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Maan Z.N.,Imperial College London | Maan Z.N.,St Andrews Center for Plastic Surgery and Burns | Maan I.N.,King's College London | Darzi A.W.,Imperial College London | Aggarwal R.,Imperial College London
British Journal of Surgery | Year: 2012

Background: Selection criteria for surgical training are not scientifically proven. There is a need to define which attributes predict future surgical performance. The aim of this study was to examine the predictive value of specific attributes that impact on surgical performance. Methods: All studies assessing the predictive power of specified attributes with regard to outcome measures of surgical performance in MEDLINE, Embase, the Cochrane Central Register of Controlled Trials and Educational Resources Information Centre databases, and bibliographies of selected articles from 1950 to November 2010 were considered for inclusion by two independent reviewers. Information on study identifiers, participant characteristics, predictors assessed, evaluation methods for predictors, outcome measures, results and statistical analysis was collected. Quality assessment was carried out using the Hayden criteria. Results: Visual-spatial perception correlated with both subjective and objective assessments of surgical performance, including rate of skill acquisition. Visual-spatial perception did not correlate with operative ability in experts, although it did with operative ability at the end of a training programme. Psychomotor aptitude, assessed collectively, correlated with rate of skill acquisition. Academic achievement predicted completion of a training programme and passing end-of-training examinations, but did not predict clinical performance during the training programme. Conclusion: Intermediate- and high-level visual-spatial perception, as well as psychomotor aptitude, can be used as criteria for assessing candidates for surgical training. Academic achievement is an effective predictor of successful completion of training programmes and should continue to form part of the assessment of surgical candidates. © 2012 British Journal of Surgery Society Ltd.


Masud D.,St Andrews Center for Plastic Surgery and Burns | Norton S.,St Andrews Center for Plastic Surgery and Burns | Smailes S.,St Andrews Center for Plastic Surgery and Burns | Shelley O.,St Andrews Center for Plastic Surgery and Burns | And 3 more authors.
Burns | Year: 2013

Introduction: Burn in the elderly has a high mortality. Scoring systems incorporating age, and/or co-morbidities have been developed to assist in predicting outcomes in this high risk group. Life expectancy has increased in the general population and within the elderly age group medical co morbidity, physiological response to injury and socioeconomic factors give rise to the concept of biological versus chronological age. For a given age, baseline pre morbid state can vary. It is more valid to consider biological rather than chronological age when calculating risk. The Canadian Study of Health and Aging (CSHA) clinical frailty scale, incorporating fitness, co-morbidities and level of dependence was used to analyse our elderly burn patients admitted to Burns ITU, their surgical management and one-year survival. Method: Data from patients with burns greater than 10% and aged over 65 years managed on the Burns ITU between 2005 and 2009 were obtained. A frailty score (1-7) was assigned to each patient based on the records of their admission assessment. 42 patients met the study criteria for analysis. 18 (42.9%) patients, with mean age 74.9 years (range 65-95 years) survived (S) their ITU stay and of these, 83.3% survived at 1 year. 24 (57.2%) patients, mean age 78.4 years (range 66-95 years) died (D) whilst on ITU. There was no significant difference between the two groups with regard to age, percentage burn (30% TBSA range 10-85%) (P > 0.05 using T Test) or inhalational injury (p > 0.05 using Z test). Using Mann-Whitney U test analysis, the frailty score between the two groups showed a significant difference at p = 0.0001 (Mann-Whitney U test = 78), median = 3 (S) and median = 5 (D). This suggests patients with better pre-morbid capacity, as evaluated by the frailty scoring system, were more likely to survive their burn insult and treatment. Significantly, more patients in the group that survived underwent surgical debridement (Mann-Whitney U test = 111, p = 0.02). Conclusion: Frailty scoring system appears to be a useful adjunct in predicting outcome in burns requiring admission to HDU/ITU in the senior population. The frailty score may predict which patients will benefit from surgery which also continues to be an important determinant of outcome in these patients. © 2012 Elsevier Ltd and ISBI.


PubMed | Anglia Ruskin University and St Andrews Center for Plastic Surgery and Burns
Type: | Journal: Journal of plastic, reconstructive & aesthetic surgery : JPRAS | Year: 2016

We report our experience with free tissue transfer in the elderly based on a retrospective review of patients aged 70 years who underwent surgery during a 7-year period. A total of 110 free tissue transfers in 104 patients, with a mean age of 78 years (range: 70-92 years), were identified for inclusion. The demographic and operative variables and postoperative medical and surgical complications were analyzed. Sixty-four of the 110 procedures encountered at least one complication. Medical complications were observed in 25 cases and were predominantly pulmonary, whereas surgical complications occurred in 54 cases in addition to one perioperative death. Successful free tissue transfer was achieved in 105 of the 110 flaps. There was no statistically significant difference in the rate of postoperative complications between patients aged 70-79 years and those aged 80 years. Anesthetic time was a statistically significant predictor of postoperative medical complications (odds ratio 1.345, 95% confidence interval 1.117-1.663, P=0.001). Preoperative comorbidity status, graded according to the ACE-27 index, was a statistically significant predictor of flap recipient site complications. Free tissue transfer may be performed in aging patients with a high degree of technical success and low operative mortality. Chronological age alone should not be used as a criterion when evaluating a patient for free tissue transfer. The patients premorbid status should be carefully assessed. To minimize postoperative medical complications, duration of general anesthesia should be kept to a minimum.


Roberts G.,Broomfield Hospital | Lloyd M.,Broomfield Hospital | Parker M.,Chelmsford | Martin R.,St Andrews Center for Plastic Surgery and Burns | And 3 more authors.
Journal of Trauma and Acute Care Surgery | Year: 2012

BACKGROUND: To assess trends in mortality after burn injuries treated in a regional specialist burns service between 1982 and 2008. METHODS: Patient and burn-specific information and mortality were collated from written admission ledgers and the hospital coding department for 11,109 patients. The data set was divided into age cohorts (0 -14, 15- 44, 45- 64, and <65 years) and time cohorts (1982-1991, 1992-2000, and 2000 -2008). Lethal area 50 (LA50) was calculated by logistic regression and probit analysis. Mortality was related to the Baux score (age + total %burned surface area) by logistic regression. RESULTS: In the time period 2000 to 2008, the LA50 values with approximate 95%confidence intervals (CIs) were 100%(CI, 85.5-100%) in the 0 to 14 cohort (LA10, 78.3%; CI, 64.1-92.5%), 76.4%(CI, 69.1- 83.8%) in the 15 to 44 cohort, 58.6%(CI, 50.8 - 66.5%) in the 45 to 64 cohort, and 30.8%(CI, 24.7-36.9%) in the <65 cohort. The point of futility (the Baux Score at which predicted mortality is 100%) was 160 and the Baux50 (the Baux score at which predicted mortality is 50%) was 109.6 (CI, 105.9 -113.4) in the 2000 to 2008 cohort. CONCLUSIONS: Mortality is markedly improved over earlier data from this study and other historical series and compares favorably with outcomes published from the US National Burn Repository. The Baux Score continues to provide an indication of the risk of mortality. Survival after major burn injury is increasingly common, and decisions by nonspecialist about initial triage, management, and futility of care should be made after consultation with a specialist burn service. Copyright © 2012 by Lippincott Williams & Wilkins.


Jabir S.,St Andrews Center for Plastic Surgery and Burns
BMJ case reports | Year: 2013

A circumferential full-thickness burn to the penis is a rarely encountered injury. However, when it does occur, it proves a management challenge to the plastic and burns surgeon in terms of reconstruction. This is due to the need of not only regaining adequate function of the organ, but also because of the need for a pleasing aesthetic outcome. Split-skin grafts have been utilised successfully to resurface full thickness burns of the penis and have given good results. Yet the success of split-skin grafts, especially those applied to an anatomically challenging region of the body such as the penis, depends on a number of carefully thought-out steps. We discuss the case of a circumferential full-thickness burn to the penis which was treated with split-skin grafting and highlight important pitfalls that the plastic and burns surgeon need to be aware of to ensure a successful outcome.


Jabir S.,St Andrews Center for Plastic Surgery and Burns
BMJ case reports | Year: 2013

Sciatic nerve palsy following total hip replacement is a rare but serious complication. The neurological sequelae that follow range from pure sensory loss to combined motor and sensory loss involving most of the lower limb. The loss of nociceptive feedback predisposes patients to accidental damage to the lower limb. We present the case of a lady with sciatic nerve palsy who sustained full-thickness burn injuries to her foot via a hot water bottle. The dilemma between debridement and grafting following a recent history of surgical trauma (ie, total hip replacement) versus secondary healing via dressings and regular review is discussed. Although grafting is the standard treatment in such burns, we recommend secondary healing over grafting provided the burns are not extensive. This enables potential recovery of sensation and reduces operative trauma to the limb which may retard resolution of the neuropraxia.


Kannan R.Y.,St Andrews Center For Plastic Surgery And Burns | Mathur B.S.,St Andrews Center For Plastic Surgery And Burns | Tzafetta K.,St Andrews Center For Plastic Surgery And Burns
Journal of Plastic, Reconstructive and Aesthetic Surgery | Year: 2013

In this article, we describe the use of chimeric free fibular flaps to reconstruct three-dimensional spatial defects in the orofacial region. Recent insights into permutations possible with the chimeric fibular flap have allowed us to achieve our reconstructive objectives with a single chimeric flap and minimise donor-site morbidity as well as operating time. In an overall series of 34 free fibular flaps from 2009 to 2012, we performed twelve cases of free chimeric fibular flaps with osseo-myo-cutaneous/OMC (n = 7), multi-pedicled osseo-musculo-cutaneous/Mp-OMC (n = 4) and multi-pedicled osseo-cutaneous/Mp-OC (n = 1) variants for either post-excisional defects or osteo-radionecroses. We had an overall flap survival rate of 100% with one partial flap loss due to the 'puppeteer' effect. Based on our experiences, we find the chimeric fibular flap to be an excellent addition to our reconstructive arsenal for complex orofacial defects. © 2012 Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and Aesthetic Surgeons. All rights reserved.


Leon-Villapalos J.,St Andrews Center for Plastic Surgery and Burns | Eldardiri M.,St Andrews Center for Plastic Surgery and Burns | Dziewulski P.,St Andrews Center for Plastic Surgery and Burns
Cell and Tissue Banking | Year: 2010

Burns are tissue wounds caused by thermal, electrical, chemical cold or radiation injuries. Deep injuries lead to dermal damage that impairs the ability of the skin to heal and regenerate on its own. Skin autografting following burn excision is considered the current gold standard of care, but lack of patient's own donor skin or unsuitability of the wound for autografting may require the temporary use of dressings or skin substitutes to promote wound healing, reduce pain, and prevent infection and abnormal scarring. These alternatives include deceased donor skin allograft, xenograft, cultured epithelial cells and biosynthetic skin substitutes. Allotransplantation is the transplantation of cells, tissues, or organs, sourced from a genetically non-identical member of the same species as the recipient. Human deceased donor skin allografts represent a suitable and much used temporizing option for skin cover following burn injury. The main advantages for its use include dermoprotection and promotion of reepithelialisation of the wound and their ability to act as skin cover until autografting is possible or re-harvesting of donor sites becomes available. Disadvantages of its use include the limited abundance and availability of donors, possible transmission of disease, the eventual rejection by the host and its handling storing, transporting and associated costs of provision. This paper will explore the role of allograft skin in burn care, defining the indications for its use in burn management and the future potential for allograft tissue banking. © 2009 Springer Science+Business Media B.V.


Hrsikesa Sharma H.S.,St Andrews Center For Plastic Surgery And Burns | Loshan Kangesu L.K.,St Andrews Center For Plastic Surgery And Burns
JPRAS Open | Year: 2015

We report three patients with vicryl rapide inclusion cysts and suture sinus tracts as late presentations and complications of primary hypospadias repair. All three patients underwent correction surgery to remove the cysts and lay open the suture sinus tracts with wounds closed with tissue glue with no further complications reported up to time of publication. Level of evidence: V. © 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons.


Manaf Khatib M.K.,St Andrews Center For Plastic Surgery And Burns | Matthew Ives M.I.,St Andrews Center For Plastic Surgery And Burns | Matthew Griffiths M.G.,St Andrews Center For Plastic Surgery And Burns
Journal of Plastic, Reconstructive and Aesthetic Surgery | Year: 2013

A 30 year old tree surgeon presented to our services with a Gustilo IIIB fracture to his right lower leg. An anterolateral thigh flap was planned for the reconstruction. Intraoperatively, there were no suitable perforators seen and a neurocutaneous perforator flap based on the vessels associated with the anterior branch of the femoral cutaneous nerve was used. The nerve was preserved in the flap harvest. He was discharged and later followed up in clinic with no complications. © 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

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