Faculty Bibliography

PURPOSE: To determine the most accurate imaging modality for detection of silicone implant ruptures. MATERIALS AND METHODS: Forty single-lumen silicone implants were surgically placed in 20 rabbits. Each rabbit received one intact and one ruptured implant and was examined with mammography, magnetic resonance (MR) imaging, ultrasound (US), and computed tomography (CT). Five radiologists reviewed all images in a random fashion and graded each for rupture. The radiologist who performed US also graded her impression during examination with US. Receiver operating characteristic (ROC) analysis was performed. RESULTS: MR imaging and CT were the most accurate modalities in detection of implant ruptures, with areas under the ROC curves (Az) of .95 and .91. Mammography and US were statistically significantly inferior, with Az of .77 for each (P < .05). CONCLUSION: MR imaging and CT are statistically more accurate than US and mammography for detection of intracapsular silicone implant ruptures when only the images are reviewed

BACKGROUND. An alternative to mechanical stapling or hand suturing is needed to permit laparoscopic common bile duct exploration. We evaluated the strength and healing characteristics of canine choledochotomies sealed with a fibrinogen solder and a diode laser. METHODS. After creation of a 0.5 cm longitudinal choledochotomy, the edges were coapted with forceps, and a fibrinogen solder mixed with indocyanine green dye was applied. The solder was sealed in place with an 810 nm diode laser (125 W/cm2). RESULTS. Immediate mean leakage pressure was 264 +/- 7 mm Hg compared with 83 +/- 66 mm Hg in suture controls. This increased to 364 +/- 115 mm Hg at 2 days and was more than 510 mm Hg at 7 days. On histologic examination rapid reabsorption of the solder with no signs of inflammation or stenosis was seen. No episodes of dehiscence or peritonitis occurred. CONCLUSIONS. Laser soldering provides a watertight choledochotomy closure with adequate immediate strength allowing a reliable, technically feasible common bile duct exploration via a laparoscopic approach

Twenty-one consecutive patients who had earlier superiorly based pharyngeal flap surgery and persistent velopharyngeal insufficiency were seen between 1976 and 1991. Patients were divided into two treatment groups, depending on the results of videofluoroscopic and nasopharyngoscopic assessment. The first group consisted of 18 patients who had bilateral port insufficiency and required a complete reconstruction of a new superiorly based pharyngeal flap that was elevated from a scarred posterior pharyngeal wall. After an average follow-up of 6.2 years, 15 patients had normal resonance, 2 patients had improvement but continued hypernasality, and 1 patient was hyponasal. The second group consisted of 3 patients who had 'patch' flaps to a unilateral port insufficiency. Postoperatively, all 3 of those patients had normal resonance. Indications for the decision to 'redo' or patch flaps are described

The history of skull trepanation is almost as old as that of humanity. For thousands of years it has been performed for the treatment of numerous medical maladies. The Andean Incas, early Asians and South Seas Islanders, are amongst the many people to perform calvarial trepanation. Hippocrates described techniques for the use of the trepan in early Greek times. With the production of a skull opening comes the challenge of developing methods for closing the defect. It is in reality, more challenging to repair the defect than to create it. Man, with his never ending ingenuity, has tried to develop many techniques. We will discuss some of them and present our method of choice for closure of skull defects

Posterior plagiocephaly historically has been associated with synostosis of the lambdoid suture. The incidence, diagnosis, and modes of treatment for stenosis of the lambdoid suture remain controversial. Commonly, the lambdoid suture is found to be open both on radiographic examination and at the time of surgery. The study reports on nine patients who presented with unilateral posterior plagiocephaly and who were found to have open lambdoid sutures, but a stenosed region of the asterion. The area of involvement included the distal-most lambdoid suture, the parietomastoid, occipitomastoid, and proximal squamosal sutures. Positional molding or torticollis was ruled out in all patients. All the patients showed progressive involvement of the skull base, including anterior shifts of the ipsilateral ear, compensatory ipsilateral frontal bossing and malar protrusion. Stenosis of the asterion was diagnosed with three-dimensional computed tomography scans, corroborated at the time of surgery and confirmed histologically. Surgical correction involved resection of the affected asterion and reconstruction using a bandeau-technique, barrel staves of the occipital bone and bone graft transposition. This approach provided excellent esthetic results in all patients

Nine patients (7 men, 2 women) with external nasal deviation underwent corrective procedures using a monobloc nasal osteotomy technique. The deformities ranged from mild to severe. Eight patients had post-traumatic deviations, whereas 1 had a unilateral cleft nasal deformity. For this monobloc technique, osteotomies were performed at unequal levels to correct the height difference, no periosteal undermining was performed, and septal dissection was undertaken only after monobloc repositioning. There was no need for grafts or microplate fixation. Minimum follow-up was 8 months. All patients had improvement in their external deviation, 1 patient was mildly undercorrected, and only 1 patient (cleft nasal) required a radical submucosal resection

The effects of unilateral facial nerve ablation on craniofacial development in the rabbit were examined. In this experimental model, 10 newborn rabbits 12 days of age underwent unilateral resection and cautery of the facial nerve. They were allowed to grow to skeletal maturity and were sacrificed at 6 months. Analysis of variance was used to compare direct measurements of prepared skulls in the experimental animals with 3 unoperated control litter mates and with 5 litter mates who underwent a sham procedure (exposure of the facial nerve without section). The animals with facial nerve resection demonstrated an average snout deviation toward the side of injury of 8.3 degrees, apparently due to shortening of the maxilla and mandible on the affected side. This study provides new data regarding the role of the functional matrix in the modulation of craniofacial growth and development

The principle of distraction osteogenesis, well-established in the enchondral bones of the axial skeleton, has recently been applied to the membranous bones (mandible, cranium) of the craniofacial skeleton in the experimental animal and in the human. In the craniofacial skeleton, however, the technique has been used only to lengthen bone in a direction along its major axis, i.e., unidimensional distraction. A canine model is presented to demonstrate the feasibility of distracting membranous bone away from its dominant axis, i.e., multidimensional distraction. Four mongrel dogs, 5 months of age, were the subjects of this study. Two osteotomies were made in the zygomatic arch, and the bone-lengthening device was fixed to the zygoma. After 7 days of external fixation, the osteotomized segment was lengthened 1 mm/day away from the long axis of the bone for 15 days. External fixation was then maintained for a minimum of 4 weeks, after which the dogs were sacrificed. Craniofacial CT with three-dimensional reconstruction documented multidimensional bone lengthening, and histologic analysis of the specimen confirmed the presence of new cortical bone in the expanded areas. Refinement in technique and miniaturization and internalization of the bone-lengthening device may allow for more precise changes in the amount and direction of lengthening, thus making distraction osteogenesis more widely applicable for use in the human craniofacial skeleton

Eighty-six patients with anterior neck burn sequelae underwent scar resection up to the limits of the aesthetic unit of the neck and immediate resurfacing with a scapular-parascapular free flap (the extended scapular flap). The flap was raised in all patients above the deep fascia as a thin skin-subcutaneous tissue flap, providing an initially acceptable aesthetic result. The flap was anastomosed to the facial artery and vein. The donor area was closed directly, or a 4- to 5-cm-wide skin graft was used which could be completely removed in a secondary procedure if the patient requested it. There were four failures early in the series but no losses in the last 70 patients. In order to improve the final aesthetic result, 45 patients underwent complementary defatting procedures (average of three) and Z-plasties initiated 30 days after the initial surgery at intervals of 1 month. Analysis revealed 96 percent good aesthetic results (as determined by the cervicomental angle obtained and the subjective opinion of the patients). There were no recurrences of scar contractures, and good function of the neck was regained in the majority of the patients. Anterior neck burn sequelae thus can be safely treated with en block resection and resurfacing using this flap