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A 12-YEAR-OLD GIRL INVOLVED IN A MOTOR VEHICLE crash is transported to a district hospital in subSaharan Africa with a femur fracture and splenic laceration. Because resources and surgical personnel are limited, resuscitation efforts for the injured girl are inadequate. However, governments, the World Health Organization (WHO), funding agencies, and international nongovernmental organizations (NGOs) are beginning to reassess the importance of surgical services in developing countries and to prioritize the support, resources, training, and workforce required. Global surgical initiatives are hindered by the lack of data reflecting the magnitude of the unmet need. In this Viewpoint, we (1) describe the progress of global surgery initiatives, (2) delineate research priorities, (3) review metrics that assess the cost-effectiveness of surgical services, and (4) discuss approaches to building surgical capacity to reduce the global surgical burden of disease.

To introduce and analyze suction-assisted analysis of nasal valve strength in functional septorhinoplasty. This is a novel method for helping the surgeon analyze the integrity of a patient's airway during surgery.In this prospective study, 20 patients who underwent functional septorhinoplasty were analyzed. Negative pressure using suction tubing was placed at the nasal sill, and measurements of the amount of maximal depression of the nasal valve were performed in the operating room immediately before incision and immediately after closure of the incisions.All 20 patients had an immediate decrease in the deviation of the weakest point of the valve, with a mean change of 2.14 mm. The change on both sides was statistically significant (paired t test, P.001). This novel method helped the surgeons decide which grafts provided the most immediate structural benefit.Structure-based septorhinoplasty can immediately improve the strength of the nasal valve. Suction-assisted analysis of the nasal valve can be a useful "real-time" tool for determining which maneuvers improve the strength of the nasal valve.

The use of autologous bone for head and neck reconstruction requires a separate harvesting procedure which provides limited quantities of bone that may become infected or undergo resorption after being implanted. In this study, a collagen/ceramic carrier containing osteoinductive factor extract (OFE) was used in a rabbit facial augmentation model. Bone-inducing activity of these implants were evaluated in subcutaneous, intramuscular, and subperiosteal sites. Implants with (test) and without OFE (control) were placed on opposite sides of the face in 40 rabbits, and were harvested at 21 days. Bone formation was evaluated by implant alkaline phosphatase determinations and histomorphometry. Osteoblastic activity, bone formation, and preservation of facial augmentation were noted in the OFE implants, showing maximal bone formation when implanted subperiosteally. Control (no OFE) and demineralized bone implants showed no bone formation. Before these implants can be used clinically, novel bone-inducing factors must be manufactured by recombinant deoxyribonucleic acid (DNA) methodology to verify activity of the homogeneous molecule which would be free of other proteins or infectious agents.

• The effectiveness of local anesthetics is improved by the addition of a vasoconstrictor with an increased duration of action and the ability to decrease both systemic toxic reactions and local bleeding. Epinephrine, the standard drug for vasoconstriction, has some limitations due to potential cardiac and local toxic effects. Using an animal model, we compared the effects of various concentrations of epinephrine and two other vasoconstrictors, phenylephrine hydrochloride and felypressin, on local blood flow. We also examined the local effects of bupivacaine hydrochloride and ropivacaine hydrochloride, a new local anesthetic. We found that felypressin was as effective a vasoconstrictor as epinephrine, with fewer potential toxic reactions. Phenylephrine (Neo-Synephrine), on the other hand, was less effective, with a shorter duration of action. As expected, bupivacaine produced vasodilation, while ropivacaine was found to have vasoconstrictive properties. ( Arch Otolaryngol Head Neck Surg . 1991;117:160-163)

• Keloids and hypertrophic scars are characterized by excessive collagen formation. Interferon gamma is a lymphokine that can down-regulate collagen synthesis in vitro and in vivo and, therefore, has potential therapeutic benefit in the management of abnormal scars. Intralesional scar injections of interferon gamma were performed to determine the tolerance toxicity and to obtain preliminary evidence for the efficacy of this treatment in the management of hypertropic and keloid lesions. All scars decreased in linear dimensions and flattened out. Five of 10 scars studied decreased at least 50% in linear dimensions. Interferon gamma can safely be administered intralesionally once per week up to a dosage of 0.05 mg for 10 weeks with no serious toxic effects. The commonest reported side effect was a mild headache. ( Arch Otolaryngol Head Neck Surg . 1990;116:1159-1162)

Patients with facial paralysis have a degree of lagophthalmos and paralytic ectropion. We present our experience in the surgical management of 25 consecutive patients treated for these problems. Paralytic lagophthalmos was corrected using gold weights inserted into the upper eyelid. The advantages and disadvantages of this surgical technique are reviewed. Medial canthoplasty and lateral canthoplasty were performed to rectify paralytic ectropion. Ancillary procedures included browpexy, upper-lid blepharoplasty, and temporalis sling. The results were excellent in 23 of 25 patients and good in the remaining two. After a minimum of 6 months' follow-up, there were no complications. The authors believe that the above procedures will yield consistently excellent cosmetic and functional results in patients with paralysis of the eyelids.

What is facial beauty? Scientists, artists, facial plastic surgeons, and many in the beauty industry have attempted with little success to define it. We do know it is a reasonably objective quality: for example, even 2-month-old infants prefer to look at faces that adults see as attractive.1Recent scientific studies have expanded our knowledge of beauty and its biological basis.

Medicine is of all the Arts the most noble; but owing to the ignorance of those who practice it, and of those who, inconsiderately, form a judgement of them, it is at present far behind all the other arts.—Hippocrates, The Law by 'health' is meant a personal state of well-being, not just the availability of health services—a state of health that enables a person to lead a socially and economically productive life. . . .—Halfdan Mahler, Director General of the World Health Organization To the Editor .—Medicine is a profession that has always reflected the complexities and contradictions of the people and society in its historic time. Our art, insofar as we strive to meet the needs of patients (with our limited knowledge), is necessarily imperfect. Physicians, individually and as a group, make and have always made errors of judgment. Yarborough's article 1 "Collagen injection: a case study

The Ben Shuster Memorial award is presented for the most outstanding research paper in facial plastic and reconstructive surgery delivered by a resident or fellow at a national meeting. This year's award goes to Peter Costantino, MD, for his paper on "Evaluation of Hydroxyapatite Cement." Honorable mention goes to Dean Toriumi, MD, Chicago, Ill, for his paper, "The Quest for the Ideal Bone Inducing Implant." The Ira Tresley award recognizes the best original research in facial plastic surgery and was awarded to Lawrence P. A. Burgess, MD, Washington, DC, for his project, "Wound Healing: Relationship of Wound Closing Tension to Scar Width in Rats." The Investigator Development award of the American Academy of Facial Plastic and Reconstructive Surgery supports the work of a young faculty member conducting significant research in facial plastic surgery in the training of residents. This award was presented to Daniel Kuriloff, MD, Ann Arbor, Mich, for

The Ben Shuster Memorial Award is presented for the most outstanding research paper on any clinical work or research in facial plastic and reconstructive surgery delivered at a national meeting (or its equivalent) between March 1, 1988, and February 28, 1989, by a resident or fel Dennis H. Kraus, MD low. Each entrant must be the sole or senior author and also an Academy member. Studies prepared during the first year after completion of residency training will be considered, provided research was conducted during the author's resident program or fellowship. This year the Ben Shuster Memorial Award went to Dennis H. Kraus, MD, Cleveland, Ohio, for his paper entitled, "Prevention of Hair Growth in Myocutaneous Flap Reconstruction."—

In Reply .—We thank Drs Kersten and Kulwin for their comments. Our article contained a description of the surgical technique for ptosis repair in conjunction with blepharoplasty, but, as we stated, "ophthalmologic consultation is recommended in the initial workup of all patients with ptosis. In this way, the degree and type of ptosis may be redocumented and any other ocular abnormalities may also be noted." The main point of the authors' letter is that a test for ocular dominance should be included in the preoperative ophthalmologic evaluation of patients with ptosis. We would certainly agree with this recommendation. We have normally used the phenylephrine (Neo-Synephrine) test rather than the manual test they recommend. When phenylephrine eye drops are placed into the eye that is most ptotic, it will stimulate Muller's muscle, which will cause the ptotic lid to raise and unmask a ptosis on the contralateral side, if one is