Mimis Cohen

Monobloc craniomaxillofacial distraction osteogenesis in a newborn with severe craniofacial synostosis: A preliminary report

Severe craniofacial synostosis can be a devastating problem for a newborn infant. Reasons for early surgical intervention include cranial stenosis, hydrocephalus, inadequate globe and corneal protection, compromised airway patency, and feeding problems. In this preliminary report, we describe the management of severe craniofacial synostosis in a newborn infant by means of cranial and midfacial distraction osteogenesis.

Mastery of plastic and reconstructive surgery

Combining the authority of a textbook with the step-by-step, illustrative detail of an atlas, this extraordinary reference presents surgical techniques practiced and perfected by the most respected plastic surgeons in the field. With the aid of nearly 5,000 photographs, these master plastic surgeons discuss how to perform the latest reconstructive and aesthetic procedures, achieve successful results, choose the most effective method, and avoid or manage potential complications. This three-volume masterpiece is destined to become a classic reference for all practitioners

Staged reconstruction after gunshot wounds to the abdomen.

Immediate closure of abdominal incisions after exploration and treatment of gunshot wounds is not always feasible or advisable. Significant bowel edema after massive fluid resuscitation might preclude primary closure, whereas any attempt to close under tension might result in complications ranging from wound dehiscence, infection, and necrosis to the abdominal compartment syndrome with abdominal, cardiopulmonary, and renal complications. For these difficult cases, the open technique has been recommended. The abdomen is left open and is closed when the patients condition permits. When immediate wound approximation is not possible, temporary coverage can be achieved with a mesh, patch, or a split‐thickness skin graft and the definitive reconstruction is deferred for a more optimal time. The purpose of this retrospective study is to report the authors’ experience with staged abdominal wall reconstruction after gunshot wounds. From 1989 to 1998, 1933 patients underwent exploratory laparotomy for penetrating wounds to the abdomen. Twenty‐nine patients in grave condition and with multiple medical problems were comanaged by the Trauma and Plastic Surgery Services at Cook County Hospital with the following protocol: The abdomen was initially left open and exposed viscera were covered with a variety of methods, including a Gore‐Tex patch (W. L. Gore and Associates, Inc., Flagstaff, Ariz.). A split‐thickness graft was subsequently placed on the granulation tissue over viscera at an average of 14 days after the last laparotomy. These planned ventral hernias were definitively treated at an average of 7 months after the skin grafting procedure, primarily using the components separation technique. In 24 patients, the fascia was closed primarily without tension, while five patients required the use of synthetic mesh to restore fascial continuity. Nine patients underwent closure of a colostomy or repair of fistulas simultaneously with abdominal wall reconstruction. One patient developed a postoperative hernia, two developed superficial wound dehiscence that healed without further surgery, and one required re‐exploration for a failed anastomosis after colostomy closure. All but one patient maintained a stable abdominal wall after the reconstruction. The authors concluded that staged abdominal wall reconstruction should be primarily recommended for patients with complex abdominal wounds and a compromised general condition that precludes primary closure. With this treatment protocol, patients can recover faster from their trauma surgery and the risk of perioperative complications can be reduced. After final reconstruction, the continuity, stability, and strength of the abdominal wall are maintained in the vast majority of cases with the use of autogenous tissue and without the need for alloplastic material. With close cooperation between the trauma team and the plastic surgeon and appropriate timing and planning of each stage, the success rate of the technique is high and the incidence of complications limited. (Plast. Reconstr. Surg. 108: 83, 2001.)

Longitudinal analysis of mandibular asymmetry in hemifacial microsomia.

&NA; Reconstruction of the mandible is one of the key elements in the skeletal rehabilitation of patients with hemifacial microsomia. Unfortunately, knowledge about longterm mandibular skeletal growth in these patients is lacking. The purpose of this study was to analyze mandibular skeletal growth longitudinally in unoperated hemifacial microsomia patients from childhood to adolescence. The longitudinal records of 26 patients with unoperated unilateral hemifacial microsomia were utilized. The average age at initial records was 3.1 years, and the average age at final records was 16.7 years. Posteroanterior cephalometric radiographs were utilized to evaluate both horizontal and vertical mandibular asymmetry. Patients also were analyzed according to the grade and side of the mandibular deformity. A paired t test (p < 0.05) and a two‐way ANOVA were used to analyze the data. There were 5 patients with grade I, 14 with grade II, and 7 with grade III. The results indicated that the skeletal mandibular asymmetry in hemifacial microsomia is not progressive in nature and that growth of the affected side in these patients parallels that of the nonaffected side. The grade and the side of the mandibular deformity did not influence these findings. These results should be considered when treatment strategies are developed to reconstruct the asymmetrical mandible in hemifacial microsomia.

Craniofacial applications of three-dimensional laser surface scanning.

Recent innovations in technology have generated a variety of techniques for medical imaging. One of these initially developed for industry is laser surface scanning. Laser surface scanning is a noninvasive method for acquiring three-dimensional (3D) images. In this article, the technology of 3D laser surface scanning is described, and a few applications are reported as it relates to craniofacial research and clinical practice. Advantages and disadvantages of this imaging modality are discussed. Three-dimensional laser surface scanning holds great promise as it relates to the documentation, analysis, and evaluation of treatment results in craniofacial anomalies.

Iliac versus cranial bone for secondary grafting of residual alveolar clefts.

Secondary bone grafting of the maxilla in the mixed transitional dentition stage has become a well-accepted procedure in the surgical protocol for rehabilitation of patients with residual alveolar clefts. This retrospective study was undertaken to evaluate and compare the long-term results obtained with iliac or cranial cancellous bone graft material in the area of alveolar clefts and was based on the independent experience of two plastic surgeons from the same center using exclusively cranial or iliac cancellous bone, respectively. The criteria for surgery were similar. The surgical technique, with the exception of the bone-grafting material, also was similar, and all patients were treated by the same group of orthodontists. Fifteen patients from each group, from a total of over 100 patients, were randomly selected and included in the study. All patients were followed up from 18 to 60 months. Operative and perioperative parameters, donor-site morbidity, and long-term results were evaluated, compared, and analyzed. There were no significant differences between the two groups, and equally good results in terms of bone incorporation, tooth eruption, and appearance were obtained with both iliac and cranial bone grafts. We conclude from our study that successful bone grafting is primarily achieved by adherence to meticulous surgical technique, simultaneous closure of coexisting oronasal or palatal fistulae, use of cancellous bone particles only, and coverage of the grafts with well-vascularized flaps. The source of bone graft does not seem to primarily influence the success of the outcome.

Magnetic resonance imaging of the levator veli palatini muscle in speakers with repaired cleft palate.

Objective: To obtain detailed anatomic and physiologic information on the levator veli palatini muscle from MRI in individuals with repaired cleft palate and to compare the results with those from normal subjects reported by Ettema et al. (2002). Design: Prospective study. Setting: University-based hospital. Participants: Four men (ages 22 to 43 years) with repaired cleft lip and palate. Main Outcome Measures: Four quantitative measurements of the levator veli palatini muscle from rest position and dynamic speech magnetic resonance images were obtained: the distance between the origins of the muscle, angle of origin of the muscle, muscle length, and muscle thickness. Results: The length and thickness of the levator veli palatini muscle varied among the subjects and were different from measurements obtained from normal subjects in a previous study. The distance between origin points, length, and thickness of the levator veli palatini muscle were smaller than those of the normal subjects. There were systematic changes of the levator veli palatini muscle, depending upon vowel and consonant types. Levator veli palatini muscle angle of origin and length became progressively smaller from rest, nasal consonants, low vowels, high vowels, and fricative consonants. These changes are consistent with those of the normal subjects. Conclusions: This study contributes to a better understanding of cleft palate anatomy in comparison with normal anatomy of the levator veli palatini muscle. The use of MRI shows promise as an important tool in the diagnosis and eventual aid to treatment decisions for individuals born with cleft palate.

Vitamin C reduces ischemia-reperfusion injury in a rat epigastric island skin flap model

Free radicals have been implicated in the cause of ischemia-reperfusion injury. Various agents have been used in an attempt to reduce ischemia-reperfusion injury pharmacologically, including free radical scavengers. Vitamin C (ascorbic acid), a well-known free radical scavenger, has not, to the best of our knowledge, been evaluated in this respect. Previous work at our institution has shown that vitamin C decreases capillary permeability, thus significantly reducing fluid resuscitation requirements in postburn cases. Because this is due in part to the scavenging effect of vitamin C on free radicals, we investigated the role, if any, of vitamin C on ischemia-reperfusion injury in a rat epigastric island skin flap model. Twenty-four adult Sprague-Dawley rats were divided into control and vitamin C groups. Superficial epigastric island skin flaps measuring 6.0 × 3.5 cm were raised. Pedicles were isolated and occluded with microvascular clamps for 6 hours. The flaps were then sutured back to their beds over Steri-Drape barriers. Fifteen minutes before reperfusion, the control group flaps were perfused via femoral artery cannulation with normal saline (2.5 ml/kg). The vitamin C–treated group was perfused in a similar fashion with 2.5 ml/kg of a vitamin C/normal saline solution (27 mg/ml). The animals were observed for 7 days, and the percentage of flap survival was determined using a paper template technique. The vitamin C–treated group demonstrated a significantly higher percentage of flap survival than did the control group (25.8% mean vs. 7.5% mean, p < 0.025). In this animal model, vitamin C reduced or limited reperfusion injury after 6 hours of ischemia. Its presumed mechanisms of free radical reduction and its relative safety make vitamin C a promising area of investigation in future animal studies as well as in human studies examining reperfusion injury.

Dissecting cellulitis of the scalp

Dissecting cellulitis of the scalp or perifolliculitis capitis abscedens et suffodiens is a rare, chronic, progressive, suppurative disease of the scalp of unknown etiology. It is characterized by painful nodules, purulent drainage, burrowing interconnecting abscesses, and cicatricial alopecia. The pathogenesis is unknown, although it is probably related to follicular occlusion, secondary infection, and deep inflammation. Black men in their second to fourth decade are predominantly affected. Treatment varies from systemic antibiotics to incision and drainage, x-ray epilation of the affected areas, systemic steroid administration, and surgical excision. Our experience with four patients with extensive scalp disease is presented. Wide excision of the affected areas and split-thickness skin graft are favored as our treatment of choice.

Immediate unrestricted feeding of infants following cleft lip and palate repair.

Postoperative feeding regimens after cleft lip and palate repair continue to be a controversial issue. This study was designed to test the feasibility of immediate unrestricted feeding after lip and palate closure with attention to operative outcome or complications. A retrospective analysis of two feeding protocols involved 80 infants with both unilateral and bilateral defects. Protocol A utilized tube and syringe feedings, and protocol B utilized unrestricted bottle or breast feedings. There were no instances of lip or palate wound complications in the unrestricted group. We conclude that immediate unrestricted feeding may be instituted safely, thus improving and simplifying postoperative management after cleft lip and/or palate repair.