Prediction of land use changes based on Land Change Modeler and attribution of changes in the water balance of Ganga basin to land use change using the SWAT model

Conflicts between increasing irrigated agricultural area, commercial crops, shifting cultivation and ever increasing domestic and industrial demand has already been a cause of tension in the society over water in the Ganga River Basin, India. For the development of sustainable water resource strategies, it is essential to establish interaction between landuse changes and local hydrology through proper assessment. Precisely, seeing how change in each LULC affects hydrologic regimes, or conversely evaluating which LULC shall be appropriate for the local hydrological regime can help decision makers to incorporate in the policy instruments. In this study, hydrologic regimes of the Ganga River basin have been assessed with landuse change. Catchment hydrologic responses were simulated using Soil and Water Assessment Tool (SWAT). Meteorological data from IMD of 0.25° × 0.25° spatial resolution were taken as the climate inputs. Simulated stream flow was compared at different gauge stations distributed across the Gang River and its tributaries. Urbanization has been the topmost contributor to the increase in surface runoff and water yield. While increased irrigation demands were the dominant contributor to the water consumption and also added to the increased evapotranspiration. This study can be important tool in quantifying the changes in hydrological components in response to changes made in landuse in especially basins undergoing rapid commercialization. This shall provide substantive information to the decision makers required to develop ameliorative strategies.

Modeling hydrology, groundwater recharge and non-point nitrate loadings in the Himalayan Upper Yamuna basin

The mountainous Himalayan watersheds are important hydrologic systems responsible for much of the water supply in the Indian sub-continent. These watersheds are increasingly facing anthropogenic and climate-related pressures that impact spatial and temporal distribution of water availability. This study evaluates temporal and spatial distribution of water availability including groundwater recharge and quality (non-point nitrate loadings) for a Himalayan watershed, namely, the Upper Yamuna watershed (part of the Ganga River basin). The watershed has an area of 11,600 km(2) with elevation ranging from 6300 to 600 m above mean sea level. Soil and Water Assessment Tool (SWAT), a physically-based, time-continuous model, has been used to simulate the land phase of the hydrological cycle, to obtain streamflows, groundwater recharge, and nitrate (NO3) load distributions in various components of runoff. The hydrological SWAT model is integrated with the MODular finite difference groundwater FLOW model (MODFLOW), and Modular 3-Dimensional Multi-Species Transport model (MT3DMS), to obtain groundwater flow and NO3 transport. Validation of various modules of this integrated model has been done for sub-basins of the Upper Yamuna watershed. Results on surface runoff and groundwater levels obtained as outputs from simulation show a good comparison with the observed streamflows and groundwater levels (Nash-Sutcliffe and R(2) correlations greater than +0.7). Nitrate loading obtained after nitrification, denitrification, and NO3 removal from unsaturated and shallow aquifer zones is combined with groundwater recharge. Results for nitrate modeling in groundwater aquifers are compared with observed NO3 concentration and are found to be in good agreement. The study further evaluates the sensitivity of water availability to climate change. Simulations have been made with the weather inputs of climate change scenarios of A2, B2, and A1B for end of the century. Water yield estimates under climate change scenarios have been made and implications on groundwater and groundwater quality have been assessed. The delicate groundwater resource balance that connects livelihoods of millions of people seems to be under tremendously increasing pressure due to the dynamic conditions of the natural environment of the region and the future climate changes.

Snowmelt contributions to discharge of the Ganges

Himalayan headwaters supply large quantities of runoff derived from snowmelt and monsoon rainfall to the Ganges River. Actual snowmelt contribution to discharge in the Ganges remains conjectural under both present and future climatic conditions. As snowmelt is likely to be perturbed through climatic warming, four hydrological models, VIC, JULES, LPJmL and SWAT, appropriate for coupling with regional climate models, were used to provide a baseline estimate of snowmelt contribution to flow at seasonal and annual timescales. The models constrain estimates of snowmelt contributions to between 1% and 5% of overall basin runoff. Snowmelt is, however, significant in spring months, a period in which other sources of runoff are scarce.

Localization of the cortical response to smiling using new imaging paradigms with functional magnetic resonance imaging

Functional magnetic resonance imaging (fMRI) can serve to localize activity in the cerebral cortex. The present study was performed to develop a quantitative means of describing the cortical location activated during voluntary smiling in multiple subjects and to determine whether this location is specific to smiling when compared with other motor tasks. Five human subjects were instructed to smile or to tap the fingers of both hands. Both tasks were performed in a blocked-trial paradigm that consisted of alternating 15-second blocks of a repetitive motor task and 15 seconds of rest. Smiling was also performed as an event-related paradigm in which the subject smiled briefly once every 15 seconds for 20 repetitions that were combined to produce an average response to a single smile. A series of 300 images was acquired using an echo-planar imaging sequence (24-cm field of view; 5-mm slice thickness; repetition time/echo time, 1000/27.2 msec). Each subject's three-dimensional brain images were transformed to Talairach coordinates by stretching or compressing the brain images to fit the standard brain as defined in the Talairach atlas. This allowed data from five subjects to be combined for a numeric description. Functional activation maps acquired by use of the event-related paradigm contained significantly fewer motion artifacts than maps acquired with the blocked-trial paradigm, allowing better visualization of functionally active areas. Three-dimensional Talairach coordinates to describe the locations of peak cortical activity after smiling and finger tapping were established. These coordinates were consistent among subjects. During smiling, statistically significant activation was seen in the motor cortex, primarily along the precentral sulcus; this was inferior and anterior to the region that was associated with finger tapping. This study demonstrates that motion artifacts associated with traditional blocked-trial fMRI protocols can be overcome by employing an event-related paradigm to obtain an average response from a single smile. With the implementation of new imaging paradigms with fMRI, an area of the cerebral cortex has been identified that is specifically activated during voluntary smiling, and remains consistent among subjects. Quantification of fMRI data represents a powerful tool by which to study the cortical response to motor activity and to monitor possible alteration in this activity after injury or surgery. When combined with biofeedback therapy, this technique may help to improve the outcome of facial reanimation procedures in the future.

The role of transforming growth factor-beta in the modulation of mouse cranial suture fusion

Transforming growth factor-beta (TGF-beta) is actively expressed during mouse calvarial suture fusion. However, the role TGF-beta plays in this process remains unclear. The present study was performed to investigate whether modulation of suture fusion can be achieved by blocking the bioavailability of TGF-beta. Both in vitro and in vivo models were studied. For the in vitro model, the posterior frontal sutures from 24-day-old mice were harvested and cultured for 2, 3, or 4 weeks in the presence of 20 microg/ml of pan-specific TGF-beta polyclonal antibody or rabbit IgG as a control. Culture media were changed every 48 hours and fresh antibody or rabbit IgG was added during each media change. Suture fusion was evaluated by histometric analysis. For the in vivo model, TGF-beta antisense plasmid DNA complexed with lipofectamine was injected into the subgaleal layer along the frontal suture of 22-day-old mice under anesthesia. For control groups, empty vector plasmid DNA+ complexed with lipofectamine was used. The posterior frontal sutures were harvested at various time points and examined by histometric analysis and reverse transcription and polymerase chain reaction for the detection of messenger RNA. The in vitro studies demonstrated that the presence of TGF-beta antibody in culture media delayed posterior frontal suture fusion. By 3 weeks in culture, new bone area was only 20 percent of that in control groups as determined by histometric analysis. By the end of the fourth week, suture fusion was only 25 percent completed compared with controls. The in vivo studies demonstrated that, compared with the control, posterior frontal suture fusion was significantly delayed in the animals injected with antisense plasmid DNA. Suture fusion was complete in control animals by postnatal day 45. There was a 70 percent inhibition of suture fusion (new bone area) in antisense groups measured with histometric analysis. Four days after antisense plasmid DNA injection (age of 26 days), messenger RNA expression for TGF-beta 1 was 77 percent lower than in the control group. We have demonstrated that modulation of TGF-beta affects calvarial suture formation in vitro and in vivo with TGF-beta antibody and TGF-beta1 antisense plasmid DNA treatment, respectively. These data indicate that TGF-beta may play a causative role in mouse posterior frontal suture fusion. Modulation TGF-beta 1 gene expression in vivo can alter the natural history of cranial suture fusion.

Giant congenital nevi: a 20-year experience and an algorithm for their management

A variety of treatment options exists for the management of giant congenital nevi. Confusion over appropriate management is compounded because not all giant congenital nevi are pigmented, and malignant potential varies between different types. The present study sought to define factors in the presentation of giant congenital nevi that could provide an algorithm for their management, with respect to both the extent of resection and subsequent reconstructive options.A retrospective review of all patients who presented with a congenital nevus of 20 cm2 or greater since 1980 was performed, distinguishing among nevi involving the head and neck, the torso, and the extremities. Sixty-one patients with giant congenital nevi were evaluated (newborn to age 16 years), of which 60 nevi in 55 patients have been operated on. Giant congenital nevi having malignant potential were pigmented nevi (53 patients) and nevus sebaceus (four patients). Those not having malignant potential were verrucous epidermal nevi (three patients) and a woolly hair nevus (one patient). Of the 60 giant congenital nevi operated on, expanded flaps were used in 25, expanded full-thickness skin grafts were used in 10, split-thickness or nonexpanded full-thickness skin grafts were used in 13, and serial excision was used in 30. After 1989, operations tended to use multimodality treatment plans, with an increased use of expanded full-thickness grafts and immediate serial tissue expansion. The use of serial excision, particularly in the extremities, also increased after 1989. Serial excision was the treatment of choice when it could be completed in two procedures or less, which occurred in more than 80 percent of cases using serial excision alone. Expanded flaps were the most common mode of reconstruction in the head and neck region and were used in 49 percent of these procedures. Serial excision was the most common form of treatment in the extremities, used in 50 percent of procedures. Tissue expansion in the extremities was infrequently used to provide an expanded flap (8 percent of procedures), whereas it was frequently used to provide expanded full-thickness skin grafts harvested from the torso (used in 31 percent of procedures). On the basis of these data, algorithms for the extent of resection and subsequent reconstructive options for giant congenital nevi were developed. Their management should be formulated relative to pigmentation, malignant potential, and anatomic location of the respective lesions.

Quantitative assessment of cranial defect healing and correlation with the expression of TGF-beta

Circular parietal defects from 3 to 12 mm in diameter were made in 45 6-month old skeletally mature guinea pigs, and animals were sacrificed after survival periods of 3 days to 12 weeks. The original defect was harvested in continuity with a rim of surrounding bone and the adjacent dura and pericranium. After 12 weeks, all 3 and 5 mm defects were completely covered by a bridge of bone, while residual defects were noted within the 8 and 12 mm wounds. Percentage of new bone formation was significantly higher within 3 mm defects, than in all larger defects at each time interval from 1 week on (P < .05), reaching a mean of 93% in 3 mm defects and remaining below a mean of 31% in the remaining defect sizes. Immunolocalization demonstrated an osteogenic front in which the osteoblasts stained strongly for all isoforms of TGF-beta, with the intensity decreasing after the majority of the defects had reossified; this front was located at the advancing bone edge of the defect as well as the endocranial side adjacent to the dura. In conclusion, isoforms of TGF-beta are upregulated during a limited "window" of time corresponding to the period of calvarial reossification, and are localized to osteoblasts within an osteogenic front at the periphery and dural surfaces of the defects.

Early surgical intervention in a patient with Kasabach-Merritt phenomenon

A 3-day-old male infant with a 3-cm firm subcutaneous mass was found to have decreased platelets, decreased fibrin, and increased fibrin split products diagnostic of Kasabach-Merritt phenomenon. The vascular lesion was resected without complications. We suggest that early surgical intervention is an excellent therapeutic option for Kasabach-Merritt phenomenon.

Furlow palatoplasty to restore velopharyngeal competence following tonsillectomy avulsion of a pharyngeal flap

OBJECTIVE

We report the successful use of a Furlow palatoplasty to salvage velopharyngeal competence following iatrogenic avulsion of a pharyngeal flap that had been previously established to treat velopharyngeal insufficiency associated with a submucous cleft palate.

INTERVENTION

A tonsillectomy, conducted by a surgeon unaffiliated with a cleft palate team, was used to remove enlarged tonsils that had developed after pharyngeal flap surgery and extended into the lateral ports causing nasal obstruction and hypernasality because of mechanical interference with port closure. A posttonsillectomy evaluation revealed avulsion of the pharyngeal flap, which was successfully treated using a Furlow palatoplasty.

CONCLUSIONS

To our knowledge, this is the first report of iatrogenic avulsion of a pharyngeal flap caused by tonsillectomy. Based on a review of the literature and this case experience, we would conclude that tonsillectomy should not be regarded as a routine procedure in patients previously treated with a pharyngeal flap. If required, it should be performed by a skilled otolaryngologist, preferably one affiliated with a multidisciplinary cleft palate team who is familiar with pharyngoplasty surgery. Finally, our experience would suggest that the Furlow palatoplasty is sufficiently robust to be used as a secondary salvage procedure to restore velopharyngeal sufficiency following iatrogenic avulsion of a pharyngeal flap.

Distraction osteogenesis of the craniofacial skeleton

In summary, distraction osteogenesis is a safe and effective means of achieving bone lengthening. These techniques were originally applied to the long bones of the extremities; over the past 10 years they have been effectively applied to the bones of the craniofacial skeleton. The new bone regenerate that is observed after distraction osteogenesis is stable, and relapse rates after skeletal advancement are believed to be lower than with conventional osteotomy and bone graft techniques. There is considerable variability in distraction protocols employed in clinical practice, including differences in the types of devices used and in the rate, rhythm, latency, and period of consolidation for distraction osteogenesis. The greatest application for distraction osteogenesis in the craniofacial skeleton has been with mandible lengthening, for which there is presently a 10-year clinical experience. Midfacial advancement is a newer application of distraction osteogenesis, for which clinical experience has been accrued over the past 5 years. This latter experience indicates that distraction osteogenesis is a viable treatment option for lengthening of the hypoplastic mandible and midface. These techniques have advantages over conventional means of bone graft and rigid fixation because of the quality of the bone regenerate, the decrease in the long-term relapse rate of the advanced bone segments in both the mandible and the midface, and the simultaneous soft-tissue elongation that accompanies the distraction process. Distraction osteogenesis is particularly applicable to the correction of severe deformities of the mandible and midface in children with developmental hypoplasia and syndromic craniosynostosis. However, growth is an added variable in this patient population. The amount of overcorrection in lengthening of the hypoplastic bone required to compensate for continued growth discrepancy of the adjacent facial bones is difficult to predict. Therefore, the families of these patients should be informed that many children will require repeated operations at a later age as they reach skeletal maturity.

Congenital pressure necrosis of the forearm in a newborn infant

The authors report a case of congenital pressure necrosis of the forearm presenting in a newborn infant. The patient presented with an edematous and purpuric upper extremity with no underlying vascular compromise. After demarcation of the nonviable tissue during the first month of life, the extremity was debrided, and a thin split-thickness skin graft was applied. Graft contracture over the subsequent year was released and reconstructed with a full-thickness skin graft. Patient follow-up at age 22 months demonstrated progressive return of strength and function of the extremity with restoration of soft-tissue bulk and contour. When presented with this unusual circumstance, the plastic surgeon should be familiar with its differential diagnosis and management. Conservative debridement and age-appropriate resurfacing of the remaining wound were the essential treatment principles followed in this patient.

Efficacy of preoperative decontamination of the oral cavity

This two-part study consisted of: (1) a survey to assess current practice patterns, and (2) an experiment designed to assess the results of varying intraoral preparations. A 48 percent response rate was obtained from the survey of the 318 active members of the American Society of Maxillofacial Surgeons. This survey demonstrated that significant controversy continues regarding the efficacy of preoperative decontamination of the oral cavity. This prospective, randomized experimental study of 30 patients (saline, 10; povidone-iodine, 10; no preparation, 10) demonstrates a significant and sustained reduction of both anaerobic and aerobic bacteria after intraoral preparation with povidone-iodine solution but not saline. The patient's age, use of preoperative intravenous cephalosporin, and type and length of procedure did not influence the postoperative bacterial counts. Although none of the patients in this study developed an infection, recommendations are provided for standardized preoperative treatment of the oral cavity.

Osteogenesis in cranial defects: reassessment of the concept of critical size and the expression of TGF-beta isoforms

Transforming growth factor-betas (TGF-beta) have been demontstrated to be upregulated during osteoblast function in vitro and during cranial suture fusion in vivo. The authors hypothesized that spontaneous reossification of calvarial defects was also associated with upregulation of TGF-beta. The present study was designed to (1) evaluate the concept of a critical-size defect within the calvaria in an adult guinea pig model and (2) investigate the association between the ossification of calvarial defects and TGF-beta upregulation. Paired circular parietal defects with diameters of 3 and 5 mm and single parietal defects with diameters of 8 or 12 mm were made in 45 six-month-old skeletally mature guinea pigs. Three animals per defect size were killed after survival periods of 3 days, 1 week, 4 weeks, 8 weeks, or 12 weeks. New bone ingrowth was evaluated by assessing for linear closure by a traditional linear method and by a modified cross-sectional area method using an image analysis system in which the thickness of new bone was taken into account. Immunohistochemistry was performed using rabbit polyclonal antibodies to localize TGF-beta1, -beta2, and -beta3. All specimens were photographed, and the intensity of immunostaining was graded based on subjective photographic assessment by three independent reviewers. No defect demonstrated any measurable bone replacement after a survival period of 3 days. All 3- and 5-mm defects were completely reossified after 12 weeks based on the linear analysis of new bone, indicating these defects to be less than critical size. However, new bone formation in the 5-mm defects never exceeded a mean of 40 percent by cross-sectional area of new bone. Percent of new bone formation by cross-sectional area was significantly higher within 3-mm defects than in all larger defects 4 weeks after the craniotomy, reaching a mean of 89 percent new bone by 12 weeks. Persistent gaps were noted on linear analysis of the 8- and 12-mm wounds by 12 weeks, and mean percent new bone by cross-sectional area remained below 30 percent. Immunolocalization demonstrated osteogenic fronts at the advancing bone edge and the endocranial side, in which the osteoblasts stained strongly for all isoforms of TGF-beta. The intensity of osteoblast expression waned considerably after the majority of the defect had reossified. These data indicate that histometric analysis based on cross-sectional area more accurately reflects the osteogenic potential of a cranial defect than does linear inspection of defect closure. Although the interpretation of immunolocalization studies is highly subjective, independent assessment by three reviewers indicates that isoforms of TGF-beta were upregulated during a limited "window" of time corresponding to the period of active calvarial reossification, and expression of TGF-beta corresponded to osteoblast activity within osteogenic fronts.

Ulnar nerve compression by an anomalous muscle following carpal tunnel release: a case report

We describe the acute development of ulnar nerve compression following carpal tunnel release in a patient with an accessory palmaris longus muscle. Although anomalous muscles in the wrist are relatively common and may produce ulnar nerve compression, this particular occurrence following carpal tunnel release has not been previously described in the literature. We theorize that the compression of the ulnar nerve proximal to Guyon's canal was caused by increased tension along the long axis of the anomalous accessory palmaris longus muscle as a consequence of transverse carpal ligament division.

Effects of transforming growth factor-beta and mechanical strain on osteoblast cell counts: an in vitro model for distraction osteogenesis

Factors known to regulate bone production during distraction osteogenesis include mechanical strain on bone forming cells and up-regulation of transforming growth factor-beta (TGF-beta) during the distraction, or strain phase of distraction osteogenesis. In the present study, an in vitro model was used to evaluate the functional effect of exogenous TGF-beta1 on mitogenesis in murine-derived MC3T3 osteoblasts during the period of active mechanical strain. The first hypothesis to be tested was that mitogenic suppression of MC3T3 osteoblasts by TGF-beta1 is further enhanced when these cells are also subjected to mechanical strain. To test this hypothesis, MC3T3 osteoblasts were seeded on flexible and rigid membranes. These were subjected to cyclic, vacuum-induced strain, simulating physiologic stress loads. After 24 hours, all cells were transferred to media containing TGF-beta1, and strain was continued for an additional 48 hours. The study was repeated by using two doses of TGF-beta1. This study demonstrated that final cell counts were significantly decreased in the presence of TGF-beta1 in both the nonstrained and strained groups (p < 0.0001). The final cell count in the strained group was significantly less than that in the nonstrained group (p < 0.0001) for both concentrations of TGF-beta1 tested, confirming the initial hypothesis. The second hypothesis to be tested was that alteration in the mitogenic response of MC3T3 osteoblasts after strain is not directly due to autocrine factors produced by the strained osteoblasts. To test this hypothesis, a proliferation assay was performed on nonconfluent MC3T3 osteoblasts by using conditioned media collected from strained and nonstrained osteoblasts. This study demonstrated no significant differences in cell counts after addition of conditioned media collected from strained versus nonstrained cells, confirming the latter hypothesis. The present study demonstrates the functional significance of mechanical strain on osteoblast cell counts. Furthermore, this may help to explain the temporal relationship observed during the early distraction (strain) phase of distraction osteogenesis in rodent models in which peak up-regulation of TGF-beta1 gene expression correlates with peak suppression of osteoblast function as measured by gene expression of extracellular matrix proteins.

Biomaterials in the face: benefits and risks

An extensive review of biomaterials in the face was conducted in an American Society of Maxillo-facial Surgeons-sponsored biomaterials symposium. The symposium was held in Boston, MA, immediately preceding the 1998 annual meeting of the ASPRS/PSEF. The scope of the symposium extended from current reconstructive techniques for the facial skeleton, including autogenous bone and biomaterials, to potential application of new techniques in molecular biology that may enable the body's own tissues to be engineered to provide bone and cartilage to reconstruct the facial skeleton. The authors review the presentations and relevant literature on biomaterials in the face. The following topics are reviewed: current reconstructive techniques using autogenous bone grafts, methyl methacrylate cranioplasty, demineralized bone, and hydroxyapatite; biomaterials used for rigid fixation, including metallic and bioabsorbable implants; biomaterials used for facial augmentation, including porous polyethylene, hard-tissue replacement, and ceramic biomaterials; biofilm, or a layered polysaccharide matrix secreted by bacteria on the surface of implants; and potential means of inducing bone formation by directing the body's own tissues through cytokine interaction, gene transfer, and tissue engineering.

A prospective evaluation of the prevalence of submucous cleft palate in patients with isolated cleft lip versus controls

Although there is an established relationship between cleft lip and overt cleft palate, the relationship between isolated cleft lip and submucous cleft palate has not been investigated. To test the hypothesis that patients with isolated cleft lip have a greater association with submucous cleft palate, a double-armed prospective trial was designed. A study group of 25 consecutive children presenting with an isolated cleft lip, with or without extension through the alveolus but not involving the secondary palate, was compared with a control group of 25 children with no known facial clefts. Eligible patients were examined for the presence of physical criteria associated with classic submucous cleft palate, namely, (1) bifid uvula, (2) absence of the posterior nasal spine, and (3) zona pellucida. Nasoendoscopy was subsequently performed just after induction of general anesthesia, and the findings were correlated with digital palpation of the palatal muscles. Patients who did not satisfy all three physical criteria and in whom nasoendoscopy was distinctly abnormal relative to the control group were classified as having occult submucous cleft palate. Classic submucous cleft palate was found in three study group patients (12 percent), all of whom had flattening or a midline depression of the posterior palate and musculus uvulae on nasoendoscopy and palpable diastasis of the palatal muscles under general anesthesia. An additional six study group patients (24 percent) had similar nasoendoscopic criteria and palpable diastasis of the palatal muscles; they were classified as having occult submucous cleft palate. No submucous cleft palate was identified in the control group. Seventeen patients in the study group had an alveolar cleft with a 53 percent (9 of 17) prevalence of submucous cleft palate. In the present study, classic submucous cleft palate in association with isolated cleft lip was 150 to 600 times the reported prevalence in the general population. All children with an isolated cleft lip should undergo peroral examination and speech/resonance assessment no later than the age of 3 years. Any child with an isolated cleft lip with velopharyngeal inadequacy or before an adenoidectomy should be assessed by flexible nasal endoscopy to avoid missing an occult submucous cleft palate.

Long-term remodeling of vascularized and nonvascularized onlay bone grafts: a macroscopic and microscopic analysis

The present study was performed to compare vascularized and nonvascularized onlay bone grafts to investigate the potential effect of graft-to-recipient bed orientation on long-term bone remodeling and changes in thickness and microarchitectural patterns of remodeling within the bone grafts. In two groups of 10 rabbits each, bone grafts were raised bilaterally from the supraorbital processes and placed subperiosteally on the zygomatic arch. The bone grafts were oriented parallel to the zygomatic arch on one side and perpendicular to the arch on the contralateral side. In the first group, vascularized bone grafts were transferred based on the auricularis anterior muscle, and in the second group nonvascularized bone grafts were transferred. Fluorochrome markers were injected during the last 3 months of animal survival, and animals were killed either 6 or 12 months postoperatively. The nonvascularized augmented zygoma showed no significant change in thickness 6 months after bone graft placement and a significant decrease in thickness 1 year after graft placement (p < 0.01). The vascularized augmented zygoma showed a slight but statistically significant decrease in thickness 6 months after graft placement (p < 0.003), with no significant difference relative to its initial thickness 1 year after graft placement. In animals killed 6 months after bone graft placement, both the rate of remodeling and the bone deposition rate measured during the last 3 months of survival were significantly higher in the vascularized bone grafts compared with their nonvascularized counterparts (p < 0.02). By 1 year postoperatively, there were no significant differences in thickness, mineral apposition rate, or osteon density between bone grafts oriented perpendicular and parallel to the zygomatic arch. These findings indicate that the vascularity of a bone graft has a significant effect on long-term thickness and histomorphometric parameters of bone remodeling, whereas the direction of placement of a subperiosteal graft relative to the recipient bed has minimal effect on these parameters. In vascularized bone grafts, both bone remodeling and deposition are accelerated during the initial period following graft placement. Continued bone deposition renders vascularized grafts better suited for the long-term maintenance of thickness and contour relative to nonvascularized grafts.

Surgical management of the facial nerve in craniofacial trauma and long-standing facial paralysis: cadaver study and clinical presentations

BACKGROUND AND OBJECTIVES

Examination of the extratemporal branches of the facial nerve reveals several branching patterns of the facial nerve, indicating the variability in the course of the nerve. Due to such variance, injury to this nerve often accompanies facial trauma and surgical dissection for the repair of facial bone injuries, and it may result in high morbidity.

METHODS AND MATERIALS

A study of 12 fresh cadavers was performed to 1) review the variability in location of the extratemporal branches of the facial nerve, 2) identify the soft tissue injuries in which the facial nerve is at risk, and 3) discuss surgical options for repair. The authors identified the zygomatic and buccal and the extratemporal branches of the facial nerve. Among the five extratemporal branches, there is a significant crossover between all, except the temporal and the mandibular branches. This indicates that dissection should proceed with great caution, since injury to the temporal and marginal mandibular branches is unlikely to resolve spontaneously. The management of injuries within one year and those of longer duration is discussed.

RESULTS AND/OR CONCLUSIONS

Two of the 5 major branches of the extratemporal facial nerve have a high morbidity following injury. Repair should be performed within the first 72 hours. Graft, if required, should be placed in 9 to 12 months.

Biomechanical and histologic alteration of facial recipient bone after reconstruction with autogenous bone grafts and alloplastic implants: a 1-year study

Potential alteration of the underlying recipient bone resulting from a graft or implant has significant clinical relevance. The present study was designed to evaluate the biomechanical and histologic alteration of facial recipient bone with autogenous bone graft and alloplastic implants over a 1-year period. The bilateral arches of 15 rabbits were randomized between four groups: (1) control (n = 6), subperiosteal exposure of the zygomatic arch was made; (2) onlay (n = 12), bone graft was placed as an onlay to the zygomatic arch; (3) inlay (n = 6), bone graft was placed as an inlay within the zygomatic arch; (4) implant (n = 6), a stainless steel plate was placed as an onlay to the zygomatic arch. Animals were killed 1 year after grafting. In the onlay groups, all steel implants and half of the onlay bone grafts (n = 6) were separated from the zygomatic arch; the remaining onlay bone grafts (n = 6) were left on the zygomatic arch. Three-point breaking strength was measured through the center of the graft/implant site on the zygomatic arch, followed by histologic evaluation and histometric assessment of residual bone density. The findings demonstrated no difference in the breaking strength per unit bone area between the control zygomatic arch group and the onlay group in which the bone graft was left in place. Breaking strength of the zygomatic arch in the former two groups was significantly greater than that in either group in which the onlay bone graft or implant had been removed, and was also greater than the breaking strength in that group in which inlay bone had been placed (p < 0.05). Histologic assessment showed full-thickness conversion in architecture of the zygomatic arch from compact to woven bone beneath onlays of either autogenous bone graft or steel implant; histometric assessment demonstrated an accompanying decrease in bone density in the latter groups relative to the control zygoma (p < 0.05). We conclude that onlay autogenous bone graft and alloplastic implants to the facial skeleton induce transformation of both graft and recipient bone from compact to woven architecture, accompanied by a reduction in bone density. The biomechanical strength of recipient facial bone is significantly weakened if an onlay bone graft or implant is removed. Weakening occurs per unit area of remaining bone, and is therefore independent of any thinning that may occur within the recipient bone because of graft/implant placement. These findings may impact upon decisions to augment stress-bearing regions of the facial skeleton with bone graft or implants, particularly if the graft/implant may eventually require removal.

Biomechanical evaluation of titanium, biodegradable plate and screw, and cyanoacrylate glue fixation systems in craniofacial surgery

Choice of appropriate fixation after reduction of displaced bone fragments or advancement of osteotomized segments requires knowledge of the maximal force to which these segments can be subjected. The present study was performed to obtain a biomechanical comparison of a variety of resorbable fixation systems as an alternative to metal plates and screws. Sheep cadaver parietal bone segments were osteotomized and fixed with one of six methods of fixation: (A) titanium plates and screws consisting of (1) miniplates and 2.0-mm-diameter screws; (2) midface plates and 1.5-mm screws; (3) microplates and 1.0-mm screws; (B) resorbable systems consisting of combinations of butyl-2-cyanoacrylate glue and biodegradable polylactic acid/polyglycolic acid copolymer plates and 2.0-mm screws as follows: (1) direct glue fixation of segments; (2) resorbable plates fixed to bone segments with cyanoacrylate glue; (3) resorbable plates fixed with resorbable screws. Compression testing was performed upon bone segments advanced and fixed across a central gap, and distraction testing was performed on bone segments fixed in direct contact. Force to failure in both distraction and compression was significantly greater in bone segments fixed with titanium miniplates than with any other method of fixation. Segments fixed with plates and screws, either nonresorbable or resorbable, achieved stronger fixation in distraction than in compression for all plate sizes tested. Resorbable plate and screw fixation was as strong as standard titanium midface and microplating systems in distraction, and stronger than the latter techniques in compression. With compressive forces of relapse, fixation with glue and resorbable plates was as strong as standard titanium midface and microplating systems. However, with distractive forces of relapse, glue fixation of either the bone segments or resorbable plates was weaker than both titanium and resorbable alternatives in which plates and screws were used. These findings may have direct impact on the choice of fixation devices used to support osteotomized or fractured bone segments, which are subjected to persistent muscular and soft-tissue pull.

Analysis of the distribution of cutaneous perforators in cutaneous flaps

An anatomic and statistical analysis was performed on the distribution of cutaneous perforators that perfuse the scapular, radial forearm, and lateral arm cutaneous flaps. Perforators were categorized as direct, terminal, and intransitive, depending upon perforator origin and termination site relative to the source artery. Statistical cluster analysis of perforator distributions was performed to determine the regions in which cutaneous perforators are consistently found. The scapular and radial forearm flaps could be divided into up to three well-perfused segments. The analysis predicted the possibility of dividing the lateral arm flap into as many as seven segments while maintaining perfusion. Clinical applications of this method for preoperative flap design and elevation as well as final results are shown.

The kleeblattschädel anomaly in Apert syndrome: intracranial anatomy, surgical correction, and subsequent cranial vault development

We present a case of Apert syndrome in which intracranial anomalies of the cranial base were localized to the lesser wings of the sphenoid and sphenoid ridge. The lesser wings of the sphenoid were displaced superiorly to follow the fused coronal sutures bilaterally, where they met at a single point on the skull vertex. Careful preoperative study of the intracranial anatomy in the kleeblattschädel anomaly led to a surgical plan for early correction of the anomaly. The present report indicates that an aggressive approach to the correction of the kleeblattschädel anomaly beginning early in infancy can result in normalization of the trilobar skull configuration. Although this approach can correct the kleeblattschädel anomaly, 3.5-year follow-up in this patient with Apert syndrome demonstrates progressive turricephaly despite repeated cranial vault remodeling. Although the trilobar skull configuration can be corrected through early surgical intervention, the long-term correction of progressive turricephaly in patients with Apert syndrome remains an unsolved problem.

Preauricular skin defects. A consequence of a persistent ectodermal groove

BACKGROUND

The term aplasia cutis is used to describe congenital localized defects of the skin. This affliction is the end result of various in utero events. Aplasia cutis of the face, although rare, has been associated with numerous dysmorphic features and described under many clinical terms.

OBSERVATIONS

We studied 10 patients with oval, atrophic patches distributed in a linear pattern on the preauricular region of the face. Most of the defects were bilateral, and all consistently fell in an oblique line extending from the preauricular region to the angle of the mouth. This line corresponds to the region of fusion between the maxillary and mandibular facial prominences during embryonic development.

CONCLUSIONS

This type of facial aplasia cutis may be the result of incomplete fusion of the ectodermal groove between the maxillary and mandibular facial prominences. Although other types of facial skin defects may share a similar pathogenic mechanism, they are distinct in that they occur in different regions and may have other abnormal facial features.

Hydroxyapatite cement paste cranioplasty for the treatment of temporal hollowing after cranial vault remodeling in a growing child

Postoperative depression of the temporal fossae and calvarial contour deficits are common sequelae following orbital rim advancement and cranial vault remodeling in children. Reconstructive options in the growing child are limited. Autogenous bone graft has a high rate of resorption when placed as an onlay to augment the craniofacial skeleton, and many of the available alloplasts will not remodel to adapt to the growing calvarium. We report a 9-month follow-up of the use of hydroxyapatite cement paste for the reconstruction of postoperative bitemporal hollowing and depressions in cranial contour in a 4.5-year-old boy. This is the first case of which we are aware that reports the use of hydroxyapatite cement paste for craniofacial augmentation in a growing child. Longitudinal follow-up of this patient will help to determine the long-term outcome of hydroxyapatite cement paste in this setting.

Syndactyly repair performed simultaneously with circumcision: use of foreskin as a skin-graft donor site

A boy who had simple syndactyly involving the third web space of the left hand presented for elective syndactyly repair. Circumcision had been delayed because of neonatal medical problems. Elective syndactyly repair and circumcision were performed in one operation at age 9 months. Penile foreskin was used as a full-thickness skin graft for the syndactyly repair. The foreskin provided a functional syndactyly repair with good aesthetic characteristics. This obviated the need for two separate operations and for an additional skin graft donor site. To our knowledge, this is the first reported case in which foreskin was used for the repair of syndactyly. In boys with syndactyly, the authors advocate that parents be informed of this reconstructive option. Should the parents consider it to be suitable, then elective circumcision should be delayed until the time of syndactyly repair so that foreskin may be used for the syndactyly repair.

A CT scan technique for quantitative volumetric assessment of the mandible after distraction osteogenesis

Distraction osteogenesis has become an accepted method of treatment for patients requiring reconstruction of hypoplastic mandibles. We present a quantitative analysis of volumetric changes after distraction osteogenesis in a series of 10 patients. Group I (n = 5 patients, 3 unilateral craniofacial microsomia, 1 Goldenhaar syndrome, and 1 bilateral craniofacial microsomia) underwent unilateral distraction of the mandible. Group II (n = 5 patients, 1 Nager syndrome, 1 bilateral craniofacial microsomia, 1 developmental micrognathia, and 2 Treacher Collins syndrome) underwent bilateral distraction of the mandible. Predistraction and postdistraction axial and three-dimensional computed tomographic (CT) scans were digitized and transferred to a computer for analysis with image-processing software to determine the changes in volume of the mandible and bony regenerate. The CT-derived volume method was validated by scanning three dry cadaver mandible specimens and comparing the volume data with those derived from a water-displacement method. The difference between the two methods was less than 5 percent. The mean distracted length, as recorded from the calibrated device, was 22.6 mm in the 10 patients. In the unilateral distraction group, the mean increase in hemimandibular bone volume was 2.8 cc, with a mean percentage increase of 27 percent in the distracted hemimandible. In the bilaterally distracted patients, the mean increase in total mandibular volume was 7.9 cc, with a mean percentage increase in bone volume of 25 percent. This study represents the first attempt to quantify the increase in bone volume resulting from distraction osteogenesis. Quantitative volumetric analysis of CT scans is an accurate method to measure the amount of bone regenerate in patients undergoing distraction osteogenesis of the mandible or the extremities. The concept and utility of quantifying the volumetric changes in bone following distraction osteogenesis may become more important as multiplanar devices are developed and used in other areas of the craniofacial skeleton.

The temporal branch of the facial nerve: how reliably can we predict its path?

A thorough examination of the temporal branch of the facial nerve was performed to characterize precisely the number of rami crossing the zygomatic arch and their location with respect to bone and soft-tissue landmarks. Fresh cadaver dissection was performed in 12 facial halves, dissecting the facial nerve superiorly from the stylomastoid foramen to identify all branches crossing the zygomatic arch. There were a median of three (range two to four) rami of the temporal branch crossing the lower aspect of the zygomatic arch, with distinct anterior and posterior divisions identified in each dissection. In 8 of the 12 dissections, one or more separate middle divisions of the nerve also were seen at the inferior aspect of the zygomatic arch. Superior to the zygomatic arch, frequent interconnections were noted between all divisions of the temporal branch, but no connections were noted to other branches of the facial nerve. Previous descriptions of the course of the temporal branch based on soft-tissue landmarks most closely correlated with nerve rami that were found in the present study to be located within the anterior division of the nerve. On crossing the inferior aspect of the zygomatic arch, the anterior and middle divisions of the temporal branch were located a median of 12 and 4 mm anterior to the articular eminence, respectively; the posterior division ranged in location from 10 mm posterior to 7 mm anterior to the articular eminence. The range over which rami of the temporal branch crossed the inferior aspect of the zygomatic arch was equally divided anterior and posterior to the articular eminence and covered up to 50 percent of the total length of the zygomatic arch. The present study confirms that the temporal branch is not a single nerve branch but consists of multiple rami that cross the zygomatic arch anywhere for over half the length of its inferior border. Techniques for localizing the nerve based on reference points from two soft-tissue landmarks are therefore unreliable.

Identification and assessment of velopharyngeal inadequacy

PURPOSE

To review current literature with respect to the diagnosis and assessment of velopharyngeal inadequacy (VPI), including present knowledge about the most common causes of VPI.

METHODS

Data sources include published reports over the past 20 years derived from computerized databases and bibliographies of pertinent articles and books. Indexing terms used were "velopharyngeal incompetence," "velopharyngeal inadequacy." "velopharyngeal insufficiency."

CONCLUSION

VPI is most commonly associated with cleft palate, submucous cleft palate, and following adenoidectomy. The otolaryngologist can prevent the latter by preoperative identification of physical stigmata associated with VPI. Perceptual assessment is the criterion standard for diagnosis of VPI. Multiview videofluorography and flexible nasal endoscopy provide the best direct assessments to help plan and direct the optimal treatment of VPI.

A dynamic analysis of changes in the nasolabial fold using magnetic resonance imaging: implications for facial rejuvenation and facial animation surgery

An anatomic study was performed on living subjects using magnetic resonance imaging (MRI) to distinguish the relative contribution of skin, subcutaneous tissue, and muscle to dynamic changes in the nasolabial fold during facial animation and aging. MRI scans with the face in repose and then holding a full smile were performed in both young and old adult subjects. Anatomic landmarks were identified, and measurements characterizing their position were made on the MRI console. MRI resulted in excellent image resolution of facial tissue planes. Comparison between young and old subjects with the face in repose demonstrated that progressive thickening of the dependent portion of the check fat pad and overlying skin, with no appreciable change in the muscle plane comprising the levators of the upper lip, resulted in a deeper and more acute nasolabial fold in older subjects. In both age groups there was significant shortening of the mimetic muscles with smiling, with the lateral mimetic muscles drawn closer to the underlying facial bones. This was accompanied by redistribution of the cheek fat pad, thereby maintaining projection of surface landmarks within the cheek mass in young subjects with smiling. These findings indicate that in order to diminish the nasolabial fold, surgery for facial rejuvenation should be directed to the skin and subcutaneous tissue planes superficial to the mimetic muscles to the upper lip. In order to recreate a natural nasolabial fold during surgery for facial reanimation, contraction of the levator muscles to the upper lip should result in redistribution of the cheek fat pad without change in surface projection of the cheek mass or upper lip; this can only be accomplished if the reconstructed levator muscle is positioned deep to the cheek fat pad, with its insertion toward the deep (mucosal) surface of the upper lip.

Submucous cleft palate: diagnostic methods and outcomes of surgical treatment

The following statements summarize our interpretation of the literature regarding submucous cleft palate: Incidence and Diagnosis of Submucous Cleft Palate 1. In surveys of classic stigmata of submucous cleft palate among the general population, the incidence has been reported to be 0.02 to 0.08 percent. In the larger of these series, the incidence of velopharyngeal inadequacy among patients identified to have submucous cleft palate was 1 to 9. The incidence of occult submucous cleft palate is not known, since these patients will only be detected during the evaluation of patients who present with velopharyngeal inadequacy. 2. The diagnosis of submucous cleft palate is made by identification of the classic stigmata on physical examination. The diagnosis of occult submucous cleft palate is only pursued if the patient has velopharyngeal inadequacy. 3. For consistency in evaluating and reporting data, patients with an overt cleft of the secondary palate that extends beyond the uvula should be reported as having a cleft palate, and not a submucous cleft palate, even if a submucous cleft exists in a portion of the palate anterior to the overt cleft. 4. The true incidence of otitis media with effusion in the presence of submucous cleft palate has yet to be determined using a prospective study. Surgical Treatment of Velopharyngeal Inadequacy in Patients with Submucous Cleft Palate 1. The technique that has most consistently been documented to result in a significant correction of velopharyngeal inadequacy is the pharyngeal flap. There is recent evidence from one large center supporting the efficacy of the Furlow Z-plasty in selected patients with submucous cleft palate. Both these procedures appear to be most effective in patients with good lateral pharyngeal wall motion. 2. If a pharyngeal flap is performed as the primary procedure to act as an obturator against which the lateral pharyngeal walls appose for closure, we do not see the need for adjunctive palatal procedures. The dynamic component of velopharyngeal competence following such a pharyngeal flap consists of lateral wall motion, which is not enhanced by further surgical manipulation of the palate. However, a pharyngeal flap may be performed as an adjunctive procedure to a palatal pushback in order to provide lining for the resultant defect in the nasal mucosa. 3. The present literature does not support "prophylactic" operations on patients who present with the physical stigmata of submucous cleft palate prior to reaching an age at which it can be demonstrated by perceptual speech assessment that velopharyngeal inadequacy remained refractory to speech therapy. A significant number of patients will never develop velopharyngeal inadequacy; therefore, surgery would be unnecessary. In addition, objective data regarding the outcomes of different surgical techniques cannot be gathered if patients with submucous cleft palate are operated on without having had velopharyngeal inadequacy documented prior to those operations. 4. In order to objectively compare the outcomes of different surgical techniques, any future studies should be prospective and utilize uniform means of assessment. As minimum criteria, these would include preoperative and postoperative perceptual speech assessments performed by a trained speech pathologist and preoperative nasopharyngoscopy and multiview videofluoroscopy. The latter two studies should be repeated postoperatively only in those patients who have persistent velopharyngeal inadequacy.

The histomorphologic changes in vascularized bone transfer and their interrelationship with the recipient sites: a 1-year study

In 13 New Zealand White rabbits with a mean age of 6 months, vascularized bone transfers incorporated as paired auricular anterior myo-osseous flaps were harvested; they were placed in either an inlay or an onlay position relative to the zygomatic arch. The onlay bone transfers were placed either in full contact or in partial contact with the zygomatic arch. The animals were sacrificed 1 year after transfer. At 1 year, the inlay transfer simulated the adjacent zygoma in width and thickness. Onlay full contact transfers maintained significant aug mentation in thickness of the zygoma, while the onlay partial contact transfers did not; the thickness of the augmented zygoma in the onlay full contact subgroup was significantly greater than that in the onlay partial contact transfers. The onlay partial contact grafts had remodeled into the zygoma in bone contact, where the orientation of mismatched osteons within the bone transfers had transformed to match that of the native zygoma. In areas of bone contact between the onlay and the host bone, full-thickness conversion from a cortical to a trabecular architecture had occurred in both the transfer and host bones. These findings have numerous implications regarding mechanisms that could be exploited clinically to optimize the survival of a bone transfer; they also raise questions regarding alteration of the recipient bed after placement of an onlay bone transfer.

A prospective study of the relationship between strabismus and head posture in patients with frontal plagiocephaly

A prospective study was performed on 16 unoperated patients with frontal plagiocephaly to characterize the relationship between strabismus and abnormal head posture. Serial eye examinations were performed preoperatively and for 24 to 46 months following fronto-orbital advancement. In 14 patients (88 percent), preoperative clinical examination and CT scan indicated coronal plagiocephaly (synostotic); unicoronal synostosis was documented during fronto-orbital advancement in all these patients. Ten patients had abnormal head posture on preoperative examination, 9 of whom had strabismus at some time during the study. These 9 patients all had unicoronal synostosis with ipsilateral strabismus and a contralateral head tilt. All had eye muscle findings consistent with superior oblique paresis, although in 2 patients these signs first developed following fronto-orbital advancement. Strabismus resolved spontaneously in 2 patients between 2 and 8 months following fronto-orbital advancement; the remaining 7 patients underwent extraocular muscle surgery following fronto-orbital advancement, with early resolution of strabismus in all cases. The head tilt resolved or improved significantly in all 9 patients following resolution of the strabismus. Two patients had recurrent superior oblique paresis following surgical correction, necessitating secondary strabismus surgery. The present study indicates that extraocular muscle dysfunction is the major cause of abnormal head posture in patients with coronal plagiocephaly and emphasizes the need for long-term ophthalmologic surveillance in these patients.

Morbidity associated with increased intracranial pressure in Apert and Pfeiffer syndromes: the need for long-term evaluation

Although the incidence of elevated intracranial pressure is increased in patients with the craniosynostosis syndromes, the significance of these findings and their impact on clinical practice remain unclear. The morbidity related to elevated intracranial pressure in patients with Apert and Pfeiffer syndromes was reviewed. Sixty-seven patients with Apert syndrome and 39 patients with Pfeiffer syndrome were identified. The morbidity in 5 of the 106 patients (4.7 percent) was felt to be directly related to persistently elevated intracranial pressure. These included 2 deaths, 1 due to brainstem herniation after an elective subcranial Le Fort III advancement and 1 following removal of a lumboperitoneal shunt during the surgical release of syndactyly. The remaining 3 complications included bilateral papilledema detected 3.5 years after cranial vault remodeling in 1 patient and venous hypertension with excessive bleeding detected during elevation of the bicoronal flap in 2 patients, resulting in delay of a planned Le Fort III advancement. Patients with the syndromal craniosynostoses are at risk for complications resulting from elevated intracranial pressure from infancy through adulthood despite surgical attempts to increase cranial capacity in infancy. Clinical guidelines are proposed by which these patients should be evaluated beyond infancy in a regular fashion so as to reduce morbidity from unrecognized elevations in intracranial pressure.

Cutaneous pseudolymphoma: an unusual presentation of a deep subcutaneous thigh mass

Cutaneous pseudolymphoma is considered to be a benign (reactive) cutaneous lymphoid infiltrate; the term designates reactive diseases of the skin that histologically mimic cutaneous lymphoma. We report a case in which a 63-year-old female presented with a 5-month history of a progressive skin eruption and an enlarging subcutaneous mass following a presumed insect bite. Excisional biopsy showed this to be a pseudolymphoma extending from the dermis into the subcutaneous tissue. A number of pathological features that distinguish pseudolymphoma from cutaneous lymphoma, including histology, immunophenotype, and immunogenotype, are reviewed. The case herein challenges previous beliefs that pseudolymphoma is confined to cutaneous involvement and indicates that the process can involve deeper tissues. The final criterion for distinguishing benign from reactive processes is biological behavior. Since the depth of invasion in cutaneous pseudolymphoma has not previously been appreciated, the patient will need to be carefully examined periodically until the biological behavior of the process has been determined.

Bilateral cleft lip and palate associated with agenesis of the hand and distal forearm

We report on a child who was born with an incomplete bilateral cleft lip and palate associated with agenesis of the left hand and distal forearm. No other anomalies were noted. The patient was the first child of a term pregnancy with a negative family history, and the mother took no prenatal medications. Ultrasonogram performed at 34 weeks' gestational age failed to detect any congenital anomalies. Thorough genetics evaluation, including chromosome analysis, showed no further abnormalities; the birth defects were believed to be nonsyndromic. To our knowledge, the association of bilateral cleft lip and palate with agenesis of the upper extremity has not been previously reported. Moreover, it is important to note that a prenatal ultrasonogram, even when performed late in the third trimester, may fail to detect these significant congenital anomalies.

Surgical anatomy of the facial nerve

(1) The temporal branch of the facial nerve emerges within the parotid gland to cross the zygomatic arch at the deep surface of the temporoparietal fascia. The nerve is separated from the deep temporal fascia immediately above the zygomatic arch by a loose areolar plane; this plane may be obliterated when previous surgical procedures have been performed in this region. (2) The temporal branch can be found within a trajectory that has been described relating the lower portion of the auricle to the lateral aspect of the eyebrow. However, one must be aware that these surface landmarks may vary with respect to the underlying skeleton and from one individual to the next. (3) Recent studies indicate that the temporal branch consists of not one, but multiple rami that cross the zygomatic arch. Because there are multiple rami to the temporal branch of the facial nerve, any single trajectory can describe only a portion and not the entirety of the temporal branch. (4) The zygomatic, buccal, and marginal mandibular branches of the facial nerve innervate the mimetic muscles of the face from either their superficial or deep surfaces. Several mimetic muscles are innervated by two or more branches of the facial nerve. (5) Interconnections between the zygomatic and buccal branches are noted in over 70% of cases, whereas interconnections between the temporal or marginal mandibular branches to other facial nerve branches occur in less than 15% of cases. (6) The zygomatic, buccal, and marginal mandibular branches lie in intimate relationship with the retaining ligaments of the face. Surgical dissection for release of the zygomatic ligament, the masseteric cutaneous ligament, or the mandibular ligament should be performed meticulously and with extreme caution.

A study of intracranial volume in Apert syndrome

The present study was undertaken to characterize the intracranial volume in patients with Apert syndrome. Radiographic and CT-based techniques for measuring intracranial volume were found to show close correlation when validated in dry normal adult skulls. A standard-deviation score of intracranial volume, determined from CT scans in 20 patients with Apert syndrome from birth to 30 years of age, was calculated with reference to a normative database of age- and sex-matched controls. Analysis of the data showed no significant difference in standard-deviation score between Apert patients with or without ventriculomegaly, before or after cranial vault surgery, or between male and female patients. The mean standard-deviation score among all Apert CT scans compared with normative data was 3.1, which was highly significant (p < 0.001). However, the growth curves showed no significant difference in intracranial volume between Apert and normal patients below 3.5 months of age. In summary, intracranial volume in Apert syndrome is within normal range at birth but increases to greater than 3 standard deviations above normal after 3.5 months of age, a finding independent of cranial vault surgery.

Revascularization of free mandibular reconstruction after early emergency arterial ligation

A 70-year-old man with a squamous cell carcinoma involving the anterior arch and body of the mandible underwent resection and reconstruction with a 10-cm free vascularized iliac crest bone graft, preserving periosteum and minimal adjacent soft tissue. On postoperative day 12, he experienced bleeding from an orocutaneous fistula, requiring emergency ligation of the arterial pedicle to control hemorrhage. After ligation, continued bleeding was noted from the margin of the graft, with active filling of the venous pedicle. The 10-cm mandibular bone graft survived without appreciable resorption during a period of follow-up of 5 years. We believe that bone graft survival in the present case was due to early vascular communication between the periosteum and adjacent soft tissues of the graft with the recipient bed. This mechanism may serve to maintain bone graft viability after early arterial disruption, when repeat arterial anastomosis is believed to be contraindicated.

Cervicovertebral anomalies and basilar impression in Goldenhar syndrome

Although previously unreported, neurologic compromise may occur secondary to anomalies of the cervical spine in the oculoauriculovertebral spectrum. Medical records and cephalograms were reviewed from 18 patients with classic Goldenhar syndrome and from 18 normal adults. One patient, a 22-year-old man, had experienced a 5-year history of progressive neurologic compromise from basilar impression; the remaining 17 patients were asymptomatic. Radiographic evidence of cervicovertebral fusion was documented in 11 of 18 patients (61 percent). Fusion occurred at every cervical level other than the atlantoaxial joint. Radiographic indices that characterize the cranial base were not significantly different between asymptomatic Goldenhar patients and normal adults. Posterior inclination of the odontoid with respect to the foramen magnum appears to be the best indicator that a patient is at risk for basilar impression. Careful radiographic evaluation may indicate which patients require more careful surveillance with periodic neurologic examination and CT and/or MRI scans.

Surgical anatomy of the SMAS: a reinvestigation

There has been considerable disagreement in descriptions of the SMAS. Fresh cadaver dissection, combining anatomic dissection done with the aid of the operating microscope and histologic cross section of facial tissues, was performed in 24 facial halves. Histologic preparation was made on tissue macrosections, each 10 cm in length. Consistent findings include the following: (1) Although the SMAS is closely applied to the superficial surface of the parotid gland, a thin but distinct parotid fascia can be identified between parotid gland and SMAS. (2) The SMAS terminates superiorly within 1 cm below the zygomatic arch, and is not continuous with the temporoparietal fascia. (3) The SMAS in the cheek lies in continuity with the orbicularis oculi muscle of the lower eyelid. (4) Considerable variability exists in the histologic appearance of the SMAS in different facial regions within a single cadaver, as well as in a given facial region between cadavers. Because of its variability, histologic identification of the SMAS should be made in continuity with known reference structures, such as the platysma.

The composite lateral arm free flap: vascular relationship to triceps tendon and muscle

We studied the vascular relationship of the lateral arm flap to triceps tendon and muscle in 16 dissected cadaver arms. We designed composite lateral arm free flaps containing fasciocutaneous components, triceps muscle, and/or triceps tendon. Vascular communication between the lateral arm fascia and triceps tendon was negligible. In contrast, a mean of 3.6 vessels passed through triceps muscle from the posterior radial collateral artery to the harvested triceps tendon; in each dissection at least 1 vessel entered the proximal 5 cm and 1 vessel entered the distal 5 cm of harvested tendon. Methylene blue injections confirmed that perfusion of the triceps tendon was through triceps muscle and not through lateral arm fascia. We used the composite lateral arm free flap in 6 patients, 3 with triceps muscle and 3 with triceps tendon. Baltimore Therapeutic Evaluation testing in those patients where triceps tendon was harvested showed no deficit in elbow extension. Complete coverage of composite defects was achieved with a single surgical procedure in all patients.

Toxic shock syndrome following latissimus dorsi musculocutaneous flap breast reconstruction

Acute toxic shock syndrome (TSS) not related to menstruation has comprised an increasing proportion of cases reported to the Center for Disease Control in recent years. We report a patient with TSS resulting from a postoperative donor site infection after bilateral breast reconstruction with latissimus dorsi musculocutaneous flaps. The diagnosis, management, and outcome of TSS are reviewed. The plastic surgeon should be aware of TSS as a potential postoperative complication of routine procedures in plastic surgery.

Scalp reconstruction with a prefabricated abdominal flap carried by the radial artery

Custom prefabrication of free flaps provides an unlimited variety of applications, since flaps can be created with expendable tissues and without restriction to naturally occurring vascular territories. These principles also can be used to customize flaps that could not be completed by conventional means. We report a case of scalp reconstruction using a random-pattern abdominal flap in which a radial artery fascial flap was induced to serve as the vascular carrier. In addition to providing durable scalp coverage, the prefabricated free flap enabled salvage of an abdominal flap that would otherwise have been aborted after intermediate transfer to the forearm.

Relationship between skin fluorescence and blood flow in normal and in chronically ischemic subjects dosed with fluorescein

To elucidate parameters diagnostic of chronic ischemia, the fluorescence of skin on the foot, leg, arm, and forehead of six chronically ischemic patients and six normal subjects injected with fluorescein was measured serially using a surface-measurement fluorometer (dermofluorometer). Simultaneously collected plasma samples were assayed spectrofluorometrically for unmetabolized fluorescein. The time courses of plasma fluorescein content and dermofluorometer readings were jointly analyzed by combining a standard pharmacokinetic model, a model predicting skin site from plasma concentrations of fluorescein, and a model predicting the dermofluorometer response to those skin concentrations. Fluorescein plasma clearance (0.22 +/- 0.06 versus 0.46 +/- 0.20 L/h/kg) in ischemic patients was only half, and half-life was double (2.4 +/- 1.0 versus 1.3 +/- 0.3 h) those in normal subjects, with volume of distribution (Vdss = 0.46 L/kg) being similar. Despite the ischemia diagnosis for all patients involving claudication of the lower extremities, patients could be distinguished statistically from normal subjects on the basis of fluorescence readings taken on the arm, but not those using the foot or leg. The rate constant describing flux of fluorescein from the arm skin site in patients was only half that in normal subjects, and the peak reading on the arm occurred at 42 +/- 14 min after fluorescein injection in patients, but at only 15 +/- 6 min in normal subjects. Lack of discrimination between subject groups via leg and foot readings may be due to several physiologic and/or experimental factors, including the need to take skin surface readings much earlier than previously recognized.(ABSTRACT TRUNCATED AT 250 WORDS)

Catheter irrigation for treatment of pyogenic closed space infections of the hand

We studied 29 patients admitted to San Francisco General Hospital with flexor tenosynovitis (6 patients), pyogenic arthritis (17 patients), and deep space infections (6 patients). All patients underwent catheter irrigation of the infected space for at least 48 hours postoperatively. In 23 patients no further operative procedures were required. Infection was controlled without amputation in all patients. Median hospital stay was the same for patients with tenosynovitis, pyogenic arthritis, and deep space infections (8 days). Thirteen of 17 patients followed for at least one month, including 7 of 9 patients with pyogenic arthritis, were found to have regained at least 50% of baseline motion. In this series the outcome of treatment for pyogenic arthritis was comparable to that for tenosynovitis. We believe that catheter irrigation should be considered as a treatment option in pyogenic arthritis. A prospective trial comparing the efficacy of treatment modalities for pyogenic arthritis is indicated.

Lateral cervical cyst containing gastric epithelium

A lateral cervical cyst, presumably of branchial origin, was found to contain gastric epithelium. This is an extremely rare condition and, to our knowledge, represents the first such report in a branchial cyst. The literature is reviewed and speculations are made with respect to the embryologic and clinical implications of this anomaly.