Graftless Syndactyly Release.

Syndactyly release aims to address skin deficits by resurfacing web spaces and sides of digits to allow independent digital motion while minimizing the risk of web creep and scar contractures. Conventional methods include the use of a dorsal and interdigitating flaps with full-thickness skin grafts. More recently, there have been several descriptions of "graftless" syndactyly release without skin grafts, thus avoiding a further (usually distant) donor site. However, the indications of when and when not to use these techniques remain unclear. In addition, the inevitable scarring from extra recruitment of local adjacent skin is perhaps underemphasized. In this article, we revisit the trilobed flap technique which serves to balance the amount of skin needed for resurfacing digits while minimizing local donor site scarring. The geometry and nuances of the flap inset are illustrated in detail to guide those embarking on this technique. The trilobed syndactyly release technique is a reproducible, safe, and reliable method for the release of simple syndactyly.

Outcomes in facial transplantation - a systematic review.

Facial transplantations have become a clinical reality as the last reconstructive option in severely disfigured patients. To date, clinical outcomes remain unclear. The purpose of this paper was to analyse the outcomes in facial transplantation (FT) and determine the risks and benefits of FT based on short- and long-term outcomes. An electronic literature search was performed across PubMed, EMBASE and the Cochrane Central Register for Controlled Trials (CENTRAL) databases to capture all the relevant records relating to outcomes in FTs from 2005 to 2021. Articles for inclusion were decided upon pre-defined inclusion and exclusion criteria. A total of 48 FTs has been performed to date. A total of 90 studies met the eligibility criteria and were included in the outcome analysis. Studies were analysed based on each of the 48 cases and outcomes categorised into short-term (<36 months) and long-term (>36 months) outcomes. Primary outcomes included patient and graft survival and secondary outcomes included functional, surgical revision events, immunological, medical complications, aesthetics, psychosocial and quality of life. Mortality rate, infection and malignancy incidence remain high, and patients should be fully informed of the potential life-threatening complications. FTs improve outcomes such as quality of life and psychosocial recovery in the short- and long-term. Outcomes remain under-reported in peer-review journals.

The Exoscope versus operating microscope in microvascular surgery: A simulation non-inferiority trial.

BACKGROUND: The Exoscope is a novel high-definition digital camera system. There is limited evidence signifying the use of exoscopic devices in microsurgery. This trial objectively assesses the effects of the use of the Exoscope as an alternative to the standard operating microscope (OM) on the performance of experts in a simulated microvascular anastomosis. METHODS: Modus V Exoscope and OM were used by expert microsurgeons to perform standardized tasks. Hand-motion analyzer measured the total pathlength (TP), total movements (TM), total time (TT), and quality of end-product anastomosis. A clinical margin of TT was performed to prove non-inferiority. An expert performed consecutive microvascular anastomoses to provide the exoscopic learning curve until reached plateau in TT. RESULTS: Ten micro sutures and 10 anastomoses were performed. Analysis demonstrated statistically significant differences in performing micro sutures for TP, TM, and TT. There was statistical significance in TM and TT, however, marginal non-significant difference in TP regarding microvascular anastomoses performance. The intimal suture line analysis demonstrated no statistically significant differences. Non-inferiority results based on clinical inferiority margin (Δ) of TT=10 minutes demonstrated an absolute difference of 0.07 minutes between OM and Exoscope cohorts. A 51%, 58%, and 46% improvement or reduction was achieved in TT, TM, TP, respectively, during the exoscopic microvascular anastomosis learning curve. CONCLUSIONS: This study demonstrated that experts' Exoscope anastomoses appear non-inferior to the OM anastomoses. Exoscopic microvascular anastomosis was more time consuming but end-product (patency) in not clinically inferior. Experts' "warm-up" learning curve is steep but swift and may prove to reach clinical equality.

The use of mobile computing devices in microsurgery.

Mobile computing devices (MCDs), such as smartphones and tablets, are revolutionizing medical practice. These devices are almost universally available and offer a multitude of capabilities, including online features, streaming capabilities, high-quality cameras, and numerous applications. Within the surgical field, MCDs are increasingly being used for simulations. Microsurgery is an expanding field of surgery that presents unique challenges to both trainees and trainers. Simulation-based training and assessment in microsurgery currently play an integral role in the preparation of trainee surgeons in a safe and informative environment. MCDs address these challenges in a novel way by providing valuable adjuncts to microsurgical training, assessment, and clinical practice through low-cost, effective, and widely accessible solutions. Herein, we present a review of the capabilities, accessibility, and relevance of MCDs for technical skills acquisition, training, and clinical microsurgery practice, and consider the possibility of their wider use in the future of microsurgical training and education.

Microvascular anastomotic coupler application learning curve: A curriculum supporting further deliberate practice in ex-vivo simulation models.

INTRODUCTION: Microvascular anastomosis with coupler devices has revolutionized microsurgery practice. Couplers are considered easier to apply and offer improved operating time while maintaining success rates. This study aims to map the learning curve, skill acquisition, and decay of novice microsurgeons in performing coupler anastomosis. METHODS: Novice microsurgeons performed consecutive coupler applications on a three-layer silastic vessel in two phases. Overall time, total movements, and total path-length were objectively measured and the overall surgical performance was calculated using hand motion analyzer (Dextrous MD, Inition, London, UK). RESULTS: Sixty coupler anastomoses were performed using the synthetic, three-layered silicone vessel by 5 novices, 40 for phase 1, 12 for phase 2 and 8 for phase 3. During the phase 1 and phase 2 learning curves deliberate practice, the novices required an average of 8 (6-9) and 4 (2-6) consecutive repetitions, respectively, before reaching the experts' performance. There was an average improvement of 69% (p < 0.001) from their baseline performance during phase I and 37% (p < 0.001) during phase II. End-product assessment revealed that 4 out of 40 coupler applications during phase 1 (10%), 3 out of 20 during phase 2 (15%), and 1 out of 8 during exit performance-phase 3 (12.5%). During phase 3 end-product assessment with f-cMP, 7 out of 8 arterial and venous coupler anastomoses demonstrated an adequate range of flow measures. CONCLUSION: This study demonstrated objectively learning curves and skill decay following a suggested coupler application curriculum and quantified objective thresholds for ethical animal model training and safe supervised clinical sessions in the OR.

TAp73 is a marker of glutamine addiction in medulloblastoma.

Medulloblastoma is the most common solid primary brain tumor in children. Remarkable advancements in the understanding of the genetic and epigenetic basis of these tumors have informed their recent molecular classification. However, the genotype/phenotype correlation of the subgroups remains largely uncharacterized. In particular, the metabolic phenotype is of great interest because of its druggability, which could lead to the development of novel and more tailored therapies for a subset of medulloblastoma. p73 plays a critical role in a range of cellular metabolic processes. We show overexpression of p73 in a proportion of non-WNT medulloblastoma. In these tumors, p73 sustains cell growth and proliferation via regulation of glutamine metabolism. We validated our results in a xenograft model in which we observed an increase in survival time in mice on a glutamine restriction diet. Notably, glutamine starvation has a synergistic effect with cisplatin, a component of the current medulloblastoma chemotherapy. These findings raise the possibility that glutamine depletion can be used as an adjuvant treatment for p73-expressing medulloblastoma.

Medicons: toward clinical examination diagrams standardization in medical documentation.

BACKGROUND: Electronic patient records (EPRs) allow efficient and accurate medical documentation. Diagrams have traditionally been used to document clinical signs in patient notes. The interpretation of these diagrams may vary among doctors across a range of specialties, but this has never been tested previously. This study investigated how common diagrams were interpreted and explored the use of digitalized diagrams - Medicons in creating a common language to be used in digital clinical examination proformas. MATERIALS AND METHODS: A cross-sectional survey utilizing a multiple-choice questionnaire was carried out across London hospitals. Seventeen digitalized examination diagrams were included in a multiple-choice questionnaire to test doctors' perception and explore their opinions of diagram usage. The questionnaire was sent to junior doctors in training. RESULTS: A total of 206 responses were received from 31 foundation year 1 trainees, 45 foundation year 2 trainees, 94 core surgical trainees and 36 core medical trainees. Diagrams were interpreted correctly, on average, 75% of the time. The majority of doctors (94%) felt that diagrams facilitated the understanding of clinical examination, documentation of pathologic site (98%) and improved the efficiency of documentation (89.8%). All doctors felt that diagrams may benefit overall medical care provision. CONCLUSION: Digitalizing signs and symptoms in EPR will enhance clinical documentation and may contribute to better patient care. New initiatives need to be employed to increase the use of diagrams - Medicons, as young doctors perceived these to improve clinical documentation. Standardized electronic proformas should be included into EPR to improve the efficiency and accuracy of clinical examination documentation.