Iatrogenic instrumentation-induced plastic surgical referrals.

Iatrogenic instrument-induced injuries are presented. Most mistakes or accidents are preventable. Some are trivial and do not come to the patient's attention, while others can cause injury resulting in pain, disfigurement, prolonged hospitalization, and possibly even death. The major strides made in the field of surgery to today's level of sophistication are to a large extent the result of vast technological advancements that have been made. It behooves the user of this surgical equipment to follow the simplest precautionary rules of operation and to be completely au fait with the workings of the equipment. In this way, many injuries can be prevented. In many cases, the surgeon must bear the ultimate responsibility for injury.

Post-laser hypersensitivity and the atopic patient.

Laser resurfacing has become an extremely popular modality in the treatment of the aging face. Reported complications associated with carbon dioxide laser resurfacing are on the increase. One such complication involves the occurrence of significant hypersensitivity in laser and non-laser-treated areas, often occurring for weeks or months after the original treatment and necessitating topical or systemic steroid therapy. In an effort to identify patients at risk, those with significant hypersensitivity reactions were interviewed retrospectively. Questions regarding their background atopic characteristics were posed. Their responses to certain questions were then compared with those of a control group of 50 patients from the same pool who suffered no ill effects after laser therapy. A total of 151 patients were included in the study (pool). Of these, 14 patients (9.3 percent) suffered significant hypersensitivity. Detailed history in these patients revealed possible prior "allergic sensitivity" in 78.6 percent of patients. In contrast, only 30 percent of 50 nonsymptomatic laser-treated patients admitted to any positive allergic tendencies. It is likely that carbon dioxide laser resurfacing may trigger a sensitivity reaction in susceptible individuals.

Aesthetic perspectives regarding physically and mentally challenged patients.

Cosmetic surgery was undertaken on a limited number of physically or mentally challenged patients. Motivation for surgery seemed to mimic those of average cosmetic surgery patients, although the request for surgery was more difficult for some patients in view of their physical or mental challenges. Patient and surgeon satisfaction was extremely high. In each case, expectations were realistic. Physical or mental variations should not cloud the indications for cosmetic surgery; on the contrary, it may be a wonderful way for the plastic surgeon to contribute to bettering the life of those less fortunate.

In search of the ideal nose.

The proportions of the so-called ideal nasal shape and the operations designed to achieve this have been the subject of innumerable papers. The vast majority of patients in the authors' practices desire a more refined version of the nose and do not want the so-called nosejob look with ideal proportions. A total of 2930 cosmetic rhinoplasties performed over the past 20 years, based on the philosophy of refining the more unrefined features of the nose according to the patients' wishes, have been reviewed, and almost all of these patients were satisfied with the long-term shape of their nose, even though in many cases these noses would be considered less than ideal by some of the newer criteria.

Anatomical attachments to the proximal phalangeal base--a case for stability.

Transverse midshaft fractures of the proximal phalanx are often unstable and require open reduction and internal fixation. In contrast, fractures of the base of the proximal phalanx are occasionally amenable to conservative treatment in the form of manipulation and a graded mobilisation programme. This stability may be the result of splinting of the fracture by the surrounding anatomical structures, but to our knowledge this has not been previously elucidated anatomically. In this study we define the extent of attachment of the various anatomical structures to the base of the proximal phalanx. The contribution of the joint capsule, collateral ligaments, accessory collateral ligaments, interosseous muscles, and volar (palmar) plate may confer stability to fractures in the proximal 6-9 mm range at the base of the proximal phalanx, once they are reduced and immobilised in the correct positions.

Full-house/spaghetti wrist injuries. Analysis of results.

An analysis of the results of treatment of 19 'full-house' injuries is presented. In this series 'full-house' syndrome/spaghetti wrist injuries refers to those injuries involving ten or more structures severed at the volar wrist. Gratifying results in overall hand function were obtained in 18 patients. However, ulnar nerve intrinsic recovery and fine sensibility recovery was disappointing. Recommendations for improvement in the management of these injuries are made.

Wound modulation via sclerotherapy and tissue adhesion. Observations and discussion.

Fluid accumulation in a 'dead space' after surgery or trauma predisposes the area involved to delayed healing. The fluid may promote inflammatory mediators and other wound-modulating factors, which encourages the continued existence of the dead space. Tissue adhesion by means of agents such as tetracyclines has long been described. With this concept, tissue adhesion has been accomplished with varying success in diverse clinical situations involving non-healing wounds and prophylactically in seroma-prone areas. A total of 69 patients were treated and monitored. The most impressive response to tetracycline tissue adhesion in this study was seen in intra-oral sites, with rapid closure of wounds. More complex wounds such as orocutaneous fistulas or wounds of a more chronic nature such as pressure sores did respond but took longer to resolve. The lateral thigh was found to be the most difficult and unresponsive area to treat (particularly after delayed presentation). Successful prophylactic use of tetracycline in seroma-prone areas (latissimus dorsi/parascapular flaps, etc.) is also described.

Abdominoplasty following colostomy.

An abdominoplasty was performed on a 57-year-old woman, 5 years after she had undergone a permanent colostomy for ulcerative colitis. The abdominoplasty was performed in an attempt to reduce the increased abdominal girth thought to be responsible for excess leakage of effluent from the colostomy site with changes in posture and increased abdominal pressure. A simple abdominoplasty flap was designed to decrease the excess abdominal tissue without impinging on the colostomy site. The result was dramatic in accomplishing the set-out goals. An added bonus was a reversal of preoperative urinary incontinence. This outcome is thought to be a result of more efficient voiding after abdominal muscle plication and stabilization.

Shaving and dermabrasion of the facial lesions in tuberous sclerosis. A case report.

Tuberous sclerosis is a disease characterised by convulsive seizures, mental deficiency and angiofibromas. These angiofibromas are hamartomas consisting of hyperplastic connective and vascular tissue. A case is reported where multiple angiofibromas of the face resulted in significant disfigurement. The lesions were treated by shaving and dermabrasion; the short-term result was very satisfactory.

Blepharoplasty lateral internal suspension suture: BLISS technique.

The lower blepharoplasty procedure has had numerous surgical variations described and remains a challenge to those performing the operation. Disappointments with the technique revolve around complications such as lateral third scleral show, hollow sunken eyelids, rounding of the eye and overall long-term, tired, drawn appearance of the lower lids. Multiple adjuncts to the blepharoplasty procedure have been described. These vary in their difficulty of execution and associated complications. The concept of internal muscle suspension has been accepted as a successful adjunct by many authors but often the technique chosen has been a complicated one, adding time and complexity to the procedure.

Klippel-Feil anomaly, cleft palate, and bifid tongue.

The Klippel-Feil anomaly is a condition characterized by congenital vertebral fusion, which may be associated with a short neck and a low posterior hairline. In the patient presented here, there was congenital cervical fusion, cleft palate, and bifid tongue. The occurrence of cervical fusion and cleft palate has been reported previously, but this is the first report, to the author's knowledge, of these malformations being accompanied by a bifid tongue. The embryological association between Klippel-Feil anomaly and cleft palate has been alluded to on few occasions. Investigators have suggested that the short, fused neck limits movement of the head and thus of the tongue from between the palatal shelves. This report postulates that the mechanism is more complex and that it is based on a change in structural relations between certain key areas involved in the background of palatal shelf elevation.

Degloving injuries and flap viability assessment.

Degloving injuries are associated with major morbidity. The management of these injuries is still not resolved. The method of management used by the authors involves the harvesting of split skin from the surface of the flap and assessment of flap viability based on surface dermal capillary bleeding. The skin grafts are then used to cover denuded areas. This technique has proved to be effective, time-saving and morbidity-reducing in the cases reviewed here and in recent publications. The issue addressed in this trial was the effect of partial de-epithelialisation on the survival length of a flap. Two groups of dorsal rat flaps were compared. In one group, the flaps were raised and restitched after a period of time and in the second group, the surfaces of identical flaps were partially de-epithelialised and then restitched. The survival length of these flaps was compared, as well as the metabolic responses to surgery in the two groups. No statistically significant differences were found in these 2 groups. It was concluded that partial de-epithelialisation did not have a detrimental effect on duration of flap length survival, thus encouraging the continued use of the clinical technique described above in the handling of degloving injuries.

Umbilical keloid: an early start.

A case of umbilical keloid formation following cord separation in an infant is described. Treatment involved excision of the mass and reconstruction of the umbilicus with histological confirmation of the excised lesion. To our knowledge, this is the first report of an umbilical keloid occurring at such an early age.

Burn contracture preventing uterine expansion.

Two patients are described who previously sustained full-thickness burn injuries to their abdomens requiring split-thickness skin grafting. This created a restriction on the expanding pregnant uterus, necessitating surgical release and split-thickness skin grafting. These patients continued through normal pregnancy to subsequent normal vaginal delivery.

An analysis of proximal phalangeal fractures.

To attain accurate reduction in the proximal phalanx as opposed to the other phalanges, we have found open reduction and internal fixation to be necessary in a large proportion of cases in our series. The cause of injury in the majority of cases was blunt assault, possibly a unique spectrum in this type of trial and a probable influence on treatment choice. There were 50 fractured proximal phalanges in 40 patients analyzed according to their modes of treatment, immobilization, and functional results. Treatment for proximal phalangeal fractures have been structured according to these results.

Early postoperative mobilization of flexor tendon injuries using a modification of the Kleinert technique.

The results of 99 flexor tendon repairs in all zones of injury in 36 patients are reported. Both superficialis and profundus tendons were repaired in all cases. Postoperatively patients were managed by an immediate active extension program using a modification of the Kleinert technique and physiotherapy. Results of the study are based on the Buck-Gramcko system of evaluation of flexor tendon repair. In the 70 digits that underwent operations, the results were excellent in 31% of the cases, good in 30%, fair in 20%, and poor in 19% of the cases. There were two tendon ruptures. This study corroborates evidence that early mobilization and hand therapy appear to play an important part in the postoperative management of flexor tendon injuries.

Atypical Mycobacterium and breast surgery.

An unusual case of atypical mycobacterium infection following breast ptosis correction is described. This was successfully treated with a combination antibiotic regime. Breast surgery and atypical mycobacterium is discussed with reference to diagnosis management and suggested treatment regimes.

New innovations in scar management.

As current aesthetic surgical techniques become more standardized and results more predictable, a fine scar may be the demarcating line between acceptable and unacceptable aesthetic results. With this in mind, a scar management program has been adopted based on the modalities of wound support, hydration, and hastened maturity, all factors gleaned from scientific evidence published over the past 25 years. Tension on a scar in one axis will result in a stretched scar, probably initiated by neutrophils and their neutral proteases [18,26]. Tension on a scar from many directions or intermittently will result in a hypertrophic scar, possibly initiated by lymphocytes but definitely related to a prolongation of the inflammatory process, with increased fibroblast activity and overabundant extracellular matrix secretion [24,26]. The common initiating factor is the tension on the scar, and the critical element needed to counteract this tension is scar support. Clinical experience has shown us that the most reliable way to support a scar is by using microporous tape. Hydration is a second beneficial influence on scar control and is the basis of the use of silicone sheeting and gel [7,29,36]. Alpha Centella cream has two main components. The first is an extract from the plant Bulbine frutescens. This increases hydration under the tape by leaving a layer of fatty vesicles of glycoprotein on the skin surface. This also has antibacterial properties. The second component is the principal terpenoids extracted from the Centella asiatica plant. These include asiatic acid, madecassic acid, and asiaticoside. Centella asiatica has been documented to aid wound healing in a large number of scientific reports [5,12,21,22,33,34,40]. The most beneficial effect appears to be the stimulation of maturation of the scar by the production of type I collagen [4,19] and the resulting decrease in the inflammatory reaction and myofibroblast production. Thus these components have been incorporated into the formulation of a scar management program. This publication reviews much of the available literature relating to scar management and describes the formulation and use of a scar management program based on this information.

Intergroup comparisons of carpal tunnel dimensions.

Although it is a common disease entity worldwide, idiopathic carpal tunnel syndrome is rarely seen in black South Africans. This study compares anatomic dimensions of the carpal canal in black and white population groups, using computed tomography. No significant anatomic differences were found between the groups tested; thus, other explanations need to be sought to explain the difference in occurrence of carpal tunnel syndrome in these groups. A parameter, the carpal canal index, was defined and may prove useful in future investigations of this region.