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Orbital volume measurements in enophthalmos using three-dimensional CT imaging.

The purpose of this study was to investigate enophthalmos by measuring the volume of various orbital structures using off-line computer techniques on images generated by a CT scanner. Eleven patients with enophthalmos had CT scans of the orbits consisting of 30 to 40 adjacent 1.5-mm slices. The data from the scans were analyzed on a Nova 830 stand-alone computer system using software programs that allowed measurement of total bony orbital volume, total soft-tissue volume, globe volume, orbital fat volume, neuromuscular tissue volume, and apex-to-globe distance in the horizontal plane. These data were analyzed comparing the volumes in the normal eye with the volumes in the enophthalmic eye in each patient. The analysis demonstrated a statistically significant increase in bony orbital volume in the enophthalmic eye, but the total soft-tissue volume, fat volume, neuromuscular tissue volume, and globe volume were the same as in the normal eye. The apex-to-globe distance, a measure of the degree of enophthalmos, was less in the enophthalmic eye than in the normal eye. These results suggest that in the majority of patients, the cause of posttraumatic enophthalmos is increased bony orbital volume rather than by soft-tissue loss or fat necrosis. (Several patients showed no volume discrepancies, and it is likely that cicatricial contracture is responsible for the enophthalmos in these cases.) This study suggests that the objective of surgery for correction of enophthalmos in patients with a volume discrepancy should be to decrease the volume of the bony orbit and to increase the anterior projection of the globe.

Fistula formation and repair after palatal closure : An institutional perspective

&NA; We retrospectively reviewed 119 consecutive patients who underwent cleft palate repair at the Mayo Clinic to determine the incidence of postoperative fistula formation, to assess possible contributing factors, and to review the methods of surgical management. Fistulas of the secondary palate were included, but nasal‐alveolar fistulas and intentionally unrepaired anterior palatal fistulas were excluded. Six patients whose repairs were performed after 2.5 years of age were excluded to ensure a more uniform patient population. Cleft palate fistulas occurred in 13 of the 113 patients (11.5 percent). The median age at repair was 8.2 months, and the median follow‐up period was 5.2 years. Several variables were analyzed by means of the log‐rank test to determine their significance in postoperative fistula formation. Sex, extent of clefting (as estimated by the Veau classification), and type of palatal closure did not significantly affect the rate of fistula formation. However, patients who had palatal closure at an age younger than 12 months had a lower incidence of fistula formation (7.8 percent) than children whose closures were performed between the ages of 12 and 25 months (19.4 percent) (p = 0.058). The strongest predictor of the occurrence of a cleft palate fistula was the surgeon performing the procedure (p = 0.008). Fistula repair was deemed necessary in 11 of 13 patients, and 91 percent of these fistulas were healed with a single operation. Most of these fistulas were closed by using local flaps and two‐layered closures. Cleft palate repair carries a significant but acceptable risk of fistula formation, which can be managed with local flaps. Fistula occurrence is related most to the experience level of the operating surgeon.

The clinical behavior of desmoplastic melanoma

BACKGROUND Desmoplastic melanoma (DM) is a rare variant of malignant melanoma. A better understanding of the clinical course of DM will impact on its treatment. METHODS We reviewed the medical records of 59 patients with DM seen at the Mayo Clinics Scottsdale and Rochester since 1985. RESULTS Thirty-seven (63%) patients were male with a mean age of 62.8 years. The mean DM thickness was 6.5 mm. A total of 23 patients (39%) experienced local recurrence (LR). LR correlated with positive, unknown, or <1 cm margins. Fifty percent of patients who locally recurred subsequently developed metastatic disease. No patients were found to have positive nodal disease during ELND (16) or SLN biopsy (12). Only 1 patient (2%) developed delayed regional node metastases. Sixteen patients developed metastatic disease. The most common site was the lungs (81%). CONCLUSIONS LR is a significant problem and correlates with an increased risk of systemic metastatic disease. With the rare occurrence of lymphatic spread, we recommend patients undergo SLN biopsy only. DM appears to preferentially metastasize to the lungs and should be targeted when evaluating the patient for metastatic disease.

Pilot Study of Association of Bacteria on Breast Implants with Capsular Contracture

ABSTRACT Capsular contracture is the most common and frustrating complication in women who have undergone breast implantation. Its cause and, accordingly, treatment and prevention remain to be elucidated fully. The aim of this prospective observational pilot study was to test the hypothesis that the presence of bacteria on breast implants is associated with capsular contracture. We prospectively studied consecutive patients who underwent breast implant removal for reasons other than overt infection at the Mayo Clinic from February through September 2008. Removed breast implants were processed using a vortexing/sonication procedure and then subjected to semiquantitative culture. Twenty-seven of the 45 implants collected were removed due to significant capsular contracture, among which 9 (33%) had ≥20 CFU bacteria/10 ml sonicate fluid; 18 were removed for reasons other than significant capsular contracture, among which 1 (5%) had ≥20 CFU/10 ml sonicate fluid (P = 0.034). Propionibacterium species, coagulase-negative staphylococci, and Corynebacterium species were the microorganisms isolated. The results of this study demonstrate that there is a significant association between capsular contracture and the presence of bacteria on the implant. The role of these bacteria in the pathogenesis of capsular contracture deserves further study.

Massive abdominal-wall hernia reconstruction with expanded external/internal oblique and transversalis musculofascia

&NA; We describe a technique for expansion and primary closure of massive and large recalcitrant abdominal‐wall hernias in the middle and lower abdomen utilizing expanders placed in the lateral abdominal wall between the external oblique and the deeper complex of the internal oblique and transversalis fasciae. Since this technique describes expansion of the lateral abdominal wall, insertion incisions are made in the lateral abdominal wall away from the primary zone of injury surrounding the abdominal hernia and without interrupting the blood supply or innervation to the abdominal‐wall muscle, fascia, or skin. This technique, described in four patients with massive abdominal‐wall hernias, has been used successfully for primary closure with vascularized autogenous abdominalwall fascia, obviating the need for interposition of prosthetic material or extraabdominal flaps. (Plast. Reconstr. Surg. 100: 326, 1997.)

Update on cranial bone grafts in craniofacial surgery.

A large series of cranial bone grafts performed during a 6-year period is presented. The types of grafts are discussed and the techniques of taking the grafts are described. The complications have been few. Full-thickness skull penetration occasionally occurs but should not be a cause for concern. The skull has gradually become our main bone graft donor site.

Indirect intracranial volume measurements using CT scans: clinical applications for craniosynostosis.

This paper describes a method for obtaining indirect intracranial volume measurements using CT scans with CTpak, a software package for quantitative analysis of CT scan data. The validity of this technique was confirmed by comparing direct measurement of the intracranial volume of five dry skulls with axial scans at 1.5- and 4-mm slice intervals to determine indirect volume. The indirect intracranial volume measurement technique was then used to compare preoperative and postoperative intracranial volume in 30 patients with craniosynostosis who underwent cranial vault and orbital osteotomies with reshaping and advancement. Our findings show that the suture release and simultaneous reshaping procedures usually carried out are, in fact, associated with increased intracranial volume. The observed intracranial volume gain is attributable to a combination of factors, including the surgical procedure carried out and ongoing growth. These factors are further modified by the diagnosis, age of the patient, and time interval between CT scans.

Craniofacial osteotomies to facilitate skull base tumour resection

In order to expose deeply situated tumours of the skull base in various regions, the concept of osteotomies of segments of the facial skeleton has been developed. The portion of skeleton overlying the tumour is removed, the lesion is resected and the removed bony structure is then reinserted. This has greatly facilitated tumour removal in difficult areas. The advantages of this approach are, to the surgeon, total en bloc resection of deeply situated tumours with few complications; for the patient, an improvement in the quality of the aesthetic result following resection of recurrent or potentially lethal tumours.

An anatomic comparison of septocutaneous free flaps from the thigh region.

Various free flaps have been utilized in the thigh region, however there are few systematic clinicoanatomic studies of the thigh region. The purpose of this study is to clarify the clinicoanatomic characteristics of the free septocutaneous thigh flap. Forty-two dissections were carried out in unenbalmed cadavers. The pedicle was observed in all specimens in the anterolateral thigh (ALT), medial thigh, gluteal thigh, and lateral thigh flaps. The pedicle was observed in 46% of the specimens in the anteromedial thigh flap. The pedicle was observed in 86% of the specimens in the posterior thigh flap. The pedicle length (153 ± 23 mm) of the ALT flap was the longest pedicle in the thigh flaps. The internal diameter of the pedicle of the ALT flap (3.0 ± 1.0 mm), which could be used for anastomosis, is the largest in the septocutaneous thigh flaps. The clinicoanatomic characteristics of thigh flaps are clarified.

Vascularized skull bone grafts in craniofacial surgery.

Vascularized skull bone grafts based on a pedicle of temporalis muscle have been used in 30 zygomatic arch and malar reconstructions, 1 mandible reconstruction, and 1 palate reconstruction. The surgical technique, complications, and postoperative results are reviewed. Technetium bone scans obtained within one week of operation confirm blood supply to the transferred bone. After a mean followup of 13 months, there is no evidence of bone graft resorption. We have used a team approach and careful surgical technique, and no serious complications have been encountered.