Lipofilling-A Regenerative Alternate for Remodeling Burn Scars: A Clinico-Immunohistopathological Study.

Introduction Any injury involving the dermis will lead to scarring. Scar tissue can cause functional limitations, cosmetic impairments, pain, and itch. Adipose-derived stem cells have also been shown to play a role in scar modulation. This study evaluates changes in lipofilled scar over the period of time and compares it with non-lipofilled scar tissue. Materials and Methods A prospective case-control study with intraindividual follow-up was performed on 30 adult patients with post-burn scars from November 2016 to May 2019. Clinical, histopathological, and immunohistochemical parameters were assessed among the case and control regions of the scar. Results Mean age of the study population was 30.6 years. The duration of the scar included in this study ranged from 1 to 28 years, with a mean duration of 5.91 years. There was a significant reduction in pain, itch, stiffness, and an increase in the pliability of the scar, and a substantial improvement in the modified Vancouver Scar Score in the lipofilled group. In histopathological analysis, the case group showed organized parallel collagen fibers, a significant reduction in melanocytes, improvement in vascularity, and a significantly increased amount of collagen fibers at the reticular dermis. Immunohistochemical analysis indicated new cell synthesis in the scar tissue and reduced melanocytes. Conclusion The remodeling effect of adipocyte-derived stem cells is long-lasting, and there is a gradual improvement in most of the parameters. Lipofilling has regenerative capacity, which leads to the improved overall appearance of scar and improvement at the cellular level.

Cryogenic Refrigerant Burns: A Rare Occupational Hazard.

BACKGROUND: Cryogenic burns induced by coolant gases used in refrigerators and air conditioners are rarely encountered, despite the wide use of these gases. To date, only a few cases have been reported in the literature. This study examined the occupational circumstances leading to such injuries, relevant injury sites, types of chemicals involved, and treatment measures. METHODS: This study was conducted in a tertiary burn center in India between March 2015 and March 2019. The demographic details, chemicals involved, and burn regions and characteristics were analyzed. FINDINGS: There were 15 burn cases all involving injury to the hand. All injuries were managed initially with dressings and nonoperative management. One patient required anti-edema therapy with limb elevation and fingertip debridement, while another patient required skin grafting. All patients had satisfactory hand function after treatment. CONCLUSIONS/APPLICATION TO PRACTICE: Cryogenic burn injuries caused by refrigerants are rare, and their etiology varies considerably. Exposure time is the primary factor that determines burn depth and severity; hence, reducing exposure time is important in first aid. Our findings suggest that after exposure, the patient should be treated in a specialized burn center. Adequate knowledge regarding the pathophysiology of these types of burn injuries and their management is necessary; otherwise, misjudgments in the treatment plan can lead to adverse consequences.

Trapezius Transfer to Restore Shoulder Function in Traumatic Brachial Plexus Injury: Revisited and Modified.

Background: Trapezius transfer has shown promise to restore shoulder movements and has stood through the passage of time. We here in describe a modification of trapezius transfer technique and review the current literature available. Methods: The modified trapezius transfer in which the trapezius muscle is extended with folded tensor fascia lata graft and attached as distally possible to the deltoid insertion was done in twelve patients at tertiary health care centre in India. Post-operative splinting and staged physiotherapy were given. Results: Results were described in the form of improvement in degree of shoulder abduction and Disabilities of the Arm, Shoulder and Hand (DASH) score. Six months post-surgery there were improvement in shoulder abduction and DASH score with mean 116 degrees (10-180 degree) and 38 (23-58) respectively. One patient showed poor results due to poor compliance in post-operative period. There were no major complications observed. Conclusions: The modified technique of trapezius transfer described here is a feasible option with good biomechanical outcomes. The technique is simple and can be adopted easily by emerging brachial plexus surgeon as a technique for secondary reconstruction of shoulder joint.

Postburn Nasal Reconstruction With Distally Based Radial Artery Perforator Flap: A Novel Technique.

Postburn total nasal reconstruction associated with face burns is challenge to all reconstructive surgeons. The local tissue flaps for reconstruction is virtually out of options, forcing surgeons to opt for distant tissues for nasal reconstruction. Here in, we have described the use of distally based radial artery perforator flap for total postburn nasal reconstruction which has not been described for nasal reconstruction. The anatomy and technique of the flap and case series is presented in this report. Two cases of total nasal reconstruction using the distally based radial artery perforator flap are presented, one case post thermal burn and another post chemical burn. Radial artery distal perforator-based pedicled flap is a versatile option for nasal reconstruction especially when there is a paucity of unscarred skin in loco regional options.

"Namaste Flap": Modification of Subcutaneous Pedicle Propeller Flaps in the Reconstruction of Postburn Axillary and Elbow Contractures.

INTRODUCTION: The reconstruction of the postburn contracture area is always a challenge in the field of plastic surgery. Moreover, the joints are very sensitive to trauma and immobilization, showing a susceptibility to stiffness. The aim of this article is to emphasize the use of "Namaste flap"-modification of subcutaneous pedicle propeller flaps in the reconstruction of postburn axillary and elbow contractures. METHODOLOGY: This is a prospective case study of axillary and elbow contractures managed at a tertiary care hospital using Namaste flap-modification of subcutaneous pedicle propeller flaps from 2010 to 2016. The surgical technique involved raising 2-limbed subcutaneous pedicle-based propellar flap over the contracture using the unburnt skin at the axillary and cubital fossa. The flap with both the limb thus raised was rotated by 90 degrees in the same direction and inserted into the defect. RESULTS: Nine patients including 6 patients with elbow and 3 patients with axillary contractures were included in this study. The mean degree of contracture in axilla and elbow was 78.3 degrees and 59.1 degrees, respectively. The functional results postoperatively were satisfactory. The mean postoperative degree of joint movements in axilla and elbow was 176.3 degrees and 173.6 degrees, respectively. No major complications were encountered. There was a mean period of 12 months of follow-up. CONCLUSIONS: In cases where normal skin is still present on the axillary and cubital fossa with scar contracture caused by extensive burns, the subcutaneous propeller flap methods and their modifications should be considered one of the most useful versatile reconstruction methods. Namaste flap in addition to the advantages of subcutaneous pedicle propeller flap also negates the disadvantages caused by the use of split skin grafting of the donor area.

Synovial Sarcoma of Palm Masquerading as a Neural Tumor: A Challenging Differential Diagnosis.

Synovial sarcoma is one of the common soft-tissue tumors of the body and is usually found on the lower extremity, head-and-neck regions. Reports of monophasic variant of synovial sarcoma in the palm are a rare entity. It can present as a challenge for the surgeons mimicking other conditions. Very few cases of this malignancy are reported in the palm. Painful palmar mass is an unusual presentation for this variant of sarcoma. Preoperative suspicion and planned surgical approach pave the way for the proper management. Neoplasm of the hand is very challenging, as it needs surgical resection balancing with resection margin and functionality of the hand. These cases are notorious for late recurrences and metastasis. Long-term follow-up is of utmost importance. We are reporting a case of palmar monophasic synovial sarcoma with its management and follow-up.

Concept of Lethal Triad in Critical Care of Severe Burn Injury.

BACKGROUND: The trinity of hypothermia, acidosis and coagulopathy, the lethal triad in trauma setting is a well-known risk factor associated with high risk of death. Burn is also a pathological situation where inflammatory response, endothelial injury, hypovolemia, reduced end-organ perfusion, cellular hypoxia, and myocardial depression are frequently encountered. This study aimed to study the occurrence and outcome of patients presenting with the 'triad of death' in burn population. METHODS: The study population included patients between 18 years and 60 years presenting to the department with thermal and scald burns with total body surface area involving 50-70%. The study was conducted for a period of 180 days and patients were followed up for 30 days. A p value <0.05 was considered statistically significant. RESULTS: One hundred and ninety-six patients were admitted during study period. Fifty patients out of them were eligible and were included in the study. The average abbreviated burns score index was 11 in lethal triad subgroup when compared to eight in the subgroup without the lethal triad. The mortality in the subgroup with lethal triad was higher (68.8% vs 17.6%, p = 0.0009). The "on admission" acidosis, hypothermia, and coagulopathy were independently associated with significantly increased mortality. The overall relative risk of mortality in the presence of lethal triad was 3.896. CONCLUSION: This study reiterates the fact that the lethal triad is seen in burn patient. Burn associated with on admission lethal triad has significantly higher mortality rates. There are only countable studies addressing this issue in burn setting. HOW TO CITE THIS ARTICLE: Muthukumar V, Karki D, Jatin B. Concept of Lethal Triad in Critical Care of Severe Burn Injury. Indian J Crit Care Med 2019;23(5):206-209.

Adipofascial perforator flaps: Its role in reconstruction of soft-tissue defects of lower leg and ankle.

BACKGROUND: Despite advances in surgical skills, adipofascial flaps are still less preferred option for coverage of leg defect. We evaluate the use of perforator-based adipofascial flap in small-to-medium-sized soft-tissue defects in the lower limb. PATIENTS AND METHODS: After localisation of perforators along the major axial vessels in the lower limb using handheld Doppler, adipofascial flap based on the nearest best perforator of anterior tibial artery, posterior tibial artery and peroneal artery was raised to cover soft-tissue defect in 21 patients. The flap was transposed over the defect and covered by split-skin graft. Donor site was primarily closed. Flap complications, functional and aesthetic outcomes are noted in follow-up. RESULTS: There was partial loss of flap in five patients. After debridement and dressings, split-skin grafting was done for four patients and one patient was managed with local flap. Scar over the flap was stable with no reports of recurrent ulceration or breakdown of wound in 6-month follow-up. Four of five patients reported adequate healing of the fractured bone. Average visual analogue score was 8.24/10 for appearance of donor site as evaluated by the patient. CONCLUSIONS: Perforator-based adipofascial flap is a good alternative for coverage of small-to-medium-sized soft-tissue defect of the leg, particularly over the malleolus and lower part of the leg. Use of adipofascial tissue and primary closure of the donor site causes minimal donor-site morbidity. Adipofascial perforator flap provides aesthetically superior recipient-site scar with satisfactory functional outcome.

Role of Square Flap in Post Burn Axillary Contractures.

BACKGROUND: Post-burn contractures are a commonly encountered problem and many techniques have been described in their treatment. Z-plasties are the commonest local flap procedure done for linear bands with adjacent healthy tissue. Our aim was to assess the use of square flap technique in axillary contractures. METHODS: Ten patients with type I and II axillary contractures underwent release by the square flap technique. All cases were followed up for at least one year and analysed for range of motion and aesthetic outcome. RESULTS: All cases achieved full range of movement postoperatively with no recurrence during follow up period and a good cosmetic outcome. CONCLUSION: Square flap was shown to be a reliable technique for mild to moderate axillary contractures of the anterior or posterior axillary folds even when there is significant adjacent scarring of chest wall or back of types I and II.

A review and critical appraisal of central axis flaps in axillary and elbow contractures.

Contractures of the axilla and elbow can produce a significant impact on quality of life by reducing the ability to perform activities of daily living. Varieties of techniques are available for resurfacing defects following contracture release but graft or flap loss, donor-site morbidity, esthetics, and recurrences are still challenges for reconstructive surgeons. Central axis "propeller" flaps based on a random, subcutaneous pedicle were first described for axillary and elbow contractures to deploy the unburnt skin of axillary dome in type I and II contractures (Kurtzman and Stern) by moving them 90° to straddle the contracting bands. This strategy provided better esthetics and avoided prolonged splinting. Over more than two decades, there have been several design modifications of these flaps with extended applications to cubital fossa. A comprehensive review of published literature on the topic is presented to discuss classifications, design modifications, and applications of such flaps in managing axillary and elbow contractures.

Subcutaneous pedicle propeller flap: An old technique revisited and modified!

BACKGROUND: Post-burn axillary and elbow scar contracture is a challenging problem to the reconstructive surgeon owing to the wide range of abduction and extension that should be achieved, respectively, while treating either of the joint. The aim of this paper is to highlight the use of subcutaneous pedicle propeller flap for the management of post-burn axillary and elbow contractures. METHODOLOGY: This is a prospective case study of axillary and elbow contractures managed at a tertiary care hospital using propeller flap based on subcutaneous pedicle from 2009 to 2014. Surgical treatment comprised of subcutaneous-based pedicle propeller flap from the normal tissue within the contracture based on central axis pedicle. The flap was rotated axially to break the contracture. The technique further encompassed a modification, a Zig-Zag incision of the flap, which was seen to prevent hypertrophy along the incision line. There was a mean period of 12 months of follow-up. RESULTS: Thirty-eight patients consisting of 22 males and 16 females were included in this study among which 23 patients had Type II axillary contractures and 15 had moderate flexion contractures at elbow joint. The post-operative abduction achieved at shoulder joint had a mean of 168° whereas extension achieved at elbow had a mean of 175°. The functional and aesthetic results were satisfactory. CONCLUSION: The choice of surgical procedure for reconstruction of post-burn upper extremity contractures should be made according to the pattern of scar contracture and the state of surrounding skin. The choice of subcutaneous pedicle propeller flap should be emphasised because of the superior functional results of flap as well as ease to learn it. Moreover, the modification of propeller flap described achieves better results in terms of scar healing. There is an inter-positioning of healthy skin in between the graft, so it prevents scar band formation all around the flap.

Post-burn axillary contracture: A therapeutic challenge!

BACKGROUND: Axillary post-burn scar contracture is a challenging problem to the reconstructive surgeon owing to the wide range of abduction that should be achieved. The aim of this paper was to highlight the various options used in managing axillary contractures in our hospital. MATERIALS AND METHODS: This is a retrospective hospital-based study of axillary contractures managed at Safdarjung Hospital (a tertiary care hospital) from 2009 to 2013. The study consisted of 44 patients from all age group and both sex included in it. Patients with a bilateral axillary contracture were excluded. Axillary contracture was released and resurfaced using split skin graft and/or with different types of flaps including the propeller flap, parascapular flap. All the reconstructed cases were followed-up for a period of 12 months. Assessment was done on the basis of functional and aesthetic outcome. RESULTS: Forty-four patients consisting of 25 males and 19 females presented with axillary contractures that involved 44 axillae. The mean age of the study group was 17.1 years. Injuries involved the anterior axillary fold in 8 (18.18%), posterior fold in ten (22.72%), both folds and axillary fossa in 14 (31.81%) and both folds plus part of the chest wall and arm (sparing the axillary fossa) in 12 (27.27%) axillae. Surgical treatment included split-thickness skin graft in 15 (34.1%), local skin flaps in 4 (9.1%), Z-plasties in 4 (9.1%), parascapular flaps in 3 (6.82%), while propeller flaps in 12 (27.27%) and square flap were used in 6 (13.64%) patients. The percentage of improvement in abduction had a mean of 156°. The functional and aesthetic results were satisfactory. CONCLUSION: The choice of surgical procedure for reconstruction of post-burn axillary contractures can be made according to the pattern of scar contracture and the state of the surrounding skin. The choice of a flap should have priority over the skin graft because of the superior functional and aesthetic results of flaps.

The versatility of perforator-based propeller flap for reconstruction of distal leg and ankle defects.

Introduction. Soft tissue coverage of distal leg and ankle region represents a challenge and such defect usually requires a free flap. However, this may lead to considerable donor site morbidity, is time consuming, and needs facility of microsurgery. With the introduction of perforator flap, management of small- and medium-size defects of distal leg and ankle region is convenient, less time consuming, and with minimal donor site morbidity. When local perforator flap is designed as propeller and rotated to 180 degree, donor site is closed primarily and increases reach of flap, thus increasing versatility. Material and Methods. From June 2008 to May 2011, 20 patients were treated with perforator-based propeller flap for distal leg and ankle defects. Flap was based on single perforator of posterior tibial and peroneal artery rotated to 180 degrees. Defect size was from 4 cm × 3.5 cm to 7 cm × 5 cm. Results. One patient developed partial flap necrosis, which was managed with skin grafting. Two patients developed venous congestion, which subsided spontaneously without complications. Small wound dehiscence was present in one patient. Donor site was closed primarily in all patients. Rest of the flaps survived well with good aesthetic results. Conclusion. The perforator-based propeller flap for distal leg and ankle defects is a good option. This flap design is safe and reliable in achieving goals of reconstruction. The technique is convenient, less time consuming, and with minimal donor site morbidity. It provides aesthetically good result.

Micropigmentation: tattooing for the treatment of lip vitiligo.

BACKGROUND: Vitiligo of the lips is a common concern of great psychological consequence. Medical therapies are often ineffective mainly due to the absence of hair follicles. Tattooing implants pigment into the skin. For treatment of vitiligo, tattooing works best in the lip area, particularly in a dark skin. AIMS AND OBJECTIVES: To assess the effectiveness of medical tattooing for lip vitiligo. MATERIAL AND METHODS: Fifteen patients with localised stable lip vitiligo patients (10 women and 5 men; age range: 30-55 years; mean age: 42 years) from the outpatient department were included in the study. The period of follow-up was from 2 to 3 years. The procedure was performed under local anaesthesia on an outpatient basis, unless carried out in conjunction with other procedures. An electric tattooing machine with cluster needles was used. RESULT: Cosmetically acceptable results were seen in all patients. In dark-complexioned patients, pigmentation was better as compared to fair subjects. No allergic reactions to the pigment or koebnerisation of the vitiligo were noted. CONCLUSION: Tattooing is relatively easy, safe and effective option for lip vitiligo. It is cosmetically more acceptable; sensations are well maintained and are generally devoid of any significant adverse effects.