Augmented Reality-Assisted Design of Local Flaps: A New Practical and Educational Tool in the Field of Plastic Surgery.

ABSTRACT: Augmented reality (AR) is a new and promising technology that has been incorporated into several aspects of our everyday life, including surgery. Examples of its application throughout various fields of surgery, although most of them are in experimental stage, have already been demonstrated and published. In this article, we describe the utilization of AR to design effectively and accurately surgical flap markings just with the help of an AR-compatible mobile phone and a low-cost application. We believe that, due to its ease of use, AR will play a pivotal role to the education and the training in the field of plastic surgery and burns, and other surgical specialties alike.

Geometry and design of a rhomboid flap.

The rhomboid flap is a versatile random-pattern transposition flap with many clinical applications and has been adapted in many variations. The rhombic area of excision is associated with an area of "waste", while adapting Quaba's "square peg into a round hole" design is associated with the "pin-cushioning" effect. Using trigonometric calculations, we outline the association between different rhombic areas of excision and "waste", and a method to design a classical Limberg rhomboid flap.

Compartment Syndrome of the Forearm Following Dermofasciectomy-A Rare and Devastating Complication.

We present a case of compartment syndrome of the forearm following harvesting of a full thickness skin graft from the medial forearm for a double digit dermofasciectomy. The patient underwent forearm fasciectomy followed by multiple surgical debridements. At 18 months, despite intensive physiotherapy, the patient was left with a very significant residual functional deficit. This case highlights a previously undescribed but devastating complication of closure of a forearm skin graft donor site.

E-cigarette burn injuries: Comprehensive review and management guidelines proposal.

INTRODUCTION: Electronic cigarettes (EC) have been reported to be associated with burns secondary to explosions of the device or battery, or contact from overheating, resulting in flame, contact or chemical burns. In addition to this, there have also been reported cases of soft tissue and bony trauma with or without associated burns. Using collective evidence, this review aims to summarise all reported burns associated with ECs, and its implications on immediate management with a particular focus on surgical treatment. METHODS: A search was conducted on PubMed, EMBASE and Medline for all case reports, case series and letters to editors published since 2014, using terms "electronic cigarette", "e-cigarette", "vaping" and "burn". The search was repeated by the co-author to avoid bias and a review of the bibliographies of each paper was conducted to ensure all relevant cases were included. The mechanisms, type and severity of burn injury, and management and treatment outcomes of the patients were recorded. Exclusion criteria included non-English articles, explosions with no associated burn and publications with insufficient information. RESULTS: 90 patients from 19 case series or case reports were included. With the exception of one study, gender was recorded with a male predominance (95.6%). Mean age is 30.1years (range 18-59). The most common type of burn was flame. However, there were reports of chemical burns associated with ECs. The mean total body surface area (TBSA) affected was 4.9% (range 1-27.25%) with the majority of burns being mixed partial and full thickness. 22 patients underwent excision and autologous skin grafting within range of three to 21days. One patient had a full thickness contact burn excised and closed, one patient received a xenograft following debridement and one had biosynthetic skin dressing. 42 patients were managed conservatively with dressings or ointments. DISCUSSION: In this review over a three-year period (2015-2017), 90 cases of EC related burn injuries were reported, however, this is likely an underestimation of the problem. The suggested mechanism for EC related injuries is battery malfunction. ECs are powered by Lithium ion batteries which are susceptible to "thermal runaway" reactions, which result in device overheating with potential for subsequent explosion. We explain hypothesized triggers for these reactions and mechanisms of other injuries associated with ECs such as chemical burns and blast injury. CONCLUSION: EC-associated burn injury results in combined thermal and chemical burns, which should be managed in tandem. Explosion injuries sustained whilst using the device may result in both facial trauma or inhalation injury and therefore should be reviewed with a high index of clinical suspicion. It is noted that there is no agreed standard for management for such burns by specialist bodies in the UK. We suggested a treatment algorithm to provide guidance for the burn injuries associated with ECs.

Deliberate self-harm scars: Review of the current literature.

INTRODUCTION: Deliberate self-harm (DSH) can be defined as self-inflicted injury without suicidal intent. Treatment of DSH scars may involve a lengthy process and is not commonly treated in its initial stages to allow scar maturation. This review aims to assess the challenges behind scar treatment and outcomes of different surgical methods used to resurface DSH scars. METHODS: A review of the literature using CENTRAL, Cochrane, Medline and Embase from January 1990 to February 2016 was conducted. Our search strategy incorporated a combination of MeSH terms "Deliberate self-harm scars" and "self-inflicted scars". Relevant bibliographies of literature were manually reviewed for additional resources. Non-English studies, non-human studies and studies prior to 1990 were excluded. RESULTS: A variety of techniques were described with including excision and full thickness skin graft reconstruction, excision with Integra resurfacing followed by split-thickness skin graft reconstruction, multiple excisions and laser therapy. A detailed summary of these findings is outlined. All studies reviewed show improved cosmetic outcome in treatment of DSH scars to some degree and no studies reported repeated self-harm. DISCUSSION: The literature surrounding the treatment of DSH scars is limited. There is a lack of use of reproducible and standardized scoring systems to compare between studies. The psychology behind DSH and their resultant scars adds another dimension of complexity beyond simple scar reconstruction. CONCLUSION: When considering treatment, patient expectations must be carefully evaluated. Research in this area is lacking but understandable due to the nature of the self-harm.

Two Interesting Cases of Meralgia Paraesthetica.

Meralgia paraesthetica (MP) is a condition originally described by Bernhardt in 1878 and was eventually named by Roth in 1895. It is caused by compression of the lateral femoral cutaneous nerve (LFCN) resulting in varying types of discomfort. Severity of the symptoms can range from mildly uncomfortable to painfully disabling. In this article we discuss 2 patients with a LFCN injury occurring as a result of laparoscopic ventral rectopexy (LVR). The first patient is a 46-year-old female who reported pain and dysesthesia in the left groin and the anterolateral thigh, 2 days post LCR. A conservative approach was taken and at the 6-month follow-up the symptoms had resolved. The second patient is a 51-year-old female who reported increased sensitivity to bed sheets over the anterolateral aspect of her left thigh, in the immediate post-operative period following LVR. She was similarly managed conservatively but her symptoms persisted. The LFCN arises from the dorsal branches of the second and third lumbar roots. It crosses the iliacus muscle deep to the fascia. Injury or entrapment to surrounding neural structures including the LFCN, commonly results following common laparoscopic procedures. In some cases, additional surgical intervention is required for successful management of the symptoms. In our patients, the MP syndrome was clearly related to the operation because symptoms appeared in the immediate post-operative period and were not present beforehand. LVR is a relatively new and evolving procedure with few reports of associated peri-operative complications.Key words: Meralgia paraesthetica, laparoscopy, rectopexy, lateral femoral cutaneous nerve.

Reversed palmaris longus muscle: a report of two cases.

The palmaris longus muscle is the most superficial muscle of the volar forearm which demonstrates significant anatomical variance. A reversed palmaris longus muscle is one such variant. Here we discuss two cases in which reversed palmaris longus was postulated as a cause of wrist discomfort.

Severe acute pancreatitis: pathogenesis, diagnosis and surgical management.

BACKGROUND: Severe acute pancreatitis is a subtype of acute pancreatitis, associated with multiple organ failure and systemic inflammatory response syndrome. In this qualitative review we looked at the principles of pathogenesis, classification and surgical management of severe acute pancreatitis. We also looked at the current shift in paradigm in the management of severe acute pancreatitis since the guideline developed by the British Society of Gastroenterology. DATA SOURCES: Studies published between 1st January 1991 and 31st December 2015 were identified with PubMed, MEDLINE, EMBASE and Google Scholar online search engines using the following Medical Subject Headings: "acute pancreatitis, necrosis, mortality, pathogenesis, incidence" and the terms "open necrosectomy and minimally invasive necrosectomy". The National Institute of Clinical Excellence (NICE) Guidelines were also included in our study. Inclusion criteria for our clinical review included established guidelines, randomized controlled trials and non-randomized controlled trials with a follow-up duration of more than 6 weeks. RESULTS: The incidence of severe acute pancreatitis within the UK is significantly rising and pathogenetic theories are still controversial. In developed countries, the most common cause is biliary calculi. The British Society of Gastroenterology, acknowledges the Revised Atlanta criteria for prediction of severity. A newer Determinant-based system has been developed. The principle of surgical management of acute necrotizing pancreatitis requires intensive care management, identifying infection and if indicated, debridement of any infected necrotic area. The current procedures opted for include standard surgical open necrosectomy, endoscopic necrosectomy and minimally invasive necrosectomy. The current paradigm is shifting towards a step-up approach. CONCLUSIONS: Severe acute pancreatitis is still a subject of grey areas in its surgical management even though new studies have been recorded since the origin of the latest UK guidelines for management of severe acute pancreatitis.

The Use of Chemotherapeutics for the Treatment of Keloid Scars.

Keloid scars are pathological scars, which develop as a result of exaggerated dermal tissue proliferation following cutaneous injury and often cause physical, psychological and cosmetic problems. Various theories regarding keloidogenesis exist, however the precise pathophysiological events remain unclear. Many different treatment modalities have been implicated in their management, but currently there is no entirely satisfactory method for treating all keloid lesions. We review a number of different chemotherapeutic agents which have been proposed for the treatment of keloid and hypertrophic scars while giving insight into some of the novel chemotherapeutic drugs which are currently being investigated. Non-randomized trials evaluating the influence of different chemotherapeutic agents, such as 5-fluorouracil (5-FU); mitomycin C; bleomycin and steroid injection, either alone or in combination with other chemotherapeutic agents or alternative treatment modalities, for the treatment of keloids were identified using a predefined PubMed search strategy. Twenty seven papers were identified. Scar improvement ≥50% was found in the majority of cases treated with 5-FU, with similar results found for mitomycin C, bleomycin and steroid injection. Combined intralesional 5-FU and steroid injection produced statistically significant improvements when compared to monotherapy. Monotherapy recurrence rates ranged from 0-47% for 5-FU, 0-15% for bleomycin and 0-50% for steroid injection. However, combined therapy in the form of surgical excision and adjuvant 5-FU or steroid injections demonstrated lower recurrence rates; 19% and 6% respectively. Currently, most of the literature supports the use of combination therapy (usually surgery and adjuvant chemotherapy) as the mainstay treatment of keloids, however further investigation is necessary to determine success rates over longer time frames. Furthermore, there is the potential for novel therapies, but further investigation is required to elucidate their true efficacy.

Surgical management of idiopathic torticollis secondary to a fibrotic band.

Congenital muscular torticollis (CMT) is the third commonest congenital deformity, commonly presenting in the first week of life. Due to contracture and shortening of the sternocleidomastoid muscle, the head is tilted towards the affected side; however there may also be a varying degree of rotation towards the contralateral side. Most infants with CMT can be managed non-surgically, however if this is unsuccessful surgery may be necessary, with many different techniques described. In this case report, we describe a 17-year old woman with persistent left sided CMT despite botulinum toxin paralysis that was successfully treated with surgery.