Attributes of a Good Microsurgeon-A Brief Counsel to the Up-and-Coming Prospects.

Microsurgery, which deservedly sits on top of the reconstruction ladder, has been a boon to plastic surgery. It is because of this marvelous tool that plastic surgeons the world over have been able to tackle many reconstructive dilemmas, which were once considered to be an improbability. Microsurgery-aided revolutions have rendered a new meaning to all forms of reconstruction-whether it is postoncological, posttraumatic, or postlymphedema reconstruction. As the most advanced reconstructive medium at our disposal that has broadened the horizons of plastic surgery exponentially, it is but obvious that many budding plastic surgeons are drawn toward this subspecialty. In lieu of the aforementioned facts, it is necessary to sensitize all such aspiring surgeons about the various intricacies concerning the field of microsurgery. This article with its focus on the six desirable microsurgical attributes of "Clarity, Curiosity, Perseverance, Passion, An Open Mindset and Action," is meant to be a modest attempt on part of the authors to share their microsurgical insights, procured through their respective journeys, with budding aspirants, hoping to sensitize as well as motivate them for the challenging path that lies ahead.

Chronic Fistulas of Thigh Presenting Unusually in an Operated Patient of Carcinoma Rectum. More Than What Meets the Eye!

Chronic skin lesions of the thigh (wounds, fistulas etc) are relatively uncommon, vis-à-vis, their notorious cousins over the distal limb. Even when present, the cause is usually obvious, mostly as trauma or a systemic affliction. We present an unusual case of chronic fistulas over the right thigh in a patient of carcinoma rectum for which anterior resection and an end colostomy was done 4 years earlier. Postsurgical pelvic abscesses finding their way into the thigh are a known entity, but they are usually accompanied by systemic/local features and their presentation is within a shorter time span. The novelty of our case lies in its manifestation (as a cluster of chronic fistulas and not a frank abscess), its late presentation as well as in the absence of any systemic/local inflammatory signs. Our primary objective is to educate wound physicians about the origin of such fistulas whenever they deal with patients who have had a preceding surgical intervention of the abdomen. In our humble opinion, this will ease out many diagnostic and management dilemmas, that such patients can potentially pose.

"Double Barrel" Lymphaticovenous Anastomosis: A Useful Addition to a Supermicrosurgeon's Repertoire.

Microsurgical amelioration of lymphedema has gained much traction in recent years and is now an established modality of treatment for this condition. Despite the development of many newer techniques, lymphaticovenous anastomosis still remains the most frequently carried out microsurgical procedure for lymphedema. One of the most common hurdles faced by lymphatic surgeons while carrying out a lymphaticovenous anastomosis is a mismatch in sizes of the vein and the lymphatic vessels. Method: This article describes a novel but simple "double barrel" technique, developed by the authors for carrying out lymphaticovenous anastomosis in cases of such lymphaticovenous mismatch. Seventeen double barrel anastomoses were carried out in 12 lymphedema patients, over a 4-year period from 2017 to 2021. Results: The overall success rate was 100%, as measured by clinical observation (venous washout, lymphatic backflow), the Acland vessel strip test, and by means of intraoperative ICG lymphography. Mild leakage was observed in four cases after release of the venous clamp and was corrected by application of additional sutures. Conclusions: The double barrel technique is a safe and effective tool that can be employed to deal with the bane of size mismatch, a persistent problem faced by lymphedema surgeons universally. Although we do not advocate it as a total replacement for other techniques, it can be a worthy addition to the present set of available options. In specific scenarios of mismatch with additional challenges, the double barrel technique has the potential to be considered as primus inter pares.

Excision, skin grafting, corticosteroids, adjuvant radiotherapy, pressure therapy, and emancipation: the ESCAPE model for successful taming of giant auricular keloids.

The authors treated 24 giant auricular keloids (mean size, 11 cm) from January 2008 to July 2012 using a novel protocol consisting of complete excision, skin grafting, a 1-time intraoperative injection of triamcinolone, immediate radiotherapy, and sustained pressure therapy. At 1 year, the success rate was 87.5%.

Actinomycetoma leg ulcers in north India.

INTRODUCTION: Actinomycetoma is a chronic subcutaneous infection caused by aerobic branching actinomycetes. Its clinical features are firm tumefaction of the affected site and the presence of abscesses, nodules, and sinuses that drain a seropurulent exudate containing filamenting granules. Cutaneous actinomycetoma has traditionally been deemed uncommon in the northern part of India, but recent studies have refuted this long-held notion. Thus, clinicians have to be more vigilant when they come across patients with long-standing cutaneous lesions with typical mycetomic features, as early diagnosis and treatment hold the key to a cure. MATERIALS AND METHODS: This prospective study was carried out from June 2009 to December 2012 and comprises 13 cases of chronic nonhealing ulcers of the lower limb subsequently diagnosed as mycetoma. Socioetiological aspects, prevalence, early diagnosis, and treatment modalities of this condition are described in the study along with a simple, yet inclusive, scoring system to evaluate the post-treatment results. RESULTS: Ten out of 13 cases with clinical suspicion of actinomycetoma were diagnosed with the condition. A majority of these diagnosed patients were middle aged and belonged to lower socioeconomic status. There was no sexual preponderance. Early treatment in the form of modified Welsh regime (amikacin + cotrimoxazole + rifampicin) was started and showed acceptable results. Post-treatment outcomes were measured on the basis of a new scoring system (Masoodi's score) devised by the authors. Two patients had a score of > 7 (good), 5 patients had a score of 4-6 (fair), and 3 patients had a score of ≤ 3 (poor). CONCLUSION: Correct identification of the infective aetiological agent is imperative to direct therapy against actinomycetoma. Treatment success depends on an early diagnosis and instigation of treatment. Efficacy of chemotherapy, if started after an early diagnosis in the form of modified Welsh regime, produces acceptable results in the form of clinical and physical remission or cure. The functional and cosmetic parameters do not respond as well to treatment and the authors propose a new scoring system which takes into account the post-treatment results in totality.

Motorcycle muffler-induced "pillion burns" of distal leg: a persistent problem of increasing proportions in Indian settings.

Motorcycles have emerged as a viable mode of transport for millions in the third world. Mufflers (exhaust pipes in some countries) remain a potential "Achilles' tendon" or a designing flaw in the mass-produced, economical motorcycles of the developing world. Owing to the excessive temperature they attain while the hot exhaust gases pass through them and their proximity to the lower limbs while riding a motorcycle, they can lead to burns of varying nature in the lower leg. This is a descriptive retrospective study of muffler-induced lower leg burns treated at our hospital from January 2008 to December 2012. Various parameters including history, exact mode of injury, age, sex, degree and location of burn, treatment modalities, and other relevant circumstantial/logistical factors associated with such injuries were noted; data were tabulated and statistically arranged to gain an insight into this problem. Possible interventions that may help avoid such injuries are also briefly mentioned. Certain findings that are quite distinct to the findings of a few earlier studies carried out on this topic (in the developed world) remain the highlight of our study. The typical muffler-induced burns in the Indian setting occur almost exclusively in the male pillions, most of the times in the right leg in an area near the medial malleolus, and are usually second degree and respond to conservative management. Prompt treatment can circumvent much of the dreaded complications. Preemptive efforts in designing of motorcycles and following traffic regulations at the individual level remain the key to prevention.

Aspects of sexual life in patients after burn: the most neglected part of postburn rehabilitation in the developing world.

Burn patients are rendered with physical as well as mental scars; the latter usually are more protean in their manifestations. Rehabilitation after burn can be a grueling experience and the associated stress can blemish the patient's sexuality and intimacy. There is dearth of literature regarding the quality of sexual life after burn as well as sexual rehabilitation; it is fully known that a healthy sexual life is intricately related to a person's mental well being and a sexually compromised person can never be totally happy. The objective of this study was to ascertain the degree of satisfaction in postburn patients regarding their sexual lives, parameters associated with sexual dissatisfaction, if present, and ways to address the same. Quality of sexual life was investigated by making burn patients answer the Maudsley Marital Questionnaire (the sexual scale only) 6 months after burn. A control group of nonburn patients matched with the cases was made to answer the same and values were compared for significance. Results of the Maudsley Marital Questionnaire sexual scale were obtained for both groups and compared by means of a χ test (Pearson). The results were found to be highly significant, and there was a marked difference in the values of the two groups (χ = 117.8945, two-tailed P < .0001). A readily palpable deterioration in the sexual lives of burn patients is the most significant finding of this study. Also highlighted were the sociodemographic characteristics of this sexually suffering group and various other relevant parameters.

Routine use of urinary hCG test in adult burn females to detect "hidden" pregnancies: a review.

Burns occurring in conjunction with pregnancy can be a potentially life threatening scenario as it may lead to a rapid depletion of the already diminished maternal reserves. The management protocol in a pregnant burn female has to be tailored, taking into consideration the additional factor of fetal well being and the fetal susceptibility to various agents. For such alterations to be incorporated, it is imperative on part of the treating doctor to correctly ascertain the pregnant/non-pregnant status of an adult burn female. Though most cases of pregnancy can be straightforwardly diagnosed on basis of history/examination but it is not a totally reliant method. Ours is a prospective study which reveals the inadequacy of history/examination as the only method of diagnosing pregnancy in adult burnt female group. We also found routine urinary hCG usage as a viable method of picking up these "hidden" cases of pregnancy and thus avert the potential catastrophe of not altering the management in accordance with pregnancy and subsequent endangering of maternal and fetal life. An ancillary observation of our study was the need of the attending doctor to be well versed in his obstetrical knowledge and skills and if not so, then an effort be taken on part of the institution to undertake a reorientation program which will help the attending resident/doctor to brush up his obstetrical attainments.

Changes in sleep architecture after burn injury: 'Waking up' to this unaddressed aspect of postburn rehabilitation in the developing world.

BACKGROUND: Changes in sleep architecture are common phenomena observed in post-traumatic patients; such altered sleeping patterns have negative implications on various phases of rehabilitation. Sleep is an essential process, without which one cannot function effectively and, hence, any aberrations in the quality of sleep in such patients need to be critically analyzed. OBJECTIVE: To probe the quality of sleep in postburn patients at one year compared with a group of adequately matched controls. METHODS: Quality of sleep in postburn patients at one year was measured using the Pittsburg Sleep Quality Index questionnaire and compared with a group of adequately matched controls. Data were tabulated and subjected to statistical analysis using Pearson's χ(2) test. RESULTS: The relationship between the postburn state and sleep disturbances was found to be statistically significant. Other relevant parameters are also highlighted and discussed. DISCUSSION: Sleep is one of aspect of functioning that may be least taken into account by professionals during the phase of postburn rehabilitation because more obvious threats receive preferred treatment. Unless these problems are dealt with in the postburn period, rehabilitation can never be complete. CONCLUSION: Postburn patients experience significant changes in sleep architecture, which need to be taken into account to enable complete rehabilitation of the patient.

HISTORIQUE: Les modifications à l'architecture du sommeil sont courantes chez les patients après un choc post-traumatique. Une telle perturbation des habitudes de sommeil a des conséquences négatives sur les différentes phases de la réadaptation. Le sommeil est un processus essentiel, sans lequel il est impossible de fonctionner avec efficacité. C'est pourquoi il faut procéder à l'analyse critique des aberrations à la qualité du sommeil de ces patients. OBJECTIF: Sonder la qualité du sommeil chez les patients qui ont subi des brûlures par rapport à celle d'un groupe de sujets témoins appariés de manière pertinente. MÉTHODOLOGIE: Les chercheurs ont mesuré la qualité du sommeil après que des patients eurent été victimes de brûlures à l'aide du questionnaire PSQI sur l'indice de qualité du sommeil de Pittsburg et ont comparé les résultats à ceux d'un groupe de sujets témoins appariés de manière pertinente. Ils ont mis les résultats en tableau et les ont soumis à l'analyse statistique au moyen du test du χ2 de Pearson. RÉSULTATS: Le lien entre le statut après les brûlures et les perturbations du sommeil a été considéré comme significatif. D'autres paramètres pertinents sont également soulignés et exposés. EXPOSÉ: Le sommeil est un aspect du fonctionnement dont les professionnels tiennent peut-être moins compte pendant la réadaptation après des brûlures, car les problèmes plus évidents sont favorisés. À moins qu'on règle ces problèmes dans la période suivant les brûlures, la réadaptation ne pourra jamais être complétée. CONCLUSION: Après des brûlures, les p atients présentent des changements importants à l'architecture de leur sommeil, dont il faut tenir compte pour mener leur réadaptation à terme.