The Marshall technique: an economic one-stage technique for nipple-areola reconstruction.

The goals of nipple-areola reconstruction are symmetry in position, shape, size, colour, tone, texture, sensation and responsiveness. These goals are best attempted when the breast-mound reconstruction has been completed. We describe a technique in which the skin of the neo-areola is raised as a split-thickness skin graft, and then re-grafted to the same site with a free nipple graft. This technique is always available, requires no special equipment, causes no donor-site morbidity and produces excellent results. The disadvantage is that it may be more difficult following radiotherapy or if the mastectomy scar traverses the desired site of nipple-areola reconstruction. As with any skin graft, the neo-areola may lose pigmentation, imperfectly 'take' or contract with time. This technique has not been previously described in the literature.

Parental perceptions of grommet insertion in children with cleft palate.

Otitis media with effusion is almost universal in children with cleft palate and can delay speech, language and educational development by causing hearing loss. Grommet insertion at the time of cleft palate repair is common. There is debate about whether the benefits of grommets outweigh the risk of complications. A postal questionnaire was used to investigate parental perceptions of middle-ear ventilation via grommet insertion in children attending the multidisciplinary cleft palate clinic. These children's case notes were reviewed. Many children had speech and language delay, but parents thought this improved after grommet insertion. Overall parents were pleased with the results. This confirms that grommets have an important part to play in the management of children with cleft palate.

Modified diagram of Friedman's symbolic representation of cleft lip and palate anomalies.

This paper describes the modification of the symbolic representation of Cleft Lip and Palate anomalies described by Friedman et al. These modifications were made in order to facilitate the computerisation of clinical records and database integration, and to improve the compliance and accuracy of cleft data collection.

Timing of hard palatal closure: a critical long-term analysis.

The controversy about timing of cleft palate surgical procedures is focused on early palatoplasty for improved speech versus delayed hard palate repair for undisturbed facial growth. Timing and technique of palate repair are the most important influences on speech and facial growth, yet there is no consensus on the age or technique for surgery. The Oxford Cleft Palate Study was initiated to evaluate critically the long-term follow-up of 44 patients with early versus late closure of the hard palate. A multidisciplinary approach was used to determine the incidence of speech deficiencies, palatal fistulas, maxillofacial growth disturbances, and hearing abnormalities and to assess objectively the long-term effects of two different treatment modalities on the cleft palate patient. The 44 patients were selected randomly, interviewed, and examined by the multidisciplinary Oxford Cleft Palate Study team. The average age at follow-up in the early closure group was 17.0 years versus 18.2 years in the late closure group. There was a similar number of unilateral and bilateral clefts in both the early and late closure groups. The hard palate was closed in the early group at an average age of 10.8 months versus 48.6 months in the late closure group. All operative procedures in each group were performed by the same senior plastic surgery consultant. Both consultants have since retired and did not participate in the study. Each patient was evaluated by the same plastic surgeon, speech pathologist, orthodontist, and otologist. All examiners were blinded in that they were unaware of the type or timing of the surgical technique and had no prior knowledge of or access to the patient's medical records. Furthermore, none of the examiners participated in the initial care and surgery of these patients. Statistically significant greater speech deficiencies were noted with delayed hard palate closure, especially in articulation, nasal resonance, intelligibility, and substitution pattern assessment (overall intelligibility, p < 0.01). Likewise, the persistent palatal fistula rate in the late closure group was 35 percent in comparison with 5 percent for the early closure group (p <0.02). No significant differences in hearing or maxillofacial growth impairment were delineated in either group. Our data suggest that delaying hard palate closure results in significant speech impairment without a beneficial maxillofacial growth response.

The amniotic band disruption complex. The pathogenesis of oblique facial clefts; an experimental study in the foetal rat.

This paper reports the findings of an experimental foetal rat study which has shown that it is possible to produce facial clefts by stimulating the tethering and disruptive effects of amniotic bands. Of the 10 experimental foetuses, 9 (90%) survived the in utero surgery and are included in the present study. Facial and palatal clefts were produced in all 9 (100%) of these foetuses.

The post-injury changes that occur in transected foetal nerves; an experimental study in the rat.

The findings of this experimental foetal rat study have shown that transection of the peripheral branches of the maxillary and facial nerves on the 18th day of gestation is followed by axonal degeneration and regeneration. Although these processes are similar to those which occur in the adult animal, they occur more rapidly in the foetus. In this study the regenerating axons had crossed the wound and entered the neural tubes of the distal nerve segments by 24 hours after injury.

The amniotic band disruption complex. The pathogenesis of congenital limb ring-constrictions; an experimental study in the foetal rat.

This paper reports the findings of an experimental foetal rat study which has shown that it is possible to produce mild, moderate and severe limb ring-constrictions by simulating the ligature effect of amniotic bands. Of the 40 experimental foetuses, 36 (90%) survived the in utero surgery and are included in the present study. Of these 36 foetuses, limb constriction rings were produced in 35 (97%), and an in utero limb amputation in one (3%).

Hypospadias and the embryogenesis of the penile urethra.

The findings of a histological study of a rare specimen of a human hypospadias penis are presented. These findings suggest that distal pits are due to arrested development of the glandar urethra. The present findings also indicate that accessory urethrae and possibly the ventral position of the urethral meatus are the result of an intrinsic abnormality of the urethral plate.

The anatomy of the thoracodorsal artery within the latissimus dorsi muscle.

This paper reports the findings of an anatomical study of the primary and secondary muscular branches of the thoracodorsal artery within the latissimus dorsi muscle. Twenty latissimus dorsi muscles were studied, harvested from 13 fresh cadavers and the findings support the hypothesis that it is possible to thin safely a latissimus dorsi muscle flap at the time of flap transfer.

The thinned latissimus dorsi free flap: a case report.

The clinical use of a thinned free vascularised latissimus dorsi muscle flap is described. The ability to thin successfully the latissimus dorsi muscle flap at the time of transfer has extended its clinical use to include such recipient sites as the face, anterior tibial region and dorsum of the foot.

The place of plastic surgery in the undergraduate surgical curriculum.

This paper reports the findings of a national survey of Medical Schools and Plastic Surgery Units. The survey has shown that plastic surgery is included in the undergraduate curriculum of 78% of the Medical Schools in the United Kingdom, and that this teaching load is shared by 77% of the Plastic Surgery Units in the United Kingdom. The results of a survey of medical students from the University of Oxford are also presented.

Dermatofibrosarcoma protuberans: the problems of surgical management.

This paper reports the findings of a study of five patients each of whom had a dermatofibrosarcoma protuberans. The difficulties encountered in making an accurate clinical diagnosis and ensuring adequate surgical excision of this uncommon skin tumour are discussed. Recommendations are made on methods designed to reduce the high recurrence rate normally associated with this locally aggressive tumour.

Local transposition of a distally-based island forearm flap to close a complicated excisional wrist defect in a nonagenarian: some anatomical and clinical considerations.

A distally based island forearm flap was used in a 93-year-old patient to reconstruct a dorsal forearm defect following tumour resection. Augmentation of the venous out-flow using a microvascular venous anastomosis was required. The expediency and safety with which this island flap can be used is emphasized with a cautionary note on venous drainage.

The anatomy of the subscapular-thoracodorsal arterial system: study of 100 cadaver dissections.

The results of 100 cadaver dissections of the subscapular-thoracodorsal arterial system are presented. These results confirm the anatomical reliability of the thoracodorsal artery and report the consistent presence of a branch of the thoracodorsal artery to the serratus anterior muscle. The branches to serratus anterior were of sufficient dimensions to support either a latissimus dorsi flap or a serratus anterior flap. A direct cutaneous branch from the thoracodorsal artery to the skin of the axilla was identified in only 47% of the dissections.

The intra-uterine healing of foetal muscle wounds: experimental study in the rat.

This work confirms that foetal wound healing is rapid, occurs without an apparent inflammatory response and takes place without the deposition of collagen. It is shown for the first time that foetal muscle wounds heal by regeneration. This study also shows that, immediately after injury, there is a degeneration of mesenchymal and ectodermal elements in that part of the lip between the wound and the mid line. This degeneration is followed by regeneration of only the mesenchymal elements.

A fortuitous donor site for full-thickness skin grafts in the correction of syndactyly.

The ideal donor site for full-thickness skin grafts to the non hair-bearing areas of the fingers is the glabrous skin of other digits. The use of these sites is usually restricted because of the limited amount of skin available and the donor site morbidity. We were recently presented with a clinical situation in which one congenital abnormality of the fingers requiring full-thickness skin grafts for its correction was associated with another congenital abnormality of the digits: amputation of the supernumerary fingers and toes provided the ideal donor site for the full-thickness skin grafts needed in the hand.