Jonathan A. Dunne

Is sentinel lymph node biopsy warranted for desmoplastic melanoma? A systematic review

BACKGROUND Desmoplastic melanoma (DM) is an uncommon malignancy associated with a high local recurrence rate. The aim of this systematic review was to determine the positivity rate of sentinel lymph node biopsy (SLNB) in patients with DM. The secondary outcome was to establish if SLNB is warranted for both pure DM (PDM) and mixed DM (MDM). METHODS A full systematic literature review of SLNB in DM was performed by two authors in January 2016. Ovid MEDLINE, Ovid EMBASE and the Cochrane Central Register of Controlled Trials were searched. RESULTS Sixteen studies involving 1519 patients having SLNB in DM were included, of which 99 patients had positive SLNB (6.5%). Two articles reported a significantly reduced disease-free survival (DFS) with positive SLNB and three published a reduced melanoma-specific survival (MSS). Six studies compared SLNB in MDM and PDM. Of the 275 patients, 38 (13.8%) had a positive SLNB in MDM compared to 17 of 313 patients (5.4%) with positive SLNB in PDM. CONCLUSIONS Rates of positive SLNB in DM are reduced compared to other variants of melanoma; however, nodal status may still predict DFS and MSS. MDM is associated with a higher rate of micro-metastases to regional lymph nodes than PDM, and DFS and MSS may be lesser in MDM than in PDM. We would recommend the consideration of SLNB in MDM. However, with such low rates of positive SLNB in PDM, and in the absence of high-risk features to stratify patients, we would not recommend SLNB in PDM.

Electrical burn injuries secondary to copper theft

overhead power lines (33,000 V). The risk of burns in this activity is significant, and may account for up to 10 % of electrical burns presenting to a regional unit [5]. We report three of these complex cases presenting between 2007 and 2011. All cases were males, aged 22, 25 and 42 years, sustaining burns of 32, 45 and 16.5 % total body surface area (TBSA), respectively. All patients survived, and there was a mean length of stay of 47 days (range 32–59) and all patients were involved in theft from 11,000 V electrical substations. Burns primarily affected the head, neck, trunk and upper limbs. In the patient with 16.5 % burns, the depth was all full-thickness, however, the other two cases had mixed depth burns. All patients required admission to intensive care, with a mean period of intubation of 8 days (range 2–18). The mean number of acute procedures was 7 (range 5–8), while two patients had immediate upper limb fasciotomies, one of which later required amputation. Multiple secondary procedures have been required, in particular to reconstruct hands and the head and neck (mean 2, range 1–4). Reconstruction has consisted of debridement, contracture releases and split-thickness skin grafts. One patient had an external fixator applied to the first web space following contracture release, having declined free flap reconstruction. Invariably, burns and related injuries occurring after copper theft from electrical substations carry substantial morbidity [6], and other studies have recognised an increase in case frequency [7]. Theft of copper may lead to electrical, flash or contact burns, and the patient may sustain blast effects with associated traumatic injuries. The cost of health care is considerable both acutely and longer-term, as rehabilitation and reconstruction may be life-long. Based on current data [8], the cost of acute bed days alone for these three patients combined was £147,000. The We welcome the paper by Duci et al. [1], highlighting the complexity and high mortality of electrical injuries, requiring management in a dedicated burns service. Of the high voltage injuries, two committed suicide and the remainder were accidental, with injuries in the workplace commonest. We would like to highlight copper theft as an international cause for high voltage electrical injury, with an illustration of cases over a 5-year period from the Yorkshire regional burns unit in the United Kingdom (UK). Prevention strategies are essential to reduce these devastating injuries. Copper price has risen dramatically in recent years, with a six-fold increase over the past decade and a large demand from booming economies such as China. Metal theft is one of the fastest rising crimes in the UK, [2] and during sharp price increases scrap copper may reach 90 % of the value of new copper [3]. Approximately 100 copper thefts per month occur in the UK, and the number correlates with a rise in price [4]. Sites with abundant copper are commonly sources of high voltage, such as electrical substations (11,000 V) and

A survey of microsurgery training among UK plastic surgery and maxillofacial surgery trainees.

Microsurgery continues to be a fundamental technique in many surgical subspecialties. It is an integral part of several specialty programs, such as plastic surgery, vascular surgery, maxillofacial, and ENT surgery. The ultimate goal of every surgical training program is to produce competent professionals capable of meeting the healthcare needs of society. Our aim in this survey was to compare microsurgical experience among the two surgical subspecialty programs deemed to have the highest microvascular workloads; plastic and maxillofacial surgery. An online survey was developed, compromising 13 questions on microsurgery training, experience, and satisfaction. The survey was disseminated online through national trainee organizations and at trainee days. All trainees of all levels in all the deaneries (training regions) of the UK and Ireland were asked to complete the survey. Trainees not in a training program and junior trainees, such as core surgical trainees, were excluded. In this study, where the answers were for the number of procedures, the choices given were in categories; 1–3, 4–7, 8–10, 11–13, 14–17, 18–20, and more than 20 (Table 1). Seventy-seven responses were received. One trainee in a nontraining program and two others in the core surgery training program where excluded. Of the included 74 trainees, 34 (46%) were plastic surgery trainees and 40 (54%) were maxillofacial trainees. Forty-seven percentage of the plastic trainees and 50% of the maxillofacial trainees were in the first 3 years of their training (ST 3–5). All the trainees have attended at least one microsurgical training course before or during their training period. Nine plastic surgery and six maxillofacial surgery trainees did not answer the question regarding happiness with their training program. Of the trainees who answered this question 15 of the plastic surgery group (60%) and nine (26%) of maxillofacial group were unhappy with the microsurgery training they are receiving. Overall 79% of the plastic surgery trainees and 75% of the maxillofacial surgery trainees said that they have assisted in more than 20 free flaps procedures (Table 1). The results also show that 59% of the plastic surgery trainees and 50% of the maxillofacial surgery trainees have assisted in microsurgery anastomosis. However, only 20% of the plastic surgery group and 27% of the maxillofacial group has actually performed microsurgical anastomosis. The commonest free flaps encountered during the period of plastic microsurgery training program are deep inferior epigastric perforator flap and transverse rectus abdominus myocutaneous flaps. Following this are the free radial forearm flap (RFF), anterolateral thigh (ALT) flap, and the free Latissimus Dorsi flap. These differ to maxillofacial training experience in this cohort who most commonly were exposed to RFF, fibular flap and the ALT Flap. Both plastic and maxillofacial surgery trainees felt they were competent raising the RFF (Table 2). Only 13 (38%) of the 34 plastic surgery trainees and 16 (40%) of the 40 maxillofacial surgery trainees feel *Correspondence to: Ammar Allouni, MB.Bch, M.Sc., MRCS, Department of Plastic Surgery, University Hospital of North Durham, North Road, Durham DH1 5TW, UK. E-mail: Allouni@hotmail.com Received 13 February 2014; Revision accepted 9 March 2014; Accepted 11 March 2014 Published online 24 March 2014 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/micr.22251

RE: Pleomorphic adenomas: Post-operative radiotherapy is unnecessary following primary incomplete excision: A retrospective review

which is undertreatment of BCC as per the guidelines established by Telfer et al., in 2008. The surgical management of primary basal cell carcinoma, the commonest skin cancer in humans, is highly effective with recurrence rate as low as <2% in a completely excised lesion. In a large series of treatment of two thousand-sixteen BCC, Breuninger & Dietz clearly demonstrated the subclinical infiltration of BCC (lesion up to 10 mm in diameter) as high as 30% in ones resected with 2 mm, 16% with 3 mm and 5% with 5 mm margin. It further increases to 48, 34 and 18% with 2, 3 & 5 mm margin respectively for BCC with diameter of 10e20 mm. Wettstein et al. demonstrated recurrence in one out of 13 patients in control group treated with surgery compared to none in the study group of 10 patients treated with surgery with intralesional injection of interferone-a 2b. In the view of inadequate peripheral excision margin, the recurrence in control group cannot be validated. Although the team mentioned about all the specimens having undergone frozen section (FS) analysis, frozen section itself lacks 100% accuracy. As established in a large study across 34 hospitals by Howanitz & colleagues, there was 3.5% discordance between frozen section and final histologic diagnosis, furthermore, they also mentioned about previous reporting of FS accuracy rate as low as 89%. On the basis of all these, the authors conclusion about the use of interferon-alpha with surgery in future to decrease the rate of recurrence without additional morbidity is dubious in the absence of appropriate controls.

A national audit of compliance with specialist skin cancer quality improvement guidelines.

permits further rotation and easier closure of the donor defect. Any resulting standing cone at the apex of the rotation flap can then be excised, provided this will not compromise flap vascularity. We recommend this technique for appropriate cases because it provides a reliable lifeboat when the axillary defect is large and a posterior arm flap would provide inadequate coverage or direct closure of the donor defect would create undue tension. This combination provides skin with comparable colour and thickness to axillary skin, minimises wound tension and avoids tight scars and reduced range of moment in the shoulder in the postoperative period. It does, however, place additional scars on the lateral chest wall.

Guidelines on body recontouring after bariatric surgery are available

Bucknor and colleagues rightly state that recently updated National Institute for Health and Care Excellence (NICE) guidelines for management of obesity did not include reconstructive body contouring surgery after massive weight loss.1 However, NICE accredited national commissioning guidelines for such surgery were published in 2014, to standardise referrals and avoid …

Re: Introduction of new techniques in burn care in Australia and New Zealand: a survey

We read with interest the article by Kim et al. regarding new burn care techniques in Australia and New Zealand, and would like to highlight the important and complementary role of new technologies. Telehealth involves transmission of digital images and video, and specialist assessment of acute burn injuries by video link and direct inspection has been shown to correlate closely. It may differ significantly from the referring physician, emphasizing the importance of specialist input. Regional burn care units are particularly suited due to the large geographical areas in Australasia. Burn telehealth may lead to savings due to the avoidance of air transport costs; however, the number of sites with video conferencing equipment is restricted by expense. The rapid rise and advanced computer capabilities of smartphones may provide a solution, and a recent study in the U.S. military highlights their potential. Smartphones must ensure data protection, and the new Australian app PicSafe Medi permits remote storage of data, maintaining confidentiality. Opportunities linked to smartphone use are not limited to highincome countries (HIC). Africa is the fastest growing mobile phone market in the world, and Samsung estimates 7% are smartphones. Greater outreach to Australasia’s Pacific and Asian neighbours may be possible, with smartphone videoconferencing feasible across the globe. There is increasing demand for healthcare information online; however, the majority of smartphone burn apps do not specify how long first aid is required for. A significant number of patients do not receive adequate first aid at the first point of health care contact, and more apps educating on early burn management may be effective for both the public and healthcare professionals. In conjunction with evolving techniques, we strongly advocate the use of new technology in burn care to educate on prevention, improve first aid and permit greater access to specialist services.

MY plastic surgery course

The inaugural MY plastic surgery course was held over two days at Hatfield Hall, Wakefield. The faculty consisted of plastic surgery consultants from Pinderfields General Hospital, Wakefield, and plastic surgery registrars from Yorkshire. The course convenors were Mr Majumder, a plastic surgery consultant at Pinderfields General Hospital, and Mr Pinder, a plastic surgery year 5 specialist trainee. The aim of the course was to provide a broad overview of each of the wide range of subspecialties represented, coupled with practical development of dexterity and confidence in plastic surgical techniques. It is aimed at those considering a career in plastic surgery and attracts mainly foundation year doctors but also medical students and core surgical trainees. The absence of plastic surgery from the medical school curriculum and the limited exposure available at foundation level mean that many students and trainees have a limited knowledge of the realities of plastic surgery. Despite undertaking special study modules and theatre experience, as foundation year 2 doctors planning …