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The use of hydroxyapatite in reconstructive surgery has been hampered by the fact that it is very slowly invaded by host tissues, a process that is critical to graft incorporation. Implant compatibility may be augmented by providing cellular binding sites and by seeding cells before implantation.Bone-forming cells were seeded onto hydroxyapatite disks, and precoated with fibronectin and fetal calf serum or phosphate-buffered saline. Cellular adhesion and proliferation was analyzed in vitro. For in vivo studies, experimental and control hydroxyapatite disks were seeded with green fluorescent protein-expressing cells and implanted into mice.Fibronectin/fetal calf serum pretreatment improved cell attachment and cell growth significantly in vitro. After 48 hours, experimental disks (n = 5) contained 2.8 times more attached cells than controls (p0.001), and after 7 days this difference had increased further (4.2 times) (p0.001). In the in vivo part of the study, sections from implants (n = 4) harvested 3 days after implantation demonstrated an average of 122 +/- 50 green fluorescent protein-labeled cells/mm in the fibronectin/fetal calf serum group compared with 85 +/- 21 cells/mm in the phosphate-buffered saline controls. After 10 days, the cells had in general decreased in number in both groups, but the relation in cell density was similar to the first time point (19 +/- 11 versus 12 +/- 11 cells/mm).In vitro attachment and proliferation of bone-forming cells on hydroxyapatite is significantly increased by pretreatment with fibronectin/fetal calf serum, but this difference is less profound and not significant in vivo.

Just before midnight on the 29 October 1998 the on-call plastic surgeons were alarmed because of a fire accident thought to involve a few burned patients. Quite soon the information suggested an in-door fire disaster in which many of the 400 young people visiting a disco were caught by a rapidly spreading fire. A cross-sectional survey of the resulting overload, triage and initial treatment of burns was analysed. Two-hundred and thirteen patients were transported to the four hospitals in Gothenburg area and a total of 150 were admitted as inpatients, 73 to Sahlgrenska University Hospital. The initial organisation at the scene of the fire was seriously inadequate because of incorrect information about the number of casualties. As there was no triage officer the principle of "scoop and run" was practised, placing the major burden on the receiving hospitals. The emergency disaster plan in our hospital was not launched, because of misinformation and lack of communication. Early documentation in emergency case books was incomplete as the whole organisation was overloaded. Intubation or tracheostomy and escharotomy at the intensive care unit were not delayed. Triage for transportation to burns units was adequate.

In the 10-year period 1986-1996, 85 patients were admitted to our unit with craniofacial injuries, 56 of whom had orbital fractures. These were studied with respect to the type of injury, type and location of fracture, presence of ocular and intracranial injury, and associated injuries to the head and body, as well as operative techniques used. Both the patient's and the surgeon's opinion on the aesthetic result were noted. The patients were also given a questionnaire about their quality of life after the injury. Road traffic crashes accounted for 31 (55%) of the injuries, falls for 9 (15%), and horse-riding for 6 (11%). The Injury Severity Score (ISS) ranged from 4 to 41 (mean 18). Twelve also had eye injuries, which resulted in complete blindness in one eye in 4 (7%). Thirty patients had 41 neurological injuries (54%), frontal contusions being the most frequent diagnosis (n = 15). Exact repositioning with rigid fixation included bone grafting to the orbit in 11 patients, and the dominating bone graft was split calvarium (n = 5). Forty-two patients completed a questionnaire, 26 of whom (64%) had no aesthetic complaints. Seven of the 42 were too disabled to work one year after the injury. Re-exploration was infrequent and the aesthetic outcome, both in the surgeon's and the patient's opinion, was good. However, the older the patient, the worse the outcome.

Since the beginning of craniofacial surgery, there has been an ongoing search for surgical techniques to enhance outcome while, at the same time, decreasing the invasiveness of the surgical treatment of craniofacial deformities. The purpose of this study was to test a recently reported minimally invasive treatment modality, the dynamic spring, in a rabbit calvarial model for efficacy and safety. Specifically, the results of spring cranioplasty on skull growth, the underlying brain, and adjacent bone were to be assessed. The study population consisted of 36 7-week-old New Zealand white rabbits. The rabbits were divided into four treatment groups (9 rabbits each): control, sham surgery, stainless steel springs, and memory metal springs. Postoperative analysis included weekly radiographs to evaluate movement of amalgam markers placed at standardized locations. Additionally, 16 rabbits (4 from each group) were killed at 14 days after surgery, and postmortem histological analysis was done. The remaining rabbits were followed until they were adults and were then killed and similarly analyzed. No morbidity or mortality occurred in the immediate perioperative period secondary to the surgery. Postmortem histological analysis of all study animals revealed no intracranial, subcutaneous, or skin infections and no technical complications related to the surgery. Statistical analysis using ANOVA and pair-wise comparisons between treatment groups revealed a statistically significant difference (P < 0.05) between the marker movement in the spring groups versus the sham and control groups. There were no significant differences between the sham and control groups or between the two spring groups. In conclusion, this study confirms the efficacy and safety of the dynamic spring in a rabbit model.

The aim of the present study was to evaluate the possibility of mobilizing calvarial bone with a fully implantable and bioresorbable device. The animal model used was the New Zealand white rabbit (n = 12). An island bone flap attached to the dura mater was created in the parietal region and amalgam markers were placed in this bone flap and in the ipsilateral frontal bone. In one group of six rabbits (group 1), a specially processed contractile 70L/ 30D,L polylactic acid plate, 15 X 6 X 0.6 mm, was attached to the island flap by one extremity, and to the fixed ipsilateral frontal bone by the other. In group 2 (control), no plate was added. Bone marker movement was followed with serial radiography. In group 1, there was a progressive reduction in mean marker distance over the first 48 hours, and stability thereafter. In group 2 (control), mean marker distance remained stable until the second postoperative week, after which time there was a slight increase until the end of the experimental period. At 4 weeks, the mean marker separation differed significantly between group 1 (mean, -3.62 mm; SD, 0.79 mm) and group 2 (mean, 0.34 mm; SD, 0.14 mm; p

Object. Brachycephaly is a characteristic feature of Apert syndrome. Traditional techniques of cranioplasty often fail to produce an acceptable morphological outcome in patients with this condition. In 1996 a new surgical procedure called “dynamic cranioplasty for brachycephaly” (DCB) was reported. The purpose of the present study was to analyze perioperative data and morphological long-term results in patients with the cranial vault deformity of Apert syndrome who were treated with DCB. Methods. Twelve patients have undergone surgery performed using this technique since its introduction in 1991 (mean duration of follow-up review 60.2 months). Eleven patients had bicoronal synostosis and one had a combined bicoronal—bilambdoid synostosis. Perioperative data and long-term evolution of skull shape visualized on serial cephalometric radiographs were analyzed and compared with normative data. Changes in mean skull proportions were evaluated using a two-tailed paired-samples t-test, with differences being considered significant for probability values less than 0.01. The mean operative blood transfusion was 136% of estimated red cell mass (ERCM) and the mean postoperative transfusion was 48% of ERCM. The mean operative time was 218 minutes. The duration of stay in the intensive care unit averaged 1.7 days and the mean hospital stay was 11.8 days. There were no incidences of mortality and few complications. An improvement in skull shape was achieved in all cases, with a change in the mean cephalic index from a preoperative value of 90 to a postoperative value of 78 (p = 0.000254). Conclusions. Dynamic cranioplasty for brachycephaly is a safe procedure, yielding high-quality morphological results in the treatment of brachycephaly in patients with Apert syndrome.

The aim of the study was to evaluate the modified pi-plasty procedure for the treatment of sagittal synostosis, assessing the issues of safety, complications, morphological outcome, and degree of parental satisfaction. A retrospective evaluation of 110 patients with nonsyndromal single suture sagittal synostosis operated on with the modified pi-plasty procedure was undertaken. Cephalometric radiographs were obtained preoperatively and postoperatively at ages 3 and 5 years in three standardized projections. The Cephalic Index and the Axial Width Ratio were determined and used as objective outcome measures. An evaluation of the radiographic digital markings was carried out using a Beaten Copper Score. A parental questionnaire was used to obtain a subjective esthetical outcome assessment. The patient population consisted of 76% boys and 24% girls with a 20% incidence of a positive familial history of craniosynostosis. The mean age at surgery was 7.73 months. Morbidity from the procedure was minimal and there were no mortalities. The Cephalic Index changed from a mean preoperative value of 65% to a postoperative mean value of 72% (P = 0.00004). The mean Axial Width Ratio changed from a preoperative 80% to 72% at the 3-year evaluation (P = 0.00029). The Beaten Copper score changed from a mean preoperative value of 2.35 to 5.42 postoperatively at 3 years (P = 0.00001). The response rate to the questionnaire was 86%, and there were significant postoperative improvements in all studied aspects of the skull shape. The modified pi-plasty is a safe technique, and it induces significant objective changes in skull morphology toward normality. It also yields a high degree of parental satisfaction with regard to aesthetic outcome, as evaluated by a written questionnaire.

A prospective developmental assessment was performed on 26 patients operated on with dynamic cranioplasty for sagittal synostosis. Because this technique entails the application of compressive force, it was of great concern to assess the effect of surgery on development and mental status. The surgical technique used was a modified pi procedure. Perioperative variables were recorded. Six patients underwent preoperative intracranial pressure (ICP) measurements. To evaluate objectively the developmental outcome, the Griffiths' Mental Development Scales was used for analysis before and after surgery. A parental questionnaire was used for subjective outcome measurement. Preoperative ICP recordings during sleep ranged from 12.8 to 22.8 mmHg (mean, 16.1 mmHg). The mean age at the time for surgery was 6.9 months (range, 4-16 months; standard deviation [SD], 2.32 months). The surgical technique included shortening of the anteroposterior diameter of the skull by a mean of 16.6 mm. The mean global development quotient (GDQ) preoperatively was 104.5 (range, 82-144; SD, 12.4) and the mean GDQ postoperatively was 101.4 (range, 62-129; SD, 13.6). Mean age at follow-up was 16.3 months (range, 9-40 months; SD, 4.04 months). There was no significant correlation between the amount of intraoperative shortening and mental development. In comparison of means, the GDQ preoperatively did not differ significantly from the GDQ postoperatively. The modified pi procedure is safe and efficient. When surgery was performed before 1 year of age, no significant (p = 0.33) effect on mental development-either detrimental or beneficial-was demonstrated.

We followed up 10 patients whose non-syndromal bicoronal synostosis had been operated on with a dynamic cranioplasty technique developed by this craniofacial unit in 1992. With this technique, the growth of the brain is redirected in an anteroposterior direction as wire-mediated compression and restraint are exerted on the transverse and vertical dimensions of the skull. The mean operating time was 160 minutes (range 120-275) and mean stay in the intensive care unit was 36 hours (range 23-58). There was no operative mortality and few complications. The surgical results were assessed objectively by analysis of cephalometric tracings. The mean (SD) cephalic index was 87.6 (4.9) preoperatively and 77.7 (1.8) postoperatively (p = 0.001). The modified Whitaker scale was used as a subjective outcome measurement, and nine patients were classified as Whitaker grade 1 (no additional surgery). One patient required additional intracranial surgery. A questionnaire was sent to all families to obtain an additional subjective measurement of outcome. Parents' satisfaction was high. We conclude that dynamic cranioplasty is a safe and efficient operation for treatment of brachycephaly.

Fifty-four patients were studied a mean of five years after their breasts had been reconstructed between 1984 and 1990 using the lateral thoracodorsal (LTD) flap in combination with either a thin shell, non-low-bleed (n = 35) or a thick shell, low bleed (n = 19) silicone gel implant. The rate of capsular contracture (Baker III-IV) was 11% in the first group and 10% in the second according to a modified Baker classification. Open capsulotomy was common in both groups of patients (15/35 in the first group and 13/19 in the second). Investigation by applanation tonometry of the capsular contracture agreed with the modified Baker classification. The cosmetic results were evaluated clinically and from photographs. Best scores were recorded for scars and ptosis in both evaluations. There were no significant differences between the general cosmetic results in the two groups. The patients graded their estimations of the final outcome of their breast reconstruction on a 10-point visual analogue scale (VAS); the mean for the first group was 8.7 and for the second 9.2. None of the patients regretted her operation and they would all recommend the procedure to another patient.

With the inception of craniofacial surgery elaborate surgical procedures were introduced for the treatment of craniosynostosis. Recently the use of implantable springs to aid simple strip craniectomies for these conditions has been described. Having shown the feasibility of using springs for dynamic skull reshaping, several questions remain to be answered, all of them about how to control the spring action clinically. One of the most important questions concerns force. The purpose of this study was to evaluate experimentally the effect of two springs of different strengths on the growth of rabbit calvaria after strip craniectomy. Thirty-two 6-week-old rabbits were randomised into one of four groups: sham-operation where only amalgam markers were inserted after subperiostal dissection; strip craniectomy of the sagittal suture, no expansion; strip craniectomy of the sagittal suture and insertion of an expander element made of titanium molybdenum alloy (TMA); and strip craniectomy sagittal suture and insertion of an expander element made of stainless steel (SS). SS springs delivered a range of forces from 2.42-2.18 N, whereas the TMA expander elements delivered a range from 1.39-1.09 N. The parietal bone marker separation after 12 weeks was 4.9 mm in the TMA group and 7.4 mm in the SS group. This resulted in a significant increase of the calvarian height compared with control groups. Histological examination showed intramembranous bone formation in the bone gap in all groups.

To analyse how male cases suffering from lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH) are handled within a well-defined health-care region in Scandinavia, an interactive computer program containing 20 cases suffering from LUTS due to BPH was used for recording the diagnostic process and the treatment decisions; 37 out of a total of 50 urologists practicing within a small health region participated. The diagnostic process varied considerably due to a varying choice of diagnostic tests and the large differences in interpreting the qualities described by the tests. The probability that a patient would be offered a treatment within the region was analysed. For many patients the probability that a treatment was chosen was in the vicinity of 50%. No treatment probability was correlated to the symptom score of the patients. While the probability that a transurethral prostatic resection would be offered to the patients within the region was correlated significantly to urodynamic variables, residual urine and to cystoscopy findings, the probability that transurethral microwave or finasteride therapy would be offered was not correlated to any of the described qualities. The costs of the diagnostic process in all the patients incurred by each of the urologists varied by up to 500%. It was estimated that approximately 40% of the costs involved diagnostic tests that did not influence the decision to offer or not to offer treatment. In conclusion, the enormous variations in the handling of the cases recorded in the study stress the need that a management formula should be used in the handling of patients with LUTS.

Introduction: While several studies report that bone morphogenetic proteins (BMPs) and vascular endothelial growth factor (VEGF) can act synergistically to improve bone tissue engineering, others suggest that VEGF inhibits osteogenesis. The purpose of these experiments was therefore to evaluate the effect of dual transfection of these growth factors and potential mechanisms of interaction on gene expression and osteogenesis in vitro and in vivo. Methods: Marrow-derived mesenchymal stem cells (MSCs) were exposed to recombinant VEGF protein or transfected with adenoviruses encoding BMP2, VEGF, or LacZ in a variety of ratios. Alterations in gene and protein expression in vitro as well as bone formation in vivo were assessed. Results: MSC exposure to AdV-VEGF or recombinant VEGF inhibited BMP2 mRNA expression, protein production, and MSC differentiation. Coculture experiments revealed that BMP2 suppression occurs through both an autocrine and a paracrine mechanism, occurring at the transcriptional level. Compared to controls, cotransfection of VEGF and BMP2 transgenes prevented ectopic bone formation in vivo. Conclusion: VEGF is a potent inhibitor of BMP2 expression in MSCs, and supplementation or overexpression of VEGF inhibits osteogenesis in vitro and ectopic bone formation in vivo. Strategies to utilize MSCs in bone tissue engineering therefore require careful optimization and precise delivery of growth factors for maximal bone formation.

Background Growth inhibition of the ossification center, "the external trabecular network," would result in localized hypoplasia of nasomaxillary structures, resulting in the typical features of the Binder syndrome patient, with the retracted columella/lip junction and a lack of the normal triangular flare in the lower part of the columella. This study focused on a long-term follow-up of more than 5 years for three different grafting techniques. Methods Ninety-two patients with Binder syndrome were subjects for consecutive reconstructive plastic surgery between 1972 and 1995. The primary surgical approach was degloving the midface subperiosteally, and reconstruction was identical but differed in the grafts used: septum repositioning (n = 26), L-shaped bone graft (n = 51), or L-shaped cartilage graft (n = 15). Anthropometric variables on digitalized profile photographs were used. Results The angle of convexity of the face at the tip of the nose (glabella-pronasale-pogonion) improved in all three groups from 155 to 158 degrees to 144 to 149 degrees at the short-term follow-up and to 148 to 149 degrees at the long-term follow-up. The nasolabial angle changed, from a narrow angle of 76 to 88 degrees in all groups before surgery, to 100 to 106 degrees at the long-term follow-up after surgery. Conclusions The L-shaped bone graft was favorably used in the depressed nasal dorsum, whereas frontal repositioning of the septum was optimal when the upper part of the nose was considered normal. The consistency in tip projection for all groups over time may be explained by the extensive surgical release of the soft tissues before grafting.

Maxillonasal dysplasia is characterized by a concave facial profile and a flat nose. The etiology of Binder syndrome is skeletal hypoplasia around the piriform aperture and excavations-fossae prenasales, bilaterally in the nasal floor-which are pathognomonic. There is no real shortage of the soft tissues. In 2 medical centers in Sweden and Mexico, different grafts were used for reconstruction, but the focus was similar, filling out the maxilla anterior to the nasal floor and supporting the nasal framework to normalize tip projection. The basis for this study was to compare the long-term results between bone grafts in Sweden and cartilage grafts in Mexico. Sixteen patients from both groups were available for long-term follow-up. Simplified digital analysis of anthropometric variables were performed in the short-term and long-term follow-ups. The Swedish group had primary at the mean age of 21.3 years, whereas mean follow-up period was 16.8 years later. The Mexican group had primary at the age of 13.6 years, and the follow-up period was 8.4 years. Secondary correction was necessary in 25% of the patients in the bone graft group (Sweden) and in 19% of patients in the cartilage group (Mexico). Bone grafts slightly relapsed in tip projection and remodeled to some extent in the nasolabial angle. Cartilage grafts showed stability in the tip projection quotients and resulted in a postoperative normalization of the nasolabial angle but developed a slight relapse between the short-term and long-term follow-ups. Both techniques were stable in nose tip-length ratio, and a normalization of anthropometric variables was demonstrated in all the long-term follow-ups. Both the bone and cartilage graft techniques at the 2 centers rendered the intended result of an increased and normalized angle of convexity of the face and nasal tip projection. An experience in the properties and behavior of either graft is necessary to get a long-term stable outcome.

Anecdotal studies have reported explosive tumor growth in patients with a history of squamous cell carcinoma after hyperbaric oxygen (HBO) treatment. Conflicting experimental results have followed. In this study, squamous cancer cells were subjected to daily HBO treatment. No difference in cellular proliferation was noted in vitro when comparing HBO and control treated cells (P = 0.534). Similarly, immunostaining for in vivo DNA synthesis failed to demonstrate any significant difference in the number of proliferating cells after treatment with HBO (P = 0.388). No significant difference in tumor volume or mass was found after in vivo implantation (P = 0.471). HBO was found to reduce tumor hypoxia, which trended towards significance when compared with controls (P = 0.057); however, there was no difference in serum VEGF levels or vessel ingrowth. Thus, even though HBO may reduce the levels of hypoxia within squamous cell tumors, it does not appear to enhance short-term growth or promote cellular proliferation or angiogenesis.

The aim of the present study was to evaluate in young animals the dynamics of calvarial bone healing when exposing a bone defect to continuous forces for up to 13 weeks. Six-week-old rabbits after a sagittal suture strip craniectomy were randomized for either of the following protocols: (1) no spring was applied (n 7); (2) a titanium-molybdenum alloy (TMA) lower-force spring was inserted across the craniectomy gap (n 9); (3) a stainless steel (SS) higher-force spring was applied (n 8), or (4) sham operation (n 8). Results showed that the surgically created calvarial bone gap was after 3 weeks kept widened both when a spring of lower force (TMA) and when a spring exerting a higher force (SS) was applied. At 6 weeks, none of the rabbits of the spring-exposed (2 and 3) groups had any bone bridging the gap, while bone bridging was visible in animals of the 2 groups (1 and 4) lacking springs. Strikingly enough, in both spring-treated groups, the surgically created defect was still after 13 weeks incompletely bridged by bone, interposed by connective tissue, most evidently in those exposed to higher forces (SS). In contrast, a normal sagittal suture enclosed by lamellar bone was seen in both the sham and the strip groups. We conclude that exposing a surgically created calvarial bone defect to continuous mechanical forces delayed the bridging of the bone defect by at least 13 weeks, even if the force exerted by either spring was very low. In any case, when a higher force (SS group) was applied, the bone reunion was efficiently prevented. No side effects were recognized.

The aim of this study was to compare the safety, morphological outcome, and degree of parental satisfaction of the new spring-mediated cranioplasty with those of the modified pi-plasty in the management of sagittal synostosis. Ten patients with non-syndromic sagittal synostosis treated with the spring-mediated cranioplasty were followed prospectively. A control group of 10 sex-matched patients operated on with the modified pi-plasty procedure was chosen. Cephalometric radiographs were obtained preoperatively and postoperatively at 1 year of age. Cephalic index, axial width ratio, length ratio, width ratio and height ratio were used as objective measures of outcome. Parents were sent a questionnaire to obtain a subjective aesthetic assessment of outcome. Significantly less blood replacement was required (p = 0.003), and shorter duration of postoperative anaesthesia (p = 0.030) and postoperative hospital stay (p = 0.013) were found in the spring-mediated cranioplasty group. There were no complications or deaths in either group. Also significant was the inter-group difference in the postoperative change in the height ratio (p = 0.030), the most change being seen in the spring group. The change in the subjective parental aesthetic evaluation of skull shape was significant in both groups. In conclusion, the spring-mediated procedure was morphologically more effective than the modified pi-plasty procedure in the management of sagittal synostosis with the additional benefits of less blood transfusion needed and shorter duration of hospital stay.

The aim of this study was to characterise the preoperative morphology of the skull in sagittal synostosis in an objective and quantified way. The shapes of the skulls of 105 patients with isolated premature synostosis of the sagittal suture (SS group) were studied and compared with those of a control group of 72 children with unilateral incomplete cleft lip (UICL). A standardised radiocephalometric technique was used to obtain the images. A modification of a method developed by Kreiborg was used to analyse the radiocephalograms, which included the digitisation of 88 landmarks in the calvaria, skull base, and orbit (42 in the lateral and 46 in the frontal projections), the production of plots of mean shape for each group, and the intergroup comparison of a series of 81 variables (linear distance between selected landmarks, and angles defined by groups of three landmarks). Data from a subgroup of 66 patients aged 5 to 8 months were further compared to age-matched normative data in terms of seven angular and linear calvarial, cranial base and orbital variables. In a comparative analysis of the mean lateral plots, the foreheads of the study group (SS) had a more pronounced anterior slope and were also more convex. The vertex area was located more anteriorly, and was less convex. The occipital curvature was more prominent. Analysis of the mean frontal plots revealed a lack in convexity and lateral projection of the upper parietal regions, as well as a lower location of the line of maximum skull width. Comparison of the mean values of an SS subgroup to age-matched normative data showed a longer (p