Giant Penoscrotal Lymphedema: Planning And Surgical Technique To Treat A Rare Debilitating Disease.

BACKGROUND: Giant penoscrotal lymphedema is a rare condition and is treated by surgical debulking and reconstruction with remaining skin and skin grafts. The described techniques may result in a staged surgery, multiple blood transfusions, orchidectomy and early debulking of the scrotal skin. We present a case series describing our technique to address all the concerns, discuss management to decrease progression and transmission in secondary cases and present a novel questionnaire to assess of quality of life of these patients. METHODS: This descriptive case series was done from July 2016 to October 2019. Patients with Campisi grade 5 disease were included. Clinical assessment and relevant investigations were done to identify the cause and confirm the extent of the disease. Procedural detail, post-op haemoglobin levels (Hb), need for transfusion and weight of excised specimen were recorded. Wound healing, recurrence and body mass index were noted on follow up. A scrotal lymphedema quality questionnaire was developed and was filled on follow-up visit. RESULTS: Twelve patients were operated on. The mean history was 3.0±0.5 years. 4 tested positive for microfilariae, while 4 out of 8 who tested negative had taken the anthelmintic drug. The mean weight excised was 15.8±2.3 kg, mean pre-operative score on quality-of-life assessment questionnaire was 83.3±2.6 versus 9.3±0.8 post operatively. The mean follow up time was 1.4±0.6 years. 1 patient had a minor recurrence necessitating re excision. Mean Hb was 13.5±0.5 mg/dl preoperatively compared to 11.8±0.5 mg/dl post operatively, with none requiring transfusion. CONCLUSIONS: Single staged excision with split thickness skin grafting is an effective and safe way to treat patients with giant scrotal lymphedema. It's the single best way to address the quality of life of patients.

Lower extremity reconstruction: utility of smartphone thermal imaging camera in planning perforator based pedicled flaps.

BACKGROUND: Presence of good size perforators are mandatory to design perforator based pedicelledflaps specially in lower limb as flap failure rate isrelativelyhigh. We have explored the use ofsmartphonebaseddynamic thermal imagingand compared it with doppler to devise a protocol forplanning and executionof pedicled perforator flaps anddescribedits use in deciding delay of flap. We have also compared the time required for detecting dominant perforators. METHODS: This prospective case series was done atJinnah burn and reconstructive surgery center Lahore from July to September 2018and included patients requiring pedicled fasciocutaneous or musculocutaneous flapfor lower extremity reconstruction. Smartphonebased dynamic thermal imaging and doppler wereused to map out suitable perforators and confirmed intraoperatively. Comparison was made regarding their ability to locatedominant perforatorsandtotal time required.Utility of thermal imaging to ascertain flap perfusion postoperatively was also assessed.Flaps were designed according to thermal mapping. Clinical judgement supplemented with thermal imaging was usedto ascertain flap survival. RESULTS: The study included 15 patientsin which22 out 23 dominant perforators as located withthermal imaging were confirmed intra-operatively (positive predictive value = 95.7%) as compared to 22 out of 32 with doppler(positive predictive value=68.8%). Mean time required with doppler was 591.27±252.48, compared to 598.47±192.94 seconds with thermal imaging. In two cases flap was delayed. Partial flap necrosis occurred in one case. CONCLUSION: Dynamic thermal imaging can be reliably usedin planning of pedicled perforator flaps for lower limb reconstruction. We have found itmore reliable than handhelddoppler in locating dominant perforators.

Medial Sural Artery Perforator Flap: A Versatile Option For Soft Tissue Reconstruction Of Head And Neck And Limbs.

BACKGROUND: To assess the outcome of Medial Sural Artery Perforator Flap (MSAP Flap) as an option for the soft tissue reconstruction of head and neck and limbs. METHODS: This descriptive case series was conducted at Jinnah Burn and Reconstructive Surgery Center, Lahore during October 2016 to August 2017. All patients in whom MSAP flap (free and pedicled) was performed for reconstruction are included. Patients were followed at one week and one month after the discharge and data was entered into the proformas. RESULTS: In total, 18 patients were operated with this flap. Free and pedicled MSAP flap were performed for reconstruction of soft tissue defects in the head and neck and the lower limb. The maximum dimensions of the flap were 14 cm length and 10 cm width. The maximum pedicle length was 16cm. All flaps survived and showed good outcome. There was necrosis of the distal margin of a pedicled flap, but no case of venous congestion and flap failure was observed. The flap donor site was closed primarily in 7 patients while split skin graft was used in the rest of the patients. CONCLUSIONS: The MSAP flap provides a thin skin paddle and has minimal donor site morbidity as compared to the other options. It is a good addition to the armamentarium of perforator flaps which are thin and pliable, can be harvested by two team approaches, under the tourniquet and has a hidden donor site.

Extended Islanded Reverse Sural Artery flap for Staged Reconstruction of Foot Defects Proximal to Toes.

Obective: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.