Indian Journal of Plastic Surgery
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January-April 2014
Volume 47 | Issue 1
Page Nos. 1-154

Online since Monday, March 31, 2014

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EDITORIAL  

Was attending the conference worth value for money? Highly accessed article p. 1
Surajit Bhattacharya
DOI:10.4103/0970-0358.129614  
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ICON OF THE ISSUE Top

Brigadier Rasamay Ganguly p. 4
Manomoy Ganguly
DOI:10.4103/0970-0358.129616  
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PROF. MIRA SEN (BANERJEE) C.M.E. ARTICLE Top

Maxillary reconstruction: Current concepts and controversies p. 8
Subramania Iyer, Krishnakumar Thankappan
DOI:10.4103/0970-0358.129618  
Maxillary reconstruction is still an evolving art when compared to the reconstruction of the mandible. The defects of maxilla apart from affecting the functions of the speech, swallowing and mastication also cause cosmetic disfigurement. Rehabilitation of the form and function in patients with maxillary defects is either by using an obturator prosthesis or by a surgical reconstruction. Literature is abundant with a variety of reconstructive methods. The classification systems are also varied, with no universal acceptance of any one of them. The oncologic safety of these procedures is still debated, and conclusive evidence in this regard has not emerged yet. Management of the orbit is also not yet addressed properly. Tissue engineering, that has been hyped to be one of the possible solutions for this vexing reconstructive problem, has not come out with reliable and reproducible results so far. This review article discusses the rationale and oncological safety of the reconstructing the maxillary defects, critically analyzes the classification systems, offers the different reconstructive methods and touches upon the controversies in this subject. The management of the retained and exenterated orbit associated with maxillectomy is reviewed. The surgical morbidity, complications and the recent advances in this field are also looked into. An algorithm, based on our experience, is presented.
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ORIGINAL ARTICLE Top

Secondary bilateral cleft lip-nose deformity correction by rhinoplasty with simultaneous Abbe flap p. 20
Nitin J Mokal, Manpreet Juneja
DOI:10.4103/0970-0358.129619  
Aim: The purpose of this article is to review modification and outcome of secondary rhinoplasty along with Abbι flap for correction of secondary bilateral cleft lip deformity. Materials and Methods: A total of thirteen patients of secondary bilateral cleft lip-nose deformity having tight upper lip, lack of acceptable philtral column, Cupid's bow definition, irregular lip scars, and associated nasal deformity were selected. All the patients received Abbι flap and simultaneous nasal correction. All cases were treated during a period of three years. Mean patient age at the time of the operation was 21 years, and ranged from 16 to 27 years. The average follow-up period was three years. Results: Assessment of results was based on comparing preoperative and postoperative clinical photographs done by surgeon and patient relatives and patient satisfaction questionnaires. The columellar lengthening and upper lip vermillion correction achieved was satisfactory. There were no perioperative complications such as airway obstruction, bleeding, infection, wound disruption, or flap necrosis.
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Precision carving of costal cartilage graft for contour fill in aesthetic and reconstructive rhinoplasty p. 25
Uday Bhat, Sanchit Garg, Eulalia J D'Souza, Nikhil Agarkhedkar, Ibohal Akoijam Singh, Amresh S Baliarsing
DOI:10.4103/0970-0358.129620  
Background: Autogenous costal cartilage is a good option for large volume requirements in rhinoplasty, when septal or conchal cartilages do not suffice. Reluctance to use costal cartilage is due to apprehension of warping. However, warping can be avoided if we follow the principle of balanced section as advocated by Gibson and Davis. "Warping" can also be utilized to change the curvature of the graft. Materials and Methods: We have used 69 costal cartilage grafts as a solid piece for contour fill in rhinoplasty in 31 patients over the last 10 years. Principle of balanced section as advocated by Gibson and Davis was adhered to while carving the grafts, however some grafts were allowed to warp to get different sizes and shapes. Results: All the procedures were uneventful. Aesthetic appearance of all patients was satisfactory and acceptable to all the patients. In two cases, the dorsal graft minimally shifted to one side, but remained straight. In one patient, there was late appearance of distortion. Conclusion: The mode of cartilage warping is predictable and it can be used to advantage. Apprehension to use costal cartilage graft is unjustified, as with precision carving a desired shape can be obtained.
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The management of non-melanocytic skin malignancies of the scalp and calvarium p. 36
Harun Çöloglu, Burak Özkan, Mesut Sener, Ahmet Çagri Uysal, Hüseyin Borman
DOI:10.4103/0970-0358.129621  
Background: The management of advanced cutaneous malignancies has been controversial. Thirteen patients with nonmelanoma skin neoplasias that had invaded the bone of the calvarium and scalp were treated in our centre. Objective: The purpose of this study was to evaluate our experience in treating these malignancies with scalp resection and full or partial thickness cranium reconstruction. Patients and Methods: From June 2008 to March 2012, thirteen patients with locally advanced tumours of the scalp invading the calvarium were treated with wide local excision of the scalp combined with an underlying craniectomy and dural resection if needed. Results: Using histopathological diagnosis eleven patients were diagnosed with basal cell carcinoma and two patients with squamous cell carcinoma. A full thickness cranium resection was performed in seven patients and partial in six patients. Conclusion: These large cancers occasionally invade adjacent structures, as well as bone, presenting a challenging surgical problem. In general, giant rotational or island scalp flaps and free tissue transfers are needed to close the area. Finding clean margins are an important part of treating patients with bone involvement and can usually be attained using outer tabula curettage thus preventing unnecessary morbidity.
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Anatomic and mechanical considerations in restoring volume of the face with use of hyaluronic acid fillers with a novel layered technique p. 43
Mohan K Thomas, James A Dsilva, Ateesh J Borole, Sudhir M Naik, Soma G Sarkar
DOI:10.4103/0970-0358.129622  
Context: Facial fillers have revolutionized the field of cosmetic facial rejuvenation as it has become the prime sought - after rejuvenation procedure offering youthful, 3-dimensional look with minimal invasiveness. Fillers are expensive and need to be redone periodically hence a sound understanding of structural basis on which they are laid is important in reducing the quantity of filler required in each sitting as well as increasing the longevity of results. Aim: The aim of the following study is to analyse a novel method of facial filling "The pillars pyramids and tie beams (PPT)" technique and its advantages over the conventional methods. Subjects and Methods: A novel technique of injecting the facial fillers was employed on 67 patients visiting our clinic. These patients were followed-up for a period of 3 years. Results: We observed that the amount of filler material required in initial sitting remains the same, however the frequency of touch up visits is decreased and so is the amount of filler material required for follow-up injections. Conclusion: Facial contour remodelling is being revolutionised by the new filler materials for volume augmentation and no uniform consensus has been reached on the techniques currently used in clinical practice. We advocate this novel PPT technique of facial filling in facial rejuvenation to restore a youthful look as a primary goal.
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Trans-nipple removal of fibro-glandular tissue in gynaecomastia surgery without additional scars: An innovative approach p. 50
RK Mishra
DOI:10.4103/0970-0358.129623  
Context: The established techniques that have been used to treat gynaecomastia are said to have relatively less patient satisfaction rate as they leave some visible scars or mild elevation over the nipple areola complex, resulting in aesthetically unsatisfactory results. Even the slightest elevation or smallest scar over nipple areola complex leave patients extremely self conscious and in a dilemma of having a second intervention to get rid of that blemish. Aims: The aim of the study is to achieve - A flat chest without adding a scar and with no chances of re-occurrence of the condition. This article suggests an innovative approach to address the problem. Materials and Methods: The author presents trans-nipple incision approach for the delivery of fibro-glandular tissue component following liposuction for maximum patient satisfaction. This method consists of a unique small criss-cross incision right on the nipple itself for retrieving any volume of tough fibro-glandular tissues. Between the duration of January 2012 to October 2013, 28 male patients of different ages were operated with this technique. Results: The surgery resulted in well-shaped, symmetric chest contour without any visible elevation or additional scars on nipple areola complex. No complications were noticed in any of the patients. Conclusions: The presented technique is proved to have a high patient satisfaction rate and to be promising method to achieve good aesthetic results in gynaecomastia surgery.
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ORIGINAL ARTICLES Top

Gynaecomastia correction: A review of our experience p. 56
Arvind Arvind, Muhammad Adil Abbas Khan, Karthik Srinivasan, Jeremy Roberts
DOI:10.4103/0970-0358.129624  
Introduction: Gynaecomastia is a common problem in the male population with a reported prevalence of up to 36%. Various treatment techniques have been described but none have gained universal acceptance. We reviewed all gynaecomastia patients operated on by one consultant over a 7-year period to assess the morbidity and complication rates associated with the procedure. Materials and Methods: Clinical notes and outpatient records of all patients who underwent gynaecomastia correction at University Hospital North Staffordshire between 01/10/2001 to 01/10/2009 were retrospectively reviewed. A modified version of the Breast Evaluation Questionnaire was used to assess patients satisfaction with the procedure. Results: Twenty-nine patients and a total of 53 breasts were operated on during the study period. Patients underwent either liposuction alone (6 breasts - 11.3%), excision alone (37 breasts - 69.8%) or both excision and liposuction (10 breasts - 18.9%). Twelve operated breasts (22.6%) experienced some form of complication. Minor complications included seroma (2 patients), superficial wound dehiscence (2 patients) and minor bleeding not requiring theatre (3 patients). Two patients developed haematomas requiring evacuation in theatre. No cases of wound infection, major wound dehiscence or revision surgery were encountered. Twenty-six patients (89.7%) returned the patient satisfaction questionnaire. Patients scored an average 4.12 with regards comfort of their chest in different settings, 3.98 with regards chest appearance in different settings, and 4.22 with regards satisfaction levels for themselves and their partner/family. Overall complication rate was 22.6%. Grade III patients experienced the highest complication rate (35.7%), followed by grade II (22.7%) and grade I (17.6%). Overall complication rates among the excision only group was the highest (29.8%) followed by the liposuction only group (16.7%) and the liposuction and excision group (10.0%). There were high satisfaction rates amongst both patients and surgeon. Eleven patients (37.9%) had their outcome classified as 'excellent' by the operating surgeon, 16 patients (55.2%) as 'good', 1 (3.4%) as 'satisfactory' and 1(3.4%) as 'poor'. Conclusion: Gynaecomastia is a complex condition which poses a significant challenge to the plastic surgeon. Despite the possible complications our case series demonstrates that outcomes of operative correction can be favourable and yield high levels of satisfaction from both patient and surgeon.
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Inter-observer reliability of clinical measurement of suprasternal notch-nipple distance and breast ptosis p. 61
Emma Hansson, Jonas Manjer, Anita Ringberg
DOI:10.4103/0970-0358.129625  
Context: Suprasternal notch-nipple distance and breast ptosis are two measurements that are often used in everyday plastic surgical clinical practice. Nonetheless, the reliability of standard breast measurements has never been tested. Aim: The aim of the present study was to test the inter-observer reliability of clinical measurement of ptosis and suprasternal notch-nipple distance. Settings and Design: Six raters measured ptosis and suprasternal notch-nipple distance in 12 breasts on the same day. Statistical Analysis Used: Intra-class correlation (ICC) coefficients, the coefficient of variation (CV) and Bland-Altman plots. Results and Conclusions: The results show that there is certain variation between different raters. The ICC of average measures between raters is 0.92 for the ptosis and 0.94 for the suprasternal notch-nipple distance, that is, the agreement between different raters is high. According to the Bland - Altman plots, the overall assessment of the comparisons of measurements between the different raters shows that the direction of the mean differences is close to zero. This study shows that there is a good reliability for measurements of suprasternal notch-nipple distance and ptosis. Nonetheless, there is a slight inter-rater variability in the measurements. Even though standardised, measurement of breasts is not an exact science and care has to be taken when the measurements are performed. The surgeon should have this in mind when measurements are used in clinical practice to evaluate breasts and to choose the right surgical method, as well as when guidelines for indications for surgery are set up.
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IDEAS AND INNOVATIONS Top

The expanded inframammary fold triangle: Improved results in large volume breast reductions p. 65
Karan Chopra, Kashyap Komarraju Tadisina, Alexandra Conde-Green, Devinder P Singh
DOI:10.4103/0970-0358.129626  
Context: The inferior pedicle, Wise-pattern reduction mammaplasty is the most popular technique for breast reduction because of its reproducible results and reliability. However, complication rates in super obese patients or patients receiving large volume reductions are high, ranging from 35 to 78%. These complications include delayed healing, infection, seroma, nipple-areolar complex necrosis, fat necrosis and development of hypertrophic scars. Aims: This study aimed to determine whether a modification to the standard Wise-pattern reduction technique, an expanded inframammary fold skin triangle, produces improved outcomes in high-risk large volume breast reduction patients. We report that this modification leads to improved outcomes by decreasing wound complications and improving aesthetic appearance. Settings and Design: Twenty-two patients received the inferior pedicle Wise-pattern reduction mammaplasty, which was modified to include an 8 cm wide inferior pedicle. This pedicle was de-epithelialized and an 8 Χ 3 cm 2 triangle of skin was preserved at the inferior base to reduce tension at the triple point, inverted T-closure. Materials and Methods: A retrospective review was performed on all patients who underwent reduction mammaplasty with the expanded inframammary fold (eIMF) technique as well as all patients who received the standard wise pattern technique. Statistical Analysis Used: A student t-test was performed for both reduction populations using SPSS software package. Statistical significance was defined as P < 0.05. Results: The average patient age was 32.25 years old (range 18-59), average BMI was 35.0, and average tissue mass removed per breast was 1378.39 g. The modified technique was found to produce a statistically significant (P < 0.05) increase in the amount of breast tissue removed (693.96 g increase in the left and 571.21 g in the right) as well as a statistically significant (P < 0.05) reduction in dehiscence (75% reduction) and post-operative infection (44.10%). Conclusions: This method is an easily reproducible and reliable technique that produces a favourable cosmetic outcome with acceptable, sustainable results in high-risk reductions in obese patients.
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ORIGINAL ARTICLES Top

Manual lymphatic drainage and therapeutic ultrasound in liposuction and lipoabdominoplasty post-operative period p. 70
Igor F. B. Masson, Bruna D. A. de Oliveira, Aline Fernanda Perez Machado, Thiago Saikali Farcic, Ivaldo Esteves Júnior, Cristiano Schiavinato Baldan
DOI:10.4103/0970-0358.129627  
Background: Physiotherapy in the plastic surgery post-operative (PO) is essential to provide means for an adequate and fast recovery as it restores function through the use of physiotherapeutic procedures. Aim: The aim of the following study is to verify the effects of the association between the manual lymphatic drainage and the therapeutic ultrasound on pain, oedema and the tissue fibrosis in liposuction and lipoabdominoplasty PO. Design: This is a clinical trial prospective. Materials and Methods: Eighteen women aged between 18 and 60 years participated in this study, in the late PO period following lipoabdominoplasty or liposuction in the abdomen, flanks and lower trunk, which showed tissue fibrosis of the flanks and abdomen regions. They were divided into two groups: Liposuction group and lipoabdominoplasty group. A total of twelve sessions of therapeutic ultrasound followed by the manual lymphatic drainage were performed. The patients were assessed with regard to pain, oedema and tissue fibrosis in different moments: Initial assessment, during assessment and final assessment through the application of the protocol of evaluation of cysts fibrosis levels. Statistical Analysis: The test of equality for two proportions and the confidence interval test for mean to evaluate the distribution of variables. The significance level adopted for statistical tests was 5% (P < 0.05). Results: There was a statistically significant reduction of pain, swelling and tissue fibrosis in both groups. Conclusion: the association between manual lymphatic drainage and the therapeutic ultrasound reduced the swelling and the tissue fibrosis and made pain disappear in liposuction and lipoabdominoplasty PO period.
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Free style perforator based propeller flaps: Simple solutions for upper extremity reconstruction! p. 77
Nikhil Panse, Parag Sahasrabudhe
DOI:10.4103/0970-0358.129628  
Background: The introduction of perforator flaps by Koshima et al. was met with much animosity in the plastic surgery fraternity. The safety concerns of these flaps following the intentional twist of the perforators have prevented widespread adoption of this technique. Use of perforator based propeller flaps in the lower extremity is gradually on the rise, but their use in upper extremity reconstruction is infrequently reported, especially in the Indian subcontinent. Materials and Methods: We present a retrospective series of 63 free style perforator flaps used for soft tissue reconstruction of the upper extremity from November 2008 to June 2013. Flaps were performed by a single surgeon for various locations and indications over the upper extremity. Patient demographics, surgical indication, defect features, complications and clinical outcome are evaluated and presented as an uncontrolled case series. Results: 63 free style perforator based propeller flaps were used for soft tissue reconstruction of 62 patients for the upper extremity from November 2008 to June 2013. Of the 63 flaps, 31 flaps were performed for trauma, 30 for post burn sequel, and two for post snake bite defects. We encountered flap necrosis in 8 flaps, of which there was complete necrosis in 4 flaps, and partial necrosis in four flaps. Of these 8 flaps, 7 needed a secondary procedure, and one healed secondarily. Although we had a failure rate of 12-13%, most of our failures were in the early part of the series indicative of a learning curve associated with the flap. Conclusion: Free style perforator based propeller flaps are a reliable option for coverage of small to moderate sized defects. Level of Evidence: Therapeutic IV.
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Early ultrasound therapy for rehabilitation after zone II flexor tendon repair p. 85
Krishnamurthy Geetha, Narayanan Chandramouli Hariharan, Jagannathan Mohan
DOI:10.4103/0970-0358.129629  
Background: In our Institute, most of the patients treated for hand injuries were industrial workers with poor compliance. For rehabilitation after zone II flexor tendon repair, we had tried various early mobilization protocols. As these protocols demanded a degree of commitment from the patients, our results were suboptimal. Hence, to improve the results, we implemented a new rehabilitation protocol by administering the pulsed ultrasound therapy during the early phase of tendon healing. Materials and Methods: This is a prospective study done over a period of five years from January 2008 to January 2013. A total of 100 patients and 139 digits with zone II flexor tendon injuries were studied. After randomization, we administered pulsed ultrasound therapy of different frequencies and intensities for a total of 72 patients and 99 digits and formulated three groups. The results of ultrasound treated cases were compared with each other and with the results of cases treated by immobilization protocol. The results were analyzed using 'Original Strickland' criteria. Results: 72% excellent-good results in ultrasound (Group 1) protocol, 75% excellent-good results in ultrasound (Group 2) protocol, and 77% excellent-good results in ultrasound (Group 3) protocol were achieved. There was no case of rupture in the first two groups. The rupture rate was 7% in ultrasound (Group 3) protocol. Only 25% excellent-good results were obtained in the immobilization protocol. Conclusion: After zone II flexor tendon repair, pulsed ultrasound therapy during the early rehabilitation phase is safe and effective. The results are comparable to early mobilization protocols.
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Deviation of the penoscrotal median raphe: Is it a normal finding or within the spectrum of hypospadias? p. 92
Arvind Mohan, Laura Ashton, Milind Dalal
DOI:10.4103/0970-0358.129630  
Introduction and Objectives: Hypospadias is the most common congenital abnormality of the penis, and is most commonly diagnosed during the postnatal physical examination. However, milder forms of the condition can be difficult to detect, leading to delayed referral to specialist teams. We aim to determine whether there is an association between hypospadias and the position of the penoscrotal raphe. Materials and Methods: A case - control study was performed where clinical photographs from children undergoing hypospadias correction were compared with a control group of children without the condition. The position of the penoscrotal raphe was documented as midline, left or right. Pearson's chi squared test was used to determine significance. Results: Images for 80 children undergoing hypospadias correction were compared with 80 normal children in the maternity ward. 88.8% of the children with hypospadias had a penoscrotal raphe deviated from the midline compared with only 13.8% in the control group (P < 0.0003). Conclusions: Our study demonstrates a significant association between hypospadias and deviation of the penoscrotal raphe from the midline. Consideration should be given to whether to include this finding within the spectrum of abnormalities seen in hypospadias. Examination of the penoscrotal raphe is simple to perform and could aid in the early diagnosis in children with milder forms of the condition.
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Cadaveric study of anatomical variations of the median nerve and persistent median artery at wrist p. 95
Pawan Agarwal, Shivkant Gupta, Prashant Yadav, D Sharma
DOI:10.4103/0970-0358.129632  
Background: Awareness of anatomical variations of the median nerve at wrist is important in repair of traumatic injuries and treatments of compression syndrome because in these situations precise dissection of the nerve is mandatory and such variations are not infrequent. Materials and Methods: In this study, 52 hands of 52 fresh cadavers were dissected and median nerve anatomy along with the presence of persistent median artery (PMA) was noted. Results: A total of 26 hands (50%) had the deviation from the standard text book anatomy of the median nerve. There was early division of the median nerve into the medial and lateral branches in 11.53% hands. There was early branching of the 2 nd common digital nerve in 9.6% hands. The transligamentous motor branch to the thenar muscle was most prevalent (42.3% hands). The single motor branch to the thenar muscles was found in the majority of hands (84.6%). The PMA was present in 11.53% hands and it was associated with variations in the median nerve anatomy in all cases. Conclusions: This study shows a high percentage of deviation from standard anatomy as well as a high percentage of transligamentous thenar muscle motor branch. The presence of PMA was associated with variations in the median nerve anatomy in all cases. Therefore if PMA is present there are very high chances of associated median nerve anomalies.
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The effect of recombinant hirudin on rabbit ear flaps with venous insufficiency p. 102
Serdar Duzgun, Mustafa Nisanci, Erkin Unlu
DOI:10.4103/0970-0358.129633  
The effect of recombinant hirudin, which is the most powerful antithrombotic agent, on flaps with venous insufficiency was investigated. Oedema and congestion are frequent on flaps, causing necrosis unpredictably. Venous insufficiency and thrombosis are experimentally and clinically more frequent than arterial occlusion. Twenty-one adult New Zealand rabbits were used in this study. Skin flaps (3 × 6 cm) were elevated on a 1-cm-wide pedicle on rabbit ears. The artery, nerve, and vein were exposed and examined with the aid of a surgical microscope. Venous insufficiency was established by cutting the vein and nerve. In the control group, no additional surgical or medical procedures were performed and the ear flap was inset to its original location. Subcutaneous low molecular weight heparin (LMWH; 320 IU/kg) was administered to a second group of rabbits after the same surgery, and recombinant hirudin (2 μg) was administered via the pedicle artery 5 minutes after the vein and nerve were bound and cut in a third group of rabbits. Compared with control and LMWH groups on day 3 and 7, the hirudin-treated group had less hair loss, lower oedema scores and less haematoma formation. Furthermore, a lower size of necrotic areas and an increase in the circulating area on day 7 was found in the hirudin-treated group. In addition, angiography revealed new vessel development (neovascularisation) only in the hirudin group. On histologic sections, hirudin-treated animals had lower oedema, inflammation and congestion scores than animals in the other two groups. Thus, when administered into the ear flap through the pedicle as a pure recombinant preparation, hirudin increased flap survival by its antithrombotic effects and by accelerating neoangiogenesis. Recombinant hirudin may be used in clinical practice to treat flaps with venous problems and to increase survival rates.
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Education in plastic surgery: Are we headed in the right direction? p. 109
Nishant Khare, Vinita Puri
DOI:10.4103/0970-0358.129636  
Introduction: Plastic surgery in India is in an era of transition. The speciality faces many challenges as it grows. The present study attempts to identify these challenges and the prevalent mood among the teachers and the trainees. Materials and Methods: The study was conducted from September 2011 to June 2012. In an E-mail based survey a questionnaire was mailed to professionals actively involved in teaching and training of residents in plastic surgery in many institutes running MCh courses in plastic surgery (Group I) [Appendix 1]. Another questionnaire was mailed to residents undergoing training in plastic surgery and those who had completed their training within past 2 years (Group II) [Appendix 2]. Chi-square test was applied to test for statistical significance. Observations: 29 Group I and 33 Group II subjects responded to the questionnaire. While 72.4% teachers believed that the current system is producing plastic surgeons with enough skill level, only 9.1% of the respondents in Group II thought the same (Chi-square = 28.1; df = 2; P < 0.001). Whereas 58.6% Group I respondents thought that their student is sufficiently equipped to compete in today's scenario [Figure 1], only 18.2% Group II respondents thought that their training is enough [Figure 2]. (Chi-square = 16.4; df = 2; P < 0.001). Nearly 28% respondents in Group I and only 3% in Group II thought that scientific research and publications should be made mandatory for successful completion of plastic surgery training (Chi-square = 9.4; df = 2; P = 0.009). Adequate exposure was thought to be available in general plastic surgery (Group I: 92% Group II: 81%), maxillofacial surgery (Group I: 72% Group II: 68%) and hand surgery (Group I: 84% Group II: 69%). Both groups agreed that exposure is lacking in craniofacial surgery, aesthetic surgery and microvascular surgery. Aesthetic surgery (38.7%) and microvascular surgery (32.6%) were the most frequent response when the Group II respondents were enquired about the subspeciality they would like to focus on in their practice. Inter-departmental exchange of students for limited period of time was favoured by 86.2% of Group I respondents and 93.9% Group II respondents (Chi-square = 1.3; df = 2; P = 0.49). Conclusion: The current training programme is differently perceived by teachers and the trainees. We recommend that constant deliberations at national and regional forums should take place regarding our education and training programmes.
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CASE REPORTS Top

Total upper eyelid reconstruction by single staged malar-cheek flap p. 116
Rajeev B Ahuja, Pallab Chatterjee, Gaurav K Gupta, Prabhat Shrivastava
DOI:10.4103/0970-0358.129637  
We report a case of total upper eyelid reconstruction by a new technique after excision of an eyelid tumour. The eyelid was reconstructed by a horizontal, laterally based flap from just under the lower eyelid combined with a chondro-mucosal graft from the nasal septum. Surgical outcome was an excellent aesthetically reconstructed eyelid, which was mobile and properly gliding on the globe to achieve complete eye closure.
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Palmar arch reconstruction using dorsal venous arch of foot for revascularisation of multiple digits p. 120
KS Krishnakumar, Kiran Petkar, Sameer Lateef, Jyoti Rasalkar, TJ Arun, V Suresh
DOI:10.4103/0970-0358.129639  
A case of trauma causing total loss of superficial and deep palmar arches of hand with ischemia of all the digits was managed using dorsal venous arch of the foot to reconstruct the palmar arch. The ends of the venous arch were anastomosed to radial and ulnar arteries and the tributaries to the arch were coapted to the cut ends of the common digital vessels and princeps pollicis. The surgery yielded gratifying results, successfully revascularising all the digits.
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Anomalous superficial ulnar artery based flap p. 124
CV Ramani, Girish K Kundagulwar, Yadav S Prabha, Jaiswal Dushyanth
DOI:10.4103/0970-0358.129643  
Upper limb shows a large number of arterial variations. This case report describes the presence of additional superficial ulnar artery which was used to raise a pedicle flap to cover an arm defect thus avoided using the main vessel of the forearm - radial or ulnar artery. Vascular anomalies occurring in the arm and forearm tend to increase the likelihood of damaging the superficial anomalous arteries during surgery. Superficial ulnar or radial arteries have been described to originate from the upper third of the brachial artery; here we report the origin of the anomalous superficial ulnar artery originating from the brachial artery at the level of elbow with the concomitant presence of normal deep radial and ulnar arteries.
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Custom-made approach to a patient with post-burn breast deformity p. 127
Yalcin Bayram, Cihan Sahin, Celalettin Sever, Huseyin Karagoz, Yalcin Kulahci
DOI:10.4103/0970-0358.129646  
Second and third degree burns on breasts at preadolescent period may cause severe breast deformations. This deformation can be variable depending on severity and location of the burns, personal adolescent patterns, and treatment modality in acute burn period. A 21 year old female patient admitted to our department for her breast deformation due to burn contracture at the inferior pole of the right breast. On physical examination we defined that development of the volume of the right breast was equal to the left, and inferior pole of the right breast was flattened due to contracture, and nipple was projected to inferior. We found that inframammary crease of the right breast was 2 cm lower than that of left; andthe distance of nipple-inframamary crease was 4.7 cm while areola-inframmary crease was 2 cm. New nipple-areola complex level was identified according to left breast's level. Medial and lateral lines were planned to merge inferiorly at 2 cm above inframmary crease in a plan similar to vertical mammaplasty. Superior pedicle carrying nipple areola was desepitelised. Lower parenchymal V flap was transposed superiorly and attached to the pectoral muscle. Inferior parts of the lateral and medial glandular flaps were excised to form new inframammary crease. The desired laxity of skin at the lower pole was obtained by performing a new Z- plasty between lateral and medial skin flaps. Breast symmetry was confirmed by postoperative objective measurements between left and right breasts. Patient's satisfaction and aesthetic appearance levels were high. Breasts deformation patterns caused by burns, trauma and mass exsicion due to cancer could not be addressed with traditional defined techniques. Special deformations can be corrected by custom made plannings as we presented here.
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Successful combined approach to a severe Fournier's gangrene p. 132
Tommaso Agostini, Francesco Mori, Raffaella Perello, Mario Dini, Giulia Lo Russo
DOI:10.4103/0970-0358.129648  
We present a case of a successful reconstruction of a severe Fournier's gangrene (FG) involving the scrotum, the perineum, the right ischial area and extended to the lower abdomen. There are many different surgical techniques to repair and reconstruct the defect following debridement in FG. The authors treated this complex wound using negative pressure wound therapy (NPWT), dermal regeneration template and a split-thickness skin graft. Complete recovery was achieved and no major complications were observed. The patient showed a satisfying functional and aesthetic result.
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Resolution of concomitant Achromobacter xylosoxidans burn wound infection without adjustment of antimicrobial therapy p. 137
Zhi Yang Ng, George Fang, Kah Woon Leo
DOI:10.4103/0970-0358.129650  
Achromobacter xylosoxidans is part of an emerging group of Gram negative bacterial infections with potentially severe sequelae, especially in the immunocompromised population such as burn patients. While antimicrobial therapy for patients with A. xylosoxidans bacteremia has been reported, the literature is scarce with regard to treatment in patients with positive tissue cultures only. Herein, we report our institution's experience with such a case and a brief review of the current literature on this micro-organism in the setting of non-bacteremic infection.
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Knowledge and awareness of skin donation in medical students: Overcoming the barriers p. 141
Nikhil Panse, Smita Panse, Mrida Jhingan, Priya Kulkarni, Giriraj Gandhi, Yashwant Kulkarni
DOI:10.4103/0970-0358.129652  
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Subtotal lower lid reconstruction from upper eyelid full thickness bridge flap with earlier 2 nd stage surgery at 3 weeks p. 143
Ram Lal Sharma, Gopal Damani
DOI:10.4103/0970-0358.129654  
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Surgical reconstruction or prosthetic rehabilitation following orbital exenteration: The clinician's dilemma p. 146
Himanshi Aggarwal, Pradeep Kumar
DOI:10.4103/0970-0358.129655  
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Free saphenous venous flap and its modifications: Turbo- and supercharged p. 147
Kathleen Yee Kuin Chang, Wan Azman Wan Sulaiman, Arman Zaharil Mat Saad
DOI:10.4103/0970-0358.129658  
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Superior gluteal artery perforator flap for meningomyelocele defect: A saviour when other options vanish p. 149
Ismail Kucuker, Billur Sezgin, Serhan Tuncer, Suhan Ayhan
DOI:10.4103/0970-0358.129660  
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A novel technique of monitoring a completely covered free flap p. 150
Kiran Petkar, KS Krishnakumar, Sameer Lateef, TJ Arun, V Suresh
DOI:10.4103/0970-0358.129662  
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Thumbs up for the correct size and shape of a full thickness skin graft p. 152
Jurga Pikturnaite, Shaheel Chummun
DOI:10.4103/0970-0358.129663  
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A simple method of managing unsterile overhead light handles in operating room Highly accessed article p. 153
Shabeer Ahmad Wani, Nieves Vega Saglam, Sara AlFadil, Sari M Rabah
DOI:10.4103/0970-0358.129666  
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