Utilizing the Subunit Concept to Achieve Better Outcomes in Lower Limb Reconstruction: A Clinical Experience in an Asian Population.

Background: The goals of reconstruction have progressed from filling a defect to enhancing function and aesthetic appearance. We aimed to achieve better aesthetic and functional outcomes in terms of shoe fitting and mobility. This is accomplished via a classification of the subunits and aesthetic considerations of the lower limb. Methods: Between April 2017 and December 2021, 66 cases of lower extremity free fasciocutaneous flap reconstruction cases were included in this retrospective study. Data parameters include age, sex, comorbidities, etiology of lower limb wounds, choice of free flap reconstruction, recipient arterial vessels, complications of flap reconstruction, and need for secondary debulking procedures. Physiotherapy records were also examined to determine the time to independent ambulation. Results: In total, 66 subjects were identified. The mean age was 48.6. An estimated 74.2% (n = 49) were men, 50% (n = 33) had diabetes, and 16.6% (n = 11) had peripheral vascular disease. Of the total wounds, 65.1% (n = 43) were caused by infection, whereas the remaining 34.9% (n = 23) were due to trauma. Of the cases, 72.7% (n = 48) had free anterolateral thigh flap reconstruction, 25.8% (n = 17) were reconstructed with superficial circumflex iliac artery perforator flaps, and 1.5% (n = 1) was reconstructed with medial sural artery perforator flaps. Cases that required secondary debulking procedures comprised 7.6% (n = 5). Conclusions: Free fasciocutaneous flaps are useful in lower extremity reconstruction. Based on the subunit principle and aesthetic considerations for lower limb reconstruction, it can aid in optimizing functional rehabilitation and decreasing secondary procedures.

Maximizing Micrograft Take in Extensive Back Burns.

Extensive burns involving the back pose unique challenges. Offloading in the prone position is not possible with concomitant deep facial and neck burns. We describe our experience in maximizing graft take in a patient who had extensive back burns with concomitant anterior body burns. The two main goals in graft fixation for extensive back wounds are mechanical stabilization of micrografts to reduce shearing and prevention of water logging from exudates or bleeding to optimize contact with wound bed. Guided by the stages of wound healing, graft take, and burn care, we describe three stages of postoperative negative pressure wound therapy (NPWT) in a patient with 54% TBSA burns treated with micrografting. After complete excision of the deep dermal burns of the entire back, the wounds were covered with micrograft-allograft composites. In phase I, days 1 to 3, conventional topical negative pressure dressing with a thin sponge was applied and a leak-proof seal was achieved with gel sealant and high tack adhesive drapes. In phase II, days 4 to 5, foam dressings with topical negative pressure were applied, but with a less stringent seal, supported by wall suction. In phase III, the selective removal of allografts was initiated to facilitate expansion of micrografts. Negative pressure was continued for another 2 weeks at the most dependent site to prevent wound maceration from exudates. Micrograft take was optimized with the patient in the supine/semirecumbent position. The back wounds healed completely between 60 and 70 days without repeat micrografting. Since prone positioning was not possible in this patient, clearance of exudates and maintenance of micrograft contact with the wound bed using this technique proved successful.

Use of the Descending Branch of the Lateral Circumflex Femoral Artery as an Arterial Graft in Living Donor Liver Transplant.

BACKGROUND: Reconstructing the hepatic artery in living donor liver transplantation presents the challenges of a short and small donor vessel stump, which is compounded by poor surgical access for microsurgical anastomosis. Arterial interpositional grafts (eg, the radial artery) have been used to overcome these problems. The purpose of this presentation is to describe the use of the descending branch of the lateral circumflex femoral artery (DLCFA) as an alternative when the patient has had an abnormal Allen's test precluding the use of the radial artery or if a Y-graft is needed. METHODS: The DLCFA resides in the septum between the rectus femoris and vastus lateralis muscles. A linear incision made over the proximal third of this septum exposed the avascular plane in which the vessel resides. A graft exceeding 10 cm could be harvested with diameters ranging between ≤2 and 7 mm. There were several muscular branches emanating from the profunda femoris artery system that could be dissected to the required length for a Y-shaped graft. Three cases of living donor liver transplantation using the DLCFA (straight and Y grafts) are described. RESULTS: After DLCFA interpositional grafting, all patients had normal resistive indices on duplex ultrasonography of the intrahepatic arterial system. Follow-up of the 3 patients was between 2 and 6 months. There was no donor site morbidity. CONCLUSIONS: The DLCFA graft was a useful arterial graft for hepatic artery reconstruction. It was easily harvested with minimal donor site morbidity.

The diathermy scratch pad: A cheap and efficient tool for chemical and explosion-related burns.

The burn center in our hospital is a national and regional (Southeast Asia) center. Of all admissions, 10% are related to blast explosions, and 8% due to chemical burns. In the acute burn management protocol of Singapore General Hospital, early surgical debridement is advocated for all acute partial-thickness burns. The aim of early surgical debridement is to remove all debris and unhealthy tissue, preventing wound infection and thereby expediting wound healing. In chemical burns, there can be stubborn eschars that are resistant to traditional debridement. We would like to present a novel technique using the diathermy scratch pad as a cheap and efficient tool for the dual purpose of surgical debridement and dermabrasion.

Retrospective study of elderly frequent attenders presenting with chest pain at emergency department.

BACKGROUND: The aims of the study were to identify the characteristics of elderly frequent attenders to the emergency department (ED) presenting with chest pain and to assess the 1-year prognosis for developing adverse cardiac events. FINDINGS: Patients over 75 years old, with four or more attendances to the ED between 1 January 2010 and 31 December 2010 with at least one attendance due to chest pain, were selected from a database. Data was collected on demographic details, visit history, disposition and admission outcomes. Each patient was followed up for 12 months after the index episode via the hospital electronic registry for adverse cardiac outcome. Adverse cardiac outcomes included death from cardiac event, acute myocardial infarction (ST elevation myocardial infarction (STEMI)/non-ST elevation myocardial infarction (NSTEMI)) or unstable angina. A total of 158 patients with 4 or more visits to the ED accounted for 290 visits with chest pain during 2010. There is a high prevalence of coronary risk factors in this cohort (hypertension 92.4%, hyperlipidaemia 65.2%, diabetes 49.4% and smoking 26.6%). The hospital admission rate was also high at 83.5%. Over the ensuing 12 months, 8 patients died of a primary cardiac event and a further 29 patients developed 36 non-fatal cardiac events. We could not establish any significant relationship between increase in adverse cardiac outcome and individual risk factors or even two or more risk factors (P = 0.0572). Patients with two or more attendances with chest pain were more likely to develop adverse cardiac outcome (P = 0.0068). CONCLUSIONS: Elderly frequent attenders to the ED, who present with chest pain, have more cardiac risk factors and are more likely to develop adverse coronary outcomes if they re-attend with chest pain.