Negative Pressure Wound Therapy (NPWT): Our Experience in Pakistan With Locally Made Dressing.

Introduction Worldwide numbers of patients suffering from complex wounds appear to increase annually. These patients present with acute, sub-acute and chronic wounds which can be difficult to manage. Management of these patients typically requires a multi-disciplinary approach by a plastic surgeon, orthopaedic surgeon and infectious disease control team. Despite the advent of numerous new techniques and technologies, negative pressure wound therapy (NPWT) remains a cornerstone to the management of complex wounds. We present our experience with NPWT in this study. Methods This is a retrospective study of 380 patients who were treated with NPWT in the last 10 years at a single center. We receive hundreds of infected wounds of limbs each year which are either post-traumatic or post-debridement. Frequency of dressing change, C-reactive protein levels, bacterial cultures, complication rate and cost of apparatus in each case were noted. All patients received systemic antibiotics during the treatment. Results We reviewed hospital data of 520 patients in which debridement was performed. Of the 520 patients derided, 380 patients were treated with NPWT, and included in study. Number of NPWT sessions was decided on the basis of wound status (adequate healthy granulation tissue, clinically improved circulation). A single session of NPWT dressing was applied in 84% (n = 320) patients, 8% (n = 31) patients needed two sessions of NPWT dressing, 6% (n = 24) patients had three sessions of NPWT dressing and only 1% (n = 5) patients did not respond to NPWT dressing. 78% (n = 297) patients had reduced levels of C-reactive protein levels and wound cultures were negative in 54% (n = 208) patients after application of NPWT dressing. Minor complications occurred in 0.7% (n = 3) patients due to occult osteomyelitis. In 0.5% (n = 2) patients, NPWT dressing was discontinued due to persistent leakage near a natural orifice. Sinus formation was seen in 6% (n = 23) patients who were treated with curettage and conventional dressings. The mean pain score on the verbal analogue scale was 3 out of 10. The mean cost of an NPWT dressing apparatus was 90 dollars. Conclusion We conclude from this study that NPWT dressing can be easily applied to any region of the body and it can be customized to the needs of patients from different socio-economic status.

Satisfaction in Patients After Rhinoplasty Using the Rhinoplasty Outcome Evaluation Questionnaire.

Introduction Rhinoplasty is a challenging procedure. The goal of the surgery is not only to restore the function and youthful appearance of the nose but also to improve quality of life. With the passage of time, the trend has been changing rapidly from more invasive to less invasive procedures. Although the technical aspects of rhinoplasty are important, patient satisfaction is the factor that dictates the success of the procedure. Materials and methods A total of 118 rhinoplasties were performed in our department between 2016 and 2018. The Rhinoplasty Outcome Evaluation (ROE) questionnaire was used to study the patients' satisfaction level. Ninety out of 118 patients took part in this study. Rhinoplasty was done using an open technique in all cases. The ROE questionnaire was filled preoperation and six months postoperation. Data analysis was done using SSPS statistic version 20 (IBM Corp., Armonk, NY, US). Results The main reasons for rhinoplasty in our patients were: aesthetic 23.3% (n=21), functional 25.5% (n=23), and a combination of both in 51% (n=46) patients. The mean ROE score of all patients preoperation was 30.5 (males: 31.3, females 29.8) and the mean score postoperation was 79.5 (males 78.2, females 80.9) at six months with no statistical differences (CI 17.11 - 12.59, P=0.762). However, both genders showed a statistically significant improvement between the preoperative and postoperative scores (mean difference = 49.3, CI 63.25 - 35.34, P<0.01), indicating an overall good satisfaction level after surgery. The satisfaction level of patients was inversely proportional to their level of understanding and knowledge of the surgical procedure. This difference was statistically significant ( CI 7.36-10.42, P<0.01). Minor corrections or modifications were done in eight patients under local anesthesia, with no significant difference in ROE scores as compared to those who had single surgery (CI 0.7 - 1.6, P=0.92). There was no statistically significant difference in the before and after surgery ROE scores among patients operated by different surgeons as well (P=0.82). Conclusion Our study shows that rhinoplasty, despite being a complex procedure, has proven benefits in terms of functional as well as aesthetic outcomes. The ROE questionnaire proves to be a valid tool for estimating patient satisfaction in our population. There is a need for further training and education of surgeons in Pakistan to improve the functional and aesthetic disabilities of nasal deformities.

Functional Outcomes of Secondary Procedures in Upper Extremity Replantation and Revascularization.

Introduction Traumatic amputation of the upper limb has significant associated morbidities and disabilities. After successful replantation surgery, the micro-surgeons' tasks are far from over. The replanted and revascularized segments have numerous functional restrictions and need various corrective secondary procedures. The aim of our study was to compare the functional results after secondary procedures by administering the Quick Disability of the Arm, Shoulder, and Hand (QuickDASH) questionnaire to patients who had successful upper limb replantation and revascularization. Materials and methods This prospective observational study involved 40 patients who had a partial or complete amputation of the upper limb and underwent secondary procedures to correct function after successful replantation and revascularization surgery. The patients' functional outcomes after various secondary procedures were recorded using the QuickDASH questionnaire. Results The mean QuickDASH score for thumb injuries was 42.3 pre-surgery but improved to 29.5 after secondary procedures, which was statistically significant (CI 11.12-14.87, p<0.01). The mean difference in the QuickDASH scores for finger injuries was also statistically significant: 45.5 preoperation and 33.7 postoperation (CI 9.89-13.70, p<0.01). For wrist injuries, the mean QuickDASH score was 52.8 presurgery and was 46.3 postoperatively (CI 1.81-6.58, p=0.0023). The QuickDASH scores of the patients with arm and forearm injuries showed no statistically significant improvement, with a preoperation score of 58.3 declining to 55.2 (p=0.98). The overall replantation and revascularization scores were 49.725 and 41.175 pre and postoperation, respectively (CI 8.35-8.75, p<0.01). Conclusion The study finds that the level and mechanism of injury are important predictors of the functional outcomes of the replantation and revascularization of amputated upper-limb appendages. Most replanted and revascularized upper limbs have numerous functional limitations, and achieving good functional results requires one or more secondary procedures, whose type depends on various factors such as the injury type and mechanism. The QuickDASH results for functional outcomes before and after secondary procedures indicate that it is an easy-to-use, reliable, and effective measure of functional outcomes.

Skin sparing mastectomy and immediate breast reconstruction.

OBJECTIVE: To evaluate skin sparing mastectomy(SSM) and immediate breast reconstruction(IBR) in terms of the survival, chances of recurrence, aesthetic restoration and prevention of psychosocial problems. DESIGN: An interventional study. PLACE AND DURATION OF STUDY: The Department of Plastic and Reconstructive Surgery, CMH, Rawalpindi from November 1998 to November 2003. MATERIALS AND METHODS: Twenty-eight patients of breast cancer, included in the study, were discussed in a Multidisciplinary Breast Clinic. Detailed metastatic work-up was performed. In all patients SSM with en-bloc level II axillary clearance and IBR was done. RESULTS: The patients' age ranged between 25-46 years. Two patients (7%) were nullipara. Tumor size was T1 in 10 (36%) and T2 in 18 patients (64%). In all the patients a circum-areolar incision was used. A contralateral uni-pedicled TRAM flap was used in 24 (86%) and latissimus dorsi flap in 4 patients (14%). All the flaps survived completely. There was marginal necrosis of native skin flaps in 03 (10.5%), infection in 03 (10.5%), axillary seroma in 03 (10.5%) and abdominal seroma in 01 patient (3.5%). As late complication 5 patients (19%) developed fat necrosis. Adjuvant chemotherapy was given in 6 (21%) and adjuvant radiotherapy in 4 patients (14%). No recurrence encountered in maximum follow-up . We found an excellent aesthetic restoration in 23 (82%), good in 1 (3.5%) and fair in 4 patients (14%). CONCLUSION: SSM for patients with early breast cancer is an oncologically safe procedure. IBR can greatly reduce the psychological trauma associated with breast loss including diminished feelings of feminity, decreased libido, social behavior, sense of mutilation and depression.