Aesthetic surgical training in the UK independent sector--the clients' view: Results of a survey on 155 private patients.

As training opportunities in cosmetic surgery become less frequent in teaching hospitals, this survey set out to examine the attitudes of patients towards extending this training into the independent health sector. We questioned 155 private patients, 95% of who were happy for trainees to sit in during their consultations. Of these, 85% were comfortable with the presence of the trainee throughout their appointments and 92% said they saw advantages in having such trainees present. However, patients were less enthusiastic about trainees carrying out procedures, under consultant supervision and for a reduced fee. The survey found that while 49% felt it was a good idea, only 32% would consider it for themselves. Seventeen percent of patients thought this offer alone was inappropriate. This survey has shown that while the vast majority of private patients supported and were happy to participate in higher surgical training during private consultations, fewer would consider the possibility of cosmetic surgery performed by supervised trainees for reduced fees. The implications of these findings for higher surgical training in Plastic Surgery in the UK are discussed.

Paediatric day-case otoplasty: local versus general anaesthetic.

BACKGROUND: Correction of prominent ears (otoplasty) is routinely done as an elective cosmetic procedure. The operation is typically performed under general anaesthesia, which is favoured in the paediatric population, being considered more 'humane' than local anaesthesia. AIM: Our aims were to demonstrate the feasibility of paediatric otoplasty as a day case procedure and to examine the relative efficacy of general versus local anaesthesia, paying particular attention to post-operative morbidity. METHODS: Data were gathered retrospectively from case notes, day case surgery pro-formas and dressing clinic notes to compare post-operative morbidity in the two groups. Specific parameters assessed included vomiting, post-operative bleeding, wound dehiscence, necessity of overnight stay and need for revision surgery. RESULTS: Eighty-five children, underwent a day case otoplasty procedure (age range 4-17 years; mean 7.3). Forty-four received a general anaesthetic, whilst forty-one received percutaneous infiltration of local anaesthetic. Local anaesthetic was well tolerated by the children. No procedure was abandoned due to pain. No disadvantage was demonstrable in either group by performing the operation as a day case procedure. Post-operative vomiting was shown to be a significantly greater problem in the children receiving general anaesthesia (p<0.0001). CONCLUSION: Otoplasty as a day case procedure appears acceptable whether general or local anaesthesia is used. In addition, percutaneous infiltration of local anaesthetic, results in a marked reduction in post-operative vomiting without compromising surgical outcome.

Palmar fasciectomy and keloid formation.

A 53-year-old Caucasian with keloid formation on the palmar surface of the hand following Dupuytren's contracture release is presented. Only two other cases of keloid formation on the hand have been found in English literature, both on black patients. This is the first known case with association of Dupuytren's disease to be reported. Surgical excision of the keloid with intraoperative injection of triamcinolone of the wound edges resulted in clinical cure.

Expandable anatomical implants in breast reconstructions: a prospective study.

Following success with two-stage anatomical breast reconstructions, we started using expandable anatomical implants for breast reconstruction to achieve one-stage reconstruction. Sixty-three breast reconstructions were carried out with one-stage expandable anatomical implants over a period of 15 months, September 1995 to December 1996. To assess the performance of these implants, 20 patients with mean age 51.1 years (range 34-68 years), who were operated between February 1996 and June 1996, were entered into a prospective study. Overall, very satisfactory results were achieved, with a mean follow-up of 10.1 months (range 8-12 months). Minor complications were recorded in 3 patients and minor secondary adjustment was required in 7 patients.

Breast reconstruction with anatomical expanders and implants: our early experience.

Dissatisfied with the upper pole fullness produced by the Becker expander/mammary prosthesis, we started using 'anatomically' shaped expanders and implants, as described by Maxwell, for breast reconstruction. We reviewed the results of our first 24 breast reconstructions in 19 patients, who were deemed suitable for reconstruction with this technique between August 1994 and April 1995 (9 months). The most commonly used expander was 500 cc (range 400-700 cc) and an average of 2.73 inflations was required before replacing the expander with a definitive implant. The minimum follow-up was 6 months. Few complications were recorded and all patients were very happy with the final result. We found that the anatomically shaped expanders and implants produced better aesthetic reconstructions compared to dome shaped prostheses. Importantly, the procedure was technically simple and the results readily reproducible.

The "Niplette": an instrument for the non-surgical correction of inverted nipples.

Inverted and non-protractile nipples are a common problem which cause psychological distress and interfere with a woman's ability to breast feed. A new instrument, the "Niplette", readily corrects the defect without the need for surgery. It is cheap and all patients found it comfortable and easy to use. Breast feeding is possible after treatment. The device should replace surgery in medical practice for this common condition.

Partial flexor tendon injuries: to repair or not.

The correct management of partially divided flexor tendon injuries is still in dispute. This study compares the results of repair with non-repair in zone 2 injuries. We conclude that tendons divided by 60% or less in cross-sectional area should not be repaired.

The management of the complete ring avulsion injury.

The complete ring avulsion injury presents a difficult choice between microvascular repair and further amputation. The former is technically difficult and the latter leaves an undesirable result. We describe an alternative method whereby a thinned groin flap is applied to volar surface and sides of the finger and a full-thickness skin graft covers the dorsum. This provides good quality cover to the volar aspect and avoids bulk on the dorsum.

The distally-based brachioradialis muscle flap.

We describe the brachioradialis muscle flap based distally on the radial artery. It is quickly raised and provides excellent cover for soft tissue defects of the hand. In the two clinical cases the brachioradialis tendon has also been used for extensor tendon reconstruction.

The use of the reverse latissimus dorsi flap in the closure of lower spinal defects.

Described is the distally based or reverse latissimus dorsi flap. Its use in closing lower spinal defects in four patients with five flaps is presented. With its predictable blood supply, which is rarely damaged by previous surgery, the flap can provide versatile and reliable cover to the lower back.