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This study prospectively measured teasing and emotional adjustment before and after ear reconstruction in younger and older children with microtia. Participants with isolated microtia (n = 28) were divided into two groups by age at surgery, with a younger group aged 3-5 years (n = 13) with a mean age of 4.0 (0.71) years at the time of surgery and an older group aged 6-10 years old (n = 15) with a mean age of 7.87 (1.30) years. Children and their parents were interviewed preoperatively and a year after surgery about teasing and emotions about their ear(s). Teasing began between the ages of 2.4-4.8 years. A third of the younger group and all of the older group reported preoperative teasing. Before surgery, the older group reported higher rates of negative emotions about their ear(s) and teasing was correlated for all ages with feeling sad, worried, and mad about their ear(s). After surgery, teasing and negative emotions significantly decreased with increased happiness about their ear(s). Postoperative teasing was correlated with trying to hide their ear(s). There were significant interactions from before to after surgery based on surgery age for frequency of teasing, sadness, and feeling mad, with the older group showing relatively greater change postoperatively. Teasing and negative emotions about their ear(s) decreased for all ages after surgery, with a potential protective factor seen in younger surgery age.

Summary Objectives Microtia ranges from a smaller ear to the absence of the external ear and has been associated with psychosocial distress. Traditional ear reconstruction takes place beginning at age six. Use of an alloplastic implant allows for earlier surgery starting at age three, which may reduce potential negative psychological effects. However, few studies have examined psychosocial outcomes of ear reconstruction with groups that include young children. Methods Children ( N = 23) with microtia and their parents completed two microtia-related scales, negative emotions and microtia social awareness, and the Behavioral Assessment System for Children – Second Edition (BASC-2) subscales of anxiety, depression, and social skills before surgery and one year after surgery. Participants (74% male) were three to nine years old with a mean age of 6.13 ± 2.10 years and were grouped by age at surgery, three to six years ( n = 11) or seven to ten years ( n = 12). The sample identified as Latino (96%) or "other" (4%). Results Pre and postoperative scores by age group were compared using two-way repeated measures analyses of variance. Children and parents reported significantly less negative emotion and microtia social awareness following surgery, with an interaction for parental report of older children showing higher negative emotion preoperatively. Older children also had higher scores of depression and anxiety before surgery and both groups reported significant decreases following surgery, along with improved social skills. Older children showed significantly greater gains in social skills. Conclusion All participants and their parents reported improved psychological functioning postoperatively. However, older children may be at greater risk of psychological concerns given the longer time they have to cope with the impact of microtia on self-image and exposure to social stressors. Undergoing reconstructive surgery earlier may be a protective factor for children with microtia.

The objective was to investigate the effects of brain-derived neurotropic factor (BDNF) and ciliary neurotropic factor (CNTF) on peripheral nerve regeneration. Thirty Sprague-Dawley rats underwent left sciatic nerve transection and repair according to three experimental groups: epineurial coaptation (EC), EC with BDNF delivered by an osmotic pump (EC-BDNF), and EC with BDNF and CNTF delivered similarly (EC-BDNF/CNTF). Nerve regeneration was assessed using sciatic functional indices, quantitative histomorphology, and molecular analysis for proteins associated with nerve regeneration. Analysis of variance (ANOVA) comparing all groups at each time point demonstrated significant differences between groups on days 20, 30, 40, 50, 60, and 80. A paired, two-tailed Student's t-test with the Bon-ferroni correction for multiple comparisons demonstrated that at 40 days postoperatively, animals in the EC-BDNF/CNTF group (n = 7) manifested superior functional recovery compared with those in the EC group (n = 9) and those in the EC-BDNF group (n = 9) (P < 0.001 and P < 0.05, respectively). At 80 days, the animals in both the EC-BDNF (P < 0.01) and EC-BDNF/CNTF (P < 0.05) groups demonstrated greater functional recovery compared with those in the EC group, with no significant difference between the two factor groups at the endpoint. Morphometric analysis demonstrated that nerves from animals in the EC-BDNF/CNTF group had the largest mean axon diameters as compared with those from the EC (proximal: P < 0.001, distal: P < 0.05) and EC-BDNF (proximal: P < 0.01) groups. No significant differences were seen in nerve cross-sectional area. In distal nerve segments, Western blot analysis revealed that expression of myelin-associated glycoprotein was higher than control for the EC group and lower than control for both the EC-BDNF and EC-BDNF/CNTF groups. We conclude that BDNF/ CNTF combined treatment increases the early rate of functional sciatic nerve regeneration over treatment with BDNF alone, although the degree of maximal recovery was similar at the conclusion of the experiment.

Additional experience with the chondrocutaneous flap in the repair of auricular defects showed that (i) the entire medial surface of the auricle can be easily and rapidly exposed through this approach, and (ii) the transhelical scar on the lateral surface of the ear remains inconspicuous. The skin of the lateral surface of the ear is similar to that of the eyelids and forms flat, smooth scars which do not hypertrophy. Furthermore, these scars are hidden under the curl of the helix. Through this approach, correction of the protrusion can be accomplished by any method or combination of methods which call for manipulation on the medial surface of the auricle. The scar is remote from the site of manipulation of the cartilage. An additional advantage of this procedure is that it can be combined easily with a small reduction in the size of the scapha.

To investigate the effect of brain-derived neurotrophic factor (BDNF) and collagen tubulization (CT) on the regeneration of transected peripheral nerves. METHODS AND DESIGNS: The left sciatic nerve of 40 Sprague-Dawley rats was transected then repaired using one of four techniques; epineurial coaptation, CT, CT with BDNF delivered by an osmotic pump to the repair site, or CT with BDNF covalently cross-linked to the collagen matrix (CT/linked-BDNF). Sciatic functional indices were measured preoperatively at 10-day intervals for 90 days. Segments of the sciatic nerves proximal and distal to the repair site were harvested at 90 days for histologic and morphometric evaluation.Animals repaired by CT/linked-BDNF (n=10) demonstrated the most favorable functional recovery of all groups, with statistically significant differences seen compared with animals repaired by CT (n=10, P=.05) and epineural coaptation (n=9, P.001). Animals repaired by CT with BDNF delivered by an osmotic pump (n=8) and CT also showed statistically superior functional recovery compared with those repaired by epineurial coaptation (P=.005 and P=.02, respectively). Nerves repaired by CT/linked-BDNF had the largest mean axon diameters proximal and distal to the repair site.Brain-derived neurotrophic factor and CT improve the rate and the degree to which recovery of sciatic function occurs after nerve transection and repair. Animals repaired by CT/BDNF-linked demonstrated the most favorable functional recovery of all groups. Animals whose repair technique included BDNF had the largest mean axon diameters of all groups.

There are many ethical and legal implications in a variety of activities in the neurosurgeon's day-to-day practice. Awareness of and proper attention to these issues are a professional responsibility that should be attended to, to ensure that the practice of medicine is carried out efficiently and effectively, to maintain public confidence, and to try to avoid micromanagement by third parties. The authors discuss four such subjects of particular interest to them, namely: 1) reporting of certain diseases and conditions to authorities and third parties; 2) acting without the consent of the patient to prevent harm to him or her and/or others; 3) reporting problems with drugs and devices; and 4) the detection and treatment of colleagues impaired by alcohol, drugs, or mental or physical illness.

A multidisciplinary International Working Group of scientists was assembled to address the question of standardizing reporting techniques for multiview videofluoroscopy and nasopharyngoscopy, the generally accepted standards for direct observation of the velopharyngeal valve. This report is a first attempt to propose standards while seeking feedback from the readership in order to further develop a common methodology.

A procedure has been presented for the reconstruction of full thickness destruction of the oral commissure resulting from electrical burns. Major features are the translocation of orbicularis oris muscle remnants to restore muscle continuity, and the use of local skin and mucosa to provide the elements of a normal commissure.

✓ Two cases of sphenoethmoidal encephalocele with cleft palate are reported in detail. The encephaloceles had prolapsed into the nose and nasopharynx, and protruded into the mouth. Previous examples of this entity are reviewed. Such patients have a typical facial appearance: hypertelorism, median cleft lip, and bifid nose of varied severity. Ocular findings include coloboma of the optic nerve or anophthalmia. The prolapsed cerebral tissue varies from nonfunctional glia elements to vital structures of the hypothalamus-pituitary area. Agenesis of the corpus callosum has been reported consistently. Transcranial access to the bone defect, particularly its posterior portion, is difficult because of distorted cerebral anatomy and abnormal vasculature. The fragility of the prolapsed cerebral tissue makes it difficult to preserve the cerebral tissue intact and to reposition it into the cranium. When there is a cleft palate, it is possible to repair the encephalocele extracranially through a transoral, transpalatal approach, preserving and repositioning the content of the sac. Dural closure and obliteration of the bone defects are other essential steps of the operation. Both patients reported here were successfully operated on by the transoral, transpalatal route, at the age of 3 months and 4 years, respectively. They were followed for several years and had comprehensive endocrinological work-ups. One patient exhibited some pituitary deficiency requiring substitution therapy.

A total of 202 patients with pharyngeal flaps were assessed with nasopharyngoscopy and multiview fluoroscopy to determine the role of lateral pharyngeal wall movement postoperatively. Variations in the construction of flaps resulted in three categories: namely, a long narrow flap with a high insertion, a short broad flap with a low insertion, and an intermediate-size flap that is inserted in a position somewhere between the first two. It was found that in all cases where there was no evidence of velopharyngeal insufficiency, the sole determiner of velopharyngeal closure was the medical excursion of the lateral pharyngeal walls to the sides of the flap. In flap failures, the causes for velopharyngeal insufficiency were inappropriate degree, level, and symmetry of the lateral pharyngeal wall motion. The success of pharyngeal flap surgery depends largely on the preoperative assessment of the velopharyngeal mechanism and the choice of a type of pharyngeal flap that will best assist closure of the velopharyngeal port during speech.

With the help of nasopharyngoscopy, it was possible to delineate specific morphologic changes in the palates of patients with velopharyngeal insufficiency, without an overt cleft and without the triad of symptoms of submucous cleft palate, visible through the oral cavity. Such malformations are part of the broad spectrum of the faulty midline mesodermal fusion of the palate. This anomaly is aptly called occult submucous cleft palate, because it can only be detected by viewing the functioning palate from the nasal surface. The musculus uvulae is either absent or deficient and is frequently associated with some degree of muscular diastasis that does not involve the oral surface. Like the cleft of the secondary palate, the submucous cleft palate often occurs as part of a generalized syndrome of multiple malformations.

THE MOST FREQUENT deformity of the auricle is the loss of all or of part of the helix. This type of deformity is usually seen in burns around the head which involve the external ear and leave its margin scarred and jagged. The free border of the ear is sometimes lost as a result of marginal lacerations, or it may be sacrificed in the process of eradication of tumors. The recently introduced composite grafts of skin and cartilage taken from the helical portion of the auricle 1 also leave a deformity which calls for reconstruction at the time of the original operation. There are two methods of reconstruction of the helix. The first one utilizes a skin tube. 2 Such a tube is ordinarily formed in the supraclavicular region where thin, hair-free skin is available. The tube is then migrated in stages toward the mastoid region and draped around the auricle. The

The procedure for lengthening of the first metacarpal in cases of partial loss of the thumb described here utilizes a contiguous skin flap from the hand, reinforced by an iliac-bone graft. It is completed in one operative stage. Its prerequisite is the presence of intact skin along the radial border of the hand. It is not suggested that this procedure will replace the reconstruction of the thumb by transposition of a neighboring finger, but, if feasible, it is preferable to a method of repair in which an abdominal-skin tube is used. The use of the local hand flap imparts nearly normal sensation and a tactile sense to the new thumb.

Among the various dysplasias, or defects, of the ectodermal appendages, Goeckermann1differentiated the syndrome of hereditary ectodermal dysplasia of the anhidrotic type as a definite clinical entity.2Early cases of this condition were described by Thurnam3in 1848 and by Guilford4in 1883. In 1938 Lord and Wolfe5listed about 50 cases collected from the world literature. However, most of the authors have agreed that the small number of cases reported is due not so much to the rarity of the syndrome as to the unfamiliarity of members of the medical profession with the clinical picture. The main symptoms of this condition are dysplasias of the ectodermal appendages—the sweat glands, hair, teeth and nails—resulting in anhidrosis, hypotrichosis, anodontia and dystrophy of the nails. The other symptoms which are most consistently observed are deformity of the nose and papillary lesions of the skin. Because of the nasal deformity and protruding supraorbital

In recent years a great deal has been written about battle injuries of the face. There have been several publications and reports dealing with emergency and early treatment of gunshot wounds of the face. This paper is based on experiences in a general hospital of the zone of the interior, and consequently it will deal exclusively with the late treatment of such injuries. It may therefore be considered as a continuation of the experience of medical installations in the theater of operation. It is not the purpose of this paper to describe the various standard reconstructive procedures, such as rhinoplasty, blepharoplasty and cheiloplasty, which are used frequently in treatment of gunshot wounds of the face; I shall rather discuss the problems which are fairly specific in the management of this kind of battle injury and with which the civilian physician may not be familiar. The majority of facial wounds are

Industrial hand injuries consisting of massive necrosis of soft tissue with exposure of the bones and joints are among the most severe encountered in civilian practice. Salvaging and rehabilitating these extremities requires aggressive, purposeful treatment. It is aimed at preserving all salvageable structures, maintaining functional position, and restoring as much motion as possible by mobilization of joints and tendon substitution. These cases differed so nmuch in area and depth of involvement and in associated damage that conmparative evaluation and statistical analysis is of little value. However, observing these patients several years later, there could be no doubt that the rehabilitative effort was thoroughly justified. See image in the PDF file See image in the PDF file The permanent disability in dorsal injuries consisted of limitation of function of the joint and reduced strength. A serviceable grasp and pinch mechanism was established in all cases. Palmar and volar injuries have a poorer rehabilitative prognosis. Structural restoration of the hand is of little value unless there will be serviceable sensation and function. Damage to the neurovascular supply was responsible for the only amputation performed in this group.

The history of surgical correction of the pendulous abdomen is briefly reviewed. Based on our experience in 30 consecutive cases, the method of lipocutaneous reduction is outlined, incorporating modifications of previously described techniques.

THE NASAL VESTIBULE PRACTICALLY all rhinoplastic maneuvers are performed through the intranasal route by incisions made in the nasal vestibule. The latter forms a dilatation inside the aperture of the nostril. It is bound laterally by the ala and the lateral crus of the alar cartilage and medially by the columella and the membranous septum. The vestibule extends from the nares to the intercartilaginous fold, which separates the alar and lateral cartilages. In a frontal section each vestibule has the approximate shape of a right-angle triangle, with the lateral wall of the nostril forming the hypotenuse. The concavity of the lateral crus and its junction with the medial crus form the high vault of the vestibule. This vault makes the diameter of the vestibule larger than the diameter of the nostril. The lining of the vestibule consists of a thin layer of the skin intimately adherent to the underlying cartilage.

HEMANGIOMA of the nasal bone constitutes an unusual but distinctive entity. The Table contains data on the ten published cases. 1-8 The first patient in whom serial roentgenograms demonstrated the evolution of a nasal bone hemangioma is the subject of this report. Report of a Case A 50-year-old white man was admitted to the Montefiore Hospital and Medical Center in July 1967 with the complaint of swelling of the nose (Fig 1, left ). In February 1961 a cardboard box fell from a shelf and struck the patient on the right side of the bridge of the nose. Initial roentgenograms immediately following the injury showed no abnormality (Fig 2). The patient noted persistent discomfort and tenderness. A second roentgen examination in August 1961 was again normal. The patient then noted the appearance of a slowly growing soft tissue swelling at the site of trauma. Repeat x-ray film study in April and

THE RECONSTRUCTIVE procedures in a variety of nasal deformities not limited to cutaneous losses alone but including defects of varying magnitude of the entire nasal wall are grouped together under the term subtotal rhinoplasty. In the repair of these deformities the surgeon has a choice of a variety of procedures. Frequently for repair of a relatively small nasal defect he will resort to a large, distant flap, perhaps of the sickle-flap variety, or to a cervical or brachial skin tube. Nevertheless, his first consideration will always be whether a satisfactory reconstruction can be effected either by a free graft, utilizing the principle of a composite auricular graft, or by a contiguous skin flap. These procedures offer the advantage of great economy of time and effort, and in properly selected cases they will bring about a better result than can be obtained from a distant flap. The anticipated secondary scarring or

Four cases of fibrodysplastic lesions of the mandible have been presented. Their histologic structure is essentially the same but their clinical picture and behavior differ widely. At present, out of many conflicting opinions, the concept of fibrous dysplasia as a benign tumor originating in a mesenchymal defect seems to be the most acceptable explanation. Better understanding of these tumors can come primarily from an integrated study based on long term follow-up of such cases. Watchful observation, conservative surgery and radical resections have their place in the treatment of fibrous dysplasia. The modality does not depend entirely on the pathologic diagnosis but on the clinical behavior of the tumor.

Poulard's method of correction of depressed scars is "resurrected." The modifications presented here extend the usefulness of this procedure to more extensive depressions. While they are applicable to most depressed, retracted, adherent scars anywhere on the body, they are particularly useful in the correction of the disfiguring tracheotomy scar.

IN cranium bifidum, a congenital or traumatic defect of the skull, the cranial contents herniate, causing what is variously called a meningocele, cephalocele, encephalocystocele, etc. In the literature these terms are often used interchangeably. Although, strictly speaking, a cranial meningocele does not contain brain, neural elements are usually found in the wall. Cranial meningocele is much rarer than spinal meningocele and constitutes only 10% of central nervous system hernias. Cranial meningoceles are of two types: the sincipital, which form external tumefactions, and the basal. Located within the nose or pharynx, between 5% and 10% of cranial meningoceles are reported to be of the basal type. Among 546 patients with meningocele at the Boston Children's Hospital, Ingraham and Swan1found 84 to be cranial, and among these 64 were occipital, 9 were parietal, 6 were frontal, and only 5 (6%) were endonasal. Endonasal Meningoceles. —A basal meningocele usually exits from