The van der Woude syndrome in a large kindred: variability, penetrance, genetic risks.

The van der Woude syndrome was studied in a seven-generation kindred. Lip pits were the most common manifestation of affected persons. They occurred in 88% of the affected and were the only manifestations in 64%; clefts of lip and palate occurred in 21%. Penetrance was 96.7%. Careful examination showed minor manifestations of the syndrome in several individuals who had considered themselves unaffected. The distribution of manifestations and the risk to off-spring differed appreciably from that reported in the literature. The implications of these findings for genetic counseling are discussed.

Immediate correction of sagittal synostosis.

A technique for correction of sagittal synostosis with achievement of an immediately pleasing cosmetic result is presented. Even with replacement of bone and no attempt to inhibit bone union, premature reclosure does not occur. Moss' theory of dural tensions is discussed to explain the effect.

Floating C-shaped orbital osteotomy for orbital rim advancement in craniosynostosis: preliminary report.

A method of lateral orbital rim advancement is described for periorbital deformities associated with coronal and metopic synostosis in infants. The technique offers the advantages of a smooth lateral rim contour and improvement in accompanying malar recession. In 13 patients with follow-up periods of up to 2 years following surgery, improved orbital contour has been appreciated. Further observation is warranted to determine whether this improvement will last into adulthood.

Alternative techniques in the treatment of unilateral coronal synostosis.

Premature closure of one coronal suture results in bilateral abnormalities. There is always ipsilateral flatness of the orbital rim, and contralateral frontal bossing is often found. The authors have employed three operative techniques for correction of unilateral coronal synostosis: frontal bone overlay, lateral canthal advancement, and the tongue-in-groove procedure. The choice of operative technique depends upon the exact deformity to be corrected. The authors believe that altering the relations between the bone and dura by techniques such as radical remodeling and dural plication may improve the results of surgical correction of craniosynostosis.

Late surgical treatment of unilateral coronal synostosis using methyl methacrylate.

Three techniques combining the shaping of calvarial and facial bone with onlay of methyl methacrylate are presented for use in the late treatment of unilateral coronal synostosis deformities. The procedures described are suggested as possible alternatives to extensive bone repositioning procedures. They have the advantage of being quicker and are therefore potentially safer operations. Acrylic is malleable and does not resorb; thus, permanent superior esthetic results may be achieved. The two most serious risks when using this technique are infection and limitation of growth. The risk of infection may be reduced by attaching the acrylic implant securely to surrounding bone, under sterile conditions, beneath well-vascularized skin. Growth limitation may be obviated by not placing acrylic across sutures in children with enlarging skulls.

Indications for neck dissection in carcinoma of the lip.

In the past, neck dissections have been recommended only when nodes were clinically palpable or when they became so. A retrospective ten year study of thirty-seven patients with carcinoma of the lip and with an unusually high mortality has allowed reevaluation of indications for neck dissection. (1) Ten of thirty-seven patients died of this disease and nearly all of the ten died with and because of regional metastases. (2) Seven patients with nonpalpable nodes initally had nodal metastases later which, despite neck dissection at that later time, proved lethal. (3) Two patients who, despite nonpalpable nodes, had undergone neck dissections and were found to have occult bilateral nodal metastases were effectively cured with early neck dissection. This suggests that early bilateral supramohyoid neck dissections for small carcinomas of the lip and ipsilateral radical neck dissections for large primaries may yield higher cure rates than currently achieved.

A salvage technic for extruded arteriovenous shunts.

In view of the often prolonged periods of pretransplantation and chronic dialysis, every effort should be made to maintain existing arteriovenous shunts or fistulas and to salvage eroded ones when possible. The transposition of unwounded bipedicle flaps or small regional rotation advancement flaps over exposed cannulas is a surgical technic that can salvage eroded shunts and prevent their extrusion and removal.

An adjunct to mammoplasty: the pectoral muscle flap.

The pectoralis major muscle has overcome many of the complications of augmentation mammoplasty after subcutaneous mastectomy. It places the implant deep to prevent skin slough and irregularities in skin surface contour. The flap eliminates abnormal implant posture when the pectoralis major is contracted. The short (5 to 7 days) staging of the procedure allows sealing of the pocket from external innoculation of bacteria while preventing unretrievable skin and nipple shrinkage.

Proteolytic enzymes as adjuncts to antimicrobial prophylaxis of contaminated wounds.

When a tissue is injured, its vessels exhibit a marked increase in vascular permeability. Blood proteins, including fibrinogen, traverse the vessel walls and lead to the development of a surface coagulum. This inflammatory response continues until primary closure of the wound edges is accomplished. The thickness of the surface coagulum is roughly proportional to the time interval between wounding and closure. This coagulum encompasses the surface contaminants, preventing contact with either topical or systemic antibiotics. The presence of this surface coagulum limits the time in which antibiotic prophylaxis is effective. At three hours after injury, antimicrobial prophylaxis of contaminated wounds has no therapeutic value. Hydrolysis of the protein coagulum by proteolytic enzymes enhances the activity of the antibiotic in experimental wounds. The success of proteolytic enzymes as adjuncts to delayed antibiotic treatment can be correlated with the clot lysis activity of the enzymes in vitro. Travase, the most potent fibrinolytic enzyme, is the most effective adjunct to delayed antibiotic therapy of contaminated wounds. In contrast, the active enzymes found in Elase, which exhibit no significant clot lysis activity in vitro, do not potentiate the activity of antibiotics in wounds subjected to a delay in treatment. Travase prolongs the period of effective topical antibiotic action for at least eight hours in experimental contaminated wounds. The therapeutic merit of Travase is also apparent when the antibiotic is administered systemically. Travase shows promise as an adjunct to a variety of antibiotics that are effective against both gram-positive and gram-negative organisms. The results of these experimental studies support our belief that clinical studies support our belief that clinical studies should now be initiated to test the therapeutic value of Travase as an adjunct to antibiotics in heavily contaminated wounds subjected to an unavoidable delay in treatment.

A more reliable gram staining technic for diagnosis of surgical infections.

The purpose of this study was to identify pitfalls in the Gram staining technic that limit its diagnostic value. In our clinical experience, gram-positive organisms were often decolorized too easily. Factors have been identified that alter the susceptibility of gram-positive organisms to decolorization in the Gram staining technic. The age of the bacterial culture, the preparation of the smear, the fixation technic, and the mordant have an important influence on the ease with which gram-positive organisms are decolorized. On the basis of these studies, a more reliable and reproducible Gram staining technic has been developed for the diagnosis of surgical infections.

Early ambulation after skin grafting of depressed wounds of the leg.

Silicone molds can be fitted precisely to skin grafted, depressed surgical defects of the leg and can be secured in place with a tight-fitting elastic support. The gravitational effect and resultant edema under the skin graft can be reduced. Earlier ambulation and better results than have been reported in the past can be obtained.

Galeal-pericranial flaps in head and neck reconstruction. Anatomy and application.

Head and neck deformities of congenital, traumatic, or neoplastic cause often require reconstruction. At the University of Virginia over the past 14 years, we have used galeal, temporalis fascial, and pericranial flaps to correct these defects in more than 150 patients. Dissection of these flaps on both cadavers and reconstructive patients had demonstrated new anatomic findings different from those reported in standard textbooks. The galea is the most superficial layer of fascia. The pericranium is the next tissue layer. It is continuous above and separate from the temporalis muscle fascia. We may, therefore, consider three separate fascial layers for reconstruction. A rich vascular plexus arises from branches of the external and internal carotid arteries. Blood flow is axial to the galea and temporalis fascia. Pericranium has a dual supply from peripheral axial vessels and from perforating vessels from the overlying galea. Galeal, temporalis fascial, and pericranial flaps are reliable, thin, and supple and have a good arc of rotation and minimal donor site morbidity. They may be used to cover bone, cartilage, or implants, may be folded for bulk, may be used to carry blood to poorly vascularized recipient sites, or may be used to nourish bone, cartilage, skin, and mucosal grafts. Their versatility permits a wide variety of potential applications in head and neck surgery.

Surgical management of vascular malformations of the head and neck.

The evaluation and treatment of non-involuting hemangiomas with arteriovenous components and arteriovenous malformations of the head and neck remain difficult. Surgical excision is still the most important and effective method of controlling these lesions. Radiotherapy should never be used. It is ineffective, dangerous, and often complicates any later operation that may be required. Evaluation of vascular malformations with computerized tomography, arteriography, magnetic nuclear imaging, and Doppler mapping will aid diagnosis. Adjunctive hypotensive anesthesia, intraoperative embolization with Gelfoam, and temporary peripheral suture ligations have made the surgical task more manageable. The integration of reconstructive techniques into the surgical program is essential if optimum results are to be obtained. Incisions must be planned so that future flap patterns are preserved. Axial vessels may be needed later. Fascial slings, muscle transfers, nerve grafts, and tissue expansion of adjacent normal tissue may be needed to maintain and restore function and features. Above all, the treatment of each patient requires individual planning. The most common errors in the treatment of vascular hemangiomas result from missed diagnoses and faint-heartedness in tackling the surgical removal of such highly vascular tumors. Many patients go for years without finding a surgeon who will help them. We believe that aggressive surgical treatment offers much to many of these patients.

Pharmacokinetics of a new skin wound cleanser.

Iodophors are effective germicidal agents that have prolonged antiseptic activity in contaminated wounds. A nontoxic surfactant, Pluronic F-68, has been used to formulate a safe and effective iodophor. The parameters necessary to regulate the activity of the iodophor were studied to develop a potent, yet safe bactericidal solution for use in human subjects. The parameters found to be most important were the pH of the solution and the concentration of sodium iodide. Lowering the pH of iodophors increased their stability and antiseptic activity. The free iodine in iodophor solutions prepared with a low pH is predominantly the highly biocidal diatomic iodine (I2). The concentration of iodide regulated the equilbrium of the dissolved iodine between its free and complexed form. Increasing the concentration of iodide in the iodophor lowered the amount of free iodine in solution and enhanced the concentration of the complexed iodide. It is the level of free iodine in an iodophor that determines its antiseptic activity. Low levels of free iodine yielded iodophors that had a slow bacterial kill rate but a prolonged duration of action. Manipulation of these variables permitted the generation of iodophors that varied considerably in their kill rates of bacteria and their duration of antibacterial activity. Iodophors tested in this study demonstrated a distinct superiority to noncomplexed iodine solutions (tincture and aqueous iodine solutions) as wound and skin cleansers.

Quantitative microbiology: its application to hand injuries.

Quantitative microbiologic analysis of civilian hand injuries has been accomplished in thirty-four patients. Most traumatic soft tissue injuries exhibited an insignificant level of contamination. The number of bacteria recovered from most of those wounds was comparable to that encountered in clean elective surgical hand cases. We now view most civilian hand wounds as clean wounds carrying a very low risk of infection. Our patients with traumatic hand injuries are considered candidates for immediate reconstruction, which includes vascular, bony, or neural repair as well as immediate implantation of Silastic rods in preparation for subsequent tendon grafting.

Emergency tracheostomy.

On rare occasions, emergency tracheostomy is indicated to establish an airway. Using a large bore needle as a guide, tracheal intubation is assured with minimal damage to vital structures in the neck.

Biology of infections of split thickness skin grafts.

The purpose of this study was to identify determinants of split thickness skin graft infection. The bacterial count of the experimental wounds was proportional to the incidence of infection in split thickness skin grafts. When the wound was heavily contaminated with 107 organisms, infection developed under most grafts. Graft take frequently occurred in wounds subjected to a lower level of inoculum. The importance of bacterial counts as a determinant of potential skin graft infection was also suggested by a clinical study. We now routinely use quantitative bacterial counts to identify the granulating wounds that are ready for grafting. The type of organism played no significant role in the development of infection.

Mechanical cleansing of contaminated wounds with a surfactant.

Mechanical cleansing of a wound with a sponge soaked in a surfactant has prevented the development of experimental wound infection. The surfactant utilized for wound cleansing is Pluronic F-68, a member of a family of block copolymers called Pluronic polyols. Long-term toxicity studies and clinical trials suggest that this surfactant is safe for human use. Pluronic F-68 is a nonionic detergent that does not have any intrinsic antibacterial activity. Although mechanical cleansing with saline-soaked sponges effectively removes bacteria, it damages the wound and impairs its resistance to infection. The severity of the damage to the skin exerted by the sponge can be correlated with its porosity. Sponges with a low porosity are abrasive and exert more damage to skin than do sponges with a higher porosity. The addition of Pluronic F-68 to even the most abrasive sponges ensures that the bacterial removal efficiency of the sponge scrub is maintained, while tissue trauma is minimized. This dual effect of the surfactant results in a dramatic reduction in the infection rate of contaminated wounds. On the basis of these results, a clinical trial with surfactant-soaked sponges would appear to be indicated.

Development of a plastic surgical teaching service in a women's correctional institution.

A plastic surgical teaching service has been organized at a women's correctional institution to provide a previously unrecognized medical need and to serve a valuable educational function for our residents in training. A total of 177 surgical candidates demonstrating a wide range of reconstructive problems including tattoos, scars, keloids, neoplasms of the skin and hands, deformities of the face and breasts, and numerous disabilities of the hands were identified among 241 inmates requesting examination. Thus far, 116 operative procedures have been performed on 101 patients. Patient acceptance has been high, and the support of prison authorities has been enthusiastic. Persistent efforts to convince legislators of the wisdom of supporting this program financially have only been partially successful and will require further accumulation of sociologic data bearing on the rehabilitative potential of the detained patient with a correctable deformity. Meanwhile, residents in training gain maturity as they provide a very "private" type of service for what has traditionally been considered a very "public" population of patients.

A new filtered sump tube for wound drainage.

A new filtered sump tube has been designed for drainage of collections of fluids from wounds without the danger of infection by airborne contaminants. A two-staged filter has been attached to the vent lumen that removes particulate matter and bacteria from the air that passes through the filter. A clinical evaluation of this tube confirms the superiority of sump drainage as compared with closed suction drainage in the removal of fluids from wounds or cavities.