Schwannomas of the sciatic nerve: A rare and neglected diagnosis. A review of the literature with two illustrative cases.

OBJECTIVE: Schwannomas of the sciatic nerve, which is the largest nerve of the human body, are very rare accounting for ≤ 1% of all schwannomas. They often may raise confusion with other more common causes of sciatica, such as lumbar degenerative and inflammatory diseases or spinal tumors, which may often lead to a late correct diagnosis. PATIENTS AND METHODS: We present two cases of sciatic nerve schwannomas that were recently treated at our Institution, and we review the pertinent English literature on this topic over the last 15 years, yielding twenty three cases to analyze. RESULTS: Even if sciatic nerve schwannomas are a rare occurrence, a thorough clinical and radiological evaluation of the sciatic nerve should be considered whenever a sciatic pain is not otherwise explained. A positive Tinel sign and a palpable mass along the course of the sciatic nerve may be strong clues to achieve the diagnosis. Combined morphological and advanced functional MRI imaging may help to differentiate benign from malignant peripheral nerve sheath tumors, avoiding unnecessary preoperative biopsy. CONCLUSIONS: A standard microsurgical technique guided by ultrasound and neurophysiologic monitoring, allows in most of the cases a safe removal of the tumor and very satisfactory post-operative results for the patients.

Cleft Lip and Palate Repair.

INTRODUCTION: Cleft lip and palate is the most frequent congenital craniofacial deformity. In this article, the authors describe their experience with cleft lip and palate repair. METHODS: Data regarding patients presenting with primary diagnosis of cleft lip and/or palate, between 2009 and 2015, were reviewed. Details including demographics, type of cleft, presence of known risk factors, surgical details, and follow-up visits were collected. Documented complications were reported. Caregivers' satisfaction was assessed with a survey. The survey used to assess satisfaction with cleft-related features was based on the cleft evaluation profile (CEP). In addition, 4 assessors used visual analog scale (VAS) to assess the aesthetic satisfaction. RESULTS: Seven hundred fifty-two patients with primary diagnosis of cleft lip and/or palate underwent surgical correction at "S. Chiara" Hospital, 432 (57.45%) male and 320 (42.55%) female. The most common cleft types in our study were incomplete cleft palate (152 patients) and left unilateral complete cleft lip and palate (152 patients). Associated syndromes were found in 46 patients (6.12%). Cleft lip was repaired using a modified Tennison-Randall technique when the defect was unilateral, whereas a modified Mulliken technique was used for bilateral cleft lip. Cleft palate was repaired using the Bardach technique or Von Langenbeck technique at 5 to 6 months of age. Cleft lip and palate was repaired in several surgical steps. In total, complications were reported in 81 of 752 patients (14.16%). Average fathers' satisfaction score assessed using CEP was 4.5 (lip), 4.8 (nose), 4.7 (teeth), 4.8 (bite), 4.2 (breathing), 4.6 (profile). Average mothers' satisfaction score assessed using CEP was 4.3 (lip), 4.6 (nose), 4.4 (teeth), 4.5 (bite), 4.1 (breathing), 4.4 (profile). Average level of aesthetic satisfaction, assessed using VAS, was 8.7 (fathers), 8.1 (mothers), 7.9 (lay person), and 8.0 (senior cleft surgeon). CONCLUSION: The multidisciplinary management of children with oral cleft determinated good results, in terms of satisfaction and aesthetic appearance. From our experience, periosteoplasty and lip-adhesion are key surgical techniques.

Deforming Mucocutaneous Leishmaniasis of the Nose.

The authors present a clinical report of deforming mucocutaneous leishmaniasis of the nose in a native American woman, left untreated for 25 years. The nose was reconstructed using the local tissue displaced as flaps, and using cartilage grafts taken from the nasal septum and the ear shell. To the best of the authors' knowledge, the literature offers just 1 report on a similar patient.

Popliteal Pterygium Syndrome With Syngnathia.

Popliteal pterygium syndrome is a condition characterized by skin webs on the popliteal fossa, which may impair mobility unless surgically repaired. Affected individuals may also have syndactyly on the fingers and/or toes. Most people with this disorder present cleft lip and cleft palate and they can have syngnathia, that is a congenital adhesion between maxilla and mandible by fibrous bands, which affects the opening of the mouth. The case that we report is about a 2-month-old male, who presented skin webs bilaterally on the popliteal fossa, syndactyly between the IV and the V toe of the right foot and between the III and the IV toe of the left foot, and genital malformations. He was born with complete bilateral cleft lip and complete cleft palate on the left side and incomplete cleft palate on the right side and syngnathia with 4 fibrous bands between the mandibular arch and the maxilla arch on the right side, which affected the opening of the mouth. The case of our patient is very interesting because there have been few reported patients affected by popliteal pterygium syndrome with syngnathia.

A facial marker in facial wasting rehabilitation.

BACKGROUND: Facial lipoatrophy is one of the most distressing manifestation for HIV patients. It can be stigmatizing, severely affecting quality of life and self-esteem, and it may result in reduced antiretroviral adherence. Several filling techniques have been proposed in facial wasting restoration, with different outcomes. The aim of this study is to present a triangular area that is useful to fill in facial wasting rehabilitation. METHODS: Twenty-eight HIV patients rehabilitated for facial wasting were enrolled in this study. Sixteen were rehabilitated with a non-resorbable filler and twelve with structural fat graft harvested from lipohypertrophied areas. A photographic pre-operative and post-operative evaluation was performed by the patients and by two plastic surgeons who were "blinded." The filled area, in both patients rehabilitated with structural fat grafts or non-resorbable filler, was a triangular area of depression identified between the nasolabial fold, the malar arch, and the line that connects these two anatomical landmarks. RESULTS: The cosmetic result was evaluated after three months after the last filling procedure in the non-resorbable filler group and after three months post-surgery in the structural fat graft group. The mean patient satisfaction score was 8.7 as assessed with a visual analogue scale. The mean score for blinded evaluators was 7.6. CONCLUSION: In this study the authors describe a triangular area of the face, between the nasolabial fold, the malar arch, and the line that connects these two anatomical landmarks, where a good aesthetic facial restoration in HIV patients with facial wasting may be achieved regardless of which filling technique is used.

Polyacrylamide gel injection for treatment of human immunodeficiency virus-associated facial lipoatrophy: 18 months follow-up.

BACKGROUND: Lipoatrophy of the face affects the quality of life and body image of individuals receiving antiretroviral therapy. The objective of this study was to assess the safety and efficacy of a permanent nonbiodegradable polyacrylamide gel filler, used for facial wasting rehabilitation. METHODS: Thirty-two individuals positive for the human immunodeficiency virus (HIV) were enrolled in the study between January 2007 and January 2009 and treated using nonbiodegradable polyacrylamide gel injections for a facial wasting rehabilitation. RESULTS: Local infection, foreign body reaction, and migration of the product were not observed during follow-up (18 months). Small, palpable, nonvisible nodules were recorded in 13 cases at the end of follow-up. CONCLUSIONS: Polyacrylamide hydrogel is an appropriate treatment option in restoring facial contours in immunocompromised people with HIV. Injections of large volumes of polyacrylamide gel (8 to 12 mL) are not associated with a high rate of complications such as infection and foreign body reaction and allow improvement in quality of life in a limited time.

An alternative alar cinch suture.

Nasal widening is commonly associated to maxillary osteotomies, but it is only partially dependent on the amount of skeletal movement. Techniques for controlling lateralization of the ala, including the alar base cinch technique, originally described by Millard, have been well reported by Collins and Epker and later modified by others. In this article, authors report the effect of a new alar cinch suture technique on a sample of 32 patients.

Easy closure of anterior palatal fistula with local flaps.

BACKGROUND: Anterior palatal fistula is often observed in the treatment of the cleft palate with a push-back palatoplasty. High rate of incomplete closure is reported. We describe a reliable new technique with reverse local flaps to close an anterior palatal fistula. MATERIALS AND METHODS: One hundred seventeen cleft patients, treated with push-back palatoplasty, underwent repair of an anterior palatal fistula by our group. Fistulas were located in the anterior hard palate, with a variable size between 0.1 cm to more than 0.5 cm. Two reverse local flaps from the nasal mucosa of the lateral palatal edges are used to close the fistula. A third flap is elevated from the premaxilla in bilateral clefts. The flaps are elevated toward the center of the fistula. The closure is made in 2 layers for unilateral cleft and in 3 layers for bilateral cleft, using absorbable sutures. RESULTS: Complete closure of the anterior palatal fistula was achieved in 77 patients (65%) after the first surgery, 27 patients (23%) required a second attempt to close the fistula, and 10 patients (8.5%) required a third surgery. Three patients (2.5%) continued to have a fistula after 5 surgeries. CONCLUSIONS: We believe that our method is reliable and easy to perform, and it has a high success rate. The technique is indicated to correct small- to medium-size defects.

Calcitonin gene-related peptide and thermal injury: review of literature.

The aim of this review article is to report about the anti-inflammatory properties of calcitonin gene-related peptide (CGRP) in burns. CGRP is a 37-amino acid neuropeptide, primarily released from sensory nerves and is well known as the most potent and long-lasting microvascular vasodilator in vitro and hypotensive agents in vivo.A wide range of proinflammatory stimuli can induce the release of neuropeptides from cutaneous sensory nerves, including heat, physical trauma, UV radiation, and irritant chemicals. These proinflammatory stimuli are known to induce the release of CGRP from cutaneous sensory nerves. The anti-inflammatory effects of CGRP in a range of species and in human clinical conditions are detailed, and potential therapeutic applications based on the use of antagonists and gene targeting of agonists are discussed.

Use of fast-setting hydroxyapatite cement for secondary craniofacial contouring.

Patients who have previously had surgical correction of major craniofacial deformities will often have residual contour deformities they wish to have improved at a later date. The development of hydroxyapatite cement has simplified these procedures. The setting time is reduced to 5 to 8 minutes by mixing the cement with a phosphate-based solution, increasing the tensile strength, and maintaining the same biocompatibility and osseoconductivity. This study includes 48 patients who presented with a variety of residual contour irregularities secondary to a craniofacial congenital anomaly or a posttraumatic defect. All but one of the patients with congenital craniofacial conditions had their initial surgical correction performed by the senior author (Magee) and had regular follow-up visits. Variable amounts of hydroxyapatite cement were used according to the size of the defect to be corrected. Five patients had a postoperative complication: two infections, one seroma, one persistent swelling, and one drain retention. Patients were followed from 6 months to 3 years (mean, 1 year 5 months). Good results were achieved in 38 patients, acceptable results with minor asymmetries were seen in seven patients, and three other patients required a second intervention to obtain a better contour. Cranioplasty with fast-setting hydroxyapatite cement is a simple and reliable procedure, with a low complication rate. Attention to simple technical and operative principles can provide excellent results.

Surgical treatment of nasal hemangiomas.

The treatment of nasal hemangiomas continues to be controversial. The authors' experience with early surgical treatment of nasal hemangiomas is presented. This retrospective study includes 11 patients. Surgical intervention consisted of excision of the nasal hemangioma and reconstruction by local tissue transfer or rearrangement. Age at surgery ranged from 10 months to 6.5 years (mean age, 2.2 years). All patients have acceptable nasal contour and have demonstrated excellent nasal growth. The authors' experience demonstrates that early surgical intervention is an acceptable alternative for the management of nasal hemangiomas.