Lilli Cooper

Systematic review: Early versus late dangling after free flap reconstruction of the lower limb

INTRODUCTION AND AIMS Dangling regimes after free flap surgery to the lower limb vary between centres and clinicians. There is currently no accepted gold standard. This review examines the evidence for early versus late post-operative dangling after free flap reconstruction of the lower limb. The secondary aim is to evaluate the regimes used. MATERIAL AND METHODS Medline, Embase and the Cochrane library were searched for all studies on dangling or rehabilitation after free flap reconstruction in the lower limb (December 2015). All studies outlining a clear dangling regime were included. Data were extracted by two authors independently and analysed using the software package Review Manager (RevMan 5). All authors were contacted for further information. RESULTS 197 patients were included from 8 studies: 1 randomized, 6 cohort and 1 case-series. Although some studies did not state the aetiology, of those that did; 42% were trauma, 31% oncology, 20% complex wounds and 7% infection. The majority of flaps were latissimus dorsi, 18% parascapular, 15% anterolateral thigh and the remainder was mixed. Forty-eight percent of patients dangled on post-operative day (POD) 7, 29% on day 6, 4% on day 5 and 18% on day 3, with varying regimes. A meta-analysis of comparable studies showed circulatory benefit after 4 days of dangling using tissue oxygen saturation as a measure. Four flap failures (2.0%) were reported. CONCLUSIONS There is physiological benefit in post-operative dangling. A 3-day flap training regime is sufficient for physiological training. However, the optimal flap training regime remains unclear. It may be appropriate to start dangling as early as POD 3. More research is needed to determine the optimal time to start dangling and the regime.

Developing a Three-Layered Synthetic Microsurgical Simulation Vessel

Background Microsurgery is increasingly relevant, and is difficult to learn. Simulation is relied upon ever more in microvascular training. While living models provide the ultimate physiological feedback, we are ethically obliged to optimize non‐living models to replace, refine, and reduce the use of animals in training. There is currently no three‐layered synthetic vessel available for microsurgical training. Methods A three‐layered synthetic vessel was designed with a simulation company. One anastomosis was performed by 14 microsurgical experts at one center. The realism of the vessel was assessed via user questionnaires and the construct validity using objective, validated task scores to assess the anastomosis performance and the final product. Videos were obtained, which were anonymized and marked remotely by a consultant plastic surgeon. Results The synthetic vessel intima and media displayed reasonable realism, while the adventitia was less realistic. Areas for improvement were identified. Both the task specific assessment score and the final product assessment appropriately identified experts. Conclusion A three‐layered synthetic model for microvascular training is a hygienic and useful intermediate‐level alternative to commonly used synthetic and ex vivo alternatives.

Free tissue transfer in patients with sickle cell disease: Considerations for multi-disciplinary peri-operative management

INTRODUCTION AND AIMS Sickle cell disease (SCD) is an increasingly common condition in the UK. The safety of free tissue transfer in these patients is controversial, and no specific guidelines exist. The aim of this paper is to create recommendations for the plastic surgical multidisciplinary team for use in the assessment and management of SCD patients undergoing free tissue transfer and reconstruction. METHOD A literature review was performed in PubMed of sickle [TiAb] AND plast* adj3 surg*. RESULTS Sickle cell disease is explained, as is the relative peri-operative risk in different genotypes of SCD. Acute and chronic manifestations of SCD are described by system, for consideration at pre-operative assessment and post-operative review. The evidence surrounding free tissue transfer and SCD is discussed and the outcomes in published cases summarised. An algorithm for peri-operative multi-disciplinary management is outlined and justified. CONCLUSION Free tissue transfer theoretically carries a high risk of a crisis, due not only to long anaesthetic times, but the potential requirement for tourniquet use, and the relatively hypoxic state of the transferred tissue. This paper outlines a useful, practical algorithm to optimise the safety of free tissue transfer in patients with SCD.

Dermoscopy in the assessment of pigmented lesions: NICE guideline NG14, 2015

Dermoscopy describes the in vivo microscopic inspection of skin lesions using polarised or non-polarised light. It can make the diagnosis of melanoma 9e15 times more likely than the naked eye alone. A meta-analysis of 12 studies and 6535 lesions by the National Institute for Clinical Excellence (NICE) revealed a sensitivity and specificity of 88% for dermoscopy compared to 70% and 82% for clinical examination. When converted to a hypothetical group of 1000 lesions, the benign lesions selected for biopsy was 18% with the naked eye and 12% with dermoscopy; the melanomas not selected for biopsy (missed) was 12% for dermoscopy and 30% for the naked eye. In recognition of this, NICE newly mandates its use by trained staff in the assessment of suspected melanomas. Dermoscopic photography is also recommended for the monitoring of clinically atypical melanocytic lesions which do not immediately warrant surgery. Plastic surgeons are at the cutting edge of skin cancer management in the United Kingdom (UK), yet a recent survey suggested that only 53% of plastic surgery trainees had used a dermatoscope (n Z 10/19) and only one had received training. It may be argued that dermoscopy is less relevant to plastic surgeons compared to dermatologists and general practitioners (GPs) since they receive a higher ratio of malignant/high risk to benign referrals. However, this overlooks high risk melanoma patients followed up by plastic surgeons and the small, but not insignificant, number of patients with incidental lesions after referral for other reasons. For all groups, even if excision biopsy is performed readily regardless, accurate diagnosis is required to rationalise or expedite treatment pathways. Of over 2000 lesions excised by plastic surgeons in one study, only 65% were correctly identified pre-operatively by clinical examination. Seven of a total of 10 melanomas were incorrectly diagnosed clinically, of which six had been

A modification of the collar-and-cuff sling to elevate the hand.

Elevation of the hand is routinely sought after surgery and with pathology such as inflammation and infection. Many models of sling have been described. The collar-and-cuff model is a traditional low-cost method that is easily learned and applied, is versatile, and customized to each patient. It is, however, frequently misapplied so that it immobilizes the arm but does not produce sufficient elevation. We describe a minor modification that achieves high elevation while retaining all other advantages.