Pari-Naz Mohanna

Donor-Site Hernia Repair in Abdominal Flap Breast Reconstruction: A Population-Based Cohort Study of 7929 Patients.

Background: The authors investigated hernia repair rates following pedicled transverse rectus abdominis myocutaneous (TRAM), free TRAM, and deep inferior epigastric perforator (DIEP) flap breast reconstruction in English National Health Service hospitals. Methods: Women diagnosed with breast cancer who underwent pedicled TRAM, free TRAM, or DIEP flap breast reconstruction procedures in English National Health Service hospitals between April of 2006 and March of 2012 were identified using the Hospital Episode Statistics database. Women who underwent mastectomy without reconstruction acted as controls, and hernia repair rates were calculated for all four groups. Multiple Cox regression was performed to estimate the relative risk of hernia repair among the reconstruction groups, adjusted for age, obesity, previous abdominal surgery, reconstruction year, and bilateral flap harvest. Results: Between 2006 and 2012, 7929 women had a DIEP or TRAM flap breast reconstruction. The overall hernia repair rate within 3 years was 2.45 percent after abdominal flap breast reconstruction, and 0.28 percent among the 15,679 women who had mastectomy only. Mean time to hernia repair following an abdominal flap harvest was 17.7 months. Compared with DIEP flaps, free and pedicled TRAM flap procedures were associated with adjusted hazard ratios of 1.81 (95 percent CI, 1.24 to 2.64) and 2.89 (95 percent CI, 1.91 to 4.37), respectively. The only independent risk factor for hernia repair was age older than 60 years (p = 0.039). Conclusions: Abdominally based autologous breast reconstruction carries a small risk of subsequent donor-site hernia repair. The rates herein can be used to inform patients and to assess quality of care across service providers. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Thermal injuries to autologous breast reconstructions and their donor sites – literature review and report of six cases

Breast reconstruction using autologous techniques has now become the gold standard. In recent years the focus has been on maintaining excellent cosmesis whilst minimising the incidence of partial or complete flap loss and donor site morbidity. However, an area which is frequently overlooked is the sequelae resulting from denervation of these flaps and their donor sites which can potentially lead to thermal injury. We report on six patients who sustained burns following free autologous breast reconstruction using either a DIEP or a muscle sparing TRAM. Four of the burns were confined to the flap skin paddle and two to the abdominal donor site. To prevent such thermal injuries all patients undergoing flap reconstruction should be educated regarding the vulnerability of the flap and its donor site as well as means of protecting these susceptible areas during daily activities.

Ascending hypopigmentation of the forearm following injection of triamcinolone.

Corticosteroid injections are used to treat a range of conditions that include keloid scarring, trigger finger and tenosynovitis refractive to other conservative interventions. Despite the common usage of steroid injections patients may not be adequately counselled and consented for their potential side effects. We report a case of hypopigmentation following treatment for De Quervain’s tenosynovitis which resulted in significant behavioural changes. A 23 year old right hand dominant African Engineer presented to the Accident and Emergency department with sudden onset of radial sided wrist pain and stiffness of his right thumb with no associated history of trauma. On examination tenderness was elicited over the first extensor compartment by palpation and passive movement of the thumb and a positive Finkelstein Test was exhibited. De Quervain’s tenosynovitis was diagnosed and the patient was initially prescribed oral non steroidal antiinflammatories and placed in a thumb spica splint. With no improvement after one month a peritendinous Triamcinolone injection (10 mg) was administered to the first extensor compartment with a further injection 6 weeks later. Complete resolution of symptoms occurred 4 weeks

Customised Silicone Prostheses

Chest wall deformities can be corrected with an array of procedures which include the use of fillers, pedicled muscle flaps and procedures involving alteration of the skeletal structure such as the Ravitch operation. In this chapter we describe the technical highlights, indications, preoperative considerations, surgical technique and the postoperative management of patients undergoing chest wall reconstruction using customised silicone prostheses.

A Randomized Control Trial Exploring the Effect of Mental Rehearsal and Cognitive Visualization on Microsurgery Skills

Background Many factors are known to influence the performance of surgeons within the operating theater, including tiredness, previous experience, and stress levels. The effects of mental rehearsal and cognitive visualization on microsurgical skills have not been assessed. Methods Thirty-six subjects recruited from the Northwick Park Microsurgery Skills Course were randomized into three groups; (1) a control group (C) with no mental rehearsal script, (2) a visual anastomosis group (VA), with a detailed rat anastomosis script, and (3) a visual relaxation (VR) group with a relaxation script, unrelated to the anastomosis. Participants ran through relevant scripts from day 2 to 5 and were assessed through recorded arterial rat anastomosis, scored using the structured assessment of microsurgery skills. Results Results were analyzed by double-blinded assessors. No statistical significance was found on Monday and Tuesday (first day post intervention), p = 0.326 (VA vs. C) and p = 0.283 (VR vs. C). A statistically significant difference was noted at the end of day 4; p < 0.001 (VA vs. VR) and p = 0.001 (VA vs. C). Further analysis demonstrated that domains within the global rating scoring system showed statistical significance for (1) dexterity: VA versus VR, p = 0.001, (2) visuospatial skills: VA versus VR, p = 0.001, and VA versus C, p = 0.002, and (3) operative flow: VA versus VR, p = 0.044, and VA versus C, p = 0.026. Conclusion The benefits of cognitive visualization and mental rehearsal in microsurgery may result in fewer complications from errors and thus lead to enhanced patient safety and better operative outcomes.

An elastic band foreign body circumferentially around the proximal phalanx, detected 2 years post injury

Constriction of digits by rings, rubber bands and hair has been reported in the literature and can affect any age group. Presentation is variable both in respect of timing and severity of the injury. We report on a rare case of elastic band constriction of a digit resulting in erosion of the extensor tendon and proximal phalanx. A sixty-three-year old right-handed woman was referred for a Plastic Surgical opinion. She presented with a 2-year history of a non-healing wound on the dorsum of her left ring finger proximal phalanx following a knock on the car hand brake. She had originally presented to the Emergency Department with a grossly swollen finger but no other associated injuries. Once her wedding band was cut off the swelling significantly improved. Three weeks later she noticed two areas of skin breakdown over the dorsum of the proximal phalanx. These areas began to over-granulate and were treated with silver nitrate sticks. This conservative management continued for 2 years until she was referred to the Plastic Surgery department. Examination revealed two area of over-granulation, over the dorsum and radial border of the left ring finger proximal phalanx. There was a 45 extension block of the PIPJ with normal sensibility. Radiographs demonstrated erosion of the underlying proximal phalanx (Figure 1). Surgical exploration under local anaesthesia revealed an elastic band wrapped circumferentially around the proximal phalanx at the site of the bony erosion with absence of the extensor tendon. The elastic band was not circumferentially intact and there was no evidence of a surrounding foreign body granuloma. Biopsies were taken of the area of over granulation, the surrounding skin and bone, and sent for microbiology and histological examination. Microbiology demonstrated no bacterial growth and histological examination showed normal granulation tissue and bone. The patient declined extensor tendon reconstruction.