Prabhat Shrivastava

Post-burn scars and scar contractures

The mortality and morbidity from burns have diminished tremendously over the last six to seven decades. However, these do not truly reflect whether the victim could go back to society as a useful person or not and lead a normal life because of the inevitable post-burn scars, contractures and other deformities which collectively have aesthetic and functional considerations. This article gives an overview of the post-burn scars and scar contractures, especially their prevention, minimisation and principles of management.

Pre-hospital care in burn injury

The care provided to the victims of burn injury immediately after sustaining burns can largely affect the extent and depth of the wound. Although standard guidelines have been formulated by various burn associations, they are still not well known to public at large in our country. In burn injuries, most often, the bystanders are the first care providers. The swift implementation of the measures described in this article for first aid in thermal, chemical, electrical and inhalational injuries in the practical setting, within minutes of sustaining the burn, plays a vital role and can effectively reduce the morbidity and mortality to a great extent. In case of burn disasters, triage needs to be carried out promptly as per the defined protocols. Proper communication and transport from the scene of the accident to the primary care centre and onto the burn care facility greatly influences the execution of the management plans

Securing aesthetic outcomes for composite grafts to alar margin and columellar defects: A long term experience.

Introduction: Composite grafts for nasal reconstruction have been around for over a century but the opinion on its virtues and failings keeps vacillating with a huge difference on the safe size of the graft for transfer. Alar margin and columellar defects are more distinct than dorsal nasal defects in greater difficulty in ensuring a good aesthetic outcome. We report our series of 19 consecutive patients in whom a composite graft was used to reconstruct a defect of alar margin (8 patients), alar base (7 patients) or columella (4 patients). Patients and Methods: Patient ages ranged from 3-35 years with 5 males and 14 females. The grafts to alar margin and base ranged 0.6-1 cm in width, while grafts to columella were 0.7-1.2 cm. The maximum dimension of the graft in this series was 0.9 mm x 10 mm. Composite grafts were sculpted to be two layered (skin + cartilage), three layered wedges (skin + cartilage + skin) or their combination (two layered in a portion and three layered in another portion). All grafts were cooled in postoperative period for three days by applying an indigenous ice pack of surgical glove. The follow up ranged from 3-9 months with an average of 4.5 months. Results: All of our 19 composite grafts survived completely but they all shrank by a small percentage of their bulk. Eleven patients rated the outcome between 90-95% improvement. We noticed that composite grafts tended to show varied pigmentation in our patients, akin to split skin grafts. Conclusion: In our opinion, most critical to graft survival is its size and the ratio of the marginal raw area to the graft bulk. We recommend that graft width should not exceed 1 cm to ensure complete survival even though larger sized grafts have been reported to survive. We recommend cooling of the graft and justify it on the analogy of ‘warm ischemia time’ for a replantation, especially in warmer climes like ours in India. We have outlined several considerations in the technique, with an analysis of differing opinions that should facilitate a surgeon in making an informed choice.

A new paradigm in facial reanimation for long-standing palsies?

Background: A chance observation of return of excellent facial movement, after 18 months following the first stage of cross-face nerve grafting, without free functional muscle transfer, in a case of long-standing facial palsy, lead the senior author (RBA) to further investigate clinically. Patients and Methods: This procedure, now christened as cross-face nerve extension and neurotization, was carried out in 12 patients of very long-standing facial palsy (mean 21 years) in years 1996-2011. The mean patient age and duration of palsy were 30.58 years and 21.08 years, respectively. In patients, 1-5 a single buccal or zygomatic branch served as a donor nerve, but subsequently, we used two donor nerves. The mean follow-up period was 20.75 months. Results: Successive patients had excellent to good return of facial expression with two fair results. Besides improved smile, patients could largely retain air in the mouth without any escape and had improved mastication. No complications were encountered except synkinesis in 1 patient. No additional surgical procedures were performed. Conclusion: There is experimental evidence to suggest that neurotization of a completely denervated muscle can occur by the formation of new ectopic motor end plates. Long-standing denervated muscle fibres eventually atrophy severely but are capable of re-innervation and regeneration, as validated by electron microscopic studies. In spite of several suggestions in the literature to clinically validate functional recovery by direct neurotization, the concept remains anecdotal. Our results substantiate this procedure, and it has the potential to simplify reanimation in longstanding facial palsy. Our work now needs validation by other investigators in the field of restoring facial animation.

Total upper eyelid reconstruction by single staged malar-cheek flap

We report a case of total upper eyelid reconstruction by a new technique after excision of an eyelid tumour. The eyelid was reconstructed by a horizontal, laterally based flap from just under the lower eyelid combined with a chondro-mucosal graft from the nasal septum. Surgical outcome was an excellent aesthetically reconstructed eyelid, which was mobile and properly gliding on the globe to achieve complete eye closure.

A novel route for placing free flap pedicle from a palatal defect

One of the better options available to repair a large palatal defect is by employing a free flap. Almost all the times such free flaps are plumbed to facial vessels. The greatest challenge in such cases is the placement of the pedicle from palatal shelf to recipient vessels because there is no direct route available. As majority of large palatal fistulae are encountered in operated cleft palates there is a possibility of routing the pedicle through a cleft in the maxillary arch or via pyriform aperture. When such a possibility doesn’t exist the pedicle is routed behind the maxillary arch. We describe a novel technique of pedicle placement through a maxillary antrostomy, in this case report, where a large palatal fistula in a 16 year old boy was repaired employing a free radial artery forearm flap. The direct route provided by maxillary antrostomy is considered the most expeditious of all possibilities mentioned above.

Burns demand our attention

An extensive burn injury is one of the most devastating conditions encountered in medicine. It severely impacts the physical, physiological, psychological, social and financial status of not only the victim but that of his entire family. Better understanding of pathophysiology, early burn wound excision and provision of skin cover, development of newer skin substitutes and equivalents, and remarkably improved anaesthetic procedures, ICU care and ventilation have surely contributed to better survival statistics of a thermally injured individual. But despite so many advances, the ultimate goal of making a burn victim functionally independent and aesthetically acceptable to achieve the societal reintegration and return to profession still remains a long cherished but elusive goal for majority of the burn survivors even in the developed world. Statistics prove that developing countries have a huge load of burn injuries (estimated 6–7 million new cases per year in India) with majority of thermally injured victims being primarily managed in the peripheral hospitals. Private sector does not have many established and functioning burn units. Very few can afford the exorbitant cost of treatment at the corporate set up. Moreover, a large number of victims are from low socioeconomic status and are not insured either. The National Programme for Prevention of Burn Injuries is also not yet in place in our country. In India, meagerly equipped government hospitals bear the brunt of this massive load. At many places, even the services of all the members of the multidisciplinary team are also not available. Despite this entire crunch, such a massive load has been managed for years by plastic surgeons and general surgeons of these government hospitals. Besides the surgeon, the credit must also go to the selfless and dedicated service of the staff, especially the resident doctors and the nursing personnel. These overworked and underappreciated vital cogs are intimately associated with the day to day care of these patients in the casualty, burn wards, OTs, OPD, physiotherapy, etc. Staying abreast with the recent trends simultaneously keeping basic fundamentals firmly in place is essential for all the members of the burn team. The dedicated manuals/texts/journals play a major role in this aspect. This special supplement of Indian Journal of Plastic Surgery (IJPS) is aimed for this very purpose. A broad range of topics have been chosen for this issue. We shall remain indebted to our national and overseas contributors, all of whom have loads of experience and are leaders in their respective fields. They have done a magnificent job of bringing together the most current information regarding various aspects of burn management. The reading of this volume makes a comprehensive review of the subject and we are hopeful that it shall be useful for the residents and the teachers alike. In recent times, aesthetic surgery has taken such a lead in the minds of young plastic surgeons that burn management has been literally overlooked as a discreet topic. ‘Burn care’, despite being such a vast specialty within the super specialty of Plastic Surgery, is assigned just one session in the four-and-a-half day long National Plastic Surgery meetings! In this era of highly lucrative cosmetic surgery, the editorial staff at IJPS needs to be complimented for having dedicated the entire issue to the cause of burns. Wish you all a ‘happy and pleasant’ reading.