Therapeutic Plasma exchange therapy in Burns

Severe burn injury affects the body in many devastating ways, the most severe being systemic inflammatory response syndrome. This results in a myriad of effects like increasing capillary permeability, thereby fluid loss. It also causes a surge in inflammatory mediators like interleukin (IL)-6, which further increases the capillary leak and fluid loss. This results in refractory hypotension in patients despite adequate fluid resuscitation. Plasma exchange has been used in the management of a number of illnesses with a significant inflammatory component, and, therefore can be considered to have a role in burn injury. In our article, we would like to share our experience of using therapeutic plasma exchange therapy in burn patient.

Reconstruction of Defects Following Excision of Basal Cell Carcinoma of Face: A Subunit-based Algorithm

Introduction

Basal cell carcinoma (BCC) is a locally invasive, slowly spreading tumor arising in the basal layer of epidermis and rarely metastasizes. Surgical excision with adequate margins is curative. Reconstruction of post-excisional defects on the face is both essential and challenging.

Clinical Cases and Methods

A retrospective review of hospital records for patients operated for BCC of the face excluding the pinna at our institute in the last 3 years was done and a review of the literature was carried out to identify the most common principles governing the optimal reconstruction of post-excisional defects on the face. Literature search was made in Embase, Medline, and Cochrane databases in the last two decades with the filters placed for human and English language studies with the search terms (Facial Basal cell carcinoma) AND reconstruction AND (Humans[Mesh]).

Results

Records of 32 patients with facial BCC who underwent excision and reconstruction at our hospital were identified and details were recorded. Our literature search with the terms and filters mentioned above revealed 244 studies with duplicates removed. After further hand-searching, 218 journal articles were identified, reviewed, and a reconstruction algorithm was designed based on the findings.

Discussion

Reconstruction of post-BCC excisional defects of the face relies on an adequate understanding of the general principles of reconstruction, subunit principle of facial esthetics, flap anatomy and vascularity as well as operator experience. Complex defects need innovative solutions, multidisciplinary approaches, and newer methods of reconstruction like perforator flaps and newer techniques like supermicrosurgery.

Conclusion

Multiple reconstructive options for post-excisional defects of the BCC over the face are available and most defects can be approached in an algorithmic manner. Further well-designed prospective research studies are needed to compare outcomes of different reconstructive options for a given defect and identify the most suitable options.

The Impact of “COVID-19” and “Webinar Pandemic” on Plastic Surgery Practice in Teaching Institutes and Resident Training—A Multicentric Perspective

Introduction The study was carried out to quantify the changes induced by the pandemic in plastic surgery practice and training and to study the impact of the webinars on plastic surgery education from a residents’ perspective.

Methods In this multicentric study, the number and type of surgeries, cause of injuries, and their regional variation during the coronavirus disease 2019 (COVID-19) period (February–September 2020) were compared with pre–COVID-19 time. An online survey on the impact of webinars was conducted for plastic surgery trainees across the country.

Results There was a significant reduction in total number of surgeries (p = 0.003). The procedures for hand (p = 0.156), faciomaxillary injuries (p = 0.25), and replantations (p = 0.46) were comparable; there was a significant reduction in combined orthopedic-plastic-surgical procedures (p = 0.009) during the pandemic. There was a significant reduction in road accidents (p = 0.007) and suicidal injuries (p = 0.002) and increase in assault (p = 0.03) and domestic accidents (p = 0.01) during the COVID-19 period.

A usefulness score of >8 was given for the webinars by 68.7% residents. There was no significant difference in perception of utility when correlated with the academic program at their institutes (p = 0.109); 92% opined webinars should continue in post-COVID times.

Conclusion There was a drastic reduction in number of elective and emergency procedures during the COVID-19 time, negatively affecting resident training program. Majority of residents felt that webinars could prove a useful adjunct to training in formal training program in post-COVID-19 scenario.

Innovative Application of Ziplock Tags for External Tissue Expansion

Tissue expansion is a technique, which uses the biomechanical properties of skin and thereby aiding in wound closure. Commercially available devices for external expansion are not cost-effective. Hence, in this article, we would like to share our experience of innovative use of ziplock as external tissue expansion.

Role of Burn Blister Fluid in Wound Healing

Blisters are characteristic finding of second-degree superficial burns. Varied opinions for the management of burn blisters are available in literature. Most accepted one is to puncture it in a sterile way, keep the overlying skin as a biological cover, and over that put a moist sterile biological dressing. Fluid in the blister is ultrafiltrate of the plasma, which is rich in proteins such as immunoglobulins, various cytokines, prostaglandins, and interleukins. This fluid is pro-inflammatory, and the evidence regarding its effect on wound healing is varied. Instead of drainage, the burn blister fluid can be aspirated and immediately sprayed over the other areas of the same wound. We found this method feasible as an adjuvant therapy for second-degree superficial burn wounds. In this case report, we share our experience of the same.

Role of Phenytoin in Diabetic Foot Ulcers

Of the complications of diabetes mellitus, foot ulcers are the most dreaded complications, as they can progress at an alarming rate and can be very difficult to treat. Various modalities have been described in the treatment of diabetic foot ulcers. One such modality of phenytoin therapy uses the disadvantage of the drug, that is, gingival hyperplasia to the advantage of wound healing. We hereby report a case of diabetic foot ulcer managed with injection phenytoin sprayed topically over the wound.

Prophylactic Tracheostomy for Inhalational Burns

BACKGROUND

Various studies have reported different conclusions over the safety and benefits of early tracheostomy in burns. Our study aimed to assess the role of prophylactic tracheostomy in treatment and improvement of outcomes in inhalational burns in India.

METHODS

In a retrospective descriptive analysis of burns admitted over 1 year in Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER) Tertiary Burns Center in India, patients with thermal burns of TBSA less than 60% and those with indirect evidence of airway burns were enrolled and divided into two groups who underwent prophylactic tracheostomy vs. patients for whom prophylactic tracheostomy was not done. Mortality was the final point and primary variable measurement.

RESULTS

Totally, 10 patients with inhalational burns were admitted. Out of the 4 patients for whom prophylactic tracheostomy was undertaken, three patients survived, while one died. Out of the 6 patients for which prophylactic tracheostomy were not performed, 4 patients died; while 2 survived. The average percentage of burns TBSA in the prophylactic tracheostomy group was 34%. Average age of patients in the prophylactic tracheostomy group was 31.3 years. The average percentage burns TBSA in the group, where prophylactic tracheostomy was not carried out was 42%. Average age of patients in the prophylactic tracheostomy group was 36.2 years.

CONCLUSION

Our study is a pilot study to investigate the possibility and a way to improve outcomes in patients with inhalational injuries. Larger trials may be needed to facilitate or disprove the same.

New 5-D Coding System for Categorization of Plastic Surgery Conditions

BACKGROUND

There is need for a coding system for categorizing the plastic surgery conditions to facilitate efficient data exchange, retrieval, research, time-series analysis, clinical audit, insurance and legal purposes. This is a pilot study to assess feasibility of newly proposed 5-D coding system in categorizing the plastic surgery conditions.

METHODS

Retrospective analysis of records of plastic surgery patients visited in last 15 months was done. Each patient was assigned a code according to the newly proposed 5-D system of coding and recorded in excel sheet. Data analysis was done to categorize various plastic surgery conditions. Results of analysis were shown to 11 plastic surgeons and their feedback was taken.

RESULTS

Feedback taken from participants showed 5-D coding system was useful and practically easy to categorize the plastic surgery conditions.

CONCLUSION

Proposed new 5-D coding system is easy and useful in categorization of plastic surgery conditions.