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

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

2012-02-03

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

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

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

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

Effects of short-term venous augmentation on the improvement of flap survival–An experimental study in rats - Corrected Proof

2012-01-27

Summary: Introduction: Flap necrosis due to blood circulation disorders is a serious problem in reconstructive surgery. Methods to achieve both arterial and venous microvascular augmentation at the flap periphery have therefore been developed to prevent post-surgical circulation problems, especially for large pedicle flaps and free flaps containing three more vascular territories. Moreover, the benefits of microvascular venous augmentation (VA; superdrainage) alone have been established, but the optimal duration of post-surgical venous drainage has not yet been determined.Methods: The surviving flap area was compared after standard and short-term VA in the extended island flap model of the rat abdomen.A flap model using the left superficial inferior epigastric artery/vein as the vascular pedicle was used as a control group (n = 6). The lateral branch of the right superficial inferior epigastric vein remained unresected at the end of the flap in the VA group (n = 7), but was ligated at 24 h post-surgery in the temporary venous augmentation (TVA) group (n = 7).Results: The flap survival rates on postoperative day 7 in the control, VA and TVA groups were 74.8 ± 8.4%, 90.1 ± 3.7% and 89.9 ± 3.5%, respectively. The surviving areas were significantly improved in the VA and TVA groups in comparison to the control group (p ＜ 0.01), but there was no significant difference between the VA and TVA groups.Conclusions: The short-term venous drainage from the flap end after surgery was as effective as long-term VA. Flap transplantation could therefore be clinically easier and more reliable when starting short-term venous drainage during surgery.

Immunomodulatory effects of pre-irradiated extremity allograft in the rodent model - Corrected Proof

K. Muramatsu, A. Moriya, T. Hashimoto, T. Taguchi — 2012-01-27

Summary: Allogeneic human hand transplantation requires combination immunotherapy to maintain viability. Immunosuppression will be lifelong, with doses as high or higher than those required for solid organ allotransplantation. The risks associated with lifelong immunosuppression are unacceptable, particularly for younger transplant patients. It therefore becomes imperative to explore ways to reduce or eliminate the requirement for immunosuppression. Reconstructive surgery should consider, to a large extent, graft pre-treatment as a strategy for the transplantation of vascularised limb tissue allografts with reduced requirement for immunosuppression. In the clinical setting of composite tissue allograft (CTA), the graft is always procured from a cadaveric donor. Therefore, only a short time is available between harvesting the graft from the donor and transplanting into the recipient. This period provides the only opportunity to manipulate the CTA. Quite a few studies, however, have so far investigated donor pre-treatment and pre-transplant modification of the extremity allograft. Work from our group and others has demonstrated that removal of allogeneic bone marrow in the limb graft by irradiation and its rapid reconstitution with recipient marrow cells can significantly prolong the survival of limb allografts in the absence of immunosuppression. In the current work, we review these studies and discuss the immunomodulatory effects on the extremity allograft.

Removal of a titanium ring using a dental saw - Corrected Proof

A.F. Chambers, A. Harper — 2012-01-27

Summary: Titanium is becoming increasingly popular in the manufacture of jewellery. Titanium rings are notoriously difficult to remove in an emergency situation and there is speculation amongst the general public that amputation is sometimes necessary due to the indestructibility of this material. We present the case of removal of a titanium ring using a dental saw allowing the patient’s finger to be preserved.

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

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

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

The boomerang osteotomy – A new method of reduction malarplasty - Corrected Proof

2012-01-27

Summary: Background: To achieve optimal outcomes in reduction malarplasty, it is important to preserve the natural curvature of the cheek while reducing the zygoma prominence and the width of the midface. The present article introduces an effective technique that aims to achieve these purposes.Methods: Through an intraoral approach, boomerang-shaped bone incision lines are marked on the anterior aspect of the zygomatico-maxillary junction. The lines are placed medial to the most prominent part of the zygoma. The zygomatic arch is divided at its posterior part through a small incision made in the pre-auricular region. By performing these manoeuvres, a unit of bone–composed of a part of the zygoma body and zygomatic arch – is mobilised. The mobilised bone is shifted medially, reducing the width of the midface and making the zygoma region less prominent. After performing reduction malarplasty for 89 patients (10 males and 79 females) using this technique, clinical outcomes were evaluated.Results: Outcomes of the treatment was optimal, with over 80% of the patients evaluating the results as excellent in terms of effectiveness in malar prominence, facial width and symmetry.Conclusion: Because the continuity of the main part of the zygoma body and zygomatic arch is preserved in our technique, medial transfer of the zygoma is enabled while preserving the natural curvature of the malar region and the superior–inferior position of the zygomatic arch. Because of these advantages, we recommend our technique as an effective technique of reduction malarplasty.

The role of the internal mammary vessels as recipient vessels in secondary and tertiary head and neck reconstruction - Corrected Proof

N.A. Roche, P. Houtmeyers, H.F. Vermeersch, F.B. Stillaert, Ph.N. Blondeel — 2012-01-27

Summary: Background: Successful microsurgical free tissue transfer for head and neck reconstruction highly depends on the quality of the recipient vessels. In most cases, vessels near the site of resection are available; however, when the bilateral vascular network in the neck is compromised or inaccessible due to prior surgery and/or irradiation, alternatives have to be sought.Methods: Secondary or tertiary head and neck reconstruction was performed using the internal mammary vessels (IMVs) as recipient vessels in seven patients who had undergone previous neck dissection and radiation therapy. Indications were: tracheal–oesophageal fistula or stenosis (n = 4), oesophageal–cutaneous fistula (n = 1), saliva fistula (n = 1) and oral cancer (n = 1). Free flaps used for reconstruction were radial forearm flap (FRFF) (n = 5), anterolateral thigh flap (ALT) (n = 3) and transverse rectus abdominis myocutaneous flap (TRAM) (n = 1). Within two patients an additional ALT flap was necessary for soft-tissue coverage and resurfacing of the neck. The IMVs were separately exposed in a standard fashion over the second or third rib. The pedicle of the flap was anastomosed anterograde and end-to-end to the recipient vessels in all cases. Mean pedicle length was 14.3 cm (11–20 cm), with a mean distance of 9.8 cm (7–13 cm) between the resection and recipient vessel site.Results: All patients were tumour free at time of re-operation and no sign of radiation injury was observed in the recipient vessels. All flaps survived and all patients healed without major complications. Mean follow-up time was 18 months. Four patients died of local recurrence or distant metastases during follow-up.Conclusion: In the vessel-depleted neck, the IMVs are a reliable and easy accessible recipient area for microsurgical reconstruction of the head and neck. Surgical management and technique refinements for dissection of the vessels are discussed. In combination with free flaps with a long pedicle, especially perforator flaps, vein grafts are unnecessary and microsurgery can safely be performed outside the zone of injury.

Third-degree burn leading to partial foot amputation – Why a notebook is no laptop - Corrected Proof

Felix Julian Paprottka, Hans-Günther Machens, Jörn Andreas Lohmeyer — 2012-01-25

Summary: So far a few case reports about laptops causing burns have been published. Now for the first time, we report on a case, in which notebook-induced thermal injuries placed in a patient’s lap resulted in severe second- and third-degree burns. As a consequence, a partial amputation of the left foot had to be performed. Furthermore, we measured maximum temperatures of 12 popular laptops, which were running full load for 3 h. For this experiment air circulation underneath the device was blocked in order to simulate surrounding conditions, which were present when the patient got injured. Although this setting may be the reason for most of all notebook burns, this kind of test has not been part of any scientific publication until now. Patients with lower extremity sensation, altered consciousness or decreased peripheral sensitivity have a higher risk for thermal injuries.

Open rhinoplasty using conchal cartilage during childhood to correct unilateral cleft-lip nasal deformities - Corrected Proof

Hiromu Masuoka, Katsuya Kawai, Naoki Morimoto, Satoko Yamawaki, Shigehiko Suzuki — 2012-01-25

Summary: Background: Although many articles have investigated the optimal method for the primary correction of nasal deformities during unilateral cleft lip repair, residual nasal deformities often remain. Such residual deformities are commonly corrected around the age of 5. We have started performing two-stage nasal repair operations for unilateral cleft lip patients. During the first stage, the nasal floor is elevated, and the alar base is brought into the correct position by muscle reconstruction during primary lip repair. During the second stage, the slanting nasal apex and drooping alar rim are corrected at pre-school age. This article describes the methods and results of second-stage open rhinoplasty.Methods: Open rhinoplasty is performed. The conchal cartilage is harvested and used as a strut to strengthen and extend the septum. The lower lateral cartilages are sutured to the grafted cartilage and fixed in the correct position. The operative results of 38 patients were evaluated photogrammetrically. The nasal height, nostril height and the columella angle on a basilar view of the nose were measured.Results: In most patients, the nose was refined and became less distorted. Poorly projecting nasal tips and drooping alar rims were corrected. The reformed configuration was relatively well maintained for many years. Photogrammetric analysis demonstrated increases in both the nasal height to nasal width ratio and the nostril height to nostril width ratio, and improvement of the columella angle.Conclusion: Performing open rhinoplasty using conchal cartilage during childhood effectively improves unilateral cleft-lip nasal deformities.

Reconstruction with Vertical Rectus Abdominus Myocutaneous flap in advanced pelvic malignancy - Corrected Proof

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

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

Reply to the letter to the Editor on “Low-dose propranolol for infantile haemangioma” - Corrected Proof

Swee T. Tan, Tinte Itinteang, Philip Leadbitter — 2012-01-24

We thank you for the opportunity to respond to Dr Zheng’s letter regarding our article, Low-Dose Propranolol for Infantile Haemangioma. The serendipitous discovery of accelerated involution of infantile haemangioma induced by propranolol and acebutalol has resulted in a paradigm shift in the management for this condition. This mirrors the previous serendipitous observation of the effect of high dose steroids on infantile haemangioma which naturally invited logical questions on the (1) mechanism of action; (2) the optimal dose regimen and duration of treatment; and (3) the side effects of treatment in infants and young children with problematic infantile haemangioma. Over the last 40 years, some of these questions have been answered and the dose regimen settled on 2–3 mg/kg/day but the mechanism of action of steroid therapy remains incompletely elucidated with induced apoptosis through the up-regulation of mitochondrial cytochrome b gene being proposed.

Negative pressure of manual liposuction with Coleman technique is highly dependant on the position of plunger of the syringe - Corrected Proof

C. Herold, P. Utz, M. Pflaum, M. Wilhelmi, P.M. Vogt, H.O. Rennekampff — 2012-01-24

Autologous fat transplantation has gained wide recognition and adoption. Despite an ever-increasing degree of standardization, many techniques have been advocated and individual factors likely still play a significant role in the success of this operative technique. It is generally felt that reduced negative pressure during harvesting adipose tissue leads to a higher grade of graft viability. Studies have in fact demonstrated the superior viability of adipose tissue harvested with reduced pressure as compared to conventional suction assisted liposuction. A negative pressure of 760 mmHg has been shown to provoke an adipocyte injury rate of 90%. The Coleman technique advises using gentle manual syringe liposuction. According to Boyle’s law, negative pressure inside the barrel of the syringe increases as the volume is enlarged by drawing back on the plunger. The pressure gradient inside the cannula tip will similarly further increase as the plunger is withdrawn. From a practical perspective we were interested in quantifying the exact negative pressure inside the syringe at different positions of the plunger. We analysed negative pressure readings at various plunger positions using standard sterile 10 cc BD Luer Lock syringes (Byron medical, Mentor, Santa Barbara, CA, USA) and a manual manometer (VDO, Regensburg, Germany).

Special considerations in virtual surgical planning for secondary accurate maxillary reconstruction with vascularised fibula osteomyocutaneous flap - Corrected Proof

Yi Shen, Jian Sun, Jun Li, Mei-mei Li, Wei Huang, Andrew Ow — 2012-01-24

Summary: Background: This article describes our special considerations in virtual surgical planning for secondary maxillary reconstruction with vascularised fibular osteomyocutaneous flap and our revised surgical design for maxillary reconstruction.Methods: Eleven patients with different maxillary defects according to Brown’s revised classification underwent virtual surgical planning for secondary accurate reconstruction. For different horizontal class defects, the fibular was osteomised to match the maxillary alveolar arch by using the mirror image of the contralateral alveolar ridge or the curve of the mandibular arch and dentition.Results: Maxillary reconstruction was performed with the guidance of preoperative virtual planning and using fibular osteotomy and reposition guide templates to replicate the virtual planning intra-operatively. Virtual surgical planning was replicated intra-operatively in all patients. The fibulae were osteotomised into four segments in three patients with the horizontal class d2 defect and three segments in eight patients with the horizontal class b–d1 defects, respectively. The overall success rate for 11 flaps was 100%. Good bony unions and wound closure were observed and intelligible speech was achieved in 11 patients. Maximum incisal opening ranged from 3.0 to 4.0 cm. All patients tolerated a regular diet postoperatively. Postoperative midfacial appearance was good in all patients.Conclusion: We recommend that the horizontal class d defect in Brown’s revised classification of maxilla and midface be divided into two sub-types according to whether it involves the contralateral canine or not. Special considerations in virtual surgical planning are helpful to perform accurate secondary maxillary reconstruction with a vascularised fibular osteomyocutaneous flap.

The tertiary management of pretibial lacerations - Corrected Proof

Steven Lo, M.J. Hallam, Shona Smith, Tania Cubison — 2012-01-24

Summary: Pretibial lacerations remain one of the commonest yet most neglected conditions facing emergency departments and plastic surgeons alike. Furthermore, these injuries afflict the most vulnerable groups of adults - the elderly and the infirm. It is essential therefore to have an approach to pretibial lacerations based on best available evidence, in order to optimize wound outcomes, but perhaps more importantly, to safeguard the general health of the vulnerable individual. We present an evidence-based approach to the tertiary management of these injuries and propose a treatment algorithm that we have utilized in our unit to successfully manage 40% of tertiary referrals of pretibial lacerations in a conservative manner.

Lip replantation: A viable option for lower lip reconstruction after human bites, a literature review and proposed management algorithm - Corrected Proof

2012-01-24

Traumatic lip amputation by human bite is a rare event, and most articles in the current literature focus on loss of lip resulting from animal bites or injury. We are presenting our experience of a lip amputation as a result of human bite, which was treated with lip replantation.

Letter of response: Recognising phenytoin therapy as a cause of thickening of the eyelids and paranasal region - Corrected Proof

S.E. Thomson, A. Tahir, C. Dunkin — 2012-01-24

We read with interest your account of the potential cutaneous side effects of phenytoin therapy in a patient who underwent debulking therapy of an olfactory groove meningioma one year previously. As in the reported case many patients who undergo intracranial surgery are concomitantly prescribed prophylactic anti-epileptic therapy and it is useful to highlight the potential cutaneous manifestations of this drug.

Fracture fixation through flaps - Corrected Proof

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

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

Reply to discussion: Macrolane is no longer allowed in aesthetic breast augmentation in France. Will this decision extend to the rest of the world? - Corrected Proof

B. Chaput, J.P. Chavoin, C. Crouzet, J.L. Grolleau, I. Garrido — 2012-01-19

I would like to thank Dr. Per Heden, who has extensive experience of Macrolane, for this additional information. Since March 11, 2005, the precautionary principle is part of the French Republic constitution. The scandal PIP (Poly Implant Prothèse) is not the first crisis that led parliamentarians to that decision. The contaminated blood affair, mad cow diseases… have contributed to promote this basic principle a few years ago. This communication is not only the viewpoint of Chaput et al. but also of the AFSSAPS’ expert group who have considered that at the present time, the available scientific literature on hyaluronic acid injections close to the breast parenchyma was insufficient.

Discussion: Macrolane is no longer allowed in aesthetic breast augmentation in France. Will this decision extend to the rest of the world? - Corrected Proof

Per Hedén — 2012-01-16

I would like to respond to the correspondence and communication submitted by Chaput et al. regarding the decision of the French Agency for Safety of Health Products (AFSSAPS) to no longer approve Macrolane™ (Q-Med AB, Uppsala, Sweden) and other fillers for aesthetic breast augmentation.

Proximal-type epithelioid sarcoma: Case report of an unusual presentation - Corrected Proof

R.S.R. Woods, M.P. Dempsey, H.F. Rizkalla, M.E. McMenamin, D. O’Donovan — 2012-01-13

Summary: Epithelioid sarcoma, first described by Enzinger in 1970, classically presents in young adults and usually arises in the distal extremities. The proximal-type variant, first described in 1997 as a rare aggressive form of sarcoma, usually arises more proximally. It carries a higher mortality rate than classical limb epithelioid sarcoma and is often resistant to multimodal treatment. We report the case of a 27-year old male who had a delayed diagnosis of proximal-type epithelioid sarcoma of the forearm. This was originally thought to be a necrotising soft tissue infection and was unfortunately metastatic at the time of eventual diagnosis. The clinical and histopathological features of this challenging tumour are discussed and the relevant literature is reviewed.

Type IV hypersensitivity to a textured silicone breast implant - Corrected Proof

D. Dargan, C. McGoldrick, K. Khan — 2012-01-12

Summary: We present a case of hypersensitivity to a breast implant in a 57-year old female with breast cancer and hypersensitivity to adhesive dressings. A mastectomy, axillary node clearance, latissimus dorsi flap and silicone implant-based reconstruction were performed. The mammary wound dehisced within three weeks and the implant required removal. No pus was present, and cultures were negative.Three years later, a further silicone implant was inserted. Within three weeks from insertion, the patient required readmission with serous discharge from the wound, flu-like symptoms, low-grade pyrexia and painful swelling at the operative site. The implant was removed. Capsule biopsies demonstrated a large lymphoid cell reaction, in keeping with a delayed hypersensitivity reaction. Patch testing to samples of the implant was positive.

Complications of ear rings - Corrected Proof

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

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

The methodology of negative pressure wound therapy: Separating fact from fiction - Corrected Proof

Graeme E. Glass, Jagdeep Nanchahal — 2012-01-12

Summary: Background: Negative pressure wound therapy (NPWT) is a technique that has gained such rapid acceptance for such a diversity of wound management problems that the evidence for optimal use has struggled to keep up. While clinical studies have sought to evaluate its effectiveness for a variety of acute and chronic wounds, preclinical studies have suggested that features such as the magnitude and periodicity of negative pressure, the wound filler and interface materials and the drainage conduit might introduce key pathophysiological variations at the wound bed influencing healing. Optimising the methodological approach is the key to achieving the best outcomes with NPWT. The aim of the present study was to evaluate and summarise the clinical and experimental evidence for how these methodological variations influence wound healing when using NPWT.Methods: A literature review was conducted to evaluate each component of NPWT inciting methodological variation with reference to clinical and preclinical variables including wound volume reduction, blood flow, granulation and growth factor stimulation.Results: Fourteen commercially available NPWT systems are currently available. Both foam and gauze transmit NP efficiently. While some preclinical evidence suggests foam may preferentially promote cell proliferation, there is no clear evidence to favour one wound filler. Most wound contraction occurs within the first −50 mmHg and physiological optimisation may be achieved within −80 mmHg. Cyclical NP-mediated cell mechanotransduction may alter the healing characteristics of the wound bed but no definitive clinical protocol has been established. There is insufficient evidence to credit NPWT with reduced bacterial wound colonisation.Conclusion: There is an urgent need to develop evidence-based NPWT regimes, tailoring the methodological aspects of therapy to the clinical need. An individualised strategy may yield improved outcomes and realise the potential of this powerful therapeutic intervention.

The reinnervation pattern of wounds and scars after treatment with transforming growth factor β isoforms - Corrected Proof

James Henderson, Mark W.J. Ferguson, Giorgio Terenghi — 2012-01-12

Abstract: Background: Wounds deprived of innervation fail to heal normally, and hypertrophic scars may be abnormally innervated. Manipulation of wounds alters the subsequent degree of scarring, and isoforms of transforming growth factor beta (TGFβ) are well established in this role, whilst TGFβ3 is undergoing clinical trials as an antiscarring agent for clinical use. It is unclear if treated wounds show changes in their innervation patterns as they mature into scars.Methods: Mice underwent 1cm2 full thickness skin excisions which were treated with TGFβ1 or TGFβ3. Wounds were harvested between 5 and 84 days (n=6 at each time point). Sections underwent histological scar assessment and immunohistochemical staining for protein gene product 9.5 (PGP9.5), a pan-neuronal marker, and the sensory neuropeptides calcitonin gene related peptide (CGRP) and substance P (SP).Results: There was no difference in the reinnervation pattern between the peripheral and central parts of the wounds.Wounds treated with TGFβ3 healed with dermal collagen organised more like normal skin, whereas TGFβ1 treated wounds had abnormally orientated collagen within the scar compared to control treated wounds. Nerve fibre growth into the wounds followed a similar pattern in control and treated wounds, with only one significant difference during the healing process- at 42 days, the density of nerve fibres immunostained with PGP9.5 within the scar was greater than in control wounds. By 84 days, the density of PGP9.5, CGRP and SP immunopositive fibres were similar in control wounds and those treated with TGFβ isoforms.Conclusions: Changes in reinnervation patterns of wounds treated with TGFβ isoforms were only slightly different from those of control wounds, and by 84 days, the patterns were similar.

Securing fingertip dressings: The new ‘cinch pink’ technique - Corrected Proof

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

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

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

G.L. Ross — 2012-01-11

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

Long-term follow-up of syndromic craniosynostosis after Le Fort III halo distraction: A cephalometric and CT evaluation - Corrected Proof

2012-01-09

Summary: Background: Midface distraction osteogenesis (DO) in craniofacial synostosis (CFS) patients has been described by several authors. However, very few cephalometric and computed tomography (CT) long-term follow-up studies are available.Method: A total of 40 consecutive patients affected by CFS subjected to Le Fort III and rigid external distraction (RED) were examined. All patients had pre-DO cephalometric records, immediately post-DO and 6–12 months post-DO. Twenty-seven patients had mid-term records (3 years post-DO) and 20 patients had long-term records (5–10 years post-DO). Fourteen patients had CT data within 1-year of DO, while 10 patients had long-term CT data (range 5–9 years).Results: Excellent post-surgical stability was recorded. Short- and long-term CT data demonstrated excellent ossification at the osteotomy sites post-DO. In the growing patients, surface resorption in the zygomatic-temporal and in the subspinal area (p < 0.05) was observed in the long-term follow-up, as well as a mild increment of the corrected exorbitism (p < 0.05), as only appositional and no sutural growth occurs post Le Fort III, whereby orbital volume does not increase after surgery.Conclusion: Significant advancement of the midface can be achieved and maintained through Le Fort III and RED. In the long term, in growing patients, in general a class III malocclusion does not re-occur, but physiological remodelling processes at the maxillary-zygomatic level, not coupled with sutural growth, tend to mildly re-express the original midfacial phenotype and the exorbitism.

Ulnar subluxation of the median nerve following carpal tunnel release: A case report - Corrected Proof

B. L’Heureux-Lebeau, A. Odobescu, T. Moser, P.G. Harris, M.A. Danino — 2012-01-09

Summary: Complications of carpal tunnel release, while infrequent, include incomplete release resulting in persistent symptoms or recurrence due to postoperative scarring, as well as iatrogenic damage to nerves and vessels. We present the case of a patient who underwent carpal tunnel release with resolution of symptoms in the immediate postoperative period. At one and a half years post release he started to experience numbness and tingling in a median nerve distribution triggered by repetitive ulnar to radial deviation of the wrist, with no symptoms at rest. Dynamic ultrasound showed a subluxation of the median nerve from one side of the palmaris longus tendon to the other. The patient’s symptoms were triggered as the median nerve squeezed in between the palmaris longus and flexor digitorum superficialis tendons.

An in vivo mouse model of human skin replacement for wound healing and cell therapy studies - Corrected Proof

Aihua Guo, W. Andrew Owens, Martin Coady, Dalie Liu, Colin A.B. Jahoda — 2012-01-09

Successful testing/analysis of the efficacy of engineered human skin replacements has long been restricted by the paucity of animal models that reliably mimic human skin conditions. The nude (athymic) mouse is an established host for human tissues, and has been extensively used for testing skin substitutes and skin equivalents directly grafted to the mouse skin. This model has also been employed to study human skin wound healing, by pre-establishing human skin grafts on mice, and excising skin from the grafts using punch biopsies. Here we aimed to further develop the model and establish a method that could have future application in assessing the effectiveness of skin equivalents in a human skin environment. As an exemplar we used Integra (Integra Life Sciences Corporation, Plainsboro, NJ) a bilayer artificial skin replacement with a “dermal” layer composed of bovine collagen gel cross-linked with shark chondroitin-6-sulphate that is well established as a dermal replacement with multiple applications. Integra has also been used in combination with cultured keratinocytes in wound healing models and a method has been devised for incorporating dermal cells into this matrix in vitro In our study, therefore, Integra, with and without incorporated dermal cells was introduced into full thickness punch wounds in pre-established human skin grafts on nude mice ().

Why haematomas cause flap failure: An evidence-based paradigm - Corrected Proof

Graeme E. Glass, Jagdeep Nanchahal — 2012-01-09

Summary: Background: Haematomas compromise flaps in the absence of a pressure effect and pedicle thrombosis. While animal models confirmed the toxic effect of whole blood on adjacently sited random pattern flaps, our understanding of this phenomenon remains incomplete. Our aim was to identify mechanisms by which a subjacent haematoma leads to flap compromise to inform clinical practice.Methods: A literature review was conducted of all peer-reviewed publications relating haematoma to tissue compromise including free transferred tissue, vascularised flap models and brain injury. Clinical correlation was made with free vascularised flaps and rhytidectomy skin flaps.Results: Haematomas compromise around 2–4% of free tissue transfers and local flaps. We propose that several mechanisms are responsible. Cytokines, generated by platelet degradation, recruit neutrophils, releasing both reactive oxygen species and proteolytic enzymes. Reactive oxygen species (ROS), including superoxide and hydroxyl (OH−) are also produced by ATP degradation, promoted by NAD+ sequestration. Additionally, the complement cascade is triggered by thrombin. Ferrous ions, freed by complement-mediated lysis of erythrocytes and degradation of haemoglobin also promote generation of ROS. Reactive oxygen species, complement and activated neutrophils cause endothelial cell disruption, leading to activation of pro-thrombotic mechanisms and small vessel occlusion, with consequent tissue ischaemia, which in turn generates further ROS.Conclusion: Haematomas cause tissue injury by a complex sequence of inter-related biochemical and cellular processes merging on a common pathway of local tissue ischaemia which the overlying tissue is unable to regulate. Emergent evacuation of haematoma must be considered irrespective of envelope tension.

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

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

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

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

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

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

The lobular transposition flap – A useful adjunct to reconstruct helical defects - Corrected Proof

D.B. Saleh, J. Tan, P. Mohammed, S. Majumder — 2012-01-09

Summary: We detail our adjunct to Antia and Buch’s chondrocutaneous advancement flap for helical reconstruction. It is simple, reliable and negates the need for transfer of the defect to the lobule and/or V–Y advancement of the helical crus.

‘Animal-type’ melanoma of the scalp with satellitosis and positive sentinel nodes in a 4-year-old child: Case report and review of the literature - Corrected Proof

S. Sestini, G. Gerlini, P. Brandani, R. Gelli, G. Talini, C. Urso, L. Borgognoni — 2012-01-06

Summary: Background: Although showing a rapidly rising incidence, paediatric melanoma is relatively rare, accounting for 1–4% of all cases of melanoma and for 1–3% of all paediatric malignancies. The overall survival rate in paediatric patients seems to be similar to that recorded in adults. ‘Animal-type’ melanoma (ATM) is a rare melanoma subtype, occurring both in childhood and in adults, that shows a close histological resemblance to the heavily pigmented melanocytic tumours observed in grey and white horses.Case presentation: : We present a case of ATM of the scalp with satellitosis and two positive sentinel nodes in a 4-year-old male child. No other tumour deposits were found in the subsequent regional lymphadenectomy; the patient has been tumour free for 30 months.Conclusions: We treated our case of ATM in a child as the other types of paediatric melanoma, therefore as an adult melanoma. ATM is generally considered a neoplasm with an indolent course, that occasionally shows an aggressive behaviour, and patient deaths of ATM have been reported. Due to the rarity of ATM, further studies are needed to better define the biological behaviour of this particular melanoma subtype and the therapeutic and follow-up strategies.

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

Ravi Jandhyala — 2012-01-06

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

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

2012-01-05

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

Re: Use of gentamicin collagen sponges for the treatment of periprosthetic breast implant infection - Corrected Proof

P. Benito — 2012-01-05

I have read with interest the paper entitled “Use of gentamicin collagen sponges for the treatment of periprosthetic breast implant infection”. The author addresses a worrisome complication deriving from the use of breast implants by means of an antibiotic release system widely in use in other surgical specialities in which it has shown its efficacy.

Pivoting distraction osteogenesis in hemifacial microsomia - Corrected Proof

2012-01-05

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

Inferior-based pharyngeal flap for correction of stress velopharyngeal incompetence in musicians: Case reports and review of the literature - Corrected Proof

A. Visser, J.J. van der Biezen — 2012-01-04

Summary: Stress velopharyngeal incompetence (SVPI) is a special form of velopharyngeal incompetence observed in musicians who play wind and brass instruments. Due to high intraoral pressures generated while playing, the velopharyngeal structures fail to seal off the nasopharynx properly, resulting in unwanted nasal air leakage or noises. We present two young female professional clarinetists who experience symptoms of SVPI that preclude the development of their professional career. Both musicians underwent an inferior based pharyngeal flap, a well-known flap frequently used in cleft palate surgery. Both musicians were symptom-free after surgery and remain free of nasal noises while playing the clarinet after 2 and 4 years of follow-up. We present a review of literature of management of SVPI and show that the inferior-based pharyngeal flap is a feasible option for management of these potentially career ending symptoms.

Single-stage salvage hypospadias repair - Corrected Proof

J. Hardwicke, A. Park — 2012-01-04

We read with interest the recent article by Gill & Hameed promoting the use of a two-stage technique for revision of hypospadias. The treatment of primary hypospadias is performed, in the majority of cases, by single-stage techniques, with a two-stage technique reserved for more proximal meati and cases of salvage or revision hypospadias, the “hypospadias cripples”.

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

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

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

Quick Response codes in plastic surgery - Corrected Proof

Matthew D. Gardiner, Mary-Clare Miller, Andrew N.M. Fleming — 2012-01-03

Recent articles have reviewed smartphone applications that are useful to plastic surgeons. We would like to highlight the use of Quick Response code readers, which were omitted by these reviews.

Re: Digital infrared thermography for the pre-operative planning of microsurgical breast reconstruction: A comparison with CTA - Corrected Proof

2012-01-03

We would like to take the opportunity to reply to the letter by de Weerd, Weum and Mercer. The authors present an emotive response to our ‘correspondence’ to this journal, using terms such as ‘misleading’ to describe our contribution to the Journal. Their personal attack on our original comparison of two techniques for imaging perforators is to a large degree unfounded, and we would like to clarify our position.

Thermoregulation in peripheral nerve injury-induced cold-intolerant rats - Corrected Proof

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

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

Innovations in plastic surgery using cheap readily available materials in a resource poor environment – From CoRSU Uganda - Corrected Proof

Harry Tustin, Andrew M. Hodges — 2011-12-29

Surgical practice in an environment where access to both conventional material resources and financial support are limited often provides motivation to improvise with locally available materials.

Congenital fistula of palate - Corrected Proof

Chuanqi Qin, Bing Shi — 2011-12-28

Palatal fistula is a common complication after cleft palate repair. However, congenital fistula of the palate is rarely reported. Five patients with congenital fistula of the palate were admitted to our department. We described the clinical character and illustrated two represented cases here.

Anatomy of the infratemporal crest: Implications for cross-facial nerve grafting in temporal myoplasty - Corrected Proof

Asha Ali, Steven Lo, Charles Nduka, Philip Adds — 2011-12-26

Summary: Temporalis transfers for reanimation in facial palsy have been criticised for the lack of neural input from a functioning facial nerve. Cross-facial nerve grafting to the deep temporal nerves may provide a solution. An anatomical study was performed to further elucidate the deep temporal nerves (DTN) and arteries, examining anatomical variation and infratemporal distribution.Seventeen temporalis muscles were dissected from 13 cadavers as part of a BSc project. The number, branching pattern, length and diameter of DTN were recorded. Arteries supplying the deep surface of temporalis and their relation to DTN were noted. Six specimens were processed using Sihler’s staining technique. Arteries were injected with Iodixanol X-ray contrast medium and radiographs taken. All specimens displayed a single DTN originating from the anterior branch of V3. A mean of 3 branches was observed. The nerve length was 14.22±3.95mm. The point of entry of DTN into temporalis showed great consistency. Upon exiting the infratemporal fossa, the posterior deep temporal artery was deep and posterior to DTN in 65% of specimens. The branching pattern of DTN can be classified into three types. The deep arterial supply to temporalis was constant in all specimens.This study provides an anatomical basis for the planning and execution of cross-facial nerve grafting to temporalis, and for protection of vital structures. Furthermore, it helps to clarify inconsistencies in the literature regarding nomenclature of the nerve branching pattern of the deep temporal nerves.

Late partial failure of a free ALT flap - Corrected Proof

Marco Pignatti, Fortune C. Iwuagwu, Tom F. Browne — 2011-12-26

Summary: Late failure of microsurgical flaps is a rare event and it has been reported as a consequence of compression of the vascular pedicle or late infection.We report a case of late partial failure occurring 3 weeks post-operatively which was shown by vascular imaging to be caused by a previously unidentified complete occlusion of the right external iliac artery.After successful vascular bypass surgery, the suffering flap developed granulation tissue and was skin grafted.In patients carrying multiple risk factors for peripheral vascular disease, the risk of proximal vessel occlusion as a cause of flap failure, should be kept in mind.

Nasal patency after open rhinoplasty with spreader grafts - Corrected Proof

2011-12-26

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