Successful same day discharge after immediate post-mastectomy alloplastic breast reconstruction: A single tertiary centre retrospective audit.

BACKGROUND: Immediate Post-Mastectomy Alloplastic Breast Reconstruction (IPMABR) traditionally requires a post-operative overnight stay. Recent initiatives have identified same day discharge as a safe option. METHODS: A retrospective audit of all cases at a tertiary breast cancer centre was performed. Patients received surgery at a day care facility or regional hospital (RH). Unplanned admission was defined as any patient unable to be discharged or any patient returning to the emergency room within the first 24 h. Planned admission cases had a history of BMI >40, obstructive sleep apnoea or previous anaesthetic complications. Data were collected on planned same day discharge, unplanned admission and planned admission cases. Factors differentiating the groups were identified and variables predicting unplanned admission were determined. RESULTS: A total of 785 patients received IPMABR over a 5-year period of which 743 had satisfactory data sets for review. Greater than 96% of patients receiving care at the day care facility were successfully discharged. The success rate for same day discharge at the RH was 65%. We determined that the greatest variables determining successful planned discharge were shorter surgical time (67 min; SD 6 min; p<.01), shorter PACU time (130 min; SD 21 min; p<.01) and surgical institution (p<.01). This difference between institutions was significant when all other variables (age, co-morbidities, unilateral/bilateral and BMI) were controlled, indicating a strong institutional bias. There was no difference between groups in complication rates (infection, dehiscence, seroma and haematoma). CONCLUSION: Same day discharge following IPMABR is safe and greatly reduces resource use. It is imperative that members of the perioperative team understand the validity and benefits of the programme to ensure success and reduce unplanned admissions.

A Reliable Method to Measure Lip Height Using Photogrammetry in Unilateral Cleft Lip Patients.

There is still no reliable tool to determine the outcome of the repaired unilateral cleft lip (UCL). The aim of this study was therefore to develop an accurate, reliable tool to measure vertical lip height from photographs. The authors measured the vertical height of the cutaneous and vermilion parts of the lip in 72 anterior-posterior view photographs of 17 patients with repairs to a UCL. Points on the lip's white roll and vermillion were marked on both the cleft and the noncleft sides on each image. Two new concepts were tested. First, photographs were standardized using the horizontal (medial to lateral) eye fissure width (EFW) for calibration. Second, the authors tested the interpupillary line (IPL) and the alar base line (ABL) for their reliability as horizontal lines of reference. Measurements were taken by 2 independent researchers, at 2 different time points each. Overall 2304 data points were obtained and analyzed. Results showed that the method was very effective in measuring the height of the lip on the cleft side with the noncleft side. When using the IPL, inter- and intra-rater reliability was 0.99 to 1.0, with the ABL it varied from 0.91 to 0.99 with one exception at 0.84. The IPL was easier to define because in some subjects the overhanging nasal tip obscured the alar base and gave more consistent measurements possibly because the reconstructed alar base was sometimes indistinct. However, measurements from the IPL can only give the percentage difference between the left and right sides of the lip, whereas those from the ABL can also give exact measurements. Patient examples were given that show how the measurements correlate with clinical assessment. The authors propose this method of photogrammetry with the innovative use of the IPL as a reliable horizontal plane and use of the EFW for calibration as a useful and reliable tool to assess the outcome of UCL repair.

Propranolol for infantile haemangiomas: single centre experience of 250 cases and proposed therapeutic protocol.

OBJECTIVE: To assess the safety and efficacy of systemic propranolol for the treatment of complicated infantile haemangiomas. DESIGN: Retrospective review of case notes of paediatric patients treated with propranolol for complicated infantile haemangiomas. SETTING: Tertiary care children's hospital. PATIENTS: All paediatric patients with complicated infantile haemangiomas who commenced treatment with propranolol from July 2008 to December 2011 and have completed treatment for at least 3 months. RESULTS: 250 patients were treated with propranolol; 34.4% were premature and 5.6% postmature. Indications for propranolol included: vision compromise (42.0%), bleeding and/or ulceration (30.4%) airway obstruction (8.8%), feeding difficulty (8.4%), risk of permanent disfigurement (4.4%) and other (6%) (nasal obstruction, auditory canal obstruction, large haemangioma, compression of neck structure and spinal cord). Median age at beginning of treatment was 4.5 months. Median age at end of treatment was 16.7 months. Median length of therapy was 11.8 months. Adverse effects (such as wheezing, worsening of ulceration, sleep disturbance, diarrhoea) occurred in 38 patients (15.2%), leading to modifications in management in 26 patients (10.4%). 240 patients (96%) had good to excellent response to treatment. 20 patients (8%) experienced regrowth of the haemangioma on cessation of propranolol and six patients (2.4%) required propranolol to be restarted. CONCLUSIONS: In appropriately selected patients, propranolol is a safe and effective treatment for infantile haemangiomas.

Challenging diagnosis of peripillous sheaths.

Peripillous sheaths, or hair casts, are asymptomatic, white, cylindrical concretions that encircle the hair without adhering to it. They are infrequently documented in the literature, are often misdiagnosed, and generate avoidable apprehension and expense for parents and caregivers. Dermoscopy is the standard for a rapid, noninvasive, cost-effective diagnosis. We describe a case of peripillous sheaths presenting in a boy.

Functional outcome after the Hoffer procedure.

BACKGROUND: Children with obstetrical brachial plexus injury often develop an internal rotation and adduction contracture about the shoulder as a secondary deformity, resulting in an inability to externally rotate and abduct the shoulder. The Hoffer procedure is evaluated for its potential benefit in improving shoulder abduction and external rotation and its impact on activities of daily living. METHODS: This is a retrospective review of patients treated in brachial plexus injury clinic who underwent tendon transfer procedures about the shoulder. Preoperative and postoperative active movement and active range of motion were measured and recorded using the Mallet scale and the Active Movement Scale. RESULTS: Twenty patients were included in the study. Average age at time of surgery was 6.35 years. Thirteen patients had primary brachial plexus reconstructive surgery and four patients had concomitant wrist extension tendon transfer procedures. All patients had full passive range of motion preoperatively. The average follow-up period was 25.45 months. Average differences in pre-Hoffer and post-Hoffer Mallet scale scores are as follows: active abduction, 1.20; external rotation, 1.35; hand-to-neck, 1.25; hand-to-back, 0.75; hand-to-mouth, 0.65; and aggregate score, 5.20 (p<0.001 for all). Average differences in relevant pre-Hoffer and post-Hoffer Active Movement Scale scores are as follows: shoulder abduction, 2.10; shoulder external rotation, 4.25; and shoulder internal rotation, -0.80. All patients maintained full range of motion passively; thus, no functional loss was experienced. These results showed very high statistical significance (p<0.001 for all) and clinical significance. Younger patients (≤6 years) and those with better preoperative shoulder flexion and shoulder internal rotation yielded better postoperative results. CONCLUSIONS: The Hoffer procedure provides clinically and statistically significant improvement in external rotation and abduction while preserving functional internal rotation range in the child with obstetrical brachial plexus palsy and secondary shoulder deformity. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Reversed palmaris longus muscle: Anatomical variant - case report and literature review.

The palmaris longus, a slender fusiform muscle, is especially prone to exhibiting anatomical variance relative to other muscles in the upper extremity. The most frequent anatomical variation is the completely absent palmaris longus, followed by the reversed, duplicated, bifid or hypertrophied palmaris longus muscles. The reversed palmaris longus muscle represents a structure that is tendinous proximally and muscular distally (opposite of the normal palmaris longus). The present report describes a case of reversed palmaris longus muscle, followed by a literature review to illustrate the wide spectrum of anatomical variations in the palmaris longus muscle and their clinical and surgical relevance.

Le grand palmaire, un muscle fusiforme mince, est particulièrement enclin aux variations anatomiques par rapport aux autres muscles des membres supérieurs. La variation anatomique la plus fréquente est l'absence de grand palmaire, suivie de son inversion, de son dédoublement, de sa bifidité et de son hypertrophie. L'inversion du grand palmaire est une structure tendineuse sur le plan proximal et musculaire sur le plan distal (à l'opposé du grand palmaire normal). Le présent rapport décrit un cas d'inversion du grand palmaire, suivi d'une analyse bibliographique pour démontrer le large spectre de variations anatomiques du grand palmaire et leur pertinence clinique et chirurgicale.

Review of burn injuries secondary to home oxygen.

The use of long-term home oxygen therapy (HOT) has become increasingly common for treatment of chronic pulmonary diseases. Although illegal to smoke while on HOT, there is an increasing incidence of burn injuries in those patients who smoke while on HOT. The importance of recognition of the prevalence of this injury, the obstacles faced when treating these patients, and understanding the proposed algorithmic approach to be taken with patients on HOT, including prescription, reassessment, and prevention of burn injury are outlined in this review. Retrospective epidemiological data including circumstances, admission, treatment, and disposition were collected and reviewed on the patients treated from 1999 to 2008 with burns secondary to smoking while on HOT. Seventeen patients sustained injuries secondary to smoking on HOT over the 9-year period; 9 patients were female and 8 were male. All the patients were on HOT for chronic obstructive pulmonary disease. Mean patient age was 69.1 ± 2.5 years and mean TBSA 2.8 ± 0.4%; 11.8% (2/17) sustained inhalation injury requiring intubation and 23.5% (4/17) required wound debridement and skin grafting. Mean hospital stay was 42.8 ± 12.5 days; 10.3 ± 5.4 days in the burn intensive care unit and 32.5 ± 11.0 days in the ward. Before the burn injury, 23.5% (4/17) lived in long-term care facilities. On discharge from hospital, 47.1% (8/17) were transferred to extended care facilities or other acute care hospitals, and 11.8% (2/17) died during their hospitalization. After recovery, there was a 35.3% reduction in patients able to return home and/or live independently. A significant number of burn injuries secondary to smoking while on HOT was observed. These patients differ from standard burn patients because they are older in age, have higher rates of inhalation injury, and have much longer lengths of hospitalization, despite smaller TBSA injuries. Prevention of this injury would improve the safety of the patient and those around them as well as healthcare resource allocation. A proactive multidisciplinary algorithmic approach is presented which can be used to manage patients on HOT at risk for continued smoking to decrease the incidence and the impact of burn injuries in this patient population.

Blunt carotid artery injury after minor facial trauma.

A healthy young man presented three days after suffering a punch to the face resulting in minimally displaced mandibular fractures. History revealed an episode of anterograde amnesia and a delayed episode of dysphonia. Apart from the fractured mandible, the physical examination was otherwise noncontributory. Imaging revealed severe luminal narrowing of the left cervical internal carotid artery distal to the carotid bifurcation, consistent with carotid dissection; and two focal hypodensities in the left frontal and parietal cortices, highly suggestive of acute secondary embolic infarcts. The patient was treated with systemic anticoagulation for three months and experienced no further neurological symptoms. His mandibular fractures, treated conservatively, healed without any complications. Blunt carotid artery injuries are uncommon and diverse. Neurological symptoms may develop in a delayed fashion, thus, a high index of suspicion based on knowledge of the injury mechanisms and patterns of associated injuries may enable earlier diagnosis and treatment. Angiographic imaging is essential for the diagnosis and classification of injury characteristics (eg, type, location, etc). Treatment must be considered on an individual patient basis depending on the presentation, grade and morphology of the lesion. Although no level I clinical trials exist on the topic, anticoagulation seems to be the treatment of choice in most cases and surgical intervention is not commonly indicated. Carotid artery dissection without complete thrombosis may be effectively treated with systemic anticoagulation or antiplatelet therapy in the majority of cases.

Un jeune homme en santé a consulté trois jours après avoir subi un coup à la figure ayant suscité des fractures mandibulaires peu déplacées. Les antécédents ont révélé un épisode d'amnésie antérograde et un épisode tardif de dysphonie. À part la fracture de la mandibule, l'examen physique n'a rien révélé. L'imagerie a établi un important rétrécissement intracavitaire de la carotide cervicale gauche interne dans la région distale de la bifurcation carotidienne, évocatrice d'une dissection carotidienne, ainsi que deux hypodensités focales dans les cortex pariétal et frontal gauche, hautement évocatrices d'infarctus emboliques secondaires aigus. Le patient a reçu des anticoagulants systémiques pendant trois mois et n'a souffert d'aucuns autres symptômes neurologiques. Ses fractures mandibulaires, traitées de manière classique, ont guéri sans complication.Les lésions carotidiennes fermées sont peu courantes et diversifiées. Des symptômes neurologiques peuvent se manifester tardivement. Ainsi, un fort indice de présomption fondé sur la connaissance des mécanismes de la lésion et des modes de lésions connexes peuvent favoriser un diagnostic et un traitement plus rapides. L'angiographie est essentielle pour poser le diagnostic et classer les caractéristiques de la lésion (p. ex., lieu, foyer, etc.) Le traitement dépend de chaque patient compte tenu de la présentation, du grade et de la morphologie de la lésion. Même s'il n'existe aucun essai clinique de niveau I sur le sujet, les anticoagulants semblent constituer le traitement de première intention dans la plupart des cas. L'intervention chirurgicale est rarement indiquée. Dans la majorité des cas, la dissection carotidienne sans thrombose complète peut être traitée avec succès par des anticoagulants systémiques ou des antiplaquettaires.

Teaching ear reconstruction using an alloplastic carving model.

BACKGROUND: Ear reconstruction is challenging surgery, often with poor outcomes. Our purpose was to develop a surgical training model for auricular reconstruction. METHODS: Silicone costal cartilage models were incorporated in a workshop-based instructional program. Trainees were randomly divided. Workshop group (WG) participated in an interactive session, carving frameworks under supervision. Nonworkshop group (NWG) did not participate. Standard Nagata templates were used. Two further frameworks were created, first with supervision then without. Groups were combined after the first carving because of frustration in the NWG. Assessment was completed by 3 microtia surgeons from 2 different centers, blinded to framework origin. Frameworks were rated out of 10 using Likert and visual analog scales. Results were examined using SPSS (version 14), with t test, ANOVA, and Bonferroni post hoc analyses. RESULTS: Cartilaginous frameworks from the WG scored better for the first carving (WG 5.5 vs NWG 4.4), the NWG improved for the second carving (WG 6.6 vs NWG 6.5), and both groups scored lower with the third unsupervised carving (WG 5.9 vs NWG 5.6). Combined scores after 3 frameworks were not statistically significantly different between original groups. A statistically significant improvement was demonstrated for all carvers between sessions 1 and 2 (P ≤ 0.09), between sessions 1 and 3 (P ≤ 0.05), but not between sessions 2 and 3, thus suggesting the necessity of in vitro practice until high scores are achieved and maintained without supervision before embarking on in vivo carvings. Quality of carvings was not related to level of training. CONCLUSIONS: An appropriate and applicable surgical training model and training method can aid in attaining skills necessary for successful auricular reconstruction.