Mohammad M. Al-Qattan

The surgical management of high-grade gynecomastia

It is now well accepted that low grades of gynecomastia are best treated with liposuction alone. However, the surgical management of the high-grade gynecomastia (Simon’s grade III) has remained problematic because both liposuction and conventional subcutaneous mastectomy (without skin excision) have frequently resulted in significant residual skin redundancy, requiring a second operation for skin resection. Our preferred approach to high-grade gynecomastia has been the single-stage subcutaneous mastectomy and circumareolar concentric skin reduction with deepithelialization. However, in the rare case of tubular breast deformity in the male and also in patients with gynecomastia who underwent massive weight loss, simple mastectomy and free nipple graft is performed. Therefore, these 2 groups of patients will be excluded from the current series. Twenty-four consecutive males with high-grade gynecomastia were reviewed. All patients underwent subcutaneous mastectomy with concentric skin resection. There were no major complications such as infection, hematoma, seroma, or nipple-areola complex necrosis. The main disadvantage of the technique was the mild residual skin redundancy, which was noted in all 24 patients. This redundancy, however, was never severe enough to require a secondary procedure, and all patients were satisfied with the final result.

Embryology of the Upper Limb

An increased understanding of embryogenesis has advanced our fundamental knowledge of limb anomalies. Animal models with similar limb patterning have been used to dissect and manipulate crucial signaling centers that affect limb development and orientation. Experimental embryologists can produce limb anomalies that are similar to the human phenotype encountered in clinical practice. The evaluating physician must possess a basic comprehension of embryogenesis and limb formation to comprehend congenital limb anomalies and to communicate relevant knowledge to the family. This Current Concepts article is intended to provide an update of limb development that is germane to the clinical scenario.

Abdominoplasty in multiparous women with severe musculoaponeurotic laxity

The results and complications of abdominoplasty in 20 consecutive multiparous women with very severe musculoaponeurotic laxity are presented. All patients presented with an abdomen that resembled a full-term pregnancy when the patient was in the erect posture. This very severe laxity was the end result of repeated pregnancies. All patients underwent a standard abdominoplasty with wide longitudinal plication using size 1 prolene sutures. Follow-up averaged 1 year. None of the patients had a major complication. However, all the patients had recurrence of the musculoaponeurotic laxity. Causes and classification of this recurrent laxity are discussed along with possible solutions.

Problems associated with the use of silicone gel sheeting for hypertrophic scars in the hot climate of Saudi Arabia

Twenty five consecutive Saudi patients who underwent treatment of hypertrophic scars using Cica-care silicone gel sheets were included. The scars were secondary to burns or traumatic friction injuries. There were 15 females and 10 males with a mean age of nine years. Patients were given detailed instructions in applying and washing the gel and attended a review clinic regularly. At each visit, problems and scar assessment using the Vancouver scale were documented by an experienced occupational therapist. Problems associated with gel sheeting were common and included persistent pruritus (80%), skin breakdown (8%), skin rash (28%), skin maceration (16%), foul smell from the gel (4%), poor durability of the sheet (8%), failure of the sheet to improve hydration of dry scars (52%), poor patient compliance (12%) and poor response of the scar to treatment (24%). Most of these problems were eliminated by temporary interruption of treatment, more frequent washings of the gel sheet, better skin hygiene and occasionally by changing the brand of gel sheets. Permanent discontinuation of treatment occurred in only one patient and was because of lack of response to treatment. The modes of action of silicone gel in the treatment of hypertrophic scars are discussed.

Surgical management of post-burn skin dyspigmentation of the upper limb

The technique and results of surgery in 23 patients with skin dyspigmentation of the upper limb are presented. The study population was divided into two groups. Group A (n=15 patients) had hyperpigmented skin grafts in the palm or the palmar aspect of the digits. All patients underwent excision of the hyperpigmented grafts and coverage with split-thickness plantar skin grafts. The plantar grafts gave an excellent colour and texture match and all patients were satisfied with the result. Group B (n=8 patients) had post-burn hypopigmentation on the dorsal aspect of digits, hand or forearm. These patients underwent dermabrasion and thin split-thickness grafting harvested from the upper thigh or buttock. All grafts healed well with no residual hypopigmentation. However, the graft was slightly hyperpigmented when compared to the surrounding skin. Despite this complication, all patients were satisfied and considered this slight hyperpigmentation much better than the preoperative hypopigmentation. The pathogenesis of skin dyspigmentation and other treatment techniques are discussed.

Variations in the Course of the Thenar Motor Branch of the Median Nerve and Their Relationship to the Hypertrophic Muscle Overlying the Transverse Carpal Ligament

PURPOSE Previous anatomical and clinical studies classified the course of the thenar motor branch of the median nerve into 3 types: the extraligamentous, subligamentous, and transligamentous courses. The presence of a truly preligamentous course has been questioned. Furthermore, there has been recent interest in the presence of a hypertrophic muscle over the transverse carpal ligament (TCL). The current study has 2 aims: to determine the prevalence of the various types of thenar motor branch with particular attention to the existence of the preligamentous type, and to investigate whether the hypertrophic muscle is associated with certain thenar motor branch types. METHODS One hundred consecutive patients undergoing open carpal tunnel releases were studied prospectively. The following data were documented: type of thenar motor branch, presence of hypertrophic muscle over the TCL, and number of thenar branches. RESULTS In 100 consecutive patients undergoing open carpal tunnel releases, extraligamentous, subligamentous, transligamentous, and preligamentous types were seen in 56, 34, 9, and 1 patient, respectively. All transligamentous and preligamentous branches were associated with the presence of a hypertrophic muscle over the TCL. Twenty-six of the extraligamentous branches were also associated with the hypertrophic muscle. CONCLUSIONS The extraligamentous type seems to be the most prevalent thenar motor branch type in most previous studies of various races, including our Middle Eastern population, whereas the preligamentous type is rare. Finally, it is important for the surgeon to know that transligamentous and preligamentous types are associated with the presence of hypertrophic muscle origin over the TCL and that the motor branch will be within this hypertrophic muscle. Incision of this muscle should be done carefully and on the ulnar side to avoid injury to the thenar motor branch.

A review of burns related to traditions, social habits, religious activities, festivals and traditional medical practices

This paper reviews burns that occur because of specific social habits and traditions; religious beliefs and activities; social events and festivals; and traditional medical practices. A literature review did not reveal any article that specifically reviews such burns. These injuries are not only interesting (being nation-specific) but are also important with regards to implementation of preventive measures in various countries around the world.

Garlic burns: case reports with an emphasis on associated and underlying pathology.

Garlic burns is a well-described entity although only few cases have been reported in the literature [1–9]. All previous reports included information regarding the etiology and management of the burn and none have stressed on the fact that the patient should be investigated further for the possibility of underlying or associated pathology. We here report on three cases of garlic burns of the upper limb that required assessment and treatment of the underlying pathology. Furthermore, we review the literature to investigate the associated pathology in the reported cases.

Car-tyre friction injuries of the foot in children.

In a prospective study, 25 cases of car-tyre friction injuries of the foot in children were included. The mechanism of injury was similar in all patients: As the car-tyre impacted on the childs foot, the driver was usually trying to stop the car resulting in an injury of variable severity, depending on the amount of energy absorbed by the foot. The site of injury varied according to the position of the foot in relation to the tyre at the time of impact. Sixteen out of the 25 patients presented with acute injuries. The severity of foot injury was classified into five grades and the plan of management in these patients was guided by the grade of the acute injury. The remaining nine patients presented with secondary deformity and principles of secondary reconstruction were also demonstrated with clinical examples. Prevention of these injuries are discussed.

The "beggar's" hand and the "unshakable" hand in children with total obstetric brachial plexus palsy.

&NA; A total 12 consecutive children with secondary deformities following total obstetric brachial plexus palsy were included in this retrospective study. In all patients, the main complaints were two socially disabling hand postures: the “beggars” hand and/or the “unshakable” hand. All children had a supinated forearm with no active pronation and were teased by their friends, who called them “beggars.” When the impairment was severe and involved the right hand and wrist, children also complained that they were not able to shake hands. The management approach to these children was described, with the main aim of surgery being the correction of the abnormal posture. Other simultaneous tendon transfers were also performed to improve hand function if there were suitable musculotendinous units. Successful reconstruction was accomplished in all patients. Preoperatively, some children refused to go to school because of teasing, and most did not want to interact socially. After surgery, all children attended school regularly, and parents reported much better social interaction. However, the functional gain was never enough to dramatically improve the daily use of the limb. The contralateral normal limb remained the dominant one for all daily activities, including writing and eating. (Plast. Reconstr. Surg. 109: 1947, 2002.)