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Summary Background The coronavirus disease-2019 (COVID-19) pandemic has generated enormous pressure on healthcare establishments, prompting the restructuring of services to rationalise resources. Complex head and neck reconstructive surgery in this setting may carry substantial risk to patients and staff. This paper outlines the management strategy and outcomes of major head and neck oncological cases at a single regional tertiary referral centre. Methods A database review was undertaken of consecutive patients undergoing major head and neck surgery and reconstruction during the COVID-19 pandemic at St Andrew's Centre for Plastic Surgery & Burns, Chelmsford UK. Patient demographics, tumour and reconstruction characteristics as well as peri‑operative information were determined. Patients were prospectively contacted with regard to COVID-related symptoms and investigations. Results Twenty-two patients (15 males and 7 females) with a mean age of 67 years (range: 36–92 years) were included between March 1 and June 13, 2020. Patients underwent pre-operative throat swabs at 72 h and 24 h as well as chest CT scanning as part of a robust protocol. Twelve free flaps, four loco-regional flaps, four parotidectomies and 23 cervical lymphadenectomies were performed. Two patients required a return to theatre. No post-operative deaths occurred and flap survival rate was 100%. A single patient tested positive for COVID-19 pre-operatively and no post-operative COVID-19 infections occurred. Conclusion Although head and neck surgery represents a high-risk procedure to patients and healthcare professionals, our institutional experience suggests that in the presence of a robust peri‑operative protocol and judicious patient selection, major head and neck surgery, including free tissue transfer reconstruction, may be performed safely.

Summary Introduction This study evaluates COVID-19 related patient risk, when undergoing management within one of the largest specialist centres in Europe, which rapidly implemented national COVID-19 safety guidelines. Method A prospective cohort study was undertaken in all patients who underwent surgical (n = 1429) or non-operative (n = 191) management during the UK COVID-19 pandemic peak (April–May 2020); all were evaluated for 30-day COVID-19 related death. A representative sample of elective/trauma/burns patients (surgery group, n = 729) were selected and also sub-analysed within a controlled cohort study design. Comparison was made to a random selection of non-operatively managed (non-operative group, n = 100) or waiting list (control group, n = 250) patients. These groups were prospectively followed-up and telephoned from the end of June (control group) or at 30 days post-first assessment (non-operative group)/post-operatively (surgery group). Results Complex general (9.2%, 136/1483) or regional (5.0%, 74/1483) anaesthesia cases represented 14.2% (210/1483) of operations undertaken. There were no 30-day post-operative (0/1429)/first assessment (0/191) COVID-19 related deaths. Neither the three sub-speciality plastic surgery, or non-operative groups, displayed increases in post-operative/first assessment symptoms in comparison to each other, or to control. The proportion of COVID-19 positive tests were: 7.1% (1/14) (non-operative), 5.9% (2/34) (burns) and 3.0% (3/99) (trauma); there were however no significant differences between these groups, the elective (0%, 0/54) and control (0%, 0/24) groups (p = 0.236). Conclusion We demonstrate that even heterogeneous sub-speciality patient groups, who required operative/non-operative management, did not incur an increased COVID-19 risk compared to each other or to control. These highly encouraging results were achieved with described, rapidly implemented service changes that were tailored to protect each patient group and staff.

Summary Background The popularity of the DIEP flap has increased over the last decade. However, there is little information regarding the transfusion rates of this complex procedure. The current study reports the transfusion rates in patients who underwent DIEP flap reconstruction in our unit with an attempt to correlate significant blood loss with potential predictors such as the abdominal flap weight. Methods-material A retrospective review of 131 patients who underwent DIEP reconstruction was performed. Patients' characteristics, risk factors, incidence of blood transfusions, Hb drop and complications were reviewed. For statistical analysis the two-tailed Student t -test, chi-squared significance test and multiple regression model were used. Results 12 patients (9.1%) were transfused compared to 80.3% and 18.8% described in the literature. Definite association was found between the presence of a complication and transfusion. No correlation was found between age, obesity, chemotherapy and/or radiotherapy or tamoxifen treatment and blood loss. However, operation duration, complications and weight all found to have significant correlation. On average, every additional hour of surgery adds 0.25 g of Hb drop; the presence of a complication adds 0.45 g of Hb drop, and every extra gram of tissue removed from the abdomen adds an extra 0.001 g of Hb drop. Conclusion The different transfusion rates published reflect variations in surgical strategies, different operative technical details but mostly transfusion protocols applied in each unit. As a correlation with complications was found, it is quite important to identify predictors for significant blood loss to optimise the operation outcome which in our study are additional time of surgery, the presence of complication and increased flap weight.

There has been only one documented case in the English literature with the diagnosis of primary Squamous Cell Carcinoma (SCC) of the nipple; we present a further case of a primary SCC of the nipple, thus raising awareness to the skin or breast specialist of this possible presentation for SCC. We present the case of a 34 year old lady who presented to our plastic surgery unit with an erythematous, scaly lesion on her right Nipple Areola Complex (NAC). The lesion was histologically confirmed on biopsy to be an SCC and subsequently formally excised. Histology confirmed complete excision of the lesion with adequate margins with no lymphovascular or perineural invasion. This case report describes a rare presentation of a primary moderately differentiated SCC of the nipple. Although SCC of the nipple is a rare diagnosis, in view of its similar presentation to Paget disease of the nipple, it must be considered and careful examination of the histology must be performed in order to ascertain a definitive diagnosis. Patients presenting with lesions of the NAC cannot be assumed to have either Paget's disease or SCC and biopsy should be performed before arranging further investigations or treatment, as the pathways for the two conditions can be very different.