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

Wing flap reconstruction for large defects of the lower lip - Corrected Proof

Yumiko Uchikawa, Masaki Yazawa, Masayoshi Takayama, Kazuo Kishi — 2012-05-18

Summary: Full-thickness lower lip defects most often occur due to tumour resection or injury. Because the lower lip is important for both eating and speaking, reconstruction of the region must restore the structure and function of the tissue. Here, we describe a new procedure to reconstruct the lower lip, using a ‘wing flap’: a mental V–Y rotational advancement flap that contains the mental nerve. This flap can preserve the sensory innervation of the lower lip, and it allows effective reconstruction of the muscle sling. We have employed this method twice and have obtained good aesthetic and functional outcomes. No special technique is required to reconstruct the lip using this flap, and it yields a satisfactory outcome. Thus, we recommend it as an effective method for reconstruction in wide lower lip defects.

One stage breast reconstruction following prophylactic mastectomy for ptotic breasts: The inferior dermal flap and implant - Corrected Proof

G.L. Ross — 2012-05-17

Summary: Introduction: Immediate reconstruction following prophylactic mastectomy for larger ptotic breasts is difficult. Tissue expansion in these patients often results in poor cosmetic outcomes. Autologous options may not be possible due to clinical unsuitability or patient choice. Using the inferior dermal flap with implant achieves lower pole fullness and allows a one-stop reconstruction in the larger ptotic breast.Methods: The inferior dermal flap and implant was performed on ten patients (20 breasts). Average age was 43 (range 36–53). The average BMI was 37 (range 32–43). The distance from nipple to IMF varied from 15 cm to 26 cm. The average implant size was 533 (range 390–620). Complications were minimal with one patient experiencing delayed wound healing at the T-junction and one patient developing inferior pole erythema postoperatively that settled with antibiotics.Conclusion: The inferior dermal flap and implant provides a one-stop reconstructive option. It is reliable, safe and maintains the breast envelope while giving excellent size, shape and symmetry in the larger ptotic patient.

Outcomes in facial aesthetics in cleft lip and palate surgery: A systematic review - Corrected Proof

V.P. Sharma, H. Bella, M.M. Cadier, R.W. Pigott, T.E.E. Goodacre, B.M. Richard — 2012-05-17

Summary: Background: While there are internationally validated outcome measures for speech and facial growth in cleft lip and palate patients, there is no such internationally accepted system for assessing outcomes in facial aesthetics.Method: A systematic critical review of the scientific literature from the last 30 years using PUBMED, Medline and Google Scholar was conducted in-line with the PRISMA statement recommendations. This encompassed the most relevant manuscripts on aesthetic outcomes in cleft surgery in the English language.Results: Fifty-three articles were reviewed. Four main means of determining outcome measures were found: direct clinical assessment, clinical photograph evaluation, clinical videographic assessment and three-dimensional evaluation. Cropped photographs were more representative than full face. Most techniques were based on a 5-point scale, evolving from the Asher-McDade system. Multiple panel-based assessments compared scores from lay or professional raters, the results of which were not statistically significant. Various reports based on cohorts were poorly matched for gender, age, clinical condition and ethnicity, making their results difficult to reproduce.Conclusions: The large number of outcome measure rating systems identified, suggests a lack of consensus and confidence as to a reliable, validated and reproducible scoring system for facial aesthetics in cleft patients. Many template and lay panel scoring systems are described, yet never fully validated. Advanced 3D imaging technologies may produce validated outcome measures in the future, but presently there remains a need to develop a robust method of facial aesthetic evaluation based on standardised patient photographs. We make recommendations for the development of such a system.

Description of a communication between the facial and zygomaticotemporal nerves - Corrected Proof

A. Odobescu, H.B. Williams, M.S. Gilardino — 2012-05-14

Summary: Communicating branches between the facial and the trigeminal nerves are known to exist; however, both their frequency and significance are incompletely understood. In our anatomic dissections, we observed a consistent anastomosis between the temporal branch of the facial nerve and the zygomaticotemporal branch of the trigeminal nerve.The facial nerves were dissected in 17 cadaveric half faces. The communicating facial-zygomaticotemporal nerve branches piercing the superficial layer of the deep temporal fascia were identified and followed through the fascial and muscular planes.Fourteen out of 17 dissected cadaveric half faces contained communications between trigeminal and facial nerves. In these specimens, one or two branches from the temporal branch of the facial nerve would penetrate the superficial layer of the deep temporal fascia to join the zygomaticotemporal nerve. These communications were found at an average of 36 mm lateral and 2 mm superior to the lateral canthus.Due to the cadaveric nature of the study it is difficult to ascertain the function of the described communication. Our histochemical analysis suggests that these connections contain myelinated fibers, which could either be proprioceptive or motor fibers.

A comparative study of finger pulp reconstruction using arterialised venous sensate flap and insensate flap from forearm - Corrected Proof

Hede Yan, Weiyang Gao, Feng Zhang, Zhejie Li, Xinglong Chen, Cunyi Fan — 2012-05-14

Summary: Objective: The aim of this study was to investigate the feasibility of finger pulp reconstruction using arterialised venous flaps from forearm and compare the outcomes of arterialised venous sensate flap and insensate flap.Methods: Twenty-seven arterialised venous flaps were reviewed retrospectively in the reconstruction of finger pulp defects in 23 patients, including 15 sensate flaps (sensate group) and 12 insensate flaps (insensate group). Nine flaps in this series were harvested from the dorsal aspect of the forearm and the other 18 were harvested from the volar aspect. Standardised assessment of outcomes in terms of objective sensory recovery, pinch power of the reconstructed digits, cold intolerance and time of returning to work was completed.Results: All flaps survived completely. Twenty-six flaps were available for follow-up of more than 9 months (mean, 15.4 months). Almost all the flaps in the sensate group obtained normal sensation, while most cases of the insensate group only achieved protective sensation. Cold intolerance was present in most cases of the insensate group in comparison with the sensate group with only one case suffering from slight cold intolerance. There was no significant difference of pinch power between the two groups. All the patients were contented with the aesthetic outcomes of the surgery.Conclusion: The arterialised venous sensate flap from forearm is a practical alternative for finger pulp reconstruction with satisfactory functional and aesthetic outcomes. The forearm region can be an acceptable donor site for arterialised venous sensate flap in the reconstruction of larger finger pulp defect.

Commentary to ‘Asymmetric asymmetric implants for breast asymmetry’ - Corrected Proof

MG Berry — 2012-05-14

I was delighted to receive an invitation to review this case report. Although brief, it ushers in a new era of planning to what remains the most common cosmetic surgery procedure in the UK and across the Atlantic and I applaud the extension of the principles of biodimensional planning whereby the individual patient and her unique tissue characteristics select the truly bespoke mammary augmentation.

Flap hitch: An adjunct to flap thinning - Corrected Proof

Suresh M. Anandan, Mahendra Kulkarni, Indraneil Basu — 2012-05-14

Reconstruction of soft tissue defects of the sole is a challenging problem. Bulky flaps interfering with footwear is common sequelae. Multiple operations are often required to achieve a functional foot. We describe the case of a motorcyclist who sustained degloving injury to his left sole when he was hit by a car. The defect was resurfaced by a free latissimus dorsi flap and a meshed skin graft. After a year partial flap thinning was done, as it was bulky. Though he was grateful for the reconstruction he still could not wear a shoe, the gait was affected and he felt the flap was wobbly. 8 months later he underwent a further flap thinning .At this stage lack of adherence of the flap to the undersurface was noted and a flap hitch was done. 3 looped nylon sutures were used to lift up the internal portion of the sole bearing part of the flap and suspended onto periosteum of the lateral malleolus, navicular and posteromedial calcaneum (). The flap hitch promotes adhesion and permanent uplift of the flap. This also produced a good contouring of the flap. Though flap hitch has been described in various parts of the body we do think this is worth considering in combination with flap thinning especially for the wobbly sole flap.

Reconstruction of a contracted eye socket using an anterofrontal superficial temporal artery island flap and scapha composite grafting in an elderly patient - Corrected Proof

Naoko Omori, Nobuyuki Mitsukawa, Yoshitaka Kubota, Kaneshige Satoh — 2012-05-14

Summary: There are numerous methods for reconstruction of the eye socket. However, the use of an island flap on the forehead based on the anterofrontal branch of the superficial temporal artery has not been reported upon. This article describes an experience of eye-socket reconstruction in a 90-year-old woman with an anterofrontal superficial temporal artery island flap, a temporoparietal fascia flap and scapha composite grafting in a one-step procedure. Deep fornices were obtained and the convex eye socket was stably and easily fitted with the ocular prosthesis, which the patient started to wear 4 weeks after the operation. The socket and eyelids are without any deficits and in good condition with a 1-year follow-up.

A mobile phone initiative to increase return for speech therapy follow-up after cleft palate surgery in the developing world - Corrected Proof

Daniel Y.J. Foong, Daniel P. Butler, Keo Vanna, Tea Sok Leng, James Gollogly — 2012-05-14

Volunteering surgical teams have had success in performing cleft palate repairs in the developing world: however integrated, multidisciplinary post-operative follow-up remains absent.

Use of beard hair as a donor source to camouflage the linear scars of follicular unit hair transplant - Corrected Proof

S. Umar — 2012-05-14

A linear scar (also termed a strip scar) is an inevitable outcome of follicular unit hair transplant (FUHT). The scar remains a challenge for both the surgeon and patient because it presents a continuous line of bald skin that is easily traced by the eye and requires hair styles long enough to cover. The scenario is worse when the scar widens, which can occur at any time from weeks to months after surgery. There are several methods, all with limitations, for both minimizing and repairing the strip scar: trichophytic closure, controlled tension at closure, scar revision, and tattooing.

iPad local flap pre-operative planning: A good training tool - Corrected Proof

Amir Sadri, Adrian D. Murphy, Joy Odili — 2012-05-11

Summary: The iPad can allow uploaded photographs to be edited using commonly available software. This provides a valuable opportunity for trainees to plan and discuss local flap options with senior colleagues. The application of the iPad in this capacity provides junior plastic surgeons with a good training tool and also improves patient care. We describe our experience with using the iPad to plan and reconstruction a scalp wound.

A novel approach for management of ear keloids: Results of excision combined with 5-fluorouracil injection - Corrected Proof

Nishant Khare, Surendra B. Patil — 2012-05-11

Keloids of the ear are a challenging problem. Excision of keloid without any adjuvant treatment results in a recurrence rate of 45–100%. Numerous adjuvant treatments have been used with limited success. Ear lobe keloids are frequently encountered, as these lesions are excised, recurrences can be devastating because with each recurrence, the keloid consumes more local soft tissue, and can grow to compromise the underlying cartilage.

Three-dimensional virtual model and animation of penile lengthening surgery - Corrected Proof

Ruiheng Wang, Dongyun Yang, Shirong Li — 2012-05-07

Summary: Background: Three-dimensional digital models, animations, and simulations have been used in the plastic surgical field for surgical education and training and patient education. In penile lengthening surgery, proper patient selection and well-designed surgical interventions are necessary; however, no such surgical or patient education tool exists.Methods: Using magnetic resonance images as references, a preliminary three-dimensional digital model of the penis with its adjacent structures was constructed using Amira 5. This preliminary model was imported into Maya 2009, a computer modeling and animation software program, for processing to correct many defects. The refined model was used to create digital animation of penile lengthening surgery, including ordered steps of the procedure, using Maya 2009 and Adobe After Effects CS4.Results: A three-dimensional digital animation was created to illustrate penile lengthening surgery. All major surgical steps were demonstrated, including exposure, transversal incision of the fundiform ligament, partial division and release of the suspensory ligament.Conclusions: Three-dimensional digital models and animations of penile lengthening surgery may serve as resources for patient education to facilitate patient selection and resident education outside the operating room.

Are we referencing online resources according to the journal's guidelines? - Corrected Proof

Nigel Mabvuure, Marc Davies — 2012-05-07

The internet has increased the sources of information which researchers can use to inform their work. These sources still need to be cited in the main text and listed in the references section to allow readers to access the same sources. Whilst reading some articles in the Journal of Plastic, Reconstructive and Aesthetic Surgery (JPRAS), we found that the reference lists in some articles did not have full information about their online sources. Furthermore, some of the links provided in the reference lists were non-functional. JPRAS advises authors to include the author's name, title of the article, uniform resource locator (URL) and the date the accessibility of that link was verified when referring to an online resource. The journal gives the following as an example of a complete reference of an internet resource:

Less scarring or more symmetry? Reconstruction following metachronous bilateral breast cancer - Corrected Proof

Michael Bezuhly, Jodi Bucholtz, Leif Sigurdson — 2012-05-04

Summary: No literature exists to guide the management of patients diagnosed with metachronous disease of the contralateral breast after previous delayed reconstruction. If the patient is undergoing a skin-sparing mastectomy of the contralateral breast, is it aesthetically preferable to preserve the native skin envelope and decrease scarring, or is it better to include more flap skin to maintain symmetry with the previous reconstruction? To answer this question, the authors developed an online survey with links to multiple Canadian breast cancer groups. Participants were asked which digitally-modified photograph they preferred out of each of three pairings representing different stages of reconstruction (breast mound, nipple reconstruction and tattooing/areolar reconstruction). Of 230 respondents, more than 70% preferred the symmetric photograph when presented with the breast mound and nipple reconstruction pairings. For the pairings depicting complete reconstruction following tattooing/areolar reconstruction, there was no difference in the proportion of respondents who preferred the symmetric or asymmetric reconstruction. This finding underscores the importance of tattooing/areolar reconstruction to the ultimate aesthetic outcome following metachronous bilateral reconstruction.

Surgical treatment of a Morel-Lavallée lesion of the distal thigh with the use of lymphatic mapping and fibrin sealant - Corrected Proof

Rebecca M. Jones, Andrew M. Hart — 2012-05-03

Summary: Introduction: A Morel-Lavallée lesion can occur after a closed degloving injury. It is a persistent seroma that may be resistant to conservative methods of treatment such as percutaneous drainage and compression therapy. We present a novel, successful method of surgical treatment.Case report: A 70 year-old lady developed a 30 × 15 cm rapidly enlarging right medial thigh/knee swelling after being hit by a car. Conservative treatments failed, sarcoma was excluded, and the diagnosis confirmed, by MR imaging and cytology prior to referral. The lesion was excised, and blue dye lymphatic mapping used to identify and ligate feeding lymphatic vessels. The cavity was then closed using fibrin sealant spray and resorbable quilting sutures. A pressure garment was fitted.Result: The wound healed without complication, with no recurrence at six months. The patient returned to normal activities without pressure garments.Conclusion: This method provides a novel, successful approach to the surgical treatment of a chronic Morel-Lavallée lesion.

Preoperative asymmetry of upper eyelid thickness in young Chinese women undergoing double eyelid blepharoplasty - Corrected Proof

Francisco G. Bravo — 2012-05-03

The authors present a large series of 1217 patients undergoing double eyelid blepharoplasty in young asian women operated by a single surgeon. In order to evaluate the presence of eyelid asymmetries preoperatively the authors develop an original method to analyze the differences in thickness of both upper eyelids through MRI imaging. These differences are later confirmed through intraoperative weighing of the resected specimens. Although, as the authors acknowledge in their text, the intraoperative weighing is highly susceptible to researcher bias, their preoperative results through MRI imaging showing a high incidence of upper eyelid asymmetries are an important finding for plastic surgeons performing double eyelid blepharoplasty procedures.

Aesthetic and reconstructive rhinoplasty: A continuum - Corrected Proof

Frederick J. Menick — 2012-05-03

Summary: The anatomy and aesthetics of the nose never change and are similar for cosmetic and reconstructive rhinoplasty. The disciplines differ in the cause of injury, which determines the site and degree of damage, the subsequent deformity, and the therapeutic approach to repair.The cosmetic surgeon modifies the bony-cartilaginous framework to support and mould the overlying skin. A thick, scarred or large skin envelope may limit the expected result but cannot be altered.When severe scarring or necrosis occurs after a cosmetic rhinoplasty or filler injection, missing external skin and internal lining become a controlling factor in achieving nasal shape and must be replaced in exact dimension and border outline, guided by the principles of aesthetic nasal reconstruction.This paper illustrates the use of a 3 stage forehead flap and anatomic reconstruction of the tip cartilages to repair a full thickness necrosis of the tip after a cosmetic filler injection. An overview of presentation and treatment of this complication is presented with reconstructive guidelines to direct the surgeon to successful repair.

Sentinel lymph node biopsy in thick malignant melanoma: A 10-year single unit experience - Corrected Proof

Neil G. Fairbairn, Georgios Orfaniotis, Mark Butterworth — 2012-05-03

Summary: Between the years 2000–2010, 195 patients were diagnosed with ≥4 mm Breslow thickness malignant melanoma in our unit. Median follow-up was 36.8 months. 49% of patients were male and 51% were female. Median age was 74 years. The commonest melanoma type was nodular (55%). The commonest tumour location was on the extremity (45%). 64% of tumours were ulcerated. Median mitotic rate was 9. Median Breslow thickness was 7 mm 66 patients underwent sentinel lymph node biopsy. 44 (67%) patients had negative results and the remaining 22 (33%) patients were positive for metastatic melanoma. There was no statistically significant correlation between any of the patient or tumour variables (age, sex, melanoma type, melanoma site, Clark level, Breslow thickness, mitotic rate, ulceration) and sentinel lymph node status. Patients with Breslow thickness melanoma of <6 mm had a significantly better 5-year disease free and overall survival compared with those patients with >6 mm Breslow thickness melanoma (63.5% vs. 32.9%; P = 0.004 and 73.9% vs. 54.7%; P = 0.02 respectively). Recurrence rate was 50% in those with positive sentinel lymph node biopsy compared to 23% in those with negative results. Distant recurrence was the commonest in both groups. 5-year disease free survival was 64.1% in the SLNB –ve group and 35.4% in the SLNB +ve group (P = 0.01). There was no significant difference in overall survival between the SLNB –ve and SLNB +ve groups (70.3% vs. 63.7% respectively; P = 0.66). We conclude that sentinel lymph node biopsy in our unit has provided no survival benefit in those with thick melanoma over the past 10 years but is an important predictor of recurrence free survival. Breslow thickness remains an important predictor of disease free and overall survival in thick melanoma.

Reconstruction of elbow region defects using radial collateral artery perforator (RCAP)-based propeller flaps - Corrected Proof

Masahiro Murakami, Shimpei Ono, Nobuaki Ishii, Hiko Hyakusoku — 2012-05-01

Summary: Perforator-based propeller flaps permit flap rotation up to 180°. This ability to transfer skin from one longitudinal axis to another has led to the increasing use of perforator-based propeller flaps in extremity reconstruction, especially lower-extremity reconstruction. However, the application of perforator-based propeller flaps to upper-extremity reconstruction is still limited. This article reports two cases of successful reconstruction of elbow region defects with radial collateral artery perforator (RCAP)-based propeller flaps.The elbow region has a variety of perforators available for perforator-based propeller flap reconstruction. Among them, the RCAP seems to be one of the most reliable options. This is because there are less anatomical variations of perforators' location on the lateral upper arm than on the medial upper arm. By using an RCAP perforator as a flap pedicle, the small-to-medium sized defects (<6 cm in diameter) around elbow regions can be closed primarily without skin grafts.

Botulinum neurotoxin A: A review - Corrected Proof

MG Berry, Jan J. Stanek — 2012-05-01

Summary: Despite its ubiquity in cosmetic circles and broad general awareness, a literature search of botulinum neurotoxin in JPRAS and BJPS yielded a mere 4 articles germane to cosmesis. A pair each detailing its application in masseteric hypertrophy and the use of cryoanalgesia. Given that botulinum neurotoxin A is the most commonly used cosmetic treatment, with American figures being most accurate, a review of the background, development and scientific evidence would be perhaps useful, if not overdue, as Plastic Surgeons increasingly incorporate non-surgical interventions into their practices as part of a comprehensive facial rejuvenation strategy.

Intercostal neuroma as a source of pain after aesthetic and reconstructive breast implant surgery - Corrected Proof

John T. Nguyen, Ian A. Buchanan, Priti P. Patel, Nika Aljinovic, Bernard T. Lee — 2012-04-30

Summary: The development of persistent post-operative pain after implant placement for aesthetic or reconstructive breast surgery can lead to significant patient morbidity. Although there are many etiologies for post-operative pain, the diagnosis of an intercostal neuroma is important as this can be treated surgically. We describe three cases of an intercostal neuroma in patients with breast implants. A Tinel’s sign can be elicited along the lateral chest wall and a local anesthetic block temporarily alleviates this pain. Surgical management with identification and clipping of the intercostal neuroma and burying into the underlying muscle significantly decreases post-operative pain long term. In patients with persistent pain after breast implant placement, plastic surgeons must be aware of this treatable cause of pain.

Corrected Proof

Juan P. Barret — 2012-04-30

Dr Sheridan's book is the latest addition to Burn Care Literature through a compact text that, on a step-wise manner, delineates burn treatment with a focus on the multidisciplinary approach.

Asymmetric asymmetric implants for breast asymmetry - Corrected Proof

P. Mallucci, O.A. Branford — 2012-04-30

Summary: The indications, advantages, and disadvantages of round and anatomical implants have previously been described. The principles of biodimensional implant selection have been developed by several authors, where the objective choice of breast prosthesis for augmentation is based on the patient's breast tissues. This process has largely been applied to anatomical implant selection. We report a case of breast asymmetry, where we have applied the same concepts in the selection of implants based on tissue dimension. This resulted in an anatomical implant being used to augment the left breast, and a round implant on the right. To our knowledge a round implant and an anatomical implant have not previously been employed in the same patient to correct breast asymmetry. This resulted in excellent postoperative symmetry.

Odontogenic skin sinus: A commonly overlooked skin presentation - Corrected Proof

M.K. Herd, T. Aldridge, S.D. Colbert, P.A. Brennan — 2012-04-30

Summary: Facial skin lesions present routinely to clinic and are largely dermatological in origin. Odontogenic infections are an unusual cause of facial lesion and are well-described in the dental literature; however they are regularly overlooked and mismanaged, often to considerable aesthetic detriment. We present such a case and highlight important avoidable pitfalls.

Necrotising fasciitis of the thigh secondary to colonic perforation – The femoral canal as a route for infective spread - Corrected Proof

A. Wiberg, E. Carapeti, A. Greig — 2012-04-27

Summary: A 57 year-old man with a history of corticosteroid use presented with abdominal pain and diarrhoea. He was initially treated for presumed Clostridium difficile colitis, but later developed a left inguinal mass with spreading erythema. A CT scan showed gas within the retroperitoneal tissues, with surgical emphysema of the left groin. Necrotising fasciitis was diagnosed, and the patient underwent extensive debridement of the left thigh and inguinal region. The femoral vein was covered in infected fascia in the femoral canal, and a laparotomy revealed a posterior perforation of the sigmoid colon. Necrotising fasciitis of the thigh is a rare complication of colonic perforation. Our case highlights the femoral canal as a potential channel for the spread of intra-abdominal infection into the thigh.

Re: Surgical tips: Areolar tattoo prior to nipple reconstruction - Corrected Proof

Charles Yuen Yung Loh, Philip Lim, David Lam — 2012-04-26

We read with interest this article regarding areolar tattooing prior to nipple reconstruction. However, we must disagree with the author and this particular technique in various aspects which we will highlight below. The criticism that the traditional technique of performing a nipple reconstruction before tattooing can be flawed with inconsistent pigment over the scarred skin does not do justice to the advances in tattooing techniques and pigments that are currently available.

Acute vasculitis resulting in free flap failure: The importance of early recognition and options for management - Corrected Proof

2012-04-26

Summary: Unusual or unexpected medical causes for free flap failure do occur but are uncommon. We present a rare case of a fibula free flap failure due to an acute vasculitis which was undiagnosed until after the flap had failed. In addition to two successful flap salvages and intravenous heparin, an epoprostenol infusion was commenced but a third salvage was not successful. The vasculitis resulted in marked blood vessel wall thickening, and cutaneous manifestations which presented as late signs. High peri-nuclear anti nuclear cytoplasmic antibody (pANCA) and myeloperoxidase (MOP) titres were subsequently found and histology from several blood vessels showed marked inflammation throughout the wall. A diagnosis of microscopic polyangiitis was made and high dose steroids were subsequently commenced. Interestingly, he had vasculitis several years previously treated with oral steroids but had been discharged from the rheumatology clinic. This rare case illustrates the potential hazards of free flap surgery in the vasculitides and discusses the warning signs and various management options to reduce the likelihood of flap failure in these patients.

Branchi-oculo-facial syndrome: A case report to highlight recent genetic considerations - Corrected Proof

2012-04-26

Summary: Branchio-oculo-facial syndrome (BOFS) is a rare entity described during the last century which has been recently linked to mutations of the gene encoding for the transcription factor named ‘TFAPA2’. We report here a sporadic case of BOFS with a partial phenotype caused by a de novo mutation of this gene and discuss recent genetic findings.

The anatomy of the pectoral nerves and its significance in breast augmentation, axillary dissection and pectoral muscle flaps - Corrected Proof

2012-04-25

Summary: Background: In many plastic surgeries, a detailed understanding of the pectoral nerve anatomy is often required. However, the information available on the anatomy of pectoral nerves is sparse and unclear. The purpose of this study is to provide detailed anatomical information on the pectoral nerves to allow for their easy intra-operative localisation and to improve the understanding of the pectoral muscle innervation.Methods: We dissected 26 brachial plexuses from 15 fresh cadavers. The origins, locations, courses and branches of the pectoral nerves were recorded.Results: We found three constant branches of the pectoral nerve. The superior branch travelled in a straight course to the pectoralis major to innervate the clavicular aspect. The middle branch coursed on the under-surface of the pectoralis major near the pectoral branch of the thoraco-acromial artery to innervate the muscle's sternal aspect. The inferior branch passed beneath the pectoralis minor muscle to innervate the pectoralis minor muscle and the costal aspect of the pectoralis major muscle.Conclusions: Knowing the pectoral nerves' origins, courses and connections, in addition to understanding the functional consequences of iatrogenically severing these nerves, leads to a better understanding of the pectoral muscle's innervation. Precise anatomical data on the pectoral nerve allow for its easy localisation during axillary breast augmentation, axillary dissection, removal of the pectoralis minor muscle and harvesting the pectoralis major muscle island flap.

Value of preoperative imaging in the diagnostics of isolated metopic suture synostosis: A risk–benefit analysis - Corrected Proof

2012-04-25

Summary: Radiographic evaluation including plain radiographies and computed tomographic (CT) scans are considered as a necessary tool for diagnosis of craniosynostosis. As recently concerns about harmful effects of ionising radiation in children have been raised, some authors have suggested the use of magnetic resonance imaging (MRI) as a helpful alternative in preoperative imaging of patients with isolated metopic synostosis. Besides confirming the diagnosis of trigonocephaly, MRI is the superior technique for the evaluation of underlying brain anomalies. However, if the benefit of preoperative imaging justifies possible side effects is still discussed controversially. Hence, this study investigated the value of preoperative imaging for the diagnosis of isolated synostosis of the metopic suture compared to a sole clinical examination.In a series of 63 cases with isolated metopic craniosynostosis operated at the Department of Oral and Maxillofacial Surgery, 48 (76.2%) patients received additional radiography or MRI investigation, while in 15 (23.8%) patients the diagnosis was based on clinical examinations only. In all patients, diagnosis was confirmed intra-operatively by a fused metopic suture. CT scans with three-dimensional reconstruction (12.5%) or plain radiographs (39.6%) did not provide any additional benefit for the diagnosis or the surgical treatment. In 23 patients (47.9%), MRI showed the typical soft-tissue alterations like triangular brain deformation in the frontal area. Besides these findings, no brain or other underlying anomalies were diagnosed which had required any additional treatment. The incidence of underlying brain abnormalities in isolated metopic synostosis seemed not to be different from that of the general population.As the characteristic clinical manifestations were sufficient for an accurate diagnosis of isolated metopic synostosis, and with respect to the biological effects of ionising radiation and risks of sedation especially in infants, preoperative imaging should be reduced to a minimum.

Outcomes of 52 patients with congenital melanocytic naevi treated with of UltraPulse Carbon Dioxide and Frequency Doubled Q-Switched Nd-Yag laser - Corrected Proof

Nada Al-Hadithy, Khalil Al-Nakib, Awf Quaba — 2012-04-23

Summary: Background: A variety of treatment options exist for the management of congenital melanocytic naevi (CMN). Surgical treatment has been the traditional approach. Recently, lasers have been introduced to treat CMN. This study assesses the effectiveness of UltraPulse Carbon Dioxide (UCO2) and Frequency Doubled Q-Switched (FDQS) Nd-Yag laser up to a 15 year period which is the longest follow-up period of any study, as far as we are aware.Materials & methods: We performed a retrospective review of 52 patients with 314 CMN, treated with UCO2 laser and FDQS Nd-Yag laser. The reduction in visible pigmentation, signs of recurrence and any adverse skin changes were evaluated clinically by two clinicians independent to the laser operator.Results: There was minimal visible pigmentation after completion of treatment in 40 patients. Treatment failure occurred in 5 patients, recurrence in 5 and partial success in 2. 5 patients developed hypertrophic scarring, 1 developed hyperpigmentation and 1 patient developed an intracranial melanoma. 87% of patients were satisfied with their treatment and in hindsight would not have chosen surgery. Mean follow-up period was 8 years (interquartile range 3–11years).Conclusion: UCO2 and FDQS Nd-Yag lasers are clinically useful treatment options for patients with CMN and have minimal complications. This combined laser regime is particularly effective for the treatment of CMN in cosmetically sensitive and anatomically critical areas, especially when surgical excision may not be straight forward and/or leave unacceptable scars.

Repairing proximal and middle lower-leg wounds with retrograde sartorius myocutaneous flap pedicled by perforating branches of medial inferior genicular artery or posterior tibial artery - Corrected Proof

Yu-ming Shen, Dong-ning Yu, Xiao-hua Hu, Feng-jun Qin, Ming Li, Fang-gang Ning — 2012-04-23

Summary: Background and objectives: The blood supply of the lower one-third of the sartorius muscle is mainly provided by the descending genicular artery (saphenous artery). The terminal branches of the saphenous artery, together with the perforators of the posterior tibial artery and medial inferior genicular artery, form a stable and rich anastomotic network in the genus inferior medialis. Based on this anatomy, we designed a retrograde sartorius myocutaneous flap to repair wounds in the proximal and middle thirds of the lower leg.Methods: A sartorius myocutaneous flap with the posterior tibial (or medial inferior genicular) artery perforators as the pedicle was designed. The flap was based on a retrograde flow route: medial inferior genicular and posterior tibial artery perforators, the vascular network at the inferomedial knee, the saphenous artery, saphenous artery perforators, to the sartorius muscle. With this design, the flap can be transferred to the middle and proximal tibia. Between January 2007 and June 2010, 12 patients with middle/proximal lower-leg wounds were successfully treated with this method.Results: Ten of 12 myocutaneous flaps survived with primary healing of wounds. Two cases developed a small degree of distal superficial skin necrosis but with normal muscular blood supply and healed after conservative treatment.Conclusion: Retrograde sartorius myocutaneous pedicle flaps from the perforating branches of the medial inferior genicular artery or posterior tibial artery have advantages in terms of reliable blood supply, ease of operation and minimal amount of damage, and can be used to repair proximal and middle lower-leg wounds. They are especially applicable when lower-leg flaps are unavailable due to poor soft-tissue conditions following trauma or multiple operations. However, the safety flap size needs to be determined in future studies.

Objective evaluation of the latissimus dorsi flap for breast reconstruction using three-dimensional imaging - Corrected Proof

2012-04-23

Summary: Background: The latissimus dorsi muscle flap is a common method for the reconstruction of the breast following mastectomy. The study aimed to assess the quality of this reconstruction using a three-dimensional (3D) imaging method. The null hypothesis was that there was no difference in volume between the reconstructed breast and the opposite side.Methods: This study was conducted in forty-four patients who had had immediate unilateral breast reconstruction by latissimus dorsi muscle flap. The breast was captured using the 3D imaging system. Ten landmarks were digitised on the 3D images. The volume of each breast was measured by the application of Breast Analysis Tool software. The symmetry of the breast was measured using Procrustes analysis. The impact of breast position, orientation, size and intrinsic shape on the overall breast asymmetry was investigated.Results: The null hypothesis was rejected. The reconstructed breast showed a significantly smaller volume when compared to the opposite side, p < 0.0001, a mean difference of 176.8 cc and 95% CI (103.5, 250.0). The shape and the position of the reconstructed breast were the main contributing factors to the measured asymmetry score.Conclusions: 3D imaging was efficient in evaluating the outcome of breast surgery. The latissimus dorsi muscle flap on its own for breast reconstruction did not restore the volume and shape of the breast fully lost due to complete mastectomy. The modification of this method and the selection of other or additional surgical techniques for breast reconstruction should be considered. The asymmetry analysis through reflection and Procrustes matching was a useful method for the objective shape analysis of the female breast and presented a new approach for breast shape assessment. The intrinsic breast shape and the positioning of the breast were major components of postoperative breast asymmetry. The reconstructed breast was smaller overall than the un-operated breast at a significant level when assessing the breast volume using the surface area. 3D imaging by multiple stereophotogrammetry was a useful tool for volume measurements, shape analysis and the evaluation of symmetry.

Findings of computed tomography in stage IIB and IIC melanoma; a six-year retrospective study in the South-East of Scotland - Corrected Proof

Georgios Orfaniotis, Joanna C. Mennie, Neil Fairbairn, Mark Butterworth — 2012-04-23

Summary: Introduction: Patient prognosis in malignant melanoma is directly related to clinical stage, and accurate staging is key to appropriate management. Revised BAD/BAPS (British Association of Dermatologists/British association of Plastic Surgeons) 2010 guidelines for the management of cutaneous melanoma recommend that Computed Tomography (CT) is no longer indicated for AJCC (American Joint Cancer Committee) IIB and IIC disease (Breslow thickness 2.01 – 4 mm with ulceration or >4 mm), unless the patient is symptomatic. Previous UK guidelines had recommended that all patients with AJCC IIB or worse disease should have chest, abdomen and pelvic CT as staging investigations. New guidelines also now include head CT in their recommendations. Our aim was to investigate regional CT findings in those patients diagnosed with AJCC IIB and IIC disease, and establish whether our findings affirmed new UK guidelines.Methods and patient group: A retrospective review of case notes was performed on 172 cases of AJCC IIB and IIC disease referred across Lothian, Borders and Fife to melanoma services during the period of January 2004 to January 2010. Clinical findings, results of initial and follow-up CT scans along with changes in patient management were noted. Chest, abdomen and pelvic CT scan were defined as one scan as they were always performed together. CT head and CT neck were defined as separate scans. A positive CT result was defined as those reported with metastasis or an indeterminate result leading to further investigations. Change in management was defined as specific active treatment started or stopped eg surgery or chemo/radiotherapy.Results: A total of 269 scans were performed on 130/172 patients. One hundred and four initial staging CT scans were performed on 75 patients, and detected one (1.3%) occult melanoma metastasis. At follow-up, 165 scans were performed in 82 patients and detected 56 metastasis in 32(39%) patients leading to a change in management in 29(35%). Two of these 32 patients had occult melanoma metastasis. Symptomatic patients had statistically significant more metastatic disease diagnosed at follow-up CT scanning than asymptomatic patients p < 0.0001. Head CT detected 15/56 (27%) of all metastasis.Conclusion: CT scanning should only be performed in AJCC IIB and IIC melanoma patients if symptoms of clinical metastatic disease are present. Head CT should be included in the staging process. Our regional results concur with new BAD/BAPS 2010 guidelines.

Geometrical analysis of the V–Y advancement flap applied to a keystone flap - Corrected Proof

J. Pauchot, J. Chambert, D. Remache, A. Elkhyat, E. Jacquet — 2012-04-18

Summary: Background: The V–Y advancement flap and, more recently, the keystone flap are commonly used to cover skin defects. Both flaps allow for primary closure after advancement by substituting the initial defect for a narrower defect distributed over a greater length.The first objective of this study was to develop a geometrical analysis of the V–Y advancement flap. The second objective was to explain the benefit of using the keystone flap compared to a single V–Y advancement flap.Material and method: A geometrical analysis is proposed using a two-dimensional analysis in which the flaps are assumed to have a rigid-body behaviour. First, in the case of the V–Y advancement flap, a trigonometric relationship is defined between the distance of closure before and after advancement, thus implying the value of the flap's apex angle. Second, by considering the keystone flap as the association of three V–Y advancement flaps, the trigonometric relationship is applied to the keystone flap.Results: In the case of the V–Y advancement flap, the optimal apex angles are between 20° and 60°. At less than 20°, the length of the flap increases in an exaggerated manner. At greater than 60°, the distance of closure, particularly at the apex of the flap where a corner stitch is performed, is greater than the distance of closure of the initial defect. In the case of the keystone flap, the width of the final defect around the flap is clearly smaller and more regular compared to the final defect around a single V–Y advancement flap.Conclusion: The geometrical analysis of the V–Y advancement flap in our description illustrates the major benefit of the keystone flap over a single V–Y advancement flap.

Effects of hyperbaric oxygen therapy on rapid tissue expansion in rabbits - Corrected Proof

Zhaoyu Ju, Jianhua Wei, Hao Guan, Junrui Zhang, Yanpu Liu, Xinghua Feng — 2012-04-18

Summary: Background: Tissue expansion has been widely used to provide additional soft tissue for clinical reconstruction. Rapid expansion requires a much shorter clinical period than conventional expansion; however, less natural skin growth occurs resulting in a larger stretch-back ratio and insufficient extra soft tissue for clinical use. In this study, hyperbaric oxygen therapy (HBOT) was used in the inflation phase of rapid expansion to increase natural skin growth.Methods: Twelve rabbits were divided into two groups. Each group received rapid expander inflation every day. One group received HBOT and the other did not. Blood flow in the expanded skin of each rabbit was assayed in the 10-day inflation phase. After the inflation phase, a rectangular expanded flap of each rabbit was harvested. The instant stretch-back ratio, tension, weight and histological characteristics of the flaps were evaluated.Results: (1) After the second inflation day, the mean blood flow of the HBOT group became significantly higher than that of the control with each day (P < 0.05). At the last day, the blood flow of the HBOT group increased to 131 ± 17 pu, while the control group decreased to 35 ± 5 pu. (2) The mean instant stretch-back ratio of the HBOT group under no-tension conditions was 29 ± 4%, which was significantly less than that of the control group, 46 ± 3% (P < 0.01). (3) The mean flap tension of the HBOT group was 15.3000 ± 1.47648 g and 12.9833 ± 0.73598 g in the transverse and longitudinal axis, respectively, both significantly smaller than that of the control group (33.9167 ± 4.78390 g and 26.5000 ± 2.45031 g, respectively) (P < 0.01). (4) Mean per unit flap weight of the HBOT group was 0.221 ± 0.005 g cm–2, significantly heavier (P < 0.01) than that of the control group (0.143 ± 0.010 g cm–2). (5) Histologically, the epidermal layer and thickness of the expanded skin of the HBOT group were much thicker than those of the control group, and more vessels were visible in the subcutaneous tissue.Conclusions: The use of HBOT in the inflation phase of rapid expansion can effectively promote blood flow in the expanded skin, increase its natural skin growth and reduce the instant stretch-back ratio and tension of expanded skin.

Is the term “obstetrical brachial plexus palsy” obsolete? An international survey to assess consensus among peripheral nerve surgeons - Corrected Proof

Peter D. Phua, Hanny T. Al-Samkari, Gregory H. Borschel — 2012-04-18

Summary: Background: Brachial plexus injury diagnosed following delivery often causes lifelong disability and frequently results in litigation. While there is no universally accepted name for this condition, the term ‘obstetrical brachial plexus palsy’ (OBPP) is commonly used worldwide. The difficulty with the term ‘OBPP’ lies with the use of the word ‘obstetrical’, which some have construed to imply obstetrical malpractice even if none occurred. Many regions, especially in the United States, are suffering increasing obstetrician shortages, sometimes as a result of unsustainable liability insurance premiums. We wanted to determine whether surgeons felt that an alternative to the term ‘OBPP’ was more appropriate.Methods: We surveyed peripheral nerve surgeons worldwide to determine the appropriateness of the term ‘OBPP’ and alternative terms.Results: The majority of US-based surgeons (94%) preferred alternative terms, such as ‘neonatal brachial plexus palsy’. However, only 53% of surgeons from other regions preferred alternative terms. This difference was statistically significant (p < 0.0002).Conclusions: More precise and descriptive alternatives to the term ‘OBPP’ are available and acceptable to many surgeons. An alternative to ‘OBPP’ may improve communication between practitioners, families and the legal system, especially in the United States. Our peripheral nerve organisations may be able to provide further leadership on this matter.

A new device expanding operability of fingertip replantation: Subzone 1 fingertip replantation assisted by non-enhanced angiography in a 2-year-old boy - Corrected Proof

2012-04-18

Summary: Fingertip replantation in young children is difficult, especially in cases with amputation at subzone 1. Replantation is preferred whenever possible, but the identification of vessels of operative size can be very challenging. Non-enhanced angiography (NEA; Genial Viewer; Genial Light, Shizuoka, Japan) emits infrared light with the wavelength of 850 nm, which is exclusively absorbed by haemoglobin. The light penetrates the bones and other soft tissues, effectively visualising vessels containing blood, and the image is shown in real time on the screen of a laptop computer. We present a case in which preoperative NEA visualised vessels in the amputated fingertip, allowing a successful replantation in a 2-year-old boy. By taking the guesswork out of vessel localisation, NEA can be useful in expanding operability of replantation surgery in fingertip amputations.

Dual perforator propeller internal mammary artery perforator (IMAP) flap for soft-tissue defect of the contralateral clavicular area - Corrected Proof

Eva Meia Rüegg, Laurent Lantieri, Alexandre Marchac — 2012-04-16

Summary: The internal mammary artery perforator (IMAP) flap represents the evolution from axially pedicled flaps (deltopectoral flap) to perforator flaps. Both flaps are typically used for neck and tracheostoma reconstruction in male patients. We present the case of a 68-year-old obese female patient with a right upper thoracic radionecrosis secondary to breast irradiation. Soft-tissue defect measured 12×18cm. She also complained of left breast hypertrophy. Following radical debridement, a left IMAP flap extending from midline to the anterior axillary fold was raised, based on the second and fourth IMAP vessels. The flap was rotated 180° on its second and fourth perforators to cover the defect and the left breast was reshaped. The flap survived entirely and wound healing was uneventful. Ptosis and breast hypertrophy were corrected at the same time. The IMAP flap can be harvested all the way to the anterior axillary fold and used as a large propeller flap, which makes this flap suitable for contralateral thoracic reconstructions, even in female patients.

Perforator anatomy of the ulnar forearm fasciocutaneous flap - Corrected Proof

Jon A. Mathy, Zachary Moaveni, Swee T. Tan — 2012-04-16

Summary: The ulnar forearm fasciocutaneous flap (UFFF) is a favourable alternative to the radial forearm flap when thin and pliable tissue is required. The precise anatomy of the cutaneous perforators of UFFF has not been previously reported.The position of cutaneous perforators >0.5 mm was recorded while raising 52 consecutive free UFFFs in 51 patients at our Centre.Three (6%) UFFFs in two patients demonstrated direct cutaneous supply through a superficial ulnar artery, a known anatomic variance. There was no cutaneous perforator >0.5 mm in one flap. Among the remaining 48 dissections, an average of 3 (range, 1–6) cutaneous perforators were identified. Ninety-four percent of these forearms demonstrated at least one perforator >0.5 mm within 3 cm, and all had at least one perforator within 6 cm of the midpoint of the forearm. Proximal perforators were more likely to be musculo-cutaneous through the edge of flexor carpi ulnaris or flexor digitorum superficialis, while mid- to distal perforators were septo-cutaneous.UFFF skin paddle designed to overlie an area within 3 cm of the midpoint between the medial epicondyle and the pisiform is most likely to include at least one cutaneous perforator from the ulnar artery, without a need for intra-operative skin island adjustment. This novel anatomic finding and other practical generalisations are discussed to facilitate successful elevation of UFFF.

Convenient coverage of soft-tissue defects around the knee by the pedicled vastus medialis perforator flap - Corrected Proof

He-Ping Zheng, Jian Lin, Yue-Hong Zhuang, Fa-Hui Zhang — 2012-04-16

Summary: Various reconstructive methods have been reported for coverage of soft-tissue defects around the knee; however, there is still no report about the pedicled vastus medialis perforator flap; hence, this article aims to elaborate on this approach for resurfacing of defects around the knee. From January 2010 to December 2010, six patients with defect size ranging from 5.0 × 3.3 to 10.5 × 7.0 cm received soft-tissue coverage with the pedicled vastus medialis perforator flap. Among them, five cases were male, and the other female. The age of patients ranged from 20 to 52 years, with an average of 34.5 years. The injury of one patient was caused by being crushed by a heavy metal object, and the rest sustained injuries in traffic accidents. The defect in one case was located at the inferomedial aspect of the thigh, and the rest around the knee. Five flaps survived completely, while one case suffered marginal necrosis due to infection. The donor sites healed without complication. Postoperative follow-ups of the patients ranged from 1 to 18 months. Through the article, we demonstrate the feasibility of using the pedicled vastus medialis perforator flap for reconstruction of knee injuries, which makes the knowledge of the vastus medialis-related flap series more complete and also enriches the methods of repairing defects around the knee.

Extradural myelomeningocele reconstruction using local turnover fascial flaps and midline linear skin closure - Corrected Proof

2012-04-16

Summary: Myelomeningocele is the most common neural tube defect. Repair typically involves deep closure with regional muscle flaps (e.g. latissimus dorsi, gluteus maximus) and skin closure with rotation, bipedicle, or rhomboid flaps. We describe the reconstruction of large myelomeningocele defects using (1) local fascial turnover flaps with or without paraspinous muscle flaps for deep coverage of the dural repair followed by (2) linear, midline skin closure.

Correction of breast contour deformities using polyurethane breast implant capsule in revisional breast surgery - Corrected Proof

Bassem M. Mossaad, James D. Frame — 2012-04-16

Summary: Surgeons are commonly confronted with breast contour deformities and defects that result from previous surgical interventions. These soft tissue deformities can be corrected by conventional reconstructive flap surgery using autologous tissue, but there can be donor site morbidity. Smaller volume replacement is possible using temporary fillers such as hyaluronic acid or polylactic acid, or by using ‘permanent’ fillers such as autologous fat, but large defects are notoriously difficult to fill and often the fillers resorb or migrate.The patient described in this case report had an exchange of polyurethane implant (PU) in the left breast and correction of a contralateral breast contour filling deformity. A left breast partial capsulectomy was performed after implant removal and the capsule graft was inserted into a predissected pocket where soft tissue augmentation was required. A biopsy from the PU capsule was reported to show a foreign body type giant cell reaction to PU material in a fibrous capsule, lined by synovial metaplasia. The post-operative result showed satisfactory soft tissue revolumisation.PU breast implant structured capsule has thus been used as filler to correct breast soft tissue deformity and contour defects. Clearly it may have a use in other anatomical sites.

Challenges in obtaining aesthetic breast ideals: Reply to: Concepts in aesthetic breast dimensions: Analysis of the ideal breast. J Plast Reconstr Aesthet Surg 2012 Jan; 65(1):8–16. - Corrected Proof

Marc-James Hallam, Charles Nduka — 2012-04-16

We read with interest this paper defining the ideal breast dimensions as a 45:55 ratio of upper to lower pole proportions. Whilst we commend the authors for attempting to tackle such a difficult problem we are however unsure if the proposed methodology is suitable or sound.

Partially irreversible paresis of the deep peroneal nerve caused by osteocartilaginous exostosis of the fibula without affecting the tibialis anterior muscle - Corrected Proof

Felix Julian Paprottka, Hans-Günther Machens, Jörn Andreas Lohmeyer — 2012-04-12

Summary: Dysfunction of the lower limb's muscles can cause severe impairment and immobilisation of the patient. As one of the leg's major motor and sensory nerves, the deep peroneal nerve (synonym: deep fibular nerve) plays a very important role in muscle innervation in the lower extremities. We report the case of a 19-year-old female patient, who suffered from a brace-like exostosis 6-cm underneath her left fibular head causing a partially irreversible paresis of her deep peroneal nerve. This nerve damage resulted in complete atrophy of her extensor digitorum longus and extensor hallucis longus muscle, and in painful sensory disturbance at her left shin and first web space. The tibialis anterior muscle stayed intact because its motor branch left the deep peroneal nerve proximal to the nerve lesion. Diagnosis was first verified 6 years after the onset of symptoms by a magnetic resonance imaging (MRI) scan of her complete left lower leg. Subsequently, the patient was operated on in our clinic, where a neurolysis was performed and the 4-cm-long osteocartilaginous exostosis was removed. Paralysis was already irreversible but sensibility returned completely after neurolysis. The presented case shows that an osteocartilaginous exostosis can be the cause for partial deep peroneal nerve paresis. If this disorder is diagnosed at an early stage, nerve damage is reversible. Typical for an exostosis is its first appearance during the juvenile growth phase.

Lateral facial contouring via a single preauricular incision - Corrected Proof

2012-04-11

Summary: Many Asians have faces with prominent zygomas, and therefore reduction malarplasty is one of the most frequently undergone surgeries in Asia, including South Korea. It is performed using various surgical approaches (external, intraoral, bicoronal or their combination). The reduction technique that is the most effective, safest and with the lowest morbidity needs to be determined. From December 2005 to January 2010, 1652 patients who wanted to undergo zygoma reduction for purely aesthetic reasons were operated on using a novel technique that we have developed (the 3S technique), which is a simple and safe surgical technique that results in only a short scar. First, under local anaesthesia, a 13- to 15-mm-long skin incision is made at each sideburn. The subperiosteal dissection is continued anteriorly all the way to the body of the zygoma. Zygoma reduction is then performed in three steps: (1) malar shaving (lateral area of the zygoma body), (2) lateral corticotomy (zygomatic arch) and (3) full-thickness osteotomy (pretubercular area of the temporomandibular joint). Next, the zygomatic arch is displaced medially with digital pressure (infracture). Finally, a Silastic drain is inserted through the incision site, skin repair is completed and a gentle compressive dressing is applied. Most of the patients were satisfied with the results of the operation. This technique provides the following advantages: (1) it is simple and safe because it is performed under only local anaesthesia; (2) only one scar is created at the sideburn; (3) no foreign bodies, such as wires or miniplates, are used; and (4) it is minimally invasive, and as such there are fewer potential complications (e.g., no cheek drooping due to a wide muscle incision or dissection, less oedema and bleeding and a short hospitalisation time). The presented technique is simpler and more effective than previously described surgical techniques for reduction malarplasty.

A modified method of labia minora reduction: The de-epithelialised reduction of the central and posterior labia minora - Corrected Proof

Y.J. Cao, F.Y. Li, S.K. Li, C.D. Zhou, J.T. Hu, J. Ding, L.H. Xie, Q. Li — 2012-04-09

Summary: Objective: The aim of this study was to introduce a new method of labiaplasty. Here we describe the surgical procedure, outcomes and the advantages and disadvantages of this method.Method: The medical records of 167 patients aged between 20 and 43 years who underwent reduction of the labia minora from May 2006 to March 2011 were reviewed. The procedures performed in these studies used de-epithelialised reduction of the middle and posterior sections of the labia minora.Results: All the surgeries were performed successfully, and 164 patients experienced an uneventful postoperative period. A minor dehiscence occurred in one patient, who recovered with no requirement for additional treatment. Another two women felt that the reduction was not fully achieved. All of the patients were satisfied with the eventual aesthetic appearance.Conclusions: The de-epithelialised reduction of the middle and posterior portion of the labia minora is a simple and safe method that is associated with satisfactory outcomes.

Therapeutic strategies in post-facial paralysis synkinesis in pediatric patients - Corrected Proof

Julia K. Terzis, Dimitrios Karypidis — 2012-04-09

Summary: Synkinetic movements comprise abnormal involuntary contractions of one or more facial muscle groups which follow the desired contraction of another facial muscle group. They are frequently encountered in patients with long standing facial paralysis and seriously affect their psychological status due to the impairment of their facial appearance, function and emotional expressivity.Patients and methods: Eleven pediatric patients (2 male and 9 female) presenting with post-facial paralysis synkinesis were included in the study. Mean age was 10.3 ± 4 years and mean denervation time 72.5 months.Results: Patients underwent the following types of treatment:- Cross facial nerve grafting (CFNG) and secondary microcoaptations with botulinum toxin injection which had an improvement of 100% (3 in the 3 grade synkinesis scale) (n = 2).- Cross facial nerve grafting (CFNG) and secondary microcoaptations without botulinum toxin injection which had an improvement of 66%(2 in the 3 grade synkinesis scale) (n = 5).- CFNG and direct muscle neurotization with (n = 2) or without (n = 1) botulinum toxin injection where the improvement was 33%.- Contralateral nasalis muscle myectomy was performed in one patient along with CFNG and secondary microcoaptations which resulted in 66% synkinesis improvement. Biofeedback was invariably undertaken by all patients. Postoperative improvement in eye closure and smile was also noted in the respective cases treated for synkinesis ranging from 25 to 50%, with all patients achieving optimum functional return.Conclusion: CFNG with secondary microcoaptations and botulinum toxin injections was found to be a very efficient surgical modality addressing post-facial palsy synkinesis with high improvement in facial function and symmetry. Facial neuromuscular re-education contributes considerably in the treatment.

Second free flaps in head and neck reconstruction - Corrected Proof

2012-04-09

Summary: Introduction: Ablative surgery for head and neck cancer often results in defects that require free flap reconstruction. Improved survival after refined oncologic and adjuvant techniques has led to an increase in the number of patients undergoing a second free flap reconstruction. The objective of this study was to assess outcomes following a second free flap in head and neck reconstruction.Materials and methods: Following ablative defects in the head and neck, 1475 patients underwent reconstructive surgery over a period of 17 years. A second free flap for reconstruction was performed on 123 of these patients. In Group 1, 93 patients had a reconstruction for either tumour recurrence, second primary tumour or reconstructive complications (fractured plate, osteoradionecrosis, orocutaneous fistula). In Group 2, 30 patients had a second free flap following primary free flap reconstructive failure.Results: Flap success for Group 1 patients was 86/90 (96%) compared to group 2 patients, 22/30 (73%) (p 0.05).Conclusion: A second free flap may be required for reconstruction of head and neck defects following complications of the initial reconstruction, presence of a second primary or tumour recurrence. Success rates for second free flap reconstructions were significantly lower in those patients with initial free flap failure.