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2.  The effect of recombinant hirudin on rabbit ear flaps with venous insufficiency 
The effect of recombinant hirudin, which is the most powerful antithrombotic agent, on flaps with venous insufficiency was investigated. Oedema and congestion are frequent on flaps, causing necrosis unpredictably. Venous insufficiency and thrombosis are experimentally and clinically more frequent than arterial occlusion. Twenty-one adult New Zealand rabbits were used in this study. Skin flaps (3 × 6 cm) were elevated on a 1-cm-wide pedicle on rabbit ears. The artery, nerve, and vein were exposed and examined with the aid of a surgical microscope. Venous insufficiency was established by cutting the vein and nerve. In the control group, no additional surgical or medical procedures were performed and the ear flap was inset to its original location. Subcutaneous low molecular weight heparin (LMWH; 320 IU/kg) was administered to a second group of rabbits after the same surgery, and recombinant hirudin (2 μg) was administered via the pedicle artery 5 minutes after the vein and nerve were bound and cut in a third group of rabbits. Compared with control and LMWH groups on day 3 and 7, the hirudin-treated group had less hair loss, lower oedema scores and less haematoma formation. Furthermore, a lower size of necrotic areas and an increase in the circulating area on day 7 was found in the hirudin-treated group. In addition, angiography revealed new vessel development (neovascularisation) only in the hirudin group. On histologic sections, hirudin-treated animals had lower oedema, inflammation and congestion scores than animals in the other two groups. Thus, when administered into the ear flap through the pedicle as a pure recombinant preparation, hirudin increased flap survival by its antithrombotic effects and by accelerating neoangiogenesis. Recombinant hirudin may be used in clinical practice to treat flaps with venous problems and to increase survival rates.
PMCID: PMC4075196  PMID: 24987213
Flap; hirudin; venous insufficiency
3.  Education in plastic surgery: Are we headed in the right direction? 
Plastic surgery in India is in an era of transition. The speciality faces many challenges as it grows. The present study attempts to identify these challenges and the prevalent mood among the teachers and the trainees.
Materials and Methods:
The study was conducted from September 2011 to June 2012. In an E-mail based survey a questionnaire was mailed to professionals actively involved in teaching and training of residents in plastic surgery in many institutes running MCh courses in plastic surgery (Group I) [Appendix 1]. Another questionnaire was mailed to residents undergoing training in plastic surgery and those who had completed their training within past 2 years (Group II) [Appendix 2]. Chi-square test was applied to test for statistical significance.
29 Group I and 33 Group II subjects responded to the questionnaire. While 72.4% teachers believed that the current system is producing plastic surgeons with enough skill level, only 9.1% of the respondents in Group II thought the same (Chi-square = 28.1; df = 2; P < 0.001). Whereas 58.6% Group I respondents thought that their student is sufficiently equipped to compete in today's scenario [Figure 1], only 18.2% Group II respondents thought that their training is enough [Figure 2]. (Chi-square = 16.4; df = 2; P < 0.001). Nearly 28% respondents in Group I and only 3% in Group II thought that scientific research and publications should be made mandatory for successful completion of plastic surgery training (Chi-square = 9.4; df = 2; P = 0.009). Adequate exposure was thought to be available in general plastic surgery (Group I: 92% Group II: 81%), maxillofacial surgery (Group I: 72% Group II: 68%) and hand surgery (Group I: 84% Group II: 69%). Both groups agreed that exposure is lacking in craniofacial surgery, aesthetic surgery and microvascular surgery. Aesthetic surgery (38.7%) and microvascular surgery (32.6%) were the most frequent response when the Group II respondents were enquired about the subspeciality they would like to focus on in their practice. Inter-departmental exchange of students for limited period of time was favoured by 86.2% of Group I respondents and 93.9% Group II respondents (Chi-square = 1.3; df = 2; P = 0.49).
The current training programme is differently perceived by teachers and the trainees. We recommend that constant deliberations at national and regional forums should take place regarding our education and training programmes.
PMCID: PMC4075197  PMID: 24987214
Education; plastic surgery; survey; teachers; training; trainees
4.  Total upper eyelid reconstruction by single staged malar-cheek flap 
We report a case of total upper eyelid reconstruction by a new technique after excision of an eyelid tumour. The eyelid was reconstructed by a horizontal, laterally based flap from just under the lower eyelid combined with a chondro-mucosal graft from the nasal septum. Surgical outcome was an excellent aesthetically reconstructed eyelid, which was mobile and properly gliding on the globe to achieve complete eye closure.
PMCID: PMC4075198  PMID: 24987215
Eyelid tumour; sebaceous carcinoma; upper eyelid reconstruction
5.  Palmar arch reconstruction using dorsal venous arch of foot for revascularisation of multiple digits 
A case of trauma causing total loss of superficial and deep palmar arches of hand with ischemia of all the digits was managed using dorsal venous arch of the foot to reconstruct the palmar arch. The ends of the venous arch were anastomosed to radial and ulnar arteries and the tributaries to the arch were coapted to the cut ends of the common digital vessels and princeps pollicis. The surgery yielded gratifying results, successfully revascularising all the digits.
PMCID: PMC4075199  PMID: 24987216
Dorsal venous arch graft; finger revascularization; palmar arch reconstruction
6.  Anomalous superficial ulnar artery based flap 
Upper limb shows a large number of arterial variations. This case report describes the presence of additional superficial ulnar artery which was used to raise a pedicle flap to cover an arm defect thus avoided using the main vessel of the forearm - radial or ulnar artery. Vascular anomalies occurring in the arm and forearm tend to increase the likelihood of damaging the superficial anomalous arteries during surgery. Superficial ulnar or radial arteries have been described to originate from the upper third of the brachial artery; here we report the origin of the anomalous superficial ulnar artery originating from the brachial artery at the level of elbow with the concomitant presence of normal deep radial and ulnar arteries.
PMCID: PMC4075200  PMID: 24987217
Anomalous artery based flap; arterial variations of the forearm; superficial ulnar artery based flap
7.  Custom-made approach to a patient with post-burn breast deformity 
Second and third degree burns on breasts at preadolescent period may cause severe breast deformations. This deformation can be variable depending on severity and location of the burns, personal adolescent patterns, and treatment modality in acute burn period. A 21 year old female patient admitted to our department for her breast deformation due to burn contracture at the inferior pole of the right breast. On physical examination we defined that development of the volume of the right breast was equal to the left, and inferior pole of the right breast was flattened due to contracture, and nipple was projected to inferior. We found that inframammary crease of the right breast was 2 cm lower than that of left; andthe distance of nipple-inframamary crease was 4.7 cm while areola-inframmary crease was 2 cm. New nipple-areola complex level was identified according to left breast's level. Medial and lateral lines were planned to merge inferiorly at 2 cm above inframmary crease in a plan similar to vertical mammaplasty. Superior pedicle carrying nipple areola was desepitelised. Lower parenchymal V flap was transposed superiorly and attached to the pectoral muscle. Inferior parts of the lateral and medial glandular flaps were excised to form new inframammary crease. The desired laxity of skin at the lower pole was obtained by performing a new Z- plasty between lateral and medial skin flaps. Breast symmetry was confirmed by postoperative objective measurements between left and right breasts. Patient's satisfaction and aesthetic appearance levels were high. Breasts deformation patterns caused by burns, trauma and mass exsicion due to cancer could not be addressed with traditional defined techniques. Special deformations can be corrected by custom made plannings as we presented here.
PMCID: PMC4075201  PMID: 24987218
Burn; burn contracture; post-burn breast deformity
8.  Successful combined approach to a severe Fournier's gangrene 
We present a case of a successful reconstruction of a severe Fournier's gangrene (FG) involving the scrotum, the perineum, the right ischial area and extended to the lower abdomen. There are many different surgical techniques to repair and reconstruct the defect following debridement in FG. The authors treated this complex wound using negative pressure wound therapy (NPWT), dermal regeneration template and a split-thickness skin graft. Complete recovery was achieved and no major complications were observed. The patient showed a satisfying functional and aesthetic result.
PMCID: PMC4075202  PMID: 24987219
Dermal regenerative template; fournier's gangrene; vacuum-assisted closure therapy
9.  Resolution of concomitant Achromobacter xylosoxidans burn wound infection without adjustment of antimicrobial therapy 
Achromobacter xylosoxidans is part of an emerging group of Gram negative bacterial infections with potentially severe sequelae, especially in the immunocompromised population such as burn patients. While antimicrobial therapy for patients with A. xylosoxidans bacteremia has been reported, the literature is scarce with regard to treatment in patients with positive tissue cultures only. Herein, we report our institution's experience with such a case and a brief review of the current literature on this micro-organism in the setting of non-bacteremic infection.
PMCID: PMC4075203  PMID: 24987220
Achromobacter xylosoxidans; alcaligenes xylosoxidans; burn; tissue culture
18.  Secondary bilateral cleft lip-nose deformity correction by rhinoplasty with simultaneous Abbe flap 
The purpose of this article is to review modification and outcome of secondary rhinoplasty along with Abbé flap for correction of secondary bilateral cleft lip deformity.
Materials and Methods:
A total of thirteen patients of secondary bilateral cleft lip-nose deformity having tight upper lip, lack of acceptable philtral column, Cupid's bow definition, irregular lip scars, and associated nasal deformity were selected. All the patients received Abbé flap and simultaneous nasal correction. All cases were treated during a period of three years. Mean patient age at the time of the operation was 21 years, and ranged from 16 to 27 years. The average follow-up period was three years.
Assessment of results was based on comparing preoperative and postoperative clinical photographs done by surgeon and patient relatives and patient satisfaction questionnaires. The columellar lengthening and upper lip vermillion correction achieved was satisfactory. There were no perioperative complications such as airway obstruction, bleeding, infection, wound disruption, or flap necrosis.
PMCID: PMC4075212  PMID: 24987200
Abbe flap; bilateral cleft lip; rhinoplasty
19.  Precision carving of costal cartilage graft for contour fill in aesthetic and reconstructive rhinoplasty 
Autogenous costal cartilage is a good option for large volume requirements in rhinoplasty, when septal or conchal cartilages do not suffice. Reluctance to use costal cartilage is due to apprehension of warping. However, warping can be avoided if we follow the principle of balanced section as advocated by Gibson and Davis. “Warping” can also be utilized to change the curvature of the graft.
Materials and Methods:
We have used 69 costal cartilage grafts as a solid piece for contour fill in rhinoplasty in 31 patients over the last 10 years. Principle of balanced section as advocated by Gibson and Davis was adhered to while carving the grafts, however some grafts were allowed to warp to get different sizes and shapes.
All the procedures were uneventful. Aesthetic appearance of all patients was satisfactory and acceptable to all the patients. In two cases, the dorsal graft minimally shifted to one side, but remained straight. In one patient, there was late appearance of distortion.
The mode of cartilage warping is predictable and it can be used to advantage. Apprehension to use costal cartilage graft is unjustified, as with precision carving a desired shape can be obtained.
PMCID: PMC4075213  PMID: 24987201
Autogenous cartilage; balanced section; costal cartilage graft; rhinoplasty; warping
20.  The management of non-melanocytic skin malignancies of the scalp and calvarium 
The management of advanced cutaneous malignancies has been controversial. Thirteen patients with nonmelanoma skin neoplasias that had invaded the bone of the calvarium and scalp were treated in our centre.
The purpose of this study was to evaluate our experience in treating these malignancies with scalp resection and full or partial thickness cranium reconstruction.
Patients and Methods:
From June 2008 to March 2012, thirteen patients with locally advanced tumours of the scalp invading the calvarium were treated with wide local excision of the scalp combined with an underlying craniectomy and dural resection if needed.
Using histopathological diagnosis eleven patients were diagnosed with basal cell carcinoma and two patients with squamous cell carcinoma. A full thickness cranium resection was performed in seven patients and partial in six patients.
These large cancers occasionally invade adjacent structures, as well as bone, presenting a challenging surgical problem. In general, giant rotational or island scalp flaps and free tissue transfers are needed to close the area. Finding clean margins are an important part of treating patients with bone involvement and can usually be attained using outer tabula curettage thus preventing unnecessary morbidity.
PMCID: PMC4075214  PMID: 24987202
Bone invasion; calvarium; non-melanocytic; reconstruction; scalp; skin malignancies
22.  Anatomic and mechanical considerations in restoring volume of the face with use of hyaluronic acid fillers with a novel layered technique 
Facial fillers have revolutionized the field of cosmetic facial rejuvenation as it has become the prime sought – after rejuvenation procedure offering youthful, 3-dimensional look with minimal invasiveness. Fillers are expensive and need to be redone periodically hence a sound understanding of structural basis on which they are laid is important in reducing the quantity of filler required in each sitting as well as increasing the longevity of results.
The aim of the following study is to analyse a novel method of facial filling “The pillars pyramids and tie beams (PPT)” technique and its advantages over the conventional methods.
Subjects and Methods:
A novel technique of injecting the facial fillers was employed on 67 patients visiting our clinic. These patients were followed-up for a period of 3 years.
We observed that the amount of filler material required in initial sitting remains the same, however the frequency of touch up visits is decreased and so is the amount of filler material required for follow-up injections.
Facial contour remodelling is being revolutionised by the new filler materials for volume augmentation and no uniform consensus has been reached on the techniques currently used in clinical practice. We advocate this novel PPT technique of facial filling in facial rejuvenation to restore a youthful look as a primary goal.
PMCID: PMC4075216  PMID: 24987203
Aging face; facial fillers; facial rejuvenation; hyaluronic acid
23.  Trans-nipple removal of fibro-glandular tissue in gynaecomastia surgery without additional scars: An innovative approach 
The established techniques that have been used to treat gynaecomastia are said to have relatively less patient satisfaction rate as they leave some visible scars or mild elevation over the nipple areola complex, resulting in aesthetically unsatisfactory results. Even the slightest elevation or smallest scar over nipple areola complex leave patients extremely self conscious and in a dilemma of having a second intervention to get rid of that blemish.
The aim of the study is to achieve - A flat chest without adding a scar and with no chances of re-occurrence of the condition. This article suggests an innovative approach to address the problem.
Materials and Methods:
The author presents trans-nipple incision approach for the delivery of fibro-glandular tissue component following liposuction for maximum patient satisfaction. This method consists of a unique small criss-cross incision right on the nipple itself for retrieving any volume of tough fibro-glandular tissues. Between the duration of January 2012 to October 2013, 28 male patients of different ages were operated with this technique.
The surgery resulted in well-shaped, symmetric chest contour without any visible elevation or additional scars on nipple areola complex. No complications were noticed in any of the patients.
The presented technique is proved to have a high patient satisfaction rate and to be promising method to achieve good aesthetic results in gynaecomastia surgery.
PMCID: PMC4075217  PMID: 24987204
Fibro-glandular tissue; gynaecomastia; innovative approach in gynaecomastia surgery; no additional scars; peri-areolar; trans-nipple
24.  Gynaecomastia correction: A review of our experience 
Gynaecomastia is a common problem in the male population with a reported prevalence of up to 36%. Various treatment techniques have been described but none have gained universal acceptance. We reviewed all gynaecomastia patients operated on by one consultant over a 7-year period to assess the morbidity and complication rates associated with the procedure.
Materials and Methods:
Clinical notes and outpatient records of all patients who underwent gynaecomastia correction at University Hospital North Staffordshire between 01/10/2001 to 01/10/2009 were retrospectively reviewed. A modified version of the Breast Evaluation Questionnaire was used to assess patients satisfaction with the procedure.
Twenty-nine patients and a total of 53 breasts were operated on during the study period. Patients underwent either liposuction alone (6 breasts - 11.3%), excision alone (37 breasts - 69.8%) or both excision and liposuction (10 breasts - 18.9%). Twelve operated breasts (22.6%) experienced some form of complication. Minor complications included seroma (2 patients), superficial wound dehiscence (2 patients) and minor bleeding not requiring theatre (3 patients). Two patients developed haematomas requiring evacuation in theatre. No cases of wound infection, major wound dehiscence or revision surgery were encountered. Twenty-six patients (89.7%) returned the patient satisfaction questionnaire. Patients scored an average 4.12 with regards comfort of their chest in different settings, 3.98 with regards chest appearance in different settings, and 4.22 with regards satisfaction levels for themselves and their partner/family. Overall complication rate was 22.6%. Grade III patients experienced the highest complication rate (35.7%), followed by grade II (22.7%) and grade I (17.6%). Overall complication rates among the excision only group was the highest (29.8%) followed by the liposuction only group (16.7%) and the liposuction and excision group (10.0%). There were high satisfaction rates amongst both patients and surgeon. Eleven patients (37.9%) had their outcome classified as ‘excellent’ by the operating surgeon, 16 patients (55.2%) as ‘good’, 1 (3.4%) as ‘satisfactory’ and 1(3.4%) as ‘poor’.
Gynaecomastia is a complex condition which poses a significant challenge to the plastic surgeon. Despite the possible complications our case series demonstrates that outcomes of operative correction can be favourable and yield high levels of satisfaction from both patient and surgeon.
PMCID: PMC4075218  PMID: 24987205
Plastic Surgery; University Hospital North Staffordshire; Correction; gynaecomastia; surgery
25.  Inter-observer reliability of clinical measurement of suprasternal notch-nipple distance and breast ptosis 
Suprasternal notch-nipple distance and breast ptosis are two measurements that are often used in everyday plastic surgical clinical practice. Nonetheless, the reliability of standard breast measurements has never been tested.
The aim of the present study was to test the inter-observer reliability of clinical measurement of ptosis and suprasternal notch-nipple distance.
Settings and Design:
Six raters measured ptosis and suprasternal notch-nipple distance in 12 breasts on the same day.
Statistical Analysis Used:
Intra-class correlation (ICC) coefficients, the coefficient of variation (CV) and Bland–Altman plots.
Results and Conclusions:
The results show that there is certain variation between different raters. The ICC of average measures between raters is 0.92 for the ptosis and 0.94 for the suprasternal notch-nipple distance, that is, the agreement between different raters is high. According to the Bland — Altman plots, the overall assessment of the comparisons of measurements between the different raters shows that the direction of the mean differences is close to zero. This study shows that there is a good reliability for measurements of suprasternal notch-nipple distance and ptosis. Nonetheless, there is a slight inter-rater variability in the measurements. Even though standardised, measurement of breasts is not an exact science and care has to be taken when the measurements are performed. The surgeon should have this in mind when measurements are used in clinical practice to evaluate breasts and to choose the right surgical method, as well as when guidelines for indications for surgery are set up.
PMCID: PMC4075219  PMID: 24987206
Breast measurements; breast ptosis; breast surgery; suprasternal notch-nipple distance

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