Phenytoin induced rhinophyma treated by excision and full thickness skin grafting.

A 49-year-old man suffering from post-traumatic epilepsy presented with a severe rhinophyma probably induced by phenytoin. Initial surgical shaving was soon followed by recurrence, formation of intraepidermal cysts and persistent infection. Ultimate treatment by full thickness excision and a full thickness skin graft resulted in a pleasing cosmetic result. Radical excision of the affected skin followed by full thickness skin graft nasal reconstruction should be considered for cases of recurrent severe rhinophyma with inclusion cysts to eradicate chronic infection and improve cosmesis.

Comparison of nipple and areolar sensation after breast reduction by free nipple graft and inferior pedicle techniques.

Breast reduction with free nipple-areolar transplantation has traditionally been used for patients with gigantomastia. It is a widely held belief that there is little or no recovery of sensation in the nipple-areolar complex after this procedure. We set up a retrospective study to compare nipple-areolar sensation after free nipple grafting with that after breast reduction by the more commonly performed inferior pedicle technique. We reviewed 38 patients (17 free nipple grafts and 21 inferior pedicles) at least 1 year after breast reduction and measured the nipple and areolar pressure sensibility in each breast with Semmes-Weinstein monofilaments. We found some degree of recovery of sensation in all patients, with areolar sensation being similar in the two groups but nipple sensation being superior in the inferior pedicle group. In addition, we assessed the erectile function of the nipples in each group.

Flap repair: an effective strategy for minimising sexual morbidity associated with the surgical management of vulval intra epithelial neoplasia.

OBJECTIVE: To assess the sexual function after local excision and flap repair for symptomatic vulval intraepithelial neoplasia (VIN). STUDY DESIGN: A retrospective analysis of five sexually active women who had persistent, symptomatic VIN diagnosed in a dedicated tertiary referral vulval clinic and treated with local excision and flap repair. Sexual function was assessed using a modified version of the Sabbatsberg Sexual Self-Rating Scoring (SRS) system. RESULTS: The mean age of the cohort was 32 years (range 30 to 51). Four patients had previously been unsuccessfully treated with local excision. Follow up ranged from 5 to 33 months. The SRS scores were 90, 90, 81, 72 and 25. Endogenous depression may explain this last score. There has been no recurrence of VIN. CONCLUSION: In sexually active women with symptomatic VIN III, a flap reconstruction should be considered in addition to local excision as the treatment of choice.

Flap repair: an effective strategy for minimising sexual morbidity associated with the surgical management of vulval intra epithelial neoplasia

Objective: To assess the sexual function after local excision and flap repair for symptomatic vulval intraepithelial neoplasia (Vin). Study Design: A retrospective analysis of five sexually active women who had persistent, symptomatic VIN diagnosed in a dedicated tertiary referral vulval clinic and treated with local excision and flap repair. Sexual function was assessed using a modified version of the Sabbatsberg Sexual Self-Rating Scoring (SRS) system. Results: The mean age of the cohort was 32 years (range 30 to 51). Four patients had previously been unsuccessfully treated with local excision. Follow up ranged from 5 to 33 months. The SRS scores were 90, 90, 81, 72 and 25. Endogenous depression may explain this last score. There has been no recurrence of VIN. Conclusion: In sexually active women with symptomatic VIN III, a flap reconstruction should be considered in addition to local excision as the treatment of choice (AU)

Prevention of Frey's syndrome and volume deficit after parotidectomy using the superficial temporal artery fascial flap.

Frey's syndrome (gustatory sweating) is thought to be caused by aberrant regeneration to the sweat glands of the face. We present a double-layered fascial flap based on the superficial temporal artery which can be used to cover the parotid bed at the time of parotidectomy and consists of both the temporoparietal fascia and the fascia over the temporalis muscle. We used this superficial temporal artery fascial flap (STAFF) in 24 of 47 patients reviewed after parotid surgery and found a significantly lower incidence of gustatory sweating and a far less noticeable post-parotidectomy volume deficit or 'hollow'.

The 'turkey wattle' sign revisited: diagnosing parotid vascular malformations in the adult.

The turkey wattle sign describes enlargement of a facial mass on dependency of the head and when the sign is present it is pathognomonic of a vascular malformation or haemangioma. We present a case of vascular malformation of the parotid gland in which this sign was demonstrated. The clinical and radiological features of this rare parotid mass are discussed with reference to the literature.

Skin injuries afflicting three oil workers following contact with calcium bromide and/or calcium chloride.

Calcium bromide brine is a highly concentrated aqueous solution of calcium bromide and calcium chloride. It is used extensively in the oil industry. This solution and its components are recognized as causes of skin injury and information is available from the manufacturers on their safe use and handling. Two patients who were injured following unprotected skin exposure to this solution and one patient who was injured following exposure to calcium chloride powder are reported. All sustained skin injuries characterised by an absence of pain and a delayed clinical appearance of the full extent of the injury. Furthermore healing was complicated by graft loss or was slow. Although organic bromine compounds are recognized as a cause of skin injuries, no previous reports of such injuries to humans secondary to calcium chloride or bromide exposure were found in the medical literature. Our experience with these patients is described.

Aggressive limb salvage using tibio-pedal bypass grafting with free tissue transfer in a diabetic patient.

A 63-year-old man presented with intermittent claudication, diabetes, and an ischaemic heel ulcer. After control of infection, the os calcis was left exposed. An aggressive combined infra-inguinal revascularization and reconstruction procedure involving free-tissue transfer resulted in rapid wound healing with independent walking by day 26. Recent improvements in surgical techniques mean that this approach should be considered in selected patients.

Injuries to the nail bed in childhood.

Many fingertip injuries in childhood involve the nail bed. Deformities of the nail are a frequent result of failure to repair the nail bed at the time of injury. Secondary correction of nail deformities seldom achieves good results. We present the results of our experience in the management of 19 children with 22 injuries involving the nail bed. All achieved normal nail growth and the overall result of the repair was good in 91%. Complications were few and parental satisfaction with the management was high. Every effort should be made to perform a meticulous primary repair of all nail bed injuries.

Fracture of the radial forearm osteocutaneous donor site.

Since the introduction of the osteocutaneous radial forearm flap in 1983, fractures of the radius have been reported to occur in approximately 30% of cases. Fracture of the donor forearm has been the cause of the most significant morbidity, and the difficulty in management of these fractures has been reported. We report our experience in managing three fractures involving the donor forearm. Optimum results can be achieved by early stabilization with external fixation and vascularized bone grafting. Excessive resection of the radius should be avoided and alternative sources of vascularized bone used to avoid mutilation of the forearm.

Reconstruction of the vermilion after "lip-shave".

During the year 1986, 12 "lip-shave" defects were reconstructed using orbicularis oris myomucosal flaps, in the Northern Ireland Plastic and Maxillo-Facial Service. Three of these were extended lip-shaves. The planning of a V-Y plasty for myomucusal advancement is described and some representative results are shown. We feel that the myomucosal advancement flap is a valuable technique to overcome some of the problems in reconstruction of the vermilion after lip-shave.

The posterior auricular flap: anatomical studies.

The aim of this study was to investigate the blood supply of the auriculomastoid skin and to prove the reliability of the posterior auricular vessels for supply of a skin flap in this region. This was done by means of studies of arteriograms, cadaver dissections, India ink perfusion, lead oxide injection and contact radiographs. Information from operative dissections performed in the course of superficial parotidectomies and neck dissections was included, as was information from 11 clinical flap transfers. The conclusion was drawn that the auriculomastoid skin could safely be transferred on the posterior auricular vessels, either as an island flap or as a free flap.

The posterior auricular flap: intra-oral reconstruction.

During 1986, the posterior auricular flap was used, in the Northern Ireland Plastic and Maxillo-Facial Service, for the reconstruction of a variety of post-excisional defects in the head and neck. In this paper, we present the results of its use in intra-oral defects. The operative technique is described in detail and representative case reports are presented. The posterior auricular flap would appear to have a role to play in the reconstruction of defects in the oral cavity as the skin quality equals that of the radial forearm flap, and in many cases it may be transferred as an island pedicle flap without the need for microvascular anastomosis.

Practical miniaturized membrane oxygenator for isolated organ perfusion.

Silastic membrane tubing oxygenators possess valuable atraumatic properties, but no satisfactory miniature system for isolated organ perfusion has been achieved. We describe the construction of a new type of miniaturized Silastic membrane tubing oxygenator, 1.5 m long, 1.5-mm diameter, 75-micron wall thickness, incorporated in a single self-supporting unit readily applicable to isolated organ perfusion because of its simplicity, durability, and small prime volume of less than 3 ml. In vitro experiments using out-dated human banked blood demonstrated that the unit can effectively oxygenate blood of hematocrit 35% at flow rates of at least 10 ml/minute and that higher flow rates may be used to oxygenate blood or perfusates of a lower hematocrit. The results were verified in three different practical experimental applications: isolated rat liver, rabbit heart, and rat free skin flap perfusion.