Correspondence and communications and quicker, avoiding an oedematous hand, generally considered a precursor of CRPS Type 1. 4. A prophylactic fasciectomy of the remaining normal palmar fascia is carried out to try to avoid further palmar disease arising in this hand. With modern instrumentation, this actually leaves little dead space, without the risk of haematoma feared by McCash. Arguably,3,4 this reduces the likelihood of further development of disease, as pointed out many years ago to the senior author, and practiced routinely, by Professor Buck-Gramcko. Over the period between December 2000 and April 2009, four patients who had developed CRPS Type 1 following previous fasciectomy, developed further new disease in the same (one case), or other (three cases), hand which was progressing into the finger(s). These patients included three men and one woman with a mean age of 61 (range 57e67) years. Prior to these presentations, none of the patients developed recurrence in the rays operated on originally. One patient was diabetic and another consumed more than 35 units of alcohol per week. The four patients were monitored until it was clear that disease was progressing into one, or more, fingers. They subsequently underwent palmar fasciectomy using the open palm technique, without need to open the finger, with mobilisation of the hand immediately from the day after surgery. In the first two cases, only fascia obviously affected by Dupuytren’s disease was resected. In the two more recent patients, the unaffected longitudinal fascial fibres of the palmar fascia were also resected from the superficial palmar arch to the distal edge of the superficial transverse ligament. All of the patients recovered full hand mobility quickly after the second operation and none developed CRPS Type 1 within twelve months from surgery. None suffered any complications. In particular, the two patients who had radical palmar fasciectomies did not develop haematomas in the palm. After suffering CRPS Type 1 following surgery for Dupuytren’s disease, recurrence, or extension, of disease may be viewed as ‘better left well alone’. However, the associated and increasing disability is not always satisfactory. All surgeons would avoid surgery for further palmar disease with no finger contracture. Most would agree to minimise the extent of any further surgery. Unfortunately, while fasciotomy is the least aggressive of our surgical treatments, it has the highest rate of disease recurrence. While our study sample is too small to prove the efficacy of this algorithm of management, the problem is so rare that we could not change this if we waited a further decade before presenting our data. We feel that this subject needs discussion and present this study in the hope of stimulating other authors to present an alternative.

Funding None.

Conflict of interest statement None.

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References 1. Hueston JT. Table top test. Med J Aust 1976;2:189e90. 2. McCash CR. The open palm technique in Dupuytren’s contracture. Br J Plast Surg 1964;17:271e80. 3. Millesi H. Dupuytren-Kontraktur. In: Nigst H, Buck-Gramcko D, Millesi H, editors. Handchirurgie, Band 1. New-York: Thieme; 1981. 15.1e15.57. 4. Hueston JT. Dupuytren’s contracture. In: Flynn JE, editor. Hand surgery. Baltimore: Williams & Wilkins; 1982. pp. 797e823.

H. Van Dam D. Elliot Hand Surgery Department, St. Andrew’s Centre for Plastic Surgery, Broomfield Hospital, Chelmsford, Essex, UK E-mail address: [email protected] ª 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2013.12.024

Academic mentoring in surgery: Applying the nearpeer principles to the training hierarchy: Including medical students Dear Sir, There is a growing realisation in surgery that academic collaboration is more productive than small groups working competitively. This has led to different models of collaboration. An example of one is the Reconstructive Surgery Trials Network, led by an academic consultant plastic surgeon, and aims to capitalise on NHS architecture and systems to deliver multi-centre trials by pooling resources and expertise (http://reconstructivesurgerytrials.net/). A second type of collaboration is registrar-led and delivered. The pioneering, and perhaps most successful, of such systems is West Midlands Research Collaborative (http://www. wmresearch.org.uk/) which undertakes multi-centre registrar-led studies in general surgery.1 Other specialties and regions have their own collaboratives (http://www.asit. org/resources/collaboratives). General surgeons have now extended the scope of such collaboratives by establishing Student Audit and Research in Surgery (STARSurgUK) in which students coordinate data collection for multi-centre studies (http://www. asit.org/news/STARSurgUK1). We commend and support these efforts. However, these larger scale operations might be daunting for novice students, and may not fulfil their individualised academic learning needs. It might also be difficult to gain publication as a leading author in such collaboratives due to the number of individuals involved. For novice medical students and trainees, smaller collaborations may be complementary to

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Correspondence and communications

Figure 1 Illustration of the various collaborations within the cell, involving medical students, junior doctors and registrars based on the central parallel collaborations between SH and NTM and JNR. Names of collaborators are listed in the acknowledgements section.

involvement in larger collaborations, by providing more personal mentorship to build confidence and develop academic skills. We describe our experience with a productive “cell” system. The central collaborations were between two plastic surgery registrars (JNR and SH) in parallel with a then-4th year medical student (NTM). Other students and trainees have also been involved (see acknowledgements). E-mail, telephone and social media correspondence then facilitated projects surveying the academic output of British medical students, and then of students attending a British Association of Plastic, Reconstructive and Aesthetic Surgery (BAPRAS) undergraduate conference. Further projects in 2012 led to the publication of six more articles, as well as poster presentations at national surgical meetings: the Association of Surgeons in Training and BAPRAS conferences. This on-going collaboration has also involved other students and trainees of different grades. Collaboration between the first and second authors began with reviews of near-peer teaching literature, prompted by the report of a near-peer programme in Southeast Scotland, described by the latter.2 Again, regular correspondence has led to further collaboration on projects, resulting in publications.3,4 These collaborations have harnessed modern communication media to associate like-minded individuals based in different centres across the entire UK (Glasgow, Merseyside, Yorkshire and the South East), and to maintain links in spite of geographical movements arising from career progression. Our collaborations have so far included 11 individuals (three medical students, four registrars and four core trainees/foundation doctors). Figure 1 illustrates the network of individuals involved. A total of 13 articles have been published between 2012 and 2013. Three conference presentations have been delivered, several of which have been published in journal supplements. Another poster is to be presented at the winter BAPRAS meeting in 2013. Students have been lead authors in all articles.

We present our experience to stimulate registrars, junior trainees and medical students to establish similar groups in addition to membership of regional or national research collaboratives. Indeed, such collaborations have been formalised by organisations such as the UK Medical Student Association (UKMSA) where trainees can submit project ideas for which medical students apply to undertake under the trainee’s supervision (http://www. ukmsa.org/?page_idZ5178). Several medical schools have also started their own similar societies including one co-founded by NTM at Brighton and Sussex Medical School (http://www.researchnetwork.co.uk/). Unlike research collaboratives described above, these schemes offer more personal mentorship. Both approaches offer students ‘ready-made’ projects. However, a student personally approaching registrars may be more demonstrative of initiative on the part of the student. Registrars benefit by developing research supervision skills whilst students gain academic skills, as well as evidence of research participation that might aid career progression. We believe that this may further stimulate students’ interest in academic plastic surgery. Also, with increasing competition for training posts, aspiring plastic surgeons are encouraged to begin accumulating evidence of these competencies early, even as undergraduate students where possible.5

Conclusions A model in which students are used as data collection agents in exchange of authorship after a long list of registrars is inappropriate. In our model, undergraduate students develop by leading in projects under supervision. We advocate the development of cells like this, which can be maintained despite job changes and long distances between individuals. These collaborations may be complementary to larger research collaboratives. To foster inter-cell collaboration and to provide transparent

Correspondence and communications regulation, ‘cells’ could join a web-based register that requires participants to observe a code of practice. Inter-cell collaboration could be stimulated if their collective interests were listed on such a register. Plastic surgery has a history of innovation: here is another opportunity to lead the way.

Ethical approval

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Quilting sutures, fibrin tissue adhesive or both in reducing the incidence of seroma in the latissimus dorsi flap donor site? An evidence-based analysis

Not required. Dear Sir,

Funding None.

Conflicts of interests None.

Acknowledgements The authors wish to thank Alex Cumberworth, Stefan Klimach, Mohammad Mahmud, Dariush Nikkhah, Marco Malahias, MJ Hallam, Michelle Griffin, and Jenny Lane who have all contributed to the collaborations described above.

References 1. Bhangu A, Kolias AG, Pinkney T, Hall NJ, Fitzgerald JE. Surgical research collaboratives in the UK. Lancet 2013;382(9898): 1091e2. 2. Rodrigues J, Sengupta A, Mitchell A, et al. The Southeast Scotland Foundation Doctor Teaching Programmeeis “nearpeer” teaching feasible, efficacious and sustainable on a regional scale? Med Teach 2009;31(2):e51e7. 3. Mabvuure NT, Rodrigues J, Cumberworth A, Mahmud M. Twelve tips for running successful junior doctor-led teaching programmes for medical students. Med Teach 2013;35(8): 628e32. 4. Klimach S, Mabvuure NT, Rodrigues JN. A review of JPRAS’ contribution to undergraduate surgical education. J Plast Reconstr Aesthet Surg 2013;66(10):e290e3. 5. Mabvuure N, Jalali RE, et al. The UK plastic surgery trainee. J Plast Reconstr Aesthet Surg 2012;65(4):e108e9.

Nigel Tapiwa Mabvuure Glasgow Royal Infirmary, Glasgow, UK Jeremy Neil Rodrigues Royal Hallamshire Hospital, Sheffield, UK E-mail address: [email protected] Sandip Hindocha Whiston Hospital, Liverpool, UK ª 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2014.01.011

The latissimus dorsi (LD) flap is a safe, reliable, and popular method of breast reconstruction. The most common complication of LD flap in breast reconstruction is seroma formation in the back. The principles of preventing the seroma-related morbidity after breast reconstruction have focused on obliteration of the dead space. Among the various preventive measures, quilting suture is one of the most commonly used modalities. Recently, the fibrin tissue adhesive (FTA) has started to gain its popularity in plastic and reconstructive surgery. FTA is hypothesized to seal the transected vessels and lymphatics, producing hemostasis and tissue adherence through the fibrin-mediated cascade. However, there has been no consensus on how to effectively reduce the incidence of seroma in LD flap donor site. The purpose of this study is to analyze the clinical efficacy of quilting sutures, FTA and their combination in reducing the incidence of seroma through an evidence-based review. We searched the PubMed database from January 1990 to October 2013. We used the following key words: latissimus dorsi, quilting suture, and fibrin tissue adhesive. We excluded the non-English articles and studies in experiment animals. This search was supplemented by a review of reference lists of potentially eligible studies. Two reviewers independently extracted data in two steps: titles and abstracts, and then full text articles. We chose the studies of the highest level of evidence in order to compare the following four combinations of preventive measures1: Quilting sutures versus no quilting sutures2; FTA versus no FTA3; Quilting sutures with FTA versus Quilting sutures; and4 Quilting sutures with FTA versus FTA. Relevant studies were assigned a level of evidence according to the Oxford Centre for Evidence-Based Medicine levels of evidence 2011 [http://www.cebm.net/mod_product/design/files/ CEBM-Levels-of-Evidence-2.1.pdf]. Results of the statistics were assessed using odds ratio (OR) with 95% confidence intervals (CI). Through our electronic and reference search we identified four citations. There were one systematic review (Therapy: Level I Evidence), two randomized controlled trials (RCTs) (Therapy: Level II Evidence), and one caseecontrol study (Therapy: Level IV Evidence). In the trial conducted by Daltrey et al.1 that randomized 108 women undergoing LD breast reconstruction, compared to those without quilting sutures, quilting sutures reduced the overall incidence of seroma from 46 of 48 (96 per cent) to 43 of 52 (83 per cent) (p Z 0.036) (Therapy: Level II Evidence). Further systematic review and meta-analysis conducted by Sajid et al.2 confirmed that compared to patients without quilting sutures, quilting sutures were

Academic mentoring in surgery: applying the near-peer principles to the training hierarchy: including medical students.

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