A multidisciplinary approach to triage patients with breast disease during the COVID-19 pandemic: Experience from a tertiary care center in the developing world.

BACKGROUND: The COVID-19 pandemic has created a need to prioritize care because of limitation of resources. Owing to the heterogeneity and high prevalence of breast cancers, the need to prioritize care in this vulnerable population is essential. While various medical societies have published recommendations to manage breast disease during the COVID-19 pandemic, most are focused on the Western world and do not necessarily address the challenges of a resource-limited setting. AIM: In this article, we describe our institutional approach for prioritizing care for patients presenting with breast disease. METHODS AND RESULTS: The breast disease management guidelines were developed and approved with the expertise of the Multidisciplinary Breast Program Leadership Committee (BPLC) of the Aga Khan University, Karachi, Pakistan. These guidelines were inspired, adapted, and modified keeping in view the needs of our resource-limited healthcare system. These recommendations are also congruent with the ethical guidelines developed by the Center of Biomedical Ethics and Culture (CBEC) at the Sindh Institute of Urology and Transplantation (SIUT), Karachi. Our institutional recommendations outline a framework to triage patients based on the urgency of care, scheduling conflicts, and tumor board recommendations, optimizing healthcare workers' schedules, operating room reallocation, and protocols. We also describe the "Virtual Blended Clinics", a resource-friendly means of conducting virtual clinics and a comprehensive plan for transitioning back into the post-COVID routine. CONCLUSION: Our institutional experience may be considered as a guide during the COVID-19 pandemic, particularly for triaging care in a resource-limited setting; however, these are not meant to be universally applicable, and individual cases must be tailored based on physicians' clinical judgment to provide the best quality care.

Mandibular reconstruction using osteocutaneous radial forearm flap.

OBJECTIVE: To describe the use of radial forearm osteocutaneous free flap in complex mandibular reconstruction. STUDY DESIGN: A case series. PLACE AND DURATION OF STUDY: Combined Military Hospital, Rawalpindi, from January 1998 to January 2008. METHODOLOGY: Patients having a small bony component and a large soft tissue mandibular defect requiring reconstruction were selected. These defects include composite through-and-through defects of the cheek in the retromolar trigone, small lateral bony defects with large intra and extra oral soft tissue defects and small central bony defects with large extra oral tissue loss. Radial forearm osteocutaneous free flap was employed. Complications and graft acceptance were determined at follow-up. RESULTS: Patients were followed-up for an average period of 28 months. Complications occurred in 8 patients. Wound infection and partial wound dehiscence were the most common complication observed in 3 patients. Non-union at recipient site was seen in 2 patients. Flap donor site healed uneventfully in all patients with no fractures at the donor site. CONCLUSION: The radial forearm osteocutaneous flap covers oromandibular defects with large intra-oral and extra oral soft tissue losses. Lateral and anterior mandibular defects were reconstructed satisfactorily in our series.

Quality of life assessment in patients with locally advanced head and neck malignancy after ablative surgery and reconstruction with microvascular free flaps.

OBJECTIVE: To assess the improvement in Quality Of Life (QOL) after ablative surgery in locally advanced head and neck malignancies by microvascular free flaps reconstruction. STUDY DESIGN: Quasi-experimental. PLACE AND DURATION OF STUDY: Department of Plastic Surgery, Combined Military Hospital, Rawalpindi, from September 2005 to February 2007. METHODOLOGY: A total of 44 patients with locally advanced stage III and IV malignancy of head and neck were included in the study. All patients were treated with ablative surgery and reconstruction with microvascular free flaps. QOL was assessed by using a scoring questionnaire (including 5 parameters for extra oral cancers including physical and role function, body image, weight loss score and pain donor site morbidity; and an additional 5 parameters for intraoral tumours that included swallowing, speech, drooling of saliva and mouth opening). A high score indicated a poor QOL. Patients were assessed pre-operatively and then at 2, 4 and 6 months postoperatively. RESULTS: Mean accumulative score and mean individual parameter scores for both extra- and intraoral tumours were significantly improved (p < 0.05). CONCLUSION: Microvascular free flap reconstruction after ablative surgery in locally advanced head and neck malignancy had a profound impact on the improvement of QOL. There was an initial deterioration of physical scores postoperatively and postradiotherapy, followed by gradual improvement. By the end of 6 months, it surpassed the pre-operative QOL scores.

Limb salvage in malignant tumours of the upper limb using vascularised fibula.

INTRODUCTION: Modern reconstructive techniques can prevent amputation in most cases of malignant musculoskeletal tumours. The free fibula has emerged as the primary method of bridging long bone gaps during limb salvage. METHODS: Limb salvage was attempted in 23 patients (15 males and eight females) aged 17-57 years. The tumour was located in the humerus in 18 patients, radius in four patients and the metacarpals in one patient. Osteogenic sarcoma was the most common tumour (11 cases) followed by Ewing's sarcoma in six patients. After neoadjuvant chemotherapy, MRI was repeated and resectability assessed. Wide local excision was performed and the bony defect bridged by free fibulae. RESULTS: All the flaps survived. The average length of defect reconstructed was 18 cm and the average time for bone union was 7 months. At a minimum follow up of 12 months, 21 patients were alive and disease free. One patient required amputation due to recurrence and one died of metastatic disease. Secondary surgery was needed in eight patients (five tendon transfers, two latissimus dorsi flap readjustments and one bone graft). Overall patient satisfaction was high with 21/23 patients having a useful limb. CONCLUSION: Limb salvage in the upper limb using vascularised fibula in patients with malignant musculoskeletal tumours can result in good tumour control along with reasonable limb function.

The 'expansile' supraclavicular artery flap for release of post-burn neck contractures.

UNLABELLED: Soft tissue defects in the cervico-facial region can result from trauma, tumour excision or post-burn scarring. All rungs of the reconstructive ladder offer possible reconstructive options for these defects. The supraclavicular artery based flap is an extremely reliable local flap for this purpose. It offers thin and pliable skin with good colour match and minimal donor site morbidity. An additional advantage, in our experience, is that this skin can stretch postoperatively to allow further improved neck contour and mobility. MATERIALS AND METHODS: Between June 2000 and January 2004, 27 patients underwent reconstruction of neck defects after release of post-burn contractures with the supraclavicular artery based skin flap at our hospital. After discharge the first follow-up visit was on the 10th postoperative day. The patients were advised to wear a custom made Watusi splint for 3 to 4 months. The patients were subsequently followed up at 3 months, 6 months and 1 year. The dimensions of the flap were measured and the patients photographed at the time of discharge and at subsequent visits. RESULTS: All the flaps survived completely. The average operating time for contracture release and flap coverage was 2 h. The hospital stay ranged from 5 to 8 days. Follow-up ranged from 1 to 4 years with an average of 22 months. Complications included epidermolysis (n=2) and delay in donor site healing (n=2). Almost all patients had some widening of the donor site scar. In our experience the width of the flap increased in the postoperative period. At the time of surgery, the width of the flap ranged between 9 and 12 cm. At the 3-month follow-up there was an average increase in width of 24.2%. At 6 months, the average increase in width was 42.8% of the original flap width. At 1 year the average flap expansion was 63% of the original. The length of the flap ranged from 18 to 24 cm and generally remained unaltered during follow-up.