Prediction of land use changes based on Land Change Modeler and attribution of changes in the water balance of Ganga basin to land use change using the SWAT model.

Conflicts between increasing irrigated agricultural area, commercial crops, shifting cultivation and ever increasing domestic and industrial demand has already been a cause of tension in the society over water in the Ganga River Basin, India. For the development of sustainable water resource strategies, it is essential to establish interaction between landuse changes and local hydrology through proper assessment. Precisely, seeing how change in each LULC affects hydrologic regimes, or conversely evaluating which LULC shall be appropriate for the local hydrological regime can help decision makers to incorporate in the policy instruments. In this study, hydrologic regimes of the Ganga River basin have been assessed with landuse change. Catchment hydrologic responses were simulated using Soil and Water Assessment Tool (SWAT). Meteorological data from IMD of 0.25°â€¯× 0.25° spatial resolution were taken as the climate inputs. Simulated stream flow was compared at different gauge stations distributed across the Gang River and its tributaries. Urbanization has been the topmost contributor to the increase in surface runoff and water yield. While increased irrigation demands were the dominant contributor to the water consumption and also added to the increased evapotranspiration. This study can be important tool in quantifying the changes in hydrological components in response to changes made in landuse in especially basins undergoing rapid commercialization. This shall provide substantive information to the decision makers required to develop ameliorative strategies.

Hürthle cell neoplasms. Malignant potential.

We studied the records of patients with Hürthle cell neoplasms seen at the University of California at San Francisco, from 1943 to 1982, because of controversy concerning the malignant potential of these tumors. Of our 84 patients, 71 had Hürthle cell adenomas (HCAs), nine had Hürthle cell change in chronic thyroiditis, and four had Hürthle cell carcinomas. Coexisting papillary thyroid carcinoma occurred in three patients with HCA. Twelve patients with HCAs had multiple lesions, five of which were bilateral. Patients with HCA were followed up for 675 patient-years, 45 for four years or more (maximum duration, 36 years). There were no recurrences or deaths among the patients with benign Hürthle cell tumors. Thus, patients with HCA had a benign course, and histologic examination results accurately reflected malignant potential.

Preauricular skin defects. A consequence of a persistent ectodermal groove.

BACKGROUND: The term aplasia cutis is used to describe congenital localized defects of the skin. This affliction is the end result of various in utero events. Aplasia cutis of the face, although rare, has been associated with numerous dysmorphic features and described under many clinical terms. OBSERVATIONS: We studied 10 patients with oval, atrophic patches distributed in a linear pattern on the preauricular region of the face. Most of the defects were bilateral, and all consistently fell in an oblique line extending from the preauricular region to the angle of the mouth. This line corresponds to the region of fusion between the maxillary and mandibular facial prominences during embryonic development. CONCLUSIONS: This type of facial aplasia cutis may be the result of incomplete fusion of the ectodermal groove between the maxillary and mandibular facial prominences. Although other types of facial skin defects may share a similar pathogenic mechanism, they are distinct in that they occur in different regions and may have other abnormal facial features.

Relationship between skin fluorescence and blood flow in normal and in chronically ischemic subjects dosed with fluorescein.

To elucidate parameters diagnostic of chronic ischemia, the fluorescence of skin on the foot, leg, arm, and forehead of six chronically ischemic patients and six normal subjects injected with fluorescein was measured serially using a surface-measurement fluorometer (dermofluorometer). Simultaneously collected plasma samples were assayed spectrofluorometrically for unmetabolized fluorescein. The time courses of plasma fluorescein content and dermofluorometer readings were jointly analyzed by combining a standard pharmacokinetic model, a model predicting skin site from plasma concentrations of fluorescein, and a model predicting the dermofluorometer response to those skin concentrations. Fluorescein plasma clearance (0.22 +/- 0.06 versus 0.46 +/- 0.20 L/h/kg) in ischemic patients was only half, and half-life was double (2.4 +/- 1.0 versus 1.3 +/- 0.3 h) those in normal subjects, with volume of distribution (Vdss = 0.46 L/kg) being similar. Despite the ischemia diagnosis for all patients involving claudication of the lower extremities, patients could be distinguished statistically from normal subjects on the basis of fluorescence readings taken on the arm, but not those using the foot or leg. The rate constant describing flux of fluorescein from the arm skin site in patients was only half that in normal subjects, and the peak reading on the arm occurred at 42 +/- 14 min after fluorescein injection in patients, but at only 15 +/- 6 min in normal subjects. Lack of discrimination between subject groups via leg and foot readings may be due to several physiologic and/or experimental factors, including the need to take skin surface readings much earlier than previously recognized.(ABSTRACT TRUNCATED AT 250 WORDS)

Lateral cervical cyst containing gastric epithelium.

A lateral cervical cyst, presumably of branchial origin, was found to contain gastric epithelium. This is an extremely rare condition and, to our knowledge, represents the first such report in a branchial cyst. The literature is reviewed and speculations are made with respect to the embryologic and clinical implications of this anomaly.

Surgical anatomy of the facial nerve.

(1) The temporal branch of the facial nerve emerges within the parotid gland to cross the zygomatic arch at the deep surface of the temporoparietal fascia. The nerve is separated from the deep temporal fascia immediately above the zygomatic arch by a loose areolar plane; this plane may be obliterated when previous surgical procedures have been performed in this region. (2) The temporal branch can be found within a trajectory that has been described relating the lower portion of the auricle to the lateral aspect of the eyebrow. However, one must be aware that these surface landmarks may vary with respect to the underlying skeleton and from one individual to the next. (3) Recent studies indicate that the temporal branch consists of not one, but multiple rami that cross the zygomatic arch. Because there are multiple rami to the temporal branch of the facial nerve, any single trajectory can describe only a portion and not the entirety of the temporal branch. (4) The zygomatic, buccal, and marginal mandibular branches of the facial nerve innervate the mimetic muscles of the face from either their superficial or deep surfaces. Several mimetic muscles are innervated by two or more branches of the facial nerve. (5) Interconnections between the zygomatic and buccal branches are noted in over 70% of cases, whereas interconnections between the temporal or marginal mandibular branches to other facial nerve branches occur in less than 15% of cases. (6) The zygomatic, buccal, and marginal mandibular branches lie in intimate relationship with the retaining ligaments of the face. Surgical dissection for release of the zygomatic ligament, the masseteric cutaneous ligament, or the mandibular ligament should be performed meticulously and with extreme caution.

Distraction osteogenesis of the craniofacial skeleton.

In summary, distraction osteogenesis is a safe and effective means of achieving bone lengthening. These techniques were originally applied to the long bones of the extremities; over the past 10 years they have been effectively applied to the bones of the craniofacial skeleton. The new bone regenerate that is observed after distraction osteogenesis is stable, and relapse rates after skeletal advancement are believed to be lower than with conventional osteotomy and bone graft techniques. There is considerable variability in distraction protocols employed in clinical practice, including differences in the types of devices used and in the rate, rhythm, latency, and period of consolidation for distraction osteogenesis. The greatest application for distraction osteogenesis in the craniofacial skeleton has been with mandible lengthening, for which there is presently a 10-year clinical experience. Midfacial advancement is a newer application of distraction osteogenesis, for which clinical experience has been accrued over the past 5 years. This latter experience indicates that distraction osteogenesis is a viable treatment option for lengthening of the hypoplastic mandible and midface. These techniques have advantages over conventional means of bone graft and rigid fixation because of the quality of the bone regenerate, the decrease in the long-term relapse rate of the advanced bone segments in both the mandible and the midface, and the simultaneous soft-tissue elongation that accompanies the distraction process. Distraction osteogenesis is particularly applicable to the correction of severe deformities of the mandible and midface in children with developmental hypoplasia and syndromic craniosynostosis. However, growth is an added variable in this patient population. The amount of overcorrection in lengthening of the hypoplastic bone required to compensate for continued growth discrepancy of the adjacent facial bones is difficult to predict. Therefore, the families of these patients should be informed that many children will require repeated operations at a later age as they reach skeletal maturity.

The role of transforming growth factor-beta in the modulation of mouse cranial suture fusion.

Transforming growth factor-beta (TGF-beta) is actively expressed during mouse calvarial suture fusion. However, the role TGF-beta plays in this process remains unclear. The present study was performed to investigate whether modulation of suture fusion can be achieved by blocking the bioavailability of TGF-beta. Both in vitro and in vivo models were studied. For the in vitro model, the posterior frontal sutures from 24-day-old mice were harvested and cultured for 2, 3, or 4 weeks in the presence of 20 microg/ml of pan-specific TGF-beta polyclonal antibody or rabbit IgG as a control. Culture media were changed every 48 hours and fresh antibody or rabbit IgG was added during each media change. Suture fusion was evaluated by histometric analysis. For the in vivo model, TGF-beta antisense plasmid DNA complexed with lipofectamine was injected into the subgaleal layer along the frontal suture of 22-day-old mice under anesthesia. For control groups, empty vector plasmid DNA+ complexed with lipofectamine was used. The posterior frontal sutures were harvested at various time points and examined by histometric analysis and reverse transcription and polymerase chain reaction for the detection of messenger RNA. The in vitro studies demonstrated that the presence of TGF-beta antibody in culture media delayed posterior frontal suture fusion. By 3 weeks in culture, new bone area was only 20 percent of that in control groups as determined by histometric analysis. By the end of the fourth week, suture fusion was only 25 percent completed compared with controls. The in vivo studies demonstrated that, compared with the control, posterior frontal suture fusion was significantly delayed in the animals injected with antisense plasmid DNA. Suture fusion was complete in control animals by postnatal day 45. There was a 70 percent inhibition of suture fusion (new bone area) in antisense groups measured with histometric analysis. Four days after antisense plasmid DNA injection (age of 26 days), messenger RNA expression for TGF-beta 1 was 77 percent lower than in the control group. We have demonstrated that modulation of TGF-beta affects calvarial suture formation in vitro and in vivo with TGF-beta antibody and TGF-beta1 antisense plasmid DNA treatment, respectively. These data indicate that TGF-beta may play a causative role in mouse posterior frontal suture fusion. Modulation TGF-beta 1 gene expression in vivo can alter the natural history of cranial suture fusion.

Cervicovertebral anomalies and basilar impression in Goldenhar syndrome.

Although previously unreported, neurologic compromise may occur secondary to anomalies of the cervical spine in the oculoauriculovertebral spectrum. Medical records and cephalograms were reviewed from 18 patients with classic Goldenhar syndrome and from 18 normal adults. One patient, a 22-year-old man, had experienced a 5-year history of progressive neurologic compromise from basilar impression; the remaining 17 patients were asymptomatic. Radiographic evidence of cervicovertebral fusion was documented in 11 of 18 patients (61 percent). Fusion occurred at every cervical level other than the atlantoaxial joint. Radiographic indices that characterize the cranial base were not significantly different between asymptomatic Goldenhar patients and normal adults. Posterior inclination of the odontoid with respect to the foramen magnum appears to be the best indicator that a patient is at risk for basilar impression. Careful radiographic evaluation may indicate which patients require more careful surveillance with periodic neurologic examination and CT and/or MRI scans.

Localization of the cortical response to smiling using new imaging paradigms with functional magnetic resonance imaging.

Functional magnetic resonance imaging (fMRI) can serve to localize activity in the cerebral cortex. The present study was performed to develop a quantitative means of describing the cortical location activated during voluntary smiling in multiple subjects and to determine whether this location is specific to smiling when compared with other motor tasks. Five human subjects were instructed to smile or to tap the fingers of both hands. Both tasks were performed in a blocked-trial paradigm that consisted of alternating 15-second blocks of a repetitive motor task and 15 seconds of rest. Smiling was also performed as an event-related paradigm in which the subject smiled briefly once every 15 seconds for 20 repetitions that were combined to produce an average response to a single smile. A series of 300 images was acquired using an echo-planar imaging sequence (24-cm field of view; 5-mm slice thickness; repetition time/echo time, 1000/27.2 msec). Each subject's three-dimensional brain images were transformed to Talairach coordinates by stretching or compressing the brain images to fit the standard brain as defined in the Talairach atlas. This allowed data from five subjects to be combined for a numeric description. Functional activation maps acquired by use of the event-related paradigm contained significantly fewer motion artifacts than maps acquired with the blocked-trial paradigm, allowing better visualization of functionally active areas. Three-dimensional Talairach coordinates to describe the locations of peak cortical activity after smiling and finger tapping were established. These coordinates were consistent among subjects. During smiling, statistically significant activation was seen in the motor cortex, primarily along the precentral sulcus; this was inferior and anterior to the region that was associated with finger tapping. This study demonstrates that motion artifacts associated with traditional blocked-trial fMRI protocols can be overcome by employing an event-related paradigm to obtain an average response from a single smile. With the implementation of new imaging paradigms with fMRI, an area of the cerebral cortex has been identified that is specifically activated during voluntary smiling, and remains consistent among subjects. Quantification of fMRI data represents a powerful tool by which to study the cortical response to motor activity and to monitor possible alteration in this activity after injury or surgery. When combined with biofeedback therapy, this technique may help to improve the outcome of facial reanimation procedures in the future.

Biomechanical evaluation of titanium, biodegradable plate and screw, and cyanoacrylate glue fixation systems in craniofacial surgery.

Choice of appropriate fixation after reduction of displaced bone fragments or advancement of osteotomized segments requires knowledge of the maximal force to which these segments can be subjected. The present study was performed to obtain a biomechanical comparison of a variety of resorbable fixation systems as an alternative to metal plates and screws. Sheep cadaver parietal bone segments were osteotomized and fixed with one of six methods of fixation: (A) titanium plates and screws consisting of (1) miniplates and 2.0-mm-diameter screws; (2) midface plates and 1.5-mm screws; (3) microplates and 1.0-mm screws; (B) resorbable systems consisting of combinations of butyl-2-cyanoacrylate glue and biodegradable polylactic acid/polyglycolic acid copolymer plates and 2.0-mm screws as follows: (1) direct glue fixation of segments; (2) resorbable plates fixed to bone segments with cyanoacrylate glue; (3) resorbable plates fixed with resorbable screws. Compression testing was performed upon bone segments advanced and fixed across a central gap, and distraction testing was performed on bone segments fixed in direct contact. Force to failure in both distraction and compression was significantly greater in bone segments fixed with titanium miniplates than with any other method of fixation. Segments fixed with plates and screws, either nonresorbable or resorbable, achieved stronger fixation in distraction than in compression for all plate sizes tested. Resorbable plate and screw fixation was as strong as standard titanium midface and microplating systems in distraction, and stronger than the latter techniques in compression. With compressive forces of relapse, fixation with glue and resorbable plates was as strong as standard titanium midface and microplating systems. However, with distractive forces of relapse, glue fixation of either the bone segments or resorbable plates was weaker than both titanium and resorbable alternatives in which plates and screws were used. These findings may have direct impact on the choice of fixation devices used to support osteotomized or fractured bone segments, which are subjected to persistent muscular and soft-tissue pull.

The temporal branch of the facial nerve: how reliably can we predict its path?

A thorough examination of the temporal branch of the facial nerve was performed to characterize precisely the number of rami crossing the zygomatic arch and their location with respect to bone and soft-tissue landmarks. Fresh cadaver dissection was performed in 12 facial halves, dissecting the facial nerve superiorly from the stylomastoid foramen to identify all branches crossing the zygomatic arch. There were a median of three (range two to four) rami of the temporal branch crossing the lower aspect of the zygomatic arch, with distinct anterior and posterior divisions identified in each dissection. In 8 of the 12 dissections, one or more separate middle divisions of the nerve also were seen at the inferior aspect of the zygomatic arch. Superior to the zygomatic arch, frequent interconnections were noted between all divisions of the temporal branch, but no connections were noted to other branches of the facial nerve. Previous descriptions of the course of the temporal branch based on soft-tissue landmarks most closely correlated with nerve rami that were found in the present study to be located within the anterior division of the nerve. On crossing the inferior aspect of the zygomatic arch, the anterior and middle divisions of the temporal branch were located a median of 12 and 4 mm anterior to the articular eminence, respectively; the posterior division ranged in location from 10 mm posterior to 7 mm anterior to the articular eminence. The range over which rami of the temporal branch crossed the inferior aspect of the zygomatic arch was equally divided anterior and posterior to the articular eminence and covered up to 50 percent of the total length of the zygomatic arch. The present study confirms that the temporal branch is not a single nerve branch but consists of multiple rami that cross the zygomatic arch anywhere for over half the length of its inferior border. Techniques for localizing the nerve based on reference points from two soft-tissue landmarks are therefore unreliable.

The kleeblattschädel anomaly in Apert syndrome: intracranial anatomy, surgical correction, and subsequent cranial vault development.

We present a case of Apert syndrome in which intracranial anomalies of the cranial base were localized to the lesser wings of the sphenoid and sphenoid ridge. The lesser wings of the sphenoid were displaced superiorly to follow the fused coronal sutures bilaterally, where they met at a single point on the skull vertex. Careful preoperative study of the intracranial anatomy in the kleeblattschädel anomaly led to a surgical plan for early correction of the anomaly. The present report indicates that an aggressive approach to the correction of the kleeblattschädel anomaly beginning early in infancy can result in normalization of the trilobar skull configuration. Although this approach can correct the kleeblattschädel anomaly, 3.5-year follow-up in this patient with Apert syndrome demonstrates progressive turricephaly despite repeated cranial vault remodeling. Although the trilobar skull configuration can be corrected through early surgical intervention, the long-term correction of progressive turricephaly in patients with Apert syndrome remains an unsolved problem.

Morbidity associated with increased intracranial pressure in Apert and Pfeiffer syndromes: the need for long-term evaluation.

Although the incidence of elevated intracranial pressure is increased in patients with the craniosynostosis syndromes, the significance of these findings and their impact on clinical practice remain unclear. The morbidity related to elevated intracranial pressure in patients with Apert and Pfeiffer syndromes was reviewed. Sixty-seven patients with Apert syndrome and 39 patients with Pfeiffer syndrome were identified. The morbidity in 5 of the 106 patients (4.7 percent) was felt to be directly related to persistently elevated intracranial pressure. These included 2 deaths, 1 due to brainstem herniation after an elective subcranial Le Fort III advancement and 1 following removal of a lumboperitoneal shunt during the surgical release of syndactyly. The remaining 3 complications included bilateral papilledema detected 3.5 years after cranial vault remodeling in 1 patient and venous hypertension with excessive bleeding detected during elevation of the bicoronal flap in 2 patients, resulting in delay of a planned Le Fort III advancement. Patients with the syndromal craniosynostoses are at risk for complications resulting from elevated intracranial pressure from infancy through adulthood despite surgical attempts to increase cranial capacity in infancy. Clinical guidelines are proposed by which these patients should be evaluated beyond infancy in a regular fashion so as to reduce morbidity from unrecognized elevations in intracranial pressure.

Submucous cleft palate: diagnostic methods and outcomes of surgical treatment.

The following statements summarize our interpretation of the literature regarding submucous cleft palate: Incidence and Diagnosis of Submucous Cleft Palate 1. In surveys of classic stigmata of submucous cleft palate among the general population, the incidence has been reported to be 0.02 to 0.08 percent. In the larger of these series, the incidence of velopharyngeal inadequacy among patients identified to have submucous cleft palate was 1 to 9. The incidence of occult submucous cleft palate is not known, since these patients will only be detected during the evaluation of patients who present with velopharyngeal inadequacy. 2. The diagnosis of submucous cleft palate is made by identification of the classic stigmata on physical examination. The diagnosis of occult submucous cleft palate is only pursued if the patient has velopharyngeal inadequacy. 3. For consistency in evaluating and reporting data, patients with an overt cleft of the secondary palate that extends beyond the uvula should be reported as having a cleft palate, and not a submucous cleft palate, even if a submucous cleft exists in a portion of the palate anterior to the overt cleft. 4. The true incidence of otitis media with effusion in the presence of submucous cleft palate has yet to be determined using a prospective study. Surgical Treatment of Velopharyngeal Inadequacy in Patients with Submucous Cleft Palate 1. The technique that has most consistently been documented to result in a significant correction of velopharyngeal inadequacy is the pharyngeal flap. There is recent evidence from one large center supporting the efficacy of the Furlow Z-plasty in selected patients with submucous cleft palate. Both these procedures appear to be most effective in patients with good lateral pharyngeal wall motion. 2. If a pharyngeal flap is performed as the primary procedure to act as an obturator against which the lateral pharyngeal walls appose for closure, we do not see the need for adjunctive palatal procedures. The dynamic component of velopharyngeal competence following such a pharyngeal flap consists of lateral wall motion, which is not enhanced by further surgical manipulation of the palate. However, a pharyngeal flap may be performed as an adjunctive procedure to a palatal pushback in order to provide lining for the resultant defect in the nasal mucosa. 3. The present literature does not support "prophylactic" operations on patients who present with the physical stigmata of submucous cleft palate prior to reaching an age at which it can be demonstrated by perceptual speech assessment that velopharyngeal inadequacy remained refractory to speech therapy. A significant number of patients will never develop velopharyngeal inadequacy; therefore, surgery would be unnecessary. In addition, objective data regarding the outcomes of different surgical techniques cannot be gathered if patients with submucous cleft palate are operated on without having had velopharyngeal inadequacy documented prior to those operations. 4. In order to objectively compare the outcomes of different surgical techniques, any future studies should be prospective and utilize uniform means of assessment. As minimum criteria, these would include preoperative and postoperative perceptual speech assessments performed by a trained speech pathologist and preoperative nasopharyngoscopy and multiview videofluoroscopy. The latter two studies should be repeated postoperatively only in those patients who have persistent velopharyngeal inadequacy.

Scalp reconstruction with a prefabricated abdominal flap carried by the radial artery.

Custom prefabrication of free flaps provides an unlimited variety of applications, since flaps can be created with expendable tissues and without restriction to naturally occurring vascular territories. These principles also can be used to customize flaps that could not be completed by conventional means. We report a case of scalp reconstruction using a random-pattern abdominal flap in which a radial artery fascial flap was induced to serve as the vascular carrier. In addition to providing durable scalp coverage, the prefabricated free flap enabled salvage of an abdominal flap that would otherwise have been aborted after intermediate transfer to the forearm.

A study of intracranial volume in Apert syndrome.

The present study was undertaken to characterize the intracranial volume in patients with Apert syndrome. Radiographic and CT-based techniques for measuring intracranial volume were found to show close correlation when validated in dry normal adult skulls. A standard-deviation score of intracranial volume, determined from CT scans in 20 patients with Apert syndrome from birth to 30 years of age, was calculated with reference to a normative database of age- and sex-matched controls. Analysis of the data showed no significant difference in standard-deviation score between Apert patients with or without ventriculomegaly, before or after cranial vault surgery, or between male and female patients. The mean standard-deviation score among all Apert CT scans compared with normative data was 3.1, which was highly significant (p < 0.001). However, the growth curves showed no significant difference in intracranial volume between Apert and normal patients below 3.5 months of age. In summary, intracranial volume in Apert syndrome is within normal range at birth but increases to greater than 3 standard deviations above normal after 3.5 months of age, a finding independent of cranial vault surgery.

Giant congenital nevi: a 20-year experience and an algorithm for their management.

A variety of treatment options exists for the management of giant congenital nevi. Confusion over appropriate management is compounded because not all giant congenital nevi are pigmented, and malignant potential varies between different types. The present study sought to define factors in the presentation of giant congenital nevi that could provide an algorithm for their management, with respect to both the extent of resection and subsequent reconstructive options.A retrospective review of all patients who presented with a congenital nevus of 20 cm2 or greater since 1980 was performed, distinguishing among nevi involving the head and neck, the torso, and the extremities. Sixty-one patients with giant congenital nevi were evaluated (newborn to age 16 years), of which 60 nevi in 55 patients have been operated on. Giant congenital nevi having malignant potential were pigmented nevi (53 patients) and nevus sebaceus (four patients). Those not having malignant potential were verrucous epidermal nevi (three patients) and a woolly hair nevus (one patient). Of the 60 giant congenital nevi operated on, expanded flaps were used in 25, expanded full-thickness skin grafts were used in 10, split-thickness or nonexpanded full-thickness skin grafts were used in 13, and serial excision was used in 30. After 1989, operations tended to use multimodality treatment plans, with an increased use of expanded full-thickness grafts and immediate serial tissue expansion. The use of serial excision, particularly in the extremities, also increased after 1989. Serial excision was the treatment of choice when it could be completed in two procedures or less, which occurred in more than 80 percent of cases using serial excision alone. Expanded flaps were the most common mode of reconstruction in the head and neck region and were used in 49 percent of these procedures. Serial excision was the most common form of treatment in the extremities, used in 50 percent of procedures. Tissue expansion in the extremities was infrequently used to provide an expanded flap (8 percent of procedures), whereas it was frequently used to provide expanded full-thickness skin grafts harvested from the torso (used in 31 percent of procedures). On the basis of these data, algorithms for the extent of resection and subsequent reconstructive options for giant congenital nevi were developed. Their management should be formulated relative to pigmentation, malignant potential, and anatomic location of the respective lesions.

The histomorphologic changes in vascularized bone transfer and their interrelationship with the recipient sites: a 1-year study.

In 13 New Zealand White rabbits with a mean age of 6 months, vascularized bone transfers incorporated as paired auricular anterior myo-osseous flaps were harvested; they were placed in either an inlay or an onlay position relative to the zygomatic arch. The onlay bone transfers were placed either in full contact or in partial contact with the zygomatic arch. The animals were sacrificed 1 year after transfer. At 1 year, the inlay transfer simulated the adjacent zygoma in width and thickness. Onlay full contact transfers maintained significant aug mentation in thickness of the zygoma, while the onlay partial contact transfers did not; the thickness of the augmented zygoma in the onlay full contact subgroup was significantly greater than that in the onlay partial contact transfers. The onlay partial contact grafts had remodeled into the zygoma in bone contact, where the orientation of mismatched osteons within the bone transfers had transformed to match that of the native zygoma. In areas of bone contact between the onlay and the host bone, full-thickness conversion from a cortical to a trabecular architecture had occurred in both the transfer and host bones. These findings have numerous implications regarding mechanisms that could be exploited clinically to optimize the survival of a bone transfer; they also raise questions regarding alteration of the recipient bed after placement of an onlay bone transfer.

A prospective study of the relationship between strabismus and head posture in patients with frontal plagiocephaly.

A prospective study was performed on 16 unoperated patients with frontal plagiocephaly to characterize the relationship between strabismus and abnormal head posture. Serial eye examinations were performed preoperatively and for 24 to 46 months following fronto-orbital advancement. In 14 patients (88 percent), preoperative clinical examination and CT scan indicated coronal plagiocephaly (synostotic); unicoronal synostosis was documented during fronto-orbital advancement in all these patients. Ten patients had abnormal head posture on preoperative examination, 9 of whom had strabismus at some time during the study. These 9 patients all had unicoronal synostosis with ipsilateral strabismus and a contralateral head tilt. All had eye muscle findings consistent with superior oblique paresis, although in 2 patients these signs first developed following fronto-orbital advancement. Strabismus resolved spontaneously in 2 patients between 2 and 8 months following fronto-orbital advancement; the remaining 7 patients underwent extraocular muscle surgery following fronto-orbital advancement, with early resolution of strabismus in all cases. The head tilt resolved or improved significantly in all 9 patients following resolution of the strabismus. Two patients had recurrent superior oblique paresis following surgical correction, necessitating secondary strabismus surgery. The present study indicates that extraocular muscle dysfunction is the major cause of abnormal head posture in patients with coronal plagiocephaly and emphasizes the need for long-term ophthalmologic surveillance in these patients.