Journal of Plastic, Reconstructive & Aesthetic Surgery - Articles in Press

Survival of pedicled pectoralis major flap after secondary myectomy of muscle pedicle including transection of thoracoacromial vessels: Does the flap remain dependent on its dominant pedicle? - Corrected Proof

M.E.E. van Rossen, P.V. Verduijn, M.A.M. Mureau — 2010-07-28

Summary: Background: The pectoralis major (PM) flap is a frequently used flap for head and neck reconstructions. The muscle is easy to transpose on the dominant thoracoacromial bundle and has relative low morbidity. Some patients complain of pain and restricted neck motion after PM flap transposition. Secondary contraction due to radiotherapy, atrophy or insufficient denervation during transposition can be causes for this function deficit. In a series of ten patients we analysed the causes of this contraction and show the results of secondary myectomy of the PM pedicle with transection of the thoracoacromial bundle.Methods: Between 2000 and 2008 a total of 12 myectomies were performed in ten patients. Indication, radiation, denervation of the PM, and follow-up before and after myectomy were analysed retrospectively.Results: Indications for PM flap reconstruction were floor of mouth malignancy, covering of neck wound, (osteo)radionecrosis, and larynx fistula. In six cases the PM muscle was denervated primarily. Seven patients received preoperative radiation on the wound bed. The interval between PM flap reconstruction and myectomy ranged from five months to seven years. There was no (partial) necrosis of the PM flaps after myectomy (median follow-up 15 months). All patients were satisfied with the result of myectomy.Conclusion: Myectomy of the PM pedicle with transection of the thoracoacromial bundle after muscle transposition is an effective method to treat secondary neck contracture. The procedure is safe, regardless of pre- or postoperative radiotherapy. Our results question the general accepted theory that muscle flaps remain dependent on their dominant pedicle.

A new trend for the treatment of blepharoptosis: Frontalis-Orbicularis Oculi Muscle flap shortening technique. J Plast Reconstr Aesthet Surg 2010;63: 233–9 - Corrected Proof

Mano Sira, Philip Gilbert, Raman Malhotra — 2010-07-26

Lai et al present an interesting technique using a Frontalis-Orbicularis Oculi Muscle (FOOM) transfer to correct blepharoptosis. The use of the Frontalis muscle to correct ptosis with poor levator function is well documented. The authors, however recommend their technique for blepharoptosis regardless of levator function, especially for severe or recurrent ptosis. We would suggest that this technique may not be the ideal procedure of choice for all severe ptoses and disagree with their suggestion that levator is too weak to correct severe or recurrent ptosis.

Dermatofibrosarcoma protuberans recurring as a hybrid dermatofibrosarcoma/giant cell fibroblastoma in an adult: A case report - Corrected Proof

J. Warbrick-Smith, K. Hollowood, J. Birch — 2010-07-23

Summary: We report the case of a 44-year-old man who presented with a new area of nodularity within his scar five years after excision of a dermatofibrosarcoma protuberans (DFSP). A wide local excision was performed for suspected DFSP recurrence. Histology revealed recurrent tumour showing combined histological features of DFSP and giant cell fibroblastoma (GCF). We present this case to highlight the potential diagnostic pitfall of DFSP recurring as giant cell fibroblastoma and as further evidence that DFSP and GCF are manifestations of the same disease spectrum.

Surgical management of arteriovenous malformation - Corrected Proof

Anniek Visser, Trevor FitzJohn, Swee T. Tan — 2010-07-22

Summary: This article presents our experience in managing a series of consecutive patients with arteriovenous malformation (AVM) referred to our Vascular Anomalies Centre over a 14-year period. These patients were culled from our prospective Vascular Anomalies Database 1996–2010. The medical records of these patients were reviewed to supplement the data collected.Out of 1131 patients with vascular anomalies, 53 patients (22 males, 31 females) with AVM were identified. Their mean age was 29 (range: 3–88) years with 14 stage-III, 34 stage-II and five stage-I AVMs, affecting the head and neck area (n=32), lower limb (n=13), upper limb (n=7) and trunk (n=1). Eight patients with eight stage-III and 14 patients with 15 stage-II AVMs underwent definitive surgery following preoperative embolisation in 10 patients. Seventeen patients required reconstruction with free flaps (n=8) or local or regional flaps (n=9), tissue expansion (n=4), tendon recession (n=1), tendon transfer (n=1), osseo-integration (n=1) and skin grafting (n=5). Fourteen patients required a combination of reconstructive techniques. During an average follow-up of 54 (range: 10–135) months, two (8.7%) lesions recurred but were improved following surgery. One patient with life-threatening stage-III AVM underwent ‘palliative’ surgery following preoperative embolisation and the lesion had improved and remained stable during the 4-year follow-up period.AVM is a challenging clinical problem that requires a multidisciplinary team approach. Complete surgical excision remains the gold-standard treatment and immediate reconstruction is an integral part of definitive surgery for AVM. The heterogeneous nature of AVM requires treatment to be tailored for individual patients and the complex excision defects necessitate expertise in a variety of reconstructive techniques. Our experience shows a recurrence rate of 8.7% following definitive surgery for AVM.

Delayed autologous free Anterolateral thigh flap failure - Corrected Proof

W. Bhat, J.D. Wiper, A.J. Platt — 2010-07-22

Flap reconstruction following excision of large tumours is a common plastic surgical procedure. Failure of the flap most often happens within the seven days of surgery and monitoring is not required beyond 3–4 days. We report a case of a 59-year-old gentleman who had an anterolateral thigh free flap for a grade II leiomyosarcoma and radiotherapy, who had flap failure 16 months, post surgery.

Histological appearance of StratticeTM tissue matrix used in breast reconstruction - Corrected Proof

E. Katerinaki, U. Zanetto, G.D. Sterne — 2010-07-22

Strattice™ tissue reconstructive matrix (LifeCell, Branchburg, NJ, USA) is a porcine acellular dermal matrix that can be used in expander/implant breast reconstruction. We would like to report on a case of histological confirmation of host integration of Strattice™ reconstructive tissue matrix in human tissue. Human acellular dermal matrix used in soft-tissue repair including tissue expander/implant breast reconstruction has been previously reported to offer the benefit of improved control of the inframammary fold, as well as providing an extra layer of protection over the lower pole of the expander as it is used as an extension of the pectoralis major muscle pocket.

A case of smooth muscle hamartoma in the finger - Corrected Proof

N.T.J. Hamnett, H. Tehrani, P. McArthur — 2010-07-21

A six-year-old right hand dominant male was referred to our department with a flesh coloured lesion on the radial aspect of the distal inter-phalangeal joint of the right middle finger. The parents of the child had noted the development of the lesion over the previous two years; the lesion had initially been asymptomatic but had recently become tender, leading to presentation.

Outcomes of direct muscle neurotisation in adult facial paralysis - Corrected Proof

Julia K. Terzis, Dimitrios Karypidis — 2010-07-21

Summary: Fifty-seven adult patients with facial paralysis, who underwent direct muscle neurotisation, were reviewed and divided into three categories depending on the function that direct neurotisation was aiming to augment. Group 1 included 30 patients who underwent direct neurotisation for eye closure and blink, group 2 consisted of 23 patients for smile augmentation, and group 3 comprised 31 patients for depressor.The age of the patients ranged from 21 to 74 years. Denervation time (Dt) ranged from 8 months to 42 years. Eight patients had partial facial paralysis, and 49 patients had complete facial paralysis. The results were based on the functional and electromyography (EMG) scoring of the neurotised muscles showing an overall EMG mean improvement of 26.56% in eye closure, 34.47% in smile restoration and 32.67% in depressor function by the procedure. Median improvement in all facial functions was one grade (25%) in theTerzis grading systems regarding the respective facial functions. The prerequisites are Dt less than 6 months and a functional contralateral facial nerve. In cases where Dt is more than 27 months and preoperative EMG’s are silent, a free or pedicled muscle should be used to substitute the denervated native facial muscle. Promoting expressivity and augmenting facial muscle function using direct muscle neurotisation are important components in facial reanimation.

Abdominoplasty in patients with and without pre-existing scars: A retrospective comparison - Corrected Proof

A. Karthikesalingam, M. Kitcat, C.M. Malata — 2010-07-21

Summary: Background: Over the past decade, abdominoplasty has become an increasingly popular aesthetic procedure both in improving anterior abdominal contour and scar revisions. The associated post-operative complications have been widely reported. Many factors such as obesity, smoking and pre-existing abdominal wall scars are hypothesised to increase the risk of these problems. However, there are no published data analysing the effect of segmental interruption to the blood supply that may have been caused by pre-existing scars. This study attempted to quantify the effect of pre-existing scars on the incidence of complications after abdominoplasty.Methods: All 123 abdominoplasties under the care of a single surgeon (2000–2007) were reviewed retrospectively with respect to indications, presence of abdominal scars, and post-operative complications. Patients with pre-existing scars were compared with unmatched ‘controls’ (no scars) by univariate analysis using the Student’s t-tests, Mann–Whitney U, and Fisher’s Exact tests and by multivariate analysis employing a simple logistic regression.Results: One hundred and twenty-three patients (97% female, median age=40 years) underwent abdominoplasties for abdominal laxity (46%), multiple scars (22%) and ‘diastasis recti’ (11%). Seventy per cent (87/123) had pre-existing scars (29% single, 71% multiple) of which 32 patients have supraumbilical scars, fifty-five patients with infraumbilical scars and 36 patients with no pre-existing scar. A quarter of patients developed complications such as: infection (14.6%), delayed wound healing (8.1%) and wound dehiscence (4.9%). Smoking and diabetes were the only independent risk factors for complications following an abdominoplasty.Conclusion: Our study suggests that pre-existing scars, both supra-umbilical and infraumbilical, did not significantly predispose to abdominoplasty complications. Smoking and diabetes were independent risk factors, a finding of clinical importance.

Life-threatening bleeding and radiologic intervention after aesthetic surgeries with minimal invasive approaches: Report of two cases - Corrected Proof

Youn-Hwan Kim, Jong-Do Kim, Giuseppe Visconti, Jeong-Tae Kim — 2010-07-21

Summary: In this article, the authors report two cases of life-threatening bleeding after cosmetic surgeries that have been successfully treated with radiologic intervention.A 25-year-old female and a 35-year-old female presented at their institutions because of postoperative bleeding after intraoral mandibular angle ostectomy and endoscopic-guided trans-axillary breast augmentation, respectively. A ruptured traumatic pseudo-aneurysm of the right superficial temporal artery was diagnosed in the first case and a haematoma posterior to the right pectoralis major, due to active bleeding from a perforator of internal mammary artery, in the second case. Attempts were made to stop the haemorrhage using standard methods, but failed. Therefore, superselective microcatheter angioembolisation has been successfully performed in both the cases.At 22-month follow-up for the first case and at 12-month follow-up for the second case, the patients are asymptomatic and the cosmetic outcomes are being preserved.With radiologic intervention, the authors gained satisfactory results in the above-mentioned situations. Using this, with only local anaesthesia and the absence of incisions, a precise approach with immediate treatment to the haemorrhaging site is possible. This can be an excellent solution for arterial bleeding that is difficult to access anatomically after aesthetic surgeries, and in selected cases. Furthermore, this procedure is less disfiguring and preserves the aesthetic surgery outcomes.

Trigger finger: Functional pulley release by ‘N’ – plasty - Corrected Proof

Amit Pabari, Olivier Alexandre Branford, Srinivasan Iyer — 2010-07-21

We read with great interest the recently published article by Mehrotra describing the ‘N’ plasty technique for functional release of A1 pulley. The author describes the use of two opposing vertical incisions of the fibrous sheath to accomplish release of trigger finger without sacrificing pulley function. The need for similar pulley enlargement also arises in cases of primary flexor tendon repair, as there is a need for seamless passage of the suture under the pulley. We would like to commend the author for the addition of this technique, particularly in view of the extending body of evidence of sutureless enlargement of the pulley.

Early and late complications of Polyalkylamide gel (Bio-Alcamid)® - Corrected Proof

Lisa Nelson, Kenneth J. Stewart — 2010-07-20

Summary: This case report summarises early and late of complications that have developed inpatients treated with Bio-alcamid for HIV-associated facial lipoatrophy and describes the management strategy employed to treat the most serious of these cases.

Patient satisfaction in relation to nipple reconstruction: The importance of information provision - Corrected Proof

D. Harcourt, C. Russell, J. Hughes, P. White, C. Nduka, R. Smith — 2010-07-20

Summary: 127 women who had previously undergone surgical nipple reconstruction completed self-report questionnaires to assess body image, anxiety, depression, information preference, and satisfaction with surgical outcome, information provision, and the decision to undergo the procedure. Whilst most women were satisfied with the outcome of surgery and of their decision to have nipple reconstruction, this study highlights the importance of information provision that meets patients’ needs at the time of decision-making, in particular information about likely nipple sensation after surgery.

An unusual cause of carpal tunnel syndrome - Corrected Proof

A.J. Robinson, M. Haj Basheer, K. Herbert — 2010-07-20

Summary: Most cases of carpal tunnel syndrome are idiopathic. One condition associated with carpal tunnel syndrome is a lipofibromatous hamartoma. We describe a case of a lipofibromatous hamartoma presenting as a soft tissue wrist swelling with associated symptoms and signs of carpal tunnel syndrome.We advocate that all soft tissue swellings of the wrist with associated neurological signs be investigated appropriately, avoiding unnecessary additional surgery.

A perforator solution for excisional defects of pilonidal sinus - Corrected Proof

Youn Hwan Kim, Shenthilkumar Naidu, Chang Yeon Kim, Kang Hong Lee, Jeong Tae Kim — 2010-07-15

Pilonidal sinus is a chronic inflammatory disease that originates from invagination of hair follicles into the skin fold. It periodically causes an inflammatory reaction, associated with abscess formation. Although it is a benign disease, the clinical symptoms of chronic irritation and discharge of the coccyx cause discomfort.

Diagnosis and localisation of flexor tendon injuries by surgeon-performed ultrasound: A cadaveric study - Corrected Proof

2010-07-14

Summary: Background: Flexor tendon injuries are common problems faced by hand surgeons. To minimise the surgical trauma associated with localisation and retrieval of the proximal tendon end, we investigated the use of surgeon-performed ultrasound in the evaluation of injured flexor tendons in a cadaver model. Our goal was to use surgeon-performed ultrasound: (1) to correctly diagnose flexor tendon injuries and (2) to correctly localise the proximal tendon ends within 1cm.Methods: Flexor tendon injuries with varying degrees of retraction were randomly created in individual digits of cadaver upper extremities, with a number of tendons left uninjured. A surgeon, blinded to the injury status of each digit, imaged each tendon by ultrasound. Predicted injury status of each tendon and localisation of the proximal stump was recorded. A total of 81 tendons were studied.Findings: Correct diagnosis of flexor tendon injury was made in 78 of 81 tendons (96.2% success). Correct localisation of the proximal tendon stump was made in 39 of 50 lacerated tendons (78% success). Small finger injuries were most difficult to assess (66.7% success). With the small finger excluded from our analysis, the localisation success rate increased to 86.8%. The average time taken to image each digit was just under 2.5min.Conclusions: Surgeon-performed ultrasound evaluation of the hand is a reliable means to diagnose flexor tendon injuries and to accurately localise the proximal tendon ends. This imaging modality may limit the need for extensive surgical exploration during flexor tendon repair. We do not recommend using this technique to image flexor tendon injuries of the small finger at this time.

Objective improvement in upper limb lymphoedema following ipsilaterall latissimus dorsi pedicled flap breast reconstruction – A case series and review of literature - Corrected Proof

2010-07-14

Summary: Objective: We present a series of three patients whose upper limb lymphoedema (following total oncologic mastectomy and level III axillary clearance) resolved significantly after ipsilateral pedicled latissimus dorsi (LD) flap breast reconstruction.Methods: A retrospective review of the medical records of patients who had undergone oncologic mastectomy and level III axillary clearance with subsequent LD pedicled flap reconstruction was carried out. Individuals who had undergone review and treatment by the lymphoedema service were identified and patients with incomplete pre- or post-operative records were excluded. A minimum follow-up period of 2 years of conservative therapy, as well as 2 years post-operatively was undertaken.Results: The rate of improvement of lymphoedema following conservative therapy was, on average, 0.095mL/week and reached a plateau at 2-year follow-up. Following latissimus dorsi flap breast reconstruction, the rate of improvement in lymphoedema increased in all three cases, with an average improvement of 2.55mL/week and remained sustained in the follow-up period.Conclusion: Pedicled myocutaneous flap reconstruction of the ipsilateral breast proved to be a useful treatment for upper limb lymphoedema in our series. This adds an important dimension to the assessment and treatment of patients with upper limb oedema resulting from mastectomy and axillary clearance.

Comparing the effectiveness of Q-switched Ruby laser treatment with that of Q-switched Nd:YAG laser for oculodermal melanosis (Nevus of Ota) - Corrected Proof

Cheng-Jen Chang, Ching-Song Kou — 2010-07-12

Summary: Background and objective: The objective of this study was to compare the efficacy and safety of Q-switched Ruby laser versus Q-switched neodymium:yttrium–aluminium–garnet (Nd:YAG) laser for oculodermal melanosis (Nevus of Ota) birthmarks in a large group of patients.Study design/Materials and methods: A retrospective review was conducted of 94 patients with Nevus of Ota treated with a Q-switched Ruby laser and a Q-switched Nd:YAG laser over a 3-year period. The subjects’ ages ranged from 3 to 64 years; there were 70 females and 24 males, all of whom were of Asian descent. The number of treatments ranged from 1 to 8. Duration of treatment ranged from 6 months to 3 years and 10 months, with a mean of 14 months. Patients (n=47) received Q-switched Ruby laser treatment (694nm) using light dosages of 7–10Jcm−2. Subsequent patients (n=47) received Q-switched Nd:YAG laser treatment (1064nm) using light dosages of 7–10Jcm−2. The primary efficacy measurement was the quantitative assessment of clearing and fading response using the DermaSpectrometer for the Q-switched Ruby laser group versus the Q-switched Nd:YAG laser group.Results: Based on a paired t-test, clinical and statistically significant differences in clearing and fading response were observed amongst the Q-switched Ruby laser-treated subjects as preferred to the appearance of Q-switched Nd:YAG laser-treated group (P<0.05). In both groups, transient hyperpigmentation resolved in all subjects within 6 months. Permanent hyperpigmentation or scarring was not observed in either group.Conclusion: Use of a Q-switched Ruby laser resulted in better clearing and fading as compared with Q-switched Nd:YAG laser.

An alternative model for teaching basic principles and surgical skills in plastic surgery - Corrected Proof

E.J. Whallett, J.C. McGregor — 2010-07-12

The European Working Time Directive is restricting the training of junior surgeons. This is compounded by fewer opportunities in the operating theatres because of the reduced numbers of staff on the ‘shop floor’ endeavouring to cover service commitments. Pressure is also put on consultants to get through cases to decrease waiting times and lists.

Low-dose propranolol for infantile haemangioma - Corrected Proof

Swee T. Tan, Tinte Itinteang, Philip Leadbitter — 2010-07-09

Summary: In 2008, propranolol was serendipitously observed to cause accelerated involution of infantile haemangioma. However, the mechanism by which it causes this dramatic effect is unknown, the dosage empirical and the optimal duration of treatment unexplored. This study determines the minimal dosage and duration of propranolol treatment to achieve accelerated involution of problematic infantile haemangioma.Consecutive patients with problematic proliferating infantile haemangioma treated with propranolol were culled from our prospective vascular anomalies database. The patients were initially managed as inpatients and commenced on propranolol at 0.25mgkg−1 twice daily, and closely monitored. The dosage was increased to 0.5mgkg−1 twice daily after 24h, if there was no cardiovascular or metabolic side effect. The dosage was increased further by 0.5mgkg−1 day−1 until a visible effect was noticed or up to a maximum of 2mgkg−1 day−1, and was maintained until the lesion had fully involuted or the child was 12-months old.A total of 15 patients aged 3 weeks to 8.5 months (mean, 11 weeks) underwent propranolol treatment for problematic proliferating infantile haemangioma, which threatened life (n=1) or vision (n=2) or nasal obstruction (n=3) and/or caused ulceration (n=6) and/or bleeding (n=2) and/or significant tissue distortion (n=12). The minimal dosage required to achieve accelerated involution was 1.5–2.0mgkg−1 day−1. Rebound growth occurred in the first patient when the dose was withdrawn at 7.5 months of age requiring reinstitution of treatment. No rebound growth was observed in the remaining patients. No other complications were observed.Propranolol at 1.5–2.0mgkg−1 day−1, administered in divided doses with gradual increase in the dose, is effective and safe for treating problematic proliferating infantile haemangioma in our cohort of patients. Treatment should be maintained until the lesion is completely involuted or the child is 12-months old. Larger scale studies confirming the safety and efficacy of propranolol may broaden the indications of treatment of proliferating infantile haemangioma.

Outcome research on secondary cleft rhinoplasty: the Leipzig experience - Corrected Proof

2010-07-09

We have been enthralled by the recent Chaithanyaa et al’s publication in this journal regarding the outcome of secondary cleft rhinoplasty. It is our pleasure to share some current state of knowledge based on our experience of cleft lip-nasal deformity (CLND) care.

The surgical management of injectional anthrax - Corrected Proof

N. Jallali, S. Hettiaratchy, A.C. Gordon, A. Jain — 2010-07-08

Anthrax is caused by the spore forming, gram-positive aerobic organism Bacillus anthracis. Three clinical forms of anthrax are recognised; respiratory, gastrointestinal and cutaneous, with the latter being the most common. An isolated fatal case of injectional anthrax as a result of heroin use has been previously reported. Recently, there has been an outbreak of injectional anthrax in Europe (www.hps.scot.nhs.uk/anthrax) and we describe our experience of the surgical management of two cases.

Strategies to ensure success of microvascular free tissue transfer - Corrected Proof

M.D. Gardiner, J. Nanchahal — 2010-07-08

Summary: Free tissue transfer has revolutionised tissue reconstruction. Surgical technique is just one of many perioperative factors that determine the eventual outcome of the procedure. Many of these factors can be modified to ensure success. A search of the MEDLINE database using search terms related to perioperative management of free tissue transfer was performed. Further articles were identified by performing related-article searches in MEDLINE. The various perioperative factors that have been demonstrated to affect clinical outcome are discussed along with the current evidence for their optimisation. We present an algorithm for the management of patients undergoing free tissue transfer.

Conversion of closed suction drain to open system using a colostomy bag following regional lymphadenectomy may permit early hospital discharge - Corrected Proof

F. Choukairi, A. Soueid, F. Fahmy — 2010-07-05

Post-operative drainage following regional lymph node dissection can frequently be one of the limiting factors for early discharge from hospital due to the presence of a drain in situ. Traditionally patients are kept in the hospital until the drains are removed but in regional lymph node dissections, this period can often exceed ten days, even though patients are usually ambulant in the second or third post-operative day.

Pregnancy in the early stages following DIEP flap breast reconstruction–A review and case report - Corrected Proof

W. Bhat, S. Akhtar, A. Akali — 2010-07-05

Summary: We report a case of a 30-year-old lady who became pregnant 3 months after undergoing a DIEP breast reconstruction. There are reports of pregnancy following TRAM, DIEP flap breast reconstruction and abdominoplasty performed after breast reconstruction, however this is the only case in the literature of a pregnancy within 3 months of DIEP breast reconstruction. The literature on breast reconstruction and pregnancy is reviewed.

Laser hair removal following reconstructive surgery - Corrected Proof

A. Rodgers, D. Sainsbury, A. Tahir, S. Pape — 2010-07-05

Unwanted hair may compromise the aesthetics of a reconstructive procedure, with potential psychosocial consequences. Laser therapy is an efficient method of hair removal for hirsutism and hypertrichosis. Reconstructive surgery is a relatively new indication for laser hair removal; to our knowledge there are no publications regarding this. Laser hair removal utilises light in the red or near-infrared spectrum targeting the melanin pigment in hair follicles with thermal energy, thus impairing future hair growth. We performed an audit of all patients undergoing laser hair removal at the Royal Victoria Infirmary, Newcastle-upon-Tyne following a variety of reconstructive procedures, to devise standards for future practice. All patient were treated with the Laserscope Gemini long-pulsed Nd:YAG laser (1064nm). We performed a retrospective analysis of case and operative notes, augmented by a patient questionnaire. Patient details including site, severity and cause of hair growth were recorded, as were laser specific details (fluence, spot size, pulse duration and complications). The questionnaire assessed patients’ experience of procedural pain, outcome and level of satisfaction.

Total ear replantation using the distal radial artery perforator - Corrected Proof

W. Wong, P. Wilson, J. Savundra — 2010-07-05

Summary: We present a case of total ear replantation where the ear was initially perfused on a perforator vessel from the radial artery prior to replantation using the radial artery as a donor vessel.

Two pedicled perforator flaps combined with a fascia graft for a large lateral lumbar defect - Corrected Proof

Hiroki Mori, Tomoyuki Yano, Kentaro Tanaka, Mutsumi Okazaki — 2010-07-05

Large lateral lumbar defects are relatively rare, and repair is challenging for plastic surgeons because of both the limited number of recipient vessels for the free flap and because of the possibility of lumbar hernia. Herein we describe a case of two pedicled perforator flaps combined with a fascia graft for repair of a large lateral lumbar defect.

Nipple-sparing mastectomy in women with large or ptotic breasts - Corrected Proof

Jennifer E. Rusby, Gerald P.H. Gui — 2010-07-02

Nipple-sparing mastectomy has been shown to have equivalent oncological outcome to skin-sparing mastectomy in carefully selected patients and acceptable rates of nipple necrosis. Its role in risk-reducing mastectomy is established. However, it is widely considered that nipple-sparing mastectomy is only suitable for women with small and non-ptotic breasts. The reasons cited are that an excessive skin envelope may result in higher rates of nipple necrosis or in nipples that are poorly positioned on the reconstructed breast mound. A malpositioned, preserved nipple may result in a significant aesthetic compromise compared with a correctly positioned reconstructed nipple.

Clinical outcomes of patients with prominent nasolabial folds corrected by the technique: Dermo-fascial detachment and fat grafting - Corrected Proof

Feng-Chou Tsai, Chuh-Kai Liao — 2010-06-30

Summary: Background: Prominent nasolabial folds (NLFs) due to ageing are a major aesthetic concern among Asian women. The main causes are drooping of the cheek mass, depressions (folds) and dermal attachments. We have conducted a study to analyse the long-term outcomes of the conventional dermo-fascial detachment and fat grafting technique.Methods: A total of 209 patients with NLFs of different severity were included in the study. Dermo-fascial detachment was used to completely dissect the attachments; then, the space was filled with fat grafts. The outcomes and related factors were analysed statistically based on the classification of NLF grades.Results: The average operating time was 28.4min, and no postoperative infections were found. A high improvement ratio was noted: at the 3-month, 1-year and 2-year follow-up consultations; the improvement ratio was about 100%, 97.4±2.6% and 66.7±9.2%, respectively. At the 2-year follow-up, the improvement ratio of the severe grade group (71.4±10.1%) remained higher than that of the mild grade group (50.0±22.3%). Six cases relapsed to the original grade (15.4%), and two cases were worse after 2 years (5.1%). No statistical correlation between age and the grade of the condition was determined (p=0.746). Total filling amounts with fat grafts made no statistical difference to the outcomes of the long-lasting group (1.93±0.26cc) and the non-long-lasting group (1.84±0.19cc) (p=0.435).Conclusion: Dermo-fascial detachment and fat grafting is a safe and reliable technique for the correction of prominent NLFs with high improvement ratios, minimal morbidities and long-lasting outcomes.

Classification of convex nasal dorsum deformities in Asian patients and treatment outcomes - Corrected Proof

Yong Ju Jang, Ji Heui Kim — 2010-06-30

Summary: Background: A new classification system for dorsal humps in Korean patients with nasal dorsum deformities was designed. Patients were treated based on these classifications, and their treatment outcomes were assessed.Methods: A total of 164 patients, who underwent rhinoplasty for correction of convex nasal dorsum deformities, were analysed. Convex dorsum deformities were classified based on anthropometric measurement, nasal length, hump length and tip projection. The three classifications were generalised hump, isolated hump and relative hump because of a low tip. Postoperative photographs were analysed to assess hump reduction outcomes.Results: Generalised hump was the most common deformity, occurring in 88 (53.7%) patients; an isolated hump was observed in 67 (40.9%) patients and a relative hump, with a low tip, was observed in nine (5.5%) patients. Successful surgical outcomes were achieved in 65.9% of generalised hump cases and 80.6% of isolated hump cases (p=0.014). Of the fair or poor outcomes, 89.6% were attributable to hump undercorrection.Conclusion: Our classification system could help surgeons tailor management of convex nasal dorsum deformities. The present study showed that the milder the deformity, the better was the outcome. It was also found that excessive conservation in hump reduction was the main factor predictive of unsatisfactory outcome.

The microbiological basis for a revised antibiotic regimen in high-energy tibial fractures: Preventing deep infections by nosocomial organisms - Corrected Proof

G.E. Glass, S.P. Barrett, F. Sanderson, M.F. Pearse, J. Nanchahal — 2010-06-30

Summary: Background: Deep surgical site infections (SSI’s) complicate Gustilo IIIB tibial fractures in 8–13% of cases. Antibiotic prophylaxis typically covers environmental contaminants. However, nosocomial organisms are usually implicated in deep infection. We used the microbiological profile of infected Gustilo IIIB tibial fractures to define a new, dynamic prophylactic regimen which recognises the need for prophylaxis against nosocomial organisms at the time of definitive closure.Methods: The microbiological profiles of Gustilo IIIB tibial fractures presenting over a 2-year period from January 2006 to December 2007 were reviewed. The environmental contaminants were compared with the organisms isolated from deep SSI’s and correlated with the prophylactic antibiotic regimen used.Results: Fifty-two patients were included. Nine developed a deep tissue infection. The pathogens implicated included resistant Enterococci, Pseudomonas, Enterobacter and MRSA. Standard antibiotic prophylaxis provided cover for these combinations in only one of nine cases. This would have improved to eight of nine cases with the use of teicoplanin and gentamicin, given as a one-time dose during definitive soft-tissue closure. Specimens taken from wound debridement were neither sensitive nor specific for the subsequent development of deep infection and did not predict the organisms responsible.Conclusions: Following high-energy open fracture, a single prophylactic antibiotic regimen directed against environmental wound contaminants does not provide cover for the organisms responsible for deepest SSI’s and may have depopulated the niche, promoting nosocomial contamination prior to definitive closure. We advocate a dynamic prophylactic strategy, tailoring a second wave of prophylaxis against nosocomial organisms at the time of definitive wound closure, and at the same time avoiding the potential complications of prolonged antibiotic use.

Breast augmentation: part II – adverse capsular contracture - Corrected Proof

M.G. Berry, V. Cucchiara, D.M. Davies — 2010-06-28

Summary: Although adverse capsular contracture (ACC) following breast augmentation remains an enigmatic phenomenon, significant progress has been made in diminishing its occurrence during the previous surgical generation. Given the rising global frequency of breast augmentation, however, ACC is likely to be with us for the foreseeable future and an understanding of its nature, and particularly prevention, will continue to be of foremost importance as breast augmentation undergoes a paradigm shift from anti-contracture to aesthetic result as the key outcome measure. Whilst clinical research has hitherto been the mainstay of investigation, providing both understanding and practical guidance, further improvements may derive from new developments in the fields of immunology and molecular biology: convergence of these complementary avenues may eventually yield a non-surgical treatment for ACC. This review presents a summary of our extant knowledge, providing evidence where it exists and a consensus view where it does not. It aims at providing a sound comprehension of the underlying aetiopathology that has provoked the measures seen to date and guides selection of the appropriate therapeutic strategy, which will be expanded in a future review.

Prophylactic cross-face nerve flap for muscle protection prior to facial palsy - Corrected Proof

2010-06-28

Summary: The facial muscles of a 28-year-old woman with left acoustic neuroma were successfully protected with a vascularised cross-face nerve flap using a vascularised lateral femoral cutaneous nerve along with a perforator of the lateral circumflex femoral system. It was transferred as a vascularised cross-face nerve flap to bridge a 15-cm-long defect between the bilateral buccal branches. Three months after the nerve flap transfer, the total tumour including the facial nerve was resected. Postoperatively, rapid nerve sprouting through the nerve flap and excellent facial reanimation were obtained 3–6 months after resection. This method is a one-stage reconstruction procedure, has minimal donor-site morbidity and results in strong postoperative muscle contraction. To our knowledge, this is the first report on a prophylactic cross-face nerve flap technique for the protection of facial muscles before facial nerve transection, and also the usefulness of vascularised lateral femoral cutaneous nerve flap.

The origin of regenerating axons after end-to-side neurorrhaphy without donor nerve injury - Corrected Proof

Jae Kwang Kim, Moon Sang Chung, Goo Hyun Baek — 2010-06-28

Summary: The purpose of this study was to determine the origins of regenerated axons after end-to-side neurorrhaphy (ETSN) without donor nerve injury by comparing the time of appearance of regenerating axons for proximally coapted ETSN and distally coapted ETSN.Thirty rabbits were used in each group. In the proximal ETSN group, the ulnar nerve was transected and the distal end sutured to the median nerve 3cm above the elbow joint, whereas in the distal ETSN group, it was 3cm below the elbow joint. Coaptation was performed by wrapping the aponeurosis of nearby muscle. Observations were made weekly for 6 weeks after ETSN. Axonal regeneration was studied by morphometric analysis and immunohistochemistry.The times of appearance of regenerating axons differed in the proximal and distal ETSN groups. Axonal densities in proximal segments of donor nerves continuously increased and the axonal diameters of proximal segments of donor nerves continuously decreased with time after ETSN.Our findings suggest that regenerated axons after ETSN without donor nerve injury originate from the central nervous system rather than coaptation sites.

Superior pedicle breast reduction for hypertrophy with massive ptosis - Corrected Proof

2010-06-28

Summary: Breast hypertrophy, combined with massive ptosis with a suprasternal notch-to-nipple distance of more than 40cm, remains an endeavour. Different refinements of the initial technique with free nipple grafts have been described to circumvent the problems of nipple underprojection, areolar hypopigmentation and loss of sensibility secondary to nipple grafting, as well as lacking breast projection due to scarce glandular tissue. Techniques relying on nipple areola complex transposition, rather than grafting, have been described with inferior, superomedial and medial pedicles. The aim of this study is to present the results obtained in a series of 10 patients suffering from bilateral breast hypertrophy with massive ptosis, which was defined as a distance >40cm from the suprasternal notch-to the nipple. All breasts were managed with a superior pedicle and inverted T technique. The mean preoperative suprasternal notch-to-nipple distance was 44±2cm, and the resection weight ranged from 800 to 2490g per breast with an average of about 1450g in this patient population presenting with overweight or obesity. With a mean nipple areola complex (NAC) lift of 20±3cm, neither nipple nor areola necrosis was observed. One partial epidermolysis of the areola and two cases of delayed wound healing at the trifurcation point of the inverted T were conservatively managed. Only one re-operation was necessary for an important wound dehiscence of the lateral part of the horizontal scar. These results underscore the safety of the superior pedicle technique in cases of massive ptosis with transposition of the NAC of approximately 20cm, that is, a pedicle length of about 25cm.

Keratin sparing dorso-ulnar split skin grafts as a reconstruction option for hand defects - Corrected Proof

Ioannis Goutos, George C. Cormack, Sudip J. Ghosh — 2010-06-28

Soft tissue loss in the hand is a challenging problem faced by plastic and reconstructive surgeons. There are a wide variety of options for management ranging from conservative approaches to graft and flap reconstruction. We report our experience with the use of split skin grafts harvested from the dorso-ulnar aspect of the hand using a keratin sparing approach for the treatment of hand defects in 50 adult patients. 42 patients had traumatic glabrous skin loss and 8 following elective excisional surgery to the hand. No patients had exposure of tendon or bone and their average age was 43 years with a range between 17 and 84 years. The average defect size was 2×1.5cm (range=1×1–2×4cm) and the average graft size 3×2cm (range=1×2–3×5cm). The technique employed is shown in . Graft sites were inspected on day 7 post-operatively, at which time the patient was allowed to mobilise the hand fully if healing was complete. Patients in the study were asked to score their overall satisfaction with the donor site using the following descriptive scale: poor, satisfactory, good and excellent. The average period of follow-up was 12 months (range=8–14 months).

The arrow flap for nipple reconstruction: Long term results - Corrected Proof

F. Farace, A. Bulla, A. Puddu, C. Rubino — 2010-06-28

Nipple Areola Complex reconstruction is the final step in breast reconstruction. Although it could be considered a minor surgical procedure, it has an important impact on the whole procedure.

Venous drainage of delayed distally-based sural flap: Evaluation by duplex scanning - Corrected Proof

2010-06-28

Congestion is the main problem encountered with distally-based flaps. The retrograde venous drainage of these flaps can be tenuous, and venous congestion invariably results in loss of the flap. In a series of 70 consecutive delayed distally-based sural flaps (DBSFs), the cumulative rate of flap necrosis was reported to be 36%. Patients with one or more of three high-risk diseases, which are diabetes mellitus, venous insufficiency, and peripheral arterial disease, have a flap necrosis rate of 60%. Several modifications of the DBSF have been proposed to improve flap survival. The modifications include interpolation flap, flap with a gastrocnemius muscle cuff, supercharged flap, and delayed flap. Recently, we demonstrated the usefulness of a delay procedure for improving flap blood supply with the delayed DBSF by using intraoperative fluorescence angiography. However, there have been no reports focussing on the venous drainage of delayed DBSFs. Accordingly, we examined the venous drainage of delayed DBSFs by duplex scanning.

Metastatic implantation squamous cell carcinoma in a split-thickness skin graft donor site - Corrected Proof

Amer Hussain, Chidi Ekwobi, Stewart Watson — 2010-06-28

Summary: We present the case of a patient who developed a possible implantation metastatic squamous cell carcinoma (SCC) at a donor site 2 months following split-thickness skin graft (STSG) harvesting. This case highlights implantation of malignant cells from a contaminated hollow needle as a mechanism of spread to skin graft donor sites and offers an important learning point in the practice of local anaesthetic cutaneous cancer surgery.

A rare case of congenital ulcerated subcutaneous fat necrosis of the newborn - Corrected Proof

R. Perrotta, D. Virzì, M.S. Tarico — 2010-06-28

The male child was presented to our observation on his third day of life for evaluation and treatment of ulcerated wounds on his left forearm. He was a full term infant delivered via caesarean section. The child was apparently in good health, weighed 2,950kg and didn’t show any associated diseases; laboratory parameters were also within normal ranges. His mother neither referred any relevant event nor made use of medicines or drugs during pregnancy.

Breast reconstruction: A quantitative assessment of the quality of information available to patients - Corrected Proof

C. Macdonald, M.S. Lloyd, B. Mathur, V. Ramakrishnan — 2010-06-25

The internet provides a cheap and updatable resource for patient’s information. This allows greater accessibility than written information received by the patient in clinic. Breast reconstruction patients are a group that benefit from guidance through the various methods of reconstruction presently practised. This relies on accurate explanations of current reconstructive techniques independent of the surgeon’s preference and skill set. An educated treatment choice can then be made especially when undergoing immediate reconstruction where time is of the essence. We know that information is important and that patients seek information from the internet. However, internet information has not been clearly validated allowing assessment of quality. Quality of information although difficult to define, has been categorised by the information research institutes using scoring tools. Although no scoring tool is fully comprehensive, they have allowed clearer definition of what quality entails. Some previous work has been carried out on the quality of medical information on the internet. We found a lack of work on the quality of breast reconstruction information. Our analysis of the information available to patients was separated in to several different phases.

A new experimental venous super-drained transmidline abdominal skin flap model in pig - Corrected Proof

Xin Minqiang, Luan Jie, Mu Lanhua, Mu Dali — 2010-06-24

The vascular compromise in the contralateral random portion is a major drawback of the transmidline abdominal flap, regardless of what technique is used, resulting in partial congestive necrosis of skin and/or cutaneous fat. Venous superdrainage was recommended as a safeguard to the viability of this portion. But the mechanism and efficacy remains unclear. However, some researchers got different results based on different or even the same animal models. Therefore, the aim of this experiment was to design a venous super-drained flap model in pig relevant to the human counterpart for the further study of the mechanism of venous superdrainage in transmidline skin flap.

Salvage (tertiary) breast reconstruction after implant failure - Corrected Proof

2010-06-24

Summary: Background: Salvage breast reconstruction is defined as a complete revision of a previous reconstruction in case of unsatisfactory results or failure of primary or secondary breast reconstruction. We have termed this ‘tertiary breast reconstruction’. This article presents our experience with tertiary reconstructions, including the indications, method of reconstruction and outcomes.Methods: A retrospective note review was performed for all patients who underwent breast reconstruction with autologous tissue under one surgeon between 2002 and 2009 at the University Hospital, Ghent. Out of these 688 patients, 54 patients (7.8%) required tertiary surgery with autologous tissue after failure of implant breast reconstruction.Results: The first reconstructive surgery involved 38 unilateral and 16 bilateral cases with a total of 70 operated breasts. A further 11 breasts were reconstructed following risk-reducing mastectomy or at the patient’s request for aesthetic reasons. Out of 81 free-flap reconstructions, the deep inferior epigastric artery perforator (DIEAP) flap was the most harvested at 66 (81%). The mean±SD operating time was 7.2±1.8h and the mean hospital stay was 7.2±1.9 days. One total flap loss (1.2%) occurred. The mean follow-up was 31 months with a range between 3 months and 6 years. During follow-up, 30 patients (55.5%) needed secondary procedures to improve the aesthetic outcome. Donor-site corrections were performed in 18 patients (33%). Revisions of the breast flap were performed in 29 patients (53%).Conclusions: Restoring the breast envelope and footprint, in addition to excision of scar tissue, is the key step in breast reconstruction. Further corrections are required depending on the amount of the initial damage to the breast or subsequent postoperative complications.

Questions about ‘Posterior perilunate carpal dislocation associated with a multifragmentary distal radius fracture’ - Corrected Proof

M. Felix Freshwater — 2010-06-24

I just read the case report ‘Posterior perilunate carpal dislocation associated with a multifragmentary distal radius fracture’ and have several questions that I believe I and other readers would appreciate the authors answering:

Hand in Hand: Surgeons and Psychiatrists in the Management of Syndrome of Self-Demand Healthy Limb Amputation - Corrected Proof

James K.-K. Chan, Sophie M. Jones, Anthony J. Heywood — 2010-06-24

We would like to thank Drs. Chrisopher Ryan and Tarra Shaw for their clarification on the diagnoses of body dysmorphic disorder (BDD) and body integrity identity disorder (BIID). Their insight is most helpful as there seems to be a paucity of clear information about BIID in the literature, or indeed, its distinction from BDD. These terms are often used loosely both in the medical literature and media. In fact, no formal definition of BIID appears in the literature, although there is a tentative definition structured as diagnostic criteria found in the Diagnostic and Statistical Manual of Mental Disorders. There remains dispute regarding the correct diagnostic terminology for patients who suffer syndrome of self-demand healthy limb amputation. Moreover, some authors believe that BIID may actually represent a subset of BDD and other syndromes. In any case, the main aim of our article was to raise awareness of the legal and ethical implications in the treatment of patients who desire limb amputation, including those presenting in the emergency setting. These concepts remain relevant irrespective of the exact underlying psychiatric diagnosis.

Hundred fascia-sparing myocutaneous rectus abdominis flaps: An update - Corrected Proof

Moustapha Hamdi — 2010-06-21

Dr. Erni and his team presented an update of their previously published technique of fascia-sparing myocutaneous rectus abdominis (RA) flaps. In this well-written article, the authors reported their follow-up of this technique. The RA musculocutaneous flap was raised with most of the muscle but sparing the anterior sheath of its fascia. By using this technique, several perforators were included within the flap, which increase the blood supply to the skin. The results showed low complication rate for the reconstructed area or the donor site. This makes sense because there is more blood supply to the skin flap. However, the incidence of fat necrosis was significantly reduced by better surgical experience and preoperative perforator mapping, which allow to select the ‘dominant’ perforator. However, the most significant point, which the authors tried to make, was also the low hernia/bulging incidence that occurred in the donor site.

A simple technique for secure external fixation of hand fractures: Bent K-wires wrapped in cement - Corrected Proof

Amit Pabari, Padmanabhan Subramanian, Srinivasan Iyer — 2010-06-21

We read with great interest the recently published article by Barabas and James, utilising K-wires and cement as an external fixator for the management of hand fractures. The technique of using K-wires and cement as an external fixator for hand fractures was first described by Crockett in 1974. Since then, various modifications have been described.

A new non-incisional correction method for blepharoptosis - Corrected Proof

Manju Meena, Milind Naik, Mohd Javed Ali, Santosh Honavar — 2010-06-21

We congratulate Shimizu and colleagues for introducing this novel technique for the correction of blepharoptosis. The authors have hypothesised that the correction of mild to moderate blepharoptosis can be achieved with their minimally invasive technique. Principle behind this technique is almost similar to conjunctivomullerectomy where shortening of posterior lamella induces correction of mild to moderate blepharoptosis. Moreover, the deep nature of the suture is also likely to re-attach the dis-inserted edge of levator aponeurosis to the upper edge of the tarsus. Because there is no incision required, the author’s technique eliminates the disadvantages of eyelid crease incision (scar and interruption of nerve supply) as well as that of conjunctival excision (dry eye).

Dermographism improves clinical monitoring of free flaps - Corrected Proof

Hagen Schumacher — 2010-06-21

It is well documented that early recognition of postoperative vascular compromise can improve the salvage of free flaps. Clinical monitoring is most commonly used and was found to be very reliable with a sensitivity of 98% and specifity of 75%. While trained nursing staff can effectively detect postoperative flap problems, there are potential situations where perfusion problems could be recognised too late. These include flaps which are difficult to monitor, for example very pale flaps or hospital locations, where observation of free flaps is not routinely undertaken, such as on the intensive care unit or on non-plastic surgical wards when patients are under joint care with other specialities.