A three-dimensional scar assessment tool for keloid scars: Volume, erythema and melanin quantified.

BACKGROUND: There is no non-invasive objective assessment tool to measure keloid scar characteristics over time. This study aimed to ascertain the ability of the Antera 3D® camera to detect differences in keloid features pre- and post-steroid injection. In order to identify whether those variation could be considered as treatment response predicting factors. METHODS: Enrolled patients received three intra-lesional steroid injections at four-weekly intervals. Images were taken with the Antera 3D camera 12 and 24 weeks after treatment. Keloids' colour, volume, and area as well as haemoglobin and melanin average levels and variation have been analysed pre- and post-steroid injection. t Tests and relative risk have been used to analyse the significance and association strength of our finding. RESULTS: Forty patients have been enrolled in the study. Significant changes as been recorded in keloids' volume and colour after steroid injection (P < 0.05). 53% have recorded a Hb reduction showing no recurrence of pathology, patient who had increase in Hb showed an early recurrence. Melanin variation was significant after steroid injection (P < 0.05) but no correlation has been found with treatment response. CONCLUSIONS: The Antera 3D camera is able to detect differences in the investigated keloid's features helping in two ways: by providing an objective, longitudinal method to monitor and document changes in scar morphology, and through monitoring haemoglobin change, which strongly correlates to both response to treatment and likelihood of recurrence. Allowing clinicians to identify which patients will respond early, in order to change treatment if necessary, limiting morbidity and costs.

The effect of template-based sequential (TBS) coding on an NHS plastic surgical practice.

INTRODUCTION: Clinical coding is often a mystery to us surgeons, but in actuality, it has a huge bearing on the financial sustainability of our services. Given the rapid innovations in plastic surgical procedures, clinical coders often struggle to decipher the extent of surgery. Meeting midway is the way forward here. METHODS: In a prospective audit over a six-month period, we analysed data from 2586 patients in our practice: a combination of general plastic surgery and specialist facial reanimation services. This involved comparing data from the first three months where coding was performed by clinical coders based on operating notes per se (phase I) and the subsequent three months when the operating surgeon filled in the OPCS 4.7 (version 2014) codes at the time of completing the operating notes; the clinical coders then vetted this information (phase II) as part of a sequential TBS coding system. RESULTS: In terms of outpatient income, there was a 3% increase in facial palsy income and 6% increase in general plastic services, but the most significant improvement was in terms of procedural income per case. General plastic surgery cases saw an increase of 49%, while facial palsy income increased by 58% over the same period. Greater insight into OPCS and HRG codes also allowed for the calculation of the actual tariffs for specific procedures. CONCLUSIONS: Having the operating surgeon as the primary coder, using a template, with subsequent vetting by the clinical coders, improves data capture, and this in turn increases income. Future recommendations include the use of proforma-based operating notes for workhorse procedures.

An objective assessment of botulinum toxin type A injection in the treatment of post-facial palsy synkinesis and hyperkinesis using the synkinesis assessment questionnaire.

This study aimed to provide reliable and valid evidence that botulinum toxin type A (BTX-A) is a successful treatment for facial synkinesis in facial palsy by using the synkinesis assessment questionnaire (SAQ) tool. Fifty-one patients completed questionnaires pre- and post-BTX-A treatment over 103 cycles of treatment. Each patient was individually assessed and then treated according to their presenting symptoms with a dosage in each injection site of between 0.5 and 5 U of BTX-A. A two-tailed paired samples t-test was used to compare the scores for each question before and after treatment. A significant difference was found between all scores before and after treatment at the level of p < 0.05. There was not only an improvement in the mean score in the post-treatment group but also a smaller spread of scores in the post-treatment group than in the pre-treatment group. The study showed that SAQ scores decreased significantly for every question on the SAQ after treatment. This indicates that BTX-A is an effective treatment for synkinesis, adding further weight to current evidence. The study also indicated that BTX-A continues to be effective even after three rounds of treatment, with a significant decrease in overall scores after each treatment cycle.

Assessment of the reproducibility of facial expressions with 3-D stereophotogrammetry.

OBJECTIVE: There is little research into analyzing whether facial expression changes are secondary to actual treatment or normal day-to-day variation. This study aims to ascertain whether nine-facial expressions were reproducible. SUBJECTS AND METHODS: Thirty-nine white subjects performed nine-facial expressions, captured by three-dimensional stereophotogrammetry in three sessions. After initial capture (session 1), each expression was repeated after 15 minutes (session 2) and then 4 weeks (session 3) after the initial session. Statistical analysis was performed on the mean variability of facial landmarks between session 1 and 2 and session 1 and 3. RESULTS: Repose was the most reproducible expression. The least reproducible was "blow-out-the-cheeks." Analysis between session 1 and 2 showed no significant differences in expression reproducibility. Analysis between session 1 and 3 showed significant differences for the "smile-with-lips-open" and "blow-out-the-cheeks" expressions. CONCLUSION: Facial expressions are reproducible in a 15-minute period. There are significant differences in the ability to reproduce facial expressions 4 weeks apart for "smile-with-lips-open" and "blow-out-the-cheeks."

Bilateral breast reduction surgery in England: a postcode lottery.

INTRODUCTION: There is good evidence for the benefits of bilateral breast reduction (BBR). However, such surgery is often considered cosmetic and is rationed. The NHS Modernisation Agency and the British Association of Plastic Surgeons (as was) have produced national guidelines, but Primary Care Trusts adapt these for local implementation. METHODS: We surveyed the funding criteria for BBR of all 303 Trusts in England. 245 (81%) responded. RESULTS: The NHS guidelines were followed accurately by only 11 Trusts. 198 trusts specified a maximum BMI (range 25 to 32; guideline 30). 187 accepted musculoskeletal symptoms as an indication and 117 accepted intertrigo. 31 required a professionally fitted bra. Many Trusts included other restricting criteria that are not in the NHS guidelines. Some Trusts mentioned the American Society of Plastic Surgeons' guidelines, but did not follow them wholly. CONCLUSIONS: Even with explicit guidelines, considerable variation in local funding criteria exists with resultant inequalities in provision. The so-called 'postcode lottery' of healthcare in the UK is rife within Plastic Surgery. The recent reconfiguration of English Primary Care Trusts provides an excellent opportunity for the rationalisation of BBR provision and to this end we will distribute our findings and the NHS guidelines to the new Trusts and to the National Institute for Health and Clinical Excellence.

Objective assessment of keloid scars with three-dimensional imaging: quantifying response to intralesional steroid therapy.

BACKGROUND: Treatment of keloid scars poses a significant challenge. Assessment of treatment response and research in this area depend on the availability of objective, accurate, and reproducible outcome measures. At present, scars are assessed using subjective grading systems, or with cumbersome investigations such as direct casting. The authors assessed the feasibility of objectively monitoring response to intralesional steroid treatment in routine clinical practice with quantitative three-dimensional imaging. METHODS: Scar volume was quantified using a validated three-dimensional speckle-pattern stereophotogrammetry before and for a minimum of 8 weeks after intralesional steroid therapy in 12 patients with keloid scars. RESULTS: Mean scar volume at the start of treatment was 0.73 +/- 0.701 cc (range, 0.12 to 2.15 cc); this was reduced to 0.14 +/- 0.302 cc (range, 0.007 to 1.08 cc) after monthly intralesional injections of triamcinolone acetate (p < 0.001; analysis of variance). The majority of patients achieved a greater than 50 percent response within 8 weeks of the start of therapy, but poor treatment response was noted and quantified in a minority of patients. CONCLUSIONS: Three-dimensional stereophotogrammetry is a rapid and noninvasive method of scar volume assessment that could allow accurate and objective monitoring of treatment response to be incorporated into clinical practice. Therefore, it can be of considerable value in assessing treatment efficacy and evaluating new therapeutic strategies.