Infantile (desmoid-type) fibromatosis

Infantile (desmoid-type) fibromatosis is an uncommon, locally aggressive tumor that is seldom reported in the dermatologic literature. We describe a case of infantile (desmoid-type) fibromatosis in a 2-year-old girl. Surgical disposition entailed amputation of the affected digit. Our report is intended to heighten awareness of this potentially fatal tumor, and emphasize the importance of timely diagnosis and treatment.

Log-linear allometry of normal fetal craniofacial growth

Normative data on human craniofacial growth during the fetal period and important to provide a broader perspective on normal morphogenesis as well as to serve as reference for analyzing craniofacial syndromes in which growth has gone awry. Over a 19-year period, the Teratology Unit at the University of Michigan Medical Center has collected data on 2,568 legally donated fetuses that have undergone necropsy examination at various gestational ages. From previous analyses, 609 of the total fetal population (25%) were designated as typical for age or body weight on the basis of normal morphology, absence of maceration, and general growth symmetry. Of the 609 fetuses reviewed, 54 were excluded secondary to incomplete data. The remaining 555 constitute the basis of this study. Seven craniofacial measurements were recorded, including head circumference (HC), brain weight, inner canthal and outer canthal distances, and distances from nasion to menton, outer canthus to tragus and auditory meatus to vertex. Statistical analysis was carried out using the single-factor allometric model of Sewall Wright. Size was estimated as the first unstandardized principal component of the logarithms of lengths and of cube roots of weights, and then allometry was expressed in the regressions of each log variable on size. Significant allometry was found as were significant differences in errors about the allometric relation, but no evidence for more than a single factor or of "nonlinearity" in the regression curves was noted. Although there were differences of specific allometric coefficients between the various measurements (i.e., the slope of the curve for IC was significantly smaller than the slope of the curve generated for HC), these specific growth rates remain in relatively strict proportion to one another from early in gestation (body weight, 54.2 gm) to later in gestation (body weight, 1,000 gm).

The association between pH level and corneal recovery from induced edema

Corneal acidosis has been shown to reduce corneal hydration control (CHC) as measured by the rate, expressed as the percent recovery per hour (PRPH), at which the thickness of the cornea decreases exponentially after an increased hydration load. Since the effect of pH on corneal function is of scientific interest and may have clinical implications, we explored the relationship between pH and PRPH in greater detail by examining the effect of different stromal pH levels on corneal hydration control. Corneal edema was induced using a 90-min exposure to wearing a hypoxic contact lens (CL). Following removal of the CL, random assignment over four eye-test combinations of either 0, 3, 5, and 7% CO2 were made while pH and corneal thickness were monitored using slit lamp fluorophometry and optical pachometry to measure corneal pH and corneal thickness, respectively. From these measurements we determined the pH-dose/PRPH relationship. The average stromal pH +/- 1SD resulting from exposure to either the 0, 3, 5, and 7% CO2, was 7.65 +/- 0.11, 7.30 +/- 0.09, 7.15 +/- 0.08 and 7.04 +/- 0.07 (p < 0.001), respectively. Analysis based on a quadratic model of the dose-response relationship between PRPH and corneal pH indicates that PRPH is relatively unchanged for pH in the physiological range (pH = 7.40-7.65) and then decreases notably below the physiological range.

Log-linear allometry of fetal craniofacial growth in Down's syndrome

Trisomy 21 develops as a result of nondisjunction of two homologous chromosomes during either the first or second meiotic division. One of the more important consequences of these genetic alterations is the predictable, although variable disturbance in the architecture of the craniofacial region [1]. Postnatal craniofacial morphology has been extensively studied in Down's syndrome (DS). However, little information is available on human prenatal development of the head and face in such patients. The time at which changes in craniofacial phenotype first emerge in Down's syndrome fetuses and at which physical growth begins to diverge from normal is unknown. To explore these questions, we compared prenatal craniofacial growth in 50 Down's syndrome fetuses with that of 555 fetuses judged to be "typical for body weight and age" using the method of log-linear allometry [2].

Critical analysis of results of craniofacial surgery for nonsyndromic bicoronal synostosis

We retrospectively assessed the intermediate and long-term results of craniofacial surgery in 22 consecutive patients with nonsyndromic bicoronal synostosis to determine the outcome of corrective surgery. The study population consisted of 13 males and 9 females whose ages ranged from 6 weeks to 24 months (mean, 5.6 months) at the time of initial surgery. All patients had been assigned a diagnosis of nonsyndromic bicoronal synostosis. Each patient underwent resection of both coronal sutures and frontal orbital advancement with cranial vault remodeling using a floating forehead technique. Age at initial operation was 5 months or less in 13 patients and 6 months or more in 9. Complications occurred in 5 patients (23%), and 1 patient with an associated metabolic disorder died from respiratory arrest postoperatively. Follow-up ranged from 6 to 168 months (mean, 53.2 months). Results were graded according to the need for and extent of reoperation. Residual aesthetic deformities were documented in 12 patients (55%). Three patients (14%) required calvarial recontouring or cranioplasty to achieve satisfactory forehead contour or bony continuity. Total reoperation for recurrent deformity was required at a mean age of 29.7 months in 8 patients (36%) and is pending in another (4%). Four patients (18%) required a third operation (two total reoperations and two cranioplasties) to achieve satisfactory results. Eight of 13 patients (62%) operated on at 5 months of age or younger required total reoperation compared with 1 of 9 (11%) operated at 6 months of age or older. When analyzed alone, age of operation was a statistically significant determinant of the need for reoperation (p < 0.03). However, when subjected to multivariate analysis, neither age at operation nor the presence of an associated anomaly or positive family history had a significant effect on outcome.

Primary temporal melanoma without diffuse leptomeningeal involvement: a variant of neurocutaneous melanosis

Plastic surgeons who treat congenital giant nevi should be aware of the neurocutaneous melanosis syndrome and its variants. When neurologic symptoms are present concurrent with MRI evidence of central nervous system involvement, treatment of the cutaneous lesion must be tempered by knowledge of a poor prognosis. In the otherwise asymptomatic patient, the plastic surgeon should consider screening with MRI imaging, realizing that the clinical significance of a positive MRI scan without neurologic symptoms is unknown.

Piriform aperture stenosis: a rare cause of neonatal airway obstruction

Because neonates are obligate nasal breathers, neonatal nasal obstruction may have serious consequences. Prompt diagnosis and appropriate treatment are essential to avoid severe hypoxia. Anterior inlet, piriform aperture stenosis is an extremely rare cause of neonatal nasal airway obstruction and can easily be confused with choanal atresia or stenosis. Computed tomography with direct coronal scans is the best means of establishing a definitive diagnosis. We present our experience with four neonates having nearly complete piriform aperture stenosis. Prompt surgical enlargement of the nasal inlet through an upper buccal sulcus approach is recommended.

Metopic synostosis: evaluation of aesthetic results

Analysis of intermediate- and long-term results of surgical treatment of metopic synostosis is lacking. We therefore retrospectively studied 23 patients with metopic synostosis (14 males, 9 females) who have been followed from 3 months to 8.1 years (mean 42.5 months) after operation. Age at first operation ranged from 2 to 56 months (mean 8.2 months), with 15 patients operated on before 6 months and 8 after 7 months. Fronto-orbital remodeling and calvarial vault reshaping with floating forehead techniques were carried out in all patients. Stabilization of bony segments was accomplished with microplates and screws in 7 patients (30 percent), wires in 15 (65 percent), and absorbable sutures in 1. Complications included minor wound dehiscence (n = 1), seizures (n = 1), and increased intracranial pressure (n = 1). Postoperative photographic documentation of surgical results was available in 17 of the 23 patients. Aesthetic outcome in these 17 patients was graded (I = none or minor contour irregularities; II = moderate; and III = severe) by one of the authors (Cohen) and by a lay panel (n = 3) according to the degree of residual cranio-orbital deformity. Judged by the surgeon, grade I results were present in 53 percent, grade II in 35 percent, and grade III in 12 percent. To date, total reoperation (reoperative fronto-orbital remodeling and calvarial vault reshaping) was necessary in 2 patients (9 percent), one of whom had signs of increased intracranial pressure 3 years after the original craniofacial procedure, while partial reoperation (temporal cranioplasty) was carried out (n = 2) or recommended (n = 3) in another 5 patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Phototherapy in the treatment of depression in the terminally ill

Research in affective disorders has shown that there is a clear link between mood and light exposure, and that exposure to bright wide-spectrum light (phototherapy) may be an effective antidepressant treatment in some clinical situations. Cancer patients, especially those in the terminal phase of illness, have a high incidence of depression. Furthermore, their mobility is often severely reduced, resulting in little exposure to direct sunlight. We report the use of phototherapy in three terminally ill patients to alleviate symptoms of depression.

Patterns of abnormal myogenesis in human cleft palates

To test the hypothesis that soft palate muscles are abnormal in cleft palate, we compared soft palate morphogenesis in fetuses with cleft palate (n = 4) to age-matched (n = 3) and nonmatched (n = 1) control specimens. The morphologic status of all soft palate and masticatory structures were classified into one of six stages based on the level of histogenesis. At 54 mm crown-rump length (CRL), the levator veli palatini (L), palatopharyngeus (PP), and palatoglossus (PG) in cleft subjects demonstrated mesenchymal condensation into myoblastic fields, lagging behind the control specimens (97 mm CRL), which displayed definitive fields of myoblasts and myotube formation. In the 175 mm and 225 mm cleft and the 170 mm and 192 mm control specimens, muscular morphology was similar and had reached its postnatal appearance for the tensor veli palatini (175 m only) and L, PP, PG (225 mm only). Muscle fiber directions were, however, disoriented and disorganized, especially close to the medial epithelial edge of the cleft. The levator veli palatini, could not be distinguished as a discrete muscle in the cleft specimens, and what we believed to be the PP and PG seemed "normal" at the level of light microscopy, but malpositioned in a superior direction. This preliminary study demonstrates for the first time that early myogenesis in cleft palates differs from normal.

Surgical correction of severe scaphocephalic deformities

Sagittal synostosis may result in severe skull deformities. Characteristic components of the deformity include extreme elongation, frontal and occipital bossing, temporal pinching, and angulatory apical skull deformation. Conventional strip craniectomy often fails to correct these complex problems completely in severe early or late cases of sagittal synostosis. Techniques for total calvarial vault reconstruction have previously been reported, but a single large series has not been presented. Eighteen consecutive patients ranging in age from 3 months to 5 years (mean = 12 months) with severe early and late scaphocephalic skull deformities underwent total calvarial vault reshaping. All children required transfusions ranging from 250 to 1,100 mL. Operative times averaged 6 hours, and hospital stay ranged from 4 to 7 days. There was no perioperative mortality. Two patients experienced transient syndrome of inappropriate secretion of antidiuretic hormone, which responded to fluid restriction. One patient was noted to have a 2-cm parietal craniectomy defect 9 months after operation. Microscrews, which were used in all 18 patients, had to be removed in 2 patients when they became palpable. Excellent aesthetic results were noted in all 18 patients up to 36 months of follow-up.

The use of attachments in combination implant and natural-tooth fixed partial dentures: a technical report

When implants and natural teeth are combined, forces on the abutments need to be controlled so that neither the teeth nor the implants sustain excessive amounts of force. The technique described addresses reduction of potentially harmful cantilever effects in a fixed prosthesis that is facultatively removable. A nonrigid attachment is used in the implant crown. Telescopic copings are definitively cemented on the natural teeth. Provisionally cemented overcastings incorporate this nonrigid connection between the pontics and the implant crowns. The means of connection employs a semiprecision attachment in which the female connector is placed within the relatively immobile implant crown. The male connector is placed on the pontic seating into the implant crown. This relationship limits cantilever forces exerted on the natural-tooth abutment. The nonrigid connection of the tooth-supported retainer limits cantilever forces and directs occlusal loads axially in a direction along the long axis of the implant. This arrangement is acceptable as compared to the complete tooth-supported arrangement described by Shillingburg; in this situation, the implant will not migrate. Since 1986, this arrangement has been used clinically without attachment migrations, implant failure, or endodontic therapy, with only minor screw-loosening episodes.

Acrylic splints for dental alignment in complex facial injuries

Twenty-four patients with complex facial injuries were managed by wide subperiosteal exposure, precise anatomical reduction, rigid internal fixation, and immediate bone grafting when indicated, in conjunction with dental impressions, model surgery, and fabrication of dental splints to establish proper preinjury occlusion. The study population consisted of 18 men and 6 women, whose ages ranged from 18 to 49 years (mean, 30.7 yr) at the time of injury. High velocity motor vehicle accidents were responsible for facial injuries in 18 patients, gunshot wounds in 2, low velocity blunt trauma in 3, and falls in 1. All facial fractures involved the occlusion, and unstable and/or comminuted palatal/maxillary and mandibular fractures, often with edentulous segments, were the major indications for fabrication of acrylic splints. Depending on the nature of the fracture pattern, model surgery was performed on the maxillary and/or mandibular models and segmented along fracture lines. These fragments were then repositioned according to dental wear facets and preinjury occlusion. When possible, preinjury occlusal records were obtained before splint fabrication. Models were mounted on a Galetti articulator and palatal, lingual, and/or occlusal splints were fabricated. Edentulous segments were compensated for by local buildup of the splints to produce an occlusal stop. Arch bars were fixed directly to the splint with acrylic. Twenty-six splints were used in the 24 patients to establish proper occlusal relationships before internal fixation of fractures. The types of splints were palatal (n = 8), palatal-occlusal (n = 6), lingual (n = 8), lingual-occlusal (n = 1), and occlusal (n = 3).(ABSTRACT TRUNCATED AT 250 WORDS)

Soft-palate myogenesis: a developmental field paradigm

Surgical correction of clefts of the soft palate leads to varying degrees of normal function although the repair itself is successful. Explanations for this include structural abnormalities of the muscles. Previous studies have focused primarily on gross anatomical features of late fetal and postnatal cleft palate musculature; however, infrequent reference has been made to early prenatal morphologic patterns of soft-palate development, beginning with the embryo. Thus we evaluated the chronology of prenatal myogenesis of the soft palate from its early mesenchymal phase through the appearance of definitive palatal muscles and associated structures in a sample of 22 human fetuses that represented postfertilization weeks 6.5 to 20.5 (18- to 192-mm crown-rump length). Specimens were histologically prepared for descriptive and morphometric light microscopy. Data were collected on the earliest appearance times of identifiable soft palate and associated structures within the mesenchymal field and on their individual stages of myogenesis (e.g., for muscles, from mesenchyme to myoblasts to fascicles). Analyses showed that (1) palatal muscles and related bony structures emerge sequentially as densely staining mesenchymal subfields within the larger mesenchymal soft-palate field during the 6- to 9-week period, with the tensor veli palatini muscle appearing earliest, and the musculus uvulae latest; (2) further morphogenesis of the soft palate and associated structures follows a definite timeline; and (3) by 16 to 17 weeks the postnatal palatal morphology is in place.

Whole organ evaluation of collagen in the developing human larynx and adjoining anatomic structures (hyoid and trachea)

The collagen composition (types I, II, and III) of the normal developing human larynx and trachea was examined by biochemical methods. Autopsy specimens of larynges with attached upper tracheal rings were obtained from 28 humans ranging in age from birth to 44 years. The specimens were randomly collected, but excluded if laryngeal disease existed. The age, sex, and cause of death were documented. Collagen is important in the growth, development, repair, regeneration, and structural and functional integrity of the laryngeal framework. A preliminary report of selected cartilaginous components of the larynx was previously published by the authors, which studied the changes in the phenotypic expression of the collagen genes in children from the newborn period to 5 years 10 months of age. The current study included all of the functioning components of the skeletal larynx and trachea. The results of biochemical examination of these tissues are reported, and the potential clinical significance of the results of the study is discussed.

Insidious onset of familial craniosynostosis

A mother, son, and daughter are presented, in whom serial photographs document an insidious and late onset of exorbitism and midfacial retrusion consistent with a diagnosis of familial nonsyndromic craniosynostosis. Papilledema was found in the 4.5-year-old daughter because of increased intracranial pressure secondary to a reduction in cranial vault size, whereas optic nerve sheath swelling on CT scan was found in the son.

Surgical techniques of cranial vault expansion for increases in intracranial pressure in older children

Standard craniofacial techniques to expand the cranial vault were successful in treating elevations of intracranial pressure (ICP) in 7 older children. Of the 7 patients, a diagnosis of craniosynostosis was made in 6 and deformational head deformity with slit ventricle syndrome in 1. There were 5 boys and 2 girls, whose ages ranged from 3 1/2 to 8 years (mean, 5.2 yr). Three patients had previously undergone surgical treatment of craniosynostosis. One patient presented with visual changes and papilledema. Another with a deformational skull deformity was shunt-dependent and was diagnosed with slit ventricle syndrome. This patient had undergone several temporal craniectomies to control recurrent symptoms of increased ICP. The remaining 2 patients appeared to have craniosynostosis as an explanation for reduced cranial vault size and elevated ICP, but the specific sites of sutural fusion could not be identified. Total follow-up ranged from 3 to 18 months, and evidence of resolution of signs and symptoms of increased ICP was achieved in each of the 7 patients. Plastic surgeons involved in caring for children with craniosynostosis should be particularly aware of the possibility of increased ICP developing or recurring following craniofacial surgery.

A modification of the transcoronal flap that enhances orbital exposure and cosmesis

The transcoronal surgical approach for the treatment of orbital disease has become increasingly popular since it affords excellent surgical exposure through a cosmetically acceptable incision. Exposure of the inferior orbit, however, can be difficult due to limited flap mobility in the frontal plane. Increased inferior exposure may be obtained by extending the incision inferiorly in preauricular skin. In children and young adults without excess preauricular skin folds or wrinkling, however, the wound may be quite apparent, compromising cosmesis. To overcome this drawback, we demonstrate a modified transcoronal incision that redirects the inferior limbs into the postauricular sulcus. This incision not only results in superior cosmesis, but avoids important preauricular neurovascular structures and enhances orbital exposure.

The habenula and pain: repeated electrical stimulation produces prolonged analgesia but lesions have no effect on formalin pain or morphine analgesia

Recent studies have found that electrical stimulation of the habenula or microinjection of morphine into it reduces pain in several pain tests. The present study explored additional properties of the habenula. Expt. 1 examined the influence of the duration of stimulation on the duration of poststimulation analgesia in the formalin test. Expt. 2 was carried out to determine whether destruction of the habenula would affect either baseline pain levels or analgesia produced by morphine administered systemically in the formalin test. The results showed that the duration of analgesia is related to the duration of electrical stimulation. However, habenular lesions did not affect baseline pain levels or morphine analgesia. These studies support earlier evidence that manipulation of the habenula can produce analgesia, but suggest that it is not tonically active in modulating pain or necessary for the analgesic effects of systemically administered morphine.

A self-retaining method to maintain vertical position of the maxilla during Le Fort I osteotomies

A simple technique that relies on a fine wire to maintain vertical relationships of the maxilla during Le Fort I osteotomy is described. The advantages are (1) the hands of the assistant are free to help adapt plates, (2) it decreases the assistant's need to maintain a pose, and (3) the time of the operation decreases.