Are Surgical Drains Needed in DIEP Flap Surgery? The Drain-Free DIEP Flap Concept.

BACKGROUND: Studies support an inherent morbidity associated with the use of surgical drains-such as postoperative pain, infection, reduction in mobility, and delay in patient discharge-and they do not prevent seroma or hematoma. The authors' series aims to evaluate the feasibility, benefits, and safety of performing drainless deep inferior epigastric perforator (DIEP) flap surgery and to formulate an algorithm for when this can be used. METHODS: A retrospective review of DIEP reconstruction outcomes of two surgeons was performed. Over the course of 24 months, consecutive DIEP flap patients were included from the Royal Marsden Hospital in London and Austin Hospital in Melbourne, and drain use, drain output, length of stay (LOS), and complications were analyzed. RESULTS: A total of 107 DIEP flap reconstructions were performed by two surgeons. Thirty-five patients had abdominal drainless DIEP flaps, and 12 patients had totally drainless DIEP flaps. Mean age was 52 years (range, 34 to 73 years) and mean body mass index was 26.8 kg/m 2 (range, 19.0 to 41.3 kg/m 2 ). Abdominal drainless patients showed a potential trend toward shorter hospital stays as compared with the ones with drains (mean LOS, 3.74 days versus 4.05 days; P = 0.154). Totally drainless patients had an even shorter, statistically significant, mean LOS of 3.10 days, as compared with patients with drains (4.05 days, P = 0.002), with no increase in complications. CONCLUSIONS: The avoidance of abdominal drains in DIEP flaps reduces hospital stay without increasing complications, and this has become our standard practice for patients with a body mass index of less than 30 kg/m 2 . It is our opinion that the totally drainless DIEP flap procedure is safe in selected patients. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Cross Facial Nerve Grafting for Smile Restoration: Thoughts on Improving Graft Inset.

Cross facial nerve grafts (CFNGs) are one of the most ubiquitous and time-honored surgical tools used in facial reanimation. They may be used for targeting different mimetic muscles in the subacute setting as well as to innervate newly placed muscle flaps in varied facial subunits. In our experience, when used specifically for smile reanimation in two-stage strategies with either traditional "babysitting" approaches in nerve transfers or free functional muscle transfers, the second stage may present some challenges in CFNG identification as well as injury to the previously banked nerve graft. We present some technical modifications in the first-stage CFNG inset that can make the second stage easier and safer. These modifications include: (1) marking the course of the nerve graft with surgical metal clips and inserting loose circumferential sutures throughout the distal course of the nerve in the recipient area to avoid displacement; (2) transferring the nerve graft through the nasal sills rather than lips, protecting it from damage during insertion of free functional muscle transfer; and (3) routing the nerve from the lateral nose to the preauricular area over the zygomatic arch, allowing easier dissection and banking of adequate graft length to provide tension-free coaptation with the flexibility of nerve coaptation in variable positions.

The Role of Simulation in Microsurgical Training.

Simulation has been established as an integral part of microsurgical training. The aim of this study was to assess and categorize the various simulation models in relation to the complexity of the microsurgical skill being taught and analyze the assessment methods commonly employed in microsurgical simulation training. Numerous courses have been established using simulation models. These models can be categorized, according to the level of complexity of the skill being taught, into basic, intermediate, and advanced. Microsurgical simulation training should be assessed using validated assessment methods. Assessment methods vary significantly from subjective expert opinions to self-assessment questionnaires and validated global rating scales. The appropriate assessment method should carefully be chosen based on the simulation modality. Simulation models should be validated, and a model with appropriate fidelity should be chosen according to the microsurgical skill being taught. Assessment should move from traditional simple subjective evaluations of trainee performance to validated tools. Future studies should assess the transferability of skills gained during simulation training to the real-life setting.

Improving Fellowship Training in Microsurgery: A Threshold Concepts Perspective on the Curricula of Fellowship Programs.

BACKGROUND: The theory of "threshold concepts" argues that within every discipline there is knowledge that transforms understanding and leads to a previously inaccessible way of thinking, without which the learner cannot progress. This study investigates the factors influencing the development of the characteristic ways of thinking and practicing as a microsurgeon during a microsurgical fellowship. We analyze the challenges in the development of these characteristics during focused fellowship training in microsurgery, of which some could potentially represent "threshold concepts." METHODS: A qualitative research methodology was followed. Semistructured interviews with trainers and trainees from microsurgical units in the United Kingdom (UK) and the United States (US) were conducted. Data were analyzed using the Dedoose (Manhattan Beach, CA) qualitative data analysis software and interpreted using the theory of "threshold concepts." RESULTS: Five trainees and four trainers from the UK and the US participated in this research project. Although initially some trainees had particular difficulty in developing their practical microsurgical skills, this improved rapidly with adequate practice. Cognitive skills and especially the ability to expect the unexpected and the ability recognize complications presented as a significant challenge for trainees and transformed their understandings regarding the qualities of a microsurgeon. CONCLUSIONS: Microsurgical fellowship curricula can be redesigned using the theory of threshold concepts, creating a dynamic framework that addresses individual trainee needs to develop the practical and cognitive skills necessary for independent practice of microsurgery.

The simple transverse intraosseous phalangeal suture for zone 1 flexor digitorum profundus injuries: case series and review of the literature.

BACKGROUND: Zone 1 flexor digitorum profundus injury often precludes the use of a simple core suture as a result of a distal remnant that is too short. The aim of this study was to assess the senior author's (S.I.) simple technique for reinsertion of the flexor digitorum profundus tendon. METHODS: The case series consisted of 12 patients who required a primary flexor digitorum profundus repair in zone 1, with all repairs performed by the senior author. A Bruner incision was extended to the pulp to expose the base of the distal phalanx. A two-strand repair was anchored to the distal phalanx using the author's technique, which involved passing a 3-0 polypropylene suture on a straight needle through a hypodermic needle that had been drilled through the base of the distal phalanx. This provided a stable, intraosseous, internal repair, allowing a standard early active mobilization regimen. RESULTS: Two patients had excellent results and 10 had good results in terms of distal interphalangeal joint range of movement (mean, 57 degrees; range, 51 to 80 degrees) and Quick Disabilities of the Arm, Shoulder and Hand questionnaire scores (mean, 12; range, 0 to 31.8). There were no reported tendon ruptures at the time of writing this article (range, 6 to 37 months after surgery). CONCLUSIONS: The authors present a technique for the repair of zone 1 flexor digitorum profundus injuries that is simple, can be performed quickly, is easily learned, and has results that compare favorably with other techniques in the literature. Furthermore, there is limited morbidity to surrounding fingertip structures. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Assessment methods in surgical training in the United Kingdom.

A career in surgery in the United Kingdom demands a commitment to a long journey of assessment. The assessment methods used must ensure that the appropriate candidates are selected into a programme of study or a job and must guarantee public safety by regulating the progression of surgical trainees and the certification of trained surgeons. This review attempts to analyse the psychometric properties of various assessment methods used in the selection of candidates to medical school, job selection, progression in training, and certification. Validity is an indicator of how well an assessment measures what it is designed to measure. Reliability informs us whether a test is consistent in its outcome by measuring the reproducibility and discriminating ability of the test. In the long journey of assessment in surgical training, the same assessment formats are frequently being used for selection into a programme of study, job selection, progression, and certification. Although similar assessment methods are being used for different purposes in surgical training, the psychometric properties of these assessment methods have not been examined separately for each purpose. Because of the significance of these assessments for trainees and patients, their reliability and validity should be examined thoroughly in every context where the assessment method is being used.

Simulation-based surgical education.

The reduction in time for training at the workplace has created a challenge for the traditional apprenticeship model of training. Simulation offers the opportunity for repeated practice in a safe and controlled environment, focusing on trainees and tailored to their needs. Recent technological advances have led to the development of various simulators, which have already been introduced in surgical training. The complexity and fidelity of the available simulators vary, therefore depending on our recourses we should select the appropriate simulator for the task or skill we want to teach. Educational theory informs us about the importance of context in professional learning. Simulation should therefore recreate the clinical environment and its complexity. Contemporary approaches to simulation have introduced novel ideas for teaching teamwork, communication skills and professionalism. In order for simulation-based training to be successful, simulators have to be validated appropriately and integrated in a training curriculum. Within a surgical curriculum, trainees should have protected time for simulation-based training, under appropriate supervision. Simulation-based surgical education should allow the appropriate practice of technical skills without ignoring the clinical context and must strike an adequate balance between the simulation environment and simulators.

An elderly patient presenting with hip pain following a fall: an unusual presentation of necrotising fasciitis.

Necrotising fasciitis (NF) is a rapidly progressive soft tissue infection involving necrosis of subcutaneous tissues. Early surgical intervention reduces mortality, but initial clinical findings are often non-specific and can delay the diagnosis. An 80-year-old patient, presented to our emergency department with pain in her left hip and mild bruising following a fall. An x-ray, requested to investigate a possible hip fracture, in fact demonstrated air in the subcutaneous tissues. She rapidly deteriorated and soon developed blood-filled blisters, crepitus and fixed staining of the skin. She underwent urgent debridement of involved tissues in theatre confirming the diagnosis of NF. The presence of subcutaneous emphysema on plain radiograph as in this case, is extremely specific to the diagnosis of NF. Although other imaging modalities can aid diagnosis these remain as an adjunct rather than a definitive diagnostic tool and should not delay surgical intervention based on clinical findings.

Necrotising fasciitis of the thumb.

Necrotising fasciitis is a rare condition that should be diagnosed early and managed aggressively in order to avoid death. We present a case of necrotising fasciitis of the thumb and discuss the assessment and management of this serious condition. A 44-year-old woman presented with a painful and erythematous right thumb and progressive swelling of her hand following a minor injury to the tip of her thumb 3 days previously. A diagnosis of necrotising fasciitis was made and the patient underwent urgent debridement of non-viable tissue. She required 1 week of supportive therapy in intensive treatment unit and was discharged from hospital after 3 weeks. Necrotising fasciitis is a rapidly progressing life-threatening infection, usually caused by streptococcal organisms. Immediate resuscitation, broad-spectrum intravenous antibiotics and early surgical debridement are necessary in order to avoid significant morbidity and mortality.

Pyogenic flexor tenosynovitis leading to an amputation.

Flexor tenosynovitis is an aggressive closed-space infection of the digital flexor tendon sheaths of the hand. We present a case of pyogenic flexor tenosynovitis in an immunocompromised patient and discuss the importance of early diagnosis and referral to a specialist hand surgery unit. A 61-year-old man visited his general practitioner because of swelling and tenderness of his left index finger. The patient was discharged on oral antibiotics but returned 4 days after because of deterioration of his symptoms and was referred to a plastic surgery unit. A diagnosis of flexor tenosynovitis was made and the patient required multiple debridements in theatre, resulting in the amputation of the infected finger. Pyogenic flexor tenosynovitis is a relatively common but often misdiagnosed hand infection. Patients with suspected flexor tenosynovitis should be referred and treated early to avoid significant morbidity, especially when risk factors for poor prognosis are present.

The theoretical base of e-learning and its role in surgical education.

INTRODUCTION: The advances in Internet and computer technology offer many solutions that can enhance surgical education and increase the effectiveness of surgical teaching. E-learning plays an important role in surgical education today, with many e-learning projects already available on the Internet. EDUCATIONAL THEORY: E-learning is based on a mixture of educational theories that derive from behaviorist, cognitivist, and constructivist educational theoretical frameworks. CAN EDUCATIONAL THEORY IMPROVE E-LEARNING?: Conventional educational theory can be applied to improve the quality and effectiveness of e-learning. The theory of "threshold concepts" and educational theories on reflection, motivation, and communities of practice can be applied when designing e-learning material. E-LEARNING IN SURGICAL EDUCATION: E-learning has many advantages but also has weaknesses. Studies have shown that e-learning is an effective teaching method that offers high levels of learner satisfaction. Instead of trying to compare e-learning with traditional methods of teaching, it is better to integrate in e-learning elements of traditional teaching that have been proven to be effective. CONCLUSIONS: E-learning can play an important role in surgical education as a blended approach, combined with more traditional methods of teaching, which offer better face-to-interaction with patients and colleagues in different circumstances and hands on practice of practical skills. National provision of e-learning can make evaluation easier. The correct utilization of Internet and computer resources combined with the application of valid conventional educational theory to design e-learning relevant to the various levels of surgical training can be effective in the training of future surgeons.

Renal cell carcinoma metastasis to the paranasal sinuses and orbit.

The authors report a rare case of renal cell carcinoma (RCC) metastasis to the paranasal sinuses. The authors review RCC and its potential for sinonasal metastasis and discuss the variable presentation and need for clinical suspicion for early diagnosis and treatment. A 74-year-old man presented with numbness of the left side of the face, reduced visual acuity and ptosis 12 years after nephrectomy for RCC. Imaging studies showed a lesion in the left pterygopalatine fossa and the histological features supported the diagnosis of metastatic RCC. RCC metastasis to the paranasal sinuses is very rare and can present with various symptoms depending on the affected organ. These symptoms occasionally are the initial manifestation of renal RCC and it is very important to recognise them so that the patient receives the appropriate therapy to improve survival.

Reverse digital artery flap from radial and ulnar borders of palm.

Reconstructing skin defects of the volar aspect of fingers can be a challenging task due to a lack of local expendable tissue. The reverse digital artery flap is a versatile and reliable technique that can be used to manage such disabling injuries. Various authors have used this flap effectively, but most have used the digit itself as the donor site. This limits the size of the flap and also necessitates skin grafting to cover the donor site. Large reverse digital artery flaps can be raised from the radial and ulnar borders of the palm facilitating coverage of significant digital defects and primary closure of the donor site, resulting in minimal donor-site morbidity. We describe 3 illustrative cases to highlight the flaps versatility.

Vanadium(V) compounds with the bis-(hydroxylamino)-1,3,5-triazine ligand, H2bihyat: synthetic, structural, and physical studies of [V2(V)O3(bihyat)2] and of the enhanced hydrolytic stability species cis-[V(V)O2(bihyat)]-.

Reaction of the ligand 2,6-bis[hydroxy(methyl)amino]-4-morpholino-1,3,5-triazine (H(2)bihyat) with NaV(V)O(3) in aqueous solution followed by addition of either Ph(4)PCl or C(NH(2))(3)Cl, respectively, gave the mononuclear vanadium(V) compounds Ph(4)P[V(V)O(2)(bihyat)].1.5H(2)O (1) and C(NH(2))(3)[V(V)O(2)(bihyat)] (2). Treatment of V(IV)OSO(4).5H(2)O with the ligand H(2)bihyat in methyl alcohol under specific conditions gave the oxo-bridged dimer [V(V)(2)O(2)(mu(2)-O)(bihyat)(2)] (3). The structures for 1 and 3 were determined by X-ray crystallography and indicate that these compounds have distorted square-pyramidal arrangement around vanadium. The ligand bihyat(2-) is bonded to vanadium atom in a tridentate fashion at the pyridine-like nitrogen atom and the two deprotonated hydroxylamino oxygen atoms. The high electron density of the triazine ring nitrogen atoms, which results from the resonative contribution of electrons of exocyclic nitrogen atoms (Scheme 4 ), leads to very strong V-N bonds. The cis-[V(V)O(2)(bihyat)](-) species exhibits high hydrolytic stability in aqueous solution over a wide pH range, 3.3-11.0, as it was evidenced by (1)H and (51)V NMR spectroscopy and potentiometry. The high affinity of the H(2)bihyat ligand for the V(V)O(2)(+) unit, its tridentate character, as well as its small size, paves the way for potential applications in medicine, analysis, and catalysis for the C(NH(2))(3)[V(V)O(2)(bihyat)] compound. The molecular structures, vibrational and electronic spectra, and the energetics of the metal-ligand interaction for compounds 1 and 3 have been studied by means of density functional calculations.

NMR investigation of the interaction of vanadate with carbasilatranes in aqueous solutions.

Reaction of vanadate with carbasilatranes [methoxy{N,N',N' '-2,2',3-[bis(1-methylethanolato)(propyl)]amino}silane (1), methoxy{N,N',N' '-2,2',3-[bis(1-ethanolethanolato)(propyl)]amino}silane (2), and {N,N',N' '-2,2',2-[bis(ethanolato)(glycolpropyl ether)]amino}silane (3)] in aqueous solution results in the formation of vanadosilicates and five-coordinated chelate vanadium(V) complexes as evidenced by 51V, 1H, and 13C NMR spectroscopy. Chiral carbasilatrane S,S-1 was characterized in the solid state by X-ray diffraction, revealing a trigonal bipyramidal geometry around the metal ion, with one unidentate methoxy group and one atrane nitrogen atom at the axial positions and one carbon and two atrane oxygen atoms at the equatorial plane of the bipyramid. Crystal data (Mo Kalpha; 100(2) K) are as follows: orthorhombic space group P2(1)2(1)2(1); a = 8.8751(6), b = 9.7031(7), c = 14.2263(12) A; Z = 4. The complexation of vanadium either with 1 or 2 is stereoselective yielding approximately 94% of the complex containing ligand in the S,R-configuration. The lower ability of the S,S- and R,R-diastereoisomers of 1 and 2 to ligate vanadate was attributed to stereochemical factors, dictating a square pyramidal geometry for the chelated complexes. A dynamic process between the vanadium chelate complexes and the respective carbasilatranes was evaluated by 2D {1H} EXSY NMR spectroscopy. These spectra show that the vanadate complexes with the open carbasilatranes exchange more slowly with the free ligand compared to the respective alcohol aminate complexes.