Presentation and multidisciplinary management of a unique case of lower limb dysmelia resulting from amniotic band syndrome

A neonate was born with a unique congenital lower limb dysmelia due to an abnormal presentation of amniotic band syndrome. An anomalous soft tissue tether from the plantar surface of the right foot to the right buttock caused extreme knee flexion, tibial rotation and malformation of the developing foot. This complex malformation required a multidisciplinary team (MDT) approach to decide between reconstruction and amputation. The band of tissue was released operatively at 73 days postdelivery, improving knee extension, and the tissue was banked on the thigh as a tube pedicle for future reconstruction. The patient underwent rehabilitation, which has been shown to be vital for synovial joint formation. At 18 months old, the decision was made to proceed with through-knee amputation and a prosthesis. The literature discussed shows the importance of an MDT approach in complex lower limb cases to give the best functional outcome for the patient.

Is tropical pus in the hand special? A retrospective study comparing hand infection cases in Darwin and Adelaide

BACKGROUND

Hand infections are a common reason for presenting to hospital and can be associated with significant morbidity and prolonged antibiotic use. Factors recognized to influence patient outcomes include resistant organisms and delayed presentation. Surgeons working around Australia may assume that hand infections and appropriate treatment algorithms will be similar between sites. This is the first study to examine differences between hand infections presenting in Darwin (with its tropical climate) vs. those in a more temperate city (Adelaide).

METHODS

This is a two-site retrospective study, where diagnostic discharge codes were used to identify cases for a 12-month period and patient age, sex and rurality, duration of hospital stay, microbiology results and subsequent trips to theatre were reviewed.

RESULTS

Despite significant differences in rurality between FMC and RDH patients, there was no significant difference in length of hospital stay, duration of intravenous antibiotics or return trips to theatre across the two sites. RDH reported a 25% rate of MRSA, compared to 18% at FMC, as well as a statistically significant increase in uncommon microbes, with 30% compared to 12% of patients growing microbes that may not be covered by antibiotics routinely administered in metropolitan areas. A limitation of this study was that compliance with antibiotics and hospital stay were not accounted for.

CONCLUSION

It is often our training years that determine our norms of everyday practice, but fewer Australian surgical training posts are located in tropical centres. The results of this study highlight the importance of not assuming that the spectrum of organisms causing hand infections are the same as that in the surgeons' state of origin.

Restorative Strategies for Bilateral Mutilated Hands in a Secondary Care Level: A Report of a Case in Mexico

This case report aims to delineate the challenges and management strategies for a patient with bilateral mutilated hands within a secondary care level in Mexico, contributing to medical literature and potentially guiding future patient care. Mutilated hands represent a significant surgical and rehabilitative challenge due to the profound structural damage they cause, leading to considerable functional impairment and psychological distress. The complexity of these injuries necessitates a multidisciplinary approach, particularly in resource-constrained settings. We present a case of a 45-year-old male with no prior significant medical history who sustained bilateral mutilated hands from an industrial accident involving hot rollers. The patient underwent extensive surgical reconstruction and postoperative care, facing complications such as skin graft integration issues and infections, which required a multidisciplinary treatment approach.

Plastic Surgery Teaching to United Kingdom Undergraduate Medical Students: A Systematic Review

Background  There are varying reports about United Kingdom medical students' exposure and teaching methods regarding plastic and reconstructive surgery. To date, no systematic review has been done looking at this topic. Methods  Three databases (PubMed, Embase, and Medline) were searched from January 1, 2011 to July 20, 2023 for studies that assessed United Kingdom medical students' exposure to plastic surgery and suggested recommendations to improve teaching. Three authors performed data extraction and screening, as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Results  Fifteen studies were included. Medical students' average current exposure to plastic surgery was 29.44%, but this was highly variable across the studies. The most common method of currently teaching plastic surgery was through lectures (34% of studies), and the most common suggested method of teaching was through courses (40% of studies). Many of the studies (12/15) were deemed as being at high risk of bias. Conclusion  More recent studies need to be performed to assess current levels of teaching of plastic surgery in the United Kingdom medical school curriculum. Greater exposure to plastic surgery through lectures and integrated clinical placements is needed to ensure equitable access for all medical students to plastic surgery as a profession.

A Comparative Analysis of the Outcomes of Various Graft Types in Burn Reconstruction Over the Past 24 Years: A Systematic Review

Burn injuries, a major global health concern, result in an estimated 180,000 fatalities annually. Despite tremendous progress in treatment methods over the years, the morbidity and mortality associated with burns remain significant. Autologous skin grafting, particularly split-thickness skin grafting (STSG), has been a cornerstone in burn reconstruction, and it has facilitated survival and functional recovery for total body surface area (TBSA) significantly. However, the requirement for primary closure at the donor site due to the constraints of full-thickness donor harvesting continues to pose challenges. The introduction of dermal regenerative templates (DRT) in the late 1970s marked a substantial step forward in tissue engineering, addressing the inadequacy of dermal replacement with STSGs. This systematic review aimed to compare the outcomes of different graft types - bioengineered, autografts, allografts, and xenografts - in burn reconstruction over the last 24 years. The review focused on the pros and cons of each graft type, offering clinical insights grounded in experience and evidence. The approach involved a systematic review of studies published in English from January 2000 to January 2024, covering randomized controlled trials (RCTs), cohort studies, case-control studies, and case series. The participants comprised individuals of all ages who underwent burn reconstruction with skin grafts, specifically split-thickness grafts, full-thickness grafts, composite grafts, and epidermal grafts (autografts, allografts, and xenografts) and bioengineered grafts. The primary outcomes were functional and cosmetic results, patient satisfaction, graft survival, and complications. The risk of bias was evaluated using the Cochrane risk-of-bias tool for randomized trials version 2 (RoB 2), the Newcastle-Ottawa Scale (NOS) for non-randomized studies, and the Canada Institute for Health Economics (IHE) quality appraisal tool for case series. Our initial search yielded a total of 1,995 articles, out of which 10 studies were selected for final analysis. Among the four clinical trials assessed, 75% showed a high risk of bias. The studies reviewed involved various graft types, with six studies (60%) concentrating on allografts, three (30%) on autografts, and one (10%) on bioengineered skin grafts. The outcomes were varied, underlining the intricate nature of burn wound management. Our evaluation revealed promising results for autologous-engineered skin substitutes and allografts but also highlighted methodological disparities among the studies included. The dominance of observational studies and the diversity of outcome measures present obstacles to direct comparisons. Future research should address these limitations, employing well-structured RCTs, standardized outcome measures, and exploring long-term outcomes and patient-specific factors. The rapidly evolving field of regenerative medicine offers great potential for novel grafting methods. This systematic review provides valuable insights into the diverse outcomes of burn reconstruction using different graft types. Autologous-engineered skin substitutes and allografts seem to hold significant promise, suggesting a possible shift in grafting techniques. However, methodological inconsistencies and the lack of high-quality evidence underscore the necessity for further research to fine-tune burn care approaches.

Prevalence and Determinants of Plastic Surgery Among Adults in Saudi Arabia

BACKGROUND

Social and cultural factors have a significant impact on body image standards, and the media's messages play a crucial role in shaping beauty ideals. People's perceptions of beauty can be negatively affected by social media, which promotes unrealistic beauty standards and can lead to a desire for plastic surgery. Plastic surgery includes both reconstructive and aesthetic procedures and has become increasingly popular worldwide. In Saudi Arabia, there has been a significant increase in the number of women seeking cosmetic surgery, particularly breast augmentation, rhinoplasty, and liposuction, indicating that cosmetic surgery is becoming more accepted as a way to enhance beauty.

AIMS

To investigate the frequency of performance of plastic and aesthetic surgical procedures among adults aged 18 to 60 years old in Saudi Arabia, as well as the determinants that may contribute to it.

METHODOLOGY

A cross-sectional web survey with a representative sample (n = 3238) of individuals in Saudi Arabia was carried out from 10 April 2023 to 28 October 2023.

RESULTS

The study included a cohort of 3238 participants, with 1328 individuals choosing to undergo plastic surgery. Among the surgical subgroups, the predominant procedure of choice was breast augmentation, representing 1009 cases (31.2%), while a minority opted for alternative plastic surgical interventions. Notably, the primary impetus behind plastic surgery, as indicated by the majority of participants (38.4% of the overall 41% who underwent the procedure), was appearance enhancement. Examination of the participants' demographic profile revealed a predominance of women between the ages of 18 and 30, married individuals, predominantly having a primary level of education, with a subset working in the public sector. Furthermore, a considerable segment of participants (32.6%) indicated low income, while 31.8% fell into the category of obesity.

CONCLUSION

To address the multifaceted nature of plastic surgery decisions in Saudi Arabia, the key focus should be on promoting cultural acceptance, creating a supportive environment, and establishing ethical guidelines. This entails conducting awareness campaigns, promoting inclusive beauty standards, facilitating community discussions, fostering collaboration with support organizations, integrating mental health services, and ensuring rigorous monitoring of safety and professionalism in plastic surgery practices. By implementing these recommendations, individuals seeking plastic surgery can enhance their overall well-being and satisfaction.

Early Discharge and Patient-Initiated Follow-Up in Hand Surgery: A New Norm Following Simple Hand Surgery?

AIMS

The demand for elective hand surgery has increased substantially over the last 10 years. With COVID-19 providing an added challenge of restrictions on face-to-face consultations, already overflowing follow-up clinics will be stressed further. Our aim is to assess the viability, effectiveness, and safety of an early discharge directly from the operating theatre following common hand surgery procedures with the safety net of open-access follow-up.

METHODS

All eligible patients undergoing open-hand surgery under local anaesthesia between February 2019 and December 2020 were offered early discharge. Informed consent was obtained in the clinic, and they were counselled on rehabilitation immediately prior to surgery. Patients were given a custom-made "open-access business card" with clear post-operative instructions and hand exercises, along with information on how to get in touch to request clinic follow-up. A review was completed at a minimum of two months following surgery. Administrative support staff were briefed beforehand to minimise any delays in follow-up requests and either book patients who requested follow-up into a routine elective clinic or utilise ring-fenced emergency elective clinic slots depending on the patient's individual requirements.

RESULTS

A total of 105 patients were included in this study, with an average age of 60 years. The average interval between surgery and review was 20 weeks. Eighty-nine patients had a successful early discharge, with 16 patients requesting clinic follow-up. The average time to follow up in the clinic was 35 weeks (range: four to 84 weeks). There were no complications that we were made aware of, and the most common reason for returning to the clinic was a new complaint, unrelated to the surgery.

CONCLUSIONS

Although virtual follow-up is now well established in both the fracture and elective clinic settings, early discharge is largely uncharted water. Our pilot demonstrates that early discharge and patient-initiated follow-up for common elective hand surgical procedures under local anaesthesia are efficient, safe, and viable.

Innovative Reconstructive Management of Foot Macrodactyly in a Pediatric Patient: A Case Report

Macrodactyly is a rare congenital anomaly characterized by disproportionate hypertrophy of one or more digits or the forefoot, involving some or all tissue types. It is nonhereditary and can present alone or alongside other deformities. Usually, macrodactyly is treated with amputation of the affected toe or finger to reduce the chance of recurrence. In this paper, we present the case of a child with macrodactyly who was treated successfully without amputation and instead with a reconstruction of the toe shape to resemble a near-natural-looking toe with intact functions. The patient was a one-year-old female who presented with macrodactyly of her right great toe, right second toe, and forefoot. She had no history of other congenital deformities or systemic diseases. A reconstruction surgery was performed, which involved debulking the right great toe, right second toe, and forefoot. Also, it included the creation of the first web space and the restoration of the nailbed of the second toe. Postoperative follow-up revealed minimal complications. Thus, a second reconstructive surgery was performed, which included debulking and further reconstruction of the foot to improve the result. Several techniques exist for the reduction of macrodactyly that can achieve optimal results. The choice of technique depends on the specifics of the case and the experience of the surgeon. We therefore hope our technique will be beneficial for the management of future cases of macrodactyly. One year of follow-up after the second operation revealed maintained function and no regrowth recurrence.

Tendon Transfer to Treat Radial Nerve Palsy Following COVID-19 Infection

Multiple manifestations have been associated with the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus. Among them are mononeuritis multiplex (MNM) and other neurological complications, whose connection to coronavirus disease 2019 (COVID-19) is still unclear. One of the most common sites of nerve injury is the radial nerve, which can be treated with both nerve or tendon transfer. In this case report, a patient who was afflicted with severe COVID-19 infection and developed mono neuritis multiplex after prolonged mechanical ventilation with radial nerve palsy was treated with multiple tendon transfers. This is a way to use an established mechanism of resolving the manifestations of radial nerve palsy to aid in the recovery of COVID-19-related mononeuritis multiplex.

The Impact of COVID-19 on the Surgical Wait Times for Plastic and Reconstructive Surgery in Ontario

Purpose: The aim of this study was to assess the impact of COVID-19 on surgical wait times for Plastic and Reconstructive Surgery (PRS) in Ontario, Canada. Methods: Ontario's wait time data has fourteen reporting categories for PRS. For each category, the mean wait time for consultation and for surgery were reported. Each category was given a priority ranging from 1 to 4. Two periods, three-month and six-month, were selected and compared to the same calendar months of the previous year. Wait times, surgical volume and percent change to the provincial wait time target were reported and compared to the baseline data. Results: This study reviewed 9563 consults and 15,000 operative cases. There was a 50% reduction in the volume of surgical consults during the study period compared to the baseline period (P = 0.004). The reduction ranged from 46% to 75% based on the reporting category. The volume of surgical cases decreased by 43% during the study period compared to the baseline period (P = 0.005). A statistically significant increase in the mean wait times for surgery was observed, involving priorities 2 to 4 (overall mean = 32 days, P ≤ 0.01). There was a 15% decrease in the percentage of surgeries meeting the provincial target times (P < 0.0001). Conclusion: COVID-19 has caused a significant reduction in the volume of cases performed in the majority of PRS categories with an overall increase in the wait times for consultation and for surgery. Recovery following COVID-19 will require strategies to address the growing volume of cases and wait times for surgery across all PRS categories.

Unusual Presentation of Familial Unilateral Postaxial Polydactyly With Metacarpal Delta Phalanx: A Report of a Rare Case

The term "delta phalanx" is proposed to characterize an uncommon deformity that typically affects the middle phalanx of a finger. It has the appearance of the Greek capital letter delta, meaning it is shaped like a triangle. Because the faulty epiphysis occurs proximally to distally instead of along its usual horizontal course, the bone has a semilunar shape. Functional impairment or significant finger shortening are indications for surgery. A variety of congenital hand anomalies are linked to the delta phalanx. Few cases of middle delta phalanx in the ulnar polydactyly finger have been documented. This case study investigates an extremely uncommon occurrence of metacarpal delta phalanx in an ulnar polydactyly finger.

Pediatric Burns: A Systematic Review and Meta-Analysis on Epidemiology, Gender Distribution, Risk Factors, Management, and Outcomes in Emergency Departments

Pediatric burns pose a significant public health concern, ranking as the fifth most common nonfatal injury globally. This review consolidates data on the epidemiology, outcomes, and management of pediatric burns presenting to emergency departments. A systematic review was conducted across multiple databases, yielding 22 articles from 1992 to 2020. Utilizing the methodological index for non-randomized studies (MINORS) instrument, non-comparative studies scored from 2 to 11 with an average of 6.87, while comparative studies ranged from 12 to 16, averaging 13.67. The review included a total of 828,538 pediatric patients who were evaluated in the systematic review. Predominantly male victims ranged from 53% to 83%. The youngest victims were aged between 0 to 4 years. Burn etiology was largely attributed to scalds. A majority suffered from second-degree burns, with some studies reporting up to 89%. Limited data on total body surface area (TBSA) were documented, with only 2.5% requiring hospitalization. Common interventions included immediate resuscitation and skin grafting. Essential areas for future research are identified, including household risks, pre-treatment decisions, and the significant role of family dynamics in burn injury recovery. Pediatric burns remain a considerable concern, particularly among males and in household environments. The data underline the imperative for prevention strategies and optimized emergency care to positively influence outcomes for burn victims. Future research areas range from evaluating pre-treatment decisions to assessing community awareness regarding burn first aid.

Surgeons' perspectives on operation report documentation

BACKGROUND

Operation report documentation is essential for safe patient care and team communication, yet it is often imperfect. This qualitative study aims to understand surgeons' perspectives on operation report documentation, with surgeons reviewing cleft palate repair operation reports. It aims to determine how surgeons write an operation report (in narrative and synoptic report formats) and explore the consequences of incomplete documentation on patient care.

METHODS

A qualitative semi-structured interview was conducted with cleft surgeons who were asked to consider operation reports and hypothetical clinical cases. Eight operation reports performed at one centre for cleft palate repair were randomly selected for review.

RESULTS

An operation report's purpose-patient care, complication documentation, future surgery, and research-will influence the detail documented. All cleft palate repair operation reports had important information missing. Synoptic report writing provides clearer documentation; however, narrative report writing may be a more robust communication and education tool. Surgeons described a bell-curve response in the level of training required to document an operation report-residents knew too little, fellows documented clearly, and Consultants documented briefer reports to highlight salient points.

CONCLUSIONS

An understanding of surgeons' perspectives on operation report documentation is richer after this study. Surgeons know that clear documentation is essential for patient care and a skill that must be taught to trainees; barriers may be the documentation method. The flexibility of a hybrid operation report format is necessary for surgical care.

Patient Experiences With Hand Surgery in the Office Versus Ambulatory Surgery Center

Background In hand surgery, physicians are working to improve patient satisfaction by offering several minor procedures in the physician's office via the Wide-Awake Local Anesthesia No Tourniquet (WALANT) method. This study investigates the degree of patient satisfaction, out-of-pocket costs, peri- and postoperative pain, convenience, and comfort experienced with in-office hand procedures compared to ambulatory surgery center (ASC) procedures. Methods A 10-question survey consisting of a 10-point Likert scale of agreement and numerical questions was administered to patients treated with minor hand operations in the office and ASC settings in Florida, USA. The surgical procedures included are bony reconstruction, percutaneous pinning, open reduction internal fixation, closed fracture reduction, mass removal, endoscopic carpal tunnel release, Dupuytren's release/tendon repair, and trigger finger release. Procedures and patient demographics were assessed via chart review. Independent samples t-test was used to determine statistical associations with significance defined as p < 0.05. Results Patients reported a strong level of agreement in response to questions 1-3 and 6-8, indicating a high degree of convenience, comfort, and overall satisfaction with both in-office and ASC procedures. Positive metrics gauged in questions 1-3 and 6-8 averaged 9.64 ± 0.14 in the office setting and 9.62 ± 0.16 in the ASC setting. Questions 4 and 5 averaged 2.74 ± 0.29 in the office setting and 2.84 ± 4.12 in the ASC setting, indicating mild disagreement that the surgery or recovery period was painful. In-office patients reported taking 0.91 ± 2.80 days off work and ASC patients reported taking 12.43 ± 22.51 days off work following surgery (p = 0.0039). Respondents reported an out-of-pocket cost averaging $348 ± $943 in the office setting and $574 ± $1262 in the ASC setting, depending on insurance coverage (p = 0.3019). Conclusions Though costs and time off of work differed between the two groups due to the different procedures in either setting, patient satisfaction metrics were comparable. While patient satisfaction depends on the operating physician, these results demonstrate that patients treated in-office and in an ASC have similar levels of approval with their hand surgery care.

Limberg flap in mastectomy T-junction necrosis: an underutilised technique

The Wise-pattern skin-sparing mastectomy (SSM) is well known for its efficacy in large ptotic breasts, and its safety in facilitating immediate breast reconstruction. An unfortunate sequalae for all SSM techniques is mastectomy skin flap necrosis (MSFN) with a reported range of occurrence of 5%-30%. For the Wise pattern, the common area of wound dehiscence or necrosis is the T-junction. Different techniques have been described in the management of MSFN-ranging from primary closure to local and distant flaps. Full thickness MSFN results in wound breakdown and can expose a prosthesis, subsequently closure must be obtained with potential for the prosthesis to be explanted. To date, there has been no reports in the literature of the usage of a rhomboid flap in an SSM with immediate prepectoral implant. We discuss our experience in the usage of this local cosmetic flap to avoid prosthesis loss and have reviewed the literature regarding MSFN, the application of the rhomboid (Limberg) flap in breast surgery and its applicability in MSFN to preserve underlying prosthesis.

Aesthetic Surgery Gone Wrong: A Case Report and Literature Review of Acute Kidney Injury Secondary to Hematoma After Liposuction

Liposuction is a widely used cosmetic surgery that involves the removal of excess fatty tissue. Although it is generally considered a safe and effective procedure, complications can arise. Acute kidney injury (AKI) is a serious complication, which can be caused by various factors. Extravasation of blood from vessels damaged by the cosmetic liposuction procedure cause hypovolemia and intravascular depletion, significant factors leading to pre-renal acute kidney injury. In this case report, we present the case of a 29-year-old female patient who developed AKI after undergoing a liposuction and "Brazilian Butt Lift (BBL)" procedure. The patient experienced persistent nausea, vomiting, and abdominal pain postoperatively and was admitted to the ICU. The patient's condition gradually worsened over the next few days, and imaging of the abdomen revealed a complex, clotted hematoma in abdominal and pelvic cavities that required surgical intervention. Her care involved a collaborative effort from critical care, plastic surgery, and nephrology specialists. This case highlights the potential complications of cosmetic surgery and the need for comprehensive postoperative care to manage these complications effectively. It also emphasizes the importance of identifying and managing risk factors for AKI during liposuction to minimize the risk of this serious complication.

Augmentation-Mastopexy: Analysis of 95 Consecutive Patients and Critical Appraisal of the Procedure

Single-stage mastopexy-augmentation has been demonstrated to be a safe procedure. However, revisions may still be necessary. We evaluate 95 consecutive patients undergoing mastopexy-augmentation and introduce a new surgical technique for the procedure: the modified dual plane technique. In this retrospective study, 95 patients (mean age 34 ± 11 years) underwent mastopexy-augmentation between 2009 and 2019. The procedures were classified as subglandular, dual plane, or modified dual plane technique. The outcome measures included major and minor complications. A total of 19 patients underwent a subglandular procedure, 32 patients a dual plane procedure, and 44 patients a modified dual plane procedure. We observed a high overall complication rate in the subglandular group (n = 12, 63%), dual plane group (n = 15, 47%), and modified dual plane group (n = 10, 23%). Complications leading to implant loss/change occurred in seven patients in the subglandular group (37%), six patients in the dual plane group (19%), and no patient in the modified dual plane group. While we observed a high complication rate in patients undergoing mastopexy-augmentations, the modified dual plane technique was associated with a lower complication rate.

Management of a fusiform brachial artery aneurysm associated with birth trauma

Brachial artery aneurysms in children are rare. Surgical treatment is generally recommended.We present the case of a female toddler with a pulsatile swelling on the medial aspect of the right upper arm without history of recent trauma. Medical history revealed a traumatic birth with labour arrest. Postnatally diffuse trunk and arm haematomas as well as a temporary right arm discolouration were detected. Preoperative ultrasound revealed a true brachial artery aneurysm. A full-body MRI ruled out any accompanying lesions. Primary resection and end-to-end anastomosis were performed. Recovery was uneventful. 6-month and 12-month follow-up showed normal motor function and arterial patency; ultrasound also demonstrated harmonious growth of the anastomosed vessel segments.No other publication has associated birth trauma with brachial artery aneurysm yet. Correct diagnosis and prompt curative surgery are key to prevent severe complications. Further reports and data on long-term outcome are needed to optimise clinical management.

Alveolar Soft Part Sarcoma of the Nasolabial Fold: A Case Report and Literature Review

Alveolar soft part sarcoma (ASPS) is a rare malignancy that is morphologically characterized by a distinctive nodular, organoid, or nested growth pattern in which the cells are separated by vascularized septa. The diagnosis is based on a combination of pathologic and immunohistochemical findings and the presence of an ASPSCR1-TFE3 gene fusion revealed by next-generation sequencing. ASPS most commonly occurs as a painless mass in the lower extremity, with likely involvement in the lungs if metastasis is present. Here we report a case of ASPS that exhibited the characteristic ASPSCR1-TFE3 gene fusion along with a reciprocal fusion of TFE3-ASPSCR1, which presented in the nasolabial fold of a 31-year-old female. An intraoral approach was utilized for complete surgical resection of the malignancy, resulting in continued remission after 11 months.

Diffuse Neurofibroma in a Micronesian Male

Neurofibromatosis type 1 (NF1) is an autosomal dominant genetic disorder, with variable clinical features, most commonly including café-au-lait macules and neurofibromas. The incidence of NF1 is approximately one in 3,000 individuals. Diffuse neurofibroma is the rarest subtype of neurofibromas. We present a case of a 39-year-old Micronesian male presenting with a substantially large and heavy overgrowth on his back, found to be consistent with diffuse neurofibroma on histopathologic examination. The patient also met the diagnostic criteria for NF1 based on clinical examination. Imaging showed the dermal and subcutaneous thickening without deep extension into the underlying fascial layer or muscles. A patient-centered, multidisciplinary approach was taken in the workup and management of this case. Our patient expressed disinterest in surgical interventions.

Tibialis Anterior Muscle Hernia in a Young Woman

Muscle herniation is defined as a myofascial defect resulting in protruding of the muscle through the fascia covering it. It can present anywhere in the body, the most common is the lower limbs. Tibialis muscle herniation is considered a rare entity with few reported cases. Here, we present the case of a 24-year-old Saudi female patient who complained of swelling and pain in the anterior aspect of the left leg for three months. She underwent surgical repair of the fascia with a good outcome. This case presentation aims to contribute to the literature on myofascial herniation by specifically addressing tibialis anterior herniation of the leg and emphasizing the importance of considering it a differential diagnosis in similar presentations. This report highlights the excellent surgical outcomes and satisfactory results in patients with muscle herniation.

Oral Microbiome as a Tool of Systemic Disease on Cleft Patients: A New Landscape

The oral cavity microbiome comprises benign and pathogenic bacteria, with more than 700 species identified. However, the current literature regarding resident bacterial flora in the oropharyngeal cavities in cleft lip/palate (CLP) patients still needs to be completed. This review aims to evaluate the role of the oral microbiome of cleft patients as an indicator in systemic diseases for which cleft patients might be at higher risk in the short or long term. A literature review was performed in July 2020 using Biomedical Reference Collection Comprehensive, Cumulative Index to Nursing and Allied Health Literature (CINAHL) Complete, Dentistry & Oral Sciences Source via Elton B. Stephens Company/Online Database (EBSCO), Turning Research into Practice (TRIP), and PubMed. The keywords used were "oral, bacteria, microbiome, biota, flora, cleft, palate." The resulting 466 articles were deduplicated using Endnote. The total amount of articles' abstracts without duplicates was filtered using a set criterion. The title and abstract filter criteria included 1) cleft lip (CL) and/or cleft palate (CP) patients, 2) changes in the oral microbiome in CL and/or CP patients, 3) male and female patients 0-21 years old, and 4) English language. The full-text filter criteria included 1) CL and/or CP patients vs. non-cleft control patients, 2) oral bacteria, 3) nonprocedural measurements of microorganisms, and 4) case-control studies. A Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) flow chart was created using the EndNote data results. The final five articles of the systematic search indicated that the oral cavity of cleft lip and/or palate patients resulted in 1) contradicting levels of Streptococcus mitis and Streptococcus salivarius; 2) lower levels of Streptococcus gordonii, Bordetella dentium, Fusobacterium nucleatum, Veillonella parvula, Bacillus and Lautropia when compared to the control group; 3) higher levels of Staphylococcus epidermidis and Methicillin-sensitive Staphylococcus aureus compared to the control group; 4) presence of Enterobacter cloacae 36.6%, Klebsiella pneumoni 53.3%, and Klebsiella oxytoca 76.6% vs. absence in the control non-cleft group. Patients with CL and/or CP are at higher risk for caries, periodontal diseases, and upper and lower respiratory infections. The results from this review indicate that relative levels of certain bacteria may be associated with these issues. The lower levels of S. mitis, S. salivarius, S. gordini, and F. nucleatum in the oral cavity of cleft patients could be linked as a possible cause of the higher incidence of tooth decay, gingivitis and periodontal disease as high levels of these bacteria are associated with oral disease. Further, the higher incidence of sinusitis in cleft patients might be linked to low levels of S. salivarius in the oral profile of these patients. Likewise, E. cloacae, K. oxycota, and K. pneumoni have been linked with pneumonia and bronchiolitis, both of which are increased in cleft patients. The oral bacterial dysbiosis of cleft patients observed in this review may play a vital function in the oral microbiome's diversity, which could play a role in disease progression and disease markers. The pattern seen in cleft patients potentially demonstrates how structural abnormalities can lead to the onset of severe infection.

An Update on Tissue Contraction in Immediate Breast Reconstruction Using an Adjustable Implant Partially Filled With Air

Background With the use of nipple-sparing mastectomy (NSM) and skin-sparing mastectomy (SSM) techniques, utilizing a prepectoral underfilled adjustable saline implant allows for tissue contraction and thickening of the flap. This procedure allows for immediate reconstruction using an adjustable implant as a spacer with less risk of skin flap compromise and improves cosmetic outcomes. Methods A retrospective chart review of patients presenting to a single surgeon from September 2013 to September 2021 for breast reconstruction utilizing an underfilled prepectoral adjustable implant following SSM or NSM was performed. Baseline patient demographics, clinical information, postoperative complications, conversion to silicone implant, and contraction distance were recorded and analyzed. Results Fifty-four patients underwent prepectoral breast reconstruction using a Spectrum™ adjustable implant following an NSM or SSM. Tissue contraction and skin flap elevation were observed in all patients. The amount of tissue contraction averaged 4.4 cm (mean). Seven patients (12.96%) developed seromas. Four patients (7.41%) developed hematomas in the early postoperative period. Two patients (3.67%) developed capsular contracture. Two patients (3.67%) had a displaced port. After converting the air to saline, 25 patients (46.29%) opted for a secondary reconstructive procedure to exchange the saline implants for silicone gel implants. Conclusion Tissue contraction reduces the need for skin excision in ptotic breasts undergoing reconstruction procedures following NSM or SSM. The partially filled implant initially functions as a spacer to prevent flap adherence to the pectoral muscle and minimizes tension on the flap to promote flap thickening, elevation around the underfilled implant, and maximizes breast projection and overall aesthetic outcome.

Referral and Management of Pretibial Lacerations in Two District General Hospitals

Background Pretibial lacerations are common injuries that have a significant yet underestimated association with morbidity and mortality. Although they may occur in any age group, they are commonly followed by an often relatively minor trauma in elderly and frail patients. The six-month mortality among such patients may be more than double the age group average. Currently, 5.2 in 1000 patients per year present to the emergency departments in UK hospitals due to pretibial lacerations. The associated acute admissions have a high financial cost. Despite the significant disease burden, there is a paucity of evidence on the optimal management of such injuries. This study aimed to describe the typical demographic and injury factors of individuals presenting to two district general hospitals, as well as their subsequent management and referral. Methodology Relevant patients were identified through NHS coding searches. Subsequently, it was found that 99 patients presented to an NHS trust with pretibial lacerations throughout 2020. A retrospective manual evaluation of clinical documentation was performed to identify the details of the patients' injury, management, referral, and demographics. Results The patients had a mean age of 55.4 (SD 28.3), and 56.6% were female. The most commonly presenting mechanism of injury was direct blunt trauma. The majority of cases were solely managed and discharged directly by the emergency department (74.8%). Of the 99 patients, 25 (25.3%) were referred to specialist services, 12 (12.1%) were managed conservatively, and 13 (13.1%) underwent operative intervention. The mean length of stay for those referred was 5.9 days, and the mean for the same was greater for those managed conservatively compared to those managed operatively (9.0 vs. 2.6 days). Among patients discharged by the emergency department, the most common method of wound closure was steristrips (n = 40; 54.1%), followed by conservative management with dressings (n = 22; 29.7%), sutures (n = 10, 13.5%) and glue (n = 5; 6.8%). Conclusions Overall, this study showed that the majority of patients presenting with pretibial lacerations have minor wounds that can be effectively managed in the emergency department. However, those with considerably more injuries should be provided an early referral to specialist services, where they would ideally receive early surgery and comprehensive follow-up.

Challenges in Anaesthetic Management in a Case of Facial Plexiform Neurofibromatosis Posted for Debulking Surgery

A patient diagnosed with facial plexiform neurofibromatosis type 1 who is 18 years old and is scheduled for tumour resection and debulking surgery of his face is the subject of this study. The purpose of this paper is to describe the anaesthetic treatment that was administered to this patient. In addition, we analyze the relevant literature, with a particular emphasis on the implications of modifying neurofibromatosis to achieve anaesthesia. Our patient was found to have multiple huge tumours all over his face. When he first arrived, he experienced cervical instability as a result of the enormous mass on the back of his head and in the region of his scalp. He also expected to have difficulty maintaining an airway and breathing through a bag and mask. To protect the patient's airway, a video laryngoscopy was performed, and a difficult airway cart was maintained on standby in the event it was required. In conclusion, the purpose of this case study was to demonstrate the relevance of comprehending the one-of-a-kind anaesthetic requirements of persons diagnosed with neurofibromatosis type 1 who are about to undergo surgical procedures. Neurofibromatosis is an extremely uncommon kind of disease that requires the anesthesiologist's undivided attention in surgical settings. Careful pre-operative planning and competent intra-operative treatment are required when dealing with patients who are expected to have difficult airway management.

[The use of platelet-rich plasma in the treatment of cicatricial stenosis of the larynx and cervical trachea]

Despite the technical achievements of recent years in medicine, the problem of frequent recurrent stricture formation of the lumen of larynx and cervical trachea remains urgent. The etiology and pathogenesis of development of scar stenosis of the larynx and trachea were considered, and the analysis of the drugs' use for topical therapy in the comprehensive treatment of this pathology was conducted in the presented review. Special attention was paid to plasma enriched with platelets, its use in otorhinolaryngology, in particular in the treatment of laryngeal diseases. Positive and negative sides of the adjuvant therapy use have been identified. The search for means helping to prevent recurrent stricture formation of laryngeal lumen and cervical trachea determines the interest of the considered problem.

One Versus Two Veins in Free Anterolateral Thigh Flap Reconstruction: A Systematic Review and Meta-Analysis

There is considerable debate in the literature as to whether one or two venous anastomoses are optimal in the anterolateral thigh (ALT) free-flap reconstruction. The literature is currently devoid of a systematic review and meta-analysis of studies evaluating these procedures. This review will therefore be the first to address this clinical question. In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, two authors (EW and SR) independently searched the following electronic databases: MEDLINE, EMBASE, CINAHL, and the Cochrane Central Register of Controlled Trials (CENTRAL). Case-control, randomised control and observational studies were included. The authors did not include case reports, case series, letters or abstracts. All patients were included regardless of age, co-morbidity status, and the anatomical site of reconstruction. Venous congestion/thrombosis, flap take-back rate due to venous insufficiency, flap loss and operative time were the primary outcome measures. Secondary outcome measures included partial flap loss and haematoma formation. The Newcastle Ottawa Scale was used to assess the risk of bias in the included studies. Review Manager 5.4 data synthesis software was used for the analysis. The authors identified eight observational studies, with a total of 1741 patients reviewed, demonstrating a significantly lower flap take-back rate for a double venous anastomosis and a shorter operative time in the single venous anastomosis group. However, other reported measures, including venous congestion and flap loss, showed a non-significant difference (P>0.05). The limitations of the evidence included in this review were that all studies were observational in design. The flap take-back rate is significantly less when anastomosing two veins, and the authors recommend that utilising a second vein can circumvent the caveat of venous compromise.

Atypical case of arteriovenous malformation invading into a pedicled medial arm flap

A 54-year-old woman who had previously undergone total excision of an arteriovenous malformation (AVM) of lower lip and chin along with pedicled medial arm flap reconstruction, presented with recurrence of swelling in the same region. The patient reported progressive difficulty in feeding, talking and constant aching pain besides aesthetic concerns. On evaluation, recurrence of AVM with invasion into the flap substance was identified. We performed debulking surgery, which resulted in a considerable reduction in pain and improved lower lip functioning and aesthetic appeal of the face. This case is unique due to the rare presentation of an AVM invading the normal flap tissue. Such a finding has never been reported before for a pedicled flap, along with details of the histopathology and imaging description. There are lacunae in the understanding of the progression of vascular malformations and this additional information will add to the existing literature on AVM.

Ectopic extramammary Paget's disease of the abdominal wall with abdominoplasty reconstruction

Ectopic extramammary Paget's disease describes an exceedingly rare intraepithelial adenocarcinoma arising within non-apocrine tissues. We present a case report of E-EPMD arising on the lower abdomen without underlying secondary malignancy in a 56-year-old female patient. We performed a wide local excision of the lesion with subsequent mini abdominoplasty reconstruction.

Extensive papulonodular xanthoma: a diagnostic clue to homozygous familial hyperlipidaemia

A man in his early 30s, presented with multiple soft tissue swellings over the buttocks, around the knees, ankles and dorsum of both the hands since childhood. His father and paternal uncle had similar lesions, and his father had coronary artery disease. One of his sisters had a history of sudden death due to an unknown cause at 14 years. The patient and his parents had very high serum levels of total cholesterol and low-density lipoprotein. Based on the above findings, a clinical diagnosis of familial hyperlipidaemia type II was made. Larger lesions were excised in stages, and histopathological evaluation revealed the lesions to be eruptive xanthoma. A cardiac assessment revealed no significant abnormality. Lipid-lowering agents and low-dose aspirin were started, and the patient was advised for regular cardiology and endocrine evaluation. This case emphasises its rare presentation and the importance of early diagnosis and management to prevent any untoward future incidence.

Severe thoracic pyomyositis in a patient with systemic lupus erythematosus

Pyomyositis may mimic deep vein thrombosis and be misdiagnosed in patients with systemic lupus erythematosus (SLE). We report here on patient with SLE with severe thoracic pyomyositis presented with right upper arm swelling and fever. The patient fully recovered after a serial surgical debridement and antibiotic therapy. Pyomyositis, as well as deep vein thrombosis, should be considered during the differential diagnosis of patients with SLE experiencing fever and unilateral limb oedema. CT and identification of causal pathogens are crucial in the diagnosis of pyomyositis. Early effective antibiotic treatment as well as surgical intervention can together bring about a better outcome.

Multiple simultaneous venous flow-through free flap salvage for multifinger revascularisations

A 22-year-old man presented with traumatic crush-avulsion injuries to the left index, ring and small fingers resulting in complex soft tissue loss and acute three-finger ischaemia. The patient underwent immediate revascularisation and soft tissue resurfacing of the three digits using three separate venous flow-through free flaps performed in a single-stage operation. Continued follow-up after 9 months confirmed successful salvage of these three digits. Multiple simultaneous venous flow-through free flaps can be considered as a viable alternative reconstructive modality for traumatic multi-digit ischaemia where both graft-based digital artery reconstruction and soft tissue coverage are required for multiple digits.

Apert syndrome: an informative long-term dentofacial outcome

The management of patients with Apert syndrome (AS) is complex and reflects the multisystem disease as a result of premature fusion of cranial vault, cranial base and midface sutures as well as extremity anomalies characterised by syndactyly. Early cranial sutural fusion results in craniocerebral disproportion which can lead to crisis surgical intervention due to raised intracranial pressure, ophthalmic and compromised airway concerns. Childhood inventions are often determined by psychosocial concerns and adult surgical interventions are often determined by cosmetic concerns. Treatments are provided by many different specialists within multidisciplinary teams (MDT). The treatment pathway extends from birth well into adulthood and is often associated with a heavy burden of care. Due to the extensive nature of the interaction with these patients MDT members have opportunities to provide enhanced patient-centred care and support.This case report provides an overview of the current knowledge of the aetiology of AS, illustrates the pathway of surgical and non-surgical management of AS and provides a long-term review of the dentofacial treatment outcomes.By having a better understanding of the impact of AS and treatment provided, MDT members can not only provide improved clinical treatment but also offer improved patient experiences for those with craniofacial anomalies, in particular, an increased awareness of the psychosocial challenges they endure.

Anaplastic large cell lymphoma, ALK-negative of the breast diagnosed a short time after removal of breast implant in a patient with breast carcinoma: diagnostic and therapeutic considerations

A case of mass-forming breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) with onset a short time after explanation of the cosmetic prosthesis is reported. The cause of implant removal was carcinoma diagnosed in the ipsilateral breast. The rarity of an almost synchronous manifestation of BIA-ALCL and breast carcinoma and the diagnostic challenges of mass-forming BIA-ALCL in a previously operated breast substantiate this report. The clinical course, diagnostic workup and therapeutic considerations are presented and discussed in detail. This case shows that a diagnosis of BIA-ALCL must always be considered even without a prosthesis in place in patients with a long history of textured implants.

Challenges in the management of extensive aplasia cutis congenita

Aplasia cutis congenita (ACC) is a rare group of congenital disorders characterised by focal or widespread absence of skin, predominantly affecting the scalp. A Malay female infant was born at 37 weeks with extensive ACC, affecting 37% of total body surface area, including her scalp and trunk. There is no consensus on the management of ACC given the rarity and variable presentation. A multi-disciplinary team comprising neonatologists, paediatric dermatologists, plastic surgeons and medical laboratory scientists at the skin bank, employed a more aggressive surgical approach with the aim of avoiding potentially catastrophic morbidity, including sagittal sinus haemorrhage and brain herniation. Out of several surgical options, the team used a staged artificial dermal matrix (Integra) and cultured epithelial autograft application, followed by regular wound dressing, and eventually allowed the child to achieve complete epithelialisation of her trunk, and most of scalp before she was discharged from hospital.

Long-term treatment outcomes from the perspective of a patient with unilateral cleft lip and palate

The management of patients with orofacial cleft (OFC) often extends from diagnosis or birth well into adulthood and requires many different specialists within multidisciplinary teams (MDT). The aims of treatment are to restore form and function relating to hearing, speech, occlusion and facial aesthetics. People with OFCs that include the lip, alveolus and palate (cleft lip and palate (CLP)) require several different staged and coordinated surgical and non-surgical interventions, and the treatment pathway is associated with a heavy burden of care. Due to the extensive nature of the interaction with these patients, MDT members have opportunities to provide enhanced patient-centred care and support. This case report provides an overview of the current knowledge of the aetiology of OFC and the management of these patients. It provides a unique perspective from one of the coauthors who has a unilateral CLP (UCLP) and reports on his treatment experiences and long-term treatment outcomes. By having a better understanding of the impact of UCLP and treatment provided, MDT members can not only provide improved clinical treatment but also offer improved patient experiences for those with craniofacial anomalies, in particular, an increased awareness of the psychosocial challenges, they endure throughout their treatment pathway and beyond.

Correction of whistle deformity secondary to cleft lip repair by V-Y plasty: a simple and effective technique

Several techniques are available for the surgical repair of the cleft lip, however, avoiding secondary deformities and achieving consistent results remains a challenge. The whistle deformity is a secondary lip deformity characterised by inadequate fullness of the central upper lip with abnormal exposure of the central incisors when the lips are at rest, giving a whistling appearance. The causes include scarring of the vermilion and failure to restore the mucosal or muscular continuity. Various surgical options are available ranging from simple procedures like V-Y plasty and Z-plasty to complex procedures like complete lip redo, locoregional flaps, fillers and grafts. V-Y plasty is a simple, effective procedure for lip lengthening that can be performed under local anaesthesia as an outpatient procedure. It is less technique sensitive and also allows for some degree of muscle repair. We present a case of whistle deformity satisfactorily corrected with V-Y plasty.

The vertical gracilis myocutaneous flap for breast reconstruction in a massive weight loss patient

The number of patients undergoing bariatric surgery is increasing worldwide. Different types of free flaps are often used for breast reconstruction following mastectomy. We present a not previously described case using a vertical myocutaneous gracilis flap for breast reconstruction in a massive weight loss patient. The patient was a 61 year-old woman who previously had a lumpectomy for an in situ ductile carcinoma of her left breast. Subsequently the patient underwent a full mastectomy in 2020 due to a recurrence. The massive weight loss population poses a challenge in reconstructive surgery, due to their higher risk of complications. However, we still believe free flaps should be considered as a valid option for breast reconstruction in these patients. Due to the often increased size of perforator vessels in these patients, other flaps may prove more suitable than the usually preferred ones.

Impact of Early Surgical Intervention of Plastic Surgeons on the Prognosis of Necrotizing Soft Tissue Infection

Background

Necrotizing soft tissue infection (NSTI) is a rare, severe bacterial infection that causes rapidly progressive soft tissue necrosis from the skin to the muscle. The gold standard for treating NSTI is a prompt diagnosis, early surgical debridement of necrotic tissue, and antimicrobial therapy. This study investigated the relationship between the involvement of plastic surgeons and the clinical course of NSTI cases treated at Yokosuka General Hospital Uwamachi.

Methodology

This study involved 28 patients with NSTI who were treated at Yokosuka General Hospital Uwamachi. Patient background, outcomes (mortality and amputation), and days to the first surgery were compared in the early and nonearly plastic surgery intervention groups. Moreover, the duration of treatment was also compared in surviving patients. Differences between the two groups were analyzed using Fisher’s direct probability test, Mann-Whitney U test was used for comparison of continuous variables between the two groups, and Spearman’s rank correlation analysis was used for the bivariate correlation coefficient. The significance level was set at <5%.

Results

There were eight and 20 patients in the early and nonearly plastic surgery intervention groups (14 in later intervention and six in nonintervention), respectively. A difference in the median number of days to the first surgery between the early (zero days) and the nonearly (two days) intervention groups was significant (p = 0.002). In the survival groups, the median treatment duration in the early (n = 8) and nonearly (n = 13) intervention groups was 44 and 82 days, respectively, which was significantly shorter in the early intervention group (p = 0.003).

Conclusions

The number of days until the first surgery and the length of the treatment period were significantly shorter in the early plastic surgery intervention group than in the nonearly intervention group.

Atypical Fibroxanthoma Within a Melanoma: A Case Report

The finding of a pigmented lesion within another distinct lesion is rare but not unheard of. Here, we describe the presence of an atypical fibroxanthoma within a melanoma in a 72-year-old female referred to the plastics surgery department with a pigmented lesion on her left knee. It was excised in view of clinical suspicion of melanoma. The histopathology report documented a single lesion with two distinct components, namely a melanoma of superficial spreading type with a Breslow thickness of 3.0mm, and a central nodule of atypical fibroxanthoma.

Biodegradeable temporising matrix use in a traumatic chest wound

The Welsh Centre for Burns and Plastic Surgery is responsible for a population of 10 million people in Wales and England. We describe the use of biodegradable temporising matrix (BTM) in a large traumatic chest wound in a 23-year-old woman. BTM is a synthetic dermal substitute and has been utilised to achieve soft tissue coverage in complex wounds. This wound was sustained after the patient fell from a tractor into a large silage rake, resulting in injuries to her chest and limbs. Following meticulous debridement, her resulting full thickness skin defect measured 30 × 30 cm extending from the sternal notch to the upper abdomen, with bone, muscle and breast tissue exposure. The central chest area is complex to reconstruct due to the contours of the breasts and tendency to contracture following skin graft reconstruction. We demonstrate the first reported use of BTM for breast reconstruction, as far as we are aware.

Symphyseal fracture in a three-month-old infant

Mandibular fractures are rare in infants, and diagnosis can be easily missed due to the difficulty in obtaining an adequate history and the subtle signs. A high index of suspicion and detailed history taking from the caregiver are mandatory to pick up these cases.There are a plethora of management options that have been reported in dealing with such fractures. They range from conservative management to internal fixation by absorbable plates. While conservative management does not interfere with mandibular growth and teeth development, any surgical intervention can carry this risk. Nevertheless, a severely displaced fracture may need anatomical reduction and fixation to allow early nutrition.This study reports a 3-month-old male infant with a fracture in the mandibular symphysis who underwent reduction of the fracture and circummandibular fixation using immobilisation by an acrylic splint for 4 weeks. His long-term follow-up after 20 months showed adequate dentition with proper healing of the fracture site.

Burn injury from filling balloons with nitrous oxide

We present the case of a female teenager who sustained nitrous oxide burns to the medial aspect of both thighs from contact with a nitrous oxide canister being used to fill balloons. There was a delay in presentation as the injury was not initially recognised. These burns were initially assessed as being superficial partial-thickness burns but took a prolonged time to heal despite regular wound care. This was complicated by a lack of adherence to recommended treatment for much of the patient care as well as the patient testing positive for COVID-19 during their management, which prevented surgery and significantly extended time to healing. While small numbers of similar cases have been previously described this is the first reported case outside of the Netherlands and in a child. Being aware of such cases ensures early referral to specialist burn care for appropriate management to give patients the best possible outcome.

Bilateral Anteverted Conchal Bowls: Surgical Correction of a Rare Anomaly

Anteverted conchal bowl is a rare auricular anomaly in which a convexity of the conchal bowl is seen. The condition may pose both aesthetic and functional implications for affected patients. Most cases are benign and require minimal or no intervention. In severe cases, the external acoustic meatus can be occluded, giving rise to a host of complications. Correction of anteverted conchal bowls is achieved by either conservative or surgical modalities, with the latter commonly undertaken in the post-neonatal stage. Reconstructive surgery can be performed using relatively simple techniques and yields desirable results. Here, we present a case of a patient surgically treated in our Plastic Surgery Unit in the North East of Scotland, along with a description of the operative methods utilised.

The Effects of Depression and Anti-Depressants on Quality of Life After Breast Reconstruction: A Post-Hoc Analysis

Background

A personal history of depression prior to breast cancer diagnosis and its effect on post-diagnosis quality of life (QOL) in women undergoing breast reconstruction is relatively unknown. We performed the current study to determine if depression alters QOL for patients who undergo breast reconstruction by assessing the pre-to-post-operative change in patient-reported BREAST-Q scores.

Methodology

We conducted a single-center, post-hoc analysis of 300 patients with completed BREAST-Q data who underwent breast reconstruction from November 2013 to November 2016 following a diagnosis of breast cancer. Patients completed the BREAST-Q at four time points: pre-operatively, six weeks following tissue expander (TE) insertion for patients undergoing staged reconstruction, and six and 12 months following the final reconstruction. Medical records were reviewed to identify patients who had a pre-cancer diagnosis of clinical depression and/or anti-depressant medication use. BREAST-Q scores were compared between groups and within groups. Groups compared were the depression (n = 50) and no depression (n = 250) patients, along with anti-depressant (n = 36) and no anti-depressant (n = 14) use in the depression group.

Results

Within-group Sexual Well-being scores at the six-week post-TE follow-up for patients in the depression group (median = 37, interquartile range [IQR] = 25-47) were significantly lower (p < 0.01) than the scores for patients in the no depression group (median = 47, IQR = 39-60). There were no statistically significant differences in BREAST-Q scores in other domains. When compared to patients diagnosed with depression who were not taking anti-depressants, anti-depressant medication use did not result in statistically significant higher BREAST-Q scores, although Satisfaction With Breasts six months post-operatively, Psychosocial Well-being at six weeks post-TE, Sexual Well-being at six weeks post-TE and six months post-operatively were clinically higher in patients taking anti-depressants for depression.

Conclusions

Patients with a diagnosis of depression prior to breast cancer had lower BREAST-Q Sexual Well-being scores in the six-week TE group with or without anti-depressant medication. Patients with a pre-cancer diagnosis of depression considering TEs may benefit from additional counseling prior to breast reconstruction or electing a different method of breast reconstruction. Anti-depressant medications may provide clinically higher BREAST-Q scores in patients with a pre-cancer diagnosis of depression. Adding an anti-depressant medication to a patient’s treatment plan may provide additional benefits. Larger samples are required to properly determine the impact of anti-depressant medications on BREAST-Q scores in patients with a pre-cancer diagnosis of depression.

Dermal nipple-areola complex flap method in female to male gender affirming surgery

Subcutaneous mastectomy plays a major role in female to male (FtM) gender affirming surgery, and obtaining a flattering chest contour remains a challenge to the surgeon. We present an operative method using a dermal nipple-areola complex (NAC) flap, with the aim to create a naturally masculine appearance, while reducing the risk of NAC complications by maintaining sufficient neurovascularisation. This case report describes how the novel approach may potentially be applied as an alternative to the traditionally performed free nipple graft technique in FtM gender confirming surgery. The technique is simple, provides an aesthetically appealing outcome and presumably poses a low risk of NAC complications. Intraoperatively, it allows for good exposure and a uniform removal of breast tissue, as well as repositioning and/or resizing of the NAC where required.

A Rare Case of Facial Artery Branching-A Review of the Literature and a Case Report with Clinical Implications

Background and Objectives: Vascular variations appear as morphologically distinct patterns of blood diverging from the most commonly observed vessel patterns. The facial artery is considered to be the main vessel for supplying blood to the anterior part of the face. An anatomical understanding of the facial artery, its course, its topography, and its branches is important in medical and dental practice (especially in neck and face surgery), and is also essential for radiologists to be able to interpret vascular imaging in the face following angiography of the region. A profound knowledge of the arteries in the region will aid in minimizing the risks to the patient. Materials and Methods: In our publication a narrative literature review and a case report are presented. Results: A rare case of a facial artery pattern has been described anatomically for the first time with respect to its course and branching. This variation was found on the left side of a 60-year-old male corpse during anatomical dissection. The anterior branch of the facial artery arched in the direction of the labial angle, and there divided into the inferior and superior labial arteries. At the same time, the posterior branch coursed vertically and superficially to the masseter muscle. It here gave off the premasseteric branch, and continued towards the nose, where it ran below the levator labii superioris and the levator labii superioris alaeque nasi muscles and terminated at the dorsum nasi. Conclusions: Our review of the literature and the case report add to knowledge on the facial artery with respect to its topographical anatomy and its branching and termination patterns, as well as the areas of supply. An exact knowledge of individual facial artery anatomy may play an important role in the planning of flaps or tumor excisions due to the differing vascularization and can also help to prevent artery injuries during aesthetic procedures such as filler and botulinum toxin injections.

Resection and reconstruction of idiopathic scrotal elephantiasis: surgical approach and quality of life assessment

Scrotal elephantiasis (SE) is a condition considered rare in western industrialised countries but common in filaria prone regions. If no apparent causes are found for SE, it is called idiopathic SE. Medical and conservative therapies are ineffective against idiopathic SE, and surgical intervention is mandatory to treat this disabling condition. Nevertheless, it remains unclear whether surgical intervention improves quality of life among patients with idiopathic SE. Herein, we report a case of a 41-year-old man who underwent acute scrotal resection and reconstruction, secondary to haemorrhage from his idiopathic SE. The aim of this study was to describe the operative approach and assess patient satisfaction after surgical treatment. The patient had no recurrence of SE after surgical treatment at 6 months follow-up and had considerable improvements assessed by general and disease-specific quality of life questionnaires.

Subcutaneous Endoscopy in Plastic and Reconstructive Surgery

Background Scar visibility is a major deterrent to patients seeking reconstructive surgery. Endoscopic surgery can address a wide range of problems, from minimizing or concealing scars to improving access and outcomes in certain situations. This case series includes a wide range of reconstructive surgery problems addressed by subcutaneous endoscopic surgery. Having one or more trained assistants is a major deterrent to the performance of endoscopic surgery by the lone practitioner. The single (or two-port technique for muscle harvest) used in most cases simplifies subcutaneous endoscopic surgery. Methods A single-port endoscopy technique, with a 4-mm, 30-degree side viewing telescope and sheath, optical camera and cold light source, was used. Case records were reviewed for access incisions, procedure abandonment, postoperative pain, complications, and patient satisfaction. Results A total of 53 endoscopic surgical episodes between 2003 and 2013 were reviewed. Using a single port, most cases were done successfully. The access site was changed peroperatively in one case. Complications included transient nerve palsy in one case, which recovered completely. There was minimal intraoperative bleeding. Postoperative pain was low except in one case and managed with minimal analgesia. Patient satisfaction was high in all cases. Conclusions Subsurface endoscopy done on a wide range of reconstructive surgery procedures and resulted in minimal scars and high patient satisfaction.