Transplantation of a latissimus dorsi flap between identical twins.

We present a case of composite tissue transplantation of a latissimus dorsi flap between monozygotic twins. The recipient twin, a 19 year old male, suffered from a complex spinal kyphoscoliosis for which he had undergone multiple previous operations over many years. Soft tissue breakdown on his back causing metalwork exposure had necessitated the removal of his most recent spinal rod. This in turn led to rapid severe deterioration of his spinal deformity and consequent critical impairment of lung function. Robust soft tissue cover was required urgently in order to allow the insertion of a new spinal rod. His previous surgeries and body habitus precluded an adequate autologous reconstruction. Instead, reconstruction using composite tissue transplantation from his identical twin brother was successfully undertaken. We discuss the ethical, psychological and surgical issues involved in this case.

A comparison of the cosmetic and psychological outcome of breast reconstruction, breast conserving surgery and mastectomy without reconstruction.

METHOD: The cosmetic and psychological outcomes of patients who underwent reconstructive surgery, conservative surgery or simple mastectomy for breast cancer between 1995 and 2002 were compared. RESULTS: There was a significant correlation between good psychological adjustment and good cosmetic outcome scores (p=0.01-0.05). There was no difference in cosmetic outcome between different reconstruction methods. Reconstruction patients rated their cosmetic outcome better than conservative surgery patients, and conservative surgery patients better than mastectomy patients. There were no differences in psychological outcome between patient groups. CONCLUSION: Good perception of cosmetic outcome is associated with good psychological adjustment. There is no cosmetic advantage of one type of reconstruction over another. Reconstruction patients have a better body image compared with other treatment groups but there are no other psychological advantages of one type of treatment over another.

Ocular contamination during lesional surgery-a hazard for the plastic surgeon.

UNLABELLED: Protective glasses reduce the risk of transconjunctival virus transmission although this has never been characterised for local anaesthetic skin lesion surgery. This study investigated the use of, and need for, protective eyewear during Plastic Surgery and the surgeons' attitude to risk. MATERIALS AND METHODS: Study 1. A multi-center questionnaire recorded the attitudes of Plastic Surgeons' regarding google use and ocular viral transmission. Study 2. A single surgeon performed local anaesthetic skin lesion surgery over 8 months whilst wearing clean goggles. After each procedure the goggles were inspected for macroscopic splashes ans a record made of whether the operator had been aware of the splash occurrence. RESULTS: Study 1. There were 36 respondents to the questionnaire (response rate of 84%). All grades recognised the risk of conjunctival contamination but most respondents did not wear goggles. Respondents changed their behavior, however, in 'high risk' cases. Study 2. 143 procedures resulted in 42 splashes. The surgeon was only aware of the splash in 6 cases. CONCLUSION: Despite widespread recognition of the importance of eye protection, goggle use is still infrequent. Our study stresses the frequency of potential splashes to the eye and need for routine use of goggles to prevent viral transmission.

Home oxygen therapy and cigarette smoking: a dangerous practice.

Oxygen as a therapeutic agent is an important form of home therapy for hypoxic chronic obstructive pulmonary disease (COPD) and improved survival has been demonstrated in hypoxic COPD patients receiving continuous oxygen. However, some patients, despite dissuasion, continue to smoke and we describe the case of a patient on home oxygen who sustained a partial-thickness facial flash burn whilst engaged in this habit. A review is made of the literature, as also a comparison of all discovered cases of burns in home oxygen users, followed by a discussion of the implications of this potentially hazardous form of therapy.

Effective treatment of chondrodermatitis nodularis chronica helicis using a conservative approach.

BACKGROUND: Chondrodermatitis nodularis chronica helicis (CNCH) is usually treated by surgical excision, but is prone to recurrence. OBJECTIVES: To examine whether CNCH could be treated nonsurgically using a home-made, pressure-relieving prosthesis. METHODS: A retrospective comparison was made of the outcome in 41 subjects treated surgically and 15 treated nonsurgically between 1999 and 2001. RESULTS: Thirteen of the 15 patients (87%) treated nonsurgically were healed at follow-up after 1 month of conservative treatment and so have avoided surgery to date. In contrast, the recurrence rate of the surgically treated group was 14 of 41 (34%) patients. CONCLUSIONS: As a result of this study, we recommend that patients presenting with CNCH be managed conservatively in the first instance.

Autologous free tissue breast reconstruction using the internal mammary perforators as recipient vessels.

Perforator flaps have become popular for autologous free tissue breast reconstruction because they reduce the donor site morbidity. It is possible to apply the this principle to the recipient site. We present our experience of using the perforating vessels from the internal mammary artery and vein as recipient vessels for autologous free tissue breast reconstruction flaps in 21 out of 54 consecutive cases (39%). We discuss the technique and its advantages.

A case report of cutis laxa in one of identical twins.

A 29-year-old man with cutis laxa presented requesting surgery to improve his appearance. The patient had an unaffected identical twin brother which allowed us to compare how he had changed over the years in relation to his sibling and this also provided us with a gold standard for any surgery performed. The patient underwent staged surgery including upper lid blepharoplasties and two facelifts.

Reanimation for facial palsy using gracilis muscle grafts.

Twelve patients have been reviewed at least 2 years after gracilis muscle transfer, preceded by crossface nerve grafting, for complete unilateral facial palsy. Levels of satisfaction among the patients were good. Examination showed all had voluntary movement of the graft which could produce reasonable mouth symmetry in most patients. However, the involuntary spontaneity and expressive movements were not so satisfactory, though still worthwhile. The technique and some lessons learned from this experience are discussed. It appears from electromyographic studies that continuing innervation and activity can occur in these grafts for many years postoperatively.

Properties of synaptic linkage from long ranging afferents onto dorsal horn neurones in normal and deafferented cats.

1. In intact cats, dorsal horn cells sometimes respond to afferents entering the cord three or four segments more rostral. If dorsal roots near a segment have been cut for at least 4 weeks, many more cells respond to these long ranging afferents. Using extra- and intracellular recording, we examined the change in the nature of the connectivity of the long ranging afferents from dorsal roots L3 and L4 onto cells in L7. 2. In intact animals 33% of all cells in L7 recorded extracellularly and 48% of those recorded intracellularly exhibited responses to electrical stimulation of skin whose afferents entered the spinal cord over dorsal roots L3 and L4. Most of these responses had a long latency and followed high frequency stimulation poorly. 3. Thirty-eight to fifty-one days after cutting dorsal roots L5-S2, 76% of cells recorded intracellularly in L7 responded to long ranging afferents, in contrast to 48% in the intact cord. In these preparations 48% of all cells responded in less than 5 msec versus 12% in intact cats. Furthermore, 21% of the cells had natural receptive fields in the distant dermatome versus 1% in intact animals. 4. Chronic deafferentation of a segment increased the number of cells responding to afferents arriving over distal dorsal roots and increased the speed and power of the responses.