From the combination of knowledge and actions, someone can improve their skill and ability. It will lead them to live and work much better. This is why, the students, workers, or even employers should have reading habit for books. Any book will give certain knowledge to take all benefits. This is what this hands off tells you. It will add more knowledge of you to life and work better. Try it and prove it.
From the combination of knowledge and actions, someone can improve their skill and ability. It will lead them to live and work much better. This is why, the students, workers, or even employers should have reading habit for books. Any book will give certain knowledge to take all benefits. This is what this hands off tells you. It will add more knowledge of you to life and work better. Try it and prove it.
We used three types of subcutaneous pedicle flaps harvested from the unaffected side of the nostril to repair postoperative nose deformity caused by primary cleft lip surgery. By moving the subcutaneous pedicle flap from a nearby tissue-rich area, it was possible to achieve a favourable symmetrical nasal contour for the narrowing of the nostril cavity, depression of the nostril floor and the columella deviation of the affected side. The method, we used here is technically simple. We believe this procedure is a method of choice for repairing small deformities of the nose occurring after primary or secondary cleft lip surgery.
Sir, An essential requirement in plastic and reconstructive surgery is the art of flap surgery. A number of courses are available for trainees in plastic surgery designed to teach and reinforce surgical principles and operative techniques. In the UK, certain conditions imposed by the Department of Health on the use of fresh cadavers for the purpose of surgical training, mean that such courses invariably use preserved cadavers. The embalming process, however, both alters the normal texture of tissues and disrupts tissues planes. In general, educational value will be improved the more closely an anatomical specimen resembles an operative specimen. This is more significant when tissue planes and fine structures such as perforating vessels are the subject in question. We recently had the opportunity to attend the Second Annual Fresh Cadaver Flap Course at Duke University Medical Centre (DUMC), NC, USA. The course fee, including travel and subsistence expenses, is competitive with other flap courses. Taking place in the recently completed Fresh Tissue Laboratories, this 2-day weekend course, systematically and comprehensively covers the majority of skin, fascial, muscle and myocutaneous flaps. Dissection of the whole body is completed in eight 90-min sessions covering the head and neck, breast, anterior and posterior trunk, upper limb, hand, lower limb and foot regions. The faculty is comprised of internationally renowned surgeons who provide excellent tuition and a wealth of personal experience. On average, three to five participants are allocated to each cadaver, with whom they remain for the duration of the course. The faculty rotate around the dissection groups, with two per table instructing on an anatomical region corresponding to their field of expertise. Less familiar as well as standard flaps are either demonstrated or guided by the instructors. During break periods, there is ample opportunity to practice raising many of the flaps ourselves. Lunch provides a forum for discussion, which includes case presentations, decision-making and debate on reconstructive options. The Duke Fresh Cadaver Flap Course is a well-organised, comprehensive and enjoyable course led by a number of highly motivated and enthusiastic individuals. Our experience has confirmed the clear benefit of fresh cadavers with their close resemblance to living tissue, both in terms of tissue handling and preservation of tissue planes. Plastic surgery residents at DUMC are fortunate to have open access to the laboratory, enabling them to develop and consolidate their skills in a safe environment similar to the operating room. We believe that a Fresh Tissue Laboratory is an invaluable resource for training and research in plastic surgery. The presence of such a facility in the UK would only serve to enhance our training.
Presently, predicting cup size after reduction mammaplasty is largely based on experience. Regnault and Daniel (1984) proposed a formula for estimating the appropriate weight of reduction to achieve a desired cup size. To validate their method, we studied 75 consecutive patients undergoing bilateral breast reduction mammaplasty. Patients were measured pre-operatively and 6 weeks post-operatively using two techniques to determine bra size. Actual weight of breast tissue excised was compared to the predicted values using the Regnault and Daniel formula for each measuring technique (Methods A and B). A modified formula (Method C) was developed to increase the accuracy. The results obtained using Methods A and B were compared with those of Method C. A paired sample t test showed no significant difference between actual and predicted weight of reduction for using Method A or C. Method B systematically underestimated the weight of tissue to be removed. The mean estimate for Method B was 730 g, a difference of -45 g (CI: -81.7 to -8.9; p = 0.015). For Method A, the mean was 765.5 g, a difference of 9.4 g (CI: -68.1 to 49.3; p = 0.75). This compared to Method C where the mean predicted weight of tissue to be removed was 770.4 g, a difference of -4.5 g (95% CI: -42.4 to 33.4; p = 0.81). The implications of these findings are discussed.
Velopharyngeal function is often compromised by the resection and reconstruction of oropharyngeal and palatal tumours. While free tissue transfer has improved the outcomes of head and neck reconstruction. In general, palatal reconstruction remains a challenge.Velopharyngeal function was analysed in eight patients following microsurgical reconstruction of defects of between 50 and 100% of the soft palate. The radial forearm fasciocutaneous free flap was used in all cases. The outcome of reconstruction was analysed by patient questionnaire and with standardised tests of speech and swallowing function. Velopharyngeal function post-operatively ranged from poor to near normal. Poor function appeared due to the loss of active elevation and contracture of the reconstructed palate producing failure of velopharyngeal closure during swallowing and speech.The results emphasise the limitations of reconstruction of a dynamic structure such as the soft palate with the static fold of skin and soft tissue produced by a fasciocutaneous flap. The relatively poor results obtained suggest that an anatomical approach to soft palate reconstruction is inadequate and reduction of the calibre of the velopharyngeal aperture is required to compensate for the lack of mobility in the reconstructed palate.
We treated four patients with scaphocephaly using a combination of distraction and contraction techniques and achieved satisfactory results. Radial osteotomies in the frontal and occipital bones flattened these abnormal bossing bones and accelerated the disappearance of bony bumps created by distraction. This technique facilitates the achievement of the desired shape of the skull through fine adjustments of the distraction and contraction devices.
Over 90% of all adults human cancers are of epithelial origin comprising mainly of skin and aero-digestive tract cancers. A significant proportion of our discipline's workload consists of management of these cancers. This review article is to provide clinicians with a summary of the current research findings in invasion and metastasis of epithelial cancers and the translation of some of this information to clinical use particularly related to skin and head and neck cancers (HNSCC). Metastasis is the leading cause of death in cancer patients. Although surgical resection of isolated metastases is beneficial for some patients, the overall efficacy of surgery, chemotherapy or radiotherapy is limited. Clearly, with today's advances in surgery a majority of these primary cancers are resectable and a cure attainable if surgeons could control or inhibit metastasis.
In the advanced stage of hypopharyngeal cancer, extensive resection may sometimes leave both the cervical soft tissue and pharyngoesophageal defects that must be reconstructed at the same time. In this study, a new reconstructive method using the rectus abdominis musculoperitoneal flap is described. Three patients underwent pharyngoesophageal reconstruction by this method. Complete survival of the flaps was seen in all patients, but one patient developed a fistula due to rapid local recurrence of the tumour. We believe that the rectus abdominis musculoperitoneal flap can be an alternative choice for reconstruction of pharyngoesophageal defect, especially when there is a large area of cervical soft tissue defect at the same time.
Neurofibromatosis of the orbitopalpebral complex is a debilitating disease. The development of safe craniofacial surgical technique has greatly improved outcome in the surgical palliation of this progressive condition, and various centres have reported their experience. Extensive upper eyelid neurofibroma creates a functional and aesthetic problem, which is inadequately addressed in the literature. The experience of the senior author (DM) representing the treatment of 27 such patients is currently reported. The stigmata of eyelid neurofibromatosis were scored retrospectively by a novel scale applied to standardised photographs at patient presentation. A numeric severity score was given to each of: upper eyelid ptosis, canthal malposition, and oculo-palpebral diastasis. Disease progression and post-operative result were similarly scored at various stages follow-up photography. All patients underwent a full thickness, transverse or transverse-oblique resection of upper eyelid disease, with immediate levator reconstruction and canthopexies as necessary. A mean improvement of 3.33 points was achieved in the majority of patients (median one operation per patient; mean 1.5, range 1-3). Secondary eyelid procedures (n=9 pts) represented tumour debulking, canthopexy, or procedures to deepen the fornix in patients with prostheses. This series demonstrates that a tailored, often radical palpebral remodelling in orbitopalpebral neurofibromatosis may provide functional and aesthetic benefit.
The authors' affiliations were not correctly represented in the published article. They appear correctly above. Analysis of 109 Japanese children's lip and nose shapes using 3-dimensional digitizerBritish Journal of Plastic SurgeryVol. 58Issue 3PreviewWe assessed lip and nose shapes, which played an important role in performance evaluations, before and after cleft lip and nose surgery. We used a noncontact-type semiconductor laser 3-dimensional measurement system on normal Japanese children to obtain 3-dimensional images of noses and lips, which were accurate enough to measure facial shapes. We could rotate these images on the computer, therefore we measured the following points: the distance between the peaks of the Cupid's bow and the width of the labial fissure (frontal view), and the width of the nose and the nasal tip protrusion (basal view). Full-Text PDF
INTRODUCTION:Pulsed dye laser (PDL) treatment is based on the principle of selective photothermolysis and is widely considered to be the treatment of choice for a variety of cutaneous vascular lesions. OBJECTIVE:To review the indications and outcome of PDL treatment and summarise new developments. METHOD:A literature-based study has been conducted entailing the review of publications over the period January 1993-December 2003 using the databases Medline and Cochrane CENTRAL. RESULTS:The PDL was found to be effective in port wine stain, facial telangiectasia, leg telangiectasia <0.5 mm, scars, hypertrophic scars and ulcerated haemangioma. DISCUSSION:Essential characteristics of lesions suitable for PDL treatment are discussed and guidelines are presented for future research.
Ahmed is an Arab boy, partially sighted, missing his right hand and whose left thumb is his best digit, even though it started life as a toe. He was walking home on a summer afternoon, saw a small high tech object gleaming in the sun, and reached for it. He regained consciousness in the back of a stranger's car and began the long and erratic journey to repair and reconstruction. Scarred and disabled, his injuries are typical of cluster bombs, or ‘sub-munitions’ as the military jargon goes. These devices, for the few readers who do not already know, are bombs that separate at a pre-ordained altitude into nearly 200 ‘bomblets’ whose diminutive name belies their ruthless capability. They are small explosive charges whose advantage lies in their ability to maim rather than to kill: a maimed soldier demands attention and takes at least one other out of the fight. Spreading over a wide area, the advantage of such munitions against scattered troops is easy to understand, and their effects can be devastating and as varied as their payload. But in built-up civilian areas their most relevant quality is that they cannot discriminate civilian from soldier, child from adult. Perhaps we should be glad that on impact up to 10% do not explode, but in fact they then effectively become small coke-can sized multicoloured anti-personnel mines. And guess which personnel are so naive as to pick them up? Children. In Afghanistan1Biukha O. Brennan M. Injuries and deaths caused by unexploded ordnance in Afghanistan: review of surveillance data, 1997–2002.BMJ. 2005; 330: 127-128Google Scholar, 2EditorialLandmines and cluster bombs–picking up the pieces.Lancet. 2002; 359: 273Google Scholar the lesson learned is that unexploded ordnance (UXO) poses a greater threat than landmines, and that children are the main victims of these brightly coloured sub-munitions so easily confused with similarly coloured food relief dropped from above (Fig. 1). By now some of you are getting nervous. Has the editor lost his mind: stay clear of editorials on political subjects, too dangerous. Too ambiguous. Too sensitive. Stick to plastic surgery. Oh, okay. Malignant melanoma. We all agree melanoma is not a good thing. It serves no purpose, kills almost randomly and our patients die unpleasant and premature deaths. So when we discovered that sunshine played a part in its genesis we had something to fight. We cannot outlaw sunshine (although they are not doing badly in Yorkshire) so let's make sure it is used safely. Cover up. Use sun blocks. Be safe. Care for your kids. Umm. Do you see where I'm going? Too simple? Maybe, but let's just remember that Iraq was a war of liberation. Western coalition forces are there to make things better, to improve life after Sadaam. Not to make Iraq a worse place for its people.3Roberts L. Lafta R. Garfield R. Khudari J. Burnham G. Mortality before and after the invasion of Iraq: cluster sample survey.Lancet. 2003; 364: 1857-1864Google Scholar, 4Horton R. Comment: the war in Iraq: civilian casualties, political responsibilities.Lancet. 2004; 364: 1831Google Scholar So, the rapid effective clean up of Western and Iraqi UXO should be conducted in Iraq as it would in those countries of the coalition, should not it? It must be unacceptable for children to be at risk firstly from the use of indiscriminate weapons in civilian areas, and secondly from any tardiness in cleaning up the UXO that litters these places. But what proportion of our munitions budget is devoted to clean-up? What small fraction? And then who treats these children. A lucky few have been funded by charities to get access to western reconstructive surgery. What about the rest? Iraqi medicine was excellent and will be again, but at present it is undeniably run down and unable to cope. So whose responsibilities are these children, and their wounded relatives? Surely some duty of care must attach to the coalition. In Britain, the government is making great strides in reducing waiting lists for elective surgery. What is it doing for the children whom its own sub munitions have damaged? Perhaps it feels the British public would resent the Health service being clogged with these cases. I doubt it: in the recent aftermath of the Indian Ocean tsunami the British public, like many others, has shown just how generous and caring it is, pre-empting its own government in its eagerness to help. Should the coalition have used cluster bombs in or near cities or civilians? Should there be an international strategy for treating the civilian casualties, of this war of liberation? Reconstructive surgeons, so plentiful and wealthy in the west and so sparse in Iraq, have a legitimate voice in these matters. We should express our opinions.
Prediction of necrosis has a clinical relevance in all fields of plastic surgery. The new application of indocyanine green (ICG) fluoroscopy in plastic surgery allows an objective quantification of skin perfusion and a high topographical resolution. The aim of the present study is to determine threshold values for flap perfusion under well-defined experimental conditions. Twenty random pattern flaps with a length to width ratio of 4:1 (8 x 2 cm(2)) were dissected on the anterior abdominal wall of 20 male Sprague-Dawley rats. ICG fluoroscopy was performed at the end of the operation. The animals were sacrificed at the seventh postoperative day with a reliable necrosis of the distal part of the flaps. Postoperative ICG fluoroscopy then was analysed both in regions that will survive and undergo necrosis. At day 7 a mean area of 5.5 cm(2) (57% of the total flap area) survived and a mean of 3.8 cm(2) (43%) became necrotic. The surviving part of the flap had a mean perfusion index of 62% compared to reference skin. The distal parts of the flap that necrotised showed an average perfusion index of only 19% postoperatively. Differences were statistically highly significant (p<0.001). Indocyanine green fluoroscopy is a useful tool to evaluate perfusion topographically and predict necrosis. From a statistical point of view a perfusion index of less than 25% of the reference skin can be considered as a sign of developing flap necrosis.
Toxic epidermal necrolysis (TEN) is an acute drug-induced life-threatening disorder characterised by extensive epidermal exfoliation and high rate of mortality. Between October 2000 and April 2003, five severe TEN patients were evaluated using a specific TEN severity-of-illness scale (SCORTEN) and treated for the first time, with a combined therapy using Intravenous Human Immunoglobulins (IVIG) and plasmapheresis. The standardised mortality ratio (SMR) analysis ([Sigma observed deaths/Sigma expected deaths]x100) was applied to establish how IVIG and plasmapheresis treatment could reduce TEN patient mortality. The observed mortality was one out of five patients corresponding to 20%. The expected mortality based on SCORTEN was 3.319 corresponding to 66%. The SMR analysis revealed a 70% reduction in mortality (SMR=0.30; 95% confidence interval, 0.0-0.96). Our series show a low mortality rate (20%) related to the severity of the patients (66% expected mortality). The use of IVIG in association with plasmapheresis has a rational basis and may be effective in severe TEN patients.
This is a descriptive analysis of 50 consecutive cases of therapeutic mammaplasty, the use of reduction mammaplasty and radiotherapy to treat breast tumours. Breast cancers may lie within the normal excision site of a recognised mammaplasty method (scenario A) or outside of the expected excision sites (scenario B), then requiring a modified mammaplasty. A third group are central tumours requiring removal of the nipple. This series includes 13 scenario A, 27 scenario B and 10 central tumours. Wise pattern skin incision was used in 29 (58%) and vertical in 14 (28%). Seven different pedicles were employed but inferior (11), superior (9) and superio-medial (19) comprised the majority (78%). In the 27 scenario B cases an extension of the nipple aereolar pedicle was used to fill the tumour defect in 19 (70%) and a secondary pedicle in 8 (30%). There were no incomplete excisions of invasive tumour but incomplete excision of DCIS requiring mastectomy occurred in 4 (8%) patients. There are no deaths or recurrences to date (mean follow-up 13 months, range 3-32). Complications have occurred in 8 (16%) with a return to theatre for one complication (2%) and the four patients (8%) requiring mastectomy. No patient has had a delay in adjuvant treatment. Cosmetic outcome was deemed good/excellent in 63%, satisfactory in 33%, poor in 4%. Follow-up is restricted to 3-32 months.
After the surgical correction of aponeurotic blepharoptosis or blepharoplasty, the positions of the eyebrow and hairline change as if the frontal belly is independent from the occipital belly of the occipitofrontalis muscle. Therefore, the occipitofrontalis muscle was studied physiologically with electromyographic evaluation in healthy subjects and anatomically with cadaver dissections. Along with contraction of the levator muscle to maintain an adequate visual field, at a less upward gaze position, contraction of only the frontal belly was induced, and at a more upward gaze position, contraction of both the frontal and the occipital bellies was always induced to lift the eyebrow with the upper eyelid skin. The superficial fascia overlying the occipital belly becomes the temporoparietal fascia and ends at the superior end of the frontal belly, thus creating a superficial musculoaponeurotic system that lifts the eyebrow and pulls the scalp forwards. Beneath the superficial musculoaponeurotic system, the occipital belly of the occipitofrontalis muscle becomes the galea aponeurotica and inserts into the underside of the frontal belly, thus creating a deep musculoaponeurotic system that pulls the superficial musculoaponeurotic system with the scalp backwards. Thus, the occipitofrontalis muscle appears to be composed of two physiologically and anatomically different muscles.
