However, in 2007 Interplast did not have funding for this outreach, and so we needed an alternative solution. My family and I travel regularly to the islands, and as such are aware of some very pressing medical needs – both global and individual. In particular we frequent Tavarua – a surfing island resort in the southwest corner of Fiji – where we help with their medical needs and also go surfing. Tavarua island resort was birthed with a vision to impact a whole community, and has achieved that end for nearly 30 years now. They have a long tradition not only of improving the living conditions of the locals Fijians, but also of investing thousands each year in medical aid.

One of the resort owners is the son of David Roseman, a prominent physician from Scripps hospital in California, and this has created a link between Tavarua and the Scripps Fiji Alliance, a huge philanthropic organization that sends medical teams all around Fiji every month. The resort also hosts many international guests, and in particular the Surfers Medical Association (coordinated by Paula Smith and her husband) who have been frequenting the area for over 20 years, and have introduced many significant changes in health and lifestyle awareness to the local communities around the island. Another prominent American doctor, Lance Hendricks, is both associated with the Scripps Fiji Alliance and also runs his own foundations called Loloma. He does aid trips several times a year to remote islands in Fiji and the South Pacific. He is an anaesthesiologist from Scripps hospital and is somewhat iconic in the South Pacific.

In conjunction with Jon Roseman, my family and I coordinated a trip to Tavarua with the specific aim of forging an Australian – American alliance with both Lance Hendricks and the SMA, and at the same time treating some of the islanders who had very pressing needs. Lance came with about 10 crates of anaesthetic and surgical supplies and also tens of thousands of dollars worth of donations from Loloma. We came over with approximately AUD$50,000 of medical supplies in 7 crates. This comprised of surgical equipment for the operations we had planned and more donations to give to Loloma for distribution around various centres in Fiji. Lance’s many years of service in Fiji, as well as our previous links with the Fijian medical association through Interplast, opened the door for us to bring the equipment and donations through customs, and they were gratefully received. We met with the SMA and at an evening seminar I presented some of my previous experiences in Fiji. Interestingly, many of the visiting doctors from USA were not aware of the scope of reconstructive plastic surgery as practiced in Australia. Paula Smith then brought to my attention several very needy patients they had identified in their missions to the villages, but were unable to treat due to the special nature of the conditions.

Once we established our parameters, we allocated surgery for five very pressing cases.

1. A two-year-old boy with a huge tumour on his back had presented in Nabila. The mass was so large that the child could not walk properly, and his parents were keeping him locked inside out of sight and out of social contact, possibly expecting him to die, and asked if the SMA could help. He needed the tumour to be excised and the back defect then closed.
2. An 11-year-old boy who was a urinary cripple after having a failed circumcision one year previously. The child’s penis had been transacted through the glans and had then healed by secondary intention, leaving him unable to properly urinate because his ureter was obstructed by scar. As a result hesat at home in social isolation with constantly wet pants, and was emotionally and physically traumatised. He required complex reconstructive surgery after his defect had been recreated and defined in theatre.
3. A 15-year-old girl with a two year history of a discharging sinus on her leg arising from spontaneous haematogenous osteomyelitis. Someone had told her that she needed her leg amputated and was desperate for a second opinion. She required drainage of osteomyelitis of the tibia, flap repair and long-term intravenous antibiotics.
4. A 25-year-old professional rugby player who had suffered a peri lunate dislocation of his wrist playing his sport three weeks prior to our arrival. Because he wanted desperately to play in the World Cup he had avoided medical intervention, but had come to the realisation that his injury was too severe to ignore. The local professor of Surgery, and Orthopaedic surgeon from Suva and a friend and colleague of both Lance and myself, referred this man to us for wrist reconstruction because he knew of my special interest in wrist surgery.
5. A 53-year-old man from Tavarua who had chronic wrist pain following an old rugby injury. He required formal wrist fusion.

Because of social and political changes in Fiji the available facilities were limited, and yet Lance was able to coordinate with Nadi hospital so that we could use theatre facilities that were not being utilized by anyone else. He also brought all the necessary equipment so that we would have no impact on the local infrastructure. We sorted our equipment on Tavarua and then transported it to Nadi, and set up the facility. The team consisted of Lance (anaesthetics) and myself (surgery), Steve Sullivan (a premed student from California), Noni Crock and Hannah Crock (both students, one of whom was doing medical work experience as part of her formal education). The latter three were able to assist us as we had no set up nurse, no theatre technician, no anaesthetic nurse and no scrub nurse. We worked together to prepare all the work areas required, coordinate the patients, and start proceedings.

The first operation we did was to remove the tumour from the 2-year-old boy’s back. The mass was extremely extensive and was embedded in the trapezius muscle and attached to the spinous processes of the thoracic vertebrae. Fortunately it was well encapsulated and was able to be removed in-toto. The specimen was stored in formalin and prepared for transport back to Melbourne, where Melbourne Pathology services were waiting to identify the disease process. The operation was extensive and complicated, and required a post-operative drain tube. Surgery took about one and a half hours, and the child stayed in hospital for one day. The pathology showed the tumour to be lipoblastomatosis, and as such our operation was curative. The boy is now normally assimilated back into the life of his family.

The next case was to reconstruct the young boy’s penis. The patient was prepped and draped with disposable sterile drapes, and then the situation was assessed. I had discussed his case over the phone with a number of colleagues in Australia, but it was difficult to know what to do without a proper examination, and that needed to be carried out under anaesthetic. Ultimately this approach proved far more valuable than any hi-tech investigations. Once the defect had been defined, a new ureter was reconstructed by creating an island flap out of the remaining foreskin and another “waist coat” flap from the remaining skin on the penile shaft. The tiny amount of remaining glans was de-epithelialized and preserved in the reconstruction.

The flaps were fashioned and intertwined around a catheter to reconstruct the mutilated penis. The catheter and a drainage bag were left in-situ for several days after surgery and he was given a course of antibiotics. This surgery took nearly two hours, and he stayed in hospital for 5 days. The catheter fell out just prior to his discharge, and he was able to urinate normally with no spraying or dribbling, and he has been continent of urine. The last check up was made 6 months after surgery, and he is completely rehabilitated and living a normal life again.

The third case we performed was the wrist fusion. Under anaesthetic with a tourniquet to control bleeding, the broken scaphoid and osteo-arthritic wrist joints were debrided, packed with bone graft (from the hip) and the wrist was fused using a Synthes fusion plate donated by Synthes and Scripps hospital. To minimise the risk of non-union, we implanted a bone-stimulating device (worth $5000Aus) into the construct. The drill we used was a standard Makita power drill from Bunnings Hardware worth A$219.00, which worked very well, as we were not able to conjure up the A$12,000.00 for a medical drill! His surgery took about 2 hours; he stayed in hospital for 5 days on IV antibiotics, and then was discharged home. 6 months later his wrist was pain free and his hand function was good, except for limited movement of the ring finger which was deformed as a result of a childhood injury, and he had some MCPJ stiffness in one finger also related to this.

In the fourth case we reconstructed the ruby player’s wrist. I discussed at length the options and predicted outcomes, and because he had committed to retire from sport and pursue his engineering career we decided on a ligament reconstruction rather than a bony fusion procedure. I performed a reconstruction modelled on Anthony Berger’s technique (a Melbourne-based hand surgeon who is a world leader in the field). His surgery took about 1.5 hours, he stayed in hospital for approximately 5 days afterwards (but was transferred to Lautoka where he could be visited by relatives) and at 5 months post operatively claimed that his wrist was “as good as new” – although he was not playing rugby any more.

Finally we treated the girl with osteomyelitis. This case was left until last because of the risk of cross infection for the other operations. We excised the unstable skin in front of the tibia, and then debrided the periosteum and bone, and covered the defect with a large neurovascular island flap as described by Felix Behan, a Melbourne plastic surgeon who has championed this form of reconstruction. Certainly his premise held true – in years gone by I would have recommended a microvascular muscle transfer or a pedicled muscle flap with skin grafts for this defect, but the Behan flap solved the solution in a fraction of the time, and with very limited resources in a primitive setting. Her surgery took 1 hour, and at the same time we also inserted a peripherally placed central venous catheter (PICC line) into the girl’s cubital fossa, and arranged for the administration of IV antibiotics for a three-month period. She stayed in hospital for a few days while the family familiarized themselves with the process. At 3 months I dressed a tiny area of granulation at one end of the reconstruction, which was related to an underlying dissolving suture extruding. At 6 months she was fully healed, pain free and with no evidence of infection.

One of the reasons for delaying this report is that the recovery period for the bulk of these operations is long and I wanted to ensure that the surgeries had been successful. We now have confirmed reports from all the patients, and are thrilled at the outcomes. In particular we were touched by the response of the children’s parents. All of them wrote to us and their letters of thanks were overwhelming – the depth of the their suffering prior to this intervention was inestimable. Some may argue that a small-scale enterprise like this is not worth the effort or expense. Personally I think that every intervention is priceless, and it is a privilege to serve these people in whatever way we can. Above all, it is particularly gratifying when the recipients of aid are so grateful for help. This endeavour was undertaken as a foundation for future visits and it is our hope that we establish a long term connection that paves the way not only for us, but also for other specialists / practitioners to share their time and expertise with a people who, for one reason or another, cannot access the care we take for granted.

John Crock and his wife Wendy were already working in Fiji on an insland in the Western province, and they arrived at the airport the day the team arrived. Wendy left to return home just before the team arrived. Immediately after she left, John Crock coordinated with the local customs officers to do the behind the scenes negotiation of receiving the interplast luggage / supplies.

John had made prior arrangement to meet the customs official Mr Jonetani, who came to the airport to make the appropriate liaisons. John had also organised for luggage handlers from a local tour company to deal with the containment of supplies, and at the same time take the team out for a local Indian dinner. This streamlined the whole arrival process significantly: the team were met in customs, the boxes taken from them and were put on a bus for handling / storage overnight, and then the team were escorted to dinner at a local favourite Indian Restaurant. (This was on the back of being upgraded to business class in a 747 aircraft on the flight over, which made for a luxurious start to the trip). We were then taken back to the Tenoa International for the night.

Thee next morning we were met by the tour company driver who took us first to church and then to the airport where our luggage was transferred to Air Fiji for shipment to Labasa. Catherine Boaden bartered with the airline officials, which was a lengthy and laborious process, but somehow we managed to have our goods shipped with us for no extra cost. Initially there was a great deal of resistance from the airline, who told us the plane was overbooked, but this dilemma was somehow resolved beautifully.

We then flew to Suva, where we had a 4 hour stopover. During this time we consulted with a local patient who had arranged to meet us at the airport, and then we caught a taxi to Suva central where we visited the Hibiscus festival – an annual event which is the equivalent of our Melbourne Show. We then returned to the airport for the trip north, which was uneventful, and were met at the upgraded Labasa airport by Mr Bhushan Ogale, some local Rotarians and some hospital staff, who took our supplies to the hospital and our luggage to the Grand Eastern Hotel.

The hospital staff have not changed in the last year: Mr Bhushan Ogale still heads up the surgical team, Dr Abi Choudhary is still on staff and Robert Bayappa is also in the team. Their positions are due for renewal this December, but unfortunately they are given no assurance of tenure until the deadline, which makes forward planning impossible, and threatens the ongoing commitment of expatriate surgeons.

Ann Garcia is still in anaesthesia, and Dr Mugdha Puranik has returned from positions in India and the Maldives as a consultant. She expressed great interest in establishing internet links with Dr Portelli, who had initiated this a couple of years ago but had not had the interest of the local staff at that time. The mood in the department this year was much more positive, and they were extremely accommodating.

Mrs Salma Hussein is still the theatre manager, and there was a real sense of camaraderie in the unit as the long time theatre nurses are cooperating beautifully. Catherine Boaden was well known to the staff, and continued on from her previous 12 years of experience in the unit.

The out patient facilities were unchanged, and although a new wing of the hospital has progressed, and a new canteen has been finished, the core of the operations is still archaic. Matilda and Aruna did a great job of coordinating the 85 new patients we saw on the first day, and the 45 new patients we saw subsequently. This year records were taken electronically, and patient photos and notes were stored and archived which made information retrieval easy.

The theatre facilities were also unchanged (two old theatres, a single rudimentary wash up area, one tiny “MOT” area, a public holding bay and a dedicated post op recovery room), with no plans for refurbishment. In spite of the adverse conditions the local surgeons manage to do some amazing procedures – the local perception of medical treatment means that many patients present with end stage pathology, which makes treatment for the local surgeons even more difficult. In spite of this the team do a great job.

The wards have open windows with filthy old fly screen covers behind fixed louvers, and the six bed bays are very tired. The new wing of the hospital is allocated for medical cases, and the old wing will be retained as a dedicated surgical area. There are only two wall suction units on the ward, which is totally inadequate. The dressing rooms on the ward are dirty and used for multi functions. The flooring is linoleum and is worn and cracked.

A full list of the consultations and operations has been provided as a supplement to this report, along with photos of each patient seen, intraoperative photos and a DVD summary which may be shown as part of ongoing fundraising. In summary about 130 patients were seen, minor cases were culled or offloaded and the major surgeries were prioritised. All records were generated and stored electronically, and hand written duplicates were made to comply with current Australian regulations. Both operating theatres were utilised. The emergency theatre was used for quick cases so as not to cripple the hospital’s ability to deal with their ongoing obstetric and surgical emergencies, of which there were a few.

The other theatre was used for major cases, and head and neck, reconstructive and major hand cases were the mainstay or our reportoir. A cross finger flap and a cross leg flap were left for Mr Bhushan to divide at the appropriate time. Ongoing teaching was afforded to the local medical staff, and pre-prepaired DVDs on hand examination and local anaeshetic block techniques were given to the appropriate consultants by Drs Crock and Portelli respectively.

Meetings were held with the local Rotarians, and we actively participated in the “Festival of the Friendly North” which was running while we were in Labasa. This meant manning a hospital stall and helping with public awareness programs. Mr Crock ran a slideshow of Interplast cases, which generated huge public interest.

The Interplast supplies were adequate, although it was felt the suture supplies could be rationalised, the K wire driver could be packaged much more efficiently, Kaltostat and jellonet supplies could be increased, and the instruments could be repaired. In particular the tenotomy scissors need sharpening. We take for granted the quality of our own supplies – for example the local 10ml syringes not only did not plunge properly, but they also leaked! Our supplies were greatly appreciated.

The overwhelming sentiment we experience was one of tremendous gratitude that the same team (almost) has returned for 3 years running. A real sense of team was engendered and the local support was overwhelming. They are crying out for ongoing commitment by a stable team. This should be a platform to develop services such as internet backup and ability to consult us regarding difficult cases. Mr Bhushan Ogale has already started doing this, but there is room for improvement. In particular the team need encouragement to continue improvising with Vacuum assisted dressings, which will result in a reduction of the (huge) amputation rate. Mr Ogale has committed to keep us informed about future developments over the next few months.

On anther front, Mr Crock has helped three other medical ventures in the islands, which revolve around coordinating medical services for local villages associated with tourist resorts of a rather adventurous nature. The whole concept has been discussed in parliament and has been mooted as a model in the recently passed Qoliqoli bill (which revolves around land rights and fishing rights for local tribes). This work is an extension of a project started 20 years ago by the owners of the Tavarua Island resort where Mr Crock works, and by the Loma Loma foundation started by Dr Lance Lambert from California.

Fiji’s future hangs in the balance. 160,000 people populate the northern province and of these at least 40% rely on the sugar trade for a living. Next year their preferential trade agreement with the EU runs out, and their livelihood is at stake. There are many untapped resources in the islands, but they need help and direction to develop appropriately. Our medical input, albeit minor, is an integral part of this and must be maintained. In the long run our small efforts will make a major difference.

The draining population is in the vicinity of 50,000. 25,000 live in the township capital, 5,000 come from the international yachting meca, Savu Savu, and the rest live in the remote interior or the surrounding islands. Labasa itself is predominantly Indian and is the nerve centre of sugar production in Fiji. Presently the country is basking in a trade agreement with the EC, who pay 30% inflated prices for the countries sugar in a longstanding preferential market deal.

Accordingly, extravagant inefficiency (including hand harvesting) istolerated. In 2007 this agreement finishes and Fiji is in danger of sinking in the sea of competition for its main cash crop. In order to come up to the standard of its main competitor, Brazil, mechanised harvesting will have to be introduced, as well as the infrastructure to collect ethanol (for fuel additives and alcohols such as Rum) as a by product from the sugar cane. There is some hope that some investment from India and Malaysia may allow this to realise, but at this stage the hope is only speculative.

Without its sugar Fiji relies on tourism. Currently plans for an international airport on the North Island have been shelved by authorities in Suva, in spite of the fact that funding is available for this venture. Accordingly the livelihood of those in the north is currently hanging in the balance. In the meantime, the people of that area continue to be very poor but in many cases blissfully happy and fairly unaware of the precarious situation that they are in.

As a whole the Fijians (both Indo-Fijian and Indigenous) are very grateful for help offered to them and neither see this as a sign of weakness nor inferiority. This appreciation was evident on our arrival: when our team arrived at the hotel the head receptionist greeted us extremely warmly and told usthat she had kept a piece of forgotten luggage from our last trip one whole year ago. She joyfully produced the parcel with the greeting “We have prayed that God would bring you back and we kept this in hope”.

The community also demonstrated this sentiment, and many of the locals remembered us well from the year before. Not only did some of the Rotarians remember us, but also links with local expat missionaries and indigenous church leaders who had helped us in 2004 were re-established and strengthened. Separate dinners were held with the local Rotarians, the Hospital Board of Trustees, and with local Pastors. At all of these meetings the resounding sentiment was extreme gratitude that a team from Australia was committed to return to the district and offer help to a community of people who feel rather neglected by the world outside them.

The local Indian surgeons are excellent and were extremely helpful in co-ordinating our venture and yet the reality is that they have little or no training in Plastic and Reconstructive Surgery, and patients requiring this form of specialist care often go wanting. Not only had these surgeons triaged patients for our assessment, but they had also made the community aware that we were coming by placing an announcement on the local radio station, and even though an American Interplast Team had been through only 3 months before, on our first day 99 souls crowded into the tiny antiquated outpatient facility for assessment. A further 16 people knocked on the operating room reception door over the next week seeking our help. Although patients came from even the far reaches of Fiji, the majority were from the North Island.

In addition a recent Interplast trip to Lautoka (attended by surgeons Kirsty McGill and Murray Beagley) had performed surgery on a young boy with severe burns scar contractures, and this child required second stage procedures to be performed. Kirsty communicated with me (JC) prior to the trip alerting me to the needs of this, and other, patients, and our team was able to finish off the good work which had been started by these others.

The surgical cases ranged from fungating tumours, debilitating infections, horrendous burns scar contractures, complex hand pathology, head and neck tumours to minor lumps and bumps, keloid scars, split earlobes and cosmetic surgery cases. It was a fascinating study in a community’s perception of what Plastic Surgeons do.

The aim of this visit was to offer plastic and reconstructive surgery to the locals. It was made clear that we would not be doing cleft lip and palate surgery nor hypospadias repairs and we indicated that we had a particular interest in hand surgery. The vast majority of cases were bona fide reconstructive problems, many of them either life threatening or debilitating. However even in this poor remote corner of the world people are exposed to the television (sometimes only in the public arena, watching Extreme Makeover on a shopfront TV set), and this has impacted peoples’ perceptions of normality. In spite of the fact that they go home to a bare shack for a house, and have jobs netting 90c FJ an hour, some local folk presented for correction of prominent ears and abdominoplasty- driven by a desire to look ‘normal’.

A severe burns scar contracture, characteristic of the neglected state of some of these people.

After a gruelling day of preoperative assessments the team met at night for a debriefing and we triaged the cases. All non-urgent cases were identified. Life threatening and/or major cases were prioritised. The next day we arranged for the patientsto be contacted and counselled and the skeleton of the weeks’ list was booked, leaving room for additions.

We worked our way through the list utilising two theatres; Dr Portelli anaesthetising in one theatre and the local anaesthetists working in the adjacent operating room. We also had access to an area called the ‘MOT’ – an alcove used for anaesthetising minor cases. The facilities were rudimentary. We were treated to some Betadine and one bar of soap for the week, which we all shared for surgical scrubs. The water was nice and cool in the sink before lunch, after which time it generally ran out (for periods of time). The concrete operating room floor was possibly a bit bumpier than last year, but they had improved the air-conditioning unit stuck in the window (which was boarded up to keep one’s mind off the outside world). This was good as it appeared that the surgical gowns had been donated from post war Europe (the winter models, at least). They were also styled with flowing open sleeves, which begsthe question, were these designed to give the surgeon an added French cavalier feel?

The new wing of the hospital has not progressed much since last year and this is to be set aside for general medical and psychiatric use. There are no plans afoot to improve the operating complex. (Next door to the hospital a first class law court complex is nearing completion, having been started a few months ago).

We tried to coordinate the timing of our cases with the local surgeons, who occasionally required one theatre for their emergency workload. Notwithstanding, they had cancelled their own elective lists for the duration of our visit. We utilised the two operating rooms as much as we could, and worked together on major cases when only one room was free. Any gaps in our original list were well and truly filled with emergency cases.

During the week we were invited on ward rounds with the local surgeons and asked to assist them manage their difficult in-patient cases. In addition emergency reconstructive cases presented during our time. In particular we reconstructed the hand of a young lad who had been dragged along behind a ute and ground off the dorsum of his wrist some 5 weeks prior to our arrival. He had been languishing on the ward asthe local surgeons were at a loss as to how to proceed with his management. In this particular case we were able to radically debride the wound, reconstruct the extensor compartment with multiple tendon grafts and then cover the defect with a large groin flap.

We also assisted in the management of a boy who had had his ankle dragged along under a car, another young fisherman who had been attacked by a Moray eel, as well as many other serious but less spectacular problems. All the cases were photographed for documentation, although on the first day some of the cases could not be photographed as the camera battery went flat! At the end of our time in Lambasa we had consulted 116 patients and performed 64 surgical procedures.

Follow up has been co-ordinated with the local surgeons and phone contact and email contact has been maintained with Dr Bushan Ogle.

In 2004 we had helped the local surgeons treat a young girl who had nearly been killed by a tiger shark on the reef of her local village in the far north. We had reconstructed her lower leg by cable grafting all the major nerves at the level of the knee, as the shark had latched onto the popliteal fossa. On the fifth day of our time in Labasa this year she walked into the operating room to show us how her life had been salvaged. She had both dorsiflexion and plantar flexion of the foot with some protected sensation in the heel and an advancing Tinel’s sign in the distribution of the posterior tibial nerve. It was a great privilege to witness this knowing that in her outback community an amputation is effectively a prison sentence as crutches are not available, much less a decent prosthesis.

This man was only able to drag himself along the ground because of an amputation.

Thanks to the INTERPLAST venture, this lady was able to walk back to visit the team following complex reconstruction of her leg. She nearly died after a shark attack which all but amputated her leg in 2004, and using reconstructive techniques the team was able to more than salvage her limb.

We were also delighted to be greeted by a postal worker at the Post Office several days before our departure who remembered us warmly. He had once been one of the senior workers but over one year ago his livelihood was dashed by an injury which led to a gross flexion contracture of his dominant index finger. His digit was permanently flexed at over 90 degrees at the PIP joint and this precluded him from effectively picking up parcels, which in turn made it virtually impossible for him to perform his normal duties. His career was in taters. We were able to correct his deformity using standard plastic surgery reconstructive techniques, and when we saw him this year he told us that he was now able to perform all of his normal duties at work and was a useful (and senior) member of the postal team again.

From flexion contracture to surgery: This sequence of events transformed this man’s life and got him back into the workforce.

Sadly, not all the news we received following our last visit was good. In 2004 a beautiful 8-year-old girl presented with a painless mass in the gastrocnemius. We took a biopsy which we flew back to Graham Mason at Melbourne Pathology. He diagnosed synovial cell sarcoma. This dear little girl died in our absence this year.

The team dispersed in several groups. Mr Jim Beaumont co-ordinated the baggage, although Mr Crock had arranged for baggage handling to be performed by a tour company based in Nadi because the surgical cases were flown there from Labasa and had to be stored for 24 hours prior to the baggage being flown home. (Becauseof the size of the aircraft some of the baggage was delayed and was flown down separately from Labasa on the day of departure). Mr Crock also arranged for the departing team members to be given a tour of the west coast of Viti Levu on the day of their departure. Mr Crock stayed in Fiji and ran medical clinics at a number of outlying posts including one on the beautiful but remote Yanuca Island, where in 2004 the Geelong Rotarians had built a new nursing post and also equipped the village with new water storage tanks. Last year Mr Crock unofficially opened this facility and this year revisited the island and ran more clinics.

The Labasa tour was very successful. Asignificant surgical caseload was handled, follow up arrangements were secured and links with the local community were strengthened. The community is certainly deserving of a long term commitment from Interplast, and were more than pleasantly surprised that the same members returned two years running. They have expressed a heartfelt desire that we continue this trend.

Dr Portelli has expressed and interest in ongoing internet based education of the local anaesthetic staff. Together with Mr Crock he collected some 12 boxes of medical supplies to donate to the hospital. Mr Beaumont has also expressed an interest in developing a link with the hospital to mentor the theatre nursing staff. He was very involved in both community work and with nursing staff to strengthen ties with our country.

The local medical staff who co-ordinated this visit were Dr Bushan Ogle and Dr’s Abi Choudhary and Robert Gayappa, two consultant surgeons on staff. Dr Ogle is now the medical director of the hospital and is friendly, efficient and helpful. The theatre staff remains relatively stable, however the theatre manager has recently been replaced and the new manager is Mrs Salma Hussein, who was extremely helpful in co-ordinating with Mr Jim Beaumont.

The anaesthetic staff is currently is a state offlux, and is headed by Dr Ann Garcia who is a senior registrar. The unit has been encouraged to utilise the ongoing assistance of Dr Renald Portelli who has offered to give them internet based support.

Teaching was given in several forms: didactically; semi-formally; and hands on assisting with both the Surgical and Nursing staff. In addition the use of VAC dressings has been introduced to the Hospital, and Dr Crock taught the surgeons how to use this device. It is hoped a study will be performed to measure the impact of this technology on patient care.

Dr Crock instructing Dr Ogle on the use of the VAC dressing.

Postoperative surgical tracking was arranged between Dr Ogle and Mr Crock and ongoing phone and email contact has been maintained. In addition, links have been strengthened with local community members. In particular, Mr Crock has developed ties with a prominent local community member, Mr Coco Singh, who has many contacts in both the Indian and Fijian community of the north. Both the local community at large and the local medical community are crying out for ongoing assistance in managing patients who have plastic and reconstructive surgical problems.

It would also be extremely advantageous to offer support in the IT department to facilitate communication with team members when they cannot be physically present. Currently Dr Bushan Ogle spends quite a lot of his own time and effort to maintain email links but there are no facilities in the theatre complex (and they are fairly scant in the hospital precinct) which makes it near impossible for the other surgeons to make email contact with us readily.

Recommendations for further visits include:

• Continued use of digital photography to document cases
• (Electronic) post operative flow sheets to help with post operative management
• IT support to facilitate ongoing contact with interested parties
• Encouragement of the hospital administration to improve its surgical facilities
• Formalize the mentoring program of the theatre team to improve operating room flow/dynamics
• Donations of operating gowns to the hospital
• Donations of surgical packs to the hospital

Unfortunately, the Melbourne contingent had airport problems – they were separated from their luggage due to a technical failure at the airport. They were re-routed back to Melbourne, spent 6 hours in the Airport Hilton and then flew out again at midnight direct to Nadi. This whole exercise added an extra 12 hours travelling to their trip.

It was planned that the team would meet at the Tenoa International Hotel, Nadi, on Saturday June 26, however the airport debacle put an end to this. The majority of the team made it to Labasa by Sunday 27, and were greeted by the local Rotarians who took them out to lunch. The team stayed at the Grand Eastern Hotel in Labasa, which was an extremely comfortable venue, with pleasant surrounds, very friendly (for the most part) staff, an exceptionally helpful manager, and the team was provided with very satisfactory cuisine. Sue Atwood, Val Nicholson and the Crock family spent many hours visiting the hospital as well as visiting local missionaries and watching their activities. They also spent some time communicating with the hospital administration. On Friday July 2, Sue Atwood and Val Nicholson returned to Melbourne The remaining team went to Savu Savu for the weekend, were hosted by local representatives and after the weekend returned to Labasa to continue consulting and operating until July 7. In addition the local Rotary Club was extremely hospitable and hosted the team to dinner on several occasions.

Clinical Duties

The week started with an Outpatient Session on Monday 28 June, and from 8am until 12.30pm over 40 patients were seen. From this, lists were booked to fill the eight-day operating schedule, although every morning of each subsequent day, late arrivals or emergency cases were seen on an ad hoc basis and booked for theatre if required. The surgeons were also invited on hospital ward rounds and helped manage some inpatients with various problems.

The cases had been co-coordinated and booked by a newly appointed general surgeon from India, Dr. Bashan Ogle, who was given the brief that we were a plastic surgery team who would perform predominantly hand surgery on this trip. He successfully triaged a number of most appropriate, and at often times challenging, cases that comfortably fell within the repertoire of a general plastic surgeon, although there was by no means an emphasis on hand problems.

The cases included pathologies involving most parts of the body and most age groups: inoperable and operable parotid tumours, difficult burns scar contractures, keloid scars, cosmetic deformities due to scarring or benign tumours, scar contractures of hands and fingers, old post-traumatic hand problems and congenital problems relating to the hands and feet. The cases were assessed by the whole team initially – Messrs. Crock and Donahoe making pre-operative clinical assessments and formulating a treatment plan; Dr. Portelli assessing the patients for anaesthesia; and Mr. Beaumont helping co-ordinate the Theatre Lists and requirements for surgery.

Where appropriate the patients were allocated theatre times, and the appropriate hospital arrangements were made. The theatre facilities were basic but adequate. The equipment supplied by the Interplast team served us for all the cases, bar one patient with severe burns scar contractures, who will require extensive reconstructive surgery in order to regain some quality of life. It was felt that the risks associated with his surgery rendered it unwise to proceed with the facilities and conditions available to us. It was hoped that Rotary Australia will be able to be generate enough funding to bring this one patient back to Melbourne for treatment – to restore function and form to his head 3 and neck, and both upper limbs (shoulders, elbows, wrists and hands). Two patients presented with malignant parotid tumors and again it was felt that surgical intervention would potentially be life threatening and was unwise. No plans were made for further treatment of these souls.

Wherever possible, the team tried to incorporate the local surgeons in the surgical process, and Dr Ogle and his juniors attended surgery wherever possible and also asked for help in managing a number of complex trauma cases. This included the reconstruction of a young woman’s leg (who had fallen victim to a tiger shark) – she had cable grafts to both her common peroneal and posterior tibial nerves in the leg, as well as extensive skin grafting to two wounds on the calf. The team also assisted with amputations for diabetic patients, and helped the local surgeons manage acute trauma cases which had come through the emergency department at the time of the expedition.

In addition to hands on surgery the team also began to establish a means of ongoing communication with Dr. Bashan Ogle utilizing Internet services and the use of digital cameras and electronic transfer of files, thus providing for ongoing assistance in managing plastic surgical cases in the absence of a team being on the ground.

Educational Endeavours

In addition to coordinating the surgical setups, Mr. Jim Beaumont was extremely active in educating the nursing staff at Labasa Hospital, and in the short time we were there set up programs which radically altered the way they processed their equipment, they co-coordinated the surgical workload, they dealt with their post-operative recovery patients, and they co-coordinated the running of the theatre floor.

Dr. Portelli also had significant discussions with the Anaesthetic Department and was able to take some of his knowledge and skills as the ex-chairman of the Australian Society of Anaesthesiologists, and hopefully planted some seeds which will result in improvement of services in the Anaesthetic Department at Labasa Hospital.

Mr. Crock also ran numerous education sessions on various aspects of plastic surgery using powerpoint presentations for the theatre staff and surgical trainees.

General Impressions and Future Plans

In the short time we were there, we were able to get a very good feel for the Fijian way of life, and the medical/surgical conditions which befall the community. The two things which stand out glaringly are the crippling side effects of diabetes and the poorly treated machete and light industrial accidents that occur as a result of the local sugar farming and wood-milling. We believe that Rotary and Interplast can both have a major ongoing impact on the health of the indigenous Fijian community by supplying teams to intermittently assist with the management of traumatic cases as well as helping train the local surgeons in the art of treating these cases.

Rotary and Interplast can also help with ongoing triage of congenital cases, and helping with community awareness of diet and exercise, in an attempt to reduce the impact of diabetes on the community. In addition huge benefits would be obtained by establishing internet chat sites to enable virtual ward rounds by Australian surgeons and two way interaction to steer the management of cases in Fiji. The local surgeons and Rotarians were very keen to establish this
but need help with IT planning and equipment such as digital cameras.

All of the team were extremely keen to make an ongoing commitment to establish liaisons with Labasa Hospital in an attempt to improve the health services to the Fijian community in the longer term.

Since returning to Australia, the administration at Knox Private Hospital has expressed their keen desire to support Mr. Beaumont in an ongoing site-specific mentoring role to the Labasa theatre nurses, and Dr. Portelli has also sourced disposable anaesthetic equipment which could be re-sterilised and reused. This would be of invaluable assistance – as local resources are rather limited.

Messrs. Crock and Donahoe have also had discussions about how to establish the local surgeons with the basic skills required to deal with the kind of cases that they are presented with. It was also felt that a useful exercise would be to run a low budget trip to Labasa using the local facilities, but perhaps bringing some good quality surgical equipment which could then be donated to the hospital. This concept would clearly have to be developed with the Interplast secretariat.

Squamous cell carcinoma develops in the squamous cell layer of the epidermis, but its progression is more subtle and is often unrecognised and illogically classified in the current environment. As Bernard Ackerman from the USA very aptly points out, solar keratosis is an in situ squamous cell carcinoma. As with all cancers, the body is constantly sending immune cells throughout the tissues to hunt down and eradicate any mutancy, and as a result, many early carcinomas are eradicated before they become problematic. Solar keratosis falls into this category and may resolve spontaneously in a percentage of patients.

Nevertheless, the histology of this condition shows bizarre shaped basal cells which contain many nuclei (this is abnormal), bizarre shaped squamous cells, a recognisable prickly cell layer and clear cell layer, and a keratinocyte layer that contains bizarre and sick-looking cells, and instead of the skin being sealed by a layer of dead keratinocytes, this skin of solar keratosis is piled high with sick keratinocytes that have visible nuclei in them and refuse to fall off. The pathology is contained entirely within the epidermis, and the cell layers are recognisable.

The next progression towards squamous cell carcinoma is called Bowenoid keratosis. This is one step further on from solar keratosis, and all of the cell layers are bizarre and unrecognisable and the bizarre cells extend down along the hair follicles, sebaceous glands and sweat glands into the dermis, although they are still separated from the dermis by the peri-potential basal cell layer which normally sits under the basal cells. There is a ramina membrane thus separating the epidermis from the dermis.

The next progression of squamous cell carcinoma is when the tumour transgresses this barrier, and penetrates into the dermis. This is called early invasive squamous cell carcinoma. Clinically, the appearance of these tumours change. Both solar keratosis and Bowenoid keratosis appear as a
roughened, scaly area of skin, which may occasionally bleed when scratched. The early invasive squamous cell carcinoma takes on a slightly warty or crusty appearance and feels thicker. As the progression into the dermis continues, and invasive squamous cell carcinoma becomes more established, the tumour becomes very thick, may contain a central core of dead tissue and paradoxically may appear localised, albeit over a large area.

If left untreated, the squamous cell carcinoma can become enormously thickened, crusty, wart-like, with or without tissue necrosis. Squamous epithelium is not only found in the epidermis of the skin, but it is also found covering the mucosal surface of the lips, inside the mouth, the tongue and areas of the aerodigestive tract, including sinuses within the skull (which are there to reduce the density of the bone to lighten the skull and therefore lighten the weight of the head, which needs to be supported by the neck musculature).

Squamous cell carcinoma can also involve these tissues, and can therefore be found in the mouth, throat and facial sinuses. The clinical behaviour of squamous cell carcinoma depends on the site of the tumour and the thickness of the tumour. Tumours arising from the tongue, aerodigestive tract and sinuses tend to be much more aggressive and should really be treated in a specialist unit with a multi-disciplinary team approach that involves not only an appropriate surgeon, but also an oncologist and radiotherapist, along with their appropriate support teams. To this end, this kind of tumour presenting in a private setting is usually referred on to a multi-disciplinary team.

Squamous cell carcinoma of the skin however, tends to be fairly localised in most cases and is eminently treatable in the private clinic setting. Only in extremely advanced cases, is there a very small percentage chance of metastatic disease.

There are three forms of treatment for squamous cell carcinoma. Surgery remains the mainstay, with the highest cure rates, and is the most definitive form of therapy. Laser therapy has a role to play in some instances, and chemotherapy has a role to play in some instances, but both the latter modalities have a lower cure rate and are often not definitive. Laser therapy may be undertaken either using a standard CO2 laser, a pulsed dye laser or new PDT laser which involves photosensitisation of tissues, with a chemotherapeutic agent prior to applying the laser beam.

The chemotherapeutic treatment of squamous cell carcinoma involves applying creams to the tumour that will either kill the cancer cells, or stimulate an immune response to the cancer cells. Efudex (5-fluoro-uracil) is a chemotherapeutic agent that produces very aggressive blistering which erodes away the tumor. The wound subsequently heals with minimal scarring.

Imiquimod (Aldara cream) is another agent which is currently being trialled for the treatment of squamous cell carcinoma. This is an immune stimulating drug, and again produces blistering over the tumour when applied to the affected area. When the blistering heals, the skin tumour is eradicated. This is successful in about 80% of people who are treated for superficial forms of squamous cell carcinoma.

This treatment has PBS authority only for the treatment of genital warts, and if it is being used for the treatment of squamous cell carcinoma, it is not subsidised by the government, and a typical treatment will cost in excess of $500 purely for the cream alone. In addition, treatment with Imiquimod will take up to six to 12 weeks, depending on the regime used. (Different regimes are prescribed by different practitioners and as it is still in the trial phase, no recommended preferred approach has been decided upon, although from my reading of the literature, the most successful regime to date is to apply the cream twice a day for three consecutive days for 6 consecutive weeks). The only disadvantage of this therapy is that patient compliance is not so good, as the blistering can be quite severe.

It is not recommended that any skin cancer be treated conservatively without first obtaining a tissue biopsy of the area in order to make an accurate diagnosis, and once treatment has been undertaken it is sometimes worthwhile repeating the biopsy to prove cure.

In this talk, it is noticed that the melanocytes, from which melanoma is derived, are cells which migrate from the neural crest in the developing embryo. Because these cells are migratory in nature, it is probably true to say that when they become malignant, this explains their propensity to migrate once again, and metastasize. This is why melanoma is a much more serious skin condition than either basal cell carcinoma or squamous cell carcinoma. Nevertheless, not all melanomas do metastasize, and an understanding of skin anatomy and function will explain why this is the case.

Normally, the melanocytes are found along the basal cell layer, scattered in amongst these cells, where they produce pigment and transport the pigment into the basal cells, to produce either suntan in Caucasians who tan, freckles in Caucasians who do not, and skin pigmentation in Asians and Africans. Occasionally, melanocytes are found in the dermis in groups. These are cells that have arrested their migratory course during development, and these lesions produce a whole range of benign pigmented skin spots. To the lay person, these are broadly known as “moles”, but the histological classification of these lesions is extremely complicated and hundreds of different types of pigmented skin lesions have been described. These are beyond the scope of this document.

There is one condition however, called the dysplastic naevus syndrome, where the moles are slightly larger than normal and they may have an irregular shape and in some cases, mimic melanoma. Dysplastic naevi may in fact turn into melanoma, but usually do not. They are, however, often markers of a propensity to develop melanoma elsewhere in the skin, and the condition may be familial and dysplastic naevus syndrome has been classified according to a number of clinical associations, and this classification may be a useful prognosticator in discussing the development and behaviour of melanoma in some individuals.

When the melanocytes become malignant, and melanoma develops, they have two growth phases: One is called the radial growth phase, where the malignant cells spread sideways along the junction of the epidermis and dermis. The other growth phase is called the vertical growth phase.

As pointed out in the normal skin anatomy document, there are no lymphatics in the epidermis and no lymphatics in the superficial part of the dermis (papillary dermis), but there are lymphatics and large blood vessels in the deeper parts of the dermis (radicular dermis). To this end, the radial growth phase of melanoma is unimportant and does not affect the prognosis of the disease, as the tumour cells here are not able to metastasise anywhere else in the body. Therefore, the tumour may grow sideways, and yet not be life-threatening. However, when vertical growth phase takes place, the tumour grows down through the epidermis into the papillary dermis and then on into the reticular dermis, and the deeper the tumour grows, the greater the risk of metastatic disease.

The classification of melanoma was simplified in the year 2000, and now the best way to grade melanoma is by measuring the depth of the tumour from the granular cell layer, to the deepest part of the tumour within the dermis. Tumours less than 1mm thick, have a very high cure rate from surgical excision. Tumours 1-2mm thick have cure rates in the order of 85-90%. Tumours 2-3mm thick have cure rates in the order of 60-80%, and tumours greater than 4mm thick have cure rates significantly less than 40% of the time.

The diagnosis of melanoma is not easy. In a melanoma screening clinic, performed in Western Australia, the accuracy of diagnosing melanoma by specialist surgeons who normally treat this condition on a regular basis, was less than 40% in an unfiltered population (which means, people came off the street to be assessed cold by treating surgeons). These figures line up with similar studies performed in both England and America, where melanoma screening clinics were conducted and run by both dermatologists and/or plastic surgeons, but there were no referring doctors; rather the patients came straight to the clinics. Accuracy rate of diagnosis improved significantly when the patients had been first screening both other practitioners. However, to put it in context, an average GP will see one new case of melanoma every two years in a busy suburban practice, although the new skin magnifying glasses and various light adjutants do marginally improve the rate of diagnosing melanoma by simply scanning the skin. The gold standard diagnosis is histological confirmation of the disease. This can be performed by a punch biopsy without compromising the treatment or prognosis of the disease. It can also be performed by using a simple shave biopsy, although this technique may interfere with subsequent prognostication as the depth of the tumour will be altered as a result of the biopsy. (This is really of only academic interest in most instances.)

The treatment of melanoma, once the diagnosis has been established, should always be surgical. Diathermy or curettage does not only inadequately treat the tumour, it also can potentially lead to metastases, and makes subsequent site surveillance almost impossible. The use of creams, such as Imiquimod or Efudex for melanoma, has not been proven, and once again may result in metastatic disease being precipitated.

Surgical treatment of melanoma involves excising the lesion with a reasonable margin and closing the defect in whatever way necessary to produce the best aesthetic and functional outcome. Plastic surgeons undergo rigorous training for usually up to six years to learn the techniques to achieve this main. The role of sentinel node biopsy is controversial and is currently under debate. This involves injecting of dye into the region of the tumour excision, which is carried up the lymphatics to the nearest node. This node then becomes obvious because it is filled with the dye, and the node is then removed and assessed histologically to see if it contains any cancer cells. The controversy over the this technique exists because there has been no proven benefit from doing this procedure.

There is no evidence to show that it reduces the risk of recurrence or loco-regional spread of the disease, it does not increase survival of patients with melanoma and makes subsequent staging of the disease difficult. It also interferes with normal defence mechanisms for the body’s handling of tumour cells that may metastasise. Nevertheless, some centres believe there is a place for sentinel node biopsy and this technique is therefore employed in those units.

The follow-up of melanoma depends on the thickness of the primary, and whether or not there is any evidence of secondary spread to either the nodes or other parts of the body. In this practice, the first adjutant test to be ordered is a PET scan. This is a test which involves injecting radioactive glucose into the bloodstream, which is then taken up by tumour cells which avidly incorporate glucose as they are growing quite fast. A PET scan will give an accurate indication as to whether or not any metastatic disease has taken place or not. However, it is not a definitive test. Usually this is followed up by various other modalities of imaging, such as CT, MRI scan and/or bone scans.

The treatment of advanced melanoma again is controversial and involves aggressive ablative surgery, radiotherapy, chemotherapy, or alternate therapies. Ablative surgery has a role to play for debulking tumour, which enables the body to fight the disease more effectively. It also has a role to play for immunotherapy. This is a trial that is currently being run out of the United States, where 3g of tumour is flown to a centre in the United States, where it is processed and turns into a vaccine which is subsequently produced and shipped back to Australia where it is administered to the patient. This is still in a trial phase and treatment with the vaccine cannot be guaranteed as there is a double-blind trial going on, in which a percentage of people will receive traditional chemotherapy, and a percentage of people will receive the immunotherapy. The results will be assessed in several years time to see which
modality is more effective.

Radiotherapy is good for controlling regional disease. It does not affect the spread of subsequent melanoma cells to other areas of the body, but seems to be good in controlling localised lesions, especially lithic lesions in bone which can be painful. It is therefore recommended as an adjunct to surgery.

Chemotherapy has been used for melanoma with very limited success. There are many different regimes, ranging from isolated limb perfusion where extremely toxic chemotherapeutic agents are infused into a limb, which is exsanguinated and a tourniquet put on (if the agents were to leak into the general circulation, the dose would be fatal. Usually the limb is heated during this process. This obviously is only useful for extensive disease of the arms or the legs.

The various systemic chemotherapeutic regimes for melanoma at this stage are extremely toxic, and have many side-effects. The response rates are in the order of about 10%, although some figures vary and it is not clear as to whether they actually improve the length of life. Various alternate therapies are available for treatment of melanoma, but sadly there is little discourse between alternate therapists and traditional medical practitioners, and to this end, patients wishing to seek alternative therapies are encouraged
to research the Internet for themselves.

Finally, a proportion of people with metastatic melanoma go into spontaneous remission and there are some people who co-exist with single metastases of melanoma for many years and remain asymptomatic and healthy. As such, it is a condition which still at times eludes our understanding.

The skin is made up of two layers; the epidermis and the dermis. In the developing foetus, the epidermis is formed from the outermost cell covering of the embryo, called the ectoderm. It acts as a sealant over the whole body. The dermis however, comes from within the foetus, from a layer called the mesoderm. When the skin is mature, the epidermis has a pluri-potential stem cell layer at its base. These cells subsequently divide and become basal cells, which in turn divide and become squamous cells, which then in turn divide and become prickly cells, then a clear cell layer is next seen, underlying a layer of keratinocytes. The keratinocytes subsequently die, but act as a sealant to the skin, much like the plastic laminate that is sometimes applied over paper sheets.

All of these cell types are ectodermal in origin, and as such, are native to the outside covering of the body. It would appear that this effects the characteristics of malignancies (cancers), developing from these cells, as they tend to remain localised. When basal cells become malignant, they (for all intents and purposes) never metastasise, but are locally invasive.

Squamous cell carcinoma rarely metastasise and this again probably relates to the behaviour of these cells during the body’s formation.

In contrast, malignant melanoma and other malignant skin tumours such as the Merkel cell tumour originate from cells not derived from the cell layers thus far described, and their behaviour is totally different to that of the non-melanocytic skin cancers. These will be discussed at a separate time.

The cause of basal cell carcinoma is varied, but essentially, is sun damage in susceptible individual. There are some genetic conditions that predispose to basal cell carcinoma formation, and some poisonings (such as low level arsenic poisoning) can produce multiple basal cell carcinomata. Basal cell carcinoma is almost unheard of in heavily pigmented people, but is quite common in fair skinned Caucasians. There is some conjecture as to whether or not trauma can produce basal cell carcinoma, and although there are some reports of this, the literature is not conclusive. Although over 20 different sub-types of basal cell carcinoma have been described, they basically fall into two main groups: The papillonodular group and the diffusely infiltrating group.

The papillonodular group

The papillonodular group of tumours have a well-demarcated edge, are well-defined, often have a raised pearly edge or look like a bleb of water has been injected under the skin. They also have
characteristic blood vessels growing in them which are called telangiectasia.

The diffusely infiltrating group

The diffusely infiltrating group of tumours are much less distinct and it is very difficult to clinically assess the edge of the tumour. At times, they may look as indistinct as merely being a rough area of skin that is slightly reddened. Paradoxically, these tumours tend to be quite aggressive and can be very difficult to treat.

As alluded to above, basal cell carcinoma may be multiple and both multiple papillonodular or diffusely infiltrating tumours can exist concurrently. Basal cell carcinomata are most commonly found in the head and neck region, but they can be found anywhere on the body.

Treatment

The treatment of basal cell carcinoma is varied. Although surgery is the gold standard and is curative in most instances (over 99%), sometimes the disadvantages of surgery (namely scarring, the ablative nature of the treatment and at times disfigurement) may outweigh the advantage of ablating basal cell carcinoma. To this end there are some chemotherapeutic agents that are available in cream form which can treat basal cell carcinoma. The cure rate of these various agents is usually only around 80%, and they have some disadvantages: sometimes these treatments are time-consuming, may produce painful blistering and may be costly. Nevertheless, off the potential benefits of curing some forms of basal cell carcinomata without the need for surgery (and therefore without leaving a scar) outweigh the benefits of a high cure rate. A good example of this is a superficial papillonodular basal cell carcinoma on the nose, where ablative treatment may require excision and flap repair or full thickness grafting, which leaves permanent scarring with associated cosmetic deformity, whereas chemotherapeutic treatment will not leave this scarring or deformity.

The development of non-surgical modalities for treating basal cell carcinoma are improving and also changing with time. A few years ago interferon [1] alpha was placed on the PBS schedule (which means that Medicare will pay for the treatment) for the treatment of basal cell carcinoma in cosmetically sensitive areas. This treatment modality required injection of the tumour three times a week with an agent, and the treatment had significant side-effects including severe flu-like illness. This drug has been withdrawn from the PBS schedule, so although it is still available, a treatment course costs well in excess of $1,000 and offers a cure rate of only 70-80%. The immune stimulating agent Imiquimod (Aldara cream), which has been used for a long time to treat genital warts, has now been shown to be effective against some kinds of basal cell carcinoma. There are various regimes for using this cream, but in my practice, I have it applied twice daily for three consecutive days over 10 consecutive weeks. The cream produces quite severe blistering, which is then treated with vitamin E cream. Once the process is complete and the blistering has resolved, the basal cell carcinoma is cured in approximately 80% of cases.

The sap of the common garden weed, euphorbia peplus (Milkweed) contains alkaloids that are effective against some superficial forms of basal cell carcinoma or squamous cell carcinoma. A company in Brisbane (Peplin Biotech) is currently marketing the active ingredient of this sap, but as yet, it is not available to be purchased as a pharmaceutical. Nevertheless, a home remedy for treatment of some conditions is to apply the sap of the Milkweed to roughened areas of skin. It is recommended that this not be undertaken without previously biopsying the area to obtain histological confirmation of the lesion that is being treated. It is always inadvisable to treat skin lesions without having histological confirmation, as some melanomas do not contain pigment, and can mimic basal cell carcinoma.

Having said all of this, surgery remains the most definitive way to treat skin cancer and in many instances the procedure can be performed in such a way to minimize or mask scarring and the cosmetic results are in most instances, excellent.

In this practice, scar management is routinely undertaken to aid and speed up the maturation of scarring so that the best outcome is achieved. Surgery may be as simple as excising the lesion and closing the defect primarily. However, for larger lesions or lesions that are removed from areas such as the nose or eyelids, where direct closure of a defect would cause unsightly deformity or even functional impairment, then either a flap or a graft is used. As a general principle, local flap skin gives the best colour match and functional outcome, although this may be at the expense of a contour deformity. These contour changes may either be insignificant or may be doctored up at a later date to produce the best result. A new generation of neurovascular island flaps is revolutionising flap reconstructions and giving vastly superior reconstructions when compared with traditional flap repairs. Grafts tend to change colour with time, and although in some instances, they give an excellent result, they must be used with great discretion.

There is a new modality of treatment that involves laser called PDT (photo-dynamic therapy) and this involves applying a cream to the tumour which is taken up selectively by malignant cells, and renders them ultra-sensitive to laser light beams. The laser is then applied to the tumour, which is killed by heat ablation, but the normal surrounding skin is left unscathed. Early trials would suggest that this form of therapy may become more popular in the future, and offers another non-surgical option in the treatment of these non-life threatening skin malignancies. I purposely have not mentioned laser or cryotherapy in my list of treatment options. This essentially involves burning or freezing of the lesion, and creating a full thickness defect that is then allowed to heal secondarily. My personal opinion is that this is an unsatisfactory mode of treatment, given the other options that are available.

Normally, tendons run inside a tendon sheath, with has a number of thickenings along its course which act as pulleys. The tendon is incredibly smooth and the gliding motion up and down the tendon sheath is beautiful and frictionless.

Occasionally, however, either a lump develops in the tendon, or a tightening of the one of the pulleys occurs, and the tendon gets irritated against the pulley of the tendon sheath. Almost always, the first annular pulley (which is found at the distal crease in the palm, under the little, ring and middle fingers, and under the proximal crease of the palm, of the index finger and thumb) becomes involved in the process.

Their resultant effect is that pain is experienced in the hand, and clicking may be felt, and the finger might be bent at the proximal interphalangeal joint, or in the case of the thumb, the interphalangeal joint and in the worst cases the finger may either be permanently stuck or have to be pulled straight with the other hand, in order to fully extend the digit or thumb.

As alluded to above, the cause falls into two broad categories;

• The congenital form is usually noticed within the first year of life, and is due to a lump in the tendon, and this almost exclusively involves the thumb, but really may involve other digits.
• The degenerative form may be part of another degenerative process such as rheumatoid arthritis or some other connective tissue disease, or may simply occur for no particular reason.

Commonly, the ring finger is involved, but any of the digits may be involved with this process. Non-operative treatment involves injecting steroids such as Kenacort A-40, into the region of the A-1 pulley. In a significant percentage of people, this treatment modality is successful. The needle itself is not overly painful, but does cause aching in the hand, which may be particularly severe on the first night of treatment. This subsequently settles down and after about a two week period, the effect of the injection is felt and triggering may resolve either partially or completely.

For those cases where steroid injection does not work, operative treatment is indicated. This involves making a skin crease incision, blunt dissection down to the A-1 pulley preserving the neurovascular bundles on either side of the tendon sheath, and retracting them out of the way. The A-1 pulley is then divided with a scalpel and the incision may be extended with a pair of scissors, once all the appropriate structures have been identified.

The wound is closed with a fine Prolene suture and adhesive dressings placed over the suture line and a light dressing is applied for a short period of time. Patients are encouraged to start using the hand the following day after surgery, although it is inadvisable to do heavy manual labour for at least a week after surgery, as this man result in wound infection and/or wound breakdown.

The potential risks and complications of surgery, include damage to the neurovascular bundles, infection. bleeding, wound break-down, scar problems.

Any hand surgery can precipitate regional pain syndrome, land this procedure is no exception. Complications following the surgery are rare, and in most instances the condition is treated quickly and efficiently, as a simple operation that can be performed in a Day Case facility. The procedure can be done under local anaesthetic, but it is more comfortable for all involved to have a quick anaesthetic.

The treatment is usually instantaneous and permanent, however, if an infection develops as a result of surgery, this may lead to recurrent triggering at a later date.

Please note: Trigger finger release may be contra-indicated in rheumatoid arthritis as release of the pulley may affect the biomechanics of the hand and result in worsening hand deformity, secondary to the destructive forces at play in this disease process.

Skin forms the covering to the body, and its function is not only protective, but also its thermoregulation and is integrally involved in homeostasis (balance) of fluid levels in the body. The skin is divided into two sections; the outside layer is called the epidermis and the deep layer is called the dermis. The dermis in particular has two recognisable layers; the papillary dermis which abuts the epidermis, and the reticular dermis which abuts the underlying fat of the subcutaneous tissues.

The epidermis contains only cells with no blood vessels, lymphatics or nerve endings. The dermis is rich in both blood vessels and nerve endings and also contains hair follicles, muscle which attaches to the skin and the hair, sweat glands, sebaceous glands and some other structures. The blood vessels in the superficial part of the dermis (papillary dermis) are tiny, and there are no lymphatics in this part of the dermis. In the deeper (reticular) dermis however, the blood vessels are much larger and there are abundant lymphatics.

When the skin is forming in the developing foetus/embryo, the outer layer, which becomes the epidermis, is derived from what is called the ectoderm, which covers the developing foetus. The cells of this layer are pluri-potential stem cells, and the very base of the epidermis. Basal cells which then differentiate into squamous cells, which then differentiate into prickly cells, then there is a clear cell layer, and finally there is a layer of keratinocytes. As the keratinocytes age, they stack up on one another and the outer layer of keratinocytes are dead cells, which are rather like a aminating layer on the outside of the skin. Once the body is fully formed, and the child comes into the world, the epidermis of the skin replenishes itself every month or two and this process continues on until death. The cells of the epidermis therefore are dynamic and are constantly changing.

In contrast, the dermis cells are permanent. They are formed in the developing embryo/foetus from the mesoderm layer that is sandwiched between the ectoderm and the endoderm in the developing embryo. The mesoderm layer differentiates (changes) into a number of different structures including muscle, bone, blood vessels and glands and dermis. The dermis itself contains a number of structures.

Nerve cells are different and they migrate throughout the body, and it is believed that growth of nerve through tissues results in differentiation of tissue parts and even tissue regions.

The astute reader would have realised that my discussion of the cells in the epidermis did not mention melanocytes or pigment cells. That is because these cells actually come from the nerve cell line, and migrate from the neural crest to the developing embryo to park themselves at the junction of the epidermis and the dermis. They then nestle down into the basal cell layer, produce pigment (which is a characteristic of all nerve cells) and transport the pigment into the basal cells. This process continues on after birth and that is why freckles and various pigmented lesions develop throughout childhood and on into adolescence. These are the cells that produce malignant melanoma. The behaviour of the melanocytes varies for different races. African Negroes have the highest concentration of melanocytes (particularly the Sudanese and Ethiopian groups) and albinism is a rare congenital deformity where no pigment cells are formed whatsoever. This condition is life-threatening.

There is another nerve cell which also migrates into the epidermis from the neural crest and this is the Merkel cell line. This too can develop into an aggressive tumour, the Merkel cell tumor.

Skin has been subdivided into six different groups, based on the amount of pigment found, ranging from Type I which is the kind of skin which burns and never tans, through to Type 6 which is the negroid type skin, which never burns.

The skin plays an integral role in our temperature control as the blood vessels dilate and release heat in hot weather and constrict and keep the warm blood flowing in the core of the body in cold weather. Sweating also has a bearing on fluid balance in the body, and again is related to temperature. The skin is naturally moisturised by sebum which is released from sebaceous glands in the skin. This natural moisturiser also has some sun block activity, however this is not enough to be significant for the average Caucasian in a sunny climate such as Australia. This is reflected by the fact that the highest rate of skin cancer in the world is found in both Queensland and
Western Australia, where there is a very large migrant population of British Caucasians, who have gone to live in a very harsh, sunny climate.

Understanding of the skin anatomy is a springboard to understanding skin conditions. On this website, only cancerous skin conditions will be discussed, however there is a vast array of inflammatory skin conditions, which sometimes enter into the differential diagnosis of skin cancer. As such, it is imperative that dermatologists and plastic surgeons collaborate together in the management of this complex area of pathology.

When a wound is formed, the injured blood vessels vasoconstrict for a period of approximately 45 minutes. Once blood clot formation has happened at the site of the vascular injury, active vasodilation begins after about one hour, and then cellular events start to occur. Initially, polymorphonucleocytes are released into the wound and their function is to phagocytose debris and start to autolyse the wound.

Vasodilation continues on over the next week, while the number of white cells being released into the wound increases. At the same time, epithelialisation in the surface of the wound begins within a day of wound formation. After a couple of days, the white cells start to differentiate into fibroblasts and collagen synthesis begins.

In a small wound, epithelialisation will have completed after about a week or two, but the cellular events continue to unfold. The PMN cell count drops off and fibroblasts are the predominant active cell in the wound. Collagen synthesis starts in earnest, and wound contraction starts to occur.

After about a month, active vasodilation is still going on, mononucleocytes are the predominant wound cell, epithelialisation is complete, collagen synthesis is starting to peter off, wound contraction is still occurring and collagen remodelling is in full swing. Vasodilation persists for quite some time and collagen remodelling becomes the main feature of the wound underneath the healed epithelium. There are numerous growth factors that influence the process as well as other factors that are less well understood. For example, epithelium releases [EDFTGF alpha AFGF, beta FGF EGF] smooth muscle releases [PDGF and MDGF], whereas fibroblasts release [PDGF alpha FGFa FGFb FGF EGF TGF alpha MDGF IGF IL1 and IL2].

An analogy of the process is rather like a building construction site. Over the first three months, the raw materials for the building are dumped on the building site, and then over the next two years, the raw materials are rearranged in a neat, orderly fashion.

Positive factors in wound healing include the right level of moisture at a cellular level, and good oxygenation of the tissues, the correct balance of steroids, vitamins, in particular A, E and C, the correct balance of minerals, in particular zinc, magnesium and others, and the right balance of growth factors. The things that mitigate against wound healing are physical shearing stress, haematoma formation (blood is particularly toxic to tissues once it has broken down), infection, particularly those caused by staph, strep and pseudomonas, and other factors such as dehydration, nutritional diseases, such as diabetes, nutrition imbalances, other disease processes and external factors such as chemotherapy and radiotherapy.

Surgical technique has a bearing on scar quality, and in particular suture placement should be done in such a way as to prevent inversion of wound edges, to allow approximation of epidermis and dermal elements in the wound edges, so there is not a step between the two, and appropriate dressings should be placed on raw wound beds to minimize scarring. For a neat suture line, simply a support dressing, such as Steri-Strips or Mefix is adequate and this is able to be wet post-operatively. In some instances, if the suturing is strong enough, no dressing at all is required, and the wound can be washed and simply covered with a bland Vaseline-type ointment. If the area is at risk of becoming infected, then Bactroban ointment is appropriate to use for a few days.

For superficial wounds, the current dressings available are categorised into several groups:

• Hydrocolloids are those dressings which contain material which absorbs the growth factors and the various nutrients released in the serous exudate that comes out of the wound, and the dressing is designed to hold the growth factors etc, on the wound surface. These dressings tend to be good to promote auto-debridement of the wound, but sometimes precipitate hypergranulation and are not so good for encouraging epithelialization of the wound.
• Calcium alginate dressings are designed to create a layer of calcium alginate over the wound. These dressings tend to be good to encourage epithelialization, but are not good at cleaning up sloughy wounds. Various brand substitutes are available. In the hydrocolloids, Duoderm Extra Thin, Duoderm CGF, Comfeel Transparent, Comfeel Ulcer Dressing, Comfeel Plus, are all adhesive occlusive dressings. They have the disadvantage of sticking quite firmly to the wound, and producing an offensive, seeping malodorous paste over the wound, and as mentioned above, tend to result in hypergranulation of the tissues.
• Aquacel is a hydrocolloid, but comes in a cloth form. This tends to not work if it is kept dry, sticks to the wound and is relatively ineffective. If it is wet, it has a much more beneficial effect on the wound, however, technically it is difficult to use as it slides around on the wound, and has to be secured with a Tegederm or some other occlusive dressing, and holding it in the correct position is quite difficult.
• Calcium alginate dressings such as Caltostat or Algostat are appropriate for some wounds, but they have a propensity to dry out and become adherent to the healing epithelium and if they are forcibly removed, they may produce irreparable damage to the fresh tissue and donor sites may end up not healing for a period of months as a result of this trauma.
• Polymem dressings are the best of both worlds. They are an absorbent sponge that has hydrocolloid embedded in it, along with an actant but not only do they encourage autolysis and auto-debridement of slight sloughy wounds, they also encourage epithelialisation and they do not produce the malodorous soup paste over the wound. In addition they are easy to secure, and in keeping with very fragile skin, they can be held in place with a Tubigrip or a crepe bandage, and do not even need to be secured with tape, which may cause further skin damage. Sometimes sloughy wounds will need some sort of antimicrobial therapy.
• There are various dressings that contain silver, such as Alginate or Polymem Silver Dressings or Aquacel AG. These tend to be useful for wounds that are heavily colonised, but have limited value for seriously sloughy infected wounds. SSD cream (silver sulfadiazine) is traditionally used on burns. This however is very messy and technically difficult to apply and hold in place, and I think with time will be replaced by Polymem Silver Dressings, which are by far superior and much easier to use.
• Steroid and antibiotic mixture creams such as Kenacomb are excellent to use on hypergranulating wounds, and I find are superior to treatment with silver cautery, however, they should not be used for longer than two or three weeks, as they cause the wound to regress.
• Bactroban ointment is also very useful for infected wounds, but again should not be used for longer than 10 days.

Once the wound is healed, then scar management plays a role in speeding up the maturation of the scar process. Silicone gel pads, iontophoresis using dexamethasone and steroid injections are all ways of treating scars, and all have their place. For a routine wound, scar management for a period of two to three months is adequate, but for people at risk of hypertrophic scars, their wounds should be treated for approximately six months. True keloid scars develop up to a year after injury, and should therefore be kept under strict surveillance for a long period of time, and management of these scars should be aggressive and early to avoid irreparable and irreversible scar damage. For serious problem scars that look to be early hypertrophic, an injection of Kenacort A-10 is adequate. If they appear to be not responding to this or are suspected to be keloid, then Kenacort A-40 intralesionally is a better choice of agent.

Keloid scars and hypertrophic scars are not an extension of one another. They are histologically different and they are clinically different, and often the term keloid is used inappropriately and erroneously. A true keloid scar spreads beyond the zone of injury, usually takes about a year after the injury before it starts to develop, continues to grow for a period of time and does not resolve. Hypertrophic scars are an exaggerated normal scarring response. They peak at about three to six months, and then resolve slightly with time. Usually hypertrophic scars are precipitated by something, such as a poor wound-healing environment, e.g. infection or contamination of the wound. Keloid scars on the other hand, tend to be more genetically driven, and the wound healing factors may not have been anything out of the ordinary to produce bad scarring.