Journal of Plastic, Reconstructive & Aesthetic Surgery

Management of complex melanomas of head and neck region

Rajive Mathew Jose, William Kisku, Anup Pradhan, Dan Prinsloo — 2009-03-02

Summary: Though many of the melanomas encountered in the head and neck region are amenable to simple excision and direct closure or skin grafts, there is a subset of patients who are deemed complex cases in view of the large size of the tumour, depth of invasion or proximity to aesthetically and functionally important structures. This was a retrospective study which looked at complex melanomas of the head and neck region treated in the last 10 years. There were a total of 19 cases, including four women and 15 men. Their ages ranged from 59 to 83 years (mean: 69 years). The Breslow thickness of these tumours ranged from 1 to 40mm, with an average of 9mm. The resectional procedures used herein included wide local excision (15 patients), wide excision with partial maxillectomy (one patient), wide excision with total maxillectomy (one patient) and orbital exenteration (two patients). Neck dissections were performed in 12 cases and parotidectomy was performed in five cases.Reconstruction was performed using local (two cases), regional (five cases) and free flaps (11 cases) in a total of 18 cases.There were four complications, including two nerve injuries during neck dissection (vagus and marginal mandibular nerve).Four patients died during follow-up due to metastatic disease and had a median survival of 3.5 years (range: 2–8 years, mean: 3 years). One patient is alive with recurrent disease and distant metastases 4 years after the original surgery. The remaining 14 patients are alive and free of recurrence with a follow-up period ranging from 2 to 7 years (median: 4.5 years).

Knowledge and perceptions of facial plastic surgery among a selected group of professionals in Lagos, Nigeria

W.L. Adeyemo, B.O. Mofikoya, B.O. Bamgbose — 2009-03-09

Summary: This was a questionnaire-based study among a selected group of professionals in Lagos, Nigeria to assess their knowledge, attitude and perceptions to facial plastic surgery. A well-structured questionnaire was administered to a group of professionals in the banking industry and the civil service. The respondents were asked if they had heard of ‘facial plastic surgery’ before and if they were familiar with some selected facial plastic surgery procedures. They were also asked if they had ever considered undergoing facial plastic surgery for any real/perceived facial abnormalities; if they knew any close relatives/friends who had undergone facial plastic surgery and if they considered the result satisfactory or not. A total of 130 respondents participated in the study; of these, 102 (78.5%) respondents had some knowledge of ‘facial plastic surgery’ while 28 (21.5%) respondents had no prior knowledge of facial plastic surgery. Fifty-five of the 102 respondents had some knowledge of liposuction of the face and neck. Nineteen of the 130 respondents expressed willingness to undergo facial plastic surgery for removal of facial wrinkles and excess fat on the cheeks and neck. Only 17 (13%) of the respondents had ever thought of undergoing facial plastic surgery; of these 17 respondents, nine claimed that their facial appearance was the main reason. Respondents with perceived facial abnormalities were more likely to undergo plastic surgery than those without perceived abnormalities (P=0.000). Twenty-four (18.5%) of the 130 respondents knew of a friend/close relative who had undergone facial plastic surgery before, and the majority (19 of the 24) considered the result of the surgery satisfactory. We conclude that most of the study participants had some knowledge of facial plastic surgery; however, only a few expressed willingness to undergo facial plastic surgery for removal of facial wrinkles and folds/fat on the cheeks and neck. The fact that only a few of the respondents knew someone who had undergone facial surgery may reflect the low level of availability of facial plastic surgery procedures in Nigeria.

Reverse facial artery flap from the submental region

2009-03-04

Summary: Background: Of all the local flaps that allow elevation of a sufficiently large-sized flap while also leaving an inconspicuous donor-site scar, the submental island flap is frequently used for the reconstruction of a defect in the lower two-thirds of the face. However, this flap has certain disadvantages such as the technique being slightly difficult to perform and, more importantly, that it carries a significant risk of injury to the facial nerve.Methods: Here, we propose the reverse facial artery flap, elevated from the submandibular region. Our method creates a flap that includes only the platysma under the skin island, without either the submental or facial artery. However, above the superior border of the skin island, the flap includes the facial artery along with subcutaneous soft tissue. The blood circulation of the skin island is in a random pattern and that of the subcutaneous pedicle is in an axial pattern.Results: Four cases were treated using our method. There were no complications in all four cases, and the results were also cosmetically very good.Conclusions: As compared to the submental island flap, our method is easier to perform and carries a much lower risk of damage to the marginal mandibular branch of the facial nerve, as the facial artery crosses over the facial nerve at only one point. In addition, the method produces a thin flap. Therefore, when considering correction of a small-sized defect in the lower two-thirds of the face, our method has a number of advantages over the submental island flap.

Salvage reconstruction of the oesophagus: a retrospective study of 15 cases

2009-03-23

Summary: Salvage reconstruction of the oesophagus is still considered a challenging procedure for all head and neck surgeons. The risk of postoperative infection and delayed wound healing is high because of thick scar formation and persistent inflammation. Furthermore, recipient vessels for free tissue transfer or vascular supercharge are not always available. Alimentary tract reconstruction with skin or musculocutaneous flap may be necessary, but this method is susceptible to fistula formation.[Nakatsuka T, Harii K, Asato H, et al. Comparative evaluation in pharyngo-oesophageal reconstruction: radial forearm flap compared with jejunal flap. A 10-year experience. Scand J Plast Reconstr Surg Hand Surg 1998; 32: 307–10]In the past 10 years, we have experienced 15 cases of salvage reconstruction of the oesophagus after prior cancer treatment or aorto-oesophageal fistula; the cervical oesophagus was reconstructed in five cases and the cervico-thoracic oesophagus in 10.In four cases of cervical oesophagus and six of cervico-thoracic oesophagus we performed free jejunal transfer including two long segment transfers with double vascular pedicle. The cervico-thoracic oesophagus was also reconstructed with pedicled alimentary tract transfer (colon interposition or jejunal pull-up) with vascular supercharge in four cases. In one case, cervical oesophageal defect was reconstructed with a latissimus dorsi musculocutaneous flap. We also used a deltopectoral flap to cover the skin defect in three cases.In three cases, a second salvage operation was necessary because of flap necrosis that was caused by unreliable recipient vessels resulting from scar formation and persistent inflammation. Successful restoration of the oesophagus and oral alimentation was achieved in 11 cases.From this study, we concluded that free jejunal transfer is a useful procedure for salvage reconstruction of the oesophagus, particularly for cervical oesophagus or short oesophageal defects. Nonetheless, surgeons should know the indications and limitations of this procedure thoroughly and always be ready to choose other reconstructive options if necessary.

22q11 chromosome abnormalities and the cleft service

N. Nugent, A. McGillivary, M.J. Earley — 2009-03-02

Summary: Deletion of chromosome 22q11 gives rise to a spectrum of anomalies, including cleft palate. These are grouped together as the DiGeorge or velocardiofacial syndrome. Patients with this chromosomal abnormality account for a small, but noteworthy proportion of patients attending our cleft service. They frequently have other significant comorbidities consistent with their diagnosis.Over a ten-year period, 16 patients within our cleft service have been diagnosed, using chromosome analysis, as having deletions at 22q11. All had either a cleft palate and/or velopharyngeal incompetence, for which they underwent repair of the cleft palate or pharyngoplasty. Several have required secondary palate surgery following initial palate surgery. Poor quality of speech was the indication for secondary procedures in the majority of cases. Fourteen of the 16 have other comorbidities, ranging from congenital heart disease to ocular abnormalities. In addition, 15 of the 16 have developmental delays and/or learning difficulties. Other specialties, such as ENT, cardiology, genetics and ophthalmology have been involved in the care of all these patients.Although comprising only a small proportion of patients attending a cleft team, the diagnosis of this chromosomal abnormality is significant, as these patients may require substantial input of resources and the expertise of several specialties. Early recognition of features of this entity and diagnosis can aid more efficient intervention.

Baseline Quality of Life in patients with Klippel–Trenaunay syndrome

2009-03-16

Summary: Background: Klippel–Trenaunay syndrome (KTS) is a congenital group of disorders characterised by vascular malformations (capillary malformation (CM), venous malformation (VM), and lymphatic malformation (LM)) and disturbed growth regulation. The burden caused by KTS symptoms can be evaluated using Quality of Life (QoL)-measuring questionnaires. This study aimed to assess the QoL in KTS patients using the Short Form Health Survey Questionnaire (SF-36) and Skindex-29 questionnaires, and to determine three grades of severity (mild, moderate and severe) according to the scores obtained. In addition, we compared the SF-36 results to those of a general Dutch population sample and a selected group of other chronic conditions.Methods: KTS patients of the Dutch KTS foundation and of two medical centres answered SF-36 and Skindex-29 questionnaires. Control data of validated Dutch population SF-36 scores and literature-acquired scores for other diseases were available.Results: A total of 78 patients were enrolled, of whom 34 (43.6%) were male; the mean age was 39.3 years (SD: 17.1; range: 12–78 years). The Dutch KTS group scored significantly lower than the general Dutch population on all SF-36 scales except Mental Health and Role Emotional. Furthermore, they scored significantly lower than other medical conditions on the Physical Functioning and Bodily Pain scales. According to the Skindex-29 results, KTS patients fall in the categories – symptoms: severe to very severe; emotions: diminutive to mild and functions: mild. The total score is lower than 40, indicating a negligible negative impact on QoL; however, new cut-off values are being calculated.Conclusions: Classification according to severity is important to educate patients accordingly, predict prognosis and set treatments. Especially in cases of severe KTS, physicians should not only be attentive to the physical aspects but also to the psychological and social aspects of KTS.

Giant naevus, giant excision, eleg(i)ant closure? Reconstructive surgery with Integra Artificial Skin® to treat giant congenital melanocytic naevi in children

C. Schiestl, D. Stiefel, M. Meuli — 2009-03-16

Summary: Background: The optimal surgical treatment of giant congenital melanocytic naevi remains a considerable challenge in reconstructive surgery. None of the currently available techniques is universally applicable. The goal of this pilot study was to test Integra Artificial Skin® (Integra) in the surgical treatment of giant congenital melanocytic naevi.Methods: Between May 2000 and March 2004, Integra was used in 12 children (n=12; aged seven months to 11 years, mean 3.8 years). Giant congenital melanocytic naevi covered 1–12% of the total body surface area (mean 4.2%) located over the trunk in 50%, and over face and extremities in 25% each.Results: In eight children, Integra implantation was primarily successful; in four patients a partial or complete removal and re-implantation was necessary due to complications. The final take rate of Integra ranged from 95–100%, except for one patient with a take rate of 30% (mean 93%). Second stage split-thickness skin grafting yielded take rates from 95–100% (mean 98%). Functional and cosmetic outcome was rated excellent in 58%, good in 25% and fair in 17% (follow-up six months to four years, mean 2.2 years).Conclusions: These results suggest that Integra is a new and valid method to successfully treat giant congenital melanocytic naevi in early childhood in a definitive manner and with high-quality results.

Free tissue transfers in the first 2 years of life – A successful cost effective and humane option

R.M. Pinder, A. Hart, R.I.S. Winterton, A. Yates, S.P.J. Kay — 2009-03-12

Summary: Experience shows that young children are favourable candidates for microsurgical reconstruction, having few of the established risk factors for flap failure. In children's reconstructive surgery free tissue transfer (FTT) permits reconstruction whilst retaining growth potential, and reduces the overall number and duration of care episodes, and their related distress to the child and family.We present one centre's experience of free tissue transfer in children less than 2 years of age, over a 15-year period, demonstrating that free tissue transfer can be successfully employed in children under 2 years old. Salient aspects of patient selection, pre-operative counselling, and per-operative management are presented. Data from all free flaps in children under 2 years of age at the time of surgery were collected prospectively.Forty-seven flaps were performed as 37 separate procedures, in 32 children under 2 years of age. In ten patients, double transfers were performed in single procedures. Free tissue transfers were performed for reconstruction of congenital defects, following trauma and meningococcal septicaemia. All but one flap survived.In our series operative and ischaemia times, re-exploration, complication and flap failure rates were not higher than in comparable adult or older paediatric series from this unit, suggesting that there is no microvascular, or other, factor inherent to the infant that should preclude the use of free tissue transfer. Individual microsurgeons with appropriate facilities should not be inhibited from performing free tissue transfers which are humane and cost effective when compared with alternatives for very young children.

The pedicled descending branch muscle-sparing latissimus dorsi flap for trunk and upper extremity reconstruction

Corrine Wong, Michel Saint-Cyr — 2009-03-23

Summary: Background: The major blood supply of the latissimus dorsi muscle flap is based on the descending and tranverse branches of the thoracodorsal artery. This segmental blood supply allows the muscle to be split and harvested based solely on vascularization from the descending branch, thus sparing the latissimus dorsi muscle function. This article reports the use of the descending branch muscle-sparing latissimus dorsi myocutaneous flap in reconstructing defects on the trunk and upper extremities.Methods: Five patients with defects on the trunk or upper extremities had soft tissue reconstruction with a pedicled descending branch muscle-sparing latissimus dorsi myocutaneous flap. A transverse skin paddle design was used in all cases. All flaps were performed by the senior author. Complications were recorded, and range of motion analysis was performed comparing operated and non-operated sides during follow-up appointments.Results: The descending branch muscle-sparing latissimus dorsi flap was used for reconstruction of: the chest wall (2), axilla (2) and upper extremity (1). The skin paddles harvested ranged from 15×7cm to 24×9cm. All donor sites were closed primarily. There was one case of minor wound dehiscence on the donor site and one case of wound infection (reconstruction was for chronic, severe axillary hidradenitis suppuritiva). There were no incidences of seroma. In all cases, there was no difference in strength or range of motion around the shoulder joint when comparing the operated to the non-operated side.Conclusion: The pedicled descending branch muscle-sparing latissimus dorsi myocutaneous flap with a transversely orientated skin paddle results in minimal functional deficit of the donor site, absence of seroma, low rate of flap complications and an aesthetically acceptable scar.

Reconstruction for sternal osteomyelitis at the lower third of sternum

Chao-Hsiang Lee, Jung-Hsien Hsien, Yueh-Bih Tang, Hung-Chi Chen — 2009-03-16

Summary: Background: Sternal wound infection causes considerable morbidity and mortality for open-heart patients. Treatment of the wounds at the upper two-thirds is easier with pectoralis major muscle or other flaps. However, there would be more problems with the lower one-third sternal wounds.Methods: From 1983 to 2007, 32 patients of osteomyelitis involving the lower sternum were treated with one of the following methods:(1) Latissimus dorsi with fasciocutaneous extension flap(2) Tri-pedicled pectoralis major musculocutaneous flap(3) Pectoralis major muscle with rectus abdominis muscle flap(4) Pectoralis major muscle with omentum flap(5) Free vastus lateralis muscle flap and skin graftingResults: The viability of these flaps was good except for one of the five patients with pectoralis major–rectus abdominis muscle. One of the patients from the free vastus lateralis muscle group died of heart failure 6 weeks after surgery, but the coverage of sternal wound was successful. No recurrent sternal infection was found.Conclusions: For coverage of sternal wounds, the transferred tissue must have optimal blood supply in order to overcome the infection. According to the descending degree of ease, the ladder of reconstruction is from (1) to (5), depending on the relative length of the sternal wound and the arc of rotation of these flaps. In pectoralis major with rectus abdominis flap group, it is suggested that the upper sternal wound be covered with pectoralis major muscle but lower third sternal wounds with omentum instead of rectus abdominis muscle.

Gluteal artery perforator flap: a viable alternative for sacral radiation ulcer and osteoradionecrosis

Young-Woo Cheon, Myung Chul Lee, Young Seok Kim, Dong Kyun Rah, Won Jai Lee — 2009-04-06

Summary: Radiotherapy is a crucial part in the treatment of cancer; however, it may cause adverse effects to normal tissue such as radiation-induced ulcer and osteoradionecrosis. The few cases of conservative management that were reported had a limited value and unsatisfactory results. The most reliable method to treat sacral radiation ulcer and osteoradionecrosis is a wide excision of the affected tissue, followed by coverage with well-vascularised tissue. Musculocutaneous free flaps and local gluteus maximus musculocutaneous flaps have been used; however, there were many drawbacks such as dissection of recipient vessel in the previously radiated area and donor-site morbidity. During a 4-year time period at our institute, we found favourable clinical results using gluteal artery perforator procedure for radiation-induced ulcers and osteoradionecrosis of the sacral area.The 10 patients, who were treated with gluteal artery perforator flaps, had chronic non-healing radiation ulcers or bone exposure of the sacrum. Intra-operatively, massive debridement of bone and soft tissue was performed, while the well-vascularised skin with only a colour change was preserved. The flap was designed to include two or more perforators using Doppler flowmetry and the perforators were preserved with surrounding subcutaneous tissue during the flap elevation. The mean post-operative follow-up period was 25.7 months. As regards the surgery, there was one major complication (of partial flap loss) and three minor complications (of wound dehiscence). In the patient with partial flap loss due to infection and a floating flap, the contralateral superior gluteal artery perforator flap was used to treat complications. Other complications were conservatively treated and well healed.Gluteal perforator flaps are a valuable alternative in treating sacral radiation ulcers and osteoradionecrosis. Sufficient excision of devitalised tissue is a crucial procedure to achieve optimal results.

Performing two DIEP flaps in a working day: an achievable and reproducible practice

2009-03-16

Summary: Background: While the deep inferior epigastric artery perforator (DIEP) flap is a reliable technique for autologous breast reconstruction, the meticulous dissection of perforators may require lengthy operative times. In our unit, we have performed 600 free flaps for breast reconstruction over 8 years and have reduced operative times with a combination of preoperative computed tomographic angiography (CTA), various anastomotic techniques and the Cook–Swartz implantable Doppler probe for perfusion monitoring. We sought to assess the feasibility of performing two DIEP flaps within the working hours of a single day.Methods: A review of 101 consecutive patients undergoing DIEP flap breast reconstruction in a 12-month period was performed, comparing one DIEP flap per day (n=43) to two DIEP flaps per day (n=58). Complications, outcomes and techniques used were critically analysed. For cases of two DIEP flaps per day, a comparison was made between the use of two separate operating theatres (n=44) and a single consecutive theatre (n=14).Results: Complications did not increase when two DIEP flaps were performed in a single working day. The use of vascular closure staple (VCS) sutures and ring couplers resulted in statistically significant reductions in anastomotic times. The use of two separate theatres for performing two DIEP flaps resulted in a reduction of 59min in operative time per case (p=0.004).Conclusion: Two DIEP flaps can be safely and routinely performed within the hours of a single working day. By minimising operative times, these techniques can improve productivity and substantially decrease surgeon fatigue.

Preserving the neurovascular supply in the Hall-Findlay superomedial pedicle breast reduction: an anatomical study

2009-02-26

Summary: Background: The Hall-Findlay superomedial pedicle technique is widely used for breast reduction, and, despite low complication rates, nipple–areola complex (NAC) necrosis and denervation are still the two most common complications, particularly when resection volumes exceed 600g. An understanding of the anatomy of the neurovascular pedicle of the NAC is paramount in avoiding these complications.Methods: An anatomical study was undertaken on 11 female cadaveric breast specimens (nine fresh and two embalmed). The neurovascular anatomy of the breast was explored through dissection, microdissection, radiographic, computed tomographic, photographic and cross-sectional studies. The superomedial pedicle was mapped out on each specimen, and the course of the relevant nerves and vasculature was identified.Results: The arterial supply to the superomedial pedicle was found to originate from a single dominant vessel in each specimen, while the venous drainage was via an extensive branching network. Both vascular patterns traversed the pedicle in a superficial plane. The innervation of the pedicle was via intercostal branches, which coursed extremely superficially in the pedicle.Conclusion: De-epithelialisation or superficial thinning of the superomedial pedicle for breast reduction is at high risk for complications related to vascular compromise or denervation. Where greater resection is needed, this should be done from the deep surface or the base of the pedicle, contrary to previous descriptions.

The variation in breast density and its relationship to delayed wound healing: A prospective study of 40 reduction mammoplasties

C.J. Baldwin, E.J. Kelly, A.G. Batchelor — 2009-07-24

Summary: The proportions of glandular and adipose tissue within the breast vary. This study records the variation in density of breast tissue excised at 40 consecutive bilateral breast reductions. Age, body mass index (BMI), breast size and wound healing problems were related to breast density.The removed breast tissue was weighed and volume determined by water displacement. Delayed wound healing was defined as any breast unhealed after 2 weeks.The density of excised tissue varied between 0.8 and 1.2g/cm3. There was no correlation between age or BMI and breast density. Delayed wound healing occurred in 32% of patients. There was no correlation between delayed wound healing and breast density. However, there was a direct relationship between increasing BMI and delayed wound healing.In this study, breast density varied by up to 50%. The density of breast tissue cannot be predicted by age, BMI or breast size. There is no relationship between delayed wound healing and breast density.

The influence of geography on uptake of plastic surgery services – analysis based on bilateral breast reduction data

S. Nair, E.A. Richardson, W.R.E. Thompson, N.K. Shortt, K.J. Stewart — 2009-04-06

Summary: The hub-and-spoke model was introduced in the National Health Service (NHS) with the goal of providing equitable access to health care for all. This study uses bilateral breast reduction (BBR) surgery to assess the success of this model in delivering equity of access for plastic surgery within a publicly funded health-care system. This study also assessed the effect of socioeconomic deprivation on patients seeking BBR. The hospital records were used to identify all patients who underwent BBR at the St. John's Hospital between 1996 and 2005 (N=1081). Patients living outside the catchment area were excluded.Realistic travel distances and times to the hospital and clinics were calculated using patients' postcodes and geographic information systems (GIS) network analysis. Carstairs deprivation scores were obtained for the residential postcode of each patient. The main findings of this study are (1) accessibility to a plastic surgery clinic is an important factor in determining whether an eligible female patient undergoes BBR and (2) most deprived parts of the catchment area accounted for a significantly greater proportion of patients.

Motivational factors and psychological processes in cosmetic breast augmentation surgery

2009-03-06

Summary: Background: We investigated how and why prospective cosmetic breast augmentation patients decide to undergo such surgery. The results can offer important insights to plastic surgeons in addressing their patients' motives and expectations, and thereby avoiding potential patient dissatisfaction and disappointment. It is also a necessary first step to better understand the increasing tendency among women in the Western society to seek cosmetic breast augmentation.Method: A qualitative, descriptive and phenomenological design was employed. Fourteen female prospective breast augmentation patients, aged 19–46 years, were recruited from a private plastic surgery clinic and interviewed in depth based on an informant-centred format. The interviews were tape-recorded, transcribed verbatim and coded and analysed phenomenologically using a QSR-N*Vivo software program.Results: We detected four psychological processes associated with cosmetic breast augmentation surgery (create, improve, repair and restore). The data could further be categorised into one basic drive (femininity), six generating factors (appearance dissatisfaction, ideal figure, self-esteem, comments, clothes and sexuality) and five eliciting factors motivating the decision (media, knowledge of former patients, physicians, finances and romantic partner).Conclusion: These new insights into how and why women seek cosmetic breast augmentation may aid plastic surgeons in enhancing their communication with patients. This can be achieved by addressing the patient's psychological process and motives, and thereby better assist them in making the best decision possible in their particular situation. It may also lay the groundwork for future quantitative studies on the prevalence of certain motives for undergoing such surgery and, as such, help explain the increasing popularity of cosmetic breast-augmentation surgery.

Tranquilli-Leali or Atasoy flap: an anatomical cadaveric study

2009-03-16

Summary: Background: The Tranquilli-Leali and Atasoy volar V–Y advancement flaps are considered workhorse flaps in the reconstruction of fingertip amputations. However, their description in the literature in terms of surgical dissection and blood supply is often indistinct. This study describes the differences between the two flaps and highlights their unique blood supply based on a thorough cadaveric study and review of the literature.Methods: Using 16 fresh cadaveric fingers, eight Tranquilli-Leali and eight Atasoy volar V–Y advancement flaps were dissected, mapping the arterial blood supply using an injectable blue resin. In addition, a thorough literature search on the subject was done.Results: In all eight fingertips dissected as decribed by Tranquilli-Leali, the flap was supplied by the anastomotic connections between the terminal branches of the palmar digital arteries and dorsal nail-bed arcades via the fibro-osseous hiatus. In contrast, in all eight fingertips which were dissected as described by Atasoy, the flaps were perfused through the terminal branches of the palmar digital arteries.Conclusions: The Tranquilli-Leali and Atasoy volar V–Y advancement flaps, used to reconstruct fingertip amputations, are distinct from one another in several ways. The most obvious difference is their technique of flap dissection, which, in turn, dictates a unique blood supply. Through careful dissection and a review of the literature, this anatomical study has brought to light the specific vascular supply to each flap that was evaluated.

A reverse flow cross finger pedicle skin flap from hemidorsum of finger

Satyanarayan Mishra, S. Manisundaram — 2009-04-22

Summary: A reverse-flow cross-finger pedicle skin flap raised from the hemidorsum has been used, which is a modification of the distally based dorsal cross-finger flap. The flap is raised from the hemidorsum at a plane above the paratenon, the distal-most location of the base being at the level of the distal interphalangeal joint. Thirty-two flaps were used from as many fingers of as many patients. Of these, 31 (97%) flaps survived fully; there was stiffness of finger in one (3%) patient and the two-point discrimination was 4–8mm (n=14). Follow-up period was 2 months to 3 years, the median being 1 year and 3 months. The advantages of this flap are that there is less disruption of veins and less visible disfigurement of the dorsum of the finger when compared to other pedicled cross-finger skin flaps. The disadvantage of this flap is its restricted width. It is recommended as the cross-finger pedicle skin flap of choice when the defect is not wide.

Modified thin abdominal wall flap (glove flap) for the treatment of acute burns to the hands and fingers

2009-03-09

Summary: Background: Burns to the dorsum of the fingers and hands require debridement and immediate coverage by skin flap at the earliest opportunity. In such situations, the conventional abdominal wall flap is still commonly used as it is a convenient and safe technique, but the foremost problem with this flap is that it is thick and therefore cosmetically unacceptable; it is also functionally not very suitable as the bulkiness of the digits prevents full range of motion. We have developed a modified thin abdominal flap (glove flap) which attains good results.Methods: Incisions are made in the skin of the abdominal wall only where the hand is to be inserted and where each of the finger tips will be pulled through. The flap is undermined just under the skin to the depth that preserves the subcutaneous vascular networks to create a thin flap. The interdigital area of the flaps should not be undermined so as to create a glove-type pocket. The hand is then inserted in this subcutaneous pocket. After insertion of the injured hand for 10 to 14 days, the flap is resected and attached to the hand.Results: Seven hands of 5 patients were treated by this technique and all the flaps survived safely. The function of the hands and fingers, including range of motion (ROM) in each joint, was successfully salvaged. The reconstructed hands and fingers were aesthetically pleasing.Conclusions: Although the abdominal wall flap is not a new technique, our modifications to this flap make it possible to acquire functionally and aesthetically better results. Although many excellent techniques such as perforator flaps have been reported recently, we conclude that the abdominal wall flap is still a very useful technique because it can be performed easily, safely and within a short time.

Morphological and functional evaluation of visual disturbances in a bilateral hand allograft recipient

2009-02-24

Summary: Allograft recipients are exposed to risks owing to immunosuppression, and there is always the possibility that psychological issues interfere with the procedure's outcomes.An episode of blindness was suspected in a bilateral hand allograft recipient. The patient underwent a multidisciplinary evaluation, and clinical, electrophysiological, laboratory and a combination of functional and morphological magnetic resonance imaging (MRI) tests ruled out any visual process and revealed a secondary benefit, which turned out to be the use of privileges of the transplant support centre for several months.Composite tissue allograft recipients require a thorough psychological assessment before and after transplant procedures to prevent malingering.

Protective effect of grape seed extract against ischaemia/reperfusion injury in a rat epigastricflap model

2009-02-26

Summary: Proanthocyanidins are potent natural antioxidants which belong to a class of polyphenols. Proanthocyanidin-rich extracts are prepared from grape seeds. The effect of grape seed proanthocyanidin extract (GSPE) on the viability of abdominal skin flaps exposed to warm ischaemia and subsequent reperfusion were studied in 40 male Wistar rats. In the control group (group I; n=20), rats were fed with standard, non-purified rat diet, and the study group received GSPE 100mgkg−1 per day 1 week prior to surgery and 1 week following surgery. Abdominal island flaps were elevated in both the groups and subjected to 8h of warm ischaemia, followed by reperfusion. Mean flap survival areas in groups I (control group) and II (treatment group) were calculated to be 58.3%±11.72 and 81.0%±11.88, respectively. Flap survival on day 7 was significantly higher in group II compared to group I (p<0.01). Histopathological semi-quantitative analysis of the specimens revealed infiltration by polymorphonuclear leucocytes, oedema formation and necrosis in group I, whereas neo-vascularisation and fibrosis were the prominent findings in group II.

In vivo observations of cell trafficking in allotransplanted vascularized skin flaps and conventional skin grafts

2009-03-27

Summary: The problem of allogeneic skin rejection is a major limitation to more widespread application of clinical composite tissue allotransplantation (CTA). Previous research examining skin rejection has mainly studied rejection of conventional skin grafts (CSG) using standard histological techniques. The aim of this study was to objectively assess if there were differences in the immune response to CSG and primarily vascularized skin in composite tissue allotransplants (SCTT) using in vivo techniques in order to gain new insights in to the immune response to skin allotransplants.CSG and SCTT were transplanted from standard Lewis (LEW) ad Wistar Furth (WF) to recipient transgenic green fluorescent Lewis rats (LEW–GFP). In vivo confocal microscopy was used to observe cell trafficking within skin of the transplants. In addition, immunohistochemical staining was performed on skin biopsies to reveal possible expression of class II major histocompatibility antigens.A difference was observed in the immune response to SCTT compared to CSG. SCTT had a greater density cellular infiltrate than CSG (p<0.03) that was focused more at the center of the transplant (p<0.05) than at the edges, likely due to the immediate vascularization of the skin. Recipient dendritic cells were only observed in rejecting SCTT, not CSG. Furthermore, dermal endothelial class II MHC expression was only observed in allogeneic SCTT. The immune response in both SCTT and CSG was focused on targets in the dermis, with infiltrating cells clustering around hair follicles (CSG and SCTT; p<0.01) and blood vessels (SCTT; p<0.01) in allogeneic transplants.This study suggests that there are significant differences between rejection of SCTT and CSG that may limit the relevance of much of the historical data on skin graft rejection when applied to composite tissue allotransplantation. Furthermore, the use of novel in vivo techniques identified characteristics of the immune response to allograft skin not previously described, which may be useful in directing future approaches to overcoming allograft skin rejection.

How long are fasciocutaneous flaps dependant on their vascular pedicle: A unique case of SIEA flap survival

2009-05-18

Summary: Background: While it has long been held that muscle flaps maintain their dependency on their vascular pedicle for the long term, fasciocutaneous flaps have been less well investigated. Recent studies of the deep inferior epigastric artery perforator (DIEP) flap have suggested that these flaps may maintain long term dependence on their vascular pedicles for survival. There is no literature concerning these effects in the superficial inferior epigastric artery (SIEA) flap.Case report: We describe a unique case in which the pedicle of a superficial inferior epigastric artery (SIEA) flap for breast reconstruction was avulsed 11 days postoperatively, with the flap surviving on its inferior wound edge alone.Conclusion: Fasciocutaneous flaps may lose dependency on their vascular pedicles in the short term following transfer, developing alternative pathways for vascular supply and ultimately survival. A conservative approach early in the course of flap compromise due to perforator ligation or avulsion, in cases where immediate re-anastomosis may not be feasible, is thus supported.

Management of microstomia in adult burn patients revisited

2009-11-26

Summary: Objective: This study aims to review our experience in the surgical management of microstomia following facial burns.Patients and methods: For this retrospective study, we searched our burn patients' database for oral commissuroplasties with local mucosal flaps and reviewed the 18 patients suffering from microstomia after facial burns who had been operatively treated between 1995 and March 2007. Fifteen of the patients were primarily treated for severe facial burns in our burns unit, three were referred to our outpatients clinic for secondary reconstruction. Reconstruction of the oral commissures was performed according to one of the following methods: (1) triangular scar excision and mucosal Y–V advancement (n=10), (2) scar excision and wound closure with full-thickness or split-skin graft (n=4) and (3) division of the contracture and closure of the resulting defect with two rhomboid mucosal flaps per side (n=4).Results: All patients showed acceptable aesthetic results and a good functional outcome. Apart from minor wound-healing disturbances, which neither required surgery nor worsened the result, no complications were observed. Patient satisfaction was high.Conclusion: Commissuroplasty is an early functional post-burn corrective procedure that often must be performed prior to completion of scar maturation. Mucosal advancement flaps are a viable procedure for the treatment of microstomia after facial burns, resulting in good aesthetic and functional outcome. Direct scar excision and skin grafting, although unavoidable in cases of extensive perioral scarring, frequently produces inferior results.

The Nitric acid burn trauma of the skin

2009-10-30

Summary: Nitric acid burn traumata often occur in the chemical industry. A few publications addressing this topic can be found in the medical database, and there are no reports about these traumata in children.A total of 24 patients, average 16.6 years of age, suffering from nitric acid traumata were treated. Wound with I° burns received open therapy with panthenol-containing creams. Wound of II° and higher were initially treated by irrigation with sterile isotonic saline solution and then by covering with silver-sulphadiazine dressing. Treatment was changed on the second day to fluid-absorbent foam bandages for superficial wounds (up to IIa° depth) and occlusive, antiseptic moist bandages in combination with enzymatic substances for IIb°–III° burns. After the delayed demarcation, necrectomy and mesh-graft transplantation were performed. All wounds healed adequately.Chemical burn traumata with nitric acid lead to specific yellow- to brown-stained wounds with slower accumulation of eschar and slower demarcation compared with thermal burns. Remaining wound eschar induced no systemic inflammation reaction. After demarcation, skin transplantation can be performed on the wounds, as is commonly done.The distinguishing feature of nitric-acid-induced chemical burns is the difficulty in differentiation and classification of burn depth. An immediate lavage should be followed by silver sulphadiazine treatment. Thereafter, fluid-absorbent foam bandages or occlusive, antiseptic moist bandages should be used according to the burn depth. Slow demarcation caused a delay in performing surgical treatments.

The effect of growth hormone on fibroblast proliferation and keratinocyte migration

Sang Woo Lee, Suk Hwa Kim, Ji Youn Kim, Yoonho Lee — 2009-12-21

Summary: Background: The beneficial effects of growth hormones (GHs) on wound healing have been reported. Although the mechanism of how GH promotes wound healing is unclear, there are reports showing that the principal factor lies in the GH-stimulated production of IGF-1 in topical wounds. In this study, a human primary cell model was devised to examine how the topical application of GHs affects fibroblast proliferation and keratinocyte migration, which play fundamental roles in wound healing.Methods: The fibroblasts were cultured in media with different concentrations of GH. The amount of fibroblast proliferation was assessed using a tetrazolium-based colourimetric assay (MTT assay). The amount of newly formed IGF-I mRNA was measured by reverse transcription and polymerase chain reaction (RT-PCR). Keratinocyte migration was compared using a migration assay.Results: Fibroblast proliferation was significantly higher in the experimental group than in the control group (the absorbance of 2.5IU L−1 GH applied group: 0.3954±0.056, control group: 0.2943±0.0554, P<0.05), and the promotion of IGF-I formation by fibroblasts was observed. There was more keratinocyte migration in the experimental group than in the control group (the remaining gap in the 2.5IU L−1 GH applied group after keratinocyte migration: 46.57±2.22% of the primary gap, control group: 75.14±3.44%, P<0.05).Conclusion: GH enhances the local formation of IGF-1, which activates fibroblast proliferation and keratinocyte migration. These results highlight the potential of the topical application of GHs in the treatment of wounds.

Engineering cartilage substitute with a specific size and shape using porous high-density polyethylene (HDPE) as internal support

Yujia Wu, Lie Zhu, Hua Jiang, Wei Liu, Yu Liu, Yilin Cao, Guangdong Zhou — 2009-11-30

Summary: Despite the great advances in cartilage engineering, constructing cartilage of large sizes and appropriate shapes remains a great challenge, owing to limits in thickness of regenerated cartilage and to inferior mechanical properties of scaffolds. This study introduces a pre-shaped polyglycolic acid (PGA)-coated porous high-density polyethylene (HDPE) scaffold to overcome these challenges. HDPE was carved into cylindrical rods and wrapped around by PGA fibres to form PGA-HDPE scaffolds. Porcine chondrocytes were seeded into the scaffolds and the constructs were cultured in vitro for 2 weeks before subcutaneous implantation into nude mice. Scaffolds made purely of PGA with the same size and shape were used as a control. After 8 weeks of implantation, the construct formed cartilage-like tissue and retained its pre-designed shape and size. In addition, the regenerated cartilage grew and completely surrounded the HDPE core, which made the entire cartilage substitute biocompatible to its implanted environment as native cartilage similarly does. By contrast, the shape and size of the constructs in the control group seriously deformed and obvious hollow cavity and necrotic tissue were observed in the inner region. These results demonstrate that the use of HDPE as the internal support of a biodegradable scaffold has the potential to circumvent the problems of limitations in size and shape, with promising implications for the development of engineered cartilage appropriate for clinical applications.

An unusual presentation of a vascular birthmark: A focal area of congenital lipoatrophy on the buttock

Safa E. Sandoval, Jamal M. Bullocks, M. John Hicks, Larry H. Hollier — 2009-11-16

Summary: A 3-year-old girl presented with a focal area of congenital lipoatrophy on the buttock. There was no history of trauma or injections to the site. An excisional biopsy of the lesion was performed. The pathology of the lesion was most consistent with a vascular malformation with capillary predominance. This is an unusual presentation of a capillary malformation that has not been reported in the literature. The normal clinical presentation, natural history, pathologic findings, and imaging findings of capillary malformations are reviewed. These characteristics are compared to other easily confused lesions, such as haemangiomas, including infantile, rapidly-involuting, and non-involuting haemangiomas. Usually, the clinical appearance of congenital vascular lesions confers the ability to correctly distinguish these birthmarks. However, as this case demonstrates, the possibility of a vascular lesion should be considered with any congenital cutaneous lesion regardless of its appearance.

Successful re-plantation of an amputated nasal segment by supermicrosurgery: A case report and review of the literature

Sukwha Kim, Hoijoon Jeong, Tae Hyun Choi, Jun Sik Kim — 2009-11-13

Summary: The nose is a critical aesthetic subunit of the face, but because of the difficulties in anastomosis of the small-sized arteries and veins, several cases of nasal replantation have been reported. Using supermicrosurgical techniques, we successfully replanted a patient's nasal segment which had been amputated by a falling sharp metal pipe. The result was excellent both aesthetically and functionally, and the patient was very satisfied.The nose is located at the centre of face and is thus important aesthetically. The nose also has functions in olfaction, respiration, humidification, filtration, temperature regulation and phonation. However, the nose protrudes from the face and is readily injured by trauma, and in injured cases, reconstruction of the nose is essential. Recently, with the development of microsurgery, microsurgical replantation of the amputated nose has been reported. We performed successful replantation of the nasal alar and tip that were completely amputated and smaller in size than previous reports, using a supermicrosurgical technique.

Total lower eyelid reconstruction with free posterior auricular chondrocutaneous flap

Antonio Rampazzo, Bahar Bassiri Gharb, Hung Chi Chen — 2009-11-06

Summary: Lower eyelid is characterised by a thin musculocutaneous anterior lamella and a posterior lamella composed of tarsus and conjunctiva. Several techniques have been reported for total lower eyelid reconstruction suitable especially for the elderly patients with skin laxity. We report a total lower eyelid reconstruction with a free posterior auricular chondrocutaneous flap with a good functional and aesthetic outcome in a young patient. This technique can be taken into consideration for complex soft-tissue defects of the eyelids.

Nonchoroidal intraorbital malignant melanoma arising from naevus of Ota

Hannah John, Jonathan A. Britto — 2009-10-22

Summary: A case report of nonchoroidal intraorbital malignant melanoma arising from naevus of Ota, in a Caucasian female.

Respiratory management of Pierre Robin sequence using nasopharyngeal airway with Kirschner wire

Masaru Horikiri, Susam Park, Mikio Kinoshita, Daisuke Matsumoto — 2009-11-02

Summary: Background: The Pierre Robin sequence (PRS) is a relatively rare symptom complex characterised by glossoptosis, micrognathia and respiratory obstruction. The initial problem that children with PRS face is obstructive dyspnoea, which can result in death without appropriate respiratory management. We designed and used a modified airway with a Kirschner wire (K-airway) in children with PRS who suffered from dyspnoea that did not improve with conservative treatment.Methods: The subjects were four children diagnosed with PRS at the Department of Plastic Surgery, Shizuoka Children's Hospital, from February 2007 to December 2008. Since dyspnoea was not improved by conservative treatment, a φ0.8-mm Kirschner wire was set inside a nasopharyngeal airway bent in a form to lift the root of the tongue in order to prevent glossoptosis. The respiratory condition was evaluated with a test for sleep apnoea.Results: Successful improvement in dyspnoea with the K-airway was noted in all cases. In Case 1, the subject was discharged from hospital without using the K-airway (92 days of age). In Case 2, the subject was discharged from hospital using the airway only at nighttime (122 days of age).Conclusions: This method is safe because it is less invasive, and its effects can be easily evaluated, suggesting that it is a good method to try prior to surgical treatment.

Case report: Pyoderma gangrenosum following Deep Inferior Epigastric Perforator (Diep) free flap breast reconstruction

2009-11-19

Summary: Pyoderma gangrenosum is a rare but significant cutaneous disease that can lead to skin ulceration and necrosis. It is idiopathic but can occur post surgically. There has been only a limited number of case reports of PG complicating breast surgery.

Onco-reconstructive techniques in the treatment of tuberculosis of the breast

J.K. Dickson, J. Sarginson, V. Moonesamy, D. Oliver — 2009-11-06

Summary: A 54-year-old woman presented with mastitis, which did not respond to conventional oral antibiotic therapy. Tissue biopsy led to the diagnosis of tuberculosis of the breast. The underlying causative organism was found to be Mycobacterium abscessus, recognised as being a particularly pathogenic strain of tuberculosis. Initial treatment involved surgical debridement and antibiotic therapy. Following this, onco-reconstructive techniques were used to remove scarred tissue from the affected side and reduce the contra lateral breast to match leading to a good aesthetic outcome.

Sciatic nerve palsy – a complication of posterior approach using enhanced soft tissue repair for total hip arthroplasty

Parkash Lohana, David J. Woodnutt, Dean E. Boyce — 2009-11-30

Summary: Sciatic nerve palsy is a rare but well recognised complication of total hip replacement. There are a variety of potential causes of sciatic nerve palsy and its prevalence with different approaches has been mentioned in the literature.The posterolateral or ‘Southern’ approach with some form of enhanced soft tissue repair is a commonly used approach for primary total hip arthroplasty. However, the sciatic nerve is recognised to be in close proximity to the surgical field. We report a case of sciatic nerve palsy after this approach as a result of a surgical suture used for soft tissue repair.

Three-flap cover for total hand degloving

Azmat M. Doctor, Jimmy Mathew, Sunderraj Ellur, Anusham A. Ananthram — 2009-11-05

Summary: Re-surfacing after a total hand degloving injury is one of the most difficult management problems in hand surgery. We present one such case that was managed using three flaps for cover. The radial forearm flap is very thin and pliable, resulting in satisfactory coverage of first web space and the thumb remnant, and facilitates a mobile thumb. The groin–hypogastric flap covered the remnant fingers admirably. The patient had a good first web and could use the hand to lift objects and hold a pen to write legibly within 2 months of the injury.

V–Y gastrocnemius muscle slide with turnover fascial flap for compound Achilles defects: A simple solution

N.K. Agrawal, V. Bhattacharya — 2009-10-26

Summary: Background: Compound defects of the Achilles region pose a reconstructive challenge. Poor vascularity of the Achilles region predisposes to complications. Repair of the tendon with simultaneous soft-tissue cover gives the patient the best chance to recover.Materials and methods: Gastrocnemius musculotendinous V–Y slide for Achilles tendon defect with non-axial turnover fascial flaps based on the proximal end of the defect with a split-skin graft on the fascial flap was used in two patients. The vascular bases of such flaps and the technical details has been discussed.Results: The functional and aesthetic results were highly satisfactory with minimal donor-site morbidity. The flap was thin enough to fit the contour of the Achilles region. The fascial flap with skin graft was durable and withstood footwear well. The flap also allowed tendon gliding beneath it, with near-complete movements at the ankle joint.Conclusion: Large flaps can sufficiently be raised with a wide base to cover small- to medium-sized defects. It is a good, rapid and cost-effective solution for a difficult clinical problem.

Ensuring safer mandibular angle resection surgery by using a calibrated mandibular angle hook

Raymond C.W. Goh, Chun-Li Lin, Lun-Jou Lo — 2009-12-14

Mandibular angle resection to correct the square face is associated with a high level of patient expectation and little tolerance for aesthetic or functional errors. In performing this procedure, it is imperative for the surgeon to be mindful of the anatomical location of the inferior alveolar nerve. Preservation of this nerve is vital to avoiding post-operative sensory deficits, which can often become a cause of protracted patient dissatisfaction. Anatomic studies that document the course of the inferior alveolar nerve within the mandible provide valuable knowledge to help guide surgical planning, and to ensure safe execution of angle resection.

Facial pressure ulcer following prone positioning

Rahim S. Nazerali, Kyle R. Song, Michael S. Wong — 2009-11-27

Prone positioning is becoming commonplace practise in plastic surgery. With the popularisation of circumferential body contouring and improved results in posterior contouring, there has been an increase in prone positioning. We present a case of facial pressure sore resulting from prone positioning as a cautionary reminder to all.

This is linear verrucous epidermal nevus, not acanthosis nigricans

Niti Khunger, Sushruta Kathuria — 2009-12-28

This is with reference to an article published in your journal, ‘Acanthosis nigricans and an alternative for its surgical therapy’, Isken T, Sen C, Iscen D, et-al, J Plast Reconstr Aesthet Surg 2009; 62: 148–150. This is to state that the clinical description and image shown in this case report is clearly that of linear verrucous epidermal nevus and not that of acanthosis nigricans.

Low dose of Hyaluronidase to treat over correction by HA filler–A Case Report.

Harikumar Menon, Mohan Thomas, James D'silva — 2010-02-04

Hyaluronic acid (HA) is probably the most popular filler for correction of deep facial lines as well as facial soft tissue augmentation. The peri orbital region is among the more delicate and difficult areas to treat with filler injections on account of the thin skin in the region. One of the possible complications with HA gel injection is over correction which is particularly troublesome in the tear trough area.

Modifications to the C-V flap for nipple reconstruction

J.K. O'Neill, A. Goodwin-Walters — 2009-12-02

We read with interest the article ‘Modified C-V flap for nipple reconstruction: our experience in 50 patients’ by El-Ali et al in the August JPRAS (Vol. 63p 991-996). Our senior author has found that the C-V flap gives an excellent nipple reconstruction too but has two different modifications that we feel may be useful to others. No credit is taken for the original development of the first of the two modifications (the origin of which we are unaware of) but we believe that it is currently undescribed in the literature.

A simple and practical method for axillary osmidrosis resection

Xiaowei Liu, Tongchun Mao, Zeyuan Lei, Dongli Fan — 2009-12-04

Axillary osmidrosis (AO) is characterized by an excessive, unpleasant odor that originates from the apocrine glands in the axillary area. The purpose of treatment is to eradicate the apocrine glands with minimal effect on the appearance of the axillary area. While many new techniques have proven effective (e.g., laser, suction-assisted liposuction), their application is limited by the need for specialized instrumentation. Here we present a simple, practical and radical surgical method based on limited incision. First, the area to be undermined is marked and an incision line of 2cm is cut into the subdermal fat tissue. We evert the flap strongly with index finger, dragging the skin flap with two mosquito forceps to expose the glands sufficiently. And the mosquito forceps is good at exposing the glands in the marginal area of the flap through the narrow incision, especially in the patient with large area of apocrine glands. Then, the flap is defatted and the glands resected with eye scissors. To ensure complete removal, we scrape the distant pole of the flap with a curette to avoid blind spots. Finally, the incision is closed with 3-0 silk suture. For drainage, we make five to eight incisions 3mm long for drainage, and make suture lines around the surgical area for a bolus dressing to close the wound ().

Gravitational retrograde venous perfusion - a technique for limb extremity salvage when microvascular arterial repair is not possible.

L. Ferguson, E. Chipp, S. Rayatt — 2009-11-18

We read with interest the article entitled ‘Gravitational retrograde venous perfusion – a technique for limb extremity salvage when microvascular arterial repair is not possible’ by Power et al in July 2009 edition of JPRAS. The article suggests a protocol of limb position management, which the authors hypothesise enables tissue perfusion via retrograde venous blood flow.

Pre-operative planning of free flaps - will we burn the bridge we are about to cross?

Y.S. Lau, S.K. Varma — 2009-11-09

We read with interest the description of pre-operative flap design for breast reconstruction using the microvascular Transverse Rectus Abdominis Myocutaneous (TRAM) flap by Patel et al and we congratulate them on their excellent aesthetic results.

The ‘Vacsplint’ for Hands

Nicolas Kairinos, Donald A. Hudson — 2009-12-16

A novel technique of applying negative pressure wound therapy to a hand is described. The two foam slabs are placed on the volar and dorsal surface of the hand and forearm with strips between fingers. The slabs are then stapled together from distal to proximal until the level of the proximal interphalangeal joints (PIPJ's). The metacarpophalangeal joints (MCPJ's) are then flexed to 90°, whilst keeping the proximal interphalangeal joints (PIPJ's) in extension. The dorsal foam overlying the MCPJ's shifts distally and the volar slab proximally by a few centimetres. The two slabs are stapled further in this position. The same principle can be used for wrist extension (). The dressing is completed with adhesive occlusive drape and suction tubing. On application of suction, the differential contractile forces acting on either side of the joints (due to the different lengths of foam) result in the dressing assuming a functional position ( and ).

The smart phone: An indispensable tool for the plastic surgeon?

T. Hunter, J. Hardwicke, S. Rayatt — 2009-12-07

Recent advances in telecommunication technologies have given rise to a surge in mobile internet usage, as powerful devices become ever more available and affordable. Medical uses have been highlighted by other authors, and we would like to emphasise how such devices can be an invaluable tool for education, reference and communication in the area of plastic and reconstructive surgery. The smart phone, such as the Apple iPhone®, provides an intuitive user interface and high-resolution display, allowing ease of access to internet-based media resources. We have listed some of the best tools pertinent to plastic surgery (). Emedicine.com, contains over 6500 articles covering all areas of medicine and surgery. There are over 700 articles pertaining to plastic surgery, subdivided into topics such as breast, burns, trauma, head and neck, and facial plastic surgery. The majority of these topic areas have links to high quality images and multimedia resources, which present well on the iPhone platform. The microsurgeon.org website, again presents well on the high-resolution screen, and provides detailed synopses of commonly used free flaps, with diagrammatic aids.

Increased culture sensitivity with direct inoculation of seroma fluid in blood culture bottles

P.G. Ngan, J.K. O'Neill, A. Goodwin-Walters — 2009-12-21

We recently encountered a case in which seroma fluid sent to microbiology for microscopy, culture and sensitivities was negative for any pathogens on culture but fluid taken from the seroma at the same time and directly inoculated into blood culture bottles – i.e., direct inoculation of “enrichment cultures” yielded a Staphylococcus aureus. This has highlighted to us the greater sensitivity of the blood culture enrichment technique and we suggest it is incorporated routinely into plastic surgery practice, as the technique may especially be useful in cases where there is suspicion of infection but previous culture has been negative and in early infection with a low number of pathogens present or antecedent antibiotics.

Intraoperative diagnostic cytology of intra-parotid lymph nodes

J.K. O'Neill, D. Izadi, E. Sheffield, A. Orlando — 2009-12-18

Intraoperative diagnostic cytology can be utilised instead of frozen section in selected cases. It can be useful when there is a high level of clinical suspicion of malignancy but previous fine needle aspirations (FNAs) of a suspicious palpable mass have been inconclusive. It has advantages over frozen section because it is quicker, requires less equipment and does not involve transection of the specimen. Two case studies are presented below:

Precautions in using keystone flap

Hung-Chi Chen — 2009-04-13

Following ablation of head and neck cancers there are many options of reconstruction, depending on many factors, such as age, defect size and location, tissue components required for reconstruction, general health of the patients and special medical problems, job, socio-economic condition and motivation of the patients, experience of the surgeons and facilities of the hospital, etc. Regardless of many advantages of the keystone flap as described by the authors, this flap has the following limitations which the plastic surgeons should take into consideration before deciding to use this flap:

Discussion of: Complications of polyacrylamide hydrogel (PAAG) injection in facial augmentation. JPRAS 2010;63(1):e9–12.

G.B. Stark — 2009-06-19

‘Non-invasive’ procedures for facial corrections are trendy and rapidly increasing in numbers. With regard to late complications, well–documented, long-term studies are scarce and basically absent. However, the economic interest is strong.

Multiple choice questions in plastic surgery

Derick Amith Mendonca — 2009-12-21

Having just commenced preparing for the FRCS Plast examination, I ventured out to buy a good revision book that focussed on the theoretical aspect of the test. It soon dawned on me that, something on the surface that appeared to be ‘just another MCQ book in Plastic Surgery’ was actually so much more than that.

Hopkins reunion

M. Felix Freshwater — 2010-04-01

Every two years the Johns Hopkins Medical and Surgical Association holds a reunion in Baltimore. This year was different because it was not only a reunion but also a celebration of Paul Manson's tenure as chief of plastic surgery and his impending retirement after a third of a century at Hopkins, a period that began in 1976, his first year of residency.