Topical negative pressure has been demonstrated to improve graft take in a number of noncomparative studies. This study aimed to assess whether split-thickness skin graft take is improved qualitatively or quantitatively with topical negative pressure therapy compared with standard bolster dressings. A blinded, prospective, randomized trial was conducted of 22 adult inpatients of Liverpool Hospital between July of 2001 and July of 2002 who had wounds requiring skin grafting. After grafting, each wound half was randomized to receive either a standard bolster dressing or a topical negative pressure dressing. Skin graft assessment was performed at 2 weeks by a single observer blinded to the randomization. Two patients were lost to follow-up and were excluded from the study. There were 20 patients (12 men and eightwomen) in the study group. The median patient age was 64 years (range, 27 to 88 years), and the mean wound size was 128 cm2 (range, 35 to 450 cm2). The wound exposed subcutaneous fat in eight patients, muscle in six patients, paratenon in four patients, and deep fascia in two patients. At 2 weeks, wounds that received a topical negative pressure dressing had a greater degree of epithelialization in six cases (30 percent), the same degree of epithelialization in nine cases (45 percent), and less epithelialization in five cases (25 percent) compared with their respective control wounds. Graft quality following topical negative pressure therapy was subjectively determined to be better in 10 cases (50 percent), equivalent in seven cases (35 percent), and worse in three cases (15 percent). Although the quantitative graft take was not significant, the qualitative graft take was found to be significantly better with the use of topical negative pressure therapy (p < 0.05). Topical negative pressure significantly improved the qualitative appearance of split-thickness skin grafts as compared with standard bolster dressings.

Primary squamous cell carcinoma (SCC) of the breast is a rare condition that has been reported in the literature for over 70 years. We present a series of five cases and discuss management of this condition. METHODSFive (5) primary squamous cell cancers of the breast were identified from the Strathfield Breast Centre database which has prospectively recorded 1658 breast cancers for the period 1989-1999. These records were reviewed, the criteria for inclusion as primary squamous cell cancers were verified and the histopathology was reviewed. CASE REPORTS Case 1A 69-year-old woman presented with a large fungating mass, filling the lateral half of her right breast and a large clinically involved right axillary lymph node. She also presented with mid-thoracic back pain. Computed tomography (CT) scans confirmed the large soft tissue mass in the right axilla but also revealed a right-sided pleural effusion and extensive vertebral body destruction. Bone scans confirmed widespread metastatic carcinoma, and a core biopsy of the breast confirmed squamous cell carcinoma. The patient died of her distant metastatic disease while receiving palliative radiotherapy. Case 2A 71-year-old woman presented with a large cystic mass in her left breast. Aspiration of the cyst resulted in resolution of the mass, and cytological evaluation revealed occasional large degenerate atypical and vacuolated cells of uncertain significance together with macrophages and inflammatory cells. The mass recurred twice over the ensuing 2 months and was subsequently excised. Histopathology showed a cystic mass containing a poorly differentiated squamous carcinoma. The patient proceeded to the completion of mastectomy and in-continuity axillary dissection. Of the 25 axillary nodes examined, none contained metastatic disease. The patient remains alive and disease-free four years postoperatively. Case 3A 50-year-old woman presented with a fungating right breast mass. The mass was fixed to the chest wall but investigations revealed no evidence of metastatic disease. Fine needle cytology and subsequent core biopsy revealed squamous cell carcinoma. She was treated initially with chemotherapy (5-fluorouracil and cisplatinum) followed by radiotherapy. She did not complete therapy due to poor compliance, and when she presented several months later she was noted to have a mass measuring 8 cm in diameter, fixed to the chest wall and clinically involving axillary nodes. Investigations again failed to demonstrate any evidence of spread outside the axilla and after extensive discussions a Halsted radical mastectomy was carried out together with excision of part of the chest wall, removing the third to sixth ribs. A Goretex graft repair of the chest wall and a latissimus dorsi rotation flap with split skin graft were required for reconstruction. Local excision of the tumour was deemed histologically clear from both the chest wall and axilla with only one of the 16 lymph nodes examined containing metastatic SCC. Despite this treatment though, the chest wall tumour recurr...

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Surgeons should be aware of the reconstructive options available in such circumstances, and should choose appropriate management depending on the clinical situation, in order to optimise the functional result for the patient.

Background: Between 1993 and 1995, 315 anti-reflux procedures were undertaken on our service. A previous antireflux procedure had been performed in 31 patients referred (10%). Previous surgery was, in the main (go%), a Nissen fundoplication. Methods: Re-operative investigations in all patients were manometry, 24 h pH monitoring, oesophagoscopy and barium radiology. On this basis the causes of failure of the previous surgery were established as hiatal failure in 20 (65%), unrecognized oesophageal dysmotility in three ( 10%) and fundoplication failure (slipped and disrupted) in eight (25%). Contrary to standard recommendations for re-operation most re-operative surgery was performed transabdominally (94%). Complications occurred in 16%. Results: Review was undertaken at a mean of 21 months following surgery, and 91% of patients reported a good to excellent symptomatic outcome. Conclusions: Transabdominal re-operative anti-reflux surgery has an acceptable complication rate and a surprisingly good symptomatic outcome in the medium term.