Local Flap Reconstruction of Burn Contractures in Extremities and Neck: A Nine-Year Experience with Long-Term Outcome Evaluation in Southwestern Iran.

Background: Treating burn scar contractures remains challenging for reconstructive surgeons; no clear guidelines declare the optimal and most effective technique. We evaluated the efficacy of local flaps in treating patients with post-burn contractures. Methods: This retrospective study included 243 patients with post-burn contractures referred to Taleghani Hospital (Khuzestan, southwest Iran) for local flap reconstruction from 2011 to 2020. Patients' demographic data, detailed descriptions of scars, surgical procedures, and flap outcomes were assessed. A plastic surgeon conducted all surgical procedures, the goals of which were to release the scar and cover the defect. Joint range of motion (ROM) (according to goniometric measurements), complications, need for second-stage surgery, and patient satisfaction were assessed. Results: After scar release, 70.4% of joints were covered with a Z-plasty and similar local flaps, 26.1% with a Z-plasty plus skin grafts, and 3.5% with only skin grafts. The outcome after one year revealed a significant improvement in mean ROM (by 45.80% of the normal ROM; P< 0.001). The mean functional and aesthetic satisfaction scores were 9.45 and 7.61 out of 10, respectively. The complication rate was 10.82%: re-contracture occurred in 3.82%, flap tip necrosis in 1.27%, and partial flap necrosis in 0.31%. Conclusion: Simple local flaps such as the Z-plasty are safe and effective in covering the joint following post-burn contracture release. Due to the feasibility, minimal need for facilities, steep learning curve, acceptable functional and aesthetic outcomes, and low complication rate, we strongly recommend the Z-plasty for reconstructing burn contractures, particularly in LMICs.

Intralesional triamcinolone alone or in combination with botulinium toxin A is ineffective for the treatment of formed keloid scar: A double blind controlled pilot study.

Cutaneous injury can ignite excessive fibroproliferative growth that results in keloid formation. Keloids are associated with significant morbidity related to disfigurement and/or symptoms (e.g., pain and pruritus). First-line treatment of formed keloids involves topical or intralesional steroids. Recurrent or resistant keloids are managed by surgical excision or cryotherapy, followed by steroidal application or adjuvant irradiation. Although adjuvant irradiation appears to be most efficacious, alternative therapeutic options are needed for patients without access to radiation centers. Botulinum Toxin A (BTA) appears to have similar inhibitory effects to irradiation on the cell cycle via downregulation of pathogenic cytokines. Herein, we conducted a study to compare the efficacy of intralesional triamcinolone used alone, or in combination with BTA, in the treatment of formed keloid scars. Twenty patients with a cumulative of 40 keloids completed the study. There was no significant difference between treatment arms with respect to height vascularization, pliability, and pigmentation scores. The addition of BTA resulted in significant symptomatic improvement of pain and pruritus as compared to intralesional triamcinolone alone (p < 0.001). Irradiation is only effective when administered in the adjuvant setting where inhibitory effects on cell cycle and migration are optimized. Future studies with intralesional triamcinolone and BTA should be performed adjuvantly.

Ten-year experience in face and neck unit reconstruction using tissue expanders.

BACKGROUND: Tissue expansion allows optimal aesthetic reconstruction by the use of a similar adjacent tissue to reconstruct a defect without creation of significant donor site morbidity, especially in the face and upper neck area. METHODS: A total of 78 patients underwent facial reconstruction by insertion of a tissue expander (TE) in the cheek or the neck due to burn scar, traumatic scar, leschmaniasis or large pigmented nevi. RESULTS: All reconstructions were completed satisfactorily; complications were: complete extrusion (2.6%), incomplete extrusion (3.8%), partial necrosis (14.1%), haematoma (6.4%), wide scar (33.3%), hypertrophic scar (17.9%), lower lid ectropion (1.3%), post-expansion atrophy (2.6%), permanent decrement in sensation (1.3%), sagging (14.1%) and infection (2.6%). CONCLUSIONS: The lateral facial areas and neck contain essentially the same type of skin; hence, tissue expansion allows optimal aesthetic reconstruction by the use of a similar adjacent tissue and expanding either the lower face or the neck interchangeably without creation of major donor site morbidity; even when we use free flaps for coverage, although we achieved good contour and sufficient bulk, but due to poor colour match, reconstruction with expanded skin of the upper neck is needed for better result.

Comparing the Alteration of Nasal Tip Sensibility and Sensory Recovery Time following Open Rhinoplasty with and without Soft Tissue Removal.

In this study we evaluated sensory alteration in nasal tip and adjacent upper columella (territory of external nasal nerve) after open rhinoplasty. Two groups were randomly selected, each containing 25 patients with thick nasal skin; sensory testing was done preoperatively in all patients; in group one, subdermal soft tissue in tip and supratip areas was removed but in group two no soft tissue removal was done; we compared sensory pressure threshold values 3 weeks and 6 months postoperatively. Results showed no statistical difference between the two groups in nasal skin sensibility at these times; also this study showed that 6 months after rhinoplasty normal sensation of nasal skin will be achieved.

"Suture fixation of the fingers": an effective method for positioning burned and contracted fingers using a pulley system as a guide.

Preserving function of the hand is the aim of treatment in burned hands; appropriate splinting is one of the important measures during acute and chronic treatment. We introduce an effective safe method for positioning of fingers without violating the joints; In this method before performing skin graft for palmar finger burn or contracture release we suture tip of finger with silk 2-0 and fix it to dorsum of hand while extending the finger and for preventing slipping we insert some pulley like circles tied with silk 2-0 fixing over dorsum of mid phalanx.

Polytetrafluoroethylene (Gore-Tex) tube used as a support conduit in open gastrostomy: report of a new technique.

BACKGROUND: When percutaneous endoscopic gastrostomy (PEG) or percutaneous radiographic gastrostomy (PRG) are not possible or fail, surgical gastrostomy would be the convenient method. Stamm's procedure has increasingly replaced other methods of surgical gastrostomy (SG). However, this procedure has various complications. In this study we used a Gore-Tex tube as a conduit to support a French 18 catheter for gastrostomy and evaluated its safety, efficacy, and usefulness in decreasing postoperative complications. METHODS: Forty patients with CNS trauma, swallowing dysfunction or esophageal obstruction and in whom PEG had either failed or was not possible were enrolled. Patients were randomized into two equal groups of Gore-Tex assisted modified Stamm's gastrostomy (GAMSG) and the conventional Stamm gastrostomy (CSG). In the GAMSG group we initially secured a 6-10 cm length and 8mm diameter tubular Gore-Tex to the gastric and abdominal wall as a conduit and then passed a French 18 catheter through it. Conventional Stamm procedure was applied to all patients in CSG group. Groups were compared for insertion times, pain, dislodgment, leakage rate, surrounding skin erythema and major complications. These patients were followed monthly for 6 months. RESULTS: The overall complication rate after GAMSG group was 5.3% (0% major) compared with 33.3% for Stamm gastrostomies (11.2% major) (p<0.05). Pain, operation site erythema, and tube leakage was significantly less in GAMSG group (p<0.05). CONCLUSIONS: Applying a tubular Gore-Tex conduit as a support for a feeding tube in Stamm's method effectively lowers complication rates without significantly increasing operation time or expenses.

Efficacy of propranolol in wound healing for hospitalized burn patients.

Burn patients have the highest metabolic rate among critically ill or injured patients. Because propranolol decreases energy expenditure and muscle protein catabolism, in this study, we hypothesized that propranolol would improve healing process and decrease wound-healing time. This study was a double-blind randomized clinical trial; a total of 79 burn patients who referred to this center from January 2006 to January 2007 fulfilled the inclusion criteria. Thirty-seven patients were randomly placed in propranolol group and 42 in control group. The propranolol group received propranolol orally with the dose of 1 mg/kg/d and maximum dose of 1.98 mg/kg/d given in six divided doses. This dose was adjusted to decrease the resting heart rate by 20% from each patient's baseline value. The control group received placebo. The most common cause of burn in both groups was flame followed by flash. Patients with superficial burns in the propranolol group needed less time to heal for acceptable wound healing in superficial burns (16.13+/-7.40 days vs 21.52+/-7.94 days; P=.004). We also found that patients with deep burn injury needed less time to be ready for skin graft (28.23+/-8.43 days vs 33.46+/-9.17 days; P=.007) when compared to that of the control group. The use of propranolol decreased the size of the burn wound that finally needed skin graft. Patients in the propranolol group with an average burn size of 31.42% TBSA finally needed 13.75% of TBSA skin graft compared with that of control patients with an average burn size of 33.61% TBSA who needed 18.72% of TBSA skin graft, and patients in the control group with an average burn size of 33.61% TBSA finally needed 18.72% of TBSA skin graft (P=.006). Patients in the propranolol group had a shorter hospital stay period than the control group (30.95+/-8.44 days vs 24.41+/-8.11 days; P=.05). Administration of propranolol, improved burn wound healing, and decreased healing time and hospital stay period. The use of propranolol decreased the surface area of wounds that needed to be skin grafted.

Bowel perforation by crumpled paper in a patient presenting with acute abdominal pain.

Many of the abdominal foreign bodies are due to accidental ingestion. Our objective in this case report is to emphasize the importance of the enquiry about the foreign body in the differential diagnosis of acute abdominal pain. According to our knowledge, this is the first report of bowel perforation caused by paper ingestion. A 14-year-old boy with abdominal pain underwent exploratory laparotomy and was found to have abdominal pus and ileal perforation. A crumpled paper was found at the site of perforation. Postoperative enquiry revealed that the patient had ingested 10 crumpled papers. We highlight that recording the history is an important aspect in the management of patients with acute abdominal pain and that foreign bodies should be included in its differential diagnosis.