Reconstruction of Defects Following Excision of Basal Cell Carcinoma of Face: A Subunit-based Algorithm.

Introduction: Basal cell carcinoma (BCC) is a locally invasive, slowly spreading tumor arising in the basal layer of epidermis and rarely metastasizes. Surgical excision with adequate margins is curative. Reconstruction of post-excisional defects on the face is both essential and challenging. Clinical Cases and Methods: A retrospective review of hospital records for patients operated for BCC of the face excluding the pinna at our institute in the last 3 years was done and a review of the literature was carried out to identify the most common principles governing the optimal reconstruction of post-excisional defects on the face. Literature search was made in Embase, Medline, and Cochrane databases in the last two decades with the filters placed for human and English language studies with the search terms (Facial Basal cell carcinoma) AND reconstruction AND (Humans[Mesh]). Results: Records of 32 patients with facial BCC who underwent excision and reconstruction at our hospital were identified and details were recorded. Our literature search with the terms and filters mentioned above revealed 244 studies with duplicates removed. After further hand-searching, 218 journal articles were identified, reviewed, and a reconstruction algorithm was designed based on the findings. Discussion: Reconstruction of post-BCC excisional defects of the face relies on an adequate understanding of the general principles of reconstruction, subunit principle of facial esthetics, flap anatomy and vascularity as well as operator experience. Complex defects need innovative solutions, multidisciplinary approaches, and newer methods of reconstruction like perforator flaps and newer techniques like supermicrosurgery. Conclusion: Multiple reconstructive options for post-excisional defects of the BCC over the face are available and most defects can be approached in an algorithmic manner. Further well-designed prospective research studies are needed to compare outcomes of different reconstructive options for a given defect and identify the most suitable options.

Therapeutic Plasma exchange therapy in Burns.

Severe burn injury affects the body in many devastating ways, the most severe being systemic inflammatory response syndrome. This results in a myriad of effects like increasing capillary permeability, thereby fluid loss. It also causes a surge in inflammatory mediators like interleukin (IL)-6, which further increases the capillary leak and fluid loss. This results in refractory hypotension in patients despite adequate fluid resuscitation. Plasma exchange has been used in the management of a number of illnesses with a significant inflammatory component, and, therefore can be considered to have a role in burn injury. In our article, we would like to share our experience of using therapeutic plasma exchange therapy in burn patient.

Innovative Application of Ziplock Tags for External Tissue Expansion.

Tissue expansion is a technique, which uses the biomechanical properties of skin and thereby aiding in wound closure. Commercially available devices for external expansion are not cost-effective. Hence, in this article, we would like to share our experience of innovative use of ziplock as external tissue expansion.

Keystone Flap for Postburn Finger Flexion Contracture Release.

Flexion contracture of finger is a major cause of disability in postburn patients. Various methods have been described to cover the resultant defect after surgical release of finger flexion contracture. Local flaps are used when there is sufficient tissue available on lateral sides of the finger to recruit into the defect. Keystone flap can be designed on volar aspect of finger to cover the post contracture release defect. Use of local flap reduces need of skin graft and donor site morbidity. Here we discuss a case of postburn finger flexion contracture release using type-3 keystone flap. Postoperative results are satisfactory. Various pros and cons of the technique are discussed. Keystone flap is a new addition to the armamentarium of plastic surgeons for release of postburn flexion contracture of fingers.

Innovative Cost-Effective Application of Donut Dressing in Skin Grafting.

One of the measures for the successful take of a skin graft is the prevention of friction, especially in cases of pressure ulcers in patients with head injury leading to altered sensorium. With existing measures such as the use of a pressure-relieving bed, frequent change of position, etc graft loss is common. Some additional measures are required. This study highlights the role of a donut-shaped ring dressing to protect the skin graft from friction.

Plastic surgery practices amidst global COVID-19 pandemic: Indian consensus.

INTRODUCTION: The COVID-19 pandemic having spread globally has profound implications on medical and surgical care, which is given by the health care providers. At this time, though there are guidelines and recommendations for medical management of these patients, there is a lack of guidance on how a plastic surgeon should approach the COVID-19 suspect or infected patient who presents either in an elective or emergency setting. We aim to provide a consensus guideline based on the current recommendations of the Indian Council of Medical Research (ICMR) and the pooled experience of the major centers performing plastic and reconstructive surgery in India. METHODS: The current guidelines and recommendations on the COVID-19 pandemic were studied from both government and nongovernment sources including ICMR. The problems in the specialty of plastic surgery were categorized into four groups and for each group, separate and individual guidelines have been formulated. GUIDELINES: Consensus guidelines have been formulated for the specialty of Plastic and Reconstructive surgery. The patients requiring plastic surgery service have been categorized into four groups of acute, subacute, chronic, and late category. Acute cases are the ones who require intervention within 24-48 h. Subacute cases are the ones who require intervention in the next 3-10 days, while the chronic are the ones who need plastic surgery preferably within a month. The late category are the ones who need surgery within the next six months. This has been done based on the urgency and priority of surgical intervention titrated against the risks of operating and inadvertently acquiring the exposure of COVID-19-positive patients. CONCLUSION: Currently, in the wake of COVID-19 pandemic, there are no clear guidelines specific to the vast majority of patients who come for a plastic surgery intervention. This puts the patients at risk due to the impending plastic surgery problem while at the same time it poses a risk of exposure to COVID-19 for the surgical team. Consensus guidelines are presented, to steer the plastic surgeon in his work, in the wake of COVID-19 crisis. The guidelines are based on firm scientific evidence from the reputed research and regulatory bodies and have been made in consonance with plastic surgery experts around the country, so that these practices best suit the needs of the patients, while being mindful of resource limitations and infection risks. The approach of "delayed conservative treatment" works best in the present case scenario.

Role of Phenytoin in Diabetic Foot Ulcers.

Of the complications of diabetes mellitus, foot ulcers are the most dreaded complications, as they can progress at an alarming rate and can be very difficult to treat. Various modalities have been described in the treatment of diabetic foot ulcers. One such modality of phenytoin therapy uses the disadvantage of the drug, that is, gingival hyperplasia to the advantage of wound healing. We hereby report a case of diabetic foot ulcer managed with injection phenytoin sprayed topically over the wound.

Cadaveric Bilateral Transhumeral Upper Limb Transplantation: Journey to the Next level.

Organ transplant has, arguably, been the pinnacle of the advancement in medical science so far and vascularized composite allotransplantation has been the most recent addition to it. The scope of vascularized tissue allotransplantation has been widening with each passing day and more and more reports regarding the safety and efficacy of the procedure have been described. Due to the limited available literature on the management of the complications and implications of the hand transplant, the importance of each report on the procedure is paramount. A mid-arm allotransplant is a challenge in terms of expected motor recovery, and many controversies exist over the efficacy of the procedure altogether. Moreover, our case was complicated by a long ischemia time due to logistic reasons. We share our experience of a transhumeral upper limb allotransplantation, the complications associated with it along with the early postoperative results at 10 months follow up.

Prophylactic Tracheostomy for Inhalational Burns.

BACKGROUND: Various studies have reported different conclusions over the safety and benefits of early tracheostomy in burns. Our study aimed to assess the role of prophylactic tracheostomy in treatment and improvement of outcomes in inhalational burns in India. METHODS: In a retrospective descriptive analysis of burns admitted over 1 year in Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER) Tertiary Burns Center in India, patients with thermal burns of TBSA less than 60% and those with indirect evidence of airway burns were enrolled and divided into two groups who underwent prophylactic tracheostomy vs. patients for whom prophylactic tracheostomy was not done. Mortality was the final point and primary variable measurement. RESULTS: Totally, 10 patients with inhalational burns were admitted. Out of the 4 patients for whom prophylactic tracheostomy was undertaken, three patients survived, while one died. Out of the 6 patients for which prophylactic tracheostomy were not performed, 4 patients died; while 2 survived. The average percentage of burns TBSA in the prophylactic tracheostomy group was 34%. Average age of patients in the prophylactic tracheostomy group was 31.3 years. The average percentage burns TBSA in the group, where prophylactic tracheostomy was not carried out was 42%. Average age of patients in the prophylactic tracheostomy group was 36.2 years. CONCLUSION: Our study is a pilot study to investigate the possibility and a way to improve outcomes in patients with inhalational injuries. Larger trials may be needed to facilitate or disprove the same.

Autologous Platelet-rich Plasma Enriched Pixel Grafting.

Autologous platelet-rich plasma contains concentrated platelets after graded centrifugation, which has various applications. Skin grafting is an age-old procedure, which has been used for wound coverage. But the healing process is longer and may be difficult, depending on the wound site, skin defect size, and patient comorbidities, and is difficult to be carried out in patients who have limited donor sites, such as in burns or those who are not fit for long procedures. Hence, pixel grafting can be used in these areas. Platelet-rich plasma can be used to aid the graft take, and thereby decreasing patient morbidity and improve the surgeon's efforts.

New 5-D Coding System for Categorization of Plastic Surgery Conditions.

BACKGROUND: There is need for a coding system for categorizing the plastic surgery conditions to facilitate efficient data exchange, retrieval, research, time-series analysis, clinical audit, insurance and legal purposes. This is a pilot study to assess feasibility of newly proposed 5-D coding system in categorizing the plastic surgery conditions. METHODS: Retrospective analysis of records of plastic surgery patients visited in last 15 months was done. Each patient was assigned a code according to the newly proposed 5-D system of coding and recorded in excel sheet. Data analysis was done to categorize various plastic surgery conditions. Results of analysis were shown to 11 plastic surgeons and their feedback was taken. RESULTS: Feedback taken from participants showed 5-D coding system was useful and practically easy to categorize the plastic surgery conditions. CONCLUSION: Proposed new 5-D coding system is easy and useful in categorization of plastic surgery conditions.

Intense pulsed light vs silicone gel sheet in the management of hypertrophic scars: an interventional comparative trial in the Indian population.

Introduction: Hypertrophic scars are abnormal scars that are a source of great functional, psychological and financial burden to the patient. Currently available treatment modalities are either very cumbersome to use or have not provided very satisfactory results. Intense pulsed light (IPL) therapy for the management of hypertrophic scars has been recently introduced. However, most of the studies available are from the Western population. In this trial, we aim to study the effect of IPL on the South Indian population with darker skin and compare it with an existing treatment modality (silicone gel sheet). Materials and Methods: This trial was an interventional clinical trial conducted from September 2015 to March 2017 on 28 patients with 65 hypertrophic scars. Each scar was divided into 2 equal parts (4.6 x 1 cm2). One half of the scar was treated to 4 sessions of 29J/cm2 of IPL at 3 weekly intervals. A silicone gel sheet (SGS) was applied over the other half and changed at 3 weekly intervals. The Vancouver scar scale was used to grade both halves of the scar before treatment, at each visit and 3 weeks after treatment completion. Results: Scars treated with IPL showed a significant reduction in the pliability (p=0.002) and hyperpigmentation (p=0.000) as compared to scars treated with SGS. Though the percentage reduction in the height of the scar was more in the IPL group (15.4% as compared to 4.6%in the SGS group), the result was not statistically significant (p<0.065). As most scars in our study showed normal vascularity at the beginning, the percentage reduction in vascularity between both groups was the same (p<0.597). The reduction in the median VSS score was more in the IPL group compared to SGS group (p=0.00). Conclusion: IPL therapy offers a safe and effective means of hypertrophic scar treatment, especially on large scars where other treatment modalities may not be feasible. Minimal side effects that occur can be prevented with proper pre, intra and post procedure cooling.

Effectiveness of Fibrin Glue in Adherence of Skin Graft.

BACKGROUND: Graft fixation is important for graft take. Fibrin glue has been proposed as an ideal material, because of its human origin and it provides firm adhesion in seconds or minutes. OBJECTIVE: To evaluate the efficiency of fibrin glue, in increasing the take of skin graft. Assessment includes surgical time taken for graft fixation, haematoma/seroma formation, engraftment and wound closure by day 14. METHODS: The study is an observational prospective study conducted in the Department of Plastic Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, from January 2016 to June 2016. Sixteen patients who underwent split skin grafting were assessed during the study period. Fibrin glue was used on the recipient bed before grafting. RESULTS: Better haemostasis and graft adhesion, with a significant reduction of surgical time, were noted. CONCLUSION: The safety profile of fibrin glue was excellent as indicated by the lack of any related serious adverse experiences. These findings demonstrate that it is safe and effective for attachment of skin grafts, with outcomes at least as good as conventional methods.

Proposal of a new classification scheme for periocular injuries.

BACKGROUND: Eyelids are important structures and play a role in protecting the globe from trauma, brightness, in maintaining the integrity of tear films and moving the tears towards the lacrimal drainage system and contribute to aesthetic appearance of the face. Ophthalmic trauma is an important cause of morbidity among individuals and has also been responsible for additional cost of healthcare. Periocular trauma involving eyelids and adjacent structures has been found to have increased recently probably due to increased pace of life and increased dependence on machinery. A comprehensive classification of periocular trauma would help in stratifying these injuries as well as study outcomes. MATERIAL AND METHODS: This study was carried out at our institute from June 2015 to Dec 2015. We searched multiple English language databases for existing classification systems for periocular trauma. We designed a system of classification of periocular soft tissue injuries based on clinico-anatomical presentations. This classification was applied prospectively to patients presenting with periocular soft tissue injuries to our department. RESULTS: A comprehensive classification scheme was designed consisting of five types of periocular injuries. A total of 38 eyelid injuries in 34 patients were evaluated in this study. According to the System for Peri-Ocular Trauma (SPOT) classification, Type V injuries were most common. SPOT Type II injuries were more common isolated injuries among all zones. DISCUSSION: Classification systems are necessary in order to provide a framework in which to scientifically study the etiology, pathogenesis, and treatment of diseases in an orderly fashion. The SPOT classification has taken into account the periocular soft tissue injuries i.e., upper eyelid, lower eyelid, medial and lateral canthus injuries., based on observed clinico-anatomical patterns of eyelid injuries. CONCLUSION: The SPOT classification seems to be a reliable system to address eyelid injuries. This classification scheme would guide the ophthalmic and facial reconstructive surgeons to provide optimal outcomes in eyelid injuries. Based on the classification scheme and review of existing literature, an algorithm is presented to facilitate repair and reconstruction.

Are lasers superior to lights in the photoepilation of Fitzpatrick V and VI skin types? - A comparison between Nd:YAG laser and intense pulsed light.

BACKGROUND AND OBJECTIVES: There are no large volume comparative studies available to compare the efficacy of lasers over lights for hair removal in Fitzpatrick V and VI skin types. This study is designed to compare the efficacy of Nd:YAG laser versus IPL in the darker skin types. STUDY DESIGN/MATERIALS AND METHODS: Thirty-nine patients included in Group-1 were treated with Nd:YAG and 31 in Group-2 with IPL. Both groups received 5 sessions of treatment. The hair counts were assessed using digital photography and manual counting method before and after treatment and the results were analysed. Patient satisfaction scores and pain scores were recorded in each session and compared. RESULTS: Mean hair reduction in the IPL group was 25.70 and Nd:YAG group was 24.12 (95% CI). In the Nd:YAG group, 59% of subjects had burning sensation while the figure was 32.3% in IPL group. Burning was less in IPL group (p < 0.023). There were no statistically significant differences noticed regarding hyperpigmentation in both the groups (p < 0.115). CONCLUSION: Both Nd:YAG and IPL are equally effective for epilation of the darker skin types. Nd:YAG is associated with mild burning sensation in a significant number of patients. Patient satisfaction scores were comparable in both the groups.