Philip M. Gilbert

Treatment of rhinophyma with the Versajet™ Hydrosurgery System☆

Rhinophyma is thought to represent the most severe expression of acne rosacea for which surgery is the mainstay of treatment. The use of Versajet Hydrosurgery System has not been previously described for the treatment of this condition. We present six patients with moderate to severe rhinophyma ranging from 41 to 77 years of age who were treated successfully with this technique.

Comment on: Macrovascular arteriovenous shunt (MAS) between ulnar artery and its venae comitantes: The cause of arterial thrombosis and insufficiency in a distally-based ulnar forearm perforator (UAP) flap used for intraoral reconstruction

1. Arnez ZM, Papa G, Novati F, et al. Macrovascular arteriovenous shunt (MAS) between ulnar artery and its venae comitantes: the cause of arterial thrombosis and insufficiency in a distally based ulnar forearm perforator (UAP) flap used for intraoral reconstruction. J Plast Reconstr Aesthet Surg 2014 May;67(5): 739e41. 2. Smith AR, Sonneveld J, van der Meulen JC. AV anastomosis as a solution for absent venous drainage in replantation surgery. Plast Reconstr Surg 1983 Apr;71(4):525e32. 3. Inoue G, Tamura Y. The use of an afferent arteriovenous fistula in digit replantation surgery: a report of two cases. Br J Plast Surg 1991 Apr;44(3):230e3.

Nasal reconstruction in panfacial burns: useful techniques in challenging cases.

AbstractNasal reconstruction after severe panfacial burns can be challenging to correct because of scarring, loss of suitable donor sites, and variably limited blood supply of local flaps. We describe 2 cases of subtotal nasal reconstruction in which we overcame these difficulties. Both cases had alar subunit loss, which had left significant functional and esthetic deformities. However, both cases were managed very differently because of availability of donor sites.The first patient had 70% total body surface area burns with bilateral alar subunit loss: nasal reconstruction required a meticulous multistaged forehead flap. The second patient required nasal reconstruction using a turn-down flap to maximize take of a composite graft from previously burned ear donor sites.A number of surgical techniques have been described to manage subtotal burns nasal reconstruction, foremost of which are the nasolabial and paramedian forehead flaps. Cartilage grafts from the septum and the conchal bowl can be integrated into these flaps. Composite grafts can be unpredictable and are often used with caution.Such cases demonstrate that large composite grafts can be an extremely robust method of reconstruction even in a subset of patients with extensively scarred recipient and donor sites. In our second case, composite grafting avoided multistaged procedures such as the forehead flap and can be considered as a first-line procedure in large alar subunit loss.

Erroneous terminology for an intradermal suture

We write with regards to the erroneous description of an ‘intradermal’ suture as a ‘subcuticular’ suture. The terms subcuticular, intracuticular and intradermal are used by various authors to describe the same type of suture. Such interchangeable descriptions are confusing, particular for the less surgically experienced reader. A Pubmed search of the literature using the terms ‘subcuticular’ þ ‘intradermal’ þ ‘suture’ in the [title/abstract] field returned 5 results. Within these articles, we noted that Knote and Bohmert and Pineros-Fernandez et al. use the terms interchangeably, whilst Smoot uses the term ‘subcuticular, intradermal’ as a single nomenclature. Meinke uses the term intradermal to describe a particular technique for subcuticular closure to the extent where the author considers an intradermal suture to be a subgroup of a subcuticular suture. Mosby’s medical dictionary defines a subcuticular suture from its latin roots as : [subbeneath, cutis-skin] with the definition of a suture that is placed to bring together tissues immediately beneath the skin, rather than through the skin. Although the term subcuticular seems to be in more common use, we feel the term intradermal is more accurate as this type of suture, when properly performed, just traverses the dermal layer of the skin. The word ‘subcuticular’ could potentially misguide readers as to the methodology used in an article, or even worse lead junior surgical trainees to place their suture in the wrong (and unsecure) layer when asked to perform a ‘subcuticular suture’. We therefore urge future publications to ensure that accurate terms are used within their literature. This would improve the interpretation of the methodology used with literature particularly for the less surgically experienced reader.

Harvesting split skin graft from degloved skin—why waste dermis?

Sir, Mopuri et al. describe a technique for harvesting a split skin graft from degloved skin, but have totally missed the point about how best to manage the degloved skin. McGrowther and Sully describe the use of the Gibson– Ross dermatome because the whole point is to convert the degloved skin into a full-thickness skin graft which will give a much better cosmetic and functional result than a split skin graft. If the skin surface of the degloved skin is damaged, it would be unsuitable for taking a split skin graft, yet as long as the dermis/fat interface is undamaged, it can still be used as a Wolfe graft. The take of properly defatted degloved skin is excellent. Why waste precious dermis?

Bullous pemphigoid mistaken for a burn.

Burns in the elderly are extremely common. Often, the history is obscure or nonexistent because of confusion or dementia. We describe the case of a 78-year-old woman who was admitted to a burns center with the history of a 21% scald burn. However, this burn had unusual characteristics, and further investigation confirmed the cause to be bullous pemphigoid. This case report highlights the extreme care that must be taken in the assessment of children and the elderly who may not be able to give a complete history. We also present a table to aid in the differential diagnosis of unusual burns, which may be useful in such circumstances.