Pilot Evaluation of Perioperative High Dose Rate Brachytherapy in Head Neck Cancers.

Perioperative high dose rate brachytherapy involves insertion of brachytherapy catheter over the tumor bed during surgical removal of disease followed by radiation in the postoperative period. It has applications in radiotherapy dose escalation or reirradiation and for extending the surgical margins. We report here initial results of treatment in five cases of locally advanced head and neck cancers.

Comparison of Efficacy of Vacuum Dressing Versus Conventional Dressing Over Autologous Split Skin Grafts in Burn Wounds: A Single-Center Prospective Cohort Study.

This study was carried out to compare the efficacy of vacuum dressing and conventional dressing over split skin grafts in burn patients. It was a single-center prospective cohort study on patients, with less than 40% TBSA burn, undergoing skin grafting at 2 different sites simultaneously over the burn wounds. One site underwent conventional dressing following grafting, and the other underwent vacuum dressing. The primary objective was to compare the percentages of skin graft uptake on Day 5 and Day 14. The secondary objectives were to compare the duration of dressings, time for complete epithelization, need for regrafting, and wound swab culture positivity rates. Three independent examiners assessed the efficacy of dressings in terms of epithelization percentage, need for continued dressing, graft loss, wound swab culture positivity rate, and qualitative assessment of grafts. A total of 16 patients were included in the study. The graft loss, number of days of dressings, and complete epithelization time were statistically lower in the negative-pressure wound therapy (NPWT) group compared with the conventional group (P values .007, .006, and 0009, respectively). The percentage of epithelization was also found to be higher in the NPWT group (P = .006). The incidence of positive cultures and clinically significant graft loss was found to be lower in the NPWT group. However, this was not found to be statistically significant. NPWT dressings can be used in burn wounds following skin grafting and have been found to reduce the time for epithelization compared to conventional dressing.

Outcome of Nasal Layer Reinforcement With Autologous Dermis in Cleft Palate Repair on Postoperative Fistula Formation.

Palatal fistulae are challenging complications following cleft palate repair. The addition of acellular dermal matrix (ADM) to cleft palate repair has been shown to reduce fistula formation in previous studies. The use of autologous dermal graft has all the structural advantages of ADM, has less rejection and immunogenic potential, and is cost effective.A prospective study.Patients with Group II and III cleft palate (Nagpur Classification) without prior intervention for palatal repair in the Department of Plastic Surgery at PGIMER from January 2020 till June 2021.The addition of autologous dermal graft for palatoplasty.Outcome of the study was fistula development or exposure of dermal graft.Autologous dermal graft was harvested of average dimension of 8.73 cm2 (range 5.25-18 cm2) from groin region. Sixteen patients were included in the study. Among them, 2 patients (12.5%) developed postoperative fistula (Type III &V Pittsburgh Classification).Our study showed that the rates of postoperative fistula formation are comparable with prior literature using artificial dermal matrices.

Iatrogenic partial glanular amputation: A rare complication of circumcision.

Circumcision is a customary ritual across many cultures. However, the safety of such procedures remains a concern. A boy underwent circumcision in 2014 by a religious worker at the age of 7 years. Post circumcision, the patient had gradual narrowing of the penis, between the glans and the shaft, with an iatrogenic partial glanular amputation and presented to us at the age of 14 years. The patient underwent end-to-end urethroplasty and glansplasty. Postoperatively, the patient did well and the wound remained healthy. Circumcision has complications even in expert hands. Religious circumcision can result in dreadful complications in children and adolescents.

Division of Fasciocutaneous Pedicled Flaps-Is It Time to Change Practice?: A Prospective Randomized Controlled Trial.

INTRODUCTION: The study was carried out to evaluate the safety of early division of the pedicled flaps and to identify the optimum day of division. METHODS: This prospective, parallel arm, open-label, noninferiority, randomized controlled trial was carried out from January 2019 to July 2020. All patients (age, ≥5 years) undergoing reconstructive procedures using pedicled flaps were randomized in 1:1 ratio to receive either early division or conventional division protocol. In the early-division group, the flap perfusion, if satisfactory on day 8 by clinical and thermographic methods, a clamp was applied on the pedicle. The clamp was gradually tightened to produce controlled delay, and perfusion assessment was repeated after complete tightening. If satisfactory, the flaps were divided. Primary endpoints were flap at 24 hours after division, day of division, and day of complete inset of the flap. Secondary end points included perfusion of the flap on day 8, morbidity parameters (wound infection/suture dehiscence, need for secondary surgery and donor site morbidity), quality of life, and function scores. RESULTS: Thirty-five patients were included in each group. The 2 groups were similar in terms of various demographic, clinicopathological variables, defect and flap characteristics. The flap survival rate was similar (P = 0.31) between the early (34/35) and standard (35/35) division groups. The early-division group had a significantly early mean day of flap division (mean difference of 12.74 days; P < 0.00001) and complete flap inset (mean difference of 12.09 days; P < 0.00001). All flaps had satisfactory perfusion on day 8. The wound infection rate was 1.33 times significantly higher in the conventional group (P = 0.033). There was a higher incidence of donor site morbidity (9% vs 0%) in the conventional group when compared with the early division group. The quality of life and function scores at 3 weeks (mean difference 2.37; P < 0.001) and 6 weeks (mean difference 3.76; P < 0.001) and adjacent joint stiffness were significantly higher in the early division group when compared with conventional group. CONCLUSIONS: The pedicled flaps can be divided significantly early at an average duration of 10 to 11 days after flap inset with increased patient satisfaction rate and with a reduced postoperative morbidity. The authors have included a diversity of pedicled flaps used in different anatomic locations. By using stratified block randomization, we could ensure that the distribution was similar between the 2 groups, thus minimizing the heterogeneity in the analysis. This could also potentially indicate the usefulness of the controlled delay technique, irrespective of the anatomic location and type of the flap.

"Superman" Latissimus Dorsi Flap for Breast Reconstruction: A Technical Innovation for Covering Extensive Mastectomy Defect.

Breast reconstruction in extensive post-mastectomy defects is challenging for a reconstructive surgeon. While a plethora of options is available for breast reconstruction, pedicled latissimus dorsi (LD) flap remains the flap of choice for most surgeons. However, the size of the skin paddle of the LD flap may not suffice for extensive defects. We present a technical modification in the planning of the LD flap for its use in extensive defects.

Botulinum Toxin for a Better Scar in Cleft Lip Surgery: A Prospective Randomized Control Trial.

INTRODUCTION: An unsightly scar following cleft repair can undo the good work of even an experienced surgeon. A functioning orbicularis oris muscle beneath the lip scar maintains a zone of dynamic tension resulting in a stretched scar. Botulinum toxin type A (BTA) can be used to create a temporary paralysis of the orbicularis muscle during the healing phase. This may lead to better scar formation after a cleft lip repair. METHOD: The present prospective randomized control trial enrolled 28 infants with unilateral cleft lip undergoing primary lip repair. They were randomized to receive injection of either BTA (botox group) or normal saline (control group) intraoperatively into adjacent orbicularis oris muscle immediately after completion of cleft lip repair. Blinded experts reassessed the scar after 6 months. Objective assessment was undertaken employing Visual Analogue Scale (VAS), Vancouver Scar Scale (VSS), and photographic scar width measurements. RESULTS: Twenty-two subjects were able to complete a follow-up duration of 6 months. Children in the BTA (Botox Group) had a statistically significantly better VAS score and lesser scar width compared to the control group. However, the difference in the VSS score between both groups was not statistically significant. On comparing patients with cleft lip alone with cleft lip and palate, no statistically significant difference was found in VAS, VSS, and scar width. There were no complications associated with the use of botulinum toxin A. CONCLUSIONS: Botulinum toxin type A injection is a safe and effective addition to improve scar appearance following cleft lip repair. There was improvement in appearance of the scar in terms of width, but no improvement was seen in the scar pigmentation. The scar outcome is independent of cleft lip classification.

Circumstances surrounding end-of-life in pediatric patients pre- and post-heart transplant: a report from the Pediatric Heart Transplant Society.

BACKGROUND: Although mortality has decreased considerably in pediatric heart transplantation, waitlist and post-transplant death rates remain notable. End-of-life focused research in this population, however, is very limited. This Pediatric Heart Transplant Society study aimed to describe the circumstances surrounding death of pediatric heart transplant patients. METHODS: A retrospective analysis of the multi-institutional, international, Pediatric Heart Transplant Society registry was conducted. Descriptive statistics and univariate analyses were performed to 1) describe end-of-life in pediatric pre- and post-heart transplant patients and 2) examine associations between location of death and technological interventions at end-of-life with demographic and disease factors. RESULTS: Of 9217 patients (0-18 years) enrolled in the registry between 1993 and 2018, 2804 (30%) deaths occurred; 1310 while awaiting heart transplant and 1494 post-heart transplant. The majority of waitlist deaths (89%) occurred in the hospital, primarily in ICU (74%) with most receiving mechanical ventilation (77%). Fewer post-transplant deaths occurred in the hospital (22%). Out-of-hospital death was associated with older patient age (p < .01). CONCLUSIONS: ICU deaths with high use of technological interventions at end-of-life were common, particularly in patients awaiting heart transplant. In this high mortality population, findings raise challenging considerations for clinicians, families, and policy makers on how to balance quality of life amidst high risk for hospital-based death.

Management of extra-articular shaft fractures of the non-thumb metacarpals: plate-screw fixation versus K-wire fixation.

Metacarpal fractures are common injuries and comprise nearly 36% to 42% of all fractures in the hand. The majority of these can be managed non-surgically. Operative fixation when needed, can be done by a variety of techniques. In this study, we have compared the outcomes of two techniques, plate-screw fixation and K-wire fixation. We have conducted a prospective, non-randomized, comparative study of patients who presented with extra-articular metacarpal shaft fractures of non-thumb metacarpals over a period of 18 months. 30 patients were enrolled according to the inclusion criteria and were alternately allotted to the plate-screw group and the K-wire group. At admission, patient demographics, clinical features, number of fractures, and fracture patterns were recorded, and radiographs were taken. In the plate-screw group, low-profile plates and screws were used, and in the K-wire group, 1 or 2 K-wires were used for fixation after fracture reduction. Hand mobilization exercises were started within one week in the plate-screw group, while in the K-wire group full mobilization was allowed at 4 weeks post-surgery. The Disabilities of Arm, Shoulder and Hand (DASH) score was calculated and compared between the two groups at 6 months and 12 months after surgery. The mean 6-month DASH score in the plate-screw group was 6.3287±2.2453, while it was 17.1627±6.2103 in the K-wire group (p value <0.001). At the end of 1-year follow-up, the mean DASH score in the plate-screw group was 5.1080±1.6637, and in the K-wire group, it was 5.1073±1.9392 (p value =0.848). In conclusion, extra-articular metacarpal shaft fractures of the non-thumb metacarpals treated by plate-screw fixation had significantly better DASH scores and hence better functional outcomes at the end of 6 months. However, at the end of 1 year, the DASH scores in both the groups were almost similar, suggesting similar functional outcomes in the long term.

Clinical Outcomes of Surgical Management of Primary Brachial Plexus Tumors.

Introduction This study evaluates the clinical presentation, tumor characteristics, and clinical outcomes of surgically treated benign and malignant brachial plexus tumors (BPTs). Methods A prospective study of patients with BPTs from June 2015 to August 2020 was conducted. All patients underwent surgical resection with microneurolysis and intraoperative electrical stimulation to preserve the functioning nerve fascicles. Results Fourteen patients with 15 BPTs underwent surgical resection. Mean age was 37.8 ± 12.3 years; with male to female ratio 4:10. The clinical presentations were swelling (100%), pain (84.6%), and paresthesia (76.9%). The lesions involved roots (5/15), trunk (5/15), division (1/15), and cords (4/15). Thirteen patients had benign pathology (8 schwannomas, 3 neurofibromas, 2 lipomas) and two had malignant neurofibrosarcoma. Gross total resection was achieved in all cases except a dumbbell tumor. The mean follow-up period was 24 ± 5 months. Postoperatively, all patients reported improvement in pain and paresthesia with no new sensory deficit. All patients had developed initial motor weakness (Grades 2-4); however, full power (Grade 5) was recovered by 3 to 5 months. Conclusion Total resection can be achieved by appropriate microneural dissection and electrophysiologic monitoring and is potentially curative with preserving function.

Perioperative high dose rate brachytherapy in head and neck cancers: case report and review of clinical application.

Perioperative high dose rate brachytherapy is a radiotherapy treatment technique which involves intraoperative insertions of brachytherapy catheters into the tumor bed during the surgical resection followed by treatment in the post-operative period. We report here two cases to highlight its use in the primary treatment and reirradiation of head and neck cancers.

Assessment of Clinical and Histological Changes in the Skin Paddle of Pectoralis Major Myocutaneous Flap in Intraoral Reconstruction: A Prospective Cohort Study.

PURPOSE: This study was carried out to characterize the clinical and histological changes in the cutaneous portion of the transferred pedicled pectoralis major myocutaneous flaps used in intraoral reconstruction in patients with head and neck malignancy. METHODS: This was a prospective cohort study carried out from July 2016 to 2018. All patients underwent ablative surgery for oropharyngeal cancers and primary reconstruction with pedicled pedicled pectoralis major myocutaneous flaps. The intraoral flaps were examined for color, texture, presence of hair, chronic inflammatory changes, and ulceration. At 12 months, incisional biopsies were taken from the skin paddle of the intraoral flap and contralateral normal buccal mucosa, and flap histology was compared with that of the contralateral buccal mucosa. RESULTS: Twenty patients were included in the final analysis (M/F, 4:1; mean ± SD age, 51.38 ± 6.76 years). Fourteen flaps resembled oral mucosa, 3 had a mixed appearance of both skin and mucosa, and 3 had appearance of normal skin at 1 year follow-up. The epidermis and stratum corneum were retained in all the flap biopsies; however, severe attenuation was noted in 7 patients (had mucosal appearance) but was significantly different from oral mucosa(P = 0.0003). Cutaneous appendages were found in all the flap epithelia. Thirteen flaps showed grossly attenuation, of which 11 patients had a gross appearance resembling oral mucosa and 2 had a mixed appearance. The biopsies showed varied degree of chronic changes like desquamation in around 35% (7 patients), hyperkeratosis in 35% (7 patients), and chronic candidiasis in 30% (6 patients). CONCLUSIONS: Although the intraorally transferred flaps demonstrate a morphological appearance similar to oral mucosa, there is a histological preservation of skin elements and architecture.

Quality of Life in Patients with Reconstructions After Resections for Oral Cavity Cancers.

To determine effects of reconstruction in advanced oral cavity cancers in achieving a quality of life (QOL), which can help patients to cope with their routine day to day activity. A Cross sectional analysis involving 32 patients of stage III and IV oral cavity cancers already operated in the department of otolaryngology and head and neck surgery was carried out. All these patients had resection of their tumors along with reconstruction. Patients who consented for QOL assessment and follow up through personal visit and telephonic interviews were included in the study. Voice related quality of life; Swallowing related QOL; overall Quality of life (WHO QOL BREF II) and disability assessment scale (WHO DAS II) were used for assessing the various QOL parameters during post-operative period. Patients with stage T3 tumors had better QOL compared to patients with T4 stage tumors. Patients who had reconstruction with free flaps had better QOL compared to those with Pectoralis Major myocutaneous (PMMC) flaps or those reconstructed with combinations of flaps involving delto-pectoral flaps or local flaps along with a free flap or PMMC. Patients with lower stage tumors have better QOL even after reconstruction. If available, free flaps should be preferred over local flaps. Delto-pectoral flaps should be a less preferred option in terms of QOL. Every patient should be counseled accordingly while any reconstruction plan is included in the management of cancers of oral cavity.

Donor Site Changes in Bone Thickness, Volume, and Density Following Split Cranial Bone Graft Harvest.

The calvarium can provide large amount of good quality corticocancellous autogenous bone graft. Although many studies have highlighted the advantages of the split cranial bone graft, there is no published work available in the literature about the fate of donor site of the split cranial bone graft. The present study was undertaken to assess the donor site as regards to the thickness, volume, and the density of the residual bone over a period of 12 months in the postoperative period. A total of 30 patients in the age group of 15 to 43 years were studied from January 2015 to January 2016. Postoperative computer tomography scans were taken at 2 weeks, 6 months, and 1 year postoperative to measure the bone thickness, volume, and density at the donor site of the split cranial bone graft harvest. The bone thickness at the donor site showed progressive increase in the thickness over the period of study and the average increase in thickness was about 12.4% at the end of 1 year. The average increase in volume at the donor site was of 2.65% after 12 months. Similarly, the average bone density increased by 3.7% at the end of 1 year. This prospective study conclusively proves that the residual bone at the donor site of the split cranial bone graft harvest site continues to grow in thickness and density over a period of 1 year.

High-pressure chemical injection injury to the hand: usually underestimated injury with major consequences.

The damages caused by high-pressure injuries are often underestimated. Such incidents are characterised by a small punctiform entry wound and the normal colour of skin. The internal damage caused by these injuries can be severely devastating in nature. These injuries required emergent surgical debridement and irrigation. Postoperatively intensive physiotherapy is required for the successful return of hand function. The final functional outcome depends on the initial latency to treatment, nature of injected material, location and volume of injection and postoperative physiotherapy.

Use of Modified Islanded Paramedian Forehead Flap for Complex Periocular Facial Reconstruction.

The paramedian forehead flap is a workhorse flap for reconstructing the nose and periorbital regions. Many variants are described including an islanded flap. However, eyebrow reconstruction is not usually performed with these flaps. The authors describe a patient suffering from postburn scarring medial to the left eye, including loss of the left eyebrow. He underwent a single-stage transfer of the paramedian forehead flap. The flap incorporated scalp hair, which restored the missing eyebrow hair after transfer. The donor defect closed primarily. The paramedian forehead flap is amenable to customization by including a segment of hair-bearing scalp to concomitantly reconstruct the nasal dorsum and eyebrow.