Penile allotransplantation for penis amputation following ritual circumcision: a case report with 24 months of follow-up.

INTRODUCTION: Ritual circumcision complicated by gangrene is a leading cause of penile loss in young men in South Africa. This deeply rooted cultural tradition is unlikely to be abolished. Conventional reconstructive techniques using free vascularised tissue flaps with penile implants are undesirable in this often socioeconomically challenged group because donor site morbidity can hinder manual labour and vigorous sexual activity might lead to penile implant extrusion. The psychosociological effects of penile loss in a young man are devastating and replacing it with the same organ is likely to produce the maximum benefit. METHODS: We first performed a cadaver-to-cadaver penile transplantation as preparation. After approval from the Human Research Ethics Committee was obtained, we recruited potential recipients. We screened the potential participants for both physical and psychological characteristics, including penile stump length, and emotional suitability for the procedure. A suitable donor became available and the penis was harvested. We surgically prepared the penile stump of the recipient and attached the penile graft. Immunosuppression treatment with antithymyocyte globulin, methylprednisolone, tacrolimus, mycophenolate mofetil, and prednisone were commenced. Tadalafil at 5 mg once per day was commenced after 1 week as penile rehabilitation and was continued for 3 months. We collected on quality-of-life scores (Short Form 36 version 2 [SF-36v2] questionnaires) before surgery and during follow-up and measured erectile function (International Index for Erectile Function [IIEF] score) and urine flow rates at 24 months post transplant. FINDINGS: The warm ischaemia time for the graft after removal was 4 min and the cold ischaemia time was 16 h. The surgery lasted 9 h. An arterial thrombus required urgent revision 8 h after the operation. On post operative day 6, an infected haematoma and an area of proximal skin necrosis were surgically treated. The recipient was discharged after 1 month and first reported satisfactory sexual intercourse 1 week later (despite advice to the contrary). The recipient reported regular sexual intercourse from 3 months after the operation. An episode of acute kidney injury at 7 months was reversed by reducing the tacrolimus dose to 14 mg twice per day. At 8 months after surgery, the patient had a skin infection with phaeohyphomycosis due to Alternaria alternata, which we treated with topical antifungal medication. Quality-of-life scores improved substantially after the operation (SF-36v2 mental health scores improved from 25 preoperatively, to 57 at 6 months and 46 at 24 months post transplant; physical health scores improved from 37 at baseline to 60 at 6 months and 59 at 24 months post-transplant). At 24 months, measured maximum urine flow rate (16·3 mL/s from a volume voided of 109 mL) and IIEF score (overall satisfaction score of 8 from a maximum of 10) were normal, showing normal voiding and erectile function, respectively. INTERPRETATION: Penile transplantation restored normal physiological functions in this transplant recipient without major complications in the first 24 months. FUNDING: Department of Health, Western Cape Government.

The Blood Supply of the Breast Revisited.

BACKGROUND: Many surgeons are under the impression that the blood supply is clearly defined in textbooks. Unfortunately, the majority of textbooks supply inadequate information and illustrations can be misleading in many instances. None of the textbooks describe a segmental pattern of blood supply when in actual fact a basic segmental pattern does exist. The reason for inadequate information is the perpetuation of facts since the work of the pioneers Cooper and Manchot from one textbook to another. A paucity of research studies thereafter and the fact that the results of some of these studies did not find their way into textbooks is another contributing factor. METHODS: The findings of research studies since the descriptions by Cooper and Manchot are analyzed and compared in an effort to find common ground and its clinical implication. RESULTS: Researchers concurred on the main sources of blood supply; these are internal thoracic, lateral thoracic, anterior intercostal, and acromiothoracic (thoracoacromial) arteries. However, the different research studies showed considerable variation in the branches from the main sources to supply the nipple-areola complex. CONCLUSIONS: Even though the locations of the main sources of blood supply are constant, partial or complete absence of branches from the main sources does occur and therefore the blood supply to the nipple-areola complex is unpredictable. Cognizance of the basic segmental pattern and the variations resulting from embryologic development will be helpful for the surgeon to use or adapt a technique to minimize the risk of nipple necrosis.

Improving the longevity and results of mastopexy and breast reduction procedures: reconstructing an internal breast support system with biocompatible mesh to replace the supporting function of the ligamentous suspension.

BACKGROUND: The reasons for recurrent ptosis in mastopexy and breast reduction procedures are twofold. First, available surgical techniques do not reconstruct the normal breast anatomy responsible for maintaining breast shape. Second, in many instances the techniques rely on atrophied tissue to provide long-term support. The discovery in 1997 of the ligamentous suspension (the supporting system of the breast) gave rise to the concept that reconstruction of this anatomical structure was needed to ensure a sustained postoperative result. Applying the latest knowledge regarding the structural and vascular anatomy of the breast in the surgical technique and utilizing material other than atrophied breast tissue enabled us to prevent the recurrence of breast ptosis. METHODS: A surgical technique was developed to replace the supportive function of a failed ligamentous suspension in 112 patients with ptotic breasts. This was done by reconstructing an internal breast-supporting system (IBSS) with biocompatible mesh. RESULTS: Satisfactory breast shape, nipple projection, and upper breast fullness was obtained with this technique in mastopexy patients with moderate-sized ptotic breasts. In patients with larger breasts good results were obtained with a simultaneous breast reduction. The longest follow-up is 6 years 3 months. CONCLUSIONS: With this technique recurrent breast ptosis can be prevented in mastopexy and breast reduction procedures. The results are such that it eliminates the need for silicone prostheses to obtain satisfactory upper-breast fullness. The surgical technique is especially indicated in patients with skin of poor quality or patients with high expectations.

Enhancing pedicle safety in mastopexy and breast reduction procedures: the posteroinferomedial pedicle, retaining the medial vertical ligament of Würinger.

BACKGROUND: Nipple necrosis, a potential postoperative complication of breast surgery procedures, should be avoided. Because of the great variation in the blood supply to the nipple, it is advisable to include as many arteries in the pedicle as possible. According to the literature, the perforators of the internal thoracic artery are the most constant and reliable sources of blood to the nipple-areola complex. It is also supplied by the lateral thoracic artery and the anterior intercostal arteries. If two of the above-mentioned main vessel branches are included in the pedicle, the vascular supply to the breast will be more reliable. According to the anatomical studies of Würinger and van Deventer, we can safely include the dual blood supply to the nipple-areola complex. METHODS: In the authors' technique, a pedicle is raised that includes the horizontal septum and the medial vertical ligament of the breast (i.e., inferior and superomedial pedicles), but with the breast tissue remaining attached to the pectoral fascia. The second, third, and fourth perforators of the internal thoracic artery are found in the medial vertical ligament, and the inferior mammary branches of the anterior intercostal arteries are in the horizontal septum. The authors have performed this technique in 106 consecutive patients (211 breasts) between 2001 and 2009. RESULTS: Good results regarding breast shape, nipple projection, and upper breast fullness were obtained. CONCLUSIONS: The posteroinferomedial pedicle technique is safe and versatile and can be used with a periareolar, vertical scar, or inverted-T skin approach. The technique is easy to perform and has a short learning curve.

Cranial fasciitis presenting as a frontonasal mass.

We report the unusual case of a newborn baby with cranial fasciitis of the frontonasal area. Herein, we present the clinical, pathologic, and radiologic findings of a male neonate with cranial fasciitis of the skull. Cranial fasciitis is a benign fibroblastic tumor related to nodular fasciitis, but it has a predilection for the scalp of children. One case has been described in neonates (Neurosurgery. 2001;48:430-435).

Modified Charles procedure using negative pressure dressings for primary lymphedema: a functional assessment.

OBJECTIVE: The Charles procedure is an aggressive operation usually only indicated for severe lymphedema as it often yields an unpredictable outcome. We modified this procedure in order to achieve predictable results. METHODS: The modification entailed the use of a negative-pressure dressing after the initial debulking surgery and then the delay of skin grafting by 5 to 7 days. Patients were graded by means of a lower limb functional scale to assess their functional status pre- and postoperatively. RESULTS: Eight patients with severe primary lymphedema underwent a modified Charles procedure. All patients underwent this procedure without any major complications with an average resection of 8.5 kg of lymphedematous tissue. Minor complications included operative blood loss and additional regrafting (3 patients). The average follow-up was 27.3 months. CONCLUSION: The results show a dramatic functional improvement in quality of life and a high overall satisfaction rate of patients undergoing this procedure. Our modification makes this a relatively simple procedure with a predictable outcome.

Midface distraction without osteotomies in an infant with upper respiratory obstruction.

Midface hypoplasia is a common craniofacial anomaly and may manifest as part of a wider syndrome or as an isolated finding. Underlying this condition is a complex morphology, resulting from development across multiple interacting suture systems. Current treatment relies on various combinations of osteotomies and distraction using internal or external devices. Such procedures, while often successful, involve significant morbidity and trauma to the very young patients whom comprise the majority of the treatment group. The present article describes the successful development of a technique for midfacial distraction without osteotomies. In a case study representing a series of 11 patients, a 4-month-old baby girl with midface hypoplasia and respiratory obstruction requiring nasopharyngeal intubation underwent this 2-stage procedure. After 72-day distraction, upper incisor-posterior clinoid process distance had increased 18.4 mm, and by 4 months after removal of the distraction devices, it had increased a further 2.6 mm. Craniofacial morphology was markedly improved combined with complete resolution of her respiratory obstruction. No blood transfusion or intensive care facility was required. This innovation demonstrates a procedure with similar efficacy but significantly reduced morbidity and cost compared with existing methods. Interestingly, continued growth after the distraction period may allude to a different mechanism of induced osteogenesis than previously described.