Setting up a new microsurgical breast service in a non-tertiary hospital: Is it safe, and do outcomes compare to centres of excellence?

AIMS: Access to autologous reconstruction continues to be limited in some areas of the United Kingdom. This is, in part, due to the perceived difficulty offering this service outside of a large tertiary centre. We present our experience setting up a new microsurgical breast reconstruction service in a district hospital and compare our results to the published outcomes of large volume centres. METHODS: Patient data were collected prospectively from the start of the service to date (July 2018- July 2020) with the capture of demographics, management, and outcomes. The BREAST-Q tool was used preoperatively and at a minimum of 3 months. RESULTS: The first 40 patients undergoing DIEP reconstruction were included. Of these, 70% were immediate, mean age was 49 years (27-68) and BMI was 28.1 kg/m2 (22-32.5). In all, 50% had one or more co-morbidities other than breast cancer. Median length of stay was 3 days (2-6) with 75% of patients discharged on day 2 or 3. Ten patients' stay exceeded 3 days - mostly due to social reasons. Flap loss occurred in 1 patient (2.5%). Twenty-one patients developed complications (52%) within 90 days: seven Clavien-Dindo Grade I, two Grade II and ten Grade IIIb. Fat necrosis and mastectomy flap necrosis were the most common complications. Surgical intervention was higher in those needing adjuvant therapy. Patient-reported outcomes showed post-operative improvement across all domains except abdominal physical well-being at median 11.3 months. CONCLUSIONS: We present the shortest published length of stay for unilateral DIEP reconstructions. We are the first paper to publish patient-reported outcomes following a breast microsurgical enhanced recovery protocol. We demonstrate how a new microsurgical service, utilising an enhanced recovery protocol and careful patient selection can immediately achieve outcomes comparable to well-established centres. There is no reason why all patients should not have access to microsurgical breast reconstruction locally.

Techniques used by United Kingdom consultant plastic surgeons to select implant size for primary breast augmentation.

BACKGROUND: Techniques used to estimate implant size for primary breast augmentation have evolved since the 1970s. Currently no consensus exists on the optimal method to select implant size for primary breast augmentation. METHODS: In 2013 we asked United Kingdom consultant plastic surgeons who were full members of BAPRAS or BAAPS what was their technique for implant size selection for primary aesthetic breast augmentation. We also asked what was the range of implant sizes they commonly used. The answers to question one were grouped into four categories: experience, measurements, pre-operative external sizers and intra-operative sizers. RESULTS: The response rate was 46% (164/358). Overall, 95% (153/159) of all respondents performed some form of pre-operative assessment, the others relied on "experience" only. The most common technique for pre-operative assessment was by external sizers (74%). Measurements were used by 57% of respondents and 3% used intra-operative sizers only. A combination of measurements and sizers was used by 34% of respondents. The most common measurements were breast base (68%), breast tissue compliance (19%), breast height (15%), and chest diameter (9%). The median implant size commonly used in primary breast augmentation was 300cc. SUMMARY: Pre-operative external sizers are the most common technique used by UK consultant plastic surgeons to select implant size for primary breast augmentation. We discuss the above findings in relation to the evolution of pre-operative planning techniques for breast augmentation.

Severity of upper-limb panga injuries and infection rates associated with early v. late tendon repair.

BACKGROUND: Panga or machete attacks are a common cause of significant upper-limb trauma in South Africa. Pangas are a multipurpose household tool used predominantly for foraging and agricultural purposes and are highly contaminated. While some centres advocate immediate primary repair if no concern exists regarding the risk of infection, others delay definitive repair until satisfied there is no evidence of infection. OBJECTIVES: To compare infection rates and tendon re-rupture following early primary repair (within 24 h), primary repair after 24 h, and delayed repair following initial debridement. METHODS: We conducted a multicentre, retrospective, observational study of 49 patients (mean age 28.9 years; range 17 - 69), who were followed up for a mean of 3.4 months (range 0 - 8). The injuries sustained included 32 flexor tendon injuries, 14 extensor tendon injuries, 9 fractures and 21 peripheral nerve injuries. RESULTS: Of the patients, 17 underwent early primary repair (within 24 h), 19 delayed primary repair, and 13 delayed repair following primary washout. Wounds were assessed postoperatively using the ASEPSIS wound scoring system and patients were clinically assessed for tendon rerupture. No significant differences were found in the comparative infection rates for early primary repair (5.9%; 1/17), delayed primary repair (10.5%; 2/19) and delayed repair following primary washout (23.1%; 3/13; p=0.662). CONCLUSION: Our results indicate indicate that panga injuries can be repaired safely at first presentation with no increased risk of infection or re-rupture.

Cross-over limb replantation: a case report.

Following traumatic bilateral arm amputation in a 46-year-old woman, orthotopic replantation was not possible. The patient underwent replantation of the left forearm to the right proximal forearm. At two years she has a sensate hand, with good recovery of her long flexors of the hand and wrist extensors. DASH score is 93.9 and Chen's score is III (medium). We demonstrate a high level of function compared to the contralateral prosthetic limb. There have only been four similar cases described. Although a rare circumstance, a cross-limb replant can provide a level of function and independence superior to a simple prosthesis. Cross-limb transfer should be considered in situations where bilateral arm amputation is present and neither can be orthotopically replanted.

The severity of kettle burns and the dangers of the dangling cord.

Kettle scalds are a major cause of paediatric burn injury. Whilst preventative measures have been advocated for years, the incidence of this type of injury is increasing. Information is lacking regarding severity and mechanism of injury. We prospectively analysed all paediatric scald injuries that warranted referral to a tertiary burn centre to quantify severity, outcome, look into how these burns occurred with a view to providing information for preventative strategies and audited the safety features of 19 top selling kettles. A total of 119 kettle burns were included in the study. Mean age at time of injury was 2 years 1 month (5 months to 12 years). Mean TBSA was 11.8% (2-30) and 62% sustained TBSA >10%. Mean length of stay was 10.4 (1-120) days and a surgical procedure was required in 62% of all kettle scalds. Grafting was undertaken in 52% of patients. Mean number of surgical procedures was 1.7 (median 1, range 1-9). Pulling the kettle cord was the main mechanism of injury (74% vs. 37%). "Cord-pullers" were also significantly younger (mean 20 months vs. 51 months, p<0.05) and underwent significantly more grafting in "cosmetically sensitive" areas (69% vs. 23%, p<0.05). 4 cases of inhalational injury occurred as a result of pulling the kettle cord. Mean kettle cord length was 66 cm (range 45-80) with only 30% employing a coil tidy feature. In view of these findings we discuss current legislative policy on kettle cord length and report on the current safety of today's kettles. Areas for future prevention are discussed.

Intra-lesional steroid for the management of symptomatic Infantile Digital Fibromatosis.

BACKGROUND: Infantile Digital Fibromatosis (IDF) is a benign, often asymptomatic nodular proliferation of fibrous tissue occurring almost exclusively on the extremities. Conventional treatment has included radical surgery but this is associated with a high level of recurrence. Whilst some authors suggest a strictly conservative approach, this is unacceptable when lesions become symptomatic from pain, contracture formation or functional deformity METHODS: We present a retrospective analysis of 12 symptomatic lesions of which 7 were treated with a novel technique of intra-lesional steroid. From 2004-2009, a total of ten patients received treatment for symptomatic IDFs. Patients were followed-up for an average of 5 years 9 months (range 8-131 months). RESULTS: Corticosteroid was well tolerated with no significant complications and was associated with lower morbidity that compared with surgery. There was no significance difference between rate of recurrence (1/7 vs. 5/10) for those treated with corticosteroid than compared to those patients who underwent surgery (p = 0.3) but the study is underpowered. CONCLUSIONS: This is the first ever study to look at the role of intra-lesional steroid in the management of IDF. Whilst the majority of asymptomatic Infantile Digital Fibromatoses can be safely observed until natural resolution, intra-lesional corticosteroid is a safe and well-tolerated alternative to surgery for all symptomatic digital fibromatoses of infancy. We suggest it replaces surgery as first-line treatment but look forward to a large multicentre trial to allow comparison.

Propranolol as first-line treatment for rapidly proliferating infantile haemangiomas.

Infantile haemangioma is the commonest childhood tumour and approximately 10% requires treatment.(1,2) Recent reports have highlighted the impressive efficacy of propranolol in treating rapidly proliferating haemangioma. The aims of our study were to prospectively assess the efficacy of propranolol as a first line treatment for problematic haemangioma, and develop a treatment regime. 31 consecutive patients with rapidly proliferating infantile haemangioma with functional impairment or cosmetic disfigurement were treated with propranolol as a first line treatment. All patients had cardiovascular pre-treatment work-up and commenced on propranolol at 3 mg/kg/day. A rapid halt in haemangioma proliferation was seen in 100% of patients and significant regression in 87% of patients. This treatment is well tolerated and has little side effects. Since this study, our unit has adopted the policy of using propranolol as a first line treatment for all problematic proliferative infantile haemangiomas.