Plastic Surgery Cases Research Articles

Plastic Surgery Case Review: Oral Board Study Guide

Albert S. Woo, ed. Plastic Surgery Case Review: Oral Board Study Guide . New York, NY: Thieme, 2014. ISBN-10: 1604068205, ISBN-13: 978-1604068207, $89.99. ![Graphic][1] Plastic Surgery Case Review: Oral Board Study Guide (edited by Albert Woo, MD) is exactly what the title suggests, a short study guide outlining 50 cases which could be encountered for the plastic surgery oral boards. Each case begins with a classic board-style photo, followed by a one- to two-page description of key points for the work-up, treatment, possible complications, and critical errors. The authors of each chapter (primarily residents, fellows, and faculty at Washington University in St. Louis) developed this book based on the “mock oral” resident examinations from their institution, primarily as a resource for those preparing for the exam. The book's chapters are written concisely, mostly in a bullet-point format and with critical points emphasized in bolded font. The format is clear and easy to follow, with good … Corresponding Author: Dr Angela Cheng, 1365 Clifton Road, Atlanta, GA 30322. E-mail: angela.cheng2{at}emory.edu [1]: /embed/inline-graphic-1.gif

Smile Enhancement Through Periodontal Surgery

Illustrations of the periodontal plastic surgery cases are presented. Results: Standard measures, golden proportions, and symmetry are concepts that mostly applied for guidance of image designing. Nevertheless, aesthetic attainment is possible with the presence of different measures and proportions and symmetry or asymmetry. Specific mathematical measures and symmetry should not be considered as beauty criteria and the violation of computational formulas and asymmetry should not be introduced as inconsistency. Symmetric smile, which follows proved measures, is not necessarily aesthetic. However, measures, proportions, and symmetry are all aspects of beautiful art work but rarely suffice for attaining beauty phenomenon. Conclusions: In modern society, we insist on finding a form that follows determined rules. Medical and periodontics sciences can have rules in repair and reconstruction of the beauty and health by anatomic symmetric smile principles. Nonetheless, physicians may not be able to achieve beauty despite of applying most complete world standards. Countless individual differences in facial features lead to achieving countless outcomes in aesthetic proceedings. Eventually, individual’s kindness and personality can create a wonderful attraction while smiling that is unjustifiable.

Impact of Specialty Training on the Association between Flap Size and Incidence of Complications following Microvascular Head and Neck Reconstruction for Cancer.

The scope of otolaryngology and plastic surgery overlap within head and neck reconstruction is increasing; yet comparative outcome studies between these two subspecialties are limited. A retrospective review was performed on all patients who underwent microvascular reconstruction of a postablative head and neck defect at a quaternary academic medical center between January 2000 and October 2011. Postoperative outcomes were reviewed by subspecialty and Mann-Whitney analysis was used to investigate any flap size differences between cohorts with and without complications. A consecutive series of 129 (66.8%) otolaryngology cases and 64 (33.2%) plastic surgery cases comprised the entire study sample. Plastic surgery flaps were significantly larger than otolaryngology flaps (9.7 vs. 8.5 cm, p = 0.004). Flap complication rates (31.8 vs. 37.5%, p = 0.429) and flap failure rates (5.4 vs. 4.7%, p = 0.429) were comparable between subspecialties. However, a significant difference in flap size was evident between the cohorts with and without flap complications following microvascular reconstruction by otolaryngology (9.18 vs. 8.15 cm, p = 0.042). This difference was not detected following reconstruction by plastic surgery (9.34 vs. 9.04 cm, p = 0.225). For the overall sample, there was a correlation between increasing flap size and higher tumor stages (significant at T4, p = 0.003) as well as advanced T-stage and medical complications (p = 0.004). Plastic surgeons should maintain an active role in the reconstruction of complex, microvascular head and neck cases such as those that require larger flaps and/or of advanced T-stages.

Evolution of practice patterns in plastic surgery using Current Procedural Terminology mapping: a 9-year analysis of cases submitted by primary and recertification candidates to the American Board of Plastic Surgery.

Understanding plastic surgery practice patterns allows the specialty to detect subtle shifts in the market and develop proactive strategies to maintain market share. Current Procedural Terminology codes from American Board of Plastic Surgery recertification and primary certification candidates from 2003 to 2011 were examined. Statistical analyses identified significant changes (p < 0.05) in the percentage of surgeons performing each type of procedure and trends in average case volume per surgeon. The overall number of procedures decreased from 2003 to 2011. There was a statistically significant (p < 0.05) decrease in the percentage of recertification and primary certification candidates performing facial cosmetic and facial malignancy procedures. Both groups also experienced statistically significant decrease in facial plastic surgery case volume. The percentage of surgeons performing breast reconstruction remained stable for the recertification group and increased significantly for primary certification surgeons. Breast reconstruction volume increased significantly for both groups. Craniofacial surgery remained stable in the percentage of surgeons performing the cases and case volume. Hand surgery experienced a significant loss of recertification surgeons performing hand surgery; however, hand surgery case volume remained stable for both groups. From 2003 to 2011, plastic surgery lost market share in facial cosmetic, facial malignancy, and hand surgery and maintained market share in breast and craniofacial surgery. CPT mapping enables us to analyze these trends to better train plastic surgeons to adapt to changing pressures both from economic recovery and from competing specialties seeking to benefit from redistribution of case loads.

Predictors and causes of unplanned re-operations in outpatient plastic surgery: a multi-institutional analysis of 6749 patients using the 2011 NSQIP database

Unplanned re-operations carry significant implications for healthcare services, surgical outcomes, and patient safety. However, there has been a paucity of large scale, multi-centre studies that evaluate the predictors and causes of unplanned re-operation in outpatient plastic surgery. This study retrospectively reviewed the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) and identified all plastic surgery outpatient cases performed in 2011. Multiple logistic regression analysis was utilised to identify independent risk factors and causes of unplanned reoperations. Of the 6749 outpatient plastic surgery cases identified, there were 125 (1.9%) unplanned re-operations (UR). Regression analysis demonstrated that body mass index (BMI, OR = 1.041, 95% CI = 1.019–1.065), preoperative open wound/wound infection (OR = 3.498, 95% CI = 1.593–7.678), American Society of Anesthesiologists (ASA) class 3 (OR = 2.235, 95% CI = 1.048–4.765), and total work relative value units (RVU, OR = 1.014, 95% CI = 1.005–1.024) were significantly predictive of UR. Additionally, the presence of any complication was significantly associated with UR (OR = 15.065, 95% CI = 5.705–39.781). In an era of outcomes-driven medicine, unplanned re-operation is a critical quality indicator for ambulatory plastic surgery facilities. The identified risk factors will aid in surgical planning and risk adjustment.

The Relationship between Preoperative Wound Classification and Postoperative Infection: A Multi-Institutional Analysis of 15,289 Patients

BackgroundDespite advances in surgical techniques, sterile protocols, and perioperative antibiotic regimens, surgical site infections (SSIs) remain a significant problem. We investigated the relationship between wound classification (i.e., clean, clean/contaminated, contaminated, dirty) and SSI rates in plastic surgery.MethodsWe performed a retrospective review of a multi-institutional, surgical outcomes database for all patients undergoing plastic surgery procedures from 2006-2010. Patient demographics, wound classification, and 30-day outcomes were recorded and analyzed by multivariate logistic regression.ResultsA total of 15,289 plastic surgery cases were analyzed. The overall SSI rate was 3.00%, with superficial SSIs occurring at comparable rates across wound classes. There were similar rates of deep SSIs in the clean and clean/contaminated groups (0.64%), while rates reached over 2% in contaminated and dirty cases. Organ/space SSIs occurred in less than 1% of each wound classification. Contaminated and dirty cases were at an increased risk for deep SSIs (odds ratios, 2.81 and 2.74, respectively); however, wound classification did not appear to be a significant predictor of superficial or organ/space SSIs. Clean/contaminated, contaminated, and dirty cases were at increased risk for a postoperative complication, and contaminated and dirty cases also had higher odds of reoperation and 30-day mortality.ConclusionsAnalyzing a multi-center database, we found that wound classification was a significant predictor of overall complications, reoperation, and mortality, but not an adequate predictor of surgical site infections. When comparing infections for a given wound classification, plastic surgery had lower overall rates than the surgical population at large.

Changes in the workload composition in a Plastic Surgery Unit over a 12 year period

Guidelines issued by the British Association of Plastic Reconstructive and Aesthetic Surgeons suggest that the ratio of elective to emergency cases in plastic surgery units should be 2:1. To investigate how the workload composition of a regional plastic surgery unit compared with these guidelines. The changes in the workload composition of a regional plastic surgery unit were examined by retrospectively analysing all plastic and reconstructive surgery cases performed over 12 years (1998-2009). This time period saw a change from a 1:2 ratio of elective to trauma procedures, to the recommended ratio, at a time when the overall caseload increased by almost 40 % (3,281 procedures in 1998 to 4,529 procedures in 2009). Expansion of staff numbers at consultant and non-consultant grades, and increased resources (allocated theatre sessions and outpatient clinics) were pivotal to this change.

Resident Involvement and Plastic Surgery Outcomes

Intraoperative experience is an essential component of surgical training. The impact of resident involvement in plastic surgery has not previously been studied on a large scale. The authors retrospectively reviewed the American College of Surgeons National Surgical Quality Improvement Program database from 2006 to 2010 for all reconstructive plastic surgery cases. Resident involvement was tracked as an individual variable to compare outcomes. A total of 10,356 cases were identified, with 43 percent noted as having resident involvement. The average total relative value units, a proxy for surgical complexity, and operative time were higher for procedures with residents present. When balanced by baseline characteristics using propensity score stratification into quintiles, no differences in graft, prosthesis, or flap failure or mortality were observed. Furthermore, there were no differences in overall complications or wound infection with resident involvement for a majority of the quintiles. Multivariable logistic regression analysis revealed that resident involvement was a significant predictor of overall morbidity, but not associated with increased odds of wound infection, graft, prosthesis or flap failure, or overall mortality. Residency has the dual mission of training future physicians and also providing critical support for academic medical centers. Using a large-scale, multicenter database, the authors were able to confirm that well-matched cohorts with-and without-resident presence had similar complication profiles. Moreover, even when residents were involved in comparably more complex cases with longer operative times, infection, graft and flap failure, and mortality remained similar.

A 9-Year Comparison of Practice Profiles of Candidates for Primary and Recertification Examinations of the American Board of Plastic Surgery Relative to Economic Indicators

This study compared the practice profiles of plastic surgeons applying for recertification/maintenance of certification with those applying for primary certification by the American Board of Plastic Surgery between 2003 and 2011. American Board of Plastic Surgery case logs from both recertification and primary certification candidates from 2003 to 2011 were examined. Deidentified data included operative year, Current Procedural Terminology codes, and the candidate's designation of the case relative to (1) cosmetic or reconstructive and (2) the Maintenance of Certification in Plastic Surgery module (i.e., comprehensive, cosmetic, craniomaxillofacial, and hand). Department of Commerce unemployment data from 2003 to 2011 served as an economic indicator for the period studied. A negative trend in the median number of cases per candidate was observed for both groups for cosmetic, reconstructive, and total number of cases, corresponding to a rise in unemployment. With every 1 percent increase in the unemployment rate, recertification candidates demonstrated a greater loss of cosmetic cases relative to primary candidates and an accelerated decline in reconstructive cases starting in 2007. Distribution of the four Maintenance of Certification modules demonstrated a negative trend for cosmetic and comprehensive cases in both groups. Hand and craniofacial consistently constituted approximately 20 percent of cases for primary and 14 percent of cases for recertification candidates. There was a shift away from hand cases toward craniofacial cases in both groups. Both primary and recertification candidates reported a decline in overall caseload from 2003 to 2011. Negative economic trends have a greater impact on the practice profile of recertification candidates.

From the operating room to the courtroom

Malpractice litigation has increased in recent decades, contributing to higher health-care costs. Characterization of complications leading to litigation is of special interest to practitioners of facial plastic surgery procedures because of the higher proportion of elective cases relative to other subspecialties. In this analysis, we comprehensively examine malpractice litigation in facial plastic surgery procedures and characterize factors important in determining legal responsibility, as this information may be of great interest and use to practitioners in several specialties. Retrospective analysis. The Westlaw legal database was examined for court records pertaining to facial plastic surgery procedures. The term "medical malpractice" was searched in combination with numerous procedures obtained from the American Academy of Facial Plastic and Reconstructive Surgery website. Of the 88 cases included, 62.5% were decided in the physician's favor, 9.1% were resolved with an out-of-court settlement, and 28.4% ended in a jury awarding damages for malpractice. The mean settlement was $577,437 and mean jury award was $352,341. The most litigated procedures were blepharoplasties and rhinoplasties. Alleged lack of informed consent was noted in 38.6% of cases; other common complaints were excessive scarring/disfigurement, functional considerations, and postoperative pain. This analysis characterized factors in determining legal responsibility in facial plastic surgery cases. Several factors were identified as potential targets for minimizing liability. Informed consent was the most reported entity in these malpractice suits. This finding emphasizes the importance of open communication between physicians and their patients regarding expectations as well as documentation of specific risks, benefits, and alternatives.

Local expression of inflammatory cytokines in the facial tissue of children with a cleft lip and palate

The cleft lip and/or palate are among the most common congenital anomalies that occur in early development. Cytokines play an important role in the proliferation, growth, differentiation, survival and the functional activity of many cells and the upregulation of cytokines might be involved in the pathological processes of the maxillofacial region. The purpose of our study was to evaluate the expression of pro-inflammatory and anti-inflammatory cytokines in the facial tissue of children with the cleft lip and palate.The study involved 14 patients with the unilateral cleft lip and palate at the age of three months to 10 years and five months. Soft and hard palate tissue samples were collected during the primary cleft operation if the parents had given their informed written consent. All the tissue samples were stained with hematoxylin and eosin and by immunohistochemistry for IL-1α, IL-6, IL-8, IL-10 and TNF-α. The intensity of immunostaining was graded semiquantitatively.IL-1α containing structures were not detected in any of soft, cartilage and bone tissue samples, meanwhile IL-6, IL-8, IL-10 and TNF-α showed explicit expression. The expression of IL 6 was observed in the tissues of all the patients. IL-6 positive cells were found in the range from no positive to moderate of positive structures in the visual field. IL-8 positive osteocytes were found in the range from few positive to moderate, but IL-8 positive chondrocytes were found in abundance. IL-10 was richly secreted by osteocytes in bone and by chondrocytes in cartilage obtained from all the cases of plastic surgery. In all the cases we also observed numerous IL-10 positive gingival epithelial cells. Despite these data obtained, moderate to numerous macrophages and neutrophils expressed TNF-α.The sporadical and scarce expression of IL-6 indicates its insignificant role in the cleft lip and palate affected tissue. Rich cytokine IL-10 expression proves the compensated local anti-inflammatory effects of the cleft affected soft and hard tissue.

Medicolegal Review of Deaths Related to Propofol Administration: Analysis of 36 Autopsied Cases

Propofol is a widely used anesthetic in anesthesia and sedation. Recent cases of propofol-induced death have been associated with adverse effects, abuse, or intoxication. However, there are few forensic reports of propofol-associated death. We reviewed and analyzed 36 cases of death related to propofol administration recorded by the National Forensic Service in 2000-2011. The number of women was 28 (77.8%). Subjects in their 20s and 30s accounted for 61.1% of cases. Cause included medical accidents, 16 (44.4%); suicides, 2 (5.6%); and undetermined, 18 (50%; suicide/accident). Of the 16 medical accidents, 8 were internal medicine cases (conscious sedation endoscopy), 3 surgical cases, 3 plastic surgery cases, 1 urology case, and 1 obstetrics and gynecology case. In 20 cases of suicide or undetermined (suicide/accident), the victims were nurses (9 cases), doctors (4 cases), hospital administrators (2 cases), homemakers (2 cases), bar hostesses (2 cases) and an office worker (1 case). The doctor included 2 plastic surgeons, an internist, and a resident anesthesiologist. The autopsy findings were nonspecific; congested parenchymal organs (34 cases), pulmonary edema (8 cases), cerebral edema (2 cases), pulmonary and cerebral edema (2 cases), putrefaction (2 cases), mucosal petechiae in the interior of the larynx (1 case), and cerebral ischemic necrosis and pneumonia (1 case). The blood propofol concentrations ranged between 0.007 mg/L (cardiopulmonary resuscitation) or 0.23 mg/L (no cardiopulmonary resuscitation) and 4.38 mg/L in medical accident cases, and from 0.12 mg/L to 108.3 mg/L in suicide or undetermined (suicide/accident) cases. Other drugs were detected in 17 cases and alcohol was detected in only 2 cases. Blood concentrations in cases of medical accident were lower than in cases of undetermined cause.

Development of a free perforator adipofascial flap of the DIEA system with minimal donor side mobidity for special reconstructive plastic surgery cases

Development of a free perforator adipofascial flap of the DIEA system with minimal donor side mobidity for special reconstructive plastic surgery cases

Nymphoplasty: classification and technical refinements

BACKGROUND: Hypertrophy of the labia minora is a functional and esthetic problem that can have a significant impact on quality of life. Current surgical procedures are based on the excision of excess tissue and reconnection of the edges. However, anatomical alterations associated with labial hypertrophy such as hypertrophy of the foreskin of the clitoris are common, and, if not treated properly, may limit the results of surgery and cause esthetic and functional sequelae. The present report proposes a classification of the different types of hypertrophy and recommended treatments, and describes refinements in the labia minora reduction techniques. METHODS: A total of 20 female genital plastic surgery cases from the Center for Plastic Surgery of Brasilia and at Hospital das Forcas Armadas from June 1999 to March 2008 were retrospectively reviewed. Patients were classified into three groups according to the degree and location of labia minora hypertrophy. RESULTS: The patients were satisfied with the esthetic results of surgery. No complications were reported, and all patients underwent surgery of the labia minora in accordance with the protocol proposed by the authors and based on hypertrophy type. CONCLUSIONS: The surgical procedures reviewed in this study were based on the classification of labia minora hypertrophy. Satisfactory esthetic and functional results were obtained, thus providing new methods for the surgical reduction of labia minora and foreskin of the clitoris without surgical stigma or reduction of sensitivity and no effects on sexual function.

Surgical Periodontal Therapy at Tokyo Dental College Suidobashi Hospital: A Statistical Profile in 2010-2011

The aim of the present study was to investigate the profile of surgical periodontal therapy performed at the Suidobashi Hospital of Tokyo Dental College, during the period of April 2010 through March 2011. A total of 112 periodontal surgeries in 69 patients (mean age: 51.4 years; 28 men and 41 women) were registered for the data analysis. The surgical interventions performed by 17 dentists comprised 79 cases of open flap debridement, 27 cases of periodontal regenerative therapy with enamel matrix derivative and 6 cases of periodontal plastic surgery. Eighty percent of the surgical sites were in the molar region and 41 cases had furcation involvement. In these patients, an improvement in oral hygiene status was observed prior to surgery: the mean plaque score of 45% at initial visit was significantly reduced to 31% after initial periodontal therapy (p<0.01). At sites that subsequently received open flap debridement or periodontal regenerative therapy, the mean probing depth and clinical attachment level after initial therapy was 6.4 mm and 7.6 mm, respectively. These values were significantly lower than those at initial visit (p<0.01). Lower prevalence of sites with positive bleeding on probing was observed after initial therapy. The initial periodontal therapy performed was considered to be effective in improving the periodontal condition of the sites prior to surgery. More effort, however, is indicated in improvement of patient oral hygiene status.

Reply

Sir: We thank Drs. Kwan and Reid for their invaluable comments on the importance of the skin envelope regarding the use of biomaterials for craniofacial reconstruction. In our practice, we have been fortunate that the majority of our pediatric patients have had a well-vascularized, pliable skin envelope that has allowed the use of biomaterials without fear of major complications. Nevertheless, the risk of early and late exposure of subcutaneously implanted biomaterials in the facial skeleton is well documented in the literature.1,2 In the context in which implant exposure is a concern because of poor skin quality, biomaterials may still find a role. Biomaterials designed to be replaced by bone, such as demineralized bone matrix and bioactive glass, are both osteoinductive and osteoconductive, and as we found in this study,3 incorporate into the surrounding skeleton with a mineral density approaching or equivalent to that of surrounding bone. However, autologous bone graft and vascularized tissue would of course remain the benchmark against which all these materials are judged. Biomaterials at this juncture remain an alternative option, with the advantage of “off-the-shelf availability.” However, we hope that with advances in tissue engineering and biomedical research, they may come to be regarded as the standard materials for craniofacial reconstruction. Harvey Chim, M.D. Arun K. Gosain, M.D. Department of Plastic Surgery Case School of Medicine Cleveland, Ohio DISCLOSURE Neither of the authors has any financial interests or commercial associations with any device or product mentioned in this exchange of communications.

Facility Cost Analysis in Outpatient Plastic Surgery: Implications for the Academic Health Center

The authors examined the economic patterns of outpatient aesthetic and reconstructive plastic surgical procedures performed within an academic health center. For fiscal years 2003 and 2004, the University of Michigan Health System's accounting database was queried to identify all outpatient plastic surgery cases (aesthetic and reconstructive) from four surgical facilities. Total facility charges, cost, revenue, and margin were calculated for each case. Contribution margin (total revenue minus variable direct cost) was compared with total case time to determine average contribution margin per operating suite case minute for subsets of aesthetic and reconstructive procedures. A total of 3603 cases (3457 reconstructive and 146 aesthetic) were identified. Payer mix included Blue Cross (36.7 percent), health maintenance organization (28.7 percent), other commercial payers (17.4 percent), Medicare/Medicaid (13.5 percent), and self-pay (3.7 percent). The most profitable cases were reconstructive laser procedures ($66.20; n = 361), scar revision ($36.01; n = 25), and facial trauma ($32.17; n = 64). The least profitable were hand arthroplasty ($13.93; n = 35), arthroscopy ($17.25; n = 15), and breast reduction ($17.46; n = 210). Aesthetic procedures (n = 144) yielded a significantly higher contribution margin per case minute ($24.21) compared with reconstructive procedures ($22.28; n = 3093) (p = 0.01). Plastic surgical cases performed at dedicated ambulatory surgery centers ($28.60; n = 1477) yielded significantly higher contribution margin per case minute compared with those performed at hospital-based facilities ($25.58; n = 2123) (p < 0.01). Use of standardized accounting (contribution margin per case minute) can be a strategically effective method for determining the most profitable and appropriate case mix. Within academic health centers, aesthetic surgery can be a profitable enterprise; dedicated ambulatory surgery centers yield higher profitability.

Can a Picture Really Paint a Thousand Words?

Plastic surgeons require a three-dimensional appreciation of form and function in order to meet reconstructive challenges. The popular perception that plastic surgeons must be artistic was tested in an observational study of sketch illustrations in plastic surgery case notes. Only in the trunk and breast category of illustrations could career plastic surgeons demonstrate superior artistic skill to non-career plastic surgeons and there was little correlation between the artistic merit of a diagram and the likelihood of its meaning being understood by an independent observer. Simple but accurate outline sketches are as capable of leading an observer to the correct diagnosis as complex works of art, while illustrations with low diagnostic scores are not only misleading but may also have medico-legal implications.

Economics of microsurgical cases and routine cases in a medical center.

This report describes the economic impact of microsurgical cases and routine plastic surgery cases in our medical center. The study is based on a financial analysis of the practices of two surgeons. Financial data of patient encounters (admission to the hospital or a surgical unit) identified with each surgeon were categorized into microsurgical and related cases and routine cases (including cosmetic procedures and general hand cases). Revenues, costs, and profits were tabulated. Data were analyzed for 2 fiscal years (1994-95 and 1995-96). Analysis of the first fiscal year showed that microsurgery encounters (n = 188) generated $4.4 million in revenue with a profit margin after direct costs of $2.5 million (57 percent) and a net profit, after indirect costs, of $1 million (23 percent). Routine encounters (n = 262) generated $1.7 million with a net loss of -$145,000 after direct and indirect costs. In the second fiscal year, microsurgery encounters (n = 230) had income of $4.7 million, a profit over direct costs of $2.5 million (53 percent), and a net profit after indirect costs of $0.9 million (19 percent). Routine cases (n = 202) in the same period earned $1.3 million with a net loss of -$107,000. This analysis formulates a comprehensive definition of microsurgical practice and shows that cases within this definition generated dramatically higher hospital incomes and profits compared with routine plastic surgical practice. In the circumstances of our medical center, development of this subspecialty is fiscally justifiable.

Tissue expansion in late repair of tendo Achillis rupture

The Journal of Bone and Joint Surgery. British volumeVol. 77-B, No. 1 ArticlesFree AccessTissue expansion in late repair of tendo Achillis ruptureA Mohammed, A Rahamatalla, CH Wynne-JonesA MohammedSearch for more papers by this author, A RahamatallaSearch for more papers by this author, CH Wynne-JonesSearch for more papers by this authorPublished Online:1 Jan 1995https://doi.org/10.1302/0301-620X.77B1.7822399AboutSectionsPDF/EPUB ToolsAdd to FavouritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InRedditEmail FiguresReferencesRelatedDetailsCited ByRupture of a Breast Tissue Expander Due to Chest Wall Exostosis: Case Report and Literature Review1 December 2015 | Plastic Surgery Case Studies, Vol. 1, No. 3Complex Achilles Reconstruction for Massive Soft Tissue Loss: Allograft, Autograft, and Use of a Temporary Cement SpacerJournal of Orthopaedic Trauma, Vol. 24, No. 8Surgical Strategies: Delayed Diagnosis or Neglected Achilles’ Tendon Ruptures1 April 2008 | Foot & Ankle International, Vol. 29, No. 4A Combined Repair Technique for Early Neglected Achilles Tendon Ruptures16 October 2007 | European Journal of Trauma and Emergency Surgery, Vol. 34, No. 1Quantitative Review of Operative and Nonoperative Management of Achilles Tendon Ruptures30 August 2017 | The American Journal of Sports Medicine, Vol. 30, No. 4A reversed Z-plasty skin incision for Achilles tendon reconstructionFoot and Ankle Surgery, Vol. 8, No. 4Soft tissue expansion prior to arthroplasty in the multiply-operated kneeThe Journal of Arthroplasty, Vol. 11, No. 5 Vol. 77-B, No. 1 Metrics Downloaded 96 times History Published online 1 January 1995 Published in print 1 January 1995 InformationCopyright © 1995, The British Editorial Society of Bone and Joint Surgery: All rights reservedPDF download