WALANT Protocol: Stop before you block

The use of Wide Awake Local Anaesthetic No Tourniquet (WALANT) amongst Plastic and Orthopaedic Hand Surgeons has been accelerated by the impact of the COVID-19 pandemic and associated risks of general anaesthesia. Benefits of WALANT include a bloodless field, improved recovery, on-table testing, as well as cost and time savings. Whilst more clinical trials are underway to fully elucidate safety-profile and outcomes, there is a lack of consensus and clarity over contraindications to WALANT. A survey of trainees identified that only one-in-five were aware of the appropriate reversal agent in the event of inadequate perfusion. We feel that a WALANT checklist should be developed and implemented for use immediately prior to administration of local anaesthetic with adrenaline to an extremity, building on the successes of the World Health Organisation (WHO) and the Royal College of Anaesthetists checklists. Such a checklist should include contraindications to WALANT and make the operator aware of the availability, dose and location of Phentolamine as a reversal agent. Introducing this checklist will help to facilitate safer and more effective use of WALANT within Hand Surgery

Optimal Strategies for Addressing Developmental Breast Asymmetry and the Significance of Symmetrical Treatment: A Systematic Review

BACKGROUND: Approximately one quarter of women are affected by asymmetry as a result of abnormal breast development, which can lead to significant emotional distress. Despite this, there is currently no widely accepted approach for managing this prevalent condition. This systematic review aims to review the available literature on the management of developmental breast asymmetry. METHODS: A comprehensive search in MEDLINE, EMBASE and CENTRAL databases was conducted for primary clinical studies reporting on the management of developmental breast asymmetry from 1962 to November 2022. The primary outcome measures were long term aesthetic outcome and patient reported outcomes. RESULTS: 11 case series and 2 cohort studies were included, comprising a total of 1237 patients with a mean age of 26.5 years (range 14-65). Twelve studies (92%) addressed asymmetry through surgical means, using various augmentation and reduction procedures, while one study (8%) utilised external prosthesis. Meta-analysis of the data was not deemed to be possible due to heterogeneity of data, a narrative synthesis of the literature was provided. CONCLUSIONS: There is no consensus on how to manage developmental breast asymmetry. Furthermore, there is a lack of consistency in the classification of patients with developmental breast asymmetry and in the reporting of outcomes, highlighting the need for a consensus. Further research outlining long term aesthetic and patient reported outcomes is needed to understand which procedures provide optimal outcomes. Additionally, external breast prosthesis is a promising non-surgical alternative and further studies into its efficacy are needed

Facial skin ageing: Key concepts and overview of processes

INTRODUCTION: The face is a cosmetically sensitive region where the process of ageing is most clearly manifested. With increased focus on anti-ageing and longevity, more anti-senescent treatments are being proposed despite limited evidence. This study outlines the pathways and mechanisms underpinning the biological process of ageing in the face. METHODS: Comprehensive searches of MEDLINE, EMBASE, Cochrane Library and CINAHL from inception to 2020. Inclusion criteria included all empirical human research studies specific to facial ageing features, written in the English language. RESULTS: A total of 65 papers met inclusion criteria for analysis. Pathways were subdivided into intrinsic and extrinsic senescence mechanisms. Intrinsic pathways included genetics, generation of reactive oxygen species and hormonal changes. Extrinsic pathways included photoageing and damage to skin layers. The combined intrinsic and extrinsic pathway alterations result in wrinkles, higher laxity, slackness and thinning of the skin. Skin functions such as barrier immune function, wound healing, thermoregulation and sensory function are also impaired. CONCLUSION: The ageing process is unique to the individual and depends on the interplay between an individual's genetics and external environmental factors. Through understanding the molecular and cellular mechanisms, an appreciation of the consequent structural and functional changes can be achieved. Based on this knowledge, further research can focus on how to slow or impede the ageing process and identify specific targets to develop and evolve new treatment strategies

Three-Dimensional Photography and Computer Modeling as a Reconstructive Surgical Training Tool

BACKGROUND: Reconstructive surgery operations are often complex, staged, and have a steep learning curve. As a vocational training requiring thorough three-dimensional (3D) understanding of reconstructive techniques, the use of 3D photography and computer modeling can accelerate this learning for surgical trainees. OBJECTIVES: The authors illustrate the benefits of introducing a streamlined reconstructive pathway that integrates 3D photography and computer modeling, to create a learning database for use by trainees and patients alike, to improve learning and comprehension. METHODS: A computer database of 3D photographs and associated computer models was developed for 35 patients undergoing reconstructive facial surgery at the Royal Free Hospital, London, UK. This was used as a training and teaching tool for 20 surgical trainees, with an MCQ questionnaire assessing knowledge and a Likert scale questionnaire assessing satisfaction with the understanding of core reconstructive techniques, given before and after teaching sessions. Data were analyzed using the Mann-Whitney U test for trainee knowledge and Wilcoxon rank sum test for trainee satisfaction. RESULTS: Trainee (n = 20) knowledge showed a statistically significant improvement, P < .01, as did trainee satisfaction, P < .05, after a teaching session using 3D photography and computer models for facial reconstruction. CONCLUSIONS: Three-dimensional photography and computer modeling are useful teaching and training tools for reconstructive facial surgery. The authors advocate the implementation of an integrated pathway for patients with facial defects to include 3D photography and computer modeling wherever possible, to develop internal databases for training trainees as well as patients. This algorithm can be extrapolated to other aspects of reconstructive surgery

Epidermal grafting versus split-thickness skin grafting for wound healing (EPIGRAAFT): study protocol for a randomised controlled trial

BACKGROUND: Split-thickness skin grafting (SSG) is an important modality for wound closure. However, the donor site becomes a second, often painful wound, which may take more time to heal than the graft site itself and holds the risk of infection and scarring. Epidermal grafting (EG) is an alternative method of autologous skin grafting that harvests only the epidermal layer of the skin by applying continuous negative pressure on the normal skin to raise blisters. This procedure has minimal donor site morbidity and is relatively pain-free, allowing autologous skin grafting in an outpatient setting. We plan to compare EG to SSG and to further investigate the cellular mechanism by which each technique achieves wound healing. METHODS/DESIGN: EPIGRAAFT is a multicentre, randomised, controlled trial that compares the efficacy and wound-healing mechanism of EG with SSG for wound healing. The primary outcome measures are the proportion of wounds healed in 6 weeks and the donor site healing time. The secondary outcome measures include the mean time for complete wound healing, pain score, patient satisfaction, health care utilisation, cost analysis, and incidence of adverse events. DISCUSSION: This study is expected to define the efficacy of EG and promote further understanding of the mechanism of wound healing by EG compared to SSG. The results of this study can be used to inform the current best practise for wound care. TRIAL REGISTRATION: Clinicaltrials.gov identifier, NCT02535481 . Registered on 11 August 2015

Octa-ammonium POSS-conjugated single-walled carbon nanotubes as vehicles for targeted delivery of paclitaxel

Background: Carbon nanotubes (CNTs) have unique physical and chemical properties. Furthermore, novel properties can be developed by attachment or encapsulation of functional groups. These unique properties facilitate the use of CNTs in drug delivery. We developed a new nanomedicine consisting of a nanocarrier, cell-targeting molecule, and chemotherapeutic drug and assessed its efficacy in vitro. Methods: The efficacy of a single-walled carbon nanotubes (SWCNTs)-based nanoconjugate system is assessed in the targeted delivery of paclitaxel (PTX) to cancer cells. SWCNTs were oxidized and reacted with octa-ammonium polyhedral oligomeric silsesquioxanes (octa-ammonium POSS) to render them biocompatible and water dispersable. The functionalized SWCNTs were loaded with PTX, a chemotherapeutic agent toxic to cancer cells, and Tn218 antibodies for cancer cell targeting. The nanohybrid composites were characterized with transmission electron microscopy (TEM), Fourier transform infrared (FTIR), and ultraviolet-visible-near-infrared (UV-Vis-NIR). Additionally, their cytotoxic effects on Colon cancer cell (HT-29) and Breast cancer cell (MCF-7) lines were assessed in vitro. Results: TEM, FTIR, and UV-Vis-NIR studies confirmed side-wall functionalization of SWCNT with COOH-groups, PTX, POSS, and antibodies. Increased cell death was observed with PTX-POSS-SWCNT, PTX-POSS-Ab-SWCNT, and free PTX compared to functionalized-SWCNT (f-SWCNT), POSS-SWCNT, and cell-only controls at 48 and 72 h time intervals in both cell lines. At all time intervals, there was no significant cell death in the POSS-SWCNT samples compared to cell-only controls. Conclusion: The PTX-based nanocomposites were shown to be as cytotoxic as free PTX. This important finding indicates successful release of PTX from the nanocomposites and further reiterates the potential of SWCNTs to deliver drugs directly to targeted cells and tissues

Complications of Cosmetic Botulinum Toxin A Injections to the Upper Face: A Systematic Review and Meta-Analysis

BACKGROUND: Botulinum toxin A (BoNT-A) injections are a popular non-surgical procedure for facial rejuvenation. Its increase in popularity and utilization is met with limited regulations, potentially posing a significant risk to patient safety and public health. OBJECTIVES: The authors sought to assess the safety profile of cosmetic glabellar and forehead BoNT-A injections and evaluate BoNT-A type on complication rate. METHODS: A systematic search of MEDLINE and EMBASE was performed for studies reporting complications after cosmetic BoNT-A in the glabellar or in the forehead region in the glabellar or in the forehead region. A random effects meta-analysis was carried out to assess complication rate. Where there were sufficient randomized-controlled trials, a network meta-analysis was performed. RESULTS: Of 556 identified articles, 24 were included in the final quantitative analysis, with 4268 BoNT-A injection sessions and 1234 placebos. Frequently observed treatment-related complications in the BoNT-A intervention group included headache, local skin reactions, and facial neuromuscular symptoms. The overall BoNT-A complication rate was 16%. The odds ratio of developing complications from abobotulinum toxin injections compared with placebo was 1.62 (1.15, 2.27; P > 0.05) and that from onabotulinum toxin injections compared with placebo was 1.34 (0.52, 3.48; P > 0.05). In 30% of the studies, the injectors were doctors, whereas the training status of the practitioner was not reported in the remaining 70%. CONCLUSIONS: Cosmetic BoNT-A injections in the glabellar and forehead region appear to be safe, and most complications are mild and transient. Nevertheless, the literature demonstrates heterogeneous reporting of complications and a lack of consistency of the definition of treatment-related complications. LEVEL OF EVIDENCE: 2

Patient-Reported Outcome Measures in a Facial Reconstruction Case Series Following the Implementation of an Integrated Craniofacial Multidisciplinary Team Clinic, Three-Dimensional Photography, and Computer Modeling

BACKGROUND: Facial reconstruction surgery is often a complex and staged process, leading to lengthy reconstructive journeys for patients. The integration of a clinical pathway can give patients a clearer understanding of what to expect at each stage of their reconstructive journey. OBJECTIVES: The authors demonstrate how the incorporation of multidisciplinary team clinics, three-dimensional (3D) photography, and 3D modeling into an integrated pathway can streamline the process for patients undergoing facial reconstructive surgeries and aid their understanding of their surgeries. METHODS: A novel clinical pathway was developed for patients undergoing facial reconstructive surgery at a tertiary reconstructive unit in London. A case series was collated of 35 patients who had been through the integrated pathway. Patient-reported outcome measures (PROMs) were assessed using FACE-Q scales, Global Aesthetic Improvement Scale, Self-Perception of Age score, and Ordinal Rank change in facial aesthetic appearance, determined subjectively and objectively. Statistical analysis was performed to calculate mean averages for each scale and PROM. RESULTS: High patient satisfaction with overall facial appearance, aging appearance, and the decision-making process was demonstrated. The average perceived improvement in age-related facial appearance was -7.7 years postreconstruction compared with prereconstruction. The Ordinal Rank improvement on facial aesthetic appearance showed considerable improvement, both subjectively and objectively. CONCLUSIONS: The authors advocate the implementation of an integrated clinical pathway for facial reconstruction, with positive impacts observed in terms of patient satisfaction and objective assessments of facial appearance. Similar principles can be extrapolated to other aspects of reconstructive surgery

Cosmetic business mechanics in London: A cross-sectional analysis and audit of ASA compliance

INTRODUCTION: The proliferation of providers and practitioners of cosmetic botulinum toxin and dermal filler has profound public health implications. The Advertising Standards Authority (ASA) regulates the use of advertising materials in the United Kingdom and prohibits the promotion of prescription-only medicines. AIMS: We aim to perform a cross-sectional analysis of the practitioners in London, UK to evaluate the distribution of clinics within Greater London, prices advertised for interventions, and compliance with the ASA code. We also aim to identify whether there are any differences in cost of botulinum toxin or dermal filler between the boroughs. METHODS: Between December 2021 and January 2022, we performed a systematic search using the internet search engine Google. Five searches were performed (1) [london] botox, (2) [london] botulinum toxin, (3) [london] anti wrinkle injection, (4) [london] filler, (5) [london] dermal filler. One hundred websites per search string were systematically reviewed and those which met the inclusion/exclusion criteria of each search string were included and analyzed. Each clinic's product/service range compliance with the ASA/CAP code was assessed. Any reference to Botulinum Toxin or anti-wrinkle injections was noted and analyzed. Further analysis would look to calculate price per milliliter (mL) of botulinum toxin and dermal filler per borough and to calculate whether there were any statistical differences between the 32 different London boroughs. RESULTS: A total of 500 websites were visited and evaluated. After removal of duplicates, a total of 233 independent clinics was identified. A total of 206 out of the 233 clinics sampled (88%) were in direct infringement of the enforcement notice through advertising a prescription medicine. The overall average cost per mL of dermal filler was £330.89 and there was a statistically significant variance across London boroughs (p < 0.05). The overall average cost per mL of Botulinum Toxin was £284.45 and the variance across London boroughs was close to significant (p = 0.058). CONCLUSION: This paper demonstrates poor compliance with the ASA/CAP guidelines and further provides an insight into the industry mechanics associated with aesthetic injectables in a major UK city, identifying regional variance in price and clinic density. The advertising of prescription-only medication may pose a potential risk to patients and will be an important consideration in proposed legislation to introduce licensing to the industry