Steven Lo

Implications of rationing and the European Working Time Directive on aesthetic breast surgery: A study of trainee exposure in 2005 and 2011

BACKGROUND There are concerns that current trainees may be lacking operative experience in aesthetic and functional breast surgeries. Reduced exposure to such cases during training may stem from rationing, EWTD compliance, and an increasingly consultant-led service. These issues are examined in a single NHS hospital, with analysis of trends over time, and are contrasted with the changes that have occurred in a related private hospital. METHODS A single NHS hospital trusts database was retrospectively analysed for all aesthetic breast surgeries from 2005 to 2011, noting the total number of cases and the grade of the principal surgeon. The analysis was repeated in a related private sector hospital in the same catchment area. RESULTS A statistically significant drop of 55% of NHS aesthetic breast surgeries performed in 2011 compared to 2005 was demonstrated with an increasing trend for consultant led procedures. The NHS caseload decline was matched by a corresponding increase of 57% within the private sector. CONCLUSIONS Current trainees in plastic surgery face a significant reduction in operative exposure to aesthetic breast surgeries compared to their predecessors due to the EWTD working hours, surgical rationing policies, and an increasingly consultant led service. Approaches to maintaining training standards are discussed.

A review of tissue glue use in facial lacerations: potential problems with wound selection in accident and emergency.

Objectives: The purpose of this study was to review the types of facial lacerations for which tissue glue was used as a closure method and assess whether current evidence was being followed. Methods: A retrospective analysis of facial lacerations presenting to an adult Accident and Emergency Department was made over a 6-month period. Results: Out of 200 facial lacerations, 45 were closed using tissue glue. The mean length of the wounds was 2.05 cm, with a range of 0.5–6 cm; 42 were linear and three were non-linear. Senior house officers closed 16 wounds, middle grade doctors closed 19, emergency nurse practitioners closed seven, and consultants closed three. Six cases were closed against current evidence (13%). This included three lacerations that were non-linear and three lacerations greater than 4 cm in length. Four out of six of these cases were closed by senior house officer grades (80%). Conclusion: The lack of clarity over the use of tissue glue for facial wounds may be attributable to a lack of awareness and training, and the misinterpretation of randomized trials. Greater awareness is needed of the role of tissue glue, especially among senior house officers.

Enabling the diagnosis of necrotising fasciitis without associated skin changes in a paediatric patient with acute lymphoblastic leukaemia: The LRINEC score ☆

Necrotising fasciitis (NF) is a rapidly progressive and lifethreatening soft tissue infection. Typically, associated skin changes range from purple red to dusky blue and necrosis in later stages. Diagnosis is based on clinical suspicion, and may be aided by a positive LRINEC (Laboratory Risk Indicators for Necrotising Fasciitis) score. This case reports NF presenting without typical skin changes in a paediatric patient with undiagnosed acute lymphoblastic leukaemia (ALL). A 6-year-old girl presented to paediatrics with pyrexia, abdominal tenderness and pain in the right knee and ankle. She had been generally unwell for the preceding 2 weeks with night sweats, vomiting and weight loss. On examination, a mild blanching rash was noted over her trunk, arms and legs. Her right limb was erythematous with tenderness in the right knee. Initial laboratory tests revealed pancytopenia with haemoglobin concentration 71 g/L, platelets 47 10/L, white cell count 2 10/L and significant neutropenia of 0.3 10/L. The Erythrocyte Sedimentation Rate was elevated at 110 mm/h while her biochemistry results showed hyponatremia (130 nmol/L), hypoalbuminaemia (27 m/L) and an elevated C-Reactive Protein (191). Antistreptyolysin (ASO) titres were positive while blood cultures revealed Group G Streptococcus (GGS) infection. She was treated with intravenous clindamycin and benzylpenicillin.

The importance of early flap coverage in deep sternal wounds.

BackgroundChronic or persistent wound infection is one of the key outcome measures after flap reconstruction in deep sternal wound infection (DSWI). This study aimed to assess potentially modifiable factors associated with chronic infection in patients undergoing flap reconstruction. Materials and MethodsAn analysis of a prospective database of 5239 median sternotomies performed during a 5-year period was carried out. Seventy-seven cases of DSWI were recorded, of which 23 cases proceeded to flap reconstruction. The flap-reconstructed patients were placed into groups according to the primary outcome measure of those who experienced chronic infection and those who remained infection free. ResultsOf the flap-reconstructed patients, 22% experienced subsequent chronic infection, whereas 78% remained infection free. The only 2 variables that were associated with chronic infection were the timing of flap reconstruction; median time 29.5 days (vs 12 days in the infection-free group), P = 0.011 and time taken from diagnosis of wound infection/dehiscence to referral to the plastic surgical team; median 21 days (vs median 8 days in the infection free group), P = 0.02.Each day of delay from the diagnosis of clinical infection to flap cover equated to an increase in risk of chronic infection of 1.2 times per day (OR = 1.205, P = 0.039). ConclusionsThis study suggests that chronic infection after flap reconstruction in DSWI is associated with late flap cover. We suggest the need for a consensus agreement on the combined care and early management of DSWI.

Vacuum-assisted closure should not replace conventional therapy in the treatment of sternal wounds

wide separation of parotid tissue from the tragal cartilage and SCM. This is a safe plain if dissection is performed superficial to SCM muscle fibres. feel for the base of the mastoid process and turn the finger deep to feel for the styloid process, both of which are exposed within the surgical field. identification of the facial nerve between the two processes, with the facial nerve usually deep to a small amount of fatty tissue and a small ‘sentinel’ artery.