Niri Niranjan

Structured assessment of microsurgery skills in the clinical setting

Microsurgery is an essential component in plastic surgery training. Competence has become an important issue in current surgical practice and training. The complexity of microsurgery requires detailed assessment and feedback on skills components. This article proposes a method of Structured Assessment of Microsurgery Skills (SAMS) in a clinical setting. Three types of assessment (i.e., modified Global Rating Score, errors list and summative rating) were incorporated to develop the SAMS method. Clinical anastomoses were recorded on videos using a digital microscope system and were rated by three consultants independently and in a blinded fashion. Fifteen clinical cases of microvascular anastomoses performed by trainees and a consultant microsurgeon were assessed using SAMS. The consultant had consistently the highest scores. Construct validity was also demonstrated by improvement of SAMS scores of microsurgery trainees. The overall inter-rater reliability was strong (alpha=0.78). The SAMS method provides both formative and summative assessment of microsurgery skills. It is demonstrated to be a valid, reliable and feasible assessment tool of operating room performance to provide systematic and comprehensive feedback as part of the learning cycle.

An anatomical method for re-siting the umbilicus

The umbilicus is the only normal scar on the body and it is the most noticeable scar following abdominoplasty and TRAM or DIEP flap procedures. We describe a technique for resiting the umbilicus that attempts to recreate the anatomical structure by attaching the superficial fascia to the periumbilical skin to produce a fullness around the depression in which the umbilicus sits. This is aesthetically desirable and avoids the uncomfortable tethering of the umbilicus to the rectus sheath associated with other techniques.

Vascularised Achilles tendon graft reconstruction--by the tendon for the tendon.

The management of posterior heel defects whether the result of trauma or post-operative that result in a loss of the Achilles tendon and overlying skin is complex and challenging. Various techniques have been employed to reconstruct these compound defects often comprising of a free tissue transfer combined with a fascial tendon reconstruction. We present a single-stage method of Achilles tendon reconstruction based upon a local vascularised tendon graft combined with a free antero-lateral thigh flap transfer and a review of the current literature.

Perineal reconstruction: From lotus petal to “canopy”. An alternative to the standard surgical algorithm

hydrocephaly, which affected nearly half of the horizontal diameter of the lumbar region. After the neural tube was closed in neurosurgery, the size of the cutaneous defect made the use of traditional coverage techniques impossible. After marking the gluteal myocutaneous propeller flaps, they were dissected under a magnification of 4.5. By pivoting, taking as an axis the superior gluteal artery, practically the entire defect could be covered (Figure 1). The most apical area required a random rhomboid flap to be applied for complete closure. The flaps survived entirely, with venous congestion noted in the immediate postoperative period (Figure 2). The patient was discharged 26 days after birth, having obtained coverage with thick, well-vascularised tissue. In our opinion, the double propeller flap based on the superior gluteal artery is an ideal option for the coverage of massive neural tube defects, avoiding the dissection of small perforators.

Perianal Paget's disease: a diagnostic dilemma

Perianal Pagets disease (PPD) is part of the spectrum of pagetoid skin lesions occurring outside the region of the nipple/areolar complex that are collectively referred to as extramammary Pagets disease (EMPD). However, unlike Pagets disease of the breast, which in the vast majority of cases is invariably associated with an underlying ductal carcinoma, most cases of EMPD occur as either insitu or invasive adenocarcinomas with visceral malignancy being a rare entity. We present a case of a 50-year-old man who was referred to us with PPD. This case highlights the difficulties associated with making a clinical diagnosis of this condition. Furthermore, investigative workup to exclude possible malignancy with associated metastatic spread as well as the treatment options available are also discussed. In addition, this case highlights the need for a multidisciplinary team approach when dealing with this difficult problem.

Innovative Techniques: A Novel Technique for Intraoperative Estimation of Breast Implant Size in Aesthetic and Reconstructive Breast Surgery

The estimation of breast implant size in both aesthetic and reconstructive surgery often is a matter of clinical and intraoperative trial and error, with subsequent differences in the resulting postoperative outcomes. Numerous techniques for preoperative estimation of implant size are in current use. However, although such techniques are inexpensive, they often are inaccurate and prone to error on the part of both the surgeon and the patient. Techniques for intraoperative estimation of breast implant size involve either the use of trial sizers or the surgeon’s own guesswork based on the preoperative consultation. A novel technique is presented that uses commonly available surgical gauze swabs. The senior author has applied this technique in both aesthetic and reconstructive breast surgery for many years. This easily reproducible method is inexpensive and produces reliable and highly satisfactory results.

Recipient vessel exposure in the axilla during microvascular breast reconstruction.

Over the years, the favored recipient vessels for microvascular breast reconstruction have changed from the thoracodorsal to the internal mammary vessels, mainly due to the deep position and poor exposure of the vessels in the axilla and all the technical difficulties this reflects. We used the simple maneuver of arm adduction during microvascular anastomoses in the axilla and compared it with the conventional method of abducted arm regarding the exposure of the vessels, the position of the operator and the assistant, and the operative time. We found that this innovation considerably improved the exposure of the vessels and the operators position, facilitating easier and faster anastomoses.

Retrograde dissection of the vascular pedicle of deep inferior epigastric artery perforator (DIEAP) flap.

The deep inferior epigastric artery perforator (DIEAP) flap became the gold standard in breast reconstruction, but the dissection has a steep learning curve and the most demanding stage is the intramuscular dissection of the vascular pedicle. We present a retrograde technique to dissect the deep inferior epigastric pedicle that permits completion of the dissection and check the viability of the flap on one side before progressing to the other, which can be used as a lifeboat. We consider this technique reliable, safer than the conventional technique, and a brilliant training model in DIEAP flap harvesting.

Tuberous breast deformity: A modified technique for single-stage correction

Introduction: Tuberous breast deformity is one of the most challenging congenital breast anomalies. Severe forms present as hypoplasia of lower medial and lateral quadrants and breast base constriction. We present a modified technique based on redistribution of breast tissue for single-stage aesthetic correction of this deformity. Material, Methods and Surgical Technique: The technique is based on Lejours method of single vertical scar breast reduction. The breast tissue is divided into three superiorly based pedicles. However, instead of joining the three pedicles, they are spread to redistribute tissue to quadrants which are deficient. This technique is combined with implant insertion if the breast volume is deficient or mastopexy if there is significant ptosis. The level of nipples is matched to achieve symmetry and areolar reduction done where indicated. We have used this for six patients with Type I/II/III (von Heimburg, 2000) tuberous breast deformity. Results and Discussion: The aesthetic results have been very good in terms of shape, volume, symmetry and patient satisfaction. A historical summary of the development of techniques for correction of tuberous breast is presented along with description of our method and its results.

Salvage of total loss of DIEP and skin envelope in breast reconstruction with tissue expansion

We present two cases of breast reconstruction using abdominal tissue expansion as a salvage procedure for those patients who have had multiple sequential complications using the traditional free flap techniques yet still request some form of reliable breast reconstruction.