Shaheel Chummun

Desmoid tumour of the breast

Desmoid tumour of the breast is a rare fibroblastic tumour whose spectrum ranges from being locally inert to aggressive and destructive, and represents 0.2% of all breast tumours. A 22-year-old woman, 2 years post-cosmetic augmentation mammoplasty with silicone implants, presented with a 6-month history of an enlarging mass in her left breast. Ultrasound showed a well-defined, hypoechoic mass arising within the muscles of the anterior chest, deep beneath the implant and not involving the underlying rib. Fine needle aspiration (FNA) showed features in keeping with changes associated with silicone implants. A provisional diagnosis of scarring and fibroblastic proliferation was made. The lesion was excised and the implant, noted to be intact, was exchanged. Immunochemistry showed strong positivity for vimentin and variable positivity for SMA and desmin, and patchy positivity for beta catenin. A final diagnosis of aggressive fibromatosis was made. Although the association of desmoid tumour and breast implants has been described, this case is unique as the FNA was highly suggestive of a silicone granuloma and the diagnosis of desmoid tumour was made on definitive pathology. The aetiology of desmoid tumours is reviewed and current treatment modalities discussed.

Poly Implant Prothèse (PIP) breast implants: Our experience

INTRODUCTION This study describes our experience on the management of patients with PIP (Poly Implant Prothèse) breast implants between 2000 and 2008. MATERIALS AND METHODS The medical records of patients were reviewed. Data was collected on clinical presentation, investigations, management and outcome. RESULTS 44 patients, with bilateral breast implants, and a median age of 33 years (18-54 years), were reviewed, and of these, 31 patients were asymptomatic. Symptoms at presentation included lymphadenopathy, capsule formation, breast lump, seroma and breast pain. Patients underwent mammography, ultrasound and MRI scanning of the breasts as part of the imaging investigations. 5 patients declined explantation. Reasons for explantation included patient anxiety, silent rupture, aesthetic breast change, palpable nodes and breast lump. 17 out of a total of 78 implants (21.8%) were noted to have ruptured; 2 had a simple tear and 15 were totally disintegrated. 1 patient underwent removal of the implants, 18 underwent exchange of implants, and 20 patients had a capsulotomy and exchange of implants. Postoperative complications included wound infection, seroma, axillary lymphadenopathy, hypersensitive scar and overgranulation of the wound. CONCLUSION Our series confirms the high rate of PIP implant rupture (21.8%), the majority of which were asymptomatic. The main reasons for explantation were patient anxiety and silent rupture of implants. It is imperative that patients should be appropriately counselled, prior to surgery with regards to removal of the implants, given the increased rupture rates noted.

A long-term evaluation of 150 costochondral nasal grafts

INTRODUCTION This paper reviewed the outcome of cantilevered costochondral grafts used for dorsal nasal augmentation in the management of patients treated at the Australian Craniofacial Unit (ACFU), Adelaide over a 29-year period. MATERIALS AND METHODS All patients undergoing dorsal nasal augmentation with costochondral grafts as part of their craniofacial management between 1981 and 2009 were identified using the ACFU database, and their medical notes were reviewed. RESULTS 107 patients (50 M, 57 F), with a mean age of 12.3 years (range: 2-62 years) and requiring a total of 150 costochondral grafts, were identified from the departmental database. Mean follow-up after nasal augmentation was 5.6 years (1 month-31.5 years). 46% of the patients were diagnosed with Binder syndrome/Chondrodysplasia punctata; other diagnoses included Tessier midline clefts, cleft lip and palate and frontonasal dysplasia. A dorsal midline incision (49%) was the commonest method of access, with 84% of patients having mini-screw fixation for graft stabilisation. Complications included screw palpability, infection, skin necrosis and graft fracture. The commonest reasons for a replacement graft were graft atrophy and fracture, infection and persistent deformity. CONCLUSION Cantilevered nasal costochondral grafting is an excellent technique for improving nasal contour and function in a wide variety of clinical situations.

Does vascular injury affect the outcome of open tibial fractures

Background: Consensus on the definition of a Gustilo grade IIIC injury was sought, and the influence of vascular injuries on outcome of severe open tibial fractures was investigated. Methods: Three thousand three hundred fifty-one plastic and orthopedic surgeons were sent questionnaires to determine their interpretation of Gustilo grade IIIC injuries. Notes of patients with severe open tibial injuries reconstructed at Frenchay orthoplastic center with free tissue transfer between 2006 and 2010 were reviewed. Data were collected on patient demographics and vascular integrity. Outcome was measured using the Enneking score. Results: Four hundred seventy-six plastic surgeons and 2875 orthopedic surgeons were contacted. Seven hundred fifty-three responses (22.5 percent) were received; 46.2 percent thought a grade IIIC injury was a devascularized limb, 24.2 percent felt it was a one- or two-vessel injury, 6.9 percent thought it represented any vascular injury, and 22.7 percent had no definite answer. Sixty-eight patients (50 men and 18 women; mean age, 42.7 years) were identified. Fifty had normal angiograms and 18 sustained vascular injuries. Forty-two percent of vascular injuries were to the anterior tibial artery, 37 percent were to the posterior tibial, and 27 percent were to the peroneal. Mean follow-up was 11.2 months. Mean Enneking score for patients without and with vascular injury was 29.8 and 24.4, respectively (p = 0.004). Conclusions: Vascular injury independently influences long-term limb function. The authors suggest a modification to the current classification to improve communication among surgeons, and advocate the use of preoperative angiography before free soft-tissue reconstruction of severe open tibial fractures.

The Management of Nonsyndromic, Isolated Sagittal Synostosis.

Aim:Isolated sagittal synostosis is the commonest form of craniosynostosis. The reasons for surgery are to normalize the head shape and to increase the cranial volume, thus reducing the risk of raised intracranial pressure and allowing for normal brain development. It has been suggested that sagittal synostosis may impair neuropsychological development. This systematic review appraised the literature on the management of sagittal synostosis. Methods:A literature search was performed with the assistance of a professional librarian. Studies selected had to satisfy the criteria set by PICO (patients, intervention, comparison, and outcome). Cranial index and neuropsychological outcome were used as outcome measures. MINORS was used to assess the methodological quality of the selected articles. A score of 75% was deemed to be of satisfactory quality, and the quality of the evidence from the selected studies was graded using the GRADE system. Results:One hundred forty-eight articles were initially identified. Only 6 articles fulfilled the PICO criteria and scored a minimum of 75% on MINORS. Four studies compared 1 technique to another with documented cranial indices. Two studies compared 1 group to another and assessed the neuropsychological development. According to GRADE, the quality of evidence was deemed to be very low. Conclusions:This systematic review assessed cranial index and neuropsychological outcome following surgery for isolated, nonsyndromic sagittal synostosis. The quality of the evidence in the published literature was noted to be of very low quality. There is a need for better-designed, prospective studies to guide surgeons involved in management of sagittal synostosis.

How to get out of a sticky situation

The tie-over dressing is well established for securing skin grafts as it fulfils a number of essential criteria, such as pressure, absorption of exudates and splinting, required for successful graft take. A skin graft dressing is expected to immobilise the graft, be easy and quick to apply and to remove, and be comfortable to remove for the patient. Over the years many variations of the traditional technique have been proposed to improve the technique. Although the application of a firm even pressure across the graft improves take, it has been proposed that it is in fact fixation of the graft and not pressure itself that is the main objective of the dressing. In support of this, a recent study

Proximally pedicled medial plantar flap based on superficial venous system alone for venous drainage

The proximally pedicled medial plantar flap is well described for coverage of wounds around the ankle and heel. This flap is usually based on the deep venae comitantes for venous drainage, with the superficial veins divided during dissection. Usually any disruption of the deep venous system of the flap would result in abandoning this choice of flap. Venous congestion is a recognised complication of medial plantar flaps. The patient described in this case report had a medial ankle defect with exposed bone, for which a proximally pedicled medial plantar flap was used. As we raised the flap, both venae comitantes of the medial planter artery were found to be disrupted. The flap was raised based on the superficial veins draining into the great saphenous, as the only system for venous drainage, with no evidence of venous congestion. The flap was successfully transposed into the defect and healed with no complications. The proximally pedicled medial plantar flap can safely rely on the superficial venous system alone for drainage. In addition, preserving the superficial veins minimise the risk of venous congestion in this flap. We recommend preservation of superficial venous system when possible.

Early discharge protocol for regional node dissections for skin cancer: The Frenchay Hospital Lymphadenectomy Algorithm

The Plastic Surgery Unit at Frenchay Hospital, Bristol has developed a treatment algorithm (January 2011) for patients with suspected metastatic lymphadenopathy, to streamline the patient’s care pathway by reducing any delay in treatment and post-operative hospital stay. Nine consultant plastic surgeons used to undertake lymphadenectomies for metastatic skin malignancies; these are now performed by 3 consultant plastic surgeons. The outcome of 50 consecutive patients, treated as per the new algorithm over a 16 month period by the senior author, between January 2011eMay 2012, was reviewed, and compared to that of 50 consecutive patients treated between 2007 and 8.

The ‘Gamgee’ turnover flap for lower limb dressing

Sir, The circumferential application of Gamgee (Gauze tissue BP) dressings over large areas of burns and wounds on the torso and proximal limbs is well-established, providing a dressing that is quick, neat and secure [1]. However, the application of Gamgee to the lower limb can sometimes be awkward. The thigh often has a bigger circumference than the leg, resulting in an excess of Gamgee over the leg and a corresponding deficiency over the thigh area (Fig. 1). An elegant method of efficiently using all the available Gamgee is to design a turnover flap from the excess Gamgee over the leg area to cover the deficient area over the thigh. The flap is designed as shown (Fig. 2), cut up to the apex at the knee and ‘turned over’ into the deficient area (Fig. 3). The resulting flap and limb dressing can then be secured with staples, SurgifixTM netting or crepe

Does a trauma clinic help improve the diagnosis of soft tissue hand injuries

Soft tissue hand injuries represent a major part of the trauma workload in most plastic surgery units in the UK. It is therefore crucial that such injuries be appropriately assessed and managed, so as to reduce the risk of any potential complications. Also, inappropriate assessments may lead to unnecessary operations and their potential complications. In an attempt to improve its trauma service, the Plastic Surgery Unit at Frenchay Hospital has made several innovations to its service, one of which being the creation of a trauma clinic manned by a senior plastic registrar. The aim of our study was to assess the rate of negative exploration in soft tissue hand injuries and also to assess the impact that the trauma clinic will have on the diagnosis of soft tissue injuries. The pre- and post-operative diagnosis of 50 patients prospectively recruited from the pre- and post-trauma clinic were compared and analysed using the t test. The overall rate of negative exploration was 7% (8% pre-trauma clinic and 6% post-trauma clinic). The correct diagnosis was made in 68% in the pre-trauma clinic group and 74% in the post-trauma clinic group. Additional diagnoses were made in 24% and 20% of pre- and post-trauma groups, respectively. The seniority of the senior house officers also influenced the rate of accurate diagnosis.