The variation in breast density and its relationship to delayed wound healing: a prospective study of 40 reduction mammoplasties.

The proportions of glandular and adipose tissue within the breast vary. This study records the variation in density of breast tissue excised at 40 consecutive bilateral breast reductions. Age, body mass index (BMI), breast size and wound healing problems were related to breast density. The removed breast tissue was weighed and volume determined by water displacement. Delayed wound healing was defined as any breast unhealed after 2 weeks. The density of excised tissue varied between 0.8 and 1.2g/cm(3). There was no correlation between age or BMI and breast density. Delayed wound healing occurred in 32% of patients. There was no correlation between delayed wound healing and breast density. However, there was a direct relationship between increasing BMI and delayed wound healing. In this study, breast density varied by up to 50%. The density of breast tissue cannot be predicted by age, BMI or breast size. There is no relationship between delayed wound healing and breast density.

Long term study into surgical re-exploration of the 'free flap in difficulty'.

BACKGROUND: Free tissue transfers must survive in order to achieve their surgical goals. There is little consensus about managing the 'failing' free flap, and practice is often guided by anecdote. MATERIAL AND METHODS: We have prospectively collected data about all free flaps performed within our department between 1985 and 2008 (2569 flaps). We identified 327 flaps which were re-explored a total of 369 times. We analysed these flaps with regard to indication for re-exploration, operative findings and outcome. RESULTS: Thirteen percent (327) of free flaps were re-explored. Of these, 291 (83%) had a successful outcome. Successful re-explorations took place at a mean 19h post-op and unsuccessful re-explorations at a mean 56h post-op. Clinical diagnosis prior to re-exploration was confirmed operatively in 91% of cases. CONCLUSION: We have considered the factors that allowed us to achieve the salvage rates described over a prolonged period, and identified two key areas. Firstly, we favour a model for free flap monitoring with clinical judgement at its core. Secondly, we feel the facility to recover patients post-operatively in a specialised, warmed environment, and return them to theatre quickly should the need arise, is essential. These two simple, yet institutionally determined factors are vital for maintaining excellent success rates.

The treatment of chronic osteomyelitis: a 10 year audit.

Despite modern surgical techniques and advanced antimicrobial therapy, osteomyelitis remains a difficult and challenging problem. A 10 year audit study from 1990 to 2000 was carried out to assess the outcome of treatment of chronic osteomyelitis. A total of 41 patients with chronic osteomyelitis (26 male, 15 female with an age range of 10-76 years, mean 45.3 years) underwent extirpation and reconstruction with muscle interposition. The duration of osteomyelitis ranged from 1 to 69 years (mean 16.6 years) and many patients had undergone multiple attempted procedures prior to definitive treatment. Thirty-seven patients underwent free microvascular muscle transfer and four patients underwent local transposition muscle flaps. Two of the 41 patients developed recurrent sepsis at 12 months (4.4% recurrence rate). These were treated successfully with elevation of the flap and curettage of the remaining infection and debris and re-insetting of the flap. Only one patient in the series required a below knee amputation and this was as a result of persistent intractable bone pain rather than recurrence of the osteomyelitis.

Drainage in breast reduction surgery: a prospective randomised intra-patient trail.

One hundred and fifty bilateral breast reductions were prospectively randomised intra-operatively to receive a unilateral wound drain. Seven patients required post-operative evacuation of haematoma, three on the drained and four on the undrained sides. There was no statistical difference in haematoma formation between drained and undrained sides (p = 1), or the incidence of wound healing or other complications. We believe that routine wound drainage in breast reduction surgery is an unnecessary intervention.

Pectoralis major "trapdoor" flap for silicone breast implant medial knuckle deformities.

Loss of breast parenchyma through surgery and physiologic involution can lead to problems of subglandular silicone breast implant palpability and even contour irregularities. This can give rise to patient concern and detracts from the aesthetics of the breast augmentation, particularly when it occurs medially. We present a simple solution to this problem on the medial side of the breast in the form of a small segmental medially based pectoralis major "trapdoor" flap that augments the implant soft-tissue cover intracapsularly, at the site where it is deficient. The technique, which has been used with success in five patients over 3 years, is described.

Successful free flap transfer and salvage in sickle cell trait.

The presence of sickle cell haemoglobin is generally regarded as a contraindication to free tissue transfer. We present the case of a 42-year-old male with sickle cell trait who had free transfer of a latissimus dorsi flap to cover a gunshot wound to his thigh. His initial haemoglobin S was 36%. Early flap failure from venous thrombosis was successfully salvaged by re-anastomosis to alternative vessels.

Fix and flap: the radical orthopaedic and plastic treatment of severe open fractures of the tibia.

We performed a retrospective review of the case notes of 84 consecutive patients who had suffered a severe (Gustilo IIIb or IIIc) open fracture of the tibia after blunt trauma between 1990 and 1998. All had been treated by a radical protocol which included early soft-tissue cover with a muscle flap by a combined orthopaedic and plastic surgery service. Our ideal management is a radical debridement of the wound outside the zone of injury, skeletal stabilisation and early soft-tissue cover with a vascularised muscle flap. All patients were followed clinically and radiologically to union or for one year. After exclusion of four patients (one unrelated death and three patients lost to follow-up), we reviewed 80 patients with 84 fractures. There were 67 men and 13 women with a mean age of 37 years (3 to 89). Five injuries were grade IIIc and 79 grade IIIb; 12 were site 41, 43 were site 42 and 29 were site 43. Debridement and stabilisation of the fracture were invariably performed immediately. In 33 cases the soft-tissue reconstruction was also completed in a single stage, while in a further 30 it was achieved within 72 hours. In the remaining 21 there was a delay beyond 72 hours, often for critical reasons unrelated to the limb injury. All grade-IIIc injuries underwent immediate vascular reconstruction, with an immediate cover by a flap in two. All were salvaged. There were four amputations, one early, one mid-term and two late, giving a final rate of limb salvage of 95%. Overall, nine pedicled and 75 free muscle flaps were used; the rate of flap failure was 3.5%. Stabilisation of the fracture was achieved with 19 external and 65 internal fixation devices (nails or plates). Three patients had significant segmental defects and required bone-transport procedures to achieve bony union. Of the rest, 51 fractures (66%) progressed to primary bony union while 26 (34%) required a bone-stimulating procedure to achieve this outcome. Overall, there was a rate of superficial infection of the skin graft of 6%, of deep infection at the site of the fracture of 9.5%, and of serious pin-track infection of 37% in the external fixator group. At final review all patients were walking freely on united fractures with no evidence of infection. The treatment of these very severe injuries by an aggressive combined orthopaedic and plastic surgical approach provides good results; immediate internal fixation and healthy soft-tissue cover with a muscle flap is safe. Indeed, delay in cover (>72 hours) was associated with most of the problems. External fixation was associated with practical difficulties for the plastic surgeons, a number of chronic pin-track infections and our only cases of malunion. We prefer to use internal fixation. We recommend primary referral to a specialist centre whenever possible. If local factors prevent this we suggest that after discussion with the relevant centre, initial debridement and bridging external fixation, followed by transfer, is the safest procedure.

Feminizing genitoplasty for congenital adrenal hyperplasia: what happens at puberty?

PURPOSE: We document the postpubertal outcome of feminizing genitoplasty. MATERIALS AND METHODS: A total of 14 girls, mean age 13.1 years, with congenital adrenal hyperplasia were assessed under anesthesia by a pediatric urologist, plastic/reconstructive surgeon and gynecologist. Of these patients 13 had previously undergone feminizing genitoplasty in early childhood at 4 different specialist centers in the United Kingdom. RESULTS: The outcome of clitoral surgery was unsatisfactory (clitoral atrophy or prominent glans) in 6 girls, including 3 whose genitoplasty had been performed by 3 different specialist pediatric urologists. Additional vaginal surgery was necessary for normal comfortable intercourse in 13 patients. Fibrosis and scarring were most evident in those who had undergone aggressive attempts at vaginal reconstruction in infancy. CONCLUSIONS: These disappointing results, even in the hands of specialists, highlight the importance of late followup and challenge the prevailing assumption that total correction can be achieved with a single stage operation in infancy. Although simple exteriorization of a low vagina can reasonably be combined with cosmetic correction of virilized external genitalia in infancy, we now believe that in some cases it may be best to defer definitive reconstruction of the intermediate or high vagina until after puberty. The psychological issues surrounding sexuality in these patients are inadequately researched and poorly understood.

Internal mammary vessels as recipients for free TRAM breast reconstruction: aesthetic and functional considerations.

The utilisation of the internal mammary vessels (IMVs) as recipient vessels for free TRAM reconstruction of the breast is well established. To gain adequate access to the IMVs, a medial segment of the ipsilateral third costal cartilage is usually excised. Concern has been expressed regarding potential complications specific to use of this site, including pneumothorax, intercostal neuralgia, chest wall herniae and contour defects. We present a retrospective study of our experience with free TRAM breast reconstruction, using the IMVs as recipient vessels, to ascertain the incidence of such complications. Twenty-five consecutive cases were studied. The clinical notes were analysed for information regarding immediate and late complications. All the patients were recalled and underwent assessment and examination by the authors. There were no cases of haemo- or pneumothorax on the side of the reconstruction. There were no complaints of chest pain suggestive of intercostal neuralgia. No discernible contour defects at the site of rib excision were found and no thoracic herniae were demonstrated. We suggest that internal mammary vessels can safely be used as recipients for free TRAM reconstruction of the breasts with no added aesthetic or functional morbidity.

Sarcoid involvement of the supraorbital nerve: MR and histologic findings.

We report the MR and histologic findings of neurosarcoidosis presenting as a mass involving the supraorbital nerve in a 29-year-old woman in whom this was the first manifestation of the disease. The features and associations of neurosarcoidosis and the response to treatment are discussed.

Microvascular free-tissue transfers in elderly patients: the leeds experience.

Free-tissue transfer in the elderly has received increasing attention in the literature. Existing reports are limited by small samples or inadequate definition of the term elderly. This study reviewed 5 years' experience with free-tissue transfer in a geriatric population (mean age 75 years, range 70 to 83 years). Forty-nine free flaps were performed in 42 patients between 1986 and 1991. This review focuses on the 39 flaps undertaken in 33 head and neck cancer patients, the main indication being reconstruction after tumor resection (80 percent). In the head and neck cancer group, donor sites included the radial forearm (20), rectus abdominis (6), jejunum (5), and others (8). Thirty-four flaps (87 percent) were primarily successful. Reexploration was required in 10 patients (26 percent) for compromised flaps (5) and bleeding (5). Three of the compromised flaps were salvaged, giving an overall flap success rate of 95 percent. One patient (3 percent) died within 30 days of surgery. These results compare favorably with other published series in elderly patients, as well as with larger cohorts of younger subjects. Free flaps are safe in the elderly. Chronologic age alone should not be an exclusion criterion when selecting patients for free-tissue transfer.

Petrosectomies for invasive tumours: surgery and reconstruction.

Tumours involving the temporal bone have historically carried a bad prognosis. The only prospect of cure is radical en bloc resection. Temporal bone resection for malignancies is, however, such a formidable undertaking that many centres label such tumours as unresectable. Additionally, the enormity of the surgical defect poses a major reconstructive challenge. A review of 14 petrosectomies (in 12 males and 2 females) performed for extensively invasive neoplasms in and around the ear is presented. All underwent immediate reconstruction, the majority (12/14) with free tissue transfers. 9 of the 14 patients (64%) are still alive after a mean follow-up of 70 months (range 4-8 years). With the use of free tissue transfers, an aggressive approach with regard to the resection margins can safely be adopted in the full knowledge that the eventual size of the defect need not compromise tumour clearance. Additionally, free flaps provided a reliable dural seal. This approach of radical en bloc resection with free flap reconstruction has decreased the mortality (compared to the literature), while largely reducing the morbidity to that of unavoidable cranial nerve resection.

Prediction of outcomes in 150 patients having microvascular free tissue transfers to the head and neck.

Medical records of 150 patients who had undergone microvascular free tissue transfer to the head and neck (85% for malignancy) were retrospectively assessed to identify predictors of postoperative outcomes and complications. 5% of flaps failed and 20% required re-exploration. Surgical and medical problems occurred in 23% and 67% patients respectively; mortality was 4.7%. 132 records were analysed by logistic regression. Mortality and stroke were commoner in patients with previous myocardial infarction or steroid medication. Chest infection was commoner in men and with increasing age. Hypoxaemia was associated with bronchodilator therapy. Thromboembolism was commoner in patients on diuretics. Nutritional problems were more frequent in patients on opioids, with low weight or hypertension. Donor site infection was related to haemoglobin concentration, cerebrovascular disease, hypertension, opioid consumption or previous radiotherapy. Recipient site infection was associated with hypertension. Flap failure was related to nitrate or bronchodilator treatment. Re-exploration was associated with opioid or bronchodilator therapy. It was concluded that several factors predicted complications and death following microvascular surgery to the head and neck.

An audit of Björk flap tracheostomies in head and neck plastic surgery.

Patients undergoing head and neck surgery for malignancy especially resection of parts of the upper aerodigestive tracts need a secure airway intra- and postoperatively. A tracheostomy is an effective method of achieving this objective. In our unit the Björk flap technique1 has been the preferred type of tracheostomy. Ninety-five consecutive Björk flap tracheostomies performed by one surgeon preceding major head and neck resection for malignancy in patients aged 17-79 years (median = 61 years) were retrospectively evaluated. The technique was quick and provided a secure airway. The tracheostomy tubes were left in situ for a median of 5 days (range 1-17 days). After extubation subsequent stoma closure was uneventful, 60% healing within 1 week. No patient developed tracheal fistula, clinical tracheal stenosis or cosmetically unacceptable scarring. There was no tracheostomy-related mortality. It is concluded that the Björk flap tracheostomy technique can be safely used in head and neck cancer surgery in adults.

Multispiral three-dimensional computed tomography in the investigation of craniosynostosis: technique optimization.

21 infants with craniosynostosis were studied with a new three-dimensional (3D) computed tomography (CT) methodology. We describe technique optimization using multiple spiral data acquisitions with low dose (85 mAs) technique. One caudal volume of 3 mm slice thickness was obtained with a further two volumes of 1 mm slice thickness at the vertex. Image reconstruction of spiral raw data allowed overlapping 3 mm sections to be generated without the dose increase that would result from conventional axial CT scanning. We illustrate common technical artefacts of 3D CT and explain their cause and solution. A dramatic dose reduction to the lens was achieved with no loss in 3D image quality. Lens dose was 8.91 mSv compared with 24.6 mSv using the standard paediatric head technique.

Reinnervation and neovascularisation in prefabricated free muscle flaps.

In this study, immediate muscle reinnervation in flap prefabrication was investigated and compared with those flaps which were reinnervated after prefabrication. Using the flow-through wrap-around technique for neovascularisation, denervated external abdominal oblique random muscle flaps in Lewis rats were either immediately reinnervated by implantation of the epigastric nerve or reinnervated late after free transfer, following the prefabrication period of 15 days. Half of the flaps from each group were microsurgically transferred to isogeneic rats. Thirty days later, the flaps were harvested, and neovascularisation and reinnervation were studied with microangiography and immunohistochemistry using antibodies to protein gene peptide (PGP) 9.5, calcitonin gene-related peptide (CGRP), and von Willebrand factor (vWF). Microangiography and quantification of the vWF-stained vessels in the flaps confirmed increased neovascularisation over a longer time course. Reinnervation was found to have no influence over neovascularisation. Nerve sprouting was present 15 days after nerve implantation to the muscle and became widespread by 30 days. CGRP immunoreactivity, which is thought to have some role in trophic and regulatory processes, was observed only after 30 days of reinnervation. Regardless of the timing and extent of reinnervation, a considerable amount of muscle atrophy was observed in the flaps.