Marc-James Hallam

Refinements in smile reanimation: 10-Year experience with the lengthening Temporalis Myoplasty

The lengthening Temporalis Myoplasty (LTM) is an innovative dynamic facial reanimation procedure that has been used to great effect following its conception during the early 1990s by the senior author. Since its first description in the literature the technique has been refined and it has become clear from correspondence that certain technical aspects of the procedure require particular attention to detail. We discuss from experience of more than a hundred cases and highlight not only the important technical aspects of the procedure but also the importance of pre-operative assessment and the avoidance of complications.

The tertiary management of pretibial lacerations

Pretibial lacerations remain one of the commonest yet most neglected conditions facing emergency departments and plastic surgeons alike. Furthermore, these injuries afflict the most vulnerable groups of adults - the elderly and the infirm. It is essential therefore to have an approach to pretibial lacerations based on best available evidence, in order to optimize wound outcomes, but perhaps more importantly, to safeguard the general health of the vulnerable individual. We present an evidence-based approach to the tertiary management of these injuries and propose a treatment algorithm that we have utilized in our unit to successfully manage 40% of tertiary referrals of pretibial lacerations in a conservative manner.

Implications of rationing and the European Working Time Directive on aesthetic breast surgery: A study of trainee exposure in 2005 and 2011

BACKGROUND There are concerns that current trainees may be lacking operative experience in aesthetic and functional breast surgeries. Reduced exposure to such cases during training may stem from rationing, EWTD compliance, and an increasingly consultant-led service. These issues are examined in a single NHS hospital, with analysis of trends over time, and are contrasted with the changes that have occurred in a related private hospital. METHODS A single NHS hospital trusts database was retrospectively analysed for all aesthetic breast surgeries from 2005 to 2011, noting the total number of cases and the grade of the principal surgeon. The analysis was repeated in a related private sector hospital in the same catchment area. RESULTS A statistically significant drop of 55% of NHS aesthetic breast surgeries performed in 2011 compared to 2005 was demonstrated with an increasing trend for consultant led procedures. The NHS caseload decline was matched by a corresponding increase of 57% within the private sector. CONCLUSIONS Current trainees in plastic surgery face a significant reduction in operative exposure to aesthetic breast surgeries compared to their predecessors due to the EWTD working hours, surgical rationing policies, and an increasingly consultant led service. Approaches to maintaining training standards are discussed.

Exploiting the perforator concept to minimise donor site morbidity in harvesting the radial forearm free flap

Fig. 1. Propeller flap marked by reverse planning technique (note blue dot denoting position of perforator vessel). he radial forearm free flap (RFF) is a highly versatile and eliable workhorse flap but its harvest often leaves a signifiant donor site requiring soft tissue coverage. Most often this s achieved through the use of a skin graft, which aside from eing unaesthetic has been reported to fail (full or partial) ue to the poor “take” observed over the exposed flexor carpi adialis tendon. Even if the skin graft does not fail it may till cause adhesions with the underlying musculo-tendinous tructures.1,2 We describe the use of a propeller flap based on n ulnar artery perforating vessel to avoid these problems. The location and anatomy of the ulnar artery and its perorators have been well described in the literature and can be asily located using a hand-held Doppler device. These ulnar erforators have been shown to be reliable in supporting a arge skin paddle and can be used to form flaps based on the roximal, middle, and distal forearm regions.3 Flaps raised n this territory also leave donor sites that are amenable to irect closure and are aesthetically pleasing.4 Following harvest of the RFF the ulnar border of the donor ite incision in the proximal third/middle third of the forerm is elevated at the subfascial plane. Dissection precedes lnarwards until a suitable perforator is identified. Reverse lanning marks out an elliptical flap (Fig. 1) and the flap is slanded on the perforator (Fig. 2). In the case shown, the ◦ ap was rotated approximately 150 and inset into the donor ite defect (Fig. 3). The mobility of the surrounding skin of

The importance of early flap coverage in deep sternal wounds.

BackgroundChronic or persistent wound infection is one of the key outcome measures after flap reconstruction in deep sternal wound infection (DSWI). This study aimed to assess potentially modifiable factors associated with chronic infection in patients undergoing flap reconstruction. Materials and MethodsAn analysis of a prospective database of 5239 median sternotomies performed during a 5-year period was carried out. Seventy-seven cases of DSWI were recorded, of which 23 cases proceeded to flap reconstruction. The flap-reconstructed patients were placed into groups according to the primary outcome measure of those who experienced chronic infection and those who remained infection free. ResultsOf the flap-reconstructed patients, 22% experienced subsequent chronic infection, whereas 78% remained infection free. The only 2 variables that were associated with chronic infection were the timing of flap reconstruction; median time 29.5 days (vs 12 days in the infection-free group), P = 0.011 and time taken from diagnosis of wound infection/dehiscence to referral to the plastic surgical team; median 21 days (vs median 8 days in the infection free group), P = 0.02.Each day of delay from the diagnosis of clinical infection to flap cover equated to an increase in risk of chronic infection of 1.2 times per day (OR = 1.205, P = 0.039). ConclusionsThis study suggests that chronic infection after flap reconstruction in DSWI is associated with late flap cover. We suggest the need for a consensus agreement on the combined care and early management of DSWI.

Challenges in obtaining aesthetic breast ideals: Reply to ‘Concepts in aesthetic breast dimensions - Analysis of the ideal breast’

In summary, despite the limited number of cases in this study, conventionalmonitoringmethods are still judgedbyus as superior over the implantable Doppler system as a standard monitoring device. The main reasons for this are the adverse effects we experienced and the additional costs of the implantable Doppler system. In buried flaps, flaps that are difficult to monitor with conventional methods or other selected cases the implantable Doppler system probably has an advantage over conventional monitoring methods.

Accurately Monitoring Fluid Infiltration During Multiple-Site or Large-Volume Liposuction

Although the majority of large-volume liposuction is conducted without significant complications, careful fluid management is important to prevent problems such as fluid overload and electrolyte imbalance. The authors discuss a number of techniques that are currently used to monitor the rate and volume of infiltration before liposuction. Accurately monitoring fluid infiltration during liposuction is important to achieve good cosmetic results and prevent complications.