British journal of plastic surgery最新文献

Replantation of digits following avulsion amputation is a challenge due to the severity of damage to the digital vessels. When the digital vessels are absent or severely injured, standard artery-to-artery or vein-to-vein anastomoses may be impossible and arteriovenous shunting can be used as a salvage procedure for arterial inflow or venous drainage. Previous cases of successful replantation of avulsed digits that were reperfused using afferent arteriovenous shunting reported small segments of tissues only, usually at the level of the distal phalangeal joint or distal to it. Our case demonstrates that afferent arteriovenous shunting can also provide adequate perfusion to a large piece of tissue in the thumb even when the amputation level is at the interphalangeal joint.

Motor recovery after proximal nerve injury remains extremely poor, despite advances in surgical care. Several neurobiological hurdles are implicated, the most fundamental being extensive cell death within the motorneuron pool. N-acetyl-cysteine almost completely protects sensory neurons after peripheral axotomy, hence its efficacy in protecting motorneurons after ventral root avulsion/rhizotomy was investigated.

In adult rats, the motorneurons supplying medial gastrocnemius were unilaterally pre-labelled with retrograde tracer (true-blue/fluoro-gold), prior to L5 and 6 ventral root avulsion, or rhizotomy. Groups received either intraperitoneal N-acetyl-cysteine (ip, 150 or 750 mg/kg/day), immediate or delayed intrathecal N-acetyl-cysteine treatment (it, 2.4 mg/day), or saline; untreated animals served as controls. Either 4 (avulsion model) or 8 (rhizotomy model) weeks later, the pre-labelled motorneurons' mean soma area and survival were quantified.

Untreated controls possessed markedly fewer motorneurons than normal due to cell death (avulsion 53% death; rhizotomy 26% death, P<0.01 vs. normal). Motorneurons were significantly protected by N-acetyl-cysteine after avulsion (ip 150 mg/kg/day 40% death; it 30% death, P<0.01 vs. no treatment), but particularly after rhizotomy (ip 150 mg/kg/day 17% death; ip 750 mg/kg/day 7% death; it 5% death, P<0.05 vs. no treatment). Delaying intrathecal treatment for 1 week after avulsion did not impair neuroprotection, but a 2-week delay was deleterious (42% death, P<0.05 vs. 1-week delay, 32% death). Treatment prevented the decrease in soma area usually found after both types of injury.

N-acetyl-cysteine has considerable clinical potential for adjuvant treatment of major proximal nerve injuries, including brachial plexus injury, in order that motorneurons may survive until surgical repair facilitates regeneration.

For 1378 patients treated in the 11 years 1988–1998 by conventional excision of 1635 basal cell carcinomas, 1516 first index lesions were histologically completely excised.

All patients having more than one BCC excised were identified from the data base from 1988 to 2003 to give minimum 5 years follow for last treated primary lesions in 1998. Measured clearance margins around the initial lesions at or near sites of presumptive recurrent lesions were noted and the lesions recorded photographically. All incompletely excised lesions whether or not re-excised were excluded.

The median age for all patients was 70 years. Over minimum 5 years follow up, six patients developed nine subsequent lesions contiguous with the scar or graft repair of primary index lesion excision site (probable recurrences). The median interval to recurrence was 41 months (4 months–8 years 10 months), with median lateral clearance margin around the primary tumour of 2 mm (0.3–6.8 mm).

A further nine patients developed 11 new lesions near (within 1 cm of) the scar or graft of primary index lesion excision site (possible recurrences). The median interval to recurrence was 59 months (1 year–8 years 6 months). The median lateral clearance margin around the primary tumour was 4.1 mm (0.8–5.8 mm). For the two groups combined the maximum recurrence rate expressed as a percentage of index lesions was 1.3% (20/1516). Two thirds of possible and probable recurrences occurred in the temple and forehead, although these sites represented only 22% of all lesions, which may rather suggest new lesions in an area of field change as opposed to residual disease.

The measured clearance margins reported here perhaps suggest that some original lesions may well have been completely excised primarily and many ‘recurrences’ were new primaries.

These figures indicate there is a low order of probability for the incidence of recurrent basal cell carcinoma during minimum 5 years follow period after conventional surgical excision and conventional histological assessment of tumour resection margins.

We report the case of a large venous malformation of the tongue, preventing the patient from being able to contain it within the oral cavity. The extent of the malformation precluded a complete surgical excision. The immediate problems were; impending airway compromise, inability to speak, eat or drink, severe discomfort due to exposure-induced dryness and an embarrassing spectacle. This case demonstrates that even malformations considered to be incurable may be managed appropriately.

Angiolymphoid hyperplasia with eosinophilia (ALHE) is an uncommon benign, idipathic vasculoproliferative condition manifested by multiple or solitary subcutaneous nodules, usually in the head and neck region of young adults. It is very rare in the extremities especially in the hands. Although recurrence is common, surgical excision is still regarded as the treatment of choice. We report an 11-year-old girl with histologically confirmed ALHE on the dorsum of her left hand, which underwent complete spontaneous regression within 10 weeks. Angiolymphoid hyperplasia is a benign disease and it is important to recognise this condition so that early superficial lesions can be observed for 3–6 months pending spontaneous regression.

The authors present eight cases of lower eyelid reconstruction after extended excision of cutaneous carcinomata. To recreate the supporting function of the lower eyelid it is necessary to reconstruct a rigid structure, which must replace the tarsus and has to be covered by sufficiently thin skin. A condrocutaneous helix island flap, based on the frontal branch of the temporal artery, allows us to reconstruct both lamellae of the eyelid at the same time. The reverse flow to the flap through this vascular pedicle is assured by the anastomotic branches from the supratrochlear and supraorbital arteries. Using this flap we have been able to recreate morphology and function of the lower eyelid with a good cosmetic result in the donor site as well.

Hibernoma is a rare benign tumour of brown fat. In most cases it presents as a voluminous slow-growing mass in the regions where remnants of brown fat can remain in adults. We report a case of a hibernoma on the thigh and present the diagnostic and therapeutic elements of this type of tumour, whose differential diagnosis of liposarcoma.

Quantification of sensory recovery after peripheral nerve surgery is difficult and no accurate techniques are available at present. Quantification of reinnervated skin has been used experimentally, and in some clinical studies, but the lack of knowledge about the normal sensory distribution has been a problem. The purpose of this study was, therefore, to map the density of sensory end organs, nerve fibres and free nerve endings in the glabrous skin of the human hand.

Skin biopsies were taken from patients undergoing acute and elective hand surgery. Nerve fibres were stained in the epidermis and papillary dermis and quantified in five sites on the palm of the hand, using protein gene product 9.5 immunoreactivity—a panneuronal marker.

The finger tip skin was found to have more than twice the nerve fibre density in the papillary dermis than the skin of the palm, and the number of Meissner corpuscles in the finger tip was also higher than in the palm. We found a reduction in innervation density with increasing age in the dermis, however, that was not the case for the epidermis. The innervation of the epidermis showed high interindividual variability and unlike the papillary dermis did not display any pattern of distribution in the hand.