Refinement of the Superomedial Pedicle Technique: A New Approach to Breast Reshaping Following Reduction.

INTRODUCTION: We present an alteration of the superomedial pedicle technique in breast reduction to control lateral fullness and create a more natural and contoured breast during reshaping. This approach has been adopted by the senior author (NC) in 79 patients over the past 4 years. METHODS: A wise pattern skin incision is used, and the nipple-areola complex (NAC) is maintained on a de-epithelialized superomedial pedicle. Instead of fully releasing the pedicle from the lateral parenchyma for rotation and inset, a bridge of tissue between the pedicle on its most posterior aspect and the lateral pillar is maintained. Key holding sutures are subsequently placed in Scarpa's fascia for reshaping. RESULTS: We find that with this refinement, the connection with the lateral pillar pulls the lateral parenchyma medially and superiorly when the pedicle is rotated into its new position, adding a natural curve to the side. The superior medial pedicle is still attached in its postero-lateral aspect to the lateral pillar and theoretically, will provide an even more robust vascular supply to the NAC. In our series, three patients developed minor skin healing issues amenable to treatment with dressings. No one suffered from nipple loss or other serious complications, and no dog ear revisions were required. CONCLUSIONS: We present a simple alteration of the superomedial pedicle technique that we believe results in improved breast contouring. Our experience suggests that this simple adaptation is safe, effective, and reproducible. LEVEL OF EVIDENCE IV: 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 .

Association of Complex Lymphatic Drainage in Head and Neck Cutaneous Melanoma With Sentinel Lymph Node Biopsy Outcomes: A Cohort Study and Literature Review.

Importance: Although sentinel lymph node biopsy (SLNB) is a vital staging tool, its application in head and neck melanoma (HNM) is complicated by a higher false-negative rate (FNR) compared with other regions. This may be due to the complex lymphatic drainage in the head and neck. Objective: To compare the accuracy, prognostic value, and long-term outcomes of SLNB in HNM with melanoma from the trunk and limb, focusing on the lymphatic drainage pattern. Design, Setting, and Participants: This cohort observational study at a single UK University cancer center included all patients with primary cutaneous melanoma undergoing SLNB between 2010 to 2020. Data analysis was conducted during December 2022. Exposures: Primary cutaneous melanoma undergoing SLNB between 2010 to 2020. Main Outcomes and Measures: This cohort study compared the FNR (defined as the ratio between false-negative results and the sum of false-negative and true-positive results) and false omission rate (defined as the ratio between false-negative results and the sum of false-negative and true-negative results) for SLNB stratified by 3 body regions (HNM, limb, and trunk). Kaplan-Meier survival analysis was used to compare recurrence-free survival (RFS) and melanoma-specific survival (MSS). Comparative analysis of detected lymph nodes on lymphoscintigraphy (LSG) and SLNB was performed by quantifying lymphatic drainage patterns by number of nodes and lymph node basins. Multivariable Cox proportional hazards regression identified independent risk factors. Results: Overall, 1080 patients were included (552 [51.1%] men, 528 [48.9%] women; median age at diagnosis 59.8 years), with a median (IQR) follow-up 4.8 (IQR, 2.7-7.2) years. Head and neck melanoma had a higher median age at diagnosis (66.2 years) and higher Breslow thickness (2.2 mm). The FNR was highest in HNM (34.5% vs 14.8% trunk or 10.4% limb, respectively). Similarly, the false omission rate was 7.8% in HNM compared with 5.7% trunk or 3.0% limbs. The MSS was no different (HR, 0.81; 95% CI, 0.43-1.53), but RFS was lower in HNM (HR, 0.55; 95% CI, 0.36-0.85). On LSG, patients with HNM had the highest proportion of multiple hotspots (28.6% with ≥3 hotspots vs 23.2% trunk and 7.2% limbs). The RFS was lower for patients with HNM with 3 or more affected lymph nodes found on LSG than those with fewer than 3 affected lymph nodes (HR, 0.37; 95% CI, 0.18-0.77). Cox regression analysis showed head and neck location to be an independent risk factor for RFS (HR, 1.60; 95% CI, 1.01-2.50), but not for MSS (HR, 0.80; 95% CI, 0.35-1.71). Conclusions and Relevance: This cohort study found higher rates of complex lymphatic drainage, FNR, and regional recurrence in HNM compared with other body sites on long-term follow-up. We advocate considering surveillance imaging for HNM for high-risk melanomas irrespective of sentinel lymph node status.

Karyopherin abnormalities in neurodegenerative proteinopathies.

Neurodegenerative proteinopathies are characterized by progressive cell loss that is preceded by the mislocalization and aberrant accumulation of proteins prone to aggregation. Despite their different physiological functions, disease-related proteins like tau, α-synuclein, TAR DNA binding protein-43, fused in sarcoma and mutant huntingtin, all share low complexity regions that can mediate their liquid-liquid phase transitions. The proteins' phase transitions can range from native monomers to soluble oligomers, liquid droplets and further to irreversible, often-mislocalized aggregates that characterize the stages and severity of neurodegenerative diseases. Recent advances into the underlying pathogenic mechanisms have associated mislocalization and aberrant accumulation of disease-related proteins with defective nucleocytoplasmic transport and its mediators called karyopherins. These studies identify karyopherin abnormalities in amyotrophic lateral sclerosis, frontotemporal dementia, Alzheimer's disease, and synucleinopathies including Parkinson's disease and dementia with Lewy bodies, that range from altered expression levels to the subcellular mislocalization and aggregation of karyopherin α and ß proteins. The reported findings reveal that in addition to their classical function in nuclear import and export, karyopherins can also act as chaperones by shielding aggregation-prone proteins against misfolding, accumulation and irreversible phase-transition into insoluble aggregates. Karyopherin abnormalities can, therefore, be both the cause and consequence of protein mislocalization and aggregate formation in degenerative proteinopathies. The resulting vicious feedback cycle of karyopherin pathology and proteinopathy identifies karyopherin abnormalities as a common denominator of onset and progression of neurodegenerative disease. Pharmacological targeting of karyopherins, already in clinical trials as therapeutic intervention targeting cancers such as glioblastoma and viral infections like COVID-19, may therefore represent a promising new avenue for disease-modifying treatments in neurodegenerative proteinopathies.

Postgraduate Assessment Approaches Across Surgical Specialties: A Systematic Review of the Published Evidence.

PURPOSE: Ensuring competence for surgical trainees requires holistic assessment of the qualities and competencies necessary to practice safely and effectively. To determine the next steps toward achieving this aim, the authors conducted a systematic review to summarize and appraise the available evidence related to any assessment approach to postgraduate surgical training and to identify the dominant themes for assessment approaches across different specialties or countries. METHOD: Medline and Embase were searched on January 10, 2019, without language or time restrictions. Any peer-reviewed study that described an assessment framework (in practice or novel) throughout postgraduate surgical training globally was included. An iterative review and thematic analysis were performed on full-text articles to determine assessment themes. Studies were then grouped by assessment themes. A tailored quality assessment of the studies included in the final analysis was conducted. Assessment themes and validity were compared across surgical specialties and countries. RESULTS: From an initial 7,059 articles, 91 studies (evaluating 6,563 surgical trainees) were included in the final analysis. Ten defined assessment themes were extracted. Ten studies (11.0%) were deemed low risk of bias based on the quality assessment tool used and thus were determined to be high quality. Minor differences in assessment themes were observed between specialties and countries. Assessment themes neglected by individual surgical specialties and assessment themes that need validated assessment tools were identified. CONCLUSIONS: This review highlights the low quality of evidence and fragmented efforts to develop and optimize surgical assessments. The minor differences observed demonstrate a common approach, globally and across specialties, related to surgical assessments. A paradigm shift in assessment approaches, which will require national and international collaboration, is required to optimize design and validation so that a comprehensive assessment of surgical competence can be implemented.

Undergraduate plastic surgery in the United Kingdom: The students' perspective.

Plastic Surgery is consistently ranked as one of the most competitive for higher surgical training in the United Kingdom. With falling rates of undergraduate Plastic Surgery education there is a danger that potentially excellent candidates will be deterred from applying for training positions. We sought to investigate a cohort of UK medical students with an established interest in Plastic Surgery regarding the factors that influence their interest in the specialty. A cross-sectional study design was used with questionnaires distributed to medical students attending the BAPRAS Undergraduate Day in London and Glasgow University Plastics Undergraduate National Conference in 2019. The questionnaire included factors attracting and deterring them from a career in Plastic Surgery, alongside their undergraduate exposure to the specialty and suggestions on how it could be improved. The most common factors attracting students to a career in Plastic Surgery were variety (25%), surgical intricacy (15%) and immediate effect on patient quality of life (12%). The most common factors deterring students from a Plastic Surgery career were a competitive national selection process (41%), work-life balance (15%) and length of training (12%). As 47% of students had not received undergraduate education in Plastic Surgery, their perceptions of the specialty will be likely be influenced from external, often negative, sources such as television and other media. To safeguard the future Plastic Surgery workforce, universities should collaborate with local departments and professional bodies to meet the needs of medical students for undergraduate exposure through mentorship, workshops, taster days and clinical placements.

A retrospective comparison of 3M™ Micropore™ with other common dressings in cosmetic breast surgery.

BACKGROUND: Surgical site infection has considerable cost implications for healthcare providers. Evidence suggests that the use of Micropore™ tape as a dressing for surgical incisions may be associated with reduced/comparable rates of infection in surgical wounds. 3M™ Micropore™ tape is significantly cheaper than conventional wound dressings. The purpose of this study was to compare differences in the rate of wound healing problems including superficial incisional surgical site infection (SSI) and wound healing problems following cosmetic breast procedures between Micropore™ tape and other common wound dressings. METHODS: A clinical database was utilised to identify all patients undergoing elective breast surgery at a UK private cosmetic surgery group between May and November 2017. The patients were divided into 2 groups: those whose wounds were dressed with 3M™ Micropore™ tape post-operatively and those dressed with other common wound dressings. Data was analysed to assess the prevalence of post-operative wound healing problems (superficial incisional surgical site infection and delayed wound healing) in each group. RESULTS: 1216 patients were identified in our database, 659 patients receiving Micropore™ and 557 patients receiving conventional wound dressings. The overall prevalence of wound healing problems in the Micropore™ tape and conventional wound dressing group were 12% and 10% respectively, with no statistical difference (p = 0.3913). There was no statistical significance between the use of antibiotics and prevalence of wound healing problems in either group. CONCLUSION: The results of our study suggest that there is no difference between the use of Micropore™ tape and other conventional wound dressings in the prevalence of post-operative wound healing problems in cosmetic breast surgery. Our findings support the routine use of Micropore™ tape in post-operative dressing for clean, non-contaminated, directly closed, elective surgical wounds. We suggest a larger scale, prospective, randomized study should be conducted to confirm these initial findings.

Increasing motivation and engagement in neurosurgery for medical students through practical simulation-based learning.

BACKGROUND: Simulation-based learning (SBL) is an essential adjunct to modern surgical education. Our study aimed to evaluate the educational benefit and motivational impact of a pilot practical neurosurgical module. MATERIALS AND METHODS: 38 clinical medical students from several EU Medical Schools attended an international surgical course focused on teaching and learning basic surgical skills. We designed a pilot neurosurgical workshop instructing students to insert an intracranial pressure bolt using an ex vivo pig model. Each delegate was assessed by two consultant neurosurgeons using a validated assessment tool. Structured questionnaires were distributed on completion of the module. RESULTS: Delegate performance increased (p < 0.001) with no difference in performance improvement across year of study (p = 0.676) or medical school (p = 0.647). All delegates perceived this workshop as a potential addition to their education (median 5/5, IQR = 0), and indicated that the course provided motivational value towards a neurosurgical career (median 4/5, IQR = 1), with no difference seen between year of study or medical school (p > 0.05). CONCLUSION: Our pilot neurosurgical workshop demonstrated the educational value of practical SBL learning for motivating students towards a surgical career. Homogeneous views across year of study and medical school underline the value of developing a unified strategy to develop and standardise undergraduate surgical teaching with a practical focus.

Hands train the brain-what is the role of hand tremor and anxiety in undergraduate microsurgical skills?

INTRODUCTION: Physiological hand tremor occurs naturally, due to oscillations of the upper extremities. Tremor can be exacerbated by stress and anxiety, interfering with fine motor tasks and potentially impact on surgical performance, particularly in microsurgery. We investigated the link between tremor, anxiety and performance in a neurosurgical module as part of an international surgical course. METHODS: Essential Skills in the Management of Surgical Cases (ESMSC) course recruits medical students from European Union (EU) medical schools. Students are asked to suture the dura mater in an ex vivo swine model, of which the first suture completed was assessed. Questionnaires were distributed before and after the module, eliciting tremor risk factors, self-perception of tremor and anxiety. Johnson O'Connor dexterity pad was used to objectively measure dexterity. Direct Observation of Procedural Skills (DOPS) was used to assess skills-based performance. Anxiety was assessed using the Westside Test Anxiety Scale (WTAS). Tremor was evaluated by four qualified neurosurgeons. RESULTS: Forty delegates participated in the study. Overall performance decreased with greater subjective perception of anxiety (p = 0.032, rho = - 0.392). Although increasing scores for tremor at rest and overall WTAS score were associated with decreased performance, this was not statistically significant (p > 0.05). Tremor at rest did not affect dexterity (p = 0.876, rho = - 0.027). CONCLUSIONS: Physiological tremor did not affect student performance and microsurgical dexterity in a simulation-based environment. Self-perception of anxiety affected performance in this module, suggesting that more confident students perform better in a simulated neurosurgical setting.

Reflecting on the Germanwings Disaster: A Systematic Review of Depression and Suicide in Commercial Airline Pilots.

BACKGROUND: The 2015 Germanwings Flight 9525 disaster, in which 150 people were killed after the co-pilot may have intentionally crashed the plane in a suicide attempt, highlights the importance of better understanding the mental health of commercial airline pilots. However, there have been few systematic reviews investigating the topic of mental health in commercial aviation. This systematic review aims to identify the types and prevalence of mental health disorders that commercial airline pilots experience with a focus on mood disorders and suicide risk. METHODS: A systematic literature search was performed using PubMed, EMBASE, and PsycINFO databases. Eligible studies were assessed and data was extracted and analyzed. RESULTS: 20 studies were identified. The prevalence of depression experienced by commercial airline pilots in this review ranged from 1.9% to 12.6%. Factors that negatively impacted the mental health of pilots included substance abuse, experiencing verbal or sexual abuse, disruption in sleep circadian rhythms and fatigue. DISCUSSION: This systematic review identifies that commercial airline pilots may experience depression at least as frequently as the general population. Commercial airline pilots experience occupational stressors, such as disrupted circadian rhythms and fatigue which may increase risks of developing mood disorders. Most studies identified in this review were cross-sectional in nature with substantial limitations. There is a clear need for further higher quality longitudinal studies to better understand the mental health of commercial airline pilots.