Autologous breast reconstruction using the immediately lipofilled extended latissimus dorsi flap

BACKGROUND

The latissimus dorsi flap is a popular choice for autologous breast reconstruction. To dramatically improve volume, we report our experience of using the immediately lipofilled extended latissimus dorsi (ELD) flap and show it as a valid option for autologous breast reconstruction.

METHODS

Patients undergoing the procedure between December 2013 and June 2016 were included. Demographic, clinical and operative factors were analysed, together with in-hospital morbidity and duration of postoperative hospital stay.

RESULTS

A total of 71 ELD flaps with immediate lipofilling were performed. Forty-five reconstructions were immediate and the remaining 26 delayed. Median (range) volume of autologous fat injected immediately was 171 ml (40-630 ml). Contralateral reductions were performed in 25 patients with the median reduction volume 185 g (89-683 g). Median duration of admission was 6.5 (3-18) days and patients were followed up for 12 months (1-37). Three total flap failures occurred and had to be excised (4%). One haematoma occurred requiring drainage (1%). Signs of infection requiring intravenous antibiotics occurred in five patients (7%). In 5 patients wound dehiscence occurred, and only two of these required resuturing (3%). In total, 7 patients developed a seroma requiring repeated drainage (10%). Three reconstructions experienced mild mastectomy flap necrosis with no needing reoperation (4%).

CONCLUSIONS

Our experience represents the largest series to date and shows that in carefully selected patients the technique is safe, can avoid the requirement for implants, and has the potential to streamline the reconstructive journey.

Intra-operative digital specimen radiology reduces re-operation rates in therapeutic mammaplasty for breast cancer

BACKGROUND

The aim of this study was to evaluate our experience with intra-operative imaging of therapeutic mammaplasty specimens at Edinburgh Breast Unit.

METHODS

A retrospective review was performed of patients who underwent therapeutic mammaplasty in Edinburgh Breast Unit between 2007 and 2013 who had intraoperative specimen radiography.

RESULTS

98 (100%) patients who underwent therapeutic mammaplasty for breast cancer had intra-operative imaging using the faxitron(®) system. 3 out of those 97 (3%) patients had a re-operation because of positive margins confirmed pathologically on cavity excision specimens, but only 1 out of 3 (1%) patients had residual breast cancer present within the re-excision specimen. None required mastectomy. Median age was 58 (range 34-81). Median follow up was 3.1 years (range 6 months - 5.5 years). There was no local recurrence or conversion to mastectomy in this group.

CONCLUSION

Complete excision rate in patients who had intra-operative imaging during therapeutic mammaplsty procedure was 97% in our group. Faxitron(®) system is a useful adjunct in helping to achieve low incomplete excision rates.

Therapeutic mammaplasty--extending indications and achieving low incomplete excision rates

AIMS

The aim of this study was to report the outcomes of the first 50 consecutive therapeutic mammaplasty procedures at the Edinburgh Breast Unit.

METHODS

A retrospective case-notes analysis was performed. In addition a validated patient satisfaction and outcomes questionnaire was sent to all patients.

RESULTS

Fifty therapeutic mammaplasty procedures were performed in 48 patients, with contralateral synchronous breast reduction performed in 42 of these patients. The median age was 58 years (range, 34-81). The median total tumour size was 28 mm (range, 7-83 mm) and 11 patients had multifocal tumours. The median wide local excision weight was 119 g (range, 15-815) and the median total excision weight was 354 g (range, 20-1725). Neoadjuvant letrozole was used in 16 patients and neoadjuvant chemotherapy was given in six. Incomplete excision (DCIS) occurred in only one patient who underwent reexcision. Complications occurred in 19 breasts overall, delaying adjuvant chemotherapy in one patient. Median reported patient satisfaction with appearance was 9.5 out of ten, with 33 of 35 respondents reporting that they definitely or probably would choose the same operation again.

CONCLUSIONS

Therapeutic mammaplasty can be performed with a low rate of incomplete excision and complications, and high patient satisfaction, even with large tumours and multifocal disease. In this study the use of neoadjuvant letrozole in selected oestrogen receptor positive tumours, intraoperative radiographic imaging of specimens, and targeting further excision to around the tumour bed, was associated with a very low rate of incomplete excision.

Cochlear implantation in older patients: outcomes and comparisons

OBJECTIVES

A review of adults receiving cochlear implants (Cls) at the Yorkshire Cochlear Implant Service (YCIS) was performed to assess whether age affects use or outcomes.

METHODS

A retrospective analysis of all patients over the age of 50 implanted and habilitated at the YCIS was undertaken. Outcome measures included quality of life (QoL) questionnaires and speech perception tests: CUNY sentences and BKB sentences. Comparisons were made between patients implanted age 50 to 59 (A), 60 to 69 (B) and 70 and over (C). Patients with English as a second language and those implanted for less than 9 months were excluded. Data was analysed using a repeated measure regression model.

RESULTS

80 adults were included; A, 31; B, 29; C, 20. Significant improvements were seen in speech perception scores in all groups from pre-implant to 3 months. No statistically significant difference was found between the 3 groups in any outcome measure. QoL scores overall showed increased independence and greater participation in social activities with all patients feeling their implant had been successful.

DISCUSSION

Increased life expectancy and availability of cochlear implants (Cls) has led to greater numbers of older patients being eligible for implantation. Our results show improved speech perception and QoL outcomes in all groups. The lack of statistically significant differences between age groups supports the benefits of Cls in the older population. Older age should not be a discriminating factor in candidacy for cochlear implantation and referral of older patients to implant centres should be encouraged.

North of England and Scotland Study of Tonsillectomy and Adeno-tonsillectomy in Children(NESSTAC): a pragmatic randomised controlled trial with a parallel non-randomised preference study

OBJECTIVES

To examine the clinical effectiveness and cost-effectiveness of tonsillectomy/adeno-tonsillectomy in children aged 4-15 years with recurrent sore throats in comparison with standard non-surgical management.

DESIGN

A pragmatic randomised controlled trial with economic analysis comparing surgical intervention with conventional medical treatment in children with recurrent sore throats (trial) and a parallel non-randomised cohort study (cohort study).

SETTING

Five secondary care otolaryngology departments located in the north of England or west of Scotland.

PARTICIPANTS

268 (trial: 131 allocated to surgical management; 137 allocated to medical management) and 461 (cohort study: 387 elected to have surgical management; 74 elected to have medical management) children aged between 4 and 15 years on their last birthday with recurrent sore throats. Participants were stratified by age (4-7 years, 8-11 years, 12-15 years).

INTERVENTIONS

Treatment was tonsillectomy and adeno-tonsillectomy with adenoid curettage and tonsillectomy by dissection or bipolar diathermy according to surgical preference within 12 weeks of randomisation. The control was non-surgical conventional medical treatment only.

MAIN OUTCOME MEASURES

The primary clinical outcome was the reported number of episodes of sore throat in the 2 years after entry into the study. Secondary clinical outcomes included: the reported number of episodes of sore throat; number of sore throat-related GP consultations; reported number of symptom-free days; reported severity of sore throats; and surgical and anaesthetic morbidity. In addition to the measurement of these clinical outcomes, the impact of the treatment on costs and quality of life was assessed.

RESULTS

Of the 1546 children assessed for eligibility, 817 were excluded (531 not meeting inclusion criteria, 286 refused) and 729 enrolled to the trial (268) or cohort study (461). The mean (standard deviation) episode of sore throats per month was in year 1 - cohort medical 0.59 (0.44), cohort surgical 0.71 (0.50), trial medical 0.64 (0.49), trial surgical 0.50 (0.43); and in year 2 - cohort medical 0.38 (0.34), cohort surgical 0.19 (0.36), trial medical 0.33 (0.43), trial surgical 0.13 (0.21). During both years of follow-up, children randomised to surgical management were less likely to record episodes of sore throat than those randomised to medical management; the incidence rate ratios in years 1 and 2 were 0.70 [95% confidence interval (CI) 0.61 to 0.80] and 0.54 (95% CI 0.42 to 0.70) respectively. The incremental cost-effectiveness ratio was estimated as 261 pounds per sore throat avoided (95% confidence interval 161 pounds to 586 pounds). Parents were willing to pay for the successful treatment of their child's recurrent sore throat (mean 8059 pounds). The estimated incremental cost per quality-adjusted life-year (QALY) ranged from 3129 pounds to 6904 pounds per QALY gained.

CONCLUSIONS

Children and parents exhibited strong preferences for the surgical management of recurrent sore throats. The health of all children with recurrent sore throat improves over time, but trial participants randomised to surgical management tended to experience better outcomes than those randomised to medical management. The limitations of the study due to poor response at follow-up support the continuing careful use of 'watchful waiting' and medical management in both primary and secondary care in line with current clinical guidelines until clear-cut evidence of clinical effectiveness and cost-effectiveness is available.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN47891548.

The semi-permeability of silicone: a saline-filled breast implant with intraluminal and pericapsular Aspergillus flavus

Fungal infection of breast implants is a rare complication. Growth of fungi within the lumen of saline-filled implants has previously been demonstrated in laboratory studies, however, clinical infections are rare. We report a case of Aspergillus flavus growth within and around a saline-filled breast implant that was inserted 18 months previously. This was successfully treated with implant removal and wound irrigation. Possible routes of microbial contamination as well as survival mechanisms of organisms within saline-filled implants are discussed. This case re-iterates that the silicone envelope of a saline-filled implant is selectively permeable and we believe this is instrumental in facilitating intraluminal microbial growth. This also emphasises the importance of stringent asepsis when dealing with saline-filled breast implants including avoiding contamination of the saline filling fluid.

Radiological imaging in primary parotid malignancy

In a retrospective analysis of the preoperative imaging of patients presenting with primary malignant parotid disease, all relevant images were collected and reviewed by two experienced head and neck radiologists, blinded to the diagnosis. Forty-two patients (25 male, 17 female), median age 67.5 years (range 15-86), were included in the study of which 32 had undergone CT scanning, nine MR and three ultrasound. Forty tumours (93%) were correctly diagnosed as malignant when compared with histology. The two false negatives arose in a patient who had received an ultrasound scan only and in a patient with lymphoma, whose CT scan was reported as a pleomorphic adenoma. Neither had undergone prior radiotherapy. A poorly defined tumour boundary was the most consistent observation for both MR and CT images for the malignant tumours examined. Local infiltration was correctly correlated with pathological findings in eight of the nine MR scans, however, CT proved less reliable, correct in 14 of 24 cases (p=0.01). No correlation was identified between any of the imaging features examined and the final histological diagnosis. A poorly defined tumour boundary with evidence of local invasion was the best indicator of malignancy and was reported more frequently from MR scans than from CT. Imaging alone, however, proved unreliable in the prediction of final histological diagnosis or grade of tumour.

IgG in brain correlates with clinicopathological damage in HTLV-1 associated neurologic disease

OBJECTIVE

To test the authors' hypothesis that antibody deposition in autopsy specimens from patients with human T-lymphotropic virus type 1-associated myelopathy/tropical spastic paraparesis (HAM/TSP) would correlate with CNS damage.

METHODS

Endogenous immunoglobulin G (IgG) was detected using antihuman IgG in autopsy tissues from HAM/TSP and control patients. IgG was isolated from the CSF, CNS, and sera of patients with HAM/TSP and tested for reactivity to heterogeneous nuclear ribonucleoprotein A1 (hnRNP A1), an autoantigen recently associated with molecular mimicry in HAM/TSP.

RESULTS

In situ IgG localized to elements of the corticospinal system including neurons of the frontal cortex and precentral gyrus, as well as throughout axons in subcortical white matter, periventricular white matter, posterior limb of the internal capsule, midbrain, pons, and medulla. Similarly, there was IgG deposition within the posterior-column/medial lemniscal sensory system, including the arcuate fibers of the cranial-cervical junction, the nucleus cuneatus, and throughout the course of the medial lemniscus in the medulla, pons, and midbrain. IgG from brain, CSF, and serum of the patients with HAM/TSP showed immunoreactivity with hnRNP A1.

CONCLUSION

Patients with HAM/TSP develop antibodies specific for neurons and axons that are preferentially damaged in the CNS.

Mucous cyst of the alar base: a rare complication following rhinoplasty

Mucous cyst formation following rhinoplasty is a rare complication and typically presents late. Previously reported cases invariably involve the dorsum of the nose or nasal tip. We present a case where this unusual lesion was found to involve the alar base.

The double-barrelled end-to-end microvascular anastomosis

We describe a simple alternative method of microvascular anastomosis to the internal jugular vein, which is useful when part of the internal jugular vein has been sacrificed and the free flap has two draining venae commitantes. In our hands, this method has proven to be quick, efficient and successful.

Encapsulated fat necrosis: a case of 'thigh mouse'

Encapsulated fat necrosis is a rare condition with clinical features that closely resemble a lipoma. The aetiology and pathogenesis are not fully understood but the condition has a distinctive histological appearance. We describe a case of encapsulated fat necrosis that exhibited unusual mobility. The literature is also reviewed.

Normal saline wound dressing--is it really normal?

Gauze swabs soaked in normal saline are frequently used as dressing on open wounds. Their exact mechanism of action is not known. This study was designed to assess the hypothesis that normal saline dressings act in part as an osmotic dressing. Ten patients had skin ulcers (n = 10) dressed with normal saline soaked sponges. Acting as controls (n = 10) identical sponges were placed upon intact skin. The sponge fluid osmolarity and electrolyte concentrations were serially assayed to test our hypothesis. In the control group, the osmolarity, sodium and chloride concentrations increased with time as a result of evaporation, altering it from an isotonic to a hypertonic dressing. However, in the ulcer group, the osmolarity, sodium and chloride concentrations in the sponge fluid remained relatively isotonic with time. This result is statistically significant (P< 0.05). We postulate that, as a result of evaporation, the sponge dressing increases its tonicity. This draws fluid from the wound into the dressing so that a dynamic equilibrium occurs and the sponge dressing regains isotonicity. The dressing remains functional provided that the wound fluid is absorbed freely from the wound. This process is terminated when either the dressing completely absorbs the wound fluid or the dressing dries out. The latter often occurs prematurely in a contaminated wound or in a wound where exudate forms a non-permeable barrier which prevents osmosis and allows the remaining water in the dressing to evaporate completely. This correlates with the observation in clinical practice that for maximum efficacy the dressing should be changed regularly.

Goosecoid-like (Gscl), a candidate gene for velocardiofacial syndrome, is not essential for normal mouse development

Velocardiofacial syndrome (VCFS) and DiGeorge syndrome (DGS) are characterized by a wide spectrum of abnormalities, including conotruncal heart defects, velopharyngeal insufficiency, craniofacial anomalies and learning disabilities. In addition, numerous other clinical features have been described, including frequent psychiatric illness. Hemizygosity for a 1.5-3 Mb region of chromosome 22q11 has been detected in >80% of VCFS/DGS patients. It is thought that a developmental field defect is responsible for many of the abnormalities seen in these patients and that the defect occurs due to reduced levels of a gene product active in early embryonic development. Goosecoid-like ( GSCL ) is a homeobox gene which is present in the VCFS/DGS commonly deleted region. The mouse homolog, Gscl, is expressed in mouse embryos as early as E8.5. Gscl is related to Goosecoid ( Gsc ), a gene required for proper craniofacial development in mice. GSCL has been considered an excellent candidate for contributing to the developmental defects in VCFS/DGS patients. To investigate the role of Goosecoid-like in VCFS/DGS etiology, we disrupted the Gscl gene in mouse embryonic stem cells and produced mice that transmit the disrupted allele. Mice that are homozygous for the disrupted allele appear to be normal and they do not exhibit any of the anatomical abnormalities seen in VCFS/DGS patients. RNA in situ hybridization to mouse embryo sections revealed that Gscl is expressed at E8.5 in the rostral region of the foregut and at E11.5 and E12.5 in the developing brain, in the pons region and in the choroid plexus of the fourth ventricle. Although the gene inactivation experiments indicate that haploinsufficiency for GSCL is unlikely to be the sole cause of the developmental field defect thought to be responsible for many of the abnormalities in VCFS/DGS patients, its localized expression during development could suggest that hemizygosity for GSCL, in combination with hemizygosity for other genes in 22q11, contributes to some of the developmental defects as well as the behavioral anomalies seen in these patients. The mice generated in this study should help in evaluating these possibilities.

A role for lasers in the treatment of pigmented skin grafts

The development of aberrant pigmentation represents an unwelcome complication to an otherwise successful split skin graft resulting in a loss of colour match and, so it follows, of cosmesis. We present two cases where lasers have been successful in the treatment of this problem.

Training in surgical outpatients

The consultants in this department, where the trainees are predominantly SHOs, organise their outpatient clinics such that one consultant sees mainly new patients (A), another mainly follow-up patients (C) and the third a mixture (B). A prospective audit was conducted to assess the impact of these different arrangements on training. Details of the training received were recorded at 32 consecutive clinics. A training episode (TE) occurred if the trainee and consultant jointly reviewed, or directly discussed, the patient in the clinic. A total of 550 patients attended and trainees were involved with 254 (46 per cent). A TE occurred in only 88 (16 per cent). The 235 (43 per cent) new patients produced 66 (28 per cent) TE and the 315 follow-up patients 22 (7 per cent) TE. Seventeen of 46 (37 per cent) procedures were a TE. The TE for the individual consultants were (new and follow-up): A 0, 8 (7 per cent); B 19 (22 per cent), 7 (8 per cent); C 47 (57 per cent), 7 (6 per cent). Outpatient training was greatly influenced by clinic organisation. Follow-up patients, who often have complex problems, rarely generate a TE. Training in surgical outpatients has not received the same attention as operative training and this deficiency needs to be addressed.

Written discharge advice sheets reduce visits to the general practitioner

A prospective audit of early post-operative morbidity in patients who would not normally receive routine outpatient review was undertaken. One-hundred-and forty-seven (92 per cent) of 162 patients invited returned for assessment. Thirty-five patients (24 per cent) had complications. These were of a minor nature with infected wounds being most numerous. Much of this morbidity appeared avoidable if the patients had received appropriate advice whilst in hospital. Also noted was the surprising frequency with which patients required to consult their general practitioner (GP) for guidance regarding an otherwise uncomplicated convalescence. Written advice sheets for the patients were drawn up and the study repeated. One-hundred-and-fifty (93 per cent) of 162 patients attended including 11 (7.3 per cent) who did not receive an advice sheet. Twenty-five (16.7 per cent) had complications. Although the overall complication rate was not significantly different there were significantly fewer wound infections in the second group (6 (4 per cent) versus 15 (10 per cent); p < 0.05). The number of GP visits was also reduced (24 (16.3 per cent) versus 13 (8.7 per cent); p < 0.05). Written post-operative advice sheets should be given to all patients following minor surgery.

Management of minor head injuries in the accident and emergency department: the effect of an observation ward

The management of 483 patients presenting with minor head injury to the accident and emergency (A&E) departments of two Scottish hospitals was studied prospectively. Such patients comprised 5.7 and 3.9% of the total attendances to each department. Of the 277 patients assessed in the former department, 83 (30%) fulfilled at least one of the currently accepted criteria for recommending admission to hospital and 49 (17.7%) patients were actually admitted. Patients in whom head injury was not the principal reason for admission were excluded from the study. In the same time period the second department dealt with 206 patients with minor head injury, 49 (24%) of whom had criteria for admission. However, significantly fewer, 10 (4.9%) patients, were actually admitted. The major relevant factor when comparing the two departments was the existence in the former of an observation ward. These results support the view that easy access to hospital beds is a major determinant of management in patients presenting with minor head injury to the A&E department and may be more influential than clinical findings.