Refinement of the Superomedial Pedicle Technique: A New Approach to Breast Reshaping Following Reduction.

INTRODUCTION: We present an alteration of the superomedial pedicle technique in breast reduction to control lateral fullness and create a more natural and contoured breast during reshaping. This approach has been adopted by the senior author (NC) in 79 patients over the past 4 years. METHODS: A wise pattern skin incision is used, and the nipple-areola complex (NAC) is maintained on a de-epithelialized superomedial pedicle. Instead of fully releasing the pedicle from the lateral parenchyma for rotation and inset, a bridge of tissue between the pedicle on its most posterior aspect and the lateral pillar is maintained. Key holding sutures are subsequently placed in Scarpa's fascia for reshaping. RESULTS: We find that with this refinement, the connection with the lateral pillar pulls the lateral parenchyma medially and superiorly when the pedicle is rotated into its new position, adding a natural curve to the side. The superior medial pedicle is still attached in its postero-lateral aspect to the lateral pillar and theoretically, will provide an even more robust vascular supply to the NAC. In our series, three patients developed minor skin healing issues amenable to treatment with dressings. No one suffered from nipple loss or other serious complications, and no dog ear revisions were required. CONCLUSIONS: We present a simple alteration of the superomedial pedicle technique that we believe results in improved breast contouring. Our experience suggests that this simple adaptation is safe, effective, and reproducible. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Addressing sexual function in adult burns victims: A multidisciplinary survey of current practice in UK burn units.

BACKGROUND: Burn injury was shown to affect a patient's sexuality. Cultural and social inhibitions may mean this topic is often overlooked. AIMS: To assess current opinion and management strategies amongst UK burns care teams in relation to addressing sexual function after burn injuries. METHOD: An online questionnaire was circulated to all members of the British Burn Association. RESULTS: The majority of UK burn care professionals reported that sexual function after burn injury was an important (79% of respondents) and unaddressed problem (85% of respondents) in current clinical practice. However, over 90% of professionals reported that they 'never' or 'only occasionally' ask patients about their sexual function concerns. Multiple different management strategies are employed by UK burns centers, with a number of respondents indicating no designated individual responsible for leading care in this area. CONCLUSIONS: Currently no standardized method is in common use to address sexual function concerns of adult burns victims. The authors suggest this topic may be included in future information leaflets for patients and in burns awareness courses for medical professionals.

Body image in paediatric burns: a review.

Burn injuries in children can result in life-long disfigurement. As medical and surgical techniques of burn management improve survival prospects more than ever before, body image adjustment is increasingly a central consideration in the care of burn-injured individuals. An appreciation that both physiological and psychosocial processes underpin such injuries is key to understanding wound healing. Perceptions of idealized body images in Western society challenge children and their families as they grow up with and adapt to disfigurement from burns. Whilst many studies have examined the psychosocial recovery of adults with burn injuries, few have considered the impact on burn-injured children. This paper explores the models of body image and discusses the relevance of these to research and practice in understanding how to manage burns in children.

Multiple familial pilomatrixomas in three generations: an unusual clinical picture.

Pilomatrixomas are benign cutaneous tumors derived from hair matrix cells of unclear etiology. Pilomatrixomas commonly demonstrate somatic mutations in CTNNB1, a gene coding ß-catenin, a protein involved with hair follicle development. Multiple familial pilomatrixomas rarely occur and are most often associated with autosomal dominant conditions such as myotonic dystrophy and familial adenomatous polyposis (FAP). Nine families with multiple familial pilomatrixomas and no demonstrable underlying association have been reported in the literature. We present a tenth family in which five members spanning three generations grew multiple pilomatrixomas in the absence of any previously reported associations. No evidence of myotonic dystrophy, FAP, or other known associations was found. Extreme tiredness, behavioral problems, and sensory disturbances were common features across three generations but bore no temporal relation to the pilomatrixomas. The existence of a germline mutation in CTNNB1 to explain these symptoms has yet to be shown. Pilomatrixomas are potentially cutaneous markers of significant underlying pathologies. Patients presenting with multiple or familial pilomatrixomas should be thoroughly assessed for other pathologies and offered genetic screening to ensure that important diagnoses are not overlooked.

Nasal reconstruction in panfacial burns: useful techniques in challenging cases.

Nasal reconstruction after severe panfacial burns can be challenging to correct because of scarring, loss of suitable donor sites, and variably limited blood supply of local flaps. We describe 2 cases of subtotal nasal reconstruction in which we overcame these difficulties. Both cases had alar subunit loss, which had left significant functional and esthetic deformities. However, both cases were managed very differently because of availability of donor sites.The first patient had 70% total body surface area burns with bilateral alar subunit loss: nasal reconstruction required a meticulous multistaged forehead flap. The second patient required nasal reconstruction using a turn-down flap to maximize take of a composite graft from previously burned ear donor sites.A number of surgical techniques have been described to manage subtotal burns nasal reconstruction, foremost of which are the nasolabial and paramedian forehead flaps. Cartilage grafts from the septum and the conchal bowl can be integrated into these flaps. Composite grafts can be unpredictable and are often used with caution.Such cases demonstrate that large composite grafts can be an extremely robust method of reconstruction even in a subset of patients with extensively scarred recipient and donor sites. In our second case, composite grafting avoided multistaged procedures such as the forehead flap and can be considered as a first-line procedure in large alar subunit loss.