Indian Journal of Plastic Surgery
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   Table of Contents - Current issue
May-August 2015
Volume 48 | Issue 2
Page Nos. 107-232

Online since Wednesday, August 19, 2015

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Protecting our specialty p. 107
Mukund Jagannathan
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Dr. Fernando Ortiz-Monasterio p. 109
Surajit Bhattacharya
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Vascularised composite allotransplants: Transplant of upper extremities and face p. 111
Subramania Iyer
Transplantation of solid organs and bone marrow has become a highly acceptable and often the only available clinical solution in many situations. It has been practiced across the globe for quite a long time since the first kidney transplant in 1954. Transplantation of tissues other than these, which was termed composite tissue allotransplantation and currently as vascularised composite allotransplantation (VCA) is gaining acceptance as a solution for complex reconstructive problems. This involves the transfer of multiple types of tissue such as bone, muscle, nerve, skin and blood vessels. The advantage of these over the conventional reconstructive methods is its ability to give aesthetically and functionally superior equal composite substitute to the missing or deformed part. The composite tissues transplanted commonly include the upper extremities, face and abdominal wall. Among these, hand transplants were the first to be done and have been carried out more than any other VCA. This article reviews the current scenario of VCA especially of the hand and face, in the light of experience of the two bilateral hand transplants done recently in India.
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Composite tissue allotransplantation - Global perspectives p. 119
Surajit Bhattacharya
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Namaste (counterbalancing) technique: Overcoming warping in costal cartilage p. 123
Kapil S Agrawal, Manoj Bachhav, Raghav Shrotriya
Background: Indian noses are broader and lack projection as compared to other populations, hence very often need augmentation, that too by large volume. Costal cartilage remains the material of choice in large volume augmentations and repair of complex primary and secondary nasal deformities. One major disadvantage of costal cartilage grafts (CCG) which offsets all other advantages is the tendency to warp and become distorted over a period of time. We propose a simple technique to overcome this menace of warping. Materials and Methods: We present the data of 51 patients of rhinoplasty done using CCG with counterbalancing technique over a period of 4 years. Results: No evidence of warping was found in any patient up to a maximum follow-up period of 4 years. Conclusion: Counterbalancing is a useful technique to overcome the problem of warping. It gives liberty to utilize even unbalanced cartilage safely to provide desired shape and use the cartilage without any wastage.
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Magnetic resonance neurography of the brachial plexus p. 129
Vaishali Upadhyaya, Divya Narain Upadhyaya, Adarsh Kumar, Ashok Kumar Pandey, Ratni Gujral, Arun Kumar Singh
Magnetic Resonance Imaging (MRI) is being increasingly recognised all over the world as the imaging modality of choice for brachial plexus and peripheral nerve lesions. Recent refinements in MRI protocols have helped in imaging nerve tissue with greater clarity thereby helping in the identification, localisation and classification of nerve lesions with greater confidence than was possible till now. This article on Magnetic Resonance Neurography (MRN) is based on the authors' experience of imaging the brachial plexus and peripheral nerves using these protocols over the last several years.
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Magnetic resonance neurography of the brachial plexus p. 137
Anagha Rajeev Joshi
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How were lipofilling cannulae designed and are they as safe as we believe? p. 139
Memet Yazar, Sevgi Kurt Yazar, Kamuran Zeynep Sevim, Fatih Irmak, Merva Soluk Tekesin, Erol Kozanoglu, Semra Karsidag
Background: Most practitioners in plastic surgery believe that blunt tipped cannulae are safer. Interestingly, there is no study about their safety, and the problem is exactly this. As the use of blunt tipped cannulae is somehow difficult, some surgeons try other extreme alternatives, such as sharp and cutting tipped injection needles. But, they can cause complications such as vessel damage. According to these hypotheses, we tried to design a cannula which would ease the application of lipofilling and which would minimise the trauma. Contrary to the injection needle, the tips of the cannula would be blunter, and trauma would be diminished. Objectives: After designing such a cannula, we compared it with the most frequently used Coleman type cannulae with regard to ease in utilisation, and safety. We also tried to evaluate the potential for trauma, of the regularly used cannulae. Materials and Methods : In the first part, the penetration capacity of all cannulae was measured and compared, and in the second part, the tissue damage was evaluated in an experimental model. Results: According to the statistical and histological findings, the pointed-tip cannulae, blunted to a certain degree, can be applied easily through the tissues. The surgeon works more comfortably and we have noted that these cannulae cause less tissue damage.
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Objective analysis of microtia reconstruction in Indian patients and modifications in management protocol p. 144
Mohit Sharma, Raghuveer Reddy Dudipala, Jimmy Mathew, Abhijeet Wakure, Krishnakumar Thankappan, Deepak Balasubramaniam, Subramania Iyer
Introduction: An ideal ear, with representation of all anatomic landmarks, is the aim of any reconstructive surgeon embarking on reconstructing the ear in a microtia patient. The literature is abundant with the description of techniques, but these have been reported mainly in Caucasian and Oriental population. There have been very few publications on results in the population belonging to the Indian subcontinent. In spite of strictly adhering to the recommended techniques of reconstruction, the results obtained in these patients have often been marred by problems that are not reported with the Oriental or Caucasian populations. This may necessitate a relook into the management strategy of these cases. Hindering the assessment of the results, their reporting and auditing the improvement obtained by such change in the management strategy, is the lack of a standardized method for assessment of the outcome. Hence, an attempt was made in a series of patients who underwent microtia reconstruction to assess the outcome using a new tool based on the attained definition of anatomical components of the reconstructed pinna. Further effort was made to document the modifications in the technical execution of the reconstruction during the period of the study. Materials and Methods: A retrospective review of 44 patients and a prospective analysis of 11 patients, who underwent ear reconstruction for microtia from December 2003 to September 2014 at a tertiary care teaching hospital, was undertaken. Taking a cue from Nagata's description of an 'ideal reconstructed ear' which should show all the anatomical components, we developed an objective grading system to assess our results. The technique had undergone several changes during these years combining the principles of three universally accepted methods, that is, those described by Nagata, Brent, and Firmin. These changes, as well as the reasons behind them, were documented. Results: On objectively measuring and analysing the replication of normal morphologic characteristics of the reconstructed ears, we documented progressive improvement of our results. Good or excellent results could be achieved in 70% of cases in the second group compared to a poor outcome in more than 2/3 rd of the cases carried out during the initial period. Based on these results and the changes adopted in our practice we propose suggestions for management of microtia cases in the Indian population. Conclusions: An objective, weighted grading system has further enabled us to critically evaluate the outcomes and to further improve upon the existing results. Our amalgamation of the salient features of the established techniques as well as changes made based on our experience has enabled us to get good results more consistently in our attempts at microtia reconstruction. We believe that the adoption of such amalgamated methods will be more suitable in Indian patients.
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Thoracodorsal artery perforator flap: Indeed a versatile flap p. 153
Leena Jain, Samir M Kumta, Shrirang K Purohit, Rashmi Raut
Introduction: The thoracodorsal artery perforator (TDAP) flap has emerged as one of the ideal perforator flaps. We, hereby, describe its versatility in indications (free/pedicled), methods of harvest (patient position and paddle orientation) and perforator consistency. Materials and Methods: We have performed a total of six TDAP flaps-five free and one pedicled, over a period of 1-year from March 2014 to February 2015 at a single centre. Our indications have been: Reconstruction of oral cavity, breast and upper and lower extremities. Results: We had neither any failures nor any re-explorations. The average perforator length is about 6 cm and the pedicle length can be extended to 12-14 cm by including the thoracodorsal artery. There is inconsistency in perforator position; however, the presence of a perforator is certain. It can be harvested in lateral, prone or supine position, thus, does not require any position change allowing a two-team approach to reconstruction. The paddle can be oriented vertically or horizontally, both healing with scars in inconspicuous locations. Apart from providing a good colour match for extremities, this flap can be thinned primarily. Conclusion: The versatility of TDAP has several advantages that make it a workhorse flap for most reconstructions requiring soft tissue cover. Further, the ease of harvest makes it a good perforator flap for beginners. Its use in chimerism with the underlying latissimus dorsi muscle provides reconstruction for coverage and volume replacement.
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Single nucleotide polymorphism of bone morphogenetic protein 4 gene: A risk factor of non-syndromic cleft lip with or without palate p. 159
Sathyaprasad Savitha, SM Sharma, Shetty Veena, R Rekha
Background: The bone morphogenetic protein (BMP) signalling pathway is crucial in a number of developmental processes and is critical in the formation of variety of craniofacial elements including cranial neural crest, facial primordium, tooth, lip and palate. It is an important mediator in regulation of lip and palate fusion, cartilage and bone formation. Aim: To study the role of mutation of BMP4 genes in the aetiology of non-syndromic cleft lip with or without palate (NSCL ± P) and identify it directly from human analyses. Materials and Methods: A case-control study was done to evaluate whether BMP4T538C polymorphism, resulting in an amino acid change of Val=Ala (V152A) in the polypeptide, is associated with NSCL ± P in an Indian paediatric population. Genotypes of 100 patients with NSCL ± P and 100 controls (in whom absence of CL ± P was confirmed in three generations) were detected using a polymerase chain reaction-restriction fragment length polymorphism strategy. Logistic regression was performed to evaluate allele and genotype association with NSCLP. Results: Results showed significant association between homozygous CC genotype with CL ± P (odds ratio [OR]-5.59 and 95% confidence interval [CI] = 2.85-10.99). The 538C allele carriers showed an increased risk of NSCL ± P as compared with 538 T allele (OR - 4.2% CI = 2.75-6.41). Conclusion: This study suggests an association between SNP of BMP4 gene among carriers of the C allele and increased risk for NSCLP in an Indian Population. Further studies on this aspect can scale large heights in preventive strategies for NSCLP that may soon become a reality.
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Single nucleotide polymorphism of BMP4 Gene: A risk factor of non-syndromic cleft lip with or without cleft palate p. 164
Michael H Carstens
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Arterial segments as microvascular interposition grafts in venous anastomosis in digital replantations p. 166
Shiv Shankar Saha, Anurag Pandey, Chirayu Parwal
Introduction: Microvascular anastomosis is a crucial procedure in replantation surgeries. Venous insufficiency is one of the most consistent cause of failure or re-exploration in these surgeries necessitating the use of venous grafts. Materials and Methods : We discuss our study of 9 such replantation surgeries executed in calendar year 2013-2014, including a double finger replantation done in the same patient having total amputation of 4 fingers of the same (right) hand, in which an arterial segment was used as a microvascular interposition graft for venous anastomosis. Out of these 9 surgeries, 3 were re-exploration procedures for venous compromise and 6 were successful primary replantations. Results: In all, 8 replants were successful and one failed due to arterial compromise. Discussion: In our experience and extensive review of the previously available literature, we would like to portray the advantages of arterial segments as microvascular grafts in replant surgeries. Specifically, in a crush amputation injury for which the use of a vascular interposition graft is being contemplated. If any other digit is also amputated and is unsuitable for replantation, it can act as a potential donor site to harvest the arterial segment. However, when dealing with single finger amputation, the surgeon must be confident about the single digital arterial anastomosis, before harvesting the second digital artery as a microvascular graft. Conclusion: In our study, we found the use of arterial grafts in microvascular anastomosis of veins advantageous, as arterial segments have better ability to resist spasm due to environmental changes, better pressure tolerance as compared to venous segments, and provide an appropriate calibre match and ease of harvest in the same operative field.
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"Ride-on" technique and other simple and logical solutions to counter most common complications of silicone implants in augmentation rhinoplasty p. 172
Kapil S Agrawal, Manoj V Bachhav, Charudatta S Naik, Shikha Gupta, Anup V Sarda, Vyoma Desai
Augmentation rhinoplasty can be carried out using a wide range of materials including autologous bone and/or cartilage as well as alloplasts. Use of biologic bone and cartilage grafts results in lower infection rates, but they are associated with long-term resorption and donor-site morbidity. Alloplastic materials, in particular silicone, have been associated in literature with extrusion, necrosis of the tip, mobility and deviation or displacement of the implant, immobile nasal tip and infection. However, they have the advantages of being readily available and easy to reshape with no requirement for harvesting autografts. Aim: To overcome these problems associated with silicone implants for which the authors have devised a novel technique, the "rideon technique". Materials and Methods: The present study was carried out on 11 patients over a period of 4 years. The authors have devised a simple technique to fix the silicone implant and retain it in place. Restricting the implant to only dorsum avoided common complications related to the silicone implant. Results: The authors have used this technique in 11 patients with encouraging results. Follow-up ranged from 12 months to 36 months during which patients were assessed for implant mobility, implant extrusion and tip necrosis. There was no incidence of above mentioned complications in these patients. Conclusion: The "rideon technique" provides excellent stability to silicone implants and restricting the implant only to dorsum not only eliminates chances of tip necrosis and thus implant extrusion but also maintains natural shape, feel and mobility of the tip.
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White Roll Vermilion turn down flap in primary unilateral cleft lip repair: A novel approach p. 178
RK Mishra, Amit Agarwal
Aim: Numerous modifications of Millard's technique of rotation - advancement repair have been described in literature. This article envisions a new modification in Millard's technique of primary unilateral chieloplasty. Material and Methods: Eliminating or reducing the secondary deformities in children with cleft lip has been a motivating factor for the continual refinement of cleft lip surgical techniques through the years. Vermilion notching, visibility of paramedian scars and scar contracture along the white roll are quite noticeable in close-up view even in good repairs. Any scar is less noticeable if it is in midline or along the lines of embryological closure. White Roll Vermilion turn down Flap (WRV Flap), a modification in the Millard's repair is an attempt to prevent these secondary deformities during the primary cleft lip sugery. This entails the use of white roll and the vermilion from the lateral lip segment for augmenting the medial lip vermilion with the final scar in midline at the vermilion. Result: With an experience of more than 100 cases of primary cleft lip repair with this technique, we have achieved a good symmetry and peaking of cupid's bow with no vermilion notching of the lips. Conclusion: WRV flap aims to high light the importance of achieving a near normal look of the cleft patient with the only drawback of associated learning curve with this technique.
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White roll vermilion-turn down flap in primary unilateral cleft lip repair: A novel approach p. 184
Jyotsna Murthy
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Tunica vaginalis flap following 'Tubularised Incised Plate' urethroplasty to prevent urethrocutaneous fistulaa p. 187
Raashid Hamid, Aejaz A Baba, Altaf Shera, Sarfaraz Ahmad
Introduction: Surgery for hypospadias has been continuously evolving, implying thereby that no single technique is perfect and suitable for all types of hypospadias. Snodgrass technique is presently the most common surgical procedure performed for hypospadias. Materials and Methods: We analysed the results of tunica vaginalis flap (TVF) as an additional cover to the tubularised incised plate (TIP) repair. Results: A total of 35 patients of hypospadias were repaired using TIP urethroplasty and TVF as a second layer. Mean age at the time of presentation was 6.63 ± 3.4 years. Post-operative complications namely wound infection, flap necrosis, scrotal haematoma, scrotal abscess, urethral fistula, meatal stenosis were recorded and analysed during follow-up period. Need for re-do surgery was considered as failure of the operative procedure. Out of 35 patients, 8 (22.85%) patients had proximal penile hypospadias and 27 (77.14%) patients had distal penile hypospadias. Mean post-operative follow-up was 24.53 months. During the follow-up complications noticed included wound infection (n = 2), urethrocutaneous fistula (n = 1) and meatal stenosis (n = 1). Wound infection was managed with appropriate antibiotics as per hospital policy/culture and sensitivity reports. Meatal stenosis responded to bougie dilatation/calibration during follow-up. Conclusion: To conclude, TVF as an additional cover is associated with an acceptable complication rate and good cosmetic results if performed with meticulous tissue handling
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Surgical revirgination: Four vaginal mucosal flaps for reconstruction of a hymen p. 192
Hemant A Saraiya
Introduction: Over centuries, virginity has been given social, religious and moral importance. It is widely believed as a state of a female who has never engaged in sexual intercourse, and her hymen is intact. Hymenoplasty for torn hymen is carried out not only for the sake of cultural and religious traditions but also for the social status and interpersonal relationships. Materials and Methods: 2.5 cm long and 1 cm wide four vaginal mucosal flaps were raised from the anterior vaginal wall just behind labia minora. Two flaps were based proximally, and their two opposing flaps were based distally. These flaps were overlapped in a crisscross fashion and were sutured with 5/0 Polyglactin (Vicryl® ) sutures leaving no area raw. The donor area was closed primarily. When some remains of a torn hymen were found, one to three vaginal mucosal flaps were added to its remains as per the need for reconstruction. Results: We operated upon 11 patients. In nine cases, the hymen was reconstructed with four flaps. In remaining two, it was reconstructed from the remains using vaginal mucosal flaps. All flaps healed without any infection or disruption. Sutures got absorbed in 25-35 days. In all cases, this newly constructed barrier broke with only moderate pressure at the time of penetrative sex serving the purpose of the surgery completely. Conclusion: Erasing evidence of the sexual history simply by 'Surgical Revirgination' is extremely important to women contemplating marriage in cultures where a high value is placed on virginity.
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Extended effect after a single dose of type A botulinum toxin for asymmetric masseter muscle hypertrophy p. 196
Kasturi Bhattacharjee, Manpreet Singh, Harsha Bhattacharjee
Facial asymmetry can either be physiological or pathological and is a common cosmetic concern. A 35-year-old Indian male presented with broad appearing lower face and prominent left jaw since adolescence. Parotid enlargement and other local disorders were ruled out. Ultrasonographic thickness of right masseter muscle was 13 mm while that of left was 14.9 mm, in unclenched state. Type-A botulinum toxin (T-ABT) was injected, evenly at five points, in both muscles within the "safe zone". Using a 29 gauge needle, 15 and 25 international units were delivered to right and left masseters, respectively. Six months post - injection, a reduction of 2.9 mm and 4.4 mm was observed along with a reduced external facial asymmetry. At 24 months, patient maintains a satisfactory facial contour with no significant early or late post-injection complications. Intra-massteric injection of T-ABT can be used effectively as a primary or adjunct procedure for holistic oculo-facial sculpting.
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Bony tumour in an unusual location on the mandible p. 200
Aashish Sasidharan, Amish Gohil, Santosh Koshy, Ashish Kumar Gupta
Osteomas are benign osteogenic tumors that are seen in the facial bones, but uncommonly in the mandible. In the facial bones, both central and peripheral osteomas have been described. Peripheral osteomas have been described to occur in the frontal, ethmoid, and maxillary sinuses but are not common in jawbones. When in the mandible, they are usually found over the angle and inferior border of the mandible. We report on a solitary peripheral osteoma located unusually in the sigmoid notch of the left mandible causing facial asymmetry.
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Congenital urethrocutaneous fistula in an adolescent male p. 204
Satish M Kale, Nikunj B Mody, Surendra B Patil, Pranam Sadawarte
A urethrocutaneous fistula is a common complication after hypospadias repair, but congenital fistula is a rare anomaly. We present a 16-year-old boy with this unusual anomaly. Its etiology, embryology, and management are discussed in brief.
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A rare case of plexiform schwannoma of the lower lip: Treatment and management p. 208
Subha Dhua
An 18-year-old female presented with a swelling on the lower lip, which was insidious in onset and gradually progressive. The mass was completely excised under local anaesthesia. Complete histopathologic and immunohistochemical studies were conducted. The Antoni A areas were found along with typical verocay bodies composed of palisading nuclei and surrounding spaces filled with eosinophilic filaments. No necrosis was noted and there were no atypical mitotic figures. In the Antoni B region, a closely textured matrix with areas of edema, myxomatous changes, cystic degeneration and dilated vessels were noted. On the basis of the histopathologic and immunohistochemical staining with S-100 protein, a diagnosis of plexiform schwannoma was made and has been reported in this study. The post-operative view confirmed complete recovery after 6 weeks of surgery. This is a rare case with the tumour located in the lower lip, as very few cases have been reported in literature and it may be the first one reported from India.
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Intraosseous keratin cyst of the distal phalanx p. 212
Rohini Prasad, Arivind Bhamidi, Arun Kumar Rajeswaran, Ramamurthy Bhuvaneshwari
Keratin or epidermoid cysts of the phalanges are rare lesions mimicking osteolytic lesions such as infection, malignancy and other tumours. Definitive diagnosis can be made by histopathology only and treatment is by simple excision and curettage. We present a case of intraosseous keratin cyst of the distal phalanx and review of literature.
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A word of caution p. 215
Satish Arolkar
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Hyperbaric oxygen and topical oxygen are different treatments p. 216
Ozturk Handan, Aktas Samil
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Innovation and beyond: Dangers in improvised negative pressure wound therapy systems p. 217
Philip Philip Philip
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The levels of evidence of articles published by Indian authors in Indian journal of plastic surgery p. 218
Nikhil Panse, Parag Sahasrabudhe, Sagar Khade
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Giant lipoma of the back p. 220
Luca Grimaldi, Roberto Cuomo, Antonio Castagna, Andrea Sisti, Giuseppe Nisi, Cesare Brandi, Carlo D'Aniello
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Extended uses of scalp vein set in plastic surgery p. 222
Hardeep Singh, Rakesh Kumar Khazanchi, Aditya Aggarwal, Sanjay Mahendru, Vimalendu Brajesh, Sukhdeep Singh
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Universal Splint for upper limb support during reconstruction by pedicled abdominal flap p. 223
Bharat Mishra, Ramesh K Sharma, Harbans Singh
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Temporal artery rupture following firework rocket injury p. 225
Mohd Azam Haseen, Adil Ali Mahmud, Fakhrul Huda, Mohd Haneef Beg
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Mayo clinic p. 227
HS Adenwalla
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Dr. Anil Chadha p. 231
Ayyappan Ayyappan
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