Richard Haywood

Comparison of 1- and 2-knot, 4-strand, double-modified kessler tendon repairs in a porcine model.

PURPOSE To compare 1- and 2-knot, 4-strand, double-modified Kessler tendon repairs. It was our hypothesis that a 1-knot technique using an unbraided suture material would be stronger if it is possible for some movement to occur between strands on loading, redistributing forces such that the load is equally shared. METHODS Fifty-six porcine flexor tendons were allocated to either a 1- or 2-knot, 4-strand, double-modified Kessler repair, and tested by incremental cyclical loading in vitro. RESULTS The 1-knot technique was significantly stronger. Gap formation was initially greater in the 1-knot group, consistent with movement of strands, but with increasing physiological levels of applied force, there was no significant difference between the groups. CONCLUSIONS The 1-knot technique was significantly stronger than the 2-knot technique.

Inadvertent free intercostal artery perforator flaps

Two cases of free lateral intercostal artery perforator flaps are presented in this article. Both flaps were raised instead of thoracodorsal artery perforator flaps, which had been the initial operative plan. The free intercostal artery perforator flap can be technically difficult, the pedicle is relatively short and the vessel diameters can be small. The pedicle may need to be dissected along the intercostal groove to obtain sufficient vessel length and diameter. Despite all these issues, we describe a relatively straightforward salvage operation if a perforator flap raised on a presumed thoracodorsal artery axis is found to be an intercostal artery perforator flap.

DIEP Flap Rescue by Venesection of the Superficial Epigastric Vein

Microsurgical breast reconstruction with the deep inferior epigastric perforator flap is a technically challenging procedure, where flap survival depends on sufficient arterial input and venous outflow. Rarely, these flaps can become congested because of insufficient venous pathways and dominance of the superficial venous system. We describe a simple technique to allow the rescue of congested flaps by intermittent venesection of the superficial inferior epigastric vein. This relieves the venous congestion in the immediate postoperative period, allowing the flap to develop venous drainage through alternate channels.

CONTRALATERAL DIEV AS AN INTERPOSITIONAL VEIN GRAFT FOR VENOUS SUPERCHARGE IN THE SALVAGE OF A CONGESTED DIEP FLAP

Venous congestion is a major risk in DIEP flap breast reconstruction, ranging from 8% to 29%. Early intervention to solve the congestion ensures successful outcomes. Despite the different salvage techniques described, this is still the most common complication during a DIEP flap breast reconstruction. We report a further technique to salvage a venously congested DIEP flap using the contralateral DIEV as an interpositional graft between the ipsilateral SIEV and the serratus branch of the thoracodorsal vein. A 56 years old female underwent a delayed DIEP flap reconstruction and immediate contralateral breast reduction. A right 810 g DIEP flap was raised on two medial row perforators. The ipsilateral SIEV was preserved with a length of 4 cm. Contralateral perforators were clamped for 30 mins and the flap showed adequate perfusion. The DIEV was primarily anastomosed using a 2.0 mm coupler to the IMV with anterograde flow. After 30 min, the flap became congested despite patent anastomosis. The venous anastomosis was revised in retrograde fashion to the IMV, but the flap remained congested. The SIEV was engorged and dilated and the removal of the ligaclip immediately solved the congestion. The contralateral DIEV was harvested obtaining a 10 cm vein that was used as an interpositional graft between the SIEV and the serratus branch of the thoracodorsal vein, resolving the flap congestion. No postoperative partial flap failure, fat necrosis or donor site functional problems were noticed 6 months postoperatively. Venous congestion of DIEP flap can be mainly associated with a superficial dominant venous system or with an excessive flap weight in relation to the diameter of the perforating veins. Venous supercharge is a useful option to solve the congestion, but an interpositional graft may be needed to connect the superficial to the deep system or to another recipient vein. The graft can be obtained from the lower leg or the foot adding further scars. The basilica vein has been described as a venous bypass adding morbidity. Galanis and Nguyen summarized the different techniques within a useful algorithm for DIEP flap congestion salvage. Recently, the ipsilateral DIEV has been used to anastomose the ipsilateral SIEV to the IMV disconnecting the deep system. We chose to harvest the contralateral DIEV as an interpositional graft because it has the advantage of the accessibility in the same surgical field, quick harvesting technique (approximately 30 min) avoiding additional scars. It has sufficient length to anastomose the SIEV to the IMV, to the ascending branch of the DIEV, or to a recipient vein in the axilla as in our case. The good calibre match and length allowed an easy anastomosis, avoiding sacrificing the pedicle of the latissimus dorsi and subsequently the possibility of a rescue flap. We found the use of the contralateral DIEV as an interpositional graft for venous supercharge a useful tool to solve venous congestion of a DIEP flap.

Mid-palm hand amputation: Reconstruction of the superficial palmar arch

1. Rohrich RJ, Gosman AA, Brown SA, Tonadapu P, Foster B. Current preferences for breast reduction techniques: a survey of board-certified plastic surgeons 2002. Plast Reconstr Surg 2004; 114(7):1724e33 [discussion 1734e6]. 2. Davison SP, Mesbahi AN, Ducic I, Sarcia M, Dayan J, Spear SL. The versatility of the superomedial pedicle with various skin reduction patterns. Plast Reconstr Surg 2007;120(6): 1466e76. 3. Hall-Findlay EJ. A simplified vertical reduction mammaplasty: shortening the learning curve. Plast Reconstr Surg 1999;104(3): 748e59 [discussion 760e3]. 4. James A, Verheyden C. A retrospective study comparing patient outcomes of wise pattern-inferior pedicle and vertical patternmedial pedicle reduction mammoplasty. Ann Plast Surg 2011; 67(5):481e3.

Angiosarcoma of the breast following reconstructive surgery in the absence of radiotherapy or lymphoedema

Primary angiosarcomas following reconstructive surgery are thought to be attributable to radiotherapy or lymphoedema. We report the first case of a patient presenting with breast angiosarcoma demonstrating multiple morphologies (including the rare epithelioid subtype) arising after breast-conserving reconstruction for a previous adenocarcinoma, in the absence of these predisposing risk factors.Level of Evidence: Level V, diagnostic study

Images of post-pneumonectomy syndrome: progressive mediastinal displacement causing bronchial narrowing by stretching.

Decreased serum factor B concentration associated with opsonisation of Escherichia coli in the idiopathic nephrotic syndrome. Pediatr. Res. 1977; 11: 910–6. 7. Spika JS, Halsey NA, Fish AJ et al. Serum antibody response to pneumococcal vaccine in children with nephrotic syndrome. Pediatrics 1982; 69: 219. 8. Uncu N, Bulbul M, Yildiz N et al. Primary peritonitis in children with nephrotic syndrome: results of a 5‐year multicentre study. Eur. J. Pediatr. 2010; 169: 73–6. 9. Kaleida PH, Starr SE. Group B streptococcal peritonitis in a child with the nephrotic syndrome. J. Med. Assoc. Ga. 1978; 67: 721–2. 10. Bannatyne R, Stringel G, Simpson J. Spontaneous peritonitis due to group B streptococci. Can. Med. Assoc. J. 1979; 121: 442–3.

The "periosteal anchor stitch": opening up the surgical field.

Recent trends in autologous breast reconstruction have moved away from use of the thoracodorsal vessels to use of the internal mammary vessels as the first-choice recipient site. The use of the internal mammary vessels may provide for a shorter operative time and a higher-quality aesthetic reconstruction as they allow medial placement of a flap. However their main disadvantage is the limited exposure of the vessels provided by removal of a segment of the rib cartilage. Clinical and anatomical studies of the internal mammary vessels suggest that the most appropriate sized portion of the recipient artery and vein for microanastomosis are located at the third intercostal space. Most surgeons therefore resect a segment of the third costal cartilage and rib. This is the basis of our practice. Where possible mastectomy scars are periareolar, or positioned as a transverse incision across the breast at the level of the nipple. In the male, the nipple is located over the 4th intercostal space, however this position is not reliable in women and may be considerably lower. As a result the edge of the upper, medial skin flap of a mastectomy overlaps the operative site, and thus requires retraction. This is especially so in immediate reconstructions. The fibers of the pectoralis major muscle are split to expose the third costal cartilage and also require retraction. One of the keys to maximize microsurgical efficiency is to create a wide, clear stable operative field. This means minimizing instrumentation including the number of retractors and pairs of hands. This can be achieved by the use of self-retaining retractors. The design of self-retainers such as the West’s and Travers’ is such that both limbs open outwards at equal distance from the central hinge-point. To provide adequate exposure of the third intercostal space a greater force for retraction is required on the upper, medial skin flap than on the lower skin flap. If both claws are positioned solely on the skin flaps or pectoralis major muscle, the self-retainer drifts caudally and laterally. The muscle is torn and the upper medial skin flap obscures the operative site. To overcome these problems, we use an anchoring suture for the lateral arm of our self-retaining retractor. Using a round bodied needle, a loose, double suture of 0 nylon is placed in the third costal cartilage 1 to 2 cm lateral to the planned cartilage excision. A double suture is used to spread the load and prevent tearing out. Silk was used initially, but this does not glide through the cartilage as easily as a monofilament suture. Once the first quarter of the needle is in the cartilage, the rest of the needle is ‘‘pushed’’ through, thus allowing the curve of the needle to come through the firm cartilage. The claw of the lateral arm of the self-retaining retractor is hooked into the loops of this suture, thereby providing an anchor point for retraction laterally (see Fig. 1). The retractor is opened with the medial claw retracting the upper medial portion of the mastectomy flap and split pectoralis major medially. This prevents stripping of the muscle laterally, allows for maximal medial retraction and exposure of the recipient vessels for further dissection and provides stability to the operative site for subsequent microsurgical anastomosis. We describe a surgical technique to improve the surgical exposure of the internal mammary recipient vessels. We *Correspondence to: Amit K. Shah, M.A.(Hons) M.B./B.Chir. M.R.C.S.(Eng), ST-4 Plastic and Reconstructive Surgery, Department of Plastic and Reconstructive Surgery, Norfolk and Norwich University Hospital, Colney Lane, Norwich NR4 7UY, UK. E-mail: as329@hotmail.com

Deltopectoral groove full-thickness skin graft donor site for head and neck skin cancer excisions

Skin grafts have long been a main stay in the reconstruction of skin cancer excision defects. Sun-exposed areas such as the head and neck are common sites for skin cancer and, therefore, postexcision reconstruction. Donor sites for full-thickness skin grafts are myriad. Several sites are well established such as the supraclavicular fossa, inner arm, groin and periauricular regions. We propose the use of the deltopectoral groove as a donor site for reconstruction of selected, larger head and neck skin cancer excision defects. A large graft can be harvested, up to a 12 cm 7 cm skin ellipse in elderly elastic skin. There are