A simple mnemonic, B.U.R.N.S., for burns first aid.

INTRODUCTION: Burn injuries remain common in the world, with an average of more than thousands of cases requiring medical attention each year. Singapore sees an average of 220 burns admissions annually. Given the high number of burn cases in Singapore, the authors identified that there is a need for more public awareness on first aid burn treatment. Acute management of burns can improve eventual patient outcome. The authors devised a simple mnemonic that can be used in burns education for first aid treatment, intended to be taught to trained personnel, who will have the first contact with these burn patients. The aim of the study was to assess the viability of implementing this mnemonic, B.U.R.N.S, to facilitate first aid education for burns. MATERIAL AND METHODS: In this study, we presented this mnemonic as a poster to 30 full-time burn care medical professionals. Feedback was then obtained from this group of medical professionals and used to revise the mnemonic. The mnemonic was then subsequently taught to 400 medical professionals, who are predominantly involved in the pre-hospital management of burns. They are then asked to reiterate the mnemonic to test the ease of remembering the mnemonic. Objective feedback was obtained with a 5-point scoring system. RESULTS: The results indicated a significant improvement in burn first aid knowledge after the implementation of the mnemonic, from a score of 3.67-4.77, The content was deemed as appropriate and easy to understand and recall, and participants were able to reiterate the content, and will recommend this mnemonic to be used for burns teaching for first aid. CONCLUSION: The study results suggest that this B.U.R.N.S. mnemonic and visual aid is simple and easy to apply, especially for uniformed personnel, as these individuals may have the first contact with the burns victims, and it is important for them to render the appropriate burns first aid treatment. Overall, burns first aid awareness and education can be improved with the implementation of this mnemonic and poster. Moving forward, we aim to integrate the B.U.R.N.S. into educational programmes in professional institutions involved in responding to burns (medical and nursing schools of Singapore), as well as in schools and public institutions, for educational purpose to raise public awareness. We wish to also be able to do so on an international level when courses are conducted.

Connexin 43 upregulation in burns promotes burn conversion through spread of apoptotic death signals.

BACKGROUND: Burn wounds continue to worsen after initial injury in a process known as burn conversion, which lasts about 3-5 days. It causes burn wounds to enlarge and deepen, leading to greater morbidity. Apoptosis is one of the factors contributing to the conversion of the zone of stasis into the zone of coagulation. Suppression of apoptosis has been associated with reducing burn conversion. Connexin 43 (Cx43) gap junctions facilitate the spread of apoptotic signals from dying cells to healthy neighbouring cells in injured tissues through the bystander effect. OBJECTIVES: The study is to understand the role of Cx43 in burn conversion. METHODS: In our study, 15 burn tissue samples were arranged into three groups as early (beginning of burn conversion), intermediate (extensive burn conversion) and late (established burn conversion) burns. RESULTS: We found a striking increase in the amount of Cx43 protein expressed in the dermal fibroblasts (identified with heat shock protein 47 (HSP47) staining) in the zone of stasis in early and intermediate burns. These dermal fibroblasts also express high levels of cleaved-Caspase 3 indicating on-going apoptosis. CONCLUSIONS: Our findings suggest that elevation of Cx43 may play an active role in burn conversion spreading apoptosis in the early and intermediate burn wound.

Biomechanical comparison of monocortical and bicortical plate fixation for rib fractures in a cadaveric model using a locking plate system.

BACKGROUND: Surgical stabilization of rib fractures is an established form of treatment for complex rib fractures. Plate fixation with bicortical screws placement can cause injury to intra-thoracic organs and pleural irritation from protruding screw tips. The aim of this study is to compare the biomechanical properties of monocortical and bicortical plate fixation for rib fractures using a locking plate system. METHODS: Ten pairs of fresh-frozen cadaveric ribs were harvested. Native ribs were mounted onto a biomechanical tester and statically loaded to failure to induce a rib fracture. The native stiffness of the rib was measured. Next, the ribs were stabilized using the Synthes MatrixRIB (Johnson & Johnson, USA) locking plate. Left-sided ribs were fixed in a bicortical manner and right-sided ribs were fixed in a monocortical manner. The repaired ribs were subjected to cyclic loading of 50,000 cycles between 2 to 6 N to simulate physiological respiration, followed by static loading at a rate of 10 N/min until failure. The pre and post-repaired stiffness were measured. A high-speed camera was used to record the mechanism of failure. RESULTS: One left-sided rib was omitted from the study because the fracture occurred at the drill hole site. Left-sided ribs demonstrated a mean native stiffness of 10.0 N/mm (SD 3.71) and right-sided 11.92 N/mm (SD 3.57). After plate fixation, pre and post cyclic stiffness was 3.32 N/mm (SD 1.21) and 4.41 N/mm (SD 3.29) for the bicortical group; 3.14 N/mm (SD 1.24) and 3.91 N/mm (SD 1.98) for the monocortical group. There is no statistical difference found between the two groups (P=0.872). CONCLUSIONS: Our results show that there is no difference in stability between monocortical and bicortical fixation for rib fractures using a locking plate system. Monocortical fixation is recommended to avoid potential complications.

Large animal models for long-segment tracheal reconstruction: a systematic review.

BACKGROUND: The reconstruction of extensive tracheal defects is an unresolved problem. Despite decades of research, a reliable and practical substitute remains to be found. While there have been clinical reports of successful long-segment tracheal reconstruction, reproducibility and widespread applicability of these techniques have yet to be achieved. Large animals such as the dog, pig, sheep, and goat have comparable tracheal morphology and physiology to humans making them useful preclinical models to screen potential therapeutic strategies. MATERIALS AND METHODS: The literature was reviewed to identify large animal models commonly used for tracheal reconstruction. A systematic search of PubMed and EMBASE was performed for large animal studies reporting on the reconstruction of long-segment tracheal and carinal defects. Fifty-seven studies were identified for analysis. RESULTS: There is no standard large animal model available for tracheal research. In recent years, livestock species have gained favor over dogs as animal models in this field. The minimum requirements for successful tracheal replacement are rigidity, vascularity, and epithelial lining. Early attempts with synthetic prostheses were met with disappointing results. An autologous tracheal substitute is ideal but hindered by limited donor site availability and the lack of a dominant vascular pedicle for microsurgical reconstruction. Although tracheal allotransplantation enables like-for-like replacement, there are unresolved issues relating to graft vascularity, immunosuppression, and graft preservation. Tissue engineering holds great promise; however, the optimal combination of scaffold, cells, and culture conditions is still indeterminate. CONCLUSIONS: Despite impressive advances in tracheal reconstruction, a durable substitute for extended tracheal defects continues to be elusive.

Reduction mammoplasty as a treatment for symptomatic central venous stenosis.

Central venous stenosis is a rare cause of unilateral breast edema occurring in hemodialysis patients that needs to be differentiated from other differential diagnoses, including, but not limited to, inflammatory breast carcinoma, mastitis, lymphedema, and congestive heart failure. All reports of similar cases in the available literature have described improvement or resolution of the edema after treatment. Herein, we report and discuss the pathophysiology of breast edema formation in a patient who presented with massive left-sided breast edema 7 years after being diagnosed with central venous stenosis. Medical and minimally invasive therapy had not been successful, so she underwent reduction mammoplasty to relieve the symptoms.

Precise breast implant placement using percutaneous chest wall markings.

BACKGROUND: Traditionally, pre-operative breast markings are usually made using an indelible marker. These markings are at risk of being removed by pre-operative cleaning, positional changes and parenchymal changes post-incision. We present our approach to breast surgery with rib or intercostal markings using methylene blue. METHODS: Using an indelible marker, markings are made on the breast and the inframammary crease. A blue needle (23 G) mounted on a 1 ml syringe is prepared, and aliquots of 0.1 ml of methylene blue are injected. Excessive infiltration and pre-operative local anaesthetic infiltration result in diffusion of the dye and difficulty with accuracy. Dye is injected directly over the bony periosteum closest to the inframammary fold. RESULTS: We achieved good symmetry of bilateral breast implants. Photographs were taken pre-operative and 3 months post-operative and were evaluated independently by medical officers. All results were rated as good or very good. We had 39 patients and follow-up was between 3 and 24 months. There were no implant-related complications. CONCLUSIONS: For accurate implant placement, a fixed position must be found. Our technique utilises the relative immobility of the ribs for accurate implant placement. Disadvantages to our method were few, and we had two cases of dizziness or patients feeling faint due to pain. There is also a potential allergic or anaphylaxis reaction, but we did not experience any allergic reaction.

Aesthetic and Non-aesthetic Indications for Orbicularis Oculi Myectomy.

INTRODUCTION: Crows' feet wrinkles are caused by the action of the orbicularis oculi muscle on overlying skin. Treatment options range from botulinum toxin to a multitude of surgical methods. We first described our technique in 2003 and refined it in 2006. We highlight the evolution of our technique and look at our results to assess the effectiveness of our technique. OBJECTIVE: The aim of this article is to show our experience of 13 years in 134 patients with our technique of orbicularis oculi myectomy. METHODS: From September 2000 to July 2013, we operated on 134 patients with an age range of 28-77 years. Of these patients, 104 had myectomies via lifting and 22 via a blepharoplasty approach. Five patients had myectomies for treatment of blepharospasm and a further three patients to restore symmetry in facial palsy. An evaluation of the results was performed by two medical students. RESULTS: Our results showed reduction of the wrinkles in all cases. For the statistical analysis the Wilcoxon test was performed. The p value was less than 0.001 showing a significant reduction of crows' feet wrinkles in both sides when the orbicularis myectomy was performed, via blepharoplasty or lifting. For myectomy performed for blepharospasm or facial palsy, the statistical analysis was not done due to the low numbers. CONCLUSION: In the appropriate patient, orbicularis oculi myectomy is an effective and long-term treatment for crows' feet wrinkles with a low risk of complications and high patient satisfaction. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Facial reanimation utilizing combined orthodromic temporalis muscle flap and end-to-side cross-face nerve grafts.

BACKGROUND: Individuals with facial paralysis of 6 months or more without evidence of clinical or electromyographic improvement have been successfully reanimated utilizing an orthodromic temporalis transfer in conjunction with end-to-side cross-face nerve grafts. The temporalis muscle insertion is released from the coronoid process of the mandible and sutured to a fascia lata graft that is secured distally to the commissure and paralyzed hemilip. The orthodromic transfer of the temporalis muscle overcomes the concave temporal deformity and zygomatic fullness produced by the turning down of the central third of the muscle (Gillies procedure) while yielding stronger muscle contraction and a more symmetric smile. The muscle flap is combined with cross-face sural nerve grafts utilizing end-to-side neurorrhaphies to import myelinated motor fibers to the paralyzed muscles of facial expression in the midface and perioral region. Cross-face nerve grafting provides the potential for true spontaneous facial motion. We feel that the synergy created by the combination of techniques can perhaps produce a more symmetrical and synchronized smile than either procedure in isolation. METHODS: Nineteen patients underwent an orthodromic temporalis muscle flap in conjunction with cross-face (buccal-buccal with end-to-side neurorrhaphy) nerve grafts. To evaluate the symmetry of the smile, we measured the length of the two hemilips (normal and affected) using the CorelDRAW X3 software. Measurements were obtained in the pre- and postoperative period and compared for symmetry. RESULTS: There was significant improvement in smile symmetry in 89.5 % of patients. CONCLUSION: Orthodromic temporalis muscle transfer in conjunction with cross face nerve grafts creates a synergistic effect frequently producing an aesthetic, symmetric smile. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors at www.springer.com/00266 .

Effect of negative-pressure wound therapy on open fractures of the lower limb.

INTRODUCTION: Early debridement and coverage has long been regarded as the standard of care for open fractures of the lower limb, as infection is a serious complication. However, the best time for wound closure remains controversial. Negative-pressure wound therapy (NPWT) is thought to result in reduced flap infection and failure. To determine the effect of NPWT, we reviewed patients with open fractures of the lower limb and compared the rates of infection and flap failure in two time-based cohorts. METHODS: Two cohorts of patients (periods 2003-2004 and 2008-2009) with Gustilo type IIIB open tibial fractures were recruited and their outcomes were compared. In the 2003-2004 cohort, wounds were dressed with occlusive dressing. In the 2008-2009 cohort, all patients underwent NPWT. Data was retrospectively analysed with regard to infection, failure, age, type of flap, comorbidities and defect size. The incidences of infection and flap failure were further analysed for any statistical difference between the different treatment protocols. RESULTS: In the 2003-2004 cohort, 33% of patients developed infection and 11% had flap failure. However, in the 2008-2009 cohort, 10% of patients developed infection and 6% had flap failure. The difference in the incidence of infection was statistically significant between the two cohorts (p = 0.029). CONCLUSION: Patients in the 2008-2009 cohort had better outcomes, and we are of the opinion that performing NPWT may have contributed to this result.

Sternoclavicular joint infection: classification of resection defects and reconstructive algorithm.

BACKGROUND: Aggressive treatment of sternoclavicular joint (SCJ) infection involves systemic antibiotics, surgical drainage and resection if indicated. The purpose of this paper is to describe a classification of post resectional SCJ defects and highlight our reconstructive algorithm. Defects were classified into A, where closure was possible often with the aid of topical negative pressure dressing; B, where parts of the manubrium, calvicular head, and first rib were excised; and C, where both clavicular, first ribs and most of the manubrium were resected. METHODS: Twelve patients (age range, 42 to 72 years) over the last 8 years underwent reconstruction after SCJ infection. There was 1 case of a type A defect, 10 type B defects, and 1 type C defect. Reconstruction was performed using the pectoralis major flap in 6 cases (50%), the latissimus dorsi flap in 4 cases (33%), secondary closure in 1 case and; the latissimus and the rectus flap in 1 case. RESULTS: All wounds healed uneventfully with no flap failure. Nine patients had good shoulder motion. Three patients with extensive clavicular resection had restricted shoulder abduction and were unable to abduct their arm past 90°. Internal and external rotation were not affected. CONCLUSIONS: WE HIGHLIGHT OUR RECONSTRUCTIVE ALGORITHM WHICH IS SUMMARISED AS FOLLOWS: for an isolated type B SCJ defect we recommend the ipsilateral pectoralis major muscle for closure. For a type C bilateral defect, we suggest the latissimum dorsi flap. In cases of extensive infection where the thoracoacromial and internal mammary vessels are thrombosed, the pectoralis major and rectus abdominus cannot be used; and the latissimus dorsi flap is chosen.

Preferred use of the ipsilateral pedicled TRAM flap for immediate breast reconstruction: an illustrated approach.

BACKGROUND: Recent experience with the ipsilateral TRAM flap has shown that it has the advantage of a longer functional pedicle length, which allows tension-free inset of well-vascularized tissue into the breast pocket. This leads to better positioning and shaping of the reconstructed breast with minimal disruption of the inframammary fold. The purpose of this article was to provide an illustrated approach to the ipsilateral TRAM flap and to clarify the technique when applied in the context of immediate breast reconstruction following cancer extirpation. METHODS: A prospective evaluation of 89 patients who underwent immediate breast reconstruction following skin-sparing mastectomy for breast cancer was performed. All patients underwent ipsilateral TRAM reconstruction. The innate insetting advantage of the ipsilateral TRAM flap is illustrated in the article. The key steps of the technique were as follows: (1) The ipsilateral corner of the flap was used as the axillary tail, leaving the more bulky part to form the main body of the breast; (2) To avoid undesirable twists, a right TRAM was rotated clockwise so that its apex points superiorly; (3) This flap was subsequently tunneled into the breast pocket while preserving the inframammary fold. The opposite maneuvers were done for the left side; (4) If the flap was congested, venous augmentation was performed where the tributary of the axillary vein or the thoracodorsal vein was anastomosed with the inferior epigastric vein from the flap with an interposed vein graft (17% of cases). RESULTS: All flaps survived and flap-related complications included partial necrosis of tissue across the midline (2.2%), palpable fat necrosis (22%), and hematoma requiring drainage (2.2%). All flaps were raised concurrent with the resection, and the combined operative time ranged from 3.5 to 6 h, with a mean hospital stay of 7 days. CONCLUSION: The ipsilateral TRAM flap was a reliable flap with low complication rates and short surgery time. It was our preferred choice for pedicled breast reconstruction in all cases, except for the ptotic breast or if abdominal scarring excludes its use.

A multi-staged approach to the reconstruction of a burnt Asian face.

This article describes the management of chemical burns to the Asian face with resultant full thickness loss to the right side of the face including the eyelid and nose. We detail the techniques used to reconstruct the face which include skin grafting according to the aesthetic units of the face, accurate placement of junction lines, use of a chondrocutaneous graft to reconstruct the alar grove and scalp strip grafting for eyebrow reconstruction. We obtained a successful result that minimised scar formation in the burnt Asian face.

A unique presentation of epignathus.

Palatal clefts in conjunction with space-occupying lesions of the oral or nasal cavities are of interest because they may represent a developmental etiology of palatal clefts. Epignathus is a rare space-occupying tumor of the nasopharynx that can arise from the upper jaw, palate, and sphenoid. It can protrude through the mouth, causing respiratory embarrassment and death. The pathogenesis of epignathus is unknown, but several theories have been proposed. Management depends on the size of the tumor and requires a multidisciplinary approach.