Indian Journal of Plastic Surgery
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May-August 2018
Volume 51 | Issue 2
Page Nos. 109-261

Online since Monday, October 29, 2018

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EDITORIAL  

Academic integrity and plagiarism: The new regulations in India Highly accessed article p. 109
Dinesh Kadam
DOI:10.4103/ijps.IJPS_208_18  
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ICON OF THE ISSUE Top

Dr. Anil Chadha p. 111
Ayyappan Thangavel
DOI:10.4103/ijps.IJPS_129_18  
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ORIGINAL ARTICLES Top

Aesthetic subunits of the trunk: Anatomy and behavior of skin and adipose tissue in each unit for better outcomes in liposuction p. 115
Sanjay Parashar, Aniketh Venkataram
DOI:10.4103/ijps.IJPS_117_18  
Background: Liposuction and abdominal contouring is one of the most common procedures performed by plastic surgeons worldwide. Surprisingly, there has been few attempts at dividing the abdomen into subunits to delineate and aid in this endeavour. We have evolved a system of abdominal aesthetic subunits which has enabled us to achieve high quality results. Materials and Methods: A system of 8 subunits of the abdomen was evolved after analysing 1000 cases: Upper midline, upper rectus, lower rectus, pubic, Lateral abdomen, Lumbar Posterior midline and Bra Roll. Results: The system was used in 2000 cases with good results. The system enabled the performance of tailored liposuction in each area, with greater accuracy, better results and fewer complications. Conclusion: Our success with this classification validates its use, and makes liposuction more scientific and effective.
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Brachioradialis to flexor digitorum profundus tendon transfer to restore finger flexion p. 123
R Srikanth, Koteswara Rao Rayidi, Subha Kakumanu
DOI:10.4103/ijps.IJPS_7_18  
Introduction: The main deformity following an adult lower brachial plexus injury is the loss of finger flexion. Distal nerve transfers have been used to restore finger and thumb flexion followed by tendon transfers for intrinsic replacement for opening of the fingers. When patients present beyond 6 months, only tendon transfers are applicable. Since the brachioradialis (BR) is always spared in such injuries, it is the ideal muscle to provide finger flexion. Wrist extensor power may not be normal for the use of the radial wrist extensor to serve as donor. BR to FDP transfer provides reasonable flexion range and an acceptable hand function to permit activities of daily living, when associated with ancillary procedures like opponensplasty, PIPJ arthrodesis. Materials and Methods: Eleven patients underwent a BR to FDP tendon transfer between January 2013 and January 2017 of which eight patients came for follow-up. Results: Four of the eight patients got a functionally useful hand to carry out activities of daily living with hook grip, span grasp, key pinch, chuck grip and pulp pinch. These patients also underwent simultaneous or secondary ancillary procedures. Four of the patients need secondary procedures to further improve functionality of the hand inspite of having a flexion range. Conclusion: The BR is an effective donor in providing adequate range and power of finger flexion in lower plexus injuries.
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The refinement of the median tubercle of cleft lip p. 131
Jyotsna Murthy
DOI:10.4103/ijps.IJPS_214_17  
Aim: Repair of cleft lip aims to bring symmetry and provide normal aesthetics for the lip. Several techniques have been employed; however, the finer aspect of median lip tubercle has not been emphasised in cleft lip repair. Materials and Methods: We have modified cleft lip repair, both unilateral and bilateral, preserving all the tissues of the median tubercle to provide normal-looking median tubercle of the lip. The modified technique was carried out by a single surgeon on 322 cases of unilateral cleft lip and 68 cases of bilateral cleft lip. Follow-up was done for 1–3 years on these children to evaluate the outcome. Results: The evaluation showed excellent results in more than 80% of patients in unilateral cleft lip repair, on 1–3 years of follow-up; 20% had acceptable results. Of 68 patients with bilateral cleft lip, none had any complication, and excellent results were obtained in 70%. Result was rated acceptable in 30%; 15% may need revision surgery for white roll and vermilion adjustment. Conclusion: We present the technique of reconstructing a normal-looking median tubercle in cleft lip repair. The technique was modified based on the study of normal upper lip and embryology of cleft lip, with emphasis on creating better median tubercle of the lip.
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Correlation of compound muscle action potential generated by donor nerves with the recovery of elbow flexion in Oberlin transfer in brachial plexus injury p. 137
Mukund Ramchandra Thatte, Binita Bharat Raut, Amita Shivyogi Hiremath, Sushil Ramesh Nehete, Nayana Somala Nayak
DOI:10.4103/ijps.IJPS_31_17  
Objective: To study the correlation of compound muscle action potential of donor nerves with the recovery of elbow flexion in Oberlin transfer in brachial plexus injury. Introduction: Distal nerve transfer using motor fascicle of ulnar or median nerve to restore elbow flexion is a part of reconstructive surgery after upper brachial plexus injury, first described by Oberlin et al. However, one of the most critical influences on functional outcome is number of functioning motor axons in donor fascicle which is reflected by its compound muscle action potential. We studied whether nerve transfers with donor nerves showing higher amplitudes will yield better reinnervation of muscle and therefore better function as estimated by clinical examination. Methods: We prospectively studied 30 cases of upper brachial plexus injury, of which were treated with Oberlin transfer using ulnar or median or both nerves. The prerequisites were no elbow flexion and hand and wrist flexors showing the power of more than Medical research Council MRC Grade 4. Donor nerves selected either ulnar or median having CMAP >4 mv in our electrophysiology laboratory during nerve conduction study. Patients were followed up for 1 year and assessed clinically for restoration of elbow flexion, weight tolerance. Results: A total of 30 patients of Oberlin transfer were evaluated for improvement power of biceps and elbow flexion. (MRC) grading was done at 1 year. Twenty-seven patients had a good result (MRC grade ≥3), i.e., 90% of patients. Based on the MRC grades, we categorised the patients into two groups as follows: Group A and Group B. Group A included patients with MRC Grade 4–5 and Group B included Grades 3–3.5. We tried to establish a correlation between CMAP and MRC scores by comparison of MRC grade patients for their pre CMAPs which revealed a statistically significant higher CMAPs between the groups. (Mann–Whitney U-test, P = 0.028). This indicates the association of higher pre-CMAPs with higher MRC grades. Conclusion: We conclude that higher the compound muscle action potential of donor nerves, better the recovery of elbow flexion in Oberlin transfer in brachial plexus injury.
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Autologous fat grafting in the treatment of velopharyngeal insufficiency: Clinical outcomes and treatment tolerability survey in a case series of 21 patients p. 145
Renzo Panizza, Marco Ghiglione, Enrico Maria Zingarelli, Michela Massa, Claudio Carlini, Rossella Arnoldi, Alessio Pini Prato, Silvia Scarrone, Francesco Vaccarella
DOI:10.4103/ijps.IJPS_183_17  
Introduction: Velopharyngeal insufficiency (VPI) is the inability to close the velopharyngeal sphincter during phonation and/or feeding. VPI is clinically characterised by hypernasal speech and nasal regurgitation. In cases of severe VPI, pharyngoplasty is recommended. Cases of mild-to-moderate VPI can be treated with fat grafting of the posterior pharyngeal wall in addition to speech therapy. The lipofilling can also be useful after pharyngoplasty to improve the outcomes. Materials and Methods: Twenty-one patients (14 males and 7 females), ages 4–23 affected by mild-to-moderate VPI and treated with lipofilling were included in this retrospective study. The mean injected fat volume was 7.95 cc (median 6 cc, min 4 cc, max 20 cc and range 16 cc). The follow-up ranged from 6 to 60 months. The pre- and post-operative Borel–Maisonny scores were compared using Wilcoxon test. Moreover, we performed a telephone survey with the aim to assess the parental perception on child's speech and quality of life after the surgical treatment. Results: Despite the small sample size, in this case series, we observed a statistically significant Borel–Maisonny score improvement and a parental satisfaction rate of about 85%. Conclusions: The augmentation of the posterior pharyngeal wall in addition to speech therapy improved the Borel–Maisonny score and the intelligibility of this case series of patients affected by mild-to-moderate VPI. In these patients, evaluated in a multidisciplinary approach, this technique allowed us to avoid major surgical procedures that would modify the anatomy of the velopharyngeal port. However, prospective comparative studies or randomised controlled trials could be useful to compare fat grafting with velopharyngoplasty techniques, with the aim to clarify indications and to define a specific treatment protocol.
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Application of embryonic equivalents in male-to-female sex reassignment surgery p. 155
Balakrishnan Margabandu Thalaivirithan, Maithreyi Sethu, Dinesh Karuvakkurichi Ramachandran, Mahadevan Kandasamy, Jaganmohan Janardhanam
DOI:10.4103/ijps.IJPS_62_18  
Introduction: The feeling of incongruence between phenotypic sex and psychological recognition of self-gender is termed gender dysphoria. Transsexualism is the most extreme form of this disorder. Aims and Objectives: The aims and objectives of the study are to evaluate the esthetic and functional outcome of embryonic equivalents-based male-to-female sex reassignment surgery in transwomen using the institutional scoring system. Materials and Methods: Thirty transwomen who had undergone male-to-female embryonic equivalents-based sex reassignment surgery (MFEEbSRS) from October 2012 to March 2016 were retrospectively studied. The outcome was evaluated by two independent plastic surgeons, based on interview with the individuals, visual assessment, and measurements. Surgical Technique: Clitoris was created from reduced glans on dorsal penile pedicle mounted on the crura of the conjoined corpora cavernosa. De-gloved unfurled proximal penile skin formed the introitus, hood for clitoris and labia minora. Neo-external urethral meatus was fashioned from the distal portion of the bulbar urethra. Distal de-gloved inverted penile tube flap was used for the creation of neovagina. Reduced scrotal flaps formed the labia majora. Observation and Results: The maximum length of neovagina in the study was 12 cm, and the average length was 9.8 cm. Based on our institutional scoring system for the assessment of esthetic and functional outcome, we got excellent results in all transwomen. Conclusion: The esthetic and functional outcome in all the patients was good. All patients were relieved of their primordial feminine tension and satisfied with the surgery. Their personality, lifestyle, and self-esteem improved remarkably following surgery.
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COMMENTARY Top

Commentary on: Application of embryonic equivalents in male-to-female sex reassignment surgery p. 167
Richie Gupta
DOI:10.4103/ijps.IJPS_164_18  
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ORIGINAL ARTICLES Top

The role of plastic and reconstructive surgeon in trauma care: Perspectives from a Level 1 trauma centre in India p. 170
Maneesh Singhal, Ravikiran Naalla, Aniket Dave, Moumita De , Deepti Gupta, Shashank Chauhan
DOI:10.4103/ijps.IJPS_212_17  
Background: As the morbidity and mortality due to trauma are ever increasing, there is proportionally growing need of trauma care facilities across the country. In the context of expanding designated trauma care facilities, the role of plastic and reconstructive surgeon needs to be analysed and defined at least at a Level 1 trauma centre. Materials and Methods: We included the patients who were operated under the department of plastic, reconstructive & burns surgery at a Level 1 urban trauma centre between January 2016 and December 2017. We analysed the demographic data and categorised operative data according to anatomical areas and interacting specialties. Results: A total of 1539 procedures were performed under the division of plastic reconstructive and burn surgery. Amongst them, 81% were male, and 19% were female. Mean age was 27.3 years (range: 3–90 years). The anatomical locations treated were upper limb (49%), lower limb (35%), head and neck (8%) and trunk (8%). Interdepartmental cases were 600 and majority of them were in collaboration with orthopaedics (n = 298), general surgery (n = 163), neurosurgery (79) and maxillofacial surgery (60). Conclusion: There is a significant role of plastic surgeon at a Level 1 trauma centre in India. The plastic surgeon's interventions are limb saving and sometimes lifesaving, many at times morbidity of post-traumatic sequelae are either prevented or treated. Along with other core specialties involved in the management of trauma, plastic surgeons play an integral role in a Level 1 trauma centre. The policymakers should take note to augment the number of plastic surgeons at a Level 1 apex trauma centre on par with other specialties, as the workload is heavy and is steadily on an increasing trend.
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Adipose tissue: A natural resource for multipotent mesenchymal stem cells with potential translation to trigerminal layers p. 177
Bhaskar Vyas, Atul Shah, Anant Marathe, Ansarullah , Rajni Vyas, Ramesh Bhonde
DOI:10.4103/ijps.IJPS_150_17  
Background: The article reports basic science research that establishes that adipose tissue (AT)-derived mesenchymal stem cells (MSCs) have a potential to transgerminal translation. Study Design: MSC confirmation was obtained by phenotypic spindle-shaped cells as well as with four positive and three negative markers. The translineage translation of adipose-derived MSCs (ADMSCs) was established. Materials and Methods: The lipoaspirate was subjected to enzymatic digestion with collagenase. Stromal vascular factor (SVF) was isolated. With two passages, pure culture of ADMSCs was obtained. They were translated to all the three germinal layers. Results: AT-derived SVF contains ~30% MSCs. They are capable of being translated into endoderm, mesoderm and ectoderm. Conclusion: AT is a rich source for MSCs, with immense research possibilities for regeneration and rejuvenation.
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Transverse cervical vascular pedicle: It's extended use as ‘second-line’ recipient vessels in thoracic and upper arm reconstructions in addition to head-and-neck reconstructions p. 182
Srijana Muppireddy, Parvathi Ravula, Srikanth Rangachari, Najma Shaik, Sushma Maaturu
DOI:10.4103/ijps.IJPS_9_18  
Background: Selection of recipient vessels is one of the key factors for a successful microvascular reconstruction. Non-availability of primary recipient vessels in the vicinity necessitates surgeon to approach a remote second-line vascular access. Transverse cervical vessels (TCV) have been described as second-line vascular access for head-and-neck reconstructions. Due to its location, their use can be extended to the proximal chest and upper arm reconstructions. Aim: The aim of the study is to analyse the reliability of TCV as second-line recipient vessels for the upper arm and chest reconstructions in addition to the head-and-neck reconstructions. Materials and Methods: During 2010–2017, 14 TCV were explored as the choice of second-line recipient pedicle for specific indications. Clinical experience with different reconstructions discussed. Results: Out of 14 transverse cervical arteries, 13 were of adequate size for anastomosis. About 12 successful reconstructions were performed involving the head and neck (7), proximal thorax (3) and upper arm (2) for indications such as scarring from different aetiology (8), previous free flaps (2) and sacrificed vessels (2). In one case, the arterial anastomosis was shifted to superior thyroid artery. All the chest and upper arm reconstructions needed a realignment of the pedicle without any kink. Transverse cervical vein (TCv) could be used only 5/14 times either alone or along with external jugular vein (EJV). In other cases, EJV alone was used. All the 12 flaps survived without any vascular event. Conclusions: Transverse cervical vessels are reliable second-line recipient vessels in the head and neck; in addition, they are of use in the upper arm and proximal chest defects.
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Outcomes following pharyngeal reconstruction in total laryngectomy – institutional experience and review of literature p. 190
Deepak Balasubramanian, Narayana Subramaniam, Priyank Rathod, Samskruthi Murthy, Mohit Sharma, Jimmy Mathew, Krishnakumar Thankappan, Subramania Iyer
DOI:10.4103/ijps.IJPS_79_17  
Background: Pharyngeal reconstruction is a challenging aspect of reconstruction after resections for head-and-neck cancer. The goals of reconstruction are to restore the continuity of the pharyngeal passage to enable oral alimentation and rehabilitation of speech wherever possible. This study was performed to determine the outcomes following pharyngeal reconstruction in total laryngectomy (TL) using different reconstructive options and to determine the predictors of pharyngocutaneous fistula (PCF) and swallowing dysfunction. Materials and Methods: Retrospective analysis of patient data between 2003 and 2010 of patients undergoing TL with partial or total pharyngectomy. Demographic and treatment details were collected and analysed. Univariate analysis was performed to determine predictors of PCF and swallowing dysfunction. Results: Fifty-seven patients underwent pharyngeal reconstruction following TL, 31 of whom had received prior treatment. Following tumour resection, 31 patients had circumferential defects and 26 patients had partial pharyngeal defects. The flaps used include pectoralis major myocutaneous flap (n = 29), anterolateral thigh flap (n = 8), gastric pull-up (n = 13) and free jejunal flap (n = 7). PCF was seen in 20 patients, of which 15 (75%) were managed conservatively and 5 required another surgery. At last follow-up, 99 patients (68%) were on full oral alimentation. Tracheo-oesophageal puncture and prosthesis insertion was done in 20 patients, of whom 17 (85%) developed satisfactory speech. Partial pharyngeal defects were associated with a higher risk of PCF on univariate analysis (P = 0.006) but were not significant on multivariate analysis. Post-operative swallowing dysfunction was significantly higher with hypopharyngeal involvement by tumour (P = 0.003). Conclusion: Pharyngeal reconstruction in TL is feasible with good results. Majority of the patients swallow and regain acceptable swallowing function within 3 months.
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Comparison of subdermal and perforator delay techniques on a rat flap model p. 196
Dincer Altinel, Burcu Biltekin, Merdan Serin, Ugur Sahin, Muzaffer Altindas
DOI:10.4103/ijps.IJPS_28_17  
Background: In this study, we investigated the subdermal and perforator delay phenomena as a method to improve flap survival. Materials and Methods: In this experimental study, we used 24 rats in three groups. In the control group, the dorsal flaps were elevated and reinserted back to their place. In the experimental groups, we practiced the delay phenomena with two different techniques. In the first experimental group, cranial and lateral side incisions were performed; however, the flaps were not cut-off from the underlying fascia. In the second experimental group, we placed a silicon sheet under the planned flap to cut-off the circulation from the perforator vessels. Four weeks after the delay procedure, the flaps were raised completely and reinserted back to their place. Results: The average of necrotic area in the control group was 21.9% (±7.70). There was no necrosis in both experimental groups (P < 0.0001). Histological examination revealed that collagen density in both of the experimental groups was increased in comparison to the control group, it has only been found a significant first experimental group (P = 0.0315). We have not found any significant difference in lymphocyte density between the groups. Angiographic imaging has showed an increase in the vascular density in the flaps of the first experimental group. Conclusion: We believe that both of these delay techniques can be adapted to clinical applications and used safely to increase flap survival.
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Autogenous control augmentation system – a refinement in diced cartilage glue graft for augmentation of dorsum of nose p. 202
Gambhir Singh Swaroop, J Sasidhar Reddy, Mahesh Chand Mangal, Anubhav Gupta, Bheem Singh Nanda, Nikhil Jhunjhunwala
DOI:10.4103/ijps.IJPS_69_18  
Background: In the context of different grafts being used for dorsal augmentation, diced cartilage with glue has gained worldwide acceptance. Aims: To develop a system of tools to objectively evaluate the desired dimensions of the required graft for dorsal augmentation and to prepare a corresponding customized-glued-diced cartilage construct. Materials and Methods: A modification of the diced cartilage glue technique called Autogenous control augmentation system (ACAS) was used in ten patients. Results: Of the ten patients, in which this technique was used, eight underwent primary rhinoplasties and two underwent secondary rhinoplasties between July 2017 and December 2017 with a follow-up ranging from 3 to 8 months. In all the cases, the dorsum is straight, and height is maintained. Conclusion: The technique has all the advantages of the diced cartilage glue. The shape resembles alloplastic implant with height and width varying from radix to tip. There is tapering of the cephalic and caudal ends for more natural results. The brow tip aesthetic lines are better defined. The limitation of this study is short follow up.
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Defining giant mandibular ameloblastomas – is a separate clinical sub-entity warranted? p. 208
Aditya V Kanoi, Tibar Banerjee, Narayanamurthy Sundaramurthy, Arindam Sarkar, Pooja Kanoi, Sushovan Saha
DOI:10.4103/ijps.IJPS_194_17  
Context: The term giant mandibular ameloblastoma (GMAs) while being in popular usage in the medical literature remains largely equivocal. Although a few authors have in the past attempted to ascribe definite criteria to this entity, these are by and large arbitrary and without any benefit in decision-making or contributing to its management. Aims: The aim of this study is to propose a set of objective criteria for GMAs that can be clinically correlated and thereby aid in the management of this entity. Patients and Methods: Of a total of 16 patients with ameloblastoma of the mandible presenting at our institute from August 2012 to September 2016, 11 patients were identified as having GMAs as per the criteria proposed. Results: The defects in the mandible following segmental resection ranged from 7 to 11.5 cm in length (mean: 9.3 cm). No clinical or radiological evidence of tumour recurrence was found during a mean follow-up period of 10.7 months (range: 2–28 months). Conclusions: Defining GMA based on objective inclusion and exclusion criteria allows segregation of these lesions, thereby helping to remove ambiguity, simplify decision-making and facilitate communication among treating reconstructive surgeons. Inclusion criteria include: (i) The segmental bone defect following resection with a minimum 1 cm margin of healthy bone should exceed 6 cm (ii) The segmental bone defect should involve the central mandibular segment.
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Adipofascial perforator flaps: Its role in reconstruction of soft-tissue defects of lower leg and ankle p. 216
Deepak Nanda, Shamendra Anand Sahu, Durga Karki, Sanjay Kumar, Amrita Mandal
DOI:10.4103/ijps.IJPS_19_17  
Background: Despite advances in surgical skills, adipofascial flaps are still less preferred option for coverage of leg defect. We evaluate the use of perforator-based adipofascial flap in small-to-medium-sized soft-tissue defects in the lower limb. Patients and Methods: After localisation of perforators along the major axial vessels in the lower limb using handheld Doppler, adipofascial flap based on the nearest best perforator of anterior tibial artery, posterior tibial artery and peroneal artery was raised to cover soft-tissue defect in 21 patients. The flap was transposed over the defect and covered by split-skin graft. Donor site was primarily closed. Flap complications, functional and aesthetic outcomes are noted in follow-up. Results: There was partial loss of flap in five patients. After debridement and dressings, split-skin grafting was done for four patients and one patient was managed with local flap. Scar over the flap was stable with no reports of recurrent ulceration or breakdown of wound in 6-month follow-up. Four of five patients reported adequate healing of the fractured bone. Average visual analogue score was 8.24/10 for appearance of donor site as evaluated by the patient. Conclusions: Perforator-based adipofascial flap is a good alternative for coverage of small-to-medium-sized soft-tissue defect of the leg, particularly over the malleolus and lower part of the leg. Use of adipofascial tissue and primary closure of the donor site causes minimal donor-site morbidity. Adipofascial perforator flap provides aesthetically superior recipient-site scar with satisfactory functional outcome.
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Primary free fibula reconstruction in life-threatening haemorrhage from high flow arteriovenous malformation of mandible p. 222
Parvathi Ravula, Srikanth Rangachari, Rammurti Susarla, Laxman Sambari, Srinivas Saraswathi Jammula
DOI:10.4103/ijps.IJPS_13_18  
Background: High flow arteriovenous malformation (AVM) of the mandible is rare, but it can present as a life-threatening emergency with severe intraoral bleeding for the first time. The gold standard of treatment for an AVM of the mandible is selective embolisation combined with resection and subsequent reconstructions. With the advent of advanced multidisciplinary techniques aimed at definitive therapy, surgical resection and primary reconstruction can provide an ideal anatomical and functional cure. There are no previous reports on primary resection and reconstruction for life-threatening haemorrhage from high flow AVM of the mandible. Aim: We discuss our approach aimed at definitive therapy in life-threatening intraoral bleeding from large high flow AVM of the mandible. Subjects and Methods: Four patients were managed for life-threatening intraoral bleeding during 2015–2017. Compression was applied over the bleeding point before the airway could be secured by endotracheal tube. Under general anaesthesia, the external carotid artery (ECA) was temporarily occluded using an umbilical tape loop ligature to control the bleeding. Emergency selective embolisation was done, followed by curative resection and primary mandible reconstruction using free fibula flap. Outcome assessed. Results: Temporary occlusion of the ECA successfully controlled the bleeding immediately and facilitated selective embolisation and definitive therapy. All the four cases were successfully reconstructed with a good outcome. There was no recurrence during the follow-up period. Conclusion: In life-threatening intraoral bleeding from large high flow AVM of the mandible, emergency selective embolisation followed by curative resection and primary reconstruction is safe in achieving an ideal cure.
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An important superficial vein of the radial aspect of the forearm: An anatomical study p. 231
Madhubari Vathulya, Mohd Salahuddin Ansari
DOI:10.4103/ijps.IJPS_19_18  
Introduction: The superficial veins of upper limbs are seldom talked about. They are always avoided quoting them to be variable in anatomy. Other than the cephalic and basilic veins, no other superficial vein has caught the eyes of anatomists and other health professionals significantly. This article tries to explain the importance of a superficial vein that closely traces the radial vessels and explains its possible use in microvascular reconstruction. Materials and Methods: The forelimbs of 26 upper limbs of fresh frozen cadavers were dissected out. The anatomy of the superficial vein that follows the radial vessels was traced out from wrist to cubital fossa. Their relation to the deep venous system and cephalic veins was followed and documented. Results: All the 26 upper limbs showed the existence of the superficial vein that follows the radial vessels. The study also revealed the existence of venous perforators which are in turn the communication channels between the deep and superficial venous systems. Conclusion: The existence of the surface vein can logically hold an explanation for flap failure or success when one vein anastomosis is contemplated for radial forearm-free tissue transfers.
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REFLECTIONS Top

Borrowed feathers or Jugad p. 235
Ravin Thatte
DOI:10.4103/ijps.IJPS_172_18  
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CASE REPORTS Top

Birth palsy in congenital varicella syndrome: A lesson in anatomy p. 238
Ajeesh Sankaran, Praveen Bhardwaj, Hari Venkatramani, Shanmuganathan Raja Sabapathy
DOI:10.4103/ijps.IJPS_56_18  
While brachial plexus palsy sustained due to birth trauma is well known, congenital palsies are decidedly rare. We report such a case caused by congenital varicella syndrome, with associated congenital Horner's syndrome and heterochromia iridis. The surprising juxtaposition of a classic upper plexus palsy and a Horner's syndrome raises points of interest. Similar reports in literature are reviewed, and the genesis of a very characteristic group of findings is discussed.
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Scalp replantation in a cervical spine injury patient: Lessons learnt p. 243
Vithal Malmande, Naveen Rao, Amaresh Biradar, Abhilash Bansal, Chandrika Dutt
DOI:10.4103/ijps.IJPS_206_17  
Total scalp avulsion injury with cervical spine injury is rare. This article is to describe the technical difficulties and precautions to be taken during anatomical replantation. The patients with cervical spine injury should not be considered as an absolute contraindication for anatomical replant if patients are fit for general anaesthesia. We found that the supratrochlear and supraorbital vessels which are anterior and superficial temporal vessels which are lateral can be used to replant without much technical difficulty. We conclude that anatomical replant is always better keeping in mind the technical limitations of anatomical replant in case of cervical spine injury.
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LETTERS TO EDITOR Top

Shaping the nasal tip: A new approach to transdomal suturing p. 247
Argyro Kypraiou, Petros V Vlastarakos, Stefanos Papailiadis
DOI:10.4103/ijps.IJPS_218_17  
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Popliteal pterygium syndrome: A rare syndrome p. 248
Surya Rao Rao Venkata Mahipathy, Alagar Raja Durairaj, Narayanamurthy Sundaramurthy, Manimaran Ramachandran
DOI:10.4103/ijps.IJPS_138_17  
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Encounter of plastic surgeons with pentazocine abuse: Lack of awareness or information overloaded p. 250
Neeti Neha, Veena Singh, Nandesh Kumar
DOI:10.4103/ijps.IJPS_193_17  
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Heterotopic ossification of the vascular pedicle of fibula causing trismus p. 252
Nikunj Mody, Samir Kumta, Shrirang Purohit, Rani Ummul, Sushil Nehete, Leena Jain
DOI:10.4103/ijps.IJPS_85_18  
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Fixators to retractors: Use of k-wires and glove rings as self-retaining retractors p. 254
Narayanamurthy Sundaramurthy, Manimaran Ramachandran, Surya Rao Rao Venkata Mahipathy, Alagar Raja Durairaj, Praveen Ganesh Natarajan
DOI:10.4103/ijps.IJPS_116_18  
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Reply - management of vascular anomalies: Review of institutional management algorithm p. 255
Shamendra Anand Sahu, Ankur Goyal, Shruti Marwah, Aniket Dave, Moumita De , Deepti Gupta
DOI:10.4103/ijps.IJPS_73_18  
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BOOK REVIEW Top

Essentials of aesthetic surgery Jeffery J. Janis p. 258
Surajit Bhattacharya
DOI:10.4103/ijps.IJPS_145_18  
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OBITUARY Top

Antony Charles Harington WATSON (1936–2018) p. 260
Mukund Ramchandra Thatte
DOI:10.4103/ijps.IJPS_181_18  
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