Adapting Elements of Cleft Care Protocols in Low- and Middle-income Countries During and After COVID-19: A Process-driven Review With Recommendations.

A consortium of global cleft professionals, predominantly from low- and middle-income countries, identified adaptations to cleft care protocols during and after COVID-19 as a priority learning area of need.A multidisciplinary international working group met on a videoconferencing platform in a multi-staged process to make consensus recommendations for adaptations to cleft protocols within resource-constrained settings. Feedback was sought from a roundtable discussion forum and global organizations involved in comprehensive cleft care.Foundational principles were agreed to enable recommendations to be globally relevant and two areas of focus within the specified topic were identified. First the safety aspects of cleft surgery protocols were scrutinized and COVID-19 adaptations, specifically in the pre- and perioperative periods, were highlighted. Second, surgical procedures and cleft care services were prioritized according to their relationship to functional outcomes and time-sensitivity. The surgical procedures assigned the highest priority were emergent interventions for breathing and nutritional requirements and primary palatoplasty. The cleft care services assigned the highest priority were new-born assessments, pediatric support for children with syndromes, management of acute dental or auditory infections and speech pathology intervention.A collaborative, interdisciplinary and international working group delivered consensus recommendations to assist with the provision of cleft care in low- and middle-income countries. At a time of global cleft care delays due to COVID-19, a united approach amongst global cleft care providers will be advantageous to advocate for children born with cleft lip and palate in resource-constrained settings.

Evaluation of a Pediatric Facial Paralysis Education and Family Support Day.

INTRODUCTION: Facial paralysis impairs the mimetic functions of the facial musculature. In pediatric patients, free functioning muscle transfer neurotized with an intact contralateral facial nerve is the gold standard for smile reanimation. In response to requests from families of children with facial paralysis, the Division of Plastic and Reconstructive Surgery at the Hospital for Sick Children hosted an inaugural "Facial Paralysis Family Day." The objective was to create an opportunity for families to meet, exchange stories, and build support networks. METHODS: This study was a quality improvement project to conduct a needs assessment and evaluate the feasibility and satisfaction of implementing a family support intervention for individuals living with facial paralysis. RESULTS: The needs assessment demonstrated that families were most interested in advances in medicine, therapy and coping sessions and meeting other families. The post-event evaluation questionnaire indicated that attendees enjoyed the event, would attend again and found it highly valuable connecting and networking other families. It also indicated that key needs identified were addressed, with excellent ratings for the presentation discussing advances in medicine (100% rated "good" or "very good"), the therapy sessions (92% rated "good" or "very good") and the presentations by patients and their families (100% rated "good" or "very good.") DISCUSSION:: Two areas of improvement highlighted were elaborating further on medical advances and facilitating interactions between families. Overall, this event was well regarded and will likely be repeated at our institution and serve as a valuable resource for other hospitals planning to organize a similar event.

Assessing Performance in Simulated Cleft Palate Repair Using a Novel Video Recording Setup.

OBJECTIVE: To test the feasibility of implementing a high-fidelity cleft palate simulator during a workshop in Santiago, Chile, using a novel video endoscope to assess technical performance. DESIGN: Sixteen cleft surgeons from South America participated in a 2-day cleft training workshop. All 16 participants performed a simulated repair, and 13 of them performed a second simulated repair. The repairs were recorded using a low-cost video camera and a newly designed camera mouth retractor attachment. Twenty-nine videos were assessed by 3 cleft surgeons using a previously developed cleft palate objective structured assessment of technical skill (CLOSATS with embedded overall score assessment) and global rating scale. The reliability of the ratings and technical performance in relation to minimum acceptable scores and previous experience was assessed. RESULTS: The video setup provided acceptable recording quality for the purpose of assessment. Average intraclass correlation coefficient for the CLOSATS, global, and overall performance score was 0.69, 0.75, and 0.82, respectively. None of the novice surgeons passed the CLOSATS and global score for both sessions. One participant in the intermediate group, and 2 participants in the advanced group passed the CLOSATS and global score for both sessions. There were highly experienced participants who failed to pass the CLOSATS and global score for both sessions. CONCLUSIONS: The cleft palate simulator can be practically implemented with video-recording capability to assess performance in cleft palate repair. This technology may be of assistance in assessing surgical competence in cleft palate repair.

Gracilis Free Muscle Transfer in the Treatment of Pediatric Facial Paralysis.

Facial paralysis in children is a disabling functional and aesthetic issue. In cases where recovery is not expected, there are numerous options for reconstruction of the midface "smile." At the Hospital for Sick Children in Toronto, Canada, we have been using a free functional gracilis muscle transfer. In this article, we review the technical details of the procedure, which we have refined over the past 30 years, and also briefly discuss secondary and adjunctive procedures.

A prospective study of pediatric hand fractures and review of the literature.

OBJECTIVE: Hand fractures represent a leading cause of morbidity in children. However, little information exists correlating the mechanisms and environment of injury with outcomes and treatments. We examine the demographics, etiology, anatomic location, mechanism, and management of pediatric hand fractures in our center's hand unit. METHODS: We conducted a prospective observational study on all children with acute hand fractures evaluated in the Plastic Surgery Emergency Clinic during a 3-month period in 2010. Data pertaining to demographics, referral patterns, injury pattern, clinical outcomes, and other factors related to hand fractures were then analyzed and interpreted. RESULTS: Most children were referred by our institution's emergency department. More than 60% were boys, and nearly half were between 10 and 15 years old. The right and left hands were injured at equal rates. Most of the injuries (90%) occurred in the afternoon or evening. More than 85% occurred in urban, rather than rural, environments. Crush injuries were the leading cause in toddlers, whereas sports-related injuries became the major cause of injury in older groups. Proximal phalanges were the most common bone injured, and the fifth digit was the most commonly injured digit. More than 80% of the fractures were managed nonsurgically. CONCLUSIONS: The pattern of pediatric hand fracture in different age groups is highlighted in this article. The observations from this study will hopefully encourage further review with a larger cohort and a focus on preventative measures for pediatric hand fractures.

Conjoined Twin Separation: Review of 30-Year Case Experience and Lessons Learned.

BACKGROUND: Conjoined twinning is a rare medical phenomenon, and numerous challenges remain with respect to surgical separation and reconstruction. The purpose of this study is to present a detailed discussion of the authors' institutional experience with eight conjoined twin separations over the past three decades, focusing on challenges and lessons gleaned from these cases. METHODS: The records of all patients who underwent conjoined twin separation at The Hospital for Sick Children in Toronto, Ontario, Canada, from 1984 to 2018 were retrospectively reviewed. RESULTS: Eight sets of conjoined twins were analyzed. Half of the sets [ n = 4 (50 percent)] were female. There were four sets (50 percent) of ischiopagus twins, three sets (37.5 percent) of omphalopagus twins, and one set (12.5 percent) of craniopagus twins. The median age at separation was 6.75 months. The mean durations of intensive care unit and hospital stay were 14.1 ± 12.9 days and 4.9 ± 4.8 months, respectively. Mean length of follow-up was 6.7 ± 4.4 years. Three deaths occurred in our series, with an overall survival rate of 81 percent. Two sets of twins experienced expander-related complications such as infection and bowel perforation. Three twins required reoperation because of flap necrosis or dehiscence after separation. CONCLUSIONS: The authors' results highlight the unique nature of each operation and the great ingenuity required in managing the particular considerations of each case and also adhering to a systematic approach of evaluation and planning. A number of novel strategies were used at the authors' center and have now become commonplace. The lessons learned from such procedures may improve care for future generations of patients. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

Transfer of the deep temporal nerve for eyelid reconstruction in Mobius syndrome - an anatomic feasibility study and proposed surgical approach.

Facial paralysis may result in significant functional, esthetic, and psychological morbidity. Mobius syndrome is a form of bilateral congenital facial paralysis that is particularly difficult to treat owing to the lack of readily available donor nerves, particularly in the upper face. In this study, we evaluate the feasibility of using the deep temporal nerves as donors for the innervation of free muscle grafts in the periorbital region. Preserved and fresh cadaver facial halves are dissected, and the course of the deep temporal nerves delineated. We find the middle branch of the deep temporal nerve to be located consistently 4.6 cm from the posterior edge of the tragus along the zygomatic arch, giving an easily identifiable surface landmark for our donor. Finally, we outline a proposed surgical approach for using the middle deep temporal nerve to innervate a free muscle graft to the eyelids through an interpositional nerve graft.

Impact of Technology on Conjoined Twin Separation: Are We Further Ahead?

SUMMARY: The success of conjoined twin separation has increased since the 1950s, notwithstanding the numerous technical and physiologic challenges encountered in such procedures. Together with improvements in our understanding of conjoined twin physiology and the accumulation of surgical expertise, technological advances have largely paralleled the improvement in outcomes. In particular, advances in imaging modalities, adjuncts to abdominal wall closure such as mesh and tissue expansion, and three-dimensional modeling have been instrumental in advancing care for these patients. Considered together, these domains have allowed multidisciplinary teams to better delineate conjoined anatomy, facilitated improved surgical planning and decision-making, and assisted in overcoming the frequent challenges associated with soft-tissue closure. This review delineates the improvements in these modalities and their relationship to increasingly successful conjoined twin separation in recent years.

Dynamic Reconstruction of Facial Paralysis in Craniofacial Microsomia.

BACKGROUND: Craniofacial microsomia is associated with maxillomandibular hypoplasia, microtia, soft-tissue deficiency, and variable severity of cranial nerve dysfunction, most often of the facial nerve. This study evaluated the incidence of facial paralysis in patients with craniofacial microsomia and outcomes after free functioning muscle transfer for dynamic smile reconstruction. METHODS: A single-center, retrospective, cross-sectional study was performed from 1985 to 2018 to identify pediatric patients with craniofacial microsomia and severe facial nerve dysfunction who underwent dynamic smile reconstruction with free functioning muscle transfer. Preoperative and postoperative facial symmetry and oral commissure excursion during maximal smile were measured using photogrammetric facial analysis software. RESULTS: This study included 186 patients with craniofacial microsomia; 41 patients (21 male patients, 20 female patients) had documented facial nerve dysfunction (22 percent) affecting all branches (51 percent) or the mandibular branch only (24 percent). Patients with severe facial paralysis (n = 8) underwent smile reconstruction with a free functioning muscle transfer neurotized either with a cross-face nerve graft (n = 7) or with the ipsilateral motor nerve to masseter (n =1). All patients achieved volitional muscle contraction with improvement in lip symmetry and oral commissure excursion (median, 8 mm; interquartile range, 3 to 10 mm). The timing of orthognathic surgery and facial paralysis reconstruction was an important consideration in optimizing patient outcomes. CONCLUSIONS: The authors' institution's incidence of facial nerve dysfunction in children with craniofacial microsomia is 22 percent. Free functioning muscle transfer is a reliable option for smile reconstruction in children with craniofacial microsomia. To optimize outcomes, a novel treatment algorithm is proposed for craniofacial microsomia patients likely to require both orthognathic surgery and facial paralysis reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Selective fascicular coaptation of free functioning gracilis transfer for restoration of independent thumb and finger flexion following Volkmann ischemic contracture.

Children are prone to developing moderate to severe Volkmann ischemic contracture following a supracondylar fracture of the humerus or its treatment. Given the variable extent of forearm muscle damage, tendon transfers and tenodeses are often unavailable. To address these contractures, intensive hand therapy and a free functioning muscle transfer are required. Despite functional improvement following free muscle transplantation, reconstructed patients with severe Volkmann ischemic contracture tend to have persistent difficulty with fine motor activities owing to the losses of intrinsic muscle function and independence of thumb and finger flexion. The authors demonstrate how selective coaptation of separate fascicular territories of the gracilis nerve branches to the branches of the anterior interosseous nerve that innervate flexor pollicis longus and flexor digitorum profundus may be performed to establish a degree of independent thumb and finger flexion with a single free gracilis transfer. This technical refinement as well as its long-term outcomes in a series of three patients is presented.

Assessment of eye closure and blink with facial palsy: A systematic literature review.

Facial palsy can cause the impairment of eye closure and affect blink, ocular health, communication, and esthetics. Dynamic surgical procedures can restore eye closure in patients with decreased facial nerve function. There are no standardized measures of voluntary and spontaneous eye closure that are used to evaluate the outcomes of blink restoration procedures. The purpose of this systematic literature review was to identify the measures used to assess normal and abnormal eye closure and blinking in patients with facial palsy. A literature search of the PubMed database using the keyword "facial nerve/surgery" was conducted. Only English language articles that pertain to the use of facial paralysis assessment systems published in the past 20 years, which involve eyelid closure were included. There were 57 articles that used a facial paralysis classification system with an eyelid closure component: House-Brackmann Facial Nerve Grading Scale (n = 43, 67%); Sunnybrook Facial Grading Scale (n = 9); palpebral fissure heights (n = 4), and the electronic clinician-graded facial function tool (n = 3) and three additional measures were reported once. Although the Terzis and Bruno Scoring System, blink ratio, and electronic, clinician-graded facial function scale(eFACE) Clinician-Graded Scoring System were valid measures of eyelid closure, there was no one comprehensive eye assessment that demonstrated all aspects of eye closure in facial palsy, which include closure amplitude, spontaneity, and quality of life. For blink assessment, eFACE is the most comprehensive tool currently available and recommended to be used with a patient-reported quality of life supplement that captures the specific domains related to facial nerve dysfunction.

Segmental Gracilis Muscle Transplantation for Midfacial Animation in Möbius Syndrome: A 29-Year Experience.

BACKGROUND: Möbius syndrome is a complex congenital disorder of unclear cause involving multiple cranial nerves and typically presenting with bilateral facial and abducens nerves palsies. At The Hospital for Sick Children, Toronto, Ontario, Canada, microneurovascular transfer of free-muscle transplant is the procedure of choice for midfacial animation. The primary aim of this study was to investigate surgical outcomes of the procedure in terms of complications, secondary revisions, and smile excursion gains. METHODS: A retrospective 29-year review was performed using patient records from a single tertiary care center. The authors included children with Möbius syndrome who had undergone facial animation surgery with a free segmental gracilis muscle transfer and microneurovascular repair between January 1, 1985, and August 31, 2014. Smile excursion measures were obtained using the Facial Assessment by Computer Evaluation-Gram on a subset of the included patients. RESULTS: A total of 107 patients undergoing 197 reconstructive procedures met inclusion criteria. Most reconstructions relied on the motor nerve branch to the masseter for innervation [n = 174 (88 percent)]. Thirteen complications were reported, of which six required surgical interventions. Three revision procedures were performed: scar revision, muscle repositioning, and removal of infected permanent suture material. The use of the motor nerve branch to the masseter resulted in good commissure excursion gains (average, 4.61 mm for bilateral cases and 9.34 mm for unilateral reconstructions). CONCLUSION: Midfacial animation with segmental gracilis muscle transfer for patients with Möbius syndrome provides gains in the amplitude and symmetry of oral commissure excursion and carries a reasonably low complication rate. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Effectiveness and safety of the use of gracilis muscle for dynamic smile restoration in facial paralysis: A systematic review and meta-analysis.

BACKGROUND: Smiling is a fundamental component of social interactions. Significant challenges arise for patients with facial palsy. One of the key procedures for dynamic smile restoration is the microneurovascular transfer of a gracilis muscle. We aimed to assess the effectiveness and safety of dynamic smile reanimation surgery using the free gracilis muscle unit in patients with facial palsy. METHODS: We conducted a systematic review and meta-analysis of studies reporting surgical outcomes of dynamic smile restoration using free gracilis muscles identified from EMBASE, Medline, and Web of Science databases from their inception to March 15, 2018. Two-stage screening and data extraction were performed by two independent reviewers. Pooled proportions were calculated using random-effects models. RESULTS: Thirty-one studies including 1647 patients who underwent 1739 free gracilis flaps were included. Twelve (38.7%) studies measured perioperative smile excursion change using six different tools. Six of these studies were homogeneous and were used in meta-analyses of smile excursion improvement, which revealed a mean change of 7.5 mm (95% CI 6.0-9.0 mm, I2 86.7%) perioperatively. Twenty (64.5%) studies reported perioperative complications, and pooled proportions of flap failures were of 2.9% (95% CI 1.3-4.5%, I2 47.7%). CONCLUSIONS: Dynamic smile restoration using a free gracilis muscle may represent an effective procedure to regain oral commissure motion and is associated with an approximately 3% rate of flap failure. Masseteric nerve coaptations lead to larger improvements in perioperative smile excursion (10 mm) than cross-facial nerve grafts (6.8 mm). Future studies with homogeneous reporting of smile excursion and patient-reported outcome measures are needed.

Anatomic characteristics of supraorbital and supratrochlear nerves relevant to their use in corneal neurotization.

BACKGROUND: Corneal denervation can lead to opacification and blindness. A new treatment technique, surgical corneal neurotization, transfers healthy donor nerve, (most commonly contralateral supratrochlear or supraorbital) to the affected limbus to prevent corneal destruction and improve healing potential of the cornea following insult. We examine gross and histomorphometric anatomy of the supratrochlear and supraorbital nerves relevant to their use in corneal neurotization. METHODS: For each of nine adult cadaver heads, bilateral supraorbital and supratrochlear nerves were dissected from the supraorbital rim to the anterior hairline. The following data were recorded for each nerve: exit from the orbit through a notch versus foramen; horizontal distance from midline at the supraorbital rim; and distance from orbital exit to first branching point. Samples of all left supraorbital and supratrochlear nerves were obtained at the level of the supraorbital rim and at points 3 cm and 6 cm distally for histomorphometric analysis. Myelinated axon counts were determined for each sample. RESULTS: Four supraorbital foramina, 14 supraorbital notches, two supratrochlear foramina, and 15 supratrochlear notches were identified. Average supraorbital and supratrochlear distances to midline were 26.5 mm and 21 mm respectively. Average myelinated axon counts for both nerves were greater at the orbital rim (supraorbital: 6018, supratrochlear: 2533) than at 6 cm distally (supraorbital: 1621, supratrochlear: 1112). CONCLUSIONS: Anatomic dissection shows relative close approximation of the supraorbital and supratrochlear nerves, with a high proportion of both nerves exiting the orbit through foramina. The supraorbital nerve at the orbital rim contains the greatest number of myelinated axons.

Treatment of neurotrophic keratopathy with minimally invasive corneal neurotisation: long-term clinical outcomes and evidence of corneal reinnervation.

AIM: To report clinical outcomes and evidence of corneal innervation in patients with neurotrophic keratopathy (NK) treated with minimally invasive corneal neurotisation (MICN) using a sural nerve graft and donor sensory nerves from the face. METHODS: Patients undergoing MICN at The Hospital for Sick Children, Toronto, Canada were prospectively recruited. Data on central corneal sensation (CCS, measured with Cochet-Bonnet aesthesiometer), best-corrected visual acuity (BCVA) and corneal epithelial integrity were collected. In four patients who subsequently underwent keratoplasty, immunohistochemical analysis was performed on the corneal explants. One patient underwent magnetoencephalography (MEG) after MICN to characterise the neurophysiological pathways involved. RESULTS: Between November 2012 and February 2017, 19 eyes of 16 patients underwent MICN. Mean follow-up was 24.0±16.1 months (range, 6-53). Mean CCS significantly improved from 0.8±2.5 mm to 49.7±15.5 mm at final follow-up (p<0.001). Mean BCVA remained stable, and the number of episodes of corneal epithelial defects after MICN was significantly reduced compared with the year leading up to the procedure (21% vs 89%, respectively; p<0.0001). In the four eyes that underwent keratoplasties after MICN, all transplants fully re-epithelialised and regained sensation subsequently. Immunohistochemistry of the corneal explants demonstrated evidence of corneal reinnervation. In one patient who was 8 months after MICN, novel neuroactivity was detected on MEG in the ipsilateral somatosensory cortex on mechanical stimulation of the reinnervated cornea. CONCLUSIONS: By providing an alternative source of innervation, MICN improves corneal sensation and stabilises the corneal epithelium, permitting optical keratoplasty for patients with NK-related corneal opacity.

Management of Bilateral Facial Palsy.

Bilateral facial paralysis is a rare entity that occurs in both pediatric and adult patients and can have congenital or acquired causes. When paralysis does not resolve with conservative or medical management, surgical intervention may be indicated. This article presents the authors' preferred technique for facial reanimation in patients with bilateral congenital facial paralysis. Specifically, a staged bilateral segmental gracilis transfer to ipsilateral nerve to masseter is discussed.

Sensory and functional morbidity following sural nerve harvest in paediatric patients.

BACKGROUND: The sural nerve is a common donor site for nerve reconstruction. The only study describing outcomes in paediatric patients was following bilateral sural nerve harvest before the age of 1 year. Bilateral nerve harvest at such a young age may limit patients' ability to perceive a sensory difference. The objective of this study was to understand the sensory and functional deficit after unilateral sural nerve harvest in paediatric patients. METHODS: A prospective case series was performed in children (age 6-18 years) following unilateral sural nerve harvest. The contralateral foot was used as a control. Sensory Threshold Evaluation was performed by Weinstein Enhanced Sensory Test (WEST) - Foot, and a Functional Sensory and Pain Questionnaire was administered. Sural nerve harvest was performed by a minimally invasive technique using a nerve stripper. RESULTS: Twenty-eight feet of 14 patients that underwent unilateral sural nerve harvest were assessed. As a group, the 14 feet with sural nerve harvest demonstrated significantly higher thresholds in the four areas tested (p <0.05), thus identifying objective sensory loss at each location. The location of sensory loss in each patient was variable, with heavier sensory thresholds detected in 69.6% of areas tested than those in the corresponding location in the contralateral foot. Greater sensory loss was detected at the proximal lateral foot than at the distal lateral foot. Responses to the questionnaire revealed that only one patient perceived a sensory loss that affected their function. CONCLUSIONS: Unilateral sural nerve harvest in paediatric patients resulted in measurable sensory loss. Despite loss of innervation, only two patients reported intermittent dysaesthesia or cold sensitivity, and the majority of the patients reported no functional deficit.

Long-Term Outcomes of Smile Reconstruction in Möbius Syndrome.

BACKGROUND: Gracilis muscle transplant is the standard of care for smile reconstruction in children with Möbius syndrome. The authors describe the long-term clinical efficacy, durability, and psychosocial impact of this approach at a mean follow-up of 20 years. METHODS: Patients with Möbius syndrome who underwent gracilis muscle transfer between 1985 and 2005 were included in the study. The authors assessed midfacial movements using photographs and Scaled Measurement of Improvement in Lip Excursion measure, administered the patient-reported Facial Clinimetric Evaluation Scale, and used semistructured interviews. RESULTS: The mean age at surgery was 13.2 ±10.6 years and the mean follow-up was 20.4 ± 4.4 years postoperatively. Twenty-two gracilis muscle transplants were performed, all innervated by the motor nerve to the masseter. Photographic analysis using Scaled Measurement of Improvement in Lip Excursion software demonstrated that movement of the muscle was unchanged 20 years after surgery. Smile symmetry was stable long term. The overall mean Facial Clinimetric Evaluation score of the cohort was 62.3 ± 12.0. Facial comfort (86.4 ± 21.2) and social function (69.9 ± 18.5) subdomains were the highest. Although the facial movement subdomain score was 35.6 ± 12.4, the score related to smiling alone was 84.1 ± 20.2, indicating satisfaction with the midfacial reconstruction. Interview responses indicated high satisfaction with surgery; fulfilled expectations of social acceptance; improved communication; enhanced self-confidence; and a sense of increased facial symmetry, spontaneity, and smile excursion. CONCLUSION: Segmental gracilis muscle transplantation provides long-lasting, durable improvements in objective and patient-reported measures of facial function.

Microvascular Hepatic Artery Anastomosis in Pediatric Living Donor Liver Transplantation: 73 Consecutive Cases Performed by a Single Surgeon.

BACKGROUND: Living donor liver transplantation is an important strategy of procuring segmental liver allografts for pediatric patients with liver failure, as suitably sized whole donor organs are scarce. The early pediatric living donor liver transplantation experience was associated with high rates of hepatic artery thrombosis, graft loss, and mortality. Collaboration with microsurgeons for hepatic artery anastomosis in pediatric living donor liver transplantation has decreased rates of arterial complications; however, reported outcomes are limited. METHODS: A 14-year retrospective review was undertaken of children at the authors' institution who underwent living donor liver transplantation with hepatic artery anastomosis performed by a single microsurgeon using an operating microscope. Data were collected on demographics, cause of liver failure, graft donor, vessel caliber, vessel anastomosis, arterial complications, and long-term follow-up. RESULTS: Seventy-three children with end-stage liver failure underwent living donor liver transplantation with microvascular hepatic artery anastomosis. The commonest cause for liver failure was biliary atresia (63 percent). A total of 83 end-to-end hepatic artery anastomoses were completed using an operating microscope. Hepatic artery complications occurred in five patients, consisting of three cases of kinked anastomoses that were revised without complications and two cases of hepatic artery thrombosis (3 percent), of which one resulted in graft loss and patient death. Patient survival was 94 percent at 1 year and 90 percent at 5 years. CONCLUSIONS: Microvascular hepatic artery anastomosis in pediatric patients undergoing living donor liver transplantation is associated with a low hepatic artery complication rate and excellent long-term liver graft function. Collaboration between microsurgeons and transplant surgeons can significantly reduce technical complications and improve patient outcomes. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

In Vivo Confocal Microscopy Reveals Corneal Reinnervation After Treatment of Neurotrophic Keratopathy With Corneal Neurotization.

PURPOSE: To document the presence and location of new sensory nerve fibers after corneal neurotization using in vivo confocal microscopy (IVCM) in 2 patients with neurotrophic keratopathy (NK). METHODS: Two patients with unilateral advanced NK received corneal neurotization to surgically reinnervate the cornea. IVCM was used to identify subbasal nerve fibers and document corneal reinnervation. In 1 patient (case 1), IVCM was performed before and after corneal neurotization; in the second patient (case 2), IVCM was performed after neurotization and corneal transplantation. RESULTS: In case 1, who had hand motion visual acuity due to NK-associated corneal perforation that necessitated cyanoacrylate gluing, preoperative IVCM identified no subbasal nerves; however, subbasal nerves were identified 6 months after corneal neurotization, and there were no further episodes of persistent epithelial defects. In case 2, in whom NK with a total absence of corneal sensation was the result of treated basal skull meningioma, corneal sensation, visual acuity, and ocular surface health improved after corneal neurotization. Deep anterior lamellar keratoplasty was performed 2.5 years after corneal sensation was reestablished. IVCM demonstrated corneal reinnervation at the stromal and subbasal level in a pattern different from the normal cornea. CONCLUSIONS: Corneal neurotization restores corneal sensation by reinnervating the stromal and subbasal layers of the cornea. In doing so, corneal neurotization may halt the process of NK and prevent further visual loss.