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Ischemia reperfusion injury (IRI) is characterised initially by restriction of oxygenated blood flow to an organ bed, resulting in tissue hypoxia and ischaemic injury, followed by further 'reperfusion' injury upon restoration of perfusion, with an influx of oxygen, inflammatory cells and generation of free radicals. The culmination is a complex interplay between cellular and biochemical processes involved in inflammation and coagulation, exhibited as the 'no re-flow' phenomenon. Under ideal circumstances, autologous free tissue transfer is performed with short ischemic times. However, there are certain clinical scenarios where the ischaemic period can be prolonged due to technical and non-technical factors. IRI is inevitable and can be possibly more pronounced in such cases. In these cases, there may be a role for plastic surgeons to adopt some of the anti-ischaemia reperfusion injury (IRI) practices used in solid organ transplantation (SOT). Knowledge of the current trends in SOT IRI reduction should be discussed by plastic surgeons to assess whether certain facets can be extrapolated into the plastic and reconstructive armamentarium. These can be applicable to more challenging microsurgical cases, including composite free tissue transfer. Three important aspects are discussed further in this editorial: (1) cold flushing, (2) machine perfusion and pharmacological manipulation. Ongoing research will need to study the impact these potential interventions will have on the acute complications but also in which subset of patients they would be most beneficial. This area is novel and exciting but cautious implementation is advised with careful scrutiny of future data.

Overestimation of burn size especially in children is common. It is unclear if this may cause harm. This study was designed to assess the accuracy of burn size estimation by referring non-burn clinicians and investigate whether inaccurate estimates caused any harm. Three and a half years retrospective review of pediatric resuscitation burns (ie, ≥10% TBSA) referred to a tertiary burns center from other hospitals was performed. This included basic demographics, data from referring emergency departments (initial TBSA estimations and fluid volumes prescribed), and data on arrival to the burn center (actual burn TBSA sustained, fluid volumes given prior to arrival, and actual fluid volumes required). Clinical parameters at 8 and 24 hr after injury were also examined. Forty-six patients were identified. Mean age was 3.9 years and weight 18 kg. Mean time to arrival from initial burn injury to our tertiary center was 5 hr. Thirty-two children (70%) had their burns overestimated, seven (15%) underestimated, and another seven (15%) were correctly estimated. After accurate calculations of the burn size and the required resuscitation fluids on arrival to the burns center, only five children of the entire cohort of 46 patients (11%) had received more fluids than required. These five children were in the overestimated burn size group. Only three children received the appropriate amount of fluid prior to arrival to the burns center. There were no mortalities or significant clinical adverse events in any of the children. Overestimation led to overprescription of fluid volumes, but this did not translate into over-resuscitation, and in most cases was in fact associated with inadequate fluid administration. Although 70% of the children in our cohort had the burn size overestimated, only 11% had actually received more fluids than required before arrival. None of these children went on to have any significant complications as a result of overestimation. Training and education is essential for clinicians in emergency departments. However, estimation of size in pediatric burns, in particular scalds, is challenging and the importance of early transfer to a specialist service cannot be overemphasized.

Traditionally, the vertical rectus abdominis muscle (VRAM) flap has been used as a robust and effective loco-regional reconstruction for perineal defects. We present a unique approach using a vertical skin paddle pedicled deep inferior epigastric artery perforator (DIEP) flap for the management of large perineal defects following colorectal tumour excision. As a colorectal and plastic surgery tertiary referral centre, over the last 5 years, we have developed a vast experience in reconstructing these defects in collaboration with our general surgical colleagues in the multidisciplinary setting. Our main reconstructions consisted of pedicled VRAM flaps, although we have used other local and free flap options when and as required. We have since moved towards this improved technique of the pedicled DIEP flap reconstruction and present our initial experience, highlighting its main advantages, particularly over the VRAM flap. Level of Evidence: Level V, therapeutic study.

Peri-operative anaesthetic techniques are important in maximising microsurgical success and analgesic delivery. The National Mastectomy and Breast Reconstruction Audit highlighted variation in breast free flap reconstruction success. As current UK peri-operative anaesthetic practice is unknown, a national survey was conducted. A link to an online questionnaire was sent to lead consultant anaesthetists in each UK unit undertaking breast free flap reconstruction. Data was collected on important aspects of peri-operative anaesthetic technique including fluid therapy, haemodynamic monitoring, analgesic strategy and transfusion practice. A response was received from 34 of the 41 units identified (83 %). Twice as many units undertook deep inferior epigastric artery perforator (DIEP) flap reconstruction compared with transversus abdominis musculocutaneous (TRAM) flap reconstruction. Peri-operative fluid therapy was mainly ‘liberal’ in nature with little evidence of a ‘goal-directed’ approach. The intraoperative haemodynamic monitor of choice was continuous arterial blood pressure monitoring. Use of oesophageal Doppler or lithium diluted cardiac output (LiDCO) monitoring is not widespread. Many units undertake some form of regional analgesic strategy, with transversus abdominis plane and rectus sheath blocks the commonest techniques. Peri-operative blood transfusion practice showed considerable variation between units. There is a wide national variation in reported peri-operative anaesthetic technique for breast free flap reconstruction. Further research is recommended to confirm whether this translates into varied clinical outcomes. Although modern breast free flap reconstruction failure rates are currently low, targeting peri-operative anaesthetic technique could lead to improved clinical outcomes. In addition, improved peri-operative anaesthetic technique has a key role to play if enhanced recovery programmes after surgery (ERAS) for breast free flap reconstruction are to be created. Level of Evidence: Not ratable.

The Shouldice Hospital prides itself with excellent hernia repair outcomes. The Shouldice concept exhibits a unique, successful business model, and is a clear example of the concept of a highly innovative value proposition. Exploring Shouldice's fundamental principles and extrapolating them to other settings might help healthcare professionals offer improvements to patient care. Carpal tunnel syndrome (CTS) is the most common elective hand disorder, which can be debilitating for patients. Surgical intervention is extremely effective when necessary. It would be prudent to develop efficient pathways for the treatment of CTS, and other common disorders in the future. This review aims to explore the successes behind the Shouldice model, cross-fertilise surgical and management grounds by familiarising surgeons with the Shouldice model to help generate key ideas for the future, and extrapolate key information to postulate the ‘carpal tunnel treatment centre’ as a potential enterprise that can be designed on the basis of the Shouldice model. Optimal healthcare delivery while improving the patient journey, in a cost-effective manner, requires careful planning and execution. It is important to further explore and capitalise on this knowledge, to improve our service to patients and the multidisciplinary healthcare workforce, particularly in light of restructuring of the NHS and the reduction in training opportunities for surgical residents.

The concept of surgical expertise and the processes involved in its development are topical, and there is a constant drive to identify reliable measures of expert performance in surgery. This review explores the notion of whether surgical experts are “born” or “made”, with reference to educational theory and pertinent literature. Peer-reviewed publications, books, and online resources on surgical education, expertise and training were reviewed. Important themes and aspects of expertise acquisition were identified in order to better understand the concept of a surgical expert.The definition of surgical expertise and several important aspects of its development are highlighted. Innate talent plays an important role, but is insufficient on its own to produce a surgical expert. Multiple theories that explore motor skill acquisition and memory are relevant, and Ericsson's theory of the development of competence followed by deliberate self-practice has been especially influential. Psychomotor and non-technical skills are necessary for progression in the current climate in light of our training curricula; surgical experts are adaptive experts who excel in these.The literature suggests that surgical expertise is reached through practice; surgical experts are made, not born. A deeper understanding of the nature of expert performance and its development will ensure that surgical education training programmes are of the highest possible quality. Surgical educators should aim to develop an expertise-based approach, with expert performance as the benchmark.

Background Groin dissection is commonly performed for the treatment of a variety of cancers, including melanoma, and squamous cell carcinoma of the skin, penis or vulva. It is uncertain whether insertion of a drain reduces complication rates, and, if used, the optimum time for drain removal after surgery is also unknown. Objectives To assess the current level of evidence to determine whether placement of a drain is beneficial after groin dissection in terms of reducing seroma, haematoma, wound dehiscence and wound infection rates, and to determine the optimal type and duration of drainage following groin dissection if it is shown to be beneficial. Search methods In September 2014 we searched the following electronic databases using a pre-designed search strategy: the Cochrane Wounds Group Specialised Register; The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library). In November 2013 we searched Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid EMBASE and EBSCO CINAHL. We did not restrict the search and study selection with respect to language, date of publication or study setting. Selection criteria We considered all randomised controlled trials (RCTs) comparing wound drainage with no wound drainage in individuals undergoing groin dissection, where the most superior node excised was Cloquet's node (the most superior inguinal lymph node). No limits were applied to language of publication or trial location. Two review authors independently determined the eligibility of each trial. Data collection and analysis Two review authors, working independently, screened studies identified from the search; there were no disagreements. Main results We did not identify any RCTs that met the inclusion criteria for the review. Authors' conclusions There is a need for high quality RCTs to guide clinical practice in this under-researched area.

Burns education appears to be under-represented in UK undergraduate curricula. However current postgraduate courses in burns education provide formal training in resuscitation and management. Simulation has proven to be a powerful modality to advance surgical training in both technical and non-technical skills. We present a literature review that summarises the format of current burns education, and provides detailed insight into historic, current and novel advances in burns simulation for both technical and non-technical skills, that can be used to augment surgical training. Addressing the economic and practical limitations of current immersive surgical simulation is important, and this review proposes future directions for integration of innovative simulation strategies into training curricula.

Background Teaching practical skills is a core component of undergraduate and postgraduate surgical education. It is crucial to optimize our current learning and teaching models, particularly in a climate of decreased clinical exposure. This review explores the role of educational theory in promoting effective learning in practical skills teaching. Methods Peer-reviewed publications, books, and online resources from national bodies (eg, the UK General Medical Council) were reviewed. Results This review highlights several aspects of surgical education, modeling them on current educational theory. These include the following: (1) acquisition and retention of motor skills (Miller's triangle; Fitts' and Posner's theory), (2) development of expertise after repeated practice and regular reinforcement (Ericsson's theory), (3) importance of the availability of expert assistance (Vygotsky's theory), (4) learning within communities of practice (Lave and Wenger's theory), (5) importance of feedback in learning practical skills (Boud, Schon, and Endes' theories), and (6) affective component of learning. Conclusions It is hoped that new approaches to practical skills teaching are designed in light of our understanding of educational theory.

The population of overweight patients presenting to burn facilities is expected to increase significantly over the next decades due to the global epidemic of obesity. Excess adiposity mediates alterations to key physiological responses and poses challenges to the optimal management of burns. The purpose of this study is to document the general epidemiological aspects of thermal injuries in the obese population, outline relevant physiological aspects associated with obesity, and draw attention to topics relating to the management, rehabilitation, and prognosis of burns in this emerging subpopulation of patients.

Introduction Simulation occupies a central position in surgical education. It offers a safe environment for trainees to develop and improve their skills through sustained deliberate self-practice and appropriate feedback. This review explores the role of simulators and the simulation environment in light of educational theory to promote effective learning. Data sources Information was obtained from peer-reviewed publications, books and online material. Conclusion A simplistic perspective frames simulation as a means of gaining technical skills on basic models by offering a safe alternative to carrying out procedures on real patients. Although necessary, that aspect of simulation requires greater depth to satisfy the growing demand for alternatives to traditional clinical learning. A more realistic view should frame simulation as a means to gaining mastery within a complex clinical world. In order to strike the balance on simulating an ideal clinical scenario, alignment of the simulator and the simulation environment in the appropriate context appears crucial.

Objectives Venous thromboembolism (VTE) causes approximately 25,000 deaths each year from hospital-acquired thrombosis in the UK. Patient understanding of risk factors and preventive measures is important in preventing VTE. This audit was designed to assess surgical patient awareness and understanding of VTE risk factors and prophylaxis. Design A questionnaire was designed to assess preoperative patient understanding of components of the National Institute for Health and Clinical Excellence (NICE) guidelines. Leaflets were designed to address gaps in understanding and junior doctors were given guidance on patient education. A second group of patients completed the same questionnaire after introduction of the education system. Setting Worthing Hospital, UK. Participants One hundred and twenty-one patients due to undergo major general surgery. Seventy-one participants completed the questionnaire prior to implementation of the education system, and 50 after. Main Outcome Measures Improvement in patient awareness of VTE, its risk factors and its preventative measures (in response to the education system). Results Following the introduction of a targeted VTE education system, there was a significant improvement in the awareness of VTE to 90% ( P< 0.01), its signs to 80% ( P< 0.01), and its preventative measures to 84% ( PConclusions Patient education is of paramount importance in reducing the risks of VTE perioperatively. A simple method of introducing patient education at pre-assessment clinic and as part of their discharge planning, for major elective surgery, is an effective system in improving patient understanding of VTE, its risk factors and the importance of prophylaxis. It may also increase compliance.

Objective\ud \ud Leadership is particularly important in complex highly interprofessional health care contexts involving a number of staff, some from the same specialty (intraprofessional), and others from different specialties (interprofessional). The authors recently published the concept of “The Burns Suite” (TBS) as a novel simulation tool to deliver interprofessional and teamwork training. It is unclear which leadership behaviors are the most important in an interprofessional burns resuscitation scenario, and whether they can be modeled on to current leadership theory. The purpose of this study was to perform a comprehensive video analysis of leadership behaviors within TBS.\ud \ud Methods\ud \ud A total of 3 burns resuscitation simulations within TBS were recorded. The video analysis was grounded-theory inspired. Using predefined criteria, actions/interactions deemed as leadership behaviors were identified. Using an inductive iterative process, 8 main leadership behaviors were identified. Cohen’s κ coefficient was used to measure inter-rater agreement and calculated as κ = 0.7 (substantial agreement). Each video was watched 4 times, focusing on 1 of the 4 team members per viewing (senior surgeon, senior nurse, trainee surgeon, and trainee nurse). The frequency and types of leadership behavior of each of the 4 team members were recorded. Statistical significance to assess any differences was assessed using analysis of variance, whereby a p < 0.05 was taken to be significant. Leadership behaviors were triangulated with verbal cues and actions from the videos.\ud \ud Results\ud \ud All 3 scenarios were successfully completed. The mean scenario length was 22 minutes. A total of 362 leadership behaviors were recorded from the 12 participants. The most evident leadership behaviors of all team members were adhering to guidelines (which effectively equates to following Advanced Trauma and Life Support/Emergency Management of Severe Burns resuscitation guidelines and hence “maintaining standards”), followed by making decisions. Although in terms of total frequency the senior surgeon engaged in more leadership behaviors compared with the entire team, statistically there was no significant difference between all 4 members within the 8 leadership categories. This analysis highlights that “distributed leadership” was predominant, whereby leadership was “distributed” or “shared” among team members. The leadership behaviors within TBS also seemed to fall in line with the “direction, alignment, and commitment” ontology.\ud \ud Conclusions\ud \ud Effective leadership is essential for successful functioning of work teams and accomplishment of task goals. As the resuscitation of a patient with major burns is a dynamic event, team leaders require flexibility in their leadership behaviors to effectively adapt to changing situations. Understanding leadership behaviors of different team members within an authentic simulation can identify important behaviors required to optimize nontechnical skills in a major resuscitation. Furthermore, attempting to map these behaviors on to leadership models can help further our understanding of leadership theory. Collectively this can aid the development of refined simulation scenarios for team members, and can be extrapolated into other areas of simulation-based team training and interprofessional education

Educational theory highlights the importance of contextualized simulation for effective learning. The authors recently published the concept of "The Burns Suite" (TBS) as a novel tool to advance the delivery of burns education for residents/clinicians. Effectively, TBS represents a low-cost, high-fidelity, portable, immersive simulation environment. Recently, simulation-based team training (SBTT) has been advocated as a means to improve interprofessional practice. The authors aimed to explore the role of TBS in SBTT. A realistic pediatric burn resuscitation scenario was designed based on "advanced trauma and life support" and "emergency management of severe burns" principles, refined utilizing expert opinion through cognitive task analysis. The focus of this analysis was on nontechnical and interpersonal skills of clinicians and nurses within the scenario, mirroring what happens in real life. Five-point Likert-type questionnaires were developed for face and content validity. Cronbach's alpha was calculated for scale reliability. Semistructured interviews captured responses for qualitative thematic analysis allowing for data triangulation. Twenty-two participants completed TBS resuscitation scenario. Mean face and content validity ratings were high (4.4 and 4.7 respectively; range 4-5). The internal consistency of questions was high. Qualitative data analysis revealed two new themes. Participants reported that the experience felt particularly authentic because the simulation had high psychological and social fidelity, and there was a demand for such a facility to be made available to improve nontechnical skills and interprofessional relations. TBS provides a realistic, novel tool for SBTT, addressing both nontechnical and interprofessional team skills. Recreating clinical challenge is crucial to optimize SBTT. With a better understanding of the theories underpinning simulation and interprofessional education, future simulation scenarios can be designed to provide unique educational experiences whereby team members will learn with and from other specialties and professions in a safe, controlled environment.

Summary Background Changes in undergraduate medical curricula, combined with reforms in postgraduate education, have training implications for surgical skills acquisition in a climate of reduced clinical exposure. Confidence and prior experience influences the educational impact of learning. Currently there are limited formal basic surgical skills programmes integrated into UK undergraduate curricula. Context Early skills targeting is valuable for students entering surgical, related allied specialties and even traditionally non-surgical specialties, such as General Practice. Such experience can make students more confident and subsequently competent future junior doctors and trainees. Innovation The integration of skills training through the use of simple low-fidelity training models can bridge the gap between undergraduate skills education and postgraduate training, whereas approaches involving more recent advances in simulation may prepare students further by making available more contextualised and scenario-based learning environments. Implications We suggest that it is an ideal time for the introduction of dedicated basic surgical skills programmes into UK undergraduate medical curricula. Training will benefit all students. Importantly, training can inspire confidence, clinical interest, and can also provide a solid foundation of skills that can support and enable junior doctors’ further postgraduate training.

Background Axillary dissection is commonly performed for breast carcinoma. It is uncertain whether insertion of a drain reduces complication rates. Objectives To assess the effects of wound drainage after axillary dissection for breast carcinoma on the incidence of postoperative seroma formation. Secondary outcome measures include the incidence of infection and length of hospital stay. Search methods We searched the Cochrane Wound and Breast Cancer Group's Specialised Registers (22 February 2013), MEDLINE (1950 to 22 February 2013), EMBASE (1966 to 22 February 2013), the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) and ClinicalTrials.gov (22 February 2013) for all prospectively registered and ongoing trials (22 February 2013). Reference lists of included studies were handsearched by two independent review authors to look for additional eligible trials. Selection criteria All randomised controlled trials (RCTs) comparing wound drainage versus no wound drainage in individuals after axillary dissection for the treatment of breast carcinoma were included. All disease stages were considered. Breast-conserving surgery and mastectomy were considered. Patients undergoing sentinel node biopsy without axillary dissection were not included. No limits were applied to language or study location. Two review authors independently determined the eligibility of each study. Data collection and analysis Two review authors independently extracted data for each included study using a predesigned data extraction proforma and assessed risk of bias using The Cochrane Collaboration's 'Risk of bias' tool. Discrepancies were resolved by consensus discussion with a third review author. Dichotomous variables were analysed using a Mantel-Haenszel model to produce odds ratios (ORs). Continuous variables were analysed using an inverse variance model to produce a mean difference (MD). Main results Seven RCTs including 960 participants were identified. The quality of trials was generally low, with several studies at risk of selection bias, and no studies used blinding during treatment or outcome assessment. There was a high level of statistical variation between the studies, which therefore reduces the reliability of the evidence. The OR for seroma formation was 0.46 (95% confidence interval (CI) 0.23 to 0.91, P = 0.03) in favour of a reduced incidence of seroma in participants with drains inserted. There was no significant difference in infection rates between drainage and no drainage groups (OR = 0.70; 95% CI 0.44 to 1.12, P = 0.14). The mean difference in length of hospital stay, reported in four trials consisting of 600 participants, was 1.47 days greater in the drained population (95% CI 0.67 to 2.28, P = 0.0003). A mean difference of 0.79 fewer postoperative seroma aspirations was found in the drained population (95% CI 1.23 to 0.35 fewer, P = 0.0004) in two trials including 212 participants. No significant difference in volume of seroma aspirations was reported (MD -19.44, 95% CI -59.45 to 20.57, P = 0.34) in three trials including 519 participants. No significant difference in the incidence of lymphoedema was noted (OR 2.31 favouring no drainage, 95% CI 0.47 to 11.37, P = 0.30), with only six instances reported in three trials of 360 participants, nor was any significant difference in the incidence of haematoma observed (OR 1.68, 95% CI 0.33 to 8.51, P = 0.53), with only five instances reported in two trials of 314 participants. Authors' conclusions There is limited quality evidence that insertion of a drain following axillary lymphadenectomy reduced the odds of developing a seroma and reduced the number of post-operative seroma aspirations. These benefits should be balanced against an increased length of hospital stay in the drained population.

Educational theory highlights the importance of contextualized simulation for effective learning. We explored this concept in a burns scenario in a novel, low-cost, high-fidelity, portable, immersive simulation environment (referred to as distributed simulation). This contextualized simulation/distributed simulation combination was named "The Burns Suite" (TBS). A pediatric burn resuscitation scenario was selected after high trainee demand. It was designed on Advanced Trauma and Life Support and Emergency Management of Severe Burns principles and refined using expert opinion through cognitive task analysis. TBS contained "realism" props, briefed nurses, and a simulated patient. Novices and experts were recruited. Five-point Likert-type questionnaires were developed for face and content validity. Cronbach's α was calculated for scale reliability. Semistructured interviews captured responses for qualitative thematic analysis allowing for data triangulation. Twelve participants completed TBS scenario. Mean face and content validity ratings were high (4.6 and 4.5, respectively; range, 4-5). The internal consistency of questions was high. Qualitative data analysis revealed that participants felt 1) the experience was "real" and they were "able to behave as if in a real resuscitation environment," and 2) TBS "addressed what Advanced Trauma and Life Support and Emergency Management of Severe Burns didn't" (including the efficacy of incorporating nontechnical skills). TBS provides a novel, effective simulation tool to significantly advance the delivery of burns education. Recreating clinical challenge is crucial to optimize simulation training. This low-cost approach also has major implications for surgical education, particularly during increasing financial austerity. Alternative scenarios and/or procedures can be recreated within TBS, providing a diverse educational immersive simulation experience.

To the Editor: Appropriate intraoperative patient positioning by surgeons and anaesthetists is essential to prevent pressure sores. Facial pressure sores are rare, and their occurrence is possibly underreported [1]. We report a unique case of a stage 2 forehead pressure sore developing after a 21-h operation in the prone position despite full anesthetic precautions, and we advocate use of the Mayfield head frame to prevent deterioration if re-operation is required in the prone position in such scenarios. A 43-year-old overweight gentleman with sacral chondrosarcoma and no other significant medical history underwent hemisacrectomy and two-stage reconstruction with a free latissimus dorsi musculo-osseo-cutaneous flap. He was intubated and lay in the prone position for the duration of the second-stage reconstruction. He was placed on a cami table, with full padding precautions and a head ring. The total duration of the operation was 21 h. Postoperatively the patient was noted to have a 4 9 2 cm grade 2 forehead pressure ulcer (Fig. 1). The patient returned to the operating room for an exploration of the free flap following an absent venous Doppler signal, although clinically the flap appeared viable. On this occasion he was placed in a Mayfield head frame to avoid further pressure on his forehead sore. Intraoperatively the flap was indeed viable, but the internal venous Doppler revealed it required repositioning. This procedure took 2 h. The forehead pressure sore was unchanged postoperatively as a result of the avoidance of pressure on it and the shorter operative period. It was subsequently treated conservatively with regular dressings and healed 2 months later. In our case, the Mayfield head frame was utilized when the patient was taken back to the operating room for flap exploration in the prone position to avoid further facial tissue compromise. This frame is generally used for head stabilization during intracranial surgery. However, there have been reports of hematomas following its use if placed against anatomically thin bone (such as the squamous part of the temporal bone) or pathologically thin bone (as can happen after chronic intracranial hypertension) [2, 3]. Goodwin et al. [4] believe the use of the head frame prevents the development of facial pressure sores in patients undergoing sacrectomy. Facial pressure sores can cause much physical and emotional morbidity, adding to the already appreciable healthcare costs of treating these patients. As the number of prone cases in surgery increases, it is crucial to recognize all patients at risk and to address all contributory factors, particularly if prolonged procedures are anticipated. Established methods to reduce facial pressure sore development include widening of the facial–pillow contact area to disperse the pressure, checking facial skin status frequently, and changing head position regularly (when the H. Sadideen (&) H. Giele Department of Plastic and Reconstructive Surgery, West Wing, John Radcliffe Hospital, Oxford, UK e-mail: hazim.sadideen@doctors.org.uk