Comparison of single intra operative versus an intra operative and two post operative injections of the triamcinolone after wedge excision of keloids of helix.

OBJECTIVE: To compare single intra-operative versus an intra-operative and two post-operative injections of triamcinolone after wedge excision of keloids of helix. METHODS: The randomised controlled trial was conducted at the King Edward Medical University, Lahore, from January, 2011, to March, 2014, and comprised female patients over 14 years of age presenting with post-piercing keloids of helix not treated previously by any means and amenable to wedge excision. The subjects were divided into Group A who were given a single intra-operative injection of triamcinolone, and Group B who had an intra-operative and two post-operative injections of triamcinolone. Extra-lesional wedge excision of keloids was done, followed by infiltration of flaps and wound base with 0.5-1cc of triamcinolone 40mg/cc. Group B patients were given additional injections of triamcinolone at 1st and 2nd monthly visits. Both groups were observed for the evidence of hypertrophy or complications. Development of hypertrophy within one year of completion of treatment was considered recurrence. RESULTS: The 70 patients in the study were divided into two equal groups of 35(50%) each. The mean age of Group A was 22.34±4.95 years and that of Group B was 22.88±4.22 years (p=0.624). The Mean size of the keloids was 2.54±0.516 cm(2) in Group A and 2.61±0.569 cm(2) in Group B (p=0.613). Recurrence rate in Group A was 3(8.5%) and 2(5.7%) in Group B (p= 0.64). The complication rate was 3(8.5%) in Group A and 8(22.8%) in Group B (p=0.10). CONCLUSIONS: Single injection of triamcinolone was as effective as three in reducing recurrence with less complication rate.

Outcome of modified turn in flaps for the lining with primary cartilage support in nasal reconstruction.

Turning in adjacent skin from the residual nose to line a full-thickness defect is still a controversial option. Text books continue to perpetuate that such flaps are poorly vascularized and may not survive if longer than 1.5 cm. The rationale of our study was to challenge the traditional thoughts about the turn-in flaps for the lining and describe our modified technique of raising these flaps so that well-vascularized thin tissue can be provided for the lining. The study was conducted at the Department of Plastic Surgery, KEMU, Lahore, from January 2007 to March 2011. Eighteen patients were included. They had posttraumatic full-thickness nasal defect of variable extent, involving the lower third of the nose. In the first stage of reconstruction, the epithelialized portion and 5-mm portion of normal adjoining skin were dermabraded. The residual skin of nasal dorsum, side walls, and alae was turned in to form inner lining of 2 nostrils. These flaps were based on healthy dermabraded skin to ensure adequate blood supply. Residual septal and conchal cartilages were used for primary support. Standard ipsilateral paramedian forehead flap with slight oblique design was used for resurfacing. Final assessment of airway patency and alar rim contour was made by the patient at 6 months as satisfactory, just satisfactory, and not satisfactory. There were 12 female and 6 male patients. There was necrosis of distal portion of the forehead flap in 1 case. Partial graft loss at the donor site with bone exposure was noted in another case. There was partial dehiscence and necrosis of turndown flap in 3cases. Mean flap size was 2.05 ± 0.28 cm. As regards airway patency, 12 patients were satisfied, 4 patients were just satisfied, and 2 patients were unsatisfied. When asked about alar rim contour, 3 patients said it to be satisfactory, 9 patients found it just satisfactory, and 6 patients declared it unsatisfactory. Nasal turndown flaps provide reliable tissue for the lining and allow primary placement of cartilage grafts.

Comparative study of conventional and topical heparin treatment in second degree burn patients for burn analgesia and wound healing.

OBJECTIVE: To compare clinical outcome of topical conventional with topical heparin treatment in 2nd degree or partial thickness (PTB) burn patients. METHODS: Patients, between the ages of 14 and 60 years with 2nd degree burns involving <20%. Total body surface area (TBSA) on front of chest, abdomen and upper limbs excluding hands and lower limbs were enrolled from September 2015 to August 2016. Patients were randomized to conventional or heparin treatment groups. Clinical outcome measured were healed wound size, pain scores and total consumption of analgesic medication required to relieve pain. Safety of the treatment and adverse events were also measured RESULTS: Out of 66 patient included in study mean (SD) age of participants was 27 (10) years, of which 59% were males. Mean (SD) TBSA burn was 14% (3) [23 (35%) had SPTB, and 43 (65%) had DPTB]. The burn injury was caused by flames in 68% and by hot liquids in 32% patients. There was no statistically significant difference in distribution of patients according to age, gender, TBSA burn, etiology or depth of burns in the two treatment groups. As compared to conventional treatment group, heparin treatment group had significantly better outcomes. Number of days needed for wound healing was significantly lower in the heparin group than the conventional group (SPTB 14±1 vs. 20±4 days; P-value <0.000 and for DPTB, 15±3 vs. 19±2 days; P-value <0.003). Mean pain score was also lower in the heparin group (for both SPTB and DPTB 3±1 vs. 7±1; P-value <0.000). Similarly, total consumption of analgesic medication was significantly less in the heparin group (53±27 vs. 119±15mg; P-value <0.000 for SPTB and 46±6 vs. 126±12mg; P-value <0.000 for DPTB). In both groups, no patient had wound infection, skin necrosis, leucopenia, thrombocytopenia, worsening renal function, or abnormal liver enzymes CONCLUSION: Treatment of second degree or partial thickness burns (PTB) with topical heparin is superior to conventional treatment in terms of wound healing as well as for pain control. The treatment with topical heparin is well-tolerated and is without higher adverse effects.

Comparison of bupivacaine moistened dressing and conventional dressing for pain relief on skin graft donor sites.

OBJECTIVE: To compare the effectiveness of bupivacaine moistened dressing and conventional dressing in patients requiring split thickness skin graft for reconstruction of various defects. STUDY DESIGN: Randomized controlled trial. PLACE AND DURATION OF STUDY: Department of Plastic Surgery and Burns Unit, Mayo Hospital, King Edward Medical University, Lahore, from January 2011 to January 2013. METHODOLOGY: One hundred and fifty patients requiring split thickness skin grafting for various soft tissue defects were divided into two groups A and B, with 75 patients in each group. In Group A, skin graft donor site dressing was kept moist with 12 mL/100 cm2 of 0.25% bupivacaine solution and in Group B, dressing was moistened with same amount of normal saline. Outcome was measured by calculating rescue analgesia requirements in the two groups after 24 hours. Significance was determined by comparing analgesia sparing effect of each dressing using chi-square test. RESULTS: In Group A, 5 out of 75 (6.7%) patients required rescue analgesia. In Group B, 72 out of 75 (96%) patients required rescue analgesia (p < 0.0001). There was 93.3% effectiveness of bupivacaine soaked dressing while only 4% effectiveness of conventional dressing. CONCLUSION: Bupivacaine soaked dressing is much more effective in pain relief and in reducing the requirement of rescue analgesia, in early postoperative period, at split thickness skin graft donor site compared to the conventional dressing.

Comparison of postoperative pain relief by intercostal block between pre-rib harvest and post-rib harvest groups.

OBJECTIVE: To compare intercostal nerve block before and after rib harvest in terms of mean postoperative pain score and mean postoperative tramadol usage. STUDY DESIGN: Randomized controlled trial. PLACE AND DURATION OF STUDY: Department of Plastic Surgery, Mayo Hospital, KEMU, Lahore, from January 2011 to July 2012. METHODOLOGY: Patients (n = 120) of either gender with ASA class-I and II requiring autogenous costal cartilage graft were inducted. Patients having history of local anaesthetic hypersensitivity and age < 15 years or > 60 years were excluded. Subjects were randomly assigned to pre-rib harvest (group-1) and post-rib harvest (group-2). Local anaesthetic mixture was prepared by adding 10 milliliters 2% lidocaine to 10 milliliters 0.5% bupivacaine to obtain a total 20 ml solution. Group-1 received local anaesthetic infiltration along the proposed incision lines and intercostals block before the rib harvest. Group-2 received the infiltration and block after rib harvest. Postoperative consumption of tramadol and pain scores were measured at 6 and 12 hours postoperatively using VAS. RESULTS: Mean age was 31.43 ± 10.78 years. The mean pain scores at 6 hours postoperatively were 1.033 ± 0.609 and 2.4667 ± 0.812 in pre-rib harvest and post-rib harvest groups respectively (p < 0.0001). The mean pain scores at 12 hours postoperatively were 1.45 ± 0.565 and 3.65 ± 0.633 in pre-rib harvest and post-rib harvest groups respectively (p < 0.0001). The mean tramadol used postoperatively in first 24 hours was 169 ± 29.24 mg and 255 ± 17.70 mg in prerib harvest and post-rib harvest groups respectively (p < 0.0001). CONCLUSION: Intercostal block administered before rib harvest as preemptive strategy result in decreased postoperative pain scores and narcotic use.