Resurfacing in Facial Burn Sequelae Using Parascapular Free Flap: A Long-Term Experience

Background It is difficult to treat large post burn sequelae (scars and defects) over face. Available methods include skin grafts, local flaps, tissue expansion, and free flaps. These surgical options should be chosen wisely, depending upon individual patient requirements and area involved. In patients with large post burn scars and defects in which the surrounding tissue is also involved, use of free tissue transfer is extremely useful. Patients and Methods A retrospective analysis was done between 2011 and 2019 of fifty-two cases with extensive facial burn deformities in whom secondary reconstruction was done with free parascapular flap cover in or department. Outcome was assessed by direct questionnaire. Results There was no complete flap loss in the series. Two cases were re-explored for venous insufficiency and suffered partial marginal necrosis. Twenty patients had to undergo further debulking procedure. Forty-seven patients were satisfied by the final outcome. Conclusion Post burn facial deformities are difficult to treat, in many cases there are no local options and tissue from different regions is to be used for reconstruction. Free parascapular flaps can be used as an effective method in such cases with a high level of patient satisfaction.

Aggressive malignant phyllodes tumor of breast with omental metastases – A case report

Distant metastasis from malignant Phyllodes tumour (PT) is rare. They generally metastasize to the lung, bone, pleura, and liver. We present a very rare case of a 25-year-old woman with intraabdominal metastases from malignant phyllodes tumour of the breast. She presented with left breast lump and the biopsy was Phyllodes tumour. She underwent a two staged surgery; left modified radical mastectomy followed by left latissimus dorsi musculocutaneous flap cover. She received adjuvant radiation therapy to left chest wall. Following which she developed intrabdominal mass which was proven to be metastasis from Phyllodes tumour. She was then advised palliative chemotherapy. Malignant Phyllodes with distant metastases has a dismal prognosis. We propose it is preferable to have a CT Thorax and Abdomen as a staging workup for patients with malignant PT to identify those with poor prognosis.

Customized vacuum assisted closure therapy of wounds as a simple and cost-effective technique of wound closure-a prospective observational study from underdeveloped world

Background: Aim of the study was to study the efficacy and cost-effectiveness of indigenously designed customized vacuum assisted closure (VAC) of wounds in our patients. The management of difficult to heal wounds has been the main force that led to the development of advanced gadgets for their management. The technique of vacuum assisted closure has revolutionized the management of difficult to heal wounds and delivers better results as compared to conventional technique. Our aim was to assess the efficacy and cost effectiveness of customized VAC therapy.Methods: This prospective study was conducted in the department of surgery and allied specialties, GMC Srinagar, from June 2018 and September 2020. During this period, 80 patients were subjected to VAC therapy and were included in this study.Results: VAC dressing was used in 80 patients. 55 were males and 25 were females. Most of the wounds in our study were located over lower limbs (70%). RTA was the most common mode of injury followed by fall from height. After the VAC therapy, 78.8% patients were managed by STSG, 11.3% by flap cover, 6.3% by secondary suturing and 3.8% healed by secondary intention. Pain was experienced by 30% of the patients, 7.5% had hypoalbuminemia, 3.8% had surrounding skin maceration. The average total cost of the VAC therapy was 863.13 (±399.82) Indian rupees (11.76 USD). The mean duration of hospital stay for our patients was 22 days.Conclusions: Customized VAC Therapy has revolutionary potential in the management of the difficult to treat wounds as far as its safety, speed and cost effectiveness is considered especially in a setup of poor income nations like ours.

A STUDY ON DIFFERENT SURGICAL OPTIONS OF LOWER THIRD LEG DEFECTS AND ITS OUTCOME

Background: The bones of the lower third are vulnerable to injury. Due to the paucity of soft tissues around them, the fractures that occur are often open. Most muscles become tendons at that level and in the case of soft tissue loss, skin graft may not sufce and flap cover becomes mandatory. Conventional teaching recommends gastrocnemius muscle and myocutaneous aps and fasciocutaneous aps for the upper third leg defects, soleus aps for the middle third defects and free aps for the lower third defects. Aim: Different surgical options in management of lower third leg defects. Material And Method: The study was conducted from JANUARY 2018 to December 2019, in the Department of Plastic & Reconstructive Surgery Institute of Post Graduate Medical Education and Research (IPGME&R) and SSKM Hospital, KOLKATA. Result: 70 patients admitted to the Department of Plastic & Reconstructive Surgery and referred patients from Department of General Surgery & Orthopaedic Surgery, IPGME&R and SSKM Hospital, KOLKATA. Association of FLAP LOSS with Pedicled ap was statistically signicant (p=0.0259). We found that association of DONOR SITE MORBIDITYwith Pedicled ap was not statistically signicant (p=0.7679). Conclusion: We consider that perforator propeller aps are ideal in reconstructing small-medium defects of the middle and distal third of the leg, being safe, easy to perform, providing similar tissue in texture and thickness of damaged tissues, with low donor-site morbidity.

SQUAMOUS CELL CARCINOMA OF THE TEMPORAL REGION MANAGED WITH WIDE LOCAL EXCISION AND FREE LATERAL THIGH FLAP COVER

Squamous cell carcinoma is the second most common form of cutaneous malignancy and is usually due to exposure of ultraviolet radiation (UV-B), inammation (from trauma or burns), chemical exposure and immunosuppression. Squamous cell carcinoma is a malignant proliferation of the epidermal keratinocyte. It is most common in elderly Caucasian population. Lesions occur most commonly on the face, neck, ears, hands and arms but metastases are rare. Here, we present a case of an elderly gentleman who came with an ulceroproliferative lesion of the left temporal scalp for 6 months. Biopsy proved to be a well differentiated squamous cell carcinoma. Wide local excision was done and the defect was closed using a free thin lateral thigh ap.

Reconstruction of pressure ulcers with flaps in a tertiary care centre

Background: Patients with pressure ulcers have multiple risk factors and develop various post- operative complications. The purpose of the study is to analyse the outcome of management of pressure ulcers with different flaps.Methods: This is a retrospective study done in a series of patients who underwent flap reconstruction of pressure ulcers between 2016 and 2019 in the Department of Plastic and Reconstructive Surgery, Thanjavur medical college, Tamilnadu, India. Totally twenty-eight patients were operated for stage III and stage IV pressure ulcers with various types of flaps depending upon the site of pressure ulcers. Post operatively flaps were monitored for viability and post-operative complications. Results: Total 22 males, 5 females and 1 male child had undergone surgery for pressure ulcers. The age group ranged from 3years to 62 years with an average of 37 years. The sites of the pressure ulcers were as follows: 14 (50%) sacral; 10 (35.7%) ischial; 3 (10.7%) trochanteric and 1 (3.6%) multiple pressure ulcers. Most of the patients (60.7%) had traumatic paraplegia and developed pressure ulcers. 18 patients with stage III and 10 patients with stage IV pressure sores were operated with different flaps. Duration of treatment ranged from 29 to 118 days. The mean hospitalization was 78 days. Conclusions: Effort is needed to prevent the development of pressure ulcers through the early identification of risk and early implementation of preventive measures. Flap cover is ideal to prevent recurrence. Post-operative follow- up with physiotherapy and rehabilitation are very important.

Optimising Hand Surgery during COVID-19 Pandemic

Background: With the emergence of the COVID-19 pandemic, most health-care personnel and resources are redirected to prioritize care for seriously-ill COVID patients. This situation may poorly impact our capacity to care for critically injured patients. We need to devise a strategy to provide rational and essential care to hand trauma victims whilst the access to theatres and anaesthetic support is limited. Our center is a level 1 trauma center, where the pandemic preparedness required reorganization of the trauma services. We aim to summarise the clinical profile and management of these patients and highlight, how we modified our practice to optimize their care. Methods: This is a single-centre retrospective observational study of all patients with hand injuries visiting the Department of Plastic Surgery from 22nd March to 31st May 2020. Patient characteristics, management details, and outcomes were analysed. Results: A total of 102 hand injuries were encountered. Five patients were COVID-19 positive. The mean age was 28.9 ± 14.8 years and eighty-two (80.4%) were males. Thirty-one injuries involved fractures/dislocations, of which 23 (74.2%) were managed non-operatively. Seventy-five (73.5%) patients underwent wound wash or procedure under local anaesthetic and were discharged as soon as they were comfortable. Seventeen cases performed under brachial-plexus block, were discharged within 24 hours except four cases of finger replantation/ revascularisation and one flap cover which were discharged after monitoring for four days. At mean follow-up of 54.4 ± 21.8 days, the rates of early complication and loss to follow-up were 6.9% and 12.7% respectively. Conclusions: Essential trauma care needs to continue keeping in mind, rational use of resources while ensuring safety of the patients and health-care professionals. We need to be flexible and dynamic in our approach, by utilising teleconsultation, non-operative management, and regional anaesthesia wherever feasible.