The timing of physiologic closure of the metopic suture: a review of 159 patients using reconstructed 3D CT scans of the craniofacial region.

PURPOSE: The purpose of this study was to determine the normal physiologic timing of the closure of the metopic suture in non-craniosynostotic patients. METHODS: This clinical study involved a consecutive series of infants and young children who underwent 3D CT-scan evaluation for deformational plagiocephaly or suspected traumatic head injury. All patients with evidence of craniosynostosis were excluded from the study. Every infant and child referred to our Craniofacial Team for deformational plagiocephaly between 1997 and 2000 (n = 84) received a baseline pre-treatment 3D CT-scan of the head. Our study also included a series of selected pediatric trauma patients (1 to 24 months of age) between 1997 and 2000 (n = 75) who received CT-scan to rule out head injury. The CT scan results were reviewed for closure of metopic suture by a single observer. RESULTS: The earliest evidence of metopic suture closure was at 3 months, the age at which 33% of patients (4/12) were closed. At 5 months of age, 59% (13/22) of sutures were closed. At 7 months of age, 65% (15/23) were closed. At 9 months of age, 100% (10/10) were closed. All patients greater than 9 months of age within the study had complete metopic suture closure. CONCLUSION: Our findings suggest that normal or physiologic closure of the metopic suture occurs much earlier than what has been previously described. This study establishes that metopic fusion may normally occur as early as 3 months of age, and that complete fusion occurred by 9 months of age in all patients in our series. Therefore, 3-D CT scans showing complete closure of the metopic suture at an early age (3 to 9 months) cannot be considered as evidence of metopic synostosis, and thus, should not be the decisive factor for early surgical intervention.

Reossification of the orbital wall following ventral translocation of the fronto-orbital bar and cranial vault remodeling.

The purposes of this study were to determine the extent of ossification of the orbit following ventral translocation of the fronto-orbital bar and to find out whether age at the time of the procedure and presence of a concomitant syndrome adversely affect ossification. A retrospective review of 27 patients with craniosynostosis was conducted at the St. Louis Children's Hospital and the Children's Hospital of Oklahoma. Patients with preoperative, perioperative, and postoperative three-dimensional computed tomography scans were included. Eighty-eight percent of the lateral orbital wall defects and 92 percent of the defects within the roof of the orbit ossified completely in the postoperative period. When syndromic patients were compared with nonsyndromic patients (based on clinical findings only), three of the 19 syndromic defects and three of the 30 nonsyndromic defects demonstrated incomplete ossification in the lateral orbital wall (p > 0.05). Similarly, two of the 19 syndromic defects and two of the 30 nonsyndromic defects demonstrated incomplete ossification within the roof of the orbit (p > 0.05). With respect to age at the time of the procedure, four of the 37 defects and two of the 12 defects demonstrated incomplete ossification in the lateral orbital wall for age at the time of the procedure less than 12 months and greater than 12 months, respectively (p > 0.05). Similarly, two of the 37 defects and two of the 12 defects had incomplete ossification within the roof of the orbit for age at the time of the procedure less than 12 months versus more than 12 months, respectively (p > 0.05). Ossification of the orbital wall and roof is complete in the majority of cases within 1 year after the procedure, and neither age at the time of the procedure nor presence of a concomitant syndrome adversely affects ossification of the orbit after ventral translocation of the fronto-orbital bandeau.

The "shutter flap" for large defects of the forehead.

Acquired defects involving exposed bone in the central forehead can be challenging to reconstruct. We present a simple technique in which two superiorly based flaps of galea frontalis and skin are transposed medially, like the shutter of a camera. Full-thickness grafts are used to close the donor site. This is a remarkably easy way to close some very large forehead wounds.

Thrombin promotion of isometric contraction in fibroblasts: its extracellular mechanism of action.

Isometric force generated by fibroblasts plays an essential role in tissue contraction during normal wound healing and pathologic contractures. Thrombin, a serine protease present in all wounds, has been shown to promote wound healing. The purpose of this study was to determine the extracellular mechanism by which thrombin promotes isometric contraction by fibroblasts in an in vitro collagen lattice model of tissue contraction. The amount of isometric force generated by human fibroblasts can be measured directly with a stabilized collagen lattice attached to a force transducer. Thrombin promoted isometric contraction by human fibroblasts in a dose-dependent manner. In addition, thrombin-promoted isometric contraction is dependent on the enzymatic and anionic binding activity of thrombin, as demonstrated by inhibition with specific enzymatic and anionic binding inhibitors. These results suggest that thrombin may promote isometric contraction by fibroblasts through the enzymatic cleavage of its cell surface receptor, resulting in a new amino terminus that serves as a "tethered ligand" to activate the receptor directly. To test this mechanism of action, a synthetic peptide (SFLLRN) representing the "tethered ligand" region of the activated thrombin receptor was synthesized and examined for its ability to promote isometric contraction by fibroblasts. This peptide promoted fibroblast contraction in a dose-dependent manner. In contrast, a control isomer peptide (FSLLRN), in which the two amino-terminal amino acids were reversed, failed to promote this response. These findings demonstrate that human alpha-thrombin promotes isometric contraction by human fibroblasts and that binding to and cleavage of its cell surface receptor are integral to this response.

Completely embedded ring in the finger of a growing child.

A case of a completely embedded ring in the finger of a growing child is presented. Because the ring was completely covered with epithelium or eschar, the diagnosis was masked until radiographs were obtained. Although bony erosion was present, neither digital sensation nor circulation was compromised. The patient regained nearly full, active motion after the ring was removed.

Giant basal cell carcinoma. Report of two cases and review of the literature.

Only 10% of all basal cell carcinomas are located on the trunk. Giant basal cell carcinomas are rare and are preferentially located on the trunk. We report two giant basal cell carcinomas of the trunk, one of which was fatal. Our review also includes a summary of previously reported cases of giant basal cell carcinoma. An analysis of these cases discloses an interesting feature of large basal cell carcinoma: Once giant basal cell carcinomas reach a critical mass, they demonstrate extremely aggressive behavior.

Effect of cleft palate repair and pharyngeal flap surgery on upper airway obstruction during sleep.

The effect of von Langenbeck palatoplasty and pharyngeal flap surgery on upper airway obstruction during sleep was studied by obtaining polysomnographic sleep studies on 10 patients undergoing each procedure at 1 to 2 days prior to surgery, 2 to 3 days postoperatively, and approximately 3 months postoperatively. The effects of von Langenbeck palatoplasty on sleep-related upper airway obstruction were usually minimal and clinically insignificant, whereas severe obstructive sleep apnea was present in all but one of the patients undergoing pharyngeal flap surgery at 2 to 3 days postoperatively. In most patients the upper airway obstruction was resolved at the 3-month postoperative sleep study. These data suggest that palatoplasty carries with it a very slight risk of upper airway obstruction, whereas pharyngeal flap surgery has as a very frequent concomitant the occurrence of severe obstructive sleep apnea in the immediate postoperative period.

Role of topical tretinoin in melanoma and dysplastic nevi.

The retinoids have been investigated extensively as chemopreventive and therapeutic agents in a variety of neoplasms. They have been shown to inhibit the proliferation of transformed cell lines in vitro and transplanted tumors in vivo. In cultured murine melanoma cells, retinoids inhibit proliferation and induce differentiation. Human melanoma cell lines have shown a mixed response. The clinical experience with retinoids in melanoma has been limited. Previously we investigated the activity of topical B-all-trans-retinoic acid (Retin-A, vitamin A acid, retinoic acid, and tretinoin) against intracutaneous metastases from malignant melanoma. We saw complete remission of multiple lesions in one individual and regression of several lesions in a second patient. This experience led us to conduct the present pilot trial of topical tretinoin in dysplastic nevus syndrome. The latter is a precursor of malignant melanoma. We saw regression of some of the treated lesions to benign nevi showing minimal or no dysplasia. Thus topical tretinoin appears to possess some activity against melanoma and at least one of its precursor conditions. In view of these preliminary results, more extensive trials are warranted to better define the role of tretinoin in the chemoprevention of malignant melanoma in high-risk lesions.

The care of burned upper extremities.

Two sets of factors will ultimately influence the outcome of the burned upper extremity. The first set of factors is the depth and severity of the burn. The second set is the group of complications of the burn injury attributable to edema, inflammation, immobility, and malposition. An awareness of the potential pitfalls that follow burn injury has resulted in improved primary care and a lessening of deformity. Progressive acute care with topical chemotherapy, early motion, thoughtful splinting, and timely burn wound closure are essential to reduce the need for secondary operations. Reconstructive efforts should be tailored to the individual needs of the patient. These procedures should be carefully planned with a view toward balancing aesthetic and functional considerations and minimizing the time required for rehabilitation.

Characteristics and uses of biologic dressings and skin substitutes.

Biologic dressings used for temporary coverage of open wounds exert both mechanical and physiologic effects by protecting the wound, maintaining microbial control, and hastening wound maturation. Synthetic wound dressings modeled after the biologic dressings have been evaluated by several investigators. Those studies have shown unilaminate synthetic membranes to be ineffective when applied to full-thickness wounds and have identified a bilaminate construction as being necessary for membranes to serve as effective skin substitutes. The desirable properties of skin substitutes have been identified and incorporated in the design of recently developed membranes. Recent studies in this and other laboratories have resulted in the development of collagen-synthetic bilaminates, a totally synthetic biologically inert bilaminate, and tissue culture-derived membranes. The characteristics and limitations of each skin substitute determine the optimum usage of these composite membranes and define the modifications needed to improve the effectiveness of such dressings.

Blood pressure drop as a result of fluorescein injection.

Our experience with intravenous fluorescein involved 38 administrations in 29 patients. In all, 24 percent were associated with a drop in blood pressure of 20 mmHg or more and 8 percent with a blood pressure fall of 60 mmHg or more. We believe that physicians using fluorescein in bolus form should be aware of the problem of blood pressure reduction and be prepared to take restorative measures when necessary.

Activity of isotretinoin against squamous cell cancers and preneoplastic lesions.

We investigated the effect of the synthetic vitamin A derivative isotretinoin (13-cis-retinoic acid) on advanced cancers in 103 patients and on preneoplastic lesions in five patients. Six of 14 patients with squamous cell epithelial cancers had objective regressions of skin or subcutaneous metastases. Three of five patients with preneoplastic lesions had objective responses. The major dose-limiting toxic effects were reversible dermatitis, emotional lability, and headaches. We conclude that the growth of some squamous cell epithelial malignancies can be inhibited by isotretinoin and suggest that other retinoids should be evaluated as antitumor agents.

Evaluation of digital escharotomy in burned hands.

A controlled study of digital escharotomy showed a statistically significant increase in the number of salvaged phalanges. This procedure has minimal risk and should be considered in patients with vascular compromise of the upper extremity requiring escharotomy, who also have circumferentially burned fingers.

Comparison of coarse mesh gauze with biologic dressings on granulating wounds.

Twenty patients with large area granulating wounds were selected for the study. On each patient, a small area of uniform appearance was divided into four subareas, and each subarea was randomly assigned treatment with a single 24 hour application of cadaver allograft, fresh porcine xenograft, formalinized xenograft, or "wet-to-dry" applications of coarse mesh gauze changed three times daily. At 24 hours, all four areas were uncovered. The subareas were ranked in terms of appearance on a best, second best, third best, and worst scale by experienced paramedical personnel who were not told which area received which treatment. Contact sponge quantitative microbiology was performed on each subarea before and after treatment on seventeen of the twenty patients. The results of these rankings suggest that coarse mesh gauze, changed three times daily, was significantly better at improving wound appearance than any of the biologic dressings. Among the biologic dressings, formalinized xenograft was significantly the worst. There was no significant difference between cadaver allograft and porcine xenograft. Analysis of quantitative cultures was limited by the problems of applying statistical methods to series of paired cultures in which initial values are quite different. Within the framework of such limitations and our 24 hour study, there was not significant change in surface colonization when either coarse mesh gauze or biologic dressings were used.

The quantitative swab culture and smear: A quick, simple method for determining the number of viable aerobic bacteria on open wounds.

The quantitative swab culture is a reliable method for quantifying the number of viable bacteria colonizing open wounds. For open wounds in burn patients, the swab bacterial count is linearly related to biopsy quantification of viable bacteria in the underlying tissue. This technique is simple and requires no surgical manipulation of the wound. For a wound of uniform appearance, the standard deviation of a single swab culture from the mean log bacterial count for a series of cultures from widely spaced areas on the wound is +/- 0.85 logs; 95% confidence limits are +/- 1.7 logs from the mean. A Gram-stained smear from a wound swab requires less than 10 minutes to prepare. Visualization of bacteria on the smear indicates that 106 or more bacteria per swab are present. The value of the smear and swab techniques for predicting safe wound closure may be inferred from the published reports of others and the direct relationship between the swab and biopsy counts of viable bacteria for open wounds.

Infection in the burned upper extremity.

Infection invariably accompanies thermal injury. The degree to which a patient is jeopardized by infection is related to the size and depth of the burn, the density and virulence of the microorganisms colonizing the burn wound, and the competence of his immune defenses. The aim of topical therapy is to limit microbial colonization of the burn wound to levels below those associated with invasive infection of the viable tissue beneath the eschar. The use of effective topical and systemic antimicrobial agents has been associated with the emergence of other bacterial, fungal, and viral infections and a delay in separation of the eschar, presumably caused by the suppression of bacterial débribement of the burn wound. The treatment of fractures in thermally injured patients may require compromise to permit optimal wound care and alertness toward the development of osteomyelitis. Because of the frequency of suppurative thrombophlebitis in burned patients, particular care is needed in the management of intravenous cannulae. The treatment of burns is largely the control of infection. Awareness of the septic complications of thermal injury and constant vigilance against them is critical in successful burn management.