The utility of the lateral orbital orbicularis propeller flap in periocular reconstruction.

AIMS: The lateral orbital orbicularis propeller flap (LOOP) is a propeller flap raised on a non-axial orbicularis oculi pedicle. Once mastered, it is speedy to raise, extremely reliable, and capable of transposing thin, supple, and relatively hairless skin and subcutis from the temple region to the periocular region. We aim to present our experience in using the LOOP flap for the reconstruction of a range of periocular defects. METHOD: Retrospective review utilising our Mohs database, electronic records, and image library. RESULTS: A total of 44 reconstructions were performed. Of the 39 lower lid defects, 22 were full-thickness (bilamellar). Posterior lamella reconstructions in these 22 cases were free tarsoconjunctival graft (20), conchal cartilage with perichondrium (1), and Hewes flap (1). A total of 13 reconstructions of the 22 were total or near-total lid reconstructions. A further 17 patients had anterior lamella defects alone, of which 3 amounted to resurfacing the entire lid. However, 5 patients underwent upper lid reconstruction, 2 of which were 50% lid, 2 required a free tarsal graft, and 1 conchal cartilage graft with buccal mucosa. There were no instances of necrosis of either the flap or the posterior lamella grafts. There were 7 minor complications. CONCLUSION: In our unit, the LOOP flap has become the reconstruction of choice for laterally based, transversely extensive defects of upper lid, lower lid, and malar areas. Its reliability, relative simplicity, and excellent cosmetic and functional outcomes merit much wider utilisation amongst the plastic and ophthalmic surgery community.

Prognosis of patients with hepatocellular carcinoma treated with sorafenib: a comparison of five models in a large Canadian database.

Several systems (tumor-node-metastasis [TNM], Barcelona Clinic Liver Cancer [BCLC], Okuda, Cancer of the Liver Italian Program [CLIP], and albumin-bilirubin grade [ALBI]) were developed to estimate the prognosis of patients with hepatocellular carcinoma (HCC) mostly prior to the prevalent use of sorafenib. We aimed to compare the prognostic and discriminatory power of these models in predicting survival for HCC patients treated with sorafenib and to identify independent prognostic factors for survival in this population. Patients who received sorafenib for the treatment of HCC between 1 January 2008 and 30 June 2015 in the provinces of British Columbia and Alberta, and two large cancer centers in Toronto, Ontario, were included. Survival was assessed using the Kaplan-Meier method. Multivariate Cox regression was used to identify predictors of survival. The models were compared with respect to homogeneity, discriminatory ability, monotonicity of gradients, time-dependent area under the curve, and Akaike information criterion. A total of 681 patients were included. 80% were males, 86% had Child-Pugh class A, and 37% of patients were East Asians. The most common etiology for liver disease was hepatitis B (34%) and C (31%). In all model comparisons, CLIP performed better while BCLC and TNM7 performed less favorably but the differences were small. The utility of each system in allocating patients into different prognostic groups varied, for example, TNM poorly differentiated patients in advanced stages (8.7 months (m) (95% CI 6.5-11.5) versus 8.4 m (95% CI 7.0-9.6) for stages III and IV, respectively) while ALBI had excellent discrimination of early grades (15.6 m [95% CI 13.0-18.4] versus 8.3 m [95% CI 7.0-9.2] for grades 1 and 2, respectively). On multivariate analysis, hepatitis C, alcoholism, and prior hepatic resection were independently prognostic of better survival (P < 0.01). In conclusion, none of the prognostic systems was optimal in predicting survival in sorafenib-treated patients with HCC. Etiology of liver disease should be considered in future models and clinical trial designs.

Report into "on the day cancellations" for plastic surgery in patients who failed to stop their medication.

It was noted that a number of patients were having their procedures cancelled on the day of surgery because their antiplatelet or anticoagulative medications had not been stopped preoperatively. The team recognised that this problem was leading to an unnecessary waste of the department's labour and financial resources, and more importantly was becoming a source of disappointment and anxiety to patients. A retrospective analysis of all plastic surgery cases was performed for procedures listed for the previous 12 months. All cancellations and the reasons for them were recorded, which came to 23 cases. The sum of the financial tariffs for each cancelled procedure was calculated to assess the financial impact of the identified problem: £20,000. A root cause analysis was performed to assess where this problem was arising in the patient's preoperative journey. The common theme was the lack of information for the gatekeeper regarding the patients' anticoagulant and antiplatelet medications. A new gatekeeper form was introduced to practice with a subsection specifically highlighting antiplatelet and anticoagulative medications. In addition, this issue was highlighted to the relevant staff in the department. After four months, a second PDSA cycle was performed in the same manner. Seven cases were cancelled due to anticoagulants or antiplatelets not being stopped prior to surgery. This equated to a net loss of £11,865 to the department when projected over 12 months, improving on the performance prior to the newly introduced changes.

The critical evaluation of laser Doppler imaging in determining burn depth.

This review article discusses the use of laser Doppler imaging as a clinimetric tool to determine burn depth in patients presenting to hospital. Laser Doppler imaging is a very sensitive and specific tool to measure burn depth, easy to use, reliable and acceptable to the patient due to its quick and non-invasive nature. Improvements in validity, cost and reproducibility would improve its use in clinical practice however it is difficult to satisfy the entire evaluation criterion all the time. It remains a widely accepted tool to assess burn depth, with an ever-increasing body of evidence to support its use, as discussed in this review. Close collaboration between clinicians, statisticians, epidemiologists and psychologists is necessary in order to develop the evidence base for the use of laser Doppler imaging as standard in burn depth assessment and therefore act as an influencing factor in management decisions.

The combination of fibrin glue and quilting reduces drainage in the extended latissimus dorsi flap donor site.

BACKGROUND: The use of quilting sutures in the extended latissimus dorsi flap donor site significantly reduces the incidence of donor-site seroma. However, the donor site has a drain inserted, and the duration of use of this drain often dictates when a patient is discharged to home from the hospital. Fibrin glue has been shown to reduce the need for drainage at other operative sites. The authors therefore evaluated the use of fibrin glue (Tisseel Lyo; Baxter Healthcare, Norfolk, United Kingdom) in addition to quilting in reducing the total volume and duration of drainage following extended latissimus dorsi flap breast reconstruction. METHODS: The authors compared a group of 11 consecutive, prospective patients who underwent extended latissimus dorsi donor-site closure with fibrin glue and quilting with a control group of 24 consecutive, retrospective patients who underwent extended latissimus dorsi donor-site closed with quilting alone. RESULTS: The results show that the combination of fibrin glue and quilting in the extended latissimus dorsi flap donor site significantly reduces average drainage in the immediate postoperative period: 13 ml compared with 170 ml (p