Epidemiological Predictors of Financial Toxicity in Surgical Burn Injuries: A Multicenter, Longitudinal, Cohort Study.

BACKGROUND: Burns constitute a major global health challenge, causing over 11 million injuries and 300,000 deaths annually and surpassing the economic burden of cervical cancer and HIV combined. Despite this, patient-level financial consequences of burn injuries remain poorly quantified, with a significant gap in data from low- and middle-income countries. In this study, we evaluate financial toxicity in burn patients. METHODS: A prospective, multicenter cohort study was conducted across two tertiary care hospitals in India, assessing 123 adult surgical in-patients undergoing operative interventions for burn injuries. Patient sociodemographic, clinical, and financial data were collected through surveys and electronic records during hospitalization and at 1, 3, and 6 months postoperatively. Out-of-pocket costs (OOPCs) for surgical burn treatment were evaluated during hospitalization. Longitudinal changes in income, employment status, and affordability of basic subsistence needs were assessed at the 1-, 3-, and 6-month postoperative time point. Degree of financial toxicity was calculated using a combination of the metrics catastrophic health expenditure and financial hardship. Development of financial toxicity was compared by sociodemographic and clinical characteristics using logistic regression models. RESULTS: Of the cohort, 60% experienced financial toxicity. Median OOPCs was US$555.32 with the majority of OOPCs stemming from direct nonmedical costs (US$318.45). Cost of initial hospitalization exceeded monthly annual income by 80%. Following surgical burn care, income decreased by US$318.18 within 6 months, accompanied by a 53% increase in unemployment rates. At least 40% of the cohort consistently reported inability to afford basic subsistence needs within the 6-month perioperative period. Significant predictors of developing financial toxicity included male gender (odds ratio, 4.17; 95% confidence interval, 1.25-14.29; P = 0.02) and hospital stays exceeding 20 days (odds ratio, 11.17; 95% confidence interval, 2.11-59.22; P ≤ 0.01). CONCLUSIONS: Surgical treatment for burn injuries is associated with substantial financial toxicity. National and local policies must expand their scope beyond direct medical costs to address direct nonmedical and indirect costs. These include burn care insurance, teleconsultation follow-ups, hospital-affiliated subsidized lodging, and resources for occupational support and rehabilitation. These measures are crucial to alleviate the financial burden of burn care, particularly during the perioperative period.

First Successful Separation of Craniopagus Twins in India-Plastic Surgical Considerations.

Separation of total vertical craniopagus with shared venous sinuses poses multiple challenges. Provision of soft-tissue cover to the exposed brains at the time of total separation is one of them, due to the large size of the defect and paucity of local tissues. Staged separation of twins is advised with partial venous and parenchymal disconnection in the first stage and total separation in the second stage. Tissue expanders are inserted in the first stage, and second stage planned to coincide with the period of adequate expansion. In the child being reported, emergency second stage was done due to the deteriorating general condition of the children. Left with inadequate expanded skin, the critical defect in a twin was managed with bilateral trapezius myocutaneous flaps. High ionotropic support of the postoperative period resulted in superficial necrosis of the flap, which was managed by debridement, allograft application and autograft later. Both twins had well-healed wounds by 3 months.

Surgical Leadership Training beyond the Traditional Mentorship Model.

In this article, I reflect on my experience of being awarded the International Resident Travel Scholarship for "Plastic Surgery the Meeting 2019." I was the first Indian to be awarded the scholarship, and it offered me not only monetary assistance but also mentorship for future leadership positions. The award further opened doors for several future opportunities in the form of memberships in the American Society of Plastic Surgery (ASPS) committees and Resident Advisory Board of the prestigious "Plastic and Reconstructive Surgery Journal." I believe this article will make more residents aware and utilize such opportunities for their career development.

Plastic Surgeons and COVID-19 Pandemic.

The world is suffering from the unprecedented problem of the COVID-19 pandemic. As healthcare professionals, we face the imminent danger of exposure. For Plastic, Reconstructive and Burn surgeons, safety and smooth functioning of day-to-day work during this pandemic is of the utmost priority. However, it is also our responsibility to stop the human-to-human transmission chain and conserve the medical resources for rational use. The disease has spread throughout the country, and with the number of infections increasing day by day, it is very important to adhere to the safety principles. This document aims to provide some insights into the world of plastic, reconstructive and burn surgeons in the time of the COVID-19 outbreak.

Adult Tessier cleft 30: technical case report and review of literature.

Atypical facial clefts are rare anomalies that occur due to the failure of embryonic fusion of the branchial arches. The midline mandibular cleft or Tessier 30 cleft is one such rare anomaly. Such anomalies are diagnosed at birth and treated within a few months of age by establishing soft tissue and bony continuity, followed by orthognathic treatment in adulthood. It is very rare for such clefts to go untreated until adulthood. We present one such case report and our technique of management in a patient who presented to us at 25 years of age with a lower lip and mandible cleft with ankyloglossia, which was managed with a single-staged reconstruction.

Extended anterolateral thigh flap reconstruction of a recurrent pelvic chondrosarcoma excision defect with exposed bowel.

The pedicled anterolateral thigh (ALT) flap has proven to be a reliable and versatile technique for the reconstruction of complex abdominal wall defects. Its robust vascular supply, large skin paddle and potential for a two-team approach make it an excellent choice for such challenging reconstructions. This case report emphasises the effectiveness of the pedicled ALT flap in managing complex abdominal wall defects, providing both functional restoration and satisfactory aesthetic results. However, careful patient selection and meticulous surgical planning remain paramount to ensure optimal outcomes.

Insight on Pediatric Burn Morbidity and Mortality at a Tertiary Indian Burn Care Center: A Case For Burn Prevention.

Pediatric burns pose a significant health burden in LMICs. Despite efforts to address burn prevention and management, morbidity and mortality rates remain high, particularly among children. Understanding pediatric burn epidemiology and predictors of clinical outcomes is crucial for developing effective prevention strategies and improving patient-care. This retrospective cohort study analyzed pediatric burn patients admitted to a tertiary burn-center in India, between March-2022 and December-2023. Demographic date, burn characteristics, treatments, complications and outcomes were collected. Statistical analysis, including logistic and linear regression, was conducted to identify predictors of mortality, sepsis, and hospital stay length. Among 332 pediatric burn patients, median age was 3 years, with a male predominance. Scald burns were the most common, followed by electrical and flame burns. Median total body surface area burned was 20%, with upper and lower extremities most affected. The incidence of electrical burns increased with age and was associated with a longer length of stay. Mortality rate was 14.2%, with age >10 years, male gender, and TBSA >30% predicting mortality. Complications like sepsis significantly increased mortality risk, while deep burns were associated with longer hospital stays. This study underscores importance of targeted prevention efforts and specialized care. Scald burns among young children highlight the need for safer cooking practices, while the high incidence of electrical burns in older children suggests age-specific education interventions are necessary. Predictors of mortality identified can guide risk assessment and resource allocation, emphasizing the importance of infection control and wound management strategies in improving outcomes.

Don't Play It by Ear: Technical Considerations to Optimize Outcome and Procedural Safety of Congenital Microtia Reconstruction in a Dextrocardia Patient With Situs Inversus Totalis, Butterfly Vertebra, and Hemivertebra.

Background: Microtia can occur as a standalone condition or as part of a genetic syndrome. We report the first case of microtia presenting in a patient with dextrocardia, situs inversus totalis, butterfly vertebra, and hemivertebra, and we present technical recommendations for optimizing anaesthetic and surgical harmony in this extraordinary case.Patients with situs inversus dextrocardia should be checked for signs of Kartagener syndrome. Dextrocardia requires mirroring the placement of electrocardiogram (ECG) leads and the use of shocking paddles for cardiopulmonary resuscitation. Central venous access should be performed under ultrasound guidance because of varied course. Cervical vertebral deformities necessitate a thorough airway assessment since neck mobility may be limited due to pain or aberrant curvature. Conclusions: In this case, Brent's approach was used to treat the microtia, but rib cartilage was harvested from the ipsilateral side to lessen the chance of damaging the pericardium due to unfamiliar anatomy. These factors must be taken into account to perform a safe surgery on such patients.

Review of Replantation Services from a Level One Trauma Center in India.

The aim of this article is to examine the elements that contribute to effective operation of a specialized replantation center and to provide readers with a general idea of the outcome of replantation services in India. A dedicated high-volume center coupled with a sound referral system is the backbone of replantation services in a country. A retrospective study was done on all patients who visited a level 1 trauma center in India from November 1, 2017, to December 31, 2018, for various amputations. The medical records and digital pictures of these patients were extracted from the records and analyzed. During the study period, 77 replants were performed on 63 patients at our center. Males were 68% of the study, mostly belonging to the 20 to 40 years age group (63%). Thirty-four percent of cases were smokers. Agricultural injuries (49%) were the most common cause of amputation. Finger replantation was the most common type of replantation (82%). The rate of successful replantation was highest for scalp (100%) followed by hand (71%) and thumb (67%). Setting up dedicated replantation services is essential, especially in highly populated areas. Manpower, resources, and a protocol-led approach help in achieving optimum results. A multidisciplinary team approach with round-the-clock availability plays a vital role in intraoperative decision-making and planning postoperative rehabilitation.

Experimental Models and Practical Simulators for Supermicrosurgery: An Updated Systematic Review and Meta-Analysis.

BACKGROUND: Supermicrosurgical simulators and experimental models promote test viability, a faster learning curve, technical innovations, and improvements of the surgical dexterities. The authors aimed to present a systematic review and meta-analysis of preclinical experimental models and simulation platforms used for supermicrosurgery. METHODS: An electronic search was conducted across the PubMed MEDLINE, Embase, Web of Science, and Scopus databases in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Data collection included the types of experimental models and outcomes. Pooled estimates were calculated with a random-effect meta-analysis using the DerSimonian-Laird model. RESULTS: Thirty-eight articles were incorporated in the qualitative synthesis. Twenty-three articles reported the use of in vivo models (60.5%), 12 used ex vivo models (31.5%), and three used synthetic models (7.9%). The superficial inferior epigastric system of rats was the most common in vivo model, whereas chicken wings and hindlimbs were the most common methods used in ex vivo models. The most common methods to evaluate patency of anastomoses were gross inspection, passage of nylon thread into the lumen, and intravascular flow of an injected dye. Nineteen studies were incorporated in the meta-analysis. The overall rate of a successful anastomosis was 94.9% (95% CI, 92.3 to 97.5%). The success rate of in vivo models using rats was 92.5% (95% CI, 88.8 to 96.3%). The success rate of ex vivo models was 97.7% (95% CI, 94.6 to >99%). CONCLUSION: Simulators that have high fidelity concerning the dissection of the vascular pedicle, flap elevation, supermicrovascular anastomosis, and adequate assessment of a successful anastomosis possess adequate predictive validation to evaluate and simulate the supermicrosurgical technique. CLINICAL RELEVANCE STATEMENT: Supermicrosurgical simulators are designed to reproduce specific clinical scenarios; therefore, these should be implemented sequentially to develop specific competencies. Supermicrosurgical models must be regarded as mutually inclusive learning platforms to optimize the learning curve.

Current Fat Grafting Practices and Preferences: A Survey from Members of ISPRES.

Fat grafting has established its niche in a wide spectrum of aesthetic and reconstructive procedures. A consensus-based method of harvest, processing, enrichment, injection, and assessment is lacking, despite the rising trends in its application. We conducted a survey among plastic surgeons to evaluate and identify trends of fat grafting practices. Methods: We conducted an electronic survey with a 30-item questionnaire of 62 members of the International Society of Plastic Regenerative Surgeons. We collected demographic information, techniques, and experiences related to large volume (100-200 ml) and small-volume (<100 ml) fat grafting. Results: The majority of the respondents worked predominantly as aesthetic surgeons. The donor area selection was based on the patient's fat availability (59.7%). For fat enrichment, platelet-rich-plasma and adipose stem cells were routinely used by 12.9% and 9.7% of respondents, respectively. A 3- to 4-mm cannula with three holes was the most preferred instrument for large-volume fat harvesting (69.5%). For small-volume fat grafting, 2-mm cannulas (75.8%) with Mercedes tip (27.3%) were used most commonly. For processing, decantation of fat was performed by 56.5% of respondents (without exclusivity). For handheld injections (without exclusivity), respondents preferred a 1- to 2-mm cannula with a 1 cm3 syringe. The most popular method of outcome assessment was photographic evaluation. Conclusions: The respondents' tendencies were similar to those reported in the previous literature, with some exceptions, such as the technique for preparing fat and enrichment. A wider cross-sectional survey, involving national delegates and global representatives of plastic surgeons, is anticipated.

Medical and Surgical Care of Critical Burn Patients: A Comprehensive Review of Current Evidence and Practice.

Critically ill burn patients pose several unique challenges to care providers. The concepts of fluid resuscitation, nutritional management, organ support and wound care are rapidly evolving. There is a pressing need to review emerging evidence and incorporate these into practice for the effective management of burn patients. We have searched the PubMed and Google Scholar databases to review the current evidence on the acute care management of adult as well as paediatric burn patients. The rationales for current practices have been integrated into the review. The management of critically ill burn patients requires an in-depth knowledge of the pathophysiology of burn injury, a tailored approach for timely resuscitation, timely diagnosis of organ specific problems, and comprehensive wound care. This review will help the doctors and healthcare providers involved in the management of critical burn patients in their day-to-day practice.

Impact of COVID-19 and containment measures on burn care: A qualitative exploratory study.

BACKGROUND: Burn care in India is limited by multiple constraints. The COVID-19 pandemic and the containment measures restricted access to non-COVID emergency conditions, including burns. The aim of this study was to explore the impact of the pandemic on burn care in India. METHODS: Using the qualitative exploratory methods, we conducted in-depth interviews (IDI) with plastic and general surgeons representing burn units from across India. Participants were selected purposively to ensure representation and diversity and the sample size was guided by thematic saturation. Thematic analysis was undertaken adopting an inductive coding using NVivo 12 Pro. RESULTS: 19 participants from diverse geographic locations and provider types were interviewed. Three major emerging themes were, change in patient and burn injury characteristics; health system barriers, adaptation, and challenges; and lessons and emerging recommendations for policy and practice. There was change in patient load, risk factors, and distribution of burns. The emergency services were intermittently disrupted, the routine and surgical services were rationally curtailed, follow-up and rehabilitation services were most affected. Measures like telemedicine and decentralising burn services emerged as the most important lesson. CONCLUSIONS: The ongoing pandemic has compounded the challenges for burns care in India. Urgent action is required to prioritise targeted prevention, emergency transport, decentralise service delivery, and harnessing technology for ensuring resilience in burns services.

Optimising Hand Surgery during COVID-19 Pandemic.

Background: With the emergence of the COVID-19 pandemic, most health-care personnel and resources are redirected to prioritize care for seriously-ill COVID patients. This situation may poorly impact our capacity to care for critically injured patients. We need to devise a strategy to provide rational and essential care to hand trauma victims whilst the access to theatres and anaesthetic support is limited. Our center is a level 1 trauma center, where the pandemic preparedness required reorganization of the trauma services. We aim to summarise the clinical profile and management of these patients and highlight, how we modified our practice to optimize their care. Methods: This is a single-centre retrospective observational study of all patients with hand injuries visiting the Department of Plastic Surgery from 22nd March to 31st May 2020. Patient characteristics, management details, and outcomes were analysed. Results: A total of 102 hand injuries were encountered. Five patients were COVID-19 positive. The mean age was 28.9 ± 14.8 years and eighty-two (80.4%) were males. Thirty-one injuries involved fractures/dislocations, of which 23 (74.2%) were managed non-operatively. Seventy-five (73.5%) patients underwent wound wash or procedure under local anaesthetic and were discharged as soon as they were comfortable. Seventeen cases performed under brachial-plexus block, were discharged within 24 hours except four cases of finger replantation/ revascularisation and one flap cover which were discharged after monitoring for four days. At mean follow-up of 54.4 ± 21.8 days, the rates of early complication and loss to follow-up were 6.9% and 12.7% respectively. Conclusions: Essential trauma care needs to continue keeping in mind, rational use of resources while ensuring safety of the patients and health-care professionals. We need to be flexible and dynamic in our approach, by utilising teleconsultation, non-operative management, and regional anaesthesia wherever feasible.

Approach to a Patient with Cutaneous Malignancy in the Time of COVID-19 Pandemic.

The world is facing an unprecedented crisis of COVID-19 pandemic. This disease has weakened the economy, paralyzed the healthcare system, and worn out the human resources. Patients with cutaneous malignancy or skin cancer comprise a substantial part of the patient population and they need appropriate management of the cancer as they face the risk of COVID-19. In the wake of COVID-19 pandemic, the approach to management of cutaneous malignancy needs to be reassessed. The challenges in the management of skin cancer during COVID-19 are discussed in this article. Risk stratification considering the type and nature of malignancy, age, comorbidity, and treatment option is crucial in making the suggestions. Patient care, adequate infection control, safety of healthcare worker, and rational use of resources are the cruxes of management in this trying time.

Managing Burns During COVID-19 Outbreak.

The coronavirus disease pandemic has affected our practice as healthcare professionals. As burn surgeons, we are obliged to provide the best possible care to our patients. However, due to the risk of viral transmission, the goal should be to provide safe care to our patients as well as ensure the safety of the whole team providing burn care. The burn patients are usually debilitated and require a prolonged hospital stay and multiple operative procedures which put them and everyone involved in their care at increased risk of coronavirus infections and transmission. This warrants special caution to the burn team while managing such patients. In this review, we aim to highlight the key considerations for burn care teams while dealing with burn patients during the COVID-19 pandemic.

Versatility of the Pedicled Latissimus Dorsi Myocutaneous Flap in Reconstruction of Upper Limb and Trunk Soft Tissue Defects.

Purpose The purpose of the study was to share our indications, technique, outcome, and complications associated with the pedicled latissimus dorsi myocutaneous flap (LDMF) for reconstructing various upper limb and trunk soft tissue defects. Patients and Methods We reviewed the prospectively collected data of the patients who underwent reconstruction of upper limb/trunk soft tissue defects with pedicled LDMF between January 2016 and March 2019. By analyzing the clinical scenarios, the location of flap inset, the arc of rotation, reach of the flap, and associated complications, we put forward few significant findings from our experience. Results Thirty-four patients were included in the study: 13 of them underwent LDMF for coverage of upper limb defects, 12 of them for postradical mastectomy soft tissue defects, 8 for posterior trunk reconstruction, and 1 for sternal wound infection. LDMF was successfully used to cover the scapula, anterior and posterior arms, axilla, cubital fossa, mid-forearm, breast, sternum, and midline dorsal wounds. When used reversely, the flap could cover the exposed spine in the midline dorsum. Three patients (9%) had major complications (two patients had partial flap necrosis which required additional debridement and skin grafting, and one patient required an additional transpositional flap). Three patients had minor complications (managed nonoperatively). Conclusion Pedicled LDMF is a straightforward and versatile option for reconstruction of the varied upper limb and trunk soft tissue defects with minimal complications. Level of Evidence This is a level IV, therapeutic, retrospective study.

Paraneoplastic cerebellar degeneration as a manifestation of metastatic recurrent carcinoma breast: rare scenario.

Carcinoma breast presenting with paraneoplastic cerebellar degeneration is a rare scenario. We report a case of a 52-year-old woman, which is a follow-up case of completely treated carcinoma breast presenting with paraneoplastic cerebellar degeneration which, on investigation, revealed metastatic disease with recurrence at previous scar site and metastasis to contralateral axilla. The patient was given pulse methyl prednisolone therapy and underwent wide local excision of nodule and right axillary lymph node dissection with 14 cycles of trastuzumab and paclitaxel as adjuvant therapy. However, there was no detectable change in neurological symptoms at 6-month follow-up postoperatively. This case report highlights the need for clinicians to be aware of all possible presentations of carcinoma breast and its recurrence, including rare manifestations as in this case.