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Background Plastic surgery training in the UK continues to evolve towards an outcome-based rather than time-served curriculum. UK plastic surgery trainees are appointed nationally, and are assessed according to national standards, but training is delivered regionally. This study sought opinion from current UK plastic surgery trainees in order to highlight strengths and shortcomings of the higher surgical training programme. Method A cross-sectional study was designed and administered by the UK Plastic Surgery Trainees Association (PLASTA). A questionnaire was distributed to all UK plastic surgery trainees holding a National Training Number, using the REDCap web-based application. Results Of the 320 UK plastic surgery trainees, 131 (41%) participated in this survey, with responses from all 12 UK training regions. The most common subspecialty career aspirations for trainees were hand surgery, cleft lip and palate, lower limb and oncoplastic breast reconstruction. The survey highlighted regional variation in teaching programmes, the ability to achieve indicative operative logbook numbers, and training in aesthetic surgery. Of the trainees, 82% expressed a desire to undertake a fellowship within their training, but most did not know whether their deanery would support this. Fifteen per cent of the respondents were currently training flexibly and the majority of these had experienced negative behaviours towards their less than full time working status. Of the respondents, 44% reported stress, 25% reported a lack of autonomy and 17% reported feeling burnt out at work at least once a week. A total of 85% perceived that they did not have access to a mentoring service. Conclusions Plastic surgery remains a popular and highly competitive surgical speciality in the UK, and many trainees reported high levels of satisfaction during their training. Aspects of training that could be improved have been highlighted and recommendations made accordingly.

Background The current study introduces and demonstrates our experience of using a sequential thoracoacromial artery perforator (TAAP) flap to repair the sternocleidomastoid (SCM) flap donor site in this context. The aims of this technique are to optimize both esthetic and functional outcomes and to reduce postoperative complications for patients. Methods Between September 2013 and March 2017, the SCM flap combined with sequential TAAP flap was used for reconstruction postradical parotidectomy in 12 patients. Flap characteristics, patient outcomes, and postoperative complications were monitored and objectively measured, with 10 to 24 months of follow-up. Results There were no incidences of total flap loss. All TAAP flap donor sites were closed directly, and all healed without any complications. The SCM flap and TAAP flap donor areas were esthetically acceptable, with good esthetic and functional outcomes achieved in all 12 patients. Conclusions The sequential TAAP flap has a consistent vascular supply and provides a reliable surgical approach to reconstruct the SCM flap donor site with good esthetic and functional outcomes.

Aim Flexor digitorum profundus (FDP) avulsion or Jersey finger is a common injury in hand trauma. Common methods of surgical repair include Mitek bone anchor or a pull-out technique using tunnels drilled through the bone. We present a novel method of FDP tendon repair using extraosseous tunnels. Method Once the avulsed FDP tendon is retrieved, a double-Kessler or Krakow repair is performed with a 3-0 Prolene suture through the distal FDP tendon. Extraosseous tunnels are created either side of the distal phalanx using 18-gauge needles passing through the nailplate and sterile matrix, avoiding the germinal matrix. Suture ends are then passed through the needles. After removing the needles, the suture is knotted over a Jelonet roll. We reviewed this method in a cohort of 16 paediatric and adult patients with FDP avulsion or division at its insertion. Patients were followed-up for at least 6 weeks. All patients underwent post-operative rehabilitation with hand therapists. Function was measured subjectively and using distal interphalangeal joint (DIPJ) flexion and loss of extension. Results 14 patients regained normal or near-normal function. The remaining two had significant polytrauma and developed complex regional pain syndrome. Mean range of DIPJ flexion was of 49.6° at a mean of 11 weeks’ follow-up, mean loss of extension was 11.6°. Conclusions Our results show good outcomes comparable to those in the literature using existing methods. This method is simple and requires no complex instrumentation while providing reliable FDP fixation.

This article portrays the authors’ clinical experience of a complex case of lower extremity reconstruction using a recycled pedicle from 10 years old free latissimus dorsi musculocutaneous flap to supply a new free anterolateral thigh flap for proximal tibia wound defect reconstruction. It provides clinical evidence that muscle neovascularization occurs and supports the dogma peripheral tissue neovascularization. This case stipulates that recycling of pedicle is feasible, when used with appropriate strategy and safety and also provides evidence for the long-term survival of greater saphenous vein grafts in lower extremity reconstruction.

Supplemental Digital Content is available in the text., Background: There is no international consensus on the use of perioperative thromboprophylaxis in digital replantation. Suboptimal perioperative management may lead to replant failure, which compromises extremity function, worsens psychosocial outcomes for patients, and incurs significant cost. This systematic review evaluates and compares the efficacy and safety of perioperative antithrombotic protocols used in digital replantation. Methods: A Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)--compliant prospectively registered (PROSPERO, CRD42018108695) systematic review was conducted. Cochrane Central Register of Controlled Trials, Medline, EMBASE, and Scopus were searched up until December 2019. Articles were assessed for eligibility in duplicate by 2 independent reviewers. All comparative studies that examined the use of perioperative thromboprophylaxis in digital replantation were eligible for inclusion. Results: Collectively, 1,025 studies were identified of which 7 met full inclusion criteria reporting data from 635 patients (908 digital replants, 86% men, average age 37.3 years). Laceration was the most commonly reported mechanism of injury (68%), with 33% of replantation occurring in Tamai zone III. Fourteen distinct perioperative protocols were identified. One study reported significantly higher digital survival with continuous heparin infusion versus bolus heparin. Five studies demonstrated a significantly higher incidence of complications among patients treated with systemic heparin. Conclusions: The clinical efficacy and safety of perioperative antithrombotic therapy following digital replantation remains equivocal. The perceived benefits of improved digital survival must be tempered against the adverse systemic side effects of antithrombotic and anticoagulant therapies until further prospectively collected data sets become available.

Therapeutic mammaplasty (TM) may be an alternative to mastectomy, but few well designed studies have evaluated the success of this approach or compared the short-term outcomes of TM with mastectomy with or without immediate breast reconstruction (IBR). Data from the national iBRA-2 and TeaM studies were combined to compare the safety and short-term outcomes of TM and mastectomy with or without IBR.The subgroup of patients in the TeaM study who underwent TM to avoid mastectomy were identified, and data on demographics, complications, oncology and adjuvant treatment were compared with those of patients undergoing mastectomy with or without IBR in the iBRA-2 study. The primary outcome was the percentage of successful breast-conserving procedures in the TM group. Secondary outcomes included postoperative complications and time to adjuvant therapy.A total of 2916 patients (TM 376; mastectomy 1532; mastectomy and IBR 1008) were included in the analysis. Patients undergoing TM were more likely to be obese and to have undergone bilateral surgery than those having IBR. However, patients undergoing mastectomy with or without IBR were more likely to experience complications than the TM group (TM: 79, 21·0 per cent; mastectomy: 570, 37·2 per cent; mastectomy and IBR: 359, 35·6 per cent; P 0·001). Breast conservation was possible in 87·0 per cent of patients who had TM, and TM did not delay adjuvant treatment.TM may allow high-risk patients who would not be candidates for IBR to avoid mastectomy safely. Further work is needed to explore the comparative patient-reported and cosmetic outcomes of the different approaches, and to establish long-term oncological safety.La mamoplastia terapéutica (therapeutic mammaplasty, TM) puede ser una alternativa a la mastectomía, pero hay pocos estudios bien diseñados que hayan evaluado el éxito de esta estrategia o hayan comparado los resultados a corto plazo de la TM con la mastectomía con o sin (+/-) reconstrucción mamaria inmediata (immediate breast reconstruction, IBR). Para comparar la seguridad y los resultados a corto plazo de la TM y la mastectomía +/- IBR se combinaron los datos de los estudios nacionales iBRA-2 y TeaM. MÉTODOS: En el estudio TeaM se identificó el subgrupo de pacientes al que se realizó una TM para evitar la mastectomía y se compararon los datos demográficos, las complicaciones, los resultados oncológicos y el tratamiento adyuvante con las pacientes sometidas a mastectomía +/- IBR del estudio iBRA-2. La variable principal fue el porcentaje de éxito de la cirugía conservadora de mama en el grupo TM. Las variables secundarias fueron las complicaciones postoperatorias y el intervalo de tiempo hasta el inicio del tratamiento adyuvante.Se incluyeron en el análisis 2.916 pacientes (TM n = 376; mastectomía n = 1.532; IBR n = 1.008). La TM era más frecuente en pacientes obesas o en las sometidas a cirugía bilateral en comparación con las pacientes con IBR. Sin embargo, las pacientes sometidas a una mastectomía +/- IBR tenían más probabilidades de desarrollar complicaciones que las del grupo TM (TM n = 79, 21,0%; mastectomía n = 570, 37,2%; mastectomía y IBR n = 359, 35,6%; P 0,001). La conservación de la mama fue posible en el 87% de las pacientes con TM y el procedimiento no retrasó el inicio del tratamiento adyuvante. CONCLUSIÓN: La TM puede permitir que pacientes de alto riesgo que no serían candidatas a IBR eviten la mastectomía de una forma segura. Se necesitan más trabajos para comparar los resultados percibidos por las pacientes y los estéticos de las diferentes estrategias terapéuticas y establecer la seguridad oncológica a largo plazo.

Selective non-operative management (SNOM) has been proposed as a safe and adequate strategy for penetrating extremity trauma (PET) management. This may reduce unwarranted surgical exploration and enhance cost-effectiveness. Our experience at a UK major trauma centre advocates SNOM-PET as a viable and safe strategy for selected patients. A PET management algorithm is proposed.A retrospective review was undertaken for isolated PET from October 2015 to October 2016. Examination findings were recorded as positive if neurovascular or tendon deficits were elicited. Surgical exploration was recorded as positive if neurovascular or tendon injuries were found. Diagnostic statistics were employed for upper limb (UL) and lower limb (LL) examinations.One hundred sixty patients [112 UL and 48 LL PET injuries] were included. Fifty-six out of 112 (50%) patients with UL PET had no examination findings. Twenty-three out of 56 (41%) patients had negative surgical explorations and 33 of 56 (59%) patients had positive surgical explorations. Thirty-four out of 48 patients with LL PET had no examination findings. All 34 patients had negative surgical explorations. The sensitivity (0.61 vs 1.00, p = 0.005), specificity (0.82 vs 0.97, p = 0.043) and negative predictive value (NPV; 0.41 vs 1.00, p 0.001) were lower for UL PET than for LL PET examinations. There were no statistically significant differences in sensitivity, specificity as well as NPV and positive predictive value between plastic surgery residents and emergency medicine residents for UL and LL examinations.This is the first UK evaluation of SNOM-PET. It may be safely utilised for LL PET. UL PET should be surgically explored. SNOM-PET may avoid unwarranted surgical exploration, associated complications and cost.

Purpose Gold standard recipient arteries in head and neck free flap microvascular reconstruction are currently branches of the external carotid. However, these arteries can be compromised by neck dissection or radiotherapy, resulting in ‘vessel-depleted neck’ and ‘frozen neck’ respectively. In such cases, the transverse cervical artery (TCA) may be a suitable recipient artery. Methods The origin, course and diameter of the TCA were determined in 46 sides of neck from 23 cadavers. The distances from the origin of the TCA to the angle of the mandible, floor of the mouth and mandibular symphysis were measured to determine the pedicle length required for free flap anastomosis. Results The TCA was present bilaterally in all subjects investigated and its course across the posterior triangle of the neck was constant between individuals. The mean distances from the origin of the TCA to the angle of mandible, floor of mouth and mandibular symphysis were 10.0, 9.2 and 12.6 cm, respectively. There were no significant differences in these distances between the left and right sides of the neck (p > 0.05 for all comparisons). The distances from the TCA origin to the angle of the mandible and floor of the mouth were significantly longer in males than in females (p = 0.004) and correlated directly with the greater height of males compared to females (p = 0.0004). The mean diameter of the TCA measured 2 cm from its origin was 2.2 mm. Conclusion The TCA is a suitable and reliable recipient artery for free flap microvascular reconstruction, when branches of the external carotid artery are unavailable.

Deep inferior epigastric artery perforator (DIEP) flap has become the gold standard in autologous breast reconstruction. Attention is now being focused on the impact of DIEP flap harvest technique on abdominal hernia rates. The aim of this study was to evaluate DIEP abdominal wall morbidity in relation to flap harvest and fascial closure technique. A retrospective analysis of patients undergoing DIEP flap breast reconstruction between 2012 and 2016 was performed. Post-operative evaluation of the abdominal wall integrity was performed by an operating consultant. The rectus fascia was closed using one of three techniques. The study included 202 patients, in whom 234 DIEP flaps were performed. Eight patients (3.4%) developed a clinically evident abdominal bulge post-operatively and one (0.5%) had a hernia. Harvesting two or more perforators was more likely to result in post-operative abdominal hernia/bulge than taking a single perforator (

Articular cartilage is renowned for its poor intrinsic capacity for repair. Current treatments for osteoarthritis are limited in their ability to reliably restore the native articular cartilage structure and function. Mesenchymal stem cells (MSCs) present an attractive treatment option for articular cartilage repair, with a recent expansion of clinical trials investigating their use in patients.This paper provides a current overview of the clinical evidence on the use of MSCs in articular cartilage repair.The article demonstrates robust clinical evidence that MSCs have significant potential for the regeneration of hyaline articular cartilage in patients. The majority of clinical trials to date have yielded significantly positive results with minimal adverse effects. However the clinical research is still in its infancy. The optimum MSC source, cell concentrations, implantation technique, scaffold, growth factors and rehabilitation protocol for clinical use are yet to be identified. A larger number of randomised control trials are required to objectively compare the clinical efficacy and long-term safety of the various techniques. As the clinical research continues to evolve and address these challenges, it is likely that MSCs may become integrated into routine clinical practice in the near future.

It is widely accepted that during postnatal development trabecular bone adapts to the prevailing loading environment via modelling. However, very little is known about the mechanisms (whether it is predominantly modelling or remodelling) or controls (such as whether loading influences development) of fetal bone growth. In order to make inferences about these factors, we assessed the pattern of fetal trabecular development in the humerus and femur via histomorphometric parameter quantification. Growth and development (between 4 and 9 months prenatal) of trabecular architecture (i.e. thickness, number and bone volume fraction) was compared across upper and lower limb bones, proximal and distal regions, and sexes. The data presented here indicate that during prenatal development trabeculae became thicker and less numerous, whilst bone volume fraction remained constant. This partly mimics the pattern of early postnatal development (0-2 years) described by other researchers. Thickness was reported to increase whilst number reduced, but bone volume fraction decreased. This is perhaps because the balance of bone modelling (deposition vs. resorption) changes post partum. Published histological data suggest that bone deposition slows after birth, while resorption rates remain constant. Hence, fetal development may be characterized by relatively high rates of modelling and, particularly, bone deposition in comparison to postnatal. With respect to measures of thickness, number and bone volume fraction prenatal development was not bone, site, or sex specific, whilst postnatally these measures of architecture diverge. This is despite reported developmental variation in the frequency, speed and amplitude of fetal movements (which begin after 11 weeks and continue until birth), and probably therefore loading induced by muscular contractions. This may be because prenatal limb bone micro-architecture follows a generalised predetermined growth trajectory (or genetic blueprint), as appears to be the case for gross distribution of trabecular tissue.

Single-incision laparoscopic surgery (SILS) is a safe approach for cholecystectomy, with the potential to minimise the iatrogenic trauma sustained from the operation. However, a number of reports show SILS to be technically challenging and as such there is expected to be a significant learning curve for expert surgeons adopting the new technique, as well as for junior surgical trainees. There are inherent risks to patient safety associated with practicing and developing new skills in a real-life theatre environment. However, thus far, there have been no realistic SILS training models available. We tested the feasibility of conducting SILS cholecystectomies on a cadaveric porcine model with standard operating equipment, which may provide a platform to facilitate safe training and assessment protocols. In this paper we provide an account of the training model technique, and review the literature surrounding SILS training and performance evaluation.

We have entered an age which our mentors did not have the luxury of experiencing during their training. Young residents can go onto various online platforms and learn stepwise aesthetic and reconstructive procedures recorded on video. Educational platforms such as the RADAR Resource (http://www.surgery.org/radar), provided by the American Society for Aesthetic Plastic Surgery (ASAPS), and the Plastic Surgery Education Network (http://www.psenetwork.org), provided by the American Society of Plastic Surgeons (ASPS), are available to all surgeons worldwide. Electronic videos and smartphone applications now render most surgical textbooks obsolete.1 Furthermore, patients can access social media sites such as YouTube (San Bruno, CA), Facebook (Menlo Park, CA), and Twitter (San Francisco, CA) and can acquire increased exposure and a basic understanding of aesthetic surgery with only a finger touch. Recently there has been a focus on sharing aesthetic procedures live on newer social media platforms, …

Digital replantation is nowa routine procedure formany hand surgery units.1 Skeletal shortening is important to allow the direct repair of structures in replantation. Good alignment can be technically challenging; however, time spent securing optimal osteosynthesis will make the subsequent steps far easier.2,3 We describe a technical tip that can allow for safer and more precise skeletal shortening. A 29-year-old male forestry worker presented with a combination of degloved, crush, and avulsion amputations sustained at work to his right dominant fingers. The resulting metacarpal hand (sparing the thumb) had only the middle finger suitable for salvage as a heterotopic replantation to the index finger stump. The T-Ring (Precision Medical, Thousand Oaks, CA) digital tourniquet has a rigid plastic radiolucent ring supporting a silicone diaphragmwith a central hole. This is usually applied over the finger as a low pressure (150–165 mm Hg) digital tourniquet.4 For this case, the tourniquets were applied over the proximal and distal bone ends as a combined soft tissue retractor and protector retained by stitches. This is very stable and is self-supporting, so the operator or assistant does not need to hold these retractors, thereby reducing interference and sharps injury potential. Shortening of the index finger proximal stump and the middle finger proximal phalanx was necessary to normalize the bone length discrepancy, and was easy and safe to perform with this retractor variant. The T-Ring can also act as an alignment guide while performing the saw cut which cannot be achieved with a latex glove (►Fig. 1). This retraction method is also of great benefit during the 90–90 wire osteosynthesis, providing a clear view with no chance of tissue entanglement during drilling or wiring (►Fig. 2). After completion of the osteosynthesis, the tourniquet can be removed atraumatically by snapping the plastic ring at two specially weakened points (►Fig. 1) and the silicon component is cut with scissors for full release. Correcting the digit Fig. 1 The T-Ring positioned over the proximal bone stump retracting the soft tissue and helping align the saw cut. The sutures have been placed around the weakened “break point” of the ring.

It is widely accepted that during postnatal development trabecular bone adapts to the prevailing loading environment via modelling. However, very little is known about the mechanisms (whether it is predominantly modelling or remodelling) or controls (such as whether loading influences development) of fetal bone growth. In order to make inferences about these factors, we assessed the pattern of fetal trabecular development in the humerus and femur via histomorphometric parameter quantification. Growth and development (between 4 and 9 months prenatal) of trabecular architecture (i.e. thickness, number and bone volume fraction) was compared across upper and lower limb bones, proximal and distal regions, and sexes. The data presented here indicate that during prenatal development trabeculae became thicker and less numerous, whilst bone volume fraction remained constant. This partly mimics the pattern of early postnatal development (0–2 years) described by other researchers. Thickness was reported to increase whilst number reduced, but bone volume fraction decreased. This is perhaps because the balance of bone modelling (deposition vs. resorption) changes post partum. Published histological data suggest that bone deposition slows after birth, while resorption rates remain constant. Hence, fetal development may be characterized by relatively high rates of modelling and, particularly, bone deposition in comparison to postnatal. With respect to measures of thickness, number and bone volume fraction prenatal development was not bone, site, or sex specific, whilst postnatally these measures of architecture diverge. This is despite reported developmental variation in the frequency, speed and amplitude of fetal movements (which begin after 11 weeks and continue until birth), and probably therefore loading induced by muscular contractions. This may be because prenatal limb bone micro-architecture follows a generalised predetermined growth trajectory (or genetic blueprint), as appears to be the case for gross distribution of trabecular tissue.