Depo-Provera: an injectable contraceptive

Medroxyprogesterone acetate (Depo-Provera) is now approved for use as an injectable contraceptive. It is highly effective and has the advantage of only needing to be administered once every 12 weeks. The most common side effects are menstrual irregularities, amenorrhea in particular. Several illustrative cases are presented that demonstrate appropriate patient selection for this agent.

Mandibular lengthening by distraction for airway obstruction in Treacher-Collins syndrome

Mandibular lengthening by distraction was performed in a 6-year-old tracheostomy-dependent Treacher-Collins syndrome patient. Detailed preoperative imaging revealed an occluded retrotongue base pharyngeal airway, which, following mandibular distraction, became patent and permitted tracheostomy removal. Mandibular distraction as a technique must be targeted toward clinical problems--management of upper-airway obstruction may be one such scenario.

Associated injuries in facial fractures: review of 839 patients

Patients with facial trauma may have associated injuries requiring immediate or specialised attention. This paper reports the incidence and nature of significant associated neurosurgical, ocular, spinal, torso and extremity injuries in facial fracture patients treated by the Department of Plastic and Reconstructive Surgery from June 1989 to June 1992. Of 839 patients treated during the period, 95 patients (11.3%) sustained significant concomitant injuries outside the facial skeleton. There were 45 (5.4%) patients with associated neurosurgical injuries, 33 (3.9%) with ocular injuries, 8 (0.9%) with spinal injuries, 16 (1.9%) with injuries of the torso, and 62 (7.4%) with injuries of the extremities. The spectrum of the injuries is presented. Most neurosurgical injuries are a result of focal impact and the intervention required is related mainly to local fracture management and the repair of dural tears. The risk of significant ocular injury is highest when the fracture involves the orbit. Injuries of the spine, torso (chest, abdomen, pelvis), and limbs were seen mainly in road trauma patients.

Cephaloceles: classification, pathology, and management--a review

The spectrum of diseases that give rise to cephaloceles is reviewed with particular reference to conditions encountered by craniofacial teams. The broad term cephalocele contains the more focused term meningoencephalocele, which is most commonly used by craniofacial surgeons. The interesting pathology of frontoethmoidal meningoencephaloceles is described with reference to the experience of the Australian Craniofacial Unit from 1975 to 1993. Further observations supporting the uniqueness of this entity are made. Although the meningoencephalocele associated with craniofacial clefts does not in itself affect treatment, the management of frontoethmoidal meningoencephaloceles is dependent on a knowledge of their unique natural history. Long-term follow-up has allowed a number of conclusions to be reached in the light of treatment. Basal and posttraumatic encephaloceles are described with respect to their place in the classification system as well as the principles of treatment.

Sports-related facial fractures: a review of 137 patients

One hundred and thirty-seven patients with sports-related facial fractures were reviewed. These made up 16.3% of 839 patients with facial fractures seen at the Department of Plastic and Reconstructive Surgery, Royal Adelaide Hospital, between June 1989 and June 1992. Males made up 93.4% of patients and 89.1% were aged below 35 years. There was an intent to injure in 11%. Australian Rules football was the causative sport in 52.6%, all the injuries being the result of human contact. Orbitozygomatic fractures were the most frequently observed overall (62%) as well as in Australian Football (58.3%). Cricket contributed to 14.6%, the ball being the agent of injury in all but one of the patients. Horse-riding injuries were the most severe. 89.1% of the patients required surgery and hospital stays ranged from 0 to 18 days with an average stay of 4.7 days. Sports activities, although a significant source of enjoyment, are a significant cause of facial fractures with their attendant morbidity.

Basal encephalocoele: imaging and exposing the hernia

Basal encephalocoeles are rarely reported anomalies. Eight cases seen by one unit manifested external facial features and internal cerebral anomalies characteristic of the individual encephalocoele subgroups. CT and MR imaging delineates the anatomy of the skeletal defect and the associated cerebral abnormalities. Such imaging of cases of median cleft face syndrome may identify previously unsuspected basal encephalocoeles. Transcranial correction with increased exposure, if needed, by the technique of facial bipartition has been performed in five cases.

Apert's syndrome

This paper discusses 33 cases of Apert's syndrome which were treated in the Australian Craniofacial unit at the adelaide Children's Hospital. The main features were discussed. We found that mild ventricular dilatation is common in Apert's syndrome but without associated raised intracranial pressure. Severe ventricular dilatation was seen in only one case. No shunt procedures were performed. We also studied the changes in the ventricular size after transcranial corrective procedures. There was no significant change in the ventricular size, the increase in the skull volume was compensated by expansion of the brain tissue and to some extent by increase in the subarachnoid space. Two cases with unusual features are also described.

Progressive hemifacial atrophy (Romberg's disease): skeletal involvement and treatment

Progressive hemifacial atrophy (Romberg's disease) manifests variable involvement of the skin, soft tissue and underlying cranio-facial skeleton. Significant bony deformation has been identified in those patients with early onset disease, the result of factors both intrinsic to the disease process and secondary to the abnormal environment in which the skeleton develops (functional matrix). Treatment demands combined osteotomy and augmentation of the skeleton in concert with conventional approaches to soft tissue correction.

The cloverleaf skull anomaly: managing extreme cranio-orbitofaciostenosis

The cloverleaf skull anomaly represents the most manifestly extreme form of cranio-orbitofaciostenosis with hydrocephalus that has to date been associated with a uniformly poor outcome and frequent death in infancy. Assessment of the primary deformity and the approach to treatment in a consecutive series of 10 patients with the cloverleaf skull anomaly in the one unit are presented. Early predictable surgical correction of the cranio-stenosis is possible by fronto-orbital advancement and lambdoid craniectomy. Less satisfactory correction of hydrocephalus and orbitostenosis is possible with the attendant increased morbidity. Early survival and the potential for a satisfactory long-term outcome depend on the management of the faciostenosis and an airway that may be anomalous at multiple levels. The initial approach was routine tracheostomy, which provided short-term relief but with the morbidity associated with such airway maintenance in any environment other than the most sophisticated health services. More recently, upper airway surgery (uvulopalatopharyngoplasty, adenoidectomy, and soft palatal split) has ensured airway control and avoided the progression to tracheostomy. When utilized later (1 to 10 years), such surgery may alleviate the symptoms of upper airway obstruction and sleep apnea and permit delay of midfacial advancement.

Aggressive surgical management of sleep apnea syndrome in the syndromal craniosynostoses

Obstructive sleep apnea syndrome (OSAS) frequently develops in patients with craniosynostosis and associated midfacial stenosis. In the past, conservative measures or tracheostomy have been used to manage this condition. Although the course of OSAS in these patients is multifactorial, a major factor is the marrow nasopharyngeal space. Aggressive surgical intervention to enlarge the nasopharyngeal space can reduce the severity of OSAS and therefore avoid the need for tracheostomy. Surgical approaches include adenotonsillectomy, uvulopalatopharyngoplasty, and midface advancement.

Posterior pharyngeal tattooing: localising the implant in velopharyngeal incompetence

A technique of preoperative localisation of pharyngeal wall implants for velopharyngeal incompetence is described. The nasal approach in the non-sedated patient permits precise and permanent posterior pharyngeal wall tattooing for accurate implant location.

Soft tissue expansion in the management of the rare craniofacial clefts

Management of the rare craniofacial clefts requires correction of both the soft tissue and skeletal hypoplasia. Tissue expansion of adjacent and distant soft tissue has been used to reconstruct these facial clefts with like quality tissue. Additionally, such soft tissue expansion permits tension free reconstruction of the skeletal clefts by osteotomy and bone graft.

Craniofacial clefting and sutural dystopia

Sutural anomalies in conjunction with craniofacial clefting are unusual. A case of median frontal clefting is presented in which there was an absence of a normal metopic suture and replacement by paramedian frontal sutures. The association of an underlying brain anomaly, with attendant surgical difficulties, is noted, as are the radiological techniques of preoperative diagnosis.

Crouzon twins with cloverleaf skull malformations

We describe unique monozygotic twins with Crouzon's disease and cloverleaf-shaped skull deformities who have been closely followed since birth. Their abnormal skull shapes were identified during antenatal ultrasound examination. The twins had gross exophthalmos and hydrocephalus with papilledema, so early calvarial decompression surgery was required. Although born to healthy parents of normal appearance, a third cousin of the twins had a milder form of Crouzon's disease, and there was a family history of high-arched palate on the twins' paternal side. Because Crouzon's disease is an uncommon condition and the cloverleaf skull shape is unusual in patients with Crouzon's disease, identical twins with this constellation of deformities must be exceptionally rare.

The missing maxilla: restoring aesthetic balance with mandibular surgery

Traumatic loss of large portions of the maxilla remains uncommon. Reconstruction demands careful attention to both the anatomy of the primary deformity as well as the associated secondary changes if there is to be acceptable restoration of facial aesthetics and function. In concert with rebuilding the missing maxilla, reconstruction may frequently involve repositioning the apparently undisturbed mandible.

The treatment of facial disharmony and malocclusion by jaw surgery. Case reports

Examples are given of the Australian Cranio-Facial Unit's methods of dealing with facial disharmony and malocclusion by orthognathic surgery. Members of the Unit specialize in different aspects of craniofacial structure and function, and their teamwork is described. Treatment planning and assessment are illustrated by traditional cephalometric and other analytical procedures, and by pattern profile analysis. An appraisal is made of the Unit's increasing use of computer technology to facilitate these analyses, and to integrate various sources of information about facial disharmony.

Frontofacial advancement with a free flap: deadspace versus drainage

Presented is an adult case of Crouzon's syndrome undergoing a single stage frontofacial advancement where the employment of a microvascular free flap for extradural deadspace obliteration and to seal any communication with the nose may have contributed to the development of a major extradural infection.

Neuropsychologic outcome after craniofacial fracture

Forty eight patients with facial fractures resulting from trauma were admitted to a Plastic Surgical Unit. The fractures were treated on standard lines and ten of the patients required craniotomy for CSF rhinorrhea or repair of depressed frontal fractures. Neuropsychologic assessment was carried out on all patients approximately 17 months after the initial injury. An assessment of the extent to which the trauma had affected the personality and social adjustment of each individual was also carried out at that time. In four patients there was no evidence of any neuropsychologic impairment on any of the tests administered. The neuropsychologic deficits were most noticeable in those who had suffered a cranial fracture. In patients with facial fractures but no evidence of cranial fractures, there was no association between neuropsychologic impairment and site of injury. Loss of consciousness was associated with poor social adjustment and a marked change in personality. The best predictor of subsequent neuropsychologic deficits and social maladjustment was found to be the Glasgow Coma Score at the point of admission to the hospital after injury. It is concluded that with this type of injury careful neuropsychologic assessment is important in identifying the subtle deficits that might otherwise remain undetected.

Monocortical non-compression miniplate osteosynthesis of mandibular angle fractures

The technique of monocortical non-compression miniplate fixation of mandibular angle fractures is reviewed. A study of our first 50 patients treated using this technique reveals that consistent reduction and stabilization of these mandibular fractures can be achieved without the requirement for intermaxillary fixation. Such results were produced with minimal postoperative morbidity.

Craniofacial osseous landmark determination from stereo computer tomography reconstructions

The accurate and reproducible determination of the three dimensional (3D) co-ordinate positions of anatomical landmarks from computer tomography (CT) images has been limited even though potentially the data have been available for several years. This paper describes a method of acquisition of osseous landmark positions using an off-line computing technique based on multiple stereo images of 3D CT reconstructions. The use of stereo pairs greatly enhances the consistent identification of osseous landmarks. Further, the technique is of particular value where access to the CT scanner is restricted due to heavy clinical demand and separate high quality graphics facilities are unavailable. Osseous landmark position data were determined for dried skulls and patients with craniofacial conditions. Accuracies of the order 1.7mm (median) were obtained. These results encourage the use of the technique for acquisition of landmark positions for the study of the craniofacial complex in three dimensions.

Obstructive sleep apnea in Apert's and Pfeiffer's syndromes: more than a craniofacial abnormality

Nine acrocephalosyndactyly type I patients (Apert's syndrome) and three acrocephalosyndactyly type V patients (Pfeiffer's syndrome) were evaluated for the relative importance of upper and lower airway abnormalities in the generation of obstructive sleep apnea. All patients were found to have a combination of upper and lower abnormalities. The influence of lower pathology was greater in the infants, and the influence of upper airway, specifically pharyngeal, was greater in the adults. A comparison between preoperative and postoperative polysomnography revealed little improvement with standard craniofacial advancements. Furthermore, three patients are described who succumbed to pulmonary death despite tracheostomy. Conservative treatment with prone or lateral positioning and medical pulmonary regimens is advocated. Finally, the pathogenesis of this diffuse airway pathology is discussed.

Application and comparison of techniques for three-dimensional analysis of craniofacial anomalies

Traditionally, cephalometric analysis has been limited to data determined from two-dimensional (2-D) cephalograms. With imaging facilities such as CT and biplanar radiography now available, the natural extension has been towards the use of three-dimensional (3-D) coordinate positions of landmarks for comparative purposes. While these data have been potentially available for several years, the accurate and reproducible extraction of anatomic landmarks suitable for comparative purposes has been limited. This paper presents results of the application of traditional comparative techniques to well determined 3-D coordinate data acquired from biplanar radiography and CT for a patient with Treacher Collins syndrome and further provides a comparison with the technique of strain analysis, often referred to as finite element analysis, which has been applied recently to craniofacial data. Comparisons of distances and angles between landmarks, landmark coordinate positions, and strains of the patient relative to experimental reference standards reveal that the essential skeletal features of Treacher Collins syndrome have been identified and quantified by the analysis techniques. Further, a measure of the significance of the deviations has been determined by comparisons with the experimental reference standards.

Craniofacial deformation in cystic hygroma

Mandibular and dentoalveolar deformities associated with cystic hygroma of the head and neck have previously been described. This small series has identified changes involving the entire craniofacial skeleton, attributable to both the local and distant effects of massive facial lymphangiomas, without evidence of any actual soft tissue ingrowth into bone. In view of the inability to excise such lesions and normalize the soft tissue anatomy, the surgical approach to the craniofacial skeletal abnormality should be to reserve the required osteotomies or ostectomies until the completion of facial growth.

Facial dysmorphology in the neglected paediatric head and neck burn

The morphological distortion of the facial skeleton induced by untreated paediatric burns of the head and neck reinforces the theories of craniofacial growth and the modern principles of acute burn management and post-burn facial reconstruction.