Is it justified to refuse breast reduction to smokers?

INTRODUCTION AND AIMS: There are several studies in the literature suggesting that smoking increases the complication rate in various plastic surgery operations. We did a study on 402 patients to see the effect of smoking on breast reduction. The objective was to raise the controversial issue of whether breast reduction could be refused to smokers who fail to stop smoking in the peri-operative period. MATERIALS AND METHODS: The records of patients who had undergone breast reductions between April 1999 and May 2004 at the Leicester Royal Infirmary, Leicester were reviewed retrospectively for age, body mass index, smoking habits and wound-related complications. RESULTS: A total of 764 breast reductions were performed in 402 patients during this period. Twenty-eight per cent (112) of these patients were smokers. The mean age was 33.9 (range 19-68)+9.5 years in smokers and 34.4 (range 16-73)+10.6 years in non-smokers. About 90% of patients had bilateral breast reductions. Wound-related complications were seen in 35% of smokers as against 13% of non-smokers, P value<0.001. Overall, smokers had a 2.3 x higher chance of developing a complication. The probability of a smoker developing wound infection was 3.3 x more in comparison to a non-smoker. Smokers were also three times more likely to develop T-junction necrosis. CONCLUSION: Smoking increases the complication rate of breast reduction significantly. Hence, patients must be strongly encouraged to quit smoking before surgery and abstain until the wound has completely healed. Stoppage of smoking in the peri-operative period should be adopted as an essential eligibility criterion for breast reduction.

Calciphylaxis: a rare limb and life threatening cause of ischaemic skin necrosis and ulceration.

Calciphylaxis (uraemic gangrene syndrome) is a rare complication of chronic renal failure and secondary hyperparathyroidism. Patients present with painful purple skin lesions which undergo necrosis and ulceration. The histology is specific. There is medial calcification with intimal hyperplasia and thrombosis of the lumen of small sized arteries in the underlying subcutaneous tissue. Death frequently arises from overwhelming sepsis. Early recognition of this condition and prompt parathyroidectomy can lead to rapid relief of symptoms and ulcer healing and may be life saving.

The surgical treatment of drooling in Leicester: 12 years experience.

The experience of the surgical treatment of drooling in the 12-year period 1985-1997 has been retrospectively reviewed. Details of 71 out of a total of 79 patients were available. Of these, 69% underwent bilateral submandibular duct diversion and unilateral parotid duct ligation. Excellent or good control of drooling was obtained in 65 patients (92%) which compares favourably with other series. A ranula occurred in 10% and settled spontaneously. Transient airway obstruction occurred in one patient.

Mixed connective tissue disease presenting to the acute hand service.

Mixed connective tissue disease is an autoimmune condition with a specific autoantibody. It commonly presents as Raynaud's disease and the patient is usually treated symptomatically. We present an unusual case of mixed connective tissue disease presenting as a acutely inflamed joint with considerable bony destruction.

Closure of an ischial pressure sore with a sartorius musculocutaneous flap.

A method for the reconstruction of ischial defects is outlined, citing some particular advantages of the technique.

Treatment of drooling by parotid duct ligation and submandibular duct diversion.

A new combination of operations is described for controlling drooling in patients with cerebral palsy. Fourteen patients underwent ligation of one parotid duct and diversion of both submandibular ducts at the same operation. Drooling was controlled in all. Transient oro-facial swelling was the commonest complication.

A prospective trial of adrenaline infiltration for controlling bleeding during surgery for gynaecomastia.

Twenty patients with gynaecomastia undergoing operations on 33 breasts were entered into a prospective randomised controlled clinical study. The breasts were randomised to receive nothing or adrenaline infiltration prior to mastectomy. Blood loss during surgery and drainage afterwards were compared between the two groups. Statistical analysis using the Wilcoxon rank sum test (two-tailed) showed a statistically significant reduction in operative blood loss (p less than 0.01) but no difference in postoperative drainage. There was no adverse effect on the viability of the skin flaps or the nipple-areola complex.

Thermal injury associated with infant walking-aids.

Leicester Royal Infirmary and Government statistics have shown that an increase in the use of baby-walkers has been accompanied by a rise in the incidence of burns associated with their use. These burns tend to be more severe than the average for this age-group. Three case histories are presented as illustrations. The head, neck and hands are particularly affected. Three mechanisms of injury are identified. Safety guidelines are unrealistic and not enforced, testing is inadequate, and the devices hinder normal motor development.

A possible new operative method for the treatment of metacarpophalangeal joint stiffness.

A case is reported in which metacarpophalangeal joint capsulotomy is augmented by the use of a flap of fibrous tissue from around previously implanted silicone sheet as a form of capsular reconstruction.

Changes in plasma catecholamine concentrations following infiltration with large volumes of local anaesthetic solution containing adrenaline.

Plasma catecholamine concentrations have been measured in nine patients undergoing rhinoplasty following infiltration to the facial area of 21 ml of 0.5% lignocaine with adrenaline 1:200,000 and in seven patients undergoing brachial plexus blockade with 40 ml of 0.5% lignocaine, 0.25% bupivacaine and adrenaline 1:200,000. In the rhinoplasty group there was a 566% increase in plasma adrenaline concentration 2 min after cessation of infiltration, whilst in the brachial plexus group a 112% increase in the plasma concentration of adrenaline occurred at 10 min after completion of the block. There was no change in plasma noradrenaline concentration in either group. It is concluded that the so-called safe dose of adrenaline (1.0 microgram kg-1 during halothane anaesthesia) is meaningless unless the site of administration is specified.

The best dressing for a nail bed is the nail itself.

The replacement of a surgically avulsed nail as a splint and dressing with "Superglue" is reported. It provides a painless cover for the sterile matrix and facilitates the dressing of finger tip injuries.

Avulsion of the scalp treated by microvascular repair: the use of leeches for post-operative decongestion.

A 28-year-old fitter and turner was scalped at work. The scalp was avulsed from the nuchal area to the eyebrows in one piece. It was successfully replanted by microvascular surgery. Leeches were used to decongest the flap when venous drainage appeared inadequate during the first week. Only a small part of the flap eventually failed to survive and normal hair growth returned in all other areas.

The "tadpole flap": an advancement island flap for the closure of anterior palatal fistulae.

Anterior palatal fistulae immediately behind the incisor teeth may be difficult to repair. A modification of Millard's island palatal flap is described which can be advanced to close these defects--a "tadpole flap". This method of closure has been successfully used in 11 patients. The technique is described.