Plastic Surgery Fellowship at Nippon Medical School Hospital: An Integrative Approach to Modern Plastic Surgery Education.

Plastic surgery requires extensive wide-ranging surgical knowledge, special technical dexterity, and personal skills in order to achieve improved quality of life and satisfying outcomes for patients. For decades, international plastic surgery fellowship programs have offered opportunities to enhance the subspecialty training of young plastic surgeons abroad and promote international exchange of information in the field of plastic surgery. However, concerns around enrolling in a nontraditional educational strategy at the postgraduate level have restricted young plastic surgery residents from pursuing comprehensive training opportunities overseas. Therefore, we present a personal experience of a distinct established international fellowship program in plastic, reconstructive, and aesthetic surgery at Nippon Medical School Hospital, Japan, as an example. This institution has adopted the use of highly skilled surgical techniques, providing basic research education along with the teaching of essential personal skills needed in modern plastic surgery. As a mean to promote international educational collaboration in plastic surgery, we discussed the modern plastic surgery educational strategies worldwide that participate in developing a successful plastic surgeon's career.

The use of botulinum toxin in keloid scar management: a literature review.

INTRODUCTION: Administration of botulinum toxin is an increasingly popular procedure in the medical and aesthetic field. There is emerging evidence that it can influence fibroblast activity and minimise tension around the scar by virtue of muscular chemoimmobilisation. This review aims to explore the current evidence base behind the treatment of keloid scars with botulinum toxin. METHODS: A detailed literature review was conducted using PubMed Medline, Embase and Web of Science databases. Manuscripts were appraised and classified in accordance with the Joanna Briggs Institute Levels of Evidence by an independent consultant in evidence synthesis. The results of this search are presented in descending order of evidence for botulinum toxin as a primary management agent as well as a secondary adjunct following extralesional keloid excision. DISCUSSION: On the basis of level 1 evidence, botulinum toxin appears to be equivalent to triamcinolone in producing a short-term reduction in keloidal volume, height and vascularity. A number of level 1 and 2 studies also suggest that botulinum toxin may be particularly helpful in alleviating symptoms of keloid associated pain and itch. There are currently limited studies appraising the value of botulinum toxin in the postoperative management of keloid scars. CONCLUSION: Botulinum toxin may represent a promising agent in the management of keloid scars. However, further research involving large-scale studies with comparative designs and long-term follow-up is warranted to delineate the value of this therapeutic modality in scar management protocols.

Percutaneous collagen induction (microneedling) for the management of non-atrophic scars: literature review.

INTRODUCTION: Percutaneous collagen induction (PCI) or needling techniques are increasingly popular in the reconstructive and aesthetic arena. The underlying mechanisms of action rest on producing a pattern of non-ablative and non-confluent puncture wound pattern to the dermis with a resulting regenerative effect to the skin. METHODS: A detailed English literature review was conducted using PubMed Medline, Embase and Web of Science; the manuscripts were appraised and classified according to level of evidence as well risk of bias. Results are presented in descending order of evidence for non-atrophic scars. DISCUSSION: On the basis of level 1 evidence currently available, the combination of needling and silicone gel can improve the short-term pliability, height and vascularity of hypertrophic and keloid scars. According to level 2 evidence, needling alongside spray keratinocytes can produce a statistically significant improvement to patient/observer scar ratings and improve pigmentation in hypopigmented burn scars at 12-month follow-up. Results from mixed cohort studies also point towards needling having a beneficial effect on fat graft retention. Level 3 data suggest that needling can render significant resurfacing effects to both mature and actively hypertrophic burn scars at 12-month follow-up based on objective scar scales; furthermore, favourable histological changes are seen, including better collagen alignment in the dermis and increased epidermal thickness. CONCLUSION: Needling techniques are promising adjuncts to non-atrophic scar management. Further research with long-term follow-up and comparative design protocols incorporating other resurfacing modalities is warranted before the exact value of needling is delineated in scar management protocols.

Intralesional excision as a surgical strategy to manage keloid scars: what's the evidence?

INTRODUCTION: Keloid scars are a particularly challenging clinical entity and a variety of management approaches have been described in the literature including intralesional surgery. The current literature lacks a summative review to ascertain the evidence base behind this surgical approach. METHODS: A comprehensive English literature database search was performed using PubMed Medline, EMBASE and Web of Science from their individual dates of inception to March 2018. We present the different rationales proposed for the use of this technique, the clinical outcomes reported in the literature as well as the scientific basis for intralesional excision of keloid scars. DISCUSSION: A number of arguments have been proposed to support intralesional excision including avoiding injury to neighbouring non-keloidal skin and the deep layer of the dermis, removal of the most proliferative fibroblastic group as well as debulking to facilitate the administration of injectable steroid. The most current literature does not provide sufficient support for the adoption of intralesional excisions based on data emerging from basic science as well as clinical outcome studies. CONCLUSION: Emerging evidence supports the extralesional excision of keloid scars based on current mechanobiological, histological as well as clinical outcome data. Further trials comparing extralesional and intralesional surgical practices are eagerly awaited to ascertain the role of intralesional excisions in the keloid management arena.

W-plasty in Scar Revision: Geometrical Considerations and Suggestions for Site-specific Design Modifications.

BACKGROUND: A large proportion of scars in clinical practice represent good candidates for surgical revision by virtue of their unfavorable characteristics and relative orientation with respect to skin relaxed tension lines. W-plasty is a very popular excisional revision technique, which involves breaking up the scar margins into small triangular components, which are advanced and interdigitated without any rotation or transposition. METHODS: We performed an extensive literature search using Pubmed MEDLINE, Web of Science, and Embase using the following keywords [W-plasty] AND [scar] AND [revision]. We retrieved 13 articles pertinent to the indications, geometrical design, and technical evolution of the W-plasty scar revision variants. We formulate indications for the use of isosceles/equilateral as opposed to scalene triangle W-plasty and integrate our experience with regards to the choice of geometrical design for different bodily regions. CONCLUSIONS: W-plasty represents a popular technique in reconstructive plastic surgery practice. We believe that the exact W-plasty design should be guided by the relaxed skin tension line definition and to this effect propose 2 main variants of geometrical design pertinent to the index anatomical site.

London calling Gaza: The role of international collaborations in the globalisation of postgraduate burn care education.

Burn injuries represent a significant epidemiological problem, with the vast majority occurring in low- to middle-income countries. These regions also represent areas where lack of socioeconomic growth and geopolitical instability pose additional barriers not only to healthcare provision but also to the acquisition of continuing professional development. Long-distance, web-based learning programmes ('tele-education') have been identified as a successful and powerful means of propagating up-to-date medical education and training in poor-resource, isolated or conflict-ridden regions. This report evaluates the role of tele-education in delivering a distance-learning Master's degree in Burn Care to a group of 11 healthcare professionals working in the occupied Palestinian territories (OPT), which was funded as part of a collaboration between Queen Mary University of London and IMET-Pal (International Medical Education Trust - Palestine). We present our experience in delivering the programme in a conflict-ridden part of the world, which includes the specific adaptations to tailor the programme to regional needs as well the unique challenges faced by students and faculty in enhancing the educational value of this unique initiative. The academic achievements of this group of healthcare professionals were found to be comparable to historical student cohorts from privileged socioeconomic backgrounds and the majority of students felt that participation in the programme contributed to a direct improvement to their daily burn care practices. The successful outcomes achieved by our students support the constantly emerging evidence that targeted, well-delivered, long-distance learning programmes can become powerful tools in combating inequalities in global healthcare and health education.

The evidence behind the use of platelet-rich plasma (PRP) in scar management: a literature review.

INTRODUCTION: Autologous platelet-based concentrates represent increasingly popular adjuncts to a variety of medical, surgical and aesthetic interventions. Their beneficial potential rests on the ability to deliver a high concentration of growth factors to the target tissues. There are currently no reports in the literature appraising the evidence behind the use of platelet-rich plasma (PRP) in scar management. METHODS: A detailed English literature review was conducted using PubMed Medline, Embase and Web of Science; the manuscripts were appraised and classified according to the Joanna Briggs Institute Levels of evidence. The results are presented in descending order of evidence separately for atrophic, keloid, surgical and traumatic scars. DISCUSSION: On the basis of level 1 evidence currently available, it appears that PRP can improve the quality of atrophic acne scars treated with ablative fractional CO2 laser and decrease the duration of laser-related side effects including oedema and erythema. Regarding surgical scars, the current data suggest that PRP may improve wound healing and early scar quality; furthermore, incorporation of PRP in fat-grafting procedures undertaken in conjunction with non-ablative, fractional laser can contribute to better wound healing as well as a significant improvement in texture, colour and contour in traumatic scar resurfacing. There are no high level studies at present to support the incorporation of autologous platelet-based concentrates in the management of keloid scars. CONCLUSION: PRP is a promising adjunct in scar management practice. Further research with long-term follow-up is warranted to delineate the value of this modality in different subtypes of scars.

Isotopic Split-skin Graft for Resurfacing of Deliberate Self-harm Scars.

We present a novel surgical approach for the revision of deliberate self-harm scars. The isotopic skin graft technique employs the harvest of a thin split-skin graft from the affected area, excision and closure of wide dermal scars with replacement of the graft back onto the harvest site. We present the sequential steps of the surgical technique and a case series of 2 patients treated with our novel approach.

Acute Acalculous Cholecystitis in Burns: A Review.

Acute acalculous cholecystitis (AAC) is an acute inflammatory disorder of the gallbladder, which can complicate the recovery of burn patients. No formal literature review has been performed about this uncommon but potentially fatal complication in burn care. A Pubmed search from 1950 to 2015 was performed using MESH terms: "acalculous cholecystitis," "burns or thermal injuries or thermal damage," and "cholecystitis or gallbladder inflammation." The articles were analyzed and data collected individually on the incidence, presenting symptoms or signs, risk factors, investigations, and treatment modalities used. An International Burns Injury Database (IBID) search was additionally performed to identify the incidence of AAC in burn patients between 2005 and 2015 in the United Kingdom. Nineteen articles were identified which described 90 cases of AAC and thermal injuries. The incidence of AAC in burns ranges between 0.4 and 3.5%, typically affecting males (82.4%) with a mean age of 35 (range 13-89), and 97.8% of burns were >30% total body surface area (range: 22-80%). The majority of patients had established known risk factors for acquiring AAC, including blood transfusion (56.6% of patients), sepsis (52.2%), mechanical ventilation (45.5%), prolonged fasting or total parenteral nutrition administration (44.4%), and use of narcotic medication (10%). The IBID search identified one case of AAC among 145,227 burn injuries during 2005 to 2015 in the United Kingdom. AAC is a rare life-threatening condition that is associated with large thermal burns. Improvements in burns critical care have probably improved the management of known risk factors and reduced the incidence of this condition over recent decades.

Burns education: The emerging role of simulation for training healthcare professionals.

Burns education appears to be under-represented in UK undergraduate curricula. However current postgraduate courses in burns education provide formal training in resuscitation and management. Simulation has proven to be a powerful modality to advance surgical training in both technical and non-technical skills. We present a literature review that summarises the format of current burns education, and provides detailed insight into historic, current and novel advances in burns simulation for both technical and non-technical skills, that can be used to augment surgical training. Addressing the economic and practical limitations of current immersive surgical simulation is important, and this review proposes future directions for integration of innovative simulation strategies into training curricula.

Steroid tape: A promising adjunct to scar management.

INTRODUCTION: Intralesional steroid administration is a popular adjunct to scar management with numerous reports in the literature appraising this modality in hypertrophic and keloid scars. The percutaneous delivery of steroids using adhesive tape is an alternative modality, which was first described in the dermatological literature in the 1960s. It is infrequently used in most countries apart from the Orient, where it represents one of the mainstays of specialist scar management protocols. METHODS: An English and Japanese literature review was performed and reports were stratified using the Joanna Briggs Institute Levels of Evidence. Data were extracted relating to the maximum dose of steroid that can be delivered safely, the reported therapeutic efficacy, as well as the side effects associated with the percutaneous delivery of steroids. DISCUSSION: Steroid tape has the potential to be a safe and patient-friendly adjunct to scar management for carefully selected cases of keloid and hypertrophic scars. The main limitation for its widespread adoption is the lack of data to enable the determination of safe exposure thresholds in adult and paediatric patients. CONCLUSION: Despite the existing encouraging reports regarding the potential to be a useful adjunct in scar management, steroid tape is not widely used apart from a limited number of scar services worldwide. Further research is warranted to delineate the role of this modality in specialist scar management protocols.

Brachytherapy in the adjuvant management of keloid scars: literature review.

INTRODUCTION: Radiation therapy is a well-recognised modality for the adjuvant treatment of keloid scars. It can be conventionally delivered as external beam using a large apparatus at a distance from the lesion or as brachytherapy with specialised equipment to enable the delivery of treatment in the immediate vicinity of the keloidal tissue. METHODS: An English literature review was performed with keywords 'brachytherapy' and 'keloid' using the databases PubMed, Embase and Web of Science from their individual dates of inception until June 2017. Studies pertinent to the field are presented in a chronological manner to depict the evolution of different brachytherapy strategies over the last decades. We also discuss considerations relating to the risk of secondary carcinogenesis, which are relevant to shared decision-making in the clinical setting. DISCUSSION: Low dose rate interstitial brachytherapy was first introduced in the English literature in 1976 and currently appears to have been superseded by more modern approaches, including high dose rate interstitial brachytherapy. This modality compares favourably to more traditional modes of radiotherapy in terms of recurrence as well as rates of symptomatic relief from keloidal symptoms. Superficial brachytherapy was introduced more recently in the relevant literature and appears to be associated with favourable therapeutic outcomes compared to external beam radiation therapy. CONCLUSION: Brachytherapy is a valid modality of radiotherapy for the adjuvant treatment of keloid scars, with high dose rate interstitial and surface regimens gaining in popularity over recent years. Further research needs to focus on randomised controlled trials to further establish the role of different radiotherapy modalities in keloid scar management.

Diabetes mellitus and burns. Part II-outcomes from burn injuries and future directions.

Diabetes mellitus is an increasingly prevalent comorbidity in patients presenting to burn facilities. Diabetic patients tend to be older and present in a delayed manner with deeper injuries predominantly affecting the lower limb. Morbidity from burns is higher in this cohort including a longer length of hospital stay, greater need for surgical interventions and increased rate of infective complications. Nevertheless, there seems to be little effect of diabetes on associated mortality. The second part of this review article concentrates on the epidemiological profile of diabetic burn patients and the effect of the disease on morbidity and mortality. In addition, we present a review of therapeutic adjuncts, which may hold promise for the future management of this cohort of burn patients.

Diabetes mellitus and burns. Part I-basic science and implications for management.

The number of diabetic patients presenting to burn services is predicted to increase significantly over the next decades. Diabetes mellitus represents an independent risk factor for sustaining burn injuries and mediates alterations to key physiological systems including the vascular, renal, nervous, gastrointestinal and immune system. The effects of the pathophysiological permutations need to be carefully considered during both the acute as well as the long-term rehabilitation phase of injury. The purpose of the first part of this review is to outline the metabolic permutations observed in diabetes mellitus pertinent to the clinical presentation and management of burn patients.

Sexual Function Following Burn Injuries: Literature Review.

Sexual function is a profound facet of the human personality. Burns due their sudden and devastating nature can have longstanding effects on intimate function by virtue of physical sequelae as well as alterations in body image and perceived desirability. A considerable number of patients encounter problems with intimate function in burns rehabilitation; nevertheless, the topic appears to be poorly addressed in specialist centers worldwide. Review of the literature suggests that a number of parameters can affect the quality of sexual life following burn injuries including age at the time of injury, location, and severity of the burn as well as coping mechanisms employed by the individual survivor. Addressing issues of intimacy relies on awareness, education, and a holistic approach on behalf of the multidisciplinary team members and, to this effect, recommendations are made on managing sexual function concerns in burns rehabilitation.

Nutritional care of the obese adult burn patient: a U.K. Survey and literature review.

Obesity is an emerging healthcare problem and affects an increasing number of burn patients worldwide. An email survey questionnaire was constructed and distributed among the 16 U.K. burn services providing adult inpatient facilities to investigate nutritional practices in obese thermally injured patients. Responses received from all dieticians invited to participate in the study were analyzed, and a relevant literature review of key aspects of nutritional care is presented. The majority of services believe that obese patients warrant a different nutritional approach with specific emphasis to avoid overfeeding. The most common algebraic formulae used to calculate calorific requirements include the Schofield, Henry, and modified Penn State equations. Indirect calorimetry despite being considered the "criterion standard" tool to calculate energy requirements is not currently used by any of the U.K. burn services. Gastric/enteral nutrition is initiated within 24 hours of admission in the services surveyed, and a variety of different practices were noted in terms of fasting protocols before procedures requiring general anesthesia/sedation. Hypocaloric regimens for obese patients are not supported by the majority of U.K. facilities, given the limited evidence base supporting their use. The results of this survey outline the wide diversity of dietetic practices adopted in the care of obese burn patients and reveal the need for further study to determine optimal nutritional strategies.

Neuropathic mechanisms in the pathophysiology of burns pruritus: redefining directions for therapy and research.

Pruritus in burn wounds is a common symptom affecting patient rehabilitation. Over the last decades, there has been a resurgence of interest into more effective strategies to combat this distressing problem; nevertheless, no reports exist in the literature to propose pathophysiological mechanisms responsible for the generation and persistence of pruritic symptoms in the late phases of burns rehabilitation. Neuronal pathways mediating pruritic and painful stimuli share striking similarities, which allows the comparative exploration of the less extensively studied pruritic mechanisms using pain models. Furthermore, emerging anatomical, neurophysiological, and pharmacological evidence supports the involvement of neuropathic mechanisms in chronic burns pruritus. This work updates the conceptual framework for the pathophysiology of burns itch by embracing the contribution of the central nervous system in the maintenance of symptoms into a chronic state. The proposed pathophysiological model paves new avenues in burns pruritus research and is likely to have implications in the quest for more effective therapeutic regimens in clinical practice.

Obesity and burns.

The population of overweight patients presenting to burn facilities is expected to increase significantly over the next decades due to the global epidemic of obesity. Excess adiposity mediates alterations to key physiological responses and poses challenges to the optimal management of burns. The purpose of this study is to document the general epidemiological aspects of thermal injuries in the obese population, outline relevant physiological aspects associated with obesity, and draw attention to topics relating to the management, rehabilitation, and prognosis of burns in this emerging subpopulation of patients.

Reconstruction of the burnt perionychium: literature review and treatment algorithm.

Nail apparatus deformities associated with burn injuries can cause significant functional and aesthetic concerns. The majority of perionychial deformities result from eponychial retraction and scarring, whereas a minority are due to direct damage to the regenerative part of the nail complex. A variety of different techniques have been described for reconstruction including the use of local flaps, skin/composite grafts, and microvascular transfer. The authors review the different strategies available in the current burns literature and present an algorithm for the management of perionychial burn deformities.