The C-V flap for nipple reconstruction after previous skin-sparing mastectomy and immediate breast reconstruction: refinements of donor-site closure.

BACKGROUND: The C-V flap including its modifications is very popular flap used for nipple reconstruction. METHODS: This report describes a refinement of the C-V flap used in nipple reconstruction for patients who previously have undergone skin-sparing mastectomy and immediate breast reconstruction. Closure of the V flap donor sites is facilitated by means of designing two opposing advancement "areolar" skin flaps. RESULTS: Our modification ensures that no "dog ears" remain after the donor sites of the two V flaps are closed and that all scarring remains within the skin paddle of the neo-areola without any extensions on the mastectomy skin flaps. CONCLUSION: Our refinement of the closure for the donor site of the C-V flap used in nipple reconstruction produces an aesthetically pleasing result without unnecessary donor-site scar extensions on the mastectomy skin flaps.

A rare case of giant cutaneous horn.

Cutaneous horn, a clinical manifestation of hyper-proliferation of compact keratin, can represent a wide array of underlying benign and malignant pathologies. Here we report a unique case of a giant cutaneous horn (7x4x3 cm) that developed on a chronic ulcer in a non sun-exposed area. This case presented challenges in terms of diagnosis and treatment. We also review the literature about this rare condition.

Neurotrophin-3-enhanced nerve regeneration selectively improves recovery of muscle fibers expressing myosin heavy chains 2b.

The purpose of this study was to evaluate the effect of neurotrophin 3 (NT-3) enhanced nerve regeneration on the reinnervation of a target muscle. Muscle fibers can be classified according to their mechanical properties and myosin heavy chain (MHC) isoform composition. MHC1 containing slow-type and MHC2a or 2b fast-type fibers are normally distributed in a mosaic pattern, their phenotype dictated by motor innervation. After denervation, all fibers switch to fast-type MHC2b expression and also undergo atrophy resulting in loss of muscle mass. After regeneration, discrimination between fast and slow fibers returns, but the distribution and fiber size change according to the level of reinnervation. In this study, rat gastrocnemius muscles (ipsilateral and contralateral to the side of nerve injury) were collected up to 8 mo after nerve repair, with or without local delivery of NT-3. The phenotype changes of MHC1, 2a, and 2b were analyzed by immunohistochemistry, and fiber type proportion, diameter, and grouping were assessed by computerized image analysis. At 8 mo, the local delivery of NT-3 resulted in significant improvement in gastrocnemius muscle weight compared with controls (NT-3 group 47%, controls 39% weight of contralateral normal muscle; P < 0.05). NT-3 delivery resulted in a significant increase in the proportion (NT-3 43.3%, controls 35.7%; P < 0.05) and diameter (NT-3 87.8 micron, controls 70.8 micron; P < 0.05) of fast type 2b fibers after reinnervation. This effect was specific to type 2b fibers; no normalization was seen in other fiber types. This study indicates that NT-3-enhanced axonal regeneration has a beneficial effect on the motor target organ. Also, NT-3 may be specifically affecting a subset of motoneurons that determine type 2b muscle fiber phenotype. As NT-3 was topically applied to cut nerves, our data suggest a discriminating effect of the neurotrophin on neuro-muscular interaction. These results would imply that muscle fibers may be differentially responsive to other neurotrophic factors and indicate the potential clinical role of NT-3 in the prevention of muscle atrophy after nerve injury.

Algorithm for an aesthetically pleasing nipple-areola complex with the use of the C-V flap in cases of skin-sparing mastectomy and immediate reconstruction.

BACKGROUND: This article provides an algorithm for achieving an aesthetically pleasing nipple-areola complex in cases of skin-sparing mastectomy and immediate reconstruction METHODS: If the contralateral nipple was big enough and the nipple-sharing technique could be used in the future for reconstruction, we left a round skin paddle at the time of the skin-sparing mastectomy and immediate flap reconstruction. The diameter of the round skin paddle was approximately the same as the contralateral areola. For nipple reconstruction we placed the graft from the contralateral nipple in the middle of the aforementioned skin paddle. If the contralateral nipple was not sufficiently large for use as a donor, then the C-V flap was used for nipple reconstruction. In these cases we deliberately left an oval skin paddle when the skin-sparing mastectomy and immediate flap reconstruction were performed. The short diameter of the oval skin paddle was approximately the same as the diameter of the contralateral areola. The position and the height of the C-V flap were marked in order to transform the oval skin paddle to a round one when the donor site of the C-V flap was closed. RESULTS: Following this algorithm an optical illusion of a nipple-areola complex that is similar to the contralateral normal one is created. CONCLUSION: From our experience this algorithm can help create an aesthetically pleasing nipple-areola complex and also provides a ready pattern to our tattoing experts for the dermatography of the nipple-areola complex.

The role of antibiotic prophylaxis in clean incised hand injuries: a prospective randomized placebo controlled double blind trial.

A prospective, randomized, double blind, placebo controlled trial was designed to investigate the effect of prophylactic flucloxacillin on the infection rate in clean incised hand injuries, which included trauma to skin, tendon and nerve in adults. Using strict exclusion criteria, a total of 170 patients were recruited into one of three trial groups; Group A - intravenous flucloxacillin on induction followed by an oral placebo; Group B - intravenous flucloxacillin on induction followed by an oral flucloxacillin course or Group C - oral placebo. Thirteen of the patients were subsequently withdrawn, leaving 92% available to complete the trial. Infection was diagnosed using clinical criteria. The infection rates in the three groups were Group A - 13%, Group B - 4% and Group C - 15%. Strictly, the results demonstrate no statistically significant difference in the infection rates between the groups.

Skin replacement in Dupuytren's disease.

We have reviewed 90 rays in 67 patients who had undergone radical digital dermofasciectomy. Follow-up was from 24 to 100 months. Problems with skin grafts, moving two-point discrimination and active range of joint movement were noted. The recurrence rate in this series was 8%, a very much better figure for disease control than has been reported for standard approaches for Dupuytren's disease. Radical digital dermofasciectomy is strongly recommended for all cases of recurrent Dupuytren's disease requiring reoperation and as a primary procedure when there is significant skin involvement.

Circumcision: a refined technique and 5 year review.

The vast majority of circumcisions currently performed in the UK are for phimosis or balanitis and the patients are not looking for the denuded glans appearance of a ritual circumcision. We present a refinement of the sleeve technique of circumcision, which involves Horton's test to define the proximal incision margin, and bipolar electro-dissection. A review of all patients undergoing circumcision at the Wordsley Plastic Surgery Unit, in a 5-year period, has shown this technique to be safe with a haematoma rate of only 1.4%, and an overall complication rate of 3%.

An unusual case of galactorrhea in a postmenopausal woman complicating breast reduction.

Galactorrhea is a relatively common condition, but has rarely been seen following breast reduction surgery. To date there are only seven cases reported in the literature, all in premenopausal women. Postsurgical galactorrhea is a diagnosis of exclusion and differential diagnosis is extensive. Common causes should be excluded first. We present the case of a 56-year-old postmenopausal woman who underwent bilateral breast reduction and developed galactorrhea 2 months postoperatively. MRI scan of the skull as well as Thyroid-Stimulating Hormone (TSH), prolactin levels were normal. She was on long-term hormonal replacement therapy. Because of suspected nerve-related pain in her right breast she was commenced on amitriptyline. We hypothesise that galactorrhea may have been caused by underlying neuroma or irritation of the anterior branch of the T4 intercostal nerve or hormonal replacement therapy or a combination of both.

Mesh assisted direct closure of bilateral TRAM flap donor sites.

The pedicled transverse rectus abdominis myocutaneous (TRAM) flap remains a popular choice for patients requesting breast reconstruction. Criticism of all techniques that harvest the rectus abdominis muscle centre on abdominal wall weakness.[Dulin WA, Avila RA, Verheyden CN, Grossman L. Evaluation of abdominal wall strength after TRAM flap surgery. Plast Reconstr Surg 2004; 113: 1662-1665] Primary fascial closure of the donor site has been shown to reduce abdominal wall weakness and the subsequent risk of hernia and bulge. [Mizgala CL, Hartrampf CR Jr, Bennett GK. Abdominal function after pedicled TRAM flap surgery. Clin Plast Surg 1994; 21: 255-272]2 Primary fascial closure of all uni-lateral and most bilateral muscle preserving TRAM flap donor sites is possible. In a series of 23 bilateral TRAM flaps, excessive abdominal tension prevented direct fascial closure of the donor site in seven. Using a technique that includes muscle preservation, muscle relaxation and mesh assistance; tensionfree, direct fascial closure was achieved in all. The mesh buttress supports the rectus sheath during closure and provides long term shape and stability.

Ilioinguinal block dissection for malignant melanoma.

A retrospective analysis of 41 patients treated for metastatic inguinal lymph node malignant melanoma is presented: 16 underwent inguinal node excision and 25 ilioinguinal node excision. The two groups were well matched for age, sex and other characteristics. The mean time in hospital (inguinal 20 days, ilioinguinal 18 days) and the complication rates (inguinal, ten of 16 patients, ilioinguinal, 13 of 25) were similar in each group. The incidence of groin relapse, defined as the development of symptomatic melanoma in the region of the inguinal or iliac node basins following block dissection, was lower after ilioinguinal block dissection (inguinal, three patients; ilioinguinal, none). Histological examination demonstrated a high proportion of iliac node involvement (13 of 25 patients), even in those with a single mobile inguinal lymph node clinically and no clinical or computed tomographic evidence of iliac node involvement. This supports the value of ilioinguinal block dissection and suggests that the associated morbidity need not be greater than that associated with inguinal clearance alone.

A qualitative histological assessment of various storage conditions on short term preservation of human split skin grafts.

This paper provides a qualitative description of the histological appearances and changes occurring in human split skin grafts stored at 4 degrees C in various configurations over a 4-week period. During the storage time, changes were seen in all layers of the epidermis and dermis. The most notable early features were nuclear and cellular swelling and pleomorphism. After 7 days nuclear and cellular shrinkage, halo formation and pyknosis became evident. The most worrying histological feature was the development of dermo-epidermal blebs. These were evident by day 7 and progressed to cleavage of, and ultimately complete separation of, the epidermis from the dermis.A comparison of these features in human split skin grafts stored as sheets or meshed 1(1)(2):1, stored either rolled or flat, at either strictly or roughly 4 degrees C revealed differences. We conclude that the viability of stored skin is improved if it is stored at a uniform 4 degrees C as rolled sheets.

Intratendinous rupture of flexor digitorum profundus caused by non-specific synovitis.

Closed ruptures of flexor tendons in the hands of patients without rheumatoid arthritis are rare. We report a case of closed rupture of the flexor digitorum profundus of the middle finger in zone II, secondary to acute florid synovitis forming a tumour-like mass. No similar case has been reported to our knowledge. The management of this unexpected finding at surgical exploration is discussed.

Home inflation of tissue expanders: a safe and reliable alternative.

The concept of tissue expansion by the placement of inflatable subcutaneous silicone implants was popularised by Radovan in the late 1970s and is now widely used in clinical practice. After the initial placement of the expander, a series of outpatient visits is required during which the expander is serially inflated. These visits can be very stressful for the patient and are costly in terms of patient transport and clinic time. We present a series of 26 expanders (in eight patients) that were inflated at home by the patient or a relative, and compare the results with those from 30 expanders (in 15 patients) inflated in the outpatient department. The results show that whilst there was a slightly higher incidence of minor infections in the group inflated at home (42% versus 23%, P> 0.05), the overall success rate of the operation was greater in the home-inflation group (96% versus 90%, P> 0.05). However, these differences were not statistically significant. This study provides evidence to support the practice of inflation at home, which is safe, cost effective and less stressful for the patient.

Neurotrophin-3 delivered locally via fibronectin mats enhances peripheral nerve regeneration.

A better understanding of the mechanisms of nerve regeneration could improve the outcome of surgical nerve repair. We have previously shown that axonal regeneration is increased by nerve growth factor. Neurotrophin-3 (NT-3) belongs to the same family as nerve growth factor but acts on a distinct neuron subpopulation. As little is known about its role following nerve injury, we have investigated the effect of NT-3 delivered via fibronectin mats, previously shown to support nerve regeneration comparable to nerve grafts. NT-3 stimulation (0.1-1000 ng/ml) of neurite extension from embryonic chick dorsal root ganglia in vitro has shown that fibronectin can bind and release bioactive NT-3. Fibronectin mats impregnated with NT-3 (500 ng/ml) were grafted into 1 cm sciatic nerve defects in adult Lewis rats. Plain mats were used as controls. Computerized quantification of penetration distance, volume of axonal regeneration and myelinated fibre counts was undertaken using immunostaining for axonal markers (growth-associated protein 43, calcitonin gene-related peptide, substance P, vasoactive intestinal peptide and neuropeptide tyrosine), or S100 or thionine blue staining up to 8 months postoperatively. The maximal effect of NT-3 occurred at day 15, when for GAP43-immunostained axons both penetration distance (NT-3, 6.10 +/- 0.42 mm; control, 4.11 +/- 0.41 mm; P < 0.01) and staining area (NT-3, 0.137 +/- 0.012 mm2; control, 0.077 +/- 0.018 mm2; P < 0.05) were significantly increased. Similar results were found for each neuronal subpopulation investigated. By 8 months after repair, the NT-3 group supported a significantly greater number of myelinated axons (NT-3, 7003 +/- 402; control, 4932 +/- 725; P < 0.05) of similar diameter and g-ratio to controls. These results demonstrate the contribution of NT-3 to the increase of nerve regeneration promoted by growth factors.

NT-3 modulates NPY expression in primary sensory neurons following peripheral nerve injury.

Peripheral nerve transection induces significant changes in neuropeptide expression and content in injured primary sensory neurons, possibly due to loss of target derived neurotrophic support. This study shows that neurotrophin-3 (NT-3) delivery to the injured nerve influences neuropeptide Y (NPY) expression within dorsal root ganglia (DRG) neurons. NT-3 was delivered by grafting impregnated fibronectin (500 ng/ml; NT group) in the axotomised sciatic nerve. Animals grafted with plain fibronectin mats (FN) or nerve grafts (NG) were used as controls. L4 and L5 DRG from operated and contralateral sides were harvested between 5 and 240 d. Using immunohistochemistry and computerised image analysis the percentage, diameter and optical density of neurons expressing calcitonin gene-related peptide (CGRP), substance P (SP), vasoactive intestinal peptide (VIP) and NPY were quantified. Sciatic nerve axotomy resulted in significant reduction in expression of CGRP and SP, and significant upregulation of VIP and NPY (P < 0.05 for ipsilateral vs contralateral DRG). By d 30, exogenous NT-3 and nerve graft attenuated the upregulation of NPY (P < 0.05 for NT and NG vs FN). However, NT-3 administration did not influence the expression of CGRP, SP or VIP. The mean cell diameter of NPY immunoreactive neurons was significantly smaller in the NT-3 group (P < 0.05 for NT vs FN and NG) suggesting a differential influence of NT-3 on larger neurons. The optical densities of NPY immunoreactive neurons of equal size were the same in each group at any time point, indicating that the neurons responding to NT-3 downregulate NPY expression to levels not detectable by immunohistochemistry. These results demonstrate that targeted administration of NT-3 regulates the phenotype of a NPY-immunoreactive neuronal subpopulation in the dorsal root ganglia, a further evidence of the trophic role of neurotrophins on primary sensory neurons.

The submental island flap.

The submental island flap is a reliable source of skin of excellent colour, contour and texture match for facial resurfacing and leaves a well hidden donor site. The flap is safe, rapid and simple to raise. We report on its use in 12 cases of facial or intraoral reconstruction. Complications were few. However, there was one case of complete flap loss following its use in a reverse flow manner, due to the presence of an unreported, but constant, valve in the venous system of the face. We believe this flap to be a worthwhile addition to the existing surgical armamentarium.

The natural history of cold intolerance of the hand.

When cold intolerance occurs in the injured hand, it is persistent in the majority of cases (79 per cent). Statistically, there is a link between the development of cold intolerance and the incidence of early postoperative pain. Postoperative pain relief should be of high quality and may possibly prevent the onset of cold intolerance.