Indian Journal of Plastic Surgery
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   Table of Contents - Current issue
September-December 2016
Volume 49 | Issue 3
Page Nos. 299-437

Online since Friday, December 30, 2016

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Editorial p. 299
Mukund Jagannathan
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Dr. Ivo Pitanguy: Strived for a 'human right to beauty' p. 300
Surajit Bhattacharya
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Healing ulcers and preventing their recurrences in the diabetic foot Highly accessed article p. 302
S Raja Sabapathy, Periasamy Madhu
Fifteen percent of people with diabetes develop an ulcer in the course of their lifetime. Eighty-five percent of the major amputations in diabetes mellitus are preceded by an ulcer. Management of ulcers and preventing their recurrence is important for the quality of life of the individual and reducing the cost of care of treatment. The main causative factors of ulceration are neuropathy, vasculopathy and limited joint mobility. Altered bio-mechanics due to the deformities secondary to neuropathy and limited joint mobility leads to focal points of increased pressure, which compromises circulation leading to ulcers. Ulcer management must not only address the healing of ulcers but also should correct the altered bio-mechanics to reduce the focal pressure points and prevent recurrence. An analysis of 700 patients presenting with foot problems to the Diabetic Clinic of Ganga Hospital led to the stratification of these patients into four classes of incremental severity. Class 1 – the foot at risk, Class 2 – superficial ulcers without infection, Class 3 – the crippled foot and Class 4 – the critical foot. Almost 77.5% presented in either Class 3 or 4 with complicated foot ulcers requiring major reconstruction or amputation. Class 1 foot can be managed conservatively with foot care and appropriate foot wear. Class 2 in addition to measures for ulcer healing would need surgery to correct the altered bio-mechanics to prevent the recurrence. The procedures called surgical offloading would depend on the site of the ulcer and would need an in-depth clinical study of the foot. Class 3 would need major reconstructive procedures and Class 4 would need amputation since it may be life-threatening. As clinicians, our main efforts must be focused towards identifying patients in Class 1 and offer advice on foot care and Class 2 where appropriate surgical offloading procedure would help preserve the foot.
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Nasal correction in nasomaxillary hypoplasia (Binder's syndrome): An optimised classification and treatment p. 314
Venkata Ramana Yamani, Shakuntala Ghosh, Shreekumar Tirunagari
Background: Nasomaxillary hypoplasia is a rare congenital disorder involving the central face. It imparts a distinctive appearance to the individual face as the age advances. Severity of the disorder varies, so do the manifestations. Methods: This was a retrospective study conducted on the records and photographic data of 560 rhinoplasty cases performed between 2006 March and 2016 March. About 16 cases of nasomaxillary hypoplasia were selected from the group and they were classified based on the severity of the features. Surgical correction performed in each group was detailed. Results: Three percent of the 560 rhinoplasties performed in our centre turned out to be cases of Binder's syndrome. Nasal correction with locoregional autologous cartilage grafts was sufficient in mild cases. Loco-regional cartilage grafts along with costal cartilage grafts were needed for moderate and severe cases. Anterior nasal floor along with alar base augmentation was performed to achieve a proper aesthetic profile in moderate and severe cases. Post-operative results were excellent in mild and moderate cases and acceptable in severe cases. Discussion: We attempted to correct the deformity only after growth of the nose and maxilla was completed. We used cartilage grafts as a mainstay as cartilage has long-term stability without resorption unlike bone grafts. Instead of following en bloc technique of cartilage assembly, we have reconstructed the nasal dorsum, columella and tip separately as this principle is more functionally acceptable with less warping or stiffness of the nose. Importance was given to proper anchorage of grafts. Conclusion: We have attempted to put together the various features into three categories of mild/moderate/severe based on previous anthropometric studies of nasal anatomical parameters. The second objective of our study was to advise a logical surgical protocol for each group so that future surgeons can follow an easy surgical guideline to attain optimal cosmetic and functional results.
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Silicone Foley's catheter as an effective alternative to Hunter's rod in staged flexor tendon reconstruction of the hand p. 322
Tawheed Ahmad, Sheikh Adil Bashir, Mohammad Inam Zaroo, Adil Hafeez Wani, Saima Rashid, Summaira Jan
Context: Staged flexor tendon reconstruction is most suitable treatment method for extensive zone II tendon injuries. The Hunter's rod used in this procedure is costly and not easily available, which adds to the miseries of both patients as well as treating surgeon. Aims: The aim of this study is to evaluate the results of staged zone II flexor tendon repair using silicone Foley's catheter as a cheaper and readily available alternative to Hunter's rod. Settings and Design: This was a prospective study. Materials and Methods: Seventy digits in 35 patients were treated by the staged flexor tendon reconstruction using silicone Foley's catheter in place of Hunter's rod, and the patients were followed for an average period of 18 months. Early controlled motion exercise protocol was instituted in all cases. Results: As per the Strickland scale, total active motion obtained was excellent in 70%, good in 20%, fair in 7.1% and poor in 2.9% of patients. Conclusions: Silicone Foley's catheter is cheaper, easily available and an effective alternative to Hunter's rod in staged flexor tendon reconstruction procedure, yielding high rates of excellent and good results with fewer complications.
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Midface-lift patient satisfaction: A 5-year follow-up study p. 329
Pascali Michele, Davide Quarato, Ilaria Bocchini, Cervelli Valerio
Context: Several studies showed, from the clinical point of view, the advantages of the various techniques and surgical approaches to obtain facial rejuvenation. A few studies have highlighted the satisfaction or not of patients who underwent a traditional facelift; however, a long-term follow-up study measuring patient satisfaction with midface-lift surgery has not been published yet. Aims: The aim of this study is to measure individual patient satisfaction with the midface lift, to find out from each patient his/her level of satisfaction 1 and 5 years after the operation and to compare the results to assess the benefits of the surgery. Background: Several studies showed, from a clinical point of view, the advantages of the various techniques and surgical approaches to obtain facial rejuvenation; however, a long-term follow-up study measuring patient satisfaction with midface-lift surgery has not been published yet. Materials and Methods: Between January 2005 and January 2010, 163 patients underwent a midface lift. All patients were asked to complete a standardised survey 1 and 5 years after surgery, in order to measure outcomes among facial aesthetic patients. Statistical Analysis Used: The paired t-test. Results: All patients reported an improvement as a result of the midface lift. Statistically significant differences in judgement criteria were found for malar eminence and nasojugal groove. Almost all of the patients turned out to be completely satisfied with their appearance with the new look. Conclusions: Patients were extremely satisfied with their decision to undergo a midface lift and with the outcomes and quality of life following the procedure.
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Pre-maxillary complex morphology in bilateral cleft and hypothesis on laterality of deviated pre-maxilla p. 336
Jyotsna Murthy, Devi Manisha
Introduction: Pre-maxillary complex (pre-maxilla [PMX] + vomer) morphology in bilateral complete cleft of primary and secondary palate (BCLCP) is very complex and less reviewed in literature. Materials and Methods: In this retrospective cross-sectional study, 200 consecutive BCLCP patients were selected. Their pre-operative clinical photographs and dental casts were evaluated by a single investigator at two different points of time, to study the morphology of PMX and vomer with special emphasis on deviation of vomer and rotation of PMX. Results: It is found that in above 70% of patients, PMX and vomer both displaced or deviated towards left side in horizontal plane and PMX rotated anticlockwise at PMX vomerine suture (PVS). In 10% of cases, both PMX and vomer are displaced towards the right side, PMX rotated clockwise at PVS. In 11% of cases, vomer is displaced towards the left side, but PMX rotated clockwise at PVS. In 5% of cases, vomer is displaced towards the right side, but PMX rotated anticlockwise at PVS. Both PMX and vomer are in midline in 4% of cases. Conclusion: Specific morphological deviation of vomer and PMX has been studied. We put forward the probable hypothesis to explain the deviation and rotation of PMX.
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A 20-year experience in unilateral cleft lip repair: From Millard to the triple unilimb Z-plasty technique p. 340
Percy Rossell-Perry
Background: This study describes a 20-year experience of treating patients with unilateral cleft lip. During this time, various techniques were used including Millard's technique and its modification and two types of geometrically designed procedures. The study objective was to compare surgical outcomes of different surgical techniques for unilateral cleft lip repair. Materials and Methods: This is a retrospective audit of outcomes after unilateral cleft lip repair performed by a single surgeon since 1995. Of the 827 patients who underwent surgery, 277 met the criterion of having anthropometric measurements performed ≥1 year postoperatively. The patients were stratified into three groups according to cleft severity: incomplete, complete with less deficiency (3–6 mm difference between cleft and non-cleft lip height) and complete with more deficiency (>6 mm difference between cleft and non-cleft lip height). Anthropometric measurements, scar assessment and complications were recorded. Results: There were no differences in outcomes between Millard and Reichert-Millard techniques for incomplete unilateral cleft lip. For complete unilateral cleft lip and less tissue deficiency, lip symmetry was better using upper rotation advancement plus double unilimb Z-plasty than the Reichert-Millard technique. For complete unilateral cleft lip and more tissue deficiency, lip symmetry was better after triple unilimb Z-plasty than after upper rotation advancement plus double unilimb Z-plasty. Conclusions: We presented a 20-year experience performing unilateral cleft lip repair. An individualised classification system with corresponding surgical techniques was successfully used during this period. The individualised surgical protocol used in this study allowed us to achieve improved surgical outcomes.
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Gracilis muscle transposition as a workhorse flap for anal incontinence: Quality of life and functional outcome in adults p. 350
Guru Dayal Singh Kalra, Amit Kumar Sharma, Kaustubh Sharad Shende
Background/Purpose: Anal incontinence is one of the most psychologically and socially debilitating conditions in an otherwise healthy individual. It can lead to social isolation, loss of self-esteem, self-confidence and depression. This study is devoted to the problem of anal incontinence in the adult patients. The aim of our study is to analyse the results of gracilis muscle transposition for anal incontinence and improvement in quality of life (QOL) of patients. Materials and Methods: This was a retrospective study. A total of 18 patients with complaint of anal incontinence were enrolled in this study. All patients were treated with gracilis muscle transposition. Results: All patients are continent, and there is an improvement in their QOL. Conclusion: Gracilis muscle transposition is a good option for patients of anal incontinence who are not treated by non-surgical means.
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Awkward defects around the elbow: The radial recurrent artery flap revisited p. 357
Maksud M Devale, Rohit P Munot, Chirag A Bhansali, Neeraj D Bhaban
Background: Soft tissue defects on the posterior aspect of the elbow are commonly seen in patients treated with internal fixation for fractures around the elbow joint. An axial flap based on the radial recurrent artery (RRA) is very useful for such defects, especially if a posterior midline arm incision has been taken for skeletal fixation. The aim of this study is to describe the usefulness of RRA flap (based on the RRA) in the management of such defects. Materials and Methods: We present a retrospective analysis of 4 cases managed with the RRA flap for soft tissue reconstruction of defects around the elbow joint at our institute from January 2015 to August 2016. All the patients were males with a history of exposed implant following internal fixation of olecranon/distal humerus fracture. The size of defects ranged from 4 cm × 4 cm to 7 cm × 5 cm. Results of the analysis are presented here. Results: All flaps survived completely. There was no infection, hematoma or distal neurovascular deficit. There was minimal donor site morbidity. Conclusion: The RRA flap is a useful, simple flap for defects around the elbow joint in select patients providing one stage, reliable, cosmetically acceptable coverage.
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Turned in fasciocutaneous island flap from face and neck based on subdermal microcirculation for reconstruction of the oral cavity following cancer surgery p. 362
Kalpesh Jayantkumar Gajiwala
Background: The skin and soft tissues of the face and neck have a rich plexus of dermal-subdermal vessels, which creates the possibility of raising a fasciocutaneous flap based on this vascular supply. A turned in fasciocutaneous island flap (TIFCIF) from an adjacent area of the defect can provide a simple substitute to many complex reconstructive procedures. Materials and Methods: Fifteen patients underwent wide excision for oral cancer and upper neck dissection, maintaining bone framework, between August 2010 and June 2014. The reconstruction was done with a 'turned in fasciocutaneous island flap' (TIFCIF) from the upper neck-lower face based on subdermal superficial adipofascial microvascular network instead of a specific known feeder vessel. The upper cervical flap, the donor site, when raised during the initial incision and the upper neck dissection, was cut off from the facial artery, the submental artery, the superior thyroid and the transverse cervical arteries. The microcirculation depended largely on the rich vascular plexus formed of the branches of the superficial temporal and the maxillary arteries. The donor site was primarily closed in Fourteen of the Fifteen patients. Eight patients received post-surgery irradiation. Results: All the flaps survived and healed and withstood radiation well. Two patients had flap dehiscence from suture line, of which one needed reattachment while other a minor one healed by itself and one patient had occasional drooling. There was no difficulty in eating or swallowing. Conclusions: A random patterned TIFCIF based on superficial subdermal adipofascial microcirculation, formed of a rich vascular plexus in the face and neck region can provide a simple alternative for intraoral reconstruction.
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Limb salvage with microvascular free fibula following primary bone sarcoma resection p. 370
Sahasrabudhe Parag, Panchwagh Yogesh, Jesal Rathod, Panse Nikhil, Jadhav Amit
Background: Extremity sarcomas are challenging to manage. Total eradication of tumour has to be balanced with restoration of limb function to prevent mortality and morbidity. Disease-free survival with maximum limb function is the ultimate goal in these patients. Materials and Methods: We present a series of ten cases of extremity malignancies, where limb salvage was attempted with microvascular free fibula for limb reconstruction from the period of 2008 to 2015. Results: Of the ten cases in the study, there were two females and eight males. There were nine patients with lower limb malignancies and one patient with upper limb malignancy. There were four patients with Ewing's sarcoma of femur, five patients with osteosarcoma of femur and one patient with chondrosarcoma of the humerus. The follow-up period ranged from 1.2 to 6.2 years with mean follow-up of 3.1 years. There were two deaths during follow-up, both were due to distant metastasis. The assessment of the function was done on the basis of Musculoskeletal Tumour Society functional score. Maximum score was 30 and minimum score was 24, the average score being 26. Of the eight surviving patients, three patients had full weightbearing, four patients had partial weightbearing at end of 2 years and one patient of upper limb reconstruction had complete upper limb function. None of the patients had to undergo limb amputation. Conclusion: Limb salvage with vascularised fibula graft offers good functional outcome along with good disease-free survival rates.
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Timed wake-up anaesthesia in hand: A modification to wide awake surgery of hand p. 378
Jagannath Kamath, Trivikram Shenoy, Nikil Jayasheelan, Naufal Rizwan, Vartika Sachan, Rajashekar Danda
Introduction: Wide awake surgery of the hand (WASH) is a well-accepted technique in hand surgery which allows the surgeon to identify and rectify on the table of some of the inadvertent shortcomings in the surgical procedures to optimise the final outcome. The advantage, however, precludes the use of tourniquet. We describe a modified method which preserves all the advantages of WASH and allows the surgeon to use tourniquet. Patients and Methods: Thirty-one cases of hand surgeries were carried out using the modified technique where a wrist block was supplemented with the ultra-short acting intravenous propofol which allowed the surgeon to use the upper arm tourniquet. The propofol infusion was stopped, and the tourniquet was released after the important surgical step. Within an average of 10 min of stoppage of the infusion, all the patients were awake for active intraoperative painless movements to aid the surgeon to identify, rectify and fine tune the procedure to optimise the results. Results: Five of the 31 patients needed correction based on the intraoperative movements. All the 31 patients were pain free at the surgical site during surgery. All the 31 patients were cooperative enough to perform full range of pain-free intraoperative movements. No patient experienced significant tourniquet pain during the procedure. Patient's and surgeon's satisfaction at the end of the procedure has been quite satisfactory. Conclusion: Timed wake-up anaesthesia, an improvement over the original WASH, has been suggested where the surgeon can add without subtracting the benefits of the procedure in the form of usage of the tourniquet providing the clear tissue plane and haemostasis during the surgery. However, an additional cost is incurred for the use of anaesthesia and equipment should be kept in mind.
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Siliconomas of the lower limb: Tumour-like excision and reconstruction p. 384
Tommaso Agostini, Raffaella Perello
Background: Silicone oil injection can cause several complications including pain, cellulitis, abscesses, skin compromise, migration, embolism and multiorgan failure. Oil-infested tissue excision remains the solely treatment to prevent such complications. Objectives: The authors evaluate tumor-like excision of the oil-infested tissue as a treatment for patients experiencing silicone injections in the lower limbs, to both preserve aesthetic appearance and solve further risk of complication from silicone. Methods: Between January 2004 and January 2011 a total of 12 consecutive, nonrandomized female patients underwent surgical management of siliconoma of the lower limb. The mean age was 41-years, range from 22 to 61 years and all patients didn't referred comorbidities. Eight siliconomas were located on the leg and 4 were on the thigh. The mean area of siliconoma was 35 cm2, range from 25 to 60 cm2. Each patient was evaluated by ultrasonography and EchocolorDoppler of the soft tissue and in order to achieve a “staging” of siliconoma. Results: Healing was uneventful in all cases. Three patients (25%) suffering hypertrophic scarring underwent further injection of corticosteroids to improve hypertrophic scars quality. Two patients (16.6%) required a further session of structural fat grafting to improve thigh's profile. All patients were satisfied with the cosmetic results and indispositions requiring medical therapy disappeared. Conclusions: Tumor-like excision and immediate reconstruction appears to be a safe and consistent surgical option that preserves aesthetic appearance for patients victims of illegal oil silicone injection of the lower limbs.
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Innovative modified hair follicle harvesting technique with reverse rake scalp elevator for lower occipital donor area in follicular unit extraction hair transplantation p. 390
Chandrakant Rambhau Gharwade
Follicular unit extraction (FUE) is one of the widely practiced minimally invasive follicular harvesting techniques employed during hair transplantation. FUE technique has an advantage of utilising lower occipital area and supra-auricular region as a safe donor area described by Unger, in addition to the standard occipital donor area used in strip method (follicular unit transplant). Despite its potential advantages such as rapid recovery, minimal scarring and reduced post-operative pain; its widespread acceptance is limited due to various factors in variable contribution like steeper learning curve and potentially higher follicular transection rates (FTRs). The main practical drawbacks in harvesting FUE from lower occipital donor region that lie inferior to the standard donor area, is its acute angle (10°–15°) of emergent hair from scalp skin, higher variance angle (15°–35°) between hairs below the skin and hair exit angle above the skin and comparatively loose scalp, preventing to provide stable platform for punching. Hair transplant surgeon faces difficulty in aligning and engaging the FUE punch leading to very high hair follicle transection rate, and therefore, it is not a preferred site for harvesting follicles in FUE. Authors description of modified technique using reverse rake scalp elevator helps in negating the acute angle of the hair follicles exit from scalp skin and reducing the variance angle between emergent hair and hair below the skin in lower occipital region thereby reducing FTR. Furthermore, an added advantage of reducing the overall operative time and surgeon fatigue, improve donor area healing, availability of a comparatively larger donor area which increases the confidence of the beginners. This method will be of help as it is easy to duplicate and follow by novice hair transplant surgeons and also for those who are routinely doing mega hair transplants sessions.
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A systematic review of the factors predicting the interest in cosmetic plastic surgery p. 397
Panagiotis Milothridis, Leonidas Pavlidis, Anna-Bettina Haidich, Efharis Panagopoulou
Background: A systematic review of the literature was performed to clarify the psychosocial characteristics of patients who have an interest in cosmetic plastic surgery. Methods: Medical literature was reviewed by two independent researchers, and a third reviewer evaluated their results. Results: Twelve studies addressing the predictors of interest in cosmetic surgery were finally identified and analysed. Interest in cosmetic surgery was associated with epidemiological factors, their social networks, their psychological characteristics, such as body image, self-esteem and other personality traits and for specific psychopathology and found that these may either positively or negatively predict their motivation to seek and undergo a cosmetic procedure. Conclusions: The review examined the psychosocial characteristics associated with an interest in cosmetic surgery. Understanding cosmetic patients' characteristics, motivation and expectation for surgery is an important aspect of their clinical care to identify those patients more likely to benefit most from the procedure.
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Complex dorsal dislocation of the distal interphalangeal joint: Perspectives on management p. 403
Ajeesh Sankaran, R Ravindra Bharathi, S Raja Sabapathy
Distal interphalangeal joint dislocations are only rarely complex and irreducible. We present a case and illustrate our approach to management of this problem. Open reduction is necessary, and preferred approach is volar. It is imperative to identify the injured soft tissue and repair them as is feasible.
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Cardiac troponin I: A potent biomarker for myocardial damage assessment following high voltage electric burn p. 406
Arindam Bose, Chandra B Chhabra, Shobha Chamania, Nanda Hemvani, Dhananjay S Chitnis
Myocardial infarction (MI) following high voltage electric burn is very rare, and its pathogenesis remains controversial. Electrical burns represent only 4% of all burns. Hence, clinical managements have taken a slow pace in developing. The recent guidelines laid down by the cardiology societies include cardiac troponin I (cTnI) as the gold standard marker for the assessment of myocardial damage assessment. Two patients were admitted to our hospital at the different time with the same kind of high voltage electric burn. Both patients had complained with chest discomfort during admission, and cardiac parameter assessment was done for both the patients. cTnI was also measured for both patients, and marked increase in the values was seen within 5 h of onset of myocardial damage and got into normal range within 72 h. Myocardial damage following electric burn needs to be suspected and assessed as early as possible. Hence, cTnI should be the valuable tool to detect the severity of myocardial damage incurred in the electric burn cases.
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Surgical excision and contoured custom made splint to treat helical keloid p. 410
Ankita Chamaria, Reuben Fernando De Sousa, Meena Ajay Aras, Kennedy Mascarenhas
Helical keloids are difficult to treat as surgical excision requires effective compression of the operative scar to prevent recurrence while retaining the contour and elasticity of the helix. The authors fabricated a conforming custom made post-operative splint from a commonly used dental material. Splints could be fabricated in both pre-operative and post-operative stage.
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Assessment of hand function after successful replantation of upper limb at arm p. 415
V Koteswara Rao Rayidi, Venkata Bhargava Velde, Narsimha Rao, N Ram Babu, Laxman Sambari
In upper arm replantation, a successful anastomosis guarantees the viability and good quality repair determines the overall function of the hand.There is paucity of successful arm replantation case reports in the literature. This is a case report of a successful arm replantation in a four year child with a near total functional outcome. We have used different scores to assess the functional outcome.
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Distal phalanx amputation with delayed presentation and successful reconstruction with reposition and flap after 2 weeks p. 419
Jefferson Braga-Silva, Renato Franz Matta Ramos, Gabriela Meirelles Marchese, Pedro Salomao Piccinini
Traumatic finger amputations are common, causing significant functional and cosmetic deficits. Microsurgical replantation techniques are the mainstay of treatment for most such injuries although they require adequate conservation of the amputated segment for a successful result. In distal finger amputations, replantation is the procedure of choice, as long as the amputated fragment is viable. If replantation is not an option, reposition + flap using a neurovascular flap can be an efficient option, as this offers improved skin coverage. To the best of our knowledge, this case illustrates the longest cold ischaemic time with a successful outcome.
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The extended myocutaneous pectoralis major flap: A new tool for the successful coverage of the lower third in sternal dehiscence p. 422
Eduardo Simon-Sanz, Enrique Salmerón-González, Eloisa Villaverde-Domenech, Alberto Pérez-García, Alberto Ruiz-Cases
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Cross-sectional study of epidemiology of congenital anomaly of the hand in a tertiary care centre in India over 1 year p. 424
Nikunj B Mody, Shankar Srinivasan, Mukund Thatte
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A novel technique for the management of microform cleft lip p. 426
Akshay Omkumar, Mohit Sharma
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Muscle hernia involving the extensor carpi ulnaris muscle p. 427
Venkatraman Indiran
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A novel technique for continuous cooling till re-establishment of blood flow during major limb replants p. 429
R Jayakumar, Rahul Bamal, Amrita Mandal
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Silicone breast implants and echocardiographic interactions: A brand new study p. 430
Roberto Cuomo, Giuseppe Nisi, Luca Grimaldi, Cesare Brandi, Carlo D'Aniello
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Severe iatrogenic nostril stenosis p. 431
Leonidas Pavlidis, Georgia Alexandra Spyropoulou, Fotios Chatzinikolaou, Efterpi Demiri
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Concerns with the use of Genelyn cadavers for surgical simulation p. 432
Tarak Agrebi Moumni Chouari, Karim El-Shakankery
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Reply: Concerns with the use of Genelyn cadavers for surgical simulation p. 434
Charles Yuen Yung Loh, Nigel Yong Boon Ng, Thanassi Athanassopoulos
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Michael Felix Freshwater p. 436
Surajit Bhattacharya
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