Beyond Borders: A Global Microsurgery Training and Case Exposure Survey.

BACKGROUND: Microsurgery is essential in modern reconstructive surgery and plastic surgery training. Surgeon's proficiency and experience are crucial for effective microsurgical interventions. Despite anecdotal evidence of varying quality of microsurgery training globally, no empirical studies have investigated this. We conducted a global survey to investigate microsurgical training and clinical case exposure among plastic surgery trainees worldwide. METHODS: An online survey was conducted using a secure platform to gather information on microsurgical case exposure and training among plastic surgery trainees between August 2020 and April 2021. Participants provided consent and completed a 37-question survey across four themes: clinical caseload, surgical exposure to microsurgery, microsurgical simulation training exposure, and barriers and opportunities. RESULTS: A total of 202 responses were received, with most respondents in formal training programs (86.7%). The data highlighted regional variation in microsurgery case indications and flap types, with North America and Europe exhibiting the highest activity levels in microsurgery. Trainees in Asia have the highest cumulative practical exposure in microsurgery, followed by Australia and Oceania, and North America. Only 39.6% of respondents reported formal microsurgical simulation training, and almost one-third (29.7%) received no simulation training. Trainee access to practical experience is limited by several factors, including insufficient time and procedure complexity. Notably, practical experience was most commonly denied without reason being given. CONCLUSION: Our study highlights significant disparities in microsurgical training and exposure among plastic surgery trainees globally. Further research is needed to identify strategies for addressing these issues, given the growing demand for complex reconstructive microsurgery and its impact on health care inequalities.

Intraoperative Vasopressor Usage in Free Tissue Transfer: Should We Be Worried?

BACKGROUND: The role of vasopressors has long been a subject of debate in microsurgery. Conventional wisdom dictates the avoidance of vasopressor use, due to concerns such as peripheral vasoconstriction, inducing vasospasm of the anastomoses, and leading to failure in perfusion. It has since become common practice in some centers to avoid intraoperative vasopressor use during free tissue transfer surgery. Recent studies have suggested that this traditional view may not be supported by clinical evidence. However, none of these studies have separated vasopressor use by method of administration. METHODS: We conducted a retrospective review of our experience of vasopressor use in free flap surgery at a single high-volume center. The outcome measures were flap failure, flap-related complications and overall postoperative complications (reported using the Clavien-Dindo classification). Groups were compared using Chi-square or Fisher's Exact test where appropriate. RESULTS: A total of 777 cases in 717 patients were identified. 59.1% of these had vasopressors administered intraoperatively. The overall failure rate was 2.2%, with 9.8% experienced flap-related complications. There was no difference in flap loss when vasopressors were administered, but an increased rate of microvascular thrombosis was noted (p = 0.003). Continuous administration of vasopressors was associated with reduced venous congestion, whereas intermittent boluses increased risk of microvascular thrombosis. CONCLUSION: Our study confirms previous findings that intraoperative vasopressor use in free flap surgery is not associated with increased failure rate. Administering vasopressors continuously may be safer than via repeated boluses.

Intraoperative Near-infrared Fluorescence (NIR) Imaging With Indocyanine Green (ICG) Can Identify Bone and Soft Tissue Sarcomas Which May Provide Guidance for Oncological Resection.

BACKGROUND: Complete excision of sarcomas to maximize function without compromising the oncological outcome can be challenging. The aim of this study was to investigate the feasibility and potential drawbacks of near-infrared (NIR) fluorescence imaging with indocyanine green during resection of bone and soft tissue sarcomas. METHODS: Eleven patients with high-grade sarcomas were enrolled in the study. All patients received intravenous indocyanine green (75 mg) between 16 and 24 hours before the resection. Sarcomas were resected under NIR guidance and specimens were sent for routine histopathological analysis. RESULTS: Majority of treatment naive tumors demonstrated fluorescence. There were no adverse events from the indocyanine green administration. In 3 cases, the fluorescence was reported by the surgeon to have been of definite guidance leading to further tissue resection to improve the margin. CONCLUSION: This is the first report of NIR fluorescence guidance in the setting of open sarcoma surgery. The technique is acceptable to patients and surgeons and was able to guide resection. Multicenter studies are required to assess the utility of this technique in a large cohort of patients with regards to quantification of fluorescence, resection guidance, and longer follow-up period.

A novel problem, a tested solution: A case of an infected left ventricular titanium plug.

Persistent infection of left ventricular-assisted devices are challenging to treat. We describe a case of a middle-aged man who presented with cardiogenic shock and profound heart failure from sarcoid myocarditis, necessitating the placement of a left ventricular assist device. After recovery of cardiac function, the device was decommissioned but complicated by infection in the implant bed, chest wall, and of the titanium plug left in situ. This to our knowledge is the first report of an infected titanium plug and we describe an option of using a latissimus dorsi flap using its vascularized tissues to treat the infected plug. This is another example where a multidisciplinary approach can yield rewarding results in cases such as these.

Early Breast Angiosarcoma Development After Radiotherapy: A Cautionary Tale.

This is a short clinical report depicting an exceptionally early presentation of radiation-induced angiosarcoma and overview of the literature. This case highlights the need for a high level of clinical suspicion in those patients presenting with unresolving cutaneous skin changes after radiotherapy for breast cancer.Breast-conserving therapy, comprising breast-conserving surgery and adjuvant radiotherapy, has largely replaced mastectomy in the treatment of early-stage breast carcinoma. Breast angiosarcoma is a rare but severe long-term complication associated with postoperative radiotherapy (Int J Radiat Oncol Biol Phys. 2002;52:1231-1237). It often presents as a bluish/purple skin lesion in a breast previously treated for breast cancer. This case explores an unexpectedly early presentation of radiation-induced breast angiosarcoma, which was initially thought to be benign bruising. Management remains challenging and prognosis is poor because of its aggressive local and regional invasion and early metastasis, commonly to the lungs and liver. Early surgical resection with wide margins is the treatment of choice (J Plast Reconstr Aesthet Surg. 2011;64:1036-1042).

Multiple familial pilomatrixomas in three generations: an unusual clinical picture.

Pilomatrixomas are benign cutaneous tumors derived from hair matrix cells of unclear etiology. Pilomatrixomas commonly demonstrate somatic mutations in CTNNB1, a gene coding ß-catenin, a protein involved with hair follicle development. Multiple familial pilomatrixomas rarely occur and are most often associated with autosomal dominant conditions such as myotonic dystrophy and familial adenomatous polyposis (FAP). Nine families with multiple familial pilomatrixomas and no demonstrable underlying association have been reported in the literature. We present a tenth family in which five members spanning three generations grew multiple pilomatrixomas in the absence of any previously reported associations. No evidence of myotonic dystrophy, FAP, or other known associations was found. Extreme tiredness, behavioral problems, and sensory disturbances were common features across three generations but bore no temporal relation to the pilomatrixomas. The existence of a germline mutation in CTNNB1 to explain these symptoms has yet to be shown. Pilomatrixomas are potentially cutaneous markers of significant underlying pathologies. Patients presenting with multiple or familial pilomatrixomas should be thoroughly assessed for other pathologies and offered genetic screening to ensure that important diagnoses are not overlooked.

Merkel cell carcinoma of the head and neck: challenges in implementing best practice.

OBJECTIVE: Merkel cell carcinoma (MCC) is a rare, aggressive skin tumor. Controversies regarding optimal management persist due to inadequate data and knowledge regarding tumor biology. Head and neck MCC increases both oncological and reconstructive challenges, compounded by predominantly elderly patients. We review our practice and outcomes, review evidence, and discuss the difficulties in delivering best practice management. METHODS: All patients with primary head and neck MCC, managed by a single multidisciplinary team between January 2001 and December 2010, were identified through retrospective analysis of a pathology coding database. A literature review was performed. RESULTS: Twenty patients, with a mean age of 83.5 years (40-99 years) and presenting with mean symptom duration of 5 months, had primary tumors involving the nose (n = 2), periorbital region (n = 5), cheek (n = 6), and the temple and scalp (n = 7). Mean tumor size was 2.1 cm (range, 0.5-7.5 cm). Reconstructive techniques were direct closure (n = 8), skin grafting (n = 7), local flaps (n = 4), and free anterolateral thigh flap (n = 1). Two (10%) patients presented with nodal disease. Eight (40%) patients re-presented with nodal recurrence at a mean of 7 months with 6 undergoing salvage neck dissections. Adjuvant radiotherapy was completed in 5 cases, and chemotherapy used for palliation in 1 case. Most of the patients declined radiotherapy due to adverse effects or frailty. CONCLUSIONS: Our series demonstrates the profound challenges in managing head and neck MCC, including tailoring definitive primary treatment and current consensus management to elderly patients. Regional nodal assessment and management remains crucial to achieving this goal.

Malignant phyllodes: 10 year review of management through a sarcoma service.

BACKGROUND: Phyllodes tumours of the breast are rare, and their treatment is still subject to discussion. They are classified as benign, borderline, or malignant based on histopathological characteristics of the stroma. This study demonstrates 10 years' experience in diagnosis and management of malignant phyllodes. METHODS: All patients referred for discussion at our sarcoma multidisciplinary team meeting from 2003 to 2013 with a diagnosis of malignant phyllodes were identified. Patient demographics, biopsy details, excision extent, final pathology, reconstruction, adjuvant treatment, recurrence and overall survival were assessed. RESULTS: Thirty patients were identified over the 10 year period. Eight (26.7 %) had their diagnosis upgraded to malignant phyllodes on completion excision, compared to initial biopsy. Nine (30 %) had breast surgery elsewhere as definitive treatment before referral to our service. Four of these (44.4 %) required more extensive excision and three developed metastases (33.3 %) and died. Twenty-one patients had primary surgery through our service and three (14.3 %) died from disease. Overall, 13 patients had radical mastectomy, 92.3 % with adequate margins (>1 cm histologically) and no local recurrence, 9 simple mastectomy 22.2 % with adequate margins and 1 local recurrence and 8 wide local excision with 37.5 % adequate margins and 1 local recurrence. CONCLUSION: For malignant phyllodes patients, the best chance to reduce recurrence and improve survival is adequate excision and radical mastectomy should be considered. For borderline lesions, consideration should be given for referral to a specialist centre and we recommend delayed reconstruction, because of the chance of histological upgrade to malignancy.

Clinical characteristics and treatment outcomes of angiosarcoma of the head and neck: A 17-year single-centre experience.

INTRODUCTION: Angiosarcomas in the head and neck region are aggressive tumours associated with high local recurrence and metastatic rates. We present our 17-year experience at the North of England Bone and Soft Tissue Tumour Service. METHODS: A retrospective review of our prospectively maintained database was undertaken, looking for patients diagnosed with angiosarcomas affecting the head and neck. Data were gathered using a pre-defined proforma to include demographics, histological characteristics, treatment modalities, adjuvant therapies, local recurrence, distant spread, and disease-specific survival. RESULTS: A total of 23 patients (17 males, 6 females) were identified, with a mean age of 76 years at presentation. Fourteen presented with scalp lesions, whereas the remainder arose on the face. Eighteen patients underwent resection with curative intent, whereas three received palliative radiotherapy and two received comfort-based care only. Of the patients undergoing surgery, 12 had local flap reconstruction and 6 underwent free tissue transfer. Clear resection margins were obtained in nine cases (50%). Fourteen patients (78%) presented with local recurrence after surgery, and 11 (61%) developed distant metastases. The median disease-specific survival time for patients treated with curative intent was 38 months. Eight patients had mapping biopsies ahead of their resection; however, complete resection was achieved in only two cases. DISCUSSION: Angiosarcomas of the head and neck are associated with a poor prognosis, with most patients rapidly developing local recurrence, resulting in adverse clinical outcomes. Mapping biopsies do not demonstrate a clear advantage for achieving complete surgical resection. A radical surgical approach is warranted, given the aggressiveness of the pathology. However, there remains no consensus on optimal surgical management; we recommend further synthesising studies to determine the most appropriate treatment pathway.

What is the diagnostic accuracy of fluorescence-guided surgery for margin assessment in appendicular bone and soft tissue tumors? - A systematic review of clinical studies.

BACKGROUND: Fluorescence-guided surgery (FGS) is a novel technique to successfully assess surgical margins intraoperatively. Investigation and adoption of this technique in orthopaedic oncology remains limited. METHODS: The PRISMA guidelines were followed for this manuscript. Our study was registered on PROSPERO (380520). Studies describing the use of FGS for resection of bone and soft tissue sarcomas (STS) on humans were included. Diagnostic performance metrics (sensitivity, specificity, positive predictive value [PPV], negative predictive value [NPV] and accuracy) and margin positivity rate were the outcomes assessed. RESULTS: Critical appraisal using the Joanna Brigs Institute checklists showed significant concerns for study quality. Sensitivity of FGS ranged from 22.2 % to 100 % in three of the four studies assessing his metrics; one study in appendicular tumors in the pediatric population reported 0 % sensitivity in the three cases included. Specificity ranged from 9.38 % to 100 %. PPV ranged from 14.6 % to 70 % while NPV was between 53.3 % and 100 %. The diagnostic accuracy ranged from 21.62 % to 92.31 %. Margin positivity rate ranged from 2 % to 50 %, with six of the seven studies reporting values between 20 % and 50 %. CONCLUSIONS: FSG is a feasible technique to assess tumor margins in bone and STS. Reported performance metrics and margin positivity rates vary widely between studies due to low study quality and high heterogeneity in dying protocols. LEVEL OF EVIDENCE: Level III, diagnostic study.

Intraoperative near-infrared fluorescence guided surgery using indocyanine green (ICG) may aid the surgical removal of benign bone and soft tissue tumours.

BACKGROUND: Benign bone and soft tissue tumours encompass a broad, heterogenous range of tumours with varying clinical characteristics. These are often managed surgically with either curettage or marginal excision, but unfortunately have high rates of local recurrence. Indocyanine green (ICG) is a fluorescent dye which can be used to identify solid malignancies intraoperatively but its use is not yet established in benign bone and soft tissue tumours. This study aims to assess whether these tumours fluoresce when administered with ICG pre-operatively and whether this helps surgeons to identify tumour intra-operatively. PATIENTS AND METHODS: Patients with locally aggressive benign bone and soft tissue tumours were administered with 25-75 mg of ICG preoperatively at the induction of anaesthesia. Fluorescence was imaged intraoperatively using the Stryker SPY-PHI camera. RESULTS: Of the 12 patients included, 11 tumours fluoresced. The surgeons felt the fluorescence guided the procedure in 7 out of the 11 cases which fluoresced. It was felt to be particularly useful in the curettage of bone tumours, in which curettage could be repeated until the absence of fluorescence on imaging. After 12 months, no patients had local recurrence of the tumour. There were no adverse events recorded in this study and surgeons found the technology acceptable. CONCLUSIONS: The use of ICG for fluorescence guided surgery is a promising technology to improve outcomes of surgery for benign bone and soft tissue tumours. Further, longer term, study with a control arm is needed to identify whether it results in a reduction in the local recurrence rate.

'Thou shalt not throw away a living thing': A single-centre 10-year experience using the spare parts principle for complex sarcoma reconstruction.

INTRODUCTION: For aggressive limb sarcomas beyond reconstructive reach, an amputation may be the only alternative to achieve a complete tumour resection. However, very proximal amputations result in greater loss of function and quality-of-life impact. The spare parts principle advocates utilising tissues distal to the amputation site, for reconstructing complex defects and preserving the function. We aim to present our 10-year experience utilising this principle in complex sarcoma surgery. METHODS: A retrospective review of our prospective sarcoma database was conducted for sarcoma patients treated with an amputation between 2012 and 2022. Cases in which distal segments were used for the reconstruction were identified. Demographic data, tumour characteristics, and surgical and non-surgical treatment, along with oncological outcomes and complications, were recorded and analysed. RESULTS: Fourteen patients were eligible for inclusion. The median age was 54 years at presentation (8-80 years) with 43% being females. Nine had a primary sarcoma resection, two were treated for recurrent tumours, two presented intractable osteomyelitis following sarcoma treatment and one had an amputation as a palliative procedure. The latter was the only oncological case in which tumour clearance was not achieved. Three patients developed metastasis and subsequently died during follow-up. DISCUSSION: Careful balancing of oncological goals and preservation of function is required for proximal limb-threatening sarcomas. When an amputation is required, tissues distal to the cancer site provide a safe reconstructive alternative, optimising patient recovery and preserving function. Our experience is limited by the small number of cases presenting with these rare and aggressive tumours.

What Is the Significance of Indeterminate Pulmonary Nodules in High-Grade Soft Tissue Sarcomas? A Retrospective Cohort Study.

BACKGROUND: Sarcomas are rare, aggressive cancers which frequently metastasise to the lungs. Following diagnosis, patients typically undergo staging by means of a CT scan of their chest. This often identifies indeterminate pulmonary nodules (IPNs), but the significance of these in high-grade soft tissue sarcoma (STS) is unclear. Identifying whether these are benign or malignant is important for clinical decision making. This study analyses the clinical relevance of IPNs in high-grade STS. METHODS: All patients treated at our centre for high-grade soft tissue sarcoma between 2010 and 2020 were identified from a prospective database. CT scans and their reports were reviewed, and survival data were collected from patient records. RESULTS: 389 suitable patients were identified; 34.4% had IPNs on their CT staging scan and 20.1% progressed into lung metastases. Progression was more likely with IPNs ≥ 5 mm in diameter (p = 0.006), multiple IPNs (p = 0.013) or bilateral IPNs (p = 0.022), as well as in patients with primaries ≥ 5 cm (p = 0.014), grade 3 primaries (p = 0.009) or primaries arising deep to the fascia (p = 0.041). The median time to progression was 143 days. IPNs at diagnosis were associated with an increased risk of developing lung metastases and decreased OS in patients with grade 3 STS (p = 0.0019 and p = 0.0016, respectively); this was not observed in grade 2 patients. CONCLUSIONS: IPNs at diagnosis are associated with significantly worse OS in patients with grade 3 STS. It is crucial to consider the primary tumour as well as the IPNs when considering the risk of progression. Surveillance CT scans should be carried out within 6 months.

Watch One, Do One? A Systematic Review and Educational Analysis of YouTube Microsurgery Videos, and a Proposal for a Quality Assurance Checklist.

Background Educational resources on the internet are extensively used to obtain medical information. YouTube is the most accessed video platform containing information to enhance the learning experience of medical professionals. This study systematically analyzed the educational value of microsurgery-related videos on this platform. Methods A systematic review was conducted on YouTube from April 18 to May 18, 2020, using the following terms: "microsurgery," "microsurgical," "microsurgical anastomosis," "free flap," and "free tissue transfer." The search was limited to the first 100 videos, and two independent reviewers screened for eligible entries and analyzed their educational value using validated scales, including a modified version of the DISCERN score (M-DISCERN), Journal of the American Medical Association (JAMAS) benchmark criteria, and the Global Quality Score (GQS). Evaluation of video popularity was also assessed with the video power index (VPI). Results Of 356 retrieved videos, 75 (21%) were considered eligible. The educational quality of videos was highly variable, and the mean global scores for the M-DISCERN, JAMAS, and GQS for our sample were consistent with medium to low quality. Conclusions A limited number of videos on YouTube for microsurgical education have high-educational quality. The majority scored low on the utilized criteria. Peer-reviewed resources seem to be a more reliable resource. Although the potential of YouTube should not be disregarded, videos should be carefully appraised before being used as an educational resource.

Postoperative radiotherapy delay in head and neck cancer patients undergoing major resection and free flap reconstruction.

BACKGROUND: Delays to postoperative radiotherapy (PORT) are frequent and associated with poorer oncologic outcomes in head and neck cancer (HNC) patients. Free flap patients have been suggested as the most at-risk group. Thus, PORT delivery experienced by HNC patients who required a free flap reconstruction was analysed, identifying reasons for the delays if any. METHODS: A retrospective analysis of a single tertiary unit's PORT delivery to HNC patients undergoing major resection followed by free flap reconstruction between 2017 and 2020. RESULTS: Eighty-seven patients were identified. Thirty-two patients received PORT within 6 weeks of their surgery date. Reasons for the delays could be categorised into surgery-derived, system-derived and patient-derived reasons. Five patients (5.74%) received PORT >6 weeks after their surgery due to surgical complications. No patients experienced surgical complications during their PORT. CONCLUSION: In our experience, surgical aspects of free flap reconstructions do not appear to overtly delay or interrupt PORT.

Head and neck research in plastic surgery-Ahead of the rest? An analysis of abstracts presented at British association of plastic reconstructive and aesthetic surgeons meetings.

INTRODUCTION & AIMS: Historically, the head and neck (H&N) discipline has been integral to the service a plastic surgeon provides. Recently, it has been postulated that its popularity is declining. The output of scientific meetings may indicate the popularity of each sub-speciality interest, also allowing comparison with other H&N conferences. AIM: To analyse the proportion of H&N themed, podium and poster presentations from British Association of Plastic Reconstructive and Aesthetic Surgeons' (BAPRAS) scientific meetings and the resulting contribution to published literature. MATERIAL AND METHODS: H&N-themed abstracts were identified from finalised programmes of the biannual BAPRAS meetings between 2008 and 2015. PubMed and Google Scholar databases were searched using keywords and author names from each abstract to identify subsequent publication in a peer-reviewed journal. RESULTS: Overall, 19.3% (350/1815) of BAPRAS abstracts were H&N themed. The publication rate of H&N abstracts was 40.3% (141/350), comprising 43.0% (114/265) of podium and 31.8% (27/85) of poster presentations. H&N reconstruction and cleft and craniofacial were the most frequent topics, with facial palsy having the lowest conversion rate at 15.4%. The mean time to publication was 17.8 months. Research was published in 39 journals, with a mean impact factor of 2.151 (range = 0.772-11.541). The most popular journal was Journal of Plastic, Reconstructive & Aesthetic Surgery (JPRAS; 31.7%; 45/141). Published abstracts originated from 17 different countries. The senior author was a plastic surgeon in 77.3% of abstracts. CONCLUSIONS: From the multiple potential sub-specialties, H&N-themed abstracts consistently contributed 20% of all research presented at BAPRAS. The 40.3% publication rate exceeds the international average of scientific meetings. H&N remains a prominent field in the armamentarium of a plastic surgeon.