Correction of cryptotia using tissue expansion.

The anatomy and surgical correction of cryptotia are reviewed. Another technical procedure using retroauricular tissue expansion is presented. This method allows release of the auricle and construction of the auriculocephalic sulcus without the problems associated with older soft-tissue techniques, e.g., incomplete correction, multiple scars, poor color match of skin grafts, and donor-site morbidity.

A convenient infant tourniquet.

A simple, readily available blood pressure cuff designed specifically for neonates, infants, and small children is recommended for use in hand surgery as a tourniquet. Most institutions that have pediatric medicine or surgical departments have these as stock, and thus the problem of illfitting standard cuffs can be avoided where a tourniquet is needed.

Microsurgical reattachment of totally amputated ears.

At a time when microsurgical reattachment of amputated limbs is commonplace, successful reattachment of total ear amputations is rare. Avulsed vessels, small diameters (0.3 to 0.7 mm), and technical difficulties provide primary obstacles. Three clinical cases of ear reattachments are presented which encompass the clinical spectrum of an uncomplicated success, a salvage of an impending failure, and a late failure due to venous thrombosis. In all cases there was difficulty with identification of vessels, with differentiation of arteries from veins, and in the performance of venous anastomoses. Vein grafts were necessary in two of the three patients. Anticoagulation was essential in alleviating venous thrombosis. Medicinal leeches (Hirudo medicinalis) were used to salvage one case with venous thrombosis. Despite the technical difficulties and long operative times, successful microvascular reattachment of an amputated ear is superior to any other means of reattachment or reconstruction.

Aplasia cutis congenita: failed conservative treatment.

Large scalp defects in aplasia cutis congenita present a management dilemma. In these lesions, prolonged conservative treatment may cause as much risk as does operative treatment. As a result of our experience, we suggest that one should be prepared to undertake early surgical intervention, rather than prolonged conservative treatment, for larger defects. Decreasing the size of the defect should decrease the risk of complications, since these appear to be related. The management of this condition should be a compromise of both operative and conservative modalities.

Osseointegration in sinus-forming bone.

Osseointegration, using bone-anchored titanium fixtures, is a well-established technique for both intraoral and craniofacial prosthetic rehabilitation. The use of this technique in children can be complicated by craniofacial growth and sinus development. This study evaluates the effects of sinus formation and growth on the fate of osseointegrated titanium fixtures in the growing porcine model. At 3 weeks of age, six Landrace White cross male pigs had a 3.75 x 3.0 mm titanium fixture (Noblepharma) inserted into their right frontal bone where the right frontal sinus would subsequently develop. Preoperative CT scans with three-dimensional reconstructions were used to determine the insertion site. To follow the effects of growth and sinus formation, CT scans with three-dimensional reconstructions and cephalometric radiographs were taken at 1, 3, 6, and 9 weeks postoperatively and at sacrifice. The pigs were sacrificed serially, and direct osteometric measurements were taken to determine skull symmetry. All skulls were sectioned, and osseointegration was determined clinically, radiologically, and histologically with light and scanning electron microscopy. Five of the six fixtures osseointegrated. There were no apparent growth disturbances due to the fixtures. As growth progressed, the osseointegrated fixtures submerged into the frontal bone in a posteroinferior direction to become completely intraosseous 14 weeks after insertion. As the frontal sinus pneumatized, the fixtures remained osseointegrated, but progressive amounts of the fixtures became exposed in the sinus. From this study it would appear that osseointegrated titanium fixtures do not have any effect on calvarial growth and gradually submerge into the growing bone. As sinus development ensues, the fixtures remain integrated but become partially exposed within the sinus.(ABSTRACT TRUNCATED AT 250 WORDS)

Concertina effect and facial aging: nonlinear aspects of youthfulness and skeletal remodeling, and why, perhaps, infants have jowls.

The effect of aging on the orbitomaxillary region is evaluated in the present study. The observation was made that infants look like aged individuals in terms of the midface soft-tissue contours of the midface. Because preliminary work has shown that the facial skeleton remodels throughout life, this observation led to the hypothesis that infants and older individuals appear similar because they have comparable skeletal dimensions, specifically in the orbitomaxillary region. The design is a retrospective analysis of three-dimensional computed tomographic scan data. Three groups of male subjects were studied: infant, ages 1 to 12 months (n = 5); youthful, ages 15 to 24 years (n = 13); and old, ages 53 to 76 years (n = 12). Orbital and zygomaticomaxillary vertical dimensions were measured in both medial and lateral planes between fixed anatomical landmarks. Results were compared by using analysis of variance, Student-Newman-Keuls, and Student's t tests. The findings show that skeletal remodeling is such that the ratio of the maxillary height to orbital height is greatest during youth; during infancy and old age, there is a short maxilla relative to a larger orbit. This finding is significant in the medial plane from orbital rim to pyriform aperture (p < 0.05). Furthermore, there is an actual decrease in vertical maxillary height in this medial plane (p < 0.01) from youth until old age, which occurs secondary to normal skeletal remodeling in the dentate individual. The combined effect of downward expansion of the orbital shelf and the upward migration of the pyriform effectively decreases the space available to support the overlying soft tissues of the midface. An accordion-like or "concertina" effect may lead to compression or restriction of the facial soft tissues over a relatively deficient bony platform. These results highlight the importance of skeletal remodeling in determining the soft-tissue contours of the aging face. The process of skeletal remodeling may also allow for a tentative definition of facial youthfulness. Infants are born with a short maxilla relative to a large orbit, and the maxillary wall is angled posteriorly. This ratio and angle change from infancy until youth, when there is a balance between the bony skeletal support and the overlying soft-tissue envelope, i.e., the skin, facial muscles, and adipose tissue. It is when skeletal remodeling continues past this point that a disharmony occurs. Because the ratio of maxilla/orbit, and the angle of the maxillary wall, in the older person reverts toward that of an infant, the attainment of youth occurs partly in a nonlinear or multimodal manner. This work is part of an emerging concept of facial aging, which we would term an integrated model of facial aging. This model allows facial aging to be viewed as a biological "system," in which there are primary and secondary factors that interact in the process of facial aging. Additional research such as this continues to suggest the importance of bony remodeling in facial aging.

Relative maxillary retrusion as a natural consequence of aging: combining skeletal and soft-tissue changes into an integrated model of midfacial aging.

The contribution of maxillary retrusion to the formation of the nasolabial fold is evaluated in the present study. Clinical observation of patients from the craniofacial unit with concomitant maxillary retrusion revealed prominent signs of midfacial aging: specifically these individuals displayed a prominent nasolabial fold at an early age. This observation led to the hypothesis that relative maxillary retrusion occurs as a normal feature of the aging process. Retrusion of the lower facial skeleton below the soft tissue of the nasolabial fold causes the nasolabial fold to appear more prominent. To test this hypothesis, computed tomographic data were assembled retrospectively and included both males and females, young and old. The age range of the males (n = 14) was 18 to 24 years (young) and 43 to 57 years (old); the age range of the females (n = 14) was 15 to 30 years (young) and 43 to 57 years (old). All individuals had complete upper dentition and had no bony facial injury. Computed tomographic data were reconstructed into three-dimensional images, and a technique was developed to create a standardized lateral view which eliminated rotational variance. Analysis of anterior-posterior changes showed that there is a tendency for the lower maxillary skeleton at pyriform to become retrusive with age relative to the upper face in individuals with complete dentition. Findings were very significant for both males and females (p = 0.0001 and p = 0.002, respectively). In both groups, a slight increase in vertical maxillary dimension was noted, consistent with previous studies. It is suggested that relative maxillary retrusion is a factor in the development of the nasolabial fold. The skeletal features of normal midfacial aging can be combined with the soft-tissue features such as ptosis and atrophy into an integrated model of midfacial aging. A model such as this has significance regarding both the timing and choice of procedure used to restore the aging midface.

Closed flexor tendon rupture in the palm: an unusual but predictable clinical entity.

Closed intratendinous ruptures of flexor tendons are uncommon. Two such cases that occurred within the lumbrical origin are reported. Accurate history taking and clinical examination usually enable the site of rupture to be determined. Ultrasound examination can also help to localize the site. The role of the lumbrical, extrinsic flexors and trauma in the aetiology of the rupture are discussed.

Tissue expansion for the treatment of complete syndactyly of the first web.

Tissue expansion is a well-established technique for the management of soft tissue deficiencies. In congenital hand surgery the construction of an adequate first web is paramount. We used tissue expansion in four hands in three patients with complete complex syndactyly of the first web space. Two of these patients had Apert's syndrome and the other an isolated mitten hand anomaly. The expander is preferably placed early in life so that first web construction is completed in the first year. Tissue expander ports are left exposed. There have been no infections, flap or expander loss in our series.

A review of nasolabial flaps for intra-oral defects.

The nasolabial flap has been used in 23 patients for reconstruction of moderate size intra-oral defects. Versatility in design of the flap is allowed by the numerous blood vessels supplying the nasolabial skin. Flap vascularity was reliable, there being no cases of total loss and three cases (12%) of partial necrosis. Recurrence of tumour occurred in 8.7% of cases and in those operated in the first instance for recurrence, there was no further local disease. There were minor problems of intra-oral hair growth, donor site distortion and obstructive sialadenopathy. However, because of its simple elevation, proximity to the defect and versatility, we believe that the nasolabial skin flap is a useful procedure for closure of selected intra-oral defects.

Echinoidea tenosynovitis.

Suppurative tenosynovitis involving the digital fibrous flexor sheaths in the hand can be a devastating problem. A case is reported of tenosynovitis resulting from Echinoidea sp. (sea urchin) spines. The need for awareness of flexor sheath penetration is stressed. Early aggressive operative intervention by a hand surgeon will minimize the subsequent morbidity.

Finger injuries to children involving exercise bicycles.

OBJECTIVE: A previously unreported source of injuries to children, the exercise bicycle, is identified and the associated injuries and their treatment are described. DESIGN: A retrospective review of clinical records and the records of the Victorian Injury Surveillance System. SETTING: The Plastic Surgery Unit of the Royal Children's Hospital, Parkville, Victoria. PATIENTS: Seventeen children with finger injuries from exercise bicycles presented to the Emergency Department of the hospital and one presented to one of us (K L M) at his private practice. Sixteen of the 18 children were under five years of age; 10 were less than two years of age. Five times as many boys as girls were injured. INTERVENTIONS: Fourteen children required surgical treatment of their injuries. RESULTS: Four children had superficial injuries not in need of surgical repair. Eleven children had single digit injuries--five had injuries that were repaired by suture; five had complete avulsion of the tip of the digit that required flap graft repair; and one child underwent amputation of the index finger. Three boys had multiple digit injuries, each one requiring the amputation of a digit and repair of other digits. Two of these boys underwent replantation of a digit; only one replantation was successful. CONCLUSIONS: The most dangerous parts of the exercise bike were the wheel, the chain and the sprocketwheel. Design modifications and education of parents about the risks for children playing near exercise bikes are warranted.

The "chemical leech": intra-replant subcutaneous heparin as an alternative to venous anastomosis. Report of three cases.

Three successful cases of distal finger replantation are described where suitable veins were unavailable for anastomosis after arterial flow had been re-established. To prevent infarction, calcium heparin was injected subcutaneously into the replants at intervals over 9 days. This allowed the venous blood to escape into the dressings while an adequate microvenous circulation was re-established, thus simulating the effect of a leech. Complete survival of all three distal replantations was observed. No attempted case has been unsuccessful. The procedure is simple and can be administered by the nursing staff. It avoids some of the problems associated with the use of medicinal leeches and systemic heparin. Applications of this technique in other areas of replantation and flap surgery are suggested.

Hide and seek: pre-operative ultrasonic localization of non radio-opaque foreign bodies.

Ultrasound has long been used as a diagnostic and therapeutic tool in surgery. We have extended its use to hand surgery, where is has several applications. Non radio-opaque foreign body extraction is invariably a frustrating exercise of 'hide and seek'. Accurate pre-operative localization with ultrasound illustrating size, shape, depth, soft tissue and bony relationships can ensure rapid and complete removal. Several cases are presented to demonstrate the use of ultrasound for the detection of non radio-opaque foreign bodies. The technique used will be described. We feel pre-operative localization by ultrasound is a useful technique to assist with the removal of non radio-opaque foreign bodies.

Experimental calvarial growth disturbance by micro-plate and screw fixation.

A study was designed to help ascertain the effects of rigid internal fixation in the growing skull. Five piglets underwent plating of the left coronal suture at 3 weeks of age. At the time of surgery metal markers were placed to follow bone growth. Cephalometric radiographs, direct osteometry at sacrifice, gross pathological examination and specimen radiography revealed a localized disturbance of growth. There was a restriction of sutural displacement and appositional bone growth at the site of the plate. Local restriction of sutural growth was almost complete during the experimental period. There was an alteration to a 'mature' suture morphology, without synostosis, of the suture on the plated side not seen on the control side. A plagiocephalic pig was not produced nor was there an orbital deformity. A large local contour deformity developed and by the end of the experimental period the plate had become completely incorporated in bone. These effects were statistically significant as well as clinically significant. The clinical use of this type of fixation in reconstructive surgery of the infant craniofacial skeleton is questioned in light of the result.