A retrospective cohort study of cutaneous squamous cell carcinoma of the scalp: features of disease and influence of sociodemographic factors on outcomes.

BACKGROUND: Cutaneous squamous cell carcinoma (SCC) is an increasingly prevalent and potentially fatal disease with considerable implications if not recognized early and treated promptly. Several disease features contribute to a higher risk profile and adverse outcomes in affected patients. AIMS: Given the clinical observation that elderly males from rural communities often present with large SCCs of the scalp, we sought to investigate and describe features of disease and sociodemographic factors from a cohort of patients with scalp SCCs. METHODS: Histology reports of scalp primary SCCs were retrospectively assessed. Disease and demographic features were recorded. Descriptive statistics were generated, and statistical analyses (Fisher's exact, Mann-Whitney U and Spearman's rank test) were utilized to examine relationships between high-risk disease features and sociodemographic features. RESULTS: Ninety-three occurrences of scalp SCC in 61 patients were assessed. The average age at presentation was 78.81 years. Males were predominantly affected at a 14:1 ratio. Half of all tumours were greater than 2 cm (47/93 (50.54%)). The geographical distance from treatment was significantly associated with larger tumours at presentation. (rs = .34 P = 0.002). Recurrence and metastasis rates were determined amongst 188 patients with a primary scalp SCC, and low rates were observed (2.66% and 2.13%, respectively). CONCLUSIONS: Elderly males are inordinately affected by scalp SCC compared to females. Those living further from care exhibited larger tumours at presentation. Data from this study characterize features of SCC of the scalp and provide evidence to suggest that rural isolation may act as a mediator of high-risk presentation and larger tumour size.

Levels of Evidence in Plastic and Reconstructive Surgery Research: Have We Improved Over the Past 10 Years?

Levels of evidence (LOE) aid in the critical appraisal of evidence by ranking studies based on limitation of its design. Analyzing LOE provides insight into application of evidence-based medicine. The aim of this study is to determine if the quality of evidence in plastic surgery research has improved over the past 10 years. Systematic review of research published in Plastics and Reconstructive Surgery journal over the years, 10-year period (2008, 2013, 2018), was performed. LOE for each article was determined using the American Society of Plastic Surgeons (ASPS) guidelines. Each level was calculated as percentage of publications per year and compared yearly and between different topics. Eight hundred eighty-four studies were included in the final analysis. The LOE of the research improved over the study period. Level 4 evidence was the most frequent published (50.6%, 447/884), with a decline from 63.2% in 2008 to 41.3% in 2018. Level 1 evidence improved each year and accounted for 2.1% of all research in 2018. Aesthetic surgery was the most frequent published topic with upper limb research demonstrating an 18.5% increase in high-quality evidence over the study period. Increased awareness of evidence-based medicine has improved the quality of plastic surgery research over the past decade. It is vital this continues to provide gold standard patient care.

Botulinum Toxin Treatment for Mild to Moderate Platysma Bands: A Systematic Review of Efficacy, Safety, and Injection Technique.

Background: Platysma bands are characteristic of an aging neck. Resection and plication of the platysma muscle is the basis of treatment. However, unfavorable surgical outcomes and improved understanding of platysma band etiology have shifted treatment towards nonsurgical rejuvenation. Objectives: The aim of this paper was to assess the efficacy, injection techniques, and complications associated with botulinum toxin injection for the treatment of platysma bands. Methods: A systematic literature search was performed to identify articles reporting botulinum toxin injections for platysma bands in neck rejuvenation. The search included published articles in three electronic databases-Ovid MEDLINE, EMBASE, and the Cochrane Library-between January 1985 and December 2017. Results: Three studies met the inclusion criteria, with a total of 78 patients undergoing botulinum toxin injection for platysma bands. Incobotulinumtoxin A was used in 62.3% (n = 45/78) of patients, with 38.4% (n = 30/78) receiving abobotulinumtoxin A. Efficacy was assessed using the Merz platysma score scale. A mean score improvement of 2.0 points, with a response rate of 93.7%, was observed after 14 ± 2 days. At 3 months, the mean score improvement was 1.2 points with a response rate of 86%. Patient-reported metrics demonstrated an improvement in 91% (n = 71/78) of subjects. The three studies used a standard injection technique, with a maximum 20 IU of incobotulinumtoxin A and 5 U abobotulinumtoxin A administered per band. Complications were reported in 15.4% (n = 12/78) of patients, with none requiring further intervention. Conclusions: Botulinum toxin is a highly effective treatment for isolated platysma bands. A safe injection technique is described and recommended for clinical practice.

Trapezius flaps for reconstruction of head and neck defects following oncological resection - A systematic review.

OBJECTIVE: Head and neck (H&N) reconstruction after cancer resection is challenging. Myocutaneous trapezius flaps provide an alternative reconstruction for patients not suitable for microvascular free tissue transfer. METHODS: A systematic review was performed on studies involving trapezius flaps for H&N reconstruction post oncological resection between the years 1985-2015. Data extracted included patient numbers and demographics, operative technique and complications. Complication rates, for the study cohort, were calculated and a univariate analysis was preformed evaluating patient and flap-related risk factors. RESULTS: Seventeen studies met the inclusion criteria, with a total of 157 trapezius flaps. Intraoral defects were the most frequent recipient site (74.5%). The mean skin paddle width was 6.84 cm (range 3-15 cm) and length was 11.1 cm (range 4-25 cm). Type 2 (superficial branch of transverse cervical artery) accounted for 77.1% (118/153) of all trapezius flaps performed. The complication rate was 15.9%, with 15 reported flap related and 7 donor site complications. Skin paddle size, pedicle selection, primary versus salvage reconstruction and radiotherapy were not identified risk factors for complications. CONCLUSION: Trapezius flaps are a reliable and versatile myocutaneous flap for both primary and salvage surgery reconstruction of H&N defects following oncological resection.

ASCOT: Autologous Bone Marrow Stem Cell Use for Osteoarthritis of the Thumb-First Carpometacarpal Joint.

BACKGROUND: The first carpometacarpal joint (CMCJ) in the hand is a commonly affected joint by osteoarthritis. It causes significant thumb base pain, limiting functional capacity. Microfracturing and application of autologous stem cells has been performed on large joints such as the knee but has never been evaluated for use in the smaller joints in the hand. Our aim was to determine the potential benefit of microfracturing and autologous bone marrow stem cells for treatment of osteoarthritis of the first CMCJ in the hand. METHODS: All inclusion criteria were satisfied. Preoperative assessment by the surgeon, physiotherapist, and occupational therapist was performed. The first CMCJ was microfractured and the Bone Marrow Stem Cells were applied directly. Postoperatively, the patients were followed up for 1 year. RESULTS: Fifteen patients met inclusion criteria; however, 2 patients were excluded due to postoperative cellulitis and diagnosis of De Quervain's tenosynovitis. The mean scores of the 13-patient preoperative and 1 year follow-up assessments are visual analog score at rest of 3.23-1.69 (P = 0.0292), visual analog score on activity of 7.92-4.23 (P = 0.0019), range of motion 45.77o-55.15o (P = 0.0195), thumb opposition score 7.62-9.23 (P = 0.0154), Disability of the Arm, Shoulder and Hand score of 51.67-23.08 (P = 0.0065). Strength improved insignificantly from 4.7 kg preoperatively to 5.53 kg at 12 months (P = 0.1257). All patients had a positive Grind test preoperatively and a negative test after 12 months. CONCLUSIONS: This innovative pilot study is a new approach to osteoarthritis of the thumb.

Tumor Margin Assessment With Loupe Magnification Enables Greater Histological Clearance of Facial Basal Cell Carcinomas Compared With Clinical Examination Alone.

BACKGROUND: Surgical excision of facial basal cell carcinomas (BCCs) is a balance between oncological clearance and conservation of cosmetic and functionally sensitive tissues. OBJECTIVE: To assess if loupe magnification (LM) can enhance the visual assessment of BCC tumor margins resulting in a greater histological clearance. MATERIALS AND METHODS: This prospective study randomized patients with primary facial BCCs into preoperative tumor margin assessment with LM (study group) or clinical examination alone (control group). Basal cell carcinomas were excised with a predetermined surgical margin of either 2, 3,, or 4 mm. Mean histological margin, incomplete excision rate, and method of closure were recorded and compared between LM and control groups, across a range of surgical margins. RESULTS: Ninety-four BCCs were excised from 93 patients, 47 BCCs in each group. The mean histological margin was larger in the study versus control group for each group (2-mm margin, 1.8 vs 1.4, 3-mm margin, 2.4 vs 2.3, 4-mm margin, and 3.1 vs 2.7), but only statistically significant in the 4-mm group (p = .032). There was no difference in method of closure between LM and control groups. CONCLUSION: Loupe magnification improved tumor margin assessment for facial BCC enabling a greater diameter of histological clearance. The use of LM should become a standard practice for facial BCC excision.

Patient awareness and sun protection behaviour following excision of basal cell carcinoma.

BACKGROUND: Limited information is available regarding disease awareness and sun protection behaviour in patients previously treated for non-melanoma skin cancer. METHODS: Using a telephone-administered questionnaire, we investigated these characteristics in 250 patients in the west of Ireland who had undergone excision of basal cell carcinomas between January 2011 and December 2012. RESULTS: Only 28.8% of respondents knew that the lesion they had excised was a BCC and understood that there was a significant chance of developing another similar lesion in the next 3 years. Women and patients under age 65 were significantly better informed about their diagnosis than men (p = 0.021 and 0.000 respectively). The majority of patients (71.2%) knew that the overall effect of UV radiation on the skin was harmful and did employ some form of sun protection (avoid midday sun 72%; stay in shade 74%; wear hat 73.6%; wear sunscreen 72.8%). Females were statistically more likely to exercise better sun-protection behaviour (p = 0.002). While 76.8% of patients undertook some form of outdoor activity every day, only 22.8% wore sunscreen every day. CONCLUSIONS: Greater efforts should be made to communicate disease details and sun protection implications associated with basal cell carcinoma, especially to male patients. Improved population specific skin cancer awareness may lead to earlier detection and thus decrease both the patient morbidity and economic burden associated with locally advanced basal cell carcinoma.

Trends in the Level of Evidence in Clinical Hand Surgery Research.

BACKGROUND: The application of evidence-based medicine (EBM) to the practice of hand surgery has been limited. Production of high-quality research is an integral component of EBM. With considerable improvements in the quality evidence in both orthopedic and plastic and reconstructive surgery, it is imperative that hand surgery research emulates this trend. METHODS: A systematic review was performed on all hand surgery articles published in 6 journals over a 20-year period. The journals included Plastic and Reconstruction Surgery, Journal of Plastic, Reconstructive and Aesthetic Surgery, Journal of Hand Surgery-European Volume, Journal of Hand Surgery-American Volume, Journal of Bone & Joint Surgery, and the Bone & Joint Journal. The level of evidence of each article was determined using the Oxford level of evidence. The quality of methodology of randomized controlled trials (RCTs) was assessed using Jadad scale. Statistical analysis involved chi-squares and Student t test (P < .05). RESULTS: A total of 972 original hand surgery research articles were reviewed. There was a significant increase in the average level of evidence of articles published between1993 and 2013. High-quality evidence only accounted for 11.2% of evidence published, with a significant increase over the study period (P = 0.001). Quantitative evaluation of the 26 published RCTs, using Jadad scale, revealed a progressive improvement in study design from 0.3 in 1993 to 3.33 in 2013. CONCLUSIONS: Hand surgery research has mirrored trends seen in other surgical specialties, with a significant increase in quality of evidence over time. Yet, high-quality evidence still remains infrequent.

Current practice patterns of drain usage amongst UK and Irish surgeons performing bilateral breast reductions: Evidence down the drain.

INTRODUCTION: Bilateral breast reduction (BBR) is one of the most frequently performed female breast operations. Despite no evidence supporting efficacy of drain usage in BBRs, postoperative insertion is common. Recent high quality evidence demonstrating potential harm from drain use has subsequently challenged this traditional practice. The aim of this study is to assess the current practice patterns of drains usage by Plastic & Reconstructive and Breast Surgeons in UK and Ireland performing BBRs. METHOD: An 18 question survey was created evaluating various aspects of BBR practice. UK and Irish Plastic & Reconstructive and Breast Surgeons were invited to participate by an email containing a link to a web-based survey. Statistical analysis was performed with student t-test and chi-square test. RESULTS: Two hundred and eleven responding surgeons were analysed, including 80.1% (171/211) Plastic Surgeons and 18.9% (40/211) Breast Surgeons. Of the responding surgeons, 71.6% (151/211) routinely inserted postoperative drains, for a mean of 1.32 days. Drains were used significantly less by surgeons performing ≥20 BBRs (p = 0.02). With the majority of BBRs performed as an inpatient procedure, there was a trend towards less drain usage in surgeons performing this procedure as an outpatient; however, this was not statistically significant (p = 0.07). CONCLUSION: Even with the high level of evidence demonstrating the safety of BBR without drains, they are still routinely utilised. In an era of evidence- based medicine, surgeons performing breast reductions must adopt the results from scientific research into their clinical practice.

The oncologic safety and practicality of breast conservation surgery in large breast tumors 5 centimeters or more.

BACKGROUND: Surgery remains a therapeutic strategy for women with breast cancer, and long-term outcomes for breast conservation surgery (BCS) and radiotherapy are equivalent to those for mastectomy. To date, there are few published data assessing the oncologic safety and practicality of BCS in women with large breast cancers ≥ 5 cm. The current study compares survival outcomes for women with breast cancer ≥ 5 cm undergoing BCS or mastectomy. METHODS: All women undergoing surgery for breast cancer ≥ 5 cm between January 2004 and December 2011 were included in this study. Kaplan-Meier survival curves statistically compared the overall survival (OS), disease-free survival (DFS), and local recurrence-free survival (LRFS) in the BCS and mastectomy groups. Statistical analysis involved chi-square analysis and t test. The mean length of follow-up was 55.25 months (range, 6-115 months). RESULTS: A total of 217 women had surgery for tumors ≥ 5 cm (BCS in 51, mastectomy in 166). There was no statistical difference in the OS, DFS, and LRFS between groups (P = .439; 95% confidence interval, 0.114-0.347). The re-excision rate of women undergoing BCS was 45.1%, with 65.2% of women undergoing a completion mastectomy. Extensive ductal carcinoma in situ represented the only significant risk factor associated with inadequate margins (P = .021). Larger tumor size was associated with a greater risk of local recurrence (P = .039). CONCLUSIONS: This study is one of the largest studies to date to report BCS + radiotherapy as a safe oncologic treatment option for women with large breast cancers. However, the higher re-excision rate advocates a need to investigate ways to improve patient selection.

An Analysis of the "Classic" Papers in Aesthetic Surgery.

INTRODUCTION: Over the past 50 years, there has been a significant increase in published articles in the medical literature. The aesthetic surgery literature is vast, consisting of a plethora of diverse articles written by a myriad of illustrious authors. Despite this considerable archive of published material, it remains nebulous as to which precise papers have had the greatest impact on our specialty. The aim of our study was to identify and analyse the characteristics of the top 50 papers in the field of aesthetic surgery in the published literature. METHODS: The 50 most cited papers were identified in several surgical journals through the Web of Science. The articles were ranked in order of the number of citations received. These classic 50 papers were analysed for article type, their journal distribution, level of evidence as well as geographic and institutional origin. RESULTS: Six journals contributed to the top 50 papers in aesthetic surgery with Plastic and Reconstructive Surgery contributing the most with 31 papers.

Plastic surgery and the breast: a citation analysis of the literature.

BACKGROUND: A large proportion of the plastic surgery literature is dedicated to the breast. It is one of the most common topics in our specialty, yet it is unclear which articles have been the most influential. The purpose of this study was to identify the top 100 most-cited articles on breast in the plastic surgery literature and examine the characteristics of each individual article. METHODS: Using an electronic database through the Web of Science, we were able to determine the 6 journals that contributed to the 100 most-cited articles on breast in the plastic surgery literature. RESULTS: Each article was examined individually looking at characteristics such as subject matter, article type, country of origin, institution, authorship, and year of publication. Plastic and Reconstructive Surgery contributed the most articles to the top 100 with 81 articles including the most-cited article which has been referenced 673 times to date. The United States produced 73% of the top 100 articles, and the most prolific institution was the University of Texas M. D. Anderson Cancer Center with 15 articles. CONCLUSIONS: This study has identified the most influential articles on breast in the plastic surgery literature over the past 68 years and highlighted many important scientific breakthroughs and landmarks that have occurred during this time.

A barbed suture repair for flexor tendons: a novel technique with no exposed barbs.

BACKGROUND: Barbed suture technology has shown promise in flexor tendon repairs, as there is an even distribution of load and the need for a knot is eliminated. We propose that a quick and simple, novel, barbed technique without any exposed barbs on the tendon surface has comparable strength and a smaller cross-sectional area at the repair site than traditional methods of repair. METHODS: Forty porcine flexor tendons were randomized to polybutester 4-strand barbed repair or to 4-strand Adelaide monofilament repair. The cross-sectional area was measured before and after repair. Biomechanical testing was carried out and 2-mm gap formation force, ultimate strength of repair, and method of failure were recorded. RESULTS: The mean ultimate strength of the barbed repairs was 54.51 ± 17.9 while that of the Adelaide repairs was 53.17 ± 16.35. The mean 2-mm gap formation force for the barbed group was 44.71 ± 17.86 whereas that of the Adelaide group was 20.25 ± 4.99. The postrepair percentage change in cross-sectional area at the repair site for the Adelaide group and barbed group was 12.0 ± 2.3 and 4.6 ± 2.8, respectively. CONCLUSIONS: We demonstrated that a 4-strand knotless, barbed method attained comparable strength to that of the traditional Adelaide repair technique. The barbed method had a significantly reduced cross-sectional area at the repair site compared with the Adelaide group. The 2-mm gap formation force was less in the barbed group than the Adelaide group. Barbed repairs show promise for tendon repairs; this simple method warrants further study in an animal model.

100 citation classics in the melanoma literature: a bibliometric analysis.

BACKGROUND: Modern immunologic therapies targeting genetic mutations have created a renewed interest in melanoma research, and this is reflected in the increasing number of published works. OBJECTIVE: The purpose of this study was to identify the top 100 most cited articles in melanoma and to examine the characteristics of each individual article. METHODS: Using an electronic database through the Web of Science, we were able to determine the 22 journals that contributed to the 100 most cited articles in melanoma. RESULTS: Each article was examined individually looking at characteristics such as subject matter, article type, country of origin, institution, authorship, and year of publication. The New England Journal of Medicine contributed the most articles to the top 100 with 20 articles, whereas the most cited article originated from the Archives of Surgery and has been cited 2,384 times. The United States produced 74% of the top 100 articles, and the most prolific institution was the National Cancer Institute in Maryland with 18 articles. CONCLUSION: This study has identified the most significant contributions to melanoma research over the past 63 years and identifies many important scientific breakthroughs and landmarks that have occurred during this time.

Rapidly enlarging cutaneous nodules on a full-thickness skin graft following an excision of a squamous cell carcinoma - a diagnostic clue for multiple myeloma.

Cutaneous extramedullary plasmacytomas (EMPs) are rare plasma cell neoplasms of the skin occurring in 2-4% of patients with multiple myeloma (MM). We describe a man diagnosed with IgA lambda MM (Stage III) after rapidly enlarging cutaneous nodules developed in the surgical site of recently excised skin malignancies. Cutaneous EMP must be considered for expanding cutaneous nodules at sites of surgery or trauma.

Incisional hernia appendicitis: A report of two unique cases and literature review.

INTRODUCTION: Acute appendicitis is a common surgical emergency. The presence of an inflamed appendix in an incisional hernia is rare. Incisional hernias complicate both open and laparoscopic surgery. PRESENTATION OF CASE: We describe two unique cases of acute appendicitis within incisional hernias following an open cholecystectomy and a diagnostic laparoscopy. Acute appendicitis was diagnosed intraoperatively and a formal appendicectomy was performed with subsequent primary repair of the hernial defect in each case. DISCUSSION: The method chosen for primary repair of an incisional hernia containing an acutely inflamed appendix depends on a number of factors including size of hernial defect and degree of contamination. Closure of 5mm port sites is not routine in current surgical practice. Herniation of intra-abdominal contents through such defects can occur rarely. The repair of an incisional hernia using mesh in a contaminated surgical field is controversial. There may be advantages in the use of biological meshes. CONCLUSION: Surgical awareness of potential complications relating to the management of incisional hernia appendicitis is of primary importance in determining intraoperative strategy.