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Two major problems in maxillocraniofacial surgery are the limited amount of fresh autogenous bone, the standard material for bone grafting, and the resorption of the grafted bone. Experimental studies with demineralized, devitalized bone matrix have shown induction of endochondral ossification. Fifty-five demineralized allogeneic implants have been used in 44 patients over the past two years for a variety of congenital (n = 37) and acquired (n = 7) defects. The allogeneic bone was obtained from cadavers, prepared as powders, chips or blocks, and was demineralized. After having been sterilized by irradiation, they were used to augment contour, fill defects, or construct bone within soft tissue. Of implanted sites that could be evaluated by physical examination, 31 of 31 were solid by three months. By radiographic examination three of 19 were healed by three months, and an additional 11 were positive by six months. Induced bone was seen in four of four biopsy specimens. Infection occurred in four of 44 patients (9%), comparable with conventional grafts. Implant resorption occurred in four instances. Allogeneic demineralized implants offer several advantages over conventional bone grafting, such as avoidance of a harvesting operation, ease of manipulation, and potentially unlimited material in banked form. In addition, healing by induced osteogenesis may bypass the resorption seen with healing of mineral-containing grafts.

In 1983, we evaluated the stability of midface position after Le Fort III advancement for midface hypoplasia secondary to Crouzon's or Apert's syndromes. The patients were operated upon from 1972 to 1980, and mean follow-up was 5.8 years (Kaban et al, 1984). In this study, we present an additional 3 1/2 year follow-up of these patients to look at what happens to midface position after Le Fort III osteotomy in growing and nongrowing patients.

A child with duplicate maxilla is presented, along with a review of the literature of similar cases. Partial duplications of the maxilla are frequently accompanied by cleft lip and palate, multiple uvulae, hypertelorbitism, and intracranial anomalies with hydrocephalus. Theories of the morphopathogenesis for this malformation sequence are discussed.

A retrospective study of 122 facial fractures in 109 children, under 16 years of age, is reported. The data are analyzed in terms of fracture type, sex, age, etiology, therapy, and complications.

The possibility of venous air embolism exists whenever the craniofacial operative field is above the level of the heart. Craniotomy with the high-torque craniotome is hypothesized to have produced venous air embolism in the patient described in this report. The diagnosis of venous air embolism is determined by transesophageal Doppler probe, transesophageal echocardiogram or external echocardiogram, and end-tidal N2 and CO2 determinations. Treatment includes control of the air entry sites, aspiration of air from the right atrium via a catheter placed prior to operation, and discontinuing nitrous oxide. If these measures are unsuccessful, the operative field should be transposed below heart level and the procedure terminated. In the event of significant hemodynamic compromise, closed cardiac massage should be tried; if that fails, open cardiac massage and direct aspiration are necessary. The true incidence of venous air embolism in craniofacial operations may be much higher than previously suspected. We therefore recommend placement of appropriate monitoring equipment to detect intracardiac air in those major craniofacial procedures in which there is a potential for intravascular air ingress.

Of 42 patients who underwent cosmetic surgery, 4 patients, who gave no indication of an impending life change before surgery, obtained a legal separation or divorce 3-6 months later. These 4 patients had had strong parental domination and hostile relationships with younger siblings; they had a need for success on their own terms and for the rapid closure of potential conflict. The authors suggest that such patients are undergoing significant identity changes that become conscious only after cosmetic surgery, which tests out their shift from passivity and withdrawal to activity and participation.

A patient with a repaired upper lip cleft may acquire a deformity in the lower lip. Records of 63 cleft lip patients who exhibited lower-lip abnormalities were analyzed in order to characterize the soft-tissue and skeletal configuration. The typical deformity was a hypertrophied, superiorly displaced, and anteriorly rotated lower lip. Skeletal analysis of the mandible revealed a variable and inconsistent degree of vertical elongation with posterior displacement of the chin. Operative correction of the cleft lip lower-lip deformity required evaluation of both the soft-tissue and skeletal abnormalities. Soft-tissue procedures gave permanent correction, provided there was a normal maxillary-mandibular relationship. Skeletal correction alone did not completely rectify the abnormal lower-lip posture.

This is a follow-up study of 20 children who had surgical correction of hemifacial microsomia in an effort to improve facial growth and minimize secondary distortion. In group 1 (skeletal types I and IIA), 10 children underwent elongation and lengthening of the mandible. In group 2 (skeletal types IIB and III), 10 children had total construction of a new temporomandibular joint and mandibular ramus with rib grafts and costochondral junction. In both groups, an open bite was created on the affected side to provide space for tooth eruption and downward growth of the middle face. The mean follow-up was 50.9 months (18 to 117 months) in group 1 and 45 months (18 to 50 months) in group 2. Analysis of our early results showed that all patients have had downward growth of the midface on the affected side. All five patients in group 1, followed to complete closure of the surgically created open bite, have maintained a level occlusal plane. In group 2, the one patient followed to completion of facial growth continues to have a level occlusal plane and facial symmetry. Appropriately timed mandibular construction and/or elongation in children with hemifacial microsomia is safe and effective. There is a decrease in secondary deformity on the affected side, and the eventual overall facial growth is optimized. Some group 2 children will need secondary elongation and augmentation of the mandible. Nevertheless, this study demonstrates that early mandibular correction may obviate the need for maxillary and orbital procedures in adulthood.

Complex orthopedic and craniofacial surgical procedures have stimulated renewed interest in the physiology of bone grafting. The experimental and clinical evidence that a nonvital implant can stimulate local host cells to become bone-forming cells (osteoinduction) is reviewed. Studies of induced osteogenesis were derived from old clinical observations of heterotopic ossification in scars and muscle. When demineralized bone is placed within soft tissues of a rat, a remarkable sequence of endochondral ossification occurs. In contrast, mineral-containing bone particles stimulate obligatory resorption by host mono- and multinucleated cells. The biochemical, endocrine, and physicochemical aspects of induced osteogenesis are actively being investigated. Present understanding of the mechanism of bone induction is discussed along with descriptions of preliminary clinical trials with allogeneic demineralized implants.

An instance of progressive vascular malformation is presented to illustrate the use of total circulatory arrest and to highlight the need for an understanding of the biologic factors of such lesions.

The following types of ocular dermoids were seen in a retrospective study of 50 children with these lesions: 34 epibulbar dermoids, 12 lipodermoids, and 4 dermoid cysts. Forty-six percent had hemifacial microsomia, and one-half of these had additional stigmata of the Goldenhar variant of the syndrome. Ninety-seven percent of the dermoids were found in the temporal half of the globe; of these, 76 percent were in the inferolateral quadrant, straddling the corneoscleral limbus. The majority of children had an oblique astigmatism in the involved eye. Epibulbar dermoids may be removed by careful superficial keratectomy, but caution should be exerted in excising lipodermoids because of the risks of affecting ocular motility and tear secretion.

An analysis of associated deformities in 74 patients with isolated microtia is reported. Microtia should be considered a microform of hemifacial microsomia because of similar (1) asymmetrical nature of the defects, (2) incidence and pattern of seventh nerve paresis, (3) correlation of the degree of seventh nerve weakness with grade of auricular deformity and not with the severity of mandibular hypoplasia, (4) right-sided preponderance, (5) incidence of associated cleft lip and palate, (6) male predilection, and (7) equivocal mode of inheritance. These clinical observations confirm the concept that microtia and hemifacial microsomia have the same etiopathogenesis which is not shared by mandibulofacial dysostosis.

We report a patient with tuberous sclerosis who had chronic bleeding from the fibrous papules on his face. Dermabrasion and local excision of these was a simple and effective treatment. Follow-up at one year is reported.

Five hundred and eighty birthmarks were reviewed; 356 were hemangiomas and 224 were malformations. Bony alterations occurred in association with only 1 percent of hemangiomas, in contrast with 34 percent of patients with vascular malformations. These alterations in bone development were classified according to size, shape, and density changes. Hypertrophy and distortion were typical of lymphatic malformations. Hypoplasia and demineralization were characteristic findings in the extremity venous malformations. Destructive and intraosseous changes were more commonly noted in the arterial or high-flow lesions. Possible mechanisms of altered skeletal growth include mechanical, physiological, and developmental processes.