Kavit Amin

The psychological impact of facial changes in scleroderma

The physical disabilities associated with scleroderma are well known but the psychological impact of the condition has received less attention. Few studies have examined appearance related issues, most notably of the face. The aim of this study is to evaluate the psychological impact of facial, aesthetic and functional changes in scleroderma. One hundred seventy-one patients with a clinical diagnosis of scleroderma were recruited into the study. Digital photographs were objectively graded into groups based on severity of disfigurement as judged by an observer. Facial movement was recorded using a modified House–Brackmann Grading Scale. Psychological evaluation comprised the Derriford Appearance Scale short-form (DAS), the Noticeability and Worry score and the Hospital Anxiety and Depression Scale (HADS). Severity of disfigurement predicted decreased mouth opening, the extent to which participants judged their appearance as noticeable to others, and the level of appearance-related concern as measured by the DAS24. There was an inverse relationship with age. Facial changes were ranked as the most worrying aspect of the condition. This study shows facial disfigurement impacts on patient with scleroderma independent of functional changes related to systemic disease. The major difficulty is with the perceived noticeably of the condition to other people and the resulting self-consciousness in social encounters.

The drain game: Abdominal drains for deep inferior epigastric perforator breast reconstruction

INTRODUCTION The deep inferior epigastric perforator (DIEP) flap is often preferred for breast reconstruction as it allows for autologous reconstruction with less donor site morbidity versus transverse rectus abdominis myocutaneous (TRAM) flap reconstruction. Our group has presented and published data for the duration of donor site back drain use in latissimus dorsi (LD) flap breast reconstruction due to insufficient evidence and a requirement for further investigation in the literature; this evidence is still lacking for DIEP reconstruction. AIM To compare inpatient hospital stay, drainage parameters and donor-site complications associated with closed suction abdominal drain removal by post-operative day (POD) 3 regardless of output (early group), with removal after POD 3 where instructions were by drainage volume/24 h±output consistency (late group), in post-mastectomy DIEP reconstruction donor sites. METHOD A retrospective review of DIEP breast reconstructions, between January 2011 and July 2012, was undertaken to facilitate 1 year minimum follow-up per patient. RESULTS Of 78 patients who underwent DIEP breast reconstructions, 74 hospital records contained complete documentation. There were 41 patients in the late, and 33 in the early removal group; both groups were matched for age and number of donor site drains (2 per patient). Mean drain removal day (4.32±0.10 days vs. 2.87±0.06 days, p<0.0001), total drainage (518.90±41.53 mls vs. 283.79±18.06 mls; p<0.0001) and hospital inpatient stay were greater for patients in the late versus early group. There were no differences in total complications (21.95% (9/41) vs. 12.12% (5/33); p=0.46), seroma (4.88% (2/41) vs. 0% (0/33); p=0.20), dehiscence (4.88% (2/41) vs. 9.09% (3/33); p=0.47) or haematoma (7.32% (3/41) vs. 3.0% (1/33); p=0.42) rates between the late and early groups. DISCUSSION These data suggest significant advantages for patients who have abdominal drains removed early by POD 3, without increased post-operative complications including seroma rates; these data are in keeping with our LD data. We recommend drain removal and patient discharge by POD 3.

The Vascularized Medial Femoral Corticoperiosteal Flap for Thumb Reconstruction

Summary: We present an interesting method of shaping a vascularized medial femoral condyle (MFC) flap into a “neophalanx” for phalangeal reconstruction. Our patient presented with limited strength and function secondary to fracture nonunion of the proximal phalanx of the dominant thumb. Following excision of the pseudarthrosis, an MFC corticoperiosteal flap was harvested, sculpted into a prism shape and inset. The superomedial genicular pedicle was anastomosed to the princeps pollicis artery and a cephalic tributary. On follow-up, new bone growth was seen on radiographs and the patient had substantially improved function, with full metacarpophalangeal extension, a Kapandji score of 9, and a markedly reduced Disabilities of the Arm, Shoulder and Hand score of 2.68. The MFC flap is useful for reconstruction of bony defects, with minimal donor morbidity. This versatile vascularized flap can be crafted to requisite shapes and is useful for small defects in the hand, including phalangeal reconstruction.

Medial Sural Artery Perforator Flap: Using the Superficial Venous System to Minimize Flap Congestion

Use of the pedicled medial sural artery perforator (MSAP) fasciocutaneous flap has been widely reported in the literature for ipsilateral lower limb reconstruction. Depending on defect location, the MSAP flap may be utilized as a propeller or V-Y advancement flap [1]. This perforator flap is typically based on the proximal perforator of the medial sural artery supplying the gastrocnemius muscle. One of the main issues encountered when performing an MSAP flap is venous congestion [2], a commonly described complication in other perforator based flaps [3]. We describe a useful technique to overcome this problem by including the superficial vein into the original flap design. A 57-year-old woman was referred to our department with a malignant melanoma in the left popliteal fossa. Histologically the lesion was reported as having a 0.8 mm Breslow thickness. The resulting defect was 5 cm×5.5 cm (Fig. 1). Handheld Doppler was used to locate and mark the perforators preoperatively across the medial head of gastrocnemius. Although more accurate methods can be used to map the perforator, handheld Doppler offers time efficiency and reduces input from radiological investigations [4]. Flap harvest commenced with an incision placed above the medial border of the medial head of the gastrocnemius. A branch of the long saphenous vein superficial to the fascia was encountered and preserved and seen to enter the medial side flap (Fig. 2). Two perforators were identified. The vein was mobilized free from the lateral skin flap to provide enough mobility for flap advancement. The flap was raised subfascially from distal to proximal with identification and preservation of two MSAP (Fig. 3). The two perforators were skeletonised with minimal intra-muscular dissection. This ensured the flap could be advanced proximally 5 cm in a V-Y fashion and inset (Fig. 4). No venous congestion was encountered following flap inset (Fig. 5). This case report suggests that venous augmentation with the superficial branch of the long saphenous vein in MSAP flap improves venous drainage, as has previously been described by Hallock [2]. It can most effectively be utilized in V-Y advancement MSAP flaps, where the movement is unidimensional, as no rotation of the flap is required which may lead to vascular compromise and consequent flap compromise. In the distally based flap, the technique of phlebotomy to relieve flap congestion via an exteriorised segment of short saphenous vein has been described, contributing to favourable flap survival [5]. Short saphenous branch preservation is a useful and relatively simple method of reducing the risk of MSAP flap congestion without prolonging dissection time. Fig. 1 Wide local excision of malignant melanoma left popliteal fossa with resulting 5 cm ×5.5 cm defect. V-Y advancement flap designed based on a dominant perforator marked with an X. Fig. 2 The medially located superficial branch of the short saphenous vein. Fig. 3 Two median sural artery perforators were identified and dissected on the lateral aspect of the flap. Fig. 4 V-Y flap raised subfascially and advanced into defect. Fig. 5 Medial sural artery perforator flap 4 months postoperatively.

Burns from acetylene gas: more than skin deep

Oxyacetylene welding torches are commonly used in industry, yet serious burns are fortunately rare. When dealing with the sequelae of these burn injuries, one must be aware of the high pressure component of these flame burns, which can penetrate and dissect the subcutaneous tissue. Appropriate initial assessment and preoperative planning are, therefore, essential to exclude and identify problems such as, compartment syndrome, subcutaneous emphysema and acute carpal tunnel syndrome. We present a case in which an innocuous palmar burn revealed a penetrating flame injury into the carpal tunnel.

Subungual malignant melanoma - re-learning the lesson

The authors present two patients referred by colleagues after traumatic hand injury. However, upon closer inspection, both patients had pigmented lesions under the nail bed, which upon biopsy showed proven subungual malignant melanoma. The authors wish to emphasise the importance of this diagnosis, especially in emergency care.

Corrigendum: Fat harvest using a closed-suction drain

[This corrects the article on p. 288 in vol. 43.].

Latissimus dorsi intercostal artery perforator musculocutaneous flap in chest wall reconstruction.

We describe the latissimus dorsi (LD) intercostal artery myocutaneous perforator flap in reconstructing a defect after sarcomatous excision and our appreciation of anatomical descriptions and studies in modern day surgery. A 43-year-old female presented with a biopsy proven sarcomatoid carcinoma in the right posterior axillary fold which necessitated extensive resection to establish oncological clearance. Initial plan was to reconstruct the defect with a myo-cutaneous LD-flap based on the reliable thoraco-dorsal vessels. In the lateral decubitus position, standard markings for LD flap harvest with wider excision of the tumour were performed with excision of the underlying fascia including serratus and lateral border of LD. The superior edge encompassed the inferior angle of scapula extending to the midline with the inferior border at the level of the 12th rib. Dissection continued in the submuscular plane towards the axilla. Branches to serratus, circumflex scapular, and other smaller medial intercostal perforators were ligated. Further dissection at the deep margin required sacrifice of the thoracodorsal pedicle to ensure complete tumour clearance prior to definitive reconstruction, an unforeseen consequence of the planned reconstruction. During flap harvest alternate plans were made when a large 10th intercostal artery perforator was identified. A strong doppler signal was identified, located between the costal margin of the 10th rib and posterior axillary line. The flap, dissected and mobilized solely on the 10th intercostal perforator, was propellered into the defect 1808 counter-clockwise, while the donor-site was closed directly (Fig. 1). Physiotherapy postoperatively enabled full mobility with minimal winging of the scapula. The LD muscle (type V by Mathes and Nahai) consists of a large vascular pedicle, and known secondary pedicles. The secondary pedicles support the flap in the event of dividing the dominant pedicle. Intramuscular anatomical studies have shown the thoracodorsal artery enters the muscle and diverges into around five branches in the upper third. However, the 7th to 11th muscular perforators of the posterior intercostal artery (PIA) nourish majority of the muscle. The 10th muscular perforator is at the intersection between the 10th intercostal space and posterior axillary line. Posterior rami are continuous with musculocutaneous perforators of the LD through fine choke arteries within the fasciocutaneous layer. The main limitation is the position of the perforator, limiting reach. Free-style perforator flaps have been described as revolutionary in soft tissue reconstruction to permit tissue bulk and provide optimal contour and minimal donor site morbidity. These flaps serve as a “backup” plan in the event of change in reconstructive circumstances. Gillies and Millard laid down principles in plastic surgery advocating the need for a backup plan in the 1950s, indicating that primary resection should not be overshadowed by planning a subsequent reconstruction. We have found the LD flap remains an option including when there is doubt about the viability of the primary pedicle. *Correspondence to: Damir Kosutic, M.D., Ph.D., F.R.C.S., (Plast), Consultant Plastic and Reconstructive Surgeon, The Christie NHS Foundation Trust, Manchester, UK. E-mail: dkosutic@hotmail.com Received 23 April 2015; Revision accepted 24 October 2015; Accepted 24 November 2015 Published online 15 December 2015 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/micr.30014

Haemostatic property of cyanoacrylate in pedicled flaps.

We present a technique that can, in principle, be applied to any pedicled flap that is routinely used for reconstructions of the forehead. In our experience, cyanoacrylate glue applied to the pedicle before the flap is inserted decreases postoperative bleeding and wound exudate.

Saving grace: distally pedicled gracilis muscular flap in lower limb salvage.

During the 1970s, the incidence of limb amputation following surgery for sarcoma excision was as high as 50%. Two important developments have led to modern day limb salvage, namely chemotherapy and precision imaging techniques. We present a case of limb salvage in a patient with osteosarcoma plagued with recurrent infection after prosthetic revision. We discuss the use of the distally based pedicled gracilis muscular flap, which has little mention as a reconstructive option for defects around the knee.