Introduction A recognised complication of carotid endarterectomy (CEA) is postoperative haematoma, which can threaten the airway. Previous studies have looked at medical methods of preventing this complication. This study aims to evaluate the impact of simple direct pressure postoperatively on the development of haematoma. Materials and methods From 2011 to 2016, 161 consecutive CEA were performed by a single surgeon or trainee under supervision. After 80 operations, the postoperative technique was altered, with additional pressure being applied by the surgeon to the skin incision from completion of suturing until each patient was awake in the recovery room. The rates of postoperative haematoma and other complications were compared between the pre- and post-intervention groups, as well as grade of surgeon, urgency of operation and antiplatelet/anticoagulant use. Results Post-carotid haematomas were eliminated in the post-intervention group (0/81); in the pre-intervention group 7/80 patients developed haematoma (P < 0.05). There were no significant differences in urgency of surgery, antiplatelet/anticoagulant use, grade of surgeon or other complications (stroke: 2/80 vs 0/81 P < 0.05), suggesting that this was not a learning curve effect. Discussion The results suggest that applying direct pressure helps to reduce oozing, provides time to monitor and identify additional bleeding and protects the wound from excessive strain that may be caused by coughing while the patient wakes up. We advise that the lead surgeon should apply such pressure to ensure precise and focal targeting, for maximum effect. Conclusion During recovery from CEA, focused and prolonged pressure by the operating surgeon is a highly effective method of reducing haematoma.

Wide-awake, local anesthesia, no tourniquet (WALANT) is a technique that removes the requirement for operations to be performed with a tourniquet, general/regional anesthesia, sedation or an anesthetist. We reviewed the WALANT literature with respect to the diverse indications and impact of WALANT to discuss the importance of future surgical curriculum integration. With appropriate patient selection, WALANT may be used effectively in upper and lower limb surgery; it is also a useful option for patients who are unsuitable for general/regional anesthesia. There is a growing body of evidence supporting the use of WALANT in more complex operations in both upper and lower limb surgery. WALANT is a safe, effective, and simple technique associated with equivalent or superior patient pain scores among other numerous clinical and cost benefits. Cost benefits derive from reduced requirements for theater/anesthetic personnel, space, equipment, time, and inpatient stay. The lack of a requirement for general anesthesia reduces aerosol generating procedures, for example, intubation/high-flow oxygen, hence patients and staff also benefit from the reduced potential for infection transmission. WALANT provides a relatively, but not entirely, bloodless surgical field. Training requirements include the surgical indications, volume calculations, infiltration technique, appropriate perioperative patient/team member communication, and specifics of each operation that need to be considered, for example, checking of active tendon glide versus venting of flexor tendon pulleys. WALANT offers significant clinical, economic, and operative safety advantages when compared with general/regional anesthesia. Key challenges include careful patient selection and the comprehensive training of future surgeons to perform the technique safely.

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Background: Postoperative acute and chronic pain following breast surgery is a common complication that needs resolving to allow for improved patient outcomes. Previously, thoracic epidurals and paravertebral blocks have been the accepted standard administered intraoperatively. However, more recently the introduction of the pectoral nerve block (PECS and PECS-2 blocks) has appeared promising to control the pain more effectively, but further robust analysis is required to prove its efficacy. The authors aim to study the efficacy of a new block, S-PECS, that combines a serratus anterior and a PECS-2 block. Methods: In this study, the authors performed a single-center, randomized, controlled, double-blind group trial in 30 female patients undergoing breast augmentation surgery with silicone breast implants and the S-PECS block. Divided into two groups of 15, the PECS group received local anesthetics and the no-PECS control group received a saline injection. All participants were followed up at recovery and at 4, 6, and 12 hours postoperatively. Results: The authors’ results showed that the pain score in the PECS group was significantly less than in the no-PECS group across all time points: recovery, and at 4, 6, and 12 hours. Furthermore, the patients who received the S-PEC block were 74% less likely to request pain medications compared with the no-PECS group (P < 0.05). Conclusion: Overall, the modified S-PECS block is an effective, efficient, and safe method of controlling pain in patients undergoing breast augmentation surgery, with additional applications yet to be explored.

Background Plastic surgery as a specialty is afflicted with one of the highest incidence rates of thromboembolic events, with abdominoplasty procedures known to assimilate the greatest rates of Deep Vein Thrombosis (DVT). Objectives To develop a prophylactic protocol to reduce the rate of DVT occurrence post-abdominoplasty. Methods A total of 1078 abdominoplasty patients were enrolled onto an 8-point prophylaxis protocol with an inclusive holistic approach over a 7-year period. A 4-week smoking, HRT and COC cessation period was imposed on all patients and a maximum BMI score of 40 was required of all preoperative patients. Participants were administered with compression stockings, flowtrons and enoxaparin. Individuals with a DVT history were also required to be 1-year treatment free prior to surgery. Furthermore, the protocol necessitated post-operative deambulation of fit patients within 4 hours. Results Between 2008 and 2013, no incidence of DVT was recorded in all 1078 abdominoplasty surgery patients, indicating the potential for this protocol to lead to a significantly lower incidence than any previously published methodology. Different hypotheses of DVT proportions were investigated to identify rates statistically significant with our sample, thereby providing conservative incidence rate estimates. Conclusions This 8-point DVT prophylaxis protocol is the first non-criteria based inclusive protocol aimed at preventing abdominoplasty-associated DVT. As a result, not a single incident of DVT was recorded over the seven-year period of this study. We believe that a holistic and procedure-specific approach to prophylaxis can drastically reduce the occurrence of DVT in abdominoplasty surgery. With over 116,000 procedures performed annually in the United States, abdominoplasty has become one of the most popular and sought-after surgeries in the plastic and cosmetic field 1. Despite its ever-increasing popularity and the advancement of techniques, abdominoplasty, as with any other surgery, has its complications. Such complications can include infection, seroma, haematoma, thrombosis, embolism, scarring and even death. Complications rates have been reported as high as 37%, with some studies reporting a 16% major complication rate 2. One of the most serious and troubling complications for both the surgeon and patient is deep vein thrombosis (DVT). With over 1 million patients tested, an estimated 250,000 cases of DVT are diagnosed per year in the United States alone.

Introduction: Scald injuries are the most common type of thermal injury in the paediatric population [1]. Despite domestic accidental scalds being so common, there is limited awareness of the frequency and severity of these injuries. Awareness of trends in paediatric scalds including age, mechanism of injury and first aid would help guide future allocations of funding for burns prevention and first aid treatment in the paediatric cohort.

Aim Postoperative acute chronic pain following breast surgery is a common complication which needs resolving to allow for improved patient outcomes. Previously thoracic epidurals and paravertebral blocks (PVB) have been the gold standard administered intra-operatively. However, more recently the introduction of the Pectoral nerve block (PECS and PECS-2 blocks) has looked promising to control the pain more effectively, but further robust analysis is required to prove its efficacy. The authors aim to study the efficacy of a new block S-PECS that comprises a serratus anterior and a PECS-2 block associated. Methods In this study we performed a prospective, single-centre randomised controlled double-blind group trial in 30 female patients undergoing breast augmentation surgery with silicone breast implants and the S-PECS block. Divided into groups of 15, the S-PECS group received local anaesthetics with the no-PECS control group receiving a saline injection. All participants were followed up at recovery (REC), 4, 6 and 12 (4H, 6H and 12H) hourly postoperatively. Results Our results showed that the pain score in the S-PECS group was significantly less than the no-PECS group across all time points REC, 4H, 6H and 12H. Furthermore, the patients that received the S-PECS block were 74% less likely to request pain medications compared to the no-PECS group (p &lt; 0.05). Conclusion Overall, the modified S-PECS block is an effective, efficient and safe method of controlling pain in patients undergoing breast augmentation surgery with additional applications yet to be explored.

Aim Plastic surgery as a speciality is afflicted with one of the highest incidence rates of thromboembolic events, with abdominoplasty procedures known to assimilate the greatest rates of Deep Vein Thrombosis (DVT). Methods A total of 1078 abdominoplasty patients were enrolled onto an 8-point prophylaxis protocol with an inclusive holistic approach over a 7- year period. A 4-week smoking, HRT and COC cessation period was imposed on all patients and a maximum BMI score of 40 was required of all preoperative patients. Participants were administered with compression stockings, flowtrons and enoxaparin. Individuals with a DVT history were also required to be 1-year treatment free prior to surgery. Furthermore, the protocol necessitated post-operative deambulation of fit patients within 4 hours. Results Between 2008 and 2013, no incidence of DVT was recorded in all 1078 abdominoplasty surgery patients, indicating the potential for this protocol to lead to a significantly lower incidence than any previously published methodology. Due to the zero-incidence rate of DVT, different hypotheses of DVT proportions were tested to find out the rates that could be statistically consistent with our sample, thereby providing conservative incidence rate estimates. Conclusion This 8-point DVT prophylaxis protocol is the first non-criteria based inclusive protocol aimed at preventing abdominoplasty-associated DVT. As a result, not a single incident of DVT was recorded over the seven-year period of this study. We therefore believe that a holistic and procedure-specific approach to prophylaxis can drastically reduce the occurrence of DVT in abdominoplasty surgery.