Quantitative 3D maxillary arch evaluation of two different infant managements for unilateral cleft lip and palate.

OBJECTIVE: A two-institution retrospective study was undertaken to determine whether two different prepalatoplasty protocols quantitatively affect maxillary arch morphology in infants with complete unilateral cleft lip and palate (UCLP). DESIGN: Serial maxillary dental casts, obtained at regular intervals through the first 18 months of life from preintervention until palatoplasty were evaluated quantitatively using computer-assisted three-dimensional digitization and analysis for three populations: institution 1 (protocol 1), institution 2 (protocol 2), and unaffected individuals (neither cleft nor treatment). Sequential UCLP patients from institution 1 were matched for age and initial alveolar cleft width, sex and cleft side having been demonstrated to be nonsignificant, with UCLP patients from institution 2 and to unaffected individuals for age for the analysis. SETTING: Both treatment institutions are well-established regional interdisciplinary cleft centers. Institution 1 is located in a tertiary, academic children's hospital in a metropolis within a primarily agrarian region of the Midwest; institution 2 is a freestanding private clinic located in a small city within a primarily agrarian region of an eastern state; the unaffected population is a historic archive acquired in the 1930s. Data acquisition (model digitization) and computer processing were performed at institution 1. PATIENTS: Eighty-five casts of 28 infants from institution 1, 106 casts of 31 infants from institution 2, and 68 casts of 29 unaffected infants were analyzed. All infants had alginate impressions taken prior to intervention and at several additional 6-month intervals after that, consistent with each institution's treatment protocol. INTERVENTIONS: At institution 1, patients with UCLP underwent lip adhesion and placement of a passive alveolar molding plate at 7 weeks of age, definitive cheiloplasty at 7 months of age, and one-stage palatoplasty at 14 months of age. At institution 2, patients with UCLP underwent definitive cheiloplasty at 3 months of age, had no maxillary orthopedics, and had vomer flap hard palate repair at 12 months of age and soft palate repair at 18 months of age. MAIN OUTCOME MEASURES: The outcome measures included directly digitized (cleft segment and hemialveolar ridge lengths) and derived (alveolar base width, alveolar cleft gap, maxillary frenum-alveolar base perpendicular angle, and rates of change over time of digitized cleft segment and hemialveolar ridge lengths) features. The data were assessed by comparing simple linear regression lines and an unpaired, two-tailed t test. RESULTS: Prior to initiating therapy, there were no statistically significant differences between the two populations with clefts. However, both populations with clefts differed significantly from unaffected individuals (p < .001), with increased maxillary base widths and larger perpendicular/frenum angles. At the time of palatoplasty, the two populations with clefts had statistically significant differences between them in the maxillary base width (p < .01) and the cleft gap distance (p < .05). The base width of institution 1 did not differ significantly from that of widths of unaffected children, and that of institution 2 was significantly less, although the latter had already received first-stage palate repair. Alveolar segment growth rates were similar for the greater and lesser segments, respectively, and the left side hemialveolus of both groups. The growth rate for the noncleft side hemialveolus of institution 2 exceeded (p < .05) that of both institution 1 and unaffected patients. CONCLUSION: Two different regimens for the initial management of UCLP can significantly affect maxillary alveolar arch growth with respect to the treatment used and in comparison with unaffected controls.

Applications of the posterior thigh flap.

As our population ages and spinal cord injuries continue at their present rate due to motor vehicle accidents and handgun injuries, the development of pressure sores will most likely increase in frequency. The three major populations at risk to develop pressure sores include the elderly, long-term hospital patients, and neurologically impaired patients. the posterior thigh flap evolved during our experience with the lower extremity muscle flaps. We have used 22 posterior thigh flaps in 21 patients. We have found that it is a reliable flap with a dependable blood supply that can be used in the soft tissue coverage of trochanteric, ischial, and some sacral wounds. In addition, the posterior thigh flap can be used as a pedicled flap in the management of heel and foot wounds. In this review, the anatomy and application of the posterior thigh flap are elaborated.

Trigger finger secondary to anomalous lumbrical insertion: a case report and review of the literature.

Trigger finger is a relatively common clinical entity, most frequently caused by stenosing tenosynovitis. Several other conditions not related to tenosynovitis also have been described as a cause of triggering, and these have been reviewed. We present a rare anomaly of the fourth lumbrical muscle insertion as a cause of triggering of the right little finger. This was completely relieved following excision of the anomalous muscle. This rare anatomic variant should be added to the list of potential causes of trigger finger.

Calcification of breast implant capsule.

We have presented a case of bilateral capsular calcification, an extremely rare but clinically important complication of augmentation mammoplasty. Little is known about its pathogenesis, but it is believed to be related to the presence of molecular silicone and/or Dacron patches in the pericapsular environment. This condition may mask calcifications of the breast due to carcinoma, and it often exacerbates the symptoms of capsular contracture. We recommend removal of the calcified capsules and replacement of the implants in the submuscular position.

Physical, biomechanical, histologic, and biochemical effects of rapid versus conventional tissue expansion.

Clinical tissue expansion has been quite successful but takes 2 to 3 months. This study compares the effects of a conventional tissue expansion regimen of 6 weeks with an accelerated regimen of 2 weeks in the dog model, which is biomechanically similar to the human. In 22 dogs, the skin expanded 34.4 percent in the 2-week and 35.8 percent in the 6-week protocol, excluding stretch and recruitment. There was thinning of the panniculus carnosus in the 6-week group and otherwise no significant decrease in dermal thickness in either group. The biomechanical properties of elasticity and creep did not differ in expanded skin from both groups, while stress/relaxation mildly decreased from a control value of 53.5 percent to 48.8 percent in the 6-week group (p less than 0.05). Collagen activity was increased in both the 6-week and the 2-week groups (p less than 0.001) over nonexpanded skin, and immunohistochemical staining with a monoclonal procollagen antibody demonstrated collagen synthesis by dermal fibroblasts in both groups. We conclude that rapid tissue expansion did not demonstrate any deleterious effects when compared with a conventional regimen.

Animal models of human tissue expansion.

Although tissue expansion is being used extensively in humans, many fundamental scientific questions remain to be addressed which can best be answered using an animal model. Presently, no single animal has been identified for research of this kind which is comparable both subjectively and objectively to humans. This study evaluates the skin of the rat, guinea pig, pig, and dog and identifies the dog as the best model based on biomechanical and practical considerations.

A new instrument for serial measurements of elasticity in hypertrophic scar.

The "elastometer," a hand-held device, was designed and constructed to permit noninvasive quantification of the elastic properties of normal skin or hypertrophic scar. The instrument utilizes a constant-tension spring and a sensitive strain gauge to distract two loci of skin. Normal skin from 15 dogs was measured in vivo with the elastometer and in vitro using standard tensometry. The results correlated significantly by regression analysis (r = .87, p less than .01, 1/Young's Modulus of Elasticity v percent stretch in vivo). Normal dorsal hand skin was tested elastometrically in six volunteers of both sexes. Values (units: percent stretch) ranged from 29 to 43 with a small standard error (+/- 4%). In nine patients with hypertrophic burn scars, the mean percent stretch was 16.2 +/- 1.8 v 37.9 +/- 6.5 in the mirror-image normal skin. There was no overlap between the two groups. There was a trend towards higher values in older scars. Elastometric measurements have increased appreciably in some burn scars undergoing treatment. The elastometer should be useful in documenting objectively the spontaneous maturation of burn scars and/or their response to treatment.

Role of radionuclide imaging in the evaluation of wrist pain.

The cause of hand and wrist pain can be difficult to determine, especially when standard radiographs are normal or show only nonspecific changes. This study reports the effectiveness of radionuclide imaging in the evaluation of patients with hand and wrist pain of uncertain cause. Eighty-eight patients with hand and wrist pain and initially normal standard radiographs were evaluated prospectively by additional radiographic methods including the following: routine tomography, wrist arthrography, computerized tomography, or magnetic resonance imaging. Each patient also had bone scintigraphy. The diagnosis established by clinical assessment and by other imaging methods was then compared with the scintigraphic findings. The presence or absence of focal scintigraphic abnormalities correlated with the presence or absence of focal pathology definable by the conventional methods in 88% of patients. As expected, scintigraphy was chiefly of value in defining the locus of an injury or other process in the wrist, rather than the nature of an abnormality. The scintigrams were abnormal in 95% of cases involving complete intrinsic ligament ruptures and fractures and were normal in 96% of patients with no definable injury. Scintigraphic findings correlated poorly with partial intrinsic ligament injuries and in cases of synovitis. Radionuclide imaging is a sensitive means of detecting focal lesions in patients with hand and wrist pain of unknown cause.

Ganglions of the hand and wrist.

The ganglion is the most common soft tissue tumor of the hand and wrist, originating from the joint capsule or tendon sheath. Accurate diagnosis and proper treatment of these entities require a thorough knowledge of the anatomy of the wrist and hand as well as of the ganglion itself. Definitive therapy is based on total surgical removal of the cyst and its connections to the joint or tendon sheath.

Persistence of injectable collagen in the human larynx: a histopathologic study.

This is a report of the histologic findings in a human larynx that had undergone collagen injection for glottic insufficiency 14 months prior to autopsy. The patient's management before augmentation with collagen included extended supraglottic laryngectomy, radiation therapy, and Polytef injection. Connective tissue changes secondary to other forms of treatment were apparent bilaterally and changes limited to the site of collagen injection were identified. There have been reports of persistence of injected collagen in the canine larynx at 1 year but this is the only study documenting persistence in a human subject. The implant appeared homogeneous and was easily distinguished from host collagen and the reactive fibrosis associated with particulate Polytef. These findings are similar to those observed in the canine model and suggest that there is persistence of injected collagen in the human larynx.

Lateral asymmetry: hard or simple-minded?

A letter or a three-dimensional shape was presented in the center of the visual field. Following the off-set of this stimulus either a comparison letter or a three-dimensional shape was flashed briefly in either the right or left visual field. The subject's task was to respond SAME, or DIFFERENT. The stimuli could be in the same plane, rotated in two dimensions (letters) or in three dimensions (three-dimensional shapes). The left visual field presentations (right hemisphere) of same-pair matches for letters only produced faster reaction times and fewer errors. In all other conditions reaction time measures showed no hemisphere effects. By contrast, error score data indicated that the left hemisphere was overwhelmingly more accurate.

Effect of Bordetella pertussis vaccination in mice and the isolated tracheal response to isoprenaline.

The administration of Bordetella pertussis vaccine to mice has been associated with the development of an impaired beta-adrenoceptor responsiveness and in many respects has resembled human asthma. Trachea (n = 12) were isolated from Swiss-Webster mice 5 days following the intraperitoneal administration of 2 x 10(9) B. pertussis organisms. The tracheal smooth muscle response to carbachol was measured and compared with that found in trachea from unvaccinated mice (n = 15). The contractile response was similar in both groups. The tracheal smooth muscle relaxant effects of isoproterenol were measured in these two groups. The EC50 value for isoprenaline (6.5 x 10(-7) M) in trachea from B. pertussis treated mice was significantly (P < 0.05) greater than that noted in the control animals (2.3 x 10(-7) M). These studies demonstrated that in tracheal smooth muscle isolated from B. pertussis vaccinated mice, the relaxant effects of isoprenaline are impaired.