Structure-based redesign of the catalytic/metal binding site of Cfr10I restriction endonuclease reveals importance of spatial rather than sequence conservation of active centre residues

Thirty years ago, submental fat deposition and platysma band formation were inadequately addressed by surgeons attempting facial rejuvenation procedures. Simple skin envelope tightening as practiced commonly at that time resulted in reappearance of submental bands within months, disappointing both patient and surgeon. During each subsequent decade, existing techniques for aesthetic surgical treatment of the submental and neck areas were refined, and new techniques were introduced. The earliest in this evolution of surgical approaches to rejuvenate the aging submental region was direct excision of redundant anterior cervical skin and platysma muscle bands. Later, periauricular incision approaches without anterior skin excision were used to address platysma muscle bands and remove excess submental fat. Today, the standard approach for submental and anterior neck rejuvenation is some variation of "corset" platysmaplasty and suction-assisted lipectomy both superficial and deep to the platysma muscles. The introduction of endoscopy to plastic surgery has stimulated interest in performing many surgical procedures through limited-incision approaches. While endoscopic techniques may not have a clear application for the submental area, redundant submental soft tissues producing obliquity of the cervicomandibular angle may be treated through a single submental incision approach under direct vision. A technique practiced by the author since 1981 for performing submental lipectomy and platysmaplasty through a single limited anterior submental incision without skin excision is described and discussed. Postoperative compression of the submental area with an elastic garment facilitates smooth skin contraction and redraping for all patients except those with poor or no residual skin elasticity.     

Large arteriovenous malformations of the face: aesthetic results with recurrence control

Large facial arteriovenous malformations are problematic for patients because of grotesque disfigurement, risk of rapid enlargement, and life-threatening rupture. Successful treatment of these relentless complex lesions is one of the most difficult challenges facing plastic surgeons. From a series of 300 large facial arteriovenous malformations, 85 patients were treated with embolization and excision; six of these cases (representing six separate anatomic regions: labial, auricular, eyelid, cheek, chin, and occipitoparietal) were selected for review. The purpose of this article was to look critically at the management of these six facial arteriovenous malformations, including patient presentation, angiographic procedures, surgical planning and technique, and postoperative long-term follow-up care. Lessons learned from the six representative cases provide clues for the management of large facial arteriovenous malformations and demonstrate the possibilities of recurrence and their occasionally relentless behavior. The cases show that long-term control of these lesions with acceptable aesthetic results can be achieved. The mainstay of treatment includes the following: (1) selective intra-arterial embolization with fine catheters and direct lesional embolization; (2) judicious resection and reconstruction with local or expanded tissue flaps; and (3) careful follow-up with serial examinations, duplex, and arteriography.     

Human humoral immune response to Dirofilaria species

BACKGROUND: Keloids are relatively common sequelae of trauma to the skin of the head and neck. A wide variety of treatment approaches developed over the years document the difficulty in eradicating these lesions. OBJECTIVE: To review the senior author's (W.H.L) 15-year experience in treating keloids both medically and surgically. DESIGN: A retrospective analysis of 202 patients with histologically documented keloids of the head and neck with at least a 2-year follow-up. RESULTS: A combination of precise surgical excision, postoperative steroid infiltration, silicone sheeting, and conservative auricular radiotherapy has resulted in an acceptable 15% recurrence rate overall. CONCLUSIONS: The treatment of facial keloids remains a challenge for the facial plastic and reconstructive surgeon. Precise surgical techniques with adjuvant therapies have resulted in a relatively low recurrence rate.     

Fractal estimation of the senile brain atrophy

A survey of senior nurses in 100 randomly selected large (<30000 new patients/year) UK Accident & Emergency Departments (AED) was undertaken to investigate which grade of staff/specialty sutured facial lacerations and to obtain an inter-specialty perspective of standards of care. Of the 80 hospitals whose AED senior nurse responded, half had resident oral and maxillofacial surgeons but only 20% had resident plastic surgeons. Lacerations were mainly sutured by AED doctors (55% of hospitals), oral and maxillofacial surgeons (21%), plastic surgeons (12%) and AED nurses (11%). Overall the highest standard of care was considered to be provided by oral and maxillofacial and plastic surgery registrars and the lowest by nurses and consultants. Overall, oral and maxillofacial surgery services were ranked first, plastic surgery second and A&E third. Monofilament polypamide was the most favoured suture material, but polybutester and polypropylene were also widely used.     

Treatment of American cutaneous leishmaniasis: a comparison between low dosage (5 mg/kg/day) and high dosage (20 mg/kg/day) antimony regimens

There is debate about the margin of normal tissue that should be included with excisions of melanocytic lesions of the skin, and about which lesions should be referred for specialist care. We describe the determinants of the margins of excised melanocytic skin lesions and of referral patterns from primary care. Copies of the pathology reports of melanocytic skin lesions excised from two cities in tropical Queensland were obtained; questionnaires about each lesion were administered to the excising doctor. Data about 3275 lesions (2914 naevi, 130 lentigos, 151 melanomas, 51 dysplastic naevi, 21 Hutchinson's melanotic freckles and eight other melanocytic lesions) were analysed. Twenty-one per cent of the treatment sessions involved the excision of more than one lesion; 5% involved three lesions or more. Most lesions were managed by one doctor. The overall mean margin of excision was 2.8 mm. It was greater for longer qualified doctors, surgeons and college-affiliated general practitioners, for lesions excised to address malignancy (3.0 mm) rather than cosmetic appearance (2.4 mm), for Hutchinson's melanotic freckles (5.9 mm) and melanomas (5.1 mm) compared with benign lesions (2.7 mm) (P < 0.001) and for older patients (2.6 mm for those < or = 15, 3.5 mm for those > 40 years) (P = 0.001). Wider excisions of skin melanocytic lesions are performed by older and more experienced doctors, on older patients, and for lesions in which malignancy is being addressed.     

Facial Impairment Scales for Clefts

The purpose of this paper is to present the Facial Impairment Scales for Clefts. The Facial Impairment Scales for Clefts consist of four, 24-photograph, empirically derived scales of severity of cleft impairment. They were developed (1) to serve as research tools in single and multicenter studies of the surgical, psychosocial, and integrated treatment outcomes of facial clefts and (2) to assist in clinical assessment staging of the aesthetic severity of cleft impairment. Study 1 was conducted to extend the generalizability of the Facial Impairment Scales for Clefts to other groups of raters, including plastic surgeons. Reliability of scale ratings between children (n = 54) and plastic surgeons (n = 23) was examined. Rank orders of photographic subjects by severity of cleft impairment by children were highly correlated with ranks given by plastic surgeons. Study 2 in this series was conducted to assess if new photographs could be reliably fitted to scales. One-hundred and thirty-four medical student raters were able to scale new photographs reliably to the standard measures. These findings suggest that the Facial Impairment Scales for Clefts have sufficient reliability and validity for use in studies of severity of facial impairment.     

Use of octyl-2-cyanoacrylate for skin closure in facial plastic surgery

Octyl-2-cyanoacrylate is a long carbon chain cyanoacrylate derivative that is stronger and more pliable than its shorter chain derivatives. One hundred and eleven patients underwent elective surgical procedures by the same surgeon using either octyl-2-cyanoacrylate or sutures for skin closure at the University of Illinois at Chicago. Most patients underwent excision of benign skin lesions with a mean wound size of 112 mm3. Patients were randomized into either control (vertical mattress suture closure) or test groups (closure with octyl-2-cyanoacrylate). Surgical judgment was used to determine which wounds in each group required application of subcutaneous sutures to relieve tension and aid in skin edge eversion. Generally, full-thickness (through dermis) wounds larger than 1 cm3 required the use of subcutaneous sutures. The time required to close the epidermis with suture (mean, 3 minutes and 47 seconds) was about four times that of octyl-2-cyanoacrylate (mean, 55 seconds). Wounds were evaluated at 5 to 7 days for infection, wound dehiscence, or tissue reaction, and at 90 days using the modified Hollander wound evaluation scale. At 1 year, photographs of the wounds were evaluated by two facial plastic surgeons that graded the cosmetic outcome using a previously validated visual analog scale. There were no instances of wound dehiscence, hematoma, or infection in either group. Results of wound evaluation at 90 days determined by the modified Hollander scal revealed equivalent cosmetic results in both groups. Results of the visual analog scale ratings showed scores of 21.7 +/- 16.3 for the 49 patients treated with octyl-2-cyanoacrylate and 29.2 +/- 17.7 for the 51 control patients treated with sutures. The lower visual analog scale score represented a superior cosmetic outcome at 1 year with the octyl-2-cyanoacrylate as compared with sutures. This difference is statistically significant at p = 0.03. Additionally, patient satisfaction was very high in the group treated with octyl-2-cyanoacrylate.     

Our experience with the use of cerium sulphadiazine in the treatment of extensive burns

The development of the burn disease with infection as the most important complication represents still a major problem in burn patients. With the introduction of the method of early surgical excision of the Af1p4r with immediate grafting in major burns, improved survival has been achieved, particularly in children. However, especially in adults, early massive excisions did not prove to be of much benefit for survival. In these cases, more-or-less sequential staged excisional procedures have been introduced by many renown burn surgeons. In 1976 Monafo et al. presented the cerium nitrate-silver sulphadiazine cream (CSD) combination for topical therapy. The addition of 2.2% of the rare earth metal cerium salt to silversulphadiazine causes the formation of a relatively hard, yellow, leather-like eschar with excellent resistance to infection and good long-term adherence to the burn wound. This allows the surgeon to perform late tangential excision and immediate autografting thus decreasing the open wound size and the rate of severe infections originating in the burn wound itself. We report our experience with the treatment of 20 patients with deep burns exceeding 20% of the BSA with cerium nitrate-silver sulphadiazine cream compared with a similar group of burn patients treated by silver sulphadiazine cream alone. CSD proved to be safe and effective in the treatment of deep and extensive burns. Its advantages include easy and painless application and removal, turning the necrotic skin to yellow, and a leathery crust with good resistance to infection, thus enabling later, or staged, sequential excisions in cases where early massive excisions are not possible.     

Application of endoscopic techniques in aesthetic plastic surgery

Although plastic surgeons had been slow to incorporate endoscopic techniques into their surgical armamentarium, there has been considerable interest in this field during the last 2 years. The aim of endoscopic brow lifting has been to achieve elevation of the brow through small scalp incisions without the associated nerve damage of the open approach and to accurately address excision of the muscles responsible for frowning. Endoscopic neck lift is a more recently pioneered technique which, although still in developmental stages, appears to provide good results. The technique involves undermining the skin of the neck extending from the chain to the jawline around the ear. Endoscopic facelifting is still very much in the experimental stages. Endoscopic techniques reduce the need for an incision in front of the ears. Using the endoscope, it has become a simple matter to perform a transaxillary breast augmentation using very small axillary incisions and precise placement of the implants. This results in excellent symmetry postoperatively and easy scar concealment. Abdominoplasty is another example of a procedure usually associated with a long incision and some degree of postoperative pain and immobility. Endoscopic abdominoplasty has been devised to provide not only contouring of abdominal fat through liposuction, but correction of the weakened abdominal muscle through a small incision placed just above the suprapubic hairline.     

Effects and risks of substituted amphetamines (Ecstasy)]

In a consecutive series of 174 children with low-level spina bifida, there was hindfoot deformity in 263 of the 348 feet; 86 were in equinus, 108 were in calcaneus, 41 were in valgus, 20 were in varus, and eight had convex pes valgus. Surgery was performed on 222 (64%) feet. The deformities were symmetric in 114 children. Spasticity causing deformity necessitated surgery in only 44 feet. Calcaneus deformity in the foot is considerably more common in patients with L4 lesions, and in these circumstances, muscle imbalance is clearly a major factor. However, many patients with calcaneus deformity had L5 or sacral lesions. This suggests that muscle imbalance is not so important a factor as has been thought in the causation of deformity in the lower limb in myelomeningocele.     

Repeatedly successful closure of the larynx for the treatment of chronic aspiration with the use of botulinum toxin A

Botulinum toxin A was used preoperatively to temporarily paralyze the intrinsic laryngeal muscles to hinder movements during the healing period after operation. In addition, toxin was injected into the cricopharyngeal muscle to allow a better passive drainage of the saliva into the esophagus. We treated six patients. Three suffered from chronic aspiration problems after multiple lower cranial nerve lesions, and three patients were apallic (after stroke and major brain injury). Two weeks before scheduled operation, we injected the toxin into the posterior cricoarytenoid muscles, the aryepiglottic muscles, and the vocalis muscle on both sides, as well as the cricopharyngeal muscle. The amount of injected toxin varied between 1.0 and 1.4 mL, equal to 200 to 280 units of botulinum toxin A (Dysport). After a complete palsy of these muscles (controlled by direct electromyography), a closure of the larynx was performed. After laminotomy and exposure of the intralaryngeal structures, the false vocal cords were mobilized and adapted with sutures. Because involuntary movements of the intralaryngeal musculature were absent, primary healing without complications occurred in all cases. Aspiration and related complications disappeared in all patients. In addition, the intensity of patient care could be considerably reduced. Preoperative use of botulinum toxin A allows sufficient laryngeal closure. This procedure is especially useful in the treatment of children and young adults, preserving the ability of later speech rehabilitation because of the return of voluntary movements of the intrinsic laryngeal muscles 6 months after the injection. Furthermore, this technique, as minimal surgical intervention, can be performed in high-risk patients.     

Operative management of adrenal metastases from lung carcinoma

Most surgeons consider patients with solitary adrenal metastasis from a primary lung carcinoma incurable and avoid excision of both the adrenal and primary lung tumors. However, several cases of successful surgical management of these patients recently have been reported. We reviewed 12 surgically treated patients with isolated adrenal and lung disease and identified 2 survivors of greater than fifteen years (17%) and 4 additional patients who are still alive following combined resection (34%). This survival rate, albeit in a selected population, represents an improvement over the natural history of nine months' survival. We suggest that if after six to twelve months of following patients with lung cancer and isolated adrenal metastasis no other evidence of spread of disease is evident, the tumor biology may be favorable and resection of both adrenal and lung lesions is reasonable.     

Quantitative analysis of inputs to somatostatin-immunoreactive descending interneurons in the myenteric plexus of the guinea-pig small intestine

An unusual case of bilateral inflammatory external/internal root resorption developed in the maxillae of a 28 year-old female approximately 4 years following routine segmental orthognathic surgery. The patient experienced dental pain in a tooth adjacent to a segmental osteotomy cut 8 months postsurgery, however, the tooth later became asymptomatic. A definitive diagnosis of inflammatory cervical root resorption was not established until nearly 4 years later on routine dental examination. The external/internal resorptive lesions were located 4 to 6 mm apical to the connective tissue attachment on 3 of the 4 tooth roots adjacent to osteotomy cuts. Two of the affected teeth required non-surgical root canal therapy due to pulpal communication with the resorptive defects. The lesions were accessed by flap surgery, thoroughly debrided, and obturated with an intermediate restorative material until definitive restorative therapy could be completed. All sites healed uneventfully and the patient has been closely observed for approximately 2 years without symptoms or recurrence of the resorptive lesions. Dental health care providers should be alert to the possible occurrence of inflammatory root resorption in sites adjacent to osteotomy cuts over extended periods of time. Routine radiographic examination may be beneficial in the postoperative management of the segmental orthognathic surgery patient.     

Recognizing neoplastic skin lesions: a photo guide

Malignant lesions of the skin are common. Patients who develop squamous cell carcinoma and malignant melanoma often have recognizable precursor conditions. A few skin lesions resemble malignancies. Lesions that are growing, spreading or pigmented, or those that occur on exposed areas of skin are of particular concern. Knowing the similarities and differences between these lesions allows the primary physician to make a diagnosis in most cases by simple inspection and palpation. When in doubt, it is appropriate to perform an excisional biopsy of small lesions or punch biopsy of larger lesions. Removal of premalignant lesions will reduce the occurrence of malignant disease. Almost all skin cancers can be cured by early excision or destruction. For these reasons, physicians should be aware of the risk factors for skin cancer, educate patients about risk reduction and include skin inspection for premalignant and malignant lesions as a part of routine health maintenance examinations.     

Fibula osteoseptocutaneous flap for reconstruction of osteoradionecrosis of the mandible

Osteoradionecrosis of the mandible poses formidable problems for treatment. In the last 6 years, the fibula osteoseptocutaneous free flap was used in 12 cases to replace mandibles with radionecrotic damage. The presence of a pathologic fracture, exposed necrotic bone, or a persistent fistula not responding to conservative treatment were the indications for such a radical approach. Mandible defects after resection were around 8.0 cm long, and in all cases intraoral mucosa, skin, or both were included with the bone excision. All vascularized fibula osteoseptocutaneous flaps transplanted were successful with good primary bone healing. Adequate facial symmetry and improvement in oral function was achieved. No evidence of osteoradionecrosis recurrence was observed after a mean follow-up period of 3 years and 9 months. The advantages of using the fibula osteoseptocutaneous flap for mandible reconstruction are numerous, and good aesthetic and functional results can be obtained when it is used for reconstruction after radical excision of osteoradionecrotic lesions.     

Birth after electroejaculation coupled to intracytoplasmic sperm injection in a gun-shot spinal cord-injured man

Cervical reconstruction after postburn scarring remains a challenge for the plastic surgeon. Several well-known procedures are possible: split or full-thickness skin grafts, local flaps, free skin flaps, expanded skin,... In order to evaluate each technique, three procedures are compared with a long-term follow-up (> or = 1 year): skin expansion, free flap surgery and full-thickness skin grafting. Fifteen patients are reviewed, with five patients operated according to each method. In this study, each burn patient was suffering from a severe neck burn contracture, restricting the neck motility to a few degrees. These patients were operated on by different surgeons, according to their personal indications. The full-thickness skin graft is usually harvested from the abdomen (by means of a miniabdominoplasty) and is applied under a tie-over dressing. This simple procedure has few complications and gives satisfactory results. Skin expansion provides a good texture and color matching but has a higher morbidity and necessitates several procedures. Free flap surgery is time-consuming, gives a good functional result but poor cosmetic aspect (different colour, excessive bulk). Comparing the functional and aesthetic result of the three types of reconstruction in terms of morbidity, neck mobility, skin elasticity, skin sensitivity, matching and scar recurrence, full-thickness skin grafting seems to be the most adequate technique.     

Long-term assessment of CO2 facial laser resurfacing: aesthetic results and complications

Several series have documented the ability of the carbon dioxide laser to smooth facial rhytids; however, follow-up has been limited to several months. Since 1995, more than 600 full or partial facial resurfacings were performed with the pulsed CO2 laser. To assess the long-term efficacy and safety of this procedure, the results of 211 resurfacings were retrospectively reviewed using a custom-designed database. Variables that were input included patient demographics, Fitzpatrick skin type, smoking history, prior and concurrent facial procedures, laser pass data, and postoperative complications. Short and long-term aesthetic results were graded by a blinded panel of plastic surgery reviewers (none of whom performed the laser resurfacing) using a standardized photographic rhytid scale. For each facial region, this scale consisted of eight high-resolution photographs depicting increasingly severe wrinkling. Facial rhytids were almost completely ablated at the 3 and 6 month follow-up. Some relapse was seen at 1 year, but the overall aesthetic result remained very good. Regions with dynamic rhytids (e.g., the perioral region) showed more recurrence. The best and most durable results were seen in the cheeks. Infection and scleral show each occurred in 13 patients (6 percent). Forty-five patients (21 percent) developed postprocedure hyperpigmentation, but the overwhelming majority of this group were treated before our postoperative antipigment regimen. Hypopigmentation was noted in 17 patients (8 percent) in this early follow-up group. Two patients (1 percent) developed postoperative scarring. It is hoped that these data will serve to provide additional information on the long-term results of laserbrasion.     

Leprosy affects facial nerves at the main trunk: neurolysis can possibly avoid transfer procedures

The predilective sites of lesions in leprous peripheral nerves are well established, and their surgical decompression is common practice when sensorimotor disorders persist after medication. By contrast, the precise localization of leprous facial neuropathy still remains unclear, and musculofascial transfers have been the only type of surgical treatment. The goal of this study was to clarify where leprosy affects facial nerves and to determine whether neurolysis might suffice to restore facial function. In five Indian and two Egyptian patients suffering from leprous facial neuritis, the nerves were stimulated transcranially at the brainstem to evoke efferent motor nerve action potentials, which were recorded from the exposed nerves. Lesions were detected at the main trunk proximally from the first bifurcation in all cases. Epineuriotomy revealed fibrosis of the interfascicular epineurium in all instances, as an indication for interfascicular neurolysis. One patient was able to close his eye and showed a better smile soon after surgery. After 16 and 21 months, respectively, one patient had improved distinctly, two patients slightly, two patients showing no progress, and two patients were lost to follow-up. It is concluded that (1) leprous facial neuropathy is located at the main trunk close to the first bifurcation and not exclusively at the peripheral zygomatic branches, (2) microsurgical neurolysis can be considered in leprous facial neuropathy before transfer procedures as long as voluntary or spontaneous activity is present in the affected muscles, and (3) intraoperative transcranial electrical stimulation is an effective means of localizing the site and proximal extent of leprous facial neuropathy.