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

Risk and outcome analysis of 1832 consecutively excised basal Cell carcinoma's in a tertiary referral plastic surgery unit - Corrected Proof

2010-03-12

Summary: Background: Basal cell carcinomas are the most prevalent of all skin cancers worldwide and form the majority of the surgical workload for most modern cutaneous malignancy centres. Primary surgical removal of basal cell carcinomas remains the gold standard of treatment but, despite almost two centuries of surgical experience, rates of incomplete surgical excision of up to 50% are still reported.The aim of this study was to assess, quantify and perform comparative analysis of the outcomes and predictive factors of consecutive primarily-excised basal cell carcinomas in a tertiary centre over a six-year period.Methods: Retrospective audit was conducted on all patients who underwent surgical excision of basal cell carcinomas from January 2000 to December 2005. Assessment parameters included patient biographics, tumour management differences and detailed histopathological analysis of tumour margins and subtypes.Results: One thousand eight hundred and thirty two basal cell carcinomas were excised from 1329 patients over the designated time period. Two hundred and fifty one (14%) lesions were incompletely excised with 135 (7.4%) involving the peripheral margin only, 48 (2.6%) the deep margin only and 41 (2.2%) involving both. Nasal location was the most common predictor of incomplete excision.Conclusions: Overall basal cell carcinomas excision rates compared favourably with international reported standards but attention to a variety of surgical and histological risk factors may improve this further.

Attaining symmetry in breast reconstruction - Corrected Proof

John K. Dickson, James M. Taylor, Ruchika Rajan, Ajay L. Mahajan — 2010-03-12

In breast reconstruction, attaining symmetry in size, shape, projection and position of both the breast and nipple-areolar complex is key to achieve an aesthetically pleasing outcome. Techniques have been described to help to achieve this symmetry. Often surgeons estimate symmetry or use complex measurements when marking a patient for the procedure. The footprint, conus and the envelope are the three components that need to be taken into consideration when reconstructing the breast. While the conus provides projection, the skin envelope is the major factor in establishing the shape of the breast. The envelope of the reconstructed breast depends on available native chest wall skin and the skin island of the flap used for reconstruction. Provided the scars on the chest wall are symmetrical, reconstruction involving mirror-image skin paddles helps attain symmetry of the skin envelope. In addition, final symmetry of the skin envelope is obtained by reconstructing identical nipple areolar complexes.

Health-related quality of life in children and adolescents with syndromic craniosynostosis - Corrected Proof

2010-03-11

Summary: Syndromic craniosynostosis is a congenital disorder characterised by premature fusion of calvarial sutures combined with other anomalies. The facial appearance is different and patients may show physical impairment, mental or developmental disabilities, elevated intracranial pressure and obstructive sleep apnoea. The impact of this condition on daily functioning has not been studied before. The aim of this study is to assess the health-related quality of life in children and adolescents with syndromic or complex craniosynostosis and to determine the impact of these syndromes on parents.A prospective study was performed in 111 children. Health-related quality of life was measured by international standardised quality-of-life questionnaires, the Infant Toddler Quality of Life Questionnaire (ITQoL), Child Health Questionnaire Parental Form 50 (CHQ-PF50), Child Health Questionnaire Child Form 87 (CHQ-CF87) and Short-Form Health Survey (SF-36). For comparison, we used Dutch population norms of health-related quality-of-life-scores.Parents' scores for patients with syndromic or complex craniosynostosis were significantly lower than those for the norm population. Apert syndrome had the largest impact on the different domains. Scores on the CHQ-PF50 scales for ‘physical functioning’, ‘parental impact emotional’ and ‘family activities’ for these patients were significantly lower than scores for patients with other syndromes, possibly due to the complexity of the syndrome, which includes complex syndactyly, cognitive impairment and behaviour problems. Parents reported a reduced health-related quality of life for themselves, mostly psychosocial with clearly significantly lower general health perceptions.In conclusion, syndromic craniosynostosis has a large impact on the health-related quality of life of these children and their parents, both physical and psychosocial.

Reduction mammaplasty and related impact on psychosexual function - Corrected Proof

M. Romeo, G. Cuccia, A. Zirilli, E. Weiler-Mithoff, F. Stagno d'Alcontres — 2010-03-08

Summary: Introduction: Reduction mammaplasty brings an effective improvement, both from the physical and psychological points of view. However, psychosexual consequences are as yet poorly studied, although scars, impairment of sensibility, change in shape and asymmetry can have a negative effect on sexual life.Aim: These authors retrospectively reviewed 55 patients to verify the existence of a close relationship between this popular surgical procedure and psychosexual function.Material and methods: All patients were compared to a group (51 healthy women) chosen from the hospital personnel. Both groups answered four psychological questionnaires (Short Form (SF)-36, Hamilton Anxiety Rating Scale (Ham-A), Hamilton Rating Scale for Depression (Ham-D), Female Sexual Function Index (FSFI)) anonymously, in addition to the scar-assessment test as a single physical test. Psychological tests aim to evaluate self-esteem, quality of life (SF-36) and sexual function in women (FSFI, a test based on Erectile Function Index of Male). High levels of anxiety and depression were used as exclusion criteria in our study (Ham-D and Ham-A). Statistical analysis was based on non-parametric correlation test adjusted for small groups and Spearman's rho test to verify the associations among sub-items scales.Results: Almost all patients (98%) fulfilled the inclusion criteria for our study. Sexual function index was equal in both groups, but it still showed a higher quality of life in the control group. Nevertheless, the SF-36 value of the patients' group is still enough to allow for acceptable self-esteem.Conclusions: We can confirm that reduction mammaplasty does not impair sexual satisfaction or quality of life; moreover, we believe that this procedure can improve such indices. Further investigation will compare patient's values prior to and following surgery to put in evidence a stronger relationship between mammary reduction and sexual function.

Where to find facial artery perforators: a reference point - Corrected Proof

Zhi Yang Ng, Quentin A. Fogg, Taimur Shoaib — 2010-03-08

Summary: Reconstructive surgery of the midface using facial artery perforator (FAP) flaps is being used more frequently now as it has been reported to provide better aesthetic results and reduce a traditional two-stage procedure to a one-stage technique. However, the wide acceptance of this approach is limited by a poor understanding of the anatomy associated with this technique. This was investigated through a cadaveric study. The facial artery (FA) of 16 cadaveric half-faces were each identified, cannulated with coloured latex and then dissected to give an accurate and quantified description of FA perforating branches. A lateral-view picture of each specimen was taken and analysed using ImageJ 1.42q. Cadaveric dissections showed that each hemiface could be regarded as a single entity. The values of the means were as follows: FA length=116±22mm, FA diameter=2.62±0.74mm, number of FAPs=4±2, FAP length=14.12±3.46mm and FAP diameter=0.94±0.29mm. A reference point, A, where FAPs were consistently found to originate, was also identified. Therefore, the FAP flap is a viable and valuable addition to plastic reconstructive techniques. The localisation of point A with precise measurements can facilitate the design and use of such FAP flaps for the reconstruction of nasal, as well as perinasal and perioral defects.

Merkel cell carcinoma: Our experience with seven patients in Korea and a literature review - Corrected Proof

2010-03-08

Summary: Background: Merkel cell carcinoma (MCC) is a rare but malignant cutaneous neuroendocrine carcinoma. As MCC has primarily been reported in Caucasians, MCC cases in Korea have not yet been reported. The purpose of this study was to retrospectively review our experience with the surgical treatment of MCC in Korea and to study its management and outcome.Method: We retrospectively reviewed seven MCC case files between 2000 and 2008 from a single institution. We analysed patient characteristics, tumour location and size, staging, treatment methods and outcomes. We performed polymerase chain reaction (PCR) to detect Merkel cell polyomavirus (MCPyV) from formalin-fixed paraffin-embedded tissue specimens.Results: Two patients had stage I tumours, four patients had stage II tumours and one patient had a stage III tumour. Wide local excision with a clear resection margin was the primary modality of treatment in all cases. Adjuvant radiotherapy and chemotherapy were performed for selected patients. Recurrence was observed in two out of the seven cases during the follow-up period. MCPyV was detected by PCR in all seven cases.Conclusion: MCC is an aggressive skin cancer, and pathologic lymph node evaluation is important for staging. Wide excision is the primary modality of treatment, but adjuvant radiotherapy could be positively considered if the tumour is large and the lesion is not confined to the dermis. MCPyV was detected by PCR in all cases, which suggests that MCPyV is also a putative aetiological agent in the carcinogenesis of MCC in Korea.

Mirror foot – A reflection on three cases - Corrected Proof

A. Mishra, K. Nelson, P. McArthur — 2010-03-08

Summary: Introduction and aims: Mirror-foot abnormalities are distinctly uncommon entities and represent extreme forms of congenital duplication. We present a reflection on three different cases of mirror foot and discuss their surgical management.Patients and methods: The first patient had a right-sided mirror foot with a central great toe and three complete medial rays. The second patient had quadruplication of the left great toe ray. The third had a full complement of metatarsals associated with two extra complete rays placed medial to the great toe of the right foot. All patients underwent complex ray resection and concurrent reconstruction of the medial arch of foot. All three cases of mirror foot presented and were operated on in the pre-ambulatory period.Results: All three patients recovered with good functional and aesthetic results. Follow-up duration ranged from 3 to 5 years.Conclusion: Surgical treatment of the mirror foot is less complicated than that of its upper limb equivalent. Essentially, there must be an initial surgical reduction in the number of digits, coupled with tendon transfers as necessary to maintain foot arches.

An approach to bilateral facial paralysis - Corrected Proof

Alex C.S. Woollard, Douglas H. Harrison, Adriaan O. Grobbelaar — 2010-03-08

Summary: Möbius syndrome is characterised by a congenital paralysis of the Facial and Abducens nerves. Treatment centres around functional free muscle transfers. We present 20 cases of Möbius reanimation, currently the largest published series. Our preferred approach has evolved over time to be a single stage bilateral procedure using segmental Latissimus dorsi muscles driven by the masseteric branch of the Trigeminal nerve. All cases showed significant improvement when reviewed by the senior surgeon and independent panel of observers. It was the senior authors’ opinion that a more spontaneous smile was achieved in patients under ten years of age.

Corrected Proof

Tuija M. Yla-Kotola — 2010-03-04

According to its preface, this book is written with the intention to introduce all the opportunities that fat grafting can provide. Dr Coleman and Dr Mazzola have edited a huge amount of data about fat grafting written by several experts around the world.

Necrotizing pyoderma gangrenosum: an unusual differential diagnosis of necrotizing fasciitis - Corrected Proof

Benoit Ayestaray, Emmanuel Dudrap, Emilie Chartaux, Eva Verdier, Pascal Joly — 2010-03-04

Pyoderma gangrenosum is a neutrophilic dermatosis, of unknown aetiology, described by Brocq in 1908. The familiy of neutrophilic dermatosis is characterised histologically by a neutrophilic and lymphocytic infiltrate, without vasculitis or infectious cause. Different forms of pyoderma gangrenosum are described according to their clinical signs and the associated diseases: classic (or ulcerative), pustular, bullous and vegetative pyoderma gangrenosum. A beginning lesion of pyoderma gangrenosum can be mistaken for a skin infection, because of its inflammatory character and a frequent hyperthermia. The differential diagnosis with a cellulitis can be difficult. We report a case of pyoderma gangrenosum, appeared without trauma. Its clinical aspect was first similar in a cellulitis, then in a necrotizing fasciitis because of necrotic areas. This case illustrates the difficulty of diagnosis between a dermo-hypodermal infection and a neutrophilic dermatosis. It also presents a very unusual variant of pyoderma gangrenosum, which is necrotizing.

Corrected Proof

M. Felix Freshwater — 2010-03-04

The U.S. Food and Drug Administration demands that all new drugs be proven to be both safe and effective before it will approve them for use. As patient safety is a vital issue for all practising plastic surgeons, it is worthwhile to analyse ‘Patient Safety in Plastic Surgery’ to see if it is indeed both safe and effective. After all, what could be worse than a book on patient safety that was neither safe nor effective?

Osteogenic capacity of vascularised periosteum: An experimental study on mandibular irradiated bone in rabbits - Corrected Proof

Jacques Yachouh, Pierre Breton, Jean-Paul Roux, Patrick Goudot — 2010-03-02

Summary: Background: Free flaps are presently the best way to treat advanced mandibular ostonecrosis. Nevertheless, the functional and morphological results can be improved. To avoid a mandibular resection, a free periosteal flap was envisioned. In a preliminary study, the authors opted for a pedicled periosteal flap and evaluated the effect of the latter on regeneration of a rabbit irradiated mandibular bone.Methods: Two bone fragments were taken from the basilar part of the mandible of 15 rabbits through skin incision. Those fragments were then exposed to a 30-Gy irradiation. One bone fragment was implanted in a pedicled periosteal flap elevated from the medial aspect of the femur while the other was subcutaneously fixed as a control. We retrieved the fragments at day 10, 20, 30 and 90 to make a histological analysis without prior decalcification using histomorphometry technique.Results: In the periosted fragments, an increased osteoblastic and osteoclastic activity as well as neovascularisation evoked intense remodelling. In the subcutaneous fragments, bone resorption was much more important than osteogenesis and vessels were absent.Conclusion: We have concluded than periosteum, which has already been proven to be efficient in normal bone regeneration, can be just as such efficient in irradiated bone regeneration.

Salvage of a complicated penis replantation using bipedicled scrotal flap following a prolonged ischaemia time - Corrected Proof

2010-03-02

Summary: Microsurgical replantation is the standard method to treat penile amputation. The loss of variable area of skin is a common complication following penile replantation due to prolonged ischaemia time, postoperative venous congestion, oedema and wound infection. There is limited literature available on the management of complications following replantation. A skin graft is commonly used to resurface the denuded areas after skin necrosis. However, this simple and rapid approach has some inherent disadvantages, including paresthesia, contracture, mismatched skin colour and disfiguring donor site. In this report, we present the salvage of a replanted penis by a bipedicled scrotal flap in which the skin fragment was necrosed due to prolonged ischaemia time. Cosmetic and functional outcomes in the 1-year follow-up period were satisfactory.

Soft tissue distraction in the management of severe preaxial polydactyly of feet - Corrected Proof

Anuj Mishra, Kathryn Nelson, Selvadurai Nayagam, Paul McArthur — 2010-03-02

Polydactyly is the commonest congenital deformity of the foot. A spectrum of defects exists from minor soft tissue duplications to major bony abnormalities. Preaxial polydactyly is represented by an extra digit on the medial side of the foot. This group is often difficult to treat due to associated first metatarsal anomalies. Soft tissue distraction has been described for the management of congenital hand and foot anomalies. We present the use of soft tissue distraction in a case of severe preaxial polydactyly of feet.

Scalp abscess – a cautionary tale - Corrected Proof

Nora F. Nugent, Michael Murphy, Jason Kelly — 2010-03-02

Summary: Transcranial extension of frontal sinus infection is a rare, but not eradicated entity. We present a 21-year-old male, in whom a persistent scalp abscess heralded the discovery of skull vault osteomyelitis and extradural abscesses secondary to frontal sinusitis. Patients with prolonged or unusual symptoms with a history of sinusitis or trauma warrant further investigation as they may have developed serious intracranial complications. Urgent management, both surgical and antimicrobial, is indicated in such scenarios.

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

Yusuke Shimizu, Tomohisa Nagasao, Toru Asou — 2010-02-25

Summary: Purpose: The present report introduces our correction method for blepharoptosis, in which major incisions are made on neither the skin nor the conjunctiva of the upper eyelid, and no dissection of the eyelid tissues is required.Methods: After turning the upper eyelid inside out, threads are introduced into it through the conjunctiva close to the superior fornix. Then the superior palpebral levator muscle and the tarsus are connected using threads. This thread application is performed at two-to-four locations of the upper eyelid. By tightening the threads, the tarsus is elevated and the ptotic eyelid is corrected. A total of 624 eyelids in 390 patients with mild or moderate ptosis were operated on with this surgical method. Effectiveness of the treatment was evaluated referring to the degree of improvement. Furthermore, frequencies of complications were evaluated.Results: Among 416 eyelids with mild ptosis, complete correction of ptosis was achieved with 406 eyelids (97.5%). Among 208 eyelids with moderate ptosis, improvement was achieved with 185 eyelids (88.9%), with complete correction for 156 eyelids (75%).Conclusion: Since the present method enables effective correction of the blepharoptosis with a simple technique, minimised recovery time and no scarring, it provides a useful surgical option for the treatment of mild and moderate blepharoptosis.

Surgical tip: A cheap and readily available alternative to the 10cc syringe lock for Coleman fat grafting - Corrected Proof

K.S. Alexander, N. Kang — 2010-02-22

The 10cc syringe lock () helps to maintain the negative pressure within a syringe during harvest of fat for Coleman fat transfer. This maintains the negative pressure within the syringe with little effort. Unfortunately, there is only syringe lock supplied in each instrument set. If it is lost or desterilised, a new surgical set must be opened to replace the syringe lock. The syringe lock costs £57 to buy separately from Mentor.

Decades of change in plastic surgery training - Corrected Proof

R.M. Pinder, F. Urso-Baiarda, S.L. Knight — 2010-02-22

Surgical training has traditionally been an apprenticeship with long hours spent at work learning from consultants within a ‘firm’ structure that received, managed and discharged their own patients. In 1995 Sir Kenneth Calman reformed higher surgical training through the introduction of annual assessments culminating in a Certificate of Completion of Surgical Training (CCST). The development of a bottleneck at entry to higher surgical training created the ‘lost-tribe’ of ‘workhorse’ senior house officers (SHOs), the plight of whom was recognised in the UK Government's paper ‘Unfinished Business’. This ultimately led to the introduction of Modernising Medical Careers (MMC) in 2003. During this time the British Medical Association (BMA) worked hard to secure ‘the New Deal’, reducing the maximum working week to 56h, recently further reduced to 48h through the implementation of the European Working Time Directive (EWTD). Changes to surgical training, working patterns and the introduction of Government-implemented target-driven rewards for Trusts have cumulatively reduced working hours and surgical trainee experience.

The bacteriology of children prior to 1st stage autologous ear reconstruction - Corrected Proof

Karen A. Eley, David T. Gault — 2010-02-19

Abstract: In virtually all surgical specialities the use of peri-operative antibiotic prophylaxis to minimise wound site infection is routine practice. Antibiotic selection is targeted towards the pathogens most commonly encountered at the surgical site.The surgical management of microtia is by autologous rib cartilage reconstruction, a process that involves at least two surgical stages. The pits and recesses of the microtia ear are difficult to clean and may shelter unusual pathogens not routinely found as skin commensals, requiring modified prophylaxis. This retrospective review of 37 patients undergoing 1st stage ear reconstruction, examines the pre-operative ear site, nose and throat swabs to determine the common pre-operative bacteria encountered in children prior to ear reconstruction, to aid in appropriate antibiotic selection.

Upper eyelid reconstruction with a horizontal V–Y myotarsocutaneous advancement flap - Corrected Proof

José Rosa, Diogo Casal, Paula Moniz — 2010-02-19

Summary: Upper eyelid tumours, particularly basal cell carcinomas, are relatively frequent. Surgical ablation of these lesions creates defects of variable complexity. Although several options are available for lower eyelid reconstruction, fewer surgical alternatives exist for upper eyelid reconstruction. Large defects of this region are usually reconstructed with two-step procedures. In 1997, Okada et al. described a horizontal V–Y myotarsocutaneous advancement flap for reconstruction of a large upper eyelid defect in a single operative time. However, no further studies were published regarding the use of this particular flap in upper eyelid reconstruction. In addition, this flap is not described in most plastic surgery textbooks.The authors report here their experience of 16 cases of horizontal V–Y myotarsocutaneous advancement flaps used to reconstruct full-thickness defects of the upper eyelid after tumour excision. The tumour histological types were as follows: 12 basal cell carcinomas, 2 cases of squamous cell carcinomas, 1 case of sebaceous cell carcinoma and 1 of malignant melanoma.This technique allowed closure of defects of up to 60% of the eyelid width. None of the flaps suffered necrosis. The mean operative time was 30min. No additional procedures were necessary as good functional and cosmetic results were achieved in all cases. No recurrences were noted.In this series, the horizontal V–Y myotarsocutaneous advancement flap proved to be a technically simple, reliable and expeditious option for reconstruction of full-thickness upper eyelid defects (as wide as 60% of the eyelid width) in a single operative procedure. In the future this technique may become the preferential option for such defects.

Infratemporal fossa reconstruction following total auriculectomy: An alternative flap option - Corrected Proof

2010-02-18

Summary: Reconstruction following oncologic resection in the head and neck is complex due to large surgical defects left after removal of skin, subcutaneous, and skeletal structures. It is essential to adequately fill the defect as well as provide an acceptable tissue match in terms of tone, texture, thickness and contour. A 55-year-old male presented with an advanced melanoma in the right pre-tragal area. Surgical resection was performed including a total auriculectomy. A tunnelled right supraclavicular artery island (SAI) flap was used to repair the surgical defect. A Doppler probe ensured adequate circulation within the flap, especially in the distal tip. Reconstruction using the SAI flap after oncologic ear resection reduced operating room time, required less technical expertise, and provided excellent tissue match compared to more traditional methods of surgical defect reconstruction including free flaps, local flaps, and pedicled myocutaneous flaps. Successful use of the SAI flap in this case further expands the flaps versatility. We recommend that the reconstructive surgeon consider the SAI flap when presented with challenging infratemporal fossa and lateral skull base cases.

The osmotic tissue expander: A 5-year experience - Corrected Proof

Shaheel Chummun, P. Addison, K.J. Stewart — 2010-02-18

Summary: Tissue expansion is a valuable technique in soft tissue reconstruction. Osmotic expanders are self-inflating and obviate the need for repeated injections. In doing so, they eliminate port site problems and may reduce the potential to introduce infection. The use of such expanders has become more common in recent years. We report on our experience with the Osmed™ osmotic expanders over the last 5-years.

The ‘T’ – a simple technique for finger dressings - Corrected Proof

Christopher J. Lewis, Thomas H. McKinnell, Sarah A. Pape — 2010-02-17

Traditional finger dressings (e.g. following a nail bed repair or pulp laceration) usually consist of a non-adherent layer and dressing gauze, wrapped around the finger and covered in a tubular stockinette dressing. Patients often find them to be bulky and awkward yet lacking sufficient cushioning to the very tip of the finger. In addition, tight dressings may lead to digit necrosis. We present a simple alteration by cutting the dressings into a template T shape.

Response to Pollard RL, O'Broin E. Compartment syndrome following prolonged surgery for breast reconstruction with epidural analgesia. J Plast Reconstr Aesthet Surg 2009;62:e648–e649 - Corrected Proof

G.J. Mar, M.J. Barrington — 2010-02-17

We read with interest the correspondence relating to a case of compartment syndrome following reconstructive breast surgery. We commend the authors for drawing attention to the fact that prolonged major surgery is a risk factor for the development of compartment syndrome. There are a number of issues we would like to address relating to the post-operative analgesia however. We recently published a systematic review on the association between post-operative analgesia and a delayed diagnosis of compartment syndrome. In our review we found 28 case reports or series which discussed whether the choice of analgesia delayed the diagnosis of compartment syndrome, of which 23 discussed the potential role of epidural analgesia. In 32 of the 35 patients described, classic signs and symptoms of compartment syndrome were present in the presence of epidural analgesia, including 18 patients with documented breakthrough pain. Our conclusion is that there is no convincing evidence that patient-controlled analgesia (PCA) opioids or regional analgesia delay the diagnosis of compartment syndrome provided patients are adequately monitored in the post-operative period. This case report bears similarities with many of the previous case reports published on this topic. Stating that the ‘degree of pain was undoubtedly masked by the analgesia’ demonstrates a lack of understanding of the anatomy of epidural analgesia and the pharmacology of PCA opioids and is unsubstantiated. Firstly, the patient complains of bilateral leg cramps that were not trivial discomfort if PCA opioids were required for analgesia. Secondly, whilst there is no mention of which vertebral interspace the epidural was placed, it is our practise to place an epidural catheter close to the T 9-10 thoracic vertebral interspace for Diep Flap procedures in order to provide analgesia for the abdominal incision. The chance of an epidural infusion at this level leading to significant analgesia in the calf, which derives sensory innervation from L3-S1 dermatomes, is unlikely. Even if local anaesthetic spread was that low, the dilute local anaesthetic solution should not lead to dense sensory or motor blockade. The analgesic effect of PCA opioids is only moderate and is unlikely to mask the pain of compartment syndrome and in fact can be used to expedite the diagnosis if hourly usage is increasing unexpectedly. Although this patient was regularly examined by the surgical unit, it would appear that compartment syndrome was simply not considered as a possible cause for her symptoms. Pain is an unreliable symptom of compartment syndrome. If there is any doubt over the diagnosis, compartmental pressure manometry is useful and may have avoided serious morbidity in this case. Placing a needle into the calf compartments is easy and cheap to perform and avoids delays when deciding if a fasciotomy is required. Regardless of the type of analgesia used, a high index of clinical suspicion, ongoing effective clinical assessment of patients, and compartment pressure measurement are essential for early diagnosis. Compartment syndrome is missed because the diagnosis is not considered.

Corrected Proof

Paul M.N. Werker — 2010-02-17

This book on head and neck reconstruction contains 44 chapters in seven sections covering the full spectrum of problems encountered in head and neck surgery and their solutions. It also includes 2 DVD's containing 5 operative procedures. The book is edited by two of the world's leading microsurgeons in this field and all chapters are written by experts from all over the world, who share their expertise and insights on the latest advances and techniques in head and neck surgery and reconstruction.

Prefabricated flap composed by skin and terminal gastromental vessels. Experimental study in rabbits - Corrected Proof

2010-02-17

Summary: Background: The angiogenic induction property of the omentum makes it a promising pedicle for prefabricating flaps. Therefore, the objective of this paper is to establish the abdominal area to be prefabricated by the omental pedicle and to analyse the prefabricated potential (PP) according to the time delay between the pedicle introduction and the flap release.Methods: Forty-four rabbits were divided into four groups (A, B, C and D). In group A, a piece of skin, subcutaneous tissue and abdominal cutaneous muscle was fully released and sutured again in place. In the other groups, a 9-cm2 omental pedicle containing the gastromental vessels distally tied was transposed and sutured to abdominal cutaneous muscle. A second procedure, consisting of incision and release of the flap that contained skin, subcutaneous and cutaneous abdominal muscle pediculated only by the omentum, was carried out. The only variation was the time delay between the two procedures: 7, 21 and 56 days for groups B, C and D, respectively. The flaps were inspected 15 days after the last procedure. The pieces of viable area were immunostained using anti-CD31 for estimation of the microvascular density.Results: The mean and maximum viable areas in group D were 45.29 and 99.37cm2, respectively (average PP=5.03 and maximum PP=11.04). There was no significant difference between the viable areas in groups C and D. The mean microvascular densities of groups B, C and D were 24.54, 33.20 and 27.03 vessels/mm2, respectively.Conclusion: The omental tissue has great potential for prefabrication of flaps, and the delay time for the second procedure should be at least 21 days.

Choice of anesthetic technique for ear reconstruction using a tissue expander and cartilage framework - Corrected Proof

Bo Pan, Lingxin Wei, Xiaoming Deng, Hongxing Zhuang, Haiyue Jiang — 2010-02-17

Ear reconstruction is one of the most challenging arenas for plastic surgeons. We have designed a three-stage ear reconstruction technique using tissue expansion followed by insertion of a cartilage framework. These techniques have been utilised for microtia patients over the last decade. In the majority of the patients the operations were performed under local anesthetic. Our practice of using local anesthesia for such surgery contrasts with a general, international acceptance of general anaesthesia for such surgery. Despite this, we feel that, it represents a near-ideal technique because of its simplicity, low cost and lack of the cardiovascular effects observed with general anesthesia. In this paper, we describe our experience using this anesthetic regime.

Use of Dermabond as a dressing for prominent ear correction: a sound alternative to head dressings - Corrected Proof

Esta S. Bovill, Richard Boulton, Simon Wharton — 2010-02-15

Head dressings remain in widespread use following pinnaplasty, despite the absence of evidence for their use, and potential for associated complications. Slippage is the most frequently encountered post-operative problem following prominent ear correction, with reports of incidence ranging from 43%–67%. Such dressings can also be uncomfortable, bulky and a source of anxiety, with potential for obscuring complications such as infection and haematoma. They have been associated with anterior skin and cartilage necrosis, whilst packing of the concha has been implicated in the high incidence of post-operative nausea and vomiting after pinnaplasty. 2-Octyl-Cyanoacrylate (Dermabond) skin adhesive used as an alternative dressing has the potential to abrogate such problems. We describe its use in a retrospective comparative study.

Management of an Unfortunate Triad after Breast Reconstruction: Pyoderma gangrenosum, Full-Thickness Chest Wall Defect and Acinetobacter Baumannii Infection - Corrected Proof

2010-02-15

Summary: If diagnosed late, post-surgical pyoderma gangrenosum (PSPG) is a rare, tricky and potentially life-threatening complication. Once diagnosed, immunosuppressive agents may provoke further complications. Well-intentioned extensive serial debridement may cause deep skin and soft-tissue defects, requiring skin grafting and possible flap surgery. The combination of necessary immunosuppressive treatment, protracted hospital stay and broad-spectrum systemic antimicrobial therapy may encourage serious acquired multidrug resistance (MDR). We report an unfortunate triad following breast reconstruction of PSPG, full-thickness chest wall defect and MDR with Acinetobacter baumannii infection. Interdisciplinary treatment using free flap surgery and negative-pressure wound therapy with instillation therapy (V.A.C.Instill® Wound Therapy) enabled survival and complete wound closure.

A rare complication after septoplasty procedure in a misdiagnosed submucous cleft palate case: palatal fistula - Corrected Proof

Burak Ersoy, Sarper Yılmaz, Hakan Şirinoğlu, Özhan Çelebiler, Ayhan Numanoğlu — 2010-02-15

Summary: Nasal septoplasty is a common and low-risk procedure performed very frequently in plastic surgery as well as in otorhinolaryngology. The development of a palatal perforation following a nasal septoplasty procedure is a very rare event with only a few cases reported in the literature. A patient with palatal fistula formation after septoplasty procedure is presented here, who was later on diagnosed with submucous cleft palate during the repair of the palatal fistula.

Revision reduction malarplasty with coronal approach - Corrected Proof

Rong-Min Baek, Jino Kim, Sang Woo Lee — 2010-02-15

Summary: Background: Although reduction malarplasty is one of the most popular aesthetic surgical procedures in Asia, there have been a few reports of complications or unfavourable results. A poor understanding of the repositioning vector of the malar segment or improper fixation can result in unsatisfactory outcomes, such as non-union or inferolaterally displaced malunion of the malar complex. The authors present some revision malarplasty cases of patients with unfavourable or complicated outcomes to emphasise the importance of accurate repositioning and firm fixation of the malar complex in reduction malarplasty.Methods: A total of 20 patients underwent revision malarplasty by the coronal approach after an unfavourable primary reduction malarplasty. The major complaints included cheek drooping, depression, asymmetry and overcorrection. After repositioning the inferolaterally displaced malar complex to the appropriate position and obtaining bone-to-bone contact, rigid fixation was performed with a plate and screw. The calvarian bone was grafted to the bony gap. Midface and forehead lifts were also performed when indicated.Results: Most patients had satisfactory results without severe complications. Two patients required a secondary revision due to asymmetry and non-union. Three patients developed frontal palsies, which were all temporary.Conclusion: Precise repositioning of the malar complex and firm fixation are essential for reduction malarplasty. The coronal approach is recommended when encountering unfavourable results or complications because it offers a wide surgical field for repositioning and fixation of the malar complex.

Supratrochlear artery based V-Y flap for partial eyebrow reconstruction - Corrected Proof

Fabrizio Schonauer, Salvatore Taglialatela Scafati, Guido Molea — 2010-02-15

The eyebrow is a subunit of the forehead aesthetic unit of the face. Both position and continuity of the eyebrow hairline play key roles in the general harmony of the face. A 59-year old male patient was admitted to our Unit with a nodular skin lesion at the lateral third of the left eyebrow. Surgical excision was then planned. Emergency and course of the left supratrochlear artery were marked by means of a hand-held Doppler. A V-Y skin island flap was planned based on the supratrochlear artery (). Tumour was excised with a 0.5cm margin, creating a defect of 3.1 × 3.8cm. Flap dissection was performed in the subgaleal plane from lateral to medial. The thin frontalis muscle attachments were divided from the upper margin of the skin island. The supratrochlear artery and vein were intramuscularly dissected and skeletonised in the area where the fibres of the frontalis muscle blend with those of the corrugator supercilii, thus providing a perforator-like flap (). The flap, just connected to the glabellar region by the artery and vein, was then advanced to cover the defect; the flap survived entirely. At 14 months follow-up, neither forehead motility anomalies, nor sensation deficits were observed. The reconstructed eyebrow was slightly shorter than the contralateral; continuity, alignment and position symmetry of the eyebrow were preserved ().

A peculiar case of spontaneous bilateral mammary implant capsule detachment - Corrected Proof

2010-02-15

The most common local complication in patients with silicone mammary implants (SMIs) is excessive peri-SMI connective tissue capsule formation and its subsequent contracture. In other cases breast prosthesis itself breaks down. Traumatic rupture of the surrounding fibrous capsule without disruption of the prosthetic envelope has been reported. In all cases of silicone breast implant complications, at surgical exploration the capsule is so firmly sticking to the chest wall that, in some cases, it is difficult to carry out a complete capsulectomy.

Lateral calcaneal artery as a recipient pedicle for microsurgical foot reconstruction - Corrected Proof

Hak Chang, Soon-Sung Kwon, Kyung-Won Minn — 2010-02-11

Summary: In the microsurgical reconstruction of the foot, anterior tibial artery–dorsalis pedis artery and posterior tibial artery–plantar artery are mainly used as recipient arterial pedicles. These arteries are the main sources for foot circulation and the preservation of these arterial circulations is very important. Although the end-to-side technique or the flow-through technique is selected for the microsurgical anastomosis, the possibility of injury to the circulation of these main arteries exists. We showed the availability of this artery with an angiographic injection study in five fresh cadavers as a reliable recipient artery. We also used the lateral calcaneal artery as a recipient pedicle in foot reconstruction without sacrificing the main circulation in two clinical cases. The diameters at the level of the calcaneus were 1.3mm and 1.5mm, respectively.

RE: Plastic, reconstructive and aesthetic surgeon: impact of managing perceptions on aesthetic publications - Corrected Proof

D. Saleh, C.S.J. Dunkin — 2010-02-11

Abood and Mallucci's recent editorial tells an interesting story but also raises a number of questions. Plastic surgery is served well by a number of high quality journals. As the new title of this journal atests, these include papers on the aesthetic and reconstructive aspects of our work. Abood surveys the aesthetic content of these journals. However, aesthetic surgery is practiced increasingly by clinicians without formal plastic and aesthetic surgery training, including general and breast surgeons, dermatologists, maxillofacial surgeons, ear, nose and throat surgeons and ophthalmologists. These clinicians may not be regular readers of plastic, reconstructive and aesthetic surgery journals. If not, how do they disseminate their aesthetic research, results and experience and continue their professional development? We sought to investigate the aesthetic output of the major journals serving these other specialties.

Breach procedure for axillary hyperhidrosis - Corrected Proof

Fabrizio Schonauer, Luigi Canta, Guido Molea — 2010-02-11

We read with interest the communication on ‘A simple and practical method for axillary osmidrosis resection’ by Liu X, Mao T, Lei Z, Fan D appeared on JPRAS 2009. We found the description of the technique very useful with the support of intra-operative pictures. The use of artery clips to evert the skin flaps can be easily reproduced. However it is surprising that the Authors did not consider and mention in the References a paper by Mr N Breach appeared in the Annals of the Royal College of Surgeons of England in the late 70ies, when he was Senior Registrar at the Plastic Surgery Department of the Queen Victoria Hospital, East Grinstead, UK. Since then this latter procedure for surgical treatment of axillary hyperhidrosis has been widely adopted, especially in the Western world and in the UK where is known as the ‘Breach’ procedure. The main difference with the technique described in the paper by Liu X et al. consists in the number of incisions that has now been minimized.

Response letter re: Objective assessment of surgical performance and its impact on a national selection programme. JPRAS Dec 2009 - Corrected Proof

J.C. Pollock, J.N. Rodrigues, A. Raurell — 2010-02-05

We read the paper by Carroll et al with interest and we congratulate the authors on tackling the difficult field of higher surgical trainee selection. With the expansion of medical student numbers, and the possible contraction of training places due to the economic squeeze, competition for numbers is likely to increase. This makes the need for a robust selection system, that is evidence based, even greater. However we feel that the study design and use of statistics does not reflect the conclusions reached and leaves the paper fundamentally flawed.

Contribution of lip proportions to facial aesthetics in different ethnicities: A three-dimensional analysis - Corrected Proof

Wendy W. Wong, Drew G. Davis, Matthew C. Camp, Subhas C. Gupta — 2010-02-04

Summary: Background: Lip augmentations are commonly performed procedures in the United States, with annual numbers surpassing 100 000. While lips contribute to facial beauty, the relative influence of this feature to whole facial appeal has not yet been established. What is also of increasing interest is the consideration of ethnic differences in the evaluation of beauty. However, most current anthropometric measurements refer to Caucasians, and their use in the treatment of Asian American patients would be inappropriate.Methods: Three-dimensional models of 197 male and female Caucasian, Chinese and Korean subjects were created using surface-imaging technology. The lips and corresponding faces from these models were ranked according to subjective aesthetic appeal by 20 male and female raters of various ages, occupations and ethnicities. The raters' results were subsequently compared with individually measured lip parameters.Results: Rankings between lips and their corresponding whole faces differed greatly. Lips that were rated as the most attractive were smaller than average in midline upper lip surface heights, bilateral paramedian lip surface heights, upper lip angles and volume in the lower lip. Both Asian groups exhibited significantly different lip parameters and lip-projection volumes from that of Caucasians.Conclusions: The results from this study suggest that there are indeed measurable differences in the baseline Asian lip morphology as compared with Caucasians. Tailoring lip enhancement treatment to each individual's anatomy, ethnic background and personal goals can optimise outcomes. What is also of interest is that lips did not contribute as much to facial attractiveness as previously thought.

Management of primary cutis verticis gyrata with tissue expansion and hairline lowering foreheadplasty - Corrected Proof

Anuj Mishra, Hamid Tehrani, Kevin Hancock, Christian Duncan — 2010-02-03

We report the case of an 18-year-old girl with cutis verticis gyrata (CVG) involving 80% of the scalp. The deformity comprised alopecia within deep cutaneous infolds and an elevated frontal hairline with high forehead (a); no other associated conditions were noted. The patient had become increasingly aware of her condition, avoiding social interaction and wearing hats whenever in public. At the first of a planned two-stage procedure, the scalp was undermined in a subgaleal plane through bi-temporal incisions. Vertical bands holding the scalp to pericranium were released and two 550-cc tissue expanders were placed (b). Combined subsequent serial tissue expansion of 1000cc improved both furrows and alopecia. The second-stage procedure allowed expanded tissue advancement, excision of redundant scalp, hairline-lowering foreheadplasty and browpexy (c). At 6 months' postoperative review, the patient was extremely pleased with her outcome, being able to wear her hair with a parting in public for the first time, and becoming ever-increasingly socially confident ().

Lip cancer: a 5-year review in a tertiary referral centre - Corrected Proof

D. Casal, L. Carmo, T. Melancia, C. Zagalo, O. Cid, J. Rosa-Santos — 2010-02-03

Summary: Introduction: Lip cancer is second only to skin cancer in terms of frequency in the head and neck region. Surgery is the treatment of choice for most of these cancers. Although there are several strategies to reconstruct lip tumours after tumour ablation, scarce attention has been paid to the impact of the specific reconstructive modality on recurrence and survival.Patients and methods: A retrospective review of 228 patients treated for lip cancer in the Head and Neck Surgery Department of the Portuguese Institute of Oncology Francisco Gentil, Lisbon, Portugal, from 1993 to 2000 with at least 2 years of follow-up was conducted. All the cases were evaluated for demographic features, tumour characteristics, lip reconstructive surgery used and recurrence and survival.Results: There were 184 male and 44 female patients (4:1 ratio), with an average age of 67.6±13.3 years. Most tumours were squamous cell carcinomas (94.7%), and were located in the lower lip (99.5%). Squamous cell carcinomas were well differentiated in 70.8% of cases. Tumour size and neck staging were strongly correlated (Pearson's coefficient of 0.805; p<0.001). Microscopical signs of neuroinvasion or lymphatic invasion were associated an increased risk of death due to cancer (chi-square=18.5; df=3; p=0.016). The different strategies used for lip reconstruction after tumour ablation did not differ significantly in the probability of later recurrence or death.Conclusions: Our data seem to lend support to the classical view that the most significant aspect of lip cancer surgery is tumour ablation, and that this is not affected by the subsequent reconstructive strategy. Hence, this seems to indicate that experienced surgeons are rightly not willing to compromise complete excision of the tumour for the sake of an easier or better reconstruction.

A new approach to the antecubital scar contracture: rhomboid rotation flap - Corrected Proof

Nazım Gümüş — 2010-02-03

Scar contracture is still one of the most complicated challenges developing after either skin damages or burns. Although splints, pressure therapy, massage, and rehabilitation have been widely used for softenning of the scar later the skin injury, in some cases all methods are ineffective to avoid developing a scar contracture which is capable of deforming the apperance of skin surface and restricting joint motions. Several approaches to the correction of contractures have been proposed, including skin grafts, Z-plasty, local flaps, regional flaps, transposition flaps, rotating flaps, axial flaps, perforator flaps, and free flaps, but many of which still have some disadvantages such as necrosis, donor site morbidity, long operation time, and difficult surgical dissection, so there is no ideal technique. In this study, a new method for releasing antecubital contractures was presented.

Use of the scratch pad for granulation tissue debridement - Corrected Proof

D.M. Seoighe, K. Power — 2010-02-03

Prior to skin grafting a clean granulating wound, it is common practice to do a superficial debridement taking way any potentially contaminated non-viable tissue or wound exudate/slough on the surface. This optimises graft take by ensuring it is in direct contact with a well vascularised bed. There is no specific instrument for this and often it is carried out using the back of the Addisons forceps or another such instrument with a blunt edge. Currettage or scraping the wound with a scalpel is also used to do this.

Trainees assisting in private practice – are they covered? - Corrected Proof

Kelvin Ramsey — 2010-02-03

In the current climate of enforced reduction in working hours, our trainees may find that training outside the NHS is becoming increasingly important. Some training programmes in this country incorporate fixed periods working in the private sector, while other trainees may seek experience in aesthetic surgery on a more ad-hoc basis depending on the practice of their consultant, while others undertake cosmetic fellowships out of programme. Wherever the training is received, aesthetic surgery remains a significant part of the FRCS(Plast) syllabus and thus should be supported.

Evaluation and selecting indications for the treatment of improving facial morphology by masseteric injection of botulinum toxin type A - Corrected Proof

Li Gaofeng, Tan Jun, Pan Bo, Zou Bosheng, Zhong Qian, Liu Dongping — 2010-02-01

Summary: Few reports exist on effective methods of evaluating the effects and selecting indications for the treatment of improving facial morphology by masseteric injection of botulinum toxin type A. The method for selecting indicative factors, as determined by the change of masseteric area volume at a standard frontal view when tightly clenching teeth, was used in this study. Patients with varying masseteric area volume were randomly enrolled. Bilateral masseteric muscles were treated with multi-point percutaneous intramuscular injections of botulinum toxin type A, 30–50 u for each side. Changes in facial appearance and satisfaction of patients were observed and standard frontal view photographs were taken pre-treatment and 2–3 months post-treatment. Following this, the anterior facial height(FH), bizygomatic facial width (FWz) and intergonial width (FWg) were measured from the photographs. The indices of FH/FWz and FWg/FWz were calculated and analysed. The results showed that the volume of masseteric area was reduced and the facial morphology was improved at 2–4 weeks post-injection, with maximum reduction at 2–3 months post-injection. All of the 32 patients were satisfied with the clinical effects. The pre-treatment and post-treatment values of FH/FWz were 0.8309±0.0423 and 0.8331±0.0382, respectively, and FWg/FWz values were 0.8281±0.0209 and 0.7925±0.0206 (P<0.01), respectively. In conclusion, the appropriateness of masseteric injection of botulinum toxin type A for improving facial morphology can be determined by the changes in masseteric area volume at a standard frontal view of tightly clenched teeth. In addition, the facial index of FWg/FWz can be used to evaluate the treatment.

Treating facial nerve palsy by true termino-lateral hypoglossal–facial nerve anastomosis - Corrected Proof

F.H. Sleilati, M.W. Nasr, H.A. Stephan, Z.D. Asmar, N.E. Hokayem — 2010-01-29

Summary: Hypoglossal–facial nerve anastomosis is a time-proven technique for the repair of facial nerve palsy. Efforts have been made to reduce hypoglossal nerve injury, the main drawback of the technique.In this study, the anastomosis is a true termino-lateral neurorrhaphy with only an epineural window in the hypoglossal nerve sheath. A re-routing technique of the temporal facial nerve is also performed to allow a direct anastomosis to the hypoglossal nerve without the need for a jump graft.The first three results reported are very encouraging, with a satisfactory return of facial mimics and without any impairment of lingual function.

Intercostal adipofascial perforator flap for reconstruction of overcorrected gynaecomastia deformity - Corrected Proof

F. Salim, J. Chana — 2010-01-29

Summary: The intercostal perforator fasciocutaneous flap has previously been described in addressing defects in the breast, trunk and arm 1,2,. We describe the first case of an inter-costal artery perforator adipofascial flap in the reconstruction of the male chest following overcorrection of gynaecomastia.

Immediate nose reconstruction by forehead flap in a 4-month-old girl with a 20-year follow-up–the oldest technique for the youngest patient - Corrected Proof

Klaus Exner, Andreas Gohritz, Nils Stechl, Thomas Gohla — 2010-01-28

Summary: The forehead flap is one of the oldest reconstructive techniques and is still regarded the standard procedure for large nasal defects. Controversy exists regarding reconstructions in infants, but only very few long-term results of this technique in infants have been documented.We report on a 4-month-old girl requiring subtotal nose reconstruction due to necrosis caused by a congenital vascular malformation. An immediate forehead flap and later refinements were performed. The functional and aesthetic result after a period of 20 years is presented.According to this report, a forehead flap can be applied for nasal reconstruction also in very young children with good nasal function, growth and appearance over the long term.

Madura Foot - Mind the Soil - Corrected Proof

N. El Muttardi, D. Kulendren, B. Jemec — 2010-01-28

Summary: ‘Madura foot’ or mycetoma is a chronic granulomatous soft-tissue infection, caused by either true fungi (eumycetoma) or Gram-positive aerobic bacteria (actinomycetoma). The infection is endemic to equatorial, tropical or sub-tropical regions. However, sporadic cases have been reported in the Western world mostly in the migrant population. The disease follows a slow progression from the time of traumatic inoculation to presentation of symptoms, characterised by a triad of chronic indurated swelling, draining sinuses and discharging granules. The granules are diagnostic as they represent collections of fungal hyphae or bacterial filaments. We present a case of a 4-year eumycetoma of the left foot in a 16-year-old Somalian girl, resident in the UK for over a year. She underwent aggressive surgical debridement with a 6-month course of anti-fungal medication. We emphasise the need for suspicion of this rare dermatosis, in view of the increasing immigrant population.

The ‘Ten Test’: application and limitations in assessing sensory function in the paediatric hand - Corrected Proof

Hank H. Sun, Tanya M. Oswald, Neil S. Sachanandani, Gregory H. Borschel — 2010-01-27

Summary: Background: The Ten Test, first described in 1997 by Strauch et al., is a simple, rapid, reliable and sensitive method to evaluate hand sensibility in adults. In this study, we validated its use in children.Methods: We asked patients to rate sensibility elicited by a light moving touch on the palmar surface of digits in reference to sensibility elicited by the same touch in a digit confirmed as normal.Results: A total of 73 subjects (age range: 1–12 years) were tested. Patients under age 5 years were significantly less likely to complete the test. The kappa statistic for the Ten Test in nine subjects, each tested separately by two examiners, demonstrated very strong inter-observer reliability (kappa=1.0, p<0.003).Conclusions: The Ten Test is a simple, validated, non-threatening method to evaluate hand sensibility in children and adolescents. We recommend its clinical use in patients age 5 years and older.

Deep superior epigastric artery perforator ‘propeller’ flap for abdominal wall reconstruction: A case report - Corrected Proof

2010-01-27

Summary: As the concept of ‘free style perforator’ flap and the ‘propeller’ flap is widely accepted, any region of the body can be used as a possible donor site for a perforator flap. A ‘propeller’ flap is a local flap that is rotated to different extents (up to 180°) about a reliable perforator to cover adjacent defects. Rectus abdominis perforators (epigastric artery perforators) are the main perforators in the abdominal region from the deep inferior epigastric artery or the deep superior epigastric artery. Traditionally, deep inferior epigastric artery perforators have been often used in the abdominal region because they provide a dominant blood supply to abdominal skin. In the described case, a large abdominal wall defect (20.5×19cm) caused by tumour resection was covered successfully using a superior epigastric artery perforator ‘propeller’ flap.