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

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.

Low dose of Hyaluronidase to treat over correction by HA filler–A Case Report. - Corrected Proof

Harikumar Menon, Mohan Thomas, James D'silva — 2010-02-04

Hyaluronic acid (HA) is probably the most popular filler for correction of deep facial lines as well as facial soft tissue augmentation. The peri orbital region is among the more delicate and difficult areas to treat with filler injections on account of the thin skin in the region. One of the possible complications with HA gel injection is over correction which is particularly troublesome in the tear trough area.

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.

A new design of a dorsal flap in the rat to study skin necrosis and its prevention - Corrected Proof

Christopher P. Kelly, Arunesh Gupta, Mustafa Keskin, Ian T. Jackson — 2010-01-25

Summary: Background: The Mcfarlane flap or dorsal pedicled flap has become the standard model for pedicled rat skin flap study but its reliability has been called to question. In the past, there were possible confounding variable with the McFarlane flap and various methods were used to adjust these variables. We have developed a new model for studying skin flap necrosis and its prevention that eliminates these confounding variables.Methods: The flap is a significant modification of the McFarlane flap where we form a blind ended pedicled tube using a 3cm×9cm dorsal flap. Survival area is measured using digital photography and computer assisted analysis. This new flap is compared with the standard McFarlane flap with n=25 in each group.Results: The mean survival area of the new flap (15.673cm2+SD3.37) is comparable with the McFarlane flap (18.904cm2+SD3.79). The relative merit lies in the elimination of the confounding variable of the graft bed influence on our flap without a significant reduction in the survival area.Conclusion: A new rat model is presented that may be used in studying the effect of various treatment modalities on pedicled skin flaps. This model has the benefit of eliminating graft bed effect without the risk of flap and wound infection or desiccation that have been encountered using other models. The new flap also has better demarcation of necrosis area in this study.

Minimally Invasive Lateral Canthopexy (MILC) - Corrected Proof

2010-01-25

Summary: Many techniques have been described for lateral canthopexy. Here, we describe a technical modification of lateral canthopexy that involves percutaneous placement of a canthopexy suture through the confluence of the lateral superior and inferior grey lines or lateral canthal angle. A total of 52 canthopexies in 26 patients have been performed with excellent results and few complications. Our lateral canthopexy modification is a minimally invasive technique that is simple to perform, with absolute assurance of capturing the lateral canthal tendon.

Medial plantar venous flap technique for volar oblique amputation with no defects in the nail matrix and nail bed - Corrected Proof

2010-01-25

Summary: Background: Skin grafting is a simple technique used during volar oblique amputation; however, it is not appropriate to use this technique if the bone or tendon is exposed. Moreover, in volar oblique amputation, if the severed section is large and elongated, skin grafting makes the lack of volume conspicuous, and reconstruction with a V–Y advancement flap occasionally results in a nail deformity that resembles a parrot's beak. We used a medial plantar venous flap for the correction of large volar oblique amputation.Methods: Reconstructive surgery was performed on patients with volar oblique amputation in whom the proximal severed volar regions extended from the nail matrix to the distal interphalangeal (DIP) joint. The medial plantar venous flap was harvested, the distal subcutaneous vein or communicating vein of the medial plantar area was anastomosed to the proper digital artery, and the proximal vein of the flap was anastomosed to the dorsal subcutaneous vein of the stump of the digit.Results: The flaps survived in all the patients. At 12 months after the surgery, all the treated fingers had attained a good shape. Patients who underwent reconstruction with medial plantar venous flaps attained good sensory restoration.Conclusion: In volar oblique amputation, if the remaining nail matrix and nail bed are uninjured, then patients can expect the restoration of shape, function and sensory input after surgery. In this study, we used the medial plantar venous flap for large volar oblique amputation cases and obtained good results.

Thoracodorsal artery perforator flap and Latissimus dorsi myocutaneous flap – Anatomical study of the constant skin paddle perforator locations - Corrected Proof

Mark Schaverien, Corrine Wong, Steven Bailey, Michel Saint-Cyr — 2010-01-25

Summary: Background: Ischaemic flap complications can be a problem following harvest of the latissimus dorsi (LD) musculocutaneous flap or thoracodorsal artery perforator (TAP) flap. We investigate the reliable locations of the perforators of the thoracodorsal artery.Methods: Twenty latissimus dorsi flaps harvested from cadavers were used in the study. In fifteen flaps the thoracodorsal artery was injected with coloured latex, and the locations of perforators were recorded. In five flaps perfusion of the skin paddle was evaluated using 3D CT angiography following injection of the thoracodorsal artery with a barium sulphate/gelatin mixture.Results: At least one perforator originating from the descending branch of the thoracodorsal artery was found in all specimens, whereas no perforators from the transverse branch were found in 33% of flaps. At least one perforator originating from the descending branch in all flaps was found between 9.5 and 15.4cm from the posterior axillary fold, within 4.3cm of the lateral border of the latissimus muscle. 58% of all perforators from the descending branch, and 39% of all perforators from the thoracodorsal artery were found in this region. CT scanning of the hemiback flaps demonstrated contrast in the superior two-thirds. Perfusion of the skin paddles in three locations was demonstrated- superior transverse (bra strap), vertical and lower transverse.Conclusions: Thoracodorsal artery perforators could be found within a reliable region. Positioning of the TAP flap skin paddle over this region will maximise the chances of including a perforator and may reduce the risk of ischaemia. For a musculocutaneous LD flap, the skin paddle can be in any of the 3 popular locations, i.e. upper transverse, vertical and lower transverse, as they were shown to be well vascularised.

One-stage reconstruction of the entire pubic, vulvar and perineal area by pedicled anterior thigh musculo-fasciocutaneous flap - Corrected Proof

2010-01-25

Unilateral or bilateral fasciocutaneous flaps and bilateral flaps such as the gracilis myocutaneous flap have become a standard component of pelvic exenteration and subsequent reconstruction, especially in the perineogenital area. The advantages of these techniques include coverage of the large pelvic defect left by resection and by radiochemotherapy. The flaps provide non-irradiated tissue and blood supply to the operative site supporting healing and psychosocial rehabilitation of the patients.

Combined sliding flap using a single perforator enables simple closure of the donor site: a case report - Corrected Proof

2010-01-18

Summary: We report the case of a 39-year-old man with a dermatofibrosarcoma protuberans (DFSP) on the right shoulder. A wide surgical excision of the tumour was performed, creating a 12-cm-wide defect. An anterolateral thigh flap created from two semicircular skin paddles was harvested and the two skin paddles were slid towards each other to cover the circular defect. The sliding technique is a useful design that preserves the suprafascial plexus and enables a single perforator to supply two split-skin paddles. Using this design, the donor site can be closed primarily without requiring a skin graft. This technique can be applied to other free flaps to reconstruct wide defects after the resection of cancers.

Endothelial activation with prothrombotic response in irradiated microvascular recipient veins - Corrected Proof

Halle Martin, Ekström Mattias, Farnebo Filip, Tornvall Per — 2010-01-18

Summary: Background: Surgical wounds within previously irradiated tissues are common in reconstructive surgery and subject to an increased incidence of postoperative complications due to vascular dysfunction, including thrombosis in both microvascular anastomosis and the microcirculatory bed. However, there is no study that has described gene expression patterns in radiated human blood vessels. This study aims to determine if radiation can induce changes in gene expression that can promote thrombus formation in human microvascular recipient veins.Methods: Paired biopsies from radiated recipient veins and non-radiated flap veins were simultaneously harvested from 15 patients during free-flap reconstruction, 4–215 weeks from termination of radiation. Radiated and non-radiated veins were compared using a custom-made Taqman® low-density array (TLDA) to analyse differential gene expression in a large number of genes involved in inflammation and coagulation. Results were confirmed by real-time polymerase chain reaction (RT-PCR) and immunohistochemistry.Results: Results from TLDA indicate an acute increase of cytokines and leucocyte adhesion molecules related to activation of transcription factor nuclear factor kappa-B (NF-kB), confined to the first 3 months after radiotherapy treatment. Results were confirmed by RT-PCR and activity localised to the endothelium by immunohistochemistry. RT-PCR analyses of genes associated with coagulation showed sustained expression of plasminogen activator inhibitor-1 (PAI-1) in radiated veins.Conclusion: We found an acute inflammatory response with endothelial activation, followed by a sustained PAI-1 gene expression in irradiated microvascular recipient veins that can explain adverse effects years after radiation, such as microvascular occlusion and poor surgical wound healing. We believe that the results contribute to the search for therapeutic adjuncts to cope with the adverse effects of radiation therapy and strongly advocate postoperative, rather than preoperative, radiotherapy whenever possible.

Three cases of giant pilomatrixoma – considerations for diagnosis and treatment of giant skin tumours with abundant inner calcification present on the upper body - Corrected Proof

2010-01-18

Summary: Background: Pilomatrixoma frequently occurs as a solitary, small tumour on the face or upper extremities of people younger than 20 years.Methods: We report three cases of giant pilomatrixoma. In all these cases, outward appearances and imaging investigations suggested malignant tumours. Preoperative biopsies suggested that case 1 was a basal cell carcinoma, but cases 2 and 3 had no malignant features on biopsy. Two of the cases experienced rare complications – hypercalcaemia caused by parathyroid-related protein (PTHrP) production and multiple occurrences.Results: All three tumours were removed with a 1–3-cm margin. The postoperative histopathologies showed pilomatrixoma in all three cases.Conclusions: Rarely, pilomatrixoma develops to a giant size with various atypical outward appearances consistent with a malignant tumour. Preoperative clinical appearances frequently lead to misdiagnosis, and preoperative examinations are unreliable. Therefore, when a giant tumour with abundant inner calcification is present in a young patient, the possibility of a pilomatrixoma should be considered.

Breast fat grafting (lipomodelling) after extended latissimus dorsi flap breast reconstruction: A preliminary report of 200 consecutive cases - Corrected Proof

2010-01-15

Summary: Background: The efficacy of fat grafting has long been a controversial issue. Breast lipomodelling after extended latissimus dorsi flap reconstruction was first attempted at the Plastic and Reconstructive Surgery unit of Leon Berard Cancer Centre in 1999. We present the results of a retrospective report of the first 200 consecutive patients treated at our institution from 1999 to 2003.Methods: We identified specific requirements of the patients, and collected information on the surgical techniques used and the volumes of fat tissue injected. We analysed and compared the results of a total of 244 lipomodelling sessions.Results: The graft consisted of 70% fat graft, 13% oily supernatant and 17% serum residues. Approximately 30% was lost during centrifugation. On average, 176ml of fat were injected in each breast. Very satisfactory results were obtained in 94.5% of the cases, with a majority of patients (80%) being very satisfied with the procedure and only 1.5% complications.Conclusion: Our results demonstrate the safety and feasibility of breast lipomodelling. It is a new approach to improve reconstructive outcome after extended latissimus flap breast reconstruction.

Response to letter - Corrected Proof

K. Power, A. Turkmen, D.A. McGrouther — 2010-01-15

Thank you for your correspondence. We would argue in favour of the retrograde venous perfusion hypothesis and I will outline the reasons for this. Case 1. As outlined in the text, we accept that there may have been some terminal branches of the dorsal metacarpal arteries present in the dorsal skin attachment, but we fail to see how this would be sufficient to adequately perfuse the entire digit. If this was the case, you would expect bleeding from the tips of the fingers due to arterial pressure. The effect of dependency is immediate, the dorsal veins filled and there was a capillary refill with associated bleeding on pin-prick. We fail to see how lowering the hand could have had such a rapid effect if it was not for retrograde venous inflow. Dependency led to progressive desaturation of the blood in the tips consistent with stasis. This was reversed immediately by elevating and lowering the hand which is consistent with a to-and-fro circulation via the venous system.

Therapeutic angiogenesis by autologous bone marrow cell implantation together with allogeneic cultured dermal substitute for intractable ulcers in critical limb ischaemia - Corrected Proof

2010-01-11

Summary: Therapeutic angiogenesis by autologous bone marrow cell implantation improves blood supply in patients with critical limb ischaemia. In addition, allogeneic cultured dermal substitute is effective for intractable ulcers. The present study determined the effectiveness of bone marrow cell implantation combined with allogeneic cultured dermal substitute in treating severely ischaemic ulcers. We treated eight consecutive patients with severely ischaemic ulcers using this procedure. Stromal cells aspirated from bone marrow were processed to obtain suspensions of mononuclear cells, platelets and endothelial progenitor cells and immediately injected intramuscularly into the lower leg and around the wound, on which allogeneic cultured dermal substitute was applied and changed weekly. Skin ulcers were subsequently closed by skin grafting, if necessary. Angiogenesis was confirmed by postoperative analyses such as ankle–brachial pressure index, angiography, thermography and 99mTechnetium–Tetrofosmin perfusion scintigraphy. Above- or below-knee amputation was avoided in all patients and wounds were completely closed in six of them. These results indicate that this combined therapy effectively treated ischaemic ulcers. Since the incidence of this condition might increase in the future, this therapeutic approach should play an important role in the preservation of ischaemic limbs.

Re: Use of Aquamid as a filler for facial rejuvenation in orientals. Plast Reconstr Aesthet Surg 2009; 62;1245–9. - Corrected Proof

Shimpei Ono, Rei Ogawa, Hiko Hyakusoku — 2010-01-11

We wish to comment on the article by Yagi et al. that is entitled ‘Use of Aquamid as a filler for facial rejuvenation in orientals’ and was published in the October, 2009 issue of the Journal of Plastic, Reconstructive and Aesthetic Surgery.

Management of groin seromas with external quilting sutures and open drainage - Corrected Proof

C.B. Chuo, S. Srivastava — 2010-01-11

A 78-year old male had a right inguinal dissection for metastatic melanoma with proximal sartorius muscle transposition. Fibrin sealant was used at wound closure and two low-suction drains were inserted. Drainage was 300–400ml every 24hours over the next six days, and then drains were removed. A week later, the incision had healed and 1250ml was aspirated from a groin seroma. This had re-accumulated four days later.

Modern Surgical Management of Peripheral Nerve Gap - Corrected Proof

Amit Pabari, Shi Yu Yang, Alexander M. Seifalian, Ash Mosahebi — 2010-01-11

Summary: The management of peripheral nerve injury requires a thorough understanding of the complex physiology of nerve regeneration. The ability to perform surgery under magnification has improved our understanding of the anatomy of the peripheral nerves. However, the level of functional improvement that can be expected following peripheral nerve injury has plateaued. Advancements in the field of tissue engineering have led to an exciting complement of commercially available products that can be used to bridge peripheral nerve gaps. However, the quest for enhanced options is ongoing. This article provides a review of the current treatment options available following peripheral nerve injury, a summary of the published studies using commercially available nerve conduits and nerve allografts in humans and the emerging hopes for the next generation of nerve conduits with the advancement of nanotechnology.

A case of large sporadic neurofibroma of the hand - Corrected Proof

Robert A Pearl, Greg O'Toole — 2010-01-11

Summary: We report the case of a large sporadic neurofibroma arising in the palm of the 40 year old nurse. Isolated neurofibroma in the hand are rare and pose both diagnostic and treatment challenges for the surgeon. Preoperative imaging can be useful to delineate the anatomical relationships of a soft tissue lesion but is not always diagnostic. The key points in the management of these tumours are discussed.

Treatment of sagittal synostosis: Subtotal cranial vault remodelling with right-angled Z-osteotomies - Corrected Proof

Suk Ho Moon, Hye Won Paik, Jun Hee Byeon — 2010-01-08

Summary: Introductions: Sagittal synostosis is the most common type of non-syndromic craniosynostosis with fusion of the sagittal suture. Various techniques have been introduced for the treatment of this irregular calvarial deformity. However, since these methods were not suitable for patients who were aged over 1 year when they were diagnosed with sagittal synostosis, a new approach should be undertaken.Patients and methods: Between 2001 and 2005, five patients who were diagnosed with sagittal synostosis, after the age of 1 year, were treated with subtotal cranial vault remodelling. The procedure consisted of right-angled Z-osteotomies in the frontal and parieto-occipital bones, a shortening of the sagittal strut, and barrel-stave osteotomies in the temporal bone. They were undertaken to expand bitemporal diameter and to shorten anteroposterior diameter.Results: Cranial index increased from 68.2 to 77.8 immediately after surgery and to 78.4 post-surgery 36 months. Cranial morphologies were satisfactory during follow-up. The main advantage of the procedure is the easy control of fixation angle according to the surgeon's preference. There were no major complications including infections or relapses.Conclusions: The treatment goal of sagittal synostosis is to eliminate factors that may impede brain development by assuring an adequate cranial cavity and to maintain an aesthetically acceptable cranial morphology. We obtained functionally and aesthetically favourable results by right-angled Z-osteotomies. Further, our one-staged procedure is safe, especially in patients over the age of 1 year.

Three-dimensional anthropometric analysis of the Chinese nose - Corrected Proof

Yan Dong, Yimin Zhao, Shizhu Bai, Guofeng Wu, Bo Wang — 2010-01-08

Summary: Information about normal nasal dimensions is essential to rhinoplasty, but reports of anthropometric measurements of the Chinese nose are limited. Three-dimensional (3D) measuring apparatuses have been introduced into craniofacial anthropometry and have demonstrated advantages over conventional methods. This study aims to introduce a new 3D method for anthropometry and to provide guidance for plastic surgeons treating the Chinese nose. A total of 289 young Chinese adults (146 males and 143 females) were recruited for this study and a 3D stereo photogrammetry system (3DSS –II, Shanghai Digital Manufacturing Corporation, China) was used to acquire their facial image data. Geomagic Studio 10.0 software was used to process the data and to realign the images in a unified co-ordinate system. For each image, the co-ordinate values of 17 landmarks of the nose were collected, and the mean was calculated for males and females separately. Points based on the mean co-ordinate values were used to establish 3D stereo models. Subsequently, nasal parameters—including nine linear measurements, three angular measurements and seven proportions—were obtained by analysing these models. The 3D stereo models representing the Chinese male and female nasal shapes were built and the nasal parameters were acquired. Some differences between male and female nasal shapes were identified. This study describes a new method for 3D anthropometric analysis of the nose; the method would be applicable to anthropometry of other parts of the body as well. The 3D models of Chinese noses built in this study will provide very useful guidance for plastic surgeons in clinical practice.

Use of cyanoacrylate compounds in vascular anastomosis - Corrected Proof

M.S. Akhtar — 2010-01-08

I read with interest the article by Gorhan Ulusoy et al, using ‘lid technique’ combining sutures with cyanoacrylate tissue adhesives for vascular anastomosis. Throughout history vascular surgeons have been more comfortable using sutures for vascular anastomosis, but recently there is a trend to look for sutureless techniques to be efficient and in an era of minimally invasive surgery to find comfortable ways of performing procedures. There was always an element of apprehension to adopt this idea due to multifactorial factors namely; tissue toxicity, compromising the lumen, breakdown of anastomosis and aneurysm formation at suture line. Many people have tried to find an effective yet safe sutureless technique.

A case of deep burns, while diving The Lusitania - Corrected Proof

John N. Curran, Kevin G. McGuigan, Eoin O'Broin — 2010-01-08

Summary: We present the first documented case of severe burns, sustained by a diver as a result of auto-ignition of air-activated heat packs at high partial pressure of oxygen and high ambient pressure. Our patient was diving the shipwreck of The Lusitania off the south coast of Ireland. This is a significant wreck, lying 90 metres down on the seabed. Torpedoed by a German U-boat in 1915, its loss prompted American involvement in WW1. Several unlikely events combined in this case to bring about serious and life threatening injuries. Herein we discuss the case and explore some of the physical and chemical processes that lead to these injuries.

Classification of soft-tissue degloving in limb trauma - Corrected Proof

Z.M. Arnez, U. Khan, M.P.H. Tyler — 2010-01-07

Summary: Compressive, tortional and abrasive deforming forces are translated to the limbs during high energy trauma. The long bones may be fractured in many patterns with a varying extent of fragmentation and comminution but the soft-tissues appear to absorb the forces in a predictable way. We retrospectively reviewed a series of 79 complex limb injuries treated in a dedicated centre where the clinical notes and photo-documentation were meticulously kept and where the outcomes were known. The soft-tissue injuries were then described and revealed four patterns of injury: abrasion/avulsion, non-circumferential degloving, circumferential single plane and circumferential multi-plane degloving. These patterns occurred either in isolation or occasionally in combination. Resuturing of degloved skin was only successful in non-circumferential (pattern 2) cases. Radical excision of devitalised tissue followed by soft-tissue reconstruction in a single procedure was successful in all patterns apart from pattern 4 (circumferential multi-plane degloving). In pattern 4 we recommend serial wound excision prior to reconstruction.

Capsular flap for coverage of an exposed implant after skin-sparing mastectomy and immediate breast reconstruction - Corrected Proof

2010-01-07

Summary: Native skin-flap necrosis following skin-sparing mastectomy (SSM) is treated by raising a capsular flap, formed as a consecutive physiological reaction around breast implant. Using this highly vascularised thin tissue layer as an implant coverage withdraws pressure from the defect and allocates a good background for wound healing.

The ‘v-intermammary dart’ - a simple method for avoiding central dog ears in reduction mammaplasty - Corrected Proof

S. Murphy, M.J. Earley — 2010-01-06

Massive reduction mammaplasty using any of the techniques that utilise the vertical scar can run the risk of closely approximating sternal scars and unsightly central scarring. The central or sternal area beneath the cleavage is very visible and important in the cosmetic outcome of this procedure. It is the area that a woman in a bra, will still be able to see.

Application of the Goes double-skin peri-areolar mastopexy with and without implants: a 14-year experience - Corrected Proof

Donn M. Hickman — 2010-01-04

Summary: Peri-areolar mastopexy is commonly used for mild ptosis requiring no more than 3cm of nipple elevation. The nature of areolar scar and gland remodelling inherent to a circular skin reduction prompts circumspection when correcting more moderate-to-severe cases. The purpose herein is to convey the reproducibility and applicability of the Goes double-skin peri-areolar mastopexy without mesh, for breast ptosis requiring nipple elevation of 4–9cm, in a series outside the work of the principal innovator.A series of 217 consecutive patients underwent circumareolar eccentric skin excision based on four cardinal landmarks, deepithelialised dermal sleeve and glandular reshaping with and without implants (174 augmentation-mastopexies and 43 mastopexies). Implantation and implant change involved the use of saline implants placed in the subpectoral space. Average nipple elevation was 5.1cm in the augmentation-mastopexy group and 6.5cm in the mastopexy group.There were major complications in 4.4% of breasts and occurred only in the mastopexy-augmentation group. There was no nipple loss, serious infection or haematoma. There were minor complications in 13.1% of breasts (11.8% in the mastopexy-augmentation group, and 18.6% in the mastopexy group). A minimal (10%) areolar necrosis occurred on a breast in one patient undergoing augmentation-mastopexy for tubular breasts with micromastia. Revision rate was 4% for the entire series.Based on the principles of circular skin design with fixed skin landmarks, internal breast shaping and special attention when augmentation is done simultaneously, the peri-areolar double-skin mastopexy can be safe, effective and reproducible when applied to cases of increasing complexity.

Lumbar hibernoma: a rare cause of soft tissue swelling - Corrected Proof

S.H.A. Shah, R.A.J. Wain, F.S. Butt — 2010-01-04

Hibernomas are rare benign tumours that arise most often in adults from the remnants of foetal brown adipose tissue. The term was established due to morphological similarities of hibernoma cells to those of “hibernating glands” of animals. Hibernomas are slow growing, painless neoplasms which neither recur, if completely excised, nor have any malignant potential. Diagnosis can be difficult as hibernoma may be confused with lipoma or liposarcoma. This case is rare because of the unusual tumour location.

Distribution of adipose-derived stem cells in adipose tissues from human cadavers - Corrected Proof

2009-12-31

Summary: Background: Adipose-derived stem cells (ASCs) possess multipotency in vivo and in vitro, and thus are thought to be very promising precursors for use in regenerative medicine. ASCs can be concentrated from adipose tissue by enzymatic digestion and transplanted to increase angiogenesis or for cosmesis. ASC transplants are now being performed in a clinical setting. Although data on ASCs are extensive, the distribution of ASCs in human fat tissue has not been fully clarified. Thus, it is important to identify the distribution of ASCs to obtain cell populations rich in ASCs for clinical use.Methods: ASCs express CD34, a cell surface marker. As CD34 is also expressed by endothelial cells, we immunohistochemically stained 2-μm-thick serial paraffin sections of fat tissue obtained from various parts of formalin-fixed cadavers with anti-CD31 and anti-CD34 antibodies to distinguish ASCs from endothelial cells.Results: CD34(+)/CD31(–) cells were mainly found in connective tissue tracts and perivascularly. Among fat tissues obtained from various sites, fat tissues in the thoracic back and lower abdomen were richest in CD34(+)/CD31(–) cells.Conclusion: The concentrations of CD34(+)/CD31(–) cells in adipose tissues differ between sites. The sites most highly enriched for ASCs were identified, and it is now possible to select the best sites for collection of ASCs for transplantation.

Combined early cleft lip and palate repair in children under 10 months – a series of 106 patients - Corrected Proof

Andrew M. Hodges — 2009-12-28

Summary: This article reviews a series of 106 patients presenting with cleft lip and palate who underwent a simultaneous combined cleft lip and palate repair under the age of 10 months. The technique is described together with the early postoperative results. A single surgeon (the author) operated on the 106 patients. The youngest patient was 6 weeks old, and the smallest weighed 2.3kg. All patients underwent palate repair, followed by lip repair, at a single sitting. The palate repair used the Sommerlad technique with radical muscle repositioning and bilateral lateral Langenbeck-type releasing incisions when indicated. Of the total, 71 patients (67%) had a unilateral lip and palate cleft and underwent a modified Millard repair; 34 (32%) had a bilateral lip defect and underwent a modified Mulliken repair; and one (1%) had a midline cleft lip. Ten patients were excluded from the study, as their palate was deemed too wide to close. Instead, they underwent cleft lip repair and vomer flap to the anterior palate alone. The mean duration of the procedure was 97min. There was neither mortality, nor significant anaesthetic complications. Two patients who had low oxygen saturation postoperatively were taken back to the theatre. In both cases, the soft palate sutures were removed and the airway improved to a safe degree, permitting return to the ward for subsequent final repair. All patients were discharged home without any ongoing problems. One patient subsequently developed a unilateral dehiscence of a bilateral lip, and seven patients underwent a second procedure to close a palatal fistula. Early follow-up results are encouraging, with only 8% of patients to date requiring a second procedure.Conclusion: Although technically challenging, cleft lip and palate repair in a single simultaneous procedure is a successful and, most importantly, a safe procedure, which enables the complete clefting condition to be repaired early and in a single operation.

This is linear verrucous epidermal nevus, not acanthosis nigricans - Corrected Proof

Niti Khunger, Sushruta Kathuria — 2009-12-28

This is with reference to an article published in your journal, ‘Acanthosis nigricans and an alternative for its surgical therapy’, Isken T, Sen C, Iscen D, et-al, J Plast Reconstr Aesthet Surg 2009; 62: 148–150. This is to state that the clinical description and image shown in this case report is clearly that of linear verrucous epidermal nevus and not that of acanthosis nigricans.

A new mechanism associated with compositae graft success - Corrected Proof

Daegu Son, Hoijoon Jeong, Taehyun Choi, Junhyung Kim, Kihwan Han — 2009-12-28

Summary: It is believed that the subcutaneous fat of the skin compositae grafts acts as a mechanical barrier limiting vascularisation. This study aims to determine a new mechanism associated with compositae graft take. Ten 3×3cm rectangular full-thickness skin compositae grafts on the back of a pig were taken and then randomly changed to another place. Silicone sheets were then inserted between the graft and the recipient to block the direct contact of the dermis at the lateral surface of the graft and control the number of surface contacts. The take rate was measured using the digital VISITRAK®. The microcirculation of the graft was evaluated by microangiograms using a latex–lead oxide solution. There was a 20.5% graft take in all four surface-blocked groups. The microangiograms showed vessel connections not only between the vessels of the dermis, but also between the subcutaneous fat of the graft and perforators from the basal surface of the wound. The subcutaneous layer does not produce a barrier but works as a significant source of vessel communication. Direct vessel-to-vessel anastomosis between the vessels of the subcutaneous fat at the graft and the basal surface of the recipient wound are another important mechanism for the success of compositae grafts.

Foster replantation of fingertip using neighbouring digital artery in a young child - Corrected Proof

Jing-hong Xu, Zheng-jun Gao, Jing-ming Yao, Wei-qiang Tan, Javed Dawreeawo — 2009-12-28

Summary: Reconstruction of an amputated fingertip in a young child demands special techniques for success. We report a 2.5-year-old female patient with an amputated left index fingertip with the vascular defect being too severe to perform the usual replantation. Comparing several methods, we used the neighbouring digital artery as the feeding artery to perform foster replantation. Finally, the patient was satisfied with the appearance and function of her fingers. The clinical case, techniques, results are described and discussed. We consider it a useful technique, especially for those with a rather severe vascular defect.Patient: A 2.5-year-old girl suffered a crush amputation of the left index fingertip. Only the flexor tendon of the amputated fingertip was connected to the proximal finger tissue and the blood supply was completely lost ().Methods: The distal amputated fingertip was fixed using Kirschner wire under general anaesthesia. Then, microsurgery operation was carried out immediately to replant this amputated fingertip. Both ulnar and radial digital arteries were avulsed, while the dorsal vein was intact and the digital nerve was also surviving. The integrity of blood vessels was too traumatised to connect to the proximal part. In the case of the distal part of the ulnar artery of the injured index finger, the blood supply was established by anastomosing the distal end of the amputated tip and the radial artery of the middle finger, which was the feeding artery (). A 11/0 nylon suture was used. The dorsal vein and digital nerve were repaired by means of microsurgical anastomosis. The wound was covered with the dorsal skin of the middle finger and the palmar skin of the index finger to form a skin pedicle, and then, immobility of the two fingers was maintained to prevent avulsion.Result: The index tip obtained good blood supply and survived completely (). Detachment of the index and middle finger was performed after 3 weeks, and both of the fingers showed good blood supply (). The appearance and function of the index and middle fingers were satisfactory 3 months postoperatively.

Transport disc distraction osteogenesis as an alternative protocol for mandibular reconstruction - Corrected Proof

Soung Min Kim, Jung Min Park, Hoon Myoung, Jong Ho Lee — 2009-12-25

Transport disc distraction osteogenesis (TDDO) has been recently introduced for the correction of skeletal malformations and discrepancies in the maxillofacial area. Through the use of a reconstruction plate-guided distraction device in mandibular discontinuity defects, TDDO can reconstruct the three-dimensional mandibular shape with combined soft tissue restorations.

Chronic abscess formation following mesh mastopexy: Case report - Corrected Proof

J.M. Dixon, I. Arnott, M. Schaverien — 2009-12-25

Summary: Mastopexy is a challenging procedure that relies on the redistribution of breast parenchyma and tightening of the skin envelope to provide long-lasting correction of ptosis. Recurrent ptosis, however, is an inevitable complication of many techniques and internal parenchymal supports using autologous or non-autologous material have been tried in an attempt to counteract the effects of gravity. Several studies have reported good long-term outcomes using synthetic mesh with a low rate of complications, however concerns remain including foreign body reaction, infection, and oncological surveillance. This article reports a case of chronic breast abscess formation following the use of polypropylene mesh in mastopexy and the radiological and operative findings.

A pilot application of image-guided navigation system in mandibular angle reduction surgery - Corrected Proof

Lin Yanping, Chen Xiaojun, Ye Ming, Wang Xudong, Shen Guofang, Wang Chengtao — 2009-12-23

Mandibular angle reduction is the one of the most popular methods applied toward correcting the prominent mandibular angle(PMA) in Asian countries. The purpose of this study is to apply a computer-aided surgical 3D planning and image-guided navigation system (Navi-CMFS) in mandibular angle reduction surgery, aiming at improving the surgical accuracy, minimizing surgical risks and optimizing clinical results.

Use of Dermabond™ in cleft lip repair - Corrected Proof

Andrew D.H. Wilson, Nigel Mercer — 2009-12-23

We read with interest the recently published article by Collin et al on the use of Dermabond™ tissue adhesive in the final stage of cleft lip repair. This article presents a retrospective review of 22 patients in whom Dermabond was used versus 14 patients who had Novafil used as their dermal closure. We would like to commend the senior author on his transition from a Novafil closure to the use of Dermabond™, and congratulate the authors on being able to demonstrate a cost saving of £500 per patient on average. In their article, the authors do draw our attention to the main weakness of their study, namely the small patient cohort. They report their findings as ‘early’ and recommend continued review and audit of the process.

The effect of growth hormone on fibroblast proliferation and keratinocyte migration - Corrected Proof

Sang Woo Lee, Suk Hwa Kim, Ji Youn Kim, Yoonho Lee — 2009-12-21

Summary: Background: The beneficial effects of growth hormones (GHs) on wound healing have been reported. Although the mechanism of how GH promotes wound healing is unclear, there are reports showing that the principal factor lies in the GH-stimulated production of IGF-1 in topical wounds. In this study, a human primary cell model was devised to examine how the topical application of GHs affects fibroblast proliferation and keratinocyte migration, which play fundamental roles in wound healing.Methods: The fibroblasts were cultured in media with different concentrations of GH. The amount of fibroblast proliferation was assessed using a tetrazolium-based colourimetric assay (MTT assay). The amount of newly formed IGF-I mRNA was measured by reverse transcription and polymerase chain reaction (RT-PCR). Keratinocyte migration was compared using a migration assay.Results: Fibroblast proliferation was significantly higher in the experimental group than in the control group (the absorbance of 2.5IU L−1 GH applied group: 0.3954±0.056, control group: 0.2943±0.0554, P<0.05), and the promotion of IGF-I formation by fibroblasts was observed. There was more keratinocyte migration in the experimental group than in the control group (the remaining gap in the 2.5IU L−1 GH applied group after keratinocyte migration: 46.57±2.22% of the primary gap, control group: 75.14±3.44%, P<0.05).Conclusion: GH enhances the local formation of IGF-1, which activates fibroblast proliferation and keratinocyte migration. These results highlight the potential of the topical application of GHs in the treatment of wounds.

Remodelling of the pinna in myxoid degeneration of the ear - Corrected Proof

J. Kean, K.J. Stewart — 2009-12-21

Summary: Idiopathic deformation of the pinna is not widely reported in the current literature. We present a series of cases in which patients have required surgery for spontaneous thickening and deformation of the auricular cartilage, and a description of a technique for surgical correction.Four cases of idiopathic deformation of the pinna are reported. Our preferred technique of scaphoid rim incision and anterior carving of the cartilage is described, with intra-operative photographs.Each patient reported spontaneous swelling of the upper poles of the ears beginning in the second or third decade of life. In 3 cases the deformity was bilateral, although in each of these cases one side was more severely affected than the other. Histology for these cases was reported as myxoid degeneration of the ear. All of the reported patients were pleased with the aesthetic outcome of their auricular remodelling.Currently, there are no typical patient demographics for idiopathic myxoid degeneration of the ear. We have achieved good aesthetic results by hand carving the anterior aspect of the deformed cartilage via scaphoid rim incisions.