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Syndromic hypoplasia of the orbit and midface results in noticeable dysmorphology. Correction involves advancement of the orbito-facial complex either directly or by distraction osteogenesis. The surgery is challenging no matter where it is performed, however, the challenges are amplified on a surgical mission. Komedyplast Surgical Charity (Chicago, IL) has been performing complex craniofacial procedures, including midfacial advancement at the Monobloc level, for 13 years with safety and success. As such, key points need specific attention to avoid complications in a remote location, where staff and resources may be less than adequately equipped to handle them.

Background The sagittal plane computed tomographic (CT) scan has been proposed as the most important radiologic view in the diagnosis of orbital floor fractures. Before the advent of high-resolution CT, several articles were published in the radiology literature debating the need for direct sagittal views, which required cumbersome patient positioning. Today, the ability to easily create high-quality sagittal reformations requires reassessment of the importance of this view in the evaluation of orbital floor fractures. Materials and methods Computed tomographic studies of 24 orbital floor fractures for which coronal and sagittal images were available were included. Five independent reviewers evaluated all image sets and recorded maximum fracture width, depth, posterior shelf length (PSL), and presence of medial wall fracture and of trap door deformity. Direct fracture width measurements were obtained via coronal images, whereas depth and PSL were measured directly in the sagittal plane. Indirect measurements in a given plane were obtained by counting the number of slices in which the fracture was present and multiplying by the slice thickness. Cronbach alpha analysis was used to provide an intraclass correlation coefficient, where greater values signify less interreviewer variability. Results The Cronbach alpha values for width, depth, and PSL were 64%, 59%, and 85% in the coronal view and 76%, 55%, and 51% in the sagittal view, respectively. The alpha values for presence/absence of medial wall fracture and trap door deformity were greater in the coronal view at 73% and 55%, respectively. The intrareviewer variability was not significantly correlated with the degree of patient rotation or CT scan slice thickness. The interreviewer variability was significantly less among attending reviewer then resident reviewers. Conclusions There was less interreviewer variability when the measured variables were assessed indirectly (width was best assessed in the sagittal plane, and depth and PSL were best assessed in the coronal view). These findings support the idea that additional views aid the surgeon's ability to further define fracture anatomy than might be possible with any single view, thereby improving preoperative planning and reconstructive strategies.

Maxillofacial injuries in the partially edentulous patient present unique challenges that are best treated in conjunction with appropriate dental specialists. Many surgeons who treat complex maxillofacial injuries are not involved in the process of reconstruction of the occlusion and alveolus; however, dental rehabilitation is an important and often overlooked component of treatment of the partially edentulous patients. Working with dental specialists and understanding the role they play in perioperative planning, the plastic surgeon is in a position to optimize reconstruction and rehabilitation of these injuries. The appropriate dental specialists working with the plastic surgeon can provide the surgeon with the necessary orthodontic, prosthodontic, and radiologic expertise that is required to successfully treat these patients. In this article, the authors present their management algorithm for maxillomandibular rehabilitation in the partially edentulous patient and discuss the role of the appropriate dental specialists for obtaining optimal aesthetic and functional outcomes.

Background Proper wound healing is pivotal to successful surgical outcomes. Previous studies have shown that growth factors can be used to enhance tissue repair under impaired healing conditions. However, because of limited delivery methods, the growth factors in these studies were delivered either topically or as a single local administration. Methods Sixty Sprague-Dawley rats were divided equally into five groups and served as untreated normal controls or were implanted subcutaneously with a novel sustained-release drug delivery system through a dorsal incisional wound. This system delivered either transforming growth factor (TGF)-beta alone, platelet-derived growth factor (PDGF) alone, or TGF-beta and PDGF in combination, or served as unloaded sham controls. Wound healing was impaired in all treated rats by the administration of cyclophosphamide on days 1, 3, and 5. Wound tensile breaking strength was determined on days 4, 7, and 14. Results Sustained release of either TGF-beta or PDGF alone not only failed to improve the healing of cyclophosphamide-induced impaired wound healing but resulted in a paradoxical decrease in wound tensile breaking strength by day 7. However, the combined delivery of both TGF-beta and PDGF improved wound healing and significantly increased wound tensile breaking strength by day 7. Conclusions Sustained-release delivery of TGF-beta and PDGF in combination, but not separately, by a subcutaneously implanted drug delivery system significantly improves cyclophosphamide-induced impaired wound healing in rats.

Empirical and experimental evidence abounds as to the negative effects of smoking on skin flaps. The ideal duration of preoperative smoking cessation is unclear. The present study evaluates the effect of various durations of smoking cessation on skin flap survival in a rat model.Forty smoke-exposed and 10 non-smoke-exposed Sprague-Dawley rats were divided into five groups: controls and 0 days, 2 weeks, 4 weeks, and 8 weeks of smoking cessation. All animals had a dorsally based random pattern flap created and either bilateral pure axial superficial inferior epigastric (superficial inferior epigastric) flaps or a unilaterally superficial inferior epigastric axial with random component flap. The percentage of flap necrosis was assessed 2 weeks postoperatively.The mean amount of random skin flap necrosis was 16.6 +/- 13.0 percent, 30.3 +/- 8.4 percent, 27.6 +/- 7.9 percent, 27.1 +/- 6.1 percent, and 29.7 +/- 10.3 percent, respectively. There was significantly less flap necrosis in the controls than in all other groups (p0.03). There was no necrosis of any of the pure axial superficial inferior epigastric flaps. The mean amount of superficial inferior epigastric axial with random component skin flap necrosis was 11.1 +/- 6.2 percent, 31.1 +/- 6.0 percent, 36.0 +/- 8.4 percent, 21.7 +/- 4.0 percent, and 19.1 +/- 6.3 percent, respectively. All smoke-exposed groups had significantly greater flap necrosis than controls, with the exception of the 8-week group (p0.02).Smoking irreversibly increases the risk of flap necrosis in a random pattern flap out to 2 months of preoperative cessation. Preoperative smoking does not result in any necrosis of pure axial flaps. In axial with random component flaps, significant decreases in skin flap necrosis are not seen until 4 weeks of preoperative cessation.

BACKGROUND Despite refinements in radiotherapy, radiation-impaired wound healing continues to be a major source of postoperative morbidity with few treatment options. The application of polypeptide growth factors has been investigated in both the clinical and laboratory settings. The authors used a novel sustained-release delivery system to examine the effect of transforming growth factor (TGF)-beta and fibroblast growth factor (FGF) on radiation-impaired wound healing in a rodent model. METHODS Eighty Sprague-Dawley rats underwent dorsal skin surface irradiation of 2500 cGy using a medical linear accelerator producing energy of 6 MeV followed by creation of a full-thickness skin incision. Six groups of 16 animals underwent either sham irradiation (irradiation control); irradiation only; irradiation and unimpregnated delivery system only; or irradiation and either TGF-beta, FGF, or TGF-beta plus FGF combined. Four animals from each group were euthanized at 4, 7, 14, and 28 days, and the harvested specimens underwent ultimate tensile strength testing and histologic evaluation. RESULTS All five irradiated groups had significantly lower ultimate tensile strength than the sham-irradiated control group at all time points (p < 0.05), thus validating the authors' model of radiation-impaired wound healing. Functional analysis demonstrated that all three growth factor-treated groups had significantly higher tensile strengths than either of the untreated irradiated groups at 14 days after wounding (p < 0.05). Histologic evaluation of the irradiated groups revealed increased cellularity and more organized collagen architecture of all treated groups when compared with the untreated groups, with the most pronounced differences seen at 7 days and 14 days after wounding. CONCLUSIONS This study effectively demonstrates that TGF-beta and FGF act individually and synergistically when delivered locally by means of a sustained release system to improve ultimate tensile strength in an acute postirradiation impaired wound-healing model.

The concept of fat transplantation is not a new one in plastic surgery. Studies assessing fat graft viability following transplantation, however, have yielded conflicting observations. The present study evaluated the long-term fate of transplanted autologous fat using a novel facial augmentation model the authors have developed in the rabbit.Thirteen adult New Zealand White rabbits underwent fat harvest using a modified Coleman technique. The left upper lip was used as the recipient site; the right upper lip remained unaltered in each case. After harvest from the groin, 1 ml of adipose tissue was transplanted to the left upper lip of each rabbit. Rabbits were euthanized 1, 3, 6, and 12 months after unilateral lip augmentation. Coronal sections of both upper lips were evaluated histologically; the right upper lip served as an internal control in each case.Histologic evaluation of specimens harvested at all postoperative time points demonstrated viable, transplanted fat graft in each case. Use of the nonoperated right lip allowed for paired evaluation of the experimental and control sides. A significant inflammatory response was present in the early phases, with evidence of neovascularization. Transplanted fat tissue was clearly visible in rabbits harvested 1 year postoperatively.The authors have established a novel, reproducible model with an internal control for long-term evaluation of transplanted fat. Histologic examination suggests an early inflammatory response to the injected fat followed by sequestration of nonviable tissue. The transplanted fat remained viable at 1 year, with good overall survivability and minimal fibrosis.

Background: Failure of palatal shelf fusion at the precise gestational time point when shelf elevation and migration normally occur results in clefting. The present study defined the mechanism of clefting in the congenital caprine model by evaluating the temporal sequence of palatal shelf fusion. Methods: Six Spanish-type goats pregnant with twins were gavaged for 10 days (gestational days 32 to 41) with anabasine. Goats were examined with ultrasound throughout this period to assess fetal movement and evaluated histologically. Twelve untreated, unclefted fetuses served as controls. Results: After anabasine induction, real-time ultrasound confirmed a dramatic decrease in fetal movement. Hyperflexion of the neck occurred throughout the experimental period compared with control fetuses, in which spontaneous neck movements occurred. Histologic evaluation of the induced fetuses demonstrated the tongue wedged between the palatal shelves throughout the period of fusion. The shelves remained vertically oriented without elevation, ultimately resulting in clefting. The unclefted, control group demonstrated progressive elevation and migration of the palatal shelves between gestational days 38 and 40, with contact and fusion of the medial edge epithelia in the midline. Conclusions: Palatal clefting in the congenital caprine model occurred concomitant with reduced fetal movement. Resultant neck hyperflexion causes the tongue to obstruct medial migration of the palatal shelves and fusion, whereas the shelves themselves are either directly prevented from elevation secondary to anabasine impairment or indirectly secondary to the obstructing tongue. Although the molecular mechanism for the teratogenic effects of anabasine remains elusive, the authors have demonstrated an association between reduced fetal movement and palatal clefting in their congenital caprine model.

Objective: Despite cleft palate repair, velopharyngeal competence is not achieved in ∼15% of patients, often necessitating secondary surgical correction. Velopharyngeal competence postrepair may require the conversion of levator veli palatini muscle fibers from injury-susceptible type 2 fibers to injury-resistant type 1 fibers. As an initial step to determining the validity of this theory, we tested the hypothesis that, in most cases, repair induces the transformation to type 1 fibers, thus diminishing susceptibility to injury. Interventions: Single permeabilized levator veli palatini muscle fibers were obtained from normal palates and nonrepaired congenitally-clefted palates of young (2 months old) and adult (14 to 15 months old) goats and from repaired palates of adult goats (8 months old). Repair was done at 2 months of age using a modified von Langenbeck technique. Main Outcome Measures: Fiber type was determined by contractile properties and susceptibility to injury was assessed by force deficit, the decrease in maximum force following a lengthening contraction protocol expressed as a percentage of initial force. Results: For normal palates and cleft palates of young goats, the majority of the fibers were type 2 with force deficits of ∼40%. Following repair, 80% of the fibers were type 1 with force deficits of 20% ± 2%; these deficits were 45% of those for nonrepaired cleft palates of adult goats (p < .0001). Conclusion: The decrease in the percentage of type 2 fibers and susceptibility to injury may be important for the development of a functional levator veli palatini muscle postrepair.

Objective: Levator veli palatini muscles from normal palates of adult humans and goats are predominantly slow oxidative (type 1) fibers. However, 85% of levator veli palatini fibers from cleft palates of adult goats are physiologically fast (type 2). This fiber composition difference between cleft and normal palates may have implications in palatal function. For limb muscles, type 2 muscle fibers are more susceptible to lengthening contraction-induced injury than are type 1 fibers. We tested the hypothesis that, compared with single permeabilized levator veli palatini muscle fibers from normal palates of adult goats, those from cleft palates are more susceptible to lengthening contraction-induced injury. Interventions: Congenital cleft palates were the result of chemically-induced decreased movement of the fetal head and tongue causing obstruction of palatal closure. Each muscle fiber was maximally activated and lengthened. Outcome Measures: Fiber type was determined by contractile properties and gel electrophoresis. Susceptibility to injury was assessed by measuring the decrease in maximum force following the lengthening contraction, expressed as a percentage of the initial force. Results: Compared with fibers from normal palates that were all type 1 and had force deficits of 23 ± 1%, fibers from cleft palates were all type 2 and sustained twofold greater deficits, 40 ± 1% (p = .001). Conclusion: Levator veli palatini muscles from cleft palates of goats contain predominantly type 2 fibers that are highly susceptible to lengthening contraction-induced injury. This finding may have implications regarding palatal function and the incidence of velopharyngeal incompetence.

Volunteer surgical missions to provide cleft care to patients in developing countries has been done successfully for a number of years. Similar missions that provide craniofacial surgery introduce a dramatic step up in complexity. While articles have addressed protocols for the safe delivery of cleft care around the world, little has been written on volunteer craniofacial surgical missions. Komedyplast was established in March 2001 as a 501c(3) nonprofit organization to provide craniofacial surgical care to underserved populations and educate local surgeons in craniofacial principles. During 9 annual missions, the organization has provided surgical care to more than 150 patients with various complex, congenital, craniofacial conditions. The article addresses important safeguards that have been implemented to maximize safety and minimize risk.

Background Midfacial hypoplasia and growth disturbances following cleft palate repair are well-known consequences of the maxillary scarring inherent with each repair technique. The present study investigated the influence of in utero palatoplasty, and cleft repair in 6-week-old goats, on midfacial growth and bony palatal development in the authors' congenital caprine cleft palate model in an effort to identify an inherent component of facial growth impairment associated with the cleft anomaly. Methods At 85 days' gestation, eight clefted fetuses underwent in utero cleft palate repair using a modified von Langenbeck technique; eight fetuses remained as unrepaired controls. At 6 weeks of age, eight goats underwent cleft palate repair using the same technique. All goats were euthanized at 6 months of age; dry skull measurements and cephalometric analyses were performed. Results Fetal Repairs: Both repaired and unrepaired clefted goats demonstrated significant evidence of maxillary hypoplasia compared with unclefted controls. Repaired goats showed a decrease of 15.7 percent in maxillary length, and unrepaired clefted goats showed a decrease of 18.0 percent in maxillary length, compared with unclefted controls. There was no significant difference in maxillary growth between the repaired and unrepaired clefted groups. Bony cleft width was reduced by 48 percent anteriorly and 60 percent posteriorly. Thirty-seven percent of repaired congenital clefts demonstrated partial bony fusion involving 10 to 70 percent of the palatal length. This was accompanied by an 8.8 percent decrease in maxillary width at the level of the third molar crown compared with unclefted controls and an 18.3 percent decrease in maxillary width compared with unrepaired clefted goats. Unrepaired clefted goats demonstrated neither a decrease in maxillary width nor any narrowing or fusion of the bony cleft. Newborn Repairs: Significant midfacial growth impairment was seen in animals that underwent cleft palate repair at 6 weeks of age compared with those repaired in utero and with unclefted controls. Repaired clefted goats demonstrated a significant decrease in maxillary length by 29.5 percent compared with unclefted controls and 16.4 percent compared with the group repaired in utero. Repaired goats also demonstrated a significant decrease in maxillary width in the transverse dimension at the level of the third molar. A decrease in maxillary width of 25.3 percent was seen compared with the unclefted controls and 18.1 percent compared with the fetal repairs. Bony cleft width was reduced by 32 percent anteriorly and 27 percent posteriorly following repair at 6 weeks of age. Although all goats demonstrated narrowing following repair, partial bony palatal fusion was not seen in this group. Conclusions In utero cleft palate repair does not contribute to impairment of midfacial growth. The authors attribute this finding to the scarless nature of mucoperiosteal healing in the privileged fetal environment. However, the cleft palate anomaly does have an inherent component of facial dysmorphology that is evidenced as maxillary hypoplasia or retrusion in unrepaired clefted animals. Cleft repair in the newborn period, or thereafter, results in midfacial growth impairment in a manner similar to that seen clinically. The authors attribute this finding to the scarring that routinely accompanies conventional palatoplasty. The combination of the growth impairment inherent in the cleft anomaly and that attributable to postnatal repair scarring yields the midfacial retrusion commonly associated with cleft palate.

The key to achieving an excellent result following rhinoplasty lies in a strong fundamental knowledge of nasal anatomy. The purpose of this study was to analyze the anatomic and histologic relationship of the nose to the alar-facial crease. Fifteen cadaver noses were dissected and a total of thirty lower lateral cartilages were measured. Two fresh cadaver noses were fixed in neutral buffer formalin and embedded in paraffin. They were then sectioned into 6-mu coronal and sagittal sections and stained with hematoxylin and eosin, Eosin von Geison, and safranin to evaluate for collagen, elastin and muscle, respectively. Measurements of the lower lateral cartilages showed the average lateral crural height was 23.5 mm (+/- 2.5 mm), lateral crus width was 11.7 mm (+/- 1.5 mm), lateral domal width was 5.7 mm (+/- 0.9 mm), and intercrural distance was 20.2 mm (+/- 3.2 mm). No statistical differences were noted between male and female cadaver measurements. Histologic sections showed the area of the alar-facial crease to have a greater quantity of elastin fibers compared with muscle, collagen, or cartilage. These elastin fibers were predominantly orientated vertically (anterior-posterior) rather than horizontally (cephalo-caudad). This study demonstrates a higher ratio of elastin to collagen fibers in the region of the alar-facial crease.

Purpose: The purpose of this study was to review the results of 800 scaphotrapeziotrapezoid fusions performed over a 27-year period. Methods: The patients were evaluated for postoperative range of motion, grip and pinch strength, pain, return to work, arthritis, and complications. Results: The overall range of motion was 70% to 80% of the nonoperated side and strength was 69% to 89%. Of the patients 88% returned to previous employment. Arthritis developed in 1.8% of the patients. The overall complication rate was 13.4%. Conclusions: Scaphotrapeziotrapezoid fusion is a viable treatment option especially for a high-functional-demand young population with significant wrist pathology. Complications, specifically nonunion, can be minimized with careful technique. (J Hand Surg 2003;28A:397-404. Copyright © 2003 by the American Society for Surgery of the Hand.)

Hydroxyapatite cements have recently been employed as bone substitutes in craniofacial reconstruction. They are easily applied, nonresorbable, available in unlimited quantity, and eliminate donor-site morbidity. Norian CRS (craniofacial repair system) is a new carbonated calcium phosphate paste that is unique in that it more closely resembles bone than do traditional hydroxyapatite pastes. Norian is a low-order crystalline apatite soluble at a low pH, facilitating its resorption and replacement by host bone. The cement was first used for craniofacial surgery in North America at the Children's Hospital of Philadelphia. This report presents the authors' experience with this bone substitute in both pediatric and adult craniofacial reconstruction. Sixteen adult and pediatric patients underwent craniofacial reconstruction involving the use of carbonated calcium phosphate paste for correction of defects that required from 5 to 110 g of carbonated calcium phosphate paste (mean, 28.5 g). The patients were all followed for a minimum of 14 months. Minor complications included one case of infection and two cases involving cement microfragmentation. In the authors' experience, carbonated calcium phosphate paste has proved to be an excellent alloplastic material for osseous augmentation and reconstruction in the craniofacial skeleton. Few problems were encountered using this material; no significant morbidity was encountered. Although this material seems to be promising as a bone substitute, further follow-up will be necessary to evaluate its potential role in craniofacial surgery.

Surgical outcomes and patient satisfaction with composite resection and primary closure for the management of upper-lip defects following Mohs' surgery were evaluated. Twenty-seven patients underwent upper-lip reconstruction following Mohs' surgery from 1993 to 1997. Twelve of these patients were selected for this report based on adequate follow-up examinations and photographs. There were nine women and three men with a mean age of 46 years (range, 33 to 70 years). Eleven patients underwent Mohs' surgery for basal cell carcinoma and one patient for squamous cell carcinoma of the upper lip. The defects varied in size and location, often extending beyond a single aesthetic subunit. The reconstruction was performed an average of 7 days after Mohs' surgery (range, 1 to 23 days). In 50 percent of the cases, a full-thickness excision was performed, which included orbicularis oris and inner-lip mucosa. The functional results were graded as near normal to normal in all cases. There were no observed changes in oral continence, eating or speech. Two patients experienced numbness medial to the operative site, but this had no adverse affect on lip function. The aesthetic results were graded as very good to excellent in all cases. Eleven of the 12 patients were satisfied with their lip appearance and function. Conventional wisdom dictates that during reconstruction of upper-lip defects, one should attempt to maintain a majority of the uninvolved tissue for the best result. Although these techniques result in wound closure, they fail to consider lip aesthetics. By using a vertically oriented composite resection of the tipper lip with the additional resection of uninvolved tissue, normal lip architecture is maintained. In our experience, this results in a superior aesthetic and functional result.

Myxoma is a rare benign tumor composed of stellate or spindle-shaped cells in a loose myxoid stroma. Few cases involving the hand have previously been described. We present a rare case of recurrent myxoma in the intermetacarpal space and detail the clinical behavior of this indolent tumor.

The induction of cleft palate by Nicotiana glauca (wild tree tobacco) during the first trimester of pregnancy was compared between Spanish-type goats and crossbred western-type sheep. Cleft palate was induced in 100% of the embryonic/fetal goats when their pregnant mothers were gavaged with N. glauca plant material or with anabasine-rich extracts from the latter, during gestation days 32-41. Seventy-five percent of newborn goats had cleft palate after maternal dosing with N. glauca during gestation days 35-41, while no cleft palates were induced when dosing periods included days 36-40, 37-39, or day 38 only. The induced cleft palates were bilateral, involving the entire secondary palates with complete detachment of the vomer. Eleven percent of the newborn goats from does gavaged during gestation days 32-41 had extracranial abnormalities, most often contractures of the metacarpal joints. Most of these contractures resolved spontaneously by 4-6 weeks postpartum. One newborn kid also had an asymmetric skull due to apparent fetal positioning. No cleft palates were induced in lambs whose mothers were gavaged with N. glauca plant or anabasine-rich extracts during gestation days 34-41, 35-40, 35-41, 36-41, 35-51, or 37-50. Only one of five lambs born to three ewes gavaged with N. glauca plant material during gestation days 34-55 had a cleft palate, but all five of these lambs had moderate to severe contractures in the metacarpal joints. The slight to moderate contracture defects resolved spontaneously by 4-6 weeks postpartum, but the severe contractures resolved only partially. Embryonic/fetal death and resorption (determined by ultrasound) occurred in 25% of pregnant goats fed N. glauca compared to only 4% of pregnant sheep. Nicotiana glauca plant material contained the teratogenic alkaloid anabasine at 0.175% to 0.23%, dry weight, demonstrating that Spanish-type goats are susceptible to cleft palate induction by the natural toxin anabasine, while crossbred western-type sheep are resistant. However, clinical signs of toxicity were equally severe in goats and sheep, even though maternal alkaloid tolerance was generally lower in sheep. We postulate that an alkaloid-induced reduction in fetal movement during the period of normal palate closure is the cause of the cleft palate and multiple flexion contractures. Teratology 61:203-210, 2000. Published 2000 Wiley-Liss, Inc.

The role of fetal surgery in the treatment of non-life-threatening congenital anomalies remains a source of much debate. Before such undertakings can be justified, models must be established that closely resemble the respective human anomalies, and the feasibility and safety of these in utero procedures must be demonstrated. The authors recently described and characterized a congenital model of cleft palate in the goat. The present work demonstrates the methodology they developed to successfully repair these congenital cleft palates in utero, and it shows palatal healing and development after repair. A surgically created cleft model was developed for comparative purposes. Palatal shelf closure normally occurs at approximately day 38 of gestation in the caprine species. Six pregnant goats were gavaged twice daily during gestational days 32 to 41 (term, 145 days) with a plant slurry of Nicotiana glauca containing the piperidine alkaloid anabasine; the 12 fetuses had complete congenital clefts of the secondary palate. Repair of the congenital clefts was performed at 85 days of gestation using a modified von Langenbeck technique employing lateral relaxing incisions with elevation and midline approximation of full-thickness, bilateral, mucoperiosteal palatal flaps followed by single-layer closure. Six congenitally clefted fetuses underwent in utero repair, six remained as unrepaired controls. Twelve normal fetuses underwent surgical cleft creation by excision of a 20 x 3 mm full-thickness midline section of the secondary palate extending from the alveolus to the uvula, at 85 days of gestation. Six surgically clefted fetuses underwent concurrent repair of the cleft at that time; six clefted fetuses remained as unrepaired controls. At 2 weeks of age, no congenitally or surgically created clefts repaired in utero demonstrated gross or histologic evidence of scar formation. A slight indentation at the site of repair was the only remaining evidence of a cleft. At 6 months of age, normal palatal architecture, including that of mucosal, muscular, and glandular elements, was seen grossly and histologically. Cross-section through the mid-portion of the repaired congenitally clefted palates demonstrated reconstitution of a bilaminar palate, with distinct oral and nasal mucosal layers, after single-layer repair. In utero cleft palate repair is technically feasible and results in scarless healing of the mucoperiosteum and velum. The present work represents the first in utero repair of a congenital cleft palate model in any species. The use of a congenital cleft palate model that can be consistently reproduced with high predictability and little variation represents the ideal experimental situation. It provides an opportunity to manipulate specific variables, assess the influence of each change on the outcome and, subsequently, extrapolate such findings to the clinical arena with a greater degree of relevance.

Limited wrist arthrodesis is a useful method for treating specific carpal disorders that maximizes residual wrist motion and strength while eliminating pain. Selective fusion of specific carpal units can be used in degenerative arthritis, rotary subluxation of the scaphoid, midcarpal instability, scaphoid nonunion, Kienböck’s disease, and congenital synchondrosis or partial fusion of specific carpal joints. This report presents our experience with more than 1000 limited wrist arthrodeses, and provides a review of the indications and technical considerations for specific intercarpal fusions, and subsequent results. To date this is the largest series of intercarpal arthrodeses and the study has demonstrated that these techniques are reliable and effective in dealing with a wide range of wrist disorders.

Any animal model of a human congenital anomaly established by iatrogenic methods involving intrauterine fetal manipulation has limited clinical applicability. A congenital model that more closely simulates the etiopathogenesis of a human anomaly may provide data that can more readily be extrapolated to that anomaly and, therefore, be used in diagnostic and management strategies. The present work provides a description and characterization of a congenital model of cleft palate in the goat. Palatal shelf closure normally occurs at approximately day 38 of gestation in the caprine species. Sixteen pregnant goats were gavaged twice daily during gestational days 32 through 41 [term, 145 days] with a plant slurry of Nicotiana glauca containing the piperidine alkaloid teratogen anabasine. Gross analysis and measurement of fetal clefts were performed at 60, 70, and 85 days gestation (four fetuses were studied at each time point). Seventeen clefted kids were sacrificed at specific intervals after birth (2 weeks, and 1, 3, and 6 months); after skull debridement and preparation, they were compared with 12 unclefted control kids. Complete clefting of the secondary palate occurred in 97 percent of the fetuses. In all cases, the cleft extended from the posterior aspect of the alveolar ridge to the uvula; the majority of these clefts were bilateral, with complete detachment of the vomer. Morphologically, these clefts were similar to human clefts. Eighteen percent of clefted newborn kids demonstrated gross maxillary hypoplasia and midfacial retrusion at birth with a relative Class III malocclusion. Direct measurement of the congenital caprine skulls confirmed these findings. The incidence of midfacial growth abnormalities in these clefted animals raises questions regarding the etiopathogenesis of facial dysmorphology that is unrelated to scarring of the maxilla. This congenital cleft palate model is currently being used to explore these questions and others related to craniofacial growth and palatal function after in utero repair.

A retrospective review of 22 patients who sustained snowblower injuries to the hand was performed. There were 17 men and 5 women, ranging in age from 20 to 68 years (average age, 39.7 years). Fifty percent were manual laborers, 25% were unemployed, 15% were office workers, and 10% were not categorized. The dominant hand was involved in 86% of patients. In all patients, injuries occurred during an attempt to unclog manually the snowblower of wet snow. Patients were evaluated initially in the emergency room, where their wounds were irrigated and debrided, subungual hematomas drained, and nail bed lacerations repaired. Patients with more extensive injuries were taken to the operating room for definitive treatment including open or closed reduction of fractures, fingertip replacement as composite grafts or skin grafts, revision amputations, tenorrhaphies, and digital nerve repairs. All injuries occurred distal to the metacarpophalangeal joints. Only 1 patient sustained an injury to the proximal phalanx. Ten patients injured only 1 finger, 6 patients injured 2 fingers, and 6 patients injured 3 fingers. The middle and ring fingers were most commonly injured (39.6% and 33.3% respectively), followed by the index and little fingers (16.7% and 8.3% respectively), and the thumb (2.1%). Phalangeal fractures were the most common type of injury, occurring in 29.2% of patients, and usually involved the distal phalanx. This was followed in frequency by nail bed injuries (22.9%), amputations (22.9%), tendon lacerations (14.6%), soft-tissue avulsions (6.3%), and digital nerve injuries (4.2%). Snowblower injuries can involve bone, soft tissue, nail bed structures, nerves, and tendons, and may even result in amputation of one or several fingers. These injuries are localized to the distal portions of the fingers. The middle and ring fingers are most commonly involved, with relative sparing of the thumb. Fractures are the most frequent injury, followed by nail bed injuries and amputations. Snowblower injuries are often managed as open fractures with intravenous antibiotics; irrigation and debridement; and repair of bone, soft tissue, and nail bed structures.

Extensor tendon subluxation at the metacarpophalangeal joint occurs only rarely in patients without rheumatoid arthritis. Almost all reported cases involve disruption of the radial sagittal band with ulnar subluxation of the extensor tendon. A technique of sagittal band reconstruction is described that entails weaving a retrograde segment of extensor tendon upon itself after passing it through the deep transverse metacarpal ligament. Twenty-one sagittal band reconstructions were performed in 16 patients. This series included 18 cases of ulnar subluxation secondary to radial sagittal band disruption and 3 cases of radial subluxation secondary to ulnar sagittal band disruption. Using this technique, pain was eliminated in every case and there has been no recurrence of extensor tendon subluxation.

A method for analysis of silicon in tissue was developed to determine silicon content in breast parenchymal and periprosthetic capsular tissues of patients with silicone or saline implants and to compare levels in tissues from normal (nonaugmented) breasts. It is of interest to determine whether increased silicon content in tissues can be associated with morbidity in patients who have received silicone implants. This manuscript addresses the issues involved in analysis of breast tissue samples for silicon and compares silicon levels with tissue histologic findings and patient morbidity. One hundred sixty tissue samples were obtained for silicon analysis from 72 patients during augmentation, capsulectomy with or without replacement mammoplasty, mastectomy, or biopsy procedures and were frozen in acid-washed polystyrene tubes at 220 degrees C until analysis. Samples were thawed, sectioned to approximately 0.1 g (dry weight), and digested in nitric acid before analysis by inductively coupled plasma emission spectroscopy, monitoring emission intensity at 251.6 nm. Tissue silicon levels (breast parenchymal and periprosthetic capsular tissue) in patients with silicone gel implants were much higher (mean, 9,287 micrograms/g, n = 106) than in patients with saline implants (mean, 196 micrograms/g, n = 37) or nonaugmented breasts (mean, 64 micrograms/g, n = 17). Histologic examination was performed on 54 tissue samples stained with hematoxylin-eosin. Tissue samples were rated as to degree of inflammation and calcification, and amount of giant cells, foamy histiocytes, and vacuoles containing a colorless refractory material. Vacuolization and foamy histiocyte ratings correlated significantly with tissue silicon concentration. No correlations were found between tissue silicon concentration and inflammation, calcification, or giant cell rating. Implant age (number of years an implant was in place before sampling) correlated with capsular tissue silicon concentration in patients with intact implants but not in those with ruptured implants. No difference in tissue silicon concentration was found between patients with or without signs or symptoms of morbidity. Using 0.1 g of tissue, the method was linear to 1,000 micrograms/g, and sensitivity was 3.7 micrograms/g. Precision between runs (mean, 5.1 micrograms/g; coefficient of variance, 13.7%; n = 13) was calculated from multiple analyses of a bovine liver standard (National Bureau of Standards, reference material 1577a). Significant biologic variability (21.4% to 52.5%) was seen in tissues with high silicon levels. Paraffin-embedded, formalin-fixed tissues are not amenable to silicon analysis by this method, because of leaching of silicone from the tissues during preparation. Thus only fresh frozen tissue samples were used.

The role of the plastic surgeon in the diagnosis and management of congenital anomalies is often a complicated one that involves the integration of input from numerous specialists into the evaluation process. Diastematomyelia is a serious neurosurgical problem that often presents with cutaneous findings in a neurologically asymptomatic patient. Early recognition of these cutaneous manifestations by the plastic surgeon, evaluation with an MRI scan, and consultation with a pediatric neurosurgeon can prevent delayed diagnosis of this surgically correctable anomaly and irreversible neurologic sequelae.

Frontal sinus fractures are relatively uncommon due to the high-impact force required to produce these. However, their management is quite complex, with the treatment algorithm incorporating many factors in which the status of the nasofrontal ducts is critically important. Traditionally, this has been evaluated by both axial and coronal computed tomographic (CT) scan views. Anatomically, we propose that this is better evaluated by coronal and sagittal CT views. We evaluated the role of sagittal CT scan views in determining the status of the nasofrontal ducts in patients with frontal sinus fractures.A retrospective analysis examining 8 patients with frontal sinus fractures, from August 2004 to January 2008, was performed. Axial, coronal, and sagittal CT scan views were obtained routinely as part of the facial trauma workup. These views were assessed to determine the status of the nasofrontal ducts. The operative findings were also reviewed.Five of the 8 patients had displaced anterior and posterior table frontal sinus fractures. Of these, 4 required surgical intervention that included addressing the nasofrontal ducts. Two of the 8 patients had displaced anterior table fractures that required no intervention of the nasofrontal ducts. One patient had nondisplaced anterior and posterior table fractures and did not require surgery. The sagittal CT view clearly demonstrated the anatomy of the nasofrontal ducts in all 8 patients, including patients in whom the axial and/or coronal views were questionable. Intraoperatively, where the patency of the nasofrontal ducts was directly evaluated, there was a direct correlation with the sagittal image findings.The sagittal CT view provides invaluable information for evaluating the patency of the nasofrontal ducts in frontal sinus fractures. The ability to evaluate the frontal sinus in an anteroposterior dimension (the usual vector of the injury) and in a superoinferior dimension (the anatomic pathway of the ducts) is the reason for this imaging advantage.

Biomaterials have shown promise as potential substitutes for human tissue. Studies have demonstrated that attachment of a vascularized pedicle to dermal matrix grafts yields tissues that are resilient enough to patch hernia defects in rats. The purpose of this study was to examine the possibility of creating a viable composite graft completely from biomaterials.Acellular dermal matrix was enveloped around a square wafer of hydroxyapatite bone substitute. This composite graft was inserted into an extraperitoneal pocket overlying the abdominal musculature. In 30 Sprague-Dawley rats, the superficial epigastric arteriovenous pedicle was dissected free and placed within the midportion of the matrix construct on one side of each animal. A second graft was inserted on the opposite side without the addition of a vascularized pedicle. Each animal served as its own control. Animals were divided into three equal groups and euthanized at time points of 30, 60, and 90 days.Histologic evaluation of specimens was performed using hematoxylin and eosin and trichrome stains. At 30 days, the dermal matrices demonstrated full-thickness cellular infiltration in all specimens. Collagen deposition was significantly greater in the experimental group at every time point. Cellularity was significantly greater in the experimental group at 30 days, but there were no significant differences between groups at 60 or 90 days.These results suggest that provision of an arteriovenous blood supply to nonbiologic tissue grafts significantly increases collagen deposition and early cellular deposition. Based on these findings, biomaterials may offer an exciting new method for tissue engineering.

Limited wrist arthrodesis is the surgical fusion of selected bones of the wrist. In each case the extent of the fusion is determined by the extent of the disease process. Limited wrist arthrodesis is an alternative to complete wrist fusion when there is a localized area of degenerative change or instability in the carpus. It relieves pain yet still allows a good range of motion. Since 1968, 36 patients have had 38 limited wrist arthrodeses. Twenty-four cases have involved carpal bones only. Fourteen of these were "triskaphe" arthrodeses: scaphoid-trapezium-trapezoid arthrodeses. Eleven cases have included the radius, and 3 have included the index metacarpal.