THE WESTERN JOURNAL OF MEDICINE
THE
WESTERN
JOURNAL
OF
MEDICINE
o *
FEBRUARY 1991 FEBRUARY
1991
o *
154 154
o
*
melanoma. Interleukin 2 and lymphokine-activated killer cells have also been effective: Response rates with this combination have been 20% to 30%. Treatment recommendations, therefore, include wide surgical extirpation for thick melanomas, selective regional adenectomy, and systemic therapy in some patients. ALAN E. SEYFER, MD Portland, Oregon
REFERENCES Bergmann L: Malignant melanoma-Prognosis and actual treatment strategies with chemotherapy and biological response modifiers. Eur J Cancer Clin Oncol 1989; 25 (Suppl 3):S31-S36 Creagan ET: Regional and systemic strategies for metastatic malignant melanoma. Mayo Clin Proc 1989; 64:852-860 Legha SS: Current therapy for malignant melanoma. Semin Oncol 1989; 16 (Suppl 1):34-44 Mastrangelo MJ, Schultz S, Kane M, Berd D: Newer immunologic approaches to the treatment of patients with melanoma. Semin Oncol 1988; 15:589-594
2
205
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2
tinues to expand the lower extremity reconstructive horizons. The application of the insensate scapular free flap with its thin, well-vascularized skin paddle has recently been described for the treatment of foot wounds. If this skin is carefully tailored and the excess trimmed, it is possible to achieve foot reconstruction on the plantar surface. It is now known that the fibula transferred as a vascularized graft can be osteotomized and folded on itself to provide a strong reconstruction for the tibia. A recent series reinforces the concept that osteomyelitis can be successfully managed by bone debridement, free muscle transfer, and delayed bone grafting. Free tissue transfer techniques are being applied to patients with severe peripheral vascular disease in whom the only alternative is amputation. THOMAS R. STEVENSON, MD
Sacramento, California REFERENCES
Lower Extremity Reconstruction LOWER
following seinclude restoring limb function, covering vital structures, and maintaining a satisfactory appearance. Techniques available to meet these goals include fasciocutaneous flaps, muscle flaps, tissue expansion, and free tissue transfer. Several new procedures have been introduced that expand treatment alternatives and permit the successful management of lower extremity soft tissue and bone defects. Deficits involving skin and subcutaneous tissue are amenable to treatment using skin grafts, pedicle flaps with or without a defined vascular supply, and fasciocutaneous flaps. The lateral supramalleolar flap has been described recently and offers stable soft tissue coverage of the lateral malleolus. Fasciocutaneous flaps have shown their usefulness in the soft tissue reconstruction of the distal lower leg. Finally, V-Y flaps of skin and fascia based on perforating vessels entering the flap from its deep surface have been used to cover metatarsal heads, the posterior heel, and the lateral malleolus. These V-Y flaps appear reliable and are versatile in design. Muscle and musculocutaneous flaps continue to demonstrate their versatility. The biceps femoris musculocutaneous flap has been shown to have an extended application in lesions of the anterolateral thigh. The medial gastrocnemius muscle is being used with increasing frequency to cover a threatened or exposed knee prosthesis. In addition, muscle transferred into a fibrotic cavity has been shown to increase the antibiotic concentration in that area. Tissue expansion in the lower leg offers promise for difficult scar reconstructions but has a higher complication rate than in other areas because of problems with skin instability and the constricting deep fascial layer. When appropriate precautions are taken, however, tissue expansion for lesions below the knee can be done successfully. This involves the use of a temporary silastic bag injected with an increasing volume of a saline solution. A recent innovation has had an effect on orthopedic and plastic surgery. After a careful corticotomy is done, bone can be slowly separated using an external fixator, with the regeneration of new bone at the osteotomy site. This permits the lengthening of bone along with the correction of angulation and rotational deformities. This technique may prove useful in the treatment of the bony deficit in osteomyelitis. The area of bone infection could be excised and the proximal bone lengthened to bridge the deficit. Free tissue transfer using microsurgical techniques conEXTREMITY RECONSTRUCrIVE GOALS
vere trauma
Manders EK, Oaks TE, Au VK, et al: Soft-tissue expansion in the lower extremities. Plast Reconstr Surg 1988; 81:208-219 Masquelet AC, Beveridge J, Romana C, Gerber C: The lateral supramalleolar flap. Plast Reconstr Surg 1988; 81:74-81 Seyfer AE, Lower R: Late results of free-muscle flaps and delayed bone grafting in the secondary treatment of open tibial fractures. Plast Reconstr Surg 1989; 83:77-84
Facial Reanimation RESTORING NORMAL facial movement after facial nerve damage is challenging. Spontaneous animation and the creation of a normal balanced smile can only be accomplished by reinnervating the paralyzed facial muscles with facial nerve fibers from the ipsilateral side. Therefore, in cases of distal seventh nerve injuries, interpositional nerve graft reconstruction is the most physiologic approach. If facial paralysis is due to intracranial injury, however, other more complicated forms of reconstruction are necessary. Nerves from the ipsilateral side of the face can be transferred to the distal facial nerve to reinnervate the muscles. These include the hypoglossal, lingual, phrenic, greater auricular, spinal accessory, and the ansa-cervicalis. Portions of the temporalis, masseteric, and frontalis muscles can be transferred to mimic facial muscle movement. Muscle contractions after such techniques are not spontaneous, and a synthetic smile must be learned and practiced. With the introduction of microvascular surgery, techniques have been devised to create more spontaneous facial muscle activity. A cross-facial nerve graft and a functional muscle transplantation are used in a two-stage operation to reanimate the face. During the first stage, a sural nerve graft is connected to distal branches of marginal mandibular, buccal, or zygomatic branches of the unparalyzed facial nerve. This nerve graft is tunneled subcutaneously below the lip. The free end of the nerve graft is left subcutaneous near the tragus on the paralyzed side. Over the next six to eight months, the axons from the unparalyzed side grow across the sural nerve graft to the paralyzed side. The axonal growth can be followed by percussing over the nerve graft until an electrical shock sensation is elicited. Once Tinel's sign is detected on the paralyzed portion of the face, the second-stage operation is done. A frozen-section biopsy of the free end of the cross-facial nerve graft is done to determine if axons have in fact grown from the unparalyzed side to the paralyzed side. If axons are present on frozen section, then the serratus anterior muscle is transplanted from the back to the face. The artery and vein to the
EPITOMES-PLASTIC SURGERY
206
EPITOMES-PLASTIC SURGERY
206
serratus anterior are microsurgically anastomosed to the facial artery and vein. The free end of the sural nerve graft is repaired to the long thoracic nerve of the serratus anterior muscle. The nerve will eventually grow into the newly transplanted muscle and functionally innervate the muscle. Eventually, when the patient moves the unparalyzed side of the face, nerve impulses will travel across the nerve graft and stimulate the transplanted serratus anterior muscle. This approach can restore some spontaneous animation, particularly in patients younger than 50. GREGORY M. BUNCKE, MD San Francisco, California
REFERENCES Buncke HJ, Whitney TM, Milliken RG: Facial paralysis, In Buncke HJ (Ed): Microsurgery Replantation Transplantation-An Atlas Test. Philadelphia, Pa, Lea & Febiger, 1990 Harii K: Treatment of longstanding facial paralysis by combining vascularized muscle transplantation with crossface nerve grafting, In Buncke HJ, Furnas DW (Eds): Symposium on Clinical Frontiers in Reconstructive Microsurgery. St Louis, Mo, CV Mosby, 1984, pp 159-171 Manktelow RT: Free muscle transplantation for facial paralysis. Clin Plast Surg 1984; 11:215-220 Seckel BR, Upton J, Jones HR Jr, Murray JE: Rapid regeneration of the chronically damaged facial nerve following ipsilateral free gracilis transfer. Plast Reconstr Surg 1983; 71:845-854
Soft Tissue Augmentation IDENTIFYING A SAFE, lasting substance for use in soft tissue augmentation continues to challenge plastic surgeons and dermatologists. The most widely accepted substrate for such use is Zyderm collagen implant, approved by the Food and Drug Administration (FDA) in 1981. It is composed of enzymatically purified bovine collagen suspended in a saline solution and comes in two concentrations, Zyderm I and II. Both are recommended for the diminution of facial wrinkles, acne scars, and other depressed scars. Neither is recommended for larger defects. Correction is transient, and touch-ups are necessary every 4 to 12 months to maintain correction. Zyplast, collagen cross-linked by glutaraldehyde, was introduced in 1985. The cross-linking stabilizes the collagen against degradation but not to the extent initially hoped. Touch-ups are required on a 4- to 24-month basis. The use of Zyplast is recommended for the correction of deeper contour deficiencies. Pretreatment skin tests to determine hypersensitivity are necessary. It is now recommended the skin test be repeated at four weeks to decrease the incidence of treatmentassociated hypersensitivity reactions. There has been a continual interest in autologous fat grafting since its first use in 1893. Doubts linger as to the stability of correction beyond three to four months, and many still doubt the efficacy of this technique. Small fat grafts (4 to 6 mm in diameter) have been injected in a manner similar to the use of collagen with variable results. Supporters of the technique argue that correction lasts longer and sensitivity reactions are less severe. All agree that resorption will occur, and overcorrection and touch-ups are necessary. Inflammatory reactions, firmness, and lumpiness have been reported. In the laboratory, an adipocyte precursor with the potential to differentiate into mature adipocytes has been identified. Single-cell suspensions of these cells may show promise in creating true fat pads where injected. Fibrel gelatin matrix implant has been approved by the FDA for the treatment of depressed scars. Reports claim an average loss of correction by 20% at two years. Local reactions have been mild, and no other adverse reactions have yet
been reported. Medical grade silicone (polydimethylsiloxane) is not commercially available but continues to be used by a few practitioners. When used, proper technique is essential; there is no room for error. Technique-related problems and severe local reactions to the silicone have been reported. JANE S. WESTON, MD Palo Alto, California REFERENCES
Billings E Jr, May JW Jr: Historical review and present status of free fat graft autotransplantation in plastic and reconstructive surgery. Plast Reconstr Surg 1989;
83:368-381 Klein AW: Indications and implantation techniques for the various formulations of injectable collagen. J Dermatol Surg Oncol 1988; 14 (Suppl 1):27-30 Klein AW, Rish DC: Substances for soft tissue augmentation: Collagen and silicone. J Dermatol Surg Oncol 1985; 11:337-339 Millikan L: Long-term safety and efficacy with Fibrel in the treatment of cutaneous scars-Results of a multicenter study. J Dermatol Surg Oncol 1989; 15:837-842 Moscona R, Ullman Y, Har-Shai Y, Hirshowitz B: Free-fat injections for the correction of hemifacial atrophy. Plast Reconstr Surg 1989; 84:501-507
Maxillofacial Trauma THE DIAGNOSIS, management, and treatment of complex craniomaxillofacial trauma are challenging for plastic and reconstructive surgeons. Maxillofacial trauma is usually considered a phenomenon of youth, but current population trends indicate the average age is increasing. There is a 50% longer median hospital stay in patients older than 65 compared with younger groups. This increased time is due to multisystem injuries, rather than the extent of maxillofacial fracture. Periodontal disease, bone resorption, and dental restorations or missing teeth are much more frequent in the geriatric age group. Rigid internal miniplate fixation eliminates some of the problems of intermaxillary wire fixation, resulting in fewer complications-that is, less risk to crown or bridge work, less weight loss, and decreased breathing
problems. The timing and staging of craniofacial fractures repair have traditionally been weighed against other possible lifethreatening conditions. The early repair of facial fractures does not appear to affect adversely the recovery or outcome in patients with head injuries, however. Much attention has recently been focused on rigid fixation (miniplates) as a method of improving fracture healing. It has been shown that fixation by means of interfragmental stabilization and compression tends to neutralize torsional and sheer forces, allowing primary bone healing and union. Rigid fixation is therefore indicated in cases where onlay bone grafts may be exposed to motion, shear, and torsional forces. Recent contributions clearly substantiate the basic principles of maxillofacial treatment: accurate diagnosis, early anatomic fracture reduction, stable osseous fixation, and the restoration of preinjury occlusion. The care of older patients will continue to be challenging. ROBERT A. HARDESTY, MD Loma Linda,
California
REFERENCES Davidson J, Nickerson D, Nickerson B: Zygomatic fractures: Comparison of methods of internal fixation. Plast Reconstr Surg 1990; 86:25-32 Derdyn C, Persing JA, Broaddus WC, et al: Craniofacial trauma: An assessment of risks related to timing of surgery. Plast Reconstr Surg 1990; 86:238-245 Falcone PA, Haedicke GJ, Brooks G, Sullivan PK: Maxillofacial fractures in the elderly: A comparative study. Plast Reconstr Surg 1990; 86:443-448 Gruss JS, Van Wyck L, Phillips JH, Antonyshyn 0: The importance of the zygomatic arch in complex midfacial fracture repair and correction of posttraumatic orbitozygomatic deformities. Plastic Reconstr Surg 1990; 85:878-890 Lin KY, Bartlett SP, Yaremchuk MJ, Falloon M, Grossman RF, Whitaker LA: The effect of rigid fixation on the survival of onlay bone grafts: An experimental study. Plast Reconstr Surg 1990; 86:449456
THE
WESTERN
JOURNAL
OF
MEDICINE
o *
FEBRUARY 1991 FEBRUARY
1991
o *
154 154
o
*
melanoma. Interleukin 2 and lymphokine-activated killer cells have also been effective: Response rates with this combination have been 20% to 30%. Treatment recommendations, therefore, include wide surgical extirpation for thick melanomas, selective regional adenectomy, and systemic therapy in some patients. ALAN E. SEYFER, MD Portland, Oregon
REFERENCES Bergmann L: Malignant melanoma-Prognosis and actual treatment strategies with chemotherapy and biological response modifiers. Eur J Cancer Clin Oncol 1989; 25 (Suppl 3):S31-S36 Creagan ET: Regional and systemic strategies for metastatic malignant melanoma. Mayo Clin Proc 1989; 64:852-860 Legha SS: Current therapy for malignant melanoma. Semin Oncol 1989; 16 (Suppl 1):34-44 Mastrangelo MJ, Schultz S, Kane M, Berd D: Newer immunologic approaches to the treatment of patients with melanoma. Semin Oncol 1988; 15:589-594
2
205
205
2
tinues to expand the lower extremity reconstructive horizons. The application of the insensate scapular free flap with its thin, well-vascularized skin paddle has recently been described for the treatment of foot wounds. If this skin is carefully tailored and the excess trimmed, it is possible to achieve foot reconstruction on the plantar surface. It is now known that the fibula transferred as a vascularized graft can be osteotomized and folded on itself to provide a strong reconstruction for the tibia. A recent series reinforces the concept that osteomyelitis can be successfully managed by bone debridement, free muscle transfer, and delayed bone grafting. Free tissue transfer techniques are being applied to patients with severe peripheral vascular disease in whom the only alternative is amputation. THOMAS R. STEVENSON, MD
Sacramento, California REFERENCES
Lower Extremity Reconstruction LOWER
following seinclude restoring limb function, covering vital structures, and maintaining a satisfactory appearance. Techniques available to meet these goals include fasciocutaneous flaps, muscle flaps, tissue expansion, and free tissue transfer. Several new procedures have been introduced that expand treatment alternatives and permit the successful management of lower extremity soft tissue and bone defects. Deficits involving skin and subcutaneous tissue are amenable to treatment using skin grafts, pedicle flaps with or without a defined vascular supply, and fasciocutaneous flaps. The lateral supramalleolar flap has been described recently and offers stable soft tissue coverage of the lateral malleolus. Fasciocutaneous flaps have shown their usefulness in the soft tissue reconstruction of the distal lower leg. Finally, V-Y flaps of skin and fascia based on perforating vessels entering the flap from its deep surface have been used to cover metatarsal heads, the posterior heel, and the lateral malleolus. These V-Y flaps appear reliable and are versatile in design. Muscle and musculocutaneous flaps continue to demonstrate their versatility. The biceps femoris musculocutaneous flap has been shown to have an extended application in lesions of the anterolateral thigh. The medial gastrocnemius muscle is being used with increasing frequency to cover a threatened or exposed knee prosthesis. In addition, muscle transferred into a fibrotic cavity has been shown to increase the antibiotic concentration in that area. Tissue expansion in the lower leg offers promise for difficult scar reconstructions but has a higher complication rate than in other areas because of problems with skin instability and the constricting deep fascial layer. When appropriate precautions are taken, however, tissue expansion for lesions below the knee can be done successfully. This involves the use of a temporary silastic bag injected with an increasing volume of a saline solution. A recent innovation has had an effect on orthopedic and plastic surgery. After a careful corticotomy is done, bone can be slowly separated using an external fixator, with the regeneration of new bone at the osteotomy site. This permits the lengthening of bone along with the correction of angulation and rotational deformities. This technique may prove useful in the treatment of the bony deficit in osteomyelitis. The area of bone infection could be excised and the proximal bone lengthened to bridge the deficit. Free tissue transfer using microsurgical techniques conEXTREMITY RECONSTRUCrIVE GOALS
vere trauma
Manders EK, Oaks TE, Au VK, et al: Soft-tissue expansion in the lower extremities. Plast Reconstr Surg 1988; 81:208-219 Masquelet AC, Beveridge J, Romana C, Gerber C: The lateral supramalleolar flap. Plast Reconstr Surg 1988; 81:74-81 Seyfer AE, Lower R: Late results of free-muscle flaps and delayed bone grafting in the secondary treatment of open tibial fractures. Plast Reconstr Surg 1989; 83:77-84
Facial Reanimation RESTORING NORMAL facial movement after facial nerve damage is challenging. Spontaneous animation and the creation of a normal balanced smile can only be accomplished by reinnervating the paralyzed facial muscles with facial nerve fibers from the ipsilateral side. Therefore, in cases of distal seventh nerve injuries, interpositional nerve graft reconstruction is the most physiologic approach. If facial paralysis is due to intracranial injury, however, other more complicated forms of reconstruction are necessary. Nerves from the ipsilateral side of the face can be transferred to the distal facial nerve to reinnervate the muscles. These include the hypoglossal, lingual, phrenic, greater auricular, spinal accessory, and the ansa-cervicalis. Portions of the temporalis, masseteric, and frontalis muscles can be transferred to mimic facial muscle movement. Muscle contractions after such techniques are not spontaneous, and a synthetic smile must be learned and practiced. With the introduction of microvascular surgery, techniques have been devised to create more spontaneous facial muscle activity. A cross-facial nerve graft and a functional muscle transplantation are used in a two-stage operation to reanimate the face. During the first stage, a sural nerve graft is connected to distal branches of marginal mandibular, buccal, or zygomatic branches of the unparalyzed facial nerve. This nerve graft is tunneled subcutaneously below the lip. The free end of the nerve graft is left subcutaneous near the tragus on the paralyzed side. Over the next six to eight months, the axons from the unparalyzed side grow across the sural nerve graft to the paralyzed side. The axonal growth can be followed by percussing over the nerve graft until an electrical shock sensation is elicited. Once Tinel's sign is detected on the paralyzed portion of the face, the second-stage operation is done. A frozen-section biopsy of the free end of the cross-facial nerve graft is done to determine if axons have in fact grown from the unparalyzed side to the paralyzed side. If axons are present on frozen section, then the serratus anterior muscle is transplanted from the back to the face. The artery and vein to the
EPITOMES-PLASTIC SURGERY
206
EPITOMES-PLASTIC SURGERY
206
serratus anterior are microsurgically anastomosed to the facial artery and vein. The free end of the sural nerve graft is repaired to the long thoracic nerve of the serratus anterior muscle. The nerve will eventually grow into the newly transplanted muscle and functionally innervate the muscle. Eventually, when the patient moves the unparalyzed side of the face, nerve impulses will travel across the nerve graft and stimulate the transplanted serratus anterior muscle. This approach can restore some spontaneous animation, particularly in patients younger than 50. GREGORY M. BUNCKE, MD San Francisco, California
REFERENCES Buncke HJ, Whitney TM, Milliken RG: Facial paralysis, In Buncke HJ (Ed): Microsurgery Replantation Transplantation-An Atlas Test. Philadelphia, Pa, Lea & Febiger, 1990 Harii K: Treatment of longstanding facial paralysis by combining vascularized muscle transplantation with crossface nerve grafting, In Buncke HJ, Furnas DW (Eds): Symposium on Clinical Frontiers in Reconstructive Microsurgery. St Louis, Mo, CV Mosby, 1984, pp 159-171 Manktelow RT: Free muscle transplantation for facial paralysis. Clin Plast Surg 1984; 11:215-220 Seckel BR, Upton J, Jones HR Jr, Murray JE: Rapid regeneration of the chronically damaged facial nerve following ipsilateral free gracilis transfer. Plast Reconstr Surg 1983; 71:845-854
Soft Tissue Augmentation IDENTIFYING A SAFE, lasting substance for use in soft tissue augmentation continues to challenge plastic surgeons and dermatologists. The most widely accepted substrate for such use is Zyderm collagen implant, approved by the Food and Drug Administration (FDA) in 1981. It is composed of enzymatically purified bovine collagen suspended in a saline solution and comes in two concentrations, Zyderm I and II. Both are recommended for the diminution of facial wrinkles, acne scars, and other depressed scars. Neither is recommended for larger defects. Correction is transient, and touch-ups are necessary every 4 to 12 months to maintain correction. Zyplast, collagen cross-linked by glutaraldehyde, was introduced in 1985. The cross-linking stabilizes the collagen against degradation but not to the extent initially hoped. Touch-ups are required on a 4- to 24-month basis. The use of Zyplast is recommended for the correction of deeper contour deficiencies. Pretreatment skin tests to determine hypersensitivity are necessary. It is now recommended the skin test be repeated at four weeks to decrease the incidence of treatmentassociated hypersensitivity reactions. There has been a continual interest in autologous fat grafting since its first use in 1893. Doubts linger as to the stability of correction beyond three to four months, and many still doubt the efficacy of this technique. Small fat grafts (4 to 6 mm in diameter) have been injected in a manner similar to the use of collagen with variable results. Supporters of the technique argue that correction lasts longer and sensitivity reactions are less severe. All agree that resorption will occur, and overcorrection and touch-ups are necessary. Inflammatory reactions, firmness, and lumpiness have been reported. In the laboratory, an adipocyte precursor with the potential to differentiate into mature adipocytes has been identified. Single-cell suspensions of these cells may show promise in creating true fat pads where injected. Fibrel gelatin matrix implant has been approved by the FDA for the treatment of depressed scars. Reports claim an average loss of correction by 20% at two years. Local reactions have been mild, and no other adverse reactions have yet
been reported. Medical grade silicone (polydimethylsiloxane) is not commercially available but continues to be used by a few practitioners. When used, proper technique is essential; there is no room for error. Technique-related problems and severe local reactions to the silicone have been reported. JANE S. WESTON, MD Palo Alto, California REFERENCES
Billings E Jr, May JW Jr: Historical review and present status of free fat graft autotransplantation in plastic and reconstructive surgery. Plast Reconstr Surg 1989;
83:368-381 Klein AW: Indications and implantation techniques for the various formulations of injectable collagen. J Dermatol Surg Oncol 1988; 14 (Suppl 1):27-30 Klein AW, Rish DC: Substances for soft tissue augmentation: Collagen and silicone. J Dermatol Surg Oncol 1985; 11:337-339 Millikan L: Long-term safety and efficacy with Fibrel in the treatment of cutaneous scars-Results of a multicenter study. J Dermatol Surg Oncol 1989; 15:837-842 Moscona R, Ullman Y, Har-Shai Y, Hirshowitz B: Free-fat injections for the correction of hemifacial atrophy. Plast Reconstr Surg 1989; 84:501-507
Maxillofacial Trauma THE DIAGNOSIS, management, and treatment of complex craniomaxillofacial trauma are challenging for plastic and reconstructive surgeons. Maxillofacial trauma is usually considered a phenomenon of youth, but current population trends indicate the average age is increasing. There is a 50% longer median hospital stay in patients older than 65 compared with younger groups. This increased time is due to multisystem injuries, rather than the extent of maxillofacial fracture. Periodontal disease, bone resorption, and dental restorations or missing teeth are much more frequent in the geriatric age group. Rigid internal miniplate fixation eliminates some of the problems of intermaxillary wire fixation, resulting in fewer complications-that is, less risk to crown or bridge work, less weight loss, and decreased breathing
problems. The timing and staging of craniofacial fractures repair have traditionally been weighed against other possible lifethreatening conditions. The early repair of facial fractures does not appear to affect adversely the recovery or outcome in patients with head injuries, however. Much attention has recently been focused on rigid fixation (miniplates) as a method of improving fracture healing. It has been shown that fixation by means of interfragmental stabilization and compression tends to neutralize torsional and sheer forces, allowing primary bone healing and union. Rigid fixation is therefore indicated in cases where onlay bone grafts may be exposed to motion, shear, and torsional forces. Recent contributions clearly substantiate the basic principles of maxillofacial treatment: accurate diagnosis, early anatomic fracture reduction, stable osseous fixation, and the restoration of preinjury occlusion. The care of older patients will continue to be challenging. ROBERT A. HARDESTY, MD Loma Linda,
California
REFERENCES Davidson J, Nickerson D, Nickerson B: Zygomatic fractures: Comparison of methods of internal fixation. Plast Reconstr Surg 1990; 86:25-32 Derdyn C, Persing JA, Broaddus WC, et al: Craniofacial trauma: An assessment of risks related to timing of surgery. Plast Reconstr Surg 1990; 86:238-245 Falcone PA, Haedicke GJ, Brooks G, Sullivan PK: Maxillofacial fractures in the elderly: A comparative study. Plast Reconstr Surg 1990; 86:443-448 Gruss JS, Van Wyck L, Phillips JH, Antonyshyn 0: The importance of the zygomatic arch in complex midfacial fracture repair and correction of posttraumatic orbitozygomatic deformities. Plastic Reconstr Surg 1990; 85:878-890 Lin KY, Bartlett SP, Yaremchuk MJ, Falloon M, Grossman RF, Whitaker LA: The effect of rigid fixation on the survival of onlay bone grafts: An experimental study. Plast Reconstr Surg 1990; 86:449456
