Surajit Bhattacharya

Cleft lip: The historical perspective

The earliest documented history of cleft lip is based on a combination of religion, superstition, invention and charlatanism. While Greeks ignored their existence, Spartans and Romans would kill these children as they were considered to harbour evil spirits. When saner senses prevailed Fabricius ab Aquapendente (1537–1619) was the first to suggest the embryological basis of these clefts. The knowledge of cleft lip and the surgical correction received a big boost during the period between the Renaissance and the 19th century with the publication of Pierre Francos Petit Traité and Traité des Hernies in which he described the condition as “lievré fendu de nativité” (cleft lip present from birth). The first documented Cleft lip surgery is from China in 390 BC in an 18 year old would be soldier, Wey Young-Chi. Albucasis of Arabia and his fellow surgeons used the cautery instead of the scalpel and Yperman in 1854 recommended scarifying the margins with a scalpel before suturing them with a triangular needle dipped in wax. The repair was reinforced by passing a long needle through the two sides of the lip and fixing the shaft of the needle with a figure-of-eight thread over the lip. Germanicus Mirault can be credited to be the originator of the triangular flap which was later modified by C.W. Tennison in 1952 and Peter Randall in 1959. In the late 50s, Ralph Millard gave us his legendary ‘cut as you go’ technique. The protruding premaxilla of a bilateral cleft lip too has seen many changes throughout the ages – from being discarded totally to being pushed back by wedge resection of vomer to finally being left to the orthodontists.

Collagen sheet dressings for cutaneous lesions of toxic epidermal necrolysis

Toxic epidermal necrolysis (TEN) is associated with a significant mortality of 30–50% and long-term sequelae. Treatment includes early admission to a burn unit, where management with precise fluid, electrolyte, protein, and energy supplementation, moderate mechanical ventilation, and expert wound care can be provided. Specific treatment with immunosuppressive drugs or immunoglobulins did not show an improved outcome in most studies and remains controversial. We have treated the cutaneous lesions of seven patients of TEN with collagen sheet dressings and have found a significant reduction in morbidity. The sheets are a one-time dressing, easy to apply and they reduce fluid loss, prevent infection, reduce pain, avoid repeated dressings and gradually peal off as the underlying lesions heal.

Authorship issue explained.

When it comes to the fact that who should be an author and who should not be offered ghost authorship, it seem we are all in agreement. [1] Each author should have participated sufficiently in the work to take responsibility for the content. Authorship credit should be based only on substantial contributions to (a) conception and design, or analysis and interpretation of data; and to (b) drafting the article or revising it critically for important intellectual content; and on (c) final revision of the version to be published. Conditions (a), (b), and (c) must all are met.

The transversely split gracilis twin free flaps

The gracilis muscle is a Class II muscle that is often used in free tissue transfer. The muscle has multiple secondary pedicles, of which the first one is the most consistent in terms of position and calibre. Each pedicle can support a segment of the muscle thus yielding multiple small flaps from a single, long muscle. Although it has often been split longitudinally along the fascicles of its nerve for functional transfer, it has rarely been split transversely to yield multiple muscle flaps that can be used to cover multiple wounds in one patient without subjecting him/her to the morbidity of multiple donor areas.

What is new in burn care

A burn injury is not limited to the skin but is associated with the dysfunction of almost every cell in the body and various organs leading to alterations, not only in cellular functions but also in cellular signaling pathways. The current thought that alterations and new treatments of these pathways may restore cellular function and productivity, which in turn may lead to an improved energy metabolism, cell survival, morbidity, and mortality is perhaps the most cutting-edge research in burn care. Hypermetabolism is associated with cell deaths (apoptosis) in skeletal muscles, fat, liver, kidney, lung, heart and gut. These detrimental cellular events are also associated with dysfunction of the cellular organelles such as the mitochondria or the endoplasmic reticulum, thus making burn a truly systemic disease. The areas of advancement in burn care that have improved results of both acute injuries as well as long-term outcome include acute care, burn wound treatment, control of the hypermetabolic responses, and control of life-threatening infections. Both the mortality as well as the length of hospital stay of burned patients have been greatly reduced because of improvement in acute care, such as resuscitation and management of inhalation injuries, early excision and grafting, the control of infections and improving the immune system, improvements in provision of metabolic and nutritional requirements, evolution of effective skin banks, infection control, and alternative wound-closure materials and strategies. Gene therapy is another emerging technique to alter dermal and epidermal regeneration and to improve wound healing. Non-viral constructs have been shown to effectively change the cells into a productive and active cell that releases growth factors and other signaling factors to improve dermal and epidermal regeneration. Liposomal gene constructs have been shown to transfect dermal stem cells increasing the therapeutic possibilities of this futuristic technology! Skin substitutes are creating a revolution and it is now possible to construct an artificial skin, which is called cultured skin substitute (CSS). CSS is the patients own skin (epithelium) in combination with a dermal substitute (Integra) that represents a full-skin substitute including both dermis as well as epidermis. The use of bilayer artificial skin has improved the survival and cosmetic results of early eschar excision in patients with massive full-thickness burns. This technique is helping both, in the acute stage to cover large raw areas as well as in reducing the amount of donor sites taken from the patient and improving cosmesis associated with an improved quality of life in severely burned patients. The challenge that remains is to make this science economically viable for those who need it most. The scope of surgery too has changed from covering chronic burn wounds and treating disfiguring deformities to management of the acute burn wound. Thus escharectomy, tangential excision, meshed skin grafting, micro-skin grafting, and meek grafting are all invaluable arsenals of our armamentarium. Softened freeze-dried glutaraldehyde-preserved skin, chlorhexidine-alcohol refrigerated porcine skin, and frozen amniotic membrane are all effective as burn dressings. The reconstruction in the burn patient is often a long process requiring multiple procedures and stages. It demands a stepwise and prioritized approach, aiming at both maximum function as well as optimal appearance. With better anaesthetic and critical care support surgeons do not hesitate to climb up the reconstructive ladder and microsurgical reconstructions for the sake of better function and cosmesis are becoming more and more common. Rehabilitation of burn patients to effectively reintegrate them in the society as productive members has been a Herculean task, which is still ongoing. Vocational training has rendered these patients the skills and developmental improvements that are truly outstanding, leading to their return as useful and productive members of their family. The devastating effects of burns are long lasting at both an individual and societal level. These impacts are compounded in resource-poor settings, where the human and material resources necessary to deal with this complex public health problem are thinly distributed over a large population base. A structured and comprehensive approach to burn care must be applied to these resource-poor settings in order to improve outcomes. A combination of improved management and prevention strategies has resulted in important declines in morbidity and mortality in the developed world. Unfortunately, without adequate resources in first-aid, acute surgical management and rehabilitation facilities, patients that do survive their burn injuries in developing countries often have poor, disfiguring and disabling long-term outcomes. Burn care truly deserves a helping hand from both governmental and non-governmental sources and philanthropists should come up with a modestly funded burn care strategy for the developing world.

Dr. Ivo Pitanguy: Strived for a 'human right to beauty'

an Institution of Aesthetic Surgery and a one‐man industry. He pioneered procedures that underpinned a burgeoning global industry and dedicated his life to helping people live a better and happier life. He often said, ‘I saw the importance of saving lives and saving functions but it seemed that nobody gave importance to the stigma of deformity and how people suffered with that’. It is this stigma, which kept people away from friends and relatives and made them lesser individuals because of a lack of self‐esteem, that prompted Dr. Pitanguy to take it up as a lifelong crusade and a challenge worth dedicating all his resources.

Michael Felix Freshwater

Felix, as he was known to his friends and colleagues, was born in New York City on February 4, 1948. He graduated from Stuyvesant High and Brooklyn College. Here, he was elected to Phi Beta Kappa and received his Bachelor of Science degree magna cum laude and the Jonas Scholarship with which he attended Yale School of Medicine. After leaving Yale, he spent almost three years as a fellow in the Division of Plastic Surgery at Johns Hopkins. He then went to Miami for his plastic surgery residency under the one and only Ralph Millard, who revolutionised cleft lip surgery. Millard knew that Felix was interested in hand and microsurgery and encouraged Felix to get further training at what was then the foremost centre at the time, Jewish Hospital in Louisville, Kentucky. After completing his training in hand surgery, he returned to Miami in late 1979 where he started practicing and joined the medical school faculty where he was a voluntary professor of surgery.

Fibrous dysplasia and cherubism

Fibrous dysplasia (FD) is a non-malignant fibro-osseous bony lesion in which the involved bone/bones gradually get converted into expanding cystic and fibrous tissue. The underlying defect in FD is post-natal mutation of GNAS1 gene, which leads to the proliferation and activation of undifferentiated mesenchymal cells arresting the bone development in woven phase and ultimately converting them into fibro-osseous cystic tissue. Cherubism is a hereditary form of fibrous dysplasia in which the causative factor is transmission of autosomal dominant SH3BP2 gene mutation. The disease may present in two distinct forms, a less severe and limited monostotic form, and a more aggressive and more widespread polyostotic form. Polyostotic form may be associated with various endocrine abnormalities, which require active management apart from the management of FD. Management of FD is not free from controversies. While total surgical excision of the involved area and reconstruction using newer micro-vascular technique is the only definitive treatment available from the curative point of view, but this can be only offered to monostotic and very few polyostotic lesions. In polyostotic varieties on many occasions these radical surgeries are very deforming in these slow growing lesions and so their indication is highly debated. The treatment of cranio-facial fibrous dysplasia should be highly individualized, depending on the fact that the clinical behavior of lesion is variable at various ages and in individual patients. A more conservative approach in the form of aesthetic recontouring of deformed bone, orthodontic occlusal correction, and watchful expectancy may be the more accepted form of treatment in young patients. Newer generation real-time imaging guidance during recontouring surgery adds to accuracy and safety of these procedures. Regular clinical and radiological follow up is required to watch for quiescence, regression or reactivation of the disease process. Patients must be warned and watched for any sign of nerve compression, especially visual impairment due to optic nerve compression. Rather than going for prophylactic optic canal decompression (which does more harm than good), optic nerve decompression should be done in symptomatic patients only, and preferably be done via minimal invasive endoscopic neuro-surgical approach than the conventional more morbid open craniotomy approach. There is growing research and possibilities that newer generation bisphosphonate medication may change the management scenario, as these medications show encouraging response in not only reducing the osteoclastic activity, but simultaneously also stimulating the osteoblastic and osteocytic activities. The explosion of genetic research and stem cell therapy may lead to better understanding and subsequently better treatment of FD in future.

Pelvic floor repair.

Overview ................................................................................................................................ 1 Your admission Date ............................................................................................................ 2 The Anaesthetic .................................................................................................................... 2 The Repair Operation ............................................................................................................ 2 After the Operation ............................................................................................................... 2 Going home ........................................................................................................................... 3 Getting back to Normal ......................................................................................................... 3 Work, Driving and Sex .......................................................................................................... 4 Complications ....................................................................................................................... 4 Questions and Support ........................................................................................................ 5

Winds of change: Hope for cleft lip and palate patients

If patient satisfaction is a metre to calibrate specialists then the obstetrician surely scores over all others, as the overjoyed patient and her family are gifted every time with a bundle of joy. Second in this list will be the ophthalmologist as he/she transforms the dull and opaque world of the patient into a bright and colourful one. Third in this list surely is a plastic surgeon treating cleft lip and palate (CLP) patients. A 45-minute surgery transports a child from despair to delight; and anxiety to ecstasy. From being an object of curiosity, the child gets seamlessly assimilated and accepted in his play group. In short, it is a transformation from a life of ridicule to a life of hope and happiness ever after. India, undoubtedly, has a very large cleft population, which at over a million is well above the entire population of some countries! Every passing year adds another 32,000 - 35,000 to the figure. Therefore, prevention should be our goal. The omnipresence of the sonologist in the far reaches of our population has aided in early detection of CLP in the unborn foetuses, offering parents a choice in medical termination of pregnancy. Though the foetuses are not in jeopardy of life or limb, this choice is socially accepted in India, though some human rights activists term this practice of “cosmetic murder” as the extremes of eugenics. Joanna Jepson, a British clergywoman, herself afflicted with a congenital jaw deformity, has initiated a legal suit to stem this practice in the UK. Even as the genetic answer to this malady eludes humankind, the big challenge for research on cleft lip and palate is to make a quantum shift from studying individual genes to defining individual protein networks, a nexus of proteins that interact in a highly regulated manner. Since clefting is usually a sum of the combined actions of multiple gene products, it is likely that what we now call non-syndromic may have a distinct heterogeneous character, other manifestations being too subtle to manifest. Further research, however, might begin to better define these conditions. The salutary role of Government Medical Colleges and non-governmental Organizations like the Smile Train in addressing the vast backlog of patients waiting for cleft surgeries can not be overemphasized. Due to their untiring efforts, though poised on the threshold of clearing this ‘quantity challenge’ of ever-growing numbers, it is time for us to switch gears and turn our attention to ‘quality’. Only an infinitesimal proportion of our operated patients get the benefit of orthodontics and speech pathology and for the majority, orthognathic surgery is a distant dream. Many of the top paediatric hospitals are developing their own cleft clinics in order to provide patients with comprehensive multi-disciplinary care from birth through adolescence. Allowing an entire team to care for a child throughout their cleft lip and palate treatment allows for the best outcomes in every aspect of a childs care. While the individual approach can yield significant results, current trends indicate that team-based care leads to better outcomes for CLP patients. However, in a heterogenous India, we shall mostly continue to rely upon individual surgeons; and they shall harmoniously coexist with burgeoning multi-specialty centres of excellence. There is a large amount of research dedicated to the psychosocial development of individuals with cleft palate. A CLP may impact an individuals self-esteem, social skills, and behavior; and they tend to report feelings of anger, sadness, fear, and alienation from their peers. Yet these children are similar to their peers with regard to “how well they liked themselves.” Our Guest Editor, Dr. Jyotsna Murthy, has invited a galaxy of professionals working in the field of CLP to contribute to this issue and one can only marvel at both the quality and the quantity of research and clinical work under way, in all six continents, to bring back smiles to these thousands of afflicted faces.