Dariush Nikkhah

Applications of Smartphone thermal camera imaging system in monitoring of the deep inferior epigastric perforator flap for breast reconstruction

The rise in Smartphone availability has brought about the development of multiple mobile applications and devices utilized in the clinical setting. Hardwicke et al. have described the use of the FLIR ONE miniature thermal imaging camera (FLIR Systems, Wilsonville, Ore) in the evaluation of patients undergoing free tissue transfer. Thermal imaging captures the infrared radiation (IR) emitted from the skin surface and has been extensively used in plastic surgery as a means of determining burn depth, detecting post-operative infection, and postoperative free flap monitoring. The smartphone-friendly product enables clinicians to utilize this technology at a fraction of the price of standard thermographic cameras. The device clips into the mobile phone charging port and requires the installation of the FLIR ONE mobile application to operate. It possesses both a thermal and digital camera that takes photographs simultaneously. The images are then merged by the software allowing for the addition of greater physical detail an otherwise raw thermal reading. Hardwicke et al. argue that despite low image resolution and propensity for background thermal interference, it serves as an effective and inexpensive method of locating perforating vessels and evaluating overall tissue perfusion. We have used this in the peri-operative assessment of patients undergoing deep inferior epigastric perforator (DIEP) flap breast reconstructions. The device is portable and its software is similar to that of traditional Smartphone cameras which makes it easy to use and requires no additional training, however, factors such as vasoconstriction, warming blankets, or low ambient temperature significantly impact on accuracy. The heat signal identified by the camera strongly correlates with the position of the perforators as demonstrated by pre-operative radiological investigations and Doppler findings, even in the face of abundant overlying soft tissue (Fig. 1A). We propose that the perforators are best visualized following a 3–4 minute period of cooling of the skin as this will result in the faster warming of tissues immediately adjacent to the vessels allowing for more accurate localization (Fig. 1B). We are currently investigating additional uses of this device including monitoring of digital replantation and pre-operative assessment of hand trauma patients. Our positive experience with the camera is in keeping with that described by Hardwicke et al. and there is currently a need for larger comparative studies in order to better evaluate the clinical applicability of the FLIR ONE thermal imaging system.

Cross-clamping of bony stumps in preparation for osteosynthesis in digital replantation.

Stable bony osteosynthesis is essential in digital replantation and provides a platform for success in subsequent steps in the procedure. To aid in rapid osteosynthesis bone ends must make accurate contact; this will ensure effective bony union. Bony shortening is often necessary to allow for a tensionless anastomoses avoiding the need for vein grafting in some cases. It also enables the surgeon to accurately shape the recipient and amputated bone parts, which is particularly the case in crush avulsion injuries. Furthermore, shortening of the bony stumps can enable anastomoses outside of the zone of trauma. However, achieving an accurate and clean cut can sometimes be difficult, as one has to stabilize the amputated and recipient bone. We describe a few simple technical maneuvers that allow for efficient preparation of bone stumps before osteosynthesis. Preparation follows the standard principles; periosteum and surrounding soft tissues are stripped circumferentially from the bony stumps to allow for a clean cut with a hand held saw. One must also ensure that the soft tissues and prepared neurovascular bundles are pulled away so that they are not caught in line with the saw. One can place a glove over the soft tissues and to shorten the bone if necessary through the aperture of the glove. The key maneuver to allow for quick shortening is to place two clamps across the bone stump to stabilize it (Fig. 1A). Often it can be difficult to get a clean trans-

Atraumatic skin sparing mastectomy flap retraction for internal mammary vessel dissection in autologous breast reconstruction

Internal mammary harvest for recipient vessels in deep inferior epigastric perforator (DIEP) breast reconstruction was first described by Haranisha. Microsurgery in these cases can be challenging as one has to operate in a small field, which is deep and furthermore the movement of the chest can result in unwanted movements. Gaining adequate space and having a reproducible method of retraction for the surrounding mastectomy skin flaps is important so that the set up for microsurgery is comfortable. Exposure of the internal mammary vein (IMV) and artery (IMA) can either be between the rib or by removing a rib; there are advocates for both but little evident one is superior to the other. Once mastectomy is performed or the mastectomy skin flaps are elevated in a delayed case, the pectoralis major is divided across its fibers. The third rib is removed or if there is sufficient space through the interspace access to recipient vessels is achieved through this approach. A self-retaining retractor is placed across the cut end of the pectoralis major. However in cases of immediate breast reconstruction, the medial tissues can obscure the view and access to the IMA and IMV can be suboptimal. Often it can be difficult to put another retractor here; some have used hooks to pull the skin flaps aside, however this can leave marks on the tissues and theoretically can result in pressure necrosis by occluding the sub-dermal arterial plexus. We describe a technique that enables adequate visualization of the medial intercostal spaces for internal mammary vessel dissection in skin sparing mastectomy incisions while minimizing the need for metallic retractors. The technique involves using 2.0 Vicryl stitches as an alternative to a selfretaining retractor. The surgeon simply takes a bite from the medial edge of the pectoralis major where it inserts into the sternum. The stitch is left long and placed over gauze to prevent a mark on the skin flaps (Fig. 1A). The suture is placed under two adjacent staples placed at any vector and a mosquito clamp is placed behind it to maintain retraction. The tension is set by pulling as hard as required and then using a mosquito clamp to secure the position. Several of these 2.0 Vicryl retraction sutures are placed to allow for comfortable microsurgical access (Fig. 1B). Once the vessels have been prepared, the mosquitoes can be released to relieve the tension on the skin flaps. This can be useful if the surgeon needs to take a break before microsurgical anastomoses. However as the Vicryl stitches remain in it is simple for the surgeon to set up the exact optimal exposure by reapplying the mosquito clamps behind the staples.

The Antia ‐ Buch Flap Revisited

About 10% of all basal and squamous cell carcinomas occur on the ear or pre-auricular area. The mainstay treatment of such lesions is surgical excision. The reconstruction of the defect that is left after complete excision remains a challenge for the surgeon due to the complex shape of the ear and thin adherent skin. The standard reconstructive options available are wedge excision with direct closure, skin grafting, local skin flaps, chondrocutaneous advancement flaps (as described by Antia and Buch) and multistaged reconstruction with tube pedicles. However, the sheer number of options suggests that none of these is perfect. We describe refinements to the original chondrocutaneous advancement flap described by Antia and Buch for the reconstruction of the upper to mid-pole of the external ear using a single-stage procedure that maintains both the shape and projection of the affected ear. Our primary aim in this study was to describe simple steps to help optimise reconstruction of helical rim defects by minimising cupping and distortion.

Technical Tip for Proximal Release During Open Carpal Tunnel Release Using a Subcutaneous Pocket.

Technical steps to avoid incomplete proximal release of the carpal tunnel are described. Local anaesthesia is infiltrated as a subcutaneous bleb over the distal wrist crease and extending 2-3 cm over the forearm fascia. Tumescence of local anaesthesia into the subcutaneous plane helps create a pocket between the forearm fascia and subcutaneous tissues. Intraoperatively a subcutaneous pocket is made above the transverse carpal ligament and antebrachial fascia with blunt dissection. A retractor is placed under the pocket, which facilitates optimal visualization to allow reliable complete proximal release of compression.The authors have found that this technique is reproducible and reliable across their collective experience.

Resurrection of an ALT flap with recombinant tissue plasminogen activator and heparin

The authors present the salvage of an anterolateral (ALT) thigh flap, which was congested secondary to venous thrombosis for a period of more than 12xa0h. This case report details the technical steps that were employed and the evidence base behind them.Level of Evidence : Level V, therapeutic study.

Novel Polypropylene Barbed Threads for Midface Lift-"REEBORN Lifting".

Ji Hoon Kim, MD Jae Don Seo, MD Jae Don Plastic Clinic Seoul, Republic of Korea Sir: I recent years, minimally invasive procedures for facial rejuvenation have become more popular. In 2012, the official statistics of the American Society of Plastic Surgery showed that the cosmetic surgical procedures decreased 12% when compared with 2000, but in the same time period, minimally invasive cosmetic procedures increased by more than 130%.1 Face lift with barbed thread is a novel alternative for these patients as it is less invasive procedure and can be performed through minimal incisions or punctures. Since the introduction of the first antiptosis threads (APTOS) by Sulamanidze et al2 in the late 1990s, several other techniques have been described using modifications of the initial threads in terms of the material, the direction of the barbs, and the insertion technique. Recently, novel polypropylene barbed threads sealed with distal mesh and temporal fixation mesh were introduced in the market with the name REEBORN (PrestigeMedicare, South Korea). Ideal candidates for thread lifts include patients with minimal signs of ageing, getting prominence of the jaw, deeper nasolabial folds, and ptosis of the malar fat pad. The REEBORN threads consist of 5 parts from distal to proximal as follows: (1) a smooth part that is used as a guidance for the insertion to the needle, (2) a segment with cogs, (3) mesh segment, (4) proximal cogs segment, and (5) smooth segment for fixation to the mesh and deep temporal fascia (Fig. 1). The advantages of the REEBORN barbed threads are the increased tensile strength and the placement in the sub-SMAS plane. The tensile strength apart from the cogs is ensured by the distal mesh, which with a pore size of more than 1 mm allows for less extensive scar formation. Furthermore, a separated segment of mesh is provided for the fixation to the deep temporal fascia, increasing the stability of the threads and the longevity of the lifting effect. The thread placement in a deeper plane compared to other threads reduces the suture extrusion and also the traction line during rest, and animation is avoided. The procedure can be performed under local anesthesia and sedation. For midface correction, 4 threads on each side of the face are indicated: 2 on the midface for malar fat pad lifting and nasolabial fold correction and 2 on the lower face for jowl correction. After a 2-cm incision in the temporal area, inside the hair-bearing skin to be invisible, a sub-superficial muscular aponeurotic system plane is created with a trocar and the threads are passed with a needle through a cannula. The proximal end of the threads is fixed to a mesh, and the deep temporal fascia and the distal free ends were cut. Our preliminary results using REEBORN threads for facial rejuvenation are satisfactory. Minor skin dimpling, bruising, and edema are common after the procedure and usually last 3 days to 1 week. Seven patients completed minimum follow-up of 6 months (6–13 months). During this period, the lifting effect was maintained and the patients were satisfied with the final result. None of the patients experienced major complications necessitating thread removal. Longer follow-up and more studies are necessary to prove the safety of the procedure and the longevity of the results (Fig. 2).