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True Median Cleft Lip-15 Years of Review and Prevalence

Hamzan MI, Sulaiman WAW

Cleft Palate Craniofac J, 2020 08;57(8):1051-1054.
PMID: 32476501 DOI: 10.1177/1055665620926346

OBJECTIVES: The author presents 4 cases and attempts to analyze the prevalence of true median cleft lip (MCL) in one center. Embryology, associated anomalies, and surgical treatment are discussed.
DESIGN: A retrospective descriptive study.
SETTING: Hospital Universiti Sains Malaysia.
PARTICIPANTS: All patients with congenital facial cleft deformities from 2005 to 2019 were retrieved from the Plastic Surgery OR Registry. All characteristics in interest were individually tabulated and evaluated. Four cases were reviewed and discussed.
OUTCOME: Prevalence of true MCL.
RESULTS: Out of the 494 patients included in the study, only 4 (0.81%) were affected with a median cleft, and the prevalence of true median cleft was hence determined to be 3 (0.61%) among the cleft population.
CONCLUSION: The prevalence of the true MCL is rare which makes it hard to categorize these clefts, and the surgical protocol needs to be established for the definitive treatment.
Cross-Leg Free Flap: Crossing the Border Zone of Ischemic Limb-A Case Report of Limb Salvage Procedure following a Delayed Diagnosis of Popliteal Artery Injury

Lam HY, Sulaiman WAW, Ismail WFW, Halim AS

Arch Plast Surg, 2023 Mar;50(2):188-193.
PMID: 36999154 DOI: 10.1055/a-1962-6009

Vascular injury following traumatic knee injury quoted in the literature ranges from 3.3 to 65%, depending on the magnitude and pattern of the injury. Timely recognition is crucial to ensure the revascularization is done within 6 to 8 hours from the time of injury to avoid significant morbidity, amputation, and medicolegal ramifications. We present a case of an ischemic limb following delayed diagnosis of popliteal artery injury after knee dislocation. Even though we have successfully repaired the popliteal artery, the evolving ischemia over the distal limb poses a reconstruction challenge. Multiple surgical debridement procedures were performed to control the local tissue infection. Free tissue transfer with chimeric latissimus dorsi flap was done to resurface the defect. However, the forefoot became gangrenous despite a free muscle flap transfer. His limb appeared destined for amputation in the vicinity of tissue and recipient vessels, but we chose to use a cross-leg free flap as an option for limb salvage.
Fulltext Bigger Bust No Longer on Trend: Malaysians Prefer Moderation in Ideal Female Breast Augmentation

Hamzan MI, Sulaiman WAW, Ismail NN

Indian J Plast Surg, 2021 Sep;54(3):321-326.
PMID: 34667518 DOI: 10.1055/s-0041-1734572

Background It is important to correctly determine the ideal female breast anatomy and aesthetic proportions in order to prepare for surgery and establish its goals. Leaving the preference to the operating surgeons alone might leave unsatisfactory results, which especially leads to reoperation, quite often in the aspect of breast dimension. Methods This study was conducted using an online graphic questionnaire. We attempted to seek male and female perspectives toward their preferred ideal female breast size for breast augmentation, in order to provide up-to-date data to assist breast surgeons in attaining satisfactory surgical results. Results Sixty males and 67 females participated in the study comprising Asian major ethnicities of Malay, Chinese, and Indian. Universally, 46.6% of men and 53.5% of women preferred 30 mm diameter for the most ideal nipple-areola complex (NAC) size. For the perfect bust, they generally favored size C and D cup (37.8% and 38.5%, respectively). Conclusion The majority of women seek natural breast beauty and the longing for an oversized look appears to have infiltrated practice but these assumptions have finally been challenged by these findings.
Fulltext Skin Microcirculatory Changes in Relation to Arteriovenous Fistula Maturation

Chai SC, Sulaiman WAW, Saad AZM, Rasool AH, Shokri AA

Indian J Nephrol, 2019 1 17;28(6):421-426.
PMID: 30647495 DOI: 10.4103/ijn.IJN_402_17

Maturation of arteriovenous fistula (AVF) involves complex vascular remodeling. In this study, we evaluated the changes of skin microvascular perfusion over the extremity with AVF maturation using the laser Doppler fluximetry (LDF). A total of 45 patients with chronic kidney disease, Stages IV-V, were included; they had undergone AVF creation from July 2014 to June 2016 at our institute. The measurement of skin microvascular perfusion was accomplished proximal and distal to the fistula anastomosis site: pre- and post-operative day 1, week 2, week 6, and week 12. Thirty-two patients with mean age of 55.6 had achieved AVF maturation. There were 40.6% radial-based and 59.4% brachial-based AVF. There was a 32.8% reduction of mean skin perfusion distal to the fistula by day 1 compared to the baseline perfusion; however, perfusion increased 47% by week 2 compared to day 1 and no dramatic change was subsequently noted. There was an increase of mean skin perfusion, proximal to fistula anastomosis, over 12 weeks with 35.8% at day 1 from the baseline. However, the changes of the mean skin perfusion were not statistically significant. There was no significant relation of skin perfusion changes with the type of fistula, diabetes mellitus, hypertension, and hyperlipidemia. LDF successfully detected the subclinical change of skin microvascular perfusion in relation to AVF creation. Reduction of skin perfusion distal to the fistula suggests that in patients with existing perfusion inadequacy of extremities, they may experience ischemic symptoms as early as day 1 postoperation, and require close monitoring for distal limb ischemic-related complications.
Fulltext A harmless evil: Giant fungating benign breast mass in an adolescent mimicking malignancy - Case report

Heng SSL, Yahya MM, Sulaiman WAW, Saad AZM

Int J Surg Case Rep, 2021 Mar;80:105202.
PMID: 33500231 DOI: 10.1016/j.ijscr.2020.10.096

INTRODUCTION: Juvenile giant fibroadenoma is a rare type of fibroadenoma characterized by rapid growth of a breast tumor in an adolescent. Benign in nature, they rarely present as fungating and ulcerating tumors. Benign tumors masquerading as malignancies are surgical conundrums. No co nsensus exists yet on the management of these cases. We aim to discuss the dilemma in managing a bleeding, fungating giant fibroadenoma in an adolescent female and highlight risks of alternative therapies.
PRESENTATION OF CASE: A 19-year-old lady presented with a bleeding, fungating breast mass worsened with topical herbal concoction. Examination revealed a 10 × 15 cm fungating breast mass that obliterated her nipple- areolar complex (NAC). Computed Tomography (CT) scan reported a huge heterogeneously enhancing mass 10.6 × 14.5 × 15.1 cm with loss of normal fat plane with the overlying skin but a clear fat plane with the pectoralis muscle posteriorly.
DISCUSSION: Giant breast masses that fungate and ulcerate usually indicate a sinister pathology. Traditional remedies have been reported to exacerbate growth. In cases where most of the breast parenchyma and NAC has been destroyed, it is no longer possible to proceed with breast conserving techniques. Breast reconstruction is crucial in adolescents and should be tailored to the patient's existing breast size as well as body habitus.
CONCLUSION: In juvenile giant fibroadenomas where breast parenchyma and NAC has been destroyed, breast reconstruction is the goal. The lack of consensus in both diagnosis and management further compounds the difficulty in dealing with this sensitive population. Awareness needs to be raised regarding negative effects related to traditional medicine.
Fulltext Lower eyelid fornix deepening: A new indication for the facial artery myomucosal flap

Saad AZM, Nordin NR, Sulaiman WAW, Jamayet N, Johar SFNM, Hussein A

Arch Plast Surg, 2021 Jan;48(1):80-83.
PMID: 33503749 DOI: 10.5999/aps.2020.00206

Eye socket contracture is a well-known late complication of enucleation surgery, and the additional insult of radiotherapy at an early age causes even further fibrosis and scarring of the socket. Management of the contracted socket is challenging, and several methods have been proposed. We report a case of eye socket contracture after enucleation and radiotherapy in which multiple reconstructive procedures failed. The recurrent contracture caused difficulty in housing and retaining the eye prosthesis. We reconstructed the lower eyelid with a facial artery myomucosal flap and nasolabial flap, and the upper eyelid with a Fricke flap following reconstruction of the orbital rims (supraorbital and infraorbital rims with a calvarial bone graft, and further augmentation of the infraorbital rim with a rib bone graft). Cosmesis post-reconstruction was acceptable and the prosthesis was retained very well.
Fulltext Is Ebola a sexually transmitted disease? Implication of Ebola RNA persistence in the semen

Sulaiman WAW, Mat LNI, Hoo FK, Mohamed MH, Lim SMS

J Infect Public Health, 2017 07 27;11(2):299.
PMID: 28757292 DOI: 10.1016/j.jiph.2017.07.015
Fulltext Guillain-Barré syndrome complicating dengue fever: Two case reports

Boo YL, Aris MAM, Chin PW, Sulaiman WAW, Basri H, Hoo FK

Ci Ji Yi Xue Za Zhi, 2015 11 17;28(4):157-159.
PMID: 28757747 DOI: 10.1016/j.tcmj.2015.09.007

Guillain-Barré syndrome is a rare neurological manifestation associated with dengue infection. More common antecedent infections include Campylobacter jejuni and Cytomegalovirus infection. Here, we report two cases of Guillain-Barré syndrome complicating dengue infection.
Fulltext Incomplete anterior choroidal artery syndrome in a pregnant female

Mat LNI, Sulaiman WAW, Hoo FK, Apandi LMA, Basri H

Ci Ji Yi Xue Za Zhi, 2019 09 16;31(4):292-293.
PMID: 31867263 DOI: 10.4103/tcmj.tcmj_20_19
Patency of permanent vascular access creation in paediatric patients with end stage renal disease

Ho HL, Halim AS, Mat Saadk AZ, Sulaiman WAW, Ilias MI

Med J Malaysia, 2021 Sep;76(5):737-740.
PMID: 34508385

Renal transplant is the first-line therapy in paediatric patients with end-stage renal disease (ESRD). Wong HS and Goh BL reported up to 79% of 1061 paediatric patients still require long-term haemodialysis (HD).1 The lack of deceased and living donors is attributable to the poor awareness, cultural and religious grounds. Permanent vascular access (PVA) in paediatrics therefore, serves more as a long term treatment rather than a bridging therapy. We observed 5 children and an adolescent, all with previous indwelling catheters, who underwent arteriovenous fistula (AVF) creation and report the outcomes. The aim of this report is to determine the factors that influence the longterm patency of paediatric AVF. Factors such as body weight, vessel diameter, preoperative preparations, microsurgical technique and postoperative maintenance are discussed. In addition, considerations on the choice and timing of PVA is highlighted.
The fate of adipose tissue and adipose-derived stem cells in allograft

Farhana S, Kai YC, Kadir R, Sulaiman WAW, Nordin NA, Nasir NAM

Cell Tissue Res, 2023 Nov;394(2):269-292.
PMID: 37624425 DOI: 10.1007/s00441-023-03827-w

Utilizing adipose tissue and adipose-derived stem cells (ADSCs) turned into a promising field of allograft in recent years. The therapeutic potential of adipose tissue and ADSCs is governed by their molecular secretions, ability to sustain multi-differentiation and self-renewal which are pivotal in reconstructive, genetic diseases, and cosmetic goals. However, revisiting the existing functional capacity of adipose tissue and ADSCs and their intricate relationship with allograft is crucial to figure out the remarkable question of safety to use in allograft due to the growing evidence of interactions between tumor microenvironment and ADSCs. For instance, the molecular secretions of adipose tissue and ADSCs induce angiogenesis, create growth factors, and control the inflammatory response; it has now been well determined. Though the existing preclinical allograft studies gave positive feedback, ADSCs and adipose tissue are attracted by some factors of tumor stroma. Moreover, allorecognition is pivotal to allograft rejection which is carried out by costimulation in a complement-dependent way and leads to the destruction of the donor cells. However, extensive preclinical trials of adipose tissue and ADSCs in allograft at molecular level are still limited. Hence, comprehensive immunomodulatory analysis could ensure the successful allograft of adipose tissue and ADSCs avoiding the oncological risk.
Case Report: A Challenging Case of Tetanus Presenting with Headache

Rahim AIA, Azlan EAM, Rahman MR, Pathi NM, Ismail M, Sulaiman WAW

Am J Trop Med Hyg, 2023 Dec 06;109(6):1242-1244.
PMID: 37955309 DOI: 10.4269/ajtmh.23-0035

Tetanus is a life-threatening infectious neurological condition that has become uncommon due to large-scale immunization campaigns. We describe a rare instance of generalized tetanus presenting with a headache on a tropical island in Malaysia. A 43-year-old woman presenting with headaches and generalized body weakness, which progressed into trismus and neck stiffness. Her medical history indicated a wound on the sole of her foot caused by shattered glass in an unhygienic area, but no tetanus prophylaxis had been administered. The patient was subsequently given immunoglobulin, tetanus toxoid, metronidazole, and sedatives in the recommended dosages. Her neurological condition improved remarkably, but she suffered blood pressure fluctuations due to dysautonomia. She was successfully discharged with complete recovery after 6 months of follow-up. The case demonstrates the significance of appropriate identification and care of tetanus, as well as the lethal effects of untreated wounds in vulnerable patients.
Functional outcomes in total talus reconstruction with triangular double-barrel free fibula flap following oncological resection: A retrospective case series review

Rosli MA, Sulaiman WAW, Ismail WFW, Yahaya S, Saad AZM, Wan Z, et al.

J Plast Reconstr Aesthet Surg, 2021 Oct 07.
PMID: 34756555 DOI: 10.1016/j.bjps.2021.09.032

BACKGROUND: With the advent of new techniques, foot salvage is feasible following talus oncological resection. As the reconstruction aims to achieve a pain-free, stable ankle for ambulation, biological limb reconstruction is the best option. This case series will evaluate the primary indications, complications, and functional outcomes of the reconstructed talus and highlighting the technical aspects of the surgery with a novel technique of triangular double-barrel free fibula flap.
METHODS: We performed a retrospective case note review of patients undergoing foot salvage surgeries and primary talus reconstruction with double-barrel free fibula flaps between 2009 and 2019. Patient demographics, aetiologies, operative details, complications, and outcomes were analysed. All patients underwent the same talar reconstruction technique whereby a wide-based triangular framework was created from two bony struts of the osteotomized fibula. The Musculoskeletal Tumour Society (MSTS) scoring system was used to analyse the short- to mid-term functional outcomes.
RESULTS: Four consecutive patients with aggressive benign and malignant tumours were identified. They consist of three males and one female, with a median age of 32 (range 27-39). Patients were followed up for a median duration of 60 months (range 24-132). Two flaps were complicated with venous thromboses; however, all were salvageable following re-explorations. All patients achieved solid bony fusion with good functional and aesthetic outcomes. The median MSTS score was 74.5% (range 66-76). No donor site morbidity and local recurrence were reported.
CONCLUSION: The triangular double-barrel free fibular flap is a good option for limb salvage following total talus resection, with good short- to mid-term functional and aesthetic outcomes.
Spontaneous Bilateral Basal Ganglia Haemorrhage Secondary to Methanol Poisoning

Sohor NJ, Loh WC, Pang RY, Khan AH, Chia PK, Sulaiman WAW, et al.

Neurol India, 2023;71(6):1260-1262.
PMID: 38174472 DOI: 10.4103/0028-3886.391392

Methanol toxicity remains as major problem in the medical field.[1],[2],[3] With its active metabolite, formic acid often leads to severe metabolic acidosis and to some extend brain damaged.[4],[5],[6] We are reporting a case of brain hemorrhage at the right external capsule and left basal ganglia with mass effect and obstructive hydrocephalus in a methanol poisoning patient. A confused 29-year-old gentleman was brought into hospital. Initial investigation showed severe metabolic acidosis with raised anion gap. Initial brain CT scan was normal. Subsequently, serum methanol was reported to be high (112 mg/dL). Intravenous (IV) ethanol 10% was given without any delayed. As there was no improvement in his consciousness level, a repeat brain CT was performed and it showed multiple cerebral hemorrhage with obstructive hydrocephalus. Hence, clinicians should have high index of suspicion for cerebral hemorrhage in a patient with methanol toxicity, who presented with altered mental status and severe metabolic acidosis.
Fulltext Complementary alternative medicine use among patients with dengue fever in the hospital setting: a cross-sectional study in Malaysia

Ching SM, Ramachandran V, Gew LT, Lim SMS, Sulaiman WAW, Foo YL, et al.

BMC Complement Altern Med, 2016 Jan 29;16:37.
PMID: 26825057 DOI: 10.1186/s12906-016-1017-0

BACKGROUND: In Malaysia, the number of reported cases of dengue fever demonstrates an increasing trend. Since dengue fever has no vaccine or antiviral treatment available, it has become a burden. Complementary and alternative medicine (CAM) has become one of the good alternatives to treat the patients with dengue fever. There is limited study on the use of CAM among patients with dengue fever, particularly in hospital settings. This study aims to determine the prevalence, types, reasons, expenditure, and resource of information on CAM use among patients with dengue fever.
METHODS: This is a descriptive, cross-sectional study of 306 patients with dengue fever, which was carried out at the dengue clinic of three hospitals. Data were analysed using IBM SPSS Statistics version 21.0 and logistic regression analysis was used to determine the factors associated with CAM use.
RESULTS: The prevalence of CAM use was 85.3% among patients with dengue fever. The most popular CAMs were isotonic drinks (85.8%), crab soup (46.7%) and papaya leaf extract (22.2%). The most common reason for CAM use was a good impression of CAM from other CAM users (33.3%). The main resource of information on CAM use among patients with dengue fever was family (54.8%). In multiple logistic regression analysis, dengue fever patients with a tertiary level are more likely to use CAM 5.8 (95% confidence interval (CI 1.62-20.45) and 3.8 (95% CI 1.12-12.93) times than secondary level and primary and below respectively.
CONCLUSION: CAM was commonly used by patients with dengue fever. The predictor of CAM use was a higher level of education.
Study site: Dengue clinic, Hospital Serdang, Hospital Kajang and Hospital Kuala Lumpur, Selangor, Malaysia.
Fulltext Knowledge on the action to be taken and recognition of symptoms of stroke in a community: findings from the May Measurement Month 2017 blood pressure screening Programme in Malaysia

Ching S, Chia YC, Chew BN, Soo MJ, Lim HM, Sulaiman WAW, et al.

BMC Public Health, 2019 Nov 29;19(1):1602.
PMID: 31783831 DOI: 10.1186/s12889-019-7922-7

BACKGROUND: Information regarding the knowledge on the action to be taken during stroke and good recognition of stroke symptoms is mandatory in helping to plan out educational strategies to deliver health education to the community.
METHODS: This is a cross-sectional study of adults aged 18 and above attending a blood pressure screening program in community in conjunction with May Measurement Month 2017 in Malaysia. A structured self-administered questionnaire was given to the participants who gave verbal consent. Data analysis was done using SPSS v. 23 and multiple logistic regression was used to identify the determinants of knowledge on actions to be taken during stroke and recognition of stroke symptoms.
RESULTS: Out of 4096 respondents, 82.9-92.1% of them able to recognise the common stroke symptoms. and 74.2% of the study respondents will go to hospital within 4.5 h of stroke onset. According to binomial logistic regression analyses, adults aged 45 years old and above (OR 1.39 95%CI 1.01-1.92), being Malay (OR 1.74, 95% CI 1.27-2.40), being non-smokers (OR = 2.491, 95% CI: 1.64-3.78), hypertensives (OR: 1.57, 95% CI: 1.02-2.42)and diabetics (OR: 2.54, 95% CI:1.38-4.69) are determinants of right actions to be taken during stroke. Meanwhile, respondents aged 45 years old and older (OR = 1.68, 95% CI: 1.39-2.03), being Malay (OR = 1.49, 95% CI: 1.24-1.79), hypertensive (OR = 1.32, 95% CI: 1.04-1.66) and those who had a previous history of stroke (OR = 2.25, 95% CI: 1.01-5.00) are determinants of good recognition of stroke symptoms.
CONCLUSIONS: The overall knowledge of stroke in our study population was good. Older age, being Malay, non-smokers, hypertensives and diabetics are determinants of right actions to be taken during stroke. Meanwhile, older age, being Malay, hypertensive and those who had a previous history of stroke are determinants of good recognition of stroke symptoms.
Collapsed wall: destructive and reconstructive surgery of anterior abdominal wall tumour in a young girl

Che Ghazali K, Mazian HA, Keat KC, Kai MWP, Md Hashim MN, Zakaria AD, et al.

J Surg Case Rep, 2019 Feb;2019(2):rjy345.
PMID: 30788087 DOI: 10.1093/jscr/rjy345

Natural history of abdominal wall soft tissue sarcoma is still poorly understood due to its rarity. In unpublished data of our institution, only seven cases of abdominal wall soft sarcoma with ICD-10 coding of 49.4 were found for past 10 years. We illustrate a case of juvenile fibrosarcoma of anterior abdominal wall. This is a case of young girl with anterior abdominal wall tumour, underwent wide local excision with immediate reconstruction. There are few options of surgical treatment for this case, but which is the best. It is always a challenge in managing young patient with giant abdominal wall defect in view of long term effect namely weakened abdominal wall, pregnancy related issue and risk of herniation and surgical site recurrence as well.
A Review of Skin Banking Guidelines and Standards Worldwide: Towards the Harmonization of Guidelines for Skin Banking in Therapeutic Applications for the Regions under the Asia Pacific Burn Association (APBA)

Heng WL, Wang QW, Sornarajah R, Tremblay J, Putri NM, Hamid SSA, et al.

Burns Trauma, 2020;8:tkaa019.
PMID: 33123605 DOI: 10.1093/burnst/tkaa019

Currently, there are no harmonized guidelines which govern skin banking in the Asia Pacific region. Therefore, skin banks are either unregulated or rely on their nation's legislation or international accreditation to uphold their quality standards. A new set of skin banking guidelines was developed through a comprehensive review and collation of best international practices for the Asia Pacific Burn Association (APBA) members, from donor screening and testing, to skin recovery, processing, storage and distribution, and quality assurance. National regulatory requirements reviewed include the European directives, Australia's Therapeutic Goods Administration and Singapore's tissue banking standards. Further technical and quality management recommendations are referenced from the American Association of Tissue Banks (AATB), the United States Food and Drug Administration standards and guidance documents, various relevant European guides, Japanese Society of Tissue Transplantation guidelines and the Asia Pacific Association of Surgical Tissue Banking. Adapted mainly from the AATB standards, the new Asia Pacific Burn Association Guidelines for Skin Banking in Therapeutic Applications offer a comprehensive manual, addressing: governance and contracts; staff responsibilities; quality management; facilities, equipment and supplies management; donor consent and testing; and recommendations of good practices pertaining to skin recovery, processing, storage and distribution. Besides complementing current generic regulations, they provide technical specifications of major aspects unaddressed in most legislations. This inaugural set of new regional skin banking guidelines would be a start for regional members of the APBA to adopt, and will hopefully culminate in a set of standards so that, in the long run, skin allografts from this region can be of similar quality, which can simplify import process and facilitate the exchange of allografts between members.

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