Summary document on safety and recommendations on liposuction for lipoedema: Joint British association of aesthetic plastic surgeons (BAAPS)/British association of plastic reconstructive and aesthetic surgeons (BAPRAS) expert liposuction group.

Liposuction plays an important role as a surgical treatment option for lipoedema. This article serves to critically review the evidence in the literature, as well as explain the differences between the lipoedema population compared with the aesthetic surgery population undergoing liposuction. It is not a comprehensive text on lipoedema management but serves to guide surgeons. This guidance was produced on behalf of the British Association of Aesthetic Plastic Surgeons (BAAPS) and the British Association of Plastic Reconstructive and Aesthetic Surgeons (BAPRAS) by the expert liposuction group. The guidance is based on the evidence available in the literature, along with a specialist expert opinion on liposuction for lipoedema, to provide plastic surgeons with a consensus recommendation for surgical treatment. The aim is to identify best practice to maximise the safety of patients. This article summarises current practices and safety considerations and outlines recommendations covering various aspects of patient care.

Summary document on safety and recommendations for aesthetic liposuction: Joint British Association of Aesthetic Plastic Surgeons (BAAPS)/British Association of Plastic Reconstructive and Aesthetic Surgeons (BAPRAS) expert liposuction group.

Liposuction is one of the commonest surgical aesthetic procedures performed worldwide. Despite being perceived to be a technically simple procedure, poor patient selection, sub-optimal technical execution or sub-optimal peri­operative management could lead to significant harm. This guidance was produced on behalf of the British Association of Aesthetic Plastic Surgeons (BAAPS) and British Association of Plastic Reconstructive and Aesthetic Surgeons (BAPRAS) by the expert liposuction group. The guidance is based on the evidence available in the literature along with specialist expert opinion in aesthetic liposuction to provide plastic surgeons with consensus recommendation. The aim is to identify best practice to maximise the safety of patients. This article summarises current practices and safety considerations and outlines recommendations covering various aspects of patient care.

The nomenclature of groin dissection for melanoma - Time to simplify.

INTRODUCTION: A wide variety of terms are used to describe different extents of groin dissection for stage 3 melanoma which may result in confusion and reduce effectiveness of research. We aim to evaluate the published terminology. METHODS: A PubMed review was conducted using the terms 'melanoma' plus 'inguinal'; 'groin'; 'pelvic'; 'ilioinguinal' dissection. 63 papers were included from 1956 to March 2015. A review of anatomy and coding was also conducted. RESULTS: Inguinal dissection was described using 8 terms from 56 papers with 7 papers using multiple terms for the same procedure. 'Superficial dissection' was the most common term despite inguinal-nodal tissue being separated into superficial and deep layers anatomically. ICD10PCS and OPSC code for 'inguinal' with no anatomical definition, CPT codes for 'inguinofemoral/superficial'. Combination inguino-pelvic dissection was described using 11 terms from 51 papers with 15 papers using multiple terms for the same procedure. 'Ilioinguinal' and 'Deep' were the most common despite most pelvic dissections including obturator nodes. ICD10PCS and OPSC code for 'pelvic' with no anatomical definition and CPT codes for 'superficial plus pelvic'. CONCLUSION: Many different terms are used to describe the same procedures, often within the same article. The lack of clarity can confuse readers, hinder comparative research and jeopardise patient care. Imprecise documentation of anatomical definition limits surgical outcome reporting and can impede planning for revision surgery. Standardisation is necessary and groin dissection should be defined by anatomical boundaries e.g. 'superficial' and 'deep' inguinal; 'pelvic'; 'inguino-pelvic' with clear documentation of extent.

One stage mastopexy augmentation in the ptotic patient. The superiorly based dermal flap for autologous reinforcement of the inferior pole.

BACKGROUND: The use of one stage mastopexy augmentation in the ptotic patient remains controversial. Expansion of breast volume and reduction of the skin envelope contradict each other and increase the risks of potential complications. By carefully selecting and consenting patients appropriately I describe the use of the superiorly based dermal flap for autologous reinforcement of the inferior pole to increase safety and reliability in one stage mastopexy augmentation. OBJECTIVES: To determine whether the superiorly based dermal flap could provide a safe and reliable method of one stage mastopexy augmentation. METHODS: 40 one staged mastopexy augmentation procedures were performed on 21 patients. Patients were excluded if they smoked, BMI >30, had significant co-morbidities, had unrealistic expectations, required a nipple lift of >8 cm, wanted >400cc volume in primary cases or >25% increase in volume in secondary mastopexy augmentation. Both round and anatomical implants were used in either the sub glandular or dual plane pocket depending on patient's aesthetic wishes. RESULTS: The average implant size was 290cc and average nipple lift was 5 cm. After an average follow up of 27months there have been no implant based complications, no reoperations and no infections/haematomas/seromas. CONCLUSIONS: Careful selection and consent of patients make the use of the superiorly based dermal flap for autologous reinforcement of the inferior pole a safe reliable technique in one stage mastopexy augmentation.

Risk-reducing surgery increases survival in BRCA1/2 mutation carriers unaffected at time of family referral.

The aim of this study was to establish if risk-reducing surgery (RRS) increases survival among BRCA1/2 carriers without breast/ovarian cancer at the time of family referral. Female BRCA1/2 carriers were identified from the Manchester Genetic Medicine Database. Those patients alive and unaffected at the date of first family ascertainment were included in this study. Female first-degree relatives (FDRs) without predictive genetic testing who otherwise met eligibility criteria were also included. The effect of breast and ovarian RRS on survival was analysed. The survival experiences of RRS and non-RRS patients, stratified by BRCA status, were examined with Kaplan-Meier curves and contrasted using log-rank tests and Cox models. 691 female BRCA1/2 mutation carriers without breast or ovarian cancer at time of family ascertainment were identified; 346 BRCA1 and 345 BRCA2. 105 BRCA1 carriers and 122 BRCA2 carriers developed breast cancer during follow-up. The hazard of death was statistically significantly lower (P < 0.001) following RRS versus no RRS. 10-year survival for women having RRS was 98.9 % (92.4-99.8 %) among BRCA1 and 98.0 % (92.2-99.5 %) among BRCA2 carriers. This survival benefit with RRS remained significant after FDRs were added. Women who had any form of RRS had increased survival compared to those who did not have RRS; a further increase in survival was seen among women who had both types of surgery. However, formal evidence for a survival advantage from bilateral mastectomy alone requires further research.

Contralateral mastectomy improves survival in women with BRCA1/2-associated breast cancer.

BRCA1/2 mutation carriers with breast cancer are at high risk of contralateral disease. Such women often elect to have contralateral risk-reducing mastectomy (CRRM) to reduce the likelihood of recurrence. This study considers whether CRRM improves overall survival. 105 female BRCA1/2 mutation carriers with unilateral breast cancer who underwent CRRM were compared to controls (593 mutation carriers and 105 specifically matched) not undergoing CRRM and diagnosed between 1985 and 2010. Survival was assessed by proportional hazards models, and extended to a matched analysis using stratification by risk-reducing bilateral salpingo-oophorectomy (RRBSO), gene, grade and stage. Median time to CRRM was 1.1 years after the primary diagnosis (range 0.0-13.3). Median follow-up was 9.7 years in the CRRM group and 8.6 in the non-CRRM group. The 10-year overall survival was 89 % in women electing for CRRM (n = 105) compared to 71 % in the non-CRRM group (n = 593); p < 0.001. The survival advantage remained after matching for oophorectomy, gene, grade and stage: HR 0.37 (0.17-0.80, p = 0.008)-CRRM appeared to act independently of RRBSO. CRRM appears to confer a survival advantage. If this finding is confirmed in a larger series it should form part of the counselling procedure at diagnosis of the primary tumour. The indication for CRRM in women who have had RRBSO also requires further research.

Is superficial inguinal node dissection adequate for regional control of malignant melanoma in patients with N1 disease?

INTRODUCTION: The optimum extent of surgery for inguinal nodal metastases due to melanoma remains controversial. Recent evidence suggests a conservative superficial groin dissection (SGD) may provide adequate regional control. AIM: To evaluate patients with N1 stage disease treated with SGD to determine the recurrence rates and to evaluate whether SGD was adequate for regional control in these patients. MATERIALS AND METHODS: Patients undergoing SGD between April 2005 and April 2012 were retrospectively analysed from a prospectively collected database. RESULTS: Sixty patients were treated by SGD of which 40 had palpable disease and 20 had a positive sentinel node. Overall median follow-up was 38 months, with median follow-up for the SNB group being 29 months and that of the PD group 49 months. Three patients (5%) developed groin recurrence following SGD. All patients recurred within the superficial site of surgery; there was no deep inguinal or pelvic recurrence. Distant recurrence occurred in 22 patients (36.7%), with 21 of these patients coming from the PD group and one from the SNB group. This difference was statistically significant (p < 0.05). Overall survival at 5 years was 70.3%. Survival at 5 years in the PD group was 63.8% and in the SNB group it was 90.9%, this difference was approaching significance (p = 0.08). CONCLUSION: SGD appears adequate for local disease control in patients with N1 sentinel node positive disease. Longer term followup for N1 palpable disease is required to determine the suitability of SGD for this group of patients.

Elucidating role of salivary proteins in denture stomatitis using a proteomic approach.

Denture stomatitis (DS) is the most common oral pathology among denture wearers, affecting over one-third of this group. DS is usually associated with C. albicans. However, unlike other oral candidiasis, most DS patients have intact host immunity. The presence of a denture alone is usually sufficient for DS. Saliva and its protein contents can theoretically predispose some denture wearers to DS and others resistant toward DS. Here we proposed for the first time to define salivary proteomic profiles of denture wearers with and without DS. SELDI-TOF/MS analysis suggests that there is a proteomic differentiation among control, localized and generalized DS. Based on initial SELDI-TOF/MS profiling, we further used reversed phase liquid chromatography, MALDI-TOF/MS, and LC-MS/MS to characterize the salivary proteins associated with DS. Nineteen proteins based on SELDI-TOF/MS profiling were found including cystatin-SN, statherin, kininogen-1, desmocollin-2, carbonic anhydrase-6, peptidyl-prolyl cis-trans isomerase A like peptides, cystatin C, and several immunoglobulin fragments. The proteomic content gives evidence of the interaction between host tissue, saliva, and candida. Further examination in larger populations of these proteins may help to gain a better understanding of DS pathological processes and improve DS treatments.

The use of combined radial forearm cutaneous and radial forearm fascial flaps in head and neck reconstruction: a case series.

INTRODUCTION: Reconstruction of complex head and neck cases involving bony and dural defects poses many issues. The primary aims of reconstruction are to provide a tight dural seal with good cranial support while also achieving a satisfactory cosmetic result. AIMS: This study describes the use of combined radial forearm cutaneous flap and radial forearm fascial flaps for reconstruction of complex skull defects where each component is used for a distinct reconstructive purpose. The benefits of this technique are illustrated in the cases of three patients requiring reconstruction following tumor resection. METHODS: The fascial component was used as a seal for dural defects. The cutaneous flap was then used to reconstruct the concomitant cutaneous defect. CONCLUSION: The combined use of the fascial and cutaneous components of the radial forearm flap, where each is used for a distinct reconstructive purpose, increased the reconstructive versatility of this commonly used flap. The fascial flap was a thin, pliable, and highly vascularized piece of tissue that was effectively used to provide a watertight seal for the dural defect. The simultaneous use of the cutaneous flap gave support to the bony defect while providing a good cosmetic result.

Second free flaps in head and neck reconstruction.

INTRODUCTION: Ablative surgery for head and neck cancer often results in defects that require free flap reconstruction. Improved survival after refined oncologic and adjuvant techniques has led to an increase in the number of patients undergoing a second free flap reconstruction. The objective of this study was to assess outcomes following a second free flap in head and neck reconstruction. MATERIALS AND METHODS: Following ablative defects in the head and neck, 1475 patients underwent reconstructive surgery over a period of 17 years. A second free flap for reconstruction was performed on 123 of these patients. In Group 1, 93 patients had a reconstruction for either tumour recurrence, second primary tumour or reconstructive complications (fractured plate, osteoradionecrosis, orocutaneous fistula). In Group 2, 30 patients had a second free flap following primary free flap reconstructive failure. RESULTS: Flap success for Group 1 patients was 86/90 (96%) compared to group 2 patients, 22/30 (73%) (p < 0.05). In Group 1, partial necrosis occurred in four patients whereas in Group 2, there was only one partial necrosis (NS; p > 0.05). CONCLUSION: A second free flap may be required for reconstruction of head and neck defects following complications of the initial reconstruction, presence of a second primary or tumour recurrence. Success rates for second free flap reconstructions were significantly lower in those patients with initial free flap failure.

Implications of a positive sentinel node in oral squamous cell carcinoma.

BACKGROUND: The role of sentinel node biopsy in head and neck cancer is currently being explored. Patients with positive sentinel nodes were investigated to establish if additional metastases were present in the neck, their distribution, and their impact on outcome. METHODS: In all, 109 patients (n = 109) from 15 European centers, with cT1/2,N0 tumors, and a positive sentinel lymph node were identified. Kaplan-Meier and univariate and multivariate logistic regression analysis were used to identify variables that predicted for additional positive nodes and their position within the neck. RESULTS: A total of 122 neck dissections were performed in 109 patients. Additional positive nodes were found in 34.4% of cases (42/122: 18 same, 21 adjacent, and 3 nonadjacent neck level). Additional nodes, especially if outside the sentinel node basin, had an impact on outcome. CONCLUSIONS: The results are preliminary but suggest that both the number and the position of positive sentinel nodes may identify different prognostic groups that may allow further tailoring of management plans.

Variations in the anatomy of the posterior auricular nerve and its potential as a landmark for identification of the facial nerve trunk: a cadaveric study.

The posterior auricular nerve (PAN) is the first extracranial branch of the facial nerve trunk. It innervates the posterior belly of the occipitofrontalis and the auricular muscles and contributes cutaneous sensation from the skin covering the mastoid process and parts of the auricle. This study was carried out to provide a detailed account of its anatomy and to ascertain its reliability as a surgical landmark for the facial nerve. Eleven facial sides from six formalin-fixed cadavers were dissected. The course and arborisation pattern of the PAN was observed, and its position of emergence from the facial nerve trunk (FNT) was measured. The PAN arose from the posterolateral aspect of the FNT 1.6-11.1 mm from the stylomastoid foramen (5.4 ± 3.3 mm). It arose as a single branch (45.4%), or from a common trunk that divided into two (36.4%) or three branches (18.2%), with the other branches passing into the parotid gland. The PAN continued deep (63%), or lateral to the mastoid process (9.1%), or through the tissue of the parotid gland (27.3%). In all cases the PAN ran in a consistent, superficial location posterior to the external auditory meatus. The PAN takes a variable course; however, its consistent location behind the external auditory meatus makes it easily identifiable in superficial dissection, and therefore a potential surgical landmark for identifying the FNT.

Versatility of the proximally pedicled anterolateral thigh flap and its use in complex abdominal and pelvic reconstruction.

BACKGROUND: The anterolateral thigh flap was described by Song et al. in 1984. Although more usually used as a free flap, it also has remarkable versatility as a pedicled flap. There are, however, no well-established guidelines that exist to define the extent of defects that can be reconstructed using this flap. In this article, the authors evaluate their experience with consecutive cases of the pedicled anterolateral thigh flap in complex abdominal and pelvic reconstruction. METHODS: A retrospective review of medical records and photographic archives was performed looking at 28 proximally pedicled anterolateral thigh flaps in 27 patients. RESULTS: The authors identified the arcs of rotation achieved, the types of defects reconstructed, points of surgical technique that enhanced their results, and some pitfalls of this flap. Useful points of surgical technique identified included suprafascial flap harvesting, extended harvesting of fascia, utilization of fascia to protect the pedicle, harvesting as a composite flap with the vastus lateralis, prudent preservation of large perforators that transgress the lateral aspect of the rectus femoris, synergistic use with a sartorius "switch," complete flap deepithelialization to fill dead space, and simple conversion to a free flap when pedicle length is inadequate. Pitfalls identified included the increased risk of pedicle avulsion in the morbidly obese, the risk of atherosclerotic plaque embolization in an atheromatous pedicle, and the potential inadequacy of thigh fascia for reconstituting abdominal wall integrity. CONCLUSIONS: This versatile flap has a wide arc of rotation. Multiple surgical modifications can be employed to tailor the flap to individual patient needs.

Sudden death of a 7-year-old boy due to undiagnosed glioblastoma.

We present a case of sudden death of a 7-year-old boy who at autopsy was found to have an undiagnosed glioblastoma. The boy was asymptomatic until 2 hours before death complaining of a headache and was later found unresponsive in bed. A medicolegal autopsy was notable for a large hemorrhagic mass of the right frontal lobe, which on analysis was diagnostic of a glioblastoma. We feel that this is a unique case for 2 main reasons; high-grade gliomas of the cerebral cortex are rare in the pediatric population, and it is unusual for a large neoplasm to remain asymptomatic until 2 hours prior to death.

Sentinel node biopsy in head and neck squamous cell cancer: 5-year follow-up of a European multicenter trial.

BACKGROUND: Sentinel node biopsy (SNB) may represent an alternative to elective neck dissection for the staging of patients with early head and neck squamous cell carcinoma (HNSCC). To date, the technique has been successfully described in a number of small single-institution studies. This report describes the long-term follow-up of a large European multicenter trial evaluating the accuracy of the technique. METHODS: A total of 227 SNB procedures were carried out across 6 centers, of which 134 were performed in clinically T1/2 N0 patients. All patients underwent SNB with preoperative lymphoscintigraphy, intraoperative blue dye, and handheld gamma probe. Sentinel nodes were evaluated with hematoxylin and eosin (H&E) staining, step-serial sectioning (SSS), and immunohistochemistry (IHC). There were 79 patients who underwent SNB as the sole staging tool, while 55 patients underwent SNB-assisted elective neck dissection. RESULTS: Sentinel nodes were successfully identified in 125 of 134 patients (93%), with a lower success rate observed for floor-of-mouth tumors (FoM; 88% vs. 96%, P = 0.138). Also, 42 patients were upstaged (34%); of these, 10 patients harbored only micrometastatic disease. At a minimum follow-up of 5 years, the overall sensitivity of SNB was 91%. The sensitivity and negative predictive values (NPV) were lower for patients with FoM tumors compared with other sites (80% vs. 97% and 88% vs. 98%, respectively, P = 0.034). CONCLUSIONS: Sentinel node biopsy is a reliable and reproducible means of staging the clinically N0 neck for patients with cT1/T2 HNSCC. It can be used as the sole staging tool for the majority of these patients, but cannot currently be recommended for patients with tumors in the floor of the mouth.