Automated tracking of facial features in patients with facial neuromuscular dysfunction.

Facial neuromuscular dysfunction severely impacts adaptive and expressive behavior and emotional health. Appropriate treatment is aided by quantitative and efficient assessment of facial motion impairment. We validated a newly developed method of quantifying facial motion, automated face analysis (AFA), by comparing it with an established manual marking method, the Maximal Static Response Assay (MSRA). In the AFA, motion of facial features is tracked automatically by computer vision without the need for placement of physical markers or restrictions of rigid head motion. Nine patients (seven women and two men) with a mean age of 39.3 years and various facial nerve disorders (five with Bell's palsy, three with trauma, and one with tumor resection) participated. The patients were videotaped while performing voluntary facial action tasks (brow raise, eye closure, and smile). For comparison with MSRA, physical markers were placed on facial landmarks. Image sequences were digitized into 640 x 480 x 24-bit pixel arrays at 30 frames per second (1 pixel congruent with0.3 mm). As defined for the MSRA, the coordinates of the center of each marker were manually recorded in the initial and final digitized frames, which correspond to repose and maximal response. For the AFA, these points were tracked automatically in the image sequence. Pearson correlation coefficients were used to evaluate consistency of measurement between manual (the MSRA) and automated (the AFA) tracking methods, and paired t tests were used to assess the mean difference between methods for feature tracking. Feature measures were highly consistent between methods, Pearson's r = 0.96 or higher, p < 0.001 for each of the action tasks. The mean differences between the methods were small; the mean error between methods was comparable to the error within the manual method (less than 1 pixel). The AFA demonstrated strong concurrent validity with the MSRA for pixel-wise displacement. Tracking was fully automated and provided motion vectors, which may be useful in guiding surgical and rehabilitative approaches to restoring facial function in patients with facial neuromuscular disorders.

An unusual presentation of a linear epidermal nevus.

We report an unusual presentation of a linear epidermal nevus in an adolescent male. Epidermal nevi most commonly appear in infancy and early childhood. They often are found in association with other organ system anomalies. We describe a palmar linear epidermal nevus that caused impairment of the patient's use of his hand. Therapeutic management involved surgical excision of the nevus and reconstruction of the area with a full-thickness skin graft.

The natural history of the growth of the hand: I. Hand area as a percentage of body surface area.

The use of a patient's own hand as a tool to estimate the area of burn injury is well documented. The area of the palmar surface of one hand has been estimated to be 1 percent of the body surface area. The area of the palmar surface of the hand was measured to test the accuracy of this estimate and then compared with the body surface area as calculated by formulas in common use. This study also sought to determine the natural history of the growth of the hand to permit development of a readily available, bedside means of estimating hand area and body surface area. Bilateral hand tracings were obtained from 800 volunteers ranging in age from 2 to 89 years. The area of each tracing was determined using an integrating planimeter. The height and weight of each individual were measured, and his/her body surface area was calculated. The palmar hand's percentage of body surface area was determined by calculating the quotient for hand area divided by body surface area. Additionally, the width of the hand was measured from the ulnar aspect at the palmar digital crease of the small finger to the point where the thumb rested against the base of the index finger. The length of the hand was measured from the middle of the interstylon to the tip of the middle finger. These two figures were multiplied together to obtain a product which approximated the area of the hand. Based on the most commonly used DuBois formula for calculating body surface area, the area of palmar surface of the hand corresponds to 0.78 +/- 0.08 percent of the body surface area in adults. The percentage varies somewhat with age and reaches a maximum of 0.87 +/- 0.06 percent in young children. Multiplying the length of the hand by its width overestimates the area of the hand as determined by planimetry by only 2 percent. A patient's own hand may be used as a complementary, readily available template for estimation of burn area or other areas of disease or injury. In adults, the area of tracing of the outline of the hand is 0.78 percent of the body surface area, whereas in children, this number tends to be slightly higher. In the emergency room or on the wards, a simple product of length multiplied by width of the hand will closely approximate the area as determined by planimetry. This method allows a more accurate determination of the area of the palmar surface of the hand than the 1 percent estimate, which may lead to an overestimation of the size of a burn wound in adults.

Mycobacterium chelonae: nonhealing leg ulcers treated successfully with an oral antibiotic.

BACKGROUND: Mycobacterium chelonae is an important human pathogen and should be considered when a physician is faced with nonhealing cutaneous wounds, including ulcers of the lower leg. METHODS: The medical literature was searched from 1965 to the present using the key words "Mycobacterium chelonae" and "leg ulcers." A case of Mycobacterium chelonae infection is reported. RESULTS AND CONCLUSION: Clarithromycin as single-agent oral therapy has been effective in treating these infections once the proper diagnosis is established. Diagnosis of M. chelonae infection requires being alert to this infectious agent and obtaining cultures for mycobacteria. Aggressive surgical debridement with direct excision of the wound might now be unnecessary because of the effectiveness of oral clarithromycin administered as a single oral agent.

Occult craniocerebral injuries from dog bites in young children.

Although dog bite injuries to the head and scalp of children occur frequently, penetrating dog bite wounds to the cranial vault occur only occasionally and may go unnoticed on initial examination. Substantial morbidity and mortality can ensue if these penetrating injuries are not detected and treated. The authors detail the evaluation of dog bites of the scalp in young children. They highlight the ease with which puncture wounds of the calvarium may be missed during physical examination as a result of scalp displacement at the time of puncture. The cranial puncture may not be large and may later be covered by scalp that returns to its native position. Well-scrutinized skull films and a careful, methodical physical examination are advocated. Recognized craniocerebral injuries should be explored. Depressed cranial fractures should be irrigated, debrided, and elevated. Dural tears should be repaired. Expedient management is necessary to prevent meningitis and its associated sequelae.

Natural history of the growth of the hand: part II--hand length as a treatment guide in the pediatric trauma patient.

BACKGROUND: In a previous study, we defined the natural history of the growth of the hand. In particular, we demonstrated that the palmar aspect of the hand is approximately 0.78% of body surface area (BSA). We also demonstrated a relationship between the area of the palmar surface of the hand and the total BSA as growth proceeds. Seeking to improve the usefulness of hand size as a guide to predicting body size, we examined the length of the hand as a predictor of body mass and BSA. METHODS: Bilateral hand tracings were obtained from 800 volunteers ranging in age from 2 to 89 years. The hand tracings were measured, and the length and width of the hands were determined. The height and weight of each individual were measured, and his or her BSA was calculated. The data was subjected to statistical and graphical analyses. RESULTS: Hand length is an excellent predictor of BSA and body mass. Hand length as a predictor of body size is independent of the gender of the subject and most accurate for ages 2 to 17 years. The correlation is so highly predictive that it is possible to derive a treatment guide based on hand length. The length of the hand predicts body weight and BSA and can be used to predict baseline intravenous fluid requirements and the volume of packed red blood cells to be transfused to raise the hematocrit 3%. CONCLUSIONS: Hand length is a simple measurement that may be used as a treatment guide. Hand length will predict body weight and body surface area independently of the gender of the subject.

The surgical treatment of Molluscum contagiosum in a pediatric AIDS patient.

Molluscum contagiosum (MC) has arisen as an opportunistic pathogen in human immunodeficiency virus (HIV) disease. Recent reports have focused on the presentation of MC in adults who are HIV positive. The authors describe MC in a pediatric patient with acquired immmune deficiency syndrome. This particular patient showed the same atypical lesion morphology, distribution, and chronic course that is seen in the adult HIV patient. As in the adult patient, treatment in the pediatric patient also remains challenging, with limited success of traditional treatment modalities. The authors were able to achieve long-term remission and an excellent cosmetic result through meticulous superficial surgical excision of the patient's MC lesions.

Management of alcohol withdrawal in microvascular head and neck reconstruction.

Alcohol use is a risk factor for head and neck cancer. One of the primary therapeutic modalities is surgical tumor ablation followed by immediate reconstruction. Such therapy places patients in a controlled environment, without alcohol, creating the risk of alcohol withdrawal syndrome. The authors attempted to identify the incidence of alcohol withdrawal among patients undergoing free-flap reconstruction for head and neck cancer and were interested in the effect of alcohol withdrawal on the postoperative course of affected patients. In this retrospective review of 51 patients, six experienced alcohol withdrawal or delirium tremens. No difference in the rate of overall complications was seen between the patients who experienced withdrawal and those who did not, although patients who experienced withdrawal did have a statistically significant ratio of non-flap-related to flap-related complications. A review of the current management for alcohol withdrawal is included and places an emphasis on preoperative screening, close observation, rapid diagnosis, and immediate medical care.

Relationship between muscle activity of the frontalis and the associated brow displacement.

Although the relationship between regional facial muscle activity and resultant displacement of the face is important to the refinement of many of the treatments of facial paralysis and palsy, this relationship has not been adequately explored. We analyzed the relationship between frontalis muscle activity as measured with surface electromyography and the associated eyebrow displacement as measured with the maximal static response assay in 16 human volunteers. We hypothesized that graded, sustained muscle activity would correlate with graded, sustained elevation of the eyebrow. We found that (1) the relationship between the muscle activity and the corresponding displacements was best described by activity versus displacement squared (r2 = 0.993); (2) there was a wide variation between individual brows for the relationship between muscle activity and displacement; (3) there was a normal amount of asymmetry of the relationship between muscle activity and displacement between the two brows of a subject; (4) left and right frontalis generated the same amount of muscle activity, but left brows elevated significantly higher; (5) the method of simultaneous measurement of muscle activity and displacement used in this study yielded results similar to those previously reported; and (6) the methods used in this study are useful to further investigate the relationship between muscle activity and displacement.

Tissue expander infections in children: look beyond the expander pocket.

Infection of the expander pocket is the most common complication encountered with soft-tissue expansion. It is usually due to direct inoculation with skin flora either at the time of expander insertion or from extrusion of the device. The authors report two cases of infection of tissue expanders in which the children had concomitant infected sites distant from the prosthesis. Etiological bacteria of common pediatric infections like otitis media and pharyngitis were cultured from the infected expander pocket, raising suspicion that translocation of the organism to the expander had occurred. Aggressive antibiotic treatment, removal of the prosthesis, and flap advancement is advocated.

Replantation of the midfoot in a child--six-year follow-up with pedobarographic analysis.

A 22-month old child underwent successful replantation of her midfoot at the level of Chopart's joint after a traumatic lawn mower amputation. The child demonstrated good sensation and function. Heel-to-toe length was 2 cm shorter, along with anterior migration of the heel pad on the injured foot. Pedobarographic analysis at 6-year follow-up demonstrated a normal range in the dynamic distribution of foot pressure measurements, except in the region of the medial heel. With replantation more commonly considered as an option in traumatic injuries, long-term functional evaluation is important in demonstrating the success of a replantation. The patient demonstrated a good result at 6-year follow-up, but will need further evaluation until skeletal maturity is reached.

A comparison of gradual distraction techniques for modification of the midface in growing sheep.

The authors carried out experiments to advance the midface in growing sheep using a distraction force across the zygomaticomaxillary sutures. They wished to assess the possibility of performing distraction osteogenesis across intact sutures as well as distraction after Le Fort osteotomies. Their results demonstrate that the technique of gradual distraction after osteotomy is successful in the growing animal. Bilateral distraction across intact sutures did not advance the midface or change the dental relationship. Unilateral distraction was successful in angulating the midface away from the distracting force in the intact growing animal. Alternating unilateral distraction or "waltzing" was surprisingly effective in advancing the midface in one of the animals studied and may become applicable in some craniofacial deformities. In all intact animals there was some expansion of the zygomaticomaxillary suture as well as a substantial migration of the distraction devices through the bone.

Aeromonas species isolated from medicinal leeches.

Aeromonas hydrophila infections are a recognized complication of the use of medicinal leeches. The authors performed an experiment designed to find a safe and practical way to sterilize the leech gut of pathogenic organisms. Leeches were incubated for a 12-hour period in solutions of antibiotic effective against A. hydrophila. The incubations in the antibiotic solutions failed to eradicate pathogenic bacteria from the gut of the leeches. The authors examined cultures of bacteria isolated from the guts of the commonly used Hirudo medicinalis (European leech) and found a wide variety of pathogenic organisms. A. hydrophila is widely believed to be the most common enteric pathogen, but the authors found A. sobria more frequently in their experiment. They also cultured the guts of the leech H. michaelseni recently used clinically in South Africa. A. caviae was the most common pathogen encountered in these leeches. A. caviae and A. sobria cause a spectra of disease similar to A. hydrophila. The authors endorse the current recommendation that all patients who have leech therapy for congested flaps or replants receive broad-spectrum prophylactic antibiotics. This appears to be the safest and simplest way to prevent leech-related infections.

Design of the cyclops flap for chest-wall reconstruction.

The cyclops flap is a little-known but not forgotten alternative in chest-wall reconstruction for women. Female patients having a large, pendulous breast with a contralateral adjacent defect may be reconstructed by this technique. The flap derives its name from the repositioning of the remaining nipple to the center of the chest. The design of the flap is described. By knowing the width and length of the defect, the surgeon can design incisions on the remaining breast tissue that will allow the flap to advance easily, reliably filling the defect. The flap is an axial-pattern flap nourished by the lateral thoracic artery and the variable external mammary artery. This arterial inflow will serve the medial portion of the flap. The operation is straightforward and predictable. In using this design scheme three times in the last two years, there have been no complications. There is little discomfort after surgery. Occasionally, patients will benefit from this reconstructive option.

Unusual masses found within ruptured silicone gel breast prostheses.

Imaging of breast implants has assumed more importance in medicine than ever before. Radiologists and surgeons alike have struggled to accurately identify folds in prostheses, rupture of prostheses, and migration of gel. Here we present two patients with an unusual presentation of masses within the gel of ruptured silicone gel-containing prostheses. In one instance, the mass was an organized hematoma. In the other, two round, calcified masses were found that we presume are hematomas that have become calcified over time. Radiologists and surgeons identifying spherical or ovoid masses seemingly within gel breast prostheses should entertain the possibility that the mass represents an organized hematoma and that the implant is ruptured.

Ultrasound-guided retrieval of small foreign objects in subcutaneous tissue.

STUDY OBJECTIVE: To identify the physical properties of the materials most easily located in subcutaneous tissue through the use of conventional ultrasound. METHODS: High-resolution real-time sonography was performed by a credentialed sonographer on a chicken breast impregnated with five objects-a metal paper clip, a wooden toothpick, a plastic coffee stirrer, a shard of glass, and an 18-gauge needle. Transducer frequencies ranging from 3.5 to 7.5 MHz with linear, curvilinear, and sector-scanning formats were used. All images were interpreted by a staff attending radiologist with other study authors present. The chicken breast was then subjected to radiography for comparison. RESULTS: Wood yielded the strongest acoustic shadow; plastic had the next-best acoustic shadowing. The 7.5-MHz probe yielded its best resolution at shallow depths, whereas the 5-MHz probe was best at greater depths. CONCLUSION: We conclude that ultrasonography is an excellent technique for the localization and retrieval of nonradiopaque foreign objects in the superficial subcutaneous tissue. It should be given consideration for use in the removal of nonradiopaque superficial foreign objects when conventional radiographic techniques are not effective.

Academic surgeons, take heart: the story of a student, his mentor, and the discovery of the etiology of angina pectoris.

Edward Jenner is renowned for developing a vaccination for smallpox. He trained as a surgeon and was an ardent anatomist and naturalist. Part of his formal training was directed by John Hunter, the father of scientific surgery. Jenner diagnosed Hunter as suffering from angina pectoris and correctly identified the cause of angina pectoris from a series of autopsies he conducted. After Hunter died during an altercation in committee, his postmortem examination proved Jenner correct. Jenner can be recognized as the first to correctly ascribe the etiology of angina pectoris to coronary atherosclerosis.

Repositioning the stoma of the cervical esophagostomy.

The stoma created with a diverting cervical esophagostomy is often an unsightly inconvenience for the patient because of the high incidence of leakage from the collecting appliance. Secure attachment of a collection device at the base of the neck is difficult. The stoma of the cervical esophagostomy may be moved away from the base of the neck using a tubed skin flap modeled after that originally described by Wookey. Such a procedure has the advantages of removing the appliance from an area of high visibility and providing a flatter base that decreases leakage and soiling. We advocate this simple procedure in patients who desire to rid themselves of a cervical appliance, but who are poor operative candidates for a more extensive procedure replacing the entire esophagus.