Design and manufacturing of a patient-specific nasal implant for congenital arhinia: Case report

Arhinia (congenital absence of the nose) is a congenital rare disease, which has been reported in less than 60 cases in the literature. It consists of the absence of external nose, nasal cavities and olfactory apparatus and is generally associated with midline defects, microphthalmia, blepharophimosis and hypotelorism. Aesthetic problems as well as associated functional anomalies can potentially impact on the development and interpersonal relationships of the child at a later stage in life.

Arhinia requires extensive management in early life in order to ensure airway patency and protection by means of tracheostomy, and to allow adequate pharyngeal and feeding function to the child. Aesthetic issues are managed with reconstructive surgery or an external prosthesis. There is no previous description in Literature of internal prosthetic devices used to sequentially shape soft tissues in complex reconstruction.

We present an example of design and manufacturing of a bespoke nose implant produced by means of 3D printing and directly assessed on-table by means of 3D surface scanning.

Analysis of the Fgfr2C342Y mouse model shows condensation defects due to misregulation of Sox9 expression in prechondrocytic mesenchyme

Syndromic craniosynostosis caused by mutations in FGFR2 is characterised by developmental pathology in both endochondral and membranous skeletogenesis. Detailed phenotypic characterisation of features in the membranous calvarium, the endochondral cranial base and other structures in the axial and appendicular skeleton has not been performed at embryonic stages. We investigated bone development in the Crouzon mouse model (Fgfr2^C342Y) at pre- and post-ossification stages to improve understanding of the underlying pathogenesis. Phenotypic analysis was performed by whole-mount skeletal staining (Alcian Blue/Alizarin Red) and histological staining of sections of CD1 wild-type (WT), Fgfr2^C342Y/+ heterozygous (HET) and Fgfr2^C342Y/C342Y homozygous (HOM) mouse embryos from embryonic day (E)12.5-E17.5 stages. Gene expression (Sox9, Shh, Fgf10 and Runx2) was studied by in situ hybridisation and protein expression (COL2A1) by immunohistochemistry. Our analysis has identified severely decreased osteogenesis in parts of the craniofacial skeleton together with increased chondrogenesis in parts of the endochondral and cartilaginous skeleton in HOM embryos. The Sox9 expression domain in tracheal and basi-cranial chondrocytic precursors at E13.5 in HOM embryos is increased and expanded, correlating with the phenotypic observations which suggest FGFR2 signalling regulates Sox9 expression. Combined with abnormal staining of type II collagen in pre-chondrocytic mesenchyme, this is indicative of a mesenchymal condensation defect. An expanded spectrum of phenotypic features observed in the Fgfr2^C342Y/C342Y mouse embryo paves the way towards better understanding the clinical attributes of human Crouzon-Pfeiffer syndrome. FGFR2 mutation results in impaired skeletogenesis; however, our findings suggest that many phenotypic aberrations stem from a primary failure of pre-chondrogenic/osteogenic mesenchymal condensation and link FGFR2 to SOX9, a principal regulator of skeletogenesis.

Combined soft and skeletal tissue modelling of normal and dysmorphic midface postnatal development

BACKGROUND

Midface hypoplasia as exemplified by Treacher Collins Syndrome (TCS) can impair appearance and function. Reconstruction involves multiple invasive surgeries with variable long-term outcomes. This study aims to describe normal and dysmorphic midface postnatal development through combined modelling of skeletal and soft tissues and to develop a surgical evaluation tool.

MATERIALS AND METHODS

Midface skeletal and soft tissue surfaces were extracted from computed tomography scans of 52 control and 14 TCS children, then analysed using dense surface modelling. The model was used to describe midface growth, morphology, and asymmetry, then evaluate postoperative outcomes.

RESULTS

Parameters responsible for the greatest variation in midface size and shape showed differences between TCS and controls with close alignment between skeletal and soft tissue models. TCS children exhibited midface dysmorphology and hypoplasia when compared with controls. Asymmetry was also significantly higher in TCS midfaces. Combined modelling was used to evaluate the impact of surgery in one TCS individual who showed normalisation immediately after surgery but reversion towards TCS dysmorphology after 1 year.

CONCLUSION

This is the first quantitative analysis of postnatal midface development using combined modelling of skeletal and soft tissues. We also provide an approach for evaluation of surgical outcomes, laying the foundations for future development of a preoperative planning tool.

Small Molecule Inhibition of Transforming Growth Factor Beta Signaling Enables the Endogenous Regenerative Potential of the Mammalian Calvarium

Current approaches for the treatment of skeletal defects are suboptimal, principally because the ability of bone to repair and regenerate is poor. Although the promise of effective cellular therapies for skeletal repair is encouraging, these approaches are limited by the risks of infection, cellular contamination, and tumorigenicity. Development of a pharmacological approach would therefore help avoid some of these potential risks. This study identifies transforming growth factor beta (TGFβ) signaling as a potential pathway for pharmacological modulation in vivo. We demonstrate that inhibition of TGFβ signaling by the small molecule SB431542 potentiates calvarial skeletal repair through activation of bone morphogenetic protein (BMP) signaling on osteoblasts and dura mater cells participating in healing of calvarial defects. Cells respond to inhibition of TGFβ signaling by producing higher levels of BMP2 that upregulates inhibitory Smad6 expression, thus providing a negative feedback loop to contain excessive BMP signaling. Importantly, study on human osteoblasts indicates that molecular mechanism(s) triggered by SB431542 are conserved. Collectively, these data provide insights into the use of small molecules to modulate key signaling pathways for repairing skeletal defects.

Frontofacial surgery in children and adolescents: techniques, indications, outcomes

The techniques of frontofacial surgery are most valuable in the clinical management of complex craniofacial deformity to achieve a range of functional and aesthetic gains in children from infancy to maturity. A variety of complex craniofacial osteotomies that can be used to separate the orbits from the skull base have been described. In addition, the combination of circumorbital release and pterygomaxillary disjunction allows advancement of the orbitomaxillary segment for powerful clinical benefit. For the purpose of this article, the principal frontofacial strategies include the monobloc frontofacial advancement by distraction (MBD), frontofacial bipartition advancement by distraction (BpD), orbital box osteotomy (FFBx), and frontofacial bipartition (FFBp). These techniques are broadly used for two purposes: to allow for the translocation of one or both orbits to correct orbitofacial disproportion (hypertelorism, vertical orbital dystopia, or a combination of both), or to advance the orbitomaxillary segment for orbital volume expansion and protection of the eye in syndromes featuring severe exorbitism (oculo-orbital disproportion). Here we describe aspects of our experience of frontofacial surgery in the Craniofacial Centre at Great Ormond Street Hospital for Children, London, with reference to the principles underpinning frontofacial surgical techniques, their challenges, and their impact on function and aesthetics.

The Christmas tree foreheadplasty: a novel technique used in combination with a bandeau for fronto-orbital remodelling in craniosynostosis

PURPOSE

Craniosynostosis of the coronal, metopic and frontosphenoidal sutures results in deformity of the forehead. This may cause both functional and psychological difficulties for patient and parent. We describe a novel surgical technique, the 'Christmas tree foreheadplasty', used in combination with a supraorbital bandeau to achieve fronto-orbital remodelling.

METHODS

Between November 2008 and September 2011, 32 patients with craniosynostosis underwent fronto-orbital remodelling with a supraorbital bandeau in combination with Christmas tree foreheadplasty. Indications for surgery, age at surgery, blood transfusion requirements, length of hospital stay and perioperative complications were assessed. A 'blinded', independent reviewer, age-matched controlled, panel photograph study was also undertaken to review results of the surgery. A parental satisfaction survey by telephone questionnaire was undertaken.

RESULTS

Mean age at surgery was 16 months. Average hospital stay was 3 days. Mean follow up time to this report was 19.5 months. Indications for the procedure included unicoronal, frontosphenoidal, metopic and bicoronal synostosis. Thirty of the 32 patients required a blood transfusion. One patient has required revision surgery following extrusion of prosthetic fixation plate. Surgical outcome measured by 'blinded' independent reviewers indicated that a significantly different preoperative score from normal was rendered to no significant difference from age-matched normal controls postoperatively. Parental satisfaction score of forehead appearance was significantly improved by the technique.

CONCLUSION

The Christmas tree foreheadplasty is a commendable and reproducible technique for forehead remodelling in combination with supraorbital bandeau and is now used more widely for forehead reconstruction for congenital cases.

A clinical analysis of Dupuytren's disease of the thumb

Although Dupuytren's disease of the thumb was first described in 1833, the literature on this subject is limited to a few anatomical and clinical studies. This study examined the pattern of cords of Dupuytren's disease in 260 thumbs in 181 consecutive patients with evidence of disease relating to the thumb attending an out-patient clinic over a period of 36 months. Discrepancies in the literature are discussed in the light of the findings of this more detailed analysis and a simple but practical pictorial system for recording disease severity and detailing progression over time is presented.

Advances in the molecular pathogenesis of craniofacial conditions

The impact that the understanding of fibroblast growth factor receptor (FGFR) biology and its relevance to the pathogenesis of the craniosynostoses has made cannot be underestimated. As the genetic and molecular pathology of other conditions become increasingly understood, there is much hope that robust and relevant animal models of these conditions may be generated. From these models-and in conjunction with laboratory studies in vitro-comes a real hope of improved therapeutic strategies. The future lies in increased cooperation between clinicians working in high-volume centers and basic scientists. This article decribes the results of a decade of research in which the molecular pathology of the craniosynostoses was unravelled. The understanding of the importance of FGFR mutations to the genetic etiology of craniosynostosis opened up novel studies in developmental biology in various tissues. Such studies describe the functional effects of FGFR mutations. Investigations of FGFR expression in human craniofacial development have related functional molecular studies to human craniosynostosis syndromes, which provides a link between the gene mutation and the affected child.

Orthognathic Surgery in Juvenile Rheumatoid Arthritis Patients

BACKGROUND

Mandible advancement osteotomy in juvenile rheumatoid arthritis patients for class II anterior open-bite malocclusion is controversial; however, there is no literature discussing outcomes of surgery in this group of patients. An evaluation of such outcomes was undertaken at The Hospital for Sick Children.

METHODS

A retrospective chart review revealed that eight patients with juvenile arthritis underwent orthognathic surgery during a period of 5 years. All of the patients had a bilateral sagittal split osteotomy of the mandible, six had a simultaneous Le Fort I osteotomy, and four had an additional advancement genioplasty. The age of the patients at the time of surgery ranged between 17 and 22 years (mean, 18 years), with three male patients and five female patients. The patients were under follow-up for a minimum of 8 months after surgery, and measurements were performed studying preoperative and postoperative lateral cephalometric radiographs.

RESULTS

All patients have an improved occlusion and improved facial aesthetics. One patient continued to suffer from temporomandibular joint pain. The mean mandible advancement was 9.6 mm (range, 3.9 to 18.3 mm). The mean mandible relapse after surgery was 2.1 mm (range, 1 to 3.1 mm). No exacerbation of the juvenile rheumatoid arthritis was encountered as a result of the surgical procedure.

CONCLUSIONS

Orthognathic surgery in juvenile rheumatoid arthritis patients improves the patient's occlusion, facial aesthetics, and therefore quality of life. The relapse rate postoperatively did not significantly affect the clinical outcome, and the authors recommend orthognathic surgery for this patient population. Future presurgical plans in this patient population will include a small posterior open bite and positioning the incisors edge to edge to allow for some postoperative relapse.

Expression of FGFR-2 and FGFR-3 in the normal human fetal orbit

AIMS

To demonstrate the expression patterns of two fibroblast growth factor receptors (FGFR-2 and FGFR-3) in the normal human fetal orbit.

METHODS

6 microm orbital slide sections were prepared from 12 week old human fetal material obtained within established ethical guidelines. Radioactive in situ hybridisation techniques were used to demonstrate the expression patterns of FGFR-2 and FGFR-3 within these sections. Only one foetus had appropriate orbital sections taken.

RESULTS

FGFR-2 was expressed within the extraocular muscles (EOMs) and the optic nerve sheath and to a lesser degree within the orbital periosteal margins and the cranial sutures. FGFR-3 was expressed a lot within the periosteal margins and cranial sutures but not within either the EOMs or the optic nerve sheath.

CONCLUSIONS

FGFR-2 and FGFR-3 are differentially expressed within different orbital components. FGFR-2 gene mutations may be responsible for craniosynostotic syndromes such as Crouzon, Pfeiffer, and Apert, while those in the FGFR-3 gene may cause isolated unicoronal synostosis. EOMs may be histologically abnormal in cases of Apert, Pfeiffer, and Crouzon syndromes but not isolated unicoronal synostosis. The pattern of expression of FGFR-2 in the normal human fetal orbit may explain some of the EOM histological findings seen in some cases of Apert, Pfeiffer, and Crouzon syndromes.

Remodelling the upper eyelid in the management of orbitopalpebral neurofibromatosis

Neurofibromatosis of the orbitopalpebral complex is a debilitating disease. The development of safe craniofacial surgical technique has greatly improved outcome in the surgical palliation of this progressive condition, and various centres have reported their experience. Extensive upper eyelid neurofibroma creates a functional and aesthetic problem, which is inadequately addressed in the literature. The experience of the senior author (DM) representing the treatment of 27 such patients is currently reported. The stigmata of eyelid neurofibromatosis were scored retrospectively by a novel scale applied to standardised photographs at patient presentation. A numeric severity score was given to each of: upper eyelid ptosis, canthal malposition, and oculo-palpebral diastasis. Disease progression and post-operative result were similarly scored at various stages follow-up photography. All patients underwent a full thickness, transverse or transverse-oblique resection of upper eyelid disease, with immediate levator reconstruction and canthopexies as necessary. A mean improvement of 3.33 points was achieved in the majority of patients (median one operation per patient; mean 1.5, range 1-3). Secondary eyelid procedures (n=9 pts) represented tumour debulking, canthopexy, or procedures to deepen the fornix in patients with prostheses. This series demonstrates that a tailored, often radical palpebral remodelling in orbitopalpebral neurofibromatosis may provide functional and aesthetic benefit.

Potential blindness: an unusual complication of lateral canthopexy

Lateral canthopexy is a commonly performed procedure in craniofacial and cosmetic surgery. In craniofacial surgery, lateral canthal fixation is performed in conjunction with a wide range of transcranial or subcranial procedures during the process of soft tissue re-suspension. A number of fixation materials have gained popular use. A case of craniofrontonasal dysplasia is reported in which a wire loop canthopexy fixation has become disengaged 3 months after a history of trauma and rotated to present a sharp surface against the sclera. Urgent surgical exploration prevented the apparently imminent complication of globe penetration with associated threat to vision.

Tripier's innervated myocutaneous flap 1889

A translation of Tripier's publication in 1889 is presented. This paper includes description of two bipedicled myocutaneous flaps based on the orbicularis oculi muscle and designed as 'bucket-handles'. The author intended that these flaps be a transfer of innervated and functioning muscle and designed the flaps with full awareness of the need to maintain the original muscle length and nerve supply to retain function. This paper was, perhaps, the first description of an innervated myocutaneous flap. A third and new variant of the Tripier flap is described and illustrated.

The fascial planes of the temple and face: an en-bloc anatomical study and a plea for consistency

Many investigators have detailed the soft tissue anatomy of the face. Despite the broad reference base, confusion remains about the consistent nature of the fascial anatomy of the craniofacial soft tissue envelope in relation to the muscular, neurovascular and specialised structures. This confusion is compounded by the lack of consistent terminology. This study presents a coherent account of the fascial planes of the temple and midface. Ten fresh cadaveric facial halves were dissected, in a level-by-level approach, to display the fascial anatomy of the midface and temporal region. The contralateral 10 facial halves were coronally sectioned through the zygomatic arch at a consistent point anterior to the tragus. These sections were histologically prepared to demonstrate the fascial anatomy en-bloc with the skeletal and specialised soft tissues. Three generic subcutaneous fascial layers consistently characterise the face and temporal regions, and remain in continuity across the zygomatic arch. These three layers are the superficial musculo-aponeurotic system (SMAS), the innominate fascia, and the muscular fasciae. The many inconsistent names previously given to these layers reflect their regional specialisation in the temple, zygomatic area, and midface. Appreciation of the consistency of these layers, which are in continuity with the layers of the scalp, greatly facilitates an understanding of applied craniofacial soft tissue anatomy.

The upper buccal sulcus approach, an alternative for post-trauma rhinoplasty

We suggest that it is possible to correct the stigmata of the post-traumatic nasal deformity by means of an upper buccal sulcus approach alone. This approach is demonstrated in a series of ten cadaveric subjects for the correction of nasal skeletal deviation or bossing. Furthermore, the technique, which avoids internal nasal scarring and violation of the internal nasal valve, has been successfully employed in four patients with a minimum of 9 months follow-up. We suggest that it is possible to conserve the internal nasal valve and avoid problems of nasal tip retractions using this approach in selected cases.

Thumb function without the abductor pollicis longus and extensor pollicis brevis

Two patients are reported in which one thumb has lost the abductor pollicis longus and extensor pollicis brevis tendons. This is an uncommon injury in isolation, and these cases provide an opportunity to assess the functional importance of these musculotendinous units.

Toward pathogenesis of Apert cleft palate: FGF, FGFR, and TGF beta genes are differentially expressed in sequential stages of human palatal shelf fusion

OBJECTIVE

Critical cellular events at the palatal medial edge epithelium (MEE) occur in unperturbed mammalian palatogenesis, the molecular control of which involves a number of growth factors including transforming growth factor beta 3 (TGF beta 3). Apert syndrome is a monogenic human disorder in which cleft palate has been significantly correlated to the fibroblast growth factor receptor (FGFR) 2-Ser252Trp mutation. We report the relative expression of these genes in human palatogenesis.

METHODS

The expression of the IgIIIa/b and IgIIIa/c transcript isoforms of FGFR2 and the proteins FGFR1, FGFR2, and FGFR3 was studied in situ throughout the temporospatial sequence of human palatal shelf fusion and correlated with the expression of TGF beta 3. In addition, the immunolocalization of the ligand FGFs 2, 4, and 7 was undertaken together with the intracellular transcription factor STAT1, which is activated by FGFR signaling.

RESULTS

FGFRs are differentially expressed in the mesenchyme and epithelia of fusing palatal shelves, in domains overlapping those of their ligands FGF4 and FGF2 but not FGF7. Coexpression is seen with TGF beta 3, which is implicated in MEE dynamics and FGF and FGFR upregulation, and STAT1, an intracellular transcription factor that mediates apoptosis.

CONCLUSIONS

The coregulation of molecules of the FGFR signaling pathway with TGF beta 3 throughout the stages of human palatal fusion suggests their controlling influence on apoptosis and epitheliomesenchymal transdifferentiation at the MEE. Experimental evidence links FGFR2-IgIIIa/b loss of function with palatal clefting, and these correlated data suggest a unique pathological mechanism for Apert cleft palate.

From genotype to phenotype: the differential expression of FGF, FGFR, and TGFbeta genes characterizes human cranioskeletal development and reflects clinical presentation in FGFR syndromes

Mutations in the fibroblast growth factor receptor (FGFR) genes 1, 2, and 3 are causal in a number of craniofacial dysostosis syndromes featuring craniosynostosis with basicranial and midfacial deformity. Great clinical variability is displayed in the pathologic phenotypes encountered. To investigate the influence of developmental genetics on clinical diversity in these syndromes, the expression of several genes implicated in their pathology was studied at sequential stages of normal human embryo-fetal cranial base and facial ossification (n = 6). At 8 weeks of gestation, FGFR1, FGFR2, and FGFR3 are equally expressed throughout the predifferentiated mesenchyme of the cranium, the endochondral skull base, and midfacial mesenchyme. Both clinically significant isoforms of FGFR2, IgIIIa/c and IgIIIa/b, are coexpressed in maxillary and basicranial ossification. By 10 to 13 weeks, FGFR1 and FGFR2 are broadly expressed in epithelia, osteogenic, and chondrogenic cell lineages. FGFR3, however, is maximally expressed in dental epithelia and proliferating chondrocytes of the skull base, but poorly expressed in the osteogenic tissues of the midface. FGF2 and FGF4, but not FGF7, and TGFbeta1 and TGFbeta3 are expressed throughout both osteogenic and chondrogenic tissues in early human craniofacial skeletogenesis. Maximal FGFR expression in the skull base proposes a pivotal role for syndromic growth dysplasia at this site. Paucity of FGFR3 expression in human midfacial development correlates with the relatively benign human mutant FGFR3 midfacial phenotypes. The regulation of FGFR expression in human craniofacial skeletogenesis against background excess ligand and selected cofactors may therefore play a profound role in the pathologic craniofacial development of children bearing FGFR mutations.

Negative autoregulation of fibroblast growth factor receptor 2 expression characterizing cranial development in cases of Apert (P253R mutation) and Pfeiffer (C278F mutation) syndromes and suggesting a basis for differences in their cranial phenotypes

OBJECT

Heterogeneous mutations in the fibroblast growth factor receptor 2 gene (FGFR2) cause a range of craniosynostosis syndromes. The specificity of the Apert syndrome-affected cranial phenotype reflects its narrow mutational range: 98% of cases of Apert syndrome result from an Ser252Trp or Pro253Arg mutation in the immunoglobulin-like (Ig)IIIa extracellular subdomain of FGFR2. In contrast, a broad range of mutations throughout the extracellular domain of FGFR2 causes the overlapping cranial phenotypes of Pfeiffer and Crouzon syndromes and related craniofacial dysostoses.

METHODS

In this paper the expression of FGFR1, the IgIIIa/c and IgIIIa/b isoforms of FGFR2, and FGFR3 is investigated in Apert syndrome (P253R mutation)- and Pfeiffer syndrome (C278F mutation)-affected fetal cranial tissue and is contrasted with healthy human control tissues. Both FGFR1 and FGFR3 are normally expressed in the differentiated osteoblasts of the periosteum and osteoid, in domains overlapped by that of FGFR2, which widely include preosseous cranial mesenchyme. Expression of FGFR2, however, is restricted to domains of advanced osseous differentiation in both Apert syndrome- and Pfeiffer syndrome-affected cranial skeletogenesis in the presence of fibroblast growth factor (FGF)2, but not in the presence of FGF4 or FGF7. Whereas expression of the FGFR2-IgIIIa/b (KGFR) isoform is restricted in normal human cranial osteogenesis, there is preliminary evidence that KGFR is ectopically expressed in Pfeiffer syndrome-affected cranial osteogenesis.

CONCLUSIONS

Contraction of the FGFR2-IgIIIa/c (BEK) expression domain in cases of Apert syndrome- and Pfeiffer syndrome-affected fetal cranial ossification suggests that the mutant activation of this receptor, by ligand-dependent or ligand-independent means, results in negative autoregulation. This phenomenon, resulting from different mechanisms in the two syndromes, offers a model by which to explain differences in their cranial phenotypes.

Aggressive keloid scarring of the Caucasian wrist and palm

Keloid scarring of the distal upper extremity is very rare. We report a Caucasian woman who presented with aggressive keloids of the hand and wrist causing De Quervain's syndrome, superficial radial-nerve entrapment and ulnar-nerve compression at the wrist. Multiple operations were required to alleviate her symptoms. A number of management conundrums arose, requiring defensive planning to pre-empt the possible complications of recurrent keloid scarring as a result of the surgical procedures.

Differential expression of fibroblast growth factor receptors in human digital development suggests common pathogenesis in complex acrosyndactyly and craniosynostosis

The Apert hand is characterized by metaphyseal fusions of the metacarpals and distal phalanges, symphalangism, and soft-tissue syndactyly. More subtle skeletal anomalies of the limb characterize Pfeiffer and Crouzon syndromes. Different mutations in the fibroblast growth factor receptor 2 (FGFR2) gene cause these syndromes, and offer the opportunity to relate genotype to phenotype. The expression of FGFR1 and of the Bek and KGFR isoforms of FGFR2 has, therefore, been studied in human hand development at 12 weeks by in situ hybridization. FGFRs are differentially expressed in the mesenchyme and skeletal elements during endochondral ossification of the developing human hand. KGFR expression characterizes the metaphyseal periosteum and interphalangeal joints. FGFR1 is preferentially expressed in the diaphyses, whereas FGFR2-Bek expression characterizes metaphyseal and diaphyseal elements, and the interdigital mesenchyme. Apert metaphyseal synostosis and symphalangism reflect KGFR expression, which has independently been quantitatively related ex vivo to the severity of clinical digital presentations in these syndromes. Studies in avian development implicate FGF signaling in preventing interdigital apoptosis and maintaining the interdigital mesenchyme. Herein is proposed that in human FGFR syndromes the balance of signaling by means of KGFR and Bek in digital development determines the clinical severity of soft-tissue and bony syndactyly.

Contact dermatitis complicating pinnaplasty

Proflavine allergy is uncommon, occurring in approximately 6% of patients attending contact dermatitis clinics. Proflavine wool is used by many surgeons in the UK as a dressing that can be moulded to conform to the contours of a corrected prominent ear. It may have bacteriostatic properties. We present a case where contact dermatitis in response to proflavine developed after pinnaplasty. This caused diagnostic confusion, a lengthened hospital stay and an unsightly hypertrophic scar.

Enigma of raised intracranial pressure in patients with complex craniosynostosis: the role of abnormal intracranial venous drainage

OBJECT

In this study the authors investigated whether patterns of intracranial venous drainage in children with complex craniosynostosis associated with raised intracranial pressure (ICP) were abnormal and, thus, could support the theory that venous hypertension is a major contributor to raised ICP that can lead to impaired visual function or even blindness in these patients.

METHODS

The authors analyzed the anatomy of intracranial venous drainage as demonstrated in the results of 24 angiography studies obtained in 23 patients, all of whom had either a craniosynostosis-related syndrome (18 patients) or a nonsyndromic multisutural synostosis (five patients). Twenty-one patients had experienced raised ICP (in 19 patients diagnosis was based on invasive ICP monitoring and in two patients on clinical grounds alone) 1 to 6 weeks before undergoing angiography. Of the two remaining patients (both with Apert syndrome) whose ICP monitoring was normal immediately before angiography, each had undergone two previous cranial vault expansion procedures. On results of 18 angiography studies a 51 to 99% stenosis or no flow at all could be observed in the sigmoid-jugular sinus complex either bilaterally (11 patients) or unilaterally (seven patients). In 11 of these patients a florid collateral circulation through the stylomastoid emissary venous plexus was also seen. Two angiography studies were performed in one patient with Crouzon syndrome. A comparison of the two studies demonstrated a progression of the abnormal venous anatomy in that case. The authors found no obvious correlation between each patient's baseline ICP and the degree of abnormality of their venous anatomy, as judged on the basis of a venous-phase angiography severity score.

CONCLUSIONS

Based on their findings, the authors assert that in children with complex forms of craniosynostosis in whom other factors, such as hydrocephalus, are absent, abnormalities of venous drainage that particularly affect the sigmoid-jugular sinus complex produce a state of venous hypertension that, in turn, is responsible for the majority of cases of raised ICP. The incidence of these changes is unknown, but an analysis of the ages of the children in this study indicated that the period of particular vulnerability to the effects of venous hypertension lasts until the affected child is approximately 6 years old. After that age the collateral venous drainage through the stylomastoid plexus will likely become sufficient to allow ICP to normalize.

Double tongue, intraoral anomalies, and cleft palate--case reports and a discussion of developmental pathology

OBJECTIVE

Isolated cleft palate is the most common presentation of the nonsyndromic cleft lip/palate combinations and is multifactorial in etiology. We report two cases of children with clefts of the secondary palate coexistent with double tongue and in either case mandibular epulis or superiorly displaced salivary gland.

RESULTS AND DISCUSSION

In each case, the palatal cleft correlated anatomically with the intraoral space-occupying lesion. The ratio of tongue volume to intraoral volume during palatogenesis is discussed with reference to the pathogenesis of cleft palate. These clinical cases propose the model of a unifying sequence of developmental events whereby deformation of palatal shelf elevation results in secondary palatal clefting.

Maxillary distraction osteogenesis in Pfeiffer's syndrome: urgent ocular protection by gradual midfacial skeletal advancement

Distraction osteogenesis is increasingly recognised as a potentially useful technique to achieve the co-ordinated augmentation of craniofacial skeletal and soft tissue. A case is presented where bilateral maxillary distraction was successfully used to advance the midface in the treatment of recurrent ocular dislocation, in a 10-month-old boy with Pfeiffer's syndrome.

Extraction site healing complicated by neoplasia

Malignant melanoma arises from melanocytes, dendritic cells of neural crest origin. Melanocytes occur within the basal layers of the epidermis, mucous membranes, retina and uveal structures of the eye and the meninges. Rarely, they may also occur in the bladder, adrenal medulla and ovaries. These melanomas metastasise widely and metastases in the oral mucosa have been seen in about 3% of patients with cutaneous melanoma, and can complicate the healing of extraction sites. This paper presents a case of malignant melanoma of the mandible.

Residency experienced--in pursuit of structured apprenticeship

British surgical training is currently undergoing an upheaval. The introduction of Higher Surgical Training (HST) as a continuum to the consultant grade will have wide implications. I recently undertook a year as a resident in general surgery at the Beth Israel Hospital, Boston, USA; in lieu of a second year as an SHO in the UK. This paper compares the American Residency system with that evolving in Britain.