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Background: Gestational gigantomastia (GGM) is a rare complication of pregnancy. Management usually is initiated with bromocriptine. If this is unsuccessful, surgery may be required. The surgical management may be by breast reduction or by mastectomy and delayed reconstruction., Case: A 24-year-old woman (G1P0) presented at 24 weeks gestation with massive hypertrophy of her breasts. A decision to operate was made by a multidisciplinary team. At 30 weeks gestation, bilateral mastectomies were performed, with removal of more than 8 kg per side. Reconstruction was started 10 months after delivery using tissue expanders followed by definitive implants., Conclusion: GGM can be successfully reconstructed. Knowledge of the treatment process and the expected outcomes can help clinicians inform their patients., Level of Evidence V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Objective: A systematic review to assess the efficacy of tamoxifen in the management of idiopathic pubertal gynecomastia., Data Sources: Searches were conducted using the databases of Medline (search engine PubMed) and Web of Science®., Study Selection: Studies reporting the use of Tamoxifen for the treatment of gynecomastia in adolescents., Outcome Measure: Resolution of gynecomastia., Results: A total of 164 publications were found; 59 were selected for retrieval and six were included in the review. There were no randomized controlled studies; the studies found have methodological flaws but show promising results. No clinical side-effects were reported or observed., Conclusion: Tamoxifen may be effective for the treatment of pubertal gynecomastia, and it seems safe to use. Randomized controlled studies are necessary to confirm this indication.

Background: Venous thrombo-embolism (VTE) prophylaxis is of paramount importance in the management of surgical patients. Mechanical as well as pharmacologic modalities may be used. With the use of anticoagulative agents, there is a potential for increased operative and postoperative bleeding., Aim: To assess the safety of perioperative use of low-molecular-weight heparin (LMWH) in the setting of breast reduction surgery., Methods: Retrospective assessment of the reoperation rate due to haematoma formation for breast reductions performed under a regimen of preoperative and postoperative administration of LMWH during a 10-year period., Results: A total of 720 patients (1358 breasts) received preoperative and postoperative treatment with LMWH. Reoperation due to haematoma formation was required for 37 breasts in 37 patients (5.1% of patients and 2.7% of breasts). Eight patients (1.1%) required transfusion. No patient or operative factors were associated with the need for reoperation. There were no documented cases of deep vein thrombosis or VTE., Conclusion: The use of a pre- and postoperative LMWH prophylaxis regimen is associated with a reoperation rate for haematoma that is in the upper range reported in the literature., (Copyright © 2012 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

The infection of a breast implant or tissue expander is a major complication with significant psychological and medical ramifications. The incidence has been reported to range from 1.1% in cosmetic augmentations to as high to 24% in a series of reconstructive cases. Gentamicin Surgical Implant is a surgical implant comprised of a lyophilised collagen matrix impregnated with a broad-spectrum antibiotic. When placed in the operative field, it achieves very high local concentrations of drug several fold above the minimal inhibitory concentrations; and the collagen carrier is absorbed. Its beneficial use has been reported in other fields of surgery. Gentamicin sponges were used in four cases of periprosthetic infections. The implants were removed, the pockets cleaned with pulse lavage and the implants were replaced, together with a gentamicin collagen implant. This was followed by a 6-week systemic antibiotic regimen. The patients had uneventful recovery and have not developed capsular contracture. Gentamicin collagen sponges may be used as an adjunct in the salvage of infected breast implants. Periprosthetic infections, as well as the use of gentamicin, are reviewed., (Copyright © 2011 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

A simple method for the infiltration of tumescent anesthesia is presented. An assembly is made using an infusion set, a three-way tap, and two unidirectional valves. The assembly and use of this system are straightforward and easy. The addition of unidirectional valves prevents the risk of reverse injection or aspiration of fluid from the patient.

The primary question addressed was whether muscle flaps (MFs) offer a significant advantage over an omental flap (OF) in the management of deep sternal wound infection (DSWI) following cardiovascular surgery in terms of outcome (morbidity and mortality). Altogether, 333 citations (from PubMed and EMBASE and using a manual search, without language restriction) were identified using the reported strategy. Focusing on publications from single institutions with experience with both types of flap in the treatment of DSWI, 16 studies represented the best evidence on the topic. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses were tabulated. These 16 observational studies covered 1046 patients, and all reported mortality rates. Unadjusted data from five of six studies investigating a possible association between mortality and flap type suggested a higher mortality rate following reconstruction with MFs. A meta-analysis of all six studies indicates a slight, but not significant, survival advantage for reconstruction with an OF [overall relative risk 1.29 (95% confidence interval 0.58-2.88)]. Thirteen studies reported on the number of individual postoperative complications for a total of 964 patients. Data, unadjusted for potentially confounding surgical factors, on complications following flap closure, such as complete or partial flap loss, haematoma, arm or shoulder weakness and chronic chest wall pain, suggested that these complications were more common following MF reconstruction. Four studies evaluated patients with recurrent sternal wound infection (n=521). Two of these were associated with a high incidence (>17.5%) of re-exploration for recurrent sternal infection following MF reconstruction. The most commonly reported complications following an OF were abdominal or diaphragmatic hernias, with an incidence of <5%. We conclude that the weight of current evidence is insufficient to prove the superiority of reconstruction with MFs to a laparotomy-harvested, OF in the treatment of DSWI. The results suggest that use of the omentum may be associated with lower mortality and fewer complications.

Tattooing is increasingly common in Western society. The aim of the study was to create an overview of the surgical options when a tattoo is present in the operative site and to present an algorithm for the surgical plan.A literature-based study was conducted, using the Pubmed database. The following search terms have been used: "tattoo" in combination with "incision," "scar," and "surgery." Apart from the literature, we also used our own clinical experience with the tattoos.An overview is presented on the different options when a tattoo is at risk because of a surgical intervention. An algorithm is presented to help surgeons to choose the best option before the operation.By realizing that a tattoo can be of great value to a patient and by using surgical skills to preserve the tattoo as much as possible, it becomes possible to increase patient satisfaction in these difficult cases.

The aim of this study is to prospectively evaluate the changes in the sensation of the skin of the abdominal wall and thighs following abdominoplasty. Patients underwent standard full abdominoplasty with reinsertion of the umbilicus. Sensory testing was performed preoperatively and at least 1 year postoperatively. Predetermined targets on the abdominal wall, umbilicus, and on the anterior thighs were tested for light touch, sensory thresholds, using Semmes-Weinstein monofilaments (SW), vibration, and temperature. Fourteen patients completed the study. On average targets demonstrated a decrease in sensory thresholds, average from SW 3.61 to 4.14 (P < 0.001), the targets that had the most significant decrease were the umbilicus SW 3.67 to 6.97 (P = 0.001) and the infra umbilical 3.75 to 6.57 P = 0.001. Similar findings were seen for the other modalities tested, there was a significant disappearance in their perception at the umbilical target and at the lower abdominal regions. We did not identify any significant decrease in the sensation of the thighs. Abdominoplasty causes lasting sensory changes concentrating on the umbilical and infraumbilical regions. This study enables surgeons to inform their patients about the expected sensory outcome following abdominoplasty.

A varying period of training followed by examinations is the usual way to become a specialist in one of the many fields of Medicine. Plastic Surgery is one of the surgical fields that require good technical and cognitive skills. The best way to train and evaluate a candidate is hard to judge. The model of training and board examination varies, every country having its own method. This is a descriptive report presenting the ways of training residents in Plastic Surgery and then examining them in Romania, Israel, U.S.A., Germany and the Netherlands. Specific points regarding the structure and the format are addressed for all models and also for factors that might influence the objectivity of the examination. The authors bring their thoughts on these issues.

Background: The sural nerve is a sensory nerve that innervates the proximal part of the lateral aspect of the foot. The sural nerve is often harvested for nerve grafting. Sensory loss in the area supplied by the sural nerve could be expected, causing a lack of protective sensation and a potential risk of injury. The sensory outcome of sural nerve harvesting has not been documented in children. The aim of this study was to evaluate the sensory deficit following sural nerve harvest in infants., Methods: The authors conducted a controlled study. Evaluation and mapping of the sensory thresholds in the sural nerve distribution were performed using the Semmes-Weinstein monofilament method on four predetermined sites on the foot. A questionnaire was used to elicit subjective findings. The inclusion criteria were children older than 6 years who had undergone bilateral sural nerve harvesting for brachial plexus reconstruction in the first year of life. Normal volunteers served as controls., Results: Fourteen patients and 14 controls were enrolled in the study. Eighty-six percent of the feet that were operated on had a sensory deficit (p = 0.0001). The patients reported no concerns regarding the sensation of their feet., Conclusions: Sural nerve harvesting in children leaves a measurable sensory deficit; however, this deficit does not seem to have clinical implications for the patients.

Background: Skin stretching harnesses the same viscoelastic properties of the skin as expansion, with the difference that the forces are applied externally and not internally. An improvised system for wound closure is presented., Method: The system is assembled using silicone vascular loops used as sutures and the flow controllers of intravenous sets as locking devices. The wounds are gradually closed by increasing the tension applied by the devices., Results: The system has been applied to nine traumatic wounds in six patients. The average size of the wounds was 70 cm; the average number of devices used was 4.3 (range, 1-9; median, 3); the average time to achieve closure was 1.55 days (range, 0-2 days; median, 2 days)., Conclusion: This system permits the closure of wounds not suitable for closure by primary intention and avoids the use of skin grafts or flaps.

Background: High-pressure injection injury is an injury caused by accidental injection of substances by industrial equipment. This injury may have devastating sequelae. The goal of this study was to assess the long-term outcome of high-pressure injection injury to the hand., Methods: In this historical prospective study, patients who had previously sustained high-pressure injection injury were examined. Assessment included measurement of grip and pinch strength, range of motion, two-point discrimination, and use of a questionnaire regarding present complaints and return to the work force., Results: Twenty-three patients were examined. Follow-up length was on average 8.5 years. The injured hand was most often (43 percent) the right dominant hand, the index in 65 percent, the thumb in 25 percent, and other locations in 10 percent. Only 43 percent of patients returned to their previous employment. Patient complaints were, in descending frequency, cold intolerance, hypersensitivity, paresthesias, constant pain, and impairment of activities of daily living. Metacarpophalangeal range of motion was decreased on average by 8.1 percent (p = 0.019), proximal interphalangeal joint range of motion was decreased by 23.9 percent (p = 0.001), and distal interphalangeal range of motion was decreased by 29.7 percent (p= 0.018). Maximum grip was decreased compared with the expected grip by 12 percent (p = 0.023). Pinch was decreased by 35 percent (p < 0.001). Two-point discrimination was increased by 49 percent (p < 0.007)., Conclusion: This study confirms the fact that high-pressure injection injury to the hand is a significant problem. Virtually all patients suffer sequelae of this injury. The injury has significant repercussions for future function and reintegration into the work force.

Lateral canthopexy is a commonly performed procedure in craniofacial and cosmetic surgery. In craniofacial surgery, lateral canthal fixation is performed in conjunction with a wide range of transcranial or subcranial procedures during the process of soft tissue re-suspension. A number of fixation materials have gained popular use. A case of craniofrontonasal dysplasia is reported in which a wire loop canthopexy fixation has become disengaged 3 months after a history of trauma and rotated to present a sharp surface against the sclera. Urgent surgical exploration prevented the apparently imminent complication of globe penetration with associated threat to vision.

Introduction: Burns of the hands may result in the formation of web space contractures-post burn syndactyly. We present our experience using the three-square technique originally described by Bandoh for minor syndactyly., Method: Tissues of the contracted web are regard as forming three facets of a cube. If elevated and transposed 90 degrees on their base the facets will fall into place and line the interior of the cube creating a deepened web-space. The first flap is based on the web itself either dorsally or volarly. The second flap is based distally on one of the fingers. The third flap is based laterally on the other finger. Surgery is followed by a splinting regimen., Results: The design of the flaps is simple and the operation is easy to perform. This technique has achieved good functional and cosmetic results; there have been no flap losses or significant complications., Conclusion: The three-square-flip-flap is a simple reliable and safe method for the treatment of post burn syndactyly.

Background: In patients with deep circumferential burns, adequate resolution of burn-induced compartment syndrome (BICS) is achieved by surgical escharotomy. Surgical escharotomy is traumatic, may cause considerable blood loss, does nothing toward debridement of the burn wound, and entails possible morbidity and complications. Debridase is a Bromelain derived enzymatic preparation capable of lysing the burn eschar within 4 hours, obviating the need for surgical debridement. It has an affinity to burned necrotic tissue and does not damage healthy skin. In our clinical assessment of the Debridase efficacy, we found in several cases of deep burns of the limbs that the measured IC pressure subsided after 2-4 hours of Debridase application and none of the enzymatic escharotomy treated patients suffering from circumferential burns developed BICS. To confirm these observations we conducted this controlled study., Aim: to assess the efficacy of Debridase for treating BICS in an animal model., Materials and Methods: A model for BICS was developed by making circumferential burns to pig legs and monitoring the anterior compartment the legs. BICS was induced in the legs of 5 pigs, 20 legs. 10 legs were treated with Debridase and 10 served as nontreated controls, treated by surgical escharotomy at the conclusion of the experiment., Results: Debridase reduced BICS within 30 minutes from application. Debridase was as effective as a standard surgical escharotomy., Conclusion: Escharectomy using an effective enzymatic debriding agent is potentially an adequate, simple, fast and effective procedure to treat BICS, it has the added benefit of burn debridement without surgical escharotomy.

A system is presented for the application of tie-over dressings. Following skin grafting, the graft is secured with a tie-over dressing covered with a sheath of 3-way stretch fabric. The fabric is secured with the aid of staples. This system is easy to apply and is useful for securing grafts in otherwise difficult anatomic locations.

The issue of immediate control of acute external traumatic hemorrhage is poorly dealt with in the medical literature. A compact unit incorporating the desired components capable of applying significant compression over diverse body areas has been suggested in the past but not formally demonstrated effective in practice. In this report we describe the treatment of a young man presenting with a very large, complex, profusely bleeding facial gunshot wound. The calvarium remained intact. The upper airway was diverted and secured by performing a cricothyroidotomy. A transparent elastic adhesive dressing was then applied by covering the anterior aspect of the face by a contact pad followed by sequential wrapping of the roll covering all structures between the forehead and the neck. This procedure successfully controlled the hemorrhage and maintained the victim's condition hemodynamically stable until definitive surgical intervention at the level 1 medical center. We attribute the survival of this victim to the innovative dressing technique and excellent cooperation between the trauma team and hospital staff. This case demonstrates the contribution of elastic adhesive compression dressing towards saving the lives of those inflicted by severely challenging bleeding wounds. We suggest this technique be considered by Emergency personnel working in the prehospital arena in selected cases.

Terrorists are recently using cellular phones to remotely detonate bombs. A patient was injured while assembling a bomb connected to a cellular phone. The patient sustained combined injury to the head and to the dominant hand which held the phone. Amputation of the hand was required, the facial injuries were reconstructed. The characteristics of this unusual type of injury are described and compared to injuries caused by other bombs and explosive devices.

Background: Post-rhytidectomy sialocele is a rare complication. The usual treatment uses prolonged drainage. The use of antisialogogues has been described previously, but has potential side effects. Transdermal scopolamine SCOPODERM TTS is indicated for the prevention of motion sickness and also has antisialogugue action., Methods: An interventional case report is presented., Results: The application of transdermal scopolamine SCOPODERM TTS resulted in resolution of a post-rhytidectomy sialocele within 6 days., Conclusion: Transdermal scopolamine delivery should be considered as an option for the treatment of post-rhytidectomy parotid fistulas.

Mini vacuum drains can be helpful in reconstructive surgery. The drains may be assembled using a scalp needle and a vacuum tube. The addition of the adapter that is used with the vacuum tubes for blood sampling improves the ease of use and practicality of these drains and increases their safety.

We present a child with neurofibromatosis type I (NF-I) who underwent excision of a large upper lid neurofibroma using a CO2-laser. Plexiform neurofibromas are notorious for their bleeding tendency and the inability to achieve complete surgical excision. The CO2-laser is an adjunct to achieving better hemostasis and delineation of the tissue in the absence of natural tissue planes caused by the tumor's diffuse mode of growth. Using the CO2-laser achieves better cosmesis, while reducing operation time and limiting complications.

We describe a 76-year-old white male with subungual amelanotic melanoma. The lack of pigmentation of the lesion may cause misdiagnosis and aggravate its poor prognosis.

Metastases to the uterus from extragenital cancers are significantly rarer than metastases to the ovaries. Of the approximately 200 cases of metastases to the uterus from extragenital cancers that have been reported in the literature, more than half are cases of metastases from breast carcinoma and only 16 are cases of metastases from colorectal carcinoma. A case of isolated metastases restricted to the myometrium of the right uterine comu from sigmoid colon carcinoma, without involvement of the ovaries, is described. The patient who six months previously had surgery for sigmoid colon carcinoma presented with right lower abdominal pain and a palpable mass in the region of the right uterine cornu. The diagnosis of isolated metastases restricted to the myometrium of the right uterine cornu was confirmed by total abdominal hysterectomy and bilateral salpingo-oophorectomy. This case illustrates that a growing uterine mass in a patient with a history of primary extragenital cancer, regardless of whether abnormal uterine bleeding is present or absent, should alert the physician to consider the possibility of uterine metastases.