Download 2011 Plastic Surgery Congress supplement

ANZJSurg.com supplement
2011 Plastic Surgery Congress
Australian Society of Plastic Surgeons | New Zealand Association of Plastic Surgeons
Abstracts from the
2011 Plastic Surgery Congress
Wednesday 6 to Sunday 10 July 2011
Gold Coast Convention and Exhibition Centre,
Broadbeach, Queensland, Australia
Hosted by the Australian Society of Plastic Surgery
(ASPS) and the New Zealand Association
of Plastic Surgeons (NZAPS)
Supplement published by ANZJSurg.com
1
ANZJSurg.com supplement
2011 Plastic Surgery Congress
Australian Society of Plastic Surgeons | New Zealand Association of Plastic Surgeons
Oral Abstracts
ABSTRACT 7
MANAGEMENT OF PIP IMPLANTS – A SINGLE
PRACTISE EXPERIENCE
ABSTRACT 29
THE USE OF INTERPOSITIONAL A-V-A VENOUS
FLOW-THROUGH FLAPS FOR
RECONSTRUCTION OF VOLAR SOFT TISSUE
DEFECTS IN SEVERE DUPUYTREN’S
CONTRACTURE
Timothy Cooper
Rodin Clinic, Nedlands, WA, Australia
K Bjorklund, D Brooks, A Islur
The PIP implant controversy became public in early
2010. The author had used a large number of PIP
implants in the period 2005 to 2007. The paper
details the authors approach to managing the
problem.
Section of Plastic Surgery, University of Manitoba,
Winnipeg, Canada & Dept of Microsurgery, The
Buncke Clinic, San Francisco, California, USA
Introduction: In severe or recurrent Dupuytren’s
disease significant dermal involvement may be
present. Radical fasciectomy may result in
exposure of tendons and neurovascular bundles. In
such cases, venous flow-through flaps (VFTF)
provide an alternative reconstructive option.
ABSTRACT 11
REJUVENATION OF THE FACE WITH FAT
COMBINED WITH PRP
Mohammed AlNasir
Specialist Hospital, Saudi Arabia
Methods: We present five cases in which VFTF’s
were used for reconstruction of volar soft-tissue
defects following release of long-standing
Dupuytren’s contracture. All patients presented with
MCP flexion contracture greater than 40° and PIP
contracture greater than 85°. All had significant
dermal involvement and 3 of 5 patients presented
with recurrent disease. Treatment for all patients
included radical fasciectomy, PIP volar plate and
collateral ligament release. Palmar or digital volar
soft tissue defects with exposed flexor tendon
sheath and neurovascular bundles occurred in all
patients. VFTF’s were harvested from the distal
ipsilateral forearm and anastomosed in an A-V-A
type fashion. Flaps ranged in size from 3x2 cm to
8x2 cm. Anastomosis was performed with the digit
in full extension. Range of motion began 1 week
post-operatively.
Introduction: Fat has been used for the last 20
years to augment and complement different body
parts.
The use of fat combined with PRP (plasma RiCH
Platelets) is relatively new.
Patients and Methods: 35 patients underwent fat
injection combined with prp between April 2010 and
Dec 2010 in different facial parts: cheeks, lips,
periorbital, forehead and preauricular area.
All patients were satisfied with results at 6 months
especially in the 15 patients who had fat injection
alone in the past and they reported a superior result
of fat prp compared with just fat.
Results: All patients underwent MRI study 1 week
and at 6 months after the injection the results of the
MRI at 6 months showed 10% resorbtion of the fat
compared with 30-50% resorbtion rate of only fat
injection reported in the literature.
Results: VFTF’s survived in all patients. Significant
epidermolysis occurred in 1 patient; however,
healing went on to occur uneventfully. Range of
motion improved significantly in all patients. No
secondary operations were necessary and no
recurrence of Dupuytren’s contracture has occurred
Conclusion: Facial rejuvenation with fat combined
with PRP is an excellent method with high patient
satisfaction rate.
Discussion: VFTF’s provide a reconstructive
method for severe Dupuytren’s contracture with
numerous advantages: wellvascularized soft-tissue
coverage of exposed structures; A-V-A interposition
design allows full and immediate extension of the
digit without vascular compromise; and
reconstruction is not limited by size or location of
defect.
2
ANZJSurg.com supplement
2011 Plastic Surgery Congress
Australian Society of Plastic Surgeons | New Zealand Association of Plastic Surgeons
ABSTRACT 30
THE HISTOLOGIC DISSECTION OF
MICROVESSELS WITH MONOPOLAR CAUTERY:
ARE WE GETTING BURNED?
ABSTRACT 31
EARLY MANAGEMENT OF SEVERE FACIAL
TRAUMA WITH FREE MUSCLE TRANSFER
David Colbert, James Savundra, Brigid Corrigan,
Anthony Williams
K Bjorklund, D Grynspan, T Hayakawa, E Buchel, S
Logsetty
Dept of Plastic and Reconstructive Surgery, Royal
Perth Hospital, Perth, WA, Australia
Section of Plastic Surgery, University of Manitoba,
Winnipeg, Manitoba, Canada
Severe facial trauma can result in challenging
reconstructive problems for the plastic surgeon.
Traditional treatment has included serial
debridement and delayed bony and soft tissue
reconstruction, with multiple operations and soft
tissue contractures potentially resulting in
suboptimal aesthetic and functional outcomes. We
report two cases of complex head and neck trauma
treated with early aggressive wound debridement
and free tissue transfer during the initial operation.
The first, a 51 year old truck driver with a
penetrating right sided facial injury from a steel rod,
was managed with rigid fixation of his mandibular
fractures and an immediate gracilis muscle free flap.
The second, a 14-year-old female pedestrian hit by
a motor vehicle at high speed and dragged along
the road, sustained an open head injury associated
with a large skull defect and significant soft tissue
degloving. Management included aggressive wound
debridement and an immediate latissimus dorsi
muscle free flap. Both patients’ wounds have
healed well with satisfactory functional and
aesthetic outcomes. We feel that complex
composite traumatic facial defects can be safely
and effectively treated with early debridement and
the immediate transfer of free tissue.
Purpose: Cautery is routinely used by our surgeons
in the dissection of microvessels for free flaps. The
associated flap failure rate for DIEP’s is less than
2%, better than published results (5-10%). The
current literature suggests that endothelial damage
and thrombosis occurs when cautery is used for
dissection of vessels. We embarked on this study to
determine what cautery injury, if any, occurred to
microvessels.
Methods: Following ethics approval, samples were
taken from recipient vessels of patients undergoing
breast reconstruction with DIEP free flaps. These
were sectioned and stained with H&E. A single
pathologist reviewed them for features of thermal
injury. Cautery settings were recorded for each
sample.
Results: Nineteen cases and one control were
collected. Histological orientation and small size of
sample precluded analysis of 3 veins. The control
showed no arterial changes, but segmental
hypereosinophillia was noted in the vein. Of the
cautery samples, only 1/19 arteries showed mild
histological features suggestive, but not conclusive
for cautery effect. 1/16 veins showed segmental
changes suggestive of cautery artifact. Two
additional veins showed extensive
hypereosinophillia.
ABSTRACT 39
SUBPERIOSTEAL MIDFACE LIFT – REVIEW OF
114 CONSECUTIVE CASES
Conclusions: Our study suggests that the use of
cautery within 1-2mm of microvessels does not
produce significant damage. Histologically, the
arteries were well preserved and showed minimal
damage. The veins showed more changes but
these features may be an artifact of tissue handling
or processing; more controls are needed. Overall,
these findings confirm that cautery is safe and
efficient for use in dissection of microvessels and
does not correlate to the setting.
James Trott
Trott Plastic & Cosmetic Surgery Centre, Adelaide,
SA, Australia
This retrospective study is of 114 consecutive cases
having a subperiosteal midface lift for rejuvenation
of either the lower eyelid or anterior cheek or both.
All procedures were done by the author and have at
least 6 months follow up.
3
ANZJSurg.com supplement
2011 Plastic Surgery Congress
Australian Society of Plastic Surgeons | New Zealand Association of Plastic Surgeons
The aim of the study was to determine the following:
performed showed all cases having positive staining
for CD34 and negative for EMA and S100 protein.
All patients had surgical excision of the lesion to
confirm the diagnosis. Follow-up was possible for
three out of four cases at 2 years, 6 years and
7years with recurrence in two cases.
• Time taken for recovery from the possible
consequences of the procedure – e.g. pain swelling
numbness & abnormal mouth movements.
• Any complications.
Conclusion: In summary all four cases displayed
clinical and pathological features consistent with
current reports of this tumour in the literature. SAF
is slow growing benign soft tissue tumour with
symptoms secondary to local pressure effects.
Recurrence is well documented in the literature and
has been our experience in at least two patients in
this case series. Increasing awareness of this
pathological entity with more reported cases
highlights that this tumour may not be as rare as
once thought.
• Any unresolved or new aesthetic issues.
• The need for any secondary procedures.
• The patient’s perspective of the outcome & the
time for return to social interaction.
Methodology involved examining the case records
& photographs of the first 114 patients undergoing
this procedure. A questionnaire was then sent to
each patient along with a copy of their before &
after photographs. 55 patients provided meaningful
responses. An analysis of this material will be
presented.
ABSTRACT 42
THE STINGRAY FLAP: A MODIFICATION OF
THE KEYSTONE FASCIOCUTANEOUS
PERFORATOR FLAP
ABSTRACT 40
SUPERFICIAL ACRAL FIBROMYXOMA: A
CLINICOPATHOLOGICAL ANALYSIS OF THE
FIRST FOUR CASES OF THIS NEW
PATHOLOGICAL ENTITY TO BE REPORTED IN
AUSTRALIA
L Wetton, L Teston
Bankstown Hospital, Sydney, NSW, Australia
It is widely reported that the Keystone island flap is
a simple and time efficient reconstructive technique
1
that reduces the need for skin grafting . The shape
2
of the flap provides structural advantages and the
use of local tissues provides an aesthetically
pleasing outcome.
Linda Monshizadeh, Robert Love
Sir Charles Gairdner Hospital, Perth, WA, Australia
Superficial Acral fibromyxoma is a rare soft tissue
tumour with predilection for the extremities. It was
first described by Fetsch et al.¹ in 2001 and is now
gaining widespread acceptance as a specific entity.
We describe the first case series in Australia of four
such patients.
The area of greatest tension lies at the centre of the
3
original defect in the Type I keystone island flap.
These cases demonstrate the successful use of a
modification of the keystone island flap, which has
been successfully used in the upper and lower limb.
In this modification the original defect is closed in a
fish-mouth fashion, utilizing skin, which is routinely
excised with the tumour. This reduces the tension at
the maximum tension site. We maintain the
dimensions of the flap, but the modification allows
the width of the inset flap to be wider and therefore
provides more versatility for the flap use. Apart from
a recent letter to the editor where a similar
modification has been used in one case, we are not
aware of any other large-scale use of this
modification having been reported in the literature.
Aim: To examine a case series of superficial acral
fibromyxoma and compare clinicopathological
features of these with previously documented cases
described in the literature.
Methods and Results: Four cases were studied.
Details were obtained from pathology records over
the past twenty years. All patients were male with
mean age of 51, presenting with a mass or nodule
of average size 1.5cm. Sites of the lesions included
the middle finger (subungual), great toe (subungual)
in two cases and the sole of the foot. Histologically,
all tumours showed proliferation of spindle cells
arranged in a storiform or fascicular arrangement
within a mixture of myxoid and collagenous stroma.
There was no evidence of pleomorphism or
malignancy. Immunohistochemical studies
References:
Findlay M. Demystifying the Keystone Island Flap: a
Simple single technique well suited to both simple
4
ANZJSurg.com supplement
2011 Plastic Surgery Congress
Australian Society of Plastic Surgeons | New Zealand Association of Plastic Surgeons
and complex surgery. ANZ J.Surg, 2010; 80(Suppl.
1) A76-A77.
Dept of Plastic, Reconstructive, Hand and Burn
Surgery, BG-Trauma Centre, Eberhard Karls
University Tuebingen, Germany
Behan F. The Keystone Design Perforator Island
Flap in Reconstructive Surgery. ANZ J. Surg. 2003;
73:112-120
The blood supply of microvascular free flaps is
rated as very critical. Some aspects of the DIEP flap,
even though they have been extensively
researched, remain controversial and results seem
contradictory. To shed further light onto the
perfusion dynamics of the DIEP flap we performed
various studies:
Rao K, Raine C. Letter to the Editor Re: Keystone
design flap: tension-reducing modification.
Doi:10.1111/j.1445- 2197.2010.05392.x ANZ J Surg
2010.
ABSTRACT 43
MICROVASCULAR ANASTOMOSIS USING THE
VASCULAR CLOSURE DEVICE IN FREE FLAP
RECONSTRUCTIVE SURGERY: A 13-YEAR
EXPERIENCE
1. A comparison of arterial perfusion of the DIEP
flap in an anatomical and clinical setting, based on
single perforator rows.
2. A study on the venous outflow of DIEP flaps and
the benefits of supercharging
Chaitan Reddy, David Pennington, Harvey Stern
3. A postoperative follow-up and analysis of the
perfusion of the DIEP flap.
Dept of Plastic and Reconstructive Surgery, Royal
Prince Alfred Hospital, Sydney, NSW, Australia
Our results were concurrent with many previous
findings but also revealed new aspects that may be
critical in the clinical implementation of the DIEP
flap.
The achievement of patency of the microvascular
anastomosis in free flap surgery is dependent on a
number of factors, central to which is atraumatic
handling of the vessel lumen, and intimal apposition.
Initial laboratory studies demonstrating the
superiority of the non-penetrating vascular closure
staple (VCS – Anastoclip ®) were followed by our
report in 1999 on a series of free flaps. There is still
a paucity of data in the literature on the use of
nonpenetrating devices for microvascular
anastomosis, and our review gives evidence to
support the routine use of the VCS in microsurgical
free flap surgery. We now report on its successful
use over a thirteen year period in 819 free flap
reconstructions. Our data indicates the VCS device
to be as effective as sutured anastomoses in free
tissue transfer surgery. There is also statistically
significant data to demonstrate a higher vascular
patency rate of the VCS device over sutured
anastomoses when sub group analysis is performed.
Furthermore, the major advantage of the VCS is
reduction in anastomosis time, from approximately
25 minutes per anastomosis for sutures to between
five and ten minutes for staples.
1. The perfusion dynamics of Patient’s DIEP flaps
show no significant difference (p 0.05) between the
two immediately adjacent zones, regardless of the
use of lateral or medial perforator rows.
2. Supercharging with the contralateral SIEV
showed a significantly better venous drainage of the
contralateral zones.
3. On the 3rd postoperative day, there was a
decrease in the cutaneous oxygen saturation of 22
percent and a decrease in blood flow of 18 percent
on average.
These results highlight the need for further research
for the complete understanding of the perfusion
dynamics of the Diep flap. Based on our findings we
believe:
1. The selection of the DIEP-zones should be
assessed individually depending on the anatomy in
question and the characteristics of the perforators,
ABSTRACT 46
A PERIOPERATIVE ANALYSIS OF THE DEEP
INFERIOR EPIGASTRIC PERFORATOR FLAP:
ARTERIES, VEINS AND ZONING
2. That the supercharging of the contralateral SIEV
leads to an improved venous outflow and thus a
higher flap survival by reduction of venous
congestion,
A Amr, J Rothenberger, B Hirt, O Lutz, HE Schaller,
A Rahmanian-Schwarz
3. A careful postoperative monitoring of the Diep
flap, especially on the 3rd postoperative day may
increase flap survival.
5
ANZJSurg.com supplement
2011 Plastic Surgery Congress
Australian Society of Plastic Surgeons | New Zealand Association of Plastic Surgeons
ABSTRACT 49
INTERPRETATION AND APPLICATION OF THE
GUSTILO TYPE 3C CLASSIFICATION: A
PROPOSAL FOR MODIFICATION
the flap to protect the inset (split). Our aim was to
determine which approach results in less necrosis.
Methods: A pedicled pectoralis profundus muscle
flap was raised in 32 Sprague-Dawley rats and
transposed to the lateral chest wall. 21 days later,
flaps were randomised into one of four treatment
groups according to the surgical approach (marginal
or split) and whether or not the vascular pedicle was
ligated. Necrosis was assessed 48 hours later; both
clinically and by analysis of digital photographs.
Tom Wigglesworth, Umraz Khan
Dept of Plastic Surgery, Frenchay Hospital, Bristol,
United Kingdom
Introduction and Aims: This study aims to
improve the clinical outcome of sever lower limb
injuries by providing clarity and consistency in the
application of the Gustilo Type 3C classification.
Methods: Interpretation of a 3C injury was
assessed based on the number of axial lower limb
arteries intact. A questionnaire was distributed to
surgeons registered in BAPRAS and BOA 2008
directories. Results were analysed according to
speciality and grade.
Results: The rate of necrosis in the marginal group
was higher than the split group (63% vs 0%,
p<0.001, McNemar). More necrosis occurred in the
former when the pedicle was ligated (p<0.001,
Fisher’s exact). Measured necrosis was also higher
in the marginal group (18% vs 0%, p=0.002,
Wilcoxon signed ranks). 29% more flap could be
raised using the split approach (p=0.001, MannWhitney U).
Results: 159/476 (33.4%) BAPRAS members and
594/2875 (20.7%) BOA members responded; 418
consultants 193 registrars. 37.5% defined a 3C
injury as ‘complete devascularisation of the wound
site and below’, 6.2% as ‘one of three lower limb
vessels intact’, 13.4% as ‘two of three lower limb
vessels intact’. 18.9% felt unable to answer due to
retirement or specialisation. 24.1% believed all or
none of the answers defined a 3C injury.
Conclusion: In our model, splitting the flap
produces significantly less necrosis, regardless of
status of the pedicle. It also offers more exposure of
structures deep to the flap. These findings are
important because they provide a detailed model for
testing, which is presented as a proposed
management algorithm. It also highlights conditions
that must be met for translation to a human
population.
Conclusion: Confusion surrounds the correct
interpretation of a Gustilo Type 3C injury. To aid
application of the classification, we propose that a
Type 3C injury defines only one lower limb vessel
intact, whereas a Type 3C+ is a devascularised limb.
Using this, surgeons may be more consistent in
their selection of appropriate management options,
therefore improve clinical outcome is lower.
ABSTRACT 54
MATHEMATICAL MODELLING OF THE TIBIA
FOR THE DESIGN OF A PERIOSTEAL
RECONSTRUCTION IN TRAUMA
S Allison, M Wagels, S Senewiratne, D Rowe, DR
Theile, P Jenkins
Princess Alexandra Hospital, Brisbane, QLD,
Australia
ABSTRACT 53
RE-RAISING MUSCLE FLAPS: A
RAONDOMISED CONTROLLED ANIMAL STUDY
Introduction: Infection and non-union are feared
complications of compound tibial injuries. Use of a
corticoperiosteal descending genicular artery free
flap to treat established tibial non-union has been
2
described with 15-20cm of periosteum available
(Cavadas and Landin, 2008). The ability of a formal
periosteal reconstruction to prevent non-union has
never been investigated. The first stage in pursuing
this is to accurately estimate the area of periosteum
required.
Michael Wagels, Shireen Senewiratne, Dan Rowe,
David R Theile
Princess Alexandra Hospital, Brisbane, QLD,
Australia
Introduction: 30-70% of reconstructed compound
lower limb injuries will need to be re-exposed. 25%
will need revision after the re-exposure if muscle is
used. Re-exposure is achievable by re-raising the
inset to protect the pedicle (marginal) or by splitting
Methods: Length and girth at five points were
measured in five human cadaveric skeletons. This
data was analysed (Geogebra 3.2.0, 2009) to
6
ANZJSurg.com supplement
2011 Plastic Surgery Congress
Australian Society of Plastic Surgeons | New Zealand Association of Plastic Surgeons
create a three-dimensional mathematically
modelled tibia from which the relationship between
length and circumferential surface area were
extracted and represented graphically.
returned in the combined time period of 2009 and
2010 (p=0.03). Distance from CSC was a significant
factor in predicting whether a patient would return
for SLT (<20km = 50%, >20km=30.4% return,
p=0.033).
Results: A case report is presented to demonstrate
the utility of the model in estimating the area of
periosteum required to cover a given defect in a leg
of any size. A moderate amount of periosteal
stripping (12cm) translates to a circumferential
2
periosteal requirement of 70cm .
Introducing multidisciplinary cleft care teams in the
developing world presents many challenges.
Although uptake is improving, return for SLT
remains low. The factors contributing to this must
be identified and solutions generated. Cellphone
and internet-based telecommunication technologies
may represent a potential solution to a number of
these barriers.
Conclusion: Large amounts of periosteum are
required if a formal periosteal reconstruction is to
become part of primary lower limb reconstruction
after trauma. This need cannot be met by existing
periosteum containing flaps. Realising this is
important in designing a suitable periosteumcontaining flap and studies that compare its effect
on non-union rates with conventional soft tissue
reconstructions.
ABSTRACT 56
THE SUPERIOR THYROID ARTERY
PERFORATOR (STAP) FLAP FOR HEAD AND
NECK RECONSTRUCTION: ANATOMICAL
STUDY AND CLINICAL SERIES
Jeremy Wilson¹, Warren Rozen¹, Richard Ross²,
Michael Findlay¹, Mark Ashton², Felix Behan³
ABSTRACT 55
THE CHALLENGES OF INTRODUCING
MULTIDISCIPLINARY CLEFT PALATE CARE IN
THE DEVELOPING WORLD
¹Peter MacCallum Cancer Institute, East Melbourne,
VIC, Australia
Daniel Butler, Nabil Samman, Jim Gollogly
²Royal Melbourne Hospital, Parkville, VIC, Australia
Children’s Surgical Centre (CSC), Phnom Penh,
Cambodia
³Western Hospital Melbourne, Footscray, VIC,
Australia
In the developing world there remains a lack of any
integrated post-operative care pathway for patients
with a cleft palate. Subsequently, the focus on
enhancing the care of patients born with a cleft
palate in the developing world is moving towards
generating the skills and resources required to form
local multidisciplinary cleft care teams. An area
receiving particular attention is speech and
language therapy (SLT). The potential success and
practicalities of introducing these programmes
remains unknown.
Background: Locoregional options for head and
neck reconstruction are sparse, with existing
options limited in their utility by both donor site
morbidity and robustness. A recently described flap
has involved the use of redundant anterior neck
skin to reach defects as cranial as the temple. We
undertook an anatomical study to identify the
vascular basis for this flap, and to modify flap
design to improve its versatility and donor morbidity.
Methods: Thirty-five consecutive computed
tomographic angiograms (CTAs) of the neck were
reviewed, assessing the vascular supply of the
anterior skin of the neck. Based on these findings, 5
consecutive patients underwent head and neck
reconstruction using a flap based on the dominant
perforator of the region.
In 2008 there were no speech and language
therapists in Cambodia and so a project began to
train one of the health care professionals working at
CSC to become a speech and language therapist.
We report the performance of this programme and
the patient-specific factors that impact upon
whether they return for follow-up.
Results: In all cases, a perforator over 0.5mm was
identified within a 2cm radius of the midpoint of
sternocleidomastoid at its anterior border. This
perforator was seen to emerge through the
investing layer of deep cervical fascia as a
fasciocutaneous perforator, and to perforate the
platysma on its ipsilateral side of the neck, proximal
Patients that underwent primary cleft palate repair
between January 1st 2008 and June 30th 2010
were identified. The overall return for SLT was
35.3%. The return for therapy in 2008 was 23.5%,
which was significantly lower than the 41.4% that
7
ANZJSurg.com supplement
2011 Plastic Surgery Congress
Australian Society of Plastic Surgeons | New Zealand Association of Plastic Surgeons
to the midline. This was seen to be a superior
thyroid artery perforator (STAP) in 29 of 30 cases
and an inferior thyroid artery perforator (ITAP) in 1
case. Five consecutive patients underwent
preoperative imaging and successful flap planning
and execution based on this dominant perforator.
expense of a statistically significant increase in
patient reported post-operative swelling. No
objective benefits were derived in terms of reducing
ecchymosis, haematoma or pain.
ABSTRACT 60
THE ‘MESENTERIC WRAP’ AS SOFT TISSUE
AUGMENTATION IN OESOPHAGEAL
RECONSTRUCTION WITH THE FREE JEJUNAL
FLAP
Conclusion: The STAP flap is a newly described
flap, with reliable vascular anatomy and broad
application for head and neck reconstruction.
ABSTRACT 59
POST-OPERATIVE HILOTHERAPY IN SMASBASED FACELIFT SURGERY: A PROSPECTIVE,
RANDOMISED, CONTROLLED TRIAL
Thomas E Pennington, Nora Nugent, Elias Moisidis
BM Jones, R Grover, JP Southwell-Keely
The free jejunal flap has become a ‘workhorse’ flap
in oesophageal reconstruction post-total
laryngopharyngectomy. Amongst the more serious
complications is salivary fistula formation caused by
anastomotic leakage. This can lead to erosion into
vital structures, including the carotid vessels, with
catastrophic consequences.
St Vincent’s Hospital, Darlinghurst, Sydney, NSW,
Australia
King Edward VII Hospital Sister Agnes, United
Kingdom
Background: Ecchymosis, oedema, haematoma
and pain after SMAS based facelift surgery are all
the direct result of the physical trauma of surgery
and subsequent inflammatory response.
Hilotherapy is a novel form of cryotherapy that
purports to minimise these events through facemasks circulating cooled, sterile water. This study
was performed to assess the validity of Hilotherapy
in this population of patients.
The risk of fistula formation, particularly in the
irradiated neck, has led some to advocate
recruitment of extra soft tissue to cover and protect
the neo-oesophagus in the form of the combined
1
free jejunum/pectoralis major flap technique . We
describe an alternative technique whereby the
jejunal mesentery is wrapped around the proximal
and distal bowel and vascular anastomoses to
protect the neooesophagus with additional
vascularised soft tissue. This involves harvesting
extra mesentery during the flap raise and fashioning
a protective mesenteric wrap. It does not invoke
extra abdominal morbidity and avoids the functional
and cosmetic deformity of the pectoralis major
donor site, and unsightly neck bulk of the pectoralis
major flap. Using this technique, first described by
2
Nahai in 1984 , we have had no incidences of
fistula formation in three patients.
Methods: Over 14 weeks fifty consecutive patients
were randomised to postoperative facial cooling
with Hilotherapy or management with standard
dressings alone, while fifteen subsequent,
consecutive patients were randomised to cooling of
one side of the face but not the other. Assessment
of ecchymosis, oedema, haematoma and pain was
performed independently by clinical staff and
patients. The second analysis was undertaken to
better delineate pain relief using each individual
patient as their own control.
Results: The Hilotherapy mask produced a
statistically significant difference in facial skin
temperature (p = 0.01). In the second limb of the
study patients reported a statistically significant
increase in facial swelling 6-8 days post surgery in
the half of the face that was treated with the mask
(p = 0.05) but there was no significant difference in
ecchymosis, haematoma and pain between
comparison groups (p > 0.10) in either limb of the
study.
References:
P Moradi, GE Glass, DD Atherton, S Eccles, M
Coffey, A Majithia, AJD Speirs, P Clarke, SH Wood
Reconstruction of Pharyngolaryngeal Defects with
the Jejunal Free Flap: a 10 year Experience from a
Single Reconstructive Centre. Plastic and
Reconstructive Surgery. 126(6):1960-1966
F Nahai, RS Stahl, TR Hester, AA Clairmont,
Advanced applications of revascularized free jejunal
flaps for difficult wounds of the head and neck.
Plastic and Reconstructive Surgery. 74(6):778-82
Conclusion: In this randomised, controlled trial
Hilotherapy masks produced significant facial skin
cooling after SMAS based facelift surgery at the
8
ANZJSurg.com supplement
2011 Plastic Surgery Congress
Australian Society of Plastic Surgeons | New Zealand Association of Plastic Surgeons
ABSTRACT 66
MICROSURGICAL BREAST RECONSTRUCTION
IN THIN PATIENTS
tissue with a hidden scar and allows for coning and
shaping a small breast rapidly and predictably,
without the need for turning the patient or
transferring major muscles. Its limitations include a
relatively short pedicle and limited breast volume.
Dean Trotter¹, Venkat Ramakrishnan²
¹Royal Melbourne Hospital and Royal Women’s
Hospital, Melbourne, Parkville, VIC, Australia
We present our experience with the TUG flap and
show that it is a good option for patients who are
unable to have an abdominal flap, and that it has
superseded gluteal flaps as our second line choice
for breast reconstruction.
²St Andrew’s Centre for Plastic Surgery and Burns,
Chelmsford, Essex, United Kingdom
Breast Reconstruction in thin patients is a
challenging and increasingly common procedure.
Improved diagnostic methods and genetic testing,
coupled with increasing awareness of breast
reconstruction, has resulted in younger and thinner
patients seeking reconstruction, often bilateral.
Alloplastic reconstructions have limitations due
potential complications related to radiotherapy or
lack of soft tissue cover, while traditional
autogenous options are often limited due to lack of
sufficient donor tissue. We present our experience
with several techniques that offer excellent
reconstructive options for this difficult patient group,
including “stacked” and bipedicled deep inferior
epigastric artery perforator (DIEP) flaps, and DIEP
and transverse upper gracilis (TUG) flaps with
implants. We will also present a novel procedure,
the autoaugmented TUG flap.
ABSTRACT 70
COMPLIANCE OF AUSTRALIAN PLASTIC
SURGEONS WITH MEDICAL BOARD OF
AUSTRALIA ADVERTISING GUIDELINES
Rowan Gillies, Damian Marucci
St Vincent’s Hospital, Sydney, NSW, Australia
Background: There has been an increase in
advertising by plastic surgeons, both online and in
print. The Medical Board of Australian (MBA) has
published guidelines backed by legislation for the
advertising of regulated health services. This study
evaluated the compliance of Australian plastic
surgeons with the MBA guidelines.
Methods: Websites of all ASPS members were
reviewed. The use of testimonials, and “special
offers”, both specifically prohibited by the guidelines,
were recorded. The provision of financing options
was also noted. Data were analysed using Fisher’s
exact probability test. ‘Australian Cosmetic Surgery
Magazine’ (ACSM) was reviewed for guideline
breaches related to disclosure of compensation
paid for articles written.
ABSTRACT 67
THE TUG FLAP, TECHNICAL CONSIDERATIONS
AND RECENT REFINEMENTS
Dean Trotter¹, Venkat Ramakrishnan²
¹Royal Melbourne Hospital and Royal Women’s
Hospital, Melbourne, Parkville, VIC, Australia
Results: 64% of plastic surgeons had websites. 7.5%
of websites contained testimonials. 5.5% of
websites advertised “special offers”. 7% of websites
offered finance for surgical treatments. There were
significant variations between states in both
testimonials and special offers. NSW had a
significantly greater number of testimonials than the
national average (p < 0.05). Interview style
advertorials in ACSM were represented as actual
reporting without disclosure of financial
compensation.
²St Andrew’s Centre for Plastic Surgery and Burns,
Chelmsford, Essex, United Kingdom
Autologous free tissue transfer is an ideal method of
breast reconstruction. The lower abdomen is a
popular source for flaps to reconstruct the breast
due to limited functional and aesthetic morbidity.
However, in some patients abdominal flaps cannot
be performed so other alternatives need to be
considered, such as gluteal flaps and autologous
latissimus dorsi flaps.
Conclusion: Overall, there is a high rate of
compliance of ASPS member websites with MBA
guidelines, however there are a small but significant
number of websites that do not comply, particularly
in NSW. The style of advertorials in ACSM is in
breach of the guidelines.
The transverse upper gracilis myocutaneous (TUG)
flap is an addition to the palette of the breast
reconstructive surgeon. This reliable flap is based
on a perforator arising from the medial circumflex
femoral artery. It provides adequate autologous
9
ANZJSurg.com supplement
2011 Plastic Surgery Congress
Australian Society of Plastic Surgeons | New Zealand Association of Plastic Surgeons
ABSTRACT 71
HARMONIC SCALPEL IN MUSCLE FLAPS: A
NON-RANDOMISED ANIMAL STUDY
Introduction: Breast cancer is the most commonly
diagnosed cancer in the UK with 45,000 new
patients being diagnosed annually. The numbers of
patients seeking reconstruction is rising. The
literature confirms the impression of clinicians,
offering all types of reconstruction, that abdominally
based reconstructions have the highest patient
satisfaction rates compared with Latissimus Dorsi
and implantonly based reconstructions. The recent
RCS audit on breast reconstruction also however
confirms that these reconstructions come with the
highest complication rates. This presentation details
the evolution of patient care designed to reduce the
complication rate of the free DIEP flap
reconstruction.
J Gu, M Wagels, S Senewiratne, D Rowe, DR
Theile
Princess Alexandra Hospital, Brisbane, QLD,
Australia
Background: Muscle flaps are commonly raised
using electrosurgery (ES). We have observed
marginal necrosis in reliable free muscle flaps
without microvascular complications. The harmonic
scalpel (HS) is an established alternative to ES.
There are few reports of its use in muscle flaps and
its effect on angiogenesis in muscle has never been
investigated. This study aims to compare wound
complications and angiogenesis in ES and HS
using a rat muscle flap model.
Materials and Methods: A retrospective data
collection from the notes of the first 130 patients in
a personal series of DIEP flaps was collected. The
emphasis was on pre and post-operative planning,
anaesthetic technique, post-operative recovery
regimes, complications and further surgery.
Methods: Pectoralis profundus was raised,
transposed and covered with skin graft in Sprague
Dawley rats using bipolar ES (n=14) and HS (n=22).
Graft take and wound complications were assessed
five days later, at which time the vascular pedicle to
the muscle flap was ligated. Flap survival was
assessed 48 hours later. Barium contrast
angiography was used to assess neovascularisation.
Results and Discussion: A total of 130 patients
underwent operation with 145 individual flaps
including the bilateral operations. The standard
regime of duplex ultrasound mapping of perforators,
anaesthetic and operative techniques and postoperative care are presented. The complications
experienced in the 7-year time are detailed and
provide the framework to the evolution of the
current patient pathway in this series of 145
consecutive DIEPs without flap loss.
Results: There was no significant difference
between HS and ES in time taken to raise the flap
or in the incidence of most wound complications.
The haematoma rate was lower in the HS group
(7.1% vs 41%, p=0.05). More vessels could be
demonstrated on angiography in HS flaps (9.6 vs
3.2, p=0.02) but the rate of flap necrosis was not
significantly different.
ABSTRACT 74
MALIGNANT MELANOMA IN
BUCKINGHAMSHIRE: DATA FROM THE
INCEPTION OF THE SKIN CANCER MDT
Conclusions: HS did not save time raising muscle
flaps but caused fewer haematomas. HS
potentiated angiogenesis in muscle, probably by
causing less tissue injury than ES. This has
implications for all muscle flaps, particularly those
reliant upon neovascularisation. These observations
should be formally tested in a human population.
1
1
1
2
J Cubitt , N Smith , AA Khan , MR Middleton , PG
1
Budny
¹Stoke Mandeville Hospital, Aylesbury, United
Kingdom
²John Radcliff Hospital, Oxford, United Kingdom
Introduction: The incidence of cutaneous
melanoma in Britain has increased significantly over
the last 30 years. Our study investigates the
presentation, surgical management and survival
outcomes of melanoma in our region (population
700,000) at around the time of inception of our skin
cancer MDT.
ABSTRACT 73
BREAST RECONSTRUCTION USING DEEP
INFERIOR PERFORATOR FLAPS: A 7-YEAR
EXPERIENCE
J Cubitt, AA Khan, E West, M Tyler
Stoke Mandeville Hospital, Aylesbury, United
Kingdom
Methods: A retrospective case-note review of all
patients who were diagnosed with primary
10
ANZJSurg.com supplement
2011 Plastic Surgery Congress
Australian Society of Plastic Surgeons | New Zealand Association of Plastic Surgeons
malignant melanoma in 2003 was conducted. Data
collection focussed on clinical and histopathological
features, surgical procedures, complications,
disease recurrence (nodal and non-nodal) and 5year survival.
palate group had significantly lower Z scores for
both the outpatient appointment and operation (i.e.
were more malnourished) than either the cleft lip
group or the non cleft group.
Conclusion: Malnutrition is a well documented
problem associated with cleft lip and palate. Our
research confirms this malnutrition but also
highlights the severity of the malnutrition. The
patients with cleft lip and palate are unable to feed
adequately and therefore need intervention. We
operate on these patients once they reach a target
weight of 3kg and repair both lip and palate in 1
operation to enable to patients to feed and improve
their nutritional status
Results: 98 patients were included (63% male, 37%
female; meal age 60.5years). Mean Breslow
thickness was 2.02mm. 35% of patients presented
with an AJCC stage 2A or higher. 14% developed
nodal disease and 14% developed non-nodal
recurrences.
We report a 5-year disease-free survival of 78%
and an overall survival of 80% (female 81%, male
80%) across all AJCC stages at presentation. The
melanoma-specific mortality rate was 6% in our
cohort.
ABSTRACT 79
BENEFIT OF PERFORMING PUNCH BIOPSY IN
SUSPECTED CUTANEOUS MALIGNANCIES
REFERRAL
Conclusions: Our survival outcomes for melanoma
were comparable to those reported in the literature
and national UK melanoma guidelines. We discuss
the differences observed and areas for service
improvement. We hope our study will act as a point
of reference for other Plastic Surgical units auditing
their own melanoma outcomes.
Willy Low, Mark Lee
Sir Charles Gairdner Hospital, Perth, WA, Australia
Purpose: Retrospective study of new referrals with
cutaneous lesions seen in Plastic Surgery clinic
over 3 months, to identify:
ABSTRACT 75
NUTRITIONAL STATUS OF CLEFT LIP AND
PALATE CHILDREN IN UGANDA
• Source of referral
• Waiting time for patients to be seen in clinic and to
have surgery
J Cubitt, G Galiwango, A Hodges
Comprehensive Rehabilitation Service for Uganda,
Kisubi, Uganda
To determine if punch biopsy performed upon
referral affects waiting and surgery time
Objective: The objective of this study is to
investigate the nutritional status of patients with cleft
lip and/or palate when compared to non cleft lip or
palate patients.
Methodology: N=107
The referrals came from General Practitioners
(GPs), Dermatologists and internal specialty teams.
Design: A retrospective analysis was carried out of
all patients aged less than 1 year who were
operated on in Comprehensive Rehabilitation
Service for Uganda (CoRSU) hospital since opening
in April 2009 to November 2010. The data was
divided into 3 groups: cleft lip patients; cleft lip and
palate patients and non cleft patients. The WHO
anthropometric calculator was used to calculate
weight-for-age Z scores on each patient for the
initial outpatient appointment and the operation. The
demographic data and Z scores were compared
using independent T tests.
Referrals with and without punch biopsy results
were assessed to determine the average waiting
time for initial consultation and for surgery.
Results: 79.4% of referrals were from GPs and the
others were from Dermatology and Internal
Specialty teams.
45 punch biopsies were performed upon referral.
10 out of 12 referrals (83.3%) from dermatologists
had punch biopsy results upon referral, compared
to 28 out of 85 referrals (32.9%) from GPs.
Results: 321 patients were identified: 131 patients
with cleft lip alone; 112 patients with cleft lip and
palate and 78 patients with no cleft. The cleft lip and
The average waiting time for patients to be
reviewed in clinic was 99.5 days. This was reduced
11
ANZJSurg.com supplement
2011 Plastic Surgery Congress
Australian Society of Plastic Surgeons | New Zealand Association of Plastic Surgeons
to 80.7 days if punch biopsy was performed prior to
referral. The waiting time if punch biopsy was not
performed was 113.2 days.
3, 6, 9 and 12 months or at the time of any
admission.
Outcomes are also formally measured by patients
completing the BreastQ® patient outcome measure.
The data for the BreastQ® is then entered by clinic
staff and subsequently scored. Pre and postoperative photographs are also taken.
The average waiting time for patients to have
surgery was 26.74 days. The waiting time for
patients with and without punch biopsy results upon
referral was 23.4 and 29.1 days respectively.
Results: 140 patients have had consultations
regarding breast reconstruction and 79 have gone
on to have major postmastectomy breast
reconstructive surgery. Of that group 57 were of
normal or overweight BMI – “non-obese” and 22
were of obese or morbidly obese BMI – “obese”. In
the month following stage 1 reconstruction 65% of
non-obese patients were complication-free vs 23%
of obese patients. In contrast, long term outcomes
were comparable.
The number of patients requiring biopsies after
clinical review was 22 (33.33%) and the length of
time for the patients from this category to have
surgery was 31.1 days.
Conclusions:
• Punch biopsy reduces both waiting time and
surgery time
• The majority of referrals are from GP’s (79.4%)
Conclusion: Obese patients having all types of
breast reconstruction surgery are at higher risk of
early complications than their non-obese
counterparts. However, late complications are not
more prevalent and outcomes are equivalent in both
groups.
• GP’s are least likely to perform punch biopsies
(32.9%)
• Punch biopsy helps with prioritization and
management of skin cancers
• It is important to establish punch biopsy guidelines
for GP’s to expedite referrals
ABSTRACT 85
PSYCHOPLASTICS – MEETING A NEED
ABSTRACT 84
BREAST RECONSTRUCTION IN THE OBESE
PATIENT – EARLY COMPLICATIONS VS LONGTERM OUTCOMES
Nicola R Dean, Randall Long
Flinders Medical Centre, Adelaide, SA, Australia
Background: Body dysmorphic disorder and other
psychopathologies can be present in those seeking
plastic surgery. Lack of recognition of these
pathologies can potentially result in serious harm to
the patients or sometimes even to the treating
surgeons. At the less extreme end of the scale,
patients with distorted expectations of surgery are
high risk for dissatisfaction and litigation. The
authors present their experience of setting up a
“psychoplastic service” to reduce the risk of such
adverse events and to try to provide the best
treatment for these patients.
,
Nicola R Dean¹ ², Jia Miin Yip²
¹Flinders Medical Centre, Adelaide, SA, Australia
²Flinders University, Adelaide, SA, Australia
Background: Women requesting breast
reconstruction after cancer are a population in
which obesity is a common problem. Obesity is
known to be a general risk factor for complex
surgery but specific information on risks for
reconstruction is less easily available. Knowing the
risk that obesity confers on patients contemplating
breast reconstruction will allow doctors to more fully
inform patients, so that they can make educated
choices about reconstruction.
Method: Retrospective review of 16 cases over 2.5
year period.
Results: Incidence of significant psychopathology,
as detected by plastic surgeon, in the “new patient”
population of a general plastic surgery clinic was
approximately 2.5%. This did not include patients
with established and controlled mental illnesses. All
patients deemed to require psychiatric assessment
by the plastic surgeon, did have significant
Methods: A breast reconstruction database was
set-up to collect data on all patients having breast
reconstruction through the Flinders Breast
Reconstruction Service. Complications are recorded
contemporaneously at outpatients appointments at
12
ANZJSurg.com supplement
2011 Plastic Surgery Congress
Australian Society of Plastic Surgeons | New Zealand Association of Plastic Surgeons
psychiatric issues when assessed by the
psychiatrist. There was a high incidence of
personality disorder and childhood sexual abuse.
Three patients had body dysmorphic disorder and 3
had forensic histories involving assault against
others. Patients in the service have had better than
expected outcomes from surgery and those who
have not proceeded to surgery have been able to
access appropriate services to treat their psychiatric
conditions.
flaps is easier and allows a more ptotic shape to be
constructed.
Results: Small areas of skin necrosis have arisen
in some cases. Patient outcomes have been
examined with photography, complication data and
the BreastQ measurement tool. A randomised trial
of the RoFA mastectomy is now underway.
ABSTRACT 87
THE ATTRACTIVE BREAST – FROM THE EYES
OF THE PUBLIC
Conclusion: Significant psychopathology is not
rare in the population of patients presenting to
plastic surgeons. To ignore this aspect of patient
care does a disservice to the patients and may
endanger the doctors and nurses treating them.
Anh Nguyen, George Pratt, Will McMillan, Graeme
Southwick, Morris Ritz
Melbourne Institute of Plastic Surgery, Melbourne,
VIC, Australia
ABSTRACT 86
AN ALTERNATIVE INCISION PATTERN FOR
MASTECTOMY – THE ROTATION FLAP
APPROACH (ROFA) AND IMPLICATIONS FOR
RECONSTRUCTION
Introduction: There is no consensus in the
literature about the ideal breast. A survey was
conducted to ascertain public perception of what
constitutes an attractive breast.
,
Nicola R Dean¹ ², Jia Miin Yip¹, Stephen Birrell²
Aim: To examine public opinion about breast
aesthetics
¹Flinders University, Adelaide, SA, Australia
Method: A colour pictorial survey was designed to
examine public opinion about breast size, shape,
upper pole fullness, nipple position, nipple size,
overall breast attractiveness and naturalness and
attitudes towards cosmetic surgery and breast
surgery. The survey was distributed at a 4-day expo,
throughout pharmacies and fitness clubs and online
at www.surveymonkey.com. The data was collated
by the first author and statistical analysis was
performed on the results.
²Flinders Medical Centre, Adelaide, SA, Australia
Background: The default technique for
mastectomy is via excision of a horizontal skin
elipse. This, by definition excises more skin in the
central axis than at either end. This technique leads
to the greatest tightness and resistance to
expansion in the area where it is most needed. In
contrast, there is often loose redundant skin where
it is not wanted – under the axilla. Mastectomy
patients also dislike the flat, “concave” medial
cleavage area and the scar extending to near the
midline. In patients seeking reconstruction the
limitations are the difficulty of achieving good
expansion for a prosthesis or the necessity for
insertion of a large skin paddle in an autologous
reconstruction.
Results: There were 1298 respondents to the
survey from ages 18 to over 65 years. The majority
of respondents’ perception of an attractive breast
was a breast that had shape, volume, perkiness
and small nipples. More than 75% of female
respondents were not content with their breasts.
The majority of respondents would consider
cosmetic surgery.
New Technique: The Rotation Flap Approach
(RoFA) mastectomy is a new approach developed
from a number of existing concepts in plastic
surgery. The principle is that of a rotation flap – as
used on the scalp for skin defects. It is modified in
very large breasts by using elements of Wise and
Hall-Findlay markings. This technique for
mastectomy leaves excess skin behind in the
central axis of the breast line, instead of in the axilla
and does not result in a scar that extends medially.
Reconstruction with either prostheses or autologous
Conclusion: Everyday women and men have
described the attractive breast as having the
following features – shape, volume and small and
perky nipples.
13
ANZJSurg.com supplement
2011 Plastic Surgery Congress
Australian Society of Plastic Surgeons | New Zealand Association of Plastic Surgeons
ABSTRACT 91
REVISITING THE ‘UNREPAIRABLE’ PALATAL
FISTULA: THE ‘YIN-YANG’ INSET OF
BILATERAL BUCCINATOR FLAPS
ABSTRACT 94
VOLUME SYMMETRY AS A DETERMINANT OF
BREAST RECONSTRUCTION OUTCOME
1, 2
1, 2
Jia Miin Yip , Nicola Dean
David Watson1, 2
Samuel Yang, Andrew Broadhurst
, Marika Tiggemann2,
¹Flinders Medical Centre, Bedford Park, SA,
Australia
Royal Children’s Hospital, Brisbane, QLD, Australia
Palatal fistulae are not an uncommon complication
of cleft palate repair. Typically a symptomatic defect
is reconstructed using a mucoperiosteal turnover
flap and an adjacent transposition flap.
Uncommonly, larger fistulae require reconstruction
using buccinator, nasolabial, tongue or even free
flaps.
²Flinders University, Bedford Park, SA, Australia
Objective: To evaluate the importance of volume
symmetry of reconstructed breast(s) as a
determinant of patient satisfaction with outcome
utilizing a 3D laser scanner and a validated patient
reported outcome measuring tool.
We have accumulated a series of 5 patients who
have needed buccal myomucosal flap repairs of
their large palatal fistulae. We also present a unique
case of a girl who had routine closure of her cleft
palate with Veau-Wardill- Kilner (VWK) flaps that
inexplicably underwent bilateral full thickness
necrosis. This left her with an ‘unrepairable’ defect
of the entire secondary palate except for a narrow,
posterior strip of soft palate.
Method: 51 patients who have had breast
reconstruction by 3 different plastic surgeons were
scanned in a standardized fashion using a 3D laser
scanner to determine the volume of both breasts.
Volume symmetry was determined by the ratio of
the smaller breast volume to the larger breast
volume. Outcomes measuring tool used was The
Breast-Q©.
Results: Patient mean age was 52 years (range
35-73) and types of reconstruction studied were
implant only (n=16), latissimus dorsi flap and
implant (n=9), latissimus dorsi flap only (n=12), free
transverse rectus abdominis myocutaneous (TRAM)
flap (n=11), and DIEP flap (n=3). Sixteen were
immediate reconstructions, 27 delayed, and 8 were
mixed. Mean volume symmetry score was 0.849
(range 0.511-0.994). There was no correlation
between volume symmetry of reconstructed
breast(s) with patient satisfaction with outcome and
satisfaction with breasts. There was also no
correlation between satisfaction with outcome and
the different types of reconstruction or timing
(immediate, mixed, delayed) of reconstruction.
There was however, a good correlation between
patient satisfaction with outcome and satisfaction
with the information they received preoperatively
(Spearman´s rho=0.786).
Fistulae of this dimension would traditionally require
a free flap reconstruction. However, we describe the
novel application of bilateral buccal myomucosal
flaps inset in a ‘yin-yang’ pattern to reconstruct this
‘unrepairable’ defect. There was no significant
donor morbidity and each of the pedicles was
divided in a staged manner over a five week period.
In the 18 months since the secondary procedure, no
recurrence has developed. She experiences no
nasal regurgitation and no significant speech
problems.
The use of local flaps to repair a palatal fistula of
this size has not previously been reported. Insetting
bilateral buccinator flaps in this fashion has also not
been described. Our reconstruction demonstrates
the versatility and functional durability of a unique
local solution to an ‘unrepairable’ problem.
References:
Conclusion: Volume symmetry of reconstructed
breast(s) was not a determinant of patient
satisfaction with outcome in this group of patients.
There was however a good correlation between
patient satisfaction with information received
preoperatively and satisfaction with final outcome.
1. Hill, et al. Br J Plas Surg. 1999 52 (8)658-671
2. Abdel-Aziz. Int J Pediatr Otorhinolaryngol. 2008
72 (11)1657-61
14
ANZJSurg.com supplement
2011 Plastic Surgery Congress
Australian Society of Plastic Surgeons | New Zealand Association of Plastic Surgeons
ABSTRACT 95
SKELETAL RECONSTRUCTION OF PAEDIATRIC
LOWER EXTREMITY BONY TUMOURS WITH
FREE VASCULARIZED FIBULAR GRAFT
procedure due to growth plate or double barrel
replacements. Graft survival and subsequent quality
of life is high. The need for secondary corrective
surgery for leg length discrepancy reflects the
survival and subsequent growth of this population.
MJ Woodfield, CJ Coombs, M O’Sullivan, G Lee
ABSTRACT 96
THE NEW SURGICAL TECHNIQUE OF THE
DORSO-LATERAL CROSS-FINGER FLAP FOR
SOFT-TISSUE RECONSTRUCTION ON FINGERS
The Royal Children’s Hospital, Melbourne, VIC,
Australia
Background: The free vascularised fibula graft
(FVFG) has been widely used for bony
reconstruction. For tumours of the lower extremity in
children, the FVFG can successfully replace the
skeletal defect resulting in a functional osseous
reconstruction. In this study, the authors present the
Royal Children’s Hospital experience with the FVFG
for lower extremity bony reconstruction following
tumour resection.
A Kubitskiy², R Mullin², A Bogov¹
¹Republical Clinical Hospital of Tatarstan, Kazan,
Russia
²Auburn Hospital, Auburn, NSW, Australia
Background: Soft-tissue defects on fingers are one
of the most common injuries and can be difficult and
challenging for hand surgeons. We aimed to
develop a simple and reliable surgical approach to
cover skin defects on fingers.
Methods: From a study period of 27 years, 20
consecutive free vascularised fibular grafts were
reviewed from 19 patients who had undergone
single stage tumour resection and reconstruction for
the tibia (n=12) or femur (n=8). Each graft was
reviewed for time to bony union, hypertrophy,
functional outcome and complications.
Methods: The dorso-lateral cross-finger flap is
based on the dorsal branch of the digital artery and
can be harvested from MCP proximally to DIP
distally on the distal pedicle. The length/ width ratio
was up to 7/1. The donor site was covered with fullthickness grafts. The base of the pedicle was
sutured as a tube and the pedicle itself was
periodically clamped for ischemic training. The
pedicle was cut in 2-3 weeks postoperatively
depending on blood supplying of the recipient site.
The long and mobile vascular pedicle containing
axial vessels allowed to start hand exercise on the
third-fourth postoperative days. This flap was used
in 42 patients from 15 to 60-year-old with soft-tissue
2
defects on 1-5th fingers from 3.2 to 14 cm .
Results: 19 patients (range 4-17 years) were
identified, with a mean follow up post surgery of 5.2
years. Sarcomas were predominant; Ewings (10),
osteosarcoma (5), chondrosarcoma (1), with the
remainder adamantinoma (1), osteofibrous
dysplasia (1), and anerurysmal bone cyst (1).
Average defect size was 15cm and average graft
size was 21.5cm. Single strut fibula grafts were
used in 75% of cases with double-barrelled fibula
grafts used in 25%. Internal fixation for augmenting
fixation was used in 40% of cases, and external
fixation was used in 60% of cases. The time to
union was on average 9.1months, and graft
hypertrophy (>20% of graft maximal thickness)
occurred in 17 of 20 cases. One FVFG was later
repeated, due to lack of bony union. Of the
procedures, 25% were going to require bone
lengthening due to the use of a double barrel
segment resulting in limb shortening or growth plate
resection for tumour clearance. The rate of nonpredicted secondary surgery was 15%, with the
most common surgery either epiphysiodesis or
ilizarov bone distraction for correction of leg length
discrepancy.
Results: All the patients had good and satisfactory
outcomes. The partial necrosis of the flap was
found in 3 cases but successful coverage of skin
defects was achieved in all patients. No cases with
infections were found.
Conclusions: The novel method of dorso-lateral
cross-finger flap has advantages: easy to perform,
does not require microsurgical technique, possibility
of earlier physiotherapy. This flap is especially
indicated for soft-tissue defects on the radial side of
IF and the ulnar side of LF.
Conclusions: Microvascular transfer of
vascularised fibular graft for skeletally immature
lower extremity reconstruction is effective and
successful. Limb salvage may be a staged
15
ANZJSurg.com supplement
2011 Plastic Surgery Congress
Australian Society of Plastic Surgeons | New Zealand Association of Plastic Surgeons
Background: Skin reducing mastectomy (SRM)
has the potential to offer the oncological
advantages of a mastectomy, while at the same
time allowing complete breast reconstruction (minus
nipple areola reconstruction) in a single operation.
By using a Wise pattern incision both the vertical
and horizontal dimensions of the breast skin
envelope can be controlled. It however does
present some technical challenges and risks related
to the vascularity of the long random pattern upper
flap.
ABSTRACT 97
A UNIVERSAL TECHNIQUE FOR MALE
MASTECTOMY
Amy O’Connor, Hugh Bartholomeusz
Greenslopes Private Hospital, Brisbane, QLD,
Australia
We describe a new two stage technique for male
mastectomy with universal application from the
female-tomale sexual reassignment surgery patient
to the treatment of gynaecomastia. The procedure
aim is subcutaneous mastectomy and application of
the aesthetics of the male chest which include
removal of excess skin and breast tissue, areolar
reduction and repositioning, elimination of the
inframammary crease and scar minimisation. The
“Flying Brevet” technique can be universally applied
to any breast volume as demonstrated in our case
series of female-to-male mastectomy patients. In
the first stage a superior incision encompasses skin
and areola and permits areolar reduction,
repositioning and removal of excess skin. Under
general anaesthesia mastectomy is carried out to
the level of the pectoral fascia with obliteration of
the inframammary fold. Liposuction may be
performed during the initial procedure to smoothe
chest wall contours. If the second stage is required,
it is based on an inferior semicircular incision and
the use of existing scars permits removal of any
redundant skin and definitive nipple-areolarcomplex remodelling. Complications with this
procedure include postoperative haematoma 6%,
hypertrophic scarring 10% and a single incidence of
fat necrosis. No nipple-areolar-complex necrosis
has been reported and nipple sensation is retained
in 60% of patients. The scars are somewhat hidden
under the bulk of the pectoralis major muscle and
there is a high rate of patient satisfaction. Our
technique permits reduction of large volume breast
tissue and application of the aesthetics of the male
chest wall with minimal scars and complications.
Aim: To describe operation and report our
experience (the first Australian series) with the first
20 cases at a specialist breast cancer institute,
including the learning curve.
Methods: Data were collected from the Westmead
Breast Cancer Institute prospective database from
between June 2010 March 2011. Information
relating to patient and tumour demographics,
complications and aesthetic outcome were collected
and analysed. Patient-reported outcomes were also
assessed.
Results: 13 patients underwent 20 SRM, 6
unilateral and 7 bilateral. Major complications
resulting in implant loss occurred in 2 patients (4
breasts), a further 2 patients experienced superficial
epidermolysis which required dressings only.
Conclusion: SRM adds another option for carefully
selected patients who either are contemplating or
requiring a mastectomy and desire an immediate
artificial reconstruction. We recommend that for
surgeons not familiar with insertion of implants or
experienced in tissue expander insertion that this
operation be performed as a combined procedure
between the oncological surgeon and reconstructive
surgeon. When successful this operation results in
a high degree of patient satisfaction.
ABSTRACT 100
CRANIAL DYSPLASIAS
ABSTRACT 99
SKIN REDUCING MASTECTOMY AND SINGLESTAGE IMMEDIATE IMPLANT
RECONSTRUCTION – LESSONS LEARNED
Matthew Starr, Mark Gianoutsos
Sydney Children’s & Prince of Wales Hospitals,
Randwick, NSW, Australia
1
1
James R French , Elisabeth Eldström Elder ,
1
2
Meagan E Brennan , Thomas Lam
Cranial dysplasias can present as dramatic defects,
and usually antenatally or at birth. Associated
morbidities include raised intracranial pressure,
retardation of brain development, developmental
delay, progression of cranial deformity with
increasing age, which in turn leads to abnormal
facial growth and assymmetry of the mandible and
¹Westmead Breast Cancer Institute, NSW, Australia
2
Westmead Hospital, NSW, Australia
16
ANZJSurg.com supplement
2011 Plastic Surgery Congress
Australian Society of Plastic Surgeons | New Zealand Association of Plastic Surgeons
maxilla. Whilst cranial dysplasias present particular
operative challenges, consensus amongst
craniofacial surgeons and neurosurgeons suggests
that corrective surgery is best performed early,
particularly before the age of one year. Surgery
performed in early infancy prevents progression
towards raised intracranial pressure and retardation
of brain development, leads to normalised blood
flow below prematurely closed sutures, osseous
defects postsurgery undergo reossification more
completely, abnormal craniomaxillofacial
development is avoided and the ability to correct
abnormalities in the cranial base is optimised.
satisfaction measuring multiple indicators, both
physical and psychological. Significantly, no
patients reported persistent post-operative
sensitivity.
Discussion: The Kohout reduction labioplasty is an
effective method for reducing labia minora. It has
been performed by the senior author for over 12
years. This review is one of the largest in the
medical literature, and demonstrates the reliable
aesthetic result & long-term patient satisfaction of
this technique. Complications were less frequent
than previously reported by other techniques.
References:
We present a case involving the late presentation of
a seven year old girl from Papua New Guinea with
craniosynostosis and large frontal encephalocele.
This case illustrates the pitfalls associated with
delay in surgical correction, as well complex
multidisciplinary planning, surgical techniques and
risks associated with performing a total cranial vault
reconstruction for the child patient with a significant
cranial dysplasia.
Alter, G. J. A new technique for aesthetic labia
minora reduction. Ann. Plast. Surg. 40: 287, 1998.
Choi, H. Y., and Kim, K. T. A new method for
aesthetic reduction to the labia minora (the
deepithelialized reduction labioplasty). Plast.
Reconstr. Surg. 105: 419, 2000.
ABSTRACT 102
6 YEARS EXPERIENCE OF LOWER LIMB FREE
FLAPS IN A MAJOR TRAUMA CENTRE: A NEW
PARADIGM FOR TIMING OF RECONSTRUCTION
ABSTRACT 101
REDUCTION LABIOPLASTY: A NEW
TECHNIQUE
Fred Clarke, Mark Kohout
George Pratt, Richard Ross, Barry Hsieh, Michael
Leung, Frank Bruscino-Raiola
Australia Plastic Surgery, Broadway, Sydney, NSW,
Australia
Dept of Plastic and Reconstructive Surgery, The
Alfred Hospital, VIC, Australia
Background: An enlarged labia minora can cause
functional, aesthetic and psychological problems.
Labioplasty is an increasingly requested procedure
in current plastic surgical practice with many
techniques described in the medical literature.
However, there are limited studies of adequate
sample size, and few have reviewed long-term
results and patient satisfaction.
Introduction: The planning and timing of free flap
reconstruction in lower limb trauma has long been a
topic of discussion. Earlier wound coverage with
vascularized tissue is considered an independent
factor in better outcomes. We present a series of 85
consecutive lower limb free flap reconstructions
which show an evolution in the management of
severe injuries.
Methods: The study is a retrospective review of
patients between 1999- 2011 undergoing reduction
labioplasty. The procedures were performed by one
surgeon, using a technique not previously described
in the literature. Patients in the study were followed
up at 1 week, 6 weeks and 6 months. In addition, a
recent patient questionnaire was mailed to all
patients to determine long-term satisfaction.
Methods: All relevant institutional ethics approval
was sought and obtained. Lower limb free flaps in
trauma performed during the research period of Jan
2005-Jan 2011 were identified by use of the units
internal database. Search was performed using
keywords “free flap” and “lower limb” and also by
searching by ICD 9 identifiers. Once identified, chart
review was undertaken.
Results: 250 patients aged from 16-63 years
underwent reduction labioplasty. 7 patients (2.8%)
had complications including haematoma & minor
dehiscence. Only 2 patients required a return to the
operating theatre (acute bleeding and wound
notching revision). Patients reported high levels of
Results: 85 free flaps were performed for lower
limb trauma in 78 patients during the study period.
Flap failure rate was 3.5%. VAC dressings were
used in 98% of cases and external fixateurs in 65%.
17
ANZJSurg.com supplement
2011 Plastic Surgery Congress
Australian Society of Plastic Surgeons | New Zealand Association of Plastic Surgeons
The mean time to definitive reconstruction was 8
days and this was found to correlate with Injury
Severity Score.
however this has also been reported following
alternative methods of finger-tip reconstruction.
ABSTRACT 105
OUTCOME FOLLOWING PARTIAL TEMPORALIS
MUSCLE AND FASCIA LATA SLING
Conclusion: These results suggest that previously
established axioms relating early definitive wound
management to better outcomes may be outdated.
Whilst early wound coverage remains desirable, in
the setting of severe trauma it is often necessary to
delay definitive wound coverage for various reasons.
In the era of VAC dressings and external fixateurs,
this does not seem to have a negative impact on
endpoints.
Francesca Rannard¹, Fazel Fatah²
¹Prince of Wales Hospital, Sydney, NSW, Australia
²City Hospital, Birmingham, United Kingdom
Purpose: Facial paralysis inhibits facial expression,
speech, eye protection, and oral competence. An
option for reanimation of the mid third of the face is
a temporalis muscle and fascia lata sling.
Previously the entire temporalis has been used. A
technique is described here in which the muscle is
only partially divided and the outcomes measured to
determine whether a satisfactory result could still be
obtained.
ABSTRACT 103
OUTCOME FOLLOWING EXTENDED
SEGMÜLLER FLAP REPAIR
F Rannard, M Dowd
Nepean Hospital, Kingswood, NSW, Australia
Introduction: Segmüller described a homodigital
lateral V-Y advancement flap for the treatment of
finger-tip injuries in 1976. Recently, an extension of
this flap has been used to enable a greater
advancement and therefore ability to cover the
majority of finger-tip defects.
Methods: The technique was performed on 17
patients between 2004 and 2007. Patients were
examined pre – and post-operatively regarding
facial symmetry and function. Patients were also
asked to complete a questionnaire and grade
specific facial functions on a visual analogue scale
(0-10).
Methods: This study reports the outcome following
51 extended Segmüller flaps performed by the
senior author. Data was collected from patient
records and a patient questionnaire.
Results: The major pre-operative complaints
reported were dribbling (65% of patients) and
appearance (59%). Oral competence was given a
mean score of 4/10 pre-operatively and improved to
8/10 post-op. No patients reported dribbling as a
concern in the post-op questionnaire. In fact, an
improvement was reported for all functions
assessed. The ability to show their teeth improved
from 2/10 to 6/10. Their smile symmetry improved
from 2/10 to 7/10. Their ability to blow improved
from 3/10 to 6/10 and their speech improved from
5/10 to 8/10. Patients gave a mean satisfaction
rating of 8.7/10 (range 4-10) and gave a score of
7.5/10 for overall facial symmetry.
Results: A good range of movement was
maintained, with a mean flexion of 64 degrees at
the DIPJ (range 35-85 degrees) and 102 degrees at
the PIPJ (range 80-115 degrees). 87% achieved full
extension at DIPJ and 83% at the PIPJ. Of the
questionnaire responders, 95% of patients gave an
overall satisfaction rating of above 8/10. 81% gave
above 8/10 for aesthetic appearance, and 76%
gave above 8/10 for use of that finger during normal
activity. Only 4% reported pain at rest above 3/10
severity with over 80% reporting no pain at all. 14%
reported pain above 3/10 during normal activity and
29% during heavy manual type activity. 43%
reported difficulty with cold intolerance of over 3/10
severity. Reported tip sensitivity was varied, ranging
from 0-10/10 with a mean of 3/10.
Conclusion: We believe that this technique reliably
achieves a large improvement in facial function and
high level of patient satisfaction.
Discussion: The extended Segmüller flap is a
reliable method of reconstruction which maintains
maximal length, enables early mobilisation,
preserves range of movement, and is usually
relatively pain-free. There can be cold intolerance;
18
ANZJSurg.com supplement
2011 Plastic Surgery Congress
Australian Society of Plastic Surgeons | New Zealand Association of Plastic Surgeons
ABSTRACT 106
ONLAY GRAFTING MATERIALS USED IN THE
UK AND THE COMPARISON WITH EXPERIENCE
IN AUSTRALIA
ABSTRACT 107
SURGICAL MANAGEMENT OF METACARPAL
FRACTURES: COMPARISON OF TWO
METHODS.
Francesca Rannard¹, Kaveh Shakib²
Michael Dowd, Alexander Kubitskiy
¹Prince of Wales Hospital, Sydney, NSW, Australia
Auburn and Nepean Hospitals, Sydney, NSW,
Australia
²University College London Hospital, United
Kingdom
Background: Many different methods of surgical
management of metacarpal fractures have been
reported. However, patients still have unsatisfactory
results and complications such as stiffness, chronic
pain and loss of sensation. In this study we aimed
to compare management of these fractures with
closed reduction and K-wire fixation to open
reduction and internal fixation (ORIF).
Purpose: The use of implantable biomaterials has
become an integral part of facial surgery as they
avoid donor-site morbidity and they have simplified
surgery in terms of time and complexity. The ideal
material is not toxic or antigenic, easily shaped, and
maintains its desired form. We carried out a study in
the UK to establish the materials most commonly
used by Maxillofacial and Plastic surgeons.
Methods: 25 patients with closed fractures of 4 and
5th metacarpal bones were included in this study.
13 patients were treated with K-wire fixation and 12
with ORIF. All patients were divided into 3 groups
depending on the site of the fracture: neck and
distal shaft, midshaft, proximal shaft or base of
metacarpal bone. All patients were seen from 2 to
12 months postoperatively. We determined both the
clinical and radiological signs of bone healing and
assessed functional impairment.
Method: A questionnaire was posted to all
consultants included in the register of BAOMS and
BAPRAS.
Results: Onlay grafting was practiced by 70% of
maxillofacial and 47% of Plastic surgery
respondents. The most common reason for their
use was cosmetic camouflage 83% and structural
repair 76%. Porous polyethylene (Medpore)
followed by autogenus bone were the most
common material used. The infection rate of 0-2%
for facial grafts was reported by majority of
respondents. Infection rates of over 30% for ear
implants, was reported by 90% of maxillofacial and
96% of plastic surgeons. The overall satisfaction
rates with the materials used was 72% for
maxillofacial and 81% for plastic surgeons.
Results: In groups with proximal and distal shaft
fractures the best results were achieved with K-wire
fixation. In the group with midshaft fractures both
methods showed similar outcomes. However, the
patients from the group who had ORIF
demonstrated a quicker recovery. 2 patients from
the ORIF group had soft-tissue infections and
another 2 had diminished of sensation.
Conclusion: Over 12 different implant material
used in facial surgery were reported, with Medpore
implants considered as having qualities the most
like an ideal implant material. However, some
surgeons in Australia have expressed concerns
over using Medpore and feel that there is a high
rate infection and that they may extrude. The results
of the study is discussed and compared against the
experience of surgeons in Australia.
Conclusions: Each method of treatment had its
own advantages and disadvantages. K-wire fixation
may give better results for proximal or distal shaft
fractures, is less traumatic and usually easier and
quicker to perform. However ORIF provides more
stable fixation and allows early mobilisation. The
risk of complications might be minimised by careful
soft tissue dissection and appropriate postoperative
care.
19
ANZJSurg.com supplement
2011 Plastic Surgery Congress
Australian Society of Plastic Surgeons | New Zealand Association of Plastic Surgeons
ABSTRACT 108
THE POSSIBLE ROLE OF CORTICOSTEROID
INJECTION IN THE MANAGEMENT OF
PATIENTS WITH DUPUYTREN’S
CONTRACTURE
ABSTRACT 109
COMPARING BARBED VERSUS NON-BARBED
WOUND CLOSURE IN ABDOMINOPLASTY AND
BREAST REDUCTION
Matthew J Peters, Grant Fraser-Kirk, Gerard Bayley
Leo KP Kim, William B Connolly
Greenslopes Private Hospital, Brisbane, QLD,
Australia
Sydney Hospital, Hands Unit, Sydney, NSW,
Australia
Introduction: Polydioxanone barbed suture
(QuillTM PDO) use in wound closure is claimed to
reduce the incidence of wound infection,
dehiscence, tissue ischaemia, suture granuloma,
and dog ear occurrence. Improved scar outcomes
have also been described. The aim of this study
was to compare the clinical outcomes of QuillTM
PDO suture use in abdominoplasty and breast
reduction procedures with traditional closure
techniques.
Aim: In Dupuytren’s disease, surgery is a treatment
of choice for symptomatic contractures of the hand.
For ectopic deposits in the hand and feet, steroid
injections have been worthwhile. It is a condition in
which many treatment modalities have been
attempted with a high rate of recurrence and many
associated morbidities. We have explored the
possible role of corticosteroid injection (CSI) in
conservative management of the disease.
Method: A retrospective study was conducted
using a selected group of patients treated with CSI
in the last 2 years. 20 patients selected for this
review only included those patients that did not
require immediate surgical interventions based on
severity of the disease. Details of patient
management were recorded from review of notes,
interviews and clinical examinations where possible.
Results were tabulated including ultra sound
imaging and photographs followed by a survey of
patients to rate their satisfaction with the treatment.
Nodules, contractures and cords of areas other than
hands as well as incidence of recurrence have been
included to determine the role of CSI in different
locations.
Methods: A retrospective case control study
comparing barbed (QuillTM PDO) and non-barbed
closure techniques in abdominoplasty and breast
reduction procedures were undertaken utilizing data
from the practice of a single surgeon (GB). Patient
demographics, wound complications (including
infection, dehiscence, ‘spitting,’ dog ear occurrence
and hypertropic scarring), and wound outcomes
were assessed. Statistical analysis was performed
using Chi-square test.
Results: A total of 93 patients were analysed. In
patients who underwent abdominoplasty, there was
no statistically significant difference in wound
complications or wound outcomes. In patients who
underwent breast reduction, no statistically
significant difference in wound complications or final
wound outcome between the barbed and nonbarbed groups was evident. However, the nonbarbed group recorded a higher mean wound
satisfaction at the first postoperative review (96%, p
= 0.003).
Results: This will be presented at the meeting.
Conclusions: Although surgery is the
recommended treatment for the well advanced
disease, other modalities needed to be explored
given the high incidence of recurrence and
associated morbidities. There is a role for CSI in the
management of Dupuytren’s disease in clinically
less severe cases where the clinical progression
may be altered.
Conclusion: Barbed sutures are a safe and
effective method of wound closure in
abdominoplasty and breast reduction, with no
statistically significant difference in wound
complications or final scar outcome when compared
with traditional nonbarbed suture wound closure
methods.
References:
Ketchum LD, Donahue TK. The injection of Nodules
of Dupuytren’s disease with triamcinolone acetonide.
J Hand Surg Am. 2000 Nov;25(6):1157-62
Hurst LC, Badalamente MA. Nonoperative
treatment of Dupuytren’s disease. Hand Clin. 1999
Feb;15(1):97-107, vii. Review.
20
ANZJSurg.com supplement
2011 Plastic Surgery Congress
Australian Society of Plastic Surgeons | New Zealand Association of Plastic Surgeons
ABSTRACT 111
RISK FACTORS OF TISSUE EXPANSION
FAILURE IN BURN SCAR RECONSTRUCTION
Radovan C. Breast reconstruction after mastectomy
using the temporary expander. Plastic Reconstr.
Surg. 1982 Feb:69(2):195-208.
Eng-Kean Yeong², Kuo-Wei Chen², Zheng-Hoong
Chan¹
Radovan C. Tissue expansion in soft-tissue
reconstruction. Plast Reconstr Surg. 1984
Oct;74(4):482-92.
¹University of Queensland, Brisbane, QLD, Australia
Bozkurt A, Groger A, O'Dey D, Vogeler F,
Piatkowski A, Fuchs PCh, et al. Retrospective
analysis of tissue expansion in reconstructive burn
surgery: evaluation of complication rates. Burns.
2008 Dec;34(8):1113-8.
²National Taiwan University Hospital, Taipei,
Taiwan
Background: Tissue expansion has become
invaluable for reconstruction of burn sequelae.
However, its use is hindered by the complications
that often result in expansion failure. This study
attempts to identify the risk factors of expansion
failure in burn patients since such factors have not
been clearly defined.
Cunha MS. Nakamoto HA, Herson MR, Faes JC,
Gemperli R, Ferreira MC. Tissue expander
complications in plastic surgery: a 10-year
experience. Rev Hosp Clin Fac Med Sao Paulo
2002;57(3):93–7
Methods: This study included 62 tissue expansions
in 37 burn patients from January 2001 to June 2009
at the National Taiwan University Hospital. Factors
including patient’s age, gender, comorbidities,
expander size, implantation site, volume injected at
implantation, preinflation volume ratio (PVR =
volume injected at implantation / expander size),
final inflation volume ratio (FIVR = cumulative
volume injected at completion of expansion /
expander size), and expansion duration were
analyzed. Cases were grouped into success (n = 53)
and failure (n = 5) groups. Logistic regression was
used in multivariate analysis for identifying
predictors of expansion failure.
Tavares Filho JM, Belerique M, Franco D, Porchat
CA, Franco T. Tissue expansion in burn sequelae
repair. Burns. 2007 Mar;33(2):246- 51.
Pitanguy I, Gontijo de Amorim NF, Radwanski HN,
Lintz JE. Repeated expansion in burn sequela.
Burns. 2002 Aug;28(5):494-9.
Zellweger G, Kunzi W. Tissue expanders in
reconstruction of burn sequelae. Ann Plast Surg.
1991 Apr;26(4):380-8.
Chun JT, Rohrich RJ. Versatility of tissue expansion
in head and neck burn reconstruction. Ann Plast
Surg. 1998 Jul;41(1):11-6.
Results: The mean age of the patients was 29.6
years. The male to female ratio was 1 to 1.4.
Expansion complication and failure rates were 53%
(n=33) and 15% (n=9), respectively. The risk factors
statistically correlated to expansion failure (p<0.05)
were age, EDV, PVR, and implantation at lower
limb. Expansion of lower limbs carried a risk of
failure 43 times greater than other sites.
Youm T, Margiotta M, Kasabian A, Karp N.
Complications of tissue expansion in a public
hospital. Ann Plast Surg. 1999;42(4):396–401.
Friedman RM, Ingram AE Jr, Rohrich RJ, Byrd HS,
Hodges PL, Burns AJ, et al. Risk factors for
complications in pediatric tissue expansion. Plast
Reconstr Surg. 1996 Dec;98(7):1242-6.
Conclusion: We conclude that tissue expansion
should be avoided in older patients and lower limbs.
The largest possible expander size and inflation at
time of implantation should be used to minimize the
risk of expansion failure.
Gibstein LA, Abramson DL, Bartlett RA, Orgill DP,
Upton J, Mulliken JB. Tissue expansion in children:
a retrospective study of complications. Ann Plast
Surg. 1997 Apr;38(4):358-64.
Neale HW, High RM, Billmire DA, Carey JP, Smith
D, Warden G. Complications of controlled tissue
expansion in the pediatric burn patient. Plast
Reconstr Surg. 1988 Nov;82(5):840-8.
References:
Neumann CG. The expansion of an area of skin by
progressive distention of a subcutaneous balloon;
use of the method for securing skin for subtotal
reconstruction of the ear. Plast Reconstr Surg
(1946). 1957 Feb;19(2):124-30.
Cherry GW, Austad ED, Pasyk KA, Rohrich RJ.
Increased survival and vascularity of random
21
ANZJSurg.com supplement
2011 Plastic Surgery Congress
Australian Society of Plastic Surgeons | New Zealand Association of Plastic Surgeons
complication rates were significantly higher in
immediate breast reconstructions that utilised tissue
expanders or implants. The most common
complication was capsular contacture. There were
no significant differences between reconstructions
utilising only autologous tissue.
pattern skin flaps elevated in controlled expanded
skin. Plast Reconstr Surg. 1983;72:680-687.
Marks MW, Argenta LC, Thornton JW. Burn
Management: the role of tissue expansion. Clin
Plast Surg 1987;14(3):543-548.
Almeida MF. Expanded shoulder flap in burn sequel.
Acta Chirurgie Plassticae 2001:43(3):86-90
Methods: The author is in the process of
conducting a retrospective case-control study of
approximately 400 consecutive breast
reconstructions performed by two Sydney-based
Plastic and Reconstructive surgeons (Dr Stern and
Pennington) across three hospital campuses during
the period 2005-2009. The aim of this study is to
compare complication rates in immediate versus
delayed breast reconstructions in Australia. The
study will examine whether there are any
statistically significant differences between breast
reconstructions that are performed immediate or
delayed, with the use of tissue expanders / implants
or autologous tissue only, with different flaps (DIEP,
TRAM or Latissimus dorsi), and unilateral or
bilateral.
Neale HW, Kurtzman LC, Goh KB, Billmire DA,
Yakuboff KP, Warden G. Tissue expanders in the
lower face and anterior neck in pediatric burn
patients: limitations and pitfalls. Plast Reconstr Surg.
1993 Apr;91 (4):624-31.
Tarrier N, Gregg L, Edwards J, Dunn K. The
influence of pre-existing psychiatric illness on
recovery in burn injury patients: the impact of
psychosis and depression. Burns. 2005
Feb;31(1):45-9.
Hudson DA, Grob M. Optimising results with tissue
expansion: 10 simple rules for successful tissue
expander insertion. Burns. 2005 Feb;31 (1):1-4.
Results and Conclusions: Not yet available. It is
anticipated that either preliminary or full results and
conclusions will be available for presentation at the
Plastic Surgery Congress.
Zoltie N. Chapman P. Joss GS. Tissue expansion: a
unit review of non-scalp, non-breast expansion. Br J
Plast Surg 1990:43:325-7.
ABSTRACT 115
DORSAL METACARPAL ARTERY FLAP – SRI
LANKAN EXPERIENCE
Manders EK. Reconstruction using soft tissue
expanders. In Cohen M, ed. Mastery of plastic and
reconstructive surgery. Boston: Little, Brown & Co;
1994. 201-15.
Kolitha Karunadasa, Gayan Ekanayake, Thushan
Beneragama, Dammika Dissanayake, Dulip Perera
ABSTRACT 114
COMPLICATION RATES IN IMMEDIATE VERSUS
DELAYED BREAST RECONSTRUCTION
National Hospital of Sri Lanka, Colombo, Sri Lanka
Introduction: Soft tissue cover of traumatized hand
is vital in preservation of denuded tendons, bones,
and neurovascular bundles as well as for immediate
or staged reconstruction of those which is
necessary for a functional, supple hand. The dorsal
metacarpal artery flap oriented along the long axis
of the hand was used to achieve soft tissue cover in
the setting of trauma. The flap perfusion is based on
a retrograde flow through the cutaneous perforators
of dorsal intermetacarpal arteries. The flap was
islanded over the Doppler detected perforator. The
flap could be rotated almost 1800 according to the
site and shape of the defect.
Matthew Starr¹, Harvey Stern²
¹Sydney Children’s & Prince of Wales Hospitals,
Randwick, NSW, Australia
²Royal Prince Alfred Hospital, Camperdown, NSW,
Australia
Background: There is an increasing trend for
breast reconstructions to be performed immediately
post-mastectomy rather than delayed. Proponents
argue that immediate reconstruction offers a better
aesthetic outcome, obviates the need for a second
operation, and avoids to some degree the adverse
pychological effects suffered by women who
undergo mastectomy alone. However, a recent
study by Sullivan et al published in Plastic and
Reconstructive Surgery in 2008 indicated that
compared with delayed reconstructions,
Material and Method: Our series comprises 19
cases covering soft tissue defects of index, middle,
ring and little fingers over both palmar and dorsal
aspects. Flap dimensions range from 1.5–2.5 cm in
with and 5.5–8cm in length and the flap was raised
22
ANZJSurg.com supplement
2011 Plastic Surgery Congress
Australian Society of Plastic Surgeons | New Zealand Association of Plastic Surgeons
from proximal to distal direction preserving
paratenon over the extensor tendons. In all cases
donor site was closed primarily without a skin graft.
The flap was used in acute trauma in 18 patients
and in elective setting in one patient with a non
vascularised iliac crest bone graft.
Transfusion rate, length of stay, ICU admission,
operative time, patient demographics and
complications were recorded
Results: The blood transfusion rate was
significantly higher in the recent group compared to
the earlier group. This can be attributed to the use
of cell saver in the latter group. The complication
rate was not different between the groups. However,
iIn the recent group there was less technical
problems but more infections. One set of springs
had to be removed in this group due to
uncontrollable infection. Operating time and length
of stay had not changed between the groups.
Results: Eighteen flaps survived without
complications, one patient had a wound infection
and necrosis of distal half of the flap.
Conclusion: These flaps are versatile and reliable
for resurfacing of soft tissue defects of the dorsum
of proximal phalanges, proximal interphalangeal
joint and the palmar defects of proximal phalanges
without significant donor morbidity.
Conclusion: Spring-mediated cranial reshaping is
safe for the treatment of sagittal synostosis. The
use of cell saver may decrease the need for
transfusion. As with all prostheses, meticulous
infection control and minimal handling of the
prosthesis is required to reduce infective
complications.
ABSTRACT 117
SPRING MEDIATED CRANIOPLASTY EARLY
AND RECENT EXPERIENCE – HOW CAN WE
IMPROVE?
Andre Safvat¹, Mark Rahman², Mark Gianoutsos²,
Jeremy Hunt²
¹Liverpool Hospital Sydney, NSW, Australia
ABSTRACT 118
ALLOPLASTIC IMPLANTS FOR CRANIAL BONE
RECONSTRUCTION IN WESTERN AUSTRALIA
²Sydney Children’s Hospital Randwick, NSW,
Australia
D Hng, I Bhaskar, C Budgeon, M Khan, N Knuckey,
G Lee
Introduction: Sagittal synostosis is the most
common single suture synostosis. It is
characterized by ridging of the sagittal suture.The
skull growth is narrowed biparietally & in the
temporal regions. There is also a compensatory
growth in the frontal region (frontal bossing), and/or
occipitally (occipital “coning”).
University of Western Australia, Perth, WA,
Australia
Aim: Large bone defects after complicated
neurosurgical interventions, including primary
cranioplasty, require secondary reconstruction of
bone and/or soft tissues. A variety of surgical
options are available for reconstructing the bony
deficit; autologous, allogeneic, and alloplastic
implants. Recently, there has been a trend towards
using alloplastic materials, the most popular being
titanium mesh, polymethylmethacrylate, and
hydroxyapatite cement. Each has its own unique
characteristics but none on its own fulfils the
properties of an ideal construct. We provide a
retrospective review of our outcomes, and a
literature review to identify the factors for
consideration when planning cranial bone
reconstruction.
Traditionally Scaphocephaly is treated with
extended strip craniectomy and subsequent helmet
therapy if diagnosed early. Alternatively it is treated
by total cranial vault reshaping if the diagnosis is
made after 6 months of age.
The pioneering work of Lauritzen with Spring
cranioplasty has revolutionized the treatment of
scaphocephaly. We have been performing spring
cranioplasty for the treatment of early
scaphocepahly since 2007. This is a review of our
experience with spring mediated cranial remodeling.
Methods: All patients who underwent cranioplasty
procedures in tertiary hospitals of Western Australia
were identified between 1999–2009. Patient
demographics, co-morbidities, indications, and
complications were recorded. Outcomes were
analysed using descriptive statistics with univariate
and multivariate stepwise logistic regression models.
Material and Methods: Retrospective review of 15
consecutive cases of sagittal synostosis from
February 2009 to December 2010 (recent group)
are compared to the earlier 15 cases done at our
institution from December 2007 to February 2009
(earlier group).
23
ANZJSurg.com supplement
2011 Plastic Surgery Congress
Australian Society of Plastic Surgeons | New Zealand Association of Plastic Surgeons
Results: A total of 118 patients received alloplastic
implants for bony reconstruction. The majority of
these cases were secondary cranioplasties (n=108,
91.5%). Implants used were titanium mesh (n=86),
polymethylmethacrylate (n=21), hydroxyapatite
cement (n=5), or a combination (n=6). There were a
total of 35 complications (29.7%), the most common
being infection requiring implant removal (10.2%).
Intra-operative CSF leak was significantly
associated with complications (P= 0.0095), as was
diabetes (P= 0.0081). Diabetes was also a
significant risk factor for infection requiring implant
removal (P=0.0045).
Conclusions: Patients undergoing multi visceral
resection after neo adjuvant chemo radiotherapy
can achieve early healed and stable perineal
closure with low morbidity. The versatility of the
VRAM flap in obtaining stable cover in this difficult
group confirms our support for immediate VRAM
reconstruction in pelvic exenterative procedures.
Conclusion: Cranioplasty is a procedure
associated with significant surgical morbidity.
Optimal outcomes for secondary reconstruction of
bony and soft tissue defects requires careful
decision making.
University of Sydney, Sydney, NSW, Australia
ABSTRACT 122
ADVANCED MICROSURGICAL EXERCISES –
ANIMAL ORGAN TRANSPLANT
VG Ilie, C Wang
Microsurgery is one of the essential skills of the
modern plastic surgeon. It is amenable to
development in the laboratory via exercises on
living and non-living tissues. The learning curve is
accelerated by practice focused on the various
surgical steps of the microsurgical procedures.
ABSTRACT 120
THE VRAM FLAP FOR RECONSTRUCTION IN
ADVANCED PELVIC MALIGNANCY
We describe the techniques and the variations we
use for rat heart and kidney transplants, reporting
on 112 transplants executed in 2010 by one micro
surgeon. We focus on learning curve, complications
(bleeding, ureteric dehiscence, long-term organ
malfunction) and set of skills involved.
Thanassi Athanassopoulos², Terry Creagh¹, Frank
Frizelle³
¹Aberdeen Royal Infirmary, Scotland
²Southern General Hospital, Glasgow, Scotland
In order to achieve proficiency (defined by over 90%
success rate), a series of 30-40 operations need to
be performed (more for kidney transplant, where
ureteric anastomosis demands a separate set of
skills). Prior experience on non-vital models is
recommended. The transplants involve complex
microdissection with vessel control and preparation,
various techniques of arterial and venous
anastomosis, all on the background of controlling
the duration and depth of anaesthesia.
³Dept of Surgery, University of Otago, New Zealand
Background: The management of the perineal
wound after radical pelvic surgery in an irradiated
field for advanced pelvic malignancy is a challenge.
One method to reduce the morbidity of the perineal
wound is the pedicled vertical rectus abdominis
myocutaneous (VRAM) flap.
Method: Patients undergoing VRAM reconstruction
at Christchurch Hospital, New Zealand following
pelvic surgery were identified prospectively. The
data collected included demographic information,
operative variables and tumour variables.
Video recording the initial procedures provides an
opportunity for technical refinement in mentored
feedback.
We suggest that for the advanced micro surgeon,
animal transplantation provides the perfect adjuvant
for training and skill maintenance. It provides
challenges in surgical planning and difficult intraoperative decision making. The aim of long term
function of the transplanted organ mirrors the goals
of human reconstructive microsurgery.
Results: 37 patients were identified in total
undergoing VRAM reconstruction. The mean age
was 58.6 years (range 40- 86). There were 23
female and 14 male patients. 22 patients underwent
surgery for recurrent pelvic disease. 23 patients
were alive and 14 patients were dead at the end
point of data collection. 34 patients received pre
operative neo adjuvant chemo–radiotherapy. There
were 19 complications and 6 patients required reintervention for flap complications.
24
ANZJSurg.com supplement
2011 Plastic Surgery Congress
Australian Society of Plastic Surgeons | New Zealand Association of Plastic Surgeons
ABSTRACT 127
IMPLANT SURFACE ANTIMICROBIAL THERAPY
CAN PREVENT BIOFILM FORMATION AND
CAPSULAR CONTRACTURE FOLLOWING
AUGMENTATION MAMMAPLASTY IN AN IN
VIVO PIG MODEL.
important in decreasing the development of
capsular contracture.
ABSTRACT 131
FREE JEJUNAL INTERPOSITION
RECONSTRUCTION POST
PHARYNGOLARYNGECTOMY: 368
CONSECUTIVE CASES.
Anita SW Jacombs, James M Allan, Pedro M
Valente, Karen Vickery, Anand K Deva
Diana Perez-Smith, Michael Wagels, David A Sharp,
Renee Cook, David R Theile
Australian School of Advanced Medicine (ASAM),
Macquarie University, NSW, Australia
Dept of Plastic and Reconstructive Surgery,
Princess Alexandra Hospital, Brisbane, QLD,
Australia
Background: Capsular contracture is the most
common complication after breast augmentation
mammoplasty. Increasing evidence suggests that
subclinical bacterial infection (biofilm) is important in
its aetiology. We have previously demonstrated a
positive link between significant capsular
contracture (Baker Grade 3 or 4), positive tissue
culture and biofilm. Subsequently, our in vivo pig
model demonstrated a causal link between pocket
inoculation with Staphylococcus epidermidis, and
development of bacterial biofilm and capsular
contracture.
Background: The use of free jejunum (FJ) for the
reconstruction of pharyngolaryngectomy defects
(PLD) was first reported by Seidenberg in 1957.
Theile et al. reported favourable outcomes in a
series of 201 consecutive cases in 1995. Tubed
fasciocutaneous flaps are an alternative
reconstruction and there is debate over which is
superior. FJ has been the preferred method at our
institution for 33 years. We review our experience
and analyse temporal changes in outcomes.
Using the in vivo pig model we assessed the
efficacy of antibiotic-impregnated mesh inserted at
implantation, to prevent biofilm development and
capsular contracture.
Methods: 368 consecutive FJ reconstructions were
performed between 1977 and 2010. Data were
collected by retrospective chart review for tumour
characteristics, treatment, complications and return
to oral diet. A small subset (19 patients) were
examined for dysphonia using the Therapy
Outcome Measure (TOM) dysphonia scale.
Comparisons were made between our previously
published series and new data.
Methods: 5 pigs were surgically implanted with 28
mammary implants and inoculated with human S.
epidermidis. Antibioticimpregnated mesh
(TxRxPharma) was inserted under 50% of the
implants. The implants were explanted at 16 weeks
and degree of contracture independently measured
using the Baker Grade. Implants and surrounding
capsule were removed for microbiological culture
and Scanning Electron Microscopy (SEM).
Results: Overall perioperative mortality was 3.8%
and flap loss was 3.0%. Anastomotic leak and
stricture rates were 8.2% and 10.9% respectively. A
full oral diet was achieved in 91.6% of patients.
Dysphonia was mild or absent in 73%. Dysphonia
resulted in significantly higher levels of handicap
and distress (TOM 4.5 vs 2.9, p=0.015, FET).
Results: One control implant was extruded. The
remaining 13 control implants were contracted with
a Baker Grade of 4 (n=7) or 3 (n=6). None of the
treated implants were contracted (P<0.001, Chisquare=23.143), Baker Scale of 1 (n=8) or 2 (n=6).
Biofilm was easily demonstrated by SEM in all
contracted capsules.
Conclusions: This is the largest series of FJ PLD
reconstructions reported to date. Outcomes overall
compare favourably with other methods. The
unpublished series shows deterioration in leak and
stricture rates. This may be attributable to changes
within the surgical team. Good outcomes in FJ are
highly operator dependant. This is a cogent
reminder of the need to monitor outcomes of PLD
reconstruction.
Conclusion: Implant surface modification with an
antibiotic-impregnated mesh prevented or retarded
biofilm development around silicone breast implants.
The subsequent development of capsular
contracture in antibiotic-treated implants was not
observed in this study. Strategies for preventing
biofilm disease around silicone implants may be
25
ANZJSurg.com supplement
2011 Plastic Surgery Congress
Australian Society of Plastic Surgeons | New Zealand Association of Plastic Surgeons
ABSTRACT 132
IDENTIFICATION OF BACTERIAL BIOFILM IN
DOUBLE CAPSULES SURROUNDING BOTH
HUMAN AND PIG BREAST IMPLANTS
ABSTRACT 135
REFLECTANCE CONFOCAL MICROSCOPY IN
THE DIAGNOSIS OF NON-MELANOMA SKIN
CANCER AND BENIGN LESIONS VERSUS
NORMAL SKIN: A BLINDED PROSPECTIVE
TRIAL
James M Allan, Pedro M Valente, Anita SW
Jacombs, Steven Merten, Karen Vickery, Anand K
Deva
Mahyar Amjadi, Brendon Coventry, John
Greenwood
Dept of Plastic, Reconstructive & Aesthetic Surgery,
Macquarie University, NSW, Australia
Adelaide University, Adelaide, SA, Australia
Background: Double capsule is a rare complication
of breast augmentation mammoplasty. To date only
a handful of cases have been published and
presence of double capsule at explantation has
been associated with presence of late seroma,
capsular contracture and textured implant surface. It
has been postulated that shear forces that separate
capsule from the implant may be important in the
development of a double capsule.
Background: Non-melanoma skin cancers (NMSC)
are the most commonly diagnosed cancers in
Australia1. Reflectance Confocal Microscopy (RCM)
generates images comparable to histology. Past
clinical trials on NMSC using RCM have shown
234
promising results , but the role of RCM needs
better definition.
Objectives: We aimed to compare RCM to excision
biopsy histology in NMSC management in an
Australian population to evaluate its diagnostic use.
We report the finding of a breast implant double
capsule in both human and pigs. Implants and the
capsules were analysed using microbiological
culture, polymerase chain reaction (PCR) and
scanning electron microscopy (SEM)
Materials and Methods: Patients referred with
difficult-to-diagnose skin lesions before excision
were included. RCM images of each lesion were
obtained prior to surgical intervention and were
compared with the post-operative histological
findings.
Methods: Bilateral double capsules were identified
surrounding breast implants in a human female at
time of explantation for capsular contracture. Single
double capsules were identified in two pigs 16
weeks after inoculated breast augmentation as part
of a larger study. Implants and capsules were
analysed using enhanced microbiological culture,
PCR and SEM.
Results: A total of 137 patients were examined. Of
129 that were later histologically proven to be
malignancies, 106 were diagnosed as ‘malignant’
by RCM. A further 23 were diagnosed as ‘normal’
by RCM (6 Basal Cell Carcenoma [BCC] and 17
Squamous Cell Carcenoma [SCC] on histology);
demonstrating a false negative rate of 23/129
(17.83%) or a sensitivity of 82.17%. Of 8
histologically-proven, nonmalignant lesions, RCM
incorrectly attributed ‘malignancy’ in 2 cases, based
on criteria defined during the study; giving a false
positive rate of 2/8 (25%) or a specificity of 75%.
Results: Human double capsules cultures grew
Gram-positive cocci. PCR was positive for
Staphylococcus epidermidis on both pig and human
samples. SEM identified cocci shaped bacterial
biofilm on the double capsule.
Similarly pig double capsules were contracted with
a Baker Grade of 3 & 4. Microbiological cultures
grew Gram –positive cocci consistent with the
Staphylococcus epidermidis used for inoculation,
and SEM identified cocci-shaped bacterial biofilm
on capsule surface.
Conclusion: The results show that RCM can
provide diagnostic information which is reliable for
over 82% of clinically difficult-to-diagnose, but
histologically proven NMSC. In addition, RCM might
better define margins to perhaps reduce re-excision
rates. As such, RCM can provide a particularly
useful tool as an adjunct to clinical evaluation.
Conclusion: Identification of bacterial biofilm in
capsules in both human and pig specimens suggest
that and inflammatory process as well as shear
forces may be important in the formation of double
capsule.
26
ANZJSurg.com supplement
2011 Plastic Surgery Congress
Australian Society of Plastic Surgeons | New Zealand Association of Plastic Surgeons
ABSTRACT 137
EXPERIENCE IN DERMOMUSCULAR POUCH
COVERAGE OF IMMEDIATE IMPLANTS
FOLLOWING SKIN REDUCING SUBCUTANEOUS
MASTECTOMY
immediate breast reconstruction. Plast Reconstr
Surg 110:206–211
Querci della Rovere G, Nava M, Bonomi R,
Catanuto G, Benson JR (2008) Skin-reducing
mastectomy with breast reconstruction and
subpectoral implants. J Plast Reconstr Aesthet Surg
61:1303– 1308
Rowan Gillies, Ling-Yun Chang, Elias Moisidis
St Vincents Hospital, Paddington, NSW, Australia
ABSTRACT 139
ORBITAL APEX SYNDROME: CASE SERIES
DISCUSSION FROM A PLASTIC SURGERY VIEW
POINT
Immediate one stage implant reconstruction of the
breast is an evolving technique. The use of dermal
substitutes for lower pole coverage is common in
1
the United States . Availability, regulation and
concerns over the use of the product itself have
curtailed its introduction into Australia.
Dermomuscular pouch coverage of an immediate
implant is an autologous alternative to this
technique. The pouch is derived from pectoralis
major and an inferiorly based dermal flap following
a skin reducing subcutaneous mastectomy. Its use
is applicable to women with large and/or ptotic
breasts.
Sepehr Lajevardi, Joseph Rizk, Justine O’Harra,
Jack Zoumaras, Michael Miroshnik, Roland Jiang,
Megan Hassel, Robert Gates, Nick Lotz, John
Vandervord
Dept of Plastic & Reconstructive Surgery, Royal
North Shore Hospital, St Leonards, NSW, Australia
Plastic surgeons managing patients with facial
trauma may find that the patient has
ophthalmoplegia or visual defect. One important
differential diagnosis to consider in such a case is
Orbital Apex Syndrome (OAS). OAS is
characterized by visual loss from optic neuropathy
and ophthalmoplegia involving multiple cranial
nerves. OAS may result from a variety of
inflammatory, infectious, neoplastic, iatrogenic,
traumatic, and vascular conditions. The mechanism
involved is pressure on the orbital apex structures
(CN II, III, IV and VI) by the underlying pathology
causing the presenting symptoms. OAS is best
assessed by MRI and CT scanning. In some cases
a surgical biopsy is needed for definitive diagnosis.
Swift relief of pressure within the orbital apex is
paramount for a good outcome. In cases of trauma
and facial fractures, decompression surgery may be
required. In other cases early use of antibiotics or
steroids may be indicated. Patients require close
monitoring through clinical examination and imaging
to monitor for any signs of progression or resolution
of pathology.
The dermomuscular pouch technique has been in
development since 2002. First as expander
2
coverage and then for immediate implant and
implant/expander coverage3. The procedure is not
yet commonly used in Australia. We present our
results for 6 consecutive patients over the past 2
years and describe their preoperative
characteristics and postoperative results. We
describe the technique and propose criteria for its
use.
By its nature, this technique requires close
cooperation between the oncological and
reconstructive surgeon both intraoperatively and in
patient selection.
It should be added to the options offered to women
in the appropriate setting. Specifically, those who
live in remote areas, are not appropriate for
autologous reconstruction, do not require post
operative radiotherapy, and have a significant
degree of ptosis could benefit from this technique.
We present 3 cases that on presentation found to
have decreased visual acuity and ophthalmoplegia,
and were diagnosed with OAS. In two of the
patients OAS was secondary to facial trauma and in
one other due to infectious pathology. We will
review the investigative approach in each case and
the progress of each patient following treatment.
Plastic surgeons will need to be mindful of orbital
apex syndrome when reviewing patients with
ophthalmoplegia and visual defects as well as be
References
Breuing KH, Colwell AS (2007) Inferolateral
AlloDerm hammock for implant coverage in breast
reconstruction. Ann Plast Surg 59:250– 255
Hammond DC, Capraro PA, Ozolins EB, Arnold JF
(2002) Use of a skin-sparing reduction pattern to
create a combination skin – muscle flap pocket in
27
ANZJSurg.com supplement
2011 Plastic Surgery Congress
Australian Society of Plastic Surgeons | New Zealand Association of Plastic Surgeons
involved in performing biopsy or decompression
surgery.
ABSTRACT 140
EARLY EXPERIENCE WITH CONICAL-SHAPED
POLYURETHANE COATED BREAST IMPLANTS
JPS Heather, JS Januszkiewicz, STJ Gilbert
New Zealand Institute of Plastic and Cosmetic
Surgery, New Zealand
It is a common assumption that anatomic or shaped
breast implants produce more ‘natural’ appearing
results than round. Our group last year presented
on the outcomes of a comparative study that
showed this to be a relative misconception:
subjective appreciation of breast beauty and
‘naturalness’ by both expert surgeons and nonexperts did not differ between implant shapes.
Patient factors were more important in guiding the
correct choice of implant.
A new shape of breast implant has become
available in New Zealand and Australia since late
2010. These conical shaped, polyurethane coated
gel implants (Silimed) offer more projection relative
to base diameter and volume than other currently
available implants.
We have examined the comparative geometry of
these novel implants and present our developing
indications for their use, illustrated by the clinical
experience of the two senior authors over the past
eight months.
ABSTRACT 141
NEW DEVELOPMENTS IN TENDON REPAIRS:
THE MODIFIED ADELAIDE REPAIR AND THE
KNOTLESS BARBED SUTURE TENORRHAPHY
“Adelaide” suture configuration by interlocking its
distal locking components to improve gapping and
maximum load capacity. Additionally we introduce a
new tendon repair technique: The knotless barbed
suture tenorrhaphy.
Tim Peltz¹, Roger Haddad¹, Peter Scougall², Sean
Nicklin¹, Jeremy Hunt¹, Mark Gianoutsos¹, Bill
Walsh¹
Method: Deep flexor tendons were harvested from
adult sheep forelimbs (n=36). Three groups were
randomly divided and 12 repairs in each group were
performed using different repair techniques: The (4strand) “Adelaide” repair technique, the (4-strand)
“Modified Adelaide” repair technique and a new (4strand) barbed suture tendon repair technique. All
repairs were performed by one surgeon using 3-0
braided polyester sutures (Ticron) for the “Adelaide”
and “Modified Adelaide” repair group and a new
polyglyconate 3-0 barbed suture (V-Loc) for the
barbed suture repair group. Cyclic (3N to 30N) and
static tension loading was performed. Digital images
were used to measure gapping (ImageJ, NHI, USA).
¹Surgical & Orthopaedic Research Laboratories,
Prince of Wales Hospital, University of New South
Wales, Sydney, NSW, Australia
²Sydney & St. Lukes Hospital Hand Units, Sydney,
NSW, Australia
Introduction: In previous studies the “Adelaide”
tendon repair has shown better results in strength
and stiffness than other modern four strand repairs
and was recommended for the best compromise of
simplicity and strength. In this study we modified the
28
ANZJSurg.com supplement
2011 Plastic Surgery Congress
Australian Society of Plastic Surgeons | New Zealand Association of Plastic Surgeons
Load displacement curves were compared and a
statistical data analysis performed.
0.99). The closest agreements were between
scores by external observers and the patients’ own
scores as per The Breast-Q© (adjusted r2=0.47,
p=0.03). Scores that correlated best include
‘contour’, ‘placement of the mound’, and ‘closeness
of match’. There was virtually no correlation
between volume symmetry measured by 3D
scanning and either patient scores or scores from
external observers.
Results: Significant differences between the three
tested groups could be shown regarding gapping
and maximum load to failure. These results were
independent to the size of the tendon or other
factors. The barbed suture tendon repair and the
“Modified Adelaide” repair show superior
biomechanical behaviour compared to the
conventional “Adelaide” tendon repair technique.
Especially the knotless barbed suture repair
technique seems to reduce the risk of early gapping
significantly.
Conclusion: Assessment of aesthetic outcome by
external observers from clinical photographs
appears to correlate better with patient satisfaction
with outcome than objective assessment of volume
symmetry by the 3D laser scanner.
ABSTRACT 142
COMPARING METHODS FOR EVALUATING
BREAST RECONSTRUCTION OUTCOME: 3D
LASER SCANNING TECHNOLOGY, PANEL
REVIEW OF POSTOPERATIVE PHOTOGRAPHS,
AND PATIENT REPORTED OUTCOME.
1, 2
1, 2
Jia Miin Yip , Nicola Dean
1, 2
David Watson
ABSTRACT 143
OPTIMISING EPIDERMAL ATTACHMENT TO
BIOMATERIALS
1, 5
2, 5
Gil Stynes , George Kiroff , Keith McLean³,
4, 1
Wayne Morrison , Mark Kirkland2
, Marika Tiggemann2,
¹University of Melbourne, Geelong, VIC, Australia
²Deakin University, Burwood, VIC, Australia
¹Flinders Medical Centre, Bedford Park, SA,
Australia
³CSIRO, ACT, Australia
²Flinders University, Bedford Park, SA, Australia
4
Bernard O’Brien Institute of Microsurgery, Fitzroy,
VIC, Australia
Aim: To examine the relationships between
objective and subjective methods of assessing
breast reconstruction outcome.
5
Purpose: Currently, biomaterials such as
intravenous lines, catheters, implanted prostheses
& robotics, and devices that breach skin eventually
become infected. With the aim of creating a
permanent & functional interface with skin, we
aimed to attach collagen to biomaterials covalently,
to demonstrate the strength of the bond, & to show
improved epidermal cell attachment.
Method: 47 patients who have had breast
reconstructions were evaluated by 3 different
methods: 3D scanning for volume symmetry, clinical
photography review by a panel of experts and nonexperts, and a validated patient reported outcome
measure designed specifically for breast
reconstruction patients (The Breast-Q©). Breast
volumes were calculated using a Cyberware 3D
whole body laser scanner, and volume symmetry
was calculated as the ratio of the smaller breast
volume to the larger breast volume.
Methodology: Metal (tantalum) & a polyurethanebased polymer were exposed to a vacuum chamber
full of ionising plasma (the fourth state of matter),
irrevocably changing surface properties. Stability of
attached collagen was assessed by incubating in
8M urea or with epidermal cells for periods of up to
40 days & measuring residual collagen by ELISA.
Strength of epidermal attachment was assessed
with immunolabelled electron and confocal
microscopy.
Results: The patients ages ranged from 35 to 73
(mean 52.5). Types of reconstruction studied were
implant only (n=16), latissimus dorsi flap and
implant (n=8), latissimus dorsi flap only (n=12), free
transverse rectus abdominis myocutaneous (TRAM)
flap (n=9), and DIEP flap (n=2). The panel
consisted of 3 surgeons, and 7 non-surgeons
(including 2 breast reconstruction patients)
assessing outcome using visual analogue scales &
descriptive subscales. Mean volume symmetry, as
measured by the scanner was 0.85 (range 0.51-
Results: Ionising plasma significantly improved the
bonding of collagen. Improved epidermal
attachment was demonstrated by visualising
29
The Geelong Hospital, Geelong, VIC, Australia
ANZJSurg.com supplement
2011 Plastic Surgery Congress
Australian Society of Plastic Surgeons | New Zealand Association of Plastic Surgeons
Conclusions: This novel technique improves the
projection of the second stage of autologous ear
reconstruction without the morbidity, scarring and
surgical time of raising a TPF flap. This reliable
technical improvement has caused a change of
practice of our unit.
immunolabelled focal adhesions and
hemidesmosomes.
Conclusions: Vacuum plasma permanently
changes the surface properties of biomaterials,
enabling the covalent bonding of collagen.
Covalently bound collagen then provides an
excellent foundation for the growth and attachment
of epidermal cells. These results will enable
progression to animal studies, whereby the creation
of a permanent & functional external interface
between biomaterials & skin will be tested.
ABSTRACT 153
THE RELATIVE CONTRIBUTIONS OF THE INSET
AND THE WOUND BED ON FULL THICKNESS
GRAFT TAKE: A NONRANDOMISED
CONTROLLED ANIMAL STUDY
ABSTRACT 147
NOVEL TECHNIQUE IN SECOND STAGE
AUTOLOGOUS EAR RECONSTRUCTION –
ELIMINATION OF THE TEMPOROPARIETAL
FASCIAL FLAP
KG Chan, M Wagels, S Senewiratne, D Rowe, DR
Theile,
Justine O’Hara, John Vandervord, Nicholas Lotz
Introduction: When a full thickness skin graft fails,
it is common to observe partial survival of graft
adjacent to the inset. This suggests that the inset
makes an important contribution to graft survival.
Our aim was to determine the contribution of the
inset to graft by controlling for contact with the
wound bed.
Dept of Plastic & Reconstructive Surgery, Princes
Alexandra Hospital, Brisbane, QLD, Australia
Plastic & Reconstructive Surgery Dept, Royal North
Shore Hospital, NSW, Australia
Background: This paper describes an advance in
ear reconstruction to achieve a more aesthetic
result with less morbidity. Total ear reconstruction
necessitated by congenital deformity or trauma in
our unit is by autologous rib graft for framework
fabrication following the principles of Francoise
Firmin.
Method: Pectoralis profundus muscle flaps were
raised and covered with a full thickness graft in 36
Sprague-Dawley rats. In 14 of these, a silicone
sheet was secured between graft and flap using
absorbable sutures (silastic group), leaving 22
controls. Group allocations were not randomised.
The primary outcome of skin graft necrosis was
measured using ImageJ analysis software
(Rasband, 1997). Wound outcome data were also
collected to assess for confounding.
Methods: This novel technique utilised in the
second stage involves tunnel creation for placement
of the banked cartilage wedge. This enables the
mastoid fascia to be elevated on the posterior
surface of the cartilage framework in continuity,
therefore allowing split skin grafting of the posterior
surface of this construct. The mastoid skin is then
advanced into the post-auricular sulcus, succeeding
in projecting and covering the framework, without
the morbidity and scarring of raising a
temporoparietal fascial (TPF) flap. All patient and
surgery details were recorded in a database for
accuracy.
Results: 100% of graft loss at day 5 was noted in
the silastic group compared to 85.7% in the control
group (p=0.039, Mann- Whitney U) despite
significantly fewer wound complications overall (29%
vs 77%, p=0.005, FET). There was a significant
increase in the incidence of graft edge dehiscence
in the silastic group (14% vs 0%, p<0.005, FET).
Results: Twenty one patients and 22 second stage
ear reconstructions were performed using this
technique between January 2008 and January 2011.
Patients included 11 female and 10 male and
right/left/bilateral ears were 17/3/1. Three patients
(14.2%) underwent minor revision surgery, one for
minor recontouring, one partial flap necrosis
requiring graft and one for re-elevation. The
aesthetic results were judged as good to excellent
by the two primary surgeons and all patients were
happy with their results.
Conclusions: The inset alone will not keep a graft
alive. Its contribution may actually be quite small in
view of the wound complications observed,
particularly dehiscence. The phenomenon of
bridging in grafts works probably because of the
quality and quantity of adjacent wound bed contact.
30
ANZJSurg.com supplement
2011 Plastic Surgery Congress
Australian Society of Plastic Surgeons | New Zealand Association of Plastic Surgeons
ABSTRACT 156
LOCAL FLAP RECONSTRUCTION FOR
ORBITAL EXENTERATION DEFECT – THE
PRINCESS ALEXANDRA HOSPITAL
EXPERIENCE
Method: Five patients with syndromic
craniosynostosis underwent PVE with cranial
springs. This involved a bicoronal osteotomy
anterior to the lambdoid sutures followed by spring
placement across the osteotomy gap. Springs were
removed via a small second procedure 3 months
later. Perioperative and postoperative data were
prospectively recorded. Pre – and post-treatment
CT scans were obtained for all patients to assess
changes in head shape and ICV.
KG Chan, J Huang, PJ Belt, DR Rowe, G Bayley,
DR Theile, JE Emmett
Dept of Plastic & Reconstructive Surgery, Princes
Alexandra Hospital, Brisbane, QLD, Australia
Results: The preoperative CI was 1.05, the postspring removal CI was 0.88 (p<0.05). The average
preoperative ICV was 36cm³ greater than normative
data. The postoperative ICV was 186cm³ greater.
(p<0.001). Average maximal springexpansion
distance was 49mm (SD11).
Reconstruction of orbital exenteration defect with
limited loss of bony orbit post resection of nonmelanoma skin cancer involving periorbital tissue in
adults is mainly achieved by means of local,
regional or free flaps with advantages and
disadvantages of the different methods. We present
the Princess Alexandra Hospital’s experience of
reconstructing such defects by means of single
local flap or combination of local flaps in a
consecutive series of 12 patients. We believe our
method offer effective, stable coverage of the
defects and good comparable aesthetic results of
both the reconstruction and donor site when
compared to free flap options. There is also added
benefit of low complications, reduced operative
duration and recovery time in hospital compared to
free flaps especially in the majority of our patients
who are elderly with significant co-morbidities.
The average spring-insertion time was 73 minutes,
and 56 minutes for spring-removal. The operative
blood loss was less than 50mls in each case, but
two of five cases required blood transfusion day-1
postoperatively. Average hospital stay for insertion
was 3 days, and for removal was 5 days. There was
one unplanned ICU admission.
Conclusion: PVE with springs is useful in
increasing ICV. It is an effective treatment for
patients with bicoronal synostosis with reduced
operative time, greater vault expansion and less
blood transfusion requirements when compared
with traditional PVE.
ABSTRACT 163
POSTERIOR VAULT EXPANSION USING
CRANIAL SPRINGS – CHILDREN’S HOSPITAL
AT WESTMEAD EXPERIENCE
ABSTRACT 165
BIOABSORBABLE CONSTRUCT
CRANIOPLASTY IN MULTISUTURE
CRANIOSYNOSTOSIS
O Ou Yang¹, DD Marucci¹, R Chaseling¹, M
Pelletier², RJ Gates¹, WR Walsh²
Susan O’Mahony, Richard Theile, Rob Campbell,
Martin Wood, Matthew Peters
¹Craniofacial Unit, Children’s Hospital at Westmead,
Westmead, NSW, Australia
Mater Children’s & Royal Children’s Hospitals,
Brisbane, QLD, Australia
²Surgical & Orthopaedic Research Laboratories,
Prince of Wales Hospital, University of New South
Wales, Randwick, NSW, Australia
Purpose: In the setting of multisuture
craniosynostoses, where skull bones are thin, soft
and have multiple gaps, the traditional Cranial Vault
Remodeling procedure requires significant
modification. We have recently been presented with
this scenario in 3 cases requiring Cranioplasty for
cranial vault expansion. This paper describes the
design and application of a bioabsorbable construct
as a Cranioplasty scaffold in this situation.
Background: Bicoronal craniosynostosis may lead
to craniocerebral disproportion, raised intracranial
pressure, mental retardation and death. Posterior
vault expandion (PVE) may be required to increase
intracranial volume (ICV). Traditional PVE, however
carries significant operative risks such as massive
blood loss, dural tear and air embolism. We present
our experience of performing PVE with cranial
springs as riskminimising strategy in children with
bicoronal synostosis.
Methodology: 3 babies with syndromic multisuture
craniosynostosis underwent posterior Cranial Vault
Remodeling to increase cranial volume and improve
31
ANZJSurg.com supplement
2011 Plastic Surgery Congress
Australian Society of Plastic Surgeons | New Zealand Association of Plastic Surgeons
Conclusions: The skin scratch method provides a
useful adjunct to clinical free flap assessment.
bony coverage of the underlying brain. Following
removal of deficient native bone, a scaffold was
constructed using bioabsorbable Polylactide
(‘Macropore’) to provide the cranial structure. The
thin bone pieces removed were attached to the
inner surface of the construct, which was then
secured to the anterior cranium. Clinical and
radiological follow-up determined the adequacy of
vault expansion and the ossification of the cranial
vault.
ABSTRACT 168
IMMEDIATE TISSUE EXPANDERS FOR BREAST
RECONSTRUCTION: THE ACUTE
COMPLICATIONS AND THEIR PREDICTORS
Rebecca A Stevens
’
Royal Brisbane and Womens Hospital, Brisbane,
QLD, Australia
Results: One baby developed an early CSF leak
requiring a shunt, this had no adverse impact on the
bioabsorbable construct. All 3 children recovered
well. Clinical and radiological followup
demonstrated adequate cranial volume and
progressive vault ossification. 2 underwent
subsequent bifronto-orbital advancement (BFOA)
surgery, where ossification of the posterior vault
was directly observed. One further case is planned
in a four-year old Apert child.
Background: When considering immediate breast
reconstruction post mastectomy, some women who
are unsuitable for autologous breast reconstruction
may be suitable for a staged procedure with tissue
expanders and subsequent breast implant. It is
thought that this is a more morbid procedure than
immediate autologous reconstruction, but what are
the complication rates, and is there any way of
predicting those patients at increased risk of these
complications?
Conclusion: In multisuture craniosynostoses,
where cranial bone is grossly deficient, the firm
bioabsorbable construct in posterior Cranial Vault
Remodeling allows for adequate volume expansion
and subsequent cranial ossification, and facilitates
future BFOA surgery.
Methods: A 2 year retrospective study of
consecutive patients who underwent immediate
breast reconstruction with tissue expanders.
Analysis of complications including wound infection,
seroma, haematoma, skin necrosis, and expander
explantation. Analysis of age, co-morbidities,
smoking, anticoagulants, size of expander,
mastectomy pathology and length of time drains
were left in as possible predictors of complications.
ABSTRACT 167
SKIN SCRATCH METHOD FOR MONITORING
PALE DONOR FREE FLAPS
F Sofiadellis, M Mirkazemi
Results: Overall complication rate 42%, smokers
with complications 78%, non smokers with
complications 28%, wound infection 15%,
haematoma 0%, seroma 23%, necrotic skin 10%,
removal of implant 15%. Cordiero’s1 data
demonstrated lower overall complications at 5.8%,
infection 2.5% and explantation 2.7%.
Austin Health, Docklands, VIC, Australia
Purpose: To date we have no reliable objective test
for post operative free flap monitoring. This paper
describes an additional technique that may be used
as a reliable adjuvant to clinical monitoring of pale
donor site free flaps.
Conclusion: Our complication rates differ
significantly to those published in other centres. The
predictors of complications may allow more refined
patient selection for this particular technique of
breast reconstruction, and therefore lead to lower
overall complication rates.
Methods: Firm stroking of well perfused skin,
produces an initial red line, followed by a flare
around that line, and then finally a “wheal”. This
provides an immediate and more reliable way to
asses cutaneous free flap perfusion.
Reference:
Mechanism: Firm stroking of the skin produces an
initial red line (capillary dilatation) followed by an
axon-reflex flare with broadening erythema
(arteriolar dilatation) and the formation of a linear
“wheal” (transudation of fluid/edema). This is
termed as the triple response of Lewis.
Cordeiro. A Single Surgeon’s 12-Year Experience
with tissue Expander/ Implant Breast
Reconstruction: Part 1. A Prospective Analysis of
Early Complications. PRS Sept 2006.
32
ANZJSurg.com supplement
2011 Plastic Surgery Congress
Australian Society of Plastic Surgeons | New Zealand Association of Plastic Surgeons
ABSTRACT 169
FACIAL NERVE INJURY FOLLOWING FACELIFT
SURGERY – INCIDENCE AND MANAGEMENT
good pain relief, but thumb pinch weakness is of
concern in the younger, active patient. Long term
instability of prostheses can result, especially with
associated MP joint laxity. Osteotomy benefits with
short term pain relief, but progression of the arthritis
is common.
Warwick Nettle, Ellis Choy
Silkwood Medical, Sydney, NSW, Australia
Arthrodesis can improve hand function by restoring
a pain free, stable and strong base of thumb and
can benefit patients under 55 years of age, or those
who place greater demands on their hands. The
literature suggests that arthrodesis of the thumb
CMC joint may result in long term increased
incidence of STT and MP joint arthritis, as well as
reducing ADL performance arising from reduced
mobility of the thumb.
The facelift case load of the senior author (WN) for
a 15 year period from January 1996 to December
2010 was analysed for facial nerve dysfunction post
surgery.
All cases were performed by the senior author
utilising the Lateral SMASectomy method as
described by Dr Dan Baker of New York University
with whom the senior author trained.
This presentation reports the long term clinical and
functional outcomes of 33 basal fusions between
1991 and 2006 (follow up 3 – 19 years). All were
independently assessed. The findings noted: –
excellent reduction in pain, excellent patient
satisfaction, improved DASH scores and minimal
complications. Progressive STT arthritic
degeneration was rare. Bilateral basal fusions were
well tolerated. The authors suggest that thumb
CMC joint fusion should be considered for treatment
of thumb CMC arthritis in the younger, demanding
and active patient, ahead of an arthroplasty.
Multiple ancillary procedures such as eyelid surgery,
browlift surgery and fat transfer were performed on
many of these patients.
The incidence of facial nerve dysfunction was
recorded and analysed for its relationship to
amongst other factors age, previous facial surgery,
ancillary facial procedures and duration of
dysfunction.
Facial nerve dysfunction post facelift surgery falls
into several arbitrary but we feel distinct groups
related to duration of dysfunction:
ABSTRACT 171
CLINICAL PHOTOGRAPHY IN PLASTIC
SURGERY IN AUSTRALIA: CURRENT USE AND
CONSIDERATIONS
• early postop lasting for up to 1 week
• intermediate postop lasting from 1 week to
12weeks
Richard J Ross, Heather Cleland
• longer term / intermediate postop lasting from 12
weeks to 1 year
The Alfred Hospital, Prahran, VIC, Australia
Background: The use of clinical photography has
become commonplace in plastic surgery units
worldwide. Images can provide rapid, portable and
objective documentation to facilitate treatment
decisions but not without specific medicolegal
considerations. A study into current patterns of use
of clinical photography in Australia is needed to
better inform health policy and guide clinical
practice.
• long term postop lasting more than 1 year
Recommendations are given for how to analyse and
manage postoperative facial nerve dysfunction
following facelift surgery.
ABSTRACT 170
LONG TERM OUTCOME OF THUMB CMC JOINT
FUSION
Stephen Coleman, Marguerite Copley
BHULC, Manly, QLD, Australia
Aim: This study aimed to investigate the current
use of clinical photography by plastic surgeons in
Australia.
Osteoarthritis of the trapeziometacarpal joint is a
common cause of hand pain. Surgical options for
managing thumb CMC joint pain are arthroplasty,
osteotomy, and arthrodesis. Arthroplasty results in
Methods: A thirty-three item anonymous online
survey was disseminated via email to all 378 active
members of the Australian Society of Plastic
Surgeons. Current use, indications for imaging and
33
ANZJSurg.com supplement
2011 Plastic Surgery Congress
Australian Society of Plastic Surgeons | New Zealand Association of Plastic Surgeons
modalities of consent were investigated amongst
private and public practices.
Baron Guiliume Dupuyten in 1831 and extensively
studied since then looking at its anatomy and
pathophysiology. Current treatment for Dupuytren’s
disease is almost exclusively surgical which
involves different degrees of fasciectomy. However
Auxillium pharmaceuticals have recently completed
phase 3 trials of Clostridium Histolicium collagenase
that can be used to rupture dupuytren’s cords at an
office based setting. We have contributed to the
final stages of this trial by trialing the use of
clostridium Histolyticum collagenase (CHC) on 12
patients.
Results: A total of 130 responses were received
(33.4%). The majority of respondents routinely use
clinical photography (95%), feel it facilitates better
outcomes (93%) and consider that it should be a
routine part of patient monitoring in plastic surgery
(93%). Most frequently, these images were used for
pre – and post-operative comparison and for
interesting cases. Images were most often taken
using personal digital cameras in both public and
private settings. In the public system, this was
usually due to greater convenience (96% agree)
and ability to transmit images for advice (76%
agree). A departmental camera was not often
readily available (13%), either due to inaccessibility
(28%) or non-existence (62%). There was no
significant difference between levels of consent
obtained for identifiable images versus
nonidentifiable images in private practice, but verbal
consent was most often used in the public system.
Most respondents felt written consent was required
for identifiable images for either facilitating
treatment decisions (81%) or research purposes
(79%). Implied consent was seen by the majority of
respondents as adequate for non-identifiable
images or either purpose.
Method: We have looked at 124 dupuytren’s cases
and devised a pattern description, which classifies
dupuytren’s presentations to pencil band type and
sheet pattern. This was based on initial clinical
observation and intraoperative correlation. It was
evident from preliminary clinical indications that the
drug was only usable on the pencil band
presentations. 12 pencil band type presentations
received CHC injection and fingers mobilized from
day 1. 2 repeat injections were given at 1-month
intervals under the same protocol.
Results: All 12 cases reached full extension
parameters defined by the phase 3 study. No cases
of tendon rupture were reported. However 2 cases
proceeded to have debilitating pain upon flexing the
finger, which failed to be recognized as a
complication by the initial phase 3 trial. These 2
cases proceeded to have surgical fasciectomy and
revealed extensive deep tissue scarring.
Conclusions: This study is the first investigation of
clinical photography practices in plastic surgery in
Australia. Clinical photography is a valuable tool for
improving outcomes for plastic surgery patients and
therefore used widely. Surgeons facilitate these
outcomes often using their own equipment, in the
face of inconsistent policy and inadequate
equipment, storage and dissemination systems. As
a consequence, they may be placing themselves at
increased legal risk. A rapid, secure and
appropriately accessible storage modality is
required to protect patient confidentiality while
making best use of technology.
Conclusion: Clostridium Histolyticum Complex is a
novel method for treating Dupuytren’s disease with
its own set of advantages and disadvantages. The
drug is not usable on all presentations of
Dupuytrens disease and an understanding of the
patterns of presentation was necessary for its
clinical use. Phase 3 studies reveal very promising
clinical results in achieving full extension with
negligible damage to flexor tendons. However our
initial use of this drug in our clinical setting revealed
complications such as flexion pain and deep tissue
scarring which were not recognized as
complications in the phase 3 trials. The prevalence
of such complications needs to be further
characterised and investigated by larger studies in
the future.
ABSTRACT 172
CLOSTRIDIUM HISTOLYTICUM COLLAGENASE
FOR TREATMENT OF DUPUYTREN’S DISEASE:
CASE STUDY OF 12 PATIENTS
Yasith Edirisinghe, Mr John Crock
New Zealand
Background: Dupuytren’s disease is a fibroblastic
proliferative disorder of the palmar fascia. This
results in progressive contractures that can affect
any anatomical rays of the hand. This condition has
been of interest from its first detailed description by
34
ANZJSurg.com supplement
2011 Plastic Surgery Congress
Australian Society of Plastic Surgeons | New Zealand Association of Plastic Surgeons
ABSTRACT 173
2 YEAR RESULTS COLLAGENASE INJECTIONS
FOR DUPUYTREN’S CONTRACTURE
considered related to CCH treatment (none
occurred in a treated finger).
Conclusion: The long term durability of response
for all joints following CCH treatment was 80.7%,
with a 19.3% overall nominal 2-year recurrence rate.
Additionally, 97.9% of patients avoided surgical
intervention for recurrence of a successfully treated
joint during that time. These follow-up results after
CCH treatment for patients with Dupuytren’s
contracture are very encouraging and can be
favorably compared to published surgical
fasciotomy and fasciectomy results, and are
improved over available needle aponeurotomy
results.
Stephen Coleman¹, Clayton A Peimer, Philip Blazar,
F Thomas D Kaplan, Ted Smith, James Tursi, Brian
Cohen, Greg Kaufman
¹BHULC, Manly, QLD, Australia
Hypothesis: Collagenase clostridium histolyticum
(CCH, XIAFLEX®) has demonstrated safety and
efficacy as a non-surgical treatment for Dupuytren’s
contracture. To determine the long term durability of
response, contracture recurrence, and safety,
subjects from five Phase III studies were offered
enrollment in a Year 2-5, non-treatment follow-up
study (CORDLESS).
ABSTRACT 174
MANAGEMENT OF AN INFECTED/EXPOSED
BREAST AND HIP PROSTHESES, A SINGLE
SURGEON EXPERIENCE WITH 5 PATIENTS
Methods: In five Phase III studies, subjects with
metacarpophalangeal (MP) or proximal
interphalangeal (PIP) joint contractures of ³20 and
100 degrees received 0.58mg CCH per treatment
cycle. Each cycle consisted of injection,
manipulation the following day, and 30 day followup. Patients received a maximum of 3 treatment
cycles per cord depending on achievement of
clinical success (defined as contracture reduction to
5 degrees full extension). Patients were observed
annually with their reevaluation 2 years after
initiation of Phase III studies. In joints that achieved
primary clinical success, recurrence was defined as
contracture increase by at least 20 degrees with a
palpable cord, or if the joint had further medical or
surgical treatment. Statistical analyses included
nominal recurrence rates and a Kaplan- Meier (KM)
analysis.
Laith Barnouti
Bankstown Public Hospital, NSW, Australia
Background: Wound breakdown with exposure of
the prosthesis is a challenge for the plastic surgeon.
The conventional management has been
implant/prosthesis removal, wash out and
IVAntibioics.
The purpose of this study is to present a new idea
into the management of infected and exposed
prosthesis. A closed circuit management of the
prosthesis was used.
Methods: A retrospective study was carried out on
a single plastic surgeon’s experience between 2009
and 2011. Patients with infected and/or exposed
devices were treated with soft tissue debridement,
wash out, Antibiotic and wound closure.
Postoperatively, the prostheses were washed out
through the drain on a regular basis.
Results: 634 of 950 eligible subjects (66.7%) were
evaluable in CORDLESS. Mean follow-up time from
the first dose of CCH was 2.1 years. These 634
subjects represented 1065 treated joints (641 MP,
424 PIP). 619 joints (449 MP, 170 PIP) achieved
clinical success in the earlier studies. 500
successfully treated joints (80.7%) demonstrated a
durability of response at 2 years without recurrence.
119 joints (61 MP, 58 PIP) recurred resulting in a
nominal 2-year recurrence rate of 19.3% (±1.6% SE)
overall, 13.6% (±1.6%) for MP joints, and 34.1%
(±3.6%) for PIP joints. The 2-year KM estimate
recurrence rate was 24.1% (±2.0%) overall, 17.6%
(±2.1%) for MP joints, and 41.4% (±4.4%) for PIP
joints. Of the 619 successfully treated joints, only 13
(2.1%) patients elected surgical correction of the
joint before year two. In the followup phase, only 30
AEs and 9 SAEs were reported, and none were
Three infected and exposed breasts implants, one
infected and exposed breast expander and one
chronically infected and exposed hip prosthesis
were treated with this method. The salvage rates
were calculated. Patient wound culture pathogens
were analysed
Conclusions: Salvage of the infected or exposed
prosthesis is possible through a non conventional
management of wound infection. Removing the
prosthesis and IVAntibiotic remain the safest
method of managing the infection, however in
certain circumstances the infected and exposed
35
ANZJSurg.com supplement
2011 Plastic Surgery Congress
Australian Society of Plastic Surgeons | New Zealand Association of Plastic Surgeons
prosthesis can be salvaged by leaving the implant
in situ, providing healthy soft tissue coverage and a
closed circuit wash out technique.
No tendon ruptures or systemic allergic reactions
were reported. Most adverse events were related to
the injection or finger extension procedure.
ABSTRACT 175
INJECTABLE COLLAGENASE CLOSTRIDIUM
HISTOLYTICUM: A NEW NONSURGICAL
TREATMENT FOR DUPUYTREN’S
CONTRACTURE RUNNING HEAD: INJECTABLE
COLLAGENASE FOR DUPUYTREN’S
CONTRACTURE
Conclusions: Collagenase clostridium histolyticum
is the first FDAapproved, nonsurgical treatment
option for Dupuytren’s contracture that is highly
effective and well tolerated.
ABSTRACT 181
TECHNIQUES OF PYROCARBON TRAPEZIUM
IMPLANTATION: THE CHALLENGE OF
TREATMENT OF BASAL THUMB ARTHRITIS
CONTINUES.
David Gilpin
AHSS, Spring Hill, QLD, Australia
David Stabler
Purpose: The Collagenase Option for the
Reduction of Dupuytren’s (CORD II) study
investigated the efficacy and safety of injectable
collagenase clostridium histolyticum (XIAFLEX®) in
patients with Dupuytren’s contracture.
Southport, QLD, Australia
Prosthetic replacement of the trapezium has largely
proven to be unsuccessful.
Recently Pyrodisk replacement of the trapeziometacarpal joint has been described. There are
many technical difficulties with this procedure. It is
difficult to correct subluxation of the
carpometacarpal joint and it is difficult to gain
access to remove the beak osteophyte from the 1st
metacarpal and the pommel osteophyte from the
trapezium. Access to the flexor carpi radialis tendon
is also difficult.
Methods: This was a prospective, randomized,
placebo-controlled trial with 90-day double-blind
and 9-month open-label phases. Patients with
contractures affecting metacarpophalangeal (MP) or
proximal interphalangeal (PIP) joints were
randomized 2:1 to collagenase (0.58 mg) or
placebo. Cords received a maximum of 3 injections.
Cord disruption was attempted the day after
injection using a standardized finger extension
procedure. Primary end point was reduction in
contracture to 0° to 5° of normal 30 days after the
last injection.
In addition, Pyrodisk replacement of the
carpometacarpal joint does not address the
frequent situation where the osteoarthritis is actually
pan-trapezial with involvement of the scaphotrapezio-trapezoid joint.
Results: Sixty-six patients were enrolled; 45 cords
(20 MP:25 PIP joints) received collagenase and 21
cords (11 MP:10 PIP joints) received placebo in the
double-blind phase. Significantly more cords
injected with collagenase than placebo met the
primary end point (44.4% vs 4.8%; P<.001). Mean
percentage decrease in degree of joint contracture
from baseline to 30 days after last injection was
70.5% ± 29.2% in the collagenase group and 13.6%
± 26.1% in the placebo group (P<.001). Mean
increase in range of motion was significantly greater
in the collagenase (35.4 ± 17.8º) than in the placebo
(7.6 ± 14.9º; P<.001) group. Efficacy after openlabel treatment was similar to that after the doubleblind phase: 50.7% of all joints achieved 0° to 5° of
normal. More patients were satisfied with
collagenase (P<.001). No joint had recurrence of
contracture. One patient had a flexion pulley rupture
and one patient underwent routine fasciectomy to
address cord proliferation and sensory abnormality.
A new technique is presented with Pyrodisk
replacement of the entire trapezium and part of the
trapezoid with ligament reconstruction. Despite the
fact that this is a technically challenging procedure,
it has proven to be very successful and addresses
many of the previous technical difficulties.
ABSTRACT 182
RESULTS OF PYRODISK TRAPEZIUM
REPLACEMENT
David Stabler
Southport, QLD, Australia
The results of a continuing clinical trial are
presented. Over a period of 2 years, 112 Pyrodisk
replacements of the trapezium have been
performed. The results of these operations have
been assessed in terms of pain relief, correction of
36
ANZJSurg.com supplement
2011 Plastic Surgery Congress
Australian Society of Plastic Surgeons | New Zealand Association of Plastic Surgeons
mal-alignment, range of motion and return of key
pinch.
Further research is under way to improve the shape
and sizing of the pyrocarbon implants to further
enhance the success of the procedure.
The results appear to show that the procedure is
superior to simple osteectomy and ligament
reconstruction of the CMC joint.
Poster Abstracts
POSTER 1
MAXILLARY DESMOID TUMOUR IN THE
PAEDIATRIC POPULATION: CASE REPORT
AND REVIEW OF THE LITERATURE
POSTER 3
LOWER LIP RECONSTRUCTION EMPLOYING
BILATERAL VY NEUROVASCULAR ISLAND
FLAPS
Joseph G Rizk¹, Nathan Essey², Sean Nicklin¹
Joseph Rizk, Vincent Choi, Naveen Somia
¹Sydney Children’s Hospital, Sydney, NSW,
Australia
Westmead Public Hospital, Sydney, NSW, Australia
The lower lip plays a crucial role in oral function and
facial appearance. Defects of the lower lip, whether
they are a result of tumour excision or trauma can
be a difficult reconstructive challenge. Providing
adequate length of neuratized tissue yields a better
result.
²Notre Dame University Sydney, NSW, Australia
Desmoid tumours are rapidly developing
histologically benign fibrous neoplasms originating
from the musculoaponeurotic structures throughout
the body. These tumours may cause significant
local morbidity.
Many techniques have been described for lower lip
reconstruction each with advantages and
disadvantages. This poster provides a literature
review of lower lip reconstruction and describes the
senior authors method of reconstruction for large
defects, the bilateral VY neurovascular island flap.
We report on a case of maxillary desmoid tumour in
a 15 month old female with free tissue transfer
reconstruction. We present details of the case and a
review of the literature of paediatric maxillary
desmoid tumour cases as well as unusual free flaps
in the paediatric population, particularly under 2
years of age is presented.
POSTER 4
LATE COMPLICATION OF POLYACRYLAMIDE
HYDROGEL INJECTION FOR BREAST
AUGMENTATION MAMMAPLASTY
POSTER 2
BILATERAL TESSIER NUMBER 4 FACIAL
CLEFT TREATMENT IN THE DEVELOPING
WORLD
Joseph Rizk, Verinder Sidhu, Jake Lim
Westmead Hospital, Sydney, New South Wales,
Australia
Joseph Rizk, Kevin Ho, Michael McGlynn
Polyacrylamide hydrogel has been widely used for
injection augmentation mammaplasty in Eastern
Europe, the former Soviet Union, and China.
Reports indicated that polyacrylamide hydrogel
seems to be a biocompatible material and was
stable over time, non-degradable, confined to the
breast, and migration resistant. Contrary to this
other researchers reported various complications,
such as multiple indurations, palpable lumps,
unsatisfactory contour, delayed inflammation and
spontaneous leakage of injected polyacrylamide
hydrogel with migration.
Sydney Chldren’s Hospital, Randwick, Sydney,
NSW, Australia
Bilateral Tessier no. 4 facial cleft is a rare
craniofacial malformation and few cases have been
reported. The is no one treatment option for all
Tessier no. 4 facial clefts and treatment is tailored
to the particular patient. Protection of ocular
function is paramount and usually the initial
emergent situation. There are limitations in
overseas mission and this makes treatment
challenging. We describe a case of bilateral Tessier
4 cleft treated in the developing world.
37
ANZJSurg.com supplement
2011 Plastic Surgery Congress
Australian Society of Plastic Surgeons | New Zealand Association of Plastic Surgeons
We present a patient who had polyacrylamide
hydrogel bilateral breast augmentation 10 years
previous to presentation of a spontaneous right
breast abscess due to migration and leakage of
polyacrylamide. As more patients from China travel
to Australia we may be presented with patients
having complications due to this type of breast
augmentation. We describe the management of the
patient and a literature review of long term
polyacrylamide hydrogel breast augmentation
outcomes.
culture, tradition and falsely religion because
religion has nothing to do with it represent a criminal
disfigurement of the human body and an excusable
invasion of the human rights that affect around 200
million women world wide, I am shedding a light on
this issue and presenting my technique for treating
women from 2 continents.
Patients and Methods: 30 patients from Africa and
Asia who have had partial excision of the clitoris
and or the labia minora ; during childhood and
presented to the clinic complaining of reduction of
clitoral sensation and absence of sexual pleasure.
POSTER 5
CLINICAL APPLICATIONS OF SERRATUS
ANTERIOR MUSCLE PERFORATOR FLAP
I present AlNasir technique in treating these
patients.
Mohammed AlNasir
Discussion and Results: The technique involves
resection of the scar, softening of the scar with fat
grafting liberation of the clitoris from the mons pubis
with its dorsal vascular pedicle recreation of a new
clitoris with two lateral flaps based on the
ischopubial vascular pedicles.
Specialist Hospital, Saudi Arabia
I am presenting the clinical application of this flap in
different reconstruction needs.
The serratus anterior flap is not commonly used
although it is a versatile option for the surgeon
sparing the latissmus dorsi flap for future application
if needed.
Excellent results were obtained in all patients in
terms of absence of local surgical complications
and the emergence of sexual pleasure.
Patients and Methods: 22 patients had this flap for
different pathologies that included post tumour
excision, burn and Trauma.
Conclusion: This surgical treatment has given
hope to women to be real women and to give them
something back from what life has taken from them.
Discussion and Results: Sparing the seratus
anterior muscle and raising a skin padel ranging
from 11x12 cm based on a direct cutaneous branch
from arterial branch to the seratus anterior
measuring 8-9 cm long and 1-2 mm in diameter has
allowed a relatively easy dissection and primary
closure of the site.
POSTER 7
PUBLIC PERCEPTION OF THE FIELD OF
PLASTIC SURGERY
All patients had a micro vascular transfer under a
microscope with no flap loss, skin necrosis or
hematoma. 2 patients developed seroma that was
aspirated.
²Southern Health, Dandenong, VIC, Australia
P Gill¹, F Bruscino-Raiola¹, M Leung¹,²
¹Alfred Hospital, Prahran, VIC, Australia
Background: The field of plastic surgery is
constantly evolving. This study aims to assess the
public’s understanding of the scope of practice of
plastic surgeons; to determine if there is a need to
educate the public and increase their awareness of
the nature of a plastic surgeon’s work.
Conclusion: The serratus anterior perforator flap is
a useful and practical flap for the reconstructive
surgeon.
Methodology: A cross sectional study was
performed. Participants were systematically
selected from the White Pages for a telephone
survey. The participants’ demographics were
recorded. Participants were excluded if they or
anyone they knew had prior interactions with a
Plastic Surgeon. Participants selected the
commonest area of specialisation of Plastic
POSTER 6
CLITORAL RECONSTRUCTION
Mohammed AlNasir
Specialist Hospital, Saudi Arabia
The partial or total excision of the clitoris or other
parts of the female genital organs in the name of
38
ANZJSurg.com supplement
2011 Plastic Surgery Congress
Australian Society of Plastic Surgeons | New Zealand Association of Plastic Surgeons
Surgeons. The final set of questions determined
their choice of surgeon in three different scenarios:
breast reduction, excision of skin cancer from the
facial region and hand trauma.
good randomised controlled trials showing that
quilting and fibrin sealant reduce seroma rates.
There are also good randomised controlled trials
showing steroid use can reduce seroma
reaccumulation.
Results: 213 of the 257 participants were eligible to
complete the survey. 65% were female, with 38%
between the ages of 46 and 65 years. The
dominant field of practice was reconstructive
surgery (36%). Just 19% of participants would
consult plastic surgeons across the three clinical
scenarios. Dermatologists (47%) were chosen over
plastic surgeons (24%) to excise skin cancers from
the face. Breast surgeons (53%) were chosen over
plastic surgeons (23%) to perform breast reduction
surgery. In hand trauma, 58% of participants would
consult a Hand Surgeon and merely 10% would
consult with Plastic Surgeons.
Conclusion: Seromas are more common in
bilateral than unilateral breast reconstructions.
There may be an association with increased body
mass index. Quilting and fibrin glue can be used to
reduce the incidence of seromas.
POSTER 9
EARLY IMPRESSIONS OF USING THE COOK
PROBE – A NURSING PERSPECTIVE
Daniel Luo, Leanne Simpson, Mark Lee, Mr Adrian
Brooks, Mr Joseph Luo
Dept of Plastic Surgery, Sir Charles Gairdner
Hospital, Perth, WA, Australia
Conclusion: There is a lack of understanding of the
field of plastic surgery amongst the general public,
which may be linked to the misrepresentation of the
practice by the media.
Purpose: The Cook implantable venous Doppler
probe can be used as an adjunct in monitoring free
flaps. One of its suggested advantage is to ease
free flap monitoring and improve salvage rates by
allowing earlier detection of complications. There
are no published studies with regards to the
learning phase of using the probe. This is a review
of its ease of use after a 3 month learning phase.
POSTER 8
SEROMA RATES POST LATISSIMUS DORSI
FLAP – AUDIT OF RISK FACTORS AND
LITERATURE REVIEW
Daniel Luo, Linda Monshizadeh, Lip Teh, Mark
Hanikeri, Joseph Luo
Method: After 3 months of using the Cook probe in
our unit, a questionnaire was given to all nurses
involved with its monitoring. The questions were
directed at how the nurses rated the probe
compared to clinical monitoring, as well as its ease
of use
Dept of Plastic Surgery, Sir Charles Gairdner
Hospital, Perth, WA, Australia
Purpose: To quantify the seroma rates after
latissimus dorsi harvest for breast reconstruction.
To identify potential risk factors for seromas. To
review the current literature with regards to surgical
techniques that can be used to reduce the
incidence of seromas, as well as effective ways to
treat seromas when they occur
Results: There were no free flap failures during this
time. There were 12 responses. 100% felt that
clinical monitoring was more reliable. 91% had
times where they could not confidently identify the
venous sound. 50% however felt that it did
contribute to their ability to monitor the flap. 83% felt
they needed more training with its use. The probes
were well tolerated by all patients.
Methodology: This is a retrospective review of all
patients’ notes who had latissimus dorsi flaps done
between October 2009 and 2010 at Sir Charles
Gairdner Hospital. Risk factors like body mass
index, age, axillary dissection and number of days
drains were left in were analysed
Conclusion: Despite its suggested advantage of
easing free flap monitoring, the Cook probe comes
with a significant learning phase. Training is
mandatory prior to its use. Despite the initial
difficulty in its use, it is still felt to be an important
adjunct to monitor free flaps.
Result: 30 latissimus dorsi flaps were done in this
one year period. 25 were for breast reconstruction.
The seroma rate is 23% (3 of 13) for unilateral
breast reconstruction and 58% (7 of 12) for bilateral
breast reconstructions. This is a statistically
significant difference. Patients with body mass
index less than 25 did not have seromas. There are
39
ANZJSurg.com supplement
2011 Plastic Surgery Congress
Australian Society of Plastic Surgeons | New Zealand Association of Plastic Surgeons
POSTER 10
DIFFERENTIAL DIAGNOSES IN THE
DETERIORATING WOUND DESPITE ADEQUATE
SURGICAL DEBRIDEMENT
Acute compartment syndrome is a potentially limb
and life threatening condition. We describe a case
of volar forearm compartment syndrome resulting
from the traumatic rupture of the flexor digitorum
profundus muscle belly in a two-year-old boy. The
child fell from his bike and presented to the
emergency room with a swollen and painful left
forearm, and his flexed digits painful to extend and
cool to touch. Radiographs revealed no fractures.
The patient was taken to theatre for urgent
exploration and decompression. Fasciotomies were
performed, and a large hematoma secondary to a
tear in the flexor digitorum profundus muscle belly
was found. The fasciotomy wounds closed one
week later, and at the three-month clinic review the
patient had well healed wounds and normal range
of motion. While acute compartment syndrome
most commonly occurs secondary to fractures or
vascular injuries, this case report highlights that
seemingly minor soft tissue injuries can also be
causative. There is only one previous report of
compartment syndrome caused by rupture of the
forearm musculature in a child, occurring while
1
playing a “tug of war” game . This case report also
highlights the high degree of clinical suspicion
required to diagnose acute compartment syndrome
in children, as younger patients can present with
milder findings and can be more difficult to
2
examine .
Daniel Luo¹, Fariza Abu Hassan¹, Joseph Luo²,
Ruvy Gurfinkel¹, Robert Love²
¹Royal Perth Hospital, Perth, WA, Australia
²Sir Charles Gairdner Hospital, Perth, WA, Australia
Purpose: Using a case series, to raise awareness
of the diagnosis of Pyoderma gangrenosum in the
clinically septic patient with a rapidly deteriorating
wound. To support the use of VAC dressings in
patients with pyoderma gangrenosum. To review
the treatment options for pyoderma gangrenosum
Methodology: Case study 1 – A 30 year old man
presented 1 week after an angle grinder injury
clinically septic with an expanding area of necrosis
over the injury site. Case study 2 – a 75 yo man
became septic with a deteriorating wound 1 week
after an elective groin dissection and pedicled
turndown rectus flap. Both patients were treated
with aggressive debridement because they were
clinically septic. Despite adequate debridement,
both patients continued to deteriorate.
Results: The wounds improved and patients
became systemically well only after the diagnoses
of pyoderma gangrenosum was made and
corticosteroid treatment was started. Despite the
risk of pathergy, these wounds seem to respond
well to the VAC dressings.
References
G Choi, J Huang, V Fowble, J Tucci. Volar Forearm
Compartment Syndrome Following Flexor Digitorum
Profundus Muscle Rupture in a 3-Year-Old Girl. Am
J Orthop. 2008; 37(6):108-109
Conclusion: The deteriorating wound in a clinically
septic patient despite adequate surgical
debridement is a major concern for the treating
physician. It is important in these cases to broaden
the surgical sieve to include immune conditions like
pyoderma gangrenosum. Pyoderma gangrenosum
is a clinical diagnoses and clinicians need to be
aware that in rare cases, the immune response can
make the patient look clinically septic.
J Laine, S Kaiser, M Diab. High Risk Pediatric
Orthopedic Pitfalls. Emerg Med Clin N Am. 2010;
28:85-102
POSTER 12
AVOCADO HAND: HAND INJURIES WHILE
HANDLING AVOCADOES
David Colbert¹, Jeremy Rawlins¹, Howard Peach²
POSTER 11
CASE REPORT: VOLAR COMPARTMENT
SYNDROME AFTER FLEXOR DIGITORUM
PROFUNDUS MUSCLE RUPTURE IN A 2 YEAR
OLD BOY
¹Dept of Plastic Surgery, Royal Perth Hospital,
Perth, WA, Australia
D Colbert, M Strahan
Attempting to remove the stone from an avocado
can result in serious injury to the hand. This injury is
a common cause of referrals to the plastic surgery
department at both Royal Perth Hospital (Australia)
²Dept of Plastic Surgery, Leeds General Infirmary,
West Yorkshire, United Kingdom
Dept of Plastic Surgery, Royal Perth Hospital, WA,
Australia
40
ANZJSurg.com supplement
2011 Plastic Surgery Congress
Australian Society of Plastic Surgeons | New Zealand Association of Plastic Surgeons
and Leeds General Infirmary (England). Twenty-two
cases were reviewed over a five-year period, with
all injuries sustained while removing the stone with
a knife. All 22 were explored in theatre, with 21
having significant tendon, artery or nerve damage
requiring repair. Better public awareness of the
dangers in incorrectly handling avocadoes could
help avoid this easily preventable injury.
provides useful data for the surgical treatment of
basal cell cancers.
POSTER 14
PANNICULUS MORBIDUS: A CASE REPORT OF
A CAUTIOUS APPROACH WITH SUCCESSFUL
RESULTS
M J Mickelburgh, V M Hinckley
POSTER 13
A 2-YEAR PROSPECTIVE STUDY OF BASAL
CELL INCOMPLETE EXCISION RATES OF
SEVEN PLASTIC SURGEONS WORKING IN
QUEENSLAND
Royal Brisbane Hospital, Brisbane, QLD, Australia
Background: Panniculus morbidus describes the
end stage of morbid obesity. We report a case of a
62 year old, 202kg woman who had been housebound for three years. Her pannus reached to within
10cm of the ground. The patient underwent
panniculectomy at the Royal Brisbane Hospital.
This case is significant in its description of the
technique of pannus suspension and the method of
closure.
Ryan Livingston, Abdullah Akhram, Paul Millican
Plastic Surgical Dept, Greenslopes Private Hospital,
QLD, Australia
Background: This study was undertaken to
establish the incidence of incomplete excision rates
for highly skilled and trained operators (plastic
surgeons) in Queensland and review the histology
from these specimens.
Method: The patient was managed by a multidisciplinary team including a plastic surgeon,
bariatric surgeon, dietician, psychologist,
physiotherapist and occupational therapist. The
patient underwent gastric banding prior to her
panniculectomy. The suspension technique
involved the use of a sternum frame, Steinman pins
and chains. The pannus was infiltrated with a
tumescence mixture. An Esmarch bandage was
used to compress the lymphatic fluid from the
pannus before it was resected. A 9.1kg pannus was
resected. The wound was closed primarily in 3
layers over 2 large bore suction drains and 4
Penrose drains. The wound was supported with a
compression garment post-operatively.
Methods: From 2008 to February 2010, 1471 basal
cell carcinomas (BCC’s) were excised by seven
plastic surgeons in the operative theatres at
Greenslopes Private Hospital. Information was
prospectively collected with regard to site, size and
type of closure at each operation. Histological data
was then recorded in an excel spreadsheet for
analysis.
Results: The overall incomplete excision rate was
5.37%. Mixed morphology subtype had the highest
incomplete excision rates of 9.17%, followed by
miconodular (7.86%), superficial multifocal (7.38%),
invasive (3.59%) and discrete (1.50%) subtypes.
Gorlin Syndrome was the highest risk factor for
incomplete excision (36.36%). The ear had the
highest incomplete excision rate of 8.19% followed
by other facial regions. Closure of the excision
defect by full thickness graft had the worst
incomplete excision rate (7.69%), followed by local
flap (7.02%), direct closure (3.50%) and Split skin
graft (3.36%). Pigmentation, size, ulceration and
perineural invasion did not negatively effect excision
rates. Incomplete excisions were more likely to
occur at the superficial margin (91.10%) than the
deep margin. There was a 1.02% chance of a
secondary cancer involving the margin of excision.
Results: The patient had no complications and was
discharged on day 11. On the first post-operative
visit the patient stated that the operation had
“changed her life”. The patient’s current weight is
102.5kg.
Conclusions: This technique is easily reproducible.
We believe the key to the success of this procedure
was the evaluation and integration of previously
reported techniques of pannus suspension and
wound closure and the careful consideration of this
patient and her individual requirements.
Conclusion: This large prospective collection of
data with histological analysis, outlines potentially
higher risk histological groups and regions. It
41
ANZJSurg.com supplement
2011 Plastic Surgery Congress
Australian Society of Plastic Surgeons | New Zealand Association of Plastic Surgeons
POSTER 15
MICROCYSTIC ADNEXAL CARCINOMA: A
SUCCESSFUL MANAGEMENT OF A LARGE
SCALP LESION
POSTER 16
COMPARISON OF INTRAMEDULLARY FIXATION
VERSUS PLATE AND SCREW FIXATION
TECHNIQUES FOR METACARPAL FRACTURES
LHC Kim, L Teston
LHC Kim, T Heath, AET Yeo, AK Deva
Dept of Plastic & Reconstructive Surgery,
Bankstown Hospital, NSW, Australia
Hand Unit, Sydney Hospital, NSW, Australia
Introduction: Intramedullary fixation (IM) and plate
and screw fixation (PS) are the two commonest
operative techniques employed for metacarpal
fractures in our unit. There has been no long term
comparative outcome study. We sought to compare
patient satisfaction and functional outcome of
metacarpal fractures treated by these two
techniques.
Microcystic adnexal carcinoma (MAC) is a rare
malignant cutaneous neoplasm, also known as
sclerosing sweat duct carcinoma, sweat gland
carcinoma with syringomatous features. This
disease entity was first described by Goldstein et al
in 1982, emphasizing the importance of its
distinction from the benign counterparts such as
syringoma, desmoplastic trichoepithelioma,
trichoadenoma, or non melanoma skin cancer.
Methods: We performed a retrospective follow up
of the functional outcome of 40 patients who had
undergone either IM or PS for closed extra-articular
second to fifth metacarpal fracture between January
2009 and June 2010. Several outcome measures
were used: patient satisfaction, visual analogue
scale and Disabilities of arm, shoulder and hand
score, total active motion and grip strength.
Slightly more than 300 cases have been reported
throughout the world to date. Despite its benign
appearance the actual involvement is often much
more extensive and deeply infiltrative due to its
aggressive propensity to spread far beyond the
clinically visible margins. Although metastasis is
rare, there are several cases with logoregional and
distant metastases, to the lymph nodes and
mediastinum or lung, respectively. It is frequently
misdiagnosed either clinically or pathologically and
adequate deep biopsy is essential.
Results: 12 patients who had been treated with IM
and 28 patients treated with PS were included.
Mean follow up period was 14.2 months in the IM
group and 10.4 months in the PS group. Age, sex,
hand dominance, fracture site, time from injury to
surgery and the seniority of operator were similar in
the two groups. Fracture pattern and follow up
period differed. There was no statistically significant
difference in the outcome measures between the
two groups. Two IM wires were removed due to
pain and altered sensation. Residual deformity was
observed in 3 patients treated with PS.
We report a case of an extensive MAC on the scalp
of a 56 year old Asian woman successfully treated
with surgical excision in conjunction with
intraoperative frozen section and adjuvant
radiotherapy.
Although Mohs micrographic surgery might be
considered the gold standard, it cannot be justified
practically due to its time consuming and labour
intensive nature especially in large tumours as in
this case as well as the lack of availability in many
centres.
Discussion: There was no signicant difference in
patient satisfaction and the long term functional
outcome measures between the two groups. A
randomised study is indicated to further evaluate
the long term functional outcome of metacarpal
fractures treated by these surgical interventions
limb injuries.
The paucity of literature describing successful
utilization of frozen section in the setting of local
excision makes this case unique.
We recommend the use of itnraoperative frozen
section to assist in identifying the extent of disease
and in reducing multiple re-excisional procedures.
42
ANZJSurg.com supplement
2011 Plastic Surgery Congress
Australian Society of Plastic Surgeons | New Zealand Association of Plastic Surgeons
POSTER 17
EVALUATION OF A PERIOPERATIVE BREAST
PROSTHESIS RECONSTRUCTION PROTOCOL
Background: Recently a widespread migration
from caddy screws to single wrap screws has been
observed. There has been long term speculation
that single wrap screws increase operative time
compared to caddy screws. The aim of our study
was to quantify the individual difference in time
between single wrap and caddy screw insertion in
the real world operating theatre environment.
Jennifer M Roy, Nicola R Dean, Nicholas J Marshall,
Philip A Griffin
Dept of Plastic & Reconstructive Surgery, Flinders
Medical Centre, Adelaide, SA, Australia
Methods: A prospective audit was conducted in the
operating theatre. 37 patients requiring open
reduction internal fixation with screws were included
over a four month period. The outcome group
consisted of 28 patients using single wrap screws;
the control group consisted of nine patients using
caddy screws. Scrub nurses and scout nurses were
blinded to the process. 2 of the authors formed the
data collectors; the primary author analysed the
data.
Background: Breast reconstruction patients are at
high risk of prosthesis infection at between 2.5 and
28% (Alderman 2002, Cordeiro 2006, Nahabedian
2003, Van Geel 2003, Vinton 1990). The study
examined prosthesis infection rates in breast
reconstruction patients and evaluated the effect of a
perioperative protocol on the rate of prosthesis
infection.
Methods: Retrospective analysis of 69 breast
reconstruction patients, who had 177 prostheses
inserted over a three year period was performed. A
perioperative protocol was implemented in June
2008 and two years of data was collected prior to
implementation. The protocol standardized all
perioperative care relating to breast prosthesis
reconstruction including handling, skin preparation
and prophylactic antibiotics.
Results: We identified a 325% increase in time with
the use of single wrap screws. A difference of 30.79
seconds (95% C.I., 25.89 to 35.69 s) per screw
between single wrap screws and caddy screws was
demonstrated. (p<0.0001)
Conclusion: This study has demonstrated a
significant quantitative increase in time for single
wrap screw insertion compared to caddy screws.
The increased time involved with single wrap screw
usage should serve as an impetus towards
reevaluation of single wrap screws as standard
policy. Whilst there may be advantages to single
wrap screw use, time is not one of them.
Results: Prosthesis infection occurred in 9 of 177
prostheses (5.1%, 95% confidence interval 2.4 to
9.4%) and in 7 of 69 patients (10.1%, 95%
confidence interval 4.2 to 19.8%). The number of
infections prior to the implementation of the protocol
at 8 (7.5%) was significantly higher than one (1.4%)
after the protocol was implemented (P=0.054).
POSTER 19
SURGICAL AND NON SURGICAL CORRECTION
OF THE CONGENITALLY INVERTED NIPPLE: A
REVIEW OF THE CURRENT LITERATURE
Conclusions: The rate of infection in breast
prostheses in our reconstruction patients was
similar to those that reported by other centres.
Implementation of a perioperative protocol for
breast reconstruction with prosthesis significantly
reduced prosthesis infections. Although no one
aspect of infection control was identified as an
infection risk, implementing a standardised infection
control protocol for breast prosthesis surgery was
able to reduce the number of infections.
Jessica Savage, Mark A Boccola, Warren M Rozen,
Mark W Ashton, Chris Milner, Richard Rahdon, Iain
S Whitaker, Jack Brockhoff
Reconstructive Plastic Surgery Research Unit,
University of Melbourne, VIC, Australia
Introduction: The congenitally inverted nipple
represents a common structural abnormality of the
breast. Defined as a nipple that lies on the same or
lower plane than the areola, inverted nipples cause
aesthetic concerns, predispose to impaired breast
feeding and lead to nipple irritation. The ideal
intervention would offer quick, definitive, scar free
eversion with maintained lactation.
POSTER 18
SINGLE WRAP SCREWS QUANTITATIVELY
INCREASING OPERATIVE TIME
Rudy Yeh, David Worsley, Brad Seeto
St Vincents Hospital, NSW, Australia
43
ANZJSurg.com supplement
2011 Plastic Surgery Congress
Australian Society of Plastic Surgeons | New Zealand Association of Plastic Surgeons
Method: Reviewing the medical literature of the
past two decades using the MEDLINE database
revealed over 40 relevant publications offering
operative and non-operative interventions for the
correction of congenitally inverted nipples. We
present a review of this literature highlighting both
fundamental and novel technical descriptions of
correction of the congenitally inverted nipple.
Animal models of musculocutaneous and
fasciocutaneous abdominally based flaps have
been developed and used to investigate factors that
may increase flap survival, to simulate complex
surgical conditions and even to investigate the
possibility of free flaps secreting therapeutic
proteins.
We describe techniques for raising 4 reliable and
reproducible abdominally based flaps in rodents
including transverse rectus abdominus
musculocutaneous (TRAM) flaps in rats and mice,
superficial epigastric flaps in rats and perforator
(DIEP) flaps in rats.
Findings: Non-operative measures, primarily based
on negativepressure suction devices or piercing,
are advocated for maintaining lactation in a scar
free manner. Reported to maintain eversion in near
100% of patients, they require the dedication of the
user over several months.
This poster is designed to help any plastic surgeon
who is interested in performing research on
abdominally based flaps in rats and mice or
alternatively a plastic surgical trainee who is looking
to increase microsurgical skills.
Popular methods of surgical correction of the
inverted nipple include ‘incision-and-release’ and
local flap methods. Modifications to these
techniques have evolved to include autologous
grafts and various splints. These surgeries offer a
quick and acceptable correction but cannot
generically be recommended for women hoping to
breast feed.
POSTER 21
TURBAN TUMOUR: INNOVATIONS
A Jatan, J Cha, R Yeh, M Baldwin
The diversity of methods for treating the
congenitally inverted nipple, demonstrates the lack
of a globally accepted approach. The majority of
technical descriptions published comprise case
series and expert opinions, making direct
comparison of techniques impossible. This paper
aims to provoke discussion and to improve the
clinical acumen of treatment providers.
Dept of Plastic & Reconstructive Surgery, Prince of
Wales Hospital, Sydney, NSW, Australia
Dermal eccrine cylindromas are rare benign
tumours of the adnexae that show a proclivity for
the head and neck region, in particular the scalp,
giving rise to the term ‘turban tumour’. First
described by Ancell in 1842, the consist of large
multiple tumours can envelope the entire scalp and
pose problems related to vascularity and blood loss,
in addition to topographical-related difficulties of
obtaining wound healing in a single procedure. We
report a case of a turban tumour in a 65-year-old
woman referred to our institution. Management
proceeded in a multidisciplinary setting with preoperative radioembolisation. Complete scalp and
forehead excision with grafting was followed by the
creative and novel use of the rigid external device
craniofacial frame with excellent results.
Furthermore, the latter technique lends itself to
other head and neck reconstructive situations. It is
this type of innovative thinking that distinguishes
plastic & reconstructive surgeons and will ensure
the longevity of our specialty.
POSTER 20
ABDOMINALLY BASED MICROSURGICAL FLAP
MODELS IN RATS AND MICE
J Cubitt, T Pennington, C Wang, A Bishop, A
Sharland
Microsearch Foundation of Australia, University of
Sydney, NSW, Australia
Animal models have been used for many years in
surgical research to pioneer different surgical
techniques, improve understanding of anatomy and
physiology and hone surgical skills. The benefit of
such models has been particularly important in
developing relatively young specialties like plastic
surgery and many plastic surgical flaps are
designed and studied in animals long before they
are used in humans.
References:
Crain R, Helwig E. Dermal cylindroma (dermal
eccrine cylindroma). American Journal of Clinical
Pathology 66: 434, 1961
The development of microvascular techniques has
meant that free flaps, often using tissue from the
abdomen, are being used more and more frequently.
44
ANZJSurg.com supplement
2011 Plastic Surgery Congress
Australian Society of Plastic Surgeons | New Zealand Association of Plastic Surgeons
Irwin L, Bainbridge L, Reid C et al. Dermal eccrine
cylindroma (turban tumour). British Journal of
Plastic Surgery 43: 702 – 205, 1990
2. Behar, et al. European journal vascular
endovascular surgery. 34(3):299-301
3. Kryger, et al; Journal Hand Surgery. 32(9):14661470
Sherman JE, Hoffman S, Goulian D. Dermal
cylindroma: surgical approach. Plastic &
Reconstructive Surgery 68: 596 – 602, 1981.
POSTER 23
EPITHELIOID SARCOMA – A CASE
PRESENTATION
POSTER 22
THE SURGICAL MANAGEMENT OF IDIOPATHIC
RADIAL ARTERY ANEURYSMS AT THE
ANATOMIC SNUFFBOX: A NOVEL SOLUTION
TO AN UNCOMMON PROBLEM
Francesca Rannard¹, Tim Peltz²
¹Prince of Wales Hospital, Sydney, NSW, Australia
²St Luke’s & Sydney Hospital Hand Surgery Unit,
Sydney, NSW, Australia
Samuel Yang, Gerard Bayley
Princess Alexandra Hospital, Brisbane, QLD,
Australia
Purpose: Epithelioid sarcoma is a rare high-grade
soft tissue sarcoma that has only recently been
described in the literature. It has an unusual clinical
behaviour and often has metastatic disease at
presentation. We present an interesting case of an
epithelioid sarcoma and literature review on this
topic.
Idiopathic aneurysms of the distal radial artery are a
rare entity. There are no significant series
previously described in the literature that we are
aware of. Symptoms can range from a subclinical
presentation, through to a critical digital ischaemia.
We believe that the artery develops this pathology
because of repetitive compression of the radial
artery between the tendon of extensor policis
longus (EPL) and the first metacarpal head and
trapezium at the level of the anatomic snuffbox.
Case Report: The case of a 62 year old woman
with a recurrent soft tissue tumour of the left ring
finger is presented. The tumour had been excised
previously and reported as a benign periosteal
chondroma.
Patients with this condition were initially treated with
medical therapies and splinting. However, those
who had pathology that was resistant to this
management underwent surgery.
MRI and x-ray did not show any features suggestive
of malignancy. Due to the recurrent nature a radical
excision was suggested. Prior to the excision, the
patient noticed a new nodule at the dorsum of her
left hand. An ultrasound showed that it was
attached to the radial sagittal band of the extensor
mechanism over the third metacarpal. Both lesions
were then excised.
We operated on 6 patients over 4 years for this
condition. The procedure essentially entails the
resection of the pathological segment of radial
artery and reconstructing it with a vein graft routed
dorsal to the EPL tendon. Thus far, the operation
has proved successful in correcting the symptoms
of idiopathic radial artery aneurysms. Additionally,
these results have remained durable and stable
with a mean follow up of 21.6 months. Patient
satisfaction was high and all said that they would
undergo the same procedure again if needed.
The pathology of the ring finger again showed a
benign periosteal chondroma. The more recent
nodule was reported as an epithelioid sarcoma.
PET scan showed no evidence of local or distant
metastasis. A wide excision of the sarcoma was
performed. 2 years on, there was no detectable
local or distant spread.
This series describes a pathology that has not
previously been discussed in the literature as far as
we are aware. Importantly, we detail the surgical
management of this condition that has thus far
proved to be successful and durable.
Conclusion: Epithelioid sarcoma often has a trivial
presentation but a high mortality in those with
metastatic disease (reported as occurring in up to
45% of patients). Early diagnosis and excision is
essential. It is therefore important for surgeons to
be aware of this tumour.
References:
1. Amrani, et al. Cases Journal. 1: 170
45
ANZJSurg.com supplement
2011 Plastic Surgery Congress
Australian Society of Plastic Surgeons | New Zealand Association of Plastic Surgeons
POSTER 24
MILITARY GUNSHOT INJURY: IMMEDIATE
RECONSTRUCTION WITH DISTALY BASED
POSTERIOR INTEROSSEOS FLAP AND
PRIMARY AUTOLOG BONE GRAFTING
Introduction: Reconstruction of large full thickness
anterior abdominal wall defect is a reconstructive
challenge, and life saving for the patient. The aim of
the procedure is to provide early, adequate cover
for the abdominal viscera with functional stability.
Sinan Oksuz, Huseyin Karagoz, Ersin Ulkur, Cihan
Sahin
Material and Methods: We report this patient, a 19
year old soldier with a large full thickness anterior
abdominal wall defect following a blast injury. He
underwent an emergency extended right
hemicolectomy. An end ileostomy and a colostomy
was located in the right and left hypochrondia
respectively, just below the costal margin. His whole
anterior abdominal wall was reconstructed using a
single stage pedicle extended anterolateral thigh
flap. The defect extended from the xiphisternum to
the pubic symphysis and almost up to the lateral
abdominal walls. Dimensions of the flap were 30 x
20 cm and the shape tailored to the defect. The flap
was harvested as a composite flap including the
fascia lata on the right lateral circumflex femoral
vascular pedicle. The inset was performed with the
fascia lata suturing to the remaining muscularfascial edge of the abdominal wall. The arc of
rotation was 180 0. Donor defect was covered with
a meshed split skin graft.
GATA HEH Plastic Reconstructive & Aesthetic
Surgery Clinic, Istanbul, Turkey
Introduction: High-energy weapon injuries result in
wide tissue damage. Civilian gunshot wounds are
typically caused by low-velocity weapons which
cause a more localized pattern of injury and usually
occur under conditions of limited contamination.
Due to the large caliber of the weapons used,
military injuries are often devastating. In addition,
they encompass composite tissues and require
multiple procedures for reconstruction. These
wounds are frequently contaminated, and they
necessitate further delays in definitive treatment in
order to establish infection control. Such injuries
have been treated with extensive, serial
debridement and staged wound management that
includes delayed fracture fixation and bone grafting.
Results: The entire flap survived. A minor wound
dehiscence occurred adjacent to the ileostomy,
which was managed with debridement and delayed
suturing.
Case Report: In this case report immediate
treatment of a hand wound caused by military
gunshot is reported. A 21-year-old man who shot
his right hand with a high velocity rifle was treated.
Even though it was a contaminated and high-energy
injury, early reconstruction was planned. The
patient was operated within the first day of injury.
The soft tissue defect was reconstructed with a
distally based posterior interosseos flap and the 3rd
metacarpal bone defect was reconstructed with an
iliac crest bone graft. There was neither sign of
infection nor wound problem.
Discussion and Conclusion: After a follow up of
six months he is able to walk and stand straight
without a hernia. The extended anterolateral thigh
flap can be used in single stage reconstruction of
large anterior abdominal wall defects providing a
stable neoabdominal wall.
POSTER 26
PERCUTANEOUS NEEDLE FASCIOTOMY FOR
DUPUYTREN’S DISEASE: A LITERATURE
REVIEW
Conclusion: High velocity military gunshot injuries
can immediately be reconstructed with bone grafts
and flaps without delay after minimal but definitive
debridement of the necrotic tissue and foreign
bodies.
D Hng
Royal Perth Hospital, Perth, WA, Australia
POSTER 25
RECONSTRUCTION OF NEAR TOTAL
ANTERIOR ABDOMINAL WALL DEFECT WITH
AN EXTENDED ANTEROLATERAL THIGH FLAP
Dupuytren’s disease of the fingers was first reported
in European medical literature in the 17th century. It
is widely recognized that it is a disease that cannot
be cured but can be controlled with surgery, often
multiple individual procedures. There is no
consensus on the most effective operation for this
condition. Options include fasciotomy (open or
percutaneous), limited or radical fasciectomy, or
dermofasciectomy, with added variation in
Kolitha Karunadasa, Gayan Ekanayake, Thushan
Beneragama, Dulip Perera
Plastic & Reconstructive Surgery Unit, National
Hospital of Sri Lanka, Colombo, Sri Lanka
46
ANZJSurg.com supplement
2011 Plastic Surgery Congress
Australian Society of Plastic Surgeons | New Zealand Association of Plastic Surgeons
techniques for the healing of the subsequent skin
wounds.
irregularities and formed a bed for subsequent
replacement of the defect. The dorsal metacarpal
artery of the medial dorsal interosseous muscle III
metacarpal bone had been found and mobilized.
Percutaneous needle fasciotomy has recently
become a procedure requested by patients because
of its minimal invasiveness, quick recovery, and
proposed patient satisfaction. The method of
percutaneous needle fasciotomy (PNF) is described,
and merits of careful patient selection and inherent
risks based on surgical and patient factors.
Vertical V-shaped flap had been carved from the
medial dorsal interosseous muscle III of metacarpal
bone and located in the bed formed from the same
bone. Similar flap had been cut out horizontally from
the collateral ligament of metacarpophalangeal joint
III and placed on top of the vertical muscle flap.
Main phalanx and metacarpal bone osteosynthesis
had been performed with Kirschner’s wire under
visual control. Then the joint capsule carefully and
hermetically sutured. Finally tendon extensor
muscles II-IV had been sutured.
A literature review is provided. Retrospective data
has been published comparing surgical techniques
using patient satisfaction and DASH scores to
document outcomes and disability. Unfortunately
there is gross disparity in outcome measures and
definitions of recurrence. Whilst there is suggestion
of earlier recurrence on follow-up after PNF,
evidence does not support one procedure over the
other when comparing surgical interventions.
POSTER 28
ADVANCED MICROSURGICAL EXERCISES –
ANIMAL ORGAN TRANSPLANT
PNF is a safe and effective procedure that can be
repeated. Whilst it appears to be a viable option for
carefully chosen patients in the appropriate setting,
its role is yet to be established from evidence-based
practices.
VG Ilie, C Wang
University of Sydney, Sydney, NSW, Australia
Microsurgery is one of the essential skills of the
modern plastic surgeon. It is amenable to
development in the laboratory via exercises on
living and non-living tissues. The learning curve is
accelerated by practice focused on the various
surgical steps of the microsurgical procedures.
POSTER 27
POSSIBILITY OF METACARPOPHALANGEAL
ARTICULATION’S RECOVERY VIA LOCAL
TISSUES UTILIZATION IN CASE OF INTRAJOINT
FRACTURE
We describe the techniques and the variations we
use for rat heart and kidney transplants, reporting
on 112 transplants executed in 2010 by one
microsurgeon. We focus on learning curve,
complications (bleeding, ureteric dehiscence, longterm organ malfunction) and set of skills involved.
Arsen Manaseryan, Aida Gasparyan, Gor Zalyan
Medical Centre “Surgery” LTD, Yerevan, Armenia
From 2000 to 2006 we have operated 420 patients
(males from 3 to 72 years old) with various
localisations of injuries in the wrist area.
In order to achieve proficiency (defined by over 90%
success rate), a series of 30-40 operations need to
be performed (more for kidney transplant, where
ureteric anastomosis demands a separate set of
skills). Prior experience on non-vital models is
recommended. The transplants involve complex
microdissection with vessel control and preparation,
various techniques of arterial and venous
anastomosis, all on the background of controlling
the duration and depth of anaesthesia.
We’ve performed the operation on 30 patients with
intra-joint fractures to restore the
metacarpophalangeal joint by utilising local tissues.
In the long term the motions were fully restored in
26 patients. Two patients developed anchylosis of
joints which had been rectified later by repeat
operation of the joint arthrodesis. Let us consider
the procedure on patient “G” – 68 years old male.
The wound’s debridement had been performed
under general anaesthesia of the patient. Bone
fragments and cartilage articular metacarpal head
III had been removed. The wound had been
thoroughly revised and recurrently treated with
antiseptic solutions. The broken medial articular
metacarpal head III had been refreshed with
rongeur. Then the rasp treatment eliminated
Video recording the initial procedures provides an
opportunity for technical refinement in mentored
feedback.
We suggest that for the advanced microsurgeon,
animal transplantation provides the perfect adjuvant
for training and skill maintenance. It provides
47
ANZJSurg.com supplement
2011 Plastic Surgery Congress
Australian Society of Plastic Surgeons | New Zealand Association of Plastic Surgeons
challenges in surgical planning and difficult
intraoperative decision making. The aim of long
term fuction of the transplanted organ mirrors the
goals of human reconstructive microsurgery.
myocutaneous flap in consecutive patients that
have undergone pelvic exenteration surgery at
Royal Prince Alfred Hospital from Janurary 1989
until August 2010. We also report a pilot quality-oflife review of exenteration patients who underwent
immediate reconstruction with a myocutaneous flap.
POSTER 29
EVALUATION OF VERTICAL RECTUS
ABDOMINIS MYOCUTANEOUS FLAP FOR THE
RECONSTRUCTION OF PELVIC DEFECTS
AFTER PELVIC EXENTERATION
POSTER 30
MEDIAN STERNOTOMY SCARRING USING A
KERATIN BASED GEL
1
2
Anita SW Jacombs , Philip Rome , Michael J
3, 4
Solomon
1
1
N Hamesh Jina , Jeremy Simcock , Martin Than,
2
3
Sharon Cassidy , Clive Marsh
¹Dept of Plastic, Reconstructive and Aesthetic
Surgery, Australian School of Advanced Medicine,
Macquarie University, Sydney, NSW, Australia
1
Dept of Plastic Surgery, Christchurch Hospital,
Christchurch, New Zealand
2
²Dept of Plastic and Reconstructive Surgery, Royal
Prince Alfred Hospital, Epping, NSW, Australia
3
RJK Developments Ltd, Christchurch, New
Zealand
³Dept of Colorectal Surgery and Surgical Outcomes
Research Centre, Royal Prince Alfred Hospital,
Epping, NSW, Australia
4
Aim: Midline sternotomy wounds frequently heal
with cosmetically poor scar formation. A local study
has demonstrated that 10% of patients maintained
a hypertrophic scar more than two years following
median sternotomy. Studies from the University of
Miami have demonstrated accelerated wound
healing in acute wounds in comparison to a
conventional transparent absorbent dressing in a
porcine model. The mechanism is through early
keratinocyte activation and proliferation. We attempt
to improve scar outcomes by introducing a keratin
based gel to modify scar maturation.
University of Sydney, NSW, Australia
Pelvic exenteration is increasingly being used for
surgical management of advanced and recurrent
pelvic cancers. Exenteration can include resection
of levator, piriformis, gluteus and obturator muscles
as well as sacrum, pubis and ischial bones, and
usually the complete genitourinary apparatus
(bladder, prostate, vagina and uterus). These
radical resections usually occur in tissue previously
treated with radiotherapy, either associated with
past primary or as the recurrent pre-exenteration
neoadjuvant therapy. Primary closure is associated
with increased morbidity due to large extirpative
defects, a non-collapsable dead space and
irradiated poorly vascularised tissue that often
results in a challenging wound-healing problem.
Methods: We recruited 20 patients into a
prospective randomised study. Each half of the
patient’s wound was randomised to either an
aqueous cream control or keratin treatment. The
keratin comes in a gel formulation and is designed
for dry wounds. This is highly hydrophilic and
maintains a moist healing environment whilst being
able to absorb moderate amounts of exudate. Both
products were applied twice daily over each half of
the wound for 6 months. The patients were
reviewed after 3 and 6 months to assess
components of the scar. The scar was evaluated
using the Manchester Scar Scale (MSS), Patient
and Observer Scar Assessment Score (POSAS)
and clinical photography.
Immediate reconstruction with a myocutaneous flap
may improve wound outcomes by providing healthy
well vascularised tissue that can fill the dead-space
ameliorating the problems of primary closure. The
Vertical Rectus Abdominis Myocutaneous (VRAM)
flap is often flap of choice for pelvic exenteration
reconstruction as it has a robust blood supply, a
reliable skin paddle, precludes formation of an
additional donor-site and flap can be raised and
inserted without additional patient repositioning.
Results: Patients were on average 60.6 years old,
70% male and 95% Caucasian. There was 82%
overall compliance with both the treatment and
control groups. There were no postoperative
complications and pruritis and paraesthesia were
the most common symptoms noticed in 25% of
We have retrospectively reviewed the operative and
wound outcomes and complications for primary
closure versus immediate reconstruction with
48
SOS Nursing, Christchurch, New Zealand
ANZJSurg.com supplement
2011 Plastic Surgery Congress
Australian Society of Plastic Surgeons | New Zealand Association of Plastic Surgeons
patients. This had resolved in all patients by 6
months. The mean MSS at 3 months in the
treatment group and control group was 12.58 and
12.43 which improved to 12.00 and 12.58
respectively. The mean POSAS in the treatment
and control groups were 16.85 and 17.95 at 3
months in the patient component and 18.55 and
19.00 at 3 months in the observer component at 3
months. This reduced to 15.00 and 16.65 at 6
months in the patient group and 16.70 and 17.85 at
6 months in the observer group for the treatment
and control arms respectively. Hypertrophic scarring
was noted in 10% of patients.
Waikato District Health Board, Hamilton, New
Zealand
Introduction: This paper aims to identify the
pattern of injuries arising from avocado stoning.
There is anecdotal evidence suggesting avocado oil
only causes temporary neuropraxia and therefore
exploration in theatre could be avoided.
Methods: A retrospective review of twenty case
notes was performed between January 2007 and
March 2010. Demographic data, clinical
presentation, operative findings and post-operative
recovery were obtained.
Conclusion: This study attempts to modify scar
maturation in the early stages of remodelling.
Overall trends are consistent between both scar
scoring systems and between patient and observer.
Temporary scar symptoms were experienced by the
patients with both treatment and control modalities.
We found that there is some improvement in scar
characteristics using keratin based gel compared
with aqueous cream after 6 months with a more
noticeable difference over time.
Results: There was a clear female dominance in
gender distribution (19:1; Female: Male). The age
ranged from 16 to 66. Twelve Patients sustained
partial or complete division of their digital nerves.
The nerves were intact in four and contused in four
patients. Clinical findings correlated with operative
findings in sixteen patients. In short term follow up
all were recovering satisfactorily.
Discussion: There was a clear female dominance.
The mechanism of injury for all patients was a stab
injury into the non-dominant hand.
POSTER 31
SYMPLASTIC GLOMUS CELL TUMOUR: A CASE
REPORT AND A REVIEW OF THE LITERATURE
From the pattern of injuries in this case series there
is evidence that avocado stoning injuries can result
in nerve and tendon division. Exploration of the
wound and repair of structures is justified. The
series doesn’t support the anecdotal suggestion
that avocado injuries presenting with clinical
symptoms are as a result of avocado oil induced
neuropraxia.
K Mooney, B Nye, J Simcock
Christchurch Public Hospital, Canterbury, New
Zealand
A 61-year-old female presented with an 8 year
history of a painful subungual lesion on the left
index finger. After complete local excision, histology
was consistent with a symplastic glomus cell tumour.
The important differential diagnosis of a glomus
tumour of uncertain malignant potential was
excluded. Only 13 cases of symplastic glomus cell
tumours have been reported in the literature to date.
The defining feature is marked nuclear atypia in the
absence of any other criteria for malignancy. These
criteria include large size, deep location, atypical
mitotic activity and necrosis. Symplastic glomus cell
tumours are considered benign lesions and excision
is mostly curative. There have been two cases of
recurrence documented. Hereby, the authors report
a case and review the current literature on
symplastic glomus cell tumours.
Hand injuries arising from avocado stoning are
potentially avoidable. Education of the public to use
the correct technique and utensils to stone
avocados is important.
POSTER 33
EAR RECONSTRUCTION USING THE ANTIA
BUCH PRINCIPLES
Vlad I Ilie, Victor G Ilie, Mihaela Lefter
Royal Hobart Hospital, Hobart, TAS, Australia
Chondrocutaneous flaps have been used in ear
reconstruction in various technical forms since the
initial description by Antia and Buch.
POSTER 32
AVOCADO STONING AND ASSOCIATED HAND
INJURIES
We report our experience with 20 patients who
underwent ear reconstruction post oncological
Shabana Alam, Sami Al Ani
49
ANZJSurg.com supplement
2011 Plastic Surgery Congress
Australian Society of Plastic Surgeons | New Zealand Association of Plastic Surgeons
resection, followed by reconstruction using
composite flaps.
imaging but rather compliments the decision to
send patient for operative exploration.
All the patients have been operated by the same
surgeon, in the same department. A simple
technical modification (e.g. cartilage resection)
allows for a more realistic result.
POSTER 35
A REVIEW OF MAXILLOFACIAL INJURIES IN A
MAJOR VICTORIAN TRAUMA CENTRE
Carly Fox, Neela Janakiramanan, David Morgan
The technical ease of the operation and the
predictable results make us recommend this
technique for all levels of expertise.
Dept of Maxillofacial Surgery, Alfred Hospital,
Melbourne, VIC, Australia
The Alfred Hospital is a major Melbourne inner-city
tertiary referral hospital, specializing in the
management of trauma patients Victoria-wide. It
remains the busiest trauma centre in Australia. As a
result, the patients treated at this hospital are often
victims of high-energy insults, with multiple injuries
and multisystem involvement. The spectrum of
maxillofacial injuries in these patients is broad, with
a higher proportion of devastating facial injuries.
POSTER 34
REDUCING THE DELAY IN DIAGNOSIS OF
NECROTIZING FASCIITIS
A Winder, J Simcock
Christchurch Public Hospital (CPH), Christchurch,
New Zealand
Introduction: Necrotizing fasciitis (NF) is an
uncommon necrotizing soft tissue infection that
causes local tissue destruction, necrosis and lifethreatening sepsis. Delayed treatment has been
linked to worse outcomes. Some patients present
classically and are diagnosed promptly; others
where the diagnosis is missed are observed and
treated late. We aimed to review features at
presentation that may help in the early detection of
NF in patients with delayed diagnosis.
The Maxillofacial Unit at the Alfred Hospital
maintains a database of all maxillofacial patients
treated at this institution. We present a review of the
spectrum of maxillofacial injuries managed in the
last 12 months. We include aetiology, nature of the
injury, and management of injuries. We compare
these findings with those of other institutions around
Australia.
POSTER 36
IS IT GYNAECOMASTIA? IS IT BREAST
CANCER?
Methods: We retrospectively reviewed 42 cases of
NF presenting to CPH from 1998 to 2010. The data
was segregated into two groups; those diagnosed
on admission (surgery within 6 hours of
presentation, 15 patients) and those were the
diagnosis was delayed (surgery later then 6 hours,
27 patients).
Kelly Thornbury, Darrell Perkins
St George Hospital, Kogarah, NSW, Australia
Male breast cancer is rare, but the incidence is
increasing. The prognosis for male breast cancer is
generally believed to be worse than that of female
breast cancer. Risk factors for male breast cancer
include family history of breast cancer, BRCA2
gene abnormalities, Kleinfelter’s sydrome, hormonal
abnormalities as a result of obesity, testicular
disorders and exposure to radiation. Given that this
malignancy is rare, is screening for malignancy in
patients who present with gynaecomastia important
to consider? We present a report of a case of a man
who presented for surgical correction of his bilateral
“gynaecomastia”. He was subsequently diagnosed
was with bilateral breast cancer. The negative
outcomes that would have resulted had avulsion
liposuction been performed to correct the so called
“gynaecomastia”, would have been potentially
devastating in this case of bilateral breast cancer.
Results: Those with a delayed diagnosis tended to
be younger (49.8 years vs. 62.8 years) and fitter (59%
have one medical co-morbidity compared to 80%).
57% of patients had one late sign at presentation
compared to 71.4% who did not. Laboratory risk
indicator scores for NF (LRINEC) scores were ³6 in
48% vs. 26.6%. 88% of patients have at least one
late symptom or LRINEC score ³6 or APACHE
score ³8 at presentation compared to 93.3%.
Conclusion: Clinical signs alone may be
insufficient to make the diagnosis of NF on
admission. Combining clinical signs, LRINEC and
APACHE 2 score can be used to stratify disease
likelihood. This does not replace the need for
surgical admission, frequent review and appropriate
50
ANZJSurg.com supplement
2011 Plastic Surgery Congress
Australian Society of Plastic Surgeons | New Zealand Association of Plastic Surgeons
POSTER 38
EFFECT OF TOPICAL SILVER TREATMENT IN
COMBINATION WITH TOPICAL NEGATIVE
PRESSURE ON BACTERIAL LOAD OF
PSEUDOMONAS AND STAPHYLOCOCCAL
BIOFILMS IN VITRO
This report discusses a rational approach to
investigation and reiterates the importance of
clinical suspicion and careful examination of the
male breast.
POSTER 37
GUNSHOT INJURIES TO BRACHIAL PLEXUS:
OUTCOME ANALYSIS
Pedro M Valente, Karen Vickery, Anand K Deva
Gayan Ekanayake, Dulip Perera, Thushan
Beneragama, Dammika Dissanayake, Kolitha
Karunadasa, Vipula Perera, Amila Rathnayake.
Australian School of Advanced Medicine (ASAM),
Macquarie University, NSW, Australia
Background: Chronic wounds remain a major
source of patient morbidity. Chronic wounds have
been shown to be infected with bacterial biofilm.
Bacteria within biofilms are resistant to traditional
treatments including antibiotics and host immune
response, thus delaying wound healing. Topical
negative pressure (TNP) dressings aid wound
healing in vivo by reducing oedema and improved
oxygen perfusion. Topical silver is a well
established bactericidal agent used in wound
management. This study tested the combined effect
of TNP and silver on pseudomonas and
staphylococcus biofilms.
National Hospital, Colombo, Sri Lanka
Background: The surgical decisions in brachial
plexus injuries following gunshot wounds are unique.
These are impacted by the clinical presentation and
intraoperative nerve status.The objective of this
study is to clarify the factors which may improve the
surgical technique and outcome of the brachial
plexus lesions caused by gunshot injuries.
Methods: Sixty five patients who had brachial
plexus lesions caused by gunshot and shrapnel
injuries were included in this study. All of them were
male with an average age of 23 years. Varying
degrees of improvements were seen in majority of
the patients with complete recovery observed in
three patients. The patients were classified and
managed according to the locations, clinical and
electrophysiological findings, and additional nerve
crossings.
Methods: Pseudomonas aeruginosa (Ps)
Staphyloccocus epidermidis (SE), S aureus (MSSA
and MRSA) biofilms were grown in vitro on plastic
coupons, inserted into our wound model and treated
with standard polyurethane VAC foam +/ – TNP or
silver impregnated foam +/ – TNP for 3 and 5 days
and quantitative bacterial counts (CFU) determined.
Results: The injury was due to shrapnel in 42
patients and bullet in 23 patients. Surgical
procedures were performed from 3 months to 18
months after the injury. Partial static lesions
recovered better when treated with distal nerve
crossings. The motor recovery was superior when
the nerve was physically intact and compressed by
surrounding fibrosis or the nerve was incontinuity
with fibrosis or neuroma.
Results: Silver foam reduced Ps biofilm CFU by
103fold, this was reduced a further 104 fold with
TNP. The effect of silver on staphylococcal biofilms
varied. Silver alone reduced CFU counts in: 1)
MSSA up to 107; 2) MRSA by 106; and 3) SE by
102. There was limited further reduction with TNP at
3 and 5 days.
Conclusions: In vitro silver impregnated foam
impressively reduces bacterial biofilm load. Addition
of TNP to the silver foam produced an additive
effect against Ps biofilms. However, this additive
effect was not seen for staphylococcal biofilms. This
may have implications for treatment of chronic
wounds with MRSA and require increase in silver
concentration or frequency of dressing change.
Conclusion: Surgical treatment is benefitted by
distal nerve crossings and early interventions when
progression is static. Intraoperative findings of the
nerve being intact correlates better with satisfactory
recovery.
51
ANZJSurg.com supplement
2011 Plastic Surgery Congress
Australian Society of Plastic Surgeons | New Zealand Association of Plastic Surgeons
POSTER 39
PARAVERTEBRAL BLOCKADE FOR DAY CASE
BREAST AUGMENTATION: A RANDOMIZED
CLINICAL TRIAL
hypothesis. PVB is an anaesthetic technique that
could be more widely utilised in the day case setting.
POSTER 40
ALTERNATIVE METHODS OF DELIVERING
LIDOCAINE TO A WOUND WHEN DOING A
VACUUM-ASSISTED CLOSURE DRESSING
CHANGE
Sarah Gardiner¹, Malcolm Bond¹, Glenda Rudkin²,
Rodney Cooter³
¹Flinders University School of Medicine, Adelaide,
SA, Australia
K Thompson, K Chan, D Rowe
²Specialist Anaesthetic Services, Adelaide, SA,
Australia
Dept of Plastic & Reconstructive Surgery, Princess
Alexandra Hospital, Brisbane, QLD, Australia
³Waverley House Plastic Surgery Centre, Adelaide,
SA, Australia
Background: Vacuum-assisted closure dressings
can be painful when changed. Factors that
contribute to a patient’s overall pain experience
during a vac-dressing change include large wounds,
longer time between dressing changes, having a
lower pain threshold, and anxiety.
Background: Bilateral breast augmentation (BBA)
is an increasingly popular day procedure that
requires sophisticated anaesthesia/ analgesia to
promote a safe and expedient recovery. Local
infiltrate is routinely used for its ease of application.
We hypothesised that ropivacaine injected by an
anaesthetist into the paravertebral space was more
effective than ropivacaine injected directly into the
zone of surgical dissection.
We suggest two alternative methods to that used by
Franczyk et al, which involves injecting 0.2%
lidocaine directly into the suction tubing 30 minutes
prior to a dressing change.
Method: We suggest using 2% lidocaine. The
volume can be estimated by calculating the volume
of the sponge used on the wound.
Methods: Forty female patients undergoing sub
pectoral BBA were recruited, in a prospective,
randomised single blind study, to either a group
receiving ropivacaine via paravertebral block (PVB)
or surgical infiltration of ropivacaine. Both groups
were sedated with propofol, titrated to effect.
Our first method involves turning off the vacdressing machine, clamping the tube, injecting
lidocaine directly into the vac-dressing in multiple
areas ~1cm apart and leaving for 30-45 minutes
prior to removing the dressing.
Data collected included demographic characteristics,
intraoperative cooperation scores, post operative
nausea and vomiting, analgesia use and visual
analogue scale pain scores. All patients were asked
to complete a preoperative anxiety and quality of
recovery questionnaire, and to record their pain
scores and analgesia requirements on discharge.
The outcome measures were: (i) intra-operative
patient co-operation (assessed by plastic surgeon),
(ii) propofol requirement (iii) post operative pain, (iv)
quality of recovery.
The second is similar to the method used by
Franczyk et al’s but instead of injecting standard
volumes based on an approximate size of the
wound, we suggest injecting enough lidocaine that
causes the dressing to bulge.
Conclusion: We feel that our methods may reduce
the pain experienced during a vac-dressing change
because of the higher concentration of the lidocaine
and due to increased contact of the lidocaine with
the wound. We hope to test these methods in a
double-blind randomised control trial.
Results: Forty patients completed the study. PVB
improved intraoperative co-operation (p < 0.001),
reduced propofol requirement (mg.kg.min-1) (p =
0.013), decreased postoperative pain at home (p =
0.004) and improved quality of recovery (p = 0.039).
There were no PVB complications.
References:
Franczyk M, Lohman R, Agarwal J et al. The Impact
of Topical Lidocaine on Pain Level Assessment
during and after Vacuum-Assisted Closure Dressing
Changes: A Double-Blind, Prospective,
Randomised Study. PRS Journal [Internet]. Cited
Conclusions: This is the first study to show PVB is
superior to comparative direct surgical infiltration of
ropivacaine for day case BBA, confirming our
52
ANZJSurg.com supplement
2011 Plastic Surgery Congress
Australian Society of Plastic Surgeons | New Zealand Association of Plastic Surgeons
We report a rare case of subacute Mycobacterial
Abscessus infection of bilateral breast
augmentation which has been not reported in the
literature with polyurethane coated silicone breast
implant. Patient presented with scar retraction and
discomfort in the right augmented breast over seven
months after surgery. Over next four weeks period,
the area of concern became more inflamed and
eventually led to a discharging sinus with implant
exposure that required removal and routine culture
of discharge did not isolate any pathogens but the
excised scar and capsule eventually grew
Mycobacterium Abscessus. After consultation with
local infectious disease experts, further scar
excision with total capsulectomy was performed
after 6 weeks on the appropriate antibiotic followed
by a prolonged course of appropriate antibiotics.
Interestingly, granulomata were found in the skin
scar and capsule specimen sent for histological
analysis. Atypical Mycobacterial breast implant
infection is rare but should be excluded in all breast
implant infections. Review of atypical mycobacterial
breast implant infection is discussed. We strongly
advocate total capsulectomy in addition to removal
of implant and prolonged course of antimycobacterial agent guided by the advice from a
local infectious disease expert as a comprehensive
treatment for this rare condition.
February 25 2011. 124(854-861), 2009. Available
from: www.PRSJournal.com
POSTER 41
CASE REPORT OF CHRONIC STERNOTOMY
WOUND CLOSURE WITH BILATERAL
PECTORALIS MAJOR ADVANCEMENT FLAP IN
A PATIENT ON LEFLUNOMIDE
KG Chan, S Senewiratne
Dept of Plastic & Reconstructive Surgery, Princes
Alexandra Hospital, Brisbane, QLD, Australia
A patient with Rheumatoid arthritis on Leflunomide
suffered chronic symptomatic sternal non union
following cardiac bypass surgery. Open re-wiring of
sternum attempted 14 month post primary
sternotomy resulted in infected wound that required
open drainage and washout 2 weeks later.
Leflunomide was not ceased at the primary bypass
procedure and was stopped two weeks prior to
open re-wiring as a precautionary measure by the
primary treating cardiac surgery team. However,
serum Leflunomide’s active metabolite remain
measurable at a significant level after stopping the
medication for over six weeks. Full elimination of
the drug to non detectable serum level using the
drug manufacturer’s recommended regime with
cholestyramine was instituted before definitively
closure of the sternotomy wound. The wound
healed successfully and remains stable and pain
free. Leflunomide (ARAVA®) is an isoxazole
immunomodulatory agent which inhibits
dihydroorotate dehydrogenase (an enzyme involved
in de novo pyrimidine synthesis) and has
antiproliferative activity. Active metabolite of
Leflunomide can be detected up to 2 years after
cessation of the drug. In vitro, it can inbibit
osteoblast proliferation. It has also been shown to
increase the risk of early healing complications in
patients with rheumatoid arthritis undergoing
elective orthopaedic surgery. However, little
guideline exists on Leflunomide therapy in light of
large chronic complex surgical wounds. We
propose full Leflunomide elimination prior to any
attempt to cover any complex or chronic wounds.
POSTER 43
DUPUYTREN’S DISEASE IN MAORI PATIENTS:
A CASE SERIES OF ADMISSIONS TO WAIKATO
HOSPITAL, HAMILTON, NEW ZEALAND 1999 –
2008
Daniel Mafi, Sami Alani
Waikato Hospital, Hamilton, New Zealand
Purpose: Dupuytren’s Disease (DD) is traditionally
described as a condition of the “Vikings”, being
common in Northern European populations and
also in those countries settled predominantly by
migrants from Northern European countries such as
New Zealand. In a study of over 9900 patients
population prevalence was estimated at
1
730/100000 for whites vs 130/100000 for blacks.
Anecdotally DD is rarely seen in the native Maori
population of New Zealand, but very little ethnicspecific research for the condition exists. We
describe a case series of Maori patients treated in
our hospital for Dupuytren’s Contracture
POSTER 42
MYCOBACTERIUM ABSCESSUS INFECTION IN
POLYURETHANE COATED BREAST IMPLANT
AUGMENTATION
KG Chan, PJ Belt
Methodology: Retrospective chart analysis of
patients undergoing Dupuytren’s contracture
release at Waikato Hospital between 1999 to Dec
Dept of Plastic & Reconstructive Surgery, Princes
Alexandra Hospital, Brisbane, QLD, Australia
53
ANZJSurg.com supplement
2011 Plastic Surgery Congress
Australian Society of Plastic Surgeons | New Zealand Association of Plastic Surgeons
2008. Patient characteristics and disease severity at
time of presentation are described. Via the Hospital
Maori cultural Department (Maori Kaitiaki) we intend
to interview each patient to gauge European
ancestry. [Ethical approval pending]
results show that the flow field and particle
deposition pattern have been changed after the
nasal plastic surgery. The volume flow rate as a
function of the pressure drop in the nasal airway
was computed numerically and compared between
the before and after the plastic surgery.
Results: 227 patients underwent DD contracture
releases during the study period. 212 (93%) of
these identified themselves as NZ Europeans. Only
eight patients (3.5%) identified themselves as Maori.
The mean age was 63 years. Seven were male.
Three patients (38%) had unilateral disease only.
The most common digits affected were the ring
finger (4 patients). Only 2 patients (25%) had
identified risk factors for DD at presentation.
Although the plastic surgery was performed on the
nostril but the pattern of the deposition for micro
particles is changing in the other parts of the nasal
passage. The deposition of nanoparticles, however,
shows similar trends in the postoperative and
preoperative nasal passages. As a result, CFD can
be used as a tool for virtual surgery to test various
scenarios and for selecting the proper procedure for
the optimal outcome of the operation before the
surgery.
Conclusion: Dupuytren’s Disease (DD) is only
rarely seen in Maori populations. To the best of our
knowledge this is the only description of the disease
presenting within this population.
POSTER 45
TAKING THE STING OUT OF LOCAL
ANAESTHETIC IN INTRADERMAL
ANAESTHESIA
References:
1. Saboeiro AP, et al,. Racial Distribution of
Dupuytren’s Disease in Department of Veterans
Affairs Patients. PRS 106(1): 71 – 75
AN Freeman
POSTER 44
CFD STUDY OF THE NASAL PLASTIC
SURGERY EFFECT ON THE FLOW RATE AND
DEPOSTION OF NANO/ MICROPARTICLES IN
HUMAN NASAL PASSAGE
Learning Objectives: Develop an appreciation for
current techniques and additives to reduce pain on
intradermal local anaesthetic infiltration.
The Alfred Hospital, Melbourne, VIC, Australia
Background: Local anaesthetics have been in use
since 1884 and have become invaluable to the
practise of modern medicine and surgery. Among
their various uses, they provide analgesia and
enable procedures to be performed in all of the
body’s regions. The cornerstone of local
anaesthesia has been drugs of amide class,
including lignocaine and ropivacaine. Various other
drugs have been used, including the opioid partial
agonist tramadol, and the benzodiazepine
midazolam. The commonest side-effect of local
anaesthetic is the pain of infiltration.
1
O Abouali , P Farhadi, E Keshavarzian, A
Faramarzi2, J Tu3
1
Dept of Mechanical Engineering, Shiraz University,
Shiraz, Iran
2
Ear, Throat and Nose Department, Shiraz Medical
University, Shiraz, Iran
3
School of Aerospace, Mechanical and
Manufacturing Engineering, RMIT University,
Australia
Methods: A literature review was performed to
search for techniques to reduce the pain of local
anaesthetic infiltration using OVID Medline and
Google scholar. A succinct list of techniques in use
was created. This was further explored and
expanded upon in a limited fashion with clinical
trials and studies featuring evidence and
adaptations for the use of those drugs.
The effect of nasal plastic surgery on the flow
patterns and deposition of micro/nano-particles in
the realistic human nasal airways is investigated by
CFD (Computational fluid dynamic) technique. For
this aim a three dimensional computational models
of both sides of human nasal passages were
developed for the before and after plastic surgery. A
series of coronal CT scan images from a live patient
was used to construct the model. The governing
equations for the airflow and particle motion in the
nasal passages were solved numerically. The
Results: Various techniques for reducing the pain
of local anaesthetic infiltration have been described.
These are related to the patient and site; the
formula injected; and the technique of injection.
54
ANZJSurg.com supplement
2011 Plastic Surgery Congress
Australian Society of Plastic Surgeons | New Zealand Association of Plastic Surgeons
With regard to patient and site, reassurance,
distraction, systemic pre-medication, pressure,
topical local anaesthetic, and cooling have been
reported as beneficial. The formula being injected
can be warmed, have adjuvants such as pH buffers
added, and have its anaesthetic agent substituted.
Injection techniques include minimising the volume
injected, using small needles, injecting slowly, and
injecting through open wounds.
followed up for a minimum of 1 year. Follow up
included Functional self assessment (DASH
questionnaire), sensitivity testing, 2-point
discrimination, Semmes-Weinstein monofilament
testing and range of motion evaluation.
Results: 46 patients (40 male and 6 female) with a
mean age of 40 years (Range 3 to 86 years) were
followed up over an average of 5 years (Range,12
months to 8 years).At the time of review all flaps
survived, all patients regained full functional use
and had returned to work. The aesthetic
appearance was considered satisfactory. The
average DASH score was 13.06 (range, 0–61.67).
Conclusion: There is a range technique for the
reduction of pain in intradermal local anaesthetic
infiltration. They relate to the patient, the agent, and
the technique on injection itself.
Implication: Local anaesthesia infiltration continues
to be a painful procedure; however this can be
mitigated to some extent.
82% of patients demonstrated a normal 2Point
Discrimination (<6 mm). The mean 2 Point
Discrimination on the resurfaced finger was 5.50
mm (range, 2–8mm) and 2.78 (range, 2–4 mm) in
the uninjured contra lateral finger. Sensibility testing
on Semmes-Weinstein pressure included 35%
patients with diminished light touch, 30% displayed
diminished protective sensibility and 10% displayed
loss of protective sensibility. The flap was divided
on average at 12 days (8-15 days). There was no
major donor site morbidity. Donor finger Active
ROM was reduced in 2 patients PIPJ (by 6 degrees
& 20 degrees) MCPJ (by 8 degrees & 2 degrees).
POSTER 46
THE MALIGNED FINGER TIP REPAIR
F Sofiadellis, J Crock
Austin Health, Docklands, VIC, Australia
Purpose: The cross finger flap is an established
technique for finger tip reconstruction. We review
our experience with this flap with special reference
to long-term functional and neurosensory recovery.
Conclusions: Finger tip defect reconstruction
should be individualized to each patient. Surgeons
should consider simple techniques on
reconstructive ladder first. The cross finger flap
remains a useful reconstructive option.
Methods: A retrospective review of 46 patients
from June 2003 to August 2009. The senior author
was involved in all operations. Patients were
55