One-stop autologous breast reconstruction: A safe and effective cost-saving pathway.

INTRODUCTION: Patients undergoing autologous breast reconstruction usually require further operations as part of their reconstructive journey. This involves contralateral breast symmetrization and nipple-areola complex (NAC) reconstruction. Restrained access to elective operating space led us to implement a one-stop breast reconstruction pathway. METHODS: Patients undergoing contemporaneous contralateral breast symmetrization and immediate NAC reconstruction with free nipple grafts between July 2020 and June 2021 were identified. A retrospective review of our prospectively maintained database was conducted, to retrieve surgical notes, postoperative complications, and length of inpatient stay. A cost analysis was performed considering savings from contralateral symmetrization. RESULTS: A total of 50 eligible cases were identified, which had unilateral one-stop breast reconstructions. Complication rates and length of stay were not affected by this approach, with only one free flap being lost for this cohort. This approach resulted in £181,000 being saved for our service over a calendar year. DISCUSSION: A one-stop breast reconstruction pathway has proven to be safe and effective in our unit. During these uncertain times, it has streamlined the management of eligible patients, while releasing capacity for other elective operations. Patients avoid having to wait for secondary procedures, finishing their reconstructive pathway earlier. We plan to continue providing this service which has shown to be beneficial clinically and financially.

Is Routine Imaging Necessary for the Management of Pediatric Hand Fractures Postoperatively?

BACKGROUND: Pediatric hand fractures heal remarkedly well, and clinically significant displacement after operative fixation is rare. Radiation exposure in medical practice is regulated by the Ionizing Radiation Medical Exposure Regulations 2017, and unnecessary radiation should be avoided. In the literature, there is paucity of information regarding the number of radiographs required in the postoperative period and guidelines are lacking. METHODS: This study aims to examine whether routine imaging or the lack of it influences functional outcome and time to discharge from the clinic. A retrospective data of pediatric hand fractures requiring intervention between 2014 and 2018 at our institution were conducted before and after elimination of routine postoperative imaging. A total of 230 patients were included in the study. RESULTS: Two cohorts of patients were identified. The first had routine postoperative radiographs, whereas the second did not have routine radiographs. There was no change in management and difference in the range of motion at discharge between the 2 groups (P = 0.74). Patients without routine imaging were discharged earlier from clinic (74.4 vs 108.2 days, P = 0.012). CONCLUSIONS: This study shows that clinically significant fracture displacement is rare after operative reduction and fixation in pediatric age group. It demonstrates our experience in refraining from routine postoperative radiographs. The overall benefit is to avoid unnecessary radiation and subsequent costs implicated.

Dual pedicle epiphyseal transfer for paediatric bony sarcoma reconstruction: Technique and review of outcomes.

Skeletal reconstruction after tumour resection in paediatric patients is challenging. The resultant reconstruction needs to meet the demands of graft incorporation as well as the potential for growth. The vascularised fibular epiphyseal transfer (VFET) offers the potential for both. We retrospectively reviewed eight paediatric patients treated with VFET after bony tumour resection. All patients underwent a dual pedicle transfer with the peroneal artery for the diaphyseal blood supply and the recurrent branch of the anterior tibial artery for the physis. This is the largest series in literature for dual pedicle transfers for bony reconstruction. We present our surgical technique and outcomes in terms of functional limb salvage and growth.

Trainee and trainer experiences and recommendations for plastic surgery training: A qualitative pilot study.

BACKGROUND: The COVID-19 pandemic has compounded existing training issues for plastic surgeons. The issues that exist result from a complex interplay of system, generational and individual factors, and can be hard to tease out by quantitative means. This pilot study aimed to investigate the perceptions of trainees and trainers of plastic surgical training in the UK. METHODS: Ten semi-structured interviews were performed using purposive sampling in a central London plastic surgical unit. These were coded into and discussed in four themes: Medical directives and service demands; Sociocultural norms within plastic surgical training; Equity and access; and Plastic surgery training methods. RESULTS: This study showed that current plastic surgery training is not optimised for learning or well-being, and that inequities are fostered, to the detriment of the specialty. Investment and planning are required to support our trainers and protect the diversity of our trainee group, with efficient and monitored learning essential to maintain our breadth and competence of practice. CONCLUSION: Expanding this work through a broader study could provide valuable information to contribute to the development of future training schemes and curricula within British plastic surgery.

Augmented Reality and Plastic Surgery Training: A Qualitative Study.

Background and objective The coronavirus disease 2019 (COVID-19) pandemic has led to many challenges in face-to-face teaching and training in plastic surgery. However, it has also proved to be an incubator for many technological solutions. Augmented reality (AR) platforms may offer a safe, equitable, and efficient means to provide training in plastic surgery. This study aimed to explore the user's experience of AR as an educational intervention during the COVID-19 pandemic in the United Kingdom (UK). Materials and methods The Proximie® AR platform (Proximie Limited, London, UK) has been in use in a UK plastic surgical department for facilitating webinars, visual libraries, and streamed procedures. The experience of a range of trainers and trainees was qualitatively explored through 10 individual interviews. Data-emergent theme analysis was also performed. Results AR was well-received in the context of COVID-19 and training in general as a means to enable theatre access, and visual revision, remotely. The potential for its use in remote coaching and telementoring was also discussed. Recommendations were made by the users to optimise the experience both from the trainer and learner perspectives. Data were presented pertaining to the following themes: surgical AR as a substitute for hands-on learning; surgical AR and theoretical learning; considerations specific to streamed procedures using Proximie®; considerations in the use of technology in general. Conclusion Harnessing novel technologies in surgical education offers an exciting opportunity, fast-tracked by COVID-19, but applicable beyond it. Though this study includes a small sample size, its findings suggest that AR platforms may offer a uniquely interactive remote educational experience in surgical training. Strategies and suggestions for its use are discussed, as well as broader considerations in using technology in surgical education.

Balancing Training Opportunities and Patient Outcomes: A Single Surgeon's Experience.

ABSTRACT: Microvascular free tissue transfer is the criterion standard of reconstruction post-oncological resections of the head and neck region. We present a consultant's first 200 consecutive microvascular head and neck reconstructions in independent practice. A retrospective analysis of a prospectively collected database of all head and neck reconstructions performed in the first 3 years of practice was performed. These included 200 consecutive microvascular head and neck reconstructions performed by a single surgeon at a tertiary referral center. We review the results and complications in this series and discuss factors significant for successful outcomes in head and neck reconstruction. We also highlight that different parts of the surgery in the majority of cases were performed by a trainee under the supervision of the senior surgeon and thus discuss the need for training future plastic surgeons with an interest in head and neck reconstruction.

Locally Advanced Scalp Tumors: Clinical and Survival Outcomes of a Tertiary Unit.

INTRODUCTION: Locally advanced nonmelanoma skin cancers of the head and neck are well described in the current literature. However, data about clinical and survival outcomes are lacking. We present survival data from a tertiary head and neck cancer unit in London. METHODS: A retrospective analysis of data collected from a single institution was conducted. All patients with locally advanced cutaneous scalp carcinomas invading the skull between 2011 and 2019 were included. Data included patient demographics, tumor, comorbidities, interventions, flap survival, and metal work exposure. Survival outcomes were examined using Kaplan-Meier analysis. RESULTS: Twenty-three patients were identified. The mean age was 72 years. Eighteen patients were male, and 5 were female. Five patients were immunosuppressed. Nineteen patients underwent outer cortex drill-down/full-thickness calvarial resection, followed by reconstruction with free tissue transfer. Six patients had titanium mesh reconstruction after segmental skull resections. Three patients underwent further surgery because of exposed metalwork. Disease-free survival at 3 years after surgery was 60%. CONCLUSIONS: Locally advanced nonmelanoma skin cancers invading the bone are sporadic. There are little published data on clinical and survival outcomes in this group. Despite the nature of these skin lesions, a high degree of local control can be obtained by extensive surgical resection, outer table drill-down, and calvarial resection. We conclude that aggressive management of the bony invasion improves disease-free survival and improves local control.

Anatomical variant of physeal blood supply to the fibula.

Vascularised epiphysial fibula bone transfers in the paediatric population provides a solution to growth suppression in extremity reconstruction. We report a case of an anatomical variant to the epiphysial blood supply that has never been reported in literature. A 6-year-old girl underwent a free vascularised fibula flap for reconstruction of her right humerous following osteosarcoma resection. While identifying and dissecting the recurrent epiphysial branch, a large branch from the peroneal artery was identified which directly entered the head of the fibula. No dominant supply from the anterior tibial (AT) vessels to the head of the fibula was seen. This led to the need for a bipedicled flap with diaphyseal supply from the AT vessels and the epiphysial transfer based on the peroneal artery. The patient made an uneventful recovery from the procedure. The same technique may be used by surgeons that may encounter this unique variant in clinical practice.

Perioral pressure ulcers in patients with COVID-19 requiring invasive mechanical ventilation.

BACKGROUND: Facial pressure ulcers are a rare yet significant complication. National Institute for Health and Care Excellence (NICE) guidelines recommend that patients should be risk-assessed for pressure ulcers and measures instated to prevent such complication. In this study, we report case series of perioral pressure ulcers developed following the use of two devices to secure endotracheal tubes in COVID-19 positive patients managed in the intensive care setting. METHODS: A retrospective analysis was conducted on sixteen patients identified to have perioral pressure ulcers by using the institutional risk management system. Data parameters included patient demographics (age, gender, comorbidities, smoking history and body mass index (BMI)). Data collection included the indication of admission to ITU, duration of intubation, types of medical devices utilised to secure the endotracheal tube, requirement of vasopressor agents and renal replacement therapy, presence of other associated ulcers, duration of proning and mortality. RESULTS: Sixteen patients developed different patterns of perioral pressure ulcers related to the use of two medical devices (Insight, AnchorFast). The mean age was 58.6 years. The average length of intubation was 18.8 days. Fourteen patients required proning, with an average duration of 5.2 days. CONCLUSIONS: The two devices utilised to secure endotracheal tubes are associated with unique patterns of facial pressure ulcers. Measures should be taken to assess the skin regularly and avoid utilising devices that are associated with a high risk of facial pressure ulcers. Awareness and training should be provided to prevent such significant complication.Level of evidence: Level IV, risk/prognostic study.

Functional Outcomes of the Medial Sural Artery Perforator Flap in Oral Cavity Reconstruction.

BACKGROUND: The medial sural artery perforator (MSAP) flap is an ideal option for reconstruction of oral cavity defects owing to its thin and pliable nature and favorable donor site. Our study presents an assessment of functional outcomes including speech and swallowing in patients with oral cavity tumors reconstructed with MSAP flaps. METHODS: Patients undergoing MSAP reconstruction for oral cavity tumors between January 2014 and January 2018 were identified from our prospective head and neck cancer database. Functional outcomes were assessed in conjunction with the Speech and Language Team with a minimum follow-up of 6 months. Function (speech and swallowing) was recorded as a performance status scale set up by the assessing health care professional. RESULTS: A total of 38 patients underwent reconstruction with the MSAP flap over the study period. The patient cohort included 10 female patients and 28 male patients. The age range was from 30 to 78 years, with a mean age of 56.8 years. Complications included 1 flap loss and 1 donor site wound dehiscence.Most patients (84.2%) had intelligible speech at 6-month follow-up and further improvement at 1 year (92.1%). All patients resumed feeding on postoperative day 4, and only 7.8% (n = 3) of the patients required assistance with feeding at 1-year follow-up. CONCLUSIONS: The MSAP flap provides adequate small-volume replacement for oral cavity reconstructions. Our results indicate that most patients achieve a full diet with no restrictions by 1 year after reconstruction. Most of our patients demonstrated excellent speech with little or no need for repetition in conversation. Over the past few years, this has become the flap of choice for oral cavity reconstruction in our unit.

A structured pathway for accelerated postoperative recovery reduces hospital stay and cost of care following microvascular breast reconstruction without increased complications.

INTRODUCTION: Accelerated recovery protocols have proved effective in many surgical procedures but are infrequently applied in breast reconstruction. In this study, we evaluate the impact of a structured pathway for accelerated postoperative recovery in patients undergoing microvascular breast reconstruction at a high-volume center. METHODS: We describe our care pathway for patients undergoing deep inferior epigastric artery perforator (DIEP) flap breast reconstruction at our center. We compared length of stay (LOS), complication rates, readmission rates, and cost of inpatient care before (pre-protocol (Pre-P)) and after (post-protocol (Post-P)) the implementation of the protocol. RESULTS: Patients in the Post-P group (n = 198) had a significant reduction in mean LOS as compared to those in the Pre-P (n = 183) group (3.6 +/- 0.85 vs. 4.7 +/-1.04 days, p = 0.006). There was no significant difference in the rates of major (Pre-P 16.9% vs. Post-P 14.7%, p = 0.71) or minor (Pre-P 21.3% vs. 17.1%, p = 0.22) postoperative complications between groups. The readmission rates were also similar (Pre-P 6.5% vs. Post-P 4.5, p = 0.69). Implementation of the protocol resulted in a significant reduction in the mean cost of in-patient care. CONCLUSION: A simple protocol for accelerated and streamlined postoperative recovery effectively reduces LOS and patient care costs following DIEP flap breast reconstruction without compromising patient safety.

Preoperative Perforator Mapping in SGAP Flap: Does Magnetic Resonance Imaging Make the Difference?

BACKGROUND: Preoperative vascular mapping has emerged as an excellent adjunct to perforator flap surgery, improving operative time while aiding the surgeon in the selection of the ideal perforator. This study evaluated the effect of preoperative vascular mapping by magnetic resonance imaging to identify tissue for a superior gluteal artery perforator (SGAP) flap on total operative time and compared radiologic mapping by magnetic resonance imaging with Doppler ultrasonography for perforator localization. The authors also investigated whether drawing the flap according to magnetic resonance imaging perforator localization or tissue availability affected the outcome of the donor site. METHODS: A prospective study was performed on patients undergoing SGAP flap breast reconstruction. Patients were randomized into two groups. One group received preoperative magnetic resonance imaging for flap tissue planning based on localization of the perforator. The other group received flap planning based on tissue availability and then underwent external Doppler ultrasonography to identify the dominant perforator. An ad hoc outcome scale was created to evaluate outcomes of the donor sites. RESULTS: Preoperative vascular mapping by magnetic resonance imaging or external Doppler ultrasonography was performed the day of surgery on 35 and 27 patients, respectively. The mean flap elevation times of the imaging patients versus the ultrasonography patients were 252 and 228 minutes, respectively. The differences between flap elevation times and cosmetic outcomes for the two patient groups were not significant. CONCLUSION: The authors' findings indicate that the use of magnetic resonance imaging for SGAP flap planning did not reduce operative time, and that donor-site outcomes were not affected by the modality used for preoperative perforator mapping. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Breast reconstruction with Superior Gluteal Artery Perforator free flap: 8 years of experience.

INTRODUCTION: The SGAP flap represents an alternative for autologous breast reconstruction when DIEP is not available. In this article, we report eight years of experience in breast reconstruction using SGAP free flap and discuss our results, how our procedures have evolved, the outcomes and complications rates and how to perform this procedure efficiently while managing the challenges inherent to this type of flap. MATERIALS AND METHODS: A retrospective study was conducted from June 2009 and June 2017. Patients requiring SGAP flap breast reconstruction were enrolled. Donor site availability was categorised into 4 classes according to the availability of tissue. An ad hoc outcome scale was created to standardise the results and ensure data comparability. RESULTS: A total of 119 patients were enrolled in the study. We recorded 18 cases of excellent results, 57 good, 30 moderate and 14 poor. Our results show that donor site class impacts complications and patient outcome. The odds ratio analysis demonstrated that the third class donor site has a protective impact on complications and has a direct correlation with good patient outcomes. CONCLUSIONS: SGAP flap can provide very good outcomes, and it should be considered as another option when DIEP is not available. Patient selection and efficiency are the keys to achieve optimal results and minimise complications. Although this flap is available for patients with a low BMI, the donor site has to provide enough tissue to achieve symmetry with the contralateral breast and allow a tension-free closure without contour deformity.