Indian Journal of Plastic Surgery
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   Table of Contents - Current issue
September-December 2017
Volume 50 | Issue 3
Page Nos. 227-325

Online since Thursday, March 8, 2018

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Farewell, dear readers… Highly accessed article p. 227
Mukund Jagannathan
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Dr. Kuldeep Singh Goleria: A True Karma Yogi p. 228
Vinita Puri
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A learning module in hair restoration surgery: A simple and economic method to learn all steps of strip method of hair follicles harvesting and implantation p. 230
Anil Kumar Garg, Seema Garg
Background: There is a global increase in demand for hair transplant as well as increasing demand for trained assistants and surgeons. It is a fact that permanent donor hair follicles are limited and any loss during learning is permanent and irreversible, so there is no place to learn and/or practice on a patient. Objective: To develop a learning module in hair restoration surgery to learn all steps of strip method of hair follicles harvesting and methods of implantation. Materials and Methods: In this learning module, the materials used are paper, pencil, plant leaf, foam and thread. The last step is on goat skin. Module has been divided into multiple steps. The first step is training of microsurgery position, the second step is training of movement at wrist using paper and pencil, the third step is strip harvesting and slivering on foam model, the fourth step is learning of follicle dissection on leaf model, the fifth step is thread follicle implantation on leaf bed. After practising on non-living model finally, all steps are practised on goatskin, starting from slivering, follicle dissection and implantation of goat follicles on leaf. Conclusion: This is very economical and user-friendly system to learn all steps of strip method of hair follicle harvesting and methods of implantation as well. The materials used are available around us and anyone can learn as well as train his or her technicians in very short time.
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Three component cartilage framework reconstruction for correction of post-traumatic nasal septal collapse p. 236
Uday Bhat, Tarush Gupta, Mahesh Nair, Mayur Mantri, Mangesh Pawar, Amresh Baliarsing
Background: Post-traumatic nasal septal collapse results in flat, broad, non-projecting nose due to mid-vault collapse. These patients may have airway obstruction due to poorly supported internal valve. Traditional techniques like 'cantilever graft technique' or conventional 'L-graft technique' produce a rigid lobule as the single unit framework extends to the tip. These grafts also lack in internal valve support. Materials and Methods: Twelve patients with post-traumatic nasal septal collapse were treated with three component cartilage framework technique in the past 3 years. The framework was reconstructed in three components-septal, columellar and dorsal onlay; using costal cartilage. If needed, upper lateral cartilage support grafts were also provided. Results: At 6 months' follow-up, all 12 patients were satisfied with the outcome. The nasal projection and dorsal definition were aesthetically pleasing, and there was free natural movement of the lobular part of the nose. One graft was revised for further improvement in outcome. Airway obstruction, when present was also relieved. Conclusion: This technique has distinct advantages over the conventional techniques as the framework of separate components maintains pliability of the lobule, supports the internal valve and offers good control of aesthetic needs.
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A comprehensive functional classification of cleft hand: The DAST concept p. 244
Alok Sharma, Namita Sharma
Context: Phenotypic expressions of the congenital cleft hand are variable and might baffle even the experienced as to the choice of surgery. The morphological parameters defining the anomaly dictate not only the functional capacity of the anomalous hand but also the degree of possible surgical restoration. Despite a large number of classifying systems available, none encompass all the relevant issues. Aims: The purpose of this work is to present an all-inclusive and universally acceptable classification of the deformity which would graphically represent the entire gamut of possible presentations; principal and associated. Furthermore, based on such staging, the choice of surgical procedure and the stages of surgical intervention can be standardised to ensure the best results for the patient. Patients and Methods: This study is based on a series of 27 patients with a total of 38 cleft hands. Results and Conclusions: The necessity to include and to assess all determinants of function and complexity in these hands to standardise the choice of management, gave rise to the DAST system of classification; an acronym for all the morphological determinants of the anomaly (D = Digits missing, A = Associated anomalies in the hand, S = Site of cleft, T = Functional state of the Thumb). Numerical values were assigned to each component in increasing order of complexity. Score for each determinant as well as the aggregate score indicates the degree of complexity in a graphic manner. The DAST classification has a predictive value in choice of procedure and prognosticating surgical outcomes.
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A novel technique using a subcutaneously pedicled islanded prolabial flap for the secondary correction of bilateral cleft lip and nasal deformity p. 251
Nitin J Mokal, Mahinoor Feroze Desai
Context: The bilateral cleft lip and nose deformity frequently requires lip revision surgery at the time of secondary rhinoplasty. The goal is to achieve an adequate philtrum with a well-shaped Cupid's bow, white roll alignment and a central vermilion tubercle. Aims: We have devised a new technique of using prolabial tissue tailored as an island of skin based on a subcutaneous pedicle for the secondary reconstruction of the philtral aesthetic unit in patients with bilateral cleft lip nasal deformity. Settings and Design: This technique was used in 21 patients from March 2012 to August 2015. All patients had undergone primary lip repair at other institutions and required lip revision with simultaneous rhinoplasty. Subjects and Methods: The objective criteria considered in the post-operative evaluation by the authors included improvement of philtral ridge projection, symmetry of philtral column and nasal sill and white roll continuity. The ten individual parameters were given a score from 1 to 4 (with 1 = lowest and 4 = highest for each individual parameter) and the total score was rated as 31–40 = excellent, 21–30 = good, 11–20 = fair and 0–10 = Poor. The patients' overall satisfaction was assessed at 6 months postoperatively to record their impression of the aesthetic improvement after our procedure. Results: The follow-up period ranged from 6 months to 3 years. The prolabial flap had no post-operative complications. The authors' assessment judged 15 (71.4%) patients as having an excellent outcome and 6 (28.5%) patients as having a good outcome. All patients expressed subjective satisfaction with the post-operative appearance of their upper lip and rated their results as improved and overall satisfaction scoring was high. Conclusions: This technique is a new addition to the repertoire of procedures which already exist for the correction of bilateral cleft lip nose deformity. It is safe, reliable and has a good aesthetic outcome with no significant morbidity.
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A study the various clinical and electrophysiological parameters of severity of carpal tunnel syndrome, their correlation with post-operative recovery p. 260
Sushil Ramesh Nehete, Binita B Raut, Amita S Hiremath, R Mukund Thatte
Objective: We aimed to study the various clinical and electrophysiological parameters of severity of carpal tunnel syndrome (CTS) and to see if the severity of CTS affects recovery after surgery. Patients and Methods: A prospective study of 35 patients suffering from CTS. Clinical severity was assessed using visual analogue scale and standard questionnaires such as Levine and Disabilities of Arm, Shoulder and Hand questionnaires. All the patients underwent electrophysiological evaluation to assess electrophysiological severity of CTS. According to modified Padua classification, they were classified into three groups, namely, minimal to mild, moderate and severe to extreme. All patients underwent Carpal tunnel release in our unit. The clinical assessment was repeated 3 months post-operatively. Results: Out of 33 patients, majority (65.7%) of the patients were suffering from moderately severe CTS. The clinical provocative tests were positive in majority of patients. Clinically and statistically significant (P < 0.001) improvement was seen in all clinical severity scores. However, it did not show any statistical correlation with electrophysiological severity of the disease when compared among the groups. There was no association of age, gender of the patient, body mass index, hand dominance, affected side of the patient, results of provocative tests and the presence or absence of thenar muscle atrophy when compared among the three severity groups (P > 0.05). Conclusions: Although pre-operative clinical scores of severity and electrophysiology have a diagnostic role in CTS, they do not correlate with post-operative recovery and in turn fail to predict the extent of post-operative recovery before surgery.
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Evaluation of facial artery perforator-based flaps in reconstruction of facial defects p. 266
Goutam Guha, Dipmalya Chatterjee, Siddhartha Biswas, Kaushik Das, Rupnarayan Bhattacharya, Tapan Sarkar
Introduction: Several flaps have been described for reconstructing facial or oral defects. Flaps such as forehead and pectoralis major are often too bulky for small-to-moderate-sized defects, for which nasolabial flaps are often ideal. However, nasolabial flaps have limited mobility and reach and may need two stages, particularly for intraoral defects. According to recent literatures, facial artery provides numerous small cutaneous perforators, based on which skin flaps can be islanded, with greater mobility and reach for reconstruction of small-to-moderate-sized intraoral and facial defects in one stage. Our study aims to evaluate the reliability and versatility of facial artery perforator-based flaps in the reconstruction of such defects. Materials and Methods: A ethical committee-approved retrospective study was conducted on data of the patients attending our outpatient department between February 2014 and October 2015 with small-to-moderate-sized facial/oral lesions. The total sample size was 23. We studied the relation of flap survival with size of flap, route of inset and neck dissection, functional and aesthetic outcomes and feasibility of adjuvant therapy in cases of malignancies. Results and Analysis: A wide range of facial defects, especially intraoral defects, could be reconstructed in one stage using facial artery perforator-based flaps. The flaps were reliable. Complications included only partial skin loss of the flaps in a few cases. Complications were directly related to the length of the flaps and the route of inset. Functional and aesthetic outcomes were satisfactory and none of the flaps showed any significant post-radiotherapy changes. Conclusions: We concluded that facial artery perforator flap can be a simple, safe, versatile and one-stage alternative to the traditional flaps in the reconstruction of small-to-moderate-sized facial defects. Neck dissection can be safely done in the same sitting.
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Acetic acid dressings: Finding the Holy Grail for infected wound management p. 273
Kapil S Agrawal, Anup Vidyadhar Sarda, Raghav Shrotriya, Manoj Bachhav, Vinita Puri, Gita Nataraj
Background: Wounds have since long, contributed majorly to the health-care burden. Infected long-standing non-healing wounds place many demands on the treating surgeon and are devastating for the patients physically, nutritionally, vocationally, financially, psychologically and socially. Acetic acid has long been included among agents used in the treatment of infected wounds. In this study, we have evaluated the use of acetic acid for topical application in the treatment of infected wounds. Materials and Methods: A total of 100 patients with infected wounds were treated with topical application of 1% acetic acid as dressing material after appropriate cleaning. A specimen of wound swab was collected before first application and further on days 3, 7, 10 and 14. Daily dressings of wounds were done similarly. Minimum inhibitory concentration (MIC) of acetic acid against various organisms isolated was determined. Results: The patients treated ranged between 9 and 60 years, with the mean age 33 years. Nearly 70% of patients were male. Aetiologies of wounds: infective 35, diabetic 25, trauma 20, burns 10, venous ulcers 5 and infected graft donor site 5. Various microorganisms isolated include Pseudomonas aeruginosa (40%), Staphylococcus aureus (2%), Acinetobacter (12%), Escherichia Coli (5%), Proteus mirabilis (3%), Klebsiella (18%), methicillin-resistant S. aureus (10%), Streptococcus (2%) and Enterococcus (1%), Citrobacter (1%). Few wounds (6%) also isolated fungi. About 28%, 64% and 8% of patients isolated no growth on culture after 7, 14 and 21 days, respectively. MIC of all isolated organisms was ≤0.5%. Conclusion: pH of the wound environment plays a pivotal role in wound healing. Acetic acid with concentration of 1% has shown to be efficacious against wide range of bacteria as well as fungi, simultaneously accelerating wound healing. Acetic acid is non-toxic, inexpensive, easily available and efficient topical agent for effective elimination of wound infections caused due to multi-drug resistant, large variety of bacteria and fungus.
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Ad hoc posterior tibial vessels perforator propeller flaps for the reconstruction of lower third leg soft- tissue defects p. 281
Thalaivirithan Margabandu Balakrishnan, Jayagosh Ramkumar, Janardhanan Jaganmohan
Introduction: Lower third leg soft tissue defects with anatomical and pathological constraints are posing formidable challenges to reconstructive surgeon. Aim: This retrospective study was conducted to assess the effectiveness of ad hoc posterior tibial vessels perforator-propeller flaps for the reconstruction of small and medium sized soft tissue defects in the lower third leg. Patients and Methods: 22 patients (16 were males and 6 were females) were involved in this study between period of January 2012 and December 2016.We followed the protocol of initial non delineating exploratory incision made to find out single best perforator in all patients. All the defects in leg reconstructed with adhoc posterior tibial vessel propeller flaps. Results: All 22 flaps survived well. All in an average of 13 months follow up period, had pain free walking, with minimal scarring and acceptable aesthesis at the reconstruction sites with no need for any secondary procedure. Conclusion: With inability of preoperatively dopplering the perforators in the lower third leg region, the exploratory posterior nondelineating incision was used in all cases to secure the single best perforator for the propeller flaps. Thus adhoc posterior tibial vessel propeller flaps are dependable, easily adoptable for the reconstruction of soft tissue defects of the lower third leg region.
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The conundrum of deep vein thrombosis prophylaxis in burns in India and review of literature p. 288
SS Shirol, Srinivas Kodaganur, M Raghavendra Rao, Vinaykumar Tiwari
Objective: The aim is to assess the practice of deep vein thrombosis (DVT) prophylaxis among the plastic surgeons attending National Academy of Burns India Conference 2012 (NABICON 2012). Background: DVT prophylaxis in burns is a controversial issue as there is no consensus among the community of burn surgeons about the prevalence of DVT, the incidence of pulmonary embolism, the indications for DVT prophylaxis, dosage and duration of low molecular weight heparins (LMWH) and the complications related to DVT and LMWH. Methodology: A survey was conducted among plastic surgeons attending the NABICON 2012 held at New Delhi, by circulating a questionnaire. The respondents were divided into two groups based on whether burns constituted more than or less than 50% of their practice. The data thus collected were tabulated and analysed. Results: Almost 70% of all the respondents practice some form of DVT prophylaxis. There was significantly higher incidence of complications related to the use of LMWH among the surgeons whose practice of burns was >50%. There was no significant difference between the two groups in relation to the incidence and complication of DVT or recommendation of DVT prophylaxis. Conclusion: Majority of plastic surgeons practice DVT prophylaxis routinely and consider multiple criteria such as percentage of burns, age, lower limb involvement, the degree of burns and associated co-morbidities for starting the LMWH.
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Planning community-based intervention for speech for children with cleft lip and palate from rural South India: A needs assessment p. 295
Subramaniyan Balasubramaniyan, Vaidyanathan Raghunathan, B Rajashekhar, B WC Sathiyasekaran, Roopa Nagarajan
Background and Aim: A community-based rehabilitation programme, Sri Ramachandra University-Transforming Faces project, was initiated to provide comprehensive management of communication disorders in individuals with CLP in two districts in Tamil Nadu, India. This community-based programme aims to integrate hospital-based services with the community-based initiatives and to enable long-term care. The programme was initiated in Thiruvannamalai (2005) district and extended to Cuddalore (2011). The aim of this study was to identify needs related to speech among children with CLP, enroled in the above community-based programme in two districts in Tamil Nadu, India. Design: This was a cross–sectional study. Participants and Setting: Ten camps were conducted specifically for speech assessments in two districts over a 12-month period. Two hundred and seventeen individuals (116 males and 101 females) >3 years of age reported to the camps. Methods: Investigator (SLP) collected data using the speech protocol of the cleft and craniofacial centre. Descriptive analysis and profiling of speech samples were carried out and reported using universal protocol for reporting speech outcomes. Fleiss' Kappa test was used to estimate inter-rater reliability. Results: In this study, inter-rater reliability between three evaluators revealed good agreement for the parameters: resonance, articulatory errors and voice disorder. About 83.8% (n = 151/180) of the participants demonstrated errors in articulation and 69% (n = 124/180) exhibited abnormal resonance. Velopharyngeal port functioning assessment was completed for 55/124 participants. Conclusion: This study allows us to capture a “snapshot” of children with CLP, living in a specific geographical location, and assist in planning intervention programmes.
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Journal club and post-graduate medical education p. 302
Surajit Bhattacharya
A journal club is an educational meeting in which a group of individuals discuss published articles, to keep themselves abreast of new knowledge, promoting in them the awareness of current research findings, teaching them to critique and appraise research, and encourage them to utilize research in evidence based practice of the speciality. With so much of market driven research in journals the role of journal club becomes even more vital to differentiate a genuine recent advance from a clever but outright harmful rediscovery of the wheel which has been long discarded. Journal clubs can be department initiated or journal initiated and there are randomized control trials to prove that they improve reading habits, knowledge of epidemiology and statistics, and use of medical literature in practice. Choosing the journal club articles, assessing them and presenting them in the journal club meeting are all of vital importance and as a trainee advances in his training he/she is expected to imbibe the best from his seniors and peers in the club. I a journal club one is simply expected to summarize the research question, the methods, the results and the conclusions and not slavishly read through the article. It is the presenter's interpretation that is more important than actually rehashing the contents of the article.
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Nasal reconstruction with pre-laminated forehead flap p. 306
NS Prasanna
Loss of nasal skin as well as loss of both lateral alar cartilages and vestibular lining with exposure of septum presents a grotesque deformity by itself, with further danger of loss of nasal bones and other cartilaginous structures leading to total loss of nose. The Goal of the treatment is to restore the skin cover as well as lining and cartilage support, restoring nose while avoiding the deformity. In an elderly patient with Spiritual restrictions, with diabetes and Hypertension, the treatment was needed to be carried out under local anesthesia as a daycare procedure. Forehead flap was pre-Laminated on forehead before the transfer to have all the three layers of nasal covering.Next the flap was transferred, customizing to recipient site. Finally pedicle was divided retaining the supratrochlear vessels, ensuring the vascularity of the reconstruction and retaining the ability to debulk/manipulate the flap later.
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Alveolar soft part sarcoma of the forearm p. 310
B Asokan, P Ramanan, M Sundararaj, E Kovarthini
Alveolar soft part sarcoma (ASPS) is a rare form of soft-tissue sarcoma arising from connective tissue. It is most often seen in adolescents and young adults and has high propensity for recurrence and metastasis. Clinically, it mimics haemangioma or arteriovenous malformations. In our case report, an 18-year-old female presented with markedly vascular tumour in the left forearm, for which excision biopsy was done. Histopathological report revealed ASPS. The patient was screened for metastasis. Ultrasound abdomen, computed tomography (CT) chest, CT brain and whole-body skeletal survey was done. The patient was found to have bilateral pulmonary metastasis. The patient was given 6 cycles of chemotherapy with adriamycin, cyclophosphamide and vincristine. There was no locoregional and pulmonary recurrence for 11 months after being treated by excision of the tumour followed by chemotherapy.
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New, small, needle holders: Their designs and usage techniques p. 314
Bandikatla Venkata Ratnam
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A simple technique for temporary marking of the electrical stimulation points in brachial plexus injury patients p. 316
Karan Rajiv Choudhry, Hari Venkatramani, S Raja Sabapathy
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Bed pad as an alternative painless, comfortable and economical burn wound dressing p. 317
Kirti Garude, Shankar Srinivasan, Nikunj Bhavesh Mody, Bipin Ghanghurde, Jovita Saldanha, Arvind Vartak, Suhas Abhyankar
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The use of corneal blade in hand surgery p. 319
Jagannath Kamath, Nikil Jayasheelan, Sumana Kamath, Premjit Sujir, Rajashekar Danda
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Dumb-bell lipoma of finger digital flexor sheath: Unusual presentation p. 320
Elankumar Subbarayan, Devi Prasad Mohapatra, Sudhanva Hemant Kumar, Preethitha Babu, Senthil Kumaran
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Tribute to Dr. Anthony Dugald Dias (1926–2018) p. 322
Ravin Thatte
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Dr. Bijoy Methil (1973–2018) Highly accessed article p. 324
Sameer A Karkhanis
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