Microsurgical breast reconstruction accounts for 22% of breast reconstructions in the UK. Despite thromboprophylaxis, venous thromboembolism (VTE) occurs in up to 4% of cases. Using a Delphi process, this study established a UK consensus on VTE prophylaxis strategy, for patients undergoing autologous breast reconstruction using free-tissue transfer. It captured geographically divergent views, producing a guide that reflected the peer opinion and current evidence base. Methods Consensus was ascertained using a structured Delphi process. A specialist from each of the UK's 12 regions was invited to the expert panel. Commitment to three to four rounds of questions was sought at enrollment. Surveys were distributed electronically. An initial qualitative free-text survey was distributed to identify likely lines of consensus and dissensus. Each panelist was provided with full-text versions of key papers on the topic. Initial free-text responses were analyzed to develop a set of structured quantitative statements, which were refined via a second survey as a consensus was approached. Results The panel comprised 18 specialists: plastic surgeons and thrombosis experts from across the UK. Each specialist completed three rounds of surveys. Together, these plastic surgeons reported having performed more than 570 microsurgical breast reconstructions in the UK in 2019. A consensus was reached on 27 statements, detailing the assessment and delivery of VTE prophylaxis. Conclusion To our knowledge, this is the first study to collate current practice, expert opinion from across the UK, and a literature review. The output was a practical guide for VTE prophylaxis for microsurgical breast reconstruction in any UK microsurgical breast reconstruction unit.

Unicortical fixation has some practical and theoretical advantages over bicortical fixation. Questions have been raised to its adequacy for post-operative mobilization. We hypothesized that fixation using a plate and eight unicortical screws would be as strong as using a plate and four bicortical screws. A total of 40 unicortical and 40 bicortical fixations were compared using a cadaveric metacarpal model. Unicortical fixation was performed using an eight-hole parallel plate and bicortical fixation with a four-hole straight plate. Fixations were tested to failure using four-point bending load. The mean load to failure was 414N SD 38(SE) for the unicortical group and 296N SD 29(SE) for the bicortical group. Significant differences between these two constructs were observed. The mean stiffness of the fixation was higher for the bicortical group than the unicortical, although this difference did not reach significance. Unicortical fixation alone is sufficient to enable early post-operative mobilization in a live model. Level of evidence: 2

Capsular contracture presents a particular clinical challenge, remaining one of the most common complications of aesthetic and reconstructive breast surgery. 1 Adams Jr., W.P. Capsular contracture: what is it? what causes it? how can it be prevented and managed?. Clin Plast Surg. 2009 Jan; 36: 119-126 Abstract Full Text Full Text PDF PubMed Scopus (162) Google Scholar It's exact aetiology has yet to be fully elucidated, but is likely to be related to how variables affect myofibroblast activity; histologically the predominant cell type in the capsule layer 2 Coleman D.J. Sharpe D.T. Naylor I.L. Chander C.L. Cross S.E. The role of the contractile fibroblast in the capsules around tissue expanders and implants. Br J Plast Surg. 1993 Jan; 46 (Elsevier): 547-556 Abstract Full Text PDF PubMed Scopus (58) Google Scholar . For example, subclinical colonization of the implant pocket with bacteria has been identified as a principle factor. 1 Adams Jr., W.P. Capsular contracture: what is it? what causes it? how can it be prevented and managed?. Clin Plast Surg. 2009 Jan; 36: 119-126 Abstract Full Text Full Text PDF PubMed Scopus (162) Google Scholar Beyond the avoidance of risk factors, no related definitive preventative measures exist in practice. 3 Araco A. Caruso R. Araco F. Overton J. Gravante G. Capsular contractures: a systematic review. Plast Reconstr Surg. 2009 Dec 1; 124: 1808-1819 Crossref PubMed Scopus (127) Google Scholar It has been proposed that rates of capsule formation can be reduced by precise, atraumatic, bloodless dissection; appropriate triple antibiotic breast pocket irrigation; the use of nipple shields and minimizing any points of contamination during the procedure. 1 Adams Jr., W.P. Capsular contracture: what is it? what causes it? how can it be prevented and managed?. Clin Plast Surg. 2009 Jan; 36: 119-126 Abstract Full Text Full Text PDF PubMed Scopus (162) Google Scholar The implant itself can also play a role in the likelihood of capsule formation and, in particular, meta-analyses have demonstrated the superiority of textured over smooth breast implants in decreasing the rate of capsular contracture. 4 Barnsley G.P. Sigurdson L.J. Barnsley S.E. Textured surface breast implants in the prevention of capsular contracture among breast augmentation patients: a meta-analysis of randomized controlled trials. Plast Reconstr Surg. 2006 Jun 1; 117: 2182-2190 Crossref PubMed Scopus (259) Google Scholar

This provides adequate space for swelling following injury or manipulation using the readily available consumables.Splitting a cast or removing a backslab is also easier as scissors or a plaster saw can be used over the ACF with a lower risk of skin damage.

The most common burn wound assessment continues to be the clinical inspection and the tactile examination, which are subjective and remain challenging even for experienced burn surgeons. Recently, hyperspectral imaging camera systems have been increasingly used to support the evaluation of burn wounds. The aim of our study was to determine if hyperspectral imaging analysis differentiates and objectifies the assessment of burn wounds in burns of the upper extremities.We included 97 superficial partial, deep partial dermal burns, and full thickness burns. Hyperspectral imaging analysis was performed for all burns using proprietary software. The software recorded parameters for tissue oxygenation (StO2), tissue hemoglobin index, and near-infrared perfusion. These values were compared with the recordings for healthy, non-burned skin.We found that hyperspectral imaging analysis effectively differentiates burn wounds and shows the ability to distinguish even superficial partial burns from deep partial burns in the near-infrared perfusion analysis feature. Although, it was not possible to differentiate burn wounds in all features.Currently, it is important to optimize the respective reference values of the individual burn degrees for an objectified assessment.

Introduction Dissection of regional lymph nodes (RLNs) can lead to significant morbidity and a high prevalence of complications. Published guidance states that these procedures should be carried out by surgeons who are members of a specialist skin multidisciplinary team who carry out a combined minimum of 15 axillary/groin dissections per year. However, there is little evidence to guide this minimum figure of procedures. We report on the burden of service provision and prevalence of complications across the South West of England and Wales. Methods A 12-month review of dissections of RLNs for skin cancer was undertaken covering five Plastic Surgery Units with a collective catchment of 8.4 million people. Detailed data were collected on patient demographics, pathology, timing of surgery, and prevalence of complications. Results A total of 163 dissections were carried out. Forty-three per cent of patients experienced one or more complication. In that 12-month period, an average of 8 axillary/groin dissections was carried out per surgeon. A funnel plot demonstrated that the prevalence of complications for individual surgeons was within the limit of the plot but, in many cases, this was based only on a relatively small number of procedures per consultant. If surgeons carried out 10 procedures per year, the upper and lower limits on the plot were 73% and 11%, respectively. Conclusions Funnel plots can provide a useful guide as to whether the prevalence of complications for procedures for individual surgeons lies within acceptable limits. Based on these results, 10 procedures per consultant per year should be sufficient to enable meaningful assessment of the prevalence of complications.

BackgroundWedge resections of the helical rim may result in a significant deformity of the ear with the ear not only smaller but cupped and prominent too. Our technique involves resection of the wedge in the scaphal area without extending into the concha followed by advancement of the helical rim into the defect. This technique is most suitable for peripheral defects of the helical rim, in the middle third. MethodsOur modified surgical technique was applied to reconstruction of the pinna after resection of the tumor in 12 patients. Free cartilaginous helical rim, length of helical rim to be resected, and projection of the ear from the mastoid was measured. This was then compared with measurements after the operation, and the patient satisfaction assessed with a visual analog scale. ResultsThe free cartilaginous rim was 91.67 ± 5.61 mm. Of this, 21.92 ± 3.78 mm was resected, which amounted to 23.84% ± 3.35% of the rim. Although this resulted in a mean increase in ear projection of 6.42 ± 1.68 mm, the aesthetic outcome was good (visual analog scale, 9.08 ± 0.9). ConclusionsThis technique reduces cupping and does not make the ear as prominent as it may do after a conventional wedge resection and results in high patient satisfaction.

Injury to the collateral ligament of the metacarpophalangeal (MP) joint is less common in the finger than the thumb and can have a significant impact on function. When it affects the middle finger, we have observed a more extensive mechanical disturbance than that affecting just the MP joint, and for the central two fingers with less accessible ligaments, we have developed a strong method of reconstruction using a tendon graft which also corrects the mechanical disturbance caused by loss of suspension of the assemblage nucleus which holds the flexor tendons and adjacent structures into the convexity of the transverse palmar arch.

We present a longstanding case of subtle Madelung's deformity in association with a new traumatic radial styloid fracture. Magnetic resonance imaging accurately distinguished this deformity from an acute fracture and highlighted the correct cause of the patient's pain. An unnecessary procedure was avoided.

We present a longstanding case of subtle Madelung's deformity in association with a new traumatic radial styloid fracture. Magnetic resonance imaging accurately distinguished this deformity from an acute fracture and highlighted the correct cause of the patient's pain. An unnecessary procedure was avoided.

INTRODUCTION The treatment of soft-tissue injuries associated with tibial diaphyseal fractures presents a clinical challenge that is best managed by a combined plastic and orthopaedic surgery approach. The current study was undertaken to assess early treatment outcomes and burden of service provision across five regional plastic surgery units in the South-West of England. SUBJECTS AND METHODS We conducted a prospective 6-month audit of open tibial diaphyseal fracture management in five plastic surgery units (Bristol, Exeter, Plymouth, Salisbury, Swansea) with a collective catchment of 9.2 million people. Detailed data were collected on patient demographics, injury pattern, surgical management and outcome followed to discharge. RESULTS The study group consisted of 55 patients (40 male, 15 female). Twenty-two patients presented directly to the emergency department at the specialist hospital (primary group), 33 patients were initially managed at a local hospital (tertiary group). The mean time from injury to soft tissue cover was significantly less (P < 0.001) in the primary group (3.6 ± 0.8 days) than the tertiary group (10.8 ± 2.2 days), principally due to a delay in referral in the latter group (5.4 ±1.7 days). Cover was achieved with 39 flaps (19 free, 20 local), eight split skin grafts. Nine wounds closed directly or by secondary intention. There were 11 early complications (20%) including one flap failure and four infections. The overall mean length of stay was 17.5 ± 2.8 days. CONCLUSIONS Multidisciplinary management of severe open tibial diaphyseal may not be feasible at presentation of injury depending on local hospital specialist services available. Our results highlight the need for robust assessment, triage and senior orthopaedic review in the early post-injury phase. However, broader improvements in the management of lower limb trauma will additionally require further development of combined specialist trauma centres.

Restoration of hand function is rarely achieved after a complete closed traction lesion of the supraclavicular brachial plexus. We describe the injury, treatment, rehabilitation and long-term results of two patients who regained good function of the upper limb and useful function in the hand after such an injury. Successful repairs were performed within six days of injury. Tinel's sign proved accurate in predicting the ruptures and the distribution of pain was accurate in predicting avulsion. The severe pain that began on the day of injury resolved with the onset of muscle function. Recovery of muscle function preceded recovery of sensation. Recovery of the function of C and Adelta fibres was the slowest of all.

A 54-year-old woman presented with mastitis, which did not respond to conventional oral antibiotic therapy. Tissue biopsy led to the diagnosis of tuberculosis of the breast. The underlying causative organism was found to be Mycobacterium abscessus, recognised as being a particularly pathogenic strain of tuberculosis.(1) Initial treatment involved surgical debridement and antibiotic therapy. Following this, onco-reconstructive techniques were used to remove scarred tissue from the affected side and reduce the contra lateral breast to match leading to a good aesthetic outcome.

This article, by the Emergency Response Advisor of Shell Exploration and Production, Aberdeen, explains the contingency arrangements which exist to deal with emergencies in the North Sea. The contingency planning aims to prevent emergencies happening so that lives, property, and the environment are not at risk. Or, if a situation develops into an emergency, an effective contingency plan will minimize the risk. In an emergency the Co-ordinator is responsible for mobilizing support in resolving the problem and he has the authority to commit such resources as he deems necessary to resolve it. Training and exercising are essential if the response is to be effective. Public affairs is also part of the Emergency Response Team.