Mandibular reconstruction with vascularized iliac crest: a 10-year experience

Since 1978, 35 patients have undergone mandibular reconstruction with vascularized iliac crest. During this time, the technique of raising and shaping the iliac crest has undergone a series of modifications. Initially, osteocutaneous segments based first on the superficial circumflex iliac system and later on the deep circumflex iliac system were used. More recently, only the inner table of the ilium has been employed, and where intraoral lining is required, an ulnar forearm free flap has been added. Thirty-two patients were reconstructed successfully. Of the three anastomotic failures, one bony segment was able to survive as a free graft. There were no donor-site complications. With continued experience, operative morbidity has been minimized, while the technique has been modified to tailor the reconstruction to the specific requirements of the patient. It is concluded that vascularized iliac crest provides the most appropriate mandibular reconstruction for a range of congenital and acquired defects.

Hairline indicators of craniofacial clefts

The review of a complete series of Tessier craniofacial cleft patients presenting to the South Australian Cranio-facial Unit has identified within the hairline a regular marker of clefting. Tongue-like projections of the temporal and frontal hairline pointing in the direction of their respective clefts have been identified for Tessier clefts numbered 7 to 14. No hairline indicator was revealed in "southbound" clefts numbered 0 to 6 without "northbound" extension. The hairline markers of laterally and superiorly bound clefts are a complementary element of the Tessier classification system.

Speech results of cleft palate surgery: two methods of assessment

After 10 years' work in the area of cleft palate, we decided to assess the acceptability of the speech of the children concerned. To ensure objectivity, untrained listeners, who were not aware that they were listening to children with repaired cleft palate, were asked to evaluate the child's spontaneous speech by comparing it with the speech of three of that child's peers. The results suggested that the child spoke less acceptably than his peers. As our aim was to compare the child with his peers, a rank ordering was selected as a means of evaluation rather than absolute judgements, i.e. a rating scale. The tape recordings of the cleft repaired children were also assessed by a speech pathologist experienced in the management of these children. The results of this assessment were comparable with results obtained overseas. In the light of our findings, we suggest that peer group comparison by untrained "naïve listeners may be a useful adjunct to the traditional assessment by the speech pathologist.

Technical aspects of the cranio-facial approach to tumours of the orbit and skull base

During the period July 1980-August 1987, 21 patients required cranio-facial extension of conventional neurosurgical osteotomies for tumours of the skull base and orbit. Five different types of combined osteotomies are described. Their applications to the treatment of various tumours and the subsequent reconstructions are presented and discussed.

Helmet-induced skull base fracture in a motorcyclist

Observations after a fatal motorcycle accident suggested that the face bar of a full-face helmet may transmit an impacting force to the skull base via the chin strap and the mandibular rami and condyles, bypassing the energy-absorbing facial bones. If this mechanism is confirmed, the structural properties of these face bars will need to be reassessed.

Hemifacial microsomia: a multisystem classification

Variability of deformities in hemifacial microsomia has precluded the general acceptance of any classification based on one reference organ. We present a review of hemifacial microsomia classifications and propose a TNM-style multisystem classification. This alphanumeric coding system, SAT, provides cohesion to existing hemifacial microsomia classifications. The acronym SAT is derived as follows: S = skeletal, A = auricle, and T = soft tissue. There are five levels of skeletal deformity (S1 through S5), four levels of auricular deformity (A0 through A3), and three levels of soft-tissue deformity (T1 through T3). Hence a patient with minimal deformity would be classified S1A0T1, whereas a patient with the most severe deformity would be S5A3T3.

Craniofacial infection in 10 years of transcranial surgery

Infection following transcranial surgery may be devastating. A review of 170 transcranial operations is presented with a focus on postoperative infection and its relationship to patient age, preoperative microbiology, pattern of operation, length of operation, and the use of antibiotic prophylaxis. The overall postoperative infection rate was 6.5 percent, but the infection rate in adults (23.5 percent) was much higher than in children (2.2 percent). Higher infection rates were found in adults with craniofacial dysostoses undergoing lengthy frontofacial advancements which required tracheostomy airway management. The residual frontal extradural dead space following advancement in adults is a sanctuary to infecting organisms from the respiratory tract--especially Pseudomonas transferred from the tracheostomy site into the upper airway and intracranial dead space by ventilation forces. Operating times for patients who became infected were 2 1/2 hours longer than average operating times for transcranial operations. Preoperative microbiology of the craniofacial region was not a good predictor of subsequent infection. Recommendations include operative intervention at an early age, short preoperative hospital stay, antibiotic prophylaxis to include gram-negative cover, surgical measures to either fill or isolate the dead space, and strict tracheostomy care--preferably with the patient being barrier-nursed.

Frontoethmoidal meningoencephaloceles

Frontoethmoidal meningoencephaloceles constitute a well-defined clinical entity with remarkable epidemiologic peculiarities, being very prevalent in Southeast and Southern Asia, but relatively rare in Western Europe, Japan, Australia, and North America. They do not show an increased risk of recurrence in siblings and offspring, unlike other cephaloceles and neural tube defects generally, from which they should be distinguished. Combined craniofacial and neurosurgical operative treatment permits one-stage correction of the whole deformity, the associated hypertelorism being reduced by selective orbital translocation and the nasal deformity by rhinoplasty. In planning these procedures, three-dimensional CT scanning is very helpful. Although our experience is chiefly with cases referred in childhood, we have some experience with operations done in infancy and believe this to be the ideal age.

Long-term effects of incorporated lime and topdressed lime on the pH in the surface and subsurface of pasture soils

Soil profiles from limed and unlimed commercial pastures and from lime trials on pastures in the Crookwell district of the Southern Tablelands of New South Wales were sampled and pH measured at 2- or 5-cm intervals to depths ranging from 10 to 60 cm. A single application of lime (3.6-5.6 t/ha depending on the soil) incorporated into the surface 10 cm had a long-term effect and maintained pH above 5.5 in the top 30 cm for at least 12 years. Lime applied as a topdressing to soils on granite raised the pH by at least 0.2 pH units to a depth of 15 cm after 6 years. The depth affected was less on the heavier-textured basaltic soils and on the initially more acid sedimentary soils. There appears to be a role for top-dressing with lime to prevent subsurface acidity from developing under pastures and to correct it in the upper layers of light textured soils. The pH profiles from a given treatment were variable and highlighted the problem of obtaining a field measurement for soil pH that is representative of the plant's environment.

Genetic variability for manganese concentration in Phalaris aquatica growing in acid soil

High levels of manganese in forage can retard the growth of livestock. The feasibility of breeding for lower manganese concentration in shoots of phalaris was examined in a variable population growing in acid, manganiferous soil. Sampling leaves of a particular physiological age in a field-growing breeding population provided an adequate indicator of manganese concentrations in whole shoots. Significant family differences were demonstrated. When transferred to sand culture, high manganese selections maintained consistently higher tissue manganese concentrations than low manganese selections over a wide range of manganese treatments. However, the range of variation was much smaller than in the field. Inheritance of manganese concentration was studied in 52 field-grown half-sib families and their parents from the breeding population. Mean family leaf sample concentrations ranged from 179 to 331 8g Mn g-1. Narrow-sense heritability estimates were 0.72 from the half-sib analysis and 0.40 from the parent-offspring relation. The former estimate is considered the more accurate, because the parent-offspring estimate was depressed by high random variation in some parent means. The mean manganese concentration of the population is predicted to decrease by approximately 80 8g g-1 in each generation in which progeny are raised only from those 25% of plants with the lowest manganese concentration. Although this estimate may have been influenced by available soil aluminium, it indicates that breeding for lower manganese concentration in phalaris is feasible.

Fever without a focus

Bacteremia occurs in 3 to 4 percent of ambulatory young children with fever. Bacteremic children may not appear seriously ill or have an identifiable source of infection, but they are at risk of developing septic complications if they are not treated appropriately. The physician must be aware of clinical criteria that identify children at increased risk for unsuspected bacteremia. Careful management leads to a relatively safe and successful outcome.

Skeletal morphology of anterior encephaloceles defined through the use of three-dimensional reconstruction of computed tomography

We have used three-dimensional reconstruction of computed tomography to study the morphology of anterior encephaloceles. The findings based on living patients rather than cadaver specimens confirm previous findings suggesting 'blow out' defects which displace otherwise normal osseous structures.

New perspectives in the management of severe cranio-facial deformity

It is postulated that craniosynostosis is due to a growth abnormality in all or part of the cranial capsule. Release of the stenosed part in the first months of life will re-establish the balance between the rapidly growing brain and eye, and the cranial capsule. Three periods for operative treatment are described: early, intermediate and late. Only in the early period can operative treatment restore normal growth dynamics; in the late period the aim is correction of an established deformity. The relationship between cranial clefts and frontonasal encephaloceles is explored. If the space-occupying encephalocele is removed early, the distorted facial bones adopt a more normal position, whereas cranial clefts do not respond to early operation by remoulding. The treatment of the acquired deformities of acute cranio-facial trauma have taken on new perspectives with the application of the multi-disciplinary approach and surgical techniques developed in the treatment of congenital deformities resulting in considerable reduction in the period of hospitalisation.

The stability and potency of vaccines prepared from inactivated foot-and-mouth disease virus concentrates

The stability of 146S particles in concentrates of foot-and-mouth disease virus stored at 4 degrees C was similar to that of 146S particles in a conventional virus preparation. Proteolytic degradation of VPl was not observed in the stored conventional virus preparation or inhibitor-supplemented concentrate but was observed in a supplement-free concentrate. The potencies of vaccines made from the conventional and concentrated preparations and stored in parallel at 4 degrees C appeared to decrease after 16 weeks. The vaccines made from the supplement-free concentrate and the Trasylol supplemented concentrate appeared to be at least as potent as the conventional vaccine and were clearly superior to vaccine made from ox serum supplemented concentrate.

Cephaloceles: treatment, outcome, and antenatal diagnosis

A series of 74 cephaloceles (17 cranial meningoceles and 57 meningoencephaloceles) is reported. Infants born with large meningoencephaloceles containing recognizable cerebral tissue usually did badly despite endeavors to conserve brain function by expanding the cranial capacity (5 cases) or decompressing hydrocephalic ventricles (9 cases). Infants with cranial meningoceles almost all did well, even when there was associated hydrocephalus. The etiological diversity of cephaloceles is emphasized. Frontoethmoidal meningoencephaloceles, which occur with noteworthy frequency in South and Southeast Asia, require separate consideration in both genetic counseling and treatment; the associated facial deformities (hypertelorism and orbital dystopia) can be corrected with a one-stage craniofacial reconstruction. Antenatal diagnosis by ultrasound is now often possible and was achieved in 4 cases; we suggest that neurosurgeons should participate in such antenatal evaluations.

Fronto-ethmoidal meningoencephaloceles: morphology and treatment

Twenty-five cases of fronto-ethmoidal meningoencephaloceles have been studied. The relationship to other sincipital meningoencephaloceles is explored. In all cases the exit holes from the anterior cranial fossa are at the site of the foramen caecum. The facial component of the defect determines the sub-classification: naso-frontal, naso-ethmoidal and naso-orbital. The cranio-facial deformity may consist of hypertelorism, orbital dystopia, elongation of the face and dental malocclusion. These reflect the distorting influence of the extruded intracranial contents on facial growth. Early removal of the meningoencephalocele by the cranio-facial route is recommended to allow normal growth forces to be re-established. In older patients with established deformities translocation of the orbits may be necessary.

Three-dimensional reconstruction of craniofacial deformity using computed tomography

The computed tomographic studies obtained routinely in the examination of patients with congenital or acquired defects of the skull and facial bones can be utilized as a substrate to provide an accurate three-dimensional representation of osseous abnormalities. The total dose of x-irradiation is reduced as other means of radiological examination are eliminated. Osseous structures are faithfully reproduced. Complete inspection of the reproduced structure can be made from any viewpoint, including internal inspection.

Chemotherapy of squamous cell cancer of the head and neck

Forty patients with advanced squamous cell cancer of the head and neck were treated with methotrexate, cisplatin, and bleomycin. Major regression of disease occurred in 69%; 30% of patients achieved complete remission. Fifteen patients received chemotherapy as the initial treatment, followed by either radiotherapy or surgery or both. Subsequent therapy was not prejudiced by this approach. The results demonstrate the marked sensitivity of these tumors to these three agents, and the need for further assessment of their use in optimal patient care.

The assessment of available manganese and aluminium status in acid soils under subterranean clover pastures of various ages

Three methods of estimating available manganese and aluminium status in acid soils were compared on three groups of soils from the Pejar district near Goulburn, New South Wales in which differences in pH had been brought about by different periods under subterranean clover pasture. Managanese extracted by 0.01 M calcium chloride gave the best correlation with the manganese concentration in rape and subterranean clover grown in pot culture, and provided the best index of available manganese. Soil solution manganese was inferior to CaCl2-extractable manganese and was more difficult to determine. Extraction with neutral ammonium acetate was unsatisfactory because this reagent overestimated available forms of manganese in soils containing high levels of reactive manganese. Aluminium extracted by 0.01 M CaCl2 was well correlated with exchangeable aluminium and with percentage aluminium saturation of the effective cation exchange capacity. None of the three measures of aluminium status alone was an effective index for predicting lime response by rape on these soils because both manganese and aluminium status were involved in this response. These three parameters were equally effective in multiple regressions for yield responses of rape to lime. Because of its relative ease of determination, CaCl2 extraction is preferred as a practical measure of aluminium status. Aluminium interacted with and increased the toxic effects of manganese in rape. Thus CaCl2-extractable manganese alone only provided a satisfactory index of a 'critical' value for manganese toxicity in rape for soils low in available aluminium. Subterranean clover was only slightly affected by aluminium and manganese levels in these soils, and manganese toxicity symptoms were only observed on soils containing 50 ppm or more CaCl2-extractable manganese. Nodulation failure in pots occurred in all soils with pH below 5.2 (water) or below 4.3 in CaCl2, whereas nodulation was normal when these soils were treated with CaCO3 to raise the pH to 5.8-6.0 (water). With one exception nodulation appeared adequate at field sites from which soils showing nodulation failure in the glasshouse had been collected.

Change in soil pH, manganese and aluminium under subterranean clover pasture

Changes in soil pH, manganese and aluminium as a result of long periods under subterranean clover pasture were examined in soils formed on granite, basalt and sedimentary rocks near Goulburn, New South Wales. Decreases in the pH of yellow duplex soils formed on granite, sedimentary rocks and basalt had occurred to depths of 60, 40 and 30 cm, respectively. The smaller depth of acidification in the latter two soils is considered to be due to their shallower A horizons over well buffered, clay B horizons. Under the oldest pastures (55 years) the decreases exceeded one pH unit throughout the entire sampled depth (60 cm). In some soils, under old improved pastures, calcium chloride-extractable manganese had increased to more than 20 ppm throughout the 60 cm profile and to greater than 50 ppm in the surface 10 cm. These levels are considered toxic to sensitive plant species and the highest levels may be toxic to subterranean clover. The amounts of extractable manganese in soils appear to be determined by both pH and the amounts of reactive manganese. In general, the amounts of total and reactive manganese were appreciably higher in the soils of basaltic origin. Substantial increases in extractable and exchangeable aluminium had also accompanied the decrease in pH and, in the surface 10 cm, were greatest in the soils formed on sedimentary parent materials. In many of the soils under old improved pastures, exchangeable aluminium, as a percentage of the effective cation exchange capacity, now exceeds 12%, especially in the 5-10 cm layer, and is probably harmful to sensitive species. Increases in exchangeable aluminium also occurred below the surface 10 cm and, in the granitic soils under the oldest pastures, exchangeable aluminium accounted for 30-50% of the effective cation exchange capacity throughout the 5-50 cm soil depth. The adverse changes in pH, manganese and aluminium observed in this study can be expected to continue under many improved pastures and to generate soil conditions unsuitable for many agricultural plants. The use of lime to arrest or reverse these changes seems inevitable.

Nasendoscopy: significant refinements of a direct-viewing technique of the velopharyngeal sphincter

The need for a three-dimensional record of velopharyngeal sphincter function in patients with craniofacial anomalies and speech problems is discussed. A refined split-screen video technique using color nasendoscope image, lateral video-fluoroscopy, and synchronous speech recording with the patient awake and in supine position is described. A special signal processor is used to position the color nasendoscopy image. The examination is recorded on 1-in. videotape. The technique allows three-dimensional appraisal of sphincter function with direct viewing and enables assessment of a range of abnormalities, assessment of the effectiveness of pharyngoplasties, and prediction of speech deformities and their management following midface craniofacial surgery.

Severe cranio-facial deformities and their management

Historical attitudes to cranio-facial deformities are discussed. A simple nosology of cranio-facial deformities is given, the main groups being craniosynostosis syndromes, facial clefts, tumours, trauma, facial microsomias, and midface hypoplasias. Each group is briefly discussed, with emphasis on the craniosynostosis syndromes and facial clefts. Cases from these two groups are illustrated before and after surgery, showing the dramatic improvement offered by cranio-facial techniques. The basic principles of cranio-facial surgery are briefly discussed, and the complications discussed. The South Australian Cranio-Facial Unit experience with complications is discussed, especially blindness and persistent C S F leaks. The necessity for only a few cranio-facial units each with a high workload is reiterated, and new directions for cranio-facial surgery discussed, including the use of microvascular techniques and early surgery to minimise later deformity, particularly in cases with plagiocephaly.

Relations between plant aluminium content and the growth of lucerne and subterranean clover: their usefulness in the detection of aluminium toxicities

ln an experiment with lucerne (Medicago sativa) and subterranean clover (Trifolium subterraneum), grown in solution cultures at two levels of phosphorus, each at five aluminium levels and pH 4, growth and aluminium transport to the leaves were comparable in both species up to the fourth aluminium level (40�M All. The highest aluminium level (200 �M Al) caused a much greater growth depression in lucerne than in subterranean clover. In lucerne, aluminium concentrations in leaf dry matter peaked at the fourth aluminium level. Concentrations below this peak could indicate non-toxic as well as toxic supplies of aluminium. Leaf analysis, therefore, appears to be of little value in the detection of aluminium problems in lucerne. In subterranean clover leaves, aluminium concentrations increased to values in excess of 1 70 ppm of the dry matter at the highest aluminium level. In a second experiment, in which subterranean clover plants were grown in pots in two acid soils at two phosphorus x five aluminium levels, close, inverse, linear relations were found between relative yield (Al/no Al x 100) and leaf aluminium concentrations. These relations differed between soils, harvests and phosphorus levels, and would therefore be of little help in providing quantitative estimates of yield depressions in subterranean clover caused by aluminium. However, the lines all converged within the range of 100-1 50 ppm aluminium in leaf dry matter of plants in the no aluminium treatment, suggesting that this range represented a 'threshold' above which yield reductions due to aluminium occurred.

Microvascular surgery in maxillo-facial reconstruction

The recent advances in microvascular surgery have been applied to maxillo-facial reconstruction in the area of the lower jaw and soft tissue of the face. Five cases are presented, demonstrating some of the techniques and results in patients suffering from congenital, post-traumatic and post-cancer resection deformities.

The acute toxicity of ethanol: dosage and kinetic nomograms

We are concerned with the frequency of potentially lethal ethanol intoxications (about 1 pint of hard liquor) in teenagers. We present 2 illustrative cases, discuss the acute toxicity of ethanol, and present 2 simple calculating charts for dosage and kinetics. The widespread use and economic impact of ethanol have kept this potent sedative-hypnotic free of the same federal regulations that control the availability of other drugs with a similar potency and margin of safety.

Selection in Lupinus albus L. for lower seed manganese concentration

Seeds of 49 Mediterranean white lupin accessions and of 36 F5 families derived from 13 of them were analysed for manganese concentration. High concentrations in the range 1770–4640 µg g-1 dry matter were found in material grown near Canberra and lower ones (1060-2750 µg g-l) at Wagga Wagga, N.S.W. A small number of L. angustifolius L. lines grown under comparable conditions at both sites had 7- to 70-fold lower concentrations of manganese in their seeds than L. albus. The means for accessions and families of L. albus varied widely and continuously about the site means. High alkaloid lines had approximately two-thirds the manganese concentration of low alkaloid lines. Seeds from primary inflorescences had 6% lower manganese concentrations than those from higher order inflorescences. About one-quarter of the variation within the low alkaloid class was associated with seed yield variation, there being a negative correlation between these traits. There was no line x site interaction. Broad sense heritabilities at Canberra and Wagga Wagga were moderately high, so that selection for lower concentrations should be effective. The results suggest that selection for higher yield could be almost as effective as direct selection in reducing seed manganese concentration. The reduction should be sufficient to enable white lupin seeds, grown on soils no higher in available manganese than those used in this study at Canberra, to be safely used as a high protein supplement in pig and poultry rations. Selection for lower seed manganese should not affect seed calcium, phosphorus or protein concentrations, but would tend to increase seed yield and plant height at maturity.

A de-epithelialized free groin flap for facial contour restoration

The transfer of de-epithelialized free groin flaps to restore facial contour after tumour resection and in hemifacial microsomia is described. The flap can be transferred in one stage and remodelled at a later minor operation. This provides an acceptable alternative to the other more difficult and often less successful methods of restoring soft tissue deficiencies of the face.

Psychosocial aspects of head and neck cancer surgery

Thirty-six patients who underwent major surgical excision and reconstruction for head and neck cancer were subjected to a psychosocial assessment in hospital and, later, in their home environments. The information gained from the survey is discussed, with particular reference to those factors which can be used by the head and neck surgical team to improve the quality of the patients' existence.

Use of an innervated deltopectoral flap for intraoral reconstruction

The technique for the transfer of sensitive skin into the mouth for intraoral reconstruction is described. This procedure may be performed at one or two operative stages. Supraclavicular nerves supply sensation to the tip of the standard deltopectoral flap--which may be swung up with the nerves left in continuity, or the nerves may be divided and anastomosed to an appropriate sensory nerve in the mouth.

Craniofacial surgery: the team approach

Craniofacial surgery offers a new hope to some grossly deformed people. This complex surgery, which is based on a multidisciplinary team approach, needs to be carefully rationalized and regionalized to facilitate investigation, to improve planning, to reduce the number of complications, and to conserve financial resources. To date the Cranio-Facial Clinic at the Adelaide Children's Hospital and the Royal Adelaide Hospital has reviewed 37 cases and operated upon 13 of these. This work is presented together with a review of the team approach.

Heavy metal contents of soils and plants adjacent to the Hume Highway near Marulan, New South Wales

HCL-extractable zinc, lead, cadmium and copper in soils as well as concentrations of these elements in bracken (Pteridium esculentum) were found to decrease along four leeward traverses at right angles to the Hume Highway near Marulan. Similar results were obtained for the above-ground portions of rye corn (Secale cereale) grown in a glasshouse on soils collected along one of these traverses. Zinc accession is similar to, but cadmium and lead accessions are considerably lower than, those observed by other workers in the United States probably owing in the case of cadmium to the use of purer zinc oxide in Australian tyre manufacture and in the case of lead to smaller cars and a smaller proportion of vehicles operating on leaded fuel. Zinc and cadmium analyses of Australian and foreign tyres confirmed the relative purity of the zinc oxide used in the manufacture of tyres in Australia. No serious health hazard appears to arise from heavy metal contamination of roadside soils and vegetation by vehicular traffic on the Hume Highway.

Far Red and White Light-promoted Utilization of Calcium by Seedlings of Phaseolus vulgaris L

The cotyledons and embryo axes of seeds of Phaseolus vulgaris L. cv. Pinto contained 16% of the total calcium in the seed. The remaining 84% was in the testas. There was no evidence that calcium in testas was used in seedling growth or that calcium was leached from seedlings during growth.An external supply of calcium decreased the incidence of hypocotyl collapse (a severe symptom of calcium deficiency), increased the calcium content of all organs, and increased the dry weight of all organs except cotyledons. Light treatments decreased the incidence of hypocotyl collapse and increased the calcium content and dry weight of all organs except cotyledons and hypocotyls.White light was more effective than far red light for decreasing incidence of hypocotyl collapse. Usually the effects of white light and far red light on the calcium content and dry weight of organs were similar, and usually those of white light were quantitatively greater than those of far red light. It is suggested that the light-promoted effects were associated with photomorphogenesis and that differences in data obtained with white light and far red light could be associated with photosynthesis.

Skin trauma in patients receiving systemic corticosteroid therapy

Surprisingly extensive skin damage may result from trivial accidents in patients treated with systemic corticosteroids. In one year 21 such patients were admitted to a plastic surgical unit. Skin necrosis and delayed healing are problems in these patients, and skin grafting may be necessary.