[A three-year aid program for plastic surgery in Peshawar (Pakistan). Ongoing management of severely injured patients of the Afghanistan war: 1,528 large operations, 5,171 smaller interventions, 15,932 patients examined]

Since 1980 Interplast Germany has sent many plastic surgeons to developing countries. In 1989 a new Interplast Germany program for helping Afghan refugees in Pakistan's Peshawar was started. The Federal Republic of Germany financed the first two years; thereafter, the European Community and Help supported the project. Twenty-four teams with 123 nurses, surgeons and anesthesiologists operated on 1,528 patients in two hospitals. In the same period 5,171 smaller operations have been performed and 15,932 patients have been examined. Low expense for the teams, good support by officials, and professional administration have made this project highly effective for 3 years.

Prospectives in cleft lip and palate repair

A recent focus on fetal surgery has raised the possibility of fetal cleft lip and palate repairs. Because of the fetus's marked plasticity, fetal repairs may have results that more closely approximate normality. Furthermore, the impact on cost management could be dramatic with a decreased need for extensive postoperative care, orthodontia, and speech therapy. This article considers the future prospects of intrauterine cleft lip repair as the next generation of surgical advances.

General surgery, the general surgical subspecialties, and prerequisite training

Currently, several specialties (cardiothoracic, pediatric, and colorectal) require a full general surgery residency before specialty training. Plastic surgery has, in essence, a de facto requirement since most residents have had at least 5 years of general surgery training before initiation of a plastic surgery residency. Forces within both general surgery and plastic surgery will dictate that such a de facto requirement will not persist in the future. The pressures that compel plastic surgery to modify the traditional role of general surgery as preparatory training for requisite or specialty residency training can be extended by analogy to the other specialties as well. This article will hypothesize that the premises and the conclusions about the relationship between plastic surgery and general surgery apply equally well to the other specialties. If the traditional and historical role of full general surgery residency as prerequisite training for a specialty residency is discarded, careful thought must be given to any substitute system to graduate surgical education. In particular, attention must be directed to the three components of clinical skills to be acquired and to an expectation of operative or technical experience.

Care of maxillofacial injuries: survey of plastic surgeons

The purpose of this survey was to evaluate the current trends in the care of facial trauma. Data were obtained through the responses of a survey mailed to all those members and candidates listed in the 1989 American Society of Plastic and Reconstructive Surgeons Directory. A total of 2777 questionnaires were sent, with 1113 (40 percent) returned by means of a self-addressed envelope. Demographic results show that over 70 percent of the treating plastic surgeons fall within the age range 30 to 50 years. Although significant advances have occurred, treatment goals have remained unchanged. These center around the principles of accurate reduction and precise stabilization of fracture segments. The results of this survey reveal that a number of acceptable techniques were employed in the surgical repair of mandibular and zygomatic complex fractures. In the care of Le Fort III fractures, 59 percent of the respondents preferred the use of miniplates and screws for stabilization. Only 26.8 percent believed that facial fracture repair should be performed within the initial 24 hours. With frontal sinus fractures, the vast majority of plastic surgeons (82.1 percent) obtained a neurosurgical consultation. When the posterior wall was involved, 45.6 percent favored removal of the sinus mucosa, 29.7 percent obliterated the frontal sinus with a variety of autogenous materials, while 20.5 percent preferred cranialization. In summary, this survey shows a wide variation in the practice of facial fracture management within the plastic surgical community.

Recent advances in surgical reconstruction of the gynecologic cancer patient

Despite significant advances in radiation oncology and chemotherapy, radical en bloc resection of pelvic tissue remains an important part of the armamentarium of the gynecologic oncologist. Total pelvic exenteration can be the only hope of women who failed more conservative therapy. The time has come where it is appropriate to employ temporary techniques in the discipline of reconstructive surgery to restore these women to an acceptable quality of life. It may be the next challenge for the pelvic surgeon to participate in such surgical reconstruction. This challenge is becoming an active part of the oncologic surgical practice in head and neck surgery, and in breast surgery. Reconstructive surgery of the vulva has been well described in the literature with the use of cutaneous and myocutaneous flaps, and it is beyond the scope of this paper to recount them here. This paper reviews the techniques that are available for reconstruction of a functional vagina, restoration of a functional rectum with elimination of colostomy, and reconstruction of a continent urostomy that will allow better physiologic protection of the upper renal tracts and improve the aesthetics of a urine ostomy bag.

Nasal trauma. Pathomechanics and surgical management of acute injuries

This article delineates the structural features of the nose and discusses the major patterns of nasal injury as seen in the cadaveric laboratory and in the setting of two large metropolitan surgical centers. Diagnostic methods are reviewed, including a test of structural integrity by digital compression. Methods of reduction, internal fixation, and techniques of grafting that include the use of overlay and underlay cantilevers complete the author's approach to nasal injury.

Developing concepts and treatment of complex maxillary fractures

The last decade has witnessed a tremendous evolution in the management of maxillary fractures--an evolution that mirrors an overall more aggressive contemporary approach to complex maxillofacial trauma. This article briefly reviews past contributions to the current management of these fractures, the author's approach to management, and the future of this continually improving field.

Gunshot wounds to the face. Current concepts

The primary goal in reconstructing a gunshot wound to the face is identical to that for a major injury of the hand or lower extremity: primary healing of the soft tissue. This prevents the cascade of soft-tissue infection, further delay in healing, bone graft infection, and soft-tissue contracture. Current craniofacial techniques and methods of fixation allow for concomitant bony reconstruction without compromising primary healing of the soft tissues. The result is not only that the soft tissue is healed but also that the original contour, stretch, and pliability are maintained. Once the soft tissue collapses around inadequate bony reconstruction, it is difficult to restore the original situation. Despite the techniques outlined, there is no substitute for sound surgical judgment. Inevitably, cases will arise when the ideal reconstruction cannot be performed because of other injuries, inappropriate initial management at referring institutions, or medical complications. Compromises are then required in the interest of the patient's overall care, with the knowledge that the best chance to restore the anatomy of the hard and soft tissue is in the first few days after the injury.