Nicholas Tang

Background Native skin flap necrosis is a potentially devastating complication following skin-sparing or nipple-sparing mastectomy with a reported incidence of as high as 30%. Treatment depends on the depth and extent of tissue necrosis and can range from dressings to surgical debridement and further reconstruction. This can have implications on patient physical and psychological wellbeing as well as cost of treatment. This study aims to identify and appraise cost-effective non-surgical adjuncts for the prevention of native skin flap necrosis. Methods A systematic review was performed using the preferred reporting items for systematic reviews and meta-analyses (PRISMA) statement and structured around existing recommended guidelines. A search of MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature and ClinicalTrials.gov was performed with the medical subject headings 'mastectomy' and 'flap necrosis'. After exclusion, 12 articles were selected for review and analysed. Results A total of 8439 mastectomies were performed on 7895 patients. Preventative non-surgical adjuncts that demonstrated statistically significant reduction in mastectomy flap necrosis included topical nitroglycerin ointment (P = 0.000), closed-Incision negative pressure wound therapy (P = 0.000), topical dimethylsulfoxide ointment (P = 0.03), oral cilostazol (P = 0.032), and local heat pre-conditioning (P = 0.047). Conclusions This study identifies multiple adjuncts that may aid in preventing mastectomy skin flap necrosis, especially in high-risk patients. Further studies could aim to define standardized protocols and compare the various adjuncts in different circumstances.

Background Lymphoedema is an incurable and progressive disease that affects not only physical function but overall quality of life. Surgical treatment options for the management of lymphoedema are being increasingly performed. This study aims to review post‐operative health‐related quality of life (HRQOL) following surgical treatment of lymphoedema. Methods A systematic search of the PubMed and Medline databases was performed from the date of their inception until September 2018 to evaluate HRQOL following different surgical options for the treatment of lymphoedema. Results One hundred and thirteen articles were identified. Twenty‐one articles were included in the final review, comprising a total of 736 patients. HRQOL improvements appear to be sustained for at least 6–12 months post‐operatively. In particular, major benefits were noted in the domains based around physical functioning. Patient satisfaction similarly mirrors HRQOL improvements, following an initial dip in the immediate post‐operative period. Conclusion All surgical treatment modalities for the management of lymphoedema confer significant HRQOL improvements across a diverse range of health domains, with this critical outcome of surgery an important pre‐operative consideration. Recommendations for ongoing research are suggested.

A 30-year-old, right-hand-dominant transgender woman was brought to the emergency department following self-inflicted amputation of her right hand with a power saw. Initial assessment revealed complete guillotine amputation of the hand at the mid-carpal joint. The amputated hand was deemed suitable for urgent replantation. Further assessment of the patient revealed that this amputation had been premeditated over the preceding three months. The patient had purchased a tarpaulin to prevent blood spillage, a tourniquet and a bucket for ice to 'anaesthetise' the hand. There was no associated illicit drug use, no recent changes in medication and no recent stressors, and her mood had been stable over the past six to nine months. Despite the patient understanding the significant functional impairment without replantation, she did not wish for re-attachment but was accepting of other treatment.