Management of a giant lymphocele following varicose vein surgery: a case report.

BACKGROUND: A lymphocele or lymphocyst is formed when lymphatic fluid accumulates in a space, following disruption of lymphatic channels. Here, we report a case of a giant lymphocele in a middle-aged female, who underwent Trendelenburg operation (saphenofemoral junction ligation) for varicose veins of her right lower limb. CASE PRESENTATION: A 48-year-old Pakistani Punjabi female presented to the plastic surgery outpatient department with a history of painful, progressive swelling of the right groin and medial aspect of the right thigh for 4 months. After investigation, it was diagnosed as a giant lymphocele. A pedicled gracilis muscle flap was used to reconstruct and obliterate the cavity. There was no recurrence of the swelling. CONCLUSION: Lymphocele is a common complication after extensive vascular surgeries. In the unfortunate case of its development, prompt intervention must be done to prevent its growth and ensuing complications.

Taking a step down on the reconstruction ladder for head and neck reconstruction during the COVID-19 pandemic.

BACKGROUND: Most of the head and neck cancers are time-critical and need urgent surgical treatment. Our unit is one of the departments in the region, at the forefront in treating head and neck cancers in Pakistan. We have continued treating these patients in the COVID-19 pandemic with certain modified protocols. The objective of this study is to share our experience and approach towards head and neck reconstruction during the COVID-19 pandemic. RESULTS: There were a total of 31 patients, 20 (64.5%) were males and 11 (35.4%) patients were females. The mean age of patients was 52 years. Patients presented with different pathologies, i.e. Squamous cell carcinoma n = 26 (83.8%), mucoepidermoid carcinoma n = 2 (6.4%), adenoid cystic carcinoma n = 2 (6.4%) and mucormycosis n = 1 (3%). The reconstruction was done with loco-regional flaps like temporalis muscle flap n = 12 (38.7%), Pectoralis major myocutaneous flap n = 8 (25.8%), supraclavicular artery flap n = 10 (32.2%) and combination of fore-head, temporalis major and cheek rotation flaps n = 1 (3%). Defects involved different regions like maxilla n = 11 (35.4%), buccal mucosa n = 6 (19.3%), tongue with floor of mouth n = 6 (19.3%), mandible n = 4 (12.9%), parotid gland, mastoid n = 3 (9.6%) and combination of defects n = 1 (3%). Metal reconstruction plate was used in 3 (9.6%) patients with mandibular defects. All flaps survived, with the maximum follow-up of 8 months and minimum follow-up of 6 months. CONCLUSION: Pedicled flaps are proving as the workhorse for head and neck reconstruction in unique global health crisis. Vigilant use of proper PPE and adherence to the ethical principles proves to be the only shield that will benefit patients, HCW and health system.

Negative Pressure Wound Therapy (NPWT): Our Experience in Pakistan With Locally Made Dressing.

Introduction Worldwide numbers of patients suffering from complex wounds appear to increase annually. These patients present with acute, sub-acute and chronic wounds which can be difficult to manage. Management of these patients typically requires a multi-disciplinary approach by a plastic surgeon, orthopaedic surgeon and infectious disease control team. Despite the advent of numerous new techniques and technologies, negative pressure wound therapy (NPWT) remains a cornerstone to the management of complex wounds. We present our experience with NPWT in this study. Methods This is a retrospective study of 380 patients who were treated with NPWT in the last 10 years at a single center. We receive hundreds of infected wounds of limbs each year which are either post-traumatic or post-debridement. Frequency of dressing change, C-reactive protein levels, bacterial cultures, complication rate and cost of apparatus in each case were noted. All patients received systemic antibiotics during the treatment. Results We reviewed hospital data of 520 patients in which debridement was performed. Of the 520 patients derided, 380 patients were treated with NPWT, and included in study. Number of NPWT sessions was decided on the basis of wound status (adequate healthy granulation tissue, clinically improved circulation). A single session of NPWT dressing was applied in 84% (n = 320) patients, 8% (n = 31) patients needed two sessions of NPWT dressing, 6% (n = 24) patients had three sessions of NPWT dressing and only 1% (n = 5) patients did not respond to NPWT dressing. 78% (n = 297) patients had reduced levels of C-reactive protein levels and wound cultures were negative in 54% (n = 208) patients after application of NPWT dressing. Minor complications occurred in 0.7% (n = 3) patients due to occult osteomyelitis. In 0.5% (n = 2) patients, NPWT dressing was discontinued due to persistent leakage near a natural orifice. Sinus formation was seen in 6% (n = 23) patients who were treated with curettage and conventional dressings. The mean pain score on the verbal analogue scale was 3 out of 10. The mean cost of an NPWT dressing apparatus was 90 dollars. Conclusion We conclude from this study that NPWT dressing can be easily applied to any region of the body and it can be customized to the needs of patients from different socio-economic status.