The Reconstructive Trauma Surgery Fellowship is a based at the Queen Elizabeth Hospital, Birmingham, and focuses on the multidisciplinary management of major trauma from presentation to discharge. It is unique to the UK in that it provides both management and leadership experience as well as operative surgical skills particularly in terms of reconstruction on complex trauma patients including those from the military. This paper describes the relevance of fellowships in modern surgical training, composition of the reconstructive trauma fellowship and the relevance for both civilian and military trainees.

INTRODUCTION:The evolution of medical practice is resulting in increasing subspecialisation, with head, face and neck (HFN) trauma in a civilian environment usually managed by a combination of surgical specialties working as a team. However, the full combination of HFN specialties commonly available in the NHS may not be available in future UK military-led operations, necessitating the identification of a group of skill sets that could be delivered by one or more deployed surgeons. METHOD:A systematic review was undertaken to identify those surgical procedures performed to treat acute military head, face, neck and eye trauma. A multidisciplinary consensus group was convened following this with military HFN trauma expertise to define those procedures commonly required to conduct deployed, in-theatre HFN surgical combat trauma management. RESULTS:Head, face, neck and eye damage control surgical procedures were identified as comprising surgical cricothyroidotomy, cervico-facial haemorrhage control and decompression of orbital haemorrhage through lateral canthotomy. Acute in-theatre surgical skills required within 24 hours consist of wound debridement, surgical tracheostomy, decompressive craniectomy, intracranial pressure monitor placement, temporary facial fracture stabilisation for airway management or haemorrhage control and primary globe repair. Delayed in-theatre procedures required within 5 days prior to predicted evacuation encompass facial fracture fixation, delayed lateral canthotomy, evisceration, enucleation and eyelid repair. CONCLUSIONS:The identification of those skill sets required for deployment is in keeping with the General Medical Council's current drive towards credentialing consultants, by which a consultant surgeon's capabilities in particular practice areas would be defined. Limited opportunities currently exist for trainees and consultants to gain experience in the management of traumatic head, face, neck and eye injuries seen in a kinetic combat environment. Predeployment training requires that the surgical techniques described in this paper are covered and should form the curriculum of future military-specific surgical fellowships. Relevant continued professional development will be necessary to maintain required clinical competency.

The authors regret an incorrect Fig. 1 published in the above mentioned paper. Please find correct figure below: The authors would like to apologise for any inconvenience caused. Craniofacial implants at a single centre 2005-2015: retrospective review of 451 implantsBritish Journal of Oral and Maxillofacial SurgeryVol. 55Issue 3PreviewCraniofacial endosseous implants are regularly used to support prostheses in the rehabilitation of complex defects, but reported success rates vary. To review our own clinical practice over 10 years, and particularly to examine the impact of radiotherapy and the timing of placement on the survival of implants, we retrospectively audited the records for all patients who had endosseous implants for prosthetic rehabilitation in our unit between 2005 and 2015. We reviewed 167 records, which gave 451 implants, of which, 222 (49%) were auricular, 98 (22%) nasal, and 131 (29%) orbital. Full-Text PDF

Craniofacial endosseous implants are regularly used to support prostheses in the rehabilitation of complex defects, but reported success rates vary. To review our own clinical practice over 10 years, and particularly to examine the impact of radiotherapy and the timing of placement on the survival of implants, we retrospectively audited the records for all patients who had endosseous implants for prosthetic rehabilitation in our unit between 2005 and 2015. We reviewed 167 records, which gave 451 implants, of which, 222 (49%) were auricular, 98 (22%) nasal, and 131 (29%) orbital. Most were placed after ablative operations for cutaneous malignancy (n=103 patients, 62%). The failure rate of implants placed in bone that was irradiated either before or after placement was significantly higher than that of those placed in non-irradiated bone (univariate analysis: 11% compared with 2%, p<0.001: Kaplan-Meier survival analysis: p<0.001). The timing of placement in relation to radiotherapy (before compared with after) seemed to have no impact on success (p=0.96). Our findings are in keeping with previous reports, and the principal observation is that radiotherapy adversely affects success. We work closely with our maxillofacial prosthetists and place implants at the time of ablation. Our findings seem to support this practice regardless of whether or not the patient will later require adjuvant radiotherapy.

VIRTUS is the first United Kingdom (UK) military personal armour system to provide components that are capable of protecting the whole face from low velocity ballistic projectiles. Protection is modular, using a helmet worn with ballistic eyewear, a visor, and a mandibular guard. When all four components are worn together the face is completely covered, but the heat, discomfort, and weight may not be optimal in all types of combat. We organized a Delphi consensus group analysis with 29 military consultant surgeons from the UK, United States, Canada, Australia, and New Zealand to identify a potential hierarchy of functional facial units in order of importance that require protection. We identified the causes of those facial injuries that are hardest to reconstruct, and the most effective combinations of facial protection. Protection is required from both penetrating projectiles and burns. There was strong consensus that blunt injury to the facial skeleton was currently not a military priority. Functional units that should be prioritised are eyes and eyelids, followed consecutively by the nose, lips, and ears. Twenty-nine respondents felt that the visor was more important than the mandibular guard if only one piece was to be worn. Essential cover of the brain and eyes is achieved from all directions using a combination of helmet and visor. Nasal cover currently requires the mandibular guard unless the visor can be modified to cover it as well. Any such prototype would need extensive ergonomics and assessment of integration, as any changes would have to be acceptable to the people who wear them in the long term.

Skin cancers such as malignant melanoma, squamous cell carcinoma, and basal cell carcinoma are common on the scalp, 1 Ouyang Y.H. Skin cancer of the head and neck. Semin Plast Surg. 2010; 24: 117-126 Crossref Google Scholar and the usual treatment is wide local excision with disease- free margins. Margins vary depending on the type of cancer, the size and depth of invasion, and the cytological findings, as described in the British Association of Dermatology guidelines. 2 British Association of Dermatologists: Clinical guidelines. URL: www.bad.org.uk (accessed 10 February 2016). Google Scholar

Cnidaria stings cause a wide range of cutaneous and systemic symptoms, normally occurring shortly after the venomous insult (1). We report a case of worsening cutaneous reaction over an eight-year period following a Cnidaria attack sustained whilst maritime swimming. The lesion was characterised by severe, ulcerating chronic inflammation that required wide local excision and skin grafting. Prevention and early identification of Cnidaria envenomation is important for those treating maritime swimmers.

Explosive weapons remain the leading cause of death, injury, and disability to combatants in battle. Recent conflicts in Iraq and Afghanistan have seen considerable advances in the surgical knowledge and skills needed to save life and limb of multiply injured casualties. Global terrorism has seen explosive weapons move from battlefield to urban centres, often with devastating effects.

Interface fellowships have been created in areas where surgical specialties overlap to offer doctors the benefits of multidisciplinary teaching and surgical practice. Unbundling specialty territoriality in this way allows the fellows to expand their understanding of surgery and improve their ability to provide the best quality care for their patients.1 The United Kingdom has 18 interface fellowships in reconstructive aesthetic surgery, 10 in hand surgery, nine in breast and oncoplastic surgery, seven in head and neck surgery, and six in cleft lip and palate surgery.2 These fellowships are open to surgical trainees from numerous specialties and have approval from the General Medical Council, the royal colleges, and postgraduate deaneries. The reconstructive trauma surgery interface fellowship at the Queen Elizabeth Hospital, Birmingham, is a new addition to the interface fellowship family and has been running for a year. The posts were initially for three months but have now been increased to four months after feedback from fellows, with start dates in March, July, and November. The main aims of the fellowship are for doctors to take an active role in all aspects of major soft tissue and skeletal trauma and to work closely with all individuals and teams involved …

The concept of ‘the military wound’ is not an easy entity to define as the wounds seen in conflict can be of many types: those caused by recognised or improvised weapon systems may have similarities to civilian wounds as well as the wounds soldiers sustain outside of battle. This paper will focus on the current treatment approaches to wounds sustained by deployed UK Armed Forces Personnel and caused by a weapon system. Since 2001, the majority of military wounds sustained by UK Armed Forces Personnel have been caused during conflicts in Iraq and Afghanistan. During this time, there have been evolutions in the conduct of the conflicts and modifications to medical care. These have led to a change in the types and severity of injuries now requiring reconstruction. Explosive devices used against coalition forces are increasingly popular owing to their low cost, ease of construction, magnitude of devastation and their ability to be detonated remotely with little or no risk to the perpetrator. Use of such devices has been shown to produce a higher proportion of extremity injuries than seen in previous conflicts fought with conventional firearms [1]. Explosive munitions were the mechanism of injury in 75% of wounds sustained by 1281 US service personnel in Operations Iraqi Freedom (OIF) and Enduring Freedom (OEF) between October 2001 and January 2005. Only 16% of wounds were gunshot injuries [2]. Of 68 Navy and Marine Corps casualties treated at the Naval Medical Centre, San Diego between April 2003 and December 2005, Improvised Explosive Devices (IEDs) were responsible for 55% of wounds treated [3]. 54% of casualties presenting to a British Field Hospital in Iraq between January and October 2006 had sustained injury secondary to improvised explosive devices, representing the most common mechanism [4]. In response to this changing threat, there have been rapid adaptations of Personal Protective Equipment and in design and armouring of vehicles.This has led to a reduction in the proportion of casualties sustaining fatal torso or head penetration. The effects of blast have been fully described [5-7] and the resultant injury patterns are well recognised (Figure 1). These are predominantly traumatic amputations with extensive bony fractures and soft tissue disruption associated with heavy contamination. The limbs are most commonly involved, extremity injury being found in 67.8% of casualties seen at a British Field Hospital in Iraq during the first ten months of 2006 [4]. Geiger et al found that extremity injuries accounted for 91.2% of injuries in OIF 1 and 2 [3]. Figure 1. Extremity injury as a result of close proximity to explosive device