Don A. Hudson

Choosing the superomedial pedicle for reduction mammaplasty in gigantomastia.

Background: The optimal reduction technique for the treatment of macromastia greater than 1 kg remains controversial. Conventionally, breast amputation and free nipple grafting has been used, but this leaves a flat and insensate nipple. Anatomical studies have suggested the superomedial technique to be a safe choice in these patients. Methods: A retrospective study analyzing the outcome of reduction mammaplasty for macromastia greater than 1 kg using the superomedial pedicle technique was performed. Data were collected over a 10-year period from 1995 to 2005. All reduction mammaplasty patients with resection weights greater than 1 kg per breast were included in the study. Results: Sixty-one patients were included (122 breasts). The mean age was 29 years. The mean suprasternal notch to nipple distance was 35 cm on the left and 35 cm on the right, and the mean nipple to inframammary crease distance was 19 cm on the left and 20 cm on the right. The Wise keyhole reduction pattern technique was used for all patients. Mean follow-up was 12 months. The mean resection weight per breast was 1360 g for the left breast and 1398 g for the right breast. Fifteen different surgeons performed the operations over this period. All patients had viable nipples postoperatively; there was partial areola necrosis in eight breasts (6.5 percent), with only minor other complications, including T-junction breakdown in 22 breasts (18 percent) and dog-ear excisions. Conclusions: This study has confirmed the superomedial pedicle technique to be safe and reliable for resections greater than 1 kg.

Plantar melanoma: Results of treatment in three population groups☆

BACKGROUND The frequency of plantar melanoma varies widely in different population groups. The plantar surface is an infrequent site in white persons but is common in the black population. The effect of ethnicity on melanoma of the plantar surface has not previously been well defined. The aim of this study was to analyze the results of a standard protocol of treatment of melanoma of the sole in 3 homogeneous population groups treated during a 15-year period at a university referral hospital. METHODS A retrospective analysis of 1403 consecutive patients with melanoma treated between 1977 and 1991 was performed. Eighty-five patients (35 black, 25 white, and 16 of mixed ancestry) had primary cutaneous melanoma involving the sole of the foot. RESULTS Acral lentiginous melanoma was the most common histogenetic type and occurred in 49 patients. Significantly more black patients (20 of 35) had metastatic disease compared with white patients or groups with mixed ancestry (P < .05). The Breslow depth was significantly more advanced in black patients (7.1 mm) with stage I disease than in white patients (3.3 mm) or those of mixed ancestry (3.6 mm) (P < .05). The 5-year survival rate was 60% for white patients, 26% for black patients, and 24% for those of mixed ancestry. CONCLUSIONS Black patients were seen more frequently with advanced local disease, and nearly half had disseminated disease. Those of mixed ancestry had a histogenetic type resembling that of black patients, but the Breslow depth of penetration was similar to that of white patients. Education programs to heighten awareness of both patient and physician are required to enable earlier diagnosis and improve outcome.

Full-thickness skin grafts: maximizing graft take using negative pressure dressings to prepare the graft bed.

Background:Full thickness skin grafts (FTSGs) remain a good option for resurfacing defects of the face, neck, and dorsum of the feet. It results in soft, pliable, functional skin with minimal contraction. However, FTSG may result in patchy or irregular “take” resulting in recurrent contractures and pigmentary discrepancies. This study examines the use of a negative pressure dressing (NPD) to increase FTSG take. Methods:Wounds resulting from trauma, postburn contracture release, and an excision of a congenital nevus were included in the study. The wounds were prepared by surgical excision or debridement. A NPD was then applied for a period of 7 days, at which time the wounds were inspected and, if there was sufficient granulation tissue, covered with a FTSG. If the wound had not yet granulated sufficiently another NPD was placed and reassessed in 7 days. The FTSGs were harvested from the groin and abdominal area exactly to the size of the defect. A sponge bolster dressing was then applied. The take of the FTSG was judged using a grid of 1 × 1-cm squares. The wounds were measured and the amount of graft take was calculated as a percentage of the wound size. Complications in both the wound as well as the donor sites were noted. Results:Twenty-four patients were included in the study. The mean age was 6 years (range 1–14 years), including 9 burn contracture excisions, 14 road traffic accident-related injuries, and 1 excision of a congenital nevus. The site involved was the foot (6 patients), ankle (9 patients), axilla (2 patients), forearm (4 patients), face (2 patients), and the neck (1 patient). The average surface area of the defect was 78 cm2 (range 18–264 cm2). Groin skin was harvested in all the cases. The NPD was applied on average for 8 days (range 7–15 days). The mean graft take was 95% (range 70%–100%). Only 1 patient had significant graft loss of 30%. Donor site morbidity was low, attaining primary closure in all but 2. Mean follow-up was 9 months. Conclusion:The results of this study confirm that the use of NPD enhances FTSG take.

Computational Modeling of Microarterial Anastomoses With Size Discrepancy (Small-to-Large)

OBJECTIVE Among causes of anastomotic failure in microvascular surgery is vessel size mismatch. Where the option of an end-to-side anastomosis is unavailable, an end-to-end construct must be used. Several end-to-end techniques are described to deal with size mismatch. The aim of this study was to numerically model arterial flow patterns and wall shear stresses in four idealized end-to-end anastomoses, where the upstream or recipient artery is smaller. The four techniques modeled were: an invaginating anastomosis; a fish-mouth incision of the smaller vessel; an oblique section of the smaller vessel; and a wedge excision of the larger vessel. MATERIALS AND METHODS Flow rate in the right femoral artery of a single outbred male Wistar rat was recorded by transit time ultrasound. Initially, upstream vessel diameter in the models was set at 1 mm, and downstream at 2 mm. The wedge technique was further modeled using a shorter wedge, and using a downstream vessel diameter of 3 mm. Walls were deemed noncompliant. Flow was modeled by the finite volume method using the commercially available computational fluid dynamics code Fluent (Fluent Inc., Lebanon, NH; http://www.fluent.com). RESULTS Ring vortices were seen in the invagination and fish-mouth models and showed similar characteristics, although they were less pronounced in the fish-mouth model. The oblique section model demonstrated complex, spiral, counter-rotating vortices that dissipated downstream. Flow separation was least in the first wedge model, with centralization of flow during high but decelerating flow rate. Shortening the wedge length or increasing the downstream vessel diameter to 3 mm led to flow separation. Wall shear stresses were broadly similar for all constructs. CONCLUSION Of those modeled, excision of a wedge of the larger vessel proved the best construct. Where a vessel diameter ratio is 1:2, wedge length should be twice the diameter of the larger vessel. A vessel ratio of 1:3 leads to flow separation when using the wedge technique.

VADER (vacuum-assisted dermal recruitment): a new method of wound closure.

Acute wounds which cannot be closed primarily are usually closed with a split skin graft. However a split skin graft has both functional (where tendons are exposed) and esthetic sequelae (contour deformity, different skin in color and texture). A novel technique is described which allows delayed primary closure of either fasciotomy wounds or full-thickness defects after harvest of a free or pedicle flap. The technique described combines the bootlace suture technique (which achieves wound closure by progressive suture tightening) with the VAC (vacuum-assisted closure) system (which reduces tissue edema, facilitating movement of tissue, and also reduces bacterial contamination of the wound). Twelve of 14 wounds (average width of wound after insertion and tightening of bootlace suture was 5 cm) were successfully closed after an average of 8 days (range, 4–23 days) in 11 patients (mean age, 45 years; range, 18–77 years) using this technique. Of the 2 patients where the technique was not successful, one patient was noncompliant and the other developed wound-edge necrosis. Other complications were self-limiting. The combined use of 2 methods of wound management facilitates delayed primary wound closure.

Autologous Dermal Graft in Breast Reconstruction

Introduction:The role of allogenic dermis is well established in reconstructive breast surgery, where it acts as a hammock between the detached inferior border of pectoralis major and the inframammary fold. Method:The study reports on the outcome of 19 women (21 breasts as 2 were bilateral) in which autologous dermis was used rather than allogenic material. The autologous dermis was harvested from the abdomen, as a miniabdominoplasty in 15 patients, and from the contralateral breast in 4 patients having simultaneous breast reduction/mastopexy. In all, 15 women underwent immediate reconstruction (7 with tissue expanders, 8 with immediate prosthesis), whereas 4 patients underwent delayed reconstruction (with expanders). Results:Two patients developed infection requiring explantation. There were no abdominal complications after the miniabdominoplasty. The coverage of the prosthesis or tissue expander by the dermal graft was achieved on average in three-quarters of cases (range, just under two-thirds to 100%). The mean follow-up was 17 months (range, 6–36 months). Conclusions:Autologous dermis is a useful alternative to allogenic dermis. It is cheap and readily available. In patients having a contralateral breast reduction, there is no donor site. The risk of complications is not dissimilar to allogenic dermis.

A tale of two novel transplants not done: the ethics of limb allografts

When it becomes technically possible to perform a “ground breaking” surgical procedure, an important moral problem arises. In view of the strong incentive for surgeons to be the first to perform a novel operation, their judgments about whether such an intervention is justified may well be clouded. We describe two cases in which surgeons decided not to perform a novel transplant. In the second case transplantation continued to be considered until the ethical analysis performed in writing this paper was completed. #### Summary points At the Red Cross Childrens Hospital in Cape Town it was decided, on ethical grounds, against novel limb allografts for two patients—one with no hands and one with no hands or feet The costs to health and cumulative lifetime risks of immunosuppression for child recipients of a limb allograft are substantial and do not outweigh the functional benefits There are good reasons for not using “informed consent” to bypass the difficulties of weighing the benefits of limb allografts against the costs The ideal candidate for limb transplantation is somebody who could gain the most and for whom the associated costs and risks are lowest A potential recipient should be very close to this ideal if transplantation is to be morally justified In July 1994, a 3 year old boy was admitted to the intensive care unit at the Red Cross Childrens Hospital in Cape Town with meningococcal septicaemia. He developed infarction of all his fingers and these were amputated at the level of the carpus bilaterally with skin grafting of the stumps. In January 2000, a 4 year old girl was admitted to the same hospital, also with meningococcal septicaemia. She developed distal necrosis of all four limbs. Both hands were amputated just distal to the carpus, leaving three metacarpal stumps on the right hand and a vestige of …

Influence of vascular delay on abdominal wall complications in unipedicled TRAM flap breast reconstruction.

Surgically delaying a unipedicled lower abdominal transverse rectus abdominis musculocutaneous (TRAM) flap has been shown to improve flow within the flap. This delay, however, also affects blood supply and drainage of the entire anterior abdominal wall. The purpose of this study was to compare the abdominal complications between surgically delayed and nondelayed TRAM flaps. A retrospective case review of lower abdominal TRAM flap breast reconstructions was performed. A total of 35 patients were included in the study, of whom 15 had undergone delay and 20 had not. The patients were found to be matched by age and body mass index. There was a higher incidence of smokers (past or present) in the delayed series. Despite this, no abdominal flap complications were experienced in those who underwent delay. In the nondelayed series, however, three patients (15%) experienced delayed healing, and two flaps (10%) underwent severe necrosis (p = 0.047, chi-squared test). In the delayed series, one patient (7%) was found to have an abdominal bulge. No hernias were encountered. In contrast, two bulges (10%) and four hernias (20%) were identified in patients in the nonndelayed series (p = 0.6 and 0.09, respectively, chi-squared test). These data suggest that a preliminary delay procedure leads to a reduction in the incidence of abdominal wall complications in unipedicled lower abdominal TRAM flaps.