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This case study describes frostbite, a previously unreported complication following cryolipolysis, which resulted in substantial necrosis of the flank. Medical attention was not sought until one week after treatment. On examination, two distinct areas of significant frostbite in the left flank with surrounding erythema were revealed. Surgical intervention was avoided, as is recommended in cases of frostbite, and conservative treatment resulted in recovery of the affected area. Here, the authors highlight the adverse effects related to cryolipolysis, analysing the pathogenesis, clinical manifestations and management of this injury. The necessity of regulation within the cosmetic sector and the challenges associated with its implementation are also described. The authors believe emphasis must be placed on increasing patient awareness on the potential hazards of seeking cosmetic treatment from unregulated providers.

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OBJECTIVE: Scar assessment in the clinical setting is typically impeded by a lack of quantitative data and most systems rely on subjective rating scales which are user dependant and show considerable variability between raters. The growing use of digital photography in medicine suggests a more objective approach to scar evaluation. Our objective was to determine if cameras could be of practical use for measuring colour in a clinical setting. METHOD: The measurement of colour and reflectance spectra in photographs faces two difficulties: firstly the effects of variable illumination spectra, and secondly to recover accurate colour and spectral information from the sparse red, green and blue (RGB) camera signals. As a result the colour rendition is often inaccurate, and spectral information is lost. To deal with variable illumination and other factors that systematically affect all reflectance spectra ColourWorker (a method for image-based colour measurement implemented in software) calibrates the spectral responses of the camera's RGB sensors using a colour standard in the image. To make best use of the calibrated signals, it takes advantage of the fact that although a given RGB signal can be caused by an infinite number of spectra, most natural reflectance spectra vary smoothly and have predictable forms. This means given a set of examples of spectra produced by the materials of interest, it is possible to estimate the specific spectrum that produced a given RGB signal once corrected for the illumination. We describe a method for recovering spectral and chromatic information relating to surface reflectance from ordinary digital images and apply this to analyse photographs of surgical scars, taken as part of a clinical trial, in an attempt to better quantify clinical scar assessment. It should be noted the pre-existing trial protocol did not allow for a comprehensive evaluation of the accuracy of the method which would require the spectrophotometric measurement of skin regions corresponding to those in the photographs. RESULTS: Scar colour was estimated reliably, and with simple image analysis we were able to record the change in colour across the skin. Furthermore, we describe a simple automated assessment procedure that enables scar severity to be quantified and defined using a single scalar value easily. CONCLUSION: Such image-based colour measurement and assessment offers considerable advantages over other current methods, including spectrometers, which measure only a single point, or printed charts.

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INTRODUCTION: Botulinum toxin injections are an effective, well-established treatment to manage synkinesis secondary to chronic facial palsy, but they entail painful injections at multiple sites on the face up to four times per year. Cutaneous cooling has long been recognised to provide an analgesic effect for cutaneous procedures, but evidence to date has been anecdotal or weak. This randomised controlled trial aims to assess the analgesic efficacy of cutaneous cooling using a cold gel pack versus a room-temperature Control. MATERIAL AND METHODS: The analgesic efficacy of a 1-min application of a Treatment cold (3-5 °C) gel pack versus a Control (room-temperature (20 °C)) gel pack prior to botulinum toxin injection into the platysma was assessed via visual analogue scale (VAS) ratings of pain before, during and after the procedure. RESULTS: Thirty-five patients received both trial arms during two separate clinic appointments. Cold gel packs provided a statistically significant reduction in pain compared with a room-temperature Control (from 26.4- to 10.2-mm VAS improvement (p < 0.001)), with no variance noted secondary to age, the hemi-facial side injected or the order in which the Treatment or Control gel packs were applied. CONCLUSION: Cryoanalgesia using a fridge-cooled gel pack provides an effective, safe and cheap method for reducing pain at the botulinum toxin injection site in patients with facial palsy.

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Scarring is a significant clinical problem following dermal injury. However, scars are not a single describable entity and huge phenotypic variability is evident. Quantitative, reproducible inter-observer scar assessment is essential to monitor wound healing and the effect of scar treatments. Scar colour, reflecting the biological processes occurring within a scar, is integral to any assessment. The objective of this study was to analyse scar colour using the non-invasive Eykona® Wound Measurement System (the System) as compared against the Manchester Scar Scale (MSS). Three dimensional images of 43 surgical scars were acquired post-operatively from 35 patients at 3-6 months and the colour difference between the scar and surrounding skin was calculated (giving ΔLab values). The colourimetric results were then compared against subjective MSS gradings. A significant difference in ΔLab values between MSS gradings of "slight mismatch" and "obvious mismatch" (p<0.025) and between "obvious mismatch" and "gross mismatch" (p<0.05) were noted. The System creates objective, reproducible data, without the need for any specialist expertise and compares favourably with the MSS. Greater scar numbers are required to further clinically validate this device--however, with this potential to calculate scar length, width, volume and other characteristics, it could provide a complete, objective, quantitative record of scarring throughout the wound-healing process.

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AIMS: To validate a new photogrammetric technique for quantifying eye surface area and using this to quantify the degree of improvement in symmetry in patients with oral-ocular synkinesis following Botulinum toxin injection. STUDY DESIGN: Feasibility study and retrospective outcomes analysis METHODS: Ten patients' photographs were chosen from a photographic database. Their eye surface areas were measured independently by two raters using a graphics tablet. One rater repeated the procedure after 15 days. Bland-Altman plots were computed, ascertaining inter-rater and intra-rater variability. The eye surface areas of 19 patients were then derived from photographs taken before and after Botulinum toxin injections. Paired t-tests were used to analyse the significance of the difference in pre- and post-treatment symmetry. RESULTS: Ninety per cent of eye surface areas derived from the two raters were within a coefficient of variation of 0.1 (95% CI: 0.05-0.15). Similarly, 90% of eye surface areas derived from one rater had a coefficient of variation of 0.08 (95% CI: 0.04-0.12). Botulinum toxin significantly reduced synkinesis resulting from lip puckering, Mona Lisa smiling and Hollywood smiling (P<0.05). CONCLUSIONS: We have proposed a clinically valid tool for quantifying the effects of Botulinum toxin treatment for oral-ocular synkinesis. We recommend this method be used to monitor the response of such patients when receiving Botulinum toxin treatment.

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Pretibial lacerations remain one of the commonest yet most neglected conditions facing emergency departments and plastic surgeons alike. Furthermore, these injuries afflict the most vulnerable groups of adults - the elderly and the infirm. It is essential therefore to have an approach to pretibial lacerations based on best available evidence, in order to optimize wound outcomes, but perhaps more importantly, to safeguard the general health of the vulnerable individual. We present an evidence-based approach to the tertiary management of these injuries and propose a treatment algorithm that we have utilized in our unit to successfully manage 40% of tertiary referrals of pretibial lacerations in a conservative manner.

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Altered pharmacokinetics in patients with major burns may result in serum antibiotic concentrations below those required to be effective against the common pathogens encountered in burns patients. The major changes in the fluid volumes of key body compartments, which occur with a large burn, may increase the apparent volume of distribution of a drug, thereby lowering its concentration when a standard dose is given. In addition, the observed increase in renal blood flow reported in burns patients, because of the change in cardiac output, may result in a higher drug clearance and a shorter elimination half-life. As a consequence, studies have recommended higher doses or more frequent dosing or both for some antibiotics in patients with major burns, but data are lacking for many of the antibiotics reserved for treatment of life-threatening infections. The authors measured serum concentrations of two antibiotics, linezolid and meropenem, in an immunosuppressed patient who presented with a severe burn to determine whether therapeutic concentrations were achieved, thereby improving the likelihood of infection control.

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BACKGROUND: Laparoscopic liver surgery has been difficult to popularize. High volume liver centres have identified left lateral sectionectomy (LLS) as a procedure with potential for transformation into a primarily laparoscopic procedure where surgeons can safely gain proficiency. METHODS: Forty-four patients underwent either laparoscopic (LLLS) or open (OLLS) left lateral sectionectomy (of segments II/III) for focal lesions at Southampton General Hospital. RESULTS: OLLS and LLLS groups were matched for age, sex and tumour types resected. Median operative time in the LLLS group was 180 (40-340) min and 155 (110-330) min in the OLLS group (p=0.885) with median intra-operative blood loss in the LLLS group 80 (25-800) ml versus a larger 470 (100-3000) ml; p=0.002 for patients receiving OLLS. Post-operative stay was also shorter in the LLLS group (3.5 (1-6) days) compared to the OLLS group (7 (3-12) days; p<0.001). Resection margin was not different in the two groups (11 (1.5-30) mm (LLLS) versus 12 (4-40) mm (OLLS); p=1) and neither was the complication rate (13% for LLLS versus 25% for OLLS; p=0.541). There were no conversions to open in the LLLS group and no deaths in either group at 90 days. Between the first and second 12 LLLS the median operative time fell from 240 (70-340) min to 120 (40-120) min; p=0.005 as well as median post-operative hospital stay from 4.5 (2-6) days to 2 (1-4) days, p=0.001. CONCLUSION: LLLS is a viable alternative to OLLS with potential improvements in intra-operative blood loss and shorter hospital stay without adversely affecting successful resection or complication rates. Larger prospective studies are required to explore this new avenue in laparoscopic liver surgery.

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Postoperative pseudoaneurysm formation is one of the most feared complications of pancreatic leak following pancreaticoduodenectomy (PD). Surgical repair may be compromised due to a persistent enzymatic insult on the repaired vessel; therefore, preventive measures should be adopted. We report a case of ruptured hepatic artery pseudoaneurysm occurring 12 days following PD in a patient with a postoperative pancreatic fistula. Emergency surgery revealed that the pseudoaneurysm was situated at the point of surgical transfixation of the gastroduodenal artery. The pseudoaneurysm was successfully managed by under-running of the bleeding point combined with the direct application of hemostatic products to the bleeding surface (TachoSil and Tisseel) to act as a barrier from the pancreatic secretions.

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Color-flow Doppler is a useful adjunct in duplex sonography of peripheral vessels. This study was undertaken to see if color-flow Doppler could give semiquantitative information about the degree of stenosis at the origin of the internal carotid artery. The factors evaluated on color flow are the width of the lumen as estimated from the color-flow image relative to the width of the vessel, the degree of turbulence (evidenced by the mosaic pattern), and the pulse-repetition frequency necessary to prevent aliasing. A double-blind comparison with conventional duplex scanning in 146 carotid bifurcations in 74 patients was carried out. In 91%, the color-flow assessment was in complete agreement with the duplex assessment. In the remaining 9%, the color flow differed from the duplex by only one stenosis group, and the distributions of over- and under-estimation were equal. These results showed comparable assessment of the degree of stenosis with conventional duplex and color Doppler technology.

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