As well as craniofacial synostosis, complex syndactyly of hands is a distinctive feature of Apert syndrome. Consideration of blood flow to the digits is very important in separation surgery. Several reports offer information about arterial distribution in Apert's hands. Though, venous pattern has not been well discussed. Infrared venography offers a real-time image with minimal invasion. An Apert syndrome patient underwent a series of finger splitting surgeries. Infrared venography was carried out to assess veins. There was a palmar venous arch, placing distally to the metacarpophalangeal joint. The arch had to be cut to divide fused fingers sufficiently. As well as arterial abnormality, venous uniqueness should be noted in Apert syndactyly surgeries. Infrared venography, which can be carried out easily, offers good information that surgeon require.
Anomaly; Apert syndrome; hand; infrared; syndactyly; vein
As primary repair of divided flexor tendons becomes more common, secondary tendon surgery becomes largely that of the complications of primary repair, namely ruptured and adherent repairs. These occur with an incidence of each in most reported series world-wide of around 5%, with these problems having changed little in the last two decades, despite strengthening our suture repairs. Where the primary referral service is less well-developed, and as a more occasional occurrence where primary treatment is the routine, the surgeon faces different problems. Patients arrive at a hand unit variable, but longer, times after the primary insult, having had no, or bad, previous treatment. Sometimes the situation is the same, viz. an extended finger with no active flexion, but now no longer amenable to primary repair. Frequently, it is much more complex as a result of injuries to the other tissues of the digit and, also, as a result of the unaided healing process within the digit in the presence of an inactive flexor system. We present our experience in dealing with ruptured repairs, tethered repairs and pulley incompetence.
Flexor tendon injury; flexor tendon reconstruction; flexor tendon pulley reconstruction; secondary flexor tendon repair; tenolysis
Necrotizing fasciitis (NF) is among the most challenging surgical infections faced by a surgeon. The difficulty in managing this entity is due to a combination of difficulty in diagnosis, and also of early as well as late management. For the patient, such a diagnosis means prolonged hospital stay, painful dressings, an extended recovery, and in some unfortunate cases even loss of limb or life. Necrotizing fasciitis is a fairly common condition in surgical practice in the Indian context resulting in a fairly large body of clinical experience. This article reviews literature on MEDLINE with the key words “necrotizing,” “fasciitis,” and “necrotizing infections” from 1970, as well as from articles cross referenced therein. The authors attempt to draw comparisons to their own experience in managing this condition to give an Indian perspective to the condition.
Fasciitis; necrotizing necrotising infections; synergistic infections
To discuss the clinical presentation, diagnosis and management of osteomas involving the craniomaxillofacial region.
Materials and Methods:
This study was conducted from June 2004 to March 2012 at our institute. A total of 12 cases between the ages of 10 and 50 years were managed with surgical excision and reconstruction. The criteria used to diagnose osteoma included radiographic and clinical features and histological confirmation of the specimen. The total follow-up period ranged from 6 to 24 months.
Out of 12 osteomas, 10 were peripheral and 2 were centrally located. Mandible involvement was seen in six patients, four involved the orbit, one the frontal bone and one the frontal bone with the skull base. All patients undergoing excision and reconstruction had a favourable aesthetic and functional outcome. There were no recurrences and no post-operative complications.
Osteomas affect all age groups with no sex predilection and are usually clinically asymptomatic till they become large in size. Surgical excision and appropriate reconstruction is the mainstay of management. Surgery is indicated when lesion is symptomatic or actively growing and the surgical approach for exposure of the lesion should be case specific.
Craniofacial; osteoma; reconstruction
Total scalp avulsion is a serious injury, commonly occurring in Indian females working with industrial and agricultural machines. Their long hairs often get caught in a rapidly revolving machines, resulting in total avulsion of scalp. Lack of education and awareness in Indian villages often result in these patients coming late to the hospitals when replantation is not possible and scalp reconstruction remains the only available option.
Materials and Methods:
We performed our study on 22 cases of scalp avulsion injury presented to us between June 2007 and April 2012 at Department of Burn, Plastic & Reconstructive Surgery, SMS Hospital, Jaipur. In all of them a free tissue transfer was performed as an elective procedure.
Twenty two patients underwent free tissue transfer and followed up for an average period of 6 months. All patients included in this study were females with mean age of 28 yrs. Five patients in our study reported with partial necrosis of the free flaps which were subsequently managed with split-thickness skin graft (STSG). Two patients reported total necrosis of the flap which was re-operated using latissimus dorsi along with serratus anterior muscle (LDSA) from the contralateral side.
As scalp avulsion because of rapidly rotating machine leads to large size defect not amenable for local tissue reconstruction. We performed reconstruction using LDSA and omental free flaps with split thickness skin graft (STSG) for large scalp defect and achieved good and stable soft tissue cover with satisfactory cosmesis.
Latissimus dorsi with serratus anterior flap; scalp avulsion injury; scalp reconstruction
This report details our experience with the use of the temporoparietal fascia flap in different scenarios of reconstruction and to discuss our technique of harvest, clinical applications, and review of literature of this versatile flap.
Materials and Methods:
A retrospective study of 82 cases of temporoparietal fascia flap in 71 patients, operated over a period of 10 years was conducted. Patients were grouped based on various clinical indications. The follow up period ranged from a minimum of 1 to a maximum of 10 years (Mean-four and a half years). All patients were analyzed for functional and aesthetic outcome using preoperative and postoperative photographs.
No significant complications were seen in our series. Only 2 out of 82 flaps had partial necrosis of flap (2.44%). Two patients who were operated for release of submucous fibrosis developed recurrence due to continued use of tobacco. The final outcome in one patient of ear reconstruction was unsatisfactory due to flap failure. The remaining patients had satisfactory functional and aesthetic outcomes (95.77%). None had other complications like temporal branch of facial nerve injury or alopecia along the scar line.
The TPFF is one of the most reliable and versatile flap in the head and neck region. It can also be reliably used as free fascial flap. When its advantages are combined with the surgeon's resourcefulness, various defects can be successfully reconstructed using the temporoparietal facia flap with satisfactory aesthetic and functional outcome.
Head and neck reconstruction; temporoparietal fascia flap; TPFF
The objective of this study is to assess the efficacy of smartphone and its WhatsApp application as a communication method amongst the staff of plastic and reconstructive surgery section at tertiary care health facility.
Materials and Methods:
From January 2012 onwards, the authors used smartphones and its WhatsApp application as a communication method amongst their team for various aspects of patient management and as a tool for academic endorsements.
During the period of this study, there were 116 episodes regarding patient management, which were handled, in a timely fashion by using this application. In addition opinion of rotating residents in the section was sought regarding the efficacy of this method of communication. Overall majority of residents were satisfied with this mode of communication.
This new method of communication is an effective method for clinical and academic endorsements. The method is cheap and quick and easy to operate.
Communication method; multimedia; smartphone; WhatsApp
We have encountered situations of patients with critical limb ischemia accompanied by pain at rest and necrosis, who hang their legs down from the bed during sleep. This lower limb position is known to be a natural position, which reduces pain in the lower extremity induced by ischemia. However, the effect of this position on blood flow of the lower extremity is poorly understood. We studied whether measurements of skin perfusion pressure (SPP) changes by leg position and the difference between healthy adults and patients with critical limb ischemia. The subjects of this study were 10 healthy adults and 11 patients with critical limb ischemia. Patients with critical limb ischemia, including both dorsum of foot and plantar of foot, having SPP of lower limbs of less than 40 mmHg (supine position) were the object of this study. SPP was measured on four positions (supine position, lower limbs elevation position, sitting position, and reclining bed elevation of 20° position). In sitting position, both the number of healthy adults and critical patients show significant increases in SPP compared with the other three positions. These results suggest that sitting position is effective to keep good blood stream of lower limbs not only in healthy adults but also in patients with critical limb ischemia. However, an appropriate leg position should not have lower limbs hang downwards for long periods time because edema is caused by the fall in venous return in lower limbs, and the wound healing is prolonged.
Our clinical research could be more useful in the future, particularly in developing countries, for surgeons managing wounds in leg and foot and preserving ischemic limbs.
Critical limb ischemia; peripheral arterial disease; position; skin perfusion pressure
Now-a-days, deep inferior epigastric perforator (DIEP) flap breast reconstruction is widespread throughout the world. The aesthetical result is very important in breast reconstruction and its improvement is mandatory for plastic surgeons.
Materials and Methods:
The most frequent problems, we have observed in breast reconstruction with DIEP flap are breast asymmetry in terms of volume and shape, the bulkiness of the inferior lateral quadrant of the new breast, the loss of volume of the upper pole and the lack of projection of the inferior pole. We proposed our personal techniques to improve the aesthetical result in DIEP flap breast reconstruction. Our experience consists of more than 220 DIEP flap breast reconstructions. Results: The methods mentioned for improving the aesthetics of the reconstructed breast reported good results in all cases.
The aim of our work is to describe our personal techniques in order to correct the mentioned problems and improve the final aesthetical outcome in DIEP flap breast reconstruction.
Aesthetic refinements; breast reconstruction; deep inferior epigastric perforator flap
Ear projection is an important goal to be achieved after stage two (ear elevation) in cases of microtia. This is a retrospective study conducted on patients with microtia who underwent staged reconstruction for the same. This study has been carried out over a period of 10 years with 211 patients. Dental impression compound was used as a splint after ear elevation and split skin grafting to maintain the projection of the ear. Projection of the ear was measured both pre- and post-procedure and at every follow-up using goniometer and photographic documentation was simultaneously done. Statistical analysis was performed using t-test. Patients were reviewed every month and splint was continued until 6 months post-surgery. The splint was very effective in maintaining the ear projection of more than 20° even after prolonged follow-up of upto 2 years. There were no complications associated with the splint application or prolonged use.
Ear elevation; splint; microtia
Facial contour deformities presents with varied aetiology and degrees severity. Accurate assessment, selecting a suitable tissue and sculpturing it to fill the defect is challenging and largely subjective. Objective assessment with imaging and software is not always feasible and preparing a template is complicated. A three-dimensional (3D) wax template pre-fabricated over the facial moulage aids surgeons to fulfil these tasks. Severe deformities demand a stable vascular tissue for an acceptable outcome.
Materials and Methods:
We present review of eight consecutive patients who underwent augmentation of facial contour defects with free flaps between June 2005 and January 2011. De-epithelialised free anterolateral thigh (ALT) flap in three, radial artery forearm flap and fibula osteocutaneous flap in two each and groin flap was used in one patient. A 3D wax template was fabricated by augmenting the deformity on facial moulage. It was utilised to select the flap, to determine the exact dimensions and to sculpture intraoperatively. Ancillary procedures such as genioplasty, rhinoplasty and coloboma correction were performed.
The average age at the presentation was 25 years and average disease free interval was 5.5 years and all flaps survived. Mean follow-up period was 21.75 months. The correction was aesthetically acceptable and was maintained without any recurrence or atrophy.
The 3D wax template on facial moulage is simple, inexpensive and precise objective tool. It provides accurate guide for the planning and execution of the flap reconstruction. The selection of the flap is based on the type and extent of the defect. Superiority of vascularised free tissue is well-known and the ALT flap offers a versatile option for correcting varying degrees of the deformities. Ancillary procedures improve the overall aesthetic outcomes and minor flap touch-up procedures are generally required.
Facial contour deformity; facial moulage; microvascular reconstruction of contour deformity
The development and popularity of body contouring procedures such as liposuction and abdominoplasty has renewed interest in the anatomy of the superficial fascia and subcutaneous fat deposits of the abdomen. The study of anatomy of fascia and fetal adipose tissue was proposed as it may be of value in understanding the possible programing of prevention of obesity.
The present study was undertaken to understand the gross anatomy of superficial fascia of abdomen and to study the gross anatomy of future localized fat deposits (LFDs) area of abdomen in fetus.
Materials and Methods:
Four fetus (two male & two female) of four month of intrauterine life were dissected. Attachments & layers of superficial fascia and future subcutaneous fat deposit area of upper and lower abdomen were noted.
Superficial fascia of the abdomen was multi layered in mid line and number of layers reduced laterally as in adult. The future abdominal LFD (localized fat deposits) area in fetus shows brownish-white blubbary tissue without well-defined adult fat lobules.
The attachment and gross anatomy of superficial fascia of the fetus was similar to that in adults. The future LFD areas showed brownish white blubbary tissue with ill-defined fat lobules.
Localised fat deposits; obesity; subcutaneous fat; superficial fascia
Asians have low nasal dorsum, thick skin envelope, low defined alar cartilage, low projection of nasal tip and broad alar base. Augmentation rhinoplasty with silicone prosthesis has been performed with predictable results, but unfavourable results and complications still present. This series show techniques and results from single surgeon experience.
Materials and Methods:
We retrospectively reviewed 548 patients chart during January 1995 to December 2009. All patients underwent custom-made S-shape implant silicone augmentation rhinoplasty operated by a single surgeon. There were three major operative steps: (1) Intra-operative S-shape implant carving; (2) pocket dissection through bilateral rim incision and (3) tension adjustment before closure. All the patients were recorded for early surgical complications and satisfaction.
There were 519 women and 29 men. The mean age is 25.5 years (18-56 years). Mean follow-up period was 6 months (1-60 months). The majority of patient were appointed for esthetic augmentation (86.8%). 515 cases (94.9%) showed well satisfaction following the operation. The total complication rate was 6.5% (4.9% deviation, 0.7% extrusion, 0.5% hematoma and 0.3% infection). All the complications were corrected with uneventful sequelae.
Augmentation rhinoplasty with custom-made S-shape silicone implant by closed approach provides high satisfaction with acceptable early complication rate.
Aesthetic surgery; Asians; augmentation rhinoplasty; silicone implant; surgical complication
Non-healing wound in the sternal region after coronary arteries bypass graft surgery is a serious complication. For healing a chronic wound, several novel approaches have been proposed recently such as using bone marrow stem cells, platelets and fibrin glue (PFG); but a non-invasive method is highly desirable in the first approach for treatment. The current study was undertaken to evaluate the effect of the combination of PFG in one treatment.
Materials and Methods:
We report on the treatment of six patients with life-threatening chronic sternum wounds, which caused septicemia with multi-drug resistant pathogens. The ulcers were extensively debrided initially and were measured and photographed at weekly intervals. The combination of PFG was applied topically on the wound after every 2 days.
The wounds were completely closed in five patients and significantly reduced in size in one. There was no evidence of local or systemic complications and any abnormal tissue formation, keloid or hypertrophic scarring.
Our study suggests, in the first approach, PFG can be used safely in order to heal a non healing sternum wound following coronary artery bypass surgery.
Chronic wounds; fibrin glue; platelet-rich plasma; sternal wound
The severe long bone defects usually follow high-energy trauma and are often associated with a significant soft-tissue injury. The goal of management of these open long bone defects is to provide stable fixation with maintenance of limb length and soft-tissue coverage. The purpose of this article is to present the clinic-radiological outcome, complications and treatment of post-traumatic long bone defect with vascularised fibula transfer.
Materials and Methods:
Retrospective records of 28 patients were analysed who presented with post-traumatic long bone defects and in whom reconstruction with vascularised free fibula was done. Demographic data were recorded and clinical and radiological assessment was done.
Out of 28 patients in whom vascularised free fibula transfer was carried out three flaps were lost while non-union occur in three patients. Three patients developed a stress fracture of transferred free fibula in the post-operative period. Few of the patients experienced some problems in the donor leg; however, all of them improved in subsequent follow-up.
It is clearly evident from this study that timing of surgery plays an important role in the micro-vascular reconstruction in trauma cases. All the complication like flap loss, non-union or delayed union occur in patients in whom reconstruction was delayed.
The free vascularised fibula graft is a viable method for the reconstruction of skeletal defects of more than 6 cm, especially in cases of scarred and avascular recipient sites or in patients with combined bone and soft-tissue defects. Results are best when the reconstruction is done within 1 week of trauma.
Long bone defect; post-traumatic; vascularised free fibula
To study the problems faced during the surgery and follow-up of modified complete primary repair of exstrophy (CPRE) technique. Initial experience with CPRE and its short- and long-term outcomes with respect to continence status and psychosocial impact are reported.
Materials and Methods:
A retrospective review of the hospital case records from March 2008 to September 2012 was performed. Data of patients with bladder exstrophy managed by a single paediatric surgeon using modified CPRE technique were analysed. Quality of life and psychosocial impact of the surgery were assessed using Pediatric Quality of Life Inventory (PedsQL 4.0) and compared with those of typical peers.
Eight children (age 4 days-12 years) underwent CPRE using modified Mitchell's technique. Two patients (25%) experienced early postoperative complications, with infection and fistula developing in one each. All the patients were doing well on follow-up, with variable continence rates and good cosmesis. Mean duration of follow-up was 18.5 months (range 6 months-4 years). Five out of seven (71%) children were continent or partially continent. One case was lost to follow-up. PedsQL scores were comparable with those of age-matched peers in all domains except the social functioning domain in 8-12 years age group (83.53 ± 9.70 vs. 77.86 ± 10.22, P < 0.05).
Our preliminary results with modified CPRE in neonates and children have been encouraging. No major complications were observed. Continence rate was satisfactory and cosmetic results were good. Though the technique is being practiced at several Indian centres, there is a paucity of comprehensive Indian data on CPRE.
Bladder exstrophy; complete primary repair; urinary continence
Replantation is defined as reattachment of amputated limb using neurovascular and musculoskeletal structures in order to obtain recovery of limb. Re-vascularisation involves all the above steps in case of limb injuries that result in a near total amputation.
Aim and Objective:
To study the functional outcome of patients undergoing replantation of hand at wrist level.
Material and Methods:
This is a retrospective study of patients who underwent replantation of total amputation of hand at wrist level within a period of Jan 2003-June 2010. We evaluated post operative functional outcome compared to uninjured hand taking into consideration: 1. The patient's overall satisfaction with the hand. 2. Recovery of flexor and extensor function of thumb and fingers. 3. Recovery of thumb opposition. 4. Recovery of sensations in the median and ulnar nerve distribution. 5. Ability of surviving hand to perform daily tasks.
There were total seventeen patients and age range was two years to 55 years. Out of 17 patients,16 were males. All the replantations were successful except for one.
The results showed that, although the replanted hands were never functionally as good as the contralateral hand the patients were able to perform most of the daily activities.
Replantation; wrist amputation; hand amputation
The facial asymmetry correction in complex craniofacial malformations presents a challenging problem for reconstructive surgeons. Progressive hemifacial atrophy (HFA) and hemifacial microsomia (HFM) can manifest in different grades of severity. Most patients require only soft-tissue augmentation. Free flaps are the best option for correction of severe facial soft-tissue deficiency.
Materials and Methods:
Twenty-two patients of HFM and HFA were included in this study from January 2006 to March 2009 in the Department of Plastic and Reconstructive Surgery, SMS Medical College and Hospital. In all cases, atrophy correction was done using de-epithelialised parascapular free flap with the de-epithelialised surface was placed under the skin. A small skin paddle was taken for monitoring.
All cases were reconstructed with de-epithelialised parascapular free flap. There was no flap loss in this series. Hematoma was noted in five cases. Debulking and removal of skin paddle were done in all cases after 6 months. Atrophy recurrence was not observed in any of the cases on follow-up.
Contouring of face in cases of HMF and HFA is satisfactorily done with the parascapular free flap. It gives better cosmetic results with minimal donor site morbidity. Facial vessels are better recipient vessels for anastomosis. Keeping de-epithelialised surface of flap under the skin helped in preventing sagging.
Hemifacial atrophy; hemifacial microsomia; parascapular flap
Bilateral limb trauma poses many possibilities for management. In a situation of bilateral amputation, if the amputated limb is not salvageable or replantation is not advisable, the amputated limb can be used to harvest tissue for free tissue transfer to cover the amputation stump. We describe a case here in which we have used these principles.
Double free flap; free tissue transfer; microsurgery; non-replantable amputation; spare parts surgery
Adequate drainage of venous blood is the most critical part of successful free tissue transfer. We report a case of anterolateral thigh flap used for covering open communited tibial fracture. The flap was salvaged with short term augmentation of venous drainage with external shunt. The drainage was continued for six days. It was confirmed that there is no more congestion after blocking the catheter and then the drainage was discontinued on seventh day. The flap was successfully salvaged. This method has potential applications in multiple situations for successful salvage of free tissue transfer.
Extracorporeal drainage; external shunt; salvage of congested flaps; venous obstruction in free flap
Touraine Solente Gole syndrome is a rare hereditary syndrome of primary pachydermoperiostosis, with the characteristic triad of pachydermia (or elephant like skin), periostosis and acropachia. A 27-year-old patient presented with aesthetic deformity of forehead due to deep skin folds and coarsening of facial features due to progressive thickening of skin. Associated palmoplantar hyperkeratosis with broadened of finger and toe tips and digital clubbing were noticed. Dermatologic evaluation revealed cutis verticis gyrata of scalp, seborrhoeic hyperplasia of face and hyperhidrosis. Natural history of the disease and aetiopathogenesis were reviewed. Aesthetic correction of forehead through frontal rhytidectomy was attempted.
Clubbing; cutis verticis gyrata; frontal rhytidectomy; hypertrophic osteoarthropathy; pachyderma; periostosis
Total upper and lower eyelid unilateral full thickness reconstruction is a surgical challenge. A case of right orbital haemangioma with unilateral complete defect of total upper and lower eyelids with right orbital exenteration is reported, together with the surgical technique of reconstruction. Patient was a 24-year-old female who underwent right orbital exenteration with total upper and lower eyelid excision for orbital haemangioma presented after 3 weeks of the above procedure. In the first stage split thickness skin grafting is used to resurface orbital cavity raw area followed by staged reconstruction of total upper and lower eyelid reconstruction using pedicle deltopectoral flap. This reconstruction provided stable eyelid reconstruction to retain ocular prosthesis with concealed and minimal donor area. After reconstruction patient underwent rehabilitation with ocular prosthesis, now the patient is satisfied with cosmetically acceptable results.
Deltopectoral flap; total eyelid reconstruction; total upper and lower eyelid reconstruction with DP flap