White phosphorous civilian hand burns - An aid to timely treatment of a rare entity.

First discovered in 1669, white phosphorus is well known for its use in military warfare (Davis, 2002). Its application has since been expanded to include industrial disinfectants, fertilisers and fireworks (Davis, 2002). Exposure to white phosphorus can lead to severe chemical burns with high morbidity and potentially fatal systemic effects. Fortunately, civilian casualties from this potent agent are remarkably rare with few reports in the literature to date (Frank et al., 2008; Aviv et al., 2017). We present the case of a 27-year-old fisherman who sustained a chemical burn to his right hand from a substance suspected to be white phosphorus. We propose an evidence-based algorithm to guide non-military physicians literature on the acute management of white phosphorus burns to optimise timely emergency management of this uncommonly encountered substance.

Aesthetic surgery training in a changing healthcare environment.

Aesthetic surgery is a rapidly evolving sub-speciality, both technologically and conceptually. It is therefore critical that plastic surgery training coincides with this rapid evolution. Recent fiscal limitations in public health provision and trainee working-time legislation may impact the delivery of high quality aesthetic surgery training. There is an urgent need to address the delivery of aesthetic training in current training paradigms in Ireland and we propose a number of strategies to obliterate the learning curve.

The Aesthetic Surgery Literature: Do Plastic Surgeons Remain at the Cutting Edge?

BACKGROUND: The aesthetic surgery arena has become a competitive marketplace. Recognition as an authority in aesthetic surgery remains a powerful marketing tool for plastic surgeons, but have significant inroads been made by other specialties? The aims of this study were to analyze publication trends relating to the top five most commonly performed aesthetic surgical procedures, and to assess the origins (i.e., source specialty, authorship, institutions, and countries) of published aesthetic surgical research. METHODS: Based on the seventeenth annual multispecialty data set provided by the American Society for Aesthetic Plastic Surgery, the top five most commonly performed aesthetic surgical procedures were selected. A temporal analysis of publication and citation rates, source institution and country, publishing journal, funding agency trends, and level of evidence was undertaken from 1970 to 2013. RESULTS: Using the search criteria, 7762 articles were identified. There was an 8.8-fold increase in publication volume when the first decade (n = 375) was compared with the last decade (n = 3326). Over the past four decades, 52.2 percent of publications (n = 4053 of 7762) originated from plastic surgery research institutions, with varying contributions from other specialties. Competition was greatest in relation to authorship of blepharoplasty- and rhinoplasty-related publications. CONCLUSIONS: Although plastic surgeons continue to maintain a center-stage presence in terms of authorship of aesthetic surgical literature, significant contributions are now made by other specialties. Plastic surgeons must continue to foster high-quality, peer-reviewed research and innovations to maintain their visibility as leaders in the aesthetic surgery literature and sustain a competitive advantage in aesthetic surgery practice.

Scar Wars: Preferences in Breast Surgery.

BACKGROUND: The uptake of breast reconstruction is ever increasing with procedures ranging from implant-based reconstructions to complex free tissue transfer. Little emphasis is placed on scarring when counseling patients yet they remain a significant source of morbidity and litigation. The aim of this study was to examine the scarring preferences of men and women in breast oncoplastic and reconstructive surgery. METHODS: Five hundred men and women were asked to fill out a four-page questionnaire in two large Irish centres. They were asked about their opinions on scarring post breast surgery and were also asked to rank the common scarring patterns in wide local excisions, oncoplastic procedures, breast reconstructions as well as donor sites. RESULTS: Fifty-eight percent of those surveyed did not feel scars were important post breast cancer surgery. 61% said that their partners' opinion of scars were important. The most preferred wide local excision scar was the lower lateral quadrant scar whilst the scars from the deep inferior epigastric artery perforator (DIEP) flap were most favoured. The superior gluteal artery perforator flap had the most preferred donor site while surprisingly, the DIEP had the least favourite donor site. CONCLUSIONS: Scars are often overlooked when planning breast surgery yet the extent and position of the scar needs to be outlined to patients and it should play an important role in selecting a breast reconstruction option. This study highlights the need for further evaluation of patients' opinions regarding scar patterns.

Opportunities to reduce plastic surgery claims through an analysis of complaints data.

BACKGROUND: Patient expectations and demands placed on the National Health Service have significantly increased over the last decade. The analysis of adverse outcomes and measures to improve practice remain fundamental to clinical governance. We decided to investigate the reasons for plastic surgery patients making complaints and claims of negligence in order to identify trends and potential areas of improvement. METHODS: In conjunction with the hospital Patient Advice and Liaison Services (PALS) and Legal Services departments, the complaints made against the Addenbrooke's Hospital Plastic Surgery Department over a 10 year period were analysed. Patients who proceeded to make formal claims of negligence were also identified and a retrospective case note review of these performed. RESULTS: 185 patients made complaints between April 2000 and April 2010. The most common reasons for complaints were poor communication and treatment delays. 20 claims of negligence were made; 14 of these were patients undergoing breast surgery. There were 3 successful cases which all mentioned adverse scarring, suggesting that this risk was either not discussed or the informed consent process was inadequately documented. The financial compensation awarded ranged from £6000 to £34,000. CONCLUSIONS: Poor communication is highlighted as the main reason for patients making formal complaints. Inadequate documentation of informed consent discussions may also contribute to successful negligence claims.

Operating room fires: part II. optimizing safety.

BACKGROUND: The second part of the authors' study on operating room fires analyzes the construct of the nasal cannula used during facial surgery for patients under conscious sedation with supplemental oxygen. This prospective study compares two common styles of nasal cannulas with a nasopharyngeal system described in their first report. METHODS: Twenty patients underwent upper and/or lower lid blepharoplasty under conscious sedation with one of three methods of supplemental oxygen delivery: a Mac-Safe nasal cannula (Unomedical, Inc., McAllen, Texas), a Salter nasal cannula (Salter Laboratories, Arvin, Calif.), and a nasopharyngeal system with cut ends of a cannula placed into a rubber nasopharyngeal tube. Oxygen concentrations were measured at 24 locations around the face for each method at a low (3 liters/minute) and high flow rates (6 liters/minute) using a random access mass spectrometer unit. RESULTS: At both low and high oxygen flow rates, the median oxygen concentration at and above the nose was statistically lower (p < 0.001) using the nasopharyngeal system than with either the Mac-Safe or Salter nasal cannula. In addition, the oxygen concentrations measured using the two nasal cannulas were more variable than with the nasopharyngeal method, particularly at locations around and above the nose. CONCLUSIONS: This study demonstrates that mass spectrometry oxygen readings around the face are similar to room air when the cut ends of the oxygen cannulas are passed down the nasaopharyngeal tube, whereas readings are significantly higher with the nasal cannulas. The nasopharyngeal system that the authors describe represents a significantly safer means of oxygen delivery during conscious sedation.

Patient draping and endotracheal tube positioning during facelift surgery.

A comprehensive approach to facial rejuvenation often requires facelift surgery combined with ancillary facial procedures. This may require prolonged operating time under general anesthesia or conscious sedation. When general anesthesia is used, secure endotracheal tube fixation and ready access to the face is essential. We describe an anesthetic technique that assures secure tube placement, rapid intubation, and ready access to the entire face. A fiber-reinforced tube is placed orotracheally, wired to the mandibular dentition, and brought over the head in the fashion similar to a nasotracheal tube. The reinforced nature of the tube prevents kinking and allows rapid repositioning inferiorly to allow access to the upper face. In over 400 rhytidectomies, this technique has allowed rapid intubation and surgical preparation. There have been no airway-related problems or other related complications. This is a safe, effective, and rapid means of securing orotracheal intubation during facial esthetic surgery allowing ready access to the face.

A survey of cosmetic surgery training in plastic surgery programs in the United States.

BACKGROUND: Aesthetic surgery is evolving rapidly, both technologically and conceptually. It is critical for the specialty that aesthetic surgery training keep pace with this rapid evolution. To shed more light on this issue, a survey was sent to all program directors and senior plastic surgery residents to record their impressions of the quality of cosmetic surgery resident training. The authors report the results of this national cosmetic surgery training survey canvassing all 89 plastic surgery programs. METHODS: A three-page survey delineating resident preparedness in aesthetic surgery was sent to senior plastic surgery residents and program directors in April of 2006 and collected through October of 2006. RESULTS: Of 814 surveys, 292 responses were obtained from 64 percent of program directors and 33 percent of senior residents. Breast augmentation, breast reduction, and abdominoplasty were most frequently performed with the highest resident comfort levels. Rhinoplasty remained a particular area of trainee concern, but confidence levels were also low in face lifts, endoscopic procedures, and body contouring techniques. Experience with skin resurfacing, fillers, and botulinum toxin type A was another area of concern. Although 51 percent of residents felt prepared to integrate cosmetic surgery into their practices on graduation, 36 percent felt that further cosmetic training was desirable. CONCLUSIONS: The information collected revealed significant differences in opinions between program directors and senior residents. Senior residents felt deficient in facial cosmetic, minimally invasive, and recently developed body contouring techniques. On the basis of these results and the authors' experience in resident education, changes in cosmetic surgery training are suggested.

Follow-up: orthognathic surgery. Is there a future? A national survey.

BACKGROUND: The authors recently documented a significant decrease in orthognathic surgical cases performed by both plastic and oral surgeons in Ohio over a recent 5-year period. The main reason noted was related to third-party reimbursement. This is a potentially serious issue that may affect the quality of health care for patients with dentofacial deformities. Therefore, an expanded survey was conducted to determine whether this was indicative of a national trend. METHODS: A three-page questionnaire was sent nationally to plastic surgeons and oral surgeons who were members of the American Society of Maxillofacial Surgery and the American Association of Oral and Maxillofacial Surgeons, respectively. Surveys requested information regarding changes in the number of orthognathic operations over a 5-year period (1999-2003) and reasons for these changes. RESULTS: Of the 3273 surveys sent, 883 were returned, representing an overall response rate of 27 percent. Of the 883 returned, 771 (87.3 percent) were completed by oral surgeons and 112 (12.7 percent) were completed by plastic surgeons. The majority surveyed (70.0 percent) noted a decrease in the number of orthognathic procedures performed over a 5-year period, and 443 (77.3 percent) stated that the decrease was attributable to problems with insurance. Professional reimbursement per hour was calculated based on data collected from consecutive operations performed at the authors' institution. These data demonstrated that reimbursement per hour is significantly lower when orthognathic surgery procedures were compared with other standard plastic surgery operations. CONCLUSIONS: Orthognathic surgery may rapidly be becoming a cosmetic procedure. This has the potential of creating a two-tier system whereby only those who can afford it will undergo orthognathic correction.

Arterial reconstruction using the basilic vein from the zone of injury in pediatric supracondylar humeral fractures: a clinical and radiological series.

The authors describe the advantages of using the basilic vein as an arterial conduit in the management of children with supracondylar humeral fractures requiring vascular repair. Eight children, aged 3 to 10 years, presented with supracondylar humeral fractures and vascular injury. In all eight children, the arteries were successfully reconstructed with a reversed, interposition basilic vein graft harvested from the ipsilateral arm. The basilic vein was anatomically consistent with few side branches and was an excellent size match for the brachial artery. There were no postoperative thromboses. At a minimum follow-up of 1 year, all children had palpable radial pulses and the vein grafts were patent with no anastomotic or other focal stenoses. This series confirms the safety of using a donor vein from within the zone of injury for arterial reconstruction, after a supracondylar humeral fracture. Benefits include a single surgical wound on the less conspicuous medial side of the arm, reduced operating time, and preservation of donor veins that may be subsequently required for the management of atherosclerotic disease.