Surgical technique, perioperative management and early outcome data of the PAUL® glaucoma drainage device.

OBJECTIVES: To describe a surgical technique and early post-operative outcomes for a novel glaucoma drainage device-the PAUL® glaucoma implant (PGI). METHODS: A consecutive cohort study of subjects who had PGI surgery between February 2019 and May 2020 with a minimum of 6-month follow-up. Primary outcome measures included failure (intraocular pressure (IOP) > 21 mmHg or a <20% reduction of IOP, removal of the implant, further glaucoma intervention or visual loss to no light perception). Secondary outcomes included mean IOP, mean number of medications, logMAR visual acuity (VA) and complications. RESULTS: Ninety-nine eyes of 97 patients had a preoperative IOP (mean ± standard deviation) of 28.1 ± 9.0 mmHg, falling to 18.2 ± 6.8 mmHg at 1 month, 17.9 ± 6.7 mmHg at 3 months and 13.6 ± 4.7 mmHg at 6 months. 52 patients had a 12-month mean IOP of 13.3 ± 4.4 mmHg. The mean change in number of medications was a reduction of 2.38 ± 1.48. A significant reduction in the number of medications and intraocular pressure was demonstrated after PGI (p < 0.0001). No significant change was demonstrated in VA (p = 0.1158). A total of nine cases were deemed failures (six had <20% IOP reduction from baseline and three had IOP >21 mmHg). Thirty-eight (38.4%) of eyes had complete success and achieved an unmedicated IOP <21 mmHg. Ninety (90.1%) of eyes were qualified successes (with or without topical medications). Seventy-four (74.7%) eyes have achieved an intraocular pressure of <15 mmHg. Two cases of hypotony were observed. CONCLUSION: This study presents a safe surgical technique, which significantly reduces IOP and number of medications with minimal complications.

Chronic Eyelid Edema Following Periocular Hyaluronic Acid Filler Treatment.

A 54-year-old woman received multiple injections of hyaluronic acid filler to the brow region to address volume loss over a 21-month period. She then developed significant pitting edema of both upper eyelids, which persisted for 6 years. Hyaluronidase (Hyalase) was injected into the subcutaneous brows and resulted in complete resolution of the edema within 2 days. This confirms that the hyaluronic acid injected into the brows was responsible for this patient's chronic eyelid edema. This case illustrates an unusual long-term complication of periocular hyaluronic acid filler.

"Emergency" definitive reconstruction of a necrotising fasciitis thigh debridement defect with a pedicled TRAM flap.

INTRODUCTION: Necrotising fasciitis (NF) is a rare, severe, rapidly progressing and life-threatening synergistic infection primarily affecting the superficial fascia. A novel method of definitive and aesthetic reconstruction of NF thigh defects by using a pedicled transverse rectus abdominis myocutaneous (TRAM) flap without recourse to temporising skin grafts is presented. PRESENTATION OF CASE: A 30-year-old parous woman presented in extremis with fulminant NF of her left anteromedial thigh. Following emergency radical debridement and intensive care stabilisation she was reconstructed 48h later in a single stage with a pedicled TRAM flap islanded on the ipsilateral deep inferior epigastric vessels. There was excellent contour restoration of her thigh and coverage of the exposed femoral vessels. DISCUSSION: Pedicled flaps based on the rectus abdominis muscle provide a large, readily available reconstructive option for correction of substantial regional defects as herein illustrated. They are robust when based on dominant inferior vascular pedicle with a long reach and wide arc of rotation when designed transversely (as a TRAM flap). CONCLUSION: This case also illustrates that definitive flap reconstruction of NF can be successfully undertaken in the emergent setting, thereby negating the need for large areas of skin grafting which can lead to contractures with consequent functional impairment and suboptimal aesthetic results.

The use of topical vasodilators in microvascular surgery.

Topical vasodilators are widely used in reconstructive microsurgery in order to ameliorate intraoperative vascular spasm (vasospasm) and facilitate microvascular anastomoses. There is, however, a paucity of literature to support or discredit this practice. A survey of current practice in UK Plastic Surgery Departments was therefore undertaken. Email questionnaires were sent to all 281 consultant plastic surgeons in the UK and we received responses from 91 representing 35 out of the 49 'main' Plastic Surgery Units (71%). Of the 84 consultants who completed the questionnaire, the majority (94%) utilised vasodilators during microsurgery. The commonest preparations used were papaverine (52%), calcium channel blockers (47%) and local anaesthetics (27%). The most frequent reasons cited for topical vasodilator use were empirical (42%), habit (21%) and 'that it works' (16%). The agents were almost always applied topically (99%) compared to intraluminally in 19%. It is concluded that multiple vasodilators are employed routinely in UK microvascular surgical practice, but there is little scientific basis for their use.

An evaluation of incidental metastases to internal mammary lymph nodes detected during microvascular abdominal free flap breast reconstruction.

BACKGROUND: The significance of internal mammary lymph nodes (IMLNs) encountered during dissection of internal mammary vessels (IMVs) for microvascular free flap breast reconstruction (FFBR) remains uncertain. We report our experience with the opportunistic harvest of IMLNs during FFBR. Therapeutic implications and patient outcomes are explored. METHODS: All IMV anastomoses for delayed (DBR) or immediate breast reconstruction (IBR), between 1997 and 2009 were recorded. Opportunistic IMLN harvests were identified and patient characteristics and outcomes recorded from review of case records. RESULTS: Of the 293 FFBRs, 43 patients had 46 IMLNs harvested during 20 immediate and 26 delayed FFBRs. Six patients had positive nodes (4 IBR and 2 DBR), and were offered post operative chemotherapy. Four received radiotherapy to the internal mammary chain. Three of the four IMLN+ve IBR patients have died of metastatic disease at 23, 33 and 55 months after reconstruction. The two IMLN+ve DBR patients were alive at 4 and 20 months. DISCUSSION AND CONCLUSION: Although routine biopsy of IMLNs for staging in breast cancer is not standard practice, if identified during IMV recipient site preparation for microvascular anastomosis, opportunistic biopsy should be performed due to the additional staging information provided and subsequent effect upon the predicted prognosis.