The combination of fibrin glue and quilting reduces drainage in the extended latissimus dorsi flap donor site.

BACKGROUND: The use of quilting sutures in the extended latissimus dorsi flap donor site significantly reduces the incidence of donor-site seroma. However, the donor site has a drain inserted, and the duration of use of this drain often dictates when a patient is discharged to home from the hospital. Fibrin glue has been shown to reduce the need for drainage at other operative sites. The authors therefore evaluated the use of fibrin glue (Tisseel Lyo; Baxter Healthcare, Norfolk, United Kingdom) in addition to quilting in reducing the total volume and duration of drainage following extended latissimus dorsi flap breast reconstruction. METHODS: The authors compared a group of 11 consecutive, prospective patients who underwent extended latissimus dorsi donor-site closure with fibrin glue and quilting with a control group of 24 consecutive, retrospective patients who underwent extended latissimus dorsi donor-site closed with quilting alone. RESULTS: The results show that the combination of fibrin glue and quilting in the extended latissimus dorsi flap donor site significantly reduces average drainage in the immediate postoperative period: 13 ml compared with 170 ml (p

Use of dermal regeneration template (Integra) for reconstruction of full-thickness complex oncologic scalp defects.

The reconstruction of full-thickness scalp defects remains a surgical challenge. Different types of reconstruction had varying success including the use of dermal regeneration template (DRT). We reviewed the surgical outcome of 30 patients who underwent application of DRT for resurfacing of full-thickness scalp defects when the pericranium was excised and the outer cortex of the calvarial bone was burred after the excision of scalp neoplasm. This was a retrospective review of 30 patients who had scalp reconstruction with DRT undertaken by the senior author between October 2004 and June 2007. The mean age of patients in our series was 63 years (37-91 years). There were 14 men and 16 women. The indications for re-excision and DRT reconstruction in 28 patients were close margins and aggressive tumor type, whereas 2 patients had a recurrence. The mean defect size was 95 cm2 (16-275 cm2). The second stage of the reconstruction occurred on postoperative day 42 (postoperative days 27-62). The mean follow-up period was 14 months. Two patients had minor complications. For both stages, the combined average operative time was 128 minutes. The use of DRT is a rung of the reconstructive ladder that deserves consideration. In our series of 30 patients who required secondary reconstruction of complex scalp defects, the use of DRT has been seen to provide safe and durable soft-tissue cover for full-thickness scalp defects. The reduced operative time and inpatient stay are desirable characteristics particularly in elderly patients with multiple comorbidities.

Reconstruction of segmental acquired auricular defects.

The 2-stage Nagata method for auricular reconstruction in patients with microtia is a widely accepted technique. We have modified this technique into a single-stage procedure for the reconstruction of acquired segmental auricular defects. A prospective analysis was made of the senior author's first 20 consecutive cases over a 4-year period (February 2004 to February 2008). The mean age of patients in our series was 34 years (range, 17-59 years). There were 15 males and 5 females; 13 were right-sided and 7 were left-sided segmental auricular defects. Five patients had had previous auricular reconstruction including local flaps and grafts. Costal cartilage harvest was ipsilateral to the defect in all cases. All 20 patients underwent a single-stage modification of the Nagata technique. Mean duration of surgery was 8.56 hours (range, 5.5-11.5 hours). Mean hospital stay was 7.6 days (range, 4-19 days). Mean time from initial surgery to a satisfactory completion of treatment was 21 months. Overall, a low complication rate and high patient satisfaction were observed in this series. We believe the single-stage modified Nagata technique offers consistent high-quality results in the treatment of acquired segmental auricular defects. All patients undergoing autologus ear reconstruction need to be assessed in a multidisciplinary setting and should be offered all other options for treatment.

Hypospadias surgery in plastic surgery: a snapshot of today with an eye on tomorrow.

The current provision of hypospadias correctional surgery lies across the specialities of paediatric surgery, general surgery, urology and plastic surgery. This study aimed to look at how this provision is structured within plastic surgery, what plastic surgeons are currently doing and how this impacts on training. All plastic surgery units within the UK were contacted via letter and telephone in order to ascertain their current practice with regard to hypospadias surgery. Specialist registrars in the West Midlands Deanery were also questioned on their training in this area. The results indicate that 42 plastic surgeons in the UK carry out hypospadias surgery. The majority of clinicians use the Bracka two-stage repair (88%), with Snodgrass (45%) and MAGPI (43%) widely used. Operations are being carried out across the age spectrum from birth, with 51% favouring intervention at 3 years or more. Approximately two-thirds of plastic surgeons treat less than 25 patients per year. One-third treat 26 to 50, with only two clinicians claiming to treat more than 50 patients per year. Of the specialist registrars questioned in the West Midlands Deanery the majority (74%) were confident with the assessment of new cases and in obtaining consent. One-quarter of registrars (28%) only wished to carry out hypospadias surgery once they were consultants, with only one feeling that they had the necessary training to achieve this now. Plastic surgeons represent about half (52%) of the consultants currently identified in the UK as carrying out hypospadias surgery. If this provision is to be maintained then a greater opportunity for development of skills and experience needs to be created within plastic surgery training. The authors advocate the formulation of a coordinated national framework for the provision of this service, promoting a regional focus for skills and governance.

Investigation of safety and efficacy of a pneumatic finger tourniquet.

Finger tourniquets are widely used in hand surgery. However, they do not provide an estimate of the amount of pressure exerted and can potentially be left in situ with grave consequences. We assessed the pneumatic finger tourniquet in 57 adult patients in operations under local anaesthesia distal to the proximal interphalangeal joint. The average tourniquet time was 12 minutes. The tourniquet maintained its pressure for the length of the operation in 96.5% of cases. This airtight flat tubing is made of synthetic polymer, designed and manufactured by Barloworld Scientific Ltd (Staffordshire, UK). The tourniquet was easy to use and easily located after the operation. No complications were reported. This study supports the use of a pneumatic tourniquet in finger injuries requiring use of a finger tourniquet.

Two stage study of wound microorganisms affecting burns and plastic surgery inpatients.

This study was designed to identify wound microorganisms and the reasons for differing prevalence between the wards, burns unit and intensive care unit (ICU) in a regional centre for burns and plastic surgery. Antibiotic sensitivities of the 10 most prevalent microorganisms cultured from inpatient wound swabs were also investigated. Inpatient wound swab data were collected retrospectively using notes and departmental database information between January and June 2007. Data were analyzed using chi-squared tests and P-values. Eight hundred five positive wound swabs from 204 swab positive inpatients were analyzed. Stage 1 of this study demonstrated 917 positive swab episodes and 30 varieties of organism. The five most prevalent organisms cultured were Staphylococcus (23.9%), Acinetobacter (21.2%), Methicillin Resistant Staphylococcus aureus (MRSA) (20.8%), Pseudomonas (9.7%) and Enterococcus (5.2%). Stage 2 revealed that Acinetobacter baumanni (ABAU) was significantly more prevalent in military over civilian inpatients (P < .001) and that military inpatients had a significantly greater proportion of ABAU over civilian inpatients within the first 24 hours after admission (P < .001). ABAU episodes were significantly higher on the ICU over the burns unit and on the wards (P < .001). MRSA was significantly more prevalent in military inpatients (P < .001); however, no significant difference was observed within the first 24 hours after admission (P = .440). MRSA was more prevalent on the ICU over the burns unit (P = .023). Pseudomonas aeruginosa (PAER) was significantly more prevalent in military inpatients over civilian inpatients (P < .001), and on the ICU over the burns unit and wards (P = .018). Stage 1 generated a comprehensive, up to date cross section of bacterial flora, with corresponding percentage antibiotic sensitivities, in a regional burns and plastic surgery centre. This will give clinicians a snapshot of organisms affecting inpatient wounds in advance of culture and sensitivity results. Stage 2 demonstrated that ABAU, MRSA, and PAER were significantly more prevalent in the ICU setting. Furthermore, military inpatient wounds grew more ABAU, MRSA, and PAER than civilians, probably due to the longer inpatient stay, dirty nature of wounds, site and complex mechanism of injury. Finally, this study suggests that ABAU was brought into the unit by military patients.

Study of ulnar and radial arteries at wrist level in smokers.

We aimed to assess the blood flow through the radial and ulnar arteries at the wrist in chronic smokers, after a clinical observation that the ulnar artery is often difficult to palpate in chronic smokers. Sixty-four smokers and 36 non-smokers were recruited. The blood vessels were examined by palpation, and we used the hand-held Doppler and the Allen test to illustrate the dependence of the blood supply on one or the other vessel. The study showed that in 57 of the 64 chronic smokers (89%) the ulnar artery was difficult to palpate and in 28 (44%) dominant and 35 (55%) non-dominant hands blood flow through the ulnar artery was assessed as being poor using the hand-held Doppler. The Allen test was, however, within the normal limit of two seconds in all patients in this study.

Ulnar-based skin flap for Dupuytren's fasciectomy.

The mainstay of treatment for symptomatic Dupuytren's disease is operation. Various skin incisions have been described, showing that there is no single best incision. We describe an ulnar-based skin flap for excision of palmar disease. This flap allows excellent exposure of the diseased area, and provides good access to the palmar aponeurosis including the difficult area on the ulnar side of the little finger. Healing is reliable and digital disease can be approached with a skin extension as required. Recurrent disease can be treated by raising the same flap again.

Milk bottle burns.

In recent years numerous infants have been treated at Stoke Mandeville Hospital's Burns' Unit for scalds sustained in accidents that occurred during the preparation of warm milk. These were significant burns affecting young children with susceptibly thin skin that often resulted in the injured child requiring a long stay in hospital. Frequently, formal intravenous fluid resuscitation was required as was burn excision and skin grafting. We recommend the use of milk bottle warmer to avoid all the hazards associated with use of different techniques of warming milk bottle.