**Background:** Delphi research priority setting exercises in plastic and reconstructive surgery aim to encourage future research in areas that align with clinical needs. This can guide the allocation of research funding and further the knowledge base of the speciality. This systematic review evaluates the content and quality of existing Delphi research priority setting studies in plastic and reconstructive surgery, to inform future studies. **Method:** A predefined protocol and PRISMA guidelines were followed. The search was performed by a research librarian. Screening and data extraction was performed in duplicate with a third reviewer arbitrating. Primary outcomes included the number of studies and subject areas. Secondary outcomes were the methods and results (including types of stakeholders, uncertainties, numbers of stakeholders, journal impact factor, implementation plans and dissemination plans). The risk of bias was assessed using four domains of quality. Data underwent synthesis with descriptive statistics. **Results:** Seven articles were included in the review, covering breast reconstruction, craniomaxillofacial, burns, aesthetics, skin and soft tissue, and general plastics. Studies had national or international scope, used either Delphi or modified Delphi methodology, and had a variable number of rounds. Four included studies had funding, and implementation plans were absent in four included studies. **Discussion and conclusion:** Included studies had a variable methodology, making a direct comparison between studies difficult. Six of the seven included studies had a high or moderate risk of bias, and implementation plans for studies were variable or absent. The review highlights the need for future Delphi research priority setting exercises to have a more standardised method and adhere to quality criteria.

BACKGROUND:Absorbable or non-absorbable sutures can be used for superficial skin closure following excisional skin surgery. There is no consensus among clinicians nor high-quality evidence supporting the choice of suture. The aim of the present study was to determine current suture use and complications at 30 days after excisional skin surgery.METHODS:An international, prospective service evaluation of adults undergoing excision of skin lesions (benign and malignant) in primary and secondary care was conducted from 1 September 2020 to 15 April 2021. Routine patient data collected by UK and Australasian collaborator networks were uploaded to REDCap©. Choice of suture and risk of complications were modelled using multivariable logistic regression.RESULTS:Some 3494 patients (4066 excisions) were included; 3246 (92.9 per cent) were from the UK and Ireland. Most patients were men (1945, 55.7 per cent), Caucasian (2849, 81.5 per cent) and aged 75-84 years (965, 27.6 per cent). The most common clinical diagnosis was basal cell carcinoma (1712, 42.1 per cent). Dermatologists performed most procedures, with 1803 excisions (44.3 per cent) on 1657 patients (47.4 per cent). Most defects were closed primarily (2856, 81.9 per cent), and there was equipoise in regard to use of absorbable (2127, 57.7 per cent) or non-absorbable (1558, 42.2 per cent) sutures for superficial closure. The most common complications were surgical-site infection (103, 2.9 per cent) and delayed wound healing (77, 2.2 per cent). In multivariable analysis, use of absorbable suture type was associated with increased patient age, geographical location (UK and Ireland), and surgeon specialty (oral and maxillofacial surgery and plastic surgery), but not with complications.CONCLUSION:There was equipoise in suture use, and no association between suture type and complications. Definitive evidence from randomized trials is needed.

Background: Delirium is an acute cerebral disorder characterised by a disturbance in cog-nition, attention, and awareness. Often, it's undiagnosed and associated with increased morbidity and mortality. For burn patients, the reported prevalence ranges from 16% to 39%, with a multifactorial aetiology, increasing when intensive care is required. A direct comparison of delirium between surgical specialities has not been made.Aim: 1. To audit the use of the 4AT for those who become delirious during their stay. 2. Assess the proportion of patients diagnosed with delirium during hospitalisation by surgical specialities. 3. Identification of the factors associated with delirium in surgical patients.Methods: Investigators at a single centre conducted a two-phase study. An initial retro-spective audit of delirious patients under burns, general, and orthopaedic specialities over 16months, as defined by ICD-10 coding, identified compliance screening with the 4 A's Test. This informed the design of a retrospective, observational cohort study to compare factors associated with delirium and statistical comparison between four specialities to identify delirium-associated factor, where an analysis corrects for age.Results: 37% of patients with an ICD-10 code indicating delirium had a 4AT test completed. Speciality, number of operations, LOS, ICU hours, age, and discharge destination were all statistically significant independent variables. When all other variables were equal, burns had the highest predicted probability of delirium diagnosis.Conclusions: Further analysis to identify and diagnose across the specialties is required. From a patient viewpoint, their LOS, ICU hours, and operations are increased for patients coded as delirious compared to non-delirious across the specialities. On a hospital level, the mean difference in cost for a delirious compared to a non-delirious patient is AU$9317. Despite the low incidence of delirium amongst the observed specialities, burns patients were most likely to develop delirium when demographic and clinical profiles were the same, and were more likely to develop delirium at a younger age and if in ICU.(c) 2023 Published by Elsevier Ltd.

While the internet is an invaluable resource for both patients and healthcare providers in the management of burns, websites are often unregulated and highly variable in the quality of their content. Burns centres are in the unique position of possessing presumed reputability amongst the public. It is therefore imperative that their websites provide information that is consistent in its content, through a format that is accessible and coherent. In this study, we aimed to evaluate first aid websites of burns centres in the UK, Ireland, USA, Canada, Australia and New Zealand. This study highlights the importance of the leadership role that these centres should possess online. A multicentre, observational, cross-sectional study was performed over a period of two years (October 2020 to July 2022). Each centre’s website was evaluated using a 10-point scoring system to assess burns first aid content accuracy. The content was evaluated using a scoring system by Burgress et al, that is based on the basic burns first aid principles of “stop, remove, cool and cover”. 188 burn centres across the stated countries were included. The country with the highest average score was Australia & New Zealand (5), followed by the USA (2.89), Canada (1.78) and the UK & Ireland (2.89). The consistency of content and quality of these resources remains an area for potential improvement and should be considered in the future design of such websites. The most common step missed in burn first aid was to keep victims warm to prevent hypothermia.

Introduction: Keloid scars are associated with physical and psychological sequelae. No studies have investigated the general public's understanding of keloids. Targeted, short educational interventions in susceptible individuals may aid understanding of the condition and compliance with treatment. We aimed to identify the population with the highest prevalence and lowest knowledge. Methods: We surveyed four countries to determine the public's understanding of keloids. A quantitative, subjective and cross-sectional street survey was designed using the knowledge, attitudes and practice model principles. The target populations were cities in Ghana, Aus-tralia, Canada and England. Surveyors used a hybrid stratified/convenience sampling method. Primary outcomes were prevalence, exposure to keloids as an entity and overall keloid knowl-edge score compared across demographic groups. Study data have been made fully available for reproducibility and education ( https://doi.org/10.17605/OSF.IO/3KZ5E ).Results: There were 402 respondents, with a median age of 32 (interquartile range 25-45.25) years, of which 193 were females. The survey was carried out between June 2015 and Octo-ber 2017. The prevalence of self-identified keloids was 11% in Ghana, 6% in Australia, 2% in Canada and 7% in England. Prevalence, exposure and knowledge were higher in the Ghanaian population. Conclusions: There was association between knowledge, prevalence and the exposure to keloids as an entity. Findings may suggest targeting public health campaigns towards popu-lations where knowledge is lowest, and exposure to and prevalence of keloids are the highest.(c) 2022 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by El-sevier Ltd. All rights reserved.

Introduction: Delirium is a potentially modifiable, acutely altered mental state, commonly characterised as a hospital-acquired complication. Studies of adult inpatients with acute burns with and without delirium identify causative risks related to the injury or treatment and outcomes related to the patient and healthcare system. We compare patients with and without delirium, providing a high-level quantitative synthesis of delirium risks and out-comes to inform guidelines and future research. Methods: A systematic review, meta-analysis and GRADE evaluation of risks and outcomes associated with delirium in adults with acute burns was conducted using PRISMA guidelines and PROSPERO protocol CRD42021283055. The Newcastle-Ottawa Scale was used to assess quality. Results: Investigators reviewed ten studies. ASA score >= 3, Total Body Surface Area Percentage (TBSA) > 10%, surgery done, ICU admission, hospital and also Intensive Care Unit (ICU) lengths of stay all had statistically significant associations with delirium, with low-very low certainty on GRADE evaluation. Limitations were heterogeneous studies, review methodology and study bias. Conclusion: Delirium represents a significant risk to comorbid patients with burns that are hospitalised, receive ICU care, and surgery. Further research is indicated to precisely categorise delirium along the clinical journey to identify modifiable factors, prevention, and proactive therapy. (C) 2022 Elsevier Ltd and ISBI. All rights reserved.

Skin and wound blotting are non-invasive techniques used to sample the skin and wound surface chemistry, whereby a nitrocellulose membrane is applied to an intact or broken cutaneous surface to detect biomarkers. However, there has been no comprehensive review of the evidence for the techniques used and data obtained to date. The primary aim of this study was to review the utilities of surface blotting for the diagnosis and prognosis of physiological, pre-disease, and pathological states. The secondary aim was to summarise the procedural steps. A systematic literature search was conducted on 9 July 2021 using Medline, Embase, and Google Scholar databases. Investigators used McMaster's Critical Review Form for Quantitative Studies to assess quality, then performed a narrative synthesis reporting according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Twenty-five studies were reviewed. Eighteen studies were of good quality, and seven were of moderate quality. These studies conducted skin and wound blotting on 176 animals and 1546 humans. Studies reported physiological and pathological states for diagnosis and prediction of conditions, including skin tears, wound healing, biofilm detection, and skin barrier function. The four steps for blotting are surface preparation, blot preparation, application and removal of blot, and analysis. This review demonstrates that blotting can determine the skin and wound surface chemistry using a versatile and reproducible technique. However, future research is needed to validate the technique and skin biomarkers identified.

Raw survey data for international clinician survey

A 71-year-old male presented with a 15-hour history of migratory right lower quadrant (RLQ) abdominal pain. He had no nausea, vomiting, diarrhoea, dysuria or recent illnesses. His medical history was significant for a laparoscopic-assisted radical prostatectomy (2016) and laparoscopic right inguinal & femoral hernia repair (2011). A colonoscopy 2 years prior was unremarkable. Examination revealed a soft abdomen, no masses but tenderness to light palpation in the RLQ. Vital signs were normal. Full blood count, urea, electrolytes & creatinine, liver function tests and lipase were normal, while C-reactive protein was elevated at 11 mg/L. Computed tomography (CT) of the abdomen and pelvis with portal venous contrast reported a right-sided, ventrolateral or Spigelian hernia containing inflamed appendix with tip located between external oblique aponeurosis and internal oblique muscles (Fig. 1). We performed a confirmatory ultrasound, which suggested uncomplicated appendicitis in a spigelian hernia (Fig. 2). The patient underwent laparoscopic appendicectomy and hernia repair. Intra-operative findings showed a hernial gate 5 mm wide, consistent with a Spigelian hernia and incarcerated appendicitis within (Fig. 3). The appendix was removed via an Endo Catch™ with Endo Close™ repair of the hernia using interrupted 0 PROLENE sutures (MEDTRONIC, Minneapolis, US). The patient was discharged the next day without complications. Histology confirmed acute, suppurative appendicitis. Informed consent was obtained from the patient for publication of this case. Appendicitis is common, with a 7%–8% lifetime risk,1 while Spigelian hernias are relatively rare, accounting for <2% of all hernias.2 The rate of hernial appendicitis is 0.008%, most common in inguinal and femoral hernias.3 18 published studies reported appendices within Spigelian hernias. Light (2013) reported Spigelian hernia diagnosis with ultrasound had sensitivity of 90% and positive predictive value of 100%, while CT was 100% & 100%, respectively.4 12/18 (67%) studies obtained preoperative diagnosis from CT; the rest were diagnosed intraoperatively. In our case, a CT abdomen (2016) showed no hernia pre-prostatectomy, while contemporary CT, ultrasound, and intraoperative findings suggested an acquired Spigelian. Confirmatory ultrasound may have been redundant. Spieghel identified the semilunar line (linea Spigeli) in 1645. Klinkosch (1764) named the eponymous hernia resulting from its defect. These can be acquired or congenital (hypothetically from abdominal muscle aponeurotic weakness during mesenchyme development in the somatopleura2). In our case, an incisional hernia through a laparoscopic port site was a significant differential however, the hernia was separate from previous incisions. Spigelian hernias are predisposed to incarceration due to a typically small (<2 cm) hernial gate with a sharp fascial edge.5-7 The rate of strangulation was reported as 2%–14%.8 In our case, a narrow hernial gate caused extraluminal compression leading to impaired venous return and ischaemia. The literature reports open surgery in 11/18 (61%) cases and laparoscopic intra-abdominal approaches in 5/18 (28%). In 4/18 (28%), surgeons used mesh to repair the hernia at the primary operation. Only 3/18 (17%) reported studies described finding a normal appendix. This case demonstrates the anatomy, workup and management of appendicitis within a Spigelian hernia and underlines the value of preoperative imaging and laparoscopic repair. The corresponding author is the recipient of the Cynthia Banham Burn Injury Research Fellowship [Ian Potter Foundation; 2021] and received the Australian Government Research Training Program Fees Offset Scholarship for a higher degree [University of Western Australia; 2022]. This case has not been reported, presented or published before. Open access publishing facilitated by The University of Western Australia, as part of the Wiley - The University of Western Australia agreement via the Council of Australian University Librarians. Guy H. M. Stanley: Data curation; formal analysis; investigation; project administration; writing – original draft; writing – review and editing. Tristan Gilliland: Data curation; formal analysis; investigation; project administration; writing – original draft; writing – review and editing. Matthew W. Trinder: Conceptualization; methodology; supervision; validation; writing – review and editing. Yu Xin Liew: Writing – review and editing. Enoch Wong: Methodology; supervision; validation; writing – review and editing. Jennifer Ryan: Supervision; validation; writing – review and editing.

Many specialist groups have developed clinical trial initiatives in response to the growing need for more collaborative research, and these are proliferating in multiple countries across the globe. The Royal Australasian College of Surgeons (RACS), under the direction of Professor John Windsor, established the clinical trials network of Australia and New Zealand (CTANZ). CTANZ supports the Australasian clinical trials in plastic, reconstructive and aesthetic surgery (ACTPRAS) research group which has already facilitated two multicentre, international, collaborative studies.

Abstract Introduction Surgical site infection (SSI) is the most common and costly complication of surgery. International guidelines recommend topical alcoholic chlorhexidine (CHX) before surgery. However, upper limb surgeons continue to use other antiseptics, citing a lack of applicable evidence, and concerns related to open wounds and tourniquets. This study aimed to evaluate the safety and effectiveness of different topical antiseptics before upper limb surgery. Methods This international multicentre prospective cohort study recruited consecutive adults and children who underwent surgery distal to the shoulder joint. The intervention was use of CHX or povidone–iodine (PVI) antiseptics in either aqueous or alcoholic form. The primary outcome was SSI within 90 days. Mixed-effects time-to-event models were used to estimate the risk (hazard ratio (HR)) of SSI for patients undergoing elective and emergency upper limb surgery. Results A total of 2454 patients were included. The overall risk of SSI was 3.5 per cent. For elective upper limb surgery (1018 patients), alcoholic CHX appeared to be the most effective antiseptic, reducing the risk of SSI by 70 per cent (adjusted HR 0.30, 95 per cent c.i. 0.11 to 0.84), when compared with aqueous PVI. Concerning emergency upper limb surgery (1436 patients), aqueous PVI appeared to be the least effective antiseptic for preventing SSI; however, there was uncertainty in the estimates. No adverse events were reported. Conclusion The findings align with the global evidence base and international guidance, suggesting that alcoholic CHX should be used for skin antisepsis before clean (elective upper limb) surgery. For emergency (contaminated or dirty) upper limb surgery, the findings of this study were unclear and contradict the available evidence, concluding that further research is necessary.

Introduction Achieving a standard of clinical research at the pinnacle of the evidence pyramid is historically expensive and logistically challenging. Research collaboratives have delivered high-impact prospective multicentre audits and clinical trials by using trainee networks with a range of enabling technology. This review outlines such use of technology in the UK and provides a framework of recommended technologies for future studies. Methods A review of the literature identified technology used in collaborative projects. Additional technologies were identified through web searches. Technologies were grouped into themes including access (networking and engagement), collaboration and event organisation. The technologies available to support each theme were studied further to outline relative benefits and limitations. Findings Thirty-three articles from trainee research collaboratives were identified. The most frequently documented technologies were social media applications, website platforms and research databases. The Supportive Technologies in Collaborative Research framework is proposed, providing a structure for using the technologies available to support multicentre collaboration. Such technologies are often overlooked in the literature by established and start-up collaborative project groups. If used correctly, they might help to overcome the physical, logistical and financial barriers of multicentre clinical trials.

Introduction: Abdominal-based microvascular breast reconstruction constitutes approximately one-fifth of reconstructions following mastectomy for breast cancer. Enhanced recovery after surgery (ERAS) protocols have been implemented to improve patient care. The aim of this project was to identify variation in the perioperative care of women undergoing microvascular breast reconstruction to inform development of an ERAS protocol. Methods: Surveys were developed for plastic surgeons, anaesthetists and the lead clinician for breast reconstruction at each unit. These assessed most aspects of perioperative care. A team of medical student collaborators was identified. This team created a list of surgeons and anaesthetists in the United Kingdom by unit. REDCap was used to record their responses. Results: Nineteen (19/39, 49%) lead clinicians, 83 (83/134, 62%) plastic surgeons and 71 (71/100, 71%) anaesthetists from units across the UK completed the surveys. Marked variation was identified in the clinician responses when compared with the national and international guidelines. This variation covered many aspects of patient care including antibiotic and fluid prescribing, surgical technique, post-operative care and recording of patient outcomes. Conclusions: The optiFLAPP national practice survey has demonstrated variation in the perioperative care of women undergoing abdominal-based microvascular breast reconstruction. We propose a large prospective audit to assess current protocols and support development of randomised controlled trials. (C) 2018 Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and Aesthetic Surgeons.