Wrist Ganglion Cysts in Children: An Update and Review of the Literature.

Ganglion cysts are the most common soft tissue tumor of the hand and wrist, affecting pediatric and adult populations. Despite their frequency, there is no consensus within the literature regarding the best management of pediatric wrist ganglia, and there are few recent publications examining this topic. We provide an up-to-date literature review examining the current issues and controversies in the management of pediatric wrist ganglia.

Management of a rare presentation of Kindler disease with digital constriction bands-Case report.

Kindler disease is a type of epidermolysis bullosa associated with acral blistering, diffuse cutaneous atrophy, poikiloderma, mucosal stenosis, and photosensitivity. This is the first case report in the literature to describe constriction bands associated with Kindler disease causing ischemia of the fingertips requiring urgent release and full-thickness skin grafts. Dermatologists reviewing such patients need to be aware of this condition and refer to a children's hand surgeon early to avoid leaving patients with prolonged periods of pain.

Emergency department presentations with mammalian bite injuries: risk factors for admission and surgery.

OBJECTIVES: The incidence of animal bite injuries in Australia is high. There is currently no established method for reliably predicting whether a patient with a bite injury will require admission to hospital or surgery. DESIGN: A retrospective audit of mammalian bite injuries at seven major hospitals in Melbourne, Victoria, over a 2-year period. The associations between each predictor and outcome of interest were analysed with univariate and multiple regression analyses. SETTING: Seven major hospitals in Melbourne, Victoria: the Alfred Hospital, Austin Hospital, Frankston Hospital, Monash Medical Centre, Royal Melbourne Hospital, St Vincent's Hospital and Western Hospital. PARTICIPANTS: Patients presenting to emergency departments with mammalian bite injuries. MAIN OUTCOME MEASURES: Hospital admission, intravenous antibiotic therapy, surgery, reoperation, readmission. RESULTS: We identified 717 mammalian bite injuries. The mean age of the patients was 36.5 years (median, 34 years; range, 0-88 years), with an equal number of males and females. The overall rate of hospital admission was 50.8%, and the mean length of stay was 2.7 days. Intravenous antibiotics were administered in 46% of cases; surgery was undertaken in 43.1% of cases. The re-operation rate was 4.5%, the re-admission rate was 3%. CONCLUSIONS: Our study provides a detailed epidemiological analysis of animal bite injuries at seven major hospitals in Victoria. Risk factors for hospitalisation and surgery may assist in identifying patients who require admission and surgical intervention.

Developments in image-guided deep circumflex iliac artery flap harvest: a step-by-step guide and literature review.

PURPOSE: The deep circumflex iliac artery (DCIA) flap has evolved significantly over time in the intricacies of flap design and breadth of surgical application. This has been facilitated by advances in preoperative imaging and planning, in particular, computed tomographic angiography. Studies have highlighted that advanced imaging modalities and other technologies such as image-guided stereolithographic biomodeling can substantially improve flap planning, flap harvest, and operative outcomes. PATIENTS AND METHODS: The present report comprises a combined literature review and clinical cohort study of 20 consecutive patients to assess the modern technologies applied to DCIA flap planning and harvest. We have also described a step-by-step guide for the implementation of these techniques into clinical practice. RESULTS: The protocol for a single, standardized technique of computed tomographic angiography scanning is presented and was applied to a range of techniques in the preoperative planning of DCIA flaps. These include 1) bony and vascular imaging analysis of both donor and recipient sites, 2) stereolithographic "biomodeling" of both donor and recipient bony and vascular anatomy, and 3) the use of preoperative "virtual surgery" with image-guided stereotactic navigation. The application and role of each technique was explored. CONCLUSIONS: Modern imaging and stereolithographic techniques are innovations that can substantially improve surgical outcomes in DCIA flap surgery, such as has been highlighted in our clinical experience and in published studies. Notably, few outcome studies have been reported, and the need for larger case series and comparative studies is apparent.

Rhabdomyoblastic differentiation in metastatic melanoma: making sense of a rare but complex form of mimicry.

A case of melanoma with rhabdomyoblastic differentiation is presented in the context of the previously reported cases. The emerging literature seeking to identify the molecular basis of rhabdoid and rhabdomyoblastic differentiation, as well as their poor prognosis, is reviewed. The combination of a diverse range of morphology and the potential for spontaneous primary tumor regression, despite metastasis, makes the accurate diagnosis of melanoma challenging. Histopathology review is often recommended in these cases, as is referral to a specialized cancer center for discussion in a multidisciplinary meeting. Improved recognition of this rare pattern of melanoma morphology may provide the means for omics-based techniques to identify novel therapeutic targets to improve the prognostic outlook for these patients.

Total scalp reconstruction with bilateral anterolateral thigh flaps.

Large scalp defects can require complicated options for reconstruction, often only achieved with free flaps. In some cases, even a single free flap may not suffice. We review the literature for options in the coverage of all reported large scalp defects, and report a unique case in which total scalp reconstruction was required. In this case, two anterolateral thigh (ALT) flaps were used to resurface a large scalp and defect, covering a total of 743 cm(2). The defect occurred after resection and radiotherapy for desmoplastic melanoma, with several failed skin grafts and local flaps and osteoradionecrosis involving both inner and outer tables of the skull. The reconstruction was achieved as a single-stage reconstruction and involved wide resection of cranium and overlying soft-tissues and reconstruction with calcium phosphate bone graft substitute, titanium mesh, and two large ALT flaps. The reconstruction was successfully achieved, with minor postoperative complications including tip necrosis of one of the flaps and wound breakdown at one of the donor sites. This is the first reported case of two large ALT flaps for scalp resurfacing and may be the largest reported scalp defect to be completely resurfaced by free flaps. The use of bilateral ALT flaps can be a viable option for the reconstruction of large and/or complicated scalp defects.

The nomenclature of venous flow-through flaps: updated classification and review of the literature.

Venous flow-through flaps (venous flaps) are useful reconstructive options, particularly in the repair of defects with segmental vessel loss. They are relatively easy to harvest and confer several benefits at the donor site. However, given that they are based on a single central vein, their survival is notoriously unreliable and they are susceptible to ischemia and venous congestion. Various designs have been suggested to improve the circulatory physiology, and hence survival, of venous flap. More recent designs involve adaptations to the arrangement and number of efferent veins draining arterialized venous flaps. The most commonly used classification system for venous flaps, proposed by Chen, Tang, and Noordhoff, does not afford adequate description of these alternate designs. This article offers a classification system that can incorporate all reported modifications to venous flaps. This simple adaptation to the classification system proposed by Chen et al. restores its usefulness in describing modern variations to venous flap design.

The arterialized saphenous venous flow-through flap with dual venous drainage.

BACKGROUND: Venous flow-through flaps are well-described options for small defects where donor site morbidity is undesirable or in areas where useful local veins are in close proximity to the defect, particularly in the extremities. However, higher rates of flap loss have limited their utility. The saphenous venous flap in particular has been widely sought as a useful flap, and while arterialization of this flap improved survival rates, congestion has remained a limiting feature. We describe report a modification in the design of saphenous venous flaps, whereby an arterialized flap is provided with a separate source of venous drainage, and demonstrate survival of substantially larger venous flaps than previously reported. METHODS: In five consecutive patients, we describe three main modifications to the saphenous venous flap as previously described: (a) Using arterialized flaps only; (b) Reversing the flap to allow unimpeded flow during arterialization; and (c) Anastomosing additional vein(s) that are not connected to the central vein-especially at the periphery of the flap for true venous drainage. RESULTS: There was a 0% complete flap loss rate (with only one case of superficial partial loss), and ultimately better survival than previous series of saphenous venous flaps described to date. CONCLUSION: The success of these techniques offers the potential to re-establish flow to large segmental losses to axial arteries, offer safe and definitive flap coverage to traumatic wounds, improve the array of flap options in this setting, and minimize donor site morbidity.

The effect of radiotherapy on implant-based breast reconstruction in the setting of skin-sparing mastectomy: clinical series and review of complications.

BACKGROUND: With the increasing popularity of skin-sparing mastectomy techniques, implant-based breast reconstruction and use of perioperative radiation therapy, there is a growing need to scrutinize the effects they have on breast reconstruction. This study examined the effect of radiation on implant-based breast reconstruction in patients who had skin-sparing or conventional mastectomies in terms of complication, reoperation, and capsular contracture rates. PATIENTS AND METHODS: A retrospective review of 227 implant-based breast reconstructions in 132 mastectomy patients by a single surgeon was undertaken. All cases occurred over a four-year period (2006-2009) at a single institution. Complication, re-operation, and capsular contracture rates were tabulated against immediate and delayed reconstruction, skin-sparing and conventional mastectomy implant-based reconstruction, and irradiated and non-irradiated groups. Chi-square test was performed for statistical analysis. RESULTS: The overall complication and reoperation rates of 15% and 10% in these 227 reconstructions compare favorably to reviewed series. Delayed reconstruction, skin-sparing mastectomy and irradiation were all associated with a significantly increased rate of re-operation, but not to an increase in complication or capsular contracture rates. CONCLUSION: The results of this study were more favourable than those of similar studies reported in the current literature, suggesting an increased role for implant-based reconstruction in the setting of adjuvant radiotherapy for patients that undergo skin-sparing mastectomy.

Improving the utility and reliability of the deep circumflex iliac artery perforator flap: the use of preoperative planning with CT angiography.

BACKGROUND: The deep circumflex iliac artery (DCIA) is rarely used as a perforator flap, despite a clear clinical need for thin osteocutaneous flaps, particularly in head and neck reconstruction. The poor adoption of such a flap is largely due to a poor understanding of the perforators of the DCIA, despite recent publications demonstrating suitable vascular anatomy of the DCIA perforators, particularly evident with the use of preoperative computed tomographic angiography (CTA). We have applied this method of peroperative imaging to successfully select those patients suitable for the DCIA perforator flap and use it clinically. METHODS: We present a case series of patients who underwent DCIA perforator flap reconstruction following preoperative planning with CTA. Imaging findings, clinical course, and outcomes are presented. RESULTS: Six out of seven patients planned for DCIA perforator flap reconstruction underwent a successful DCIA perforator flap, with imaging findings confirmed at operation, and without any flap loss, hernia, or other significant flap-related morbidities. Because of abberent anatomy and change in defect following excision of pathology, one patient was converted to a free fibular flap. CONCLUSION: With preoperative CTA planning, the DCIA perforator flap is a versatile and feasible flap for reconstruction of the mandible and extremities.

Superior and inferior gluteal artery perforators: In-vivo anatomical study and planning for breast reconstruction.

BACKGROUND: Gluteal artery perforator (GAP) flaps have gained popularity in autologous breast reconstruction, however substantial variability in vascular anatomy has limited their more widespread utilisation. While previous anatomical studies have been limited by specimen numbers and study design, computed tomographic angiography (CTA) can demonstrate in-vivo vascular anatomy in large numbers. We thus undertook an anatomical study with the use of CTA, the largest such study in the literature, and present a clinical series utilising CTA to plan GAP flaps. METHODS: Eighty consecutive patients (160 gluteal regions) underwent pre-operative CTA, with superior and inferior gluteal artery perforators (SGAPs and IGAPs) assessed for location, size and course. The utility of pre-operative CTA is explored in a series of seven consecutive patients undergoing autologous breast reconstruction. RESULTS: There were an average of 11 SGAPs per region (range 6-17), with mean diameter 0.6mm (range 0.3-2.4) and SGAPs >0.8mm diameter identified in every region. In contrast, there were nine IGAPs per region (range 5-14), with mean diameter 0.4mm (range 0.3-1.6) and IGAPs >0.8mm diameter identified in 95% of regions. Individual SGAP and IGAP territories were different between sides and between individuals, with the central tissue variably supplied by either system. In a clinical series, CTA was found to aid operative planning and correlate with operative findings. CONCLUSION: There are regularly abundant SGAPs and IGAPs identifiable per gluteal region, and while many are diminutive in size, the identification of suitable perforators with CTA may aid operative planning for gluteal flap harvest.

Free deep circumflex iliac artery vascularised bone flap for reconstruction of the distal radius: planning with CT angiography.

Distal radius fractures in the younger population are often comminuted and intra-articular, which can increase the complexity of their management. In addition, these patients tend to place high demands on their wrists, and the prevention of functional arthritis necessitates excellent anatomical reduction. Complicated cases such as these are often limited in their management options. We present a complex case of distal radius fracture and bone loss in which initial therapy with nonvascularized bone graft failed, and osteomyelitis was a further complicating factor. With the aid of preoperative planning with computed tomographic angiography (CTA), a deep circumflex iliac artery (DCIA) bone flap was able to be assessed as a reconstructive option. The use of preoperative CTA, the first description of such imaging in this role, was able to delineate the bone to be harvested, confirm its vascular supply, and plan flap harvest. The use of a vascularized bone flap in this setting was thus undertaken and was able to provide an autologous anatomical support for the wrist while reducing the risk of recurrent infection and still preserving internal fixation. This unique application of the free DCIA bone flap was potentiated by CTA, achieving complete healing and good functional outcomes.

The in vivo anatomy of the deep circumflex iliac artery perforators: defining the role for the DCIA perforator flap.

The deep circumflex iliac artery (DCIA) provides a dependable option for use as an osteo-musculo-cutaneous flap, particularly in mandibular reconstruction. Modifications to flaps based on DCIA perforators have been sought to prevent donor site morbidity as a consequence of muscle cuff harvest. Previous studies have been inconsistent in their descriptions of perforator anatomy, and means of assessing these preoperatively have not been widely described. A clinical anatomical study was undertaken, with a cohort of 44 hemiabdominal walls in 22 consecutive patients undergoing preoperative computed tomographic angiography (CTA) before free flap surgery. The feasibility of CTA and the regional vascular anatomy were both assessed. The use of CTA was shown to demonstrate DCIA perforators with high resolution and to be able to assess vessel size and location. In 44 hemiabdominal walls, there were 44 perforators of >0.8 mm diameter. There were no suitable perforators in 40% of sides, with 32% of sides having one perforator >0.8 mm diameter, 16% having two perforators, <10% had three perforators, and only one side had over four perforators. Perforators emerged from the deep fascia on an average of 5.1 cm cranial and 3.9 cm posterior to the anterior superior iliac spine (ASIS). Of the 44 perforators identified, 82% of perforators were located within a 4 cm by 4 cm area, 3 cm superior, and 2 cm posterior to the ASIS. The current study has demonstrated the utility of preoperative CTA for identifying DCIA perforators, and for selecting patients who may be suitable for a DCIA perforator flap given the variable perforator anatomy.