Facial Scar Management by Hair Transplant: A Case Report.

Facial scars in hair-bearing areas are a difficult problem to deal with owing to the nature of the scar tissue and the poor survivability of the grafts. A 26-year-old male presented with a scar on the right cheek area. The patient complained of recurrence and widening of scar and resultant facial asymmetry after serial excision in another hospital. The scar was the result of a burn injury sustained 15 years back. The scar was managed by using 2,642 hair grafts harvested from the scalp area. The patient had excellent hair growth at the end of 1 year with a high satisfaction level. There was a visible improvement in the lip deviation. Restoration of hair in the hair-bearing region of the face may be considered a permanent single-stage solution in such patients.

Comparative Analysis of Early Excision and Grafting vs Delayed Grafting in Burn Patients in a Developing Country.

The present study attempts to compare how the patients who undergo early excision and grafting behave as compared with patients who are treated along usual conservative lines of management in centers where the resources are less than optimal. The data of 20 female patients were analyzed. Age of the patients ranged between 20 and 30 years, percentage area burn ranged between 20 and 40%, and percentage area resurfaced by skin grafting 5 to 10%. The patients were divided into two groups of 10 patients each. Group I included those patients who underwent early excision and grafting within 5 days of burn injury. Group II included those patients who were treated conservatively and the residual raw area was grafted 3 weeks or more after sustaining the burn. The two groups were compared for the amount of blood loss, transfusion requirement, graft take, and the total hospital stay. Statistical significance was tested by the application of Mann-Whitney U test. The mean percentage area burn was 29.1 ± 5.6% in group I and 24.7 ± 4.9% in group II. Mean percentage area resurfaced by skin grafting in group I was 9.4 ± 2.3% and 8.1 ± 1.6% in group II. Graft take in group I was 90 ± 7.8%, whereas that in group II was 95 ± 6.7%. Mean blood loss in group I and group II was 346 ± 17.6 ml and 241 ± 14.7 ml respectively. (P = .001). Mean transfusion requirement in the perioperative period was 1.6 pints in group I and 1.1 pints in group II. The mean hospital stay in the patients who underwent early excision and grafting was 15.1 ± 4.1 days, whereas that in the patients who underwent delayed grafting was 36.2 ± 6.3 days (P = .001). Early excision and grafting decreases the hospital stay of burn patients. The present study suggests that it has a definite applicability even in places where the resources might be less than optimal.

Education in plastic surgery: Are we headed in the right direction?

INTRODUCTION: Plastic surgery in India is in an era of transition. The speciality faces many challenges as it grows. The present study attempts to identify these challenges and the prevalent mood among the teachers and the trainees. MATERIALS AND METHODS: The study was conducted from September 2011 to June 2012. In an E-mail based survey a questionnaire was mailed to professionals actively involved in teaching and training of residents in plastic surgery in many institutes running MCh courses in plastic surgery (Group I) [Appendix 1]. Another questionnaire was mailed to residents undergoing training in plastic surgery and those who had completed their training within past 2 years (Group II) [Appendix 2]. Chi-square test was applied to test for statistical significance. OBSERVATIONS: 29 Group I and 33 Group II subjects responded to the questionnaire. While 72.4% teachers believed that the current system is producing plastic surgeons with enough skill level, only 9.1% of the respondents in Group II thought the same (Chi-square = 28.1; df = 2; P < 0.001). Whereas 58.6% Group I respondents thought that their student is sufficiently equipped to compete in today's scenario [Figure 1], only 18.2% Group II respondents thought that their training is enough [Figure 2]. (Chi-square = 16.4; df = 2; P < 0.001). Nearly 28% respondents in Group I and only 3% in Group II thought that scientific research and publications should be made mandatory for successful completion of plastic surgery training (Chi-square = 9.4; df = 2; P = 0.009). Adequate exposure was thought to be available in general plastic surgery (Group I: 92% Group II: 81%), maxillofacial surgery (Group I: 72% Group II: 68%) and hand surgery (Group I: 84% Group II: 69%). Both groups agreed that exposure is lacking in craniofacial surgery, aesthetic surgery and microvascular surgery. Aesthetic surgery (38.7%) and microvascular surgery (32.6%) were the most frequent response when the Group II respondents were enquired about the subspeciality they would like to focus on in their practice. Inter-departmental exchange of students for limited period of time was favoured by 86.2% of Group I respondents and 93.9% Group II respondents (Chi-square = 1.3; df = 2; P = 0.49). CONCLUSION: The current training programme is differently perceived by teachers and the trainees. We recommend that constant deliberations at national and regional forums should take place regarding our education and training programmes.

Serial splintage: Preoperative treatment of upper limb contracture.

INTRODUCTION: The present study aimed to study the efficacy of preoperative splints in treatment of upper limb contractures and to evaluate the response of contracture to splints depending on the etiology and the joint involved. METHODS: Ninety joints of 42 patients were studied. Patients age, gender, etiology, duration of contracture, contracture site and joint and type of contracture was noted. The range of motion of the involved joint was recorded. Serial static splints made of thermoplastic material were applied after customizing them for each patient. The range of motion and percentage movement was recorded at weekly interval and the splints were modified as per need. Time taken to reach a plateau stage was noted. To compare the statistical significance between two groups and more than two groups of continuous variable unpaired t-test and one way ANOVA respectively was applied. We considered differences to be statistically significant when the p value was below 0.05. The strength of relationship between the two continuous variables was analyzed by Pearson correlation analysis. RESULTS: Etiological factors were thermal burns (36.7%), electrical burns (13.3%), post traumatic (35.6%) and post cellulitis (14.4%). Age ranged from 2 to 70 years with a mean of 28.9±13.4 years. Sixty-two patients treated were males (68.9%) and 28 were female (31.1%). The mean range of motion present across all joints before starting the therapy was 54.7±23.6 degrees. The mean improvement in contracture angle obtained by serial splintage was 37.4±28.1 degrees. The mean time taken to achieve plateau was 23.6±3.2 days. Maximum improvement was seen in thermal burn contractures (41.2±30.3 degrees). Least improvement was seen in contractures due to cellulitis (6.5±16.2 degrees). This finding was statistically significant [F(3,86)=4.25, p=0.005]. Significant difference was seen in response to therapy based on the joint involved [F(3,86)=3.36, p=0.02]. Highest improvement in the range of motion was seen in the metacarpophalangeal joint (49.61±31.3 degrees). CONCLUSIONS: The preoperative use of splints may lead to lesser surgical intervention and in selective cases obviate surgery. Thermal burns which are the most common cause of contractures of the upper limb, show the maximum response to preoperative serial splintage. Patient with minor contracture and supple tissues are fully corrected with splints without surgical intervention. In patients undergoing surgical correction, skin graft decreases due to decreased contracture angle.

Trophic ulcers-Practical management guidelines.

The management of patients with trophic ulcers and their consequences is difficult not only because it is a recurrent and recalcitrant problem but also because the pathogenesis of the ulcer maybe different in each case. Methodically and systematically evaluating and ruling out concomitant pathologies helps to address each patient's specific needs and hence bring down devastating complications like amputation. With incidence of diabetes being high in our country, and leprosy being endemic too the consequences of neuropathy and angiopathy are faced by most wound care specialists. This article presents a review of current English literature available on this subject. The search words were entered in PubMed central and appropriate abstracts reviewed. Relevant full text articles were retrieved and perused. Cross references from these articles were also reviewed. Based on these articles and the authors' experiences algorithms for management have been presented to facilitate easier understanding. It is hoped that the information presented in this article will help in management of this recalcitrant problem.

Clinicopathological analysis of eyelid malignancies - A review of 85 cases.

BACKGROUND: Resection of eyelid malignancies leads to complex reconstructive problems due to the functional and aesthetic importance of an eyelid. Hence, a large number of such cases are referred to plastic surgery facilities. Eyelid malignancies are of varied histological types and the western and Asian data have considerable variations in case distribution and presentation. This study is an attempt to characterise these tumours in the Indian population. MATERIALS AND METHODS: The present study is a retrospective analysis of 85 consecutive cases of eyelid malignancies that reported to a tertiary health care facility in central India over a 15-year period starting from January 1996 up to December 2009. The cases were analysed for their age of presentation, sex distribution, tumour location, delay in seeking treatment, recurrence rate and variations with respect to the pathological subtype. OBSERVATIONS: Mean age of presentation for all the malignancies was 59 years. The median age of presentation was 65 years for basal call carcinoma (BCC), 58 years for sebaceous gland carcinoma (SGC), 55 years for squamous cell carcinoma (SCC) and 45 years for malignant melanoma. There was slight female preponderance as 56.28% of the patients were females. The most common location of the tumour was lower lid (58.2%) for all the malignancies. BCC was the most common malignancy (48.2%) followed by SGC (31.2%) and SCC (13.7%). Mean duration of symptoms was 9 months (range 3-21 months). The most common presenting complaint was mass with ulceration across all histological subtypes. Other associated complaints included itching, discharge from eye, pain and ptosis. The mean size of tumour at diagnosis was 2.34 ± 0.4 cm for BCC, 2.19 ± 0.6 cm for SGC and 1.99 ± 0.7 cm for SCC. The mean rate of growth of BCC was 1.39 cm/year. The corresponding values for SGC and SCC were 3.63 and 4.89 cm/year, respectively. The rate of follow-up was 89% at 3 months, 71% at 6 months, 62% at 1 year and 31% at 5 years. Recurrence rate was 1.9% for BCC and 12.7% for SGC. Surgical methods used included wedge excision and primary closure, excision and skin grafting, and tarso-conjunctival flap. CONCLUSIONS: We recommend that the surgeons treating eyelid malignancies in India should have a high index of suspicion for SGC. A wider margin of 10 mm is recommended for SGC excision as opposed to 5 mm for BCC.

Normal mouth opening in an adult Indian population.

BACKGROUND: Mouth opening among different population has been shown to vary considerably and its range is specific for a given population. The present study is an attempt to calculate the normal mouth opening in adult Indian population. METHOD: A total of 894 adults, 463 males and 431 females, in the age range of 21 to 70 years were studied. The subjects were asked to open their mouth maximally till no further opening was possible. The distance from the incisal edge of the upper incisor teeth to the incisal edge of the lower incisor teeth was measured using a calibrated fiber ruler. To determine correlation of mouth opening with age a Pearson correlation analysis was performed and statistical significance was tested by the application of t test. OBSERVATIONS: The mean maximal mouth opening for males was 51.3 mm (SD 8.3) (Range 39-70 mm). The mean maximal mouth opening for females was 44.3 mm (SD 6.7) (Range 36-56 mm). There was significant difference between the mouth opening of male and female in all the age groups with P value <0.05. A linear relationship was observed between the mouth opening and age in both males and females and the mouth opening decreased as the age increased. CONCLUSION: The mean maximal mouth opening for Indian males is 51.3±8.3 mm and for females is 44.3±6.7 mm. The mouth opening seems to decrease with age. The mouth opening of females is significantly less than the males in all the age groups.

The average Indian female nose.

BACKGROUND: This study aimed to delineate the anthropometric measurements of the noses of young women of an Indian population and to compare them with the published ideals and average measurements for white women. METHODS: This anthropometric survey included a volunteer sample of 100 young Indian women ages 18 to 35 years with Indian parents and no history of previous surgery or trauma to the nose. Standardized frontal, lateral, oblique, and basal photographs of the subjects' noses were taken, and 12 standard anthropometric measurements of the nose were determined. The results were compared with published standards for North American white women. In addition, nine nasal indices were calculated and compared with the standards for North American white women. RESULTS: The nose of Indian women differs significantly from the white nose. All the nasal measurements for the Indian women were found to be significantly different from those for North American white women. Seven of the nine nasal indices also differed significantly. CONCLUSIONS: Anthropometric analysis suggests differences between the Indian female nose and the North American white nose. Thus, a single aesthetic ideal is inadequate. Noses of Indian women are smaller and wider, with a less projected and rounded tip than the noses of white women. This study established the nasal anthropometric norms for nasal parameters, which will serve as a guide for cosmetic and reconstructive surgery in Indian women.

Effect of aging on the shape and position of the eyebrow in an Indian population.

BACKGROUND: The eyebrow is one of the most important structures of the face from an aesthetic point of view. As age increases, the brow changes its shape and position. This age-related change decreases the vitality, youth, and expression associated with the aesthetically ideal face. This article describes changes in eyebrow position in Indian women with aging. METHODS: This study recruited 80 female subjects for each of the required age ranges (20-30 years and 50-60 years) from the staff and outpatient settings at a tertiary care center in central India. Women who had any condition that could affect the measurements were excluded from the study. Standardized digital photographs in frontal view were captured with the forehead and eyebrows in a maximally relaxed position and with the eyes open. Eyebrow position was determined by measuring from a reference horizontal plane drawn between the medial canthi to vertical points on the upper brow margin at the medial canthus, pupil, and lateral canthus. The result was statistically analyzed. RESULTS: With aging, the least rise was seen in the lateral segment, which was not statistically significant. This difference was statistically significant at the medial and midbrow positions (p < 0.05). In the younger group, the lateral brow position was significantly higher than the midbrow (p < 0.05). In contrast, the older group showed a nonsignificant difference in the position of the midbrow and the lateral brow. The mean horizontal distance of the brow apex from the midpoint of the pupil for young women was 15.2 mm. CONCLUSION: The study results imply that the brow does not drop in women with age. It is recommended that in most instances, the lateral brow should be preferentially elevated, whereas the medial brow should undergo minimal or no elevation. Most patients require brow reshaping by restoration of the brow apex lateral to the level of the outer corneal limbus. By comparing eyebrow shape and position in both young and mature women, this study provides objective data that can be used to plan forehead-rejuvenating procedures in Indian women.

Anthropometry of the eyelid and palpebral fissure in an Indian population.

BACKGROUND: The shapes of the eyebrow and upper eyelid are distinctive facial landmarks. In cosmetic and reconstructive procedures, maintenance of the anatomical relations of these landmarks ensures a pleasing postoperative appearance. OBJECTIVES: The authors establish normal values for eyelid anthropometry in an Indian population. METHOD: This prospective study included 216 patients between the ages of 16 and 60 years, divided into three groups by age (Groups A to C: 16 to 30 years, 31 to 45 years, 46 to 60 years, respectively) and sex. All patients were photographed from a frontal view, with measurements taken from these photographs. Parameters included the distance between the medial canthus and the lateral canthus (ie, the width of the palpebral fissure), the distance between the open upper eyelid margin and the lower eyelid margin, (ie, the vertical dimension of the palpebral fissure), the intercanthal distance, the interpupillary distance, and the height of the open upper lid. All measured values were analyzed by independent t-test. RESULTS: There was a significant increase in palpebral fissure from Group B to Group C. A significant increase was also observed in intercanthal distance as age progressed beyond 45 years. There was a significant decrease in the interpupillary distance as age increased-from Group A to Group B and from Group B to Group C-and a similar increase in eyelid height in that age progression. CONCLUSIONS: The anatomy of the Indian population is distinct in that the palpebral fissure in men is less than that in women. It appears that changes in the eye become more pronounced after 45 years, including an increase in palpebral fissure, intercanthal distance, and height of the upper lid, along with a decrease in interpupillary distance.

Aesthetic surgery: expanding horizons: concepts, desires, and fears of rural women in central India.

BACKGROUND: We are experiencing greater demand for aesthetic surgery from rural populations. The present study attempts to understand their concepts and beliefs. METHODS: A double-blinded survey with random sampling was done in 34 villages in central India. Sample population consisted of 1,000 unmarried rural women in the age range of 18-30 years. Subjects were interviewed in person and a questionnaire was filled out based on their response. RESULTS: The response rate was 87.2%. Of the 872 respondents, 829 (95%) were aware of aesthetic surgery. Television was the most common source of information (61%). Health-care providers were a source of information for 2.5% of respondents. Aesthetic surgery was associated with "some change in face" by 35.7% of subjects. Surprisingly, 29.1% associated aesthetic surgery with face transplantation. The need for aesthetic surgery was perceived by 85.7% respondents. The face was the most common part of the body perceived to require aesthetic surgery (40.9%). Fifty-seven percent of respondents failed to identify the procedure required for aesthetic correction. Of the 711 respondents who perceived the need for an aesthetic procedure, 83.8% were willing to undergo surgery. Improved marriage prospects were the most common reason for seeking surgery. Cost was the most important variable considered while choosing surgery (49.3%). Cost was also the most frequent response when asked about the biggest fear (63.1%). CONCLUSION: We recommend that scientific knowledge should be provided to the rural population, cost should be limited to a reasonable level, and the social needs of these patients should be fulfilled to ensure a greater reach of aesthetic procedures.

Changing patterns in demography of cleft lip-cleft palate deformities in a developing country: the Smile Train effect--what lies ahead?

BACKGROUND: The past decade has seen tremendous changes in the management of cleft deformities with the advent of the Smile Train project. The present study evaluates the effect of the Smile Train project on the demographics of cleft deformities. METHOD: Data collected over the past three decades were studied retrospectively. The number of cases, age at presentation, and relative proportion of cleft lip-cleft palate patients were analyzed. Thirty patients operated on at the authors' institute for cleft lip deformity were evaluated for their awareness of cleft deformities, and the results were compared with those of 22 patients operated on elsewhere in camp settings. RESULTS: The numbers of patients with cleft deformities treated at the authors' institute from 1980 to 1989, 1990 to 1999, and 2000 to 2009 were 1189, 1050, and 374, respectively. However, the number with cleft palate has remained nearly constant over the three decades. The mean age of reporting for treatment of cleft palate was 16 months after being operated on for cleft lip at the authors' institute and 41 months after being operated on elsewhere in camps. All patients operated on at the authors' institute expressed awareness of holistic treatment of cleft deformities. Of the 22 patients operated on at other camps, 16 were ignorant about the time scale and 19 were unaware of the consequences of nonadherence to the treatment protocol. Nineteen of the 22 patients felt that enough information was not provided to them at initial surgery. CONCLUSION: The authors recommend that cleft counseling, continued cleft care for the complete complex of deformities, and responsible behavior by the initial operating team should be the goals for the future.

Changing patterns in electrical burn injuries in a developing country: should prevention programs focus on the rural population?

In the developing world, the incidence of electrical injuries has increased in the past few years. This study attempts to identify the causative and demographic risk factors that can help in formulating a targeted prevention program. The study was conducted prospectively and retrospectively from 2004 to 2009. Eighty-four consecutive patients with electrical burn injuries were analyzed for their demographic profile, age, sex, occupation, rural-urban distribution, mode of injury, and place of injury. The patients were asked to fill out a questionnaire regarding their awareness about electrical burn injuries, and the results were tabulated. The age of presentation ranged from 3 to 61 years. The most frequently affected age group was the second decade of life (33.3%). Of 84 patients studied, 71 were male and 13 female. Fifty-nine patients were from the urban area, while 25 were from the surrounding rural area. Students including children and adolescents were the most common affected single group (22.5%). Contact with live wire or contact with an object that was in contact with a live wire (secondary contact) accounted for 43 of 84 cases (51%). Home was the most common location where injury occurred (51.2%). Twenty-one of 59 cases (35.6%) reported from the urban area and 3 of 25 cases (12%) from the rural area had specific knowledge about prevention of electrical burn injury. Forty-one patients (69.4%) from the urban area and 22 (88%) from the rural area believed that adequate information regarding electrical burn injury was not available. Thirty-six patients (61%) from the urban area and 24 (96%) from the rural area believed that they would have behaved differently if the information had been available. The authors recommend that prevention programs should be modified to cater to the specific needs of the younger age groups and the rural population.

Schwannoma of upper eyelid: A rare differential diagnosis of eyelid swellings.

Schwannoma is a relatively rare benign tumour of peripheral nerve origin. The occurrence of Schwannoma in eyelid is extremely rare. As per our knowledge, only 11 such cases have been reported in the literature so far. We present a case of a 40-year-old man who presented to us with a 2-year history of slowly enlarging, painless mass in his left upper lid with resultant progressive ptosis. Ocular examination was suggestive of a firm, non-tender nodule of size 2 × 1.5 × 1 cm on the left upper lid. The mass was non-adherent to the skin or the underlying tissue. The eyelid skin and conjunctiva were indurated and signs of inflammation were present. The lateral part of eyelid showed presence of an ulcer and the lid function was severely hampered. Provisional clinical diagnosis was that of an eyelid malignancy. With this in mind, the medial part of the lid was excised and reconstructed using a tarso-conjunctival flap from the lower eyelid in conjunction with a skin graft. The histopathology and immunohistochemistry established the diagnosis of Schwannoma. We recommend that Schwannoma be considered in the differential diagnosis of well-circumscribed eyelid swellings.

Modified technique in Freyer's prostatectomy to achieve hemostasis.

This study is an attempt to develop a technique by which complete hemostasis can be achieved on table by giving traction to the Foley's catheter thereby compressing the venous plexus and the avulsed prostatic arteries at the bladder neck by the inflated balloon. A total of 170 cases of BPH were operated by Freyer's Suprapubic Trans-vesicle prostatectomy. In the technique, bladder mucosa is reposited below the balloon and the balloon is inflated to 60 ml of normal saline. The balloon is kept at the bladder neck and traction is applied to the catheter. Traction is maintained by strapping the catheter to the thigh of the patient with sticking plaster for 24-48 h. The average blood loss was 18.9 ml which proves that the Foley's balloon pressure traction method at the bladder neck is effective in achieving hemostasis in patients undergoing open prostatectomy.

Effect of Candida infection on outcome in patients with perforation peritonitis.

Perforation peritonitis is treated with surgery and antibiotics. This study was conducted to identify bacterial and fungal microorganisms responsible for peritonitis in patients with hollow viscus perforation and to examine the influence of these microorganisms on the outcome. A prospective study was conducted from May 2005 to September 2006 involving 84 consecutive patients with spontaneous gastrointestinal perforation peritonitis, who were referred for surgery. Peritoneal fluid was analyzed by microbial culture and biochemical tests for bacteria and fungi. The Jabalpur Prognostic Score was calculated. Forty-two of the 84 patients had positive peritoneal fluid cultures. Escherichia coli was the most common bacterium (n=26) and Candida (n=13) the most common fungus isolated. Bacterial isolates were largely sensitive to amikacin while all the Candida isolates were sensitive to fluconazole. Mortality was significantly higher in patients with positive peritoneal cultures (15/42) compared with those with negative peritoneal cultures (0/42, p<0.001), and in patients with mixed bacterial and fungal-positive cultures (10/13) compared with those with isolated bacterial cultures (5/29, p<0.001). Using the Jabalpur Prognostic Score, positive fungal cultures were found to be associated with a significantly higher than expected mortality. Patients with gastrointestinal perforations and positive peritoneal cultures have a poor prognosis, which is significantly worsened by the association of positive fungal cultures. Early recognition and treatment of fungal infection is advisable.

Acute gastrointestinal emergencies requiring surgery in children.

BACKGROUND: Although abdominal pain is common in the paediatric age group, problems of misdiagnosis and serious consequences are more particular in an emergency setting. This study examined the aetiologies of acute abdominal emergencies in children. MATERIALS AND METHODS: This was a retrospective study of 100 children below the age of 12 years presenting with acute abdominal emergencies (gastrointestinal) requiring operative interventions. All patients were operated on an emergency basis and the intraoperative findings were correlated with the clinical findings. RESULTS: Acute abdominal emergencies in the paediatric age group were heterogeneous, with a myriad of aetiological factors. Overall, 73% of patients were greater than 3 years of age. Early neonatal period formed the second most common group (12%). Acute appendicitis was the most common cause except in the infancy period where congenital abnormalities predominated. CONCLUSION: The correct diagnosis of acute abdomen in children requires attention to clinical details and a high degree of suspicion. Early surgical intervention in doubtful cases may be necessary to solve diagnostic problems.