Gender parity at the podium in UK plastic surgery conferences

BACKGROUND

Despite the increase in the proportion of female plastic surgeons in the United Kingdom (UK), all-male panels continue to prevail. This article sought to establish whether the genders of speakers at conferences hosted by leading UK plastic surgery associations, the British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS), and the British Association of Aesthetic Plastic Surgeons (BAAPS), are representative of the consultant workforce.

METHODS

Data on the gender distribution of plastic surgeons in the workforce over the last decade were obtained from NHS Digital Workforce Statistics. The demographics of invited speakers were sought from conference agendas for both BAPRAS (from 2012 to 2022) and BAAPS (from 2014 to 2021) posted on their association's websites.

RESULTS

The proportion of female consultants increased from 16% in 2012 to 22% in 2022. The average proportion of female speakers at BAPRAS conferences was 16% ± 9% SD that was similar to the proportion of female consultants in practice (p = 0.432). In contrast, the average proportion of female speakers at BAAPS conferences was lower than those in practice (7.88% ± 8.29% SD, p = 0.0032). At BAAPS, 43% of speakers were UK plastic surgeons.

CONCLUSIONS

Although the podium speakers at BAPRAS were reflective of the consultant population, BAAPS had little to no representation of UK based female plastic surgeons. Therefore, the conference organisers need to intentionally ensure that representation at podium is reflective of the workforce.

Patients' experience of teleconsultations in the UK

BACKGROUND

Teleconsultations were introduced for cancer surgery follow-up to ease pressure on hospital services and facilitate patients' access to those services. There is limited evidence on patients' perceptions of this swift shift in service provision.

AIMS

The purpose of this qualitative systematic review was to explore patient experiences of teleconsultations within NHS cancer surgery follow-up services to better understand patient perceptions, satisfaction and acceptability of teleconsultations within cancer services.

METHODS

Medline, Embase, PubMed and Google Scholar were searched up to 1 July 2022. Qualitative studies were synthesised using the Braun and Clarke framework.

FINDINGS

There were three overarching themes: accessibility; patient experience; and consultation.

CONCLUSION

Teleconsultations were widely accepted among cancer surgical patients. However, there were reports of a lack of rapport building and emotional support because of the absence of visual cues and patient camaraderie.

Evaluation oncotype DX® 21-gene recurrence score and clinicopathological parameters: a single institutional experience

AIMS

Oncotype DX recurrence score (RS) is a clinically validated assay, which predicts the likelihood of disease recurrence in oestrogen receptor-positive/HER2-negative (ER+/HER2-) breast cancer (BC). In this study we aimed to compare the performance of Oncotype DX against the conventional clinicopathological parameters using a large BC cohort diagnosed in a single institution.

METHODS AND RESULTS

A cohort (n = 430) of ER+/HER2- BC patients who were diagnosed at the Nottingham University Hospitals NHS Trust and had Oncotype DX testing was included. Correlation with the clinicopathological and other biomarkers, including the proliferation index, was analysed. The median Oncotype DX RS was 17.5 (range = 0-69). There was a significant association between high RS and grade 3 tumours. No grade 1 BC or grade 2 tumours with mitosis score 1 showed high RS. Low RS was significantly associated with special tumour types where none of the patients with classical lobular or tubular carcinomas had a high RS. There was an inverse association between RS and levels of ER and progesterone receptor (PR) expression and a positive linear correlation with Ki67 labelling index. Notably, six patients who developed recurrence had an intermediate RS; however, four of these six cases (67%) were identified as high-risk disease when the conventional clinical and molecular parameters were considered.

CONCLUSION

Oncotype DX RS is correlated strongly with the conventional clinicopathological parameters in BC. Some tumour features such as tumour grade, type, PR status and Ki67 index can be used as surrogate markers in certain scenarios.

253 Hospital Consultant Remote Consultations During COVID 19 - Experiences at a Large NHS Trust

Aim

COVID-19 has intensified the need for the NHS to almost utilise remote consulting technology overnight, with clinicians under increasing pressure to provide virtual services preferentially, in line with the NHS digital ideals. This study explores the clinician experience of virtual working during the pandemic in a large acute NHS Teaching Trust, and to identify the facilitators and barriers to remote consultations (RC).

Method

A multi-format online questionnaire was constructed and emailed to all 816 consultants across the trust. The survey was open for one month and during that time two reminders were sent. The data was tabulated and analysed using Microsoft excel.

Results

270 consultants responded to the questionnaire, giving a response rate of 33%, with 208 (77%) performing RCs. 92.8% of these (N=193) have increased the number of RC during the pandemic. 45.9% did not have their own office (N=124), with over half of those (N=63) sharing an office with 3 or more people. The majority of remote consultations were over telephone (82%) with only 54.4% feeling they had the right equipment for video consultations. The biggest barriers were patient related issues (technical, poor environment or not available at scheduled time).

Conclusion

The main challenges facing consultants, in the provision of virtual services were lack of appropriate hardware, an absence of a suitable environment, the prevalence of technical complications, and difficulties experienced by their patients. It is, therefore, important to recognise, both at an organisational level, and nationally, that virtual consultations may play a role in the worsening of health inequalities.

EP-238 Challenges of delivering a tertiary breast cancer service during the COVID-19 pandemic

Introduction

Delivering a breast service during the COVID-19 pandemic has been challenging. At our tertiary referral centre, we have had to coordinate care across multiple sites in order to maintain provision of services. This study looks at how this was achieved at the Nottingham Breast Institute (NBI) by a team of 6 Consultant Surgeons.

Methods

This was a retrospective review of a prospective data base (managed by one Consultant Oncoplastic surgeon) of all patients treated at the NBI over a period of 18 months, at the start the pandemic from March 2020 to October 2021. Data collected included patient demographics, hospital site, and type of surgery.

Results

Over the 18 months 1191 patients were operated on. The average age was 57.8 years (range 17 to 86); as expected the commonest indication was cancer (93.1%). 11.3% of those patients (125/1109) received neoadjuvant chemotherapy. Of these 37.4% of patients (N=446) were operated on at our usual operative base site (NBI). 49.5% and the majority of cases (N=589) were performed across two independent hospitals and a smaller proportion (12.9%) was conducted at a fourth hospital which offered 23 hour stay facilities.

Conclusions

Despite the challenges of securing operative capacity, thus far, we have been able to deliver over 1000 breast cancer surgeries during the COVID-19 pandemic. This is due in part to multisite working, surgeon flexibility, and oversight of all the patient pathways collated on one database by a dedicated surgeon.

WE8.13 Hospital consultant remote consultations during COVID 19 - experiences at a large NHS trust

Aim

Method

Results

Conclusion

Clinical application and outcomes of reconstructive microsurgery in Africa: A systematic review and meta-analysis

BACKGROUND

Reconstructive microsurgical free flap techniques are often the treatment of choice for a variety of complex tissue defects across multiple surgical specialties. However, the practice is underdeveloped in low- and middle-income countries. The aim of this systematic review was to evaluate the clinical application and outcomes of reconstructive microsurgery performed in Africa.

METHODS

Seven databases (PubMed, Web of Science, MEDLINE, CINAHL, Academic Search Complete, Embase, and Google Scholar) were searched for studies reporting microsurgical procedures performed in Africa. The risk of bias was assessed using the Joanna Briggs Institute Critical Appraisal Tools and quality of evidence using the GRADE approach. Meta-analysis was performed using a random effects model to estimate the pooled proportion of events with 95% confidence intervals. The primary outcome was free flap success rate, and the secondary outcomes were the complication and flap salvage rates.

RESULTS

Ninety-two studies were included in the narrative synthesis and nine in the pooled meta-analysis. In total, 1376 free flaps in 1327 patients from 1976 to 2020 were analyzed. Head and neck oncologic reconstruction made up 30% of cases, while breast reconstruction comprised 2%. The pooled flap survival rate was 89% (95% CI: 0.84, 0.93), complication rate 51% (95% CI: 0.36, 0.65), and free flap salvage rate was 45% (95% CI: 0.08, 0.84).

CONCLUSION

This meta-analysis showed that the free flap success rates in Africa are high and comparable to those reported in high-income countries. However, the comparatively higher complication rate and lower salvage rate suggest a need for improved perioperative care.

REVIEW REGISTRATION

Registered with the International Prospective Register of Systematic Reviews (PROSPERO) on 25th September 2020, ID: CRD42020192344.

Patient-centered digital healthcare for patients undergoing breast surgery-A cross-sectional questionnaire study

INTRODUCTION

The potential of digital health services has become apparent in recent years, more so now following the coronavirus disease outbreak. However, despite majority of UK population integrating digital-based platforms into their everyday life, there is low engagement with NHS digital services, citing lack of patient-centered approaches to the design of such services. As such, this cross-sectional questionnaire aims to understand the patient perspective pertaining the utility of web-based information in aiding their breast cancer pathway at a large volume tertiary breast institute.

METHODS

Adult patients attending the outpatients' post-operative follow-up clinic for any breast-related surgery were included. Questionnaires were provided from 1 August 2019 to 31 December 2019, focusing on awareness of the website, usage and usefulness of information offered relating to their breast surgery journey, with opportunities for open feedback.

RESULTS

Of the 104 patients completed the questionnaire, 70% (n = 73) were unaware of the breast institute's website. Patients' wanted a wide range of information, including signposting to support groups and perioperative information such as patient experiences/journey on the operative day (n = 46, 44%/n = 60, 58%) and videos explaining procedures. The most frequent free text included requests for information regarding financial support and parking, and "signposting" to other support services.

DISCUSSION

Patients welcome the breast services' website, but we need to improve awareness of this resource and include more holistic information, relating not only to their diagnosis and treatment but also to practical/support services they can access to make their patient journey smoother.

Partial repigmentation of a vitiliginous nipple areolar complex following therapeutic mammoplasty

We discuss the unusual repigmentation of a vitiliginous region of a nipple areolar complex following a therapeutic mammoplasty. We consider the autoimmune mechanisms behind the pathogenesis of vitiligo and their potential interplay with the immunological pathways involved in this patient's breast cancer and ultimately in the postoperative recovery period. This case highlights the potential interconnecting thread of immunological disruptions, which may provide a springboard for further discussion around the treatment for vitiligo. It also provides a useful point of note when counselling darker skin patients around scarring when undergoing surgical interventions.

Barriers and facilitators to breast reconstruction in ethnic minority women-A systematic review

INTRODUCTION

Post-mastectomy breast reconstruction (PMBR) is an important component of the multidisciplinary care of breast cancer patients. Despite the improved quality of life, significant racial disparities exist in the receipt of PMBR. Given the increasing population of Black, Asian and minority ethnic (BAME) women in UK, it is important to address this disparity. Our review aims to identify the barriers and facilitators influencing the uptake of PMBR in BAME women and raise awareness for physicians on interventions that could improve uptake of PMBR in BAME women.

METHODS

The methodology outlined by the Cochrane guidelines was used to structure this systematic review. Systematic searches for qualitative studies on barriers and/or facilitators to PMBR in ethnic women published in English were conducted. The following databases were searched from their inception up to June 2019: MEDLINE, EMBASE, PubMed, Cochrane Library, Google Scholar and Scopus. Reference lists of all included articles and relevant systematic reviews were also hand-searched for possible additional publications. Publication year or status restrictions were not applied. Only full text articles published in English and by peer reviewed journals are included. Exclusion criteria were as follows: quantitative studies on barriers and/or facilitators to PMBR, abstracts, conference proceedings, non-English language and non-specific to BAME women. A thematic synthesis approach was used through the development of sub-themes and themes from the findings of the included qualitative studies.

RESULTS

Five studies satisfied the inclusion and exclusion criteria. Three overarching themes emerged from our review: physician-associated factors (physician recommendations), patient-associated factors (knowledge, language, community and cultural, emotions, logistics, patient characteristics) and system-associated factors (insurance coverage, income status).

CONCLUSION

Our systematic review suggests that there is a paucity of data in the literature on the barriers and facilitators to PMBR in BAME women. Considering the expanding population of BAME women and increasing breast cancer incidence, it is imperative that future research in this field is carried out. Physician and patient-associated factors were identified as the most important yet modifiable factors. Adopting a combination of culturally tailored interventions targeting these factors may help improve the access of PMBR in BAME women.

REGISTRATION

Prospero ID: CRD42019133233.

The clinical significance of oestrogen receptor expression in breast ductal carcinoma in situ

Background

Oestrogen receptor (ER) in invasive breast cancer (BC) predicts response to endocrine therapy (ET) and provides prognostic value. In this study, we investigated the value of ER expression in ductal carcinoma in situ (DCIS) in terms of outcome and the impact on ET decision.

Methods

In total, 643 pure DCIS, diagnosed at Nottingham University Hospitals, were assessed for ER. Clinicopathological data were correlated against ER status, together with assessment of recurrence rate.

Results

ER positivity was observed in 74% (475/643) of cases. ER positivity was associated with clinicopathological variables of good prognosis; however, outcome analysis revealed that ER status was not associated with local recurrence. In the intermediate- and high-grade ER-positive DCIS, 58% (11/19) and 63% (15/24) of the recurrences were invasive, respectively, comprising 7% and 6% of all ER-positive DCIS, respectively. Invasive recurrence in low-grade DCIS was infrequent (2%), and none of these patients died of BC. The ER status of the recurrent invasive tumours matched the primary DCIS ER status (94% in ipsilateral and 90% of contralateral recurrence).

Conclusion

The strong correlation between DCIS and invasive recurrence ER status and the clinical impact of ET justify discussion of the use of ET in ER-positive DCIS treated by breast-conserving surgery. The excellent outcome of low-grade DCIS, which was almost always ER-positive, does not, in the opinion of authors, justify the use of risk-reducing ET. Therefore, the decision on ET for DCIS should be personalised and consider grade, ER status and other characteristics.

An unusual "venous circle" of the internal mammary vein encountered during microvascular anastomosis and implications for practice

The internal mammary vessels are commonly used for anastomosis in breast reconstruction. The anatomy when using the 2nd ICS has been shown to be predictable and hence preferentially used by the senior author. We present an unusual case of internal mammary vein bifurcation and immediate confluence forming a 'venous circle'.

New surgical technique: Simultaneous use of contiguous intercostal spaces during total rib preservation exposure of the internal mammary vessels in microvascular breast reconstruction

INTRODUCTION

Microvascular free tissue transfer is the gold standard for autologous breast reconstruction. For many surgeons, the internal mammary vessels (IMV) are the preferred recipient vessels. The merits of the rib preservation technique have been previously discussed. There are, however, instances in which greater access than afforded by one intercostal space (ICS) may be required, for example, multiple or redo anastomoses or inadvertent recipient vessel damage. We therefore have refined this technique further to allow exposure of two ICSs without sacrifice of the intervening rib cartilage.

METHOD

We identified all patients who had simultaneous contiguous ICSs dissected whilst preserving the intervening costal cartilage for microvascular anastomoses for breast free flaps. The indications, surgical technique, and its refinements are described.

RESULTS

Simultaneous exposure of the IMVs in both the second and third ICSs whilst preserving the intervening costal cartilage for microvascular anastomoses was successfully performed in 15 patients with no flap failures. Indications included bipedicled DIEP flaps (9), bipedicled DIEA/SIEA flap (1), stacked DIEP flaps (4), and salvage (1). One flap was successfully re-explored for venous congestion. There were no intraoperative complications.

CONCLUSION

We have demonstrated that simultaneous contiguous ICS exposure of the internal mammary recipient vessels with total rib preservation is technically feasible, has no adverse patient sequelae, and has the benefit of allowing multiple anterograde and retrograde microvascular anastomoses (even in patients with narrow ICSs). This technique preserves the intervening rib and is of particular utility in bipedicled flaps when multiple "extra-flap" anastomoses may be required.

The use of plasmakinetic cautery compared to conventional electrocautery for dissection of abdominal free flap for breast reconstruction: single-centre, randomized controlled study

Background

The plasmakinetic cautery is a surgical dissection instrument that combines scalpel-like cutting precision with electrocautery-like haemostasis properties, and operates at lower temperatures (40-170 °C) than conventional electrocautery (200-350 °C). The aim of this study is to evaluate the clinical benefits of using plasmakinetic cautery in abdominal free flap dissection for breast reconstruction.

Methods

Forty women undergoing abdominal-based microsurgical breast reconstruction (DIEP/MS-TRAM) were randomized to plasmakinetic cautery (n=20) or conventional electrocautery (n=20) for dissection of the abdominal free flap. Total abdominal wound drainage volume/duration, operation time and complications such as seroma and haematoma were examined.

Results

Age, body mass index, type of reconstruction and abdominal flap weight were similar in both groups. Mean abdominal drainage volume was (279±262) mL in conventional electrocautery group and (294±265) mL in plasmakinetic cautery group (P=0.853). Plasmakinetic cautery group mean drainage duration (4.3±2.2 days) was no difference compared to conventional diathermy group (3.8±2.0 days, P=0.501). Mean operation time in the conventional electrocautery group and plasmakinetic cautery group was 157±50 vs. 174±70 min respectively (P=0.195). There was more seroma detected in the conventional electrocautery group compared to plasmakinetic cautery group at days 7, 14 and 42 post-operation, but this was not statically significant. 2 haematomas in conventional diathermy group and 1 haematoms in the plasmakinetic cautery group required evacuation.

Conclusions

This study demonstrates that there are no significant differences between the use of plasmakinetic cautery and conventional electrocautery for abdominal free flap dissection.

Assessment of breast symmetry in breast cancer patients undergoing therapeutic mammaplasty using the Breast Cancer Conservation Therapy cosmetic results software (BCCT.core)

Background

Therapeutic mammaplasty (TM) is a standard oncoplastic technique utilising aesthetic breast reduction principles to facilitate tumour resection and breast reshaping. Simultaneous contralateral mammaplasties are often performed to maintain symmetry. BCCT.core software, which principally assesses breast symmetry, has been previously employed for evaluating cosmetic results after standard breast conservation therapy and latterly TMs for upper pole tumours. The purpose of this study was to validate this novel tool for TMs in all breast zones.

Methods

Standardised photographs of 20 consecutive patients who underwent TM were evaluated for symmetry using BCCT.core versus a plastic surgical panel completing a visual analogue scale. Results were rated as (excellent/good/fair/poor). Outcomes between the two methods were compared.

Results

Twenty patients aged 37 to 63 years with a median 36G bra size had 22 TMs (18 unilateral, 2 bilateral). Indications were invasive breast cancer (87%) and ductal carcinoma in situ (DCIS) (13%). The median (range) tumour size was 22.5 mm (6-90 mm) with a resection weight of 245.8 g (16-1,079 g). Primary nipple pedicles were superomedial (63%), inferior (21%) and superolateral (16%). Five patients required a secondary glandular pedicle for volume redistribution to maintain breast shape. The BCCT.core software vs. panel symmetry assessments were 37% vs. 39% (excellent), 63% vs. 50% (good) and 0% vs. 11% (fair). Wilcoxon matched-pairs sign rank tests and Spearman rank correlations found the pairings to be statistically significant (P<0.05).

Conclusions

Despite small patient numbers, BCCT.core gave comparable findings with the panel and is thus useful for objectively assessing cosmesis of TMs in all breast zones.

The ideal intercostal space for internal mammary vessel exposure during total rib-sparing microvascular breast reconstruction: A critical evaluation

BACKGROUND

Total rib-preserving free flap breast reconstruction (RP-FFBR) using internal mammary vessel (IMV) recipients usually involves vessel exposure in the second or third intercostal spaces (ICS). Although the third one is more commonly used, no direct comparisons between the two have hitherto been performed.

OBJECTIVES

To compare the in-vivo topography and vascular anatomy of second and third ICSs in patients undergoing FFBR using the rib-preservation technique of IMV exposure.

METHODS

An analysis of prospectively collected data on intercostal space distance (ISD), number and arrangement of IMVs, location of venous confluence, and vessel exposure time was conducted on a single surgeon's consecutive RP-FFBRs.

RESULTS

A total of 296 RP-FFBRs were performed in 246 consecutive patients. The second, third, or both second and third spaces were utilized in 282, 28, and 22 cases, respectively. The ISDs were 20.6 mm ± 3.52 for the second ICS and 14.0 mm ± 4.35 for the third ICS (p<0.0001, CI = 5.17-7.97, t-test). The second versus third ICS vein content was as follows: single 81.4% vs. 74%, dual 18.6% vs. 26%, and confluence 3.7% vs. 13%. The second ICS single vein was medial to the artery in 92.6%. The third ICS single vein was medial to the artery in 88.2% Vessel exposure times for second (47.2 mins ± 26.7) and third (46.5 mins ± 31.4) spaces were similar (p = 0.93). The overall intraoperative anastomotic revision rate was 9.1%, and the postoperative flap re-exploration rate was 4.0%, with 99.7% overall flap success.

DISCUSSION AND CONCLUSION

Preferential use of the second ICS is supported by its more predictable vascular anatomy, a broader space for performing the microanastomoses and a higher frequency of a single postconfluence (and thus larger) vein facilitating the microsurgery.

The effect of CT angiography and venous couplers on surgery duration in microvascular breast reconstruction: a single operator's experience

Background

The use of CT angiography (CTA) or venous couplers (VCs) has led to shorter operative times in free flap breast reconstruction (FFBR). However, there are no reports on the effect of these two interventions relative to each other or combined.

Methods

Abdominal based FFBRs performed by a single surgeon before introduction of either intervention were compared to those with VC only, and those after the addition of CTA to VCs (CT-VC). Operative time was defined as from "knife-to-skin" to insertion of the last stitch.

Results

One hundred and twenty patients; 40 without intervention (WI), 40 with VC, and 40 with CT-VC. Introduction of VCs did not significantly reduce operative time compared to WI (P=0.73). However, patients in the CT-VC group had significantly shorter operations vs. WI (472 vs. 586 min, P<0.00001) and vs. VC alone (472 vs. 572 min, P=0.0006). Similarly, introduction of each intervention showed a stepwise decrease in ischaemia time (WI vs. VC: 100 vs. 89 min, P=0.0106; VC vs. CT-VC: 89 vs. 80 min, P=0.0307; WI vs. CT-VC: 100 vs. 80 min, P<0.00001).

Conclusions

Combination of CTA and VC significantly reduced operative and ischaemic times for FFBR; this was predominantly due to use of CTA. CTA mitigates the surgical learning curve as demonstrated by shorter operating times via providing a vascular anatomy roadmap, thus facilitating flap harvest.

Initial Management of Traumatic Digit Amputations: A Retrospective Study of Functional Outcomes

Background Traumatic amputation of one or more digits can have a serious detrimental effect on social and economic standings which can be mitigated by successful replantation. Little has been recorded on preoperative management before replantation and how this affects the outcomes of the replanted digit.

Methods A retrospective cohort study was conducted and data collected over an 18-month period. Three protocols for preoperative management were examined: minimal (basic wound management), complete Buncke (anticoagulation, dry dressing on amputate placed on indirect ice and absence of a digital block), and incomplete (any two or three criteria from complete Buncke in addition to the minimal) protocols. Data was collected on survival rate, secondary operations, and complication rate. Function was defined by sensation, range of movement, and strength.

Results Seventy four of 177 digits were replanted with an overall survival rate of 86.5%. The rates for minimal, incomplete, and complete protocols were 95%, 87%, and 91%, respectively, and not significantly different. The complication rate was significantly different between the complete (20%) and minimal (60%) protocols (p = 0.0484). Differences in sensation and grip strength were statistically significant between protocols (p = 0.0465 and p = 0.0430, respectively). Anticoagulation, no digital block and dry gauze all showed reduced complication rates in comparison to their counterparts.

Conclusions The Buncke protocol, which includes anticoagulation, no digital block, and dry gauze, was found to significantly reduce the complication rate which suggests that it prevents compromise of tissue integrity. Significant differences were found between protocols for sensation and grip strength. A higher-powered study is needed to investigate the effects of preoperative management on complication rates and functional outcomes.

Spectrophotometric intracutaneous analysis for the assessment of burn wounds: A service evaluation of its clinical application in 50 burn wounds

INTRODUCTION

The assessment of burn depth can be challenging even to the experienced burn clinician. Clinical assessment is most widely used to determine burn depth. Because of this subjective nature, various imaging modalities have been invented. The use of photospectometry as a novel technique in burn wound depth analysis has been previously described but the literature is very limited.

METHODOLOGY

We carried out a single blinded non-randomized comparative study of healing potential of 50 burn wounds between tissue spectrophotometry analysis versus clinical evaluation.

RESULTS

ScanOSkin™ technology has an overall sensitivity of 75% and specificity of 86% in predicting healing potential of wounds. Analysis of Inter Rater Agreement (IRA) using Kappa calculations showed strengths of agreement varied from fair to moderate in perfusion and burn depth. IRA for assessing pigmentation however, was poor and this was reflected in user feedback.

CONCLUSION

There is a potential role for ScanOSkin™ tissue spectrophotometric analysis in burn depth assessment. Future studies comparing several imaging modalities with ScanOSkin^®, taking into account costs comparison may be useful for future health resources planning.

Evaluation of a microfocused ultrasound system for improving skin laxity and tightening in the lower face

BACKGROUND

The Ulthera System (Ulthera, Inc, Mesa, Arizona) employs microfocused ultrasound to cause discrete focal heating of the dermis and stimulate neocollagenesis and elastin remodeling.

OBJECTIVES

The authors investigated tightening and lifting of cheek tissue, improvement in jawline definition, and reduction in submental skin laxity in patients treated with the Ulthera System.

METHODS

A total of 103 adults were enrolled in this prospective nonrandomized clinical trial. Three-dimensional photographs obtained at baseline and 3 months posttreatment were assessed qualitatively by 3 blinded reviewers and quantitatively with AutoCAD software (Informer Technologies, Redwood City, California). The relationship between outcomes and body mass index (BMI) was examined as well. Patients rated pain during the procedure and provided subjective assessment of their outcome at 90 days. Adverse events were documented.

RESULTS

Ninety-three patients were evaluated. Blinded reviewers observed improvement in skin laxity in 58.1% of patients. During quantitative assessments, overall improvement in skin laxity was noted in 63.6% of evaluated patients. No change was detected in 54.5% of patients whose BMI exceeded 30 kg/m2 or in 12.2% of patients whose BMI was ≤30 kg/m2. At day 90, 65.6% of patients perceived improvement in the skin laxity of the lower half of their face/neck. The average procedural pain scores for the cheek, submental, and submandibular regions were 5.68, 6.09, and 6.53, respectively. Wheals, which resolved without intervention or long-term sequelae, were reported for 3 patients.

CONCLUSIONS

To the authors' knowledge, this is the largest clinical study of the effectiveness of the Ulthera System for rejuvenation of the lower face. At day 90, improvements were reported by two-thirds of patients and by nearly 60% of blinded reviewers. Outcomes were better in patients with BMI≤30 kg/m2.

LEVEL OF EVIDENCE

2.

Comparison of adipocyte viability and fat graft survival in an animal model using a new tissue liquefaction liposuction device vs standard Coleman method for harvesting

BACKGROUND

The use of autologous fat for augmentation has become common practice among plastic surgeons for both cosmetic and reconstructive procedures. Previously reported data suggest that the method of fat extraction can have profound effects on adipocyte viability and subsequent fat graft survival.

OBJECTIVE

The authors describe a pilot study comparing a new tissue liquefaction liposuction device (TLL; HydraSolve Lipoplasty System; Andrew Technologies, Irvine, California) with a standard syringe aspiration method with respect to adipocyte viability, fat graft survivability, and fat graft quality.

METHODS

Lipoaspirate from 5 patients was harvested using either TLL or the standard method. Samples were centrifuged and assayed for cell viability. All lipoaspirate samples were grafted into nude rats and harvested 42 and 84 days later. Graft survival and quality were assessed.

RESULTS

There was no difference in adipocyte viability between the lipoaspirate conditions. At 42 days, there was no significant difference in fat graft weight and the TLL grafts were more fibrotic than the standard control grafts, but this was improved with the increased centrifuge rate. At 84 days, fat grafts were equivalent with respect to graft weight and histology.

CONCLUSIONS

Lipoaspirate harvested with the TLL device and centrifuged at 3000 rpm resulted in fat grafts that were equivalent in weight and histology to those from lipoaspirate harvested with the standard syringe aspiration technique.

Topical lidocaine enhanced by laser pretreatment: a safe and effective method of analgesia for facial rejuvenation

BACKGROUND

Injectable forms of anesthesia for nonsurgical facial rejuvenation, although efficacious, are uncomfortable for the patient. Preclinical studies have demonstrated that laser pretreatment at low energies enhances absorption of topical lidocaine.

OBJECTIVES

The authors assess the safety and efficacy of laser-assisted transdermal delivery of topical anesthetic.

METHOD

Ten patients were split into 2 groups (A and B). All patients received 15 g of BLT (20% benzocaine, 6% lidocaine, and 4% tetracaine triple anesthetic cream) for 20 minutes with no occlusion. Then the cream was removed and the first blood draw taken. Group A patients were pretreated with the full ablative laser and group B patients with a fractional ablative laser to the full face. A further 15 g BLT was applied for another 20 minutes. Group A patients then underwent full ablative laser treatment, and group B received fractionated ablative laser treatment. Blood draws were taken at 60, 90, 120, 180, and 240 minutes after the initial topical anesthetic application, and the serum was analyzed for lidocaine and monoethylglycinexylidide (MEGX) levels. Patients were asked to rate the pain felt at intervals during the procedure.

RESULTS

No patient required supplemental nerve blocks. Pain scores were equivalent at the end of the first pass for both groups (P = .436). Group A patients had significantly lower pain scores at the start of the second laser treatment (P = .045), but pain scores became equivalent by the end (P = .323). Combined serum lidocaine and MEGX levels were significantly higher in group A patients up to 90 minutes (peak average of 0.61 µg/mL for group A and 0.533 µg/mL for group B; P = .0253), which corresponded to greater initial analgesic effect.

CONCLUSIONS

Data from this study demonstrate that topical anesthetic for facial rejuvenation can be enhanced with laser pretreatment while maintaining safe blood serum levels. Further studies should examine optimal application amount and time to allow safe multipass facial rejuvenation without the need for invasive nerve blocks.

Subcutaneous fat tissue engineering using autologous adipose-derived stem cells seeded onto a collagen scaffold

BACKGROUND

This pilot study examined the efficacy of 5-bromo-2-deoxyuridine-labeled autologous adipose-derived stem cells seeded onto collagen scaffolds to augment and/or regenerate the fat-enriched hypodermal tissue in an acute porcine wound model.

METHODS

Porcine autologous adipose-derived stem cells were isolated and cultured. At passage 2, the cells were labeled with 5-bromo-2-deoxyuridine, seeded onto a three-dimensional collagen scaffold, and cultured for 10 days. Scaffolds were implanted subcutaneously in adult pigs with two adipose-derived stem cell scaffolds and two control scaffolds. Animals were euthanized at 2, 4, 8, and 12 weeks; all scaffold conditions were explanted for histology and immunohistochemistry analyses.

RESULTS

For all time points, adipose-derived stem cell scaffolds had increased connective tissue matrix within the subcutaneous tissue compared with scaffold alone and untreated porcine skin (p < 0.01). The neosynthesized connective tissue was vascularized and composed of small cells within an abundant extracellular matrix organized in layers. 5-Bromo-2-deoxyuridine cells were detectable only up to 4 weeks and mature adipocytes were absent. Levels of collagen types I, III, and VI differed among the experimental groups, with increased extracellular matrix associated with the presence of adipose-derived stem cells.

CONCLUSIONS

The authors' data clearly show the efficacy of adipose-derived stem cells for soft-tissue repair and skin aging because it induces a significant increase of the dermis thickness. Moreover, the authors' results demonstrate the interest of their acute wound model and allowed them to show the skin thickness variation over time of the experiment, which is one of the challenges with which clinicians struggle in fat grafting.

Transdermal delivery of adipocyte-derived stem cells using a fractional ablative laser

BACKGROUND

Chronic wound healing problems can pose a significant clinical challenge. Transdermal delivery of adipose-derived stem cells (ADSC) may be a possible solution to healing these recalcitrant, debilitating wounds. Pretreatment of the skin with a fractionated laser has already been shown to assist transdermal drug delivery both in vitro and in vivo and may be an ideal approach to facilitating delivery of ADSC to the target tissue.

OBJECTIVES

The authors investigate in a porcine model whether ADSC can be delivered transdermally following pretreatment with a fractional laser.

METHODS

After ethics approval was obtained, the abdomens of 2 adult female domestic pigs were pretreated with an erbium:YAG fractionated ablative laser. Following laser treatment, 20 × 10(6) bromodeoxyuridine (BrdU)-labeled ADSC were applied topically to the first animal for 4 hours. The same number of BrdU-labeled ADSC was applied to the second animal for 48 hours. The animals were euthanized at the end of their respective treatment periods, and the BrdU-labeled ADSC were counted after tissue harvest.

RESULTS

At 4 hours, an average of 2.40 × 10(6) cells, or 12.0% of the total cells applied, were found in the tissue. At 48 hours, an average of 1.1 × 10(6) cells, or 5.5% of the total cells applied, were seen.

CONCLUSIONS

This pilot study demonstrates that ADSC can be delivered transdermally through skin that has been pretreated with a laser. Potential future applications of this approach might include wound-healing or aesthetic indications. Further studies need to be conducted to determine the optimal number of ADSC to use in this approach, the best methods of application, and the effect of transdermally delivered ADSC on wound healing.

Comparison of five commonly-available, lidocaine-containing topical anesthetics and their effect on serum levels of lidocaine and its metabolite monoethylglycinexylidide (MEGX)

BACKGROUND

Topical anesthetics are commonly applied for a variety of indications. Several lidocaine-containing topical anesthetics are available for purchase over the counter (OTC). Recently, the authors' group has shown that there is great interindividual discrepancy in the manner in which lidocaine is absorbed and metabolized for even a single OTC product.

OBJECTIVES

The authors compare five commonly-available lidocaine preparations and their levels of absorption when applied to the face. Three of the preparations are available OTC; two require prescriptions and were compounded in a pharmacy.

METHODS

Twenty-five subjects enrolled in this Institutional Review Board-approved study were randomly assigned to one of five groups. The five topical anesthetics were LMX-4 (4% lidocaine; Biopelle/Ferndale Laboratories, Ferndale, Michigan), Topicaine (4% lidocaine; Ebsa Laboratories, Jupiter, Florida), 2.5% lidocaine/2.5% prilocaine (generic EMLA preparation; High Tech Pharmaceuticals, Amityville, New York), LET (4% lidocaine, 1:2000 epinephrine, and 0.5% tetracaine), and BLT (20% benzoncaine, 6% lidocaine, and 4% tetracaine). After a patch test for adverse reactions, the topical anesthetic was applied to each patient's face and neck and covered with an occlusive dressing for 60 minutes. Blood was drawn at 90, 120, 150, 240, and 480 minutes to measure serum levels of lidocaine and monoethylglycinexylidide (MEGX).

RESULTS

The average age of the 17 women and eight men included in the study was 26 years (range, 22-62 years), and the average weight was 70.9 kg (range, 46.4-96.4 kg). The OTC preparations had the highest serum lidocaine and MEGX levels. Topicaine had the greatest serum levels of individual lidocaine absorption (0.808 µg/mL), followed by generic EMLA (0.72 µg/mL), LMX-4 (0.44 µg/mL), BLT (0.17 µg/mL), and LET (0.13 µg/mL). On average, Topicaine had the highest serum lidocaine and MEGX levels: 0.438 µg/mL and 0.0678 µg/mL, respectively. There were significant interindividual differences between the serum levels of MEGX and lidocaine in all groups except LET (P<.0001). There were significant differences between the 4% lidocaine-containing preparations (P=.0439); the 2.5% preparation had a greater absorption than the 4% lidocaine-containing preparation and the 6% lidocaine preparation (P=.0016). There were three adverse reactions in patients who received OTC preparations, one of which resulted in postinflammatory hyperpigmentation.

CONCLUSIONS

This study demonstrates that although topical anesthetics are considered safe, some individuals have unpredictably high absorption levels. This study also demonstrates that the concentration of lidocaine, the formulation of the drug, and the individual patient all have significant effects on serum levels of lidocaine. The authors recommend that even OTC topical anesthetics be used under the supervision of a healthcare professional to avoid adverse toxic effects and, in rare cases, death.

LEVEL OF EVIDENCE

2.

Can fractional lasers enhance transdermal absorption of topical lidocaine in an in vivo animal model?

BACKGROUND AND OBJECTIVE

It has been shown in vitro that pretreatment of skin with fractional lasers enhances transdermal delivery of drugs. The aim of this study is to demonstrate in vivo firstly that laser enhances transdermal drug absorption and secondly that this can be manipulated by altering laser settings.

STUDY DESIGN/MATERIALS AND METHODS

Four pigs were used in the IACUC approved animal study. On day 0, 5 g of 4% topical lidocaine was applied under occlusion for 60 minutes to a 400 cm(2) area on the abdomen. Blood was drawn at 0, 60, 90, 120, 180, and 240 minutes. On day 7, the Er:YAG laser was used at 500, 250, 50, and 25 µm ablative depth, respectively, over a 400 cm(2) area on the abdomen. Five grams of 4% topical lidocaine was applied immediately with occlusion for 60 minutes, and then removed. Blood was drawn at 0, 60, 90, 120, 180, and 240 minutes. The serum was extracted and analyzed for lidocaine and its metabolite monoethylglycinexylidide (MEGX).

RESULTS

Serum levels of lidocaine and MEGX were undetectable in untreated skin. Following laser treatment both lidocaine and MEGX were detectable. Peak levels of lidocaine were significantly higher (P = 0.0002) at 250 µm (0.62 mg/L), compared to 500 µm (0.45 mg/L), 50 µm (0.48 mg/L), and 25 µm (0.3 mg/L). Peak levels of MEGX were significantly higher (P ≤ 0.0001) at 250 µm (0.048 mg/L), compared to 500 µm (0.018 mg/L), 50 µm (0.036 mg/L), and 25 µm (0.0144 mg/L).

CONCLUSIONS

This study demonstrates that laser pretreatment significantly increases absorption of topical lidocaine so that it is detectable in the blood and that manipulating laser settings can affect drug absorption. Future work will look at translating this effect into clinical benefit.

An in vivo histopathological comparison of single and double pulsed modes of a fractionated CO(2) laser

INTRODUCTION

Studies examining the histopathological changes that occur in human skin following fractional laser treatment have been performed mainly in animals or abdominal tissue prior to abdominoplasty. This study looks at the effect of double pulse fractional CO(2) laser compared to single pulse treatments to assess differences in tissue injury in the face and abdomen.

METHODS

Twelve healthy subjects randomized into two groups, had two 1 cm(2) areas (infraumbilical and forehead) treated with the fractional CO(2) laser (Deep Fx, Lumenis). Settings used were 15 mJ double pulse, and 30 mJ single pulse, 300 Hz, 10% density and compared to the historic control of 15 patients treated at 15 mJ single pulse [Bailey et al. (2011), Lasers Surg Med 43: 99-107]. Treated sites were biopsied and analyzed with H&E and TUNEL staining to measure width and depth of the microthermal zones (MTZ) of ablation.

RESULTS

When comparing 15 mJ double pulse to single pulse there were significant differences both in depth (abdominal skin, P = 0.002 and facial skin, P = 0.001) and width (facial skin, P = 0.0002) of MTZ. When comparing double pulsing at 15 mJ with single pulsing at 30 mJ there were significant differences between MTZ depths in the abdomen (P < 0.01) but not in either the MTZ depth (P = 0.69) or the width in the face (P = 0.502).

DISCUSSION

This study demonstrates the differences between histopathological laser injury patterns in the face compared to the abdomen when single pulsing is used. It also demonstrates that double pulsing at 15 mJ is statistically similar to single pulsing at 30 mJ in the face. We think this could have ramifications for clinical practice where by double pulsing at lower energies may result in better clinical outcomes than increasing energies or using multiple passes at single pulse. Clinical studies needs to be performed to investigate this further.

Free tissue transfer in acute burns

Major burn injuries can be devastating for the patients and their carers both in terms of morbidity and mortality. Therefore, it is important to optimize the treatment of the injured patient. After initial resuscitation and physiological stabilization, thorough surgical débridement of the burn is necessary. Often resultant defects can be resurfaced with split skin grafting or local flaps. However, in a small percentage of cases free flap surgery is necessary. Free tissue transfer in burns surgery is rare, but is indicated in those patients in which there is loss of a vascularized surface suitable for grafting such as exposed tendon, or bone following surgical débridement, and in extreme cases for limb salvage. This review article discusses the rationale for free flap surgery in terms of types of burn injuries, perioperative considerations, and summarizes the literature in free tissue transfer in acute burns.

Cosmetic surgery training in plastic surgery residency programs in the United States: how have we progressed in the last three years?

BACKGROUND

In 2006, a survey performed by Morrison et al analyzed the experience of aesthetic surgery training from the perspective of residents and their program directors in plastic surgery programs across the United States.

OBJECTIVES

The authors conducted a survey to follow-up on the Morrison results three years after publication, to assess the changes in plastic surgery residency programs.

METHODS

In December 2009, a 17-question survey was sent to program directors, and a 19-question survey was sent to senior residents in all Accreditation Council for Graduate Medical Education-approved plastic surgery residency programs in the United States. The questions were posed in a five-point ranking format. The two additional questions included in the senior resident survey related to career aspirations and desirable areas of additional training. Ninety-two program directors and 397 senior residents received the survey.

RESULTS

Forty-four program director surveys (47.8%) and 117 (29.5%) senior resident surveys were returned. Two-thirds of programs offered a residents' clinic, which was considered the preferred method of cosmetic surgery education by residents. Residents reported increased exposure to nonsurgical procedures such as lasers and injectables. Abdominoplasty, breast augmentation, and breast reduction remained the procedures most frequently performed by residents with confidence, as in the 2006 survey. Facial aesthetic procedures, including rhinoplasty and facelift, remained challenging to residents. Many residents (55.7%) felt confident integrating cosmetic surgery into their practice. One-third of residents reported that they would apply for a cosmetic fellowship.

CONCLUSIONS

This survey shows an improvement in cosmetic surgery training for plastic surgery residents in the United States, particularly in that noninvasive cosmetic treatments are being increasingly taught. Since 2006, steps have been taken to provide more comprehensive cosmetic surgery education to residents, encouraging the delivery of the safe, high-quality care expected of a board-certified plastic surgeon.

Effect of 4% topical lidocaine applied to the face on the serum levels of lidocaine and its metabolite, monoethylglycinexylidide

BACKGROUND

Topical lidocaine is a common form of anesthesia for a wealth of procedures across a large number of disciplines, including laser treatments. Preparations can be purchased over the counter with no prescription necessary. It is considered a safer and more acceptable form of anesthetic than hypodermic injections; however, there have been reports of fatalities following its application. Above certain serum lidocaine concentrations, patients may experience effects of toxicity such as lightheadedness and paraesthesia; these effects can progress to seizures and cardiorespiratory depression, which can ultimately lead to death. The active metabolite of lidocaine, monoethylglycinexylidide (MEGX), can be almost as potent as lidocaine in terms of toxicity.

OBJECTIVES

The authors examine the levels of both lidocaine and MEGX in blood serum after application of topical lidocaine.

METHODS

Twenty-five healthy volunteers were assigned to one of four groups (A, B, C, D). Group A had 2.5 g of 4% lidocaine topical anesthetic cream applied to the face for one hour without occlusion, Group B had 5 g applied to the face for one half-hour without occlusion, Group C had 5 g applied to the face for one hour without occlusion, and Group D had 5 g applied to the face for one hour with occlusion. To evaluate serum concentrations, blood was drawn every 30 minutes for four hours.

RESULTS

Group D showed the highest serum levels of lidocaine and MEGX, a three-fold increase compared with group C, which received the same dose (5g topical 4% lidocaine) but without occlusion. In group D, peak serum levels occurred at 90 minutes for serum lidocaine, which was also the fastest of the four groups. Serum MEGX levels peaked much later than serum lidocaine levels, at 210 minutes. Individual serum levels did not exceed 0.6 µg/mL. Across the groups, there was significant interindividual variation in both lidocaine and MEGX serum levels (P = .061). Applications of 5 g of 4% lidocaine resulted in higher serum concentration of both lidocaine and MEGX. When comparing group A to group C, doubling the dose of 4% lidocaine from 2.5 g to 5 g resulted in double the serum levels of MEGX and a 50% increase in the serum lidocaine levels (P = .021). When comparing groups C and D, the addition of an occlusive dressing resulted in a tripling of the serum lidocaine levels and a doubling of the serum MEGX levels, both of which were statistically significant (P < .001). When comparing all four groups, there were significant differences between the combined serum concentrations of lidocaine and MEGX (P < .001).

CONCLUSIONS

Topical lidocaine preparations are increasingly being employed to provide a patient-friendly form of noninvasive analgesia for a multitude of procedures. Some preparations are available over the counter for unsupervised patient application. Our study has demonstrated significant interindividual variability for a given dose, especially when occlusion is applied. There have been fatalities resulting from topical lidocaine application, and our study suggests that this is the result of the unpredictability of lidocaine metabolism between individuals. Therefore, we recommend that caution be exercised with topical lidocaine preparations, in particular when applied in conjunction with occlusive dressings.

Spontaneous regression of subcutaneous in-transit malignant melanoma deposits of the lower leg after treatment with the carbon dioxide laser

Primary malignant melanoma (MM) is one of the few cancers that can show spontaneous regression, and although this is well described, the mechanisms behind this are unclear. Spontaneous regression of secondary metastatic deposits of melanoma is rare and there are only a handful of case reports supporting this phenomenon. We report a patient with in-transit MM metastatic disease of the leg, who underwent carbon dioxide (CO(2)) laser ablation, and subsequently developed remission of untreated deposits. We discuss the possible immunological mechanism for this phenomenon.