INTRODUCTION:The main cause of ischial pressure sores in paraplegic patients is prolonged sitting without pressure relief. These wounds are subject to recurrence and may need repeated reconstruction with local flaps. When all options are exhausted, the total thigh flap is the last resort. Disarticulation of the hip joint impairs stability even when sitting and causes subsequently very high discomfort. In this manuscript, we describe an alternative to the total thigh flap to avoid hip disarticulation: the foot fillet flap. MATERIALS & METHODS:This study was performed on four patients at the department of Plastic & Reconstructive Surgery of the Ghent University Hospital, Belgium. Inclusion criteria were the following: paraplegic patients affected by recurrent pressure sores, exhaustion of all local options and adequate vascular status of the lower extremities. RESULTS:All patients were kept in an air-fluidized bed for two weeks and progressed well during their post-operative course. Healing time varied from 12 to 29 days and suction drains were removed after 15 days as in any standard pressure sore flap. Hospital stay varied from 18 to 42 days. CONCLUSION:The pedicled foot fillet flap is a valuable alternative to the total thigh flap. Coverage of large, recurrent, pressure sores in the ischial, trochanteric or sacral region is ideal due to the thick glabrous plantar skin, shock-absorbing fibrofatty subcutaneous tissue and underlying muscles provided by the sole of the foot. Furthermore, coxofemoral disarticulation, mandatory in a total thigh flap, that leads to instability while sitting, is avoided.

The anterolateral thigh (ALT) perforator flap for phalloplasty is gaining popularity because it avoids the well-known scars of the radial forearm flap. However, scars are not eliminated, just moved to a different location, the thigh, that can for some patients be of great sexual value. Preexpansion of the ALT flap allows primary donor site closure, thus avoiding not only the unsightly appearance of a skin grafted ALT donor site, but also the skin graft donor site scar. Preoperative perforator location by means of computed tomography angiography allows safe expander placement through 2 small remote incisions.

BACKGROUND:The free lumbar artery perforator flap has recently been introduced as a potentially valuable option for autologous breast reconstruction in a subset of patients. Up to date, few anatomical studies, exploring the lumbar region as a donor site for perforator- based flaps, have been conducted. METHODS:An anatomical study of the position of the dominant lumbar artery perforator was performed, using the preoperative computed tomographic angiography images of 24 autologous breast reconstruction patients. In total, 61 dominant perforators were determined, 28 on the left and 33 on the right side. A radiologist defined the position of the perforator as coordinates in an xy-grid. RESULTS:Dominant perforators were shown to originate from the lumbar arteries at the level of lumbar vertebrae three or four. Remarkably, approximately 85% of these lumbar artery perforators enter the skin at 7-10 cm lateral from the midline (mean left 8.6 cm, right 8.2 cm). CONCLUSION:This study concludes a rather constant position of the dominant perforator. Therefore, preoperative-computed tomographic angiography is not always essential to find this perforator and Doppler ultrasound could be considered as an alternative, thereby carefully assessing all advantages and disadvantages inherent to either of these imaging methods.

Introduction: Patients requesting body-contouring surgery after massive weight loss often present with abdominal and lumbar skin excess as well as gluteal ptosis and loss of gluteal projection. In order to restore gluteal projection a circular abdominoplasty in combination with an autologous gluteal augmentation (all-in-one technique) can be performed.Objective: To compare outcomes for patients who underwent a circular abdominoplasty with or without autologous gluteal augmentation.Methods: In a retrospective study we analyse 24 patients who underwent a circular abdominoplasty between 2006 until 2014 at the University Hospital of Ghent, Belgium. Fourteen patients underwent a classic circular abdominoplasty (4 men and 10 women). Ten patients underwent the all-in-one technique (all women). Mean age was 43 in the classic abdominoplasty group and 41 in the all-in-one technique group. All the patients endured massive weight loss after bariatric surgery. Gluteal augmentation was performed using lumbar dermal fat rotation flaps based on perforators of the 4th lumbar artery. For statistical analysis a Fisher exact tests was used.Results: Postoperative photographs showed that gluteal projection had been increased in patients who underwent the all-in-one technique. The mean operation time in this group was 3h49min versus 2h47min in the group who underwent a classic circular abdominoplasty. The mean hospital stay in both groups was 6 days. Complication rate was comparable between both the groups.Conclusion: The all-in-one technique is an efficient method to improve both abdominal and gluteal body contour in patients who endured massive weight loss.

Introduction: As gender dysphoria is becoming increasingly accepted in the general population, the number of patients seeking gender reassignment surgery is increasing. Although not every patient with gender dysphoria requires surgery, medical practitioners taking care of these individuals should be aware of the different surgical options.Aim: To review current gender reassignment surgical techniques and update the clinician.Methods: A review of the literature was performed focusing on the most recent techniques of gender reassignment surgery.Main Outcome Measures: Main outcomes included a historical review of gender confirmation surgery leading to the techniques of choice in different divisions. For the vaginal lining, penile-scrotal skin flaps remain the technique of choice, and the gold standard for a phalloplasty remains the radial forearm flap.Results: Surgical techniques for male-to-female gender reassignment consist of facial feminization surgery, voice surgery, breast augmentation, orchiectomy, and vaginoplasty. Female-to-male gender reassignment surgery includes facial masculinization surgery, subcutaneous mastectomy, and phalloplasty procedures.Conclusion: Penile-scrotal skin flaps remain the technique of choice for the vaginal lining, although indications for a vaginoplasty with intestinal transfer are becoming more common. The gold standard for a phalloplasty remains the free radial forearm flap. Copyright (C) 2016, International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved.

The aim of this review is to extrapolate evidence regarding the use of vascularized nerve grafts (VNGs) in peripheral nerve reconstruction and summarize available data on their indications, if any, and clinical applications. A review of the literature via the PubMed database was performed with analysis of ninety-five articles on the experimental and clinical studies of VNGs. Eight relevant questions were selected to be answered about VNGs. VNGs allow faster nerve regeneration and convey a functional advantage under certain clinical conditions such as large nerves, proximal lesions, and nonvascularized recipient beds. Several donor sites are available which have been being divided by body region in this manuscript. VNGs perform better than non-VNGs and provide an advantage in selected cases. However, limited availability and donor site morbidity still limit their application. We foresee a wider application of vascularized nerve allografts to overcome these problems.

Breast reconstruction in patients who have previously undergone deep inferior epigastric artery perforator flap (DIEAP) reconstruction or abdominoplasty is often challenging. Depending on patients' body habitus, several second-choice flaps have been described such as the transverse upper gracilis (TUG) flap, profundus femoris artery perforator (PFAP) flap, superior gluteal artery perforator (SGAP) flap, and lumbar artery perforator (LAP) flap. Patients who have undergone a DIEAP flap reconstruction or abdominoplasty occasionally present with dog ears on both sides of the abdominal scar. The adipose tissue and skin of these dog ears are supplied by perforators of the deep circumflex iliac artery (DCIA). The DCIA flap was first described in 1979 by Taylor. We introduce this abdominal "dog-ear" flap for autologous breast reconstruction.

The WPATH Standards of Care (SOC) Revision Committee are reassessing criteria for sex reassignment surgery. The major points of discussion for which WPATH might provide additional guidelines are: (1) gender binary defying surgery, (2) gonad retention for fertility preservation prior to hysterectomy in transmen and castration (+ vaginoplasty) in transwomen, (3) the necessity for two referrals from qualified mental health professionals who have independently assessed the patients, prior to performing genital surgery, especially for hysterectomy and salpingooophorectomy, (4) the minimum age of 18 as eligibility to undergo irreversible (genital) surgery procedures. We have performed a literature search focussing on these subjects in order to formulate a supported opinion for changing the SOC regarding these topics.

INTRODUCTION:Male-to-female transgender persons (trans-women) receive livelong cross-sex hormonal treatment in order to induce and maintain secondary female characteristics. One of the concerns of long-term estrogen treatment is the induction of carcinomas of estrogen-sensitive tissues such as the breast. BRCA1 mutations have been shown to account for a large proportion of inherited predispositions to breast cancer.AIM:The aim of this case report is to discuss the hormonal and surgical options in the treatment of trans-women with a genetic predisposition for breast cancer.METHOD:We describe a case of a trans-woman who was found to be a carrier of a BRCA1 mutation.RESULTS:The patient underwent a breast augmentation. She refused a prophylactic mastectomy followed by a primary breast reconstruction. She also underwent a vaginoplasty and a bilateral castration. Androgen blocking treatment was stopped after surgery; estradiol treatment however was continued.CONCLUSIONS:This case points to the importance of routine investigation of family history in trans-women. Trans-women with BRCA mutations should be carefully monitored and if cancers develop, this should be reported. Follow-up should be according to the guidelines for breast cancer screening in biological women, and the guidelines for prostate cancer and colon cancer screening in men.

A case of a patient with a recurrent dedifferentiated retroperitoneal liposarcoma with extensive invasion of the thoraco-abdominal wall including the skin, requiring reconstructive surgery after debulking of the tumor is reported.

We describe a case in which the presence of a large faecalith in a 43-year-old man was the probable cause of a sigmoid volvulus.

BACKGROUND:In Uganda, as in many other parts of the world cancer of the oesophagus (CAE) is on the rise. Squamous cell carcinoma and adenocarcinoma are the common subtypes. Risk factors for this cancer have been identified but not studied systematically in Uganda. Identification of these factors would enable establishment of preventive measures.OBJECTIVE:To determine the prevalence, histological features and associated factors for CAE among patients referred to the endoscopic unit of Mulago hospital, Kampala, Uganda.METHODS:We performed a 1-year cross-sectional study in 2004 and 2005 of all patients presenting for oesophageal-gastro-duodenoscopy (EGD) at Mulago Hospital. Demographic characteristics, behavioural practices, endoscopy findings and histology results where biopsies were performed were collected using a study tool. Data analysis was done using STATA 8 statistical package.RESULTS:Two hundred nineteen patients were enrolled in the study, three were excluded because they could not tolerate the endoscopy procedure. Fifty five (19%) of the 287 had histologically proven CAE. Squamous cell carcinoma was found in 100% of tumours of the upper third, 91% middle third, and 73% lower third of the oesophagus. Four patients had a histological diagnosis of adenocarcinoma of the oesophagus. Factors that were associated with CAE included age (OR 1.63, CI 1.34-1.98, p value <0.001), smoking (OR 3.63, CI 1.82-7.23, p value <0.001) and gender (OR 2.17, CI 1.07-4.41, p value 0.032).CONCLUSION:Many patients referred for EGD in Uganda had esophageal cancer most of which were.squamous cell type. Smoking, male gender and older age were risk factors. Preventive measures should target stopping smoking.

INTRODUCTION:Ketamine is a derivative of phencyclidine and is a dissociative anaesthetic. Its use as a recreational drug is on the increase among young adults attending clubs and parties.CASE PRESENTATION:We describe the case of a 20-year-old man who presented with a 7-month history of urinary frequency, nocturia, urgency, suprapubic discomfort during micturition and episodes of severe haematuria shortly after commencing weekly recreational ketamine use. Complementary examinations were negative except for a thickened bladder wall on ultrasound examination and mild inflammatory changes on cystoscopy. So far only nine cases of ketamine-associated ulcerative cystitis have been described.CONCLUSION:We expect that in the future an increasing number of cases of cystitis caused by ketamine use will be seen in young adults.

We describe a 55-year-old bisexual Belgian man with a multi-drug resistant HIV infection who developed an Immune Reconstitution Inflammatory Syndrome (IRIS) presenting as a mucocele of the frontal sinus, one year after starting a new effective darunavir containing antiretroviral treatment regimen. His CD4+ lymphocyte count had increased from 3 cells/mm3 prior to the start of the latter treatment to 196 cells/mm3 just before he developed the IRIS phenomenon. IRIS is a paradoxical clinical deterioration during highly active antiretroviral treatment (HAART), due to an exaggerated immune-inflammatory reaction. With the increasing numbers of persons living with HIV infection and the increased use of HAART it is expected that in the future more otolaryngological manifestations of IRIS will be detected.

We describe a patient in which a venous hum, heard during abdominal auscultation, lead to the diagnosis of a vena cava inferior thrombosis.

In his Comment, Alastair Munro (Aug 14, p 566)1Munro AJ Oesophageal cancer: a view over overviews.Lancet. 2004; 364: 566-568Summary Full Text Full Text PDF PubMed Scopus (22) Google Scholar mentions that the potential influence of histology has been largely ignored in clinical trials of oesophageal cancer. He notes that the frequency of adenocarcinoma is rising, but that only a fairly small number of patients with adenocarcinomas are included in trials. In Scotland, most oesophageal cancers are adenocarcinomas, whereas in the clinical trials most cancers (77%) were squamous cell carcinomas.1Munro AJ Oesophageal cancer: a view over overviews.Lancet. 2004; 364: 566-568Summary Full Text Full Text PDF PubMed Scopus (22) Google Scholar Munro therefore concludes that the results of the clinical trials on oesophageal cancer have limited relevance for most patients with such cancer. This conclusion might be so for Scotland, but in other regions of the world patients' characteristics and types of oesophageal cancer might be more comparable with those reported in the clinical trials. In Uganda, for example, between 1998 and 2003, in the Kyadondo county (Kampala region), 111 histologically proven oesophageal cancers were reported; 85 (77%) of them were squamous cell carcinomas, eight (7%) adenocarcinomas, and 18 (16%) histologically unspecified; 63% were in men. These frequencies have not changed over time.2Wabinga HR Parkin DM Wabwire-Mangen F Nambooze S Trends in cancer incidence in Kyadondo county, Uganda, 1960–1997.Br J Cancer. 2000; 82: 1585-1592Crossref PubMed Google Scholar Not only the histology of oesophageal cancer but also risk factors for development of such cancer could differ over time and from one region to another. Squamous cell carcinoma of the oesophagus in the developed world is at least five times more common in men than in women, probably because men drink and smoke more.3Hong Zhang Shao-Hua Chen You-Ming Li Epidemiological investigation of esophageal carcinoma.World J Gastroenterol. 2004; 10: 1834-1835PubMed Google Scholar By contrast, the male-to-female ratio of this cancer in Uganda is two-to-one, suggesting that other risk factors are involved.2Wabinga HR Parkin DM Wabwire-Mangen F Nambooze S Trends in cancer incidence in Kyadondo county, Uganda, 1960–1997.Br J Cancer. 2000; 82: 1585-1592Crossref PubMed Google Scholar A rise in oesophageal cancer has been noted in South Africa and east Africa.4Interagency for Research on Cancer, WHO Cancer of the oesophagus.in: Parkin DM Ferlay J Hamdi-Chérif M Sitas F Thomas JO Waburga H Whelan SL Cancer in Africa epidemiology and prevention. IARC Press, Lyon2003Google Scholar In Kampala, Uganda, the incidence of oesophageal cancer has increased progressively in both sexes over the past 30–40 years.2Wabinga HR Parkin DM Wabwire-Mangen F Nambooze S Trends in cancer incidence in Kyadondo county, Uganda, 1960–1997.Br J Cancer. 2000; 82: 1585-1592Crossref PubMed Google Scholar This period coincides with pronounced social and lifestyle changes in this region and with the emergence of the AIDS epidemic. However, HIV infection is unlikely to be the major risk factor, since in South Africa the rise of oesophageal cancer preceded the HIV epidemic.4Interagency for Research on Cancer, WHO Cancer of the oesophagus.in: Parkin DM Ferlay J Hamdi-Chérif M Sitas F Thomas JO Waburga H Whelan SL Cancer in Africa epidemiology and prevention. IARC Press, Lyon2003Google Scholar In Africa, oesophageal cancer is predominantly of squamous-cell origin.4Interagency for Research on Cancer, WHO Cancer of the oesophagus.in: Parkin DM Ferlay J Hamdi-Chérif M Sitas F Thomas JO Waburga H Whelan SL Cancer in Africa epidemiology and prevention. IARC Press, Lyon2003Google Scholar In Uganda and other sub-Saharan African countries an increased incidence of human papillomavirus (HPV)-related squamous cell carcinomas (such as squamous cell carcinoma of the conjunctiva) has been noted.2Wabinga HR Parkin DM Wabwire-Mangen F Nambooze S Trends in cancer incidence in Kyadondo county, Uganda, 1960–1997.Br J Cancer. 2000; 82: 1585-1592Crossref PubMed Google Scholar So far only a few small, generally uncontrolled studies have looked at the potential association between HPV and squamous cell carcinoma of the oesophagus.5Lagergren J Wang Z Bergstrom R Dillner J Nyren O Cancer: a nationwide seroepidemiologic case-control study in Sweden.JNCI. 1999; 91: 156-162Crossref PubMed Scopus (68) Google Scholar The results of these studies are contradictory, but none provides clear evidence that HPV is able to induce squamous cell carcinomas.5Lagergren J Wang Z Bergstrom R Dillner J Nyren O Cancer: a nationwide seroepidemiologic case-control study in Sweden.JNCI. 1999; 91: 156-162Crossref PubMed Scopus (68) Google Scholar Risk factors for, and types of, oesophageal cancer vary in different parts of the world; therapeutic approaches and preventive measures should take these differences into account.