Videofluoroscopy in operated cleft palate patients.
To determine the existence of an optimal resting velopharyngeal (VP) gap in operated cleft palate patients
Settings and Design:
A retrospective analysis of lateral view videofluoroscopy of operated cleft palate patients.
Materials and Methods:
A total of 117 cases of operated cleft palate underwent videofluoroscopy between 2006 and 2011. The lateral view of videofluoroscopy was utilised in the study. A retrospective analysis of the lateral view of videofluoroscopy of these 117 patients was performed to analyse the resting VP gap and its relationship to VP closure.
Statistical analysis used:
Of the 117 cases, 35 had a resting gap of less than 6 mm, 34 had a resting gap between 6 and 10 mm and 48 patients had a resting gap of more than 10 mm.
The conclusive finding was that almost all the patients with a resting gap of <6 mm (group C) achieved radiological closure of the velopharynx with speech; thus, they had the least chance of VP insufficiency (VPI). Those patients with a resting gap of >10 mm (group A) did not achieve VP closure on phonation, thus having full-blown VPI. Therefore, it can be concluded that the ideal resting VP gap is approximately 6 mm so as to get the maximal chance of VP closure and thus prevent VPI.
Resting gap; videofluoroscopy; velopharyngeal incompetence; cleft palate
Haemangioma (HM) and venous malformations of the head and neck are formidable lesions as they cause cosmetic deformity and psychological problems. Their surgical excision is difficult and fraught with problems like operative blood loss, incomplete excision, disfigurement and recurrence. Endovascular techniques like sclerotherapy and embolization are increasingly being used in the treatment of these difficult lesions.
This study was undertaken to analyse the efficacy and safety of endovascular techniques in the treatment of HM and slow flow vascular malformations.
Materials and Methods:
We retrospectively reviewed the records and clinical photographs of 358 patients of HM and slow flow vascular malformations treated in our institute by endovascular approach over a 15 year period. Pre- and post-treatment photographs were compared and outcomes categorized as complete resolution (>90% reduction), considerable reduction (60-90% reduction), partial reduction (20-60% reduction) and no change (<20% reduction).
Complete resolution of the lesion was seen in 30% of the patients while 50% patients showed considerable reduction of the swelling. Complications occurred in 6.4% of patients.
We conclude that sclerotherapy is an effective and safe treatment modality for these lesions and may be considered as the primary modality in the treatment of these challenging lesions.
Bleomycin; hemangioma; sclerotherapy; sodium tetradecyl sulfate; venous malformation
Last decade has witnessed a spurt in articles focused on the topic of evidence-based medicine (EBM) and medical ethics. These articles are not only educative, but draw attention to the changing scenario of medical practice. Surgeons seem a bit less attentive to practice of EBM, more so in the developing world. The theme is now percolating in our realm for demonstrable incorporation of EBM in our practice, which is allegorical of a good physician and is also likely to become demanding legally. In practicing EBM, several conflicts may arise with the ethical vows of medicine. However, majority of these conflicting issues have germinated from a capitalistic approach to medical practice, where the fear of extraneous compulsions dictating prescriptions and procedures in the garb of ‘evidence-based practice’ conflicts ethical behaviour. This review shall appraise the reader with important definitions of medical ethics, EBM and how to incorporate best evidence into ones practice. While, EBM brings objectivity to treatment to derive measurable outcomes it should not become regimented or metamorphose as a pseudonym for defensive medicine to escalate treatment costs. EBM also has several limitations one of which is to place the onus on the practicing physician to search for the best evidence and the other is the resource constraint of practice in the developing world. How a plastic surgery practice could be made to conform to evidence based (EB) procedures is proposed as insufficient surgical skills can pose a serious threat to not only the practice of EB procedures, but to ethical responsibilities as well. In conclusion, it is necessary to incorporate ethical temperance into EB procedures to withstand societal, peer and legal pressures of current times.
Ethics; evidence-based medicine; evidence-based practice; medical ethics
Follicular unit transplant is a widely used surgical treatment for androgenic alopecia. However, for patients with extensive hair loss (Norwood 5 and above), scalp donor hair are not sufficient to cover all areas of baldness. This study aims to assess suitability of beard and body donor hair when transplanted to the scalp.
Materials and Methods:
In 35 male patients having varying degrees of androgenic alopecia, body and beard donor hair were extracted by follicular unit extraction method (under local anesthesia). They were transplanted in different locations of the scalp. Follow-up was carried out at various intervals (6 months to 2 years). The hairs were observed for colour, curl and calibre.
In all the patients, there was no change in the colour, curl or calibre of the transplanted body/beard hair. They maintained the same characteristics as in their original location.
Body and beard hair can be used as additional donor resource for treating androgenic alopecia. These hairs, however, do not change their colour, curl, and shaft diameter (calibre). Thus, proper planning is a must when using the different types of donor hair for transplanting.
Androgenic alopecia; follicular unit extraction; body donor hair
Loss of Achilles tendon combined with overlying soft tissue loss is a challenging problem. Multiple techniques like tendon graft with coverage by soft tissue flap or composite flaps have been used. All these options are technically demanding. Reports do exist whereby muscle flaps bridging the defect used as cover in course of time could transmit the tendon force across the defect. We are presenting a case where a free gracilis muscle flap used to cover the soft tissue defect at the Achilles tendon at 2 years follow up provided stable cover and produced active function of the Achilles tendon allowing the patient to stand tip toe. Mechanism of its action has been analysed by MRI and M-mode ultrasound. While in primary Achilles tendon injury reconstruction is still the recommended option, in complex situations mere filling of the gap with the flap without formal reconstruction of the tendon could give good functional outcome. This technique can be used in demanding situations.
Achilles tendon; gracilis; muscle flap; reconstruction
Congenital anomaly of nasolacrimal duct is mostly obstructive in nature or is seen in oblique facial clefts. Nasolacrimal duct drain into the inferior meatus in the nose in a normally developed face. We report a rare case of aberrant opening of distal end of nasolacrimal duct into the external skin lateral to the ala of nose in an adult patient. The only case reported so far was in an infant. The patient is a 22 year young male presenting with an opening lateral to the left ala of nose with recurrent discharge and conjunctivitis of left eye. The embryology is also discussed.
Ectopic opening; nasolacrimal duct; oblique facial cleft
Epigastric heteropagus is an extremely rare congenital anomaly, in which there is asymmetrical conjoined twinning, with the parasitic twin attached to the epigastrium. A 2-day-old male, with epigastric heteropagus and omphalocele, was operated in our institution. After excision of the parasitic twin, omphalocele was covered with a gluteal skin flap available from the parasitic twin. Post-operative course was uneventful, except for infection along the edges of the skin flaps, which was managed conservatively. Only 44 cases of epigastric heteropagus twins have been reported previously in world literature. We present a novel surgical approach for the repair of the omphalocele in a case of epigastric heteropagus twins, probably the 45th case to be reported in the world literature.
Conjoined twins; epigastric heteropagus; gluteal skin flap
Domestic burns in neonate are rare in literature. Neonates are high risk for burns because of their thin and fragile skin, fluid overload or dehydration as the fluid balance range is small and immature immune system leading to septicaemia. Neonates are not small adults, owing to their different physiological response makes the management of neonates challenging as the clinical signs are different from the adults and the resuscitation protocols or end points are also different. We present a case of 11 days old neonate, who sustained 51% scald burns when the hot water bag being used by her mother accidentally burst, the youngest reported case of domestic scald burns with such high percentage. The baby was managed by fluid resuscitation, antibiotics, dressings, ventilatory support for septicaemia and subsequently homograft application. The neonate was discharged with completely healed areas after 35 days of burns and is on regular follow up and no complications have been observed.
Accidental; neonate; scald burns
We present a case of composite oromandibular reconstruction with fibula free flap in which the vascularity to the flap was established in a retrograde direction through the distal end of the peroneal pedicle vessels. The flap was initially designed in such a way so as to anastomose with superior thyroid artery. However after initial good flow, the superior thyroid artery flow became insufficient. Therefore, an attempt was made to vascularise the flap by anastomosing the distal end of peroneal vessels with the facial artery and a tributary of the internal jugular vein so that the flap was perfused in a retrograde direction. This was successful and the retrograde flow was adequate to ensure flap survival. We believe this to be the first successful case of reverse vascular flow reported for composite oromandibular reconstruction with the fibula free flap.
Composite oromandibular defects; fibula free flap; oromandibular reconstruction; retrograde vascularisation
Medial canthal dystopia with canalicular obstruction is a common presentation following injury to the medial canthal region. Conjunctivodacryocystorhinostomy with Lester's Jones tube is considered as the standard treatment in such cases. Alternatively, these patients can be managed by retrograde intubation dacryocystorhinostomy with medial canthoplasty. We herein describe the modification of retrograde bicanalicular intubation, combined with medial canthoplasty (monopedicle flap) which gives good cosmetic results.
Bicanalicular intubation; dacryocystorhinostomy; retrograde canalicular intubation
We introduce a middle age healthy man with sequential bilateral carpal tunnel syndrome. At the surgery, we encountered a wide median nerve in both wrists. Although enlargement of median nerve in carpal tunnel has been well documented, 25 mm width of the nerve is a rare scene, underscoring that leaving the nerve under the unyielding pressure would lead to a fibrous atrophic median nerve.
Blood-nerve barrier; carpal tunnel syndrome; compressive neuropathy; median nerve; neural edema
Penile amputation is rare and hence the paucity of experience and publication. We present our case of self-inflicted penile amputation, which was successfully managed with microsurgical replantation, with relevant literature review.
Microvascular replantation; penile amputation; penile replantation
During microvascular anastomosis, it is important to maintain the microsurgical field irrigated yet dry so as to achieve a good view of the vessels for approximation. In this method, an infant feeding tube (size 4), with its tip sandwiched between layers of dry gauze and a surgical glove component placed in the anastomotic field and the other end connected to a suction apparatus, is used to maintain the microsurgical field free from flooding. It also has the additional advantage of providing a stable platform for microvascular anastomosis.
Anastomosis; microreconstruction; microsurgical field