Darren Chester - Academia.edu (original) (raw)

Papers by Darren Chester

Plastic and Reconstructive Surgery, 2005

Letters to the Editor and Viewpoints are welcome. Letters to the Editor discuss material recently... more Letters to the Editor and Viewpoints are welcome. Letters to the Editor discuss material recently published in the Journal. Letters will have the best chance of acceptance if they are received within 8 weeks of an article's publication. Letters to the Editor may be published with a response from the authors of the article being discussed. Discussions beyond the initial letter and response will not be published. Letters to the Editor are not usually peer reviewed, but the Journal may invite replies from the authors of the original publication. Viewpoints pertain to issues of general interest, even if they are not related to items previously published (such as unique techniques, brief technology updates, technical notes, and so on). Please note the following criteria for Letters and Viewpoints: • Text-maximum of 500 words (not including references) • References-maximum of five • Authors-no more than five • Figures/Tables-no more than two figures and/or one

Journal of Plastic, Reconstructive & Aesthetic Surgery, 2008

The readers of JPRAS will probably already agree that plastic surgery is indeed a very nice speci... more The readers of JPRAS will probably already agree that plastic surgery is indeed a very nice specialty and that the skills that allow us to restore form, function and cosmesis are more than just niceties! This editorial, however, aims to direct the readers to the UK-based National Institute for Health and Clinical Excellence (NICE) website and to outline existing NICE guidance relevant to plastic surgery. NICE is the independent organisation responsible for providing national guidance on the promotion of good health and the prevention and treatment of ill health in the United Kingdom. NICE produces guidance in three areas of health, namely: public health, health technologies and clinical practice. 1 The website may also be of use to international readers; providing useful evidenced-based information on both plastic surgery topics and general patient management. The information is freely available and easily accessible on the NICE website: www.nice.org.uk (Figure 1). The data is broadly categorised by guidance topic and guidance type, namely: cancer service guidance, clinical guidelines, interventional procedures and technology appraisals. Information provided in the guidelines includes key guidance recommendations or priorities, background information, evidence used to compile the report, cost effectiveness, expected benefits and recommendations on implementation and research. The focus is on patientcentred care, with versions available for patients, carers and the public carefully explaining topics in layman's terms. The process of formulating the guidance documents varies according to the type of guideline (Figure 2). Briefly, clinical guidelines are referred by the Department of Health following which stakeholders are registered. The latter includes health professionals and organisations representing patients and carers. A scope and draft guideline is prepared and following a period of consultation, the final guideline is produced. Technology appraisals are also referred by the Department of Health. NICE then commissions an independent academic centre to prepare an assessment report. An independent appraisal committee makes recommendations and, following a consultation period, produces a final document for approval by NICE before the guidance is issued. Interventional procedures are notified to NICE, usually by clinicians, following which interest can be registered by individuals or organisations, via the website. An overview is then prepared by three specialist advisors and reviewed by an independent advisory committee before a consultation document is produced. Consultees are notified and resolution requests dealt with before the guidance is issued. 2 The NICE guidance documents relevant to plastic surgery and date of publication are shown in Table 1. Table 2 indicates the number of documents for each sub-specialty.

The Journal of Hand Surgery: Journal of the British Society for Surgery of the Hand, 2006

Calcinosis cutis is the cutaneous deposition of calcium phosphate. We present the first reported ... more Calcinosis cutis is the cutaneous deposition of calcium phosphate. We present the first reported case of symmetrical calcium deposits being present in both hands at birth.

Journal of Hand Surgery, 2002

This prospective, randomized, controlled trial compared two methods of rehabilitating extensor te... more This prospective, randomized, controlled trial compared two methods of rehabilitating extensor tendon repairs in zones IV–VIII. Group A patients followed an early active mobilization regimen and Group B patients followed a dynamic splintage regimen. Data on 19 patients in Group A and 17 patients in Group B were collected at 4 weeks and at final follow-up (3 months median follow-up for both groups). Extension lag, flexion deficit and total active motion (TAM) were measured. At 4 weeks, patients in Group B had a better TAM (median 87%, range 56–102%) compared to patients in Group A (median 77%, range 52–97%). At final follow-up, there were no significant differences in the results of the two groups. There were no ruptures in either group.

The Journal of Burn Care & Rehabilitation, 2004

Over the last 20 years, confluent sheets of cultured epithelial autograft have been used for pati... more Over the last 20 years, confluent sheets of cultured epithelial autograft have been used for patients with major burns. Problems with the lack of “take” and long-term durability, as well as the time delay to produce such grafts, have led to the development of delivery systems to transfer keratinocytes to the wound bed. This review article describes the problems of using cultured epithelial autograft and the advantages of using preconfluent keratinocytes. Despite the numerous delivery systems that have been reported, most studies are limited to animal wound bed models. There are a few small clinical studies that have demonstrated enhanced healing using mainly subjective methods. There is a need for controlled, randomized clinical trials to prove the efficacy of keratinocyte delivery systems. Proposals for the use of this technology are made.

The Journal of Hand Surgery (Asian-Pacific Volume)

Background: Hand injuries are a significant and rising burden on the Emergency Department (ED), o... more Background: Hand injuries are a significant and rising burden on the Emergency Department (ED), often leading to protracted waiting times for patients awaiting specialist input. To combat this, a new treatment pathway for hand trauma was introduced at our institution to reduce waiting times and pressure on the ED. Methods: The treatment pathway performance using waiting times, length of stay and cost metrics was measured prior to and following the introduction of a new treatment pathway. Results: There were 15,539 patients reviewed in total. After the new pathway had been introduced, the number of assessments in ED significantly reduced (Year 1: 907 [19.9%] vs. Year 2: 422 [7.9%]; p < 0.001), and the proportion of patients who had an operation on the same day that they were assessed significantly increased (69 [1.5%] vs. 403 [7.5%] patients; p < 0.001). The median waiting time from assessment to operation and length of stay also significantly reduced following the introduction...

Journal of Ayub Medical College, Abbottabad : JAMC

Leeches are a well-recognized treatment for congested tissue. This study reviewed the efficacy of... more Leeches are a well-recognized treatment for congested tissue. This study reviewed the efficacy of leech therapy for salvage of venous congested flaps and congested replanted or revascularized hand digits over a 2-year period. All patients treated with leeches between 1 Oct 2010 and 30 Sep 2012 (two years) at Queen Elizabeth Hospital, Birmingham, UK were included in the study. Details regarding mode of injury requiring reconstruction, surgical procedure, leech therapy duration, subsequent surgery requirement and tissue salvage rates were recorded. Twenty tissues in 18 patients required leeches for tissue congestion over 2 years: 13 men and 5 women. The mean patient age was 41 years (range 17-79). The defect requiring reconstruction was trauma in 16 cases, following tumour resection in two, and two miscellaneous causes. Thirteen cases had flap reconstruction and seven digits in six patients had hand digit replantations or revascularisation. Thirteen of 20 cases (65%) had successful ti...

European Journal of Plastic Surgery, 2016

BackgroundDay surgery units (DSUs) have streamlined the treatment of hand trauma. This study desc... more BackgroundDay surgery units (DSUs) have streamlined the treatment of hand trauma. This study describes how the establishment of the Birmingham Hand DSU has improved the service over a 10-year period.MethodsData was collected on patients requiring surgery for acute hand trauma for a period of 1 month at four separate time points: (1) prior to establishment of DSU, (2) 1 month following DSU opening, (3) 1 year following DSU opening and (4) 8 years following DSU opening. The number and types of operation performed, day case rates, and bed occupancy rates were analysed. Statistical analysis was performed using Fisher’s exact test.ResultsThe volume of hand trauma has increased over time (77 cases/month-2002; 109-2003; 90-2004; av. 150-2011). Sharp lacerations and crush injuries remain the most common. The percentage of patients admitted has fallen (84.4% 2002; 64.2% 2003; 46.7% 2004; 33.6% 2011 p = 0.0003) whilst the day case rate has increased (13.0% 2002; 33.9% 2003; 51.1% 2004; 67.5% 2011 p = 0.004). Bed occupancy rate per patient has fallen (2.64 days-2002; 2.08-2003; 1.34-2004; 1.21-2011).ConclusionsDespite an increased caseload, increased utilisation of the DSU has led to reduced patient waiting times and bed occupancy rates whilst increasing patient satisfaction and reducing costs.Level of Evidence: Level III, risk/prognostic study.

European Journal of Plastic Surgery, 2007

The sliding subcutaneous pedicle V-Y flap is an established method for reconstructing soft tissue... more The sliding subcutaneous pedicle V-Y flap is an established method for reconstructing soft tissue defects of the face. The authors describe a modification utilising extension limbs that are closed together in a pincer-like fashion, recruiting skin lateral to the defect. The edges of the flap are curved to provide an element of rotation. A series of 15 consecutive patients who underwent this procedure were studied prospectively. The flap was found to be versatile and useful for defects up to 2.5 cm in diameter. Two flaps developed minor tip necrosis but healed satisfactorily. This flap is another useful addition to the armamentarium of the plastic surgeon and may be suited to situations when tissue laxity is less than would be ideal for a standard V-Y flap.

European Journal of Plastic Surgery, 2010

People addicted to drugs or alcohol are commonly referred to the plastic surgery department. We d... more People addicted to drugs or alcohol are commonly referred to the plastic surgery department. We describe the challenges and epidemiology of injuries in this group and suggest an algorithm for optimal management. A retrospective study was carried out of medical records of people with drug and alcohol problems treated in the plastic surgery unit between January 2004 and December 2007 inclusive is presented. Exclusion criteria: (1) elective admissions, (2) previous, but not current drug or alcohol use, (3) a short history of excessive alcohol intake, (4) isolated burn injuries, and (5) no notes available. Injuries were sustained by 77 people. Males (64) were more commonly referred than females (13), with a mean age of 37 years (20-65) at presentation. Delayed presentation (17/77) and noncompliance with treatment (16/77) was common. Only six patients were employed, nine were homeless and two lived in prison. Psychiatric illness was commonly encountered (16/ 77). Trauma (26), self-harm (16), assault (14), and inadvertent injury (13) were all more common than injury directly due to injection (8). Thirteen patients self-discharged from the ward prior to completion of treatment and 61(79%) did not complete follow-up. A holistic approach of people with drug and alcohol addiction and injury is required including early referral to social services, drug and alcohol teams. Our clinical guidelines recommend single-stage treatment, early education and advice for patients to achieve an optimal outcome.

The Journal of hand surgery, European volume

Mubashir Cheema, Darren Chester, Dominic Power: Foucher Plus: Use of an osseo-cutaneous pedicled ... more Mubashir Cheema, Darren Chester, Dominic Power: Foucher Plus: Use of an osseo-cutaneous pedicled island flap based on 1st dorsal metacarpal artery for a segmental defect of the thumb metacarpal. Oral presentation at FESSH, Antalya, Turkey, 30th May 2013

European Journal of Plastic Surgery, 2015

Background There is an increasing awareness of replantation amongst the general public, with an e... more Background There is an increasing awareness of replantation amongst the general public, with an expectation for reattachment of digits. Currently, there is a paucity of evidence on the outcomes of replantation or revascularisations in the UK with most surgical experience literature from the USA or East Asian countries. Methods We report a case series of 28 patients over a 7-year period with replantation or revascularisation performed at a tertiary National Health Service hand centre in the UK. Data was collected retrospectively from hospital clinical notes and electronic imaging. Results Out of the 28 patients identified, 16 had single digit replantation or revascularisation, of which 11 digits ultimately survived. Nine patients underwent multiple digit replantation or revascularisation with a combined total of 25 digits, only five of these digits survived. Conclusions Factors found to adversely affect survival were increased number of attempted replants, power-saw mechanism of injury and prolonged ischaemic time. Reduced ischaemic times and single digit amputations were associated with improved survival. Level of Evidence: level IV, risk/prognostic study.

European Journal of Plastic Surgery, 2010

How much involvement do primary care physicians (PCPs) have and want with cosmetic surgery? How d... more How much involvement do primary care physicians (PCPs) have and want with cosmetic surgery? How do their attitudes influence the referral of patients who are considering cosmetic surgery? An electronic survey of all PCPs in Worcestershire was done. Email addresses were identified via National Health Service (NHS) and practice websites. Results were electronically correlated. All Worcestershire PCPs were emailed (189),

European Journal of Plastic Surgery, 2015

BackgroundDespite open hand fractures being relatively common, little has been published regardin... more BackgroundDespite open hand fractures being relatively common, little has been published regarding their prevalence, mechanism of injury and outcomes.MethodsA retrospective case note review was performed of all patients presenting with open metacarpal, proximal and middle phalangeal fractures over a 25-month period at a regional hand centre.ResultsEighty-five patients were included (median age 43 years). “Sharp” injury was the commonest mechanism (39 %). Forty-three percent were managed with open reduction and internal fixation; this group was significantly more likely to require revision surgery compared to other fixation methods. Four patients developed nonunion. Overall superficial infection rate was 9.4 %, one patient developed deep infection, and there were no cases of osteomyelitis. No infections developed in the group receiving oral antibiotics alone.ConclusionsFurther research is necessary, but we postulate that some open hand fractures are suitable for day case surgery with oral antibiotic prophylaxis. The follow-up after these injuries is often protracted, and patients should be counselled accordingly, particularly of the high risk of revision surgery in patients managed with open reduction internal fixation.Level of evidence: Level IV, therapeutic study.

BMJ case reports, Jan 11, 2012

We describe a case of methaemoglobinaemia (MtHb) in a previously healthy 39-year-old gentleman wh... more We describe a case of methaemoglobinaemia (MtHb) in a previously healthy 39-year-old gentleman who presented with a traumatic glass laceration to his right wrist that required emergency surgery to control bleeding and repair his ulnar artery. The MtHb was noted on blood gas analysis by the anaesthetist after the patient had a drop in arterial oxygen saturation under general anaesthetic. We initially suspected the lidocaine local anaesthetic injected proximal to his wound for pain control in the emergency department an hour preoperatively, but then discovered that the patient was a recreational user of 'poppers' and had in fact been using these drugs just before his injury and hospitalisation. The patient's condition stabilised overnight with conservative management. Given how commonly hand surgeons and other clinical staff use local anaesthetics, we reviewed the literature on this uncommon, but potentially fatal, complication, its causes and evidence-based management.

Annals of the Royal College of Surgeons of England, 2004

Abdominal aortic aneurysm (AAA) repair requires close cooperation between surgeon and anaesthetis... more Abdominal aortic aneurysm (AAA) repair requires close cooperation between surgeon and anaesthetist. It is helpful for the surgeon to be able to see the blood pressure readings when removing the aortic clamp, and to have access to the groins and feet, in order to assess femoral pulsation and distal perfusion. Method AAA repair is generally performed using conventional cloth or disposable surgical drapes with an adhesive 'op-site'

Plastic and reconstructive surgery, 2006

The senior author (A.P.) has performed 70 consecutive breast reconstructions over 3 years using t... more The senior author (A.P.) has performed 70 consecutive breast reconstructions over 3 years using the free deep inferior epigastric perforator (DIEP) and pedicled extended latissimus dorsi flaps. This study set out to compare these two methods of reconstruction by looking at postoperative morphine requirements and lengths of stay in hospital. Patient notes were retrospectively reviewed and the total morphine used by patient-controlled analgesia was measured. The mean morphine per kilogram required by patients who had DIEP flaps (0.21 mg/kg; n = 22) was significantly less than the amount required by patients who had extended latissimus dorsi flaps (0.47 mg/kg; n = 48; p < 0.001). An observed trend also revealed that DIEP flap patients remained in hospital for less time compared with extended latissimus dorsi flap patients, although the difference was not significant (p > 0.01). This study shows that DIEP flap patients require less postoperative morphine and therefore might experi...

International Journal of Surgery, 2014

British Journal of Healthcare Management, 2014

Following complaints from junior trainees, consultants and nursing staff, the Queen Elizabeth Hos... more Following complaints from junior trainees, consultants and nursing staff, the Queen Elizabeth Hospital, Birmingham plastic surgery department underwent a structural overhaul with the aim of increasing training opportunities for senior house officers (SHOs) and improving healthcare delivery to patients. The unit was divided into teams each with dedicated SHOs allowing more trainees, to undertake shorter ward rounds, enabling quicker and more effective management of patients. This allowed trainees more time in theatre and clinic. Weekly rotas for 12 weeks prior to change were compared with those 12 weeks after. The number of clinic, theatre, ward cover and on-call sessions that SHOs were allocated to was calculated. Satisfaction was assessed using questionnaires for nurses, SHOs and consultants. Trainee logbooks were analysed to assess whether trainees gained more operative experience. Following the change, trainees were assigned to 58.5% more theatre sessions and 127% more clinic ses...

Trauma, 2007

Chemical Burns make up 3% of burns center admissions and have a mortality rate that varies from 4... more Chemical Burns make up 3% of burns center admissions and have a mortality rate that varies from 4.1 to 13%. There are over 25,000 products capable of causing chemical burns. These injuries may cause significant tissue necrosis and have the potential for systemic toxicity. This article gives an overview of the various types of chemical burns along with their management. Chemical warfare agents and extravasation injuries will also be briefly discussed.

Plastic and Reconstructive Surgery, 2005

Letters to the Editor and Viewpoints are welcome. Letters to the Editor discuss material recently... more Letters to the Editor and Viewpoints are welcome. Letters to the Editor discuss material recently published in the Journal. Letters will have the best chance of acceptance if they are received within 8 weeks of an article's publication. Letters to the Editor may be published with a response from the authors of the article being discussed. Discussions beyond the initial letter and response will not be published. Letters to the Editor are not usually peer reviewed, but the Journal may invite replies from the authors of the original publication. Viewpoints pertain to issues of general interest, even if they are not related to items previously published (such as unique techniques, brief technology updates, technical notes, and so on). Please note the following criteria for Letters and Viewpoints: • Text-maximum of 500 words (not including references) • References-maximum of five • Authors-no more than five • Figures/Tables-no more than two figures and/or one

Journal of Plastic, Reconstructive & Aesthetic Surgery, 2008

The readers of JPRAS will probably already agree that plastic surgery is indeed a very nice speci... more The readers of JPRAS will probably already agree that plastic surgery is indeed a very nice specialty and that the skills that allow us to restore form, function and cosmesis are more than just niceties! This editorial, however, aims to direct the readers to the UK-based National Institute for Health and Clinical Excellence (NICE) website and to outline existing NICE guidance relevant to plastic surgery. NICE is the independent organisation responsible for providing national guidance on the promotion of good health and the prevention and treatment of ill health in the United Kingdom. NICE produces guidance in three areas of health, namely: public health, health technologies and clinical practice. 1 The website may also be of use to international readers; providing useful evidenced-based information on both plastic surgery topics and general patient management. The information is freely available and easily accessible on the NICE website: www.nice.org.uk (Figure 1). The data is broadly categorised by guidance topic and guidance type, namely: cancer service guidance, clinical guidelines, interventional procedures and technology appraisals. Information provided in the guidelines includes key guidance recommendations or priorities, background information, evidence used to compile the report, cost effectiveness, expected benefits and recommendations on implementation and research. The focus is on patientcentred care, with versions available for patients, carers and the public carefully explaining topics in layman's terms. The process of formulating the guidance documents varies according to the type of guideline (Figure 2). Briefly, clinical guidelines are referred by the Department of Health following which stakeholders are registered. The latter includes health professionals and organisations representing patients and carers. A scope and draft guideline is prepared and following a period of consultation, the final guideline is produced. Technology appraisals are also referred by the Department of Health. NICE then commissions an independent academic centre to prepare an assessment report. An independent appraisal committee makes recommendations and, following a consultation period, produces a final document for approval by NICE before the guidance is issued. Interventional procedures are notified to NICE, usually by clinicians, following which interest can be registered by individuals or organisations, via the website. An overview is then prepared by three specialist advisors and reviewed by an independent advisory committee before a consultation document is produced. Consultees are notified and resolution requests dealt with before the guidance is issued. 2 The NICE guidance documents relevant to plastic surgery and date of publication are shown in Table 1. Table 2 indicates the number of documents for each sub-specialty.

The Journal of Hand Surgery: Journal of the British Society for Surgery of the Hand, 2006

Calcinosis cutis is the cutaneous deposition of calcium phosphate. We present the first reported ... more Calcinosis cutis is the cutaneous deposition of calcium phosphate. We present the first reported case of symmetrical calcium deposits being present in both hands at birth.

Journal of Hand Surgery, 2002

This prospective, randomized, controlled trial compared two methods of rehabilitating extensor te... more This prospective, randomized, controlled trial compared two methods of rehabilitating extensor tendon repairs in zones IV–VIII. Group A patients followed an early active mobilization regimen and Group B patients followed a dynamic splintage regimen. Data on 19 patients in Group A and 17 patients in Group B were collected at 4 weeks and at final follow-up (3 months median follow-up for both groups). Extension lag, flexion deficit and total active motion (TAM) were measured. At 4 weeks, patients in Group B had a better TAM (median 87%, range 56–102%) compared to patients in Group A (median 77%, range 52–97%). At final follow-up, there were no significant differences in the results of the two groups. There were no ruptures in either group.

The Journal of Burn Care & Rehabilitation, 2004

Over the last 20 years, confluent sheets of cultured epithelial autograft have been used for pati... more Over the last 20 years, confluent sheets of cultured epithelial autograft have been used for patients with major burns. Problems with the lack of “take” and long-term durability, as well as the time delay to produce such grafts, have led to the development of delivery systems to transfer keratinocytes to the wound bed. This review article describes the problems of using cultured epithelial autograft and the advantages of using preconfluent keratinocytes. Despite the numerous delivery systems that have been reported, most studies are limited to animal wound bed models. There are a few small clinical studies that have demonstrated enhanced healing using mainly subjective methods. There is a need for controlled, randomized clinical trials to prove the efficacy of keratinocyte delivery systems. Proposals for the use of this technology are made.

The Journal of Hand Surgery (Asian-Pacific Volume)

Background: Hand injuries are a significant and rising burden on the Emergency Department (ED), o... more Background: Hand injuries are a significant and rising burden on the Emergency Department (ED), often leading to protracted waiting times for patients awaiting specialist input. To combat this, a new treatment pathway for hand trauma was introduced at our institution to reduce waiting times and pressure on the ED. Methods: The treatment pathway performance using waiting times, length of stay and cost metrics was measured prior to and following the introduction of a new treatment pathway. Results: There were 15,539 patients reviewed in total. After the new pathway had been introduced, the number of assessments in ED significantly reduced (Year 1: 907 [19.9%] vs. Year 2: 422 [7.9%]; p < 0.001), and the proportion of patients who had an operation on the same day that they were assessed significantly increased (69 [1.5%] vs. 403 [7.5%] patients; p < 0.001). The median waiting time from assessment to operation and length of stay also significantly reduced following the introduction...

Journal of Ayub Medical College, Abbottabad : JAMC

Leeches are a well-recognized treatment for congested tissue. This study reviewed the efficacy of... more Leeches are a well-recognized treatment for congested tissue. This study reviewed the efficacy of leech therapy for salvage of venous congested flaps and congested replanted or revascularized hand digits over a 2-year period. All patients treated with leeches between 1 Oct 2010 and 30 Sep 2012 (two years) at Queen Elizabeth Hospital, Birmingham, UK were included in the study. Details regarding mode of injury requiring reconstruction, surgical procedure, leech therapy duration, subsequent surgery requirement and tissue salvage rates were recorded. Twenty tissues in 18 patients required leeches for tissue congestion over 2 years: 13 men and 5 women. The mean patient age was 41 years (range 17-79). The defect requiring reconstruction was trauma in 16 cases, following tumour resection in two, and two miscellaneous causes. Thirteen cases had flap reconstruction and seven digits in six patients had hand digit replantations or revascularisation. Thirteen of 20 cases (65%) had successful ti...

European Journal of Plastic Surgery, 2016

BackgroundDay surgery units (DSUs) have streamlined the treatment of hand trauma. This study desc... more BackgroundDay surgery units (DSUs) have streamlined the treatment of hand trauma. This study describes how the establishment of the Birmingham Hand DSU has improved the service over a 10-year period.MethodsData was collected on patients requiring surgery for acute hand trauma for a period of 1 month at four separate time points: (1) prior to establishment of DSU, (2) 1 month following DSU opening, (3) 1 year following DSU opening and (4) 8 years following DSU opening. The number and types of operation performed, day case rates, and bed occupancy rates were analysed. Statistical analysis was performed using Fisher’s exact test.ResultsThe volume of hand trauma has increased over time (77 cases/month-2002; 109-2003; 90-2004; av. 150-2011). Sharp lacerations and crush injuries remain the most common. The percentage of patients admitted has fallen (84.4% 2002; 64.2% 2003; 46.7% 2004; 33.6% 2011 p = 0.0003) whilst the day case rate has increased (13.0% 2002; 33.9% 2003; 51.1% 2004; 67.5% 2011 p = 0.004). Bed occupancy rate per patient has fallen (2.64 days-2002; 2.08-2003; 1.34-2004; 1.21-2011).ConclusionsDespite an increased caseload, increased utilisation of the DSU has led to reduced patient waiting times and bed occupancy rates whilst increasing patient satisfaction and reducing costs.Level of Evidence: Level III, risk/prognostic study.

European Journal of Plastic Surgery, 2007

The sliding subcutaneous pedicle V-Y flap is an established method for reconstructing soft tissue... more The sliding subcutaneous pedicle V-Y flap is an established method for reconstructing soft tissue defects of the face. The authors describe a modification utilising extension limbs that are closed together in a pincer-like fashion, recruiting skin lateral to the defect. The edges of the flap are curved to provide an element of rotation. A series of 15 consecutive patients who underwent this procedure were studied prospectively. The flap was found to be versatile and useful for defects up to 2.5 cm in diameter. Two flaps developed minor tip necrosis but healed satisfactorily. This flap is another useful addition to the armamentarium of the plastic surgeon and may be suited to situations when tissue laxity is less than would be ideal for a standard V-Y flap.

European Journal of Plastic Surgery, 2010

People addicted to drugs or alcohol are commonly referred to the plastic surgery department. We d... more People addicted to drugs or alcohol are commonly referred to the plastic surgery department. We describe the challenges and epidemiology of injuries in this group and suggest an algorithm for optimal management. A retrospective study was carried out of medical records of people with drug and alcohol problems treated in the plastic surgery unit between January 2004 and December 2007 inclusive is presented. Exclusion criteria: (1) elective admissions, (2) previous, but not current drug or alcohol use, (3) a short history of excessive alcohol intake, (4) isolated burn injuries, and (5) no notes available. Injuries were sustained by 77 people. Males (64) were more commonly referred than females (13), with a mean age of 37 years (20-65) at presentation. Delayed presentation (17/77) and noncompliance with treatment (16/77) was common. Only six patients were employed, nine were homeless and two lived in prison. Psychiatric illness was commonly encountered (16/ 77). Trauma (26), self-harm (16), assault (14), and inadvertent injury (13) were all more common than injury directly due to injection (8). Thirteen patients self-discharged from the ward prior to completion of treatment and 61(79%) did not complete follow-up. A holistic approach of people with drug and alcohol addiction and injury is required including early referral to social services, drug and alcohol teams. Our clinical guidelines recommend single-stage treatment, early education and advice for patients to achieve an optimal outcome.

The Journal of hand surgery, European volume

Mubashir Cheema, Darren Chester, Dominic Power: Foucher Plus: Use of an osseo-cutaneous pedicled ... more Mubashir Cheema, Darren Chester, Dominic Power: Foucher Plus: Use of an osseo-cutaneous pedicled island flap based on 1st dorsal metacarpal artery for a segmental defect of the thumb metacarpal. Oral presentation at FESSH, Antalya, Turkey, 30th May 2013

European Journal of Plastic Surgery, 2015

Background There is an increasing awareness of replantation amongst the general public, with an e... more Background There is an increasing awareness of replantation amongst the general public, with an expectation for reattachment of digits. Currently, there is a paucity of evidence on the outcomes of replantation or revascularisations in the UK with most surgical experience literature from the USA or East Asian countries. Methods We report a case series of 28 patients over a 7-year period with replantation or revascularisation performed at a tertiary National Health Service hand centre in the UK. Data was collected retrospectively from hospital clinical notes and electronic imaging. Results Out of the 28 patients identified, 16 had single digit replantation or revascularisation, of which 11 digits ultimately survived. Nine patients underwent multiple digit replantation or revascularisation with a combined total of 25 digits, only five of these digits survived. Conclusions Factors found to adversely affect survival were increased number of attempted replants, power-saw mechanism of injury and prolonged ischaemic time. Reduced ischaemic times and single digit amputations were associated with improved survival. Level of Evidence: level IV, risk/prognostic study.

European Journal of Plastic Surgery, 2010

How much involvement do primary care physicians (PCPs) have and want with cosmetic surgery? How d... more How much involvement do primary care physicians (PCPs) have and want with cosmetic surgery? How do their attitudes influence the referral of patients who are considering cosmetic surgery? An electronic survey of all PCPs in Worcestershire was done. Email addresses were identified via National Health Service (NHS) and practice websites. Results were electronically correlated. All Worcestershire PCPs were emailed (189),

European Journal of Plastic Surgery, 2015

BackgroundDespite open hand fractures being relatively common, little has been published regardin... more BackgroundDespite open hand fractures being relatively common, little has been published regarding their prevalence, mechanism of injury and outcomes.MethodsA retrospective case note review was performed of all patients presenting with open metacarpal, proximal and middle phalangeal fractures over a 25-month period at a regional hand centre.ResultsEighty-five patients were included (median age 43 years). “Sharp” injury was the commonest mechanism (39 %). Forty-three percent were managed with open reduction and internal fixation; this group was significantly more likely to require revision surgery compared to other fixation methods. Four patients developed nonunion. Overall superficial infection rate was 9.4 %, one patient developed deep infection, and there were no cases of osteomyelitis. No infections developed in the group receiving oral antibiotics alone.ConclusionsFurther research is necessary, but we postulate that some open hand fractures are suitable for day case surgery with oral antibiotic prophylaxis. The follow-up after these injuries is often protracted, and patients should be counselled accordingly, particularly of the high risk of revision surgery in patients managed with open reduction internal fixation.Level of evidence: Level IV, therapeutic study.

BMJ case reports, Jan 11, 2012

We describe a case of methaemoglobinaemia (MtHb) in a previously healthy 39-year-old gentleman wh... more We describe a case of methaemoglobinaemia (MtHb) in a previously healthy 39-year-old gentleman who presented with a traumatic glass laceration to his right wrist that required emergency surgery to control bleeding and repair his ulnar artery. The MtHb was noted on blood gas analysis by the anaesthetist after the patient had a drop in arterial oxygen saturation under general anaesthetic. We initially suspected the lidocaine local anaesthetic injected proximal to his wound for pain control in the emergency department an hour preoperatively, but then discovered that the patient was a recreational user of 'poppers' and had in fact been using these drugs just before his injury and hospitalisation. The patient's condition stabilised overnight with conservative management. Given how commonly hand surgeons and other clinical staff use local anaesthetics, we reviewed the literature on this uncommon, but potentially fatal, complication, its causes and evidence-based management.

Annals of the Royal College of Surgeons of England, 2004

Abdominal aortic aneurysm (AAA) repair requires close cooperation between surgeon and anaesthetis... more Abdominal aortic aneurysm (AAA) repair requires close cooperation between surgeon and anaesthetist. It is helpful for the surgeon to be able to see the blood pressure readings when removing the aortic clamp, and to have access to the groins and feet, in order to assess femoral pulsation and distal perfusion. Method AAA repair is generally performed using conventional cloth or disposable surgical drapes with an adhesive 'op-site'

Plastic and reconstructive surgery, 2006

The senior author (A.P.) has performed 70 consecutive breast reconstructions over 3 years using t... more The senior author (A.P.) has performed 70 consecutive breast reconstructions over 3 years using the free deep inferior epigastric perforator (DIEP) and pedicled extended latissimus dorsi flaps. This study set out to compare these two methods of reconstruction by looking at postoperative morphine requirements and lengths of stay in hospital. Patient notes were retrospectively reviewed and the total morphine used by patient-controlled analgesia was measured. The mean morphine per kilogram required by patients who had DIEP flaps (0.21 mg/kg; n = 22) was significantly less than the amount required by patients who had extended latissimus dorsi flaps (0.47 mg/kg; n = 48; p < 0.001). An observed trend also revealed that DIEP flap patients remained in hospital for less time compared with extended latissimus dorsi flap patients, although the difference was not significant (p > 0.01). This study shows that DIEP flap patients require less postoperative morphine and therefore might experi...

International Journal of Surgery, 2014

British Journal of Healthcare Management, 2014

Following complaints from junior trainees, consultants and nursing staff, the Queen Elizabeth Hos... more Following complaints from junior trainees, consultants and nursing staff, the Queen Elizabeth Hospital, Birmingham plastic surgery department underwent a structural overhaul with the aim of increasing training opportunities for senior house officers (SHOs) and improving healthcare delivery to patients. The unit was divided into teams each with dedicated SHOs allowing more trainees, to undertake shorter ward rounds, enabling quicker and more effective management of patients. This allowed trainees more time in theatre and clinic. Weekly rotas for 12 weeks prior to change were compared with those 12 weeks after. The number of clinic, theatre, ward cover and on-call sessions that SHOs were allocated to was calculated. Satisfaction was assessed using questionnaires for nurses, SHOs and consultants. Trainee logbooks were analysed to assess whether trainees gained more operative experience. Following the change, trainees were assigned to 58.5% more theatre sessions and 127% more clinic ses...

Trauma, 2007

Chemical Burns make up 3% of burns center admissions and have a mortality rate that varies from 4... more Chemical Burns make up 3% of burns center admissions and have a mortality rate that varies from 4.1 to 13%. There are over 25,000 products capable of causing chemical burns. These injuries may cause significant tissue necrosis and have the potential for systemic toxicity. This article gives an overview of the various types of chemical burns along with their management. Chemical warfare agents and extravasation injuries will also be briefly discussed.