Donald A. Hudson

Some thoughts on choosing a Z-plasty: the Z made simple.

The Z-plasty and its variations are techniques commonly performed in plastic surgery. However, there are few descriptions and comparisons of the various types of Z-plasty. This article examines the mechanics of the Z-plasty and its variations. Understanding the geometry of the different variations will allow selection of the most appropriate Z-plasty for contracture release.

Missed closed degloving injuries : Late presentation as a contour deformity

Closed degloving injuries are uncommon, and the diagnosis may be missed at the time of acute trauma. This study reports on seven patients seen during a 5-year period who presented with a contour deformity a number of months after the initial closed degloving injury. The median time to presentation was 1.4 years. In five of the seven patients, the contour deformity was present on the lateral thigh, and in two patients it occurred on the calf. Liposuction was employed to treat five patients, and all these patients reported an improvement in the contour of their limb. In two patients, because of an irregular, gritty deformity, liposuction was unsuccessful, and an open approach was required. The closed degloving injury with a contour deformity usually follows a pedestrian-motor vehicle accident. These patients present months later requesting corrective cosmetic surgery. Liposuction will improve the silhouette in most patients, but an open approach may be required where fat necrosis and heterotopic calcification have occurred.

Repeat Reduction Mammaplasty

Repeat reduction mammaplasty is an uncommonly performed procedure. Currently, no clear operative guidelines of management exist. Sixteen patients (28 breasts) with a mean age of 29 years (range, 13 to 52 years) underwent repeat breast reduction over an 11-year period. Before the first reduction, the mean notch to nipple distance was 29.6 cm (range, 24 to 38 cm) and mean nipple to inframammary crease distance was 15.5 cm (range, 12 to 18 cm). The mean mass of tissue excised was 615 g per breast. A number of different pedicles were used (six inferior, five superior, four superomedial, one unknown). All patients subsequently developed pseudoptosis. The nipple to inframammary crease distance was a mean of 11.4 cm (having initially been set at 7 cm) before the second procedure. At the second operation, two patients (three breasts) had their initial pedicles transected and the nipple-areola complex moved, and both patients developed vascular compromise of the nipple-areola complex (two breasts). Where the same pedicle was used in the second operation (five patients, 10 breasts), one patient developed unilateral nipple-areola complex necrosis. In eight patients, because of the development of pseudoptosis, the nipple was in a satisfactory position, and therefore only an inferior wedge of tissue required excision. This was performed without nipple-areola complex compromise, irrespective of the initial pedicle. The mean mass of tissue excised in the second operation was 325 g per breast (range, 120 to 620 g). Fourteen patients were available for follow-up after a mean of 5.1 years (range, 3 months to 11.7 years) following the repeat reduction mammaplasty. In the repeat breast reduction, where nipple-areola complex transposition is planned, the initial pedicle should be reused to maintain nipple-areola complex perfusion. Where the initial pedicle is not known, a free nipple graft may be the safest option. In patients with pseudoptosis, in whom the nipple does not require transposition, an inferior wedge of tissue can be safely excised, irrespective of the initial pedicle.

The management of skin infarction after meningococcal septicaemia in children

The clinical course and management of 21 children (12 females, 9 males; mean age 2.4 years) with skin necrosis secondary to meningococcal septicaemia is described. Skin necrosis was most commonly sited in the lower limbs (20 patients). Sixteen patients had multiple areas of involvement and amputation of the digits was required in 5 patients. One required an above knee amputation. Small areas of skin necrosis were managed conservatively (4 patients) but larger areas required debridement and grafting. Skin grafting was delayed in 15 patients and graft loss occurred in 8. Multiple grafting procedures were required in 6 patients. Scar revision was required in 6 patients. Nutritional support is also an important component of management.

The clinical significance of oncogene expression in subungual melanoma

Subungual melanoma is a particularly aggressive tumour. However, biological investigations of its behaviour are presently lacking due to its comparative rarity. In order to study the biology of this disease, the activity of the c-myc oncogene was studied in tumours from 24 patients with subungual melanoma using the technique of flow cytometry. High levels of oncoprotein were found in all tumours and exceeded that documented in other varieties of cutaneous melanoma. Survival analysis revealed that stratification of patients according to oncogene activity provided a useful prognostic marker with shorter disease free interval (log rank test, chi 2 = 6.6, P = 0.01) and overall survival (log rank test, chi 2 = 3.6, P = 0.07) in tumours with high oncoprotein levels. This is the first study to investigate oncogene expression in subungual disease and supports its potential application as a prognostic marker.

Another method to prevent venous thrombosis in microsurgery: an in situ venous catheter.

Free-flap failure is in the order of 4 to 10 percent. Heparin is more effective at preventing venous thrombosis than arterial thrombosis. This study was undertaken to investigate the efficacy of delivering heparin at a high dose locally but low dose systemically (heparin infusion via a catheter placed proximal to the venous anastomosis) to prevent venous thrombosis in microsurgery. A model of venous thrombosis was first established by a venous inversion graft in the rat femoral vein (this was performed in seven animals and resulted in 100 percent thrombosis). Saline and heparin were delivered proximal to the inverted vein graft to assess the effect of each in preventing venous thrombosis. Flow/patency distal to the inverted vein graft was assessed by observation under the microscope, the milk test, and rate of flow (flowmeter). Saline infused via a catheter proximal to the venous inversion graft resulted in 100 percent thrombosis in 10 animals. Heparin (100 U/ml at 2 to 3 ml/hour) infused through a catheter for 2 hours proximal to the anastomosis resulted in flow in all 10 animals during the infusion. Blood was also taken before beginning the procedure (control) and after the heparin infusion distal to the anastomosis (local partial thromboplastin time) as well as in the contralateral femoral vein (systemic). The control for all animals that received heparin was <3 minutes. The systemic partial thromboplastin time after heparin infusion was <3 minutes in seven animals, 3.3 minutes in two animals, and >7 minutes in one animal. The local partial thromboplastin time distal to the inverted vein graft was >10 minutes in nine animals and 3.7 minutes in one animal. The study also had a clinical component, in which a catheter was placed in a vein of the free flap, and heparin was infused over 5 days. This technique has been used in 83 consecutive free flaps. In three recent free flaps performed on the limbs, the local partial thromboplastin time (close to the anastomosis) was raised but the systemic time was normal. This technique offers a method in preventing venous thrombosis in microsurgery. It is simple to implement and is not associated with the systemic complications of heparin.

Impacted knife injuries of the face

Impacted knife injuries of the face are uncommon. Associated vascular, ocular and neurosurgical injuries should be excluded. The impacted knife should be removed in theatre. Four patients who presented with this injury are discussed.

A paradigm shift for plastic surgeons: no longer focusing on excising skin excess.

Plastic surgery is undergoing another quiet revolution—not so much in new techniques and technology, although these are occurring, but in concepts and understanding of the effect these newer technologies are having on human tissue. For decades, plastic surgery, especially cosmetic surgery, was concerned essentially with dealing with “excess” tissue. Because the fundamental working tissue of the plastic surgeon was the skin, the focus of the specialty was developing methods of removing excess skin. In a sense, this is illustrated by the traditional subcutaneous rhytidectomy, in which skin undermining was extended further and further. No other method was considered to exist to deal with the excess. However, the development of newer techniques (e.g., liposuction, endoscopic surgery) and the availability of botulinum toxin have led plastic surgeons to re-examine their methods of dealing with the “excess” and have questioned the dogma of focusing on the skin to achieve results. In fact, newer concepts regarding skin mechanics have evolved as a result of these techniques; they have demonstrated that surface changes may be effected by methods other than simple or sophisticated skin excision. Whereas these concepts have been alluded to in the plastic surgery literature, this editorial attempts to highlight these concepts and to provide a composite picture for reflection and consideration.

The cross-leg flap: still a useful flap in children

Reconstruction of the distal lower limb and foot is a difficult problem, especially where large areas of skin loss have occurred. The cross-leg flap is a safe and reliable alternative to free tissue transfer in paediatric lower limb trauma. By incorporating fascia or muscle the versatility of the flap can be enhanced. Our experience with the cross-leg flap in children during the last 5 years is discussed.

Letter: The influence of different sizes and types of wound fillers on wound contraction and tissue pressure during negative pressure wound therapy.

Dear Sir We congratulate the researchers from the Lund group, who have added yet another building block to our knowledge of the mechanism of action of negative pressure wound therapy (NPWT) with their article titled ‘The influence of different sizes and types of wound fillers on wound contraction and tissue pressure during negative pressure wound therapy’ by Anesäter et al. (1). Although our processed meat experiments demonstrated that tissue pressure increased during NPWT for up to 3 cm from the dressing (2), we too found that this pressure dissipated more rapidly in human tissues (unpublished data), in keeping with Anesäter et al. (1) In most instances we found that there was very little increase in tissue pressure beyond 1 cm, although this distance varied in different wounds (unpublished data). The difference in how quickly pressure dissipates in processed meat compared to human tissues is likely to be attributed to the homogenous structure of processed meat and its inherently higher substance pressure (the meat is supplied in a compressed form, in a tight plastic wrapping). Pressure is therefore conducted further through the processed meat, with less dissipation than would occur in living, inhomogeneous and less tense tissues. We have our reservations regarding the findings that pressure is reduced within 0.1 cm from the wound (1). It seems counterintuitive that something which is applying a compressive force to tissues can simultaneously reduce the pressure in these tissues. The fact that the superficial tissues are compressed (implying increased tissue pressure) is not only supported by the surface appearance when the dressing is removed but by the fact that it is possible to obtain haemostasis from an oozing wound surface by applying NPWT (3). The findings of Anesäter et al. may be explained by the fact that at 0.1 cm from the wound edge, there is very little tissue to shield the sensor from the hypobaric air pressure within the dressing. During macrodeformation, the sensor may partially come into contact with the hypobaric pressure over the wound, thereby not giving a true reflection of tissue pressure. We differ from the authors that larger foam results in greater tissue pressure than smaller foam. Preliminary in vitro work done at our unit demonstrated that large foam generated greater compression than smaller foam in both circumferential and non circumferential NPWT (unpublished). The findings of Anesäter et al. can likely be explained by our observation that the contraction force of foam appears to be related to the ratio of the total pore volume