Grafted fat has many attributes of an ideal filler, but the results, like those of any procedure, are technique dependent. Fat grafting remains shrouded in the stigma of variable results experienced by most plastic surgeons when they first graft fat. However, many who originally reported failure eventually report success after altering their methods of harvesting, refinement, and placement. Many surgeons have refined their techniques to obtain long-term survival and volume replacement with grafted fat. They have observed that transplanted fat not only adjusts facial and body proportion but also improves surrounding tissues into which the fat is placed. They have noted not only the improvement in the quality of aging skin and scars but also a remarkable improvement in conditions such as radiation damage, chronic ulceration, breast capsular contracture, and damaged vocal cords. The mechanism of fat graft survival is not clear, and the role of adipose-derived stem cells and preadipocytes in fat survival remains to be determined. Early research has indicated the possible involvement of more undifferentiated cells in some of the observed effects of fat grafting on surrounding tissues. Of particular interest is the research that has pointed to the use of stem cells to repair and even to become bone, cartilage, muscle, blood vessels, nerves, and skin. Further studies are essential to understand grafted fat tissue.

Structural fat grafting: more than a permanent filler.

British authors are the natural heirs to Charles Dickens and Graham Greene.) Nevertheless there are advantages to British readers in a British book especially, for instance, in the chapter on social paediatrics and occasionally as regards therapeutics. The new Forfar and Arneil is, like its predecessors, a good book. There are many new authors and much of it has been completely rewritten. Each chapter has a long list of references, many of them to further reading in books and important 'landmark' papers rather than to very recent original work, and that seems appropriate for a textbook of this nature. It is up to date, including references to topics such as oesophageal pH monitoring in gastrooesophageal reflux, the value of steroids in bacterial meningitis, a full account of the peroxisomal disorders, the significance of dystrophin in muscular dystrophy, the importance of vitamin A in reducing mortality in third world countries, and the use of sumatriptan in migraine and of vigabatrin and lamotrigine in epilepsy. Surprisingly, neither in this nor in Nelson's textbook could I find any reference to Angelman's syndrome. Some topics chosen at random such as Prader-Willi syndrome or haemolytic uraemic syndrome were discussed more fully in the British textbook. There is a surprising omission, however, and that is the chapter on disorders ofear, nose, and throat. Adenoids, glue ear or secretory otitis media, tonsillitis, and tonsillectomy have all been dropped from the index and deafness is dealt with in the chapter on neurology. If you look up 'tonsils' you will be referred to any entry which reads: 'Tonsils: size, presence of infection, exudate, pitting, peritonsillar swelling?'. The index entry 'ear, nose and throat problems' refers to a brief account of such problems in children with cleft palate. It is one of those crazy facts of modern life that the American book costs £60, the British £125. Who will read this new edition? I shall, and I suppose many other consultant paediatricians will also use it as a standard reference book. Undergraduate students will need a more compact text for their basic reading but should use it to look up specific topics, and doctors studying for the MRCP in paediatrics should make a systematic assault on it to provide them with a personal database to be supplemented by journals and monographs. As a textbook of British paediatrics it has no competition and it remains an excellent work of reference which must be available in all paediatric departments in Britain, but the absence of the chapter on ear, nose, and throat disorders must surely be an error and there is clearly a marketing problem for British publishers faced with American competition. If we want British textbooks, and I would not like to think that the time will be forced upon us when we shall have no choice, then it looks as if we must be prepared to pay for the privilege. DOUG ADDY Consultant paediatrician

https://adc.bmj.com/content/archdischild/68/3/435.2.full.pdf

Syndromes of the Head and Neck

The treatment of delayed unions, malunions, and nonunions requires restoration of alignment, stable fixation, and in many cases adjunctive measures such as bone-grafting or use of bone-graft substitutes.Bone-graft materials usually have one or more components: an osteoconductive matrix, which suppor

Bone-grafting and bone-graft substitutes.

Introduction: Cranio-maxillofacial trauma management requires pertinent documentation. Using a large computerized database, injury surveillance and research data describe the whole spectrum of injuries. The goal of this study was to assess the effect of the five main causes of accidents resulting in facial injury on the severity of cranio-maxillofacial trauma. Patients and Methods: During a period of 10 years (1991-2000) 9543 patients were admitted to the Department of Oral and Maxillofacial Surgery, University Hospital of Innsbruck with cranio-maxillofacial trauma. Data of patients were prospectively recorded including cause of injury, age and gender, type of injury, injury mechanisms, location and frequency of soft tissue injuries, dentoalveolar trauma, facial bone fractures and concomitant injuries. Statistical analyses performed included descriptive analysis, chi square test, Fisher's exact test, and Mann-Whitney's U test. This was followed by logistic regression analyses for the three injury types to determine the impact of the five main causes on the type of injury at different ages in facial trauma patients. Results: Five major categories/mechanisms of injury existed: in 3613 (38%) cases it was activity of daily life, in 2991 (31%) sports, 1170 (12%) violence, in 1116 (12%) traffic accidents, in 504 (5%) work accidents and in 149 (2%) other causes. A total of 3578 patients (37.5%) had 7061 facial bone fractures, 4763 patients (49.9%) suffered from 6237 dentoalveolar, and 5968 patients (62.5%) from 7769 soft tissue injuries. Gender distribution showed an overall male-to-female ratio of 2.1 to 1 and the mean age was 25.8±19.9 years; but both varied greatly depending on the injury mechanism (facial bone fractures: 35.4±19.5 years, higher risk for males; soft tissue injuries: 28.7±20.5, no gender preference; dentoalveolar trauma: 18±15.6, elevated risk for females). For patients sustaining facial trauma, logistic regression analyses revealed increased risks for facial bone fractures (225%), soft tissue lesions (58%) in patients involved in traffic accidents, and dental trauma (49%) during activities of daily life and play accidents. When compared with other causes, the probability of suffering soft tissue injuries and dental trauma, but not facial bone fractures, is higher in sports-related accidents, 12 and 16%, respectively. Conclusion: This study differentiated between injury mechanisms in cranio-maxillofacial trauma. The specially trained surgeons treating cranio-maxillofacial trauma are the primary source of information for the public and legislators on implementing preventive measures for high-risk activities. In facial trauma, older persons are prone to bone fractures (increase of 4.4%/year of age) and soft tissue injuries (increase of 2%/year of age) while younger persons are more susceptible to dentoalveolar trauma (decrease of 4.5%/year of age).

Cranio-maxillofacial trauma: a 10 year review of 9,543 cases with 21,067 injuries.

I. Introduction II. Maternal Physiology and Pathophysiology During Pregnancy A. Maternal adaptive goals during pregnancy B. Mineral ions and calcitropic hormones C. Intestinal absorption of calcium D. Renal handling of calcium E. Skeletal calcium metabolism F. Primary hyperparathyroidism G. Hypoparathyroidism and pseudohypopara- thyroidism H. Summary III. Fetal-Placental Physiology and Pathophysiology A. Fetal adaptive goals B. Mineral ions and calcitropic hormones C. Fetal-placental calcium transport D. Renal handling of calcium and the amniotic fluid E. Skeletal calcium metabolism F. Fetal response to maternal hyper- or hypoparathy-roidism G. Integrated fetal calcium homeostasis H. Summary IV. Maternal Physiology and Pathophysiology During Lactation A. Maternal adaptive goals during lactation B. Mineral ions and calcitropic hormones C. Intestinal absorption of calcium D. Renal handling of calcium E. Skeletal calcium metabolism F. Hypoparathyroidism and pseudohypoparathy- roidism G. Summary V. Neonatal P...

/pdf/maternal-fetal-calcium-and-bone-metabolism-during-pregnancy-1u8014xtio.pdf

Maternal-fetal calcium and bone metabolism during pregnancy, puerperium, and lactation.

The groin flap

A total of 207 patients with hemangiomas, vascular malformations, and lymphovenous malformations were treated by the same surgeon from 1980 to 1990. Thirty-seven patients with true hemangiomas underwent surgical treatment. Only those hemangiomas which caused functional or developmental disturbances or those with complications were treated; many more were allowed to regress spontaneously. Sixty-five patients with low-flow and 16 with high-flow vascular malformations were treated by using a variety of surgical approaches. In low-flow lesions, sclerosant therapy can be extremely effective, either alone, in small lesions, or combined with surgical resection or embolization, in larger lesions. Preoperative embolization and surgical excision are the treatment of choice in high-flow malformations. Twenty-seven patients with lymphovenous malformations had only surgical excision with a high success rate. Sixty-two patients with acquired "senile hemangiomas" underwent a single local excision with excellent results. When indicated, angiography has been of great value as a diagnostic procedure to provide information about the vascular dynamics and the extent of these lesions, although magnetic resonance imaging is now being used more frequently for this purpose. Selective angiography also was used as a therapeutic modality when embolization was part of the treatment protocol. A new classification based on clinical, histologic, and vascular flow characteristics of these lesions has been used to simplify the present nomenclature and to help in selection of the most appropriate treatment. It has the added value of being in the language of the radiologist, who should be a member of the vascular anomalies team.

Hemangiomas, vascular malformations, and lymphovenous malformations: classification and methods of treatment.

Various materials have been proposed for cranial reconstruction. Bone autograft and alloplasts such as polymethylmethacrylate (PMMA) and hydroxyapatite (HA) cement are most commonly used at the present time. Patients submitted for cranioplasty were evaluated. The prognostic factors influencing the results and the outcome were analyzed. Three hundred twelve patients who had 449 procedures performed by a single surgeon to reconstruct a calvarial deformity between 1981 and 2001 were studied. Post-tumor resection deformity was the main reason for cranioplasty (32.4%). Bone graft was the material of choice (69.5%). The main surgical site was the frontal bone (53.2%). Complications were observed in 23.6% of cases and were responsible for the least satisfactory results (P > 0.001), with infection and material exposure being the most critical complications. The eventual outcome was considered good in 91.8% of cases. The use of HA cement was associated with the worst results (P > 0.001). Bone grafts showed a high grade of partial resorption and required further surgery for correction. Multiple surgical procedures were correlated with a high rate of complications and an unsatisfactory outcome. Bone graft and PMMA are still the best materials in calvarial reconstruction. Even though HA cement is an osteoconductive material, it seems to induce what appears to be an immunoguided delayed inflammatory reaction that leads to thinning of the skin and exposure of the material, making secondary repair difficult. Before deciding which reconstructive option to use, a careful evaluation of the patient in terms of diagnosis, number of previous surgeries, and surgical site should be undertaken. If this is adopted, good results and a satisfactory outcome can be achieved on long-term follow-up.

Clinical Outcome in Cranioplasty: Critical Review in Long-Term Follow-Up

We report the experiences in 6 major craniofacial centers, with similar teams but in different parts of the world, in a total of 793 craniofacial operations. The mortality rate was 1.6%. Complications developed in 16.5% of the cases (including infections in 4.4%). This surgery has many potential advantages, not least of which is its psychosocial effects on previously disfigured patients. Certain problems seem inherent, however, for there are not yet any satisfactory solutions to them. Some of the factors that reduce morbidity and improve results include the use of hypotensive anesthesia, a reduction in operating time, rigid stabilization of the mobilized bones at the end of the operation, a diminution in the number of incisions, and extensive antibiotic therapy.

Combined report of problems and complications in 793 craniofacial operations.

The purpose of this study was to investigate enophthalmos by measuring the volume of various orbital structures using off-line computer techniques on images generated by a CT scanner. Eleven patients with enophthalmos had CT scans of the orbits consisting of 30 to 40 adjacent 1.5-mm slices. The data from the scans were analyzed on a Nova 830 stand-alone computer system using software programs that allowed measurement of total bony orbital volume, total soft-tissue volume, globe volume, orbital fat volume, neuromuscular tissue volume, and apex-to-globe distance in the horizontal plane. These data were analyzed comparing the volumes in the normal eye with the volumes in the enophthalmic eye in each patient. The analysis demonstrated a statistically significant increase in bony orbital volume in the enophthalmic eye, but the total soft-tissue volume, fat volume, neuromuscular tissue volume, and globe volume were the same as in the normal eye. The apex-to-globe distance, a measure of the degree of enophthalmos, was less in the enophthalmic eye than in the normal eye. These results suggest that in the majority of patients, the cause of posttraumatic enophthalmos is increased bony orbital volume rather than by soft-tissue loss or fat necrosis. (Several patients showed no volume discrepancies, and it is likely that cicatricial contracture is responsible for the enophthalmos in these cases.) This study suggests that the objective of surgery for correction of enophthalmos in patients with a volume discrepancy should be to decrease the volume of the bony orbit and to increase the anterior projection of the globe.

Ian T. Jackson

Papers

The groin flap

Hemangiomas, vascular malformations, and lymphovenous malformations: classification and methods of treatment.

Clinical Outcome in Cranioplasty: Critical Review in Long-Term Follow-Up

Combined report of problems and complications in 793 craniofacial operations.

Orbital volume measurements in enophthalmos using three-dimensional CT imaging.