Richard W. Griffiths

Vastus lateralis myocutaneous flap for reconstruction of defects around the groin and pelvis

We present our experience using the vastus lateralis myocutaneous flap for the repair of defects around the groin and pelvis. It is a relatively new technique, with many advantages over other flaps used in this area, though it has limitations. The history, anatomy and surgical technique of raising the flap are described and clinical cases are discussed. The importance of patient selection is highlighted.

The venous drainage of nerves: Anatomical study and clinical applications

The venous drainage of the peripheral nerves was studied in the upper and lower limbs of two human fresh cadaver subjects after total body perfusion with a radio-opaque lead oxide mixture. Four patterns of extraneural drainage were identified in which the venae nervosa drained: directly to the venae comitantes of the neurovascular bundle; indirectly via nearby veins, derived usually from muscles; to the periarterial venous plexus; or, in the case of the cutaneous nerves, to the perivenous plexus. The various patterns of the drainage along the length of the radial, median, ulnar, sciatic, anterior and posterior tibial nerves were identified. A rich longitudinal plexus of veins exists on and within the nerve which appears to be mainly free of valves. The large venae nervosa usually contained valves, whereas the tiny veins draining the nerves were valveless or exhibited a sentinel valve at their entry point into a larger venous channel. The clinical implications of these results are discussed in relation to the mobilisation of nerves, the use of island nerve flaps, possible donor sites for free arteriolised neurovenous flaps and the compressive nerve syndromes.

Q-switched ruby laser treatment of tattoos: A 9-year experience

Nine years of clinical experience of the application of the Q-switched ruby laser to the removal of tattoos is presented. This laser achieves optimal removal of blue/black amateur tattoos by its selective interaction with the dermal suspensions of pigment which constitute the tattoos. The scar free cosmesis thus achieved is a considerable improvement on non-specific laser techniques whereby the laser is absorbed to a comparable degree in both pigmented and non-pigmented tissue. Long-term results are analysed and it is noted that a variety of professional tattoos may also respond to treatment. The mechanisms and appearance are discussed and correlated with short-term healing processes. It is found that power densities in the range 1200-2800 GW/m2 are most suitable. Appropriate dosimetry can be witnessed by the appearance of opaque intradermal vacuoles corresponding to the vaporization of the tissue water surrounding the pigment suspensions. Treatment by Q-switched ruby laser offers a viable scar-free option for a wide range of dark tattoos, leading to a more acceptable clinical outcome in most cases than other current therapies.

Complications of soft tissue expansion

This paper presents a critical review of the results of tissue expansion in our clinical experience. Seventy-six expansions performed in 66 patients between 1981 and August 1986 are included in the study. Complications necessitating some revision in the original treatment plan were documented in 39% of cases. However, sufficient tissue was usually generated to complete the proposed reconstruction without compromising the final results. The complications of tissue expansion are further analysed in relation to their anatomical distribution, time of onset and ultimate consequences. Causative factors are identified and preventative measures are introduced.

A study of the long-term results achieved by the Gillies Fry procedure

Renewed interest in delayed closure for cleft palate subjects revealed that no evaluation had been undertaken of patients who underwent the original Gillies Fry procedure. In the present investigation, 10 subjects operated upon prior to 1948 according to the Gillies Fry recommendations were evaluated for facial development, occlusal relationship, speech performance and velopharyngeal seal. Comparison of the cephalometric findings with accepted norms and examination of study casts gave encouraging results for facial and occlusal development. Speech quality covered a wide range of attainment, the best being rated highly. Endoscopic examination demonstrated regular velopharyngeal seal during swallowing but only one subject who regularly achieved velopharyngeal seal in speech. It was concluded that, although some claims for the procedure may have been a little enthusiastic, advantages accrued from it which were not accorded by other surgical approaches of the time, particularly so far as facial development and occlusion were concerned.

The treatment of tattoos with trichloracetic acid: Experience with 670 patients

A review of out-patient treatment of tattoos with trichloracetic acid has been undertaken. Six hundred and seventy patients have been treated during the 6-year period between 1979 and 1984. The simple and inexpensive technique is described and the results presented.

Morbidity in the forearm flap donor arm

A retrospective study was carried out of the morbidity in the donor limb following use of the radial forearm flap in 27 patients. Of the 13 patients whose flaps contained bone, 4 sustained fractures of the radius. This was associated with a 50% loss of power of grip and pinch, and limitation of other movements, particularly pronation and supination. In the other patients little or no loss of power or range of movement was seen. No patient had cold intolerance; a few had areas of sensory loss, related to the radial nerve. Of the 12 patients whose radial arteries were reconstructed, 7 remained patient; no patient had any clinical features of ischaemia. These findings and their implications are discussed.

Anaesthesia for major craniofacial surgery: A report of 23 cases in children under four years of age

The problems of anaesthetising infants and small children for major craniofacial surgery are discussed. A series of 23 patients is presented to illustrate the practical difficulties.

Dorsal metacarpal flaps

The history of dorsal metacarpal flaps and their anatomical basis is described. In thirty hand dissections, the fascial variety of the first dorsal metacarpal artery was present in 90% and the second dorsal metacarpal artery in 97%. The origin, course, branches and termination of these arteries are illustrated. Doppler ultrasonic flowmeter studies of the vessels in 52 hands are presented but shown to be unhelpful clinically. Two patients in whom the second dorsal metacarpal flap was used, are described and possible difficulties delineated.

A comprehensive repair of the unilateral cleft lip in adults

A comprehensive operation for primary repair of adult cleft lip is described. The technique employs pyriform fossa bone graft, submucosal resection of the nasal septum and alar cartilage onlay graft in addition to a modified rotation advancement with refinements. Good results were obtained in 70% of the cases with no increase in morbidity.