Background: Multiple techniques exist to monitor free flap viability postoperatively, varying with practical and personal preference, yet the limitations of each technique remain unquantified. This systematic review aims to identify the most commonly reported limitations of these techniques in clinical practice. Methods: A systematic review was conducted according to PRISMA guidelines using MEDLINE, EMBASE, and Web of Science with search criteria for postoperative free flap monitoring techniques. Search results were independently screened using defined criteria by two authors and a senior clinician. Limitations of the techniques found in the discussion section of eligible articles were recorded and categorized using thematic analysis. Results: A total of 4699 records were identified. In total, 2210 articles met the eligibility criteria and were subsequently reviewed, with 195 papers included in the final analysis. The most frequently reported limitations of clinical monitoring were interpretation requiring expertise (25% of related papers), unsuitability for buried flaps (21%), and lack of quantitative/objective values (19%). For noninvasive technologies, the limitations were lack of quantitative/objective values (21%), cost (16%), and interpretation requiring expertise (13%). For invasive technologies, the limitations were application requiring expertise (25%), equipment design and malfunction (13%), and cost (13%). Conclusions: This is the first systematic review to quantify the limitations of different flap monitoring techniques, as reported in the literature. This information may enhance the choice in monitoring strategy for a reconstructive service, and inform the development and refinement of new flap monitoring technologies.

Global health is one of the most pressing issues facing the 21st century. Surgery is a resource and energyintensive healthcare activity which produces overwhelming quantities of waste. Using the 5Rs (Reduce, Reuse, Recycle, Rethink, and Research) provides the global surgical community with the pillars of sustainability to develop strategies that are scalable and transferable in both low and middle-income countries and their high-income counterparts.Reducing energy consumption is necessary to achieving net zero emissions in the provision of essential healthcare. Simple, easily transferrable, high-income country (HIC) technologies can greatly reduce energy demands in low-income countries. Reusing appropriately sterilized equipment and reprocessing surgical devices leads to a reduction of costs and a significant reduction of unnecessary potentially hazardous waste. Recycling through official government-facilitated means reduces 'informal recycling' schemes, and the spread of communicable diseases whilst expectantly reducing the release of carcinogens and atmospheric greenhouse gases. Rethinking local surgical innovation and providing an ecosystem that is both ethical and sustainable, is not only beneficial from a medical perspective but allows local financial investment and feeds back into local economies. Finally, research output from low-income countries is minimal compared to the global academic output. Research from low and middle-income countries must equal research from highincome countries, thereby producing fruitful partnerships. With adequate international collaboration and awareness of the lack of necessary surgical interventions in low and middle-income countries (LMICs), global surgery has the potential to reduce the impact of surgical practice on the environment, without compromising patient safety or quality of care.

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Background Epistaxis can be life-threatening. Simple first aid management can stem bleeding. This study compared knowledge of first aid management methods of epistaxis between the general public and healthcare workers. Method A cross-sectional study of 100 healthcare workers and 103 adult members of the public was conducted at a large London teaching hospital. Respondents completed a survey assessing knowledge on nasal pinching site, head tilt and appropriate adjunct treatment use for first aid management of epistaxis. Results Twenty-four per cent and 68 per cent of healthcare workers compared with 25.2 per cent and 37.9 per cent of the public answered correctly on nasal pinching position and head tilt position, respectively, with a statistical difference for head tilt position. Two per cent, 2 per cent and 24 per cent of healthcare workers mentioned ice use on the nose, ice use in the mouth or ice use but not site, respectively, compared with 0 per cent, 0 per cent and 4.9 per cent of the public, with a statistical difference for ice without site. Conclusion Healthcare workers and the public lack knowledge on first aid management of epistaxis. Improved education on first aid management is required, targeting healthcare workers and the public.