Free Tissue Transfer after Open Transmetatarsal Amputation in Diabetic Patients.

BACKGROUND: Transmetatarsal amputation (TMA) preserves functional gait while avoiding the need for prosthesis. However, when primary closure is not possible after amputation, higher level amputation is recommended. We hypothesize that reconstruction of the amputation stump using free tissue transfer when closure is not possible can achieve similar benefits as primarily closed TMAs. METHODS: Twenty-eight TMAs with free flap reconstruction were retrospectively reviewed in 27 diabetic patients with a median age of 61.5 years from 2004 to 2018. The primary outcome was limb salvage rate, with additional evaluation of flap survival, ambulatory status, time until ambulation, and further amputation rate. In addition, subgroup analysis was performed based on the microanastomosis type. RESULTS: Flap survival was 93% (26 of 28 flaps) and limb salvage rate of 93% (25 of 27 limbs) was achieved. One patient underwent a second free flap reconstruction. In the two failed cases, higher level amputation was required. Thirteen flaps had partial loss or other complications which were salvaged with secondary intension or skin grafts. Median time until ambulation was 14 days following reconstruction (range: 9-20 days). Patients were followed-up for a median of 344 days (range: 142-594 days). Also, 88% of patients reported good ambulatory function, with a median ambulation score of 4 out of 5 at follow-up. There was no significant difference between the subgroups based on the microanastomosis type. CONCLUSION: TMA with free flap reconstruction is an effective method for diabetic limb salvage, yielding good functional outcomes and healing results.

Undergraduate plastic surgery in the United Kingdom: The students' perspective.

Plastic Surgery is consistently ranked as one of the most competitive for higher surgical training in the United Kingdom. With falling rates of undergraduate Plastic Surgery education there is a danger that potentially excellent candidates will be deterred from applying for training positions. We sought to investigate a cohort of UK medical students with an established interest in Plastic Surgery regarding the factors that influence their interest in the specialty. A cross-sectional study design was used with questionnaires distributed to medical students attending the BAPRAS Undergraduate Day in London and Glasgow University Plastics Undergraduate National Conference in 2019. The questionnaire included factors attracting and deterring them from a career in Plastic Surgery, alongside their undergraduate exposure to the specialty and suggestions on how it could be improved. The most common factors attracting students to a career in Plastic Surgery were variety (25%), surgical intricacy (15%) and immediate effect on patient quality of life (12%). The most common factors deterring students from a Plastic Surgery career were a competitive national selection process (41%), work-life balance (15%) and length of training (12%). As 47% of students had not received undergraduate education in Plastic Surgery, their perceptions of the specialty will be likely be influenced from external, often negative, sources such as television and other media. To safeguard the future Plastic Surgery workforce, universities should collaborate with local departments and professional bodies to meet the needs of medical students for undergraduate exposure through mentorship, workshops, taster days and clinical placements.

Botulinum toxin A for children with salivary control problems.

OBJECTIVE: The aim of this study was to review the response of children who have received botulinum toxin A (BtA) injections for saliva control in our institution. METHODS: Retrospective case series of children attending a saliva control clinic in a paediatric tertiary referral hospital. Children were identified from the saliva control database, which has been in place since its creation in 2006. Prior to receiving BtA all the children in the study had previously undertaken a 3-month trial of pharmacological therapy, with no effect. All BtA injections were performed freehand to the parotid and submandibular glands. The background diagnosis, comorbidities for the child, age at presentation, dose of BtA, the response, and any complications were recorded. RESULTS: 97 children were identified and 175 BtA doses were given (median per child: 1, mean: 1.9). 59 (61%) were male. The age range was between 2 months and 18 years (mean 8.6 years, median 8.8 years). The dose injected varied between 0.52 units/kg and 21.28 unit/kg (mean 5 units/kg, median 4.2 units/kg). These were performed using local anaesthetic on 131 (75%) occasions. The remainder were performed under general anaesthetic. Responses to BtA were classed as effective 109 (62%), partially effective 14 (8%) or not effective 50 (29%). The response duration was between 0.25 and 18 months (mean 4 months). Complications were seen following 22 injections (10.9%). Data modelled using binary logistic regression found that male gender and children with cerebral palsy are statistically predicted to have a better response to BtA. CONCLUSION: Botulinum A injected under local anaesthetic is a safe, effective treatment for children with sialorrhoea. Ultrasound guidance is not necessary as long as anatomical landmarks are used for placement. The main adverse effect that can result is dysphagia, which is of concern in children that can swallow independently prior to injection. Male sex and cerebral palsy are statistically independent positive predictive factors for successful outcome of BtA injections for sialorrhoea, however this does not preclude other children from receiving or benefitting from it. Children that respond well to BtA initially, are likely to respond well in the future.