Plastic Surgery International The latest articles from Hindawi Publishing Corporation © 2014 , Hindawi Publishing Corporation . All rights reserved. Venous Thromboembolism following Elective Aesthetic Plastic Surgery: A Longitudinal Prospective Study in 1254 Patients Thu, 09 Oct 2014 00:00:00 +0000 Background. Venous thromboembolism (VTE) is a disorder with short-term mortality and long-term morbidity. Healthy patients submitted to elective aesthetic plastic surgeries (EAPS) have risk factors to develop VTE not well established yet. The objective of this study was to examine the incidence and risk factors for VTE in these patients. Methods. Longitudinal, prospective (minimum follow-up of 3 months), observational study. Comprehensive information on patient characteristics and surgeries performed was obtained. Preoperative, intraoperative, and postoperative risk factors were analyzed for their association with VTE. Results. A total of 1254 patients were included in the study. Postoperative VTE occurred in 17 (1,35%) of patients. VTE was more frequent in patients more than 40 years old (82.3%). Smoking, patients with 2 or 3 pregnancies, and hormone replacement therapy, and oral contraceptives use presents higher levels of VTE. In this study we have not found any correlation between liposuction, augmentation mammoplasty, mastopexy, and rhinoplasty as an isolated risk factor for VTE. Conclusions. The incidence of VTE in patients undergoing EAPS was 1.35%. Patients with more than 40 years of age, tobacco users, patients with 2 or more pregnancies, and hormone replacement therapy or oral contraceptives use presents higher levels of VTE. Denis Souto Valente, Lauro Aita Carvalho, Rafaela Koehler Zanella, and Sibelie Valente Copyright © 2014 Denis Souto Valente et al. All rights reserved. The Effect of Different Topical Agents (Silver Sulfadiazine, Povidone-Iodine, and Sodium Chloride 0.9%) on Burn Injuries in Rats Mon, 29 Sep 2014 00:00:00 +0000 It was aimed to comparatively evaluate the effects of dressing methods with silver sulfadiazine, povidone-iodine, and saline which have a common use in routine practices for burn injuries. Twenty-eight Sprague Dawley adult female rats were used in this study. All the rats were divided into 4 groups: the control group, the povidone-iodine group, the saline group, and the silver sulfadiazine group. On each rat, a second degree burn which covered less than 10% of the body surface area was created under general anesthesia by a metal comb including four probes with 2 × 1 cm area. The control group did not have any treatment during the experiment. Povidone-iodine, saline, and silver sulfadiazine administrations were performed under ether anesthesia every day. On 0, 7th, 14th, and 21st days of the study, tissue samples were taken for histological analyses. The sections taken from the paraffin blocks were stained and avidin-biotin-peroxidase method was used for collagen immune-reactivity. In the light microscope analyses, number of inflammatory cells, vascularization, fibroblast proliferation, collagen formation and epithelialization were evaluated histologically in all groups and analysed statistically. The agents that we used for injury healing in the treatment groups did not show any significant better results in comparison with the control group. In conclusion, further studies with the use of sodium chloride, silver sulfadiazine, and povidone-iodine by creating deeper and/or larger burn injury models are needed in order to accept these agents in routine treatment. Emir Burak Yüksel, Alpagan Mustafa Yıldırım, Ali Bal, and Tuncay Kuloglu Copyright © 2014 Emir Burak Yüksel et al. All rights reserved. Evaluation of the Use of Auricular Composite Graft for Secondary Unilateral Cleft Lip Nasal Alar Deformity Repair Thu, 25 Sep 2014 09:09:17 +0000 The purpose of this study is to evaluate the surgical outcome after using composite grafts for secondary cleft lip nasal deformities. A retrospective cohort study of one surgeon’s outcome of 35 consecutive performed secondary cleft lip nasal deformity repair. Thirty-five patients with secondary nose deformity related to unsatisfactory cleft lip repair were operated using the proposed surgical technique since 2008. All these patients met the study criterion of having anthropometric measurements performed at least one year postoperatively. Measurement of nostril size was performed at the right and left side of the nose, preoperatively and at least one year postoperatively. The study found statistically significant differences between the preoperatory and postoperatory nose measurements. In addition, we have not found statistically significant differences between the cleft and noncleft nostril sizes measured at least one year postoperatively. The findings suggest that the proposed technique is a good alternative to address secondary nose deformity related to cleft lip primary repair. Percy Rossell-Perry and Carolina Romero-Narvaez Copyright © 2014 Percy Rossell-Perry and Carolina Romero-Narvaez. All rights reserved. FAMM Flap in Reconstructing Postsurgical Nasopharyngeal Airway Stenosis Sun, 21 Sep 2014 09:04:37 +0000 Introduction. Postsurgical nasopharyngeal airway stenosis can be a challenge to manage. The stenosis could be as a result of any surgical procedure in the nasopharyngeal region that heals extensive scarring and fibrosis. Objective. To evaluate patients with nasopharyngeal stenosis managed with FAMM flap. Study Design. Prospective study of patients with nasopharyngeal stenosis at the Kenyatta National Hospital between 2010 and 2013 managed with FAMM flap. Materials and Methods. Patients with severe nasopharyngeal airway stenosis were reviewed and managed with FAMM flaps at the Kenyatta National Hospital. Postoperatively they were assessed for symptomatic improvement in respiratory distress, patency of the nasopharyngeal airway, and donor site morbidity. Results. A total of 8 patients were managed by the authors in a duration of 4 years with nasopharyngeal stenosis. Five patients were managed with unilateral FAMM flaps in a two-staged surgical procedure. Four patients had complete relieve of the airway obstruction with a patent airway created. One patient had a patent airway created though with only mild improvement in airway obstruction. Conclusion. FAMM flap provides an alternative in the management of postsurgical severe nasopharyngeal stenosis. It is a reliable flap that is easy to raise and could provide adequate epithelium for the stenosed pharynx. Ferdinand Wanjala Nangole and Stanley Ominde Khainga Copyright © 2014 Ferdinand Wanjala Nangole and Stanley Ominde Khainga. All rights reserved. Augmentation Rhinoplasty in Cleft Lip Nasal Deformity: Preliminary Patients’ Perspective Mon, 01 Sep 2014 00:00:00 +0000 The correction of cleft lip nasal deformity is challenging and there have been numerous methods described in the literature with little demonstrated technical superiority of one over another. The common clinical issues associated with cleft lip nasal deformity are its lack of symmetry, alar collapse on the affected side, obtuse nasal labial angle, short nasal length, loss of tip definition, and altered columella show among others. We carried out augmentation of cleft lip rhinoplasties with rib graft in 16 patients over the one-year study period. Each of these patients was reviewed and given questionnaire before and after surgery to evaluate their response on the outcome to the approach. Preoperatively, nasal asymmetry is the main complaint (, 87.5%) among our series of patients. Postoperatively, 12 (75%) patients out of the 16 reported significant improvement in their nasal symmetry with the other four marginal. All patients reported excellent nasal projection postoperatively with good nasal tip definition. Our series of patients reported overall good satisfaction outcome and will recommend this procedure to other patients with cleft lip nasal deformity. In conclusion, augmentation of cleft lip rhinoplasty can be employed to achieve perceivable and satisfactory outcome in patients with cleft lip nasal deformity. William H. C. Tiong, Mohd Ali Mat Zain, and Normala Hj Basiron Copyright © 2014 William H. C. Tiong et al. All rights reserved. The Effectiveness of Modified Cottle Maneuver in Predicting Outcomes in Functional Rhinoplasty Mon, 25 Aug 2014 05:49:18 +0000 Objective. To assess the outcomes of functional rhinoplasty for nasal valve incompetence and to evaluate an in-office test used to select appropriate surgical techniques. Methods. Patients with nasal obstruction due to nasal valve incompetence were enrolled. The modified Cottle maneuver was used to assess the internal and external nasal valves to help select the appropriate surgical method. The rhinoplasty outcomes evaluation (ROE) form and a 10-point visual analog scale (VAS) of nasal breathing were used to compare preoperative and postoperative symptoms. Results. Forty-nine patients underwent functional rhinoplasty evaluation. Of those, 35 isolated batten or spreader grafts were inserted without additional procedures. Overall mean ROE score increased significantly () from 41.9 ± 2.4 to 81.7 ± 2.5 after surgery. Subjective improvement in nasal breathing was also observed with the VAS (mean improvement of 4.5 (95% CI 3.8–5.2) from baseline ()). Spearman rank correlation between predicted outcomes using the modified Cottle maneuver and postoperative outcomes was strong for the internal nasal valve (Rho = 0.80; ) and moderate for the external nasal valve (Rho = 0.50; ). Conclusion. Functional rhinoplasty improved subjective nasal airflow in our population. The modified Cottle maneuver was effective in predicting positive surgical outcomes. Elaine Fung, Paul Hong, Corey Moore, and S. Mark Taylor Copyright © 2014 Elaine Fung et al. All rights reserved. Aesthetic Surgery Training during Residency in the United States: A Comparison of the Integrated, Combined, and Independent Training Models Sun, 24 Aug 2014 00:00:00 +0000 Background. Three educational models for plastic surgery training exist in the United States, the integrated, combined, and independent model. The present study is a comparative analysis of aesthetic surgery training, to assess whether one model is particularly suitable to provide for high-quality training in aesthetic surgery. Methods. An 18-item online survey was developed to assess residents’ perceptions regarding the quality of training in aesthetic surgery in the US. The survey had three distinct sections: demographic information, current state of aesthetic surgery training, and residents’ perception regarding the quality of aesthetic surgery training. Results. A total of 86 senior plastic surgery residents completed the survey. Twenty-three, 24, and 39 residents were in integrated, combined, and independent residency programs, respectively. No statistically significant differences were seen with respect to number of aesthetic surgery procedures performed, additional training received in minimal-invasive cosmetic procedures, median level of confidence with index cosmetic surgery procedures, or perceived quality of aesthetic surgery training. Facial aesthetic procedures were felt to be the most challenging procedures. Exposure to minimally invasive aesthetic procedures was limited. Conclusion. While the educational experience in aesthetic surgery appears to be similar, weaknesses still exist with respect to training in minimally invasive/nonsurgical aesthetic procedures. Arash Momeni, Rebecca Y. Kim, Derrick C. Wan, Ali Izadpanah, and Gordon K. Lee Copyright © 2014 Arash Momeni et al. All rights reserved. Helping Hands: A Cost-Effectiveness Study of a Humanitarian Hand Surgery Mission Wed, 20 Aug 2014 07:33:56 +0000 Purpose. Congenital anomalies and injuries of the hand are often undertreated in low-middle income countries (LMICs). Humanitarian missions to LMICs are commonplace, but few exclusively hand surgery missions have been reported and none have attempted to demonstrate their cost-effectiveness. We present the first study evaluating the cost-effectiveness of a humanitarian hand surgery mission to Honduras as a method of reducing the global burden of surgically treatable disease. Methods. Data were collected from a hand surgery mission to San Pedro Sula, Honduras. Costs were estimated for local and volunteer services. The total burden of disease averted from patients receiving surgical reconstruction was derived using the previously described disability-adjusted life years (DALYs) system. Results. After adjusting for likelihood of disability associated with the diagnosis and likelihood of the surgery’s success, DALYs averted totaled 104.6. The total cost for the mission was $45,779 (USD). The cost per DALY averted was calculated to be $437.80 (USD), which is significantly below the accepted threshold of two times the per capita gross national income of Honduras. Conclusions. This hand surgery humanitarian mission trip to Honduras was found to be cost-effective. This model and analysis should help in guiding healthcare professionals to organize future plastic surgery humanitarian missions. Kashyap K. Tadisina, Karan Chopra, John Tangredi, J. Grant Thomson, and Devinder P. Singh Copyright © 2014 Kashyap K. Tadisina et al. All rights reserved. A Systematic Review of the Evolution of Laser Doppler Techniques in Burn Depth Assessment Thu, 07 Aug 2014 06:55:29 +0000 Aims. The introduction of laser Doppler (LD) techniques to assess burn depth has revolutionized the treatment of burns of indeterminate depth. This paper will systematically review studies related to these two techniques and trace their evolution. At the same time we hope to highlight current controversies and areas where further research is necessary with regard to LD imaging (LDI) techniques. Methods. A systematic search for relevant literature was carried out on PubMed, Medline, EMBASE, and Google Scholar. Key search terms included the following: “Laser Doppler imaging,” “laser Doppler flow,” and “burn depth.” Results. A total of 53 studies were identified. Twenty-six studies which met the inclusion/exclusion criteria were included in the review. Conclusions. The numerous advantages of LDI over those of LD flowmetry have resulted in the former technique superseding the latter one. Despite the presence of alternative burn depth assessment techniques, LDI remains the most favoured. Various newer LDI machines with increasingly sophisticated methods of assessing burn depth have been introduced throughout the years. However, factors such as cost effectiveness, scanning of topographically inconsistent areas of the body, and skewing of results due to tattoos, peripheral vascular disease, and anaemia continue to be sighted as obstacles to LDI which require further research. Manaf Khatib, Shehab Jabir, Edmund Fitzgerald O’Connor, and Bruce Philp Copyright © 2014 Manaf Khatib et al. All rights reserved. Risk Factors and Surgical Refinements of Postresective Mandibular Reconstruction: A Retrospective Study Wed, 06 Aug 2014 08:26:37 +0000 Background. Postresective mandibular reconstruction is common in cases of oral and mandibular tumors. However, complications such as infection, plate exposure, or plate fracture can occur. We identified several significant risk factors of complications after reconstructive surgery and compared the effectiveness of different surgical techniques for reducing the incidence of complications. Methods. This study is a retrospective analysis of 28 oromandibular cancer cases that required reconstructive surgery between January 1999 and December 2011 at Kobe University Graduate School of Medicine in Japan. All cases were classified using Hashikawa’s CAT and Eichner’s classification methods. Then, we determined whether these classifications and different treatment or surgical methods were significantly related to complications. Results. Complications after mandibular reconstruction occurred in 10/28 patients (36%). Specifically, five patients had plate fractures, four had plate exposures, and one had an infection. Radiation therapy and closure without any flaps were significantly related to infection or plate exposure. The wrap-around technique of securing reconstruction plates was used in 14 cases, whereas the run-through technique was used in two cases. Conclusions. The success of mandibular reconstruction depends on both mechanical and biological factors, such as the location of defects, presence of occlusions, and the amount of vascularization of the flap. Akiko Sakakibara, Kazunobu Hashikawa, Satoshi Yokoo, Shunsuke Sakakibara, Takahide Komori, and Shinya Tahara Copyright © 2014 Akiko Sakakibara et al. All rights reserved. Strategy of Surgical Management of Peripheral Neuropathy Form of Diabetic Foot Syndrome in Ghana Thu, 24 Jul 2014 10:06:29 +0000 Introduction. Foot disorders such as ulceration, infection, and gangrene which are often due to diabetes mellitus are some major causes of morbidity and high amputation. Aim. This study aims to use a group of methods for the management of diabetic foot ulcers (DFU) in order to salvage the lower limb so as to reduce the rate of high amputations of the lower extremity. Materials and Methods. A group of different advanced methods for the management of DFU such as sharp debridement of ulcers, application of vacuum therapy, and other forms of reconstructive plastic surgical procedures were used. Data collection was done at 3 different hospitals where the treatments were given. Results. Fifty-four patients with type 2 diabetes mellitus were enrolled in the current study: females (68.51%) and males (31.49%) with different stages of PEDIS classification. They underwent different methods of surgical management: debridement, vacuum therapy (some constructed from locally used materials), and skin grafting giving good and fast results. Only 4 had below knee amputations. Conclusion. Using advanced surgical wound management including reconstructive plastic surgical procedures, it was possible to reduce the rate of high amputations of the lower limb. W. M. Rdeini, P. Agbenorku, and V. A. Mitish Copyright © 2014 W. M. Rdeini et al. All rights reserved. Biologic Collagen Cylinder with Skate Flap Technique for Nipple Reconstruction Thu, 10 Jul 2014 00:00:00 +0000 A surgical technique using local tissue skate flaps combined with cylinders made from a naturally derived biomaterial has been used effectively for nipple reconstruction. A retrospective review of patients who underwent nipple reconstruction using this technique was performed. Comorbidities and type of breast reconstruction were collected. Outcome evaluation included complications, surgical revisions, and nipple projection. There were 115 skate flap reconstructions performed in 83 patients between July 2009 and January 2013. Patients ranged from 32 to 73 years old. Average body mass index was 28.0. The most common comorbidities were hypertension (39.8%) and smoking (16.9%). After breast reconstruction, 68.7% of the patients underwent chemotherapy and 20.5% underwent radiation. Seventy-one patients had immediate breast reconstruction with expanders and 12 had delayed reconstruction. The only reported complications were extrusions (3.5%). Six nipples (5.2%) in 5 patients required surgical revision due to loss of projection; two patients had minor loss of projection but did not require surgical revision. Nipple projection at time of surgery ranged from 6 to 7 mm and average projection at 6 months was 3–5 mm. A surgical technique for nipple reconstruction using a skate flap with a graft material is described. Complications are infrequent and short-term projection measurements are encouraging. Brian P. Tierney, Jason P. Hodde, and Daniela I. Changkuon Copyright © 2014 Brian P. Tierney et al. All rights reserved. Outcome of Split Thickness Skin Grafting and Multiple Z-Plasties in Postburn Contractures of Groin and Perineum: A 15-Year Experience Wed, 21 May 2014 11:05:27 +0000 Background. Groin and perineal burn contracture is a rare postburn sequel. Such postburn contractures causes distressing symptoms to the patients and in the management of these contractures, both functional and cosmetic appearance should be the primary concern. Aims. To study the outcome of surgical treatment (STSG and multiple Z-plasties) in postburn contractures of groin and perineum. Material and Methods. We conducted a study of 49 patients, with postburn groin and perineal contractures. Release of contracture with split thickness skin grafting (STSG) was done in 44 (89.79%) patients and release of contracture and closure by multiple Z-plasties was done in 5 (10.21%) patients. Results. Satisfactory functional and cosmetic outcome was seen in 44 (89.79%) patients. Minor secondary contractures of the graft were seen in 3 (6.81%) patients who were managed by physiotherapy and partial recurrence of the contracture in 4 (8.16%) patients required secondary surgery. Conclusion. We conclude that postburn contractures of the groin and perineum can be successfully treated with release of contracture followed by STSG with satisfactory functional and cosmetic results. Long term measures like regular physiotherapy, use of pressure garments, and messaging with emollient creams should not be neglected and should be instituted postoperatively to prevent secondary contractures of the graft and recurrence of the contracture. Wani Sajad and Raashid Hamid Copyright © 2014 Wani Sajad and Raashid Hamid. All rights reserved. Acellular Dermal Matrices and Radiotherapy in Breast Reconstruction: A Systematic Review and Meta-Analysis of the Literature Wed, 21 May 2014 08:53:42 +0000 The increasing use of commercially available acellular dermis matrices for postmastectomy breast reconstruction seems to have simplified the surgical procedure and enhanced the outcome. These materials, generally considered to be highly safe or with only minor contraindications due to the necessary manipulation in preparatory phases, allow an easier one-phase surgical procedure, in comparison with autologous flaps, offering a high patient satisfaction. Unfortunately, the claim for a higher rate of complications associated with irradiation at the implant site, especially when the radiation therapy was given before the reconstructive surgery, suggested a careful behaviour when this technique is preferred. However, this hypothesis was never submitted to a crucial test, and data supporting it are often discordant or incomplete. To provide a comprehensive analysis of the field, we searched and systematically reviewed papers published after year 2005 and registered clinical trials. On the basis of a meta-analysis of data, we conclude that the negative effect of the radiotherapy on the breast reconstruction seems to be evident even in the case of acellular dermis matrices aided surgery. However, more trials are needed to make solid conclusions and clarify the poor comprehension of all the factors negatively influencing outcome. Luigi Valdatta, Anna Giulia Cattaneo, Igor Pellegatta, Stefano Scamoni, Anna Minuti, and Mario Cherubino Copyright © 2014 Luigi Valdatta et al. All rights reserved. Treatment of Early-Stage Pressure Ulcers by Using Autologous Adipose Tissue Grafts Thu, 10 Apr 2014 09:33:22 +0000 Assessing pressure ulcers (PUs) in early stages allows patients to receive safer treatment. Up to now, in addition to clinical evaluation, ultrasonography seems to be the most suitable technique to achieve this goal. Several treatments are applied to prevent ulcer progression but none of them is totally effective. Furthermore, the in-depth knowledge of fat regenerative properties has led to a wide use of it. With this study the authors aim at introducing a new approach to cure and prevent the worsening of early-stage PUs by using fat grafts. The authors selected 42 patients who showed clinical and ultrasonographic evidence of early-stage PUs. Values of skin thickness, fascial integrity, and subcutaneous vascularity were recorded both on the PU area and the healthy trochanteric one, used as control region. Fat grafting was performed on all patients. At three months, abnormal ultrasonographic findings, such as reduction of cutaneous and subcutaneous thickness, discontinuous fascia, and decrease in subcutaneous vascularity, all were modified with respect to almost all the corresponding parameters of the control region. Results highlight that the use of fat grafts proved to be an effective treatment for early-stage PUs, especially in the care of neurological and chronic bedridden patients. Giovanni Francesco Marangi, Tiziano Pallara, Barbara Cagli, Emiliano Schena, Francesco Giurazza, Elio Faiella, Bruno Beomonte Zobel, and Paolo Persichetti Copyright © 2014 Giovanni Francesco Marangi et al. All rights reserved. Vascular Waveform Analysis of Flap-Feeding Vessels Using Color Doppler Ultrasonography Mon, 07 Apr 2014 09:42:06 +0000 We performed vascular waveform analysis of flap-feeding vessels using color Doppler ultrasonography and evaluated the blood flow in the flaps prior to surgery. Vascular waveform analysis was performed in 19 patients. The analyzed parameters included the vascular diameter, flow volume, flow velocity, resistance index, pulsatility index, and acceleration time. The arterial waveform was classified into 5 types based on the partially modified blood flow waveform classification reported by Hirai et al.; in particular, D-1a, D-1b, and D-2 were considered as normal waveforms. They were 4 patients which observed abnormal vascular waveform among 19 patients (D-4 : 1, D-3 : 1, and Poor detect : 2). The case which presented D-4 waveform changed the surgical procedure, and a favorable outcome was achieved. Muscle flap of the case which presented D-3 waveform was partially necrosed. The case which detected blood flow poorly was judged to be the vascular obstruction of the internal thoracic artery. In the evaluation of blood flow in flaps using color Doppler ultrasonography, determination of not only basic blood flow information, such as the vascular distribution and diameter and flow velocity, but also the flow volume, vascular resistance, and arterial waveform is essential to elucidate the hemodynamics of the flap. Akihiro Ogino and Kiyoshi Onishi Copyright © 2014 Akihiro Ogino and Kiyoshi Onishi. All rights reserved. One-Stop Outpatient Management of Accessory Auricle in Children with Titanium Clip Tue, 01 Apr 2014 09:05:24 +0000 Introduction. Literature on ideal management of accessory auricles is limited. Traditionally, accessory auricles are managed by paediatricians with suture ligation at the base of the accessory auricle to induce ischaemic necrosis (Mehmi et al, 2007). This method can be associated with complications and poor cosmesis thus leading to the vogue of surgical excision ( Frieden et al, 1995; Sebben, 1989). We present our experience in managing these lesions in children with the application of a titanium clip in a one-stop outpatient setting. Methods. Data was collected retrospectively through review of patient records and telephone questionnaire identifying outcomes from the parents’ perspective. Results. Of 42 patients, 24 (57.1%) responded. Eleven (26.2%) underwent surgical excision, 6 (14.3%) had no intervention, and 1 (2.4%) was not contactable. All parents were happy with the outcome and would recommend this management to other parents. Twenty-three (96%) had no complications apart from a tiny residual nubbin, which was considered cosmetically acceptable. One child had a residual nubbin that grew in size requiring surgical excision at later stage. Conclusion. Management of accessory auricles by the application of a titanium clip in one-stop outpatient setting is safe, simple, quick, and well tolerated with no need for admission, anaesthesia, or followup due to the low complication rate. Phui Yee Wong, Tereze Laing, and Catherine Milroy Copyright © 2014 Phui Yee Wong et al. All rights reserved. Funding for Postbariatric Body-Contouring (Bariplastic) Surgery in England: A Postcode Lottery Thu, 20 Mar 2014 09:32:15 +0000 Background. With the increase in bariatric surgery in the UK, there has been a substantial increase in patients undergoing massive weight loss (MWL) seeking postbariatric body-contouring (bariplastic) surgery. However, there is a wide variation of availability on the National Health Service (NHS). Aims. To (1) review the funding policies of Primary Care Trusts (PCTs) in England for bariplastic surgery and (2) analyse the number of procedures funded in two consecutive financial years. Methods. We sent out questionnaires to all PCTs in England regarding their funding policies for bariplastic surgery and requested the number of procedures funded in 2008-09 and 2009-10. Findings. 121/147 (82%) PCTs replied to our questionnaires. 73 (60%) excluded all bariplastic procedures. 106/121 (87.6%) PCTs had referral guidelines for plastic surgery. 46/121 (38%) PCTs provided the total number of funded abdominoplasty-apronectomy (A-A) in the two financial years: total number of A-A applicants rose from 393 to 531, but approval for funding fell from 24.2% to 19.6%. Only 3 (2%) PCTs indicated increase in their future spending on bariplastic procedures in the next 5 years, with 67% planning to decrease or unsure about future funding. Conclusion. There exists a postcode lottery for bariplastic surgery in England and we feel the need for guidelines on provision of bariplastic procedures following MWL. Samrat Mukherjee, Sachin Kamat, Samuel Adegbola, and Sanjay Agrawal Copyright © 2014 Samrat Mukherjee et al. All rights reserved. Clinical Outcomes for Breast Cancer Patients Undergoing Mastectomy and Reconstruction with Use of DermACELL, a Sterile, Room Temperature Acellular Dermal Matrix Tue, 11 Mar 2014 13:15:30 +0000 Background. Decellularized human skin has been used in a variety of medical applications, primarily involving soft tissue reconstruction, wound healing, and tendon augmentation. Theoretically, decellularization removes potentially immunogenic material and provides a clean scaffold for cellular and vascular in growth. The use of acellular dermal matrix in two-stage postmastectomy breast reconstruction is described. Methods. Ten consecutive breast cancer patients were treated with mastectomies and immediate reconstruction from August to November 2011. There were 8 bilateral and 1 unilateral mastectomies for a total of 17 breasts, with one exclusion for chronic tobacco use. Reconstruction included the use of a new 6 × 16 cm sterile, room temperature acellular dermal matrix patch (DermACELL) soaked in a cefazolin bath. Results. Of the 17 breasts, 15 reconstructions were completed; 14 of them with expander to implant sequence and acellular dermal matrix. Histological analysis of biopsies obtained during trimming of the matrix at the second stage appeared nonremarkable with evidence of normal healing, cellularity, and vascular infiltration. Conclusion. Postoperative observations showed that this cellular dermal matrix appears to be an appropriate adjunct to reconstruction with expanders. This acellular dermal matrix appeared to work well with all patients, even those receiving postoperative chemotherapy, postoperative radiation, prednisone, or warfarin sodium. Christopher Vashi Copyright © 2014 Christopher Vashi. All rights reserved. Second Generation Self-Inflating Tissue Expanders: A Two-Year Experience Thu, 23 Jan 2014 13:33:38 +0000 Background. Tissue expansion is a well-established surgical technique that produces an additional amount of normal skin to cover a defect. This technique is appealing because the skin quality and color are from the patient’s own. The widely used injectable expanders are of great reliability but carry the disadvantage of being painful during injection and most of the time require multiple clinic visits. So the idea of self-inflation became attractive and hydrogel expanders were developed and became widely known for being painless during clinic visit and decrease number of visits. The first generation expanders were modified by adding an enclosing plastic shell to decrease the unopposed expansion that occurred in the first generation expanders, which lead to pressure necrosis of the skin flaps. This made it an attractive option for tissue expansion in children and some adult patients. Patients, Materials, and Methods. Charts of 17 patients were retrospectively reviewed, all of them had second generation self-inflating expanders implanted over a 2-year period for one of two purposes, the treatment of giant nevi or burn scars. Results. Fifteen patients were females and 2 were males. The indication was large burn scar in 14 cases (14/17), in which 47/55 expanders were implanted, and giant nevus in 3/17 cases in which 8/55 expanders were implanted. Extrusion of the expander occurred in 8/55 expanders (14.5%), which occurred in 6/14 patients. The highest percentage of extrusion occurred in the neck in which two out of three expanders extruded; otherwise this complication does not seem to be related to the indication, gender, nor age of the patients. It seems to be that it is technical in nature. The patients did not have to get any injections to fill the tissue expanders, which made the expansion process less painful and more convenient. Conclusion. This seems to be currently the largest published review in which second generation expanders were used. Those expanders seem to offer a desirable advantage of being painless for children, also they do not require repeated visits to the surgeon’s clinic, which is of great value for patients living in the periphery. Jamal Omran Al Madani Copyright © 2014 Jamal Omran Al Madani. All rights reserved. Hypospadias Repair: A Single Centre Experience Mon, 20 Jan 2014 09:18:47 +0000 Objectives. To determine the demographics and analyze the management and factors influencing the postoperative complications of hypospadias repair. Settings. Hayatabad Medical Complex Peshawar, Pakistan, from January 2007 to December 2011. Material and Methods. All male patients presenting with hypospadias irrespective of their ages were included in the study. The data were acquired from the hospital’s database and analyzed with Statistical Package for Social Sciences (SPSS). Results. A total of 428 patients with mean age of 8.12 ± 5.04 SD presented for hypospadias repair. Midpenile hypospadias were the most common. Chordee, meatal abnormalities, cryptorchidism, and inguinal hernias were observed in 74.3%, 9.6%, 2.8%, and 2.1% cases, respectively. Two-stage (Bracka) and TIP (tubularized incised urethral plate) repairs were performed in 76.2% and 20.8% of cases, respectively. The most common complications were edema and urethrocutaneous fistula (UCF). The complications were significantly lower in the hands of specialists than residents (-value = 0.0086). The two-stage hypospadias repair resulted in higher complications frequency than single-stage repair ( value = 0.0001). Conclusion. Hypospadias surgery has a long learning curve because it requires a great deal of temperament, surgical skill and acquaintance with magnifications. Single-stage repair should be encouraged wherever applicable due to its lower postoperative complications. Mansoor Khan, Abdul Majeed, Waqas Hayat, Hidayat Ullah, Shazia Naz, Syed Asif Shah, Tahmeedullah Tahmeed, Kanwal Yousaf, and Muhammad Tahir Copyright © 2014 Mansoor Khan et al. All rights reserved. Burn Injuries Resulting from Hot Water Bottle Use: A Retrospective Review of Cases Presenting to a Regional Burns Unit in the United Kingdom Sun, 22 Dec 2013 09:29:02 +0000 Introduction. Hot water bottles are commonly used to relieve pain and for warmth during the colder months of the year. However, they pose a risk of serious burn injuries. The aim of this study is to retrospectively review all burn injuries caused by hot water bottles presenting to our regional burns unit. Methods. Patients with burns injuries resulting from hot water bottle use were identified from our burns database between the periods of January 2004 and March 2013 and their cases notes reviewed retrospectively. Results. Identified cases involved 39 children (aged 17 years or younger) and 46 adults (aged 18 years or older). The majority of burns were scald injuries. The mean %TBSA was 3.07% (SD ± 3.40). Seven patients (8.24%) required debridement and skin grafting while 3 (3.60%) required debridement and application of Biobrane. One patient (1.18%) required local flap reconstruction. Spontaneous rupture accounted for 48.20% of injuries while accidental spilling and contact accounted for 33% and 18.80% of injuries, respectively. The mean time to heal was 28.87 days (SD ± 21.60). Conclusions. This study highlights the typical distribution of hot water bottle burns and the high rate of spontaneous rupture of hot water bottles, which have the potential for significant burn injuries. Shehab Jabir, Quentin Frew, Naguib El-Muttardi, and Peter Dziewulski Copyright © 2013 Shehab Jabir et al. All rights reserved. Sensory Recovery with Innervated and Noninnervated Flaps after Total Lower Lip Reconstruction: A Comparative Study Thu, 05 Dec 2013 15:52:36 +0000 This study compares sensory recovery after total lower lip reconstruction in a wide variety of flaps including bilateral depressor anguli oris flap, submental island flap, bilateral fan flaps, radial forearm flap, and pectoralis major myocutaneous flaps in a large number of patients. Spontaneous return of flap sensation was documented by clinical testing in the majority (3%) of patients who underwent total lower lip reconstruction. Sensory recovery occurred more often in patients with fasciocutaneous free flaps than in those with musculocutaneous flaps. Flap sensation to touch, two-point discrimination, and temperature perception was correlated with age, smoking, and radiation treated patients. We conclude that reasonable sensory recovery may be expected in noninnervated flaps, provided that the major regional sensorial nerve has not been sacrificed, and also provided that the patients age is relatively young and that enough surface contact area of the recipient bed is present without marked scarring. This trial was regestered with Chinese Clinical Trial Registry (Chi CTR) with ChiCTR-ONC-13003656. Meltem Ayhan Oral, Kamuran Zeynep Sevim, Metin Görgü, and Hasan Yücel Öztan Copyright © 2013 Meltem Ayhan Oral et al. All rights reserved. Sensory Recovery Outcome after Digital Nerve Repair in Relation to Different Reconstructive Techniques: Meta-Analysis and Systematic Review Tue, 30 Jul 2013 12:55:22 +0000 Good clinical outcome after digital nerve repair is highly relevant for proper hand function and has a significant socioeconomic impact. However, level of evidence for competing surgical techniques is low. The aim is to summarize and compare the outcomes of digital nerve repair with different methods (end-to-end and end-to-side coaptations, nerve grafts, artificial conduit-, vein-, muscle, and muscle-in-vein reconstructions, and replantations) to provide an aid for choosing an individual technique of nerve reconstruction and to create reference values of standard repair for nonrandomized clinical studies. 87 publications including 2,997 nerve repairs were suitable for a precise evaluation. For digital nerve repairs there was practically no particular technique superior to another. Only end-to-side coaptation had an inferior two-point discrimination in comparison to end-to-end coaptation or nerve grafting. Furthermore, this meta-analysis showed that youth was associated with an improved sensory recovery outcome in patients who underwent digital replantation. For end-to-end coaptations, recent publications had significantly better sensory recovery outcomes than older ones. Given minor differences in outcome, the main criteria in choosing an adequate surgical technique should be gap length and donor site morbidity caused by graft material harvesting. Our clinical experience was used to provide a decision tree for digital nerve repair. Felix J. Paprottka, Petra Wolf, Yves Harder, Yasmin Kern, Philipp M. Paprottka, Hans-Günther Machens, and Jörn A. Lohmeyer Copyright © 2013 Felix J. Paprottka et al. All rights reserved. Complements and the Wound Healing Cascade: An Updated Review Wed, 24 Jul 2013 10:25:14 +0000 Wound healing is a complex pathway of regulated reactions and cellular infiltrates. The mechanisms at play have been thoroughly studied but there is much still to learn. The health care system in the USA alone spends on average 9 billion dollars annually on treating of wounds. To help reduce patient morbidity and mortality related to abnormal or prolonged skin healing, an updated review and understanding of wound healing is essential. Recent works have helped shape the multistep process in wound healing and introduced various growth factors that can augment this process. The complement cascade has been shown to have a role in inflammation and has only recently been shown to augment wound healing. In this review, we have outlined the biology of wound healing and discussed the use of growth factors and the role of complements in this intricate pathway. Hani Sinno and Satya Prakash Copyright © 2013 Hani Sinno and Satya Prakash. All rights reserved. Open Reduction Internal Fixation Poststernotomy Mediastinitis Wed, 17 Jul 2013 09:28:48 +0000 Introduction. Mediastinitis has been reported to complicate 5% of sternotomy surgery. We have adopted an open reduction and rigid internal fixation (ORIF) approach during the conventional rescue surgery in the treatment of mediastinitis. Methods. A retrospective review was performed to compare the outcomes of patients that had an ORIF to correct postoperative mediastinitis following median sternotomy. These were compared with the outcome of the patients that did not undergo ORIF. Results. In the 5-year study period, we reviewed 35 mediastinitis patient charts. Postoperatively, the ORIF patient group remained in the Intensive Care Unit (ICU) and on a ventilator for a mean of 1.5 and 0.75 days, respectively. Patients treated without ORIF spent significantly more days in the ICU (mean of 7.5 days, ) and on a ventilator (mean of 2.15 days, ). Furthermore, it was found that none of the patients (0%) who underwent ORIF complained of any postoperative sternal instability or pain. Preoperatively, however, these rates were as high as 72%. Conclusions. In the select patient, ORIF can be a safe option in the management of mediastinitis, which we have shown to significantly decrease morbidity and mortality by providing anatomic reduction as well as physiologic stabilization. We have shown that ORIF will improve the quality of life of the patient by minimizing abnormal sternal mobility and pain and will also decrease inpatient costs by decreasing days spent in the ICU and ventilator dependence. Hani Sinno and Tassos Dionisopoulos Copyright © 2013 Hani Sinno and Tassos Dionisopoulos. All rights reserved. Assessing Improvement in Quality of Life and Patient Satisfaction following Body Contouring Surgery in Patients with Massive Weight Loss: A Critical Review of Outcome Measures Employed Mon, 01 Jul 2013 09:40:57 +0000 Body contouring following massive weight loss is a rapidly expanding field in plastic surgery. However, healthcare payers are reluctant to fund such procedures, viewing them as purely cosmetic. This has resulted in a flurry of studies assessing quality of life (QoL) and patient satisfaction following body contouring surgery in this cohort of patients to establish an evidence base to support the idea that body contouring is as much (or even more) a functional procedure as it is cosmetic. However, the methods employed in these studies are seldom ideal, and hence the conclusions are unreliable. The gold standard to assess QoL and patient satisfaction is to use patient specific psychometrically validated patient reported outcome (PRO) measures. Developing such measures consists of a three-step process which includes a review of the current literature, qualitative patient interviews to determine what patients consider the most important, and expert opinion. This study aims to appraise the currently available literature on assessment of QoL and patient satisfaction in body contouring surgery patients. This will hopefully provide an understanding of methodological weaknesses in current studies and inform future investigators of the design of ideal instruments for assessing QoL and patient satisfaction in body contouring patients. Shehab Jabir Copyright © 2013 Shehab Jabir. All rights reserved. Philtral Columns and Nostril Shapes in Nigerian Children: A Morphometric and Aesthetic Analysis Tue, 11 Jun 2013 09:51:19 +0000 Background. The upper lip-nose complex contributes significantly to the concept of symmetry and proportion of the face. A study of the morphology and aesthetic preferences of the lip-nose complex will provide a database that will serve as a guide for reconstruction. Subjects and Methods. Hundred Nigerian children participated in this study. Demographic data and standard photographs of the philtral column and nostrils were obtained. Sixty volunteers were recruited to evaluate the photographs. Each volunteer was asked to rank the photographs based on their aesthetic preference. Results. The morphology of the philtral columns was classified into four groups: (1) triangular, (2) concave, (3) flat, and (4) parallel. The nostril shape was also classified into four groups: (1) triangular, (2) round, (3) teardrop, and (4) rectangular. In both genders, the triangular shape of philtral column was the most common. There are significant age differences in the aesthetic rankings of philtral columns and nostril shapes. Conclusion. Our study establishes the basal values for the morphometric and aesthetic parameters of the lip-nose complex of 5- and 6-year-old children in Nigeria. We hope our results and reconstructive surgery will intersect at a point to treat disfigurements of the philtrum and nostrils successfully. Ibrahim Abdulrasheed and Asuku Malachy Eneye Copyright © 2013 Ibrahim Abdulrasheed and Asuku Malachy Eneye. All rights reserved. Cleft Lip and Palate Treatment Sat, 25 May 2013 15:59:20 +0000 Nivaldo Alonso, David M. Fisher, Luiz Bermudez, and Renato da Silva Freitas Copyright © 2013 Nivaldo Alonso et al. All rights reserved. Complements C3 and C5 Individually and in Combination Increase Early Wound Strength in a Rat Model of Experimental Wound Healing Thu, 23 May 2013 15:48:44 +0000 Background. Complements C3 and C5 have independently been shown to augment and increase wound healing and strength. Our goal was to investigate the combinatorial effect of complements C3 and C5 on wound healing. Methods. Each rat served as its own control where topical collagen was applied to one incision and 100 nM of C3 and C5 in collagen vehicle was applied to the other incision (). To compare between systemic effects, a sham group of rats () was treated with collagen alone on one wound and saline on the other. At day 3, the tissue was examined for maximal breaking strength (MBS) and sectioned for histological examination. Results. There was a statistically significant 88% increase in MBS with the topical application of C3C5 when compared to sham wounds (). This was correlated with increased fibroblast and collagen deposition in the treated wounds. Furthermore, there appeared to be an additive hemostatic effect with the C3C5 combination. Conclusions. The combination of complements C3 and C5 as a topical application drug to skin wounds significantly increased wound healing maximum breaking strength as early as 3 days. Hani Sinno, Meenakshi Malhotra, Justyn Lutfy, Barbara Jardin, Sebastian Winocour, Fadi Brimo, Lorne Beckman, Kevin Watters, Anie Philip, Bruce Williams, and Satya Prakash Copyright © 2013 Hani Sinno et al. All rights reserved.