Heads up reconstructive microsurgery: Utilisation of the three-dimensional microscope in microvascular procedures.

BACKGROUND: Since the earliest use of microscopes in surgery, several modifications have been made to improve the ergonomics of movement and posture, increase the resolution, and expand the visual field. The three-dimensional microscopes are latest innovation in this field. Despite the wider use of 3D microscopes in other specialities, their use in the reconstructive microsurgery in the United Kingdom is still limited. Reconstructive microsurgeons are highly skilled surgeons that are trained to operate utilising the microscope for long hours. This poses an occupational risk with a specific pattern of work-related conditions. AIMS AND METHODS: We aim in this report to demonstrate our experience utilising 3D microscopes in small cohort of patients matched to a control of patients operated utilising the traditional microscopes. Patients were matched by age, comorbidities, oncologic procedures. This was complemented by a survey completed by the operating surgeons. RESULTS: Nine patients were included in each group. There was no significant difference in operative or ischemia time and no significant post-operative complications in both groups. The surgeons reported better ergonomics, improved staff engagement, and a better teaching experience when utilising the 3D microscopes compared to traditional microscopes. CONCLUSION: The utilisation of the 3D microscopes in reconstructive microsurgery has shown to provide comfort, improve ergonomics of movement and posture without significant clinical implications in this series.

Publication rates from BAPRAS meetings: where are we now?

In the UK the BAPRAS (British Association of Plastic, Reconstructive and Aesthetic Surgeons) meetings have always represented the ideal platform for disseminating new information in the field of plastic surgery. Previous studies have suggested the publication rate for these meetings has been falling. Our aim was to re-assess the conversion rates of presented abstracts to publications. All abstracts from BAPRAS meetings between Winter 2014 and Summer 2016 were included. PubMed and Google Scholar databases were used to search for full publications. A database was collated, this included; time to publication, journal of publication and impact factor of journal. A total of 500 abstracts were presented during the study period for which the publication rate was 28.4%. The average time to publication was 16.8 months. The most common publication journal was the Journal of Plastic, Reconstructive and Aesthetic Surgery (JPRAS) (34%). Free papers were published in journals with significantly greater impact factors (p = 0.046). Publication rates were similar to previous literature for BAPRAS meetings and have increased since 2007. A continued downward trend of publication rates for BAPRAS meetings is not seen in our data. A reduction in the number of publications in JPRAS may be explained by a rise in the impact factor of the journal or increasing competitiveness for publications. When variations in methodology are accounted for publication rates are similar to other specialties. In order to continually assess the quality of papers presented at BAPRAS meetings, the conversion to publication should be regularly re-audited.

National trends in immediate and delayed post-mastectomy reconstruction procedures in England: A seven-year population-based cohort study.

INTRODUCTION: Little is known about post-mastectomy reconstruction procedural trends in women diagnosed with breast cancer in England. Our aim was to examine patterns of immediate and delayed reconstruction procedures over time and within regions. METHODS: Women with breast cancer who underwent unilateral index immediate or delayed post-mastectomy reconstruction between 2007 and 2014 were identified using the National Hospital Episode Statistics database. Women were grouped into categories based on the type of reconstruction procedure. Adjusted rates of implant and free flap reconstructions were then calculated across regional Cancer Networks using a regression model to adjust for age, disease, comorbidities, ethnicity, and deprivation. RESULTS: Between 2007 and 2014, 21 862 women underwent immediate reconstruction and 8653 delayed reconstruction. Immediate implant reconstruction increased from 30% to 54%, and immediate free flap reconstruction from 17% to 21%. Adjusted immediate implant and free flap proportions ranged from 17 to 68% and 9-63%, respectively, across regions. Free flaps became more common in the delayed setting, rising from 25% to 42%. However, adjusted rates ranged from 23% to 74% across regions. Networks with high/low rates of free flaps for immediate tended to have high/low rates for delayed reconstruction. CONCLUSION: There has been a substantial increase in the use of immediate implant reconstruction in England. In comparison, there has been an increasing use of autologous free flap reconstruction for delayed procedures. Significant regional variation exists in the type of reconstruction performed, and these patterns need to be examined to determine if variation is related to service provision and/or capacity barriers.

National trends and regional variation in immediate breast reconstruction rates.

BACKGROUND: Previous studies have identified variation in immediate reconstruction (IR) rates following mastectomy for breast cancer across English regions during a period of service reorganization, a national audit and changing guidelines. This study analysed current variations in regional rates of IR in England. METHODS: Patient-level data from Hospital Episode Statistics were used to define a cohort of women who underwent primary mastectomy for invasive or in situ breast carcinoma in English National Health Service (NHS) hospitals between April 2000 and March 2014. A time series of IR rates was calculated nationally and within regions in 28 cancer networks. Regional IR rates before and after the national audit were compared, using logistic regression to adjust for patient demographics, tumour type, co-morbidity and year of mastectomy. RESULTS: Between 2000 and 2014, a total of 167 343 women had a mastectomy. The national IR rate was stable at around 10 per cent until 2005; it then increased to 23·3 per cent by 2013-2014. Preaudit (before January 2008), adjusted cancer network-level IR rates ranged from 4·3 to 22·6 per cent. Postaudit (after April 2009) adjusted IR rates ranged from 13·1 to 36·7 per cent, with 20 networks having IR rates between 15 and 24 per cent. The degree of change was not greatest amongst those that started with the lowest IR rates, with four networks with the largest absolute increase also starting with relatively high IR rates. CONCLUSION: The national IR rate increased throughout the study period. Substantial regional variation remains, although considerable time has elapsed since a period of service reorganization, guideline revision and a national audit.

Perineal reconstruction after abdominoperineal excision using inferior gluteal artery perforator flaps.

BACKGROUND: Perineal wound complications following abdominoperineal excision (APE) for low rectal tumours remain an important cause of morbidity and prolonged hospital stay, particularly after chemoradiotherapy. The aim was to assess outcomes after using inferior gluteal artery perforator (IGAP) flaps for immediate perineal reconstruction, and to compare these with the authors' previous experience and published literature on myocutaneous flaps. METHODS: A series of patients who underwent immediate IGAP flap reconstruction after APE between April 2008 and December 2010 were examined retrospectively to determine patient demographics, length of operation, complications (perineal wound and general) and length of hospital stay. RESULTS: Forty patients with rectal adenocarcinoma (33 primary and 7 recurrent disease) underwent immediate IGAP flap reconstruction following APE. Median follow-up was 9 months. Neoadjuvant chemoradiotherapy was received by 98 per cent of the patients. Thirty-two patients underwent APE plus IGAP flaps (25 open, 7 laparoscopic), with a median operating time of 402 min, and eight patients had multivisceral resection (MVR) plus IGAP flaps (7 total pelvic exenteration (TPE), 1 abdominosacral resection), with a median duration of surgery of 561 min. There was one death (fatal stroke) and four major flap complications (10 per cent) (1 enteroperineal fistula, and 3 deep wound infections). Median length of hospital stay was 13 days after APE plus IGAP flaps and 27 days following MVR plus IGAP flaps. Late complications occurred in two patients who had vaginal reconstruction and developed perineal hernias requiring revisional surgery. CONCLUSION: Although operating times are long, the IGAP flap is robust, with no flap necrosis observed in this series.

Thermal injuries to autologous breast reconstructions and their donor sites--literature review and report of six cases.

Breast reconstruction using autologous techniques has now become the gold standard. In recent years the focus has been on maintaining excellent cosmesis whilst minimising the incidence of partial or complete flap loss and donor site morbidity. However, an area which is frequently overlooked is the sequelae resulting from denervation of these flaps and their donor sites which can potentially lead to thermal injury. We report on six patients who sustained burns following free autologous breast reconstruction using either a DIEP or a muscle sparing TRAM. Four of the burns were confined to the flap skin paddle and two to the abdominal donor site. To prevent such thermal injuries all patients undergoing flap reconstruction should be educated regarding the vulnerability of the flap and its donor site as well as means of protecting these susceptible areas during daily activities.

A composite poly-hydroxybutyrate-glial growth factor conduit for long nerve gap repairs.

There is considerable evidence that peripheral nerves have the potential to regenerate in an appropriate microenvironment. We have developed a novel artificial nerve guide composed of poly 3-hydroxybutyrate (PHB) filled with glial growth factor (GGF) suspended in alginate hydrogel. Gaps of 2-4 cm in rabbit common peroneal nerve were bridged using a PHB conduit containing either GGF in alginate hydrogel (GGF) or alginate alone (Alginate), or with an empty PHB conduit (Empty). Tissues were harvested 21, 42 and 63 days post-operatively. Schwann cell and axonal regeneration were assessed using quantitative immunohistochemistry. At 21 days, addition of GGF increased significantly the distance of axonal and Schwann cells regeneration in comparison with that observed in Alginate and Empty conduits for both gap lengths. The axons bridged the 2-cm GGF conduits gap by 63 days, with a comparable rate of regeneration seen in 4-cm conduits. Schwann cells and axonal regeneration quantity was similar for both gap lengths in each group. However, at all time points the quantity of axonal and Schwann cells regeneration in GGF grafts was significantly greater than in both Alginate and Empty conduits, the latter showing better regeneration than Alginate conduits. The results indicate an inhibitory effect of alginate on regeneration, which is partially reversed by the addition of GGF to the conduits. In conclusion, GGF stimulates a progressive and sustainable regeneration increase in long nerve gap conduits.

Subungual pilonidal sinus of the hand in a dog groomer.

Interdigital pilonidal sinus of the hand is an occupational hazard in barbers, sheep shearers and cow milkers. We present a case of a subungual pilonidal sinus of the thumb of a dog groomer, complicated by the development of osteomyelitis in the distal phalanx.

Turret exostosis of the thumb.

Eighteen cases of turret exostoses of the hand have been reported, all associated with dorsal injuries. We present a case of turret exostosis involving the volar aspect of the thumb.

Acute compartment syndrome following non-contact football injury.

Acute compartment syndrome in athletes, although rare, is a limb threatening condition which warrants emergency treatment. The case of a footballer with acute compartment syndrome of the left lower leg, without any preceding direct trauma to the calf, is reported. To our knowledge this is the only description of acute atraumatic compartment syndrome secondary to rupture of one of the heads of gastrocnemius.