Extended applications of gauze-based negative pressure wound therapy in hand surgery: a review of five cases.

UNLABELLED: Negative pressure wound therapy (NPWT) is an established treatment for a wide variety of acute and chronic wounds. Although the exact mechanism of action is still undefined, the proposed benefits of NPWT have been well described in the literature and include improved wound perfusion, granulation and reduction of oedema and bacteria. Here we describe a series of five challenging cases where NPWT dressings were applied for both elective and traumatic wounds of the upper limb. We describe the application of the dressing and the benefits seen in our patients. We believe the patients would have had inferior outcomes if managed by the best alternative conventional dressings. DECLARATION OF INTEREST: All named authors hereby declare that they have no conflicts of interest to disclose.

Ligating perforators in abdominoplasty reduces the risk of seroma.

BACKGROUND: Seroma formation, a common complication of abdominoplasty, can cause patient discomfort and inconvenience. This study aimed to compare seroma rates after ligation and diathermy of large abdominal perforating vessels during abdominoplasty. METHODS: Consecutive patients undergoing abdominoplasty with epigastric undermining between 2004 and 2011 were studied. Body mass index (BMI), age at operation, smoking history, preoperative weight loss, operative details, perioperative fluid infiltration, concomitant abdominal liposuction, ligation of perforators by clips, suture or diathermy, use of quilting sutures, weight of tissue removed, postoperative drainage, inpatient stay, and seroma rates were recorded. Statistical analysis was undertaken using the unpaired t test, Fisher's exact test, the Mann-Whitney U test, and Kendall's tau-b test. RESULTS: The study included 90 patients. The incidence of seroma was significantly lower among the patients who had perforators ligated (4/60, 6.7%) than among those who had diathermy (10/30, 33%) (p=0.002, Fisher's exact test). Seroma formation was significantly associated with a higher BMI, (27.45 vs. 25.16 kg/m2; p=0.025, t test) but not with preoperative weight loss. Postoperative fluid drainage did not differ significantly between ligated and diathermied perforators (p=0.716 Mann-Whitney U test). CONCLUSIONS: Use of ligation by clip or suture rather than by diathermy to ablate large abdominal perforators significantly reduced the incidence of seroma among abdominoplasty patients. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Prosthetic metal implants and airport metal detectors.

INTRODUCTION: Metal detectors have been present in airports and points of departure for some time. With the introduction of heightened security measures in response to fears of an increased threat of terrorism, they may become more prevalent in other public locations. The aim of this study was to ascertain which prosthetic devices activated metal detector devices used for security purposes. METHODS: A range of prosthetic devices used commonly in orthopaedic and plastic surgery procedures were passed through an arch metal detector at Birmingham Airport in the UK. Additionally, each item was passed under a wand detector. Items tested included expandable breast prostheses, plates used in wrist and hand surgery, screws, K-wires, Autosuture™ ligation clips and staples. RESULTS: No prostheses were detected by the arch detector. The expandable implants and wrist plates were the only devices detected by passing the wand directly over them. No device was detected by the wand when it was under cover of the axillary soft tissue. Screws, K-wires, Autosuture™ clips and staples were not detected under any of the study conditions. CONCLUSIONS: Although unlikely to trigger a detector, it is possible that an expandable breast prosthesis or larger plate may do so. It is therefore best to warn patients of this so they can anticipate detection and further examination.

Outcomes in the repair of pilonidal sinus disease excision wounds using a parasacral perforator flap.

INTRODUCTION: The ideal treatment for pilonidal sinus disease has yet to be defined. There are many approaches described in the literature. METHODS: Thirty-five consecutive patients who underwent wide excision of pilonidal sinus disease had the wound repaired using a parasacral perforator flap. Outcomes were assessed by case notes analysis and follow-up telephone and postal questionnaires. RESULTS: There were ten minor complications including six minor wound edge dehiscences. There were two ischaemic complications, with one flap loss. There were 3 recurrences of pilonidal disease at a mean follow-up of 33 months, giving a 5-year recurrence free rate of 86%. Of the patients questioned, all would recommend the procedure to someone else despite 69% being dissatisfied with the cosmetic outcome. CONCLUSIONS: This series indicates that the parasacral perforator flap technique is able to repair pilonidal sinus excision wounds successfully with minimal morbidity and a low recurrence rate at a mean of follow-up of 33 months. The study suggests that it may be a technique best reserved for recurrent cases of pilonidal sinus disease. Patients feel the procedure is successful despite reservations regarding the cosmetic outcome.

The evolution of a hand day-surgery unit.

INTRODUCTION: Following the merger of two major units to form a regional centre for plastic surgery in the West Midlands, acute hand surgery referrals reached overwhelming proportions. This study describes audits performed at three time points. The first highlighted the extent of in-patient delay and was instrumental in the subsequent development of a dedicated hand trauma day-case unit. PATIENTS AND METHODS: Data were collected on 77 patients in June 2002, 109 patients in November 2003 and 90 patients in November 2004. The day-case unit opened on 1 November 2003. RESULTS: The number of bed-days per patient fell from 2.63 to 1.34 (P < 0.001) over the study period. In November 2004, 51% of patients received a day-case procedure. Importantly, if admission was required at initial presentation, the delay to theatre reduced from 1.5 bed-days per patient in June 2002 to 0.6 in November 2004. Overall, the in-patient delay was significantly reduced (P < 0.001) but time from presentation to theatre was not significantly affected (P = 0.119). CONCLUSIONS: This series of audits confirmed that a significant number of acute hand injuries are suitable for day-case procedures and that simple audit can lead to a significant change in service provision. Improvements were demonstrated in reduced in-patient delay and total stay. We hope that other units find our experience useful given that it may be possible to apply this approach to other forms of ambulatory trauma.

A-a type, arterialized, venous, flow-through, free flap for simultaneous digital revascularization and soft tissue reconstruction-revisited.

Significant soft tissue injuries to palmar surfaces are frequently associated with digital vessel damage. Flap coverage might have to be combined with microsurgical revascularization using vein grafts if the digit is to be salvaged. Two cases of simultaneous digital revascularization and soft tissue reconstruction using an arterialized, venous flow-through flap are presented in detail. These flaps initially "pinked up" for 24 to 48 hours. This was followed by a period of venous congestion lasting approximately 1 week, after which flap perfusion gradually returned to normal. Good long-term functional and cosmetic results were achieved. Distal finger perfusion was maintained in both cases. This technique, although previously described, has not been popularized. It should be considered early in reconstruction of ischemic digits requiring simultaneous vascular and soft tissue reconstruction.

A prospective, controlled, randomized trial comparing early active extension with passive extension using a dynamic splint in the rehabilitation of repaired extensor tendons.

This prospective, randomized, controlled trial compared two methods of rehabilitating extensor tendon repairs in zones IV-VIII. Group A patients followed an early active mobilization regimen and Group B patients followed a dynamic splintage regimen. Data on 19 patients in Group A and 17 patients in Group B were collected at 4 weeks and at final follow-up (3 months median follow-up for both groups). Extension lag, flexion deficit and total active motion (TAM) were measured. At 4 weeks, patients in Group B had a better TAM (median 87%, range 56-102%) compared to patients in Group A (median 77%, range 52-97%). At final follow-up, there were no significant differences in the results of the two groups. There were no ruptures in either group.

Metacarpal descent, definition and normal range.

Metacarpal descent, an indication of carpometacarpal (CMC) joint mobility, was measured in 90 normal subjects by assessing the alignment of the metacarpal heads with the hand in a relaxed posture and when making a tight fist. Metacarpal descent was greater in women. Hand dominance was associated with an increase in positional angles but not metacarpal descent.

A qualitative histological assessment of various storage conditions on short term preservation of human split skin grafts.

This paper provides a qualitative description of the histological appearances and changes occurring in human split skin grafts stored at 4 degrees C in various configurations over a 4-week period. During the storage time, changes were seen in all layers of the epidermis and dermis. The most notable early features were nuclear and cellular swelling and pleomorphism. After 7 days nuclear and cellular shrinkage, halo formation and pyknosis became evident. The most worrying histological feature was the development of dermo-epidermal blebs. These were evident by day 7 and progressed to cleavage of, and ultimately complete separation of, the epidermis from the dermis.A comparison of these features in human split skin grafts stored as sheets or meshed 1(1)(2):1, stored either rolled or flat, at either strictly or roughly 4 degrees C revealed differences. We conclude that the viability of stored skin is improved if it is stored at a uniform 4 degrees C as rolled sheets.

Donor finger morbidity in cross-finger flaps.

We reviewed 16 patients who had cross-finger flap procedures carried out between 1991 and 1996 at the West Midlands Regional centre for Plastic and Reconstructive Surgery. We looked specifically at the donor finger morbidity of each patient with a median follow up interval of 43 months.At follow up there were 10 patients with cold intolerance, eight patients with subjective joint stiffness and a documented reduced range of finger joint movement. Skin graft reconstruction of the secondary defect was associated with poor colour match in eight cases (seven hyperpigmented, one hypopigmented) and visible contour deformity in eight cases. There were no clinically significant differences between split skin graft or full thickness skin graft for donor finger reconstruction. Although cross-finger flaps may provide soft tissue cover in a variety of finger pulp injuries, these results show an alarming incidence of donor finger morbidity associated with such procedures.

A 5-year audit of trainees experience and outcomes with two-stage hypospadias surgery.

The results of a 5-year audit of trainee plastic surgeons' experience and outcomes with two-stage hypospadias surgery are presented. Between June 1991 and October 1996, 87 patients had at least one of their operations performed by trainees; 79 patients had completed their surgery and were available for study. All patients underwent two-stage hypospadias correction; median duration of follow-up was 707 days. 69.5% of patients required correction of glans tilt and/or chordee correction; a small meatus was present in 62%. Trainees performed 73.2% of the first stage surgery (23.2% supervised by the consultant and 50% as most senior surgeon). The total complication rate for the first stage was 6.1%; the complications were: residual chordee and/or insufficient skin graft take (4 cases) and haematoma (1 case). Trainees performed 58.2% of the second stage surgery (24.1% supervised by the consultant and 34.2% as most senior surgeon). The fistula rate for the trainee stage 2 cases was 15.2% and the stricture rate 4.3%. All fistulae and strictures were successfully treated by one additional procedure. Complications rates for the first stage were similar between grades; consultant 4.5%; supervised trainee 5.3% and unsupervised trainee 7.3%. However, unsupervised trainees had a much higher complication rate for the second stage: 29.6%, versus consultant 3.0% and supervised trainee 5.3%. These complication rates represent the cumulative learning curve of 17 trainee surgeons. Outcomes for two individual trainees after the same number of cases (47) were studied further. These trainees had the highest and lowest complication rates for the procedure; 24% versus 9%. These figures might better reflect the range of the learning curve of this procedure. A major difference between these two trainees was the time taken to accrue 47 cases; 15 months versus 25. In the former case this concentration of training was felt to be beneficial. Further analysis of one trainee's results suggested that complications occur early in the learning curve and with appropriate supervision acceptable complication rates can be achieved.

A survey of general surgeons' attitudes towards breast reconstruction after mastectomy.

Within the last 15-20 years there have been many changes in the management of breast cancer. Along with changes in treatment, possibilities for breast reconstruction have become increasingly sophisticated and commonplace. Despite the availability of breast reconstruction, we have noted large variations in referral patterns. Because the surgical treatment of breast cancer is largely undertaken by general surgeons, we investigated general surgeons' attitudes towards reconstruction using a postal questionnaire. In 1995, a questionnaire involving hypothetical criticisms was sent to general surgical members of the Association of Surgeons of Great Britain and Ireland. A total of 136 surgeons responded, 79 (58%) of whom had a specialist interest in breast cancer. Each surgeon saw an average of 68 new cases of breast cancer per year (range 0-400). The general surgeons were concerned about three areas: (1) 32.3% felt that breast reconstruction might adversely delay the detection of local recurrence; (2) 16.6% were worried that breast reconstruction has high morbidity; and (3) 17.4% said that patients did not want breast reconstruction despite being advised of its availability. To investigate these concern's further, an extensive literature search was undertaken. There is no evidence that breast reconstruction delays the detection of local recurrence. With appropriate patient selection, the morbidity of reconstructive options appears very acceptable. Finally, immediate breast reconstruction has psychological benefits when compared with delayed reconstruction.

Preventing seroma in the latissimus dorsi flap donor site.

A technique for preventing seroma in latissimus dorsi flap donor sites is presented. The procedure involves quilting the donor site skin flaps to the underlying tissues with absorbable sutures. In a single surgeon series, a retrospective group (n = 16) of non-quilted donor sites was compared to a prospective group of quilted donor sites (n = 11). The age range and indications for surgery were similar for each group. The incidence of donor site seroma was reduced from 56% to 0% after introduction of the new technique (P = 0.003). The mean volume of postoperative drainage was significantly less in the quilted group (320 ml vs. 608 ml; P < 0.05) and the drains were removed significantly earlier (mean 3.9 days vs. 7.3 days; P < 0.01). There was no significant difference in donor site drainage and time to drain removal between the non-quilted group that developed a seroma and those that did not. The procedure is easy to learn, straightforward to perform and requires no special instrumentation. We commend it to all surgeons who use latissimus dorsi flaps.