This is the first time the concept of total quality management in burn injuries is proposed. This is a prospective study done in 1997-2003. All burn admissions to King Fahd Hospital of the University, Division of Plastic Surgery, were included. Total number of cases is 240. Male patients constituted 141 (59.2%); female patients, 97 (40.8%), and 2 cases were not specified in forms. There were 114 children (0-18 years, 50.2%) and 113 adults (19-99 years, 49.8%). The source of admission was mainly emergency room (197, 82%) followed by outpatient department (27, 11.3%), and other hospitals in 16 (6.7%). The type of burn was mainly scald (16.3%), then flame (6.98%), electrical (6.5%), chemical (2.8%), friction (0.47%), and not specified in 33% of recorded cases. The most encountered body percentage burn was 1% to 10% and 11% to 20% in 36.7% and 25.9% of cases, respectively. Sixty-six cases (28.2%) were operated on. The reason for nonoperation was not indicated in 78.5% and refusal in 1.8%. The most frequent operation was split-thickness skin grafting followed by tangential excision + split-thickness skin grafting. Operations took mostly about 2 hours (53.8%). The region operated on was mainly upper limbs (42.6%), then head and neck (27.7%). The affected body part in electrical burns was upper limb, then the head. Preoperative photography was done in 17% and post operatively in 9.4% of recorded cases. Consultations were needed in 39.4% and responded to in 48 hours in 98.2% of them. Discharge was home in 80.9%, against medical advice in 7.5%, died in 7%, transferred in 4%, and other ward in 0.5%. No significant difference was observed between pediatric age groups and adults (>18 years old), also for electrical versus nonelectrical burns in relation to total hospital stay. Similar observations were made among various age groups with respect to total hospital stay. The clinicopathologic typing relation to age groups, nationality, and sex was found significant. Recommendations and the newly proposed zone of practice and concept of total quality management in burn injuries are included.
The loss of a penis, either through trauma or other causes, is psychologically and physiologically intolerable for the victim. The ideal reconstruction should be a reliable single-stage procedure that requires minimum hospitalization and yields acceptable cosmetic and functional results. The traditional techniques, which use tube flaps, are three-to five-stage procedures that are time consuming and physically and economically difficult for the patients. 1The rectus abdominis myocutaneous flap has gained popularity for various reconstructive procedures, including coverage of the groin, 2 thigh, 2 and above-knee amputation stumps. 3 Recently it has been used for vaginal and pelvic reconstruction. 4 We have used an interiorly based rectus abdominis myocutaneous flap to reconstruct an amputated penis and urethra as a single-stage procedure. Surgical ReportA six-year-old boy was referred to our unit for possible reconstruction for his knife-amputated penis, inflicted two years earlier by his psychologically disturbed mother. He was operated on twice at his local hospital, but no details of these attempted procedures were available.Examination revealed absence of the penis, with the urethral opening flush with the scrotum, which was normal (Figure 1). There were irregular scars over the upper medial aspects of both thighs and the groin, suggesting that a gracilis myocutaneous flap had been attempted previously. A micturating cystourethrogram showed a truncated urethra (3 cm), with a short stricture posteriorly.The patient was subsequently operated on using an inferiorly based rectus abdominis myocutaneous flap. At operation a suprapubic puncture cystostomy catheter was first introduced. The right rectus muscle was used as the source of the flap. A vertical skin strip (3 x 12 cm) extending from 3 cm below the xiphoid process to 3 cm below the umbilicus was marked and an incision made down to the anterior rectus sheath, which was incised vertically at the medial and lateral borders of the rectus (Figure 2). This area was then divided at the upper border of the flap and the superior epigastric artery ligated. The whole muscle was freed from the posterior rectus sheath and dissected downward, with the attached skin, care being taken not to injure the inferior epigastric artery.At the level of the inferior border of skin, fascia was separated from the muscle pedicle and the muscle further dissected down. Subcutaneous dissection in the suprapubic area was done and a tunnel was created, through which the flap was rotated and passed underneath to the recipient area (Figure 3). The skin was folded and sutured with interrupted 4-0 chromic catgut to reconstruct the urethra. The proximal end was anastomosed to the urethral opening after appropriate fashioning and a No. 10 Foley catheter was introduced down to the bladder as a stent.The distal end of the skin was folded back dorsally to shape the glans penis (Figure 3). The borders of the rectus were approximated ventrally over the attached skin urethral tube using 3-0 chromic. Th...
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