Pharyngeal reconstruction with a modified free alt flap with parastomal fascial wings.

AIM: Previous reports have demonstrated good outcomes with the use of the Anterolateral Thigh Flap (ALT) in pharyngeal reconstruction. We report a new modification of free ALT flap pharyngeal reconstruction utilizing vascularised fascial wings or extensions placed in the parastomal gutters to cover the major neck vessels. PATIENTS AND METHODS: This was a single-center retrospective case review. Between November 2017 and January 2019, 8 patients (6 male, 2 female mean age 61, range 35 to 74) underwent near circumferential pharyngeal reconstruction by the modified technique. 3 patients had laryngopharyngectomy for radiorecurrent larynx SCC, 2 for primary, advanced laryngeal SCC, and 3 for primary hypopharyngeal SCC. RESULTS: All eight patients regained adequate swallow to maintain nutrition without tube-feeding. Two of the patients have been assessed as appropriate for tracheo-esophageal puncture and are awaiting placement. One patient uses an electrolarynx for speech and 5 patients aphonic only. One patient died 2 months after the procedure from chest infection. There were no flap failures, no fistulas and no strictures at one year. One patient who underwent a salvage laryngopharyngectomy experienced parastomal wound dehiscence, but critically there was no return to theater for exposed major vessels and the wound healed within 6 weeks requiring dressings only. CONCLUSION: Here we report outcomes of pharyngeal reconstruction with a modified single perforator free ALT flap using fascial extensions to line the parastomal gutters. In the event of parastomal dehiscence, the placement of vascularized tissue parastomally may facilitate spontaneous healing and prevent major vessel exposure.

Artificial Intelligence in plastic surgery: What is it? Where are we now? What is on the horizon?

INTRODUCTION: An increasing quantity of data is required to guide precision medicine and advance future healthcare practices, but current analytical methods often become overwhelmed. Artificial intelligence (AI) provides a promising solution. Plastic surgery is an innovative surgical specialty expected to implement AI into current and future practices. It is important for all plastic surgeons to understand how AI may affect current and future practice, and to recognise its potential limitations. METHODS: Peer-reviewed published literature and online content were comprehensively reviewed. We report current applications of AI in plastic surgery and possible future applications based on published literature and continuing scientific studies, and detail its potential limitations and ethical considerations. FINDINGS: Current machine learning models using convolutional neural networks can evaluate breast mammography and differentiate benign and malignant tumours as accurately as specialist doctors, and motion sensor surgical instruments can collate real-time data to advise intraoperative technical adjustments. Centralised big data portals are expected to collate large datasets to accelerate understanding of disease pathogeneses and best practices. Information obtained using computer vision could guide intraoperative surgical decisions in unprecedented detail and semi-autonomous surgical systems guided by AI algorithms may enable improved surgical outcomes in low- and middle-income countries. Surgeons must collaborate with computer scientists to ensure that AI algorithms inform clinically relevant health objectives and are interpretable. Ethical concerns such as systematic biases causing non-representative conclusions for under-represented patient groups, patient confidentiality and the limitations of AI based on the quality of data input suggests that AI will accompany the plastic surgeon, rather than replace them.

Single-stage nasal reconstruction with the islanded forehead flap.

BACKGROUND AND PURPOSES: Multi-staged forehead flaps are a well-recognised reconstructive workhorse for subtotal and total nasal defects. It carries the disadvantage of repeated trips to theatre for revisional surgery, which is not suited to all patient cohorts. The single-stage islanded forehead flap eliminates this need. We detail our indications and outcomes of using this flap to highlight the maintained versatility of the technique without significant compromise on reconstructive and patient outcome. SUBJECTS STUDIED AND METHODS: A prospective surgical database was collated where patients were categorised as partial or total reconstruction. We detail surgical technique and review of rationale of patient selection. Patient demographics, perioperative data and follow-up course were recorded. MAIN FINDINGS: A total of 22 patients were recorded from both the U.K. and Ethiopia via working with the charity Facing Africa. Defects occurred from a mixture of trauma, Noma and cancer resections. Thirteen were total nasal reconstructions and nine partial. The mean follow-up period was 2.25 years. We experienced two major complications which required minor revision in the theatre and two minor complications, all resolved satisfactorily. CONCLUSIONS: We demonstrate good outcomes and safety of the procedure in this first report of a varied cohort of nasal reconstructions in a heterogenous cohort of patients. We advocate the use of this flap in the multi-morbid patient where recovery can be expedited or those who have limitations from economical restraints.

Advances in image enhancement for sarcoma surgery.

The recurrence rate of soft tissue and bone sarcomas strongly correlates to the status of the surgical margin after excision, yet excessive removal of tissue may lead to distinct, otherwise avoidable morbidity. Therefore, adequate margination of sarcomas both pre- and intra-operatively is a clinical necessity that has not yet fully been met. Current guidance for soft-tissue sarcomas recommends an ultrasound scan followed by magnetic resonance imaging (MRI). For bone sarcomas, two plane radiographs are required, followed similarly by an MRI scan. The introduction of more precise imaging modalities may reduce the morbidity associated with sarcoma surgery; the PET-CT and PET-MRI approaches in particular demonstrating high clinical efficacy. Despite advancements in the accuracy in pre-operative imaging, translation of an image to surgical margins is difficult, regularly resulting in wider resection margins than required. For soft tissue sarcomas there is currently no standard technique for image guided resections, while for bone sarcomas fluoroscopy may be used, however margins are not easily discernible during the surgical procedure. Near infra-red (NIR) fluorescence guided surgery offers an intra-operative modality through which complete tumour resection with adequate tumour-free margins may be achieved, while simultaneously minimising surgical morbidity. NIR imaging presents a potentially valuable adjunct to sarcoma surgery. Early reports indicate that it may be able to provide the surgeon with helpful information on anatomy, perfusion, lymphatic drainage, tumour margins and metastases. The use of NIR fluorochromes have also been demonstrated to be well tolerated by patients. However, prior to widespread implementation, studies related to cost-effectiveness and the development of protocols are essential. Nevertheless, NIR imaging may become ubiquitous in the future, carrying the potential to transform the surgical management of sarcoma.

Plastic and reconstructive robotic microsurgery--a review of current practices.

INTRODUCTION: We sought to review the current state of robotics in this specialty. METHODS: A Pubmed and Medline search was performed using key search terms for a comprehensive review of the whole cross-section of plastic and reconstructive practice. RESULTS: Overall, 28 publications specific to robotic plastic and reconstructive procedures were suitable for appraisal. CONCLUSION: The current evidence suggests robotics is comparable to standard methods despite its infancy. The possible applications are wide and could translate into superior patient outcomes.

Combined clearance of pelvic and superficial nodes for clinical groin melanoma.

30-44% of patients with clinical groin node melanoma have involved pelvic nodes. Clinical guidelines selectively target pelvic lymph node dissection (PLND) to those meeting radiological and clinico-pathological criteria, but we lack satisfactory diagnostic tools to preoperatively identify patients with pelvic node disease. We evaluate routine PLND for all patients undergoing superficial node dissection (SLND), performed as a combined single-stage ilioinguinal lymph node dissection (ILND). Retrospective analysis of 67 ILNDs in consecutive patients presenting with palpable, cytologically melanocytic groin nodes. We examine predictors of pelvic node status and determine efficacy of 2010 UK guidelines in patient selection for PLND. 28 patients (42%) had histologically positive pelvic nodes; half had just one involved node (53.6%). 43% of pelvic metastases were radiologically occult. Significant predictors of pelvic melanoma were stage N3 groin nodes (p = 0.049), one third of groin nodes involved (p = 0.0009), positive Cloquet's node (p = 0.005), previous in transit disease (p = 0.001), and staging CT (p = 0.007). UK guidelines, primarily reliant upon staging CT, were effective selection criteria (p = 0.04), identifying 57% of pelvic metastases. CT and in-transit disease status in combination was the strongest predictor of pelvic disease (p = 0.006, RR 4.5, PPV 0.75, NPV 0.83). A combined CT and in-transit disease status provides a potentially clinically useful preoperative selection tool for ILND. With a high prevalence of occult pelvic node involvement, potential to avoid the morbidity of untreated pelvic nodes, and 5 year survival figures of 24-35% following surgery, we advocate ILND in all patients with clinically evident melanoma in a single groin node.

Reconstruction of complex oro-facial defects using the myocutaneous sub-mental artery flap.

Oro-facial defects require reconstruction that provides suitable colour match and texture. Moreover inner and outer cheek lining and bulk are key considerations. In cases of severe oro-facial infections concomitant mandibular abnormality, for example trismus, can mandate the need for tissue to obturate mandibular defects. We assessed the use of the myocutaneous sub-mental artery flap (MSA) in non-oncological patients with such defects. Twenty two consecutive patients were included in this case series. All patients were survivors of Cancrum Oris (NOMA). Demographic details, nutritional status and co-morbidities were recorded. Defects were classified according to the tissues destroyed; cheek, mandible, oral cavity, lip(s), nose and eye(s). Simultaneous procedures carried out were recorded. The surgical anatomy of the MSA is described. All patients had composite defects of the cheek and oral cavity plus another local anatomical structure. Adjunct procedures such as trismus release were carried out in 18/22 patients. Four patients required a return to theatre. There was no trismus recurrence observed. No flap losses were incurred. The MSA is a robust flap with minimal incidence of major complications. The MSA negates the need for microsurgical tissue transfer. Furthermore the MSA provides adequate bulk to obturate these defects. Future applications of the MSA may include complex oro-facial oncological defects.

Management of rhinophyma with Versajet™ and ReCell®.

Operation is the mainstay of treatment for rhinophyma. Numerous techniques for dermaplaning and dermabrasion have been described with typical healing times of roughly 3 weeks. We present a case that combined use of the Versajet™ (Smith & Nephew, UK) system with ReCell(®) non-cultured autologous skin cells (Avita Medical, UK) to expedite re-epithelialisation. After sculpting with Versajet™, a 1cm(2) split-thickness skin biopsy specimen was harvested for application of autologous skin. Postoperative pictures at 6 days show well-formed epithelial buds, and at 9 days the nose was fully healed. The application of ReCell(®) hastened healing. This could potentially avoid hypertrophic scars and lessen the number of visits to outpatients for dressing to be changed, rendering it more advantageous than other techniques.

Reconstruction of the irradiated perineum following extended abdomino-perineal excision for cancer: an algorithmic approach.

Our unit has implemented an algorithm for irradiated perineal reconstruction incorporating current evidence and a new technique in line with the advent of laparoscopic tumour excision. Our approach attempts to maintain the benefits patients derive from minimally invasive oncological surgery. Four consecutive patients had uterine retroversion to obturate pelvic deadspace and reconstruct the posterior vaginal wall. Age range was 41-84 years and mean follow-up of 21 months with mean in-patient stay of 7 days. All patients had neoadjuvant radiotherapy or chemoradiation for low rectal/anorectal adenocarcinoma. All patients had laparoscopic Extended APER and contiguous posterior vaginal wall excision and reconstruction with uterine retroversion and z-plasty skin closure. One patient required ultrasound aspiration of a pre-sacral seroma at two months. No patients returned to theatre for major complications. We highlight one minor and no major complications associated with an algorithmic approach incorporating our method of uterine retroversion and z-plasty parallel to traditional flap reconstruction methods.

The anatomy of the subscapular nerves: a new nomenclature.

We propose a new nomenclature for the consistent, additional nerves that branch from the posterior cord of the brachial plexus. We hope this will aid the plexus surgeon and the evolution of plexus reconstruction for both obstetric and adult cases of injury.

The lobular transposition flap: a useful adjunct to reconstruct helical defects.

We detail our adjunct to Antia and Buch's chondrocutaneous advancement flap for helical reconstruction. It is simple, reliable and negates the need for transfer of the defect to the lobule and/or V-Y advancement of the helical crus.