bluuebunny/crossref_metadata_2025_split huggingface dataset:
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

Abstract

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

Abstract

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

Abstract

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

Abstract

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

Abstract

Aim
In 1986 Godina reported that microsurgical reconstruction of traumatic wounds in the extremities undertaken with &gt;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 (&gt;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

Abstract

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

Abstract

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 &lt; 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

Abstract

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

Abstract

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

Abstract

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

Abstract

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

Abstract

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

Abstract

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.