bluuebunny/crossref_metadata_2025 huggingface dataset:
507 Quantifying the Limitations of Clinical and Technology-Based Flap Monitoring Strategies Using A Systematic Recurrent Themes Analysis
Authors: Kwasnicki R , Noakes A , Banhidy N , Hettiaratchy S
Published: October 2021

Aim

Multiple techniques exist to monitor free flap viability postoperatively, varying with practical and personal preference, yet the limitations of each technique remain unquantified. This systematic review aims to identify the most commonly reported limitations of these techniques in clinical practice.

Method

A systematic review was conducted according to PRISMA guidelines using MEDLINE, EMBASE and Web of Science with search criteria for postoperative free flap monitoring techniques. Search results were independently screened using defined criteria by two authors and a senior clinician. Limitations of the techniques found in the discussion section of eligible papers were recorded and categorised using recurrent theme analysis.

Results

A total of 4826 records were identified. 4643 articles met the eligibility criteria and were subsequently reviewed, with 195 papers included in the final analysis. The most frequently reported limitations of clinical monitoring were interpretation requiring expertise (25% of related papers), unsuitability for buried flaps (21%), and lack of quantitative/objective values (19%). For non-invasive technologies: lack of quantitative/objective values (21%), cost (16%) and interpretation requiring expertise (13%). For invasive technologies: application requiring expertise (25%), equipment design and malfunction (13%) and cost (13%).

Conclusions

This is the first systematic review to quantify the limitations of different flap monitoring techniques as reported in the literature. The limitations identified better inform clinicians to decide the best single or combined monitoring approach for their practice and aid development in new flap monitoring technologies.
529 Safeguarding Skin Grafts: A 21st Century Algorithm for Fixation Techniques
Authors: Patel B , Asher C , Bystrzonowski N , Healy C
Published: October 2021

Aim

Effective skin graft fixation is fundamental in preventing sheering forces, seroma and haematoma from compromising graft take. However, determining the ideal method of graft fixation remains a contentious subject. Currently, there is significant variation in fixation techniques used, based not only on clinical requirement, but also surgeon preference. Evidence-based recommendations are necessary to guide the decision-making process.

Method

We undertook a PRISMA-based assessment of the literature to define all fixation techniques and analyse their outcomes. Inclusion and exclusion criteria were composed. A search of Medline and Embase was performed, yielding 399 articles. After abstract screening, 96 were included for qualitative data analysis.

Results

Nine fixation techniques were identified: ‘tie over bolster’, ‘staple fixation’, ‘simple dressings’, ‘quilting sutures’, ‘re-look methods’, ‘foam sponge bolster’, ‘adhesive glues’, ‘negative pressure wound therapy’ and ‘less common techniques. We analyse the available evidence for each technique, identifying 13 studies with level I/II evidence. We summarise the research that underpins these nine categories, proposing an algorithm to facilitate technique selection based on anatomical and patient-specific factors.

Conclusions

An array of skin graft fixation techniques are used in plastic surgery, without clear guidelines. To our knowledge, this is the first time all fixation techniques have been defined. Our suggested algorithm is intended to aid surgeons in selecting an appropriate fixation technique and should be challenged by future research, particularly randomised control trials.
599 Intramammary Melanoma Micrometastasis Within A Silicone Implanted Breast
Authors: Payne A , Welman T , Stodell M
Published: October 2021

Case Summary

Melanoma of the abdominal wall is not uncommon, and sentinel lymph nodes are usually located in the lymphatic drainage basins of the axilla or inguinal region. Less frequently, interval sentinel lymph nodes can be found along the lymphatic vessels between the primary cancer and nearest basin.

We present the case of a 53-year-old female with silicone breast implants who underwent scar excision and sentinel lymph node biopsy for a 1mm Breslow thickness superficial spreading melanoma of the abdomen. Two lymph nodes were excised; both lying in the subcutaneous fat at the lateral aspect of the right breast capsule. Lymph node histology revealed a subcapsular melanoma deposit along with silicone lymphadenopathy in the sentinel node, and silicone lymphadenopathy in the second node. Whole body positron emission tomography (PET/CT) and magnetic resonance imaging (MRI) of the brain showed no evidence of metastases or implant rupture. Subsequent MRI breast revealed likely intracapsular implant rupture. The patient was offered removal of implants and remains under follow-up.

The unusual location of the sentinel node in our patient highlights the possibility that previous breast augmentation may have altered the pattern of lymphatic drainage to the axilla. In addition, to our knowledge, this is the first reported case of silicone and melanoma deposits in a single sentinel node.
640 Improving Junior Doctors’ Knowledge and Confidence in Assessment, Management and Referral of Burns Patients in the Emergency Department, Royal Oldham Hospital
Authors: Connolly M , Gangahar R
Published: October 2021

Aim

There are currently no online trust guidelines for adult burn injuries. We aim to improve ED trainee knowledge and confidence in managing burns patients by delivering focused teaching and developing accessible online resources.

Method

A survey circulated to junior doctors assessed their confidence in managing minor and major burns injuries. Focused teaching on burns depth, management of burns wounds and when to refer was delivered to ED trainees after completion of the survey. Online tools and resources for assessment, management and referral of burns were developed using NICE and British Burns Association Guidelines. Resources were circulated to trainees and a survey repeated to assess confidence.

Results

Initial surveys demonstrated 71% felt confident in assessing minor burns and 46% for major burns. When managing minor burns 68% of juniors felt confident and 43% for major burns. Only 25% were aware of referral criteria to a burns centre for major burns and 32% for minor burns. Following focused teaching sessions, clinician confidence in assessment and management of all burns improved to 100%. Awareness of referral criteria rose to 85-92% for all burn injuries. Qualitative feedback was positive amongst different levels of health care professionals for the new resources.

Conclusions

Burns injuries are common, yet confidence is low amongst junior doctors in their management. This was compounded by a lack of local guidance. Focused teaching and implementation of accessible online departmental guidance has improved clinician confidence and helped ensure that patients presenting with burns are managed by confident clinicians according to national guidelines.
713 Wide-Awake Local Anaesthesia No Tourniquet (WALANT) Procedures During COVID-19: A Single Centre Experience
Authors: Sutcliffe A , Khera B , Khashaba H
Published: October 2021

Aim

WALANT procedures are becoming more popular and are particularly useful in the COVID-19 pandemic. Procedures can be performed without needing access to general theatres and anaesthetic support, minimising the number of patient-healthcare interactions and avoiding aerosolisation.

Our unit has taken this approach and aim to present a case series that demonstrates the efficacy and safety of WALANT.

Method

A retrospective analysis of WALANT cases in a single plastic surgery centre during March-August 2020 was performed. All procedures using a WALANT approach were included, that would have otherwise required general anaesthetic or regional block. Data was collected on a number of variables, including patient satisfaction.

Results

37 procedures were included in analysis. The majority of the injuries consisted of hand trauma. There were no cases of post-operative complications, although one required completion in main theatres due to technicality. No patients required additional anaesthetic during the procedure and all reported pain score as 0/10. Overall patient satisfaction was 10/10 for 26 patients, 9/10 for 10 patients and 7/10 for one patient.

Conclusions

Results show the use of WALANT can facilitate an effective plastic surgery trauma service during COVID-19. Most of the procedures were performed in the outpatient department setting, without the need for main operating theatres or anaesthetic support. All procedures were performed within 24 hours of initial presentation and were able to be discharged on the same day. In addition, patient satisfaction remained high and post-operative complications were minimal. We propose that the use of WALANT should continue and increase beyond the current pandemic.
931 Deep Inferior Epigastric Perforator (DIEP) Flap: Impact of Early Drain Removal on Seroma Formation Rate and Duration of Inpatient Stay
Authors: Grigg K , Clancy R , Lewis C , Jackson P
Published: October 2021

Aim

Donor site seroma can follow deep inferior epigastric flap (DIEP) harvest. Post-surgery gradient technology (GTC) garments are worn by DIEP patients postoperatively following drain removal to reduce seroma formation. Early drain removal was considered a contributing factor to increased seroma formation rate. From June 2018 drain removal regardless of output was instigated at day two post-surgery. Prior to this, drains were removed when less than 30mls over 24 hours. We aim to assess the seroma rate post DIEP harvest with early drain removal.

Method

Retrospective review of prospectively managed database between June 2018 to May 2020. Surgical complications and length of stay in hospital were recorded.

Results

200 patients underwent DIEP flap breast reconstruction. The mean age of patients was 52 years (range 28-73). There was no significant difference in seroma complication rate between those who had drains removed on day 3 compared with day 2 ((1.02% (1/98) vs. (0.98% (1/102); p = 1). The mean length of stay in hospital for the 1st cohort was 3.86 days and for the 2nd cohort was 3.23 days. There were no complications related to drain removal.

Conclusions

Our data suggests that drain removal after 2 days postoperatively with DIEP reconstruction does not affect seroma complication rates. Moreover, it leads to a shorter hospital stay. These conclusions are in keeping with enhanced recovery protocols and an early drain removal surgical process could be advised.
942 Outcome of Image Guided Intra-Articular Thumb Base Steroid Injections-Retrospective Study of Consecutive Patient Over 4 Years in A Plastic and Hand Surgery Unit in West Lothian, Scotland
Authors: Thazhathe Peedika N N , Goswami P
Published: October 2021

Introduction

Osteoarthritis of the thumb base is a common condition. Usually effects the elderly population causing significant disability. Modalities of treatment of osteoarthritis which includes conservative measures, non-operative interventions, and surgery.

In this study we endeavored to assess how effective are image guided steroid injections for base of thumb Osteoarthritis as assessed by subjective pain relief perceived by patient and what percentage of these patients proceed to operative treatment.

Method

Retrospective data between January 2015 and December 2018 of the patients who underwent Steroid injections to the Base of thumb joints (CMCJ and/or STTJ) for Osteoarthritis under image intensifier guidance was collected from Hospital management system –TRAK and eHealth services. Follow up of the patients were done for Maximum 1 to 5 years.

Results

A total number of 692 patients with thumb base osteoarthritis were included in the study of which 546 patients underwent Image guided steroid injection to the thumb base. The mean Age of patients was 64.5 years and the Female: Male ratio was 401:145. Mean number of injections each patient received- 3.25 (1 – 7 times). Pain relief after first, second and third injections were 3.15 months, 2.63 and 1.75 months, respectively. 127 (23.2% of injections patients) underwent trapeziectomy. Mean time between first injection & Surgery was 1.3yrs (6 months -2 years)

Conclusions

This study demonstrates the effectiveness of image guided steroid injections for thumb base osteoarthritis. Though about a quarter of these patients proceed to operative management, steroid injections can delay the same considerably.
1024 The Use of the Pedicled Anterolateral Thigh (ALT) Flap for the Reconstruction of Abdominal Wall Defects in High-Risk Patients: A Case Series and Systematic Review
Authors: Newall N , Jones C , Ho W , Curnier A
Published: October 2021

Introduction

The pedicled anterolateral thigh (ALT) flap is considered as a suitable option in complex abdominal wall reconstruction. Its use as a reconstructive option is infrequent in the literature, and to date, there has been no systematic review evaluating its long-term outcomes. We report our experience with the pedicled anterolateral thigh flap for abdominal wall reconstruction in high-risk patients.

Method

A prospective database was created for patients with abdominal wall defects treated with pedicled ALT with extended fascia lata flaps between 2014 and 2017. Patient demographics, aetiology, size, location of defect and post-operative results were reviewed. Abdominal defects were classified into the following zones: 1A, upper midline; 1B, lower midline; 2, upper quadrant; 3, lower quadrant. A systematic review of the literature was conducted using PUBMED and EMBASE.

Results

4 patients (mean age 59.5 years, range 50-65 years) underwent reconstruction with pedicled ALT flaps. 3 flaps developed partial necrosis secondary to infection; 1 flap required surgical debridement, and 2 were managed conservatively. There was one flap failure, due to avulsion of the pedicle during inset. At mean follow up of 2.75 years (range 1 to 4 years) 3 patients have clinical bulging or herniation.

Conclusions

Review of the literature demonstrated 52 patients from 17 case series or reports. The overall infection and partial flap loss rates were both 6%. There were no reported flap failures. Our study demonstrates that the pedicled anterolateral thigh flap is an effective flap option for the repair of large defects of the abdominal wall in high-risk patients.
1051 The Effect of Ginger Oil on Postoperative Nausea and Vomiting (PONV) After Breast Augmentation Surgery
Authors: Saghir N , Saghir R , Sidhu M , Okhiria T , Okhiria R , Husein R , Sforza M
Published: October 2021

Aim

Postoperative nausea and vomiting (PONV) is one of the commonest complaints following general anaesthetic. Poorly controlled due to its multifactorial nature most current antiemetics are not effective and have an undesirable side effect profile. As such we have studied the effect of Ginger (Zingiber Officinale), a relatively inert yet powerful antiemetic and its properties in managing PONV.

Method

A double-blind (surgeon/anaesthetist), randomised, placebo-controlled, single-centre study was carried out in a homogenous 30 female patient cohort undergoing breast augmentation surgery. Participants were randomly allocated to have 3 drops of either Ginger oil (110mg Zingiber officinale) or a simple control oil on the laryngeal mask before insertion. PONV and visual analogue scales (VAS) were used as outcome measures and were plotted against the dose of morphine used in the patient.

Results

Multivariate analysis of variance (MANOVA) was conducted on the data. Using Pillai’s trace, there was a significant effect of ginger on PONV/VAS, V = 0.87, F(3,16)=34.78, P < 0.001. Separate univariate ANOVAs showed: PONV Mean=1.70, PONVSD=0.48 compared with no ginger treatment plan group; PONV Mean=4.20, PONVSD=0.79. VAS Mean= 5.0, VASSD=1.63 for the ginger treatment plan group; and VAS Mean=5.9, VASSD=2.33 for the no ginger treatment plan group.

Conclusions

This study has found that ginger has an important role in preventing postoperative vomiting, reducing postoperative nausea, and is useful in breast augmentation. We have demonstrated a novel application of ginger oil during induction of anaesthesia and have provided evidence of its use in opioid-induced PONV.
1058 DVT And Abdominoplasty: A Holistic 8-Point Protocol-Based Approach to Prevent DVT
Authors: Saghir R , Saghir N , Okhiria T , Sidhu M , Okhiria R , Husein R , Sforza M
Published: October 2021

Aim

Plastic surgery as a speciality is afflicted with one of the highest incidence rates of thromboembolic events, with abdominoplasty procedures known to assimilate the greatest rates of Deep Vein Thrombosis (DVT).

Method

A total of 1078 abdominoplasty patients were enrolled onto an 8-point prophylaxis protocol with an inclusive holistic approach over a 7- year period. A 4-week smoking, HRT and COC cessation period was imposed on all patients and a maximum BMI score of 40 was required of all preoperative patients. Participants were administered with compression stockings, flowtrons and enoxaparin. Individuals with a DVT history were also required to be 1-year treatment free prior to surgery. Furthermore, the protocol necessitated post-operative deambulation of fit patients within 4 hours.

Results

Between 2008 and 2013, no incidence of DVT was recorded in all 1078 abdominoplasty surgery patients, indicating the potential for this protocol to lead to a significantly lower incidence than any previously published methodology. Due to the zero-incidence rate of DVT, different hypotheses of DVT proportions were tested to find out the rates that could be statistically consistent with our sample, thereby providing conservative incidence rate estimates.

Conclusions

This 8-point DVT prophylaxis protocol is the first non-criteria based inclusive protocol aimed at preventing abdominoplasty-associated DVT. As a result, not a single incident of DVT was recorded over the seven-year period of this study. We therefore believe that a holistic and procedure-specific approach to prophylaxis can drastically reduce the occurrence of DVT in abdominoplasty surgery
1076 Online Availability of Hand Splints for Patients with Common Upper Limb Nerve Entrapment Syndromes During COVID-19 Pandemic
Authors: Teoh S H , Jivan S
Published: October 2021

Aim

Splinting is first line treatment in mild to moderate cases of carpal and cubital tunnel syndrome. During COVID-19 lockdown, patients experience prolonged waiting time for their splints from specialist service if not requiring surgery. Many of our patients have not trialled splinting prior to their specialist appointments. We aimed to look at the quality of splints commercially available for the general public to purchase thereby starting treatment earlier.

Method

Hand splints for nerve entrapment are readily available through two of the biggest UK online retailers, Amazon.co.uk and eBay.co.uk. We searched the terms ‘carpal’ and ‘cubital’ tunnel splints on both sites, the top 5 results were assessed for their suitability, accessibility, and affordability.

Results

The average cost of splints for carpal tunnel syndrome on Amazon and eBay are £9 and £8 respectively, and £15 on Amazon and £10 on eBay for cubital tunnel syndrome. We found that all top 5 hand splints found on these websites are suitable for the conditions they advertised. The average time for free delivery of splints is 2 days for Amazon and 3 days for eBay. Splints are easily sized by using the sellers wrist/elbow circumference measurement guide.

Conclusions

This study has given us the confidence to encourage patients to purchase splints, at an affordable price, from online sites whilst either waiting for specialist appointments or as part of their specialist recommended treatment. With early initiation of treatment, patients may have symptomatic relief and, in some cases, avoid the need for further treatment, leading to reduced hospital footfall.
1092 Impact Of MSLT-II on Lymph Node Clearance Surgery in A Tertiary Plastic Surgery Centre
Authors: Misky A T , Sadr A H , Nikkhah D
Published: October 2021

Aim

Cutaneous malignant melanoma is a significant public health challenge in the United Kingdom. Wide local excision with Sentinel Lymph Node Biopsy (SLNB) is the current standard of treatment for most lesions. Some patients with positive SLNB would routinely undergo locoregional Lymph Node Clearance (LNC). Results of the Multicenter Selective Lymphadenectomy Trial II (MSLT-II) published in August 2017 challenged this approach, showing no melanoma specific survival benefit, but significant morbidity associated with routine LNC. Our study aims to show a change in practice at a tertiary plastic surgical referral centre in response to these results.

Method

We retrospectively reviewed our prospectively maintained database for all LNCs performed for cutaneous, non-head and neck malignant melanoma using the search terms ‘clearance’ and ‘dissection’ between 2015 and 2019.

Results

We performed 128 axillary and groin LNCs for cutaneous malignant melanoma 2015-2019. The range of LNCs per year varied from 38 in 2015 to 10 in 2019 (mean 25.6, median 28). The total number of LNCs, as well as LNCs performed following positive SLNB decreased after August 2017.

Conclusions

The data shows that our centre acknowledged evidence and reduced the number of LNCs performed after publication of MSLT-II. We expect that the number of avoided LNCs has saved significant resources due to reduced length of stay, and avoided our patient’s significant morbidity, including seromas, infections and lymphoedema. We recommend all skin cancer treatment centres to follow the evidence in order to provide excellent care and save resources.
1098 Prophylactic Doxycycline Prior To The Excision of Ulcerated Skin Lesions. An Audit of Dose Timings and Adverse Effects
Authors: Wallace J , Gibson J , Duncan R
Published: October 2021

Aim

Antibiotic prophylaxis to reduce the incidence of surgical site infections following excision of ulcerated skin lesions is frequently recommended, although the evidence base is limited. Current Swansea Bay guidelines recommend pre-operative administration of antibiotics: for procedures performed under local anaesthetic in the Plastic Surgery Treatment Centre (PSTC), oral route is preferable. It was noted that a number of patients were experiencing nausea and vomiting following administration of the recommended oral agent (doxycycline). The aim of this audit was to quantify the proportion of patients experiencing adverse effects, and to assess whether the prophylactic dose was being administered within the recommended time frame.

Method

Data was collected over a three-week period (28/10/20- 18/11/20). All patients that received doxycycline pre-operatively during this period were included: the time the doxycycline was given, the time of operation and whether there were any adverse effects was recorded for each patient.

Results

14 patients received doxycycline during the monitored period. On average the doxycycline was given 52 minutes prior to the procedure. 2 patients received their doxycycline dose after their procedures. 4 patients experienced side effects from the doxycycline (3 vomited, 1 nausea), the average time this subset of patients received their dose was 50 minutes prior to their procedure.

Conclusions

A significant proportion of patients experience adverse after receiving doxycycline, whilst there is limited evidence to prove its benefits. Trust guidelines are under review to consider alternative antibiotics, but better evidence is required to clarify the need for antibiotic prophylaxis for ulcerated lesions.
1101 Closed Traumatic Avulsion of Both Flexor Digitorum Tendons: A Novel Treatment Method
Authors: Cuggy C , Woods J , Emma C , Natalie J , Roisin D , Lynch N
Published: October 2021

Case Report

Closed tendon avulsion of both flexor tendons (Flexor Digitorum profundus [FDP] and Flexor Digitorum superficialais [FDS]) in the same finger is an extremely rare condition. We are proposing this subtype of injury be added as a type VI to the current Leddy and Packer classification for FDP avulsion injuries. The objective of this being an increase in awareness to avoid misdiagnosis and to aid in the subsequent management if encountered. We present the case of a 27-year-old male who presented with an avulsion of both flexor tendons from their respective insertions in the ring finger following a sporting injury causing hyperextension against an actively flexed distal interphalangeal joint. This condition has previously been reported twelve times in the literature. We propose a novel treatment method not described for previous cases and examine the successful method of treatment in this case.
1102 Tackling Jersey Finger Using Extraosseous Tunnels – Study of a New Technique
Authors: Misky A T , Reissis D , Nikkhah D , Toft N
Published: October 2021

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.
1106 Timing of Free Flap Reconstruction in Sarcoma Patients
Authors: Misky A T , Williams S , Woollard A
Published: October 2021

Aim

In 1986 Godina reported that microsurgical reconstruction of traumatic wounds in the extremities undertaken with >72-hour delay caused significant tissue damage, hampering the microsurgical reconstruction and significantly increasing complication rates. It is our opinion that surgical treatment of sarcoma in the extremity is comparable to trauma surgery, given the extent of tissue destruction. The nature of sarcoma management often means that performing definitive reconstruction within 72 hours is not possible. We analyse the outcomes of our ‘delayed’ extremity reconstruction.

Method

We performed a retrospective analysis of 52 consecutive cases of free flap extremity reconstruction following sarcoma excision. Data was analysed for time from resection to reconstruction, significant patient demographics, details of the flap and post-operative complications.

Results

Between March 2017 and December 2020, we performed 52 free flaps for sarcoma reconstruction in the extremities. Mean time to reconstruction was 28 days (Median 15 days, Range: 0-316 days), with two reconstructions within 72 hours of excision. 9 patients had neoadjuvant chemo- or radiotherapy. Three patients had significant post-operative complications; two flaps failed intra-operatively (3.8%) and one patient (1.9%) experienced wound infection.

Conclusions

Godina’s study demonstrated the negative impact of delaying surgical reconstruction in the traumatised extremity, with a 12% failure and 17.5% infection rate in delayed reconstruction (72 hours to 3 weeks). Our results show that with advancements in microsurgical techniques and physiological optimization, it is possible to safely and successfully undertake delayed (>72 hours) microsurgical extremity reconstruction in sarcoma patients and achieve low flap failure and infection rates.
1117 Managing Cosmetic Surgery Complications: A Retrospective Service Evaluation
Authors: Luck J , Strachan E , Piggott B , Saour S
Published: October 2021

Aim

The cosmetic surgery industry continues to grow, both within the UK and internationally. There is a perception that the NHS is often left to deal with the complications of these procedures, particularly those performed abroad. This study aimed to evaluate the burden of cosmetic surgery complications on a tertiary London plastics service with an appraisal of the financial costs incurred.

Method

This one-year retrospective service evaluation included all emergent referrals following cosmetic surgical interventions in the UK private sector and abroad. Outpatient referrals and planned revisional procedures were excluded. Financial costs were based upon current Clinical Commissioning Group tariffs.

Results

In total, 14 patients were included (seven from the UK and seven from Europe or North Africa). Remote telemedicine advice was provided for six patients; eight patients required admission. All eight admissions were female with an average age of 42.6 years. The most common complication was infection (75%) with an average length of stay of 2.3 nights. These eight patients required six trips to theatre, two CT scans and 37 outpatient visits. The median tariff per patient was £1,510 (range £242 to £5,196), leading to an overall reimbursement of £16,471. The majority of these costs were generated during inpatient admissions (£12,855) with a lesser contribution from outpatient episodes (£3,616).

Conclusions

This project provides an overview of the impact of managing emergent complications following cosmetic surgery, both in terms of service activity and financial cost. A long-term, prospective service evaluation of both elective and emergency referrals based upon patient-level costing data is now underway.
1126 Improving Hand Trauma Clerking Using an Electronic Proforma: A Full Cycle Clinical Audit
Authors: Luck J , Spiteri K , Lim A , Moledina J , Adlard R
Published: October 2021

Aim

The BSSH standards of care in hand trauma emphasise the importance of accurate and comprehensive documentation. This quality improvement project aimed to evaluate whether an electronic proforma could improve documentation rates in hand trauma.

Method

This prospective, closed-loop audit involved two cycles of seven consecutive days. Outcomes were evaluated against BSSH standards of care using 15 data points. Pre-audit, a bespoke proforma was piloted in the hand trauma clinic and revised following feedback.

In the first cycle (‘Loop 1’), documentation in the hand trauma clinic was compared with that of the acute take, where clinicians were still using free text. The second cycle (‘Loop 2’) compared documentation pre- and post-introduction of the proforma within the acute take setting. Categorical data were interrogated using the χ2 test with significance set at p < 0.05.

Results

122 patients were included in the Loop 1 dataset. Free text clerking quality varied between clinician groups (e.g., surgical trainees significantly outperformed advanced nurse practitioners in 5/15 data points); however, some data points were universally poorly documented. 99 patients were included in the Loop 2 dataset. There was excellent uptake of the proforma in both acute take (95%) and hand trauma clinic (100%) settings. Statistically significant improvements were seen in 11/15 data points following the introduction of the proforma.

Conclusions

This project demonstrates that the introduction of a hand trauma clerking proforma led to significant improvements in documentation quality. The proforma has now been developed into a Trust-wide ClinDoc which brings additional benefits in terms of research, audit and service evaluation.
1278 The Impact of Private Sector Cosmetic Surgery Complications on an NHS Plastic Surgery Service During the COVID-19 Second Wave: A Case Series
Authors: Magness C , Forsyth M , Hasham S , O'Boyle C
Published: October 2021

Introduction

COVID-19 has demanded a dramatic reorganisation of plastic surgery services. Operating within the NHS has largely been scaled back to emergency and cancer work, with elective services either on hold or transferred to independent hospitals. During this time, with NHS resources critically stretched, a number of patients presented with serious complications of private sector aesthetic surgery, which required emergency NHS treatment. This series characterises the nature and outcome of these cases.

Method

A retrospective audit of patients referred to a UK Plastic Surgery Unit with complications arising from private aesthetic surgery performed during the Second Wave of Covid-19 in 2020.

Results

Eight patients presented. Two had surgery in the UK, five in Turkey and one in Lithuania. The primary procedures were abdominoplasty (n = 6), liposuction (n = 5). Presenting complications were Infection (n = 5) and wound dehiscence (n = 5). Two patients presented in septic shock and one developed necrotising panniculitis. One patient suffered perioperative death due to myocardial infarction. Mean hospital stay was 10 days (range 1-31) and median number of NHS surgical procedures was 2.5 (range 0-8). Three patients required removal of breast implants; four required topical negative pressure dressings and three underwent skin grafting. Up to 7 outpatient appointments were required per patient. All survivors have unsatisfactory aesthetic outcomes.

Conclusions

This case series raises important questions about the safety of major aesthetic surgery and “cosmetic tourism” during periods when the NHS’ ability to deal with severe complications may be severely limited.
1460 Spot the difference? Suspected Skin Cancer Referral Clinic 2020 Impact Audit
Authors: Kumaresan K , McGuinness C
Published: October 2021

Introduction

According to the 2018 WHO statistics nearly 18,000 people were diagnosed with melanoma in the UK and nearly 3000 died from this. We did this audit to study our skin cancer detection rates in the department of plastic surgery in Salisbury hospital before and during COVID. During COVID, our practise included telephone consultations, image reviews and some face-to-face consultations.

Method

We did two snapshot audits in January and May 2020. Based on Cancer Waiting time guidelines our hospital operational standard for patient to be seen in 2WW was 93% and Time for definitive treatment target is 96% (where the clock stops)

Result

There was significant drop in the number of patients presenting overall but the case load for plastics remained similar in both cycles. Audit showed compliance with 2WW waiting time except in 1 case in January owing to patient factors. 2% increase in biopsy rate. 24% of biopsied patient had cancer in January compared to 16% in May. Majority were squamous cell carcinomas. Average wait time to biopsy was longer in May by a week.

Conclusions

Although there has been a drastic reduction in the number of presentations there was no significant variation in the cancer detection rates. Biopsy rate was 2% higher, likely owing to a more cautious approach when using visual/ telephone consultations and image review. The audit highlights the pros and cons of using non face to face consultations in clinical practice.
1527 A Rare Case of Facial Skin Necrosis Following Subdermal Poly-L-Lactic Acid Injection
Authors: Samarendra H , Zargaran D , Saeed N , Nikkhah D , Butler P
Published: October 2021

Introduction

Non-surgical / minimally invasive aesthetic procedures are a growing trend in the UK. A range of devices are available for soft tissue augmentation, including injectable Poly-L-Lactic acid (PLLA). PLLA is used for soft tissue augmentation and is thought effective for the correction of contour deficiencies, facial wrinkles and in restoring subcutaneous volume in patients with HIV-associated lipoatrophy.

Method

In this case report, we present a rare but serious complication of subdermal injection of Poly-L-Lactic acid. A 45-year-old lady presented to our service approximately 24 hours after administration of self-sourced poly-L-Lactic acid.

Results

A 4cm ovaloid patch of full thickness skin necrosis over the zygomatic region was evident on presentation, with reactive/inflammatory changes in the adjacent skin. Vascular compromise is deemed the most likely cause, with loss of the transverse facial artery mapping to the area of necrosis. This patient was managed conservatively, with dressings and a prophylactic course of antibiotics.

Conclusions

Vascular compromise is a recognised and rare complication of subdermal injectable devices for facial soft tissue augmentation. The transverse facial artery branches from the superficial temporal artery within the substance of the parotid gland. Cadaveric and imaging studies alike demonstrate that the most common anatomical variant is a single TFA (70%), originating at the level of the temporofacial trunk of the facial nerve. It typically has a 5cm course, giving off on average 1.9 cutaneous perforators. This case highlights the importance of a detailed understanding of facial anatomy to ensure safe and effective placement of dermal fillers/devices.
1607 Seeing White: Management of TIVA During Autologous Breast Reconstruction
Authors: Vigneswaran P , Clancy R , Choo S , Love-Jones S , Jackson P , Wilson S
Published: October 2021

Background

Free flap surgery has inherent risks, and the venous drainage of the Deep Inferior Epigastric Perforator (DIEP) flap is particularly vulnerable to congestion. In these cases, an algorithm for flap salvage should be followed and one of the final steps in this process is a cephalic vein transposition.

Case Report

We describe two patients undergoing mastectomy and immediate bilateral DIEP breast reconstruction, where cephalic vein transposition was required. As part of the Enhanced Recovery After Surgery (ERAS) pathway, patients are anaesthetised with a continuous propofol infusion (Total Intravenous Anaesthesia; TIVA). When the cephalic vein was identified, the propofol infusion was visible within the vein, which would have interrupted TIVA if harvested. To maintain continuous TIVA infusion, the cannula was resited prior to harvest of the cephalic vein. The cephalic vein was anastomosed to the superficial inferior epigastric vein and resolution of the venous congestion was noted.

Conclusions

These cases although rare highlight the importance of robust preoperative planning and communication between the team and preparation for all eventualities to ensure patient safety and successful outcomes. These cases highlight the potential effects vein harvesting or transposition may have on the safe and effective delivery of anaesthetic agents and other medication. We hope these cases prompt a discussion in the preoperative stage for alternate strategies for monitoring and intravenous access in response to diversions from the standard operating procedure.
61 Burnout in Core Surgical Trainees and Potential Use of Mindfulness
Authors: Farrell S , Khadum M , Molodynski A
Published: October 2021

Aim

Surgical trainees deal with long hours and stressful work content. We aimed to assess the burnout levels in London trainees, and trial a mindfulness intervention.

Method

London core surgical trainees (CST1) were asked to complete an online survey including validated burnout scoring system (Oldenburg Inventory). 54 of a possible 78 trainees responded (69%). We then asked them to take part in a 2-week mindfulness intervention (approximately 5 minutes a day using the app Headspace). We later resurveyed.

Results

60% of trainees who answered the survey feel ‘somewhat’ or ‘completely’ burnt out. Oldenburg burnout inventory calculates 85% of trainees to be ‘disengaged’ and 93% ‘exhausted’. 13/54 trainees completed the mindfulness training. 10 out of 13 trainees found this to be ‘somewhat’ or ‘massively’ helpful for burnout.

Conclusions

A high percentage of year one surgical trainees can be categorised as burnt out. The low uptake of mindfulness may speak to lack of capacity trainees have to invest in resources that will self-resolve this. We cannot say with significance whether mindfulness helped burnout (and length of trial could be too short) but the majority who did trial report positive experience with mindfulness.
191 Improving Consent and Legibility in Orthopaedic Surgery Through Introducing Pre-Populated Stickers
Authors: Le Blevec L , Daga K , Sara X , Singh A , Javed S , Odak S , Charalambous N
Published: October 2021

Aim

Incomplete informed consent can lead to patient dissatisfaction and litigation.1 Time constraints, legibility, human error, limit completion of consent forms, putting surgeons and trusts at risk of litigation.2 The aim of this project was to assess legibility and completeness of handwritten consent forms, with the objective to improve legibility to 100% and risks listed to 100% of those endorsed by the British Orthopaedic Association (BOA).3

Method

An initial baseline study in multiple hospitals across the UK identified 113 patients who underwent hemiarthroplasties. The consent forms were assessed for legibility and risks included, compared to those listed by the BOA. Pre-populated risks stickers were introduced in 1 district general hospital (DGH) and 2 cycles repeated again (62 patients identified).

Results

Overall, 35% of consent forms 1 were illegible; 100% of the time in the risks section. Mean number of risks missing was 2.34 and most frequently missed risk was ‘death’ (missing on 35.5% of consent forms). In the DGH that introduced stickers, consent forms were 100% legible and 100% compliant to the standards set by the BOA when the stickers were used. However, sticker use remained low; only used 20% of the time in the second cycle, marginally increased from the previous cycle (18%).

Conclusions

A high proportion of consent forms are not completed to BOA standards and are illegible. Pre-populated stickers could aid in achieving 100% legibility and 100% risk inclusion. The stickers will be implemented in other trusts and methods to increase compliance with sticker use will be trialled.
361 The Automation of Doctors and Machines: A Classification for AI in Medicine (ADAM framework)
Authors: Kazzazi F
Published: October 2021

Aim

The advances in Artificial Intelligence (AI) provide an opportunity to expand the frontier of medicine to improve diagnosis, efficiency, and management. By extension of being able to perform any task that a human could, a machine that meets the requirements of General AI (AGI) possesses the basic necessities to perform as, or at least qualify to become, a doctor. In this emerging field, this article explores the distinctions between doctors and AGI, and the prerequisites for AGI performing as clinicians. With its imminent arrival, it is beneficial to create a framework from which leading institutions can define specific criteria for AGI.

Method

A normative framework was derived from medical ethical literature and current medical technology. Comparisons were made between current capabilities and the traits of doctors ('doctorhood'). A framework was created that could fulfil current patient and doctor considerations for the use of AI in medicine.

Results

This Automation of Doctors and Machines (ADAM) framework is set out across 5 levels. As the level progresses, so do the minimum requirements in the core competencies of knowledge, safety, emotion, and independence.

Conclusions

The development of AI brings with it an exciting era of modern medicine. In order to fully enhance, expand, and regulate this field, the ADAM framework provides a tool to classify its use in medicine. In being able to categorize forms of medical AI, this allows clinicians, patients, and regulators to delineate different forms of AI, and a foundation is created from which governing bodies can set and standardise levels of care.
578 Insights into Patient Satisfaction with Telephone Fracture Clinic Consultations During COVID-19
Authors: Lostis E , Graham S , Pearce O , Kelly M
Published: October 2021

Aim

The COVID-19 pandemic led to an unusually fast pace of change in clinical practice in the UK. An early requirement to reduce outpatient attendances to a pminimum meant that this Trust adopted remote consultations for fracture clinics whenever possible. This study aimed to evaluate patient satisfaction with the new system of telephone consultations to assess its acceptability and guide future decisions.

Method

299 patients who received remote telephone consultations for fracture clinic appointments at North Bristol NHS Trust during the COVID-19 pandemic in early 2020 were retrospectively identified and sent a postal survey. Satisfaction levels were assessed through degree of agreement with statements (9 items), yes/no answers (4 questions) and space for comments. Data was analysed with Excel pivot tables and Chi-squared tests.

Results

131 survey responses were included (43.8% response rate). The majority of patients were satisfied overall with the care they received (82%) and preferred a telephone consultation to a face-to-face appointment during the pandemic (78%). However, only 22% maintained this preference in ‘normal’ (pre-COVID-19) times.

Conclusions

The positive responses to the survey reassure us that telephone consultations for fracture clinic consultations are acceptable to the majority of patients during a pandemic. The results as well as free text comments will help us ameliorate the fracture clinic service to minimise infection risk without compromising on quality of care.
605 Group and Save Sampling in Total Knee and Hip Arthroplasty: Is It Necessary?
Authors: Mepani V , Raheman F , Nasr P
Published: October 2021

Aim

To induce a change in practice with regard to pre-op G&S sampling. This is common practice in elective orthopaedics. Transfusion rates are negligible. Therefore, omitting this practice can reduce the financial burden on the Trust.

Method

Patient's undergoing elective primary total knee or hip arthroplasty over a 1-year period were retrieved from a database. Data regarding pre/post-op haemoglobin levels and transfusion status was obtained from patient case notes and Trust ICE pathology reporting system.

Results

There were a total of 454 patient's (251 undergoing TKR, 203 undergoing THR). Four patient's (1.6%) in the TKR group and 11 patient's (5.4%) in the THR group required transfusion. Of these patient's, 5 had cardiac problems and 6 had pre-operative anaemia.

Conclusions

Routine G&S sampling is unnecessary in the majority of cases and should only be reserved for certain cases (patient's with significant cardiac problems and those with a transfusion history). Patient's with pre-operative anaemia should have optimisation of haemoglobin level prior to the procedure.