Preoperative planning for DIEP breast reconstruction: early experience of the use of computerised tomography angiography with VoNavix 3D software for perforator navigation.

The deep inferior epigastric perforator (DIEP) flap is normally the first choice in breast reconstruction; however, due to the considerable vascular anatomical variation and the learning curve for the procedure, muscle-sparing transverse rectus abdominis musculocutaneous (TRAM) flaps are still frequently performed to reduce the rate of complications. Accurate preoperative investigation of the perforators would allow better operative preparation and possibly shorten the learning curve. In an effort to increase accuracy of preoperative planning and to aid preoperative decision-making in free abdominal flap breast reconstruction, we have acquired the use of VoNavix, software that creates three dimensional images from computerised tomography angiography (CTA) data. The use of the VoNavix software for analysis of CTA provides superior imaging that can be viewed in theatre. It, together with CTA, enables decisions to be made preoperatively, including: which side to raise the flap; whether to aim for a medial or lateral row perforator; whether to take a segment of muscle and whether to expect an easy or difficult dissection. We have now performed over 60 free abdominal flap breast reconstructions aided with CTA, and 10 of these cases also used VoNavix technology. This paper presents our initial experience with the use of this software, illustrated with three patient examples. The advantages and disadvantages are discussed.

Post-burn breast resurfacing using an abdominal full-thickness skin graft.

We describe a case of delayed resurfacing of the right breast using the abdominal skin as a full-thickness graft in a 38-year-old woman who sustained a scald injury in childhood. The postoperative results are shown.

Failure to thrive in babies with cleft lip and palate.

We established the frequency of failure to thrive (FTT) in children undergoing primary cleft procedures by using growth charts and standard-deviation scores. Initially, 147 babies with cleft lip and/or palate undergoing 186 primary lip-and-palate repairs were studied between 1993 and 1996. Rates of FTT were categorised according to cleft type. There was an increasing rate of FTT from 32% for unilateral cleft lip and palate to 38% for bilateral cleft lip and palate to 49% for cleft palate. There was a high incidence of FTT in palatal clefts, especially if these were associated with a syndrome or anomaly (P= 0.001). The incidence of FTT with the Pierre Robin sequence was 100%. In view of the high rates of FTT, two changes were instituted: a feeding-support nurse was appointed to supervise and monitor patients at risk and all patients with the Pierre Robin sequence had supervised airway management. Thereafter, the incidence of FTT was prospectively studied in 68 babies undergoing 84 primary procedures between 1997 and 1999. There was a decrease in the incidence of FTT in comparison with the earlier cohort (9% for unilateral cleft lip and palate, 20% for bilateral cleft lip and palate, 26% for cleft palate). There was a significant decrease in the incidence of FTT in the group with the Pierre Robin sequence, from 100% to 40%. As a result of the provision of a feeding-support nurse and airway management of patients with the Pierre Robin sequence, the incidence of FTT was reduced and the audit loop closed.

Velopharyngeal incompetence and chromosome 22q11 deletion.

Chromosome 22q11 deletion gives rise to various phenotypes, including cardiac malformations, velopharyngeal abnormalities, absent thymus, and neurological defects. We assessed, in a prospective study, chromosome 22q11 deletion in 50 of 144 patients with velopharyngeal incompetence in the absence of overt clefting. 18 (12.5% of the whole cohort and 36% of patients tested for the deletion) had the 22q11 deletion. This frequency differs from an estimated population prevalence of 0.025% and suggests a need for screening for the 22q11 deletion in these patients.

Patient satisfaction with cleft lip and palate services in a regional centre.

We sent a questionnaire to the parents of 478 children aged between 3 and 14 years who are under the care of the cleft team at the Queen Victoria Hospital, East Grinstead, and received 341 replies. A wide variety of questions were asked about aspects of patient satisfaction, and the results are reported and discussed. There was a high level of satisfaction with the service provided but 30% of parents would like to be more involved in treatment-planning decisions; 33% thought they had either not enough or no knowledge about cleft lip and palate and its treatment. Only 8% of parents would rather have seen the specialists separately than together in the joint clinic.

Use of cartilage grafts for closure of cleft palate fistulae.

We describe the results of using a free cartilage graft in the closure of cleft palate fistulae in 14 patients with a mean follow-up of 8.6 months. Complete closure of the fistula was achieved in 11 patients (79%), with partial closure in the remaining three patients. This technique is simple, causes relatively little discomfort, involves little tissue dissection and can be performed as a day-case procedure. The success rate is comparable with or better than other methods, and we consider it the treatment of choice for small cleft palate fistulae.

Left or right hand dominance in children with cleft lip and palate.

The relationship between unilateral cleft lip, bilateral cleft lip, palatal clefting and left-right hand dominance was studied in 337 patients with cleft lip and/or palate aged between 3 and 14 years. There was no statistically significant difference in the laterality of handedness between different types of cleft nor between unilateral left and right sided cleft lip with or without cleft palate.

Urinary flow rates in hypospadias.

Uroflowmetry has been performed on 140 occasions in 90 patients with hypospadias before and after reconstructive surgery. Children with hypospadias tend to have a lower maximum urinary flow rate for volume voided than the general population, lying around the population 5th centile. This is observed before any surgery is performed, and appears from our cross-sectional data to be unaffected by surgery. Uroflowmetry has proved a useful and economical means of gaining an objective assessment of urinary function in this group of patients. Further longitudinal studies to confirm this cross-sectional study would be useful.

Objective evaluation of the Tajima secondary cleft lip nose correction.

The early and late results of the Tajima cleft nose correction were objectively measured by computer on 24 unilateral complete cleft lip and palate patients (age range 5-29 years, median 14). Follow-up records were divided into early (within 3 months), intermediate (3 months to 1 year) and late (1 year+); the longest follow-up was 4.2 years. Comparison of the preoperative records with the early and intermediate follow-up photographs showed an improvement in symmetry (Wilcoxon signed rank, P < 0.01). In the late follow-up group the deformity recurred and the nasal shape could not be statistically separated from the preoperative appearance. A group of 25 normal control faces showed no changes, whilst 20 control cleft patients had some worsening of nasal symmetry over the same time scale. Analysis of the components of the corrected noses showed the best improvement (and later relapse) was in dome symmetry.

Cleft palate re-repair--a clinical and radiographic study of 32 consecutive cases.

The results of clinical and radiographic assessment of palate re-repair (by a single operator) in 32 patients are presented. This has shown that radical muscle correction as a secondary procedure (following limited or no muscle correction in primary repair) has produced measurable improvement in velar function and should be considered as the first option in many patients with velopharyngeal incompetence. The results also support the concept of muscle dissection and retropositioning in primary cleft palate repair.

Facial clefts in the west of Scotland in the period 1980-1984: epidemiology and genetic diagnoses.

Two hundred and eighty six cases of cleft lip, cleft palate, or both were identified in a study attempting complete ascertainment of babies with facial clefts born to women resident in the west of Scotland in a five year period beginning 1 January 1980. The total birth prevalence (TBP) of these defects over this period was 1.53 per 1000. The TBP for cleft lip with or without cleft palate (CL[P] was 0.74 per 1000 and for cleft palate (CP) was 0.79 per 1000; 26% of CL[P] and 39.5% of CP cases had one or more major congenital anomaly associated with their facial cleft and in over half of these cases a specific genetic or syndrome diagnosis could be made. In comparison to previous European reports this study shows a high incidence of associated abnormalities and a remarkably low ratio of CL[P]:CP cases.

Early experience with the Lejour vertical scar reduction mammaplasty technique.

Over a 19-month period 25 bilateral reduction mammaplasties were performed using the Lejour technique. Results were assessed retrospectively. The mean follow-up was 12 months. The study showed that minor complications were common (40%), that nipple-areolar sensation was frequently reduced and that minor revision surgery for persistent dog-ears was often necessary (20%). Comparison with complications and revision rates in a similar group of patients who had undergone reduction mammaplasty using an inferior pedicle technique showed remarkably similar results. The positive findings of the current study were that nipple-areola necrosis was not encountered, patient satisfaction was high and the aesthetic results were generally good.

Primary cutaneous plasmacytoma: the use of in situ hybridization to detect monoclonal immunoglobulin light-chain mRNA.

A case of primary cutaneous plasmacytoma in a 16-year-old male is described. The neoplastic nature of the plasma cell infiltrate has been clearly established by the demonstration of monoclonal kappa immunoglobulin light-chain mRNA using in situ hybridization with biotin-labelled oligonucleotide probes applied to routine tissue sections.

Comparison of E-Z Derm and Jelonet dressings for partial skin thickness burns.

A prospective, randomized trial of 32 patients with partial skin thickness burns is reported comparing E-Z Derm with Jelonet as a burn dressing. The bacterial colonization rate, need for surgical treatment, time for spontaneous healing, analgesic requirements and frequency of dressing changes were assessed in each group. No statistically significant differences were found between the two groups, for any of these factors.

Vascularised versus conventional nerve grafting: a case report.

A case is described in which two lengths of the lateral cutaneous nerve of the forearm were used, one vascularised and the other not, to reconstruct the two digital nerves of the thumb. The sensory recovery of the two nerves was compared, and the vascularised nerve graft found to result in better sensation. This finding provides further support for the value of vascularised nerve grafts.

Morbidity in the forearm flap donor arm.

A retrospective study was carried out of the morbidity in the donor limb following use of the radial forearm flap in 27 patients. Of the 13 patients whose flaps contained bone, 4 sustained fractures of the radius. This was associated with a 50% loss of power of grip and pinch, and limitation of other movements, particularly pronation and supination. In the other patients little or no loss of power or range of movement was seen. No patient had cold intolerance; a few had areas of sensory loss, related to the radial nerve. Of the 12 patients whose radial arteries were reconstructed, 7 remained patient; no patient had any clinical features of ischaemia. These findings and their implications are discussed.

A split Chinese forearm flap for simultaneous oral lining and skin cover.

The use of the Chinese or radial forearm flap to provide simultaneous oral lining, mandibular reconstruction and skin cover is reported in three patients, and suggestions are made about flap design.

Musculus uvulae and levator palati: their anatomical and functional relationship in velopharyngeal closure.

The morphological relationship between the musculus uvulae and levator palati muscles and their importance in velopharyngeal closure was studied in cadavers by simulation of levator action, palate serial section and dissection, and in various subjects by nerve stimulation and blockade. These studies support the cardinal importance of the levator muscles in velopharyngeal closure. The significance of musculus uvulae activity is less clear. While lesser palatine nerve stimulation evoked a response from the musculus uvulae, a nerve block produced no detrimental effect on speech or nasendoscopic appearance in normal subjects.

Levator palati and palatal dimples: their anatomy, relationship and clinical significance.

To achieve the best results in cleft palate repair it is necessary to be aware of the normal anatomy. In a series of cadaver dissections, the levator palati muscle was found to occupy the intermediate 40% of the length of the soft palate. This normal distribution should be the aim at cleft palate repair. Observation of the oral surface of the palate during production of the sound "Ah" reveals palatal dimpling. This has been observed in many normal and cleft palate subjects. The dimpling has been reproduced in cadavers by levator palati traction and been found on dissection and serial histological section to correspond to the levator insertion.