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Summary Background Very few studies on long term evaluation of functional outcome following hypospadias reconstruction are available. Results from the modified Bretteville method have shown excellent cosmesis with a low risk of fistula and stenosis. This study addresses the question; do flow rates, quality of urinary stream and cosmesis change over time? Methods A sample of 18 patients who had undergone the 2 stage modified Bretteville technique between 1998 and 2004 were reviewed. Following a mean interval of 10 years and 5 months from initial functional assessment, repeat evaluation was performed using the "HOSE" questionnaire, flowmetry, and spray analysis. Results Improvement in mean flow rate (15.3 vs 10.1 ml/s; p value = 0.0036), reduced spraying (3.2 g vs 4.4 g; p value = 0.2927), with a mean increase in the "HOSE" score (from 13.8 (maximum score 16) to 15.4 (maximum score 16); p value = 0.0440) was observed over the follow up time. Conclusion Improvement in flow rates, flow quality, and cosmesis over a mean interval of 10 years 5 months has been demonstrated in a random cohort of patients undergoing the modified Bretteville method of hypospadias reconstruction.

Anatomical studies of the deltoid muscle were performed on 16 cadaver shoulders. The anatomy of the axillary nerve, the vascular pedicles, and the musculocutaneous perforators was assessed. These studies confirmed that part of the deltoid muscle can be used as a vascularised flap to cover defects of the shoulder while leaving some viable functioning muscle intact. We report the use of hemideltoid flaps to treat chronic radionecrotic ulcers involving the shoulders of two patients. In the first, the posterior part of the muscle was used as a local muscle flap. In the second, the anterior part of the muscle was raised with overlying skin to form a musculocutaneous flap. The flaps remained healed at one year follow-up. These soft tissue radionecrotic defects over the shoulder are an uncommon late complication of radiotherapy for breast cancer. Pedicled or free flaps are now recognised as the preferred methods of treatment.

A prospective, controlled clinical trial was undertaken to assess the efficacy and safety of two types of silicone gel, Silastic Gel Sheeting (SGS) and Cica-Care (CC), in the management of hypertrophic scars. Forty-two patients were randomly assigned to SGS and CC groups and their hypertrophic scars were divided into treated and control areas. Extensometric measurements were made at monthly intervals for 6 months and significant improvement of the treated areas relative to the control areas was observed. The two gels were not significantly different in efficacy or safety, but CC, being more adhesive and more comfortable than SGS, has advantages in ease of use and patient acceptability.

Summary Necrotising fasciitis is a rare, life-threatening infection where there is necrosis of fascia, subcutaneous tissues and skin. Three adult patients presented with this condition affecting the extremities and all had predisposing medical factors. Each one complained of severe pain that seemed disproportionate to the skin affected. They underwent prompt surgical debridement and received antibiotic treatment and supportive therapy. These cases highlight the increasing incidence and differences in presentation of necrotising fasciitis, as well as the important symptom of pain. Patients can become moribund and require intensive care support. High mortality rates are well recognised.

The paradigm for hypospadias repair is a straight, erect penis, with a vertical meatus at the tip of the glans that provides satisfactory urination and is cosmetically acceptable to the patient. We provide objective outcome data on 40 cases of hypospadias repaired using the modified Bretteville technique. The 'HOSE' questionnaire, flowmetry, wetted pad and spray pattern analysis in combination with other questionnaire data were obtained to evaluate the long-term results of the modified Bretteville technique. The average HOSE score was 15/16. Cosmesis is good, with average scores of 7.1/10 (patient) and 7.6/10 (doctor). HOSE assessment is good, with 85% of patients scoring 14 or over. Uroflow rates are very good for a hypospadiac population with 82.5% of the patients within normal limits for their age group. Wetted pad and spray pattern analysis showed 56% of patients sprayed more than 3g of urine compared to 11% in a junior football team acting as control, although there was little correlation between this objective assessment and the patients' perceived symptoms as assessed by the questionnaire. The modified Bretteville hypospadias repair provides a reliable epithelialized repair of consistent dimensions with good patient-reported cosmesis and excellent functional outcomes.

Summary Referral of suspect skin cancers as well as non malignant symptomatic skin lesions using high quality digital images transferred via a secure electronic referral system (ERS) potentially offers significant advantages regarding speed of referral, diagnosis and subsequent treatment over conventional pathways. However concerns over safety of the diagnostic process have been raised. This prospective study looks at 300 patients referred by ERS. A comparison of the diagnoses made from digital images with the diagnoses confirmed on pathology reports for lesions excised is described using a random selection of patients' images and referrals. Intra observer analysis of was also assessed. A sample group of patients with lesions deemed as benign, not requiring surgery or other treatment and therefore not seen in secondary care were revisited at a special clinic to determine the safety of the referral system. In this series of 300 patients the study concludes that digital image referral for skin malignancy and other cutaneous lesions reduced the interval between referral and diagnosis by 81% and referral to commencement of treatment in suspect lesions by 30%. Diagnostic accuracy in a random sample of 30 patients was comparable to that reported for patients seen in face to face consultations. High levels of GP and patient satisfaction were recorded. In conclusion digital image referral for skin malignancy and other cutaneous lesions is a safe and cost effective referral pathway, significantly reducing the interval between referral diagnosis and onset of treatment for skin malignancy.

All burns units look after members of the prison population at times. This can cause anxiety among the staff and unique problems with management. Four cases were reviwed from Her Majesty's Prison (HMP) Perth, Scotland, all of whom required resuscitation, and a survey undertaken of the nursing staff in our unit to assess attitudes to caring for burns prisoners in particular. Despite a careful search of the literature, no reference to the problems of managing prisoners in a burns unit could be found. However, it was found that the handling of vivlent offenders can be a significant cause of anxiety for nursing staff, and the presence of prison officers a reassurance rather than a hindrance in the management of burned prisoners. It is therefore recommended that prison officers be present at all times while managin burned prisoners.

In September 1993, the recently completed 32-bedded Burns Unit in the Queen Elizabeth Central Hospital, Blantyre, Malawi, was officially opened. This represented the culmination of 3 years' planning and construction; this paper presents our experience in developing this type of project, and an analysis of the early results of treatment in the unit. The widespread neglect of this common injury in developing countries is highlighted and the importance of input from specialists in this field working in collaboration with local medical and nursing staff is emphasized. The potential for making a significant impact in reducing the morbidity and mortality in burn injuries is highlighted.

A modified Bretteville technique for hypospadias repair is presented. This is a two-stage repair, utilising a preputial skin flap. The modification reduces the second stage to a day-case procedure. 40 cases are reported with good early functional and aesthetic results. The only major complications were two fistulae. There were no strictures.

A prospective study of 36 consecutive scald injuries in children caused by hot beverages is reported. Almost a third of these were deep dermal or full skin thickness and the highest percentage resulted in injury to the upper chest region. The study further investigates the cooling characteristics in four different types of cup. These studies clearly show the potential for significant disfigurement from this type of injury for up to 11 min from the time the drink is poured. The need for greater public awareness in relation to hot drinks is highlighted.

Reconstruction of the soft tissue facial contour defect in Romberg's disease and facial lipodystrophy using a free groin flap has been previously reported. However, controversy exists over the optimum placing of this flap within the cheek, i.e. whether it is better to have the dermis or subcutaneous fat side next to the muscle. Our experience with 6 flaps, 3 of which have been followed up for 3/12 years, is presented. In all cases the flaps were placed with the dermis side down, i.e. next to muscle. Although not a comparative study, our impression is that in the long term this technique reduces gravitational migration. Our experience with 2 flaps suggests that, in the early postoperative period at least, secure fixation by suturing to the muscle and periosteum is important. We believe that, in addition, this method gives a smoother contour and allows easy and safe secondary adjustments to be made where necessary.

A case is presented in which, following the failure of several surgical and non-surgical procedures to control the increasingly severe pain in an amputation thumb stump, a toe transfer was carried out, successfully relieving the symptoms without transfer of the pain to the donor site. The patient has remained pain-free for 3 years.

A case is presented of a child who sustained a full-thickness burn to the glabella and nose area, associated with an underlying fracture and cerebrospinal fluid leakage. This first reported case of a flare gun injury illustrates some important principles of facial management and soft tissue cover, in both the acute and the reconstructive phases.

A case of combined thoracic, intra-abdominal and vertebral injury occurring in a patient wearing a seat belt is presented; the possible mechanisms are discussed.

Ten cases of parotid duct division complicating facial lacerations are reviewed. A method of repair is described whereby a nylon thread is used as a splint over which the duct is sutured and conclusions are drawn concerning the management of this injury in the light of this experience.