Split Skin Grafting Precipitated Bullous Pemphigoid.

Bullous pemphigoid (BP) is an autoimmune subepidermal blistering dermatological condition that can be triggered by several external factors. Here, we present a case of an immunocompetent patient with no prior dermatological history, who developed BP as a result of autologous skin graft surgery. It is an uncommon surgical complication and was most likely triggered by the trauma of the surgery itself. Our patient's bullae first developed a month after his surgery at both surgical sites and subsequently became widespread. The diagnosis was confirmed histologically using punch biopsies of a bulla and the perilesional skin for direct immunofluorescence together with indirect immunofluorescence of the serum for anti-skin antibodies. Initial topical treatment and regular wound care were not improving the patient's condition at a satisfactory rate. Therefore, the patient was started on systemic steroids, which unfortunately resulted in a presumed split skin graft infection requiring admission. After histological diagnosis confirmation was achieved, the Dermatology team formulated a treatment plan, which combined both topical and systemic medication. The patient is currently making a good recovery and the graft loss resulting from the condition is only partial, requiring no further surgery. We present this case as a reminder to all clinicians that, although rare, BP can be triggered by skin grafting, even in patients with no prior history of it or any predisposing conditions. This autoimmune condition needs to be recognised and treated promptly to ensure optimal clinical outcomes and minimise graft loss.

The deleterious impact of primary care-based commissioning on plastic surgery services and patients.

The wide variation in the availability of treatments across the National Health Service (NHS) in England has led to a postcode lottery due to the rationing of available services by individual Primary Care Trusts (PCTs). In 2005 an NHS Modernisation Agency document, "Action on Plastic Surgery" was designed to aid PCTs making funding decisions on Plastic Surgery patients. Despite this and evidence in the Plastic Surgery literature, patients continue to experience difficulties in the primary care setting accessing our services.(3) The authors present two patients who presented to their GPs requesting to seen by the local Plastic Surgery service regarding their symptoms in an effort to explore the possible available treatment modalities. These patients were not referred and subsequently these patients operated upon themselves leading to complications which warranted inpatient management.

The development of varicosities within a free radial forearm flap used for distal-third tibial reconstruction.

Reports of varicosities developing in free flaps are very rare. The presence of varicose veins in recipient sites influencing the development of varicosities in free flaps, though physiologically possible, has not been documented in literature. We encountered an unusual case of varicosities developing in a free radial forearm flap used in soft-tissue reconstruction of an open distal-third tibial fracture, which is presented here. This case report thus adds an important dimension to the assessment of a patient when planning a free flap procedure in a recipient area with pre-existing varicosities.

Delayed presentation of tattoo lymphadenopathy mimicking malignant melanoma lymphadenopathy.

Tattooing is a popular cosmetic practice and the technique has been adopted in breast reconstruction. Pigment injected intradermally is transported to lymph nodes leading to permanent pigmentation. Differential diagnosis between melanoma and tattoo pigmentation of lymph nodes is done microscopically. We present the case study of a patient who presented with palpable and pigmented axillary lymph nodes, 2 years after excision of melanoma and 20 years after tattooing. Intraoperative finding of enlarged, pigmented lymph nodes is not a certain sign of metastasis, as causes other then melanoma can lead to pigmented lymphadenopathy. The diagnostic and investigation process should start with history (including history of previous tattooing) and fine needle aspiration (FNA) of enlarged lymph node. If FNA is negative an open biopsy should be performed for confirmation of diagnosis before proceeding to completion lymphadenectomy.

The benefits of otoplasty for children: further evidence to satisfy the modern NHS.

SUMMARY OBJECTIVES: To take standards from, and revalidate an existing study which addressed the psychological and social outcomes following otoplasty in children [Bradbury E, Hewison J, Timmons M. Psychological and social outcome of prominent ear correction in children. Br J Plast Surg 1992;45:97-100]. The psychosocial experiences of children undergoing otoplasty at the University Hospital of North Staffordshire were retrospectively examined and compared to the cohort in the existing study. METHODS: Retrospective questionnaires were sent to all children aged 5-16 (n=101) who were on the hospital records having undergone otoplasty between 1999 and 2003, investigating social experiences, and experience of surgery. RESULTS: This study found: 97% reported an increase in happiness; 92% reported an increase in self-confidence; 79% noted improved social experience; 100% reported bullying reduced or stopped. The Wilcoxon Rank Sum Test confirmed the statistical validity of these findings (P<0.001). The existing study found: 63% of children reported increase in happiness and confidence; 13% noted improved social experiences; 53% noted bullying had stopped entirely. CONCLUSIONS: Otoplasty is an effective procedure in alleviating psychosocial distress in the vast majority of children that undergo the operation, and hence this study supports the continued availability of otoplasty on the NHS for children with prominent ears.

The effects of fluid penetration and interfacial porosity on the fixation of cemented femoral components.

We have investigated the role of the penetration of saline on the shear strength of the cement-stem interface for stems inserted at room temperature and those preheated to 37 degrees C using a variety of commercial bone cements. Immersion in saline for two weeks at 37 degrees C reduced interfacial strength by 56% to 88% after insertion at room temperature and by 28% to 49% after preheating of the stem. The reduction in porosity as a result of preheating ranged from 71% to 100%. Increased porosity correlated with a reduction in shear strength after immersion in saline (r = 0.839, p < 0.01) indicating that interfacial porosity may act as a fluid conduit.

The building blocks of planets within the 'terrestrial' region of protoplanetary disks.

Our Solar System was formed from a cloud of gas and dust. Most of the dust mass is contained in amorphous silicates, yet crystalline silicates are abundant throughout the Solar System, reflecting the thermal and chemical alteration of solids during planet formation. (Even primitive bodies such as comets contain crystalline silicates.) Little is known about the evolution of the dust that forms Earth-like planets. Here we report spatially resolved detections and compositional analyses of these building blocks in the innermost two astronomical units of three proto-planetary disks. We find the dust in these regions to be highly crystallized, more so than any other dust observed in young stars until now. In addition, the outer region of one star has equal amounts of pyroxene and olivine, whereas the inner regions are dominated by olivine. The spectral shape of the inner-disk spectra shows surprising similarity with Solar System comets. Radial-mixing models naturally explain this resemblance as well as the gradient in chemical composition. Our observations imply that silicates crystallize before any terrestrial planets are formed, consistent with the composition of meteorites in the Solar System.

The central dusty torus in the active nucleus of NGC 1068.

Active galactic nuclei (AGNs) display many energetic phenomena--broad emission lines, X-rays, relativistic jets, radio lobes--originating from matter falling onto a supermassive black hole. It is widely accepted that orientation effects play a major role in explaining the observational appearance of AGNs. Seen from certain directions, circum-nuclear dust clouds would block our view of the central powerhouse. Indirect evidence suggests that the dust clouds form a parsec-sized torus-shaped distribution. This explanation, however, remains unproved, as even the largest telescopes have not been able to resolve the dust structures. Here we report interferometric mid-infrared observations that spatially resolve these structures in the galaxy NGC 1068. The observations reveal warm (320 K) dust in a structure 2.1 parsec thick and 3.4 parsec in diameter, surrounding a smaller hot structure. As such a configuration of dust clouds would collapse in a time much shorter than the active phase of the AGN, this observation requires a continual input of kinetic energy to the cloud system from a source coexistent with the AGN.

Effects of the initial temperature of acrylic bone cement liquid monomer on the properties of the stem-cement interface and cement polymerization.

It has been shown that preheating the femoral stem prior to insertion minimizes interfacial porosity at the stem-cement interface. In this study, the effects of methylmethacrylate monomer temperature prior to mixing on the properties of stem-cement interface and cement polymerization were evaluated for 4 degrees C, room temperature, and 37 degrees C using a test model and cementing techniques that simulated a clinical situation. The nature and extent of interfacial porosity of stem-cement interface was quantified, the static shear strength of the stem-cement interface determined, and the time and temperature of polymerization at the cement-bone interface were measured. Compared to RT monomer, preheating monomer to 37 degrees C produced higher polymerization temperatures and greater initial interfacial shear strength with an unchanged amount of interfacial porosity. Precooling monomer to 4 degrees C produced lower polymerization temperatures and decreased initial interfacial shear strength, with the amount of interfacial porosity unchanged compared to the RT group. Although clinical techniques of preheating or precooling bone cement have some effects on the properties of the stem-cement interface and cement polymerization, they do not appear to enhance implant fixation.

The effect of alendronate (Fosamax) and implant surface on bone integration and remodeling in a canine model.

Patients at high risk for osteoporosis and its associated morbidity, including postmenopausal women, are being pharmacologically managed to stabilize and improve bone mass. Alendronate sodium (Fosamax) is a commonly used antiresorptive agent effective in osteopenic women for reducing bone resorption, increasing bone density, and decreasing fracture incidence. With the increased incidence of alendronate-treated women who are undergoing hip replacement or fracture repair by prosthesis placement, data are needed to predict how alendronate affects host bone integration with uncemented surfaces. The aim of this study was to determine the effect of alendronate on new bone formation and attachment to implant surfaces in a normal and simulated estrogen-deficient, calcium-deficient canine model, using an implantable bone growth chamber. Alendronate did not affect host bone integration to surfaces commonly used in uncemented total joint arthroplasty, but there were significant differences dependent solely on the type of surface.

Iliopsoas tendinitis after total hip arthroplasty.

Determination of the cause of groin pain after total hip arthroplasty can be difficult. The case of a patient with an unusual cause of groin pain after total hip arthroplasty, iliopsoas tendinitis, is presented. The patient failed nonoperative treatment and underwent surgical release of the iliopsoas tendon with complete resolution of symptoms.

Radiographic comparison of grit-blasted hydroxyaptite and arc-deposited hydroxyapatite acetabular components. A four-year follow-up study.

High rates of aseptic loosening have been reported for microstructured hydroxyapatite-coated acetabular components. A macrostructured component surface (arc-deposition) not only improves resistance to shear forces experienced by the acetabular component and increases initial stability, but also provides channels for bone ingrowth. The purpose of this investigation was to radiographically compare a series of grit-blasted (microstructured) and arc-deposited (macrostructured) hydroxyapatite-coated acetabular components. A minimum 4-year retrospective radiographic analysis of acetabular components was performed on a total of 50 total hip arthroplasties. At 4 years, arc-deposited components were associated with fewer radiolucent lines in all Charnley zones, particularly Charnley zone III. While the 4-year results for arc-deposited hydroxyapatite acetabular components are superior to their microstructured predecessors, long-term results are still unknown.