Diagnosing PIP breast implant failure: a prospective analysis of clinical and ultrasound accuracy.

INTRODUCTION: The risk of Poly Implant Prosthesis (PIP) breast implant failure has been quantified by the Department of Health as 2-6 times greater than other brands. In the UK, removal of PIP breast implants is recommended when failure is suspected from patient history or clinical findings. Owing to conflicting reports of accuracy in current literature, ultrasound is not recommended as a routine investigation. We aimed to evaluate the accuracy of patient history, clinical impression, and ultrasound at diagnosing implant failure in a large consecutive series of women against the reference standard. We aimed to provide evidence in response to current guidelines and help guide best practice. METHODS: All patients from January 2012-January 2013 who underwent PIP breast implant explantation at the Spire Murrayfield Hospital were prospectively evaluated. Operative findings were correlated to pre-operative results of patient history, clinical impression and ultrasound imaging. Sensitivity, specificity and accuracy were calculated with 95% confidence intervals. RESULTS: A total of 192 women who underwent 384 PIP implant explantations from January 2012 to January 2013 were included. Twenty-three patients (12.0%) reported a positive patient history pre-operatively. In 35 patients (18%), failure was pre-operatively diagnosed clinically. Intra-operatively, 80 implants (21%) in 63 women (33%) had failed. The sensitivity of patient history, clinical impression and ultrasound was 12%, 34%, and 91%, respectively. The specificity was 88%, 89%, and 97%, respectively. Ultrasound was 96% accurate at diagnosing PIP implant failure, whilst patient history and clinical impression were 63% and 71% accurate, respectively. CONCLUSION: Ultrasound provides a far more reliable test of implant failure than patient history or clinical impression. Considering the availability, cost and number of women in the UK with PIP implants, we would recommend high-resolution ultrasound be implemented as a routine investigation.

Neuron-specific enolase and its mRNA are highly expressed in large congenital nevi: a study using immunocytochemistry, biochemical assay, and in situ hybridization.

The malignant transformation of congenital nevocellular nevi, both large and small, is controversial and presents problems in management. The size of the lesion is taken to indicate potential malignant transformation, but this is an arbitrary scale. A more reliable biological indicator is needed to help predict the lesions at risk. Following the localization of neuron-specific enolase to most cells of the diffuse neuroendocrine system and their neoplasms (including benign and malignant melanocytic lesions), it has been suggested that its level is related to tumor activity. In a prospective trial, the presence of neuron-specific enolase immunoreactivity, its concentration, and gene expression in nevus cells were studied in 31 congenital melanocytic nevi of various sizes (1.5 cm to bathing trunk) using immunocytochemistry, biochemical assay, and in situ hybridization. Twenty-five of the 31 congenital nevi were immunoreeactive to neuron-specific enolase antiserum, with stronger immunostaining in the larger lesions. There is an apparent linear relationship between the size of the nevi and the level of neuron-specific enolase (expressed as nanograms per milligram protein). Neuron-specific enolase mRNA was highly expressed in most of the large congenital nevi (greater than 15 cm in diameter), as revealed by autoradiography following in situ hybridization. Our results show that neuron-specific enolase and its mRNA are expressed to a greater extent in large congenital nevi compared with the smaller lesions. This might prove to be a useful indicator of those lesions at risk of malignant transformation.

Locked intramedullary nailing of open tibial fractures.

We report the use of Grosse-Kempf reamed intramedullary nailing in the treatment of 41 Gustilo type II and III open tibial fractures. The union times and infection rates were similar to those previously reported for similar fractures treated by external skeletal fixation, but the incidence of malunion was less and fewer required bone grafting. The role of exchange nailing is discussed and a treatment protocol is presented for the management of delayed union and nonunion.

The pulsed tuneable dye laser as an aid in the management of postburn scarring.

Permanent erythematous scarring following burns is a common problem which may be disfiguring and distressing for the patient. In this case the pulsed tuneable dye laser (585 nm) was used to treat the areas of scarring and also used prophylactically on an active scar.

A role for lasers in the treatment of pigmented skin grafts.

The development of aberrant pigmentation represents an unwelcome complication to an otherwise successful split skin graft resulting in a loss of colour match and, so it follows, of cosmesis. We present two cases where lasers have been successful in the treatment of this problem.

The bigger the burn, the greater the stress.

Data characterizing the endocrine stress response to burn injury in children are sparse. We have measured the levels of the stress hormones arginine vasopressin, catecholamines-adrenaline, noradrenaline and dopamine-atrial natriuretic peptide and hormones of the renin-angiotensin-aldosterone system in admission blood samples taken from 35 children admitted to the burns unit of the regional children's hospital. Hormone levels were compared with the size of burn injury. With the exception of adrenaline, there were significant positive correlations between vasopressin (r = 0.707, p < 0.0001), plasma renin activity (r = 0.721, P < 0.0001), angiotensin II (r = 0.512, P = 0.002), aldosterone (r = 0.620, P < 0.0001), noradrenaline (r = 0.430, P = 0.0189), dopamine (r = 0.627, P = 0.0024) and percentage burn surface area, and a negative correlation between atrial natriuretic peptide (r = 0.548, P = 0.0008) and burn surface area. It is concluded that the hormones which react to stress are very sensitive to burn injury in children, and that the magnitude of their response is closely related to the size of the burn surface area.

Reconstruction of a posttraumatic ear defect using tissue expansion: 30 years after Neumann.

A two-stage method suitable for reconstructing the lower part of the auricle and using an advancement-rotation flap of expanded cervical and postauricular skin is described. Expander shape and capacity should be selected after careful consideration of available donor sites and the amount of additional tissue required for reconstruction.

A hemorrhagic hazard of tissue expansion.

A case of delayed acute hemorrhage complicating tissue expansion of the scalp is presented. The likely mechanism was erosion of an occipital artery by the edge of the expander, and the risk of a similar occurrence should be considered in all patients undergoing tissue expansion.

The incidence of malignant melanoma (0 to 15 years of age) arising in "large" congenital nevocellular nevi.

While the association between large congenital nevocellular nevi and malignant melanoma has been established beyond reasonable doubt, its magnitude is the subject of wide controversy. In this study an attempt is made to estimate the risk of malignant transformation during the first 15 years of life in a sample of 39 congenital nevocellular nevi occupying a mean of 17 percent of the total body surface area collected from plastic surgical centers in England and Wales. During the period of observation, which totaled 337 years, two patients developed and died of metastatic malignant melanoma. A melanoma risk of 8.52 percent during the first 15 years of life is calculated. Although a high risk of melanoma must weigh heavily in favor of early prophylactic excision, the management of large congenital nevocellular nevi is considered to be too complicated to permit the invariable adoption of a wholesale excisional policy.

Does the pulsed tunable dye laser have a role in the management of infantile hemangiomas? Observations based on 3 years' experience.

Over a 3-year period, 50 patients with strawberry hemangiomas and 7 patients with postinvolutional redness or telangiectasia were treated with the SPTL-1 laser (Candela Corporation, Wayland, Mass.). The SPTL-1 laser emits pulsed light at a wavelength of 585 nm with a pulse duration of 450 ms. Lesions with a superficial red component were treated even if they had a significant subcutaneous component; however, wholly subcutaneous lesions were excluded. The series included 42 female patients aged between 1 and 72 months (mean 14 months) and 8 male patients aged between 3 and 12 months (mean 7 months). The mean number of treatments administered was 3.8 (range 1 to 8), and the average number of pulses per patient was 55 (range 2 to 350). This series also included 7 patients (6 female and 1 male) with postinvolutional redness or telangiectasia with a mean age of 12 years (range 2 to 23 years). They received an average of 3.4 treatments per patient (range 2 to 8) with an average of 35 pulses per treatment session (range 3 to 150). In this study group, life-threatening complications secondary to the hemangioma were rare in that only one patient suffered from an airway obstruction requiring a tracheostomy and three patients suffered from complete visual occlusion. A significant improvement in color was achieved in 30 patients (53 percent), but there was no appreciable reduction in bulk in any of the lesions despite repeated exposure to laser light.

Extended application of the biceps femoris musculocutaneous flap.

Since its description in 1977, the use of the biceps femoris musculocutaneous flap has been largely limited to reconstructions around the hip and perineum in paraplegic patients. The safety with which this flap can be transposed has been questioned owing to the segmental nature of its blood supply. Cadaver dissections in 10 fresh lower limbs showed that anterolateral transposition could be achieved without the need to sacrifice any of the major vascular pedicles (numbering two to three) which penetrate the long head of the muscle within 10 to 14 cm of the ischial tuberosity. We report on the use of this flap to resurface the anterolateral aspect of the lower thigh and restore stability and extension to the knee joint following extensive damage to the quadriceps mechanism.

Cutaneous malignant melanoma in children and adolescents in Scotland, 1979-1991.

All cases of cutaneous malignant melanoma in Scotland have been registered by the Scottish Melanoma Group since 1979, and there are currently more than 4700 cases on the registry. Of these, only 50 cases are in patients 18 years of age and younger (1.04 percent of all melanomas); 15 of these were prepubertal, i.e., 14 years or younger (0.3 percent of all melanomas). The nine cases of documented metastases occurred in children with tumor thickness of 1.50 mm or more, with only one of these metastases occurring in a prepubertal child. Eight of these patients with metastatic disease died, with a maximum survival of 4 years. A reliable clinical history was obtained from the families of 23 patients. Eight of them had a history of preexisting congenital nevocellular nevus. In this series, no case arose in a large congenital nevocellular nevus. Histological review showed that the majority of cases (58 percent) exhibited typical cytological and architectural features of malignant melanoma. In the remaining cases, the lesions were difficult to fit into any of the classic patterns of malignant melanoma or of the known benign nevocellular lesions.

The island posterior calf fasciocutaneous flap: an alternative to the gastrocnemius muscle for cover of knee and tibial defects.

The gastrocnemius muscle remains the workhorse for providing soft tissue over the knee and upper tibia. Nevertheless, we have found the island posterior calf fasciocutaneous flap to be a valuable alternative. We describe 10 cases in which an island posterior calf fasciocutaneous flap was used to cover defects over the knee and tibia. Three cases were after knee arthroplasty wound dehiscence, three cases were of traumatic soft-tissue loss, three cases involved replacement of unstable skin, and one case required closing a synovial fistula. This series is compared with 10 contemporaneous consecutive cases of soft-tissue loss around the knee that were reconstructed with a gastrocnemius muscle flap. Nine posterior calf fasciocutaneous flaps survived completely, and one flap had to be replaced because of poor flow. Although this flap is technically more demanding, we have found that it offers some advantages over the gastrocnemius. These include a greater flexibility of size and shape, a longer arc of rotation to reach suprapatellar defects, the provision of sensate skin with protective though crude sensation, less bulk, and the avoidance of a twitch. The flap is also easy to re-elevate from the recipient site for subsequent orthopedic work.

Treatment of nevi aranei with the pulsed tunable dye laser at 585 nm.

One hundred children aged < or = 12 years with spider nevi of the face have been treated with the SPTL-1 laser. The laser emits pulsed light at a wavelength of 585 nm, with a pulse duration of 450 microseconds. The series included 37 boys and 63 girls. Patients whose spider nevi were previously treated with other methods were excluded. In 97 cases the lesions were completely removed, but 29% of them required more than one treatment session. Six months later, two patients had mild recurrence of the nevi, which required further treatment. No signs of scarring or of textural or permanent pigmentary changes have been noted.

The role of cross-finger flaps in the primary management of untidy flexor tendon injuries.

This is a report of five patients who sustained untidy division of flexor tendons in zones 1 and 2, associated with overlying soft tissue loss. Contrary to traditional teaching, the tendon injuries were repaired primarily, and the tissue loss was made good with a cross-finger flap. At final evaluation, three cases were assigned excellent grades and two cases fair grades by Kleinert criteria. This unexpectedly favourable outcome may be due to a quality of the inner surface of the cross-finger flap and/or to staggering of the skin and tendon suture lines.

Functional deficit following loss of continuity of the long extensors of the fingers: a method of assessment.

A method for assessing hand function following loss of the long finger extensors in Zones 6 and 7 (Verdan, 1968) is described. It relies on a number of mechanical and functional tests combined with a detailed questionnaire.

Long term hand function without long finger extensors: a clinical study.

This study examines the premise that, following severe injuries to the dorsum of the hand, reconstruction of the long extensor tendons of the fingers may not be necessary for many patients. The long-term hand function of nine patients who sustained such injuries and had operations to provide skin cover only, has been comprehensively assessed using objective tests and a detailed questionnaire. It is concluded that provision of skin cover followed by intensive early mobilisation may be an adequate management of these injuries.

Partial thumb reconstruction using the proximal skin paddle radial artery island flap.

Four cases of partial thumb reconstruction using the radial artery island flap are presented. The flap will provide in variable amounts all the elements required for reconstruction of a severely damaged thumb.

A case report of frontonasal dysplasia.

The following report describes a case of mild frontonasal dysplasia, a rare congenital anomaly affecting the nose and frontal bone. Our patient was referred at 2 months of age with a complex nasal skin and tip deformity. This report outlines management of this patient and reviews the literature with regard to presentation and classification of this condition.