This is a prospective clinical study of 46 ear keloids in 31 patients (with a mean follow-up of 18 months) treated from January 2006 to December 2006 at The Queen Elizabeth Public Hospital, Barbados, West Indies by a single surgeon. The mean age is 21.9 years (range 3-66 years). Seven out of 46 lesions were recurrent lesions following previous surgery. All the lesions were excised surgically (extralesional). Ten out of 31 patients were given postoperative, Intralesional Triamcinolone starting from the 1 ^st post operative visit on three visits at monthly intervals. Fourteen patients were given postoperative superficial X-ray therapy of 12 Gy in three equal fractions on three consecutive days starting from the 3 ^rd postoperative day. Seven recurrent keloids of this study were given a combination of both superficial X-ray therapy and intralesional triamcinolone. All patients were followed at monthly intervals for three visits from the time of surgery and every three months until the end of the 1 ^st year and then every six months thereafter. Five of 46 postoperative surgical wounds showed evidence of recurrence during the 1 ^st year but could be suppressed with Intralesional triamcinolone. This study confirms that surgical excision of keloids supplemented with radiotherapy and/Intralesional triamcinolone is a reliable method with few complications. In addition, the study concludes that the key in preventing recurrence is regular clinical follow-up to encounter early recurring lesion (clinical evidence of raised scars or palpable nodules if deep seated) which is 100% susceptible to Intralesional triamcinolone for 2-3 times at monthly intervals.

Background: Osteogenesis driven by adipose-derived stem cells (ADSCs) is regulated by physiological and pathological factors. Accumulating evidence from in vitro and in vivo experiments suggests that melatonin may have an influence on bone formation. However, little is known about the effects of melatonin on osteogenesis, which thus remains to be elucidated. This study was performed to determine whether melatonin at physiological concentrations (0.01-10 nM) could affect the in vitro proliferation and osteogenic differentiation of rat ADSCs. Materials and Methods: ADSCs were isolated from the fat of adult rats. After cell expansion in culture media and through three passages, osteogenesis was induced in a monolayer culture using osteogenic medium with or without melatonin at physiological concentrations (0.01-10 nM). After four weeks, the cultures were examined for mineralization by Alizarin Red S and von Kossa staining and for alkaline phosphatase (ALP) activity using an ALP kit. Cell viability and apoptosis were also assayed by 3-(4, 5-dimethylthiazol-2-yl)-5-(3-carboxymethoxyphenyl)-2-(4-sulfophenyl)-2H-tetrazolium (MTT) assay and flow cytometry, respectively. Results: The results indicated that at physiological concentrations, melatonin suppressed proliferation and differentiation of ADSCs. These data indicate that ADSCs exposed to melatonin, had a lower ALP activity in contrast to the cells exposed to osteogenic medium alone. Similarly, mineral deposition (calcium level) also decreased in the presence of melatonin. Flow cytometry confirmed that cell growth had decreased and that the numbers of apoptotic cells had increased. Conclusion: These results suggest that the physiological concentration of melatonin has a negative effect on ADSC osteogenesis.

Background: Oromaxillofacial surgical procedures present a unique set of problems both for the surgeon and for the anesthesist. Achieving dental occlusion is one of the fundamental aims of most oromaxillofacial procedures. Oral intubation precludes this surgical prerequisite of checking dental occlusion. Having the tube in the field of surgery is often disturbing for the surgeon too, especially in the patient for whom skull base surgery is planned. Nasotracheal intubation is usually contraindicated in the presence of nasal bone fractures seen either in isolation or as a component of Le Fort fractures. We utilized submental endotracheal intubation in such situations and the experience has been very satisfying. Materials and Methods: The technique has been used in 20 patients with maxillofacial injuries and those requiring Le Fort I approach with or without maxillary swing for skull base tumors. Initial oral intubation is done with a flexo-metallic tube. A small 1.5 cm incision is given in the submental region and a blunt tunnel is created in the floor of the mouth staying close to the lingual surface of mandible and a small opening is made in the mucosa. The tracheal end of tube is stabilized with Magil's forceps, and the proximal end is brought out through submental incision by using a blunt hemostat taking care not to injure the pilot balloon. At the end of procedure extubation is done through submental location only. Results: The technique of submental intubation was used in a series of twenty patients from January 2005 to date. There were fifteen male patients and five female patients with a mean age of twenty seven years (range 10 to 52). Seven patients had Le Fort I osteotomy as part of the approach for skull base surgery. Twelve patients had midfacial fractures at the Le Fort II level, of which 8 patients in addition had naso-ethomoidal fractures and 10 patients an associated fracture mandible. Twelve patients were extubated in the theatre. Eight patients had delayed extubation in the post-operative ward between 1 and 3 days postoperatively. Conclusion: In conclusion, the submental intubation technique has proved to be a simple solution for many a difficult problem one would encounter during oromaxillofacial surgical procedures. It provides a safe and reliable route for the endotracheal tube during intubation while staying clear of the surgical field and permitting the checking of the dental occlusion, all without causing any significant morbidity for the patient. Its usefulness both in the emergency setting and for elective procedures has been proved. The simplicity of the technique with no specialized equipment or technical expertise required makes it especially advantageous. This technique therefore, when used in appropriate cases, allows both the surgeon and the anesthetist deliver a better quality of patient care.

Objective: This paper describes chemical injuries, which presented to us and were managed at a burn unit in Nigeria. The purpose of this paper is to highlight the etiologies of these injuries, the extent of the injuries as well as to suggest possible ways to prevent chemical injuries in our environment. Materials and Methods: We carried out a retrospective review of chemical burns treated at our center. Our sources of information were the burn unit admission registers, case notes of the patients and operation registers. The results were collated and then analyzed. Results: Twenty eight patients presented with chemical burn injuries during the study period between January 2000 and December 2003, constituting 5.7% of all patients with burns treated within that period. Seventeen (60.7%) of the patients were males while 11 (29.3%) were females with a mean age of 20.6 years. The injuries were sustained from assault in 21 (75%), armed robbery attacks in five (17.8%) and suicide attempts in two (7.1%). The agents were usually unknown. Late presentation was observed in all the patients. Raw eggs, palm oil, gentian violet and engine oil were the substances applied immediately after the injuries. Complications observed included septicemia, respiratory distress, blindness, renal failure, mentosternal contractures, ectropion, axillary contractures, hypertrophic scars, keloids and skin depigmentation. Conclusion: Chemical burn injuries are mainly due to assaults in Nigeria and are usually extensive and presented late. Education of the people and penalty for any offender will reduce the current spate of such injuries.

Background: Autologous breast reconstruction using the extended latissimus dorsi flap has been infrequently reported. In the current study, the authors are reporting their own clinical experience with this method. A review of the literature is also discussed. Materials and Methods: Over a three year period, 14 patients underwent breast reconstruction using the extended latissimus dorsi (LD) flap. Patients with small to medium sized breasts were selected. The age of the patients ranged from 29 to 42 years with a follow-up period ranging from six to 18 months. The indications, flap-related complications and donor site morbidity and aesthetic results were evaluated. Results: The main indication to use the flap was dorsal donor site preference by patients. The remaining patients were either not suitable for a flap from the abdomen or wished to get pregnant and were offered the dorsal donor site. Neither total nor partial flap loss was recorded but donor site morbidity was mainly due to seroma, which was treated conservatively in all patients, except for one who required surgery. Another two patients suffered from wound breakdown and distal necrosis of the back flaps. Mild contour deformity was also noted on the back of all patients but caused no major concern. Indeed, the overall patient satisfaction was very high. Conclusion: The extended LD flap proved to be a good option for autologous breast reconstruction in selected patients. Patients should be warned of the potential for seroma and mild contour back deformity.

Despite many medical advances, burns continue to remain a challenging problem due to the lack of infrastructure and trained professionals as well as the increased cost of treatment, all of which have an impact on the outcome. There is very little information on the pattern of outcomes among burn patients in relation to clinical aspects in India. Hence, the present study was undertaken in a burns unit to determine selected epidemiological variables, assess the clinical aspects (etiology, extent and anatomical location) and first aid measures adopted and finally to analyse the outcomes in cases of burn injuries. In addition, we have sought to suggest measures to remove myths about pre-hospital burn treatment and provide recommendations to healthcare professionals.

Tissue engineering is a multidisciplinary field that involves the application of the principles and methods of engineering and life sciences towards i) the fundamental understanding of structure-function relationships in normal and pathological mammalian tissues and ii) the development of biological substitutes that restore, maintain or improve tissue function. The goal of tissue engineering is to surpass the limitations of conventional treatments based on organ transplantation and biomaterial implantation. The field of tendon tissue engineering is relatively unexplored due to the difficulty in in vitro preservation of tenocyte phenotype. Only recently has mechanobiology allowed us to gain a better understanding of the fundamental role of in vitro mechanical stimuli in maintaining the phenotype of tendinous tissue. This review analyzes the techniques used so far for in vitro regeneration of tendinous tissue.

We have used surgical gauze under the prepuceal skin as a pack in 20 cases prior to marking incision for circumcision. The prepuceal adhesions were first dissected and seperated. The method allows a stable, well-supported prepuceal surface for marking incisions and avoids injuries to the glans. Because the prepuceal surface is taut and stable, hemostasis is easier and quicker and the operating time is reduced.

Maintenance of ear projection and post auricular sulcus in staged ear reconstruction in microtia is a trying problem. So also is the maintenance of the patency of the external auditory meatus following recanalization and meatoplasty. Numerous splints and dressing techniques have been described for the above situations. Some of the problems encountered include the availability of the materials, cost, expertise in fabrication and compliance. Aims: To devise a simple, reliable, inexpensive and readily available splint for the maintenance of post auricular sulcus and external auditory meatus opening. Settings and Design: A silicone catheter is made out of a soft and inert material that doesn't cause tissue necrosis or any loss of skin graft. The basic design is that of a simple, self-retaining type of splint that doesn't dislodge and can be prepared within minutes on the operating table. Materials and Methods: This splint has been used in four cases of microtia reconstruction and one case of congenital external auditory meatus stenosis between June 2006 and August 2007. A 14 or 16 Fr silicone Foley's catheter was used. The proximal end of a catheter of required length was retained and the distal part was cut off. The catheter was looped into a circle around the base of the reconstructed ear and secured in position with a suture. A similar construct was used in cases of external auditory meatus reconstruction or recanalization. The funnel-shaped distal drainage end was sutured to the circular frame near the region of the tragus. This funnel was inserted into the external auditory canal. Results: The catheter was found to sit snugly in the newly created sulcus, thereby maintaining the sulcus and ear projection. It aided in maintaining the meatal opening of a satisfactory diameter in the case of external auditory canal recanalization. It was never found to slip or get dislodged in any of the cases. There was no skin graft loss or tissue necrosis due to the use of the splint. Conclusions: The silicone Foley's catheter is found to be a simple, readily available, inexpensive and reliable self-retaining splint following ear elevation in microtia and external auditory meatus recanalization. The catheter is easily constructed and applied intraoperatively. The results following its usage have been uniformly good in all cases without causing any adverse events at the operated site or discomfort to the patient ensuring good compliance.

Adequate coverage of dorsal finger wounds is often a challenge. The reversed cross finger subcutaneous flap to cover defects on the dorsum of phalanx constitutes an excellent option for coverage of wounds over the middle and distal phalanges of the index, middle, ring, and small fingers. It's an easy flap and represents our first choice to cover those defects.

We describe here a case of abdominal abscesses due to Mycobacterium fortuitum following liposuction. The abscesses developed three months after the procedure and diagnosis was delayed for five months. The clues for diagnosis were persistent pus discharge in spite of broad spectrum antibiotics and failure to grow any organisms on routine culture. This condition has been rarely reported; however, the increasing number of liposuction procedures done and awareness among physicians will probably result in the identification of more cases. Combination antibiotic therapy with surgical drainage in more extensive diseases is essential for cure.

Reconstruction of the distal foot, especially of the toe has always been a challenging problem. Various methods have been tried with variable success rates and limitations. Presented here is a series of four cases, where distally based flaps were used. Two of them were Extensor Digitorum Brevis (EDB) muscle flaps and the other two were first dorsal metatarsal artery (FDMA) based skin flaps. One in each of the two was augmented with a plantar V-Y advancement flap. All flaps survived completely without any flap- or donor site-related complications. The patients were ambulated two weeks following the reconstruction and were symptom-free after an average follow-up of thirteen months. Distal flaps based on the dorsalis pedis system provide a reliable cover for distal foot defects.

Condyloma acuminatum is located in the perianal region, anal canal, vagina and the perineum. It is caused by human papillomavirus types 6 and 11. A 18 year-old man was admitted to the clinic because of a perianal mass. On examination of the patient's perianal area and inside the anal canal, a mass was found, which was nearly 8 x 8 cm in size. We could not obtain any information about venereal transmission. The mass was totally excised and the defect was reconstructed with a bilateral V-Y advancement flap. This technique has been used for sacrococcygeal, ischial and other defects but rarely used for condyloma acuminatum. We think that total excision and the use of the V-Y advancement flap technique is safe and has low morbidity in the treatment of condyloma acuminatum.

Familial chylomicronemia syndrome is a very rare condition with an incidence of one in one million. We report such a condition detected incidentally in a cleft child.

Open carpal tunnel release is the commonest surgical treatment of median nerve compression at the wrist. Although successful in most cases, there are well described complications. We report a case of laceration of the deep motor branch of the ulnar nerve at the level of the hook of hamate following a complicated carpal tunnel decompression. Good surgical technique and knowledge of wrist anatomy are essential for performing this apparently simple procedure safely.

The Baller-Gerold syndrome is a rare syndrome with very few cases published in literature. Craniosynostosis and radial aplasia are striking features, easy to diagnose. However, there are many differential diagnoses. Often, the question raised is whether the Baller-Gerald syndrome is a distinct entity. We report a patient with findings of craniosynostosis and radial aplasia consistent with the diagnosis of the Baller-Gerold syndrome. Genotypic heterogeneity could possibly underlie the phenotypic variability exhibited by these cases.

Keeping skin graft or a flap adherent to the underlying surface can sometimes be a difficult job, particularly inside a cavity. Different methods have been used for this function with varying success but the search is still on for an ideal pressure dressing.

Objects: Progressive skin necrosis of giant occipital encephalocoele is an extremely rare complication found in neonates. Infection and ulceration of the necrosed skin may lead to meningitis or sepsis. We present here a neonate with giant occipital encephalocoele showing progressive necrosis during the first day of his life. Methods: A newborn baby was found to have a huge mass in the occipital region, which was covered by normal pink-purplish skin. During the last hours of the first day of his life, the sac started becoming ulcerated accompanied with a rapid color change in the skin, gradually turning darker and then black. The neonate was taken up for urgent excision and repair of the encephalocele. Two years after the operation, he appears to be well-developed without any neurological problems. Conclusion: Necrosis may have resulted from arterial or venous compromise caused by torsion of the pedicle during delivery or after birth. The high pressure inside the sac associated with the thin skin of the encephalocoele may be another predisposing factor. In view of the risk of ulceration and subsequent infection, urgent surgery of the necrotizing encephalocele is suggested.

Variations in the position of the bifurcation of the common carotid artery and the origin or branching pattern of the external carotid artery are well known and documented. Here, we report the trifurcation of the right common carotid artery in a male cadaver aged about 55 years. The right common carotid artery was found to divide into the external and internal carotids and the occipital artery. High division of bilateral common carotid arteries and a lateral position of the right external carotid artery at its origin were also observed in the same cadaver. There were two ascending pharyngeal arteries on the right side - one from the occipital artery and another from the internal carotid artery. The intraarterial approach is one of the most important routes for the administration of anticancer drugs for head and neck cancers. A profound knowledge of the anatomical characteristics and variations of the carotid artery such as its branching pattern and its position is essential to avoid complications with catheter insertion.