Indian Journal of Plastic Surgery
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   Table of Contents - Current issue
Coverpage
May-August 2016
Volume 49 | Issue 2
Page Nos. 135-298

Online since Thursday, September 29, 2016

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EDITORIAL  

Reforms p. 135
Mukund Jagannathan
DOI:10.4103/0970-0358.191302  PMID:27833269
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ICON OF THE ISSUE Top

Harold E. Kleinert, M.D. p. 136
Dinesh Kadam
DOI:10.4103/0970-0358.191300  PMID:27833270
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Dr. Harold Kleinert and the Plough p. 139
Ravin L Thatte
DOI:10.4103/0970-0358.191298  PMID:27833271
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Harold E. Kleinert - A tribute to a pioneer p. 140
S Raja Sabapathy
DOI:10.4103/0970-0358.191297  PMID:27833272
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PROF. MIRA SEN (BANERJEE) CME ARTICLE Top

Debates to personal conclusion in peripheral nerve injury and reconstruction: A 30-year experience at Chang Gung Memorial Hospital p. 144
David Chwei-Chin Chuang
DOI:10.4103/0970-0358.191295  PMID:27833273
Significant progress has been achieved in the science and management of peripheral nerve injuries over the past 40 years. Yet there are many questions and few answers. The author, with 30 years of experience in treating them at the Chang Gung Memorial Hospital, addresses debates on various issues with personal conclusions. These include: (1) Degree of peripheral nerve injury, (2) Timing of nerve repair, (3)Technique of nerve repair, (4) Level of brachial plexus injury,(5) Level of radial nerve injury,(6) Traction avulsion amputation of major limb, (7) Proximal Vs distal nerve transfers in brachial plexus injuries and (8) Post paralysis facial synkinesis.
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ORIGINAL ARTICLES Top

Effect of external volume expansion on the survival of fat grafts p. 151
Raghuveer Reddy, Subramania Iyer, Mohit Sharma, Sundeep Vijayaraghavan, P Kishore, Jimmy Mathew, A. K. K. Unni, P Reshmi, Rakesh Sharma, Chaya Prasad
DOI:10.4103/0970-0358.191322  PMID:27833274
Introduction: External volume expansion (EVE) is one method, which has been utilised for increasing the survival of adipose tissue grafts. EVE releases positive pressure from the graft and also induces intense levels of edema that decreases diffusion of metabolites essential for graft survival initially. The ideal timing of external volume expansion in relation to the injection of the fat to facilitate survival is not yet clear. Aims and Objectives: This study was undertaken to evaluate and compare the efficacy of external volume expansion applied at variable time points in relation to the injection of the fat. Materials and Methods: Athymic mouse was the animal model and human lipo-aspirate mixed with PRP was used as graft. An indigenous dome shaped silicone device was fabricated to deliver a negative pressure of -30 mm of Hg. The EVE was applied at variable time intervals. At the end of 4 weeks visual, histological and radiological features of the injected fat were compared. The adipose tissue was stained with human vimentin to ascertain the origin of the retained fat. Results: All the grafts, which had EVE, had significantly better volume retention and vascularity. The groups which underwent a delayed EVE or prior expansion followed by concomitant graft injection and expansion showed the most optimal vascularity and graft retention. Conclusions: A delayed EVE or prior expansion followed by concomitant graft injection and expansion may be the most ideal combinations to optimize graft take. However, on account of the relatively small sample size, there was a limitation in drawing statistically significant conclusions for certain variables.
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Passage through the carotid sheath: An alternative path to the pre-spinal route for direct repair of contralateral C7 to the lower trunk in total brachial plexus root avulsion injury p. 159
Piyush Bhupendra Doshi, Yogesh Chimanbhai Bhatt
DOI:10.4103/0970-0358.191327  PMID:27833275
Context: In surgical management of global brachial plexus injuries, direct repair of contralateral C7 (cC7) to the anterior division of the lower trunk, can produce good extrinsic finger flexion. The pitfalls associated with the pre-spinal passage have, perhaps, proved to be a deterrent for using this technique routinely. Aims: The aim of this study is to demonstrate an alternative to pre-spinal route for cC7 transfer in brachial plexus avulsion injuries. Methods: We noted that the mobilised lower trunk, which reaches the level of the scalenus anterior by passage deep to the clavicle, can be brought to the suprasternal notch when brought out from below the clavicle. This area was dissected in two cadavres, and safe passage was found through the carotid sheath with the common carotid artery medially and the internal jugular vein with the vagus nerve laterally. The cC7 root dissected medial to the scalenus anterior muscle can be directly transferred along this path to the subcutaneous plane at the suprasternal notch. This study allowed us to execute a direct repair in ten clinical cases of global brachial plexus injuries. In each case, the passage was prepared rapidly and uneventfully. The repair was technically simple and could be performed comfortably using suitable fine suture materials. In none of these cases, did we need to shorten the humerus. Results: The clinical outcome of this technique is awaited. Conclusions: We advocate carotid sheath route to approximate the cC7 to the injured lower trunk in global palsies, as the risks associated with the pre-spinal route can be readily avoided.
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COMMENTARY Top

Carotid sheath route: Is it the solution for the problems of the pre-spinal route? p. 164
Anil Ghanshyam Bhatia
DOI:10.4103/0970-0358.191296  PMID:27833276
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ORIGINAL ARTICLES Top

Tuberous breast deformity: A modified technique for single-stage correction p. 166
Shweta Aggarwal, Niri S Niranjan
DOI:10.4103/0970-0358.191293  PMID:27833277
Introduction: Tuberous breast deformity is one of the most challenging congenital breast anomalies. Severe forms present as hypoplasia of lower medial and lateral quadrants and breast base constriction. We present a modified technique based on redistribution of breast tissue for single-stage aesthetic correction of this deformity. Material, Methods and Surgical Technique: The technique is based on Lejour's method of single vertical scar breast reduction. The breast tissue is divided into three superiorly based pedicles. However, instead of joining the three pedicles, they are spread to redistribute tissue to quadrants which are deficient. This technique is combined with implant insertion if the breast volume is deficient or mastopexy if there is significant ptosis. The level of nipples is matched to achieve symmetry and areolar reduction done where indicated. We have used this for six patients with Type I/II/III (von Heimburg, 2000) tuberous breast deformity. Results and Discussion: The aesthetic results have been very good in terms of shape, volume, symmetry and patient satisfaction. A historical summary of the development of techniques for correction of tuberous breast is presented along with description of our method and its results.
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Periareolar augmentation mastopexy: A new approach dealing with the cases as tuberous breasts p. 172
Roberto Molto-Garcia, María Eloísa Villaverde-Domenech, Virina González-Alonso, Francisco Ripoll-Orts, Eduardo Simon- Sanz
DOI:10.4103/0970-0358.191330  PMID:27833278
Background: Periareolar augmentation mastopexy is one of the most demanded operations at Plastic Surgery clinics. Nevertheless, it is one of the leads of malpractice claims in United States caused by the high patient expectations and the standard surgical techniques which may result in common complications. The aim of this report is to present a new surgical approach to solve these complications. Methods: After establishing a working hypothesis, we performed a revision study of our patients and we came to the following conclusion: in order to perform a periareolar mastopexy for ptosis correction, breast has to be tuberous at any level and to have abnormally short inferior pole. These findings may explain the main complications from periareolar augmentation mastopexy with the standard surgical techniques. Consequently, we started a prospective observational study including 56 patients following a new surgical technique which deals the cases as tuberous breasts. Results: During three years, fifty-six periareolar mastopexies were performed with this new surgical approach with one year follow-up. No major complications were observed and 40 of the patients (71%) described the results as very positive. Conclusion: “If a periareolar mastopexy can be performed, then it must be a tuberous breast”. According to this, a new surgical technique for periareolar augmentation mastopexy has been developed obtaining an improvement in our surgical results and achieving a totally different view on this pathology, which has not been reported in literature yet.
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Free toe pulp flap for finger pulp and volar defect reconstruction p. 178
Jyoshid R Balan
DOI:10.4103/0970-0358.191319  PMID:27833279
Background: Fingertip injury requiring flap cover is very common in the modern era. The ideal cover should fulfill both functional and aesthetic improvement. Materials and Methods: From June 2015 to April 2016, we performed seven free toe pulp flaps for finger defect reconstruction. All patients were males. Five flaps were done in emergency post-traumatic cases, and two were done in elective set up. The cases included reconstruction of three thumbs, one index and one ring finger in an emergency set up and two ring fingers in the elective. Thumb reconstruction was done with great toe lateral pulp and the other digits reconstructed with second toe pulp flap. Follow-up evaluation included both functional and aesthetic assessment. Results: Five flaps survived completely, one suffered partial loss, and one flap failed completely. The median follow-up period was 9 months. The median duration of surgery was 255 min (range 210 to 300 min). The median two-point discrimination was 6.5 mm (range 4–8 mm). There was the return of temperature sensation in all patients; two had cold intolerance. The Semmes-Weinstein monofilament score varied from 3.61 to 5.07 (median filament index value 4.31/pressure value of 2 g/mm2). Three patients had delayed donor site wound healing. Conclusions: The free toe pulp flap is an efficient choice for fingertip and volar finger defects reconstruction with an excellent tissue match.
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Effective use of simple computer programmes and clay models to demonstrate the planning and operative steps for teaching and presentations p. 185
Rahul Krishnarao Patil, Gopal Malhotra, Venugopal Srinivasan, Ahmed Osama Abdul Hamid, Mahil Cherian, Ashok Raj Koul
DOI:10.4103/0970-0358.191329  PMID:27833280
Background: Presenting and demonstrating a surgical procedure in the current era is difficult without good intraoperative pictures and videos. A long, complex, multi-staged surgery is better illustrated by detailed intraoperative images at various stages. Although desirable, it may be difficult due to various reasons. Material and Methods: A simple method of preparing illustrations with pictures/diagrams created on PowerPoint and clay models to recreate the missing links in clinical photographs has been proposed. Results: It is a simple technique with a moderate learning curve. Once familiar with technique, one can effectively use the technique to convey the details in much more clear manner. Conclusion: It is a simple and effective way of communicating through digital images, and gives the audience a 3 dimensional idea about the concept.
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One plus one: Two free flaps from same donor thigh for simultaneous coverage of two different defects p. 191
Susmitha Bandi, Rayidi Venkata Koteswara Rao, Damalacheruvu Mukunda Reddy
DOI:10.4103/0970-0358.191325  PMID:27833281
Introduction: Primary microvascular reconstruction of multiple defects is challenging particularly if it has to be simultaneous. In trauma cases, harvesting two independent free flaps from different sites is very time-consuming and adds to morbidity. To eliminate these disadvantages, we sought to find out a reliable alternative method of harvesting two independent free flaps based on the descending branch of circumflex femoral artery, i.e., one anterolateral thigh (ALT) flap and one rectus femoris muscle flap. Aim: To study the feasibility of transferring two free flaps, i.e., ALT and rectus femoris muscle flap simultaneously from the same thigh for coverage of two different limb defects. Materials and Methods: From 2003 to 2012, five patients with two defects each were managed with a total of ten flaps harvested from five donor sites based on independent pedicles of descending branch of lateral circumflex femoral artery and used to cover severe injuries of extremities. Three cases had both lower limb defects and two cases had one upper limb and one lower limb defect. In each case, one ALT flap and one rectus femoris muscle flap were used for coverage. Results: All reconstructive procedures were completed without any major complications. All flaps survived well. There were no re-explorations and no complications related to donor sites. Conclusion: We conclude that our approach of simultaneous harvest of ALT and rectus femoris muscle from the same thigh offers two flaps for two different defects in terms of economy of donor site and operating time.
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Antibiotic susceptibility of wound isolates in plastic surgery patients at a tertiary care centre p. 198
Surendra B Patil, Amit Paramne, Shree Harsh
DOI:10.4103/0970-0358.191324  PMID:27833282
Context: Wound infection increases the hospital stay and adversely affects the recovery of patients. Culture and sensitivity of wound isolates help in proper diagnosis and management of these patients. Aim: To identify common bacteria causing wound infections and their antibiotic sensitivity pattern. Study Design: A cross-sectional study. Place and Duration of Study: Government Medical College and Hospital, Nagpur from October 2013 to October 2015. Materials and Methods: Pus samples were collected by doctors in ward using Sterile Swab Sticks. Bacterial isolates were identified and cultured, and antibiotic culture sensitivity tests were performed. Statistical Analysis Used: Chi-square test. Results: There were a total of 150 patients with infected wounds. Most common organism isolated was Pseudomonas followed by Klebsiella and Staphylococcus aureus. All of these organisms were resistant to most routine antibiotics. Conclusion: We suggest a multidisciplinary approach to wound management, rational drug use, routine microbiological surveillance of wounds and institution of hospital infection control policy.
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Congenital hand anomalies in Upper Egypt p. 206
Tarek Abulezz, Mohamed Talaat, Asem Elsani, Karam Allam
DOI:10.4103/0970-0358.191303  PMID:27833283
Background: Congenital hand anomalies are numerous and markedly variant. Their significance is attributed to the frequent occurrence and their serious social, psychological and functional impacts on patient's life. Patients and Methods: This is a follow-up study of 64 patients with hand anomalies of variable severity. All patients were presented to Plastic Surgery Department of Sohag University Hospital in a period of 24 months. Results: This study revealed that failure of differentiation and duplication deformities were the most frequent, with polydactyly was the most common anomaly encountered. The mean age of presentation was 6 years and female to male ratio was 1.46:1. Hand anomalies were either isolated, associated with other anomalies or part of a syndrome. Conclusion: Incidence of congenital hand anomalies in Upper Egypt is difficult to be estimated due to social and cultural concepts, lack of education, poor registration and deficient medical survey. Management of hand anomalies should be individualised, carefully planned and started as early as possible to achieve the best outcome.
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Long-term follow-up and patient satisfaction after reduction mammoplasty: Superomedial versus inferior pedicle p. 214
Mohamed Makboul, Mahmoud S Abdelhamid, Ghada S Al-Attar
DOI:10.4103/0970-0358.191299  PMID:27833284
Background: Surgery for hypertrophied breasts represents a challenge for plastic surgeons. The search for a good post-surgical cosmetic breast has led to the development of many techniques. Objectives for reduction mammoplasty are to achieve elevated, symmetrical breasts, a round shape, good projection, small cicatrices that are not very perceptible, and a lasting result. Patients and Methods: This study was carried out on sixty cases who had done reduction mammoplasty from January 2009 to December 2014. All patients were examined and were asked for late post-operative results and overall patients' satisfaction. Results: Long-term projection and contour of the breast were more satisfactory among patients who had superomedial pedicle with a statistically significant difference. No statistically significant difference was observed between patients underwent either superomedial or inferior pedicle reduction mammoplasty with regard to breast shape symmetry, nipple symmetry and sensation. The mean score for satisfaction was higher among patients who underwent superomedial pedicle rather than the inferior pedicle method. Conclusion: The superomedial pedicle shows better long-term cosmetic results.
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Subcutaneous pedicle propeller flap: An old technique revisited and modified! p. 220
Durga Karki, Nikhil Mehta, Ravi Prakash Narayan
DOI:10.4103/0970-0358.191306  PMID:27833285
Background: Post-burn axillary and elbow scar contracture is a challenging problem to the reconstructive surgeon owing to the wide range of abduction and extension that should be achieved, respectively, while treating either of the joint. The aim of this paper is to highlight the use of subcutaneous pedicle propeller flap for the management of post-burn axillary and elbow contractures. Methodology: This is a prospective case study of axillary and elbow contractures managed at a tertiary care hospital using propeller flap based on subcutaneous pedicle from 2009 to 2014. Surgical treatment comprised of subcutaneous-based pedicle propeller flap from the normal tissue within the contracture based on central axis pedicle. The flap was rotated axially to break the contracture. The technique further encompassed a modification, a Zig-Zag incision of the flap, which was seen to prevent hypertrophy along the incision line. There was a mean period of 12 months of follow-up. Results: Thirty-eight patients consisting of 22 males and 16 females were included in this study among which 23 patients had Type II axillary contractures and 15 had moderate flexion contractures at elbow joint. The post-operative abduction achieved at shoulder joint had a mean of 168° whereas extension achieved at elbow had a mean of 175°. The functional and aesthetic results were satisfactory. Conclusion: The choice of surgical procedure for reconstruction of post-burn upper extremity contractures should be made according to the pattern of scar contracture and the state of surrounding skin. The choice of subcutaneous pedicle propeller flap should be emphasised because of the superior functional results of flap as well as ease to learn it. Moreover, the modification of propeller flap described achieves better results in terms of scar healing. There is an inter-positioning of healthy skin in between the graft, so it prevents scar band formation all around the flap.
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Diagnostic tools in maxillofacial fractures: Is there really a need of three-dimensional computed tomography? p. 225
Sheerin Shah, Sanjeev K Uppal, Rajinder K Mittal, Ramneesh Garg, Kavita Saggar, Rishi Dhawan
DOI:10.4103/0970-0358.191320  PMID:27833286
Introduction: Because of its functional and cosmetic importance, facial injuries, especially bony fractures are clinically very significant. Missed and maltreated fractures might result in malocclusion and disfigurement of the face, thus making accurate diagnosis of the fracture very essential. In earlier times, conventional radiography along with clinical examination played a major role in diagnosis of maxillofacial fractures. However, it was noted that the overlapping nature of bones and the inability to visualise soft tissue swelling and fracture displacement, especially in face, makes radiography less reliable and useful. Computed tomography (CT), also called as X-ray computed radiography, has helped in solving this problem. This clinical study is to compare three-dimensional (3D) CT reconstruction with conventional radiography in evaluating the maxillofacial fractures preoperatively and effecting the surgical management, accordingly. Materials and Methods: Fifty patients, with suspected maxillofacial fractures on clinical examination, were subjected to conventional radiography and CT face with 3D reconstruction. The number and site of fractures in zygoma, maxilla, mandible and nose, detected by both the methods, were enumerated and compared. The final bearing of these additional fractures, on the management protocol, was analysed. Results: CT proved superior to conventional radiography in diagnosing additional number of fractures in zygoma, maxilla, mandible (subcondylar) and nasal bone. Coronal and axial images were found to be significantly more diagnostic in fracture sites such as zygomaticomaxillary complex, orbital floor, arch, lateral maxillary wall and anterior maxillary wall. Conclusion: 3D images gave an inside out picture of the actual sites of fractures. It acted as mind's eye for pre-operative planning and intra-operative execution of surgery. Better surgical treatment could be given to 33% of the cases because of better diagnostic ability of CT.
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IDEAS AND INNOVATIONS Top

Precise breast implant placement using percutaneous chest wall markings p. 234
Janna Joethy, Bien-Keem Tan
DOI:10.4103/0970-0358.191294  PMID:27833287
Background: Traditionally, pre-operative breast markings are usually made using an indelible marker. These markings are at risk of being removed by pre-operative cleaning, positional changes and parenchymal changes post-incision. We present our approach to breast surgery with rib or intercostal markings using methylene blue. Methods: Using an indelible marker, markings are made on the breast and the inframammary crease. A blue needle (23 G) mounted on a 1 ml syringe is prepared, and aliquots of 0.1 ml of methylene blue are injected. Excessive infiltration and pre-operative local anaesthetic infiltration result in diffusion of the dye and difficulty with accuracy. Dye is injected directly over the bony periosteum closest to the inframammary fold. Results: We achieved good symmetry of bilateral breast implants. Photographs were taken pre-operative and 3 months post-operative and were evaluated independently by medical officers. All results were rated as good or very good. We had 39 patients and follow-up was between 3 and 24 months. There were no implant-related complications. Conclusions: For accurate implant placement, a fixed position must be found. Our technique utilises the relative immobility of the ribs for accurate implant placement. Disadvantages to our method were few, and we had two cases of dizziness or patients feeling faint due to pain. There is also a potential allergic or anaphylaxis reaction, but we did not experience any allergic reaction.
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CASE REPORTS Top

Algorithmic surgical enhancement of function after finger revascularisation p. 239
Luis Landin, Pedro Bolado, Maria-Angeles Gajete, Alvaro Gonzalez-Miranda, Jorge Bonastre
DOI:10.4103/0970-0358.191313  PMID:27833288
Secondary surgical procedures can improve the function of revascularised and replanted digits. We describe the case of a patient who underwent multidigit revascularisation and replantation following a saw injury at flexor tendon Zone II. To achieve maximal functional improvement after finger revascularisation, we performed secondary surgical procedures in an order that was determined by following a reconstructive decision procedure that covered late revascularisation, nerve reconstruction, pedicled vascularised joint transfer, staged flexor tendon reconstruction and skin revision. Performing the procedures in this manner ensured overall safety. The patient's disabilities of the arm, hand and shoulder questionnaire score improved by 45 points, and the patient was able to return to work with an almost complete range of motion.
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Premenarchal labia minora hypertrophy p. 245
Karoon Agrawal, Pankaj Kumar Patel, Shamendra Anand Sahu
DOI:10.4103/0970-0358.191323  PMID:27833289
Labia minora hypertrophy is a relatively uncommon surgical entity being popularised in the realm of vulvovaginal plastic surgeries. Apart from the unaesthetic appearance of the hypertrophied minora, these cases are also associated with itching, hygiene problem, pain while sitting down, sports activities, difficulty in wearing tight clothing, bleeding and discomfort while or after sexual intercourse, social embarrassment, insecurity and psychological diminution of confidence and self-esteem. In a country like India, due to sociocultural reasons, patients hesitate to consult a doctor for such deformities. Most of the patients suffer in silence for years. Although common in the west, very few surgeons in the country perform this simple and rewarding surgery. Here, we are presenting a case of premenarchal juvenile labia minora hypertrophy (JLMH) in an 8-year-old child. Labial hypertrophy in this age group is uncommon. We were unable to find hypertrophy of labia minora in the eight-year-old child on English literature search.
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Free gracilis flap for chest wall reconstruction in male patient with Poland syndrome after implant failure p. 249
Mario Cherubino, Francesca Maggiulli, Igor Pellegatta, Luigi Valdatta
DOI:10.4103/0970-0358.191326  PMID:27833290
Poland's syndrome (PS) is a congenital monolateral deformity that may involve breast, chest wall, and upper limb with different degrees of clinical expressions. In some cases, the problem is mainly cosmetic, and the reconstruction should be performed to achieve minimal scarring and donor site morbidity. The authors describe a case report of a male patient with PS who developed a severe capsular contraction after 25 years implant reconstruction, who was treated after explantation using free gracilis flap (FGF). In this patient, only the pectoralis major muscle was missing. An FGF was performed to reconstruct the anterior axillary fold and the soft tissue defect. There was no flap loss, the patient had a clearly improved appearance of the chest wall, and the pain syndrome was solved. In this case report, we demonstrate our experience with the use of an FGF for chest wall reconstruction in male patients with PS after prosthesis explantation.
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A case report of acampomelic campomelic dysplasia and operative difficulties in cleft palate reconstruction p. 253
M Pasupathy, Vasant Radhakrishnan, Hirji Sorab Adenwalla, Puthucode V Narayanan
DOI:10.4103/0970-0358.191310  PMID:27833291
Acampomelic campomelic dysplasia (CD) is a type of CD (CD; OMIM #114290), a rare form of congenital short-limbed dwarfism and is due to mutations in SOX9 gene family. Characteristic phenotypes of CD include bowing of the lower limbs, a narrow thoracic cage, 11 pairs of ribs, hypoplastic scapulae, macrocephaly, flattened supraorbital ridges and nasal bridge, cleft palate and micrognathia. The bending of the long bones is not an obligatory feature and is absent in about 10% of cases, referred to as acampomelic CD. A child previously diagnosed with acampomelic CD was brought to our outpatient clinic for cleft palate reconstruction. Our neurosurgeon cautioned us against performing surgery with extension of the neck in view of the possibility of producing quadriparesis, due to narrowing of the spinal canal as part of the osseous anomaly noted in the magnetic resonance imaging study of the spine, thus making the anaesthesia, surgical and post-operative procedures difficult. The cleft palate reconstruction was performed with all precautions and was uneventful.
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Superficial upper limb vasculature and its surgical implications p. 258
Richa Gupta, Anjali Aggarwal, Tulika Gupta, Harjeet Kaur, Sunil Gaba, Daisy Sahni
DOI:10.4103/0970-0358.191314  PMID:27833292
Any kind of anatomical variation whether encountered during cadaveric dissections or routine clinical or surgical procedures needs to be reported and taken into account. This can be quite helpful in planning surgeries accordingly and avoid disastrous complications. During routine cadaveric dissection, authors found a superficial course of arteries of the arm as well as the forearm, unilaterally in one cadaver. In this case, there were two brachial arteries - superficial and deep. Superficial brachial artery terminated into superficial radial and superficial ulnar artery. Deep brachial artery was trifurcated into common interosseous, medial and lateral artery branches. Authors have also discussed the developmental anomaly, which could have led to the observed morphological variation. Superficial vessels can provide large size pedicles for raising flaps for local reconstructive surgeries in the region of axilla, elbow, wrist or hand, or other regions.
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A review of three cases of mobile blast: The new culprit of hand injury p. 261
Nikunj B Mody, Surendra B Patil, Satish M Kale
DOI:10.4103/0970-0358.191309  PMID:27833293
Although blast injuries are common with war; cooking gas; firecracker, mobile phone blast cases are increasing in number in last couple of years. We present 3 cases of mobile blast in 3 children causing injury to dominant hand in them.
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Anterior urethral diverticulum: A rare presentation p. 265
Annavarupu Gopalkrishna, Somendra Mohan Sharma, B Ananda
DOI:10.4103/0970-0358.191304  PMID:27833294
Congenital anomalies of the urogenital tract are the most common anomalies found in the foetus, neonates and infants, but anterior urethral valves and diverticula are rare. Here, we present a case with congenital anterior urethral diverticulum associated with patent ductus arteriosus and polydactyly.
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Successful penile reconstruction following prior arteriovenous loop thrombosis due to undiagnosed protein-S deficiency and exogenous testosterone Highly accessed article p. 268
Parameswaran Anoop, Vithal Malmande, MN Prakash Kumar, Naveen Rao
DOI:10.4103/0970-0358.191307  PMID:27833295
Flap failure from microvascular thrombotic occlusion is a rare but significant cause for unsuccessful reconstructive surgery. We encountered thrombosis of arteriovenous loop in a patient undergoing phallus reconstruction. Further investigations revealed underlying previously asymptomatic hypercoagulable state due to protein-S deficiency in addition to long-term exogenous testosterone administration. Role of thrombophilia testing, thrombogenic potential of testosterone and the need for therapeutic perioperative anti-coagulation in such situations are described here.
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Three rare cases of cutaneous phaeohyphomycosis p. 271
Aditi Chhonkar, Deepti Kataria, Swagata Tambe, Chitra S Nayak
DOI:10.4103/0970-0358.191321  PMID:27833296
Phaeohyphomycosis is a chronic infectious condition caused by dematiaceous fungi which usually involve the skin and subcutaneous tissue. Subcutaneous phaeohyphomycosis is characterised by papulonodules, verrucous, hyperkeratotic or ulcerated plaques, cysts, abscesses, pyogranuloma, non-healing ulcers or sinuses. In India, commonly associated genera are Exophiala, Phialophora, Cladosporium, Curvularia, Fonsecaea and Alternaria. This condition involves the presence of brown-walled hyphal structures in the dermis and epidermis. Here, we are reporting a rare case series of three patients of phaeohyphomycosis with lesions on finger and dorsum of the hand.
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An unusual foreign body in the infratemporal fossa p. 275
Sharad Ramdas
DOI:10.4103/0970-0358.191312  PMID:27833297
Infratemporal fossa injuries are uncommon and often go undetected presenting later with complications. We present a case of an infratemporal fossa penetrating injury with a ball point spring following a vehicular accident. Post-traumatic trismus even following supposedly trivial injury in the area should raise suspicion of possible injury in this location.
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Replantation in scapulothoracic avulsion amputation of the right upper limb in a 3-year-old child- A preliminary report p. 279
Sanjay Mahendru, Rakesh Kumar Khazanchi, Vimalendu Brajesh, Akram Jawed, Aditya Aggarwal, Hardeep Singh, Sukhdeep Singh, S Krishnan
DOI:10.4103/0970-0358.191308  PMID:27833298
Replantations for major amputations of upper extremity have been widely performed. We report a unique case of successful replantation of scapulothoracic avulsion amputation in a child. In this manuscript, we discuss the various challenges faced during the procedure and chances of neural recovery.
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LETTERS TO EDITOR Top

Hatchet flap and rotation flap for distal dorsal finger defect reconstruction p. 283
Jyoshid R Balan
DOI:10.4103/0970-0358.191305  PMID:27833299
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Coverage of below elbow amputation stump with a soft-tissue periosteal flap p. 284
Rahul Krishnarao Patil, Ahmed Osama Abdel Hamed, Srinivasan Venugopal, Mahil Cherian, Gopal Malhotra
DOI:10.4103/0970-0358.191317  PMID:27833300
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Finger abduction splint: For the release of contracture and skin grafting p. 286
Shruti Devendra, Devendra Kumar Gupta
DOI:10.4103/0970-0358.191311  PMID:27833301
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Disposable gloves as an educational tool in teaching hand anatomy p. 287
Amitabh Thacoor, Diaa Othman, Sharmila Jivan
DOI:10.4103/0970-0358.191328  PMID:27833302
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Ingenious technique of smoothening costal cartilage graft by glass polishing disc p. 288
Kapil Agrawal, Raghav Shrotriya
DOI:10.4103/0970-0358.191318  PMID:27833303
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Camphor burns over the forehead: Socially relevant non-homicidal injury in a child p. 289
Sandhya Pandey, Dinesh Kumar Sivakumar, Ravi Kumar Chittoria, Devi Prasad Mohapatra, MT Friji
DOI:10.4103/0970-0358.191292  PMID:27833304
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Salvage oesophageal reconstruction that withstood the test of time p. 291
TM Sheeja Rajan, S Rajesh, Benoy Varghese, PV Ramnarayan
DOI:10.4103/0970-0358.191315  PMID:27833305
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Revisiting Mehendale's needle holder for cleft palate surgery: A gift from the bygone era p. 293
Raghav Shrotriya, Kapil Agrawal, Vinita Puri
DOI:10.4103/0970-0358.191316  PMID:27833306
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OBITUARY Top

Prof. U. S. Nayak M.S., M.Ch., F.R.A.C.S. p. 295
Anand U Kini, Dinesh Kadam
DOI:10.4103/0970-0358.191301  
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NOTICE OF RETRACTION Top

Retraction: Surgical reconstruction or prosthetic rehabilitation following orbital exenteration: The clinician's dilemma p. 298

DOI:10.4103/0970-0358.191331  PMID:27833307
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