Journal of Plastic, Reconstructive & Aesthetic Surgery

Oncoplastic breast surgery: A review and systematic approach

M.G. Berry, A.D. Fitoussi, A. Curnier, B. Couturaud, R.J. Salmon — 2009-06-26

Summary: Oncoplastic breast surgery (OBS) is relatively new, but has made rapid progress from its tentative steps of infancy in the 1990s. The recent Milanese Consensus Conference on Breast Conservation concluded that, firstly, oncoplastic techniques are warranted to allow wide excision and clear margins without compromising cosmesis. Secondly, such surgery is ideally performed at the same time as oncological excision. Whilst technically more challenging than standard breast conserving therapy (BCT), OBS is well proven, if not yet widely practised, both oncologically and aesthetically and a review of the available techniques is perhaps timely.The roots of breast conserving therapy can be traced to the 1930s, actually due to advances made in radiotherapy, and the last 20 years have seen it become firmly established. This review aims to summarise the key historical developments and latest innovations in OBS. Not only are our patients, who expect not only safe cancer treatment but a satisfactory aesthetic outcome, increasingly informed and demanding, but longer follow up has stimulated surgeons to improve outcomes. In many cases, particularly with ptosis and macromastia, the cancer can be treated, usually with wider excision margins, simultaneously improving the aesthetic appearance. Present at the birth of OBS, the Institut Curie has continued to introduce innovative techniques over the last two decades and a systematic approach, comprising nine basic techniques, has evolved to allow high quality treatment of any and all breast cancers suitable for OBS.

Plastic surgery and global health: How plastic surgery impacts the global burden of surgical disease

Nadine B. Semer, Stephen R. Sullivan, John G. Meara — 2009-08-25

Summary: The global burden of surgical disease is estimated as being 11% of the total global burden of disease. In this article we discuss the portion of this burden which could be ameliorated with plastic surgical expertise. Although not necessarily seen as a major player in issues related to global health, plastic surgeons are uniquely qualified to decrease the burden of surgical disease afflicting people in the developing world. Burns, traumatic injuries, and congenital anomalies are some of the areas where the presence of plastic surgical expertise can make a significant difference in patient outcomes and thereby decrease the years of life lost due to disability due to these highly treatable conditions. In light of the severe shortage of plastic surgeons throughout the developing world, it falls to those concentrated in the developed world to harness their skills and address the vast unmet needs of the developing world so as to enhance global health.

Commentary on “Plastic surgery and global health: How plastic surgery impacts the global burden of surgical disease”

Tim E.E. Goodacre — 2009-08-25

It is enormously encouraging to have this publication in the Journal to draw much needed attention to the role of reconstructive plastic surgery in managing the global burden of surgically correctable disease. At the outset of a short commentary, my sole reservation relates to the need for such a message to be broadcast as widely as possible in global medical literature, where it might be acknowledged and acted upon by those outside our discipline who have influence in world health policy direction. I hope that this important message reaches a wider audience in due course, possibly in a general medical publication.

Lower face reduction with full-thickness marginal ostectomy of mandibular corpus-angle followed by corticectomy

Toshitsugu Hirohi, Kotaro Yoshimura — 2009-08-28

Summary: Background: In Asian countries, many patients with a prominent mandibular angle desire its correction, because they consider it to be an unappealing feature. Reduction mandibuloplasty has been frequently performed through the intraoral approach, but an invisible mandibular angle forces the surgeon to perform blind ostectomy. In addition, the limited mobility of the oscillating saw leads to semi-vertical ostectomy, and leaves unnatural mandibular contours, such as loss of the mandibular angle.Methods: To overcome the drawbacks of conventional procedures, we performed en bloc mandibular corpus-angle ostectomy using a contra-angle handpiece and subsequent corticectomy in 519 patients with prominent mandibular angles. A retractor with an endoscope was supportively used in 190 patients. A pre- and postoperative cephalogram was taken in 86 patients, and the gonial angle (GA) and the mandibular plane angle to the Frankfort horizontal plane (MPA) were measured.Results: The majority of patients were satisfied with the aesthetic results. GA and MPA were increased by approximately 10°. GA was successfully improved to within the pre-set desired range in 84.5% and 60.0% of the female and male patients, respectively. The overall complication rate was 4.0%; all of these were minor complications, and no major complication such as malfracture or facial nerve injury was seen.Conclusions: Our new technique allows surgeons to perform accurate, safe and reproducible ostectomies and to reshape prominent angles to more natural-looking ones with smooth ostectomised borders.

Patient satisfaction after zygoma and mandible reduction surgery: An outcome assessment

Bong-Kyoon Choi, Raymond C.W. Goh, Zachary Moaveni, Lun-Jou Lo — 2009-08-25

Summary: An ovoid and slender face is considered attractive in Oriental culture, and facial bony contouring is frequently performed in Asian countries to achieve this desired facial profile. Despite their popularity, critical analyses of patients' satisfaction after facial-bone contouring surgery is lacking in the current literature. Questionnaires were sent to 90 patients who had undergone zygoma and/or mandibular contouring by a single surgeon at the Craniofacial Center, Chang Gung Memorial Hospital, Taiwan. The number of patients who had mandibular angle reduction and zygoma reduction were 78 and 36, respectively. The questionnaire contained 20 questions, concerning aesthetic and surgical results, psychosocial benefits and general outcome. Medical records were also reviewed for correlation with the questionnaire findings. The survey response rate was 52.2% (47 patients). A total of 95.7% were satisfied with the symmetry of their face after surgery, and 97.9% felt that there was improvement in their final facial appearance. As many as 61.7% could not feel an objectionable new jaw line or bony step and 66.0% could not detect any visible deformity. A total of 87.2% could not detect bony regrowth after surgery. Complication after surgery was experienced by 17.0% of patients, but all of these recovered without long-term consequences. All patients noted a positive psychosocial influence, and 97.9% of patients said that they would undergo the same surgery again under similar circumstances and would recommend the same surgery to friends. The majority of patients with square face seeking facial bone contouring surgery are satisfied with their final appearance. Of equal importance is the ability for this type of surgery to have a positive influence on the patient's psychosocial environment.

Craniofacial reconstruction of primary osteogenic sarcoma of the skull

2009-09-02

Summary: Background: Osteosarcoma of the skull is an extremely rare tumour. Because it has few symptoms initially, it usually presents after signs and symptoms of local invasion are present. Obtaining negative surgical margins is one of few modifiable survival factors. Resection of these invasive tumours is often limited by the ability to perform a reconstruction that is adequate in form and function. Despite this critical limitation, there are no articles describing reconstructive techniques used after resection of osteosarcoma of the skull. The purpose of this article is, therefore, to describe the reconstructive methods that can be used in the treatment of osteosarcoma of the skull.Methods: A retrospective chart, photographic and radiological study was conducted of cases performed between 1986 and 2007. Tumour characteristics and reconstructive methods were compiled.Results: Six patients were operated for osteosarcoma of the skull. The mean age at surgery was 27 years. Resection margins were positive in three cases. Bony reconstructive methods were split calvarial bone, iliac bone grafts and bone cement. Dural repair was made with a variety of materials. Complex deficits were repaired with rotation and free flaps.Conclusion: This article presents reconstructive methods used for reconstruction of skull defects left after resection of osteosarcoma of the skull. A variety of methods are available to repair complex deficits. Obtaining negative surgical margins is critical for survival. The ability to completely resect an invasive tumour is often limited by advances in reconstructive methods. Thus, progress in craniofacial reconstruction techniques warrant further investigations.

Surgical repair of transverse facial cleft: Oblique vermilion–mucosa incision

Akiyoshi Kajikawa, Kazuki Ueda, Yoko Katsuragi, Taro Hirose, Emiko Asai — 2009-08-26

Summary: Various surgical techniques have been reported for the repair of the transverse facial cleft using a straight-line closure, Z- or W-plasty, local flaps, etc. However, several problems remain such as deviation, distortion and scars in the commissure and cheek. To resolve these problems, we studied the anatomy of the commissure again and devised the most reasonable method for repair of the transverse facial cleft.In our new method, oblique vermilion and mucosa incision lines, 45° to the vermilion–cutaneous junction, were designed. After mucosal closure, the orbicularis muscle was reconstructed by cross-overlap joining the upper muscular bundle over the lower muscular bundle at an angle of 90°. The skin was sutured using horizontal straight-line closure with a small Z-plasty lateral to the nasolabial fold.We performed the new method on seven macrostomias. The patient cohort consisted of four girls and three boys, and their ages ranged from 4 months to 3 years. Symmetrical commissure and natural oral movement was obtained in the past five cases. The scar around the commissure and cheek was inconspicuous in all cases.The new method used the oblique vermilion–mucosa incision and straight-line closure, the cross-overlap joining of the muscular bundles at an angle of 90°, and the horizontal straight-line skin closure with a small Z-plasty lateral to the nasolabial fold. This method, which is anatomically reasonable, can construct a symmetrical and natural commissure without conspicuous scars.

Bilateral microtia reconstruction

Xinhai Liu, Qingguo Zhang, Yuzhu Quan, Yangchun Xie, Lei Shi — 2009-08-20

Summary: Background: Ear reconstruction for congenital microtia is a challenge for the plastic and reconstructive surgeon. Ten percent of microtia cases are bilateral. However, the published literature contains relatively little information about auricular reconstruction in bilateral microtia. Some authorities prefer to reconstruct each side at different stages. In this article, we introduce an operative method to reconstruct both sides simultaneously. This is completely feasible, and saves time and cost. Furthermore, this method allows comparison between sides during surgery, and facilitates carving of bilateral ear frameworks of equal size and shape.Methods: From March 2007 to June 2008, 21 cases of congenital bilateral microtia were treated by post-auricular skin flap expansion, autogenous rib cartilage framework implantation, post-auricular fascial flap lifting, followed by split-thickness free skin grafting to reconstruct bilateral external ears during the same stage.Results: With a follow-up duration of 6 months to 1 year, two cases in a total of 21 showed different levels of absorption and cartilage deformation. The rest (19 cases) of the bilateral reconstructed ears showed good symmetry in size, shape and location. The bilateral reconstructed ears looked symmetrical and similar in outline, with well-defined structures.Conclusion: Simultaneous bilateral congenital microtia reconstruction is feasible and effective. The authors recommend it as the treatment of choice for bilateral microtia reconstruction.

Negative pressure manoeuvre in microtia reconstruction with autologous rib cartilage

2009-09-22

Summary: In microtia reconstruction, maintaining a healthy contact between the skin and the fabricated cartilage framework is essential to attaining a smooth and accentuated contour of the reconstructed auricle. Conventional means to achieve this include bolster sutures and continuous suction drains, both of which have associated shortcomings. A new dressing method was developed and applied in 10 consecutive patients who underwent the first of a two-stage microtia reconstruction using the Nagata technique. A small catheter was introduced into the space between the skin and the cartilage framework. Negative pressure was applied through the catheter, drawing the skin onto the cartilage framework. This evens out the skin, accentuates the contour of the framework and concurrently eliminates potential dead space. Skin contact on the framework is maintained whilst the catheter is removed and an occlusive transparent dressing is applied to the ear. Of the 10 cases in which this manoeuvre was performed, one had to be converted to the bolster suture technique due to a persistent air leak from the wound. Overall results of the nine cases in which this technique was carried out successfully demonstrate smooth skin contour and excellent definition of the fabricated framework. This negative pressure manoeuvre provides a simple, safe and consistent approach to achieving a smooth and accentuated contour in auricular reconstruction.

Surgical management of polyotia

2009-07-21

Summary: Background: Polyotia is an extremely rare type of congenital external ear malformation, which is defined as an accessory ear that is large enough to resemble an additional pinna. The terms 'mirror ear' or 'accessory ear' are sometime used. We present our methods in correcting this malformation and summarise the aetiology.Methods: The posterior part of the polyotia may presents with a normal ear, a constricted ear or a microtic ear. Free auricular composite tissue transplantation was used to correct the constricted ear. Ear reconstruction was applied in cases of microtia. The anterior auricle was mainly used to form the tragus.Results: 7 cases polyotia were treated between 2004 and 2008. After free auricular composite tissue transplantation the size of the constricted ear and the contralateral ear was similar. In microtia cases the reconstructed ears were natural looking and had a satisfactory three-dimensional contour. The extra tissue of the anterior ear was excised and the tragus was reconstructed.Conclusions: Through operative intervention tailored to the individual case natural-looking and symmetric ears were acquired. The aetiology of polyotia probably relates to abnormal migration of neural crest cell.

A novel approach to thoracic wall reconstruction based on a muscle perforator

2009-07-27

Summary: When reconstructing the thoracic wall, non-adaptation of the suture line is a critical concern, especially when artificial implants are used. Therefore, a reliable and safe flap is required.Based on an anatomical study of cadavers, we decided to dissect the pectoralis major musculo-cutaneous flap into two parts, on the surface and beneath the muscle fascia, while preserving the muscle perforators. We designated the skin portion as the V–Y advancement flap or rotation V–Y advancement flap and the muscle flap as the transposition flap. Both flaps had different suture lines. We applied this method to two patients requiring reconstruction of anterior thoracic defects with artificial implants. One patient did not have adverse effects, and the flaps took well. The shape of the breast did not change significantly. However, the other patient was a heavy smoker. Although the V–Y advancement flap took well, the cutaneous triangular tip made at the time of tumour resection became necrotic. However, the underlying pectoralis major muscles successfully covered the implants and did not show any signs of infection. In conclusion, reconstruction of the anterior thoracic wall to change the suture line with a V–Y advancement flap, based on the muscle perforator and pectoralis major muscle flap, is a useful and reliable method, especially when an artificial implant is used.

Macrovascular arteriovenous shunts (MAS): A newly identified structure in the abdominal wall with implications for thermoregulation and free tissue transfer

Warren M. Rozen, Daniel Chubb, Mark W. Ashton, Damien Grinsell — 2009-07-06

Summary: Microscopic arteriovenous anastomoses are known structures that have many clinical implications, with disease states such as Reynaud's phenomenon and erythromelalgia known consequences of their abnormal functioning. These pre-capillary arteriovenous communications result in increased regional blood flow at the time of capillary filling. Recent advances in imaging technology, providing physiological and anatomical data, have identified a previously undescribed anatomical structure, that of large-vessel (macroscopic) arteriovenous communications, with profoundly different implications. Computed tomographic angiography (CTA) of the abdominal wall vasculature was undertaken in 140 patients prior to reconstructive surgery. All scans were arterial phase, demonstrating functional arteriovenous communications in all patients. These communications identified vascular shunting occurring prior to capillary filling. Fine-cut slices were able to visualise the structures, demonstrate their size as macroscopic (>1mm diameter) and map the course of the arteriovenous communications. The potential clinical implications and therapeutic possibilities in a range of medical and surgical conditions are described.

Becker expander implants: Truly a long term single stage reconstruction?

B.K. Chew, C. Yip, A.D. Malyon — 2009-08-05

Summary: Despite being more expensive than conventional tissue expanders, Becker expanders offer the advantage of single stage breast reconstruction. However, the large series in published literature which report good outcomes of Becker expanders in breast reconstruction have a mean follow up period of less than three years. This does not allow for definitive conclusions as to whether the Becker expander truly meets its design goal of a lasting single stage breast reconstruction.This study is a retrospective case note review of all patients who underwent breast reconstruction using a Becker expander at our unit from 1993 to 1998, with a mean follow up of 12.5 years. Sixty-eight Becker-only breast reconstructions were carried out following oncological and risk-reducing mastectomies, and for congenital hypoplasias.There was a high premature overall explantation rate with 68% of expanders removed by 5 years due to complications which included poor aesthetics, capsular contracture and infection. The mean time to explantation for these patients was only 23 months, and time to 50% overall expander removal (‘half life’) was just 30 months. On subgroup analysis, patients in the congenital hypoplasias group had a significantly better rate of expander retention with 67% remaining in situ at 10 years. In comparison, patients in the oncological and risk-reducing mastectomy groups had implant retention rates of 2% and 7% respectively.The Becker expander does not appear to meet its design purpose of lasting single stage breast reconstruction in post-mastectomy cases. In contrast, it appears to have significantly better longevity when used for congenital hypoplasias.

The use of Biobrane for hand surgery in Epidermolysis bullosa

J. Jutkiewicz, B.H. Noszczyk, M. Wrobel — 2009-07-27

Summary: Surgical treatment of hand contractures and pseudosyndactyly in Epidermolysis bullosa poses numerous medical and hospital management problems. For instance, the exceptional fragility of genetically defective epidermis may contribute to iatrogenic trauma or hamper and prolong healing. The interval between unavoidable contracture recurrences rarely exceeds 2 years; therefore, a search for quick treatment completion should be considered by the surgical teams. Because this goal is rarely achieved, even efforts aimed at facilitating operative procedures and improving patient comfort are often quite valuable. This study presents the initial results on the use of the Biobrane dressing in six cases with various degrees of hand contracture. Application of the product in the form of gloves was fast and easy, promoted epithelialisation and substantially reduced the risk of iatrogenic trauma during replacement of the dressings. The use of Biobrane also enabled rapid elimination of additional protective dressing layers, exposure of the healing skin and prevention of further epidermal maceration. However, the time and number of necessary procedures under anaesthesia was dependent upon the degree of hand deformity rather than on Biobrane use, so this treatment did not shorten the healing time to less than 4 weeks.

Digital artery perforator (DAP) flaps: Modifications for fingertip and finger stump reconstruction

2009-09-03

Summary: Various fingertip reconstructions have been reported for situations where microsurgical finger replantation is impossible. One method is the digital artery perforator (DAP) flap. Herein we report 13 DAP flaps for fingertip and finger stump reconstruction following traumatic finger amputations, highlighting modifications to the originally described DAP flap.Methods: From October 1998 to December 2007, a total of 13 fingers (11 patients) underwent fingertip and finger stump reconstruction with modified DAP flaps following traumatic finger amputations. We performed six adipocutaneous flaps, three adipose-only flaps, two supercharged flaps and two extended flaps. Flap size ranged from 1.44 to 8cm2 (average 3.25cm2).Results: All flaps survived completely with the exception of partial skin necrosis in two cases. One of these cases required debridement and skin grafting. Our initial three cases used donor-site skin grafting. The donor site was closed primarily in the 10 subsequent cases. No patients showed postoperative hypersensitivity of repaired fingertips. Semmes–Weinstein (SW) test result for flaps including a digital nerve branch did not differ from those without (average 4.07 vs. 3.92).Conclusions: Modified DAP flaps allow for preservation of digital length, volume and finger function. They can be raised as adiposal-only flaps or extended flaps and supercharged through perforator-to-perforator anastomoses. The donor defect on the lateral pulp can be closed primarily or by skin grafting. For traumatic fingertip and finger stump reconstructions, DAP flaps deliver consistent aesthetic and functional results.

Dermal pocketing following distal finger replantation

2009-07-21

Summary: Replantation is an ideal technique for reconstruction following fingertip amputation as it provides ‘like for like’ total reconstruction of the nail complex, bone pulp tissue and skin with no donor-site morbidity. However, fingertips are often not replanted because veins cannot be found or are thought to be too small to repair. Attempts at ‘cap-plasty’ or pocketing of replanted tips with and without microvascular anastomosis have been done in the past with varying degrees of success. We prospectively followed up a group of patients who underwent digital replantation and dermal pocketing in the palm to evaluate the outcome of this procedure. There were 10 patients with 14 amputated digits (two thumbs, five index, four middle, two ring and one little) who underwent dermal pocketing of the amputated digit following replantation. Among the 14 digits that were treated with dermal pocketing, 11 survived completely, one had partial atrophy and two were completely lost. Complications encountered included finger stiffness (two patients) and infection of the replanted fingertip with osteomyelitis of the distal phalanx (one patient). We believe that this technique can help increase the chance of survival for distal replantation with an acceptable salvage rate of 85% in our series.

The ‘round-the-clock’ training model for assessment and warm up of microsurgical skills: A validation study

2009-07-13

Summary: Microsurgery is an essential technique in free flap reconstructions today. The technical skills involved require a learning curve, which may be affected by the current issues of limited training resources and patient safety. We describe a study on the value of a microsurgery training device as an assessment and warm up tool in basic microsurgery skills.Forty volunteers with different levels of microsurgery experience performed a microsurgical ‘round-the-clock’ exercise on the training device three consecutive times. Video-recordings of these performances were rated by two blinded independent assessors using a modified Global Rating Scale to assess basic microsurgery skills on the following parameters: steadiness, instruments handling and speed. Time to complete a round was also recorded objectively. The Kruskal–Wallis test was used to analyse the construct validity of the parameters assessed between the groups of level of microsurgery experience. Crohnbach's coefficient α was used to determine the reliability index of the independent assessors.All participants improved their time on consecutive rounds of the exercise. A median of 82s (range 6–583s) improvement in time between the first and third round was observed. Different mean performance time could be identified between the groups, but individual speed did not correlate significantly with microsurgery experience. Assessment of microsurgery skills using the modified Global Rating Scale demonstrated statistically significant differences for instruments handling (p=0.03) and speed (p=0.01) between the groups with regard to microsurgery experience, and improvement in the parameters assessed for all groups. Difference in steadiness (p=0.07) was not significant amongst the juniors.Consultants performed better than juniors but, at all levels of experience, significant improvement in skills was demonstrated after practice. The ‘round-the-clock’ microsurgery training device is an inexpensive and readily available valid tool that provides a useful warm up exercise and instant assessment of basic microsurgical skills.

Structured assessment of microsurgery skills in the clinical setting

WoanYi Chan, Niri Niranjan, Venkat Ramakrishnan — 2009-07-23

Summary: Microsurgery is an essential component in plastic surgery training. Competence has become an important issue in current surgical practice and training. The complexity of microsurgery requires detailed assessment and feedback on skills components. This article proposes a method of Structured Assessment of Microsurgery Skills (SAMS) in a clinical setting.Three types of assessment (i.e., modified Global Rating Score, errors list and summative rating) were incorporated to develop the SAMS method. Clinical anastomoses were recorded on videos using a digital microscope system and were rated by three consultants independently and in a blinded fashion.Fifteen clinical cases of microvascular anastomoses performed by trainees and a consultant microsurgeon were assessed using SAMS. The consultant had consistently the highest scores. Construct validity was also demonstrated by improvement of SAMS scores of microsurgery trainees. The overall inter-rater reliability was strong (α=0.78).The SAMS method provides both formative and summative assessment of microsurgery skills. It is demonstrated to be a valid, reliable and feasible assessment tool of operating room performance to provide systematic and comprehensive feedback as part of the learning cycle.

Junior plastic surgeon's confidence in aesthetic surgery practice: A comparison of two didactic systems

2009-07-13

Summary: The importance of residents' training in aesthetic surgery and the need for acquiring confidence in performing cosmetic procedures is an established knowledge.A survey was done in two different training systems to evaluate the experience of junior plastic surgeons in performing four common aesthetic surgery procedures at the end of their residency. The first system guarantees a theoretical background and a certain number of aesthetic procedures to be performed by the trainee, in contrast to the second system where mainly theoretical knowledge in cosmetic surgery is warranted to residents.The residents' comfort in performing specific operations was quite varied between the two systems. The comparison showed that junior plastic surgeons reached a higher degree of self-confidence in aesthetic practice in system A when compared to system B.The similarities and differences between the two systems are analysed and discussed. The possibility of reforming residency programmes by following the structure and the philosophy of system A is proposed.

Surgical complications of lipoplasty – management and preventive strategies

Mohan Thomas, Harikumar Menon, James D'Silva — 2009-08-06

Summary: Background: Lipoplasty and its associated complications are well researched and documented. In most articles, the focus has been on the major life-threatening complications of liposuction. Most of these major complications are related to conditions other than surgical trauma per se, namely anaesthesia, hypothermia, long duration of surgery and fluid overload. With the exception of pneumothorax and abdominal perforation, surgical trauma does not cause major complications.Although most surgical complications are classified as minor, they present as major events for patients and the treating physician. All efforts to prevent even minor complications to enhance patient satisfaction are needed.This article presents a review of only the surgical-trauma-related complications of lipoplasty and discusses their management and preventive strategy.Methods: A review of 200 consecutive cases of lipoplasty, performed between July 2006 and December 2007, including large-volume liposuctions (LVLs) and combined liposuction abdominoplasties, was undertaken. Complications relating only to the surgical trauma of liposuction were analysed.Results: Complications such as hyperpigmentation of access points, postoperative fluid collection, asymmetry, irregularity, external genital swelling and haematoma were noted.Postoperative fluid collection and haematoma required active intervention. Drainage of fluid collection using a liposuction cannula was effective and prevented recurrence and the need for repeated aspirations. Major surgical complications such as pneumothorax and abdominal wall perforations could be avoided by following simple rules.Conclusions: Major complications related to surgery can be avoided by following well-known safety guidelines.To enhance patient satisfaction, minor complications related to surgical trauma need to be addressed aggressively. This article discusses methods to lower the incidence of most surgical complications.

Keloid treatment: Is there a role for acellular human dermis (Alloderm)?

Nima P. Patel, A. Lawrence Cervino — 2009-08-25

Summary: Background: Keloid management is faced with high recurrence rates. Keloid fibroblasts lack the normal negative feedback mechanism resulting in an exuberant scar formation. Alloderm® doesn't undergo the same proliferative process as keloidal scar dermis.Objective: To evaluate Alloderm as a treatment modality for keloidsMethods: A retrospective chart review of six patients with a total of eight large recurrent keloids was performed. Patients were treated with excision of the keloid followed by placement of Alloderm. Each patient was evaluated for recurrence and complications.Results: During follow-up ranging from 1 month to 4½ years there were 0% recurrences. Two out of 8 (25%) had residual induration. one of the two patients with residual induration, required an intralesional injection of kenalog at 6 months post-op.Conclusion: Our results from this small study show that with the use of Alloderm after keloid excision, recurrence is low. Further study is warranted.

The UK primary hypospadias surgery audit 2006–2007

M.J. Timmons — 2009-09-28

Summary: Aim: To find out what primary hypospadias surgery is being done in the United Kingdom and at what ages patients have surgery.Methods: On behalf of the British Associations of Paediatric Urologists, Paediatric Surgeons and Plastic, Reconstructive and Aesthetic Surgeons, paediatric surgeons/urologists, plastic surgeons and urologists were asked to record prospectively their data for 12 months, October 2006–September 2007.Results: There were 50 replies (response rate 50%, 79% of plastic surgeons and 40% of paediatric surgeons/urologists). Most patients had distal hypospadias. The total numbers of operations were 814 (paediatric surgeons/urologists), 436 (plastic surgeons) and 5 (one urologist). More than 20 operations a year were performed by 79% of paediatric surgeons/urologists and 35% of plastic surgeons. Both groups used a similar range of single-stage and two-stage operations. Patients' ages at surgery were less than two years for 68% of paediatric surgeons/urologists and two to four years for 60% of plastic surgeons.Conclusions: In the UK most primary hypospadias surgery in children is performed by paediatric surgeons/urologists and plastic surgeons. Both groups of surgeons use a range of procedures. Many plastic surgeons are low volume operators. Most plastic surgeons operate on children two or more years old. Plastic surgeons should change their hypospadias service. All hypospadias surgeons should contribute to future prospective outcome studies of hypospadias surgery.

Anal and perianal reconstruction after extramammary Paget's disease using a posterior thigh flap with a thin square wing

Kazuo Kishi, Hideo Nakajima, Nobuaki Imanishi, Tatsuo Nakajima — 2009-07-27

Summary: Extramammary Paget's disease regularly requires a wide resection of skin, often including the anal tract. When reconstructing the anal tract, simulating natural anatomy by creating the thinnest possible flap is essential to prevent incontinence.We reconstructed the anal and perianal area using a posterior thigh trilobed flap. The lobe to be transposed to the anal duct had a square design and was thinned. The other lobes were used to cover perianal defects and the flap donor site. Using this method, we reconstructed three patients who required large perianal area and anal tract resections. All flaps took well, and after the initial healing process, the patients did not develop lasting incontinence. We conclude that the posterior thigh flap with a thin square wing is useful for reconstruction of the anal tract and perianal area.

Commentary on “Anal and perianal reconstruction after extramammary Paget's disease using a posterior thigh flap with a thin square wing”

David S.Y. Wong — 2009-09-07

Rare and intriguing, extra-mammary Paget's disease (EMPD) is an intra-epithelial adenocarcinoma of apocrine glands which abound in the perineal and axillary areas. Besides the three essential requirements of pre-operative screening, good excision margins, and diversion colostomy, optimal operative management also demands extra ingenuity, innovation and skill where the anal canal is involved. This is rightly an exposition of the reconstructive surgeon's capability in the re-creation of form and function. Kishi et al in this issue has successfully provided yet another addition to the viable alternatives which may come of use in our armamentarium. Indeed, it is both interesting and useful to summarise the existing experience in this situation.

Extended experience and modifications in the design and concepts of the keystone design island flap

Marc D. Moncrieff, John F. Thompson, Jonathan R. Stretch — 2009-11-12

Summary: This paper describes modifications to the design of the keystone design island flap for the reconstruction of oncological defects. In particular, the paper outlines a spectrum of modifications to the design that permit the design to be tailored to a broad range of reconstructive needs, factoring in the anatomical location of the soft tissue defect and the quality of the integument in that locality. The biomechanics of the flap are also discussed in detail.

Pyogenic granuloma–treatment by shave-excision and/or pulsed-dye laser

Ajay R. Sud, Swee T. Tan — 2009-07-22

Summary: We present the results of our evolving treatment strategy for pyogenic granuloma (PG) affecting cosmetically sensitive areas, from 1996 to 2007. Fifty-one lesions in 49 patients aged six weeks to 87 years (mean, 23.5 years) affecting the head and neck skin (39%) and lip vermillion (14%), limbs (31%) and trunk (16%) were treated. Fifteen lesions (29%) had failed previous treatments elsewhere. Forty-two lesions (in 40 patients) underwent pulsed-dye laser (PDL) therapy alone, using fluences of 5.3–9.4J/cm2 (Photogenica V) or 15J/cm2 (V-Beam) without dynamic cooling, at 7mm spot-size. An average of 1.8 (range, 1–5) treatment sessions were required for lesions <5mm, while an average of 2.7 (range 1–6) sessions were needed for lesions 5–10mm in size. Five patients (with five lesions) measuring 4–6mm elected for surgical excision following 1–3 (mean, 1.7) PDL treatments. Since 2001, nine PG (in nine patients) measuring 5–20 (mean, 11) mm underwent shave-excision and immediate PDL and repeat PDL as necessary. One patient elected for surgical excision following two PDL sessions. The remaining eight patients required an average of 1.1 (range, 0–5) additional PDL sessions for eradication of their PG. PDL alone for PG <5mm, and shave-excision and immediate PDL to the base for larger lesions are effective treatments for lesions affecting cosmetically sensitive areas.

Correlation of axillary osmidrosis to a SNP in the ABCC11 gene determined by the Smart Amplification Process (SmartAmp) method

2009-07-22

Summary: Axillary osmidrosis (AO) is caused by apocrine glands secretions that are converted to odouriferous compounds by bacteria. A potential link between AO and wet earwax type has been implicated by phenotype-based analysis. Recently, a non-synonymous single nucleotide polymorphism (SNP) 538G> A (Gly180Arg) in the human adenosine triphosphate (ATP)-binding cassette (ABC) transporter ABCC11 gene was found to determine the type of earwax. In this context, we examined a relationship between the degree of AO and the ABCC11 genotype. We have genotyped the SNP 538G> A in a total of 82 Japanese individuals (68 volunteers and 14 AO patients) by both DNA sequencing and the recently developed Smart Amplification Process (SmartAmp). The degree of AO in Japanese subjects was associated with the genotype of the ABCC11 gene as well as wet earwax type. In most AO patients investigated in this study, the G/G and G/A genotypes well correlated with the degree of AO, whereas A/A did not. The specific SmartAmp assays developed for this study provided genotypes within 30min directly from blood samples. In East Asian countries, AO is rather infrequent. Although the judgement of the degree of AO prevalence is subjective, the SNP 538G> A in ABCC11 is a good genetic biomarker for screening for AO. The SmartAmp method-based genotyping of the ABCC11 gene would provide an accurate and practical tool for guidance of appropriate treatment and psychological management for patients.

Influence of decantation, washing and centrifugation on adipocyte and mesenchymal stem cell content of aspirated adipose tissue: A comparative study

Alexandra Condé-Green, Natale Ferreira Gontijo de Amorim, Ivo Pitanguy — 2009-08-13

Summary: Background: In the last decade, controversy has arisen regarding the influence of fat harvesting, processing and injection techniques on adipose tissue graft. The aim of this study is to compare the influence of three widely used fat processing techniques in plastic surgery on the viability and number of adipocytes and mesenchymal stem cells (MSCs) of aspirated fat.Methods: A prospective cross-sectional study was conducted in 20 adult healthy female patients in whom material obtained by liposuction of the lower abdomen was separated and processed by decantation, washing or centrifugation. The morphology and quantity of adipocytes were determined by histological analysis. The viability and number of MSCs in the middle layer of each lipoaspirate and the pellet derived from centrifuged samples were obtained by multi-colour flow cytometry.Results: Cell count per high-powered field of intact nucleated adipocytes was significantly greater in decanted lipoaspirates, whereas centrifuged samples showed a greater majority of altered adipocytes. MSC concentration was significantly higher in washed lipoaspirates compared to decanted and centrifuged samples. However, the pellet collected at the bottom of the centrifuged samples showed the highest concentration of MSCs.Conclusion: Based on the theory of cell survival stating the importance of adipocytes' integrity for graft survival and the theory claiming the importance of regenerative MSCs in the maintenance and stabilisation of fat transplant, washing may turn out to be the best processing technique for adipose tissue graft take. While eliminating most contaminants during the process, it preserved and maintained the quantity, integrity and viability of the most important components of aspirated adipose tissue.

Gynaecomastia and scrotal rhacosis: Two aesthetic surgical operations for men in Byzantine times

2010-06-10

Summary: Background: Nowadays, as in the past, much attention is paid to aesthetic operations in women, while only infrequently have such operations been referred to in males. Generally, male aesthetic surgery was introduced to surgical practise during the 19th century. In this study, we analysed the practise of such operations in Byzantine times and in other ancient cultures with surgical knowledge, i.e. ancient India and ChinaMethods: The sixth book of Paul of Aegina’s “Epitome of Medicine” was studied for description of aesthetic operations in males in the Byzantine period, since this book is completely devoted to surgery and is generally considered to be the most important reference for surgery in Byzantine times. The original text and its excellent translation by Francis Adams were used. References concerning aesthetic operations for males were identified. Accordingly, historical work and reviews on plastic surgery in ancient India and China were studied.Results: Mainly, two aesthetic surgical procedures for males in the Byzantine period were identified. These two procedures comprise gynaecomastia and rhacosis (scrotal relaxation). Two different techniques were reported for the surgical management of gynaecomastia, through sub-mammary or supra-mammary access. Two procedures were noted for rhacosis, for which Paul of Aegina reproduced the respective chapters from Leonides’ and Antyllus’ works. Evidence supporting male aesthetic surgery in ancient India and China or elsewhere was not found.Conclusions: Despite the dubious aesthetic result, the existence of different aesthetic surgical techniques in males substantiate the advanced level of surgery achieved by physicians in the Byzantine period.

Soft-tissue coverage of an extensive mid-tibial wound with the combined medial gastrocnemius and medial hemisoleus muscle flaps: The role of local muscle flaps revisited

Lee L.Q. Pu — 2010-06-07

Summary: The proper soft-tissue management for an extensive mid-tibial wound of the leg with a less aggressive surgical approach has rarely been discussed in the literature and the reliability and the usefulness of such an approach to this challenging clinical problem remains uncertain. In this series, four patients with an extensive mid-tibial wound (12×3 to 22×6cm) of the leg underwent the combined medial gastrocnemius and medial hemisoleus muscle flaps for soft-tissue reconstruction. Both muscle flaps were elevated with emphasis on the preservation of the critical perforators from the posterior tibial vessels to the medial hemisoleus muscle flap as possible and on the possible preservation of foot planter flexion by reconstruction of the proximal Achilles tendon to minimise functional loss. All patients except one had primary healing of their tibial wounds. One patient developed insignificant distal flap necrosis of the medial soleus flap and was treated with debridement and flap re-advancement. Three patients with tibial fracture also had evidenced healing of their tibial fractures. Limb salvage was achieved in all four patients during follow-up. Thus, the combined medial gastrocnemius and medial hemisoleus muscle flaps can be a valid option for soft-tissue coverage of an extensive mid-tibial wound of the leg when both local muscle flaps are not traumatised. Such an approach offers relatively simple but more cost-effective way to manage this complex clinical problem and should be revisited by reconstructive surgeons.

A rare complication after septoplasty procedure in a misdiagnosed submucous cleft palate case: Palatal fistula

Burak Ersoy, Sarper Yılmaz, Hakan Şirinoğlu, Özhan Çelebiler, Ayhan Numanoğlu — 2010-02-15

Summary: Nasal septoplasty is a common and low-risk procedure performed very frequently in plastic surgery as well as in otorhinolaryngology. The development of a palatal perforation following a nasal septoplasty procedure is a very rare event with only a few cases reported in the literature. A patient with palatal fistula formation after septoplasty procedure is presented here, who was later on diagnosed with submucous cleft palate during the repair of the palatal fistula.

Intercostal adipofascial perforator flap for reconstruction of overcorrected gynaecomastia deformity

F. Salim, J. Chana — 2010-01-29

Summary: The intercostal perforator fasciocutaneous flap has previously been described in addressing defects in the breast, trunk and arm 1,2,. We describe the first case of an inter-costal artery perforator adipofascial flap in the reconstruction of the male chest following overcorrection of gynaecomastia.

Capsular flap for coverage of an exposed implant after skin-sparing mastectomy and immediate breast reconstruction

2010-01-07

Summary: Native skin-flap necrosis following skin-sparing mastectomy (SSM) is treated by raising a capsular flap, formed as a consecutive physiological reaction around breast implant. Using this highly vascularised thin tissue layer as an implant coverage withdraws pressure from the defect and allocates a good background for wound healing.

Maxillomandibular distraction osteogenesis for Marshall–Smith syndrome

Nobuyuki Mitsukawa, Kaneshige Satoh — 2010-03-19

Summary: The Marshall–Smith syndrome is a very rare disorder with early overgrowth and was first reported by Marshall et al. in 1971. Patients with the Marshall–Smith syndrome have characteristic facial features and systemic congenital abnormalities. In many cases, patients die early in the postnatal period due to respiratory disorders. We treated a male child with this syndrome with plastic surgery to improve facial features – the first effort of its kind in the world. We report good results from the surgery. The treatment included bilateral mandibular distraction osteogenesis for micrognathia and tracheostomy weaning. Six months later, LeFort III maxillary distraction osteogenesis was performed for maxillary hypoplasia. The clinical course was uneventful after both surgeries. At the time of this report, facial appearance and occlusal conditions have improved markedly, although the tracheal stoma could not be closed. The patient is a long-term survivor of this condition. After considering quality-of-life issues for the patient, surgical treatment was offered for facial dysmorphism. This type of effort has not yet been reported in the literature. For patients with the Marshall–Smith syndrome who are expected to survive long, surgical treatment should be strongly considered to improve the quality of life of the affected child.

Infratemporal fossa reconstruction following total auriculectomy: An alternative flap option

2010-02-18

Summary: Reconstruction following oncologic resection in the head and neck is complex due to large surgical defects left after removal of skin, subcutaneous, and skeletal structures. It is essential to adequately fill the defect as well as provide an acceptable tissue match in terms of tone, texture, thickness and contour. A 55-year-old male presented with an advanced melanoma in the right pre-tragal area. Surgical resection was performed including a total auriculectomy. A tunnelled right supraclavicular artery island (SAI) flap was used to repair the surgical defect. A Doppler probe ensured adequate circulation within the flap, especially in the distal tip. Reconstruction using the SAI flap after oncologic ear resection reduced operating room time, required less technical expertise, and provided excellent tissue match compared to more traditional methods of surgical defect reconstruction including free flaps, local flaps, and pedicled myocutaneous flaps. Successful use of the SAI flap in this case further expands the flaps versatility. We recommend that the reconstructive surgeon consider the SAI flap when presented with challenging infratemporal fossa and lateral skull base cases.

Scalp abscess – a cautionary tale

Nora F. Nugent, Michael Murphy, Jason Kelly — 2010-03-02

Summary: Transcranial extension of frontal sinus infection is a rare, but not eradicated entity. We present a 21-year-old male, in whom a persistent scalp abscess heralded the discovery of skull vault osteomyelitis and extradural abscesses secondary to frontal sinusitis. Patients with prolonged or unusual symptoms with a history of sinusitis or trauma warrant further investigation as they may have developed serious intracranial complications. Urgent management, both surgical and antimicrobial, is indicated in such scenarios.

Innovative treatment for huge nuchal desmoid tumour: A case report with a 2-year follow-up

Yao-Chou Lee, Jing-Wei Lee — 2010-03-22

Summary: Background: The desmoid tumour is a monoclonal neoplasm originating from musculoaponeurotic tissues. It is benign in histological presentations and yet its locally invasive behaviour could lead to dire consequences such as disfigurement, functional impairment or even mortality. Surgical resection, radiotherapy, chemotherapy, hormonal therapy, non-steroidal anti-inflammatory drugs and even a wait-and-see policy, either alone or in combination, were advocated as treatment modalities.We experienced an extremely difficult case who had a huge nuchal desmoid tumour measuring 45×35×20cm in dimension with extension to the anterior neck and thoracic paraspinal area. Its intimacy with the carotid artery, jugular vein and brachial plexus made margin-free resection infeasible. Moreover, the tumour burden was so immense that the patient was plunged into profound hypoproteinaemic, septic and anaemic status, with severe pain, bleeding and odour that mandated prompt and daring management.Methods: In an effort to prevent uncontrollable tumour bleeding, we embarked on a series of strategic measures, including pre-surgical embolisation, innovative tourniquet technique, a novel method of ligature deployment, staged tumour excision and adjunct methods, such as ethanol injection and irradiation therapy.Results: The huge nuchal desmoid tumour was successfully excised under the planned strategies. The patient went through a number of complications such as sepsis, acute respiratory distress and renal failure. Fortunately, she eventually survived and exhibited no evidences of tumour relapse at 2 years' follow-up. She has resumed daily activity independently without noticeable functional deficit.Conclusion: We believe that multimodality strategies and innovative surgical techniques are the key to success in managing such a difficult case.

Correction of nipple inversion using a micro-knife and transverse to longitudinal skin closure

Miguel Suhady Cabalag, Christopher Hoe Kong Chui, Bien-Keem Tan — 2010-04-05

Summary: Through a series of 7 patients (8 nipples), we present a technique for the correction of nipple inversion. We use a micro-knife to divide the shortened ducts and fibrous tissues, as well as an internal cerclage suture and reverse strictureplasty skin closure to effectively correct and maintain the position of the inverted nipple. The advantages of the proposed technique include its simplicity, effectiveness in severe cases, and long-lasting results.

Digital sucking induced trophic ulcers caused by nerve deficit from amniotic constriction band

Omar Beidas, Ghazi M. Rayan, A. Al-Harthy — 2010-03-29

Summary: Two infants presented with amniotic constriction bands (ACB) in the distal third of the forearm. After teeth eruption they developed recurrent skin ulcerations mainly in the distribution of the median nerve from digital sucking. Both patients underwent reconstruction with multiple Z-plasties, followed by neurolysis of the ulnar nerve and sural nerve grafting of the median nerve. This neurological complication presented late in ACB as ulcerative lesions and secondary infection from digital sucking on the insensate digits. Thorough physical examination of the extremities at an early stage in children with ACB is essential to exclude an occult neurological dysfunction. Exploration of peripheral nerves is warranted in cases of deep forearm ACB during their soft tissue reconstruction.

Trigger finger at the A2 pulley in children – two case reports

Kazuo Ikeda, Naoki Osamura — 2010-03-15

Summary: Trigger fingers, especially trigger at the A2 pulley, are extremely rare. We experienced two cases of the trigger finger at the A2 pulley and treated them surgically. A flexor digitorum profundus (FDP) nodule was located at the distal entry zone of the A2 pulley in case 1; therefore, the digit could not be flexed. The FDP nodule was located at the proximal entry zone of the A2 pulley in case 2, so the digit could not been extended. The surgical treatment was successful in removing the triggering in both the cases.

Lipografted tenolysis

Olaf E. Damgaard, Peter A. Siemssen — 2010-04-05

Summary: We present a case where recurrent adherence of extensor tendons on the left foot of a 54-year-old woman was treated successfully with tenolysis supplemented by autologous fat transplant in the form of lipofilling.

Salvage of a complicated penis replantation using bipedicled scrotal flap following a prolonged ischaemia time

2010-03-02

Summary: Microsurgical replantation is the standard method to treat penile amputation. The loss of variable area of skin is a common complication following penile replantation due to prolonged ischaemia time, postoperative venous congestion, oedema and wound infection. There is limited literature available on the management of complications following replantation. A skin graft is commonly used to resurface the denuded areas after skin necrosis. However, this simple and rapid approach has some inherent disadvantages, including paresthesia, contracture, mismatched skin colour and disfiguring donor site. In this report, we present the salvage of a replanted penis by a bipedicled scrotal flap in which the skin fragment was necrosed due to prolonged ischaemia time. Cosmetic and functional outcomes in the 1-year follow-up period were satisfactory.

Supratrochlear artery based V-Y flap for partial eyebrow reconstruction

Fabrizio Schonauer, Salvatore Taglialatela Scafati, Guido Molea — 2010-02-15

The eyebrow is a subunit of the forehead aesthetic unit of the face. Both position and continuity of the eyebrow hairline play key roles in the general harmony of the face. A 59-year old male patient was admitted to our Unit with a nodular skin lesion at the lateral third of the left eyebrow. Surgical excision was then planned. Emergency and course of the left supratrochlear artery were marked by means of a hand-held Doppler. A V-Y skin island flap was planned based on the supratrochlear artery (). Tumour was excised with a 0.5cm margin, creating a defect of 3.1 × 3.8cm. Flap dissection was performed in the subgaleal plane from lateral to medial. The thin frontalis muscle attachments were divided from the upper margin of the skin island. The supratrochlear artery and vein were intramuscularly dissected and skeletonised in the area where the fibres of the frontalis muscle blend with those of the corrugator supercilii, thus providing a perforator-like flap (). The flap, just connected to the glabellar region by the artery and vein, was then advanced to cover the defect; the flap survived entirely. At 14 months follow-up, neither forehead motility anomalies, nor sensation deficits were observed. The reconstructed eyebrow was slightly shorter than the contralateral; continuity, alignment and position symmetry of the eyebrow were preserved ().

A new approach to the antecubital scar contracture: Rhomboid rotation flap

Nazım Gümüş — 2010-02-03

Scar contracture is still one of the most complicated challenges developing after either skin damages or burns. Although splints, pressure therapy, massage, and rehabilitation have been widely used for softenning of the scar later the skin injury, in some cases all methods are ineffective to avoid developing a scar contracture which is capable of deforming the apperance of skin surface and restricting joint motions. Several approaches to the correction of contractures have been proposed, including skin grafts, Z-plasty, local flaps, regional flaps, transposition flaps, rotating flaps, axial flaps, perforator flaps, and free flaps, but many of which still have some disadvantages such as necrosis, donor site morbidity, long operation time, and difficult surgical dissection, so there is no ideal technique. In this study, a new method for releasing antecubital contractures was presented.

Reconstruction of wide scrotal defect using groin fasciocutaneous island flap combined with a strip of deep fascia

Turan Aydın, Kurt Feyzi, Türkaslan Tayfun, Turgut Berna — 2010-06-07

Various techniques have been described for the reconstruction of the scrotum such as skin grafting, fasciocutaneous flaps, musculocutaneus flaps and muscle flaps. Each technique has its own advantages and disadvantages in specific situations. The groin fasciocutaneous flap was used previously in different areas and the scrotum. Its flap was used as a traditional fasciocutaneous and expanded fasciocutaneous flap for scrotal resurfacing. We used groin fasciocutaneous flap in which the flap is combined with a strip of the deep fascia to reconstruct the scrotum. This procedure additionally extended the segment of the deep fascia used for the reconstruction of the intertesticular septum of the neoscrotum. In the midline, a septum extends inward from the extended segment of the deep fascia to divide the neoscrotal pouch into two cavities for the testes. A 62-year old man was referred because of fournier's gangrene of the scrotum. The patient was neither diabetic nor immunocompromised. Afterwards, emergent debridement was performed in the department of urology at the hospital. After 10-days of intravenous antibiotics given two times per day and dressing, the infection was eliminated. Healthy granulation tissue covered the denuded testes and spermatic cords within 15-days (a). The patient was placed in supine position with both hips slightly abducted after spinal anaesthesia was induced. The bilateral island fasciocutaneous flap was designed on the long axis of the superficial circumflex iliac arteries (SCIA). The left island flap included a 8×11cm extension skin paddle. The right island flap included a 7×11cm skin paddle and a 3×7cm extension strip of deep fascia on the medial side (a). The flaps are then outlined after determining the proper pedicle length…. The pedicle is identified and dissected (superficial and deep branches of the SCIA, its concomitant veins and superficial vein). The cutaneous incision began at the medial outline of the right flap and extended to the fascia of the external oblic muscle. The suprafascial plan was developed and dissection extended to 3cm more medially along medial side for design fascial strip part of flap. The fascial incision was performed along the outline of the fascial strip and dissection was completed from medial to lateral direction below the deep abdominal fascia. Left flap dissection except the fascial part of the right flap was done in the same manner. Lateral cutaneous femoral nerves of the thighs were preserved. Bilaterally subcutaneous tunnel was made from the pedicle to defect areas. The flaps were transposed into defect area through the tunnels (b). The strip of deep fascia of the right flap was anchored just midline of the defect area and produced two separate pouches in the neoscrotum for the two testes. The medial side of the flaps was sutured together with two separate layers along midline and lateral side of the flaps was sutured along the outline of the defect area. In this manner both testicles had separate anatomic pouches. Suction drain was inserted into neoscrotum (a). The donor areas were closed primarily and suction drains were inserted in the donor areas. He was discharged 10-days after surgery. Review at 2 and 7-months revealed excellent cosmetic results (b). Magnetic resonance imaging indicated that both testes were sitting in their separate anatomic pouch in the neoscrotum (c). The follow-up data showed that sexual hormones were not altered in the follow-up period (up to seven months), and the patient told us that there was no change in his sexual behaviours during the period of follow up. Since the patient was discharged from our health control after seven months, late stage cheques couldn't be done. He remained completely satisfied with the results.

One-stage reconstruction of the entire pubic, vulvar and perineal area by pedicled anterior thigh musculo-fasciocutaneous flap

2010-01-25

Unilateral or bilateral fasciocutaneous flaps and bilateral flaps such as the gracilis myocutaneous flap have become a standard component of pelvic exenteration and subsequent reconstruction, especially in the perineogenital area. The advantages of these techniques include coverage of the large pelvic defect left by resection and by radiochemotherapy. The flaps provide non-irradiated tissue and blood supply to the operative site supporting healing and psychosocial rehabilitation of the patients.

Transport disc distraction osteogenesis as an alternative protocol for mandibular reconstruction

Soung Min Kim, Jung Min Park, Hoon Myoung, Jong Ho Lee — 2009-12-25

Transport disc distraction osteogenesis (TDDO) has been recently introduced for the correction of skeletal malformations and discrepancies in the maxillofacial area. Through the use of a reconstruction plate-guided distraction device in mandibular discontinuity defects, TDDO can reconstruct the three-dimensional mandibular shape with combined soft tissue restorations.

Benign fibrous histiocytoma (dermatofibroma) of the face: A rare entity requiring aggressive surgical management

Y. Ismail, S. Watson — 2010-04-08

A 29-year-old female was referred by the Dermatology department with a 4-month history of a papular, tethered plaque-like lesion affecting the right cheek and infra-orbital region causing intermittent discomfort. Tissue biopsy revealed a histological diagnosis of atypical fibrous histiocytoma. MRI outlined a diffuse lesion penetrating subcutaneous fat and muscle but anterior to the right maxillary antrum. There was no evidence of involvement of the infra-orbital nerve. Surgical excision was carried out incoorporating the original biopsy scar and lesion as well as a ‘cuff’ of underlying muscle. Histologically the lesion was confirmed to be a dermatofibroma composed of spindle cell fascicles and completely excised. There has been no evidence of local recurrence to date.

Facial resurfacing using tissue expanded neck skin as rotational advancement flaps: A case series

A. El Gawad, J. Goodenough, P. McArthur, W. Saker, E. Saif — 2010-04-16

Achieving satisfactory mobility in expanded neck skin used for facial resurfacing continues to present a challenge for Plastic Surgeons. Here the authors share their experience reconstructing post burn cheek defects using expanded neck skin in a 2-stage procedure.

Use of colchicine to prevent recurrence of ear keloids. A new approach

Alicia Sigler — 2010-03-29

The term keloid is derived from the Greek ‘khele’ for crab claw. This is a pathologic response to cutaneous injury, unique to humans and characterised by an overabundant extracellular matrix. They occur with equal frequency in males and females and at any age, but more often between the ages of 10 and 30 years. There is a predominance in dark pigmented individuals and in some areas as the ear, shoulders and chest. A theoretical model for molecular mechanisms in keloid development has been proposed: after an injury, skin initiates a cellular response such as hypoxia, apoptosis, angiogenesis, and cytokine-induced signalling, leading to excessive fibroplasia and eventually the formation of a keloid. They appear as a scar that grows beyond the original wound and may be raised on the skin level deforming the area. They can arise two months after an injury or take several years to do so. Besides disfiguration they produce pain, pruritus or pigmentation. If they are surgically excised without any other adjuvant therapy the recurrence rate may be up to 40% within the first year. Historically several drugs have been used to prevent collagen synthesis and accelerate the removal of collagen in keloids: aminoproprionitrile fumarate, penicillamine, interferon, 5-fluorouracil, antimicrotubular agents (colchicine) and corticosteroids. Also alternative treatment with calcium channel blockers, retinoid application, radiation, laser, cryotherapy, chemotherapy, pressure therapy and silastic gel sheeting has had unsatisfactory outcomes. Based on two Mexican reports regarding the beneficial effects of the colchicine in liver cirrhosis and in fibromatosis, this study was designed and was accepted by the ethical committee of General Hospital ‘Dr. Manuel Gea Gonzalez’ in Mexico City where it was developed; signed consents by all the patients were obtained.

Malignant melanoma re-excision specimens: The need for analysis

N.G. Patel, A.K. Shah, T. Barker, J. Garioch, M.D.S. Moncrieff — 2010-03-15

We read McGoldrick's et al. article titled ‘Malignant melanoma re-excision specimens: is there a need for histo-pathological specimens’ with much interest. We can only commend their study, the significant numbers audited and its forthright application. However, we have reservations regarding their recommendation stated in their article ‘…that all specimens taken from melanomas that have had originally clear excision biopsies need not be sent for histopathological examination.’ One of the reasons for this difference in opinion lies with three similar cases managed in our unit within the last five years. The most recent case was that of a pT4b 5.2mm Breslow thick nodular malignant melanoma on the right cheek of an 85-year-old woman which was completely excised. The scar was then subsequently widely excised with the appropriate margin. On the latter specimen's histopathological analysis however, there was a small nodule of malignant melanoma, probably within a blood vessel or lymphatic, lying 1mm from the deep margin (). In a recent presentation by Dr Balch to the UK Melanoma Study Group meeting (London, January ‘09), it was stated that satellitosis with sentinel node positivity was a particularly lethal combination, with none of the patients with this permutation alive at five years in the AJCC database, which currently contains the records of 60 000 cases. Thus, there is a small but real risk that patients may be given incorrect prognostic information, as well as missing the opportunity for appropriate adjuvant therapy or clinical trials.

Necrotizing pyoderma gangrenosum: An unusual differential diagnosis of necrotizing fasciitis

Benoit Ayestaray, Emmanuel Dudrap, Emilie Chartaux, Eva Verdier, Pascal Joly — 2010-03-04

Pyoderma gangrenosum is a neutrophilic dermatosis, of unknown aetiology, described by Brocq in 1908. The familiy of neutrophilic dermatosis is characterised histologically by a neutrophilic and lymphocytic infiltrate, without vasculitis or infectious cause. Different forms of pyoderma gangrenosum are described according to their clinical signs and the associated diseases: classic (or ulcerative), pustular, bullous and vegetative pyoderma gangrenosum. A beginning lesion of pyoderma gangrenosum can be mistaken for a skin infection, because of its inflammatory character and a frequent hyperthermia. The differential diagnosis with a cellulitis can be difficult. We report a case of pyoderma gangrenosum, appeared without trauma. Its clinical aspect was first similar in a cellulitis, then in a necrotizing fasciitis because of necrotic areas. This case illustrates the difficulty of diagnosis between a dermo-hypodermal infection and a neutrophilic dermatosis. It also presents a very unusual variant of pyoderma gangrenosum, which is necrotizing.

Soft tissue distraction in the management of severe preaxial polydactyly of feet

Anuj Mishra, Kathryn Nelson, Selvadurai Nayagam, Paul McArthur — 2010-03-02

Polydactyly is the commonest congenital deformity of the foot. A spectrum of defects exists from minor soft tissue duplications to major bony abnormalities. Preaxial polydactyly is represented by an extra digit on the medial side of the foot. This group is often difficult to treat due to associated first metatarsal anomalies. Soft tissue distraction has been described for the management of congenital hand and foot anomalies. We present the use of soft tissue distraction in a case of severe preaxial polydactyly of feet.

Decades of change in plastic surgery training

R.M. Pinder, F. Urso-Baiarda, S.L. Knight — 2010-02-22

Surgical training has traditionally been an apprenticeship with long hours spent at work learning from consultants within a ‘firm’ structure that received, managed and discharged their own patients. In 1995 Sir Kenneth Calman reformed higher surgical training through the introduction of annual assessments culminating in a Certificate of Completion of Surgical Training (CCST). The development of a bottleneck at entry to higher surgical training created the ‘lost-tribe’ of ‘workhorse’ senior house officers (SHOs), the plight of whom was recognised in the UK Government's paper ‘Unfinished Business’. This ultimately led to the introduction of Modernising Medical Careers (MMC) in 2003. During this time the British Medical Association (BMA) worked hard to secure ‘the New Deal’, reducing the maximum working week to 56h, recently further reduced to 48h through the implementation of the European Working Time Directive (EWTD). Changes to surgical training, working patterns and the introduction of Government-implemented target-driven rewards for Trusts have cumulatively reduced working hours and surgical trainee experience.

Trainees assisting in private practice – are they covered?

Kelvin Ramsey — 2010-02-03

In the current climate of enforced reduction in working hours, our trainees may find that training outside the NHS is becoming increasingly important. Some training programmes in this country incorporate fixed periods working in the private sector, while other trainees may seek experience in aesthetic surgery on a more ad-hoc basis depending on the practice of their consultant, while others undertake cosmetic fellowships out of programme. Wherever the training is received, aesthetic surgery remains a significant part of the FRCS(Plast) syllabus and thus should be supported.

Cutaneous Melanoma

Stefan O.P. Hofer — 2010-05-13

This book had been sitting on my to-do pile in the back my desk for a while before I picked it up to have a closer look. The book is a handsome and sizeable one-volume text in its 5th edition. I had not previously had the chance to read any of the earlier editions. On closer examination I was very impressed with this very comprehensive book on cutaneous melanoma. The book is a truly multidisciplinary effort on all aspects of melanoma. The editors, who are all leaders in their field on melanoma, have done a remarkable job of making this into a very uniform and consistent text through what must have been an enormous task to edit the contributions of 90 collaborators.

Gillies 2.0—senses and Sherlock Holmes

M. Felix Freshwater — 2010-08-01

The latest iteration in the Sherlock Holmes movies arrived in America on Christmas Day. Digital effects allowed its director, Guy Ritchie, to have slow motion sequences that showed how Holmes used his senses to deduce facts about other characters. Holmes was a fictional detective, but we plastic surgeons are fortunate to have been taught Gillies' principle ‘Observation is the basis of surgical diagnosis.’ This was Gillies' first principle and the basis of his others. He believed that without a proper diagnosis surgical disaster loomed and went so far as to say, ‘Mistakes in diagnosis due to inadequate examination are perhaps the commonest cause of indifferent treatment’.