Utilization of a 3D Printed Simulation Training Model to Improve Microsurgical Training.

Simulation is integral to the development and maintenance of micro- surgical skills. Several simulation models have been described ranging from bench- top to live animal models. High fidelity models are often burdened by cost and ethical issues limiting widespread implementation. This study aims to determine the feasibility of a microsurgical training platform using the Konjac noodle model. Methods: A prospective cohort study was conducted at our institution. A progressive microsurgical training curriculum was developed. A bespoke three-dimensional printed training platform was produced to enable residents to record training and assessment tasks. Microsurgical skills were blindly assessed before and after completing the training program using the University of Western Ontario Microsurgical Skills Assessment instrument. Results: Plastic surgery residents at various stages of training were recruited (n = 10). A significant improvement in vessel preparation from a pre-training median of 3 (IQR 2 -4) versus a post-training of 4 (IQR 3 -5, P = 0.0035) and suturing with a pre-training median of 3 (IQR 2 -4) versus a post-training of 4 (IQR 3 -5, P = 0.0047) domains of the University of Western Ontario Microsurgical Skills Assessment score was demonstrated after completion of the training program. There was a significant improvement in the global rating score (3 ± 1 versus 5 ± 1, P = 0.0045). Participants felt more confident performing a microsurgical anastomosis following the training program. Conclusion: The use of the Konjac noodle model and video-based assessment using a three-dimensional printed model is an effective teaching tool that improves resident's microsurgical skills.

Developing a Parental-Friendly Scoring System for Children with Congenital Hand Differences.

Background: Congenital hand differences (CHD) exhibit enormous diversity and heterogeneity. Surgeons and parents often have different concepts of severity, making things difficult during parental consultation. This study aims to align surgeon/parental views on the severity of the child's CHD using a novel severity classification. Methods: Parents of affected children were asked to score the severity of their child's abnormality pre- and post-consultation using a subjective scale (1-4) without any explanation. Furthermore, parents were asked to rate their concerns about the future function and appearance of their child's hand condition using a similar scale of 1-4. They were then asked to rate the severity of the CHD post-consultation and three months post-operatively following explanation of the 4-point scale, as follows: 1 = treatment possible to normal; 2 = treatment possible to near normal; 3 = treatment possible but always some hand differences; 4 = treatment not possible. The surgeon also independently scored all children using his perception of the scale. Results: Forty-three children with a range of CHD were recruited into the sample. Linear weighted kappa analyses comparing inter-rater agreement showed no agreement between surgeon and parents during the initial scoring without any explanations. However, with explanations added, agreement rose significantly (kappa = 0.437 post-consultation and kappa = 0.706 three months post-op). No correlation was found between severity with both appearance and function (r = 0.277 and r = -0.184, respectively). Conclusions: This study demonstrated that the use of a simple scoring system was able to improve parental understanding of the severity and prognosis of CHD. The system demonstrated a good correlation between surgeon and parents. Such a scoring system can be easily utilised in the outpatient department to manage expectations and reduce anxiety.

Thumb carpometacarpal joint osteoarthritis: Is there a role for denervation? A systematic review.

Thumb carpometacarpal osteoarthritis (CMCJ OA) is a common problem. Joint denervation presents a number of theoretical advantages over more traditional surgical options; it is minimally invasive, it does not require a prosthesis or postoperative immobilisation, and does not preclude future surgery. It can be of particular benefit in patients who require good range of motion which other forms of surgery may compromise. Despite these potential advantages, selective denervation of the thumb CMCJ is not considered as part of the routine surgical armamentarium for the treatment of thumb base OA. The purpose of this study is to analyse the evidence for thumb CMCJ denervation; evaluating patient selection, surgical techniques, complications and outcomes. A systematic review was performed on all published literature relating to thumb CMCJ denervation. Nine studies were identified with 184 denervation procedures undertaken in 175 patients. The length of follow-up was available in eight studies (mean 36.5 months [range 6-152 months]). All authors reported improvement in pain and seven studies reported improvement in function. Eleven patients in total suffered persistent joint pain, ten of which proceeded to trapeziectomy and one patient underwent a revision denervation to address potentially missed dorsal sensory branches. The overall complication rate was 11.4% (0-27.5%) consisting of minor complications. This review highlights the paucity of high-quality data and the requirement for a multi-centre, randomised study with validated outcome measures to further define the role of denervation in the management of thumb base OA.

Bilateral Breast Reconstruction with Abdominal Free Flaps: A Single Centre, Single Surgeon Retrospective Review of 55 Consecutive Patients.

Breast reconstruction using free tissue transfer is an increasingly utilised oncoplastic procedure. The aim was to review all bilateral breast reconstructions using abdominal free flaps by a single surgeon over an 11-year period (2003-2014). A retrospective review was performed on all patients who underwent bilateral breast reconstruction using abdominal free flaps between 2003 and 2014 by the senior author (DAM). Data analysed included patient demographics, indication for reconstruction, surgical details, and complications. Fifty-five female patients (mean 48.6 years [24-71 years]) had bilateral breast reconstruction. The majority (41, 74.5%) underwent immediate reconstruction and DIEP flaps were utilised on 41 (74.5%) occasions. Major surgical complications occurred in 6 (10.9%) patients, all of which were postoperative vascular compromise of the flap. Failure to salvage the reconstruction occurred on 3 (5.5%) occasions resulting in a total flap failure rate of 2.7%. Obesity (>30 kg/m(2)) and age > 60 years were shown to have a statistically increased risk of developing postoperative complications (P < 0.05). Our experience demonstrates that abdominal free flaps for bilateral breast reconstruction fares well, with a flap failure rate of 2.7%. Increased body mass index and patient age (>60 years) were associated with higher complication rates.

Assessing the Risks Associated with Antidepressant Use in Plastic Surgery: A Systematic Review.

BACKGROUND: Antidepressant use has increased dramatically over the past decade. Although there is no question about the benefits of these medications, uncertainty exists with regard to the implications of antidepressant treatment surrounding plastic surgery. This systematic review collates all of the available literature that evaluates the risks of patient antidepressant treatment, in relation to plastic surgery. METHODS: A comprehensive literature review of the PubMed and Cochrane databases was conducted. Articles were assessed by two independent reviewers using predefined data fields and selected using specific inclusion criteria. The two authors independently reviewed the literature and extracted data from included reviews, and discrepancies were resolved by consensus. RESULTS: Twenty-six articles were included in the analysis and were categorized into five groups for comparison: risk of bleeding, risk of breast cancer, risk of breast cancer recurrence, breast enlargement, and miscellaneous (unique complications). Extracted information included study type, statistical analyses, conclusion, and limitations. CONCLUSIONS: This review does not support the cessation of antidepressants in patients before plastic surgery, as the numbers needed to harm are low and the implications of withdrawal may prove to be detrimental to postoperative management. However, the use of antidepressants for mental disorders may also implicate key patient risk factors for surgical complications, and sufficient exploration into the patient's indications for the prescription is crucial. Evidence so far does not suggest that antidepressants increase the risk of breast cancer or recurrence in general, but caution should be exercised for those specifically on concurrent tamoxifen and paroxetine treatment.

Referral patterns to a surgical lymphoedema service: 10 years of experience.

INTRODUCTION: Liposuction for lymphoedematous limbs is an effective treatment for chronic lymphoedema, with excellent long-term results in well-selected patients. In 2008 NICE produced guidelines 'Liposuction for Chronic lymphoedema', acknowledging this treatment modality. However, there remain very few centers that provide this service in the United Kingdom. We aim to share our experience of our referral system at Ninewells Hospital, Dundee, Scotland. METHODS: A 10 year prospective database from 2005 to 2014 was analysed. Referral sources, patient demographics, diagnosis and treatment offered were examined. RESULTS: There were 221 referrals in total, 190 (86%) female and 31 (14%) male. The mean age was 51 (range 7-86 years). 127 (58%) were referred via their general practitioners, 72 (33%) from a hospital consultant and 22 (10%) from a lymphoedema nurse specialist. 153 (69%) referrals were from Scotland, 61 (28%) from England and 7 (3%) from Northern Ireland. The majority of patients 165 (75%) were referred with lower limb swelling. Following assessment in clinic, 146 (66%) were found to have lymphoedema whilst the rest were deemed to have other non-lymphoedematous diagnoses which include lipoedema (47, 21%), dependent oedema (8, 4%) and obesity (5, 2%). 131 (59%) were offered liposuction- 74 (34%) have received liposuction, 18 (8%) are awaiting their procedure, 3 (1%) have declined surgery, 27 (12%) are awaiting funding approval and 9 (4%) have been declined funding by their primary care trust/clinical commissioning group (PCT/CCG). 4 (2%) are awaiting investigations to further evaluate the cause of their swelling, whilst the remaining 86 (39%) were felt unsuitable for surgery and were treated conservatively. CONCLUSION: Chronic lymphoedema is a challenging condition to treat, with few specialist centers offering surgical treatment. We hereby share our referral process, diagnosis and management.

Systematic review of seat-belt trauma to the female breast: a new diagnosis and management classification.

BACKGROUND: Legislation, education and technology have led to a rise in the use of seat belts. This has significantly reduced automobile accident-related mortality, but it has increased seat belt-associated injuries. The aim of this study was to review all publications on seat-belt injury to the female breast and to analyse patterns of presentation, management and outcomes. METHODS: A literature search was performed by two independent reviewers using the PubMed, Scopus and EMBASE databases. The MeSH terms included 'seat belt breast' or 'breast traffic accident' or 'safety belt breast'. This study was supported by Level V evidence. RESULTS: In this review, 26 articles describing 42 patients were included. A total of 13 patients (31.0%) presented immediately after the road traffic accident (RTA) with pain, swelling, open wounds and/or haemorrhage of the breast. Active arterial extravasations were treated with angiographic embolization while wounds were mostly treated with dressings. Twenty-nine (69.0%) patients presented late, with a mean time of 6.77 months (3 weeks-5 years) after the RTA. This ranged from a palpable lump in the area of trauma to a worsening cleft deformity. Most late presentations were diagnosed with fat necrosis while five patients (17.2%) were found to have breast cancer. From this review, we propose a four-tier classification system that categorizes patients based on timing to presentation and symptoms, with recommended investigation and management options for each category. CONCLUSION: This is the most comprehensive systemic review to date of seat-belt injuries to the female breast, and our proposed classification may be useful in the management of such patients.

Outcome of single-stage breast reconstruction using the Natrelle 150 expander implant.

The Natrelle 150 offers the advantage of single-stage reconstruction. However, there is lack of published data on its long term outcomes, which does not allow for definitive conclusions as to whether it truly meets its design objective of a lasting single stage breast reconstruction. This is a retrospective review of all Natrelle 150 reconstructions by a single surgeon over 5 years. A total of 143 procedures were performed in 125 patients with a mean follow-up of 33 months (range, 3-65 months). Most (120, 84%) received the implant after oncological mastectomies, 22 (15%) after risk-reducing mastectomies, and 1 (0.8%) for hypoplasia. Fifty-one (35.7%) implants were explanted an average of 12.9 months after implantation. A Kaplan-Meier survival analysis demonstrates an explantation rate of 25% by 11 months. Explantation was more likely after subpectoral placement compared to reconstructions in combination with latissimus dorsi flaps (P<0.05). Risk-reducing reconstructions were also more likely to undergo explantation (P<0.05) compared to reconstructions for oncological reasons. Our data suggest that this prosthesis is only successful as a 1-stage procedure in certain patients, and has led to more careful patient selection and counseling.

A Rare Case of Cholecystitis Caused by Raoultella planticola.

A 62-year-old female presented with right upper quadrant pain. Clinical examination and ultrasound scan were consistent with gallstones and acute cholecystitis. She received 3 days of intravenous Co-amoxiclav and was discharged with 5-days of oral antibiotics with arrangements to return for an elective cholecystectomy. This was performed 5 months later which revealed an inflamed gallbladder and a localised abscess secondary to gallbladder perforation. Fluid from the gallbladder was taken which cultured Raoultella planticola, a gram-negative, nonmotile environmental bacteria (Bagley et al. (1981)). This is the first report of biliary sepsis with a primary infection by R. planticola. This patient was treated with a 5-day course of oral Co-amoxiclav and made a full recovery.