Abdominal wall closure in adult patients with untreated exstrophy of bladder.

INTRODUCTION: Bladder exstrophy is an anomaly, which if not treated early in the age, poses a surgical challenge in providing an adequate abdominal wall closure. We report our experience in patients with untreated exstrophy of the bladder, who underwent cystectomy, ileal conduit, and abdominal reconstruction using the anterior rectus sheath turndown flap and paired inguinal skin flaps. MATERIALS AND METHODS: Ten previously unoperated adult patients with exstrophy with epispadias, who underwent surgery at our institute from January 2010 till January 2021, were included in this study to evaluate the adequacy of abdominal wall closure with our technique of retrograde turndown anterior rectus sheath flap with paired inguinal flap, and to document immediate and delayed complications, especially incisional hernia. RESULTS: The mean follow-up period of the study was 16.5 months. We found that our technique provided adequate local tissue for a sturdy two-layered closure of the lower abdominal wall defect. Out of the ten patients, only one required an additional flap for abdominal wound closure. There were no stoma-related complications or incisional hernia. CONCLUSION: Abdominal wall reconstruction, for skin and fascial defects, in such complex cases can be performed by local skin and fascia using a relatively simple, safe, easy, and affordable technique as we have described. Our technique avoids the use of synthetic mesh, thereby reducing the chances of infection in such chronic open wounds.

Marjolin Ulcer: An Observational Epidemiological Study From a Tertiary Care Centre in India.

INTRODUCTION: Marjolin ulcer is a rare skin malignancy. Marjolin ulcer arises in zones of long-standing scars, inflammation, or chronic wounds. MATERIAL AND METHODS: The present study was conducted to assess the demographic profile and identify the predictors of recurrence in 55 patients with Marjolin ulcer admitted over 10 years. Patients underwent either wide local excision with 2-cm peripheral margin or amputation if clinically indicated due to joint involvement. Lymph nodes were dissected if found positive. Patients received adjuvant radiotherapy if tumor clearance was less than 4 mm or the draining lymph nodes were positive. RESULTS: Of the total 55 cases (mean age, 48.75 years; range, 24-74 years), 34 were men and 21 were women (male/female, 1.6:1). The most common cause of injury was flame burn (n = 32, 58%) followed by trauma (n = 10, 18%). The lower limb was frequently affected (n = 38, 69.1%). Twenty-six patients with resection margins less than 4 mm had received adjuvant radiotherapy. Among the 55 patients, 6 (11%) had undergone lymph node dissection. Local recurrence was noted within 18 months in 9 (16.35%) patients, of which 5 patients had a tumor-free margin of less than 4 mm. We found 2 predictors for local recurrence. First, moderately differentiated squamous cell carcinoma (P = 0.04) and, second, patients with lymph node involvement (P = 0.001). CONCLUSION: Marjolin ulcer is a high-risk skin tumor. Patients with positive lymph node or with moderately differentiated squamous cell carcinoma have high chances of recurrence. Frequent and intense follow-up is required for at least 2 years.

Distally based peroneus brevis muscle flap: A single centre experience.

PURPOSE: Defects around the distal one third of the leg and ankle are difficult to manage by conservative measures or simple split thickness skin graft. Distally based peroneus brevis muscle flap is a well described flap for such defects. METHODS: This is a retrospective analysis conducted on 25 patients with soft tissue and bony defects of distal third of lower leg and ankle, which were treated using distally based peroneus brevis muscle flap from January 2013 to January 2018. Information regarding patient demographics, etiology, size and location of defects and complications were collected. All patients were followed up for at least 3 months after surgery. RESULTS: There were 21 males and 4 females with the mean age of 39 (5-76) years. The most common cause of injuries was road traffic accident, followed by complicated open injury. The average size of defects was 20 (4-50) cm2. The mean operating time was 75 (60-90) min for flap harvest and inset. We had no patient with complete loss of the flap. Five patients (20%) had marginal necrosis of the flap and two patients have graft loss due to underlying hematoma and required secondary split thickness skin grafting. CONCLUSION: The distally based peroneus brevis muscle flap is a safe option with reliable anatomy for small to moderate sized defects following low velocity injury around the ankle. The commonest complication encountered is skin graft loss which can be reduced by primary delayed grafting.

Role of facial artery musculomucosal flap in large and recurrent palatal fistulae.

Objective : Palatal fistulas are not uncommon after palatoplasty. Although there are currently many techniques that can be used to close large palatal fistulae, most of these procedures are usually cumbersome and mostly unreliable with high recurrence rates. The facial artery musculomucosal (FAMM) flap was described to circumvent these problems. The purpose of this study was to review our experience with the FAMM flap to reconstruct palatal fistulas, most of them being recurrent. Materials and Methods : A retrospective analysis was done of 11 FAMM flaps performed between January 2007 and March 2012. Results : There were no major complications. Venous congestion was seen in two cases. Two flaps developed terminal marginal necrosis. One patient had suture line dehiscence. There were no recurrences of the fistula after repair. All patients had a satisfactory closure of the fistula. Conclusion : FAMM flap is a reliable and versatile flap that provides like with the like tissue and is a good option for closure of recurrent wide palatal fistulae.

Tendoachilles reconstruction and overlying skin cover with a peroneus brevis flap.

We report a post-traumatic case of tendoachilles injury with an overlying skin defect. Following debridement, tendon reconstruction was done by using vascularised peroneus brevis musculotendinous unit and proximal part of the same muscle provided the skin cover. Postoperative recovery was uneventful. At 2 years follow-up, he had a near-normal gait. The main advantage of this flap is not being only a local flap but also providing a vascularised tendon.

Diverse manifestations and management options in Klippel-Trenaunay syndrome: a single centre 10-year experience.

Klippel-Trenaunay syndrome is a well-known conglomeration of capillary malformations, bony or soft tissue hypertrophy, and abnormal deep or superficial veins. Although it generally presents with grossly enlarged limbs, it can present with more serious features like haematuria, haematochezia, and seizures. This retrospective study included patients admitted with the diagnosis of Klippel-Trenaunay syndrome in this institute from 2001-2010. The patients' demographic data, clinical features, associated findings, and treatments given were tabulated. A total of 19 patients were included in the study. Two patients presented with haematocezia and had to undergo bowel resection. Five presented with bleeding and ulceration. Debulking surgery was done in three of them. Patients also presented with abdominal distension, jaundice, seizures, and haematuria. Although the common presentation of varicose veins was treated with sclerotherapy, the treatment was tailored to each patient. Klippel-Trenaunay syndrome is a multifaceted disorder which can manifest in a number of different ways. These features may be missed by an unwary plastic surgeon treating them only for the limb hypertrophy.

Arteriovenous malformation of the scrotum: Is preoperative angioembolization a necessity?

Arteriovenous malformations (AVMs) of the scrotum are uncommon lesions, usually picked up incidentally during the evaluation of scrotal masses or infertility. They have also been reported to present with acute bleeding. We present a case who presented with acute pain following an abandoned surgical attempt at excision, elsewhere. Diagnosis was confirmed by duplex ultrasound and magnetic resonance imaging. Angioembolization was deferred quoting concerns with radiation exposure. The patient underwent a near total excision of the scrotal mass. This is the first reported case, in the English literature, of a surgical resection of a scrotal AVM without a preceding angioembolization. Patients should be counselled about radiation exposure risks before angioembolization, and allowed to make an informed decision.

A novel and accurate technique of photographic wound measurement.

CONTEXT: Wound measurement is an important aspect of wound management. Though there are many techniques to measure wounds, most of them are either cumbersome or too expensive. AIMS: To introduce a simple and accurate technique by which wounds can be accurately measured. SETTINGS AND DESIGN: This is a comparative study of 10 patients whose wounds were measured by three techniques, i.e. ruler, graph and our technique. MATERIALS AND METHODS: The graph method was taken as the control measurement. The extent of deviation in wound measurements with our method was compared with the standard technique. The statistical analysis used was ANOVA. RESULTS: The ruler method was highly inaccurate and overestimated the wound size by nearly 50%. Our technique remained consistent and accurate with the percentage of over or underestimation being 2-4% in comparison with the graph method. CONCLUSIONS: This technique is simple and accurate and is an inexpensive and non-invasive method to accurately measure wounds.

Post burn pruritus--a review of current treatment options.

Post burn pruritus is a well recognised symptom in almost all burn patients. Yet, there is insufficient awareness about the etiopathogenesis and a lack of a systematic approach in the assessment and treatment of this distressing symptom. The current standard therapies include antihistamines, which are effective as sole therapy in only 20% patients, and emollients. There is a lacunae of clear consensus on the care of patients not responding to antihistamines. We review the literature on the etiology and pathogenesis of post burn pruritus, which has both central and peripheral pathways. The published studies on the currently available therapeutic options to treat itch in burns are discussed. On the basis of current evidence in literature, gabapentin used in the treatment of neuropathic pain, has demonstrated great promise, and is suggested as the next option for this subset of patients, not relieved with antihistamines.

Chondroid syringoma with extensive ossification.

Chondroid syringoma is a rare appendagel skin tumor. Due to its uncharacteristic presentation, it is rarely diagnosed clinically. Here we present one such case in a 50-year-old lady. She presented with a hard mobile lesion over her nose which was excised. The histologic picture is characterized by a combination of epithelial and myoepithelial structures within a chondromyxoid and fibrous stroma. For these tumors, excision is the treatment of choice.

A prospective randomized controlled trial comparing negative pressure dressing and conventional dressing methods on split-thickness skin grafts in burned patients.

INTRODUCTION: Split-thickness skin grafting (SSG) is a technique used extensively in the care of burn patients and is fraught with suboptimal graft take when there is a less-than-ideal graft bed and/or grafting conditions. The technique of Negative Pressure Dressing (NPD), initially used for better wound healing has been tried on skin-grafts and has shown to increase the graft take rates. However, comparative studies between the conventional dressing and vacuum assisted closure on skin grafts in burn patients are unavailable. The present study was undertaken to find out if NPD improves graft take as compared to conventional dressing in burns patients. MATERIALS AND METHODS: Consecutive burn patients undergoing split-skin grafting were randomized to receive either a conventional dressing consisting of Vaseline gauze and cotton pads or to have a NPD of 80 mm Hg for four days over the freshly laid SSG. The results in terms of amount of graft take, duration of dressings for the grafted area and the cost of treatment of wound were compared between the two groups. RESULTS: A total of 40 split-skin grafts were put on 30 patients. The grafted wounds included acute and chronic burns wounds and surgically created raw areas during burn reconstruction. Twenty-one of them received NPD and 19 served as controls. Patient profiles and average size of the grafts were comparable between the two groups. The vacuum closure assembly was well tolerated by all patients. Final graft take at nine days in the study group ranged from 90 to 100 per cent with an average of 96.7 per cent (SD: 3.55). The control group showed a graft take ranging between 70 and 100 percent with an average graft take of 87.5 percent (SD: 8.73). Mean duration of continued dressings on the grafted area was 8 days in cases (SD: 1.48) and 11 days in controls (SD: 2.2) after surgery. Each of these differences was found to be statistically significant (p<0.001). CONCLUSION: Negative pressure dressing improves graft take in burns patients and can particularly be considered when wound bed and grafting conditions seem less-than-ideal. The negative pressure can also be effectively assembled using locally available materials thus significantly reducing the cost of treatment.

Mammoth orbitofrontal neurofibromatosis with herniating meningo-encephalocele.

We are presenting a mammoth orbito-frontal neurofibroma with a herniating meningo-encephalocele in a 23 year old African male. The tumour measured 87cm x 54cm and occupied the right orbito-temporo-facial region and had destroyed the right orbit. A pre operative embolization of the feeding vessels was followed by a one stage near total excision of the tumour and repair of the meningo-encephalocele in hypotensive anaesthesia. The excised tumour weighed 8 Kg and, to the best of our knowledge, is the largest orbito-facial neurofibroma reported in literature.