Burns and Plastic Surgery
Burns
In 1833, Glasgow Royal Infirmary made separate provision for the care of burn patients. After Lister’s work, the era of antiseptic treatment started in 1868, using initially carbolic oil, then bicarbonate of soda and latterly, tannic acid.
In the early 1930s, David Cuthbertson, an eminent biochemist (see Pathological Biochemistry) worked in the Royal Infirmary helping with the care of burn patients, and conceived his theories about post traumatic metabolism, describing the ebb and flow phases.
During the ebb, there is a decreased vitality of the patient, and the flow phase increases heat production, to counteract which Cuthbertson recommended raising the environmental temperature to between 30 and 32 degrees centigrade, which is the thermoneutral zone of the body’s lowest oxygen demand (find out more).
Burns Unit
During the 1939 / 45 war, the Government set up a Medical Research Council Burns Unit to improve methods of dealing with burns sustained by fighter pilots, bomber air crew and injuries sustained in tank warfare such as occurred in the Battle of El Alamein.
The Unit was placed in the Royal Infirmary, which treated over 1,000 cases a year, because the burns patients were housed in a separate building. This had occurred not for research purposes, but because the other surgeons in the Infirmary wanted these ‘damn, stinking things’ away from any proximity to other surgical patients.
The first director of the Unit (1942-1944) was Leonard Colebrook (1883-1967), a Bacteriologist. On his staff, a young Glasgow surgeon, Tom Gibson (1915-1993 read more) carried out his work on the second set phenomenon. He had previously worked in the Western Infirmary in charge of the septic wards and had been recommended to Colebrook by Professor Charles Illingworth. He had considerable experience in treating burns. A two year old burned girl had two sets of allograft skin applied taken from her father at intervals of 13 days. The first set showed growth in all directions, but there was no growth in the second set. Between the tenth and thirteenth days after the application of the second set of allograft, all epithelium had disappeared.
Peter Medawar, a scientist, was brought reluctantly from Oxford to work with Gibson on this finding, and his work on this confirmed that allograft rejection was an antigen - antibody response. It was hitherto thought that rejection was always due to infection.
Medawar’s further work with Gibson resulted in his being awarded a Nobel Prize in 1960. This original work is the basis of all subsequent tissue and organ transplantation. Medawar later wrote to Gibson, ‘I do want you to know, how clearly I understand my obligation to you for giving me my first insight into the real problem we were facing and my first understanding of the nature of clinical research’.
I do want you to know, how clearly I understand my obligation to you for giving me my first insight into the real problem we were facing and my first understanding of the nature of clinical research
Although Sir Peter Medawar always acknowledged Gibson’s contribution to his Nobel Prize winning work, Gibson’s true place in the evolution of transplantation surgery has not generally been given due recognition.
The advent of antibiotics influenced the treatment of burns greatly from the 1940s, but was not without its problems including antibiotic resistance.
In the early 1990s, to centralise trauma services in plastic surgery, a new Burns and Trauma Unit was opened in Wards 23 and 24 in the Royal Infirmary, replacing the old Burns Unit. Professor William H (Bill) Reid was in charge. For his reflections on 35 years at the Glasgow Burns Unit (1963-1998), read more.
Research and care
Glasgow developed an unfortunate reputation for having many patients who had not only skin burns, but also significant inhalational injuries. Much research was focused in this direction. An unfortunate finding was that there was synergism between the burn surface and the inhalational damage. Patients with moderate burns who had a moderate degree of inhalational damage, from either of which injury alone survival could be expected, unfortunately proved fatal. This finding greatly altered the mortality predictions.
The achieving of permanent skin cover in a burn patient is the main aim in treatment and the means of hastening this are important. Burns dressings are done under as aseptic conditions as possible.
Methods of temporary skin cover before definitive skin grafting, such as the use of human allograft and animal skin, have largely fallen into disuse and nowadays there is available a two layer dressing material.
- The inner layer is a collagen network to encourage regrowth of the dermal tissue.
- The outer layer is a silicone sheet to replace the epidermis.
When dermal regeneration has taken place, the superficial silicone sheet can be removed and replaced with very thin skin grafts, which lessen the surgical damage to the patient’s donor areas.
Once a burn has healed, there can be permanent problems with scarring, disfigurement and loss of function; and continuing care is directed to methods of diminishing the scarring and improving appearance, and physiotherapy or surgery to improve the function. In recent years, heparin has been given in higher doses to patients with lung injury to reduce the lung damage, and also to reduce the risk of venous thrombosis.
Surgery is now carried out at a much earlier stage, with a much reduced length of hospital stay, and this is probably associated with better outcomes, in terms of reduced pain and improved appearance and function.
The Scottish National Managed Clinical Network for Burns (COBIS) was set up in April 2007. The steering group has representatives from each profession involved in burn care and also representatives from patients across Scotland. The aim of the network is to ensure that patients who suffer a serious burn injury in Scotland are treated in an appropriate centre and transported safely and expeditiously to that centre, and they receive a standard of care for burn patients irrespective of where they live.
The network has set up standards for resuscitation, pain management, disaster planning, and nutrition. In a recent audit of burn care, there has been a 10% fall in the number of burns every year since 1970, and there are in Scotland approximately 500 burns patients admitted each year, half of whom are children. There are approximately 50 deaths per year as a result of fires, but only 10% of these occur in hospital.
There is a newly funded initiative in the psychological support of severely burned patients to improve psychological care in all the Scottish burn centres.
Professor William Henry Reid
Plastic Surgery
The Development of Modern Day Plastic Surgery
Modern day Plastic Surgery essentially developed in response to injuries sustained in the First World War and the work of Sir Harold Gillies (1882 – 1960) who is often referred to as “the father of Plastic Surgery”. In 1939, with the outbreak of the Second World War, the Government built Emergency Medical Services (EMS) Hospitals throughout the UK, to treat the expected casualties. Ballochmyle Hospital in Ayrshire was one such hospital and here in December 1940 the Plastic Surgery and Jaw unit opened, initially led by Mr Andrew Hutton, a Consultant from the Western Infirmary Glasgow, and assisted by Mr Maclellan, a consultant surgeon who had studied with Sir Harold Gillies.
Gillies made frequent visits to EMS Hospitals throughout the UK, and during a visit to Stracathro Hospital in Angus, he met John (Jack) Tough (1909-1977). Subsequently Tough spent several periods training under Gillies and with Rainsford Mowlem, another distinguished Plastic Surgeon and a former trainee of Gillies. Jack Tough was appointed Surgeon in Charge of the Plastic Surgery and Jaw Unit at Ballochmyle in 1943 and oversaw the early development of both Plastic and Maxillofacial Surgery. Plastic surgeons and officers in the Royal Army Dental Corps were both trained in the unit. Children’s services were made available at Seafield Children’s Hospital for the treatment of congenital and other childhood problems.
In 1948 Tom Gibson joined Tough as a Consultant Plastic Surgeon and the Burns Unit became part of the Plastic Surgery Unit, housed in Wards 40/41 of Glasgow Royal Infirmary.
In the main entrance hall of the Royal Infirmary, bronze commemorative plaques have been placed. These include Lister, MacEwen, Cuthbertson and Gibson all of whom made, during their spell in the Infirmary and afterwards, very significant contributions to the practice of medicine.
Within a few years, the unit expanded into Ward 42/43 to form a block comprising Plastic Surgery, Burns, Maxillofacial Surgery and associated prosthetic laboratory facilities. Dr Stephen Plumpton led the maxillofacial unit, and Walter Smith OBE who had worked in Ballochmyle since the beginning, was the Senior Chief Maxillofacial Technician.
The 1950s brought some further development, with the appointment of Jack Mustarde (1916-2010) as a consultant and half a ward in the Western Infirmary from the professorial surgical unit. Tom Gibson was given beds in Philipshill Hospital for General Plastic Surgery - subsequently linked to the Spinal Injuries Unit for the treatment of pressure sores and other related problems. At this time, Ian MacGregor (1921 - 1998) was Senior Registrar but the lack of facilities for another consultant in Plastic Surgery prompted his move to Surgeon in Charge of the Casualty Department in Glasgow Royal Infirmary, 1958-1960. During this time, he published “Fundamental Techniques of Plastic Surgery”, a greatly respected text which he updated with further editions over the ensuing years.
Tom Gibson was appointed Senior Lecturer in Tissue Transplantation with beds and theatres in the Western Infirmary, and freed up facilities which allowed Ian MacGregor to be appointed as a Consultant Plastic Surgeon.
Tough was determined to bring the rather fragmented services together and with the help of one of the Health Board Architects, John Peters, plans were drawn up in 1961 to build a new unit at Canniesburn Hospital, Bearsden, where the Royal Infirmary already had convalescent and private beds. It is a tribute to both men that the project was completed despite considerable opposition from the Medical and Surgical establishment of that time.
The cost of this purpose built Plastic and Maxillofacial Surgery Hospital was £996,000 (less than the estimate) and it became operational earlier than expected in September 1967 but not officially opened until May 23rd 1968. Jack Tough retired prematurely in 1970 due to ill health and survived until 1977. He had seen his plan come to fruition but could never have imagined how influential Canniesburn would become.
The unit became the centre for The West of Scotland Regional Plastic and Maxillofacial Surgery Service. Plastic Surgery adopted a Hub and Spoke model - centralising all major elective surgery into Canniesburn, while retaining the Burns Unit in Glasgow Royal Infirmary and performing trauma emergencies and less demanding surgery at a wide variety of hospitals throughout the West of Scotland. Maxillofacial Surgery chose a different model - appointing consultants and supporting staff in various hospitals throughout the region.
With 122 beds and five operating theatres, the sheer volume of elective Plastic Surgery at Canniesburn attracted visitors from all over the world. This, combined with the consultant expertise (Gibson, MacGregor, Mustarde, Reid, Jackson) and two of the most exciting and innovative Senior Registrars of that time (Lister, Acland), rapidly gained Canniesburn an international reputation as a centre of excellence. Teaching and Training courses developed, attracting participants and visitors from all over the world and this continues to the present day.
Tom Gibson was the Director of the Unit and a Professor in the Bio - Engineering department at Strathclyde University. As Editor of The British Journal of Plastic Surgery, a post he held for 11 years, he was well versed in current and future trends of that time. This enabled him to guide the unit until his retirement in1981.
Ian MacGregor followed as Director of the Unit and Bill Reid remained in charge of the Burns Unit in Glasgow Royal Infirmary. Martyn Webster replaced Mustarde on his retirement, and set up a microvascular laboratory with teaching courses. Gus McGrouther followed Ian Jackson who left early in 1981 to take up the position as Chief of Plastic Surgery in the Mayo Clinic USA, and David Soutar joined MacGregor in Head and Neck Surgery at the end of 1981. Notably there had been no increase in senior staffing (five consultants) and this was to continue for several years.
Canniesburn's influence
Canniesburn's influence nationally and internationally continue to grow and few units can demonstrate a work ethic and reputation that resulted in
- two Presidents of a UK Royal College (Gibson and MacGregor: Royal College of Physicians and Surgeons of Glasgow)
- five Presidents of their national specialty Association (Tough, Gibson, MacGregor, Reid and Soutar: British Association of Plastic Surgeons)
- two European Presidents (Webster and Soutar: European Association of Reconstructive and Aesthetic Plastic Surgery).
Similarly in sub-specialty associations, notably Head and Neck, Burns, Clefts and Craniofacial, Hands, Breast Reconstruction, Laser Surgery, Microsurgery and Aesthetic Surgery, Canniesburn`s presence and influence was very apparent.
Trainees came from all over the world, and in particular one year registrar posts were allocated to a senior trainee from both the USA and Australia throughout the 1970s and 1980s. From 1994, a succession of surgeons from Ghana have been trained, as have nurses, physiotherapists and other support staff.
This link with Ghana started when Mustarde in his retirement used his considerable influence to develop a 75 bed Reconstructive Plastic Surgery and Burns Unit, in the Canniesburn style, in Korle-Bu Teaching Hospital in Accra. Plastic Surgery teams also went out to Ghana to support and train staff and carry out surgical procedures with them and this continues to the present day. Martyn Webster followed Mustarde as the leader of this project which has grown into the charity ReSurge Africa, which now serves all of West Africa.
In 1990 a strategic review of Plastic Surgery Services was requested by the West of Scotland Health Boards, who felt that the “hub and spoke” model was too centralised. Bill Reid was the Director of Canniesburn, having succeeded MacGregor, and he included David Soutar in this review process. Soutar was the Plastic Surgeon at the Western Infirmary, whose management was leading the review, and he also provided services to Lanarkshire - one of the dissatisfied spokes. Reid and Soutar persuaded the authorities to continue to support a central hub of excellence with experts in the subspecialties, and significant increases in peripheral activity, together with appropriate staffing and some reorganisation.
Trauma Services and Emergencies in Plastic Surgery were centralised into a new Burns and Trauma Unit in wards 23 and 24 in Glasgow Royal Infirmary.
Paediatric Plastic Surgery was moved out of Canniesburn and into the Royal Hospital for Sick Children, Yorkhill and Seafield Children’s hospital, and subsequently into both the new Royal Hospital for Children on the site of the Southern General and the new Ayr Hospital. Peripheral Clinics and operating facilities were opened in several District General Hospitals in Lanarkshire, Ayrshire, and Argyll and Clyde to provide treatment locally wherever possible but transferring more complex cases to the centre at Canniesburn. This required a gradual and sustained increase in Consultants, supporting staff and facilities.
Academic and Research activities were largely separated from NHS clinical duties by forming a charitable trust in 1994 - The Canniesburn Research Trust - to safeguard and ensure Teaching, Training, Development and Research for all staff within the unit and maintain its reputation as a centre of excellence.
A succession of Research Fellows was appointed and successfully completed advanced degrees (PhD, MD MSc) enhancing Canniesburn`s academic reputation and prowess in publication. Bill Reid was appointed Professor in Bio-Engineering at Strathclyde University like Gibson before him, further strengthening and diversifying research. The Canniesburn Research Trust remains responsible for all Canniesburn Courses and Study Days, pump priming for Research Projects, and supports medical, nursing and other staff to attend conferences, instructional courses and personal development. It continues to support the Ghana Project and ReSurge Africa.
Professor William Reid retired in 1996 and David Soutar became Clinical Director. Waiting lists and waiting times were becoming a political hot potato and opened pathways for further expansion. The Plastic Surgeons offered to review current lists and restrict non urgent cases regarded as “cosmetic”. They already knew that such cases hardly ever underwent surgery in Canniesburn, although other specialties and management were sceptical mainly because of Canniesburn`s isolation. An “exceptional referral protocol” was formulated, and was required for a Plastic Surgery outpatient clinic appointment followed by an assessment by a clinical Psychologist. This early form of rationing was gradually adopted throughout Scotland to great effect and took away much of the criticism of Plastic Surgery by other specialties. In return, Health Boards agreed to increase consultant numbers and supporting staff and facilities.
Plastic Surgery was becoming more specialised and complex and Canniesburn Hospital lacked the facilities that were necessary- intensive care, imaging, laboratories and the expertise of other specialties on site. There was a need to move to a major hospital. The Plastic Surgeons -now 11 consultants- wanted to bring elective surgery, burns and emergency Plastic Surgery together on one site and maintain the Canniesburn Unit ethos and identity. The Health Board saw the advantages of clearing valuable real estate at Canniesburn and the possibilities of economies of scale.
A new build Trauma and Accident and Emergency Unit was planned for Glasgow Royal Infirmary and, with expansion of the build, could accommodate Plastic Surgery. Soutar had planned and oversaw the move which was facilitated by his appointment as the Medical Director of Glasgow Royal Infirmary in 1998 and a seat at the Senior Management table. In 2003, Canniesburn closed and Plastic Surgery moved into the new Jubilee Building in Glasgow Royal Infirmary. Soutar remained in charge of the Plastic Surgery Service until his retiral in 2008, although his titles changed with his position in Senior Management.
Canniesburn retained its name and identity, partly through signage and bricks and mortar designated wards, theatres and a separate outpatient and treatment facility, but mainly through its dedicated and highly specialised staff. Consultants now number 18 and with the extensive specialised and supporting staff, Plastic Surgery constitutes a large clinical directorate within the NHS management structure.
The Canniesburn Research Trust continues its role in education, and academic work has been strengthened and diversified with the appointment of Andy Hart to the Stephen Forrest Chair in Plastic Surgery at The University of Glasgow. Professor Hart is also the Editor of the Journal of Plastic, Reconstructive and Aesthetic Surgery, like Gibson 50 years earlier.
The Unit continues to grow as a result of operating with other specialties and working in Multi-Disciplinary Teams. Canniesburn`s reputation continues unabated despite management changes and the demands of the Health Service - a tribute to the dedication and specialism of the staff who make up the Canniesburn Plastic Surgery Unit.
David S Soutar
Image of Tom Gibson's plaque with permission from Journal of Plastic, Reconstructive & Aesthetic Surgery Tom Gibson, Plastic Surgeon (1915–93): Allograft rejection by the immune system and prediction of free tissue transplantation