Extramammary Paget disease: review of patients seen in a non-melanoma skin cancer clinic.

Extramammary Paget disease (EMPD) is a rare skin disease commonly found in the anogenital region. In this study, we aimed to identify EMPD patients seen in the non-melanoma skin cancer clinic at Odette Cancer Centre and to describe the treatments delivered and outcomes achieved. From 2000 to 2009, 14 patients were seen. Initial treatment recommendations included imiquimod and surgical excision, although half the patients required more than one treatment modality, highlighting the difficulty of achieving complete eradication of this disease.

Advanced technology in the management of fibrous dysplasia.

BACKGROUND: The aim of this paper is to describe the applications of advanced imaging technology in optimising the surgical management of complex craniofacial fibrous dysplasia (FD). METHODS: Preoperative planning involved a number of advanced technologies. Haptic modelling was used to simulate tumour excision and the design of the osteotomies, on a virtual 3D computerised tomographic (CT) scan. Rapid prototyping was employed in fabricating a physical prototype of the skull, featuring the ideal, symmetrical reconstruction. Tumour extirpation was carried out with the aid of stereotactic navigation. Intraoperatively, resorbable mesh is moulded precisely to the shape of the skull prototype, thereby transferring the surgical simulation to the patient in the operating room. The resorbable mesh serves as a template which guides the shape and spatial orientation of an autologous bone graft reconstruction. Pre- and postoperative volumetric differences were assessed to determine the accuracy of the final results. RESULTS: Short and long term follow-up examinations show excellent cosmetic outcome, with significant restoration of volumetric symmetry. CONCLUSIONS: The added complexity of using the new technologies increases preoperative planning time, but we believe that this is offset by the improved safety during the resection of the tumours as well as the excellent aesthetic outcomes.

Nipple piercing may be contraindicated in male patients with chest implants.

The authors present a man who underwent chest augmentation and nipple piercing. The patient developed chronic nipple infection, which led to unnecessary invasive diagnostic procedures, serious implant infection, and eventually urgent explantation. This unfavorable scenario illustrates the distinct features of the procedure in men, which includes close proximity of the nipple to the implant and reduced awareness by health care providers. Based on this case the authors recommend avoiding nipple piercing in men with chest implants.

Postoperative infections in craniofacial reconstructive procedures.

The rate of, and possible risk factors for, postoperative craniofacial infection is unclear. To investigate this problem, we reviewed 349 cases of craniofacial skeletal procedures performed from 1996 to 1999 at our institution. Infection rate was determined and correlated with the use of implants, operative site, and cause of deformity. The inclusion criteria consisted of all procedures requiring autologous or prosthetic implantation in craniofacial skeletal sites, as well as all procedures involving bone or cartilage resection, osteotomies, debridement, reduction and/or fixation. Procedures that did not involve bone or cartilage surgery were excluded. The criteria for diagnosis of infection included clinical confirmation and one or more of 1) intravenous or oral antibiotic treatment outside of the prophylactic surgical regimen; 2) surgical intervention for drainage, irrigation, and or debridement; and 3) microbiological confirmation. Among the 280 surgical cases that fit the inclusion criteria and had complete records, there were 23 cases of postoperative infection (8.2%). The most common site for postoperative infection was the mandible (infection rate = 16.7%). Multiple logistic regression analysis revealed gunshot wound to be the most significant predictor of postoperative infection. Additionally, porous polyethylene implantation through a transoral route was correlated with a significant risk of postoperative infection.

Spatial and temporal registration of CT and SPECT images: development and validation of a technique for in vivo three-dimensional semiquantitative analysis of bone.

UNLABELLED: The combined use of postoperative 3-dimensional CT and SPECT imaging provides a means of relating anatomy and physiology for the semiquantitative in vivo analysis of bone. This study focuses on the development and validation of a technique that accomplishes this through the registration of SPECT data to a 3-dimensional volume of interest (VOI) interactively defined on CT images. METHODS: Five human cadaver heads served as anthropomorphic models for all experiments. Four cranial defects were created in each specimen with inlay and onlay split-skull bone grafts reconstructed to skull and malar recipient sites. To acquire all images, each specimen was landmarked with 1.6-mm ball bearings and CT scanned. Bone surfaces were coated with 99mTc-doped paint. The locations of the ball bearings were marked with paint doped with 111In. Separate SPECT scans were acquired using the energy windows of 99mTc and 111In. RESULTS: Serial SPECT images aligned with an average root-mean-square (RMS) error of 3.8 mm (i.e., <1 pixel). CT-to-SPECT volume matching aligned with an RMS error of 7.8 mm. Total counts in CT-defined VOIs applied to SPECT data showed a strong linear correlation (r2 = 0.86) with true counts obtained from a dose calibrator. CONCLUSION: The capability of this multimodality registration technique to anatomically localize and quantify radiotracer uptake is sufficiently accurate to warrant further assessment in an in vivo trial.

Facial asymmetry: three-dimensional analysis using laser surface scanning.

This study evaluates six different techniques with respect to their ability to quantitatively describe facial asymmetry in three dimensions. Three-dimensional facial images were acquired using a Cyberware 3030RGB laser surface scanner. Image processing was performed on a Silicon Graphics Indigo computer workstation. The following techniques for facial asymmetry analysis were developed: asymmetry in the location of anthropometric landmarks, Euclidean distance matrix analysis (EDMA), scalar measurement of the lower ciliary margin and palpebral fissure area, clearance vector mapping, and determination of the volume of asymmetry. Techniques were applied and validated in three anthropometric models: a perfectly symmetrical plastic head model and a plaster head model with and without a unilateral cheek augmentation. In each of the anthropometric test models, each analytical technique was validated by means of static anthropometric facial models and was evaluated for intraobserver and interobserver reliability. Asymmetries in the location of anthropometric landmarks can be accurately determined to within 2 mm in x, y, and z directions of the Cartesian space. EDMA is a useful technique in describing both size and shape changes of discrete areas of the face. Measurement of the lower ciliary margin and palpebral fissure area is reliable. Clearance vector mapping is especially useful in quantifying facial surface asymmetries in facial areas where anthropometric landmarks are scarce. Volume of asymmetry is potentially useful in those patients for whom the use of injections or implants of known volume may be helpful in correcting unilateral facial deficiencies.

Soft tissue deformity after craniofacial fracture repair: analysis and treatment.

BACKGROUND AND OBJECTIVES: The primary repair of facial fractures requires sufficient subperiosteal dissection and mobilization of soft tissues to permit accurate fracture reduction. Improper repositioning of soft tissues predisposes the site to deformities with subsequent adverse effects on the aesthetics of the final result. The purpose of this paper is to describe these deformities, the modification of surgical approaches to avoid them, and the various techniques for secondary soft tissue reconstruction. METHODS AND MATERIALS: The paper reviews the assessment of soft tissue deformity and the principles of soft tissue reconstruction in addressing temporal contour deformity, cheek ptosis, eyelid deformities, and medial and lateral canthal dystopia. RESULTS AND/OR CONCLUSIONS: The morbidity of remote incisions and soft tissue degloving used in primary facial fracture repair can be minimized by using a meticulous technique and precise soft tissue repositioning at closing.

Application of a three-dimensional intraoperative navigational system in craniofacial surgery.

Recent advances in imaging technology have prompted the development of new instrumentation that permits direct interactive visualization of image data in the operating room. The ISG Viewing Wand (ISG Technologies, Mississauga, Ontario, Canada) is a frameless stereotactic system that combines three-dimensional computer-assisted imaging with a hand-guided, position-sensing, articulated arm. In this article we describe the use of the ISG Viewing Wand as a three-dimensional intraoperative navigational system in craniofacial surgery and review our initial clinical experience in 17 patients. The wand was used as an aid in the correction of craniofacial asymmetry in 12 patients and as a navigational device assisting in craniofacial skeletal resection in 5 patients. By orienting the surgeon to his exact location throughout the procedure, the ISG Viewing Wand was found to be useful in defining intraorbital anatomy, in determining ocular globe position, and in delineating tumor margins. Excellent anatomical spatial correlation was obtained, and the probe tip position was within 2 mm of its actual position in all cases. Use of the system added minimal additional time, and overall no adverse effects were attributed to use of the wand.

Progressive unilateral mandibular swelling in adolescence: a diagnostic dilemma.

Asymmetrical swelling of the mandible in adolescence may pose a significant diagnostic dilemma. The differential diagnosis ranges from traumatic, infectious, and metabolic processes to benign and malignant tumors. Among them, fibrous dysplasia, osteomyelitis, and malignancy may present with similar clinical and radiological features, making an accurate diagnosis quite difficult. This is an illustrative case involving a 14-year-old girl who initially presented with diffuse fibrous dysplasia of the mandible and in whom a superimposed osteomyelitis of the left side subsequently developed. Multiple investigations and several biopsies were required to arrive at a diagnosis. Similarities in clinical and radiographic findings of fibrous dysplasia, osteomyelitis, and malignancy are presented, and implications for treatment are discussed.

Computed tomography artifacts associated with craniofacial fixation devices: an experimental study.

This study compares the artifacts caused by eight different craniofacial fixation devices in computed tomography (CT) images. Using a Teflon CT phantom model, part I of this study involved the quantitative evaluation of the X-ray absorption properties of each fixation device. Part II utilized a human cadaveric model to determine the degree to which the artifact interfered with the visualization of anatomic structures. In part I, each fixation device was secured to the surface of the phantom and then scanned. All artifacts were compared on the basis of standard deviation in CT number. The severity of the artifact was related to the physical size of the fixation device and its composition. Vitallium devices generated a greater degree of CT artifacts than titanium devices of comparable size. In part II, fixation devices were secured to the orbital rims of human cadaveric heads and then scanned. Visualization of specified anatomic structures was graded independently. The results revealed that titanium fixation devices did not cause significant bone or soft-tissue image degradation, whereas all vitallium fixation devices, except micro mesh and micro (1.0 mm) straight plates, generated an artifact that resulted in some image degradation. The extent of image degradation was related to the fixation device size. Only the thickest vitallium fixation device, mini fragmentation (2.0 mm), resulted in bony image degradation. The degree of soft-tissue image degradation decreased as the size of vitallium fixation devices decreased such that micro fragmentation (0.8 mm) and pan fixation (1.3 mm) devices interfered with soft-tissue visualization only in the immediate vicinity of the plate. The results of this study confirm the previous work of Sullivan and colleagues and Fiala and associates. The data indicate that when postoperative imaging is an important clinical consideration: (1) the fewest number of internal fixation devices should be used to achieve rigid bony fixation, (2) the proximity of fixation devices to the regions of interest should be considered at the time of fixation, (3) titanium implants produce less artifacts than vitallium implants of comparable size, and (4) vitallium micro mesh and micro (1.0 mm) straight fixation devices do not produce artifacts resulting in significant image degradation.

Use of a new anchoring device for tendon reinsertion in medial canthopexy.

This paper describes the use of the Mitek Mini GII Anchor System for tendon reinsertion in medial canthopexy. The system is simple, fast to insert, and easy to use. It allows precise placement with minimal dissection, which is limited to the ipsilateral orbit.

Three-dimensional facial anthropometry using a laser surface scanner: validation of the technique.

Three-dimensional measurement and characterization of facial surface anatomy are fundamental to the objective analysis of facial deformity. However, existing clinical tools are inadequate. Recent innovations in laser scanning technology provide a potentially useful technique for accurate three-dimensional documentation of the face. The purpose of this study is to evaluate the reliability of interactive anthropometric landmark localization based on digitized three-dimensional facial images and to identify sources of error associated with the technique. Three-dimensional surface data were acquired using a commercially available laser scanning device (Cyberware 3030RGB digitizer), and all subsequent anthropometric analyses were performed interactively on the computer monitor. Four experimental conditions were studied, with 10 observations for each condition. A stable anthropomorphic model with prelabeled anatomic landmarks was scanned repeatedly under varying conditions of head inclination and position within the scanning gantry to determine the effect of these variables on the reliability of the technique. The scanning protocol was then repeated with the labels removed to evaluate the reliability of interactive localization of anthropometric landmarks on a digitized three-dimensional image. Optimal results were obtained with the head positioned in the center of the scanning gantry and with the Frankfort plane elevated 10 degrees from the horizontal. Under these circumstances, all 22 labeled landmarks were visualized and the variance in landmark localization was less than 0.6 mm in the x (horizontal), y (vertical), and z (depth) dimensions. Varying head position or inclination caused significant degradation of the digitized image. The variance of interactive landmark localization was analyzed in three dimensions. The reliability and the spatial orientation of variability were determined for each anthropometric point. These findings have direct implications for the clinical adaptation of this diagnostic tool for quantitative evaluation of facial surface anatomy.

The effects of temporalis muscle manipulation on skull growth: an experimental study.

Craniofacial reconstructive procedures are frequently associated with some dissection or transposition of the temporalis muscle. During active growth, such muscle manipulations may influence craniofacial development. The purpose of this study was to determine the effects of surgical manipulation of the temporalis muscle on craniofacial skeletal growth and morphology. Twenty-five New Zealand White rabbits underwent temporalis muscle surgery at 6 weeks of age. Group I (n = 6) underwent a sham procedure and served as a control group. Group II (n = 6) underwent simple elevation of the left temporalis muscle and immediate reapproximation. Group III (n = 7) underwent complete transection of the left temporalis muscle. Group IV (n = 6) underwent elevation of the left temporalis muscle and transposition to the left zygoma. Growth alterations were evaluated by standardized cephalometric x-rays. Baseline anteroposterior skull x-rays were performed preoperatively and every 3 weeks for the duration of the study. The study was terminated at 24 weeks of age. At this point, dry skull preparations were analyzed quantitatively by direct cephalometric evaluation. Manipulations of the temporalis muscle produce changes in local skull morphology and affect craniofacial growth. Skull length increases when the action of the temporalis muscle is interrupted either transiently or permanently, while skull width decreases. Temporalis muscle transposition to the orbit resulted in altered orbital dimensions. Qualitative analysis of local skull morphology further revealed posterior displacement of the external auditory meatus, a depressed temporalis fossa, and multiple resorption cavities following elevation of the temporalis muscle.

Temporal fascial periosteal and musculoperiosteal flaps in the pig: design and blood flow assessment.

The availability of a vascularized periosteal flap with bone-forming potential could greatly enhance the reconstructive capabilities of the craniofacial surgeon. Previous observations seem to indicate that the bone-forming potential of periosteal flaps depends on the vascularity of the flap. The purpose of the present experiment was to design temporal fascial periosteal and musculoperiosteal flaps in the pig and to compare the periosteal blood flow with unoperated periosteum in the same location. The radioactive microsphere (15-micron diameter) technique was used to measure periosteal capillary blood flow in periosteal flaps and unoperated control, randomized to each side of the head in nine pigs (Yorkshire; weight, 12-14 kg). The periosteum was (1) raised based on the temporalis muscle with vascular supply from the deep temporal vessels (n = 6), (2) raised based on temporoparietal fascia-deep temporal fascia with blood supply from the superficial temporal vessels (n = 6), or (3) left intact (n = 6). The mean periosteal capillary blood flow rates in the intact periosteum (0.107 +/- 0.001 ml/min/g), the temporal musculoperiosteal flaps (0.081 +/- 0.01 ml/min/g), and temporal fascial periosteal flaps (0.087 +/- 0.012 ml/min/g) were not significantly different. These observations indicate that the blood flows for both musculoperiosteal and fascial periosteal flaps were comparable to control intact temporal periosteum.

Surgical management of abdominal wall disruption after blunt trauma.

Abdominal wall disruption following blunt trauma is a rare but challenging injury, both in the acute and convalescent phases. The present report describes the recent experience with this injury at a single adult trauma center. In a 22-month period, nine patients with traumatic abdominal wall disruption were managed. Flank and anteroinferior abdominal wall defects were most common. Associated injuries included 6 patients with a pelvic fracture and 4 patients with rectosigmoid injuries. Immediate primary repair of the defect was attempted in seven cases at the time of trauma laparotomy, but was difficult and often unsuccessful because of the related tissue destruction. Delayed abdominal wall repair was performed in patients with symptomatic disability (n = 5) and, if required, restoration of intestinal continuity was performed at a separate operation before abdominal wall repair. Delayed repair with autogenous tissue included the use of tensor fascia lata, rectus femoris muscle, rectus abdominis fascia, and latissimus dorsi muscle. Reconstruction with prosthetic mesh was required in two patients. One early and one late recurrence occurred, resulting in reoperation. In conclusion, traumatic abdominal wall disruption represents a complex challenge for both general and plastic surgeons. The key to successful surgical management seems to be a delayed staged repair with autogenous tissue when feasible.

Medial canthopexy: an experimental and biomechanical study.

Medial canthopexy is associated with a significant failure rate. A cadaveric study was undertaken to evaluate the biomechanics of the medial canthal tendon and three types of fixation devices for medial canthopexy. Eight medial canthal tendons were assessed in 4 fresh-frozen cadaver heads. The medial canthal tendon was found to be much stronger than previously suspected, with an average breaking strength of 36 newtons and an elongation of 6.25 mm. The tendon-bone complex was noted to be closely matched biomechanically. Three medial canthopexy techniques were then assessed: transnasal wire over a button, 1.7-mm screw fixation into the medial orbit, and the Mitek GII anchor. Their respective holding strengths were 74%, 92%, and 97% of that of the contralateral intact medial canthal tendon. The three types of fixation devices all provided excellent ultimate biomechanical strength.

The vascularized temporoparietal fascial flap for correction of the deep superior sulcus.

The deep superior sulcus is one of the more difficult problems to correct in the enophthalmic or anophthalmic orbit. Multiple procedures as well as materials have been proposed in recent years to address the cosmetic deformity. These methods have used a number of alloplastic and autogenous materials. Ideal correction of a soft tissue deformity uses well-vascularized autogenous tissue. This paper introduces the use of the temporoparietal fascial flap for correction of the deep superior sulcus. The advantages of this flap over other materials lies in its pliability, vascularity, thinness, ease of mobilization, and minimal subsequent donor site morbidity or deformity.

Cranioplasty: indications, technique, and early results of autogenous split skull cranial vault reconstruction.

Since 1990, fresh autogenous split skull cranioplasty has been the preferred method of reconstructing complicated cranial defects at the Sunnybrook Hospital. Eight cases of split skull cranioplasties were reviewed to illustrate the indications and technical considerations of the procedure. Clinical factors believed to be detrimental to the outcome of split skull cranioplasty were identified by: 1) a history of an infected, failed, previous cranial reconstruction, 2) inadequate scalp or skin to cover the external surface of an anticipated skeletal vault reconstruction, 3) the communication of adjacent paranasal sinuses with the epidural space, 4) the presence of an avascular dead space posterior to the reconstructed cranium. These potentially negative influences were systematically addressed as part of the surgical routine in autogenous split skull cranioplasty.

Facial nerve palsy after mandibular fracture.

A 19-year-old man sustained a right parasymphyseal fracture and bilateral condylar neck fractures in a motor vehicle accident. The parasymphyseal fracture was treated by open reduction and internal fixation, and the subcondylar fractures were treated with closed reduction and maxillomandibular fixation. Three days postoperatively, a near-complete left facial nerve palsy developed. Facial nerve recovery was not full. The literature is reviewed, and possible mechanisms of this rare and devastating complication are discussed.

Comparison of laser Doppler flowmeter and radioactive microspheres in measuring blood flow in pig skin flaps.

Laser Doppler flowmetry is a noninvasive technique commonly used to monitor skin perfusion after free-tissue transfer or replantation in reconstructive surgery. Several investigators have expressed concern about the reliability of the quantitative value provided by laser Doppler flowmeters (LDF) and the extent to which they reflect nutrient blood flow. This experiment was designed to compare quantitatively the skin blood flow in the pig measured by LDF and by 15-micron radioactive microspheres (RMs). It was observed that the skin blood flow rates measured by LDF and RMs in the normal skin and in acute random-pattern and arterialized skin flaps were highly correlated (r = 0.93, P < .01). However, the skin blood flow rates measured by LDF were consistently higher (P < or = .05) than the corresponding flow rates measured by RMs, and this discrepancy increased considerably at low skin blood flow rates (< 2 mL/min/100 g). We speculated that the LDF most likely measured both nutrient and arteriovenous shunt flow in the skin and that this arteriovenous shunt flow at least in part caused the discrepancy in skin blood flow rates measured by the LDF and RMs because the 15-micron RMs are known to measure nutrient blood flow only. The inherent variations and errors in LDF technique were also discussed.