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The controversy regarding the treatment and the repair of the orbital fractures has been one of the most intense of all the other facial fractures that we have treated in modern history. Various biomaterials have been used to repair the orbital floor. Some with unnatural outcomes are still being used in some surgical circles, and others have been abandoned and did not stand the test of time. This report describes the use of the newly applied copolymers in such repairs. Since their introduction, resorbable biomaterial and their use on the orbital floor for repair have been accompanied by good outcome based on the evidence collected in various reports.

Today the use and advances of bioresorbable biomaterials in skeletal fixation is in a process of major evolution in the applications and understanding of all fixation devices. Craniofacial skeletal fixation is an essential element in the stabilization of the different components of any bony components in the biological system. The rigid fixations of the craniofacial skeletal represent a major biological region in the human skeleton where such applications produce the desired stability with maximal advantages and minimal disadvantages to any existing systems in present use. This shift in the evolutionary status, from overusing metallic components to a move of avoiding the use of metallic implants, particularly in infants and in children, to the total applications of resorbable material in all applications in the craniofacial skeleton and in all age groups, is because of the complications and safety to the patients. The metallic implants, once popular and in wide variety of uses in the 1980s, are falling by the wayside as the application and sophistication in the resorbable components become more accepted by the practicing surgeons working, in particularly, on all components of the craniofacial skeleton. The craniofacial skeleton is a unique component of the skeletal system for its proximity to the central nervous system on one hand and to the contaminates oropharyngeal airway on the other hand.

The main goal of bone healing, besides the healing of the bone, is ensuring that the dynamic system of repair is under biologic control. To do so, the soft tissue has to be kept isolated to avoid any herniation into the bony defect, that would produce and interfere with the bone interface or collapse the original defect resulting in a relapse.

Numerous perceived and suspected problems were associated with silicone gel breast implantation during the 30 years of use before the 1992 FDA moratorium. The lack of adequate safety data, the Food and Drug Agencies, requirement for such data to grant pre market approval, and widespread product liability litigation has, since that time, resulted in a proliferation of research on implant performance, silicone materials, properties, and retrospective and prospective breast implant studies. To satisfy the desire by patients for augmentation, there has also been a dramatic interest in saline breast implantation in recent years concurrent with the widespread removal of gel implants from the market place. The problems will remain the same for saline breast implants, which are FDA approved. It is the objective of this report to provide an overview of inherent silicone gel and saline implant problems, especially to provide a perspective for future new and improved implant opportunities. The objective that has been identified and the center of the controversy is the manufacturing process for the silicone shell, its mechanical integrity, and longevity because it has not changed much.

A new technique is described to close myelomeningocele defects using a bilateral bipedicled flap on a newborn with this birth defect. The skin closure is performed after total closure of the neural tube and resection of the myelomeningocele, preserving as many neural elements as possible. The muscles are closed in a separate layer to provide stability to the back and lumbodorsal spine. The advantages of the bipedicled flaps are that their survival is eminent and the closure is performed in a tension-free fashion. The final outcome is most satisfactory. We have used this procedure with minimal complications in newborns for the past 25 years.

New bone formation has always captured the imagination and attention of bone surgeons. First, closing a defect was studied, followed by creating a defect and closing it surgically. Regeneration of bone is scientifically sound and is achieved by distraction, stretching, or induction. Bone healing enhancers in the form of bioactive bone substitutes that can crystallize already have been used. Bone grafts continue to be the “workhorse” of all skeletal repairs.

The use of bone grafts is the basis of all craniofacial surgery. Bone grafts are used to stabilize the open segments, expand the patient’s structural boundaries, and fill defects created by trauma or congenital malformations. Bone grafts are harvested from local or distant sites as indicated. Biomaterial implants are used as bone substitutes when it is not possible to use bone grafts.

Bone graft surgery is the basis of all craniofacial surgery. The use of bone grafts in the craniofacial region has changed from a basic trial-and-error concept of surgical triumph to the understanding of the fundamental concepts of bone healing and bone physiology. The search for the super graft continues, and may become a reality before the end of the millennium.

The silicone crisis led to the prompt, somewhat hasty, clinical implementation of new fillers in breast implants. Although promising improved biocompatibility and radiolucency, these fillers generated severe “unpredicted” adverse effects which led to the need for immediate explantation of the Trilucent breast implant and the recall of the hydrogel-filled breast implants. Silicone is known to be a chemically inert substance, and multiple studies have since failed to prove any adverse effects directly related to its chemical interaction with tissue. 18–21 In view of the long-term experience with the application of silicone gel in breast implants since 1962, we can conclude that no better alternative material for breast implant fillers is currently available. Past experience with the application of new fillers for breast implants has pointed at the necessity for immediate implementation of the international breast implant registry (IBIR) as a safety assessment and postmarketing surveillance.

The future direction of plastic surgery is very encouraging compared to that of other surgical specialties, especially considering the shift that has occurred in health care delivery systems. Some educators and health planners believe that an over-production of specialists consequently results in a decrease in the cost of care. However, the cost of cosmetic surgery is actually increasing, and because the free-enterprise fee-for-service system of payment has been preserved in this field, cosmetic surgery has a lucrative future for its practitioners. Additionally, because practitioners interested in cosmetic surgery increasingly are not following the traditional path of education in plastic surgery, a balanced, dual practice of cosmetic surgery and reconstructive surgery has developed.

The next millennium will witness the most exciting advances in the field of plastic surgery. Some of these advances are already here today whereas others are just starting to surface. These include soft-tissue and bone reconstruction, tissue engineering, gene therapy, microsurgery, and fetal surgery to name just a few. Fetal wound healing may become a major part of intervention for correction of certain birth defects. Plastic surgery will continue to work with other specialities to solve clinical problems. Innovative techniques and other modalities will continue to rise in plastic surgery.

A method of restoring bony contour defects in the craniofacial regions employing a combination graft of autogenous bone and an alloplastic mesh is presented. Osteoinduction occurs within the confines of the alloplastic mesh from the cancellous bone and the resultant new bone conforms to the outline imposed by the alloplastic device. The advantages of this method include those of alloplastic materials combined with those of bone grafting. There is immediate restoration of an aesthetic contour with adequate strength and sound fixation.

The family of a 10-month-old black girl with a large periocular congenital melanocytic nevus (CMN) was given markedly differing advice from experienced physicians regarding how the lesion should be managed. The nevus was eventually removed surgically because of concern about the risk of malignant transformation and because of its cosmetic appearance. Histologically, the lesion was a dermal nevus, but extended deeply into subcutaneous tissue and had neuroid features. The ultrastructural characteristics of melanocytes varied according to the depth at which they resided, but cells did not differ basically from melanocytes found in smaller acquired nevi. Given the limited understanding of the biologic basis for malignant transformation, large size remains the most important risk factor in CMN.

A method of reconstructing contour defects, including stress-bearing bones, employing particulate cancellous bone for bone induction in a composite alloplastic device of polyethylene terephthalate mesh cloth impregnated with polyether urethane has been described.

C ollaboration between plastic surgeons and maxillofacial prothodontists has resulted in existing knowledge concerning the use of prefabricated silicone implants in facial reconstructi0n.l. 2 Silicone offers a high degree of biocompatibility with acceptability and “pseudotake” by the biologic systems.“‘” These implants have been custom-made to fit facial defects I5 that result from surgical ablation, trauma, or congenital anomalies or from surgical reconstruction of the bony frame when there is irregularity or overlapping of the reconstructed segment in certain congenital deformities.14, lG. Ii Prefabricated, custom-made silicone implants arc superior to commercially made implants, because they are manufactured to fit the individual defect-the defect does not have to adapt itself to the implant.‘:’ This advantage is of particular interest in the facial region, where there is limitation of soft tissue spaces and where the surgeon cannot stretch the tight spaces for subdermal alloplastic buildup. The facial skin merely covers the bony skeleton: cutaneous redundancy comes only with old age. Silicone implants, therefore, provide the best alternative to autogenous grafts, in which the prolonged intraoperative time needed for carving is an added disadvantage. The satisfactory results obtained with the use of silicone rubber have led to its wide application in reconstruction of facial deformities. Silicone is the best biocompatible, inert, nontoxic, noncarcinogenic, alloplastic material known today. It is widely used in other parts of the body (e.g., in the mammary region) and as the epoxy of pacemakers. Long-term follow-up has not revealed any untoward effects related to toxicity or carcin0genicity.l” The implants do not undergo any significant chemical changes with time; a minimal fibroblastic reaction surrounds the implant and leads to a thin film, or pseudocapsu1e.l” No foreign body reaction has been demonstrated in the vicinity of the implants.‘” We have been, therefore, encouraged in the use of this material. To date, we have

One hundred twenty-three control subjects and fifty-two caucasian female patients with cancer of the breast were typed for thirteen HL-A antigens. The frequency of the antigen HL-A7 and of haplotypes bearing this antigen were significantly higher in the group with cancer. HL-A7 positivity may be associated with increased susceptibility to cancer of the breast.

An unusual case of two primary tumors of the facial region is presented. Successful treatment was effected by radical resection and x-irradiation therapy. The deformity that resulted was absence of the hemimandible. This was corrected with a custom-made mandible, which gave a functional as well as an esthetic result.

The lateral nasal gland is surgically accessible, its duct readily cannulated and its secretory output can be easily collected, thus providing a means of monitoring the thermoregulatory response of the dog to either varying environmental conditions, or to change that is due to internal and pharmacological manipulations.

An unusual case of blowout fracture of the orbit is presented. The possibility of massive surgical mediastinal emphysema has not been well pointed out in the literature previously nor has it been associated with pure blowout fractures. The mechanisms of its development have been explained and other causes of mediastinal emphysema eliminated. In the traumatized patient with blowout fractures, this may possibly be an associated finding. A plausible but unsubstantiated explanation was offered for the bradycardia and hypotension that were present during the massive subcutaneous emphysema around the neck.

A simple trocar with inner canula is used in limited exposure sites for transcutaneous drilling. The trocar has an outer cannula which allows the special "air-powered" drill tip to pass through for transcutaneous interosseous drilling. No complications have been encountered by its use on numerous occasions.