Fibrin tissue adhesive for face- and necklift

INTRODUCTION

Although available for decades, fibrin-based tissue adhesives (FTAs) have enjoyed only variable popularity in aesthetic surgery since their introduction in the 1980s. Whilst benefits in facelift surgery have been reported for a range of measures, including expanding haematoma, oedema and ecchymosis, irrefutable evidence has not yet been forthcoming. We instigated a prospective study to test the hypothesis that an underappreciated property of FTA, namely its ability to distribute tension, would reduce complications and revision due to early relapse.

PATIENTS AND METHODS

The study group comprised 100 consecutive facelifts with FTA. The comparative group comprised the immediate preceding 100 patients who underwent similar interventions, but with drains instead of FTA. All surgery was undertaken by the senior author using standard techniques and statistical analysis employing Fisher's exact test.

RESULTS

The groups were comparable in age, gender distribution, co-morbidity and declared cigarette smoking. Complications were recorded in 24 patients with significantly more in the comparative group (p = 0.048), particularly hypertrophic scarring (p = 0.029). Although there appeared a greater prevalence of revision and cutaneous necrosis in the comparative group, these did not reach statistical significance.

DISCUSSION

To the many published benefits, we can add that FTA can reduce complications, particularly hypertrophic scarring, and it now forms an important part of our facelift practice.

Arterial injuries at the elbow carry a high risk of muscle necrosis and warrant urgent revascularisation

INTRODUCTION

Revascularisation following axial arterial system injury is effective in upper limb salvage but necrosis of muscle, the tissue most sensitive to ischaemia, may still occur. We examined the frequency of necrosis, its related factors and its functional significance.

METHODS

The clinical findings and operative management of 13 patients with injuries at the elbow referred to 2 plastic surgical hand surgery units over a 30-month period were reviewed. Good outcome was defined as minimal impairment with return to previous occupation, intermediate outcome as moderate impairment with change in occupation and poor outcome as major functional loss preventing work.

RESULTS

Seven patients injured the brachial and six injured both the radial and ulnar arteries. Concomitant injuries were severe with nerve injuries in 11 and muscle damage in 12 patients. Functional outcome was good in four cases, intermediate in four and poor in five. Muscle necrosis developed in four brachial artery injuries. In all four cases, initial successful revascularisation failed post-operatively. Case review revealed delayed recognition in three cases where pain heralded ischaemia but distal skin circulation and pulses were adequate. Of patients with necrosis, three had a poor outcome and one had an intermediate outcome.

CONCLUSIONS

The risk of muscle necrosis must be considered when managing these injuries, particularly if initial revascularisation is unsuccessful. Every effort should be made to optimise repair technique and post-operative monitoring. Limb salvage is no longer enough. Fully viable muscle is necessary to restore function and livelihoods.

Female-to-male transgender chest reconstruction: a large consecutive, single-surgeon experience

INTRODUCTION

Chest reconstruction in the female-to-male transgender individual is not a common procedure due to the low prevalence of intractable gender dysphoria. It means that few surgeons acquire sufficient expertise and many UK patients find themselves travelling abroad to centres such as Singapore, Amsterdam and the United States.

PATIENTS AND METHODS

This study retrospectively evaluated 100 consecutive patients of a single surgeon over a 3-year period with prime outcome measures including surgical technique, complications, surgical revision and patient-reported satisfaction, using a simple, 1-5 linear analogue scoring system.

RESULTS

The median age was 28 years with a median excision of 345 g per breast. Complications occurred in 11 patients, five of which required surgical haematoma evacuation. Chi(2) analysis failed to show a correlation between testosterone supplementation and haemorrhagic sequelae (p>0.1). To date, 16 patients have undergone supplementary surgery, predominantly axillary dog-ear revision. Overall patient-reported satisfaction was 4.25.

CONCLUSIONS

Whilst only a part of the process in gender transitioning, chest reconstruction is important as it is frequently the initial surgical procedure and enables the large-breasted to live in their chosen role much more easily. Historically associated with high rates of both complication and revision surgery, this study demonstrates that both may be appreciably lower and associated with high levels of patient satisfaction so that there is a realistic, high-quality option for British patients who might otherwise feel the need to travel abroad for their surgery.

Triple-flap medial canthal reconstruction

A patient with a medial facial defect, following oncological resection involving the medial canthus, nose, upper and lower eyelids, and the cheek, is presented. The defect was reconstructed using a combination of local flaps to provide tissue similar to native tissue, addressing both functional and aesthetic aspects.

Breast augmentation: Part III--preoperative considerations and planning

The past four decades since the introduction of silicone mammary prostheses have seen significant improvements in their quality and durability. Advances in our understanding of the aetiopathology and prevention of adverse capsular contracture (ACC) have occurred such that surgical technique itself has now probably become the single most important determinant of both immediate and long-term outcome. Considered a simple, and in some quarters mindless, procedure it has evolved such that high-quality short- and stable long-term results are now expected. Whilst the fundamentals of breast augmentation (BA) remain, evolutionary philosophies confront today's surgeon with a wealth of options. Of fundamental importance has been the paradigm shift from a purely, or predominantly, volumetric, through biodimensional to a tissue-based approach. With BA, more than any other aesthetic procedure, possessing more variables, choice and influential external factors a thorough understanding of the myriad options available is essential. This review seeks to cover the key elements in obtaining an optimal primary result. It provides a rational basis for the selection of an option tailored to both the patient and the individual tissue characteristics in addition to the pertinent medico-legal issues.

Aggressive management of tibial osteomyelitis shows good functional outcomes

BACKGROUND

Severe open tibial fractures can be successfully treated acutely with a combined orthopedic and plastic surgery approach, but a proportion will go on to develop chronic osteomyelitis. For the past 6 years, an aggressive approach of bone and soft tissue debridement followed by skeletal reconstruction and vascularized tissue transfer has been pursued by the orthopedic and plastic surgery teams at Liverpool Hospital. We present the results of our patient series.

METHODS

All patients treated for chronic osteomyelitis by combined skeletal stabilization, debridement, and flap coverage between January 2000 and July 2006 were included. Clinical record review was combined with patient interviews and questionnaires. Outcome measures included fracture union, stable soft tissue coverage, freedom from infection, mobility, return to work/sport, and pain.

RESULTS

Twelve patients were followed up after a mean of 4.2 years. Patients had undergone a mean of 8.4 procedures prior to treatment, and a mean of 2.5 procedures as part of their treatment. We achieved fracture union, stable soft tissue coverage, and eradicated infection in all patients. All patients were walking, 10 unaided, and 80% had returned to work. All but one patient involved in sport at the time of injury had returned to sport. Two patients had mild pain when walking long distances only.

CONCLUSION

Skeletal stabilization, debridement, and flap coverage is costly and complex surgery. However, in our series, these interventions resulted in eradication of infection and good clinical outcomes in most cases, providing an alternative to both amputation and long-term antibiotic therapy.

Successful unilateral thoracoscopy for bilateral ectopic mediastinal parathyroidectomy

Ectopic parathyroid glands are frequently located in the thymus and may become hyperplasic in patients with secondary hyperparathyroidism. When medical management fails, surgical removal is required, using either a traditional open sternotomy approach or video-assisted thoracic surgery (VATS). We were able to excise large, bilateral, mediastinal parathyroid glands using only left VATS. To the authors' knowledge, this is the first reported case of the use of unilateral thoracoscopic subtotal thymectomy for the excision of bilateral ectopic mediastinal parathyroid glands.

Oncoplastic breast surgery: a review and systematic approach

Oncoplastic breast surgery (OBS) is relatively new, but has made rapid progress from its tentative steps of infancy in the 1990s. The recent Milanese Consensus Conference on Breast Conservation concluded that, firstly, oncoplastic techniques are warranted to allow wide excision and clear margins without compromising cosmesis. Secondly, such surgery is ideally performed at the same time as oncological excision. Whilst technically more challenging than standard breast conserving therapy (BCT), OBS is well proven, if not yet widely practised, both oncologically and aesthetically and a review of the available techniques is perhaps timely. The roots of breast conserving therapy can be traced to the 1930s, actually due to advances made in radiotherapy, and the last 20 years have seen it become firmly established. This review aims to summarise the key historical developments and latest innovations in OBS. Not only are our patients, who expect not only safe cancer treatment but a satisfactory aesthetic outcome, increasingly informed and demanding, but longer follow up has stimulated surgeons to improve outcomes. In many cases, particularly with ptosis and macromastia, the cancer can be treated, usually with wider excision margins, simultaneously improving the aesthetic appearance. Present at the birth of OBS, the Institut Curie has continued to introduce innovative techniques over the last two decades and a systematic approach, comprising nine basic techniques, has evolved to allow high quality treatment of any and all breast cancers suitable for OBS.

Surgical management of liver metastases from uveal melanoma: 16 years' experience at the Institut Curie

BACKGROUND

Uveal melanoma is characterised by a high prevalence of liver metastases and a poor prognosis.

AIM

To review the evolving surgical management of this challenging condition at a single institution over a 16-year period.

PATIENTS AND METHODS

Between January 1991 and June 2007, among 3873 patients with uveal melanoma, 798 patients had liver metastases. We undertook a detailed retrospective review of their clinical records and surgical procedures. The data was evaluated with both uni- and multivariate statistical analysis for predictive survival indicators.

RESULTS

255 patients underwent surgical resection. The median interval between ocular tumour diagnosis and liver surgery was 68 months (range 19-81). Liver surgery was either microscopically complete (R0; n = 76), microscopically incomplete (R1; n = 22) or macroscopically incomplete (R2; n = 157). The median overall postoperative survival was 14 months, but increased to 27 months when R0 resection was possible. With multivariate analysis, four variables were found to independently correlate with prolonged survival: an interval from primary tumour diagnosis to liver metastases >24 months, comprehensiveness of surgical resection (R0), number of metastases resected (< or = 4) and absence of miliary disease.

CONCLUSIONS

Surgical resection, when possible, is able to almost double the survival and appears at present the optimal way of improving the prognosis in metastatic uveal melanoma. Advances in medical treatments will be required to further improve survival.

Brachial plexus impingement: an unusual complication of bilateral breast augmentation

Breast augmentation is one of the most commonly performed aesthetic procedures, with many studies documenting the early and long-term complications that might be expected. This report describes the case of an active young woman who experienced severe pain, particularly with movement. Surgical exploration showed the cause of this pain to be impingement of the patient's lower brachial plexus by the mammary prosthesis. Such a complication has not, to the authors' knowledge, been reported previously.

A comparison of the views of patients and medical staff in relation to the process of informed consent

INTRODUCTION

The quality and quantity of information required in the consent process is well documented, but there is little extant literature regarding timing of either information about the proposed procedure or the act of consent itself. With the recent introduction of a new NHS-wide consent form, we wished to determine the preferences of both patients and staff to ascertain whether any concordance of views existed.

PATIENTS AND METHODS

A 10-point questionnaire, developed in conjunction with the department of clinical psychology was completed by 242 patients selected for surgery over a 4-month period. Identical questionnaires were completed by local staff (n = 50) and national consultant plastic surgeons (n = 56).

RESULTS

The cumulative majority (61.8%) preferred information at the specialist out-patient appointment (OPA). There was a significant difference (P < 0.001) between patients and staff as to information provision by the specialist as compared to non-specialists; staff indicating it much more strongly. As to the timing of consent form signature, 40.2% preferred signature on admission with no statistically significant difference between subgroups. An additional pre-operative clinic, for consent form signing, was selected by 27.3%. Staff expressed this view more often than patients (P < 0.001).

CONCLUSIONS

Patients prefer information about a planned surgical procedure at their specialist OPA and final consent for surgery when admitted to the ward. Staff had quite definite views and felt an additional pre-operative out-patient appointment to be beneficial, more so than the patients themselves.

Hyaluronic acid: the scientific and clinical evidence

Hyaluronic acid is a naturally occurring biopolymer whose molecular structure is highly conserved between mammalian species. First described in 1934, it has since been used across a wide variety of medical fields as diverse as neurosurgery and cutaneous wound healing. Presently it has reached prominence in cosmetic practice where it is now the injectable dermal filler of choice for most surgeons. We used our experience of this technology with searches in the English language literature for the purpose of a systematic review. We present an overview, including the scientific evidence for its use in wound healing and, briefly, in other fields. We summarise the evidence for and against hyaluronic acid and provide a resumé of the current technologies available in fields such as skin regeneration and wound healing, in addition to cosmetic surgery. This overview is not intended to teach the reader about the various formulations currently on the market or how to use these materials clinically - rather to provide a solid scientific background enabling the reader to understand the attributes (and otherwise) of the material. We hope to allow clinicians to assess the evidence for a material now in common use in order that they may be fully aware of its properties.

Digitisation of the total burn surface area

The assessment of surface area of the body affected by a burn (TBSA) has long been estimated with manual charts. Initial assessment of burned patients is made frequently by clinicians with limited experience producing significant errors. Paper copies of burn charts are unwieldy, subject to loss and tend towards overestimation. Thus, a simple method of calculation, recording and transmission via email or telemedicine may produce benefits in both initial treatment and data recording. Although computer-based systems have been reported previously none have entered routine clinical practice in the UK. We devised a PC-based program, "Burn Calculator", whereby digital transcription of the burn allows automatic area calculation allowing not only a rapid, accurate figure for determination of fluid resuscitation, but also the potential for rapid electronic transmission. It also calculates fluid requirements to minimise errors during resuscitation. This initial pilot study compared figures from 50 paper charts with those from Burn Calculator to determine its accuracy and reproducibility. Previously reported variations in TBSA estimation were confirmed, as was the tendency towards TBSA underestimation resulting from transcription of a three-dimensional clinical situation to a two-dimensional representation. Burn Calculator showed high correlation (r=0.9850; p<0.0001) and reproducibility (R=0.9957) that would simplify assessment and referral plus facilitate data collection, interpretation and research.

Integrin expression and survival in human breast cancer

BACKGROUND

Integrin cell adhesion molecules are fundamental to numerous cellular functions including anchorage, differentiation and proliferation. Reduced expression of certain alpha and beta integrin subunits in primary breast cancer cells has been correlated with increased invasion and metastasis. Conversely, over-expression of the alpha6 subunit has been linked to poorer survival. The objective of this study was to measure the survival of a cohort with breast carcinoma in relation to integrin expression and to evaluate their potential as prognostic indicators.

METHOD

Integrin expression on samples from 99 consecutive patients with breast cancer was assayed using monoclonal antibodies to the subunits alpha(1,2,3,6,V) and beta(1,3,4,5). This cohort has now been followed prospectively for almost five years allowing for early assessment of survival in relation to integrin expression.

RESULTS

Whilst analysis of the data confirmed the relation of survival to proven predictors of tumour grade, tumour size and vascular invasion, statistical significance was not demonstrated with regard to both lymph node status and all integrin subunits studied.

CONCLUSION

Previous research correlating certain integrin subunits with survival has not been confirmed in this study. Despite proven molecular importance in tumour cell adhesion, invasion and metastasis, integrin expression would appear not to translate clinically as independent indicators of prognosis, at least in the short-term.

Integrin beta1-mediated invasion of human breast cancer cells: an ex vivo assay for invasiveness

BACKGROUND

The integrin cell adhesion molecule (CAM) family is intimately involved in cell adhesion and invasion through tissue basement membranes (BM). As a consequence of the short survival of patient-derived human breast cancer cells, the invasion of such cells has not been previously reported. Our aims were to optimise culture conditions in order to establish a reliable invasion assay and to assess the effect on invasion of perturbations of the beta1 integrin receptors.

METHODS

Pure suspensions of viable carcinoma cells were isolated immunomagnetically from human breast cancer (HBC) samples and introduced onto a replicated glycoprotein BM within an invasion chamber. Degree of invasion was compared to both beta1 integrin expression and tumour grade. Additionally, the effect of beta1 receptor blockade with monoclonal antibody (mAb) was assessed.

RESULTS

Invasion was significantly greater in grade II than grade III tumour cells (p=0.0012). Anti-integrin beta1 monoclonal antibody inhibited cancer cell invasion by a mean of 83.96 +/- 4.80%.

CONCLUSIONS

The invasion assay confirmed the fundamental importance of beta1 integrin receptors to transmembrane invasion and reports this for the first time in cells isolated from primary breast cancer. It represents a potent research tool for investigation of the tumour biology of invasion at the integrin beta1-mediated cell-basement membrane interface. This assay has the potential clinical application of improved stratification of patients for adjuvant therapy on a more individual basis than currently available.

Bifid median nerve: anatomical variant at the carpal tunnel

We describe a rare case of a bifid median nerve in the wrist of a 4-year-old girl who presented with a laceration of her right hand. In addition to the nerve, the carpal tunnel was duplicated with a separate tunnel for each branch.

The influence of body mass index on burn surface area estimated from the area of the hand

It is well recognised that initial estimates of the area involved in a burn injury by inexperienced clinicians are frequently excessive. In Britain the palmar surface area of the hand is taught to approximate 1% of the total body surface area (TBSA), but no allowance is made for variations in individual body weight. This study aimed to evaluate the relationship between hand surface area (HSA) and body mass index (BMI) using healthy volunteers. We found that mean HSA diminished significantly as BMI increased in both sexes (P<0.001). This effect was, however, more pronounced in women, particularly those with a BMI greater than 31 kg/m(2) in whom the HSA represented only 0.64%. Awareness of the potential for over-estimation of burn surface area using this method alone may improve the accuracy of burn area estimation and consequent need for commencing resuscitation.

Acute facial-nerve paralysis with parotid adenolymphoma

An 82-year-old woman presented with acute facial paralysis in association with parotid swelling following fine-needle aspiration cytology of a parotid adenolymphoma. Evacuation of a tense haematoma decompressed the nerve and led to complete recovery within 6 months. Additionally, the tumour is no longer evident, either clinically or radiologically, and fine-needle aspiration cytology appears to have been both diagnostic and, inadvertently, therapeutic in this case.

Audit of a one-stop breast clinic--revisited

BACKGROUND

A one-stop diagnostic service has been available for women with symptomatic breast disease at St Bartholomew's Hospital for 5 years and was originally audited in May 1993. In re-auditing the one-stop service our aim was to see if our practice had improved following the original audit and to look at the impact which these changes in practice had made to the service offered to the patient.

METHODS

A prospective audit of 4 consecutive clinics was undertaken in November 1997. A total of 300 patients (59 new and 241 follow up) were seen in clinic in this time. The primary outcome measure concerned the completeness of triple assessment in the 40 patients who required one stop investigations, including mammography, ultrasonography and fine-needle aspiration cytology. In addition, mean time to initial consultation and level of awareness of the one-stop facility and its attendant time delay were measured.

RESULTS

Of the 300 clinic attendees 40 (38 new, 2 follow-up) had one-stop investigations. As a result of the one-stop service being in practice, 36 patients (90%) had a definitive management decision made at their first outpatient visit. Of these 2 were symptomatic cancers, forming 5% of the workload. A total of 86% of the workload was benign. Four patients (10%) had equivocal results. The mean waiting time from designated appointment until surgical consultation was 36.7 minutes and was disappointingly unchanged from that of the previous audit. However this does not take into account the significant reduction in staffing levels which has occurred between the two periods of assessment.

CONCLUSIONS

The initial audit identified a significant problem with time constraints, necessitating that a large number of patients with carcinomas return at a later date for further investigations. Booking only new patients at the beginning of clinic has provided a solution. Disappointingly, our figures do not show a significant improvement in mean waiting time compared with the previous audit, despite allowing GPs greater access of referral. Encouragingly, we have been able to maintain a similar standard of provision of care despite lower staffing levels and to implement the changes suggested by the original audit (thereby closing the audit loop).

Integrin beta1 upregulation in MCF-7 breast cancer cells by angiotensin II

AIMS

Integrins are a major family of cell adhesion molecules whose function is perturbed in tumour invasion and metastasis. Angiotensin II (A II) is well-known in the systemic control of water and electrolyte homeostasis and haemodynamics, but recent evidence points to an additional local renin-angiotensin system (RAS) with possible long-term trophic effects including carcinogenesis.

METHODS

The effect of angiotensin II on MCF-7 human breast cancer cell line integrin expression was evaluated with immunocytochemistry (ICC) and immunoprecipitation (IP).

RESULTS

The experiments demonstrated a 1.40 +/- 0.14-fold increase in beta, integrin expression on MCF-7 cells following treatment with A II.

CONCLUSIONS

These findings report the first evidence of an association between integrins and the RAS in human breast cancer cells and suggest a novel research avenue for future anti-metastatic strategies, through the manipulation of cell adhesion mechanics, in the management of invasive human breast cancer.

Fibrolipoma of the median nerve

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Evaluating the return of prostatic adenocarcinoma

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An audit of patient acceptance of one-stop diagnosis for symptomatic breast disease

AIMS

The impetus for optimizing outpatient provision of breast-care services has come both from the patient and management in order to reduce anxiety and make full use of scarce resources. The one-stop diagnostic clinic for the investigation of symptomatic breast lesions is a relatively recent concept with well-known service benefits. However, acceptance to the patient has not been previously investigated.

RESULTS

The results of this prospective audit demonstrate a high level of patient satisfaction with the multi-disciplinary, one-stop breast clinic.

An audit of outcome including patient satisfaction with immediate breast reconstruction performed by breast surgeons

Reconstruction of the female breast is becoming ever more frequently requested by patients after mastectomy for cancer. One of the least complex techniques is that of local tissue expansion with a permanent prosthesis. We present our experience and the clinical outcomes of the first 100 patients to have undergone surgery in the 4 years since the introduction of this method of breast reconstruction in our unit. A retrospective study was performed with a detailed questionnaire being sent to each patient for subjective assessment of satisfaction. Data were also collected on the rates of clinical infection of the prosthesis and the need for further surgery, including capsulotomy, nipple reconstruction and contralateral procedures. With 84% expressing their satisfaction at the final result, immediate breast reconstruction is both feasible and highly acceptable to the majority of patients.

Mucoepidermoid carcinoma of the breast: a case report and review of the literature

Muco-epidermoid carcinoma is a rare primary of the breast with previous reports of only 15 cases. As the following case report demonstrates, it can be very difficult to diagnose on aspiration cytology and a negative result should be interpreted with caution.

Beds or day case unit: your choice?

The aim of this study was to assess the amount of day case surgery and potential day case surgery being performed in the main theatre block of a District General Hospital, which had a thriving Day Case Unit. Our results revealed that as well as large numbers of potential day cases being performed as inpatients, many patients (both potential day cases and long-stay elective surgery patients) are spending a day(s) in hospital prior to the day of surgery. We believe that by performing all day case surgery in our Day Case Unit and by using the Day Case Unit to perform pre-admission screening on all surgical patients, a large number of bed days will become available. These beds may be used for elective or emergency admissions. Alternatively, cutting surgical beds will free monies which can be spent on the Day Case Unit.