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A rare case of malignant schwannoma is described. The patient's main presentation was that of pain. The patient had no other symptom, particularly that related to the space-occupying lesion in the skull base that also was filling the pterygoid space. A 5-year cure was achieved by combined therapy of radiation and radical surgery. The rarity of these cases makes it impossible to do a comparative analysis including randomized clinical trials for outcome studies to find the optimal treatment for each patient.

This report demonstrates further experience in the use of the absorbable plating system since our preliminary report in 1996. We found more indications for the application of the absorbable plating system in the craniofacial skeleton in children and in covering cranial bone graft donor sites. The system is unique, the applications are widespread over the horizon, and the only limitations are those of the operating surgeon. The advantage is that in 1 year the system absorbs completely by hydrolysis, giving minimal inflammatory reaction at the site.

Microsurgical dissection of cadaver facial nerves revealed quantifiable complexities not presented in standard description. Total branches, intraparotid connections between divisions, and extraparotid connections between divisions are more common than generally noted, and 33% of the dissections demonstrated an extraplanar buccal branch originating within the parotid gland, and innervating the perioral muscles. These details of facial nerve anatomy suggest surgical procedures such as tumor resection, facial nerve reconstruction, facial reanimation, and facelifting.

A new generation of absorbable plating systems is used in a clinical setting. This new system represents state of the art innovation in biomaterial experimental design, demonstrating total absorption in one year, and well-achieved fixation of the skeleton.

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.

Bone regeneration by distraction has become an accepted method for correction of congenital and acquired deformities. Unifocal bone generation is discussed as a technical note to demonstrate its feasibility in craniofacial surgery. The technique is simplified by the reorientation of the apparatus used, and the distraction is performed over a period of time to achieve a balance in the facial skeleton. Orthodontic elastics are used to balance the occlusion.

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.

Osteoradionecrosis (ORN) of the skull is a rare but fatal complication of radiation therapy for the treatment of head and neck malignancies. The pathogenesis of ORN follows the "3Hs Theory" proposed by Marx (J Oral Maxillofac Surg 1983;41:283-288) in which radiation induces tissue injury by causing vessel thrombosis (hypovascularity), which leads to hypoxia, and results in cell death of the skin and the underlying structure of the bony element (hypocellularity) including the deep visceral structures. This note details a patient with severe and extensive ORN of the parietooccipital region of the skull because of a large dose of radiation therapy for the treatment of an invasive basal cell carcinoma of the scalp. The patient's condition was further complicated by an extensive infection with methicillin-resistant Staphylococcus aureus, which leads to meningitis and cerebral edema as well as cerebritis. The patient was successfully treated with interdisciplinary medical and surgical aggressive therapy and radical procedures involving 4 separate trips to the operating room for an 18-month period. Success was achieved because of early clinical diagnosis of ORN, aggressive eradication of infected and necrotic tissues including the brain, and restoration of functioning and viable tissues through the use of local flaps to change an open wound to a closed wound.

Brånemark osseointegrated implants were used in combination with a cranial bone graft that was harvested from the outer table of the skull in a patient with a discontinuity defect of the anterior aspect of the mandible. First, a staged procedure allowed reconstruction of the defect. The second stage was placement of the Brånemark osseointegrated implant fixtures, followed by contouring the interior genial area by adding more bone grafts. The initial stabilization was done with an adoption plate that was used to stabilize the mandibular fragments during the healing phase. This plate was subsequently removed when the osseointegrated implants were placed. The patient had a full course of oral rehabilitation and a satisfactory final outcome.

To enhance the safety of the patient a controlled depth (CD) osteotomy cutter was designed. The power-oriented depth controlled osteotomy cutter (PODCO) was developed and used in patients and infants craniofacial surgery. As the power equipment was technologically advanced, a new design allowed us to keep the same principle with a technologically advanced cutter. The new 1 mm cutter allows the surgeon to dial in the desired depth so that the osteotomy can be performed with precision and enhanced safety to the patient.

For us as surgeons, we are moving from the stages of the cleft palate speech, which is focused to nothing more than a hole closure that will require the skill of flap creation so that everything else will fall in the right place, to going beyond the hole closure and having the vision of what really entails in cognition and expressed language. The Bflap wars[ are still going as seen on the copies of the published journals and in meetings all around the globe. What affects the outcome is the developmental status of the patient, the age of the individual under the evaluation, the cognitive skill, and now the genetic constituency of the system of operation that is driving the patient’s ability to speak in a balanced way without acquiring any abnormalities. As children mature, they develop the ability to use the instinct and mentation through genetically driven and environmentally influenced actions and reactions. Specific loci in the brain related to cognitive functions and control language. In humans, the process of well-mastered communication skills starts before age 6 months and progresses gradually so that, with appropriate stimulation, education, and cognition, competent receptive and expressive language is achieved by 6 years of age. Needed for mastering expressive language, commonly called speech, are able and appropriate anatomical structures that support the cognitive skills required to mature in a normal fashion. It all starts with babbling at age 2 to 3 months and proceeds slowly until age 6 years when the mastery of the expressive language is significant. That process cannot be interrupted at any time within the rapid development. Knowing the aspects of this major function along came certain surgeons treating patients with anatomical deficiencies, a hole as a congenital deformity, the cleft palate, claiming that the surgical procedures they do are what make those patients speak well. The beginning of the flap wars was almost a century old. Also, on the other hand, for some who feel that it is imperative how the patients speak, other anatomical configuration takes better priorities. Then came other interested, powerful colleagues claiming that pretty faces should take early priority because these affect the dentition of the patient, whereas speech recognition and expression should take second priority because it can always be learned. Others, the so-called masters of the trade, claim that they can correct speech abnormalities at any age any time, giving a normal balanced speech. With all of that in conflict, in came the protocols based on dogma, not science. Statistics that are made to support a point raised more complexities about the speech issue. I recall some places around the world where patients were brought in to show the protocol being instituted at their center and followed up for many years to the point. They were in their late teens, claiming they had normal facial growth. When we asked the patients questions, we found that they had poor communication skills and severe nasal emission, and they were unable to pursue progress in cognition and expressive language, while experiencing problems with their schooling. It would have been interesting to know, if the patients could speak well, what their own perceptions of their appearance were at that time. What we have is fallout from dogma shown over and over in widespread arenas, an international phenomenon. After careful thought and carefully studying the data, we started early repair in patients who have deficiencies due to clefts. We gave them anatomical structures to start their early speech and to get, as nearly normal as possible, superior functional expressive language by the time they reach age 6 years. It is unimaginable that, in a number of centers, the protocol requires that the anatomical defect in structures necessary for intelligible speech be left unrepaired until age 6 or 8 years, when the protocol for the physiological mechanism of said children is to have by that year mastered their expression of language. Some claim they can correct any speech problem they find, including glottic stops, but this is not in agreement with most speech pathologists at present. Another problem is targeting populations. The claim is that patients who have Pierre Robin anomalad, if repaired early, will have sudden infant death syndrome, as if sudden infant death syndrome were an association of palatal congenital deformity. That is part of a dogma that has no initiation, no foundation, and no statistical evidence to support its validity. Hundreds of youngsters affected with this common congenital deformity today experience tangential effects in their function. With appropriate skills based on adequate anatomical structure repair, the child can use and acquire communicative skills early in life. Unfortunately, some practitioners follow the dogma because it is carried from book to book, without question of validity. Thus, without looking at outcome data, what has transpired, and new advances that have come to the forefront, dogma remains, although some may be nothing more than witchcraft rather then true science. Now, we all know that local tissue flaps alone do not make patients speak well. The important point is to put the muscles together so that the myofunctional physiology is regained; also, ensure that they continue their musculature innervations appropriately to make sure that they function properly. For that reason, it is known that an early 3-layer closure to bring the mucosa together SPECIAL EDITORIAL

The "forceful" and macho look of a prototypical man may not be unduly appealing to others whom he meets. This "forceful" look might not even appeal to the individual himself. In order to soften this appearance, a series of operative procedures has been devised for use on the craniofacial skeleton. These surgical steps can be done in a single operation or as a series of multiple operative procedures. Moreover, the needs of some patients may require that only special segments of these procedures be performed. This article presents these operative procedures and describes the feasibility with which they can be performed. Complications and unfavorable outcomes, when they occur, are usually related to unrealistic expectations on the part of the patient. The surgical steps routinely performed are those that contour the forehead, orbits, malar eminence, cheeks, chin, angle of the mandible, and larynx. Three categories of patients are described: the female with a male face; the male with a "forceful look"; and the patient requesting a gender identity change. The psychosocial, psychological, and behavioral problems leading to the decision for surgery will be the basis of final patient selection.