Comparative UK Cross-sectional Study of Breast Cancer Patient-Reported Outcomes for Breast-Conserving Surgery and Immediate Reconstruction, Including Contribution to an International Collaborative Pilot Study.

INTRODUCTION: Breast-conserving surgery (BCS) with adjuvant radiotherapy is oncologically comparable to mastectomy with immediate breast reconstruction (IBR) in treating breast cancer. This tertiary UK centre cross-sectional study compared BCS patient-reported outcomes with those of immediate implant-based (IBR) and free flap reconstruction (FFR), and included a contribution to a pilot international collaboration co-ordinated through the Organisation for Economic Cooperation and Development (OECD). METHODS: Validated BREAST-Q™ 'satisfaction with breasts' modules were administered to 271 consecutive patients for six months after unilateral BCS, IBR, or FFR were conducted between June and October 2018. Risk adjustment data were collected on age, body mass index, smoking, radiotherapy, specimen weight, and tumour burden. RESULTS: A total of 190 women returned completed questionnaires (131 BCS, 42 IBR, 17 FFR; 70% response rate). BCS scores (mean 68, standard deviation (SD) 23) were higher than those for IR overall (62, SD 23, p=0.04) and IBR (61, 24, p=0.03) but equivalent to those for FFR (66, SD 23, p=0.33). There was no significant difference in Q-Scores between the IBR and FFR groups (p=0.77). Scores were only minimally changed by risk adjustment and comparable to OECD mean international scores for IBR (61) and FFR (66). CONCLUSIONS: This is the first study to compare BCS and IR outcomes using a validated scale. BREAST-Q™ 'satisfaction with breasts' scores were comparable between BCS and FFR but significantly lower following IBR.

Implant-Based Reconstruction following Mastectomy in Patients Who Have Had a Previous Breast Augmentation: Lessons from the National Multicenter Implant Breast Reconstruction Evaluation Study.

BACKGROUND: Breast augmentation is the most commonly performed cosmetic procedure, and increasingly women in this group present with breast cancer or request risk-reducing surgery, but their optimal management is unclear. The authors explored the clinical and patient-reported outcomes of patients undergoing immediate implant-based breast reconstruction following previous augmentation and compared these with outcomes of patients who had not had cosmetic implants in the Implant Breast Reconstruction Evaluation (iBRA) Study. METHODS: Patients undergoing immediate implant-based breast reconstruction were prospectively recruited from breast and plastic surgical units across the United Kingdom. Demographic, operative, and oncologic data, and information regarding complications within 3 postoperative months were collected. Patient-reported outcomes at 18 months were assessed using the BREAST-Q. The clinical and patient-reported outcomes of patients undergoing immediate implant-based breast reconstruction with and without previous breast augmentation were compared. RESULTS: A total of 2108 women were included in the iBRA Study, of whom 49 had undergone a previous augmentation. Women in the augmentation group were younger (median age, 45 years versus 50 years; p = 0.01), had a lower body mass index (22.8 kg/m2 versus 24.9 kg/m2; p < 0.01), and had smaller tumors (15 mm versus 25 mm; p = 0.01) than patients without augmentation. No differences were seen in operative technique between the groups. Complications at 3 months were similar in both groups and there were no significant differences in patient-reported outcomes at 18 months. CONCLUSIONS: The clinical and patient-reported outcomes of patients undergoing immediate implant-based breast reconstruction following previous augmentation are consistent with those observed in the wider iBRA Study cohort, supporting the safety of this approach.

The inflatable carrot-An orthosis for fingertip wound healing in flexion contractures of the hand: A case report.

STUDY DESIGN: Case report. INTRODUCTION: Severe flexure contractures of the hand secondary to upper limb spasticity (ULS) cause pain, palmar hyperhidrosis, ulceration, and nail plate deformities. Nonoperative management includes traditional orthotic devices that can be very painful for severe contractures and Botox injections, which provide a temporary solution. Surgical treatment comprises of soft tissue releases, tendon transfers, and release of the flexor and intrinsic muscles, which can cause permanent functional problems. CASE DESCRIPTION: In a 28-year-old male, unfit for surgery, we present the first documented case report in literature of flexion contractures of the hand secondary to upper limb spasticity managed using the "Inflatable Carrot" orthosis, where other conservative measures failed. RESULTS: At 4 weeks, the pulp to palm distance improved from 0 to 2 cm. At 3 months, the patient regained normal nail plate architecture, improved hand hygiene, reduced infection and pain. The patient reported improved psychological well-being and motivation to engage further with our therapists. CONCLUSIONS: The inflatable carrot provided an alternative nonsurgical solution for management of flexion contractures of the hand when surgical intervention was not considered in the patient's best interests. Awareness of this orthosis among hand therapists and surgeons will broaden our armamentarium for this challenging clinical problem.

Optimising UK training in aesthetic surgery: A prospective national study using operative logbooks and questionnaires to determine factors associated with trainee participation.

INTRODUCTION: We aimed to determine the proportion of UK aesthetic surgery training taking place in the independent sector, how this experience is gained, and factors associated with trainee participation. We also aimed to draw comparisons between training in the National Health Services (NHS) and independent sectors. METHODS: Plastic Surgery Trainees were asked to complete a 10-item questionnaire, in addition to their usual operative entry on eLogbook, when logging a procedure with an aesthetic operative code, prospectively over a 6-month period. Anonymised data was exported and analysed using SPSS. RESULTS: A total of 285 questionnaires were completed; all UK training regions were represented. The majority were for NHS procedures (88%), of which 56% were for breast surgery, 23% facial surgery, 19% body contouring, and 2% non-surgical. Trainees were significantly more likely to participate in procedures when they were performed in the NHS (odds ratio, OR, 9.7, p < 0.01) or when they were body contouring surgery (OR 1.5, p < 0.01). Trainees were more likely to participate in perioperative care in an NHS setting (p < 0.01). When trainees attend the independent sector, it was usually within contracted training hours (57%) with their consultant trainer with whom they are working in the NHS (63%). CONCLUSIONS: The majority of aesthetic surgery training occurs in the NHS but this is not representative of UK aesthetic practice. There is a need to engage the independent sector to provide formal aesthetic surgery training as part of the plastic surgery training programme, including procedural participation and perioperative care. Additional aesthetic fellowships and mechanisms for mentorship by established consultants should be developed.

Plastic surgery training in the UK: Results from a national survey of trainee experiences.

BACKGROUND: Plastic surgery training in the UK continues to evolve towards an outcome-based rather than time-served curriculum. UK plastic surgery trainees are appointed nationally, and are assessed according to national standards, but training is delivered regionally. This study sought opinion from current UK plastic surgery trainees in order to highlight strengths and shortcomings of the higher surgical training programme. METHOD: A cross-sectional study was designed and administered by the UK Plastic Surgery Trainees Association (PLASTA). A questionnaire was distributed to all UK plastic surgery trainees holding a National Training Number, using the REDCap web-based application. RESULTS: Of the 320 UK plastic surgery trainees, 131 (41%) participated in this survey, with responses from all 12 UK training regions. The most common subspecialty career aspirations for trainees were hand surgery, cleft lip and palate, lower limb and oncoplastic breast reconstruction. The survey highlighted regional variation in teaching programmes, the ability to achieve indicative operative logbook numbers, and training in aesthetic surgery. Of the trainees, 82% expressed a desire to undertake a fellowship within their training, but most did not know whether their deanery would support this. Fifteen per cent of the respondents were currently training flexibly and the majority of these had experienced negative behaviours towards their less than full time working status. Of the respondents, 44% reported stress, 25% reported a lack of autonomy and 17% reported feeling burnt out at work at least once a week. A total of 85% perceived that they did not have access to a mentoring service. CONCLUSIONS: Plastic surgery remains a popular and highly competitive surgical speciality in the UK, and many trainees reported high levels of satisfaction during their training. Aspects of training that could be improved have been highlighted and recommendations made accordingly.

Adrenaline Auto-injector injuries to digits; a systematic review and recommendations for emergency management.

AIMS: Accidental injury to digits with Adrenaline Auto-injectors (AAIs) is becoming increasingly common. Digital AAI injury causes painful ischaemia that can lead to necrosis and patient anxiety. There is a lack of understanding amongst surgeons regarding how to manage these injuries. We aimed to determine an optimal treatment algorithm for their management. METHODS: We conducted a systematic review using the search engines MEDLINE, PubMed, EMBASE, CINAHL, BNI, AMED, Google Scholar. Search items included ("epinephrine OR adrenaline") AND ("Digit" OR "Finger" OR "Thumb") AND ("Injury" OR "Accidental"). RESULTS: A total of 49 articles were identified describing 111 cases. In 58 cases; 52% of cases were managed with phentolamine, 24% were managed with nitroglycerine and 7% were treated with warm soaks. The remaining 17% of cases were managed with a variety of alternative treatments. Mean recovery time following treatment with phentolamine infiltration was 33 min, whilst symptoms persisted for several hours in some cases with observation/warm soaks and nitroglycerine. Phentolamine was more effective when injected into the AAI puncture site (mean resolution time: 17 min) in comparison to injection as a digital block (74 min). CONCLUSION: Phentolamine is the most effective method of reversing symptoms and treating ischaemic digits when compared to alternative therapies. Symptoms resolved much quicker when phentolamine was infiltrated into the site of injury compared to being infiltrated as a digital block. We propose a treatment algorithm for management of these injuries. Hand surgeons should be aware of AAI injuries and be able to advise on their management.

The modified bipedicled flap for reconstruction of oncological skin defects of the trunk and extremities.

BACKGROUND/AIMS: Oncological skin defects of the extremities and trunk can be challenging. Our modified bipedicled flap utilises the principle of the bipedicled advancement flap, but allows for direct closure of the donor site (as opposed to skin grafting). It does not rely on the preservation of perforators and it random pattern, making it extremely versatile. We aimed to assess the outcomes for patients reconstructed using the modified bipedicled flap technique including oncological safety and complications. METHODS: Consecutive patients were retrospectively identified from July 2011 to January 2019 using operative records. Demographics, operative details, oncological data and complications were recorded from patient records and the institution's internal electronic patient records system. No cases, having a modified bipedicled flap, were excluded from this study. RESULTS: One hundred flaps in 98 patients were included. Mean defect dimensions were 61.7 mm by 33.1 mm. Median length of stay was 1 day, time to discharge from dressing clinic was 15 days, and the length of follow-up was 6.0 years. Eight patients required oral antibiotics for suspected localised wound infection, and 6 patients had minor wound healing problems. There were no cases of flap failure, partial flap loss, returns to theatre for flap-related complications, or local disease recurrence. CONCLUSIONS: To our knowledge, this is the largest series of bipedicled flaps published to date. Our technique is easy to execute, versatile, and allows for direct closure of the secondary defect with excellent cosmetic results. It is oncologically safe, with a low incidence of complications. We commend it for use in the reconstruction of oncological skin defects of the trunk and extremities.

A Prospective Comparison of Short-Term Outcomes of Subpectoral and Prepectoral Strattice-Based Immediate Breast Reconstruction.

BACKGROUND: Prepectoral acellular dermal matrix-assisted immediate implant-based breast reconstruction is gaining popularity, involving complete implant coverage with acellular dermal matrix. The authors aimed to compare pain, patient-reported outcome measures (including implant rippling), and safety of prepectoral and subpectoral Strattice-assisted implant-based breast reconstruction. METHODS: Consecutive patients were recruited prospectively, having either therapeutic or risk-reducing mastectomy. Patients scored their pain three times per day for the first 7 postoperative days on a Likert scale, and completed the BREAST-Q reconstruction module 3 months postoperatively. Clinical records and the authors' prospective complications database were used to compare the early morbidity of the two procedures. RESULTS: Forty patients were recruited into the study. There was no significant difference in pain scores between the prepectoral group (mean, 1.5) and the subpectoral cohort (mean, 1.5; p = 0.45) during the first 7 days. Thirty-one BREAST-Q questionnaires were returned; mean Q scores were similar for both prepectoral and subpectoral (72 and 71, respectively; p = 0.81) groups. Patients reported significantly more visible implant rippling in the prepectoral group than in the subpectoral group (seven of 13 versus two of 17; p = 0.02). There was no significant difference in length of stay or early morbidity, with implant loss being 4.7 percent in the prepectoral group compared with 0 percent in the subpectoral group. CONCLUSIONS: Early postoperative pain and quality of life at 3 months are equivalent between groups. Early experience of prepectoral implant placement with complete acellular dermal matrix coverage suggests this is safe and provides good quality of life for patients. Further studies are required to compare short- and long-term outcomes with the current standard forms of reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Keeping pace with the media; Giant Hogweed burns - A case series and comprehensive review.

Phytophotodermatitis is almost exclusively reported in the dermatological literature, but may progress to a chemical burn. There has been widespread media reporting during the summer of 2015 of burns caused by giant hogweed. However, there is a lack of awareness of this mechanism of injury amongst the burn multidisciplinary team, and there have been no published articles in the surgical literature regarding plant burns, other than sporadic case reports, for 20 years. We present a comprehensive review of plant burns and three cases from our adult and paediatric Burn Centres of burns caused by giant hogweed. Accurate diagnosis is straightforward with a detailed history and is important to prompt appropriate treatment, and prevent a misdiagnosis of non-accidental injury. This review and case series are timely to raise awareness of phytophotodermatitis and burns caused by plants to burns multidisciplinary teams. Prospective studies are warranted to assess the efficacy of topical treatments and surgical management.

The effect of anaesthetist grade and frequency of insertion on epidural failure: a service evaluation in a United Kingdom teaching hospital.

BACKGROUND: Despite being a commonly performed procedure, epidural catheter insertion has a significant failure rate. There is a lack of guidance as to how regularly the procedure should be performed in order to maintain competence. This study aimed to quantify whether increasing frequency of practice is associated with a reduction in failure rates. METHODS: Data were collected prospectively on all patients undergoing intra-abdominal or thoraco-abdominal surgery who received epidural analgesia as part of their post-operative analgesic regimen over a 36 month period. Records were examined to identify the reason for epidural catheter removal, classified according to standardised definitions, the seniority of the inserting anaesthetist, and whether or not they were a permanent member of the anaesthetic department. Data were analysed using independent t tests, Mann-Whitney tests and Fisher's test. RESULTS: 881 epidurals were inserted during the study period. 48 hour failure rate was 27.2%, whilst by 96 hours 33.9% of epidurals had failed. Increasing frequency of epidural insertion did not show a significant decrease in failure rate at either 48 (p = 0.36) or 96 hours (p = 0.28). However, long-term survival of epidurals at 96 hours was greater if inserted by permanent rather than temporary members of staff (non-permanent 60/141, 42.6% vs permanent 228/715, 31.9%, OR 1.58 (CI 1.09-2.29) p = 0.02). CONCLUSION: This study demonstrates that failure rates for postoperative epidural analgesia in major surgery are not dependent upon the frequency with which practitioners insert epidural catheters. However, failure rates are dependent on permanency of anaesthetic staff. These findings are significant when placed in the context of the General Medical Council's requirements for clinicians to maintain competence in their clinical practice, suggesting that institutional factors may have greater bearing on epidural success or failure than frequency of task performance.