Description of a communication between the facial and zygomaticotemporal nerves.

Communicating branches between the facial and the trigeminal nerves are known to exist; however, both their frequency and significance are incompletely understood. In our anatomic dissections, we observed a consistent anastomosis between the temporal branch of the facial nerve and the zygomaticotemporal branch of the trigeminal nerve. The facial nerves were dissected in 17 cadaveric half faces. The communicating facial-zygomaticotemporal nerve branches piercing the superficial layer of the deep temporal fascia were identified and followed through the fascial and muscular planes. Fourteen out of 17 dissected cadaveric half faces contained communications between trigeminal and facial nerves. In these specimens, one or two branches from the temporal branch of the facial nerve would penetrate the superficial layer of the deep temporal fascia to join the zygomaticotemporal nerve. These communications were found at an average of 36 mm lateral and 2 mm superior to the lateral canthus. Due to the cadaveric nature of the study it is difficult to ascertain the function of the described communication. Our histochemical analysis suggests that these connections contain myelinated fibers, which could either be proprioceptive or motor fibers.

Giant thoracic neurofibromatosis type 1 with massive intratumoral haemorrhage: a case report.

A 44-year-old man known to have neurofibromatosis type 1 (NF1) presented with an acute enlargement of a long-standing pedunculated thoracic mass and a 4.5 kg weight gain. He was recently treated with anticoagulation for a newly diagnosed atrial fibrillation. Intratumoral bleed was thus suspected to explain the sudden enlargement. Chest computerised tomography confirmed the presence of a large extrathoracic tumour of soft tissue density compatible with a diagnosis of neurofibromatosis and a recent massive intratumoral haematoma. Perioperative angiography demonstrated remarkable hypervascularity. The treatment plan involved embolisation and surgical resection. The histological specimen confirmed a diagnosis of neurofibromatosis type I without malignant transformation. Neurofibromatosis associated with an intratumoral haemorrhage is rare. This is the first scientific report of a massive intratumoral bleed in NF1 subsequent to anticoagulant administration. Anticoagulation should be monitored very closely in neurofibromatosis patients due to their propensity to bleed secondary to the abnormal vascular intima.

Identification of mandibular fracture epidemiology in Canada: Enhancing injury prevention and patient evaluation.

BACKGROUND: Mandibular fractures can lead to significant functional and aesthetic sequelae if treated improperly. They may act as an indicator of concomitant trauma and are very demanding on the public health care system. Thus, knowledge of mandibular fracture epidemiology is critical to effective prevention, as well the establishment of accurate trauma evaluation protocols. OBJECTIVES: To identify the epidemiology of mandibular fractures treated at a level 1 Canadian trauma centre, clarify the pathogenesis of these epidemiological patterns and suggest potential targets for preventive efforts. METHODS: A retrospective review of all mandibular fracture patients presenting to the Montreal General Hospital between 1998 and 2003 was performed. Medical records and digitized radiographic imaging were used to collect patient demographics and injury data. RESULTS: The chart review identified 181 patients with 307 mandibular fractures. Fifty-two per cent of the fractures occurred in individuals 21 to 40 years of age, 78% of patients were male, and there was wide ethnic diversity. Sixty percent of patients had multiple mandibular fractures; 29% were symphyseal/parasymphyseal fractures, 25% were condylar fractures and 23% were angle fractures. Assault was the most common mechanism of injury, with 29% of fractures involving alcohol or illegal drug use. Thirty percent of patients had an associated facial fracture, and more than one-third had another major injury. CONCLUSIONS: The present epidemiological review reveals several potential prevention targets as well as significant trends. Further research into the impact of these preventive measures could more objectively identify their impact on mandibular trauma.

Muscle preservation using an implantable electrical system after nerve injury and repair.

The value of continuous electrical stimulation of denervated muscles after nerve injury and repair has been clearly shown in a series of laboratory experiments in three animal models. This experimental background, which showed improved muscle preservation and better functional results, evolved into a clinical study that included 15 patients with peripheral nerve injuries in the upper extremities, 3 patients with brachial plexus injuries, and three patients with facial nerve paralysis. Improved functional results were obtained using this implantable system, which were similar to those achieved with the animal experiments. All patients had muscle stimulation for extended periods ranging from 127 to 346 days. Analysis of the results showed satisfactory nerve regeneration on clinical examination and with electromyographic studies. Functional muscle analysis varied somewhat from patient to patient, but every patient had a satisfactory to excellent recovery. The results from this study have clearly shown the benefits of continuous muscle stimulation using an implantable electrical system after nerve injury and repair expansion of the project to a larger patient cohort is indicated.

Management of head and neck lymphatic malformations in children.

Lymphatic malformations (LM) are complex entities. Their development and management remain controversial. A retrospective review of 35 patients treated for lymphatic malformation over a 10-year period (1985-1995) is presented. The demographics of the cases, the method of presentation, treatment modalities, and outcomes are presented. The majority or patients presented at birth, and 83% were treated before the age of 7 years. The most common presentation was an asymptomatic neck mass (74%), of which 54% were in the posterior triangle and 17% were in the submandibular space. The treatment was primarily surgical excision: 22 (63%) patients had total surgical excision, 7 (20%) had partial excision, and 6 (17%) had needle aspiration. A proposal of management is presented.

The value of continuous electrical muscle stimulation using a completely implantable system in the preservation of muscle function following motor nerve injury and repair: an experimental study.

Functional recovery following motor nerve injury and repair is directly related to the degree of muscle atrophy that takes place during the period of nerve regeneration. The extent of this muscle atrophy is related to a number of factors including the accuracy of nerve repair; the distance through which the nerve must regenerate; the age of the patient; and the type of nerve injury and other associated tendon and soft tissue and bony damage. Atrophy of muscle that is always associated with nerve injury is a combination of disuse and degeneration. Our hypothesis proposed the following question: "Would continuous electrical stimulation of the denervated muscle during the period of nerve regeneration maintain the integrity of the muscle fibers and hence their potential functional capacity?" We have completed a series of animal studies (rabbit and canine models) in our laboratory using a completely implantable system to provide continuous muscle stimulation following nerve injury and microsurgical repair. In several different experiments, the nerves under study were cut and repaired at 4 and 12 cm from the muscles to study the effects of short- and long-term recovery. In all experiments, a beneficial effect was demonstrated with improved morphology and functional capacity of the reinnervated stimulated muscles when compared with nonstimulated controls. In addition, electrical stimulation using this implantable system could be applied for extended periods without evidence of discomfort in the experimental animals.

A clinical pilot study to assess functional return following continuous muscle stimulation after nerve injury and repair in the upper extremity using a completely implantable electrical system.

This clinical pilot study evolved from a 10-year experience in the experimental laboratory using continuous muscle stimulation in a series of animal studies following nerve injury and microsurgical repair. A completely implantable system was developed (Medtronic) to provide electrical stimulation to the denervated muscles until nerve regeneration had occurred. Both peripheral nerve injuries in the extremities and facial nerve severances were studied, and a definite improvement in functional capacity was obtained as well as improved morphology compared with nonstimulated controls. In this study, 13 patients with peripheral nerve injuries in the upper extremity are included. All patients had muscle stimulation for extended periods until nerve regeneration was evident; a careful analysis of their functional capacity was then completed. There were five patients with median nerve injuries, four with ulnar nerve or combined median-ulnar nerve injuries, and four with severed radial nerves. All patients showed satisfactory nerve regeneration on clinical examination and electromyographic studies. Motor recovery was usually better than sensory return. Functional muscle analysis varied somewhat from patient to patient, but every patient had a satisfactory to excellent recovery. Patients with low nerve lesions had better results, but muscle recovery even in patients with mid-forearm or higher nerve injuries was most encouraging. Functional recovery in radial nerve injuries was close to normal in all cases. The results from this pilot study have clearly shown the benefits of continuous muscle stimulation using an implantable system following nerve injury and repair.

Alveolar cleft bone grafts: results and imprecisions of the dental radiograph.

Alveolar cleft bone grafts customarily have been evaluated by one-dimensional dental radiographic measurements. Based on the dental radiograph, remarkable successes with just a single bone graft have been reported in the literature. At the Montreal Children's Hospital, the experience with 101 alveolar bone grafts in 62 cleft lip and palate patients was retrospectively reviewed to determine (1) the precision of dental radiographs at evaluating the clinical outcome, (2) the effect of dental maturation on alveolar bone grafts, and (3) the effect of augmentation bone grafts. The dental radiograph significantly overestimated the number of clefts that could be managed orthodontically (p < 0.01, McNemar's test) and thus poorly prognosticated the ability to achieve bony obliteration of the alveolar cleft and orthodontic closure of the dental gap. Bone grafts performed during the preeruptive canine dentition yielded significantly better results (p < 0.05, chi-squared test). With each subsequent augmentation bone-graft procedure performed, there existed a trend toward improved dental arch stability and radiographic and clinical outcomes.

The importance of venous drainage in rat flaps: an experimental study.

Venous drainage of musculocutaneous grafts prepared on the backs of rats survived successfully by preserving the draining vein. Even in musculocutaneous flaps, venous drainage at the distal part of the flap plays an important role in a successful take. An experiment was prepared in a rat model in which the iliolumbar veins were utilized as the draining veins, and musculocutaneous flaps, 4 x 10 cm in size, were created. In this experiment, it was shown that even in random pattern musculocutaneous flaps, necrosis can be prevented by preserving the draining vein.

The effects of electrical stimulation on denervated muscle using implantable electrodes.

This experimental study investigated the effects of continuous electrical stimulation on denervated muscle. The canine peroneal nerve was severed and repaired microsurgically, and the denervated extensor muscle group of the leg was stimulated continuously with an implantable electrode and pulse generator. EMG study, muscle force measurement, muscle weight measurement, histology, and histochemistry were performed to study the effect at eight weeks after the operation. Continuous electrical stimulation (pulse frequency 130 pps, burst rate approximately 1 train/min) was effective in decreasing muscle atrophy and in improving muscle force. These findings may have broader clinical applications.

The importance of internal anatomy of the peripheral nerves to nerve repair in the forearm and hand.

We have completed and analyzed recent studies on the internal topography of the median and ulnar nerves of the forearm and hand. These findings have been compared with the classic studies of Sir Sydney Sunderland and more recent work by other authors has been included. Our studies confirm that there is a complex interfascicular relationship between the various components of the median and ulnar nerves in the forearm and hand, but, with careful dissection, several anatomic relationships can be defined. Individual branches and bundles can be traced within the main nerve trunks for considerable distances without significant trauma to the conducting fibers. These include the recurrent branch of the median nerve, the branches to the lumbrical muscles, the motor and sensory components of the ulnar nerve, and the dorsal sensory branch of the ulnar nerve. These findings have a direct relationship to the clinical repair of fresh nerve injuries as well as those injuries that require nerve grafting for significant gaps in the neural tissue. Intraneural neurolysis can be safely performed if detailed knowledge of the internal topography of the peripheral nerves is understood. This knowledge may also be applied to the dissection and management of neuromas in continuity. The increased awareness of the interfascicular relationships of the peripheral nerves may well influence a more favorable outlook in the care of patients with nerve injuries.

Circulation, bone scans, and tetracycline labeling in microvascularized and vascular bundle implanted rib grafts.

The circulation in microvascularized rib grafts has been compared with that in conventional rib grafts and in those augmented by a direct vascular bundle implantation into the bone grafts. A new experimental model has been designed to correlate vascular perfusion, bone scan patterns, tetracycline labeling, and histological findings in these bone grafts. Posterior microvascularized rib grafts were found to have a circulatory pattern identical to that of the normal rib. Failed microvascularized rib grafts were revascularized more slowly than conventional rib grafts. Vascular bundles implanted into rib grafts remained patent and increased the rate of revascularization. The stripping or preservation of periosteum had no observable effects on the rate or pattern of conventional rib graft revascularization. The circulation in rib grafts was accurately reflected in technetium 99 bone scans, as was the patency of the anastomoses of microvascularized rib grafts and of implanted vascular bundles. In contrast, tetracycline labeling was repeatedly observed in avascular areas of bone grafts and, therefore, is not a reliable indicator of bone graft circulation.

The vascular pattern and viability of microvascularized rib grafts based on periosteal circulation--an experimental study.

Previous reports have stressed the importance of the nutrient blood supply in rib grafts transferred by microvascular anastomoses. In the present experimental study, we have demonstrated that a rib graft transferred by microvascular anastomoses based on periosteal vessels can survive; vascular clearing studies demonstrated that the vascularity of these grafts extends not only into the cortex but the medulla as well. The relative facility of harvesting these grafts (compared with those based on nutrient vessels) should make them the favored choice. Technetium bone scintigraphy proved accurate in the assessment of both vascular pattern and microanastomotic patency. Tetracycline labeling did not correlate well with the patency of a rib graft's pedicle blood supply.

Are burn wound biopsies obsolete? A comparative study of bacterial quantitation in burn patients using the absorbent disc and biopsy techniques.

A study of bacterial quantitation in burn wounds was undertaken to compare a new absorbent paper disc technique with the standard burn wound biopsy technique. In the first part of the study 228 paired samples were used to compare the two methods; a high correlation coefficient was found with the four most commonly encountered bacteria, and both methods showed a high specificity and sensitivity for each of the organisms. In the second portion of the study, the discs were compared with burn wound biopsies that had been divided into their superficial and deep segments. Thirty paired samples were studied and again the correlation was high, indicating that the disc technique also measured the organisms found in the deeper tissue levels. The absorbent disc technique is simple, convenient, noninvasive, inexpensive, and yields reproducible results. These findings indicate that burn wound biopsies may no longer be required for infection monitoring in the burn patient.

Early enteral feeding of patients with major burns: prevention of catabolism.

The immediate onset of hypermetabolism after a major burn dictates that nitrogen and calories be supplied as early as possible to such patients to prevent the well-documented catabolic state. However, intravenous hyperalimentation is not always possible, and enteral feeding is not usually attempted in the early resuscitative period. Twelve patients with major burns (40% to 70%) were fed nasoduodenally in the early postburn period with a new solution (3.5% Aminosyn, 25% Polycose, and appropriate additions of electrolytes and vitamins). All patients reached positive nitrogen balance in 9.8 +/- 2.3 days, tolerated the feeding extremely well, and had no distention or diarrhea. Metabolic assessment showed remarkable stability. The characteristic signs of hypermetabolism, such as hyperglycemia and hypoinsulinemia or hyperinsulinemia, were absent. Furthermore, there was no persistent neutrophilia or leukocytosis and there was a significant (p less than .01) decrease in the percentage of juvenile neutrophils and a significant (p less than 0.001) increase in absolute lymphocytes between days 0 and 14 of the study. These data indicate that early enteral feeding of Polycose-Aminosyn is safe and well tolerated, and that the small intestine absorbs nutrients readily in the early postburn period, leading to positive nitrogen balance, preventing loss of serum protein, assisting in the maintenance of normal carbohydrate metabolism, and restoring granulocytes and lymphocytes to normal ratios.

Epignathus: a report of two cases.

Two cases of epignathus are presented. The classification and clinical and radiological diagnoses are reviewed. Epignathi are rare embryological tumors, but with better preoperative assessment and awareness, safe surgical excision can be carried out. A careful long-term follow-up with regular examinations is essential to detect any residual lesions or extensions of the original embryological malformation.

The painful stump neuroma and its treatment.

Successful clinical management of symptomatic neuromas continues to present a challenge to the responsible surgeon. It is unexplained why some patients with neuromas are completely asymptomatic while others exhibit debilitating symptoms. Prevention of neuromas is paramount with precise attention to severed nerves following amputations and other surgical procedures. Once established, treatment of neuromas consists of careful patient counseling, local massage, and desensitization procedures. Sympathetic blockade with guanethidine may be beneficial in some patients. When necessary, surgical excision of the neuroma along with a combination of funiculectomy, epineurial sleeve suture ligation, and silicone capping offers the best chance for eradication. In intractable or recurrent cases and following careful patient selection, neuroma excision followed by nerve grafting combined with sympathetic blockade using guanethidine can be successful in a significant number of cases.