Background The mainstay of autologous breast reconstruction involves abdominal wall-based tissue transfer in the form of free or pedicled TRAMs or more recently free DIEP flaps. Although excellent choices for breast reconstruction, all of these techniques do have significant morbidity when considering donor-site pain. This can lead to other complications such as reduced mobility, deep vein thrombosis, pulmonary emboli, respiratory infections, heavy opiate use, constipation and prolonged in hospital stay. Minimising postoperative donor-site pain is therefore of paramount importance. This article provides a review of the forms of analgesia available in the literature and in use in clinical practise. It is a summary of the published studies and exciting future options in this field. Methods A literature search was performed through Medline, EMBASE, Cochrane database and Google Scholar for any previous research publications pertaining to postoperative analgesia in patients undergoing autologous breast reconstruction using abdominal tissue. We reviewed all articles with the aim to evaluate the current knowledge and evidence of analgesic techniques in autologous breast reconstruction including benefits, limitations, indications and patient outcomes. Results The literature search yielded a total of 31 articles identifying 6 analgesic techniques: patient-controlled analgesia (PCA), epidural analgesia, continuous wound infusion with local anaesthetic, intermittent boluses of local anaesthetic, transverse abdominis plane (TAP) blocks and slow release bupivicaine. Conclusions Various anaesthetic techniques are used to reduce postoperative mortality in autologous breast reconstruction. Knowledge of these techniques is paramount as it reduces complications and expedites discharge in this group of patients. Level of Evidence: Not ratable.

Melanoma is a common malignancy with a high survival rate amongst those diagnosed early.The management of advanced disease is challenging, and current chemosurgery techniques have minimal effect on survival.Nanotechnology, offers great potential in revolutionizing the management of melanoma.New molecules and nanoparticles are designed worldwide in an aim to improve the diagnosis and spread to sentinel lymph nodes and other organs.Novel drug delivery systems are formulated to optimise the distribution and pharmacokinetics of chemotherapeutic agents while reducing their toxic effects.The scope of such molecules extends to therapeutic applications including photodynamic and photothermic therapy where light is converted to heat to combat neoplastic lesions; immunotherapy where nanoparticles are used as immunomodulators or vaccines against cancer cells; and gene therapy which targets pro-oncogenes on signal transduction pathways.This review paper presents current knowledge of the use of nanotechnology in the management of cancer, with a focus on melanoma.

We present an alternative ‘quick-fix’ solution for re-sizing screws during hand fracture plate fixation. While we recommend that suitable screw lengths are available, the described technique provides a safe, simple and cost-effective method for achieving a ‘tailor-made’ screw length when remaining available screw options would either be too short for bi-cortical purchase, or too long. Internationally, surgeons may face challenging situations including incomplete sets, damaged/dropped screws or poorly stocked individual components (screws/plates). Furthermore, all required instruments are readily available within even the most basic of surgical fracture sets.

Autologous nerve grafts are the current criterion standard for repair of peripheral nerve injuries when the transected nerve ends are not amenable to primary end-to-end tensionless neurorrhaphy. However, donor-site morbidities such as neuroma formation and permanent loss of function have led to tremendous interest in developing an alternative to this technique. Artificial nerve conduits have therefore emerged as an alternative to autologous nerve grafting for the repair of short peripheral nerve defects of less than 30 mm; however, they do not yet surpass autologous nerve grafts clinically. A thorough understanding of the complex biological reactions that take place during peripheral nerve regeneration will allow researchers to develop a nerve conduit with physical and biological properties similar to those of an autologous nerve graft that supports regeneration over long nerve gaps and in large-diameter nerves. In this article, the authors assess the currently available nerve conduits, summarize research in the field of developing these conduits, and establish areas within this field in which further research would prove most beneficial.

Flexor tendon rupture following a Colles' fracture is a rare complication with only a handful of cases reported since the initial report in 1932. We present a case in which all digital flexor tendons ruptured within 6 months of a Colles' fracture. Previous reported cases have demonstrated rupture of either the radial or ulnar digital flexors but this case is the first in which all the digital flexors have been involved. This case report highlights the clinical implications of this rare occurrence and stresses the importance of accurate reduction and thorough clinical examination following bony injuries to the wrist.

Many techniques have been described for exsanguination of the upper limb before the application of a pneumatic tourniquet. These require additional equipment such as the Esmarch bandage, the Urias bag, the Pomidor roll-cuff, the Northwick Park exsanguinator, or the Rhys-Davies exsanguinator. At a time of increasing demand on scarce resources and increasing medico-legal claims, these techniques have a number of disadvantages: increasing tourniquet and theater time, having cost implications, posing a risk of transmission of infection such as methicillin-resistant Staphylococcus aureus and Group A Streptococcus, being contraindicated in certain upper limb pathologies, and causing potential injury or even fatal pulmonary embolism. Some of these techniques continue to be in common usage but a review of the literature suggests that they may be unnecessary in routine practice, and should be reserved for select situations. The present article describes the formalization and refinement of a simple technique with new relevance, 101 years after Bier first mentioned it in the literature, where the brachial artery is compressed in the cubital fossa before elevation of the arm and then the tourniquet is inflated. This method is simple, cost-effective, time-saving, and most importantly safe and fomite free.

Metastatic, rather than primary tumours are responsible for ninety percent cancer deaths. Despite significant advances in the understanding of molecular and cellular mechanisms in tumour metastases, there are limitations in preventive treatment of metastatic tumours. Much evidence arising from laboratory and clinical studies suggests that growth factors and their receptors are implicated in cancer metastases development. We review the origin and production of growth factors and their receptors in all stages of cancer metastases including epithelial-mesenchymal transition, cancer cell invasion and migration, survival within the circulation, seeding at distant organs and metastatic tumour angiogenesis. The functions of growth factors and their receptors are also discussed. This review presents the efforts made in understanding this challenge to aid in the development of new treatment strategies for cancer metastases.

Management of paronychia should primarily be aimed at preventing any activity that results in impairment of the natural barrier function of the nail fold. Surgical treatments aim to cure paronychia by exposing the inflamed germinal matrix to permit unrestricted drainage. We describe a Swiss roll technique for treatment of chronic and severe acute paronychia.

We read with great interest the recently published article by Barabas and James, utilising K-wires and cement as an external fixator for the management of hand fractures.1Barabas A.G. James M. A simple technique for secure external fixation of hand fractures: bent k-wires wrapped in cement.J Plast Reconstr Aesthet Surg. 2010; 63: e202-e203Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar The technique of using K-wires and cement as an external fixator for hand fractures was first described by Crockett in 1974.2Crockett D.J. Rigid fixation of bones of the hand using K wires bonded with acrylic resin.Hand. 1974; 6: 106-107Crossref PubMed Scopus (27) Google Scholar Since then, various modifications have been described. In our practise we routinely use a similar technique. We would like to draw readers attention that at least 1–2 cm gap between the cement block and the underlying skin should be maintained in order to prevent the risk of iatrogenic contact burn resulting from the heat generated during the chemical polymerisation of the cement (Figure 1). This gap can easily be achieved by placing wet dressing gauze of 1–2 cm thickness whilst the cement solidifies. Once the fracture has healed, this gap provides an additional benefit of removing the external fixator with greater ease in an outpatient setting. In the original article the authors also suggest embedding the shafts of bent K-wires within the cement to prevent slipping of the cement crossbar up or down the K-wires. In our experience, this slipping and sliding can be avoided by inserting K-wires into the bone at different angles. Once these K-wires are externally fixed with the cement, a very solid immobilisation in three dimensions is routinely established. Threaded K-wires can also be utilised to improve the purchase of the bone. No external source of support or funding was received for this project by any of the authors.

Artificial nerve conduits offer an attractive alternative to nerve autografts for the repair of peripheral nerve injuries and several commercially-available conduits are currently on the market. However, at present, utilization of these conduits is limited to the repair of nerve gaps less than 3 cm in length. Thus, current research is focused on how best to design artificial conduits with improved nerve regeneration potential over longer distances. Successful nerve regeneration necessitates that the cells, extracellular matrix components, and growth factors involved interact in a highly specific manner that is tightly coordinated. Combinatorial approaches that take into account these interactions and conduits that utilize supportive factors, such as neurotrophins and stem cells, may be key components of the next generation of artificial conduits. Additionally, design strategies that combine physical cues for contact guidance and biochemical signals to enhance cellular function have shown promise. This review highlights recent advances in artificial nerve conduit design, focusing on the use of luminal fillers, with special focus on the various techniques for accessory cell and/or growth factor delivery into artificial nerve conduits.

It is estimated that worldwide, 16 million people, aged 15–64 years inject illicit drugs regularly. When peripheral venous access becomes obliterated, drug users start injecting into the subdermal area of the skin – “skin popping”. When this area ulcerates, the well vascularised granulation tissue called a “shooter’s patch" is maintained as a portal for continuing injection. These “shooter’s patches” are usually on the limbs, but have been reported on the breast and the penis. We present a case of a reconstructive muscle flap being used in an unforeseen manner as a shooters patch. Surgeons rely on muscle flaps to provide a robust reconstructive option, but we have learnt that drug users value them for their rich vascularity and high absorption.

We read with great interest the recently published article by Mehrotra describing the 'N' plasty technique for functional release of A1 pulley. 1 Mehrotra S. Trigger finger: functional pulley release by 'N'-plasty. J Plast Reconstr Aesthet Surg. 2010; 63: e114-e115 Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar The author describes the use of two opposing vertical incisions of the fibrous sheath to accomplish release of trigger finger without sacrificing pulley function. The need for similar pulley enlargement also arises in cases of primary flexor tendon repair, as there is a need for seamless passage of the suture under the pulley. We would like to commend the author for the addition of this technique, particularly in view of the extending body of evidence of sutureless enlargement of the pulley.

Iyer, Srinivasan FRCS (Plast); Pabari, Amit MBBS, MRCSEd; Khoo, Christopher T. FRCS Author Information

Suzuki et al described the pins and rubbers capsuloligamentotaxis traction system for the treatment of comminuted intraarticular fractures and fracture-dislocations involving the proximal interphalangeal joint, the distal interphalangeal joint, and trapezium. Majumder et al later detailed the lessons learned from their management of patients with complex intraarticular fractures of the base of the middle phalanges of the fingers. The researchers found that the most common patient complaint was that the protruding ends of the device caught on clothing. However, the researchers did not suggest how to resolve this problem. We describe a modification of the distal tips of the Suzuki pins and rubbers axial traction pin, from the S- (or double-opposing U-) shaped morphology of the hook, to a pigtail coil: We propose that this modification has a number of advantages, being simpler, more secure, more adjustable, and safer.

The management of peripheral nerve injury requires a thorough understanding of the complex physiology of nerve regeneration. The ability to perform surgery under magnification has improved our understanding of the anatomy of the peripheral nerves. However, the level of functional improvement that can be expected following peripheral nerve injury has plateaued. Advancements in the field of tissue engineering have led to an exciting complement of commercially available products that can be used to bridge peripheral nerve gaps. However, the quest for enhanced options is ongoing. This article provides a review of the current treatment options available following peripheral nerve injury, a summary of the published studies using commercially available nerve conduits and nerve allografts in humans and the emerging hopes for the next generation of nerve conduits with the advancement of nanotechnology.

Non-absorbable sutures are routinely used in flexor tendon repair. Silicone coated sutures are known to cause intense granuloma formation, and Ticron is well known to cause such late foreign body type reactions. We report a case of palmar granuloma following flexor tendon repair using Ticron. Although commonly used in flexor tendon repair, the authors could not find any other description of palmar granuloma following Ticron use in the literature. The granuloma was successfully treated by excision under antibiotic cover. We advise that surgeons should be aware of this complication, that suture granuloma may mimic other common conditions, and present a brief review of the literature. We conclude that the use of absorbable suture materials should be considered in flexor tendon repair, as outcomes are not dissimilar and may avoid such foreign body granulomas.