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Background Facial composite tissue allotransplantation (CTA) may be considered in cases of severe facial injury. To date, no reports have analysed the cost of potential facial CTA in the UK. The aims of this study were to establish (1) the cost implications without facial CTA, necessitating multiple reconstructive procedures in cases with severe facial deformities, and (2) if facial CTA would be cost-effective in the UK given recent European and North American published cost analyses. Methods Hospital episodes’ data from two potential candidates for facial CTA were used to calculate cost of treatment. In these cases, severe facial trauma was managed by multiple disciplinary teams performing numerous conventional reconstructive procedures. One case served as an indicator of the cost of primary reconstruction during the immediate post-traumatic episode, from admission until first discharge. The other served as an indicator of the accumulative cost of care following primary reconstruction from first discharge to six years later. Costs incurred served as a guide for the cost of standard reconstruction in the UK. These were compared with the costs of similar reconstructive procedures performed in the USA. This was used with data reporting the cost of facial CTA in the USA and France to predict the cost of facial CTA in the UK. Results Analysis revealed a cost benefit for facial CTA in a UK context that would become apparent from the third year post-transplant onwards. Conclusion Facial CTA may therefore be a more cost-effective long-term reconstructive option for patients with severe facial defects. Level of evidence: Level V, risk/prognostic study.

Breast reduction can be performed for either cosmetic or functional reasons. Macromastia may cause significant emotional and physical distress for those women affected and is associated with a constellation of symptoms including neck pain, back pain, shoulder pain, breast pain, headaches, shoulder grooving and intertrigo. Reduction mammaplasty is associated with significant improvement in patient quality of life and patient satisfaction. According to the American Society for Aesthetic Plastic Surgery, more than 103,077 women in the USA underwent breast reduction in 2015. This chapter will provide guidance on assessment and mark up for a patient due to undertake breast reduction surgery.

After mastectomy, breast reconstruction is increasingly performed using autologous tissue with the aim of improving quality of life. During this procedure, autologous tissue is excised, relocated, and reattached using microvascular anastomoses at the site of the extirpated breast. The period during which the tissue is ex vivo may allow genetic modification without any systemic exposure to the vector. Could such access permit delivery of therapeutic agents using the tissue flap as a vehicle? Such delivery may be more targeted and oncologically efficient than systemic therapy, and avoid systemic complications. The cytokine IFNγ has antitumor effects, and systemic toxicity could be circumvented by localized delivery of the IFNγ gene via gene therapy to autologous tissue used for breast reconstruction, which then releases IFNγ and exerts antitumor effects. In a rat model of loco-regional recurrence (LRR) with MADB-106-Luc and MAD-MB-231-Luc breast cancer cells, autologous tissue was transduced ex vivo with an adeno-associated viral vector encoding IFNγ. The “Therapeutic Reconstruction” released IFNγ at the LRR site and eliminated cancer cells, significantly decreased tumor burden, and increased survival compared with sham reconstruction (P

Objective Lesions involving both the trachea and the esophagus are often considered inoperable because of the lack of reliable reconstruction. The purpose of this study was to review our experience of combined supercharged jejunal and other flaps for tracheal and esophageal reconstruction. Methods A retrospective review of 5 consecutive cases with combined tracheal and total esophageal defects was performed. The esophageal defect was reconstructed with a supercharged jejunal flap, and the trachea was reconstructed with a free anterolateral thigh flap or a pedicled muscle flap. Results Primary diagnosis included tracheostoma recurrence after a total laryngectomy for laryngeal cancer in 2 patients and tracheoesophageal fistula due to esophageal stenting for complications from prior treatment for non-Hodgkin's lymphoma, parathyroid cancer, and esophageal cancer in 3 patients, respectively. Tracheal and esophageal reconstructions were staged in 4 patients, and 1 patient received simultaneous reconstruction. Tracheal necrosis developed in 1 patient with a mediastinal tracheostoma, and the patient eventually died of infection 2 months later. The other 4 patients recovered well and resumed an oral diet. Conclusions Complex and often life-threatening lesions involving both the trachea and the esophagus are not necessarily inoperable. With careful planning, these combined defects can be safely reconstructed with multiple flaps with good functional outcomes and reasonable survival.

Nipple elevation is a procedure that enhances the projection of the nipples. The aim is to achieve an aesthetically satisfying appearance that is stable over time and at the same time to maintain the sensory and lactating functions of the nipples. The surgical technique described in this report is based on release of the retracting lactiferous ducts and fibrous bands under loupes magnification and use of two layers of sutures to secure the acquired height of the nipple. The result is a satisfying projection accompanied by preservation of the sensory and lactating functions. 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 .

Written by experts from London’s renowned Royal Free hospital, Textbook of Plastic and Reconstructive Surgery offers a comprehensive overview of the vast topic of reconstructive plastic surgery and its various subspecialties for introductory plastic surgery and surgical science courses. The book comprises five sections covering the fundamental principles of plastic surgery, cancer, burns and trauma, paediatric plastic surgery and aesthetic surgery, and covers the breadth of knowledge that students need to further their career in this exciting field. Additional coverage of areas in which reconstructive surgery techniques are called upon includes abdominal wall reconstruction, ear reconstruction and genital reconstruction. A section on aesthetic surgery includes facial aesthetic surgery and blepharoplasty, aesthetic breast surgery, body contouring and the evolution of hair transplantation. The broad scope of this volume makes this a unique contribution to the field.Heavily illustrated throughout, Textbook of Plastic and Reconstructive Surgery is essential reading for anyone interested in furthering their knowledge of this exciting field.

Traditional methods of reconstruction of the hair-bearing scalp can provide incorrect directional hair growth and may require secondary procedures to complete. We present a case of reconstruction of the anterior hairline after tumour resection in an infant. Lessons learned from the case have led to a novel method for a single stage reconstruction of the anterior hairline using pedicled superficial artery flaps.

Background Minimally invasive component separation (CS) with inlay bioprosthetic mesh (MICSIB) is a recently developed technique for abdominal wall reconstruction that preserves the rectus abdominis perforators and minimizes subcutaneous dead space using limited-access tunneled incisions. We hypothesized that MICSIB would result in better surgical outcomes than conventional open CS. Study Design All consecutive patients who underwent CS (open or minimally invasive) with inlay bioprosthetic mesh for ventral hernia repair from 2005 to 2010 were included in a retrospective analysis of prospectively collected data. Surgical outcomes, including wound-healing complications, hernia recurrences, and abdominal bulge/laxity rates, were compared between patient groups based on the type of CS repair, either MICSIB or open. Results Fifty-seven patients who underwent MICSIB and 50 who underwent open CS were included. Mean follow-ups were 15.2 ± 7.7 months and 20.7 ± 14.3 months, respectively. Mean fascial defect size was significantly larger in the MICSIB group (405.4 ± 193.6 cm 2 vs 273.8 ± 186.8 cm 2 ; p=0.002). The incidences of skin dehiscence (11% vs 28%; p=0.011), all wound-healing complications (14% vs 32%; p=0.026), abdominal wall laxity/bulge (4% vs 14%; p=0.056), and hernia recurrence (4% vs 8%; p=0.3) were lower in the MICSIB group than in the open CS group. Conclusions MICSIB resulted in fewer wound-healing complications than did open CS used for complex abdominal wall reconstructions. These findings are likely attributable to the preservation of paramedian skin vascularity and reduction in subcutaneous dead space with MICSIB. MICSIB should be considered for complex abdominal wall reconstructions, particularly in patients at increased risk of wound-healing complications.

Facial paralysis refers to a condition in which all or portions of the facial nerve are paralysed. The facial nerve controls the muscles of facial expression, paralysis which results in a lack of facial expression which is not only an aesthetic issue, but has functional consequences as the patient cannot communicate effectively. The treatment of long-standing facial paralysis has challenged plastic surgeons for centuries, and still the ultimate goal of normality of the paralysed hemi-face with symmetry at rest as well as the generation of a spontaneous symmetrical smile with corneal protection has not yet fully been reached. Until the end of the 19th century, the treatment of this condition involved non-surgical means such as ointments, medicines and electrotherapy. With the advent and refinement of microvascular surgical techniques in the latter half of the 20th century, vascularised free muscle transfers coupled with cross-facial nerve grafts were introduced, allowing the possibility of spontaneous emotion being restored to the paralysed face became reality. The aim of this article is to revisit the surgical evolution and current options available as well as outcomes for patients suffering from facial paralysis concentrating on middle and lower face reanimation.

Background: The success of antimicrobial therapy has been impaired by the emergence of resistant bacterial strains. Antimicrobial peptides are ubiquitous proteins that are part of the innate immune system and are successful against such antibiotic-resistant microorganisms. The authors have previously demonstrated the feasibility of protein delivery via microvascular free flap gene therapy and here they examine this approach for recalcitrant infections. Methods: The authors investigated the production of the human cathelicidin antimicrobial peptide-LL37, delivered by ex vivo transduction of the rodent superficial inferior epigastric free flap with Ad/CMV-LL37. The vascular permeabilizing agent vascular endothelial growth factor ( VEGF) was co-administered during ex vivo transduction with adenoviral vectors in an attempt to augment transduction efficiency. A rodent model of chronic wound/foreign body infection seeded with bioluminescent Staphylococcus aureus was used to assess the biological efficacy of delivering therapeutic antimicrobial genes using this technology. Results: The authors were successful in demonstrating significant LL37 expression, which persisted for 14 days after ex vivo transduction with Ad/CMV-LL37. Transduction efficiency was significantly improved with the co-administration of 5 mu g of VEGF during transduction without significantly increasing systemic dissemination of adenovirus or systemic toxicity. They were able to demonstrate in the rodent model of chronic wound/foreign body infections a significant reduction in bacterial loads from infected catheters following transduction with Ad/CMV-LL37 and increased bacterial clearance. Conclusion: This study demonstrates for the first time that microbicidal gene therapy via microvascular free flaps is able to clear chronic infections such as occurs with osteomyelitis resulting from trauma or an infected foreign body. ( Plast. Reconstr. Surg. 123: 1157, 2009.)

The expansion of gene therapy applications from inherited disorders to acquired conditions has been mirrored by an exponential rise in both experimental work and clinical trials. This review highlights current plastic surgical delivery systems and clinical applications for targeted gene therapy. We revisit some of the vectors used both experimentally and in clinical gene therapy trials, with an emphasis on developments in plastic surgical delivery systems resulting in improved targeting of therapeutic genes. In addition, we discuss a novel technique for the delivery of gene therapy using the ex vivo transduction of free flaps, developed in our laboratory. This delivery system achieves targeted high-level transgene expression with minimal demonstrable systemic toxicity. Advances in delivery systems are essential for translating basic research into clinical therapeutics.

Distraction osteogenesis is a valuable clinical tool; however the molecular mechanisms governing successful distraction remain unknown. We have used a uniaxial in vitro strain device to simulate the uniaxial mechanical environment of the interfragmentary distraction gap.Using the Flexcell system, normal human osteoblasts were subjected to different levels of cyclical uniaxial mechanical strain. Cellular morphology, proliferation, migration, and the expression of angiogenic (vascular endothelial growth factor [VEGF] and fibroblast growth factor-2 [FGF-2]) and osteogenic (osteonectin, osteopontin, and osteocalcin) proteins and extracellular matrix molecules (collagen IalphaII) were analyzed in response to uniaxial cyclic strain.Osteoblasts exposed to strain assumed a fusiform spindle-shaped morphology aligning parallel to the axis of uniaxial strain and osteoblasts exposed to strain or conditioned media had a 3-fold increase in proliferation. Osteoblast migration was maximal (5-fold) in response to 9% strain. Angiogenic cytokine, VEGF, and FGF-2, increased 32-fold and 2.6-fold (P0.05), respectively. Osteoblasts expressed greater amounts of osteonectin, osteopontin, and osteocalcin (2.1-fold, 1.8-fold, 1.5-fold respectively, P0.01) at lower levels of strain (3%). Bone morphogenic protein-2 production increased maximally at 9% strain (1.6-fold, P0.01). Collagen I expression increased 13-, 66-, and 153-fold in response to 3, 6, and 9% strain, respectively.Uniaxial cyclic strain using the Flexcell device under appropriate strain parameters provides a novel in vitro model that induces osteoblast cellular and molecular expression patterns that simulate patterns observed in the in vivo distraction gap.

There is an increasing trend for contralateral prophylactic mastectomy, but studies focusing on bilateral free flap breast reconstruction are lacking.A retrospective review was performed of all bilateral free flap breast reconstructions performed from 2000 to 2010.Overall, 488 patients underwent bilateral breast reconstruction (bilateral immediate, n = 283; bilateral delayed, n = 93; and bilateral immediate/delayed, n = 112), which more than doubled from the years 2000-2005 to 2006-2010 [147 versus 341 (232.0 percent)]. Comparison of contralateral prophylactic mastectomy demonstrated a similar increase over the decade [139 versus 282 (203.9 percent)]. There was an increasing trend toward perforator flaps [70 versus 203 (290 percent)] compared to traditional transverse rectus abdominis myocutaneous flaps [99 versus 17 (17 percent)] between the first and second halves of the decade. Patients undergoing a bilateral immediate/delayed reconstruction were significantly more likely to undergo a revision (p = 0.05), particularly on the immediate reconstructed breast (OR, 1.59; p = 0.05). Delayed reconstruction and obesity were significantly associated with postoperative complications. Obesity, smoking, and radiation therapy significantly increased fat necrosis rates, 2.77 (p = 0.01), 2.31 (p = 0.03), and 2.38 times (p = 0.03), respectively. In comparison to unilateral reconstruction, bilateral reconstruction had significantly higher flap loss rates (p = 0.004), comparable donor-site complications, and equivalent rates of revisions.There has been an increase in bilateral free flap breast reconstruction. Bilateral immediate/delayed reconstruction had higher revision rates of the prophylactic breast to achieve symmetry. Obesity, smoking, and radiation therapy were associated with increased complications, including fat necrosis, but successful reconstruction can be achieved with acceptable risks.Therapeutic, III.

Resumen Introduccion En la actualidad no esta claro cual es el mejor abordaje para la coledocolitiasis con vesicula in situ. Recientemente en algunos centros se ha adoptado la exploracion laparoscopica de la via biliar (ELVB) como tecnica de eleccion. Material y metodos Presentamos la experiencia de ELVB en una unidad con especial interes en cirugia laparoscopica. Durante 30 meses 44 pacientes con una edad mediana de 65 anos y sospecha de litiasis de la via biliar principal fueron intervenidos por laparoscopia. Resultados En mas del 90% se completo la extraccion de calculos laparoscopicamente y solo un paciente requirio conversion a cirugia abierta. Un 18% presento complicaciones y hubo un fallecimiento en un paciente de 75 anos debido a una complicacion con el tubo en “T”. Conclusiones Consideramos que, en manos entrenadas, el abordaje laparoscopico de la via biliar tiene al menos los mismos resultados que el abordaje tradicional (colangiopancreatografia retrograda endoscopica [CPRE]) con menos ingresos y probablemente inferior mortalidad en el grupo de enfermos jovenes.

During the 1970s, the incidence of limb amputation following surgery for sarcoma excision was as high as 50%. Two important developments have led to modern day limb salvage, namely chemotherapy and precision imaging techniques. We present a case of limb salvage in a patient with osteosarcoma plagued with recurrent infection after prosthetic revision. We discuss the use of the distally based pedicled gracilis muscular flap, which has little mention as a reconstructive option for defects around the knee.

BACKGROUND Clinical use of cancer gene therapy has been prevented by the inability to deliver high levels of local transgene expression with acceptable host toxicity. The authors' laboratory has developed an ex vivo technique to genetically modify free flaps to deliver immunotherapy locally without systemic toxicity. METHODS Superficial inferior epigastric flaps were dissected in Fischer rats, perfused with a viral vector expressing the antitumor interleukin-12 (IL-12) for 1 hour, and re-anastomosed. Beneath the flaps was a bolus of 1 x 10(6) beta-human chorionic gonadotropin-secreting MADB-106 tumor cells. Tumor growth was monitored using beta-human chorionic gonadotropin levels (secreted by the tumor) and size. IL-12 expression in tissue was assessed by enzyme-linked immunosorbent assay. Tumor inflammatory infiltrate was assessed using immunohistologic staining (CD8 and CD161) and enzyme-linked immunosorbent assay (interferon-gamma). Serum levels of liver enzymes and histologic analysis were used to assess systemic toxicity. RESULTS IL-12 expression was confirmed in the flap and surrounding tissue. The rate of tumor growth in the IL-12-treated group was significantly suppressed compared with the control group (p < 0.001). Liver enzyme levels remained normal, and histological evaluation of the liver, lung, and spleen revealed no evidence of inflammation in the treated group. CONCLUSIONS Using genetically modified free flaps, the authors were able to deliver IL-12 directly into the local environment of a tumor and suppress its growth without eliciting toxic systemic effects. This technique could provide valuable adjuvant treatment after oncologic surgery for soft-tissue cancers, with the transduced flap reconstructing the defect and supplying a therapeutic agent to the resected tumor bed.

Background: Chronic wounds, particularly in diabetics, result in significant morbidity and mortality and have a profound economic impact. The authors demonstrate that pulsed electromagnetic fields significantly improve both diabetic and normal wound healing in 66 mice through up-regulation of fibroblast growth factor (FGF)-2 and are able to prevent tissue necrosis in diabetic tissue after an ischemic insult. Methods: Db/db and C57BL6 mice were wounded and exposed to pulsed electromagnetic fields. Gross closure, cell proliferation, and vascularity were assessed. Cultured medium from human umbilical vein endothelial cells exposed to pulsed electromagnetic fields was analyzed for FGF-2 and applied topically to wounds. Skin flaps were created on streptozocin-induced diabetic mice and exposed to pulsed electromagnetic fields. Percentage necrosis, oxygen tension, and vascularity were determined. Results: Pulsed electromagnetic fields accelerated wound closure in diabetic and normal mice. Cell proliferation and CD31 density were significantly increased in pulsed electromagnetic field-treated groups. Cultured medium from human umbilical vein endothelial cells in pulsed electromagnetic fields exhibited a three-fold increase in FGF-2, which facilitated healing when applied to wounds. Skin on diabetic mice exposed to pulsed electromagnetic fields did not exhibit tissue necrosis and demonstrated oxygen tensions and vascularity comparable to those in normal animals. Conclusions: This study demonstrates that pulsed electromagnetic fields are able to accelerate wound healing under diabetic and normal conditions by up-regulation of FGF-2-mediated angiogenesis. They also prevented tissue necrosis in response to a standardized ischemic insult, suggesting that noninvasive angiogenic stimulation by pulsed electromagnetic fields may be useful to prevent ulcer formation, necrosis, and amputation in diabetic patients.

Background: Cranial vault remodeling procedures are carried out for both syndromic and nonsyndromic craniosynostosis as well as to correct some acquired deformities of the cranial vault. These procedures improve not only cosmesis but also neurological symptoms. The purpose of this study was to determine the incidence of "late" cephalohematoma, an underreported complication following these complex procedures. Methods: A total of 113 patients underwent 127 cranial vault remodeling procedures using autogenous bone over a 6-year period. All patients who developed a late cephalohematoma 75 days or more after surgery were recorded. The time, size, and location of the cephalohematoma, the treatment performed, and the length of follow-up were also recorded. Ages at initial operation and postoperative follow-up were compared between patient groups for statistical differences. Results: Of the 113 patients, 17 developed 18 late cephalohematoms. The incidence for this complication was 15 percent. The median age at operation for all patients was 10 months, and most late cephalohematomas occurred 208 days later (range, 77 to 1416 days), at 12 to 24 months of age. Fronto-orbital advancement was the most commonly performed procedure, and 83.3 percent of late cephalohematomas occurred in the frontal region. No cephalohematomas became infected or required any operative intervention, but they were aspirated. Conclusions: Surgeons should inform prospective parents of patients undergoing cranial vault remodeling procedures of this potential complication. This will improve parental awareness and possible avoidance strategies in future patients. Further evaluation and follow-up are required to determine the minimum length of postoperative time after which late cephalohematomas do not occur.

The technique of vascular delay has been used by plastic surgeons for nearly 500 years and has proven useful for reliably transferring tissue and allowing for a greater volume of tissue to be reliably harvested. Delay procedures are an essential plastic surgical tool for a variety of aesthetic and reconstructive procedures. Despite the widespread use of vascular delay procedures, the mechanism by which this phenomenon occurs remains unclear. A number of groups have exhaustively examined microvascular changes that occur during vascular delay. Theories have been proposed ranging from the dilation of choke vessels to changes in metabolism and new blood vessel formation. Inherent in these theories is the concept that ischemia is able to act as the primary stimulus for vascular changes. The purpose of this review is to revisit the theories proposed to underlie the delay phenomenon in light of recent advances in vascular biology. In particular, the participation of bone marrow-derived endothelial progenitor cells in the delay phenomenon is explored. Greater understanding of the role these cells play in new blood vessel formation will be of considerable clinical benefit to high-risk patients in future applications of delay procedures.

The purpose of this study was to examine mandibular morphology and growth in patients with Crouzon, Pfeiffer, and Apert syndromes using posteroanterior cephalograms. Fifteen patients with Apert (n = 2), Crouzon (n = 11), and Pfeiffer (n = 2) (11 female, 4 male) syndrome were included in this study. All patients had serial posteroanterior cephalograms at 5, 10, and 15 years of age. The bicondylar width, bigonial width, bicondylar/bigonial ratio, and ramus to intercondylar plane angle for each patient were measured on the cephalograms and compared with age-match controls. An analysis of variance analysis was carried out to detect differences between patients and controls and sex differences between patients. In both male and female patients, there was a statistically significant reduction in bicondylar width compared with age-matched controls. Male patients also had a statistically significant increase in bigonial width compared with controls and female patients at 10 and 15 years. The resulting bicondylar/bigonial ratios were significantly reduced, and the ramus to intercondylar plane angles were significantly increased in both male and female patients compared with controls. Unlike previous reports of patients with syndromic synostosis, this study demonstrates that the mandible has significant morphologic and growth abnormalities, including constriction of bicondylar width with near normal bigonial width in female patients. These findings suggest a narrowing at the cranial base with resulting restriction of normal transverse mandibular growth at the condyle. The secondary nature of the mandibular finding is suggested by the near normal or increased transverse growth at the gonion in females and males, respectively. Consequently, the ramus appears torqued inward, forming a greater angle with the cranial base.

Summary Background: Local anaesthetic agents in combination with epinephrine are frequently used in local reconstructive procedures such as skin tumour excision and local flap closure. The purpose of this study was to measure the effect of subdermal injection of lidocaine combined with epinephrine on cutaneous blood flow in the forearm and in the face. Methods: Thirty injections were performed on the forearm and 40 injections were performed on the face in five healthy volunteers. In both anatomical regions, 0.9% phosphate buffered saline (PBS) was used as a control, and experimental injections included 1% lidocaine either alone or in combination with 1:100 000 epinephrine, and an additional combination of 1% lidocaine with 1:200 000 epinephrine used in the facial experiments. Cutaneous blood flow was measured indirectly using laser Doppler imaging (moorLDI™-Mark 2). Results: A statistically significant increase in blood flow was achieved with injection of lidocaine in the forearm compared to saline, whereas a non-statistically significant increase was achieved with saline injection compared to lidocaine in the face. This occurred in the first 5 min in the forearm and 2 min in the face. The addition of 1:100 000 epinephrine to lidocaine resulted in an immediate decrease in cutaneous blood flow which was maximal at 10 min in the forearm and 8 min in the face. This was statistically significant compared to all other injections except for the combination of 1:200 000 epinephrine with lidocaine, injected in the face. Conclusions: The vascularity of different anatomical areas may account for blood flow differences following injection with saline and lidocaine. Incisions should be delayed for 10 min in the forearm and 8 min in the face following lidocaine + epinephrine injection to allow maximal benefit to take effect. There were no significant differences between 1:100 000 and 1:200 000 epinephrine combined with lidocaine in facial injections his study.

Six patients with insufficient soft-tissue coverage after lower limb trauma were treated with pedicled fillet of foot flaps to achieve primary stump closure and to preserve leg length. The flaps used were all based on either the posterior tibial neurovascular pedicle, the anterior tibial neurovascular pedicle, or both. Five flaps survived; one patient required conversion of a through-knee to an above-knee amputation and debridement of the flap because of venous thrombosis of the pedicle. In three of the cases, a functional knee joint was preserved. The patients ranged in age from 21 to 54 years, the mean hospital stay was 55.5 days (range, 28 to 76 days), and the mean follow-up time was 14.5 months. Despite an average of 4.3 procedures from initial admission to first discharge and an average of 2.0 postamputation procedures to achieve primary stump healing, all patients have achieved independent mobility with their prosthesis. The advantages of preserving leg length and, where possible, preserving a functional knee joint compensate for repeated procedures on these patients. When planned well, a pedicled fillet of foot flap therefore achieves the aims of amputation, namely, providing primary healing of a sensate, durable, cylindrical stump that is pain-free and preserves maximal leg length. This is achieved with no donor-site morbidity and with no need for microvascular reconstruction.

Spinning is an increasingly popular form of cycle-based exercise. The workouts are often of high-intensity and participants are intermittently encouraged to achieve a high crank-set-cadence rate. We report a unique case of an open ankle fracture requiring free flap coverage, which highlights the potential perils of spinning class.

Galactorrhoea is a relatively common condition but has rarely been reported following breast reduction surgery. Literature review has revealed only four cases. We present a case of galactorrhoea following breast reduction surgery carried out 10 weeks following childbirth, and 3 weeks following cessation of breast-feeding. This resulted in severe skin and areola tissue breakdown. Four operations were subsequently performed to achieve a satisfactory cosmetic outcome. Considerations and recommendations in the timing of such procedures following childbirth and breast-feeding are discussed.

Formulation Poloxamer content (%) BSA (%) Transition temperature (C) Stiffness* (Pa) P407 P188 Total 1 16.5 0 16.5 0.25 30 10,000 2 17 0 17 1 26 10,000 3 17 6 23 0 40 10,000 4 16.8 11.2 28 0 36 18,400 5 14.4 21.6 36 0 36 48,000 6 0 45 45 0 25 96,000 *Recorded at 40C, replicating the clinical scenario of external heat application; BSA 1⁄4 Bovine Serum Albumen; C 1⁄4 Degrees Centigrade; Pa 1⁄4 A Prospective, Randomized, Controlled Pilot Study of Noncontact Low-Frequency Ultrasound (NLFU) to Accelerate Healing of Split Thickness Donor Sites Jamie Prather, MD, Evan Tummel, MD, Jane Nichols, RN, Ami Patel, Lisa J Gould, MD, PhD, FACS University of South Florida, Tampa, FL, James A Haley Veterans Hospital, Tampa, FL

1. The effects of inhibitors of nitric oxide synthase and local anaesthetics were studied on changes in human nasal airway patency and albumin extravasation in response to bradykinin and histamine, in vivo. 2. Compared with the action of the vasoconstrictor, ephedrine, 2.5 mumol, NG-nitro-L-arginine methyl ester (L-NAME), 1 mumol alone, did not change the resting value of the minimal cross-sectional area (A min) of the human nasal airway. L-NAME, 0.1 to 10 mumol, produced a dose-related inhibition of the reduction in A min caused by bradykinin, 300 micrograms. NG-monomethyl-L-arginine (L-NMMA), 1 mumol, similarly reduced the effect of bradykinin, 300 micrograms, on A min, but NG-nitro-D-arginine methyl ester (D-NAME), had no effect. L-NAME, 0.1 to 10 mumol, or L-NMMA, 10 mumol, failed to inhibit the effect of histamine, 300 micrograms on A min. 3. The inhibition by L-NAME, 1 mumol of the action of bradykinin, 300 micrograms on A min was maximal between 15 and 30 min after pretreatment with L-NAME. 4. L-NAME, 1 and 10 mumol, inhibited the extravasation of albumin into the nasal cavity induced by bradykinin, 300 micrograms, and also by histamine, 300 micrograms. D-NAME, 1 and 10 mumol had no effect on the extravasation of albumin in response to bradykinin or histamine. 5. L-Arginine, 30 mumol, reversed the effect of L-NAME, 1 mumol, on the bradykinin- and histamine-induced albumin extravasation into the nasal airway. 6. Local anaesthesia of the nasal airway with lignocaine, 10 mg, or benzocaine, 10 mg, failed to inhibit the reduction in A min or the albumin extravasation induced by either bradykinin, 300 micrograms, and histamine, 300 micrograms. 7. We conclude that the extravasation of plasma albumin caused by bradykinin and by histamine involves the generation of nitric oxide. The nasal blockage induced by bradykinin involves nitric oxide generation but the nasal blockage induced by histamine does not.