A comparison of the patient and surgeon opinion on the long-term aesthetic outcome of reduction mammaplasty: have we improved over 15 years?

In 1996 we published a study evaluating the difference between patient and surgeon opinion on the aesthetic outcome of reduction mammaplasty (see Ref. 1). The patients rated the aesthetic outcome of their surgery as significantly higher than the consultant panel. The surgical panel suggested scope for improvement. Areas of dissatisfaction were poor scarring, high placement of the nipple areola complex and high rates of revision surgery. Fifteen years on, the same team has regrouped to repeat this assessment. In 1996 the consultants scored their own patient results. In 2011 they graded the results of their former trainee who has modified her operative technique to address aesthetic problems highlighted in the first study. Forty-four patients attended a review clinic at least one year post reduction mammaplasty. Patient scored their satisfaction using the original questionnaire employed in 1996. The cohort were photographed and their images graded blindly by the original surgical panel. Statistical analysis was performed by the original statistician. The patients graded aesthetic aspects of body harmony, breast mound appearance, nipple areolar complex appearance and post-operative scarring significantly more positively (p<0.01) than both the 1996 patient cohort and surgical panel. The consultant panel showed a trend for more positive grades for all aesthetic features assessed versus their previous views but this was only significant for breast mound symmetry. They expressed that there was a decrease in post-operative breast ptosis (p<0.04) and improvement in the nipple areolar complex position (p=0.02). The rate of revision surgery has decreased from 53% to 16% between the studies. In keeping with clinical audit, outcomes have been assessed and modifications implemented to address aesthetic concerns. Assessment of outcomes following the modifications demonstrates a trend for increased patient and surgeon satisfaction. Patient satisfaction however still exceeds that of the surgeons.

Early outcome and cost-effectiveness of endoscopic versus open carpal tunnel release: a randomized prospective trial.

Proponents of endoscopic carpal tunnel release have been advocating the technique for more than 10 years but there is still debate about its efficacy, safety and cost-effectiveness. We have performed a randomized, prospective, blind trial to compare early outcome after single portal endoscopic or open carpal tunnel surgery and to assess the cost-effectiveness of the procedures. There were no significant differences in symptom and functional activity scores, grip strength or anterior carpal pain in the first 3 months. For those in employment, we found a statistically significant difference between the two treatment groups with the endoscopic group returning to work, on average, 8 (95% CI, 2-13 days) days sooner than the open group. This translates into a cost saving to industry. There were no major neurovascular complications in either group. On the basis of these findings, we recommend that endoscopic carpal tunnel release should be considered in the employed as a cost-effective procedure, but perhaps not in the general population as a whole.

Autologous free tissue breast reconstruction using the internal mammary perforators as recipient vessels.

Perforator flaps have become popular for autologous free tissue breast reconstruction because they reduce the donor site morbidity. It is possible to apply the this principle to the recipient site. We present our experience of using the perforating vessels from the internal mammary artery and vein as recipient vessels for autologous free tissue breast reconstruction flaps in 21 out of 54 consecutive cases (39%). We discuss the technique and its advantages.

Lateral digital photography with computer-aided goniometry versus standard goniometry for recording finger joint angles.

This study compares the accuracy of computer-aided goniometry with standard goniometry. 109 finger joint angles at the extremes of flexion and extension were measured by a senior hand therapist using standard goniometry. Lateral digital photographs were then taken of the hands and the same angles were read from these by computer. There was good correlation (r(2)=0.975) between the results. Computer goniometry averaged 1 degrees (95%Cl=0 degrees -+2 degrees ) more than the standard goniometry. We feel that computer goniometry of finger joints is accurate and compares well with standard goniometry.

Palmar segmental aponeurectomy for Dupuytren's disease with metacarpophalangeal flexion contracture.

Eighty palmar segmental aponeurectomies were performed between 1993 and 1999 for well-localized palmar cords with metacarpophalangeal flexion contracture. A retrospective patient review with a minimum follow-up of 1-year demonstrated a 6% rate of recurrent metacarpophalangeal flexion and two minor complications. Segmental aponeurectomy rather than limited fasciectomy is recommended for this type of disease.

Dermofasciectomy in the management of Dupuytren's disease.

Dupuytren's disease may present with well-defined subcutaneous cords or as more diffuse disease with involvement of the skin. Fasciectomy is the procedure commonly carried out for the full range of disease, but is associated with rates of recurrence of up to 66%. We reviewed 143 rays in 103 patients undergoing dermofasciectomy for diffuse disease with involvement of the skin. We found recurrence in 12 rays (8.4% of rays; 11.6% of patients) during a mean follow-up of 5.8 years, eight as cords and four as nodules. We suggest that dermofasciectomy is a better method of disease control than fasciectomy for the more diffuse type of disease with involvement of the skin.

A local anaesthetic technique for endoscopic carpal tunnel release.

A local anaesthetic technique for endoscopic carpal tunnel release is described. This accurately and rapidly blocks median and ulnar nerves in the distal forearm. It avoids the infiltration of local anaesthetic solution at the operation site, a technique which may render the endoscopic view unsatisfactory.

Skin replacement in Dupuytren's disease.

We have reviewed 90 rays in 67 patients who had undergone radical digital dermofasciectomy. Follow-up was from 24 to 100 months. Problems with skin grafts, moving two-point discrimination and active range of joint movement were noted. The recurrence rate in this series was 8%, a very much better figure for disease control than has been reported for standard approaches for Dupuytren's disease. Radical digital dermofasciectomy is strongly recommended for all cases of recurrent Dupuytren's disease requiring reoperation and as a primary procedure when there is significant skin involvement.

Primary sternal tuberculosis treated by resection and reconstruction.

We report a case of primary mycobacterial sternal infection. An 81-year-old man with an infected parasternal sinus of non-specific pathology was treated with antibiotics for four months with only palliative effect. On hospital admission CT scan showed thickened first and second intercostal spaces and chest wall, but no bone involvement. At operation, the manubrium was found to be infected also. This was excised with the first three ribs anteriorly. Histology showed caseating granulomata. No other tuberculous foci were found in the patient.

A mid-term review of the results of dermofasciectomy for Dupuytren's disease.

Clinical involvement of the palmar and digital skin by Dupuytren's disease occurs frequently. A review of 40 rays in 32 patients who had consecutively undergone dermofasciectomy is presented. The average follow-up period was 38 months, with a minimum of 24 months. Four out of the 40 rays developed recurrent nodule formation limited to the proximal or distal graft insets but there was no recurrent cord formation, suggesting better disease control than by fasciectomy alone. Full thickness graft to resurface the defect has been surprisingly complication-free.

The facial artery island flap.

A nasolabial island flap on the facial artery and anterior facial vein is described. This is a useful modification of the classic nasolabial flap for repair of defects in the floor of the mouth. The flap can be led directly into the floor of the mouth, and the pedicle can be passed deep or superficial to the mandible as required. This obviates the use of bulky carrier skin passing over the alveolus and allows all the nasolabial skin to be available for reconstruction of the defect.

Radical digital dermofasciectomy in Dupuytren's disease.

Fifteen dermofasciectomies, the excision extending from the distal palmar crease to the distal interphalangeal crease and carried out to the midaxial line on either side are reviewed, stressing the good take of skin graft in well vascularised fingers. The technique is strongly recommended as the first line of treatment in recurrent digital Dupuytren's contracture.

Injury to the brachial plexus resulting from shoulder positioning during latissimus dorsi flap pedicle dissection.

A case is described of brachial plexus injury, noted after an ipsilateral latissimus dorsi free transfer. The mode of injury is discussed and a simple method of prevention is suggested.

Mandibular reconstruction by "simple" bone graft.

In a series of 20 consecutive cases of mandibular reconstruction by simple bone grafting, 14 cases had a satisfactory outcome. The technique is relatively quick and simple. If the more complicated, lengthier procedures of vascularised bone grafting are used, it should be demonstrated with tetracycline labelling or early technetium 99M phosphate scanning that these grafts are contributing to immediate and active healing and are not just "taking" as simple bone grafts.