A Prospective Study of Patients Presenting With Pre-sternal Keloids.

INTRODUCTION: Keloid represents a pathological form of scarring. They are very common in the anterior chest area; nearly 50% of all keloids occur in this location. One of the reasons for this is that folliculitis and acne, known for triggering the development of keloids, are common on the anterior chest. The other reason is the tension load in this area due to the frequent movements of the upper limbs and the respiratory movements. These movements stretch the skin of the anterior chest horizontally. When this cyclical tension is imposed on the anterior chest wounds, there is an exacerbation and prolongation of the inflammation in the reticular dermis of the wound. These stresses induce the growth of keloids along the prevailing lines of skin tension. MATERIALS AND METHODS: We performed a prospective study in which patients were recruited over a period of one year. Patients presenting with symptomatic pre-sternal keloids and requesting treatment but were unwilling to undergo surgical intervention were included in this study. Patients with a history of previous thoracic surgery were excluded. Baseline assessment and documentation of the lesion were performed. The study patients received three sessions of intralesional injections of a combination of triamcinolone acetonide and hyaluronidase at four weekly intervals. The final assessment was performed four weeks after the third session. RESULTS: The study included 47 lesions in 47 patients with ages of the patients ranging from 16 to 70 years. Pre-sternal keloids were found to be more common among males than females, with a male-to-female ratio of 2.35:1. Patients presented with pre-sternal keloids that had been present for varying periods ranging from three to 81 months. All of our 47 patients completed the three sessions of the treatment. Following the treatment, there was an improvement in the patient's symptoms, as evidenced by the reduction in the mean pruritis scores and pain scores. There was an overall reduction in the size of the lesion. The decrease in the height of the lesions was more evident than the reduction in the craniocaudal or transverse dimensions of the lesions. There were improvements in Vancouver Scar Scale (VSS) vascularity scores and pliability scores following the treatment. CONCLUSION: We conclude that pre-sternal keloids should be considered as a distinct clinico-pathological entity. There are differences with regard to pathogenesis, clinical presentation, and management when compared to keloids elsewhere. Treatment with intralesional injections of a combination of triamcinolone acetonide and hyaluronidase effectively relieves the symptoms and may be considered in patients not willing to undergo surgical intervention. Recurrences can occur and need further treatments.

Subcutaneous Dorsomedial Triangle of Forearm: Surgical Anatomy and Clinical Implication.

Background The purpose of the study was to provide a practical landmark for localizing the dorsal branch of the ulnar artery and nerve, to approach for microsurgical flaps, for harvesting nerve grafts and also to avoid these nerves during insertion of wrist arthroscopy portals. Material and methods Forty adult cadaveric upper limbs (20 right and 20 left) were dissected for localizing the dorsal branches of the ulnar artery and nerve. The ramification patterns of the nerve were mapped. The wrist arthroscopy portals are located radial and ulnar to the tendon of extensor carpi ulnaris at the level of the wrist joint, and their designated names are '6R & 6U', respectively. The distance of branches of the nerve from the 6U and 6R portals for wrist arthroscopy was recorded. Results The present study has delineated a subcutaneous dorsomedial triangular area in the distal forearm. The construction of this triangle uses palpable landmarks, i.e. pisiform bone, styloid process and subcutaneous border of the ulna. The measure of the sides of the triangle uses proportion rather than absolute measurements and hence is person specific. The dorsal branches of the ulnar nerve and artery are consistently given off in the triangle's upper third and middle third, respectively. Four branching patterns have been mapped, with one dominant pattern in 67.5% of limbs. In three-fourths of cases, one branch of the dorsal branch of the ulnar nerve consistently overlies the 6U portal and hence runs a higher risk of injury. Conclusion The study suggests more practical, accurate, reliable and consistent surface landmarks for the localization of the dorsal branch of the ulnar artery and nerve for reconstructive microsurgery for distal hand defects.

Reconstruction of Scalp and Forehead Defects: Options and Strategies.

Background Aesthetic reconstruction of scalp and forehead defects with local flaps and minimal donor site morbidity is the primary goal of coverage. While selecting the coverage technique, essential factors such as size, location, and components of a defect, hair-bearing or non-hair-bearing nature of skin, status of the exposed skull, need for radiation, patient condition, availability of local tissue, and the potential for hairline distortion should be kept in mind. Materials and methods This is a retrospective analysis in which 54 patients who underwent soft tissue reconstruction of the scalp and forehead defects were included. The defect size was categorized into four groups: small: <4 cm2, medium: 4-50 cm2, large: 50-200 cm2, and very large: >200 cm2. Reconstruction of all defects was done according to the defect's size, location, and depth. All patients were regularly followed at intervals of two weeks, six weeks, and three months, respectively. The outcome was evaluated in terms of flap survival, flap coverage scale, the requirement of secondary treatment, postoperative complications, and final aesthetic appearance. Results In 54 consecutively treated patients with scalp and forehead defects, the male-to-female ratio was 2:1, and the overall mean age of participants was 34.8 years, ranging from 0.5 to 66 years. The most common etiology of the defect was trauma (16; 29.6%), and the most common location of the defect was combined (16; 29.6%). Rotation flap and primary closure were the most commonly performed procedure, each 12 (22.2%) in number. Out of 12 primary closure cases, two patients developed wound dehiscence because of infection. All cases of skin grafting healed well. All cases of transposition flap with skin grafting at the donor site went uneventful, and the dog ear at the base was revised later. One case of the bipedicle flap in which partial graft loss occurred at the donor area was managed with regrafting. Two cases of single rotation flap, one double rotation flap, and one free latissimus dorsi muscle flap developed distal necrosis. The excellent aesthetic outcome was found in all cases of primary closure and single and double rotation flaps. Conclusions Local flaps have an architecture similar to the recipient site, and low donor site morbidity results in an aesthetically more pleasant outcome. In our experience, scalp defects up to 50 cm2 were covered with the local scalp flaps with primary closure of the donor area. Defects ranging from 50 to 200 cm2 required local scalp flap with skin grafting at the donor area. Free tissue transfers are usually needed when the defect is very large, devoid of the periosteum, or with the calvarial defect.

Nasopalpebral Lipoma sine Coloboma Syndrome-First Case Report.

The nasopalpebral lipoma-coloboma syndrome was described for the first time in 1982. It is an autosomal dominant syndrome with complete penetrance and is characterized by features like congenital symmetric upper eyelid and nasopalpebral lipomas, bilateral symmetric upper and lower eyelid colobomas, broad forehead, widow's peak, abnormal eyebrow pattern, telecanthus, broad nasal bridge, maxillary hypoplasia, and ophthalmological abnormalities. We report a case of a milder variant of the nasopalpebral lipoma-coloboma syndrome that we have termed "nasopalpebral lipoma sine coloboma syndrome." Such a milder variant is not reported hitherto in the literature. We also describe the surgical correction of the deformity in a case that presented in adulthood, with a satisfactory and pleasing aesthetic outcome.

Reconstruction of Foot and Ankle Defects: A Prospective Analysis of Functional and Aesthetic Outcomes.

INTRODUCTION: Reconstruction of foot and ankle defects requires selecting an appropriate durable and aesthetically appealing option. From the different options, the procedure's choice depends on the defect's size, location, and donor area's availability. Patients' main goal is to have an acceptable biomechanical outcome. MATERIALS AND METHODS: In this prospective study, we have included patients who had undergone reconstruction of the ankle and foot defects between January 2019 and June 2021. Patient demographics, location and size of the defect, different procedures, complications, sensory recovery, ankle hindfoot score, and satisfaction score were recorded. RESULTS: 50 patients with foot and ankle defects were enrolled in this study. All flaps survived except one free anterolateral thigh flap. Five locoregional flaps developed minor complications, and all skin grafts healed well. The Ankle Hindfoot Score outcome has no significant relation with the anatomical location of the defects and the reconstructive procedure. All patients reconstructed using random local flap and with free flap were satisfied with the aesthetic outcome. CONCLUSIONS: Because of limited soft tissue, local flap availability is restricted to small defects. Satisfaction rates are high in local and free flaps and are best suited for reconstructing the weight-bearing part of the foot. Bulky flaps should be avoided over the dorsum and ankle region.

Reconstruction in Rhino-Orbito-Cerebral Mucormycosis Survivors: A Systematic Review.

Background: The COVID-19 pandemic has affected the entire world tremendously. Particularly during the second wave in India, a dangerous complication followed in the form of COVID-19-associated mucormycosis. On June 7th, 2021, the Indian Union Health Minister stated that 28,252 cases of mucormycosis were reported from 28 states/Union territories in the country. Methods: A PubMed search was conducted for English-language studies published from 1988 through May 22, 2021 using the terms "reconstruction AND mucormycosis." Results: The search yielded 102 results. After excluding the articles not describing reconstruction in mucormycosis, 53 abstracts were screened. Then 34 articles dealing with reconstruction in non-ROC regions were excluded. The full text of 16 articles was reviewed. Additionally, 3 articles were identified from the reference search. Due to the aggressive debridements, rhino-orbito-cerebral mucormycosis survivors may be left with complex tissue defects with significant functional and aesthetic impairments. It is essential to offer reconstructive solutions that improve their quality of life. As far as the timing of reconstruction is concerned, the consensus is in favor of delayed reconstruction after ensuring that the infection has been eliminated/controlled and that there are no recurrences. The most common defects encountered were the ones that resulted from orbital exenteration and excision of a varying extent of the involved contiguous bony and soft tissue structures. Reconstruction with pedicled flaps was preferred rather than free flaps, especially in the cases where the infection was not eliminated completely. Adjuvant antifungal therapy was used in most of the cases. Long-term follow-up was considered essential to detect and treat recurrences. Conclusions: A multitude of options are available for reconstruction in rhino-orbito-cerebral mucormycosis including skin grafts, pedicled flaps, free flaps and in some cases implants and prosthetics. These can be utilized to give as much as functional and aesthetic restoration as possible to the patient.

ECG Changes Occurring During Chest Liposuction for Gynecomastia - Artifacts or a Cause for Concern?

Currently, liposuction alone or combined with various methods of gland excision has become the standard of care in the surgical management of gynecomastia. Although liposuction is considered a safe and straightforward method of body contouring, serious complications related to the procedure, including deaths, have been reported in the literature. We report the occurrence of ECG artifacts intra-operatively while performing chest liposuction under general anesthesia. Patients may receive unnecessary and potentially dangerous therapeutic interventions if these ECG artifacts are not identified correctly. A careful and rational evaluation of the patient and the ECG by the clinician can accurately identify these pseudo-abnormalities and avoid unnecessary therapies.

Reconstruction of Heel Soft Tissue Defects: An Algorithm Based on Our Experience.

BACKGROUND: Sensory recovery and durability of the flap is the primary goal of heel soft tissue reconstruction. From the different options, the choice of the flap depends on the size of the defect, its location, and the availability of the donor area. METHODS: In this retrospective study, 40 patients having heel defects were included from Jan 2016 to Dec 2018 in which different flaps were used for the reconstruction. The outcome was evaluated in terms of flap survival, recovery of sensation, the durability of coverage, and functional denouement. We also analysed the outcome between neuropathic and non-neuropathic ulcers of the heel. RESULTS: Out of 40 patients' medial plantar artery islanded flap was performed in eight cases, extended reverse sural flap in 16 cases, islanded reverse sural flap in six cases, local flaps in six cases, cross-leg flap in two cases, and free Latissimus Dorsi muscle flaps with Skin Graft cover in two cases. The patients were observed for a mean follow-up time of 15 months (12-20 months). Only two flaps showed marginal necrosis as an immediate complication. The majority of the flaps were tenacious in the follow-up period except for the six flaps that developed delayed ulceration. Return of protective sensation (P=0.006) and mean American Orthopaedic Foot and Ankle Society subjective score (P=0.025) was significantly higher in the non-neuropathic ulcer group. CONCLUSION: Locoregional flaps can cover most of the heel defects with a satisfactory outcome. The functional outcome was lower in the reconstructed neuropathic heel ulcer group.

Management of extra-articular shaft fractures of the non-thumb metacarpals: plate-screw fixation versus K-wire fixation.

Metacarpal fractures are common injuries and comprise nearly 36% to 42% of all fractures in the hand. The majority of these can be managed non-surgically. Operative fixation when needed, can be done by a variety of techniques. In this study, we have compared the outcomes of two techniques, plate-screw fixation and K-wire fixation. We have conducted a prospective, non-randomized, comparative study of patients who presented with extra-articular metacarpal shaft fractures of non-thumb metacarpals over a period of 18 months. 30 patients were enrolled according to the inclusion criteria and were alternately allotted to the plate-screw group and the K-wire group. At admission, patient demographics, clinical features, number of fractures, and fracture patterns were recorded, and radiographs were taken. In the plate-screw group, low-profile plates and screws were used, and in the K-wire group, 1 or 2 K-wires were used for fixation after fracture reduction. Hand mobilization exercises were started within one week in the plate-screw group, while in the K-wire group full mobilization was allowed at 4 weeks post-surgery. The Disabilities of Arm, Shoulder and Hand (DASH) score was calculated and compared between the two groups at 6 months and 12 months after surgery. The mean 6-month DASH score in the plate-screw group was 6.3287±2.2453, while it was 17.1627±6.2103 in the K-wire group (p value <0.001). At the end of 1-year follow-up, the mean DASH score in the plate-screw group was 5.1080±1.6637, and in the K-wire group, it was 5.1073±1.9392 (p value =0.848). In conclusion, extra-articular metacarpal shaft fractures of the non-thumb metacarpals treated by plate-screw fixation had significantly better DASH scores and hence better functional outcomes at the end of 6 months. However, at the end of 1 year, the DASH scores in both the groups were almost similar, suggesting similar functional outcomes in the long term.

Post-traumatic wounds over the dorsum of the foot - our experience.

Post-traumatic wounds over the dorsum of the foot are commonly seen in our practice. Road traffic accidents, crush injuries due to the fall of heavy objects and burns are common causes of these injures. The subcutaneous tissue in this region is very thin, and the tendons and bone are frequently exposed in these wounds. Since the skin is loosely attached to the underlying tendons, ligaments, and bones, the skin of the dorsum of the foot is also vulnerable to avulsion trauma. Added to this, there is a paucity of local tissues for coverage. Hence the management of these wounds is quite challenging. Through this article, we intend to describe our experience with traumatic dorsal foot wounds. A total of 33 patients were eligible according to the inclusion criteria and their details were included in the final analysis. There were 26 (78.79%) males and 7 (21.21%) females, with a male to female ratio of 3.71:1. The age of the study patients ranged from 8 to 62 years, with a mean age and standard deviation of 34.39 and 13.566 respectively. Majority of the study patients were in the 21-30 years age group (n=10, 30.3%). Road traffic accidents were the most common cause of traumatic dorsal foot wounds (n=20, 60.61%). Majority of the wounds showed features suggestive of infection (n=22, 66.67%) at presentation. Most of the patients in our study needed surgical intervention, in addition to medical management (n=28, 84.84%). Surgical procedures performed include split-thickness skin grafts, local flaps and free flaps. Early complications occurred in 5 (15.15%) patients and late complications in 2 (6.06%) patients. In conclusion, post-traumatic wounds of the dorsum of the foot are very common and pose a difficult reconstructive challenge. Skin grafts, local tissue flaps and free flap options are available for reconstruction; selection of the appropriate option should be individualized in a given patient. Local or distant flaps should be preferred in comparison to skin grafts, because of their long term durability and lesser chances of contractures. Reconstruction must consider form, function, and aesthetics.