The case of a seven-year-old boy with a Ewing’s sarcoma of the humerus diaphysis extending into the epiphysis proximally. He underwent chemotherapy followed by 12 cm resection of the proximal humerus with preservation of rotator cuff. Reconstruction was performed using a 15 cm vascularized fibula epiphyseal transfer raised using a postero-lateral approach based on the peroneal artery and its venae commitans. The common peroneal nerve was protected proximally and all motor branches were preserved. The pedicle length was 7cm. When isolated on the peroneal artery, bleeding was seen at the level of the epiphysis and periosteum of the fibula head.

Introduction: Masticatory muscles or their nerve supply are options for facial reanimation surgery, but their ability to create spontaneous smile has been questioned. This study assessed the percentage of healthy adults who activate the temporalis and masseter muscles during voluntary and spontaneous smile. Methods: Healthy volunteer adults underwent electromyography (EMG) studies of the temporalis and masseter muscles during voluntary and spontaneous smile. Responses were repeated three times and recorded as negative, weakly positive, or strongly positive according to the activity observed. The best response was used for analysis. Results: Thirty healthy adults (median age: 34 years, range: 25-69 years) participated. Overall, 92% of the masseter muscles were activated during voluntary smile (22% strong, 70% weak). Seventy-seven percent of the masseter muscles were activated in spontaneous smile (12% strong, 65% weak). The temporalis muscle was activated in 62% of responses in voluntary smile (15% strong, 47% weak) and in 45% of responses in spontaneous smile (13% strong, 32% weak). No significant difference was found for males vs females or closed vs open mouth smiles. There was no significant difference in responses between voluntary and spontaneous smiles for the temporalis and masseter muscles, and their use in voluntary smile did not predict activity in spontaneous smile. Conclusions: Our study has shown that masseter and temporalis are active in a high proportion of healthy adults during voluntary and spontaneous smiles. Further work is required to determine the relationship between preoperative donor muscle activation and postoperative spontaneous smile, and whether masticatory muscle activity can be upregulated with appropriate training. (C) 2018 Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and Aesthetic Surgeons.

BACKGROUND:Extravasation occurs when a drug is inadvertently administered outside of the vein. Depending on the substance involved, this may lead to tissue necrosis with significant long-term morbidity. Children, particularly neonates, are particularly susceptible to extravasation with up to 70% of children in neonatal intensive care unit having some form of extravasation injury. These injuries are commonly referred to plastic surgeons for ongoing management.METHODS:We prospectively collected information on all extravasation injuries referred to the plastic surgery department in a children's hospital over an 18-month period. Data collected included the agent involved in the extravasation, treatment and outcomes.RESULTS:In total, there were 43 extravasation injuries recorded on the hospital risk management system during the period of this study. All of these were referred to the plastic surgery team for ongoing management. Five patients (11%) underwent washout of their injuries. Three patients (7%) suffered injuries, which led to significant tissue necrosis, delayed healing and prolonged morbidity.CONCLUSION:Smaller infants, particularly those being cared for in an intensive care setting, are at increased risk for extravasation injury. Early referral and treatment of high-risk extravasation injuries may reduce the incidence of tissue loss and morbidity.

BACKGROUND:Overgrowth of the stump skeleton is a major complication seen in children after an amputation. In advanced cases, perforation of the bone spike through the skin can occur. Many surgical treatments have been employed to treat and prevent this, with best results seen when non-vascularised osteo-chondral bone grafts are placed to try to mimic a trans-articular amputation. We reviewed our outcomes using vascularized bone flaps to prevent and treat spiking.PATIENTS AND METHODS:Between 2000 and 2016 we carried out six vascularised osteo-cartilaginous bone capping procedures. Five patients underwent the procedure as an adjunct to primary amputation and in a single patient it was used to treat established bone spiking. Trauma accounted for three cases, with the other three being tumour, vascular malformation and ischemia. Three patients had pedicled bone flaps placed on the amputation stump and three underwent free tissue transfer (free calcaneus, free scapular angle, and free proximal tibia). Five cases involved lower limb amputations, with one in the upper limb.RESULTS:One patient had an early post-operative complication in the form of partial skin flap necrosis that required debridement and skin grafting. All bone flaps survived. Mean follow-up was 6.5 years. All patients had bony union with no development of stump spiking. Two patients required further procedures unrelated to the bone flaps.CONCLUSION:Vascularised bone flaps to cap amputation stumps may be a safe and effective method of preventing and treating long-bone stump spiking following amputation in children.

ANZ Journal of SurgeryVolume 88, Issue 11 p. 1206-1208 IMAGES FOR SURGEONS Tibial nerve palsy as the presenting feature of posterior tibial artery pseudoaneurysm Adrian D. Murphy MD, FRCS (Plast), Adrian D. Murphy MD, FRCS (Plast) Department of Plastic and Maxillofacial Surgery, Royal Children's Hospital, Melbourne, Victoria, AustraliaSearch for more papers by this authorMarion Chan MBBS, Marion Chan MBBS Department of Plastic and Maxillofacial Surgery, Royal Children's Hospital, Melbourne, Victoria, AustraliaSearch for more papers by this authorSian M. Fairbank MBBS, FRACS, Sian M. Fairbank MBBS, FRACS Department of Plastic and Maxillofacial Surgery, Royal Children's Hospital, Melbourne, Victoria, AustraliaSearch for more papers by this author Adrian D. Murphy MD, FRCS (Plast), Adrian D. Murphy MD, FRCS (Plast) Department of Plastic and Maxillofacial Surgery, Royal Children's Hospital, Melbourne, Victoria, AustraliaSearch for more papers by this authorMarion Chan MBBS, Marion Chan MBBS Department of Plastic and Maxillofacial Surgery, Royal Children's Hospital, Melbourne, Victoria, AustraliaSearch for more papers by this authorSian M. Fairbank MBBS, FRACS, Sian M. Fairbank MBBS, FRACS Department of Plastic and Maxillofacial Surgery, Royal Children's Hospital, Melbourne, Victoria, AustraliaSearch for more papers by this author First published: 02 November 2016 https://doi.org/10.1111/ans.13825Citations: 3Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article.Citing Literature Volume88, Issue11November 2018Pages 1206-1208 RelatedInformation

Background: Fingertip injuries are amongst the most frequently seen hand injuries in the paediatric population. The present study evaluated the composite graft survival rate in distal digital amputations with respect to injury type, amputation level and time to surgery.Methods: We performed a retrospective review of patients who underwent composite grafting of fingertip injuries over an 11-year period at a paediatric hospital. All children who underwent non-vascularized replantation of amputated fingertips were included. Patients were excluded if they failed to attend at least one follow-up appointment. Demographic information was recorded. The nature and level of injury and time to surgery was also recorded. Graft viability was characterized as no take, partial take, or complete take. The number of secondary procedures and number and duration of follow-up appointments were recorded.Results: A total of 105 patients underwent fingertip composite grafting, of whom 96 were suitable for inclusion in this study. Themedian agewas 2.4 years (0-16 years); therewere 48 boys (46%) and 57 girls (54%). Thirty-one patients had no graft take (32%), 50 patients had partial take (52%) and 15 patients had complete take (16%). Only two patients underwent secondary revision (2%). The median number of follow-up appointments was 4, and the mean follow-up time was 68 days. Time to surgery or level of amputation did not have a statistically significant influence on outcome.Conclusions: Over two-thirds of composite grafts in children showed some degree of take, albeit partially in the majority. Morbidity was low, and most children did not require further surgery. (C) 2016 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

Background: The surgeon needs a practical rule to follow when deciding whether to excise a lymph node during sentinel node biopsy (SLNB). The "10% rule" dictates that all nodes with a radiation count of greater than 10% of the hottest node and all blue nodes should be removed, and this study observes the effects of following this rule in SLNB in melanoma.Methods: We reviewed the records of 665 patients with primary melanoma who underwent sentinel lymph node over a 5-year period (2007-2011).Results: 2064 nodes were identified in 898 nodal basins in 665 patients. 141 (21%) patients had at least one positive sentinel node. 105 positive nodal basins were identified in which more than one sentinel node was removed. In 18 of these, a less radioactive node was positive for tumour when the most radioactive node was negative. Of 175 positive nodes 157 (90%) contained blue dye staining. For cases in which the positive sentinel node was not the hottest node, the positive node had apparent blue dye staining in all 18 cases (100%), and was the second hottest node in the basin.Conclusion: In this series removing just the hottest node and all blue nodes would not have missed a single positive basin and would have resulted in a 38% reduction in the number of nodes removed compared to those taken following the 10% rule, without changing the staging in any patient. (C) 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

We present the case of a 68-year old gentleman with previously diagnosed myelodysplastic syndrome with pancytopenia who presented with exophthalmia, rhinorrhea, and ophthalmoplegia. Nasal endoscopy revealed black necrotic lesions. He was diagnosed with rhino-orbital mucormycosis and commenced on intravenous antifungals. Despite this therapy he progressed to have total unilateral loss of visual acuity and cutaneous necrosis. He underwent emergency orbital exenteration and extensive cheek and sinus debridement. Necrotic lesions were found in the orbit, the maxillary and ethmoidal sinuses. He underwent reconstruction of this defect using a free myocutaneous ALT flap with a segment of vastus lateralis. Prior to surgery his anemia and thrombocytopenia were addressed with packed red cell and platelet transfusions as well as preoperative thromboelastography (TEG) to measure functional fibrinogen to platelet ratio. Intraoperative platelet administration was guided by repeated TEG analysis. There were no significant intraoperative or postoperative bleeding complications and both flap and donor site healed unremarkably. Few reports exist in the literature related to free tissue transfer in patients with hematological disorders but low platelet count has been implicated in an increased complication rate.

Across surgical specialities there is frequently a need to refer to radiological images intra-operatively. Most modern operating theatres are equipped with digital viewing stations, which can be used for this purpose. Their disadvantage is that the surgeon may have to move away from the operative field. Furthermore, the surgeon cannot directly access the workstation. Circulating theatre staff are frequently not trained or familiar with the varieties of imaging software used. We describe a technique for sterile, intra-operative iPad use. This can be used by the surgeon to view and manipulate radiological images directly whilst not compromising the sterile operative field.

Complex regional pain syndrome (CRPS) is a chronic progressive disease characterised by severe pain, swelling and changes in the skin. Precipitating factors include injury and surgery, and a variety of causes have been described. We present the case of a 68-year-old lady who presented with features indicative of a CRPS following steroid injection for a ‘trigger’ thumb.

Following mastectomy, nipple-areola complex (NAC) reconstruction is seen as the final step in creating a reconstructed breast which closely resembles the original. Multiple surgical techniques, of varying complexity and usefulness, are available for NAC reconstruction. The principal criterion for successful NAC reconstruction is symmetry of position, size, colour, and projection. This study evaluates patients' subjective satisfaction following NAC reconstruction and dermal tattooing, as well as objective comparison of colour match. Two techniques for NAC reconstruction were used; the modified star flap (n=18) or the skate flap (n=8) with full thickness skin grafting. All patients undergoing NAC reconstruction were surveyed via questionnaire and asked to rate their satisfaction using a standard scale. Objective colour matching was carried out using a computer programme to compare post-tattooing photographs. Patient satisfaction was rated as very good or excellent for position, size, and colour match in all cases. There was no difference between those who had star flap or skate flap reconstructions. There was, however, a lower satisfaction with projection amongst those who had undergone skate flaps. This study shows a high level of patient satisfaction and good colour match following NAC reconstruction and dermal tattooing.

The resuscitation of severe burn remains a controversial area within the burn care profession. There is ongoing debate as to what percentage burn is associated with a sufficient quality of life to support initial resuscitation efforts.We conducted a survey of delegates at the 39th Annual Meeting of the British Burns Association (2005), regarding attitudes towards resuscitation following major burns. Respondents were asked the maximum percentage total body surface area (TBSA) burn beyond which they would not wish to be resuscitated. They were also asked what maximum TBSA they perceived to be commensurate with an acceptable quality of life (QOL).One hundred and forty three of 300 delegates responded to the questionnaire. Thirty three percent of respondents would not wish to be resuscitated with 50-75% TBSA burns or greater. A further 35% would not wish to have life-sustaining intervention with 75-95% TBSA burns or greater. The remaining 32% indicated that they would not want resuscitation with TBSA burns > 95%. Regardless of TBSA affected, 16% would not wish resuscitation if they had full thickness facial burns, a further 10% did not want resuscitation if both their hands and faces were affected.Our survey demonstrates the diversity of personal preference amongst burn care professionals. This would suggest that a unifying philosophy regarding the resuscitation of extensive burns will remain elusive. (c) 2007 Elsevier Ltd and ISBI. All rights reserved.

BACKGROUND:Solitary adenomas have been shown to be responsible for almost 90% of cases of primary hyperparathyroidism.AIM:The purpose of this study was to determine the utility of sestamibi scanning pre-operatively to guide minimally invasive video-assisted (MIVA) parathyroidectomy.METHODS:We reviewed 40 patients who underwent parathyroidectomy between 2003 and 2004. All patients underwent a pre-operative sestamibi scan.RESULTS:Thirty-three (82%) patients had a localized solitary adenoma on sestamibi scan. Of these patients 29 underwent attempted MIVA parathyroidectomy. MIVA parathyroidectomy was successful in 22 patients. When pre-operative sestamibi scanning was correlated with pathological diagnosis it was shown to have a sensitivity of 82% and positive predictive value of 94%.CONCLUSION:Pre-operative sestamibi scan localization of a parathyroid adenoma offers a 94% positive predictive value for adenoma location. This facilitates MIVA parathyroidectomy to be used effectively to treat primary hyperparathyroidism in the majority of patients.

Silver nitrate is commonly used as a method of chemical cauterization to areas of hypergranulation. We report two cases wherein silver nitrate in the hand was misinterpreted radiologically as foreign bodies.