Long-term assessment of early alveolar bone grafts using three-dimensional computer-assisted tomography: a pilot study.

Fifteen patients with complete unilateral cleft lip and palate who had primary alveolar bone grafting were studied with computer-assisted tomography at a mean age of 12 years. Keeping the maxillary alveolar crest parallel to the plane of the scan, 1.5-mm cuts of the maxilla were made from the infraorbital rim to the gingival third of the crowns of the teeth. A single operator reformatted the data into three-dimensional images using the Maxiview 3200 computer workstation. This allowed examination of the position, size, and spatial relationship of the grafted area and quantification of the amount of bone coverage of root surface and bone height of the alveolus in or adjacent to the graft site. Ten patients showed a lateral incisor in the line of the cleft. The average bony coverage of these tooth roots was 76.5 percent. In the five patients in whom there was lateral incisor agenesis, the canine root had average bony coverage of 82.6 percent. The average height of bone at the lateral incisor was 8.7 mm; at the canine, 14.1 mm. In two patients in whom there was only 42 percent tooth root coverage, the teeth were still viable, stable, and without mobility. Computed tomographic (CT) scans of the 15 patients demonstrated good graft survival with adequate volume. The functional and aesthetic status of the dentition in the area of the cleft also was demonstrated.

Dermal and epidermal response to soft-tissue expansion in the pig.

To evaluate the dermal and epidermal response to soft-tissue expansion in the pig, round tissue expanders were placed dorsally under tattooed patterns and inflated over 6 weeks. Surface area, skin thickness, histologic changes, and collagen content were evaluated at 6-week intervals. Epidermal thickening and dermal thinning were observed. Dermal thinning persisted 36 weeks after expansion. Dermal collagen content was decreased, although collagen density remained unchanged. Total collagen content calculated within an expanded square grid increased. These data support a theoretical gain in the dermal layer as well as epidermal layer in response to tissue expansion.

Experience with electrothrombosis in the treatment of angiomas.

We report unsatisfactory results of electrothrombosis for the treatment of venous angiomas. After we reviewed a report of successful use of electrothrombosis for treating cirsoid angiomas of the face and scalp and varices of the leg, a clinical trial was begun with 6 patients in whom previous conventional surgery was relatively unsuccessful and in whom further surgery had not been recommended owing to the high risk or probability of unsatisfactory results. Two patients had objective clinical improvement, resulting in no further treatment in 1 patient and allowing secondary surgical correction in the other. Four patients had no significant improvement. We now recommend and will continue further laboratory research with electrothrombosis for the treatment of angiomas before treating additional clinical cases.

Radiographic analysis of the midface of a stillborn infant with a unilateral cleft lip and palate.

The midface of a full-term stillborn infant with a right complete unilateral cleft lip and palate was studied with plain-film radiography and tomography, xeroradiography, and computerized axial tomography. Gross skeletal and soft-tissue deficiencies on the cleft side were evident as compared to the noncleft side and involved the entire bony maxillary complex and antrum, the orbit, and the nasal pyramid and intranasal structures. The area on the cleft side was 19 percent less than the noncleft side, and the maximal anteroposterior dimension was 16 percent less. The cleft bony palatal shelf was 12.5 mm wide compared to 20 mm on the noncleft side. The findings demonstrate the deficient and abnormal functional matrix inherent in the cleft condition.

Nasal dermal sinuses and cysts.

Nasal dermal sinuses and cysts are best detected by careful clinical inspection of the face for tiny ostia or widening of the nasal bridge and by detailed radiologic evaluation of the nasal bones, nasal septum, crista galli and falx. The sinus tracts may remain superficial to bone, extend partway into the nasal septum or pass far posterosuperiorly beneath the nasal bones, through the foramen cecum, and anterior to or through a bifid crista galli to lie between the leaves of the anterior falx. Glabellar sinuses may pass through the midline frontonasal suture to the foramen cecum, crista galli and falx. These courses correspond to embryonic midline diverticula of dura (with or without arachnoid and brain tissue) that protrude into a) the fonticulus nasofrontalis and b) the prenasal space situated behind the nasal bones and in front of the nasal capsule, occasionally reaching the surface ectoderm. Persistence of variable portions of these diverticula results in the clinical spectrum of nasal sinus tracts, fibrous cords, interposed (epi)dermoids, meningoceles, encephaloceles and 'gliomas'.

The long-term survival of onlay bone grafts--a comparative study in mature and immature animals.

Onlay bone grafting was studied with regard to age of the animal and type of bone graft used (membranous bone or endochondral bone with or without periosteum, and decalcified homograft). The bone grafts were placed in the nasal dorsum in a group of mature and immature New Zealand rabbits. Volume displacement studies were carried out. Graft survival was greatest in membranous bone and least in endochondral grafts. There was significantly greater absorption of endochondral grafts in immature animals than in the mature group. Presence or absence of periosteum did not make a significant difference in graft survival.

Anatomy of the orbicularis oris muscle in incomplete unilateral cleft lip based on histological examination.

Histological sections of tissue removed from three incomplete cleft lips at the time of repair, a nature's scar line, and a noncleft lip were examined serially in the horizontal and saggital planes. The findings confirm previous data from electrical stimulation studies of clefts and a three-dimensional histological model of the orbicularis oris in a complete cleft lip. There is a disorganized mass of muscle fibers with numerous dermal insertions and no evidence of well-defined muscle bundles running parallel to the cleft margins. The fibers are somewhat hypoplastic and less abundant than those present in noncleft lips.

Intravenous extravasation injuries: the effectiveness of hyaluronidase in their treatment.

This experimental study in the rabbit establishes a reliable model for the production of skin necrosis analogous to intravenous extravasation injuries in humans. The effectiveness of hyaluronidase in reducing the extent of tissue injury is examined, using several different toxic agents.

The anatomy of the orbicularis oris muscle in unilateral cleft lip based on a three-dimensional histologic reconstruction.

The midface of a full-term, stillborn infant with a right complete unilateral cleft lip and palate has been examined by serial histologic sections and a three-dimensional model has been created. The arrangement of the orbicularis oris muscle fibers observed differs markedly from previous descriptions. There is a chaotic arrangement of muscle fibers with no separate muscle layers distinguishable. Muscle fibers on both sides of the cleft insert into the dermis, although the amount of muscle on the medial side is quite sparse compared with the lateral side. There is no evidence of muscle bundles paralleling the cleft margins. An unexpected finding is a significant number of muscle fibers streaming over the cleft ala. In view of these findings, differing as they do from previous reports, there would seem to be strong justification for histologic investigation of the arrangement of muscle fibers in cleft lip to be repeated as further specimens become available.

Functional cleft lip repair: a sequential, layered closure with orbicularis muscle realignment.

A lip repair based on anatomic and electric stimulation studies of the orbicularis muscle in unilateral cleft lip has previously been reported by one of the authors. Following some early modifications, this technique has been used on 125 primary lip repairs. The details of the present technique are described here. The advantages of the procedure, in addition to its functional reconstruction of the orbicularis muscle, are in its applicability to clefts of all widths and superior scar formation. The sequential nature of the procedure and freedom from commitment to a fixed, measured pattern at the outset makes the teaching of the method easier and the achievement of a pleasing result more predictable.

Incorporation of the W-plasty in repair of macrostomia.

Macrostomia is an uncommon deformity, the features of which have been outlined. The importance of accurate preoperative marking of the normal landmarks and three-layered repair are stressed. Our technique combines triangular mucosal flaps at the commissure, reconstruction of the oral and buccal musculature, and skin closure using a W-plasty. This skin closure results in a less conspicuous scar while still preventing lateral drift of the commissure. We feel this is an effective surgical procedure that yields consistent clinical results.

The case of early bone grafting in cleft lip and cleft palate.

To date there are conflicting reports in the literature as to the efficacy of early maxillary orthopedic procedures and primary osteoplasty in newborns with complete clefts of the lip, alveolus, and palate. Ross accounts for the disagreement by stating that the critical variable may be the surgical procedure utilized in closing the palate, not necessarily the placement of the graft. Friede has also postulated that perhaps it is principally a difference in the graft techniques. Cephalometric evaluation of our sample at 13 years 11 months of age compared with a like sample wherein the primary osteoplasty had not been done showed the two samples to be clinically the same. We feel that in utilizing our sequence of procedures and carefully monitoring facial growth of these children we do not adversely influence facial growth and, in fact, present a more favorable maxillary segment alignment and teeth in better overall occlusion than if we had not done these procedures. From our results, we conclude that there should be no condemnation of the principle of this treatment because of individual failings and failures. Although differences in techniques can and do influence results, the concept of maxillary orthopedics and primary osteoplasty need not be thrust aside even if some techniques are found wanting.

Lymphangioma circumscriptum--a clinicopathological review.

Our experience with 3 extensive cases of lymphangioma circumscriptum and a literature review are presented. Excision of these lesions should always be thorough and include all subcutaneous tissue down to fascia. Frozen section may be helpful. Partial excision of troublesome areas or excision of the large deep cystic areas may be indicated in very extensive lesions. When these conditions are satisfied, the result of surgery should improve.

Congenital midline nasal muscle with associated nasal deformity.

A case is presented of a congenital nasal deformity consisting of a midline nasal muscle, alar cartilage defect, and partially obstructed nostril. The embryology of nasal development is reviewed, and an attempt is made to explain this unique anomaly.

The spread of sensibility into previously anesthetic skin following intercostal flap transfer in a paraplegic.

Sensibility extending into previously anesthetic sacral skin is reported two years following the transfer of a neurovascular intercostal flap in a 13-year-old paraplegic.

Experience with the Tajima procedure in primary and secondary repair in unilateral cleft lip nasal deformity.

The method of cleft lip nasal deformity repair described by Tajima and Maruyama appears to produce superior results compared to other methods we had tried. A modified technique of suture placement, aided by our special nasal retractor, greatly simplifies suture placement. In both primary and secondary cases, significant and maintained improvement has been achieved with what is a comparatively simple and standardized procedure.

Muscle repair in unilateral cleft lip, based on findings on electrical stimulation.

The appearances, distribution, and direction of muscle in the unilateral cleft lip as indicated by electrical stimulation are described. The findings differ from those reported by Fara and associates in their dissections in that functionally the fibers do not appear to parallel the margin of the cleft. Based on these findings, a method of layer-by-layer, step-by-step closure of the unilateral cleft lip is described that attempts to split the orbicularis bulge and advance the lateral muscle into the philtrum to a position more nearly imitating the direction and extent of the muscle in a normal lip.