The currently available training models are being put to scrutiny in India today, both by the residents and the teachers. Plastic surgery specialty was created primarily for reconstructive purposes but the society always perceived it from a cosmetic angle, particularly in the post second world war era. As a result, there is a need to redefine the goals of plastic surgery training in the present times so that the plastic surgeon is “future ready” to meet the needs of society and the market forces.
Materials and Methods:
The author has reviewed the currently available literature on plastic surgery training from India and the western countries. An attempt has been made to study opinions from the teachers and the trainees. The modules currently available in India and abroad have been analyzed and a suggestion has been made for drafting training programs that would meet the demands of the society as well as prepare the resident both for the aesthetic and reconstructive practice.
The plastic surgery training needs to be more vibrant and in tune with the changing times. While maintaining its core nature, the current predominantly reconstructive modules need to incorporate the aesthetic content. The evaluation should be both knowledge and competence based. The teachers need to be educated in the various teaching methods that are more applicable to grown up residents. There is a need to find ways to attract talented people in the academic plastic surgery.
Course duration; evaluation; plastic surgery; reconstructive and aesthetic content; training
Sophisticated marketing and practice-enhancing strategies can help bring patients to a surgeon's practice. However, the ability to retain these patients and also convert the consultations into surgical procedures depends on the art of consultation. This very important aspect of clinical practice is seldom taught in the medical school. In this paper, the author discusses many aspects of the art of consultation, which he has learned in his practice over the years.
Advertising; consent; consultation; documentation; marketing; office décor; photography
The treatment of musculoskeletal sarcomas has made vast strides in the last few decades. From an era where amputation was the only option to the current day function preserving resections and complex reconstructions has been a major advance. The objectives of extremity reconstruction after oncologic resection include providing skeletal stability where necessary, adequate wound coverage to allow early subsequent adjuvant therapy, optimising the aesthetic outcome and preservation of functional capability with early return to function. This article highlights the concepts of surgical margins in oncology, discusses the principles governing safe surgical resection in these tumors and summarises the current modalities and recent developments relevant to reconstruction after limb salvage. The rationale of choice of a particular resection modality, the unique challenges of reconstruction in skeletally immature individuals and the impact of adjuvant modalities like chemotherapy and radiotherapy on surgical outcomes are also discussed.
Bone tumor; reconstruction; sarcoma
Treatment of cancer is race against time! Following radical excision, breathing, speech, mastication and swallowing are hampered. Face is invariably involved. Beside functional normalcy, excellent cosmetic restoration is necessary for patient's life quality. Primary wound healing, quick resumption of adequate oral intake, prompt initiation of chemo-radiotherapy has direct bearing on cure. Primary reconstruction with pedicle or free flap is the choice of treatment in most protocols. Composite defects are requiring bone, muscle and skin restrict choice of donor site and may have shortfalls in aesthetic and functional requirements. To improve further newer, and newer modalities are being developed and used to give best aesthetic and functions. Navigation, use of three-dimensional imaging, stereo lithic model and custom made implant for reconstruction are recommended as they promise improvement in aesthetics. Robotic surgeries allow access for resection of tumours and reconstruction with free flap in deep oropharynx obviating need of doing mandibulotomy. Researchers in stem cell and tissue engineering are looking forward to regenerating tissues and avoid the need of autologous tissue flaps. Desired tissue combination across counter may be available in the future. Excellent immunosuppressant drugs have made it possible to reconstruct composite facial anatomical units with allotransplant in a single surgery, along sensory and motor recovery! Mythological heterogenic head transplant like clone Ganesha, will be a reality in the near future!!
Head; mandible; reconstruction; transplant
Management of brachial plexus injury is a demanding field of hand and upper extremity surgery. With currently available microsurgical techniques, functional gains are rewarding in upper plexus injuries. However, treatment options in the management of flail and anaesthetic limb are still evolving. Last three decades have witnessed significant developments in the management of these injuries, which include a better understanding of the anatomy, advances in the diagnostic modalities, incorporation of intra-operative nerve stimulation techniques, more liberal use of nerve grafts in bridging nerve gaps, and the addition of new nerve transfers, which selectively neurotise the target muscles close to the motor end plates. Newer research works on the use of nerve allografts and immune modulators (FK 506) are under evaluation in further improving the results in nerve reconstruction. Direct reimplantation of avulsed spinal nerve roots into the spinal cord is another area of research in brachial plexus reconstruction.
Brachial plexus injuries; nerve grafts; recent advances; reimplantation of avulsed spinal nerve roots; selective nerve transfers
The social impact of entire cadre of medical graduates admitted through donation and management seats is yet to arrive. What has arrived are the burdens of complying with various acts and facing legal challengesduring medical practice. This article deals with some recent legal requirements for catering to plastic and cosmetic surgery patients.
Consent; Medical Visa; indemnity insurance; CPA
The aim was to assess the accuracy of three-dimensional anatomical reductions achieved by open method of treatment in cases of displaced unilateral mandibular subcondylar fractures using preoperative (pre op) and postoperative (post op) computed tomography (CT) scans.
Materials and Methods:
In this prospective study, 10 patients with unilateral sub condylar fractures confirmed by an orthopantomogram were included. A pre op and post op CT after 1 week of surgical procedure was taken in axial, coronal and sagittal plane along with three-dimensional reconstruction. Standard anatomical parameters, which undergo changes due to fractures of the mandibular condyle were measured in pre and post op CT scans in three planes and statistically analysed for the accuracy of the reduction comparing the following variables: (a) Pre op fractured and nonfractured side (b) post op fractured and nonfractured side (c) pre op fractured and post op fractured side. P < 0.05 was considered as significant.
Three-dimensional anatomical reduction was possible in 9 out of 10 cases (90%). The statistical analysis of each parameter in three variables revealed (P < 0.05) that there was a gross change in the dimensions of the parameters obtained in pre op fractured and nonfractured side. When these parameters were assessed in post op CT for the three variables there was no statistical difference between the post op fractured side and non fractured side. The same parameters were analysed for the three variables in pre op fractured and post op fractured side and found significant statistical difference suggesting a considerable change in the dimensions of the fractured side post operatively.
The statistical and clinical results in our study emphasised that it is possible to fix the condyle in three-dimensional anatomical positions with open method of treatment and avoid post op degenerative joint changes. CT is the ideal imaging tool and should be used on a regular basis for cases of condylar fractures.
Computed tomography; imaging; open reduction; three-dimensional; unilateral condyle fractures
Despite the improved techniques of repair of cleft palate, fistula occurrence is still a possibility either due to an error in the surgical technique or due to the poor tissue quality of the patient. Though commonly the fistula closure is established by use of local flaps but at times the site and the size of the fistula make use of local flaps for its repair a remote possibility. The use of tongue flaps because of the central position in the floor of the mouth, mobility and the diversity of positioning the flaps make it a method of choice for closure of anterior palatal fistulae than any other tissues. The aim of this study was to analyse the utility of tongue flap in anterior palatal fistula repair.
Materials and Methods:
We had 41 patients admitted to our hospital during the period 2006-2012 for repair of palatal fistula and were enrolled into the study. In the entire 41 cases, fistula was placed anteriorly. The size of the fistulae varied from 2 cm × 1.5 cm to 5.5 cm × 3 cm. The flaps were divided after 3-week and final inset of the flap was done.
Observation and Result:
None of the patients developed flap necrosis, in one case there was the dehiscence of the flap, which was reinset and in one patient there was bleeding. None of our patients developed functional deformity of the tongue. Speech was improved in 75% cases.
Leaving apart its only drawback of two-staged procedure and transient patient discomfort, tongue flap remains the flap of choice for managing very difficult and challenging anterior palatal fistulae.
Anteriorly based tongue flap; anterior palatal fistula; cleft palate repair; cleft lip repair; hyper nasality; speech
Healing ability of nonhealing chronic ulcers can be assessed by estimating hydroxyproline, total protein and enzymatic antioxidants such as glutathione peroxidase (GPx), glutathione S-transferase (GST) in the granulation tissue.
Materials and Method:
A total of 34 patients were analysed from two groups: Limited access dressing (LAD) group (n = 17) and conventional dressing group (n = 17).
Patients treated with LAD that exerts combination of intermittent negative pressure and moist wound-healing had shown a significant increase in the hydroxyproline (P = 0.026), total protein (P = 0.004), GPx level (P = 0.030) and GST level (P = 0.045).
Patients treated with LAD indicated significantly better anabolic effect on wound-healing compared to that of patients treated with conventional dressing.
Chronic ulcers; chronic wound-healing; enzymatic antioxidants; hydroxyproline; limited access dressing; total protein
Soft-tissue defects around the knees are common in injured limbs and in the same injury the leg is often involved and the thigh is spared. Furthermore due to pliable and relatively lax skin, we have used inferiorly based thigh flap to reconstruct defects around knee joint.
Aims and Objectives:
The aim of this study is to evaluate the use of inferiorly based thigh flap to cover soft-tissue defects over the proximal one-third of the leg, patellar region, knee, and lower thigh.
Materials and Methods:
This study was conducted during the period between October 2011 and February 2013. Inferiorly based anteromedial thigh fasciocutaneous flap was performed on 12 patients and inferiorly based anterolateral thigh fasciocutaneous flap on four patients. The sites of the soft-tissue defects included patellar regions, infrapatellar region, upper one-third of leg, lower thigh, and over the knee joint.
Patients were evaluated post-operatively in terms of viability of flap, the matching of the flap with the recipient site, and donor site morbidity. All the flaps survived well except one which developed distal marginal flap loss, one in which wound dehiscence was noticed, and two in which mild venous congestion was observed. Venous congestion in two patients subsided on its own within 3 days. One patient with wound dehiscence achieved complete healing by secondary intention. Patient who developed distal flap loss required debridement and skin grafting. No appreciable donor site morbidity was encountered. Skin colour and texture of the flap matched well with the recipient site.
The inferiorly based thigh flap is a reliable flap to cover the defect over proximal one-third of the leg, patellar region, knee, and lower thigh.
Defect around the knee joint; inferiorly based thigh flap; perforator based flap
Today, tubularized incised plate (TIP) urethroplasty is the most commonly performed operation for distal and mid-penile hypospadias. Reports from different centers worldwide confirm its nearly universal applicability and low complications rate.
Evaluation of the urethral plate characters and its effect on the outcome of TIP urethroplasty.
Materials and Methods:
Between 2010 and 2013, 100 children with primary distal penile hypospadias underwent TIP urethroplasty. Urethral plates were categorized as flat, cleft, and deeply grooved. Postoperatively, patients were followed-up for evaluation of meatal stenosis, fistula formation, and glandular dehiscence at 1st, 3rd and 6th months. Patients were followed-up for urethral calibration by urethral sound 8 Fr at 3rd and 6 months follow-up. Data were statistically analysed using Epi info program to correlate between the width, plate shape, and complications.
Mean age at surgery was 4.3 years. Patients were followed-up for an average period of 6.4 months. Pre-operative location of the meatus was reported as coronal in 46, subcoronal in 50 and anterior penile in 4 cases. Urethral plate characters were flat in 26 cases, cleft in 52, and deeply grooved in 22. Urethral plate width was >8 mm in 74 cases and <8 mm in 26. Patients with urethral plate <8 mm had a statistically significant higher fistula rate (P = 0.004) and failed 8 Fr calibrations in 26.9% (P = 0.01) compared with the patients with urethral plate >8 mm. In addition, we also founds higher fistula rate and failed 8 Fr calibrations in flat urethral plate.
An adequate urethral plate width (>8 mm) is essential for successful TIP repair. Lower success rates with flat plates may need buccal mucosal augmentation to improve the results.
Hypospadias; tubularized incised plate; urethra
Following massive weight loss (MWL) medial contouring of the thigh is frequently requested to improve appearance and function. Thigh lifting can be associated with significant complications. We present a case series of post bariatric patients undergoing thigh lift using staged the liposuction, a modified T incision and a buried de-epithelialised dermal flap.
Materials and Methods:
From January to December 2012, 21 consecutive patients underwent a modified medial thigh lift. A retrospective review of the case notes was performed to assess complications that occurred.
There were no major post-operative complications in terms of reoperation, hematoma, thromboembolism and no seromas. Seven patients, all of which were smokers had minor superficial wound healing complications. Aesthetic outcomes were satisfactory for all patients at a minimum follow-up of 6 months.
The modified ‘T’ incision with staged liposuction is described. We have found the technique to be useful for a variety of different thighs. It is a reproducible method for contouring the medial thigh in MWL patients. In this series, our overall complications were low, and no seromas occurred.
Combined liposuction; modified; thigh lift; buried dermal flap
The importance of adequate nutritional support in burned patients cannot be overemphasised. For adequate long-term compliance by the patients, diet should be formulated in accordance with their pre-burn dietary habits, religious beliefs, and tastes.
Patients and Methods:
A study was conducted in 42 consecutive patients suffering from 10% to 50% of 2nd and 3rd degree thermal burns with the aim to compare nutritional status, clinical outcome, and cost-effectiveness of vegetarian and non-vegetarian diets. The patients were divided into two groups depending upon their pre-injury food habits. Total calories were calculated by Curreri formula. Both groups were compared by various biochemical parameters, microbiological investigations, weight, status of wound healing, graft take, and hospital stay and they were followed for at least 60 days postburn.
The results were comparable in both groups. Vegetarian diet was found to be more palatable and cost-effective.
Vegetarian diet is a safe and viable option for the patients suffering from burn injury. The common belief that non-vegetarian diet is superior to vegetarian diet is a myth.
Burns; diet; non-vegetarian; vegetarian; wound healing
Blood volume measurement though important in management of critically ill-patients is not routinely estimated in clinical practice owing to labour intensive, intricate and time consuming nature of existing methods.
The aim was to compare blood volume estimations using trivalent chromium [51Cr(III)] and standard Evans blue dye (EBD) method in New Zealand white rabbit models and establish correction-factor (CF).
Materials and Methods:
Blood volume estimation in 33 rabbits was carried out using EBD method and concentration determined using spectrophotometric assay followed by blood volume estimation using direct injection of 51Cr(III). Twenty out of 33 rabbits were used to find CF by dividing blood volume estimation using EBD with blood volume estimation using 51Cr(III). CF is validated in 13 rabbits by multiplying it with blood volume estimation values obtained using 51Cr(III).
The mean circulating blood volume of 33 rabbits using EBD was 142.02 ± 22.77 ml or 65.76 ± 9.31 ml/kg and using 51Cr(III) was estimated to be 195.66 ± 47.30 ml or 89.81 ± 17.88 ml/kg. The CF was found to be 0.77. The mean blood volume of 13 rabbits measured using EBD was 139.54 ± 27.19 ml or 66.33 ± 8.26 ml/kg and using 51Cr(III) with CF was 152.73 ± 46.25 ml or 71.87 ± 13.81 ml/kg (P = 0.11).
The estimation of blood volume using 51Cr(III) was comparable to standard EBD method using CF. With further research in this direction, we envisage human blood volume estimation using 51Cr(III) to find its application in acute clinical settings.
Blood volume; Evans blue dye; measurement; trivalent chromium
One of the better options available to repair a large palatal defect is by employing a free flap. Almost all the times such free flaps are plumbed to facial vessels. The greatest challenge in such cases is the placement of the pedicle from palatal shelf to recipient vessels because there is no direct route available. As majority of large palatal fistulae are encountered in operated cleft palates there is a possibility of routing the pedicle through a cleft in the maxillary arch or via pyriform aperture. When such a possibility doesn’t exist the pedicle is routed behind the maxillary arch. We describe a novel technique of pedicle placement through a maxillary antrostomy, in this case report, where a large palatal fistula in a 16 year old boy was repaired employing a free radial artery forearm flap. The direct route provided by maxillary antrostomy is considered the most expeditious of all possibilities mentioned above.
Free radial artery forearm flap; large palatal fistula; maxillary antrostomy; palatal fistula repair
Camphor is a waxy white sublimating chemical derived from natural as well as synthetic sources and widely used in various communities worldwide for a number of medicinal, culinary, and religious reasons. Camphor is burnt as an offering to God in many religious communities. We report three incidences of self inflicted injury from burning camphor on the palm resulting in full thickness burns. Non-suicidal self-injury is socially unacceptable destruction or alteration of body tissue when there is no suicidal intent or pervasive developmental disorder and we have explored an association between this and burn injury. This report also highlights the unique social and cultural pattern of this burn injury and the importance of psycho-therapeautic help for these victims.
Camphor burns; full thickness burns; hand burns; non-suicidal self-injury; self-inflicted violence
We describe the reconstruction of high voltage electric burn injury with exposed shoulder joint by thoracoacromial artery perforator propeller flap based on the delto-pectoral perforators of thoracoacromial artery. The successful use of this propeller flap to cover the exposed shoulder joint in a case with limited local flap options demonstrates its use as an alternative technique.
Exposed shoulder joint; perforator in deltopectoral groove; reconstruction; thoracoacromial artery perforator propeller flap
A low-grade fibromyxoid sarcoma is a rare soft tissue tumour that has a tendency to develop in the deep soft tissue of young adults with potential for local recurrence or distant metastasis. We describe a 40-year-old female patient with a low-grade fibromyxoid sarcoma of the shoulder that had been excised twice in the past and then had recurred after a few months. A wide resection of this tumour with flap reconstruction was performed followed by radiation to the area. The patient had no evidence of local recurrence or distant metastasis at 2 years after surgery.
Evans tumour; low-grade fibromyxoid sarcoma; shoulder
Abdominoplasty is among the most commonly performed aesthetic procedures in plastic surgery. Despite high complication rate, abdominal contouring procedures are expected to rise in popularity with the advent of bariatric surgery. Patients with a history of gastric bypass surgery have an elevated incidence of small bowel obstruction from internal herniation, which is associated with non-specific upper abdominal pain, nausea, and a decrease in appetite. Internal hernias, when subjected to elevated intra-abdominal pressures, have a high-risk of developing ischemic bowel. We present a case report of patient with previous laparoscopic Roux-en-y gastric bypass who developed acute ischemic bowel leading to abdominal compartment syndrome following abdominoplasty. To the best of our knowledge, this is the first reported case in the literature. We herein emphasise on the subtle symptoms and signs that warrant further investigations in prospective patients for an abdominal contouring procedure with a prior history of gastric bypass surgery.
Abdminoplasty; abdominal compartment syndrome; bariatric surgery