Developing an International Framework for Informed Consent in Plastic Surgery: A Focus on Cosmetic Breast Augmentation

Background

Informed consent is a fundamental pillar of patient rights and is an essential part of good clinical practice. In 2019, the International Confederation of Plastic Surgery Societies launched a survey to collect feedback on informed consent practices, with an aim to develop an international guideline for cosmetic surgery.

Methods

A 15-question survey was sent to delegates of the International Confederation of Plastic Surgery Societies for dissemination to their national society members. The survey comprised a range of quantitative and qualitative questions. Descriptive and thematic analysis was performed.

Results

There were 364 respondents. Over half of the respondents reported no local informed consent policy, whereas others noted national society, specialist college, or government policies. The majority of respondents believed that the performing surgeon should be responsible for obtaining informed consent with at least two face-to-face consultations. Most respondents agreed with a cooling-off period (duration based on procedure type and use of high-risk devices). Regarding cosmetic breast augmentation, the majority of respondents felt that the performing surgeon should be responsible for postoperative management, including cases that occur as part of surgical tourism. Some respondents incorporate financial consent as part of their informed consent practice. Most supported the development of an international informed consent guideline.

Conclusions

Informed consent should result from face-to-face consultations with the performing surgeon. There should be a minimum cooling-off period. Postoperative surveillance should be available in all settings. The findings of this survey will help inform an international standardized informed consent guideline for cosmetic surgery.

Comparing 200,000 Breast Implants and 85,000 Patients over Four National Breast Implant Registries

BACKGROUND

Growing awareness about breast implant-related adverse events has stimulated the demand for large, independent data resources. For this, data from breast implant registries could be combined. However, that has never been achieved yet.

METHODS

Real-world data from four currently active national breast implant registries were used. All permanent breast implants from the Australian, Dutch, Swedish, and American registries were included. A subpopulation present across all registries between 2015 and 2018 was subsequently selected, including only permanent breast implants inserted during primary surgery for breast reconstruction or augmentation in patients without previous breast device surgery. Nationwide coverage, patient and implant characteristics, infection control measures, and revision incidences were analyzed.

RESULTS

A total of 207,189 breast implants were registered. Nationwide coverage varied between 3% and 98%. The subpopulation included 111,590 implants (7% reconstruction, 93% augmentation). Across the registries, mean patient age varied between 41 and 49 years ( P < 0.001) for reconstruction and 31 and 36 years ( P < 0.001) for augmentation. Variation was observed in implant preferences across the countries and over the years. Infection control measures were most frequently registered in Australia. Cumulative revision incidence at 2 years ranged from 6% to 16% after reconstruction and from 1% to 4% after augmentation.

CONCLUSIONS

For the first time, independent, national, registry-based data from four breast implant registries were combined. This is a powerful step forward in optimizing international breast implant monitoring, evidence-based decision-making, and patient safety.

Lessons Learned in Implementing Patient-Reported Outcome Measures (PROMs) in the Australian Breast Device Registry (ABDR)

BACKGROUND

The Australian Breast Device Registry (ABDR) is a clinical quality registry which utilizes both surgical data and patient-reported outcome measures (PROMs) to understand device performance. The ABDR is the first national breast device registry utilizing the BREAST-Q Implant Surveillance module to conduct PROMs via text messaging as the primary method of contact for most patients. ABDR PROMs are structured upon a successful acceptability and feasibility study and a pilot study.

OBJECTIVES

This aim of this paper was to examine the challenges we faced and consider how lessons learned in implementing PROMs might inform future registry studies and interventions.

METHODS

We tracked the number of completed follow-ups and documented feedback between October 2017 and December 2018 from various stakeholders, including sites, surgeons, and patients.

RESULTS

In total, 10,617 patients were contacted: 59% of breast augmentation and 77% breast reconstruction patients responded to our PROMs survey. We encountered challenges and developed solutions to overcome several key issues, including database setup; follow-up contact methods; ethics; education of surgeons and patients; associated costs; and ongoing evaluation and modification. The strategies we devised to address these challenges included drawing on experiences from previous studies, greater communication with sites and surgeons, and having the flexibility to improve and modify our PROMs.

CONCLUSIONS

The ABDR PROMs experience and lessons learned can inform a growing number of registries seeking to conduct PROMs. We describe our approach, obstacles encountered, and strategies to increase patient participation. As more breast device registries worldwide adopt PROMs, data harmonization is crucial to better understand patient outcomes and device performance.

Breast Device Surgery in Australia: Early Results from the Australian Breast Device Registry

BACKGROUND

The Australian Breast Device Registry (ABDR) is a clinical quality registry designed to monitor the performance of breast devices; and the quality and safety of breast device surgery.

OBJECTIVE

To report on breast device surgery characteristics across Australia.

METHODS

Participants were registered patients in the ABDR from 2012 to 2018. Results are described using percentages, mean and median. Revision rates were calculated using survival analysis methods.

RESULTS

A total of 37,603 patients were registered and had undergone reconstruction (post-cancer 15.1%, risk-reducing mastectomy 3.4% and developmental deformity 2.4%) or cosmetic augmentation (74.7%) procedures. The majority of breast implant devices were silicone filled with textured surface (reconstruction 74.0% and augmentation 64.0%). Sub-pectoral plane was the most common for both reconstruction (60.1%) and augmentation (76.6%) procedures. For reconstruction surgery, the most common surgical incision was previous mastectomy scar (44.0%) and inframammary (31.8%), and for augmentation, it was inframammary (83.4%). Intraoperative/postoperative antibiotic usage for reconstruction was 85.8% and augmentation was 89.4%. Revision incidence due to complication at 12 months post-cancer reconstruction was 5.1%, risk-reducing reconstruction 5.7% and developmental deformity implants 4.5%. Revision incidence due to complication at 12 months after augmentation procedure was 1.1%. Patient-reported outcome measures (PROMs) indicate high levels of satisfaction at 1 year for augmentation and reconstruction procedures.

CONCLUSION

We report on early data from the ABDR and reflect on the uptake of the registry by surgeons and patients. The registry also benefits from international collaborative approaches to addressing challenges and is committed to facilitate international post-market surveillance.

Establishing the acceptability of a brief patient reported outcome measure and feasibility of implementing it in a breast device registry - a qualitative study

Background

To examine the acceptability of a Patient Reported Outcome Measure (PROM) that assesses perceptions and experiences of implants for breast reconstruction or augmentation, and the feasibility of implementing it in the Australian Breast Device Registry (ABDR).

Methods

The BREAST-Q Implant Surveillance (BREAST-Q IS) is a 5-question PROM derived from the BREAST-Q questionnaire. It assesses perceptions of breast appearance and sensation, and experiences of pain. Breast implant recipients (recruited via community networks, social media and notices in surgeons’ rooms) and surgeons contributing to the ABDR were invited to review the BREAST-Q-IS. Participation was by individual semi-structured interviews by telephone or email, or by completion of a paper questionnaire. Transcripts of audio recordings and emailed text were analysed thematically.

Results

Twenty one breast implant recipients (10 after reconstruction and 11 augmentation), 8 surgeons (five plastic, three breast) and 2 medical professionals performing cosmetic surgeries were interviewed. Six themes were identified: Overall impression, Emotional response to the BREAST-Q IS, Method of follow-up, Suggested improvements, Group variation, and Potential Clinical utility. Overall, breast implant recipients and surgeons found the BREAST-Q IS to be acceptable and unlikely to provoke strong emotional reactions. Email was the preferred mode of contact. Most suggested improvements were to add questions. Surgeons expressed concern that subjective responses to the PROM might not accurately reflect experiences and that the PROM would predict need for revision rather than device failure.

Conclusion

This study supports the acceptability and feasibility of BREAST-Q IS as a PROM for recipients of breast implants. Further validation of the Breast-Q IS is required.

Patient-Reported Outcome Measures for Breast Implant Surgery: A Pilot Study

BACKGROUND

The Breast-Q Implant Surveillance module (BREAST-Q IS) is a patient-reported outcome measure (PROM) that asks 5 questions on satisfaction (shape, feel, and rippling) and symptoms (pain and tightness) derived from the BREAST-Q.

OBJECTIVES

We aimed to pilot BREAST-Q IS on patients within the Australian Breast Device Registry (ABDR), an opt-out clinical quality device registry, and explored Short Message Service (SMS) communication as a follow-up method.

METHODS

Patients with a breast device surgery in the previous 10 to 15 months, age ≥18 years, with a mobile phone number, were invited to complete the 5-question PROM via SMS initially, followed by 3 phone call attempts if no response, an e-mail, and then a letter by post as a final engagement strategy.

RESULTS

The study included 197 participants [breast augmentation (BA) = 118; breast reconstruction (BR) = 79]. Mean ± SD age was 40 ± 12 years (BA) and 44 ± 11 years (BR). Mean ± SD time since surgery was 414 ± 36 days (BA) and 413 ± 51 days (BR). The total response rate, including opt-outs, was 76%. Responses indicated that >90% of BA and >79% of BR were very or somewhat satisfied with shape, feel, and wrinkling; >70% of BA and >46% of BR reported no pain or tightness. Completion of survey via SMS was 51% (BA) and 55% (BR). Further responses were received by phone (25%, 26%), post (21%, 16%), and e-mail (3%, 3%).

CONCLUSIONS

This pilot demonstrated high levels of satisfaction and low levels of pain and tightness in patients with breast augmentation and breast reconstruction 1 year postoperatively. It also showed the effectiveness of our engagement strategy, which achieved a 76% response rate. Over 50% of respondents used SMS to reply to a 5-question PROM assessing long-term surgical outcomes. This engagement strategy will be used as BREAST-Q IS is rolled out nationally.

Pilot for the Australian Breast Device Registry (ABDR): a national opt-out clinical quality registry for breast device surgery

PURPOSE

To establish a pilot clinical quality registry (CQR) to monitor the quality of care and device performance for breast device surgery in Australia.

PARTICIPANTS

All patients having breast device surgery from contributing hospitals in Australia. A literature review was performed which identified quality indicators for breast device surgery.

FINDINGS TO DATE

A pilot CQR was established in 2011 to capture prospective data on breast device surgery. An interim Steering Committee and Management Committee were established to provide clinical governance, and guide quality indicator selection. The registry's minimum dataset was formulated in consultation with stakeholder groups; potential quality indicators were assessed in terms of (1) importance and relevance, (2) usability, (3) feasibility to collect and (4) scientific validity. Data collection was by a two-sided paper-based form with manual data entry. Seven sites were recruited, including one public hospital, four private hospitals and two day surgeries. Patients were recruited and opt-out consent used.

FUTURE PLANS

The pilot breast device registry provides high-quality population-based data. It provides a model for developing a national CQR for breast devices; its minimum dataset and quality indicators reflect the opinions of the broad range of stakeholders. It is easily scalable, and has formed the basis for other international surgical groups establishing similar registries.

A Standard Set of Value-Based Patient-Centered Outcomes for Breast Cancer: The International Consortium for Health Outcomes Measurement (ICHOM) Initiative

A major challenge in value-based health care is the lack of standardized health outcomes measurements, hindering optimal monitoring and comparison of the quality of health care across different settings globally. The International Consortium for Health Outcomes Measurement (ICHOM) assembled a multidisciplinary international working group, comprised of 26 health care providers and patient advocates, to develop a standard set of value-based patient-centered outcomes for breast cancer (BC). The working group convened via 8 teleconferences and completed a follow-up survey after each meeting. A modified 2-round Delphi method was used to achieve consensus on the outcomes and case-mix variables to be included. Patient focus group meetings (8 early or metastatic BC patients) and online anonymized surveys of 1225 multinational BC patients and survivors were also conducted to obtain patients' input. The standard set encompasses survival and cancer control, and disutility of care (eg, acute treatment complications) outcomes, to be collected through administrative data and/or clinical records. A combination of multiple patient-reported outcomes measurement (PROM) tools is recommended to capture long-term degree of health outcomes. Selected case-mix factors were recommended to be collected at baseline. The ICHOM will endeavor to achieve wide buy-in of this set and facilitate its implementation in routine clinical practice in various settings and institutions worldwide.

A systematic review of dermal fillers for age-related lines and wrinkles

BACKGROUND

Dermal fillers are gaining popularity for rapid aesthetic improvement. Long-term efficacy and safety have not been well documented. The aim of this systematic review was to assess the safety and efficacy of injectable dermal fillers compared with other facial augmentation techniques for the management of age-related lines and wrinkles.

METHODS

Studies including patients receiving injectable semi-permanent or permanent dermal fillers for age-related lines and wrinkles were included in this review. Efficacy outcomes (including changes in skin thickness and patient satisfaction) and safety outcomes (including mortality, lumps and infections) were examined.

RESULTS

Three randomized control trials and six case series were included. Permanent and semi-permanent dermal fillers improved subjective ratings of appearance and resulted in higher patient satisfaction than temporary fillers. Long-term efficacy appeared good in the few studies that reported it. Short-term safety appeared favourable. Lumps were reported in all but one study but received little follow-up. Long-term safety data were limited.

CONCLUSIONS

The treatment of age-related lines and wrinkles with permanent and semi-permanent dermal fillers is more efficacious compared with temporary fillers in those studies that compared them. Case series evidence suggests that these fillers achieve their objective, which is to decrease the visible effects of age-related changes. These fillers appear at least as safe as temporary fillers in the short term in those studies that compared them. Long-term safety could not be determined.

A systematic review of permanent and semipermanent dermal fillers for HIV-associated facial lipoatrophy

The objective of this study was to assess the safety and efficacy of injectable semipermanent and permanent dermal fillers, compared to other facial augmentation techniques, for the management of facial lipoatrophy as a result of highly active antiretroviral therapy (HAART) for HIV infection through a systematic review of the literature. A systematic search strategy was used to retrieve relevant studies. Inclusion of articles was by the application of a predetermined protocol, independent assessment by two reviewers, and a final consensus decision. One randomized controlled trial (RCT), one pseudo-RCT, two nonrandomized comparative studies, and seven case series were included for review. Injections with permanent and semipermanent dermal fillers improved subjective ratings of appearance and resulted in high patient satisfaction. Although short-term safety appeared favorable, of the seven studies that reported lumps, three studies reported these events in more than 40% of patients. Long-term safety data were lacking. Evidence suggests that permanent and semipermanent dermal fillers achieve their objective, which is to decrease the visible effects of HIV-associated facial lipoatrophy, with high patient satisfaction. Safety appears favorable in the short term, but further studies are required to determine long-term outcomes.

Bilateral atypical ductal hyperplasia, an incidental finding in gynaecomastia--case report and literature review

Male breast cancer is a rare disease. Atypical ductal hyperplasia (ADH) in men is much rarer, and bilateral involvement is exceptional. A 20-year-old male presented with bilateral gynaecomastia who underwent subcutaneous mastectomies and histopathology revealed bilateral ADH. At 24 months, completion mastectomies were performed on both sides. The residual breast tissue revealed ADH similar to the initial specimen. ADH in women increases the risk of breast cancer by four to five times. To our knowledge, this is the first case report of bilateral ADH in a gynaecomastia specimen.

LETTER TO THE EDITOR: The Other Side: Failure in Fair and Balanced Reporting

Matrix metalloproteinases (MMPs) and their tissue inhibitors play important roles in the wound-healing process. An imbalance in the expression of these molecules is thought to contribute to the failure of chronic ulcers to heal. We investigated whether a mitogenic bovine whey extract enriched with growth factors modulated the expression and activity of MMP-2 and -9, and the tissue inhibitor of MMP-2 (TIMP-2) in chronic leg ulcers. Wound fluids and biopsies were collected from chronic leg ulcer patients whose ulcers were treated topically for 4 weeks with placebo or mitogenic bovine whey extract at concentrations of 2.5, 10, and 20 mg/mL. The levels of MMP-2 and -9 in wound fluid samples was assessed by gelatin zymography and showed a decrease in active MMP-2 in the 2.5 and 10.0 mg/mL mitogenic bovine whey extract-treated ulcers compared with placebo (p<0.05). Immunohistochemical analysis of ulcer biopsies for MMP-2, -9, and TIMP-2 expression showed a reduction in the number of MMP-2-positive dermal fibroblasts in the mitogenic bovine whey extract-treated ulcers compared with pretreatment biopsies (p<0.05) that persisted over the course of the study. In contrast, a transient increase in the number of MMP-9- and TIMP-2-positive cells was observed in mitogenic bovine whey extract treated ulcer biopsies compared with pretreatment levels (p<0.05). These results show that topical application of mitogenic bovine whey extract was able to modulate the expression of MMP-2, -9, and TIMP-2 in chronic leg ulcers and that its constituent growth factors may have the potential to redress the proteolytic imbalance observed in nonhealing chronic ulcers.

Injury to arms protruding through vehicle windows

Driving with an arm protruding through a window can result in limb threatening injury. A series of seven upper limb injuries sustained during motor vehicle accidents (MVAs) with a limb protruding from the vehicle window is described. The severity and complexity of these injuries are related to the ultimate functional recovery for the limb. This study serves to highlight the severity of injury and morbidity following these modalities of trauma, which although rarely fatal, carry extensive consequences and could be easily prevented with appropriate education programmes and legislation.

Regenerating lizard tails: a new model for investigating lymphangiogenesis

Impaired lymphatic drainage in human limbs causes the debilitating swelling termed lymphoedema. In mammals, known growth factors involved in the control of lymphangiogenesis (growth of new lymph vessels) are vascular endothelial growth factors-C and -D (VEGF-C/D). Here we characterize a model of lymphangiogenesis in which the tail of lizards is regenerated without becoming oedematous. Three weeks after the tail is shed (autotomy), there are a small number of large diameter lymphatic vessels in the regenerated tail. Thereafter, the number increases and the diameter decreases. A functional lymphatic network, as determined by lymphoscintigraphy, is established 6 wk after autotomy. The new network differs morphologically and functionally from that in original tails. This lymphatic regeneration is associated with an up-regulation of a reptilian homologue of the VEGF-C/D protein family (rVEGF-C/D), as determined by Western blot analysis using a human reactive VEGF-C polyclonal antibody. Regenerating lizard tails are potentially useful models for studying the molecular basis of lymphangiogenesis with a view to developing possible treatments for human lymphoedema.

Fading of nipple-areolar reconstructions: the last hurdle in breast reconstruction?

Fading of nipple-areolar reconstructions is commonly reported, but there are few formal studies of this phenomenon. The purpose of this study was to determine whether deficiencies in nipple-areolar reconstruction and pigmentation were perceived by patients, their partners and independent observers, and whether a technique could be developed to measure nipple-areolar colour reliably. A total of 57 patients, 32 partners and four independent observers completed questionnaires about the appearance of the patients' breast reconstructions in general and specifically about their nipple-areolar reconstructions. Scores for the general attributes of the breast reconstruction were used as internal controls for the scores of the nipple-areolar reconstruction. A computer software package was developed to analyse colour in photographs of the reconstructions. Independent observers thought that nipple-areolar reconstruction improved the appearance of a breast reconstruction 81% of the time. Considerably fewer patients were happy with their nipple-areolar colour than were happy with the more general attributes of the breast reconstruction (P < 0.005). Colour analysis objectively demonstrated measurable mismatch between normal and reconstructed nipple-areolar skin, which was positively correlated with time since surgery due to fading of the nipple-areolar reconstruction. In our patients, the quality of nipple-areolar reconstruction, in particular its pigmentation, is seen as inferior to that of the rest of the breast reconstruction in the eyes of patients, their partners and independent observers. The poor colour match and fading of reconstructed nipple-areolar skin are phenomena that can be measured using colour analysis.

Immunohistochemical labeling of normal melanocytes

Comparison of seven antibodies for the demonstration of normal melanocytes in formalin-fixed, paraffin-embedded surgical discard skin showed that the monoclonal antibody Mel-5 (clone TA99) directed against pigment associated antigen was the most sensitive. Quantitative data were obtained for the sensitivity of the antibodies NKI/beteb, S100, T311, Melan A (clone A103), c-kit, and Mel-5 in parallel sections of human skin. An anticytokeratin antibody (CK34betaE12) was also used to stain basal keratinocytes and provide a negative image of the melanocytes present. Optimal conditions for the use of Mel-5 in paraffin sections of skin are described.

International clinical recommendations on scar management

Many techniques for management of hypertrophic scars and keloids have been proven through extensive use, but few have been supported by prospective studies with adequate control groups. Several new therapies showed good results in small-scale trials, but these have not been repeated in larger trials with long-term follow-up. This article reports a qualitative overview of the available clinical literature by an international panel of experts using standard methods of appraisal. The article provides evidence-based recommendations on prevention and treatment of abnormal scarring and, where studies are insufficient, consensus on best practice. The recommendations focus on the management of hypertrophic scars and keloids, and are internationally applicable in a range of clinical situations. These recommendations support a move to a more evidence-based approach in scar management. This approach highlights a primary role for silicone gel sheeting and intralesional corticosteroids in the management of a wide variety of abnormal scars. The authors concluded that these are the only treatments for which sufficient evidence exists to make evidence-based recommendations. A number of other therapies that are in common use have achieved acceptance by the authors as standard practice. However, it is highly desirable that many standard practices and new emerging therapies undergo large-scale studies with long-term follow-up before being recommended conclusively as alternative therapies for scar management.

Blindness and severe visual impairment in facial fractures: an 11 year review

We present an 11 year review of facial fractures treated in the Australian Craniofacial Unit and the Department of Plastic and Reconstructive Surgery at the Royal Adelaide Hospital, specifically looking at those fractures in adults that resulted in blindness or severe visual impairment. During the period 1989-2000, a total of 2516 patients with facial fractures were treated operatively. From our facial-fracture database, 317 patients were identified as having an ophthalmological complication on presentation. Of these, 19 had severe visual impairment or blindness. The exact fracture pattern and craniofacial disruption score were recorded for each of these 19 cases using the Cooter-David facial-fracture scoring system. Laterally directed forces are implied as major causative factors in these injuries. Recommendations are made based on these findings.

Effect of healing on the expression of transforming growth factor beta(s) and their receptors in chronic venous leg ulcers

The transforming growth factor betas are of major importance in the wound repair process; however, no studies to date have investigated the role of the transforming growth factor beta receptors in chronic venous leg ulcers or what effect healing has on these proteins. To determine whether the transforming growth factor beta peptides and their receptors are expressed in chronic venous wounds, we used immunofluorescent analysis and quantitative competitive reverse transcription polymerase chain reaction to identify the protein and mRNA expression, respectively. Biopsy samples from wounds and normal skin were collected from 12 patients with chronic venous leg ulcers and three patients undergoing reconstructive surgery, respectively. Additionally four of the chronic venous leg ulcer patients were re-biopsied between 2 and 8 wk after the first biopsy when the wounds had entered the healing phase. The tissue excised from the ulcers included the surrounding intact skin, the ulcer edge, and the ulcer base. Immunofluorescent staining for transforming growth factors beta1, beta2, and beta3 was observed within the epidermis of the skin surrounding the chronic venous ulcers and in fibroblasts and inflammatory cells of the dermis, although this staining was not as strong as that seen in normal unwounded skin. Very little staining could be seen within the ulcers for any of the ligands, however. In contrast the transforming growth factor beta type I receptor was observed throughout the ulcers and the normal unwounded skin biopsies, particularly in the basal epidermal cells. No immunofluorescence for the type II transforming growth factor beta receptor was observed in any of the ulcer biopsies investigated, although it was observed throughout the epidermis and in fibroblasts and inflammatory cells in the surrounding skin. Quantitative, competitive reverse transcription polymerase chain reaction was used to analyze mRNA expression for transforming growth factor beta1 and the type II receptor in the nonhealing ulcers and normal unwounded skin biopsies. These studies revealed that transforming growth factor beta1 and transforming growth factor beta receptor II mRNA was expressed in all the chronic nonhealing ulcers albeit at very low levels for the type II receptor. In marked contrast to the staining observed in nonhealing chronic ulcers, positive immunostaining was observed for the transforming growth factor betas and both the type I and type II receptors in healing ulcers. These results suggest that the absence of a viable receptor complex for the transforming growth factor betas in nonhealing chronic venous ulcers may contribute to wound chronicity.

Mitogenic whey extract stimulates wound repair activity in vitro and promotes healing of rat incisional wounds

The ability of single growth factors to promote healing of normal and compromised wounds has been well described, but wound healing is a process requiring the coordinated action of multiple growth factors. Only the synergistic effect on wound healing of combinations containing at most two individual growth factors has been reported. We sought to assess the ability of a novel milk-derived growth factor-enriched preparation ¿mitogenic bovine whey extract (MBWE), which contains six known growth factors, to promote repair processes in organotypic in vitro models and incisional wounds in vivo. MBWE stimulated the contraction of fibroblast-populated collagen lattices in a dose-dependent fashion and promoted the closure of excisional wounds in embryonic day 17 fetal rat skin. Application of MBWE increased incisional wound strength in normal animals on days 3, 5, 7, and 10 and reversed the decrease in wound strength observed following steroid treatment. Wound histology showed increased fibroblast numbers in wounds from normal and steroid-compromised animals. These data suggest the mixture of factors present in bovine milk exerts a direct action on the cells of cutaneous wound repair to enhance both normal and compromised healing.

Microvascular free-tissue transfers in elderly patients: the leeds experience

Free-tissue transfer in the elderly has received increasing attention in the literature. Existing reports are limited by small samples or inadequate definition of the term elderly. This study reviewed 5 years' experience with free-tissue transfer in a geriatric population (mean age 75 years, range 70 to 83 years). Forty-nine free flaps were performed in 42 patients between 1986 and 1991. This review focuses on the 39 flaps undertaken in 33 head and neck cancer patients, the main indication being reconstruction after tumor resection (80 percent). In the head and neck cancer group, donor sites included the radial forearm (20), rectus abdominis (6), jejunum (5), and others (8). Thirty-four flaps (87 percent) were primarily successful. Reexploration was required in 10 patients (26 percent) for compromised flaps (5) and bleeding (5). Three of the compromised flaps were salvaged, giving an overall flap success rate of 95 percent. One patient (3 percent) died within 30 days of surgery. These results compare favorably with other published series in elderly patients, as well as with larger cohorts of younger subjects. Free flaps are safe in the elderly. Chronologic age alone should not be an exclusion criterion when selecting patients for free-tissue transfer.

Petrosectomies for invasive tumours: surgery and reconstruction

Tumours involving the temporal bone have historically carried a bad prognosis. The only prospect of cure is radical en bloc resection. Temporal bone resection for malignancies is, however, such a formidable undertaking that many centres label such tumours as unresectable. Additionally, the enormity of the surgical defect poses a major reconstructive challenge. A review of 14 petrosectomies (in 12 males and 2 females) performed for extensively invasive neoplasms in and around the ear is presented. All underwent immediate reconstruction, the majority (12/14) with free tissue transfers. 9 of the 14 patients (64%) are still alive after a mean follow-up of 70 months (range 4-8 years). With the use of free tissue transfers, an aggressive approach with regard to the resection margins can safely be adopted in the full knowledge that the eventual size of the defect need not compromise tumour clearance. Additionally, free flaps provided a reliable dural seal. This approach of radical en bloc resection with free flap reconstruction has decreased the mortality (compared to the literature), while largely reducing the morbidity to that of unavoidable cranial nerve resection.

The influence of maxillary dentures on mid-facial fracture patterns

The presence of upper arch dentures modifies fracture patterns occurring in mid-facial trauma. The fracture patterns of 16 upper denture wearers suffering maxillary fractures were retrospectively studied. Mid-facial fractures in this group were predominantly of the Le Fort I type and in 14 patients demonstrated an atypical fracture path with a vertical fracture passing from the main Le Fort I fracture to the inferior orbital rim. Full upper arch dentures generally protected the upper alveolus from fracture but, where there was discontinuity of the prosthesis, alveolar fractures mirroring the edge of the denture as it crossed the alveolar region were seen. These findings should alert the clinician to the possibility of unusual maxillary fractures in denture wearers and aid our understanding of fracture patterns in the mid-facial skeleton.

Submucous cleft palate with a discontinuous bony deformity

An unusual submucous palatal cleft is presented. In addition to the usual triad of bifid uvula, posterior bony notching, and diastasis of the velar musculature, there was a linear bony cleft involving only the maxillary component of the hard palate. The palatine bone was intact between the posterior notch and the maxillary cleft. A discontinuous palatal cleft is an extremely rare deformity and is interesting because existing theories of cleft pathogenesis do not readily explain such a defect.

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.

Burn wound zygomycosis caused by Apophysomyces elegans

A case of zygomycosis caused by Apophysomyces elegans in a patient having 25% full-thickness burns is described. Amputation of the leg was necessary to control rapid tissue invasion. The fungus was isolated from soil in the burn environment.

Oblique craniofacial fractures in children

The protected childhood environment and the anatomy of the craniofacial skeleton largely protect children from experiencing facial fractures. However, when major trauma to the head and face is sustained, an oblique pattern of fractures has been observed, distinct from those common in adults and explicable in terms of the anatomic differences between the child's and the adult's head and face. This difference in pattern of facial fracturing is relevant in terms of the examination, investigation and treatment of the primary injury, and prevention of any subsequent facial growth disturbances.

Computed tomography in the assessment of protective helmet deformation

Damage to a helmet worn by a motorcyclist or pedal cyclist involved in a crash can provide information of importance to those investigating impact responses of the helmeted head. In the past the retrieval of this information has been incomplete as it has involved the destructive dismantling of a helmet into its component layers. Conventional radiology, whilst being noninvasive, has the disadvantage that all structures traversed by the X-ray beam are superimposed in the final image. In an attempt to overcome the limitations of existing methods, computed tomography (CT) was evaluated in a study of 25 protective helmets. This was found to be an informative, noninvasive technique of investigation that provided faithful images of each helmet layer and delineated helmet damage that was not observed with other methods. Additional advantages of CT include the ease of computed data storage, the ability to reformat CT data into a variety of planes as either two- or three- dimensional images, and the facility to measure distance and density. Limiting factors include scanning cost and artefacts produced by metal in the helmet.

Pontomedullary tears and other gross brainstem injuries after vehicular accidents

In a series of 988 autopsied victims of road crashes, there were 36 (3.6%) cases of gross primary brainstem injury. These fell into three groups. The first comprised eight cases of pontomedullary tearing without other gross brain injury: in seven of these, there were associated atlanto-occipital dislocations and/or high cervical fracture-dislocations. The usual cause appeared to be facial impact inducing acute hyperextension. Second, there were 17 cases of pontomedullary tearing associated with other brainstem lacerations and/or major damage elsewhere in the brain: in all, there were fractures of the skull base, typically transverse middle fossa fractures. Most of these injuries appeared to be due to facial impacts transmitting force to the anterior skull base, although hyperextension was also a factor in some. There was a third heterogeneous group of 11 cases with brainstem lacerations in sites other than the pontomedullary junction: in some of these it appeared that the impacts had caused skull base fractures by inducing calvarial torsion. In this series, the proportion of motorcyclists (41.7%) was double the expected figure. The use of a helmet modifies the mechanisms of impact head injury; the overall benefits of helmet use are well established, but there is need for more research on helmet design.

Tessier clefts revisited with a third dimension

The classification by Tessier of rare craniofacial clefts brought, for the surgeon, order to a previously confusing array of anatomic and developmental descriptions. An ordered two-dimensional categorization of severe clefting malformations evolved from his clinical, radiologic, and surgical observations. The purpose of this paper is to report a complete series of facial clefts studied with computed tomography (CT) and three-dimensional reconstruction. The CT analysis supports some, but contradicts other, hypotheses and speculations presented by Tessier. The CT data reveal the scale of the reconstructive challenge and allow the assessment of our therapeutic interventions.

The Tessier number 9 cleft

The clinical, radiologic, and operative examination of two patients with the Tessier number 9 cleft has allowed the first complete description of this, the rarest of the rare craniofacial clefts. Soft-tissue disruption extends from the lateral third of the upper eyelid through a distorted lateral end of the eyebrow to the temporal scalp, with an associated hairline indicator. The skeletal disturbance similarly radiates superolaterally from the superolateral orbital rim across the greater wing of the splenoid to the upper squamous temporal. The three-dimensional extent of the bony disruption is associated with distortion of the cranial base and calvaria above.

Computer-based coding of fractures in the craniofacial region

A systematic approach to the coding of fractures in the craniofacial region is presented. An alpha-numeric code is formulated from an alpha component depicting the anatomical region of interest and a number which reflects the degree of disruption.

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.

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.