Robert I.S. Winterton

The UK plastic surgery trainee

(1) Are you an StR or SpR? Have you completed the specialty fellowship exam? (2) How many years of plastic surgery training have you completed since the award of your NTN? (3) Did you undertake an intercalated degree as a medical student? (4) At what stage in your undergraduate/postgraduate training did you decide on a career in plastic surgery? Did you have a 2nd choice career path? (5) How many different cities have you worked in as part of your postgraduate training? (6) On appointment of your NTN did you hold a higher qualification? If so, how did you fund your higher degree? (7) How many years of plastic surgery experience did you have on appointment of your NTN? (8) On appointment of your NTN how many PubMed-listed publications did you have? How many of these publications were in the field of plastic surgery? How many of these publications were first-author publications? (9) On appointment of your NTN how many oral research presentations at national/international level did you have? (10) On appointment of your NTN how many poster research presentations at national/international level did you have? Dear Sir,

Free tissue transfers in the first 2 years of life – A successful cost effective and humane option

Experience shows that young children are favourable candidates for microsurgical reconstruction, having few of the established risk factors for flap failure. In childrens reconstructive surgery free tissue transfer (FTT) permits reconstruction whilst retaining growth potential, and reduces the overall number and duration of care episodes, and their related distress to the child and family. We present one centres experience of free tissue transfer in children less than 2 years of age, over a 15-year period, demonstrating that free tissue transfer can be successfully employed in children under 2 years old. Salient aspects of patient selection, pre-operative counselling, and per-operative management are presented. Data from all free flaps in children under 2 years of age at the time of surgery were collected prospectively. Forty-seven flaps were performed as 37 separate procedures, in 32 children under 2 years of age. In ten patients, double transfers were performed in single procedures. Free tissue transfers were performed for reconstruction of congenital defects, following trauma and meningococcal septicaemia. All but one flap survived. In our series operative and ischaemia times, re-exploration, complication and flap failure rates were not higher than in comparable adult or older paediatric series from this unit, suggesting that there is no microvascular, or other, factor inherent to the infant that should preclude the use of free tissue transfer. Individual microsurgeons with appropriate facilities should not be inhibited from performing free tissue transfers which are humane and cost effective when compared with alternatives for very young children.

Eyelid Surgery in Ocular Myopathies

ABSTRACT Objective: To retrospectively analyse surgical outcome and complications in patients with ocular myopathy undergoing ptosis correction and to introduce preoperative prophylactic lower lid elevation in this group. Methods: The medical records of all ocular myopathy patients who had undergone oculoplastic surgery between June 1995 and May 2006 were obtained. Patients’ demographics, surgical details and measurements, and complications were recorded. Results: 29 patients were identified; 21 with chronic progressive external ophthalmoplegia (CPEO), 7 with myotonic dystrophy (MD) and 1 with oculopharyngeal muscular dystrophy (OPMD). Then, 61 procedures to adjust eyelid height were performed, comprising levator resection, brow suspension, anterior lamellar repositioning, lower lid elevation and upper lid lowering. Palpebral aperture was significantly increased in all patient groups, by procedure and diagnosis, more significantly following brow suspension compared with levator resection. The patients’ feedback was very positive. Post-operative complications were few, included corneal exposure and ulceration, ptosis recurrence, arched brow, and sling infection, all of which were successfully treated. Conclusion: Our results demonstrate subjective and objective benefit following surgery in these patients, with a low complication rate. The use of pre-operative prophylactic lower lid elevation procedures is a promising modality.

An analysis of the cosmetic surgery experience acquired through UK plastic surgery training

AIMS Cosmetic surgery is an essential component of Plastic Surgery training. Our study demonstrates the average cosmetic surgery experience of UK Plastic Surgery registrars over their 6-year training scheme. Comparison is made with the operative requirements for the Certificate of Completion of Training (CCT) and the Royal College of Surgeons (RCS) Cosmetic Certification scheme. METHODS By using the web-based eLogbook, we analysed all the cosmetic surgery operations recorded by Plastic Surgery registrars during their specialist training. The weighted mean average number of procedures was calculated for different areas of cosmetic surgery practice, according to the level of supervision. The number of RCS cosmetic credits acquired for eight domains of cosmetic surgery was calculated, thus enabling comparison with the operative requirements for certification. RESULTS eLogbook data were collated for 454 registrars from 2010 to 2016 inclusive. Trainees participated in a mean of 122 cosmetic operations during their training (50% as an assistant), which satisfies the requirement of 100 procedures for CCT. The majority of trainee involvement (66%) was with cosmetic breast and body contouring cases. Comparison with the criteria for cosmetic certification reveals that on average, trainees could certify in cosmetic breast and body contouring surgery but would be unable to accredit in other areas of practice. CONCLUSIONS Current UK training affords sufficient cosmetic surgery exposure for CCT but offers a limited breadth of exposure. Trainees who wish to certify in cosmetic surgery of the head and neck region will likely be required to seek additional experience outside their deanery training programme.

An analysis of the operative experience of plastic surgery trainees in the United Kingdom using eLogbook

INTRODUCTION We performed a comprehensive analysis of the operative experience of UK Plastic Surgery Trainees using the web-based eLogbook. METHODS An analysis of data recorded prospectively by Plastic Surgery Registrars 2010-2014 in eLogbook. RESULTS The eLogbook data of 336 Specialty Registrars entered from 2010 to 2014 was analysed. Over the six-year training programme, trainees participated in a mean of 2117 procedures and performed a mean of 1571 procedures with or without supervision. We also determined the mean number of procedures for 14 indicative operative domains performed during training and compared these to current (2012) indicative numbers required prior to the award of a Certificate of Completion of Training (CCT). CONCLUSION The eLogbook contains valuable data to determine the operative experience of UK Plastic Surgery trainees. This new data will be reflected in the updated indicative numbers required for CCT. Both trainees and trainers may use the data to monitor the acquisition of operative experience over time and target training where necessary.

Towards a global plastic surgery research network

Sir, Regenerative medicine has enormous potential to transform plastic surgery and the care we provide to our patients. This rapidly progressing scientific field has its basis in the restoration of form and function, which closely mirrors the goals of plastic and reconstructive surgeons worldwide. The convergence of bioengineering and stem cell technology can be expected to revolutionise treatment for patients with wide ranging reconstructive requirements during the twenty-first century [1–3]. Plastic surgery has a strong reputation for being highly innovative [4] and competitive [5], and attracts some of the most talented young clinicians. These factors ideally place the specialty to fully capitalise on the translational potential of cutting edge science, delivering it to the bedside for actual patient benefit. However, the implementation of novel regenerative strategies needs the support of a comprehensive international research base and the current global plastic surgery research infrastructure may not be adequate. At present, no explicit facility exists to foster international collaboration between plastic surgeons undertaking this type of research. Given the speed at which regenerative biology is progressing, such an initiative would be pivotal to ensuring that the specialty is poised to harness and build upon groundbreaking scientific discoveries [1]. The formation of an electronic network of plastic surgery researchers will be an invaluable asset to the global plastic surgery research community and will uniquely serve as a focal point for those wishing to approach the specialty for interdisciplinary collaboration. It is vital that we are open and accessible to our nanotechnology, bioengineering, and biotechnology colleagues, in order to translate scientific advances to the operating theatre and fulfill our potential as a pioneering medical specialty. Whilst the specialty is fortunate to have existing outlets for high quality research, conducted by very capable plastic surgeon scientists, as well as opportunities to interact at comprehensive scientific meetings, a dedicated arena for these individuals to congregate on a more frequent basis is not currently widely available. The creation of a broadly appealing, readily available online environment will provide new opportunities for individuals to recognise common scientific interests, form alliances and discuss novel research ideas. Such a facility would optimise research output within the specialty. Whilst similar online tools exist for a wider scientific audience, the creation of a dedicated plastic surgery research hub will provide a gateway to those wishing to collaborate with the plastic surgery community. This would be well received given where the future of the specialty lies and may contribute to increased research income for plastic surgeon scientists, as well as the creation of more research units. F. Y. Saldanha School of Clinical Medicine, University of Cambridge, Cambridge, UK

Lower lip reconstruction with a radial forearm–palmaris longus free flap and additional “cattle gate” bar of palmaris longus tendon

We report a patient in whom we reconstructed a full thickness 95% lower lip defect after excision of a large squamous cell carcinoma. A composite free radial forearm–palmaris longus flap was used with an additional length of palmaris longus tendon to add support to the inferior part of the flap. We believe that this extra bar of palmaris longus graft can add important structure to an otherwise unsupported part of the reconstruction.