Burns and Plastics

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Diffuse bruising on left breast.
(British Medical Association, 2020-11-18) Chin, Ye Ru; Warner, Robert; Burns and Plastics; Medical and Dental; Warner, Robert
No abstract available
Distally-based Peroneus Brevis turnover muscle flap in the reconstruction of soft tissue defects.
(Wolters Kluwer Health/Lippincott Williams & Wilkins, 2020-12-18) Malahias, Marco; Khalil, Haitham; Abdalbary, Sahar Ahmed; Abdelkader, Rasha; Surgery; Medical and Dental; Malahias, Marco; Khalil, Haitham
Reconstruction of the distal 3rd of the lower leg requires either local or free flap coverage if tendons or bones are exposed. The distally based, pedicled peroneus brevis (PB) flap has been shown to be a valid option in the management of distal 3rd lower limb injuries. Herein, we present 21 cases treated with distally-based PB muscle flaps between May 2017 and September 2019. The defect location varied, and included defects over the lateral and medial malleolar areas, distal tibia (middle and distal 3rd junction, and the distal 3rd), and Achilles tendon area. Methods: The PB was dissected from the lateral fibula and intermuscular septa in a cephalic to caudal direction, to a point no lower than 7 cm proximal to the lateral malleolus tip. This preserved most distal vascular perforators to the muscle, and afforded sufficient mobilization to allow successful turn-over of the muscle, with transposition into the defect within 30 minutes of tourniquet time. A meshed skin graft completed the intervention. Results: The metalwork was removed in all chronic cases (10/21), as bone union had occurred. All flaps survived completely. One patient partially lost the skin graft; the wound was healed by secondary intention. No major complications occurred and no significant patient discomfort was noted. All wounds healed completely by 9 weeks of follow-up. Conclusion: The PB turnover muscle flap is a versatile flap, ideally suited to manage up to moderately sized defects of the distal 3rd of the lower leg, with negligible postoperative morbidity.
Achieving 62-day targets in the management of skin cancer: Lessons learned and future directions for the post-COVID era.
(Elsevier, 2020-11-21) Kiely, Ailbhe L; Patel, Chantal; Ismail, Amir
No abstract available
Antia-Buch versus Franssen-Frechner technique
(Wolters Kluwer Health/Lippincott Williams & Wilkins, 2021-03-24) Abdelkader, Rasha; Malahias, Marco; Abdalbary, Sahar Ahmed; Noaman, Ayman; Surgery; Medical and Dental; Malahias, Marco
We performed a retrospective study comparing 2 patient groups. Each cohort included 22 cases of skin cancer of the external ear. Each patient required resection of the affected part of the external ear, followed by flap reconstruction. Methods: The patients in Cohort A underwent external ear reconstruction with a classic Antia-Buch flap, as described by Antia and Buch in 1967: The defect was closed by mobilizing an advancement flap from the root of the helix (upper ear), which was closed in a V-Y fashion, after a rim of healthy scaphal cartilage was resected to allow approximation of the skin. The patients in Cohort B underwent external ear reconstruction with a modified Antia-Buch flap, as presented by Franssen and Frechner in 2010. Here, a wedge of skin was removed from the ear lobe (lower ear), to allow mobilization of an advancement flap from the caudal end of the ear, to close the defect. Results: Both techniques allowed tension-free closure. Cohort B, however, required less dissection of the ear. The entire cephalic ear remained unaffected and no scaphal cartilage was sacrificed, thus preserving ear width, with scars that were overall less visible. Also, the loss in ear height associated with Cohort B was easily symmetrized by contralateral ear lobe reduction. Conclusions: Cohort B achieved closure with less ear dissection, achieving excellent morphological outcomes. The patients in Cohort B had superior levels of satisfaction with scars and ear symmetry than those in Cohort A.
A descriptive survey of operating theatre and intensive care unit temperature management of burn patients in the United Kingdom.
(e-Century Publishing. Corporation, 2021-06-15) Mullhi, Randeep; Ewington, Ian; Chipp, Elizabeth; Torlinski, Tomasz; Anaesthetics; Burns and plastics; Medical and Dental; Mullhi, Randeep; Torlinski, Tomasz; Chipp, Elizabeth
Background: Patients with major burns lose the normal thermoregulatory function of their skin. They exhibit profound changes in metabolism which aim to compensate for the heat loss associated with water loss through burnt skin. Although these changes in physiology are well documented, the optimal methods for temperature management in both the Operating Theatre and Intensive Care Unit are less clear. Methods: We distributed a survey consisting of 19 questions to all burn units and centres in the United Kingdom with the aim of ascertaining perception of both hypo and hyperthermia, as well as methods used to manage both of these scenarios. Results: In the Operating Theatre, most respondents stated that they measured core temperature (82%); either alone (33%) or in conjunction with peripheral temperature (49%). In the Intensive Care Unit, most respondents measured both core and peripheral temperature (67%), with only a small minority not measuring core temperature (13%). Taking into consideration all professional groups, patients were considered hypothermic if their body temperature was less than 36.2°C (+/-0.7°C). On average, a patient was considered hyperthermic if their body temperature was above 38.8°C (+/-0.6°C). Conclusion: Differences in perception between the professional groups surveyed did not reach clinical or statistical significance. In both the Operating Theatre and Intensive Care Unit, hypothermia was most often managed by increasing the ambient room temperature whereas hyperthermia was most often managed by giving paracetamol. As far as we are aware, this is the first study of the management of altered thermoregulation in major burn patients in the United Kingdom.
Burns objective scar scale (BOSS): validation of an objective measurement devices based burn scar scale panel
(Elsevier, 2019-11-08) Lee, K C; Bamford, A; Gardiner, F; Agovino, A; Ter Horst, B; Bishop, J; Grover, L; Logan, A; Moiemen, N; University Hospital Birmingham NHS Foundation Trust; University of Birmingham; Burns and Plastics; Research and Development; Admin and Clerical; Medical and Dental; Lee, Kwang; Bamford, Amy; Moiemen, Naiem
Aims: Hypertrophic scars in burn survivors are a major cause of morbidity but the development of evidence based treatments is hampered by the lack of objective measurements of these scars. The objective of our study is to investigate the most accurate parameters for objective scar assessment and to create a combination score to facilitate the use of a panel of objective scar measurement tools. Methods: Three independent assessors evaluated fifty five scar sites on fifty five burn patients with both the subjective modified Vancouver Scar Scale (mVSS) and a panel of objective measurement tools including the DSM II Colormeter, Cutometer, Dermascan high frequency ultrasound. The sensitivity and specificity of the objective scar parameters in predicting a mVSS score of 6 or more using the Receiving Operator Characteristic Area under the curve (ROC AUC) was then calculated and the most accurate parameters were combined to create an objective global scar score. Results: The ROC AUC values were found to be highest for the Dermascan scar thickness (0.897), dermal intensity and intensity ratio (0.914 and 0.919), Cutometer R0 value (0.942), and R0 ratio (0.944). For colour measurements, ratios of scar to normal skin performed better than the single parameters for both erythema and pigmentation measurements: DSM II Erythema ratio vs Erythema (0.885 vs 0.818), DSM II a* ratio vs a* (0.848 vs 0.741); DSM II Melanin ratio vs Melanin (0.854 vs 0.761), DSM II L* ratio vs L* (0.862 vs 0.767). Analysis of the ROC AUC with chi-square test values showed that the highest AUC (0.786) was obtained with the combination of the Cutometer R0, Dermascan scar thickness, intensity and their respective scar to normal skin ratios. A total score of 5 and above (out of 6 parameters) had the highest combined sensitivity (69.0%) and specificity (83.3%). Conclusion: The objective parameters for the DSM II Colormeter, Cutometer and Dermascan high frequency ultrasound were all found to have moderate to strong ROC AUC values and combination of the Cutometer R0 and Dermascan scar thickness and intensity values can be used to create an objective global scar scale that can accurately differentiate patients with hypertrophic burn scarring from non-hypertrophic scars or normal skin.
Effect of facial fillers on post-rhinoplasty edema: a hypothesis based on literature review
(Thieme Medical Publishers, 2024-12-03) Maamari, Salwa Al; Vansteelant, Géraldine; Appan, Shirrushtii; D'Souza, Alwyn R; Canterbury Christ Church University; University Hospital Lewisham; University Hospitals Birmingham NHS Foundation Trust; Microbiology; Medical and Dental; Appan, Shirrushtii
The quest to achieve younger and media-driven facial aesthetics has resulted in an exponential increase in the use of facial fillers. Inevitably, this has meant that it is now commonplace for facial plastic surgeons to have patients with fillers in the face. In the senior author's experience (A.R.D.), it was observed that patients with facial fillers experienced persistent edema post-rhinoplasty. It was, therefore, hypothesized that this prolonged edema may be related to fillers affecting the lymphatic drainage impacting postoperative edema following facial surgery.This article aims to gather evidence from wider literature to support the hypothesis that fillers do indeed compromise lymphatic drainage. A narrative literature review was performed using selective articles on fillers and post-rhinoplasty edema. A methodological analysis was then followed to develop a standard theory characterized through the discussion.It is theorized that due to their hydrophilic characteristics, hardness, volume, and backflow phenomena, hyaluronic acid fillers can lead to prolonged edema. In addition, they can either directly block or indirectly exert pressure on the lymphatic pathways and hinder drainage.The research findings support the hypothesis that facial fillers impact postoperative facial edema. Further research is required to objectively measure the effect of fillers on facial lymphatic drainage.The level of evidence is IV.
Letter to the editor: A treatment algorithm for hyaluronic acid filler related complications of the face
(Elsevier, 2024-08-28) Hassan, Ali; Khan, Muhammad Burhan; Ibrar, Hamna; University Hospitals Birmingham; Comsats University Islamabad; Allama Iqbal Medical College; Burns and Plastics; Medical and Dental; Hassan, Ali
No abstract available
Understanding progressive tissue loss and wound burden in combat casualties: lessons learnt for future operational capability
(BMJ Publishing Group, 2024-11-25) Staruch, Robert; Naumann, D N; Wordsworth, M; Jeffery, S; Rickard, R; Oxford University Hospitals NHS Foundation Trust; University of Oxford; Royal Centre for Defence Medicine; University Hospitals Birmingham NHS Foundation Trust; Aston University; General Surgery; Medical and Dental; Naumann, David
Understanding tissue loss following injury is important due to its prevalence among the war-wounded and the impact it has on subsequent treatment and rehabilitation. Progressive tissue loss is a type of tissue loss that has complicated extremity injury in recent conflicts. It has resulted in more proximal residual limb lengths and has influenced rehabilitation. Quantifying wound burden in combat casualties remains a challenge due to poor quality of data sets that lack the capacity for detailed analysis. The aims of this article are to outline the current hurdles in attempting to quantify wound burden in combat casualties and to propose simple interventions to improve data capture for future analysis.
Letter to the editor: Postoperative infections associated with microvascular free flaps in head and neck reconstruction: Analysis of risk factors and results with a standardized prophylaxis protocol
(Elsevier, 2024-07-25) Hassan, Ali; Hamza, Ameer; Azhar, Nurmeen; Medical and Dental; Hassan, Ali
No abstract available.
Posterior ischemic optic neuropathy following a major burn injury and review of the literature
(Oxford University Press, 2020-11-27) Hughes, Benedict; Natalwala, Ibrahim; Kiely, John; Ahmad, Mohammad; Rathi, Bharti; Phipps, Alan; Anwar, Mohammad Umair; Muthayya, Preetha; Pinderfields Hospital; Queen Elizabeth Hospital Birmingham
Posterior ischemic optic neuropathy following burns is a rare but devastating condition that can result in total bilateral visual loss. Numerous treatment modalities have been trialed, yet there is no effective therapy to delay or reverse the disease. Hence, it is imperative for burns surgeons to be aware of the potential risk factors and have a high index of suspicion right from the outset to prevent this outcome. Here, we discuss the case of a patient that developed posterior ischemic optic neuropathy subsequent to a major burn injury. We also present a literature review on optic neuropathies following burns to describe the etiology, clinical signs, and potential management.
The COVID-19 pandemic: implications for medical students and plastic surgery residency applicants.
(Lippincott Williams & Wilkins, 2021-07-01) Kiely, Ailbhe L; Nolan, Grant S
No abstract available
The conservative management of self-inflicted chemical burns: case report and literature review.
(SAGE Publications, 2022-03-24) Galo, Amenah; Farid, Mohammed; Almasharqah, Riyadh; Surgery; Medical and Dental; Farid, Mohammed
Introduction: Chemical burns, particularly injuries related to psychiatric illnesses, are underreported in the literature. We present two cases of self-inflicted alkali chemical burns managed conservatively. Frequent clinical review of the burn was aimed to ensure appropriate healing and compliance with the treatment plan based on regular dressing changes. Case 1: A 24-year-old woman presented during the first day of the initial injury with a minor self-inflicted chemical burn to the right forearm. The causative agent was an oven cleaner containing sodium hydroxide triggering an alkali-based burn. The surface area of the injury was 0.5% total body surface area (TBSA) full-thickness burn. The patient had a complex psychiatric history diagnosed with personality disorder, anxiety and depression. Case 2: A 55-year-old woman presented with a self-inflicted left forearm full-thickness burn (0.5% TBSA). This was five days after the initial injury from an oven cleaner containing sodium hydroxide. The patient had a psychiatric history of anxiety and depressive disorder.The mainstay of burn management was conservative with regular dressing changes and a topical agent. Telemedicine via a designated email address was given to the patient for virtual clinical burn review and any urgent issues. Photograph of the initial burn was taken, and clinic visits were scheduled to determine healing progress. Conclusion: Self-inflicted chemical burns are to be managed within a multidisciplinary setting including early psychiatric involvement. We advocate a holistic approach to determine conservative or operative management, taking into account patient factors, burn complexity and clinician's judgement to streamline the treatment plan. Lay summary: Chemical burns due to self-harm are rare to see in clinical practice. A review of two cases secondary to intentional burns sustained using an oven cleaning material. Patients had psychiatric issues and were on medications to control symptoms. Close observation with regular dressings and topical cream would allow burns to heal without the need for an operation. Our recommendation would be to treat these burns with dressings and regular follow up in the clinic or virtually till healed.
The ever-present costs of cosmetic surgery tourism: a 5-year observational study.
(Springer Verlag, 2021-02-24) Henry, Nader; Abed, Haneen; Warner, Robert; Surgery; Burns and Plastics; Medical and Dental; Abed, Haneen; Warner, Robert
Background: Cosmetic surgery tourism is an ever-growing industry. Despite its associated risks, an increasing number of patients are presenting to NHS services with resulting complications. This study aims to evaluate the current presentation patterns for complications in cosmetic surgery tourism, and the financial burden to the NHS reported by a single UK level one trauma centre in Birmingham, UK. Methods: From 2015 to 2020, all patients presenting to the department of plastic surgery with complications of cosmetic surgery performed outside of the UK were included. Data were collected for patients' characteristics including demographics, performed procedures, complications and treatment. A cost analysis was performed for each patient using published "National Schedule of NHS Costs." Results: A total of 26 patients presented to our hospital within the study period. All patients were female, with the mean age being 35.1 years (range 22-55years). A total of 32 cosmetic procedures were undertaken, with the majority performed in Turkey (n = 14). Abdominoplasty was the most common procedure, followed by gluteal enhancement surgery. The total financial cost to the NHS from all cosmetic surgery-related complications was £152,946, with an average cost per patient of £5,882.54 (range £362-£26,585). Conclusion: Patients seek out medical tourism for multiple reasons including cost savings, shorter waiting times and surgical expertise. The costs displayed should predominantly be viewed as a reflection of the detrimental effect these complications can have on patients' lives. Global governing bodies should focus efforts on educating patients and raising awareness on this ever-prevalent issue. 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 .
Staging computerized tomography before delayed breast reconstruction could alter the management plan
(Elsevier, 2021-06-06) Iqbal, Javeria; Malahias, Marco N; Alsharkawy, Kareem; Youssef, Sherif; Trigkatzis, Platon; Shimal, Amar; Pradhan, Poonam; Kalkat, Maninder; Khalil, Haitham H; Surgery; Plastic Surgery; Imaging; Obstetrics and Gynaecology; Medical and Dental; Malahias, Marco N; Alsharkawy, Kareem; Shimal, Amar; Pradhan, Poonam; Kalkat, Maninder; Khalil, Haitham H
Background: Delayed breast reconstruction (DBR) comprises a significant proportion of breast reconstruction practice post completion of breast cancer treatment. The tumour's biology, staging, time constraints, ongoing treatment, and patient and surgeon's preference influence the decision to pursue DBR. There are no guidelines for assessing the oncological status before DBR in otherwise asymptomatic patients, particularly in those with a higher risk of recurrence. The purpose of this study was to identify the cohort of patients who could potentially benefit from staging CT scan before DBR regardless of the reconstructive modality and its impact on the overall management. Material and methods: A retrospective review on 207 consecutive patients, who underwent staging CT scan before DBR in the period between 2009 and 2019 was performed. The CT scan findings were correlated with the breast prognostication scoring model (Nottingham Prognostic Index [NPI]) as an indicator factor for staging reasons. Results: Incidental findings were reported in 34% (71/207) of the reviewed CT scans (incidentaloma group). There was no statistical significance in the NPI scores between non incidentaloma and incidentaloma groups. However, 5.7% (12/207) had their DBR procedure cancelled or the surgical plan altered. Conclusion: The patients with moderate to poor prognosis (NPI score 3.4 and above) could benefit from CT staging scan before DBR. This scan could detect adverse prognostic features precluding major surgery, which saves patients from unnecessary surgical risks and discomfort, and direct them towards the relevant management pathway.
Salvage of extensively scarred hands: wide awake tenolysis and interpositional free tissue transfer.
(Wolters Kluwer Health, 2021-12-14) Ghoraba, Samir M; Alsharkawy, Kareem G; Hammad, Mostafa; Samak, Haitham A; Burns and Plastics; Medical and Dental; Alsharkawy, Kareem G
Background: This study introduced a dedicated technical approach to extensive hand adhesions, combined with failed primary nerve reconstruction. Wide awakelocal anesthesia no tourniquet (WALANT) tenolysis and interpositional free tissue transfer forge the main facets of the proposed reconstructive strategy. Methods: A prospective study was conducted, including 22 patients diagnosed with extensive tendon adhesions in addition to failed primary nerve repair. After wide awake tenolysis, 20 adipofascial radial forearm flaps and two ALT flaps were used to wrap the tendons, whereas the nerves were grafted after complete separation from the tendons. Nerve recovery; final total range of motion of the fingers; and the disabilities of the arm, shoulder, and hand score were recorded in detail. Results: All flaps healed uneventfully. Final assessment of the median nerve revealed M3 or more motor power and S3 sensory recovery in all patients except one patient who attained no muscle power at all and S1 as regards the sensory assessment. The ulnar nerve evaluation revealed that two of five patients did not recover motor power at all (M0), and the remaining three patients recovered M3 motor power with variable sensory outcomes. Final assessment of total range of motion of the fingers and the DASH score showed a statistically significant improvement except for one patient. Conclusion: WALANT tenolysis and interposition of well-vascularized fascial flaps along with simultaneous nerve grafts in extensively scarred hands provided goodfunctional outcomes.
Stevens-Johnson syndrome and toxic epidermal necrolysis: a comparison with practice in a large UK burns unit.
(MA Healthcare, 2021-12-02) Nagra, Raveenjot; Chipp, Elizabeth; Burns and Plastics; Medical and Dental; Chipp, Elizabeth
No abstract available
Multicentre, longitudinal, observational cohort study to examine the relationship between neutrophil function and sepsis in adults and children with severe thermal injuries: a protocol for the Scientific Investigation of the Biological Pathways Following Thermal Injury-2 (SIFTI-2) study.
(BMJ Publishing Group, 2021-10-22) Hazeldine, Jon; McGee, Kirsty C; Al-Tarrah, Khaled; Hassouna, Tarek; Patel, Krupali; Imran, Rizwana; Bishop, Jonathan R B; Bamford, Amy; Barnes, David; Wilson, Yvonne; Harrison, Paul; Lord, Janet M; Moiemen, Naiem S; Burns and Plastics; Medical and Dental; Moiemen, Naiem S
Introduction: Burn-induced changes in the phenotype and function of neutrophils, cells which provide front-line protection against rapidly dividing bacterial infections, are emerging as potential biomarkers for the early prediction of sepsis. In a longitudinal study of adult burns patients, we recently demonstrated that a combined measurement of neutrophil phagocytic capacity, immature granulocyte (IG) count and plasma cell-free DNA (cfDNA) levels on the day of injury gave good discriminatory power for the prediction of later sepsis development. However, limited by a small sample size, single-centre design and focus on adult burns patients, these biomarkers require prospective validation in a larger patient cohort. The Scientific Investigation of the Biological Pathways Following Thermal Injury-2 study aims to prospectively validate neutrophil phagocytic activity, IG count and plasma cfDNA levels as early prognostic biomarkers of sepsis in thermally injured adult and paediatric patients. Methods and analysis: This multicentre, longitudinal, observational cohort study will enrol 245 paediatric and adult patients with moderate to severe burns within 24 hours of injury. Blood samples will be obtained at 19 postinjury time points (days 1-14, day 28, months 3, 6, 12 and 24) and analysed for neutrophil phagocytic activity, IG count and cfDNA levels. Patients will be screened daily for sepsis using the 2007 American Burn Association diagnostic criteria for sepsis. In addition, daily multiple organ dysfunction syndrome and Sequential Organ Failure Assessment Scores will be recorded relationships between neutrophil phagocytic activity, IG count and plasma cfDNA levels on day 1 of injury and the development of sepsis will be examined using logistic regression models. Ethics and dissemination: This study received ethics approval from the West Midlands, Coventry and Warwickshire Research Ethics Committee (REC reference:16/WM/0217). Findings will be presented at national and international conferences, and submitted for publication in peer-reviewed journals. Trial registration number: NCT04693442.
Patient-reported outcomes for nipple reconstruction: Review of literature
(Royal College of Surgeons of Edinburgh, 2021-01-08) Tan, Yan Yu; Chin, Ye Ru; Bajaj, Kuljyot; Thomas, Sunil; Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust; Burns and Plastics; Medical and Dental; Thomas, Sunil
Background: There is currently no validated patient-reported outcome measure (PROM) that is specific to nipple-areola complex (NAC) reconstruction. This paper evaluates all patient-reported outcomes for NAC reconstruction in the literature. Methods: Systematic literature searches of The Cochrane Central Register of Controlled Trials, MEDLINE and World Health Organization International Clinical Trials Registry Platform were conducted to identify all primary studies with patient-reported outcomes for NAC reconstruction. The primary outcome measures were patient satisfaction rates for appearance and symmetry of NAC reconstruction. Results: Fifty-nine papers were included in this review. Reported patient satisfaction was generally high, with the pooled average satisfaction rate for appearance being 81.9% and symmetry 80.3%. 89.5% of respondents would do it again and 94.8% would recommend it to others. There is no standardised or validated PROM specific to NAC reconstruction and this contributes to a lack of conclusive findings from studies in this area. Conclusion: There is a need for a validated PROM that is specific to NAC reconstruction, in order to serve as a standardised outcome assessment to guide further research and improve patient care.
Palmaris profundus in the carpal tunnel
(BMJ Publishing Group, 2023-01-25) Pezas, Theodore Paul; Jose, Rajive; Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust; St George's University Hospitals NHS Foundation Trust; Burns and Plastics; Medical and Dental; Jose, Rajive
Carpal tunnel release is a routinely performed operation to relieve pressure caused by compression on the median nerve. In the majority of cases, the causation of the compression will be idiopathic. Among the secondary causes of median nerve compression is the palmaris profundus, a rare anatomical variant separate to the palmaris longus tendon. It has been suggested that it may cause carpal tunnel syndrome as it courses underneath the flexor retinaculum with the contents of the carpal tunnel reducing the space available to the median nerve. Several cases have found it intimately associated with the median nerve within the carpal tunnel. Raising awareness of this anatomical variant is therefore important for those undertaking carpal tunnel decompression in order to avoid unintended damage.

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