Extended islanded reverse sural artery flap for staged reconstruction of foot defects proximal to toes

Objective: To assess the outcome of extended delayed reverse sural artery flap for reconstruction of foot defects proximal to toes in terms of flap survival, complication and extended area

Study Design: Case series

Place and Duration of Study: Jinnah Burn and Reconstructive Surgery Centre, Lahore, from February 2015 to April 2017

Methodology: Cases who underwent delayed sural artery flap were inducted. Preoperative hand-held doppler was done to confirm the location of perforator. Two suitable perforators were chosen to raise the extended flap by crossing the proximal limit in all cases. The pedicle was kept minimum 3 cm wide and perfusion was assessed. Flap was delayed for one week and vaccum-assisted closure [VAC] dressing was applied over wound. The second surgery was performed after one week. Proximal perforator was clamped and ligated after checking adequate perfusion of flap. Flap was insetted into defect

Results: Thirty-two patients were reconstructed with delayed reverse sural artery flap. The mean age of the patients was 26.5 +12.2 years. Twenty-four [75%] patients were males and 8 [25%] were females. Twenty-two [68.7%] cases were degloving wounds after road traffic accidents [RTA], 6 [18.7%] were diabetic foot wounds, 4 [12.5%] sustained injury after falling from height and 7 [21.8%] patients had fracture of metatarsals. Twenty-eight flaps were transferred after one week delay, and only in 4 cases, flap were transferred after two weeks. All flaps survived completely. Complications of infection noted in 3 [9.3%] flaps, 3 [9.3%] flaps showed tip necrosis, 2 [6.2%] flaps undergone epidermolysis and only 2 [6.2%] showed venous congestion

Conclusion: Delayed islanded reverse sural artery perforator flap is a reliable and versatile option for resurfacing soft tissue defects of lower limb proximal to the toes with lesser complications and extended coverage area

Distally based medial hemisoleus flap: reliable option for distal tibial wounds

Objective: To determine the success [flap survival as a whole without necrosis or dehiscence up to two months as judged clinically] of distally based medial hemisoleus muscle flap for the coverage of distal tibial defects

Study Design: Case series

Place and Duration of Study: Jinnah Burn and Reconstructive Surgery Centre, AIMC, Lahore, from July 2014 to July 2017

Methodology: Patients with middle and distal third tibial defects were enrolled and stratified according to the site of the wound in middle or distal third of tibia. Soft tissue coverage was provided with distally based medial hemisoleus muscle flap on which split thickness skin graft was applied. Postoperatively, patients were followed-up after one week of discharge and then fortnightly for at least 2 months. Outcome variable was taken as flap success

Results: Out of 37 cases, flap was successful in 33 patients as complete flap survived with primary wound healing. Partial flap necrosis without dehiscence was seen in 3 cases and partial necrosis of flap with dehiscence in only one case that required another surgery for the defect. Complete flap loss was not seen in any case

Conclusion: Distally based medial hemisoleus muscle flap is reliable coverage option for middle and distal third of tibial defects

Hemisoleus muscle flap, a better option for coverage of open fractures involving middle third of tibia

Local reconstructive options for middle third of leg make good use of Soleus muscle flap. Soleus being the prime ankle planter flexor and stabiliser of the ankle in ambulation cannot be sacrificed without significant morbidity. Soleus is a bipennate muscle with independent blood supply of each half. Using one half retains its important function, increases arc of rotation, and makes it easy to orientate for coverage of defect of any shape thus obviating the need for use of whole Soleus muscle flap. Due to this geometrical advantage, it is a superior option than the whole Soleus. We conducted a study to evaluate the reliability of the medial hemisoleus muscle flap for coverage of middle third tibial defects. This descriptive study was conducted at department of plastic surgery, Jinnah Hospital, Lahore from August 2008 to May 2009. Ten patients with middle third tibial defects were included in the study. All the patients were provided soft tissue coverage with proximally based medial hemisoleus muscle flap with split thickness skin graft on it. All the flaps survived with primary healing of the wound except one patient who developed wound infection which settled after wound drainage and irrigation. Hemisoleus muscle flap is a valuable local option for soft tissue coverage of middle third of lower leg. It does not sacrifice the whole function of the Soleus muscle. Due to its longer arc of rotation, this flap can cover the defects of different size and shape in middle third of leg

Scalp as a donor site for split thickness skin grafts

Use of scalp as a donor site was reported for the first time in 1964. Since then, authors have described scalp as a donor site, which heals rapidly and re-growth of hair conceals the donor site. This study was aimed at evaluation of scalp as donor site by calculating the healing time, and frequency of post-operative complications. This was a descriptive study and was conducted at Plastic Surgery Department Jinnah Hospital, Lahore, from October, 2006 to December 2007. Thirty patients requiring split skin grafting for small to moderate sized defects [requiring up to 4 sheets] were included in this study. After taking informed consent skin graft were taken from the scalp using Zimmer Electric Dermatome. Donor site was covered with occlusive dressing. Donor site healing time and complications were recorded. Patients having scalp lesions were excluded from the study. All the patients in this study achieved healing of the donor site. None of them required grafting. 26 [86.67%] patients achieved healing by 6th post-op day.3 [10.0%] patients achieved healing by 10th postop day and the remaining 1 [3.33%] patients achieved healing by 20 days. Complications noted were folliculitis in 2 patients and scab formation in 1 patient. Alopecia, hair transplant to recipient site and hypertrophic scarring was not encountered in our study. Patients were discharged by 6th post operative day and complications were managed on outpatient basis. Overall patients' compliance and satisfaction was excellent. scalp is an excellent donor site for taking split skin graft. It has shown to be very useful in terms of quick healing, convenient post-op care and negligible complications. It should be given preference when donor site for taking skin graft is to be selected

Practicality of modified Alvarado score in the diagnosis of acute appendicitis

To evaluate the practicality of Modified Alvarado Scoring System [MASS] in the diagnosis of acute appendicitis in our set up. Prospective, quasi-experimental study from July 2005 to December 2005. Surgical Unit II, Rawalpindi General Hospital, Rawalpindi. All patients, aged 15 years or above, who were operated for Acute Appendicitis during the study period. All patients were evaluated using the Modified Alvarado Score [MAS] once decision of surgery has been made by a consultant surgeon. The MAS was correlated with the operative and histopathological findings. Out of the total 82 patients, 49 were male [60%] and 33 female [40%]. Their age range was from 15 to 60 years with peak incidence in the 2nd and 3rd decade of life. The overall sensitivity of MAS was 89%. There were 4% negative appendicectomies with MAS between 6-9, 12% with MAS between 4-5 and 50% where MAS was < 4. MASS cannot be fully relied upon to make the decision to operate in acute appendicitis, and that the decision remains clinical