Fostering innovation and sustainable thinking in surgery: an evaluation of a surgical hackathon.

INTRODUCTION: Surgery represents a major source of carbon emissions, with numerous initiatives promoting more sustainable practices. Healthcare innovation and the development of a digitally capable workforce are fundamental in leveraging technologies to tackle challenges, including sustainability in surgery. METHODS: A surgical hackathon was organised with three major themes: (1) how to make surgery greener, (2) the future of plastic surgery in 10 years, and (3) improving healthcare outcomes using machine learning. Lectures were given on sustainability and innovation using the problem, innovation, market size, strategy and team (PIMST) framework to support their presentations, as well as technological support to translate ideas into simulations or minimum viable products. Pre- and post-event questionnaires were circulated to participants. RESULTS: Most attendees were medical students (65%), although doctors and engineers were also present. There was a significant increase in delegates' confidence in approaching innovation in surgery (+20%, p < 0.001). Reducing waste packaging (70%), promoting recyclable material usage (56%) and the social media dimension of public perceptions towards plastic surgery (40%) were reported as the most important issues arising from the hackathon. The top three prizes went to initiatives promoting an artificial intelligence-enhanced operative pathway, instrument sterilisation and an educational platform to teach students research and innovation skills. CONCLUSIONS: Surgical hackathons can result in significant improvements in confidence in approaching innovation, as well as raising awareness of important healthcare challenges. Future innovation events may build on this to continue to empower the future workforce to leverage technologies to tackle healthcare challenges such as sustainability.

Preoperative CT imaging as a tool to predict incisional hernia outcomes following abdominal wall reconstruction: A retrospective cohort analysis.

INTRODUCTION: Ventral wall hernia often causes significant morbidity and requires complex abdominal wall reconstruction (AWR). This study aims to determine whether subcutaneous abdominal fat thickness (AFT) measured with preoperative CT scans could predict postoperative outcomes in patients undergoing AWR. METHODS: A retrospective cohort study was conducted on all patients who underwent AWR at our institution between 2009 and 2021, with a minimum follow-up of 12 months. Using preoperative CT scans, AFT was measured at the xiphoid process, umbilicus, and pubic tubercle, as well as the hernia dimensions. Demographic, operative, and surgical outcome data were also collected and analyzed using statistical tests. RESULTS: The results showed that 9 of 101 patients (8.9%) experienced hernia recurrence. Smoking was associated with an increased risk of hernia recurrence (p < 0.001) with a predictive odds ratio (OR) of 18.27 (p = 0.041). Increased AFT at the xiphoid (p = 0.005), umbilicus (p < 0.001), and pubic tubercle (p < 0.001) were also associated with hernia recurrence and risk of infection. Only AFT at the pubic tubercle reached significance in the regression model predicting recurrence (OR=1.10; p = 0.030) and infection (OR=1.04; p = 0.021). A cut-off value of 67 mm was associated with a positive predictive value of 42.14% (sensitivity of 67% and specificity of 91%). Hernia defect area was not associated with risk of recurrence or infection. CONCLUSIONS: Smoking and increased AFT at the pubic tubercle are significant predictive factors for recurrence and infection in patients undergoing AWR, and preoperative optimization should focus on reducing these factors.

Achieving optimal clinical outcomes in autologous fat grafting: A systematic review of processing techniques.

BACKGROUND: Autologous fat grafting (AFG) is a versatile technique in reconstructive and cosmetic surgery. Graft processing is a key source of variability resulting in unreliable clinical outcomes, with no consensus on the optimal methodology. This systematic review identifies the evidence base supporting different processing paradigms. METHODS: A systematic literature search was conducted using the PubMed, Scopus and The Cochrane Foundation databases. Studies comparing AFG processing methods and reporting long-term patient outcomes were identified. RESULTS: Twenty-four studies (2413 patients) were identified. Processing techniques evaluated included centrifugation, decantation, washing, filtration, gauze rolling, as well as commercial devices and adipose-derived stem/stromal cell (ASC) enrichment methods. Objective volumetric and subjective patient-reported outcomes were discussed. There was a variable reporting of complications and volume retention rates. Complications were infrequent; palpable cysts (0-20%), surgical-site infections (0-8%) and fat necrosis (0-58.4%) were the most reported. No significant differences in long-term volume retention between techniques were found in AFG in the breast. In head and neck patients, greater volume retention was documented in ASC enrichment (64.8-95%) and commercial devices (41.2%) compared to centrifugation (31.8-76%). CONCLUSIONS: Graft processing through washing and filtration, including when incorporated into commercial devices, results in superior long-term outcomes compared to centrifugation and decantation methods. ASC enrichment methods and commercial devices seem to have superior long-term volume retention in facial fat grafting.

Comparison of the compressive mechanical properties of auricular and costal cartilage from patients with microtia.

Children born with a small or absent ears undergo surgical reconstruction to restore their auricle. Currently, rib (costal) cartilage is used to carve the auricle. However as alternative, tissue engineered and synthetic materials are being developed to restore the auricle shape to overcome donor site morbidity and limited availability of rib cartilage. However, to date there is limited knowledge regarding the mechanical properties of the auricular and costal cartilage to optimise the required compressive properties of the graft. The remnant auricular and costal cartilage from 20 patients undergoing stage-1 microtia surgery was harvested. On the day of surgery, the cartilage was evaluated in compression, with each sample loaded to 300 g at 1 mm/s. RESULTS: The costal cartilage was observed to have a significantly higher Young's Elastic Modulus than auricular cartilage (average costal cartilage 11.43 MPa vs average auricular cartilage 2 MPa, p < 0.0001). The auricular cartilage showed a significantly higher relaxation rate than costal cartilage (average costal cartilage 0.72 MPa10-4 vs average auricular cartilage 1.93 MPa10-4, p < 0.05). The final absolute relaxation was significantly lower for elastic cartilage than costal cartilage (average costal cartilage 3.35 MPa vs average auricular cartilage 0.2 MPa, p < 0.0001). Alloplastic cartilage replacements used as alternatives for reconstruction were also evaluated. Silicone, Gore-Tex and Medpor were observed to have significantly higher Young's Elastic Modulus than costal and auricular cartilage. Costal cartilage has a higher Young's Elastic Modulus in compression compared to auricular cartilage. Current synthetic materials used to replace synthetic cartilage do not mimic costal cartilage, which should be addressed in the future.

Breast Reconstruction with a Tissue Engineering and Regenerative Medicine Approach (Systematic Review).

Current techniques for breast reconstruction include an autologous-tissue flap or an implant-based procedure, although both can impose further morbidity. This systematic review aims to explore the existing literature on breast reconstruction using a tissue engineering approach; conducted with the databases Medline and Embase. A total of 28 articles were included, mainly comprising of level-5 evidence with in vitro and animal studies focusing on utilizing scaffolds to support the migration and growth of new tissue; scaffolds can be either biological or synthetic. Biological scaffolds were composed of collagen or a decellularized tissue matrix scaffold. Synthetic scaffolds were primarily composed of polymers with customisable designs, adjusting the internal morphology and pore size. Implanting cells, including adipose-derived stem cells, with combined use of basic fibroblast growth factor has been studied in an attempt to enhance tissue regeneration. Lately, a level-4 evidence human case series was reported; successfully regenerating 210 mL of tissue using an arterio-venous pedicled fat flap within a tissue engineering chamber implanted on the chest wall. Further research is required to evaluate whether the use of cells and other growth factors could adjust the composition of regenerated tissue and improve vascularity; the latter a major limiting factor for creating larger volumes of tissue.

Pursing a career in academic surgery among African American medical students.

BACKGROUND: There are few African American students in medical school, and even fewer are choosing academic surgical careers. The objective of this study is to provide insight into what barriers URM students perceive when considering a career in academic surgery. METHODS: This qualitative, descriptive study was conducted at the University of Pennsylvania. Sixteen African American students with an interest in surgery were recruited to participate in the study. The outcomes reported are themes of how participants perceive the challenges of pursuing an academic surgical career. RESULTS: Barriers to pursuing a career in academic surgery cited by students included lifestyle concerns, financial pressures, having to work in a predominantly white environment, lack of mentorship, feelings of having to prove oneself, stressful environments and concerns of being a minority female in surgery. CONCLUSIONS: These study findings indicate that the persistent dearth of African-Americans in academic surgery is likely multi-factorial. Some ways surgical leadership can begin addressing these issues is through establishment of formal mentorship programs, ensuring non-discriminatory recruiting processes, having explicit goals of improving diversity and supporting pipeline programs.

Argon plasma surface modification promotes the therapeutic angiogenesis and tissue formation of tissue-engineered scaffolds in vivo by adipose-derived stem cells.

BACKGROUND: Synthetic implants are being used to restore injured or damaged tissues following cancer resection and congenital diseases. However, the survival of large tissue implant replacements depends on their ability to support angiogenesis that if limited, causes extrusion and infection of the implant. This study assessed the beneficial effect of platelet-rich plasma (PRP) and adipose-derived stem cells (ADSCs) on synthetic biomaterials in combination with argon plasma surface modification to enhance vascularisation of tissue-engineered constructs. METHODS: Non-biodegradable polyurethane scaffolds were manufactured and modified with plasma surface modification using argon gas (PM). Donor rats were then used to extract ADSCs and PRP to modify the scaffolds further. Scaffolds with and without PM were modified with and without ADSCs and PRP and subcutaneously implanted in the dorsum of rats for 3 months. After 12 weeks, the scaffolds were excised and the degree of tissue integration using H&E staining and Masson's trichrome staining, angiogenesis by CD31 and immune response by CD45 and CD68 immunohistochemistry staining was examined. RESULTS: H&E and Masson's trichrome staining showed PM+PRP+ADSC and PM+ADSC scaffolds had the greatest tissue integration, but there was no significant difference between the two scaffolds (p < 0.05). The greatest vessel formation after 3 months was shown with PM+PRP+ADSC and PM+ADSC scaffolds using CD31 staining compared to all other scaffolds (p < 0.05). The CD45 and CD68 staining was similar between all scaffolds after 3 months showing the ADSCs or PRP had no effect on the immune response of the scaffolds. CONCLUSIONS: Argon plasma surface modification enhanced the effect of adipose-derived stem cells effect on angiogenesis and tissue integration of polyurethane scaffolds. The combination of ADSCs and argon plasma modification may improve the survival of large tissue implants for regenerative applications.

Systematic review of methodologies used to assess mastectomy flap viability.

BACKGROUND: Accurate prediction of mastectomy skin flap viability is vital as necrosis causes significant morbidity, potentially compromising results and delaying oncological management. Traditionally assessed by clinical judgement, a more objective evaluation can be provided using intraoperative imaging modalities. This systematic review aimed to compare all intraoperative techniques for assessment of mastectomy flap viability. METHODS: A systematic literature review was performed using MEDLINE and Embase databases. Primary outcomes reported included specificity, sensitivity and predictive values of each test, and mean rates of mastectomy flap necrosis and reoperation. Secondary outcomes included cost analysis. RESULTS: Some 18 studies were included. Designs were prospective cohort study (8), retrospective case series (4), prospective case series (3), retrospective case-control study (1), prospective pilot trial (1) and cost analysis study (1). The studies compared indocyanine green angiography (ICGA) (16 studies) and fluorescein dye angiography (FA) (3 studies) with clinical judgement. Sensitivity and specificity were highest for ICGA (5 studies) ranging from 38 to 100 and 68 to 91 per cent respectively. Both methods overpredicted necrosis. Mean rates of flap necrosis and reoperation decreased with ICGA (7·9 and 5·5 per cent respectively) and FA (3 and 0 per cent) compared with clinical judgement (19·4 and 12·9 per cent). Two studies were designed to define numerical parameters corresponding to perfusion using intraoperative techniques. Two studies performed a cost analysis for ICGA; one claimed a cost benefit and the other advocated its use in high-risk patients only. CONCLUSION: ICGA and FA are potentially useful tools for mastectomy flap assessment. However, the predictive accuracy is subject to the specific settings and model of equipment used. Current recommendations support their use in high-risk patients.

Comparison of the mechanical properties of different skin sites for auricular and nasal reconstruction.

BACKGROUND: Autologous and synthetic nasal and auricular frameworks require skin coverage. The surgeon's decides on the appropriate skin coverage for reconstruction based on colour matching, subcutaneous tissue thickness, expertise and experience. One of the major complications of placing subcutaneous implants is the risk of extrusion (migration through the skin) and infection. However, knowledge of lessening the differential between the soft tissue and the framework can have important implications for extrusion. This study compared the mechanical properties of the skin commonly used as skin sites for the coverage in auricular and nasal reconstruction. METHODS: Using ten fresh human cadavers, the tensile Young's Modulus of the skin from the forehead, forearm, temporoparietal, post-auricular and submandibular neck was assessed. The relaxation rate and absolute relaxation level was also assessed after 90 min of relaxation. RESULTS: The submandibular skin showed the greatest Young's elastic modulus in tension of all regions (1.28 MPa ±0.06) and forearm showed the lowest (1.03 MPa ±0.06). The forehead demonstrated greater relaxation rates among the different skin regions (7.8 MPa-07 ± 0.1). The forearm showed the lowest rate of relaxation (4.74 MPa-07 ± 0.1). The forearm (0.04 MPa ±0.004) and submandibular neck skin (0.04 MPa ±0.005) showed similar absolute levels of relaxation, which were significantly greater than the other skin regions (p < 0.05). CONCLUSIONS: This study provides an understanding into the biomechanical properties of the skin of different sites allowing surgeons to consider this parameter when trying to identify the optimal skin coverage in nasal and auricular reconstruction.

Necrotising fasciitis caused by metastatic endometrial cancer: a rare cause of a life-threatening condition.

We report a case of necrotising fasciitis caused by metastatic endometrial adenocarcinoma. Metastases to the lumbar spine with local invasion to the iliopsoas muscle led to an iliopsoas abscess, which subsequently progressed to necrotising fasciitis of the flank. This patient lacked common risk factors for necrotising fasciitis. There are no previous reports in the literature of necrotising fasciitis with this aetiology. We discuss the available evidence for aetiology of and risk factors for necrotising fasciitis, and the relation of time to surgery with prognosis.

Biomechanical Characterisation of the Human Auricular Cartilages; Implications for Tissue Engineering.

Currently, autologous cartilage provides the gold standard for auricular reconstruction. However, synthetic biomaterials offer a number of advantages for ear reconstruction including decreased donor site morbidity and earlier surgery. Critical to implant success is the material's mechanical properties as this affects biocompatibility and extrusion. The aim of this study was to determine the biomechanical properties of human auricular cartilage. Auricular cartilage from fifteen cadavers was indented with displacement of 1 mm/s and load of 300 g to obtain a Young's modulus in compression. Histological analysis of the auricle was conducted according to glycoprotein, collagen, and elastin content. The compression modulus was calculated for each part of the auricle with the tragus at 1.67 ± 0.61 MPa, antitragus 1.79 ± 0.56 MPa, concha 2.08 ± 0.70 MPa, antihelix 1.71 ± 0.63 MPa, and helix 1.41 ± 0.67 MPa. The concha showed to have a significantly greater Young's Elastic Modulus than the helix in compression (p < 0.05). The histological analysis demonstrated that the auricle has a homogenous structure in terms of chondrocyte morphology, extracellular matrix and elastin content. This study provides new information on the compressive mechanical properties and histological analysis of the human auricular cartilage, allowing surgeons to have a better understanding of suitable replacements. This study has provided a reference, by which cartilage replacements should be developed for auricular reconstruction.

Lipotransfer for radiation-induced skin fibrosis.

BACKGROUND: Radiation-induced fibrosis (RIF) is a late complication of radiotherapy that results in progressive functional and cosmetic impairment. Autologous fat has emerged as an option for soft tissue reconstruction. There are also sporadic reports suggesting regression of fibrosis following regional lipotransfer. This systematic review aimed to identify cellular mechanisms driving RIF, and the potential role of lipotransfer in attenuating these processes. METHODS: PubMed, OVID and Google Scholar databases were searched to identify all original articles regarding lipotransfer for RIF. All articles describing irradiated fibroblast or myofibroblast behaviour were included. Data elucidating the mechanisms of RIF, role of lipotransfer in RIF and methods to quantify fibrosis were extracted. RESULTS: Ninety-eight studies met the inclusion criteria. A single, definitive model of RIF is yet to be established, but four cellular mechanisms were identified through in vitro studies. Twenty-one studies identified connective tissue growth factor and transforming growth factor ß1 cytokines as drivers of fibrotic cascades. Hypoxia was demonstrated to propagate fibrogenesis in three studies. Oxidative stress from the release of reactive oxygen species and free radicals was also linked to RIF in 11 studies. Purified autologous fat grafts contain cellular and non-cellular properties that potentially interact with these processes. Six methods for quantifying fibrotic changes were evaluated including durometry, ultrasound shear wave elastography, thermography, dark field imaging, and laser Doppler and laser speckle flowmetry. CONCLUSION: Understanding how lipotransfer causes regression of RIF remains unclear; there are a number of new hypotheses for future research.

Optimising faecal occult blood screening:retrospective analysis of NHS Bowel Cancer Screening data to improve the screening algorithm.

BACKGROUND: Colorectal neoplasia causes bleeding, enabling detection using Faecal Occult Blood tests (FOBt). The National Health Service (NHS) Bowel Cancer Screening Programme (BCSP) guaiac-based FOBt (gFOBt) kits contain six sample windows (or 'spots') and each kit returns either a positive, unclear or negative result. Test kits with five or six positive windows are termed 'abnormal' and the subject is referred for further investigation, usually colonoscopy. If 1-4 windows are positive, the result is initially 'unclear' and up to two further kits are submitted, further positivity leads to colonoscopy ('weak positive'). If no further blood is detected, the test is deemed 'normal' and subjects are tested again in 2 years' time. We studied the association between spot positivity % (SP%) and neoplasia. METHODS: Subjects in the Southern Hub completing the first of two consecutive episodes between April 2009 and March 2011 were studied. Each episode included up to three kits and a maximum of 18 windows (spots). For each positivity combination, the percentage of positive spots out of the total number of spots completed by an individual in a single-screening episode was derived and named 'SP%'. Fifty-five combinations of SP can occur if the position of positive/negative spots on the same test card is ignored.The proportion of individuals for whom neoplasia was identified in Episode 2 was derived for each of the 55 spot combinations. In addition, the Episode 1 spot pattern was analysed for subjects with cancer detected in Episode 2. RESULTS: During Episode 2, 284,261 subjects completed gFOBT screening and colonoscopies were performed on 3891 (1.4%) subjects. At colonoscopy, cancer was detected in 7.4% (n=286) and a further 39.8% (n=1550) had adenomas. Cancer was detected in 21.3% of subjects with an abnormal first kit (five or six positive spots) and in 5.9% of those with a weak positive test result.The proportion of cancers detected was positively correlated with SP%, with an R(2) correlation (linear) of 0.89. As the SP% increased from 11 to 100%, so the colorectal cancer (CRC) detection rate increased from 4 to 25%. At the lower SP%s, from 11to 25%, the CRC risk was relatively static at ~4%. Above an SP% of 25%, every 10-percentage points increase in the SP%, was associated with an increase in cancer detection of 2.5%. CONCLUSIONS: This study demonstrated a strong correlation between SP% and cancer detection within the NHS BCSP. At the population level, subjects' cancer risk ranged from 4 to 25% and correlated with the gFOBt spot pattern.Some subjects with an SP% of 11% proceed to colonoscopy, whereas others with an SP% of 22% do not. Colonoscopy on patients with four positive spots in kit 1 (SP% 22%) would, we estimate, detect cancer in ~4% of cases and increase overall colonoscopy volume by 6%. This study also demonstrated how screening programme data could be used to guide its ongoing implementation and inform other programmes.

A prospective study of the use of botulinum toxin injections in the treatment of Raynaud's syndrome associated with scleroderma.

Raynaud's syndrome contributes to the pain, paraesthesia, ulceration, and gangrene of scleroderma. Botulinum toxin has been shown to improve digital perfusion in patients with Raynaud's. This is the first study to objectively assess hand function following this treatment in patients with scleroderma. Twenty patients were treated with 100 units of botulinum toxin injected into the hand. An assessment of hand function and symptoms was performed prior to injection and then 8-12 weeks later. The outcomes assessed were change in pain, appearance, cold intolerance, pinch and power grip, ranges of movement, and Disabilities of the Arm, Shoulder and Hand (DASH) score. In total, 80% of patients reported an overall improvement in their symptoms, reduction in pain, and improved DASH score and 65% reported improvement in cold intolerance. Overall, 90% showed an improvement in pinch grip and 65% an improvement in power grip. Objective parameters were statistically significantly improved; however, subjective outcomes only showed a trend. We have found botulinum toxin to be an effective treatment for Raynaud's syndrome secondary to scleroderma.

Surface and mechanical analysis of explanted Poly Implant Prosthèse silicone breast implants.

BACKGROUND: The recent events surrounding Poly Implant Prosthèse (PIP) breast implants have renewed the debate about the safety profile of silicone implants. The intentional use of industrial-grade instead of certified medical-grade silicone is thought to be responsible for reportedly higher frequencies of implant rupture in vivo. The differences in mechanical and viscoelastic properties between PIP and medical-grade silicone implant shells were investigated. Surface characterization of shells and gels was carried out to determine structural changes occurring after implantation. METHODS: Breast implants were obtained from women at the Royal Free Hospital (London, UK). PIP implants were compared with medical-grade control silicone implants. Tensile strength, tear resistance and elongation at break were assessed using a tensile tester. Surfaces were analysed using attenuated total reflectance-Fourier transform infrared (ATR-FTIR) spectroscopy. Spearman correlation analyses and Kruskal-Wallis one-way statistical tests were performed for mechanical data. RESULTS: There were 18 PIP and four medical-grade silicone implants. PIP silicone shells had significantly weaker mechanical strength than control shells (P < 0·009). There were negative correlations between mechanical properties of PIP shells and implantation times, indicative of deterioration of PIP shells over time in vivo (r(s) = -0·75, P = 0·009 for tensile strength; r(s) = -0·76, P = 0·001 for maximal strain). Comparison of ATR-FTIR spectra of PIP and control silicones demonstrated changes in material characteristics during the period of implantation suggestive of time-dependent bond breakage and degradation of the material. CONCLUSION: This study demonstrated an increased weakness of PIP shells with time and therefore supports the argument for prophylactic removal of PIP breast implants.

The psychological impact of split-thickness skin grafts.

OBJECTIVE: To measure the psychological distress associated with a split-thickness skin graft (STSG). METHOD: A retrospective postal questionnaire survey of 102 patients who had undergone a STSG procedure within the last 3.5 years. Outcomes measures included the Hospital Anxiety and Depression Scale (HADS), Derriford Appearance Scale (DAS-59) and subjective rating scales (SRS) of noticeability and worry about the grafted and donor area. RESUTLS: Scores on the SRS correlated positively with HADS and DAS-59 scores. Rates of anxiety were higher than depression (19% vs 13%, respectively). Greater than 10% of the sample experienced significant appearance-related distress when compared to standardised test norms. Concerns about the grafted area were higher than for the donor site, but those concerned about the graft were also likely to be concerned about the donor area. Aged (< 60 years) and reason for surgery (trauma as opposed to cancer) were associated with significantly higher scores on appearance measures. CONCLUSION: STSG is not associated with high levels of psychological distress, However, there is a small but significant monitory who experience appearance-related distress, low mood and anxiety who would benefit from targeted psychological intervention, Demographic factors, such as age or gender, and length of time since surgery, are not useful discriminators in identifying vulnerable individuals. Simple SRS of visibility and worry correlate significantly with standardised psychological measures. These can be used as a short and effective screening tool to identify individuals who would benefit from postoperative psychological input. DECLARATION OF INTERNET: There were no external sources sources of funding for this study. The authors have no conflicts of interest to declare.

Beta cell nuclear musculoaponeurotic fibrosarcoma oncogene family A (MafA) is deficient in type 2 diabetes.

AIMS/HYPOTHESIS: The beta cell transcriptional factor musculoaponeurotic fibrosarcoma oncogene family A (MafA) regulates genes important for beta cell function. Loss of nuclear MafA has been implicated in beta cell dysfunction in animal models of type 2 diabetes. We sought to establish if nuclear MafA is less abundant in beta cell nuclei in humans with type 2 diabetes. METHODS: Pancreas obtained at surgery from five non-diabetic individuals and six individuals with type 2 diabetes was immunostained for insulin, glucagon and MafA. RESULTS: Beta cell nuclear MafA was markedly decreased in type 2 diabetes (1.6 ± 1.2% vs 46.3 ± 8.3%, p < 0.001). CONCLUSIONS/INTERPRETATION: Beta cell nuclear MafA is markedly decreased in humans with type 2 diabetes, which may contribute to impaired beta cell dysfunction.

Low priority? A cross sectional study of appearance anxiety in 500 consecutive referrals for cosmetic surgery.

Low priority treatment guidance is used in the National Health Service to manage requests for cosmetic surgery where there is no associated functional impairment. Provision is made in this guidance to provide surgery on exceptional grounds, and this may include significant psychological distress. However, without a good understanding of the common factors that underpin requests for surgery, ideally in the local population, it is very difficult to define an exception in a clear and consistent way. A prospective study of consecutive referrals for cosmetic surgery in an NHS plastic surgery unit was therefore completed over a five-year period. Five hundred and one men and women aged between 16 and 79 (mean 34.5 years) were assessed using standardised questionnaires and clinical interview carried out by two clinical psychologists specialising in the field. Results indicated very marked impact of appearance-related anxiety with significant withdrawal from social activities particularly intimate behaviour. Coping behaviours ranged from use of concealing clothing and complete social avoidance to ominous high risk strategies such as repeated pregnancy with late termination to maintain breast size. Treatment goals were predominantly psychosocial. High levels of psychological morbidity can be characterised as typical of people requesting cosmetic procedures in the NHS rather than exceptional, making the achievement of equitable access to limited resources impossible. Rather than define this population as 'low-priority', a constructive approach is to examine the utility of psychological interventions in a design which evaluates the comparative benefits of surgical and psychological approaches to management of appearance anxiety.