BACKGROUND Since the pioneering work of Jacobson and Suarez, microsurgery has steadily progressed and is now used in all surgical specialities, particularly in plastic surgery. Before performing clinical procedures it is necessary to learn the basic techniques in the laboratory. OBJECTIVE To assess an animal model, thereby circumventing the following issues: ethical rules, cost, anesthesia and training time. METHODS Between July 2012 and September 2012, 182 earthworms were used for 150 microsurgical trainings to simulate discrepancy microanastomoses. Training was undertaken over 10 weekly periods. Each training session included 15 simulations of microanastomoses performed using the Harashina technique (earthworm diameters >1.5 mm [n=5], between 1.0 mm and 1.5 mm [n=5], and <1.0 mm [n=5]). The technique is presented and documented. A linear model with main variable as the number of the week (as a numeric covariate) and the size of the animal (as a factor) was used to determine the trend in time of anastomosis over subsequent weeks as well as differences between the different size groups. RESULTS The linear model showed a significant trend (P 1.5 mm, mean anastomosis time decreased from 19.6±1.9 min to 12.6±0.7 min between the first and last week of training. For training involving smaller diameters, the results showed a reduction in execution time of 36.1% (P<0.01) (diameter between 1.0 mm and 1.5 mm) and 40.6% (P<0.01) (diameter <1.0 mm) between the first and last weeks. The study demonstrates an improvement in the dexterity and speed of nodes' execution. CONCLUSION The earthworm appears to be a reliable experimental model for microsurgical training of discrepancy microanastomoses. Its numerous advantages, as discussed in the present report, show that this model of training will significantly grow and develop in the near future.

Reduction mammoplasty is one of the most commonly performed procedures in plastic surgery. Occasionally, there are findings reported by pathologists that are unfamiliar to the treating surgeon. The aim of the present study was to determine the types of pathologies encountered in reduction mammoplasty specimens. From this list of diagnoses, a best practice guideline for management will be organized to better assist plastic surgeons in the management of patients with incidental findings on pathology reports. A total of 441 pathology reports from patients who underwent bilateral or unilateral reduction mammoplasty in the past three years were identified. A list of 21 different pathologies was generated from the pathology reports, along with supplemental data from recent texts and articles. Occult carcinomas were encountered in two cases (0.45%) and high-risk lesions were found in three cases (0.68%) at the authors' institution. An algorithm was then constructed to organize the pathologies according to risk of malignancy and assign them to a management guideline. There are many different lesions encountered incidentally in reduction mammoplasty specimens that may or may not confer some cancer risk. It is important for plastic surgeons to know which lesions need closer follow-up to provide the best care for their patients.

Objective To summarize current Canadian practice patterns in the diagnosis of and interventions for inhalation injuries (INHI). Methods A 10-question survey regarding the diagnosis of and interventions for INHI was sent to the medical directors of all 16 burn centres across Canada. Results The response rate to the survey was 50%. Fibreoptic bronchoscopy is required for the diagnosis of INHI in only four centres (50%). The departments of intensive care, plastic surgery, otolaryngology and respirology are involved in performing fibreoptic bronchoscopy in 87.5%, 37.5%, 12.5% and 12.5% of Canadian burn centres, respectively. Intubation for INHI is most often based on physical examination results (87.5%) and clinical history (75%). The most common physical features believed to be most consistent with INHI are dyspnea (87.5%) and hoarseness (87.5%). Common treatments include intubation (87.5%), routine ventilatory support (87.5%) and chest physiotherapy (75%). None of the centres used nebulized heparin. A total of five centres (62.5%) routinely changed the fluid resuscitation protocol when INHI was diagnosed. Only two centres (25%) routinely used prophylactic antibiotics for INHI. Conclusion Prospective, multicentre trials are needed to generate evidence-based consensus in the areas of diagnosis, grading and treatment for INHI in Canada.

In a past missive, we started to examine the process of capital budgeting at the hospital level and illustrated the principle with a relevant example (1). Intimately tied to this example was the idea that we need to spend money to save money. In our example, we detailed a purchase and demonstrated how the savings gleaned outweighed the expense, justifying the cash outlay. In doing so, we quantified the cost of a purchase from the perspective of the hospital administrator. To be honest, we used the term ‘cost’ loosely when we really meant ‘expense’. It is loose substitutions such as these that muddy the waters of cost comparisons. To some extent we quantified the cost of a surgical procedure, but did we really calculate the cost of the intervention? At the recent Canadian Society Meeting held in Calgary (Alberta), practicing staff and trainees presented an unprecedented number of articles exploring, estimating and comparing treatment on the basis of cost (2). Contrast this to presentations from before the economic crash of 2007 (3). Many argue that cost should factor into all research protocols moving forward. Granting agencies agree. Cost analysis not only ensures that care is delivered in a cost-effective manner, but it also ensures that care can continue to be delivered at all; we are sitting on the cusp of an era in which physicians will need to argue effectively to continue to ply their trade (4). But how do we decide how to calculate cost, and from whose perspective?

The present article includes a video designed to show the reader/viewer how to obtain a better lip roll in primary and secondary cleft lips as well as in traumatic cleft lips. The key is to not damage the delicate glands and fat in the lip roll. The actual surgery demonstrated in the video is a cleft lip redo with an effaced lip roll.

Purpose To examine treatment trends and costs associated with Dupuytren's disease (DD) in Canada. Methods Data regarding fasciectomies, fasciotomies and digit amputations performed for DD from 2005 to 2010 were extracted from the Canadian Institute for Health Information database. The data were analyzed according to year, sex and five-year age groups. The estimated annual physician reimbursement costs for DD in Ontario were calculated using Ontario Health Insurance Plan billing information and the 2010 Physician Schedule of Benefits. Results The number and rate of fasciectomies remained stable from 2005 to 2009 (mean of 4067 and 1.24 per 10,000, respectively), but increased in the 2009/2010 fiscal year (to 4458 and 1.32 per 10,000). The number of fasciotomies increased from 133 in 2005/2006 to 201 in 2008/2009, but dropped to 183 in 2009/2010. The mean number of amputations remained stable (12 procedures). The ratio of males to females undergoing fasciectomies remained stable (4:1). The highest rate of fasciectomies was performed for the age groups 65 to 69 years and 70 to 74 years. Estimated mean physician remuneration for DD in Ontario remained stable ($3.2 million per annum). Discussion The results regarding patient demographics are comparable with results from previous literature. There was a trend toward an increasing number of fasciectomies and fasciotomies annually, with fasciotomies increasing faster than fasciectomies, which is reflective of the aging population and the recent attention to fasciotomies in the literature. The present study was the first to investigate treatment trends and physician reimbursement costs for the management of DD in Canada.

Pyoderma gangrenosum is a great masquerader in wound diagnosis and management. Frequently misdiagnosed as a necrotizing infection, the elusive nature of its etiology and pathogenesis has thwarted the establishment of a standardized management algorithm, leaving immunosuppressant therapies as the mainstay of treatment. The present report describes a 61-year-old woman presenting with temporally discrete bilateral dorsal hand lesions successfully managed with distinctive multimodality therapies. The initial lesion was managed under the auspices of a necrotizing process using a combination of hyperbaric oxygen therapy and skin grafting with a negative-pressure dressing, both individually demonstrated to be effective for prompt wound stabilization and coverage. A subsequent contralateral hand lesion was similarly managed as a necrotizing infection before a diagnosis of pyoderma gangrenosum was considered. Stabilization and eventual resolution was achieved using intravenous and topical steroids followed by hyperbaric oxygen therapy, again highlighting the benefits of multimodality therapy in the setting of pyoderma gangrenosum.

After studying the anatomy of 10 fresh cadavers, we developed a technique for the treatment of the cervical area during face lifts. We called this technique PLATYSMA-SUSPENSION and PLATYSMA-PEXY rather than plication. This technique consists of suspending the free edge of the platysma muscle and fixing it to a resistant tissue close to the earlobe (Lore’s fascia or temporo-parotid fascia). The anterior triangle of the neck was well defined and there was no need to undermine the platysma muscle because of a perfect sliding plane between the platysma and sternocleidomastoid muscles. This technique is both simple and effective. It generates long-lasting results, without the inconveniences or complications associated with other techniques. MATERIALS AND METHODS: Ten fresh cadavers (ie, 20 hemifaces) were subjected to the proposed technique. They were photographed and filmed at all stages. Ten more cadavers were dissected to study the submental area and we discovered that the best way to recreate the cervico mental angle and to rebuild the floor of the mouth is to use a digastric corset so that we could rebuild the retaining ligaments between the platysma/digastric and mylohyoid muscles. More than 100 patients were operated by the senior author; they underwent platysma-suspension and platysma-pexy of the fascia described by Lore; associated in difficult necks (Knize 3 and 4 necks) with the digastric corset. The patients were followed-up for a minimum of 12 months. CONCLUSION: PLATYSMA-SUSPENSION and PLATYSMA-PEXY in the fascia described by Lore is an extremely long-lasting and effective technique in cervical lifting. It generates impressive results, even in the most inferior portion of the neck. It redefines the entire anterior triangle, especially the sternocleidomastoid muscle and the mandibular contours. Furthermore, PLATYSMA-SUSPENSION minimizes the risk of nerve injury and hematoma by preventing deep and unnecessary dissections because the superficial cervical fascia has a perfect sliding plane between the platysma and the deepest structures of the neck. In difficult necks, we do associate a digastric corset using a submental incision. Pre-op botulinum toxin injections appears to be of great interest leaving the muscle at rest during the post-operative phase.

A case involving a retired, elderly male war veteran with a symptomatic peroneus brevis muscle hernia causing superficial peroneal nerve compression with chosen surgical management is presented. Symptomatic muscle hernias of the extremities occur most commonly in the leg and are a rare cause of chronic leg pain. Historically, treating military surgeons pioneered the early documentation of leg hernias observed in active military recruits. A focal fascial defect can cause a muscle to herniate, forming a variable palpable subcutaneous mass, and causing pain and potentially neuropathic symptoms with nerve involvement. While the true incidence is not known, the etiology has been classified as secondary to a congenital (or constitutional) fascial weakness, or acquired fascial defect, usually secondary to direct or indirect trauma. The highest occurrence is believed to be in young, physically active males. Involvement of the tibialis anterior is most common, although other muscles have been reported. Dynamic ultrasonography or magnetic resonance imaging is often used to confirm diagnosis and guide treatment. Most symptomatic cases respond successfully to conservative treatment, with surgery reserved for refractory cases. A variety of surgical techniques have been described, ranging from fasciotomy to anatomical repair of the fascial defect, with no consensus on optimal treatment. Clinicians must remember to consider muscle hernias in their repertoire of differential diagnoses for chronic leg pain or neuropathy. A comprehensive review of muscle hernias of the leg is presented to highlight their history, occurrence, presentation, diagnosis and treatment.