The scope of plastic surgery.

OBJECTIVE: To ascertain junior doctors' awareness of the scope of public-sector plastic surgery practice. METHOD: A 12-part questionnaire asked the respondents to name, from a list, the specialty they felt was best equipped to manage patients with specific conditions. RESULTS: The data demonstrate that perception of the scope of plastic and reconstructive surgery is grossly limited. Although plastic surgeons were associated with reconstructive procedures, they were not necessarily identified as primary surgeons for procedures that they commonly perform. A significant number of respondents believed that plastic surgeons are seldom the first line of referral, and are more involved in cases with aesthetic rather than functional sequelae. DISCUSSION: These findings should be regarded with concern, particularly in light of the fact that these doctors will be responsible for carrying the burden of primary care delivery in South Africa and for referrals to secondary and tertiary levels of care. The study motivates for increased exposure to plastic surgery during undergraduate and postgraduate medical training.

Isn't it time for a cadaver skin bank in South Africa?

Improvements in comprehensive burn care, as practiced in dedicated burns units, have reduced mortality and morbidity rates significantly. Strategies deemed most important include the application of fluid resuscitation and nutrition protocols, intensive care and antimicrobial dressings, as well as early excision and grafting. Autografting is limited, however, by availability in very extensive burns, despite the use of expanded (meshed) skin. Alternatives have therefore been required, and deceased donor allograft is considered the gold standard. Fresh allograft use is limited by supply, and legislative and cultural restrictions have significantly influenced availability, despite evidence of its efficacy. This necessitates the establishment of a deceased donor skin bank in South Africa, with a mandate to procure and store allograft for distribution to burns units when required.

L'amélioration des soins aux brûlés, tels qu'ils sont pratiqués dans les unités réservées aux brûlés, a réduit significativement la mortalité et la morbidité. Stratégies jugées les plus importantes comprennent l'application des protocoles sur les fluides de réanimation et de la nutrition, les soins intensifs et les pansements antimicrobiens, ainsi que l'excision précoce et le greffage. L'autogreffe est cependant limitée par la disponibilité chez les grandes brûlures, malgré l'utilisation de la peau étendue (maillée). Des alternatives ont donc été nécessaires, et allogreffe d'un donneur décédé est considérée comme l'étalon-or. Utilisation d'allogreffe fraîche est limitée par l'offre, et les restrictions législatives et culturelles ont influencé de façon significative la disponibilité, en dépit des preuves de son efficacité. Cela nécessite la mise en place d'une banque de peau d'un donneur décédé en Afrique du Sud, qui a pour mandat de se procurer et stocker allogreffe pour la distribution aux unités des brûlures en cas de besoin.

Experimental investigation of two techniques of arterial microanastomosis used to manage a small-to-large diameter discrepancy.

INTRODUCTION: A limiting factor in the use of perforators as recipient vessels is the small-to-large diameter mismatch often encountered. Mismatches less than 1:1.5 may be managed by dilatation of the smaller vessel and by differentially-spaced suture bites. Beyond this ratio, little evidence exists to direct the choice of end-to-end anastomotic technique. Following in silico work and the characterisation of a rodent superficial caudal epigastric/femoral artery model, we conducted an experimental series examining two techniques - an oblique section of the smaller vessel and invaginating the smaller vessel inside the larger. MATERIALS AND METHODS: A paired design was used. To test for a difference in patency of >5% required a total of 156 animals (312 anastomoses). Side and technique were randomised. Two investigators performed the anastomoses. A single revision was permitted. Anastomoses were timed and patency was tested at one hour, one week and at six weeks. RESULTS: There was no significant difference in patency at each of the three time points (p = 0.8026, 0.2963 and 0.8137). The invagination technique was significantly faster to perform (p < 0.0001). There was a significant association between the investigator and both patency and the time taken to complete an anastomosis. Independent of the investigator, a revision was more likely to be necessary with the oblique end-to-end technique, and a revision having been performed showed a highly significant association with an anastomosis having failed at 1 h (p < 0.0001, OR 33.333). CONCLUSIONS: In the management of microarterial size discrepancy between 1:1.5 and 1:2.5, an invaginating anastomosis is faster to perform and produces comparable patency in a rat model.

Characterization of a rodent model for the study of arterial microanastomoses with size discrepancy (small-to-large).

Microsurgical autotransplantation of tissues is employed clinically to reconstruct defects following burns, trauma and surgical cancer ablation, and to correct congenital abnormalities. Transplant vessels of <3 mm are anastomosed by hand under the microscope. Experimentally, anastomotic patency rates decrease with increasing vessel diameter mismatch, and clinically, ratios of 3:1 or greater lead to unacceptably low arterial patency rates. A number of surgical techniques for dealing with size mismatch are described, but no one method has found favour, and few controlled studies of technique are reported. In this report, a rodent superficial caudal epigastric artery (SCEA)/femoral artery (FA) model for the study of these techniques is described in detail. The diameter ratio between these vessels lies in the clinically relevant range of 1:1.5-1:2.5. In the male Wistar rat, external vessel diameters were not found to increase markedly in size between animal weights of 300 and 500 g. The length of FA distal to the origin of the SCEA, which is important in allowing undisturbed distal run-off, was found to be negatively associated with animal body weight, implying that a smaller animal would be better for this model. Mean femoral arterial flow rate, measured by transit-time ultrasound, was noted to be statistically and physiologically significantly higher in the right artery when compared with the left. This model has advantages over interposition vein graft models in that it minimizes vessel compliance mismatch, and avoids the need for a second anastomosis.

Another look at breast projection after breast reduction.

A controversy exists between vertical mammoplasty and the "traditional" keyhole\inferior pedicle method of breast reduction. This article examines factors affecting breast projection by considering the difference in concept between vertical mammaplasty (using the modification proposed by Hall-Findley as an example) and the inferior pedicle\keyhole pattern. This article is not about "how to do" but rather about "why" things are done in a certain way. The emphasis is on understanding what is done and its effects rather than on technique. The breast can be considered a cone. Breast projection then is the ratio between the nipple projection and the breast base. Two key concepts need to be considered: the orientation of the ellipses during excision of breast tissue in breast reduction and the role of the breast base\inframammary fold. Breast projection is not determined by the scars. After an examination of each technique, methods to enhance projection are discussed.

Malignant melanoma in South Africans of mixed ancestry: a retrospective analysis.

Little is known about the behaviour of melanoma in patients of mixed ancestry. A retrospective analysis of 844 consecutive patients presenting with melanoma over a 12-year period was performed. Forty patients (4.8%) were of mixed ancestry. The data evaluated included patient age, gender, delay in presentation, presenting stage, anatomical distribution, histology, management and outcome. The mean age at presentation was 52.8 years. Twenty-seven patients were female. The mean delay in presentation was 1.54 years. Seventy per cent of melanomas were confined to the extremities, of which one-third were plantar in origin. The most common histological variant, affecting 13 patients (32.5%), was acral lentiginous melanoma; 12.5% of patients presented with in situ (Stage 0) disease, 17.5% with Stage I disease, 22.5% with Stage II disease, 27.5% with Stage III disease and 7.5% with Stage IV disease. Twenty-seven patients (67.5%) remained alive at the end of the study after a median follow-up of 5.58 years, whilst 11 (27.5%) died after a median of 2.42 years. The median survival was 3.92 years. Although the histological type and anatomical distribution reflect the disease pattern of black populations, the overall 5-year survival of 74% is similar to that seen in white populations. An education programme is needed to improve melanoma awareness in mixed race populations.

Intrauterine stab leading to a radial nerve palsy.

Penetrating injuries to the gravid uterus are rare. This report documents a fetus that sustained a complete radial nerve palsy (a hemopneumothorax) after a knife wound (complete nerve transection is suspected). Surgical exploration of the nerve was delayed because of respiratory distress. Six weeks later, when exploration was scheduled to be undertaken, some recovery was noted, and exploration was thus deferred. The injury recovered completely in the absence of formal repair.

Single-stage, autologous breast restoration.

The skin-sparing mastectomy, when performed with immediate reconstruction, is a major advance in breast reconstruction. Traditionally, reconstruction of the nipple-areola complex is performed as a subsequent procedure. In this study, 17 patients (mean age, 43 years; range, 35 to 53 years) underwent one-stage breast and nipple-areola reconstruction over a 21-month period. In all cases of breast reconstruction, a buried transverse rectus abdominis musculocutaneous (TRAM) flap was used, and all patients had a simultaneous nipple-areola complex reconstruction performed. Nine patients had a Wise keyhole pattern used and contralateral reduction performed. Four patients retained all their breast skin, and a TRAM skin island was used in another four. It has recently been shown that patients with early-stage breast cancer and peripherally sited tumors have a very low risk of nipple-areola involvement. In 10 patients with early disease and peripheral tumors, the areola was retained (as a thin full-thickness graft), but more recently, in three patients with early-stage disease, the entire nipple-areola complex was used as a thin full-thickness graft. The thin full-thickness skin graft is removed from the breast in an apple-coring fashion, so that most of the ducts are retained as part of the mastectomy specimen. (There was histological confirmation of absence of tumor in the nipples of these patients.)One-stage autologous reconstruction should be considered for all patients undergoing immediate breast reconstruction. In patients with early-stage disease and peripheral tumors, the nipple-areola complex may be retained through the use of a thin full-thickness graft that is applied to a deepithelialized CV flap on the TRAM flap. This allows the best method of nipple-areola complex reconstruction: by retaining the original breast envelope, the color match and texture in the reconstruction are ideal. Patient satisfaction in this study was high. Necrosis of the mastectomy flaps impaired the cosmetic results in some patients. A large multicenter study is required to confirm the effectiveness of this procedure.

The prognostic importance of c-myc oncogene expression in head and neck melanoma.

Melanomas of the head and neck have a poorer prognosis than melanomas arising at other cutaneous sites. To study the biology of this disease, the expression of the c-myc oncogene was studied in tumors from 97 patients with head and neck melanoma using the technique of flow cytometry. Survival analysis revealed that stratification of patients according to oncogene expression provided a prognostic marker with shorter overall survival in tumors with high nuclear c-myc oncoprotein positivity (log-rank test, chi2 = 8.77, p < 0.005). Multifactorial analysis using Cox's proportional hazards model revealed nuclear c-myc oncoprotein to be an independent prognostic marker (log-rank test, chi2 = 8.82, p = 0.005). These results support the authors' previous studies of the prognostic value of c-myc expression in melanoma and suggest that estimation of c-myc oncoprotein may be of clinical importance in identifying high-risk patients.

Serial tissue expansion for reconstruction of burns of the head and neck.

There is little reported on serial tissue expansion for reconstruction of burns of the head and neck. Fourteen children (mean age 7.8 years, range 3-11 years) treated over almost an 11 year period, had a total of 67 expanders used. Fourteen children had expansion performed on the first occasion, 14 again on a second occasion, 10 on a third occasion and one on a fourth occasion. The major complication rate (expander extruded prior to completion of the expansion process) was 21,25 and 14%, respectively. In all cases, the burn scar was completely excised or reduced in size. Serial tissue expansion should be considered as a useful method of reconstruction burns of the head and neck.

Short-scar breast reduction: why all the fuss?

The breast can be considered conceptually as a cone. This article compares and contrasts short-scar breast reduction techniques with inverted T techniques using the cone model. Four issues are examined-the base of the breast, breast projection, the inframammary fold, and the pedicle. The short-scar techniques focus on reshaping the breast parenchyma, and skin redraping occurs secondarily. Application of this model suggests that these techniques have the advantage of better projection and greater longevity. These techniques seldom give a square shape and are better at dealing with upper pole deficiency. However, the ability of the skin to redrape is the limiting factor; hence, results are less predictable with large-volume breast reductions. The emphasis of this article is on increasing the understanding of the mechanics of breast reduction. It is this factor that will enable appropriate selection of a particular technique.