Electrochemotherapy for the treatment of primary basal cell carcinoma; A randomised control trial comparing electrochemotherapy and surgery with five year follow up.

Basal cell carcinoma (BCC) are the commonest cutaneous malignancy and incidence continues to increase. There is a need to expand the therapeutic toolbox to increase options for patients that are unsuitable for or unwilling to undergo the current therapies. Electrochemotherapy (ECT) is a technique where cells are temporarily permeabilized after exposure to a brief pulsed electrical field and combined with low dose chemotherapeutics to ablate malignancies. It is a simple technique causing minimal damage to the surrounding healthy tissue and has the potential to avoid the need for complex reconstruction. ECT is an established treatment for skin metastases but its role as a primary treatment modality is not demonstrated. A prospective randomised control trial evaluating ECT against the gold standard of treatment, Surgery, was performed for patients with primary BCC and patients followed for 5 years. All lesions treated with ECT (n = 69) responded although 8/69 (12%) needed a second treatment to ensure a complete response. All surgical lesions (n = 48) showed histological evidence of complete excision with 2/48 (4%) undergoing a second excision. At 5 years, in the surgical arm there was no evidence of recurrence in 39/40 (97.5%) lesions with 1/40 (2.5%) confirmed recurrence. In the ECT arm there was no evidence of recurrence in 42/48 lesions (87.5%). There was 5 confirmed recurrences. These groups show statistical equivalence in this non inferiority study design (p = 0.33). ECT is an effective and durable treatment option for primary BCC and should be considered as part of the armamentarium of options available.

A new adaptation for a secure surgical drain placement and a comparison with four common drain fixation methods.

INTRODUCTION: The importance of postoperative drain fixation cannot be overemphasised. There are numerous described techniques for drain fixation. However, to our knowledge, there is no evidence-based comparison between the various techniques of drain fixation used in postoperative management. We describe a new method and compare its reliability with four other commonly used methods. MATERIALS AND METHODS: Five methods were chosen for testing based on current trends in clinical practice: centurion sandal with plastic locking ties, centurion sandal or lattice method, centurion sandal with half-inch Steristrips®, double and multiple looped methods. We used an Instron 8872® tensiometer to apply a measured force to a secured drain. Each fixation method was tested ten times and all fixation methods were performed by the same experienced surgeon. We measured the average number of cycles before failure, the average displacement of the tube at failure and the time needed to apply each fixation method. RESULTS: The number of cycles completed before failure showed that the centurion sandal method, the centurion sandal with plastic ties and the centurion sandal method with Steristrips had the lowest failure rate. The amount of displacement was the least in the centurion sandal with plastic ties followed by the double-loop method and centurion sandal with Steristrips. There was little difference in the time taken to complete the fixation methods (range 21-33 seconds). DISCUSSION: We recommend the use of the centurion sandal with plastic locking ties, centurion sandal with Steristrips followed by the centurion sandal method alone as fixation techniques that are quick to perform, secure and reliable.

Does Demand for Breast Augmentation Reflect National Financial Trends?

Aesthetic plastic surgery is a consumer-driven industry, subject to influence by financial forces. A changing economic environment may thus impact on the demand for surgery. The aim of this study was to explore trends in demand for bilateral breast augmentation (BBA) in consecutively presenting patients over an 11-year period and to examine if a correlation exists between these trends and changes in Gross Domestic Product (GDP), a key economic indicator. This study revealed a correlation between annual number of breast augmentation procedures performed and GDP values (r 2 = 0.34, p value = 0.059). Additionally, predicted number of BBA procedures, based on predicted GDP growth in Ireland, strongly correlated with actual number of BBA performed (r 2 = 0.93, p value = 0.000001). Predicted GDP growth can potentially forecast future demand for BBA in our cohort allowing plastic surgeons to modify their practice accordingly. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Cosmetic surgical practice: are we complying with professional standards?

UNLABELLED: Aesthetic surgery is a rapidly expanding industry and patient safety is a fundamental issue. The need for regulation has been outlined by the Professional Standards for Cosmetic Practice Report, published by the Royal College of Surgeons in January 2013 which highlighted standards of patient care. The aim of this study was to review institutional compliance with these standards. A retrospective chart review of 40 consecutive patients who underwent either bilateral breast augmentation or bilateral breast reduction between November 2012 and November 2013 within our unit was performed. Compliance with standards relating to practice management, patient consultation, patient communication and record-keeping was examined. While details of past medical history were recorded in most cases, few consultations referred to psychiatric history and cosmetic surgical history specifically. Perioperative documentation and compliance with surgical safety processes were excellent. As a self-regulating profession, it is important that plastic surgeons take the lead in auditing their practice against such published standards. We urge all professionals who carry out cosmetic procedures to regularly review their practice, thereby promoting accountability and maintaining the trust of the general public in the aesthetic surgery industry. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Electrochemotherapy for the treatment of ocular basal cell carcinoma; a novel adjunct in the disease management.

Basal Cell Carcinoma (BCC) affecting the ocular region is potentially problematic due to its ability to infiltrate aesthetic and functional structures. Due to the paucity of local tissue, resection frequently requires reconstruction with skin grafts or local flaps. Surgical treatment may not be suitable for patients with multiple co-morbidities. Electrochemotherapy (ECT) is a technique where cells are temporarily permeabilized after exposure to a brief electrical field and when combined with normally impermeant chemotherapy drugs can resolve cutaneous cancers - even those previously recalcitrant to chemotherapy or radiotherapy. Its particular advantage is its speed of application and the minimal damage to the surrounding healthy tissue structures. We present a series of 3 patients with BCCs in the peri-ocular region and significant co-morbidities deemed unsuitable for surgical resection, who underwent ECT. The lesions were all primary BCC ranging in size from 0.5 cm(2) to 1 cm(2). Two lesions were on the upper eyelid and one on the lower eyelid. ECT was performed using an 8-needle electrode and a CE approved electroporation generator with intra-lesional Bleomycin. All lesions responded to treatment. All BCC's completely resolved, with acceptable scarring. No side effects were reported from the Bleomycin or the electric pulses. ECT for peri-ocular BCC is an adjunct to surgical excision in the management of surgically problematic lesions. This technique could provide a useful initial treatment option for patients who are medically unfit or where resection and would be associated with significant morbidity.

A comparison between complete immobilisation and protected active mobilisation in sensory nerve recovery following isolated digital nerve injury.

Post-operative immobilisation following isolated digital nerve repair remains a controversial issue amongst the microsurgical community. Protocols differ from unit to unit and even, as evidenced in our unit, may differ from consultant to consultant. We undertook a retrospective review of 46 patients who underwent isolated digital nerve repair over a 6-month period. Follow-up ranged from 6 to 18 months. Twenty-four were managed with protected active mobilisation over a 4-week period while 22 were immobilised over the same period. Outcomes such as return to work, cold intolerance, two-point discrimination and temperature differentiation were used as indicators of clinical recovery. Our results showed that there was no significant difference noted in either clinical assessment of recovery or return to work following either post-operative protocol, suggesting that either regime may be adopted, tailored to the patient's needs and resources of the unit.

Paediatric ride-on mower related injuries and plastic surgical management.

Lawnmower related injuries cause significant morbidity in children and young teenagers. The 'ride-on' mowers which are more powerful than the 'walk behind' mowers are becoming increasingly popular. The incidence and severity of injuries from either type of lawnmower appears to be steadily rising as is the burden placed on local plastic surgical and emergency services in managing the care of these patients. The aims of the study were to demonstrate changing trends in lawnmower-related injuries to children presenting to a single unit over a ten-year period and to identify any association between injury severity and machine subtype ('ride-on' versus 'walk-behind'). Hospital databases, theatre records and medical case notes were reviewed retrospectively of all patients under the age of 16 treated for lawnmower related injuries over a 10 year period from July 1998 to June 2008. Data gathered included patient demographics, injury site and severity, management (type and number of surgical procedures), length of hospital stay and outcome. Injury severity score was also calculated for each case. Controlling for estimated regional population changes, there was a significant increase in the number of ride-on mower related accidents in the time period 2003-2008, compared to the time period 1998-2003. Ride-on injuries had significantly higher injury severity scores, longer hospital stays and were more likely to involve amputations as compared with walk-behind injuries. Children can sustain significant injuries with unsafe lawnmower use. The current study demonstrates the increasing incidence of ride-on mower related injuries in children and identifies a greater morbidity associated with such injuries. Such presentations place intense demands on local plastic surgical services.

Botulinum toxin for treatment of glandular hypersecretory disorders.

SUMMARY: The use of botulinum toxin to treat disorders of the salivary glands is increasing in popularity in recent years. Recent reports of the use of botulinum toxin in glandular hypersecretion suggest overall favourable results with minimal side-effects. However, few randomised clinical trials means that data are limited with respect to candidate suitability, treatment dosages, frequency and duration of treatment. We report a selection of such cases from our own department managed with botulinum toxin and review the current data on use of the toxin to treat salivary gland disorders such as Frey's syndrome, excessive salivation (sialorrhoea), focal and general hyperhidrosis, excessive lacrimation and chronic rhinitis.

The polymerase chain reaction and its application to clinical plastic surgery.

Molecular biology has become an essential component in many fields of modern medical research, including plastic surgery. Research into the molecular mechanisms underlying many disease processes offer increased understanding of the pathogenesis of disease and provide exciting therapeutic possibilities. Yet for many clinicians, the presentation of much research into molecular biological processes is couched in confusing terminology and based on scientific techniques, the basis of which are frequently difficult for the clinician to understand. The purpose of this review is to present an introduction to some of the molecular biological techniques currently in use, namely the polymerase chain reaction (PCR) and explore its applications to different aspects of plastic surgery. This review explores the role PCR now plays in all aspects of modern plastic surgery practise, with particular emphasis on normal and abnormal wound healing, the diagnosis of craniofacial anomalies, the diagnosis and treatment of cancer including melanoma and squamous cell carcinoma of the head and neck, and burns.

Advanced Merkel cell cancer and the elderly.

BACKGROUND: Merkel cell cancer (MCC) is an uncommon neuroendocrine skin cancer occurring predominantly in elderly Caucasians. It tends to metastasize to regional lymph nodes and viscera and is sensitive to chemotherapy but recurs rapidly. AIM: To report one such case, its response to chemotherapy and briefly review the literature. METHODS: A 73-year-old male with a fungating primary lesion on his left knee and ulcerated inguinal lymph nodes was diagnosed with MCC and treated with chemotherapy. The two largest case series and reviews of case reports were summarised. RESULTS: His ulcer healed after two cycles of carboplatin and etoposide with improvement in quality of life. Overall response rates of nearly 60% to chemotherapy are reported but median survival is only nine months with metastatic disease. CONCLUSIONS: Chemotherapy should be considered for fit elderly patients with MCC who have recurrent or advanced disease.

An anatomical study of the superficial inferior epigastric vessels in humans.

The lower abdominal skin and fat has become a standard for breast reconstruction in terms of skin texture, suppleness and colour. Concerns regarding donor site morbidity related to the harvest of rectus abdominis musculocutaneous flap, based on the deep inferior epigastric vessels, have turned attention towards alternative options. The superficial inferior epigastric artery (SIEA) flap is a fasciocutaneous flap that has been used for reconstruction of the breast, as well as head, neck and limb defects. In Taylor's classic dissection series the SIEA was 'absent' in 35% [Plast Reconstr Surg 56 (1975) 243]. In our series of 22 cadaver dissections (eight female, three male) the SIEA was identified in 20 and the vein (SIEV) in 21. In 15, the artery was located at the level of the inguinal ligament, within 1 cm of its midpoint. In 17, the origin, from the common femoral artery, was within 2 cm of the inguinal ligament. In 18, the SIEA arose as a common trunk with the superficial circumflex iliac artery, superficial external pudendal artery, and/or the deep circumflex iliac artery. Mean SIEA calibre was 1.9 mm and the mean pedicle length from origin to inguinal ligament was 5.2 cm. Our findings suggest that the SIEA is more consistently present and larger in calibre than previously reported, and consequently may be of greater clinical use than previously believed.

Effects of a silicone-coated polyamide net dressing and calcium alginate on the healing of split skin graft donor sites: a prospective randomised trial.

An open randomised prospectively controlled trial was performed to assess the healing efficacy, slippage rate and degree of discomfort on removal of calcium alginate and a silicone-coated polyamide net dressing on split skin graft donor sites. Sixteen patients were randomised to the calcium alginate group and 14 to the silicone-coated group. The donor sites were assessed at days 7, 10, 14 and up to day 21. The mean time to healing in the calcium alginate group was 8.75 +/- 0.78 days (range 7 to 14 days) compared to 12 +/- 0.62 days (range 7 to 16 days) for the silicone-coated group (p < 0.01). Although more silicone-coated dressings slipped (5 versus 1), the difference was not statistically significant. Pain during the first dressing change was assessed using a visual analogue pain scale. Although no significant differences were found between the groups, it was necessary to change the dressing protocol in the silicone-coated arm of the trial after entering the first two patients. Overlaid absorbent gauze adhered to the donor site through the fenestrations in the dressing necessitating the placement of paraffin gauze between the experimental dressing and the overlying cotton gauze. There was one infection in the study, occurring in the alginate group. Based on these results we recommend calcium alginate as the dressing of choice for split skin graft donor sites.

Squamous cell carcinoma of the finger masquerading as an abscess. Case report.

A 43-year-old man presented with an abscess on his left ring finger, which recurred despite multiple drainage procedures. Histological examination of the lesion was unhelpful; it was only on histopathological examination of the finger after ray amputation that the diagnosis of cutaneous squamous cell carcinoma was established. This case illustrates the need to consider malignancy when dealing with chronic finger infections.

The role of low-profile titanium miniplates in emergency and elective hand surgery.

We report our experience of a low-profile mini-plating system in the treatment of fractures of the hand in 57 consecutive patients (five children and 52 adults). Thirteen procedures were performed electively, and 44 procedures were performed on an emergency basis. Indications for plating included fixation of metacarpal (36) and phalangeal (eight) fractures, bony fixation following rotation osteotomy (six) digital replantation (two) or free toe transfer (two). Seventeen patients had postoperative problems, including restricted range of motion (12), rotation deformity (two), significant cold intolerance (two) or fracture (two). Plate removal was required in seven patients, twice as a result of a second injury, and plate removal was unsuccessfully attempted in one other patient. Two patients required extensor tenolysis. We have found this system to be useful for bony fixation in the hand. However, as with other methods of internal fixation in the hand, there may be complications.

Outcome measurement of the treatment of maxillary fractures: a prospective analysis of 100 consecutive cases.

We performed a prospective study of 100 consecutive patients presenting to our unit with complex maxillary fractures. Fracture severity was assessed according to the alpha-numeric scoring system of Cooter and David and correlated with outcome. Regional maxillary and total fracture scores demonstrated a positive correlation with complication rates, with correlation coefficients of 0.89 and 0.98 respectively. Ocular and orbital complications were most commonly seen with these complex injuries, but occlusal problems were much less common. Despite close consultant-led supervision in a specialised centre, these injuries frequently result in long term problems.