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Summary Background The coronavirus disease-2019 (COVID-19) pandemic has generated enormous pressure on healthcare establishments, prompting the restructuring of services to rationalise resources. Complex head and neck reconstructive surgery in this setting may carry substantial risk to patients and staff. This paper outlines the management strategy and outcomes of major head and neck oncological cases at a single regional tertiary referral centre. Methods A database review was undertaken of consecutive patients undergoing major head and neck surgery and reconstruction during the COVID-19 pandemic at St Andrew's Centre for Plastic Surgery & Burns, Chelmsford UK. Patient demographics, tumour and reconstruction characteristics as well as peri‑operative information were determined. Patients were prospectively contacted with regard to COVID-related symptoms and investigations. Results Twenty-two patients (15 males and 7 females) with a mean age of 67 years (range: 36–92 years) were included between March 1 and June 13, 2020. Patients underwent pre-operative throat swabs at 72 h and 24 h as well as chest CT scanning as part of a robust protocol. Twelve free flaps, four loco-regional flaps, four parotidectomies and 23 cervical lymphadenectomies were performed. Two patients required a return to theatre. No post-operative deaths occurred and flap survival rate was 100%. A single patient tested positive for COVID-19 pre-operatively and no post-operative COVID-19 infections occurred. Conclusion Although head and neck surgery represents a high-risk procedure to patients and healthcare professionals, our institutional experience suggests that in the presence of a robust peri‑operative protocol and judicious patient selection, major head and neck surgery, including free tissue transfer reconstruction, may be performed safely.

Summary Introduction This study evaluates COVID-19 related patient risk, when undergoing management within one of the largest specialist centres in Europe, which rapidly implemented national COVID-19 safety guidelines. Method A prospective cohort study was undertaken in all patients who underwent surgical (n = 1429) or non-operative (n = 191) management during the UK COVID-19 pandemic peak (April–May 2020); all were evaluated for 30-day COVID-19 related death. A representative sample of elective/trauma/burns patients (surgery group, n = 729) were selected and also sub-analysed within a controlled cohort study design. Comparison was made to a random selection of non-operatively managed (non-operative group, n = 100) or waiting list (control group, n = 250) patients. These groups were prospectively followed-up and telephoned from the end of June (control group) or at 30 days post-first assessment (non-operative group)/post-operatively (surgery group). Results Complex general (9.2%, 136/1483) or regional (5.0%, 74/1483) anaesthesia cases represented 14.2% (210/1483) of operations undertaken. There were no 30-day post-operative (0/1429)/first assessment (0/191) COVID-19 related deaths. Neither the three sub-speciality plastic surgery, or non-operative groups, displayed increases in post-operative/first assessment symptoms in comparison to each other, or to control. The proportion of COVID-19 positive tests were: 7.1% (1/14) (non-operative), 5.9% (2/34) (burns) and 3.0% (3/99) (trauma); there were however no significant differences between these groups, the elective (0%, 0/54) and control (0%, 0/24) groups (p = 0.236). Conclusion We demonstrate that even heterogeneous sub-speciality patient groups, who required operative/non-operative management, did not incur an increased COVID-19 risk compared to each other or to control. These highly encouraging results were achieved with described, rapidly implemented service changes that were tailored to protect each patient group and staff.

Squamous cell carcinoma (SCC) is the second most common skin cancer after basal cell carcinoma. Ultraviolet exposure and immunosuppression are major risk factors for SCC of the skin, with chronic sun exposure being the strongest environmental risk factor. As such, skin cancer around the nipple-areola complex (NAC) is not unusual; however, primary SCC, specifically, is indeed incredibly rare, with only four cases having been identified in the English literature. Due to the rarity of SCCs in this region, it is likely that the diagnosis may be delayed for lack of suspicion, as often they will resemble other more common cancers or conditions. This chapter outlines a systematic approach in dealing with such a rare diagnosis through presentation of a rare case report of a primary SCC of the NAC which clinically resembled Paget’s disease.

Sagittal craniosynostosis (SC) is the most common type of premature suture fusion presenting in approximately 1 in every 5000 births with a 3:1 male:female ratio. The most common indication for surgery is the improvement of the cosmetic appearance of the skull, since a cranial deformation may have a significant psychosocial impact on affected patients. Relief from raised intracranial pressure is a further indication for surgery, although an increased intracranial pressure (ICP) can be demonstrated only in a minority of affected children at diagnosis. It is even more rare to have Chiari malformations (CMs) secondary to ICP in an isolated SC, as shown in a study by Strahle et al (Neurosurg Focus 2011;31:E2), demonstrating only 5 (3%) of the 183 with isolated sagittal synostosis having a CM. The authors present the rare case of a 4-year-old boy presenting late with raised intracranial pressure (40 mm Hg) and his management with 1 stage vault expansion and decompression of CM.

Summary Background The popularity of the DIEP flap has increased over the last decade. However, there is little information regarding the transfusion rates of this complex procedure. The current study reports the transfusion rates in patients who underwent DIEP flap reconstruction in our unit with an attempt to correlate significant blood loss with potential predictors such as the abdominal flap weight. Methods-material A retrospective review of 131 patients who underwent DIEP reconstruction was performed. Patients' characteristics, risk factors, incidence of blood transfusions, Hb drop and complications were reviewed. For statistical analysis the two-tailed Student t -test, chi-squared significance test and multiple regression model were used. Results 12 patients (9.1%) were transfused compared to 80.3% and 18.8% described in the literature. Definite association was found between the presence of a complication and transfusion. No correlation was found between age, obesity, chemotherapy and/or radiotherapy or tamoxifen treatment and blood loss. However, operation duration, complications and weight all found to have significant correlation. On average, every additional hour of surgery adds 0.25 g of Hb drop; the presence of a complication adds 0.45 g of Hb drop, and every extra gram of tissue removed from the abdomen adds an extra 0.001 g of Hb drop. Conclusion The different transfusion rates published reflect variations in surgical strategies, different operative technical details but mostly transfusion protocols applied in each unit. As a correlation with complications was found, it is quite important to identify predictors for significant blood loss to optimise the operation outcome which in our study are additional time of surgery, the presence of complication and increased flap weight.

The ileal conduit for urinary diversion after radical cystectomy is a well-described procedure. Furthermore, parastomal hernias, prolapse, stenosis, and retraction of the stoma have been reported as some of the more common complications of this procedure. The subsequent repair of parastomal hernias with a biological mesh and the potential of the conduit to “tunnel” through it has also been described. In this case report, we present a combined repair of a large incisional hernia with a cystectomy and a pelvic lymphadenectomy for invasive bladder cancer, with the use of a biological mesh for posterior component abdominal wall primary repair as well as for support to the ileal conduit used for urinary diversion.

There has been only one documented case in the English literature with the diagnosis of primary Squamous Cell Carcinoma (SCC) of the nipple; we present a further case of a primary SCC of the nipple, thus raising awareness to the skin or breast specialist of this possible presentation for SCC. We present the case of a 34 year old lady who presented to our plastic surgery unit with an erythematous, scaly lesion on her right Nipple Areola Complex (NAC). The lesion was histologically confirmed on biopsy to be an SCC and subsequently formally excised. Histology confirmed complete excision of the lesion with adequate margins with no lymphovascular or perineural invasion. This case report describes a rare presentation of a primary moderately differentiated SCC of the nipple. Although SCC of the nipple is a rare diagnosis, in view of its similar presentation to Paget disease of the nipple, it must be considered and careful examination of the histology must be performed in order to ascertain a definitive diagnosis. Patients presenting with lesions of the NAC cannot be assumed to have either Paget's disease or SCC and biopsy should be performed before arranging further investigations or treatment, as the pathways for the two conditions can be very different.

We report the diagnosis and surgical management of the interesting case of a patient with a gastrointestinal stromal tumour (GIST).

Perioral facial burns have a high propensity to formation of microstomia and numerous prosthetic devices have been described that can be used postoperatively to address this problem. We introduce a novel device, the Whiston Buccal Prosthesis, which is used intraoperatively and in the early postoperative period and it acts as a surgical aid to prevent or curtail microstomia, as well as to address other problems associated with facial burns. Our device has an overall 4-fold purpose; 1) it acts as a commissural and circumoral retractor, 2) as a means of counter-pressure during excision of burn eschar, 3) counter-pressure for the graft after its placement, and 4) for access to the mouth to maintain oral hygiene. It has been used on 3 patients who have benefited from all or some of the above uses. We have used this device in 3 patients thus far. One died 2 months after her operation but received benefit in the daily maintenance of oral hygiene and also the skin grafts. The other 2 patients were young adults, 19 and 20 years old at the time of injury, who after a 3-year follow-up were discharged not having required any further surgical intervention for microstomia. The Whiston Buccal Prostheses were used for a length of time between 1 and 3 months. Although limited objective evidence exists for our device, subjectively we have seen value intraoperatively, in the prevention of microstomia, the maintenance of oral hygiene, and maintenance of grafts.

It is often difficult to apply traditional ECG electrodes on patients with extensive burns due to a large operative site, compromise of sterility, the fact that traditional placement would be within the operative site or because stick-on pads cannot stick due to prep solution, bleeding and other factors. We present an effective solution based on our experience, of using a common staple or “clip” where the ECG electrode is attached. We can see the patient in the prone position with the back having been debrided and grafted. This technical improvisation gives clinicians the ability to monitor safely and accurately the patients’ physiological parameters.

We would like to comment on the case report by Kim and colleagues concerning the surgical treatment of a gastrointestinal stromal tumour in the posterior mediastinum [1]. Gastrointestinal stromal tumours (GISTs) are the most common mesenchymal tumours of the gastrointestinal tract (5000 new cases per year in the United States) [2]. They can be found in patients with a median age of 60 y, with frequent occurrence (70%) in the muscular wall of the stomach, followed by small bowel (10-20%), oesophagus, omentum, mesentery and retroperitoneum [2,3]. GISTs can range from small benign tumours to sarcomas at all sites of occurrence. Tumours that have metastasized at presentation have a very poor prognosis. The 5-year survival in patients with malignant GISTs is less than 40% [2]. There are three key prognostic factors: mitotic rate, tumour size, and site. Tumours that are small (=2 cm) and show mitotic activity not exceeding 5 mitoses per 50 high-power fields, have an excellent prognosis. This prognosis probably is independent of site, although this has not been shown specifically for all sites. In the stomach, most epithelioid GISTs are benign. However, we have to bear in mind that a small proportion of tumours apparently lacking mitotic activity do metastasize [2,3]. GISTs in association with paragangliomas and pulmonary chondromas constitute the Carney triad. In fact, the ‘Carney triad’ is a multiple neoplasia syndrome affecting mostly females. This syndrome - or Carney complex - predisposes to a variety of tumours including adrenocortical adenomas (unilateral or bilateral) that are usually non-functioning [2,4]. Carney and Stratakis, in 2002, distinguished the inherited GISTs with paraganglioma syndrome from the Carney triad as an autosomal dominant condition in adult patients. This condition has been called Carney-Stratakis syndrome [5]. These two syndromes, even though quite rare, have entered the realm of multiple endocrine neoplasias in the last years. Carney-Stratakis syndrome is probably more frequent and may be prevalent amongst patients with GISTs that are negative for KIT/PDGFRA mutations [2]. A high index of suspicion is required by surgeons who are dealing with patients with isolated or sporadic GISTs or paragangliomas. They have to be aware of the Carney and Carney-Stratakis syndromes. A multidisciplinary diagnostic approach regarding the medical and family history of the patients is of paramount importance (especially in the younger patient with KIT or PDFGRA mutation-negative GISTs) [2]. Conflict of Interest: None declared

Toxic epidermal necrolysis (TEN) is a rare, acute life-threatening mucocutaneous disorder that is characterised by epidermal loss/exfoliation exceeding 30% total body surface area (TBSA) and is on a spectrum that includes erythema multiforme and Stevens–Johnson syndrome (SJS). It is estimated that 80% of TEN cases are related to medication reactions; the association based on the recognition that TEN usually develops 1–3 weeks following administration of the suspect drug. It is agreed that primary treatment consists of prompt withdrawal of causative drugs and transfer to a regional burn unit. Transfer to a burn unit, no more than 7 days after onset of symptoms, has been acknowledged as reducing the risk of infections, hospital length of stay and infection-related mortality. Due to the uncertainty surrounding TEN pathogenesis, several different modalities have been proposed for the treatment of TEN, including high-dose intravenous immunoglobulins, plasmapheresis, cyclophosphamide, cyclosporine and systemic steroids; however, these therapies are relatively ineffective. The use of systemic corticosteroids for treatment of TEN has in particular been deemed controversial due to associations with increased infections leading to greater length of hospital stay and increased mortality. Granulomatosis with polyangiitis (GPA), formerly known as Wegener’s granulomatosis, is a rare relapsing-remitting disorder of unknown aetiology, characterised by granulomatosis inflammation and necrotising vasculitis predominantly affecting small- to medium-sized vessels. While a 5-year survival rate of 75–83% is now realised, relapse and associated morbidity is of concern. The established treatment for GPA follows the recommendations of the French National Authority for Health (HAS) for systematic necrotising vasculitis. With induction treatment, it is recommended that GPA be treated with a combination of systemic corticosteroids and immunosuppressants. A review of the literature failed to identify any previous case where both of these conditions coincide. Our search was conducted through databases which included MEDLINE, PubMed, Scopus, AMED, CINAHL and EMBASE, using keywords: toxic epidermal necrolysis, Wegener’s granulomatosis, granulomatosis with polyangiitis. We submit the rare case of a 22-year-old woman who presented to our regional burn unit with both GPA and TEN, and we discuss the presentation, investigation and multidisciplinary management of the patient, as well as reviewing the literature regarding these two conditions., Lay Summary Toxic epidermal necrolysis is a potentially fatal condition where there is a large area of skin exfoliated after the body’s reaction to a particular medication. Its treatment is largely by stopping the medication that is thought to have caused this reaction and also by regular dressings, thus keeping the area clean from any infection. Granulomatosis with polyangiitis, also known as Wegener’s granulomatosis, is another potentially fatal condition. Its treatment is very specific; however, this treatment may be harmful to a patient with toxic epidermal necrolysis. We describe the management of a patient who presented with both conditions, which is an extremely rare event. We describe the diagnosis and treatment during the patient’s inpatient stay at a regional burns unit. From this case report we have shown insight into the multidisciplinary management needed to manage such a complex patient, who made a full recovery.