A novel technique for prevention of anterior fistula and facilitation of alveolar cleft repair: Gingivoperiosteoplasty with palatoplasty.

Background & Objectives: The Cleft palate is one of the most commonly encountered congenital deformity in plastic surgery clinics and can be associated with cleft lip and alveolus. Though palate repair can be associated with several complications, the most frequent and troublesome is anterior fistula formation. Various technical modifications are in practice to avoid this dreaded complication. We have started combining gingivoperiosteoplasty with palate repair to avoid postoperative anterior fistula formation and to close alveolar cleft at the same time. Methods: A prospective study was performed at the department of plastic and reconstructive surgery, Liaquat National Hospital, Karachi and selected patients were enrolled in the study after informed consent. A total of 15 patients were operated on from January 2017 to December 2020. All patients had cleft palate repair along with primary gingivoperiosteoplasty (GPP) at the age of standard palatal repair. Buccal/oral and nasal layers of the alveolus were dissected as per standard gingivoperiosteoplasty and repaired in continuation with nasal and oral layers of the palate. Postoperatively, the standard cleft palate repair protocol was followed. Follow-up was done at four weeks, 12 weeks, and six months and repair integrity was checked. Future follow-up at 4-5 years of age is planned to see the effect on alveolar collapse, bone growth, and the need for secondary bone grafting. Results: All patients were followed up regularly. None had a complication of fistula. The repairs of both palate and alveolus remained intact. Patients were kept on the follow-up to assess the need for alveolar bone grafting in the future. Conclusion: Gingivoperiosteoplasty combined with the palatal repair is a novel technique for the prevention of anterior palatal fistula.

Neurotization of musculocutaneous nerve with intercostal nerve versus phrenic nerve - A retrospective comparative study.

Background: Brachial plexus injuries are common after both blunt and penetrating traumas resulting in upper limb weakness. The nerve transfer to the affected nerve distal to the injury site is a good option where proximal stump of the nerve is unhealthy or absent which has shown early recovery and better results. Commonly used procedures to restore elbow flexion are ipsilateral phrenic or ipsilateral intercostal nerves (ICNs) in global plexus injuries. The use of both intercostal and phrenic nerves for elbow flexion is well described and there is no definite consensus on the superiority of one on another. Methods: All patients presented in the outpatient department of LNH and MC from January 2014 to December 2017 with pan plexus or upper plexus injury with no signs of improvement for at least 3 months were included in the study. After 3 months of conservative trial; surgery offered to patients. Results: A total of 25 patients (n = 25) were operated from January 2015 to December 2017. Patients were followed to record Medical Research Council (MRC) grades at 3, 6, 9, 12, and 18 months. The patients achieved at least MRC Grade 3; 70% at 12 months follow-up to 80% at 18 months in the phrenic nerve transfer group. While in the ICN transfer group, it is 86% and 100% at 12 and 18 months postoperative, respectively. Conclusion: Our study has shown better results with ICN transfers to musculocutaneous nerve, recorded on MRC grading system.

ALTERING THE MARKING OF THE REVERSE POSTERIOR INTEROSSEOUS ARTERY FLAP.

Background: Full-thickness defects on the dorsum of the hand requires thin, soft, and pliable skin for which there are limited locoregional flaps. The reverse posterior interosseous artery (PIA) flap based on the communicating artery fulfills all above requirements and can reach upto the fingers. However, there has been discrepancy in the surface marking of the flap and the anatomical position of the vessel pedicle. We share our alteration with the marking and ease of harvesting this flap. Method and material: This is a prospective study conducted at a private teaching hospital in Karachi, over a period of 2 years from November 2017 to December 2019. After taking consent and ensuring confidentiality of all patients who had PIA flap reconstruction, we collected patient's demographic details, mode of injury, and flap surface area. We altered the described skin marking and took measures to prevent venous congestion and noted the outcomes in term of flap congestion and flap loss. Results: Twenty-eight patients with a mode age of 32 years were operated during this period. The majority (64.2%) had a motor vehicle accident and machine injuries. The mean surface area of flaps was 6 × 10 cm2, and 11 (39.2%) flaps had venous supercharging. All patients had a 10-20° wrist extension splint for 2 weeks. The mean follow-up of the patients was 14 ± 5 days, and 6 (21.4%) flaps developed a minimal marginal flap loss, which was managed conservatively. Conclusion: By minimally altering our surface marking, we experienced a easy and quick harvesting of this flap. However, one has to be vigilant and take all described precautions for venous congestion.

Cross cheek dumbbell-shaped radial forearm free flap for bilateral trismus release.

Trismus in post-radiotherapy patients is mostly secondary to fibrosis of buccal mucosa and muscles of mastication. After releasing trismus, mucosal defect needs to be covered with soft and supple tissue. We used a non-conventional method to cover this defect i.e. dumbbell-shape forearm free-flap based on a single radial artery.

Medial Plantar Artery Perforator Flap: Experience with Soft-tissue Coverage of Heel.

BACKGROUND: Soft-tissue coverage is a challenge to the ankle and foot reconstructive surgeon due to its unique requirement of simultaneously withstanding body weight and to provide sensory feedback. We share our experience of medial plantar artery perforator (MPAP) flap, which provides a robust sensate coverage to heel defects. METHODS: Three-year retrospective study, which included soft-tissue injury to heel. All patients underwent MPAP flap for the coverage of the defect. Patients' demographic, mode of injury, defect size, flap size and survival, time to start weight bearing, return of protective sensations, and comparative 2-point discrimination with opposite heel were studied. RESULTS: We studied 16 cases with heel soft-tissue injuries. Fifteen had motor vehicle accident, and 1 had chronic diabetic wound. Mean surface area of flap was 4 × 5 cm. Except 1 flap, 15 flaps had complete survival and provided reliable wound coverage with comparable normal sensation as on other foot. CONCLUSION: We suggest that MPAP flap, when available, is a good local tissue for heel wounds coverage.