Sebaceous carcinoma of forehead: a rare malignant lesion

Sebaceous carcinoma is an uncommon malignant tumour of the sebaceous glands. This lesion typically occurs as painless and slow growing nodule in the eyelid region. In rarity, it can develop on buccal mucosa, head and neck, and other regions of the body in people in their 60s and 70s. Sebaceous carcinoma is locally aggressive and carries the potential of regional and distant spread. We present the case of a 15-year-old male who was diagnosed with sebaceous carcinoma over the forehead. After discussing the case in the board meeting, surgery was performed to remove the tumour with 1cm margin. Outer table of the frontal bone was also removed and intraoperative frozen section was done for margin clearance. After the Figure 1excision, soft tissue coverage was done with free Anterolateral thigh flap and the patient received six cycles of post-operative radiation therapy.

Application Of Cling Film Over Burn Wounds (Occlusive Wound Dressing): Our Experience

BACKGROUND

This study shares our experience and review the outcome of the use of cling film with silver sulfadiazine cream in terms of healing time, and patient's satisfaction score.

METHODS

It was a descriptive case series conducted at Jinnah Burn and Reconstructive Surgery Center, Lahore, from March 2018 to February 2019. In this study, a thick layer of silver sulfadiazine was applied and then wrapped with cling film on 35 patients sustained mix thickness burns on the trunk and limbs. Dressing was done daily after wound wash with normal saline. Consultant Plastic surgeon assessed the wound healing by observation and serial photographs. Duration of wound healing and complications were noted.

RESULTS

Complete wound healing was achieved in 25 (71.4%) patients with mean healing time of 13.3 days (range 11-15 days). The wound infection was seen in 5 (14.2%) patients, that were diagnosed by change in colour of wound edges and patients with signs of sepsis (ABA scoring). Sepsis was treated in 5 patients with debridement and culture specific antibiotics. split skin graft done in 8 (22.8%) cases.

CONCLUSIONS

Moist wound dressing with Silver Sulfadiazine and cling film is cost effective, easy to apply with good visibility of the wound and has good patient satisfaction, but is labour intensive.

Vacuum-assisted Closure in Integration of Skin Graft Over Scalp Wounds: A Randomised Control Trial

OBJECTIVE

To compare outcome of split thickness graft with and without vacuum-assisted closure over the scalp soft tissue defects in terms of graft take and complications.

STUDY DESIGN

Randomised controlled trial.

PLACE AND DURATION OF STUDY

Department of Plastic Surgery, Jinnah Burns and Reconstructive Surgery Centre, Lahore, from June 2017 to June 2018.

METHODOLOGY

Patients with scalp soft tissue defects were recruited for the study. Patients with history of poly trauma, hypertension and diabetes mellitus were excluded. Patients were randomly divided into two groups by balloting lottery method. In group A, simple dressing were done after split thickness skin graft; and into group B, VAC dressing was applied after split thickness skin graft. Outcome variables (graft take and complications rate at recipient site) were assessed clinically at 2 weeks and analysed by Chi-square test with p-value <0.05 was taken as significant.

RESULTS

Mean age of 120 patients was 33.44 ±14.65 years. Graft take was seen in 24 (40.0%) patients in group A and in 56 (93.3%) patients in group B (p = 0.0001). Seroma was recorded in eight (13.3%) in group A (simple dressing) patients and one patient (1.67%) in group B (VAC dressing, p = 0.015), hematoma was seen in 04 (6.67%) versus 0 (0.0%), respectively (p = 0.042) and graft edge dehiscence in 03 (5.0%) versus 0 (0.0%), respectively (p = 0.079).

CONCLUSION

Outcome of split skin graft over scalp soft tissue defects with VAC dressing is better than simple dressing in terms of graft take and complications rate.

Glycerol Preserved Amnion: A Viable Source of Biological Dressing for Superficial Partial Thickness Facial Burns

OBJECTIVES

To evaluate the role of amnion as a biological dressing in superficial partial thickness facial burns.

STUDY DESIGN

Randomized controlled trial.

PLACE AND DURATION OF STUDY

Jinnah Burn and Reconstructive Surgery Centre, Lahore, from January 2017 to December 2018.

METHODS

Sixty two patients with superficial partial thickness facial burns were randomly divided into two groups (A and B). Ointment containing Polymyxin B and Bacitracin was applied in group A (n=28) while amnion was applied in group B (n=34). The patients were monitored for the pain related to burns needing analgesia, time of healing of burns, and cosmetic outcome of the facial scarring over a period of six months.

RESULTS

The mean age of the patients was 26.5 ±12.2 years. 39 (62.9%) patients were male and 23 (37.1%) were females. The mean percent total facial surface area burned was 2.7% ±1. None of the patients developed facial wound infections. The average healing time was 6 ±2 days. The mean frequency of analgesia for 3 days of group B was less as compared to group A. infection rate was similar in both groups. No significant difference was observed in VAS score at 1, 3 and 6 month follow up between both groups.

CONCLUSION

Amnion is a safe, cost effective and most readily available biological dressing for superficial partial thickness facial burn management. Key Words: Amnion, Facial burn, Biological dressing, Scarring, Partial thickness burn.

Complex Reconstruction of Nose and Upper Lip after Assault

A 21-year male, farmer by profession, was admitted in Plastic Surgery Department via outpatient department, with amputation of nose and upper lip with the knife during resistance against robbery attempt. He was having the blockage of the right side of nostril and difficulty in mouth opening. Upper lip vermilion and mucosal reconstruction with the bilateral facial artery musculo-mucosal (FAMM) flap and moustache reconstruction was done with visor flap. Split thickness skin graft (STSG) was done over the donor site. Division and insetting of visor flap was done after two weeks. After three months, all three nasal layers were reconstructed. The inner lining was reconstructed with the turn down flap, L-strut from rib cartilage, and the outer lining with forehead flap.

Granulocyte Colony Stimulating Factor in Burn Patients with Neutropenia

OBJECTIVE

To assess the role of granulocyte-colony stimulating factor (G-CSF) for improving neutropenia in burns patients with neutropenia.

STUDY DESIGN

Experimental study.

PLACE AND DURATION OF STUDY

Jinnah Burn and Reconstructive Surgery Centre, Lahore, from May to October 2017.

METHODOLOGY

Patients with burn injury, having absolute neutrophil count (ANC) <500 / μL or where it was expected to decrease to <500/μL within the next 48 hours, were recruited in the study. A detailed demographic profile of patients was taken, burn site was evaluated, and sample collection by phlebotomy was done in the complete blood count (CBC) vial. Samples were run in a CBC analyser and verification of neutrophil count on the neubuar chamber was done. ANC was taken for 3 days for each patient. Injection Filgrastim was given 300 μg subcutaneous (S/C) or intravenous (I/V) once daily until the neutropenia improved. Improvement was categorised as good, moderate and poor, depending on the number of days for improvement in ANC. The response was further stratified on the basis of age, gender and percentage of burn.

RESULTS

A total of 39 patients with mean age of 32.1±14.4 years included 84.6% (n=33) males and 15.4% (n=6) females. Mean percentage of burn was 40.5±15.7%. In 12-40 years of age, there were 30/39 (76.9%) patients. Among them, 11/30 (36.6%) were good, 13/30 (43.3%) were moderate, and 6/30 (20%) were poor responders. In 41-70 years of age, there were 9/39 (23.1%) patients. Among them, 2/9 (22.2%) were good, 4/9 (44.44%) were moderate, and 3/9 (33.3%) were poor responders (p = 0.616).

CONCLUSION

The addition of G-CSF injections to the standard treatment of burn injury markedly improve the neutrophil counts in burn patients with neutropenia.

Oropharyngeal, Hypopharyngeal and Cervical Esophageal Reconstruction: An Experience of Pedicle Flaps

OBJECTIVE

To review the experience of single-stage reconstruction following pharygolaryngectomy and cervical esophageal defect with pedicle flaps in a tertiary care centre.

STUDY DESIGN

Retrospective study.

PLACE AND DURATION OF STUDY

Jinnah Burn and Reconstructive Surgery Centre, Lahore, from June 2007 to June 2017.

METHODOLOGY

All patients who underwent oropharyngeal, hypopharyngeal and cervical esophageal reconstruction with pedicled flaps were included.

RESULTS

Thirty-two reconstructions were done, of which 16 (50.0%) were supraclavicular flaps, 12 (37.5%) were pectoralis major myocutaneous flaps (PMMF) and 4 (12.5%) platysma myocutaneous flaps (PMF). Among these, 24 (75%) were males and 8 (25%) females. The mean hospital stay was 18.75 +5.45 days. Complications were noted in 12 (37.5%), salivary fistula being the most frequent found in 6 (18.75%). Wound dehiscence was noted in 4 (12.5%), partial flap necrosis and wound infection present in 1 (3.1%) each.

CONCLUSION

Oropharyngeal, hypopharyngeal and cervical esophageal reconstruction with pedicle flaps is still very useful and safe to perform, associated with minimal flap and donor site complications.

Comparison Of Outcome Of 1- And 2-Knot, 4-Strand, Doublemodified Kessler Flexor Tendon Repair With Early Active Mobilization Protocol In Patients With Flexor Tendon Lacerations Of Hand

BACKGROUND

Hand is unique for the dexterity of its function and flexor tendons have most important function in hand. Its injury is a challenging treatment. Purpose of this study is to compare the success of 1- and 2-knot, flexor tendon repair (good to excellent results) with early active mobilization in terms of total active motion (TAM) of affected hand postoperatively.

METHODS

Hundred patients with age range of 5-70 years of age presenting with flexor tendon lacerations of hand were included in the study. Subjects were randomly divided into Group A, who underwent flexor tendon repair using 4 strands of double modified Kessler repair with 1 knot and Group B, in which 4 strand double modified Kessler repair with 2 knot technique was used. All patients followed early active motion protocol started in first 48 hours. They were followed at 3, 6 and 8 weeks after surgery for TAM. Data was entered and analysed in SPSS-21.0. Frequency and percentages were calculated for outcome of procedure.

RESULTS

In group A 89.8% (44) of patients had good to excellent results in terms of total active motion (TAM) as compared with 90.9% (40) in group B using early active mobilization protocol.

CONCLUSIONS

The study concluded that that four strand double modified flexor tendon repair using either 1 or 2 knot technique are excellent choices of repair with early active mobilization protocols.

Medial Sural Artery Perforator Flap: A Versatile Option For Soft Tissue Reconstruction Of Head And Neck And Limbs

BACKGROUND

To assess the outcome of Medial Sural Artery Perforator Flap (MSAP Flap) as an option for the soft tissue reconstruction of head and neck and limbs.

METHODS

This descriptive case series was conducted at Jinnah Burn and Reconstructive Surgery Center, Lahore during October 2016 to August 2017. All patients in whom MSAP flap (free and pedicled) was performed for reconstruction are included. Patients were followed at one week and one month after the discharge and data was entered into the proformas.

RESULTS

In total, 18 patients were operated with this flap. Free and pedicled MSAP flap were performed for reconstruction of soft tissue defects in the head and neck and the lower limb. The maximum dimensions of the flap were 14 cm length and 10 cm width. The maximum pedicle length was 16cm. All flaps survived and showed good outcome. There was necrosis of the distal margin of a pedicled flap, but no case of venous congestion and flap failure was observed. The flap donor site was closed primarily in 7 patients while split skin graft was used in the rest of the patients.

CONCLUSIONS

The MSAP flap provides a thin skin paddle and has minimal donor site morbidity as compared to the other options. It is a good addition to the armamentarium of perforator flaps which are thin and pliable, can be harvested by two team approaches, under the tourniquet and has a hidden donor site.

The efficacy of excision followed by intralesional 5-fluorouracil and triamcinolone acetonide versus excision followed by radiotherapy in the treatment of ear keloids: A randomized control trial

BACKGROUND

The ear is the common site for keloid formation especially in women after ear piercing. Surgery is the main stay of treatment in these lesions but there are large numbers of treatment failures in surgery alone.

OBJECTIVE

The objective of this study was to compare the efficacy of post-excision intralesional 5-fluorouracil/triamcinolone acetonide (5-FU/TAC) and post-excision radiotherapy in the treatment of ear keloids.

STUDY DESIGN

A randomized controlled trial.

SETTING

The study was conducted from May 2014 to January 2015 at Jinnah Burn and Reconstructive Surgery Centre, Allama Iqbal Medical College, Lahore.

SUBJECT & METHODOLOGY

After approval from the hospital ethical committee, 60 patients presented in the outpatient department fulfilling the inclusion criteria were selected and randomly assigned in two groups with the help of the random number table. Patients in group A had excision followed by intralesional 5-FU/TAC injections while patients of group B had excision followed by radiotherapy. Patients were assessed at 6 months after completion of treatment for efficacy (no recurrence within 6 months of treatment).

RESULTS

In our study total of 60 patients completed the study, with 30 patients in each group. 7 patients (23.34%) in Group-A and 9 patients (30%) in Group-B were males while 23 patients (76.67%) in Group-A and 21 patients (70%) in Group-B were females i.e. male to female ratio is 1:2.75. Mean age was 31.8+6.48years. The comparison of frequency of efficacy in both groups showed that 73.33% (n=22) in Group-A and 43.33% (n=13) in Group-B had efficacy, p value was calculated as 0.01, showing a significant statistical difference.

CONCLUSION

Excision and intralesional 5-FU/TAC is an effective treatment for keloids on the ears.

Quantification and Further Refinements of Dorsal Metacarpal Artery Perforator Flap for Reconstruction of Wounds of Fingers upto Distal Interphalangeal Joints

OBJECTIVE

To assess the outcome of dorsal metacarpal artery perforator flap for coverage of finger defects extending upto distal interphalangeal joint (DIPJ).

STUDY DESIGN

Case series.

PLACE AND DURATION OF STUDY

Jinnah Burn and Reconstructive Surgery Centre, Lahore, from March 2015 to May 2017.

METHODOLOGY

Our study was carried out in two parts. 1st part of study was to measure average flap length in our population. Five hundred cases were enrolled to measure flap length, from pivot point of the flap to the distal border of extensor retinaculum. This length was traced to fingers to determine its coverage area. This was followed by clinical study in 35 cases. All patients with wounds over dorsal surface of fingers upto distal interphalangeal joint and volar surface of fingers upto mid of middle phalanx, single or multiple finger defects with exposed tendon joints or bones were included in the study. Patients with history of trauma to the dorsum of hand, metacarpal head or neck fracture and patients with history of diabetes or peripheral vascular disease were excluded.

RESULTS

Flap length decreased from radial to ulnar side of hand. Average length of flap based on the second metacarpal artery was 7cm while of the third was 6.6 cm and the fourth was 6.1 cm. This flap length covered upto mid of middle phalanx in border digits while upto PIPJ in central digits. This data was confirmed in 35 patients in which 36 flaps were raised to cover finger defects. Thirty-four flaps survived completely while tip necrosis was seen in 2 cases.

CONCLUSION

The dorsal metacarpal artery perforator flap is a thin, pliable flap, which has minimal donor-site morbidity. It can reliably cover soft tissue defects of dorsum of fingers upto mid of middle phalanx in border digits and upto PIPJ in central digits.

Properties of NiAl and Ni-Al-N thin films deposited by closed field unbalanced magnetron sputter ion plating using elemental Ni and Al targets

Approximately 1 microm thick NiAl and Ni-Al-N thin films have been deposited from individual elemental Ni (99.5% pure) and Al (99.5% pure) targets onto glass and stainless steel 316 substrates using closed field unbalanced magnetron sputter ion platting (CFUBMSIP) process. The films have been characterized using stylus profilometry, energy dispersive spectroscopy (EDAX), X-ray diffractometry (XRD) and atomic force microscopy (AFM). The X-ray diffraction patterns of both types of thin films produced confirmed the formation of beta-NiAl phase. The EDAX results revealed that all of the NiAl thin films produced exhibited the near equiatomic NiAl phase with the best results given by the one deposited using 300 Watts DC power for Ni and 400 Watts DC power for Al targets respectively. However, the Ni-Al-N thin films showed a Ni-rich NiAl phase. AFM results of both types of films produced carried out on glass samples exhibited that the coatings have quite a smooth surface with surface roughness in nanometres range.

Humidity and illumination organic semiconductor copper phthalocyanine sensor for environmental monitoring

In this investigation properties of organic semiconductor copper phthalocyanine (CuPc) capacitive humidity and illumination sensors were studied. Organic thin film was deposited by vacuum evaporation on a glass substrate with silver surface-type electrodes to form the Ag/CuPc/Ag sensor. The capacitance of the samples was evaluated at room temperature in the relative humidity range of 35-92%. It was observed that capacitance of the Ag/CuPc/Ag sensor increases with increase in humidity. The ratio of the relative capacitance to relative humidity was about 200. It is assumed that in general the capacitive response of the sensor is associated with polarization due to absorption of water molecules and transfer of charges (electrons and holes). It was observed that under filament lamp illumination of up to 1,000 lx the capacitance of the Ag/CuPc/Ag photo capacitive detectors increased continuously by 20% as compared to dark condition. It is assumed that photo capacitive response of the sensor is associated with polarization due to transfer of photo-generated electrons and holes. An equivalent circuit of the Ag/CuPc/Ag capacitive humidity and illumination sensor was developed. Humidity and illumination dependent capacitance properties of this sensor make it attractive for use in humidity and illumination multi-meters. The sensor may be used in instruments for environmental monitoring of humidity and illumination.