In vitro investigation into the forces involved during lipofilling.

Breast augmentation using implants is the most common aesthetic and reconstructive breast surgical procedure. Complications such as implant rupture maybe related to surgical technique and damage to the implant. Autologous fat transfer (lipofilling) using metallic cannulae has become a standard adjunctive, yet there is little evidence on lipofilling safety in the presence of implants. The aims of this study are to verify the effects of different cannulae and to quantify the forces applied by surgeons during lipofilling. Silicone gel-filled textured implants (200 mL), mounted on a specially constructed mould were ruptured with two different cannulae: type A (hole at tip: sharp) and type B (hole away from tip: blunt), driven at three speeds (10, 100 and 1000 mm/min), and the force at rupture was recorded. In addition, the maximum 10 forces over a 30-s period applied by 11 plastic surgeons against a breast implant in an in vitro environment were recorded using a load cell attached to a type-A cannula. Statistical analysis of comparative results was performed using t-tests, with p < 0.05 considered significant. Results showed that the implant ruptured at forces up to 25% lower when cannula A was used compared to cannula B. This supports current technique in lipofilling in the use of a blunt tipped cannula. There was a significant difference between some displacement rates only, due to the viscoelastic nature of the material. The tactile force that surgeons use during lipofilling was modelled in vitro and showed a range of maximum forces between 0.23 and 16.8 N, with a mean maximum value of 6.9 N. Limitation of this study is that it may not reflect in vivo behaviour of breast implants. More studies are needed to confirm the safety of breast lipofilling in the presence of implants using these data as a starting point.

A direct comparison of porcine (Strattice™) and bovine (Surgimend™) acellular dermal matrices in implant-based immediate breast reconstruction.

INTRODUCTION: Acellular dermal matrix (ADM) assisted implant-based breast reconstruction (IBBR) has grown in popularity over traditional submuscular techniques. Numerous human, bovine or porcine derived ADMs are available with the type used varying considerably worldwide. Yet, comparative evidence for the efficacy of different ADMs particularly xenogenic is limited. This study directly compares early outcomes of porcine (Strattice™) and bovine (Surgimend™) ADMs in IBBR. METHOD: Retrospective study of sequential experience of immediate IBBR using Strattice or Surgimend ADM. Data was collected for patients undergoing ADM assisted IBBR after prophylactic or therapeutic mastectomy in Cambridge (October 2011-March 2016). Patient demographics, adjuvant and neoadjuvant therapies, operative details, postoperative management and outcomes were analysed. KEY RESULTS: Total of 81 patients underwent IBBR with ADM; 38 bilateral and 43 unilateral (n = 119 breasts). Strattice was used in 30 breasts (25%) and Surgimend in 89 (75%). Analysis of patient specific variables showed statistical significance only for higher mastectomy weight in the Strattice group (367.1 ± 159.3 g versus 296.3 ± 133.4 g; P = 0.0379). Strattice was associated with higher rates of skin erythema post-operatively (16.7% versus 4.5%; P = 0.044). Analysed per woman or per breast, there was no statistically significant difference in rates of haematoma, infection, wound dehiscence, skin necrosis or seroma, although there was a trend towards more complications with Strattice. CONCLUSION: This study found significantly higher rates of skin erythema and a trend towards higher complication rates with Strattice in IBBR. Randomised controlled trials comparing different ADM outcomes are needed to inform best practice.

Characteristics of women who have had cosmetic breast implants that could be associated with increased suicide risk: a systematic review, proposing a suicide prevention model.

Literature indicates an increased risk of suicide among women who have had cosmetic breast implants. An explanatory model for this association has not been established. Some studies conclude that women with cosmetic breast implants demonstrate some characteristics that are associated with increased suicide risk while others support that the breast augmentation protects from suicide. A systematic review including data collection from January 1961 up to February 2014 was conducted. The results were incorporated to pre-existing suicide risk models of the general population. A modified suicide risk model was created for the female cosmetic augmentation mammaplasty candidate. A 2-3 times increased suicide risk among women that undergo cosmetic breast augmentation has been identified. Breast augmentation patients show some characteristics that are associated with increased suicide risk. The majority of women reported high postoperative satisfaction. Recent research indicates that the Autoimmune syndrome induced by adjuvants and fibromyalgia syndrome are associated with silicone implantation. A thorough surgical, medical and psycho-social (psychiatric, family, reproductive, and occupational) history should be included in the preoperative assessment of women seeking to undergo cosmetic breast augmentation. Breast augmentation surgery can stimulate a systematic stress response and increase the risk of suicide. Each risk factor of suicide has poor predictive value when considered independently and can result in prediction errors. A clinical management model has been proposed considering the overlapping risk factors of women that undergo cosmetic breast augmentation with suicide.

Detection of perforators using thermal imaging.

BACKGROUND: Perforator flaps are commonly used in reconstructive surgery and require accurate vascular anatomy navigation. Several imaging methods help surgeons, including hand-held Doppler, color Doppler ultrasound, computed tomography, and magnetic resonance angiography. A growing literature supports the efficacy of thermal imaging in identifying perforators. This study assessed the efficacy of thermal imaging and perforator anatomy in four body regions. METHODS: Twenty volunteers had their abdomen, sacrum, and both anterolateral thighs assessed for cutaneous perforators using thermal imaging. Key surface landmarks were marked with black crosshairs centered on the umbilicus, superior natal cleft, and traditional anterolateral thigh flap markings. All thermal imaging-identified perforators were marked by red crosses, immediately checked with a hand-held Doppler device, and marked with blue circles if not confirmed. A color digital photograph taken of each region was analyzed. RESULTS: Thermal imaging identified a total of 757 "hotspots," of which 732 (97.0 percent) were confirmed by hand-held Doppler. In 40 anterolateral thighs, the mean number of perforators identified was 1.3 within 2.5 cm and 4.6 within 5 cm of traditional landmarks. In the abdomen, the mean number of perforators was 0.7 and 3.7 within 2.5 cm and 5 cm of the umbilicus, respectively. In the sacral region, there was a mean number of 0.3 and 2.3 perforators within 2.5 cm and 5 cm, respectively, of the superior natal cleft. CONCLUSIONS: Thermal imaging is a quick, easy method of assessing cutaneous perforators. It should be considered a useful adjunct, and further investigated, to determine its best role among the established perforator imaging methods. CLINICAL QUESTION/LEVEL OF EVIDENCE: Diagnostic, II.

A sticky situation: methaemaglobinaemia in a hand trauma patient.

We describe a case of methaemoglobinaemia (MtHb) in a previously healthy 39-year-old gentleman who presented with a traumatic glass laceration to his right wrist that required emergency surgery to control bleeding and repair his ulnar artery. The MtHb was noted on blood gas analysis by the anaesthetist after the patient had a drop in arterial oxygen saturation under general anaesthetic. We initially suspected the lidocaine local anaesthetic injected proximal to his wound for pain control in the emergency department an hour preoperatively, but then discovered that the patient was a recreational user of 'poppers' and had in fact been using these drugs just before his injury and hospitalisation. The patient's condition stabilised overnight with conservative management. Given how commonly hand surgeons and other clinical staff use local anaesthetics, we reviewed the literature on this uncommon, but potentially fatal, complication, its causes and evidence-based management.

Effect of a "Lean" intervention to improve safety processes and outcomes on a surgical emergency unit.

PROBLEM: Emergency surgical patients are at high risk for harm because of errors in care. Quality improvement methods that involve process redesign, such as "Lean," appear to improve service reliability and efficiency in healthcare. DESIGN: Interrupted time series. SETTING: The emergency general surgery ward of a university hospital in the United Kingdom. KEY MEASURES FOR IMPROVEMENT: Seven safety relevant care processes. STRATEGY FOR CHANGE: A Lean intervention targeting five of the seven care processes relevant to patient safety. EFFECTS OF CHANGE: 969 patients were admitted during the four month study period before the introduction of the Lean intervention (May to August 2007), and 1114 were admitted during the four month period after completion of the intervention (May to August 2008). Compliance with the five process measures targeted for Lean intervention (but not the two that were not) improved significantly (relative improvement 28% to 149%; P<0.007). Excellent compliance continued at least 10 months after active intervention ceased. The proportion of patients requiring transfer to other wards fell from 27% to 20% (P<0.000025). Rates of adverse events and potential adverse events were unchanged, except for a significant reduction in new safety events after transfer to other wards (P<0.028). Most adverse events and potential adverse events were owing to delays in investigation and treatment caused by factors outside the ward being evaluated. LESSONS LEARNT: Lean can substantially and simultaneously improve compliance with a bundle of safety related processes. Given the interconnected nature of hospital care, this strategy might not translate into improvements in safety outcomes unless a system-wide approach is adopted to remove barriers to change.

Is basic emergency ultrasound training feasible as part of standard undergraduate medical education?

OBJECTIVE: Bedside ultrasonography is regularly used by surgeons and emergency physicians to perform focused assessment with sonography in trauma (FAST) in acutely-injured patients. Despite this, there is no formal ultrasound training in UK undergraduate curricula and postgraduate accreditation remains difficult to achieve. This study aims to assess the feasibility of teaching basic ultrasound skills to undergraduates using FAST scanning as a model module. DESIGN/SETTING: Students were enrolled in a 5-hour theoretical and practical FAST scanning course. Ultrasound scanning competencies were ascertained using a 1-hour formal objective structured clinical examination (OSCE) assessment consisting of case-based discussions, problem-solving exercises, a complete FAST scan on a human volunteer, and free fluid detection exercises in organic simulators. A questionnaire was used to ascertain students' opinion on ultrasonography in undergraduate training. PARTICIPANTS: Twenty-five volunteer medical students (years 3 and 5) from a London medical school. RESULTS: Students did not have prior experience of formal ultrasound training. The mean score achieved in the summative assessment was 86%. Eighty-five percent of students completed a full FAST scan at an adequate level of performance in under 6 minutes. The feedback survey indicated that all students felt confident in operating the ultrasound apparatus and were able to obtain good quality images at the end of the 5-hour course. Eighty-eight percent of students thought ultrasonography was relevant to their training; all students intended to seek formal ultrasound accreditation; 92% believed ultrasound training should be a regular component of the curriculum; and 96% of students preferred using cart-based ultrasound machines rather than hand-held devices. CONCLUSIONS: Undergraduate ultrasound tuition is an achievable educational goal which is well received by medical students. Medical schools need to consider the formal introduction of ultrasound teaching in their curricula to equip future doctors with relevant skill sets. The role of handheld ultrasound machines requires further investigation.

Spontaneous rupture of the spleen: a rare but important differential of an acute abdomen.

Spontaneous rupture of the spleen, although previously documented, is a rare phenomenon. It commonly occurs in a pathologic spleen, usually owing to hematological manifestation. We describe a rare incident of spontaneous splenic rupture presenting to an emergency department as a first manifestation. The purpose of this case report is to highlight the importance of considering spontaneous rupture of the spleen as a rare but important differential of an acute abdomen.