Cook-Swartz Doppler Probe Surveillance for Free Flaps-Defining Pros and Cons.

Introduction The main postoperative complication of free flaps is perfusion compromise. Urgent intervention is critical to increase the chances of flap survival. Invasive flap perfusion monitoring with direct blood flow feedback through the Cook-Swartz Doppler probe could enable earlier detection of perfusion complications. Materials and Methods Between 2012 and 2016, 35 patients underwent breast reconstruction or defect coverage after trauma with a deep inferior epigastric perforator, anterolateral thigh, transverse musculocutaneous gracilis, gracilis, or latissimus dorsi flap in our department. All flaps were monitored with a Cook-Swartz probe for 10 days postoperatively. The 20 MHz probe was placed around the arterial-venous anastomosis. A flap monitoring protocol was established for standardized surveillance of postoperative perfusion. In the event of probe signal loss, immediate surgical revision was initiated. Results Signal loss was detected in 8 of the 35 cases. On return to the operating room, six were found to be true positives (relevant disruption of flap perfusion) and two were false positives (due to Doppler probe displacement). There were also two false negatives, resulting in a slowly progressive partial flap loss. Flap perfusion was restored in three of the six cases (50%) identified by the probe. Following surgical intervention, three of the six cases had persistent problems with perfusion, resulting in two total flap losses and one partial flap necrosis leading to an overall 5.7% total flap loss. Conclusion Postoperative flap perfusion surveillance is a complex matter. Surgical experience is often helpful but not always reliable. The costs, false-positive, and false-negative rates associated with invasive perfusion monitoring with Cook-Swartz probe make it most appropriate for buried flaps. Level of Evidence This is an original work.

A comparison of the academic impact of plastic surgery units in the United Kingdom and Ireland using bibliometric analysis.

Academic output is just one aspect of a successful career as a plastic surgeon. However, for those with a strong interest in academia, the academic output of a department will likely be a key factor when deciding how to rank jobs. The aim of this study was to quantify and rank the academic output of plastic surgery units across the UK and Ireland. The Institute for Scientific Information (ISI) Web of Science Bibliometric analysis tool was used to collate cumulative (1950-2016), 10 year (2006-2016) and 3 years (2013-2015) research output data for plastic surgery units in the UK and Ireland. Sixty-six plastic surgery units were identified. Departments were ranked for each time period according to the number of papers produced, number of citations (Nc) and h-index (a measure of the impact of scientific output). The top 3 departments for number of papers in the last 10 years were The Royal Free Hospital, London (226) Broomfield Hospital, Chelmsford (218), and Morriston Hospital and Swansea (188). The top 3 for h-number were The Royal Free Hospital (21) Wythenshawe Hospital, Manchester (18) and Morriston Hospital (17). Academic output varies across plastic surgery units in the UK and Ireland. A number of departments have consistently maintained high academic outputs across the years and will be of interest to surgeons hoping to pursue a career in academia.

When should axillary drains be removed? A meta-analysis of time-limited versus volume controlled strategies for timing of drain removal following axillary lymphadenectomy.

BACKGROUND: Despite numerous studies over the past few decades, the optimum strategy for deciding when to remove drains following axillary lymphadenectomy remains unknown. This meta-analysis aims to compare time-limited and volume-controlled strategies for drain removal. METHODS: A total of 584 titles were identified following a systematic literature search of EMBASE, MEDLINE, Cinahl and the Cochrane library; 6 titles met our eligibility criteria. Data were extracted and independently verified by two authors. Time-limited drain removal was defined as drain removal at <5 days; volume-controlled strategies ranged from <20 ml/24 h to <50 ml/24 h. RESULTS: In all the studies, the time-limited approach resulted in earlier drain removal. Development of a seroma is 2.54 times more likely with early drain removal (Mantel-Haenszel Fixed Odds Ratio (OR) 2.54, p < 0.00001). However, there is no difference in infection rates between early and late drain removal (OR = 1.07, p = 0.76). CONCLUSIONS: This meta-analysis demonstrates that a strategy of early drain removal following axillary lymphadenectomy is safe, with no difference in infection rates; however, the incidence of seroma is significantly higher, which may necessitate more demanding outpatient care. There is a need for further well-designed clinical trials to address the clinical equipoise in this common area of surgical practice.

How to train plastic surgeons of the future.

INTRODUCTION: Plastic surgery is a competitive and over-subscribed career choice despite minimal medical school exposure. We quantify factors influencing career interest in plastic surgery, speciality appeal and workforce planning. These findings optimise and refine evidence-based plastic surgery training and postgraduate selection criteria. METHODS: Medical students from two national plastic surgery courses complete a post-course questionnaire. Data categories included past experience and career interest in plastic surgery, sources of exposure, motivational factors, and sub-speciality interest. Data were recorded on modified Likert scales, with linear regression and t-test analyses performed. RESULTS: 175 students completed the questionnaire (81% response). Duration of medical student exposure to plastic surgery was significantly associated with career interest (Linear coefficient 0.12, 95% CI 0.08-0.17, P < 0.0001; r(2) = 0.15). 75 h experience is a significant cut-off to categorise students. Mean (95% CI) career interest is 31 percentage points higher in students with >75 h experience (89.2%, 83.2-95.2) compared to students with ≤75 h experience (58.1%, 52.9-63.3) (P < 0.0001). Influential sources included: (1) Operating Room (2) Consultant/Attending interaction (3) Resident interaction. Motivational factors towards a career in plastic surgery included operative satisfaction (91%), improving patient quality of life (89%), and reconstructive surgery (88%). Sub-speciality interests included: (1) Hand and Upper Limb (28%); (2) Cleft Lip and Palate (26%); (3) Burns (15%). CONCLUSION: This study identified influential and motivational factors upon a career in plastic surgery. Medical student exposure can be tailored to maximise positive educational exposure to optimise evidence-based plastic surgery training and workforce planning.

Lack of a standardised UK care pathway resulting in national variations in management and outcomes of paediatric small area scalds.

INTRODUCTION: There is a paucity of evidence guiding management of small area partial thickness paediatric scalds. This has prevented the development of national management guidelines for these injuries. This research aimed to investigate whether a lack of evidence for national guidelines has resulted in variations in both management and outcomes of paediatric small area scalds across England and Wales (E&W). METHODS: A national survey of initial management of paediatric scalds ≤5% Total Body Surface Area (%TBSA) was sent to 14 burns services in E&W. Skin graft rates of anonymised burns services over seven years were collected from the international Burns Injury Database (iBID). Average skin grafting rates across services were compared. Length of stay and proportion of patients receiving general anaesthesia for dressing application at each service were also compared. RESULTS: All 14 burns services responded to the survey. Only 50% of services had a protocol in place for the management of small area burns. All protocols varied in how partial thickness paediatrics scalds ≤5% TBSA should be managed. There was no consensus as to which scalds should be treated using biosynthetic dressings. Data from iBID for 11,917 patients showed that the average reported skin grafting rate across all burns services was 2.3% (95% CI 2.1, 2.6) but varied from 0.3% to 7.1% (P<0.001). Service provider remained associated with likelihood of skin grafting when variations in the %TBSA case mix seen by each service were controlled for (χ(2)=87.3, P<0.001). The use of general anaesthetics across services varied between 0.6 and 35.5% (P<0.001). The median length of stay across services varied from 1 to 3 days (P<0.001). DISCUSSION: A lack of evidence guiding management of small-area paediatric scalds has resulted in variation in management of these injuries across E&W. There is also significant variation in outcomes for these injuries. Further research is indicated to determine if care pathways and outcomes are linked. An evidence-based national policy for the management of small area paediatric scalds would ensure that high quality, standardised care is delivered throughout E&W and variations in outcome are reduced.

Long-term sensation in the medial plantar flap: a two-centre study.

BACKGROUND: Reconstruction in the foot and ankle region is challenging. This study aimed to quantify objective sensation return when a sensate medial plantar flap is used for like-for-like reconstruction of foot and ankle defects. METHODS: Two-point discrimination (2PD) was assessed in flap and normal tissue at a minimum of 1 year post-operatively. A paired T-test assessed for significance. RESULTS: 8 patients were included. Mean 2PD in normal tissue and flap was 29 mm (SD: 11.9) and 33 mm (SD: 9.97) respectively with no statistically significant difference between the two (two-tailed p-value: 0.1898). Mean age was 53.2 years (range: 15-84). There was no statistically significant correlation between age and 2PD in flap tissue (r=0.6, p=0.15). CONCLUSIONS: This is the largest case series of its kind. Our results suggest that sensation in medial plantar flaps can return to near normal and demonstrate the important role the medial plantar flap plays in soft tissue reconstruction in this region.