Wide Awake Local Anesthetic No Tourniquet in Hand and Wrist Surgery: Current Concepts, Indications, and Considerations.

Background: Traditionally, the use of a pneumatic arterial tourniquet was requisite for safe and effective surgery of the hand. The use of arterial tourniquets necessitates the use of regional or general anaesthesia. Wide-awake local anaesthetic no tourniquet (WALANT) has emerged as a novel technique to overcome the limitations of tourniquet use in conjunction with regional/general anaesthesia. This review aimed to examine the safety and effectiveness of WALANT and provide guidance for surgeons with limited WALANT experience. Methods: A literature review of MEDLINE was performed up to March 2021 to identify all articles related to the use of WALANT in hand surgery. Any article reporting original data related to the use of WALANT was eligible for inclusion. Results: A total of 101 articles were identified through database searching. Of these, 79 met full inclusion criteria and described the use of WALANT in 19 elective and trauma procedures. Current data suggest that WALANT is safe and effective for use in a range of procedures. Conclusions: WALANT surgery is increasing in popularity as evidenced by the variety of surgical indications reported in the literature. There is limited comparative data on the cost-effectiveness of WALANT compared to conventional methods. Current data suggest that WALANT is safe, better tolerated by patients and associated with direct and indirect cost savings.

Management of the Congenital Cleft Earlobe with a Conchal Cartilage Graft.

Congenital earlobe clefts are the most common lower auricular malformations. They represent a unique reconstructive challenge. The goal of surgery includes restoration of a natural lobular contour and volume as well as a fine surgical scar. Several surgical techniques have been described, most of which only address the cleft deformity but not the soft tissue deficiency. We hereby describe a technique which addresses both the cleft and improves soft tissue deficiency through a conchal cartilage graft.

Management of the infected preauricular sinus.

INTRODUCTION: The preauricular sinus is a common finding in children and may often be complicated by infection. Complete excision of the sinus is the only definitive cure. Failure to recognise the presence of a sinus, particularly when infection erupts away from the sinus, may lead to inadequate management and unnecessary surgery. AIM: We report our experience in managing infected preauricular sinuses and highlight important points in our surgical technique. METHODS: A retrospective review was performed of our electronic patient database for all paediatric patients who underwent surgical excision of preauricular sinuses by the senior author at Great Ormond Street Hospital for Children between January 2013 and October 2022. RESULTS: A total of 10 patients underwent surgical management of 11 preauricular sinuses with a median follow-up time of 40 months (range 1-136). Eight patients underwent excision of the preauricular sinus due to infection. All infected cases affected the preauricular cheek skin and had previously undergone at least one unsuccessful surgical drainage prior to a referral to our unit. All cases were successfully operated on at our unit with no reported complications or recurrence. CONCLUSION: A lack of awareness of the presence of a sinus and identification of a preauricular pit by the inexperienced clinician will result in inadequate treatment of this condition and potentially unnecessary surgical procedures. Our paper highlights the importance of correctly identifying the extent of the sinus and describes a safe and reliable technique to ensure complete removal of the preauricular sinus with satisfactorily low recurrence rates.

Entrapment of the Extensor Digitorum Communis Tendon Following a Closed Metacarpal Fracture.

We report a unique patient with extensor digitorum communis (EDC) tendon entrapment following a closed metacarpal fracture. A 19-year-old male presented after punching a metal pole with his right hand. The diagnosis of a closed metacarpal fracture of the right middle finger was made, and the patient managed nonoperatively. Following subsequent worsening range of motion, further investigation was performed, and a portable ultrasound scan revealed entrapment of the right middle finger EDC tendon into the fracture site. This was confirmed intraoperatively, and the patient made a satisfactory recovery following surgical release of the entrapped tendon. We were unable to find a report of a similar injury in literature and it highlights the importance of a high index of suspicion for this rare aetiology, the role of ultrasonography as a useful adjunct in its diagnosis and the benefit of early surgical intervention in its management. Level of Evidence: Level V (Therapeutic).

A Comparison of Outcomes at Twelve Weeks of Traditional Button-Over-Nail versus Bone Anchor Repair of Zone I Flexor Digitorum Profundus Tendon Injury.

Background: The repair of zone 1 flexor tendon injury often relies on re-inserting the flexor digitorum profundus (FDP) tendon to the distal phalanx. The aim of this retrospective study is to compare outcomes at 12 weeks following traditional button-over-nail (BON) versus bone anchor (BA) repair of zone I FDP injury. Methods: Patients undergoing zone 1 FDP repair between April 2007 and September 2018 using a BON or a BA were included in the study. Patient demographics, complications, arc of flexion of distal (distal interphalangeal joint [DIPJ]) and proximal interphalangeal joint (PIPJ) and patient-rated outcomes were analysed. Results: Forty-three patients were included in the study: 21 in the BA group and 22 in the BON group. Good function was achieved by 20 patients in BA versus nine in BON. Complications occurred in five BA patients versus 10 BON patients. Patients achieved a mean active DIPJ flexion of 49° and 31° and PIPJ flexion of 92° and 57° in the BA and BON groups, respectively. Conclusion: Our study demonstrates better arc of motion, patient-rated outcomes and lower complications at 12 weeks after surgery in patients undergoing zone 1 FDP repair using a BA. Level of Evidence: Level III (Therapeutic).

Outcomes of major head and neck reconstruction during the COVID-19 pandemic: The St. Andrew's centre experience.

BACKGROUND: The coronavirus disease-2019 (COVID-19) pandemic has generated enormous pressure on healthcare establishments, prompting the restructuring of services to rationalise resources. Complex head and neck reconstructive surgery in this setting may carry substantial risk to patients and staff. This paper outlines the management strategy and outcomes of major head and neck oncological cases at a single regional tertiary referral centre. METHODS: A database review was undertaken of consecutive patients undergoing major head and neck surgery and reconstruction during the COVID-19 pandemic at St Andrew's Centre for Plastic Surgery & Burns, Chelmsford UK. Patient demographics, tumour and reconstruction characteristics as well as peri­operative information were determined. Patients were prospectively contacted with regard to COVID-related symptoms and investigations. RESULTS: Twenty-two patients (15 males and 7 females) with a mean age of 67 years (range: 36-92 years) were included between March 1 and June 13, 2020. Patients underwent pre-operative throat swabs at 72 h and 24 h as well as chest CT scanning as part of a robust protocol. Twelve free flaps, four loco-regional flaps, four parotidectomies and 23 cervical lymphadenectomies were performed. Two patients required a return to theatre. No post-operative deaths occurred and flap survival rate was 100%. A single patient tested positive for COVID-19 pre-operatively and no post-operative COVID-19 infections occurred. CONCLUSION: Although head and neck surgery represents a high-risk procedure to patients and healthcare professionals, our institutional experience suggests that in the presence of a robust peri­operative protocol and judicious patient selection, major head and neck surgery, including free tissue transfer reconstruction, may be performed safely.

The Role of Emotional Intelligence in Predicting a Successful Career for Plastic Surgeons: A Systematic Review.

The definition of a successful career in plastic surgery is both a highly variable and personal one. Career success is underpinned by a combination of skills and is often multifactorial in nature. Although clinical and academic factors have long been key determinants of success, modern medical practice is now underlining the previously understated non-clinical skills as a major contributory element. Emotional intelligence (EI) has shown clear benefits in a successful career in the business world, where it was originally popularized. As a successful career in surgery also requires proficient understanding of human emotions, the clear similarities drawn with corporate success have resulted in a growing interest in EI in the medical domain. Despite such interest, the role of EI as a predictor of career success in plastic surgery has been poorly defined. This systematic review aims to define EI, to explore its role in medical and nonmedical fields, and to investigate its impact on a successful career in plastic surgery.

Surgical Management of Cosmetic Surgery Tourism-Related Complications: Current Trends and Cost Analysis Study of the Financial Impact on the UK National Health Service (NHS).

BACKGROUND: Cosmetic surgery tourism is thriving. Lower costs and all-inclusive cosmetic surgery holiday packages have led to more patients seeking cheaper aesthetic surgery abroad. However, limited postoperative care results in patients frequently presenting to UK National Health Service hospitals with postoperative complications requiring surgery. OBJECTIVES: The authors sought to identify current trends and the financial impact of surgically managed complications from cosmetic surgery tourism. METHODS: A retrospective review of consecutive surgically managed patients attending a London Teaching Hospital between 2006 and 2018 with complications following cosmetic surgery abroad was performed. Patient demographics, procedure characteristics, and length of stay were determined and a comprehensive cost analysis was performed. RESULTS: Twenty-four patients presented with complications. Twenty-two were females aged a mean of 36 years (range, 25-58 years). Gluteal enhancement was the most common procedure (38%) and infection (92%) was the primary complication. Most procedures were undertaken in Turkey (29%) and performed in the last 5 years (63%). Twenty-one patients were inpatients and mean length of stay was 8 days (range, 1-49 days); abdominoplasty patients stayed the longest. The total cost to the hospital was $406,233, leading to an average cost per patient of $16,296 (range, $817-$41,778). Complications from abdominoplasty resulted in the highest cost per patient of $20,404. CONCLUSIONS: Cosmetic surgery tourism is on the rise as patients travel for cheaper aesthetic surgery. There is urgent need to better address this issue to help reduce the growing financial strain on the National Health Service, safeguard patients, and optimize the use of valuable resources.

Crush Injury to the Hand Following Epileptic Seizure Leading to Compartment Syndrome.

Compartment syndrome of the forearm or leg has been well documented in the literature. However, there have been few published reports of hand compartment syndrome. We hereby present the first reported case in the literature of hand compartment syndrome secondary to an epileptic seizure. A 50-year old gentleman with known epilepsy presented to the Emergency Department following a witnessed tonic-clonic seizure. The patient's chief complaints were a grossly swollen and excruciatingly painful dominant right hand. Examination revealed severely reduced range of motion and neurovascular compromise. An emergency decompression fasciotomy was performed in the operating theatre, where severe oedema was noted with viable muscle throughout. Compartment syndrome can occur in any muscle compartment of the body, including in the hand. Any crush injury to the hand should trigger a high index of suspicion by the clinician to enable prompt recognition of this surgical emergency and initiate timely management.

Gastrointestinal stromal tumours: advances in surgical and pharmacological management options.

Gastrointestinal stromal tumours (GISTs) are the most common mesenchymal neoplasm of the gastrointestinal tract. The stomach is most commonly affected. Advances in immunopathology have identified a mutation in the c-KIT proto-oncogene, leading to the development of the tyrosine-kinase inhibitor Imatinib as targeted therapy for advanced disease. Surgery, however, remains the only curative treatment of resectable primary GIST. This review article aims at reviewing the management of primary GISTs, investigating recurrences, exploring the role of surgery in metastatic disease and looking into combined surgery and molecular therapy for GISTs.

Deep inferior epigastric perforator (DIEP) flap: Impact of drain free donor abdominal site on long term patient outcomes and duration of inpatient stay.

BACKGROUND: The deep inferior epigastric perforator (DIEP) flap is widely regarded as the Gold Standard in autologous breast reconstruction. Although drain-free abdominoplasty is performed in many centres, there is a paucity of evidence comparing outcomes when applied to DIEP breast reconstruction. METHOD: A retrospective review of patients who underwent DIEP breast reconstruction without abdominal drain insertion at Royal Free Hospital between Jan 2012-Nov 2016 was undertaken. Results were compared to previously published data from our centre on patients undergoing DIEP breast reconstruction with abdominal drains between Jan 2011-Jul 2012. RESULTS: Thirty-five patients underwent abdominal drain-free reconstruction (GroupA). Of 74 patients who previously underwent reconstruction with abdominal drains, 33 patients underwent drain removal by postoperative day (POD)3 regardless of output (GroupB) and 41 underwent drain removal after POD3 following instructions on drainage volume/24 h (GroupC). There was no significant difference in the length of stay between patients in Group A and B (3.6 vs. 3.9 days; p = 0.204). Length of stay in Group C was significantly higher than Group A and B (p = 0.001, p = 0.001). There were no statistically significant differences in total (11.43% vs. 12.12% vs 17.07%, p = 0.780) or specific complications: Seroma: 2.86% vs. 0% vs. 4.88% (p = 0.774); Wound dehiscence: 8.57% vs. 9.09% vs. 4.88% (p = 0.728); Haematoma: 0% vs. 3.00% vs. 7.32% (p = 0.316) between Groups A, B and C, respectively. CONCLUSION: Our data suggests that drain-free abdominal closure in DIEP reconstruction can be safely achieved without increased postoperative complications. These conclusions support existing evidence on the use of a drain-free approach in cosmetic abdominoplasty.

Method for Securing Methlymethacrylate Bone Cement Using Histoacryl Glue During Cranioplasty for Contour Deformities.

Methylmethacrylate bone cement (MM-BC) is one of the reconstructive methods: during cranioplasty to correct cranial defects following trauma or cranial surgery. Perfect intraoperative immobilization of the MM-BC is crucial to ensure correct subsequent shaping to best improve contour defects. Current immobilization techniques reported are time-consuming and involve complex metalwork. The authors hereby present a technique that may simplify the immobilization process by using histoacryl glue to secure the MM-BC. This provides a quick, inexpensive, and readily available option providing fixation strong enough to withstand final shaping of the MM-BC.

Mitral valve prolapse and Marfan syndrome.

Marfan syndrome is a multisystemic genetic condition affecting connective tissue. It carries a reduced life expectancy, largely dependent on cardiovascular complications. More common cardiac manifestations such as aortic dissection and aortic valve incompetence have been widely documented in the literature. Mitral valve prolapse (MVP), however, has remained poorly documented. This article aims at exploring the existing literature on the pathophysiology and diagnosis of MVP in patients with Marfan syndrome, defining its current management and outlining the future developments surrounding it.