anitahazari
Tel: 01342 330 396
secretaryanitahazari@gmail.com


GMC Specialist Register Plastic Surgery 4277037
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The UK National Flap Registry: First Report 2019

10/2/2020

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It has taken six years from inception of the registry to delivery of this first report, with over 5750 cases from 97 hospitals across the UK. This registry, and certainly the first report, would not have been possible without data entry by flap reconstruction colleagues from various surgical specialties. Often these cases are long and physically demanding. 

UKNFR is the first national registry of its type in the world to collect data on all major pedicled and free flap operations. Data entry is voluntary, and it is acknowledged that unit data in this first report may not be a true representation of the case load of each participating unit.
 
An overview
• This is the first report of the UK National Flap Registry.
• The first patient record was added to UKNFR on 1 August 2015.
• Up to 8 August 2019, 5,751 operation records had been added to UKNFR, with over 180 registered consultant users actively adding data to the registry.
• Cases have been included from 97 private and NHS hospitals in England, Wales, Northern Ireland and Republic of Ireland. Surgeons in Scotland are awaiting permission from the Public Benefit and Privacy Panel (PBPP) for Health and Social Care.
• Participating speciality associations include the British Association of Plastic Reconstructive and Aesthetic Surgeons (BAPRAS), British Association of Oral and Maxillofacial Surgeons (BAOMS), British Association of Head and Neck Oncologists (BAHNO), Association of Breast Surgery (ABS) and British Society for Surgery of the Hand (BSSH).
 
Outcomes
Interpretation of the data has taken into account that some records may be incomplete and that not every case from each unit will have been included. The key outcomes were as follows:
• Overall total flap survival: breast 97.6%, head & neck 94.2%, limbs 94.5%, trunk and perineum 94.2%.
• Unplanned re-operation rate: breast 8.6%, head & neck 12.1%, limb 15.5%, trunk and perineum 12.0%.
• Average length of stay in days: breast 4.7days, head & neck 18.6, limb 12.9, trunk and perineum 11.5.
• Patency rates: Anastomotic patency of blood vessels is an objective measure of surgical outcome in free tissue transfer. More couplers were used in breast microsurgical reconstruction, constituting 81% of end-to-end vein anastomoses with over 98% patency rates.
• Outcomes were also analysed according to other groupings, such as specific risk factors or comorbidities: smoking, diabetes and an ASA score >3 were all associated with a significantly increased flap failure rate.
• The majority of flaps were from a single donor site to single recipient site (85.0% of operations)
• The most common donor flap in breast reconstruction was the deep inferior epigastric perforator flap (77.5%)
• The majority of breast reconstructions were delayed (49.0%) i.e., after completion of cancer treatment, compared to immediate (45.2%) i.e., mastectomy and reconstruction performed at the same time.

Breast-Q PROMs
After breast reconstruction, Patient Reported Outcome Measures (PROMS) were measured using the Breast-Q questionnaire at 6 months. Using a benchmark of a Breast-Q score of ≥70 (range 0-100) to define satisfaction, 72.5% of patients were satisfied with the breast reconstruction, 83.5% were satisfied with the outcome and 87.8% were satisfied with the information they were given. Though a further questionnaire was sent out at 18 months after reconstruction, the numbers of returned questionnaires were inadequate for this report and will be presented in future reports.
 
Surgeon dashboard
One of the big successes of the registry has been the surgeon dashboard. The registry displays the surgeon’s own data on a dashboard which allows easy visualisation of it in real time. This includes the number of procedures performed, case-mix, flap survival, unplanned return to theatre and length of hospital stay. The dashboard is very useful during appraisal and revalidation as it produces evidence of the surgeon’s performance in the form of a real time audit. 

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Everday Surgical Heroes: Puregraft®- Better fat transfer survival

24/3/2015

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Continuing in the series of everyday surgical heroes,that make procedures easier and safer for my patients, is the Puregraft® fat transfer bag. I have been performing lipofilling/ fat transfer for 20 years, initially as a trainee and for the last 9 years as a Consultant. Fat transfer is an important adjunctive procedure in breast reconstruction and aesthetic surgery. I have used the Coleman centrifuge to concentrate fat, then gave up using centrifugation, and continued with just washing the fat and letting it stand to separate.

I started using the Puregraft® bag about 2 years ago and it has finally been approved for use in my local NHS hospital. And what a difference it makes. It is a closed system, so processing the fat is sterile, less messy and quicker. Due to its filter, the fat appears to be cleaner with less blood. And anecdotally, my observation has been that survival rates of harvested fat with Puregraft® are higher. A recent study, now confirms this: Long-term volumetric retention of autologous fat grafting processed with closed membrane filtration. Gerth DJ, et al. Aesthet Surg J. 2014 Sep;34(7):985-94.


Another useful tool to improve outcomes for patients!


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Polyurethane coated breast implants: the answer to capsular contracture?

8/2/2015

 
One of the two reasons why breast implants need replacing is capsular contracture, the other is rupture or leaks. The implants that I currently use are high cohesive gel by Allergan and Mentor, both are FDA approved. Rupture rates in these implants are low, infact both manufacturers provide a life-time warranty for rupture. Capsular contracture, though, continues to be a problem.

Polyurethane coated implants, supplied by Polytech in the UK may be a solution. These implants have been used in South America for the last 35 years, and were used for a short period of time in the US, but were withdrawn from USA, alongwith all silicone implants in the 1990s during the years of ‘silicone controversy’.  The other finding has been the presence of 2,4TDA (toluenediamine) in the urine of women with these implants. But this has finally been resolved too, as TDA has been found in urine of women with no breast implants. Polyurethane is also used in other prosthetics such as heart valves and pacemakers, so safety is no longer an issue. 


The polyurethane coating does two things:

  •  It reduces the rate of capsular contracture to 1-3% at 15 years by stabilising the collagen fibres that make up the capsule, preventing these from sliding over each other and causing the capsule to contract like a ‘shrink-wrap’.
  • As a result of the polyurethane coating, these implants stay where they are placed, a distinct advantage when tear-drop (aka anatomical or natural-shaped) implants are used, thus preventing rotation of the shaped implant.
So I have started using these implants. Precise placement is crucial and my early results are very pleasing both for my patients, and for me when I evaluate my results. 

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Everyday Surgical Heroes: The Doppler

22/11/2014

 
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When a patient has a flap (tissue moved from one part of body to another), such as when I make a breast from the abdomen or inner thigh, the blood flow within it is monitored with the use of a doppler device. The Doppler proble is applied to the skin overlying the blood vessel and the signal is determined by a sound. 
The work of one man has resulted in the Doppler effect being used in many everyday things we take for granted- sirens, satellite communication, fetal heart monitoring, police radars and monitoring blood flow in medicine.
The Doppler signal is the change in frequency of a sound wave for an observer, moving relative to its source, named after an Austrian physicist Christian Doppler, in 1842.  
It is commonly heard when a vehicle with a siren approaches, passes and recedes. He described the effect at the age of 38 , published many articles as a Professor and then died pre-maturely at the age of 49 from lung disease. 

Everyday Surgical Heroes: The BairHugger

4/10/2014

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Invented in 1987, forced-air warming technology, the Bair Hugger™shown in the photo, looks like a plastic blanket with warm air inside, has become standard in hospitals around the world, safely warming 165+ million patients. It keeps anaesthetised patients warm and maintains 'normothermia' - normal body temperature. This makes the operation safer for the patient and as it is single-use, reduces infection. Maintaining normal body temperature is crucial in long operations, especially breast reconstructions which I do every week; when a large part of the body such as the chest and abdomen are exposed for surgery, thereby losing heat and cooling down further from the use of damp swabs and saline in the surgical field.

My breast reconstruction patients benefit tremendously even after the operation. The BairHugger is kept on overnight- it keeps the 'breast flap' warm and hence keeps the connected blood vessels which are 2-3mm in diameter flowing nicely. My reconstruction patients do feel a little 'roasted', though I prefer to say 'cosy'!. 
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Everyday Surgical Heroes: The Diathermy

15/6/2014

 
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The picture on the left shows the new generation diathermy machines used today, and is one I always use during most operations. Electrosurgical units (diathermy machines) were first introduced during the early twentieth century to facilitate stopping bleeding by closing off the ends of cut blood vessel ends (haemostasis) and/or the cutting of tissue during surgical procedures. In this process, a smoke plume is generated which is sucked up by the attached smoke evacuation tubing.

It has revolutionised the way I operate. Bleeding during surgery is kept to a minimum. Infact, it is rare for my patients to require blood transfusion even after major reconstruction surgery lasting 6-7 hours. The incidence for returning to theatre for an emergency evacuation of a haematoma (removing blood clot in the tissues) has decreased significantly, compared to the days when one used to use a knife throughout the operation. The downside of using a diathermy to perform the operation is the generation of heat in the tissues, which can cause thermal damage. To reduce this risk, I will often use it on low settings of 'pure' current- so that even if the diathermy tip accidentally touches my gloved finger, there is minimal heat and no burn. As a result of reducing bleeding during operations, the diathermy has made my dissections cleaner and faster, as the operating field is clear. Patients have benefitted too- less blood loss and reduced operation times means a quicker recovery after major surgery.

Everyday Surgical Heroes: The Coupler

11/5/2014

 
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To make a breast with skin and fat from the tummy or inner thigh after a mastectomy, involves some 'plumbing'. The tummy or inner thigh tissue with its blood supply is completely disconnected and detached from the body. It is then placed on the chest and the blood vessels or 'pipes'  are connected to those under the ribs. The size of the these 'pipes' is very small- between 1 to 3 mm in diameter. 

So similar to a plumbing pipe-coupler, plastic surgeons use a coupling device as shown in the picture, to join up the vein using an operating microscope. This has reduced the time taken to connect the veins from 45-50 mins when sutured by hand, down to approximately 8 mins when the coupler is used. In an operation that takes 6 hours , this is a significant time saving and results in less time under an anaesthetic for the patient. And it ensures that a sidewall of the vein is not caught up in a stitch, something one has to look out for in a hand-sewn 'plumbing' of the vein.

For the last 8 years,  every Tuesday, when I reconstruct a breast using skin and fat from the tummy (DIEP) or from the inner thigh (TUG), I count the venous coupler as one of my blessings- it makes my surgical life a little bit safer, quicker and more controlled, both for me and for my patients. 

Quilting in tummy-tucks reduces seroma

3/11/2013

 
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Abdominoplasty or tummy-tuck is one of the most frequently performed cosmetic operations. And seroma or fluid collection, when you return to the clinic with a feeling of  'water-bed' under the skin layer, is one of its commonest complications. For over 3 years, I have been quilting the tummy skin down onto the rectus sheath to obliterate the space where seroma forms with a Quill knotless barbed dissolving suture  in my DIEP breast reconstruction patients,  where the tummy tissue is used to reconstruct a breast. The closure of the tummy is very similar to that of a cosmetic tummy tuck. 


With quilting, I noticed that the seroma rate was significantly reduced and since incorporating the same technique for  cosmetic tummy-tuck patients, I have not looked back. The contour is much more pleasing, the tension across the tummy skin is more evenly distributed and the seroma rate is almost negligible. The only  downside is that in some slimmer patients, the quilting can show up as puckering or dimples in the skin; however, these disappear by 10 weeks when the suture is absorbed by the body. There have been  several scientific studies in plastic surgery journals which have demonstrated the reduction in seroma with quilting in tummy tucks compared to the use of tissue glue or patients with no quilting.


  1. Does Quilting suture prevent seroma in abdominoplasty? Plastic Reconstructive surgery March 2007.
  2. Suction drains, quilting sutures, and fibrin sealant in the prevention of seroma formation in abdominoplasty: which is the best strategy? Aesthetic Plastic Surgery April 2012



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