The impact of pre-existing venous pathology on lower limb free flap reconstruction and the role of preoperative screening: a systematic review.

Lower limb reconstruction is performed to replace like with like and achieve tissue durability. Free flaps are a method of reconstruction commonly used to manage cases of lower limb deficits. However, the failure rate is 8.5%, with venous thrombosis and congestion playing a significant role. Despite this, preoperative venous mapping of recipient site before free flap reconstruction is not routinely practiced, often resulting in pathologies remaining unidentified until the intraoperative stage. The aim of the review was to evaluate the existing literature on the topic of lower limb preoperative venous assessment, screening, and its effect on lower limb free flap survival. Five different databases were searched from their inception to August 2021. The search terms and included studies were independently reviewed by two investigators for their eligibility. Eleven articles were eligible for inclusion, with a combined patient population of 99, and 107 flaps were identified to have lower limb pathology at the donor or recipient vein. Venous pathology was detected preoperatively in 69 veins using ultrasound duplex scanning and computed tomography angiography; of them, 3 (4.34%) resulted in failure. In comparison, 38 veins were diagnosed with venous pathology intraoperatively; of them, 5 (13.85%) failed. The studies evaluated in this review demonstrated that preoperative screening for venous pathology showed a higher flap survival rate. It can therefore be inferred that developing a standardized preoperative process for identifying venous issues in lower limb free flap reconstruction may improve outcomes. This can be explored in future research, with a focus on assessing the validity and efficacy of such screening tools, and their role in the management of patients identified with venous pathology.

Rapidly evolving gangrenous vasculitis in a critically ill patient with ulcerative colitis: a case report.

Ulcerative colitis is a disease characterised by non-granulomatous submucosal inflammation ranging from isolated proctitis to colitis. Extra-intestinal manifestations of the condition occur in multiple organ systems, with dermatological complications occurring commonly. This case report aims to highlight an uncommon dermatological complication of ulcerative colitis with particular focus on patient care and management.

Best practice for wound repair and regeneration use of cellular, acellular and matrix-like products (CAMPs).

There are currently over 80 biomaterials derived from autologous, allogeneic, synthetic and xenogeneic sources, or a combination of any or all these types of materials, available for soft-tissue coverage to effect wound closure. Often generically referred to as cellular and/or tissue-based products (CTPs), they are manufactured under various trade names and marketed for a variety of indications.

Rupture Rates Between 2-Strand and 4-Strand Flexor Tendon Repairs: Is Less More?

The purpose of this study was to explore the difference in clinical outcome of 2-strand and 4-strand flexor tendon repairs in a single unit in adult population. A total of 109 complete divisions of a single flexor tendon were analyzed from 2016 to 2018 retrospectively. Thirty flexor tendons were repaired with 2-strand and 79 tendons were repaired with 4-strand technique. There was no significant difference in the complication rate including rupture, infection, and adhesions. These results support that 4-strand is not superior than 2-strand and that lower volume type of repair would be preferable.

Nasal reconstruction in panfacial burns: useful techniques in challenging cases.

Nasal reconstruction after severe panfacial burns can be challenging to correct because of scarring, loss of suitable donor sites, and variably limited blood supply of local flaps. We describe 2 cases of subtotal nasal reconstruction in which we overcame these difficulties. Both cases had alar subunit loss, which had left significant functional and esthetic deformities. However, both cases were managed very differently because of availability of donor sites.The first patient had 70% total body surface area burns with bilateral alar subunit loss: nasal reconstruction required a meticulous multistaged forehead flap. The second patient required nasal reconstruction using a turn-down flap to maximize take of a composite graft from previously burned ear donor sites.A number of surgical techniques have been described to manage subtotal burns nasal reconstruction, foremost of which are the nasolabial and paramedian forehead flaps. Cartilage grafts from the septum and the conchal bowl can be integrated into these flaps. Composite grafts can be unpredictable and are often used with caution.Such cases demonstrate that large composite grafts can be an extremely robust method of reconstruction even in a subset of patients with extensively scarred recipient and donor sites. In our second case, composite grafting avoided multistaged procedures such as the forehead flap and can be considered as a first-line procedure in large alar subunit loss.

Multi-resistant organisms in burn patients: an end or a new beginning.

Infections are a major cause of morbidity and mortality in burn patients, and the rise of multidrug-resistant organisms (MDROs) has made it more challenging to manage and prevent infections. This review examines the available treatment options for MDROs in burn patients and anticipates the future challenges posed by their increasing prevalence. The review covers new antibiotics, such as Eravacycline and Plazomicin, as well as non-antibiotic therapies, such as bacteriophages and nanoparticles. Future research should focus on examining the long-term efficacy, cost-effectiveness, and in vivo efficacy of different treatment modalities. The potential of alternative therapies, such as probiotics and low-frequency magnetic fields, should also be explored. Accurate and rapid diagnostic and monitoring tools for detecting MDROs in burn patients should be developed. The emergence of MDROs in burn care is a challenge and a new beginning in infection innovation and novel treatments.

Management of chemical burns.

Chemical burns represent a small number of burn injuries in the UK. They have the potential to be life-threatening with serious aesthetic and functional consequences, accounting for 30% of all deaths from burns. Chemical burns are caused by corrosive agents (acids and alkali) leading to extensive tissue damage. Understanding the pathophysiology of a chemical burn injury and identifying the nature of the offending agent is important for effective management. Prompt assessment and management of chemical injuries is vital to reduce the deleterious effect of the compound involved. This article reviews the pathophysiology of a chemical injury and the management of these burns.

Addressing sexual function in adult burns victims: A multidisciplinary survey of current practice in UK burn units.

BACKGROUND: Burn injury was shown to affect a patient's sexuality. Cultural and social inhibitions may mean this topic is often overlooked. AIMS: To assess current opinion and management strategies amongst UK burns care teams in relation to addressing sexual function after burn injuries. METHOD: An online questionnaire was circulated to all members of the British Burn Association. RESULTS: The majority of UK burn care professionals reported that sexual function after burn injury was an important (79% of respondents) and unaddressed problem (85% of respondents) in current clinical practice. However, over 90% of professionals reported that they 'never' or 'only occasionally' ask patients about their sexual function concerns. Multiple different management strategies are employed by UK burns centers, with a number of respondents indicating no designated individual responsible for leading care in this area. CONCLUSIONS: Currently no standardized method is in common use to address sexual function concerns of adult burns victims. The authors suggest this topic may be included in future information leaflets for patients and in burns awareness courses for medical professionals.

Establishment of a core outcome set for burn care research: development and international consensus.

Objective: To develop a core outcome set for international burn research. Design: Development and international consensus, from April 2017 to November 2019. Methods: Candidate outcomes were identified from systematic reviews and stakeholder interviews. Through a Delphi survey, international clinicians, researchers, and UK patients prioritised outcomes. Anonymised feedback aimed to achieve consensus. Pre-defined criteria for retaining outcomes were agreed. A consensus meeting with voting was held to finalise the core outcome set. Results: Data source examination identified 1021 unique outcomes grouped into 88 candidate outcomes. Stakeholders in round 1 of the survey, included 668 health professionals from 77 countries (18% from low or low middle income countries) and 126 UK patients or carers. After round 1, one outcome was discarded, and 13 new outcomes added. After round 2, 69 items were discarded, leaving 31 outcomes for the consensus meeting. Outcome merging and voting, in two rounds, with prespecified thresholds agreed seven core outcomes: death, specified complications, ability to do daily tasks, wound healing, neuropathic pain and itch, psychological wellbeing, and return to school or work. Conclusions: This core outcome set caters for global burn research, and future trials are recommended to include measures of these outcomes.

The helpful twin: Skin graft donation in a challenging burn case.

OBJECTIVES: This is the first report of a successful skin grafting between monozygotic twins in the United Kingdom (UK). We discuss the process of assessing the suitability of the patients for the procedure, gaining approval and extraordinary funding from the relevant bodies, developing a new protocol within the trust and the logistics of carrying out the procedure safely. METHODS: We describe the case of a 61-year-old paraplegic woman with insensate legs who presented with a 5-week old 2% TBSA deep dermal to full-thickness scald burn which was sustained accidentally in the shower. In view of the prolonged healing time and the risk of burn wound infection, skin grafting of the wound was the recommended treatment. However, given the high risk of impaired wound healing in denervated skin of quadriplegic individuals, the patient was warned of potential donor site wound healing problems. This, along with concerns over the donor site area interfering with the use of her mobility aids prompted her homozygotic twin sister to donate the necessary skin. The process was risk assessed and approval was sought from the Trust's Caldicott Guardian, NHS Specialist Commissioners and the Trust's Human Tissue Authority (HTA) Designated Individual (DI). A new protocol for the pathway in line with HTA guidance was developed. Specific patient information documents were written, psychological assessments performed and specific consent for skin donation undertaken. One week prior to and again on the day of the procedure, the donor was serologically screened for communicable diseases. A donor medical and social history assessment was also carried out. RESULTS: There was 100% graft take at day 5 post-surgery. The sister's donor site healed well by day 13. At 3 months, there were no signs of hypertrophic scarring. No additional outpatient or dressing clinic appointment were required. DISCUSSION: This is the first case of successful skin homografting between monozygotic twins in the United Kingdom. Donation of skin grafts between such patients, however, requires clinical justification, twin zygosity DNA testing, approval from the HTA and NHS commissioners with appropriate protocols and procedures in place to ensure patient safety. Liaising with the local Tissue Bank can facilitate this process. CONCLUSION: Skin grafting between identical twins is a feasible and successful procedure and offers an alternative treatment modality when wound healing in the recipient twin is suboptimal or when severely burnt. This principle should also be considered, in appropriate cases, for composite tissue transfer in situations where complex reconstructions are required.

Evaluation of high protein intake to improve clinical outcome and nutritional status for patients with burns: a systematic review.

BACKGROUND AND AIM: Patients with severe burns undergo a local and systemic response to the injury. As part of this response the patient becomes hypermetabolic. Current guidelines advise high protein intakes to counteract the catabolic response to burns, but this appears to be based on minimal experimental evidence. Hence the aim of this review was to examine the evidence for improvements in nutritional status and clinical outcome with the administration of high protein intakes for patients with burns. METHODS: Eight databases were searched for clinical trials with burn patients receiving two or more levels of protein intake at or above the level recommended for healthy individuals (0.75g/kg/d) and presenting results for at least one of the following pre-defined outcomes: nitrogen balance, length of stay, weight change, survival, physical therapy index, protein fractional synthetic rate, immunological measurements, bacteraemic days, systemic antibiotic days and net protein synthesis. RESULTS: Six studies were included, 4 of which were randomized trials. All had major methodological limitations, in particular none was blinded. There was too much heterogeneity in study design, patient characteristics and the timing and magnitude of the interventions to justify formal meta-analysis. There was no reliable evidence of improvement in nitrogen balance, but there was some evidence of increased weight gain on higher protein diets. One small study reported an increase in survival and significant improvements in infection rates and some indicators of immune function in children. Length of stay was not significantly improved. There was weak evidence of an improvement in muscle strength and endurance but no significant increase in protein synthesis in muscle or skin, or net protein synthesis in the whole body. CONCLUSION: There is currently only very weak evidence to justify administering high protein diets to patients following burns.

A historical analysis of surgery performed between 1941 and 1942 at the Bangour Maxillofacial and Plastic Surgery Unit, Scotland.

In 1939, Bangour Emergency Medical Services Hospital was built as an annexe to Edinburgh War Hospital. The Maxillofacial and Plastic Surgery Unit opened in 1941, one of the several set-ups built with the support of Sir Harold Gillies, to ensure a service with specialist skills throughout Great Britain. The unit was led by Alexander Burns Wallace, who had to rapidly adapt the service to reflect the patterns of injury reflected by the more modern warfare practiced in the Second World War, while also incorporating techniques that were, at the time, revolutionary. Although much has been written about other units, Bangour's activity revealed through its case histories' highlights that plastic surgery was developing in parallel throughout Britain. The influence of Sir Harold Gillies was clear, and his input to support the fledgling service serves as an important aspect of the newly developing specialty of plastic surgery: collaboration and sharing of knowledge. This paper analyses the work of the Maxillofacial and Plastic Surgery Unit at Bangour General Hospital in Scotland between 1941 and 1942 and demonstrates its historical significance, as well as its relevance to current practice. Ninety-two case notes from the unit recently became accessible. These were analysed and four were selected for review in this study. These cases were selected as they were well-documented with photographs and good examples of the work performed at the unit in order to highlight the innovative, creative and complicated work carried out at the Unit.

Adverse Effects of Pregnancy on Keloids and Hypertrophic Scars.

There are many well-known risk factors for keloids and hypertrophic scars (HTS) including ethnicity, family history, and history of previous keloids or HTS. An association, which has been previously observed, exists between pregnancy and growth and worsening of keloid and HTS. This association is less well known amongst physicians and less documented in the literature. In this paper we discuss two cases of extreme worsening of keloid scars during pregnancy. We have also witnessed the transformation of a pre-existing scar into a keloid scar during puberty. We attribute this to the hormonal effects of pregnancy and puberty hormones which could potentially trigger the growth of pre-existing keloids and HTS. This may have an impact on many patients and we therefore recommend women and girls who have keloid and hypertrophic scarring be made aware of this potential effect.

Once Burnt, Twice Burnt: The Vulnerability of Insensate Flap Reconstructions.

The occurrence of a burn injury in the same region as a previous burn is unusual outside the context of deliberate self-harm. Accidental burn injuries sustained to insensate flap reconstructions have previously been well reported in autologous breast reconstruction. Reports of such injuries in distant flap reconstructions of the hand and forearm are however unusual. This case report describes a 40-year-old man who required a pedicled groin flap to reconstruct a burn injury on the ulnar border of his hand. Three years later, he suffered a burn to the same area whilst using an oven. This case highlights the importance of counselling patients with insensate reconstructions regarding increased care and vigilance against inadvertent injury.

Eschar removal by bromelain based enzymatic debridement (Nexobrid®) in burns: European consensus guidelines update.

INTRODUCTION: Bromelain-based Enzymatic Debridement has been introduced as an additional concept to the burn surgeon's armamentarium and is best indicated for mid-to deep dermal burns with mixed patterns. Increasing evidence has been published focusing on special regions and settings as well as on limitations of Enzymatic Debridement to improve patient care. To better guide Enzymatic Debridement in view of the increasing experience, there is a need to update the formerly published consensus guidelines with user-orientated recommendations, which were last produced in 2017. METHODS: A multi-professional expert panel of plastic surgeons and burn care specialists from twelve European centers was convened, to assist in developing current recommendations for best practices with use of Enzymatic Debridement. Consensus statements were based on peer-reviewed publications and clinical relevance, and topics for re-evaluation and refinement were derived from the formerly published European guidelines. For consensus agreement, the methodology employed was an agreement algorithm based on a modification of the Willy and Stellar method. For this study on Enzymatic Debridement, consensus was considered when there was at least 80 % agreement to each statement. RESULTS: The updated consensus guidelines from 2019 refer to the clinical experience and practice patterns of 1232 summarized patient cases treated by the panelists with ED in Europe (2017: 500 cases), reflecting the impact of the published recommendations. Forty-three statements were formulated, addressing the following topics: indications, pain management and anesthesia, large surface treatment, timing of application for various indications, preparation and application, post-interventional wound management, skin grafting, outcome, scar and revision management, cost-effectiveness, patient´s perspective, logistic aspects and training strategies. The degree of consensus was remarkably high, with consensus in 42 out of 43 statements (97.7%). A classification with regard to timing of application for Enzymatic Debridement was introduced, discriminating immediate/very early (≤12 h), early (12-72 h) or delayed (>72 h) treatment. All further recommendations are addressed in the publication. CONCLUSIONS: The updated guidelines in this publication represent further refinement of the recommended indication, application and post-interventional management for the use of ED. The published statements contain detailed, user-orientated recommendations aiming to align current and future users and prevent pitfalls, e.g. for the successful implementation of ED in further countries like the USA. The significance of this work is reflected by the magnitude of patient experience behind it, larger than the total number of patients treated in all published ED clinical trials.

The management of eyelid burns.

Eyelid involvement is common in facial burns. Ocular sequelae, including corneal ulceration, are usually preventable and secondary to the development of eyelid deformities, exposure keratopathy, and rarely, orbital compartment syndrome. Early ophthalmic review and prophylactic ocular lubrication is mandatory in burns involving the eyelids. Early surgical intervention, often requiring repeat procedures, is indicated if eyelid retraction causing corneal exposure occurs. Permanent visual impairment is rare with such prompt management. No binding aphorisms exist regarding the tissue used for eyelid reconstruction, with each case requiring an individual approach based on available skin. This review article covers the principles of ophthalmic management in addition to intermediate and long-term management of eyelid burns.

The reconstructive journey: Description of the breast reconstruction pathway in a high-volume UK-based microsurgical centre.

INTRODUCTION: Autologous breast reconstruction, on its own, is a complex microsurgical procedure. However, this operation is usually just one of a series of steps along a patient's reconstructive journey. This includes not only a primary major surgical event but also the consequent recovery, potential complications and secondary surgeries required to optimise the final outcome. Unfortunately, there is limited information of what patients can expect from this reconstructive journey in the literature. The aim of this study was to characterise the journey of a consecutive cohort of patients through their whole reconstructive pathway in a high-volume UK-based breast reconstruction service. METHODS: A retrospective case analysis was undertaken including all the patients who had an autologous breast reconstruction at the Queen Victoria Hospital in East Grinstead between January 2012 and December 2014. Their case notes were reviewed from their initial referral to their final discharge. Number of operations, complication rates and time required to complete their journey were recorded, as well as differences between different flap options, immediate versus delayed and unilateral versus bilateral breast reconstructions. RESULTS: A total of 409 autologous breast reconstruction cases were performed in the 3-year study period. The vast majority of breast reconstructions used a deep inferior epigastric perforator flap (81.5%), with muscle-sparing transverse abdominal flaps (14.6%) and transverse upper gracilis flaps (3.9%) being the other options utilised. Free flap success was observed in 99.5% cases. Almost all patients opted for subsequent surgery (94%) of any kind. Only 75% opted for the reconstruction of their nipples. On average, 3.20 procedures were required per patient on this cohort, and these procedures were performed in 1.5 surgical episodes on average. Bilateral reconstructions reached the discharge point sooner than unilateral reconstructions and required a smaller number of operations. The average time to complete the reconstructive journey was 20.8 months. DISCUSSION: Patient-centred decision-making is fundamental to select the correct intervention for each patient and empower her in her healing journey. Standard measuring of patient satisfaction is still an unaccomplished goal in our unit.