Successful ankle replantation in two cases with different presentations

We report our experience of treating two patients with ankle amputation with different presentations. The first case was a clean-cut sharp amputation. The second case was an avulsion injury following a motor vehicle accident in a patient who arrived 8 hours after the injury. Replantation was successful in both cases. In avulsion injuries, a secondary operation for wound coverage is required at a later stage. With good strategy and a support team, encouraging limb survival outcomes are possible post-replantation.

Early outcomes of cleft and palatal width following anterior palate repair (vomerine flap) in infants with wide cleft lip and palate

BACKGROUND@#Anterior palatal repair performed during cleft lip repair using a vomerine flap may assist in recruiting additional soft tissue for subsequent completion of palatoplasty, especially in patients with a wide cleft. We present our early results in the hope of triggering a re-evaluation of this technique regarding its advantages for maxillary growth through further studies of patients with a wide cleft.@*METHODS@#A retrospective analysis of patients with complete unilateral and bilateral cleft lip and palate was performed, including cleft and palatal measurements taken during initial surgery (lip repair together with anterior palate repair) and upon completion of palatoplasty.@*RESULTS@#In total, 14 patients were included in this study, of whom nine (63.3%) had unilateral cleft lip and palate and five (37.5%) had bilateral cleft. All patients had a wide cleft palate. Lip and anterior palate repair was done at a median age of 3 months, while completion of palatoplasty was done at a median age of 10.5 months. Measurements taken upon completion of palatoplasty showed significant cleft width reduction in the mid-palate and intertubercle regions; however, the palatal arch distances at nearby landmarks showed non-significant marginal changes.@*CONCLUSIONS@#Anterior palate repair using a vomerine flap significantly reduced the remaining cleft width, while the palatal width remained. Further research is warranted to explore the long-term effects of this technique in wide cleft patients in terms of facial growth.

A 20-year experience of immediate mandibular reconstruction using free fibula osteocutaneous flaps following ameloblastoma resection: Radical resection, outcomes, and recurrence

BACKGROUND: The mandible is an important structure that is located in the lower third of the face. Large mandibular defects after tumor resection cause loss of its function. This study assessed the outcomes and tumor recurrence after immediate mandibular reconstruction using a free fibula osteocutaneous flap following radical resection of ameloblastoma. METHODS: This is a retrospective non-randomized study of outcomes and tumor recurrence of all patients diagnosed with mandibular ameloblastoma from August 1997 until August 2017 (20 years) requiring free fibula osteocutaneous flap reconstruction at a single institution. The patients were identified through an electronic operative database; subsequently, their medical records and photo documentation were retrieved. RESULTS: Twenty-seven patients were included in this study. Eighteen patients were male, while nine were female. The majority of the patients (48.1%) were in their third decade of life when they were diagnosed with ameloblastoma. All of them underwent radical resection of the tumor with a surgical margin of 2 cm (hemimandibulectomy in cases with a large tumor) and immediate mandibular reconstruction with a free fibula osteocutaneous flap. Two patients required revision of a vascular anastomosis due to venous thrombosis postoperatively, while one patient developed a flap recipient site infection. The flap success rate was 100%. There was no tumor recurrence during a mean follow-up period of 5.6 years. CONCLUSIONS: Mandibular ameloblastoma should be treated with segmental mandibulectomy (with a surgical margin of 2 cm) to reduce the risk of recurrence. Subsequent mandibular and adjacent soft tissue defects should be reconstructed immediately with a free fibula osteocutaneous flap.

The use of facial artery musculomucosal (FAMM) readvancement flap in closure of recurrent oronasal fistula

High failure rate for recurrent palatal fistulas closure pose agreat challenge to plastic surgeons. Tongue and facial arterymusculomucosal (FAMM) flaps are the more commonly usedflaps for closure of these recurrent fistulas. We report a caseof a formerly inset FAMM flap to effectively close apreviously repaired oronasal fistula.

Alopecia secondary to repaired occipital encephalocele - role of tissue expander in hair restoration

evere social and psychological problems. Tissueexpansion, although an old concept, provides a surgicalalternative to manage areas of alopecia. We describe a caseof alopecia secondary to repaired occipital encephalocelethat was successfully treated using tissue expansiontechnique.

Proliferation of Keratinocytes Induced by Adipose-Derived Stem Cells on a Chitosan Scaffold and Its Role in Wound Healing, a Review

In the field of tissue engineering and reconstruction, the development of efficient biomaterial is in high demand to achieve uncomplicated wound healing. Chronic wounds and excessive scarring are the major complications of tissue repair and, as this inadequate healing continues to increase, novel therapies and treatments for dysfunctional skin repair and reconstruction are important. This paper reviews the various aspects of the complications related to wound healing and focuses on chitosan because of its unique function in accelerating wound healing. The proliferation of keratinocytes is essential for wound closure, and adipose-derived stem cells play a significant role in wound healing. Thus, chitosan in combination with keratinocytes and adipose-derived stem cells may act as a vehicle for delivering cells, which would increase the proliferation of keratinocytes and help complete recovery from injuries.

Effects of Ischemic Preconditioning of Different Intraoperative Ischemic Times of Vascularized Bone Graft Rabbit Models

BACKGROUND: Ischemic preconditioning has been shown to improve the outcomes of hypoxic tolerance of the heart, brain, lung, liver, jejunum, skin, and muscle tissues. However, to date, no report of ischemic preconditioning on vascularized bone grafts has been published. METHODS: Sixteen rabbits were divided into four groups with ischemic times of 2, 6, 14, and 18 hours. Half of the rabbits in each group underwent ischemic preconditioning. The osteomyocutaneous flaps consisted of the tibia bone, from which the overlying muscle and skin were raised. The technique of ischemic preconditioning involved applying a vascular clamp to the pedicle for 3 cycles of 10 minutes each. The rabbits then underwent serial plain radiography and computed tomography imaging on the first, second, fourth, and sixth postoperative weeks. Following this, all of the rabbits were sacrificed and histological examinations were performed. RESULTS: The results showed that for clinical analysis of the skin flaps and bone grafts, the preconditioned groups showed better survivability. In the plain radiographs, except for two non-preconditioned rabbits with intraoperative ischemic times of 6 hours, all began to show early callus formation at the fourth week. The computed tomography findings showed more callus formation in the preconditioned groups for all of the ischemic times except for the 18-hour group. The histological findings correlated with the radiological findings. There was no statistical significance in the difference between the two groups. CONCLUSIONS: In conclusion, ischemic preconditioning improved the survivability of skin flaps and increased callus formation during the healing process of vascularized bone grafts.

Outcomes of infected grade IIIB open tibial fractures

<p><b>INTRODUCTION</b>Infection following grade IIIB open tibial fracture is common. The primary aim of managing this condition is to achieve control of infection before the bone reconstruction procedure is performed. The outcomes for such patients have not been evaluated in the literature. This study was conducted to examine the outcome of a multi-stage procedure for the treatment of infected grade IIIB open tibial fractures.</p><p><b>METHODS</b>Between 2004 and 2008, we treated 11 patients with infected grade IIIB open tibial fractures in our unit. The management of infected grade IIIB open tibial fracture comprised three stages, which included serial debridement, wound closure by local flap surgery and bone reconstruction. The margin of resection and the type of bone reconstruction depended on the anatomical location of the disease, the extent of osteomyelitis and patient preference regarding treatment options. Bone reconstruction procedures included bone grafting, plating, interlocking nail, hybrid and monolateral external fixator, and Ilizarov bone transport.</p><p><b>RESULTS</b>Gram-negative organisms were isolated from all patients. Pseudomonas aeruginosa (P. aeruginosa) (44%) was the most common organism cultured. Infection was resolved in all patients. Nine fractures achieved union, with a mean union time of 15 months. Two patients with P. aeruginosa infection developed non-union of the fracture and refused additional surgery after three years of treatment.</p><p><b>CONCLUSION</b>The multi-stage management approach is well-accepted and effective in controlling infection in infected grade IIIB open tibial fractures.</p>

Keloid Scarring: Understanding the Genetic Basis, Advances, and Prospects

Keloid disease is a fibroproliferative dermal tumor with an unknown etiology that occurs after a skin injury in genetically susceptible individuals. Increased familial aggregation, a higher prevalence in certain races, parallelism in identical twins, and alteration in gene expression all favor a remarkable genetic contribution to keloid pathology. It seems that the environment triggers the disease in genetically susceptible individuals. Several genes have been implicated in the etiology of keloid disease, but no single gene mutation has thus far been found to be responsible. Therefore, a combination of methods such as association, gene-gene interaction, epigenetics, linkage, gene expression, and protein analysis should be applied to determine keloid etiology.

Role of free tissue transfer following extirpation of advanced head and neck tumours

Extirpation of highly invasive and recurrent tumours of the head and neck in order to achieve possible cure and an improved palliation present a major challenge to the reconstructive surgeons. Free tissue transfer following advanced tumour ablation has the advantages of immediate restoration of function and aesthesis in order to improve quality of life in these patients with limited survival periods. This study was conducted at Hospital University Sains Malaysia from 1998 to 2003. Retrospective study. Seventeen patients with head and neck tumours who underwent immediate reconstruction following tumour extirpation during 5yrs were reviewed. The soft tissue defects ranged from 30 cm[2] to 240 cm[2] while the length of the mandibular defects ranged from 3.5 cm to 15 cm. The free tissue transfer used were nine free fibula osteoseptocutaneous flaps, seven free radial forearm flaps and one composite free scapular osteocutaneous flap combined with latissimus dorsi musculocutaneous flap. Our experience concludes that free tissue transfer offers an important option for closure of composite defects following ablative surgery. They provide improved palliation and good quality of life. Hence their challenges in reconstructive surgery and outcomes are discussed

Composite anterior mandibular defect reconstruction

Single technique of tissue transfer alone may not be sufficient to restore a huge composite defect in the anterior mandibular segment. Combination of a second flap of either regional or free flap is often considered complimentary in the reconstruction of a complex wound in this region. We described an innovative way by combining pedicled submental island flap and a double barrel free fibula osteoseptocutaneous flaps to reconstruct soft tissue and mandible of the mental region. This technique can be considered as a valuable adjunct in the reconstructive armamentarium to provide satisfactory contour, colour and texture match without significant donor site morbidity