Utilisation of contrast-enhanced magnetic resonance angiography in the assessment of deep inferior epigastric artery perforator flap for breast reconstruction surgery.

AIM: To identify and characterise the ideal-sized (defined as at least 2.7 mm based on the experience of plastic surgeons at Hull Royal Infirmary) perforators using magnetic resonance angiography (MRA). The study also evaluated a presumption that perforators on the left are generally larger than on the right. MATERIALS AND METHODS: Fifty consecutive patients who had undergone MRA prior to deep inferior epigastric perforator (DIEP) reconstruction were included. MRA acquisition sequences, MRA images, radiologist reports, and surgical entry database were reviewed retrospectively. Intraoperative findings were compared. The diameter and characteristics of the perforators fulfilling the criteria of being "ideal-sized", at least 2.7 mm were collected. Wilcoxon's test was used to compare the size of the left and right perforators. RESULTS: Ninety-three ideal-sized perforators were identified (diameter of 2.8-4.2 mm). Fifty-one of these were located on the left, and 42 on the right. The left perforators were indeed larger than the right (Wilcoxon's test, p=0.017). Most of the perforators were found in the superior region and medial rows. Additionally, lateral row perforators were observed to have a shorter intramuscular course. CONCLUSION: Contrast-enhanced MRA is a useful preoperative imaging technique to locate ideal DIEPs for breast reconstruction. Perforators on the left were found to be larger than the right, and more ideal-sized perforators were located on the left.

Painful, palpable and pathological: anomalous flexor digitorum superficialis brevis in the palm, comparative anatomical context, and an updated classification of anomalies of the flexor digitorum superficialis.

Anomalies of the flexor digitorum superficialis are rare and can present a diagnostic dilemma. Patients present with a painful or palpable mass, or symptoms of carpal tunnel syndrome. This review article summarizes previously reported anomalies of the flexor digitorum superficialis, reports a further case, and proposes a new classification.

Pregnancy in the early stages following DIEP flap breast reconstruction--a review and case report.

We report a case of a 30-year-old lady who became pregnant 3 months after undergoing a DIEP breast reconstruction. There are reports of pregnancy following TRAM, DIEP flap breast reconstruction and abdominoplasty performed after breast reconstruction, however this is the only case in the literature of a pregnancy within 3 months of DIEP breast reconstruction. The literature on breast reconstruction and pregnancy is reviewed.

The "open book" flap: a heterodigital cross-finger skin flap and adipofascial flap for coverage of a circumferential soft tissue defect of a digit.

A case of circumferential digital skin loss with exposed tendons from the proximal phalanx to the distal interphalangeal joint is presented. This was treated with a two-layer heterodigital cross-finger ("open book") flap from the adjacent digit, utilising a skin-only cross-finger flap to cover the palmar defect and an adipofascial flap to cover the dorsal defect.

Management of bilateral Achilles tendon rupture associated with ciprofloxacin: a review and case presentation.

Fluoroquinolone antibiotics are increasingly being recognized as a cause of Achilles tendinitis and rupture. We report the case of a 62-year old man who developed bilateral Achilles tendon rupture six days following commencement of ciprofloxacin. Tendon exploration and repair was accomplished with the use of a prosthetic substitute (Leeds-Keio ligament) but healing was complicated by left wound breakdown that was successfully repaired with a perforator-based fasciocutaneous flap. A review of the current literature on fluoroquinolone associated achilles ruptures and the various methods of tendon and soft tissue management of the primary or complicated injuries are discussed.

Cervical midline Z-plasty revision surgery for pseudoxanthoma elasticum.

A 30-year-old woman with known pseudoxanthoma elasticum was referred for surgical correction of extensive loose neck skin. She underwent a standard rhytidectomy, which produced minimal improvement. Revision surgery using a vertical elliptical skin excision, incorporating a Z-plasty was undertaken 3 months later and resulted in a satisfactory outcome.

Early breaking strength of repaired flexor tendon treated with 5-fluorouracil.

This study investigated the effect of a single intraoperative application of 5-fluorouracil, which may diminish peritendinous adhesion formation, on the tensile strength of repaired digital flexor tendons after 7, 14 and 21 days of healing. Twenty-seven deep flexor tendons from 14 rabbits were exposed to 5-fluorouracil (50 mg/ml) for 5 minutes immediately after repair whereas matched control tendons were exposed to normal saline. Tensile testing at 7, 14 and 21 days revealed no significant differences in the gap or ultimate strengths of the 5-fluorouracil treated and control tendons.

Modulation of the formation of adhesions during the healing of injured tendons.

The formation of restrictive adhesions around the musculotendinous unit after injury is one of the most vexing processes faced by the surgeon. In flexor tendons it has been shown that the synovial tissue is the source of aggressive fibroblasts which contribute to this process. Using a rabbit model, we have examined the effects of treating the synovial sheath with the antimetabolite 5-fluorouracil (5-FU) for five minutes. Inflammatory, proliferative and molecular markers were compared in the response of the treated and control tendons to injury. Compared with a control group we found that the proliferative and inflammatory responses were significantly reduced (p < 0.001) in the treated tendons. Not only was there a reduction in the cellular and cytokine response, but there also was a significant (p < 0.001) reduction in the level of activity of the known pro-scarring agent, transforming growth factor beta 1 (TGF-beta1). These pilot studies indicate that the formation of restrictive adhesions may be modulated using a simple single-touch technique in the hope of producing a better return of function.

Decrease in adhesion formation by a single application of 5-fluorouracil after flexor tendon injury.

Using an animal model, the effect of a single intraoperative application of 5-fluorouracil on digital flexor tendon adhesions was assessed. After a standard partial division of the tendon and immobilization with a stitch, the synovial sheath in 30 rabbit tendons was treated with 5-fluorouracil solution (50 mg/ml)-soaked sponge pledgets for 5 minutes. Buffered saline was substituted for 5-fluorouracil in 30 control tendons. The tendons were harvested 1 week postoperatively, and histologic sections were assessed with a light microscope. There was a significant reduction in synovial sheath thickening (p < 0.001), cell counts (p < 0.001) and proportional length of adhesions (p < 0.001) in the treated tendons. The reduction in synovial reaction and adhesion formation using this "one touch" technique presents a novel strategy for the management of the clinical problem of postoperative adhesions complicating tendon injury and repair.