Parallelogram Excision: An Algorithmic Approach for Excision Designs in High-Tension Skin Areas.

INTRODUCTION: The excision of lesions that are not oriented along the skin tension lines may cause the surgeon to design extremely broad elliptical preoperative markings, with the intent to follow the tension lines as recommended for the best postoperative course and the best quality scars. The aim of this study is to describe and clinically apply a new surgical technique called the parallelogram excision technique, in which the traditional ellipse with a major axis parallel to the tension lines is converted into a parallelogram whose lesser sides are coincident with the local skin tension lines. This technique was specifically conceived for lesions whose major axis is non-coincident with skin tension lines, and the primary advantage is that it reduces the amount of healthy tissue excised. METHODS: Preliminarily to this clinical study, a comparative geometrical analysis was conducted between various excision shapes and angles using Geometry Pad version 2.7.10 (Bytes Arithmetic LLC) and verifying the data obtained through AutoCAD 2D 2016 (Autodesk, San Rafael, CA, USA), with the purpose of optimizing the technique from a geometrical point of view. A comparison was performed between the theoretical traditional elliptical excision and the hypothetical parallelogram excision. A pilot proof of concept clinical study was performed to verify the validity of the excisional design proposed. The patients considered for parallelogram excision suffered from skin lesions with a diameter no greater than 4 cm and oriented 45° to 60° with respect to tension lines. In order to limit variability, patients' ages were between 40 and 80, and the selected areas were limbs, sternum and dorsum. Scar quality was assessed with the validated POSAS method at 6 months post-operation. RESULTS: The geometrical analysis of the parallelogram's design showed that it allows a diminution of the excised healthy skin compared to the traditional ellipse. The clinical series included 16 patients, with a mean age of 63.5. Of these, nine patients were men and seven were women. Diagnoses included basal cell carcinoma in seven cases, dysplastic naevus in five patients, Bowen's disease in three individuals, and one case where a wider excision of a malignant melanoma was performed. Six-month follow up results showed: (1) an uneventful postoperative course; (2) good scar healing with an observer's POSAS median score of 16 and a patient's POSAS median score of 19; and (3) complete excision of lesions. CONCLUSIONS: When indicated, the parallelogram excision technique appears to be a good option for the excision and primary closure of skin lesions that are not parallel to skin tension lines, since it allows a reproducible and surgeon-friendly method of preoperative marking and implies a favorable use of the local tension, which determines good quality scars. The amount of healthy tissue removed is smaller compared to traditional elliptic excisions.

Microsurgery Arena: A New Device to Develop Microsurgical Skills.

Simulation in microsurgery is an important pillar of training and maintenance of surgical skills. Between learning microsurgical skills and mastering them in clinical practice, the usefulness of low-fidelity simulators for improving microsurgery skills has been well documented. Nowadays the in vivo models represent the gold standard of microsurgical training; however, their use implies difficulties and limitations. We developed a portable, low-cost, and modern device to help trainees to practice at their convenience to maintain their microsurgical suturing skills. By using CAD and 3D printer designs, we developed a "microsurgery trainer" that contains a middle section with eight projections with holes, arranged as a circle. The idea is to pass the microsuture-preferably 7/0 or 8/0 sutures-in a clockwise manner-with the needle passing from "out to in" and "in to out" through each hole. This allows the trainee to use his/her wrist to be flexible and achieve better control over the micro needle. Studies evaluating the potential of such a device in shortening the learning curve are needed and will be crucial to define whether the "microsurgery arena" will help trainees to obtain better outcomes in microsurgical practice.

A review of forehead lipomas: Important tips for the training surgeon.

BACKGROUND: Forehead swellings can be caused by a variety of different pathologies, including lipomas. These benign lesions are composed of mature fat cells and often result in a poor cosmetic appearance causing significant psychosocial distress. Surgical removal is therefore frequently requested and they are often listed on a training local anaesthetic list. Thus, it is essential that trainees understand the nature of these lesions, their anatomical location and management, as well as differential diagnoses. METHODS: A review of the available literature on forehead lipomas and their management was performed. Searches of both MEDLINE and EMBASE were conducted, with all full text articles published in English being included for analysis. RESULTS: 14 papers were included for analysis. Forehead lipomas are slow growing lesions with 100% presenting as a solitary swelling. They are more prevalent in males with mean age at presentation being 48 years. Their aetiology is unknown, however, blunt trauma has been postulated to contribute to their formation. Differential diagnoses include cysts and extension of intracranial lesions. Surgical intervention is the only recognised treatment, with a transverse, forehead-crease incision most commonly being adopted under local anaesthetic. Exploration beneath the frontalis muscle is often required in order to achieve their excision. CONCLUSION: Important differential diagnoses must be excluded prior to attempted surgical excision of forehead lipomas. Surgeons must also be aware that the correct anatomical plane for these lesions is often beneath the frontalis muscle.

Rippling Following Breast Augmentation or Reconstruction: Aetiology, Emerging Treatment Options and a Novel Classification of Severity.

BACKGROUND: Implant rippling is a frequent complication following breast augmentation or implant-based reconstruction and results in significant patient dissatisfaction. Traditionally, the treatment has been to replace the implant, often placing it in a subpectoral pocket to reduce the risk of recurrence. Other techniques, such as increasing the implant size or tightening the capsule, can also be used. Recently, however, there has been much interest in alternative treatments, including fat grafting or insertion of an acellular dermal matrix. METHODS: We review the evidence base for emerging treatments and propose a classification to grade severity, based on the typical clinical presentation of rippling: Grade 1-MILD-rippling is palpable but not visible: (1a) palpable in the lower outer quadrant, (1b) palpable in the upper inner quadrant (cleavage area); Grade 2-MODERATE-rippling is visible only when the patient bends forward; Grade 3-SEVERE-rippling is visible with the patient upright. CONCLUSION: Our proposed classification aims to standardise the clinical description of rippling, which will be valuable in determining the efficacy of new treatments and better characterising long-term complications from breast augmentations or reconstructions. LEVEL OF EVIDENCE V: 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 .

The 'round-the-clock' training model for assessment and warm up of microsurgical skills: a validation study.

Microsurgery is an essential technique in free flap reconstructions today. The technical skills involved require a learning curve, which may be affected by the current issues of limited training resources and patient safety. We describe a study on the value of a microsurgery training device as an assessment and warm up tool in basic microsurgery skills. Forty volunteers with different levels of microsurgery experience performed a microsurgical 'round-the-clock' exercise on the training device three consecutive times. Video-recordings of these performances were rated by two blinded independent assessors using a modified Global Rating Scale to assess basic microsurgery skills on the following parameters: steadiness, instruments handling and speed. Time to complete a round was also recorded objectively. The Kruskal-Wallis test was used to analyse the construct validity of the parameters assessed between the groups of level of microsurgery experience. Crohnbach's coefficient alpha was used to determine the reliability index of the independent assessors. All participants improved their time on consecutive rounds of the exercise. A median of 82 s (range 6-583 s) improvement in time between the first and third round was observed. Different mean performance time could be identified between the groups, but individual speed did not correlate significantly with microsurgery experience. Assessment of microsurgery skills using the modified Global Rating Scale demonstrated statistically significant differences for instruments handling (p=0.03) and speed (p=0.01) between the groups with regard to microsurgery experience, and improvement in the parameters assessed for all groups. Difference in steadiness (p=0.07) was not significant amongst the juniors. Consultants performed better than juniors but, at all levels of experience, significant improvement in skills was demonstrated after practice. The 'round-the-clock' microsurgery training device is an inexpensive and readily available valid tool that provides a useful warm up exercise and instant assessment of basic microsurgical skills.

The pectoralis minor pedicled muscle flap in axillary reconstruction.

We report on the case of a patient undergoing resection of a large axillary and chest wall tumor, resulting in exposure of the brachial plexus and axillary vessels. Our experience of the use of the pectoralis minor pedicled flap for the reconstruction of such a defect is described, providing for excellent postoperative mobility of the axilla and minimal donor-site morbidity.