Circadian entrainment and phase shifting in mammals with melatonin

BACKGROUND: Diathermy procedures are indispensable in interventional endoscopy. Argon beam coagulation is an innovative no-touch electrocoagulation technique in which high-frequency alternating current is delivered to the tissue through ionized argon gas. METHOD AND PATIENTS: Before clinical application, we conducted in-vitro studies to investigate the depth and diameters of tissue coagulation in fresh operative specimens from the stomach, small intestine and colon. Five different power/gas flow settings between 40 and 155 W and 2 and 7 l/min were used. The impact time (1-10s) and the incident angle of the probe (45 degrees and 90 degrees) were also varied. The maximum depth of necrosis was 2.4 mm, the maximum diameter 1.1 cm. No perforation occurred even in critical areas such as the colon and duodenum. We therefore performed argon beam coagulation in 66 consecutive patients. Two power/gas flow settings of 40 and 70 W and 2 and 3 l/min, respectively, were used. The impact time and incident angle were varied individually. RESULTS: In 49 of the 50 patients with oozing haemorrhage from angiodysplastic lesions, polypectomy sites, erosions or ulcers or oozing of blood due to vascular penetration by tumours, definitive haemostasis was achieved in one to two sessions. In all 11 patients with residual sessile adenoma tissue, complete removal was possible. Oesophageal patency was restored in all five patients with stenosing tumours. In one patient with angiodysplasia of the caecal pole, an asymptomatic accumulation of gas in the submucosa was observed which resolved spontaneously. In two patients with extensive oesophageal carcinoma, there was a transitory--also asymptomatic--accumulation of gas in the mediastinum and peritoneal cavity but no evidence of perforation. CONCLUSION: Argon plasma electrocoagulation is an effective and relatively low-cost alternative to laser therapy in gastrointestinal endoscopy.     

Percutaneous suture closure of the femoral artery access after diagnostic heart catheter examination or coronary intervention

BACKGROUND AND OBJECTIVE: Alternative methods to the conventional one of external compression with a pressure bandage over the site of arterial puncture after percutaneous catheter introduction for coronary angiography or transluminal balloon coronary angioplasty have failed to reduce the rate of vascular complications. This study was undertaken to assess the complication rate of a percutaneously introduced suturing device (Techstar, Perclose). PATIENTS AND METHODS: To achieve immediate haemostasis and thus shorten post-interventional immobilisation the technique of percutaneous suturing of the femoral artery was used in 1030 consecutive patients (793 men, 237 women; mean age 58.6 years) without obstructive vascular disease or local vascular complications. RESULTS: Percutaneous suture closure with primary haemostasis was successful after 137 of 153 coronary angioplasties (89.5%) and after 786 of 977 left heart catheterisations (89.6%). Early mobilisation, after at most 4 hours, was possible in 923 patients with successful suture closure (89.6%). The overall complication rate was 0.78%. CONCLUSION: Percutaneous suture repair of the femoral artery after cardiac catheterisation is a safe and effective method to achieve immediate haemostasis. However, controlled studies are needed to demonstrate harmlessness of early mobilisation.     

Platelet functions and haemostasis parameters in pigs: absence of side effects of a procedure of general anaesthesia

Pigs are largely used as experimental animal models of thrombosis and for testing the anti thrombotic drug efficacy. Generally experiments are performed on pigs under general anaesthesia and observations can be affected by the anaesthetic drugs used. The effects of a general anaesthetic procedure were checked on pig haemostasis parameters; the pig was pre-anaesthetized with ketamine chloride, then intubated and ventilated with a mixture containing halothane, nitrous oxide and oxygen. Bleeding time, platelet aggregations, coagulation factors, coagulation inhibitors, fibrinolysis parameters and markers of activation of coagulation were determined on 30 Large White pigs before and under this anaesthesia procedure. Compared to human coagulation, pig is characterized by very high levels of factor V, VIII, IX, XI, XII activities, same levels of factor II, fibrinogen, antithrombin III (ATIII), low levels of protein C activities. Thrombin-antithrombin complex (TAT) and tissue plasminogen activator antigen (tPA) values were dispersed. With the reagents used, protein S, prothrombin fragment 1 + 2 (F1 + 2), D Dimers (D-D), plasminogen activator inhibitor (PAi) levels could not be determined. No difference was observed between results obtained before and under anaesthesia, particularly to increase of bleeding time, no modification of platelet aggregations and no activation of coagulation. This anaesthetic procedure does not induce any modification of pig haemostasis and can be used, without side effects, for experimental thrombosis studies in pigs.     

Tumorous necrotic nodule in the liver: unexpected effect of the microwave tissue coagulator

The microwave tissue coagulator (MTC) is used in hepatectomy because it provides excellent haemostasis during the procedure. A 59 year old man underwent partial hepatic lobectomy with MTC, for metastasis from colon cancer. A tumorous necrotic nodule was discovered in the liver. The nodule measured 2.5 cm at its largest diameter. Microscopically, it showed extensive coagulation necrosis and massive sinusoidal dilatation. To date, such a necrotic mass clinically mimicking neoplasm has not been reported as a complication of hepatectomy using MTC. Although it is unknown how the rounded necrotic nodule was formed in this case, clinicians should be aware of this phenomenon to avoid unnecessary operations. Likewise, pathologists should recognise such histological changes and review the clinical history of the patient when coagulation necrosis with massive sinusoidal dilatation is observed in a biopsy or hepatectomy specimen.     

Impulsive aggression: a behavior in search of clinical definition

During a 10-year period, 110 patients underwent mitral valve replacement (MVR). We experienced three left ventricular ruptures among these patients. Two had a type I immediate rupture, and one had a type III delayed rupture. Two patients (type I, III) survived after repair of the rupture. It was possible to control bleeding by manual compression with oxidized cellulose, collagen mat and fibrin glue with or without external mattress sutures. Following the repair, an intra-aortic balloon pump and sedative agents were used in both patients. In the other patient with a type I early rupture, control of bleeding was attempted by external direct suture using Teflon felt. The bleeding was controlled by this repair and the use of a left ventricular assist device, but the patient died of a brain infarction 5 days after the operation. The manual compression technique using oxidized cellulose, collagen mat and fibrin glue may be useful for minor lacerations, and for reinforcing repairs. The intra-aortic balloon pump and continuous sedation are useful for unloading the ventricle and reducing the tension on repairs.     

Tissue fixation security in transosseous rotator cuff repairs: a mechanical comparison of simple versus mattress sutures

The primary purpose of this investigation was to compare tissue fixation security by simple sutures versus mattress sutures in transosseous rotator cuff repair. These two repair techniques were each performed in 17 human cadaver shoulders, with two bone tunnels being used for the repair by two simple sutures and two other bone tunnels being used for the repair by one mattress suture. The repairs were loaded to failure in a servohydraulic materials test system. Rotator cuff repair by simple sutures was found to be significantly stronger than repair by mattress sutures (P = .0007). The average ultimate load to failure for the simple suture construct (189.62 N) was 39.72% greater than that for the mattress suture construct (135.71 N). Most of the failures occurred by suture breakage at the knot. Load-sharing by multiple suture tails and multiple knots in the simple suture configuration likely contributed to its superior strength characteristics compared with the mattress suture configuration.     

Perinephric abscess (presenting as abdominal pain) due to Listeria monocytogenes

The development of a haematoma after wide excision of breast tumours is not uncommon. Suction drainage is commonly used to prevent this but often increases the hospital stay and can create unsightly wounds. Argon beam coagulation is a new technique which permits large 'raw' areas to be coagulated with minimal tissue damage. We believe that this technique may reduce the development of haematomas and seromas after breast surgery. We present our initial results using argon beam coagulation after wide excision of breast tumours in 80 patients without suction drainage. One patient required a single aspiration of a seroma at the site of breast lump excision and none required surgical drainage. Argon beam coagulation appears a useful adjunct in breast surgery and may help reduce hospital stay.     

Load to failure of common meniscal repair techniques: effects of suture technique and suture material

Success of meniscal repair with early or immediate motion depends on the ability of the suture fixation to withstand the loads applied. Vertical and horizontal mattress suture techniques were tested using 2-0 Ethibond, and 0-PDS and 1-PDS sutures (Ethicon, Somerville, NJ). Mulberry knot technique was tested with 0-PDS and 1-PDS sutures. Twenty menisci (60 sutures) were tested for each suture material. Sutures were placed 3 to 4 mm from the peripheral edge of the meniscus with double barreled cannulas for vertical and horizontal mattress techniques or a spinal needle for the mulberry knot technique, reproducing clinical techniques of meniscal repair. Mechanical testing of suture fixation was performed to failure at a rate of 10 mm/min on a MTS material testing system (MTS Systems Corp, Minneapolis, MN). Suture pullouts were reported as the load displacement to failure from the inner fragment only, because clinical failure would ensue should a suture pull through the inner fragment of a tear. Vertical mattress technique with 1-PDS suture had significantly greater load to failure than any other combination (P < .05). Analysis of variance showed that the vertical mattress technique had statistically superior pullout strength (P < .0001) compared with the horizontal mattress and mulberry knot techniques, which were statistically similar. There were significant differences (P < .0001) between suture types, with 1-PDS proving best compared with 0-PDS, which was stronger than 2-0 Ethibond. Selection of suture material had the greatest impact on vertical mattress load to failure and was not important to the strength of the other techniques.     

Laparoscopic partial nephrectomy: initial experience and comparison to the open surgical approach

During an 18-month period, 6 laparoscopic partial nephrectomies were attempted, 4 of which were successful. The surgical technique was modified and improved between cases aided by new laparoscopic instrumentation, such as the argon beam coagulator and the 7.5 MHz. ultrasonic sector scanning system. In a retrospective comparison between laparoscopic and open partial nephrectomy, estimated blood loss was 525 ml. for the former versus 708 ml. for the latter procedure. However, operating time was more than 2 hours longer with the laparoscopic approach. The major advantages of the laparoscopic procedure appear to be a more rapid return to full diet, less postoperative pain and less requirement for parenteral narcotics. Despite the small size of this series and limited followup data, convalescence may be shortened by 4 weeks after laparoscopic partial nephrectomy. Patients with benign diseases of the kidney, especially with a duplicated collecting system, who require partial nephrectomy may be considered candidates for the laparoscopic approach. The advantages to the patient, however, may be offset by the technical demands on the surgeon.     

Cavernous hemangioma of the rectum--a rare cause of peranal hemorrhage

We report the case of a 34-year-old woman with severe rectal bleeding since the age of 17. The cause of the bleeding was a cavernous haemangioma of the rectum. The extent of the disease was not realised for many years. Sclerosing injections, laser coagulation and even suture ligation were helpful in acute bleeding episodes but did not result in definitive healing. Finally cure was achieved by resection of the rectum and colo-anal sleeve anastomosis. The clinical presentation and the management are described and discussed.     

Comparative study of biological glues: cryoprecipitate glue, two-component fibrin sealant, and "French" glue

BACKGROUND: Although biological glues have been used clinically in cardiovascular operations, there are no comprehensive comparative studies to help clinicians select one glue over another. In this study we determined the efficacy in controlling suture line and surface bleeding and the biophysical properties of cryoprecipitate glue, two-component fibrin sealant, and "French" glue containing gelatin-resorcinol-formaldehyde-glutaraldehyde (GRFG). METHODS: Twenty-four dogs underwent a standardized atriotomy and aortotomy; the incisions were closed with interrupted 3-0 polypropylene sutures placed 3 mm apart. All dogs had a 3- by 3-cm area of the anterior wall of the right ventricle abraded until bleeding occurred. The animals were randomly allocated into four groups: in group 1 (n = 6) bleeding from the suture lines and from the epicardium was treated with cryoprecipitate glue; in group 2 (n = 6) bleeding was treated with two-component fibrin sealant; group 3 (n = 6) was treated with GRFG glue; group 4 (n = 6) was the untreated control group. The glues were also evaluated with regard to histomorphology, tensile strength, and virology. RESULTS: The cryoprecipitate glue and the two-component fibrin sealant glue were equally effective in controlling bleeding from the aortic and atrial suture lines. Although the GRFG glue slowed bleeding significantly at both sites compared to baseline, it did not provide total control. The control group required additional sutures to control bleeding. The cryoprecipitate glue and the two-component fibrin sealant provided a satisfactory clot in 3 to 4 seconds on the epicardium, whereas the GRFG glue generated a poor clot. There were minimal adhesions in the subpericardial space in the cryoprecipitate and the two-component fibrin sealant groups, whereas moderate-to-dense adhesions were present in the GRFG glue group at 6 weeks. The two-component fibrin sealant was completely reabsorbed by 10 days, but cryoprecipitate and GRFG glues were still present. On histologic examination, both fibrin glues exhibited minimal tissue reaction; in contrast, extensive fibroblastic proliferation was caused by the GRFG glue. The two-component and GRFG glues had outstanding adhesive property; in contrast, the cryoprecipitate glue did not show any adhesive power. The GRFG glue had a significantly greater tensile strength than the two-component fibrin sealant. Random samples from both cryoprecipitate and the two-component fibrin glue were free of hepatitis and retrovirus. CONCLUSIONS: The GRFG glue should be used as a tissue reinforcer; the two-component fibrin sealer is preferable when hemostatic action must be accompanied with mechanical barrier; and finally, the cryoprecipitate glue can be used when hemostatic action is the only requirement.     

Occlusion of the semicircular canal using argon laser

The effects of argon laser on the bony semicircular canals were studied in the guinea pig. After intraperitoneal administration of Nembutal, the bulla was opened in order to approach the lateral and posterior canals. The anterior canal was approached through the posterior fossa. The argon laser was applied through a probe which was connected to a device from HGM Medical Laser Systems. One of the three semicircular canals was irradiated one to several times by argon laser (1.0-1.5 W x 0.5 sec). Histopathologic examination of the temporal bones revealed that the semicircular duct shrank immediately after irradiation. The laser produced a charred area in the bony canal wall. The semicircular canals gradually became fibrotic and ossified and completely occluded within several weeks. Heat produced in the bony canal may be responsible for the morphologic changes. On delayed observation, the cochlea of the canal-irradiated animals showed no morphologic changes. Auditory brain stem responses were normal. Caloric stimulation using 5 ml/5 sec of ice water revealed no response in the lateral canal-irradiated animals.     

Interleukin-6 stimulates coagulation, not fibrinolysis, in humans

The role of IL-6 as a mediator of haemostatic changes during severe inflammation is controversial. To assess the effect of IL-6 on haemostasis we conducted a controlled cross-over study in eight patients with metastatic renal cell cancer. In all subjects coagulation and fibrinolysis were monitored during and after a 4-h infusion of either 150 micrograms recombinant human (rh) IL-6, or during infusion of saline (control study). Mean maximum IL-6 concentrations were 1418.0 +/- 755.8 pg/ml. Compared to the control study, rhIL-6 induced activation of coagulation as reflected by a 190 +/- 55% increase in the plasma levels of thrombin-antithrombin III complexes (p < 0.001) and by a 24 +/- 11% increase in the plasma levels of in the prothrombin activation fragment F1 + 2 (p < 0.001). In contrast, fibrinolysis was not affected. We conclude that in severe inflammation IL-6 may contribute to the activation of coagulation, whereas other factors mediate changes in fibrinolysis.     

Progression of interproximal caries in the primary dentition

In the patients with invasion to the aortic window, we performed operation via median sternotomy combined with anteroaxillar thoracotomy. In such patients with T4 invasion, conventional pneumonectomy could not be performed because of the extensive invasion near the main pulmonary artery trunk. In these patients in this study, complete resection of the involved pulmonary artery could be performed using a vascular clamp without CP bypass. Operative technique was as follows: first, the pericardium was opened and taping of the aorta was applied. When the uninvolved part of the intrapericardial pulmonary artery was long enough to cut, we could use a stapling device, but the stapling device could not be used in many cases because the length of the uninvolved segment was too short to cut the left pulmonary artery. In order to carry out complete resection, it was necessary to clamp the central part of the main pulmonary artery diagonally from the left lower side to the right upper side. The pulmonary arterial stump was closed with continuous 4-0 monofilament mattress and over and over suture. We recommend an aggressive surgical approach for the tumor with invasion to the aortic window, because the prognosis is dismal in nonresected locally advanced lung cancer.     

Occlusive ligature and standardized fenestration of a Baerveldt tube with and without antimetabolites for early postoperative intraocular pressure control

OBJECTIVE: To determine the effectiveness of a surgical modification for a nonvalved aqueous tube shunt in controlling intraocular pressure (IOP) in the early postoperative period. The effect of antimetabolite use on IOP also was studied. DESIGN: A retrospective study of consecutive patients who underwent modified Baerveldt 350-mm2 implant with varied, nonrandomized, exposure to antimetabolites. PARTICIPANTS: Fifty-one eyes of 46 patients with uncontrolled glaucoma were examined. INTERVENTION: Identical surgical modification of a Baerveldt 350-mm2 tube was performed in all cases and consisted of placement of an occlusive 7-0 polyglactin suture just anterior to the plate followed by a through-and-through penetration of the tube just anterior to the occlusive ligature with a standardized 15 degrees blade. Seventeen eyes were not exposed to antimetabolite, while 2 groups of 17 eyes had 3 minutes' episcleral exposure to either 5-fluorouracil 50 mg/ml or mitomycin C 0.4 mg/ml at the location corresponding to the fenestration. The Tenon's layer and conjunctiva were not exposed because of concerns regarding conjunctival erosion over the device. MAIN OUTCOME MEASURE: Intraocular pressure and number of antiglaucoma medications required were analyzed. RESULTS: For the group, mean IOP before surgery and on postoperative days 1, 4, 10, 21, 42, 63, 84, and 112 was (in millimeters of mercury) 34.6, 20.1, 17.0, 17.2, 22.0, 17.3, 18.7, 17.4, and 15.6, respectively. There was an elevation of IOP at day 21 relative to fibrotic blockage of the fenestration before suture autolysis. This was temporized with antiglaucoma medication until suture autolysis occurred or treated with laser suture lysis (8 eyes). On day 1, hypotony occurred in 3 (6%) eyes whereas IOP greater than 30 mmHg was observed in 13 (26%) eyes. By day 10, the frequency had decreased to one (2.1 %) eye and three (6.4%) eyes, respectively. The use of antimetabolites did not result in lower IOP or less medication needed for any group at any interval (analysis of variance). CONCLUSION: This modification of a nonvalved glaucoma tube shunt device provides adequate IOP control in the early postoperative period with a low rate of hypotony and surgical complications. If elevation of IOP occurs before suture autolysis, it generally is well controlled by antiglaucoma medications or laser suture lysis. Antimetabolite exposure did not influence early postoperative IOP in this study.     

Cystic fibrosis transmembrane conductance regulator mediates the cyclic adenosine monophosphate-induced fluid secretion but not the inhibition of resorption in mouse gallbladder epithelium

The haemostatic system and the use of heparin during cardiopulmonary bypass (CPB) have been studied extensively in adults but not in children. Results from adult trials cannot be extrapolated to children because of age-dependent physiologic differences in haemostasis. We studied 22 consecutive paediatric patients who underwent CPB at The Hospital for Sick Children, Toronto. Fibrinogen, factors II, V, VII, VIII, IX, XII, prekallikrein, protein C, protein S, antithrombin (AT), heparin cofactor II, alpha 2-macroglobulin, plasminogen, alpha 2-antiplasmin, tissue plasminogen activator (tPA), plasminogen activator inhibitor, thrombin-AT complexes (TAT), D-dimer, heparin (by both anti-factor Xa assay and protamine titration) and activated clotting time (ACT) were assayed perioperatively. The timing of the sampling was: pre heparin, post heparin, after initiation of CPB, during hypothermia, post hypothermia, post protamine reversal and 24 h post CPB. Plasma concentrations of all haemostatic proteins decreased by an average of 56% immediately following the initiation of CPB due to haemodilution. During CPB, the majority of procoagulants, inhibitors and some components of the fibrinolytic system (plasminogen, alpha 2 AP) remained stable. However, plasma concentrations of TAT and D-dimers increased during CPB showing that significant activation of the coagulation and fibrinolytic systems occurred. Mechanisms responsible for the activation of haemostasis are likely complex. However, low plasma concentrations of heparin (< 2.0 units/ml in 45% of patients) during CPB were likely a major contributing etiology. ACT values showed a poor correlation (r = 0.38) with heparin concentrations likely due to concurrent haemodilution of haemostatic factors, activation of haemostatic system, hypothermia and activation of platelets. In conclusion, CPB in paediatric patients causes global decreases of components of the coagulation and fibrinolytic systems, primarily by haemodilution and secondarily by consumption.     

The utilization of a biological adhesive for wound treatment: comparison of suture, self-sealing sutureless and cyanoacrylate closure in the tensile strength test

We produced a measurement apparatus for testing the tensile strength of wounds during cataract surgery, and tested the tensile strength of treated wounds including wounds sutured with various methods, non-sutured and wounds treated with various bio-tissue adhesives. METHODS: In cataract surgery on white rabbits eyes, a corneoscleral incision 5 mm in length was made 2.5 mm from the limbus corneae, and entry into the anterior chamber was obtained 0.5 mm to the clear cornea. After treatment for closure, the corneoscleral piece was subjected to the tensile strength test. RESULTS: The tensile strengths just after surgery were (1) 0 gf/mm2 after self-sealing sutureless closure; (2) 114 gf/mm2 after vertical suture closure (one stitch with 10-0 nylon); (3) 125 gf/mm2 after horizontal suture closure (one stitch with 10-0 nylon); (4) 143 gf/mm2 after infinity suture closure (with 10-0 nylon); (5) 112 gf/mm2 after fibrin glue (Beriplast P) application (instilled on the surface of scleral incision); (6) 121 gf/mm2 after fibrin glue application (glued on corneoscleral wound); (7) 131 gf/mm2 after cyanoacrylate closure (instilled on the surface of scleral incision); (8) 139 gf/mm2 after cyanoacrylate closure (glued on corneoscleral wound). The respective strengths at four days after surgery were: (1) 86; (2) 131; (3) 137; (4) 175; (5) 109; (6) 43; (7) 138; and (8) 108 gf/mm2. At 28 days after surgery, the respective strengths were (1) 164; (2) 167; (3) 184; (4) 209; (5) 322; (6) 195; (7) 251; and (8) 175 gf/mm2. CONCLUSION: The use of fibrin glue in treatment of a wound in cataract surgery is beneficial in assisting this treatment.     

Multimodal treatment strategy for locally advanced breast cancer

BACKGROUND AND OBJECTIVE: To determine the efficacy of topical tissue plasminogen activator (tPA) for the resolution of postoperative or inflammatory intraocular fibrinous exudates. PATIENTS AND METHODS: Each treatment consisted of drops of 1 mg/ml tPA given 9 times 5 minutes apart. Records were reviewed and the results at 24 and 48 hours were recorded. Sixty-two patients had a total of 94 treatments. RESULTS: Fibrin exudates following intraocular surgery in 34 patients were treated 44 times. In 6 patients there was a positive result. Fibrin associated with intraocular infection was treated in 9 patients. None showed clear improvement. Nineteen patients had a total of 34 treatments for poorly controlled intraocular pressure (IOP) after glaucoma surgery. Five patients showed adequate control of the IOP, 12 did not change, and 2 had a questionable improvement. Eleven patients had adequate IOP control after additional treatment. Seven required suture lysis, 2 ab interno bleb revision, and 2 YAG capsulotomy or iridotomy to reduce the IOP to an acceptable level. CONCLUSIONS: Within the limits of this retrospective study and taking into account that fibrin may resolve spontaneously, it appears that topical tPA drops are not effective for the liquefaction of intraocular fibrin after surgery or in association with intraocular inflammation. They did not improve IOP control after glaucoma surgery.     

Linkage between inflammation and coagulation: an update on the molecular basis of the crosstalk

Inflammation and coagulation cannot be considered as two separate processes, since there are several connecting points making them part of unique, defensive host response. The endothelium can be considered as the first link between inflammation and coagulation, since damaged endothelium during inflammation represents a surface where proteins involved in both coagulation and the development of inflammation are expressed. During inflammation, cytokines modulate the coagulation system by downregulating the expression of thrombomodulin and the activation of protein C pattern but, at the same time, they induce the expression of tissue factor, modifying, in this way, the balance between procoagulant and anticoagulant activities. At the same time, at the site of tissue injury, platelets become activated and release several mediators that modify tissue integrity. Thrombin, formed following activation of the coagulation cascade, is essential to promote haemostasis but also stimulates several cell functions, including chemotaxis and mitogenesis, which are responsible for the spreading of the lesion and the tissue repair process. Therefore, in the study of inflammation the involvement of the coagulation pathway has to be taken into account, since the interaction between coagulation and inflammation pathways is a critical issue.     

The celluloid-acetone-dressing in palatoplasty

The article describes an older, simple, and effective method of postoperative fixation of the palatal flaps using celluloid-acetone dressing (CAD). Veau pedicle flaps and the construction of two nasal meatuses are used for the palatoplasty. After the surgery, a wire is round around teeth IV and V on each side: a prolene mattress suture, instead of wire, is used for infants without teeth. A celluloid-acetone paste is applied to the wire or suture over a layer of gauze and petroleum jelly. The CAD mixture hardens in less than 1 hour and is removed after 4 days by cutting the wire or suture. This method prevents the palatal flaps from descending; scar tissue is minimal, and assists in the formation of a high-arched roof of the palate. In addition, the patient feeds normally after the operation.