Nasal Septal Flaps for Repair of Large or Recurrent Palatal Fistula: Report of Technique and 4-Year Experience.

SUMMARY: Large or multiply recurrent oronasal fistulas following cleft palate repair present a challenging problem. Nasal septal mucoperichondrial flaps have been widely used for repair of skull base defects; however, their use in the repair of oronasal cleft palate fistulas has not previously been described. In this pilot study, the authors describe anterior palatal fistula repair using a nasal septal flap and review their experience with this technique over 4 years. Fourteen patients with anterior palatal fistulas not amenable to repair using local palatal flaps were included for analysis. The mean size of the fistula was 12 mm in maximum dimension. Flap healing with complete or near-complete closure of fistula was achieved in 13 patients (93%). Five of these patients had a small, slit-like residual fistula that was asymptomatic. Nasal septal flaps are a new technique for repair of large or recurrent palatal fistulas. The procedure is well-tolerated with minimal side effects, high success rate, and low incidence of recurrence. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Extending the indications for primary nerve surgery in obstetrical brachial plexus palsy.

PURPOSE: This study identifies a small subset of patients with obstetrical brachial plexus palsy who, while they do not meet common surgical indications, may still benefit from primary nerve surgery. METHODS: Between April 2004 and April 2009, 17 patients were offered primary nerve surgery despite not meeting the standard surgical indications of the authors. The authors performed a retrospective analysis of these 17 patients using prospectively collected data. RESULTS: This group of 17 patients were identified as having poor shoulder function at about 9 months of age despite passing the Cookie Test. Fourteen patients underwent surgical intervention and three families declined surgery. All patients in the operative group regained some active external rotation after surgery. Five patients in this group have required further interventions. Two of the three patients for whom surgery was declined have had no subsequent spontaneous improvement in active external rotation. DISCUSSION: The commonly used indications for primary nerve surgery in obstetrical brachial plexus palsy may not adequately identify all patients who may benefit from surgical intervention. Patients who pass the Cookie Test but have poor spontaneous recovery of active shoulder movements, particularly external rotation, may still benefit from primary nerve surgery.

Microsurgical hepatic artery reconstruction in paediatric liver transplantation.

BACKGROUND/AIMS: Hepatic artery thrombosis is a serious complication of paediatric liver transplantation often leading to retransplantation. It is also associated with decreased patient survival rates. In 1999 microsurgical hepatic artery reconstruction by Plastic and Reconstructive Surgeons was introduced to the Queensland Liver Transplant Service at the Royal Children's Hospital, Brisbane, in an attempt to decrease hepatic artery complications. METHODOLOGY: A review of the computerised database of the Queensland Liver Transplant Service was undertaken. Between March 1985 and December 2005, 252 transplants were performed without microsurgery. Since December 1999, 23 transplants were performed with microsurgical hepatic artery reconstruction by Plastic and Reconstructive Surgeons using the operating microscope. RESULTS: There were a total of 28 cases of hepatic artery thrombosis in 275 transplants. Survival for patients with hepatic artery thrombosis was significantly worse than for patients without (one year survival rate 61.5% versus 83.6%, p = 0.0065). The microsurgery group had a lower incidence of hepatic artery thrombosis (4.3% versus 10.7%, p = 0.29), a lower retransplantation rate (4.3% versus 9.1%, p = 0.38) and increased one year patient survival (91.3% versus 79.7%, p = 0.31). CONCLUSIONS: Microsurgical hepatic artery reconstruction in paediatric liver transplantation may decrease hepatic artery thrombosis rates, decrease retransplantation rates and improve survival.