Chirurgia plastica

Reconstruction of the injured/arthritic metacarpophalangeal joint remains challenging. Free vascularised joint transfer (VJT) using the second metatarsophalangeal joint (MTPJ) remains the gold standard, with an oblique osteotomy is usually performed to correct the natural hyperextended MTPJ during transfer. Surprisingly, few descriptions of the MTPJ arterial supply exist, despite reports of avascular necrosis of the MTP head following VJT. This study provides an up-to-date investigation of the second MTPJ blood supply. The anterior and posterior tibial arteries in three cadaveric feet were injected with an Indian ink-latex mass. The second toe was dissected in its entirety. A modified Spalteholz technique was then used to demonstrate the extraosseus and intraosseus blood supply of the metatarsal head. Irrespective of arterial dominance within the first web space, the MT head was observed to receive a constant branch from the first dorsal metatarsal artery (FDMA) at a mean distance of 2.1 cm from the MTPJ. Variable articular branches were also observed to branch from the first/second plantar metatarsal arteries. This is the first formal injection study to identify the presence of a constant articular branch from the FDMA. During VJT dissection, better knowledge of the blood supply allows planning of osteotomy without compromising blood supply to the MT head. Level of Evidence: Not ratable.

The pedicled anterolateral thigh flap (ALT) has gained importance in perineal reconstruction. Especially, the combination with muscle tissue, in the form of a chimeric flap, has clearly increased its versatility and range of application. Thus, both the skin paddle and the muscle seal, filling the dead space within the small pelvis, can be used to exactly reconstruct the defect. Nevertheless, the lateral circumflex femoral artery system is known for its vascular variability. We report a case, where we planned to close a perineal defect with a combination flap of vastus lateralis muscle and ALT flap. However, the ALT was found perfused by vessels perforating the rectus femoris muscle instead of the vastus lateralis, which gained its main perfusion by the transverse branch of the lateral circumflex femoral artery. Thus, the defect was successfully reconstructed with a combination flap of ALT and rectus femoris muscle tissue. The variable anatomy of the lateral circumflex femoral artery system is one of the main challenges of the ALT flap, frequently demanding creativity and the usage of freestyle flap design. Therefore, it is possible to make a virtue out of necessity. Level of Evidence: Level V, therapeutic study.

Aneurysms of the ulnar artery and its palmar arch are usually rare events, which are mostly related to repetitive trauma of the extremity. This syndrome is also known as hypothenar hammer syndrome, which presents two pathologic entities: the aneurysmal type and the thrombotic type. Whereas surgical treatment is not necessary within the thrombotic type, it is the gold standard to treat aneurysms of the palm with resection of the aneurysm and reconstruction of the vessel with either end-to-end anastomosis, venous or arterial grafts. We report a case of a young male patient with an aneurysm of the right ulnar artery at the wrist with history of repetitive trauma. Reconstruction with a venous forearm graft showed recurrence of the aneurysm after 2 years from surgery. The authors want to elaborate an algorithm for surgical treatment to make the right decision for choice of reconstruction. Level of evidence: Level IV, therapeutic study.

The dorsal surface of the rabbit's ear is an easy place in which to produce a long-lasting lymphoedema, since the draining collecting lymphatics can readily be occluded. After six weeks of experimental lymphostasis the fine structure was examined and found to be identical with that observed elsewhere: The lymph capillary junctions were open here, as in some other regions where their support is not great. The benzopyrones produced their usual considerable reduction in the amounts of excess protein and oedema in the tissues. While they also reduced the concentration of protein in the lymphatics, they could not reduce their excessive dilatation, nor the increased numbers of open junctions, because the system was still occluded. After 32 weeks of experimental lymphostasis without benzopyrone therapy, much collagen was deposited and an increased number of macrophages present while protein concentrations were slightly reduced.

Based on experiences with a modified vertical scar reduction mammaplasty technique over a 5-year-period, this article discusses the results obtained and complications encountered with this technique. From 1991 to 1995, 628 reduction procedures were performed using a single vertical scar technique in 228 patients. The percentage of procedures with the new technique increased from 17.4% in 1991 to 89% in 1995. There was an increase in the mean reduction weight from 528 to 1313 g (mean 1028 g, 260–3300 g). Sixty-eight percent of patients (n=154) underwent follow-up examinations at 3 and 12 months postoperatively. The complication rate including perioperative and post-discharge problems was 40.2%. Complications occurring as a result of the procedure included an excessively long vertical scar (13%), skin redundancy in the submammary fold (15%) and wound dehiscences (10%). Minor corrective surgery was carried out in 38 patients. The modified vertical scar reduction mammaplasty technique may be considered a safe standard procedure for almost all breast sizes.

120000 patients are seen with burns in emergency departments in the U.K. each year. Of these, 50% will be children. The average age of the children admitted to the North East Thames Regional Burns Unit (NETRBU) will be 4 years, and the size of the burn 10% body surface area. Some of the children admitted will be severely ill requiring intensive treatment. Many will be scarred, and have long-term morbidity. This paper offers a treatment protocol for burned children from first aid to management in the emergency department, and describes the regimen for treatment then followed in the NETRBU.

Two cases of chronic infection of the frontal bone and sinus are presented after resection of a tumour within the ethmoid bone and neurosurgical intervention for an aneurysm. Both were treated radically by means of a microvascular muscle transplant. Postoperative monitoring of one buried muscle transplant was done by the use of evoked muscle action potentials.

In three patients lower transverse rectus abdominis (TRAM) musculocutaneous flaps have been used to cover lesions following radiotherapy. Only one flap healed without complications. The other two developed partial fat necrosis followed by infection and the formation of either an abcess or a fistula; both complications eventually healed.

Primary tumors of the chest wall are uncommon. Cavernous hemangioma is rare. A presternal giant cavernous hemangioma is presented.