Introduction: Ventral wall hernia often causes significant morbidity and requires complex abdominal wall reconstruction (AWR). This study aims to determine whether sub- cutaneous abdominal fat thickness (AFT) measured with preoperative CT scans could predict postoperative outcomes in patients undergoing AWR.Methods: A retrospective cohort study was conducted on all patients who underwent AWR at our institution between 2009 and 2021, with a minimum follow-up of 12 months. Using pre- operative CT scans, AFT was measured at the xiphoid process, umbilicus, and pubic tubercle, as well as the hernia dimensions. Demographic, operative, and surgical outcome data were also collected and analyzed using statistical tests.Results: The results showed that 9 of 101 patients (8.9%) experienced hernia recurrence. Smoking was associated with an increased risk of hernia recurrence (p < 0.001) with a predictive odds ratio (OR) of 18.27 (p = 0.041). Increased AFT at the xiphoid (p = 0.005), umbilicus(p < 0.001), and pubic tubercle (p < 0.001) were also associated with hernia recurrence and risk of infection. Only AFT at the pubic tubercle reached significance in the regression model predicting recurrence (OR=1.10; p = 0.030) and infection (OR=1.04; p = 0.021). A cut-off value of 67 mm was associated with a positive predictive value of 42.14% (sensitivity of 67% and specificity of 91%). Hernia defect area was not associated with risk of recurrence or infection.Conclusions: Smoking and increased AFT at the pubic tubercle are significant predictive factors for recurrence and infection in patients undergoing AWR, and preoperative optimization should focus on reducing these factors.

Background: Complex abdominal wall reconstruction (CAWR) has evolved dramatically over the last 10 years and has become a speciality in its own right. Usually surgery is carried out by a General Surgeon, sometimes alone and sometimes in combination with a Plastic Surgeon. Patients frequently have multiple incisions over the abdomen, soft tissue excess and skin redundancy and planning the incisions to allow for a comprehensive abdominal wall reconstruction can be a challenge. In order to help simplify incision planning we examined our personal series of 150 cases to formulate a classification system for the incision and provide a simple algorithm. Methods: Over an 8 year period from 2007 to 2015, 150 patients underwent complex abdominal wall reconstruction, patient demographics, outcome and complications were recorded. Preoperative photographs of the planned incisions were reviewed by the senior author and classified into 4 groups. Results: All patients fell into one of four groups. Type 1, using existing incisions (28%). Type 2, using an abdominoplasty approach (26%). Type 3, a fleur-de-lys approach (43%). Type 4, a free style group where the incisions are so complex that the above three categories are not suitable (3%). Conclusion: Soft tissue management in CAWR can be challenging with the primary objective to achieve uncomplicated primary wound healing while optimising the aesthetic outcome. We present a simple classification system and associated algorithm, which can help surgical planning and identify cases that may benefit from a joint procedure with a Plastic Surgeon. (c) 2020 Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and Aesthetic Surgeons. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/)

Congenital variations of the shape and structure of the nipple lacks coverage in the medical literature. We present four cases of a specific and unique congenital nipple anomaly, the cleft nipple. Each woman had a normal contralateral breast and nipple-areola complex. Three of the four cases were corrected surgically with no complications experienced. Included in the discussion is a description of the techniques used in the corrective surgery and a review of the current literature on associated variations of normality.

Thirty-eight fingers in 27 patients with Dupuytren’s contracture of the proximal interphalangeal joint (PIPJ) in excess of 70° were treated using a staged technique. The first stage involved applying a mini external fixator across the PIPJ for continuous extension over 6 weeks with intensive hand therapy to maintain mobility of the joint and help correct the deformity. Twice weekly during hand therapy sessions the tension of the elastic band across the mini ex-fix was increased, allowing that full active flexion of the PIPJ against the elastic band could still be achieved. The second stage, 4 weeks after the external fixator was applied, involved an open palm technique of fasciectomy for the contracted cords restricting metacarpophalangeal joint movement and dermofasciectomy with full-thickness skin grafting over the proximal phalanx for bands restricting PIPJ movement. The external fixator was used to maintain active extension force until the graft healed. It was generally removed in the outpatient clinic under ring block 2 weeks after the second stage procedure. The patients were followed for a mean of 20.6 (6–48) months. The mean preoperative PIPJ deformity improved from 75° to 37° postoperatively. Overall, 69% of results were rated as good to excellent. Only one patient reported any on-going functional problems. There were eight cases of pin site infections and one case each of loose pins, osteoarthritics at the PIPJ, reflex sympathetic dystrophy, and disease recurrence needing PIPJ fusion. We conclude that our simple staged procedure is a valid alternative in the management of severe Dupuytren’s PIPJ contracture.

The options for reconstruction of soft tissue defects of the buttock include custom prosthetic implants and autologous tissue transfer: fat transfer, local flaps, pedicled flaps and free flaps. Optimal reconstruction involves replacement of like-with-like tissue, sufficient padding and adequate contouring. We report a case of a female patient presenting with a significant cosmetic contour defect of her left buttock following previous excision of a malignant fibrous histiocytoma. The patient had autologous buttock reconstruction using a deep inferior epigastric artery perforator free flap with an excellent result. To our knowledge a deep inferior epigastric artery perforator free flap has not previously been described to reconstruct the buttock.

Introduction: Toe syndactyly affects around 1/2000 people and is associated with significant psychological morbidity. There are multiple techniques of toe syndactyly repair described in the literature which is indicative that as yet, no one method has proved superior to others. Here we describe the technique we employ and present results of surgery including a review of patient satisfaction.Methods: We use a modification of the technique originally described by Mondolfi using interdigitating triangular skin flaps to recreate the web space and a split thickness skin graft harvested from the instep to address the skin shortage. Patient satisfaction data were collected using a multiple response 10 point modified Likert scale questionnaire.Results: 15 patients and 19 conjoined toes were operated on by a single surgeon with an average follow up time of 16.3 months (range 3-30 months). Overall satisfaction with the procedure was high with a significant increase in satisfaction from 1.3/10 preoperatively to 9.3/10 post operatively. Furthermore, patients were found to have a significant reduction in concern about their condition from a preoperative score of 8.67 to score of 0.67 following surgery (p < 0.05). Of the 19 toes divided, we had 1 skin graft failure, 1 case of mild web creep and all donor sites healed well.Conclusions: This is a simple technique that avoids unsightly dorsal scars and the glabrous skin graft provides excellent colour match with minimal morbidity. Complication rates seen with this technique are comparable or superior to those seen with other techniques already described in the literature. Toe syndactyly can be a relatively under treated condition and we have shown that offering these patients surgery can result in a highly satisfied patient group. (C) 2010 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

We aimed to validate a 2-stage technique to correct severe Dupuytren's contracture (> 700) of the PIPJ. We treated 38 fingers in 27 patients. The first stage involved use of a mini PIPJ external fixator for distraction over a 4 week period. The second stage involved an open palm technique of dermofasciectomy with full thickness skin grafting. PIPJ correction was assessed on a scale we devised using Tubiana's staging. The results were excellent in 37% fingers, good in 32%, fair in 18% and poor in 13%. Mean reduction in PIPJ contracture was 47 degrees (range 12 degrees - 74 degrees) and mean Total Active Motion (TAM) was 178 degrees (range 75 - 235 degrees). There were 8 cases of pin site infections and one case each of RSD, loose pins, OA at the PIPJ, and recurrence. We conclude that our technique is a valid alternative for treating severe Dupuytren's PIPJ contractures.

This paper documents the clinical course of the casualties treated at University College Hospital, following the detonation of a terrorist nail bomb in a public house in Soho, London. The need for adequate primary debridement is paramount, including consideration of definitive primary limb amputation.

This paper documents the clinical course of the casualties treated at University College Hospital, following the detonation of a terrorist nail bomb in a public house in Soho, London. The need for adequate primary debridement is paramount, including consideration of definitive primary limb amputation.