Mohamed El-Shazly

Soft Tissue Defects of the Heel: A Surgical Reconstruction Algorithm Based on a Retrospective Cohort Study

UNLABELLED The hindfoot is a special anatomical location, requiring unique forms of reconstruction of the thick, durable heel pad, the underlying calcaneus, and the Achilles tendon and its thin, pliable soft tissue envelope. Perhaps more than in any other region of the foot, the heel poses a reconstructive challenge to the surgeon who must consider both form and function when repairing wounds in this location. There are many possible reconstructive options, including local, distant, and free flaps. These flaps could be of muscular, myocutaneous or fasciocutaneous tissues. We reconstructed heel defects in 46 consecutive patients using several reconstructive options, and reviewed the results. Patients were classified according to preoperative demographic variables, including size, depth, site, etiology, age, vascularity, sensation, Achilles tendon condition, bone exposure or bone loss, and the patients functional needs. Neither partial nor total flap losses were observed; the reconstructions were evaluated and considered satisfactory both by surgeons and patients if they fulfilled certain criteria, namely complete coverage, durability upon weight bearing and walking, sensation, donor site morbidity, and cosmetic appearance. No recurrences of the defects were observed during the follow-up period. Heel reconstruction is a challenging task for foot and ankle reconstructive surgeons. Every step should be taken to avoid recurrences and ulcerations. In this article we present a surgical reconstruction algorithm that may allow easy and reliable decision making based on the preoperative assessment of the defect and other clinical features. LEVEL OF CLINICAL EVIDENCE 2.

Attitudes toward children with clefts in rural Muslim and Hindu societies.

Many charitable organizations conduct overseas missions to correct cleft lip and palate where surgical care is hard to obtain. However, little is known about genetic backgrounds, cultural and societal attitudes regarding the cleft deformity. A questionnaire has been designed to elicit these attitudes. The questionnaire was administered to 50 families of children with cleft lip seeking care at Operation Smile missions in each of 2 disparate rural communities, one in the state of Gujarat in India and the other in the upper Nile valley in Egypt. Saliva and blood samples were collected from all patients to investigate MSX1, IRF6, PVRL1, MHC class I chain related (MICA), TP73L, MTHFR, TGF-beta3, and RAR alpha genes, within a proposed multinational genetic research project for cleft causation using micro-array and polymerase chain reaction (PCR) methods. All patients had been operated and experienced good results through the follow-up period, which was ranging from 3–24 months. Demographic data defined literacy and educational level; answers established the degree of social isolation, the impact on the family, and the expectations of what surgery would accomplish for the child. Beliefs concerning the causation of the cleft were explored in detail. Knowledge of these issues is important for the more complete care of children in an unfamiliar cultural environment.

Increasing the success rate of the reversed-flow fasciocutaneous island sural flap: a clinical experience in 26 cases.

The reversed-flow fasciocutaneous island sural flap is presenting one of the best reconstructive options in the distal third of the leg, around the ankle and the heel up to the metatarsals. Although the surgical maneuver of this flap and many of its modifications have been well described in previous publications, the flap is unfortunately full of reported complications. In this work, we are presenting a 26-patient series of reversed-flow fasciocutaneous island flap cases in different age, sex, and etiologic groups. All flaps had survived, with a complication rate of 3.8% (1 case) in the form of partial necrosis. In this series, we standardized a modified technique in which we tried to include many ideas and tricks, in addition to some of the reported useful ones to have a higher success rate. We have summarized these points in 10 golden rules, making this flap safer and more versatile.

Clinical and pathological assessment of different suture techniques for microvascular anastomosis in rat femoral artery

This study examined the clinical and pathological features after a microvascular anastomosis of a rat femoral artery using four different suture techniques. Sixty Sprage-Dawely rats were divided randomly into 4 groups. Fifteen bisected arteries (one from each animal) in Group I, II, III and IV were sutured with the simple interrupted suture, continuous suture, sleeve suture and cuff suture, respectively. The anastomosis times in Group I, II, III and IV were 28.67, 14.67, 15.47 and 15.93 min, respectively. Immediate bleeding that stopped without intervention (grade I) was observed in 67%, 73% and 60% of the anastomosed vessels in Groups II, III and IV, respectively, while 60% of the vessels in Group I showed light bleeding that was inhibited by gentile pressure (grade II). All vessels examined appeared to be patent at 5 and 15 min after the anastomosis. On the 7th day postoperatively, the vessels of Group I showed the highest patency rate (93%) compared with Groups II (67%), III (73%) and IV (87%). Moreover, there were more pronounced pathological changes in Group I than in the other groups. These changes included endothelial loss, endothelial proliferation, degeneration and necrosis of the tunica media. Suture materials surrounded by an inflammatory reaction were also observed. In conclusion, the simple interrupted suture is preferable for microvascular anastomosis due to its highest patency rate. The other techniques investigated can be good alternatives because of their short anastomotic time and moderate pathological changes.

Assessment of the breast volume by a new simple formula

Background: With the recent introduction of improved techniques for plastic surgery of the breast and increased public awareness toward these procedures, plastic surgeons are continuously trying to improve their methods and results to reach perfection. Assessment of the breast volume is an important issue prior to the use of breast implants in any aesthetic or reconstructive breast surgery. Previous methods to measure breast volume have included use of a simple bra and breast cup size, cumbersome fluid displacement, appliances and approximate visual estimation. Objectives: In this work we have tried to develop an easy method for assessment of the breast volume for both the patient and the the surgeon through a simple mathematical formula. Materials and Methods: Fifty two volunteers were included in this study. For every one, general parameters including age, weight and height were recorded. Local breast measurements and water volume displacement were also recorded. Results: The collected data were statistically correlated. Using the analyzed data, the breast volume was calculated through a simple and direct formula on the basis of the breast circumference. Conclusion: Our method has, as its principle, the use of an accurate and simple formula, which is based only on one measurement. This is easy for both the patient and the plastic surgeon. This equation is not only a significant technical advantage for the surgeon, but also provides a universal standardization of the breast volume.

Microvascular anastomosis in an optical cavity: Is it possible?

Microsurgery is one of the highly interesting surgical procedures that can be performed using different applications and in different specialties, including plastic surgery. The endoscope is a popular instrument used in many fields, including plastic surgery. Although the operating microscope is still a must for microsurgical performance, microsurgery could be performed, depending on the experiences and facilities, by using other visual-assisting equipment. From this point of view, the authors tried to find less costly and more widespread equipment suitable for performing microsurgery that can, furthermore, be applied in special situations and indications, such as operating in an optical cavity. The authors investigated this issue with the endoscope. In this experimental project, the authors performed vascular microsurgical anastomoses of the rats’ femoral vessels to create an optical cavity in a prefabricated skin retraction model in the groin area of 10 Sprague-Dawley male rats. The microsurgical anastomoses of the femoral vessels and nerves were performed easily in a reasonable time, without recorded difficulties, and with maximum physical and visual comfort for the surgeon. The authors spent a mean time of 28.1, 27.3, and 19.2 minutes for the arterial, venous, and neural anastomoses, respectively. In this group of animals, 90 percent vascular patency and 100 percent accurate neural anastomoses were recorded. The advantage the authors noted was that this new technique of operating in the field of microsurgery, with its feasibility and difficulties, would be a point of research and application for the young generations of microsurgeons.

Inclusion and exclusion criteria to overcome bias and reach a valid conclusion for interpositional flap coverage in primary hypospadias repair with tubularized incised plate urethroplasty.

BackgroundThere is no general consensus about the best vascularized layer between the neourethra and the skin in tubularized incised plate urethroplasty (TIPU) of Snodgrass. Inclusion of 1 surgeon to repair specific forms of hypospadias by using determined surgical materials and exclusion of definite patients and conditions and definite anomaly parameters may present the needed reliable data about the role of a specific type of interpositional coverage of the neourethra. Patients and MethodsThe 37 patients had been operated by TIPU with a ventral subcutaneous dartos flap covering the neourethra who designed as group A, while 26 patients had been operated by the standard TIPU without urethral coverage who designed as group B. ResultsGood cosmetic results were obtained in 93.65% of the patients. In group A, urethral fistulae were encountered in 2 cases of distal hypospadias and 1 case of midpenile hypospadias with a total fistula rate of 8.1%. In group B, urethral fistulae were found in 5 cases of distal hypospadias and 3 cases of midpenile hypospadias with a total fistula rate of 30.7%. ConclusionsFlapless repair should not be tried as long as there is the needed experience to harvest a well-vascularized coverage. Interpositional flap coverage of the neourethra is crucial to decrease the rate of fistula in primary hypospadias TIPU repair. However, before designating a relative study, different forms of the anomaly, surgeon’s experience, the potential harvesting complications, complexity degrees of different repairs, and the used surgical materials should be really considered.

The double transverse microvascular clamp: a new instrument for microsurgical anastomoses.

Since the introduction of microvascular surgeries, the sophisticated ideas and techniques of tissue transplantations are continually advancing and searching for the best work conditions to present the best outcomes in these critical interferences. Every tissue transplant has its donor vessels, artery and vein, which should be anastomosed to recipient vessels. A new instrument, the double transverse microvascular clamp (DTMC), has been developed to be applied simultaneously, as one clamp, to both the artery and its accompanying vein. The transverse design of this clamp keeps the artery separate from its vein, allowing each anastomosis to be performed more easily. The limited clamp surface area minimizes the glazing and blurring effects. Applying only one clamp to the two vessels presents more work space and overcomes the crowdedness caused by the use of two single clamps. Using a DTMC on both the recipient and donor vessels provides optimal suture maneuverability and ideal work situation compared with the use of two double approximating clamps. We believe this DTMC would be a valuable addition to the microsurgical instruments market.

Practical guidelines for getting the most out of the gastrocnemius muscle flap units: a presented algorithm for the best flap choice

Although with the reported versatility, vascular reliability, and easy harvesting and elevation of the gastrocnemius muscle flap, still it is used for a narrow aspect of reconstructions including only small and nearby defects. The flap is unfortunately full of limited applications, unreachable coverage, and soft tissue shortage. In this work, we are presenting 20 cases of gastrocnemius muscle flap of different etiologies, in which we applied a group of modifications to have a higher grade of applicability, more arc of rotation, and more tissue surface area. The validity of these modifications was intraoperatively tested in different defect sites and sizes to report if they are really meaningful. All flaps had survived with no complications. We have summarized these modifications in four golden rules, making these muscle flaps more versatile and more applicable. An algorithm is suggested as a leading tool for the best choice of the gastrocnemius muscle units in different situations.

Comparative study of levobupivacaine and bupivacaine for bilateral maxillary nerve blockduring pediatric primary cleft palate surgery: a randomized double-blind controlled study

BACKGROUND Cleft lip and palate are common major congenital anomalies. Cleft palate (CP) repair causes pain and needs large doses of intravenous opioids. The risk of postoperative airway obstruction or respiratory depression is high, requiring continuous and vigilant monitoring. The primary outcome was to evaluate the efficacy of using different local anesthetics during bilateral maxillary nerve block (MNB) with general anesthesia on quality of recovery after primary CP repair. We hypothesized that levobupivacaine would be better than bupivacaine. Also, to investigate the potency of bilateral MNB in improving quality of postoperative analgesia. METHODS Sixty children undergoing primary CP repair surgery were enrolled in the study. Combined general anesthesia and regional bilateral MNB were used for all patients. Group L (n = 30): children received 0.15 ml/kg of 0.2% levobupivacaine, while in Group B (n = 30): children received 0.15 ml/kg of 0.2% bupivacaine. RESULTS Face, Legs, Activity, Cry, and Consolability pain score readings were 0 score in 7 cases of the Group L and 10 cases of Group B, 1 score in 14 cases of the Group L and 12 cases of Group B, and 2 score in 9 cases of the Group L and 8 cases of Group B. We found no statistically significant difference between the two study groups as regarding pain score or serious complications. CONCLUSIONS Levobupivacaine is as effective and safe as bupivacaine to be used for MNB block with a lower incidence of complications. Bilateral suprazygomatic MNB is an effective, easy, and safe method for pain relief in children undergoing primary cleft palate repair surgeries.