Autologous Fat Grafting - A Step Forward in Wound Management.

Autologous fat grafting (AFG) is an emerging therapeutic option for wounds that are not ready for grafting. The regenerative potential of autologous fat lies in the adipose derived stem cells (ADSCs) contained within the stromal vascular fraction (SVF), which are capable of differentiating into multiple cell lineages. However to date, there has been no comprehensive evaluation of its efficacy in acute complicated wounds. This study aims to critically evaluate the efficacy and safety of AFG in cutaneous wound healing. Materials and Methods: This prospective, quasi experimental study was conducted in the Department Of Plastic Surgery, SIMS, Lahore, between June 2020 and June 2021. Thirty patients with pale granulation, not ready for grafting with no vital structure exposed were included in the study after detailed history, examination and were photographed pre and postoperatively. The procedure was performed under local anaesthesia. 40 to 80 ml fat was harvested from lower abdomen and after emulsification, placed over the wound wrapped in sufra tulle dressing. The dressing was changed on third postoperative day and outcome was assessed on clinical grounds. Results: Thirty patients (M:F Ratio 1.75:1) with mean age 30 years (Range 13-45 years) were included in this study with post traumatic (n = 23) and post infective (n = 7). Of 27 patients who completed their follow up, all had healthy granulation tissue which was later on grafted. Mean number of fat dressing sessions were 2 (Range 1-3). Conclusion: Autologous fat grafting has shown promising results for cutaneous wounds without any unacceptably high complication rates reported so far. Randomised controlled trials should be done on a larger scale to prove its efficacy in the management of complicated wounds.

Psychology Behind Aesthetic Rhinoplasty - Introducing the term "SIFON".

BACKGROUND: Rhinoplasty is considered one of the challenging aesthetic procedures. Psychosocial concerns motivate the urge for aesthetic procedures especially rhinoplasty. Males who fall in this category are designated as single, immature, male, over expectant and narcissistic (SIMON) in literature. As of yet, no term depicts females showing similar characteristics. AIMS AND OBJECTIVES: The purpose of this study is to evaluate the incidence of body dysmorphic disorder (BDD) in females seeking rhinoplasty and to introduce a new term. MATERIALS AND METHODS: A prospective, questionnaire based, qualitative study was conducted in the Department Of Plastic Surgery, Services Institute Of Medical Sciences and Surgimed Hospital, Lahore between March 2018 and March 2020. 110 female candidates seeking aesthetic rhinoplasty were included in the study. BDD was evaluated using the Dysmorphic Concerns Questionnaire, DCQ (Table 1). Data were analyzed using SPSS version 25 software and correlation between the groups was evaluated. RESULTS: Out of 110 female subjects, 77.3% (n = 85) were single, 16.4% (n = 18) were married and 6.4% (n = 7) were divorced. BDD was found in 41.8% (n = 46) of the candidates, majority being single (n = 41, 89.1%) and having educational status above diploma (n = 39, 84.8%). There was a statistically higher percentage of young adults between 24 and 28 years (n = 33, 71.7%) having BDD (P = 0.0001). CONCLUSION: Considering the high frequency of BDD among females seeking rhinoplasty, a standardized term 'SIFON' is introduced to describe such individuals who are S; single, I; immature, F; female, O; over expectant, N; narcissistic as apposed to SIMON in males.

Unfiltered Nanofat Injections Rejuvenate Postburn Scars of Face.

The aim of this study was to compare the quality of postburn facial scars before and after injection of unfiltered nanofat. The study was performed in the Plastic Surgery Department of Mayo Hospital, Lahore, Pakistan, from January 2015 to December 2016. Forty-eight patients with postburn facial scars were included; age range was 4 to 32 years with Fitzpatrick skin types between 3 and 4. Patients with hypertrophic scars, contractures, or keloids were excluded. Scars were assessed by a senior plastic surgeon and the patient on the POSAS (Patient Observer Scar Assessment Scale). Fat was harvested from the abdomen and/or thighs with a 3-mm multiport liposuction cannula (containing several sharp side holes of 1 mm) using Coleman technique. The harvested fat was emulsified and transferred into 1-mL Luer-Lock syringes for injection into the subdermal or intradermal plane. Final follow-up was scheduled at 6 months, and scar was rated by the patient and the same surgeon on the POSAS. Preoperative and postoperative scar scores were compared, and P values were calculated. Results indicated that after nanofat grafting, there was a statistically significant improvement in scar quality. The most significant improvements on the observer scale were seen in pigmentation and pliability (P < 0.0001). Thickness and relief were the least improved variables (P = of 0.785 and 0.99, respectively). ImageJ scanning also showed pigmentation change (P = 0.076). A statistically significant improvement was seen in all parameters of the patient section of the POSAS (P < 0.0001). In conclusion, unfiltered nanofat grafting seems to be a promising and effective therapeutic approach in postburn facial scars, showing significant improvement in scar quality. The trial was registered on www.clinicaltrials.gov with following ID NCT03352297.

Comparative study of conventional and topical heparin treatment in second degree burn patients for burn analgesia and wound healing.

OBJECTIVE: To compare clinical outcome of topical conventional with topical heparin treatment in 2nd degree or partial thickness (PTB) burn patients. METHODS: Patients, between the ages of 14 and 60 years with 2nd degree burns involving <20%. Total body surface area (TBSA) on front of chest, abdomen and upper limbs excluding hands and lower limbs were enrolled from September 2015 to August 2016. Patients were randomized to conventional or heparin treatment groups. Clinical outcome measured were healed wound size, pain scores and total consumption of analgesic medication required to relieve pain. Safety of the treatment and adverse events were also measured RESULTS: Out of 66 patient included in study mean (SD) age of participants was 27 (10) years, of which 59% were males. Mean (SD) TBSA burn was 14% (3) [23 (35%) had SPTB, and 43 (65%) had DPTB]. The burn injury was caused by flames in 68% and by hot liquids in 32% patients. There was no statistically significant difference in distribution of patients according to age, gender, TBSA burn, etiology or depth of burns in the two treatment groups. As compared to conventional treatment group, heparin treatment group had significantly better outcomes. Number of days needed for wound healing was significantly lower in the heparin group than the conventional group (SPTB 14±1 vs. 20±4 days; P-value <0.000 and for DPTB, 15±3 vs. 19±2 days; P-value <0.003). Mean pain score was also lower in the heparin group (for both SPTB and DPTB 3±1 vs. 7±1; P-value <0.000). Similarly, total consumption of analgesic medication was significantly less in the heparin group (53±27 vs. 119±15mg; P-value <0.000 for SPTB and 46±6 vs. 126±12mg; P-value <0.000 for DPTB). In both groups, no patient had wound infection, skin necrosis, leucopenia, thrombocytopenia, worsening renal function, or abnormal liver enzymes CONCLUSION: Treatment of second degree or partial thickness burns (PTB) with topical heparin is superior to conventional treatment in terms of wound healing as well as for pain control. The treatment with topical heparin is well-tolerated and is without higher adverse effects.

Outcome of Conventional Adipose Tissue Grafting for Contour Deformities of Face and Role of Ex Vivo Expanded Adipose Tissue-Derived Stem Cells in Treatment of Such Deformities.

OBJECTIVES: To evaluate the outcomes of conventional fat grafting for facial contour deformities and to describe clinical outcome of a patient with contour deformity of face treated with ex vivo expanded adipose tissue-derived mesenchymal stem cells (ASCs) enriched fat graft. PLACE AND DURATION OF STUDY: The Department of Plastic Surgery and Tissue Engineering and Regenerative Medicine Laboratory, King Edward Medical University/Mayo Hospital, Lahore, from September 2015 to September 2017. METHODS: Patients with contour deformities of face requiring soft tissue augmentation were included. Fat was harvested, processed, and injected following a standard protocol. Both subjective and objective assessments were performed and complications were also noted. RESULTS: Twenty-five patients underwent 51 fat-grafting sessions over a period of 24 months. Eighteen (72%) patients underwent multiple fat-grafting sessions. Mean (standard deviation) soft tissue thickness after 72 hours and 6 months of first fat graft session was 18.62 (7.2) and 12.88 (6.21) mm, respectively, which corresponds to 30.77 (13)% reduction of transplanted fat. Physician and patient assessment scores were 3.42 (0.92) and 4 (1.04), respectively. Few minor complications were observed. In the patient undergoing ex vivo expanded ASCs enriched fat graft, there was minimal decrease in soft tissue thickness of treated area (44 mm vs 42 mm) 6 months postoperatively and patient was highly satisfied with the outcome after the single session. CONCLUSION: Conventional fat grafting is safe for correction of facial contour deformities. However, procedure needs to be repeated multiple times to produce satisfactory results. Beneficial effects of ex vivo expanded ASCs enriched fat grafting have a potential to alter the current treatment paradigm of fat grafting for soft tissue reconstruction.

A Modified Suction-Assisted Technique of Transfer of Diced Cartilage Graft to Carrier Material and Outcome of Direct Injection of Unwrapped Diced Cartilage in Rhinoplasty.

OBJECTIVE: To describe a modified suction-assisted technique (MSAT) of transfer of diced cartilage (DC) graft to a carrier material and to determine the clinical outcome of direct injection of unwrapped diced cartilage (UDC) in rhinoplasty. PLACE AND DURATION OF STUDY: Department of Plastic Surgery, KEMU, Mayo Hospital, Lahore from February 2011 to January 2015 METHODS:: Forty-seven patients of both genders with types 0 to 3 saddle nose deformity were included. Patients with types 4 and 5 saddle nose deformity, diabetes, hypertension, hepatic or renal disorders were excluded. Open tip rhinoplasty was performed in all patients. Eighth and/or ninth costal cartilage was harvested. Cartilage graft was diced into 1 to 2 mm pieces. The DC graft was transferred to carrier material (1-mL syringe) with MSAT. The UDC was then injected into nose and clinical outcome was determined. RESULTS: Out of 47 patients included in the study 62% were females with mean (standard deviation [SD]) age 22 (4) years. Thirty-four (72%) procedures were primary rhinoplasties while 13 (28%) were secondary rhinoplasties. Mean (SD) carrier material filling time was 12±3 seconds. All operating surgeons involved in study were satisfied with modified suction technique and declared it better than the traditional manual technique of filling the carrier material. Most of the patients were satisfied with their postoperative nasal appearance and complications were minimal. One patient required revision of surgery due to dorsal contour irregularities and another due to partial cartilage absorption at 13 ±â€Š2 months follow-up. CONCLUSION: Our MSAT of transfer of DC and injection of UDC is simple, easy to perform, reduces operative time and produces acceptable cosmetic outcome as regard patient's satisfaction.

Management of eczema herpeticum in a Burn Unit.

OBJECTIVE: To study the clinical features, course and outcome of eczema herpeticum in burn patients. METHODS: This prospective study was conducted at the King Edward Medical University / Mayo Hospital, Lahore, Pakistan, from November 2012 to October 2015, and comprised eczema herpeticum patients. Demographic and clinical features of the patients, treatment protocols and outcomes were noted. SPSS 18 was used for data analysis. RESULTS: Of the 18 patients, 10(56%) were females and 8(44%) were males. The overall mean age was 29.17±8.36 years. The mean total body surface area burnt was 30.83±8.58%. Besides, 7(39%) patients had 2nd degree burns and 11(61%) had both 2nd and 3rd degree burns. There was no history of previous skin disease. Moreover, 4(22%) patients had diabetes and 6(33%) were smokers. The mean difference between the occurrence of fever and the appearance of skin lesions was 4.44±1.46 days. The overall mean temperature was 102.22±1.06 oF. The mean duration between the eruption of skin lesions and crusting of lesions was 4.38±1.26 days. Areas involved with skin lesions were trunk in 13(72%) patients, arms 12(67%), thigh 10(56%) and face in 4(22%) patients. Also, 2(11.1%) patients developed acute respiratory distress syndrome. Tzanck test showed multi-nucleated giant cell in all patients. The mean number of days since the eruption of lesions and the settling of fever was 5.56±0.73 days. The mean duration for complete healing, which occurred in 16(89%) patients, was 3.81±0.75 weeks. The overall mean follow-up period was 15±2.03 months. CONCLUSIONS: Eczema herpeticum may occur in a burn patient and should never be missed as early diagnosis will lead to a better outcome.

Outcome of Management of Vascular Malformations of Lip.

OBJECTIVES: To describe the characteristics and outcome of management of vascular malformations of lip. PLACE AND DURATION OF STUDY: The Department of Plastic Surgery and Burn Unit, King Edward Medical University, Mayo Hospital, Lahore, from January 2009 to December 2013. METHODS: A prospective case series of 38 patients with vascular malformation of lip was performed. Demographic information and clinical features were noted. Treatment employed, complications, functional, and cosmetic outcome were recorded. Surgical debulking was performed as definitive treatment in all patients and nonsurgical techniques were added as adjuvant modalities in 18 patients. Sclerotherapy was performed for venous malformations in 10 patients. LASER was performed in 8 patients with capillary or combined malformations. Arterial malformations were managed surgically without embolization. Postexcision defects were closed primarily in 36 patients with Abbe flap in 1 and nasolabial flap in another patient for reconstruction. RESULTS: Of 38 patients included in the study 20 (53%) were males with mean (SD) age 18 (6) years. Twenty-one percent were high and 79% low-flow malformations (29% venous, 16% capillary, and 34% combined). Lower lip was involved in 70% patients with 95% having difficulty in eating and 87% abnormal speech. Referring diagnosis was incorrect in 35% patients. Postsclerotherapy and postexcision pain scores were mean (SD) 5 (1.26) and 4 (1) respectively. All patients had improvement in eating and speech with restoration of normal muscle function in mean (SD) 5.63 (1.2) weeks. Ninety-five percent patients were satisfied with their outlook. One patient had recurrence at 1 year follow-up. CONCLUSION: Surgical debulking with proper use of adjuvant procedure for vascular malformations of lip produces best functional and aesthetic results with minimal complications.

Comparison of Clinical Outcome of Facial Artery Myomucosal Flap and Tongue Flap for Closure of Large Anterior Palatal Fistulas.

Closure of large anterior palatal fistula has high recurrence rate. The objective of this study was to compare the clinical outcome of facial artery myomucosal flap (FAMM flap) and tongue flap used for closure of large anterior palatal fistula. This study was conducted from March 2008 to March 2014. Thirty-nine patients, aged 2 to 40 years, who had anterior palatal fistula 5 to 20 mm in width with associated alveolar cleft and repaired with either a tongue flap or FAMM flap were included. Patients were excluded if they had adequate local palatal tissue for closure, mid, posterior or multiple fistulae, fistula width >20 mm. Closure was performed in 2 layers. Turndown flap of oral mucoperiosteum was used to reconstruct nasal layer and oral layer was reconstructed with FAMM flap in 16 and tongue flap in 23 patients. Mean(SD) pain score was 3(1) and 7(1) in FAMM flap and tongue flap groups respectively with a P value <0.096. All patients in tongue flap group experienced difficulty in speaking and eating whereas in FAMM flap group 2 had eating problem and 2 experienced speech difficulty. Mean(SD) total operative times for FAMM flap and tongue flap were 155(38) and 242(10) minutes, respectively, P value <0.002. There was no difference for other complications and no recurrence at 1 year follow-up in both groups. The authors concluded that FAMM flap should be considered first choice for closure of large anterior palatal fistulas associated with alveolar cleft as it requires less total operative time and has less early postoperative complications.

Non-Islanded Distally Based Sural Artery Flap : A Reliable Solution for an Unreliable Flap.

OBJECTIVE: To assess the reliability of non-islanded distally based sural artery flap, in terms of number of flap failure (partial and major flap necrosis), number of surgeries related to the problem for which flap surgery was performed, hospital stay and return to work, for coverage of soft tissue defects of the distal one-third of leg, ankle and heel. STUDY DESIGN: Cohort study. PLACE AND DURATION OF STUDY: Department of Plastic Surgery and Burn Unit, Mayo Hospital, KEMU, Lahore, Pakistan, from January 2003 to March 2014. METHODOLOGY: Distally based sural artery flaps in 87 patients requiring coverage of distal lower lumb were studied, retrospectively. They were divided into two groups. G1 included 46 cases in which distally based sural artery flap was islanded. G2 included 41 cases in which flap was not islanded and pedicle was raised. The variables that were measured in two groups included age, gender, size and cause of defect, co-morbidities, number of surgeries, total hospital stay, return to work and flap related complications. Independent sample t-test and tests of proportions were used for comparison with significance at p &lt; 0.05. RESULTS: The mean age of patients was 38.4 &plusmn;16.2 years in G1 and 35.1 &plusmn;18.6 years in G2. In G1, 34 cases were traumatic, 5 caused by diabetic ulcers and another 7 cases were trophic ulcers in paraplegic patients caused by pressure sores. In G2, the cause was trauma in 32 cases, diabetic ulcers in 7 cases, trophic ulcers in 2 cases. The mean number of surgeries in G1 was 3 &plusmn;1 and 2 &plusmn;1 in G2 (p &lt; 0.001). The mean hospital stay in G1 was 43.1 &plusmn;3.6 days while 27.9 &plusmn;2.1 days in G2 (p &lt; 0.001). There was epidermolysis in 21 out of 46 islanded distally based sural artery flaps (G1) and in 9 out of 41 non-islanded flaps (G2) (p=0.0203). Partial necrosis occurred in 12 of flaps in G1 and in only 3 of G2 flaps (p=0.024). CONCLUSION: Distally based sural artery flap can be made more reliable and with lesser complications by raising the pedicle with skin rather than islanding the flap.

Comparison of single intra operative versus an intra operative and two post operative injections of the triamcinolone after wedge excision of keloids of helix.

OBJECTIVE: To compare single intra-operative versus an intra-operative and two post-operative injections of triamcinolone after wedge excision of keloids of helix. METHODS: The randomised controlled trial was conducted at the King Edward Medical University, Lahore, from January, 2011, to March, 2014, and comprised female patients over 14 years of age presenting with post-piercing keloids of helix not treated previously by any means and amenable to wedge excision. The subjects were divided into Group A who were given a single intra-operative injection of triamcinolone, and Group B who had an intra-operative and two post-operative injections of triamcinolone. Extra-lesional wedge excision of keloids was done, followed by infiltration of flaps and wound base with 0.5-1cc of triamcinolone 40mg/cc. Group B patients were given additional injections of triamcinolone at 1st and 2nd monthly visits. Both groups were observed for the evidence of hypertrophy or complications. Development of hypertrophy within one year of completion of treatment was considered recurrence. RESULTS: The 70 patients in the study were divided into two equal groups of 35(50%) each. The mean age of Group A was 22.34±4.95 years and that of Group B was 22.88±4.22 years (p=0.624). The Mean size of the keloids was 2.54±0.516 cm(2) in Group A and 2.61±0.569 cm(2) in Group B (p=0.613). Recurrence rate in Group A was 3(8.5%) and 2(5.7%) in Group B (p= 0.64). The complication rate was 3(8.5%) in Group A and 8(22.8%) in Group B (p=0.10). CONCLUSIONS: Single injection of triamcinolone was as effective as three in reducing recurrence with less complication rate.

Diagnostic Accuracy of Blood Glucose Measurements in Detecting Venous Compromise in Flaps.

Due to limitations of the current methods for monitoring flap circulation, newer methods with better diagnostic accuracy are needed. A drop in blood glucose levels within flap is a simple method that can be widely used; however, this method has been examined only in small cohorts. The objective of this study was to determine the diagnostic accuracy of blood glucose measurements within flaps in early detection of venous compromise. We sampled 127 pedicled and free flaps, including replants, performed on patients between 12 and 60 years of age. Within flap blood glucose measurements were performed using pinprick and a blood glucose meter at 0, 6, 12, 24 and 48  hours after operation. Daily examination for clinical signs of venous compromise was used to determine flap viability for up to 7th day after operation. Of the 127 flaps, 76 (60%) were performed on men and the mean age ±â€Šstandard deviation of the patients was 35.8 ±â€Š12.1 years. A cut-off value of 62  mg/dL was determined using a receiver operating characteristic curve. Using this cut-off value, the sensitivity and positive predictive values of within flap blood glucose for determining venous compromise were 90% and 91%, respectively, whereas the specificity and negative predictive values were 78% and 76%, respectively. The overall diagnostic accuracy of within flap blood glucose was 87%. We conclude that blood glucose measurement within flap has acceptable diagnostic accuracy and should be used for early detection of venous compromise.

Effect of Time Interval Between Tumescent Local Anesthesia Infiltration and Start of Surgery on Operative Field Visibility in Hand Surgery Without Tourniquet.

PURPOSE: To determine the optimal time interval between tumescent local anesthesia infiltration and the start of hand surgery without a tourniquet for improved operative field visibility. METHODS: Patients aged 16 to 60 years who needed contracture release and tendon repair in the hand were enrolled from the outpatient clinic. Patients were randomized to 10-, 15-, or 25-minute intervals between tumescent anesthetic solution infiltration (0.18% lidocaine and 1:221,000 epinephrine) and the start of surgery. The end point of tumescence anesthetic infiltration was pale and firm skin. The surgical team was blinded to the time of anesthetic infiltration. At the completion of the procedure, the surgeon and the first assistant rated the operative field visibility as excellent, fair, or poor. We used logistic regression models without and with adjustment for confounding variables. RESULTS: Of the 75 patients enrolled in the study, 59 (79%) were males, 7 were randomized to 10-minute time intervals (further randomization was stopped after interim analysis found consistently poor operative field visibility), and 34 were randomized to the each of the 15- and 25-minute groups. Patients who were randomized to the 25-minute delay group had 29 times higher odds of having an excellent operative visual field than those randomized to the 15-minute delay group. After adjusting for age, sex, amount of tumescent solution infiltration, and duration of operation, the odds ratio remained highly significant. CONCLUSIONS: We found that an interval of 25 minutes provides vastly superior operative field visibility; 10-minute delay had the poorest results. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic I.

The outcome of microvascular free flap surgery with or without the use of postoperative heparin.

OBJECTIVE: To determine the outcome of microvascular free tissue transfer with or without use of postoperative heparin in terms of flap viability and postoperative complications. STUDY DESIGN: Quasi-experimental study. PLACE AND DURATION OF STUDY: Department of Plastic Surgery, King Edward Medical University, Lahore, from July 2010 to July 2012. METHODOLOGY: Thirty eight patients requiring elective or emergency microvascular free tissue transfer were selected. Those with poly-trauma, previous failed free flap and re-anastomosis of vessels were excluded from the study. All anastomoses were performed by trained microvascular surgeons. Per operatively, Aucland test was performed to ensure anastomotic patency. Thereafter, patients were divided into two groups: in group A, heparin was not given postoperatively and in group B, heparin was given postoperatively. The flaps were monitored for signs of vascular compromise, viability or non-viability and complications of the procedure. Chi-square test was used to compare the distribution of qualitative variable in two groups. P-value less than 0.05 was considered significant. RESULTS: In group A, the number of viable flaps was 13 (81%) and non-viable flaps were 3 (19%). In group B the number of viable flaps was 11 (73%) and non-viable flaps were 04 (23%) [p = 0.68]. There was no significant difference regarding postoperative complications between the two groups (p > 0.05). CONCLUSION: Postoperative heparin does not appear to have an influence on the viability or complications of free flaps.

Comparison of bupivacaine moistened dressing and conventional dressing for pain relief on skin graft donor sites.

OBJECTIVE: To compare the effectiveness of bupivacaine moistened dressing and conventional dressing in patients requiring split thickness skin graft for reconstruction of various defects. STUDY DESIGN: Randomized controlled trial. PLACE AND DURATION OF STUDY: Department of Plastic Surgery and Burns Unit, Mayo Hospital, King Edward Medical University, Lahore, from January 2011 to January 2013. METHODOLOGY: One hundred and fifty patients requiring split thickness skin grafting for various soft tissue defects were divided into two groups A and B, with 75 patients in each group. In Group A, skin graft donor site dressing was kept moist with 12 mL/100 cm2 of 0.25% bupivacaine solution and in Group B, dressing was moistened with same amount of normal saline. Outcome was measured by calculating rescue analgesia requirements in the two groups after 24 hours. Significance was determined by comparing analgesia sparing effect of each dressing using chi-square test. RESULTS: In Group A, 5 out of 75 (6.7%) patients required rescue analgesia. In Group B, 72 out of 75 (96%) patients required rescue analgesia (p < 0.0001). There was 93.3% effectiveness of bupivacaine soaked dressing while only 4% effectiveness of conventional dressing. CONCLUSION: Bupivacaine soaked dressing is much more effective in pain relief and in reducing the requirement of rescue analgesia, in early postoperative period, at split thickness skin graft donor site compared to the conventional dressing.

Flexor Zone 5 cut injuries: emergency management and outcome.

OBJECTIVE: To determine the outcome and devise a protocol for emergency management of cut injuries in Flexor Zone 5 of hands. STUDY DESIGN: Descriptive study. PLACE AND DURATION OF STUDY: Department of Plastic Surgery and Burn Unit, Mayo Hospital, KEMU, Lahore, Pakistan, from January 2009 to March 2013. METHODOLOGY: All patients above 12 years of age with single sharp cut injuries in Flexor Zone 5, with no skeletal injuries, presenting within 12 hours in emergency were included with follow-up of 6 months, with active range of motion evaluated by Strickland's adjusted formula. Power of opponens pollicis and adductor muscles was evaluated from P0-4. Nerve repair results were evaluated serially by advancing Tinnel's sign, electrophysiological studies and sensory perception scored from S0-4 compared to the normal opposite upper limb. RESULTS: The study group comprised of 31 patients (M : F = 2.4 : 1). Average age was 27 years ranging from 17 - 53 years. In 25 (80%) cases, injury was accidental, in 3 (10%) homicidal and in 3 (10%) injury was suicidal. Four most commonly involved structures included Flexor carpi ulnaris, ulnar artery, ulnar nerve and Flexor digitorum superficialis. Median nerve and radial artery were involved in 10 cases each, while ulnar artery and ulnar nerve were involved in 14 cases each. Longtendons were involved in most cases with greater involvement of medial tendons. None of the patients required re-exploration for ischaemia of distal limb while doppler showed 22 out of 24 vascular anastomosis remained patent. Recovery of long-tendons was good and recovery after nerve repair was comparable in both median and ulnar nerves. CONCLUSION: Early and technically proper evaluation, exploration and repair of Zone 5 Flexor tendon injuries results in good functional and technical outcome.

Comparison of postoperative pain relief by intercostal block between pre-rib harvest and post-rib harvest groups.

OBJECTIVE: To compare intercostal nerve block before and after rib harvest in terms of mean postoperative pain score and mean postoperative tramadol usage. STUDY DESIGN: Randomized controlled trial. PLACE AND DURATION OF STUDY: Department of Plastic Surgery, Mayo Hospital, KEMU, Lahore, from January 2011 to July 2012. METHODOLOGY: Patients (n = 120) of either gender with ASA class-I and II requiring autogenous costal cartilage graft were inducted. Patients having history of local anaesthetic hypersensitivity and age < 15 years or > 60 years were excluded. Subjects were randomly assigned to pre-rib harvest (group-1) and post-rib harvest (group-2). Local anaesthetic mixture was prepared by adding 10 milliliters 2% lidocaine to 10 milliliters 0.5% bupivacaine to obtain a total 20 ml solution. Group-1 received local anaesthetic infiltration along the proposed incision lines and intercostals block before the rib harvest. Group-2 received the infiltration and block after rib harvest. Postoperative consumption of tramadol and pain scores were measured at 6 and 12 hours postoperatively using VAS. RESULTS: Mean age was 31.43 ± 10.78 years. The mean pain scores at 6 hours postoperatively were 1.033 ± 0.609 and 2.4667 ± 0.812 in pre-rib harvest and post-rib harvest groups respectively (p < 0.0001). The mean pain scores at 12 hours postoperatively were 1.45 ± 0.565 and 3.65 ± 0.633 in pre-rib harvest and post-rib harvest groups respectively (p < 0.0001). The mean tramadol used postoperatively in first 24 hours was 169 ± 29.24 mg and 255 ± 17.70 mg in prerib harvest and post-rib harvest groups respectively (p < 0.0001). CONCLUSION: Intercostal block administered before rib harvest as preemptive strategy result in decreased postoperative pain scores and narcotic use.

Intralesional triamcinolone alone and in combination with 5-fluorouracil for the treatment of keloid and hypertrophic scars.

OBJECTIVE: To compare the use of intralesional triamcinolone acetonide and its combination with 5 flourouracil in the treatment of keloid and hypertrophic scars in terms of reduction in initial height of the scar. METHODS: The randomised controlled trial was conducted at the Department of Plastic Surgery, King Edward Medical University, Lahore, from March 2011 to December 2012. It comprised patients of both genders having keloids or hypertrophic scars (1 cm to 5 cm in size) having no history of treatment for the scars in preceding 6 months. Those who were pregnant, planning pregnancy or lactating were excluded. The subjects were divided into two groups: Group A received intralesional triamcinolone acetonide alone; and Group B received triamcinolone acetonide + 5 flourouracil. Eight injections were given at weekly interval. Scars were assessed 4 weeks after the completion of treatment on a five-point scale. SPSS 16 was used for statistical analysis. RESULTS: The 150 subjects in the study were divided into two equal groups of 75 (50%) each. Good to excellent results were seen in 51 (68%) cases in Group A compared to 63 (84%) in Group B. Frequency of complications was 18 (24%) and 6 (8%) in Group A and Group B respectively. CONCLUSION: Combination of triamcinolone acetonide and 5 flourouracil is superior to triamcinolone acetonide therapy in the treatment of keloids and hypertrophic scars.

Outcome of modified turn in flaps for the lining with primary cartilage support in nasal reconstruction.

Turning in adjacent skin from the residual nose to line a full-thickness defect is still a controversial option. Text books continue to perpetuate that such flaps are poorly vascularized and may not survive if longer than 1.5 cm. The rationale of our study was to challenge the traditional thoughts about the turn-in flaps for the lining and describe our modified technique of raising these flaps so that well-vascularized thin tissue can be provided for the lining. The study was conducted at the Department of Plastic Surgery, KEMU, Lahore, from January 2007 to March 2011. Eighteen patients were included. They had posttraumatic full-thickness nasal defect of variable extent, involving the lower third of the nose. In the first stage of reconstruction, the epithelialized portion and 5-mm portion of normal adjoining skin were dermabraded. The residual skin of nasal dorsum, side walls, and alae was turned in to form inner lining of 2 nostrils. These flaps were based on healthy dermabraded skin to ensure adequate blood supply. Residual septal and conchal cartilages were used for primary support. Standard ipsilateral paramedian forehead flap with slight oblique design was used for resurfacing. Final assessment of airway patency and alar rim contour was made by the patient at 6 months as satisfactory, just satisfactory, and not satisfactory. There were 12 female and 6 male patients. There was necrosis of distal portion of the forehead flap in 1 case. Partial graft loss at the donor site with bone exposure was noted in another case. There was partial dehiscence and necrosis of turndown flap in 3cases. Mean flap size was 2.05 ± 0.28 cm. As regards airway patency, 12 patients were satisfied, 4 patients were just satisfied, and 2 patients were unsatisfied. When asked about alar rim contour, 3 patients said it to be satisfactory, 9 patients found it just satisfactory, and 6 patients declared it unsatisfactory. Nasal turndown flaps provide reliable tissue for the lining and allow primary placement of cartilage grafts.

Reducing the vermilion notch in primary lip repairs: Z-plasty versus the Noordhoff triangular flap.

OBJECTIVE: To compare Z-plasty and the Noordhoff flap for reducing notching in the vermilion during primary repair. STUDY DESIGN: Comparative study. PLACE AND DURATION OF STUDY: Plastic Surgery Department, Mayo Hospital, Lahore, from March 2008 to August 2010. METHODOLOGY: Patients presenting for primary unilateral cleft lip repair were included. The modified Millard's technique was used for lip repair. The percentage of the total vermilion thickness notched was recorded at 6 months follow-up. The repair was graded as: < 0.5 mm good, > 0.5 mm but < 1 mm satisfactory and > 1 mm poor. Patient satisfaction was rated on a scale of 1 to 10, with 10 being the happiest patient. RESULTS: In Group 1 (Z-plasty) 25 patients, and in Group 2 (Noordhoff flap), 20 patients achieved a good result. Five patients in Group 1 and 7 patients in Group 2 achieved a satisfactory result. Three patients in Group 2 had a poor result. Patient satisfaction and vermilion repair were comparable when comparison was made between the two groups (p > 0.05). CONCLUSION: The Noordhoff flap needs more expertise and finesse. All 3 poor results were achieved early in the study. Z-plasty was easier to execute and gave a good result in almost all hands.