Atul Parashar

Width of cleft palate and postoperative palatal fistula – do they correlate?

This study was conducted to evaluate any correlation between the measured width of cleft palates and postoperative fistula formation. Prospective study design was used where 43 consecutive cases of patients with cleft lip and palate or isolated palate who underwent cleft palate repair in an institution were observed. A preoperative or peroperative dental impression of the upper jaw was taken for the measurement of various cleft parameters. Palatoplasty was done using the Von-Langenbeck procedure or modified Veau-Wardil-Kilner-type repair. Among these, only 31 patients could be followed up for at least 4 weeks after the surgery and were included in the study. The patients developing fistulas were evaluated with respect to size, site and initial cleft dimensions. Statistical evaluation of multiple variables was performed. It was found that the width of the cleft palate has a bearing on the occurrence of postoperative palatal fistula formation, with a width of 15 mm or more having a statistically significant risk of fistula formation. The strongest association was found for the ratio of cleft width to the sum of the palatal shelves width. As this ratio increases to 0.48 or more, the risk of fistula becomes statistically significant. The ratio of cleft width to the posterior arch width is also a strong predictor of fistula formation with the risk becoming higher if the ratio is more than 0.41. Thus, the concept of wide-cleft is not vague or irrelevant but has a bearing on postoperative fistula formation, as shown in this study.

Submental tracheal intubation in oromaxillofacial surgery

Background: Oromaxillofacial surgical procedures present a unique set of problems both for the surgeon and for the anesthesist. Achieving dental occlusion is one of the fundamental aims of most oromaxillofacial procedures. Oral intubation precludes this surgical prerequisite of checking dental occlusion. Having the tube in the field of surgery is often disturbing for the surgeon too, especially in the patient for whom skull base surgery is planned. Nasotracheal intubation is usually contraindicated in the presence of nasal bone fractures seen either in isolation or as a component of Le Fort fractures. We utilized submental endotracheal intubation in such situations and the experience has been very satisfying. Materials and Methods: The technique has been used in 20 patients with maxillofacial injuries and those requiring Le Fort I approach with or without maxillary swing for skull base tumors. Initial oral intubation is done with a flexo-metallic tube. A small 1.5 cm incision is given in the submental region and a blunt tunnel is created in the floor of the mouth staying close to the lingual surface of mandible and a small opening is made in the mucosa. The tracheal end of tube is stabilized with Magil′s forceps, and the proximal end is brought out through submental incision by using a blunt hemostat taking care not to injure the pilot balloon. At the end of procedure extubation is done through submental location only. Results: The technique of submental intubation was used in a series of twenty patients from January 2005 to date. There were fifteen male patients and five female patients with a mean age of twenty seven years (range 10 to 52). Seven patients had Le Fort I osteotomy as part of the approach for skull base surgery. Twelve patients had midfacial fractures at the Le Fort II level, of which 8 patients in addition had naso-ethomoidal fractures and 10 patients an associated fracture mandible. Twelve patients were extubated in the theatre. Eight patients had delayed extubation in the post-operative ward between 1 and 3 days postoperatively. Conclusion: In conclusion, the submental intubation technique has proved to be a simple solution for many a difficult problem one would encounter during oromaxillofacial surgical procedures. It provides a safe and reliable route for the endotracheal tube during intubation while staying clear of the surgical field and permitting the checking of the dental occlusion, all without causing any significant morbidity for the patient. Its usefulness both in the emergency setting and for elective procedures has been proved. The simplicity of the technique with no specialized equipment or technical expertise required makes it especially advantageous. This technique therefore, when used in appropriate cases, allows both the surgeon and the anesthetist deliver a better quality of patient care.

Frontal reconstruction with frontal musculocutaneous V-Y island flap

Background: Defects of the frontal region are mostly caused by the ablation of tumors. When the treatment of such a defect cannot be achieved by the approximation of its margins, some of the solutions may alter the form or the continuity of the frontal aesthetic unit. Methods: With the intent of reconstructing frontal defects with proper skin, a musculocutaneous island flap of the frontal belly of the occipitofrontalis muscle based on the supratrochlearis or the supraorbitalis vessels was planned for a V-Y application in a single procedure. It was used in 31 patients. Results: The treated frontal defects ranged from 1.5 per 1.5 cm to 4.5 per 5.5 cm and, depending on the depth of the resection, exposed periosteum, bone, or dura mater. All the vessels were identified and preserved and the flaps were viable and sufficient for the defects. Three cases presented 1 cm2 of superficial skin necrosis with spontaneous healing that caused hypochromic scars. In eight patients the extirpation of the tumor compromised the rami temporales of the nervus facialis and caused postoperative asymmetry of the facial mimicking. All the followed patients presented normal sensitivity to touch stimuli on the flap skin and presented loss of sensitivity on the scalp distally to the flap and to the donor site. Conclusion: The frontal musculocutaneous island V-Y flap based on the supratrochlearis or the supraorbitalis vessels is safe and permits frontal reconstruction in a single procedure with proper maintenance of the aesthetic unit.

Special considerations in paediatric burn patients

Burn injuries are a major cause of morbidity and mortality in children. In India, the figure constitutes about one-fourth of the total burn accidents. The management of paediatric burns can be a major challenge for the treating unit. One has to keep in mind that “children are not merely small adults”; there are certain features in this age group that warrant special attention. The peculiarities in the physiology of fluid and electrolyte handling, the uniqueness of the energy requirement and the differences in the various body proportions in children dictate that the paediatric burn management should be taken with a different perspective than for adults. This review article would deal with the special situations that need to be addressed while treating this special class of thermal injuries. We must ensure that not only the children survive the initial injury, but also the morbidity and complications are minimized. If special care is taken during the initial management of paediatric burn injuries, these children can be effectively integrated into the society as very useful and productive members.

Rigid internal fixation of zygoma fractures: A comparison of two-point and three-point fixation

Background: Displaced fractures of the zygomatic bone can result in significant functional and aesthetic sequelae. Therefore the treatment must achieve adequate and stable reduction at fracture sites so as to restore the complex multidimensional relationship of the zygoma to the surrounding craniofacial skeleton. Many experimental biophysical studies have compared stability of zygoma after one, two and three-point fixation with mini plates. We conducted a prospective clinical study comparing functional and aesthetic results of two-point and three-point fixation with mini plates in patients with fractures of zygoma. Materials and Methods: Twenty-two patients with isolated zygomatic fractures over a period of one year were randomly assigned into two-point and three-point fixation groups. Results of fixation were analyzed after completion of three months. This included clinical, radiological and photographic evaluation. Results: The three-point fixation group maintained better stability at fracture sites resulting in decreased incidence of dystopia and enophthalmos. This group also had better malar projection and malar height as measured radiologically, when compared with the two-point fixation group. Conclusion: We recommend three-point rigid fixation of fractured zygoma after accurate reduction so as to maintain adequate stabilization against masticatory forces during fracture healing phase.

Management of zygomatic fractures.

To the Editor: W e read with interest the clinical paper on management of zygomatic fractures by Sargent and Fernandez.1 The authors have presented their management protocol among 243 patients with zygomatic fractures and evaluated the results with follow-up ranging from 3 to 36 months. However, the parameters of assessment during the follow-up like vertical dystopia, malar projection, and malar height asymmetry as compared to the intact side have not been presented. These are important for quantification and comparison of results of different management protocols of zygomatic fractures. It is well known that displacement of zygoma can occur after impact as well as after inadequate fixation of apparently undisplaced zygomatic fractures when masticatory forces come into play. Among 243 patients of the study group, 200 were identified to be having clinically relevant zygomatic fractures with fracture line across 3 or more buttresses. Of these, only 68 were managed with some form of fixation. Further, 31% of the operated group was having ‘‘single segment fracture,’’ which was managed by single buttress fixation. However, the exact definition of single segment fracture is not clear. This single buttress fixation in a displaced zygomatic fracture is unlikely to maintain 3-dimensional stability of the malar bone during the healing phase especially in the presence of masticatory forces. This displacement resulting in alteration of zygomatic bone projection and height has been observed in various biophysical and clinical studies. Rudderman and Mullen opined that a single miniplate will resist translatory movement but will offer little resistance to rotation across its linear axis. Thus, at least 2 miniplates have to be applied in such a manner that their weak axes do not coincide with the line joining them. We agree that there is soft tissue morbidity associated with multiple incisions and extensive exposure but this can be minimized using careful technique during exposure and closure. Further, choice of fixation points also has bearing on the final postreduction stability of zygomatic complex. It has been seen in biophysical studies3,6 that fixation across zygomaticomaxillary buttress and frontozygomatic buttress provides comparable 3-dimensional stability when compared to 3-point fixation across zygomaticomaxillary buttress, frontozygomatic suture, and inferior orbital rim. Thus, in the absence of communition of inferior orbital rim or orbital floor fracture; this form of 2-point fixation can be a reasonable alternative to 3-point fixation of zygoma without compromising the postreductional stability. This approach avoids the lower eyelid incision which is usually associated with poorer soft tissue outcomes in zygoma fractures. We are in the process of completing a clinical study evaluating the aesthetic outcomes of various fixation protocols for zygoma fractures in our attempt to find an optimal procedure.

The management of perineal wounds.

Management of perineal wounds can be very frustrating as these invariably get contaminated from the ano-genital tracts. Moreover, the apparent skin defect may be associated with a significant three dimensional dead space in the pelvic region. Such wounds are likely to become chronic and recalcitrant if appropriate wound management is not instituted in a timely manner. These wounds usually result after tumor excision, following trauma or as a result of infective pathologies like hideradenitis suppurativa or following thermal burns. Many options are available for management of perineal wounds and these have been discussed with illustrative case examples. A review of literature has been done for listing commonly instituted options for management of the wounds in perineum.

Cocktail Treatment (Combination of 5-FU + TAC) in the Treament of Hypertophic Scars and Keloids: A Clinical and Histopathological Correlation.

148 METHODS: A retrospective review of 2506 burn contractures was performed using information extracted from Resurge International’s prospectively collected database of patients in Nepal, India, Zambia between January 2004 and January 2012. Data points included patient age, type of burn sustained, time elapsed between burn injury and surgical intervention, as well as injury-specific data from pre-operative and post-operative images of contractures of the hand (n= 1960), elbow (n=371), and knee (n=176). Improvement following contracture release for the hand was scored based on digit and wrist involvement (severity of dysfunction (SOD)), and joint extension capability (functionality); for the elbow and knee, improvement was calculated by comparing preand post-operative joint angles. Multivariate analysis was then performed on all data.

Unfavourable outcomes in maxillofacial injuries: How to avoid and manage.

Faciomaxillary injuries remain one of the common injuries managed by plastic surgeons. The goal of treatment in these injuries is the three-dimensional restoration of the disturbed anatomy so as to achieve pre-injury form and function. In this article, the authors review the anatomic, diagnostic and management considerations to optimise results and minimise the late post-traumatic deformities. Most of the adverse outcomes are usually a result of poorly addressed underlying structural injury during the primary management. An accurate physical examination combined with detailed computed tomographic scanning of the craniofacial skeleton is required to generate an appropriate treatment plan. This organised approach has proven effective in restoring the injured structures to pre-injury status. Multiple clinical cases are used to illustrate the different fracture patterns along with various surgical techniques to achieve an acceptable outcome. Early diagnosis and timely management of complications in these complex injuries is also discussed.

Early debridement and delayed primary vascularized cover in forearm electrical burns: A prospective study.

AIM To look into the management options of early debridement of the wound, followed by vascularized cover to bring in fresh blood supply to remaining tissue in electrical burns. METHODS A total of 16 consecutive patients sustaining full thickness forearm burns over a period of one year were included in the study group. Debridement was undertaken within 48 h in 13 patients. Three patients were taken for debridement after 48 h. Debridement was repeated within 2-4 d after daily wound assessment and need for further debridement. RESULTS On an average two debridements (range 1-4) was required in our patients for the wound to be ready for definitive cover. Interval between each debridement ranged from 2-18 d. Fourteen patients were provided vascularized cover after final debridement (6 free flaps, 8 pedicled flaps). Functional assessment of gross hand function done at 6 wk, 2 mo, 3 mo and 6 mo follow-up. CONCLUSION High-tension electrical burns lead to significant morbidity. These injuries are best managed by early decompression followed by multiple serial debridements. The ideal timing of free flap coverage needs further investigation.