Plastic surgery procedure unit: A streamlined care model for minor and intermediate procedures: A cost-benefit analysis.

INTRODUCTION: The advent of wide-awake local anaesthesia has led to a reduced need for main theatre for trauma and elective plastic procedures. This results in significant cost-benefits for the institution. This study aims to show how a dedicated 7 days/ week plastic surgery procedural (PSP) unit, performing both elective and trauma surgeries, can lead to significant cost-benefits for the institution. METHODS: Retrospective review of all cases performed in the PSP unit between 1 September and 31 August 2018. We utilised hospital directory admissions data and the hospital's intranet operating theatre system to calculate hospital days saved. Cost analysis was performed using Saolta financial data. RESULTS: A total of 3058 operations were performed. Of these operations, 2388 cases were elective and 670 were trauma cases. The average waiting time for trauma cases for main operating theatre was 1.4 days, saving a total of 487 hospital days. The total savings associated with hospital bed days were €347,861. The estimated resource savings from performing a procedure in PSP compared with main theatre with regional anaesthesia were €529.00 and €391.00 without regional anaesthesia. The cost saved due to resources was therefore €337,226. The total cost-benefit associated with performing surgeries in PSP including hospital days and resources saved was calculated as €685,087. CONCLUSION: This study shows the benefit of performing elective and trauma operations in minor procedure units such as PSP. PSP results in a more efficient service, reducing waiting times for surgery, shorter hospital stay, reduced operating cost and an overall significant cost saving.

High-risk squamous cell carcinoma of the ear - A potential role for sentinel node biopsy.

BACKGROUND: Squamous cell carcinomas (SCCs) of the external ear have a significant rate of metastasis. The purpose of this study was to present analyzed factors associated with auricular SCC metastasis in order to identify a group that may benefit from sentinel lymph node biopsy (SLNB). METHODS: We performed a retrospective review of all operable SCCs between 2009 and 2014. The association between high-risk features and metastasis were analyzed. RESULTS: One hundred eighty-nine auricular SCCs were excised. Local recurrence was noted in 11% and 9.5% developed metastases. Cartilage, perineural, and lymphovascular invasion were significantly associated with metastasis, as were increased tumor depth and diameter (P < .001). All patients with metastasis developed nodal disease. CONCLUSION: Factors, including poor differentiation, perineural, cartilage, and lymphovascular invasion, are associated with auricular SCC metastasis. Patients with 2 or more high-risk features may benefit from SLNB in order to identify and treat early nodal disease and possibly reduce the risk of further spread.

Current practice patterns of drain usage amongst UK and Irish surgeons performing bilateral breast reductions: Evidence down the drain.

INTRODUCTION: Bilateral breast reduction (BBR) is one of the most frequently performed female breast operations. Despite no evidence supporting efficacy of drain usage in BBRs, postoperative insertion is common. Recent high quality evidence demonstrating potential harm from drain use has subsequently challenged this traditional practice. The aim of this study is to assess the current practice patterns of drains usage by Plastic & Reconstructive and Breast Surgeons in UK and Ireland performing BBRs. METHOD: An 18 question survey was created evaluating various aspects of BBR practice. UK and Irish Plastic & Reconstructive and Breast Surgeons were invited to participate by an email containing a link to a web-based survey. Statistical analysis was performed with student t-test and chi-square test. RESULTS: Two hundred and eleven responding surgeons were analysed, including 80.1% (171/211) Plastic Surgeons and 18.9% (40/211) Breast Surgeons. Of the responding surgeons, 71.6% (151/211) routinely inserted postoperative drains, for a mean of 1.32 days. Drains were used significantly less by surgeons performing ≥20 BBRs (p = 0.02). With the majority of BBRs performed as an inpatient procedure, there was a trend towards less drain usage in surgeons performing this procedure as an outpatient; however, this was not statistically significant (p = 0.07). CONCLUSION: Even with the high level of evidence demonstrating the safety of BBR without drains, they are still routinely utilised. In an era of evidence- based medicine, surgeons performing breast reductions must adopt the results from scientific research into their clinical practice.

Analysis of features associated with equivocal diagnosis and diagnostic discordance of Spitz naevi over an 18-year period.

BACKGROUND: Distinguishing Spitz naevi from malignant melanoma can pose diagnostic dilemmas and atypical subtypes present particular challenges to both clinicians and pathologists. OBJECTIVES: We aimed to review our institutional experience of Spitz naevi, to characterise demographics and analyse the clinical and histological features associated with difficult/equivocal diagnosis of such lesions. Additionally we evaluated discordant cases following expert opinion at a second institution. MATERIALS & METHODS: Data was retrospectively analysed on all cases of Spitz naevi treated over an 18-year period (1991-2009). Equivocal cases, (where a diagnosis of classical Spitz naevi could not be confidently made) were identified. The original/provisional diagnosis and second histopathological opinions were compared. RESULTS: 148 cases were identified 112 lesions were classical Spitz naevi. 36 lesions (24.3%) posed diagnostic difficulty (equivocal cases). These equivocal cases tended to occur in the lower limbs, have brown pigmentation, be smaller in size (<6mm) and occur in older (>24 years) patients. Clinical sub-types and gender were not associated with equivocal cases. Of the 36 equivocal cases, the second opinion in 23 cases (63.9%) concurred with the original diagnosis. Of the remaining 13 cases (discordant cases), 10 cases that were originally deemed malignant were reported as benign after the second opinion. Two benign lesions were reclassified as malignant. CONCLUSION: A firm histological diagnosis of Spitz naevi cannot be made with certainty in nearly a quarter of cases. Thus, additional external analysis for a second opinion should be sought for these equivocal cases.

High-throughput oncogene mutation profiling shows demographic differences in BRAF mutation rates among melanoma patients.

Because of advances in targeted therapies, the clinical evaluation of cutaneous melanoma is increasingly based on a combination of traditional histopathology and molecular pathology. Therefore, it is necessary to expand our knowledge of the molecular events that accompany the development and progression of melanoma to optimize clinical management. The central objective of this study was to increase our knowledge of the mutational events that complement melanoma progression. High-throughput genotyping was adapted to query 159 known single nucleotide mutations in 33 cancer-related genes across two melanoma cohorts from Ireland (n=94) and Belgium (n=60). Results were correlated with various clinicopathological characteristics. A total of 23 mutations in 12 genes were identified, that is--BRAF, NRAS, MET, PHLPP2, PIK3R1, IDH1, KIT, STK11, CTNNB1, JAK2, ALK, and GNAS. Unexpectedly, we discovered significant differences in BRAF, MET, and PIK3R1 mutations between the cohorts. That is, cases from Ireland showed significantly lower (P<0.001) BRAF(V600E) mutation rates (19%) compared with the mutation frequency observed in Belgian patients (43%). Moreover, MET mutations were detected in 12% of Irish cases, whereas none of the Belgian patients harbored these mutations, and Irish patients significantly more often (P=0.027) had PIK3R1-mutant (33%) melanoma versus 17% of Belgian cases. The low incidence of BRAF(V600E)(-) mutant melanoma among Irish patients was confirmed in five independent Irish cohorts, and in total, only 165 of 689 (24%) Irish cases carried mutant BRAF(V600E). Together, our data show that melanoma-driving mutations vary by demographic area, which has important implications for the clinical management of this disease.

An assessment of histological margins and recurrence of melanoma in situ.

BACKGROUND: Melanoma in situ (MIS) accounts for up to 27% of all melanomas. MIS has no metastatic potential and the aim should be to excise the lesion completely with a clear histological margin, although margin clearance remains undefined. We aimed to assess the relation of histological excision margins of MIS to recurrence and progression to invasive disease. METHODS: We analyzed all patients with MIS excised by wide local excision or staged excision in our institution over a 5-year period from December 2008 to January 2014 using a prospectively maintained database. Clinicopathologic details included patient demographics, anatomical site of lesion, melanoma subtype, histological excision margin, and recurrence. RESULTS: A total of 410 patients had MIS excised during this time, the majority of which were lentigo maligna subtype (79%). The average histological excision margin was 3.7 mm. The rate of recurrence was 2.2% (9/410), with a median follow-up of 23 months. Lentigo maligna had a similar rate of recurrence to non-lentigo MIS (2.3% vs 1.2%) (P = 0.69). The mean excision margin of those that recurred was 1.9 mm compared with an average of 3.8 mm in those that did not. The rate of recurrence of MIS with histological excision margin ≤3.00 mm was 3.8% compared with 0.5% in those with a histological margin >3.00 mm (P = 0.03). One case of MIS recurred as invasive disease. CONCLUSION: At institutions using wide local excision or staged excision for MIS, a histological margin of >3.0 mm is required to achieve a low recurrence rate.

100 citation classics in the melanoma literature: a bibliometric analysis.

BACKGROUND: Modern immunologic therapies targeting genetic mutations have created a renewed interest in melanoma research, and this is reflected in the increasing number of published works. OBJECTIVE: The purpose of this study was to identify the top 100 most cited articles in melanoma and to examine the characteristics of each individual article. METHODS: Using an electronic database through the Web of Science, we were able to determine the 22 journals that contributed to the 100 most cited articles in melanoma. RESULTS: Each article was examined individually looking at characteristics such as subject matter, article type, country of origin, institution, authorship, and year of publication. The New England Journal of Medicine contributed the most articles to the top 100 with 20 articles, whereas the most cited article originated from the Archives of Surgery and has been cited 2,384 times. The United States produced 74% of the top 100 articles, and the most prolific institution was the National Cancer Institute in Maryland with 18 articles. CONCLUSION: This study has identified the most significant contributions to melanoma research over the past 63 years and identifies many important scientific breakthroughs and landmarks that have occurred during this time.

Hydrocolloid dressing in pediatric burns may decrease operative intervention rates.

INTRODUCTION: Partial-thickness scalds are the most common pediatric burn injury, and primary management consists of wound dressings to optimize the environment for reepithelialization. Operative intervention is reserved for burns that fail to heal using conservative methods. Worldwide, paraffin-based gauze (Jelonet) is the most common burn dressing; but literature suggests that it adheres to wounds and requires more frequent dressing change that may traumatize newly epithelialized surfaces. Hydrocolloid dressings (DuoDERM) provide an occlusive moist environment to optimize healing and are associated with less frequent dressing changes. AIM: The aim of the study was to retrospectively analyze pediatric burns in a single tertiary referral center over a 10-year period comparing the impact of Jelonet and DuoDERM dressings relative to operative intervention rates. METHODS: All pediatric burns admitted between 1997 and 2007 were identified using the Hospital Inpatient Enquiry system. Demographics were collected from hospital records and theater logbooks. Acute, partial-thickness burns in patients younger than 15 years were analyzed according to dressing type applied (Jelonet or DuoDERM). RESULTS: Two hundred forty-eight pediatric burns were analyzed between 1997 and 2007. One hundred thirty-nine patients were treated with Jelonet dressings, and 109 were treated with DuoDERM. Debridement and grafting were required in 60 (43%) of the Jelonet patients compared with 10 (9%) of the DuoDERM patients (P < .05). The DuoDERM-managed patients maintained a significantly lower graft rate on subanalysis of scalds excluding early grafting within 5 days (P < .001). CONCLUSION: Observational evidence suggests that DuoDERM leads to less operative intervention and should be preferentially used in pediatric burns.

Illness representations in patients with hand injury.

PURPOSE: Differences in illness perception about hand injury may partly explain the variation in health behaviours such as adherence to post-operative therapy, coping strategy, emotional response and eventual clinical outcome. This study examined the illness perception of patients with hand injuries in the acute trauma setting. METHODS: The disability and severity of injury were assessed using the Disability of the Arm, Shoulder and Hand (DASH) questionnaire and the Hand Injury Severity Score (HISS). The revised Illness Perception Questionnaire (IPQ-R) was used to explore patients' illness beliefs and perception on hand injury. RESULTS: Fifty seven patients were recruited over the 2 month period. The IPQ-R showed good internal reliability (Cronbach's alpha, 0.68-0.86). There was no correlation between the DASH or HISS scores and the various components of the IPQ-R scores, suggesting that illness perceptions were not influenced by the recent trauma experience. Patients with dominant hand injuries and females reported significantly higher subjective disability. Younger patients believed their injury would last for a limited duration but reported a significantly higher number of related symptoms. Overall, the cohort was optimistic about their treatment and duration of recovery (high treatment control score and low time line score). Beliefs of negative consequences, chronic/cyclical duration and low illness coherence were linked with negative emotional response. High illness identity was associated with perception of pessimistic outcome (high consequences score) and negative emotional response. CONCLUSIONS: The lack of correlations suggests that illness perceptions of patients do not necessarily relate to the recent trauma experience or the severity of their hand injury. Patients in this cohort were optimistic about treatment and their recovery. There was some evidence to suggest that patients with severe injury were over-optimistic about recovery. These findings suggest that there could be a role for psychological intervention in hand injury.

Interdigital pilonidal sinus of the foot.

Pilonidal sinus of the interdigital spaces is a common condition among barbers. The condition results from a foreign body reaction to clients' hairs. It is thought that the short sharp hairs penetrate the skin when hands are rubbed through freshly cut hair. We present an unusual case of a pilonidal sinus arising in the interdigital spaces of the foot in a female hairdresser. This is to our knowledge only the second such case reported in the literature.

Intrapleural bupivicaine in latissimus dorsi breast reconstruction.

The use of intrapleural (IP) analgesia for controlling post-operative pain in breast reconstruction is not well documented. The objective of this study was to assess the value of IP bupivacaine in those patients undergoing latissimus dorsi breast reconstruction. Twenty-six patients received a single bupivacaine IP injection at induction of anesthesia. Eighteen of these patients also received a 24-hour postoperative IP infusion. A control group of 22 patients did not receive an IP block. All patients had access to morphine via patient-controlled analgesia pumps. The 24-hour morphine requirements were recorded for each group and the data were analyzed by Student t test. Significance was taken at the 5% level. The mean morphine requirement in the control group was 39.2 mg +/- 2.89 mg. This was significantly greater than the requirement of the 8 patients who had a single IP injection of bupivacaine at induction (10.1 mg +/- 2.76 mg), P < 0.001. It was also significantly greater than that of the 18 patients who received an IP infusion (2.7 mg +/- 1.35 mg), P < 0.0001. The infusion group required significantly less morphine than the single injection group did, P < 0.02. No complications following IP injection were noted in this series. Intrapleural analgesia is a safe technique and significantly reduces the requirement for postoperative opiate analgesia in those undergoing latissimus dorsi breast reconstruction.

Lichtenberg figures: cutaneous manifestation of phone electrocution from lightning.

INTRODUCTION: Lichtenberg figures are reddish, fern-like patterns that appear on the skin when a patient is struck by lightning. These appear to be a result of an inflammatory response as current spreads out causing ionisation and heat effects and damage to the small subcutaneous capillaries. CASE REPORT: A 30-year-old lady was brought to the accident and emergency department with a history of momentary loss of consciousness. All that the patient could recollect was that she had been on the phone when she heard a loud bang following which she 'blacked out'. On examination, she had characteristic cutaneous Lichtenberg figures. These revealed the true diagnosis of a lightning strike conducted through the phone line into the patient. DISCUSSION: The cutaneous manifestation of a surreptitious lightning strike through a telephone plays an important role in diagnosing the problem and is particularly significant when the patient is unconscious and unable to give a history of events or, as in this case, has retrograde amnesia. Establishing the diagnosis enables us to look for other lightning-associated injuries and to monitor the cardiac status of the patient to avoid any concomitant complications. Also, establishing the diagnosis is extremely helpful to allay patient anxiety as Lichtenberg figures on the skin can be quite dramatic, as seen in this case.