Birth prevalence of cleft lip and palate in Northern Ireland (1981 to 2000).

OBJECTIVE: The prevalence of cleft lip and/or palate (CL/P) in Northern Ireland (NI) was last reported for 1980 through 1990. This study was undertaken to update the prevalence of CL/P in NI for the 20-year period 1981 to 2000, to determine the pattern of prevalence, and to report the proportion of different cleft types and sex distribution. DESIGN: Retrospective, population-based analysis. PATIENTS/PARTICIPANTS: All live born children with CL/P in NI from 1981 to 2000 were included. A total of 750 cases were identified. Resident births outside NI, stillbirths, abortuses, and children born with atypical orofacial clefts were excluded. Those with syndromes and submucous clefts were included in the study. RESULTS: The overall prevalence of children born with CL/P within NI for the period 1981 to 2000 was 1.47 per 1000 live births, or 1:682. This was consistent with the findings reported by other U.K. studies. There were no significant changes in the prevalence rates over any 5-year period. No significant seasonality trends were noted. Clefts of the palate only were always in the majority. More boys than girls were affected by cleft lip with or without cleft palate. There was a significant left-sided predilection for unilateral clefting of the lip. CONCLUSIONS: There have been no significant changes in the birth prevalence of children born with CL/P or the distribution or laterality of cleft type in the NI population during the past 20 years.

Buccinator sandwich pushback: a new technique for treatment of secondary velopharyngeal incompetence.

OBJECTIVE: A small percentage of patients have inadequate velopharyngeal closure, or secondary velopharyngeal incompetence, following primary palatoplasty. Use of the buccinator musculomucosal flap has been described for primary palate repair with lengthening, but its use in secondary palate lengthening for the correction of insufficient velopharyngeal closure has not been described. This study presents the results of a series of patients who had correction of secondary velopharyngeal incompetence using bilateral buccinator musculomucosal flaps used as a sandwich. PATIENTS: In this prospective study between 1995 and 1998, a group of 16 patients with insufficient velopharyngeal closure as determined by speech assessment and videoradiography were selected. Nasopharyngoscopy was carried out in addition in a number of cases. Case selection was a result of these investigations and clinical examination in which the major factor in velopharyngeal insufficiency was determined to be short palatal length. DESIGN: The patients underwent palate lengthening using bilateral buccinator musculomucosal flaps as a sandwich. All patients were assessed 6 months postoperatively. The operative technique, postoperative course, and recorded postoperative complications including partial/total flap necrosis and residual velopharyngeal insufficiency were evaluated. Preoperative and postoperative speech samples were rated by an independent speech therapist. RESULTS: Ninety-three percent (15 of 16) had a significant improvement in velopharyngeal insufficiency, and 14 patients had no hypernasality postoperatively. Both cases of persistent mild hypernasality had had a recognized postoperative complication. CONCLUSION: The sandwich pushback technique for the correction of persistent velopharyngeal incompetence was successful in achieving good speech results.

Nasal reconstruction using the Washio retroauricular temporal flap.

Reconstruction of an external nasal defect presents a challenge to the reconstructive surgeon. Transferring retroauricular tissue on a temporal pedicle was first described by Washio as a means to repair the central portion of the face. This paper describes our experience with the Washio retroauricular temporal flap for nasal reconstruction in twelve patients, together with our modifications to simplify the planning and raising of the flap. There was one patient with a stitch abscess, one case of hair loss from the pedicle which recovered within one month and one elderly patient who developed thromboembolic complications. There was no instance of flap necrosis. Our results confirm that the Washio retroauricular flap is an excellent technique for difficult nasal reconstruction in young patients.

Treatment of squamous cell carcinoma of the lip using Foscan-mediated photodynamic therapy.

Carcinoma of the lip is a common cancer of the head and neck area; its incidence is approximately one-quarter that for oral cavity cancers. It occurs most frequently on the lower lip of elderly males. This non-randomized Phase II study aimed to estimate the complete response (CR) rate to Foscan-mediated photodynamic therapy (Foscan-PDT) in patients with primary cancer of the lip, duration of CR, and the tolerability and safety of Foscan-PDT. Twenty-five patients with squamous cell carcinoma (SCC) of the lip (Tis, T1, T2/N0/M0) and Karnofsky status > or = 70 received 0.15 mg/kg Foscan intravenously, followed 4 days later by a single non-thermal illumination of the tumour (light dose 20 J/cm2, irradiance 100 mW/cm2, lambda=652 nm). Response was determined after 12 weeks and mean follow up is 424 days so far. After 12 weeks, 96% of cases (24/25) showed CR, and all CRs were confirmed by biopsy. The most common adverse event was swelling and local pain at the treatment site. Tumour recurrence was observed in two patients 4 and 18 months after PDT. One patient developed a single lymph node metastasis 7 months after therapy. Photosensitivity reactions occurred in five patients. The functional results were excellent in all patients without any signs of limited mouth opening or impaired lip closure. The cosmetic outcome was better than after surgical therapy. Foscan-PDT is an effective treatment modality for small primary tumours of the lips. Foscan-PDT yields complete response rates comparable to those published for surgery or radiotherapy without causing major toxicity. It allows preservation of form and function and does not compromise future treatment options for recurrent, residual or second primary disease.

Frontonasal dysostosis in two successive generations.

Frontonasal dysostosis (also called frontonasal "dysplasia") comprises ocular hypertelorism, median facial cleft affecting nose and/or upper lip, unilateral or bilateral cleft of the alae nasi, anterior cranium bifidum occultum, or a widow's peak. Usually it is a sporadic disorder, although a few familial cases have been reported. We describe a 2-year-old girl with anterior cranium bifidum occultum, lipoma of genu and anterior part of the corpus callosum, and hypertelorism. Her mother had a history of a nasal drip at birth caused by a defect in the cribriform plate and phenotypically, a widow's peak. This observation suggests either autosomal dominant or X-linked dominant inheritance. The family illustrates the importance of identifying mild expression of frontonasal dysostosis before genetic counseling.

Complications of long operations: a prospective study of morbidity associated with prolonged operative time (> 6 h).

Reconstructive surgical procedures often take a long time to perform and duration of surgery is frequently cited as a major risk factor for postoperative complications. Whether operative time is an independent risk factor is unknown, as patients undergoing long operations may have numerous other risk factors. From September 1996 to September 1997, we prospectively assessed those patients undergoing reconstructive surgery lasting 6 h or more. A total of 62 patients were studied and they were grouped into three categories: head and neck surgery (n = 23), breast reconstruction (n = 18) and upper and lower limb surgery (n = 21). Postoperative complications were recorded and the results of each group compared. Each of the three patient categories had a similar mean duration of surgery but there were large differences in postoperative morbidity between the three groups, e.g. within the head and neck group postoperative respiratory and wound complications occurred in 43% and 26% of patients, respectively. In the limb surgery group, however, only 5% of patients had respiratory complications and 5% had wound complications. Despite having similar duration of surgery the differences in postoperative complications between the three groups suggest that duration of surgery alone is not a major determinant of postoperative morbidity and that the type of surgery performed and the patient's general health are more important predictors of outcome.

A technique for repair of the 'unrepairable' cleft palate.

The 'unrepairable' cleft palate may be described as one in which the width of the cleft exceeds the sum of the widths of the palatal shelves. A report of such a case is presented, and the technique used to repair the cleft using bilateral buccinator musculomucosal flaps is described. It is offered as a suggested technique for the management of such cases in the future.

A retrospective comparison of craniofacial form in Northern Irish children with unilateral cleft lip and palate.

OBJECTIVE: This study evaluated the craniofacial form of a sample of Northern Irish children with unilateral cleft lip and palate (UCLP). The quality of the outcomes achieved was compared with the outcomes reported for the six centers involved in the European multicenter study (Mars et al., 1992; Mølsted et al, 1992). DESIGN: Retrospective analysis. PATIENTS: All children born with complete skeletal UCLP in Northern Ireland during the years 1983 to 1987. MAIN OUTCOME MEASURES: Cephalometric analysis was used to determine the craniofacial form and soft tissue profile. The quality of the dental arch relationships was independently assessed using the Goslon ranking system. RESULTS: The sample comprised 25 children with complete skeletal UCLP who had cephalometric radiographs and study casts recorded at a mean age of 9.4 years (range, 8 to 11 years). Cephalometric analysis revealed no important skeletal differences between the Northern Irish UCLP children and the published results from the six Eurocleft centers. The soft tissue profile of the Northern Irish UCLP children was significantly more convex than the soft tissue profile recorded for center D in the Eurocleft study. The Goslon ranking system revealed that 18 (72%) of the Northern Irish UCLP children had good or satisfactory dental arch relationships. CONCLUSIONS: No clinically important differences were detected between the mean cephalometric skeletal parameters of the Northern Irish UCLP children and those published for the six cleft centers involved in the Eurocleft study. On average, the Northern Irish UCLP children were found to differ significantly from Eurocleft's center D in their soft tissue facial contour and sagittal lip profile. The quality of the dental arch relationships of the Northern Irish sample was between the best and the less good Eurocleft centers.

Early closure of a randomized trial: surgery and postoperative radiotherapy versus radiotherapy in the management of intra-oral tumours.

Tumours of the oral cavity/oropharynx occur relatively infrequently in the UK. The management of such lesions, especially the squamous cell carcinomas, is still a little controversial. Some centres advocate radiotherapy while others adopt surgery and radiotherapy. In an attempt to resolve the question of which approach gives the better results, a multicentre randomized trial was established to compare surgery plus postoperative radiotherapy with radical radiotherapy alone. It was anticipated that 350 patients would be required to give a statistically significant result, but, after 35 patients had been entered, the trial was closed prematurely with a marked difference in overall survival in favour of the combination arm (P = 0.0006). At this analysis, carried out 23 months after trial closure, the survival difference between the two arms remains statistically significant for all causes of mortality (P = 0.001; relative death rate = 0.24; 95% CI 0.10-0.59).

Complications associated with suction drains after microvascular anastomeses.

Two head and neck cases in which free flaps were used for reconstruction are presented. The circulation of the flaps was compromised due to problems directly associated with suction drains. The methods of drain fixation are discussed.

Closure of persistent post-proctectomy perineal sinus using a rectus muscle flap.

A persistent perineal sinus following proctocolectomy or proctectomy is a not infrequent complication associated with considerable morbidity. Two cases are presented where the perineal sinus was closed using a rectus abdominis flap. This method of closure allows safe, complete excision of the sinus and insertion of a muscle flap which completely fills the defect, enabling complete, primary healing of the perineum.

Musculocutaneous flaps in head and neck reconstruction.

The introduction of musculocutaneous flaps to head and neck reconstructive surgery is described. The flaps available are listed, and the most important ones described and illustrated. Both the latissimus dorsi and pectoralis major flaps are felt to have a role in head and neck reconstruction, though they have largely been superseded by microvascular free flaps such as the radial forearm flap.

Reconstruction of the vermilion after "lip-shave".

During the year 1986, 12 "lip-shave" defects were reconstructed using orbicularis oris myomucosal flaps, in the Northern Ireland Plastic and Maxillo-Facial Service. Three of these were extended lip-shaves. The planning of a V-Y plasty for myomucusal advancement is described and some representative results are shown. We feel that the myomucosal advancement flap is a valuable technique to overcome some of the problems in reconstruction of the vermilion after lip-shave.

The posterior auricular flap: anatomical studies.

The aim of this study was to investigate the blood supply of the auriculomastoid skin and to prove the reliability of the posterior auricular vessels for supply of a skin flap in this region. This was done by means of studies of arteriograms, cadaver dissections, India ink perfusion, lead oxide injection and contact radiographs. Information from operative dissections performed in the course of superficial parotidectomies and neck dissections was included, as was information from 11 clinical flap transfers. The conclusion was drawn that the auriculomastoid skin could safely be transferred on the posterior auricular vessels, either as an island flap or as a free flap.

The posterior auricular flap: intra-oral reconstruction.

During 1986, the posterior auricular flap was used, in the Northern Ireland Plastic and Maxillo-Facial Service, for the reconstruction of a variety of post-excisional defects in the head and neck. In this paper, we present the results of its use in intra-oral defects. The operative technique is described in detail and representative case reports are presented. The posterior auricular flap would appear to have a role to play in the reconstruction of defects in the oral cavity as the skin quality equals that of the radial forearm flap, and in many cases it may be transferred as an island pedicle flap without the need for microvascular anastomosis.

Tissue expansion in the treatment of alopecia.

During the period December, 1983 to August, 1984, 14 patients were treated for alopecia of the scalp using tissue expansion in the Northern Ireland Plastic and Maxillo-Facial Service. Nine of the defects were due to burns. Representative case reports are presented and the planning of advancement and rotation flaps described. The management and prevention of complications are discussed, and the conclusion drawn that tissue expansion is a valuable technique in the treatment of alopecia, allowing reconstruction of defects previously beyond adequate surgical repair.