Appearance related distress in both clinical and general populations is associated with the increasing identification of surgery as a solution, leading to referrals for cosmetic surgery and pressure on NHS resources. Cosmetic surgery guidelines are designed to control this growing demand, but lack a sound evidence base. Where exceptions are provided on the basis of psychological need, this may recruit patients inappropriately into a surgical pathway, and creates a demand for psychological assessment which transfers the resource problem from one service to another. The model described below evaluates the impact of a designated psychology service to a plastic surgery unit. Developing an operational framework for delivering cosmetic guidelines, which assesses patients using clearly defined and measurable outcomes, has significantly reduced numbers of patients proceeding to the NHS waiting list and provided a systematic audit process. The associated cost savings have provided a way of funding a psychologist within the plastic surgery service so that psychological assessment becomes routine, alternative methods of treatment are easily available and all patients have access to psychological input as part of the routine standard of care.

Neurofibromatosis is a relatively common inherited disease of the nervous system, with a frequency of almost 1 in 3000. It is associated with a wide range of vascular abnormalities. A 62-year-old man with neurofibromatosis presented to us with a sacral haematoma. This was due to spontaneous rupture of a pre-existing neurofibromata. Upon admission the patient was in hypovolaemic shock and required aggressive resuscitation prior to surgery. Haemorrhage following trauma or spontaneous rupture is an uncommon complication of neurofibromatosis. The management is discussed with emphasis on the cause and control of bleeding from these lesions.

Obtaining access to blood vessels can be difficult, especially in children. Visualization of subsurface blood vessels might be a solution. Ultrasound and visible light have been used to this purpose, but have some drawbacks. Near-infrared light might be a better option since subsurface blood vessels can be visualized in high contrast due to less absorption and scattering in tissue as compared to visible light. Our findings with a multispectral imaging system support this theory.A device, the VascuLuminator, was developed, based on transillumination of the puncture site with near-infrared light. The VascuLuminator was designed to meet the requirements of compact and safe use. A phantom study showed that the maximum depth of visibility (5.5 mm for a 3.6 mm blood vessel) is sufficient to visualize blood vessels in typical locations for peripheral venous and arterial access. A quantitative comparison of the VascuLuminator and to two other vessel imaging devices, using reflection of near-infrared light instead of transillumination, was conducted. The VascuLuminator is able to decrease failure at first attempt in blood withdrawal in pediatric patients from 10/80 (13%) to 1/45 (2%; P = .05).

Toxic shock syndrome is associated with burn injuries in children and is a cause of significant morbidity in this group. Despite multiple cases of toxic shock syndrome in adults being reported since its original description it has not been reported in adult burn patients. We report a case of toxic shock syndrome in an adult following 25% flame burns.

The use of dermofat grafts in the correction of the secondary cleft lip deformity is described. Dermofat graft augmentation of the uper lip is a relatively well established technique in aesthetic surgery, however there have been no previous description of its application in cleft lip surgery. Eleven cases are presented in which dermofat grafts have been used to correct secondary cleft lip deformities. Alternative surgical techniques and the indications for dermofat grafting are discussed.