Lip symmetry following rotation advancement cleft lip repair in 5-year-old children treated by Ralph Millard and Ron Pigott.

Objective: To compare the symmetry of the lip following Rotation-Advancement cleft lip repair by Millard and Pigott and to investigate the effect on the symmetry of cleft side and gender by using different surgical protocols. Symmetry following cleft surgery was compared to that of non-cleft children. Design: Retrospective study of photographs of children aged 5 years. Setting: Three decades of post-operative photographs of children treated by Millard and Pigott. Patients: Eighty-nine children treated by Millard, 87 by Pigott and 91 non-cleft children. Interventions: Photographs were assessed using the Symnose Computer program, a rapid semi-objective quantitative assessment of lip symmetry. Main Outcome Measures: Asymmetry score for each surgeon, and non-cleft children. Results: There was no significant difference in the median lip % mismatch score of Millard, 36.65% and Pigott, 38.52%. Right-sided clefts showed better symmetry than left-sided clefts for Millard (p<.001). This was reversed for Pigott (P=.0121). There was a difference (P<.001) between the symmetry of the two cleft cohorts and the non-cleft children (asymmetry 19.9%), and between Millard's outcomes following different lip surgical protocols (P < .0001), but no difference between Pigott's outcomes using different palate surgical protocols (P = 0.59). Conclusions: Cleft lip repair by Millard and Pigott resulted in similar lip asymmetry (37% and 39% symmetry mismatch, respectively). Lip surgical protocol and cleft side may affect lip asymmetry. Palate surgery did not affect lip asymmetry. Following cleft surgery, children were more asymmetric than non-cleft children.

Molecular cloning of CD31, a putative intercellular adhesion molecule closely related to carcinoembryonic antigen.

cDNA clones encoding CD31 have been isolated by transient expression. The sequence of CD31 expressed on human umbilical vein endothelial cells (HUVEC) is identical to that expressed on the monocyte-like cell line HL60. In HUVEC. CD31 is concentrated in regions of cell-cell contacts. CD31 is a member of the Ig superfamily and is most closely related to the carcinoembryonic antigen CEA, consisting of four contiguous C2 domains. The localization of CD31 to regions of cell-cell contacts, and the sequence similarity to CEA, a known intercellular adhesion molecule (ICAM), strongly suggest that CD31 may function as an ICAM, possibly mediating endothelial cell-cell contacts and also promoting interactions between leukocytes and endothelial cells.

A novel endothelial-specific membrane protein is a marker of cell-cell contacts.

mAbs were raised in mice against cultured human endothelial cells (EC) and screened by indirect immunofluorescence for their ability to stain intercellular contacts. One mAb denoted 7B4 was identified which, out of many cultured cell types, specifically decorated cultured human EC. The antigen recognized by mAb 7B4 is bound at the appositional surfaces of cultured EC only as they become confluent and is stably expressed at intercellular boundaries of confluent monolayers. EC recognition specificity was maintained when the antibody was assayed by immuno-histochemistry in tissue sections of many normal and malignant tissues and in blood vessels of different size and type. The antigen recognized by 7B4 was enriched at EC intercellular boundaries similarly in vitro and in situ. In vitro, addition of mAb 7B4 to confluent EC increased permeation of macromolecules across monolayers even without any obvious changes of cell morphology. In addition, when EC permeability was increased by agents such as thrombin, elastase, and TNF/gamma IFN, its distribution pattern at intercellular contact rims was severely altered. mAb 7B4 immunoprecipitated a major protein of 140 kD from metabolically and surface-labeled cultured EC extracts which appeared to be an integral membrane glycoprotein. On the basis of its distribution in cultured cells and in tissues in situ, 7B4 antigen is distinct from other described EC proteins enriched at intercellular contacts. NH2-terminal sequencing of the antigen, immunopurified from human placenta, and sequencing of peptides from tryptic peptide maps revealed identity to the cDNA deduced sequence of a recently identified new member of the cadherin family (Suzuki, S., K. Sano, and H. Tanihara. 1991. Cell Regul. 2:261-270.) These data indicate that 7B4 antigen is an endothelial-specific cadherin that plays a role in the organization of lateral endothelial junctions and in the control of permeability properties of vascular endothelium.

Soluble intercellular adhesion molecule 1 is released by human melanoma cells and is associated with tumor growth in nude mice.

We have studied the cytokine regulation of cell surface and soluble intercellular adhesion molecule 1 (ICAM-1) expression on the human melanoma cell line A375M. Unstimulated cells express ICAM-1 on their cell surface but do not secrete significant levels of soluble ICAM-1. Interleukin 1, interleukin 6, tumor necrosis factor, and gamma-interferon all increased cell surface expression of ICAM-1. Tumor necrosis factor, interleukin 1, and gamma-interferon also caused the release of soluble ICAM-1. The serum of melanoma patients has been reported to contain elevated levels of soluble ICAM-1; however, the source of this ICAM-1 is unclear. The serum from nude mice bearing s.c. human melanoma tumors was found to contain soluble human ICAM-1. ICAM-1 levels showed a positive correlation with tumor weight. The release of ICAM-1 from melanoma tumors, in response to host-derived cytokines, may have relevance to immune recognition of the tumor.

Involvement of the very late antigen 4 integrin on melanoma in interleukin 1-augmented experimental metastases.

We have previously reported that treatment with interleukin 1 (IL-1) induced the augmentation of lung tumor colonies by a human melanoma in nude mice. Here we have investigated the involvement of the alpha 4 beta 1 integrin, the very late antigen 4 (VLA-4) in this augmentation. A375M melanoma cells expressed high levels of VLA-4 and preferentially adhered to a surface coated with vascular cell adhesion molecule 1 (VCAM-1), the ligand for VLA-4 on activated endothelial cells. This adhesion was inhibited by treating tumor cells with saturating concentrations of mAb to VLA-4. The production of lung colonies was significantly enhanced in nude mice given an injection of IL-1 before A375M melanoma cells. Immunoperoxidase staining showed that VCAM-1 could be expressed on lung vascular endothelium of mice in response to IL-1. Pretreatment of melanoma cells with a mAb to VLA-4 completely abrogated the IL-1-induced augmentation of lung colonies. Using two metastatic melanoma clones (clones 2/4 and 2/60) that expressed different levels of VLA-4, we found that only VLA-4-bearing cells adhered to a VCAM-1-coated surface and formed enhanced numbers of lung colonies in IL-1-treated nude mice. This augmentation was inhibited by pretreating the tumor cells with anti-VLA-4 mAb. These results demonstrate, in vivo, the functional involvement of VLA-4 on melanoma cells in IL-1-mediated lung colony augmentation, most probably involving the interaction of tumor cells with VCAM-1 on activated endothelial cells.

Induction of vascular adhesion molecules during rejection of human cardiac allografts.

Adhesion of leukocytes to vascular endothelium is a necessary step leading to the migration of cells into underlying tissues. Vascular adhesion molecules regulate this process and may play an important role in graft rejection. Immunocytochemical studies have been used to investigate the expression of vascular adhesion molecules (ICAM-1, PECAM, VCAM-1, and ELAM-1) in normal donor heart (n = 15) and myocardial biopsies from heart transplant patients with acute rejection (n = 15). Sections were also stained with antibodies against endothelium, leukocytes, MHC antigens, and markers of cell activation. In donor heart EN4, vWF, ICAM-1, PECAM, MHC class I--and, to a lesser extent, VCAM-1 and DR antigen--are expressed on arterioles and venules, whereas ELAM-1 and Pal-E are restricted to venules. Expression of Pal-E, VCAM-1, ICAM-1, and DR antigen was increased during rejection. Capillary endothelium normally expresses EN4, ICAM-1, PECAM, MHC class I, and DR antigen but little, if any, VCAM-1 or ELAM-1. During rejection, however, there is an increased expression of all adhesion molecules. This is paralleled by an increased expression of vWF by capillary endothelium. In addition, ICAM-1 like MHC class I antigen is induced on the myocardial membrane and intercalating discs. Endocardium from donor heart expresses EN4, vWF, PECAM, MHC class I, and sometimes Pal-E and ICAM-1, but very little VCAM-1, ELAM-1 or DR antigen. There is an increased expression of Pal-E, ICAM-1, VCAM-1, and DR antigen on endocardium from rejecting heart biopsies. Proliferating Ki-67+ cells and activated T cells expressing the receptor for IL-2 were also found in biopsies during rejection episodes.

Matrix metalloproteinase expression during experimental autoimmune encephalomyelitis and effects of a combined matrix metalloproteinase and tumour necrosis factor-alpha inhibitor.

Matrix metalloproteinases (MMPs) are a large family of Zn2+ endopeptidases that are expressed in inflammatory conditions and are capable of degrading connective tissue macromolecules. MMP-like enzymes are also involved in the processing of a variety of cell surface molecules including the pro-inflammatory cytokine TNF-alpha. MMPs and TNF-alpha have both been implicated in the pathology associated with neuro-inflammatory diseases (NIDs), particularly multiple sclerosis (MS) and its animal model experimental autoimmune encephalomyelitis (EAE). We have shown that BB-1101, a broad spectrum hydroxamic acid-based combined inhibitor of MMP activity and TNF processing, reduces the clinical signs and weight loss in an acute EAE model in Lewis rats. However, little is known about which MMPs are involved in the neuroinflammatory process. In order to determine the optimum inhibitory profile for an MMP inhibitor in the treatment of NID, we investigated the profile of MMP expression and activity during EAE. The development of disease symptoms was associated with a 3-fold increase in MMP activity in the cerebrospinal fluid (CSF), which could be inhibited by treatment with BB-1101, and an increase in 92 kDa gelatinase activity detected by gelatin substrate zymography. Quantitative PCR analysis of normal and EAE spinal cord revealed the expression of at least seven MMPs. Of these, matrilysin showed the most significant change, being elevated over 500 fold with onset of clinical symptoms and peaking at maximum disease severity. Of the other six MMPs detected, 92 kDa gelatinase showed a modest 5 fold increase which peaked at the onset of clinical signs and then declined during the most severe phase of the disease. Matrilysin was localised by immunohistochemistry to the invading macrophages within the inflammatory lesions of the spinal cord. Matrilysin's potent broad spectrum proteolytic activity and its localisation to inflammatory lesions in the CNS suggest this enzyme could be particularly involved in the pathological processes associated with neuro-inflammatory disease.

A solid-phase beta-galactosidase ELISA for detecting and quantifying monoclonal antibody binding to dissociated cell cultures of postnatal rodent cerebellum.

A solid-phase, indirect beta-galactosidase-linked immunoassay (ELISA) is described for screening large numbers of monoclonal antibodies that recognize cell surface antigens of primary monolayer cerebellar cultures. Target cultures were prepared from perikaryal suspensions of postnatal rodent cerebellum seeded into poly-L-lysine pre-coated, flat-bottom microtiter wells and fixed with glutaraldehyde after growth in vitro. Hybridoma supernatants were then incubated on these cultures. After the addition of beta-galactosidase-linked anti-mouse IgG F(ab')2 fragments, antigen-positive supernatants were detected with the enzyme substrate o-nitrophenyl-beta-D-galactopyranoside. Using a monoclonal antibody specific for rat brain Thy-1 glycoprotein, this solid-phase ELISA was found to be useful in quantifying changes in the developmental expression of cerebellar surface antigens in these cultures.

A simple perfusion chamber for studying neurotransmitter release from cells maintained in monolayer culture.

A perfusion chamber is described for studying the efflux of putative neurotransmitters from CNS cells maintained in monolayer culture. We have used this apparatus to investigate the efflux of newly accumulated [3H]GABA from cell cultures of the early postnatal rat cerebellum.

Immunocytochemical and biochemical studies with the monoclonal antibody 69A1: similarities of the antigen with cell adhesion molecules L1, NILE and Ng-CAM.

We have previously raised a monoclonal antibody (69A1) which recognises a cell-surface antigen expressed on rat cerebellar neurons both in culture and in tissue sections of the developing cerebellum prior to postnatal day 17. In our current study we have undertaken a detailed analysis of the loss of labelling from the molecular layer of the cerebellum and show that this parallels the gradient of fibre maturation in this zone. This loss of labelling occurred in paraformaldehyde-fixed tissues but not in unfixed or acetone-fixed sections, suggesting it is the result of antigen modification rather than antigen loss. In cultures of dorsal root ganglia antibody 69A1 labelled neurones and some Schwann cells. Antigen 69A1 was immunoprecipitated from lysates of cultured cerebellar cells and appeared as two bands when separated by SDS-PAGE with apparent molecular weights of ca. 210 and 150 kDa. The antigen is distinct from N-CAM but shows similarities with the L1, nerve growth factor-inducible large external glycoprotein (NILE) and Ng-CAM group of cell adhesion molecules.

A cell surface antigen present on cultured cerebellar neurones appears to be transiently expressed during cerebellar development in the rat.

A monoclonal antibody has been produced from a fusion of NSO myeloma cells and splenocytes from a mouse immunized with cultures from early postnatal rat cerebellum. The binding of this antibody designated 69A1 is concentrated in the molecular layer of the developing rat cerebellum during the first two weeks postnatally but falls below the level of detection during the third week. Immunoelectron microscopy has shown antibody binding in the molecular layer to be confined to the parallel fibres of the granule neurones. The disappearance of binding coincides with a period during which the formation of new parallel fibres is completed and rapid synaptogenesis within the molecular layer begins.

"Alar leapfrog". A technique for repositioning the total alar cartilage at primary cleft lip repair.

A technique is described to reconstruct the normal degree of projection of the alar dome of the unilateral cleft lip nose by leapfrogging the spreadeagled alar cartilage up onto the back of the sturdy septum and upper lateral cartilage arch. The medial crus enclosed in a hemiforked flap slides along the membranous septal incision; the lateral crus slides along the intercartilaginous incision; they join each other as the stem of a Y, where they are secured in their new relationship to the septum and upper lateral cartilage. As the limbs approach each other, a standing cone creates the dome projection externally and a fornix within. The dipped rim rises and the charming nasal dimple reappears. Almost 200 primary cases of unilateral cleft lip nose have been treated by this technique over the past 12 years by the author. Alar dome and alar rim relapse have been infrequent. Less than 5 per cent of patients (or parents) have requested revision up to puberty. Final assessment of the effect of this radical surgery may well require a further 10 years' follow-up.

Effectiveness of burns resuscitation using two different formulae.

Prior to 1989 burns were resuscitated at the Burns Unit Frenchay Hospital according to the Mount Vernon formula. In 1989 a 33 per cent modification was introduced as suggested by Watson, Walker and Sanders. The aim of this study was to examine retrospectively the effects of the resuscitation protocols on morbidity and mortality. The total numbers of burns admitted to Frenchay in 1988 were 93 adults and 58 children. This compares with 82 adults and 55 children admitted in 1989. Of these, approximately one-fifth required intravenous resuscitation. No statistical difference was found between the two groups for age, body weight, distribution of burn, or delay in arriving at the burns unit (taken from the time of burn). In both years the volume of albumin used in resuscitation exceeded the calculated requirement after the third period (P less than 0.05). The 1989 patients were transfused with greater volumes, resulting in increased urine output (P less than 0.001). No difference in morbidity or mortality was shown. However, the investigation did show that the 1989 patients achieved urine outputs indicative of overtransfusion. It is concluded that the Watson-Walker modification is unnecessary and possibly undesirable.

Tailoring velopharyngeal surgery: the influence of etiology and type of operation.

The results of 132 consecutive endoscopically selected pharyngoplasties were assessed. Depending on the size and shape of the velopharyngeal defect on attempted closure, patients had been allocated to one of four pharyngoplasties: (1) a superiorly based pharyngeal flap combined with a V-Y pushback of the soft palate (Honig), (2) a modified Hynes approach, (3) a superiorly based pharyngeal flap, or (4) a fish flap. Patients were categorized according to etiology as having cleft palate, submucous cleft palate, disproportion, or neurologic origin. Acceptable nasal resonance was found after 81 percent of the Honig operations, 81 percent of the Hynes operations, and 63 percent of the superiorly based flap operations, vindicating the selection criteria based on palatal and pharyngeal wall movement. The fish flap operation was successful in only 50 percent and is not recommended. The cleft, submucous cleft, disproportion, and neurologic categories were equally well corrected by the Honig and Hynes operations. Side effects were common, with catarrh or snoring in 51 percent, difficulty breathing through the nose in 27 percent, and 9 percent requiring revision of their pharyngoplasty (6 of 53 Honig and 5 of 63 Hynes operations). The higher median age for those patients requiring pharyngoplasty revision (17 versus 10 years) suggests more cautious use in the older patient.

Hynes pharyngoplasty revisited.

The treatment of velopharyngeal incompetence remains unsatisfactory because the causes are many, as are the variations in anatomic and physiologic defects. Therefore, full assessment and investigation are essential in tailoring the surgery to the defect. A modified Hynes pharyngoplasty has been used in 40 patients, aged 4 to 52, over a 4-year period for velopharyngeal incompetence of varying etiologic causes. Speech was assessed before and at least 6 months after pharyngoplasty. At the same time, radiologic and, when possible, nasendoscopic investigations were undertaken. Thirty-eight patients had no or variable nasal escape (variable defined as achieving intermittent closure), whereas 33 had normal or slight hyponasal resonance. There was only one complication, an asymptomatic dehiscence of the "bucket handle" flap from the posterior wall. Thirteen patients had an assortment of side effects, none requiring surgical treatment. We believe that patients who are suitable for the described sphincter pharyngoplasty are those with slight or moderate nasal escape having a mobile palate with an anteroposterior gap of 5 mm or less.

The nose in children with unilateral cleft lip and palate.

Surgeons and orthodontists are still challenged to achieve 'better' noses for children with a unilateral cleft or lip, alveoulus and palate (UCLP). Various aspects are discussed: infant anatomy and later changes, developmental mechanics, cleft syndrome in animals with surgically produced facial clefts, untreated patients with congenital clefts, the radical primary correction of the UCLP nose, the unsolved problems in secondary rhinoplasty and suggestions for scientific communication.

Pharyngoplasty: a hazard for nasotracheal intubation.

General anaesthesia is desirable for a wide range of oral and maxillofacial operations and nasal intubation is essential for some procedures, particularly orthognathic surgery. The patient who has undergone pharyngoplasty presents with a reduced velopharyngeal orifice which may interfere with the insertion of the nasal tube. It is suggested that nasal pharyngoscopy or a similar investigation should be included as part of the preoperative assessment for these patients if nasotracheal intubation is anticipated.

Outcomes in facial aesthetics in cleft lip and palate surgery: a systematic review.

BACKGROUND: While there are internationally validated outcome measures for speech and facial growth in cleft lip and palate patients, there is no such internationally accepted system for assessing outcomes in facial aesthetics. METHOD: A systematic critical review of the scientific literature from the last 30 years using PUBMED, Medline and Google Scholar was conducted in-line with the PRISMA statement recommendations. This encompassed the most relevant manuscripts on aesthetic outcomes in cleft surgery in the English language. RESULTS: Fifty-three articles were reviewed. Four main means of determining outcome measures were found: direct clinical assessment, clinical photograph evaluation, clinical videographic assessment and three-dimensional evaluation. Cropped photographs were more representative than full face. Most techniques were based on a 5-point scale, evolving from the Asher-McDade system. Multiple panel-based assessments compared scores from lay or professional raters, the results of which were not statistically significant. Various reports based on cohorts were poorly matched for gender, age, clinical condition and ethnicity, making their results difficult to reproduce. CONCLUSIONS: The large number of outcome measure rating systems identified, suggests a lack of consensus and confidence as to a reliable, validated and reproducible scoring system for facial aesthetics in cleft patients. Many template and lay panel scoring systems are described, yet never fully validated. Advanced 3D imaging technologies may produce validated outcome measures in the future, but presently there remains a need to develop a robust method of facial aesthetic evaluation based on standardised patient photographs. We make recommendations for the development of such a system.