Nasal Measurements in Indian Population of North-East Region: Angular Parameters with Literature Review.

Background: Just like linear nasal parameters, angular nasal parameters form the basis of any rhinoplasty, especially in various ethnic groups to maintain the specific racial characteristics while creating an aesthetic nose. The objective of this study was to measure and study the outcomes of angular nasal parameters in north-east Indians and to contrast them with available literature on Oriental, Caucasian and Indian population in general. Methods: This cross-sectional study was carried out in 150 young adults from north-east region of India. Surface landmarks were marked, and standard photographs were taken. Nine angular parameters were measured from the left lateral and basal view photographs of the face using computer software. Data were analysed by Student's 't'-test for parametric data and Mann-Whitney U-test for non-parametric data using SPSS v.25. Results: All the angular measurements were found to be greater in females except nasofacial angle, columella tip angle and interaxial angle. Differences in nasofrontal angle, columella labial angle, nasofacial angle and columella tip angle between males and females were statistically significant. Nasofrontal and columella labial angles were more acute in the study population compared to Caucasians, Orientals and other Indians while nasofacial, interaxial and interalar angles were larger. Conclusion: The north-east Indian nose is dissimilar to that of rest of the country as well as that of Caucasians and Orientals with respect to angular parameters.

Conjoint muscle transfer and subscapularis slide in brachial plexus birth palsy: Clinical outcomes in shoulder functions.

BACKGROUND: Shoulder deformity and inadequate shoulder function in brachial plexus birth palsy (BPBP) occur due to imbalance between the shoulder abductors, external rotators, adductors and internal rotators. This is due to cross innervation of the regenerating axons and subsequent target muscle innervation. These lead to internal rotation deformity along with glenohumeral dysplasia. Conjoint muscle transfer in the form of latissimus dorsi and teres major muscle combined with release and slide of subscapularis muscle improves shoulder functions. This study aims to evaluate the outcomes of shoulder function after a simultaneous conjoint muscle transfer and subscapularis slide in the management of BPBP. METHODS: 18 children with BPBP, who presented with shoulder deformity and inadequate shoulder functions, underwent conjoint muscle transfer along with subscapularis muscle slide. At 18 months, shoulder functions were assessed preoperatively and postoperatively using Mallet score system and range of motions. Statistical analysis was performed to ascertain if the outcomes were statistically significant. RESULTS: Mean age was 4.64 years with a mean preoperative Mallet score of 10.89 ± 1.60 and mean postoperative Mallet score of 16.22 ± 1.86. At 18 months, mean gain in shoulder abduction at 18 months was 57.22 ± 16.11° with external rotation of 26.66 ± 7.67°. All children showed improvement in shoulder functions. There was no correlation between the clinical outcomes and age of the child. CONCLUSION: This procedure was effective in improving shoulder functions in a cohort of patients. The long-term effect of this procedure, however, remains to be evaluated by further follow-up and with similar such studies.

Clinicoradiologic follow up of cherubism with aggressive characteristics: a series of 3 cases.

Cherubism is a rare autosomal dominant disorder characterized by replacement of bone with fibrous tissue containing multinucleated giant cells. It manifests as bilateral mandibular and/or maxillary enlargement. The 2017 World Health Organization classification lists cherubism as a giant cell lesion of the jaws, distinct from fibro-osseous disorders. We discuss 3 cases of familial cherubism having aggressive characteristics and present clinicoradiologic evaluations of the lesions over 12, 18, and 1.5 years, respectively. Follow-up was observational, without active intervention. Analysis of the lesions for change in size and functional impairments was correlated with periodic imaging. All patients are currently being monitored. The outcome in 2 cases has been excellent without intervention, but 1 case had extensive involvement of the jaws and involvement of the condyle and orbit. A secondary giant cell lesion involved the palate in one patient's mother, who had had cherubic lesions in childhood.

Negative pressure wound therapy in the management of mine blast injuries of lower limbs: Lessons learnt at a tertiary care center.

BACKGROUND: Mine blast injuries of foot are devastating injuries that result in composite tissue loss or amputations. Negative pressure wound therapy has helped in the management of such combat-related wounds. The aim of this study was to report experiences gained in managing such injuries at a tertiary care center. METHODS: 17 combatants who sustained mine blast injuries were included in this study. Severity of foot injury was assessed as per Foot and Ankle Severity Score. After wound debridement, negative pressure wound therapy was started and foot defect was appropriately reconstructed. Following wound healing, the foot was assessed for Foot and Ankle Severity Score in terms of impairment. The patients were then suitably rehabilitated by shoe modifications, orthosis, or custom-made prosthesis. RESULTS: Mean age of soldiers who sustained mine blast injuries was 30.2 years. The mean Foot and Ankle Severity Score was 3.76. Temporary wound closure was achieved using negative pressure wound therapy and it prevented local and systemic infection. The defect could be reconstructed appropriately using split skin graft, regional fasciocutaneous flap, or microvascular free flap. Mean time to definitive reconstructive procedure was 16.5 days. Mean Foot and Ankle Severity Score in terms of impairment was 4.11. All soldiers could be rehabilitated and were returned to their respective units and were able to perform sedentary duties assigned to them. CONCLUSION: The negative pressure wound therapy was helpful in preventing proximal amputations due to mine blast injury and was helpful in satisfactory reconstruction of foot defects.

Posterior approach for both spinal accessory nerve to suprascapular nerve and triceps branch to axillary nerve for upper plexus injuries.

Restoration of stability and movements at the shoulder joint are the 2 most important goals in the management of brachial plexus injuries. The 2 nerves that are preferentially targeted for this purpose are the suprascapular (SSN) and the axillary (AXN) nerves. These nerve transfers have conventionally been performed by the anterior approach, but recently transfers performed by posterior incisions have been gaining popularity, by virtue of being selective and located close to the target muscles. Herein, we describe the technical details of spinal accessory nerve (SAN) to SSN and triceps branch to AXN for upper plexus injuries, both performed by the posterior approach.

Enzymatic debridement of large burn wounds with papain-urea: Is it safe?

INTRODUCTION: Enzymatic debridement is a method by which burn wounds can be prepared for coverage by skin grafts in patients presenting late. Many agents have been used in the past but none of them have been thoroughly evaluated. The present study was undertaken to assess the efficacy of Debridace, a commonly available debriding agent with papain and urea as its constituents. MATERIAL AND METHODS: A prospective descriptive study design was used to evaluate our experience. Almost symmetrical areas of the burnt surface were assessed and used for comparison. On one half of the wound, Debridace was applied while on the other silver sulphadiazine was used. The primary end point of this study was the extent of the achieved debridement at the end of the study period. Secondary outcomes were the presence of adverse effects such as pain and fever. All patients with sepsis were excluded from the study. RESULTS: The age of the subjects ranged from 9 to 80 years with an SD of 16. Large areas ranging from 5% to 20% body surface area with an SD of 4.27 were debrided by Debridace. Only two patients (3.33%) could complete the study. The rest of the recruited patients either had high fever (63.33%), excruciating pain (13.33%) or both (16.66%), which brought an end to enzymatic debridement. CONCLUSION: Debridace, a papain-urea product, cannot be considered safe as an enzymatic debriding agent in its present form for use in major burn patients who present late with deep burn wounds that are large in size.

Surgical outcomes following nerve transfers in upper brachial plexus injuries.

BACKGROUND: Brachial plexus injuries represent devastating injuries with a poor prognosis. Neurolysis, nerve repair, nerve grafts, nerve transfer, functioning free-muscle transfer and pedicle muscle transfer are the main surgical procedures for treating these injuries. Among these, nerve transfer or neurotization is mainly indicated in root avulsion injury. MATERIALS AND METHODS: We analysed the results of various neurotization techniques in 20 patients (age group 20-41 years, mean 25.7 years) in terms of denervation time, recovery time and functional results. The inclusion criteria for the study included irreparable injuries to the upper roots of brachial plexus (C5, C6 and C7 roots in various combinations), surgery within 10 months of injury and a minimum follow-up period of 18 months. The average denervation period was 4.2 months. Shoulder functions were restored by transfer of spinal accessory nerve to suprascapular nerve (19 patients), and phrenic nerve to suprascapular nerve (1 patient). In 11 patients, axillary nerve was also neurotized using different donors - radial nerve branch to the long head triceps (7 patients), intercostal nerves (2 patients), and phrenic nerve with nerve graft (2 patients). Elbow flexion was restored by transfer of ulnar nerve motor fascicle to the motor branch of biceps (4 patients), both ulnar and median nerve motor fascicles to the biceps and brachialis motor nerves (10 patients), spinal accessory nerve to musculocutaneous nerve with an intervening sural nerve graft (1 patient), intercostal nerves (3rd, 4th and 5th) to musculocutaneous nerve (4 patients) and phrenic nerve to musculocutaneous nerve with an intervening graft (1 patient). RESULTS: Motor and sensory recovery was assessed according to Medical Research Council (MRC) Scoring system. In shoulder abduction, five patients scored M4 and three patients M3+. Fair results were obtained in remaining 12 patients. The achieved abduction averaged 95 degrees (range, 50 - 170 degrees). Eight patients scored M4 power in elbow flexion and assessed as excellent results. Good results (M3+) were obtained in seven patients. Five patients had fair results (M2+ to M3).

Management strategy for facial arteriovenous malformations.

Arteriovenous malformations (AVMs) are uncommon errors of vascular morphogenesis; haemodynamically, they are high-flow lesions. Approximately 50% of AVMs are located in the craniofacial region. Subtotal excision or proximal ligation of the feeding vessel frequently results in rapid progression of the AVMs. Hence, the correct treatment consists of highly selective embolisation (super-selective) followed by complete resection 24-48 hours later. We treated 20 patients with facial arteriovenous malformation by using this method. Most of the lesions (80%) were located within the cheek and lip. There were no procedure related complications and cosmetic results were excellent.

A study of regional nerve blocks and local anesthetic creams (Prilox) for donor sites in burn patients.

BACKGROUND: Burn patient requires multiple visits to the operation theatres and undergoing anesthesia with its attendant risks and post anesthesia recovery. It is possible now with the availability of local anesthetic creams like Prilox to conduct these procedures in the minor OT without any discomfort to the patient. MATERIALS AND METHODS: Hundred patients of post burn raw areas were selected. These patients had at least one area of healthy skin on anterior, medial or lateral thigh. No patient had a known drug allergy. The age group varied from 5 to 75 years with no bias towards any sex. These patients were then given anesthesia according to the group, and were assessed for the ease of grafting, amount of graft being harvested, subjective pain score, post operative pain relief and any post operative complication. The nerve block technique being used was either femoral and/or LCT block or 3-in-1 block and popliteal fossa block. RESULTS: Both the group of patients had a virtual painless process of skin grafting. It is safe in selected patients to combine the two techniques in order to harvest larger areas. DISCUSSION: Both techniques of local anesthestic creams and nerve block are safe and convenient to use. Nerve blocks are more useful where larger grafts are required, the creams being more useful in children and where less graft is required.

Microbiological safety and clinical efficacy of radiation sterilized amniotic membranes for treatment of second-degree burns.

Amniotic membranes collected from the placentae of screened donors were processed and sterilized by gamma irradiation at 25 kGy. The sterility assurance level (SAL) of gamma irradiated amniotic membranes and clinical efficacy in second-degree burn wound healing were evaluated. Processed air-dried amniotic tissue from 159 batches of processing was checked for the bioburden level before sterilization. About 39% of the tissues had bioburden in the range of 10(1)-10(2)/100 cm(2) and 54.8% in the range of 10(2)-10(3)/100 cm(2). Based on the bioburden of the processed tissue prior to sterilization and the D(10) value of 2.3 kGy for the radiation resistant reference strain Bacillus pumilus, the sterility assurance level of the amniotic membranes irradiated at 25 kGy is found to be 10(-7) to 10(-11). The burn wound healing rate was compared between the radiation sterilized amniotic membranes and glycerol preserved amniotic membranes. Fifty patients with partial-thickness burns (up to 70% TBSA) were selected for the study. The scalds constituted 82% (41 patients) whereas flame burns accounted for 18% (9 patients). Various aspects like ease of application, patient comfort, development of fluid under the membrane, bacterial culture of drained fluid, rate of epithelialization, development of hypertrophic scars, keloids, unstable scars and restriction of joint movements were recorded with the application of gamma irradiated and glycerol preserved membranes. Radiation sterilized amniotic membranes had advantage over the glycerolized membranes with respect to the ease of application. Five patients with glycerol preserved membranes and four with gamma irradiated membranes developed fluid. The bacteriology of fluid showed Pseudomonas aeruginosa in four cases, Staphylococcus aureus in two cases, Escherichia coli in two cases and Acinetobacter in one case. The application of radiation sterilized amniotic membranes on the burn wound favoured epithelialization. In all the patients, membranes dessicated and separated in 10-14 days time leaving behind an epithelialized surface.

Reconstruction of Complex Abdominal Wall Defects.

INTRODUCTION: Reconstruction of large abdominal wall defects not amenable to primary closure remains a challenging problem. These defects result from trauma, previous surgery, infection and tumour resection. The primary objectives of abdominal wall reconstructions are to protect abdominal contents and provide functional support. The abdominal wall reconstruction aims at providing basic component parts, i.e. skin, soft tissue and fascia. For large soft tissue defects, pedicled or free flap closure can be used. In clean wounds, fascial replacement is accomplished with synthetic mesh provided there is adequate soft tissue coverage. METHODS: We treated a total of 20 consecutive patients with complex abdominal wall defects utilizing various reconstructive procedures. There were 15 males (75%) and 5 females (25%). The aetiology included dehiscence of laparotomy wounds in eight (40%), following ablative surgery for malignant tumours in seven (35%), trauma in three (15%) and congenital defects in two (10%) cases. The reconstructive procedures consisted of onlay prolene mesh in seven (35%), Gore-Tex (PTFE) dual mesh both as inlay and onlay in five (25%), facial partition release technique in three (15%), inlay prolene mesh covered with omentum and split skin graft in two (10%), inlay prolene mesh covered with expanded skin in two (10%), and Gore-Tex dual mesh covered with latissimus dorsi myocutaneous flap in one (5%) case. Postoperatively none developed mesh infection or extrusion. Three patients with malignant aetiology received postoperative radiotherapy. During follow up, one patient developed ventral hernia cephalad to the repair and one died due to recurrence of abdominal wall malignancy. CONCLUSION: The reconstruction of an abdominal wall defect requires a comprehensive plan of preoperative and post operative care of the patient and aims toward restoration of abdominal structural integrity by a variety of procedures. The use of new biomaterials and tissue expanders provides reliable and durable abdominal wall closure along with good aesthetic results.

Management of Soft Tissue Defects of the Ankle and Foot.

BACKGROUND: Treatment of soft tissue defect of ankle and foot has always been a challenging problem. METHODS: Thirty patients with soft tissue defects of the ankle and foot who underwent various reconstructive procedures in two tertiary care teaching hospitals were studied. RESULTS: Most of the defects (33%) were located in and around the ankle. Trauma was the major cause (56.6%). Defects were reconstructed with a variety of local, regional, distant and microvascular free flaps. Distally based superficial sural artery flap was used in majority of the cases (40%). Free tissue transfer using radial artery forearm flap was done in three (10%) complex wounds where other flaps were not found to be suitable. Superficial soft tissue defects on the dorsum of foot were resurfaced with split thickness skin grafts in 3 (10%) cases. Out of 27 flaps used, 26 survived completely. One inferiorly based fasciocutaneous flap developed partial necrosis. There was graft loss in one patient which required regrafting with the stored autograft. CONCLUSION: Distally based superficial sural artery flap remains the choice for reconstruction of soft tissue defects of ankle and foot because of its reliable blood supply and easy elevation.

Simultaneous and symmetrical reconstruction of heminose and restoration of nasal airway in congenital absence of heminose.

Congenital absence of heminose is an extremely rare anomaly. Reconstruction of full thickness defects of the nose requires lining, support and cover. Reconstruction of congenital absence of heminose has an additional requirement of reconstruction of the nasal airway. Simultaneous reconstruction of the heminose and internal nasal passage has not been reported earlier. In a case of congenital absence of heminose, reconstruction of the heminose and internal nasal passage was done simultaneously by using expanded forehead tissue and a nasolabial flap. The nasolabial flap is robust and supports the alar margin without any need of cartilage support. The bulk of subcutaneous tissue it carries lies on the outerside of nostril and, therefore, it does not obstruct the nasal opening. This was covered by expanded forehead tissue, which got thinned out due to tissue expansion, thus achieving symmetry with other half of nose. Skin of the nasolabial flap lines nasal passage thereby avoiding the need of splintage of nasal airway which is required if nostril is lined by split skin graft.

Total ear reconstruction in postburn deformity.

The external ear enjoys a special place in society all over the world. It is meant to be flaunted and adorned. Ear piercing is routine, with a range of jewelry pieces concentrating in enhancing its natural beauty. Persons with deformed ears have to limit their range of hair styles. There is a definite need to reconstruct the deformed ear of both sexes. To achieve desirable results in ear reconstruction is a difficult task. Although cartilage fabrication is an important step in ear reconstruction in postburn deformity of the ear, the final outcome is mainly decided by the quality and quantity of skin available in the auricular region for draping of framework.

Use of triamcinolone acetonide injection in ear reconstruction.

Reconstruction of the complicated contours of the ear is a difficult task. To maintain and recreate the reconstructed contours of ears masked by the following various reasons is even more difficult. During the first stage of cartilage transplantation, the ear contours are quite often masked as a result of prolonged edema; thick, draping skin; organized hematoma; or inflammatory exudates. Dressings and splints have been reported as management methods of the ear postoperatively after the first stage of cartilage transplantation, but it is difficult to use these for a period of 6 months, the time when edema subsides. The author used triamcinolone acetonide injection locally in the area of the scapha and triangular fossa of the reconstructed ear to recreate the contours that were masked. This is a simple and effective method for achieving the desirable contours.