Low-flow vascular malformations of the hand and forearm: a multidisciplinary experience in a tertiary paediatric centre.

BACKGROUND: Vascular malformations (VMs) involving the hand and forearm in children provide management challenges due to complex anatomy, indispensable functionality and developmental implications. METHODS: The institution's Vascular Registry was searched for patients with hand and arm VMs, supplemented by chart review of included patients. RESULTS: Twenty-one patients were identified, 52% male, with mean presenting age 5.2 years. Venous malformations predominated (71%), followed by lymphatic-venous (19%), lymphatic (5%) and glomuvenous (5%). Symptoms included pain (76%), swelling (71%), cosmetic concerns (81%), functional compromise (29%) and stiffness (5%). Imaging modality was ultrasound (100%), and magnetic resonance imaging (71%). Treatment included compression (62%), sclerotherapy (62%) and surgery (24%). Post-sclerotherapy ultrasounds showed complete sclerosis (25%), near complete sclerosis (58%) and partial sclerosis (17%). Post-surgery, patients reported improved cosmesis (80%), size (100%), pain (60%) and function (40%). Complications occurred in 24%, including bleeding, digital ischaemia and thrombosis. Mean follow-up was 3.4 years. CONCLUSION: Children with low-flow VMs of the hand and forearm experience significant symptoms and functional limitations. A multidisciplinary approach to management ensures optimal outcomes.

Re Facial aesthetic injections in clinical practice: Pretreatment and post-treatment consensus recommendations to minimise adverse outcome Region-specific changes in line with the Covid-19 pandemic.

Despite the recent publication in March 2020 of guidelines for facial injectable treatments, the speed of the COVID-19 pandemic and its safety implications necessitate changes to these guidelines The authors described what would constitute safest practice in the provision of facial injectable treatments and summarised these in table form. Adherence to a high standard of asepsis and infectious disease precautions remain a key patient safety requirement when performing facial aesthetic injections. A revision and update of these guideline summary tables follows. Changes made should enhance both patient and staff safety regarding COVID-19/SARS-CoV-2, a highly infective respiratory pathogen transmitted by respiratory droplets, respiratory/mucosal secretions and contaminated fomites. Some of the additions are COVID-19 specific and are likely to evolve and change, particularly should serological tests determining acquired immunity become available. Other additions represent further tightening of our infection control precautions.

A new approach to preexisting vertical midline abdominal scars with crossover DIEP flap breast reconstruction.

Breast reconstruction using a free transverse rectus abdominis myocutaneous flap or a deep inferior epigastric perforator (DIEP) flap is a challenge in patients with a vertical midline abdominal scar due to the poor perfusion of the lower abdominal skin ellipse across the midline. In such patients, only one half of the abdominal skin ellipse can be used with certainty, and this limits the amount of tissue available for reconstructing the breast. Two cases of breast reconstruction in patients with a lower midline abdominal scar are presented using the DIEP flap, in which the poor perfusion across the midline scar was overcome by a technique of crossover anastomoses between the two deep inferior epigastric pedicles. Reliable perfusion of the entire lower abdominal skin ellipse was achieved. This crossover anastomoses technique overcomes the poor perfusion imposed by the vertical midline abdominal scar and enables DIEP flap breast reconstruction to be offered to women with midline abdominal scars.

The dorsalis pedis fascial flap.

The dorsalis pedis fasciocutaneous flap has been used successfully in soft tissue reconstruction both as a pedicled and a free flap. The long-term donor site problems associated with this dorsalis pedis flap prompted us to look at the use of the dorsalis pedis fascial flap in soft tissue reconstruction. We describe the results of our anatomic study and clinical series of the use of the dorsalis pedis fascial flap both as a free flap and a pedicled flap. An anatomic study was performed on a fresh cadaver by injecting India ink into the anterior tibial artery and the fascial and cutaneous staining pattern was documented. Soft tissue reconstruction was performed in six patients, using the dorsalis pedis fascial flap as a free flap in four patients and a pedicled flap in two. The donor site was closed primarily in all cases. The donor and recipient wounds healed well with good aesthetic and functional results. There were no major complications in our series. The dorsalis pedis fascial flap allows us to retain the essential benefits of the dorsalis pedis flap while avoiding donor site morbidity. It provides a useful source of vascularized fascia with a potentially long pedicle.

Purse-string nipple areolar reconstruction.

We present a surgical technique of nipple areolar reconstruction that uses a purse-string to increase areolar projection while reducing loss of nipple projection. A permanent purse-string is used around a modified CV flap to advance tissue centrally to the base of the nipple reconstruction. Two opposing hemiareolar island flaps are advanced toward the base of the nipple to add tissue volume. The resulting circumareolar full thickness skin is closed using a permanent purse-string suture. Synching the purse-string suture produces an effect similar to that of a periareolar mastopexy and enhances areolar projection. Eighty-two patients underwent 108 nipple areola reconstructions. Ninety-six percent of the patients achieved good results without any flap loss or suture infections. Revision surgery was necessary in 4 patients for minor problems including asymmetry or loss of projection. The purse-string nipple areolar reconstruction method described results in a high rate of maintenance of projection and patient satisfaction.

Optimizing blepharoplasty outcomes in patients with previous laser vision correction.

BACKGROUND: Dry eye syndrome, often referred to as dysfunctional tear syndrome, can occur following laser vision correction surgery and routine blepharoplasty. Identifying patients prone to developing or worsening of dysfunctional tear syndrome following blepharoplasty can help optimize surgical outcomes. METHODS: The authors highlight the salient features of the dysfunctional tear syndrome including key steps in identifying at-risk patients. The authors discuss changes in the cornea that occur with keratorefractive surgery and their significance in patients seeking blepharoplasty. The authors suggest guidelines for blepharoplasty in these patients and discuss the timing of surgery. RESULTS: After blepharoplasty, lagophthalmos of the upper lid is a common temporary finding. This change in eyelid function may unmask underlying deficiencies in the tear film or corneal sensation. Coexisting lower lid malposition can displace the existing tear meniscus and increase exposure of the cornea. Whether in combination or alone, these findings can create a dry eye problem. Dysfunctional tear syndrome should be considered in all patients with a history of laser vision correction during the preoperative evaluation for blepharoplasty. Surgeons should rely on preoperative history and physical examination, including assessment of preoperative eyelid anatomy and the status of the ocular surface. Patients with prior laser vision correction should wait at least 6 months before undergoing blepharoplasty because of the effects on corneal sensation, tear production, and tear film alteration. CONCLUSIONS: Identification and appropriate treatment of dysfunctional tear syndrome together with intraoperative modifications will optimize postoperative outcomes and avoid a potentially disabling condition after blepharoplasty in patients with previous laser vision correction surgery.

Keystone island flap: an alternative reconstructive option to free flaps in irradiated tissue.

BACKGROUND: The Keystone Flap is an island flap that is very useful for repairing skin defects of the integument. Described as a keystone, this arc-shaped flap in fact consists of a schematically designed, perforator-based reconstructive unit which serendipitously resembles two conjoined VY flaps. This facilitates closure because of the multiple VY points at the extremes, where the surrounding tissue is advanced to close the defect while the flap size remains basically static. METHODS: A consecutive series of nine cases involving the head and neck and inguinal regions were examined to show the use of the Keystone Flap in irradiated tissue for recurrent disease. They are described by using a combination of clinical illustrations and diagrams to explain the surgical technique. RESULTS: The average age of the patients in the series is 74 years. A low complication rate and rapid wound healing with no significant flap necrosis was shown in this series. Additionally the short operation time is quite beneficial, particularly for the elderly. CONCLUSION: There is a low complication rate using Keystone flaps (this double VY is a clinical development from Diffenbach's original work of 1848(1)) and this technique is particularly useful in achieving wound healing especially after irradiation treatment. This surgical technique once mastered is easy to perform. Another bonus is that there is minimal use of postoperative analgesia. Additional XRT is well tolerated by the patients with minimal evidence of wound complications, while achieving an acceptable aesthetic appearance.

A technique for sequential segmental neuromuscular stimulation with closed loop feedback control.

In dynamic myoplasty, dysfunctional muscle is assisted or replaced with skeletal muscle from a donor site. Electrical stimulation is commonly used to train and animate the skeletal muscle to perform its new task. Due to simultaneous tetanic contractions of the entire myoplasty, muscles are deprived of perfusion and fatigue rapidly, causing long-term problems such as excessive scarring and muscle ischemia. Sequential stimulation contracts part of the muscle while other parts rest, thus significantly improving blood perfusion. However, the muscle still fatigues. In this article, we report a test of the feasibility of using closed-loop control to economize the contractions of the sequentially stimulated myoplasty. A simple stimulation algorithm was developed and tested on a sequentially stimulated neo-sphincter designed from a canine gracilis muscle. Pressure generated in the lumen of the myoplasty neo-sphincter was used as feedback to regulate the stimulation signal via three control parameters, thereby optimizing the performance of the myoplasty. Additionally, we investigated and compared the efficiency of amplitude and frequency modulation techniques. Closed-loop feedback enabled us to maintain target pressures within 10% deviation using amplitude modulation and optimized control parameters (correction frequency = 4 Hz, correction threshold = 4%, and transition time = 0.3 s). The large-scale stimulation/feedback setup was unfit for chronic experimentation, but can be used as a blueprint for a small-scale version to unveil the theoretical benefits of closed-loop control in chronic experimentation.