Mahendra Daya

Free radial forearm flap lip reconstruction: a clinical series and case reports of technical refinements.

Lip reconstruction is best suited to the dictum of replacement of like tissue with like. The use of the remaining lip in the use of the lip reconstruction becomes more difficult as the size of the defect increases. The use of local tissue for subtotal lower lip loss problems like microstomia and facial and commissure distortion are real risks. The use of free tissue transfer becomes especially an attractive option when in addition to the lip there is associated loss of other aesthetic units and/or mandibular bone loss. The potential value of local perioral tissue is more likely to maintain dynamic and sensory function of the lip. Five patients were included in the clinical series during a period of 3 1/2 years since January 2002. All 5 patients were men. The age ranged from 15 to 67 years. Four patients underwent reconstruction by composite radial forearm flaps including both the cutaneous nerve of the forearm and the palmaris longus tendon. A single patient in this group had a partial brachioradialis muscle flap raised as chimeric component to the composite radial forearm flap. In the fifth patient, 2 simultaneous free radial forearm flaps were used for both upper and lower lip and bilateral buccal mucosal reconstruction. All patients achieved the goals of providing an adequate mouth opening with competence. The refinement of dynamic palmaris sling attachment to the perioral muscle provided for very good oral competence and support. In the single patient, adding bulk with the brachioradialis muscle to the neo lower lip most likely served to improve both aesthetics and lip function. With the use of free flaps an adequate labial sulcus, near dynamic sphincter control and sensation can be restored. The major drawback, however, is aesthetics of the lip. Further refinements like vermillion tattooing, fat injections or defatting by liposuction, and secondary mucosal flap surgery to provide the neolip with a vermillion are beneficial.

Traction-Assisted Dermatogenesis by Serial Intermittent Skin Tape Application

Background: The use of both tissue expanders and skin-stretching devices is commonplace in reconstructive surgery. The authors describe a noninvasive technique of tissue expansion. Methods: This article describes a prospective study in which 26 consecutive patients consisting of eight male patients and 18 female patients were recruited for expanding the skin by the authors’ devised technique of intermittent serial traction Micropore taping of skin at weekly intervals. Once the skin was expanded, the scar revision was performed in one or two stages by excision and flap advancement. The age range of the patients was 8 to 48 years. The anatomical regions that underwent scar revision were scalp (n = 6), face (n = 9), upper limb (n = 6), and lower limb (n = 9). Results: The size of the scars to be resurfaced ranged from 35 × 50 mm on the temple to 280 × 130 mm on the scalp. The average follow-up after surgical correction was 11 months. The number of taping sessions ranged from two to 15, with an average of 6.9. Fourteen patients had successfully completed the surgical management, and four patients are in the midst of treatment. Four patients defaulted on treatment, and in four patients, the expansion failed to progress. Illustrative examples of some of the cases are described. Conclusion: Traction-assisted dermatogenesis is an additional method of tissue expansion that is easy and cost effective for reconstruction.

Nostril stenosis corrected by release and serial stenting

BACKGROUNDnThe treatment of nostril stenosis is difficult. The aim is to restore facial profile and balance and an adequate airway that is not prone to restenosis.nnnMETHODSnFourteen patients with an age distribution of 18 months to 71 years are presented. The management of the patients involved a surgical release of the nose and creation of a nostril. The nostril was reconstructed by one of a number of methods: (a) The scar was cored out and the passage either lined with skin graft or allowed to re-epithelialise. (b) The nostril opening was increased in size by z plasty technique. (c) The nostril was created by a local flap. The aim of the surgery was to create a nostril opening of adequate size to fit a nasal stent. The nasal stent was then serially upgraded in size to expand the opening of the nostril and the surrounding tissue. The upgrade in the size of the nostril was discontinued when it matched for age or the size of the contralateral one.nnnRESULTSnThe results obtained were more than satisfactory. There was adequate long term maintenance of the nostril size in all except one of the patients. Overall, the serial upgrade in the size of the stent helped emulate the growth of the lower third of the nose in a growing child.nnnCONCLUSIONnThe advocated management appears to a good solution to a very difficult problem. But continual use of the stent and patient compliance can be a drawback.

Peroneal artery perforator chimeric flap: changing the perspective in free fibula flap use in complex oromandibular reconstruction.

The fibula osteoseptocutaneous flap has undergone multiple refinements since its first description in oromandibular reconstruction. There is now a better understanding of the blood supply to the skin of the lateral aspect of the leg. Multiple free skin paddles can be harvested freestyle from the lateral aspect of the leg. The size of the flaps that can be harvested has not been clearly defined. A case report of a complex oromandibular reconstruction following a shotgun injury to the face demonstrates a way of maximizing the skin harvest. An osteoseptocutaneous fibula flap was used for the replacement of the mandible and the internal lining of the oral cavity. A larger lateral leg flap based on a musculocutaneous perforator of the peroneal artery was used for the external and full-thickness lower-lip defect. The latter flap by definition is a peroneal artery perforator flap, which to the best of my knowledge is terminology that has not been used in the English literature. The main purpose of this article is to review the blood supply of the lateral leg and how this can be utilized to reach the goals of a complex oromandibular and total lower-lip reconstruction.

Advanced Marjolin's ulcer of the scalp in a 13-year-old boy treated by excision and free tissue transfer: Case report and review of literature.

Marjolins ulcer originates in chronic scars and wounds of diverse origin. This relatively rare tumour is most commonly a squamous cell carcinoma. The reason for malignant transformation is not well understood. The burn scar is a common predilection. We present the youngest patient in the literature, a 13-year-old male with a locally advanced squamous cell carcinoma of the scalp with intracranial extension following an unhealed burn injury at the age of three. Bilateral cervical lymphadenopathy was also noted. The tumour was excised and the large defect overlying the brain was covered by free latissimus dorsi musculocutaneous flap. At four weeks a therapeutic bilateral selective neck dissection was done. Adjuvant chemotherapy was administered. This report reiterates the importance of early diagnosis. Free tissue transfer further enhances our ability to cover complex defects associated with excision of advanced lesions.

Congenital vascular anomalies in amniotic band syndrome of the limbs

INTRODUCTIONnBone abnormalities and nerve compression are sparsely reported features of amniotic band syndrome. No studies of the vascular architecture of limbs affected by this syndrome have been published.nnnMATERIAL AND METHODSnPatients with amniotic band syndrome affecting the limbs were evaluated in the period between 1997 and 2007. The arterial blood supply was studied using magnetic resonance angiography or computed tomographic angiography. The subjects comprised 8 patients with bilateral and 2 with unilateral limb involvement. The patients ages ranged from 2 months to 8 years. The male-to-female ratio was 4:6. A total of 20 limbs was investigated, comprising 18 lower limbs and 2 upper limbs. The amniotic bands were divided into superficial or deep.nnnRESULTSnThe patients were divided into 4 groups: group 1, thigh bands; group 2, below-knee amputations; group 3, leg bands; and group 4, upper limb bands. A single patient in group 1 with a deep band had a persistent sciatic artery. In group 2, three limbs demonstrated attenuated segments in the superficial femoral artery and/or abnormalities arising at the popliteal artery division. In group 3 (14 legs), 7 with deep bands showed some anomaly either in the popliteal artery division or its branches or both. In the other 7, and in group 4, all with superficial bands, no vascular abnormalities were seen except in one.nnnCONCLUSIONnOur findings show that amniotic band syndrome is definitely associated with vascular abnormalities and the depth of the band is an important contributory factor.

Use of VAC therapy and sternal plating in the treatment of sternotomy wound dehiscence

Sternal dehiscence has a high morbidity and mortality. Many treatment modalities have evolved. Early wound management and closure has a positive outcome. Vacuum-assisted closure (VAC) therapy has proven to be effective, and recently the closure of the sternum with internal plate fixation appears to be beneficial. We present a small series with their combined usage. We retrospectively reviewed eight cases of sternal wound dehiscence or sepsis referred to our unit for further management for the period January 2006 to December 2007. The subjects consisted of five males and three females with their ages ranging from 47 to 74xa0years (meanu2009=u200963xa0years). All patients had a premorbid history of hypertension and hyperlipidemia and five of diabetes. The patients were managed with a combination of serial debridement, VAC therapy, and sternal internal plate fixation and bilateral pectoralis major advancement flap. In three patients, final closure was obtained after sternal plating. Two patients achieved final closure by VAC therapy only. Three patients died of multiple-organ failure while undergoing wound bed preparation. We believe the use of VAC therapy and definitive wound closure using sternal plating, as part of a staged treatment, is an effective method for managing sternotomy wound dehiscence.

Amniotic band syndrome with persistent sciatic artery: a case report.

Amniotic band syndrome (ABS) has an incidence of 1/15 000. Deformities vary from rare but bizarre craniofacial defects or truncal defects to the commoner limb defects. The pathogenesis of ABS remains controversial. The following is a case of a 3-month-old infant with amniotic band syndrome with the typical limb reduction defects, a constriction band on the thigh associated with a persistent sciatic artery and bifurcation of the femur and the duplication of the knee and tibia on the contra lateral side. The anatomy of the persistent sciatic artery is demonstrated in magnetic resonance angiography and digital subtraction angiography. The vascular anomaly was unilateral. The patient underwent surgical correction of the constriction band by excision and multiple Z plasty. This case is the first description of the coexistence of ABS and persistent sciatic artery. Persistent sciatic artery has angiographic incidence of 0.05%. Is this purely a coincidence? Or perhaps their coexistence may serve to further the understanding of the mechanism of ABS.

Clinical experience and analysis of length gain with the use of seven-flap plasty in burn contractures.

BACKGROUNDnThe seven-flap plasty despite its excellent surgical properties in the release of burn contractures is not widely adopted by surgeons. It is likely that the surgeons may have misgivings about its reliability, its ability to release a contracture and the length gain that can be obtained.nnnSUBJECT AND METHODSnA sponge model is described to determine the gain in length obtained from the seven-flap plasty. It also helps to understand the physical mechanics. Our clinical series of 55 release procedures with the use of seven-flap plasty is described. The anatomical regions include the neck, axilla, cubital fossa, hand, perineum, popliteal fossa and the foot. Forty-nine procedures were assessed for the immediate gain in length obtained post-release.nnnRESULTSnThe sponge model demonstrated a length gain of 80%. The length of the contractures to be released ranged from 1 to 14 cm. The immediate length gain obtained in the clinical series ranged from 60 to 233% (average=105%).nnnCONCLUSIONnThe theoretical length gain in z-plasty is of little clinical significance. A host of factors such as lateral laxity, number of flaps, angle at the tips, the anatomic region, and the cause of the contracture determine the actual clinical length gain obtained following a seven-flap plasty release procedure.

Treatment of Constriction Bands of Limbs by Fat Injection: An Additional Modality

Background: Constriction bands in the majority of cases presents as a contour deformity. The gold standard of treatment is a single-stage constriction ring excision and serial Z-plasty. The expense is unsightly scarring. We present case reports of deformity correction by serial fat injections Methods and Participants: Three case studies of children in whom this modality was used in limbs to correct the deformity are presented. Results: Two participants showed a good correction of the deformity and in a single-case treatment failed requiring excision and serial Z-plasty for correction. Conclusion: Fat injection in combination with Khouri’s technique of aponeurotomies is an attractive modality of managing superficial constriction bands of limbs.