Reconstruction- A Puzzle!!!

AIM:The reconstructive surgeon has to restore defect with best aesthetic and function. In recent times the high success rate of free flap has made the large defect reconstruction a possibility. The aim is to assess and evaluate the clinical outcomes in patients undergoing free flap and local flap reconstruction.METHODS:This was a retrospective study of 53 patients undergoing reconstructions with free flaps (31) and local flap (22) from June 2015 to June 2017. Types of free flap performed were Anterolateral Thigh, Radial Forearm and Fibula. Types of Local/pedicle flap performed were Pectoralis Major Myocutaneous flap, Deltopectoral flap, Nasolabial flap, forehead and scalp flap. Patient data was collected and analyzed for flap survival, complication, operative time, functional and oncological outcomes. RESULTS:The patients included 35 males and 17 females, with a mean age of 42 years. The most common tumor location was the Buccal mucosa. The majority of the diagnosed tumors were Squamous cell carcinoma. Overall flap success rate for free flap was 88% and for local flap/pedicle flap was 100%. Venous thrombosis was the most common cause for re-exploration in free flaps. The most common complication was oro-cutaneous fistula in both local/pedicle and free flaps. The average operating time for free flap was 7hr 30mins (simultaneously harvesting the graft) and for local flap was 5hr 50mins. The most important advantages with free flap are replacement of bone tissue and reconstruction of large defects. Middle third mandibular resection has no better substitute than free fibula graft. CONCLUSION:Free flap is a reliable, feasible and easy method in reconstruction of large defect with good aesthetic and functional outcome. Local flap is effective in smaller defects but cannot replace bony tissue.

Bilateral iridocorneal endothelial syndrome in a young girl with Down's syndrome.

We describe the occurrence of bilateral iridocorneal endothelial (ICE) syndrome with glaucoma in a young girl with Down's syndrome. A 16-year-old girl with Down's syndrome was found to have secondary glaucoma in the right eye with features of progressive iris atrophy in both eyes. She was uncontrolled on maximum tolerable medical therapy for glaucoma. She underwent an uneventful trabeculectomy with mitomycin-C in her right eye. Scanning electron microscopy of the trabecular meshwork obtained in this case is described.

The economic implications of the use of anti-vascular endothelial growth factor drugs in age-related macular degeneration.

Age-related macular degeneration (ARMD) is the most common cause for visual impairment in the elderly in western countries. Recently several anti-vascular endothelial growth factor (VEGF) drugs like pegaptanib sodium (Macugen), ranibizumab (Lucentis) and bevacizumab (Avastin) are available for use in the management of wet ARMD. A major limitation of these drugs is that they require multiple intravitreal injections, every 4 to 6 weeks interval for a period of 2 years. Moreover, most of these drugs are too expensive for the general masses to afford in developing nations. Avastin, though used "off-label", offers a comparable result at affordable cost, however, long term results are awaited. The drug industry should review the entire pricing policy of these drugs in developing countries like India, and develop affordable alternative compounds. The article reviews the economic burden and affordability issues of these Anti-VEGF drugs in ARMD.