Dorsolateral musculocutaneous perforators of posterior intercostal artery: an anatomical study.

BACKGROUND: The posterior intercostal artery (PICA) is divided into four segments, vertebral, costal, intermuscular, and rectus, based on the neurovascular branching pattern. Dorsal branches arise from the vertebral segment. Several musculocutaneous perforators and a lateral branch originate from the costal segment. Musculocutaneous branches arise from the intermuscular and rectus segments. The purpose of this study is to describe in detail the musculocutaneous perforators of the costal segment of the posterior intercostal artery. METHODS: Fresh cadavers were injected with a modified lead oxide-gelatin mixture. Intercostal spaces (8-11) were dissected in twelve cadavers (six preserved cadavers and six fresh cadavers). Angiograms were assembled with Adobe Photoshop. Two fresh cadavers underwent CT angiography and three dimensional reconstructions of the intercostal perforators were performed using Materialise's Interactive Medical Image Control System (MIMICS). RESULTS: In twelve cadavers, a total of 356 perforators (size > 0.5 mm) were found to arise from the posterior intercostal arteries in 96 intercostal (IC) spaces. 154 perforators (>0.5 mm) were found in the costal segment of the PICA. An average of 6.4 perforators was found in each hemithorax. All perforators were found within 2 cm of the midscapular line. At least one perforator was found in all intercostal spaces. Two or more perforators were found in 40% of the 8th and 9th IC spaces and 60% of the 10th and 11th IC spaces. Perforators were oriented perpendicular to the direction of the muscle fibres of the latissimus dorsi and were usually present one or two intercostal spaces below their origin from the PICA. CONCLUSIONS: Perforators of the costal segment of the PICA are described in detail. We propose to call these currently unnamed musculocutaneous perforators "dorsolateral" branches of the PICA, as they are located between dorsal and lateral branches of PICA.

Orbital floor reconstruction: a case for silicone. A 12 year experience.

INTRODUCTION: Controversy still exists regarding the choice of implant material for orbital floor reconstructions, in particular the use of silicone. We aimed to evaluate the long-term outcomes of orbital floor reconstructions with silicone versus other non-silicone implants. PATIENTS AND METHODS: We conducted a 12 year retrospective review of patients who had orbital floor reconstructions for fractures at the Royal Hobart Hospital, Tasmania, Australia, from 1995 to 2007. Surgical admission notes, CT reports, operation records, outpatient notes, and complications were recorded. Long-term follow-up consisted of a structured telephone interview assessing patient outcomes and satisfaction, including ongoing disability, following orbital floor repair. RESULTS: Eighty one patients were identified as having had orbital floor reconstruction with an implant. Mean long-term follow-up was 63 months. Outcomes of Silicone implants (n=58) were compared to non-silicone implant materials (n=23) including titanium mesh, 'Lactasorb', 'Resorb-X', autologous cartilage, and bone graft. Statistically significant advantages in the silicone group were found in the number of patients with palpable implants (24% vs 63%, p=0.005), the number of patients without any complaint (67% vs 32%, p=0.004), and the number of patients requiring subsequent surgery for complications related to their implants (5% vs 23%, p=0.046). CONCLUSION: The appropriate use of silicone implants for orbital floor reconstruction can have good results, contrary to much of the literature, with low complication rates including an acceptably low rate of infection and extrusion, as well as high patient satisfaction. To establish definite guidelines for best surgical practise, particularly amongst synthetic implant materials, prospective study is required.

The ideal rotation flap: an experimental study.

BACKGROUND/PURPOSE: Numerous modifications exist and opinions vary between surgeons with regard to the design of the ideal rotation flap. A literature review revealed inconsistencies as well as three different designs of rotation flap (standard rotation flap, Ahuja's modified rotation flap, divine rotation flap) based on entirely different concepts. It is not clear which of these designs serves its purpose best in wound reconstruction since they have not been previously examined experimentally and directly compared. The aim of this study is to determine the optimal rotation flap design in wound reconstruction. Several modifications of the standard rotation flap are examined and the three different rotation flap designs are directly compared. METHODS: This study tests the ability of various rotation flaps to close triangulated defects on sheets of neoprene, a synthetic rubber compound. Section A examines four important features in the design of the standard rotation flap: triangulation of a lesion, rotation flap circumference, pivot point and the back cut. Section B compares the standard rotation flap, Ahuja's modified rotation flap and the divine rotation flap. Tension resulting from wound closure is measured and the length of scar calculated. RESULTS/CONCLUSION: The standard rotation flap remains superior in comparison to the modified rotation flap and the divine rotation flap. Triangulation of a lesion should be performed with care and, in particular, the apex of the triangle should coincide with the geometrical pivot point. A flap circumference more than five times the width of the defect is of minimal benefit. The back cut is an effective modification and should be used if necessary.

Refinements in the lotus petal flap repair of the vulvo-perineum.

BACKGROUND: Many reconstructive techniques have been used to repair the vulval, vaginal and perianal areas after excision. These range from grafts to various types of flap repair. The authors have modified a procedure called the lotus petal flap repair to provide a simpler, equally reliable, yet aesthetically enhanced technique for vulvo-perineal reconstruction. METHODS: Where primary closure was not possible the modified lotus petal flap was employed. The present flap design was based on the dense perforators supplying the perineum. The flap resembles the petals of a lotus flower as in the design of Yii and Niranjan. However, the present modification uses a thinned cutaneous flap without identification of the blood supply. The flap is sited over an area of dense perforators. Transposition with this thinner design allows for easy coverage of the defects. RESULTS: In the present series of eight patients and 12 flaps no cases of partial or complete flap failure were recorded. The only complications encountered in the series were one case of cellulitis after discharge from hospital, and a single case of urethral incontinence. CONCLUSIONS: The modified lotus flap repair is a reliable, simple, and aesthetically appealing alternative to those already available to the plastic surgeon for vulval repair.

Fractured zygomas.

BACKGROUND: The purpose of this paper is to provide a review, based on collected data, on the topic of "fractured zygoma". The review is presented under the headings of epidemiology, fracture patterns, treatment modalities and complications. Throughout the paper comparison is made with published data from around the world. METHODS: A 10-year retrospective audit was undertaken of all hospitalized patients, at the Royal Hobart Hospital, Tasmania, who had sustained a fractured zygoma. All Le Fort fractures involving the zygoma were excluded. RESULTS: A total of 263 fractures was sustained, largely due to assault. Alcohol was a significant contributing factor. Tetrapod fractures were the most frequent type of fractures witnessed. Plating was the most frequently employed fixation. Inferior orbital nerve dysfunction and other complications were seen in 24.6% and 20.7% of follow-up cases, respectively. Open reductions were nearly 4 times more likely to be accompanied by complications if inferior orbital nerve dysfunction was excluded. CONCLUSIONS: Both closed and open reductions are good treatment modalities and were used in near equal numbers of patients. There is a higher incidence of postoperative facial deformity in the closed reduction group, but more complications related to the incisions in the open reduction group. Open reduction and internal fixation is advocated for the unstable, markedly displaced or comminuted fractures. Silastic sheeting is a favoured graft for repair of the associated orbital floor defects and is associated with few complications.

Atypical pyoderma gangrenosum after breast reduction.

Although rare, pyoderma gangrenosum (PG) occurs as one of the worst local complications following plastic surgery to the breast. The early manifestations are similar to a necrotizing wound infection, so diagnosis and correct management are often delayed. Failure of response to the aggressive treatment strategies needed for necrotizing wound infections and the phenomenon of pathergy will often raise the clinical suspicion of PG. The main steps of therapy consist of minimal wound debridement and initiation of corticosteroids and/or immune modulation. Repair of skin defects requires care and attention. Smaller defects are best left to heal by secondary intention, as pathergy can reactivate the syndrome and cause an even larger skin wound. Larger defects are repaired with skin grafts or flaps. We report a case of atypical (bullous) PG in a healthy 57 year-old white woman following reduction mammaplasty.