Necrotising fasciitis: clinical judgement and early multidisciplinary collaboration is the key.

Necrotising fasciitis is a bacterial infection of subcutaneous tissue and fascia, which can rapidly progress to septic shock. Diagnosis is frequently delayed or missed due to non-specific presentation. The laboratory risk indicator for necrotising fasciitis (LRINEC) stratifies risk based on biochemical results, but external validation revealed limited accuracy. A 78-year-old female with significant co-morbidities presented with right foot pain and erythema. Vital signs were normal and C-reactive protein was 18 mg/l. LNIREC was 0. She was treated for cellulitis, but within 24 h developed skin blistering and necrosis. After consideration of risks, washout and debridement was performed under popliteal block. Recovery was prolonged and complicated by nosocomial infection. This case highlights the importance of clinical suspicion for necrotising fasciitis and the complexity of management decisions considering recovery can be protracted.

Safety of limb-salvaging surgery for sarcomas compromising major vessels: A 15-year single-centre outcomes study.

INTRODUCTION: Limb-threatening sarcomas invading major vessels present an oncological and reconstructive challenge. Curative resection involves either performing an amputation or an immediate reconstruction of the invaded vessels. We present our 15-year experience of these cases at the North of England Bone and Soft Tissue Tumour Service. MATERIALS AND METHODS: A Strengthening the Reporting of Observational studies in Epidemiology (STROBE) compliant retrospective review of our prospective database was performed including patients who required major vessel reconstruction following sarcoma excision from 2003 until 2018. Patient demographic data along with tumour and histological subtypes, treatment modality, complications and outcomes were inquired. Autologous and prosthetic vessel reconstruction approaches were compared. RESULTS: Nineteen patients were identified with the most common tumour locations being the thigh and groin areas. Five cases involved recurrent tumours. Clear resection margins were obtained in 15 cases. Autologous vein grafts were preferred over polytetrafluoroethylene (PTFE) prosthesis in 17 cases. A pedicled flap or free flap was required to achieve adequate soft tissue cover in six patients, while the rest underwent primary closure. Five patients lost the patency of the reconstructed vessels with one of these requiring an amputation. The estimated disease-specific survival at 5 years was 58%. DISCUSSION: Limb-preservation surgery in the context of vessel compromise is not only safe, but also a functionally and psychosocially beneficial means of avoiding an amputation. We believe that careful pre-operative planning and discussion in a multidisciplinary setting is key for obtaining positive outcomes.

The Newcastle Microsurgery Fellowship: A Truly Multidisciplinary Training Experience.

ABSTRACT: The Newcastle upon Tyne Hospitals NHS Foundation Trust Plastic Surgery Department offers a 12-month, intense and comprehensive fellowship covering almost every aspect of reconstructive microsurgery. Across its 2 sites at The Royal Victoria Infirmary and Freeman Hospital, over 175 free flaps are performed every year, spanning the breadth of head and neck oncology, sarcoma, facial palsy, and breast and limb reconstruction. The appointed fellow is expected to be involved in at least 90 microsurgical cases, plus a reasonable number of complex nonfree flap reconstructions. An overview of this hands-on microsurgery fellowship is hereby presented based on the experience of 2 recent fellows.

The "Segmental SMAS Model": A Didactic Concept of Face and Neck Lift Anatomy.

Profound understanding of the surgical anatomy of the face and neck is the key to successful face lift surgery. The "Segmental SMAS Model" presented herein is the result of a decade-long effort in teaching fellows a logical and coherent anatomic model of face lift anatomy. The superficial musculo-aponeurotic system (SMAS) consists of segments with distinct surgical characteristics. These are determined by the presence of a deep gliding plane and/or adhesion through fibrous insertions. In this article, we define SMAS segments that are profoundly heterogeneous in their behavior and have surgical implications on the maneuvers required for a deep plane face lift. The present model introduces several novel interpretations of the surgical anatomy of the face and neck lift procedure and hopes to convey a better understanding of face lift anatomy to training surgeons.

Minimally invasive techniques in rhinoplasty.

PURPOSE OF REVIEW: To present criteria of minimally invasive surgery, which include minimal and hidden incision lines, reduced injury to tissue and application of endoscopic techniques, when feasible; to analyze techniques in rhinoplasty for their minimally invasive character - in light of recent publications; and to discuss the techniques that best meet the criteria of minimally invasive surgery. RECENT FINDINGS: The nose consists of about 60 percent soft tissue and 40 percent skeletal elements. Surgery causes injury to both tissue types through various mechanisms, including mechanical traction, separation, incision, heat, desiccation, and others. Multiple aspects including extent of approach and degree of tissue undermining determine the minimally invasive character of techniques and maneuvers in rhinoplasty. SUMMARY: A single incision endonasal approach, the subperichondrial and subperiosteal septal plane, the supraperichondrial plane over the cartilaginous dorsum, the subperiosteal plane over the bony dorsum, limited dorsal undermining with endoscopic visualization when feasible, conventional straight lateral osteotomy or percutaneous curved lateral osteotomy; percutaneous transverse osteotomy; conventional straight paramedian osteotomy; piezo and drill paramedian ostectomy; dorsal uncapping osteotomy; conventional rasp gross dorsal contouring; piezo or drill fine dorsal contouring; (cartilaginous) middle vault 'let down'; and minimal access subperiosteal turbinate bone resection were found to best fulfil the criteria of minimally invasive surgery. A classification system for the degree of minimally invasiveness of rhinoplasty techniques is proposed as a basis for discussion.

Smoke inhalation increases intensive care requirements and morbidity in paediatric burns.

Burn survival has improved with advancements in fluid resuscitation, surgical wound management, wound dressings, access to antibiotics and nutritional support for burn patients. Despite these advancements, the presence of smoke inhalation injury in addition to a cutaneous burn still significantly increases morbidity and mortality. The pathophysiology of smoke inhalation has been well studied in animal models. Translation of this knowledge into effectiveness of clinical management and correlation with patient outcomes including the paediatric population, is still limited. We retrospectively reviewed our experience of 13 years of paediatric burns admitted to a regional burn's intensive care unit. We compared critical care requirements and patient outcomes between those with cutaneous burns only and those with concurrent smoke inhalation injury. Smoke inhalation increases critical care requirements and mortality in the paediatric burn population. Therefore, early critical care input in the management of these patients is advised.

Soft tissue sarcoma - A review of presentation, management and outcomes in 110 patients.

UNLABELLED: Soft tissue sarcomas are a rare group of mesenchymal tumours the treatment of which poses oncological and reconstructive challenges. Limb-salvage surgery aims to balance adequate excision margins for disease control and preservation of important structures to retain function. Reported here is the review of the Hull Plastic surgery sarcoma service over a twelve year period. METHOD: We performed a review of the Hull sarcoma database over a twelve year period between 1997 and 2009. Demographic data, tumour grade, operative details complications and outcomes were recorded. RESULTS: The database contained a total of 435 patients with a diagnosis of sarcoma. 110 were treated at the Plastic Surgery department over a period of 12 years between 1997 and 2009. The patients treated in our department consisted of 67 males and 43 females (median age 70 years). The most common histological type was leiomyosarcoma (n = 23). Distribution of anatomical sites affected were head and neck (n = 15), upper limb (n = 17), lower limb (n = 56), trunk (n = 22). Large tumours (greater than 8 cm) n = 30, deep tumours n = 48, and high grade (Trojani 3) n = 33. Patients were treated with surgical excision and postoperative radiotherapy in the high grade groups (2 and 3). A range of reconstructive procedures were required from skin grafting, functional muscle transfer and free flap reconstruction. Nine patients developed regional recurrence, six patients had grade 3 tumours. Three were not resectable. Fourteen patients developed distant metastases, seven had grade 3 tumours, six underwent chemotherapy, two were treated palliatively. There were twenty deaths in this group, of which sixteen were sarcoma related. Deaths in the high risk groups was seven (high grade), nine (deep tumours) and eight (tumour size >8 cm). There were six survivors from eleven in the group with all three of these risk factors. CONCLUSION: This study summarises the management of sarcoma form one unit over a twelve year period and lends further evidence to the fact that the principles of limb-salvage surgery are applicable to a wide range of tumour-types and grades, to all patient age groups and anatomical sites with good functional results and that local and free flap reconstruction provides wound cover robust enough to withstand courses of radiotherapy. Early recurrence of high-grade disease and the development of metastasis carry a worse prognosis, especially if adjuvant therapy cannot be given. LEVEL OF EVIDENCE: 4.

Microvascular free tissue transfer in acute and secondary burn reconstruction.

INTRODUCTION: The mainstay of operative treatment in burns is split skin grafting with free tissue transfer being indicated in a minority of cases. However, free tissue transfer faces a number of challenges in the burns patient. These include; overall cardiovascular and respiratory stability of the patient, availability of suitable vessels for anastomosis, sufficient debridement of devitalised tissue and a potentially increased risk of infection. We carried out a retrospective study in order to determine the indications, timing, principles of flap selection, complications, outcomes and methods of promoting flap survival when free tissue transfer was utilised for burn reconstruction in our unit. MATERIALS AND METHODS: All patients who underwent soft tissue reconstruction for burn injuries with microvascular free tissue transfer between May 2002 and September 2014 were identified from our burns database. The records of these patients were then retrospectively reviewed. Data extracted included, age, gender, type of injury, total body surface area involved, indications for free tissue transfer, anatomical location, timing of reconstruction, complications and flap survival. RESULTS: Out of a total of 8776 patients admitted for operative treatment over a 12-year period, 23 patients required 26 free flaps for reconstruction. Out of 26 free flaps, 23 were utilised for acute burn reconstruction while only 3 free flaps were utilised for secondary burn reconstruction. All 26 free flaps survived regardless of timing or burn injury mechanism. Complications included haematomas in 2 flaps and tip necrosis in 4 flaps. Two flaps required debridement and drainage of pus, 1 flap required redo of the venous anastomosis while 1 required redo of the arterial anastomosis with a vein graft. CONCLUSIONS: Free tissue transfer has a small but definite role within acute and secondary burn reconstruction surgery. Despite the complexity of the burn defects involved, free flaps appear to have a high success rate within this cohort of patients. This appears to be the case as long as the appropriate patient and flap is selected, care is taken to debride all devitalised tissue and due diligence paid to the vascular anastomosis by performing it away from the zone of injury.

A misdiagnosed burn: necrotising fasciitis in an elderly patient.

A 91-year-old man was admitted having been found unresponsive in his bed. He was previously well, but had sustained a laceration over the dorsum of his forearm after a recent fall. Initial appearances were innocuous, and suggestive of a superficial wound infection. A review of the wound by the plastic surgeons led to the diagnosis of a full-thickness burn, despite a lack of supporting evidence in the history. No clinician who had initially assessed the patient was involved in his ongoing care. Rapid clinical deterioration ensued, with sepsis and deteriorating mental state. Necrosis spread rapidly up his arm, and the diagnosis of necrotising fasciitis was made. The patient was urgently taken to theatre for circumferential excision of the necrotic tissue. He was subsequently managed on the intensive care unit where he made a promising initial recovery, but later died from pneumonia in the ward.

Sun protection--do we know enough?

INTRODUCTION: Sun protection, particularly the appropriate use of sunscreens is an important modifiable risk factor in the prevention of skin cancers. Our aim was to assess the current knowledge levels regarding sun protection, across plastic surgeons in the UK. METHODS: A 12-point questionnaire based on the points contained in the patient information packs on sun protection produced by the British Association of Dermatology was circulated electronically amongst 551 BAPRAS members. We received 73 responses (13.3%). Questions were formulated around the basic information patients would expect to receive from a skin cancer specialist at the time of the diagnosis. RESULTS: On average, participants could answer only 52.4% of the questions correctly. Only 9.7% (95% CI 3-17) of participants could accurately quantify the role of UV exposure in causation of melanoma. A total of 37.5% correctly identified the duration of action of sunscreen to be 3-4 h. Half of the participants were not aware that geographical conditions like altitude and latitude, as well as shade, could alter sun protection. A similar number could not answer questions related to the protective action of clothing. CONCLUSION: As principal stakeholders in the treatment and outcomes of skin cancer patients, plastic surgeons could be at the forefront of influencing patients' behaviour regarding sun protection measures. The results demonstrate a need for better awareness and education regarding the knowledge of sunscreens and UV protection. Improved education would lead to health benefits for patients and their relatives and influence the primary prevention of this enlarging health issue of skin cancer.