Ali Juma

How Should We Investigate Breast Implant Rupture

Abstract:  We aimed to examine a cohort of patients presenting with breast implant complications to establish the sensitivity and specificity of clinical examination, Ultrasound Scanning (US) and Magnetic Resonance Imaging (MRI) in the diagnosis of implant rupture, and to examine the correlation between US and MRI. We performed a 26‐month retrospective review. Patients underwent US and MRI to exclude rupture. Results of US and MRI were compared prospectively for concordance, then retrospectively to clinical findings and surgical diagnosis. Thirty‐four patients with 60 implants were reviewed. The sensitivities of clinical diagnosis, US, and MRI for rupture was 42%, 50%, and 83%, respectively, while the specificities were 50%, 90%, and 90%. The concordance between US and MRI was 87%. MRI is the investigation of choice for implant rupture. US is a valuable alternative with good concordance with MRI. When US is positive for implant rupture an MRI is not necessary to confirm the diagnosis. Knowledge of the sensitivity and specificity as well as the concordance between the two investigations is useful to ensure the appropriate use of available resources.

Flap Decisions and Options in Soft Tissue Coverage of the Upper Limb

Soft tissue deficiency in the upper limb is a common presentation following trauma, burns infection and tumour removal. Soft tissue coverage of the upper limb is a challenging problem for reconstructive surgeons to manage. The ultimate choice of soft tissue coverage will depend on the size and site of the wound, complexity of the injury, status of surrounding tissue, exposure of the vital structures and health status of the patient. There are several local cutaneous flaps that provide adequate soft tissue coverage for small sized defects of the hand, forearm and arm. When these flaps are limited in their mobility regional flaps and free flaps can be utilised. Free tissue transfer provides vascularised soft tissue coverage in addition to the transfer of bone, nerve and tendons. Careful consideration of free flap choice, meticulous intraoperative dissection and elevation accompanied by post-operative physiotherapy are required for successful outcomes for the patient. Several free flaps are available for reconstruction in the upper limb including the groin flap, anterolateral flap, radial forearm flap, lateral arm flap and scapular flap. In this review we will provide local, regional and free flap choice options for upper limb reconstruction, highlighting the benefits and challenges of different approaches.

Bitumen burns and the use of baby oil

Abstract This case report describes the successful use of baby oil to remove bitumen from burned skin.

Video recording of surgery to improve training in plastic surgery.

Video technology is not new in surgical practice. Specialties such as general surgery and ENT regularly perform procedures using video technology, which can be recorded and potentially used for training purposes. However, there are not reported cases of video technology in plastic surgery to assess trainee skills and progression. In our institution we have used a portable high definition, head mounted video camera (Gopro HD Hero 2, Woodman Labs, Half-Moon Bay, California, USA) to record trainees Figure 2 Video recording showing trainee operating.

The pedicled 'policeman' flap salvage of exposed vascular prosthesis - a case report.

A case report of a patient with exposed, infected, subcutaneous, extra-anatomical, vascular prosthesis is presented, which was successfully salvaged using pedicled omental flap after other reconstructive procedures had failed.

A modification of the V-Y advancement flap to cover a defect of the outer canthus and both eyelids

We describe the use of a modified V-Y advancement flap from the lateral aspect of the outer canthus to cover a defect with three components on the lateral aspects of the upper and lower eyelids and the outer canthus of the eye.

The perioperative management of patients on antiplatelet agents and anticoagulants presenting for plastic surgical operations: a survey of current practice in the UK

A significant proportion of patients who present for plastic surgical procedures take aspirin or other antiplatelet agents (clopidogrel or nonsteroidal anti-inflammatory drugs) or are on anticoagulants (e.g. warfarin). Although there have been several reports in the literature regarding the perioperative management of patients presenting for dermatologic surgery, there have been no such reports pertaining to the wider scope of plastic surgical practice. In the absence of clear guidelines for the perioperative management of these patients presenting for plastic surgical practice, we have undertaken a pilot survey of the current practices of consultant plastic surgeons in the UK. The aims of this study were to determine whether there was uniformity of practice, and whether the modes of practice differed from those outlined in the literature for other related specialities. A postal survey of 235 plastic surgical consultants was conducted. The response rate was 48%. Overall, most respondents (84%) stated that their practice was primarily based on personal preference, and only 28% stated that it was based on the local Unit policy. Only 23% of the Consultants based their practice on evidence-based medicine. There appeared to be significant variations in current practice amongst plastic surgeons. Some aspects of practice were found to vary from those recommended in the literature for other related specialities. We hope that the findings of this study will highlight the significant non-uniformity of practice within this speciality and that this may form the basis for the development of clear guidelines of the entire spectrum of plastic surgery for the preoperative management of this group of patients in the future.

When are circular lesions square? A national clinical education skin lesion audit and study.

Background Skin cancer is the most prevalent cancer by organ type and referral accuracy is vital for diagnosis and management. The British Association of Dermatologists (BAD) and literature highlight the importance of accurate skin lesion examination, diagnosis and educationally-relevant studies. Methods We undertook a review of the relevant literature, a national audit of skin lesion description standards and a study of speciality training influences on these descriptions. Questionnaires (n=200), with pictures of a circular and an oval lesion, were distributed to UK dermatology/plastic surgery consultants and speciality trainees (ST), general practitioners (GP), and medical students (MS). The following variables were analysed against a pre-defined 95% inclusion accuracy standard: site, shape, size, skin/colour, and presence of associated scars. Results There were 250 lesion descriptions provided by 125 consultants, STs, GPs, and MSs. Inclusion accuracy was greatest for consultants over STs (80% vs. 68%; P<0.001), GPs (57%) and MSs (46%) (P<0.0001), for STs over GPs (P<0.010) and MSs (P<0.0001) and for GPs over MSs (P<0.010), all falling below audit standard. Size description accuracy sub-analysis according to circular/oval dimensions was as follows: consultants (94%), GPs (80%), STs (73%), MSs (37%), with the most common error implying a quadrilateral shape (66%). Addressing BAD guidelines and published requirements for more empirical performance data to improve teaching methods, we performed a national audit and studied skin lesion descriptions. To improve diagnostic and referral accuracy for patients, healthcare professionals must strive towards accuracy (a circle is not a square). Conclusions We provide supportive evidence that increased speciality training improves this process and propose that greater focus is placed on such training early on during medical training, and maintained throughout clinical practice.