Frank R. Graewe

The Safety of Pedicles in Breast Reduction and Mastopexy Procedures

Nipple necrosis is a potential complication of breast reduction and mastopexy procedures that can be prevented if the surgeon is acquainted with the arterial blood supply to the breast, particularly the nipple–areolar complex (NAC). A review of the latest research on this with its clinical application is given.

Modified charles procedure using negative pressure dressings for primary lymphedema: A functional assessment

Objective: The Charles procedure is an aggressive operation usually only indicated for severe lymphedema as it often yields an unpredictable outcome. We modified this procedure in order to achieve predictable results. Methods: The modification entailed the use of a negative-pressure dressing after the initial debulking surgery and then the delay of skin grafting by 5 to 7 days. Patients were graded by means of a lower limb functional scale to assess their functional status pre- and postoperatively. Results: Eight patients with severe primary lymphedema underwent a modified Charles procedure. All patients underwent this procedure without any major complications with an average resection of 8.5 kg of lymphedematous tissue. Minor complications included operative blood loss and additional regrafting (3 patients). The average follow-up was 27.3 months. Conclusion: The results show a dramatic functional improvement in quality of life and a high overall satisfaction rate of patients undergoing this procedure. Our modification makes this a relatively simple procedure with a predictable outcome.

The Blood Supply of the Breast Revisited.

Background: Many surgeons are under the impression that the blood supply is clearly defined in textbooks. Unfortunately, the majority of textbooks supply inadequate information and illustrations can be misleading in many instances. None of the textbooks describe a segmental pattern of blood supply when in actual fact a basic segmental pattern does exist. The reason for inadequate information is the perpetuation of facts since the work of the pioneers Cooper and Manchot from one textbook to another. A paucity of research studies thereafter and the fact that the results of some of these studies did not find their way into textbooks is another contributing factor. Methods: The findings of research studies since the descriptions by Cooper and Manchot are analyzed and compared in an effort to find common ground and its clinical implication. Results: Researchers concurred on the main sources of blood supply; these are internal thoracic, lateral thoracic, anterior intercostal, and acromiothoracic (thoracoacromial) arteries. However, the different research studies showed considerable variation in the branches from the main sources to supply the nipple-areola complex. Conclusions: Even though the locations of the main sources of blood supply are constant, partial or complete absence of branches from the main sources does occur and therefore the blood supply to the nipple-areola complex is unpredictable. Cognizance of the basic segmental pattern and the variations resulting from embryologic development will be helpful for the surgeon to use or adapt a technique to minimize the risk of nipple necrosis.

Penile allotransplantation for penis amputation following ritual circumcision: a case report with 24 months of follow-up

INTRODUCTION Ritual circumcision complicated by gangrene is a leading cause of penile loss in young men in South Africa. This deeply rooted cultural tradition is unlikely to be abolished. Conventional reconstructive techniques using free vascularised tissue flaps with penile implants are undesirable in this often socioeconomically challenged group because donor site morbidity can hinder manual labour and vigorous sexual activity might lead to penile implant extrusion. The psychosociological effects of penile loss in a young man are devastating and replacing it with the same organ is likely to produce the maximum benefit. METHODS We first performed a cadaver-to-cadaver penile transplantation as preparation. After approval from the Human Research Ethics Committee was obtained, we recruited potential recipients. We screened the potential participants for both physical and psychological characteristics, including penile stump length, and emotional suitability for the procedure. A suitable donor became available and the penis was harvested. We surgically prepared the penile stump of the recipient and attached the penile graft. Immunosuppression treatment with antithymyocyte globulin, methylprednisolone, tacrolimus, mycophenolate mofetil, and prednisone were commenced. Tadalafil at 5 mg once per day was commenced after 1 week as penile rehabilitation and was continued for 3 months. We collected on quality-of-life scores (Short Form 36 version 2 [SF-36v2] questionnaires) before surgery and during follow-up and measured erectile function (International Index for Erectile Function [IIEF] score) and urine flow rates at 24 months post transplant. FINDINGS The warm ischaemia time for the graft after removal was 4 min and the cold ischaemia time was 16 h. The surgery lasted 9 h. An arterial thrombus required urgent revision 8 h after the operation. On post operative day 6, an infected haematoma and an area of proximal skin necrosis were surgically treated. The recipient was discharged after 1 month and first reported satisfactory sexual intercourse 1 week later (despite advice to the contrary). The recipient reported regular sexual intercourse from 3 months after the operation. An episode of acute kidney injury at 7 months was reversed by reducing the tacrolimus dose to 14 mg twice per day. At 8 months after surgery, the patient had a skin infection with phaeohyphomycosis due to Alternaria alternata, which we treated with topical antifungal medication. Quality-of-life scores improved substantially after the operation (SF-36v2 mental health scores improved from 25 preoperatively, to 57 at 6 months and 46 at 24 months post transplant; physical health scores improved from 37 at baseline to 60 at 6 months and 59 at 24 months post-transplant). At 24 months, measured maximum urine flow rate (16·3 mL/s from a volume voided of 109 mL) and IIEF score (overall satisfaction score of 8 from a maximum of 10) were normal, showing normal voiding and erectile function, respectively. INTERPRETATION Penile transplantation restored normal physiological functions in this transplant recipient without major complications in the first 24 months. FUNDING Department of Health, Western Cape Government.

Reconstruction of the lower eye lid with a rotation-advancement tarsoconjunctival cheek flap.

Repair of full-thickness defects of the lower eyelids poses a challenge because a graft in combination with a flap is typically used to replace either the posterior or the anterior lamella. This often results in aesthetically and functional unsatisfactory outcomes. A rotation-advancement tarsoconjunctival cheek flap, which reconstructs both posterior and anterior lamellae with vascularized tissue similar to the native eyelid, is described. Nine patients underwent reconstruction with a rotation-advancement tarsoconjunctival cheek flap. Indications, complications, and outcomes were evaluated. The follow-up time ranged from 6 to 60 months, with a mean of 23 months. The main indication for use of this flap is full-thickness defect of the lower eyelid between 25% and 75%, typically after tumor ablation. All patients had a functional and aesthetically satisfactory outcome. One patient underwent a revision canthoplasty. The rotation-advancement tarsoconjunctival cheek flap adheres to basic plastic surgery principles resulting in a satisfactory outcome: vascularized tissue is used to reconstruct the defect, the flap composition is similar to the native eyelid, that is, replace like with like, and the flap makes use of tissue that is in excess and therefore limits donor morbidity.

Cranial fasciitis presenting as a frontonasal mass

We report the unusual case of a newborn baby with cranial fasciitis of the frontonasal area. Herein, we present the clinical, pathologic, and radiologic findings of a male neonate with cranial fasciitis of the skull. Cranial fasciitis is a benign fibroblastic tumor related to nodular fasciitis, but it has a predilection for the scalp of children. One case has been described in neonates (Neurosurgery. 2001;48:430-435).

An unusual case of oromandibular–limb hypogenesis syndrome

The oromandibular–limb hypogenesis syndrome is a rare complex of jaw and limb defects with unclear aetiology. Multiple and variable deformities of the mandible, maxilla and tongue may occur in combination with a variety of limb defects. The wide range and combination of anomalies make classification difficult. A patient with all of the features of oromandibular–limb hypogenesis syndrome (except cranial nerve palsy) is presented. Despite severe micrognathia, synostosis of the jaws and soft-tissue synechiae between the hypoplastic tongue and the cleft palate, this patient had no respiratory difficulty and thrived with nasogastric feeding. The surgical management is discussed with emphasis given to the difficult airway and restoration of normal function of the tongue and jaws.

The Reverse frog position for harvesting bilateral free fibulas

The optimal positioning for the harvest of a fibula is with the patients hip and knee flexed, with the leg tilted away from the surgeon. However positioning can become difficult when bilateral fibulas need simultaneous harvesting. We describe the Reverse frog position which provides easy accessibility for two surgeon working simultaneously.