Indian Journal of Plastic Surgery
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   Table of Contents - Current issue
Coverpage
September-December 2018
Volume 51 | Issue 3
Page Nos. 263-351

Online since Thursday, March 7, 2019

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EDITORIAL  

A transilience? Or a natural progression?! Highly accessed article p. 263
Dinesh Kadam
DOI:10.4103/ijps.IJPS_266_18  
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ICON OF THE ISSUE Top

Tony Watson Eulogy p. 264
Ravin Thatte
DOI:10.4103/ijps.IJPS_29_19  
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ORIGINAL ARTICLES Top

Intraoperative partial pressure of oxygen measurement to predict flap survival p. 266
Ankit Gupta, Akhil Kumar, Shyam Gupta, Sameek Bhattacharaya, Manoj Kumar Jha, Vinay Kumar Tiwari, R Pradeep Kulal, Shobhit Gupta, Sahil Niyazi
DOI:10.4103/ijps.IJPS_35_17  
Introduction: Flap monitoring using partial pressure of oxygen (pO2) is a proven modality. Instruments needed are expensive and are not readily available to a clinician. Here, pO2of flap has been determined using readily available and cheap methods, and a cut-off value is calculated which helps in predicting flap outcome. Methods and Results: Total 235 points on 84 skin flaps were studied. Capillary blood was collected from flap and fingertip using 1-ml syringes after at least 30 min of flap inset, and pO2analysed using blood gas analyser. Fall/change of pO2(difference of mean of pO2[diff-pO2]) was also calculated by subtracting the flap pO2from the finger pO2. Flap was monitored clinically in post-operative period and divided into two groups depending on its survival with Group 1 – dead points and Group 2 – alive points. pO2and diff-pO2amongst both the groups were compared and found to be statistically different (P = 0.0001). Cut-off value calculated for pO2was found to be <86.3 mmHg with a sensitivity of 100% and specificity of 89.05%. The difference of >68.503 mmHg of flap pO2compared from finger pO2was calculated as a cut-off with sensitivity of 94.12 and specificity of 79.60%. Conclusions: Flap areas having intra-operative pO2value <86.3 mmHG have higher chances (60.71%) of getting necrosis later. Similarly, if diff-pO2compared to fingertip is >68.5 mmHg, chances of those points getting necrosed in post-operative period are high.
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Free fibula flap for lower limb salvage after tumour resection p. 274
Vinay Kant Shankhdhar, Prabha S Yadav, Ajay Puri, Ashish Kasat, Jaiswal Dushyant, Ram Badari Narayan Raghu, Ashish Gulia
DOI:10.4103/ijps.IJPS_113_17  
Context: Post-tumour resection lower limb salvage. Aim/Introduction: Resection of tumours of the femur and tibia around the knee and ankle joints results in large bony defects. Often arthrodesis is an alternative; in case, adequate functional motors cannot be preserved or due to economic constraints. Thus, in an immunocompromised patient, the vascularised fibula is the best form of reconstruction. The vascularised fibular flap (pedicled/free) can be used in combination with an allograft. We refer to such a combination reconstruction as ‘allocombo’. The vascularised fibular graft hypertrophies in due course of time, and till that period, the allograft provides the required mechanical strength to allow early ambulation. Subjects and Methods: A retrospective study of 24 cases of vascularised fibular graft for lower limb reconstruction was conducted from February 2003 to March 2014. The average defect size was 15.5 cm and the average length of fibula harvested was 24.35 cm. A total of 19 free fibular flaps and 5 pedicled fibula were done. Mean age was 26 years. Fibula was nestled in the allograft obtained from the tissue bank. Results: The mean follow-up time was 52 months. Free flap success rate was 96%. Successful healing was achieved at 45 ends (97.8%). Radiological evidence of union at osteotomy sites occurred at an average of 6.8 months. Eight patients eventually succumbed to disease. At the final follow-up, the mean Musculoskeletal Tumour Society functional score of the evaluable patients was 26 (range 20–30). Conclusions: Pedicled fibula is a good option if the defect is within 14 cm of the knee joint at the femoral end. The vessels have to curve around the fibular head, thus its removal improves the reach of the pedicle. The flap is easy to harvest with predictable vascular anatomy and it can provide a large amount of vascularised bone and skin paddle. It results in early ambulation, rehabilitation and reduced morbidity. We realised that fixation is easier and chances of vascular injury are less in free as compared to pedicled fibula.
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Reconstruction with free flaps in robotic head-and-neck onco-surgeries p. 283
Rajan Arora, Vinay Kumar Verma, Kripa Shanker Mishra, Hemant Bhoye, Rahul Kapoor
DOI:10.4103/ijps.IJPS_35_18  
Aims and Objective: The aim of the present article is to highlight how reconstruction with free flaps is different and difficult in cases with robotic head-and-neck cancer surgery. It also highlights the technical guidelines on how to manage the difficulties. Materials and Methods: Eleven patients with oropharyngeal cancer having undergone tumour excision followed by free-flap reconstruction been reviewed here. Nine patients had tumour excision done robotically through intraoral route while neck dissection done with transverse neck crease incision. There is a problem of difficult flap inset in this group of patient. Two patients had intraoral excision of tumour followed by robotic neck dissection via retroauricular incision. With no incision directly on the neck, microvascular anastomosis is challenging in this set of patients. Free flap was used in all the cases to reconstruct the defect. Results: Successful reconstruction with free flap was done in all the cases with good outcome both functionally and aesthetically. Conclusion: Free-flap reconstruction is possible in robotic head-and-neck cancer surgery despite small and difficult access, but it does need practice and some technical modifications for good outcome.
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Management of cleft lip and palate in Egypt: A National survey p. 290
Tarek Abdelhameed Abulezz, Ahmed K Elsherbiny, Ahmed S Mazeed
DOI:10.4103/ijps.IJPS_104_18  
Background: Variable protocols for the management of cleft lip and/or palate (CLP) patients are currently used. However, to our knowledge, there are no previously published data about cleft management and practice in Egypt. Materials and Methods: One-hundred questionnaires were distributed to cleft surgeons attending the annual meeting of the Egyptian Society of Plastic and Reconstructive Surgeons in March 2016 to investigate timing, techniques and complications of cleft surgery. Seventy-two colleagues returned the questionnaire, and the data were analysed using Microsoft Excel software. Results: The majority of cleft lip cases are repaired between 3 and 6 months. Millard and Tennison repairs for unilateral cleft lip, while Millard and Manchester techniques for bilateral cleft lip are the most commonly performed. Cleft palate is usually repaired between 9 and 12 months with the two-flap push-back technique being the most commonly used. The average palatal fistula rate is 20%. Pharyngeal flap is the method of choice to correct velopharyngeal incompetence. Polyglactin 910 is the most commonly used suture material in cleft surgery in the country. Multidisciplinary cleft management is reported only by 16.5% of participants. Conclusion: Management of CLP in Egypt is mainly dependent on personal preference, not on constitutional protocols. There is a lack of multidisciplinary approach and patients’ registration systems in the majority of centres. The establishment of cleft teams from the concerned medical specialties is highly recommended for a more efficient care of cleft patients.
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COMMENTARY Top

Commentary on: Management of cleft lip and palate in Egypt – A national survey p. 296
Jyotsna Murthy
DOI:10.4103/ijps.IJPS_246_18  
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ORIGINAL ARTICLES Top

A retrospective analysis of incidence and management of palatal fistula p. 298
Ravi Kumar Mahajan, Amreen Kaur, Sardar Mahipal Singh, Prakash Kumar
DOI:10.4103/ijps.IJPS_84_18  
Background: Cleft palate repair may be compromised by a number of complications, most commonly the development of a fistula. Fistulas may cause hypernasal speech, articulation problems and food or liquid regurgitation from the nose. Objective: The study determines the incidence and management of cleft palatal fistulas in a series of primary cleft palate repair surgeries. It is a retrospective analysis of total 185 palatal fistula cases operated at our hospital from the year 2004 to 2016. Subjects and Methods: Of 185 palatal fistulas, 132 cases had been operated at our institute for primary palatoplasty, and the rest 53 were the outside-operated cases. The patients with bilateral as well as unilateral cleft lip and palate were included. Isolated cleft palate patients were also included in the study. Palatal fistulas were subdivided into three types depending on their size. Anterior palatal fistulas were mostly treated by using tongue flap (65.57%), followed by local flaps (34.43%). Middle and posterior palatal fistulas were mostly treated by von Langenbeck Palatoplasty. One patient (>5 mm fistula) was treated using free radial forearm flap. Results: Anterior palatal fistulas (65.57%) were most commonly reported, followed by middle (24.86%) and posterior (9.18%). Most commonly, the size of the fistulas ranged from 2 mm to 5 mm. The complication rate was reported to be 3.75% in case of tongue flap and 11.9% complications were reported in case of local flaps. Conclusion: Tongue flap remains the flap of choice for managing very difficult and challenging anterior palatal fistulas compared to local flaps.
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Extended adipofascial wrap around radial forearm flap for hard palate reconstruction p. 306
BC Ashok, Pradeep Kumar Nagaraj, Srikanth Vasudevan, Anantheshwar Y.N. Rao, Sudarshan Reddy Nagireddy, Ritu Singh Batth
DOI:10.4103/ijps.IJPS_81_18  
Background: While using radial forearm free flap in palate reconstruction, the pedicle lies in the nasal floor, constantly exposed to the nasal secretions and turbulent air current. To overcome this problem, we have designed a procedure which utilises the adipofascial extension to wrap the pedicle and nasal side of the flap. Materials and Methods: The study was done during 2017 and 2018, 2 years’ period. Totally 13 consecutive patients with defect in the palate status post-oncological resection and those in whom local flaps were not enough to cover the defect were included into the study. These patients were divided into two groups. First group in whom adipofascial extension was not used to cover the pedicle and second group in whom adipofascial extension was used to cover the pedicle. The incidence of nasal crusting, secondary haemorrage, blow out and flap necrosis were analysed and compared. Results: In Group 1, we had 2 among 6 (33%) patients with secondary haemorrage. One patient had partial flap loss. On exploring, we noticed thrombosis of cephalic vein. We did not had any incidence of blow out of the pedicle. In Group 2, none of the patients had any secondary haemorrage. All flaps healed well. On doing nasal endoscopy at 6 months of follow-up, all flaps showed complete mucosalisation at the nasal side. Conclusion: Use of adipofascial extension while planning a radial forearm free flap to cover the nasal side of the flap and pedicle in the nasal floor helps to reduce the nasal crusting and secondary haemorrhage.
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The characteristics of private plastic surgery practice in developing country: An epidemiological study p. 309
Irena Sakura Rini, Made Ananda Krisna, Adi Basuki, Kasih Rahardjo Djarot
DOI:10.4103/ijps.IJPS_11_18  
Background: With the rise in working-age population, there has been notable economic growth in Indonesia. Along with it, there is an increase in expenditure for non-food items such as health-care service, without exception to plastic surgery practice. Aesthetic plastic surgery practice has gained its popularity in several other developing countries such as Brazil, Russia, India and China. Epidemiology report of private plastic surgery practice in Jakarta, the capital of Indonesia, will provide the evidence of increasing need for aesthetic plastic surgery practices as the basis for further improvement. Methods: This is a single-centre descriptive cross-sectional study with a total sampling method which included all patients registered at a private plastic surgery clinic between January 2008 and December 2016. Results: There were 1457 medical procedures. The majority (93.4%) of patients were female. More than 80% were surgical procedures, the most common ones were breast implant and blepharoplasty with the latter being similarly popular in both gender. The majority of the patients fell into 20–45-year-old group. Patients <20-year-old had undergone a more minor surgical procedure such as skin tumour and nevus excision or scar treatment while patients >45-year-old had more procedures with rejuvenation purpose. Conclusion: The epidemiology of private plastic surgery practice in an urban area of developing country resembles those in either developed or developing countries with a similar socio-demographic profile. This data can be further utilised for a more focused private plastic surgery practice improvement. The limitation however is that, the study is based on a single centre data.
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IDEAS AND INNOVATIONS Top

Marking of temporal point and lower border of temporal triangle in planning hair transplantation for male-pattern baldness p. 316
Suneet Soni, Hardik Dodia
DOI:10.4103/ijps.IJPS_135_18  
Introduction: Temporal recession in male-pattern baldness is common. The method of marking of temporal point practiced worldwide, described by Walter P. Unger, does not help in marking temporal triangle border in Indian population. We have found aesthetically superior way of marking temporal point and easy method of construction of lower border of temporal triangle. Case Series: The new marking was applied over 126 young male patients from March 2014 to December 2017; they were regularly followed up and results were observed. Conclusion: With the new method of marking, we found that the lower border of temporal triangle can be easily constructed and temporal point can be more aesthetically placed in Indian population.
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Two new clinical tests for palmaris longus p. 321
Ravindra Mohan Shenoy
DOI:10.4103/ijps.IJPS_105_18  
The palmaris longus (PL) tendon can be assessed with clinical tests whose reliability varies. Herewith, two new tests are described – the ‘Bunched Finger’ test and ‘Hooked Finger test’ that are simple and visualise the PL tendon easily and prominently.
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CASE REPORTS Top

Serial abdominal closure with Gore-tex mesh and Rives-Stoppa for an open abdomen secondary to intra-abdominal hypertension in burns p. 324
R Raja Shanmugakrishnan, Charles Yuen Yung Loh, Abhijeet Wakure, Naguib El-Muttardi
DOI:10.4103/ijps.IJPS_75_18  
Intra-abdominal hypertension (IAH) leading to abdominal compartment syndrome (ACS) commonly occurs in major burns. To relieve the excess pressure, decompressive laparotomy is done which can lead to an open abdomen. Closure of the abdomen after a decompressive laparotomy is very difficult with bowel oedema. We describe our technique of closing the open abdomen in such situations with a combination of serial abdominal wall closure with a layered mesh and the Rives-Stoppa component separation technique.
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Sympathetic dysfunction dermatitis in a revascularised upper extremity after near-total amputation – A case report and review of literature p. 327
Amol Dhopte, Surendra Patil, Nitin Barde, Rupesh Thakre, Shree Harsh, Shailesh Nisal
DOI:10.4103/ijps.IJPS_135_17  
Commonly reported complications after revascularisation or replantation of extremity are vascular thrombosis leading to complete or partial failure, bony non-union or malunion, joint stiffness and incomplete or abnormal sensory recovery. Sympathetic dysfunction dermatitis is an unreported complication after revascularisation or replantation surgery which results due to denervation of the extremity. We report a case of a young adult who developed eczematous dermatitis over the revascularised upper limb and discuss the role of sympathetic dysfunction in the development of these skin lesions. The patient was successfully treated with a short course of oral and topical steroids. Sympathetic dysfunction dermatitis is a rare form of skin eruptions occurring in the revascularised or replanted part of an extremity due to abnormal sympathetic function in the affected part.
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LETTERS TO EDITOR Top

Learn to climb the simple reconstructive ladder properly for optimum results p. 331
Rakesh Kumar Sandhir
DOI:10.4103/ijps.IJPS_66_18  
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The buried hybrid mattress suture: A novel technique p. 332
Brig Sandeep Mehrotra, Megha Sharma
DOI:10.4103/ijps.IJPS_24_18  
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Transsphenoidal encephalocele, colpocephaly and corpus callosum agenesis in a midline cleft lip and palate patient: A very rare case p. 334
Indranil Dutta, Guruaribam Nilamani Sharma, Khungdombam Palin Singh
DOI:10.4103/ijps.IJPS_118_18  
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A hybrid technique of trapezius muscle transfer for a flail shoulder in late brachial plexus injuries p. 336
Akhil Garg, KS Ajai, Satyaswarup Tripathy, Nirmal Raj Gopinathan, Ramesh Kumar Sharma
DOI:10.4103/ijps.IJPS_170_18  
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Synoviosarcoma of arm in 4-month-old infant reconstructed with sensate free anterolateral thigh flap p. 338
Balakrishnan Margabandu Thalaivirithan, Harsha Subbaraj, Jaganmohan Janardhanam
DOI:10.4103/ijps.IJPS_102_18  
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Re: The reverse dorsal metacarpal artery flap in finger reconstruction: A reliable choice p. 340
Leena Jain, Samir Madhukar Kumta, Shrirang Keshav Purohit
DOI:10.4103/ijps.IJPS_165_18  
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Re: A novel method to insert drain atraumatically after liposuction in gynecomastia p. 342
Alessandro Innocenti, Dario Melita, Marco Innocenti
DOI:10.4103/ijps.IJPS_106_18  
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Nerve trimming device p. 343
Jagannath Bantwal Kamath, Mithun Pai, Premjit Rabindra Sujir
DOI:10.4103/ijps.IJPS_157_17  
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Re: Academic integrity and plagiarism p. 344
Beuy Joob, Viroj Wiwanitkit
DOI:10.4103/ijps.IJPS_257_18  
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OBITUARIES Top

Dr. M. Ashraf Darzi: A Tribute (1951–2018) p. 346
Peerzada Umar Farooq Baba
DOI:10.4103/ijps.IJPS_244_18  
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Dr Samuel Noordhoff (1927–2018) p. 348
Jyotsna Murthy, Nitin J Mokal
DOI:10.4103/ijps.IJPS_267_18  
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Giorgio Brunelli: The champion of microsurgery p. 350
Prabha S Yadav
DOI:10.4103/ijps.IJPS_253_18  
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