Surinder Makkar

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.

Retrograde submental intubation by pharyngeal loop technique in a patient with faciomaxillary trauma and restricted mouth opening.

Submental intubation is useful for airway management during maxillofacial surgery when both nasal and orotracheal intubation are deemed unsuitable and to avoid a tracheostomy, especially when long-term ventilatory support is not required in the postoperative period. Adequate mouth opening is a prerequisite for all the techniques described for submental intubation, as the initial step is orotracheal intubation. Hence, this procedure has never been reported in a patient with the inability to open the mouth. We describe the technique of retrograde submental intubation with the help of a pharyngeal loop assembly for the first time in a patient with maxillofacial trauma and restricted mouth opening in whom oral and nasal intubations were not possible and tracheostomy was the only alternative. In this case report, with successful retrograde submental intubation, the potential complications associated with a short-term tracheostomy were avoided, as there was no indication for keeping a tracheostomy during the postoperative period.

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.

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.

Utility of multi-detector row computed tomography angiography versus Doppler in localization of perforators of anterolateral thigh flaps

Aim: Anterolateral thigh (ALT) flap is widely used in reconstruction of various defects. Preoperative imaging facilitates perforator mapping, overcoming intraoperative uncertainty. The purpose of this study was to investigate the utility of multi-detector row computed tomography angiography (MDCTA) and a handheld Doppler in locating ALT perforators. Methods: Twenty patients were randomized into two groups. Group 1 patients received MDCTA and Doppler studies whereas Group 2 received only a Doppler study. The number, location, course, and source of all cutaneous and sizable perforators were compared with intraoperative findings. Surgeons’ stress levels during flap harvest and flap harvest time were compared. Results: MDCTA findings correlated well with intraoperative findings for perforator type and segmental distribution with 100% concordance. Doppler alone had a 52% rate of concordance. The sensitivity and specificity for MDCTA in demonstrating the presence of perforators were 85.71% and 97.22%, respectively; whereas for Doppler alone the sensitivity and specificity were 80% and 87.91%, respectively. In demonstrating perforator source, MDCTA showed a sensitivity of 100% and specificity of 91.66%, with 100% accuracy. Sensitivity and specificity for sizable perforators were 90% each, with 88.88% accuracy. Doppler studies were unable to provide this information. Comparison of surgeon stress levels showed no differences between the two groups, although the time for flap harvest was significantly shorter in Group 1. Conclusion: MDCTA compared to Doppler is more sensitive, specific, and accurate with respect to location, course, and source of perforators.

Sternocleidomastoid Muscle Myocutaneous Flap for Corrosive Esophageal Strictures

We read with interest the article entitled ‘‘Sternocleidomastoid muscle myocutaneous flap for corrosive esophageal strictures’’ by Ananthkrishnan et al. [1]. The sternocleidomastoid muscle flap and its use in head and neck reconstruction has been described by Ariyan [2]. This flap has not become popular among plastic and reconstructive surgeons because of the lack of reliability of the skin island. In fact, Ariyan described the musculocutaneous blood supply to the overlying skin paddle as one of the most delicate and tenuous [3]. He reported venous congestion, ecchymosis, and blistering leading to epithelial necrosis in 10 of 24 flaps. The histological examination of these flaps revealed loss of epithelium and upper dermis [3]. The authors also have reported formation of pharygocutaneous fistula in 50% of their patients and replacement of keratin layer in all of their cases at 4 weeks. These features suggest compromised circulation at the level of skin island. The SCMMIF despite the advantages described by the authors may not be as reliable as a pectoralis major myocutaneous flap in reconstruction of cricopharyngeal area.

Appeal for an “e-Group” to Be Formed

Plastic surgery has achieved great heights in the past few decades as the members of the community have continued to share their ideas, clinical acumen, surgical skills, and new research. We are a rather small community, so it is all the more important that we reach out and grow together. Although the Internet and other sources of telecommunication have helped a lot in knowledge sharing within the community, a lot more can be done. The problems faced by plastic surgeons in developing countries are different from those faced by their counterparts in the developed world. We believe that the formation of an ‘‘e-group’’ of plastic surgeons all over the world, under the Editorial Board of Aesthetic Plastic Surgery (it being the most widely circulated journal of aesthetic plastic surgery), could go a long way in nurturing cooperation within the fraternity. In this group, each member would fill in his or her particulars and areas of interest. The members of the proposed e-group could be further divided into subgroups such as breast surgeons, facial plastic surgeons, and the like. The members of a subgroup could discuss difficult clinical problems among themselves and pose their queries to experts in that field. This discussion within the subgroup could be moderated by a specialist nominated by the editor. Such an online discussion would provide surgeons working in the peripheral centers of a developing country easy access to the best advice in the world. All forthcoming events such as continuing medical education programs, workshops, and conferences could be communicated to all the members of the group. Information about training programs and fellowships could be sent to all the members of this e-group. We think such an e-group not only would help plastic surgeons all over the world in sharing ideas, knowledge, and expertise, but also would go a long way toward bridging the gap between the privileged (developed) and the not so privileged (developing countries). Shall Aesthetic Plastic Surgery again be the leader in this endeavor?