Seth R. Thaller

Maxillofacial injuries in women

Although maxillofacial injuries account for a large number of hospital admissions, there appear to be only a few reports detailing the etiology and pattern of facial injuries in women. To delineate this problem, we performed a retrospective chart review of all women admitted to University of California, Davis Medical Center with traumatic facial injuries from July 1, 1990, to June 30, 1992. Motor vehicle accidents were the primary etiology, followed by assaults. The mandible was the most commonly injured facial bone. In a closer evaluation of female patients injured by assault, we found inadequate documentation describing the circumstances surrounding their facial injuries. This indicates that domestic violence and other forms of assaults against women may be severely underreported and has important implications for health care professionals who must always suspect physical abuse in any woman who presents with maxillofacial injuries without an obvious, known etiology.

Should nevus sebaceus of Jadassohn in children be excised? A study of 757 cases, and literature review.

The incidence of basal cell carcinoma and the need for prophylactic excision in children with nevus sebaceus of Jadassohn have been a topic of controversy. The authors performed a retrospective analysis of 757 cases from 1996 to 2002 in children aged 16 years or younger. No cases of basal cell cancer were found in the nevus sebaceus group. Recent studies in children corroborate these findings and question the need for prophylactic surgical removal of the nevus sebaceus.

The effects of insulin-like growth factor-1 on critical-size calvarial defects in Sprague-Dawley rats.

In a previous study prepared in 1992, we found that insulin-like growth factor-1 showed promise in hastening intramembranous bone repair in midfacial bone defects. For the present study, we created critical-size calvarial defects in 36 adult male Sprague–Dawley rats. The rats were then divided into two groups and killed at 1, 2, 3, 4, 5, 6, and 8 weeks. Twenty-one rats were administered insulin-like growth factor-1 subcutaneously with a 14-day osmotic infusion pump. An untreated group served as controls. Results were compared using routine histology to examine bone reconstitution of the surgical defects. Within the experimental group, we observed repair commenced at ~ 1 week and the critical-size calvarial bone defects were completely obliterated by 6 weeks; in the control group, even by 8 weeks, the surgical defects remained almost unchanged. In summary, this is further evidence that insulin-like growth factor-1 may have the potential to accelerate repair of intramembranous bone defects.

The submuscular aponeurotic system (SMAS): a histologic and comparative anatomy evaluation.

The submuscular aponeurotic system (SMAS) has been steeped in controversy. The goal of our anatomic study was to further clarify the existence of the SMAS. With an operating microscope, we performed dissections in 10 fresh cadaver heads (20 hemiheads) exposing the SMAS through a face lift incision. Through the operating microscope we were able to identify the SMAS and its relationship to other anatomic structures. Full-thickness longitudinal sections were obtained for routine histologic studies along various surgically relevant regions of the SMAS. In addition, dissections were accomplished with the operating microscope on 12 rhesus monkey fetuses ranging in age from a few weeks to 8 months. Data obtained from the fresh cadaver microdissections, topographic histology, and comparative anatomy revealed the presence of the SMAS as a distinct fibromuscular layer composed of the platysma muscle, parotid fascia, and fibromuscular layer covering the cheek.

Midfacial fractures in the pediatric population.

Fractures to the midface in the pediatric age group are rare because the mandible and cranium provide protection and absorb most of the traumatic impact. In addition, these midfacial bones are extremely elastic. When caring for midfacial fractures, standard reconstructive procedures directed toward restoration of form and function must be met. Unfortunately, diagnosis of facial fractures may be difficult because it is very dependent on the site and severity of injury as well as the childs age. Fracture management is similar to that seen in adults with the major exception related to the developing dentition, which requires adjustments in the securing of intermuxillary fixation. Children will usually recover quickly and, fortunately, complications remain rare. It is important for clinicians to closely evaluate these patients for other associated injuries. Unfortunately, due to the small numbers and poor long-term follow-up, definitive conclusions are often difficult to obtain.

Abdominal wall closure after intestinal transplantation.

Successful surgical closure of the abdominal wall after either combined or isolated intestinal transplantation may present a challenging dilemma for the plastic and reconstructive surgeon because of the following factors: restricted volume of the recipient abdominal cavity; donor-recipient size discrepancies as expressed by the donor to recipient weight ratio; and significant intraoperative edema. The purpose of this investigation is to present clinical experience with 51 consecutive patients who underwent a total of 57 sequential intestinal transplantations at the University of Miami-Jackson Memorial Hospital. A retrospective chart review of 36 pediatric (63 percent) and 21 adult (37 percent) transplantations was performed. Age of the pediatric population ranged from 1 month to 13 years (mean, 2.4 years) and of the adult population from 22 to 55 years (mean, 33.5 years). Several diagnostic classifications necessitated organ transplantation. Because of insufficient donor graft size for the recipient abdominal cavity in 19 transplantations (33 percent), several technical modifications were used to achieve anatomic and functional abdominal wall closure in all patients. In summary, the plastic and reconstructive surgeon should have a significant role in the comprehensive planning and management of abdominal wall closure in this challenging group of patients.

Reconstruction of Calvarial Defects with Anorganic Bovine Bone Mineral (Bio-Oss) in a Rabbit Model

Reconstructive surgeons have employed various procedures using either autogenous or alloplastic materials to repair cranial defects secondary to trauma, extirpative surgery, or congenital anomalies. Currently, the choice appears to be dependent on the personal choice or background of the operating surgeon. For years, our preference has been to use calvarial bone grafts as our primary source of reconstructive material. Disadvantages include uneven resorption of the bone grafts and limited quantities. For these reasons, bony substitutes present new possibilities for reconstruction of craniomaxillofacial defects. We evaluated Bio-Oss, which is a natural bone mineral derived from a bovine source that is chemically and physically identical to human bone, as a possible replacement material to reconstruct skull defects in a rabbit model.

The use of pericranial flaps in frontal sinus fractures.

Although injuries to the frontal sinus are a reasonably common traumatic injury encountered by reconstructive surgeons, definitive indications for open exploration and the optimum method for handling the residual sinus cavity remain unsettled. During the last 3 years, we have accomplished frontal sinus obliteration with an “extended” pericranial flap in 14 consecutive patients. Thus far, we have not encountered any complications.

The use of decellularized dermal grafting (AlloDerm) in persistent oro-nasal fistulas after tertiary cleft palate repair.

To assess the efficacy of decellularized dermal grafting as an adjunct to the closure of recurrent oro-nasal fistulas. Five consecutive patients with recurrent oro-nasal fistulas were repaired with decellularized dermal grafting sandwiched between oral and nasal flaps of a von Langenbeck palatal repair. All patients had previously undergone a minimum of three prior palatal repairs with the recurrence of their oro-nasal fistula in the post-alveolar area. Decellularized dermal graft was placed between the nasal mucosa and the levator veli palatine muscle. Patients were followed postoperatively and assessed for infection, dehiscence, signs of rejection, and fistula recurrence. All patients were followed for an average of three months. Clinical examination revealed no recurrence of their oro-nasal fistula nor associated symptoms of nasal reflux. Decellularized dermal grafts were not rejected nor extruded from the site of surgical repair. Decellularized dermal graft should be considered for use in the treatment of recurrent oro-nasal fistula after cleft palate repair. We would also like to encourage further clinical study.

Complications of mandibular fractures

Timely repair of mandibular fractures remains an effective means to reduce pain, restore function, and prevent complications. This study addresses the effect of the time interval between injury and treatment on the overall complication rate, the complication rate between various treatment modalities (mandibular-maxillary fixation [MMF] alone, MMF with intraosseous wire bone fixation, and MMF with rigid internal fixation), and the relationship of inpatient vs. outpatient management. Cost was also examined with respect to choice of management. We report a retrospective series of 308 consecutive patients managed at the University of Miami/Jackson Memorial Hospital. Patients who received treatment 3 to 10 days following injury were found to have a lower complication rate than earlier or later repair. We postulate that most patients with mandibular fractures may be managed on an outpatient basis, which represents a considerable savings in cost.Moulton-Barrett R, Rubinstein AJ, Salzhauer MA, Brown M, Angulo J, Alster C, Collins W, Kline S, Davis C, Thaller SR. Complications of mandibular fractures.