The advent of highly active antiretroviral therapy (HAART) has dramatically improved the life expectancy of people infected with human immunodeficiency virus (HIV). Although patients often have excellent disease control with these combinations of antiretrovirals, they are at risk for the multiple toxicities associated with these drugs. Facial lipoatrophy is a particularly distressing complication of some HAART regimes. This disfigurement can lead to significant psychosocial stress, resulting in decreased treatment compliance. Polylactic acid (PLA) facial implants provide a potential method of restoring a normal appearance.One hundred consecutive patients had a course of PLA facial implants. All patients were assessed clinically and had photographs, facial surface laser scans and completed psychological questionnaires throughout the course of treatment.After a mean of 4.85 treatments per patient, there were improvements in all measures. The mean clinical scores improved from a moderate-severe grade to none-mild grade after treatment. Three-dimensional (3D) laser surface scans showed a volume increase of 2.81 cc over the treated area of the cheek. There were significant improvements in all of the psychological measures.This study shows clear objective evidence of the psychological and physical benefit of PLA implants in HIV-associated facial lipodystrophy. (C) 2008 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

INTRODUCTION Postoperative wound infections are common. Antibiotics are often prescribed empirically, usually in the absence of any microbiological sensitivity data. This study demonstrates the role of fine-needle aspiration microbiology (FNAM) in determining the causative organisms in these wounds compared to wound swabs taken from the same patients. PATIENTS AND METHODS A total of 20 patients with clinical signs of soft tissue infection were tested using wound swabs and fine-needle aspiration. RESULTS Six of the wound swabs yielded a single organism but 16 out 20 of the FNAM group yielded a single organism (P = 0.002). CONCLUSIONS The FNAM approach allows antibiotic sensitivities to be obtained enabling specific antimicrobial therapy to be implemented early. FNAM also has a higher yield of cultures than wound swabs. Cellulitic areas can be sampled even when use of wound swabs is not possible.

Introduction: July 7, 2005 saw the detonation of four terrorist devices in London, generating in excess of 700 casualties. We present our experience as one of three major receiving centres and the lessons learnt. Methods: Prospective data were collected regarding the injury pattern and treatment of all patients admitted to UCLH and the manpower requirements to deliver treatment. Results: Landline and mobile telephone communications were near impossible during the first 2 h with little information available from the scenes of the incidents. Early documentation was poor. Sixty-seven patients were assessed in accident and emergency, 15 patients were admitted (5 to the intensive care unit). There was one in-hospital death. Characteristic patterns of blast injury were identified at point of admission, however, 8 significant injuries, including 2 spinal fractures, went undetected until the second day. These admissions had 52 surgical procedures over a 3-week period, 29 within the first 4 days. Definitive wound closure was achieved in most patients by their third visit to theatre (mean 6 days). Conclusions: During this event the hospital's major incident plan was deployed and functioned adequately despite early failure of the communication cascade. The large volume of casualties arriving in a short period of time combined with difficulties in patient identification and tracking provided a significant obstacle to continuity of care. Despite missing several significant injuries in the opening phase, no avoidable mortality or long-term morbidity occurred. Nevertheless, this highlights the importance of continual reassessment, with serial secondary surveys of all casualties. Continuity of care is integral to achievement of this goal.

INTRODUCTIONDespite awareness of the limitations of current selection and competency assessments, there is little consensus and alternatives have not been readily accepted. Essential surgical skills include visuospatial and technical ability. The aim of this study was to survey current methods of higher surgical trainee selection and assessment. We suggest ways to improve the process.MATERIALS AND METHODSNine surgical training programmes in the London deanery were surveyed through questionnaires to programme directors, existing trainees and examination of deanery publications.RESULTSTesting of visuospatial and technical ability was piloted at selection only in a single general surgical department. Practical skills were assessed in 3/9 (33%) specialties (ENT, plastic and general surgery). Once selected, no specialty tested visuospatial and technical ability. Practical skills were tested in only 1/9 (11%) specialties (plastic surgery). The remaining 8/9 (89%) were 'assessed' by interview.CONCLUSIONSLack of visuospatial and technical ability assessment was identified at selection and during higher surgical training. Airlines have long recognised early identification of these qualities as critical for efficient training. There is a need for more objective methods in this area prior to selection as time to assess surgical trainees during long apprenticeships is no longer available. We advocate a suitably validated competency-based model during and at completion of training.

Approximately 50% of patients on highly active antiretroviral therapy (HAART) develop lipodystrophy with central and visceral fat accumulation and/or facial and limb atrophy. Although the exact mechanisms of this are not fully understood, the facial atrophy encountered is secondary to atrophy of the subcutaneous fat, and not the deeper fat pads, as has been suggested. More recently, the above features in combination with hyperlipidaemia and insulin resistance have been described and are referred to as HIV-related fat redistribution syndrome. This review looks at treatment options available for this stigmatizing condition.

Hettiaratchy and Butler (Lancet 2002;360:5-6) framed face transplantation as the next logical step on the reconstructive ladder for severe facial injury, in particular, pan-facial burns. The procedure formed the basis for a Royal College of Surgeons of England working party report. Ethical, surgical, and psychological issues were identified as research priorities before face transplantation is attempted in the United Kingdom. Public engagement is a vital mechanism if people are to be informed about the risks and benefits of the technique and ultimately to be able to consent to either receiving or donating facial tissue. To sample public opinion about the procedure, 304 people attending the Royal Society Summer Science Exhibition were sampled by online questionnaire to determine their attitude toward face transplantation. Although people were more cautious about face transplantation when comparing this with solid-organ transplantation, most of the sample were in favor of the procedure, whether receiving a donor face or donating their own face after their death. Only 10% were against the idea in principle. Concerns about altered identity were not a barrier to face transplantation for 69% of the sample, with most people appropriately identifying the long-term problems of immunosuppression as the issue that most concerned them. There is a substantial population of people who, given the right circumstances, would contemplate face transplantation for themselves and would be willing to donate their own face for transplantation after their death.

There has recently been an increase in the usage of the Internet as a source of patient information. It is very difficult for laypersons to establish the accuracy and validity of these medical websites. Although many website assessment tools exist, most of these are not practical.A combination of consumer- and clinician-based website assessment tools was applied to 200 websites on cosmetic surgery. The top-scoring websites were used as links from a portal website that was designed using Microsoft Macromedia Suite.Seventy-one (35.5%) websites were excluded. One hundred fifteen websites (89%) failed to reach an acceptable standard.The provision of new websites has proceeded without quality controls. Patients need to be better educated on the limitations of the Internet. This paper suggests an archetypal model, which makes efficient use of existing resources, validates them, and is easily transferable to different health settings.

Stage IV metastatic malignant melanoma of unknown primary (TxNxM1a) is known to have a poor prognosis. However, some patients suffering from cutaneous disease originally thought to represent metastasis have fared much better than expected. We report a patient who has survived 11 years following such a diagnosis. Due to the prolonged survival and absence of an identified primary, it is unlikely that the lesion was metastatic but may represent one of a number of other possibilities. A small number of similar cases in the literature suggest a need for awareness of this unusual group of patients.

BACKGROUND:Necrotizing fasciitis (NF) is an uncommon but serious infection of fascia and skin associated with considerable morbidity and mortality. One modality proposed for improving the outcome of this condition is hyperbaric oxygen (HBO) therapy. This is a form of medical treatment that involves intermittent inhalation of 100% oxygen under pressures exceeding the atmosphere. The aim of this article is to review current practice and evidence for the use of HBO as adjunctive therapy in the management of NF. METHODS:A survey of published English literature through searches of Medline and PubMed was carried out using the following key words: "necrotizing fasciitis," "Fournier's gangrene," "necrotizing soft tissue infections," "hyperbaric oxygen therapy," "and hyperbaric oxygen chambers." RESULTS:The results of studies on the use of HBO therapy in NF are inconsistent. Some studies have demonstrated that HBO can improve patient survival and decrease the number of debridements required to achieve wound control, whereas others have failed to show any beneficial effect. CONCLUSIONS:Encouraging results have been achieved with the addition of HBO therapy to standard treatment regimes, thus justifying further research in this field. More robust evidence by way of a prospective randomized trial is necessary before widespread and routine use of HBO in the management of NF can be recommended.

The process of diagnosis and treatment can be seen as a series of decisions in which the probability of one outcome is compared with the probability of another in a series of steps using a set of heuristics derived either from experience or from medical evidence. A decision tree can be defined as the diagrammatic representation of this choice between different options.1 Guidelines and protocols are informal decision trees, but they may not take into account decision-making concepts such as heuristics or bias as explicitly as a formal decision tree. Formalizing the decision-making process reduces potential bias and provides a process that is transparent to both residents and patients. This process has been used successfully in elective hysterectomy selection, to increase the number of patients proceeding to hysterectomy via a vaginal as opposed to an abdominal route, with benefits in terms of improved surgical outcome and reduced costs.2 Since plastic surgery commonly involves complex decisions that take into account not only potential surgical outcomes but also patients’ expectations, there is a clear potential for using decision trees to formalize the process of selection and provision of information for different conditions. The basic concepts used in making a formal decision tree are illustrated in this editorial using the example of reduction mammaplasty.3 There are four main steps to decision analysis: Creating a decision tree. This step is the most difficult, because it requires formulating the decision problem, assigning probabilities, and measuring outcomes. This step relies on good auditing and evidence-based practice. Calculating the expected value of each decision alternative. Choosing the decision alternative with the highest expected value. Using sensitivity analysis to test the conclusions of the analysis. Plastic surgeons may recognize the opportunity for error in assigning values to the probabilities in a decision tree. They reason that the technique encourages decision making based on small differences in expected values that are estimates at best. The defense against this concern, which also has been recognized by decision analysts in business and engineering, is the technique known as sensitivity analysis. In sensitivity analysis, a risk assessment is made for the best and worst cases based on evidence from the literature and the surgeon’s own experiences, and defined in terms of quality-of-life outcomes. This can be used to test the potential value of a decision for different scenarios to see to what extent a choice can be justified. The patient then has the information on which to either decline or accept the risk. Bilateral breast reduction is a commonly performed procedure with good evidence for successful outcome in terms of functional improvement, notably relief of back and cervical pain. However, as with all surgical procedures, there are associated risks, and plastic surgery generally is expensive compared with other forms of surgery, although recent evidence has suggested a clear psychological benefit for some patients despite the greater cost relative to other surgical treatments.4,5 According to evidence from the United States and the United Kingdom, public demand for this operation has increased while funding has decreased.6 This increasing pressure means that it is important to provide clearly defined evidence of benefit, particularly for procedures that are life enhancing rather than life saving. Formal decision-making methods may be a useful way forward. Using the above-described conventions of decision analysis, a decision tree was created (Fig. 1). A square box represents a decision node, and each line emanating from a decision node represents a possible action. Events under the control of chance are represented diagrammatically in the decision tree by a circular chance node. Each line represents a possible outcome, and associated with each line is the probability of the outcome occurring.Fig. 1: Decision tree for reduction mammaplasty. Squares represent decision nodes, and lines emanating from these nodes represent possible actions. The circle represents the chance node, or the events under the control of chance.In the decision tree shown in Figure 1, these probabilities are based on evidence. A single patient had one or many outcomes for which the average value of the all outcomes was calculated. It was the frequency of the outcomes of many patients experiencing the same event that informed our opinion about what might happen to an individual. From these frequencies, we estimated the probability of each outcome at each stage of the decision-making process. The concept of expected value was illustrated by looking at the chance node in the decision tree named “operate.” Patients who were candidates for surgery had six possible outcomes. Using the evidence in the literature for complications from reduction mammaplasty, we assigned probabilities to these outcomes. Thus, the incidence of hypertrophic scarring was 0.05 percent and the incidence of nipple loss was 0.01 percent. Outcomes after 1 year were used. When the patient first presented to the plastic surgery department, she was either symptomatic or nonsymptomatic and clinically needed more than 500 g of breast tissue removed. According to the methods of formal decision making, a probability was assigned to each branch emanating from the chance node. Psychological assessment—historically argued to be too subjective for formal decision modelling—can also be incorporated into the decision tree using standardized psychometric scales, such as the Derriford Appearance Scale, or pain measures, to counter objections of subjectivity.7 In a reduction mammaplasty, breast cup size and anatomical sternal notch–to–nipple distance are used to judge the degree of breast deformity. This can be incorporated into a formal decision model.8–10 Decisions about sources of funding can also be incorporated into the tree. In the decision tree shown in Figure 1, it was found that the patient’s local health authority had previously funded 70 percent (via the taxpayer) of cases referred for reduction mammaplasty. Thus, the percentage of patients who made it through the decision process to this point was 42 percent. This value was calculated by multiplying the probabilities found on the top arms of the decision tree (100 percent × 0.9 × 0.99 × 0.8 × 0.85 × 0.7 = 42 percent). Numerical values were derived from known published outcomes.11 These outcomes were classified into two groups: length of life (survival) and quality of life (functional status). To characterize each outcome accurately, these two outcomes were converted into a single outcome with one dimension: duration of survival with pleasing aesthetic outcome. The resulting measure was the quality-adjusted life year. The expected value of quality-adjusted life years was calculated by multiplying the health utility value on the right (the tips of the tree) by those on the left (the root of the tree). For example, the quality-adjusted life year for an uneventful recovery with no back pain or depression was 55 × 0.78 × 0.8 × 0.7 × 0.85 × 0.8 × 0.99 × 0.9 = 14.54 quality-adjusted life years. The concept of the quality-adjusted life year may be presented to the patient by asking him or her, “Now that you have been informed of the complications of the surgery, would you be prepared to accept any one of these complications in preference to your current state now?” The question is applied to each of the possible complications arising from surgery.12 The average life expectancy for a woman in the United Kingdom is 80.5 years. The 25-year-old patient decides that 55 years of insensate nipples would be equivalent to the symptoms she is experiencing now. However, only 5 years of persistent wound problems would be equivalent to her present state. These values are termed utility assessments. The utility assessments in our decision tree are shown at the end of each of the decision tree tips. Utility assessment has historically been calculated by techniques such as the standard reference gamble, time trade-off method, and visual analogue scale, which are beyond the scope of this article.13,14 As shown by the final decision tree in Figure 1, it is clearly possible to derive a formal decision tree that allows for comparison among different potential outcomes. For example, this decision tree showed a better quality of life with hypertrophic scarring compared with persistent wound problems. The quality of life with no operation was much less than that with the operation. Sensitivity analysis has formalized subjective preoperative probabilities and uncertainty of a judgment by testing the validity of the conclusions of an analysis over a wide range of assumptions. It has been used to demonstrate that conclusions regarding the preferred choice were accurate when the probability and outcome estimates were assigned values that were within a reasonable range.15 There is an argument that formal decision trees dehumanize patient care, with numbers describing how a patient feels with no clinician or patient involvement.16,17 Patient-specific variables are particularly important because of the individual quality of cosmetic surgery. Formal decision trees can, however, promote the provision of information to enable evaluation of possible outcomes and informed consent for surgery. Formal psychological assessment can provide standardized data about pain and cosmesis that are predictive of satisfaction with outcome and that can be incorporated into the decision tree. Similarly, patients can see that the probability of nipple loss is much lower than the probability of insensate nipples, and can be allowed to make a decision as to whether they think the surgery is worthwhile based on the outcomes that are most important for them. Plastic surgery has increasingly adopted an evidence-based approach. This formalization may be used by plastic surgeons to quantify their outcomes and compare them with outcomes of other procedures to argue the case for funding in restricted settings. Formal decision trees can be used to model and evaluate the effect of complex decisions, and they have been used successfully in different health care settings. The example of reduction mammaplasty demonstrates their potential use in plastic surgery, where they can be used to justify treatment decisions and facilitate realistic patient expectations.

Gwanmesia, I. M.Sc., M.R.C.S.; Butler, P. E. M. Ph.D., F.R.C.S.; Withey, S. M.S., F.R.C.S. Author Information

Necrotizing fasciitis is a potentially life-threatening infection of the fascia which often progresses rapidly, involving the skin and subcutaneous tissue secondarily. It is a relatively uncommon condition with the perineum and the extremities as predilective sites. Necrotising fasciitis involving the chest wall is extremely rare with only 18 cases described in the literature. This article presents a new case following blunt trauma.

The senior author's experience of using the endoscopic brow lift for rejuvenation of the upper third of the face is presented. One hundred patients underwent endoscopic brow elevation. In 98 cases this was done in combination with other aesthetic procedures. Patient follow-up ranged from 4 months to 53 months (mean: 17 months). No major complications were experienced, although a patient questionnaire identified a number of troublesome but transient minor complications. Levels of patient satisfaction were found to be high. The continuing evolution of this technique is reviewed, particularly relating to methods of brow fixation.

We report a case of sensory deprivation that occurred as a consequence of progressive head and neck lymphoedema, following combined surgery and radiotherapy for squamous cell carcinoma. The management of head and neck lymphoedema is discussed and measures are suggested for improving the sensory deprivation experienced by the worst affected patients.

Severe progressive lymphoedema of the whole of the head and neck is almost always due to the combined effects of surgery and radiotherapy, compounded by repeated infections or recurrent tumour.The condition is difficult to control, and manual lymphatic drainage is the mainstay of management.We present a case of progressive lymphoedema following treatment for an occult squamous carcinoma of the head and neck, and describe the use of a lymphatic bridge to drain the facial tissue.

This case report describes a curious cause of insomnia. A 93-year-old woman presented to our follow-up clinic with the complaint of insomnia secondary to an audible click emanating from her skull. The site of loud biphasic-sound production corresponded to an area of the scalp where a squamous cell carcinoma had been removed 11 years previously.

Paralysis of the orbicularis oculi muscle leads to an unopposed action of the levator of the upper eyelid (lagophthalmos) in facial nerve palsy. The resultant exposure of the cornea may lead to keratitis, corneal ulceration, and eventual blindness. Although many surgical options exist in the treatment of lagophthalmos, upper lid loading with a gold weight implant has become one of the preferred methods to reduce the complications that may follow. The problems encountered after gold lid loading and methods to reduce postoperative morbidity are not well documented. The objective of this study was to determine the range of morbidity seen after gold weight insertion and to evaluate the effect of supratarsal fixation on subsequent morbidity. After retrospective reviews by questionnaire and case note analysis, supratarsal fixation was found to noticeably reduce the rate of implant ulceration and extrusion. This study demonstrates upper lid loading to be an effective method for the treatment of lagophthalmos, and it supports fixation of gold weights in reducing surgical morbidity.