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Application of reduction mammaplasty in treatment of giant breast tumour
British Journal of Plastic Surgery (2000),53, 265-268
9 2000The BritishAssociationof PlasticSurgeons
I
BRITISH
JOURNAL
OF
PLASTIC
SURGERY
S h o r t reports and c o r r e s p o n d e n c e Yours faithfully,
DOI:I0.1054/hips.2000.3327
Muhammad Javaid MB, FRCS(Glasg) Specialist Registrar (LAT)
Future of plastic surgery in the UK and role of overseas doctors
Department of Plastic Surgery, Selly Oak University Hospital, Birmingham NHS Trust, Birmingham B29 6JD, UK.
Sir, I read the paper by B. C. Sommerlad (Br J Plast Surg 1999; 52: 583-5) ~with interest and would like to take the discussion further on the following points. I accept a need for a major expansion in the number of consultant posts, as the number is far too small to provide both service and training commitments at the same time. Because of financial implications this is unlikely to happen in the immediate future: as in the past, implementation of manpower recommendations by Joint Planning Advisory Committee (JPAC) at local level has been less than adequate2 Like some other specialties, there will be a growing disparity between the number of accredited trainees in plastic surgery and available consultant posts in the coming years. 2.3To overcome this problem, Specialist Work force Advisory Group's (SWAG) recommendations to the Department of Health for the year 2000-2001, are likely to cut 300 National Training Numbers (NTN) in all specialties.4 Although the NTN remains unchanged in plastic surgery for the next year, the present situation is likely to worsen in the coming years. We cannot deny the need for some alternative arrangements to support the heavy service requirements in this busy specialty. However, I disagree that the option of appointing non-consultant surgeons should be resisted. Currently the majority of these doctors are overseas or other than UK nationals. As a result of recent changes in the structure of specialist registrar training and closure of the Certification scheme, the overseas doctors, who always have been a valuable pool and integral part of the NHS and this specialty, have been ignored and are currently left to accept service posts like staff grade or clinical assistant without having full training. Because of limited competence they have limited independence. By providing equivalent standard and length of training by creating more visiting training numbers or fixed training appointments, many of these will become suitable to work on 'consultant equivalent' service posts. Also, after having built up their clinical acumen they will be able to provide a high quality service with more independence. This will not only take service and time pressure off the consultants but will also provide more time and commitment for training future plastic surgeons. A Faculty or Institute of Plastic Surgery might be a body for monitoring of the standards and development of the specialty in the UK, and could also play a worldwide role. It could also have a role in conducting exit examinations in plastic surgery not only for U K trainees but also for overseas trainees from all over the world, either in the UK or in some overseas centres. I hope that while planning the expansion of the specialty and reshaping its future, education and health authorities will not forget and lose the valuable contribution made by overseas trainees.
References 1. Sommerlad BC. Plastic surgery in the UK and the USA - comparisons and contrasts: some thoughts for the future in the UK. BrJ Plast Surg 1999; 52:583 5. 2. Williams JL Problems associated with manpower. Ann R Coil Surg Engl (Suppl) 1999; 81: 173-5. 3. Ng RLH. Summary of trainee and combined trainee/consultant discussions. Pan-Thames trainee forum, Royal Society of Medicine; October 1999: 4-5. 4. Wilson C. Reduction in SpR numbers leads to service fears. Hospital Doctor 2 December 1999; 1.
DOI:10.1054/bjps.1999.3328
Application of reduction mammaplasty in treatment of giant breast tumour Sir, I read with interest the article on 'Application of reduction mammaplasty in treatment of giant breast tumour' by Yamamoto and Sugihara (Yamamoto Y, Sugihara T. Application of reduction mammaplasty in treatment of giant breast tumour. Br J Plast Surg 1998; 51: 109-12). I disagree with the authors' opinion that reduction mammaplasty is required to obtain symmetry in unilateral giant fibroadenoma. Reduction mammaplasty is indicated only when there is true hypertrophy of breast tissue. In gigantomastia due to giant fibroadenoma, there is no true breast hypertrophy. There is only stretching of the tissues and the giant size is entirely due to the tumour. When the tumour is removed the tissues go back to their original size. To substantiate this, a 38-year-old woman presented with progressive enlargement of her left breast of 2 years duration. On physical examination, her left breast was very much enlarged (Fig. 1) by a soft turnout measuring about 18 x 12 cm. F N A C did not reveal any malignant cells. Even though her right breast was also pendulous, she did not want any cosmetic surgery. It was decided to explore the left breast first through the lateral transverse limb of the inferior pedicle reduction incision. This was because there was some concern that the patient would require a reduction mammaplasty. On exploration, a giant fibroadenoma weighing 2100 g was removed (Fig. 2). The wound was closed with a drain, without doing a reduction. The patient was followed up at monthly intervals. The left breast gradually shrank. After 7 months the left breast was symmetrical with the right breast (Fig. 3). I do not believe
265
266
British Journal of Plastic Surgery that reduction mammaplasty is necessary in the removal of all giant breast tumours. Yours faithfully, M. M. Jacob MS, MCh, DNB, Consultant Plastic Surgeon Jubilee Memorial Hospital, Palayam, Trivandrum-34, India.
DOI: 10.1054/bjps.1999.333l I
A problem of identity following cleft lip repair
Figure 1--Preoperative appearance. Left breast enlarged due to giant fibroadenoma.
Sir, A 35-year-old male presented to our unit for the first time with complete left-sided cleft lip, having discovered that his deformity could be treated surgically. We repaired his cleft lip and he was discharged with no complications. However, during a routine follow-up visit, he asked whether he needed to change his photographs in his passport. We telephoned the Police Department, and they demanded a declaration from us stating that he is the same person for whom we did the repair, and only then would they replace his old photograph with a new one. This incident highlights the problems facing adults with cleft lip in developing countries where some patients still present late. We now routinely issue a certificate to every adult patient for whom we perform cleft lip repair. We are unaware of any similar problem reported in the literature. Yours faithfully, M. T. Suliman MS, FRCS, Consultant Plastic Surgeon Elfasher Teaching Hospital, Elfasher, Sudan.
DOI:10.1054/bjps.1999.3332 Figure 2--The excised tumour weighed 2100 g.
Monodigital double cross finger flaps
Figure 3--Postoperative view at 7 months. Breast symmetry has been restored without the need for reduction mammaplasty.
Sir, A cross finger flap is commonly used in reconstruction following finger injuries. We would like to present a case where two monodigital cross finger flaps from the left middle finger were used to reconstruct a large defect on the radial border of the left index finger, preserving a 1 cm skin bridge over the proximal interphalangeal (PIP) joint to reduce donor site morbidity. A 30-year-old man presented with injury to his left nondominant index finger from a router blade. The defect extended from the mid proximal phalanx to distal of the distal interphalangeal joint. On exploration it was found that the PIP joint was exposed, there was a 4 cm loss of the radial digital nerve and artery and loss of the radial slip of flexor digitorum superficialis, with damage to A2, A3 and A4 pulleys. The A2 and A3 pulleys were reconstructed with extensor retinaculum grafts and the defect was covered with two standard cross finger flaps taken from the dorsum of the proximal and middle phalanges with preservation of a 1 cm skin bridge overlying the PIP joint. The donor areas were reconstructed with thick split thickness skin grafts. He was immobilised in a splint for 3 weeks and then both flaps were
9 2000The BritishAssociationof PlasticSurgeons
I
BRITISH
JOURNAL
OF
PLASTIC
SURGERY
S h o r t reports and c o r r e s p o n d e n c e Yours faithfully,
DOI:I0.1054/hips.2000.3327
Muhammad Javaid MB, FRCS(Glasg) Specialist Registrar (LAT)
Future of plastic surgery in the UK and role of overseas doctors
Department of Plastic Surgery, Selly Oak University Hospital, Birmingham NHS Trust, Birmingham B29 6JD, UK.
Sir, I read the paper by B. C. Sommerlad (Br J Plast Surg 1999; 52: 583-5) ~with interest and would like to take the discussion further on the following points. I accept a need for a major expansion in the number of consultant posts, as the number is far too small to provide both service and training commitments at the same time. Because of financial implications this is unlikely to happen in the immediate future: as in the past, implementation of manpower recommendations by Joint Planning Advisory Committee (JPAC) at local level has been less than adequate2 Like some other specialties, there will be a growing disparity between the number of accredited trainees in plastic surgery and available consultant posts in the coming years. 2.3To overcome this problem, Specialist Work force Advisory Group's (SWAG) recommendations to the Department of Health for the year 2000-2001, are likely to cut 300 National Training Numbers (NTN) in all specialties.4 Although the NTN remains unchanged in plastic surgery for the next year, the present situation is likely to worsen in the coming years. We cannot deny the need for some alternative arrangements to support the heavy service requirements in this busy specialty. However, I disagree that the option of appointing non-consultant surgeons should be resisted. Currently the majority of these doctors are overseas or other than UK nationals. As a result of recent changes in the structure of specialist registrar training and closure of the Certification scheme, the overseas doctors, who always have been a valuable pool and integral part of the NHS and this specialty, have been ignored and are currently left to accept service posts like staff grade or clinical assistant without having full training. Because of limited competence they have limited independence. By providing equivalent standard and length of training by creating more visiting training numbers or fixed training appointments, many of these will become suitable to work on 'consultant equivalent' service posts. Also, after having built up their clinical acumen they will be able to provide a high quality service with more independence. This will not only take service and time pressure off the consultants but will also provide more time and commitment for training future plastic surgeons. A Faculty or Institute of Plastic Surgery might be a body for monitoring of the standards and development of the specialty in the UK, and could also play a worldwide role. It could also have a role in conducting exit examinations in plastic surgery not only for U K trainees but also for overseas trainees from all over the world, either in the UK or in some overseas centres. I hope that while planning the expansion of the specialty and reshaping its future, education and health authorities will not forget and lose the valuable contribution made by overseas trainees.
References 1. Sommerlad BC. Plastic surgery in the UK and the USA - comparisons and contrasts: some thoughts for the future in the UK. BrJ Plast Surg 1999; 52:583 5. 2. Williams JL Problems associated with manpower. Ann R Coil Surg Engl (Suppl) 1999; 81: 173-5. 3. Ng RLH. Summary of trainee and combined trainee/consultant discussions. Pan-Thames trainee forum, Royal Society of Medicine; October 1999: 4-5. 4. Wilson C. Reduction in SpR numbers leads to service fears. Hospital Doctor 2 December 1999; 1.
DOI:10.1054/bjps.1999.3328
Application of reduction mammaplasty in treatment of giant breast tumour Sir, I read with interest the article on 'Application of reduction mammaplasty in treatment of giant breast tumour' by Yamamoto and Sugihara (Yamamoto Y, Sugihara T. Application of reduction mammaplasty in treatment of giant breast tumour. Br J Plast Surg 1998; 51: 109-12). I disagree with the authors' opinion that reduction mammaplasty is required to obtain symmetry in unilateral giant fibroadenoma. Reduction mammaplasty is indicated only when there is true hypertrophy of breast tissue. In gigantomastia due to giant fibroadenoma, there is no true breast hypertrophy. There is only stretching of the tissues and the giant size is entirely due to the tumour. When the tumour is removed the tissues go back to their original size. To substantiate this, a 38-year-old woman presented with progressive enlargement of her left breast of 2 years duration. On physical examination, her left breast was very much enlarged (Fig. 1) by a soft turnout measuring about 18 x 12 cm. F N A C did not reveal any malignant cells. Even though her right breast was also pendulous, she did not want any cosmetic surgery. It was decided to explore the left breast first through the lateral transverse limb of the inferior pedicle reduction incision. This was because there was some concern that the patient would require a reduction mammaplasty. On exploration, a giant fibroadenoma weighing 2100 g was removed (Fig. 2). The wound was closed with a drain, without doing a reduction. The patient was followed up at monthly intervals. The left breast gradually shrank. After 7 months the left breast was symmetrical with the right breast (Fig. 3). I do not believe
265
266
British Journal of Plastic Surgery that reduction mammaplasty is necessary in the removal of all giant breast tumours. Yours faithfully, M. M. Jacob MS, MCh, DNB, Consultant Plastic Surgeon Jubilee Memorial Hospital, Palayam, Trivandrum-34, India.
DOI: 10.1054/bjps.1999.333l I
A problem of identity following cleft lip repair
Figure 1--Preoperative appearance. Left breast enlarged due to giant fibroadenoma.
Sir, A 35-year-old male presented to our unit for the first time with complete left-sided cleft lip, having discovered that his deformity could be treated surgically. We repaired his cleft lip and he was discharged with no complications. However, during a routine follow-up visit, he asked whether he needed to change his photographs in his passport. We telephoned the Police Department, and they demanded a declaration from us stating that he is the same person for whom we did the repair, and only then would they replace his old photograph with a new one. This incident highlights the problems facing adults with cleft lip in developing countries where some patients still present late. We now routinely issue a certificate to every adult patient for whom we perform cleft lip repair. We are unaware of any similar problem reported in the literature. Yours faithfully, M. T. Suliman MS, FRCS, Consultant Plastic Surgeon Elfasher Teaching Hospital, Elfasher, Sudan.
DOI:10.1054/bjps.1999.3332 Figure 2--The excised tumour weighed 2100 g.
Monodigital double cross finger flaps
Figure 3--Postoperative view at 7 months. Breast symmetry has been restored without the need for reduction mammaplasty.
Sir, A cross finger flap is commonly used in reconstruction following finger injuries. We would like to present a case where two monodigital cross finger flaps from the left middle finger were used to reconstruct a large defect on the radial border of the left index finger, preserving a 1 cm skin bridge over the proximal interphalangeal (PIP) joint to reduce donor site morbidity. A 30-year-old man presented with injury to his left nondominant index finger from a router blade. The defect extended from the mid proximal phalanx to distal of the distal interphalangeal joint. On exploration it was found that the PIP joint was exposed, there was a 4 cm loss of the radial digital nerve and artery and loss of the radial slip of flexor digitorum superficialis, with damage to A2, A3 and A4 pulleys. The A2 and A3 pulleys were reconstructed with extensor retinaculum grafts and the defect was covered with two standard cross finger flaps taken from the dorsum of the proximal and middle phalanges with preservation of a 1 cm skin bridge overlying the PIP joint. The donor areas were reconstructed with thick split thickness skin grafts. He was immobilised in a splint for 3 weeks and then both flaps were