Dr Patricia Clugston-A Spirit of Determination.

Dr Patricia Clugston was a British Columbia native who completed her plastic surgery residency training in Vancouver in 1993 before pursuing a fellowship in Nashville with Dr Patrick Maxwell in 1994. When Dr Clugston returned to Vancouver, she helped to establish a comprehensive and renowned breast reconstruction program. She spent her career advocating for and working towards better treatment options for women seeking breast reconstruction. As a determined surgeon and accomplished athlete, Dr Clugston was truly a tour de force in all aspects of her life. Patty, as she was affectionately known by her colleagues, loved her job. Dr Clugston was an avid advocate for medical education and an outstanding clinical researcher and speaker that established her as a shining star in Canadian plastic surgery. Patty had always lived life to the fullest and was determined that scleroderma would not change this. Her sharp wit, intellectual curiosity, and pragmatism masked an incredible courage as she fought bravely against a cruel disease. Dr Clugston died on March 1, 2005, at the age of 46 surrounded by the loving company of her husband, friends, and family at the Vancouver General Hospital. The Dr Patricia Clugston Chair in Breast Reconstruction was established in her name to honour her legacy and continue to improve the care of patients with breast cancer.

Originaire de la Colombie-Britannique, la docteure Patricia Clugston a terminé sa résidence en plasturgie à Vancouver en 1993 avant d'effectuer des études postdoctorales à Nashville avec le docteur Patrick Maxwell en 1994. À son retour à Vancouver, elle a contribué à mettre sur pied un programme de reconstruction mammaire complet et réputé. Elle a consacré sa carrière à préconiser et à rechercher de meilleures possibilités thérapeutiques pour les femmes qui veulent une reconstruction mammaire. Chirurgienne déterminée et athlète accomplie, elle dominait dans tous les aspects de sa vie. Patty, comme l'appelaient affectueusement ses collègues, adorait son travail. Cette défenseure passionnée de l'enseignement de la médecine était une chercheuse clinicienne et une conférencière remarquable, ce qui l'a établie comme une tête d'affiche de la plasturgie au Canada. Elle a toujours vécu sa vie au maximum et était déterminée à ne pas laisser la sclérodermie y changer quelque chose. Sa vivacité d'esprit, sa curiosité intellectuelle et son pragmatisme cachaient un courage incroyable, car elle luttait contre une maladie cruelle. Elle est décédée le 1er mars 2005 au Vancouver General Hospital à l'âge de 46 ans, entourée de l'amour de son mari, de ses amis et de sa famille. La chaire Dre Patricia Clugston en reconstruction mammaire a été créée en son nom pour commémorer sa mémoire et continuer d'améliorer les soins aux patientes atteintes du cancer du sein.

The Vascular Basis of the Pronator Quadratus Muscle Flap and Its Use in Clinical Cases.

Background Pronator quadratus (PQ) is a deeply situated muscle in the forearm which may occasionally be utilized for soft-tissue reconstruction. The purpose of this anatomical and clinical study was to confirm vascular supply of PQ muscle (PQM) in order to optimize its transfer and confirm its utility in clinical situations. Methods In Part A of the anatomical study, fresh human cadavers ( n = 7) were prepared with an intra-arterial injection of lead oxide and gelatin solution, and PQM and neurovascular pedicle were dissected ( n = 14). In the anatomical study Part B, isolated limbs of embalmed human cadavers ( n = 12) were injected with India ink-gelatin mixture and PQ were dissected. Results PQ is a type II muscle flap, with one major pedicle, the anterior interosseous (AI) vessels and two minor pedicles from the radial and ulnar vessels. The mean dimensions of the muscle were 5.5 × 5.0 × 1.0 cm 3 , mean pedicle length was 9.6 cm, and the mean diameter of the artery and the vein was 2.3 mm and 2.8 mm, respectively. The dorsal cutaneous perforating branch (DPB) of the artery supplied the skin over the dorsal forearm and wrist. This branch also anastomosed with the 1, 2 intercompartmental supraretinacular artery (ICSRA). Conclusion This study confirms the potential utility and vascular basis of the PQM flap and its associated cutaneous paddle. In the clinical part, two patients with nonhealing wounds exposing the median nerve and flexor tendons in the distal forearm were treated using the PQM flap with good results.

Shaping Plastic Surgery in British Columbia-The Courtemanche Legacy.

Dr Albert Douglas Courtemanche was born in Gravenhurst, Ontario on November 16, 1929. In 1949, he was accepted to the University of Toronto Medical School, graduating in 1955. After completing his internship at the Toronto General Hospital and at the Hospital for Sick Children, he completed his surgical training in Vancouver and in the United Kingdom. When Dr Courtemanche returned from his training in 1962, he joined Dr Cowan on the surgical staff at the Vancouver General Hospital. He was responsible for establishing a new plastic surgery ward, a dedicated operating room (OR), an integrated burn unit and also starting the UBC plastic surgery training program. Dr Courtemanche became involved in working with the Royal College, first as an examiner and then as the Chairman of the Plastic Surgery Exam Board in 1981. He eventually became the first and only plastic surgeon to ever hold the position as President of the Royal College. Dr Courtemanche emphasized throughout his career the importance of teaching and role modeling. A very proud moment in Dr Courtemanche's career was when his son Douglas became a pediatric plastic surgeon. After retiring Dr Courtemanche became a volunteer at the VanDusen Botanical Garden and completed their Master Gardeners Program.

Le docteur Albert Douglas Courtemanche est né à Gravenhurst, en Ontario, le 16 novembre 1929. En 1949, il est accepté à l'école de médecine de l'Université de Toronto, où il est promu en 1955. Après avoir terminé son internat au Toronto General Hospital et au Hospital for Sick Children, il se spécialise en chirurgie à Vancouver et au Royaume-Uni. À son retour en 1962, il complète l'unité de chirurgie du Vancouver General Hospital avec le docteur Cowan. Il met sur pied un nouveau service de chirurgie plastique, une salle d'opération réservée, une unité intégrée des grands brûlés et le programme de formation en chirurgie plastique de l'université de la Colombie-Britannique. Le docteur Courtemanche s'investit au sein du Collège royal, d'abord comme examinateur, puis comme président du comité d'examen en chirurgie plastique en 1981. Il devient enfin le premier et le seul chirurgien plasticien à occuper la présidence du Collège royal. Tout au long de sa carrière, le docteur Courtemanche a souligné l'importance de l'enseignement et de la formation par l'exemple. Il a d'ailleurs ressenti une grande fierté lorsque son fils Douglas est devenu chirurgien plasticien en pédiatrie. Après avoir pris sa retraite, le docteur Courtemanche est devenu bénévole au jardin botanique VanDusen, où il a suivi le programme de maître jardinier.

Dr Henry Shimizu: The Journey of a Canadian Plastic Surgeon, Advocate, and Artist.

Dr Henry Shimizu was a dedicated Canadian plastic surgeon with Japanese roots who spent his career practicing in Edmonton at the University of Alberta Hospital. He relished the opportunity to share his expertise by training residents and medical students. Dr Shimizu completed his plastic surgery training in the United States and was central to establishing the plastic surgery training program in Edmonton. Beyond clinical practice, Dr Shimizu was a prominent advocate in his community, serving as the Chairman of the Redress committee for Japanese internment. As a talented painter, he had produced magnificent oil paintings based on childhood recollections as an internee in the Slocan Valley. Dr Shimizu has made significant contributions to Canadian plastic surgery serving as president of the Canadian Society of Plastic Surgeons in 1978. His clinic work and dedication to the community at large were recognized with the Order of Canada in 2004 and more recently an honorary degree from the University of Victoria. Dr Shimizu continues to golf, paint, and travel in his retirement. He is happily married to his wife Joan and is the proud father of 4 children and 6 grandchildren.

Le docteur Henry Shimizu, un plasticien canadien dévoué d'origine japonaise, a exercé pendant toute sa carrière à l'University of Alberta Hospital d'Edmonton. Il adorait partager ses compétences par l'enseignement aux résidents et aux étudiants en médecine. Il a terminé sa formation en chirurgie plastique aux États-Unis et a joué un rôle essentiel dans la création du programme de chirurgie plastique à Edmonton. Au-delà de la pratique clinique, le docteur Shimizu était un militant réputé dans sa communauté : il a présidé le comité de redressement pour l'internement des Japonais. Peintre talentueux, il a produit de magnifiques peintures à l'huile sur ses souvenirs d'enfance alors qu'il était interné dans la vallée de Slocan. Le docteur Shimizu a contribué largement à la chirurgie plastique au Canada et a présidé la Société canadienne des chirurgiens plasticiens en 1978. Il a été nommé membre de l'Ordre du Canada en 2004 pour son travail clinique et son dévouement envers l'ensemble de la communauté, et plus récemment, a reçu un doctorat honorifique de l'université de Victoria. Maintenant à la retraite, le docteur Shimizu continue de jouer au golf, de peindre et de voyager. Il vit un mariage heureux avec sa femme, Joan, et est le fier père de quatre enfants et de six petits-enfants.

Dr Michael Bell: A Surgeon With Boundless Ingenuity.

Dr Michael Bell was born in Kingston, Ontario, on October 14, 1944. He was always a curious child who exhibited a tendency toward innovation and experimentation. Dr Bell was accepted into the MD program at the University of Toronto graduating in 1969 before completing his plastic surgery residency there. Dr Bell accepted a position bringing hand and microsurgery expertise to the University of Ottawa in 1976. He pioneered the widespread use of local anesthetic for surgery and developed an innovative relationship with Leonard Lee of Lee Valley tools. Canica Design created several surgical products, including an enhanced design on the traditional scalpel handle and wound closure devices. Dr Bell had a passion for making improvements to enable surgeons to advance patient care. He encourages a philosophy of critical thinking that contributes to continued design in plastic surgery. Dr Bell continues to design and craft new devices with alumni of the Lee Valley Tools team.

Le docteur Michael Bell est né le 14 octobre 1944 à Kingston, en Ontario. Il a toujours été un enfant curieux, qui affichait une tendance vers l'innovation et l'expérimentation. Accepté au programme de médecine à l'université de Toronto, il a obtenu son diplôme en 1969 avant d'y effectuer sa résidence en chirurgie plastique. Il a accepté un poste à l'Université d'Ottawa en 1976, où il a mis en valeur ses compétences en chirurgie de la main et en microchirurgie. Ce pionnier de l'utilisation généralisée des anesthésiques locaux pour la chirurgie, a noué une relation novatrice avec Leonard Lee de Lee Valley Tools. Canica Design® a créé plusieurs produits chirurgicaux, y compris la conception améliorée du manche habituel de scalpel et des dispositifs de fermeture des plaies. Le docteur Bell se passionnait pour les améliorations afin que les chirurgiens puissent faire progresser les soins aux patients. Il favorise une philosophie de pensée critique qui contribue à poursuivre les concepts en chirurgie plastique et continue de concevoir et d'inventer de nouveaux dispositifs avec les anciens de l'équipe de Lee Valley Tools.

Three-Dimensional Vascular Anatomical Study of the Tensor Fasciae Latae Muscle and Perforators.

BACKGROUND: To harvest any flap on the lateral circumflex femoral artery (LCFA) including tensor fasciae latae (TFL) muscle, a precise description of the vascular anatomy is required. There have been conflicting reports of the vascular supply of TFL and its overlying skin. The objective of this study was to evaluate the anatomy of the TFL muscle according to the location, origin, type, caliber, and length of vessels that supply the muscle. METHODS: This study was performed on human cadavers (n = 16 thighs) that were injected with a mixture of lead oxide and gelatin through the femoral artery. Whole body computed tomography scans were performed. Three-dimensional images of the arterial anatomy were created using Materialise Interactive Medical Image Control Software (MIMICS). Anatomical dissection of all cadaver thighs was performed to visualize the arterial blood supply of the muscle and its regional perforators. RESULTS: Sixteen thighs were included in the study. The main arterial supply of the TFL muscle was in all cases, the ascending branch of the LCFA (LCFA-asc) artery. The mean external diameter of the LCFA-asc artery was 2.7 mm ± 0.4 and the mean length was 3.6 cm ± 0.6. The distance from the anterior superior iliac spine to point where the vascular pedicle reaches the muscle ranged from 6.7 to 10.2 cm. The average number of cutaneous perforators was 10.9 ± 4. There were musculocutaneous perforators in all of our dissections (n = 16) and 14 of our specimens had septocutaneous perforators. CONCLUSION: The main vascular supply to the TFL muscle is the ascending branch of the LCFA, which also gives rise to septocutaneous and musculocutaneous perforators. MIMICS provides excellent three-dimensional anatomical information about the vascular supply of the TFL.

Computed Tomographic Angiography Used for Localization of the Cutaneous Perforators and Selection of Anterolateral Thigh Flap "Bail-Out" Branches.

BACKGROUND: The purpose of this study was to evaluate the territory supplied by the lateral circumflex femoral artery for the consistency of a proximal perforator that could be used as an alternative pedicle for the anterolateral thigh flap if a tedious intramuscular course is encountered during elevation of the perforator used to develop the initial surgical plan. It is hypothesized that a consistent "bail-out" perforator supplying the proximal thigh would facilitate a simpler anterolateral thigh flap harvest, with minimal modification to flap design. METHODS: Computed tomographic images of 9 fresh cadavers were imported using Materialize's Interactive Medical Imaging Control System software to create surface-rendered 3-dimensional reconstructions of 15 lower limbs. Perforators emerging proximally and laterally to a 3-cm radius circle drawn at the midpoint of the anterior superior iliac spine and superolateral patella were considered potential bail-out perforators and evaluated for their number emerging diameter, length, course, and location relative to the anterior superior iliac spine. RESULTS: An average of 2.9 ± 1.8 perforators per limb were identified. Mean pedicle length was 111 ± 20 mm, measured from the origin in the lateral circumflex femoral artery to where the perforators emerged through the deep fascia directly overlying the thigh muscles. Average diameter at origin in the lateral circumflex femoral artery was 2.8 ± 0.8 mm, and that at emergence through the deep fascia was 1.1 ± 0.3 mm. Vessel course was predominantly musculocutaneous (90%). CONCLUSIONS: A significant bail-out perforator routinely supplies the proximal anterolateral thigh and may be used as an alternative vascular pedicle for an anterolateral thigh flap if a tedious intramuscular course is encountered during elevation of a perforator identified within the conventional landmarks (3-cm radius circle at the midpoint of the anterior superior iliac spine and superolateral patella).

The Effect of Written Information on Recall of Surgical Risks of Carpal Tunnel Release Surgery: A Randomized Controlled Study.

BACKGROUND: Written information has been thought to help patients recall surgical risks discussed during the informed consent process, but has not been assessed for carpal tunnel release, a procedure with the rare but serious risk of complex regional pain syndrome. The authors' objective was to determine whether providing a pamphlet would improve patients' ability to remember the risks of surgery. METHODS: Sixty patients seen for carpal tunnel release were included in this prospective, single-blind, randomized study. Patients received either a written pamphlet of the risks of surgery or no additional information following a standardized consultation. Two weeks after the initial consultation, patients were contacted to assess their risk recall and whether they had read about the operation from any source. RESULTS: There was no difference in terms of the number of risks recalled between pamphlet (1.33 ± 1.21) or control groups (1.45 ± 1.22; p = 0.73). Recall of infection was better in the pamphlet group (p < 0.05). No patients remembered complex regional pain syndrome. There was no difference in the proportion of people who read additional information about carpal tunnel release surgery between the pamphlet (34.8 percent) and control groups (21.4 percent; p = 0.39), but reading about carpal tunnel release surgery was associated with improved recall (2.45 ± 1.13 versus 0.77 ± 0.91; p < 0.01). CONCLUSIONS: Reading about surgery improved risk recall, but providing this information in the form of a pamphlet did not, nor did it affect patients' ability to recall the risk of complex regional pain syndrome. These results demonstrate that surgeons should implement additional measures to improve comprehension of surgical risks. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, I.

The Lumbar Artery Perforator Flap: 3-Dimensional Anatomical Study and Clinical Applications.

BACKGROUND: The lumbar region is a potential donor site for perforator-based rotational or free flaps or as a recipient site for free flaps to obtain coverage for deficits in the sacral region. Because of the lack of consensus regarding the microvascular anatomy of this potential flap site, a robust investigation of the anatomy of this region is required. METHODS: Three-dimensional reconstructions (n = 6) of the microvasculature of the lumbar region were generated using MIMICS software (Materialise, Belgium) for each of the four paired lumbar vessels. Diameter, course, and pedicle length were recorded for all lumbar artery (LA) perforators. Statistical analysis was performed using SigmaStat 4.0 and graphs were generated using GraphPad Prism 6 Software. RESULTS: Perforators arising from the first pair of LAs are reliably detected along the inferior margin of the 12th rib, extending inferiorly and laterally from the midline while perforators arising from the fourth pair of LA perforate the fascia along a horizontal plane connecting the posterior iliac crests. There are significantly more cutaneous perforators arising from the first (L1) and fourth (L4) pairs of LA than from the second (L2) and third (L3) (mean ± SD: L1, 5.5 ± 1.2; L2, 1.4 ± 0.7; L3, 1.3 ± 0.7; L4, 4.8 ± 1.0; P < 0.05). The average perforator diameter arising from L1 is greater than those arising from L4 (diameter ± SD: L1, 1.2 mm ± 0.2 >L4, 0.8 mm ± 0.2; P < 0.0001). L1 and L4 perforators have longer pedicle lengths than those arising from L2 and L3 (length ± SD: L1, 98.2 mm ± 57.8; L4, 106.1 mm ± 23.3 >L2, 67.5 mm ± 27.4; L3, 78.5 mm ± 30.3; P < 0.05). CONCLUSIONS: Perforators arising from the first and fourth LAs arise in a predictable fashion, have adequate pedicle lengths, and are of suitable diameter to support a perforator flap. We present a case to support the potential use of this flap for microvascular breast reconstruction.

Anatomical Study of the Princeps Pollicis Artery Perforator Flap.

BACKGROUND: The volar aspect of the thumb often requires local flaps for reconstruction. This study characterizes perforators of the princeps pollicis artery (PPA) and evaluates the potential of a local propeller-type flap raised using these perforators for reconstruction of these defects. METHODS: Cadavers underwent whole-body lead-oxide injection and were then imaged using a 64-slice spiral computed tomographic scanner. The DICOM images were imported into Materialise's Interactive Medical Imaging Control System (Materialise, Belgium) for 3-dimensional reconstruction of the microvasculature. The number, length, caliber, and location of perforators arising from the PPA were determined and a plot was generated illustrating the relative distribution of perforators. RESULTS: A total of 16 PPA perforators were identified in the 8 specimen hands. Perforators had a mean (SD) diameter of 1.2 (0.4) mm and mean (SD) length of 8.9 (4.8) mm. The PPA perforators were consistently identified along the radial aspect of the thenar region. Seventy percent of all PPA perforators can be found over the distal 50% of the MC [20%-54%; mean (1SD)]. CONCLUSIONS: Perforators of the PPA were found in all hands and the average caliber and length of the perforators identified is sufficient for the creation of a local perforator flap. This, coupled with the mean location of these perforators, arising near the base of the thumb, confirms that a cutaneous flap from the thenar region can be raised based on this perforator as a propeller flap to obtain coverage of distal cutaneous defects of the thumb.

Reverse Radial Artery Flap Perforator Anatomy and Clinical Applications.

The pedicled reverse radial forearm flap is a well-known option for the treatment of a variety of soft tissue wounds including dorsal hand wounds. We document the number, emerging diameter, length from origin, course, and location of all perforators of the radial artery in a series of 6 fresh human cadavers after whole body lead oxide and gelatin injection to confirm and comprehensively document the anatomy of the radial artery perforators. This data provide an anatomic basis for a modification to the reversed radial forearm flap used to decrease venous congestion in the postoperative period. Two case reports are presented to provide clinical demonstration of the importance of this modification.

Confirmatory factor analysis of the Michigan Hand Questionnaire.

BACKGROUND: When the Michigan Hand Questionnaire (MHQ) was originally developed, an exploratory factor analysis (EFA) was used to reduce the originally large number of generated items to the 63 items currently present on the questionnaire. Confirmation of the implied factor model of the existing MHQ has never been performed. The objective of this study was to confirm the factor model used to create the existing MHQ, and to possibly shorten the existing MHQ using factor analysis. METHODS: Patients attending the Plastic Surgery Clinic at the QEII Health Sciences Centre with a hand complaint were asked to complete the MHQ. Confirmatory factor analysis was performed to explore the implied factor structure of the original EFA and to examine the interplay between the MHQ subscales. Further item-reduction was performed using clinically guided decisions as well as factor analysis-guided statistics. RESULTS: Initial confirmatory factor analysis showed that original EFA model does not optimally explain the relationships between items in the existing MHQ and their corresponding factors. Our abbreviated model of the MHQ consists of 23 items, and performed more favorably in all goodness-of-fit parameters than the original 63-item questionnaire. CONCLUSIONS: The factor model of the existing MHQ does not fully take advantage of the relationship between items in the MHQ and the proposed factors. This study proposes a shortened version of the MHQ that more accurately reflects hand health as well as a factor-based interpretation of the subscales that takes interdependent relationships into account.

Anatomy and physiology of perforator flaps of the upper limb.

Perforator flaps are an excellent reconstructive option for a functional upper limb reconstruction. This article explores the physiology and general principles of perforator flaps and their indications for use in reconstruction of the upper extremity. Workhorse perforator flaps of the upper extremity, such as the radial artery perforator, ulnar artery perforator, lateral arm perforator, posterior interosseous artery, first dorsal metacarpal artery perforator and perforator-based propeller flaps, are discussed in greater detail.

The use of retrograde limb of internal mammary vein in autologous breast reconstruction with DIEAP flap: anatomical and clinical study.

BACKGROUND: It has been postulated that the abdominal skin may have either predominantly deep or superficial venous drainage. This may account for complications arising from autologous breast reconstruction using the deep inferior epigastric artery perforator (DIEAP) flap. In this study, we evaluate the use of the retrograde limb of the internal mammary vein (IMV) as a second recipient vein in reconstructions with the DIEAP flap. METHODS: In Part A, 10 IMVs were harvested from 5 fresh cadavers and the flow of methylene blue through the retrograde limb and the presence of valves were evaluated under a stereoscopic microscope.In Part B, the clinical outcomes of 38 patients who underwent single or bilateral autologous breast reconstruction using the DIEAP flap technique between January 2007 and March 2011 were reviewed. A total of 48 flaps were evaluated: 31 with single vein anastomosis and 17 with 2-vein anastomosis. RESULTS: In Part A, no valves were identified in the IMVs. In all 10 cadaver IMVs, there was free flow of methylene blue in both antegrade (superior) and retrograde (inferior) directions.In Part B, a retrospective analysis of the 2 patient outcomes was performed. Outcomes assessed included total flap loss, partial flap necrosis, fat necrosis, wound infection, wound dehiscence, and hematoma. Results were compared using a 2-tailed Fisher exact test with a critical P value of 0.05. No statistically significant differences between groups were identified. CONCLUSIONS: The retrograde limb of the IMV seems to be a safe alternate recipient vein in DIEAP and muscle sparing free TRAM autologous breast reconstruction. This study does not identify a significant reduction in overall fat necrosis or overall complications when using the 2 venous repair techniques versus the simple venous repair technique.

Reliability and internal validity of the michigan hand questionnaire.

BACKGROUND: The Michigan Hand Outcomes Questionnaire (MHQ) remains one of very few to be based on validated and systematic methods in its creation. However, test-retest reliability and internal validity have not been appropriately investigated in any other English-speaking population outside the original development sample. The objective of this study is to examine the reliability and internal validity of the MHQ in a Canadian population. METHODS: All patients with a clinical hand problem but no hand immobilization who attended our Plastic Surgery Clinic were invited to participate in this study. Patients were asked to complete the MHQ, and then contacted to arrange for completion of the MHQ a second time. Internal validity was estimated using Cronbach alpha. Reliability was estimated using the method of Bland and Altman, and intraclass correlation coefficients. Correlation analysis between score differences and time between tests was performed. RESULTS: Full versions of the MHQ were completed by 116 participants on their initial visit, while only 77 participants completed a second MHQ. Cronbach alpha ranged from 0.84 to 0.95 for the MHQ subscales. Intraclass-correlation coefficients ranged from 0.71 to 0.84 for the subscales. The magnitude of the limits of agreement for the subscales ranged from 13.8 to 26.2. The difference in scores between the first and second tests was not related to the time between tests. CONCLUSION: The high values of Cronbach alpha indicate high internal validity, but that there may be redundancy between items in the MHQ, which could be eliminated without losing information. Reliability of the MHQ is considered moderate. The limits of agreement are considered wide, indicating potential issues with respect to interpretation of a change in score between 2 administrations of the MHQ.

Local flaps, including pedicled perforator flaps: anatomy, technique, and applications.

LEARNING OBJECTIVES: After reading this article, the participant should be able to: 1. Discuss the types of local flaps. 2. Analyze the advantages, disadvantages, and applications for each kind of flap. 3. Perform appropriate design and dissection techniques of local flaps. 4. Describe appropriate design and dissection techniques of local perforator and propeller flaps. SUMMARY: The purpose of this article is to comprehensively review the topic of local flaps. Local flaps are those that are elevated nearby and then transferred to an adjacent wound. Options include geometric local flaps, axial pattern local flaps and a new exciting group of flaps, local perforator flaps. The principles, advantages, disadvantages, and applications for each are carefully analyzed. Local perforator flaps can be harvested virtually anywhere in the body and represent a significant clinical advance, as these can solve a wide variety of clinical challenges. These flaps do require gentle microsurgical dissection technique with careful handling for inset of the flap and simultaneously provide the same advantages of other types of local flaps because they also use nearby tissues with a similar color match, thickness, and texture, with primary donor-site closure possible. Local perforator flaps are another very useful option that undoubtedly will become more popular as more surgeons become more familiar with their use and advantages.

Computed tomographic angiography for localization of the cutaneous perforators of the leg.

BACKGROUND: Results of vascular anatomical studies of the lower limb in the past have been primarily descriptive in nature and are therefore less useful in directing the design of local perforator-based flaps. The purpose of this study was to document the three-dimensional anatomy of the cutaneous perforators arising from the anterior tibial, posterior tibial, and peroneal arteries and provide a statistically verified method for predicting perforator location for use in the clinical setting. METHODS: Computed tomographic angiography and three-dimensional reconstructions of the lower limb using Mimics software were completed for five lead oxide-injected cadavers. The cutaneous perforators of the vessels of the tibial trunk were identified, and perforator diameter, course, and location relative to leg length were determined. Cluster analysis was performed to evaluate the consistency of perforator locations across individuals. RESULTS: The anterior tibial artery had the greatest number of perforator vessels, which clustered into three groups centered at 83 ± 6 percent (percent of tibial height ± SD), 59 ± 7 percent, and 28 ± 9 percent. Peroneal artery perforators were clustered in two groups centered at 61 ± 9 percent and 27 ± 11 percent. The posterior tibial artery perforators could also be divided into two groups; however, a larger SD in the two groups suggests that perforators arising from this vessel are more evenly spaced. CONCLUSIONS: Statistical analysis demonstrated that the major perforator vessels of the tibial trunk are conserved across individuals and can be reliably dissected using the cluster's statistical distribution. Results of this study will allow for better preoperative planning of local flaps.

Factors influencing prioritization for carpal tunnel syndrome consultation.

BACKGROUND: In a socialized medicine model, prioritization of referrals for specialist consultation is highly important in the distribution of heath care. For high-burden diseases, such as carpal tunnel syndrome (CTS), the factors that influence prioritization are not well understood. OBJECTIVE: To determine the factors that influence the prioritization of referrals for CTS consultation by plastic surgeons in Canada. METHODS: All members of the Canadian Society of Plastic Surgery with e-mail addresses were invited to participate in an online survey regarding the method by which they prioritize referrals for CTS. RESULTS: Forty per cent of invited members completed the survey (150 surgeons). Of these, 118 (79%) stated that they performed CTS surgery. The majority of respondents who performed CTS surgery prioritized their consultation list chronologically (77%). Factors that would alter the chronological order or prioritization included subsequent contact by the referring physician (24%); personal relationship with the patient (16%); and specific information in the referral letter (15%), which usually involved symptom severity or electromyography findings. Sixty-six per cent of plastic surgeons stated that there was no conscious decision on how they came to choose the method of prioritization they used for referrals regarding CTS. DISCUSSION: The majority of plastic surgeons in Canada prioritize referrals for consultation on CTS chronologically. A minority of respondents reported reassigning priority based on clinical severity. The rationale for the methods by which Canadian Society of Plastic Surgery members prioritize these referrals is poorly understood. Further study on developing evidence-based prioritization methods may be useful in assisting surgeons and their patients in outcome-based decisions.

HISTORIQUE: Dans un modèle de médecine sociale, la priorisation des aiguillages vers une consultation en spécialité revêt une grande importance dans la distribution des soins. Dans le cas des maladies au taux de morbidité élevé, telles que le syndrome du canal carpien (SCC), les facteurs qui influent sur la priorisation sont mal compris. OBJECTIF: Déterminer les facteurs qui influent sur la priorisation des aiguillages en vue d'une consultation relative à un SCC auprès des chirurgiens plasticiens du Canada. MÉTHODOLOGIE: Tous les membres de la Société canadienne des chirurgiens plasticiens qui ont fourni une adresse de courriel ont été invités à participer à un sondage virtuel sur la méthode qu'ils utilisent pour prioriser les aiguillages en vue d'un SCC. RÉSULTATS: Quarante pour cent des membres invités ont rempli le sondage (150 chirurgiens). De ce nombre, 118 (79 %) ont déclaré avoir exécuté des chirurgies du SCC. La majorité des répondants qui avaient exécuté de telles chirurgies priorisaient leur liste de consultation de manière chronologique (77 %). Les facteurs qui pouvaient modifier l'ordre chronologique ou la priorisation incluaient un contact subséquent par le médecin traitant (24 %), une relation personnelle avec le patient (16 %) et de l'information précise dans la lettre d'aiguillage (15 %), laquelle précisait généralement la gravité des symptômes ou les résultats de l'électromyographie. Quarante-deux pour cent des chirurgiens plasticiens ont déclaré qu'il n'y avait aucun processus de décision conscient dans le choix de leur méthode de priorisation. EXPOSÉ: La majorité des chirurgiens plasticiens du Canada priorise de manière chronologique les aiguillages en consultation à cause d'un SCC. Une minorité de répondants déclare réévaluer les priorités compte tenu de la gravité clinique. On comprend mal le motif de la méthode par laquelle les membres de la Société canadienne des chirurgiens plasticiens priorisent ces aiguillages. D'autres études sur l'élaboration de méthodes de priorisation fondées sur des données probantes pourraient être utiles pour aider les chirurgiens et leurs patients à prendre des décisions fondées sur les issues.

Propeller DICAP flap for a large defect on the back-case report and review of the literature.

Reconstruction of large soft tissue defects of the back is a challenging problem. Large defects of the back were reconstructed with multiple random pattern or local pedicled muscle (and skin graft) or musculocutaneous flaps. The clinical use of perforator flaps has demonstrated that harvesting of flaps on a single perforator is possible for reconstruction of large defects. We present a 71-year-old male with a lesion on his left mid back that measured 10 × 10 × 4 cm(3) . Biopsy of the lesion was consistent with dermatofibrosarcoma protruberans. Wide local excision of the lesion with 4 cm margin was performed. The soft tissue defect, ~20 cm in diameter, was reconstructed with a large propeller dorsal intercostal artery perforator (DICAP) flap. The DICAP flap measured 40 × 15 cm(2) based on a single perforator-lateral branch of dorsal rami of the seventh posterior intercostal artery on the right side. The perforator flap was elevated at the subfascial level and transposed 180° into the defect. The donor site on the right side of the back was closed directly. This case illustrates the size of the propeller DICAP flap that could be safely harvested on a single perforator from the dorsal rami of the posterior intercostal artery. To our knowledge this is the largest reported pedicled perforator flap harvested on a single perforator on the posterior trunk.