David A. Stewart

The histology of facial aesthetic subunits: Implications for common nasal reconstructive procedures

Reconstruction of cutaneous nasal defects is often a challenging problem with multiple solutions. Many factors must be considered when deciding on the appropriate reconstructive procedure, including optimally matching donor site skin to the original recipient site skin. To the best of our knowledge no objective study has been undertaken to examine which areas best match the histological features of skin from various nasal cosmetic subunits. We have undertaken a descriptive histological analysis of skin from 25 facial and nasal aesthetic subunits from four male Caucasian cadavers, aged 65-88. The three variables looked at were epidermal thickness, dermal thickness and density of pilosebaceous subunits. Our findings have been plotted on photographs of the face to provide visual maps of facial histological features by cosmetic subunit. Our results show that histologically, the best matched skin for reconstructing a given nasal defect is likely to come from an adjacent nasal subunit. Looking at distant donor sites, the helical root, helical rim and pre-auricular area are closest to nasal skin in terms of dermal thickness. In terms of density of pilosebaceous units, the helical root, pre-auricular area and lateral forehead are the three areas best matched to nasal skin.

Application of lower extremity injury severity scores in children

PurposeSevere lower extremity trauma presents challenges in decision-making in terms of reconstruction or amputation. While injury severity scores have been developed to aid decision-making in adults, evaluation of their use in children is limited.MethodsChildren presenting with severe lower limb trauma from 2000 to 2010 in a major trauma centre were identified from a trauma registry. Records were reviewed for details of the injury, surgical intervention, amputation and scores for the Mangled Extremity Severity Score, Limb Salvage Index, Predictive Salvage Index, Nerve injury, Ischaemia, Soft tissue injury, Skeletal injury, Shock, Age System and the Hanover Fracture Scale 1998.ResultsTwenty children (average age 8.7 years) were eligible for inclusion. There were three primary amputations and no secondary amputations. All of the scoring systems had poor specificity and would have recommended amputation in several limbs that were successfully reconstructed.ConclusionsCurrently available injury severity scores behave differently in children and adults. In their current format, these scores should not be used as an absolute indication for early amputation in children.

The Use of V-y Advancement Flaps for Closure of Pretibial Skin Defects After Excision of Cutaneous Lesions

MethodsWe retrospectively analyzed 88 consecutive V-Y flap closures of pretibial surgical defects of up to 45 mm in diameter. ResultsEight percent of patients developed wound infection, which showed a significant association with antihypertensive use. No bleeding complications were experienced in any of the patients, including 40 patients on antiplatelet or anticoagulation therapy. Health care costs were calculated as far less than those for patients treated with split skin grafting because of shorter hospital stay and fewer dressing visits. ConclusionV-Y flap closure is a safe and reliable technique and is a superior alternative to split skin grafting in appropriate defects in the pretibial area.

Peritoneal encapsulation as a cause for recurrent abdominal pain in a 16-year-old male

is a valuable diagnostic tool in these cases and early surgical intervention is ideal. Closing the defect with surrounding soft tissues is acceptable where faecal contamination prevents the use of a mesh. Both these methods yield excellent outcomes. Examining for the Howship–Romberg sign and the Hannington-Kiff sign in the elderly female patient with SBO is essential. These simple tests will guide the surgeon to correct diagnosis and definitive treatment.

Bilateral scaphotrapezium-trapezoid coalition with bipartite scaphoid: case report.

We report on a 15-year-old girl with bilateral scaphotrapezium-trapezoid coalitions and bipartite scaphoids. There was no history of trauma or any other associated pathology. Wrist pain was alleviated by arthrodesis of the pseudarthrosis of the scaphoid component of the coalitions. Coalition of the distal portions of the scaphoids may have interfered with union of 2 ossification centers of the scaphoid. It is also possible that the carpal coalitions predisposed the scaphoid to fracture and that this represents bilateral nonunion.

SUCCESSFUL REPLANTATION OF A FINGER IN AN 8-MONTH OLD CHILD

A successful replantation of an index fingertip in an 8-month old girl is reported. A literature review of replants in very young children suggests this is one of the youngest patients ever to undergo digital replantation and possibly the youngest finger replant performed.

Functional Outcome of Replantation of the Leg in an Infant: A Case Report with Six-Year Follow-up

Replantation of an amputated lower extremity has been described, but remains controversial because primary amputation can produce comparable functional results in adults1,2. Traumatic amputation and severe limb trauma in children is both less common and less well studied than in the adult population3-11. Children may have higher rates of limb survival because of their more rapid rate of fracture repair, lower rate of osseous nonunion, and greater potential for recovery after nerve repair12. In addition, very young children may exhibit greater central nervous system plasticity, which may contribute to enhanced functional recovery13. We present the functional outcome of the second-youngest reported case, to the best of our knowledge, of lower-extremity replantation, six years after traumatic amputation, replantation, and rehabilitation14. The study was approved under the audit provisions of the institutions Ethics in Human Research Committee, approval number 26146A. Written informed consent for publication was provided by the childs legal guardian. A fifteen-month-old boy sustained an amputation of the right leg, just below the knee, as the result of multiple blows from an ax, inflicted by a family member during a psychotic episode related to severe mental illness (Figs. 1 and 2). On arrival in the emergency department, the patient was in hypovolemic shock, with a barely recordable blood pressure. The amputated limb was placed in a sterile bag and cooled on ice. The infant was resuscitated with intravenous fluids and O negative blood, and he was transferred to the operating room within ninety minutes from injury. Fig. 1 Initial dissection and tagging of neurovascular structures. Fig. 2 Radiograph at presentation. The proximal part of the tibial segment was considered to be too short for standard internal fixation. External fixation was considered and rejected because of time constraints and the need …

Giant cell tumour of tendon sheath in a 4-year-old boy

intra-operatively. Peripheral margins were clear. Follow-up showed a good cosmetic result with no recurrence at 6 months. Infantile digital fibromatosis is a rare benign neoplastic condition, which occurs on the dorsal and lateral aspects of digits (Laskin et al., 2009; Reye, 1965). This case is unusual in both the age of presentation and the ulcerated appearance. The lesion presents in the first 3 months in one-third, with the majority presenting within the first year of life. Reports of IDF in older children and adults are rare (Grenier et al., 2008). The common presentation is one of a firm asymptomatic flesh-coloured or slightly red hemispherical nodule on the lateral or dorsolateral side of the digits. The nodules may be multiple and non-contiguous. The histological appearance under H&E staining is diagnostic. This is a benign lesion with reports of spontaneous regression. Results of surgical excision have shown around a 60% recurrence rate. Lower rates have been seen with more aggressive surgical approaches (Albertini et al., 2002). Our case shows that infantile digital fibromas may not present in the classic manner, nor in the classic age group and can be ulcerated. However, the anatomic location is a clue to include this pathology in ones’ differential diagnosis.