Awf A. Quaba

Lower limb reconstruction using the islanded posterior tibial artery perforator flap.

Background: The islanded propeller-design posterior tibial artery perforator flap is a versatile local reconstructive option for defects of the lower leg, ankle, heel, and foot. Methods: A retrospective review of patients undergoing this procedure from 1989 to 2009 was performed. Case note analysis was performed to determine demographic and perioperative factors, and complications and outcomes. Results: One-hundred six flaps were islanded on a single perforator from the posterior tibial artery in 100 patients (six bilateral). Seventy-two percent of defects were at the lower third of the leg, and 10 percent were at the ankle, heel, or foot. The median angle of rotation about the perforator was 160 degrees (range, 60 to 180 degrees). Eighty-eight percent of flaps had associated fractures, 60 percent were managed using intramedullary nailing, and 44 percent were Gustilo grade IIIb fractures. Five percent of patients subsequently developed osteomyelitis, and the primary nonunion rate was 9 percent. There was an 8.5 percent complete and 12 percent partial flap failure rate, both associated with cigarette smoking, diabetes, and peripheral vascular disease. Limb salvage for complete flap failures included free muscle flap transfer in six cases and below-knee amputation in three cases. Conclusion: The islanded propeller-design posterior tibial artery perforator flap provides reliable coverage of lower limb defects, particularly of the lower third.

A five year review of islanded distally based fasciocutaneous flaps on the lower limb.

The use of the distally based islanded fasciocutaneous flap is described in 61 patients with lower limb defects and its application in coverage of compound fractures of the tibia is highlighted. A total of 66 flaps were raised from the posteromedial border of the leg, based on a single perforator off the posterior tibial artery. Flap coverage extended to include defects of the lower one third of the leg (n = 47) as well as the ankle, heel and foot (n = 4). Bony stabilisation was performed with a tibial intramedullary locking nail in 30 out of 53 fractures; mean time to bony union was 5.9 months. Mean operating time was 1.7 hours and mean hospital stay was 25 days (range 8-98 days). Mean follow-up time was 13 months (maximum 5 years). Twenty-five flaps were used to cover Gustilo IIIb fractures primarily, with a 20% complication rate in this group. The flaps were used preferentially in males and in older females. The overall flap failure rate was 7.6%, with a further 10.6% of flaps suffering from tip necrosis and haematoma formation. Contributory factors to suboptimal healing included the presence of peripheral vascular disease and heavy smoking.

Sturge-weber Syndrome and Dermatomal Facial Port-wine Stains: Incidence, Association with Glaucoma, and Pulsed Tunable Dye Laser Treatment Effectiveness

Background: Laser therapy is the optimal approach for treating port-wine stains, but whether it is effective for patients with facial dermatomal port-wine stains and Sturge-Weber syndrome is undetermined. This project aimed to verify the incidence of Sturge-Weber syndrome and glaucoma within the population, compare the response in syndromic and nonsyndromic patients with facial dermatomal port-wine stains to laser, and determine the treatment response in relation to dermatome and color. Methods: The authors retrospectively reviewed 874 patients with facial port-wine stains (203 displayed a dermatomal pattern). Pretreatment and posttreatment photographs were assessed clinically and recorded on a statistically reliable percentage gradient. Results: Sturge-Weber syndrome was diagnosed in 30 patients. Twelve patients had glaucoma, with the port-wine stains involving the ophthalmic (V1) division of the trigeminal nerve. The highest proportion of patients with glaucoma came from those with involvement of the maxillary (V2) and/or mandibular (V3) division of the trigeminal nerve. No patients had Sturge-Weber syndrome with V3 port-wine stains alone. After laser therapy, only 45 percent of syndromal patients and 55 percent of nonsyndromic patients had a satisfactory outcome (>50 percent) in color and size reduction of dermatomal port-wine stains. Conclusions: The incidence of Sturge-Weber syndrome was 3 percent in patients with a facial port-wine stain. There was an increased risk of Sturge-Weber syndrome with involvement of V1 port-wine stains and no risk with involvement of V3 port-wine stains alone. Laser treatment produced unsatisfactory outcomes in patients with facial dermatomal port-wine stains. V3 port-wine stains responded best and V2 worst to laser.

Tissue expansion in the treatment of tubular breast deformity

Four cases of tubular breast deformity were treated using tissue expansion. The expanders were inserted through either an axillary or an infra-mammary approach in as low a position as possible. The expanders were then over-inflated and allowed to settle for a period of time before removal and insertion of a permanent implant. We present our experience using this technique and the complications and problems we had to deal with.

Experience with the adipofascial turn-over flap

Use of the adipofascial turn-over flap has been extended to cover such complex wounds of the extremities as defects over exposed joints and fracture sites. Experience with 10 consecutive cases and long-term follow-up confirmed that this flap is easy to plan and quick to raise, with minimum donor site morbidity and high success rate.

Outcomes of 52 patients with congenital melanocytic naevi treated with UltraPulse Carbon Dioxide and Frequency Doubled Q-Switched Nd-Yag laser

BACKGROUND A variety of treatment options exist for the management of congenital melanocytic naevi (CMN). Surgical treatment has been the traditional approach. Recently, lasers have been introduced to treat CMN. This study assesses the effectiveness of UltraPulse Carbon Dioxide (UCO2) and Frequency Doubled Q-Switched (FDQS) Nd-Yag laser up to a 15 year period which is the longest follow-up period of any study, as far as we are aware. MATERIALS & METHODS We performed a retrospective review of 52 patients with 314 CMN, treated with UCO2 laser and FDQS Nd-Yag laser. The reduction in visible pigmentation, signs of recurrence and any adverse skin changes were evaluated clinically by two clinicians independent to the laser operator. RESULTS There was minimal visible pigmentation after completion of treatment in 40 patients. Treatment failure occurred in 5 patients, recurrence in 5 and partial success in 2. 5 patients developed hypertrophic scarring, 1 developed hyperpigmentation and 1 patient developed an intracranial melanoma. 87% of patients were satisfied with their treatment and in hindsight would not have chosen surgery. Mean follow-up period was 8 years (interquartile range 3-11 years). CONCLUSION UCO2 and FDQS Nd-Yag lasers are clinically useful treatment options for patients with CMN and have minimal complications. This combined laser regime is particularly effective for the treatment of CMN in cosmetically sensitive and anatomically critical areas, especially when surgical excision may not be straight forward and/or leave unacceptable scars.

Clinical experience with the PLDL-1 (Pigmented Lesion Dye Laser) in the treatment of pigmented birthmarks: a preliminary report

Twenty patients aged between 2 years and 17 years (mean 9 years) with pigmented birthmarks, mainly of the head and neck, were treated with the PLDL-1 laser (Pigmented Lesion Dye Laser--Candela Corporation, Wayland, Massachusetts, USA) which emits light with a wavelength of 510 nanometers and a pulse duration of 300 +/- 50 nano-seconds. Nine patients (45%) showed excellent results after a test-patch was performed. Two patients (10%) showed some lightening of colour after initial test-patch. Six patients (30%) showed no improvement and 3 patients (15%) showed some hyperpigmentation at the test-patch sites which had not disappeared at 6 months follow-up. There was no change in the clinical behaviour at 6 months follow-up and no evidence of scarring was encountered.

Epithelioid sarcoma masquerading as Dupuytren's disease

Epithelioid sarcoma is a rare and deceptive lesion, often confused both clinically and on histopathological examination with other malignant processes. The surgical course of two patients with initial diagnoses of Dupuytrens disease is described. Early biopsy of all unusual fibrotic lesions on the palm is recommended. An aggressive surgical approach to confirmed malignancy is mandatory.

A two-year review of pain control during laser therapy using the flashlamp pulsed dye laser

Laser therapy is now accepted as the treatment of choice for port wine stains. Patient reaction to laser light exposure and methods used to control pain during 1357 treatment sessions for 350 medium to large port wine stains using the SPTL-1 laser (Candela Laser Corporation) are reported. In the majority of cases (86%) it was necessary to use either general anaesthesia or some other form of local pain control.

An adipofascial turnover flap for soft tissue cover around the clavicle

Skin defects overlying a clavicular fracture are uncommon. Soft tissue cover is essential to avoid osteomyelitis and non-union. We present two cases of exposed fractures of the middle third of clavicle following osteosynthesis. Soft tissue cover was provided by an adipofascial turnover flap based on the inferior edge of the defect. The flap was raised with considerable ease and its vascular supply was reliable. There was minimal donor site morbidity and the aesthetic outcome of the reconstructions was excellent.