Facial Aesthetic Ideals: A Literature Summary of Supporting Evidence.

BACKGROUND: To achieve the goal of enhancing facial beauty it is crucial for aesthetic physicians and plastic surgeons to have a deep understanding of aesthetic ideals. Although numerous aesthetic criteria have been proposed over the years, there is a lack of empirical analysis supporting many of these standards. OBJECTIVES: This aim of this review was to undertake the first exploration of the empirical evidence concerning the aesthetic ideals of the face in the existing literature. METHODS: A comprehensive search in MEDLINE, Embase, Scopus and CENTRAL databases was conducted for primary clinical studies reporting on the classification of the facial aesthetic units as per the Gonzales-Ulloa facial aesthetic unit classification from January 1962 to November 2022. RESULTS: A total of 36 articles were included in the final review: 12 case series, 14 cohort studies, and 10 comparative studies. These described the aesthetic ideals of the following areas: forehead (6 studies; mean level of evidence, 3.33); nose (9 studies; mean level of evidence, 3.6); orbit (6 studies; mean level of evidence, 3); cheek (4 studies; mean level of evidence, 4.07); lips (6 studies; mean level of evidence, 3.33); chin (4 studies; mean level of evidence, 3.75); ear (1 study; level of evidence, 4). CONCLUSIONS: The units that were most extensively studied were the nose, forehead, and lip, and these studies also appeared in journals with higher impact factors than other subunits. Conversely, the chin and ear subunits had the fewest studies conducted on them and had lower impact factors. To provide a useful resource for readers, it would be prudent to identify and discuss influential papers for each subunit.

WAFER trial: a study protocol for a feasibility randomised controlled trial comparing wide-awake local anaesthesia no tourniquet (WALANT) to general and regional anaesthesia with tourniquet for flexor tendon repair.

INTRODUCTION: Flexor tendons are traditionally repaired under either general anaesthesia (GA) or regional anaesthesia (RA), allowing for the use of an arm tourniquet to minimise blood loss and establish a bloodless surgical field. However, the use of tourniquets exposes the patient to certain risks, including skin, muscle and nerve injuries. A recent advancement in anaesthesia delivery involves the use of a wide-awake approach where no sedation nor tourniquets are used (wide-awake local anaesthesia no tourniquet (WALANT)). WALANT uses local anaesthetic with epinephrine to provide pain relief and vasoconstriction, reducing operative bleeding. Several studies revealed potential benefits for WALANT compared with GA or RA. However, there remains a paucity of high-quality evidence to support the use of WALANT. As a result of this uncertainty, the clinical practice varies considerably. We aim to evaluate the feasibility of WALANT as an alternative to GA and RA in patients undergoing surgical repair of flexor tendon injuries. This involves addressing factors such as clinician and patient support for a trial, clinical equipoise, trial recruitment and dropout and the most relevant outcomes measures for a future definitive trial. METHODS AND ANALYSIS: WAFER is a multicentre, single-blinded, parallel group, randomised controlled trial (RCT) to assess the feasibility of WALANT versus RA and GA. The target population is patients with acute traumatic flexor tendon injuries, across 3 major hand surgery units in England involving a total of 60 participants. Outcome assessors will be blinded. The primary outcome will be the ability to recruit patients into the trial, while secondary outcomes include difference in functional outcome, patient-reported outcome measures, health-related quality of life, cost-effectiveness and complication rates. ETHICS AND DISSEMINATION: Ethical approval was obtained from the London-City and East Research Ethics Committee (22/PR/1197). Findings will be disseminated through peer-reviewed publication, conferences, patient information websites and social media networks. TRIAL REGISTRATION NUMBER: ISRCTN identifier: 15052559.

Optimal strategies for addressing developmental breast asymmetry and the significance of symmetrical treatment: A systematic review.

BACKGROUND: Approximately one quarter of women are affected by asymmetry as a result of abnormal breast development, which can lead to significant emotional distress. Despite this, there is currently no widely accepted approach for managing this prevalent condition. This systematic review aimed to review the available literature on the management of developmental breast asymmetry. METHODS: A comprehensive search in MEDLINE, EMBASE, and CENTRAL databases was conducted for primary clinical studies reporting on the management of developmental breast asymmetry from 1962 to November 2022. The primary outcome measures were long-term aesthetic outcomes and patient-reported outcomes. RESULTS: Eleven case series and 2 cohort studies were included, comprising a total of 1237 patients with a mean age of 26.5 years (range 14-65 years). Twelve studies (92%) addressed asymmetry through surgical means, using various augmentation and reduction procedures, whereas one study (8%) utilized external prostheses. Meta-analysis of the data was not deemed to be possible because of heterogeneity of data; a narrative synthesis of the literature was provided. CONCLUSIONS: There is no consensus on how to manage developmental breast asymmetry. Furthermore, there is a lack of consistency in the classification of patients with developmental breast asymmetry and in the reporting of outcomes, highlighting the need for a consensus. Further research outlining long-term aesthetic and patient-reported outcomes is needed to understand which procedures provide optimal outcomes. In addition, external breast prosthesis is a promising nonsurgical alternative, and further studies into its efficacy are needed.

The free Thenar flap for thumb pulp reconstruction: A case report.

The thumb is acknowledged to contribute significantly to hand function, accounting for up to 40% of its overall capability. Consequently, injuries affecting the thumb can have a profound impact on the quality of life experienced by patients. When it comes to the surgical reconstruction of thumb injuries, the primary objective is to promptly provide coverage of the affected area with glabrous skin, thus preserving both the length and functionality of the thumb. Managing injuries specifically involving the thumb pulp can be particularly challenging due to the digit's size and vital role. Acquiring an adequate amount of glabrous soft tissue poses a difficulty in such cases. Various reconstructive approaches, encompassing a range of options on the reconstructive ladder, have been documented for thumb pulp injuries. The most popular options include pedicled flaps and free flaps obtained from both the hands and feet. However, a consensus regarding the optimal method for reconstructing the thumb pulp has yet to be reached. We present a case of total thumb pulp reconstruction for a 40 × 30 mm defect using the free thenar flap in a 65-year-old carpenter who sustained a work-related injury. This flap was designed and raised on the superficial branch of the radial artery with a single subcutaneous vein and a branch of the palmar cutaneous nerve, the flap measured 43 × 32 mm. It was inset transversely with an end-to-end arterial anastomosis to the ulnar digital artery, venous anastomosis to the dorsal digital vein and nerve coaptation to the ulnar digital nerve. The postoperative course was uneventful, and the patient was discharged the following day without any complications. Eight months after surgery, the patient was extremely satisfied with the results of the procedure in terms of both function and appearance. The patient had experienced an improvement in function, sensation, and aesthetics. The patient had a QuickDASH disability/symptom score of 15.91 and a QuickDASH work module score of 18.75; the range of motion in the treated thumb was almost the same as the opposite thumb. The patient successfully resumed work three weeks following the procedure, initially with modified duties, and fully regained their work capacity within six weeks. As the patient's primary concern was their ability to return to work, the utilization of a free thenar flap offered several distinct advantages. These included minimal post-operative complications, facilitated by a single operative site, allowing for reconstruction under regional anesthesia. Moreover, the procedure was conducted in a single stage, enabling the patient to be discharged on the same day without the need for further procedures. Furthermore, similar to several other reconstructive options for the thumb, the utilization of a free thenar flap offered the advantage of providing high-quality, like-for-like glabrous tissue.

Core surgical training: The influence of time and date on interview outcome.

INTRODUCTION: Core Surgical Training has become increasingly competitive over the last 5 years with the competition ratio reaching 4.16 in 2021 compared to 2.31 in 2015. This is thought to be due to two key factors: a large yearly increase in the number of applicants and an unchanging number of jobs. Steps are taken by HEE to ensure the process is as standardised and fair as possible. Interview date and time selection remains the only aspect of the process that candidates currently control. We aim to explore whether time and date of an interview has any impact on interview scores within CST. METHODS: This study is a national, retrospective cohort study. A freedom of information act request was submitted to HEE to acquire anonymised interview scores and date/time of interview for all CST interviews conducted for the 2022-2023 cohort. RESULTS: Across the two-week period whereby interviews were held 1264 interviews were undertaken. Candidates with morning interviews had a mean score of 111 (±16) and candidates in the afternoon had a mean score of 108 (±18.5) (p = 0.023). Candidates interviewing in week 1 had a mean score of 107 (±18) and candidates interviewing in week 2 had a mean score of 112 (±16.4) (p < 0.001). DISCUSSION: A small difference in score has a significant impact for candidates with their geographical location, specialty choice or event enrolment in the core training programme potentially impacted. It is therefore imperative that these findings receive further evaluation going forward to ensure the process is fair and robust for all participants.

Preoperative Imaging of Costal Cartilage to Aid Reconstructive Head and Neck Surgery: A Systematic Review.

OBJECTIVE: Autologous costal cartilage is used extensively in reconstructive surgery because of its stability, durability, and biocompatibility. The current preoperative evaluation of costal cartilage often only consists of a physical examination. Several studies have highlighted the benefits of preoperative imaging as a tool to ensure optimal graft harvest. This systematic review aims to synthesize the current evidence and establish the efficacy of the various imaging modalities for the assessment of costal cartilage. REVIEW METHODS: The data sources were explored using a search strategy based on the terms ("costal cartilage" OR "ribs" AND "imaging*") combined with Boolean operators. The primary outcome measures were the ability to measure the dimensions of costal cartilages and to detect the presence of calcifications. RESULTS: A total of 28 publications were included in the final review, with 12 case series, 7 case control studies, and 9 cohort studies. Twenty-two studies used computed tomography (CT); 4 studies used x-ray and 2 studies used ultrasonography, whereas no studies used magnetic resonance imaging. Meta-analysis of the data from these studies was not deemed possible. CONCLUSIONS: Our findings suggest that CT is the modality with the strongest evidence base that provides the greatest degree of information. The major benefits of CT are its ability to provide 3-dimensional image reconstruction for surgical planning, ability to detect synchondroses, and assess cartilage quality. Where radiation exposure is less preferable, x-ray and ultrasound (US) may play an important role. X-ray appears to be particularly useful when the main concern is the presence of calcification. The limited studies available indicate that US can provide useful and accurate information on cartilage quality and morphology. Further studies are warranted in exploring the use of US in preoperative planning, particularly in the pediatric population.

Diagnosing and managing a giant primary cutaneous malignant melanoma of the lower limb.

We present a woman who was referred to our plastic surgery unit with a suspected squamous cell carcinoma following a 3-year history of an enlarging mass on her thigh. Surprisingly, histopathological assessment confirmed the diagnosis of nodular malignant melanoma measuring 77×77×54 mm with a Breslow thickness of 52 mm, making it the largest recorded lower limb primary cutaneous malignant melanoma in the UK.

3D photography and computer modelling in nasal reconstruction.

Advances in high resolution 3D photography and computer modelling are revolutionising patient workup, surgical planning, patient satisfaction, clinical outcomes, and surgical training. We present a case in which this technology is utilised for a patient undergoing a forehead flap for reconstruction of a nasal defect, allowing us to develop a novel reconstructive algorithm. 3D photographs were taken pre-operatively, a computer model rendered and follow up photographs taken at each stage of the reconstruction using a Vectra XT camera. Patient satisfaction was measured qualitatively postoperatively. Prior to each stage we were able to use the 3D photographs to make thorough preoperative plans whilst minimising the number of outpatient appointments the patient required. With the images always at hand, we had much more time to make measurements and consider alterations. Utilising the 3D models in clinic and MDT allowed us to have more insightful outpatient appointments, in which we were able to discuss and illustrate each subsequent stage. The use of 3D photography and computer modelling allows for a greater level of care to patients by improving understanding and satisfaction and alleviating anxiety. It also reduced operative time, improves surgical planning, and acts as an excellent resource for surgical trainees and future patients.

Management of periprosthetic breast infection: a systematic review and meta-analysis.

BACKGROUND: The current management of an infected breast implant is varied. This systematic review and meta-analysis aim to synthesise the current evidence and establish the efficacy of the various managements of infected breast implants. METHODS: A comprehensive search in the MEDLINE, EMBASE and CENTRAL databases was conducted for primary clinical studies that report on the management of infected breast implants from 1946 to September 2019. The primary outcome measure was the proportion of patients with successful treatment. RESULTS: Nineteen articles that involve 1044 patients were included. Overall, 29.00% (95% CI = from 11.51% to 50.58%) of the patients with mild infection were treated exclusively with antibiotics, of which, 81.41% (95% CI = from 57.82% to 96.63%) were successfully treated without the need for surgical intervention. Another 39.01% (95% CI = from 21.41% to 58.23%) of the patients underwent surgical salvage of the infected breast implants, of which 84.56% (95% CI = from 74.92% to 92.20%) successfully retained the salvaged implants without infection recurrence. Meanwhile, 35.01% (95% CI = from 27.01% to 43.57%) of the patients underwent explantation of the infected breast implant, of which, only 39.02% (95% CI = from 23.93% to 55.28%) had re-insertion of a new implant on a later date and 4.99% (95% CI = from 1.66% to 9.99%) of these patients had recurrence of infection requiring removal of the infected implant. The commonest complication was capsular contracture, which was reported in 10.78% (95% CI = from 4.41% to 19.49%) of the patients. Changes in the quality of life and cost implications were not reported. CONCLUSION: This study consolidates current available evidence on the management of infected breast implants, which could assist decision-making and improve patient education; however, current data are limited because of the lack of level-1 evidence.

An Unusual Presentation to the Burns Unit-A Cautionary Tale.

The authors report a case of a 34-year-old female with systemic lupus erythematosus (SLE) and lupus nephritis who was referred to the regional burns service with a suspected contact burn to the left flank and hypogastrium from a hot water bottle. The patient had been applying a hot water bottle to the area at night for pain relief and after 3 days she noticed a localized area of erythema which became larger and began to blister over a period of 5 days. The blistered areas were erythematous and wet; however, the capillary refill time was sluggish. The lesion was initially diagnosed and treated as a superficial partial thickness burn that had developed secondary to prolonged contact with a hot water bottle. However, due to the history of immunosuppression as well as elements of the lesion being unusual for a burn, we consequently diagnosed this as herpes zoster infection. This case highlights the importance of always thinking of alternative diagnoses. There are several cases in the literature where shingles has been dangerously misdiagnosed, furthermore leading to patients being mistakenly treated and even operated on. In the early stages, abdominal shingles may present very similarly to superficial partial thickness burns, both with neuropathic pain, erythema, and blistering. It is important for the burns surgeon to be aware of this diagnosis as a differential in atypical presentations, and to pay particular attention to the timeline of events is the key to diagnosis.

Hand injury: investigating the accuracy of referrals to a specialist trauma centre.

Hand injury is a common presentation in the emergency department (ED). The accurate assessment of hand injuries is essential to ensure optimal management, which may need to include referral to a tertiary trauma centre. However, hand injury assessment can be challenging, particularly in children. A better understanding of the accuracy of hand injury referrals to tertiary care can help improve clinical practice and clinician training. This article reports on a service improvement project that aimed to determine the accuracy of hand injury referrals from EDs and general practices to a tertiary trauma centre. The retrospective investigation found the accuracy of referrals to be high, but also identified areas where hand injury assessment required improvement, one of them being the training of clinicians referring complex cases to tertiary care.

Improving wellbeing among UK doctors redeployed during the COVID-19 pandemic.

BACKGROUND: In response to the COVID-19 pandemic, the NHS has implemented significant workforce changes to manage the increased and changing demand on healthcare services. We aimed to investigate the impact of redeployment on the wellbeing of doctors as well as highlighting ways to improve. METHODS: We conducted a survey at three NHS trusts over 2 weeks asking redeployed doctors to rate their morale, work-life balance and perceived support and safety, and to voice concerns. RESULTS: 172 redeployed doctors responded to the survey. 66.3% felt confident in their new role, 65.7% felt satisfied or neutral with their new role and only 31.4% felt stressed at work. 66.3% felt valued by their team and 79% felt valued by the general public. 64.5% had noticed an increase in the length of breaks and 89% felt their rotas provided sufficient respite. 55.2% did not feel confident in the guidance from Public Health England/Wales on using personal protective equipment (PPE) and 54.7% did not feel safe while wearing PPE. The three most common concerns were training opportunities, PPE and family health. CONCLUSION: Our findings suggest that morale is higher than might be expected with doctors feeling valued, confident and well rested in their new role. Concerns about training opportunities/career progression, PPE and family safety need to be addressed.