British Journal of Plastic Surgery

Editorial Board

2005-12-01

Change and change again

Simon Kay — 2005-12-01

The wind of change is in the air again. The British Journal of Plastic Surgery is a great and almost a venerable title, but it seems that BJPS can never stand still. But then neither does the environment we work in. These are times of rapid development all around, as e-publishing takes off and the medical publishing market globalises. Can a small British society title do well in those conditions? When I use the term ‘do well’, for our journal I mean attract good quality papers and content, publish them in an attractive accessible and affordable manner and achieve a large enough market to sustain the journal and allow continuous development of its role.

The management of midline transcranial nasal dermoid sinus cysts

M. Hanikeri, N. Waterhouse, N. Kirkpatrick, D. Peterson, I. Macleod — 2005-12-01

Summary: The most common congenital midline nasal masses are nasal dermoid sinus cysts (NDSC) [Hughes GB, Sharpino G, Hunt W, Tucker HM. Management of the congenital midline nasal mass—a review. Head Neck Surg 1980;2:222–33.]. Their clinical importance hinges on their potential to communicate with the central nervous system. Preoperative diagnosis of an intracranial extension allows for referral to a craniofacial team with the appropriate skills and experience for a transcranial approach. All patients with a NDSC require imaging with high resolution multiplanar MRI scans and complimentary fine cut CT scan to reveal the anatomical extent of the tract and its relationship to the anterior cranial fossa.A single-stage craniofacial approach to resection of midline NDSC extending to the anterior cranial base is effective with minimal morbidity [Yavuzer R, Bier U, Jackson IT. Be careful: it might be a nasal dermoid cyst. Plast Reconstr Surg 1999;103:2082–3; Denoyelle F, Ducroz V, Roger G, Garabedian EN. Nasal dermoid sinus cysts in children. Laryngoscope 1997;107:795–800; Rohrich RJ, Lowe JB, Schwartz MR. The role of open rhinoplasty in the management of nasal dermoid cysts. Plast Reconstr Surg 1999;104:2163–70; Rahbar R, Shah P, Mulliken JB, et al. The presentation and management of nasal dermoid—a 30-year experience. Arch Otolaryngol Head Neck Surg 2003;129:464–71; Posnick JC, Bortoluzzi P, Armstrong DC, Drake JM. Intracranial nasal dermoid sinus cysts: computed tomographic scan findings and surgical results. Plast Reconstr Surg 1994;93:745–54 [discussion 755–56]; Bartlett SP, Lin KY, Grossman R, Kratowitz J. The surgical management of orbitofacial dermoids in the pediatric patient. Plast Reconstr Surg 1993;91:1208–15.]. The cyst and tract are accessed through a combination of a nasal and transcranial approach. This allows visualisation and dissection of the tract with only a small incision on the nasal dorsum to include the cutaneous punctum when present. Transnasal endoscopic techniques have been advocated where the dermoid is located within the nasal cavity and there is little or no cutaneous involvement [Weiss DD, Robson CD, Mulliken JB. Transnasal endoscopic excision of midline nasal dermoid from the anterior cranial base. Plast Reconstr Surg 1998;101:2119–23.].We present a review of five cases referred to our unit between 1999 and 2004 with a diagnosis of a midline nasal dermoid sinus cyst and radiological evidence of intracranial communication. All cases had a communication with the anterior cranial fossa diagnosed preoperatively and were treated surgically with a craniofacial approach. An intracranial extension was identified at operation in each case and this was confirmed on histopathology. The only significant complication resulted from an early postoperative infection, requiring re-operation. There were no recurrences and acceptable aesthetic outcomes have been observed in all cases.

Oro-nasal fistula development and velopharyngeal insufficiency following primary cleft palate surgery—an audit of 148 children born between 1985 and 1997

D.S. Inman, P. Thomas, P.D. Hodgkinson, C.A. Reid — 2005-12-01

Summary: We present an audit of primary cleft palate surgery in our unit including rates of two important post-operative complications.Multidisciplinary audit clinics ran from March 1998 to April 2002 to follow up all local patients with a cleft lip or palate who had undergone primary palatal surgery in our unit. One hundred and forty eight patients were studied. Patient ages at follow-up ranged from 3 years and 10 months to 17 years and 4 months. Two surgeons performed the primary surgery. One hundred and twenty eight Wardill-Kilner and 20 Von Langenbeck repairs were performed.We found a 4.7% rate of oro-nasal fistula development requiring surgical closure, and a 26.4% rate of velopharyngeal insufficiency (VPI) requiring subsequent pharyngoplasty. We noted that the type of cleft involved affected the rate of VPI, 16% of patients with unilateral cleft lip and palate versus 29.2% of patients with a solitary cleft palate requiring secondary surgery.Outcome of surgery was determined by a ‘Cleft Audit Protocol for Speech’ (CAPS) speech therapy assessment at follow-up clinics. Only 14.9% of all patients assessed demonstrated any degree of hypernasality.Our results compare favourably with other recent studies including the Clinical Standards Advisory Group (CSAG) report into treatment of children with cleft lip and palate.

Release of oral submucous fibrosis and reconstruction using superficial temporal fascia flap and split skin graft—a new technique

N.J. Mokal, R.S. Raje, S.V. Ranade, J.S. Rajendra Prasad, R.L. Thatte — 2005-12-01

Summary: Long standing oral submucous fibrosis is associated with involvement of the oral submucosa and the muscles of mastication leading to difficulty in mouth opening. Various surgical modalities are mentioned for release but each has its own limitations. This article introduces a new technique of release of submucous fibrosis and reconstruction using superficial temporal fascia flap and split skin graft. The surgical technique involves a pre-auricular incision extending into the temporal region with dissection carried out in the sub follicular plane to develop the superficial temporal fascia flap to its maximum extent. The masseter muscle origin is released from the zygomatic arch and the temporalis muscle insertion is released from the coronoid process through an external approach. The entire fibrosed mucosa is released intraorally to create a mucomuscular defect thus achieving full mouth opening. The superficial temporal fascia flap is then brought in and sutured to the intraoral defect, which is then covered with a split thickness skin graft. This procedure is performed bilaterally.A total of five patients were treated with this new technique and all of them showed good mouth opening in long term follow up. There was no donor site morbidity. The incision line is well hidden in the hair bearing area. A well vascularised superficial temporal fascia flap brings in good blood supply to the area of affected muscle and mucosa to improve its function.

Reconstruction of intraoral defects using facial artery musculomucosal flap

A. Joshi, J.S. Rajendraprasad, K. Shetty — 2005-12-01

Summary: The facial artery musculomucosal flap, technically a combination of the nasolabial flap and the buccal mucosal flap, has been a reliable, versatile flap, either superiorly or inferiorly based for reconstruction of a wide variety of postcancer excision intraoral mucosal defects including defects of the palate, alveolus, lips and floor of mouth. We have used it 17 times in 16 patients with no failures and one flap with terminal necrosis. Almost all flaps developed venous congestion which settled on its own by conservative management.

Surgical treatment of haemangioma in infants

Jiad N. Mcheik, Vincent Renauld, Gerard Duport, Pierre Vergnes, Guillaume Levard — 2005-12-01

Summary: Haemangiomas usually can be identified by their clinical course. They are characterised by presentation at birth or shortly thereafter, and a rapid proliferative phase over the first 12 months. The haemangioma then usually stabilises and slowly involutes over a period of 5–7 years. For a long time, surgery has been limited to complicated cases, and correcting after-effects following involution. Nevertheless, aesthetic, psychological or functional prejudices may justify early surgery.We conducted a retrospective study of patients treated between 1995 and 2001. A total of 31 patients with facial and cervical haemangiomas were studied. For each, the type of lesion and its topography, age and operative indications, surgery, postoperative complications and aesthetic and functional results have been considered.Thirty-one haemangiomas were operated. The average age was 30 months (1–60 months). After an average follow-up of 3 years, the results were very good in 20%, good in 66%, and fair in 14% of cases.Early curative surgery of haemangioma before spontaneous involution, and before school-age is justified because of social and psychological considerations in infants and their family.

Direct percutaneous ethanol instillation for treatment of venous malformation in the face and neck

Chih-Hsien Lee, Shyi-Gen Chen — 2005-12-01

Summary: Venous malformations of the face and neck involve multiple anatomical spaces and encase critical neuromuscular structures, making surgical treatment difficult; high recurrence rates and high morbidity are well documented. Various methods of treatment of uncertain value and risk of complications have been advocated. We present our experience in treating five patients with venous malformation in the face and neck by using direct percutaneous ethanol sclerotherapy. Four patients had large lesions (≥3cm; one patient had two large lesions in the low eyelid), and the other had a mid-sized lesion (1.5–3cm). Under general or local anaesthesia, one-third to one-quarter cavity volume of ethanol was injected percutaneously, directly into the malformation with under fluoroscopy [de Lorimier AA. Sclerotherapy for venous malformations. J Pediatr Surg 1995;30:188–93; Johnson PL, Eckard DA, Brecheisen MA, Girod DA, Tsue TT. Percutaneous ethanol sclerotherapy of venous malformations of the tongue. Am J Neuroradiol 2002;23:779–82; Pappas DC Jr, Persky MS, Berenstein A. Evaluation and treatment of head and neck venous vascular malformations. Ear Nose Throat J 1998;77:914–22; Lee CH, Chen SG. Direct percutaneous ethanol sclerotherapy for treatment of a recurrent venous malformation in the periorbital region. ANZ J Surg. 2004;74(12):1126–7. ]. Four patients required two injections. All patients had remission and alleviation of their symptoms, with no major complications. Direct percutaneous injection of absolute ethanol provides a simple and reliable alternative treatment for venous malformation in the face and neck.

Anatomical study of the cutaneous perforator arteries and vascularisation of the biceps femoris muscle

2005-12-01

Summary: We present an anatomical study that describes the distribution of the cutaneous perforators (CP) of both heads of the biceps femoris muscle.Material and methods: In this study, we dissected 18 legs from nine cadavers. The study was centered on the biceps femoris muscle and musculocutaneous perforator arteries from both muscular heads. Only perforator arteries with comitant vein diameters of over 0.5mm were selected. The vascular origin and length were also studied. In all cases, measurements were taken from the bicondyle line.Results: The measurements taken from the muscle bellies of the biceps gave the following results; for the long head 33.91cm as medium length (SD=2.70) and for the short head 23.85cm as medium length (SD=2.96).The total number of perforator arteries obtained from the two muscle bellies was 139, with the greatest percentage located in the lower half of the thigh. The majority follow an intramuscular route (80.48%) and less frequently they are septals (19.52%).The lengths of perforator arteries from its origin in the axial vessel of the muscle to the subcutaneous fat were, for the short head 5.01±1.33 (3.0–10.0), whereas the same measurement, in the long head was 4.54±1.36 (2.5–9.0).The principal vascular origin of the perforator arteries was the popliteal artery in both muscle bellies, whilst the second arterial vessel in importance was the first and second profunda perforator artery.Conclusion: From the results obtained in our work, we can deduce that it is always possible to locate perforator arteries in both muscle bellies; most frequently they have intramuscular distribution and are located in the proximity of the vascular septum. Their most common origins are the popliteal artery and first and second profunda perforator artery. Finally, it is possible to design pedicle and free flaps, with less morbidity and more versatility than musculocutaneous flaps.

The distal medial perforators of the lower leg and their accompanying veins

S. Ghali, N. Bowman, U. Khan — 2005-12-01

Summary: The skin of the lower leg is nourished by a number of perforating vessels arising from the named arteries which travel in the longitudinal axis of the limb. The distribution of these perforating arteries has been elucidated using a combination of techniques but which are essentially based on cadaveric studies. Clinically, this knowledge has provided the basis for methods of local tissue transfer in the lower limb. A common finding with the use of local fasciocutaneous flaps is venous congestion. The relationship of the veins to the arteries in perforating vessels of the lower limb has not been investigated. We studied the veins accompanying these arteries by dissecting them in 40 lower limbs (20 cadavers). A total of 40 pedicles were dissected. We concentrated our analysis of the arterial/venous relationship on the most distal vessels on the medial aspect of the lower limbs (the vascular basis for the commonly used distally based fasciocutaneous flap). We found that 25 of these arteries were accompanied by one perforating vein whereas 12 were accompanied by two or more veins. When there was a single vein this was usually larger than the artery in external diameter and lay inferior to the artery 76% of the time. When there were two veins or more, there was an interconnection between the two around the artery in over half of the samples (7/12). Surprisingly, three vessels did not have any accompanying vein. This study sheds some light on the variation in venous drainage important to the initial survival of these flap transfers.

The anatomic basis of the gracilis perforator flap

Efstathios G. Lykoudis, Georgia-Alexandra Ch. Spyropoulou, Catherine C. Vlastou — 2005-12-01

Summary: Another perforator flap, the gracilis perforator flap, has recently been added to the armamentarium of reconstructive surgeons. A detailed study of the anatomy of this flap was undertaken in this study. Forty-seven dissections were performed in cadavers and clinical cases of gracilis muscle harvesting for various reconstructive reasons. According to our findings, at least one musculocutaneous perforator of large calibre was found in the majority of the dissections performed (87%), emanating from the proximal third of gracilis. All the perforators were located within a radius of 7cm from the point of entrance of the gracilis main vascular pedicle. In their majority, they emanated proximal to that point (83%) from the middle part (anteroposterior axis) of the muscle (62%). The intramuscular course of the perforators was easily followed and few muscular branches were encountered, before they joined the main vascular pedicle. A sensory branch of the anterior obturator nerve, accompanying the perforators, was occasionally found (29%). Finally, a superficial vein, branch of the greater saphenous, was always found within the skin territory of the flap in all dissections performed in cadavers.

The combined free partial vastus lateralis with anterolateral thigh perforator flap reconstruction of extensive composite defects

N.A.S. Posch, M.A.M. Mureau, S.J. Flood, S.O.P. Hofer — 2005-12-01

Summary: Myocutaneous (MC) free flaps are useful for many reconstructive indications. Perforator flaps have become standard of care. The anterolateral thigh flap (ALT) donor site is popular. With the ALT flap varying sizes of vastus lateralis (VL) muscle can be harvested as a MC flap. The skin islands of these flaps have a great range of freedom when dissected on their perforator. It was hypothesised that the VL–ALT perforator flap would offer adequate tissue volume combining maximal freedom in planning with minimal donor site morbidity. From November 2001 to February 2003 a free partial VL with ALT perforator flap was used in 11 patients to reconstruct large defects. Indications for adding a muscular component were exposed bone, skull base, (artificial) dura, or osteosynthesis material, open sinuses, and lack of muscular bulk. Flaps were planned as standard ALT flaps, after which three types of dissection were performed: I. true MC flap; II. muscle flap with a skin island on one perforator, which could be rotated up to 180°; III. chimera skin perforator flap with muscle being harvested on a separate branch from the source vessel or on a side branch of the skin perforator. Mean skin size of the MC-ALT flaps was 131cm2. Mean muscle part size of the MC-ALT flaps was 268cm3. Muscular parts were custom designed for all defects. No total or partial flap failures were seen. Colour mismatch was seen in 6 of 8 patients, when skin was used in the facial area in this all white population. Excessive flap bulk was found in 8 of 11 patients at 6 weeks, however, only in 2 of 11 patients after 6 months. Patients were satisfied with the functional result (8 of 11 patients) as well as the cosmetic result of their reconstruction (7 of 11 patients). All less satisfied patients had received their flap for external facial skin reconstruction. Donor site morbidity was minimal. The combined free partial VL with ALT perforator flap proved valuable as a (chimera type) MC flap with maximal freedom of planning to meet specific reconstructive demands and minimal donor site morbidity.

The use of pimonidazole to characterise hypoxia in the internal environment of an in vivo tissue engineering chamber

2005-12-01

Summary: The distribution of hypoxic cells in an in vivo tissue engineering chamber was investigated up to 28 days post-implantation.Methods: Arteriovenous loops were constructed and placed into bi-valved polycarbonate chambers containing 2×106 rat fibroblasts in basement membrane gel (BM gel). Chambers were inserted subcutaneously in the groin of male rats and harvested at 3 (n=6), 7 (n=6), 14 (n=4) or 28 (n=4) days. Ninety minutes before harvest, pimonidazole (60mg/kg) was injected intraperitoneally. Chamber tissue was removed, immersion fixed, paraffin embedded, sectioned and stained immunohistochemically using hypoxyprobe-1 Mab that detects reduced pimonidazole adducts forming in cells, where pO2<10mmHg.Results: At 3 days a fibrin clot/BM gel framework filled the chamber. Seeded fibroblasts had largely died. The majority of 3 day chambers did not demonstrate tissue growth from the AV loop nor was pimonidazole binding present in these chambers. In one chamber in which tissue growth had occurred strong pimonidazole binding was evident within the new tissue. In four out of six 7 day chambers a broader proliferative zone existed extending up to 0.4mm (approximately) from the AV loop endothelium which demonstrated intense pimonidazole binding. The two remaining 7 day chambers displayed even greater tissue growth (leading edge>0.7mm from the AV loop endothelium), but very weak or no pimonidazole binding. At 14 and 28 days the fibrin/BM gel matrix was replaced by mature vascularised connective tissue that did not bind pimonidazole.Conclusion: Employing a tissue engineering chamber, new tissue growth extending up to 0.4mm from the AV loop endothelium (chambers≤7 days) demonstrated intense pimonidazole binding and, therefore, hypoxia. Tissue growth greater than 0.5mm from the AV loop endothelium (7–28 days chambers) did not exhibit pimonidazole binding due to a significant increase in the number of new blood vessels and was, therefore, adequately oxygenated.

Accelerated wound healing through the incorporation of basic fibroblast growth factor-impregnated gelatin microspheres into artificial dermis using a pressure-induced decubitus ulcer model in genetically diabetic mice

Katsuya Kawai, Shigehiko Suzuki, Yasuhiko Tabata, Yoshihiko Nishimura — 2005-12-01

Abstract: The objective of this study was to evaluate the effect of incorporating basic fibroblast growth factor (bFGF)-impregnated gelatin microspheres into an artificial dermis on impaired wound healing using a pressure-induced decubitus ulcer model in genetically diabetic mice.Daily 10h prolonged pressure at 500g/cm2 was loaded for 2 consecutive days over the femoral trochanter tertius of mice to produce ischemic necrosis. Five days after completion of the pressure load, the necrotic tissues were resected. Then, an artificial dermis incorporating bFGF-impregnated gelatin microspheres or bFGF in solution was implanted into the wound (n=5). Mice were sacrificed at 5, 7, and 10 days after implantation, and a full-thickness biopsy was taken and stained with hematoxylin and eosin for histological analysis.All experimental animals were infected because diabetic mice have little tolerance for infection. Seven days after implantation, the incorporation of bFGF into the artificial dermis reduced infection and accelerated fibroblast proliferation and capillary formation. However, the accelerated effects were more significant with the incorporation of bFGF-impregnated gelatin microspheres than with free bFGF.We conclude that the incorporation of bFGF-impregnated gelatin microspheres into an artificial dermis induced tissue regeneration in an artificial dermis in an impaired wound healing model.

Bone marrow-impregnated collagen matrix for wound healing: experimental evaluation in a microcirculatory model of angiogenesis, and clinical experience

2005-12-01

Summary: Objectives: This study aims to investigate the effect of collagen matrix impregnated with bone marrow on wound healing angiogenesis in an effective microcirculatory model and to describe our clinical experience.Methods: We used a skinfold chamber of original design which visualises microcirculation following wound creation on the dorsal skin of the mouse to establish an in vivo experimental model to estimate angiogenesis. Animals were divided into two groups: a bone marrow group (n=6) in which bone marrow-impregnated collagen matrix was applied to the wound; and a control group (n=7), in which collagen immersed in saline was applied, and functional capillary density was quantified during the repair process.Results: The increase rate in functional capillary density during wound healing significantly increased in the bone marrow group on days 3, 5 and 7 after creation of the wound but no significant difference was detected on day 10. A patient with a chronic leg ulcer that had not responded to conventional therapy for 1 year was treated with autogenous bone marrow-impregnated collagen matrix and successful wound closure was obtained.Conclusion: The present study suggested that collagen matrix impregnated with bone marrow significantly promoted the repair process, especially in the early stage. The features of the treatment, including the possible use of a patient's own cells, simple method, immediate application without any processing procedure and preservation of the inclusive potentiality of bone marrow suspension, offer significant advantages in terms of the anticipated routine clinical use.

Donor site morbidity in cross-finger flaps

H. Koch, A. Kielnhofer, M. Hubmer, E. Scharnagl — 2005-12-01

Summary: As relevant literature is scarce, this study was undertaken to assess the donor site morbidity of cross-finger flaps. It included 23 patients who had undergone reconstruction of a finger defect with a cross-finger flap. Any additional trauma to the donor finger was an exclusion criterion. Split thickness skin grafts were employed for donor site closure in 13 cases, full thickness skin grafts were used in 10 cases. Follow-up time averaged 83 months. Active and passive total range of motion of the donor finger and maximal pinch grip strength in kilopascals were measured. Both parameters were compared to the corresponding finger of the other hand. The donor site scar was evaluated for instability and pain in the donor finger was determined subjectively with a visual analogue scale. Cold intolerance and the cosmetic appearance of the donor site were also assessed.Active total range of motion of the donor fingers averaged 156°. Average active total range of motion of the contralateral control fingers was 173.6°. There was a significant difference between the donor fingers and the control fingers (p=0.03) but not between split thickness and full thickness grafted donor sites (p=0.91). Grip strength was significantly impaired in the donor fingers (p=0.03), but there was no significant difference between split thickness and full thickness grafted donor sites. Subjective cosmetic evaluation by the patients revealed significantly better results for full thickness grafted donor sites. Donor finger pain averaged 2.4 with a range of 0–8. Five of the 13 patients with split thickness grafted donor sites and two of the 10 patients with full thickness grafted donor sites mentioned cold intolerance.In conclusion, the cross-finger flap is a secure and valuable option. There is, however, significant donor site morbidity. Our results suggest that alternative solutions should also be considered and if a cross-finger flap is employed, donor sites should be closed with full thickness grafts.

Carpal tunnel syndrome: comparison of intraoperative structural changes with clinical and electrodiagnostic severity

D. Tuncali, A. Yuksel Barutcu, A. Terzioglu, G. Aslan — 2005-12-01

Summary: The aim of this study is to grade the intraoperative findings seen in carpal tunnel syndrome (CTS) based on severity, and compare it with clinical and electrodiagnostic severity.Thirty-one hands surgically treated for CTS were graded according to the severity of clinical signs, and electrodiagnostic tests. Oedema, vascularisation, and fibrosis were graded on a scale of 1–3. Pseudoneuroma or ‘hour-glass’ formation were graded as either 0 or 1. The hands were allocated by an observer into an assumptive severity group, from grade 1 to 3. Clinical severity and electrodiagnostic severity were statistically compared with each other, and with each intraoperative severity criteria.A high statistical correlation (p<0.01) was found between clinical severity and vascularisation, fibrosis, and the assumptive intraoperative severity. No correlation could be demonstrated between electrodiagnostic severity and the intraoperative criteria.Intraoperative grading should be regarded as a supportive measure to the clinical evaluation in order to obtain a sound base for surgical intervention and internal neurolysis.

Extensive facial adenoma sebaceum: successful treatment with mechanical dermabrasion: case report

Kusai A. El-Musa, Ramzi S. Shehadi, Sameer Shehadi — 2005-12-01

Summary: This report documents the successful elimination of disfiguring sebaceous adenomas from the face of a 21-year-old male patient with mechanical dermabrasion.

Correction of long term joint contractures of the hand by distraction. A case report

2005-12-01

Summary: Joint contractures are a common complication of hand trauma. The conventional treatment consists of arthrolysis, tenolysis and occasionally arthrodesis. Frequently, this does not achieve a good result, particularly when there has been a long delay in presentation. Progressive lengthening of a joint by distraction (joint distraction) allows the release of joint contractures even in cases of failure of traditional methods.We present a case of a delayed (20 years) work related traumatic flexion deformity of the PIP joint of the left index and middle fingers. This was the result of a complete division of both flexor tendons of both fingers.The range of movements, both active and passive, was limited to 90/100° in the index finger and 95/100° in the middle finger. Following joint distraction using our lengthening device (Antão™, Portugal) the patient was able to achieve an active and passive range of movements of 10/100° for the PIP joint of the index finger and 40/100° of the middle.This clinical case shows the simplicity and application of our technique for the correction of joint contractures.

Post-ablative reconstructon of the medial canthus and medial orbital wall using conchal cartilage graft with three illustrative cases

G. Dagregorio, V. Darsonval — 2005-12-01

Summary: When the medial third of the upper or lower eyelid has to be reconstructed after full-thickness tumour excision, we usually use Hübner tarsomarginal grafts, but when medial canthal lesions spread to the medial orbital wall without invading the orbital margin, conchal graft becomes our first surgical option. Previously reported solutions to this difficult problem are few and concern more directly medial orbital wall fractures. We found no article dealing specifically with the use of conchal graft in post-ablative reconstruction of the medial orbital wall. Nevertheless the concha presents great advantages over bone grafting or rib cartilage, because it is more flexible and malleable. And it is less prone to extrusion or infection as may be allografts implants. It is a very effective way to repair medial orbital defects, but graft reorientation must be perfect to match exactly the medial orbital wall concavity.

Superficial sural artery flap—a study in 40 cases

António Costa-Ferreira, Jorge Reis, José Amarante — 2005-12-01

We have read with interest the article Superficial sural artery flap—a study in 40 cases by S.S. Raveendran et al. The author's present their experience with 40 flaps and concluded that it is a safe and reliable option to treat large soft tissue defects of the distal lower limb and the proximal foot.

An adherent dressing for aplasia cutis congenita

S. Azad, S. Falder, J. Harrison, K. Graham — 2005-12-01

Aplasia cutis congenita is a rare, congenital disorder of the skin, which is present at birth and most commonly involves the scalp. The main complications include bleeding and infection. We present our experience, with a premature baby with aplasia cutis congenita, involving the vertex of the scalp, with a defect measuring 7×6cm2. The defect was managed with a Biobrane® dressing from the 1st week after birth. The adherent dressing was used for a sustained period of time allowing the baby to convalesce and gain weight. The child had bleeding from the scalp but was subsequently successfully skin grafted. The case illustrates Biobrane® as a useful temporising measure, before definitive therapy.

N. Kang — 2005-12-01

The basic premise of this book is sound. The body of knowledge on basic science which is now available and relevant to surgery is immense and getting larger by the second. Not all of it is relevant to clinical practise but we must all get to grips with this knowledge if we are to put it into practise for the benefit of our patients. A book which is able to summarise the state of the art and bridge the gap in basic science knowledge from ‘medical school into surgical training before the resident sub-specialises’ would be invaluable.

List of reviewers

2005-12-01

The Editor would like to thank the following people, who reviewed manuscripts for the journal during the last year.

Notices

2005-12-01