HoloLens in Breast Reconstruction: What Is the Future?

SUMMARY: Autologous breast reconstruction using the deep inferior epigastric perforator flap has been established as the standard for perforator-based free-flap breast reconstruction. This technique relies on the surgeon's ability to identify the patient's relevant abdominal vasculature to facilitate accurate dissection, optimize surgical outcomes, and minimize morbidity. A technique is described in which the authors incorporate augmented reality using HoloLens technology in their surgical planning to identify epigastric arteries and perforators. This technology allows the surgeon to superimpose computed tomography angiography images directly onto the patient, facilitating an in vivo appreciation of underlying anatomy before incision and dissection. This allows real-time surgical planning, increasing the value and tangibility of preoperative computed tomography angiography with the potential to enhance the accuracy and efficiency of the operative technique. Although the authors did not use the HoloLens technology to make clinical decisions, they provide evidence of its accuracy and ease of use, offering a proof of concept. The potential of this technology is demonstrated, and the authors encourage future application in free-flap breast reconstruction and beyond.

Osteofibrous dysplasia of the tibia : the importance of deformity in surveillance.

AIMS: Osteofibrous dysplasia (OFD) is a rare benign lesion predominantly affecting the tibia in children. Its potential link to adamantinoma has influenced management. This international case series reviews the presentation of OFD and management approaches to improve our understanding of OFD. METHODS: A retrospective review at three paediatric tertiary centres identified 101 cases of tibial OFD in 99 patients. The clinical records, radiological images, and histology were analyzed. RESULTS: Mean age at presentation was 13.5 years (SD 12.4), and mean follow-up was 5.65 years (SD 5.51). At latest review, 62 lesions (61.4%) were in skeletally mature patients. The most common site of the tibial lesion was the anterior (76 lesions, 75.2%) cortex (63 lesions, 62.4%) of the middle third (52 lesions, 51.5%). Pain, swelling, and fracture were common presentations. Overall, 41 lesions (40.6%) presented with radiological deformity (> 10°): apex anterior in 97.6%. A total of 41 lesions (40.6%) were treated conservatively. Anterior bowing < 10° at presentation was found to be related to successful conservative management of OFD (p = 0.013, multivariable logistic regression). Intralesional excision was performed in 43 lesions (42.6%) and a wide excision of the lesion in 19 (18.8%). A high complication rate and surgical burden was found in those that underwent a wide excision regardless of technique employed. There was progression/recurrence in nine lesions (8.9%) but statistical analysis found no predictive factors. No OFD lesion transformed to adamantinoma. CONCLUSION: This study confirms OFD to be a benign bone condition with low rates of local progression and without malignant transformation. It is important to distinguish OFD from adamantinoma by a histological diagnosis. Focus should be on angular deformity, monitored with full-length tibial radiographs. Surgery is indicated in symptomatic patients and predicted by the severity of the initial angular deformity. Surgery should focus more on the deformity rather than the lesion. Cite this article: Bone Joint J 2022;104-B(2):302-308.

Does the development and implementation of a procedure-specific proforma for skin lesion surgery improve quality of operation notes?

BACKGROUND: Operation notes often have omissions and are difficult to locate in patients notes despite clear guidance from the Royal College of Surgeons (RCS) 'Good Surgical Practice' 2014 outlining what should be included in operation notes. Procedure-specific proformas are rarely used by Plastic surgeons despite being utilised by other specialities. With an alarming rise of incidence of skin malignancies there has been an increase in the number of skin lesions referred to Plastic surgeons for excision. The need for reliable, reproducible, accurate and easily accessible operating notes for skin lesion excision is pivotal for continuity of care and treatment planning. This study aimed at comparing the quality of skin lesion operation notes prior-to and after implementation of a procedure-specific proforma in relation to RCS recommendations. METHODS: Fourteen parameters from the recommendations by the RCS 'Good Surgical Practice' 2014 guidelines were used to audit skin lesion operation notes. The study consisted of a retrospective audit of 80 operation notes and a prospective audit of 80 operation notes following the development and implementation of a skin lesion procedure-specific proforma. We assessed and compared the operation notes overall compliance with the RCS guidelines. Statistical analysis highlighting the difference between both groups was performed using the independent sample t-test. RESULTS: After implementation of the skin lesion procedure-specific proforma, the average compliance with the RCS recommendations increased significantly from 87.5% retrospectively to 98.8% prospectively (p-value 0.0414). In 6 of the 14 parameters assessed significant improvements with regards compliance to the guidelines was demonstrated. CONCLUSION: The development and implementation of a skin lesion procedure-specific proforma has demonstrated a significant improvement in the quality of operation notes within a Plastic surgery department which has the potential to minimise omissions and improve continuity of surgical patient care.

Virtual teaching during the COVID-19 pandemic.

Disruption of services has resulted in a profound knock-on effect for plastic surgery trainees, with limited training opportunities available. The emergence and increased engagement with novel surgical technologies including Augmented and Virtual reality simulation represents an essential adjunct to mitigate limited training opportunities, though is in itself necessary but not sufficient for plastic surgery training. "Hands-on" experience remains important, but simulation may help to bridge the important gap between theory and practice. With the likely future pervasive nature of technology in training, important consideration must be given to both security and consent, which should be at the forefront of developers minds at the earliest possible stage.