Hyaluronic Acid Fillers to Correct Cleft Lip Asymmetry in Adults: Description of Technique and Patient Reported Outcome Measure Using CLEFT-Q.

OBJECTIVE: To determine the efficacy of hyaluronic acid (HLA) lip filler to correct subtle cleft lip asymmetries in adults using a validated patient reported outcome measure (PROM). DESIGN: Prospective cross sectional. SETTING: UK National Health Service. PATIENTS, PARTICIPANTS: Over 18 years old with repaired cleft lip and dissatisfaction of their lip appearance. INTERVENTIONS: HLA lip filler injection. MAIN OUTCOME MEASURES: A validated, cleft specific PROM, the lip module of CLEFT-Q™ prior to treatment and again after six weeks. RESULTS: 24 patients included. A mean total CLEFT-Q™ score pre-procedure was 14.9 (Stand deviation (SD) = 4.91) and 24 (SD = 6.08) post-procedure. Difference in mean total score pre- and post-procedure were statically significant (P = .0001) in all domains on the CLEFT-Q™. No adverse outcomes. CONCLUSION: HLA filler to correct subtle cleft lip asymmetries in adults is a simple low risk technique, which can significantly improve the patient's perception of lip appearance. CONCLUSION: HLA lip filler to correct subtle cleft lip asymmetries in adults is a simple technique, low risk procedure which can significantly improve the patient's perception of lip appearance.

The impact of COVID-19 on cleft services in Great Britain & Northern Ireland.

INTRODUCTION: Cleft lip and/or palate is the most common craniofacial anomaly and occurs in 1 in 650 to 700 live births in the United Kingdom (UK). The majority of cleft surgery is elective, and as a result, almost all cleft surgery was suspended across the UK in March 2020 during the first national lockdown. The UK has centralised regional Cleft Services which all use the same agreed target-age standards for primary surgery including lip and palate repairs. The coronavirus disease-2019 (COVID-19) response has caused a delay in carrying out procedures. The severity of this delay depends on the impact of COVID-19 on local trusts and R-value within that region. As the country goes through the second and third wave, the impact could be long lasting, and we aimed to quantify it so that the data could be used to guide service prioritisation in the NHS and help future workforce planning. METHODS: An online survey was designed based on the cleft quality dashboard indicators and circulated nationally to all nine cleft regions in the UK. The survey was divided into three main headings: • Duration of suspended cleft services • Quantification of the impact on delayed in surgery/services • Changes needed to restart surgery/services RESULTS: We obtained a 60% response rate with five completed surveys from five out of nine regions. All regions reported that they suspended their cleft services in March 2020 around the time of the first wave and the first national lockdown. There has been an impact on delayed surgical and clinical interventions for cleft patients. Regions were affected differently with some on an exponential waiting list growth projection, whereas other teams are on track to recover from the backlog within 7-22 weeks. There has been an impact on the allied health professionals' services within the cleft multidisciplinary team. The cleft nurses' 24-h reviews, Speech And Language Therapy (SALT), and psychology maintained service delivery in some format. Patient-facing services such as audiology and dentistry were significantly disrupted and continue to experience delays due to reduced capacity. CONCLUSIONS: Various regions have seen a varied impact from COVID-19 on their services, from all cleft regions there seems to be an impact on achieving surgery within the national target age. The adverse effect of the COVID-19 impact is unlikely to be known for a few years to come; however, the data are a useful guide when supporting the allocation of resources within the healthcare setting. A prospective long-term study is required to assess the impact of COVID-19 on cleft surgery, follow-up, assess access to allied health professional MDT clinics, and long-term complications.

Five-year prospective fistula audit in a single center. TIG training negates consultant learning curve, but surgeons should beware the mid-range palatal defect.

The aim of primary palatoplasty is to achieve optimum speech with minimal morbidity. Symptomatic fistulae are well-recognised complications of palatoplasty and may require additional surgical intervention, increasing the burden of care. Our aims were to better understand fistula experience in our unit and compare fistula rates between an established consultant and a newly appointed training interface group (TIG) trained consultant. Post-operative fistulae were prospectively and independently recorded by Cleft Clinical Nurse Specialists as part of routine 6-week post-operative reviews. Cleft type and intra-operative hard-soft palate junction (HSPJ) width were prospectively recorded by operating surgeons. Data were collated and analysed using Microsoft Excel. Between 1 January 2014 and 31 December 2018, 250 primary palatoplasties were performed. The overall fistula rate was 8% (0% SMCP, ICP 7%, UCLP 8%, BCLP 22%). Fistulae clustered in clefts with a mid-range HSPJ width of 12-16 mm. Numerically, fistula rates remained similar over time despite increased unit activity (doubling of primary surgeries in 2017 and 2018). There was no significant difference in fistulae rates between surgeons (P > 0.05). Overall fistulae rate compared favourably with published data. TIG fellowships were designed in the context of cleft surgery to address issues relating to steep operative learning curves. These data demonstrate that results from a newly appointed TIG-trained surgeon are comparable to that of an established TIG-trained surgeon. Data also suggest surgeons should be aware of the risk of fistulae in the mid-range palatal defect and in HSPJ widths of 12-16 mm.

Major fall in urgent skin cancer referrals during the COVID-19 outbreak.

The SARS-CoV-2 cornovirus disease (COVID-19) pandemic has significantly affected referrals of new suspected cancers from primary care to specialist services in the National Health Service (NHS) across the UK.  Amongst the many factors causing delay, such as fear and uncertainty about COVID-19 transmission, reluctance to seek medical attention for cancer sypmtoms and avoiding additional pressure on NHS services, we anticipate a surge in urgent skin cancer referrals to our plastic surgery service as we enter a post-COVID recovery phase.  On the basis of previous referral data and statistical forecasting, we share our predicted numbers against our actual number of urgent skin cancer referrals for the COVID-19 period and, based on this analysis, encourage all cancer services to prepare and allocate resources appropriately for the busy months to follow.

The impact of non-severe burn injury on cardiac function and long-term cardiovascular pathology.

Severe burn injury significantly affects cardiovascular function for up to 3 years. However, whether this leads to long-term pathology is unknown. The impact of non-severe burn injury, which accounts for over 80% of admissions in developed countries, has not been investigated. Using a rodent model of non-severe burn injury with subsequent echocardiography we showed significantly increased left ventricular end systolic diameter (LVESD) and ventricular wall thickness at up to 3 months post-injury. Use of propranolol abrogated the changes in cardiac measures observed. Subsequently we investigated changes in a patient cohort with non-severe injury. Echocardiography measured at baseline and at 3 months post-injury showed increased LVESD at 3 months and significantly decreased posterior wall diameter. Finally, 32 years of Western Australian hospital records were used to investigate the incidence of cardiovascular disease admissions after burn injury. People who had experienced a burn had increased hospital admissions and length of stay for cardiovascular diseases when compared to a matched uninjured cohort. This study presents animal, patient and population data that strongly suggest non-severe burn injury has significant effects on cardiovascular function and long-term morbidity in some burn patients. Identification of patients at risk will promote better intervention and outcomes for burn patients.

Determinants of burn first aid knowledge: Cross-sectional study.

INTRODUCTION: This study investigated demographic factors, experience of burn/care and first aid course attendance as factors influencing burn first aid knowledge. METHODS: A cross-sectional study was undertaken using convenience sampling of members of sporting and recreation clubs. The main outcome measure was the proportion of correct responses to multiple-choice questions relating to four burn scenarios: (1) scald, (2) contact burn, (3) ignited clothing, and (4) chemical burn. RESULTS: A total of 2602 responses were obtained. Large gaps (30-50% incorrect answers) were identified in burn first aid knowledge across all scenarios. 15% more individuals gave correct answers if they had attended a first aid course compared to those who had not (p<0.0001); this proportion increased if the course was undertaken within the previous five years (p<0.0001) or contained a burns-specific component (p<0.0001). Males and younger (≤25 years) and older (≥65 years) age-groups had relatively lower levels of burn first aid knowledge. Gender and age were significant predictors of first aid course attendance, with males and younger (≤25 years) and older (≥65 years) age-groups less likely to have attended a first aid course. CONCLUSION: In this sample, first aid training undertaken within the last 5 years with a specific burns component was associated with enhanced burn first aid knowledge.

Complex chemical burns following a mass casualty chemical plant incident: how optimal planning and organisation can make a difference.

INTRODUCTION: Four employees at a chemical plant sustained extensive chemical burns following the explosion of a pipeline containing 100% sulphuric acid. We describe the management of these patients from the initial ED triage through to discharge from hospital in life and limb threatening chemical burns. METHODS: Four patients who sustained chemical burns to the torso and extremities are reviewed. Data was retrieved from patient case notes and operating theatre logbooks. RESULTS: Four patients sustained chemical burns during the blast and were immediately transferred to a local ED where a prompt referral was made to the burns service. All patients were male aged 25-59 years (mean 46.5). Burn size was 2-50% BSA (mean 22.5). Following RFDS transfer to the state burns service two patients required immediate excisional surgery. In these patients the chemical burn involved full thickness skin loss with extensive underlying muscle and neurovascular damage. One patient required immediate above knee amputation of one leg and fascial burn excision of the other. The other patient required fascial burn excision of both legs followed by Integra placement 24h later. Both patients had prolonged hospital stays due to the complex nature of their injuries requiring multiple trips to theatre and lengthy rehabilitation. The two patients with smaller burns had straightforward surgery and an unremarkable recovery. CONCLUSION: Early communication following this mass casualty incident allowed for organisation of tertiary services and early radical surgery which was life saving. Management lessons were learnt following this mass casualty chemical burn incident.

Methamphetamine laboratory-related burns in Western Australia--why the explosion?

INTRODUCTION: With increasing numbers of illicit drug users in both urban and rural communities, users and producers are becoming increasingly enterprising in their sourcing of mind altering drugs. An example of this is the 'amateur' production of methamphetamine in domestic dwellings. We describe the mechanism of burn seen in methamphetamine production, the pattern of clinical injury, and the difficulties in treating these patients. METHODS: A 12 month retrospective study of five patient groups presenting to our burn service with injuries following methamphetamine laboratory explosion. RESULTS: Out of five patient groups we have treated 9 individual patients (with one patient presenting on two different occasions) with burns following methamphetamine laboratory explosion. All patients were male and required hospital admission. The cause of the explosive injury was initially reported as barbeque or oven related, assault, or accident in all patients. Two patients (in separate events) required intubation for associated inhalation injury. Burn size varied from 1% to 40% BSA. 7 patients required surgical debridement and skin grafting. Injury type was thermal and chemical. All patients had difficult follow-up due to low levels of clinic attendance. CONCLUSION: Methamphetamine laboratory explosion burns are difficult injuries from the start. Invariably the true circumstances surrounding the injury are not clear, and clinicians should be suspicious of a meth lab explosion in suspect individuals with burns plus airway injury. Patient management is complex and often requires substantial analgesic and anxiolytic medication in conjunction with clinical psychology and psychiatry as an inpatient.