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Introduction: Traditional on-site missions of plastic surgeons from "high-income countries" in "low- and middle-income countries" are often limited in time and lack proper follow-up. Regular digital collaboration could lead to a more impactful and durable exchange of knowledge for plastic surgeons and residents in both settings., Aims: The aim of this study was to evaluate the satisfaction of the first twelve months of weekly digital meetings, explore advantages/disadvantages, and to provide tools for similar initiatives., Methods: Weekly meetings started from August 2021. An encrypted digital connection allowed residents and plastic surgeons from Uganda and the Netherlands to discuss cases for educational purposes, where treatment options were considered. After twelve months, a survey was sent to participants from both countries to indicate the meetings' strengths, weaknesses, and possible improvements., Results: A total of 18 participants responded to the questionnaire (ten plastic surgeons, six residents, and two researchers). The strengths of the meetings were the accessibility of the meetings, knowledge exchange and practice for residents' final exams. Possible improvements included having a clear format for patient discussion, a session moderator and better internet connectivity. Moreover, a database to assess the impact of the given intervention on the patient cases by evaluating postoperatively (e.g. three months), could further improve clinical care., Conclusions: Virtual patient discussions subjectively contributed to medical education at both locations. Improved digital infrastructure and a collaborative database could further maximize learning capacity. Furthermore, digital proctoring is a promising way to establish sustainable collaborations between high- and low-resource countries., Competing Interests: Declaration of Competing Interest All authors declare that they have no conflicts of interest., (Copyright © 2023 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Background: Most breast reconstructions are implant-based and can be performed either in a one-stage, direct-to-implant or in a two-stage, expander-implant-based reconstruction. The objective of this systematic review is to compare the safety and patient satisfaction of the two reconstruction approaches., Methods: A literature search was conducted on 27 September 2022 using various databases. Studies comparing one-stage and two-stage implant reconstructions and reporting the following outcomes were included: patient satisfaction, aesthetics, complications, and/or costs. Reviews, case reports, or series with less than 20 patients and letters or comments were excluded. Comparisons were made between the one-stage reconstruction with and without acellular dermal matrix (ADM) and two-stage implant-based breast reconstruction groups. The data extracted from all articles were analysed using random-effects meta-analyses., Results: Of the 1381 records identified, a total of 33 articles were included, representing 21529 patients. There were no significant differences between the one-stage and two-stage groups, except for the costs. The one-stage operation without ADM had lower costs than the two-stage operation without ADM, although the use of an ADM substantially increased the price of the operation to more than a two-stage reconstruction., Discussion: Equal patient satisfaction, aesthetic outcomes, and complication rates with lower costs justify one-stage breast reconstruction in carefully selected patients. This review shows that there is no evidence-based superior surgical approach. Future research should focus on the costs of the ADM versus an additional stage and patient-reported outcomes., Competing Interests: Declaration of Competing Interest There is no conflict of interest declared., (Copyright © 2023 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Background: In shared decision-making (SDM), patients and healthcare professionals (HCPs) reach a joint clinical decision based on the best available evidence and the patient's preferences. SDM seems particularly valuable in plastic surgery, as often multiple treatment options are available. This cross-sectional online survey study aimed to assess HCPs' views and knowledge about SDM, identify facilitators and barriers of SDM, and determine specific requirements for SDM within plastic surgery., Methods: Participants were HCPs working in plastic surgery in the Netherlands. Participant characteristics, SDM knowledge, perceived facilitators and barriers, and requirements were assessed using a custom-made online survey. Two researchers thematically analyzed qualitative data., Results: We received 124 responses (with a response rate of 23%). Most respondents were attending plastic surgeons (79%), and 60% had more than 10 years of experience. Almost all respondents considered SDM important (91%), and most (78%) indicated that they applied SDM during consultations. However, only 15% of the HCPs showed a comprehensive understanding of the principle of SDM. Sufficient time, available sources of information (on treatment options and SDM), and decision support tools were identified as important requirements for SDM., Conclusions: Despite the positive attitudes toward SDM, there is a clear need for SDM training of HCPs, uniform sources of information and guidelines, and improved awareness and availability of decision support tools. National plastic surgery societies can play a crucial role in improving SDM-related knowledge, the availability of information and decision support tools, and the implementation of SDM in the field of plastic surgery., Competing Interests: Declaration of Competing Interest None declared., (Copyright © 2023 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Background: Treatment indications of congenital melanocytic naevi (CMN) have shifted from the prevention of malignant transformation more towards the improvement of appearance and psychosocial health. Surgical excision is often preferred, but its safety and effectiveness remain unclear., Objective: To assess the outcomes of surgical excision of medium-to-giant CMN., Primary Outcome: safety (complications)., Secondary Outcome: effectiveness (satisfaction and CMN core outcomes)., Methods: PubMed, EMBASE, and CENTRAL were searched for studies on the excision of medium-to-giant CMN and/or CMN requiring reconstruction or serial excision. Meta-analyses of safety per patient were conducted, and pooled outcomes of safety and effectiveness were presented in summary-of-findings tables., Results: A total of 1444 studies were found, of which 22 were included, evaluating 643 eligible patients. Study quality varied, and reporting of baseline characteristics and outcomes was heterogeneous. Pooled proportions were overall 9.8% for major wound-related complications, 1.2% for minor wound-related complications, 1.2% for scar-related complications, and 4.3% for anatomical deformities. For large/giant CMN, complication rates were, respectively, 23.1%, 2.9%, 12.9%, and 2.4%; and for CMN with eyelid involvement, 0.5%, 3.3%, 0.4%, and 54.2%. Patients rated their satisfaction with the cosmetic outcome as 24.4% excellent, 71.0% good, and 4.6% poor/moderate. Physicians rated this as 18.3% excellent, 70.1% good, and 11.7% poor/moderate. Thirty-five other outcomes of effectiveness were summarized. However, many were rarely reported., Conclusions: Surgical excision of CMN appears to be safe and effective in many cases, depending on CMN size and location. Major wound-related complications and scar-related complications occurred more frequently with large/giant CMN, whereas anatomical deformities occurred with the majority of CMN with eyelid involvement., Competing Interests: Declaration of Competing Interest None., (Copyright © 2022 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Background: Transgender women and transfeminine spectrum nonbinary individuals may opt for breast augmentation. The aim of the study is to analyze the complications, surgical trends, and long-term follow-up of breast augmentations in this population over the past 30 years., Methods: All transgender women and nonbinary individuals who underwent breast augmentation at our center between 01-1990 and 01-2020 were retrospectively identified. A retrospective chart study was conducted, recording individual demographics, implant characteristics, surgical timing, postoperative complications or other reasons requiring reoperation, and implant survival. A literature search was performed in MEDLINE on clinical outcomes and revision surgery of this procedure., Results: A total of 527 individuals were identified. Median clinical follow-up time was 11.2 years (interquartile range 3.3-17.5). Median implant size increased significantly over the last years (1990-1990 median 275cc, 2000-2009 252cc, 2010-2019 375cc, p<0.01). Most individuals underwent breast augmentation and genital gender-affirming surgery in one-stage. Reoperations due to short-term complications were infrequent (hematoma (0.4%) or infection (0.4%)). Reoperations due to long-term complications comprised: implant rupture (5.7%), capsular contracture (4.9%), aesthetic problems (3.8%), low-grade infection (0.4%), or seroma (0.6%). In total, 2.5% of individuals requested larger implants. After performing the literature search and manuscript screening, 9 out of 115 identified studies were included for review. Follow-up time ranged from 30 days to 5.5 years. Reported complications requiring reoperation were capsular contraction (range 0.0-5.6%), asymmetry (3.6%), hematoma (range 0.0-2.9%), infection (range 0.0-0.9%) and implant rupture (0.7%), CONCLUSION: Implant-based breast augmentation is a safe procedure in transgender individuals., Competing Interests: Conflict of Interest None declared., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Background: Basal cell carcinomas (BCCs) excised leaving positive tumour margins, are at a higher risk of recurrence. Accordingly, complete tumour removal with preservation of healthy tissue, aiming for low recurrence rates, is the main goal in treating BCCs., Objective: The present study aimed to identify the reliability of the Whole Specimen Intraoperative Frozen Section Analysis (WIFSA) technique by comparing intraoperative WIFSA and postoperative Formalin-Fixed Paraffin-Embedded section analysis (FFPE) results in 1082 basal cell carcinomas and by assessing the recurrence rates during a follow-up period up to 10 years., Methods: A single-centre retrospective cohort of all patients with BCC of the face receiving surgical excision with the WIFSA method between January 2007 and December 2013 was evaluated. We compared the intraoperative frozen section results with postoperative FFPE in order to assess accuracy of the WIFSA. Recurrence rates were assessed among all BCCs with a tumour-free margin at final excision that had a minimum follow-up of 6 months., Results: A total of 996 patients with 1082 BCCs were treated with the WIFSA. Overall agreement of WIFSA with conventional postoperative FFPE was 98·8%, sensitivity and specificity being 99·0% and 98·7% respectively. We excluded 23 BCCs that still had positive tumour margins at the end of the procedure and another 67 for the analysis of recurrence rate because follow-up was shorter than 6 months. A total of 992 BCCs with a tumour-free margin at final excision had a mean follow-up of 5·6 years (mean 67 ± 27·7 months (range 6-117 months)). The total recurrence rate was 2·1% (21 out of 992 BCCs). The recurrence rate among the primary tumours was 1·6% (13 out of 828 cases) and 4·9% among the recurring tumours (8 out of 164 cases)., Conclusion: This study indicates that, in patients with primary or recurring BCCs, WIFSA provides a high accuracy for intraoperative specimen analysis and has a low recurrence rate after a mean follow-up of 5·6 years., Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors., (Copyright © 2017 Elsevier Ltd, BASO ~ The Association for Cancer Surgery, and the European Society of Surgical Oncology. All rights reserved.)

Gynaecomastia, breast enlargement in men, is common in all age groups. It is operated on by plastic surgeons, general surgeons and paediatric surgeons. It is therefore possible that there is a difference in the populations treated, the indications for surgery and the management used by the different practitioners. We performed a survey in order to assess the approach to treatment of gynaecomastia by the different disciplines. An electronic survey questionnaire was sent to members of the Dutch societies of surgery, paediatric surgery and plastic surgery. We received 105 responses from plastic surgeons, 95 from general surgeons and 15 from paediatric surgeons, representing respective response rates of 38.7%, 23.8% and 42.8%. Plastic surgeons operated on gynaecomastia most frequently. The diagnostic criteria and workup were similar for all disciplines, although general surgeons used more imaging. There was a difference in the side operated on. General surgeons and paediatric surgeons operated mainly on unilateral cases (74% and 52%), while plastic surgeons operated mainly on bilateral cases (85%). Pharmaceutical treatment with Tamoxifen was reported only by general surgeons (13%). All disciplines used mainly the periareolar incision. Plastic surgeons reported more often the use of other surgical approaches as well as adjunctive liposuction and they did not always submit tissue for pathological examination. Perioperative antibiotics, drains and pressure garments were not always used. All disciplines agreed that the most common complication was bleeding, followed by seroma, infection, insufficient results, inverted nipple and nipple necrosis. This survey highlights some differences in the practice of gynaecomastia surgery. The findings appear to point to the fact that the indications are different, being more aesthetic in the case of plastic surgeons. The results of this survey are important in establishing the standard of care and may be helpful for setting guidelines., (Copyright © 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Background: Venous thrombo-embolism (VTE) prophylaxis is of paramount importance in the management of surgical patients. Mechanical as well as pharmacologic modalities may be used. With the use of anticoagulative agents, there is a potential for increased operative and postoperative bleeding., Aim: To assess the safety of perioperative use of low-molecular-weight heparin (LMWH) in the setting of breast reduction surgery., Methods: Retrospective assessment of the reoperation rate due to haematoma formation for breast reductions performed under a regimen of preoperative and postoperative administration of LMWH during a 10-year period., Results: A total of 720 patients (1358 breasts) received preoperative and postoperative treatment with LMWH. Reoperation due to haematoma formation was required for 37 breasts in 37 patients (5.1% of patients and 2.7% of breasts). Eight patients (1.1%) required transfusion. No patient or operative factors were associated with the need for reoperation. There were no documented cases of deep vein thrombosis or VTE., Conclusion: The use of a pre- and postoperative LMWH prophylaxis regimen is associated with a reoperation rate for haematoma that is in the upper range reported in the literature., (Copyright © 2012 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

The infection of a breast implant or tissue expander is a major complication with significant psychological and medical ramifications. The incidence has been reported to range from 1.1% in cosmetic augmentations to as high to 24% in a series of reconstructive cases. Gentamicin Surgical Implant is a surgical implant comprised of a lyophilised collagen matrix impregnated with a broad-spectrum antibiotic. When placed in the operative field, it achieves very high local concentrations of drug several fold above the minimal inhibitory concentrations; and the collagen carrier is absorbed. Its beneficial use has been reported in other fields of surgery. Gentamicin sponges were used in four cases of periprosthetic infections. The implants were removed, the pockets cleaned with pulse lavage and the implants were replaced, together with a gentamicin collagen implant. This was followed by a 6-week systemic antibiotic regimen. The patients had uneventful recovery and have not developed capsular contracture. Gentamicin collagen sponges may be used as an adjunct in the salvage of infected breast implants. Periprosthetic infections, as well as the use of gentamicin, are reviewed., (Copyright © 2011 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Lateral canthopexy is a commonly performed procedure in craniofacial and cosmetic surgery. In craniofacial surgery, lateral canthal fixation is performed in conjunction with a wide range of transcranial or subcranial procedures during the process of soft tissue re-suspension. A number of fixation materials have gained popular use. A case of craniofrontonasal dysplasia is reported in which a wire loop canthopexy fixation has become disengaged 3 months after a history of trauma and rotated to present a sharp surface against the sclera. Urgent surgical exploration prevented the apparently imminent complication of globe penetration with associated threat to vision.

Introduction: Burns of the hands may result in the formation of web space contractures-post burn syndactyly. We present our experience using the three-square technique originally described by Bandoh for minor syndactyly., Method: Tissues of the contracted web are regard as forming three facets of a cube. If elevated and transposed 90 degrees on their base the facets will fall into place and line the interior of the cube creating a deepened web-space. The first flap is based on the web itself either dorsally or volarly. The second flap is based distally on one of the fingers. The third flap is based laterally on the other finger. Surgery is followed by a splinting regimen., Results: The design of the flaps is simple and the operation is easy to perform. This technique has achieved good functional and cosmetic results; there have been no flap losses or significant complications., Conclusion: The three-square-flip-flap is a simple reliable and safe method for the treatment of post burn syndactyly.

A prospective, non-comparative study design was used to describe our experience with a bromelain-derived debriding agent, Debridase, in 130 patients with 332 deep second degree and third degree burns treated between 1984 and 1999. Debridase was applied after saturating the burns with a moist dressing for 2-24h. Debridase was applied for a period of 4h under an occlusive dressing. Mean patient age was 18.6 +/- 19.3, 42 (32.3%) were female, and 63 (48.5%) were children under age 18. Most burns were small. Debridase was applied once in 241 (72.6%) of the 332 wounds, twice in 67 (20.18%) cases, three times in 12 (3.61%) cases, and four times in 2 (0.6%) cases. The percentage debridement by number of applications was 89 +/- 21% for a single application, 77 +/- 27% for two, and 62 +/- 27% for three Debridase applications, respectively. There were no significant adverse events. The availability of a fast acting, reliable and complication-free enzymatic debriding agent may open new horizons and provide a new treatment modality for burns.

Terrorists are recently using cellular phones to remotely detonate bombs. A patient was injured while assembling a bomb connected to a cellular phone. The patient sustained combined injury to the head and to the dominant hand which held the phone. Amputation of the hand was required, the facial injuries were reconstructed. The characteristics of this unusual type of injury are described and compared to injuries caused by other bombs and explosive devices.

A new method for the repair of meningomyeloceles is described. After neurosurgical repair and closure of the placode, the soft-tissue deficit is closed using a bilobed flap. The flap is based superiorly and laterally to the area to be covered. The first lobe crosses the midline above the defect, and the second lobe goes up the midline perpendicular to the first lobe. Once in place, the flap provides a tension-free repair; no suture lines overlie the cord closure., (Copyright 2001 The British Association of Plastic Surgeons.)

Ascaris lumbricoides, roundworm, is a Nematode parasite infecting about 1 billion people worldwide. We report the case of a ten-year-old Bedouin girl hospitalized with burns to 45% of her body surface area, including the face. The patient was intubated upon admission and mechanically ventilated. Four days later she was extubated but required reintubation 15 min later for severe hypoxemia. Laryngoscopy disclosed an unidentified tube which obstructed the opening of the larynx. The 'tube' was removed by Magill forceps. The object was identified as a 35 cm long Ascaris roundworm. Once the worm was removed the patients' respiratory condition dramatically improved. We review the main features of Ascaris infection and some similar cases of airway obstruction caused by this worm.

Contact with hot objects and surfaces often causes burns. We present a case of burns to the buttock and perineum caused by use of a hot water bottle to relieve the pain caused by an anal fissure.