Gender parity at the podium in UK plastic surgery conferences.

BACKGROUND: Despite the increase in the proportion of female plastic surgeons in the United Kingdom (UK), all-male panels continue to prevail. This article sought to establish whether the genders of speakers at conferences hosted by leading UK plastic surgery associations, the British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS), and the British Association of Aesthetic Plastic Surgeons (BAAPS), are representative of the consultant workforce. METHODS: Data on the gender distribution of plastic surgeons in the workforce over the last decade were obtained from NHS Digital Workforce Statistics. The demographics of invited speakers were sought from conference agendas for both BAPRAS (from 2012 to 2022) and BAAPS (from 2014 to 2021) posted on their association's websites. RESULTS: The proportion of female consultants increased from 16% in 2012 to 22% in 2022. The average proportion of female speakers at BAPRAS conferences was 16% ± 9% SD that was similar to the proportion of female consultants in practice (p = 0.432). In contrast, the average proportion of female speakers at BAAPS conferences was lower than those in practice (7.88% ± 8.29% SD, p = 0.0032). At BAAPS, 43% of speakers were UK plastic surgeons. CONCLUSIONS: Although the podium speakers at BAPRAS were reflective of the consultant population, BAAPS had little to no representation of UK based female plastic surgeons. Therefore, the conference organisers need to intentionally ensure that representation at podium is reflective of the workforce.

Patients' experience of teleconsultations in the UK.

BACKGROUND: Teleconsultations were introduced for cancer surgery follow-up to ease pressure on hospital services and facilitate patients' access to those services. There is limited evidence on patients' perceptions of this swift shift in service provision. AIMS: The purpose of this qualitative systematic review was to explore patient experiences of teleconsultations within NHS cancer surgery follow-up services to better understand patient perceptions, satisfaction and acceptability of teleconsultations within cancer services. METHODS: Medline, Embase, PubMed and Google Scholar were searched up to 1 July 2022. Qualitative studies were synthesised using the Braun and Clarke framework. FINDINGS: There were three overarching themes: accessibility; patient experience; and consultation. CONCLUSION: Teleconsultations were widely accepted among cancer surgical patients. However, there were reports of a lack of rapport building and emotional support because of the absence of visual cues and patient camaraderie.

Evaluation oncotype DX® 21-gene recurrence score and clinicopathological parameters: a single institutional experience.

AIMS: Oncotype DX recurrence score (RS) is a clinically validated assay, which predicts the likelihood of disease recurrence in oestrogen receptor-positive/HER2-negative (ER+/HER2-) breast cancer (BC). In this study we aimed to compare the performance of Oncotype DX against the conventional clinicopathological parameters using a large BC cohort diagnosed in a single institution. METHODS AND RESULTS: A cohort (n = 430) of ER+/HER2- BC patients who were diagnosed at the Nottingham University Hospitals NHS Trust and had Oncotype DX testing was included. Correlation with the clinicopathological and other biomarkers, including the proliferation index, was analysed. The median Oncotype DX RS was 17.5 (range = 0-69). There was a significant association between high RS and grade 3 tumours. No grade 1 BC or grade 2 tumours with mitosis score 1 showed high RS. Low RS was significantly associated with special tumour types where none of the patients with classical lobular or tubular carcinomas had a high RS. There was an inverse association between RS and levels of ER and progesterone receptor (PR) expression and a positive linear correlation with Ki67 labelling index. Notably, six patients who developed recurrence had an intermediate RS; however, four of these six cases (67%) were identified as high-risk disease when the conventional clinical and molecular parameters were considered. CONCLUSION: Oncotype DX RS is correlated strongly with the conventional clinicopathological parameters in BC. Some tumour features such as tumour grade, type, PR status and Ki67 index can be used as surrogate markers in certain scenarios.

Clinical application and outcomes of reconstructive microsurgery in Africa: A systematic review and meta-analysis.

BACKGROUND: Reconstructive microsurgical free flap techniques are often the treatment of choice for a variety of complex tissue defects across multiple surgical specialties. However, the practice is underdeveloped in low- and middle-income countries. The aim of this systematic review was to evaluate the clinical application and outcomes of reconstructive microsurgery performed in Africa. METHODS: Seven databases (PubMed, Web of Science, MEDLINE, CINAHL, Academic Search Complete, Embase, and Google Scholar) were searched for studies reporting microsurgical procedures performed in Africa. The risk of bias was assessed using the Joanna Briggs Institute Critical Appraisal Tools and quality of evidence using the GRADE approach. Meta-analysis was performed using a random effects model to estimate the pooled proportion of events with 95% confidence intervals. The primary outcome was free flap success rate, and the secondary outcomes were the complication and flap salvage rates. RESULTS: Ninety-two studies were included in the narrative synthesis and nine in the pooled meta-analysis. In total, 1376 free flaps in 1327 patients from 1976 to 2020 were analyzed. Head and neck oncologic reconstruction made up 30% of cases, while breast reconstruction comprised 2%. The pooled flap survival rate was 89% (95% CI: 0.84, 0.93), complication rate 51% (95% CI: 0.36, 0.65), and free flap salvage rate was 45% (95% CI: 0.08, 0.84). CONCLUSION: This meta-analysis showed that the free flap success rates in Africa are high and comparable to those reported in high-income countries. However, the comparatively higher complication rate and lower salvage rate suggest a need for improved perioperative care. REVIEW REGISTRATION: Registered with the International Prospective Register of Systematic Reviews (PROSPERO) on 25th September 2020, ID: CRD42020192344.

Patient-centered digital healthcare for patients undergoing breast surgery-A cross-sectional questionnaire study.

INTRODUCTION: The potential of digital health services has become apparent in recent years, more so now following the coronavirus disease outbreak. However, despite majority of UK population integrating digital-based platforms into their everyday life, there is low engagement with NHS digital services, citing lack of patient-centered approaches to the design of such services. As such, this cross-sectional questionnaire aims to understand the patient perspective pertaining the utility of web-based information in aiding their breast cancer pathway at a large volume tertiary breast institute. METHODS: Adult patients attending the outpatients' post-operative follow-up clinic for any breast-related surgery were included. Questionnaires were provided from 1 August 2019 to 31 December 2019, focusing on awareness of the website, usage and usefulness of information offered relating to their breast surgery journey, with opportunities for open feedback. RESULTS: Of the 104 patients completed the questionnaire, 70% (n = 73) were unaware of the breast institute's website. Patients' wanted a wide range of information, including signposting to support groups and perioperative information such as patient experiences/journey on the operative day (n = 46, 44%/n = 60, 58%) and videos explaining procedures. The most frequent free text included requests for information regarding financial support and parking, and "signposting" to other support services. DISCUSSION: Patients welcome the breast services' website, but we need to improve awareness of this resource and include more holistic information, relating not only to their diagnosis and treatment but also to practical/support services they can access to make their patient journey smoother.

Barriers and facilitators to breast reconstruction in ethnic minority women-A systematic review.

INTRODUCTION: Post-mastectomy breast reconstruction (PMBR) is an important component of the multidisciplinary care of breast cancer patients. Despite the improved quality of life, significant racial disparities exist in the receipt of PMBR. Given the increasing population of Black, Asian and minority ethnic (BAME) women in UK, it is important to address this disparity. Our review aims to identify the barriers and facilitators influencing the uptake of PMBR in BAME women and raise awareness for physicians on interventions that could improve uptake of PMBR in BAME women. METHODS: The methodology outlined by the Cochrane guidelines was used to structure this systematic review. Systematic searches for qualitative studies on barriers and/or facilitators to PMBR in ethnic women published in English were conducted. The following databases were searched from their inception up to June 2019: MEDLINE, EMBASE, PubMed, Cochrane Library, Google Scholar and Scopus. Reference lists of all included articles and relevant systematic reviews were also hand-searched for possible additional publications. Publication year or status restrictions were not applied. Only full text articles published in English and by peer reviewed journals are included. Exclusion criteria were as follows: quantitative studies on barriers and/or facilitators to PMBR, abstracts, conference proceedings, non-English language and non-specific to BAME women. A thematic synthesis approach was used through the development of sub-themes and themes from the findings of the included qualitative studies. RESULTS: Five studies satisfied the inclusion and exclusion criteria. Three overarching themes emerged from our review: physician-associated factors (physician recommendations), patient-associated factors (knowledge, language, community and cultural, emotions, logistics, patient characteristics) and system-associated factors (insurance coverage, income status). CONCLUSION: Our systematic review suggests that there is a paucity of data in the literature on the barriers and facilitators to PMBR in BAME women. Considering the expanding population of BAME women and increasing breast cancer incidence, it is imperative that future research in this field is carried out. Physician and patient-associated factors were identified as the most important yet modifiable factors. Adopting a combination of culturally tailored interventions targeting these factors may help improve the access of PMBR in BAME women. REGISTRATION: Prospero ID: CRD42019133233.

Correction: The clinical significance of oestrogen receptor expression in breast ductal carcinoma in situ.

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

The clinical significance of oestrogen receptor expression in breast ductal carcinoma in situ.

BACKGROUND: Oestrogen receptor (ER) in invasive breast cancer (BC) predicts response to endocrine therapy (ET) and provides prognostic value. In this study, we investigated the value of ER expression in ductal carcinoma in situ (DCIS) in terms of outcome and the impact on ET decision. METHODS: In total, 643 pure DCIS, diagnosed at Nottingham University Hospitals, were assessed for ER. Clinicopathological data were correlated against ER status, together with assessment of recurrence rate. RESULTS: ER positivity was observed in 74% (475/643) of cases. ER positivity was associated with clinicopathological variables of good prognosis; however, outcome analysis revealed that ER status was not associated with local recurrence. In the intermediate- and high-grade ER-positive DCIS, 58% (11/19) and 63% (15/24) of the recurrences were invasive, respectively, comprising 7% and 6% of all ER-positive DCIS, respectively. Invasive recurrence in low-grade DCIS was infrequent (2%), and none of these patients died of BC. The ER status of the recurrent invasive tumours matched the primary DCIS ER status (94% in ipsilateral and 90% of contralateral recurrence). CONCLUSION: The strong correlation between DCIS and invasive recurrence ER status and the clinical impact of ET justify discussion of the use of ET in ER-positive DCIS treated by breast-conserving surgery. The excellent outcome of low-grade DCIS, which was almost always ER-positive, does not, in the opinion of authors, justify the use of risk-reducing ET. Therefore, the decision on ET for DCIS should be personalised and consider grade, ER status and other characteristics.

Implications of abnormal abdominal wall computed tomographic angiography findings on postmastectomy free flap breast reconstruction.

BACKGROUND: Preoperative computed tomography angiography (CTA) of the abdominal wall vessels is used when planning free flap breast reconstruction (FFBR) because it provides a surgical road map which facilitates flap harvest. However, there are few reports on the effect of abnormal findings on the operative plan. METHODS: We conducted a retrospective study of all FFBRs performed at a tertiary referral center over a 6-year period (November 2011 to June 2017). One consultant radiologist reported on the findings. Details on patient demographics, CTA reports, and intraoperative details were collected. RESULTS: Two hundred patients received preoperative CTAs. Fourteen percent of patients (n=28) had abnormal findings. Of these findings, 18% were vascular anomalies; 36% tumorrelated and 46% were "miscellaneous." In four patients, findings subsequently prevented surgery; they comprised a mesenteric artery aneurysm, absent deep inferior epigastric (DIE) vessels, bilateral occluded DIE arteries, and significant bone metastases. Another patient had no suitable vessels for a free flap and the surgical plan converted to a pedicled transverse rectus abdominis musculocutaneous flap. The remaining incidental findings had no impact on the surgical plan or appropriateness of FFBR. More than one in 10 of those with abnormal findings went on to have further imaging before their operation. CONCLUSIONS: CTA in FFBR can have a wider impact than facilitating surgical planning and reducing operative times. Incidental findings can influence the surgical plan, and in some instances, avoid doomed-to-fail and unsafe surgery. It is therefore important that these scans are reported by an experienced radiologist.

Assessment of breast symmetry in breast cancer patients undergoing therapeutic mammaplasty using the Breast Cancer Conservation Therapy cosmetic results software (BCCT.core).

BACKGROUND: Therapeutic mammaplasty (TM) is a standard oncoplastic technique utilising aesthetic breast reduction principles to facilitate tumour resection and breast reshaping. Simultaneous contralateral mammaplasties are often performed to maintain symmetry. BCCT.core software, which principally assesses breast symmetry, has been previously employed for evaluating cosmetic results after standard breast conservation therapy and latterly TMs for upper pole tumours. The purpose of this study was to validate this novel tool for TMs in all breast zones. METHODS: Standardised photographs of 20 consecutive patients who underwent TM were evaluated for symmetry using BCCT.core versus a plastic surgical panel completing a visual analogue scale. Results were rated as (excellent/good/fair/poor). Outcomes between the two methods were compared. RESULTS: Twenty patients aged 37 to 63 years with a median 36G bra size had 22 TMs (18 unilateral, 2 bilateral). Indications were invasive breast cancer (87%) and ductal carcinoma in situ (DCIS) (13%). The median (range) tumour size was 22.5 mm (6-90 mm) with a resection weight of 245.8 g (16-1,079 g). Primary nipple pedicles were superomedial (63%), inferior (21%) and superolateral (16%). Five patients required a secondary glandular pedicle for volume redistribution to maintain breast shape. The BCCT.core software vs. panel symmetry assessments were 37% vs. 39% (excellent), 63% vs. 50% (good) and 0% vs. 11% (fair). Wilcoxon matched-pairs sign rank tests and Spearman rank correlations found the pairings to be statistically significant (P<0.05). CONCLUSIONS: Despite small patient numbers, BCCT.core gave comparable findings with the panel and is thus useful for objectively assessing cosmesis of TMs in all breast zones.

The use of plasmakinetic cautery compared to conventional electrocautery for dissection of abdominal free flap for breast reconstruction: single-centre, randomized controlled study.

BACKGROUND: The plasmakinetic cautery is a surgical dissection instrument that combines scalpel-like cutting precision with electrocautery-like haemostasis properties, and operates at lower temperatures (40-170 °C) than conventional electrocautery (200-350 °C). The aim of this study is to evaluate the clinical benefits of using plasmakinetic cautery in abdominal free flap dissection for breast reconstruction. METHODS: Forty women undergoing abdominal-based microsurgical breast reconstruction (DIEP/MS-TRAM) were randomized to plasmakinetic cautery (n=20) or conventional electrocautery (n=20) for dissection of the abdominal free flap. Total abdominal wound drainage volume/duration, operation time and complications such as seroma and haematoma were examined. RESULTS: Age, body mass index, type of reconstruction and abdominal flap weight were similar in both groups. Mean abdominal drainage volume was (279±262) mL in conventional electrocautery group and (294±265) mL in plasmakinetic cautery group (P=0.853). Plasmakinetic cautery group mean drainage duration (4.3±2.2 days) was no difference compared to conventional diathermy group (3.8±2.0 days, P=0.501). Mean operation time in the conventional electrocautery group and plasmakinetic cautery group was 157±50 vs. 174±70 min respectively (P=0.195). There was more seroma detected in the conventional electrocautery group compared to plasmakinetic cautery group at days 7, 14 and 42 post-operation, but this was not statically significant. 2 haematomas in conventional diathermy group and 1 haematoms in the plasmakinetic cautery group required evacuation. CONCLUSIONS: This study demonstrates that there are no significant differences between the use of plasmakinetic cautery and conventional electrocautery for abdominal free flap dissection.

New surgical technique: Simultaneous use of contiguous intercostal spaces during total rib preservation exposure of the internal mammary vessels in microvascular breast reconstruction.

INTRODUCTION: Microvascular free tissue transfer is the gold standard for autologous breast reconstruction. For many surgeons, the internal mammary vessels (IMV) are the preferred recipient vessels. The merits of the rib preservation technique have been previously discussed. There are, however, instances in which greater access than afforded by one intercostal space (ICS) may be required, for example, multiple or redo anastomoses or inadvertent recipient vessel damage. We therefore have refined this technique further to allow exposure of two ICSs without sacrifice of the intervening rib cartilage. METHOD: We identified all patients who had simultaneous contiguous ICSs dissected whilst preserving the intervening costal cartilage for microvascular anastomoses for breast free flaps. The indications, surgical technique, and its refinements are described. RESULTS: Simultaneous exposure of the IMVs in both the second and third ICSs whilst preserving the intervening costal cartilage for microvascular anastomoses was successfully performed in 15 patients with no flap failures. Indications included bipedicled DIEP flaps (9), bipedicled DIEA/SIEA flap (1), stacked DIEP flaps (4), and salvage (1). One flap was successfully re-explored for venous congestion. There were no intraoperative complications. CONCLUSION: We have demonstrated that simultaneous contiguous ICS exposure of the internal mammary recipient vessels with total rib preservation is technically feasible, has no adverse patient sequelae, and has the benefit of allowing multiple anterograde and retrograde microvascular anastomoses (even in patients with narrow ICSs). This technique preserves the intervening rib and is of particular utility in bipedicled flaps when multiple "extra-flap" anastomoses may be required.

The Role of CT Angiography in Assessing Deep Inferior Epigastric Perforator Flap Patency in Patients With Pre-existing Abdominal Scars.

BACKGROUND: Abdominal scars can affect the patency of deep inferior epigastric artery (DIEA) perforators and are a concern when planning free flap breast reconstruction (FFBR). Computed tomography angiography (CTA) is routinely used for preoperative DIEA flap imaging. We investigated CTA utility in predicting the most clinically useful DIEA perforators in scarred abdomens. METHODS: A single surgeon's CTA FFBR patients were studied. All were imaged by one radiologist. CTA reports, abdominal scars, and flap intraoperative details were analyzed. The operative findings were then correlated with the CTA "predictions." RESULTS: A hundred and six patients with preoperative CTAs underwent 132 FFBRs, 44% (58) from scarred and 56% (74) from virgin abdomens. All flap transfers were successful. Concordance between perforators identified by CTA preoperatively and those selected by the surgeon intraoperatively was 95% (scarred 93%; non-scarred 96%, P = 0.470). There was a significant difference in the proportion of single-perforator flaps between the two groups (scarred 46%; non-scarred 28%, P = 0.041). "Scarred" flaps were heavier (789 vs 676 g, P = 0.0244) than those harvested from virgin abdomens. CONCLUSIONS: CTA accurately predicted perforator choice in flaps from scarred and virgin abdomens. "Scarred" flaps are more likely to be heavier and based on one perforator suggesting that scarring may have an effect on intraflap vascular anatomy. Further investigations are needed to delineate the mechanism by which this occurs.

The effect of CT angiography and venous couplers on surgery duration in microvascular breast reconstruction: a single operator's experience.

BACKGROUND: The use of CT angiography (CTA) or venous couplers (VCs) has led to shorter operative times in free flap breast reconstruction (FFBR). However, there are no reports on the effect of these two interventions relative to each other or combined. METHODS: Abdominal based FFBRs performed by a single surgeon before introduction of either intervention were compared to those with VC only, and those after the addition of CTA to VCs (CT-VC). Operative time was defined as from "knife-to-skin" to insertion of the last stitch. RESULTS: One hundred and twenty patients; 40 without intervention (WI), 40 with VC, and 40 with CT-VC. Introduction of VCs did not significantly reduce operative time compared to WI (P=0.73). However, patients in the CT-VC group had significantly shorter operations vs. WI (472 vs. 586 min, P<0.00001) and vs. VC alone (472 vs. 572 min, P=0.0006). Similarly, introduction of each intervention showed a stepwise decrease in ischaemia time (WI vs. VC: 100 vs. 89 min, P=0.0106; VC vs. CT-VC: 89 vs. 80 min, P=0.0307; WI vs. CT-VC: 100 vs. 80 min, P<0.00001). CONCLUSIONS: Combination of CTA and VC significantly reduced operative and ischaemic times for FFBR; this was predominantly due to use of CTA. CTA mitigates the surgical learning curve as demonstrated by shorter operating times via providing a vascular anatomy roadmap, thus facilitating flap harvest.

Initial Management of Traumatic Digit Amputations: A Retrospective Study of Functional Outcomes.

BACKGROUND: Traumatic amputation of one or more digits can have a serious detrimental effect on social and economic standings which can be mitigated by successful replantation. Little has been recorded on preoperative management before replantation and how this affects the outcomes of the replanted digit. METHODS: A retrospective cohort study was conducted and data collected over an 18-month period. Three protocols for preoperative management were examined: minimal (basic wound management), complete Buncke (anticoagulation, dry dressing on amputate placed on indirect ice and absence of a digital block), and incomplete (any two or three criteria from complete Buncke in addition to the minimal) protocols. Data was collected on survival rate, secondary operations, and complication rate. Function was defined by sensation, range of movement, and strength. RESULTS: Seventy four of 177 digits were replanted with an overall survival rate of 86.5%. The rates for minimal, incomplete, and complete protocols were 95%, 87%, and 91%, respectively, and not significantly different. The complication rate was significantly different between the complete (20%) and minimal (60%) protocols (p = 0.0484). Differences in sensation and grip strength were statistically significant between protocols (p = 0.0465 and p = 0.0430, respectively). Anticoagulation, no digital block and dry gauze all showed reduced complication rates in comparison to their counterparts. CONCLUSIONS: The Buncke protocol, which includes anticoagulation, no digital block, and dry gauze, was found to significantly reduce the complication rate which suggests that it prevents compromise of tissue integrity. Significant differences were found between protocols for sensation and grip strength. A higher-powered study is needed to investigate the effects of preoperative management on complication rates and functional outcomes.

Plastic Surgeon-Led Ultrasound.

BACKGROUND: Portable high-frequency ultrasound is a useful adjunct to a plastic surgeon's practice. With a short learning curve, this patient-friendly imaging modality has a variety of uses that aid patient management/treatment plans. The authors describe clinical cases and review the literature regarding ultrasound performed by the surgeon. METHODS: The Sonosite S-Nerve machine with the L25X transducer was used (depth, 4.3 cm). Clinical cases that ordinarily would have been referred to the radiology department were taken from the day-to-day practice of the senior author (M.G.). The clinical scenarios ranged from acute presentations to planned elective settings. RESULTS: Ultrasound was a useful adjunct in a variety of applications, ranging from acute hand trauma visualizing neurovascular bundles and tendons, to elements of reconstructive breast surgery such as fat grafting over an implant and scar release. The ultrasound machine was also used for determination of the depth and size of collections such as seromas to facilitate drainage, for identification of lymph nodes before transfer, and for acute presentations of conditions ranging from undiagnosed swelling to foreign body localization. CONCLUSIONS: The portable ultrasound machine has become an invaluable tool in the senior author's practice. In a short time and with a short learning curve, the authors' unit identified numerous applications for its use. From a patient perspective, it is noninvasive/nonpainful and has no deleterious radiation effects, and treatment plans can be enacted without delay. It is highly recommended that surgeons become familiar with this imaging modality and assimilate it into their daily practice. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.