Summary document on safety and recommendations on liposuction for lipoedema: Joint British association of aesthetic plastic surgeons (BAAPS)/British association of plastic reconstructive and aesthetic surgeons (BAPRAS) expert liposuction group.

Liposuction plays an important role as a surgical treatment option for lipoedema. This article serves to critically review the evidence in the literature, as well as explain the differences between the lipoedema population compared with the aesthetic surgery population undergoing liposuction. It is not a comprehensive text on lipoedema management but serves to guide surgeons. This guidance was produced on behalf of the British Association of Aesthetic Plastic Surgeons (BAAPS) and the British Association of Plastic Reconstructive and Aesthetic Surgeons (BAPRAS) by the expert liposuction group. The guidance is based on the evidence available in the literature, along with a specialist expert opinion on liposuction for lipoedema, to provide plastic surgeons with a consensus recommendation for surgical treatment. The aim is to identify best practice to maximise the safety of patients. This article summarises current practices and safety considerations and outlines recommendations covering various aspects of patient care.

Summary document on safety and recommendations for aesthetic liposuction: Joint British Association of Aesthetic Plastic Surgeons (BAAPS)/British Association of Plastic Reconstructive and Aesthetic Surgeons (BAPRAS) expert liposuction group.

Liposuction is one of the commonest surgical aesthetic procedures performed worldwide. Despite being perceived to be a technically simple procedure, poor patient selection, sub-optimal technical execution or sub-optimal peri­operative management could lead to significant harm. This guidance was produced on behalf of the British Association of Aesthetic Plastic Surgeons (BAAPS) and British Association of Plastic Reconstructive and Aesthetic Surgeons (BAPRAS) by the expert liposuction group. The guidance is based on the evidence available in the literature along with specialist expert opinion in aesthetic liposuction to provide plastic surgeons with consensus recommendation. The aim is to identify best practice to maximise the safety of patients. This article summarises current practices and safety considerations and outlines recommendations covering various aspects of patient care.

Capsular contracture - What are the risk factors? A 14 year series of 1400 consecutive augmentations.

The modern era of breast augmentation and reconstruction began in 1963, with the introduction of silicone implants by Cronin and Gerow. To date, the demand for cosmetic augmentation continues to increase exponentially. However, whilst the surgical techniques and quality of mammary prosthesis have improved dramatically in recent years, patients are still confronted with significant potential complications. We performed a retrospective study of 1400 consecutive primary breast augmentations performed between March 1995 and March 2009 by a single surgeon. We specifically examined the incidence of capsular contracture and the possible causative factors. Follow up ranged from 1 to 16 years. The mean age at the time of surgery was 32.8 years and fill volume was between 195 ml and 800 ml. Our capsular contracture rate was in the order of 26.9%. BMI >30, fill volumes >350 ml, smoking and alcohol consumption did not significantly increase capsular contracture rate. Implant type, pregnancy, infection and delayed haematoma significantly increased the risk of capsular contracture. Our series has given us a unique insight into the frequency of capsular contracture and identified several risk factors. To our knowledge, this is the first report of pregnancy having a significant effect on capsular contracture. We now counsel patients thoroughly into the detrimental effects of pregnancy on the implant.

Salvage (tertiary) breast reconstruction after implant failure.

BACKGROUND: Salvage breast reconstruction is defined as a complete revision of a previous reconstruction in case of unsatisfactory results or failure of primary or secondary breast reconstruction. We have termed this 'tertiary breast reconstruction'. This article presents our experience with tertiary reconstructions, including the indications, method of reconstruction and outcomes. METHODS: A retrospective note review was performed for all patients who underwent breast reconstruction with autologous tissue under one surgeon between 2002 and 2009 at the University Hospital, Ghent. Out of these 688 patients, 54 patients (7.8%) required tertiary surgery with autologous tissue after failure of implant breast reconstruction. RESULTS: The first reconstructive surgery involved 38 unilateral and 16 bilateral cases with a total of 70 operated breasts. A further 11 breasts were reconstructed following risk-reducing mastectomy or at the patient's request for aesthetic reasons. Out of 81 free-flap reconstructions, the deep inferior epigastric artery perforator (DIEAP) flap was the most harvested at 66 (81%). The mean±SD operating time was 7.2±1.8 h and the mean hospital stay was 7.2±1.9 days. One total flap loss (1.2%) occurred. The mean follow-up was 31 months with a range between 3 months and 6 years. During follow-up, 30 patients (55.5%) needed secondary procedures to improve the aesthetic outcome. Donor-site corrections were performed in 18 patients (33%). Revisions of the breast flap were performed in 29 patients (53%). CONCLUSIONS: Restoring the breast envelope and footprint, in addition to excision of scar tissue, is the key step in breast reconstruction. Further corrections are required depending on the amount of the initial damage to the breast or subsequent postoperative complications.

Technical tips for safe perforator vessel dissection applicable to all perforator flaps.

The introduction of perforator flaps by Koshima and Soeda in 1989 was met with much animosity in the surgical community. The flaps challenged conventional teaching and were often branded as being unsafe. Surgeries using perforator flaps are now routinely practiced all over the world, with increasing emphasis on minimizing donor site morbidity, and perforator flaps are becoming the current gold standard. The simple principles and techniques of perforator dissection can be applied to all perforator flaps, provided the surgeon has an intimate knowledge of the regional anatomy. Thus, virtually any piece of skin can be harvested as long as it incorporates a feeding vessel. This article highlights the essential techniques in planning and raising perforator flaps and the common pitfalls to be avoided.

A prospective randomized trial of the efficacy of marginal quilting sutures and fibrin sealant in reducing the incidence of seromas in the extended latissimus dorsi donor site.

BACKGROUND: The extended latissimus dorsi is a workhorse flap and plays an important role in breast reconstruction. Unfortunately, seromas at the flap donor site are a frustrating problem complicating many procedures. The purpose of this study was to evaluate the efficacy of a combination of fibrin sealant (Quixil; Johnson & Johnson, Langhorne, Pa.) and limited quilting sutures at reducing seroma formation. METHODS: This was a prospective, double-blinded, clinical trial under a single surgeon. Twenty-six patients were enrolled in the study, and all were followed up for a period of 6 months. The patients were randomized to receive either quilting sutures only (group 1) or a combination of Quixil sealant and marginal quilting sutures (group 2). RESULTS: The incidence of seroma was 23.1 percent in group 1 and 7.7 percent in group 2 (odds ratio, 0.28; relative risk, 0.33). The mean total volume aspirated was significantly higher in group 1 (196.7 ml compared with 30 ml, p = 0.01). The average number of aspirations was 2.7 in group 1 compared with one in group 2. There was a significant reduction in inpatient stay for group 2 by 2 days (p = 0.01). Operative time was shortened by an average of 25 minutes. CONCLUSIONS: The combination of fibrin sealant and marginal quilting sutures significantly reduces total drainage, hospital stay, and seroma formation. In the authors' opinion, the benefits of seroma prevention outweigh the extra costs associated with this product. The potential, albeit small, risk of virus transmission and allergic reaction, however, needs to be taken into consideration, as with any blood transfusion product.

Gigantomastia--a classification and review of the literature.

INTRODUCTION: Gigantomastia is a rare, psychologically and physically disabling condition characterised by excessive breast growth. To date, there is no universal classification or accepted definition for this condition. Many authors cite gigantomastia as breast enlargement that requires reduction of over 1500 g per breast. However, there is discordance in the literature with the weight of reduction ranging from 0.8 to 2 kg, or even a D cup bra size. Practically this is a postoperative definition which is of little use to the clinician in terms of patient management or prognosis. METHOD: We conducted a literature review and meta analysis of all published cases of gigantomastia. We combined this with seven cases managed at Selly Oak Hospital, Birmingham, to give us a series of 115 patients. In order to devise a universally accepted definition of gigantomastia, a survey of 150 plastic surgery consultants within Europe was conducted. Participants were e-mailed a questionnaire, requesting their definition of gigantomastia with an appropriate excision weight. They were also asked to comment on any preoperative measurements taken to establish this predicted weight. CONCLUSION: We propose a classification of gigantomastia based on the cause, management and prognosis of the disease.

Thumb subungual melanoma: is amputation necessary?

Subungual melanoma is uncommon. Traditional teaching advocates amputation of the affected digit. Recent studies have shown that more distal levels of amputations do not compromise survival or recurrence rates. When the thumb is involved, functional and aesthetic loss can be substantial. We present a new conservative, digit-sparing approach in the treatment of subungual melanoma of the thumb. Four informed patients were recruited to undergo the new treatment. Local excision with 1cm margins down to and including the periosteum was carried out. Reconstruction was with a local flap. There has been one recurrence and no deaths with a minimum of 6 years follow up. In selected cases, conservative management of subungual melanoma allows preservation of length and minimises disability.

Soft fluted silicone drains: a prospective, randomized, patient-controlled study.

BACKGROUND: For some patients, removal of surgical drains can be the most painful part of surgery. The authors present a prospective, randomized, patient-controlled study comparing soft fluted silicone (Blake) drains with conventional rigid (Portavac) drains. METHODS: After ethical committee approval, 43 patients undergoing bilateral breast reduction surgery were recruited into the study. A Blake drain was inserted on one side and a Portavac drain was inserted on the contralateral side; the patients therefore acted as their own controls. Pain scores were measured on a descriptive scale 10 minutes before, during, and 10 minutes after drain removal. Statistical analysis was carried out using the Wilcoxon signed ranks matched pairs test. RESULTS: The results show that Blake drains are less painful before (p = 0.05), during (p = 0.01), and after removal (p = 0.009). Of those patients who expressed a preference, 27 preferred the Blake drain and 10 preferred the Portavac drain. CONCLUSION: The authors advocate the use of a silicone fluted (Blake) drain for any wound requiring drainage, especially if large-caliber drains are indicated.

Blindness after blunt facial trauma: are there any clinical clues to early recognition?

BACKGROUND: Vision-threatening injury is a relatively rare but devastating complication of maxillofacial trauma. Identification is not always straightforward. The purpose of this study was to look at our experience of blindness after blunt facial injuries to see whether any useful patterns or risk factors were identified to assist in early recognition. METHODS: This was a retrospective, qualitative study undertaken at the University Hospital of North Staffordshire. All case notes, plain radiographs, and computed tomographic scans were reviewed and the relevant data collated. RESULTS: Over a 10-year period, 17 patients were identified in which loss of vision occurred secondary to blunt injury to the face. CONCLUSION: It is important to maintain a high index of suspicion when dealing with maxillofacial trauma, particularly if the patient is not cooperative. We provide a list of salient features to look for in the examination and history to aid the clinician.

Emergency care in facial trauma--a maxillofacial and ophthalmic perspective.

Facial trauma, with or without life- and sight-threatening complications, may arise following isolated injury, or it may be associated with significant injuries elsewhere. Assessment needs to be both systematic and repeated, with the establishment of clearly stated priorities in overall care. Although the American College of Surgeons Advanced Trauma Life Support (ATLS) system of care is generally accepted as the gold standard in trauma care, it has potential pitfalls when managing maxillofacial injuries, which are discussed. Management of facial trauma can arguably be regarded as "facial orthopaedics", as both specialities share common management principles. This review outlines a working approach to the identification and management of life- and sight-threatening conditions following significant facial trauma.