Vasileios A. Pagkalos

Aplasia cutis congenita: clinical management and a new classification system.

Background: Aplasia cutis congenita is a rare, congenital disorder. In its severe phenotype, it is potentially life threatening. Its management and the timing of surgery remain controversial because of the risks involved with both conservative and surgical approaches. Most literature is based on case reports and very small case series because of the rarity of the disorder. The authors present their experience treating newborns with aplasia cutis congenita and its progressive development. Methods: Using a hospital registry, the authors found all cases of newborns diagnosed with aplasia cutis congenita during the years 2000 to 2013. Clinical data were gathered from hospital and clinic records, and photographs were obtained by the plastic surgery team. Results: Twenty-two cases of aplasia cutis congenita were included in this study: 21 on the scalp and one on the foot heel. Eleven patients were male and 11 were female. Defect size ranged from 1 to 150 cm2 (average, 29 cm2). Three patients died as a result of uncontrollable hemorrhage. Six patients underwent emergency coverage, one with allografts later replaced by split-thickness skin grafts and five by immediate split-thickness skin grafting. All of the patients who underwent immediate skin grafting survived and thrived. Conclusions: The authors emphasize the role of emergency split-thickness skin grafting in the treatment of large aplasia cutis congenita or ones with large veins or sagittal sinus exposure. The authors also present a practical, treatment-oriented classification that could assist physicians in estimating the severity and therefore prognosis of the disease and offer a treatment guideline. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Facial Reconstruction of a Mucormycosis Survivor by Free Rectus Abdominis Muscle Flap, Tissue Expansion, and Ocular Prosthesis.

Invasive sinonasal mucormycosis is a rare fungal infection that usually occurs in immunocompromised or diabetic patients, and it is often fatal. The authors present a case of a woman patient suffering from systemic lupus erythematosus and diabetes mellitus treated with prednisone, presenting with a rapidly progressive rhino-orbital-cerebral mucormycosis. She was successfully treated with combined intravenous antifungal therapy and radical debridement followed by complex defect reconstruction with a free vertical rectus abdominis myocutaneous flap, tissue expander, and ophthalmic prosthesis.

Double Back Cut in Post-mastectomy Breast Skin (Fish-Shaped Skin Paddle) in Delayed Pedicled TRAM Flap Breast Reconstruction

AbstractBreast reconstruction has become standard of care for female patients with breast cancer. The transverse rectus abdominis musculo-cutaneous flap (TRAMf) is the most common method of immediate or delayed autologous breast reconstruction following mastectomy. We share our experience with modified, double back cut of post-mastectomy skin in delayed pedicled TRAMf breast reconstruction, resulting in fish-shaped skin paddle. This sort of back cut is a simple, reliable way to obtain a natural, esthetically pleasant breast mound with inconspicuous hidden scars.Level of Evidence VThis journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Nipple elevation using loupes magnification and a double-layer purse-string suture.

Nipple elevation is a procedure that enhances the projection of the nipples. The aim is to achieve an aesthetically satisfying appearance that is stable over time and at the same time to maintain the sensory and lactating functions of the nipples. The surgical technique described in this report is based on release of the retracting lactiferous ducts and fibrous bands under loupes magnification and use of two layers of sutures to secure the acquired height of the nipple. The result is a satisfying projection accompanied by preservation of the sensory and lactating functions.Level of Evidence IVThis journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Pixie ear deformity following rhytidectomy: ‘Prevention is better than cure’

1. Weerda H. Abnormalities. In: Weerda Hilko, editor. Surgery of the auricle: tumors-trauma-defects-abnormalities. 1st ed. New York: Thieme; 2007. p. 106e16. 2. Gleeson Michael. External ear: auricle (pinna). In: Standring Susan, et al., editors. Gray’s anatomy: the anatomical basis of clinical practice. 40th ed. Edinburgh: C. Livingstone; 2008. p. 615e32. 3. Pan B, Jiang H, Zhao Y, Lin L, Guo D, Zhuang H. Clinical analysis, repair and aetiology of question mark ear. J Plast Reconstr Aesthet Surg 2010;63:28e35. 4. Posso CM, Wolff GA, Suarez LD. Question mark ear deformity: a combined method for correction. Aesthetic Plast Surg 2011; 35:646e9.

Leaking seroma following breast augmentation: technical fault or new complication?

Sir, Breast augmentation (BA) remains the most common aesthetical operation performedworldwide [1, 2]. It is considered as a simple, reliable procedure with a low complications rate. Early complications such as hematoma, seroma and infection are well known and were referenced in the scientific literature [3]. However, we have not found any published studies regarding early seroma, leaking through the surgical wound (leaking seroma). The goal of this letter is to describe leaking seroma (LS) as an early complication following breast augmentation, to present our thoughts regarding the etiology of LS, patients’ risk group, potential treatment and ways to prevent it. We reviewed 350 consecutive patients that underwent breast augmentation by the same surgeon (ABB) in a private medical center during the years 2007–2012. Breast fascial closure was performed with interrupted stitches in 172 patients (49.1 %) and with running interlocking stitches in 178 (50.9 %). Drainage was not used in any of the patients operated in this series. Medical files and operating records were extracted, and all data were statistically analyzed. We defined leaking seroma as a serous exudate discharging from surgical wound, ranging from spots on the dressing to massive fluid leak. Empirically, chosen regimen for treatment of LS, including oral antibiotic, iodine ointment dressing, non-steroidal anti-inflammatory drugs (NSAID), and complete patient rest, was employed. Seventeen patients (4.86 %) showed signs of leaking seroma, in 16 cases unilateral and in one case bilateral. Among 350 patients, two identical female twins were operated and both of them developed LS symptoms. The incidence of LS during the study period gradually decreased as shown in Table 1. Lag time between the operation date and first LS symptoms appearance varied from 5 to 50 days with mean value 15.9±11.6 days. In five patients with massive leak, the fluid from the wound was obtained for bacteriologic examination; in this group all bacterial cultures were sterile. LS treatment regimen included oral antibiotics (usually Ceftin 500 mg×2/day), iodine ointment dressings, nonsteroidal anti-inflammatory drugs (NSAID), and rest until the symptoms’ cessation. This treatment was successful in 13 out of 17 patients (76.5 %) and duration of their symptoms ranged from 3 to 20 days with mean value 8.6±4.8 days. Patients’ postoperative course was uneventful thereafter. The lack of data regarding LS in the plastic surgery literature can be explained by problematic definition of the subject. Usually, breast implant exposure and extrusion are the result of infection. It is very difficult to differentiate leaking seroma from sub-clinical infection. In our cases, the fluid discharge from the wound was serous and pellucid; all wound cultures obtained from patients with massive leak were sterile. Previous antibiotic treatment may have prevented bacterial growth and as a result, may lead to a negative bacterial culture. The lack of data can also be explained by under-reporting of postoperative complications in aesthetical plastic surgery due to the competitive character of the private plastic surgery sector. LS development can be explained by early tissue edema and exudate fluid accumulation around breast implant as a result of foreign body reaction. In some cases, excessive fluid production and non-infectious inflammatory reaction took place and caused partial wound dehiscence and subsequent LS. * Vasileios A. Pagkalos pagkalos_v@yahoo.gr

Primary contraction of skin grafts: a porcine preliminary study

Aim: Skin grafting is a common clinical practice for plastic surgeons, yet primary contraction of these grafts is a neglected topic. This study was designed to investigate primary contraction and introduce the shape of skin graft as a possible factor that modifies primary contraction behavior, using porcine models. Methods: In the first series, full-thickness skin grafts (FTSGs) and split-thickness skin grafts (STSGs) were compared. In a second series, how the shape of the skin graft affected the degree of contraction was examined. Results: The mean percentage of FTSG shrinkage was 12.04%, and the median was 12.18%. The mean percentage of STSG shrinkage was 6.87%, and the median was 5%. Circle-shaped and square-shaped FTSGs showed mean/median graft shrinkage of 5.83%/6.93% and 4.15%/3.75%, respectively. In STSGs, the circle-shaped and square-shaped grafts had mean/median graft shrinkage of 1.07%/0% and 0.31%/0%, respectively. Conclusion: Our preliminary report revealed an expected greater shrinkage of FTSGs compared with STSGs. Furthermore, in a limited number of specimens, the shape of the skin graft seemed to affect the primary contraction of the STSGs.

Increasing the Efficacy of SLNB in Cases of Malignant Melanoma Located in Close Proximity to the Lymphatic Basin.

Background. Being predictive of the entire nodal bed, sentinel lymph node biopsy (SLNB) is invaluable in the surgical management of melanoma. Although the concept is simple, sentinel lymph node (SLN) identification and removal can be technically challenging. Methods. A total of 102 consecutive patients have undergone SLNB in the Division of Plastic and Reconstructive Surgery of Soroka University Medical Center from 2009 to 2012. Patients have undergone SLNB using a radioactive tracer and blue stain in order to identify the SLN. Although SLNB usually precedes the wide excision of melanoma, primary lesions in close proximity (<10 cm) to the lymph basin require wide excision before beginning the SLN quest. Results. All pathology reports confirmed the excision of lymph nodes. Conclusions. When treating MM in close proximity to the lymph basin, changing the sequence of the SLNB procedure seems to increase the efficacy of the method.

Burying the knot in periareolar mastopexy.

Level of Evidence IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of

Double-Bladed Scalpel in Mohs Micrographic Surgery

Mohs micrographic surgery is a tissue-sparing technique that allows for excision of cutaneous tumors under complete microscopic margins control. Mohs surgery boasts high cure rates and maximum tissue conservation. We introduce the double-blade scalpel in Mohs surgery as a timesaving and easy way to harvest tissue strips of uniform width and therefore increase the intraoperative efficiency of the procedure.