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Summary: The thigh is a rich source of tissue for free flap harvest. The anterolateral thigh and gracilis flaps are most commonly used. The sartorius flap is an easily harvested flap that can be raised with the leg in the anatomically extended position without rotation. The cutaneous landmarks are readily identified and so the relevant perforators can be quickly found. Pedicle dissection is quick and easy, allowing the flap to be raised in a short time. We report our experience of using this flap both as a free muscle-only flap and as a free fasciocutaneous perforator flap for soft-tissue reconstruction in the lower limb. An anatomical study was also carried out to examine the vascular anatomy of the sartorius muscle flap and the cutaneous perforator flap. Twenty limbs from soft fixed adult cadavers were dissected and the position, length, diameter and cutaneous extension of all segmental pedicles, from the anterior superior iliac spine (ASIS) to the medial femoral condyle, were measured. Fourteen out of 20 (70%) sartorius muscles had at least one musculocutaneous perforator and, of these muscles, 13 (93%) had at least one musculocutaneous perforator that was found at 20±3cm from the ASIS. The free sartorius flap is a useful addition to flap choice from the thigh and carries a predictable cutaneous perforator in the majority of cases, allowing a fasciocutaneous perforator flap to be quickly and reliably raised with minimal donor-site morbidity. [Copyright &y& Elsevier]

Summary: Background: Lymphoedema can be treated conservatively or surgically. Early treatment is important, but the surgical indication and the effect of surgery on pain in lymphoedema-affected limbs have not been described. The objective of this study was to examine the effect of low-invasive scarless lymphatic venous anastomosis (LVA) for early or latent lymphoedema. Methods: LVA was performed in six patients (eight legs) with leg lymphoedema between April 2010 and March 2011. Lymphoedema was stage 0 (defined as subclinical) in three patients (five legs) and stage 1 in three patients (three legs). Subjective symptoms, circumference of the affected leg and a lymphoscintigram were evaluated before and 6 months after surgery. Preoperatively, subcutaneous lymph vessels and veins were identified non-invasively using ICG lymphoscintigraphy and non-invasive instruments for visualising subcutaneous vein, AccuVein system, through the skin. These vessels and veins were secured with vessel loops passed underneath and side-to-side anastomosed under a surgical microscope. Results: Subjective symptoms improved after surgery in all patients. The leg circumference improved in stage 1 cases, which all had an increased circumference before surgery. Lymph retention was observed on preoperative lymphoscintigraphy in all six patients and was improved after surgery in all cases. Conclusions: Scarless LVA performed through a small incision improves abnormal lymph circulation and subjective symptoms in cases of early lymphoedema, in which the limb circumference has just started to increase, and latent lymphoedema, in which the circumference has not increased, but abnormal findings on lymphoscintigraphy or subjective symptoms are present. [ABSTRACT FROM AUTHOR]

Summary: The effects of a fascial tissue interface on silicone implant capsule formation were studied in a rabbit model. In two experimental groups, the thoracodorsal fascia was harvested either as a free graft (Group Ia) or as a fascial flap (Group Ib), then wrapped around silicone implants prior to subcutaneous placement. In each instance the fascia was configured to form a biological interface between the implant and surrounding soft tissue. The resulting capsules were macroscopically and histologically compared to a control group (Group II) of unwrapped silicone implants which were inserted subcutaneously. The cellular response to textured and smooth surfaces on opposing sides of each implant was also separately investigated in both study groups. Statistical analysis was performed using a Student''s t-test. The capsules formed in each experimental group were observed to be thinner and less cellular when compared to the unwrapped control group (P <0.05), while no demonstrable differences between fascial flap and free graft subgroups were found (P >0.05). Furthermore, less cellularity and reduced capsule thickness were observed in the textured implant capsule surfaces in both fascial flap and free graft groups when compared to smooth implant capsule surfaces (P <0.05). Our preliminary study findings using a fascial tissue interface, either as a flap or a free graft, reveal cellular architectural characteristics of the resulting capsule that may be significant in minimising capsular contraction around silicone implants. [Copyright &y& Elsevier]

Summary: We report on a 16-year-old boy with Noonan syndrome who had short stature, hypertelorism, mild hearing loss, webbed neck, pectus deformities, hypertrophic cardiomyopathy, low posterior hairline, redundant skin, café au lait spot, curled hairs, foetal pads, and undescended testes. The father and a sister of the boy were also found with mild webbed neck, being possibly mildly affected individuals. The significant webbed-neck deformity of the boy was completely corrected by subcutaneous resection of the proximal half of the hypertrophic fascia bands, through small incisions hidden within the hairline. The advantage of this procedure is simple, safe and effective, with no visible scar on the surface of the neck. [Copyright &y& Elsevier]

Summary: Injection of ‘lighter fuel’ with suicidal intent is rare. Extravasation of the chemical may rarely cause systemic toxicity, but usually it results in extensive soft tissue damage. Such injuries when managed by the traditional expectant policy are associated with considerable morbidity. Early aggressive surgical management using ‘saline flush out’ limits the tissue damage by stopping the natural progression of the chemical mediated injury and the subsequent inflammatory response, thereby allowing better skin preservation and functional outcome in these cases. We report a case of ‘lighter fuel’ subcutaneous extravasation injury managed by ‘saline flush out’ technique soon after presentation. [Copyright &y& Elsevier]

Summary: A 71-year-old male who had been diagnosed with rheumatoid arthritis 3 years previously developed multiple subcutaneous cysts on his buttock, elbow, knee, hand and back. The diameters of the cysts were 10–15 cm. The characteristic fluid and pathology of the cysts led to the diagnosis of multiple rheumatoid bursal cyst (MRBC). The patient was keen to treat the cyst on his buttock as it hampered his sitting position. However, it resisted several kinds of sclerotherapies, including absolute alcohol, OK-432, minocycline and dexamethasone. When the cyst grew further, it was resected surgically; however, the cyst recurred immediately. It was finally brought under control by injecting it with OK-432. The thick cyst wall, which resisted the various sclerotherapies, was removed surgically, and a new capsule developed inside the cavity; adding a sclerotant to newly made thin capsule made us possible to treat this resistant large bursal cyst. [ABSTRACT FROM AUTHOR]

Summary: Chronic recurrent ischial sores are an important cause of morbidity in paraplegics and geriatric patients. Compared to sacral and trochanteric ulcers, ischial sores are the most difficult to treat, with a low success rate following conservative therapy and a high recurrence rate after surgical treatment. We report the use of the pedicled anterolateral thigh (pALT) flap for reconstruction of a chronic ischial sore. The free ALT flap has an established role in reconstruction in the head and neck and extremities. However, there are few reports concerning its clinical applications for regional reconstruction. As a pedicled flap, it has been used in the primary reconstruction of the perineum, groin, anterior abdominal wall, thigh and ischium. We present the first reported case of a paraplegic man with a recurrent ischial sore treated successfully with an island pALT flap inset via a lateral subcutaneous approach. We discuss the indications and its role as a simple and reliable secondary reconstructive option in the treatment of recurrent ischial ulcers after first-line loco-regional surgical options have been exhausted. [Copyright &y& Elsevier]

Summary: Degloving injuries occur when there is sufficient tangential force to a body surface to disrupt the structures connecting skin and subcutaneous tissues to the superficial fascia. There may also be associated injuries to the underlying soft tissues, bone, nerves and vessels. The injury may be so severe that the limb is non-viable and requires amputation. Our patient sustained a severe lower limb degloving injury after an accident where the leg was caught and dragged along the platform by a train. There was insufficient skin to cover a below knee amputation stump. So, the dermal regeneration template Integra(r) was used in association with a sensate neurovascular fasciocutaneous pedicled flap salvaged from the non-viable lower leg to reconstruct the defect and avoid the need for an above knee amputation. [Copyright &y& Elsevier]

Summary: Thrombolytic agents are frequently employed in the treatment of thrombosis in combination with early surgical exploration and management. Recombinant tissue plasminogen activator is a second generation thrombolytic agent, which acts specifically at the site of the haemostatic clot with minimal side effects. In this paper, we present a case with venous congestion of the deep inferior epigastric artery perforator (DIEAP) flap, despite a patent anastomosis, in which we achieved a successful outcome with subcutaneous recombinant tissue plasminogen activator treatment. [Copyright &y& Elsevier]

Summary: Noninfective subcutaneous emphysema of the upper extremity, albeit rare, has to be borne in mind when treating patients with subcutaneous emphysema. The misdiagnosis of this condition as its serious infective counterpart often leads to unnecessary aggressive treatment. Noninfective subcutaneous emphysema often accompanies a patient who has no systemic symptoms of illness. Unfortunately, the distinction is not always easy especially when history of injury suggests involvement of an infective or reactive element. Penetrating blackthorn injury is common, especially in rural communities, and often occurs from farming or gardening activities. Blackthorn penetration can cause numerous tissue reactions once embedded under the skin and they are often contaminated with soil. Here we present, for the first time, a case where penetrating blackthorn injury to the wrist resulted in noninfective subcutaneous emphysema involving the whole upper limb and neck, and its subsequent management. [Copyright &y& Elsevier]