Journal of Plastic, Reconstructive & Aesthetic Surgery

The PIP mammary prosthesis: A product recall study

MG Berry, Jan J. Stanek — 2012-03-14

Summary: Introduction: Concerns about the durability of silicone breast implants manufactured by Poly Implant Prothèse (PIP) have been expressed for several years prior to their formal withdrawal from the market in March 2010. Although precise details of what elements were at fault remain unclear, concerns have been raised about both the elastomer and the filler gel. Media speculation has focussed on device safety, longevity and, recently, a possible association with lymphoma, specifically anaplastic large cell lymphoma (ALCL). There is however, no actual data concerning these implants with which to guide and inform when concerned patients seek advice.Patients and methods: PIP mammary prostheses were used by the senior author for both primary and revision breast augmentation (BA) during the period January 2000–August 2005. A database of patients was constructed and attempts made to contact each patient offering a free consultation and referral for ultrasound scan (USS). Chief outcome measures included secondary surgery, the implant rupture rate and time to rupture.Results: 453 consecutive patients with PIP devices were identified. Of this number 30 had already undergone implant exchange for a variety of reasons. 180 (39.7%) could not be contacted and 19 had undergone explantation elsewhere, including the NHS. Of those who could be contacted, 47 declined consultation as they had no concerns. 97 had neither clinical signs nor radiographic evidence of implant rupture and elected to remain under regular review. At the time of writing, 38 have undergone implant exchange after ultrasonographic indication of rupture and the overall patient rupture rate for the PIP implant is 15.9–33.8%. This cohort correlates reduced implant longevity with each successive year from 2000 and no cases of ALCL have been diagnosed.Discussion: Long-term studies such as this are difficult to undertake for a number of reasons as they place a significant additional burden of resources on a practice. They are, however, essential from an industry perspective both for the provision of information and supporting audit and professional standing. Being only a single-handed practice, this initial study is the tip of an iceberg that may affect 40,000 women in the UK with PIP implants, but it does provide some hard data with which to guide our patients. It is also believed to be the first independent product recall study in aesthetic breast surgery.

Breast reconstruction following prophylactic mastectomy for smaller breasts: The superiorly based pectoralis fascial flap with the Becker 35 expandable implant

G.L. Ross — 2012-01-11

Summary: Introduction: Immediate reconstruction using tissue expander/implants following prophylactic mastectomy for smaller breasts is a reliable means of providing similar size, shape and symmetrical reconstructions. The superiorly based pectoralis fascial flap allows an immediate reconstruction of the inferior pole and may eliminate the need for tissue expansion.Methods: The superiorly based pectoralis fascial flap and implant was performed on 5 patients (10 breasts). The Becker 35 expandable implant was used in all cases and average size was 349 (range 290–400cc). Average age was 33 (range 21–43). The average BMI was 23 (range 20–26). One patient underwent further tissue expansion of the Becker 35 postoperatively. One patient developed a seroma in the abdominal fascial flap donor site that settled without the need for drainage. There were no other complications.Conclusion: The superiorly based pectoralis fascial flap provides a one-stop reconstruction of the lower pole and can eliminate the need for tissue expansion in patients with small breasts.

Female-to-male transgender chest reconstruction: A large consecutive, single-surgeon experience

M.G. Berry, Richard Curtis, Dai Davies — 2011-12-21

Summary: Introduction: Chest reconstruction in the female-to-male transgender individual is not a common procedure due to the low prevalence of intractable gender dysphoria. It means that few surgeons acquire sufficient expertise and many UK patients find themselves travelling abroad to centres such as Singapore, Amsterdam and the United States.Patients and methods: This study retrospectively evaluated 100 consecutive patients of a single surgeon over a 3-year period with prime outcome measures including surgical technique, complications, surgical revision and patient-reported satisfaction, using a simple, 1–5 linear analogue scoring system.Results: The median age was 28 years with a median excision of 345g per breast. Complications occurred in 11 patients, five of which required surgical haematoma evacuation. Chi2 analysis failed to show a correlation between testosterone supplementation and haemorrhagic sequelae (p>0.1). To date, 16 patients have undergone supplementary surgery, predominantly axillary dog-ear revision. Overall patient-reported satisfaction was 4.25.Conclusions: Whilst only a part of the process in gender transitioning, chest reconstruction is important as it is frequently the initial surgical procedure and enables the large-breasted to live in their chosen role much more easily. Historically associated with high rates of both complication and revision surgery, this study demonstrates that both may be appreciably lower and associated with high levels of patient satisfaction so that there is a realistic, high-quality option for British patients who might otherwise feel the need to travel abroad for their surgery.

Effectiveness of type A botulinum toxins for aesthetic indications and their relative economic impact

Ravi Jandhyala — 2012-01-06

Summary: Background: It is accepted that the three commercially available type A botulinum toxins (BoNT-As) are different, their units of potency are not interchangeable and no fixed dose conversion ratio exists between them. To date, there is no clear evidence demonstrating the superiority of one toxin over another clinically.Objective: The study aims to identify evidence confirming the equivocal efficacy of the formulations and to justify that attention can therefore be reasonably turned to their differing costs as a means of aiding choice of treatment. This is achieved via the development of the cost calculator presented herein, to enable direct economic comparisons to be made between the three commercially available BoNT-A formulations licensed for aesthetic indications in the UK.Methods: An online literature search using PubMed was undertaken and the latest available information on the cost for each BoNT-A treatment was accessed via the British National Formulary (BNF). Predicated on the evidence review, a cost calculator was developed which takes into account for the glabella: the number of treatments needed per patient with each product over a year and the number of treatments available with differing dilutions of each vial of each product over a year. A range of cost prices can also be introduced allowing a direct cost-comparison to be made for treating the glabella of a set number of patients over a year between different products.Results: Azzalure® (abobotulinumtoxinA) was the most cost-effective in almost all scenarios tested, whilst Vistabel® (onabotulinumtoxinA) was the least cost-effective. Of the two products with published non-inferiority with respect to each other, onabotulinumtoxinA and Bocouture® (incobotulinumtoxinA), incobotulinumtoxinA offered a lower overall cost to treat the glabella of the same number of patients when compared with Vistabel.Conclusion: In most scenarios, BoNT-A treatment with abobotulinumtoxinA will result in significant annual cost savings when compared with treatment with onabotulinumtoxinA or incobotulinumtoxinA.

Nasal patency after open rhinoplasty with spreader grafts

2011-12-26

Summary: Background: Spreader grafts have been used in cosmetic rhinoplasty, but little information is available about the objective results of treatment. This study sought to determine subjective and objective functional results of open cosmetic rhinoplasty with spreader grafts.Methods: Twenty patients (14 women, six men; mean age, 31 ± 6 years) had open cosmetic rhinoplasty. Surgery included dissection of the upper lateral cartilages, from the septum, and placement of spreader grafts, symmetrically, along the dorsal edge of the septal cartilage. Preoperative and postoperative evaluation included breathing quality score, acoustic rhinometry and a modified Glatzel mirror test.Results: Evaluation after surgery (range, 5–18 months) showed significant improvement of breathing quality (before surgery, 8; after surgery, 9.4; P ≤ 0.001) and a mean minimal cross-sectional area of the left side (before surgery, 0.6 cm2; after surgery, 0.9 cm2; P ≤ 0.01). There was no significant change of the mean minimal cross-sectional area of the right side (acoustic rhinometry) or nasal patency (modified Glatzel mirror test) between preoperative and postoperative evaluation. Complications included postoperative synechiae in two patients and septal granuloma in one patient.Conclusions: Open structure rhinoplasty using spreader grafts is effective in reconstructing the internal nasal valve and preserving or improving nasal patency.Level of evidence: : IV (case series with preoperative and postoperative testing).

The use of titanium clips in septal surgery for correction and strengthening

Yurdakul İlker Manavbaşı, Hakan Kerem, Adnan Erdem — 2012-01-03

Summary: Permanent correction of septal deformities is one of the most difficult and controversial subjects in aesthetic nasal surgery. The main reasons for failure in most of the corrective procedures are either not to weaken the septal cartilage enough to straighten it, or to treat the septum too radically causing iatrogenic deformities or predisposing it to new deformities postoperatively.Our approach to correct septal deformities relies on the principle of strengthening/reinforcing the septal cartilage (with or without some weakening maneuvers to correct the deformities beforehand) with application of titanium hemoclips at some critical locations in septum.Eighty-seven patients operated on between 2007 and 2009 are included in this study. Thirty-six of these patients had combined septo-nasal deformities while the remaining 51 had solely septal deformities. In 30 patients with septo-nasal deformity the technique was proven to be successful. The remaining 6 patients of this group had axial nasal deformity (rather than intrinsic septal problems) and did not respond to our technique successfully.Within four years of follow up, we did not encounter any recurrences, infections, ulcerations or exposure in the mucosa covering the titanium clips. None of the titanium clips were required to be removed for any reasons.

Complications of ear rings

Jennifer C.E. Lane, Gregory O’Toole — 2012-01-12

Summary: In this paper the complications of ear piercing are considered and the treatment of resultant deformities is described.

The use of a chimaeric sero-muscular flap to prevent anastomotic leakage in head and neck reconstruction with free ileocolon flap

2012-02-27

Summary: Background: In simultaneous reconstructions of cervical oesophagus and voice mechanism with free ileocolon flap, one of the most cumbersome complications is the anastomotic leakage at the junction between the colon and thoracic oesophagus.Methods: Since 2007, a chimaeric sero-muscular flap has been islanded from the distal end of the voice tube to cover the anterior aspect of the colo-oesophageal junction. Fourteen patients undergoing reconstruction of the hypopharyngo-laryngectomy defects were consecutively treated with the sero-muscular flap. The leakage rate was compared with a group of 15 patients who were reconstructed with a free ileocolon flap prior to the adoption of the new procedure.Results: All flaps survived completely. Swallowing function (scores 5–7), was restored in 69% of the patients. Speech function was restored (scores 4–5) in 59% of the patients. In the treatment group, only one patient suffered from anastomotic leakage compared to four patients in the control group.Conclusions: The chimaeric sero-muscular flap can secure the colo-oesophageal junction, improving the healing process and preventing delays in the administration of adjuvant therapy.

Inferior alveolar nerve reconstruction with interpositional sural nerve graft: A sensible addition to one-stage mandibular reconstruction

Yang-Ming Chang, Eduardo D. Rodriguez, Yong-Ming Chu, Chi-Ying Tsai, Fu-Chan Wei — 2012-02-10

Summary: Background: This study was to evaluate the sensory recovery in the lower lip and chin in patients who underwent segmental mandibulectomy involving inferior alveolar nerve and simultaneous reconstruction with fibular osteoseptocutaneous flap and interposition sural nerve graft.Material and method: From 1993 to 2004, a total of 20 patients underwent segmental mandibulectomy, simultaneous fibula osteoseptocutaneous flap reconstruction and interpositional sural nerve graft. Twelve patients were available for the study. There were seven male and five female patients with average age of 35.8 years (16–52 years). The sense at the lower lip and chin was measured by two-point discrimination both at the operated and non-operated side at an average of 64.3 months (12–146 months).Result: The operated side revealed an average of 13.7 mm for static (STPD) and 13.3 mm for moving two-point discrimination (MTPD) at the lower lip and 13.7 mm for static and 13.4 mm for MTPD at the chin. Data from the non-operated side averaged 3.4 mm for static and 3.2 mm for MTPD at lower lip and 5.1 mm for static and 4.5 mm for moving discrimination at the chin. All patients recovered better than protective sensation on the operated side, which was sufficient to prevent self-mutilation, preserve comprehensible speech and maintain oral competence. No patient complained of significant donor site morbidity.Conclusion: Simultaneous reconstruction of a segmental mandibulectomy involving inferior alveolar nerve with a fibula osteoseptocutaneous flap and interpositional sural nerve graft offers simultaneous replacement of mandibular architecture and restoration of protective perioral sensation.

Direction of innervation after interpositional nerve graft between facial and hypoglossal nerves in individuals with or without facial palsy: A rat model for treating incomplete facial palsy

2012-02-03

Summary: Background: The use of an interpositional nerve graft (IPNG) between the facial and hypoglossal nerves for incomplete facial palsy has recently been reported. However, its mechanism has not been elucidated. We established a rat model of IPNG to study incomplete facial palsy and confirmed the direction of innervation through the grafted nerve with or without facial nerve injury.Methods: Twenty rats were divided into five groups (n = 4): a control group (group A), an incomplete facial palsy group (group B), an IPNG-treated group (group C), an incomplete facial palsy group treated with IPNG (group D) and an incomplete hypoglossal nerve palsy group treated with IPNG (group E). After surgery, mimetic muscle movement was evaluated using an original scoring system. Twelve weeks after surgery, the mimetic muscles of the tongue were injected with Fast Blue and DiI. Retrograde-labelled neurons were counted through the facial and hypoglossal nuclei, and mimetic muscle specimens stained with Masson’s trichrome were examined.Results: Fast Blue-labelled neurons were noted in the hypoglossal nucleus in groups C and D, and DiI-labelled neurons within the facial nucleus were noted in groups C and E. The group D facial palsy score statistically exceeded the group B score.Conclusions: The results revealed that axonal regeneration through IPNG is bi-directional and is preferentially directed towards the injured side. Innervation from the hypoglossal nerve to mimetic muscles through IPNG prevents muscle atrophy and helps counter facial palsy.

Thermoregulation in peripheral nerve injury-induced cold-intolerant rats

L.S. Duraku, E.S. Smits, S.P. Niehof, S.E.R. Hovius, E.T. Walbeehm, R.W. Selles — 2011-12-30

Summary: Purpose: Cold intolerance is defined as pain after exposure to non-painful cold. It is suggested that cold intolerance may be related to dysfunctional thermoregulation in upper extremity nerve injury patients. The purpose of this study was to examine if the re-warming of a rat hind paw is altered in different peripheral nerve injury models and if these patterns are related to severity of cold intolerance.Methods: In the spared nerve injury (SNI) and complete sciatic lesion (CSL) model, the re-warming patterns after cold stress exposure were investigated preoperatively and at 3, 6 and 9 weeks postoperatively with a device to induce cooling of the hind paws. Thermocouples were attached on the dorsal side of the hind paw to monitor re-warming patterns.Results: The Von Frey test and cold plate test indicated a significantly lower paw-withdrawal threshold and latency in the SNI compared to the Sham model. The CSL group, however, had only significantly lower paw-withdrawal latency on the cold plate test compared to the Sham group. While we found no significantly different re-warming patterns in the SNI and CSL group compared to Sham group, we did find a tendency in temperature increase in the CSL group 3 weeks postoperatively.Conclusion: Overall, our findings indicate that re-warming patterns are not altered after peripheral nerve injury in these rat models despite the fact that these animals did develop cold intolerance. This suggests that disturbed thermoregulation may not be the prime mechanism for cold intolerance and that, other, most likely, neurological mechanisms may play a more important role.Clinical relevance: There is no direct correlation between cold intolerance and re-warming patterns in different peripheral nerve injury rat models. This is an important finding for future developing treatments for this common problem, since treatment focussing on vaso-regulation may not help diminish symptoms of cold-intolerant patients.

Delayed diagnosis and underreporting of congenital anomalies associated with oral clefts in the Netherlands: A national validation study

2012-01-05

Summary: Objective: Since 1997, the 15 Dutch cleft palate teams have reported their patients with oral clefts to the national oral cleft registry (NVSCA). During the first visit of the patient to the team – which is usually within the first year of life – the oral cleft and associated congenital anomalies are recorded through a unique recording form by a plastic surgeon/orthodontist/paediatrician. In this study, we evaluated the quality of data on congenital anomalies associated with clefts.Methods: We drew a random sample of 250 cases registered in the national database with oral clefts from 1997 through 2003; of these, 13 were excluded. Using two independent reregisters derived from two-phased medical data review, we analysed whether associated anomalies were correctly diagnosed and recorded.Results: The agreement on associated anomalies between the NVSCA and medical data ranged from moderate to poor (kappa 0.59 to 0). Seventy-seven percent of the craniofacial anomalies were underreported in the NVSCA: 30% due to delayed diagnosis and 47% due to deficient recording. Additionally, 80% of the associated anomalies of other organ systems were underreported: 52% due to delayed diagnosis and 28% due to deficient recording. The reporting of final diagnoses was somewhat better; however, 54% were still underreported (24% delayed diagnosis and 30% deficient recording). The rate of overreporting was 1.6% or lower.Conclusion: Congenital anomalies associated with clefts are underreported in the NVSCA because they are under diagnosed and deficiently recorded during the first consultations with the cleft palate teams. Our results emphasise the need for routine and thorough examination of patients with clefts. Team members should be more focussed on co-occurring anomalies, and early genetic counselling seems warranted in most cases. Additionally, our findings underline the need for postnatal follow-up and ongoing registration of associated anomalies; reregistration in the NVSCA at a later age is recommended.

Reconstruction with Vertical Rectus Abdominus Myocutaneous flap in advanced pelvic malignancy

Terrence A. Creagh, Liane Dixon, Frank A. Frizelle — 2012-01-24

Summary: Pelvic extenuative surgery produces good long term outcomes in advanced pelvic malignancies. We evaluate the use and clinical outcomes of the Vertical Rectus Abdominus Myocutaenous (VRAM) flap as a reconstruction technique in a heterogenic cohort of patients with advanced colorectal cancer in whom neo-adjuvant chemo-radiotherapy had been performed pre-operatively.Analysis of patients having VRAM flaps for pelvic reconstruction in a tertiary referral centre from 2001 to 2010 was conducted. 37 patients (23 female, 14 male) underwent pelvic extenuative surgery of which 22 (60%) had recurrent pelvic disease. All surgical and medical complications were analysed. Major flap complications were defined as ‘requiring return to the operating theatre at any stage’ and these occurred in 6 (16%) patients. There were 7 (19%) minor flap complications defined as ‘requiring conservative non surgical treatment’ The total global re-intervention rate of patients requiring return to theatre for re-operation as a result of their exenteration and reconstruction was 6 (16%).We highlight the merits and versatility of the VRAM flap in advanced pelvic malignancy in obtaining stable and supple reconstructive cover and the relative low morbidity in this difficult group confirms out strong support for immediate VRAM reconstruction in pelvic exenterative procedures.

Extended transpelvic deep inferior epigastric myocutanaeous rectus abdominis flap for posterior vaginal wall reconstruction in advanced pelvic malignancy

Ulrich M. Rieger, Gerhard Pierer — 2012-01-09

With great interest we read the case series “Reconstruction with Vertical Rectus Abdominus Myocutaneous Flap in Advanced Pelvic Malignancy” by Creagh TA et al. The authors review their experience with the transpelvic vertical rectus abdominis myocutanaeous flap for pelvic floor reconstruction after extensive pelvic exenteration in patients that had preceding radio-chemo-therapy.

Change in operative workload for rheumatoid disease of the hand: 1,109 procedures over 13 years

M. Dafydd, I.S. Whitaker, M.S. Murison, D.E. Boyce — 2011-12-19

Summary: Orthopaedic literature regarding lower limb joints reports a decline in operative management of rheumatoid arthritis since the 1980s. We investigated whether the demand for hand surgery for rheumatoid disease had changed over the last 13 years in our unit. Data for all patients undergoing operative treatment for rheumatoid arthritis of the hand and wrist over a 13-year period were analysed. Between 1996 and 2009, 1,069 patients with rheumatoid disease (182 men, 887 women) underwent a total of 1,109 hand surgery procedures. The operations were synovectomy (430, 39%), arthroplasty (252, 23%), arthrodesis (194, 18%) and tendon surgery (233, 21.0%). Linear regression analysis showed a statistically significant decrease in the number of synovectomies, arthroplasties and arthrodeses between 1996 and 2009, but no decrease in tendon surgery. We explore possible factors responsible for this change in operative workload.

Medial sural perforator plus island flap: A modification of the medial sural perforator island flap for the reconstruction of postburn knee flexion contractures using burned calf skin

Kwang Seog Kim, Eui Sik Kim, Jae Ha Hwang, Sam Yong Lee — 2012-02-10

Summary: Background: The medial sural perforator island flap may be suitable for the reconstruction of postburn knee flexion contractures. However, postburn knee flexion contractures are usually associated with burns of the calf, which is the donor site of the medial sural perforator flap. Thus, there are concerns regarding the safety of raising medial sural perforator flaps from burned calves.Methods: Between 2005 and 2010, 12 patients (11 males and 1 female) with postburn knee flexion contractures associated with second-degree burns of the calf (that healed by secondary intention) underwent reconstruction using a medial sural perforator island flap (based on the medial sural perforator) or medial sural perforator plus island flap (based on the medial sural perforator and other vessels that are pedicles of the sural flaps).Results: All 12 flaps, which ranged in size from 7 to 15 cm in width and from 9 to 23 cm in length, survived completely. Of the 12 flaps, three were medial sural perforator island flaps and nine were medial sural perforator plus island flaps. Of the nine medial sural perforator plus island flaps, two included the lesser saphenous vein, five included the lesser saphenous vein and its accompanying artery, and two included the lesser saphenous vein, the distal sural nerve and their accompanying arteries. Healing of all donor sites was uncomplicated. All patients were completely satisfied with their results.Conclusions: Although this series is not large, the authors are convinced that some reliable medial sural perforators are usually present under second-degree burned calf skin that healed by secondary intention, and that the medial sural perforator island flap or the medial sural perforator plus island flap can be safely used even though the skin may not be as pliable as normal skin.

Ocular surface area changes after double eyelidplasty

2012-02-23

Summary: Introduction: Double eyelidplasty is one of the most common cosmetic surgeries in Asia. Subjective enlargement of the ocular surface area (OSA) after double eyelidplasty was appreciated by patients. Objective measurement of the OSA provides a more scientific result. We introduce a relatively precise method, using iris as a scale combined with the digital photography and software calculation, to measure the OSA before and after double eyelidplasty.Materials and methods: One hundred and nineteen patients (108 females and 11 males) were enrolled in this study. Ninety-two patients received minimally invasive double eyelidplasty without other procedures and 27 patients received medial epicanthoplasty with modified Z-plasty besides double eyelidplasty. Digital photographs of the operative eyes in all patients were obtained preoperatively and postoperatively. The image processing software we used was ImageJ (v1.43, National Institutes of Health, United States). Preoperative and postoperative OSAs were measured. The percentage of difference of the OSA between two eyes in same patient before and after the operation was calculated and compared.Results: The average increase of the OSA among 238 operative eyes was 12.5 ± 8.2%. Preoperative and postoperative OSA differences between two eyes in same patients were significantly decreased after surgery.Conclusion: Digital photography using iris as a scale combined with software calculation is an easy and convenient method to measure the OSA; it provides quantitative information for both preoperative and postoperative evaluation. Our study revealed that double eyelidplasty not only increased OSA but also improved ocular asymmetry after surgery.

Dyslipidaemia and age-related involutional blepharoptosis

Motothugu Shirado — 2012-02-27

Summary: Background: The aetiology of age-related involutional blepharoptosis may be multifactorial. Dyslipidaemia may be involved in the pathogenesis of this disease, as dyslipidaemia, which is often related to ageing, is a risk factor for many disorders. The relationship between lipid profiles and age-related involutional blepharoptosis was evaluated to investigate this hypothesis. There are no known reference data in the literature examining the statistical association between dyslipidaemia and age-related involutional blepharoptosis.Methods: The study population was 251 consecutive Japanese patients aged 60 years or older who had at least one of the most common age-related changes of the eyelid and eyebrow, and who underwent surgical intervention. Blepharoptosis was defined as a marginal reflex distance of <2mm. Using strict exclusion criteria applied to all the patients regardless of eyelid position, 101 patients were finally enrolled. The selected demographic and clinical characteristics, as well as biochemical parameters including plasma lipids, were statistically compared between the patients who developed pure age-related involutional blepharoptosis and those who did not.Main findings: Dyslipidaemia was observed to be associated with the presence of age-related involutional blepharoptosis (odds ratio: 4.008, 95% confidence interval: 1.586–10.131, p=0.002). Univariate analysis revealed that triglycerides and non-high-density lipoprotein cholesterol were significantly higher in patients with age-related involutional blepharoptosis compared with those without blepharoptosis. With multivariate analysis, non-high-density lipoprotein cholesterol (p=0.003) and high-density lipoprotein cholesterol (p=0.044) were both significantly and independently associated with the presence of age-related involutional blepharoptosis, but in opposite directions (positive and inverse, respectively), whereas triglycerides were no longer significant.Conclusion: Dyslipidaemia, specifically atherogenic dyslipidaemia, should be considered as a possible determinant of age-related involutional blepharoptosis. Further studies are required to clarify the causal relationship between dyslipidaemia and age-related involutional blepharoptosis.

The IMAP flap for pharygoesophageal reconstruction following stricture release

R. Shayan, D.Y. Syme, D. Grinsell — 2011-11-28

Summary: Small-medium pharyngo-oesophageal or peri-tracheostoma defects represent a difficult reconstructive problem. Previous solutions included locoregional options such as the deltopectoral flap, or microvascular free tissue transfer. The authors present a novel application of the internal mammary artery perforator (IMAP) flap for reconstructing such defects. The IMAP flap may be mapped using pre-operative Doppler or CTA, and is raised on a single perforator. The relatively quick and simple flap raise provides robust fasciocutaneous tissue, may be tunneled subcutaneously to reach the neck and yields an inconspicuous donor site. The authors provide several cases demonstrating applications of the IMAP flap for reconstructing small-medium sized defects following release of annular pharyngoesophageal stricture, and studies documenting post-operative swallow. Overall, the pedicled IMAP fasciocutaneous flap is a useful technique to provide excellent composite tissue to reconstruct defects resulting from release of annular pharyngeal strictures. It is technically simple, and yields an inconspicuous anterior chest donor site.

Use of the LigaSure™ vessel sealing system in neurofibroma excision to control postoperative bleeding

Eri Konno, Kazuo Kishi — 2011-11-24

Summary: Background: The resection of neurofibromas in Von Recklinghausen’s disease (NF-1) is frequently complicated by potentially life-threatening intraoperative and postoperative hemorrhage, due to the high tumor vascularity and tissue friability.Methods: This report describes a novel technique for the resection of neurofibromas using the LigaSure™ (Valleylab, Tyco International Healthcare, Boulder, CO) vessel sealing system. We compared five cases of NF-1 tumor removal which used this vessel sealing system, with six cases that did not, and recorded the intraoperative and postoperative blood loss, length of hospitalization, and postoperative complications.Results: In all cases employing the LigaSure™, the perioperative blood loss was less than 600 ml (30 ∼ 570 ml), and no patient developed a postoperative hematoma or other bleeding complications. In contrast, the cases not using the LigaSure™ had greater blood loss as well as a higher rate of postoperative hematomas.Conclusions: The LigaSure™ provides excellent hemostasis with few complications when used for neurofibroma removal.

Extending the extended V-Y flap

Phoebe Prowse, Jonathan Morton — 2011-10-24

Summary: This case report demonstrates a modification of the so-called ‘Extended V-Y Flap’ used to simultaneously reconstruct a defect involving the upper lip, floor of nose and alar rim following tumour excision. We hope that this case serves as a reminder of the versatility of the V-Y flap in the nasolabial region, and its considerable capacity for augmentation.

Free-flap harvesting from paralytic limbs of poliomyelitis patients – A safe and feasible option

R.C.L. Chan, H.L. Liu, Y.W. Chan — 2011-12-02

Summary: Background: Many patients who had childhood poliomyelitis are still suffering from the late sequalae of the condition. Free-flap harvesting from the paralytic limbs from these patients is a logical approach for functional preservation. However, concerns have been raised regarding its safety due to its hypoplastic vascular system and potential donor site healing problems.Case report: A 53-year-old man with known childhood poliomyelitis presented with left facial sarcoma. After wide excision, the defect was reconstructed with a dual-island fasciocutaneous-free anterolateral thigh flap harvested from his paralytic limb. The pedicle and perforators were found to be no different from those in normal limbs. His recovery was smooth without complications.Conclusions: On the basis of our experience and current evidence in the literature, we believe that free-flap harvesting from the paralytic lower limb in poliomyelitis patients is a safe option that incurs no additional risk and allows maximal function preservation.

Paraspinous muscle flap for the treatment of an empyema cavity

Masaki Takeuchi, Hiroyuki Sakurai — 2011-12-02

Summary: For the reconstruction of defects localised near the midline region of the back, there have been occasional reports of reconstruction using a paraspinous muscle flap; however, to the best of our knowledge, there have been no reports of empyema space reconstruction using a paraspinous muscle flap. A patient who developed empyema after a pulmonary lobectomy and in whom a paraspinous muscle flap was used to reconstruct a dead space in the medial region of the upper back created by fenestration is presented. The dead space was filled sufficiently, and the patient had a favourable course without complications. Although the rotation arc of the paraspinous muscle flap is limited, the flap’s blood flow is stable, and flap elevation is easy and less invasive.The paraspinous muscle flap is useful for filling and closing a defect near the midline region of the back.

The cubital tunnel syndrome caused by the two synovial cysts

YongPing Li, Jie Lao — 2011-12-07

Summary: The cubital tunnel syndrome caused by several synovial cysts has been rarely reported. In our case, a 63-year-old man had sensorial and motor complaints at the ring and little fingers of the right hand. The claw deformity and the atrophy of the hypothenar and interosseous muscles in the right hand were discovered on physical examination. Froment’s sign was positive. Electromyography showed prolonged distal latencies and slowed conduction for ulnar nerve. A small spherical cyst within the cubital tunnel and another spindle-shaped cyst at the distal to the cubital tunnel were found to compress and wrap the ulnar and its branches intra-operatively. Finally, the cysts were removed and the ulnar nerve was decompressed and performed its anterior transposition. Synovial cysts were confirmed by histopathological examination.

Late infection of an alloplastic chin implant masquerading as squamous cell carcinoma

Charles J. Bain, Joy Odili — 2012-01-30

Summary: We present a case of infection of an alloplastic chin implant occurring 45 years after placement. The patient was referred to the clinic with an ulcerated submental lesion, which was thought to be a squamoproliferative lesion until surgery. The authors discuss the management of the case with reference to the literature on genioplasty and late infection of alloplastic implants.

Sitting on a gold mine: Optimal autologous reconstruction of a significant cosmetic contour defect of the buttock using a deep inferior epigastric artery perforator free flap

A. Thomas, O.A. Branford, D. Floyd — 2012-01-27

Summary: The options for reconstruction of soft tissue defects of the buttock include custom prosthetic implants and autologous tissue transfer: fat transfer, local flaps, pedicled flaps and free flaps. Optimal reconstruction involves replacement of like-with-like tissue, sufficient padding and adequate contouring. We report a case of a female patient presenting with a significant cosmetic contour defect of her left buttock following previous excision of a malignant fibrous histiocytoma. The patient had autologous buttock reconstruction using a deep inferior epigastric artery perforator free flap with an excellent result. To our knowledge a deep inferior epigastric artery perforator free flap has not previously been described to reconstruct the buttock.

A simple method for preventing pharyngocutaneous fistula after pharyngolaryngectomy using a mesenteric turnover flap

Takuya Iida, Makoto Mihara, Mitsunaga Narushima, Isao Koshima — 2011-11-21

Although a free jejunum transfer after a pharyngolaryngectomy for the treatment of hypopharyngeal carcinoma is widely performed, fistula formation remains a serious problem, especially in salvage cases after radiation therapy. Because fistula formation is potentially life-threatening due to the risk of rupture of the carotid artery, it is important to reduce the risk of fistula and abscess formation. We present a new simple prophylactic method for preventing fistula formation by reinforcing the jejunal suture lines with a mesenteric turnover flap (MTF) and its application in 12 cases.

Comments on: “A simple method for preventing pharyngocutaneous fistula after pharyngolaryngectomy using a mesenteric turnover flap”

Hung-Chi Chen — 2011-11-07

This method is useful to prevent leakage at the junction of jejunal flap and the pharynx. It is important to prevent leakage especially when the patients need postoperative radiotherapy. However, we should be careful in using this method:

A simplified landmark for the facial nerve trunk in parotidectomy: The sternocleidomastoid origin

Justin X. O’Brien, Warren M. Rozen, Jeannette W.C. Ting, Michael Leung — 2011-12-12

Facial nerve injury during parotidectomy or other procedures involving the head and neck is a feared complication, with facial paralysis having profound implications on patient quality of life. Only a precise understanding of its anatomical course and careful surgical technique can safely protect it during these procedures. As such, anatomical relationships that can aid protection of the nerve have been widely explored in the literature, and this journal has similarly offered much in terms of exploring these relationships.

Vacuum-assisted closure should not replace conventional therapy in the treatment of sternal wounds

Charles J. Bain, Steven Lo, Mark Soldin — 2011-12-12

We read the meta-analysis on vacuum-assisted closure (VAC) of infected sternal wounds with interest. The statistical analysis shows a significant reduction in length of stay using VAC as compared to ‘conventional therapy’ with no significant impact on mortality. The authors define VAC as ‘a system that promotes wound healing through the application of negative pressure by a controlled suction to the wound surface’ and suggest that it is a ‘valid alternative to conventional therapy’. The authors include a table of definitions of ‘conventional therapy’ from each of the six included papers. These therapies include debridement, pectoral muscle or omental flaps and closed irrigation techniques. In reality, these treatments vary vastly in their final outcomes, with superior results in mortality, chronic infection and hospital stay with flap reconstruction compared to washout and drains, shown in a prospective trial by Brandt and Alvarez. This still represents one of the highest levels of evidence of any study in this field, and is not superseded by the article of Damiani et al.

Perforator-supercharged local perforator-based (LP) flaps

Shimpei Ono, Rei Ogawa, Yoshihiro Takami, Hiko Hyakusoku — 2011-11-28

Local perforator-based (LP) flaps, local flaps based on perforator vessels, have become increasingly popular among surgeons during recent years. One disadvantage of the LP flap includes its limited size. If the potential LP flap’s size is smaller than the defect’s size, we usually need to choose other larger distant flaps, usually free flaps or distant pedicle flaps. In this situation, the operative indication is defined by the size of each LP flap. However, if possible, the LP flap is an ideal option particularly for covering the defects where aesthetic reconstructions are required such as face and neck. This is because the flap itself, being a local flap, provides an excellent colour and texture match at the recipient site. To overcome the limited size of the LP flap, a perforator supercharging technique has been applied to enlarge the original LP flap by the authors from 2002. We have performed a total of 18 cases of perforator-supercharged LP flaps with successful results.

Upper limb salvage following near skeletalisation

Dariush Nikkhah, Waseem Bhat, Andrew Williams, Grainne Bourke — 2011-12-05

Upper extremity limb salvage following near total skeletalisation remains difficult. Early robust soft tissue cover is crucial to enable restoration of future function. We describe the early management of a case that was repatriated to a UK trauma centre.

‘iReconstruct’: Clinically relevant plastic surgery apps

Adeyinka Molajo, Partha Vaiude, Alex Benson — 2011-12-06

We read Amin’s correspondence with interest. Amin suggested that there were few applications available to the plastic surgery trainee. The main applications (or ‘apps’) he described included Netter’s Anatomy flash cards and Leg fractures BAPRAS summary of the 2009 standards for the management of severe lower limb trauma. We agree that there are a large number of cosmetic type ‘apps’.

Pivoting distraction osteogenesis in hemifacial microsomia

2012-01-05

Bone elongation by gradual distraction osteogenesis is an innovative treatment for craniomaxillofacial deformities and has resulted in important changes in maxillo-mandibular approaches towards hemifacial microsomia.

Applications of suction diathermy in plastic surgical practice

Lucian Ion, Sherine S. Raveendran — 2012-02-20

Diathermy has an imperative role in the surgical practice and the technology underwent numerous modifications over the past years with introduction of many new devices in the market. Suction diathermy is one of the important innovations and is widely used in the otolaryngological practice. Several studies have reported the efficiency and safety of this instrument in minimising complications related to adenoidectomy in children.

Determining reactive hyperaemia time in Deep Inferior Epigastric perforators after temporary occlusion to allow the intraoperative comparison of vascular territories

Clare Jo Tollan, William M. Maclaren, Iain R. Mackay — 2012-03-15

Studies comparing the vascular territories of vessels to a flap, for example the DIEP and SIEA vessels in the lower abdomen, involve the sequential occlusion of vessels. By clamping, unclamping and reclamping, the vascular territories of each individual vessel can be compared. Microvascular studies describe a blood flow ‘stabilisation’ period of 10 min or longer after releasing the vessel clamp, before assessing a vessel using methods including laser Doppler, indocyanine green, videoangiography, tissue spectrophotometry and near-infrared. This period of reperfusion is ill defined and is of importance in intra-operative studies assessing multiple vessels in free flap transfer. The lower abdominal skin and Deep Inferior Epigastric Perforator (DIEP) flap was used as a model in this feasibility study, designed to clarify effects of different microvascular clamp times, and laser doppler scanning times following clamp release, to define the period of reactive hyperaemia, with a view to subsequently investigating physiological territories of vessels using intra-operative studies. Knowledge of these parameters would allow the design of further intra-operative studies and maximise the information gathered within operative time constraints.

A minimally invasive approach for the correction of a traumatic buttock deformity via wire subcision and volume replacement

Anthony Echo, Zachary K. Menn, Jeffrey D. Friedman — 2012-01-09

Depressed scars and other contour irregularities can have dense fibrous attachments or septae tethering the skin to the underlying structures. In such circumstances, without adequate skin release, volume replacement will often disperse around the area of depression. This will inadequately treat, and possibly augment, the area of depression. One option for correction is to perform an excision to remove the scar and septae; however, this could lead to further external scarring and significant downtime. When a depression or contour irregularity is not associated with an overlying external scar, direct excision is often a less than desirable option and a less invasive approach should be taken.

Fracture fixation through flaps

K.S. Alexander, W.L. Lam, I. Teo, J.G. Miller — 2012-01-20

Optimum management of open tibial fractures often requires a ‘fix and flap’ approach with the use of external fixators and muscle or other free flaps. Occasionally, due to the position of the wound and the fracture configuration (e.g. butterfly fragment) the pins or screws have to pass through the flap. Previous methods to overcome this problem have included dividing the flap and then wrapping the flap around the pin; a procedure which may compromise flap vascularity.

Securing fingertip dressings: The new ‘cinch pink’ technique

Maleeha Mughal, Anita T. Mohan, Olivier Alexandre Branford, Donald Dewar — 2012-01-12

Fingertip injuries are the most common type of injury faced by the hand surgeon. These include simple lacerations, nail bed injuries, crush injuries and tip amputations. Achieving a satisfactory dressing for these injuries is often difficult: The objectives are to apply an adequate dressing without compromising movement or the vascularity of the digit, whilst being robust enough to withstand the activities of daily living.

The PIP crisis: Déjà vu all over again?

M. Felix Freshwater — 2012-06-01

Until a few weeks ago, I thought that the initials PIP represented either proximal interphalangeal or positive interstitial pressure. I had no idea that they also stood for Poly Implants Prothèses. What has been called the “PIP Scandal” continues to mushroom with news finally crossing the pond. In Miami, “Gateway to the Americas”, we are now seeing patients with free gel who may have had PIP implants in Venezuela and Colombia.