Sunil Choudhary

Rhinophyma: dispelling the myths.

Rhinophyma is a relatively common condition in the west of Scotland. The Canniesburn Plastic Surgery Unit receives 12 to 13 new patients per year for surgical treatment. The reported incidence of simultaneous carcinoma in the setting of rhinophyma is on the order of 15 to 30 percent. There are conflicting reports about the association between alcohol and rhinophyma in the literature, and these are supported with little or no statistical evidence. Retrospective epidemiologic data on 45 cases of rhinophyma are presented. An audit of case notes was performed to examine histology and also alcohol consumption in these cases. The authors found no coincidental malignancies at the time of surgery, which is contrary to many previous publications. The alcohol consumption of the rhinophyma cases was compared with that of a control group that consisted of 48 men presenting for blepharoplasty. The series did not demonstrate a positive association between alcohol and rhinophyma when compared with a similar cohort of patients presenting for blepharoplasty surgery (p > 0.20) or with statistics available from the Scottish Health Survey.

Triple approach to rhinophyma

Rhinophyma is a common condition in the west of Scotland. Various surgical approaches have been described, most of which rely heavily on electrocautery, heated scalpel, or laser coagulation for hemostasis, resulting in thermal injury and substantial risk of scarring. The authors describe their experience with the “triple approach” for the surgical treatment of rhinophyma, consisting of tangential excision for debulking, the use of scissors for sculpting, and the use of mild dermabrasion for final contouring. The use of an alginate hemostatic dressing is also described. The triple approach has been used in 6 patients with pleasing results.

‘Tension Tile System’ (TTS): a simple innovative wound closure device

Wounds closed under severe tension often result in breakdown due to skin necrosis and suture cheese wiring causing both physical and financial morbidity. Although a few commercial wound closure systems have been described in the literature, but they are all expensive and not readily available. We have designed a simple and inexpensive system called ‘Tension Tile System’ (TTS) which utilizes plastic casing found in most sterile surgical suture packs. The device is easy to construct, sterile, inexpensive, easily available, and based on already proven principles of mechanical creep and stress relaxation. Large wounds in five patients were closed with the help of TTS system with no complications. We believe that this system will find wide application in all surgical fields where the wound encounters tension during closure.Level of Evidence: Level V, therapeutic study

Use of Spongostan™ for pedicle stabilisation in head and neck microvascular reconstruction

Sir, Microvascular pedicle is of utmost importance in head and neck reconstruction as kinking and unfavourable geometry of the pedicle can cause thrombosis leading to the disastrous complication of free flap failure. Head and neck areas are particularly prone due to the need to use long pedicle to reach neck donor vessels and also the possibility of neckmovements causing inadvertent kinking due to pedicle dislodgement. Various techniques and materials have been described in the literature for microvascular pedicle stabilisation, but all have some disadvantages. Tacking sutures [1] are commonly used but are not flexible and can cause vessel wall pull or constriction. Fibrin glue [2] can seep into the vessel lumen at the anastomotic site and actually cause thrombosis. Autologous fat [3] can be a good pedicle stabiliser, but large amounts will undergo necrosis and can increase the potential for wound infection. Recently, polyglycolic acid nerve conduit [4] has been described for this purpose, but it has the disadvantage of being inflexible and expensive. Polydioxanone suture fixed to the adventitia to prevent kinking have also been described but again suffers from being inflexible and hence incapable of imparting a desirable curve to the pedicle [5]. We have been using commonly available hemostatic gelatin sponge (SpongostanTM, Ethicon, Somerville, USA) as a microvascular pedicle stabiliser for most of our head and neck reconstructions. Small 1to 2-cm postage stamp style Spongostan pieces are cut out and used either as single or in stacks to support the microvascular pedicle. These are used in different configurations like ‘side rails’ along the length, stacks as foundation underneath the pedicle to obliterate dead space or ‘push inserts’ to change the acute curvature of the pedicle to attain a geometrically favourable lie of the pedicle (Figs. 1 and 2). As SpongostanTM is hemostatic, it sticks to the raw surfaces of the pedicle and base. The SpongostanTM has many advantages in this role as it is available off the shelf in every operating room, already has a great safety record as a hemostatic agent, is biodegradable, cost effective, does not migrate and incites minimal or no local foreign body reaction. It also seems to protect the pedicle from inadvertent dislodgement due to suction drains.