The Use of a Hemi Glabellar Flap for Reconstruction of Medial Canthus Defects.

BACKGROUND:  Medial canthal reconstruction is a challenging task due to its complex anatomy. The glabellar flap is a common viable technique; however, this results in narrowing of the eyebrows, bulky nasal dorsum horizontal scarring, which is aesthetically displeasing, and possible injury of the supratrochlear artery. Multiple variations have been proposed in the literature, which is often complex. In this paper, the senior author (AK) has developed an intuitive, simple technique by utilising half of the glabellar skin in 12 patients with good clinical outcomes. MATERIALS AND METHODS:  A rotational advancement flap involving the upper lateral nasal wall with the hemi glabellar was formed and transferred to the medial canthal defect. The donor site was closed in a V-Y manner. Complete closure of defect was achieved in all patients. RESULTS:  Reconstruction using the hemi glabellar technique was performed on 12 patients following resection of basal cell carcinoma (BCC) in or near the medial canthus area. Superficial cellulitis was noted in two patients; they were managed on oral antibiotics. Bruising was reported in seven patients which resolved spontaneously in 4-7 days. All patients had a good outcome at two months and six months follow up; there was no flap loss, and all patients were satisfied with the aesthetic outcome. CONCLUSION:  The technique highlighted in this article can be performed quickly and applies to the reconstruction of medial canthus defects with excellent aesthetic outcomes, an inconspicuous scar and supple skin with matching colour.

Outcomes and complications following flexible intramedullary nailing for the treatment of tibial fractures in children: a meta-analysis.

INTRODUCTION: Tibial shaft fractures are common occurrence in children and surgical treatment is sometimes required, particularly in unstable or open fractures, and in polytrauma. The aim of this study was to investigate the available evidence on the efficacy and safety of flexible intramedullary nailing (FIN) for both open and closed tibia fractures in children, exploring the main surgical outcomes and rate of complications. MATERIALS AND METHODS: Pubmed/Medline, Scopus and Cochrane Central databases were searched following the PRISMA guideline. Studies reporting on the outcomes of FIN for paediatric tibia shaft fractures were included. Weighted means were evaluated for surgical outcomes. Meta-analysis of proportion and odd ratios were used to analyse total complication rates and differences between open and closed fractures. RESULTS: Twenty-eight studies (835 patients) were included; the mean age was 11.0 ± 3.0 years. The mean follow-up was 22.5 ± 13.5 months; the mean time to full weight-bearing was 7.5 ± 3.7 weeks. The total complication rate was 28.1% (minor = 20.7%, major = 6.3%); this was greater in open fractures (13.6% vs 5.1%, p = 0.007). The rate of union was 97.5%, with a mean time to union of 11.9 ± 7.2 weeks. Malunion was found in 8.5% cases, delayed union in 3.8%, non-union in 1.4%, symptomatic hardware in 5.1%, leg-length discrepancy in 5.0%, superficial infections in 2.3%, deep infections in 1.0%, compartment syndromes in 1.4%, and refracture in 0.2%. Almost all patients returned to unrestricted physical activity. CONCLUSIONS: FIN offers excellent outcomes for the treatment of paediatric tibia shaft fractures. Patients presenting with an open fracture have a higher but acceptable complication rate. Comparative studies are needed to clarify if other treatments have superior outcomes.

Management of a swallowed denture: our experience with 34 patients.

Background: Swallowed dentures can present with upper aerodigestive tract obstruction needing urgent intervention. Removing such an ingested denture can prove challenging and needs careful planning. Aim: To share our experience of managing patients with a swallowed denture focusing on the practical aspects of denture removal along with relevant literature review. We aim to raise a public health message on the safety aspect of usage of dentures. Subjects and methods: A retrospective analysis of the patients managed by our team in the ENT department at two hospitals in Scotland, over 10 years (2009-2019), who were found to have swallowed a denture. Data on demographics, clinical history, examination findings and management of patients were collected and analysed using Microsoft Excel. Results: A total of 34 patients were admitted with a swallowed denture, of which 24 (71%) were male and 10 (29%) were female. The mean age was 60 years (range 17-83). Of the 34 patients, 2 had a feeling of something stuck in the throat but were able to eat and drink; the rest of the patients complained about dysphagia and pain in the throat, with 2 patients also showing signs of respiratory distress. Twenty-four (71%) patients required denture removal under general anaesthetic in the theatre; 20 (59%) by rigid oesophagoscopy, 1 with tracheostomy (3%), 1 with (3%) laparoscopy and gastrostomy, and 2 (6%) with external neck exploration. Seven (20%) patients were taken to the theatre and the denture was removed with Magill forceps under light sedation using intubating laryngoscope or video laryngoscope. In 1 patient (3%), the denture material was successfully removed under flexible pharyngolaryngoscopy guidance in the clinic without sedation. The final 2 (6%) patients were reassured as no foreign body was seen on flexible laryngoscopy. Conclusion: In the absence of a clear evidence of denture ingestion, a detailed history and examination are needed to identify this serious pathology. Once confirmed, the ingested denture should be removed as soon as possible to minimize the risk of serious complications.

Acellular dermis (SureDerm®) use for managing pulsatile tinnitus: a long-term follow-up of a novel surgical technique.

Introduction: Pulsatile tinnitus (PT) can be very distressing for the patient. An identifiable abnormality is rarely detected. Dural AV malformation is responsible for arterial PT. Venous PT has rarely been attributed to an obvious abnormality on venogram. Dehiscent high jugular bulb or sigmoid sinus have been thought to be potential cause for venous PT. Ligation of internal jugular vein (IJV) has been advocated as a definitive surgical treatment. To our knowledge the use of acellular dermal matrix for treatment of venous PT has not been reported previously. Objectives: To share our experience of a successful treatment of PT using acellular dermis. Methodology: Case report and literature review. Case description: A 23-year-old Caucasian female presented with right-sided PT of 9 months duration. All clinical and audiological investigations were normal. MRI brain and internal auditory canals was normal but the CT scan showed a high right jugular bulb. It also showed dehiscence of the right sigmoid plate with herniation of sigmoid sinus into the mastoid. She underwent transmastoid correction of dehiscent sigmoid sinus and jugular bulb. Acellular dermis was used for extra luminal packing of mastoid cavity and hypotympanum. The patient made a good post-operative recovery and reported resolution of tinnitus on recovering from anaesthesia. The patient was discharged home the following day. There were no sequelae from surgery. The patient has remained symptom-free 11 years following her treatment. Conclusion: The surgical goal of dehiscent sigmoid sinus correction can be accomplished with acellular dermis packing. Traditionally ligation of the IJV or rigid correction of herniated sinus has been recommended; however, we have demonstrated that a relatively thick pliable acellular dermis is more than adequate to correct herniation of the sigmoid venous sinus.

Hepatobiliary complications from ruptured silicone breast implants - a comprehensive literature review.

Cronin and Gerow first introduced silicone breast implants in 1962; they now serve as first-line for breast augmentation. Breast augmentation is effective in restoring both physical and psychological well-being in women post-mastectomy. Many studies in the literature on complications of silicone breast implant rupture focus on lymphomas and capsular contractures. Only a few studies discuss the hepatobiliary complications. By reviewing the literature over the past 30 years, the authors aim to analyse the clinical presentation, diagnostic findings, as well as management outcomes amongst women with ruptured silicone implant-related hepatobiliary complications. To the best of our knowledge, this is the first comprehensive review on this topic.

Tracheo-oesophageal groove Hodgkin's lymphoma presenting as stridor: a diagnostic challenge.

A 38-year-old male patient presented to the ear, nose and throat department with shortness of breath over last 2 months. The CT scan of the neck and chest revealed a 3.3×3 cm tumour behind the right thyroid lobe extending into the tracheo-oesophageal (TO) groove with tracheal compression. The ultrasound scan of the neck and targeted fine needle aspiration followed by core biopsy raised a suspicion of Hodgkin's lymphoma. The patient underwent a right hemithyroidectomy and incisional biopsy of the right TO groove tumour. The histology confirmed a Hasenclever's three nodular sclerosing Hodgkin's lymphoma for which he received adjuvant chemotherapy. An incidental pT1a pN0 thyroid papillary microcarcinoma in the adjacent thyroid parenchyma was completely excised. This represents a case of TO Hodgkin's lymphoma, of which there are no current published case reports. We aim to raise awareness about this rare condition by sharing the diagnostic work up and successful management in a multidisciplinary team setting.

Primary thyroid squamous cell carcinoma: a challenging management problem.

Primary thyroid squamous cell carcinoma (SCC) is a rare and highly aggressive cancer. Diagnostic work-up encompasses cervical ultrasonography, tissue biopsy and CT scan. Surgery, radiotherapy and chemotherapy are the available treatment modalities. With a mean survival rate of 7 months reported in the literature, our patient is alive 2 years after successful treatment of her advanced primary thyroid SCC with surgery and radiotherapy.

Excision of a massive lipoma of the thigh following extensive weight loss and bariatric surgery.

A 52-year-old morbidly obese man with a body mass index (BMI) of 78 kg/m2 lost a great deal of weight through diet control over a 3-year period before undergoing bariatric surgery in the form of laparoscopic sleeve gastrectomy. He continued to lose weight, reducing BMI to 56 kg/m2; however, a large left medial thigh mass persisted. Differential diagnoses included lipoma, liposarcoma and hernia. An MRI scan revealed a 37 × 23 × 23 cm oedematous fatty swelling through which contained multiple enlarged inguinal lymph nodes and the great saphenous vein. Plastic surgeons excised the mass with direct closure of skin. Pathology confirmed lipoma with localised lymphoedema. This represents a case of giant lipoma, of which several reports have been described. We highlight the importance of preoperative imaging when planning resection of large masses to delineate the regional anatomy and the need for histological and genetic analysis to differentiate liposarcoma from lipoma due to their similar presentations.

When DVT turns into surgical catastrophe: undiagnosed case of May-Thurner syndrome leading to retroperitoneal haematoma and fatal bleeding.

May-Thurner syndrome (MTS) is an unusual cause of deep venous thrombosis; even rarer is the spontaneous rupture of collaterals around the thrombosed common iliac vein due to MTS. We present a case of MTS which presented with left leg swelling and abdominal mass due to retroperitoneal haemorrhage.

A double-blinded randomised controlled trial - do subcuticular non-absorbable skin sutures have a better aesthetic outcome than skin staples in large wound closures?

Introduction: Traditionally, non-absorbable skin sutures (SS) have been utilised in the closure of the skin in large wounds. More recently, however, skin staples (SC) have been introduced with the aim of reducing closure time and infection rates. Method: A double-blinded randomized controlled trial in all patients undergoing elective open surgeries in a single unit, from May 2007 to May 2010. Data on patient demographics, type of surgery, methods of skin closure, rate of wound infection and cosmetic satisfaction were collected. Patients were then randomly allocated to skin sutures (SS) or skin staples (SC) groups. Patients and investigators were then "blinded" to the arm of trial they were allocated to. Result: In total, 369 patients were recruited, of which 218 patients completed the study. 134 patients were allocated to the SS group with a median age of 67 (IQR 61, 74). SC group had a total of 84 patients with a median age of 69 (IQR 61, 71). 15% of SS group developed wound infection, compared to 20% in SC group (p=0.202). 61% of the SS group claimed better aesthetic results compared to 46% in SC group (p=0.020). Conclusion: Our results demonstrated that patients with non-absorbable subcuticular skin closures had lower infection rates, better cosmetic outcome and better patient satisfaction outcome compared with skin staples. We therefore suggest using subcuticular sutures to close the skin in elective abdominal open surgery.