An analysis of the cosmetic surgery experience acquired through UK plastic surgery training.

AIMS: Cosmetic surgery is an essential component of Plastic Surgery training. Our study demonstrates the average cosmetic surgery experience of UK Plastic Surgery registrars over their 6-year training scheme. Comparison is made with the operative requirements for the Certificate of Completion of Training (CCT) and the Royal College of Surgeons (RCS) Cosmetic Certification scheme. METHODS: By using the web-based eLogbook, we analysed all the cosmetic surgery operations recorded by Plastic Surgery registrars during their specialist training. The weighted mean average number of procedures was calculated for different areas of cosmetic surgery practice, according to the level of supervision. The number of RCS cosmetic credits acquired for eight domains of cosmetic surgery was calculated, thus enabling comparison with the operative requirements for certification. RESULTS: eLogbook data were collated for 454 registrars from 2010 to 2016 inclusive. Trainees participated in a mean of 122 cosmetic operations during their training (50% as an assistant), which satisfies the requirement of 100 procedures for CCT. The majority of trainee involvement (66%) was with cosmetic breast and body contouring cases. Comparison with the criteria for cosmetic certification reveals that on average, trainees could certify in cosmetic breast and body contouring surgery but would be unable to accredit in other areas of practice. CONCLUSIONS: Current UK training affords sufficient cosmetic surgery exposure for CCT but offers a limited breadth of exposure. Trainees who wish to certify in cosmetic surgery of the head and neck region will likely be required to seek additional experience outside their deanery training programme.

Sentinel lymph node biopsy in melanoma: Which hot nodes should be harvested and is blue dye really necessary?

OBJECTIVES: The '10% rule' has become widely accepted by surgeons performing sentinel lymph node biopsy (SLNB) for melanoma. The purpose of this study was to compare the '10% rule' with alternative node harvesting criteria. In particular, we were interested to see whether the use of blue dye had any impact on the sensitivity of the test and whether it is necessary to remove all hot nodes. METHODS: We reviewed 537 SLNBs performed for primary melanoma from 2009-2015. SLNB was offered to all patients with 1-4 mm Breslow thickness melanoma and sentinel nodes were harvested according to the '10% rule'. RESULTS: One hundred sixteen patients (22%) had at least one positive sentinel node and there were 45 positive nodal basins from which more than one sentinel node had been harvested. Excluding blue dye and sampling only hot nodes would have enabled a 5% reduction in nodes harvested, without any compromise in the sensitivity of the test. However, applying harvesting criteria whereby not all hot nodes are taken was associated with a loss of sensitivity, with positive sentinel nodes being missed and patients understaged. CONCLUSIONS: Our data do not support the continued use of blue dye in SLNB for melanoma, as it does not improve the sensitivity of the test. This series adds to growing evidence, suggesting that the '10% rule' with the inclusion of blue nodes should be reconsidered and that radiocolloid tracer alone is sufficient for sentinel node localisation.

The rectus abdominis muscle advancement flap as a salvage option for chest wall reconstruction.

We describe a previously unreported technique of advancing the rectus abdominis muscle superiorly, based on the deep inferior epigastric artery, to cover a lower anterior chest wall defect. This technique represents an important salvage option for chest wall reconstruction and affords a great deal of intra-operative flexibility.

The gluteal fold flap: a versatile option for perineal reconstruction following anorectal cancer resection.

INTRODUCTION: Gluteal fold flaps (GFFs) have been extensively reported for vulvo-vaginal reconstruction but there are no published series of their use for perineal reconstruction following anorectal cancer excision. In this context, abdominal myocutaneous flaps remain the method of choice but may be unavailable because of pre-existing abdominal scars, or need for a colostomy/urostomy. In addition, their abdominal wall morbidity makes them less acceptable, especially given the increasing use of laparoscopic techniques for the extirpative surgery. We document our experience using GFFs following radical anorectal cancer excision. METHODS: Data were collected from a single surgeon's consecutive cases performed over a five-year period (October 2007-May 2012). The indication, surgical procedure, complications and follow-up were recorded, as was the incidence of neoadjuvant/adjuvant therapy. RESULTS: Ten gluteal fold fasciocutaneous flaps were performed in seven patients at the time of radical anorectal excision. The GFFs were performed alone (unilateral n=3, bilateral n=3) or in combination with a contralateral anterolateral thigh (ALT) myocutaneous flap (n=1). The indications for anorectal excision were rectal adenocarcinoma (n=3), anal squamous cell carcinoma (n=3) and anal adenocarcinoma (n=1). All flaps survived completely although two patients required further surgery, one for evacuation of a late donor site haematoma and another to close a small, persistent wound dehiscence. The mean follow-up period was 24 months (range 2-57). CONCLUSIONS: The GFF is a reliable, versatile and robust option for perineal reconstruction after extended anorectal excision, despite local irradiation, and should be considered for medium and selected large defects in this context.