The relation between clinically diagnosed and parent-reported feeding difficulties in children with and without clefts.

A cleft lip and/or palate (CL/P) is one of the most common craniofacial malformations, occurring worldwide in about one in 600-1000 newborn infants. CL/P is known to influence the feeding process negatively, causing feeding difficulties in 25-73% of all children with CL/P. Because there is a risk for serious complications in these children regarding feeding difficulties, there is often a need for intensive medical counseling and treatment. At this moment, adequate diagnosis and measurement remain a challenge and often lead to a delayed referral for professional help. Since parents play a big part in reporting feeding difficulties, it is important to help objectify parents' experiences, as well as the use of a frontline screening instrument for routine check-ups during medical appointments. The aim of this study is to investigate the relationship between parent perspective and standardized observation by medical professionals on feeding difficulties in 60 children with and without clefts at the age of 17 months. We focus on the information from parents and health professionals by comparing the Observation List Spoon Feeding and the Schedule for Oral Motor Assessment with the validated Dutch translation of the Montreal Children's Hospital Feeding Scale.  Conclusion: There is a need for timely and adequate diagnosis and referral when it comes to feeding difficulties in children with CL/P. This study underscores the importance of combining both parental observations and measurements of oral motor skills by healthcare professionals to enable this. What is Known: • Early identification of feeding difficulties can prevent adversely affected growth and development. • Clefts increase the probability of feeding difficulties; however, the diagnostic trajectory is unclear. • The Observation List Spoon Feeding (OSF) and Schedule for Oral Motor Assessment (SOMA) are validated to measure oral motor skills. The Montreal Children's Hospital Feeding Scale Dutch version (MCH-FSD) has been validated for the parental perception of infant feeding difficulties. What is New: • Parents of children with CL/P experience relatively few feeding problems in their child on average. • Oral motor skills for spoon feeding are associated with oral motor skills for solid foods in children with CL/P. • The extent of the cleft is associated with experiencing more feeding difficulties in children with CL/P.

Parental Attitude Toward the Prenatal Diagnosis of Oral Cleft: A Prospective Cohort Study.

OBJECTIVES: The prenatal diagnosis of oral clefts (OCs) by ultrasound can pose an ethical dilemma. The purpose of this study was to obtain insight into the psychosocial and moral considerations of prospective parents concerning OCs, the burden of OCs and parents' attitude toward possible termination of pregnancy (TOP) in order to improve counseling in the future. DESIGN: Between August 2011 and August 2014, a prospective cohort questionnaire study was administered. SETTING: Prenatal care clinic of the Wilhelmina's Children hospital, a Tertiary Care Centre. PARTICIPANTS: Parents expecting a child with an OC. MAIN OUTCOME MEASURES: Expectation of OCs in general and attitudes toward the impact and expected burden of the OC of their child. Furthermore, parents were asked if they had considered TOP. RESULTS: Most of the parents described an OC as a cosmetic disability (50.6%) or as "just a little different" (29.4%). These parents expected that the OC would not affect their own happiness and have only minor influence on the happiness of their future child. Health professionals had a considerable influence on parental opinion. A minority (6.4%, 5/85) of the respondents considered TOP, and none of the responders chose to terminate the pregnancy. CONCLUSIONS: This study suggests that future parents have very few negative perceptions of OC after prenatal counseling. Caregivers should be aware that their counseling is important for decision-making of parents.

Mechanisms of ear trauma and reconstructive techniques in 105 consecutive patients.

Acquired auricular deformities may diminish facial esthetics and cause psychological distress. The aim of this article is to provide an overview of the type of injuries and applied reconstructive techniques in a large academic hospital in The Netherlands. A retrospective chart review was conducted for the last 105 patients who underwent auricular reconstruction for an acquired deformity. Data concerning gender, affected side, cause of injury, anatomical region, the previous and further surgeries, type of cartilage, and skin cover used were collected and analyzed. 105 patients were included. Acquired auricular deformities were mainly caused by bite injuries (22 %), traffic accidents (17 %), burns (9.5 %), and post-otoplasty complications (9.5 %). The upper third of the auricle was most often injured (41 %), followed by the entire auricle (19 %). 70 % of cases required reconstruction with costal cartilage. The most common form of cutaneous cover was a postauricular skin flap (40 % of cases). This study gives a complete overview of causes and treatment of acquired auricular deformities. The results are comparable with the results of similar studies found in literature. Bite wounds are the leading cause of acquired auricular injuries. The upper third is most commonly affected. In the largest percentage of reconstructions, costal cartilage and a postauricular flap were used to correct the deformity.

Growth and prevalence of feeding difficulties in children with Robin sequence: a retrospective cohort study.

OBJECTIVES: In addition to breathing problems, patients with Robin sequence (RS) often encounter feeding difficulties (FD). Data regarding the occurrence of FD and possible influencing factors are scarce. The study aim was to elucidate these factors to improve treatment strategies. MATERIAL AND METHODS: A retrospective comparative cohort study was conducted, consisting of 69 infants diagnosed with both RS and a cleft palate and 64 isolated cleft palate only (iCPO) infants. Data regarding FD, growth, and airway intervention were collected during the first 2 years of life. A systematic review of the literature was conducted to identify reported FD in RS patients. RESULTS: RS patients had more FD (91 %) than iCPO patients (72 %; p = 0.004). Also, nasogastric (NG)-tube feeding was necessary more frequently and for a longer period (both p < 0.001). Growth was lower in RS than iCPO infants (p = 0.008) and was not affected by the kind of airway management (conservative/surgical; p = 0.178), cleft palate grade (p = 0.308), or associated disorders (p = 0.785). By contrast, surgical intervention subtype did significantly affect growth. Mean reported FD for RS in the literature is 80 % (range = 47-100 %), and 55 % (range = 11-100 %) of infants need NG-tube feeding. CONCLUSIONS: FD is present in a large proportion of infants with RS, which indicates the need for early recognition and proper treatment to ensure optimal growth. Growth during the first 2 years of life is significantly lower in RS patients than iCPO patients, which indicates the need for careful attention and long-term follow-up. CLINICAL RELEVANCE: This study indicates the need for early recognition and proper treatment of FD in RS to ensure optimal growth. In addition, growth needs careful attention and long-term follow-up.

Restoring penis sensation in patients with low spinal cord lesions: the role of the remaining function of the dorsal nerve in a unilateral or bilateral TOMAX procedure.

AIMS: The recently developed TOMAX-procedure restores unilateral genital sensation, improving sexual health in men with a low spinal lesion (LSL). It connects one dorsal nerve of the penis (DNP) to the intact ipsilateral ilioinguinal nerve. We proposed bilateral neurotization for full sensation of the glans but this entails cutting both DNPs, risking patients' erection/ejaculation ability. The objective was to select patients for a bilateral TOMAX-procedure by measuring remaining DNP function, and perform the first bilateral cases. METHODS: In 30 LSL patients with no penile- but normal groin sensation selected for a unilateral TOMAX-procedure the integrity of the sacral-reflex-arc and DNP function was tested pre-operatively using bilateral needle electromyography (EMG)-bulbocavernosus reflex (BCR) measurements, and an interview about reflex erections (RE) ability. RESULTS: In 13 spina bifida- and 17 spinal cord injury patients [median age 29.5 years (range 13-59 years), spinal lesion T12 (incomplete) to sacral], seven (23%) patients reported RE, four (57%) with intact BCR, and of nine (30%) patients with intact BCR, four reported RE (44%). CONCLUSIONS: Even patients with a LSL and no penile sensation can have signs of remaining DNP function, but cutting both DNPs to restore full glans sensation in a bilateral TOMAX-procedure might interfere with their RE/ejaculation. To avoid this risk, we propose a selecting-protocol for a unilateral- or bilateral procedure using RE and BCR measurements. Using this protocol, three patients were bilaterally operated with promising preliminary results. Full sensation of the glans could lead to further improvement in sexual function.

A practical prenatal ultrasound classification system for common oral clefts.

OBJECTIVE: Our aim is to introduce and validate a new oral cleft classification system based on prenatal ultrasound for use by professionals in daily practice. METHODS: During a 3-year period (2011-2014), all cases of prenatal oral cleft diagnosed by ultrasound were retrospectively reviewed. A new prenatal ultrasound classification system was introduced. For the purpose of validation, prenatal ultrasound images of oral cleft types were described according to the new classification system and were compared with postnatal findings by reviewing medical records. RESULTS: A total of 103 fetuses with oral cleft were identified by ultrasound. The mean gestation time at detection was 20.4 weeks (95% confidence intervals: 20.0-20.7). The association between oral cleft and other anomalies varied by cleft type; types 2b/3b and 4 were most frequently associated with other anomalies. The measure of agreement between the prenatal and postnatal findings showed a Kappa value of 0.63 (95% confidence intervals: 0.52-0.75), demonstrating the accuracy of this new classification system. CONCLUSION: A new prenatal oral cleft classification system is presented. This system appears to be accurate, and it shows the variation in the risk of associated anomalies for each cleft type. We expect that ultrasonographers will be able to use the new classification in daily practice.

Professional opinion on oral cleft during pregnancy: a comparison between Israel and The Netherlands.

OBJECTIVE: The aim of this study was to assess the opinion of obstetric care providers who perform prenatal ultrasounds to screen for anomalies and who advise women about their options, including termination of pregnancy, when an oral cleft is detected. We compared providers' opinions about pregnancy termination for isolated oral cleft in The Netherlands, where the number of terminations is low, and in Israel, where the number is high. METHODS: Online questionnaires were used. The questions assessed the providers' views regarding the estimated burden of treatment, the functioning ability, and the level of happiness of children with an oral cleft and their parents. Additionally, we assessed providers' opinions on pregnancy termination for isolated oral cleft. RESULTS: In The Netherlands, more professionals considered oral cleft a disability (rate differences 17.8%, 95% confidence interval: 0.5-33.1%) than in Israel. In the Netherlands, 10.6% of respondents (compared with 11.1% in Israel) thought that an isolated cleft was a reason for terminations of pregnancy (TOP) (rate differences 0.6%, 95% confidence interval: -12% to 10.9%). CONCLUSIONS: Prenatal care providers in The Netherlands and Israel do not differ in their opinions about the severity of oral cleft and the acceptability of TOP for an isolated oral cleft. This study shows that prenatal care providers' attitudes do therefore not explain the dramatic difference between these countries in the number of TOP for isolated oral cleft.

Effect of surgical decompression of nerves in the lower extremity in patients with painful diabetic polyneuropathy on stability: a randomized controlled trial.

OBJECTIVE: To investigate the effect of decompression of nerves in the lower extremity in patients with painful diabetic polyneuropathy on static balance using a sensitive pressure mat system. DESIGN: Non-blinded randomized controlled trial. SETTING: Single center study performed at the University Medical Center Utrecht between 2010-2013. SUBJECTS: Patients with painful diabetic polyneuropathy assessed with the Diabetic Neuropathy Symptom score and Diabetic Neuropathy Examination between 18-90 years. Exclusion criteria were: physical problems leading to instability, BMI>35 kg/m2, ankle fractures in history, amputations proximal to the tarsometatarsal joints, active foot ulcer(s), severe occlusive peripheral vascular diseases. INTERVENTION: Unilateral surgical nerve decompression at four sites in the lower extremity, the contralateral limb was used as control (within-patient comparison), with one year follow-up. MAIN MEASURES: Preoperatively and 6 and 12 months postoperatively, weight bearing and five variables of sway of the center of pressure were measured with a pressure mat with eyes open and eyes closed. T-test was used for evaluation of postoperative results. RESULTS: Thirty-nine Patients met inclusion criteria and were enrolled for stability testing. Postoperatively no significant differences for sway variables and weight bearing were seen compared to preoperatively measurements. CONCLUSIONS: There is no evidence that surgical decompression of nerves of the lower extremity influences stability within one year after surgery in patients with painful diabetic polyneuropathy.

Conservative treatment of thumb base osteoarthritis: a systematic review.

PURPOSE: To provide a systematic review of randomized controlled trials regarding the conservative treatment of thumb base osteoarthritis (OA). METHODS: A systematic literature search was conducted in the electronic bibliographic databases Medline (Pubmed) and Embase (both starting year to May 2014) using predetermined criteria for studies on nonoperative treatment of thumb base OA. RESULTS: Twenty-three articles fulfilled our inclusion criteria. Systematic evaluation demonstrated the following: (1) Hand therapy can possibly reduce pain. However, owing to the lack of good-quality (randomized controlled) trials with sufficient follow-up time, no proper conclusions can be drawn. (2) Although both steroid and hyaluronate intra-articular injections can provide pain relief, most authors conclude that injection of hyaluronate is more effective. Follow-up is rather short with a maximum of 12 months in 1 study. Furthermore, study comparison is hampered by heterogeneity of study design and outcome parameters. (3) The use of orthoses reduces pain without effect on function, strength, or dexterity. Included studies used various types of orthoses. Follow-up times varied (2 wk-7 y). (4) There is no justification for the use of transdermal steroid delivery. (5) There is insufficient evidence justifying the use of leech therapy. (6) There are no high-level evidence studies specifically evaluating the effect of analgesics and patient education in joint protection in patients with thumb base OA. CONCLUSIONS: There are only a few high-quality studies addressing the conservative treatment of trapeziometacarpal OA. Available evidence suggests only some effect of orthoses and intra-articular hyaluronate or steroid injections.

A pragmatic approach to infants with Robin sequence: a retrospective cohort study and presence of a treatment algorithm.

OBJECTIVES: Initial approaches to and treatments of infants with Robin sequence (RS) is diverse and inconsistent. The care of these sometimes critically ill infants involves many different medical specialties, which can make the decision process complex and difficult. To optimize the care of infants with RS, we present our institution's approach and a review of the current literature. MATERIAL AND METHODS: A retrospective cohort study was conducted among 75 infants diagnosed with RS and managed at our institution in the 1996-2012 period. Additionally, the conducted treatment regimen in this paper was discussed with recent literature describing the approach of infants with RS. RESULTS: Forty-four infants (59%) were found to have been treated conservatively. A significant larger proportion of nonisolated RS infants than isolated RS infants needed surgical intervention (53 vs. 25%, p = .014). A mandibular distraction was conducted in 24% (n = 18) of cases, a tracheotomy in 9% (n = 7), and a tongue-lip adhesion in 8% (n = 6). Seventy-seven percent of all infants had received temporary nasogastric tube feeding. The literature review of 31 studies showed that initial examinations and the indications to perform a surgical intervention varied and were often not clearly described. CONCLUSIONS: RS is a heterogenic group with a wide spectrum of associated anomalies. As a result, the decisional process is challenging, and a multidisciplinary approach to treatment is desirable. Current treatment options in literature vary, and a more uniform approach is recommended. CLINICAL RELEVANCE: We provide a comprehensive and pragmatic approach to the analysis and treatment of infants with RS, which could serve as useful guidance in other clinics.

Can previous diagnostic examinations prevent preoperative angiographic assessment of the internal mammary perforators for (micro)surgical use?

BACKGROUND AND AIM: Preoperative assessment of the internal mammary artery perforating (IMAP) branches enhances IMAP-based reconstructive procedures. Conventionally, color-flow Doppler, selective catheter arteriography, or CT angiography is used for such assessment. We studied how often these examinations may be rendered superfluous by assessment of previously performed diagnostic examinations. METHODS: A radiologist and a plastic surgeon jointly assessed whether information on the dominant IMAP could sufficiently be obtained from the thoracic CT scans of 12 head and neck cancer patients and 12 breast cancer patients, and from the mammary MRI of 12 breast cancer patients. Secondly, we retrospectively assessed in how many of the 10 patients who underwent an IMAP-flap head and neck reconstruction, and in how many of the 10 women who consecutively underwent a deep inferior epigastric perforator (DIEP) flap mammary reconstruction such previous diagnostic examinations were available and informative regarding the level of the dominant perforator. RESULTS: All 24 CT scans and 11 of the 12 MRI scans sufficiently allowed assessment of the level of the dominant IMAP. Previous information had already been available in all 10 DIEP flap patients and 6 of the 10 IMAP-flap patients. The distribution of IMAP dominance over the intercostal levels on the scans differed from that found by cadaveric or intraoperative assessment. CONCLUSIONS: Previously performed diagnostic CT scans and MRI scans that included the parasternal region usually allow sufficient preoperative assessment of the internal mammary perforators for reconstructive procedures. We advocate re-assessment of such previous examinations before ordering additional angiography. Additionally, we suggest to include the parasternal region in diagnostic scans.

Exerted pressure by an in-flight oxygen mask.

BACKGROUND: F-16 pilots wear an in-flight oxygen mask to prevent hypoxemia. In the contact area with the mask, the pilots experience nasal discomfort and pain, and may even develop nasal deformities. A likely cause is the pressure exerted by the mask. In this study the hypothesis was that the change in pressure exerted on the nose would be higher than on the chin, an area free of symptoms. METHODS: Six F-16 pilots and five healthy former F-16 pilots volunteered to participate in this observational pilot study. At baseline the pilots donned mask and helmet. The median delta pressure (deltap) recordings at baseline were compared to the exerted deltap during the experimental head movements. RESULTS: At baseline, there was no significant difference between the median deltap on the nose and chin (2 vs. 1.6 mmHg, T = 2). Head movements increased the median deltap on the nose by 50 mmHg (T = 0) and on the chin by 31 mmHg (T = 0) when compared to baseline. Head movements also decreased the pressure by -20 mmHg (T = 1.75) on the nose and -11 mmHg (T = 0) on the chin. CONCLUSIONS: The data show that the baseline deltap is higher on the nose than on the chin. The head movements both increased and decreased the exerted pressure on the nose and the chin. These observations suggest that further evaluation of the effect of flight conditions on the exerted pressure is worthwhile to understand its contribution to the nasal symptoms.

A systematic review on the outcome of mandibular distraction osteogenesis in infants suffering Robin sequence.

OBJECTIVES: Mandibular distraction osteogenesis (MDO) has been successfully applied in infants suffering Robin sequence (RS) with severe upper airway obstruction, but no comparative studies for the different types of MDO exist to date. The objective of the current study was to systematically review the published data considering this matter, providing a fundament for protocols and a more conscious treatment strategy for infants with RS in the near future. MATERIAL AND METHODS: For the period from January 1966 to January 2012, the Pubmed, EMBASE, and Cochrane Library databases were searched. Abstracts were screened based on predetermined selection criteria. Relevant full-text articles were retrieved. The articles were analyzed on the type of MDO used, preoperative workup, patient characteristics, postoperative outcome, and complications. RESULTS: The search yielded 109 articles. After checking abstracts and full texts on predetermined inclusion and exclusion criteria, 12 studies (four describing external MDO, five internal MDO, and three both types) were extracted for further analyses. CONCLUSION: Internal MDO seems very feasible in infants suffering RS, minimizing side effects such as hypertrophic scarring, nerve damage, and extensive care needs, although the indications for usage are more limited compared to the external device. Corresponding protocols and long-term outcome studies are needed to make a better comparison and the use and indication of the different types of distraction even more distinct. CLINICAL RELEVANCE: A base for a guideline to support the choice of a designated operative management for neonates with RS is provided, hereby obviating possible complications of the different types of MDO in the future.

Oxygen mask fit analysis in F-16 fighter pilots using 3D imaging.

BACKGROUND: The majority of Dutch F-16 pilots experience in-flight oxygen mask related nasal discomfort and injury. We aimed to analyze the fit of the oxygen mask. METHODS: We successfully scanned 35 pilots with a 3D scanner to measure the distance between the contact area on the nose and the oxygen mask in seven points, and the difference (delta) in angle between the nose and the mask relative to the facial midline. Ill fit was defined as > or = 4 mm distance, or delta > or = 4 degree angle. Intraclass correlation coefficients were used to objectify the reproducibility of the measurements. RESULTS: There were 35 pilots who had > or = 4 mm distance between the nasal dorsum and the mask and 14 pilots had delta > or = 4 degree angle. Reproducibility of the distance measurements was excellent (R > or = 0.93, CI 95% 0.86-0.96) and of the angle measurements was good (R = 0.72, CI 95% 0.5-0.8). CONCLUSION: The room for displacement that we found may be a contributor to the discomfort. It is indicative of an ill fit of the oxygen mask, since all subjects had complaints. We recommend evaluating whether improved fixation of the mask and simultaneous reduction of the pressure on the nose will improve comfort.

Bioresorbable distraction device for the treatment of airway problems for infants with Robin sequence.

Pierre Robin sequence is a well known craniofacial entity. There are numerous ways to treat the respiratory insufficiency, but sometimes surgical intervention is needed. Tracheotomy could be associated with morbidity, and distraction osteogenesis has been established as a stable method to obtain a safe airway. Distraction osteogenesis has traditionally been performed with an external device. In this manuscript we describe the feasibility of an internal bioresorbable device. Retrospective descriptive study was performed in a tertiary academic children's hospital. After multidisciplinary team consultation, 12 consecutive patients with Robin sequence were treated with this internal distraction device. The mean age at surgery was 32 days, and the average amount of mandibular distraction was 18 mm. All patients were extubated after an average of 7.5 days after the surgery. The average length of stay in the hospital was 17 days after surgery. There were no major surgical complications. A tracheotomy was prevented in all our patients, and complications were limited. Long-term studies are needed to evaluate the influence that internal distraction has on the growth of the mandible and teeth. The internal distraction system seems safe for infants with micrognathia and has certain benefits when compared to the external distractor.

The efficacy of medicinal leeches in plastic and reconstructive surgery: a systematic review of 277 reported clinical cases.

BACKGROUND: Although there are numerous case reports and small case series describing the experiences of leech therapy in various circumstances, there are relatively few large studies evaluating the effectiveness of leeching to relieve venous congestion. The therapeutic value of leeching is illustrated by these reports but the current literature lacks a cohesive summary of previous experiences. METHODS: An electronic search of PubMed, the Cochrane library and the Centre for Reviews and Dissemination between 1966 and 2009 was used to retrieve human studies published in the English language evaluating outcomes following leech therapy. The "success" and "failure" of leech therapy were the primary outcome measures and secondary outcomes included complications, number of leeches used, pharmacological adjuncts and blood transfusion requirements. RESULTS: In total, out of 461 articles, 394 articles met the exclusion criteria. The 67 included papers reported on 277 cases of leech use with an age range of 2-81 years and a male to female ratio of almost 2:1. The overall reported "success" rate following leech therapy was 77.98% (216/277). In terms of secondary outcome measures, 49.75% of cases (N = 101) required blood transfusions, 79.05% received antibiotics (N = 166) and 54.29% received concomitant anticoagulant therapy. The overall complication rate was 21.8%. CONCLUSION: In the absence of robust randomized controlled trials on which the evidence may be based, this synthesis of current best evidence guides clinicians during the process of consenting patients and using leeches in their practice.

Human adult, pediatric and microtia auricular cartilage harbor fibronectin-adhering progenitor cells with regenerative ear reconstruction potential.

Remaining challenges in auricular cartilage tissue engineering include acquiring sufficient amounts of regeneration-competent cells and subsequent production of high-quality neocartilage. Progenitor cells are a resident subpopulation of native cartilage, displaying a high proliferative and cartilage-forming capacity, yet their potential for regenerative medicine is vastly understudied. In this study, human auricular cartilage progenitor cells were newly identified in healthy cartilage and, importantly, in microtia-impaired chondral remnants. Their cartilage repair potential was assessed via in vitro 3D culture upon encapsulation in a gelatin-based hydrogel, and subsequent biochemical, mechanical, and histological analyses. Auricular cartilage progenitor cells demonstrate a potent ability to proliferate without losing their multipotent differentiation ability and to produce cartilage-like matrix in 3D culture. As these cells can be easily obtained through a non-deforming biopsy of the healthy ear or from the otherwise redundant microtia remnant, they can provide an important solution for long-existing challenges in auricular cartilage tissue engineering.

A cadaver study of the vascular territories of dominant and nondominant internal mammary artery perforators.

The perfusion territory of the pedicled internal mammary artery perforator flap has been described, but the number of perforators to be included in the flap's pedicle is controversial. We studied the vascular territory of the dominant perforator and the contribution of additional nondominant perforators to it. Therefore, the dominant perforators in 9 fresh cadavers and the nondominant perforators in 4 of these, were injected with water-based ink. The dominant perforator vascularized a territory extending from the superior border of the clavicle to the xiphoid, and from midsternal to the anterior axial fold, with a mean craniocaudal length of 19.4 cm (range, 17.0-24.0) and a mean mediolateral width of 18.6 cm (range, 16.0-22.5). Additional injection of nondominant perforators did not lead to any substantial enlargement of this territory. One single dominant perforator vascularizes a large part of the hemithorax, allowing for various flap designs. Nondominant perforators do not have to be included in the vascular pedicle of the internal mammary artery perforator flap, which leads to less donor-site morbidity.

Medicinal leeches and the microsurgeon: a four-year study, clinical series and risk benefit review.

BACKGROUND: There are case reports and small series in the literature relating to the use of medicinal leeches by plastic surgeons; however, larger series from individual units are rare. The aim of this article is to present a comprehensive 4-year case series of the use of medicinal leeches, discuss the current evidence regarding indications, risks, and benefits and highlight the recent updates regarding leech speciation. METHODS: Patients prescribed leeches in a 4-year period (July 2004-2008) were collated from hospital pharmacy records (N = 35). The number of leeches used, demographic, clinical, and microbiological details were retrospectively analyzed. RESULTS: Thirty-five patients were treated with leeches. The age range was 2 to 98 years (mean = 49.3). Leeches were most commonly used for venous congestion in pedicled flaps and replantations. Blood transfusions were necessary in 12 cases (34%) [mean = 2.8 units, range 2-5 units]. Our infection rate was 20% (7/35) including five infections with Aeromonas spp. (14.2%). The proportion of patients becoming infected after leech therapy was significantly greater in the group of patients that did not receive prophylactic antibiotic treatment (Fisher's Exact test P = 0.0005). In total, 14 cases (40%) were salvaged in entirety, in 7 cases 80% or more, in 2 cases 50 to 79%, and in 1 case less than 50% of the tissues were salvaged. In 11 cases (31%), the tissues were totally lost. CONCLUSION: Our study highlights both the benefits and the risks to patients in selected clinical situations and also the potential risks. The routine use of antibiotic prophylaxis is supported. In view of the emerging evidence that Hirudo verbana are now used as standard leech therapy, and the primary pathogen is Aeromonas veronii, until a large prospective multicenter study is published, large series of patients treated with leeches should be reported.

International trends in the treatment of microtia.

BACKGROUND: Microtia is a well-known craniofacial malformation treatable with numerous different treatment strategies and techniques. The purpose of this study was to analyze the current international trends in microtia repair. METHODS: All surgeons attending the fourth International Ear Reconstruction Congress in Edinburgh received a questionnaire by e-mail about their current surgical practice in microtia care. RESULTS: Thirty-one questionnaires were received. Most primary reconstructions are performed at ages 8 to 10 years using autologous cartilage from the ipsilateral sixth to eighth ribs. Most surgeons make a multilayer framework, leaving a subcutaneous pedicle. Suction drainage was used in all patients. On average, the second stage was performed more than 6 months later using a mastoid flap. Most surgeons do not reconstruct the middle ear. CONCLUSIONS: Microtia reconstruction is performed in many different ways, with numerous treatment and postoperative possibilities.