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SUMMARY: Lip reconstruction following excision of cutaneous malignancy should be carefully planned to avoid discarding useful tissue. In this report, we describe two cases in which the usually discarded Burrow's triangles of the cheek advancement flap are used to reconstruct adjacent anatomical structures, thus improving the functional and aesthetic outcome of the reconstruction.

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BACKGROUND: Hand sepsis is a common cause of morbidity. The study was conducted in the KwaZulu-Natal province of South Africa, investigating the bacteriological profile and aetiology of hand sepsis, aiming at optimising empiric antibiotic therapy. METHODS: This is a descriptive study of 120 patients who presented to the plastic surgery department of Inkosi Albert Luthuli Central Hospital with hand sepsis, from January 2017 to April 2019, that required surgical drainage. Data recorded included: aetiology of sepsis, underlying comorbidities, length of hospital stay, and outcome. A pus swab was taken during surgical drainage for microscopy, culture and sensitivity (MCS) analysis. The relationship between clinical factors and microbiological findings was analysed. RESULTS: The predominant bacterial strains cultured from infected patients, excluding methicillin-resistant Staphylococcus aureus, were Staphylococcus aureus (80.8%) and Streptococcus spp. (20.0%), mostly due to spontaneous onset infection (58.3%). Cultures of the more problematic Streptococcus spp. were more frequently associated in patients with diabetes mellitus (60.0%), penetrating trauma (41.9%), or blunt trauma (31.3%). The diabetes group in isolation had the longest median hospital stay of 8 (5-15) days, the most need for multiple procedures (60.0%), amputations (30.0%), and skin grafts (20.0%). The most effective antimicrobial drug particularly in mixed cultures was amoxicillin-clavulanic acid. CONCLUSION: Staphylococcus aureus infection was the most common. Streptococcus spp. occurred more frequently in patients with traumatic injury and diabetes mellitus. The latter required further surgical procedures and an increased hospital stay. Amoxicillin-clavulanic acid is the preferred empiric antimicrobial agent.

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BACKGROUND: The role of regional anaesthesia in cleft lip surgery in the developing world is not well documented. METHOD: A retrospective chart review of 100 patients aged >14 years who had cleft lip surgery during an Operation Smile South Africa (OSSA) volunteer surgical programme in Madagascar during 2007 and 2008. The nerve blocks used included a bilateral infraorbital nerve block, a dorsalnasal nerve block and a septal block supplemented with peri-incisional local in_ltration. Appropriateness of the regional anaesthesia alone for cleft lip surgery was determined by absence of any intraoperative complications, postoperative complications or conversions to general anaesthesia. RESULTS: Seventy-four patients commenced their operation under regional anaesthesia. There were no intraoperative or postoperative complications documented, and no patient required conversion to general anaesthesia. Two patients required additional analgesia in the immediate postoperative period. CONCLUSION: Regional anaesthesia for cleft lip surgery in patients >14 years of age was well tolerated and associated with few complications. It is a safe and effective option when used as the sole anaesthetic modality for cheiloplasty in the developing world.

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Supernumerary nipples are common congenital anomalies, most often occurring along the embryonic milk lines. We present a patient with an ectopic nipple on the foot. We are unable to explain the aetiology of this anomaly; however, several theories have been proposed. They are also associated with disorders of the renal and cardiovascular systems as well as pathology that affect normal breast tissue.

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Giant tumours of the breast cause massive enlargement of the breast resulting in asymmetry. Simple excision of the tumour fails to restore symmetry, and in some cases leaves the patient with a secondary deformity. We present two cases of giant fibroadenoma in adolescent females. Both patients underwent a one-stage excision of the giant fibroadenoma and reduction mammoplasty. Relevant operative details and results are presented together with a review of the literature.

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The use of Z-plasties in the closure of elliptical or circular defects is not uncommon. We present a patient in whom a double Z-plasty was performed in order to close a sacral pressure sore. The patient returned 21 years later seeking aesthetic improvements of the resultant obliteration of the natal cleft and the soft tissue and skin redundancy in the central inferior aspect of the buttocks. We met this challenge with a practical solution. The triangular flaps of the Z-plasties were returned to their original positions. This resulted in a natural shortening of the central portion of the buttock and the recreation of the natal cleft. The postoperative result was aesthetically pleasing. We report this unusual case and discuss the geometry behind the reversal of the Z-plasties as the solution to this problem. In addition, a novel interpretation of Z-plasties is presented.

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Although solitary fibrous tumor (SFT) was originally described as a pleural tumor, an increasing number of extrapleural sites of SFTs have been documented. This has been attributed not only to the heightened awareness of the spectrum of histopathological features that characterizes SFTs but also to the recognition of the role of CD34 immunostaining in soft tissue tumors in general, and in SFTs in particular. Despite the large number of documented extrapleural SFTs in adults, cranial SFTs are rare, having been documented in the meninges, scalp, and infratemporal fossa. Extrapleural SFTs are, to date, an unrecognized entity in children. We document an aggressive fibrous scalp lesion in a 30-month-old female child that demonstrated features common to benign cranial fasciitis and SFT. However, based on bright, diffuse CD34 antigen immunopositivity, a diagnosis of SFT was made. The need to include the CD34 antigen stain in a panel of immunohistochemical markers used to assess spindle cell lesions of childhood is emphasized.

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Although post-traumatic lipomas have been reported in various sites, a subpectoral location has, to the best of our knowledge, not previously been described. We report on the clinicopathological, radiological, intraoperative and postoperative details of a post-traumatic subpectoral lipoma in a 35-year-old black African female.

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bcl-2, the well known anti-apoptotic gene, cloned more than a decade ago, promotes cell viability without promoting cell proliferation. With few exceptions, high bcl-2 protein expression is associated with a favourable outcome in epithelial tumours. bcl-2 immunoreactivity in basal cell carcinomas (BCCs) is contradictory, with 67-100% immunopositivity being reported. Although BCCs are traditionally regarded as low-grade, indolent tumours, aggressive BCCs (A-BCCs) are mutilative, locally destructive tumours that often recur. bcl-2 protein expression as a predictor of BCC aggressiveness is poorly documented in the English-language literature. The bcl-2 protein immunoprofile of 50 clinically non-aggressive (NA-BCCs) and 25 clinically A-BCCs was investigated. Of the latter, 17 manifested with one, two or three recurrences. bcl-2 protein expression in each of the recurrences was also evaluated. bcl-2 expression was scored as follows: 0-5% positive cells=negative, 6-25%=1+, 26-50%=2+, 51-75%=3+, >75%=4+. "High" labeling encompassed 3+ or 4+ labeling while "low" labeling referred to 1 + or 2 + labeling. Although bcl-2 positivity was noted in all BCCs, low bcl-2 labeling was a statistically significant feature of A-BCCs (p < 0.01). High bcl-2 labeling of NA-BCCs was a reflection of the bcl-2 labeling of the dominant constituent nodular or superficial subtypes. Micronodular BCCs revealed 2+ or 3+ labeling. Initial and recurrent A-BCCs with a pure or predominantly infiltrative component, demonstrated 1+ or 2+ bcl-2 labeling. The differential bcl-2 expression in the various clinicopathological subtypes of BCCs suggests that, despite the common derivation of these tumours from a primitive basaloid stem cell and a limited potential for metastasis, they form a heterogeneous group of tumours that differ markedly in histologic and biological behaviour. While the superficial and nodular BCCs are indolent slow-growing tumours with high bcl-2 labeling, the aggressive BCCs are infiltrative, desmoplastic tumours with low bcl-2 labeling. In mixed tumours, heterogeneity of labeling is a distinctive feature and is contributed to in part by the labeling trends of the different histological subtypes. The micronodular BCC shows varied bcl-2 labeling but in combined tumours occupies a niche intermediate between the non-aggressive nodular and superficial and the aggressive infiltrative subtypes. The initial and subsequent biopsies of recurrent, adequately excised BCCs share a pure or mixed, predominantly infiltrative, stroma-rich histomorphology with low bcl-2 labeling, reflecting the immunoprofile of a more aggressive growth pattern.

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Some children with craniosynostosis demonstrate raised intracranial pressure (ICP), requiring surgical decompression. Conventional methods of measuring ICP in such children are invasive, expensive, and require expertise. Transcranial Doppler ultrasonography (TCD) is an alternative, useful means of assessing ICP qualitatively, and is noninvasive, inexpensive, and safe. We evaluated the use of TCD prospectively in 16 children with craniosynostosis and correlated TCD findings with intraoperative ICP measurements by lumbar puncture (LP) and with computed tomographic (CT) findings. TCD evaluations were performed before and after surgery to determine the pulsatility index (PI), which is known to show close correlation with ICP. The three modalities--TCD, ICP, and CT--showed poor correlation with each other. However, the fall in the PI value after surgery, as determined by TCD, was shown to be clinically useful, with a rise in the PI value after surgery being an ominous sign.

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Although folliculosebaceous cystic hamartoma (FCH) is an uncommon cutaneous entity with distinct classical and variant histopathologic features, it lacks distinctive typifying clinical features. Since the original description of five cases of FCH by Kimura et al. in 1991, 12 cases have been documented. We report a further case of FCH presenting as facial lesion in a 35 year old African male. FCH comprises prominent epithelial and mesenchymal components. The epithelial component is characterised by folliculosebaceous proliferation with cyst-like infundibular dilatation, and the mesenchymal component exhibits variable fibroplasia, vascular and neural proliferation and adipocyte metaplasia. Awareness of the lesion is important to avoid confusion with other cystic or cyst-like cutaneous lesions that contain prominent epithelial folliculosebaceous and variable mesenchymal components.

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Chronic hematic cysts are rare conditions that usually present to the ophthalmic surgeons with displacement of the globe. There is usually no, or minimal, bone involvement. Two patients with unusual presentations of chronic orbital hematic cysts are reported. These cysts resulted in significant expansion and erosion of the bony orbits. The presentation, operative findings, and reconstruction are reported and discussed.

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Membranous fat necrosis (MFN) is an under-recognized variant of fat necrosis (FN) that is characterized by the presence of membranocystic foci in which cysts are lined by an eosinophilic, homogeneous membrane with pseudo-papillary luminal projections. Although MFN has been described in systemic adipose tissue, it has not been described in lipomas. We report the rare occurrence of MFN in four lipomas. The lipomas ranged in size between 9 and 22 cm and occurred in menopausal women in the left shoulder, right upper back, right thigh, and gluteal regions. In two cases the membranocystic foci were identified macroscopically, whereas in the other two cases MFN was only identified on histologic assessment. Apart from the typical histologic appearance of the membranocystic foci, the membranes have a distinct histochemical profile that includes consistent Sudan black positivity and either periodic acid-Schiff or Ziehl-Neelsen positivity. In all cases, there was autofluorescence of the membranes on immunofluorescent examination of unstained sections. These membranocystic foci have the typical staining reactions of ceroid pigment. The exact cause of MFN in lipomas is not known, but in view of their large sizes, traumatic and ischemic etiologies are proposed.

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Congenital pigmented naevi are lesions that are usually confined to skin. We report a giant congenital naevus of the scalp which involved skin, galea, full thickness cranial bone, dura and the intracranial venous sinuses. The literature on giant congenital naevi with direct involvement of underlying bone is reviewed.

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A 60-year-old patient presented with a mycetoma of the scalp with multiple chronic sinuses due to nocardiosis of the scalp. Recurrent bleeding from the sinuses necessitated surgical excision which led to a gratifying result. The case illustrates the importance of fungal culture in the diagnosis of cutaneous lesions and emphasises the role of surgery in mycetoma that are resistant to conventional therapy.

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The traditional radial forearm flap derives its blood supply from perforators of the radial artery. This report describes an anatomic anomaly in which the flap was supplied solely by perforators of the ulnar artery. Knowledge of this previously undescribed variation might have relevance when a radial forearm flap is raised.

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