Circular excision of hemangioma and purse-string closure: the smallest possible scar

Localized cutaneous infantile hemangioma acts like a tissue expander. This rapidly growing tumor can destroy elastic fibers or cause ulceration resulting in telangiectases, cutaneous laxity, scarring, and fibrofatty residuum. Although surgeons may dispute indications and timing, most would agree that the scar of resection should be minimized. For this reason, circular excision and purse-string closure is particularly applicable for hemangioma at any stage of its evolution. The purposes of this study were to: (1) analyze the results of circular excision/purse-string closure in all three phases of the life cycle of hemangioma; (2) quantify dimensional changes after resection; and (3) compare the scars after theoretical single-stage lenticular excision with those after staged circular excision/purse-string closure. The authors retrospectively analyzed their experience in 25 children with localized hemangioma who underwent circular excision/purse-string closure from 1997 to 2000. Each hemangioma was measured preoperatively and the scars were measured at most recent follow-up (minimum, 6 months). Preoperative and postoperative dimensions were analyzed using SPSS statistical software. The study included 22 girls and three boys, with an average time to follow-up evaluation of 13.1 months. Twenty-one lesions were in the face and scalp, and five were in the extremity. Five tumors were resected in the proliferative phase (either because of ulceration, bleeding, or visual complications) and 21 were excised in the involuting or involuted phase. Six patients had a second-stage procedure: three had another circular excision and three had later lenticular excision. After single circular excision/purse-string closure, the mean long-axial diameter (length) decreased by 45 percent, the mean short-axial width (width) decreased by 73 percent, and the mean scar area was only 15 percent of the original area. All these differences were statistically significant (p = 0.001). The average width/length ratio decreased by 50 percent, indicating a tendency for scars to linearize. There was no difference in linearization for the three phases of hemangioma (p > 0.05); extremity scars became more linear that those on the face (p = 0.01). The authors devised a formula for scar length after lenticular excision/linear closure, assuming a conventional excisional ratio of 3:1 for a circular lesion. Using this equation, the authors predicted that mean scar length after circular excision, followed by lenticular excision, would be 72 percent shorter than the calculated scar that would result from conventional lenticular excision. In three patients who underwent this two-stage approach, the resultant scar was 69 percent shorter. Circular excision of hemangioma and purse-string closure reduces both the longitudinal and transverse dimensions and converts a large circular lesion into a small ellipsoid scar. If subsequent revision to a linear scar is desirable, its length will be the same or slightly less than the diameter of the original lesion. No other excision and closure technique results in a smaller scar. Another advantage of this method is minimal distortion of surrounding structures.     

Cranial suture closure pattern in water deer and implications of suture evolution in cervids

Interspecific diversity exists in cranial suture closure patterns among mammalian species. Suture closure patterns partly reflect phylogenesis, but it has also been claimed that it is influenced by biomechanical factors. Here we provide the first report on the cranial suture closure pattern in water deer. Among cervids, the water deer is an exceptional species, as it is the only one without antlers. Instead, the male water deer possess prominent canines, which are utilized during male-male combats. This unique morphological setting allowed us to examine whether the presence of prominent canines affects cranial suture closure. We found that the only sexual difference in cranial suture closure pattern is the closure of the interfrontal suture in males, which is found in some other cervid species as well. Except for the interfrontal suture closure, timing and sequence of cranial suture closure were comparable between both sexes, suggesting that the presence of prominent canines in males has no influence on cranial suture closure pattern. Our results indicate that interfrontal suture closure in males is a phylogenetic pattern, i.e. an apomorphy for Capreolini, Hydropotini and Alceini.     

Purse-string suture for nipple projection

A simple and useful technique for nipple projection is reported. A buried, subcutaneous, purse-string suture is placed through prick holes and, when tied, gives a nipple mound, without the need of skin incisions, flaps, or undermining. This procedure can be applied to inverted, missing, and/or ill-defined nipples.     

In vitro murine posterior frontal suture fate is age-dependent: implications for cranial suture biology

In CD-1 mice, the posterior frontal suture (analogous to the human metopic suture) fuses while all other cranial sutures remain patent. In an in vitro organ culture model, the authors previously demonstrated that posterior frontal sutures explanted immediately before the onset of suture fusion (at 25 days old) mimic in vivo physiologic fusion. In the first portion of this study, the authors defined how early in development the posterior frontal suture fuses in their tension-free, serum-free organ culture system by serially analyzing posterior frontal suture fusion from calvariae explanted at different stages of postnatal development. Their results revealed a divergence of suture fate leading to abnormal patency or physiologic fusion between the first and second weeks of life, respectively, despite viability and continued growth of the calvarial explants in vitro. From these data, the authors postulated that the gene expression patterns present in the suture complex at the time of explant may determine whether the posterior frontal suture fuses or remains patent in organ culture. Therefore, to elucidate potentially important differences in gene expression within this "window of opportunity," they performed a cDNA microarray analysis on 5-day-old and 15-day-old posterior frontal and sagittal whole suture complexes corresponding to the age ranges for unsuccessful (1 to 7 days old) and successful (14 to 21 days old) in vitro posterior frontal suture fusion. Overall, their microarray results reveal interesting differential expression patterns of candidate genes in different categories, including angiogenic cytokines and mechanosensitive genes potentially important in cranial suture biology.     

Technique of percutaneous anchoring suture placement

We describe a technique to assist in the placement of percutaneous anchoring sutures when used in poorly accessible tunnels such as in rhinoplasty by using a sucker tube to guide retrieval and placement of the suture needle. This technique avoids unintended catching of the needle on soft tissue within the tunnel, which could prevent the structure from becoming anchored at other than in its intended location.     

Fractal analysis of sagittal suture morphology

Quantifying shape is a broad problem in the morphological sciences. Most techniques for numerically describing shape abstract the shape into the most logical ideal Euclidean dimension. The fractional, or fractal, dimension is a simple computation that expresses shape in real, rather than ideal, space. The structured walk technique developed for the fractal analysis of rugged boundaries is applied here to the contour of the human sagittal suture in order to discriminate the separate morphological patterns of interfingering and interlocking. These attributes contribute differentially to the suture's “complexity,” a concept often used in biomechanical hypotheses. Previous techniques for estimating sutural complexity do not isolate small-scale from large-scale morphological patterns. Results indicate that despite the visual appearance of great variation, human sagittal sutures are remarkably consistent in the degree of complexity expressed separately by large-scale interfingering lateral excursions and small-scale interlocking ruggedness. There is no significant correlation between the absolute or bregma-lambda chord length of the human sagittal suture and its degree of complexity as determined by the structured walk technique.     

Craniofacial suture stenosis: morphologic effects

Craniofacial anomalies, such as Apert's and Crouzon's syndromes, are presumed to be related to premature growth arrest of cranial base growth sites. However, premature growth arrest at cranial vault sutures in animals appears to play a causative role in the development of cranial deformities characteristic of single-suture, or simple, craniosynostosis in humans. To study the possible causative role of cranial vault and other (interface) suture stenoses on the development of craniofacial deformity, a vault suture and an interface suture between the cranial vault and facial skeleton were simultaneously immobilized. Thirty-one New Zealand White rabbits at 9 days of age underwent implantation of dental amalgam growth markers adjacent to cranial vault and facial sutures. In the experimental group (n = 15), methylcyanoacrylate adhesive was applied over the coronal (vault) and frontonasal (interface suture between vault and facial skeleton) sutures to immobilize them. The remaining 16 animals served as sham-treated controls. All animals underwent serial radiographic cephalometry to document growth effects in the cranial vault, cranial base, and facial skeleton. Application of adhesive resulted in statistically significant (p less than 0.05) reduction in growth at the coronal and frontonasal sutures. This was accompanied by an overall significant reduction in neurocranial vault length during the first 30 days of development.(ABSTRACT TRUNCATED AT 250 WORDS)