Management of wounds in the community: five principles.

The care of any wound in the community requires multidisciplinary working between healthcare professionals. In this article, the authors offer five generalisable principles that colleagues providing community care can apply in order to achieve timely wound healing: (1) assessment and exclusion of disease processes; (2) wound cleansing; (3) timely dressing change; (4) appropriate (dressing choice; and (5) considered antibiotic prescription. High-quality wound care is an essential aspect of healthcare practice but lacks an evidence base and standardised practice at present. The practice and teaching of wound care should be more greatly emphasised in healthcare training for all disciplines.

The importance of early flap coverage in deep sternal wounds.

BACKGROUND: Chronic or persistent wound infection is one of the key outcome measures after flap reconstruction in deep sternal wound infection (DSWI). This study aimed to assess potentially modifiable factors associated with chronic infection in patients undergoing flap reconstruction. MATERIALS AND METHODS: An analysis of a prospective database of 5239 median sternotomies performed during a 5-year period was carried out. Seventy-seven cases of DSWI were recorded, of which 23 cases proceeded to flap reconstruction. The flap-reconstructed patients were placed into groups according to the primary outcome measure of those who experienced chronic infection and those who remained infection free. RESULTS: Of the flap-reconstructed patients, 22% experienced subsequent chronic infection, whereas 78% remained infection free. The only 2 variables that were associated with chronic infection were the timing of flap reconstruction; median time 29.5 days (vs 12 days in the infection-free group), P=0.011 and time taken from diagnosis of wound infection/dehiscence to referral to the plastic surgical team; median 21 days (vs median 8 days in the infection free group), P=0.02. Each day of delay from the diagnosis of clinical infection to flap cover equated to an increase in risk of chronic infection of 1.2 times per day (OR=1.205, P=0.039). CONCLUSIONS: This study suggests that chronic infection after flap reconstruction in DSWI is associated with late flap cover. We suggest the need for a consensus agreement on the combined care and early management of DSWI.

Cartilage-like composition of keloid scar extracellular matrix suggests fibroblast mis-differentiation in disease.

Following wound damage to the skin, the scarring spectrum is wide-ranging, from a manageable normal scar through to pathological keloids. The question remains whether these fibrotic lesions represent simply a quantitative extreme, or alternatively, whether they are qualitatively distinct. A three-way comparison of the extracellular matrix (ECM) composition of normal skin, normal scar and keloids was performed using quantitative discovery-based proteomics. This approach identified 40 proteins that were significantly altered in keloids compared to normal scars, and strikingly, 23 keloid-unique proteins. The major alterations in keloids, when functionally grouped, showed many changes in proteins involved in ECM assembly and fibrillogenesis, but also a keloid-associated loss of proteases, and a unique cartilage-like composition, which was also evident histologically. The presence of Aggrecan and Collagen II in keloids suggest greater plasticity and mis-differentiation of the constituent cells. This study characterises the ECM of both scar types to a depth previously underappreciated. This thorough molecular description of keloid lesions relative to normal scars is an essential step towards our understanding of this debilitating clinical problem, and how best to treat it.

Spatial and Single-Cell Transcriptional Profiling Identifies Functionally Distinct Human Dermal Fibroblast Subpopulations.

Previous studies have shown that mouse dermis is composed of functionally distinct fibroblast lineages. To explore the extent of fibroblast heterogeneity in human skin, we used a combination of comparative spatial transcriptional profiling of human and mouse dermis and single-cell transcriptional profiling of human dermal fibroblasts. We show that there are at least four distinct fibroblast populations in adult human skin, not all of which are spatially segregated. We define markers permitting their isolation and show that although marker expression is lost in culture, different fibroblast subpopulations retain distinct functionality in terms of Wnt signaling, responsiveness to IFN-γ, and ability to support human epidermal reconstitution when introduced into decellularized dermis. These findings suggest that ex vivo expansion or in vivo ablation of specific fibroblast subpopulations may have therapeutic applications in wound healing and diseases characterized by excessive fibrosis.

Pyoderma gangrenosum--case report.

We report the case of a woman of 34 years who had ulcerative colitis and atypical pyoderma gangrenosum. The pyoderma gangrenosum responded to conservative treatment.

Axillary Reconstruction for Hidradenitis Suppurativa with an Inner-Arm Transposition Flap Creating a Brachioplasty Effect.

BACKGROUND: Hidradenitis suppurativa (HS) is a chronic skin condition that can affect any area with apocrine sweat glands and has the potential to involve multiple sites concurrently. Commonly affected sites include the axilla, groin, perineum and perianal areas. In this study we performed a literature review on the surgical methods for HS and describe an innovative technique for reconstructing axilla HS using an inner-arm transposition flap. METHODS: We reviewed all cases (5 cases from 4 patients) of transposition flap reconstruction performed by the senior author at a single London tertiary hospital from 2008-2013. Patient related outcome measures were collected using the Derriford appearance scale (DAS 24) and a study specific questionnaire. RESULTS: All patients were satisfied with their final result. One out of five cases had a complication but did not result in flap failure. There is no disease recurrence to date. DAS 24 scores collected demonstrated acceptable postoperative distress that did not deviate far from the norm tables while study specific questionnaire reveal desirable outcomes. CONCLUSIONS: We have managed to achieve our aim through the use of the innovative inner-arm transposition flap. Our study hopes to provide an additional technique for axillary reconstruction. This technique offers the effective concealment of scars with the benefit of tightening of the arm tissue producing 'brachioplasty like' effects. All things considered it would be reasonable to conclude the innovative flap technique is a reliable, effective, and simple method that results in multiple benefits.

Implementation of national body contouring surgery guidelines following massive weight loss: A national cross-sectional survey of commissioning in England.

INTRODUCTION: National guidelines for commissioning of body contouring surgery (BCS) following massive weight loss (MWL) in England were published in 2014. Nearly three-quarters of patients who have MWL seek BCS; however, access is known to vary according to the region. The aim of national guidelines was to standardise access. The purpose of this study was to determine implementation of the national guidelines by clinical commissioning groups (CCGs) in England. MATERIALS AND METHODS: A cross-sectional, web-based survey was sent to all CCG chairs in England. RESULTS: Of 211 potential respondents, 108 completed the survey or provided funding guidelines (response rate = 52%). Eight CCGs (7%) had implemented the guidelines. A total of 69 CCGs were aware of the new guidelines (64%), and 66 CCGs stated that they fund BCS after MWL (61%). A total of 81 CCGs (75%) identified local funding guidelines, while 15 CCGs (14%) cited individual funding requests (IFRs) as the means of accessing funding. To improve patient access to BCS; 58 of 65 respondents (89%) stated cost-effectiveness, whereas 56 of 75 respondents (75%) thought patient-reported outcome measures were key. Qualitative data to improve access included an integrated pathway from bariatric surgery to BCS, an improved evidence base and greater CCG finances. One CCG stated that it cannot afford to fund cosmetic procedures. CONCLUSIONS: The purpose of national guidelines was to simplify the pathway to BCS after MWL and create fair distribution of funds across the country to needy patients; however, their uptake has been poor. Access to funding for BCS across England varies according to the location.

Quality of life among adults following bariatric and body contouring surgery: a systematic review.

BACKGROUND: Weight loss following bariatric surgery is associated with significant improvements in obesity-related comorbidities, body satisfaction and psychosocial outcomes, at least in the short term. However, in the context of extreme weight loss, body image and appearance may worsen again because the "excess" or "loose" skin can lead to both functional and profound dissatisfaction with appearance. These concerns have led to an increasing uptake of post-bariatric surgery, "body-contouring" procedures but the implications for quality of life (QoL) have not been thoroughly considered. OBJECTIVE/PURPOSE: The objective was to identify the best available evidence regarding the QoL outcomes for adults following bariatric and body contouring surgery. INCLUSION CRITERIA TYPES OF PARTICIPANTS: The review considered studies involving people aged 18 years and beyond who underwent bariatric surgery and body contouring surgery. TYPES OF INTERVENTIONS: The review considered studies that evaluated bariatric surgery as well as body contouring surgery. TYPES OF STUDIES: The review considered both experimental and epidemiological study designs. OUTCOMES: The primary outcomes were QoL as measured by validated tools at less than two years, two to five years and more than five years following body contouring surgery. The secondary outcomes were adverse events, unsatisfactory aesthetic appearance and weight gain. SEARCH STRATEGY: Six databases were searched, including Cochrane Central, MEDLINE, Embase, Web of Science, PsycINFO and CINAHL. Studies published from 1954 to 2014 were considered. Additional searches for unpublished studies were undertaken in BIOSIS citation index, Register of Current Controlled Trials and Global Health Observatory. METHODOLOGICAL QUALITY: The methodological quality of eligible studies was assessed independently by two reviewers using the Joanna Briggs Institute quality assessment tool. DATA EXTRACTION: Data extraction from the included studies was undertaken and summarized independently by two reviewers using the standardized Joanna Briggs Institute data extraction tool. DATA SYNTHESIS: Studies were too heterogeneous and could not be pooled in statistical meta-analysis. Therefore, the data results are presented as a narrative summary in relation to the outcomes of interest. RESULTS: Nine quantitative studies (four comparable cohort studies, including two group design and two four-group designs and five descriptive or case-series studies) were included in the review. The included studies reported significant clinical improvements in appearance, wellbeing and QoL. These included primary outcomes pointing to body image satisfaction, improved self-esteem and confidence, improved physical function/pain and improved social function. The secondary outcomes were related to adverse events in the early postoperative period and reported wound healing problems, including seromas, partial necrosis, dehiscence, hematoma and anemia because of blood loss. Also, some data sets shed light on appearance-related distress and body dysphoria post surgery associated with visible scars and contour deformities. CONCLUSION: Body contouring surgery has been shown to have positive benefits, especially in relation to improved wellbeing, function and QoL. However, adjustment to changing body image following body contouring is both challenging and empowering and seems to be a transitional process.

The BODY-Q: A Patient-Reported Outcome Instrument for Weight Loss and Body Contouring Treatments.

BACKGROUND: Body contouring performed for cosmetic purposes, or after weight loss, has the potential to improve body image and health-related quality of life (HRQL). The BODY-Q is a new patient-reported outcome (PRO) instrument designed to measure patient perceptions of weight loss and/or body contouring. In this article, we describe the psychometric properties of the BODY-Q scales after an international field-test. METHODS: Weight loss and body contouring patients from Canada, United States, and United Kingdom were recruited between November 2013 and February 2015. Data were collected using an iPad directly into a web-based application or a questionnaire booklet. Rasch measurement theory analysis was used for item reduction and to examine reliability, validity, and ability to detect change. RESULTS: The sample included 403 weight loss and 331 body contouring patients. Most BODY-Q items had ordered thresholds (134/138) and good item fit. Scale reliability was acceptable, ie, Person separation index >0.70 for 16 scales, Cronbach α ≥0.90 for 18 of 18 scales, and Test-retest ≥0.87 for 17 of 18 scales. Appearance and HRQL scores were lower in participants with more obesity-related symptoms, higher body mass index, and more excess skin and in those pre- versus postoperative body contouring. The 134 weight loss patients who completed the BODY-Q twice, either 6 weeks (weight loss/nonsurgical body contouring program) or 6 months (bariatric program) later, improved significantly on 7 appearance and 4 HRQL scales. CONCLUSION: The BODY-Q is a clinically meaningful and scientifically sound patient-reported outcome instrument that can be used to measure outcomes in patients who undergo weight loss and/or body contouring.

Identity transformation and a changed lifestyle following dramatic weight loss and body-contouring surgery: An exploratory study.

This article reports on two major quality-of-life perception changes for patients who had undergone plastic surgery following dramatic weight loss. The exploratory, qualitative study was undertaken with 20 patients from one teaching hospital. In-depth interviews were conducted, and a thematic analysis of the data was undertaken. The results provide unique glimpses of surgical consumption empowering and facilitating 'identity transformation', embracing improved physical function and enhanced self-esteem, confidence and quality of life, and a 'changed lifestyle'. For a minority, identity transformation was sometimes interrupted by 'identity lag', posing the need for additional health-care support throughout the adjustment process. The study provides additional insight into existing quantitative studies, adding to the body of knowledge in this area.

Impact of necrotising fasciitis on quality of life: a qualitative analysis.

Mortality rates from severe necrotising soft tissue infections are improving progressively, therefore more emphasis should be placed on assessing and improving the quality of life of surviving patients. We investigated the functional and psychological issues, ability to social integration and self-perception of appearance in such patients presenting to our unit over 4 years. To conduct the study, we used the Short Form-36 and the Derriford Appearance Scale-24, which were distributed to those willing to participate. Ten patients have returned fully completed questionnaires. The overall quality of life and level of distress about the changed appearance were moderate (average SF-36 score of 65.8, DAS-24 score of 38). Statistical correlations between the scores and demographics were carried out using the Spearman rank correlation test. The capability of psychosocial adjustment was shown to improve with longer follow-up time and older age. However pain, physical limitations and energy levels were considerably more relevant in the older individuals and improved slower with time compared to psychological issues. Our results act as a good indicator of the quality of life in people dealing with the aftermath of necrotising soft tissue infections, but further, more extensive studies are required to achieve comprehensive and statistically significant results.

Changing Body Image and Well-Being: Following the Experience of Massive Weight Loss and Body Contouring Surgery.

This paper reports on the perception of changing body image and well-being for patients who had undergone plastic surgery following massive weight loss. The exploratory, qualitative study was undertaken with 20 patients from one teaching hospital in the south of England. Semi-structured interviews were carried out and a thematic analysis of the data undertaken. The results provide important insights regarding body contouring influencing body image change and the adjustment process involved. The ability to pursue self-esteem and the accruing social benefits is emphasized in the interrelated sub themes including social acceptance, undoing depression and sexual vitality. Body contouring surgery following massive weight loss appears to facilitate improvement in body image and well-being. Adjustment to the changing body image is both empowering and challenging. Supportive educational programmes need to be developed to assist this transition to a more positive body image and appreciation; these could usefully include access to and involvement with patient support groups.

The biomechanical and histological sequelae of common skin banking methods.

Human skin allografts are used worldwide as an adjunct for the healing of burns when autograft skin is not available or not indicated. Allograft skin comes from human cadaveric donors, and so must be preserved until use. This study forms the first investigation to compare the mechanical and histological integrity of human split-thickness skin grafts preserved by either glycerolisation or cryopreservation (with or without the cryoprotectant DMSO). Stress relaxation was used to assess mechanical properties, whilst histological analysis allowed for evaluation of structural integrity. Preservation of tissue, whether by freezing or glycerolisation, altered the relaxation behaviours of skin. Young's modulus upon initial loading significantly decreased for skin frozen without cryoprotectant, but remained unchanged for skin frozen with cryoprotectant and skin preserved with glycerol. After 1.5h of stress relaxation, both fresh skin and skin frozen without DMSO displayed similar relaxation rates. Samples frozen with DMSO or preserved with glycerol had increased relaxation rate and had not reached load equilibrium within this time. To understand the structural basis for the biomechanical changes, samples were histologically assessed. All preservation protocols resulted in a similar degree of visible damage, but cryopreservation appeared particularly damaging to the extracellular matrix, whereas glycerolisation caused dramatic separation of the epidermis from the underlying dermis. The mechanical property alterations reveal that preservation results in laxity, which clinically could hinder contact dependent healing properties, but alternatively may increase capacity for coverage. The structural changes confirm that preservation techniques do not conserve grafts in an in vivo state.

A preliminary report on the development of a validated tool for measuring psychosocial outcomes for massive weight loss patients.

AIM: To validate the newly developed patient report outcome measure (PROM): the Post Bariatric Outcome Tool (PBOT). The tool is designed and developed for massive weight loss patients seeking body contouring procedures. METHOD: The PBOT was piloted with three cohorts: massive weight loss patients seeking body contouring; massive weight loss patients who have had body contouring; and healthy, non-obese subjects as controls matched for age and gender. Each cohort completed two PROMS at week one, and then for a second time at week three. The PROMS used were the new Post Bariatric Outcome Tool (PBOT) and the Derriford Appearance Scale 24 (DAS24). CONCLUSION: The PBOT was shown to be reliable both in terms of its internal consistency and test-retest reliability. Comparison to the DAS24 demonstrated the PBOT to be valid. However, the cohorts were small and responsiveness was not tested. This needs to be tested in further larger validation studies, ideally, with comparison to functional scales such as the SF-36 or other validated massive weight loss body contouring PROMs; such as the Body Q.

A multidisciplinary approach to post-bariatric plastic surgery.

Social changes over the last 100 years, but predominantly since the invention of 'fast food' have led to an explosion in obesity. The National Institute for Clinical Excellence advise referral of patients with body mass indices >40 for bariatric surgery. One third of post-bariatric surgery patients achieve massive weight loss necessitating reconstructive body contour surgery. This unique group of patients presents multiple challenges for medical and ancillary practitioners involved in their care. A multidisciplinary approach is essential.

Giant intrathoracic lipoma presenting as a lump in the supraclavicular fossa.

A 25-year-old man presented with a lump in the supraclavicular fossa. Subsequent investigations showed that the patient had a giant intrathoracic lipoma that has caused the deviation of his trachea to the left and had encased his great vessels. Multidisciplinary discussions concluded that tracheal stenting was most suitable for the patient. We describe details of his presentation, clinical findings and discuss the management options of a giant intrathoracic lipoma.