Androgens trigger different growth responses in genetically identical human hair follicles in organ culture that reflect their epigenetic diversity in life.

Male sex hormones-androgens-regulate male physique development. Without androgen signaling, genetic males appear female. During puberty, increasing androgens harness the hair follicle's unique regenerative ability to replace many tiny vellus hairs with larger, darker terminal hairs ( e.g., beard). Follicle response is epigenetically varied: some remain unaffected ( e.g., eyelashes) or are inhibited, causing balding. How sex steroid hormones alter such developmental processes is unclear, despite high incidences of hormone-driven cancer, hirsutism, and alopecia. Unfortunately, existing development models are not androgen sensitive. Here, we use hair follicles to establish an androgen-responsive human organ culture model. We show that women's intermediate facial follicles respond to men's higher androgen levels by synthesizing more hair over several days, unlike donor-matched, androgen-insensitive, terminal follicles. We demonstrate that androgen receptors-androgen-activated gene transcription regulators-are required and are present in vivo within these follicles. This is the first human organ that involves multiple cell types that responds appropriately to hormones in prolonged culture, in a way which mirrors its natural behavior. Thus, intermediate hair follicles offer a hormone-switchable human model with exceptional, unique availability of genetically identical, but epigenetically hormone-insensitive, terminal follicles. This should enable advances in understanding sex steroid hormone signaling, gene regulation, and developmental and regenerative systems and facilitate better therapies for hormone-dependent disorders.-Miranda, B. H., Charlesworth, M. R., Tobin, D. J., Sharpe, D. T., Randall, V. A. Androgens trigger different growth responses in genetically identical human hair follicles in organ culture that reflect their epigenetic diversity in life.

Perioperative Blood Loss and Transfusion in Craniosynostosis Surgery.

Craniosynostosis has an incidence of 1 in 2000 to 2500 live births and may be corrected through several methods including total calvarial remodeling and frontal orbital advancement remodeling. Blood loss during craniosynostosis surgery can be substantial, ranging from 20% to 500% of total circulating volume with a high associated risk of transfusion-related adverse events. The authors performed a retrospective analysis of all patients undergoing surgery for craniosynostosis at a tertiary pediatric craniofacial center with a focus on blood loss and subsequent transfusion.The authors reviewed 40 patients with craniosynostosis >16 years at a single-center. Data on perioperative blood loss and transfusion were obtained, including pre-, intra-, and postoperative hemoglobin, hematocrit, and use of tranexamic acid. The authors calculated estimated percentage of circulating red cell volume lost and transfused.The majority of patients had sagittal synostosis and underwent total calvarial remodeling (n = 20); the rest underwent frontal orbital advancement remodeling (n = 19) or lambdoid correction (n = 1). The average estimated volume red cell loss was 77% of circulating volume and 90% of patients received blood transfusion with an average 88.3% transfusion of circulating red cell volume. Longer operative time, younger age, and lower weight predisposed to >50% blood volume transfusion (P = 0.032, <0.005, <0.005 respectively).This single-center observational study reports red cell volume loss and volume of transfusion in children undergoing surgical correction of craniosynostosis. Red cell volume loss was comparative to that in the literature and in this cohort longer operative time, younger age, and lower weight predisposed to >50% blood volume transfusion.

Axillary skin malignancy: a rare breast cancer presentation.

A rise in incidence and decrease in mortality rates from breast cancer have lead to an increase in prevalence within developed countries. Presentation is classically with a palpable breast tissue mass that may metastasize to bone, lung, liver, brain, lymph nodes, and skin. We describe a delayed diagnosis, in an 80-year-old female patient, where, on 2 occasions, the primary initial presentation was with a cutaneous squamous cell carcinoma in the right axilla. It was not until the third referral, with an ipsilateral breast lump, that breast cancer was clinically diagnosed. This was histologically identified as the primary malignancy, most likely in-keeping with squamous cell carcinoma of the breast. This unique atypical presentation represents a diagnostic challenge and highlights a clinically relevant learning point that may avoid subsequent diagnostic delay. Cutaneous axillary lesions should be treated with a high index of suspicion, necessitating the requirement for chest examination because of the possible presence of an associated primary breast carcinoma.

A study of the effects of delayed patient presentation on cutaneous SCC progression.

BACKGROUND: A cohort study of patients, who underwent cutaneous squamous cell carcinoma (SCC) excision, was undertaken to evaluate the effects of the COVID-19 pandemic on treatment times and histopathological features. METHODS: We identified all patients who had SCCs excised in October 2020 (pandemic group); the control group included all patients who underwent excision of SCCs during October 2019 (pre-pandemic group). Collected data included SCC subtype, thickness, size, clearance margins, referral details, patient comorbidities and operative data. RESULTS: There were 140 patients (174 SCCs; pre-pandemic group=74; pandemic group=100) identified for study inclusion. Both groups were well matched for age, sex, previous history of cancer, cutaneous SCC and histological subtype. There was a delay in median patient presentation time to the GP in the pandemic versus pre-pandemic group (106 days vs. 56 days, p <0.001); this led to a longer overall time to surgery (167 days vs. 110.5 days, p < 0.001). Pandemic group SCCs had larger median Breslow depths (4 mm vs. 3 mm, p = 0.01), a greater proportion of Clark's level 4 and 5 lesions (76.9% vs. 61.1%, p = 0.03), and a higher rate of high (20-40 mm) and very high (>40 mm) risk SCCs as defined by British Association of Dermatology diameter criteria (56.1% vs. 39.2%, p = 0.03), versus the pre-pandemic group. CONCLUSIONS: There was a 57-day median SCC treatment delay, and an associated development of higher risk SCCs by the time of surgery. Despite the challenges of a pandemic, patients should seek early consultation for suspicious skin changes, and healthcare systems should maintain skin cancer treatment pathways.

WALANT: A Discussion of Indications, Impact, and Educational Requirements.

Wide-awake, local anesthesia, no tourniquet (WALANT) is a technique that removes the requirement for operations to be performed with a tourniquet, general/regional anesthesia, sedation or an anesthetist. We reviewed the WALANT literature with respect to the diverse indications and impact of WALANT to discuss the importance of future surgical curriculum integration. With appropriate patient selection, WALANT may be used effectively in upper and lower limb surgery; it is also a useful option for patients who are unsuitable for general/regional anesthesia. There is a growing body of evidence supporting the use of WALANT in more complex operations in both upper and lower limb surgery. WALANT is a safe, effective, and simple technique associated with equivalent or superior patient pain scores among other numerous clinical and cost benefits. Cost benefits derive from reduced requirements for theater/anesthetic personnel, space, equipment, time, and inpatient stay. The lack of a requirement for general anesthesia reduces aerosol generating procedures, for example, intubation/high-flow oxygen, hence patients and staff also benefit from the reduced potential for infection transmission. WALANT provides a relatively, but not entirely, bloodless surgical field. Training requirements include the surgical indications, volume calculations, infiltration technique, appropriate perioperative patient/team member communication, and specifics of each operation that need to be considered, for example, checking of active tendon glide versus venting of flexor tendon pulleys. WALANT offers significant clinical, economic, and operative safety advantages when compared with general/regional anesthesia. Key challenges include careful patient selection and the comprehensive training of future surgeons to perform the technique safely.

Evaluating the impact of a virtual international global surgery conference as a means for global surgery and health education.

Objective: Global Surgery was established as a specialty in the 1980s to improve worldwide surgical care and delivery; however, despite having significant importance, a lack of exposure remains within undergraduate and postgraduate training schemes. This study aims to evaluate the impact of a free international virtual Global Surgery conference in raising interest, awareness and knowledge for medical and allied healthcare professional students, surgical trainees and surgeons worldwide. Design: A free one-day international Global Surgery conference was organised in May 2021 and broadcast on a worldwide delegate online platform; there were seven keynote presentations. Registered delegates completed pre-and post-conference questionnaires. Data were collected including country of origin, training/professional level, Likert (1-5) scale ratings of conference keynote topics and VAS (0-10) scores for overall conference evaluation. Furthermore, qualitative feedback in relation to positive feedback and ideas for improvement was also invited, and in cases where multiple feedback was given, was categorised separately. Setting: The study was undertaken by the St Andrew's Anglia Ruskin (StAAR) Research Group, School of Medicine, Anglia Ruskin University, Chelmsford, UK. Participants: There were 230 registered delegates; the attendance rate was 81.7% (188/230), representing a variety of different training/professional levels from 50 countries. For attendees, the questionnaire response rate was 88.8% (167/188). Results: There was a significant increase in knowledge improvement regarding six conference topics, with five achieving a median (IQR) post-conference Likert score of 5(1) and one achieving a score of 4(1) (p < 0.001). Average confidence and knowledge remained unchanged on the use of social media to access worldwide surgical education (p = 0.667). Overall, the conference received high satisfaction (9.4/10) and recommendation (9.5/10) ratings. Conclusion: Our findings support the concept of free Global Surgery virtual conference integration into medical and allied healthcare professional student curricula worldwide, to promote early awareness and facilitate the growth of the healthcare 'workforce of tomorrow'.

Outcomes of major head and neck reconstruction during the COVID-19 pandemic: The St. Andrew's centre experience.

BACKGROUND: The coronavirus disease-2019 (COVID-19) pandemic has generated enormous pressure on healthcare establishments, prompting the restructuring of services to rationalise resources. Complex head and neck reconstructive surgery in this setting may carry substantial risk to patients and staff. This paper outlines the management strategy and outcomes of major head and neck oncological cases at a single regional tertiary referral centre. METHODS: A database review was undertaken of consecutive patients undergoing major head and neck surgery and reconstruction during the COVID-19 pandemic at St Andrew's Centre for Plastic Surgery & Burns, Chelmsford UK. Patient demographics, tumour and reconstruction characteristics as well as peri­operative information were determined. Patients were prospectively contacted with regard to COVID-related symptoms and investigations. RESULTS: Twenty-two patients (15 males and 7 females) with a mean age of 67 years (range: 36-92 years) were included between March 1 and June 13, 2020. Patients underwent pre-operative throat swabs at 72 h and 24 h as well as chest CT scanning as part of a robust protocol. Twelve free flaps, four loco-regional flaps, four parotidectomies and 23 cervical lymphadenectomies were performed. Two patients required a return to theatre. No post-operative deaths occurred and flap survival rate was 100%. A single patient tested positive for COVID-19 pre-operatively and no post-operative COVID-19 infections occurred. CONCLUSION: Although head and neck surgery represents a high-risk procedure to patients and healthcare professionals, our institutional experience suggests that in the presence of a robust peri­operative protocol and judicious patient selection, major head and neck surgery, including free tissue transfer reconstruction, may be performed safely.

3-Dimensional fasciectomy: A highly efficacious common ground approach to Dupuytren's surgery.

BACKGROUND: Numerous Dupuytren's fasciectomy techniques have been described, each associated with unique surgical challenges, complications and recurrence rates. We describe a common ground surgical approach to Dupuytren's disease; 3-dimensional fasciectomy (3DF). 3DF aims to address the potential contributors to the high recurrence rate of Dupuytren's disease and unite current limited fasciectomy practice that varies considerably between surgeons. METHODS: We describe the 3DF principles; raising thin skin flaps (addressing dermal involvement), excising diseased palmar fascia with a 3-5 mm clearance margin (treating highly locally recurrent conditions) and excising the vertical septae of Legueu and Juvara (providing deep clearance, hence addressing all potentially involved pathological tissue). The surgical outcomes between traditional limited fasciectomy (LF) and 3DF are compared. RESULTS: From the 786 operations included (n=585), postoperative recurrence rates were significantly lower for the 3DF group (2/145, 1.4%) than the LF group (72/641, 11.2%) (P=0.001), and the time to recurrence was significantly longer (5.0±0 years vs. 4.0±0.2 years; P<0.0001). With recurrence excluded, there were no differences between the postoperative complication rates for 3DF (5/145, 3.5%) and LF (41/641, 6.4%) (P=0.4). CONCLUSIONS: Our results suggest that 3DF leads to lower recurrence rates and a longer disease-free period for patients, without increasing complications. 3DF provides a safe, efficacious, common ground surgical approach in the treatment of Dupuytren's flexion deformity.

Secondary amyloidosis in a needle phobic intra-venous drug user.

A case of acute-on-chronic renal failure is presented that is the sequela of secondary (AA) amyloidosis in a hepatitis positive intravenous drug user (IVDU) with chronic venous ulceration. The importance of groin examination is stressed when upper limb veins in a suspected IVDU are normal. Recent epidemiological data is discussed that suggests geographical location and the subcutaneous (SC) route of drug administration are both contributing factors to the development of AA amyloidosis and not chronic infection with HIV, HBV or HCV.

Flap design and perfusion are keys of success: Axial fasciocutaneous posterior thigh flaps for deep small pelvic defect reconstruction.

BACKGROUND AND OBJECTIVES: Radical excisions of the rectum often result in large perineal and intrapelvic defects. Compromised wound healing can delay adjuvant therapies and limit the patient's prognosis. With current treatment, integrity of the abdominal wall may be maintained. The defect geometry is unique and requires extensive volume for reconstruction. This study describes the surgical technique and reports clinical outcomes of fasciocutaneous posterior thigh flaps as preliminary data for this indication. METHODS: Thirteen posterior thigh flaps were used in eleven patients between 2013-2015. Patients were prospectively followed-up for the pursposes of this case series. Flap dimensions and volume were measured in two representative cases. The surgical technique is described in detail. RESULTS: Dead space occlusion was achieved in 100% of cases. No intestinal herniation was detected. Vaginal wall defects were concurrently reconstructed in two patients. Total flap volume was calculated as 315-360 cm3. The fasciocutaneous flaps were easy to harvest, versatile to manipulate and did not result in significant function deficits. CONCLUSIONS: In contrast to classic Vertical Rectus Abdominis Muscle (VRAM) flaps, the posterior thigh flaps preserve abdominal wall function and should be considered as a reliable alternative option in reconstruction of intrapelvic defects including neighboring organs. Future studies of larger patient series should be executed to verify our findings and determine the optimal point in time for reconstruction.

Erratum: Scar Revision Surgery: The Patient's Perspective.

[This corrects the article on p. 729 in vol. 42, PMID: 26618120.].

Recurrent gluteal haematoma: two internal iliac artery-associated bleeding points.

Isolated iliac artery aneurysms are extremely rare. Gluteal artery aneurysms are also rare, more commonly affecting the superior gluteal artery in association with penetrating trauma, with those of the inferior gluteal artery usually associated with pelvic fractures. We discuss a diagnostically challenging presentation of recurrent subcutaneous gluteal haematoma due to two separate internal iliac artery-associated bleeding points. A 67-year-old man was referred, from a peripheral hospital, with a right-sided subcutaneous gluteal haematoma. This manifested 28 days following minor non-penetrating, non-fracture-associated trauma. Despite repeat blood transfusions, albeit interspersed with days of haemodynamic stability, and despite exclusion of relevant bleeding sources at endoscopy and two surgical explorations, it was only until contrast CT scanning was requested that both bleeding sources were identified and successfully treated by endovascular coil embolization. This provides an important variant and lesson to supplement current literature and understanding of more diagnostically challenging cases of an extremely rare presentation.

PBNR: Percutaneous Blunt Needle Reduction of Bony Mallet Injuries.

Mallet finger injuries are common; treatment goals include achieving joint stability, preventing extensor lag, and subsequent swan-neck deformity. We describe a simple technique for improving intraoperative bony mallet reduction, which may avoid the requirement for closed Ishiguro extension blocking wires or open fixation, and present a prospective case series (n=12). Intraoperative percutaneous blunt needle reduction (PBNR) is achieved under image intensifier guidance. Using artery forceps, a blunt fill needle tip is manipulated onto the proximal avulsed fragment; this is then guided into a reduced position and maintained using a well-formed Zimmer splint across the distal interphalangeal joint in 15- to 30-degree extension. There were 5 injuries involving >1/3 of the articular surface (Doyle's classification IVb) and 7 injuries involving >1/2 of the articular surface (Doyle's classification IVc). Mean hand therapy follow-up was 10.6±1.0 weeks, extensor lag was 4.6±1.7 degrees, and all patients achieved full functional recovery with return to normal daily activity. No complications were reported. Closed techniques, for example, Ishiguro extension blocking wires, may reduce the risks associated with open reduction, but do not avoid further articular surface damage. PBNR offers the surgeon a useful adjunct to the treatment options for bony mallet injuries, without excluding progression to surgical fixation if required. PBNR represents a less-invasive management option for bony mallet injures where surgical fixation may also be indicated.

Scar Revision Surgery: The Patient's Perspective.

BACKGROUND: Insufficient satisfaction outcome literature exists to assist consultations for scar revision surgery; such outcomes should reflect the patient's perspective. The aim of this study was to prospectively investigate scar revision patient satisfaction outcomes, according to specified patient-selection criteria. METHODS: Patients (250) were randomly selected for telephone contacting regarding scar revisions undertaken between 2007-2011. Visual analogue scores were obtained for scars pre- and post-revision surgery. Surgery selection criteria were; 'presence' of sufficient time for scar maturation prior to revision, technical issues during or wound complications from the initial procedure that contributed to poor scarring, and 'absence' of site-specific or patient factors that negatively influence outcomes. Patient demographics, scar pathogenesis (elective vs. trauma), underlying issue (functional/symptomatic vs. cosmetic) and revision surgery details were also collected with the added use of a real-time, hospital database. RESULTS: Telephone contacting was achieved for 211 patients (214 scar revisions). Satisfaction outcomes were '2% worse, 16% no change, and 82% better'; a distribution maintained between body sites and despite whether surgery was functional/symptomatic vs. cosmetic. Better outcomes were reported by patients who sustained traumatic scars vs. those who sustained scars by elective procedures (91.80% vs. 77.78%, P=0.016) and by females vs. males (85.52% vs. 75.36%, P<0.05), particularly in the elective group where males (36.17%) were more likely to report no change or worse outcomes versus females (16.04%) (P<0.01). CONCLUSIONS: Successful scar revision outcomes may be achieved using careful patient selection. This study provides useful information for referring general practitioners, and patient-surgeon consultations, when planning scar revision.

A preoperative marking template for deep inferior epigastric artery perforator flap perforators in breast reconstruction.

Preoperative perforator marking for deep inferior epigastric artery perforator flaps is vital to the success of the procedure in breast reconstruction. Advances in imaging have facilitated accurate identification and preselection of potentially useful perforators. However, the reported imaging accuracy may be lost when preoperatively marking the patient, due to 'mapping errors', as this relies on the use of 2 reported vectors from a landmark such as the umbilicus. Observation errors have been encountered where inaccurate perforator vector measurements have been reported in relation to the umbilicus. Transcription errors have been noted where confusing and wordy reports have been typed or where incorrect units have been given (millimetres vs. centimetres). Interpretation errors have also occurred when using the report for preoperative marking. Furthermore, the marking process may be unnecessarily time-consuming. We describe a bespoke template, created using an individual computed tomography angiography image, that increases the efficiency and accuracy of preoperative marking. The template is created to scale, is individually tailored to the patient, and is particularly useful in cases where multiple potential suitable perforators exist.

When are circular lesions square? A national clinical education skin lesion audit and study.

BACKGROUND: Skin cancer is the most prevalent cancer by organ type and referral accuracy is vital for diagnosis and management. The British Association of Dermatologists (BAD) and literature highlight the importance of accurate skin lesion examination, diagnosis and educationally-relevant studies. METHODS: We undertook a review of the relevant literature, a national audit of skin lesion description standards and a study of speciality training influences on these descriptions. Questionnaires (n=200), with pictures of a circular and an oval lesion, were distributed to UK dermatology/plastic surgery consultants and speciality trainees (ST), general practitioners (GP), and medical students (MS). The following variables were analysed against a pre-defined 95% inclusion accuracy standard: site, shape, size, skin/colour, and presence of associated scars. RESULTS: There were 250 lesion descriptions provided by 125 consultants, STs, GPs, and MSs. Inclusion accuracy was greatest for consultants over STs (80% vs. 68%; P<0.001), GPs (57%) and MSs (46%) (P<0.0001), for STs over GPs (P<0.010) and MSs (P<0.0001) and for GPs over MSs (P<0.010), all falling below audit standard. Size description accuracy sub-analysis according to circular/oval dimensions was as follows: consultants (94%), GPs (80%), STs (73%), MSs (37%), with the most common error implying a quadrilateral shape (66%). Addressing BAD guidelines and published requirements for more empirical performance data to improve teaching methods, we performed a national audit and studied skin lesion descriptions. To improve diagnostic and referral accuracy for patients, healthcare professionals must strive towards accuracy (a circle is not a square). CONCLUSIONS: We provide supportive evidence that increased speciality training improves this process and propose that greater focus is placed on such training early on during medical training, and maintained throughout clinical practice.

A quick snip - A study of the impact of outpatient tongue tie release on neonatal growth and breastfeeding.

A prospective study (62 neonates) of ankyloglossia and breastfeeding difficulty is presented. At 2 weeks post-frenulotomy, there were significant improvements in weight (15+/-1.2 centiles) and breastfeeding, including number of sessions/24h (19%) and bottle top-ups/24h (81%) (p<0.0001).