Magnetic resonance angiography in preoperative planning of deep inferior epigastric artery perforator flaps.

Accurate preoperative localisation of deep inferior epigastric artery perforator (DIEaP) provides optimal surgical planning for DIEaP flaps. Cross-sectional imaging by contrast-enhanced magnetic resonance angiography (CE-MRA) has advantages over previously described techniques for perforator imaging including reduced radiation exposure and better muscle to vessel contrast. A retrospective series of 10 unilateral free breast reconstructions following preoperative CE-MRA of the anterior abdominal wall is presented. Mean age of the patients at the time of surgery was 50.3 years (range 44-63 years). An average of 2.8 perforators per study (range 1-5) was identified. Mean perforator luminal diameter was 2.6mm (1.4-4.0mm) with a mean intramuscular course length of 22.3mm (6.4-51.9 mm). Perforator course length was classified as 17% long intramuscular course (>4 cm), 80% short intramuscular course (<4 cm) and 3% paramedian. In all 10 patients, DIEaP flaps were successfully elevated. In all cases the flaps were elevated on vessels identified in preoperative review of the CE-MRA. There was a significant difference in the rates of conversion from DIEaP to transverse rectus abdominis myocutaneous (TRAM) flaps in the group who underwent CE-MRA in comparison to historical controls from the previous year (P=0.025). CE-MRA is an effective tool for DIEaP flap planning.

Are routine preoperative CT scans necessary in the management of single suture craniosynostosis?

CT scanning is accepted as a regular component of the investigation of patients with simple craniosynostosis. In a series of 109 cases with simple craniosynostoses treated at Great Ormond Street Hospital for Children, a correct diagnosis on the basis of clinical findings was made in 100% of cases by an experienced clinician. CT scans with 3D reconstructions provided diagnostic confirmation in 100% of the patients when performed, but 91% of patients had already had sufficient confirmation of diagnosis by radiography. The clinical use of the scans for purposes other than diagnosis was examined. CT scanning in simple craniosynostosis in this series did not provide any additional clinical benefit as a screening method for the detection of intracranial abnormalities or for surgical planning. We propose that it may be appropriate to limit CT scanning, both axial images and three dimensional reconstructions, to selected cases where diagnostic uncertainty exists or where, it is used in surgical planning.

Tumescent steroid infiltration to reduce postoperative swelling after craniofacial surgery.

Steroids are often administered to paediatric craniomaxillofacial patients perioperatively to reduce postoperative facial swelling, although there is little evidence of their efficacy. Preoperative tumescent infiltration using 7 ml x kg(-1) of a solution consisting of 0.1 mg x ml(-1) triamcinolone acetate, 0.0125% bupivacaine, 0.025% lignocaine, 3 units x ml(-1) hyaluronidase and 1:1000000 adrenaline in Hartmann's solution was evaluated from a retrospective case controlled study of patients undergoing standard fronto-orbital remodelling for simple craniosynostosis (n = 20). Eye closure (i.e. inability to open the eyes) was used as a marker for severe facial swelling. Patients receiving the tumescent infiltration demonstrated significantly less eye closure (P < 0.005), implying that the tumescent infiltration had a significant effect on facial swelling. The avoidance of eye closure allowed more effective monitoring for neurological and ophthalmological complications, which is a significant clinical benefit. The infiltration solution has the advantage of a lower corticosteroid dose than previously reported dexamethasone-based perioperative regimens, thereby minimising any unwanted metabolic effects. The technique is advocated for the reduction of postoperative facial swelling in craniomaxillofacial surgical patients.