Metastatic melanoma vs lymphoma. Using a sentinel lymph node biopsy a diagnostic tool.

Sentinel lymph node biopsy (SLNB) is a prognostic tool used in cases of melanoma with a stage IB or greater and the absence of clinical lymphadenopathy. A positive SLNB historically indicated a need for regional lymph node clearance. However, cases of clinical lymphadenopathy in the presence of primary melanoma negates the use of SLNB and rather the British Association of Dermatologists advocate a primary block dissection of regional lymphatic tissue [NICE UK. Melanoma: assessment and management. NICE Guideline NG 14. 2015]. The following describes the case of a patient with an original stage II melanoma and a concurrent diagnosis of B cell lymphoma associated with widespread lymphadenopathy. Our multi-disciplinary team believe the use of SLNB is a more informative investigation compared with ultrasonograpphy and fine needle aspiration for such cases. In cases of clinical uncertainty due to a dual diagnosis of lymphoma, cytology would not provide nodal morphology or histological architecture, required for lymphoma grade and subtype.

Incorporating multi-source feedback into a new clinically based revision course for the FRCS(Plast) exam.

BACKGROUND: Exit exams for completion of surgical training are demanding and have relatively low pass rates with many candidates requiring multiple attempts. AIM: To establish a new, clinically based exam preparation course, utilising multi-source feedback, to identify candidates at risk of failure and improve pass rates. METHODS: We describe the process of establishing a new, unique, clinically based exam preparation course incorporating multi-source feedback from examiners, patients, nurses and other trainees. We present the course results as well as the exam results for each candidate and analyse the results of the multi-source feedback. RESULTS: Nine candidates have so far successfully completed both the preparation course and the FRCS(Plast) exam. Success in the exam preparation course accurately predicts success in the FRCS(Plast) exam. Nursing staff and patients tend to give higher scores than examiners and trainees. The majority of marginal failures from the course went on to pass the exam, indicating that the course allows candidates to successfully address weaknesses identified on the course. CONCLUSION: A clinically based exam preparation course utilising multi-source feedback allows identification of candidates at risk of failing a surgical training exit exam and allows targeted training in order to maximise pass rates.

Ten-year audit of melanoma in a central England population.

The incidence of melanoma in the North Staffordshire region has more than doubled over the last 10 years, and nearly tripled in the "thin" melanoma group (≤ 1 mm). A retrospective audit was performed to investigate the overall management of melanoma, with a focus on thin melanomas. A total of 507 patients was identified between 1999 and 2009. The incidence of melanoma is increasing in the older age groups (> 50 years), although the thin melanomas were diagnosed at a significantly younger age than the cohort as a whole (p < 0.001). The anatomical distribution was similar in both groups. More females were affected by thin melanomas (65%) compared with all melanomas (55%). This audit provides a unique insight into the incidence and characteristics of melanoma in a Central England population. The incidence of melanoma is increasing, but more so in the thin group. Thick (> 4 mm) and intermediate (1.01-4 mm) melanomas are increasing at a slower rate.

Use of dermal regeneration template (Integra) for reconstruction of full-thickness complex oncologic scalp defects.

The reconstruction of full-thickness scalp defects remains a surgical challenge. Different types of reconstruction had varying success including the use of dermal regeneration template (DRT). We reviewed the surgical outcome of 30 patients who underwent application of DRT for resurfacing of full-thickness scalp defects when the pericranium was excised and the outer cortex of the calvarial bone was burred after the excision of scalp neoplasm. This was a retrospective review of 30 patients who had scalp reconstruction with DRT undertaken by the senior author between October 2004 and June 2007. The mean age of patients in our series was 63 years (37-91 years). There were 14 men and 16 women. The indications for re-excision and DRT reconstruction in 28 patients were close margins and aggressive tumor type, whereas 2 patients had a recurrence. The mean defect size was 95 cm2 (16-275 cm2). The second stage of the reconstruction occurred on postoperative day 42 (postoperative days 27-62). The mean follow-up period was 14 months. Two patients had minor complications. For both stages, the combined average operative time was 128 minutes. The use of DRT is a rung of the reconstructive ladder that deserves consideration. In our series of 30 patients who required secondary reconstruction of complex scalp defects, the use of DRT has been seen to provide safe and durable soft-tissue cover for full-thickness scalp defects. The reduced operative time and inpatient stay are desirable characteristics particularly in elderly patients with multiple comorbidities.

The use of Dermal Regeneration Template (Integra®) for reconstruction of a large full-thickness scalp and calvarial defect with exposed dura.

The reconstruction of large full-thickness scalp defects remains a challenge, particularly when dura is exposed. Various reconstructive methods have been described in the past. Dermal Regeneration Templates (DRTs) are becoming increasingly popular in the management of acute wounds as well as the reconstruction of burn scars, oncological defects and various other complex reconstructive problems. We describe a case where Integra® was successfully used together with a Vacuum-Assisted Closure (VAC) dressing to reconstruct a full-thickness scalp defect with exposed dura. Surgical technique is discussed as well as problems encountered during the case and possible solutions.

Nursing monitoring and management of free and pedicled flaps--outcomes of teaching sessions on flap care.

BACKGROUND: Close monitoring is crucial following successful flap surgery because early detection of signs of deterioration can result in a successful intervention and salvage of the flap. An observational audit of practice highlighted short comings in flap monitoring in our Plastic Surgery unit. We created and delivered a teaching session to junior nursing staff with regard the basic principles of flaps and their postoperative care and generated a universal postoperative flap monitoring protocol to help improve and standardize care provision. METHODS: Following a group teaching session, all healthcare providers provided input to create a flap monitoring chart. A cartoon was drawn and placed around the ward to consolidate the ideas generated. RESULTS: The working relationship between doctors and nurses on the ward improved dramatically. Nursing staff felt more confident in their ability to deal with flaps postoperatively and felt more able to contact the surgeons about any concerns or clarifications needed. A re-audit of procedures following these interventions showed improvement in detection of flap ischemia. DISCUSSION: Good patient care within any healthcare system is entirely dependent on the effective function of the multidisciplinary team while maintaining the patient as the focus of care. With both subjective and objective evidences of improvement in the care of flaps in our Plastic Surgery Unit, we can confidently conclude that our teaching program and postoperative flap protocol has been a successful intervention.

Thumb subungual melanoma: is amputation necessary?

Subungual melanoma is uncommon. Traditional teaching advocates amputation of the affected digit. Recent studies have shown that more distal levels of amputations do not compromise survival or recurrence rates. When the thumb is involved, functional and aesthetic loss can be substantial. We present a new conservative, digit-sparing approach in the treatment of subungual melanoma of the thumb. Four informed patients were recruited to undergo the new treatment. Local excision with 1cm margins down to and including the periosteum was carried out. Reconstruction was with a local flap. There has been one recurrence and no deaths with a minimum of 6 years follow up. In selected cases, conservative management of subungual melanoma allows preservation of length and minimises disability.

Ulnar-based skin flap for Dupuytren's fasciectomy.

The mainstay of treatment for symptomatic Dupuytren's disease is operation. Various skin incisions have been described, showing that there is no single best incision. We describe an ulnar-based skin flap for excision of palmar disease. This flap allows excellent exposure of the diseased area, and provides good access to the palmar aponeurosis including the difficult area on the ulnar side of the little finger. Healing is reliable and digital disease can be approached with a skin extension as required. Recurrent disease can be treated by raising the same flap again.

Soft fluted silicone drains: a prospective, randomized, patient-controlled study.

BACKGROUND: For some patients, removal of surgical drains can be the most painful part of surgery. The authors present a prospective, randomized, patient-controlled study comparing soft fluted silicone (Blake) drains with conventional rigid (Portavac) drains. METHODS: After ethical committee approval, 43 patients undergoing bilateral breast reduction surgery were recruited into the study. A Blake drain was inserted on one side and a Portavac drain was inserted on the contralateral side; the patients therefore acted as their own controls. Pain scores were measured on a descriptive scale 10 minutes before, during, and 10 minutes after drain removal. Statistical analysis was carried out using the Wilcoxon signed ranks matched pairs test. RESULTS: The results show that Blake drains are less painful before (p = 0.05), during (p = 0.01), and after removal (p = 0.009). Of those patients who expressed a preference, 27 preferred the Blake drain and 10 preferred the Portavac drain. CONCLUSION: The authors advocate the use of a silicone fluted (Blake) drain for any wound requiring drainage, especially if large-caliber drains are indicated.