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There are various artificial skin substitutes available commercially. The authors have used Integra, cultured epithelium, and Apligraf in their clinic. In the present report, they present their experiences based on two case reports. The first patient was a 12-year-old boy with widespread skin defects and left axillary contracture due to epidermolysis bullosa (EB). Apligraf was used to cover the skin defects on the trunk and face and to manage ectropion and axillary contracture. The second patient was a 6-year-old boy who suffered neurocutaneous melanosis. Partial excision of a pigmented lesion on the back created a large defect. Integra application followed by repair with cultured autologous skin was accomplished, and the results were satisfactory. Skin substitute products 1) are commercially immediately available; 2) are effective for management of contractures, chronic wounds, and chronic skin illnesses; 3) decrease or avoid the risk of donor area morbidity, which is more difficult to treat in children; 4) provide long-term coverage of the wound; and 5) can be used in conjunction with autologous tissue (e.g., Integra followed by cultured epithelium applications).

This article describes Paul Tessier's influence on craniofacial surgeons and their treatment of facial trauma. It also outlines his direct contributions to primary and late treatment of facial fractures.

This is a review of mechanisms that contribute to testis-specific transcription of the histone H1t gene.The mammalian testis-specific histone H1t gene is transcribed only in primary spermatocytes during spermatogenesis. Linker histones bind to DNA and contribute to chromatin condensation by formation of the 30 nm chromatin fiber. Furthermore, linker histones contribute to regulation of transcription of specific genes. Histone H1t, which binds more weakly to DNA than the other six known linker histones, is expressed in cells that are involved in the essential processes of crossing over and mismatch repair of DNA and in cells that undergo a dramatic alteration in gene expression. However, contributions of this linker histone to these processes are unknown. Subtle differences are found in the H1t promoter compared to the other H1 promoters. Nevertheless, several lines of evidence support the hypothesis that a sequence element designated TE that is located within the H1t promoter is essential for enhanced testis-specific transcription of this gene. Transgenic mice bearing a rat H1t transgene which contains a replacement of the TE element with stuffer DNA fail to express rat H1t mRNA. In addition, an upstream sequence appears to function as a silencer element that leads to transcriptional repression of the H1t gene in nongerminal cells. Thus, multiple promoter elements appear to contribute to regulation of transcription of the histone H1t gene.

This study was undertaken to determine the incidence of serious neurologic injury associated with the harvesting of cranial bone grafts. A personal series of 1000 consecutive bone-grant harvestings (cranial, iliac, costal, tibial, and mandibular) was examined in detail for complications. Then a survey of members of the International Society of Craniofacial Surgeons was performed, and data were compiled on complications of bone-graft harvestings performed by the respondents. Data also were compiled on neurologic complications related to cranial bone-graft harvestings performed by other surgeons which the respondents were aware of through direct personal knowledge, medicolegal review, the medical literature, or other channels. No neurologic complications were associated with any of the 586 cranial bone grafts taken in the authors' series. The survey respondents reported that they had performed 12,672 cranial bone-graft harvestings. Temporary neurologic complications were associated with graft harvesting in 3 cases (0.02 percent). The respondents also identified 8 other neurologic complications (4 permanent and 4 temporary) associated with cranial bone-graft harvestings performed by other surgeons. Five cases were performed by surgeons having little or no experience in harvesting cranial bone grafts, and three were performed by surgeons having only limited training. It appears that cranial bone grafts can be harvested with an extremely low incidence of serious complications by surgeons who have had proper training. Techniques are suggested for safe harvesting of cranial bone grafts, as well as for detecting and managing complications when they arise.

Various methods of nasal lengthening presented in the literature are discussed, including extensive skin undermining, provision of extra skin by forehead flaps, bone grafts, cartilage grafts to the nasal tip, extensive dissection of nasal lining, and buccal flaps to provide additional nasal lining. This paper describes a method that entails a nasofrontal osteotomy and mobilization of previous fractures in posttraumatic foreshortened noses and a perinasal osteotomy (Le Fort II minus Le Fort I) in congenitally short noses such as seen in Binder's syndrome. Nine posttraumatic and two congenital short noses have been treated in this manner without complication. The procedure draws on experience in craniofacial surgery, where there is a nasofrontal osteotomy and division of lining in extracranial Le Fort II and III osteotomies with insertion of an interpositional bone graft. This method is recommended for markedly foreshortened noses of either traumatic or congenital origin.

The results of 32 patients who underwent transcranial monobloc frontofacial advancement by the senior author (Wolfe) are examined. Fifteen of the patients were Crouzon's, and 17 were Apert's, 14 of whom also underwent simultaneous facial bipartition. The ages ranged from 7 months to 14 years. Although a transcranial facial advancement carries with it substantial risks, with careful consideration of airway control, the anterior cranial base dura, and the retrofrontal dead space, the procedure is recommended for carefully selected patients. The indications and contraindications for the procedure in various age groups are given

The plastic surgeon performing blepharoplasty should maintain a high degree of surveillance for the presence of exophthalmos. Exophthalmos may be masked by the presence of eyelid compensations and substantial amounts of eyelid fat. The surgeon should know how to detect the condition and measure its extent.

A variety of methods are available for malar augmentation using autogenous material, and the choice of procedure will depend on the indications presented by each particular case. The ability to produce a smooth natural contour without the need for concern of late problems is a decided advantage to the use of autogenous tissue. We have presented a compendium of available methods, demonstrated clinical examples and described a new technique, which, because of its simplicity, will certainly find further applications. A new method developed by Paul Tessier for malar augmentation is also described.

A method is described for staging the transfer of a tube pedicle from the chest to the head by means of a preliminary attachment to the postauricular region. The advantages of this method are that it increases the range of the pedicle, provides a delay or at least a proof of the vascularity of the distal portion of the flap at the same time as the inset, and prevents downward gravitational pull on the pedicle and limitation of the patient's cervical motion, which have been difficulties with chest pedicles in the past.

A 92-year-old man has had multiple recurrent oncocytic tumors involving the right paranasal sinuses and orbit. A benign oncocytoma that arose from the right lacrimal sac was initially diagnosed at age 80 years. The tumor recurred at 3 and 7 years after initial resection. There was greater histologie atypia in the first recurrent tumor, which extended into the right paranasal sinuses. The second recurrence had zones of oncocytic adenocarcinoma exhibiting prominent nuclear atypia and mitotic activity; this tumor massively invaded the right paranasal sinuses and orbit. We describe the clinical and pathologic features of this rare case.

A historical review of our perception of facial flatness and convexity and what constitutes "a pleasing face," both in North America and internationally, is provided. Attractive faces may range from slightly flat ("Apollonian") to mildly bimaxillary protrusive, but marked deviations in either direction, from the dish face to extreme bimaxillary protrusion, constitute a deformation and warrant combined orthodontic and surgical treatment. Technical aspects of segmental and total maxillary setback are presented, along with four representative cases.

Sixty-seven surgeons, members of the International Craniofacial Surgery Society, responded to a questionnaire focused on assessing the incidence and risk of cranial plate and screw translocation intracranially in infants undergoing cranial surgery. Despite screws, plates, and wires being evident intracranially in individual cases, no apparent increase in seizure frequency or susceptibility to head trauma was noted in this preliminary study.

The buccal fat pad is an anatomically complex structure that has great importance in facial contour. In properly selected individuals, judicious harvesting of buccal fat can produce dramatic changes in facial appearance by reducing the fullness of the cheek and highlighting the malar eminences. Using fresh cadaver dissection, the anatomy of the buccal fat pad is delineated and its relationship to the masticatory space, facial nerve, and parotid duct is defined. An intraoral approach for buccal fat harvesting is described based on these anatomic findings. Clinical experience manipulating the buccal fat pad for aesthetic modification of facial contour is illustrated.

Analysis of a series of 85 temporalis muscle flaps performed in 81 patients is presented. The flaps were used in a wide range of locations ranging from intracranial to mandible and for a large variety of diagnostic categories. A detailed examination of the indications and use of the muscle for cranial base and palatal defects is provided. The amount of muscle used varied considerably from 10 to 90 percent. Complications associated with the use of the temporal muscle included a 2.4 percent total flap failure rate and a 9.4 percent minor complication rate. When greater than half the muscle was used, temporal hollowing, the principal donor defect, was imperceptible (39 percent) or mild (46 percent) in a majority of patients and severe in only a few (16 percent). Recommendations for prevention and treatment of this contour deformity are discussed in depth.

The evolution of craniofacial surgery has been interdependent on the development of anesthesia techniques and preoperative and postoperative care. Many of the procedures are relatively simple, but it is important to adhere to the details in performing them. If the principles presented here are followed, it will be possible to avoid many of the serious complications that occurred previously.

An overview of the various methods available for treatment of mandibular fractures is presented; these range from the application of arch bars and intermaxillary fixation alone to open reduction with compression plating. Whenever possible, particularly in young patients, mandibular fractures requiring open reduction are approached transorally.

The anatomy of the temporal region, with reference to the frontal branch of the facial nerve, was examined in 12 fresh cadaver dissections. In all dissections, the frontal branch traveled in a constant plane along the undersurface of the temporoparietal fascia and was quite superficial as it crossed the zygomatic arch. The deep temporal fascia and superficial temporal fat pad are anatomically important structures which adjoin the periosteum of the zygomatic arch and lie deep to the frontal nerve. Based on these relationships, a safe method of dissection within the temporal region is formulated.

It is believed that a variation of the 3-wall orbital expansion of Tessier can be used to correct persistent exophthalmos, as well as exorbitism. The operation is described, and the results in 3 patients are shown.

An approach to treatment of frontal sinus injuries is proposed. For injuries involving the anterior wall of the sinus in which the nasofrontal duct is patent, the anterior wall is reconstituted either primarily or using a bone graft. Injuries involving the posterior wall of the frontal sinus generally necessitate a craniotomy; the frontal sinus in these situations is cranialized and the nasofrontal duct is plugged. In primary injuries of the frontal sinus in which the nasofrontal duct is badly damaged but the posterior sinus wall intact and in late mucoceles or mucopyoceles, all sinus mucosa is stripped and the sinus is packed with cancellous bone. The authors feel that cancellous bone is a better material than fat with which to pack a sinus, particularly in the face of active infection. Three cases are presented in which infected mucopyoceles draining to the skin were treated with removal of all sinus mucosa and packing with cancellous bone, with primary healing.

Abnormal bleeding after a face lift was found to be due to a profound interference in platelet function caused by clofibrate and xylocaine acting synergistically. This did not appear to be an idiosyncratic reaction to either of the drugs, as it could be reproduced in vitro by using platelets from normal individuals. Clofibrate is a drug used commonly by persons in the age group requesting face lifts. Beware.

A limited experience (27 patients, all female) is presented utilizing the subcutaneous approach to forehead lifting. This approach has been little utilized and has been condemned in the literature for being dangerous. However, no difficulties in wound healing or alopecia have been encountered, and the procedure has the advantages of more effectively removing the vertical and transverse wrinkles in the glabellar region, raising the brows, and preserving sensation to the scalp posterior to the incision.

Our experience with the omental flap for facial soft-tissue augmentation in 7 patients is presented, along with our method of fixation of the graft to prevent gravitational descent. The history of the omental free flap, as well as the previously applied techniques for facial soft-tissue augmentation, is reviewed. It is our conclusion that the omental free flap is a safe, reliable technique. It can be readily molded to exactly conform to the patient's deformity and produces good results both in repose and during facial expression. We believe that gravitational descent of the graft can be prevented by the technique of multiple-suture fixation.

A long-standing lower eyelid deformity associated with a displaced alloplastic orbital floor implant was corrected by an orbicularis oculi muscle flap from the upper eyelid, a nasal chondromucosal graft, and a pericranial sling. Removal of the displaced acrylic implant and replacement with an autogenous bone graft also corrected the patient's diplopia.

An extension of the "crane" principle is presented for use in compound frontal defects, and several case histories are described. The procedure would obviously not be possible if a foreign material had been used for the osseous defects, since take of the skin graft depends on circulation through the autogenous bone graft.

A case is presented in which a unilateral "orbital decompression" had been previously performed, down-fracturing the orbital floor and in-fracturing the medial orbital wall. Because of persistent bilateral exophthalmos, a four-wall orbital expansion was performed. Orbital volume determinations were made before and after the second procedure, making it possible to compare the effects of the two operations.