To Divide or Not to Divide? A Case Report Using Near-Infrared Spectroscopy to Assist With Decision Making on Timing of Division of Forehead Flaps

Paramedian forehead flaps (PMFFs) are commonly performed procedures for the reconstruction of complex nasal defects and require multiple stages predicated on when the interpolated pedicle is no longer required to provide perfusion to the neo-nose. As the presence of the pedicle is disfiguring, the flap is therefore divided ideally as soon as safely possible, but that determination is challenging. Recently, a novel device that uses near-infrared spectroscopy (NIRS) to measure tissue oxygen saturation has been developed and may provide an accurate and cost-effective tool to assess tissue perfusion. Here we present the use of this technology in the management of 2 patients who underwent successful oncologic nasal reconstructions using PMFFs. Using the device as a clinical adjunct, we measured tissue oxygen saturation values in the flaps before and after pedicle division, which assisted us in deciding when to safely divide the flaps, as well as with post-division management, particularly when a low tissue oxygen saturation reading ultimately necessitated the use of nitroglycerine past to improve flap perfusion in one of our patients. Interestingly, the values we recorded corresponded well to previously published cut-off values for adequate tissue perfusion, which have to date only been reported for free flaps. To our knowledge, this is the first description of the use of NIRS in the division of PMFFs, which we overall found to be a useful and reliable adjunct to a clinical examination in assessing flap neovascularization.

Duplication of the Extensor Pollicis Longus and Index Extensor Digitorum Communis: Report of a Novel Anomaly and Review of Literature

Accessory extensor tendons in the hand are not rare, usually asymptomatic, and recognized incidentally during elective surgery or cadaveric dissection. This report describes a novel case of symptomatic duplication of accessory extensor tendons to both the thumb and the index finger causing a painful dorsal wrist tenosynovitis. Excision of the accessory tendons with decompression and tenosynovectomy of the fourth extensor compartment alleviated the patient’s symptoms without compromising motion or function.

Squamous Cell Carcinoma Arising at a Skin Graft Donor Site: Case Report and Review of the Literature

Introduction: Skin graft reconstruction is a common method of providing wound coverage. Rarely, skin grafting can be associated with the development of squamous cell carcinoma (SCC) in the graft donor site. Case Report: The patient is a 72-year old male with a 15-year history of bilateral hip wounds. He underwent a multitude of treatments previously with failed reconstructive efforts. After presenting to us, he underwent multiple debridements and eventual skin grafting. Within 4 weeks of the final skin graft, a mass developed at the skin graft donor site at the right thigh. Excisional biopsy returned a well differentiated keratinizing SCC. Discussion/Conclusion: This case demonstrates the acute presentation of SCC in a patient following a skin graft without known risk factors. The purpose of this unique case report is to highlight a very rare occurrence of SCC at a skin graft donor site.

Survival of a Free Jejunal Flap with Early Venous Obstruction

Free jejunal flap transfer is common in head and neck reconstruction, but necrosis remains a complication. A 77-year-old man underwent total pharyngo-laryngo-esophagectomy, bilateral neck dissection, and free jejunal flap transfer. We anastomosed 3 arteries (facial, transverse cervical, and superior thyroid) and 1 vein (jejunal) because the recipient site’s arterial status was poor. On day 2, ultrasonography and visualization revealed that the anastomosed vein was obstructed in the cranial jejunum but the remainder was viable. The region recovered by day 7 and the patient began oral intake on day 30. Ultrasonography revealed that the anastomosed jejunal vein showed no waveform, the facial and transverse cervical arteries showed arterial waveforms, and the superior thyroid artery showed a retrograde venous waveform. The flap had survived because the blood exited through the superior thyroid artery and vein. Thus, additional vascular and arterial anastomoses are options for free flap survival if the vascular status is poor.

Polyurethane-Coated Implants for Prevention of Double-Bubble Effect in Breast Augmentation

Breast augmentation is the most frequently performed cosmetic surgery in the United States, with approximately 279,000 patients every year. The so-called double-bubble effect (DBE) is a common complication in breast augmentation. This complication is characterized by folds running along the lower pole of the breast, forming distinct bubble-like protrusions above and below the fold. Factors that increase the risk of DBE include bulbous breasts and a large native breast volume. There is evidence that polyurethane-coated (PU) implants may help to reduce the risk of DBE. We describe here the case of a 47-year old patient for whom DBE has recurred in each of 4 tandem breast surgeries. PU implants ultimately appeared to prevent the DBE, leading to an aesthetically satisfying treatment result for the patient. This case adds weigh to the growing body of evidence that supports the use of polyurethane implants to prevent DBE.

Failure of Radiotracer Migration: Salvaging Sentinel Lymph Node Biopsy in Melanoma Care With Indocyanine Green

Reducing false negative rates for sentinel lymph node biopsies (SLNB) in melanoma is important to accurately prognosticate and to guide treatment. Traditionally, SLNB has been performed with the adjunct of radiotracers and blue dye. Although sentinel node mapping is highly successful in axillary and inguinal node basins, identification of nodes in the head and neck is not as accurate with traditional methods. One reason for this may be failure of radiotracer migration. To augment standard technique using a radiocolloid, indocyanine green (ICG) combined with near infrared spectroscopy (NIRS), has shown promising results. We demonstrate a case of an individual undergoing SLNB in the head and neck region with failure of radiotracer migration. Identification of a sentinel node was accomplished with the use of ICG and NIRS. This technology offers an opportunity to salvage the SLNB when traditional methods fail.

Case Report of a Nipple Amputation After a Horse Bite

Horse related injuries include falling from a horse, being stepped on by a horse, kicks, or bites. Bites are rare and often associated with fatalities. We present a case of a 41-year-old healthy female who suffered a complete amputation of her right nipple and abrasion of the areola following a horse bite. We managed the nipple injury as a full-thickness skin graft, similar to that of a compromised nipple in a reduction mammaplasty or mastopexy case. Barring a lack of projection and minor hypopigmentation, the nipple had normal sensation with no scar contracture. Overall, the patient was happy with her final outcome. With a healthy, minimally contaminated wound bed, and lack of poor wound healing risk factors, we believe that treating a nipple amputation as a full thickness skin graft in the emergency setting results in aesthetic outcomes, sensation, and patient satisfaction comparable if not superior to other means of nipple reconstruction in adults.

A Rare Case of Idiophatic Fournier’s Gangrene: Scrotal Reconstruction via Anterolateral Thigh Flap

Fournier’s gangrene (FG) is a surgical emergency. The main treatment plan for this disease includes several aggressive debridements, which lead to the development of massive soft-tissue defects in the affected area. Current literature describes various possible reconstructive options for the closure of those defects, yet, there is no evidence on which is the most efficient. Here we describe an unusual case of an otherwise healthy male presenting with a scrotal Fournier’s gangrene. In our case, the reconstruction was performed via anterolateral thigh flap. Due to a postoperative complication the flap was partly lost, however, consequences were managed successfully and a satisfactory result was achieved.

Digit Necrosis After Hand Surgery in Pregnancy: A Case Report

Digital blocks are routinely used for excision of lesions. We describe a unique presentation of digit necrosis after excisional biopsy with digital block and finger tourniquet in a pregnant patient with a history of ulcerative colitis. The patient had a history of a long-standing painful dorsal PIP joint mass and was scheduled for excision under local anaesthetic. On the day of the procedure, she disclosed that she was pregnant in the second trimester. After extensive discussion of risks and benefits between the patient and the surgeon, the decision was made to proceed with an excisional biopsy of the lesion because of its impact on her quality of life. Twelve hours after the procedure, she presented to the emergency department with blistering and severe pain to the digit. Doppler ultrasound showed flow through both digital arteries and the digit appeared viable. Over the coming days her pain continued to worsen and on post-operative day 3, she was admitted to hospital for attempted salvage of the digit using conservative methods. Her digit went on to demarcate at the level of the middle phalanx. Five weeks after her initial procedure, the patient underwent partial amputation of the small finger at the level of the DIP joint and 2-stage groin flap for soft tissue coverage. We discuss the effects of pregnancy and ulcerative colitis on thromboembolic events, and review the literature on digital blocks, digital tourniquet use and management of early digit necrosis. This case highlights the importance of delaying elective hand procedures in pregnant patients, especially if they have additional comorbidities such as pro-thrombotic diseases like inflammatory bowel disease.

Amish Burn Treatment Meets a Major Trauma Centre: Success With Cooperation

The Canadian Charter of Freedom and Rights asks us to be mindful of cultural or religious requests when providing healthcare, however alternative medicine is not commonly considered during acute burn resuscitation despite the value patients may place in it. We present a case study of a 46-year-old Amish gentleman with 22% TBSA (TotalBody Surface Area) deep thermal burns who requested traditional Amish burn wound treatment administered by his community elders while an inpatient at our academic burn centre. This case report illustrates the possibility of successful burn wound healing while respecting the traditional cultural beliefs of a patient and his community. Very little is found in the literature to date that describes the blending of traditional and novel treatments in an academic centre, and this largely unstudied area of medicine may present an opportunity for innovation and further discussion about the incorporation of alternative medicine in burn care.