Journal of Plastic, Reconstructive & Aesthetic Surgery

Back to the big tent

Howard Klein — 2010-03-01

I am constantly reminded about how different things are these days. Different especially in how plastic surgeons view themselves. When I began my training there was a segmentation between ‘real’ plastic surgeons (meaning those that did traditional reconstructive plastic surgery) and the cosmeticians (those surgeons who did cosmetic surgery). Even as a trainee I found this disingenuous. My experience was that as a plastic surgeon got more senior in his or her practice they tended to do more cosmetic surgery. The peculiar tension between experienced, respected plastic surgeons and what they were actually doing, versus the ridicule and shame heaped upon them for doing cosmetic surgery, always made me uneasy and was difficult to understand. This tension apparently all got too much when a group of surgeons decided to get together and announce their interest in aesthetic surgery. This group of surgeons formed their own society and proudly proclaimed themselves as aesthetic plastic surgeons. Thus the beginning of the long, cold journey between those surgeons who perceived themselves as real plastic surgeons, and those surgeons who did cosmetic surgery.

Venous malformations of the limbs: the Birmingham experience, comparisons and classification in children

Derick A. Mendonca, Ian McCafferty, Hiroshi Nishikawa, Ruth Lester — 2008-12-29

Summary: The management of vascular anomalies in upper and lower limbs is complex. The current practice at Birmingham Children's Hospital is based on a multidisciplinary approach, involving plastic surgeons, interventional radiologists, vascular surgeons, dermatologists and laser specialists. This study reviews the management strategies for peripheral venous malformations (VMs) and proposes a simple classification system to aid treatment.A retrospective review was undertaken involving all paediatric patients presenting with (VMs) of the upper and lower limbs, managed by the same multidisciplinary team over a period of 3 years. A total of 33 patients were identified, of whom 19 had lesions located in the upper limb. Treatment modalities included surgery, sclerotherapy, a combination of the two and conservative management. The indications for treatment included: (1) worsening pain, (2) increased swelling, (3) reduced function, (4) bleeding or ulceration and finally, (5) cosmetic deformity. Following treatment, outcome measures with regards to the symptoms were graded into (1) improved, (2) worsened and (3) unchanged.Based on magnetic resonance imaging, we were able to apply our classification to separate the lesions into Type 1a (superficial localised): nine, Type 1b (superficial diffused): five, Type 2 (Fascia/muscle infiltration): nine, Type 3 (Bone/joint infiltration): seven and Type 4 (Extensive whole-limb infiltration): three.In patients with upper limb VMs (n=19), eight lesions (42%) were superficial and localised (Type 1a) while the rest were diffused lesions. In contrast, in the lower limb (n=14), only one lesion (7%) was superficial while the rest were diffused lesions. Lower success rate for treatment was noted in lower limb malformations (p<0.05). In eight patients with recurrence of symptoms, six had Type 3 (intra-articular) lesions. There was one major and three minor complications following treatment.An outline of the management strategies for VMs in peripheral limbs is discussed in this article. An anatomical classification is described which aids in management and communication.

Congenital duplication of lower extremity – A case report and review of the literature

Y. Osaki, S. Nishimoto, T. Oyama, Y. Yoshimura — 2009-03-09

Summary: Congenital duplication of the lower extremity is quite rare. Only 26 cases have been reported so far.A female infant with incomplete duplication of lower limb and with hypothyroidism was reported. Her mother's pregnancy and delivery was uneventful. A tube-like skin tissue was found on the posterior aspect of the infant's left thigh. Her left foot presented equinovarous deformity. There were three extra toes on the plantar side of her foot. A band of skin with a thin horny layer, similar to the dorsal surface, could be seen on the sole. The skin tube on the thigh was simply resected. A neuro-vascular-islanded toe was made from the plantar toes and rotated to restore five toes on the foot. The transferred toe thrived in accordance with the surrounding toes. The patient could run without difficulty at the age of 3.Previous reports about this case are summarised and reviewed here.

Objective outcome assessment of the modified Bretteville Technique

L.A. Reid, A.P. Curnier, J.H. Stevenson — 2009-02-09

Summary: The paradigm for hypospadias repair is a straight, erect penis, with a vertical meatus at the tip of the glans that provides satisfactory urination and is cosmetically acceptable to the patient.We provide objective outcome data on 40 cases of hypospadias repaired using the modified Bretteville technique. The ‘HOSE’ questionnaire, flowmetry, wetted pad and spray pattern analysis in combination with other questionnaire data were obtained to evaluate the long-term results of the modified Bretteville technique. The average HOSE score was 15/16. Cosmesis is good, with average scores of 7.1/10 (patient) and 7.6/10 (doctor). HOSE assessment is good, with 85% of patients scoring 14 or over. Uroflow rates are very good for a hypospadiac population with 82.5% of the patients within normal limits for their age group.Wetted pad and spray pattern analysis showed 56% of patients sprayed more than 3g of urine compared to 11% in a junior football team acting as control, although there was little correlation between this objective assessment and the patients' perceived symptoms as assessed by the questionnaire.The modified Bretteville hypospadias repair provides a reliable epithelialised repair of consistent dimensions with good patient-reported cosmesis and excellent functional outcomes.

One-Stage Integra reconstruction in head and neck defects

Andrew Burd, Pauline S.Y. Wong — 2009-03-02

Summary: Background: Integra™ dermal regeneration template – a two-stage, tissue-engineered, artificial skin – was introduced in the UK in May 1996. There were no restrictions on clinical application and a series of applications in reconstructive surgery were undertaken. One case involved a Caucasian lady with a nose tip basal cell carcinoma (BCC) who had a single-stage reconstruction. The 6-year follow-up was remarkable as it showed a scarless repair.Objective: We undertook a clinical evaluation to explore the outcome of one-stage Integra™ reconstruction in a selected series of Chinese patients.Methods: Ten patients (five male and five female; age range: 54–86 years) with complicated or atypical cutaneous lesions involving the head and neck were treated in an outpatient setting.Results: Pathology revealed eight BCCs, one squamous cell carcinoma (SCC) and one seborrhoeic keratosis. Healing took place either by wound contraction alone or in conjunction with re-epithelialisation. All wounds were fully healed within 6 weeks. Follow-up ranged from 18 to 30 months, and there has been no recurrence of the malignant lesions.Conclusion: In selected cases, one-stage reconstruction using Integra™ can reduce operating time with no delay for frozen section, flap raising or graft harvesting. More immediate postoperative care is needed, but the long-term aesthetic results are uniformly acceptable.

Occipital artery Island V–Y advancement flap for reconstruction of posterior scalp defects

Ramesh Kumar Sharma, Puneet Tuli — 2009-02-17

Summary: Background: The management of the posterior scalp defects with ‘similar’ tissue can be challenging. Currently available techniques of transposition/rotation result in creation of unwanted dog ears, change in direction of hairs and patches of skin-grafted areas with alopecia. We describe a new method of reconstruction of full-thickness scalp defects in the occipital region by moving the locally available scalp tissue in a V–Y advancement manner. The islanded flap is based upon the ipsilateral occipital artery in the substance of occipitalis muscle. The donor site/s can be closed primarily and the operation performed in a single stageMaterials and methods: A total of seven patients have undergone reconstruction in the last 2 years with this technique. The defects in the posterior scalp region resulted either from the electrical burns (two patients), tumour excision (two patients), encephalocoele excision (one patient) or post-traumatic loss of the scalp (two patients). In all the patients the underlying bone was exposed. The remaining scalp tissue in the vicinity of the defect was moved as a V–Y advancement flap either unilaterally or bilaterally depending upon the size of the defect. The pedicle of the flaps contained ipsilateral occipital vessels at the base. The flaps were raised in the subgaleal plane and the pedicle included ipsilateral occipital artery in the substance of the occipitalis muscle.Results: The donor area could be closed primarily in all cases. All the flaps survived completely; one patient had postoperative superficial loss that eventually healed with dressings. All the wounds healed primarily with luxuriant hair growth, except one patient who had partial alopecia in the transferred flap although the flap survived completely.Conclusion: The islanded occipital artery V–Y advancement flap provides a one-stage hair-bearing scalp tissue for closure of medium and moderately large defects (up to 7×6.5cm2) in the posterior region of the scalp with primary closure of the donor site.

The orbicularis oculi muscle flap: Its use for treatment of lagophthalmos and a review of its use for other applications

F. Stagno d'Alcontres, G. Cuccia, F. Lupo, G. Delia, M. Romeo — 2009-01-15

Summary: Background: The management of lagophthalmos in patients with long-standing facial palsy is difficult, since the immobility and scleral show have to be corrected to protect the vision. In this article, the authors describe the treatment of paralytic eye with a static technique using a medially based orbicularis oculi muscle flap (OOMF) from the upper eyelid in patients with lagophthalmos.Patients and methods: From April 2006 to May 2008, five Caucasian patients with ages ranging from 45 to 71 years (mean, 61 years) were treated at the Plastic Surgery Unit of Messina University. All patients underwent orbicularis oculi muscle (OOM) transposition flap to support the lower orbicularis oculi and create a suspension of the eyelid. To validate the anatomical features of the OOM transposition flap, four fresh cadaver heads (eight eyelids) were dissected to demonstrate flap viability, feasibility and suspension effect.Results: We achieved resolution of the lagophthalmos and good cosmetic appearance in all cases. The distance between the upper and lower eyelid points during eye closing (as for sleep) was reduced postoperatively on the paralysed side compared to the contralateral healthy side. Follow-up time ranged from 3 to 25 months (mean, 12 months). All patients healed well with no complications of the flaps. There was no flap contraction, recurrent deformity or significant donor-site morbidity in the follow-up period. The incision scars were almost invisible.Conclusions: The authors believe that the switching of upper blepharoplasty technique from the upper eyelid to the paralysed and scarred lower lid can be used as a tool to treat lagophthalmos.

Total nose reconstruction using superselective embolisation and a forehead flap: overlooked in recurrent massive vascular malformations of the nose

Jong Woo Choi, Joon Pio Hong, Mu young Lee, Dea Chul Suh — 2009-03-25

Summary: Objectives: Massive vascular malformations of the nose cause serious cosmetic, functional and psychological problems. Generally, no single treatment modality to date has provided satisfactory results. Therefore, multidisciplinary treatment approaches are being standardised. In spite of standard multidisciplinary treatments, especially postoperative outcomes in massive nasal vascular malformation cases are often aesthetically and functionally unsatisfactory due to the unique characteristics of the nose. While several studies report on the management of facial vascular malformations using local and distant flaps, none is specific to the nasal region.Materials and methods: The present article describes the treatment of four patients with recurrent massive nasal vascular malformation (which invades more than two-thirds of the nose) using a combined-procedure approach involving preoperative superselective embolisation, extensive (en bloc) malformation resection and nasal reconstruction using a paramedian forehead flap. Patients were followed up for a mean of 19 months. Preoperative assessments included MR angiography, selective angiography and physical examination, including Doppler sonography. Preoperative superselective embolisation was then performed by a radiologist. On post-embolisation day 2, patients underwent en bloc resection and total nasal reconstruction with paramedian forehead flap hitherto overlooked in the treatment of nasal vascular malformation.Results: Satisfactory results were achieved in all four patients. Three patients suffered a high-flow malformation and one suffered a low-flow malformation. As confirmed by the radiologist, no recurrences were noted. Colour matching and nasal contouring were satisfactory in all cases. There were no major complications such as serious infection, recurrent ulceration, postoperative bleeding or flap failure. All patients responded positively.Conclusions: The present novel treatment of massive vascular malformations of the nose using selective embolisation, en bloc resection and a paramedian forehead flap was successful. The findings indicate that this treatment of massive nasal vascular malformations leads to successful functional and aesthetic outcomes. The patients were followed up for an average of 2 years and ongoing follow-up is scheduled.

Oral commissure reconstruction with orbicularis oris elastic musculomucosal flaps

2009-02-06

Summary: Surgical reconstruction of the oral commissure aims to restore both symmetry of the lips at rest and, more importantly, full oral competence. Moulding the lip commissure with functional and cosmetic fidelity remains till today a difficult task.A possible surgical solution, the ‘elastic flap’ principle described by Goldstein, may be found in the wide full-thickness mobilization of the upper and lower vermilion as two composite myocutaneous flaps – tissue sandwiches consisting of labial skin, orbicularis oris muscle and oral mucosa – on the axial pattern of the superior and inferior labial arteries. Based on the contralateral commissure, both flaps are easily ‘stretched’, accordion-like, to reach the predetermined point of the new commissure, using to full advantage the inherent elastic potential of both vermilions. The fibres of the orbicularis oris muscle at each end of both flaps are embricated to reconstitute a neo-modiolus, which is anchored to the residual buccinator muscle in primary reconstructions, or to the available peri-oral fibrous tissue in secondary procedures.The authors present a select group of 22 patients, who, between 1993 and 2008, underwent this reconstruction procedure for primary or secondary defects involving the oral commissure. The results were generally satisfactory, both functionally and cosmetically.The advantages of this procedure include full restoration of the dynamic function of the orbicularis ring in a single-stage operation and avoidance of either lipswitching procedures or of mobilization of mucosa and cheek skin. The final scars remain well camouflaged within the oral mucosa and the mucocutaneous junction of each lip.

Two small flaps from one anterolateral thigh donor site for bilateral buccal mucosa reconstruction after release of submucous fibrosis and/or contracture

2009-04-10

Summary: Oral submucous fibrosis causes health-related and social problems for affected patients. Free flap reconstruction has proved effective for maintaining mouth opening after release of fibrosis. Two independent free flaps from separate donor sites, such as bilateral forearm flaps or bilateral anterolateral thigh (ALT) flaps, were traditionally required for reconstruction. The former option sacrifices one of the two major arteries in the forearm. Both options are time consuming and required two donor sites. To eliminate these disadvantages, we developed a technical modification that allows harvesting of two independent flaps from one ALT thigh based on one descending branch of the lateral circumflex femoral artery (d-LCFA). Eighteen flaps from nine donor sites were harvested for post-release reconstruction of oral submucous fibrosis. Mean flap size was 4.1×7.5cm, mean pedicle length was 7.6cm, mean ischaemia time was 104min and mean total operation time was 13h and 19min. All donor sites were closed primarily, with one exception. One flap failed and was replaced with a contralateral ALT flap. One patient developed a wound infection and another developed a seroma at the recipient site. Four flaps required secondary de-bulking in three patients. The improvement in mouth opening was evaluated by inter-incisor distance (IID): mean preoperative IID was 9.6mm (range: 0–20mm), mean follow-up time was 16.2 months (range: 10–33 months); mean postoperative IID was 23.8mm and mean improvement in IID was 15.3mm (range: 10–27mm). In conclusion, two independent flaps can be harvested from d-LCFA of the same thigh, instead of from both thighs, to reconstruct bilateral buccal defects after release of submucous fibrosis and/or contracture.

Artery-dominant free jejunal transfer

2009-02-23

Summary: Although the supercharge (additional microvascular anastomosis) technique is often used in pedicled transfer of parts of the gastrointestinal tract, this is rarely performed during free jejunal transfer (FJT). The differences in blood circulation and outcomes between the usual single pedicle flap and a double pedicle flap are not well known. Therefore, we evaluated the effect of an additional arterial anastomosis in FJT.The FJT was performed using one venous and two arterial anastomoses after hypopharyngeal cancer ablation. To assess the effects of an arterial supercharge, blood–gas analysis, including the venous partial pressure of oxygen (pO2) and partial pressure of carbon dioxide (pCO2), was performed on samples drawn thrice from the jejunal vein: before harvest, after the anastomosis of a paired artery and vein and after an additional arterial anastomosis.The result revealed that the venous pO2 was elevated by the additional arterial anastomosis, compared with the two other measuring times (P=0.04). The venous pCO2 did not show significant changes.By being given a dominant artery, a jejunal flap can develop a physiological circulatory environment and can establish nutritional pathways without adverse effects.

Biomechanical stability analysis of rigid intraoral fixation for bilateral sagittal split osteotomy

Lee Ming-Yih, Lin Chun-Li, Tsai Wen-Da, Lo Lun-Jou — 2009-01-05

Summary: Background: Biomechanical stability in patients in whom mandibular prognathism was corrected with different fixation methods during bilateral sagittal split osteotomy (BSSO) surgery remains controversial and needs to be clarified.Methods: A three-dimensional (3D) finite element (FE) model of the mandible was developed to simulate the biomechanical responses of osteo-synthesis screws and the stability of different screw-placement arrangements in BSSO. Six types of fixation methods for the osseous segments were simulated with two or three screws in different placement arrangements to avoid injury to the inferior alveolar nerve.Results: A triangular configuration of the screw position across the nerve presented less stress loading than the linear configuration, and hence provided better stability as the preferred fixation method for BSSO of the mandible. When the screws were aligned in a linear setting, the stress values were 4 times higher, implying a less stable fixation. Neither two nor three screws applied at the superior border appeared to be better at exploiting the increased thickness of the cortical bone encountered in this region.Conclusions: According to the 3D-FE analysis, the configuration with three screws inserted in a triangular shape across the inferior alveolar nerve (Type 4) demonstrates the best rigidity among six screw-placement configurations. Three 2.3-mm diameter bi-cortical screws were considered a sufficient fixation tool after BSSO of the mandible.

Improvement of the maxillary bone growth suppression in the cleft palate operation with cultured dermal substitute: animal experiment and patient reports in preliminary clinical application

N. Kurokawa, K. Ueda, Y. Kuroyanagi — 2009-03-02

Summary: Cleft palate patients often show impaired maxillary bone growth after cleft-palate-correction surgery. We attempted to investigate and elucidate the effects of using allogeneic, cultured dermal substitute (CDS) to cover an exposed, palatal bone surface in animal experiments. Fibroblasts from the abdominal skin of Wistar rats were cultured. Subsequently, the fibroblasts were seeded onto a matrix that composed of hyaluronic acid and atelo-collagen. Forty Wistar rats (3-week-old males) were assigned to one of four groups: control, open-treatment, matrix and CDS groups. The control group (n=5) received no surgical operations. In the open-treatment group (n=11), the mucosa and periosteum of the left-half of the palate were removed surgically and the bone was exposed. In the matrix group (n=11), the area of exposed bone was covered with only the matrix, excluding any cells. In the CDS group (n=10), the area of exposed bone was covered with CDS.At 9 weeks postoperatively, biopsies of the wounds were obtained. Skull preparations were made and the palatal widths were determined. The palatal widths in the CDS group were significantly wider compared to the matrix and open-treatment groups (P<0.05). However, there were no significant differences when the CDS group was compared to the control group. Haematoxylin, eosin and CD31 immunostaining confirmed a larger number of capillaries in the CDS group. This animal experiment suggested that this procedure might provide an optimum wound-healing condition, thus, reducing the maxillary bone-growth suppression. Therefore, a preliminary clinical application in three patients was performed using the autologous CDS after the pushback method.

The healing of critical-sized bone defect of rat zygomatic arch with particulate bone graft and bone morphogenetic protein-2

Myung Good Kim, Dong Min Shin, Sang Woo Lee — 2009-01-27

Summary: For some critical-sized bony defects in the facial bones, it is necessary that the defect be reconstructed using an autologous bone graft from another donor site, not only to ensure stability, but also to derive aesthetic contouring. However, because of the easy gain and easy moulding of particulate bone, it would be easier to reconstruct the defect by using particulate bone graft (PBG) rather than block bone graft (BBG). This study was designed to confirm the usefulness of PBG with bone morphogenetic protein-2 (BMP-2) instead of BBG and to observe its long-term outcome in critical-sized zygomatic arch defects in a rat model. A sample of 18 Sprague-Dawley rats was divided into three groups; a 5-mm critical-sized bone defect was made in both zygomatic arches of all subjects. Each group was treated with different combinations of BMP-2 and PBG. At 2, 4, 8 and 12 weeks after treatment, each defect was compared radiologically. Histological evaluation was performed after 12 weeks. In the first group, the defects with PBG decreased more than in those with no bone graft (P<0.01). In the second group, defects with PBG and BMP-2 decreased more than in those with PBG alone (P<0.01). In the third group, there was no significant difference between the group with PBG and BMP-2 and that with in situ bone graft (instead of BBG). In conclusion, PBG with BMP-2 showed satisfactory bone healing without any additional bone graft in the animal model.

Angiogenesis and osteogenesis of non-vascularised autogenous bone graft with arterial pedicle implantation

Yao Yao, Chengge Hua, Xiufa Tang, Ya Wang, Fugui Zhang, Zhao Xiang — 2008-12-24

Summary: This study aims to investigate the effect of arterial pedicle implantation on angiogenesis and osteogenesis of autogenous bone graft.In this study, 36 New Zealand white rabbits were evaluated, in which free radial bone grafts without periosteum were harvested and implanted into the masseter muscles. In group 1, on the one side, the external maxillary artery pedicle was passed through the bone marrow cavity. In group 2, on the other hand, as control, no arterial pedicle was implanted. Microvessel density was assessed by India ink perfusion and integrated optical density of tetracycline fluorescence labelling was used to evaluate angiogenesis and new bone formation at 3 days and 1, 2, 3, 4 and 6 weeks postoperatively.The bone grafts were found to be re-vascularised at 3 days postoperatively in group 1, and at 2 weeks in group 2. At 2, 3 and 4 weeks postoperatively, the microvessel densities of group 1 were significantly higher than those of group 2. At 4 weeks postoperatively, angiogenesis of group 1 reached a peak. The tetracycline fluorescence labelling integrated optical densities of group 1 were significantly higher than those of group 2 from 2 to 6 weeks postoperatively.Implantation of arterial pedicle into non-vascularised autogenous bone graft enhances angiogenesis, and increased angiogenesis enhances osteogenesis.

Transplanted endothelial progenitor cells increase neo-vascularisation of rat pre-fabricated flaps

2008-12-31

Summary: Background: Flap pre-fabrication is dependent on the eventual re-vascularisation of the implanted vascular carrier and the presence of a desirable, donor-skin site. However, insufficient neo-vascularisation and subsequent necrosis is an obstacle for this technique. A recent discovery demonstrated that endothelial progenitor cells (EPCs) augment post-natal neo-vascularisation in ischaemic tissues. As a result, we examined whether transplantation of bone-marrow-derived EPCs (BM-EPCs) increases neo-vascularisation and augments the survival areas of pre-fabricated flap in a rat model.Methods: Rat bone-marrow-derived mononuclear cells (BM-MNCs) were isolated by density gradient centrifugation and cultured in EGM-2MV. The EPCs derived from BM-MNCs were identified by surface makers such as CD34, KDR, CD133 and double-positive staining with 1,1′-dioctadecyl-3,3,3′,3′-tetramethylindocarbocyanine-labelled acetylated low-density lipoprotein (Dil-Ac-LDL) and FITC-labelled Ulex europaeus agglutinin-1 (FITC-UEA-1). Pre-fabricated flaps were created by ligating the right femoral vascular pedicle and implanting it underneath the abdominal flap. Forty-five rats were randomly divided into three equal groups. The implantation site around the pedicle was injected subcutaneously with fluorescence-labelled BM-EPCs in group I (n=15), with vascular endothelium growth factor (VEGF) protein in group II (n=15) and with phosphate-buffered saline (PBS) in control group III. Four weeks after injection, the abdominal island flap was elevated and sutured back. Then, neo-vascularisation and flap viability was evaluated on day 7. The labelled EPCs were examined by fluorescence microscopy.Results: After 7 days of culture, the attached cells were spindle shaped and expressed CD34, KDR and CD133. These cells incorporated DiI-Ac-LDL and bound FITC-UEA-1. Greater augmentation of flap survival (87.26±10.13% vs. 66.13±9.9% and 55.59±13.06%, P<0.001), higher capillary density (38.67±9.52 capillaries per mm2 vs. 25.83±6.34 capillaries per mm2 and 26.5±5.61 capillaries per mm2, P<0.05) and larger vascular territories on the microangiogram were observed in the EPCs-treated group relative to the other two groups. The labelled cells formed new vessel structures and expressed von Willebrand factor (vWF) in the pre-fabricated flap.Conclusions: Local transplantation of BM-EPCs may be a useful strategy for increasing the survival of pre-fabricated flaps, which is consistent with ‘therapeutic vasculogenesis’. EPCs are superior to VEGF in their neo-vascularisation ability.

The effect of centrifugation on viability of fat grafts: an evaluation with the glucose transport test

Yun Xie, Danning Zheng, Qingfeng Li, Yu Chen, Hua Lei, Lee L.Q. Pu — 2009-01-07

Summary: Background: An up-to-date, simple, but useful technique to evaluate the viability of fat grafts prior to transplant is lacking. The purpose of this study is to introduce the glucose transport test – a new method to evaluate the viability of fat grafts after they are subjected to different centrifugal forces in vitro.Method: Fat grafts were harvested from healthy patients who underwent liposuction for body contouring. The glucose transport test was performed to evaluate the viability of fat grafts after centrifugation with different forces (1000–4000rpm). An MTT assay was also performed with the same experimental protocol for comparison. Routine histological examination was done in all groups to examine possible structural destruction after centrifugation.Results: When compared with the group not subjected to centrifugation, the glucose transport test showed a significant decrease in viability of fat grafts in all of the other four groups (all p<0.001). There was a linear reduction of viability in fat grafts with the increase in centrifugal force (all p<0.03). MTT assay showed similar findings on the viability of fat grafts in all five groups and correlated well with the glucose transport test (r=0.9870). Histology showed significantly distorted and fractured adipocytes when the centrifugal force reached 4000rpm.Conclusion: Our study demonstrates the harmful effect on the viability of fat grafts with an increase in centrifugal force and, for the first time, that the glucose transport test may be an effective and potentially useful method to evaluate the viability of fat grafts in a clinical setting.

The unilocular fat-cell graft

H. Ohara, K. Kishi, T. Nakajima — 2009-01-30

Summary: Autologous fat grafting has become a common procedure for augmenting soft tissue. However, there are still some problems with resorption and cyst formation after injection, which mainly arise from insufficient nourishment of the transplanted fat tissues. In this study, using a mouse model, we enzymatically digested fat tissues into unilocular fat cells, and then transplanted the unilocular fat cells by sub-dermal injection to allow the transplanted cells to easily spread within the injected area. Fat tissue was harvested from a green fluorescent protein transgenic mouse (C57BL/6), and the optimal digestion time was determined to be 30min. The fat cells were then injected into the sub-dermal layer of the head skin of a C57BL/6 mouse. As a control, minced fat without digestion was also injected. The animals were sacrificed immediately after injection and on days 1, 2 and 3, as well as at weeks 1, 2 and 4 after injection, and the recipient skins were collected for microscopic observation. The unilocular fat cells were observed to spread in a solitary manner among the recipient tissues, and no necrotic areas or cysts were observed. The minced-fat-graft control showed central necrosis in the transplanted region. In addition, the minced fat tissue needed to be injected with an 18-gauge syringe, but the unilocular fat cells could be injected with a 26-gauge syringe. Thus, the unilocular fat-cell graft was determined to be a superior alternative to conventional fat grafts.

Self-esteem and personality in subjects with and without body dysmorphic disorder traits undergoing cosmetic rhinoplasty: preliminary data

2008-12-31

Summary: Background: Many individuals with body dysmorphic disorder (BDD) seek non-psychiatric treatment. BDD occurs in about 5% of patients who seek cosmetic surgery, and rhinoplasty is the most frequently sought treatment. A correlation exists between individuals' self-esteem and demand for cosmetic surgery.Objective: To investigate whether those subjects with BDD traits requesting cosmetic rhinoplasty differ from those without BDD traits in self-esteem, personality and quality of life.Methods: This study included 54 patients applying to the 1st ENT Division of Turin University. Assessment of the patients before cosmetic rhinoplasty includes: nasal obstruction symptom evaluation, health-related quality of life, Rosenberg self-esteem scale, body dysmorphic disorder questionnaire (BDDQ) and temperament and character inventory (TCI). Based on their responses to BDDQ questions 1, 3 and 4, patients were subdivided into subgroups and then compared.Results: No difference emerged in the objective data. Lower self-esteem, higher harm avoidance (HA) and lower self-directedness (SD) are found in subjects who are worried about how they look, in those with interference in their social life due to this worry and in those who spend more than 3h per day thinking about the way they look. Novelty seeking (NS) is significantly higher in subjects who think about their looks for up to 3h than in those who spend less than 1h.Conclusion: Different subgroups of patients are identified. The first group includes pessimistic, shy, insecure subjects; people with fragile and immature personality and poor self-esteem; individuals concerned about the way they look and those who spend more time thinking about it. The second group includes more confident subjects with stronger personality and greater self-esteem. A third, less differentiated group, includes more impulsive (high NS) subjects who spend an intermediate amount of time thinking about the way they look. Patients should be carefully screened and assessed before cosmetic surgery interventions to avoid frustration to both, clinicians and patients.

A new technique for repair of acquired split-ear-lobe deformity: the free conchal cartilage sandwich graft

Rajiv Agarwal, Ramesh Chandra — 2008-12-22

Summary: Background: Split-ear-lobe repair is one of the commonest requests in cosmetic facial surgery. Frequently, the ear lobe split is prone to recurrence following surgical repair. A new technique is described that strengthens the ear lobe tissues using locally available conchal cartilage to prevent recurrence. A new classification of split ear lobe is also presented.Methods: Twenty-two women in the age range from 18 to 62 years with varying grades of split ear lobe were operated using the technique of conchal cartilage reinforcement of ear lobe. Eight females had bilateral involvement, and a total of 30 split ear lobes were repaired. A conchal cartilage disc was harvested at the time of repair of the ear lobe. This disc was placed in a pocket created in the ear lobe, and the ear lobe was repaired over this pocket. Simultaneous re-perforation of the ear lobe was done in a central location through the implanted conchal disc, and stud earring was applied.Results: Satisfactory aesthetic and functional results have been obtained in the series using the technique of conchal cartilage-graft augmentation of the ear lobe. All patients had high degree of satisfaction in being able to come out of the operating room with earrings on. There has been no stretching or re-tear of the ear lobe following implantation of conchal cartilage, over a follow-up period of 36 months.Conclusion: The conchal cartilage-graft sandwich procedure allows immediate re-perforation of the repaired ear lobe at the time of repair in a central aesthetic location, as well as providing necessary strength to the ear lobe; thus preventing recurrence in primary and recurrent, acquired split-ear-lobe deformity.

Use of the microdebrider for treatment of fibrous gynaecomastia

Terence Goh, Bien Keem Tan, Colin Song — 2009-01-15

Summary: Background: In the quest for reduced scars and better aesthetic outcomes in minimally invasive surgical techniques for gynaecomastia, suction-assisted lipoplasty and ultrasound-assisted lipoplasty are now considered accepted recent advancements. Nevertheless, the fibrous glandular breast disc encountered in young, thin patients requires a separate peri-areolar incision as the disc cannot be removed with suction lipoplasty. The use of a microdebrider (powered shaving rotary device) is a potential solution to this problem.We present a series of eight patients with fibrous gynaecomastia that was successfully treated in this way.Method: The surgery is performed under general anaesthesia. The microdebrider cannula is used to remove the fibrous glandular breast tissue. Drains are inserted and fibrin glue is sprayed subcutaneously. Patients are discharged on the next day. Drains are removed on the 5th postoperative day. A compressive vest is worn for 6 weeks. (A video of the procedure can be seen on http://www.microflap.com/video3.asp).Results: The eight patients were successfully treated. No bleeding, haematoma or seroma was encountered. All patients were satisfied with the results of the surgery.Conclusion: The microdebrider is a viable solution in the treatment of gynaecomastia with a fibrous breast disc. Excellent aesthetic results can be achieved with a single 3-mm incision.

Immediate breast reconstruction in the elderly: can it be considered an integral step of breast cancer treatment? The experience of the European Institute of Oncology, Milan

2008-12-25

Summary: Background: In the last few decades, breast reconstruction often has not been offered to the elderly population due to the reluctance of clinicians concerned about serious co-morbidities. This study aims to demonstrate that breast reconstruction is feasible and safe in the elderly cohort.Methods: Between 1999 and 2004, 63 elderly patients underwent an immediate reconstruction after breast cancer treatment at the European Institute of Oncology. A conservative treatment, combined with breast repair by plastic surgical techniques, was performed in 14 patients. In the remaining 49 patients, a modified radical mastectomy was necessary in 30 breasts, a total mastectomy in 19, a subcutaneous mastectomy in one case and a radical mastectomy in one patient. Three nipple-sparing mastectomies, along with intra-operative radiotherapy, were performed in two patients. A definitive silicone implant was used in 41 breasts and a skin expander in eight cases. A latissimus dorsi flap was performed in two patients, a pedicled transverse rectus abdominis muscle (TRAM) flap in two cases and a local advancement fasciocutaneous flap in another two patients.Results: In all patients, surgery was well tolerated despite patient age. No systemic and medically unfavourable events occurred in the immediate and late postoperative period. Infection occurred in four patients (6.34%) and partial necrosis of the mastectomy flaps in three cases (5.5% of the mastectomies). Capsular contracture grade III and IV was reported in four cases (8.89%). Total implant removal was rated 12.24%, due to infection (three prostheses), exposure (one expander) and capsular contracture grade IV (two implants).Conclusions: Implant-based technique of breast reconstruction should be made available to the elderly population.

The use of free vascularised bone grafts in spinal reconstruction

H.A.H. Winters, A.E. van Engeland, T.U. Jiya, B.J. van Royen — 2009-01-05

Summary: The use of free vascularised bone grafts (FVBGs) is an infrequently performed surgical technique for the reconstruction of spinal defects. This field of surgery brings many challenges concerning choice of FVBG, planning of the operative procedure and selection of recipient vessels. This study aims to report our experience with FVBGs, with special emphasis on the planning and surgical technique.Over a period of 10 years (1994–2004), we used FVBG for anterior spinal reconstruction in 23 patients. In 21 patients, a free vascularised fibular graft was used, and in two cases a free vascularised iliac crest graft was used. The spinal segments reconstructed involved the cervical spine (4 cases), the thoracic spine (13 cases) and the thoraco-lumbar and lumbo-sacral spine (6 cases).Re-vascularisation of the FVBG proved to be technically feasible in 22 patients, but failed in one fibular graft due to difficulties with recipient vessels in the lumbar spine. When necessary, the fibula was osteotomised and folded in a double-, triple- or quadruple-barrel construction to increase the strength of the reconstruction. Technical challenges were met with respect to the choice of the recipient vessel at various anatomical sites.The use of FVBG is a valuable technique for the reconstruction of complex spinal disorders. Successful execution requires microvascular expertise with respect to graft harvesting and appropriate choice of recipient vessels. Adequate preoperative planning in a multidisciplinary setting and adherence to the basic principles for spinal reconstruction are required.

A variation in the component separation technique that preserves linea semilunaris: a study in cadavers and a clinical case

2009-02-17

Summary: The purpose of this study is to evaluate and compare the effect of the incision of the external oblique aponeurosis along the semilunaris in amount of tension present after the undermining of the anterior rectus sheaths. Forty fresh adult cadavers were studied and divided into two groups: group A (n=20) and group B (n=20). Traction indexes were compared in three situations: (1) before any aponeurotic undermining (similar on both groups); (2) after incision and undermining of the anterior rectus sheaths (similar on both groups) and (3) group A: after undermining of the external oblique muscles with the incision of their aponeurosis along the semilunaris and group B: undermining of a continuous layer of the anterior rectus sheaths and the external oblique aponeurosis, after release of the lateral aspect of the rectus sheaths. Significance of differences was assessed using non-parametric tests. There was a significant tension reduction after each stage of dissection in both supra- and infra-umbilical levels and on both groups. Comparisons between groups A and B did not show statistically significant differences in all sites and stages of the dissections. Therefore, both techniques showed similar aponeurotic tension reduction after each stage of the dissections in cadavers.

Effects of hyperbaric oxygen on the replanted extremity subjected to prolonged warm ischaemia

2009-03-26

Summary: In this investigation, the influence of hyperbaric oxygen (HBO) therapy on the survival of a replanted extremity subjected to prolonged warm ischaemia is evaluated. Among the relative contraindications to replantation are prolonged warm ischaemia time, since an obstruction to blood reflow (‘no-reflow phenomenon’) may occur in amputated parts that are subjected to more than 6h of warm ischaemia.Twenty-three rat hindlimbs were amputated and subjected to 4h of normothermic ischaemia. The average weight of the animals was 500gm, and re-plantation of the hindlimb was performed by bone fixation followed by microvascular anastomosis of the femoral vessels. Limb re-vascularisation was confirmed at the end of all procedures by the milk test, clinical assessment and pulse oximetry recordings (>90%). Eleven animals served as a control group and no further therapy was instituted, whereas 12 animals served as the study (replantation) group and were subjected to HBO therapy for 3 days postoperatively. The therapy was conducted in a large animal chamber for 90min at 2.5ata. Limb survival was assessed by capillary refill upon compression, skin turgor assessment and colour. Confirmation of clinical findings was conducted with daily pulse oximetry readings of >90%. Animals were followed up for 7 days at which point all animals were euthanised or were euthanised earlier if a non-viable limb was present.Two of the 11 limbs in the control group survived following re-plantation, whereas eight of the 12 limbs in the experimental HBO group survived at least 7 days following replantation. This difference was statistically significant (p=0.0361) using chi-square analysis and Fisher's exact test.Although re-plantation of an amputated extremity after prolonged warm ischaemia is considered a relative contraindication due to the possibility of poor outcomes, our results indicate that the window for replantation may be increased if adjunctive HBO therapy is employed in the postoperative period.

Discussion of “Effects of hyperbaric oxygen on the replanted extremity subjected to prolonged warm ischemia”

M. Felix Freshwater — 2009-03-23

The authors are to be commended for developing an animal model for evaluating the potential value of hyperbaric oxygen (HBO). However, more work must be done before we ask our hospitals to purchase HBO chambers.

Haemodynamic changes in the fingers after free radial forearm flap transfer: a prospective study using SPP

2009-01-05

Summary: Harvesting the radial forearm flap may cause circulatory problems in the donor arm. To investigate the influence on donor hands after radial forearm flap harvesting, we assessed the process of circulatory changes prospectively by measuring skin perfusion pressure (SPP) that is clinically useful in detecting vascular lesions.The records of 17 patients (14 men and 3 women aged 59.7±11.8 years) who had undergone free radial forearm flap transfer for head and neck reconstruction, between December 2005 and April 2007, were analysed. SPP in the thumb (finger I), the middle finger (III) and the little finger (V) was measured in the 17 patients preoperatively and 1 month and 3, 6, 9 and 12 months postoperatively. All statistical tests were two sided, with a significance level defined as p<0.05.Preoperatively, baseline SPP was more dominant in finger I than in finger V. Postoperatively, SPP changed significantly in both fingers, while it showed no change in finger III and tended to be higher in finger I than in the other two.Harvesting the free radial forearm flap reduces skin perfusion in the fingers of the donor arm and, we assume, leads to a re-distribution of blood flow to the fingers, with the residual ulnar artery still supplying more blood flow to finger I than to finger V. This suggests the presence of an autoregulating mechanism whereby blood perfusion to the fingers is controlled by the physiological demands of individual fingers.

Immediate skin grafting of sub-acute and chronic wounds debrided by hydrosurgery

R. Vanwijck, L. Kaba, S. Boland, M. Gonzales y Azero, A. Delange, S. Tourbach — 2009-02-05

Summary: A wound bed may be prepared by various non-surgical debridements using autolytic, biological or enzymatic techniques. These are all effective in selective wounds but tend to be time consuming.Surgical debridement is not selective since healthy collateral tissue is also removed. Physical debridement uses whirlpool therapy to slough off necrotic tissues – the saline which comes out of the hand piece if vapourised over the wound – and therefore disseminates contaminated droplets. Hydrosurgery combines physical and surgical debridement but does not have their drawbacks. Water dissection works by using a high-pressure jet of sterile saline that travels parallel to the wound and creates a Venturi effect, thus enabling the selective removal of necrotic tissues without dissemination of contaminants.In this study, the authors report on 167 sub-acute and chronic wounds from 155 patients treated under general anaesthesia by hydrosurgery (Versajet®). Of these, 95% of the debrided wounds were immediately covered with an autologous meshed graft. Compared to other debridement techniques, hydrosurgery has two main advantages: namely its tissue selectivity and its high percentage of successful engraftment after immediate skin grafting.

Silicone moulding for pressure sore debridement

2009-01-23

Summary: The radicality of wound debridement is an important feature of the surgical treatment of pressure sores. Several methods such as injection of methylene blue or hydrogen peroxide have been proposed to facilitate and optimise the surgical debridement technique, but none of them proved to be sufficient. We present an innovative modification of the pseudo-tumour technique consisting in the injection of fluid silicone. Vulcanisation of the silicone leads to pressure-sore moulding, permitting a more radical and sterile excision. In a series of 10 paraplegic patients presenting with ischial pressure sores, silicone moulding was used to facilitate debridement. Radical en bloc debridement was achieved in all patients. After a minimal follow-up of 2 years, no complications and recurrences occurred. A three-dimensional (3D) analysis of the silicone prints objectified the pyramidal shape of ischial pressure sores. Our study showed that complete resection without capsular lesion can be easily achieved. Further, it allows the surgeon to analyse the shape and size of the resected defect, which might be helpful to select the appropriate defect coverage technique.

Early postoperative active mobilisation versus immobilisation following tibialis posterior tendon transfer for foot-drop correction in patients with Hansen's disease

Santosh Rath, Ton A.R. Schreuders, Ruud W. Selles — 2009-02-23

Summary: After tibialis posterior tendon transfer surgery for foot-drop correction, the foot is traditionally immobilised for several weeks. To test the feasibility of early mobilisation after this procedure in patients with Hansen's disease, 21 consecutive patients received active mobilisation of the transfer starting on the 5th postoperative day. Transfer insertion strength was enhanced by Pulvertaft weave. The results were compared with a historical cohort of 21 patients receiving 4 weeks of immobilisation. The primary outcomes were active dorsiflexion, active plantar flexion and total active motion at the ankle, tendon-insertion pullout and time until discharge from rehabilitation with independent walking without aid. Assessments at discharge from rehabilitation and the last clinical follow-up at more than 1 year were compared between both groups. The Student's t-test was used to compare data between the groups, and 95% confidence interval of the difference between groups was determined. A p-value of 0.05 was considered statistically significant. The average follow-up was 22 months for both groups. There was no incidence of insertion pullout of the tendon transfer in either group. In addition, there was no difference in active dorsiflexion angle between the groups at discharge (mean difference: 2.2°, p=0.22) and final assessment (mean difference: 2.3°, p=0.42). The plantar flexion angles were similar in both groups at discharge (mean difference: 0.5°, p=0.86) and final assessment (mean difference: 0.5°, p=0.57). In addition, there was no difference in total active motion between the groups at discharge (mean difference: 2°, p=0.54) and final assessment (mean difference: 1°, p=0.49). The patients were discharged from rehabilitation with independent walking at 44.04±7.9 days after surgery in the mobilisation group compared to 57.07±2.3 days in the immobilisation group. This indicates a significant difference in morbidity (mean difference: 13 days, p<0.001) between the two groups. In summary, this feasibility study indicates that early active mobilisation of tibialis posterior transfer in patients with Hansen's disease is safe and has similar outcomes to immobilisation with a reduced time to independent walking, warranting the design of a controlled clinical trial to further substantiate this.

Is the foot elevation the optimal position for wound healing of a diabetic foot?

D.J. Park, S.K. Han, W.K. Kim — 2008-12-31

Summary: In managing diabetic foot ulcers, foot elevation has generally been recommended to reduce oedema and prevent other sequential problems. However, foot elevation may decrease tissue oxygenation of the foot more than the dependent position since the dependent position is known to increase blood flow within the arterial system. In addition, diabetic foot ulcers, which have peripheral vascular insufficiency, generally have less oedema than other wounds. Therefore, we argue that foot elevation may not be helpful for healing of vascularly compromised diabetic foot ulcers since adequate tissue oxygenation is an essential factor in diabetic wound healing. The purpose of this study was to evaluate the influence of foot height on tissue oxygenation and to determine the optimal foot position to accelerate wound healing of diabetic foot ulcers.This study included 122 cases (73 males and 47 females; two males had bilateral disease) of diabetic foot ulcer patients aged 40–93 years. Trans-cutaneous partial oxygen tension (TcpO2) values of diabetic feet were measured before and after foot elevation (n=21). Elevation was achieved by placing a foot over four cushions. We also measured foot TcpO2 values before and after lowering the feet (n=122). Feet were lowered to the patient's tibial height, approximately 30–35cm, beside a bed handrail. Due to the large number of lowering measurements, we divided them into five sub-groups according to initial TcpO2. Tissue oxygenation values were compared.Foot-elevation-lowered TcpO2 values before and after elevation were 32.5±22.2 and 23.8±23.1mmHg (p<0.01), respectively. Foot-lowering-augmented TcpO2 values before and after lowering were 44.6±23.8 and 58.0±25.9mmHg (p<0.01), respectively. The lower the initial TcpO2 level, the more the TcpO2 level increased.The foot lowering, rather than elevation, significantly augments TcpO2 and may stimulate healing of diabetic foot ulcers.

Segmental excision of the distal phalanx with sparing of neurovascular bundle in macrodactyly: a report of two cases

Mohammad-Javad Fatemi, Seyed-Kamal Forootan, Aydin H. Pooli — 2008-11-25

Summary: Macrodactyly is a rare congenital condition in which overgrowth of one or more digits is seen. In this article, we introduce two patients with macrodactyly simplex congenita for which we used segmental excision of the distal phalanx with sparing of neurovascular bundles, eliminating the need for a secondary operation.

Comments on the ‘Implications of the Human Tissue Act (2004) on tissue storage for UK plastic surgeons’ editorial published in the Journal of Plastic, Reconstructive & Aesthetic Surgery (2009) 62, 983–985

Sandy Mather — 2010-01-15

We have reviewed the editorial published in JPRAS and would like to provide you with clarification regarding Plastic Surgery Units and HTA licensing. The Human Tissue Authority (HTA) licenses establishments under two separate pieces of legislation, the Human Tissue Act 2004 and The Human Tissue (Quality and safety for Human Application) Regulations 2007. The published editorial makes reference to both pieces of legislation and has misinterpreted some of the statutory requirements of the legislation.

Precision and suture positioning in otoplasty. Experience with 380 cases

B.S. Mathur, K. Shokrollahi — 2009-02-23

Numerous techniques have been described for prominent ear correction. The most popular consist of suture techniques to create an antihelical fold or set back the concha, or cartilage-scoring techniques. The post-auricular fascia also has a role in modern otoplasty. With any of these techniques, the surgeon needs to decide where to position the correcting sutures or where to incise the cartilage. We describe a simple method that can be used to accurately decide on these surgical points whilst also holding the ear in a temporarily ‘corrected’ position and avoiding the use of ink which often smudges in the operative field.

Supraorbital neuroma masquerading as local recurrence from a previously excised microcystic adnexal carcinoma

J.R. Seaward, S.N.R. Kalipershad, G.L. Ross — 2009-08-03

Summary: We present a case of a 53 year old gentleman with a previous history of a microcystic adnexal carcinoma in the supraorbital region who represented with pain and tenderness 3 years postoperatively. Although this was thought to represent local recurrence, it proved to be a supraorbital neuroma.

Aplasia cutis congenita. A case of scalp defect repair using two opposing bipedicled local flaps

J.K. O'Neill, M. Carter, R.P. Warr — 2009-07-06

Summary: Aplasia cutis congenita is a rare congenital condition characterised by the absence of some or all layers of the skin. It may also be associated with absence of underlying muscle and bone. Where dura is exposed there exists a risk of ulceration and haemorrhage and thus primary closure is indicated. We report a case of cutis aplasia successfully closed with opposing bipedicled flaps. To our knowledge this is a novel approach which offers a simple safe technique that can be applied in the neonate.

Reconstruction of full thickness scalp defects after tumour excision in elderly patients: Our experience with Integra® dermal regeneration template

B. Corradino, S. Di Lorenzo, A.A. Leto Barone, E. Maresi, F. Moschella — 2009-06-22

Summary: Background: Scalp reconstruction after wide tumor excision is particularly challenging. Free tissue transfers, local flaps, or skin grafts can be used but present some disadvantages especially with old patients with local advanced cancers, systemic diseases and in patients with a prior history of recurring scalp skin cancers in which the risk of burying a recurring tumor with a flap is likely. The Authors expose their early experience with Integra® dermal regeneration template for scalp reconstruction after scalp tumor excision.Methods: Eight patients with primary or secondary scalp tumor underwent a first surgical procedure under local anaesthesia for tumor removal and Integra® positioning followed by a second operation performed three weeks later to reconstruct the defect by removing the superficial silicon layer of Integra® and by covering the defect with a split thickness skin graft. The average surface area of the defect was 143.27 cm2. The average operating time was 30.4 minutes for the first operation and 45.6 minutes for the second operation. In six cases Integra® was grafted as a classic full-thickness skin graft. In the remaining two cases the Integra® template was meshed. The artificial derma was attached to the edge of the wound by either sutures or staples.Results: There was a full graft take on all cases. The mean follow-up was 24 months. In two cases we were able to detect early tumor recurrence two months after the operation. Satisfactory cosmetic and functional results were obtained in all patients.Conclusions: In the scalp defect reconstructions after tumor excision, Integra® allows to obtain a thicker and more durable coverage than skin graft on the skull, allowing to detect a tumor recurrence earlier than a flap reconstruction with no risk of burying an eventual underlying residual tumor. These operations are performed under local anaesthesia and are therefore suitable for elderly patients.

One-stage vermilion switch flap procedure for the correction of thin lips in patients with bilateral cleft lips

Tomoki Oyama, Yuki Yoshimura, Motohiro Onoda, Ko Hosokawa — 2009-07-06

Summary: In this article, we describe the operative method for correction of thin lips in patients with bilateral cleft lips. Two transverse triangular flaps were designed in the lower vermilion and elevated along with the labial arteries and the surrounding tissues. These flaps were inserted into the recipient site on the upper vermilion through the subcutaneous tunnels at the oral commissure through a one-stage process; the donor site was closed directly.Two patients with bilateral cleft lip underwent this operation for thin lips, and satisfying results with less morbidity were obtained. The upper lip retained its volume postoperatively, and the donor-site scar was inconspicuous.Our method enabled both the augmentation of the upper vermilion and the reduction of the lower vermilion in a one-stage procedure.

Cardiac arrest following hydrogen peroxide irrigation of a breast wound

C. Beattie, L.E. Harry, S.A. Hamilton, D. Burke — 2009-07-27

Summary: Hydrogen peroxide is commonly used for the decontamination of wounds. We report a case of a probable venous oxygen embolism resulting in cardiovascular collapse following irrigation of a necrotic breast wound with hydrogen peroxide. We discuss the differential diagnosis, mechanism of oxygen embolism and question the relative advantages versus disadvantages of using hydrogen peroxide for wound decontamination.

Thermal injuries to autologous breast reconstructions and their donor sites – literature review and report of six cases

P.-N. Mohanna, S.S. Raveendran, D.A. Ross, P. Roblin — 2009-08-17

Summary: Breast reconstruction using autologous techniques has now become the gold standard. In recent years the focus has been on maintaining excellent cosmesis whilst minimising the incidence of partial or complete flap loss and donor site morbidity. However, an area which is frequently overlooked is the sequelae resulting from denervation of these flaps and their donor sites which can potentially lead to thermal injury. We report on six patients who sustained burns following free autologous breast reconstruction using either a DIEP or a muscle sparing TRAM. Four of the burns were confined to the flap skin paddle and two to the abdominal donor site. To prevent such thermal injuries all patients undergoing flap reconstruction should be educated regarding the vulnerability of the flap and its donor site as well as means of protecting these susceptible areas during daily activities.

A case of toxic shock syndrome following a DIEP breast reconstruction

Makarand Tare, John Durcan, Niri Niranjan — 2009-07-21

Summary: Mastectomy with immediate breast reconstruction has become the standard treatment for Carcinoma breast in UK and many parts of the world. Autologus reconstruction with muscle sparing TRAM/ DIEP is the ‘Gold Standard’ for assessing the newer options for breast reconstruction.Toxic Shock Syndrome (TSS) is a rare but fatal condition particularly seen in the female population. Few cases of TSS have been reported in the Plastic Surgery literature following Silicone implant based reconstruction. We report a case of TSS following Deep Inferior Epigastric Perforator flap (DIEP)reconstruction.Due to the aggressive nature of TSS, the European Society of Intensive Care Medicine (ESICM) has initiated the ‘Surviving Sepsis’ campaign to propagate, information and management guidelines for the general public and health professionals.We present a case report with the pathophysiology of TSS.

Shotgun “12/20 burst” injuries to the upper limb

Titus S. Adams, Roderick Dunn — 2009-07-29

Summary: Barrel explosions (or “bursts”) can occur when different gauge cartridges are inadvertently placed into the breech of a shotgun. This article describes two cases in which injuries were sustained to the left hand and forearm as a result of the placement of 12- and 20-gauge cartridges into 12-bore shotguns. Although the incidence of catastrophic barrel failure and the injuries they cause are not known, there is concern that such cases may be increasing as the use of 20-gauge shotguns is becoming more popular.The unusual nature of this type of injury has not been described in the medical literature.

Reconstruction of the burned hand using a super-thin abdominal flap, with donor-site closure by an island deep inferior epigastric perforator flap

Yuanbo Liu, Bin Song, Shan Zhu, Ji Jin — 2009-08-03

Summary: A pedicled super-thin superficial inferior epigastric artery flap can provide a thin and pliable skin coverage for the hand dorsum, and debulking of the flap during elevation limits the need for secondary procedures. Simultaneously, an island deep inferior epigastric perforator flap transferred to reconstruct the flap donor site in the abdomen subsequently minimises donor-site morbidity.

Posterior compartment of the lower leg reconstruction with free functional rectus femoris transfer after sarcoma resection

F. Moschella, S. D'Arpa, R. Pirrello, A. Cordova — 2009-07-09

Summary: A 72-year-old man with the third recurrence of a low-grade liposarcoma of the right lower leg came to our attention seeking limb-salvage surgery. The tumour was removed en bloc with all the superficial posterior compartment of the leg. Appropriate foot flexion was restored by means of a free-functional rectus femoris musculocutaneous flap harvested from the ipsilateral thigh. The patient was kept on a postoperative splint for 6 weeks. Three months after the operation, clinical and elecromyographic signs of reinnervation were observed. The patient was able to walk, run and climb stairs and no donor-site morbidity was observed. Thigh extension was rated M4, comparable to the contralateral thigh. Foot flexion, without any postoperative exercise, was rated M3 with a 30° excursion. To the best of our knowledge, this is the first report of reconstruction of the posterior compartment of the leg r with a free functional rectus femoris flap. We believe this muscle could be the ideal option for such reconstruction.

Vascularised Achilles tendon graft reconstruction – By the tendon for the tendon

R. Chalmers, M. Tare, N. Niranjan — 2009-07-29

Summary: The management of posterior heel defects whether the result of trauma or post-operative that result in a loss of the Achilles tendon and overlying skin is complex and challenging. Various techniques have been employed to reconstruct these compound defects often comprising of a free tissue transfer combined with a fascial tendon reconstruction. We present a single-stage method of Achilles tendon reconstruction based upon a local vascularised tendon graft combined with a free antero-lateral thigh flap transfer and a review of the current literature.

Vacuum-assisted closure therapy in newborn gangrene

Ufuk Aydin, Yesim Ozgenel, Riza Kanturk — 2009-07-08

Summary: Gangrene of the newborn or neonatal gangrene is very uncommon, and it usually involves the extremities. Neonatal gangrene seems to be more frequent in pregnancies releated with spontaneus rupture of the amniotic sac leading to delayed delivery or dry labour. However, in most of the cases, no aetiological factor can be found. Foetal pressure necrosis and amniotic band sequence are two of the most common causes of this condition.Thrombosis, emboli, congenital heart disease, coagulopathy, sepsis and polycythaemia are some of the other aetiologic factors. Treatment of this condition is usually conservative and supportive. Conservative treatment includes adequate hydration, prevention from infections and allowing the involved area to demarcate in an aseptic environment. In some cases, surgical debridement and further reconstruction can be necessary. In order to prepare the wound bed for surgical closure after surgical debridement, vacuum-assisted closure (VAC) therapy can be a new, highly effective method in the treatment of newborn gangrene. In this article, a case of a neonatal gangrene treated with the application of VAC therapy is presented.

A freestyle pedicled thoracodorsal artery perforator flap aiding the donor-site closure of a parascapular flap

Yuanbo Liu, Bin Song, Ji Jin, Shan Zhu, Le Pan — 2009-06-22

Summary: We present a patient with a neck burn scar contracture. A parascapular free flap is used to re-surface the cervical defect, while the resultant donor-site defect is reconstructed by a freestyle pedicled thoracodorsal artery perforator flap. With the introduction of a freestyle pedicled perforator flap, large-sized donor-site defects of the parascapular flap can be closed easily and safely with minimal donor-site morbidity.The parascapular flap is the workhorse flap for defect reconstruction in our centre. The advantages of this flap have been well documented in the literature. One of the main drawbacks of the parascapular flap is that the donor site is difficult to close primarily if the flap width is significantly wide. Although Nassif reported that it can be closed directly even if the flap width is up to 15cm, in our experience, it is possible and easy to close the donor site directly when the flap width is under 12cm. Alternatively, split-thickness skin grafting is needed to prevent the wound dehiscence.In this article, we describe a technique in which the donor site of the parascapular flap was reconstructed by a freestyle pedicled thoracodorsal artery perforator flap, thereby reducing the donor-site morbidity to the minimum.

Simulated central face transplantation: age consideration in matching donors and recipients

Pejman Aflaki, Charles Nelson, Benjamin Balas, Bohdan Pomahac — 2009-09-14

Face transplantation has opened new horizons in facial reconstructive surgery. It replaces the missing facial tissues or structures with identical ones. Indications include reconstruction of central facial defects, involving all the anatomic layers such as skin, subcutaneous fat, muscles, cartilage or bone. This central part of the face has unique anatomy and complex functions performing mastication, deglutition, expression, verbal communication and integration of these processes.

Patient support groups for facial disfigurements

Reza Nassab — 2009-07-13

A number of support organisations, groups and charities exist providing disfigured patients with an array of services and information. A number of examples of such organisations and groups in the United Kingdom are given below with a description of their roles. Some groups, such as Operation Smile, also have a more global presence.

Controlling hair during craniofacial surgery requiring scalp incisions

J.K. O'Neill, S. Lee — 2009-08-26

Methods of controlling, whilst preserving, the hair during facelift surgery and other craniofacial surgery have been described. Suggestions include using sterile rubber bands, metal foil, hair braiding, beading or clipping, hair rollers, aquagel, hibiscrub, opsite and covering the hair with a swimming cap. The senior author has tried most of these techniques and found them either ineffective or time consuming (the placement of bands, beads, braids or clips can be particularly time consuming). For procedures such as an endoscopic brow lift that requires scalp incisions through the thicker scalp skin, away from the face, we describe the use of staples as a more efficient alternative.

Safe pedicle tunnelling in maxillary reconstruction

F. Moschella, S. D'Arpa, S. Di Lorenzo, A. Cordova — 2009-08-27

Free flap reconstruction of maxillary defects mandates vessel anastomosis in the neck. Neck vessels are normally reached through a submucous/supramandibular tunnel that connects the maxillary defect to the neck. Passing the pedicle through this tunnel is always a blind procedure. Even when the tunnel is very wide, concerns about shearing, turning, twisting or kinking the pedicle exist. Furthermore, it may not be a straightforward procedure as the pedicle may be difficult to pass because it sticks to the tunnel walls or even vascular clips may be hooked by the tissues and the pedicle be trapped into the tunnel.

Outcome analysis of cleft palate surgery–can static 2D MRI replace videofluroscopy?

Ramesh Sharma, A.B.M.K. Prabhu, Atul Parashar, Vipul Nanda, Niranjan Khandelwal — 2009-08-17

Velopharyngeal incompetence remains a complex issue in cleft palate surgery. Videofluoroscopy and nasal endoscopy are frequently used as diagnostic instruments for assessment of velopharyngeal integrity. However it is not possible to directly visualize the underlying musculature with these techniques.

Spectacle holding local flap modification of free ALT flap

D.Q.A. Nguyen, M. Rtshiladze, E. Moisidis — 2009-08-27

An 83-year-old man underwent a free ALT flap reconstruction following surgery to excise a recurrent SCC in the left parotid region. This necessitated a left radical parotidectomy, pinnectomy, facial nerve excision and temporal bone resection. He had a complication free recovery but required a return to theatre a month later for further excision of the histologically incomplete 12 o'clock cutaneous margin.

Earlobe reconstruction following plug and tunnel piercing

Andrew M. Williams, Sanjib Majumder — 2009-07-13

At present there is a fashion for ‘tunnel and plug’ ear piercings (). The initial piercing is performed as with any normal ear piercing, creating a hole approximately 1mm in diameter in the lobe of the ear. Clients are advised to allow the ear to heal for a period of 6 weeks with a stud in place. Gradually increasing sizes of ear plugs are then placed into the lobe, increasing by 0.2–0.6mm every 2–3 weeks as tolerated. It is advised that once a 10mm piercing is in place that the dilated hole will remain stretched despite the piercing being removed. Prior to this point being reached any stretch can recover and will constrict with removal of the piercing. This advice is obviously a generalisation which will vary between individuals.

Smoking still harms those around you: A cigarette burn to a child's eye

C.B. Man, A.K. Shah, N.K. James — 2009-09-14

A 4-year-old girl presented to the emergency department with partial thickness burns to her left eye involving the cornea, upper and lower eyelids (, respectively). The patient's mother had been smoking a cigarette in the kitchen and during a brief moment between inhalations with the cigarette held at waist level, her four-year-old daughter accidentally ran into her, her left eye colliding with the lit cigarette end.

Malignant melanoma of the lower lip: Case report

Cenk Demirdöver, Barıs Sahin, Heval Selman Ozkan, Hasan Yücel Oztan — 2009-07-13

Mucosal malignant melanoma of the head and neck region is a rare condition. Most of these lesions occur on the anterior maxillary gingival area, especially on the palatal and alveolar mucosa. They usually present as asymptomatic lesions. In the differential diagnosis benign conditions such as reactive denture hyperplasia, amalgam tattoos must be considered. Malignant melanoma of the head and neck mucosa has an aggressive nature and early diagnosis is a crucial factor that improves survival. Biopsies from any suspicious lesion in the oral cavity or lip mucosa should be performed. We present a case malignant melanoma of the lower lip.

Usage of absorbable thread and superglue for building chondral framework in auricular reconstruction

S. Nishimoto, T. Oyama, K. Fukuda, K. Kawai, M. Kakibuchi — 2009-07-23

Autologous cartilage grafting has been widely used for microtia reconstruction. Various methods to make chondral frameworks have been reported. One stream of these is to buildup a framework by assembling components, carved out from costal cartilages. Stainless steel wire is a good material to hold the components strongly together for long period of time. Though, certain percentage of exposure and infection around the wire can be seen during longterm observation after the surgery. Non-absorbable threads, typified by nylon suture, are also used. But, they still do have exposure problems.

Aesthetic “Gull-wing” type incision for minimisinsg postoperative scar contracture in the chin bone graft procedure

Soung Min Kim, Ji Hyuck Kim, Jung Min Park, Jong Ho Lee — 2009-07-09

In the reconstruction of the hard tissue defects of the oral cavity, the usefulness of the chin bone or symphysis bone graft has been gradually increased. But compared to its usefulness, the patient's discomforts such as food entrapment, wound dehiscence, postoperative swelling, and sensory deficit were remained as the main complications. Among these disadvantages, unesthetic scar formation in the anterior labial gingiva is another severe morbidity to cause other complications after the conventional chin bone graft technique. So we have designed a simple and convenient incision with minimal trauma to the gingival wound margin, and suggest that this modified ‘Gull-wing’ type incision could be used as the aesthetic and effective incisional technique with clinically favourable results.

Basosquamous carcinoma-A rare but aggressive skin malignancy

2009-08-03

Basal cell carcinoma (BCC) is the most common malignant tumor of the skin. It is considered to grow slowly, is locally invasive and rarely metastasize. Other entities exist and can mimic BCC, leading to diagnostic difficulties. When a more aggressive lesion is encountered, the surgeon is faced with the need to prepare for more aggressive primary treatment and/or postoperative care because of potential severe local destructive invasion or higher rate for distant metastases.

True Amelanotic melanoma: the great Masquerader

P. Sbano, N. Nami, L. Grimaldi, P. Rubegni — 2009-08-27

The rarity of true amelanotic melanoma and its elusive features make this a challenging disease for all dermatologists. Dermoscopy is a noninvasive technique that can assist the clinician in diagnosing skin lesions. The use of dermoscopy for true amelanotic melanoma has not been fully validated yet because of the lack of studies that are based on large series of these rare tumours.

Guy rope technique for securing DIEP flaps

Ewan Wilson, Richard Haywood — 2009-08-07

The DIEP flap is ideal for breast reconstruction due to its similarity to breast tissue in both its consistency and volume, however large flaps can cause difficulties intraoperatively. To enable the microsurgery to be undertaken comfortably, the ‘floppy’ nature of the flap needs to be addressed by firmly securing the flap, whilst allowing the ideal positioning of the flap pedicle.

How often is the superficial inferior epigastric artery adequate? An observational correlation

2009-07-21

The superficial inferior epigastric artery (SIEA) arises from the common femoral artery 2–3cm below the inguinal ligament, and passes through the femoral sheath turning, superiorly and laterally over the inguinal ligament at its midpoint. As the vessels ascend up the anterior abdominal wall, they penetrate Scarpa's fascia and lie in the superficial subcutaneous tissue. The superficial inferior epigastric artery flap takes advantage of this arterial system to the lower abdominal wall and allows for transfer of abdominal skin and subcutaneous tissue without violating the rectus fascia or abdominal musculature. The SIEA flap does not violate the rectus sheath or muscle and, when available, serves as a less morbid option for reconstructing soft tissue defects with easier dissection and a lower rate of donor site complications. Unfortunately, published reports on the superficial system are inconsistent and indicate that these vessels may be too small in calibre and length for use in microsurgical reconstruction. We discuss our observational experience of the SIEA vasculature in 64 abdominal and groin dissections prior to free tissue transfer.

The ‘criss-cross sling’ modification of the vertical scar mastopexy

B. Sivakumar, A.H. Sadr, R. Smith, A. Mosahebi — 2009-07-13

The aim of mastopexy surgery is the long-term correction of breast ptosis through elevation of the nipple-areolar complex, tightening of the skin envelope and restructuring/suspension of the breast parenchyma.

The growing breast implant – a complication of homologous fat transplantation for breast augmentation

2009-08-17

Breast augmentation has been fascinating patients and surgeons for over a century. Ever since the search for the ideal material has resulted in the use of a wide range of materials for breast enlargement, including sponges, rubber, plastics, paraffin, glass, ivory. Since its development in 1963 the silicon implant is the gold standard.

An abdominoplasty incision according to fashion trends

Hugo D. Loustau, Horacio F. Mayer — 2009-07-16

The abdominoplasty technique has evolved from the early classic resections that were a combination of vertical midline and transverse resections to various modifications in incision placement and design. Modern incisions should be dictated by the prevailing lingerie and swimsuit fashions, which currently are low-cut anteriorly and laterally high for Latin American women. Nevertheless, in patients who wear low-cut trousers or skirts, the lateral ends of the incision may be exposed.

Plastic surgery and Munchausen's syndrome: ‘surgeon, beware!’

2009-07-15

A 24-year-old woman was admitted to our department with a loss of substance of the volar aspect of her right forearm. Surgical debridement and subsequent coverage with skin graft were required. Her symptoms had started 10 months earlier when she had broken her right wrist. Right forearm cellulitis had been diagnosed 2 weeks after the gypsum was removed and treated in several hospitals under different specialties. Because her condition had gradually worsened, she was referred to our unit.

The first webspace: a useful tool for locating the circumflex scapular artery

A.S. Ali-Khan, U. Khan — 2009-08-17

The authors present a simple technique, utilising the first web to identify the triangular space when raising scapular or parascapular flaps. With the patient upright, preoperatively, or lateral () the surgeon's ipsilateral hand is placed, from behind, within the patient's axilla such that the fingers point forward and are pushed up as high as possible. The thumb should be abducted and thus lie across the patient's back at approximately 45° to the vertical. Using a marker pen, the curve of the first web is traced and then completed to form a ring or circle. The triangular space (bordered by teres major, teres minor and the long head of triceps) should lie deep to this ring and the circumflex scapular artery can be confirmed with a hand held Doppler probe, the authors then mark the spot where the Doppler signal is strongest before raising the flap ().

The use of the abdominal rotation flap for inguinal lymph node dissection – revisited

R. Taghizadeh, A.R. Barnard, V. Fung, R.B. Berry — 2009-06-08

Since Bassett's 1912 description of block dissection of the groin, the high morbidity of this procedure has prompted the publication of a number of techniques and modifications to reduce the common complications of wound infection, breakdown and necrosis, seroma and lymphoedema. Published complication rates range from 6 to 20% for wound infection, 17 to 65% for wound breakdown, 6 to 40% for seroma, and 22 to 80% for post-operative lymphoedema.

The five-flap technique for the correction of post-circumcision peno-scrotal webbing

T. Gil, I. Metanes, B. Aman, I. Gruenwald, Y. Vardi, Y. Har-Shai — 2009-04-13

A 20-year-old male suffering from post-circumcision peno-scrotal webbing was referred for consultation. Following circumcision (2 years earlier), he began to suffer from restriction in penile erection and inability to penetrate during intercourse due to the web-tethering effect. On examination, skin webbing was found between the ventral sub-coronal groove and the anterior scrotal base (A). It was speculated that the webbing had developed due to an overzealous circumcision.

Water-power: High pressure water jets and devastating lower limb injury

Cara M. Connolly, Kirsty J.G. Munro, Fiona J. Hogg, David A. Munnoch — 2009-03-05

We would like to relate three cases of lower limb injury caused by industrial high-pressure water jets, one associated with small bowel injury and one with fractures to the femur, tibia and patella.

The importance of sufficient debridement prior to Achilles tendon coverage

K. Knobloch, P.M. Vogt — 2009-07-22

We read with great interest the recent report regarding the use of Matriderm® in the management of an exposed Achilles tendon subsequent to a second degree full thickness burn injury.

Complete resolution of a recurrent giant pyogenic granuloma on the palm of the hand following single dose of intralesional bleomycin injection

M. Daya — 2009-07-27

Pyogenic granuloma is histologically a lobulated capillary haemangioma. In general the growth of the lesion is self limiting. There are multiple modalities of treatment described for this skin lesion. Surgical treatment has significant risk of recurrence. The use of intralesional bleomycin is not described in the treatment of this condition. We present a case of a rapidly growing recurrent pyogenic granuloma of the left non dominant hand in a patient on treatment with methotrexate for rheumatoid arthritis.

Bleeding under pressure

C.B. Man, N.E. Ghai, O.A. Branford, M.G. Dickson — 2009-07-23

Non-invasive blood pressure (NIBP) monitoring has been associated with petechial rashes, compressive neuropathy and compartment syndrome. We report a case of full thickness skin necrosis of the arm as a result of NIBP monitoring in a Coronary Care Unit (CCU).

HIT II – An underestimated complication in reconstructive microsurgery?

A. Jokuszies, A.D. Niederbichler, C. Herold, P.M. Vogt — 2009-07-14

Over the past three decades advanced microvascular techniques have been routinely applied in free flap transplantation and continously refined with success rates of more than 95%.

New type of skin suture–fully buried running mattress suture

I. Justan — 2009-07-21

Nowadays skin sutures have been divided into two major groups–interrupted and continuous. We have focused on continuous sutures, precisely described by Wong. Our goal was to achieve an ideal suture with excellent cosmetic results, minimal postoperative care and with easy placement and removal. We have evaluated all features of nowadays known sutures with our several previous attempts. The result of our effort is the fully buried running mattress suture ().

Purple glove syndrome: a case report. Hand surgeons and physicians be aware

2009-07-13

A 26-year-old lady was seen at the Emergency department with sudden onset of pain and discolouration of her right forearm and hand following intra-venous (IV) infusion of Phenytoin (PHT). She had been seen the night before at a peripheral clinic with history of generalized tonic-clonic seizures for which IV Diazepam was given and she was started on PHT infusion. Four hours later she complained of pain at the infusion site on the dorsum of right wrist associated with swelling of the entire hand and distal-third of forearm. Within a few hours she started developing blisters on the entire hand and distal forearm – the hand appearing like a distended glove (). The Radial and Ulnar artery pulse were not palpable at presentation. There was absence of sensation in the entire hand. The forearm was not tense and did not warrant a fasciotomy.

Wedding ring in the OR

K. Knobloch, P.M. Vogt — 2009-07-22

We read with great interest the recent report from Dr. Pollard and Chan regarding the wedding or engagement ring in the OR. Of note, bacterial load has been referenced by the authors and attributed to the wearing of the wedding ring in the OR under the glove. However, this observation is not incontrovertible. A recent level III cohort study over 4 years and 2127 surgeries by a single surgeon revealed that there is no correlation between wearing a plain wedding band under the surgical glove and an increase in postoperative infections in orthopaedics. A British study among 10 surgeons and 10 anaesthesiologists supported that a traditional band wedding ring is not a source of bacterial load following a standards surgical scrub procedure by means of microbiological testing. This observation is supported by another experimental study using ring bands under surgical gloves after proper scrubbing and microbiological workup. This study did not find a difference between the ringed and the non-ringed fingers regarding the bacterial counts.

A sterile, simple, effective & pain free method of removal of adhesive dressings

M. Cheema, N. Bali, S. Singh — 2009-08-19

Surgical wounds are commonly dressed with semi permeable self-adhesive dressings to provide a moist internal milieu for effective wound healing. However, the adhesive component makes them painful to remove, especially from hair bearing skin and may traumatise fragile tissues. This becomes more unpleasant and uncomfortable if the dressing is required to be changed more than once a day.