Anaesthetic management in facial bipartition surgery: the experience of one centre.

Facial bipartition is amongst the most radical craniofacial surgery undertaken but is performed rarely. There is little published information on its anaesthetic management. We undertook a retrospective case-note review of 22 consecutive patients undergoing bipartition surgery by the same surgical team in one centre in the period 1993-2001. There were incomplete data for two cases and these were therefore excluded. Patients were aged 2 months to 19 years. Conditions treated were facial cleft (n = 5), frontonasal dysplasia (n = 7) and facial dysostosis (n = 8).Intra-operative complications included major haemorrhage (n = 4), bradycardia (n = 3) and unintentional tracheal extubation (n = 1). There were no peri-operative deaths. All patients required intra-operative blood transfusion and 15% of them had a postoperative haemoglobin concentration > 115% of their pre-operative value. In this series, four patients required postoperative lung ventilation for a median duration of 3 days. Infants < 14 months old were significantly more likely to receive a massive blood transfusion (p = 0.0002), to have an excessively high postoperative haematocrit (p = 0.008) and to require postoperative lung ventilation (p = 0.0002) compared with older patients. We conclude that patients in this age group have a significantly increased risk of postoperative complications.

The anatomical and neurophysiological basis of the sensate free TRAM and DIEP flaps.

Recent developments in autogenous breast reconstruction using the rectus abdominis myocutaneous free flap include attempts to reinnervate the flap tissue. We have carried out anatomical studies to determine the nature of abdominal-wall cutaneous innervation, with particular emphasis on the harvesting of sensate flaps. Dissections were performed on four embalmed and 12 fresh human cadavers (32 sides). The lowest five intercostal nerve trunks were identified and traced to the lateral border of the rectus sheath. A detailed dissection of the intramuscular course of the nerves and associated vasculature was performed. The relationship of the nerves to the vascular perforators used for rectus abdominis myocutaneous flaps was determined visually, and confirmed histologically. In contrast to previous studies, we show that nerves supplying cutaneous sensation can travel with both medial and lateral vascular perforators. In order to confirm clinically useful innervation, the abdominal flap skin of five patients undergoing TRAM flap reconstruction was stimulated electrically, and sensory recordings were made directly from the related intercostal nerve just prior to flap harvest. These studies represent, to our knowledge, the first clinical application of neurophysiological techniques to outline the perforator neurosomes of flaps based on the deep inferior epigastric vascular axis. We provide the first comprehensive study of abdominal-wall innervation with regard to sensate free-flap harvest. Our dissections show complex patterns of abdominal skin innervation that have not been previously described. The implications for sensate free TRAM and DIEP flap reconstructions, as well as the potential for more accurate inclusion of innervated flap skin, are discussed.

The panda naevus: management of synchronous upper- and lower-eyelid pigmented naevi.

We report four patients presenting with rare synchronous upper- and lower-eyelid naevi. The distributions and appearances of these naevi resemble the distinctive periorbital pigmentation of the panda. The possible embryological origin of this naevus and an approach to management are discussed.

Isolated bilateral orbital neurofibromatosis in a twelve-year-old.

A patient with bilateral orbital neurofibromatosis is described. This patient had no other dysmorphic features and no systemic stigmata indicative of Von Recklinghausen's disease or endocrine syndromes. To our knowledge, this is the first report in the literature of isolated bilateral orbital neurofibromatosis in an otherwise normal patient.

The free 'V': a bipennate free flap for double eyelid resurfacing based on the second dorsal metacarpal artery.

We present a patient who had a basal cell carcinoma of the left upper eyelid and ectropion of the left lower eyelid. The patient underwent resection of the tumour and release of the ectropion resulting in a full thickness defect of the skin of his left upper and lower eyelids. The eyelids were reconstructed with a second dorsal metacarpal artery free flap from the left hand. For safety, a dorsal vein of the flap was arterialised and one of the valves of the vein had a valvotomy. The flap survived completely.