Prepectoral Prosthetic Breast Reconstruction Without ADM Using a Subfascial Approach.

BACKGROUND: Immediate prosthetic reconstruction has evolved to a prepectoral position. A technique is described where the pectoral and serratus fascia is raised from superiorly. Initially, Vicryl mesh was used to close the superior fascial defect, but later abandoned by using primary closure for tissue expanders, or creating a pocket in the infraclavicular pectoralis muscle after prosthesis (DTI) insertion. The inframammary fold is also reinforced. Patients with a BMI > 30 have axillary liposuction. METHOD: Retrospective analysis over a 4-year period. Data included age, number of breasts having expanders or DTI. Prosthetic extrusion and follow-up were recorded. The percentage coverage by fascia was calculated. RESULTS: Forty-seven patients (80 breasts) had mean age of 42 years (range 32-62), twelve patients (19 breasts) had Vicryl mesh inserted, while 35 patients (61 breasts) had closure as noted above. Tissue expanders were inserted in 39 breasts (10 mesh, 29 without). DTI (direct to implant) performed in 41 breasts (32 no mesh, 9 with mesh). Three patients with mesh developed recalcitrant seromas. The mean size of prosthesis used was 353ml (range 200-500 ml). Extrusion occurred in eight breasts (two with mesh, six without). Mean coverage of the prosthesis by fascia was 74% (range 50-100%), and nine patients also had bilateral axillary liposuction of the axillary roll. Mean follow-up was 13 months. CONCLUSION: Another technique for immediate prosthetic reconstruction providing an additional layer of prosthetic cover in prepectoral plane, without mesh. Applicable for all grades of ptosis. Extrusion rate is low. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The Role of the Inframammary Fold (IMF) in Aesthetic and Reconstructive Surgery: A Critical Analysis and Surgical Solution.

INTRODUCTION: The inframammary fold (IMF) is a critical structure in breast aesthetics and is affected by various types of breast surgery. The ideal IMF has a semi-elliptical shape, which may become attenuated with age and descends in macromastia. The aim of this study was to analyse the IMF and retain/restore its shape with sutures. METHODS: A retrospective study was conducted on breast surgeries performed over a four-year period (2019-2022). The morphometry of the IMF was evaluated preoperatively while the patients were standing. In cases where the IMF was symmetrical, sutures were used to reinforce it during surgery. When the loss of the semi-elliptical shape was clinically indicated, the IMF was mobilized, repositioned, and then sutured into place. RESULTS: The study included 56 patients: 43 undergoing immediate breast reconstruction, and 13 undergoing bilateral breast reductions. In over two thirds of the patients, the lateral IMF was inferiorly displaced compared to the medial IMF. CONCLUSION: It is recommended to reinforce the IMF in all patients undergoing breast surgery. Where the IMF has an elliptical shape preoperatively, it is reinforced. Where IMF is inferiorly displaced, mobilization and superior advancement of the IMF, followed by suture reinforcement, are necessary. This approach results in a well-defined IMF with improved breast aesthetics. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Soft Palate Mucosal Adhesion with Muscle Release: An Option in "Wide" Cleft Palates in a Cohort in Southern Africa.

OBJECTIVE: Comparison of speech outcomes in 2 similar groups of "wide" cleft palate. One received a Furlow double-opposing Z- plasty (FZP) versus a group (non-FZP) that received only a muscle release at the second stage after both received a soft palate mucosal adhesion (SPA) at the first stage. METHODS: Retrospective review. Thirty-three patients (non-FZP) versus 29 patients (FZP) between 2010 and 2016. Both groups had SPA at approximately 6 months of age. After 12 months, an FZP with hard palate closure was performed in the FZP group. in the non-FZP group, only the muscle was released from the posterior palatal shelves with hard palate closure. Speech and velopharyngeal insufficiency (VPi) were determined clinically and by videofluoroscopy. RESULTS: The FZP group (15 M: 14 F) with Veau (III = 14; IV = 5; II = 10) had a mean palate length (MPL) of 20.5 mm and mean palate width (MPW) of 11.2 mm at 8.3 months. MPW decreased to 7 mm after 20.7 months. 21% (n = 6) had fistulae. 14% (n = 4) (all males) had VPI. Their MPL was 16.3 mm. The mean follow-up was 5.5 years. In the non-FZP group, (18 M: 15 F) with Veau (III = 22; IV = 7; II = 4), the MPL was 20.5 mm and MPW was 11 mm at 8.4 months. MPW decreased to 6.5 mm after 12.5 months (P = 0.006). The fistula rate was 18% (n = 6). 24% (n = 8) predominantly male (87%) had VPI (P = 0.432). Their MPL was 17 mm; the mean follow-up was 4.7 years. CONCLUSIONS: SPA as a first stage performed in "wide" cleft palate narrows the subsequent hard palate repair and with a muscle release, may be adequate in some patients.

Modelling Genetic Benefits and Financial Costs of Integrating Biobanking into the Captive Management of Koalas.

Zoo and wildlife hospital networks are set to become a vital component of Australia's contemporary efforts to conserve the iconic and imperiled koala (Phascolarctos cinereus). Managed breeding programs held across zoo-based networks typically face high economic costs and can be at risk of adverse genetic effects typical of unavoidably small captive colonies. Emerging evidence suggests that biobanking and associated assisted reproductive technologies could address these economic and genetic challenges. We present a modelled scenario, supported by detailed costings, where these technologies are optimized and could be integrated into conservation breeding programs of koalas across the established zoo and wildlife hospital network. Genetic and economic modelling comparing closed captive koala populations suggest that supplementing them with cryopreserved founder sperm using artificial insemination or intracytoplasmic sperm injection could substantially reduce inbreeding, lower the required colony sizes of conservation breeding programs, and greatly reduce program costs. Ambitious genetic retention targets (maintaining 90%, 95% and 99% of source population heterozygosity for 100 years) could be possible within realistic cost frameworks, with output koalas suited for wild release. Integrating biobanking into the zoo and wildlife hospital network presents a cost-effective and financially feasible model for the uptake of these tools due to the technical and research expertise, captive koala colonies, and ex situ facilities that already exist across these networks.

Dealing with the Displaced Nipple-Areola Complex in Macromastia Using a Superomedial Pedicle and Inverted T Pattern.

In macromastia, especially in patients with a raised BMI, the nipple areola complex (NAC) may be displaced from the breast midline/meridian. This is poorly documented, and there is little published on surgical management. The aim of the study was to identify the incidence of displaced NAC in macromastia and discuss the management using the superomedial pedicle, by canting the vertical limbs of the inverted T/keyhole. The study also aimed to postulate a theory of pathogenesis. METHODS: The study is a retrospective review for a two-and-a-half year period. For study inclusion, the NAC had to be displaced 3 cm or more from the breast meridian. A superomedial pedicle was used with an inverted T pattern. The vertical limbs of the keyhole were canted medially for medially displaced NACs and laterally for laterally displaced NACs. RESULTS: Fifteen patients were identified: three with medial and 12 with laterally displaced NAC. Mean age was 35 years (range 21-61) with a mean BMI of 31 (range 27-37). The mean mass of tissue excised was 1158 g (range 330-1969 g). The mean follow up is 7 months (range 2-21 months). One patient suffered partial areola loss, and 2 patients had a breakdown at the angle of sorrow/inverted T junction. CONCLUSIONS: The displaced NAC is not uncommon in women with a raised BMI presenting for breast reduction. Canting the vertical limbs of the keyhole away from the deviated NAC yields satisfactory results in treating patients with a displaced NAC using a superomedial pedicle. A theory of possible pathogenesis is postulated; global attenuation of the breast footplate occurs, leading to lateral and inferior displacement of the NAC.

The Use of Vastus Lateralis Muscle Flap for Functional Lip Reconstruction.

BACKGROUND: Total or near-total lip defects poses a serious challenge to a reconstructive surgeon with static procedures not providing desired functional and aesthetic outcomes. The dynamic lip reconstructive methods using functional muscles have become a current issue in recent years showing admirable results. This study present 3 cases of successful total and near-total lip reconstruction are presented using vastus lateralis muscle. METHODS: This is a retrospective analysis of a consecutive series of 3 patients (2 men and 1 woman) aged 44 to 56 years (mean) who had resection of extensive squamous cell carcinoma 2 had both upper and lower lip involved and 1 had lower lip involvement only. After resection patients had near total full thickness lower lip defect and 40% upper lip defect. The innervated vastus lateralis muscle free flap was transferred to the lip and end-to-end vascular anastomosis on the facial artery and end-to-side to internal jaguar vein was performed. The marginal mandibular branch of the facial nerve was used for nerve coaptation. The inner and outer surfaces of the flaps were grafted with a thick-split-thickness skin graft. Drooling rating scale and patient and observer scar assessment scale as well as electromyography were performed to evaluate oral competency and aesthetic outcome. RESULTS: All patients underwent single stage near-total lower lip and 2 had part of upper lip reconstruction successfully and survived the surgical operation. One patient lost the skin graft and was managed consecutively and muscle granulated and healed. Two patients underwent radiation therapy and 1 died before starting radiation due to other unnatural causes. The 2 patients achieved perfect oral sphincter competence without drooling and at 9months postoperative demonstrated successful reinnervation of the vastus lateralis muscle. CONCLUSIONS: This study demonstrates that lip reconstruction using an innervated vastus lateralis muscle free flap is a reliable method, providing a functional lip.

Autologous Fat Grafting for the Treatment of Mild to Moderate Velopharyngeal Insufficiency.

BACKGROUND: To assess speech results following the treatment of mild to moderate velopharyngeal insufficiency (VPI) post cleft palate surgery with autologous fat grafting to the velopharynx. METHODS: A retrospective study was conducted on 9 consecutive patients who underwent velopharyngeal fat grafting for the treatment of VPI at the Red Cross War Memorial Children's hospital from 2010 to 2014. All the patients previously had primary palatoplasty performed and subsequently developed VPI. Patients were assessed pre- and postoperatively by an experienced speech and language therapist looking at perceptual speech and by 2 senior cleft surgeons interpreting lateral view videofluoroscopies. RESULTS: Eleven fat grafting procedures were performed on 9 patients and an average of 5.64 mL (range 1-7 mL) of autologous fat was transferred to the velopharynx. The average age at the time of operation was 6.5 years (range 3-14 years) with a follow-up period of 18 months (range 7-34 months). Most of the patients (7 out of 9) showed improved speech after fat grafting. One of the 7 patients had multiple procedures. The 2 who did not show speech improvement only had a single procedure. There were no complications related to the fat grafting procedure. CONCLUSION: This small study suggests that fat grafting either as a single procedure or as multiple procedures is an effective, safe, minimally invasive surgical alternative, and/or adjunct for the treatment of mild to moderate VPI in patients following cleft palate surgery and to the knowledge, is the first reported study from Africa.

Anthropometric Changes in a Prospective Study of 100 Patients Requesting Breast Reduction.

BACKGROUND: The anthropomometry of the "ideal" breast is well described, but changes that occur with enlarged breasts are not. The aim of this study was to assess the prevalence of nipple asymmetry in the horizontal plane and changes in the inframammary fold (IMF) in patients presenting with macromastia (defined as excessive development of the mammary glands by Merriam-Webster dictionary). METHODS: One hundred patients (200 breasts) presenting to the Plastic Surgery Clinic for bilateral breast reduction were enrolled in this study. Patients' characteristics captured for this study included age, body mass index (BMI), and breast anthropometric measurements, such as suprasternal notch to nipple, nipple to IMF, IMF projected to cubital fossa, midhumeral point, and nipple measurement from meridian. Basic univariate statistical analyses were performed to evaluate the impact of nipple asymmetry. RESULTS: The average age was 37 years (SD 12 years), and the median BMI was 33 (IQR 28-37). More patients presented with nipple asymmetry, of whom 45% were classified as lateral to the meridian, 19% were classified as medial to the meridian, and 36% were classified as central to the meridian. Patients with lateral asymmetry and medial asymmetry had a significantly higher BMI (median BMI 35) compared with patients with central positioning (median BMI 30). Increasing breast size was positively associated with nipple asymmetry, whereas BMI (R = -0.30, P = 0.003) and macromastia correlated negatively with IMF position (R = -0.38, P = 0.0001). CONCLUSION: In macromastia, nipple displacement from the breast meridian, especially lateral displacement, is common and is aggravated by an increase in BMI. The IMF also descends, and this is also more common in patients with a raised BMI. These changes have clinical implications.

Cryptococcosis in the koala (Phascolarctos cinereus): pathogenesis and treatment in the context of two atypical cases.

Disseminated cryptococcosis caused by Cryptococcus gattii (molecular type VGI) was diagnosed in an adult free-ranging female koala (Phascolarctos cinereus). Subclinical cryptococcosis was later diagnosed in this koala's joey. In the adult koala, a pathological fracture of the tibia was associated with the bone lysis of marked focal cryptococcal osteomyelitis. Limb-sparing orthopedic intervention, in the setting of disseminated cryptococcosis, was judged to have a poor prognosis, and the adult koala was euthanized. The joey was removed and hand-reared. Serological testing revealed persistent and increasing cryptococcal capsular antigenemia in the absence of clinical signs of disease and it was subsequently treated with oral fluconazole for approximately 16 months, rehabilitated and released into the wild. It was sighted 3 months post-release in a good state of health and again at 18 months post-release but was not recaptured on either occasion. This is the first published report of cryptococcal appendicular osteomyelitis in a koala. It is also the first report of concurrent disease in a dependent juvenile and the successful treatment of subclinical cryptococcosis to full resolution of the cryptococcal antigenemia in a free-ranging koala. This paper provides a discussion of cryptococcal osteomyelitis in animals, host-pathogen-environment interactions and treatment and monitoring protocols for cryptococcosis in koalas. Published reports describing the treatment of cryptococcosis in koalas are also collated and summarised.

Incisional Negative Pressure Wound Therapy for Prevention of Wound Healing Complications Following Reduction Mammaplasty.

BACKGROUND: It has been proposed that negative pressure wound therapy (NPWT) applied prophylactically to a closed incision may decrease the incidence of wound complications. Patients undergoing reduction mammaplasty are at risk of wound complications such as delayed healing, infection, and dehiscence, and the bilateral nature of the surgery allows for a within-patient randomized study to evaluate incisional NPWT's effect in reducing healing complications. METHODS: In this multicenter trial, 200 patients undergoing bilateral reduction mammaplasty were treated with PICO Single-Use NPWT System or standard wound-care dressings randomized to right or left breast for up to 14 days to enable within-patient comparison. Follow-up assessments were conducted to evaluate the difference in incision healing complications up to 21 days postsurgery. Healing complications (for the primary endpoint) were defined as delayed healing (incision not 100% closed by 7 days) and occurrence of dehiscence or infection within 21 days. Individual healing complications were assessed separately as secondary endpoints. RESULTS: Significantly fewer healing complications (primary endpoint) were noted in NPWT-treated breasts [113 (56.8%)] versus standard care [123 (61.8%)]. The difference of 10 (5.0%) patients with fewer healing complications using NPWT was statistically significant (P = 0.004). NPWT also resulted in a significantly lower incidence of dehiscence (secondary endpoint) compared with standard care [32 patients (16.2%) versus 52 patients (26.4%)] by day 21, a relative reduction of 38% (P < 0.001). CONCLUSIONS: This is the first major prospective, within-patient, randomized, controlled, multicenter study to provide evidence for an incisional NPWT strategy to reduce healing complications.

Breast Reduction: Decreasing Complications and Improving Long-Term Aesthetic Results with Parenchymal Sutures.

BACKGROUND: The inverted T/keyhole pattern is commonly used for large breast reductions. This technique relies on the breast skin to retain the shape. With the passage of time "fallout" (pseudoptosis) occurs impairing the cosmetic result. A technique is described that uses parenchymal sutures and inframammary fold (IMF) reinforcement sutures to maintain the intraoperative shape. METHODS: A retrospective study of 25 consecutive patients (50 breasts) where the IMF was reinforced and parenchymal sutures were inserted. The patients were followed up and the nipple to notch and nipple to IMF distance was measured and compared with that marked preoperatively and set intraoperatively. Complications, especially T junction breakdown, were also recorded. RESULTS: The mean age was 38 years (range, 16-62 years) with a mean follow-up of 12 months. The mean body mass index was 31 (range, 22-41). The mean mass of tissue excised was 925 g (range, 340-1,800 g) per side. The distance from the suprasternal notch to the nipple remained unchanged. The distance from the nipple to the IMF remained the same as that marked preoperatively except in 3 patients who developed pseudoptosis. Only 3 patients had wound dehiscence. CONCLUSION: Parenchymal and superficial fascial system sutures combined with IMF reinforcement contributes to maintaining the aesthetic result and decreasing complications, in weight stable patients.

Acellular Dermal Matrix: Treating Periocular Melanoma in a Patient with Xeroderma Pigmentosa.

We report a 7-year-old girl with xeroderma pigmentosum (XP), who presented in our clinic with a large melanoma (35 × 50 × 20 mm, Breslow depth 18 mm) in the zygomatic-malar area. Palliative surgery was performed to maintain her residual vision and to reduce the pain caused by the compression of local structures. Because of the limited access of autologous skin grafts in pediatric patients with XP who are severely affected, we opted to use an acellular dermal matrix. There was 100% graft uptake, and the pain due to compression by the tumor was alleviated. This case demonstrates that acellular dermal matrices can be safely and effectively used in oncological facial reconstruction, especially in patients with progressive conditions such as XP.

Use of Resorbable Fixation System in Pediatric Facial Fractures.

INTRODUCTION: Resorbable fixation system (RFS) is an alternative to titanium in open reduction and internal fixation of pediatric facial fractures. METHODS: This study retrospectively reviewed all medical records in a major metropolitan pediatric hospital in Cape Town, South Africa from September 2010 through May 2014. Inclusion criteria were children under the age of 13 with facial fractures who have undergone open reduction and internal fixation using RFS. Intraoperative and postoperative complications were reviewed. RESULTS: A total of 21 patients were included in this study. Twelve were males and 9 were females. Good dental occlusion was achieved in all patients and there were no complications intraoperatively. Three patients developed postoperative implanted-related complications: all 3 patients developed malocclusions and 1 developed an additional sterile abscess over the right zygomatic bone. For the latter, incision and drainage was performed and the problem resolved without additional operations. DISCUSSION: Resorbable fixation system is an alternative to titanium products in the setting of pediatric facial fractures without complications involving delayed union or malunion. The combination of intermaxillary fixation and RFS is not needed postoperatively for adequate fixation of mandible fractures. Resorbable fixation system is able to provide adequate internal fixation when both low-stress and high-stress craniofacial fractures occur simultaneously.

Pediatric Facial Fractures.

INTRODUCTION: There are few published articles describing the epidemiology of facial fractures in South Africa, and there is only one published study in pediatric patients. MATERIAL AND METHODS: This study retrospectively reviewed all medical records in a major metropolitan pediatric hospital in Cape Town, South Africa from September 2006 through May 2014. Inclusion criteria were children aged under the age of 13 with facial fractures. Fractures were assessed through head computed tomography (CT) scans. Patient's age, sex, cause of injury, general condition, existence of concomitant injuries, location of fractures, type of interventions, and length of stay were recorded and analyzed. RESULTS: A total of 53 men and 34 women were included in the study. Motor vehicle collisions (MVC) were the most common cause of facial fractures (56.3%). One hundred thirty facial fractures were presented on CT scans. The most common fractures in this study were mandible (43.1%). Comparing unrestrained motor vehicle collisions (UMVC) patients with those of other etiologies (OE), there was an increase in the average number of fractures (OE: 1.1, UMVC: 1.9; P < 0.0001), the average length of stay (OE: 4 days, UMVC: 9 days; P < 0.003), and the probabilities of sustaining concomitant injuries (OE: 31.0%, UMVC: 68.8%; P < 0.05) and requiring an operation (OE: 42.3%, UMVC: 81.3%; P < 0.01). DISCUSSION: This study establishes MVC as the most common etiology of facial fractures in South Africa. It demonstrates an increase in the complexity of facial injuries in unrestrained MVCs, suggesting the need for public awareness campaigns to install restraint devices in automobiles in South Africa.

Shouldn't Propranolol Be Used to Treat All Haemangiomas?

INTRODUCTION: Infantile haemangioma is the most common childhood tumour. These tumours can cause significant functional and cosmetic problems. While there are many treatment modalities, propranolol is increasingly being recognised as the first-line treatment of problematic haemangiomas. This study investigates the use of oral propranolol for the treatment of all haemangiomas at a tertiary children's hospital. METHOD: This is a retrospective study evaluating 15 children (3 boys and 12 girls) presenting at a tertiary children's hospital with infantile haemangioma during a 24-month period. The protocol consisted of pre-treatment ultrasonic evaluation of the lesion, followed by the commencement of propranolol therapy (2 mg/kg orally in two divided doses), with repeat imaging performed at 16-24 weeks in order to document the dimensional changes. Adverse effects of propranolol were documented. Intralesional bleomycin was utilised as a second-line modality of treatment for large or problematic haemangiomas with inadequate regression in size after oral propranolol therapy. RESULT: Fifteen (15) patients with a mean age of 7 months (Range: 3-14 months) presented with haemangiomas. Ten patients presented with lesions affecting the head and neck region (67%). Three patients presented with an ulcerated haemangioma, which responded to propranolol and simple dressings and all healed completely. The average decrease in size between the ultrasonography procedures was 48.87%. Only one patient showed no improvement. No side effects were reported. Concomitant bleomycin treatment was reserved for large problematic haemangiomas and proved successful at speeding up the involution process. CONCLUSION: This study suggests that propranolol become the first-line treatment of choice for all haemangiomas. It has proven to be effective and safe for reducing the size of all haemangiomas during the proliferative phase. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Simplified negative pressure wound therapy: clinical evaluation of an ultraportable, no-canister system.

The aim of this study was to evaluate a prototype negative pressure wound therapy (NPWT) system that has been developed to simplify NPWT for wounds at the lower end of the acuity scale. The new device has a single preset pressure of -80 mmHg, is single use and operates without an exudate canister. The disposable NPWT system (PICO™) was tested in a prospective, non-comparative, multicentre clinical trial to assess device functionality and clinical acceptance. Twenty patients were recruited for a maximum treatment period of 14 days. The NPWT devices were fitted with data log chips to enable longitudinal assessment of negative pressure and leak rates during therapy. Sixteen (80%) patients had closed surgical wounds, two (10%) patients had traumatic wounds and two (10%) patients received meshed split thickness skin grafts. The mean study duration was 10·7 days (range: 5-14 days) and the mean dressing wear time per individual patient was 4·6 days (range: 2-11). Fifty-five percent of wounds had closed by the end of the 14-day study or earlier, with a further 40% of wounds progressing to closure. Real-time pressure monitoring showed continuous delivery of NPWT. Three cases are discussed representing different wound locations and different patient factors that can increase the risk of post-surgical complications. Clinical studies of the disposable NPWT system confirmed the ability of the simplified single-use device to function consistently over the expected wear time. The anticipated reduced costs, ease of use and increased mobility of patients using this system may enable NPWT benefits to be available to a greater proportion of patients.

Intralesional bleomycin injection in management of low flow vascular malformations in children.

Low flow vascular malformations are challenging to manage, particularly with their propensity to grow, and can lead to severe disfigurement and dysfunction. Traditional surgical excision is fraught with tedious dissection and complications, particularly in the head and neck region. Trends toward less invasive techniques, such as intralesional sclerotherapy, are proving to be successful independent treatments or adjuncts in management in low flow vascular malformations. This study was a retrospective case note review, over an 8-year period, reporting the outcomes of 32 children (mean = 5.8 years, range = 5 months-11.5 years) with radiologically confirmed low flow vascular malformations, treated with serial intralesional bleomycin injection (IBI) therapy. Patient demographics, lesion characteristics, imaging findings, treatment course, radiological and clinical response to treatment were recorded. An overall 91% (n = 29) response rate was achieved, with 28% obtaining complete resolution for low flow vascular malformations. Lesions were sub-categorized into venous malformation, including mixed venous-capillary (n = 27) or lymphatic malformation (LM) (n = 5). Twenty-seven of 32 children experienced no complications. Local complications included superficial skin infection (n = 2), skin necrosis (n = 1), hyperpigmentation, and minor contour deformity. There was no recurrence and no systemic side-effects to bleomycin. Mean follow-up was 38 months (range = 6-95 months). In conclusion, serial intralesional bleomycin injections can be effective and also safe in a paediatric population for the successful management of symptomatic or disfiguring low flow vascular malformations.