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Mhm. Hi guys. Just checking. You can hear me and you can see the slides. Um, if you could just put a thumbs up in the chat, that would be great. Great. Thank you. Yeah. All right guys. So, um, hello everyone and welcome to the BSA teaching series. Uh, my name is Rishi. I'm act one, currently doing plastic surgery. Um, and today we'll be going over just a brief introduction to all things plastics. Um, so I guess with plastics, it covers quite a broad spectrum of conditions and there's considerable overlap with other specialties such as orthopedics, vascular ent as well as breast surgery. It's a topic that's not really taught a lot during medical school and it's also not really tested on considerably until later on into specialty training. Um, but I'll be covering things, um, such as wound management, burns, skin cancer and nail bed injuries. So the talk should last for around 45 minutes or, or so. So, um, let's get going. If you have any questions at all, just put them in the chat and please feel free to interrupt me. So we're gonna begin with a question. So a 44 year old male is admitted with a deep laceration to his forearm after an accident in the garden, within the first few minutes of injury. What is the most predominant type of cell seen in the hemostasis phase of wound healing? Is it neutrophils, fibroblasts? My myofibroblasts, macrophages or platelets, if you wanna put your answers in the chat and then we can go through Beyonce. Ok. Well, um I'll, I'll tell you the answer. So it's, it's number one. So the answer is neutrophils and um hemostasis tends to occur in the first few seconds to minutes of an injury. And the most predominant cell type is neutrophils along with eth erythrocytes. Um fibroblasts and macrophages. These are seen in the inflammatory phase and regenerative stages of wound healing and myofibroblasts are seen in the remodeling phase. So, surgical wounds, they can either be incisional or excisional and either clean, clean, contaminated or dirty. And although the sort of stages of wound healing are pretty similar, their contributions will vary according to the wound type. So as I said, the main stages of wound healing include hemostasis and this occurs in the first minutes to hours. Following injury, you get vasospasm in the vessels, a platelet plug formation and a generation of a fibrin rich clot. Inflammation occurs at days 1 to 7. Um This is where some me falls migrate into the wound growth factors are released, including basic fibroblast growth factor and um vegf. So, vascular endothelial growth factor, macrophages will also be present. Um and they sort of combine with fibroblasts to form a clot regeneration. So this happens typically days 7 to 56 after their initial wound. And this is where you'll get platelet derived growth factor. And sort of transformation of growth factors stimulate fibroblasts and other epithelial cells. These frats they'll produce sort of a a collagen rich network and angiogenesis occurs. So the formation of new blood vessels, finally, you'll have remodeling and this occurs from weeks six to upwards to a year after the initial injury. And during this phase, fibroblasts, they become more differentiated um into myofibroblasts and these facil sort of wound contraction, collagen fibers are remodeled and microvessels regress leaving a pale scar. So, before we move on, there are several diseases that may distort this process. Um neovascularization is an important early process and uh vascular disease shock as well as sepsis can all compromise microvascular flow and impair any sort of healing in conditions such as jaundice. This will also impair fiberglass function, um and any sort of immunity with a detrimental effect in most parts of the healing process. Finally, certain drugs um can affect wound healing and these typically include nonsteroidals, steroids, immunosuppressive drugs and any anticancer drugs as well. So, moving on to surgical management of wounds and when addressing any wounds, the key principles, these include, first of all, a good assessment of the patient and this is to identify factors that may be detrimental to wound healing. It's then important to perform a, a systematic assessment of the wound and useful and mnemonic is times so T stands for the tissue involved, whether it's going to be viable or non viable, I stands for infection or inflammation. M stands for moisture levels. E stands for the edge of the wound and S stands for the surrounding skin. Finally, it's important to ma to sort of identify the the wound management aims and this is based on patient as well as the wound assessment. So most wounds, these can be managed with secondary intention healing or primary closure. But when wounds are a bit bigger or they're more complex, um, more complex surgery may be required. And in the case of surgical closure, the reconstructive ladder can be used as a stepwise progression of wound management options. So the stepwise ladder includes, first of all, letting the wound heal by secondary intention and this occurs when the sides of the wound are not opposed. So they're typically left open primary closures. When you use suture material to oppose the wound, you get delayed primary closure. And then after that, you have graft options such as split thickness or full thickness skin graft, you can get flaps. Um and then there are various different steps of the reconstructive ladder, but those that, those are the main um surgical options. So, crime and closure using a graft or flaps, no skin grafting So, skin grafting is essentially when a piece of skin is transplanted to a new site on a patient's body. And these skin grafts are, are important when the wound can't be closed. Primarily and delayed healing is not appropriate. A skin graft has no blood supply. And so it depends on the vascularized bed onto which it's placed. And there are two different types of skin graft. So you have split thickness, skin grafts and these contain the epidermis as well as variable amounts of the dermis and skin grafts. Split thickness, skin grafts are usually acquired when um there is a larger area that needs to be covered. And this is usually the case in severe burns. These split thickness, skin grafts can also be meshed in order to increase the surface area so that they can be stretched out and placed over the wound. Full thickness, skin grafts contain the epidermis as well as the whole en entire dermis. And so the donor site must be closed directly using the sutures. Usually only a small area is taken um and they're usually taken from areas where there are secular skin. So usually the the top of the shoulder over here on the whole full thickness, skin grafts give a better cosmetic appearance, especially as they do not tend to require any meshing. So, unlike er skin grafts, flaps have their own blood supply and there are many ways to describe and characterize flaps and they can be characterized depending on their blood supply, their composition or their location. And a flap is a process of taking a block of tissue along with its blood supply and moving it from one place to another. And a flap can either be local or regional and free flaps are when tissue is raised with its own blood supply and then it is completely detached and then re attached to a new vessel at the donor site. So, based on the blood supply, there are three definitive types of flap and this includes an axial flap um where there is a designated artery that runs beneath the flaps, longitudinal axis, a random flap where there is no designated named artery that provides the blood supply to the flap. And finally, a pedicled flap and this is where the tissue is completely raised on a named vessel from a donor site and then transferred to the recipient site. So those are flaps. Um let's move on to another question. Um And this is with regards to burns. So, a 22 year old man is admitted to A&E having suffered from a thermal burn on examination, his skin blanches and appears pale and dry and the lightly layers affected include the epidermis and part of the papillary dermis. So, what type of burn has this man suffered from? Is it a superficial burn? A superficial partial thickness, burn a deep partial thickness or a full thickness burn if you wanna put your answers in the chart and then we can go through them any takers. Ok. Well, the answer is number two. So it's a superficial partial thickness burn. And these types of burn, they tend, they tend to blanch on pressure and they appear quite pale and dry, superficial burns. On the other hand, they'll be red and moist and a deep partial thickness burn will have a mottled red color and it will typically not blanch full thickness burns, uh they'll appear very leathery. So burns, they can either be thermal, chemical or electrical. And a chemical burn is when the skin is exposed to an extremely sort of alkaline or acidic substance, alkaline burns often result in deeper more severe burns. Um and electrical burns follow um any sort of exposure to an electrical current complications associated with electrical burn. These include arrhythmias, um and rhabdomyolysis. So, the immediate management of any burn includes removal of the burning source, which typically includes irrigation of the burned area. And then you need to perform a detailed assessment as to the extent of the burn. And there are many different charts that you can use. In order to record this information, the degree of the injury relates to temperature as well as the duration of the exposure. And most domestic burns are mainly skulls and typically they're seen in younger individuals. So in terms of physiology, following the burn, there is a local response with progressive tissue loss and release of inflammatory cytokines, the cardiovascular effects resulting from fluid loss and you may get um ascites development as well. There's also a marked catabolic response. And immunosuppression is common with large burns sepsis is a common cause of death following a major burn. So when assessing a patient with burns injury, a thorough a to e assessment is really important. Analgesia should be started early and wound dressing protocols vary. But in general, if a patient is to be transferred to a high level burn center, then you should dress the wound with some sort of a cling film to allow evaluation of the burn depth. Whilst minimizing fluid losses from the effect to wounds, hypothermia is also a severe risk factor following a burns injury. And this is due to extensive heat and fluid loss that can occur from the burn site as a result, giving any sort of warm fluids and reducing wound exposure time can all help in limiting hypothermia. So the severity of the burn is generally defined by the percentage total body surface area burned and the burn depth. And there are lots of different techniques that can be used to estimate the percentage total body surface area. And the most commonly used is the Wallace's rule of nine or the rule of palm where the patient's palm area represent, represent one p 1% of the total body surface area. Burn depth does not guide initial resuscitative efforts. And so administration of adequate fluid resuscitation should not be delayed in favor of an accurate burn depth evaluation. So this is just the table outlying different types of burn. And it's important to recognize deep partial thickness burns which tend to require urgent surgical intervention. Unfortunately, four thickness burns are very difficult to manage and the patient must be transferred to a burns unit. So, fluid resuscitation. So fluid resuscitation is indicated if more than 15% of the total body area is burnt in adults or more than 10% in Children. So, most of the fluid is lost within the 1st 24 hours after an injury. And the current consent and the current guidelines state that fluid resuscitation should begin at 2 mL of ringer lactate and this should be multiplied by the patient's body weight in kilograms. And this again multiplied by the percentage total body surface area of burnt. And then the calculated fluid volume is initiated. First of all, half of it should be given in the first eight hours and then the second half in the remaining 16 hours and the efficacy of a fluid replacement is determined mainly by monitoring the patient's urine output. And for adults, this should be more than 0.5 mL per kilogram per hour. And for less than and for Children who weigh less than 30 kg, this should be 1 mL per kilogram per hour. It's important to know that fluid resuscitation in an electrical burn is different and the, the equation for calculating the, the total volume and electrical burn is 4 mL instead of 2 mL. So 4 mL of ring is lactate multiply this by the patient's body weight and kilograms and again multiply this by the total body surface area burn and percentage. That's fluid resuscitation and burns. Let's move on to um the management. So as with every acute um injury, it's important to, first of all resuscitate, the patient, conservative management can be appropriate for superficial burns and mixed superficial burns that will typically heal in two weeks. But more complex burns, these may require excision and subsequent skin grafting. There is no evidence to support the use of any sort of antimicrobial prophylaxis or any topical antibiotics in a burns patient and carrot, these are indicated in circumf frontal, full thickness bones. So they go all around the torso or the limbs and division of the encasing band of burn tissue. This will potentially improve ventilation, particularly if the burn involves the chest or it can relieve compartment syndrome and edema when a when a limb is involved. So the complications of burns, so the best way to to minimize any sort of complications secondary to a burn is to transfer the patient to a dedicated burn center. So you should always transfer if the burn needs adequate shock resuscitation. If the face, the hands or the genitals are affected in any deep partial thickness or full thickness burn. If there's any sort of significant electrical or chemical burn in any patient. Um presenting with a burn of more than 25% total body surface area. So, systemic complications will arise secondary to the, there's a very large inflammatory response following a bone injury. A deterioration can occur resulting in multiple organ dysfunction where the systemic inflammatory response following the injury, this will lead to end organ failure. So, specific organ in injuries that can occur include acute lung injury. And this is can be caused by a combination of both the burn as well as inhaling smoke, which can eventually lead to acute respiratory distress syndrome, also known as a DS acute kidney injury. And this can be secondary to um hypotension and fluid loss as well as rhabdomyolysis, endocrine complications. So, again, direct fluid loss from the burn and gastrointestinal complications. And this includes either paralytic ileus or Curling's ulcer. An A Curling's ulcer is a gastric ulcer that can occur following a severe burn and the significant reduction in the plasma volume following the injury. This can lead to gastric mucosal ischemia and hence um ulcer formation. So this is just a brief introduction into burns. We just had one question. How relevant is thinning of skin and immunocompromise uh in diabetes due to chronic systemic steroid treatments. Yeah. So individuals with who are taking steroids, a well known complication of this is thinning skin and this can pose a problem particularly in determining whether the skin is suitable for either a split thickness skin graft or full thickness skin graft. And typically in elderly individuals, um we tend to, we tend to perform full thickness skin grafts because the skin is so fragile and thin that it, as you say, it will just disintegrate if we're trying to pull it apart and try and cover a larger area. And unfortunately, in elderly individuals who have suffered from major burns, their outcomes do not tend to be good. Um And they're typically managed conservatively with adequate dressings and these dressings need to be changed usually every 2 to 4 days. As uh as I said, that burns results in significant fluid losses. So these dressings can, can get extremely wet. So, yeah. So it's a good question. It's something to consider, particularly in elderly individuals and patients who may be taking the steroids resulting in the thinning of skin. So let's move on to question number three. So 51 year old diabetic woman presents to A&E with severe pain and sepsis on examination of her thigh. There is significant citti edema blistering as well as bulla formation. So a photo is taken. What is the most likely diagnosis? Is it? Fse, gangrene, melanes, gangrene, gas gangrene, necrotizing fasciitis or myositis if you wanna put your answers in the chat and then we can go through them any takers. Uh This should be an easier one. ok. Well, the answer is gas gangrene. Um and this condition is typically characterized by this bulla formation that you can see in the photo. And this um these bullae they, they tend to form as a result of the release of gas from the bacteria. Uh clostridium perfringens. So, necrotizing fasciitis. So this is a life threatening, rapidly progressing infection that spreads along the fascia and the sub subcutaneous tissue. So it's got a really high mortality um and it's a surgical emergency and they're typically two microbial types of necrotizing fasciitis that you'll come across. The first is type one, which is polymicrobial caused by a mixture of anaerobes and anaerobes. And type two is a monomicrobial infection. And this is primarily, primarily caused by streptococcus pyogenes. And it is more common in healthy individuals with a history of trauma. There are many risk factors for developing necrotizing fasciitis. And these include diabetes, chronic kidney disease, alcohol excess cancer, um malnutrition as well as immunocompromised patients. So, those who have recently undergone chemotherapy, for example. So whilst some cases may have recognizable precipitating events of any sort of skin breach. For example, any recent trauma, animal bite or scratch. This is not always the case and clinical features in necrotizing fasciitis, they will develop extremely rapidly and the patient will complain of severe pain. Often out of keeping with the typical clinical signs and patients will be hemodynamically stable and show signs of multi organ dysfunction. So, examination signs are variable but the overlying skin may appear normal in the early stages. But progression, as you can see in the photo can result in erythema, edema and, and signs of um skin ischemia. Late signs include um crept, the presence of bulla and obvious skin necrosis. So, gas gangrene, as I was saying, is a form of necrotizing fasciitis and it is caused by clostridium perfringens resulting in the release of gas within the tissue. The cholesterol organisms, these produce alpha and beta toxins that lead to extensive tissue damage and they produce large volumes of gas within the tissue. They'll present in an equally severe clinical state. Um but crepitus is often present on light palpation of the affected area. So, melanes gangrene is when the infection is more superficially CED than necrotizing fasciitis. And it's usually confined to the trunk. Fournier gangrene is a really nasty form of gangrene of necrotizing fasciitis that affects the perineum. And in terms of investigations for necrotizing fasciitis, um blood tests will show various degrees of derangement with significantly raised white cell counts and CRP an ABG will show raised lactate and metabolic acidosis and there may be signs of worsening renal function as well as a raised glucose and a coagulopathy. Imaging typically does not have a routine role in the diagnosis of necrotizing fasciitis and you should never delay uh the management um in uh requesting any sort of imaging and the laboratory risk indicator for necrotizing fasciitis. So that in ec score can be used to assist in the diagnosis of necrotizing fasciitis. A score of less than five is low risk, whereas a score of greater eight is high risk. And as I was saying, it's a surgical emergency necrotizing fasciitis needs immediate resuscitation and debridement. So any patients with suspected necrotizing fasciitis, they need urgent broad spectrum antibiotics and resuscitation with IV fluids, dish, dishwater like fluid from the wound is also suggestive of the diagnosis. The definitive management for necrotizing fasciitis is urgent surgical debridement of any necrotic tissue. So you should debride this tissue until only viable bleeding tissue is present. And all cases should be packed following debridement. And many cases will undergo a R look in 24 to 48 hours to check for evidence of further infection or further necrosis. Following this reconstructive surgery may be required after initial debridement using skin grafts or flaps. But this should only be considered once the infection has been adequately controlled. So that's a brief introduction to necrotizing fasciitis and we'll move on to your skin cancers now. So a 34 year old male presents with large, flat and irregular pigmented lesion on his torso over the past month, the diameter of the lesion has become more regular and so has its color. The doctor suspects a diagnosis of melanoma. So, what type of melanoma does the man likely have? Is it superficial spreading, nodular lentigo, maligna or acral lentiginous again, if you wanna put your answers in the chart and then we can go through them. So I'll give you the a clue. Um Just think of what the most common type of Melanoma um that's seen in, in individuals typically age between 3050. And that, that will give you the answer. Ok. Well, the answer is superficial spreading. And as I was saying, this is the most common type of melanoma seen in individuals aged between 3050. So as in the stem, it presents the large, flat and irregular pigmented lesion. So, melanomas. So, melanomas are malignant tumors. Um and uh they arise from melanocytes which are the melanin producing um neural crest cells of the body. Um So melanoma commonly arises in the epidermis and in the UK Melanoma has an incidence of approximately 17 to 100,000 people and it most commonly affects the trunk or the legs with an instance, rising with age. So they tend to metastasize early um and can spread to nearly every tissue and organ in the body. And the four main histological subtypes of a Melanoma include superficial spreading, nodular lentigo, maligna, and acral lentiginous. And the table on the right outlines the characteristic features of each with superficial spreading, accounting for the majority of cases. So the definitive pathophysiology of melanoma remains unclear. But the main contributors include UV, radiation exposure and other risk factors include previous melanoma, age race, economic status and nevi numbers. So more than 50 nor NEVI confers confers an increased risk of a Melanoma and you can use the, the pneumonic parents to remember this. So, p for previous Melanoma age A for age R for race, E for economic status and N for nevi numbers F indicates Pham syndrome uh which is familial atypical mole mole and Melanoma syndrome T is type one or type two skin. So according to Fitzpatrick skin types and S is sunbed use. So that completes the pneumonic parents. So clinical features, investigation. So early melanomas, these tend to be asymptomatic and patients usually present having noticed a new mole or changes in an existing mole such as a change in the size shape or color. And in these cases, a history should focus on the risk factors. And in more locally advanced cases, there may be evidence of bleeding or ulceration and on an examination, the ABCD E rule can be helpful. So A stands for asymmetry B board irregularity C A color that's uneven. D is a diameter of a lesion that's more than six millimeters and E is a rapidly evolving lesion. So the patient should be fully examined if the features of spread, including lymph node involvement and other differential diagnoses that you can just um consider um is a melanocytic nevi. So darkly pigmented mole and a diagnosis is typically made through an excision biopsy. Um and a sentinel lymph node biopsy aims to identify whether there is any melanoma in the primary draining lymph node. Current nice lines, nice guidelines. They suggest offering sentinel lymph node biopsy to patients with Melanoma with a Breslow thickness of more than one millimeter without clinically apparent nodal or metastatic disease. So, Breslow thickness is um the depth of the of uh the melanoma lesion and sentinel lymph node biopsy has a high sensitivity and specificity for subclinical regional lymph node involvement and can be a really good indicator for prognosis. Ok. So parents um so parents, so it's just a new monarch to remember the, the risk factors for um for Melanoma. So, P stands for previous Melanoma. A stands for age. So increasing age confers a risk for melanoma. R is race. Uh So typically, um Caucasian individuals are more at risk of developing melanoma. E is economic status. N is nevi numbers T is type one or type two skin. So paler skin um confers an increased risk for melanoma and s uh stands for sun bed use. So that's the pneumonic appearance. So, moving on to the management. So after melanoma is confirmed, um the biopsy area is you undergo a wide local excision. And the aim of a wide local excision is to improve the regional control by removing any sort of micro metastases and the peripheral margins as I alluded to are guarded by Breslin's thickness and deep margins should always be down to the deep fascia. So wide local excision is usually performed at the same time as the sentinel lymph node biopsy and any confirmed lymph node metastases from a positive sentinel lymph node, biopsy should be treated by a completion lymphadenectomy. So the whole lymph node should be removed. Unfortunately, with Melanoma, metastatic disease is common and so various immunotherapies and chemotherapies can be can be used. Prevention is always the best management and education is important. So, reducing exposure to UV light through sun creams, avoiding sunbed self checking for new or any rapidly evolving moles in patients that are high risk for Melanoma. These patients should require, should have annual screening. So this brings us to an end um on skin cancers and specifically Melanoma. Uh we'll move on to your question number five. So a 22 year old female presents to Amy with a red purple bruise to her thumb and nail bed. She was in the gym when a large weight was dropped onto the right thumb. So what part of the nail bed is responsible for 90% of the nail plate growth? Is it the cut core? The sterile matrix, the germinal matrix, the hypochondrium or the lunula. Bit of a tough question, but see how you go. Yeah, well done. So it's the germinal matrix in the germinal matrix. This lies proximal to the nail plate and is responsible for about 90% of nail plate growth. And the and the sterile matrix dis lies distal to the German matrix and provides the remaining 10%. So the nail is an essential component of the fingertip. It acts to protect the fingertip and provides a counterforce to the pulp to the to the area underneath the nail, nailbed injuries. They're really common and they typically involve younger patients as you can imagine. So, crash injuries from doors and sort of heavy equipment are the most frequent presentations. The extent of the damage is dependent on the mechanism and the force involved. And nail bed injuries may result in a hematoma formation under the nail bed, a laceration or an evulsion of the nail bed resulting in an underlying burning fracture. So the nail bed is made up of soft tissue and it's bound to the underlying periosteum of the distal phalanx. And it consists of the germinal and sy matrix which I said were responsible for nail growth. And the germinal matrix lies proximal to the nail plate and is responsible for about 90% of the nail plate growth. Sterile. Mari lies distal and is responsible for 10% of the growth, say types of injury. So, they're predominantly about three types of injury. So, first of all, a hematoma formation and this forms when blood collects between the nail and the nail bed itself, and the color of the hematoma can change from red to brown or black, giving it a bruise like appearance. The formation of a hematoma is often related to heavy impact such as a door crush injury or a weight falling on the finger. Secondly, a nail bed laceration and this occurs when there is compression of the nail bed between the distal phalanx and the nail. The nail bed laceration is usually present with an intact nail and a subungual hematoma more than affecting more than 50% of the nail surface area. So sharp objects such as knives, these can penetrate the nail and if they land with sufficient force, they can result in a nailbed laceration. Finally, you get avulsion of injuries and this is where a nail and part of the nail bed are pulled away from the rest of the finger. And this is usually caused by high energy injuries with traction and crushing forces and avulsion injuries most commonly occur in uh the ring finger and are associated with other injuries such as a distal pharynx fracture and other dislocations. So, differential diagnosis. So you should consider a distal phalanx fracture, a fingertip infection, a foreign body insertion, a neuroma or phalangeal dislocation. And the X ray on the right shows a distal phalangeal fracture and is secondary to a tendon avulsion resulting in mallet finger. So you can see an obvious deformity in the finger. Phalangeal dislocations are less common than phalangeal fractures. And they can be either at the proximal interphalangeal joint. So they're more common and you can see on the right hand side and at this, uh you so following any sort of uh initial assessment, including an A to e assessment, simple nail bed injuries, they can just be managed conservatively and they just require a short course of oral antibiotics and most nail bed injuries, these will require removal of the nail plate. Uh, they'll require nail bed repair. So this typically just involves a small suture to repair the nail bed and then splinting of that nail bed. The nail plate can then be carefully separated from the underlying sterile er plate and the germinal matrix and then soaked in a Betadine solution. And as I said, nail bed repairs, they're usually taken with very fine sutures and with appropriate treatment. Many of these injuries to the nail bed, they can make a full recovery, but it can take months for the nail to grow back normally and they can uh grow back in a sort of deformed manner. The complications of a nail bed injury. These include scarring infection, a hook nail as I was as alluded to and a split nail and this is caused by scarring of the matrix. So this is um this was the slide thankfully, it's come back up. So you can see that the, the nail, the nail itself needs to be removed in order to to to, to suture the the nail bed having done so, and the the nail plate is soaked in the Betadine solution. The plate can be put back on top in order to protect the nail bed itself. So, one final question. So a 22 year old male presents to A&E having suffered from an electrical injury, initial fluid resuscitation should be commenced. So what fluid rate should be started in this patient? Is it 2 mL of Hartman's solution? 3 mL 4 mL of Hartman's solution. 3 mL of normal saline or 4 mL of normal saline. So remember the equation we spoke about earlier um and just remember that this is an electrical injury and not a thermal burn. So the equation is slightly different. Good. Yeah. So it's 4 mL 4 mL of Hartmanns solution. And the equation is 4 mL of Harmans multiplied by the the patient's weight in kilograms, multiplied by the total body surface area percentage. And you should remember that for all electrical burns, an increased volume of Hartman's solution will be required. And Hartmann's is preferred to normal saline as it contains electrolytes that are in similar concentrations to the blood plasma. So that's everything. Um That's just a brief introduction to plastic surgery. So typical injuries that you cover as act one include burns um and hand trauma. Um and then flaps. Um typically for um breast reconstruction are also something that you might come across all the cosmetics, the cosmetic stuff that's blowing up. Nowadays, it's all all in the private sector, but this is just uh things that you might come across as a as a, as a trainee. But if you have any questions, please let me know um and put them in the chat. Um And before you go, if you could fill out a feedback form that would be really useful for me. Um I'll just put it, put the link into the chat. The cool. Sure. Yeah. So the, all the, um, talks are recorded, so you'll be able to go through the presentation. Yes. Ok. All right guys. If you have no further questions, um, please fill out the feedback form before you go be really helpful. All right. So I'm gonna end the tutorial now. Um, enjoy your evening guys. Bye bye.