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A consortium of global cleft professionals, predominantly from low- and middle-income countries, identified adaptations to cleft care protocols during and after COVID-19 as a priority learning area of need. A multidisciplinary international working group met on a videoconferencing platform in a multi-staged process to make consensus recommendations for adaptations to cleft protocols within resource-constrained settings. Feedback was sought from a roundtable discussion forum and global organizations involved in comprehensive cleft care. Foundational principles were agreed to enable recommendations to be globally relevant and two areas of focus within the specified topic were identified. First the safety aspects of cleft surgery protocols were scrutinized and COVID-19 adaptations, specifically in the pre- and perioperative periods, were highlighted. Second, surgical procedures and cleft care services were prioritized according to their relationship to functional outcomes and time-sensitivity. The surgical procedures assigned the highest priority were emergent interventions for breathing and nutritional requirements and primary palatoplasty. The cleft care services assigned the highest priority were new-born assessments, pediatric support for children with syndromes, management of acute dental or auditory infections and speech pathology intervention. A collaborative, interdisciplinary and international working group delivered consensus recommendations to assist with the provision of cleft care in low- and middle-income countries. At a time of global cleft care delays due to COVID-19, a united approach amongst global cleft care providers will be advantageous to advocate for children born with cleft lip and palate in resource-constrained settings.

Necrotizing fasciitis is a severe soft tissue infection that can involve skin, subcutaneous fat, fascia and muscle. It can result in devastating sequelae including tissue necrosis, sepsis, toxic shock syndrome, cardiopulmonary collapse and death. To control rapidly spreading necrosis, early diagnosis and aggressive surgical treatment with extensive radical debridement of the affected areas is necessary, as well as systemic administration of broad-spectrum antimicrobials and, very often, intensive care support. The subatmospheric negative pressure dressing has been previously used in acute and complex wounds management. The concept of using vacuum-assisted closure dressing as another management component is presented in the current article.

Extraskeletal Ewing's sarcoma (EES) is a rare, soft tissue, malignant neoplasm histologically similar to skeletal Ewing's sarcoma. It occurs mainly in adolescents and young adults, and affects extremities in 36% of cases and central locations (commonly paravertebral regions) in the remainder. The differential diagnosis includes other small, blue, round cell tumours. A clinical case of EES involving a great toe in a young boy is reported. EES diagnosis was confirmed by features of histological analysis and immunohistochemistry, and by the presence of the t(11;22) chromosomal translocation.

The presence of deep pigmentation in a giant congenital nevus makes its complete removal very difficult and should be taken into consideration when planning for treatment. A clinical case in which the pigmented lesion was found to extend deep into the muscle fascia is described. The lesion was surgically removed with an acceptable functional and aesthetic result through the utilization of tissue expansion. The development of new surgical techniques and the expansion of laser technology will possibly provide new treatment options in the future. Emphasis should be placed on aesthetics and function, because the excision based only on oncological anticipation is no longer valid. The presence of deep pigmentation makes certain treatment options less effective than surgical ablation.

Cutaneous ganglioneuroma has only occasionally been reported in the literature. Cutaneous ganglioneuroma is seen even more rarely in association with a giant congenital nevus. Differential diagnosis includes malignancies, especially melanoma and metastatic neuroblastoma.It is essential to rule out malignancy in a solid lesion within a congenital nevus. The present report is possibly the first relating ganglioneuroma and a congenital nevus to a cervical mass detected during routine prenatal ultrasound.

Due to the rarity of arteriovenous malformations (AVMs), there is a paucity of information on the outcomes of various treatments. Presently, the mainstays of treatment of an AVM are embolization, surgical excision or a combination of both. A retrospective study of 26 patients with AVMs treated at The Hospital for Sick Children, Toronto, Ontario between 1985 and 1995 was performed. The treatment strategies and patient outcomes were compared in terms of efficacy, complications and the response of patients and their families to their overall treatment. The overall findings showed that embolization alone was effective in controlling symptoms, but may be associated with an increased AVM size. A partial excision of an AVM does not appear to exacerbate recurrence, as has been previously reported. In fact, even after what appears to be a complete excision of the AVM, recurrence may still occur. Complications from a surgical excision of the AVM are more frequent but less devastating than complications from embolization of the lesion. The overall patient or parent satisfaction with treatment was high with respect to improvement in outcome. It is expected that with an increasing understanding of vascular malformations, and the evolution of interventional radiological techniques, complications will decrease and results as a whole will improve.Compte tenu de leur rareté, on dispose de peu d’informations sur le résultat des divers traitements appliqués aux malformations artérioveineuses (MAV). À l’heure actuelle, le traitement d’une MAV repose sur l’embolisation, l’excision chirurgicale ou sur les deux approches combinées.Les auteurs ont procédé à une étude rétrospective de 26 cas de MAV traités au

Subcutaneous fat necrosis in infancy is characterized by the appearance of subcutaneous nodules beneath a violaceous or erythematous plaque in infants exposed to ischemic stress from a variety of causes. It has been associated with hypercalcemia, hyperlipidemia and thrombocytopenia. This case of subcutaneous fat necrosis occurred 14 days after cardiac surgery in an infant taking enoxaparin who developed a paradoxical thrombocytosis. A potential etiological role for platelet sludging is discussed. Ultrasound images, not previously reported, showed thickened heterogeneous hypodense subcutaneous fat in the nodules and, thus, may be used to differentiate this condition from its surgical differential diagnoses.

Ganglion cysts are mucinous tumours that usually arise from underlying joint capsules or tendon sheaths, and are the most common soft tissue masses of the hand (1). Their pathogenesis remains controversial. The extracapsular part of the dorsal ganglia is well known, but little is known about the intracapsular component and its etiology. While a great deal of information exists for adult hand and wrist ganglia, there is a paucity of data for the pediatric population. Although they commonly occur as benign lesions in adults, ganglia of the hand and wrist are much less common in children. The exact incidence is uncertain, but Nelson et al (1) reported on a series of 543 hand and wrist ganglia. Approximately 10% occurred in patients younger than 20 years of age, and less than 2% were in patients younger than 10 years of age. However, the incidence of ganglia in children is probably underestimated because their presence is usually painless and does not interfere with function; therefore, they may not be brought to the attention of a physician. Pediatric hand and wrist ganglia seem to have different epidemiological characteristics than those of adults – a majority are found on the volar aspect of the hand and wrist in patients younger than 10 years of age (2). Studies regarding the treatment of hand ganglia in children have generally shown increased rates of recurrence with aspiration or surgery when compared with adults who have undergone similar treatment. Recurrence rates of up to 43% with various puncture techniques (3), including aspiration, and 35% following surgical excision have been reported (2). Only a few studies have examined the treatment of pediatric ganglia through observation: MacCollum (4) found a 64% spontaneous resolution rate in a series that included only dorsal wrist ganglia (gathered from several centres), and Rosson and Walker (5), whose study included patients 15 years of age or younger, reported a 76% resolution rate in a series that included foot ganglia. The objectives of the present study were to determine the most common sites of pediatric ganglia occurrence and the most effective method of treatment.

Research in surgery has traditionally focused on quantitative results, sometimes ignoring the qualitative impact on patients. The purpose of the present review was to identify appropriate measurement tools to assess the psychosocial domains of children undergoing corrective surgery for facial paralysis. More specifically, the construct of self-esteem was explored. The outcome of the present investigation is the recommendation for Harter-based assessment tools for research purposes and the Rosenberg Self-Esteem Scale for clinical use. Using these tools will allow health care professionals to assess the psychosocial issues that are important to children with facial differences and to conduct research on the psychosocial impact of corrective surgery.

When infection occurs at a surgical site, it is clear that the normal wound healing process is destroyed, interrupted or at best retarded. However, little is known about the effects of nonwound site infections on the healing process. One concern is that the level of cytokine tumour necrosis factor-alpha (TNFα) produced in the inflammatory process of the infection will have a detrimental effect on the wound healing process. Another concern is that the negative clinical manifestations of sepsis on the maintenance of homeostasis are augmented by the effects of general anesthetic agents used in surgery. Therefore, if the infection is not minor and has the potential for systemic spread, it is best to defer surgery until the infection clears. However, in nonelective surgery, the candidacy of a surgical patient is more likely to be dependent on the clinical manifestations of the infection.

Vascularized fibular transplantation has found wide application for long bone reconstruction in both congenital and acquired defects. However, in children the growth of these transplants is limited and requires the epiphysis if it is to be substantial. Also, the reconstruction of a joint is best achieved with autologus hyaline cartilage. Vascularized fibular epiphyseal transplantation, thus, may play a role in limb salvage procedures in children to both preserve joint function and facilitate long bone growth. The present paper discusses the history of vascularized epiphyseal transplantation both in the laboratory and clinical realm. In discussing its advantages and associated problems, special emphasis is directed at the vascular factors, the endocrine environment, the innervation, mechanical stressors, the recipient site and the donor site. Two case examples are presented to demonstrate the technique, the results and the long term outcome.

Juvenile xanthogranuloma is a relatively uncommon, benign histiocytic proliferative disorder. A case of juvenile xanthogranuloma in a 13-month-old girl with an unusual clinical form is described. She presented with a yellow-red projecting nodule over the helical rim of her right ear. The lesion was histologically diagnosed as juvenile xanthogranuloma after excisional biopsy. Although primarily a dermatological curiosity, plastic surgeons should be familiar with this entity, and should consider it in the differential diagnosis of benign soft tissue tumours of the ear.

The present case report describes a juvenile xanthogranuloma in a five-month-old girl. A circumscribed papule was located below the right nasal ala and above the right vermilion border. The lesion was histologically diagnosed as a juvenile xanthogranuloma after surgical resection of the mass. Juvenile xanthogranuloma is an uncommon diagnosis, with the head, neck and trunk being the most common sites.

Intravascular pyogenic granuloma is a rare tumour, with approximately 30 cases presented previously in the literature. It most commonly occurs in the veins of the head and neck and upper extremity in middle-age patients. There is a paucity of reports detailing this lesion the pediatric literature. A case involving a 14-year-old boy with an intravenous pyogenic granuloma is presented.

The management of congenital melanocytic nevi is controversial. The authors describe their management of a congenital nevus covering the breast and abdomen of a one-month-old girl over a 16-year period. To prevent damage to the developing breast, a staged approach was used. The nevus over the abdomen was resected first at six years of age and the remaining portion was removed after breast development was complete at 16 years of age. The breast defect was resurfaced with a full thickness skin graft from the groin. The patient was pleased with the postoperative result. This staged approach allowed an optimized aesthetic result.

Facial transplantation is becoming increasingly accepted as a method of reconstructing otherwise unreconstructable adult faces. As this modality is made more available, we must turn our attention to pediatric patients who may benefit from facial transplantation. In the current article, the authors present and briefly examine the most pressing ethical challenges posed by the possibility of performing facial transplantation on pediatric patients. Furthermore, they issue a call for a policy statement on pediatric facial transplantation. The present article may serve as a first step in that direction, highlighting ethical issues that would need to be considered in the creation of such a statement.La greffe de visage est une méthode de plus en plus acceptée pour reconstruire des visages adultes autrement impossibles à reconstruire. Puisque cette modalité devient plus accessible, nous devons nous pencher sur les patients d’âge pédiatrique qui pourraient en profiter. Dans le présent article, les auteurs présentent et analysent brièvement les problèmes éthiques les plus pressants liés à la possibilité d’une greffe de visage chez des patients d’âge pédiatrique. Ils réclament également la rédaction d’un document de principes sur le sujet. Le présent article peut constituer une première étape dans cette direction, car il souligne les enjeux éthiques qu’il faudrait évaluer lors de la préparation d’un tel document.

This in vitro study investigated the possibility of delivering epidermal cells to cell culture plates using a simple and inexpensive aerosolization apparatus. Full-thickness skin biopsies were incubated in dispase to separate the epidermis from the dermis, and the epidermis was treated with trypsin to separate the epidermal cells from one another. The cells were suspended in aerosolization medium (1x106 cells/mL) and sprayed onto culture plates using a sterilized pump-action aerosol nozzle. The plates were incubated and microscopically examined on a daily basis. The aerosolization process was successful in consistently delivering a uniform distribution of suspended epidermal cells. By day 4 there was evidence of cell proliferation, and by days 7 to 9 a confluent layer of cells was achieved on the plates. The monolayer consisted primarily of keratinocytes interspersed with a few fibroblasts. The aerosol method was shown to be effective at delivering a suspension of viable epidermal cells to a culture plate.

There is general agreement that congenital giant pigmented nevi (CGPN) are precursors to malignant melanoma; however, the magnitude of the risk of malignant transformation is the subject of wide controversy. The goal of this study was to present the authors' experience with CGPN and more specifically their experience with the risk of malignancy. To identify the general features of CGPN a detailed retrospective chart review was performed at The Hospital for Sick Children in Toronto (1979 to 1994, n=84). There were 39 boys and 45 girls. The average size at presentation was 5.24% of the body surface area, and 36.9% of the nevus were located on the head and neck. An important finding was the high percentage of associated extra cutaneous disorders in patients with CGPN (23%) including a case of leptomeningeal melanocytosis. Tissue expansion was the most commonly used treatment modality. One case of malignant melanoma arising from CGPN was identified. To ensure that all cases of malignant melanoma were identified in this cohort, a questionnaire was sent to all plastic surgeons in Ontario (n=118), and data from the Ontario Cancer Registry were reviewed using the diagnostic codes for malignant melanoma and for pigmented nevus. One case of malignant melanoma was identified in all records. Thus CGPN poses a significant management challenge to the plastic surgeon and the risk of malignancy is low.

Juvenile xanthogranuloma is a type of non-Langerhans cell histiocytosis that occurs most frequently in infants and children. It is usually asymptomatic and can present as either a cutaneous or extracutaneous lesion. The present case is believed to be the first reported in the English literature of juvenile xanthogranuloma presenting as an ulcerated bleeding lesion on the dorsum of the nose.

This case report outlines the sequence of events in an intraoperative anaphylactic reaction as the pockets for tissue expanders were bing developed. Previous expansion had been carried out uneventfully suggesting previous sensitization. Subsequent testing revealed significant latex allergy. Latex avoidance during repeated tissue expansion is recommended.

Giant congenital pigmented nevi of the face are rare but of major consequence. Complete early excision of these lesions is recommended not only because of the cosmetic deformity they impose but also because of their life threatening potential for malignant transformation. At the Hospital for Sick Children in Toronto 19 patients with giant congenital nevi of the face were reviewed. The anatomical location of the lesions, their morphological and histological characteristics, and the authors’ experience with surgical management of these lesions were evaluated. The risk of malignancy arising from these lesions was also evaluated. In this study, one patient died of leptomeningeal melanocytosis associated with her giant congenital nevus of the face. Although an accurate incidence of malignant transformation has not been determined, the risk of malignancy in congenital giant facial nevi must be considered.

Tissue expansion has been used successfully for reconstruction following many congenital and acquired deformities. This report outlines the use of tissue expansion for reconstructing the scrotum in a pseudohermaphrodite with undescended testes and a hypoplastic scrotum. Tissue expanders were placed in the scrotum to create space for the testes. Relative to other reconstructive options in the scrotum, tissue expansion resulted in an excellent cosmetic appearance with the advantage of providing the desirable space for the testes with no donor site morbidity.

BackgroundPilomatricoma (calcifying epithelioma of Malherbe) is a common skin neoplasm in the pediatric population that is often misdiagnosed as other skin conditions or tumours.ObjectivesThe objective of the present retrospective study was to review the clinical and histopathological presentation of this neoplasm in children.MethodsThe records of the pathology department at The Hospital for Sick Children, Toronto, Ontario, were searched for all cases of pilomatricoma between 2001 and 2006. The records of these patients were reviewed to determine sex, age, location and size of the tumour, pathological features and recurrence rate. All patients underwent surgical excision of the lesions.ResultsA total of 93 lesions in 85 patients were identified. The median age was 8.7 years. Of the 85 patients diagnosed with pilomatricoma, 44 (52%) were female. In all cases, the initial presentation was an asymptomatic, slow growing, superficial hard mass with bluish discolouration. The most common sites of occurrence were the face (48%), neck (21%) and upper limbs (18%). The size of the surgical specimens collected ranged from 0.1 cm to 2.6 cm. The diagnosis was confirmed by histopathological examination in all cases. Ghost cells and basaloid cells were described in most of the cases (83%). There were no recurrences in this series.ConclusionsThis entity should be considered with other benign or malignant conditions in the clinical differential diagnosis of solitary firm skin nodules, especially those on the face, neck and upper limbs. The diagnosis can generally be made by clinical examination. The treatment of choice is surgical excision, and the recurrence rate is very low.

A rare case of median nerve entrapment after posterior elbow dislocation is reported. Nerve entrapment was both in the healed medial epicondyle fracture and within the elbow joint and we recommend placing this type of entrapment separately in an extended classification of median nerve entrapment following elbow dislocation.

Our early experience with a rare atypical cleft of the soft palate in a 15-month-old female infant is presented. The cleft extended obliquely across the soft palate from the retromolar region on the left to the base of an intact uvula. Surgical management included a three-layer closure and lengthening of the left side of the soft palate. Close follow-up and reporting of the patient's progress are planned.

The present case report illustrates the management of an avulsion involving two-thirds of the lower lip. An unsuccessful attempt at microsurgical replantation led to a trial of composite tissue engraftment. Ultimately, the tissue sloughed, and after minimal debridement, the defect was treated by direct approximation of mucosa, muscle and skin. The treatment decisions made in caring for this injury show the challenge of microsurgical tissue replantation, the unpredictability of the composite graft and the benefit of having enough tissue to consider direct tissue approximation. Clearly, lips are worth every attempt at preservation, given their functional, cosmetic and psychological importance.

The effects of viral infections on normal wound healing are discussed. The case report presented suggests that viruses can have a detrimental effect on the normal wound healing process.

The Hospital for Sick Children, Toronto, Ontario serves as a regional pediatric burn centre for metropolitan Toronto and the province of Ontario. The demographics and outcomes of the admissions of burn patients are reviewed periodically to help in future planning of resources and preventive strategies. This study was designed to review recent admissions and detect trends of the past decade by comparing admission and outcome data from two cohorts: one from 1986 to 1988 and one from 1977 to 1979. The number of admissions increased during the past decade. There was a lower proportion of patients with flame burns and a higher proportion with scald burns. This may be due to a combination of preventive measures and changing demographics. The overall mortality rate decreased from 2.2% in the previous decade to 0.78% in the past decade.

RM Zuker, C Fielding, S Beatty. Tissue expansion for closure of the donor site of a distant pedicle flap. Can J Plast Surg 1994; 2(4):155-158. Tissue expansion continues to provide new and exciting applications in reconstructive surgery. Tissue expansion has allowed for an increase in size of specialized tissue, particularly about the head and neck. It has also been demonstrated that the blood supply of pedicle flaps can be augmented, thus extending the surviving length of expanded flaps. Recently tissue expansion has been used with free flap transfer to expand the amount of tissue to be transferred and to facilitate donor site closure. In certain situations free tissue transfer may not be recommended and pedicle flap and particularly cross leg and cross thigh flaps are required. In addition to the prolonged unnatural positioning of the patient, the donor defect of these flaps has been harshly criticized. In this report tissue expansion is used to provide adequate tissue for direct closure of the donor defect thus minimizing the deformity.

Objective In most cleft lips patients, the vermilion on the medial aspect of the repair is deficient in height. Not many surgeons have dealt with ways to augment the height of the vermilion at this location. In the unilateral cleft lip, the repair may include the insertion of a small triangular vermilion flap from the cleft side into an incision made for it in the muco–vermilion junction of the noncleft side. We have developed a new technique to further augment the vermilion in incomplete cleft lip patients. Method Vermilion remnants may be present in these patients on the scar tissue between the margins of the cleft. A diamond-shaped vermilion flap based on its attachments to the orbicularis oris muscle may be transposed into the noncleft side to an incision made caudal and parallel to the muco–vermilion border. Then the triangular vermilion flap may be inserted just distal to the island flap. Using this method, the vermilion is augmented and the muco–vermilion line parallels more the white skin roll.