Publications by authors named "Wan Azman Wan Sulaiman"

31 Publications

Heel Pad Reconstruction With Medial Plantar Flap.

Cureus 2021 Mar 19;13(3):e13987. Epub 2021 Mar 19.

Plastic and Reconstructive Surgery, Universiti Sains Malaysia School of Medical Sciences, Kota Bharu, MYS.

The heel of the foot is covered by highly specialized thick, glabrous skin containing fibroadipose tissue with numerous fibrous septae traversing the subcutaneous tissue, which acts as a shock-absorbent and prevents shearing of the skin. The loss of heel pad would cause interruption of the propelling function of the foot during walking. Therefore, heel pad reconstruction is an important procedure for wound closure in the acute phase and also functional reconstruction in delayed cases. We report a case of heel pad deformity in a patient who presented to us with left heel pain and inability to fully bear weight, which has caused her walking difficulty, following a road traffic accident. She sustained a degloving injury of the left foot and an open fracture of left calcaneum with ruptured Tendon Achilles in which the wound was initially addressed with failed reverse sural flap and the wound was allowed to heal by secondary intention. Delayed heel reconstruction was carried out with a propeller medial plantar flap and split skin graft. Postoperatively, the patient had improved functional and esthetic outcome.
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http://dx.doi.org/10.7759/cureus.13987DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8054947PMC
March 2021

Rapidly Growing Huge Lower Back Malignant Peripheral Nerve Sheath Tumour.

Cureus 2021 Mar 5;13(3):e13712. Epub 2021 Mar 5.

Plastic and Reconstructive Surgery, Universiti Sains Malaysia School of Medical Sciences, Kota Bharu, MYS.

Malignant peripheral nerve sheath tumours (also called neurofibrosarcomas) are a rare, highly aggressive soft tissue sarcomas that arise from the peripheral nerves or cells associated with the nerve sheath, such as Schwann cells, peri-neural cells and fibroblasts. It is representing 10% of all soft tissue sarcomas in which it is considered as an extremely rare malignancy, especially in patients with neurofibromatosis type I. In the general population, it affects approximately 1 in 100,000 people. This article is reporting a 56-year-old Malay female patient who is a known case of neurofibromatosis type I for 20 years, presented with a lower back, pruritic, gradually increasing swelling during the last five months. Last month before the presentation, the lesion rapidly grows, reaching a size of (15×15 cm), accompanied by foul-smelling discharge and pain exacerbated with movement. Although no history of preceding trauma or accident, the mass bleeds within contact. In conclusion, only a few cases of giant malignant peripheral nerve sheath tumours reported in the literature describing its location and growth progression. We present a massive, extremely rapid growth of cutaneous exophytic malignant peripheral nerve sheath tumours over the lower back.
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http://dx.doi.org/10.7759/cureus.13712DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8020617PMC
March 2021

Perception of the most perfect female breast shape among Malays, Chinese, and Indians community.

J Plast Surg Hand Surg 2021 Apr 11:1-8. Epub 2021 Apr 11.

Department of Medical Education, School of Medical Sciences, Universiti Sains Malaysia, Kota Bharu, Malaysia.

Researchers have long tried to search for the 'perfect' aesthetic outcome of breast surgery. Although lots of anthropometric studies have been done, there is no consensus when dealing with harmony, abstract, and proportion that make up for its ideal shape. This study was convened a survey to find the most perfect breast shape by assessing the upper pole contour and upper pole to lower pole ratio (UP:LP) preference among the Malays, Chinese, and Indians races. Hundred thirty-five individuals partook in this survey. Most of the participants generally preferred a more convex shape of upper pole contour with the Malay (50%) and Indian (35.7%) favored a more convex shape while the Chinese preferred it to be just slightly convex (42.8%). Single unmarried individuals (64.7%) significantly preferred a more convex upper pole contour ( = 0.018). The UP:LP ratio of 45:55 ( = 0.002) was the most significantly preferred proportion (37.8%) which largely comprised of the Chinese (51%), followed by Indian (21.6%) and Malay (19.6%). With these findings, using a controlled perception-preference method is a more preferred choice when describing an ideal breast shape as compare to an anthropometric measurement that might be less accurate. Therefore, breast and plastic surgeons alike need to look beyond the anthropometric numbers and should consider the other 'abstract' aesthetic shape which difficult to measure including the upper pole breast that has more convexity and the UP:LP ratio of 45:55 which showed to be the most aesthetically perfect form as agreed in the current works of literature.
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http://dx.doi.org/10.1080/2000656X.2021.1908313DOI Listing
April 2021

Prevention of firecracker injuries via the digital platform: A Malaysian experience.

Burns 2021 Feb 23. Epub 2021 Feb 23.

Reconstructive Sciences Unit, School of Medical Science, Universiti Sains Malaysia, Kubang Kerian, 16150 Kota Bharu, Kelantan, Malaysia; Hospital Universiti Sains Malaysia, Jalan Raja Perempuan Zainab II, Kubang Kerian, 16150 Kota Bharu, Kelantan, Malaysia.

Introduction: Health campaigns include physical campaigns in schools, community halls, or community malls. They can also be broadcast via television, newspaper, and radio. We launched a health campaign on social media platforms that have a powerful impact in this digital era.

Methods: A three-dimensional short animation was developed for the Burn and Blast Injury Awareness campaign. It was launched during the fasting month and Eid 2020 when firecracker-related injuries are highly incident in Malaysia. The video was launched primarily on Universiti Sains Malaysia (USM) and Wau Animation Sdn Bhd social media platforms. Each party shared the video on the top 3 social media platforms, which are Facebook, Instagram, and YouTube. The numbers of viewers, reaches, and shares, and demographic data were captured at 1 month after the release.

Results: We recorded 29,585 views, 60,920 reach, and 874 shares from the USM and Wau Animation platforms alone. The USM Facebook platform showed predominant female viewership (60%), whereas the Wau Facebook platform showed predominant male viewership (66%). In both platforms, the viewers were aged 18-34 years.

Conclusion: Health awareness campaigns on digital platforms are powerful because the message spreads faster, and it is also safe during the pandemic.
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http://dx.doi.org/10.1016/j.burns.2021.02.007DOI Listing
February 2021

Usual Presentation Has Odds: Unilateral Tibial Hemimelia in One of Dizygotic Twins.

Cureus 2021 Jan 21;13(1):e12834. Epub 2021 Jan 21.

Plastic and Reconstructive Surgery, Universiti Sains Malaysia School of Medical Sciences, Kubang Kerian, MYS.

Tibial hemimelia is a relatively rare congenital tibial longitudinal deficiency (approximately 1 per 1 million live births), unilateral or bilateral, with a relatively intact fibula. Hemimelia results from a disruption of the lower limb developmental field during embryogenesis due to slow or even abort of chondrification process, which results in leg length discrepancy. Affected leg commonly appears short and deformed with knee, ankle, and foot involvement. It may present with a variety of associated anomalies. Surgical treatment varies according to the type and degree of deformity, and reconstructive interventions are still limited. Reported cases of tibial hemimelia are very infrequent, especially tibial hemimelia in twins. Usually, the cases were in single embryo or less frequently in one of the monozygotic twins, but no reported cases regarding tibial hemimelia in one of the dizygotic twins as this article reports.
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http://dx.doi.org/10.7759/cureus.12834DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7899282PMC
January 2021

Lower eyelid fornix deepening: A new indication for the facial artery myomucosal flap.

Arch Plast Surg 2021 Jan 20;48(1):80-83. Epub 2021 Jan 20.

Department of Ophthalmology, School of Medical Sciences, Health Campus, Universiti Sains Malaysia, Kubang Kerian, Malaysia.

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.
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http://dx.doi.org/10.5999/aps.2020.00206DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7861970PMC
January 2021

A harmless evil: Giant fungating benign breast mass in an adolescent mimicking malignancy - Case report.

Int J Surg Case Rep 2021 Mar 28;80:105202. Epub 2020 Nov 28.

Reconstructive Sciences Unit, University of Sciences Malaysia, Kubang Kerian, 16150 Kelantan, Malaysia; Plastic, Reconstructive and Aesthetic Unit, Department of Surgery, University Malaysia Sabah, Sabah, Malaysia. Electronic address:

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.
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http://dx.doi.org/10.1016/j.ijscr.2020.10.096DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7982453PMC
March 2021

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).

Burns Trauma 2020 20;8:tkaa019. Epub 2020 Oct 20.

Transplant Tissue Centre, Singhealth Duke-NUS Transplant Centre, Singapore.

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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http://dx.doi.org/10.1093/burnst/tkaa019DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7573737PMC
October 2020

Blue rubber bleb nevus syndrome in a Malay girl: A case report and literature review.

Int J Surg Case Rep 2020 1;72:202-206. Epub 2020 Jun 1.

Department of Surgery, Faculty of Medicine and Health Sciences, Universiti Malaysia Sabah, Sabah, Malaysia. Electronic address:

Introduction: Blue Rubber Bleb Nevus Syndrome (BRBNS) also known as Bean's Syndrome is an atypical type of vascular malformation. To date, around 200 cases have been reported world-wide. In view of its low incidence rate, clinicians might misdiagnose and under treat. The key features of this syndrome are characterized by multiple cutaneous, soft tissue and gastrointestinal tract venous malformations.

Presentation Of Case: We report the first case of Blue Rubber Bleb Nevus Syndrome in Malaysia, a 23 years old Malay girl who suffers from multiple cutaneous venous malformation and gastrointestinal bleeding episodes.

Discussion: The typical morbidity for this syndrome is symptomatic anemia due to secondary iron deficiency due to the gastrointestinal venous malformation bleeding. In managing the gastrointestinal bleeding, it mainly depends on the severity of gastrointestinal bleeding, some may resolve spontaneously, while the others may be needing blood transfusion, and some may require GIT resections. As for cutaneous lesions, normally it is innocuous depending on the region and size. Large or problematic cutaneous venous malformation might benefit from sclerotherapy or excision.

Conclusion: Multidisciplinary approach is crucial in managing BRBNS case due to its complexity and the spectrum of multiple organ involvement to ensure the best outcome to the patient.
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http://dx.doi.org/10.1016/j.ijscr.2020.05.036DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7298517PMC
June 2020

True Median Cleft Lip-15 Years of Review and Prevalence.

Cleft Palate Craniofac J 2020 08 1;57(8):1051-1054. Epub 2020 Jun 1.

Reconstructive Science Unit, School of Medical Sciences, Universiti Sains Malaysia, Kota Bharu, Malaysia.

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.
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http://dx.doi.org/10.1177/1055665620926346DOI Listing
August 2020

The Practice of First Aid for Burn Injuries Among the Population of East Coast of Peninsular Malaysia for 2012-2016.

J Burn Care Res 2020 Jul;41(4):905-907

Reconstructive Sciences Unit, School of Medical Sciences, Health Campus, Universiti Sains Malaysia, Kelantan, Malaysia.

Burns are a devastating public health problem that result in 10 million disability-adjusted life-years lost in low- and middle-income countries. Adequate first aid for burn injuries reduces morbidity and mortality. The rate of proper first aid practices in other countries is 12% to 22%.1,2 A 5-year retrospective audit was performed on the database of the Burn Unit in Hospital Universiti Sains Malaysia for 2012-2016; this involved 485 patients from the east coast of Malaysia. The mean age of the patients is 17.3 years old. The audit on first aid practices for burn injury showed poor practice. Out of 485 burned patients, 261 patients (53.8%) claimed that they practiced first aid. However, only 24 out of 485 patients (5%) practiced the correct first aid technique where they run their burn wound under cool water for more than 20 minutes. Two hundred and twenty-two patients had not received any first aid. Two patients did not respond to the question on the first aid usage after burn injury. The mean age of patients who practiced first aid was 15.6 years old. Out of the 261 patients who practiced first aid, 167 (64%) run their wound under tap water for different durations. Others practiced traditional remedies such as the application of "Minyak Gamat" (6.5%), soy sauce (5.5%), other ointments (3.6%), milk (1.8%), and eggs (0.7%), as well as honey, butter, and cooking oil (0.4% each). First aid practices for burn injuries in the population of east coast Malaysia are still inadequate. The knowledge and awareness of school children and the general Malaysian population must be enhanced.
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http://dx.doi.org/10.1093/jbcr/iraa025DOI Listing
July 2020

Early outcomes of cleft and palatal width following anterior palate repair (vomerine flap) in infants with wide cleft lip and palate.

Arch Plast Surg 2019 Nov 15;46(6):518-524. Epub 2019 Nov 15.

Reconstructive Sciences Unit, School of Medical Sciences, Universiti Sains Malaysia, Kota Bharu, Malaysia.

Background: Anterior palatal repair performed during cleft lip repair using a vomerine flap may assist in recruiting additional soft tissue for subsequent completion of palatoplasty, especially in patients with a wide cleft. We present our early.

Results: in the hope of triggering a re-evaluation of this technique regarding its advantages for maxillary growth through further studies of patients with a wide cleft.

Methods: A retrospective analysis of patients with complete unilateral and bilateral cleft lip and palate was performed, including cleft and palatal measurements taken during initial surgery (lip repair together with anterior palate repair) and upon completion of palatoplasty.

Results: In total, 14 patients were included in this study, of whom nine (63.3%) had unilateral cleft lip and palate and five (37.5%) had bilateral cleft. All patients had a wide cleft palate. Lip and anterior palate repair was done at a median age of 3 months, while completion of palatoplasty was done at a median age of 10.5 months. Measurements taken upon completion of palatoplasty showed significant cleft width reduction in the mid-palate and intertubercle regions; however, the palatal arch distances at nearby landmarks showed non-significant marginal changes.

Conclusions: Anterior palate repair using a vomerine flap significantly reduced the remaining cleft width, while the palatal width remained. Further research is warranted to explore the long-term effects of this technique in wide cleft patients in terms of facial growth.
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http://dx.doi.org/10.5999/aps.2019.00227DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6882701PMC
November 2019

A 20-year experience of immediate mandibular reconstruction using free fibula osteocutaneous flaps following ameloblastoma resection: Radical resection, outcomes, and recurrence.

Arch Plast Surg 2019 Sep 15;46(5):426-432. Epub 2019 Sep 15.

Reconstructive Sciences Unit, School of Medical Sciences, Universiti Sains Malaysia, Kota Bharu, Malaysia.

Background: The mandible is an important structure that is located in the lower third of the face. Large mandibular defects after tumor resection cause loss of its function. This study assessed the outcomes and tumor recurrence after immediate mandibular reconstruction using a free fibula osteocutaneous flap following radical resection of ameloblastoma.

Methods: This is a retrospective non-randomized study of outcomes and tumor recurrence of all patients diagnosed with mandibular ameloblastoma from August 1997 until August 2017 (20 years) requiring free fibula osteocutaneous flap reconstruction at a single institution. The patients were identified through an electronic operative database; subsequently, their medical records and photo documentation were retrieved.

Results: Twenty-seven patients were included in this study. Eighteen patients were male, while nine were female. The majority of the patients (48.1%) were in their third decade of life when they were diagnosed with ameloblastoma. All of them underwent radical resection of the tumor with a surgical margin of 2 cm (hemimandibulectomy in cases with a large tumor) and immediate mandibular reconstruction with a free fibula osteocutaneous flap. Two patients required revision of a vascular anastomosis due to venous thrombosis postoperatively, while one patient developed a flap recipient site infection. The flap success rate was 100%. There was no tumor recurrence during a mean follow-up period of 5.6 years.

Conclusions: Mandibular ameloblastoma should be treated with segmental mandibulectomy (with a surgical margin of 2 cm) to reduce the risk of recurrence. Subsequent mandibular and adjacent soft tissue defects should be reconstructed immediately with a free fibula osteocutaneous flap.
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http://dx.doi.org/10.5999/aps.2018.01487DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6759441PMC
September 2019

Two novel genes TOX3 and COL21A1 in large extended Malay families with nonsyndromic cleft lip and/or palate.

Mol Genet Genomic Med 2019 05 28;7(5):e635. Epub 2019 Mar 28.

Hospital Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia.

Background: Nonsyndromic cleft lip and/or palate is one of the most common human birth defects worldwide that affects the lip and/or palate. The incidence of clefts varies among populations through ethnic, race, or geographical differences. The focus on Malay nonsyndromic cleft lip and/or palate (NSCL/P) is because of a scarce report on genetic study in relation to this deformity in Malaysia. We are interested to discuss about the genes that are susceptible to cause orofacial cleft formation in the family.

Methods: Genome-wide linkage analysis was carried out on eight large extended families of NSCL/P with the total of 91 individuals among Malay population using microarray platform. Based on linkage analyses findings, copy number variation (CNV) of LPHN2, SATB2, PVRL3, COL21A1, and TOX3 were identified in four large extended families that showed linkage evidence using quantitative polymerase chain reaction (qPCR) as for a validation purpose. Copy number calculated (CNC) for each genes were determined with Applied Biosystems CopyCallerTM Software v2.0. Normal CNC of the target sequence expected was set at two.

Results: Genome-wide linkage analysis had discovered several genes including TOX3 and COL21A1 in four different loci 4p15.2-p16.1, 6p11.2-p12.3, 14q13-q21, and 16q12.1. There was significant decreased, p < 0.05 of SATB2, COL21A1, and TOX3 copy number in extended families compared to the normal controls.

Conclusion: Novel linkage evidence and significant low copy number of COL21A1 and TOX3 in NSCLP family was confirmed. These genes increased the risks toward NSCLP formation in that family traits.
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http://dx.doi.org/10.1002/mgg3.635DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6503016PMC
May 2019

Collapsed wall: destructive and reconstructive surgery of anterior abdominal wall tumour in a young girl.

J Surg Case Rep 2019 Feb 8;2019(2):rjy345. Epub 2019 Feb 8.

Hospital Universiti Sains Malaysia, Universiti Sains Malaysia, Kota Bharu, Malaysia.

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.
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http://dx.doi.org/10.1093/jscr/rjy345DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6368141PMC
February 2019

Skin Microcirculatory Changes in Relation to Arteriovenous Fistula Maturation.

Indian J Nephrol 2018 Nov-Dec;28(6):421-426

Department of Orthopaedic, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia.

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.
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http://dx.doi.org/10.4103/ijn.IJN_402_17DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6309389PMC
January 2019

A prospective study evaluating wound healing with sea cucumber gel compared with hydrogel in treatment of skin graft donor sites.

Complement Ther Med 2018 Dec 4;41:261-266. Epub 2018 Oct 4.

Reconstructive Sciences Unit, School of Medical Sciences, Health Campus, Universiti Sains Malaysia, Kubang Kerian, Kelantan 16150, Malaysia; Hospital Universiti Sains Malaysia, Kubang Kerian, Kelantan 16150, Malaysia.

Background: Gamat (sea-cucumber) is a natural occurring fauna which is popularly used as traditional medication in Southeast Asian countries. There have been many animal studies done on its' biochemical properties and its' effects in vivo. The effect of gamat on human cutaneous wounds was studied using a split-skin graft donor site wound.

Methods: This was a comparative case-control study done on patients in Hospital Universiti Sains Malaysia (Hospital USM), requiring split-thickness skin grafting, whereby, the skin graft donor site was divided to almost equal halves, and applied with both gamat-based gel on one side, with Duoderm hydrogel on the other side. The epithelialization of the wounds was observed and compared on days 10, 14 and 21. Pain score, and pruritus score were also observed. Repeated measure analysis of variance (ANOVA) test and Paired t-test was used to test statistical significance accordingly.

Results: No significant differences were seen in rates of epithelialization of wounds on days 10, 14 and 21 (p > 0.01). No significant difference was also seen in the pain score and pruritus score (p > 0.01).

Conclusions: A gamat-based gel is comparable to conventional hydrogels in treatment of split-skin graft donor site. No adverse effects were observed in either group.
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http://dx.doi.org/10.1016/j.ctim.2018.10.006DOI Listing
December 2018

Outcome of the Modified Meek Technique in the Management of Major Pediatric Burns.

Ann Plast Surg 2018 09;81(3):295-301

Introduction: The modified Meek micrografting technique has been used in the treatment of severely burned patients and a number of articles have examined the use of the modified Meek technique in adults and in mixed-age groups. However, there is a paucity of research pertaining to the outcome in the pediatric age group. The aim of this study is to present our favorable outcome in pediatric major burns using the modified Meek technique.

Methods: A retrospective review of burn cases in Hospital Universiti Sains Malaysia from 2010 to 2015 was conducted. Cases of major burns among pediatric patients grafted using the Meek technique were examined.

Results: Twelve patients were grafted using the Meek technique. Ten (91.7%) patients were male, whereas 2 (8.3%) were female. The average age of patients was 6 years (range, 2-11 years). The average total body surface area was 35.4% (range, 15%-75%). Most burn mechanisms were due to flame injury (66.7%) as compared with scalds injury (16.7%) and chemical injury (16.7%). There was no mortality. All patients were completely grafted with a good donor site scar. The average graft take rate was 82.3%, although 8 cases had positive tissue cultures from the Meek-grafted areas. The average follow-up duration was 3.6 years (range, 1.1-6.7 years). Only 1 case developed contracture over minor joint.

Conclusions: The Meek technique is useful when there is a paucity of donor site in the pediatric group. The graft take is good, contracture formation is low, and this technique is cost-effective.
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http://dx.doi.org/10.1097/SAP.0000000000001565DOI Listing
September 2018

Functional Outcomes After Heel Pad Reconstruction: A Review of 7 Cases.

J Foot Ankle Surg 2017 Sep - Oct;56(5):1114-1120

Associate Professor and Consultant Plastic and Reconstructive Surgeon, Reconstructive Sciences Department, Hospital Universiti Sains Malaysia, Health Campus, Universiti Sains Malaysia, Kota Bharu, Malaysia.

Sensate, durable heel pad reconstruction is challenging. The present study assessed the functional outcomes after heel pad reconstruction using various flap techniques at our institution. From June 2011 to June 2016 (5-year period), 7 consecutive patients underwent heel pad reconstruction for various etiologies, with 3 microvascular free flaps (42.9%; 2 musculocutaneous flaps [66.7%] and 1 contralateral medial plantar flap [33.3%]) and 4 local pedicle flaps (57.1%; 3 instep medial plantar artery flaps [75.0%] and 1 distally based reverse sural flap [25.0%]). The patient records and demographic data were reviewed, and surgically related information was obtained and analyzed. The subjective components of the American Orthopaedic Foot and Ankle Society hindfoot clinical ratings scale were used to evaluate the pain and functional outcomes. Sensation was assessed using Semmes-Weinstein monofilaments, and ulcer recurrence was recorded. The mean age of the patients was 41.7 (range 11 to 70) years, the mean defect size was 59 (range 12 to 270) cm, and the mean follow-up duration was 22 (range 15 to 43) months. Complete flap survival was achieved without significant complications in all 7 patients. Patients treated with the sensate medial plantar artery flap recorded the highest mean American Orthopaedic Foot and Ankle Society score of 57.3 (maximum score of 60) and experienced a return of deep sensation at 6 (range 6 to 24) months and protective sensation at 1 year. This was followed by the reverse sural flap and the musculocutaneous flap. No recurrent heel ulceration was observed in our series of patients. In conclusion, the sensate medial plantar flap is a satisfactory method for coverage of small- to moderate-size heel defects.
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http://dx.doi.org/10.1053/j.jfas.2017.04.024DOI Listing
June 2018

Inconspicuous Nasoethmoidal Encephalocele Might Be Wrongly Diagnosed.

Arch Plast Surg 2016 May 18;43(3):291-2. Epub 2016 May 18.

Reconstructive Science Unit, School of Medical Sciences, Health Campus, Universiti Sains Malaysia, Kubang Kerian, Malaysia.

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http://dx.doi.org/10.5999/aps.2016.43.3.291DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4876161PMC
May 2016

Discovery of candidate genes for nonsyndromic cleft lip palate through genome-wide linkage analysis of large extended families in the Malay population.

BMC Genet 2016 Feb 11;17:39. Epub 2016 Feb 11.

School of Medical Sciences, Health Campus, Universiti Sains Malaysia, Kelantan, Malaysia.

Background: Nonsyndromic orofacial clefts are one of the most common birth defects worldwide. It occurs as a result of genetic or environmental factors. This study investigates the genetic contribution to nonsyndromic cleft lip and/or palate through the analysis of family pedigrees. Candidate genes associated with the condition were identified from large extended families from the Malay population.

Results: A significant nonparametric linkage (NPL) score was detected in family 100. Other suggestive NPL and logarithm of the odds (LOD) scores were attained from families 50, 58, 99 and 100 under autosomal recessive mode. Heterogeneity LOD (HLOD) score ≥ 1 was determined for all families, confirming genetic heterogeneity of the population and indicating that a proportion of families might be linked to each other. Several candidate genes in linkage intervals were determined; LPHN2 at 1p31, SATB2 at 2q33.1-q35, PVRL3 at 3q13.3, COL21A1 at 6p12.1, FOXP2 at 7q22.3-q33, FOXG1 and HECTD1 at 14q12 and TOX3 at 16q12.1.

Conclusions: We have identified several novel and known candidate genes for nonsyndromic cleft lip and/or palate through genome-wide linkage analysis. Further analysis of the involvement of these genes in the condition will shed light on the disease mechanism. Comprehensive genetic testing of the candidate genes is warranted.
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http://dx.doi.org/10.1186/s12863-016-0345-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4751652PMC
February 2016

Endothelium dependent hyperpolarization-type relaxation compensates for attenuated nitric oxide-mediated responses in subcutaneous arteries of diabetic patients.

Nitric Oxide 2016 Feb 6;53:35-44. Epub 2016 Jan 6.

Pharmacology Vascular Laboratory, School of Medical Sciences, Universiti Sains Malaysia, Health Campus, Kota Bharu, Malaysia. Electronic address:

Diabetes impairs endothelium-dependent relaxations. The present study evaluated the contribution of different endothelium-dependent relaxing mechanisms to the regulation of vascular tone in subcutaneous blood vessels of humans with Type 2 diabetes mellitus. Subcutaneous arteries were isolated from tissues of healthy controls and diabetics. Vascular function was determined using wire myography. Expressions of proteins were measured by Western blotting and immunostaining. Endothelium-dependent relaxations to acetylcholine were impaired in arteries from diabetics compared to controls (P = 0.009). Acetylcholine-induced nitric oxide (NO)-mediated relaxations [in the presence of an inhibitor of cyclooxygenases (COX; indomethacin) and small and intermediate conductance calcium-activated potassium channel blockers (UCL1684 and TRAM 34, respectively)] were attenuated in arteries from diabetics compared to controls (P < 0.001). However, endothelium-dependent hyperpolarization (EDH)-type relaxations [in the presence of indomethacin and the NO synthase blocker, l-NAME] were augmented in arteries from diabetics compared to controls (P = 0.003). Endothelium-independent relaxations to sodium nitroprusside (NO donor) and salbutamol (β-adrenoceptor agonist) were preserved, but those to prostacyclin were attenuated in diabetics compared to controls (P = 0.017). In arteries of diabetics, protein expressions of endothelial NO synthase, prostacyclin synthase and prostacyclin receptors were decreased, but those of COX-2 were increased. These findings suggest that in human diabetes, the impairment of endothelium-dependent relaxations is caused by a diminished NO bioavailability; however, EDH appears to compensate, at least in part, for this dysfunction.
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http://dx.doi.org/10.1016/j.niox.2015.12.007DOI Listing
February 2016

Long-term outcome of free fibula osteocutaneous flap and massive allograft in the reconstruction of long bone defect.

J Plast Reconstr Aesthet Surg 2015 Dec 19;68(12):1755-62. Epub 2015 Aug 19.

Orthopedics Oncology Unit, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Kelantan 16150, Malaysia.

Reconstruction of massive bone defects in bone tumors with allografts has been shown to have significant complications including infection, delayed or nonunion of allograft, and allograft fracture. Resection compounded with soft tissue defects requires skin coverage. A composite osteocutaneous free fibula offers an optimal solution where the allografts can be augmented mechanically and achieve biological incorporation. Following resection, the cutaneous component of the free osteocutaneous fibula flaps covers the massive soft tissue defect. In this retrospective study, the long-term outcome of 12 patients, who underwent single-stage limb reconstruction with massive allograft and free fibula osteocutaneous flaps instead of free fibula osteal flaps only, was evaluated. This study included 12 consecutive patients who had primary bone tumors and had follow-up for a minimum of 24 months. The mean age at the time of surgery was 19.8 years. A total of eight patients had primary malignant bone tumors (five osteosarcomas, two chondrosarcomas and one synovial sarcoma), and four patients had benign bone tumors (two giant-cell tumors, one aneurysmal bone cyst, and one neurofibromatosis). The mean follow-up for the 12 patients was 63 months (range 24-124 months). Out of the 10 patients, nine underwent lower-limb reconstruction and ambulated with partial weight bearing and full weight bearing at an average of 4.2 months and 8.2 months, respectively. In conclusion, augmentation of a massive allograft with free fibula osteocutaneous flap is an excellent alternative for reducing the long-term complication of massive allograft and concurrently addresses the soft tissue coverage.
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http://dx.doi.org/10.1016/j.bjps.2015.08.013DOI Listing
December 2015

Prognostic factors and survival rate of osteosarcoma: A single-institution study.

Asia Pac J Clin Oncol 2017 Apr 13;13(2):e104-e110. Epub 2015 Apr 13.

Department of Orthopaedics, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia.

Aim: Osteosarcoma is a highly malignant primary bone tumor. The study aim to evaluate the prognostic factors influencing the survival rate in our center.

Methods: This was a retrospective cohort study of all patients treated between January 2005 and December 2010.

Results: We included 163 patients with an age range of 6-59 years (median = 19). The median follow-up was 47 months (range 36-84). The overall survival in patients who completed chemotherapy and surgery (n = 117) was 72% at 2 years and 44% at 5 years. Histologically, 99 (85%) had osteoblastic, 6 (5%) had chondroblastic and 3 (2.5%) had telangiectatic osteosarcoma. Limb salvage surgery was performed in 80 (49%) and 41 (25%) underwent amputation. However, 46 patients (28%) underwent no surgical intervention and incomplete chemotherapy. In total, 38/79 patients had a good chemotherapy response. There was a significantly better survival rate for limb salvage versus amputation. Independent prognostic factors for survival are compliance to treatment and presence of lung metastasis.

Conclusion: The overall survival of osteosarcoma patients was influenced by the presence of pulmonary metastases and compliance to treatment. Histological subtype, different chemotherapy regimens and histological necrosis after chemotherapy did not significantly influence survival. The patients who did not complete treatment had significantly poorer survival.
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http://dx.doi.org/10.1111/ajco.12346DOI Listing
April 2017

Free saphenous venous flap and its modifications: Turbo- and supercharged.

Indian J Plast Surg 2014 Jan;47(1):147-9

Department of Reconstructive Science, School of Medical Sciences, Universiti Sains Malaysia, Kelantan, Malaysia.

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http://dx.doi.org/10.4103/0970-0358.129658DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4075207PMC
January 2014

Obesity indices and metabolic markers are related to hs-CRP and adiponectin levels in overweight and obese females.

Obes Res Clin Pract 2013 Jul-Aug;7(4):e315-20

Central Research Laboratory, School of Medical Sciences, Universiti Sains Malaysia, Kota Bharu, Malaysia.

Obese subjects had increased serum high sensitivity C-reactive protein (hs-CRP), decreased adiponectin levels, and impaired microvascular endothelial function compared to lean subjects. We investigated the relationships of serum hs-CRP, adiponectin and microvascular endothelial function with obesity indices and metabolic markers in overweight and obese female subjects. Anthropometric profile, body fat composition, biochemical analysis, serum hs-CRP and adiponectin levels, and microvascular endothelial function were measured in 91 female subjects. Microvascular endothelial function was determined using laser Doppler fluximetry and the process of iontophoresis. Mean age and body mass index (BMI) of subjects were 34.88 (7.87) years and 32.93 (4.82) kg/m(2). hs-CRP levels were positively correlated with weight, BMI, waist circumference, hip circumference, body fat and visceral fat. Adiponectin levels were positively correlated with insulin sensitivity index (HOMA-%S), and inversely correlated with waist hip ratio, triglyceride, fasting insulin and insulin resistance index (HOMA-IR). No relationship was seen between microvascular endothelial function and obesity indices, and metabolic markers. In overweight and obese female subjects, hs-CRP levels were correlated with obesity indices while adiponectin levels were inversely correlated with obesity indices and metabolic markers. No significant relationship was seen between microvascular endothelial function with obesity indices and metabolic markers including hs-CRP and adiponectin in female overweight and obese subjects.
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http://dx.doi.org/10.1016/j.orcp.2012.05.002DOI Listing
July 2014

Reduced expression of prostacyclin synthase and nitric oxide synthase in subcutaneous arteries of type 2 diabetic patients.

Tohoku J Exp Med 2013 11;231(3):217-22

Pharmacology Vascular Laboratory, School of Medical Sciences, Universiti Sains Malaysia, Health Campus.

Diabetic endothelial dysfunction is characterized by impaired endothelium-dependent relaxation. In this study, we measured the expression of endothelial nitric oxide synthase (eNOS), cyclooxygenase-1 (COX-1), cyclooxygenase-2 (COX-2), prostacyclin synthase (PGIS), and prostacyclin receptor (IP) in subcutaneous arteries of type-2 diabetic and non-diabetic patients. Subcutaneous arteries were dissected from tissues from seven diabetics (4 males and 3 females) and seven non-diabetics (5 males and 2 females) aged between 18 to 65 years, who underwent lower limb surgical procedures. Diabetics had higher fasting blood glucose compared to non-diabetics, but there were no differences in blood pressure, body mass index and age. Patients were excluded if they had uncontrolled hypertension, previous myocardial infarction, coronary heart disease, renal or hepatic failure and tumor. The relative expression levels of eNOS, COX-1, COX-2, PGIS and IP receptor were determined by Western blotting analysis, normalized with the β-actin level. Increased expression of COX-2 was observed in subcutaneous arteries of diabetics compared to non-diabetics, whereas the expression levels of eNOS and PGIS were significantly lower in diabetics. There were no significant differences in expression levels of COX-1 and IP receptor between the two groups. Immunohistochemical study of subcutaneous arteries showed that the intensities of eNOS and PGIS staining were lower in diabetics, with higher COX-2 staining. In conclusion, type-2 diabetes is associated with higher COX-2 expression, but lower eNOS and PGIS expression in subcutaneous arteries. These alterations may lead to impaired endothelium-dependent vasodilatation, and thus these proteins may be potential targets for protection against the microvascular complications of diabetes.
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http://dx.doi.org/10.1620/tjem.231.217DOI Listing
November 2013

Mutation screening of IRF6 among families with non-syndromic oral clefts and identification of two novel variants: review of the literature.

Eur J Med Genet 2012 Jun 3;55(6-7):389-93. Epub 2012 Mar 3.

Human Genome Center, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia.

Non-syndromic oral clefts share the main clinical features of Van der Woude Syndrome (VWS), with the exception of the lower lip pit. Thus, about 15% of VWS cases are indistinguishable from cases with non-syndromic oral clefts. IRF6 mutations are the major cause of VWS; however, variants in this gene show strong association with non-syndromic oral clefts, with a higher increased risk among cases with cleft lip only (CLO). A total of 39 individuals, including 16 patients with CLO and 23 patients with a family history of cleft, were examined for IRF6 mutations in the present study. Seven variants, including five known (c.-75-4 A>; G, c.-73T>; C, c.459G>; T 5, c.820G>; A, and c.1060 + 37C>; T) and two novel (c.-75-23G>; C and c.1380G>; T), were found. Both novel variants were inherited from non-affected parents and we did not find also in the 120 control chromosomes. In silico analysis revealed that both c.1380G>; T and c.-75-23G>; C variants may disrupts a putative exonic splicing enhancer and intronic splicing binding site for SC35, respectively. Taken together, the presence of deleterious IRF6 variants in patients with non-syndromic oral clefts could be most likely an evidence for VWS. While, IRF6 variants could, at best, contribute to clefting as part of a complex inheritance pattern, with both additional genes and environmental factors having a role.
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http://dx.doi.org/10.1016/j.ejmg.2012.02.006DOI Listing
June 2012

Contribution of MSX1 variants to the risk of non-syndromic cleft lip and palate in a Malay population.

J Hum Genet 2011 Nov 25;56(11):755-8. Epub 2011 Aug 25.

Human Genome Center, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia.

Oral clefts are clinically and genetically heterogeneous disorders that are influenced by both genetic and environmental factors. The present family-based association study investigated the role of the MSX1 and TGFB3 genes in the etiology of non-syndromic oral cleft in a Malay population. No transmission distortion was found in the transmission disequilibrium analysis for either MSX1-CA or TGFB3-CA intragenic markers, whereas TGFB3-CA exhibited a trend to excess maternal transmission. In sequencing the MSX1 coding regions in 124 patients with oral cleft, five variants were found, including three known variants (A34G, G110G and P147Q) and two novel variants (M37L and G267A). The P147Q and M37L variants were not observed in 200 control chromosomes, whereas G267A was found in one control sample, indicating a very rare polymorphic variant. Furthermore, the G110G variant displayed a significant association between patients with non-syndromic cleft lip, with or without cleft palate, and normal controls (P=0.001, odds ratio=2.241, 95% confidence interval, 1.357-3.700). Therefore, these genetic variants may contribute, along with other genetic and environmental factors, to this condition.
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http://dx.doi.org/10.1038/jhg.2011.95DOI Listing
November 2011

Contribution of variants in and near the IRF6 gene to the risk of nonsyndromic cleft lip with or without cleft palate in a Malay population.

Am J Med Genet A 2011 Sep 10;155A(9):2302-7. Epub 2011 Aug 10.

Human Genome Center, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia.

Several studies have shown evidence for the contribution of interferon regulatory factor 6 (IRF6) variants to the risk of nonsyndromic oral clefts in Asians; however, this has not included the Malay population. The current study attempts to address this research gap using allele and haplotype transmission disequilibrium analyses. The results showed a strong transmission distortion for multiple haplotypes to patients with nonsyndromic cleft lip with or without cleft palate. Haplotypes carrying the 243 bp allele of D1S2136 and common alleles at the rs861019 and rs2235371 were over-transmitted to patients. By contrast, haplotypes consisting of the 251 bp allele of D1S2136 and the rare allele at rs2235371 were more under-transmitted. Furthermore, several variants and haplotypes showed excess maternal transmission, but none of them attained statistical significance in maternal relative risk analyses. In contrast, a significant child genotype effect was observed for several haplotypes, indicating fetal genotype could be the major genetic contribution rather than maternal genotype. The present study therefore further supports a role for IRF6 variants in clefting in this Southeast Asian population. Overall, Asian genetic backgrounds are most likely more susceptible to the haploinsufficiency of IRF6 variants. These variants may contribute to the condition either themselves, or they may be in linkage disequilibrium with other casual variants.
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http://dx.doi.org/10.1002/ajmg.a.34169DOI Listing
September 2011