Standardisation of cleft care--a technique for creating a three-dimensional model of the cleft lip, palate and nose.

The Royal College of Surgeons Cleft Steering Group and the Craniofacial Society of Great Britain and Ireland have recommended that, for patients with a cleft of the lip and/or palate, a model is made of the deformity before primary surgery. This provides a record for audit and can be used to compare the results of treatment. There is no standardisation in the way in which a model of the cleft deformity is made, which makes inter-unit comparison difficult. In this paper, we describe our technique for making a composite model of the cleft palate, lip and nose. This method is adaptable and quick to perform, and the models are easy to store.

Vascularised muscular flaps and arterial graft infection in the groin.

The groin is the commonest site for graft infections in vascular surgery. This is a potentially catastrophic situation as limb loss or even death occurs in a large percentage of cases. Standard teaching for treatment of infected vascular grafts is removal and extra anatomical bypass grafting whilst commencing appropriate antibiotics. This review article suggests careful scrutiny of the wound, debridement and coverage of the graft with a vascularised muscular flap is appropriate in certain situations.

Use of hearing aids in the management of children with cleft palate.

OBJECTIVE: The incidence of otitis media with effusion in children with cleft palate is high. There are numerous reports looking at early insertion of ventilation tubes (VT) with associated complications. We believe that this is the first paper that discusses the use of hearing aids (HA) as the first line of management. METHODS: Children with cleft palate are managed in a special multidisciplinary clinic in our hospital. Detailed records of these children are maintained. We studied the otological management of 70 children with repaired cleft palate. RESULTS: 12 of the 70 (17.1%) had VT inserted, 17 (24.3%) were provided with HA, 14 (20%) had both grommets and HA and 27 (38.6%) had neither. Of the 31 (44.3%) children who had HA, 16 (51.6%) had good compliance with the HA. The hearing, speech and language developments in these children have been good. Twelve of the 70 patients (17.1%) have had one or more otological complications. These were significantly higher in children treated with VT. CONCLUSION: We have successfully treated 62.9% of our patients with non-surgical intervention, and show a low incidence of long term complications.

An audit of the tetanus immunisation status of plastic surgery trauma and burns patients.

This study audits the tetanus immunisation management of plastic surgery trauma patients by their referring Accident and Emergency departments, and compares this to nationally published guidelines. We assessed 269 burns and trauma patients, referred from across South Wales, using a questionnaire together with their Accident and Emergency notes or letter. The precise question(s) that had been asked regarding the tetanus immunisation status of the patient, and the immunisation management based on the results of those questions, were recorded. The accurate tetanus immunisation status of the patient was established, the wound was assessed and further management was given as indicated. Only 16 patients had been asked whether they had received a course of tetanus, and 41 patients were not questioned about their tetanus immunisation status by the referring Accident and Emergency department. As a consequence of more accurate questioning, 73 patients (27%) required further action after their arrival in the Plastic Surgery unit. This audit has demonstrated that the management of tetanus immunoprophylaxis in plastic surgery trauma patients cannot be confidently left to the referring Accident and Emergency department but should form an integral part of the treatment at the admitting unit.

Heparin-induced skin necrosis and low molecular weight heparins.

Heparin-induced skin necrosis is a rare but potentially devastating side-effect of low molecular weight heparins. These agents are widely used in surgical practice and doctors prescribing them should be aware of the condition, as failure to recognise it may increase morbidity. An unusually severe case is presented with a review of the literature.

Baby walkers--still a major cause of infant burns.

Baby walkers have been implicated in many forms of paediatric trauma, ranging from finger tip entrapment to severe head injury. Their relationship to childhood burns has been documented previously. The Department of Trade and Industry published further warnings in 1984 and the British Standards Institution in 1989. We wished to determine if the degree or frequency of thermal injury had been lessened by these recommendations. All parents of children under 15 months of age admitted to this unit in 1994 were asked if their child was in a baby walker at the time of injury. Eight of the 32 infants, aged between 6 and 12 months, were burned in their walking aid. Half of the burns were contact and half scalds, and the average in-patient stay was 8 days. One patient required formal resuscitation and three were grafted. The incidence and severity of thermal injury sustained in baby walkers remains at a high level despite increased safety measures. Perhaps it is time to concur with the American Academy of Paediatrics and recommend a ban on these dangerous aids.

The use of pH adjusted lignocaine in controlling operative pain in the day surgery unit: a prospective, randomised trial.

We report the results of a randomised, case matched, controlled, double blind study on 40 patients undergoing correction of their prominent ears, comparing efficacy of pH adjusted lignocaine to lignocaine alone in controlling operative pain. Each patient received commercial lignocaine in one ear and the same preparation reconstituted with 1 ml of 8.4% sodium bicarbonate in the other ear according to our randomisation protocol. 30 patients were studied to compare the difference between the buffered and commercial preparation infiltrated at room temperature. A further 10 patients were studied to assess the benefit the buffered preparation at room temperature had over commercial lignocaine warmed to body temperature. Linear analogue pain scores for discomfort at infiltration and during the operation itself were analysed. Buffered lignocaine imparts a significant reduction in pain on infiltration, compared to the commercial preparation at both room and body temperature. Both preparations were equally effective in obliterating pain during the operation itself.

The problem of bilateral foot reconstruction after severe burns.

Reconstruction of bilateral, distal lower limb defects presents a major reconstructive challenge. In the patient with a major burn injury, however, the problem of bilateral foot reconstruction is compounded by both the limited availability of normal unscarred donor sites and by the limited availability of recipient vessels. A case is presented where bilateral dorsum of foot defects in a patient with a 50% surface area burn were successfully reconstructed using a single parascapular free flap. The problems presented by this case are discussed.

Asymmetrical cleft palate.

Ten cases of asymmetrical cleft palate are reported. The pathogenesis, classification and management are discussed.

Formal assessment of the surgical trainee: a review of eight years experience at St Lawrence Hospital, Chepstow.

In light of the proposals for a continuum of higher surgical training, we reviewed an 8-year experience of formal assessments of surgical trainees. We undertook a retrospective analysis of 34 completed assessment forms, retrieved from records, and a postal questionnaire of 54 former (and current) trainees. Our study revealed that all trainees agreed in principle with formal assessments. Eighty-one per cent found their assessment either useful or excellent and a further 17 per cent found the advice received was influential in their careers. The consultants, in turn, were able to modify the training programme as a result of constructive feedback. Based on our experience we recommend formal assessments of surgical trainees as an important and rewarding part of an impartial peer review system within a continuum of higher surgical training.

Non-Hodgkin's lymphoma presenting as median nerve compression in the arm.

A 70-year-old woman presented with median nerve compression secondary to enlarged supratrochlear lymph nodes infiltrated with malignant non-Hodgkin's lymphoma. Peripheral nerve compression is rarely seen in this condition. The management and prognosis are discussed.

The functional results of hand replantation. The Chepstow experience.

Eight hands amputated at wrist or distal forearm level were replanted between 1983 and 1990. Steinman pins were used to obtain skeletal fixation at the wrist level in three patients. Secondary surgery was performed in seven patients. Six of the patients were available for review between 1.5 and 7.5 years (mean 3.6) after the injury. The functional results were assessed using the Tamai scoring system. Recovery of useful hand function has been achieved in most patients, although long-term recovery of sensibility was found to be disappointing. Despite this finding, five out of the six patients were highly satisfied with the result and four have returned to work.

Growth of a vascular malformation into a cross-finger flap.

We describe a vascular malformation which recurred by invading into the previously normal skin of a cross-finger flap. We suggest a similarity between the progression of a vascular malformation and the neo-vascularisation of a flap.

A critical appraisal of the use of free flaps in primary reconstruction of combined scalp and calvarial cancer defects.

Eleven patients had scalp tumours with full thickness calvarial invasion excised and reconstructed with free flap transfer as a primary procedure. Latissimus dorsi or radial forearm flaps were used, with split rib calvarial reconstruction. One flap was lost peroperatively and another necrosed at 8 days following pedicle compression against an acrylic "skull". Only six patients presently survive, two being treated for recurrence. Long-term follow-up indicates that poor prognostic factors are advanced local invasion, squamous or anaplastic tumours, and advanced age. However, palliative treatment has a role.