Fractures of the maxillary facial bones, also described as LeFort fractures, are potentially disfiguring and potentially lethal injuries that require careful examination and expectant management skills. This review article provides an overview of fracture patterns, patient assessment, and the specific management of patients with LeFort fractures.

1993 Upchurch Lecture at the Annual Meeting of the Southeastern Society of Plastic and Reconstructive Surgeons, in Hilton Head, South Carolina, on June 8, 1993.

This review of patients after forehead rhytidectomy represents the longest published postoperative follow-up to date. Fifty patients who had undergone subcutaneous forehead rhytidectomy through an anterior hairline incision were assessed by chart review, detailed questionnaire, and physical examination. The mean follow-up was 7.5 years with a range of 1 to 17 years. Benefits of the technique described include maintenance of forehead size, a mechanically efficient lift, a direct attack on wrinkles, and a low incidence of hair loss. Patient assessment indicates that the benefits of the procedure are long lasting. The disadvantages include the added precision required in executing the incision, closure, and time-consuming dissection.

Basic fibroblast growth factor (bFGF) was prepared from bovine pituitary glands and evaluated for its effect on the viability of pedicle skin flaps in rats. Pedicle flaps measuring 3 × 7.5 cm and based cephalad were created on the backs of animals. The treatment group received bFGF in saline solution intradermally by Dermo-jet injection 30minutes before flap elevation. Skin flaps treated with a single application of 80 U of bFGF demonstrated a significant increase in viability from 40.8% to 69.7% of the flap area (p<0.001); the flaps treated with 16 U of bFGF exhibited little improvement. Intradermal administration of bFGF to pedicle skin flaps produced an increase in viability that approximates the increase obtained by a surgical delay procedure; treatment of flaps with exogenous bFGF may offer advantages over surgical delay procedures.

Free nipple graft reduction mammoplasty is the procedure of choice in patients with massive breast hypertrophy, or those high-risk patients less able to undergo a more extensive procedure. A major criticism of the technique is that it creates a flat, boxy breast that lacks projection, A technical modification of free nipple graft reduction mammoplasty is presented. In this modification, a central, bulky, superiorly based dermal-parenchymal flap extending from the “keyhole” site to the superior aspect of the areola is designed. After tailoring, this central flap is folded superiorly and secured beneath the medial and lateral flaps to create the bulk of the breast mound. This central flap can be accurately tailored to achieve the desired breast size and projection. The medial and lateral breast flaps do not create the breast mound, and are only contoured over the top of this central flap to complement the final breast form.

The effects of systemic heparin on the survival of island skin flaps have been evaluated. Island flaps measuring 3 x 6 cm were created in the abdomen/groin of rats based on an inferior epigastric neurovascular pedicle. The venous drainage from the flap was occluded for various lengths of time ranging from 5 to 10 hours in the control rats and from 8 to 15 hours in the heparin-treated group of rats. The rats in the treated group received 1 ml of heparin solution (300-400 U/kg) through the contralateral saphenous vein immediately prior to the onset venous occlusion and an equivalent dose every 4 hours during venous occlusion. The group of control rats received 1 ml of saline solution. Flap survival was evaluated daily for 7 days. The flaps of control rats demonstrated a gradual decline of the survival rate after 6 hours of venous occlusion and no survival after 10 hours of venous occlusion. The flaps of heparin-treated rats exhibited complete survival until 12 hours of venous occlusion and no survival after 13 hours of venous occlusion. Thus, systemic heparin prolonged tissue tolerance to venous occlusion from 10 to 13 hours. The flaps of control rats demonstrated a significant accumulation of inosine plus hypoxanthine to 260% of normal after 8 hours of venous occlusion. The flaps of heparin-treated rats exhibited little alteration of inosine plus hypoxanthine, and contained a greater concentration of glucose and lactate than the flaps of control rats after 8 hours of venous occlusion. The results demonstrate that systemic heparin can increase tissue tolerance to venous occlusion and improve significantly the flap survival following subsequent reperfusion.

The effect of hyperbaric oxygen, administered during storage, on the survival of replanted limbs was evaluated in rats. The right hindlimbs of male Sprague-Dawley rats were severed and were replanted by microvascular anastomoses after storage in either room air or hyperbaric oxygen (100% oxygen at 2.9 atm absolute) at 23 degrees C for 5 hours. The administration of hyperbaric oxygen during storage improved limb survival from 50% in the room-air, control rats to 100% (p less than 0.05). The gastrocnemius muscle of limbs treated with hyperbaric oxygen demonstrated a higher level of energy reserves (creatine phosphate, adenosine triphosphate, glycogen, and glucose) than the same muscle in room-air, control rats. The mechanisms of the beneficial effect of hyperbaric oxygen on limb survival appears to be related to preservation of high-energy phosphates and glycogen.

A sacral ulcer is described where ischaemia due to a vascular "steal" syndrome in the gluteal angiotome was the cause of persistent failure of flap reconstruction.Thrombotic obliteration of the abdominal aorta had resulted in the development of collaterals which, paradoxically, deprived the flaps based on standard angiotomes of their major source of blood supply, as they became the major source of perfusion for the legs.Healing of the ulcer was successfully achieved only after aorto-iliac reconstruction.Two other cases of ischaemic sacral ulceration, associated with aortic occlusion, are described..

The plastic surgeon encounters a variety of lesions that are benign histologically. but malignant in terms of their manifestations and clinical course, Many of these desperate pathologic situations present exceedingly difficult problems in terms of their diagnosis and management. Clinical entities that tend to be grouped within this type of pathologic phenomenon include siant pigmented ne vi, arterio-venolymphatic malformations, neurofibromatosis, and localized overgrowth. The authors examine such lesions on the basis of their presentations, pathogeneses, and pathophysiology.

A study of patients with large cranial defects involving the frontal bone, frontal sinus, nose, and orbit does not support the contention that there is a clear superiority of reconstructive material despite a history of previous bone infection. No patient with an isolated cranial reconstruction experienced an infection despite location in the area of the frontal sinus or the use of acrylic material. All patients experiencing infection underwent simultaneous reconstruction of the frontal cranium and nose and three-or four-wall reconstruction of the orbit, where the frontal sinus had previously been eliminated and where a previous bone infection had been present. Risk factors associated with cranioplasty were timing (p = 0.001) and cranial vault reconstruction in communication with previously infected ethmoid sinuses and the nose (p = 0.03). A history of previous bone infection suggests increased risk (p = 0.15). The choice of reconstructive material was not significant, although acrylic cranioplasties did not experience the complications expected from a review of the literature. The times have been that, when the brains were out, the man would die, and there and end; but now, they rise again....

We have demonstrated previously that oxygen-derived free radicals are important mediators of tissue injury in experimental island skin flaps that have been subjected to prolonged ischemia (vascular occlusion) followed by reperfusion. In this study the role of oxygen free radicals in ischemia/reperfusion injury has been investigated in free flap transfers. Groin skin flaps were harvested, stored at room temperature for 21 to 24 hours, and transplanted to the contralateral groin. These free flap transfers normally exhibit a high incidence of complete necrosis. Treatment before the onset of reperfusion with a single dose of superoxide dismutase (SOD), a scavenger of superoxide radicals, increased the survival rate of these skin flaps from 38% in the control group to 76% (p less than 0.025). Tissue levels of SOD were measured before ischemia, after ischemia but before reperfusion, and 30 minutes after reperfusion: untreated flap tissues, which were destined to undergo necrosis, exhibited a significant decrease in SOD activity after reperfusion, whereas SOD-treated flap tissues, destined to survive, demonstrated increased enzyme activity. High levels of tissue SOD activity thus appeared to be associated with improved flap survival. The results have significant clinical implications with regard to organ preservation and transplantation.

Manson, Paul N. M.D.; Crawlgy, William A. M.D.; Hoopes, John E. M.D.; Wolfe, S. Anthony M.D. Author Information

Experience with 240 midface (Le Fort and zygoma) fractures in multiple trauma patients has emphasized that superior aesthetic results are obtained by immediate extended open reduction with primary bone grafting. Internal fixation of 1 10 zygomatic and 130 Le Fort fractures was performed in the lower midface (zygomaticomaxillary and nasomaxillary buttresses). Open reduction of the condyle was employed in five concomitant Le Fort and subcondylar fractures with a loss of ramus height to prevent superior and posterior displacement of the middle and lower face. Bone grafts were utilized in 74 patients. They were most frequently employed in the orbit and less frequently in the lower midface. Bone graft survival paralleled that observed under elective conditions, and a slightly higher infection rate was observed. Extended open reduction and immediate bone grafting adds a new dimension to the aesthetic results obtained from facial fracture treatment. Structural bony integrity and pre-injury facial architecture may be restored in the absence of soft-tissue contracture. Restoration of the pre-injury facial architecture (the essence of facial fracture treatment) is more accurately accomplished when these techniques are utilized.

Three cases of epithelioid sarcoma of the upper extremity are presented. Information regarding 112 previously published cases is reviewed. It is concluded that epithelioid sarcoma must be included in the differential diagnosis of soft-tissue tumors of the extremities. Moreover, the diagnosis of epithelioid sarcoma demands prompt and aggressive surgical intervention. Irradiation therapy and chemotherapy have not been proven to be of value in the management of epithelioid sarcoma.

Unilateral microtia is not a separate entity but rather a part of the syndrome of hemifacial microsomia. To document the high incidence of hemipalatal palsy among microtia patients, 19 patients with unilateral microtia are reviewed. Partial innervation of the levator veli palatini muscle by the VII cranial nerve, and origin of this muscle from the second branchial arch, are suggested as the basis of the inclusion of hemipalatal palsy in hemifacial microsomia.

This study was carried out to determine the perioperative mortality rate of patients over the age of 65 years who are undergoing major head and neck resections under general anesthesia. The total number of patients was 810 and the perioperative mortality rate (death within 30 days of operation) was 3.5 percent (29 of 810). This rate is relatively low when compared with the rate for patients undergoing similar procedures during the same period in the 35 to 65 years age group. Since 1975 reports of other types of surgery in the elderly have given perioperative mortality rates of from 4.8 to 26 percent. Previous studies of head and neck surgery in the elderly have given perioperative mortality rates of from 1.3 to 13.6 percent. Head and neck surgery in the elderly continues to be a safe procedure when compared with other types of surgery. As the portion of patients in the population over the age of 65 continues to increase, advanced age alone should not be a deterrent to performing aggressive surgical therapy for head and neck cancer.