Shehab Jabir

Burn injury to a reconstructed breast via a hot water bottle

Breast reconstruction following mastectomy for breast cancer has become an almost routine procedure within the United Kingdom. A number of autologous tissue flaps have been described including the latissimus dorsi (LD), transverse rectus abdominis myocutaneous (TRAM) and DIEP flap. The DIEP has now become the flap of choice for breast reconstruction as it does not involve harvest of rectus muscle hence maintaining abdominal strength and reducing the risk of abdominal herniation. It is also less painful postoperatively and has a shorter recovery phase. However, flap elevation usually results in transection of nerves responsible for cutaneous sensation and thermoregulatory function which may increase the risk of accidental thermal damage. A fit and well 76 year old lady who had a failed immediate implant reconstruction of her right breast underwent a delayed DIEP reconstruction approximately 12 months post-mastectomy. Three months post-procedure she used a hot water bottle wrapped up in a towel to relieve back pain. Unfortunately, she fell asleep with the bottle, waking up later on to find it on her chest. There were no immediate indications of a burn injury, however later on in the day she noted increased redness and blistering over the surface of the flap. This was initially managed conservatively by her GP. However, as the wound failed to heal and in fact appeared to expand, she was referred to our unit 3 weeks later. She had a clearly defined well circumscribed adherent layer of eschar over the flap (Figure 1). The patient had suffered a full thickness burn to her DIEP flap with the resulting wound measuring approximately 6 7 cm in size. The burn was debrided and a split skin graft applied soon after presentation. The graft took well and the wound healed completely within 2 weeks (Figure 2). This is the first report of a burn injury to a DIEP flap from a hot water bottle. The potential for hot water bottles to

Histological diagnosis of cardiac lipoma in an adult with tuberous sclerosis

Tuberous sclerosis complex (TSC) is an autosomal dominant multisystem disorder caused by mutations in either of the two genes, TSC1 or TSC2, which code for the proteins hamartin and tuberin, respectively. These proteins act as tumour-growth suppressors with mutations in their genes leading to multiple hamartomatous growths throughout the central nervous system, lungs, heart, kidneys, eyes and skin. There have been reports of patients with TSC having an increased incidence of cardiac neoplasms, especially rhabdomyomas. A much smaller proportion of TSC patients have also been reported to have either, angiomyolipomas or lipomas, the diagnosis in these cases being made via CT. We present the first case of an adult with TSC, where a histological diagnosis of cardiac lipoma was made and discuss its implications.

Perianal Paget's disease: a diagnostic dilemma

Perianal Pagets disease (PPD) is part of the spectrum of pagetoid skin lesions occurring outside the region of the nipple/areolar complex that are collectively referred to as extramammary Pagets disease (EMPD). However, unlike Pagets disease of the breast, which in the vast majority of cases is invariably associated with an underlying ductal carcinoma, most cases of EMPD occur as either insitu or invasive adenocarcinomas with visceral malignancy being a rare entity. We present a case of a 50-year-old man who was referred to us with PPD. This case highlights the difficulties associated with making a clinical diagnosis of this condition. Furthermore, investigative workup to exclude possible malignancy with associated metastatic spread as well as the treatment options available are also discussed. In addition, this case highlights the need for a multidisciplinary team approach when dealing with this difficult problem.

Microvascular free tissue transfer in acute and secondary burn reconstruction

INTRODUCTION The mainstay of operative treatment in burns is split skin grafting with free tissue transfer being indicated in a minority of cases. However, free tissue transfer faces a number of challenges in the burns patient. These include; overall cardiovascular and respiratory stability of the patient, availability of suitable vessels for anastomosis, sufficient debridement of devitalised tissue and a potentially increased risk of infection. We carried out a retrospective study in order to determine the indications, timing, principles of flap selection, complications, outcomes and methods of promoting flap survival when free tissue transfer was utilised for burn reconstruction in our unit. MATERIALS AND METHODS All patients who underwent soft tissue reconstruction for burn injuries with microvascular free tissue transfer between May 2002 and September 2014 were identified from our burns database. The records of these patients were then retrospectively reviewed. Data extracted included, age, gender, type of injury, total body surface area involved, indications for free tissue transfer, anatomical location, timing of reconstruction, complications and flap survival. RESULTS Out of a total of 8776 patients admitted for operative treatment over a 12-year period, 23 patients required 26 free flaps for reconstruction. Out of 26 free flaps, 23 were utilised for acute burn reconstruction while only 3 free flaps were utilised for secondary burn reconstruction. All 26 free flaps survived regardless of timing or burn injury mechanism. Complications included haematomas in 2 flaps and tip necrosis in 4 flaps. Two flaps required debridement and drainage of pus, 1 flap required redo of the venous anastomosis while 1 required redo of the arterial anastomosis with a vein graft. CONCLUSIONS Free tissue transfer has a small but definite role within acute and secondary burn reconstruction surgery. Despite the complexity of the burn defects involved, free flaps appear to have a high success rate within this cohort of patients. This appears to be the case as long as the appropriate patient and flap is selected, care is taken to debride all devitalised tissue and due diligence paid to the vascular anastomosis by performing it away from the zone of injury.

Design of patient-reported outcome instruments within plastic surgery—a short primer on methodology

Sir, There has been an increasing interest in evaluating satisfaction with appearance and quality of life outcomes in a number of sub-specialties within plastic surgery, including body contouring surgery, burns, head and neck reconstruction, and cosmetic surgery via patient-reported outcome (PRO) measures. PRO measures provide evidence of the impact of surgical and other interventions from a patient perspective and thus differs from the more traditional outcome assessment in surgery (e.g., measuring complications), or the use of semistructured interviews and other qualitative approaches to understand the patient’s perspective. Furthermore, when properly developed, PRO instruments provide data that are reproducible and suitable for statistical analysis. When used in clinical practice, PRO data enables the physician as well as the patient to appreciate the impact from a quality of life perspective, of a particular procedure. However, recent systematic reviews have demonstrated that within plastic surgery, there appears to be a dearth of well-designed PRO instruments displaying the necessary degrees of psychometric validity, reliability, and responsiveness [1–4]. Meanwhile, the research community has been using ad hoc measures (no evidence of validity or reliability) and/or generic measures (designed for use with any patient group) with plastic surgery patients, neither of which provides useful data. In order to move the field forward, the development of clinically meaningful PRO measures for plastic surgery patients is needed. However, it is important that any new PRO instrument developed for plastic surgery patients is developed following the best practice methods for the design of such measures [5, 6]. The author provides some key guidelines and principles for developing these valuable measures. The development of psychometrically sound PRO instruments requires the following two key steps:

Burn Injuries Resulting from Hot Water Bottle Use: A Retrospective Review of Cases Presenting to a Regional Burns Unit in the United Kingdom

Introduction. Hot water bottles are commonly used to relieve pain and for warmth during the colder months of the year. However, they pose a risk of serious burn injuries. The aim of this study is to retrospectively review all burn injuries caused by hot water bottles presenting to our regional burns unit. Methods. Patients with burns injuries resulting from hot water bottle use were identified from our burns database between the periods of January 2004 and March 2013 and their cases notes reviewed retrospectively. Results. Identified cases involved 39 children (aged 17 years or younger) and 46 adults (aged 18 years or older). The majority of burns were scald injuries. The mean %TBSA was 3.07% (SD ± 3.40). Seven patients (8.24%) required debridement and skin grafting while 3 (3.60%) required debridement and application of Biobrane. One patient (1.18%) required local flap reconstruction. Spontaneous rupture accounted for 48.20% of injuries while accidental spilling and contact accounted for 33% and 18.80% of injuries, respectively. The mean time to heal was 28.87 days (SD ± 21.60). Conclusions. This study highlights the typical distribution of hot water bottle burns and the high rate of spontaneous rupture of hot water bottles, which have the potential for significant burn injuries.

A systematic review of the applications of free tissue transfer for paediatric lower limb salvage following trauma

Abstract Background: Since the advent of microsurgical free tissue transfer in the 1960s, it has now become an indispensable part of limb salvage surgery. However, its application in children was initially met with concerns regarding vessel diameter, increased potential for vasospasm and its potential impact on normal growth and development. This resulted in its restriction to specialist paediatric facilities. With improvements and greater confidence in microsurgical techniques, more units are starting to rewrite the initially popularised narrative regarding free tissue transfer in paediatric limb salvage following trauma. A systematic review was undertaken, using the PRISMA criteria for systematic reviews, of all published literature relating to the use of free flaps in paediatric lower limb salvage following trauma. Methods: Inclusion and exclusion criteria were defined and Medline, Embase, PubMed and Google Scholar databases were searched from inception to September 2014 with the following search terms: “free tissue transfer”, “free flaps”, “microvascular free tissue transfer”, “paediatric/pediatric”, “children”, “lower limb”, “trauma” and “reconstruction”. Results: A total of 375 studies were retrieved following the electronic database search, of which 23 studies met the inclusion criteria. Two further studies were found via a hand-search of the reference lists of the retrieved studies. A total of 25 studies were, thus, included in the review. Conclusions: This study presents a synthesis of the literature available on the indications, timing, selection, viability, complications and functional outcome of free tissue transfer following lower limb trauma in paediatric patients. Limitations of current studies with potential areas for further research are also discussed.

Pearls and pitfalls of laparoscopic harvest of omental flap for sternal wound reconstruction in patients with significant cardiac dysfunction

Laparoscopic omental harvest was first described by Saltz in 1993 and since then, it has been reported for sternal wound reconstruction following cardiac surgery. A laparoscopic approach eliminates the significant surgical trauma associated with laparotomy and decreases the risk of abdominal contamination. Furthermore, it results in reduced postoperative pain, earlier resumption of oral nutrition, lower rate of respiratory complications and therefore, it is conceivable that it is suitable especially for seriously ill patients with multiple co-morbidities. However, establishment of CO2 pneumoperitoneum required for the laparoscopic approach induces cardiac, pulmonary, renal, splanchnic and endocrine pathophysiological changes. Notably, CO2 pneumoperitoneum can adversely affect cardiac performance by stimulating a neurohormonal response that increases systemic vascular resistance and heart rate, and decreases venous return. Such changes are poorly tolerated by patients with underlying cardiac dysfunction and may increase the risk of cardiac complications perioperatively. We performed reconstruction of sternal defects with omental flaps in 8 patients (Table 1) with significant cardiac dysfunction following deep sternal wound infection after coronaryarterybypassgrafting.The laparoscopicharvestwas conducted through four 5 mm operating ports (Figure 1). Pneumoperitonium was established by insufflating with carbon dioxide (CO2) up to 12 mmHg at rate of 5 L/min. Upon insufflation, one patient developed hypotension necessitating intravenous infusion of vesopressor agents. Another patient developed supraventricular tachycardia and required amiodarone infusion. Both incidences necessitated immediate desufflation and conversion to laparotomy for omental

Multiple glomuvenous malformations presenting in a child: follow-up over a period of 8 years

Multiple glomuvenous malformations (GVMs) are a rare condition which usually present in children with only a handful of cases reported in the literature. It is usually congenital and has an autosomal dominant inheritance pattern. They may be distributed throughout the body in either a localised, segmental or disseminated pattern. Pain, which is a characteristic feature of glomus tumours, is less often associated with GVMs. In addition, unlike glomus tumours which most commonly occur over acral skin surfaces, GVMs may occur throughout the body. A number of treatment options are available including surgical excision, laser treatments and sclerotherapy. We present the case of a 14-year-old boy with multiple GVMs which were treated with surgical excision and followed him up over a period of 8 years.