Non-islanded distally based sural artery flap: a reliable solution for an unreliable flap

Objective: to assess the reliability of non-islanded distally based sural artery flap, in terms of number of flap failure [partial and major flap necrosis], number of surgeries related to the problem for which flap surgery was performed, hospital stay and return to work, for coverage of soft tissue defects of the distal one-third of leg, ankle and heel

Study Design: cohort study

Place and Duration of Study: department of Plastic Surgery and Burn Unit, Mayo Hospital, KEMU, Lahore, Pakistan, from January 2003 to March 2014

Methodology: distally based sural artery flaps in 87 patients requiring coverage of distal lower lumb were studied, retrospectively. They were divided into two groups. G1 included 46 cases in which distally based sural artery flap was islanded. G2 included 41 cases in which flap was not islanded and pedicle was raised. The variables that were measured in two groups included age, gender, size and cause of defect, co-morbidities, number of surgeries, total hospital stay, return to work and flap related complications. Independent sample t-test and tests of proportions were used for comparison with significance at p < 0.05

Results: the mean age of patients was 38.4 +/- 16.2 years in G1 and 35.1 +/- 18.6 years in G2. In G1, 34 cases were traumatic, 5 caused by diabetic ulcers and another 7 cases were trophic ulcers in paraplegic patients caused by pressure sores. In G2, the cause was trauma in 32 cases, diabetic ulcers in 7 cases, trophic ulcers in 2 cases. The mean number of surgeries in G1 was 3 +/- 1 and 2 +/- 1 in G2 [p < 0.001]. The mean hospital stay in G1 was 43.1 +/- 3.6 days while 27.9 +/- 2.1days in G2 [p < 0.001]. There was epidermolysis in 21 out of 46 islanded distally based sural artery flaps [G1] and in 9 out of 41 non-islanded flaps [G2] [p=0.0203]. Partial necrosis occurred in 12 of flaps in G1 and in only 3 of G2 flaps [p=0.024]

Conclusion: distally based sural artery flap can be made more reliable and with lesser complications by raising the pedicle with skin rather than islanding the flap

Flexor zone 5 cut injuries: emergency management and outcome

To determine the outcome and devise a protocol for emergency management of cut injuries in Flexor Zone 5 of hands. Descriptive study. Department of Plastic Surgery and Burn Unit, Mayo Hospital, KEMU, Lahore, Pakistan, from January 2009 to March 2013. All patients above 12 years of age with single sharp cut injuries in Flexor Zone 5, with no skeletal injuries, presenting within 12 hours in emergency were included with follow-up of 6 months, with active range of motion evaluated by Strickland's adjusted formula. Power of opponens pollicis and adductor muscles was evaluated from P0-4. Nerve repair results were evaluated serially by advancing Tinnel's sign, electrophysiological studies and sensory perception scored from S0-4 compared to the normal opposite upper limb. The study group comprised of 31 patients [M: F = 2.4: 1]. Average age was 27 years ranging from 17 - 53 years. In 25 [80%] cases, injury was accidental, in 3 [10%] homicidal and in 3 [10%] injury was suicidal. Four most commonly involved structures included Flexor carpi ulnaris, ulnar artery, ulnar nerve and Flexor digitorum superficialis. Median nerve and radial artery were involved in 10 cases each, while ulnar artery and ulnar nerve were involved in 14 cases each. Longtendons were involved in most cases with greater involvement of medial tendons. None of the patients required re-exploration for ischaemia of distal limb while doppler showed 22 out of 24 vascular anastomosis remained patent. Recovery of long-tendons was good and recovery after nerve repair was comparable in both median and ulnar nerves. Early and technically proper evaluation, exploration and repair of Zone 5 Flexor tendon injuries results in good functional and technical outcome

Comparison of postoperative pain relief by intercostal block between pre-rib harvest and post-rib harvest groups

To compare intercostal nerve block before and after rib harvest in terms of mean postoperative pain score and mean postoperative tramadol usage. Randomized controlled trial. Department of Plastic Surgery, Mayo Hospital, KEMU, Lahore, from January 2011 to July 2012. Patients [n = 120] of either gender with ASA class-I and II requiring autogenous costal cartilage graft were inducted. Patients having history of local anaesthetic hypersensitivity and age < 15 years or > 60 years were excluded. Subjects were randomly assigned to pre-rib harvest [group-1] and post-rib harvest [group-2]. Local anaesthetic mixture was prepared by adding 10 milliliters 2% lidocaine to 10 milliliters 0.5% bupivacaine to obtain a total 20 ml solution. Group-1 received local anaesthetic infiltration along the proposed incision lines and intercostals block before the rib harvest. Group-2 received the infiltration and block after rib harvest. Postoperative consumption of tramadol and pain scores were measured at 6 and 12 hours postoperatively using VAS. Mean age was 31.43 A +/- 10.78 years. The mean pain scores at 6 hours postoperatively were 1.033 A +/- 0.609 and 2.4667 A +/- 0.812 in pre-rib harvest and post-rib harvest groups respectively [p < 0.0001]. The mean pain scores at 12 hours postoperatively were 1.45 A +/- 0.565 and 3.65 A +/- 0.633 in pre-rib harvest and post-rib harvest groups respectively [p < 0.0001]. The mean tramadol used postoperatively in first 24 hours was 169 A +/- 29.24 mg and 255 A +/- 17.70 mg in prerib harvest and post-rib harvest groups respectively [p < 0.0001]. Intercostal block administered before rib harvest as preemptive strategy result in decreased postoperative pain scores and narcotic use

outcome of microvascular free flap surgery with or without the use of postoperative heparin

Objective: To determine the outcome of microvascular free tissue transfer with or without use of postoperative heparin in terms of flap viability and postoperative complications. Study Design: Quasi-experimental study. Place and Duration of Study: Department of Plastic Surgery, King Edward Medical University, Lahore, from July 2010 to July 2012

Methodology: Thirty eight patients requiring elective or emergency microvascular free tissue transfer were selected. Those with poly-trauma, previous failed free flap and re-anastomosis of vessels were excluded from the study. All anastomoses were performed by trained microvascular surgeons. Per operatively, Aucland test was performed to ensure anastomotic patency. Thereafter, patients were divided into two groups: in group A, heparin was not given postoperatively and in group B, heparin was given postoperatively. The flaps were monitored for signs of vascular compromise, viability or non-viability and complications of the procedure. Chi-square test was used to compare the distribution of qualitative variable in two groups. P-value less than 0.05 was considered significant

Results: In group A, the number of viable flaps was 13 [81%] and non-viable flaps were 3 [19%]. In group B the number of viable flaps was 11 [73%] and non-viable flaps were 04 [23%] [p = 0.68]. There was no significant difference regarding postoperative complications between the two groups [p > 0.05]

Conclusion: Postoperative heparin does not appear to have an influence on the viability or complications of free flaps

Xeroderma pigmentosum

To describe the features of Xeroderma pigmentosum observed in the stage 3 of the disease. Case series. Mayo Hospital Lahore, from December 2001 to September 2008. All patients diagnosed with Xeroderma pigmentosum stage 3 in the outpatient department of the study centre, were included. The age at first presentation, tumour sites, histology, recurrence rate, new tumour formation rate and the number of biopsies taken in a single session were recorded. The follow-up time was seven years. There were 25 patients including 15 males and 10 females. The mean age at initial presentation with the tumour was 20.4 years. The maximum number of biopsies taken from one patient during the same operation was 15 [mean=4]. Complete tumour clearance was achieved in 15 patients and 3 patients were inoperable. Altogether, 70% tumours were basal cell carcinomas [BCC]. The average interval for the development of a new tumour was 6 months. Twenty [80%] of the tumours were on the face, one was on the back and 3 on the forearms. Thirteen patients had ocular complications. Fifteen had a first degree relative afflicted. All wounds were closed primarily or with split grafts. There was a family history. The tumours were mostly BCCs. The rate of new tumour formation and recurrence was exceptionally high

Factors associated with postpiercing auricular cartilage keloids

To determine the factors responsible for postpiercing auricular cartilage keloids. Observational study. Department of Plastic Surgery, King Edward Medical University [KEMU], Lahore, from March 2007 to July 2010. Fifty patients of post-earpiercing keloids affecting the cartilaginous portion were included in the study. Patients with keloids at any other site, positive family history of keloids and recurrent keloids were excluded. Information regarding age at piercing, site of piercing, use of gun or home sewing needle for piercing, use of jewellery other than gold postpiercing, itching or redness with use of jewellery, tight fitting of jewellery in the piercing hole and postpiercing infection was collected. Fisher exact and Wilcoxon rank sum tests were used to analyse the data. All the patients had low lobule piercing at a mean age of 4.52 +/- 1.15 years and cartilage piercing at an average age of 22.32 +/- 3.74 years [p < 0.001]. Eleven patients [22%] had also simultaneous high piercing in the lobule. Only cartilage piercing sites developed the keloids. Postpiercing infection was present in all the 50 patients of cartilage piercing whereas only 3 out of 11 high lobule piercing sites got infected [p < 0.001]. Cartilage bearing portion of the ear is more likely to form keloids due to its piercing in or after adolescence and prolonged wound healing caused by infection

Comparison of traditional two injections dorsal digital block with volar block

To compare the traditional two injections dorsal digital block with volar block in terms of effectiveness of anaesthesia and pain of initial pinprick. Study Design: Quasi-experimental. Place and Duration of Study: AVH and casualty operation theatres, Mayo Hospital, KEMU, Lahore, from January to June 2007. Thirty patients requiring surgical procedure distal to proximal phalanx crease on two fingers of same or one finger of both hands were included. Cases with allergy to lignocaine, previous vascular insufficiency, previous digital replantation or peripheral neuropathy were excluded. One finger of every patient received two injection dorsal block whereas the other finger received single subcutaneous injection in the midline of the phalanx with lignocaine and epinephrine [volar block]. Patient looked away during the performance of block and wrote the severity of initial pinprick on a visual analogue scale. Effectiveness of anaesthesia was made measurable by the absence of pain during the surgical procedure. Total duration of the anaesthesia and any undesirable numbness of adjacent finger were noted. The t-test was used to compare the means and p-value less than 0.05 was considered significant. The mean pain scale score were 4.27+0.87 and 5.27+1.05 for volar and dorsal techniques respectively [p < 0.05]. Volar blocks were 100% effective whereas in dorsal blocks success rate was 80% [p < 0.05]. Single subcutaneous injection in the midline of phalanx with lignocaine and epinephrine [volar block] was significantly less painful to administer, is effective and safe technique to achieve digital anaesthesia, compared to the dorsal technique