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

WAFER trial: a study protocol for a feasibility randomised controlled trial comparing wide-awake local anaesthesia no tourniquet (WALANT) to general and regional anaesthesia with tourniquet for flexor tendon repair

Introduction: Flexor tendons are traditionally repaired under either general anaesthesia (GA) or regional anaesthesia (RA), allowing for the use of an arm tourniquet to minimise blood loss and establish a bloodless surgical field. However, the use of tourniquets exposes the patient to certain risks, including skin, muscle and nerve injuries. A recent advancement in anaesthesia delivery involves the use of a wide-awake approach where no sedation nor tourniquets are used (wide-awake local anaesthesia no tourniquet (WALANT)). WALANT uses local anaesthetic with epinephrine to provide pain relief and vasoconstriction, reducing operative bleeding. Several studies revealed potential benefits for WALANT compared with GA or RA. However, there remains a paucity of high-quality evidence to support the use of WALANT. As a result of this uncertainty, the clinical practice varies considerably. We aim to evaluate the feasibility of WALANT as an alternative to GA and RA in patients undergoing surgical repair of flexor tendon injuries. This involves addressing factors such as clinician and patient support for a trial, clinical equipoise, trial recruitment and dropout and the most relevant outcomes measures for a future definitive trial. // Methods and analysis: WAFER is a multicentre, single-blinded, parallel group, randomised controlled trial (RCT) to assess the feasibility of WALANT versus RA and GA. The target population is patients with acute traumatic flexor tendon injuries, across 3 major hand surgery units in England involving a total of 60 participants. Outcome assessors will be blinded. The primary outcome will be the ability to recruit patients into the trial, while secondary outcomes include difference in functional outcome, patient-reported outcome measures, health-related quality of life, cost-effectiveness and complication rates. // Ethics and dissemination: Ethical approval was obtained from the London—City and East Research Ethics Committee (22/PR/1197). Findings will be disseminated through peer-reviewed publication, conferences, patient information websites and social media networks

3D photography and computer modelling in nasal reconstruction

Advances in high resolution 3D photography and computer modelling are revolutionising patient workup, surgical planning, patient satisfaction, clinical outcomes, and surgical training. We present a case in which this technology is utilised for a patient undergoing a forehead flap for reconstruction of a nasal defect, allowing us to develop a novel reconstructive algorithm. 3D photographs were taken pre-operatively, a computer model rendered and follow up photographs taken at each stage of the reconstruction using a Vectra XT camera. Patient satisfaction was measured qualitatively postoperatively. Prior to each stage we were able to use the 3D photographs to make thorough preoperative plans whilst minimising the number of outpatient appointments the patient required. With the images always at hand, we had much more time to make measurements and consider alterations. Utilising the 3D models in clinic and MDT allowed us to have more insightful outpatient appointments, in which we were able to discuss and illustrate each subsequent stage. The use of 3D photography and computer modelling allows for a greater level of care to patients by improving understanding and satisfaction and alleviating anxiety. It also reduced operative time, improves surgical planning, and acts as an excellent resource for surgical trainees and future patients