# St. Andrew's Textbook of Burns & Plastic Surgery

St. Andrew's Textbook of Burns & Plastic Surgery
This page is designed to assist trainee burns and plastic surgery nurses and surgeons, especially on-call and out-of-hours. Includes cross-sectional anatomical drawings, photographs and videos. It may work for us but it may not work for you. We use a combined Socratic and Newtonian approach to service delivery. We obviously then apply a modicum of Grayling and Russell. We divide our time. Everybody counts or no one counts. We certainly admire P Singer, Hume and Socrates. We would like to admire Ayer and Scruton but have doubts. The bitter comes the better on a stolen guitar. We anticipate endless revision. Everything is provisional. We are against ALL gods & monsters.
Includes tips and tricks, traps and trips and "how to do it" and "how not to do it". And of course "DON'T DO IT" & I regret doing it (but not my lawyers) The St. Andrew's Method of learning involves:
* Think
* Ask
* Adapt
* Nicely (you can be the best technical surgeon in the world but if you are not polite and nice to patients and team members your name will be writ in water)
St. Andrew's Centre for Burns & Plastic Surgery is the largest unit in the UK. We are in Chelmsford in Essex. In case you couldn't tell. We currently have 22 consultant (attending) Surgeons and about 30 trainees. All the consultants are trainees as well. They are - Ms Maria Sirotikova Ms Alison Shaw Ms Kalliroi Tzsafetta Ms Elizabeth Chipp Ms Tania Cubison Ms Linda Chilton Ms Tara Mack Ms Moley-Crabbs Ms Jane Taylor
some ugly blokes

## Contents
### Burns

* Acute burn management
The management of burn injury, burn wounds and subsequent scars. Management protocols include: first aid, retrieval, burn wound assessment and initial management The accurate assessment of burn area and depth is notoriously difficult, even by experienced and interested persons. The conventional assessment of burn depth includes: history of injury (tea scald versus boiling metal), first aid (may help a bit but certainly helps symptoms), visual appearance (red, pink, painful = superficial PT vs. white\charred insensate = full thickness) feel (moist, firm, leathery), smell, special investigations (LDI etc)
* Reconstruction and scar management

### Principles of Reconstruction

* Resurface- replace scar or skin graft with different tissue. Performed to improve function ( contracture release) or improve appearance (particularly of meshed skin grafts,).
* Release- scar band release, using grafts, fractionated CO2 [Ablative Fractional = AFX] laser or micro needling, or flaps
* Release of a primary contracture may also be beneficial elsewhere locally (I.e. Cheek resurfacing relieves lower eyelid ectropion) by relaxing secondary Contractures. For example full thickness skin graft to release Eyelid ectropion.
[tip: the release of one band often results in a new band, due to the redistribution of tension; choose the most symptomatic band(s) first and warn the patient what to expect] Replace- replacement of displaced or distorted features or landmarks. Can be cosmetic or functional.
* Revise- cosmetic or functional; surgical or laser (fractionated CO2) or micro- needling. Revision of keloid scars is not recommended as the resultant pathological scar will be bigger than the original scar.
* Reconstruction- recreation of damaged or missing parts.
* Review - feedback from patient to help judge effectiveness of intervention
Z Plasty One of the family of "alphabet" plasties. Named as the shape of the flap looks like a Z. Definition: The release of a scar using two triangular flaps. When the flaps move the central limb is realigned. The classic Z plasty has limbs of equal lengths and 60 degree angles. Classification: functional (scar lengthening) or cosmetic or both (such as split earlobe repair). Principles: a scar is released (if a contracture band) and lengthened by transposition of the two flaps. The technique relies on using laxity of skin adjacent to the central limb. The geometry of the transposition and the laxity of the skin used therefore dictates the degree of lengthening of the contracture . In cosmetic Z plasty the design of the flaps is created to re-position the central limb in a more camouflaged position and depends on accurate assessment of the surrounding lines of skin tension, natural skin creases or nearby landmark structures. V to Y Plasties Use of a triangular segment of skin to close a wound. The resultant scar is therefore Y shaped.

### Trauma

* Hand and upper limb injuries and diseases
* Lower limb injuries
* Facial injury
* Soft tissue lacerations, blast, bites and other injuries

### Elective surgery

* Hand and upper limb
* Skin cancer
* Breast reconstruction
* Head & Neck reconstruction
* Laser skin procedures
* Aesthetic procedures & Surgery
* Scar management

### Ethical Decision Making

Decisions are choices and therefore gambles. The payoff of any decisions must be weighed against the opportunity costs of such choices.
* End-of-life care
* Research
* Teaching & Training
* Innovation and adoption of novel technologies

### Authors

* Bruce Philp MA(Cantab) BMBCh (Oxon) FRCS(I) (FRCS Plast). Consultant Burns, laser and Reconstructive Plastic Surgeon. St. Andrew's Centre, Broomfield Hospital, Mid-Essex NHS Hospitals Trust, Chelmsford CM1 7ET UK
* Peter Dziewulski FRCS FRCS(Plast). Consultant Burns, laser and Reconstructive Plastic Surgeon. St. Andrew's Centre, Broomfield Hospital, Mid-Essex NHS Hospitals Trust, Chelmsford CM1 7ET UK
* Hazem Alfeky MS Plastic Surgery & Burns Fellow, St. Andrew's Centre, Broomfield Hospital, Mid-Essex NHS Hospitals Trust, Chelmsford CM1 7ET UK
Metin St. Andrew's Centre, Broomfield Hospital, Mid-Essex NHS Hospitals Trust, Chelmsford CM1 7ET UK
* Any one else who helps