Reconstructive rhinoplasty

To assess the results of reconstructive rhinoplasty. Observational study. Department of plastic surgery, Pakistan Institute of Medical Sciences [PIMS], Islamabad from January 2002 to December 2003. All the patients with acquired nasal defect due to trauma, accident, assault, infection or tumour excision were included. Patients having cleft lip nasal deformity were excluded from the study. The different surgical options used for reconstruction included skin grafts, composite grafts, median/paramedian forehead flap, nasolabial flap, scalping forehead flap and arm flap. All the operations were performed under general anaesthesia except with small defects using grafts/local flaps. The skeletal support was achieved by using a composite graft, conchal cartilage graft, or bone graft from the rib/iliac crest. The flaps were monitored closely for first 48 hours. Stitches were removed from 6-9 days. Flap division and insetting was done after 2-3 weeks. Follow up of the patients was done monthly for first 3 months and six month interval onwards. The aesthetic result was assessed objectively as well as subjectively. Twenty one patients were admitted for treatment of acquired nasal defects. Male to female ratio was 1:1.1. The mean age in males was 40.3 years, and in females 35.9 years. The most common cause was assault [47.6%] followed by accident [23.8%]. The different options used for reconstruction included skin grafts, median/paramedian forehead flaps, scalping forehead flap, arm flap. Only one flap was lost. There was no case of postoperative infection. In 2 cases, flap debulking was performed to improve the nasal contour. Reconstruction of nasal defect is a challenging task. Median or paramedian forehead flap is the most suitable option. The emphasis should be paid to the reconstructive as well as aesthetic component of the reconstruction rhinoplasty

Flexor tendon injuries of hand: experience at Pakistan institute of medical sciences, Islamabad, Pakistan

Flexor tendon injury is one of the most common hand injuries. This initial treatment is of the utmost importance because it often determines the final outcomes; inadequate primary treatment is likely to give poor long term results. Various suture techniques have been devised for tendon repair but the modified Kessler's technique is the most commonly used. This study was conducted in order to know the cause, mechanism and the effects of early controlled mobilization after flexor tendon repair and to assess the range of active motion after flexor tendon repair in hand. This study was conducted at the department of Plastic Surgery, Pakistan Institute of Medical Sciences, Islamabad from 1[st] March 2002 to 31[st] August 2003. Only adult patients of either sex with an acute injury were included in whom primary or delayed primary tendon repair was undertaken. In all the patients, modified Kessler's technique was used for the repair using non-absorbable monofilament [Prolene 4-0]. The wound was closed with interrupted non-absorbable, polyfilament [Silk 4-0] suture. A dorsal splint extending beyond the finger tip to proximal forearm was used with wrist in 20-30 [degree sign] palmer flexion, metacarpophalangeal [MP] joint flexed at 60[degree sign]. Passive movements of fingers were started from the first post operative day, and for controlled, digits were studies. 94% of the patients had right dominated hand involvement. 51% had the complete flexor digitorum superficialis [FDS] and flexor digitorum profundus [FDP] injuries. Middle and ring fingers were most commonly involved. Thumb was involved in 9% of the patients. Zone III [46%] was the commonest to be involved followed by zone II [28%]. Laceration with sharp object was the most frequent cause of injury. Finger tip to distal palmer crease distance [TPD] was <2.0 cm in 71% cases [average 2.4cm] at the end of 2[nd] postoperative week. Total number of patients was 34 at the end of 6[th] week. TPD was <2.0 cm in 55% patients and <1.0 cm in 38% cases [average 1.5 cm] at the end of 6[th] week. Total 9 patients were lost to the follow up at the end of 8[th] week. TPD was <1.0 cm in 67% [average 0.9 cm] at the end of 8[th] postoperative week. No case of disruption of repair was noted during the study. Early active mobilization programme is essential after tendon repair. Majority of the patients [92%] had fair to good results at the end of 2[nd] week which increased to 97% at the end of 8[th] week to good to excellent

Management protocol of mandibular fractures at Pakistan Institute of Medical Sciences, Islamabad, Pakistan

Maxillofacial trauma is very frequent and associated with a high incidence of mandibular fractures. Although there is universal agreement as to the treatment goals and basic therapeutic principles of reduction and stabilization, a variety of currently accepted treatment modalities indicate a lack of consensus. The authors evaluate the incidence, etiology, management and complications of 344 mandibular fractures in 228 patients treated in the Department of Plastic and Reconstructive Surgery at Pakistan Institute of Medical Sciences [PIMS], Islamabad, Pakistan, during a three year period. Indications and techniques for closed and open treatment of mandibular fractures are reviewed along with any complications of these fractures or their management. A total of 344 mandibular fractures in 228 patients were included in this study. The sex, age, etiology, presentation, fracture characteristics, associated injuries, various methods of management and any pre or postoperative complications were evaluated. Although various devices and techniques have been used to treat these fractures, modern plate and screw fixation systems have proved to provide the best rigid stabilization, early mobility and associated with least complications. There was a satisfactory bone healing in all the patients and a minimal complication rate associated with open reduction and internal fixation [ORIF]. Mandibular fractures occur with high frequency in road traffic accidents and interpersonal violence. They are among the most common types of facial fractures treated by the plastic surgeons. They must be managed carefully to maintain the function of the mandible, reestablish proper occlusion, and minimize secondary complications. Open reduction and internal fixation has proven to be the most effective method for treatment of mandibular fractures

experience of burn injueies

To study the demographical data of burn patients. This study was carried out in department of Plastic Surgery, Pakistan Institute of Medical Sciences, Islamabad, Pakistan from January 2002 to December 2003. Only admitted patients of either sex of age more than 12 years were included. Total 77 males and 65 females fulfilled the criteria. The mean age in males was 32.2 years and 24.4 years in females. Male to female ratio was 1: 1.18 respectively. Burns were common during winter season [42.2%] In 6% patients, suicidal burns were noted. 15% patients were homicidal cases. 79% patients had the burns accidentally. Stove burst [22%] was the major mechanism in females whereas in males, 18% had the direct flame injury. Kitchen [27%] was the commonest place in females. Housewives [35%] were most frequently affected. More married males [39%] were burnt as compared to 18% of the unmarried females. Inhalational injury was present in 23% patients. Males had average burns of 27.4% TBSA and females had 39.5% TBSA involvement. 18% of the deaths were among the males and 16% in females. Prevention is always the rule to be safe from burns but once it occurs, immediate and proper care should be given with aggressive treatment to minimize the post burn problems

Management of phalangeal fractures of hand

Phalangeal fractures are approximately 10% of all the fractures of skeletal system. Most fractures are functionally stable. Surgical treatment is necessary when fracture is displaced and reduction is not possible. This study was conducted in order to study the aetiology, features and management of the phalangeal fractures of hand. This descriptive study was conducted in the department of Plastic Surgery, Pakistan Institute of medical Sciences, Islamabad from June 1[st] 2002 to July 31[st] 2003. Adult patients of either sex with acute injury presenting in the out-patient department and emergency department were included whereas patients below the age of 13 years and patients with amputated digits were excluded. The site and side of fracture were noted. All patients were X-rayed pre-operatively. These patients were divided into two groups. Group A comprised of those patients in whom only closed reduction was done. Group B comprised of patients in whom operative procedure was carried out. Various modalities used were percutaneous Kirschner wire fixation, open reduction and internal fixation with K-wires, screws, microplates and dental wires/ after operation, immobilization of fracture site was done for 3 - 4 weeks. Chi square test was used for statistical analysis of complications in both the groups. 51 fractures were seen in 43 men and 8 fractures in 8 females. Mean age of the patients of group A was 35.6 years as compared to 29.5 years of group B. 31% fractures were associated with soft tissue injury. Ring finger was the commonest to be involved in 36% patients. Left hand [64%] was commonly involved. Left proximal phalanx [31%] was the most frequently injured part. Intraarticular fractures were seen in 10% cases. 15 fractures were treated conservatively and some kind of operative modality was used in 44 fractures. Crush injury remained the commonest cause. In 36% patients fractures were fixed with K-wire using open reduction and internal fixation technique. In 22% patients, only percutaneous K-wire was used. In two patients, dynamic traction device was used. One case of post operative infection was noticed in group B. Whereas only one case of malunion and one case of limited joint movement and stiffness was noted in group A. Results of both the closed reduction and open reduction and internal fixation were equally good [p < 0.05]. If there is any soft tissue injury, it is advisable to use open reduction and internal fixation technique

Maxillofacial trauma: Current practice in management at Pakistan institute of medical sciences

This study was carried out to determine the aetiology, pattern and management of maxillofacial injuries at PIMS, Islamabad. This descriptive study was conducted at Plastic Surgery Department, PIMS Islamabad from 1st February 1998 to 30th April 2002. All the adult patients presenting with maxillofacial injures were included where as patients less than 12 years of age and only facial lacerations were excluded. Similarly isolated nasal bone fractures were also excluded because these patients were routinely managed by ENT department. Age, sex, presentation, aetiology, associated injuries and treatment modalities undertaken in these patients were recorded. In 164 patients 254 fractures were noted. Most were male [86%], ranging in age from 13'71 years with a male to female ratio of 6:1 respectively. The most frequent [48%] cause noticed was road traffic accidents followed by assault. Mandible was the commonest to be involved in such injuries followed by maxilla. Most of the patients [32%] had associated facial injuries. Various treatment modalities were practiced. Maxillofacial fractures should be managed by open reduction and internal fixation as early as possible

Management of exposed cardiac pacemaker

Pacemaker pocket infections call for early recognition and aggressive management. A case report of exposed cardiac pacemaker due to sepsis and sloughing of skin successfully treated at P.I.M.S. with practical details of its management, is presented