The SSS follows a predictable course relative to surface landmarks in children with unicoronal synostosis. When creating burr holes for craniotomies, the SSS can be avoided in 99.9 % of cases by remaining at least 14.4 mm from the lateral edge of the sagittal suture. Postoperative changes in the path of the SSS provide indirect evidence for normalization of regional brain morphology following fronto-orbital advancement.

Background In order to improve the rotation of Cupid’s bow and achieve sufficient vertical lip height, several variations of the Millard rotation-advancement have incorporated a small laterally-based triangular flap above the cutaneous roll. This study uses three-dimensional photogrammetry to evaluate the outcomes of unilateral cleft lip repairs performed with and without pennant flaps. Methods Three-dimensional photographs were analyzed to assess postoperative lip height asymmetry in 90 unilateral cleft lip patients (58 complete, 32 incomplete) treated between 2001 and 2012. Cleft lip repairs were performed by 3 pediatric cleft surgeons using different techniques. Thirty-nine of 90 (43%) procedures utilized an inferiorly placed triangular flap. All patients were photographed at least 9 months postoperatively (mean = 4.2 years). Lip height asymmetry was based on the vertical distances from the subnasale to the peaks of Cupid’s bow. Results Regression analysis revealed that the use of a pennant flap was a significant predictor of postoperative lip height asymmetry (B = 4.2%, p = 0.015). The surgeon performing the repair was also a significant factor in patients with complete cleft lips (B = 3.6%, p = 0.005). All three surgeons achieved greater lip height symmetry when a pennant flap was performed. Conclusions The results of unilateral cleft lip repairs are affected by both the surgeon and the surgical technique. Procedures that utilized a pennant flap showed better philtral height symmetry than non-pennant repairs.

ANSWERReactive perforating dermatosis. MICROSCOPIC FINDINGS AND CLINICAL COURSEHistologic evaluation showed either an epidermal invagination or widely dilated hair follicle containing a prominent plug of hyperkeratosis, parakeratosis, and cellular debris. There were numerous fibers perforating through the epithelium that by histology and special stains proved to be elastic fibers. Perforating collagen fibers were not identified.Blood work revealed low levels of vitamin A (,5.0 mg/dL; normal 32.5-78.0 mg/dL), B6 (,2.0 mg/L; normal 5-50 mg/L), D (,6.0 ng/mL; normal 30-80 ng/mL), E (,5.0 mg/L; normal 5.5-17.0 mg/L), K (0.07 ng/mL; normal 0.10-2.20 ng/mL), copper (0.23 mg/mL; normal 0.75-1.45 mg/mL), and zinc (0.44 mg/ mL; normal 0.66-1.10 mg/mL). The patient was started on total parenteral nutrition, intramuscular vitamin A injections, and oral supplementation with vitamin B6, vitamin B12, vitamin C, vitamin D, vitamin E, ferrous sulfate, and folic acid. Minimally invasive surgery was consulted to discuss reversal of the duodenal switch. The patient was also started on triamcinolone 0.1% cream to the hands, legs, and arms and urea 40% cream to the thicker plaques on the medial thighs.The patient was seen in dermatology clinic 2 months later with improvement of her rash. Pink scaly plaques involving the dorsal hands, medial thighs, elbows, and legs had faded significantly, with notably less hyperkeratosis and scale (Figs. 1A-C). Furthermore, the rash was no longer symptomatic; the patient denied any persistent pain or itch. She was continued on total parenteral nutrition and may undergo reversal of her bariatric surgery in the future.

No abstract