Plastic Surgery

Lymphangioma is a rare benign proliferative lymphatic lesion that appears in chronic lymphedematous states in a variety of settings. Lymphangioma circumscriptum consists of clinically thin-walled, translucent vesicles appearing in groups most commonly located on the axilla, chest, mouth, and tongue. A 12-year-old male patient had been suffering from itching, pink-red colored, translucent vesicular lesions overlying the anterior axilla since birth. The lesions had slow-ly grown in size and number over the years. The patient had no history of trauma, or cellulites. The physical examination revealed clusters of pink-red colored vesicles, which released a clear exudate when punctured. The lesion was 50×120 mm in size. The lesion was totally excised and repaired with Z-plasty. Histopathological examination revealed slight epidermal acanthosis and enlarged lymph in the upper dermis, impinging directly onto the epidermis. These lymphatics were lined only by endothelium. The lower dermis and sub-cutis contained abnormally large muscle-coated vessels containing a proteinaceous fluid. Six months later, there was no recurrence and a cosmetically and functionally acceptable postoperative result was obtained.

At the Dalhousie Plastic Surgery Alumni Reunion at the Atlantic Plastic Surgery meeting in Halifax, Nova Scotia, in September 2001, 22 subjects, including 18 certified hand surgeons, were injected with 1.8 mL of 2% lidocaine with 1:100,000 adrenaline in three places in one finger of each hand. One hour later, the same sites of one hand were injected with phentolamine (1 mg in 1 mL), and the other hand was injected with saline. Subjects were blinded as to which hand received the phentolamine. It took an average of 85 min for the adrenaline-injected fingers to return to normal colour after phentolamine injection. It took an average of 320 min for the adrenaline-injected fingers to return to normal colour after saline injection (no phentolamine). We also observed that lidocaine with adrenaline provided an average of 549 min of anesthesia in nonphentolamine-injected fingers. Phentolamine consistently and reliably reversed adrenaline-induced vasoconstriction in the finger.

Carpal tunnel syndrome (CTS) is the source of substantial workers' compensation claims in industrialized countries. Its pathogenesis, however, continues to be questioned. The purpose of the present study was to assess the attitudes of Canadian plastic surgeons toward Workers' Compensation Board (WCB)-supported claims for CTS and to assess patterns of resource allocation across Canada.

Sixty-seven plastic surgeons were asked to read a clinical scenario and respond whether they would support a WCB claim for CTS. Provincial WCB offices were contacted and asked to provide statistics surrounding CTS claims for 1997 to 2001. Fifty-eight per cent (39 of 67) of surgeons surveyed felt that CTS should be covered as a WCB claim, while 42% (28 of 67) felt that it should not be covered by WCB. In British Columbia, 50% (six of 12) of surgeons were in support of the claim compared to 92% (11 of 12) of those from Alberta, 55% (17 of 31) of those from the Central Provinces and 42% (five of 12) of those from the Maritime Provinces. Trends of resource allocation and number of CTS claims per year are presented for the individual provinces for 1997 to 2001.

An extensive literature review revealed that there is minimal to no evidence to support the view that CTS should be a compensated claim. As defined by the WCB of Canada, a compensated claim is one that “arises out of, and in the course of, employment and that results from causes and conditions peculiar to the trade, occupation or industry.” The ambiguity in the beliefs of Canadian plastic surgeons in supporting CTS as a WCB claim reflects a situation where many of the decisions to cover CTS as a WCB claim are not evidence based.

Extramammary Paget's disease (EMPD) is a rare entity, especially in the perinoscrotal region, and typically presents in elderly white patients as a pruritic white or red patch in the area of distribution of apocrine glands. Typically, it affects a single site. Since its manifestations are insidious and easily misdiagnosed, the appropriate manage-ment is delayed. Management of this problem is complex and effective treatment can not only lower recurrence rates but also pro-vide an optimal reconstructive result.

The present report describes three patients with scrotal EMPD. Based on literature search, the etiopathology, diagnosis and management of these lesions is discussed. Reconstructive options, with special emphasis on scrotal lesions, are also discussed.

Because cutaneous anthrax, caused by Bacillus anthracis, is rare in developed countries, sporadic cases of anthrax may easily be over-looked because the diagnosis is often difficult to make. Lower eyelid involvement of anthrax is rare in clinical practice.

A 40-year-old woman with a history of contact with animals was evaluated and treated for a left lower eyelid lesion with a black eschar on it. A diagnosis of cutaneous anthrax had been made and intra-venous penicillin had been given by the department of infectious diseases before plastic surgery consultation. Any kind of surgical intervention was delayed for three months. The lesion healed secondarily and the resulting scar did not result in ectropion of the lower eyelid.

Delaying surgery is preferred because it is a safer approach when dealing with anthrax involving the lower eyelid, and secondary healing does not always result in deformity compromising function.

Currently, radial artery cannulation is the preferred method for con-tinuous hemodynamic monitoring in critically ill patients. Reported complications of radial artery cannulation include infection, digital gangrene, thrombosis, pseudoaneurysm, skin necrosis and median nerve palsy Radial artery catheter fracture is a very rare complication. A review of the English language literature revealed only one reported case.

We present an additional case of spontaneous radial artery catheter fracture.

Successful obliteration of an empyema cavity with vascularized flaps can, on occasion, best be accomplished using a free tissue transfer. A conjoint free muscle flap captures the immunological attributes of muscle necessary in the infectious milieu of these defects, augments the potential flap volume required to fill these often large defects, yet relies on only a single recipient site for the requisite microanastomoses. These advantages are demonstrated by a case using a combined latissimus dorsi/serratus anterior conjoint muscle free flap to obliterate a chronic upper thoracic empyema cavity. The internal mammary vessels were the most readily accessible recipient site, and should be considered an important alternative when managing these challenging wounds of the upper chest.

Nasal reconstruction requires a good aesthetic outcome because the nose is located in the centre of the face. Two problems commonly occur after reconstruction of the nose: abnormal appearance of the new nose, and nasal airway obstruction. The nasal dorsum should be treated as a separate unit. Several local flaps have been described for reconstruction of tissue defects on the dorsum of the nose. Most of these techniques have some disadvantages, such as colour mismatch, dog-ear formation, thickness of flaps and requirement of surgery for revision. Two patients in whom the nasal dorsum was reconstructed with distant V-Y plasty are presented. Six months later, cosmetically acceptable results were obtained. The authors believe that the distant V-Y plasty is an effective alternative to the current techniques in reconstruction of the nasal dorsum. The advantages of this technique include the following: distant V-Y plasty is a safe and useful way to reconstruct medium and large defects of the nasal dorsum; it provides good texture and colour match; the resultant scar cannot cause contour deformity because it is not a bulky flap; there are no formation of dog-ear; it can be used to cover larger defects in elderly patients; it can be used under local anesthesia in almost all cases; it requires a shorter period of operating time and hospitalization; and it is less costly.