Search

Background: The CLEFT-Q includes 12 independently functioning scales that measure appearance (face, nose, nostrils, teeth, lips, jaws), health-related quality of life (psychological, social, school, speech distress), and speech function, and an eating/drinking checklist. Previous qualitative research revealed that the CLEFT-Q has content validity in noncleft craniofacial conditions. This study aimed to examine the psychometric performance of the CLEFT-Q in an international sample of patients with a broad range of facial conditions., Methods: Data were collected between October 2016 and December 2019 from 2132 patients aged 8 to 29 years with noncleft facial conditions. Rasch measurement theory (RMT) analysis was used to examine Differential Item Function (DIF) by comparing the original CLEFT-Q sample and the new FACE-Q craniofacial sample. Reliability and validity of the scales in a combined cleft and craniofacial sample (n=4743) were examined., Results: DIF was found for 23 CLEFT-Q items when the datasets for the two samples were compared. When items with DIF were split by sample, correlations between the original and split person locations showed that DIF had negligible impact on scale scoring (correlations ≥0.995). In the combined sample, RMT analysis led to the retention of original content for ten CLEFT-Q scales, modification of the Teeth scale, and the addition of an Eating/Drinking scale. Data obtained fit with the Rasch model for 11 scales (exception School, p=0.04). Person Separation Index and Cronbach alpha values met the criteria., Conclusion: The scales described in this study can be used to measure outcomes in children and young adults with cleft and noncleft craniofacial conditions., Competing Interests: Conflict of Interest Statement Anne Klassen and Karen Wong are co-developers of the patient-reported outcome scales described in this publication and receive a share of any license revenues as royalties based on their institutions’ inventor sharing policy for their use in for-profit study. The other authors have no conflicts of interest to declare in relation to the content of this article., (Copyright © 2021 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Background/aim: Robot-assisted surgery has become increasingly routine, replacing open and laparoscopic techniques in certain domains, with recent extension to head and neck surgery through trans-oral access. Some advantages of the robot-assisted surgery include the ability to access confined spaces, enhanced dexterity instrumentation with intuitive movement, motion scaling, tremor elimination and three-dimensional (3D) endoscopic viewing with true depth perception. The aim of this study was to investigate the technical feasibility of trans-oral robotic cleft surgery (TORCS) to access the posterior pharyngeal wall and palate for potential use in the cleft population., Methods: All possible permutations of patient and robotic instrument configurations were used with the daVinci Si Surgical System® (Intuitive Surgical, USA) 0° and 30° 3D endoscopes and 8-mm training instruments to determine the optimal visualization and surgical access to the palate and posterior pharynx in a paediatric airway manikin, and to simulate posterior pharyngeal wall surgery. A full robot-assisted cadaveric Hynes pharyngoplasty was performed using 5-mm training instruments. Experiments were recorded with still and video photography., Results: TORCS is technically feasible in the paediatric cleft population. We predict a short learning curve due to the intuitive instrumentation, easier dissection and the potential to limit secondary insult compared with traditional surgery, as well as improved ergonomics for the operating surgeon., Conclusions: The as-yet unreported use of robotic-assisted cleft palate surgery may considerably enhance a surgeon's ability to perform difficult procedures of the palate and posterior pharynx in selected patients with limited access as well as lay the foundation for potential novel techniques., (Copyright © 2015 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Background: There is growing interest in the use of autologous fat grafting (AFG) for breast reconstruction. Concerns have been raised regarding its effectiveness and safety., Objective: The primary objective was to determine the oncological, clinical, aesthetic and functional, patient reported, process and radiological outcomes of AFG., Methods: A protocol was published on PROSPERO (CRD42013005254). Types of studies: All original studies., Types of Participants: Women undergoing reconstruction after surgery for breast cancer. Types of Interventions: AFG techniques for reconstruction. Types of outcome measures: Oncological, clinical, aesthetic and functional, patient reported, process and radiological. Search terms and keywords: The search strategy was devised to find papers regarding AFG for breast reconstruction., Data Sources: Electronic databases were searched from 1st January 1986 to 31st March 2014 including: PubMed, MEDLINE, EMBASE, SCOPUS, The Cochrane Library, and clinical trial registries. Identification and selection of studies: Title and abstract screening and full text assessment undertaken separately by independent researchers. Data extraction, collection and management: Data extracted by two researchers and stored in a standardised database., Results: 35 studies were included (3624 patients) with a high degree of patient and surgeon satisfaction over a mean of 1.9 sessions at 18 month follow-up. Fat necrosis was the commonest reported complication (4.4%), biopsy of a subsequent breast lump was required in 2.7% and an interval mammogram in 11.5%. The weighted mean recurrence rate was 4.4% at 24.6 months. Meta-analysis of comparative studies showed no significant difference in oncological event rates between AFG and non-AFG groups (p=0.10)., Conclusion: AFG is a potentially useful reconstructive tool, has a relatively low complication rate, with the majority of patients and clinicians satisfied or very satisfied with the results. Long term clinical and radiological follow-up is required. Further research is necessary to confirm oncological ramifications., (Copyright © 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

This article discusses the measurement of outcomes in craniofacial and pediatric plastic surgery, using examples of craniosynostosis and cleft lip and/or palate (CLP). The challenges in measuring the standard outcomes of function, aesthetics, and health-related quality of life are discussed, along with the importance of developing evidence and studying quality improvement in this specialty. The need to define specific and comprehensive goals is discussed with a focus on patient-reported outcomes (PROs). Examples from the development of the CLEFT-Q, a PRO instrument for patients with CLP, are provided to support the need to seek the patient perspective., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Objective: This study was performed to investigate whether nasal and oropharyngeal microbiological swabs taken prior to cleft lip and palate surgery correlated with the oronasal flora at the time of surgery and whether specific culture results affected surgical outcome., Methods: Prospective audit set in two designated U.K. cleft centers each with a single surgeon. Nasal and oropharyngeal microbiological swabs were taken within 2 weeks prior to surgery and again on the operating table. Adverse outcome measures included postoperative pyrexia, wound dehiscence, or fistula formation., Results: One hundred forty-four cases were recruited over 12 months. Nasal swabs cultured organisms significantly more often than oropharyngeal swabs (p < .0001). No significant difference was detected in the number of cases with a positive microbiology culture preoperatively compared with perioperative sampling (48% and 50%). The specific organisms cultured from preoperative swabs were the same as those cultured at surgery in only half of cases. Preoperative microbiology swabs were poorly predictive of the oronasal flora at surgery. Antibiotic treatment of patients with positive preoperative microbiology did not significantly reduce the incidence of bacterial colonization or significantly alter clinical outcome., Conclusion: Preoperative microbiological investigation is not helpful in predicting the nasal and oropharyngeal flora at the time of surgery. Further, culture results did not correlate with postoperative outcome, regardless of whether pre- or perioperative antibiotic therapy was instigated. This evidence suggests that microbiology screening swabs are an unnecessary investigation.

Background: While there are internationally validated outcome measures for speech and facial growth in cleft lip and palate patients, there is no such internationally accepted system for assessing outcomes in facial aesthetics., Method: A systematic critical review of the scientific literature from the last 30 years using PUBMED, Medline and Google Scholar was conducted in-line with the PRISMA statement recommendations. This encompassed the most relevant manuscripts on aesthetic outcomes in cleft surgery in the English language., Results: Fifty-three articles were reviewed. Four main means of determining outcome measures were found: direct clinical assessment, clinical photograph evaluation, clinical videographic assessment and three-dimensional evaluation. Cropped photographs were more representative than full face. Most techniques were based on a 5-point scale, evolving from the Asher-McDade system. Multiple panel-based assessments compared scores from lay or professional raters, the results of which were not statistically significant. Various reports based on cohorts were poorly matched for gender, age, clinical condition and ethnicity, making their results difficult to reproduce., Conclusions: The large number of outcome measure rating systems identified, suggests a lack of consensus and confidence as to a reliable, validated and reproducible scoring system for facial aesthetics in cleft patients. Many template and lay panel scoring systems are described, yet never fully validated. Advanced 3D imaging technologies may produce validated outcome measures in the future, but presently there remains a need to develop a robust method of facial aesthetic evaluation based on standardised patient photographs. We make recommendations for the development of such a system., (Copyright © 2012 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

The advent of self-inflating hydrogel tissue expanders heralded a significant advance in the reconstructive techniques available for the surgical restoration of a wide variety of soft tissue defects. However, their use in specific applications such as cleft palate surgery is limited on account of their isotropic expansion. An anisotropic self-inflating hydrogel tissue expander has been developed which markedly increases the potential indications for which this restorative tool may be employed. These include complex pediatric soft tissue reconstructions of the palate, nose, ear and digits. Anisotropic expansion in a hydrogel polymer network composed of methyl methacrylate and vinylpyrrolidone has been achieved by annealing the xerogel under a compressive load for a specified time period. By controlling the anisotropic processing conditions and composition we have been able to accurately tailor the ultimate expansion ratio up to 1500%. The expansion rate of the xerogel has also been significantly reduced by encapsulating the polymer within a semi-permeable silicone membrane. The structure and properties of the novel anisotropic hydrogel were characterized by attenuated total reflectance infrared spectroscopy, differential scanning calorimetry, thermogravimetric analysis and small-angle neutron scattering., (Copyright © 2010 Acta Materialia Inc. All rights reserved.)

Background: Composite tissue transplantation effectively reconstructs the most complex defects, but its use is limited because of harmful immunosuppression and the high susceptibility of skin to rejection. Development of tolerance is an ideal solution, and protocols using regulatory T cells (Tregs) to achieve this have been promising in experimental animal models. The aim of this study was to investigate the ability of human Tregs to regulate immune responses to a human skin allograft in vivo., Methods: We isolated and expanded naturally occurring CD127loCD25+CD4+ human Tregs from peripheral blood mononuclear cells (PBMCs) and examined their phenotype and suppressive activity in vitro. Using a clinically relevant chimeric humanized mouse system, we transplanted mice with human skin grafts followed by allogeneic populations of PBMCs with or without Tregs derived from the same PBMC donor., Results: Ex vivo-expanded Tregs maintain the appropriate Treg markers and retain suppressive activity against allostimulated and polyclonally stimulated autologous PBMCs in vitro. Mice receiving allogeneic PBMCs alone consistently reject human skin grafts, whereas those also receiving Tregs display stable long-term human skin transplant survival along with a reduction in the CD8+ human cellular graft infiltrate., Conclusions: We show for the first time the unique ability of human Tregs to prevent the rejection of a skin allograft in vivo, highlighting the therapeutic potential of these cells clinically.

The epidemiology of provision of plastic surgical care is poorly understood. Anecdotally, plastic surgeons in England have reported an increasing volume of work. However, it is unclear how much the workload has increased, and whether there is much geographical variation in workload within a publicly funded healthcare system. Data from English national hospital statistics from 1968-2004 and the Oxford Record Linkage Study (ORLS) from 1963-2004 were analysed for plastic surgery to study long-term trends. Linkage enables analyses to be undertaken in which individuals are counted once only each year regardless of how many plastic surgical admissions they had in the year. In addition, linked hospital admission data for plastic surgery in England, available from 2001-2005, were analysed to study geographical variation. Admission rates increased very substantially over the last four decades: per 100,000 population, they were 71 per 100,000 in England in 1968 and 408 by 2004. Admission rates in the ORLS area, measured as episodes per 100,000, rose from 73 in 1963 to 452 in 2004; and the corresponding figures for person-based rates rose from 63 to 400. Thus the increase in admission rates was a genuine, substantial increase in numbers of people in receipt of Plastic surgical care and not simply an increase in multiple admissions per patient. Geographical analysis showed 4.6-fold variation in admission rates for residents of the health authority areas (range 154 (Hampshire and the Isle of Wight) to 716 (County Durham and Tees Valley) admissions per 100,000 population). We discuss implications of the findings for workforce planning and service design in Plastic surgery within the context of the NHS, and how they may be applied to plastic surgical healthcare models globally. Detailed analysis of case-mix in the speciality, aimed at increasing understanding of both trends and geographical variation, is warranted., (Copyright © 2010 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Primary surgical repair of cleft lip and/or palate is performed before 9 months of age, often representing the first surgical intervention these children encounter. Obtaining pre-operative blood tests in young children often produces much anxiety for all involved. We reviewed the electronic data of 282 children over a five-year period undergoing primary cleft repairs to determine the value of pre-operative full blood count, and transfusion requirements. Of these, three children required post-operative blood transfusion. In two cases concurrent illness contributed to transfusion requirement. To determine if our findings were consistent with those at other Cleft Centres, the views of primary cleft surgeons in the UK and Ireland were obtained using a questionnaire. A 96% response rate was achieved. The majority of cleft surgeons stated they no longer request routine pre-operative blood tests. Few could recall any of their patients requiring transfusion, and in those that did there was an underlying medical condition contributing to transfusion requirement, and an equal number whom could not have been predicted pre-operatively. The benefit of obtaining routine full blood count and group and save in children undergoing cleft repair is small in comparison to the stress caused from obtaining these bloods, and has significant cost implications to the Health Service., (Copyright 2009 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

We report the unusual case of a baby with a paramedian cleft of the lower lip. In 1976, Tessier described a classification of craniofacial clefts based on personal observations, and he predicted the possibility of further clefts being discovered by labeling midline mandibular clefts "30." This case of a paramedian cleft of the lower lip would fit into what could be a new Tessier 28/29 cleft. In the future, clefts in new locations around the mouth may be seen, thus filling the gaps in Tessier's classification.

We retrospectively analysed all cases of iliac crest bone graft harvest for secondary grafting of the cleft alveolus during an 11-year period. The case notes were reviewed and postal questionnaires sent to all patients. Of 73 consecutive patients, 57 (78%) were male, and the mean (S.D.) age at operation was 10 (1) years. A completed questionnaire was received from 72 patients (99%). The median stay in hospital was 3 days (range 2-5). The median time until the child could walk "normally" was 7 days (range 0-56). Thirty-seven patients (51%) had a postoperative limp, which resolved after a median of 7 days (range 3-56). There were two (3%) superficial donor site infections. The median length of scar was 60mm (range 40-100) and patient satisfaction was high, with a median visual analogue scale of 9/10 (range 2-10). Harvesting bone from the iliac crest for alveolar bone grafting is well tolerated by patients, has few important complications, and gives an aesthetically acceptable scar at the donor site.

Radiotherapy is an invaluable weapon when treating cancer. However, the deleterious effects of radiation, both immediate and long-term, may have a significant effect on local tissues. Problematic wound healing in radiation-damaged tissue constitutes a major problem that is frequently overlooked during the management of patients who require radiotherapy, or have had radiotherapy in the past. Poor wound healing may lead to chronic ulceration, pain, secondary infection and psychological distress and compromise the outcome of general or reconstructive surgery. We discuss the pathophysiology of poor wound healing following radiotherapy, specific problems for radiation-damaged tissue and potential treatments to improve wound healing of irradiated tissues.

The case presented is of a 39-year-old female who, at the age of 13 years, had had a "dermatofibroma" excised from her left breast. Twenty-six years later she developed an unsightly "stretched scar". Excision biopsy demonstrated a dermatofibrosarcoma protuberans (DFSP). This was managed by wide local excision, preservation of the nipple-areolar complex, and immediate reconstruction with a pedicled latissimus dorsi flap. Review of the original histology confirmed the presence of DFSP, revising the original diagnosis. Most DFSPs recur within 3 years of primary excision. Such prolonged latency prior to recurrence has not been previously described. This reinforces the need to educate patients regarding the importance of long-term scar surveillance following skin tumour excision.

Objective: To determine whether attractiveness and success of surgical outcome differ according to the timing of cleft lip repair., Design: Three experiments were conducted: (1) surgeons rated postoperative medical photographs of infants having either neonatal or 3-month lip repair; (2) lay panelists rated the same photographs; (3) lay panelists rated dynamic video displays of the infants made at 12 months. Normal comparison infants were also rated. The order of stimuli was randomized, and panelists were blind to timing of lip repair and the purposes of the study., Setting: Four U.K. regional centers for cleft lip and palate., Participants: Infants with isolated clefts of the lip, with and without palate., Intervention: Early lip repair was conducted at median age 4 days (interquartile range [IQR] = 4), and late repair at 104 days (IQR = 57)., Main Outcome Measures: Ratings of surgical outcome (Experiment 1 only) and attractiveness (all experiments) on 5-point Likert scales., Results: In Experiment 1 success of surgical outcome was comparable for early and late repair groups (difference = -0.08; 95% confidence interval [CI] = -0.43 to 0.28; p = .66). In all three experiments, attractiveness ratings were comparable for the two groups. Differences were, respectively, 0.10 (95% CI = -2.3 to 0.44, p = .54); -0.11 (95% CI = -0.42 to -0.19, p = .54); and 0.08 (95% CI = -0.11 to 0.28, p = .41). Normal infants were rated more attractive than index infants (difference = 0.38; 95% CI = 0.24 to 0.52; p < .001)., Conclusion: Neonatal repair for cleft of the lip confers no advantage over repair at 3 months in terms of perceived infant attractiveness or success of surgical outcome.

A questionnaire survey of the perception of plastic surgery amongst 1567 members of the public, general practitioners and medical students is presented. Closed-ended format questions were designed to assess understanding of the range of conditions managed by plastic surgeons. Respondents were asked to match nine surgical specialists with 40 conditions or procedures. To investigate understanding of the multidisciplinary nature of some surgery, respondents were asked which type of surgeon might have a supplementary role. Completed questionnaires from 1004 members of the public, 335 general practitioners, and 228 medical students are presented (responses rate>65%). Significant differences were identified between public respondents and other groups. Plastic surgery was associated with reconstruction for trauma and cancer and procedures with a strong aesthetic element by all three groups. The public were poorly informed about some core plastic surgery including burns, melanoma and hand surgery. General practitioner and student respondents had a better understanding of the diversity of the specialty. However, both groups considered orthopaedic surgeons and not plastic surgeons to be hand surgeons. The strengths and weaknesses of this study are discussed together with potential areas for education and promotion.

The results of a pilot study into the value of MRI scanning in investigation of velopharyngeal function are discussed. MRI offers potential advantage over naso-endoscopy in being noninvasive and over video fluoroscopy in avoiding radiation. However, it requires costly equipment and patient cooperation, which limits its use in young patients. Ten normal volunteers and 15 patients with speech problems underwent MRI of the velopharyngeal port at rest and during sustained phonation of word /a/. Optimal planes for scanning were determined. Images were obtained in mid-sagittal, coronal and horizontal planes at the level of the hard palate and in the plane of the levator axis. Computer assisted measurements were possible of the velopharyngeal closure, forward movement of posterior pharyngeal wall, velar lift, velar extensibility and medial movement of the lateral pharyngeal wall. MRI has a potential role in investigation of velopharyngeal incompetence and planning its surgical repair., (Copyright 2000 The British Association of Plastic Surgeons.)

The most recent comprehensive review of the literature on repair of nasoseptal perforations dates back to 1985, since then there have been developments in the repair of very large perforations, previously thought to have been untreatable by surgical methods. The purpose of this article is to review the various methods which have been used to repair perforations, and their reported efficacies, with particular reference to the problem of large perforations. The article reviews the methods in use for providing mucosal cover for perforations; the options for a supporting layer; and the more recent solutions to mending perforations greater than 4 cm diameter. In conclusion, nasoseptal perforations of up to 4 cm diameter have been reported to be closed reliably with bilateral mucoperichondrial flaps and a connective tissue autograft. However, for larger perforations the only methods successfully used have been a three stage, composite graft and intranasal tissue expanders.

We describe our experiences of treating three patients with recurrent T3 squamous cell carcinoma of the larynx, following initial treatment with radiotherapy; using the technique of partial crico-laryngectomy and autologous pre-fabricated tracheal flap reconstruction as described in 1998 by Delaere (1). We have found the technique to be technically challenging. The patients require extensive speech and swallowing rehabilitation following surgery, but the functional result offers significant advantages over the other surgical salvage procedures of total or near-total laryngectomy. We describe our early results of three patients that we have treated using this technique.

Osteomyelitis of bones in the middle third of the face is rare, especially in westernized populations. The actiology is usually due to odontogenic sources or infected fracture sites. An unusual case of osteomyelitis of the zygomatic bone resulting from the use of radiotherapy in the management of recurrent basal cell carcinoma is presented. This illustrates a late complication of therapy for a cancer which commonly occurs in the head and neck region and is rapidly increasing in incidence in the UK.

The workload of plastic surgery is often poorly understood by the public and those responsible for financing health care. The authors have used linked statistical data to analyse demographic and epidemiological profiles of workload in plastic surgery in Oxfordshire. The analyses were constructed for residents of the district and for patients treated from other districts. The former provides a profile of workload generated for plastic surgery from a geographically-defined population. The latter complements this by adding information about 'imported' workload. Admission rates for plastic surgery were higher for children and elderly people than for other age groups; higher for males than females; and they increased during the 11 years of the study. Most of the increase represented an increase in people treated by the service, rather than an increase in readmissions, although there was a modest increase in the latter too. Lengths of stay per admission and total time spent in hospital per person declined considerably. The bulk of the workload in plastic surgery is concerned with the treatment of trauma (including burns), cancer and congenital malformations. The main clinical conditions treated by the specialty are documented distinguishing, for each condition, the extent to which the patients came from outside the authority in which the provider unit is cited.

The management of regional lymph nodes in the patient with primary cutaneous malignant melanoma remains a contentious issue. Early removal of nodes, which may harbour occult microscopic disease before the development of clinically detectable malignant lymphadenopathy, is thought by some to confer a survival advantage and/or improve locoregional tumour control. While tumour burden at lymphadenectomy has been shown to correlate with prognosis, there are conflicting reports regarding the efficacy of elective lymph node dissection (ELND) compared with a regimen of delayed therapeutic dissection for clinically detectable nodal involvement. Evaluation of arguments for and against ELND, together with consideration of surgical morbidity and the predictability of lymphatic drainage patterns, has allowed a clinical algorithm to emerge which may identify patients who may benefit from prophylactic surgery. A chronological summary of the relevant studies is presented and the overall division of opinion regarding the efficacy of ELND is discussed.

A prospective, randomised, double blind trial was carried out to test whether or not the application of topical anaesthetic cream (EMLA cream) before infiltration of local anaesthetic would decrease the discomfort of correction of prominent ears under local anaesthetic. 23 patients were entered into the trial. They acted as their own controls, one ear having EMLA cream applied approximately 2 h prior to surgery, and the other Aqueous cream. Immediately after surgery, the patients were asked to complete two scales describing the amount of pain they had felt in each ear, both at the time of injection of local anaesthetic and during the surgery. They were also asked whether they thought the inconvenience associated with the use of the EMLA cream was worth any improvement they felt. The results showed that, compared to the placebo cream, EMLA cream significantly decreased the pain felt both at the time of injection (p < 0.005) and during the surgery (p < 0.01). However, only 62% of patients asked felt that the inconvenience associated with the use of EMLA cream was worth the benefits that it conveyed.

Chondroplast, bovine irradiated glutaraldehyde preserved cartilage, has been available in the UK for facial contour surgery since 1986. Eighteen patients who had implants for nasal reconstruction during a 3-year period were reviewed. The mean follow up was 21 months. There was a high rate of graft loss with significant resorption in 7 cases, and loss from infection in 4. There was survival of graft in 7 cases. A prospective study is recommended to determine the reliability of this graft material in reconstructive surgery.

Nine patients who had undergone free fibula transfer were reviewed to determine the incidence of donor site complications. Problems identified included distal oedema, cold intolerance, sensory loss and weakness. However, the functional deficit was not great and most patients were not troubled by their symptoms. More serious potential complications from raising this flap are considered.

Two single and two double free vascularised joint transfers from the foot to hand have been undertaken in four patients over a period of four years. All were to replace metacarpo-phalangeal joints in young patients in whom the use of prosthetic devices was considered unsuitable. All the transfers were successfully completed, but one failed late in the second post-operative week due to sepsis. The results of the remaining three transfers compare favourably with prosthetic arthroplasty and continue to improve. Donor site morbidity in the foot has been minimal and is reviewed.

Five cases are described of a condition in which the maxilla is fused to the mandible at birth, together with details of associated anomalies. A review of the literature provides a further nine single case reports that have appeared previously. An hypothesis of the possible embryological derivation of this condition is proposed.

A review of general surgical work undertaken at a large bush hospital in Africa revealed a high proportion (16-19%) of reconstructive/plastic cases. The reasons for this are discussed, together with the feasibility of current reconstructive techniques in such a situation in the developing world. The implications for future surgical planning and the training of surgeons for developing countries are discussed.

Three patients with burns of 35%, 60% and 25% were treated with cyclosporin after the application of allograft skin. Biopsies of the allografts were taken at appropriate intervals. The drug was continued for 3 weeks, 3 months and 3 weeks respectively without ill-effects on the patients. The allografts survived during cyclosporin treatment but were rejected 12 days after cessation of treatment in Case 1 and 5-7 days in Case 2. In Case 3 where a meshed auto/allograft 'sandwich' technique was used, there was no visible evidence of rejection. It is likely that the allograft was replaced by a "creeping substitution" in the sandwich technique. The Langerhans cell is probably not solely responsible for allograft rejection.

Recurrent local carcinoma of the breast can present a challenging problem of control and reconstruction to the surgeon. The pattern of ulceration, which may extend over a wide area of the chest wall and deeply into the ribs and pleura, is often similar in appearance to the sequelae of excessive radiation therapy, which can therefore be considered as a similar management problem. Advanced carcinoma of the breast can make the last few months of life miserable. Surgery can greatly assist in the amelioration of appearance, smell, and discharge from the ulcer. We report 41 patients managed surgically between 1978 and 1987.

The analgesic efficacy of EMLA cream was compared with that produced by infiltration of lignocaine solution when used to provide anaesthesia for cutting of skin grafts. The study was performed as an open parallel group comparison in 80 patients. Pain felt during administration of the anaesthetic and during cutting of the graft was assessed using visual analogue and verbal rating scales. During graft cutting, the anaesthesia produced by EMLA was at least as effective as infiltration. On administration, infiltration produced varying amounts of pain in all patients, but in contrast EMLA produced no discomfort. In view of this lack of discomfort and the consequent greater freedom afforded regarding the area of donor site anaesthetised, EMLA can be considered the treatment of choice when skin grafts are harvested under local anaesthetic.