Reconstruction of soft tissue defects in Fournier’s gangrene at a tertiary care centre

Background: Fournier’s gangrene is an acute and potentially lethal multi-bacterial necrotizing infection that primarily involves the scrotum but may extend beyond its confines to perineum and abdominal wall. The disease may result in sepsis and death if treatment is delayed. Management consists of timely diagnosis, aggressive debridement, broad-spectrum antibiotics followed by reconstruction which still remains a surgical challenge.Methods: It is a prospective study conducted from Jan 2006 to Dec 2015 on 29 patients of Fournier’s gangrene who were referred to the department of Plastic and Reconstructive Surgery, Sheri-Kashmir Institute of Medical Sciences, Srinagar, Kashmir, for reconstruction after initial debridement by general surgeon/urologist. The patient’s age, predisposing factors, site and the size of the defects, reconstructive options used and outcome were evaluated. Assessment of testicular function was done at 6 months by sperm count and morphology.Results: A total of 29 patients of Fournier’s gangrene consisting of 28 males and one female were included in the study. The mean age was 37 years and the most common comorbidity was diabetes mellitus in 18 patients (62%). Wounds were allowed to heal by secondary intension in 8 patients. Scrotal advancement flap was done in seven patients. Split thickness skin grafting (STSG) of extensive wounds was done in 11 patients and testes were placed in medial thigh subcutaneous pocket in one patient. Two elderly diabetic patients succumbed to sepsis and multi organ failure. Overall complication rate was 18.5%.Conclusions: Thorough debridement and early wound cover are essential in the management of Fournier’s gangrene for successful rehabilitation. Various reconstructive options are available with no conclusive evidence to support flap rather than skin graft and most of the procedures result in preservation of testicular function in the long term

Negative pressure wound therapy: eleven-year experience at a tertiary care hospital

Background: Management of complicated wounds is a reconstructive challenge. A reconstructive surgeon has to be ready to face new challenges every day. Negative pressure wound therapy has revolutionized the management of complex wounds. We are presenting our experience with this wound care modality in the past 11 years.Methods: It was a prospective study conducted from January 2006 to December 2016 on patients having wounds of varied etiologies, who consented to participate in this study. Custom made low cost NPWT was used till definitive wound closure.Results: A total of 568 patients consented to participate in the study during these 11 years. No major complications were seen. Most of these were males (60.73%) in their 3rd and 4th decade. Trauma was the leading cause of wounds in 38.14%, followed by diabetic foot wounds in 21.5%. Ankle and foot was the most common site of wounds (30.92%) followed by leg (24.01%). A total of 322 small, 218 medium and 97 large size dressings were used. Most of the patients improved with the NPWT.  No major complications were seen.Conclusions: NPWT is safe, effective and has proved to be revolutionary in managing difficult wounds. With the use of customized low cost NPWT the benefit can be extended to underprivileged population in under developed nations too

Closure of anterior palatal fistula using tongue flap: our experience

Background: Palatal fistula is one of the most common complications following cleft palate repair. It occurs mostly due to tip necrosis of palatal flaps. Small palatal fistulas are usually closed by transposition of adjacent tissues, however these local tissues are not sufficient for the closure of bigger fistulas. The tongue flap serves as a reliable and most easily obtainable local flap for closure of large sized palatal fistulas.Methods: This is a prospective study conducted from Aug 2006 to July 2015 in the department of Plastic & Reconstructive Surgery, SKIMS, Srinagar, Jammu Kashmir, India. A total of 25 patients with large anterior palatal fistula were treated using anteriorly based tongue flap. Patients were selected on the basis of size of fistula (> 1x1 cm), scarred local palatal tissue or history of fistula recurrence after previous attempts of closure using local palatal tissues.Results: In present study 25 patients of palatal fistula were treated using tongue flap. Eighty percent patients were in the age group of 3 to 5 years. Male-to-female ratio was 2:3. The largest dimension of treated fistula was 4x3 cm. There was partial dehiscence of flap suture line in two patients while remnant fistula was observed in three patients. None of our patients had flap necrosis.Conclusions: Tongue flap is an excellent and versatile option for closure of large palatal fistulas with high success rate and least morbidity

Two stage flexor tendon reconstruction in hand: our experience

Background: Flexor tendon injuries in the digital flexor sheath area (zone II) are the most difficult to treat and remain a focus of both clinical attention and basic investigations. This prospective study was designed to evaluate the results of staged zone II flexor tendon repair.Methods: Seventy digits in thirty five patients were treated by Two Stage flexor tendon reconstruction and followed for an average of one and a half year. The procedure included placing a silicone catheter (cut to desire size) as an active implant and reconstruction of A2, A4 or both pulleys if damaged in first stage. During the second stage (performed three to eight months later), tendon graft replaced the silicone catheter in the pseudo sheath formed around the catheter. The proximal end of the transplanted tendon was fixed with flexor digitorum profundus tendon of respective finger using the Pulvertaft method, and the distal end of the graft was fixedwith the distal stump of respective flexor digitorum profundus tendon. Early controlled motion protocol was instituted in all cases.Results: As per Buck Gramcko scale total active motion obtained was Excellent in 70%, Good in 20%, Fair in 7.1%, and Poor in 2.9% of patients.Conclusions: Flexor tendon reconstruction using two stage tendon reconstructions is an effective way to restore digital tendon function in delayed zone II flexor tendon injuries

Merkel Cell Carcinoma: From Pathobiology to Clinical Management

Merkel cell carcinoma (MCC) is an infrequent, rapidly growing skin neoplasm that carries a greater probability of regional lymph node involvement, and a grim prognosis in advanced cases. While it is seen predominantly in old age in sun-exposed body parts, the prevalence varies among different races and geographical regions. Merkel cell polyomavirus and UV radiation-induced mutations contribute to its etiopathogenesis. The clinical presentation of MCC lacks pathognomonic features and is rarely considered highly at the time of presentation. Histopathological examination frequently reveals hyperchromatic nuclei with high mitotic activity, but immunohistochemistry is required to confirm the diagnosis. Sentinel lymph node biopsy (SLNB) and imaging are advised for effective staging of the disease. Multimodal management including surgery, radiation therapy, and/or immunotherapy are deployed. Traditional cytotoxic chemotherapies may result in an initial response, but do not result in a significant survival benefit. Checkpoint inhibitors have dramatically improved the prognosis of patients with metastatic MCC, and are recommended first-line in advanced cases. There is a need for well-tolerated agents with good safety profiles in patients who have failed immunotherapies

Role of customised negative-pressure wound therapy in the integration of split-thickness skin grafts: A randomised control study

Background: Split-thickness skin grafting (STSG) is a time-tested technique in wound cover, but many factors lead to suboptimal graft take. Role of custom-made negative-pressure wound therapy (NPWT) is compared with conventional dress in the integration of STSG and its cost is compared with widely used commercially available NPWT. Materials and Methods: This is a parallel group randomised control study. Block randomisation of 100 patients into one of the two groups (NPWT vs. non-NPWT; 50 patients each) was done. Graft take/loss, length of hospital stay post-grafting, need for regrafting and cost of custom-made negative pressure wound therapy (NPWT) dressings as compared to widely used commercially available NPWT were assessed. Results: Mean graft take in the NPWT group was 99.74% ± 0.73% compared to 88.52% ± 9.47% in the non-NPWT group (P = 0.004). None of the patients in the NPWT group required second coverage procedure as opposed to six cases in the non-NPWT group (P = 0.035). All the patients in the NPWT group were discharged within 4–9 days from the day of grafting. No major complication was encountered with the use of custom-made NPWT. Custom-made NPWT dressings were found to be 22 times cheaper than the widely used commercially available NPWT. Conclusions: Custom-made NPWT is a safe, simple and effective technique in the integration of STSG as compared to the conventional dressings. We have been able to reduce the financial burden on the patients as well as the hospital significantly while achieving results at par with other studies which have used commercially available NPWT

Reconstruction of soft tissue defects in Fournier's gangrene at a tertiary care centre

Background: Fournier’s gangrene is an acute and potentially lethal multi-bacterial necrotizing infection that primarily involves the scrotum but may extend beyond its confines to perineum and abdominal wall. The disease may result in sepsis and death if treatment is delayed. Management consists of timely diagnosis, aggressive debridement, broad-spectrum antibiotics followed by reconstruction which still remains a surgical challenge.Methods: It is a prospective study conducted from Jan 2006 to Dec 2015 on 29 patients of Fournier’s gangrene who were referred to the department of Plastic and Reconstructive Surgery, Sheri-Kashmir Institute of Medical Sciences, Srinagar, Kashmir, for reconstruction after initial debridement by general surgeon/urologist. The patient’s age, predisposing factors, site and the size of the defects, reconstructive options used and outcome were evaluated. Assessment of testicular function was done at 6 months by sperm count and morphology.Results: A total of 29 patients of Fournier’s gangrene consisting of 28 males and one female were included in the study. The mean age was 37 years and the most common comorbidity was diabetes mellitus in 18 patients (62%). Wounds were allowed to heal by secondary intension in 8 patients. Scrotal advancement flap was done in seven patients. Split thickness skin grafting (STSG) of extensive wounds was done in 11 patients and testes were placed in medial thigh subcutaneous pocket in one patient. Two elderly diabetic patients succumbed to sepsis and multi organ failure. Overall complication rate was 18.5%.Conclusions: Thorough debridement and early wound cover are essential in the management of Fournier’s gangrene for successful rehabilitation. Various reconstructive options are available with no conclusive evidence to support flap rather than skin graft and most of the procedures result in preservation of testicular function in the long term

Closure of anterior palatal fistula using tongue flap: our experience

Background: Palatal fistula is one of the most common complications following cleft palate repair. It occurs mostly due to tip necrosis of palatal flaps. Small palatal fistulas are usually closed by transposition of adjacent tissues, however these local tissues are not sufficient for the closure of bigger fistulas. The tongue flap serves as a reliable and most easily obtainable local flap for closure of large sized palatal fistulas.Methods: This is a prospective study conducted from Aug 2006 to July 2015 in the department of Plastic & Reconstructive Surgery, SKIMS, Srinagar, Jammu Kashmir, India. A total of 25 patients with large anterior palatal fistula were treated using anteriorly based tongue flap. Patients were selected on the basis of size of fistula (> 1x1 cm), scarred local palatal tissue or history of fistula recurrence after previous attempts of closure using local palatal tissues.Results: In present study 25 patients of palatal fistula were treated using tongue flap. Eighty percent patients were in the age group of 3 to 5 years. Male-to-female ratio was 2:3. The largest dimension of treated fistula was 4x3 cm. There was partial dehiscence of flap suture line in two patients while remnant fistula was observed in three patients. None of our patients had flap necrosis.Conclusions: Tongue flap is an excellent and versatile option for closure of large palatal fistulas with high success rate and least morbidity