Prophylactic venous cannulation of the pedicled TRAM flap in breast reconstruction.

Since its inception nearly 30 years ago, the pedicled TRAM flap has remained a reliable technique of breast reconstruction. However, venous congestion of the flap in the early postoperative period is well recognised and may lead to partial or total flap loss. This study describes a simple technique routinely employed by the senior author over 15 years involving intraoperative cannulation of the deep inferior epigastric vein and externalisation into an ileostomy bag, in order to facilitate drainage and reduce the likelihood of venous congestion. In addition to its role in breast reconstruction, this technique may be a useful adjunct to any form of free or pedicled tissue transfer.

Dermal substitutes do well on dura: comparison of split skin grafting +/- artificial dermis for reconstruction of full-thickness calvarial defects.

Large, full-thickness calvarial defects present a series of significant reconstructive challenges involving a range of techniques, including local and free flaps. Occasionally these conventional methods may not be possible due to technical, or patient, factors. Artificial dermis is already widely used in burns surgery and is increasing in oncological reconstruction. We believe that artificial dermis coupled with split-thickness skin grafting provides an excellent option for closure of these defects when other techniques are not appropriate.

Correction of the severely inverted nipple: areola- based dermoglandular rhomboid advancement.

Inverted nipple is a relatively common aesthetic problem presenting to a plastic surgeon. Along with the functional problems; recurrent inflammation/infection and an inability to nurse, most patients seek intervention because of the abnormal appearance. Many different surgical techniques have been described, suggesting that no one technique is universally successful. Most techniques employ, either individually or in combination, methods to tighten the nipple base or the use of areolar dermal flaps to support the nipple. We propose two modifications to the dermal flap technique. Firstly, the rhomboid dermal flaps are designed solely on the areola, the bases directed peripherally, improving vasularity and allowing true medial advancement. Secondly, the lactiferous ducts and tethering fibrous bands are released in a conical fashion allowing closure with a vertical V-Y advancement. This gives better projection and support to the nipple proper with medial recruitment of glandular tissue closing the dead space created. This technique has been used successfully by the senior author in 20 patients over a 16 year period, with a high rate of preserved nipple evertion and patient satisfaction. The technique is simple, reliable and provides sustained results over long term follow-up for the correction of the more severely inverted nipple.

Treatment of hidradenitis suppurativa with intense pulsed light: a prospective study.

BACKGROUND: Hidradenitis suppurativa is a chronic skin condition characterized by recurrent inflammation and infection of skin in intertriginous areas containing apocrine glands. Intense pulsed light uses high-energy broad-spectrum light. Current applications include hair removal and the treatment of acne vulgaris, which has a pathogenesis similar to that of hidradenitis suppurativa. The authors conducted a study to determine whether intense pulsed light is an effective treatment for hidradenitis suppurativa. METHODS: Eighteen patients were randomized to treatment of one axilla, groin, or inframammary area with intense pulsed light two times per week for 4 weeks using a Harmony Laser. The contralateral side received no treatment and acted as a control. The response to treatment was assessed using a validated examination and clinical photographs, and by measuring patient satisfaction on a Likert scale. RESULTS: After treatment, there was a significant improvement in the mean examination score that was maintained at 12 months (p < 0.001, logistical regression analysis). The improvement was confirmed by independent assessment of clinical photographs (interrater reliability, 0.79; p < 0.001). Patients reported high levels of satisfaction with the treatment. There was no concurrent improvement on the untreated control side. CONCLUSIONS: This small study suggests that intense pulsed light may be an effective treatment for hidradenitis suppurativa. It could be added to treatments used for this condition, particularly for patients keen on avoiding surgery and those with groin and inframammary disease. Further studies are required to confirm the efficacy and mechanism of action of intense pulsed light in hidradenitis suppurativa.

Dermal substitutes do well on dura: comparison of split skin grafting+/-artificial dermis for reconstruction of full-thickness calvarial defects.

Large, full-thickness calvarial defects present a series of significant reconstructive challenges involving a range of techniques, including local and free flaps. Occasionally these conventional methods may not be possible due to technical, or patient, factors. Artificial dermis is already widely used in burns surgery and is increasing in oncological reconstruction. We believe that artificial dermis coupled with split-thickness skin grafting provides an excellent option for closure of these defects when other techniques are not appropriate.

A retrospective audit of Novagold 'hydrogel' breast implants.

Novagold breast implants were withdrawn from use in the UK in December 2000 due to concerns about the metabolic fate of the implant filler material, the hydrogels polyvinylpyrrolidine (PVP) and guar gum. A total of 250 women in the UK had these implants, 66 of which were performed in our unit. A total of 44% of cases needed further surgery for complications. Capsular contracture requiring surgical intervention occurred in 32%. Symptomatic ruptures occurred in 10.5%. Infection was recorded in 1.5%. From comparison with published data, the incidence of capsular contracture is comparable, but the occurrence of rupture is almost twice that of saline-filled implants. It is hypothesised that an osmotic gradient occurs due to the hydrogel filler causing the implants to swell and weaken the elastomer shell. When the PVP/guar gum filler is released into the subcutis, a vigorous tissue reaction occurs causing pain and swelling. These results show that this composition of implant poses potential risks, which should be considered by manufacturers in the future. We advise removal of symptomatic implants, as rupture is likely to have occurred.