bluuebunny/crossref_metadata_2025 huggingface dataset:
Clinical audit, quality improvement, and safety in palliative medicine
Authors: Higginson Irene J. , Hocaoglu Mevhibe B.
Published: September 2021

Audit approaches and methods are now well advanced in palliative care, especially in clinical audit. This chapter discusses these approaches and methods, and addresses such questions as ‘Why perform clinical audit in palliative medicine?’ and ‘How do we assess the quality and safety of palliative care?’ It discusses the evolving terms of audit, quality assurance, quality improvement, safety, and governance, and how to apply clinical audit to palliative medicine. Audit requires resources, and so it must be sure to benefit patients and families, be kept as simple and efficient as possible, and have a strong educational component. There is also a need to develop and test methods of audit in a global healthcare context. If palliative approaches extend backwards to include patients earlier in care, rather than those just near to death, then the audit could become a means for clinical dialogue and education between specialties.
Apathy in Movement Disorders (Parkinson’s Disease, Huntington’s Disease)
Authors: Santangelo Gabriella
Published: September 2021

Apathy is a disabling neuropsychiatric symptom occurring in movement disorders such as Parkinson’s disease (PD) and Huntington’s disease (HD). Early identification, diagnosis, and timely treatment of apathy in movement disorders are very relevant, since apathy is related to poor disease outcome, reduced daily functioning and quality of life, and caregiver distress. This chapter discusses the phenomenology and assessment tools for screening and diagnosing apathy in PD and HD patients, including psychometric properties of several tools. Demographic, clinical, and neuropsychological correlates underlying apathy related to PD and HD are also reviewed. Furthermore, structural and metabolic brain correlates of apathy in both PD and HD are discussed: frontal-subcortical system(s) dysfunction in particular may lead to the onset of apathy. Finally, the chapter provides an overview of pharmacological treatments and their efficacy in improving apathy in PD and HD.
Apathy and Traumatic Brain Injury
Authors: Jeffay Eliyas , Grimes Kyrsten M. , Zakzanis Konstantine K.
Published: September 2021

Traumatic brain injury (TBI) is a craniocerebral trauma associated with decreased level of consciousness, amnesia, and potential abnormalities on neuroimaging. Apathy is a common symptom after TBI with a wide prevalence range (11–71%), which may be due to assessment, overlapping symptoms with depression, time since injury, and severity of injury. There is a dearth of studies exploring the neurobiology of apathy after TBI but patterns indicate the involvement of the prefrontal cortex, anterior cingulate cortex, and insula. These areas are also commonly disrupted after a TBI. Little is known regarding the neuropsychology of apathy and TBI with some evidence of executive dysfunction and acquisition memory deficits. Similarly, there is limited evidence for treatment of apathy after TBI. Many interventions implemented to date were based on empirically based interventions for neurodegenerative disorders. This review is intended to raise clinicians’ awareness of apathy after TBI and encourage researchers to explore this emerging phenomenon.
Resuscitation 2
Authors: Obladen Michael
Published: September 2021

Within 5 years of its detection, oxygen was applied to resuscitate neonates from 1780 onwards. It rapidly gained general acceptance, and infiltrated delivery rooms and, a century later, neonatal special care units. After over 240 years without scientific evidence, the use of oxygen for neonatal resuscitation is being questioned. Continuous distending airway pressure for oxygen administration was available at the beginning of the 20th century, but was not widely accepted. Alkali and analeptic drugs gained widespread but short-lived use after World War II.
Umbilical cord and umbilical care
Authors: Obladen Michael
Published: September 2021

In most human societies, ritualized and firm rules evolved for cutting the navel-string and handling the umbilical stump. These customs were not always beneficial, and contributed to umbilical infection, neonatal tetanus, and navel hernia. After prematurity, neonatal tetanus was the most frequent cause of death in poor countries up to the 19th century. It was caused by poor cord hygiene and by the age-old habit of severing the navel-string with biological products instead of man-made tools, which included palm leaves, blades of grass, mussel shells, crusts of bread, and other devices likely to be contaminated with tetanus spores. The navel-stump was covered with zinc powder, starch, oak-gall powder, grease, musk, clarified butter, and many other substances believed to protect the baby from evil, but actually creating anaerobic conditions in the umbilical wound. Care of the cord was associated with deep-rooted rituals and customs, and dangerous techniques persisted on islands well into modern times.
Measures of viability
Authors: Obladen Michael
Published: September 2021

The interest in the border of viability originated from various sources, including legal requirements, the rejection of technical life support, competition for resources, concerns about handicaps, and proximity to the fetus with its limited rights. Gestational age was determined from menstrual history by Hippocratic writers, who established the tenacious idea that 7-, but not 8-month-old infants could survive. Naegele’s rule, already published by Boerhaave in 1744, was correct when applied to the last day of menstruation. Birthweight and length were not measured until the end of the 18th century. This remarkable disinterest resulted from superstition, grossly inaccurate measurements by the authorities Mauriceau and Smellie, and the conversion chaos of the pre-metric era. A table is provided with historic mass and length units to allow determination of birthweight and body length in the older literature. The idea of viability is a remnant of vitalism, a medical doctrine popularized in 1780 by Brown. Many short-lived statements defined its border, but until now what was meant by viability remained nebulous.
Surviving against the odds
Authors: Obladen Michael
Published: September 2021

Immature survivors of outstanding intelligence include Fortunio Licetus, born in 1577, and Isaac Newton, born in 1643. Reliable descriptions began appearing around 1820, and over a dozen infants were reported born weighing under 1000 g before World War II and who developed normally. From 1876 to 2006, the birthweight at which half of the infants survived dropped from 2200 to 600 g. Statistics depended on how abortion, stillbirth, and live birth were defined, which differed greatly from country to country. World Health Organization definitions in 1993 required the registration of all infants weighing 500 g (22 complete weeks) or above. This definition was not universally adopted, resulting in considerable under-reporting. Many medical societies issued ethical recommendations concerning the obligatory or optional treatment of immature infants. The ‘window’ at which treatment is optional has been set at 22–23 weeks (Japan, Germany), 23–24 weeks (UK, US, Canada), or 24–26 weeks (France, Netherlands, Switzerland). Instead of assessing an infant’s individual prognosis, and ignoring its sex, comorbidities, and particular cause of premature delivery, these rules frequently relied on gestational age alone to initiate or withhold life support.
Holding breath
Authors: Obladen Michael
Published: September 2021

The physical properties of surfactant were identified in the early 1950s from research on warfare chemicals by Pattle in Britain and by Radford and Clements in the US. The causal relationship between respiratory distress syndrome and surfactant deficiency was established in Boston by Avery and Mead in 1959. The Australian obstetrician Liggins induced lung maturity with glucocorticoids in 1972, but his discovery was not fully accepted for another 20 years. When the major surfactant compound was identified as dipalmitoyl-phosphatidylcholine, this substance was nebulized with little effect and it became clear that there were other components of natural surfactant required besides phospholipids. A century of basic research was rewarded when Fujiwara introduced bovine surfactant substitution in Japan in 1980 to treat and prevent respiratory distress syndrome in preterm infants. Surfactant substitution greatly alleviated respiratory distress syndrome and increased the preterm infant’s chance of survival. In addition, it has set high scientific standards for the introduction of new therapies for neonates and made the randomized multicentre trial the favoured tool for clinical innovations.
Intraventricular haemorrhage
Authors: Obladen Michael
Published: September 2021

Like other problems of preterm infants, cerebral bleeding was barely known before special hospital units for ‘weaklings’ were established. Its symptoms were unspecific, the infants were considered miscarriages, and autopsies were rarely performed. Based on those postmortem findings, the theory arose at the end of the 18th century that brain haemorrhages in preterm infants result from birth trauma. Such mechanical explanations persisted for two centuries, even when it became ever more evident that this brain disorder was associated with postnatal respiratory distress. When in vivo imaging techniques (computed tomography, ultrasound scanning through the fontanelle) became available in the 1970s, the view changed and respiratory insufficiency was acknowledged as the major causative factor. Relying on these imaging techniques, Pape and Wigglesworth developed a model that explained the origin of periventricular haemorrhage and ischaemia in 1978. With the understanding of pressure-passive perfusion and cerebral flow dependent on carbon dioxide tension, the stage was set for effective preventive strategies.
Cats, frogs, and snakes
Authors: Obladen Michael
Published: September 2021

Disturbed neurulation fascinated scientists of all times. In Egypt, brainless infants were venerated as animal-headed gods. Roman law required them to be killed. The medieval world held the mother responsible, either because of assumed imagination or ‘miswatching’, or because of suspected intercourse with animals or devils. Modern embryology and teratology began with the use of the microscope by Malpighi in 1672. Details of neural tube closure were described by Kölliker in 1861 and His in 1874. From 1822, genetic disease and familiar recurrence due to insufficient nutrition were discerned and lower social class identified as a risk factor. It took a century to define the malnutrition as insufficient folate intake. The mandatory supplementation of folate in staple foods successfully reduced the incidence of neural tube defects in the US, Australia, Canada, and Chile, but it was not adopted by most European countries.
In God,s image?
Authors: Obladen Michael
Published: September 2021

Intentional modification of the infant’s head has been commonly practised at all times and in virtually every region of the inhabited world. Motives included aesthetic perception of the human head, greater attractiveness, symbolization of ethnic identity, demonstration of noble origin or sociocultural status, and supposed health benefits. The desired shape was achieved by repeated hand massage, or by using devices like cradleboards, which were applied throughout infancy. In some regions, infant head shaping was the rule rather than the exception. Whereas chronic modification of the skull during the first year of life had no adverse effects, one-time postnatal head shaping by the midwife was a dangerous procedure. Recommended by Soran in the 2nd century c.e., it remained in practice for 17 centuries. With the advent of positional plagiocephaly following the Back to Sleep campaign, head shaping has regained acceptance and is now being widely used again.
Cast aside
Authors: Obladen Michael
Published: September 2021

Trisomy 21 originated with Homo sapiens, or even before, as it exists in other primates. However, in antiquity, Down’s syndrome was rare: mothers were younger, and children failed to reach adulthood. For centuries, trisomy 21 and hypothyreosis were confused. Scientific reports originated from asylums for the mentally retarded. In 1866, John Langdon Down at Earlswood published a description of symptoms in his ‘Ethnic classification of idiots’ and coined the term ‘Mongolian’. Jerôme Lejeune identified an additional chromosome 21 causing the disorder. Maternal age rose markedly for various reasons, as did the prevalence of trisomy 21. From 1968, high-risk pregnancies were screened and interrupted because of Down’s syndrome. Non-invasive techniques now enable all pregnancies to be screened to detect chromosomal anomalies early and precisely. The topic is hotly debated and consensus unlikely. Legislation will not halt scientific progress, but it should ensure that in the same society contradictory attitudes can be held and mutually respected: the right to accept a disabled infant and the right not to accept it.
Milk demystified by chemistry
Authors: Obladen Michael
Published: September 2021

This chapter traces the decline of milk from a heavenly elixir to a tradeable food. Early cultures regarded milk not as a simple nutrient, but a living fluid. Heroes and gods were believed to have been nurtured by animals after being abandoned. Character traits were assumed to be transmitted by milk, infantile diseases were attributed to ‘bad milk’, whereas ‘good milk’ was used as a remedy. With chemical methods developed at the end of the 18th century, it became known that human milk was higher in sugar and lower in protein than cow’s milk. During the 19th century, ‘scientific’ feeding emerged which meant modifying cow’s milk to imitate the proportion of nutrients in human milk. In Paris from 1894, Budin sterilized bottled infant milk. In Berlin in 1898, Rubner measured oxygen and energy uptake by calorimetry. These activities ignored the emotional dimension of infant nutrition and the anti-infective properties of human milk and may have enhanced the decline in breastfeeding, which reached an all-time low in 1971. Milk’s demystification made artificial nutrition safer, but paved the way for commercially produced infant formula.
Selling safety
Authors: Obladen Michael
Published: September 2021

Industrialized food production appeared in 1856, pioneered by Borden in the US, Liebig in Germany, Nestlé in Switzerland, and Mellin in the UK. Their products differed remarkably and deviated from human and cow’s milk while physicians discussed the importance of minute variations in protein, fat, or carbohydrates. Proprietary formulas were free of bacteria, and the companies prospered from mass production, international marketing, and aggressive advertising. From 1932 onwards, medical societies restricted advertising to the laity. In 1939, Williams in Singapore and in 1970, Jelliffe in Jamaica suspected that commercial formula may increase infant mortality in the Third World. Breastfeeding continued to decline during the early 20th century, falling below 10% in 1970 in the US. The Swiss ‘Third World Group’ and the US ‘Infant Formula Action Coalition’ linked infant mortality and industry marketing in the Third World. The controversy of 1970–1984 led to the World Health Organization Code, which regulated the advertising and marketing of baby food. This was one of several public health statements contributing to the resurgence of breastfeeding.
Feeding the feeble
Authors: Obladen Michael
Published: September 2021

This chapter describes historic steps in feeding techniques and knowledge about the nutritional needs of premature infants. Devices to overcome weak sucking and swallowing were developed from 1851 to 1920: tube feeding by gavage, medicine droppers and pipettes, feeding bottles with air inlet, and beaked spoons for nasal feeding. Indwelling nasogastric tubes were in use from 1951. For alleged safety concerns, postnatal feeding was postponed until a week of starvation was reached in the 1950s and studies showed an association with neurological handicaps. The premature infant’s elevated need for energy, protein, and minerals has been known since 1919. However, nutritional practice lagged behind theoretical knowledge. Concentrated formula was developed in the 1940s, parenteral supplementation in the 1960s, and human milk fortifiers in the 1970s. In the 1990s, necrotizing enterocolitis was found to be more frequent in infants fed formula than in those fed human milk. Recently, probiotics were shown to reduce the risk of necrotizing enterocolitis. Compared to other aspects of neonatal medicine, there is little evidence on how to feed preterm infants.
Weak giants
Authors: Obladen Michael
Published: September 2021

Nearly 2% of all pregnancies nowadays are complicated by maternal pregestational or gestational diabetes. Long before diabetic fetopathy was acknowledged, macrosomia was dreaded by obstetricians because of the trauma risk and the need for mutilating operations. Diabetic fetopathy was described and maternal glucosuria quantified by Henrich Bennewitz in 1824. However, most authors ignored his findings and well into the 20th century, series of ‘giant babies’ were published without even mentioning diabetes mellitus. When insulin became available in 1923, maternal but not fetal mortality decreased. In 1952, Priscilla White classified six forms of maternal diabetes during pregnancy and reported an overall intrauterine, intrapartum, and neonatal death rate of 45%. But not all those infants died from macrosomia-associated traumatism and birth asphyxia: the main finding in the deceased infants was pulmonary hyaline membranes, demonstrated by Louis Gluck in 1973 to result from retarded surfactant maturation in diabetic fetuses.
Necrotizing enterocolitis
Authors: Obladen Michael
Published: September 2021

Necrotizing enterocolitis is not a new disease but one that has been reported since special care units began to house preterm infants. It was observed in the foundling hospitals of Paris (Billard 1828) and Vienna (Bednar 1850) and, as it occurred in clusters, was regarded as a nosocomial infection in the infant hospitals of Zurich (Willi 1944) and Berlin (Ylppö 1931). Clinical and pathoanatomical characterization was achieved by Schmidt and Quaiser in 1952. The unproven hypothesis of mesenteric hypoperfusion as a major aetiological factor arose from animal models and analogous perforating disorders in term infants. Despite similarities between necrotizing enterocolitis and clostridial infections, few studies employed anaerobic culture techniques. The pathogenesis remains unclear and its distinction from related disorders uncertain. It is unlikely that strategies to prevent necrotizing enterocolitis will be successful unless the disease is better understood.
Thrush
Authors: Obladen Michael
Published: September 2021

Before safe artificial nutrition, refrigeration, and microorganisms became known, thrush was a severe and frequently lethal disease in foundling hospitals. Overcrowded and understaffed, these institutions were the ideal breeding ground for this disease. Malnutrition, especially when breastfeeding was denied, contributed to the fatal course. Nosocomial infections and high mortality led to a prejudice against infant hospitals in the late 19th century. Candida albicans was discovered in 1840 when cooperation at the Paris Foundling Hospital between the Hungarian emigrant David Gruby and the Swede Frederik Berg led to this organism being the first pathogen to be identified. After World War II, Candida infections increased with the use of antibiotics. The disease became less threatening after the development of nystatin, the result of interdisciplinary cooperation in New York between the microbiologist Elizabeth Hazen and the biochemist Rachel Brown.
Systemic infection
Authors: Obladen Michael
Published: September 2021

In antiquity, transmission of disease was attributed to the miasma or contagion theory. In the Middle Ages, living in proximity to domestic animals and flies, the scarce use of soap, and absent sewage augmented the exposure to bacteria. In the early 19th century, Gordon, Holmes, and Semmelweis understood that maternal childbed fever—closely related to neonatal sepsis—was transferred by the physician’s hands to the mother during delivery. Before bacteria were discovered in the mid-19th century, septic infections in the newborn were perceived as different disorders: erysipelas, Buhl’s disease, Winckel’s disease, and so on. With the advent of microbiology, sepsis became heterogeneous and was mainly defined by the causing microorganism. In the 1940s, group B streptococci emerged as a pathogen of newborns and soon became the commonest cause of neonatal sepsis. The discovery of antibiotics made the deadly disease treatable. In the 1970s, resistant bacterial strains emerged and allied dangerously with indwelling devices, especially central venous catheters. In the developing world, neonatal sepsis remains a major cause of infant mortality.
Revived for paradise
Authors: Obladen Michael
Published: September 2021

Infant baptism originated when St Augustine proclaimed the doctrine of original sin in 412 c.e. Neonates stillborn or deceased before baptism were declared to go down to hell and were buried outside of sacred ground. From the 15th century, parents carried those infants to respite sanctuaries in remote mountain chapels, where miraculous images were believed to revive the infant in order to allow baptism and Christian burial. Monasteries made fortunes with the parents’ anguish, and in 1528 the abuse of the Oberbüren image ignited reformation and iconoclasm. From 1740, Pope Benedict XIV opposed the sanctuaries, declaring invalid their apparent signs of life: skin colour change, change from rigidity to flexibility, blood flowing from the nose, sweat on the skin, cessation of a cadaveric smell, and the movement of a feather held at the infant’s mouth. Only crying and sounds of respiration remained valid signs of revivification. Centuries of debate shed light on the difficulty of distinguishing stillborn from liveborn before the stethoscope became available. Respite sanctuaries illustrate the failure of the doctrine of original sin, which was never accepted by the faithful.
Vascular anatomy
Authors: Murphy Amanda , Morris Steven F. , Taylor G. Ian
Published: September 2021

Knowledge of cutaneous vascular anatomy has increased exponentially within the last four decades, coinciding with the early evolution of microsurgery. This chapter summarizes the progress in understanding the vascular basis of flap design and provides an introduction to the general vascular anatomy of the integument, muscle, and bone alongside a discussion of the angiosome concept and associated clinical applications.
Anaesthesia
Authors: Srinath Chetan , Yates Alan
Published: September 2021

The evolution of surgical anaesthesia began nearly 175 years ago with the first public demonstration in 1846 by William G. Morton. Modern anaesthetic techniques have developed in keeping with our understanding of human physiology and the demands of surgical innovation. Anaesthesia can be local, regional, or general and plastic surgery lends itself to local or regional techniques. Local anaesthesia infiltrates the active agent throughout the area in question, while regional anaesthesia uses discrete placement of the anaesthetic agent to block the conduction in nerves supplying sensibility to a wide predictable area. General anaesthesia involves complete loss of consciousness and awareness.
Skin grafts
Authors: O’Ceallaigh Siobhan , Shah Mamta
Published: September 2021

Skin grafts are an option for closing skin defects that cannot be closed primarily. A skin graft consists of epidermis and a portion of the underlying dermis that is detached from its blood supply and transferred to another location, usually on the same individual (an autograft). Skin grafts can also be used from cadaver donors (allografts) in extensive burn injuries, but as the recipient’s immune system will eventually reject this foreign tissue, this is only a temporary measure.
Skin flaps
Authors: Dewar Donald
Published: September 2021

Flaps can reconstruct defects of the integument, resurface mucosal defects, as well as contribute to contour. They are used where grafting is not feasible because of the nature of the defect and/or where the aims of reconstruction would be better served by vascularized tissue with both cutaneous and subcutaneous components. A skin flap can also be combined with fascia, muscle, or bone to reconstruct a complex or composite defect, and to provide tissue to restore function. Flaps may be classified according to the origin of the flap: local skin flaps are raised from tissue adjacent to the defect (usually deriving their blood supply from the subcutaneous tissue and subdermal plexus), and distant flaps are raised on dedicated vascular pedicles from a non-contiguous region. A distant flap may be moved to the defect maintaining the continuity of the pedicle (a ‘regional’ or ‘pedicled’ flap) or as a free flap, where the flap is elevated from its remote donor site and the pedicle is divided to allow the flap to be transported ‘free’ to the defect and then the vascular continuity is re-established by anastomosis to a recipient vessel in the defect. This chapter focuses on local flaps.
Microsurgery
Authors: McCombe David , Morrison Wayne
Published: September 2021

This chapter describes the history, principles, techniques, and outcomes of microsurgery applied in particular to revascularization of tissues following trauma or elective dissection to allow free tissue transfer.
Vascularized composite allotransplantation
Authors: Wilks Daniel , Kay Simon
Published: September 2021

Vascularized composite allotransplants contain the products of multiple cell lineages to reconstruct the form and function of complex, composite tissue defects. This chapter discusses the ethical principles and the immunology behind composite transplantation, including the selection of immunomodulatory agents and the immune basis and treatment of rejection. The principles of organ allocation and candidate preparation are presented prior to discussion of the clinical applications and outcomes of hand, face, abdominal wall, uterus, penis, and lower limb transplantation.
Hand therapy after peripheral nerve injury
Authors: Rosén Birgitta , Jerosch-Herold Christina
Published: September 2021

Injury to the peripheral nerve affects the whole length of the neuron and is not just localized to the site of injury, making a nerve injury different from other types of tissue injury in the body. Moreover, a nerve injury has immediate functional consequences for the brain in terms of rapid cortical functional reorganization. Lifelong limitations of hand function with loss of sensibility, muscle weakness, prehensile problems, pain, and cold sensitivity are common. Recovery can take years in adults, especially of tactile discrimination, but often remains incomplete and quality of life may be significantly affected. Numerous factors influence the outcome: age, type of injury, timing of surgery, and cognitive capacity. In addition, education, sex, and post-traumatic stress have proved to be prognostic factors. The timing of hand rehabilitation including sensory and motor re-education are also important contributors to the final outcome.
Physiological requirements for action potential conduction, sensory awareness, and motor control
Authors: Johansson Staffan
Published: September 2021

Nervous system function depends on electrical and chemical signals. The nervous impulse is a fluctuation in voltage across the neuronal cell membrane, generated by ion currents through ion-selective, voltage-sensitive membrane channels. Neuronal information is encoded in the temporal pattern of such impulses propagated along the nerve fibres at speeds that may reach about 100 m/s in fibres electrically isolated by myelin. Signal transmission to other cells via synaptic contacts occurs mainly via chemical transmitters that control membrane ion channels and give rise to electrical responses in receiving cells, with plasticity in the process making the system capable of learning and memory storage. Since impulse generation as well as synaptic transmission depends on ion flux across the membrane, energy-dependent ion pumps are critical for maintaining the ion concentration gradients necessary for the nervous signals. As a consequence, the nervous system consumes a lot of energy and is sensitive to any lack of energy.
Tactile sensory control of the human hand
Authors: Johansson Roland S. , Nordmark Per F.
Published: September 2021

This chapter details the sensory input from the hand that is mediated by a system of fast-adapting and slowly adapting nerve fibres with a specific anatomical distribution and associations with particular sensory end organs that allow multimodal sensory input and processing. This highly refined system interacts with the motor system to provide continuous feedback that allows the dexterous manipulation of the environment that distinguishes the human hand.
Tinel–Hoffman sign
Authors: Kay Simon
Published: September 2021

The Tinel–Hoffman sign is uniquely valuable to the peripheral nerve surgeon. Described by both Hoffman (1915) and Tinel (1915) on opposite sides of the First World War, its value lies in assessing nerve recovery after injury. Originally called ‘Le signe du fourmillement’ by Tinel, it relies upon the phenomenon that regenerating axon sprouts depolarize on mechanical stimulation so that percussion or pressure over the site of nerve regeneration causes the patient the sensation of tingling in the distribution of that nerve.
Nerve grafts and transfers
Authors: Bains Robert , Kay Simon
Published: September 2021

Following Cruickshank’s (1795) ingenious (and at first disbelieved) demonstration of the regenerative capacity of mammalian nerves, the eighteenth and nineteenth centuries saw a pan-European enthusiasm to redress the nihilism surrounding nerve injury. The first recorded experimental nerve grafts were performed by Philipeaux and Vulpian who attempted both nerve autografting as well as allografting in dogs. At that time, and for many years, allografts were thought to behave similarly to autografts, a belief that persisted well into the twentieth century in some clinics and laboratories. These early attempts at nerve grafting yielded poor results and most surgeons aimed for primary nerve repair despite nerve gaps. Other techniques to allow direct repair involved alteration of position, transposition of the nerve, and even sometimes bone shortening. Although primary repair was frequently possible, after these measures the repair was under tension and mechanical failure was common. Spurling (1945), Whitcomb (1946), and Woodall (1956) showed failure rates of 4%, 7.5%, and 22.4% respectively. Some recovery of function following nerve grafting was documented by Sanders (1942), Seddon (1954), and Brooks (1955). Millesi subsequently published his results for nerve grafting for injuries to the upper limb in 1984. These papers demonstrated more significant recovery of function and highlighted the detriment of delay in treatment to final outcome. Microsurgical advances were central to Millesi’s results, and he emphasized atraumatic dissection and the deleterious effect of tension at the repair site resulting in fibrosis preventing axonal regrowth. Nerve autograft is now the standard for orthotopic nerve reconstruction when primary repair cannot be achieved.
Compression neuropathies
Authors: Dahlin Lars B. , Thomsen Niels
Published: September 2021

Nerve compression disorders affect nerve trunks, particularly in the upper extremity where carpal tunnel syndrome (median nerve compression at the wrist) is the most common and ulnar nerve compression the second most common disorder. Compression affects the various components of the nerve trunk, including the intraneural blood vessels, the Schwann cells, the axons, and the connective tissue components. It results in sensory and motor dysfunction, and sometimes pain. Risk factors for nerve compression disorders are known and may predict surgical outcome. A careful clinical examination should always be done, sometimes complemented with appropriate electrophysiology and magnetic resonance imaging for diagnosis. If conservative treatment is not appropriate, or fails, simple decompression is generally the primary treatment, but problems may persist. The presence of other neuropathies should be considered.
Lower limb replantation
Authors: Tarar Moazzam N. , Ul Haq Ata
Published: September 2021

Advances in microsurgery have made possible replantation of severed body parts. Lower limb replantation has been successfully attempted and reported in the literature. Despite many similarities with replantation of the upper limb, the same degree of outcome has not been attained in lower limb replantation. This is due to the strong forces required to result in lower limb amputation and relatively less potential of recovery. In selected cases when distal amputations were caused by sharp injuries, favourable outcomes were reported. Similarities and differences between upper and lower limb replantations are outlined in this chapter with special reference to indications, assessment, operative management, and results.
Amputations in the lower limb
Authors: Khan Umraz , Gordon Alan
Published: September 2021

Amputation surgery of the lower extremity is frequently an end point of many differing disease processes. Often the most difficult decisions relate to the timing and the level of amputation. Both of these are dictated by the disease. Amputation for trauma is often more difficult both to undertake and to accept when compared to amputation for dysvascular disease or diabetes. This decision must be made by experienced surgeons in coordination with the patient, the patient’s family, and the limb-fitting professionals. This chapter outlines the principles of surgery from minor to major amputations, tries to simplify the surgical steps, and emphasizes the importance of exemplary rehabilitation after a major amputation.
Deformities of the chest
Authors: Stern Harvey
Published: September 2021

Analysis and surgical management of chest wall deformities involves understanding complex congenital and acquired conditions and well as the full spectrum of reconstructive techniques. Congenital chest wall deformity includes pectus excavatum, pectus carinatum, and Poland syndrome. In surgical correction of these conditions, timing and the understanding of the growing child is important. Traumatic chest wall deformities present a different set of challenges, especially as the context is often a very unwell patient. As cardiothoracic surgeons push the boundaries of what is possible in patients with ischaemic heart disease, iatrogenic defects are not uncommon, and repair of such defects is described. Lastly, this chapter covers surgery for the coverage of major tumour resection defects in oncological surgery.
Surgical anatomy of the breast
Authors: Jeeves Amy E.
Published: September 2021

The anatomy of the breast is integral knowledge for the surgeon undertaking oncoplastic, aesthetic, or reconstructive breast surgery. This chapter reviews the current literature on applied breast anatomy. Arterial and nerve supply, venous and lymphatic drainage, and ligamentous framework as well as the nipple–areolar complex are discussed. Relevant gross anatomy and histology are covered along with current concepts of breast aesthetics. This chapter emphasizes surgical anatomy with both historical and practical references for the plastic surgeon
Congenital deformities of the breast
Authors: Lodge Michelle L.
Published: September 2021

Congenital breast anomalies include supernumerary nipples (polythelia) and supernumerary breasts (polymastia) which can be generally found on the embryonic mammary ridge. Absence of the breast occurs less frequently and varying presentations of absence of nipples only (athelia), absence of mammary gland tissue (amazia), or absence of the entire breast (amastia). Tuberous breast deformity is a common congenital anomaly with varying degrees of constriction, hypoplasia, areolar herniation, skin deficiency, and asymmetry. Treatment consists of breast augmentation, either primarily or after tissue expansion, in combination with mastopexy. Gynaecomastia is the development of breast tissue in males. The aetiology is diverse and includes physiological, pathological, acquired, drug-related, and idiopathic causes. Poland syndrome is discussed elsewhere (Chapter 9.2).
The tissue-engineered breast
Authors: Morrison Wayne
Published: September 2021

The adipose tissue engineering paradigm of in vitro cell-seeded scaffolds subsequently implanted in vivo failed because of inadequate vascularization. Consequently, entirely in vivo models of tissue engineering are being trialled where angiogenic growth is stimulated in unison with expansion of implanted cells and matrices. In animals, impressive amounts of fat and fibroblastic tissue have been grown by matrix induction of preadipocytes or by redirecting a vascular pedicle with fat into a sealed chamber space and proof of principle shown in a human trial. The models are cumbersome limiting clinical translation and currently direct fat transfer by injection is simpler. Unlike true tissue engineering there is, however, no net gain of tissue and even when ‘successful’ it is debated whether the graft survives or is replaced by newly regenerated adipocytes. Research focuses on stem cell differentiation, cell survival, and matrix and biomechanical manipulations.
Anaesthesia and analgesia considerations in breast surgery
Authors: Rudkin Glenda , Gardiner Sarah
Published: September 2021

Breast surgery is most commonly conducted for a suspected diagnosis or treatment of cancer. Additionally, cosmetic breast surgery is an increasingly common field particularly in the day-case setting. Both oncological and plastic surgery of the breast varies in site, extent of dissection, surgical technique, and duration of procedure in the context of diverse patient factors (premorbid psychosocial profile, physical habitus, tissue quality, comorbidities). These elements all require careful consideration for the attending anaesthetist and surgical team in order to optimize the patient journey through their recovery in both the acute and long-term periods. In addition to systemic administration, improved postoperative analgesia and subsequent recovery in breast surgery incorporates regional and local anaesthetic techniques. Integral to any surgical setting is a patient-specific pain management plan. This should commence at the time of anaesthesia and continue into the postoperative period. Any risk factors for chronic pain need to be identified and managed early.
Measuring outcomes in plastic surgery of the breast
Authors: Dean Nicola R. , Cooter Rod , Pusic Andrea L.
Published: September 2021

A surgical outcome can be sensibly defined as a measurable end point relating to the goal of surgical treatments. Historically, complication rates have been used as surrogates for outcome, but now high-quality outcome measures such as the BREAST-Q are available; these should be a major focus for analysis of results in plastic surgical procedures of the breast. It is also important to collect high-quality data on complications and to document outcomes with methodologies such as standardized photography and three-dimensional laser scanning. Proper evaluation of outcomes is a potent driver of practice improvement in breast reconstruction and practical approaches to outcomes measurement in routine practice is discussed in this chapter. The history of device registries for breast devices is explained and the current and future roles for device registries are discussed.
Pressure ulcers
Authors: Hudson Donald , Moodley Sean
Published: September 2021

Pressure ulcers are a problem worldwide with social and cost implications. Patients at special risk are paraplegics, those in intensive care units who are critically sick, and older patients having prolonged bed rest for whatever reason. The important extrinsic factors are pressure, shear, and friction. There are a number of charts, which endeavour to identify patients at risk, and institute appropriate preventative measures thereby avoiding the long-term sequelae and burden of pressure ulcers. In patients with established pressure ulcers, an accurate patient and wound evaluation is vitally important. The long-term success of management of these ulcers is dependent on good patient rehabilitation and optimization of the wound. Reconstructive success is improved by following surgical guidelines. Use of fasciocutaneous flaps, designed in a V–Y configuration, is the preferred method of reconstruction with muscle flaps reserved as a back-up option. Conscientious postoperative care is equally important at ensuring a successful surgical outcome and minimizing complications
Bladder exstrophy and epispadias
Authors: Wilby Dan , Wood Dan
Published: September 2021

Bladder exstrophy and epispadias are congenital anomalies of the urogenital tract with deformity of the genitals as well as the pelvis, abdominal wall, and bladder in exstrophy. Reconstruction of the anomalies is a complex process with the aims of restoring function and appearance. Fertility and management of pregnancy in the exstrophy patient are also discussed in this chapter.
Gender reassignment
Authors: Fenton Oliver
Published: September 2021

This chapter deals with the definitions, history, incidence, and background to both gender dysphoria as a whole and male-to-female gender reassignment surgery specifically. Other chapters deal with surgical procedures for female to male reassignment that are within the scope of this textbook.
Periorbital, lower face, and neck
Authors: Waterhouse Norman , Noshi Naresh , Kirkpatrick Niall , Brendling Lisa
Published: September 2021

Facial ageing occurs as a consequence of multifactorial changes in both the external skin and underlying tissues. The ageing process may vary dramatically between individual patients and is thus influenced by genetic factors. When assessing the ageing face it is important to consider the skeletal architecture, the soft tissue layers including the anterior fat pads, the osseocutaneous ligament anchors, and finally the overlying skin. Assessment of the external skin incorporates factors such as dermal thinning, solar damage, lifestyle effects such as smoking, and Fitzpatrick skin type. Surgical correction of facial ageing attempts to reverse both gravitational change of soft tissues and also to restore volume loss. There are a variety of methods used to divide the face into regions, but for the purpose of this chapter, the surgical management of facial ageing will be separated into three anatomical areas: (1) upper face, including the upper eyelids, eyebrows, and forehead; (2) midface, including the lower eyelid/anterior cheek continuum; and (3) lower and lateral cheek, neck, and perioral region
The ethics of gender reassignment surgery
Authors: Fenton Oliver
Published: September 2021

Transgender issues are very much in the news at present. There has been discussion about both gender dysphoria in general but, more specifically, the practical, psychological, and financial implications of carrying out gender reassignment surgery. In the United Kingdom, this extends to a debate on whether it is justifiable to carry out these procedures within an already hard-pressed National Health Service. This chapter discusses the nature, history, and background of both gender dysphoria and gender reassignment surgery and whether such procedures are justifiable in terms of outcomes and patient satisfaction; and also whether these are legitimate procedures to carry out within the National Health Service.
Consulting with children
Authors: Kay Simon , Bellew Maggie
Published: September 2021

Plastic surgery deals with appearance and function, and a significant proportion of its work is in children with birth or developmental defects who require care throughout childhood and sometimes as an adult. For some plastic surgeons, children form a major part of their work whereas for others, their skills set may only occasionally be relevant to childhood conditions. Consulting with children and their families requires special circumstances and techniques for success. In this chapter (which should be read in conjunction with Chapter 13.2), the theoretical aspects of consulting with children is first examined, before considering the practical consequences for clinic arrangements.
Clinical assessment and imaging of the upper limb
Authors: Mishra Anuj
Published: September 2021

Clinical assessment of the upper limb and hand requires a detailed history of the symptoms, or, in cases of trauma, the circumstances of the injury. Examination should be systematic and guided by a thorough knowledge of anatomy and the likely pathology. Various modalities of imaging can be applied to confirm or characterize the pathology. Each has particular indications and should be applied carefully so as to obtain the most accurate result.
Anthropological, behavioural, and cultural characteristics of the human hand
Authors: Haeney James
Published: September 2021

The evolution of the form of the hand and upper limb from the early vertebrates to the mammalian limb and human hand is described. In addition to the functions of grasp, pinch, and sensibility, the hand has an important role in non-verbal communication and development.
Hand therapy, rehabilitation, and rehabilitation following tendon injury
Authors: Peck Fiona
Published: September 2021

This chapter describes the principles and techniques applied by hand therapists in the management of hand conditions in general and specific details about protocols for rehabilitation of flexor and extensor tendon injuries.
Fractures of the hand and wrist
Authors: Shewring David J.
Published: September 2021

Fractures of the phalanges and metacarpals are the most common fractures of the upper limb and account for 10% of all fractures. Along with fractures of the carpal bones, they represent 55% of upper extremity fractures. Although over the last few decades there has been an increased tendency to treat hand fractures with internal fixation, the vast majority of these fractures are stable and can (and should) be treated non-operatively. If surgical fixation is considered, then it must be appreciated that some hand fractures, particularly those affecting the proximal phalangeal shaft and intra-articular fractures, can be unforgiving. Fractures treated poorly, using inappropriate equipment in inexperienced hands can lead to irretrievably poor outcomes. Good or perfect results can be obtained with surgical fixation, but these demand careful planning with consideration of all the various methods in the surgical repertoire. The best, and possibly the only opportunity to obtain a good result is at the first surgical intervention and so those fractures requiring fixation should not be treated by unsupervised inexperienced surgeons. It is preferable to delay fixation by a few days until the best expertise is available.
Reanimation in the upper limb
Authors: Kay Simon
Published: September 2021

Reanimation of the upper limb in the situation where there is a deficiency of local muscle to produce the desired function requires importation of a functioning muscle by pedicled or free transplantation. The principles of these procedures are discussed in this chapter together with the most common scenarios where this surgery may be required.