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Murine mucopolysaccharidosis type I: targeted disruption of the murine alpha-L-iduronidase gene.

Mucopolysaccharidosis type I (MPS I) is considered to represent the prototypical mucopolysaccharide storage disorder. Although a spectrum of severity is seen within the MPS I subgroup, Hurler syndrome represents the most severe and frequent manifestation of MPS I. We describe here the generation of a murine model for Hurler syndrome by targeted disruption of the murine Idua gene. Homozygous Idua -/- mice have no detectable alpha-L-iduronidase enzyme activity and show increased urinary glycosaminoglycan levels. Although normal appearing at birth, Idua -/- mice develop a flattened facial profile and thickening of the digits discernible by 3 weeks of age. No obvious growth deficiency nor mortality is seen within the first 20 weeks of life. Radiographs reveal anterior flaring of the ribs and thickening of the facial bones as early as 4 weeks of age with more extensive dysostosis detectable by 15 weeks of age. At 4 weeks of age, lysosomal storage is noted primarily within reticuloendothelial cells with abundant lysosomes noted in Kupffer cells, splenic sinusoidal lining cells, and glial cells. More widespread lysosomal storage is noted by 8 weeks of age in hepatocytes, chondrocytes, neurons, as well as renal tubular cells. Thus, targeted disruption of the murine Idua locus has produced a murine strain representative of the severe form of MPS I. This model should permit detailed evaluation of the pathophysiology of lysosomal storage disorders and provide a small animal model for the testing and development of enzyme replacement and gene therapy regimes.

Abnormalities, Multiple↗

Rhabdomyosarcoma of the head and neck in children.

Seventeen children with rhabdomyosarcoma arising in the head and neck are presented. With a median follow-up of 2 years 3 months, 11 patients are currently living, seven patients are alive free of disease, and local control was achieved in 11 patients. Of 13 group III patients managed with irradiation and chemotherapy following biopsy, seven patients are alive, with four patients free of disease, and local control achieved in eight patients. In a subgroup of nine group III patients with tumor involving multiple head and neck sites, four patients are alive, with two patients free of disease, and local control achieved in six patients. In four groups I-II patients, local control was achieved in three, and all patients are currently living. Long-term complications include facial bone hypoplasia in three patients and cataracts in three patients. Primary irradiation and chemotherapy can locally control rhabdomyosarcoma of the head and neck, while avoiding the functional and cosmetic sequelae associated with surgical ablation.

Adolescent↗

Anterior cranial fossa tumors.

The anterior cranial fossa may be invaded by malignant or nonmalignant tumors arising in the orbit, orbital contents, nose, nasopharynx, or frontal, ethmoid, or sphenoid sinuses. Skin and maxillary tumors can also spread to the skull base. One must be aware of this and assess the situation with the neurosurgeon, and use coronal and axial CAT scans. The approach is intracranial and extracranial, with total en bloc tumor resection under frozen section control. In nonmalignant tumors immediate reconstruction is performed; in malignant tumors, especially recurrent ones, the reconstruction is delayed twelve to eighteen months to lessen the chances of later recurrences. With this approach, recurrences have been few and survival rates excellent, even in advanced recurrent lesions.

Carcinoma, Squamous Cell↗

Open reduction and interfragment wire fixation of comminuted nasal fractures.

Manual reduction is the first choice for all types of acute nasal fractures; open reduction is the choice for fractures that do not respond to manual reduction or complicated fractures at the base of the nasal pyramid. From 1968 to 1986, 564 cases of nasal fractures were treated at the Department of Plastic and Reconstructive Surgery, Jikei University School of Medicine, Tokyo. Of these, 241 were acute nasal fractures, 52 of which were associated with facial bone fractures. Deviated types of fractures that cannot be correctly repositioned by manual reduction and some depressed fractures often require a surgical approach for reduction and fixation. In our series of 241 patients with acute nasal fractures, 43 (18%) were treated by open reduction and fixed with soft stainless steel wires.

Adolescent↗

The role of alloplastic skeletal modification in the reconstruction of facial burns.

The external appearance of the face is largely dictated by its supporting facial skeleton. After an extensive thermal injury, the underlying facial skeleton may need to be either augmented or restored to maintain the functional and aesthetic appearance of the face. The factors that make a structural reconstruction difficult are poor vascularity and compliance of the scar tissue, extreme contractile forces of the scar, and unstable skin coverage. The use of an alloplast in the setting of facial burn scars may be one of the greatest challenges for an implant material. We reviewed our experience with the use of the Medpor porous polyethylene implant in facial burn reconstruction. This biomaterial has structural characteristics that allow for tissue ingrowth, yet it resists deformation by contractile forces. A total of 57 consecutive implants were placed in 24 patients with facial burns. Implants were used for the chin, the nose, the malar region, and as an ear framework. Patient follow-up ranged from 6 months to 3 years. Although 4 implants became exposed and 1 was thought to become infected, only 1 of the implants was removed. There were no other implant-related complications. We believe that skeletal modification is an important step for a successful facial burn reconstruction. Porous polyethylene offers a promising solution for the complex reconstructive problem of using an alloplast in the environment of a facial burn.

Adolescent↗

Clostridial infection following severe facial trauma.

Severe posttraumatic wound infections are uncommon occurrences in the craniofacial region. Although most reported cases have occurred following an odontogenic infection or minor soft-tissue trauma, the potential for the development of this type of infection exists following complex facial fractures. We report a case with clostridial infection in the temporalis fascia complicating a complex facial fracture. The implications regarding antibiotic usage and delay of surgical treatment are discussed.

Adolescent↗

Craniofacial injuries resulting from taxicab accidents in New York City.

Taxicab accidents are a common occurrence in New York City. This review was undertaken to characterize the nature of craniofacial injuries that result from taxicab accidents. Data were collected on 16 patients who required admission to trauma or plastic and reconstructive surgery services, after sustaining craniofacial injury as a result of a taxicab accident. Front-end deceleration collisions were the most common mechanism of injury. Fifty-six percent of the patients were thrown against the bulletproof, Plexiglas driver safety divider and sustained an injury most commonly to the anterior midface. Both bony and soft-tissue injuries were common in the entire group. Complex facial fractures were sustained by 56% of patients, with nasal-septal fractures most common, followed by naso-ethmoid-orbital, anterior frontal, anterior maxillary, and Le Fort I and II fractures. Only 1 patient in the group was wearing a seat belt and that patient was a driver. Given the high incidence of craniofacial injury, appropriate safety standards for taxicabs must be initiated, including the reevaluation of the utility of the safety divider and mandatory seat belt use for rear-seat passengers.

Accidents, Traffic↗

Exploration of the orbital floor: an indicated procedure?

Fractures to the middle third of the facial skeleton continue to increase in frequency secondary to motor vehicle accidents and interpersonal violence. Orbital floor fractures can occur either independently or may be associated with other facial bone fractures. Controversy has persistently surrounded the treatment of fractures to the floor of the orbit. We will present our investigation of 296 patients who sustained a total of 396 traumatic injuries to the orbit and were treated at the University of California, Davis Medical Center, Sacramento, California, during the period July 1, 1988 to June 30, 1989 to determine whether surgical exploration of the orbital floor is necessary or adds potential serious risks. In the 38 patients (46 orbits) who did not undergo surgical exploration of the orbital floor, 31 (82%) suffered serious residual complications. In the remaining group of 258 patients who underwent orbital floor exploration, there was a 7 percent incidence (18 patients) with residual sequelae. We conclude that exploration of the orbital floor has the potential to decrease the incidence of serious post-traumatic complications significantly, primarily enophthalmos.

Adult↗

Pediatric facial injuries in Tehran: a review of 87 patients.

Because of the Iraq/Iran conflict pediatric facial injuries were commonly seen in Iran. A series of 87 facial injuries were isolated from 1,608 patients with different types of facial injuries seen in two university hospitals in Tehran during the previous 6 years (1984-1990). Their ages ranged from 20 months to 13 years. The male-to-female ratio was 16.4:1; the highest incidence was in the lower-third region (63.21%; n = 55), and the highest incidence was in the 8- to 9-year-old age groups. Associated nonfacial injuries, clinical and computed tomographic scan findings for head injuries associated with facial injuries, treatment, and complications are reported.

Adolescent↗

Teeth located in the line of mandibular fracture.

During the last decade, rigid internal fixation with mini plates and screws has attained widespread use for stabilization of facial bone fractures. This technique permits precise, three-dimensional stabilization of bony segments, decreases the time required for immobilization of the maxillo-masticatory apparatus, and allows patients to return to their preinjury state earlier. However, there is still controversy on the appropriate management of teeth located within the line of mandibular fractures. We review the outcome of teeth retained within the fracture. We performed a retrospective chart review of all patients admitted to the University of California, Davis, Medical Center with mandibular fractures from July 1, 1986, to June 30, 1991, who had retained at least 1 tooth and had had a 3-month follow-up. We were able to include a total of 254 patients who met these criteria. These patients were then divided into groups according to location of the fracture, method of stabilization, and management of dentition within the line of fracture. Data were then analyzed using a linear model to predict the percentages of success for each method of fixation. In conclusion, we found little difference in the outcome of fracture management whether the teeth were routinely extracted or retained as long as rigid fixation was employed for stabilization of the fracture segments.

Adolescent↗

Lengthening of the mandible by distraction osteogenesis: experimental work in rabbits.

The purpose of this experimental work was to lengthen the mandible in rabbits by means of distraction osteogenesis. The excellent results on the lengthening of the extremities with the Ilizarov technique and the unpredictable results in the mobilization of the facial bones by means of osteotomies and grafts are reasons for the application of the gradual distraction method in mandibular lengthening. Bone lengthening was first performed in 1905; but Ilizarov rekindled interest in 1951 when he induced bone neoformation in the extremities by the distraction technique using multiplanar wires and external circular fixators. We lengthened the mandible in 12 New Zealand adult rabbits using different mountings of the Ilizarov apparatus by means of two fixation techniques: transfixion and nontransfixion. In the transfixion group (6 rabbits), the two wires were passed through both mandibular rami. In this group, a 2-cm lengthening was obtained. In the nontransfixion group (6 rabbits), only one mandibular ramus was included with the transfixion wires. In this group, 1-cm lengthening was achieved. Unilateral lengthening was obtained with the nontransfixion technique and the lengthening of both rami with the transfixion technique. The results were evaluated by clinical periodic postoperative radiographs and histological studies of newly formed bone and surrounding soft tissues (masticatory muscles, arteries, and so on). The results demonstrated that lengthening of the mandible is obtained by means of a mature and normal new bone that is produced in the osteotomized area.

Animals↗

Endoscopic approach for benign tumor ablation of the forehead and brow.

Resection of benign tumors of the forehead and brow raises aesthetic concerns. An endoscopic subperiosteal approach to benign bony and soft-tissue tumors in the supraorbital and frontotemporal regions permits extirpation of these masses without producing visible facial scars. Therefore, this technique was used for tumor resection in 4 patients. This procedure demonstrated magnified visualization of the masses, and safe access for excisional biopsy and bony contouring. In addition to more acceptable surgical scars, patients experienced no significant postoperative morbidity and a reduced incidence of swelling, discomfort, and scalp anesthesia. Therefore, we conclude that the endoscopic subperiosteal approach is a favorable alternative for resection of suitable tumors.

Adult↗

Various applications of titanium mesh screen implant to orbital wall fractures.

As the number of high velocity injuries increases, orbital wall fractures that involve other facial bone fractures, especially those showing multiple crushed fractures have become increasingly common. However, owing to its complex anatomic structure, our inability to visualize details and relatively thin orbital wall, corrective restorations and fixations are very difficult. Recently several reports have claimed good results using titanium implants to repair orbital fracture. Over a period of 36 months, Titanium mesh screen 1.0 (SYNTHES) were applied to the repair of orbital fracture in various ways, taking 39 examples of orbital wall fracture patients requiring operating treatment. A titanium mesh screen 1.0 was used either as an onlay implant after it was shaped to fit the anatomical shape of the fracture portion, or as cover implant to fix bony pieces after repairing a severely crushed fracture on the orbital rim or maxillary wall segments. 1.3-mm micro-screws were used to fix the titanium mesh screen when needed. The titanium mesh screen 1.0 was rigid, yet malleable enough to get the desired shape. It could be folded and screwed easily, and was also easy for follow-up with fewer artifacts on the CT findings. Therefore, we could restore and fix much easier and faster even crushed tiny bony pieces without loss and achieve more accurate three-dimensional anatomical reconstruction of orbital wall fracture.

Adolescent↗

An unusual case of heminasal aplasia: proboscis lateralis or cystic teratoma?

Unilateral aplasia of the nose is a rare congenital malformation. It is often associated with other malformations of the facial region, including abnormalities of the eye and lacrimal system, proboscis lateralis, and facial bone malformations. The authors present a case of heminasal aplasia in a 4-year-old boy who underwent surgery immediately after birth because of right-sided proboscis lateralis. A huge hemispheric tumefaction was occupying a large part of the right orbit, medial canthus, and frontonasal region of the face, causing lateroinferior protrusion of the eyeball. The right half of the external nose was aplastic. The patient was operated on by an external approach. The pathohistological findings from the top of tumefaction revealed cystic teratoma. The possible backgrounds for the onset of the tumefaction are discussed in two main directions: the cystic form of the regrowth of the remnants of inadequately excised proboscis lateralis and cystic teratoma of the ethmoidal sinus.

Biopsy↗

Repair of bony defect with combination biomaterials.

BACKGROUND: Numerous possibilities are available for the reconstruction of facial bone defects. The materials used to fill such defects must satisfy various requirements. One of the most important is that they must undergo transformation into autologous bone tissue in the process of remodeling. AIM: A report is given of the long-term results of augmentations of large bone defects performed with different bone-substitute materials in two patients. PATIENTS AND METHODS: In one case, augmentation was carried out with beta-tricalcium phosphate after the removal of a fibromyxoma. In the second case, three large cystic lesions in the mandible of a patient with Gorlin-Goltz syndrome were filled with beta-tricalcium phosphate, with a mixture of beta-tricalcium phosphate and platelet concentrate, or with hydroxyapatite of algal origin. The process of ossification was checked at 6-month intervals by means of clinical, radiologic (orthopantomograms and two-dimensional and three-dimensional computer tomograms), and histologic methods. RESULTS: At 1 year after the intervention, the site of the augmentation was in all cases occupied by hard tissue of good quality. With the given imaging procedures, it was difficult to distinguish between the original bone and the region filled with bone-substitute material. The three-dimensional computer tomogram images indicated that the contours and quality of the new bone corresponded with the physiologic and anatomical conditions. The histologic examinations show the remodeling of the bone-substitute materials. DISCUSSION: The bone-substitute materials applied in these cases fully satisfied the demands of transformation into bone (remodeling). The speed of remodeling seemed to be the fastest when the mixture of beta-tricalcium phosphate and platelet concentrate was used.

Adolescent↗