the results obtained with minimal preparation, surgical time, and morbidity.

Early treatment of rhinophyma. A neglected entity

Patients are aware when even minimal bulbosity appears secondary to acne rosacea. Many suffer psychic trauma as a result. Early surgical treatment of this entity eliminates disfiguring hypertrophy. We advocate early surgical treatment of even minimal rhinophyma.