Some reflections on war for countries at peace: Would we know what to do?

In the west we have enjoyed peace for decades, but war is globally always present. Recent events have brought this into clear evidence. Once mass casualties occur, war enters civilian hospitals. As civilian Surgeons, used to our sophisticated elective work, would we know how to step up to the mark if required? Ballistic and blast wounds pose problems that need reflection before treatment starts. Delivery of early and complete debridement to high numbers of casualties, stabilising bone and closing the wounds becomes the role of the Ortho-plastic team. This article presents reflections from the senior author after ten years of working in zones of conflict. Import factors witnessed are how civilian surgeons are soon involved in unfamiliar work and must learn and adapt fast. Critical issues that arise are pressure of time, contamination, infection, and the need to never forget the importance of antibiotic stewardship even when under pressure. The advantage of supporting the Multidisciplinary team (MDT) approach, even as resources reduce, large numbers of casualties present, and staff are all under pressure, can bring order and efficiency to the chaos: It supplies best care to the victims within that current context and reduces unnecessary duplication of surgery and waste of manpower. The surgical management of ballistic and blast injuries could be added to the curriculum of young, civilian surgical trainees. This is preferable to having to acquire these skills during war with stress and minimal supervision. This would enhance the preparedness of counties at peace for disaster and conflict should the need arise. Well trained manpower could also support neighbouring countries who find themselves at war.

A review of the first wave of lower limb amputees from the Great March of Return in Gaza: Taking stock and preparing for the task ahead.

AIM: Ballistic injuries during the Great March of Return (GMR) protests in Gaza have resulted in young, civilian amputees. This article defines this unique population, their injuries and clinical variables that impacted on amputation. METHOD: A multidisciplinary team (MDT) assessed 103 lower limb amputees (104 stumps). Individualized prescriptions of care were formulated and applied for both stump and prosthesis management. The cohort's health state was assessed at screening by applying the EQ-5D-L5 questionnaire. The EQ-5D-L5 will be repeated on completion of the prescription of care. RESULTS: The population is predominantly young, male, suffering unilateral amputation with an equal ratio of above knee (AKA) to below knee (BKA) amputations. 18% were amputated immediately and 82% with delay. Most amputations occur within 15 days of gunshot wound (GSW). All tissue elements were affected by the severe, ballistic injury. Division, gapping and tissue loss consolidated the decision for amputation rather than limb salvage. Knee zone injury was common, influencing the high numbers AKAs. Primary injury ramified beyond the amputated leg: 38% have contralateral leg injuries. 20% had physiological challenges requiring Intensive care unit (ICU) admissions. Infection was reported in 49% of amputees with 12% reporting acute sepsis. Psychologically, 49% reported severe, or extreme, anxiety and depression. AKAs were associated with greater morbidity: amputees are significantly younger, have more proximal vascular injuries, receive delayed amputations and experience longer time intervals to stump healing. ICU care and contralateral leg injuries were more frequent. One third of amputees used their prostheses', one third did not and one third do not have a prosthesis yet. The limiting factor for repair was supply of materials. 11% of amputees needed no adjustment to stump or prosthesis. Surgical stump revision was recommended in 26% of stumps and prosthetic management in 41%. A further 22%, subject to the success or failure of prescribed prosthetic adjustment, could require stump revision. CONCLUSION: Youth, proximal injury, high numbers of AKA, psychosocial issues and the need for stump and prosthetic support define this group of amputees. Unifying expertise within a National MDT will promote continuity of care necessary for decades to come. The ultimate aim is an evidence-based amputee care system in Gaza, with lower limb specialists promoting best outcomes, judicious allocation of funds and maximising amputee quality of life.

Stump-plasty: An Operation Born of Necessity in Gaza.

AIM AND OBJECTIVE: The most recent wave of lower limb amputees in Gaza arises from ballistic injuries sustained during protests. This study evaluates the requirement for surgical revision of these mature stumps to allow prosthetic fit and mobility. MATERIALS AND METHODS: A multidisciplinary team (MDT) comprising a prosthetist, orthopaedic and plastic surgeons and a physiotherapist screened 104 amputee stumps (103 cases). The 27 cases selected for surgical revision (stump-plasty) are the subject of this study.The MDT prescriptions of care issued at screening were compared to surgical procedures performed at stump-plasty and the findings. Compliance with the MDT prescription was recorded. Stump issues are identified to propose modifications of primary amputation technique to mitigate future revisions.Patients' healthcare status was assessed by questionnaire (EQ-5D-L5) at screening, then subsequently post-stump-plasty. RESULTS: More below-knee amputees (BKAs) than above-knee amputees (AKAs) required stump-plasty. Revisions varied according to the quality of tissue present at the amputation level. AKA revisions addressed bulk and contour issues whereas BKA revisions related to bone prominence, neuroma formation and lack of soft tissue cover. Despite many variations in tissue-targeted procedures being possible, the MDT prescription was followed accurately at surgery.Suggested modifications at primary amputation to decrease revisions include improved bone tip bevelling at BKA and greater soft tissue reduction at AKA. Severed nerve management needs to be rationalised to reduce primary neuroma formation and neuroma revision at stump-plasty requires consideration to attempt to reduce the recurrent risk. Removal of the fibular remnant in short BKA stumps at primary amputation could mitigate common peroneal nerve hypersensitivity later.Following stump-plasty, amputees recorded a significantly improved score in three of five dimensions of the EQ-5D-L5 questionnaire: activities, anxiety levels and pain. CONCLUSION AND CLINICAL SIGNIFICANCE: Primary ballistic injury dictates the level of amputation and the resultant stump quality. Issues arising in these complex amputee stumps benefited from measured decisions and specialist care delivered by the MDT. Stump-plasty aims to improve the amputees' prosthetic fit, mobility and health. HOW TO CITE THIS ARTICLE: Godwin Y, Almaqadma A, Abukhoussa H, et al. Stump-plasty: An Operation Born of Necessity in Gaza. Strategies Trauma Limb Reconstr 2021;16(2):102-109.

Correction of Tuberous Nipple Areolar Complex Deformity in Gynecomastia: The Deformity That Can Get Forgotten.

The desired end point of surgical reduction of gynecomastia is a masculine breast appearance and symmetry. This article concentrates on the tuberous deformity of the nipple areolar complex (NAC) that can present in gynecomastia and is sometimes overlooked at surgical correction.This deformity can be corrected at primary surgery if it is recognized preoperatively. If missed, or not adequately corrected, the postoperative result of primary reduction may be deemed incomplete by the patient and they will request revision.The deformity involves overprojection of the NAC in an anteroposterior direction, yet the base diameter may be close to normal. Correction involves reduction of the herniated breast bud, excision of excess areolar tissue, and careful radial scoring to flatten the NAC to a normal level of projection.For the NAC to have a masculine appearance, the areolae need to be symmetrical, of normal male size, and slightly oval in a transverse direction. The projection of both areola and nipple needs to be low, but present: not flattened. This article presents an operative technique to address primary or residual tuberous NAC deformity in the treatment of gynecomastia.

Isolated Dorsoradial Capsular Tear of the Thumb Metacarpophalangeal Joint: Missed Diagnosis and the Management of Delayed Presentation.

Isolated dorsoradial capsule injuries of the thumb metacarpophalangeal joint are different from those associated with collateral ligament disruption. Early suspicion of this rare injury is important because, if overlooked, ulnarward subluxation of extensor pollicis longus tendon can develop. Functionally, active thumb extension becomes impaired, and over the long term, a thumb Boutonniere's deformity becomes established. Joint hypermobility/instability may predispose to this injury. The 2 cases presented illustrate this through anatomic differences. At the time of acute injury, 3 presenting clinical features should raise suspicion of dorsoradial capsular rupture: a history of isolated hyperflexion injury to the thumb, stable collateral ligaments on examination, and x-ray evidence of palmar subluxation of the proximal phalanx on the metacarpal. Ulnarward subluxation of the extensor pollicis longus is a delayed sign. Diagnostic imaging, beyond x-ray studies, may not be helpful in defining the injury. Early exploration and repair of this injury give the best long-term outcome. Postrepair, metacarpophalangeal joint range of motion may not be fully restored, but stability and a preinjury level of hand function can usually be reestablished.

The Impact of Cervical Musculoskeletal Disorders on UK Consultant Plastic Surgeons: Can We Reduce Morbidity With Applied Ergonomics?

BACKGROUND: Based on anecdotal and observational evidence, we hypothesized that the prevalence of cervical musculoskeletal disorder (C-MSD) would be high among plastic surgeons. A questionnaire review was undertaken to test this hypothesis. Ergonomic assessment was undertaken to assess causal factors of C-MSD. METHOD: An anonymous questionnaire recording demographics, physical symptoms and behavioral responses to C-MSD was distributed to UK Plastic Surgery consultants. The postural impact of wearing loupes was assessed using motion capture techniques and recording cervical muscular activity. RESULTS: The questionnaire response rate was 81%. The prevalence of cervical spine morbidity was recorded as 32%. Employment implications included 28% of the cohort requiring sick leave. The professional impact was 7% permanently modifying their practice. There were 2 factors significant for C-MSD, the surgeons' age and the duration in hours of wearing loupes per week. Ergonomic assessment of surgeons operating in loupes demonstrated: 1. increased forward and lateral cervical flexion; 2. increased cervical muscular activity to maintain the protracted "head forward" posture; and 3. prolonged static posturing to maintain head position for visual focus. Table height adjustment and variation of loupe working distance can reduce neck flexion. CONCLUSIONS: Cervical morbidity is a prevalent problem among plastic surgeons. Long procedures, static postures and neck flexion result in the "head forward" posture. This posture exaggerates when operating with loupe magnification. Early-middle-aged consultants are more prone to cervical morbidity hence afflicted when at the top of their game. The work force is diminished for a potentially avoidable morbidity. Rather than accept this morbidity, co-operation between plastic surgeons and ergonomist may help to reduce injury.

The Gaza Hand Board.

This article describes an economical, versatile hand board that was conceived in Gaza during a surgical mission in the absence of commercially available hand holding devices. It was initially created to allow access and immobilization of the hand when addressing volar digital burn contractures. It has been applied subsequently during 5 further missions and now forms a standard part of our surgical kit. We present it to provide others with an easy solution should they need to release complex hand contractures and not have any assistant or instrument to immobilize the hand.

The application of Integra in a challenging context.

Integra dermal regeneration template is commonly used in the developed world. This case history documents the application of Integra for the first time in Gaza, Palestine. This single case history illustrates how a tried and tested technique can be imported to a more challenging environment. The emphasis in this case history is not to recount a well-known technique of Integra application but to outline how the environment has to be prepared and the surgeon adapt to minimise risk and maximise the chances of success. This first application of Integra in Gaza illustrates the importance of starting with simple cases when a technique is being piloted in an austere environment. Patient selection, local theatre set up, staff and surgical technique, as well as patient follow-up facilities, all need consideration before doing the first trial of even this most established of products in a new environment.

Soft, Brown Rupture: Clinical Signs and Symptoms Associated with Ruptured PIP Breast Implants.

BACKGROUND: Preoperative signs and symptoms of patients with Poly Implant Prothese (PIP) implants could be predictive of device failure. Based on clinical observation and intraoperative findings 4 hypotheses were raised: (1) Preoperative clinical signs including acquired asymmetry, breast enlargement, fullness of the lower pole, decreased mound projection, and change in breast consistency could be indicative of implant rupture. (2) Device failure correlates with a low preoperative Baker grade of capsule. (3) Brown-stained implants are more prone to implant failure. (4) The brown gel could be indicative of iodine ingression through a substandard elastomer shell. METHODS: Preoperative clinical signs were compared with intraoperative findings for 27 patients undergoing PIP implant explantation. RESULTS: Acquired asymmetry (P = 0.0003), breast enlargement (P = 0.0002), fuller lower pole (P < 0.0001), and loss of lateral projection (P < 0.0001) were all significantly predictive of device failure. Capsule Baker grade was lower preoperatively for ruptured implants. The lack of palpable and visible preoperative capsular contracture could be secondary to the elastic nature of the capsular tissue found. Brown implants failed significantly more often than white implants. Analysis of brown gel revealed the presence of iodine, suggesting povidone iodine ingression at implantation. CONCLUSIONS: Preoperative signs can be predictive of PIP implant failure. Brown-stained implants are more prone to rupture. The presence of iodine in the gel suggests unacceptable permeability of the shell early in the implant's life span. A noninvasive screening test to detect brown implants in situ could help identify implants at risk of failure in those who elect to keep their implants.

Convective burn from use of hairdryer for heel warming prior to the heel prick test - a case report.

BACKGROUND: Blood sampling through heel lancing is the most common invasive painful procedure performed on newborn infants. CASE PRESENTATION: We report the case of a five day old infant who sustained burns to the left foot and leg after the mother's hairdryer was used by the midwife to warm the baby's heel prior to capillary blood sampling (CBS) with an automated device. CONCLUSION: Heel warming is not recommended for routine CBS although it is often practiced. If pre-warming is to be practiced, standardised devices should be used rather than improvised techniques. This will reduce the risk of injury to these infants.

The use of local anesthetic motor block to demonstrate the potential outcome of depressor labii inferioris resection in patients with facial paralysis.

BACKGROUND: If a patient with unilateral facial paralysis has marked depressor activity on the normal side, the appearance of the lower lip when smiling is asymmetrical. Defunctioning the muscle on the contralateral side to the palsy can restore balance. This can be achieved by resecting a portion of the depressor labii inferioris muscle on the nonparalyzed side. However, the decision to resect normal muscle may be difficult for many patients. This article presents the role of a local anesthetic motor block in temporarily paralyzing the muscle before patients decide whether permanent resection will meet their needs. METHOD: A phone questionnaire with 15 patients who received motor muscle blockage before deciding to have depressor labii inferioris muscle resection was conducted. RESULTS: Ninety-three percent of the patients who underwent the local anesthetic motor block stated that it gave them valuable information regarding the outcome of their surgery and influenced their decision to undertake definitive depressor muscle resection. CONCLUSION: A trial by local anesthetic before depressor inferioris muscle resection provides patients with valuable insight into the likely outcome of the surgery.

Investigation into the possible cause of subjective decreased sensory perception in the nipple-areola complex of women with macromastia.

Patients with macromastia often comment on a lack of sensation in their nipple-areola complex. A study was designed to investigate the cause of this decreased sensation. Two hypotheses were proposed. First, the decreased sensation could result from neuropraxia of the sensory nerve fibers secondary to traction caused by the heavy breast parenchyma. The second hypothesis proposed that tissue expansion of the nipple and areola by the voluminous breast parenchyma caused a decrease in nerve fibers per surface area and hence decreased sensory perception. Sixty-one patients were assessed in the study. All patients underwent surgery in which histological biopsy of either the areola alone (31 reduction mammaplasty patients) or the nipple and areola (30 mastectomy patients) was possible. Before surgery, each nipple-areola complex was tested with Weinstein Enhanced Sensory Test monofilaments as a quantitative test of tactile sensation. Breast cup size, ptosis, and weight of tissue excised were recorded to allow general assessment of the breast size. The nipple and areola biopsy specimens were assessed using immunohistochemistry (S-100 polyclonal antibody, Dako Z311) to measure nerve fiber count per unit area. Statistical analysis was undertaken to find any association among sensitivity, breast cup size, ptosis, weight of tissue resected, and nerve fiber density in the nipple and areola biopsy specimens. Sensitivity at the areola decreased with increasing breast cup size (r = 0.47, p < 0.001) and ptosis (r = 0.42, p = 0.002 for increasing distance between inframammary crease and nipple; r = 0.49, p < 0.001 for increasing manubrium to nipple distance). There was a weak correlation between nerve fiber density at the areola and breast cup size (r = -0.22, p = 0.1). Sensitivity at the nipple was higher than at the areola. Nerve fiber density count at the nipple was higher than at the areola, but there was no statistically significant correlation between nipple sensitivity and breast cup size, ptosis, or weight of tissue resected. The results suggest that the areola and nipple are different in their neuroanatomy. The areola is a thin, pliable structure that is predisposed to stretch as the breast enlarges and therefore experience a decrease in nerve fiber density. The nipple is a compact structure that is less likely to stretch with breast enlargement. In the nipple, neither sensory perception nor nerve fiber density varied with size or breast ptosis. The perceived lack of sensation in the nipple-areola complex is multifactorial. This study shows that neither traction injury to the sensory nerves nor decreased nerve density alone can explain the subjective numbness reported by patients with macromastia. Psychological factors, such as dissatisfaction with body form or interpretation of lack of sensation in the areola as also affecting the nipple, may influence the patient's assessment of the nipple-areola sensitivity.