Abstract 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.
Case: In this report, we present the case of a patient undergoing en-bloc resection of a large triceps soft-tissue sarcoma, requiring reconstruction of the triceps tendon including its distal insertion. We describe a surgical technique using fascia lata (FL) autograft to reconstruct the patient's extensor mechanism with long-term follow-up and functional results. Conclusions: FL autograft is a viable option for reconstruction of large tendinous defects. It is simple and straightforward to harvest, inexpensive when compared with alternatives, with many potential applications.
Gracilis muscle transplant is the standard of care for smile reconstruction in children with Möbius syndrome. The authors describe the long-term clinical efficacy, durability, and psychosocial impact of this approach at a mean follow-up of 20 years.Patients with Möbius syndrome who underwent gracilis muscle transfer between 1985 and 2005 were included in the study. The authors assessed midfacial movements using photographs and Scaled Measurement of Improvement in Lip Excursion measure, administered the patient-reported Facial Clinimetric Evaluation Scale, and used semistructured interviews.The mean age at surgery was 13.2 ±10.6 years and the mean follow-up was 20.4 ± 4.4 years postoperatively. Twenty-two gracilis muscle transplants were performed, all innervated by the motor nerve to the masseter. Photographic analysis using Scaled Measurement of Improvement in Lip Excursion software demonstrated that movement of the muscle was unchanged 20 years after surgery. Smile symmetry was stable long term. The overall mean Facial Clinimetric Evaluation score of the cohort was 62.3 ± 12.0. Facial comfort (86.4 ± 21.2) and social function (69.9 ± 18.5) subdomains were the highest. Although the facial movement subdomain score was 35.6 ± 12.4, the score related to smiling alone was 84.1 ± 20.2, indicating satisfaction with the midfacial reconstruction. Interview responses indicated high satisfaction with surgery; fulfilled expectations of social acceptance; improved communication; enhanced self-confidence; and a sense of increased facial symmetry, spontaneity, and smile excursion.Segmental gracilis muscle transplantation provides long-lasting, durable improvements in objective and patient-reported measures of facial function.
Surgeons need guidance regarding appropriate personal protective equipment (PPE) during the COVID-19 pandemic based on scientific evidence rather than availability. The aim of this article is to inform surgeons of appropriate PPE requirements, and to discuss usage, availability, rationing and future solutions.
A time-dependent, two-dimensional numerical model is constructed by coupling a four-layer atmosphere to a two-layer ocean through fluxes of heat and momentum. Idealized experiments are performed to investigate the oceanic response to sea breeze forcing, changes induced in the sea breeze by coastal upwelling, and air-sea feedback during periods of active coastal upwelling. This problem is motivated by the fact that the time scale of the coastal upwelling response is short compared to most oceanic response times and is comparable to the sea breeze time scale. When forced with a longshore wind stress, the model ocean reproduces several features commonly observed in coastal upwelling regimes, including an equatorward surface jet, a poleward undercurrent, and a region of low sea surface temperatures near the coast. For the cases considered here, the sea breeze contributes significantly to the mean longshore wind stress and, consequently, plays a role in driving the coastal upwelling circulation. It also substantially increases the kinetic energy of the nearshore ocean by forcing inertial oscillations and internal gravity waves with a diurnal period. When the sea surface temperature is held constant and the land temperature is varied diurnally, the model atmosphere cyclically reproduces a realistic simulation of the sea breeze-land breeze circulation which includes such features as the sea breeze forerunner and the sea breeze front. However, a rapid decrease in sea surface temperature near the coast characteristic of coastal upwelling produces important alterations of the sea breeze-land breeze circulation. Low-level cooling of the atmosphere over the cold water leads ultimately to the formation of a shallower, sharper, faster and longer lasting sea breeze front that penetrates more than twice as far inland than it would without the upwelling. In general, the cold water causes an increase in the low-level sea breeze intensity landward of ∼6 km inland but a decrease seaward of this point. The cold water decreases the land-sea thermal contrast at night and weakens the low-level land breeze everywhere. Since the cold water in the upwelling zone perturbs the atmosphere on a horizontal scale that is small compared to the internal radius of deformation for the atmosphere, the increase in the longshore geostrophic wind it induces near the coast is small. Furthermore, the reduction in low-level sea breeze amplitude over the cold water compensates the effect of slightly increased mean longshore wind such that the change in mean longshore wind stress is negligible. Thus, although the sea breeze affects the upwelling and the upwelling affects the sea breeze, the air-sea feedback loop to the coastal upwelling process is exceedingly weak.
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.
Acoustic tomography is assessed as a means of measuring the seasonal oceanic advective heat transport into the Barents Sea from the Norwegian Sea. The assessment is made by using seasonal climatological data to simulate the regional temperature and current fields in the computer. Inversion of the synthetic acoustic travel time data gives the reconstructed ocean fields from which the advective heat flux is estimated. Resolution and variance analyses of several array geometries are performed in an effort to determine an optimal configuration for a given number of moored transceivers. Furthermore, the acoustic technique is compared to conventional methods.
Abstract Forecasts from an operational system for predicting global diurnal sea surface temperature (SST) variability are compared against multichannel sea surface temperatures calculated from advanced very high resolution radiometer data from the NOAA-9 satellite. The forecast system consists of an upper-ocean model driven by heat fluxes and wind stresses from an operational global weather prediction model. Visual pattern correlations between observed and forecast diurnal changes in SST are generally favourable, indicating that the forecast system is useful. Some systematic deficiencies are also noted: the forecasts do not reproduce the surprisingly sharp boundaries of diurnal warming regions and underpredict the amplitude of the extreme warming events
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