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Scaphocephaly is the commonest form of craniosynostosis with a varied presentation consisting of many morphological components and a range of possible surgical interventions. However, with regard to esthetic assessment, there is no universally applied assessment system. The aim was to develop a simple assessment tool encompassing multiple phenotypic components of scaphocephaly. This was done by piloting a red/amber/green (RAG) scoring system to judge esthetic outcomes following scaphocephaly surgery using photographs and experienced observers. Standard photographic views of 20 patients who had undergone either passive or anterior 2/3 vault remodelling were scored by 5 experienced assessors. Using a RAG scoring system before and after scaphocephaly correction according to 6 morphological characteristics: visual impression of cephalic index, calvarial height, bitemporal pinching, frontal bossing, posterior bullet, and displacement of the vertex. All 5 assessors were asked to score the preoperative and postoperative views independently. The RAG scores were each assigned a number (1-3) and added to give a composite score (range 6-18) and these were averaged between the 5 assessors. There was a highly statistically significant difference between both preoperative and postoperative composite scores ( P <0.0001). A subgroup analysis of the postoperative composite score between the 2 surgical techniques showed no significant difference ( P =0.759). The RAG scoring system can be used to assess esthetic change following scaphocephaly correction and it provides both a visual analogue and a numerical indicator of change. This assessment method needs further validation but is a potentially reproducible way to score and compare esthetic outcomes in scaphocephaly correction.

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Surgical and educational challenges exist in relation to the teaching of facial reconstructive surgery due to the complexities of the facial landscape and training models available. This chapter will describe the development and implementation of alternative modes of teaching facial reconstructive techniques in a multi-disciplinary setting, pioneered by Surgical Art ( www.surgical-art.com ), through the use of a bespoke multimodal training model-the Surgical Art Face©.

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BACKGROUND: Attempts at the pharmacological treatment of Dupuytren's disease have so far been unsuccessful, and the disease is not yet fully understood on a cellular level. The Renin-Angiotensin System has long been understood to play a circulating hormonal role. However, there is much evidence showing Angiotensin II to play a local role in wound healing and fibrosis, with ACE inhibitors being widely used as an anti-fibrotic agent in renal and cardiac disease. METHODS: This study was designed to investigate the presence of Angiotensin II receptors 1 (AT1) and 2 (AT2) in Dupuytren's tissue to form a basis for further study into the pharmacological treatment of this condition. Tissue was harvested from 11 patients undergoing surgery for Dupuytren's disease. Each specimen was processed into frozen sections and immunostaining was employed to identify AT1 and AT2 receptors. RESULTS: Immunostaining for AT1 receptors was mildly positive in one patient and negative in all the remaining patients. However, all specimens stained extensively for AT2 receptors. This suggests that the expression of AT2 receptors is more prominent than AT1 receptors in Dupuytren's disease. CONCLUSION: These findings have opened a new avenue for future research involving ACE inhibitors, AT2 agonists, and AT2 antagonists in Dupuytren's disease.

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Positional plagiocephaly (deformational or occipital plagiocephaly) is the most common head-shape deformity, which is presented to specialist craniofacial units. The aim of management is to reduce pressure on the affected area in the expectation that brain growth will drive normalization of the head shape. Current management includes a variety of protocols based on repositioning advice or helmet orthotics. The aim of this study is to document changes in head shape associated with use of a passive orthotic mattress for the management of positional plagiocephaly of a series of 30 patients at Alder Hey Children's Hospital between April 2008 and June 2010. Cranial vault asymmetry was assessed before treatment and was classified into mild, moderate, or severe plagiocephaly. Follow-up demonstrated a significant improvement in cranial vault asymmetry in those treated with the passive orthotic mattress.

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Intracranial infections caused by Salmonella are rare. We describe the first case of a child undergoing craniofacial surgery for trigonocephaly and subsequently developing an extradural abscess secondary to likely community-acquired Salmonella enteritidis. He underwent surgical washout but returned to theater for a further 2, alongside a prolonged course of intravenous ciprofloxacin. We observed extensive anterior skull bone loss at 78 days postoperatively. At 1 year 11 months, extensive anterior skull bone remodeling had taken place, and the child is currently well.

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This report presents a girl with a lipoblastoma of a finger presenting as a macrodactyly. Documented inflammation of the digit at birth raises suspicion of neo-adipogenesis, which is recognised in lipomas. This case highlights a rare site for lipoblastomas and explores a potential aetiopathogenesis.

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Inguinal herniation represents a common condition requiring surgical intervention. Despite being regarded as a connective tissue disorder of uncertain cause, research has focused predominantly on biochemical changes in the key tissue layer, the transversalis fascia (TF) with little direct analysis of functional tissue mechanics. Connective tissue tensile properties are dominated by collagen fibril density and architecture. This study has correlated mechanical properties of herniated TF (HTF) and non-herniated TF (NHTF) with fibrillar properties at the ultrastructural level by quasi-static tensile mechanical analysis and image analysis of collagen electron micrographs. No significant difference was found between any of the key mechanical properties (break stress, strain or modulus) for HTF and NHTF. In addition, no significant differences were found in average collagen fibril diameter, density or fibre bundle spacing. However, both groups displayed anisotropy with greater break stress (p=0.001) on average in the transverse anatomical plane compared to the longitudinal plane in a mean ratio of 2:1 (anisotropy ratio), though there was no evidence of a difference in this ratio for HTF and NHTF for both break stress and modulus. It was noted that this anisotropy ratio corresponds closely with the expected force distribution on a model cylindrical structure loaded axially. The absence of other functional differences does not support the idea of a failing (injured) tissue but is consistent with it being a tissue undergoing chronic growth/expansion under multi-vectored mechanical loading. These findings provide new clues to collagen tissue herniation for mathematical modelling and model tissue engineering.

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Correcting earlobe deformities often presents an aesthetic challenge to the surgeon. The described technique presents a simple, accurate and cost effective method of remodelling soft tissue defects of the earlobe using a soft splint.

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