Cleft 5: Cleft Emergencies

Welcome to Poplast, UK. In stage episode, we're focusing on kept surgery emergencies. Hello, and welcome to the Poplast UK podcast. My name is Stephen Brost. I'm a plastic surgery trainee in the East Millens. Today's session is on Cleft Ballet Emergencies, an important topic of plastic surgeons, and one that can be possibly daunting when on call. Today we have two fantastic experts joining us. Mr. Jason Neil Dwyer and Mr. Jonathan Simon Grant, both plastic surgeons who specialize in cleftlet and pallets in the Trent Regional Clath Network. So welcome to you both, and thank you for joining us. Most of the emergencies we will talk about are aerial post-operative, but before we get to those, how do you approach a neonate with a cleft palate presenting with an obstructed airway? I think most of the time this is quite a difficult topic for people to understand because much of the system within the UK means that these things don't actually present plastic surgeons. So you're often going to be talking about this on a slightly theoretical basis. So in general, when children are born with breathing difficulties, that is evident at the neonatal checks that are happening as the baby is born. Most children are breathing difficulties, and you're not going to be flagged up by any anti-natal screening. And so it tends to be a denote those finding. And the normally will be early pediatric involvement to any child that's showing difficulties and difficulties in neonate present as brunting breathing, intercostal recessions, cue-tug, power dot screening movements. If you are asked about this, then I'll normally be asked at the early anti-natal checks where they'll be doing things like clearing suction from the mouth. And in that situation, your child is not quite a sort of a birth-related, a huge problem. You're going to be looking to treat the respiratory obstruction. So the first thing is to have the right support in place so you should see your child should experience neonatologist or pediatrician, whichever is more appropriate for when you're working. And you're going to, first of all, look at the child, assess the airway. With the airway in a baby, what you see is what you get. So it's very, very much. If you see a small jaw that they tend to have a poor airway, and that's the commonest finding. And in that situation, then providing them, maintaining their saturations and their well, then you're going to, first of all, attempt to relieve the obstruction by using gravity. It tends to be that the tongue is falling back, it's back, all the throat. So the commonest thing to do is to lie the child on their side. Or you can, for brief periods, have the child on their front. You can't leave them on the dirt in that state. That should clear the airway and allow the child to start breathing, and then you can start any additional assessments that will come from that. If that doesn't relieve the obstruction, then into an airway, where we're going to be doing loads of techniques for the airway, and you need to then have support for people with your experience in that. Shouldn't be tempted to do that on your own. And then they charge you some very experienced and inserting various forms of airway. If you're moving down that line, you're mainly to have your pediatric airway and east is involved as well. So the first thing that we do, if sideline doesn't work, and the airway is clear, then the next thing is to attempt to insertion of an asip around your airway, and then that escalates up. If that doesn't work, you've still got the obstruction, you're then looking at other adjuncts initially in the near-nage. They tend to use CPAP or high-glow oxygen. And again, those aren't things that you'll be applying. And with that, if you work, you then might be exiting something with such glowy oil or a temporary inch-based child at which point can you have the ability to land that trial. You may do it until you need an experience with your pediatric airway and experience their energy. That's sort of in a nutshell. John, do you want to. Yeah, I'd agree with you, Jason. The issue is to contextualise the question or if you make sure in a situation of actually being phoned in a long call, consulting for plastic surgery and asked what to do. This is a child who is in a neonatal setting, and I think it's important for you to have an understanding of the kind of conditions, like pyramids and things that can precipitate breathing with cookies, but then to know very quickly who the correct people are to rally, because it's not plastic surgeons that manage airways, but it might be neonatologists, respiratory pediatricians, complex airway, EMT and the pediatric chemistry, but knowing who to call and when to call them, I think, is important. Thank you. It's really useful to revisit the MDT. It's obviously really important for a lot of plastic surgery, but it's in particular. So it's dependent to look after the child, but useful for us to be aware of everybody that we need to get involved. Should we find ourselves in a situation where that service unit is formally developed, as it might be in the hub senses? So moving on, what are the common complications that you see, most operatively, in Klaiflund, about it? So fortunately, we have a pretty robust team around the child, which is a very simple issue. Like reassurance and analgesia are important. The other thing, which is a feature of most organopter, the type of surgery would be some difficulty of feeding and re-establishing whatever feeding they were on, whether that's pure bottle feeding or bottle and puree, although it's very different if they are on tube feeding, the re-establishing that feeding can sometimes take a little while. So those are really the common things. The more serious complications, fortunately, should be relatively rare. I think we're going to talk a lot more about that through the rest of this chat. But by being rare, fortunately, they come out very infrequently, but they can catch anyone by surprise, particularly if they're not actually in a clinic and so on. So the complications that I think most people probably worry about, rightly so, in Klaiflund ballot are air-web obstruction and post-operative bleeding. So we start with air-web obstructions. What is your approach for managing a post-operative obstruction in an elected petra path? I think it's fair to say that all primary cleft surgery in some way increases air-web obstruction. And so I think one of the things when you think about it a bit is, it's often surprising that the children don't have more difficulties in breathing, because their air-web has more resistance and obstruction after either primary lip repair or primary pallet repair that did prior to that. Well, we only see issues in a limited number of patients. And the thing that you'll first see, and we tend to pick up on this quite early, is you're looking for signs of increased work of breathing when the child's asleep predominantly. So you're looking for when a child's asleep, any evidence of intercostal recession in particular, a tracheal tug increased respiratory rate, and these are significant findings. Late findings are things like reduced saturations. We tend not to see those very often. Those are what you see in cleft pallet. Most of the obstruction occurs in cleft pallet for breathing. We get a small number of cases with obstruction in cleft lip, and the signings are a little bit more subtle there. Whenever we're operating on a complete cleft lip, you get a lot of swelling around the nasal airway. And if the nose gets blocked, the first sign that we're going to get, that child's got an issue, is that a feeding goes off where you might not have expected it to. And then one of the unusual signs that you can see is something called lip sucking, where we take a child and have a big wide cleft to having lips that meet. And if they're obliquate nasal, they won't open their mouth to breathe. But if they have a critical nasal airway obstruction, what you'll then see is them sucking the lip in to allow air in to their mouth. And that's a significant sign, again, something that needs to be responded to. So I think the first thing is awareness. And then to realize what the signs of it are, we can start to talk about how you might treat that. So most children who have some degree of airway obstruction after a cleft lip, looking at the path, will probably present early. And the increased airway obstruction will be noted on the reversal of the anaesthetic, where they're conversational if the surgeon will be released, it is about how to manage that. And if the child is known to the respiratory team, it's probably an extended conversation about in the actual respiratory positions and possibly the NT. So I would hope that any child who has their web structure, which is noted, has had some form of management insulated. And in our practice, the most common intervention would be an aesopone your airway, or if they're well known to those routine perhaps reestablishing back on their seat path. And I guess those very rare children who have tracking obstacles, something like that, we would hope that they don't have obstruction, but at least they are managed in the correct place and by the correct team to look after that. From an on-call perspective, being wrote in to a situation that they're not familiar with, and they've died potentially, fortunately that is extremely rare. But progressive increase in airway resistance is very, very unlikely. But it might be due to either some airway swelling, either related to the surgery or to the intubation. And then that needs to be managed in the host anesthesia manner, thinking about ensuring oxygen supply, considering intravenous steroids, and an early conversation with the anesthetic team. The other more surgical calls, again, extremely rare, but might happen in Jordan, you have a coagulopathy. So, primarily in the video, if it hasn't been diagnosed, oddities like an unison drone, they might have a hematoma developing, and that could show as progressive airway obstruction. When you're dealing with patients who have a cleft, particularly cleft palate, you're dealing with some of the more challenging intubations in the early life. And so, don't hesitate to contact the pediatric anesthetic team to come and support. You aren't able to manage these children's airways. You need to have people on site, you can. And so, the pediatric anesthetic teams are well aware that these are their problematic interventions. They feel frightened, but on calling them. They might rather be called early and come and have a look. Even if you're just inserting those spongy airway, they'll rather be there and be involved, because they can be very, very difficult interventions anywhere. You know, just to add, one member of the team, who hasn't been mentioned so far, and I think certainly in our context, really does need to be mentioned as an exceptionally useful point of contact for anyone who is called into a situation like this. And this is the cleft nurse specialist. They are often very closely familiar with that child. Certainly, if there has been any airway management up to that point, they would probably be aware of it. And they would be an excellent starting point. If you're wondering how to manage the situation, who do I call? Who do I get help from? They're an excellent person to start with. If you're looking for advice, then you're not in an external situation. So I think people often worry about that sort of needing to acute the intubate people in terms of skin. I think that is really rare in our practice. In general, those patients will have been heavily flagged by pre-optive investigations. They were almost invariably have involvement multiple medical professionals, including complex airway, pediatricians, and the anti-surgents almost invariably. The signifiers of those are generally children who have got severe syndromic involvement. So there are 600 different syndromes involved in cleft. There are ones which tend to have a neurological component. The children in those situations tend to have a degree of hypotonia or central neurological deficit. And it's the hypotonia respiratory drive problems that result in intubation normally. And certainly, in my experience, that's been very, very rare. I can think of maybe two patients in our time when we flagged them a long, long way out. This might happen. So it's not something normally we'll see, but it's almost a reassurance to you. You'd be useful to be aware of most of these patients who probably are these who wanted to have a pre-operative lab. That's reassuring. So who move on to bleeding? Are there any particular steps that you take, either pre-operatively or intraoperatively, to try to mitigate that risk or reduce the chances of post-operative bleeding? So bleeding is something that every surgeon should be concerned about. And particularly when you're dealing with a small patient, she doesn't have a very large circulating volume. And I think reading historical accounts of palettes of bears is just down there crying. Fortunately, those days are gone. So a lot has to do with preparation. And certainly if there is any warning that the child may have some difficulty with their coagulation, that would want, you definitely want to investigate that. But that is unlikely to fall to you as an on-call surgeon. But just thinking operatively and perioperatively, any child needs to be optimised if there are concurrent illnesses that could impact on the coagulation you'd want to know about them. All the children that we operate on get pre-inputration in the flow plan aesthetic, relatively high concentration of adrenaline. We use one in a hundred thousand, which we would mix up ourselves to have that extra adrenaline on. And using pre-inputration and a bit of patience, actually the blood loss is minimal. Now we'd estimate that we're probably on average looking at a maximum of about 2025, now as per procedure rather than the historical leading whole circulatory volumes and needing the transfusion. Yeah, that shouldn't happen at all. I think the other agent that we can use intraoperatively is trynexamic acid. I think I'm a complete convert. I use it in every single case. Yes, he is too. Yeah. So yes, it uses part of the induction medication. And then the reasoning for that is that there are so few contraindications in a child who are using it, or why weight. In the past I would weight an only in those that have a bit more bleeding than I would give it, but I feel it's better to give it pre-emptively. Again with surgery, you know, gentle surgical technique, awareness of bleeders, judicious use of bipolar should stop or act of hemage during the operation. However, there are some techniques that we use that don't allow complete closure of the wound. So lateral releasing incisions in the palate, certainly when they're being made, they can bleed a little bit, but by the end of the procedure with a bit of time, the dipona anticagulation, and also if they're a little bit easier, then perhaps addressing with some surgical something like that, they should be relatively dry. But the vast majority will leave open and just rely on the child's own clotting. So they might have a little bit of blood on the bedclothes or blood in saliva or nasal discharge. But if it's primarily old blood or just a very small quantity, then that's not to be what I would know. I think that one of the things that is evident and is difficult to see from the outside is that anesthesia has got a massive role to play in terms of avoiding additional blood loss to historical levels in our patient group. Modern pediatric anesthesia is a very light touch. The methods of pain control with local anaesthetic infiltration mean the patients don't have a high opioid requirement. And the anestists are very careful to wake them up gently and not have some straining on waking or being significantly distressed because dislodging clots, even when we finished operating, is a problem when children are about salvering because they're screaming and crying. So I think it's difficult to understate the difference that makes going forward and keeping children calm after surgery making sure that their pain relief is met and that they're able to feed and fill their stomachs. All these things are really important because an upset child is much higher chance of bleeding. Thank you. So we certainly hope that it doesn't happen. But if a post of lead were to happen, if there were any significant volume, it's actually going to require a trip back to theatre, but in the meantime before we get the child back to theatre, are there any steps that you take whilst they're on the ward or on routes that you would advise people on? So I think that before we start talking about post-operative bleeding in children, I think the first thing to say is when it is likely and where it's likely to occur. So their commoner sites for bleeding are from two operations that we do. The first one is, as John's just said, is cleft palate repair with male releasing sensations. So the releasing incisions do, there's a little bit of incident bleeding anyway where you're going to get blood in the mouth and though that can be more. So that's the first place where we get significant bleeding, that's normally an isolated cleft palate or any cleft palate procedure. And the second operation that we do see bleeding from is when we've done a cleft lip repair with a vomine flap, a hard palate repair. And that bleeds from two locations. It can bleed from directly behind the pre-mexilar, just behind where the pre-mexilar is because that's where the incisor frame is and you can get a significant bleeding from there. We try to avoid, like she made many cuts in that area in order that you can get bleeding from there. And then the other area is, at the back of the vomine flap, it can extend just into the edge of the adenoids. And that area can bleed significantly as well. I think that it's helpful to know that because you've been called, you know, which patients to start to worry about where they might be bleeding from. The second thing that I think is important before we even start to talk about it is to understand that bleeding is very rarely in these children a life-threatening challenge due to volume. I think that the key thing to get into your thought process when you're starting to see these children is to realise that you have blood in the airway. This is more likely to be an airway emergency than a hypervalemic shock emergency. You can get hypervalemic shock sometimes, but you're more likely to end up with airway problems. And if you get clots in the airway, air obstruction is a significant possibility. So, the key thing when you're going into this is to realise airway and then take your management from there. Because it changes the way you approach this. So, the classic scenario for the exam is you are phoned and there's no cleft surge in contact or how you're going to manage it. That's an interesting thought process and a thought experiment. But heaven forbid that you are on a rotor and the cleft surge and for some reason isn't contactable. And you do have to manage it. And I think it's a skill that everyone who tends to cover special needs should have. So, being phoned by somebody panicking from the wall and saying the child's bleeding. In the first instance, you'd probably want to get as accurate information as you possibly can. Which is is this a significant bleed or is this a little bit of blood in Eukus or saliva. So, an accurate history and understanding of the situation and also some background on the child might be very useful. Let's assume that it is a significant bleed and things are going to need to be done. It's important to think about the whole child. The ATLS isn't over trip statement but I think some form of resuscitation ensuring that there is intravenous access. That the child has had decent analgesia because those days, if they have nothing, make bleeding in the head and neck worse. Faster than screaming and while salvering because it skyrockets the venous blood pressure. So, if you can have a comfortable child and reassured parents, that can have a remarkably positive affair. The other thing that can be done relatively easily is tronic stomach acid. That can be administered with very few risks to virtually all children in this situation. Other things that have made it into the chat, like adrenaline, so swabs placed in the baby's mouth. In my experience have very limited value. Back to my point about irritating the child. In my experience, sticking something that child doesn't want in their mouth and pressing on it leads to a lot of screaming. So, that may make the situation worse and outside of a practitioner who knows what they're doing, who is going to then walk with that child into theatre, I think something stuck in the child's mouth is probably not that useful. Unless they can see a spurting artery, but I'm not aware of any big enough arteries to do that. You can't get a finger to it. No, you'd make the airway problem worse, but let's not do that. It's not something that you want to enshrine as you do in the town there on the edge of what they've been achieved. Quite often think that sticking something to the addition of the mouth isn't the first thing that comes to mind. No, no. So from those basic interventions and questions that you want to ask of the staff, if the information you're getting suggests that this is a significant bleed, I would echo Jason's point. You're now looking at a combination of a bleeding and an airway issue, and you now need to think about who's the team that I need to rally. And I think that that would be my next step, a phone call to the pediatric anesthetic on a call. If you're aware of any on the shop floor pediatricians who could be involved, perhaps have been there, because there's probably going to be some delay between you receiving this phone call and being able to go in. But I think those safety nets and people who can manage it more acutely can be introduced right at that point. Then while you're driving in, you'd probably want to think about letting the team know. So back to the client nurse specialist, if it's in office hours, or if they have a 24 hour service, you could also try and call the surgeon who did the operation. I don't know any of my colleagues on that surgery would be upset by that call, they'd rather know than not. And even if they're not immediately available, could certainly help direct your intervention. I think the other aspect of that is that there are other people within the hospital who are used to dealing with children's airways bleeding. And certainly in our region, they're aware that if these babies present, they will be called. We have the ENT colleagues across the region who are very happy to get involved with this, it's their call. And there are various functional colleagues across the region as well. So there are more people than it appears at first who can assist with this. And the more experience you have in this, it's a difficult thing to deal with the better, particularly if you're heading towards a situation where you may be going towards the data. So if you get in and you're seeing a child and you can see that they're bleeding significantly, my take on this is that the ward is not going to be the place you can deal with this in any way. And you basically need a senior and esotist pediatric anestist to help you get that child to theatre. In that moment, with the child's mouth bleeding, the person who can solve that problem is a senior and esotist. And they will, again, it's one of these things where if you call them and say what you've got, they will be there very quickly indeed because they all know what that means. You know, like your child with a difficult inspiration that's now been made much more difficult where you may also have an access problem because you can't, you may not have sufficient access to resuscitate the child. Man, the children that I've been involved with this have almost invariably had to have entrusted needles, put into their leg. And again, if you're not experienced at doing that, you need to have people around that are. Is your senior pediatric registrarial consultant uncle? It's your senior pediatric anesthetic colleague and you then need to decide and to take the child to theatre. I know that when this is discussed very exam, there's a question about should you or should you not suction the child's mouth. I think this is, if you've got liquid clotting the mouth, I think that it's a very reasonable thing to do to under direct vision, put a yankersucker in the child's mouth, but not so would delay down to theatre, but you need to be controlling that airway the best you can. I think that if you've got stable clotting the mouth, say in one of the release incisions when you're looking the mouth as a stable clot there, I think you have to be very cautious about dislodging that until you're in a theatre situation because in general that is going to be stopping the bleeding to a degree. And once you remove it, you may then reveal a very significant hemorrhage. So again, if you've got a situation where you've got relatively control bleeding, but a large clotting, you're going to theatre, it's the priorities to get the child's theatre first, always on the list list. Okay, so two scenarios. One, you can actually get to the child or to the child's far away, but you're quite right. If they've got significant bleeding, they need to go back to theatre. So you'll either be directing or asking for the help from, and you know, is in the throat or max for oxygen in a far away hospital. Or if you're the last port of call, then it's important to see the life-saving issue here. This is about hemostasis. You're an experienced surgeon, hemostase before. It's just in a slightly different environment and being in the mouth slightly more awkward access. But once the anesthetist has anesthetized the child and stabilized their airway, that's a time where if you've got significant bleeding, you could put a finger in the mouth if you can reach it. But now that's not going to irritate the child, and it might actually have a positive effect. But it's important if you've been able to discuss it with the surgeon to have an idea of what you might be going in to find. But if you haven't, it doesn't matter. You still have to affect hemostasis. So you want to have the theatre set up fully, but the scrub nurse is already to go. So if a tray is useful, you certainly would have a gag on it, so you can hold the mouth open. But the routine equipment like bipolar on fine force of a suction, basic surgical instruments would maybe necessary. In the acute post-operative bleed, it's almost invariably going to come from a surface which has not been primarily told. So the open lateral releases, or the donor site of the Vomirine flat, which runs very close to the adenoid bed. So that's really where you're going to be aiming. You want to see the bleeder. You want to be fairly precise with your anti-curgenation bipolar. Please don't use monopolar in the scriminative. I think that's highly likely to cause more damage and not necessarily solve the problem. But I think it's really important to say, okay, this might be an extremely unfamiliar situation. But just like in necrotizing fasciitis, you have to change mental gear. You're not doing a beautiful aesthetic operation, you're saving a lot. The exactly the same conscious changing process may need to be undertaken to see it as this is a life-saving intervention. If I need to dismantle the repair to stop the bleeding then that's what I'm going to do. You can discuss it in the cold light of day with a surgeon who can then put it back together with you or on the heron or whatever. But the primary intervention is not to worry about am I going to be able to redo this operation. That's not important. It's about stopping the bleeding. Thank you very much. I think that's a reasonable point to be aware of that it's life-saving. I guess you would propose that if this were in a far away hospital, take down the pallet repair and it can then be tacked back together and then formally redone at a later stage. Yeah. So when we have this sort of thing happening around region, our approach is generally that the people call us. So we'll try and get our operation out to that peripheral hospital straight away. You know, nowadays you can just text it across. You discuss and give permission to that. That's what I'm going to say. You're going to have to. I'll have you take it apart. If you take it apart, just leave it apart. We'll transfer the patient to us the next day and sort it out. That's the reality of what we tell people because it's not about the pallet repair at this point. It's about saving the child's life and we can then deal with the problem afterwards. That's a specialist thing. I just wanted to add one other scenario that we talked about acute hemorrhage but what we do sometimes see is a secondary hemorrhage scenario. Now again, it's not common and this is almost unique to the vomerine plaque patients and when they present about a week or 10 days down the line with a bit of irritation and intermittent bleeding. And this is a scenario which is very, very akin to a post-tonsumectal hemorrhage where they have a no-grade infection in the tonsillabede. So no-grade infection around the adenine to the vomerine donor side. Some inflammation which is spinting the vessels open and intermittent bleeding. And I think just like the tonsillab secondary hemorrhage, I would use the phrase "heral" because they can progress quite quickly. But these are children that are slightly different from the acute bleed in the majority of cases their management is actually medical in treating the low-grade infection of antibiotics and also encouraging the parents to feed them or really. And if they're taking solids as rough solids as they can, you'd perhaps done ENT in the old days post-tonsumectomy the kids were faster. Now they get handed the packet of crisps in the recovery room and it's been shown that it has a very positive effect by cleaning the area because they're eating something rough. It's the same thing could be applied to the children but our other comments about the hemorrhage would apply but take a referral in a child who's a week or 10 days post-tops quite seriously and start to lay the groundwork or safely transferring that child back to the center of the procedure so that they can be monitored. They probably won't want to go back to theatre but they certainly want to be monitored unless they make sure that it's not just a "heral" bleed and then a very severe hemorrhage. So moving on from the emergence post-optic complications of airway and bleeding to slightly less urgence, the big ones that you would concern about in the time-absurgery will be a de-hisence of the wounds or a fistula formation. In the case of these being acute in the first few days or weeks after the surgery, do you ever consider taking the child's back to theatre early for a re-repair revision or do you always plan to bring them back to later stage? So de-hisence depends when you look for it. Early de-hisence is probably not commoner than people know because a lot of people don't actually look for it. We got some data on that which would suggest that it is probably about 10% cases roughly, not necessarily a fistula way through but some wound opening. And in general, the approach is to let that heal. The common shared knowledge is that once you've opened it and it starts to be here, you've got that, you're into an acute inflammatory response that you get an all tissues off your plate on them. Saliva is really, really unfriendly to open wounds. And so the tissues are actually quite master-rated after that first point and the allowable to make things bigger because of the friability due to the inflammation, sensory contact. So you make things worse if you try and stitch them again. So I haven't ever stitched anything early because of that. And I think that's a common experience isn't it, John? Fortunately, de-hisence isn't a common experience. But I absolutely echo your sentiment. I like to think of it as what could I possibly do better the second time that I or my colleague didn't do the first time and I can't think of anything that leads to the top of that list. So you're probably better treating it in optimizing the child, making sure that they don't have any intercurrent infections or nutritional issues or dehydration. And just allowing them the best opportunity to view and they'll probably be the best outcome. Great. Thank you very much. We'll move on to some closing comments. The main recurrent points that I noticed are the surgeons should keep calm. We need to keep the child calm and we need to remember that we've got a wide MDT that can support in these situations. Are there any other particular comments or remarks that you'd like to emphasize our listeners? The other question that I have seen come up is, should these patients be transferred acutely? And I think that the answer isn't, is, is neither. This isn't a lettering airway issue. It needs to be dealt with as, as such, not a, we're preserving the cleft pallet issue and that, that's the conclusion you reach when, when you take it just, you save the life, if they've got an airway bleed and then you transfer, you know, that's the way I respond to that. Yeah, I'd like to thanks to you for the opportunity for having this chat and, you know, to wish you all the best in your careers wherever they may lead you. Just to not be frightened about these scenarios that we're talking about, to talk to the surgeons that manage them in your hospital from time to time, just to, to be comfortable. When you're on an uncle, return the year's roll by and you haven't seen these things for a decade or so, you can be a little bit unfamiliar. So it's not a bad idea just to touch base and find out what your local team are doing. But also that you know the local team and can key into a lot faster that way. Good luck with your about the exam. Otherwise, all the best is a consultant person surgeon. Well, thank you both very much for an award, Mr. Syme Grant, for taking the time to speak to us today. I hope all of our listeners have found this. It was helpful and as enjoyable as I have. Thank you. PobPlusUK is a collaboration between UK and Irish plastic surgery trainees and consultants. The content reflects individual's practice and opinions may vary. If you have any feedback, do get in touch. We hope that this has been interesting and useful. If it has, remember to follow us for future sessions.