Epinephrine in the tumescent technique for hypospadia surgery.

The use of tumescent technique, which contains epinephrine, in penile surgery has not been reported previously. Two patients with hypospadias had reconstructive operation using tumescent technique with a ”One-per-Mil” tumescent solution containing epinephrine intra-operatively. The results was a clear operation field, almost bloodless during dissection, and no complication on the penis after epinephrine injection with minimal edema. Apparently, the “One-per-Mil” tumescent solution acts as a natural hydro-dissector creating avascular anatomic tissue planes for easier and more rapid dissection in surgery for hypospadias. We suggest that epinephrine is safe to be injected in penis as a future area of clinical practice.

One-sheet spiraling full thickness skin graft for penile resurfacing after paraffinoma excision.

In the midst of on-going non-illicit practice of silicone or paraffin injection to enlarge penis, the author reported 3 cases of surgical treatment to resurface the body of the penis after excision of the destructed penile skin using full thickness skin graft. The skin excision was performed technically through penile body degloving procedure. Full thickness skin graft was then applied as a single sheet donor tissue to cover the denuded penile body spirally. The full thickness graft, which is relatively easy to be performed, is no doubt much thinner than a skin flap, while it also bears a smaller degree of secondary contraction than split skin graft. The color of the skin is considerably matched as it comes from the groin, which is a nearby area of penis. The size and skin sensitization of the penis looks to be natural. The only disadvantage is the common possibility of either spiral or circular junctional scar in between graft edges and between the graft and the penile mucosa and skin to develop hypertrophic scar. However, this possible scar problem applies also to any other surgical scar with any donor tissue. Fortunately, the 3 cases posed no scar problem and normal appearance. All the patients have also regained their normal sexual function.

General concept of wound healing, revisited.

Wound healing is a transition of processes which is also recognized as one of the most complex processes in human physiology. Complex series of reactions and interactions among cells and mediators take place in the healing process of wound involving cellular and molecular events. The inflammatory phase is naturally intended to remove devitalized tissue and prevent invasive infection. The proliferative phase is characterized by the formation of granulation tissue within the wound bed, composed of new capillary network, fibroblast, and macrophages in a loose arrangement of supporting structure. This second phase lasts from day 8 to 21 after the injury is also the phase for epithelialisation. The natural period of proliferative phase is a reflection for us in treating wound to reach the goal which ultimately defines as closed wound. The final maturation phase is also characterized by the balancing between deposition of collagen and its degradation. There are at least three prerequisites which are ideal local conditions for the nature of wound to go on a normal process of healing i.e. 1) all tissue involved in the wound and surrounding should be vital, 2) no foreign bodies in the wound, and 3) free from excessive contamination/infection. The author formulated a step ladder of thinking in regards of healing intentions covering all acute and chronic wounds. Regarding the “hierarchy” of healing intention, the fi rst and ideal choice to heal wounds is by primary intention followed by tertiary intention and lastly the secondary intention.

Morphometry of Deutero Malay female nose.

Aim The objective of this study is to carry out morphometric measurements of the nose, in order to establish norms for the Indonesian as the representation of Asian, specifi cally for the Deutero Malay sub race. Method A cross sectional study was performed on 126 subjects, recruited from female students of Medical Faculty, the University of Indonesia, Jakarta. Subjects were restricted within Deutero Malay sub race (including ethnic groups of Aceh, Jawa, Sunda, Minangkabau, Riau and Bugis) in 3 generations. Subjects were photographed with digital camera in frontal, left lateral and basal view. Then from the photographs which were stored as JPEG fi les, linear as well as angular measurements were carried out. Results The intercanthal width is 3.56 cm + 0.27, alar width 4.14 cm + 0.28, length of the nose 4.0 cm + 0.21, pronasion projection 2.29 cm + 0.26 and tip angle 111.5o + 4.4, nasofrontal angle 134.6o + 7.3, nasofacial angle 36.3o + 4.3, nasolabial angle 90.4o + 8.3, and nasion projection 0.43 cm + 0.22. Conclusions The data collected from this study can be used as norms for Deutero Malay cases and will serve as a guide for quick reference, when planning aesthetic or reconstructive rhinoplasties for the Deutero Malay patient.

Morphometry of deutero malay female nose.

Aim The objective of this study is to carry out morphometric measurements of the nose, in order to establish norms for the Indonesian as the representation of Asian, specifically for the Deutero Malay sub race. Method A cross sectional study was performed on 126 subjects, recruited from female students of Medical Faculty, the University of Indonesia, Jakarta. Subjects were restricted within Deutero Malay sub race (including ethnic groups of Aceh, Jawa, Sunda, Minangkabau, Riau and Bugis) in 3 generations. Subjects were photographed with digital camera in frontal, left lateral and basal view. Then from the photographs which were stored as JPEG files, linear as well as angular measurements were carried out. Results The intercanthal width is 3.56 cm 0.27, alar width 4.14 cm  0.28, length of the nose 4.0 cm  0.21, pronasion projection 2.29 cm  0.26 and tip angle 111.5o  4.4, nasofrontal angle 134.6o  7.3, nasofacial angle 36.3o 4.3, nasolabial angle 90.4o  8.3, and nasion projection 0.43 cm  0.22. Conclusions The data collected from this study can be used as norms for Deutero Malay cases and will serve as a guide for quick reference, when planning aesthetic or reconstructive rhinoplasties for the Deutero Malay patient.

Cleft lip and palate review: Epidemiology, risk factors, quality of life, and importance of classifications.

Cleft lip with or without cleft palate is the most occurring craniofacial anomaly in human, resulting from a complex etiology involving multiple genetic and environmental factors. The defect carries lifelong morbidity and economic burden. Children with clefts will require continuous medical interventions for at least the first 18 years of life, affecting many aspects of their lives. The extent and complexity of clefts vary infinitely, later determining individual management and outcome. Identification and classification play significant roles in initial assessment of these unique cleft cases, which affect options for following correctional attempts. Some classifications even allow measurement of progress after anatomical repositioning, and success rate after surgical repairs. The challenge of developing one such widely inclusive classification is discussed.

Modification of wise pattern based design with free nipple areolar complex graft in a case of juvenile hypertrophy of the breasts.

Juvenile hypertrophy of the breast (JHB) is a rare condition leading to gigantomastia unilaterally or bilaterally in peripubertal females. The pathology is limited usually to the breast, with otherwise normal growth and development and without any other deformities. The rapid bilateral or unilateral growth of the breast in adolescent girls leads to severe physical and psychological problems. The etiology remains elusive, but it is believed to represent an end-organ hypersensitivity during a period of intense endocrine regulatory stress. The best treatment is surgical whereas the younger patients better treated with mastectomy to anticipate the high recurrency rate, while older women is best treated with reduction mammaplasty. We report one case of a woman who had a unilateral JHB. The growth of the left breast started in her pubertal age and kept growing for one year. She was treated surgically with Wise pattern based design. After two years, she had no recurrent enlargement and aesthetically, the symmetry of both breasts is achieved with a satisfying scar.

Advances in the practice of microsurgery: focusing on free anterolateral thigh perforator flap.

The purpose of this paper was to discuss an overview of the current clinical practice of microsurgery with a specific use of free anterolateral flap as one of the commonest flaps used in reconstructive surgery. A systematic review was performed through all English publication that goes to Pubmed during the period of 1997 to 2006 using keywords: “anterolateral thigh perforator flap.” The studies involved were retrospective case reviews on using microsurgical technique and involves free anterolateral thigh flap only without muscle involvement. Evaluation was done to search the indications, contraindications, area or organ to reconstruct, the cause of defects need reconstructive surgery, morbidities, functional and aesthetic results, techniques in regard of suture material, and instruments. Using 7th edition EndNote program, 230 abstracts were successfully retrieved in term of “anterolateral thigh perforator flap” of ANY FIELD and Boolean logic OR. Fifty six abstracts from many journals matched the criteria. Due to our limitation to get all of those articles, finally, 8 articles from Plastic and Reconstructive Surgery became the resources of this paper. The overall success rate in terms of flap viability is 98% (525 from 535 flaps) with partial necrosis is as low as 2.2% (12 from 535 flaps). Thinning procedure is commonly applied with regards of the thin flap needed. The recipient sites from 8 articles varies and can be any part of the body includes facial, neck, pharyngoesophagus, breast, upper and lower extremity. Four out of 8 papers mentioned functional evaluation and all stated satisfactory to excellent outcome. There are also 4 papers mentioning the aesthetic evaluation. Overall evaluation was mentioned as good to excellent. It is concluded that free anterolateral thigh perforator flap is a well established choice in most soft tissue reconstruction. It can be indicated to any area needed reconstruction especially head and neck, extremity, and go beyond conventional for breast reconstruction. It has also superior result in pharyngoesophageal reconstruction.