Robert Bains

Corneal neurotization from the supratrochlear nerve with sural nerve grafts: a minimally invasive approach.

Summary: Corneal anesthesia is a debilitating condition which can ultimately lead to blindness from repetitive corneal injury and scarring. We have developed a minimally invasive technique for corneal re-innervation that we have used with excellent results in ten eyes. This article and accompanying video describes the relevant anatomy and demonstrates the technique in detail.

Achilles tendon graft for static facial sling

Static sling surgery for the paralysed face is a commonly performed procedure for patients who are unwilling or unfit for dynamic reanimation. The sling may be constructed from autogenous tissue or exogenous material such as Goretex suture. Various autogenous tissues have been described in the literature for use in this procedure including fascia lata, temporalis fascia and palmaris longus tendon. A 65-year-old lady had been referred to our department following excision of a parotid mass. She had been treated initially by superficial parotidectomy and preservation of the facial nerve for a presumed pleomorphic adenoma. Histological examination revealed carcinoma ex-pleomorphic adenoma which was incompletely excised at the deep margin. She was planned for completion parotidectomy and sacrifice of the facial nerve. At surgery the facial nerve was sacrificed leaving a small proximal stump and distal temporal, zygomatic and buccal branches. An immediate reconstruction of the nerve was performed with sural nerve grafts from the right leg. In anticipation of the duration and likely degree of recovery of nerve function a static sling had been planned. Dynamic reconstruction had been discussed with the patient preoperatively and ruled out according to the patient’s wishes. Through the incision for the sural nerve harvest a thin (less than 10%) strip of Achilles tendon was harvested by splitting the tendon. The length of the tendon graft was 15 cm. The wounds were closed and the graft used as a Y shape to support upper and lower lips and angle of the mouth. The leg was not splinted and the patient was encouraged to mobilise gently from day one post operatively, at this stage she was discharged. She was seen in clinic for a wound check at one week and review in clinic two months post operatively. She had an excellent result from her facial sling and minimal pain from the donor site. No problems had been encountered with mobilisation. It is our usual practice to use autogenous material for facial sling surgery due to previous problems with extrusion and infection of exogenous materials. Our first choice tissue

Surgical management of a painful lipoatrophy

We present a case of painful post-traumatic lipoatrophy successfully treated by excision of the affected area. A sixty two year old female was referred to our department with a painful contour deformity of her right thigh. She had a previous history of a fall with keys is her pocket sustaining minor trauma to the area. Prior to the referral she was treated with analgesia, ultrasonic massage and physiotherapy but with no relief of her symptoms. Examination revealed a contour deformity of the lateral thigh and diffuses tenderness with pain radiating down the lateral aspect of the leg (Figure 1). MRI was consistent with fat necrosis and thickening of the iliotibial tract (Figure 2). Surgical exploration was recommended due to failure of conservative management. The patient was only concerned by the pain rather than cosmesis so reestablishment of a normal contour was not attempted. At exploration extensive scar tissue and necrotic fat was noted and the area of most tenderness was excised. The lateral cutaneous nerve of the thigh was not seen. Histological evaluation of the excised tissue revealed thick strips of dense, hyalinised fibrous connective tissue