Plastic physicians: The surgical salamanders of the COVID-19 pandemic.

At the time of writing, coronavirus disease-2019 (COVID-19) has affected 6.42 million people globally and over 380,000 deaths, with the United Kingdom now having the highest death rate in Europe. The plastic surgery department at Leeds Teaching Hospitals put necessary steps in place to maintain an excellent urgent elective and acute service whilst also managing COVID-positive medical patients in the ward. We describe the structures and pathways implemented together with complex decision-making, which has allowed us to respond early and effectively. We hope these lessons will prove a useful tool as we look to open conversations around the recovery of normal activity.

Reconstruction of the irradiated perineum following extended abdomino-perineal excision for cancer: an algorithmic approach.

Our unit has implemented an algorithm for irradiated perineal reconstruction incorporating current evidence and a new technique in line with the advent of laparoscopic tumour excision. Our approach attempts to maintain the benefits patients derive from minimally invasive oncological surgery. Four consecutive patients had uterine retroversion to obturate pelvic deadspace and reconstruct the posterior vaginal wall. Age range was 41-84 years and mean follow-up of 21 months with mean in-patient stay of 7 days. All patients had neoadjuvant radiotherapy or chemoradiation for low rectal/anorectal adenocarcinoma. All patients had laparoscopic Extended APER and contiguous posterior vaginal wall excision and reconstruction with uterine retroversion and z-plasty skin closure. One patient required ultrasound aspiration of a pre-sacral seroma at two months. No patients returned to theatre for major complications. We highlight one minor and no major complications associated with an algorithmic approach incorporating our method of uterine retroversion and z-plasty parallel to traditional flap reconstruction methods.

Long term study into surgical re-exploration of the 'free flap in difficulty'.

BACKGROUND: Free tissue transfers must survive in order to achieve their surgical goals. There is little consensus about managing the 'failing' free flap, and practice is often guided by anecdote. MATERIAL AND METHODS: We have prospectively collected data about all free flaps performed within our department between 1985 and 2008 (2569 flaps). We identified 327 flaps which were re-explored a total of 369 times. We analysed these flaps with regard to indication for re-exploration, operative findings and outcome. RESULTS: Thirteen percent (327) of free flaps were re-explored. Of these, 291 (83%) had a successful outcome. Successful re-explorations took place at a mean 19h post-op and unsuccessful re-explorations at a mean 56h post-op. Clinical diagnosis prior to re-exploration was confirmed operatively in 91% of cases. CONCLUSION: We have considered the factors that allowed us to achieve the salvage rates described over a prolonged period, and identified two key areas. Firstly, we favour a model for free flap monitoring with clinical judgement at its core. Secondly, we feel the facility to recover patients post-operatively in a specialised, warmed environment, and return them to theatre quickly should the need arise, is essential. These two simple, yet institutionally determined factors are vital for maintaining excellent success rates.

Construction of titanium cranioplasty plate using craniectomy bone flap as template.

In recent times a steady rise in cranioplasty operations has been noted because of increasing utilisation of decompressive craniectomy for trauma as well as stroke patients. A variety of techniques have been utilised for cranioplasty, with their own benefits and limitations. Titanium cranioplasty is one of the well-established and widely used techniques, with most centres utilising computer-assisted reconstruction for manufacture of titanium plates. In this paper we present a novel method for making titanium cranioplasty plates using the craniectomy bone flap as a template and the results of our experience. To date we have performed 51 cranioplasties using this method. The surgical results have been comparable to those obtained using the computer-assisted model technique. The construction cost for titanium cranioplasty plates using this method has been pound 360 cheaper per plate compared with the computer-assisted method. In addition, the CT workload and radiation exposure have been reduced.

Translaminar screw fixation of a kyphosis of the cervical and thoracic spine in neurofibromatosis.

The spinal manifestations of neurofibromatosis include cervicothoracic kyphosis, in which scalloping of the vertebral body and erosion of the pedicles may render conventional techniques of fixation impossible. We describe a case of cervicothoracic kyphosis managed operatively with a vascularised fibular graft anteriorly across the apex of the kyphus, followed by a long posterior construct using translaminar screws, which allow segmental fixation in vertebral bodies where placement of the pedicle screws was impracticable.

An approach to complex tracheostomal complications.

Fistula formation following laryngectomy, most commonly pharyngocutaneous, is the most feared non-fatal complication with an incidence range from 5 to 30%. Tracheoesophageal fistulae are rare and are, most often, associated with the creation of a surgical speech fistula or the stomal recurrence of a malignant tumour. We present five cases of complex post-laryngectomy fistulae and a new approach to management. We advocate debridement of infected or necrotic tissue, primary suture of the oesophageal and tracheal defects with interposition of healthy viable tissue as a free transfer. If necessary, the trachea can be mobilised and the tracheostome is lowered to healthy tissue outside the radiotherapy field, with excision of the manubrium and hemi-clavicles. This technique allows reconstruction as a single stage procedure and does not preclude the future creation of a further tracheoesophageal fistula for voice rehabilitation.

Reconstruction of skull base and dura using rectus abdominis muscle combined with a vascularised fascial perforator flap.

The goal of reconstruction of the skull base is to repair dural defects with a watertight seal and separate it from the nasopharynx and the exterior environment with well vascularised tissue. This prevents cerebro-spinal fluid leakage and secondary contamination leading to the potentially life threatening complications of meningitis or extradural abscess. Following large composite resections, traditional techniques to repair the dura involve the use of an autologous fascial graft or a pericranial flap, whilst a regional pedicled or free muscle flap is used to close the dead space defect. We describe a technique performed in two cases, whereby a single flap, the rectus abdominis muscle free flap, can be used to provide vascularised reconstruction both of the dura and the skull base. The anterior rectus sheath, islanded on a single perforator vessel, is used as a vascularised layer to reconstruct dura, whilst the supporting rectus abdominis muscle provides bulk to obliterate dead space. We show that this flap is suitable for reconstruction even in the presence of chronic infection. Advantages of a vascularised reconstruction are the rapid healing of the wound, even after radiotherapy, the delivery of systemic antibiotics to the site of the operation, and that it may allow early postoperative radiotherapy to be planned.

Pre- and postoperative developmental attainment in sagittal synostosis.

AIMS: To investigate whether sagittal synostosis (SS) has consequences for children's mental and psychomotor development, and whether surgery has any impact on this. METHODS: The study involved 28 children with SS who underwent corrective surgery at a mean age of 8.0 (SD 7.16) months, and 28 normal controls. All the children with SS were assessed pre- and postoperatively using the Griffiths Mental Development Scales. The controls were assessed on one occasion, at an age matched with individuals in the patient group at the time of the preoperative assessment. A further control group consisted of 13 children with SS, who had received developmental assessment on two or more occasions without surgical intervention. RESULTS: The data indicated that children with SS have significantly poorer gross locomotor function than the normal controls. Following surgical intervention the deficit was shown to have resolved; consistent with this a lesser improvement in eye-hand coordination and performance skills was shown. Overall developmental attainment also improved postoperatively. The children with SS who did not receive surgery did not show any improvement in development. CONCLUSIONS: The study shows improved developmental attainment following surgical correction of SS, which may therefore be more than a cosmetic procedure.

Paroxysmal finger haematomas (Achenbach's syndrome) with angiographic abnormalities.

We present two cases of women with Achenbach's syndrome (paroxysmal finger haematomas) with abnormal angiograms.

Inflammatory expansion of a breast augmented by a Trilucent implant.

We present a case in which a Trilucent soya-oil-filled breast prosthesis was removed because of rupture and subsequent massive breast enlargement.

Timing of the thermographic assessment of burns.

The thermographic assessment of burns using infrared imaging has previously been shown to be a useful aid in the estimation of burn depth. In this study, thermographic images of burns, obtained from 65 patients over a 4-year period, were reviewed. An infrared transparent, water-impermeable membrane was used as a wound cover to abolish evaporative cooling artefacts. Single images were obtained from patients with burns to various parts of the body, excluding the hands. A significant change in the temperature of deep burns was observed between days 2 and 3 after injury (chi-square, P < 0.01; Fisher exact probability test between days 2 and 3, P < 0.01). The results of this study suggest that thermography of burns, to assess depth, should be performed within 3 days following the injury.

Radiation-induced antrochoanal fibrosarcoma.

Therapeutic radiation for malignant conditions is known to cause sarcomatous change in an irradiated field after a latent period; equally this change may occur following radiotherapy to benign conditions which may result in a more difficult management problem later. Radiotherapy to benign conditions should be reserved for use after failure of conventional surgery or other interventional techniques.

The relationship between aortic diameter and body habitus.

Nine hundred and six men between the ages of 65 and 74 years were screened to determine whether there was a correlation between abdominal aortic diameter and body size. There was no correlation between aortic diameter and weight or obesity but there was a significant correlation with height and age. Sequential enlargement of the aorta was observed in 57 men with aortic diameters above the normal range, none of these were characterised by one particular body habitus: it is suggested that patients in this group should be rescanned regularly.

Rebound tenderness test.

The usefulness of the rebound tenderness test in indicating peritonitis was prospectively assessed in 142 unselected patients admitted as emergencies with abdominal pain and tenderness. It was found to be of no predictive value.

Skin cancer in renal transplant recipients.

Skin cancer was found in 31 of 598 patients transplanted in Oxford. No cases occurred during the first 3 years after transplantation but the prevalence rose after 12 years to 18.2 per cent. The main risk factors predisposing to skin cancer were the time after transplantation and male sex. Comparison with data from other centres suggests that exposure to ultraviolet light is a major aetiological factor in the speed of development of skin cancer. As the incidence of new cases rose progressively with time in our patients, it would seem that skin cancer is likely to become a major clinical problem as more patients enjoy prolonged survival after renal transplantation. Preventative and screening measures should be taken by transplant units both in the UK and in other countries with similar temperate climates.

Antithymocyte globulin for steroid resistant rejection in renal transplant recipients immunosuppressed with triple therapy.

Steroid resistant rejection, confirmed histologically, occurred in 35 of 187 consecutive cadaveric renal transplants treated with triple therapy (cyclosporin, azathioprine and prednisolone) in the Oxford Transplant Unit. Twenty-seven of these were treated with a rabbit antithymocyte globulin (ATG) and 19 showed recovery of function. The level of serum creatinine, the renal biopsy appearance and the requirement for dialysis at the start of ATG treatment did not predict which patients would respond to the therapy. One year after transplantation there was no significant difference between the mean plasma creatinine levels of those patients with steroid resistant rejection who had been given ATG and responded (151.6 mumol/l) and those who had responded to steroids alone (165.0 mumol/l). Adverse effects of ATG treatment included a mean fall in white cell count of 62.2% and a mean fall in platelet count of 45.1%. Two of the 27 patients who received ATG died (7.4% mortality). ATG would appear to be an effective treatment of steroid resistant rejection in patients receiving triple therapy immunosuppression, and graft function may subsequently be excellent in those patients who respond to treatment.

Post-traumatic intraventricular haemorrhage: a reappraisal.

Ten patients are described in whom intraventricular bleeding occurred after blunt head injury. A mechanism is proposed to explain this phenomenon by drawing analogies with neonatal intraventricular haemorrhage and the pathological findings in strangulation. The outcome in the patients described seems more favourable than in those hitherto reported.