Indian Journal of Plastic Surgery
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   Table of Contents - Current issue
September-December 2015
Volume 48 | Issue 3
Page Nos. 233-331

Online since Monday, January 04, 2016

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From the desk of the editor p. 233
Mukund Jagannathan
DOI:10.4103/0970-0358.173099  PMID:26933275
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Icon of this issue: Sir Archibald McIndoe p. 234
Wg Cdr Ankur Pandya
DOI:10.4103/0970-0358.173100  PMID:26933276
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Fibrous dysplasia and cherubism p. 236
Surajit Bhattacharya, RK Mishra
DOI:10.4103/0970-0358.173101  PMID:26933277
Fibrous dysplasia (FD) is a non-malignant fibro-osseous bony lesion in which the involved bone/bones gradually get converted into expanding cystic and fibrous tissue. The underlying defect in FD is post-natal mutation of GNAS1 gene, which leads to the proliferation and activation of undifferentiated mesenchymal cells arresting the bone development in woven phase and ultimately converting them into fibro-osseous cystic tissue. Cherubism is a hereditary form of fibrous dysplasia in which the causative factor is transmission of autosomal dominant SH3BP2 gene mutation. The disease may present in two distinct forms, a less severe and limited monostotic form, and a more aggressive and more widespread polyostotic form. Polyostotic form may be associated with various endocrine abnormalities, which require active management apart from the management of FD. Management of FD is not free from controversies. While total surgical excision of the involved area and reconstruction using newer micro-vascular technique is the only definitive treatment available from the curative point of view, but this can be only offered to monostotic and very few polyostotic lesions. In polyostotic varieties on many occasions these radical surgeries are very deforming in these slow growing lesions and so their indication is highly debated. The treatment of cranio-facial fibrous dysplasia should be highly individualized, depending on the fact that the clinical behavior of lesion is variable at various ages and in individual patients. A more conservative approach in the form of aesthetic recontouring of deformed bone, orthodontic occlusal correction, and watchful expectancy may be the more accepted form of treatment in young patients. Newer generation real-time imaging guidance during recontouring surgery adds to accuracy and safety of these procedures. Regular clinical and radiological follow up is required to watch for quiescence, regression or reactivation of the disease process. Patients must be warned and watched for any sign of nerve compression, especially visual impairment due to optic nerve compression. Rather than going for prophylactic optic canal decompression (which does more harm than good), optic nerve decompression should be done in symptomatic patients only, and preferably be done via minimal invasive endoscopic neuro-surgical approach than the conventional more morbid open craniotomy approach. There is growing research and possibilities that newer generation bisphosphonate medication may change the management scenario, as these medications show encouraging response in not only reducing the osteoclastic activity, but simultaneously also stimulating the osteoblastic and osteocytic activities. The explosion of genetic research and stem cell therapy may lead to better understanding and subsequently better treatment of FD in future.
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Current trends of liposuction in India: Survey and Analysis p. 249
Bijoy Methil
DOI:10.4103/0970-0358.173122  PMID:26933278
Background: Liposuction is the commonest aesthetic procedure performed by Indian plastic surgeons. However, there exists substantial disparity amongst Indian surgeons about guidelines concerning liposuction.To address this disparity, a nationwide email survey (Association of Plastic Surgeons of India [APSI] database) was started in December 2013 and continued for 5 months. Material and Methods: The survey was developed with software from The study was designed to cover most aspects of patient selection, perioperative management, technical considerations, postoperative management and complications. This is the first survey to be conducted in India for an extremely popular procedure. It is also one of the most exhaustive surveys that have been conducted in terms of the topics covered. Results and Conclusions: One hundred and eighteen surgeons (including a majority of the cosmetic surgery stalwarts in the country) completed the survey. As expected, the results show a disparity in most parameters but also consolidation on some issues. Liposuction is considered extremely safe (86.1%). The majority of surgeons (70.3%) aspirated >5 L at onetime.The majority (80.2%) felt that the limits for liposuction should be relative and not absolute. The survey highlights lack of standardization with respect to infiltration solutions. The commonest complications observed were contour irregularities, followed by seroma and inadequate skin redrape. The amount of aspirate is the only factor, which achieves statistical significance with respect to major complications. A review of the current evidence and recommendations has been incorporated, along with an in depth analysis of the survey.
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A novel 3D template for mandible and maxilla reconstruction: Rapid prototyping using stereolithography p. 263
Samir Kumta, Monica Kumta, Leena Jain, Shrirang Purohit, Rani Ummul
DOI:10.4103/0970-0358.173123  PMID:26933279
Introduction: Replication of the exact three-dimensional (3D) structure of the maxilla and mandible is now a priority whilst attempting reconstruction of these bones to attain a complete functional and aesthetic rehabilitation. We hereby present the process of rapid prototyping using stereolithography to produce templates for modelling bone grafts and implants for maxilla/mandible reconstructions, its applications in tumour/trauma, and outcomes for primary and secondary reconstruction. Materials and Methods: Stereolithographic template-assisted reconstruction was used on 11 patients for the reconstruction of the mandible/maxilla primarily following tumour excision and secondarily for the realignment of post-traumatic malunited fractures or deformity corrections. Data obtained from the computed tomography (CT) scans with 1-mm resolution were converted into a computer-aided design (CAD) using the CT Digital Imaging and Communications in Medicine (DICOM) data. Once a CAD model was constructed, it was converted into a stereolithographic format and then processed by the rapid prototyping technology to produce the physical anatomical model using a resin. This resin model replicates the native mandible, which can be thus used off table as a guide for modelling the bone grafts. Discussion: This conversion of two-dimensional (2D) data from CT scan into 3D models is a very precise guide to shaping the bone grafts. Further, this CAD can reconstruct the defective half of the mandible using the mirror image principle, and the normal anatomical model can be created to aid secondary reconstructions. Conclusion: This novel approach allows a precise translation of the treatment plan directly to the surgical field. It is also an important teaching tool for implant moulding and fixation, and helps in patient counselling.
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Pedicle streaking: A novel and simple aid in pedicle positioning in free tissue transfer p. 274
Aditya Aggarwal, Hardeep Singh, Sanjay Mahendru, Vimalendu Brajesh, Sukhdeep Singh, Ashish Khare, Umang Kothari, Rakesh Kumar Khazanchi
DOI:10.4103/0970-0358.173124  PMID:26933280
Introduction: The pedicle positioning in free tissue transfer is critical to its success. Long thin pedicles are especially prone to this complication where even a slight twist in the perforator can result in flap loss. Pedicles passing through the long tunnels are similarly at risk. Streaking the pedicle with methylene blue is a simple and safe method which increases the safety of free tissue transfer. Materials and Methods: Once the flap is islanded on the pedicle and the vascularity of the flap is confirmed, the pedicle is streaked with methylene blue dye at a distance of 6-7 mm. The streaking starts from the origin of the vessels and continued distally on to the under surface of flap to mark the complete course of the pedicle in alignment. The presence of streaking in some parts and not in rest indicates twist in the pedicle. Observation and Results: Four hundred and sixty five free flaps have been done at our centre in the last 5 years. The overall success rate of free flaps is 95.3% (22 free flap failures). There has not been a single case of pedicle twist leading to flap congestion and failure. Conclusion: This simple and novel method is very reliable for pedicle positioning avoiding any twist necessary for successful free tissue transfer.
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Tracheoesophageal puncture site closure with sternocleidomastoid musculocutaneous transposition flap p. 278
Dushyant Jaiswal, Prabha Yadav, Vinay Kant Shankhdhar, Rajendra Suresh Gujjalanavar, Prashant Puranik
DOI:10.4103/0970-0358.173125  PMID:26933281
Introduction: Tracheoesophageal voice prosthesis is highly effective in providing speech after total laryngectomy. Although it is a safe method, in certain cases dilatation or leakage occurs around the prosthesis that needs closure of tracheoesophageal fistula. Both non-surgical and surgical methods for closure have been described. Surgical methods are used when non-surgical methods fail. We present the use of the sternocleidomastoid musculocutaneous (SCMMC) transposition flap for the closure of tracheoesophageal fistula. Materials and Methods: An incision is made at the mucocutaneous junction circumferentially around the tracheostoma. Tracheoesophageal space is dissected down to and beyond the fistula. The tracheoesophageal tract is divided. The oesophageal mucosa is closed with simple sutures. Then SCMMC transposition flap is raised and transposed to cover sutured oesophagus and the defect between the oesophagus and the trachea. Results: This study was done prospectively over a period of 1 year from June 2012 to May 2013. This technique was used in patients with pliable neck skin. In nine patients, this procedure was done (inferior based flap in nine cases) and it was successful in eight patients. In one case, there was dehiscence at the leading edge of flap with oesophageal dehiscence, which required a second procedure. In two cases, there was marginal necrosis of flap, which healed without any intervention. Nine patients in this series were post-radiation. Conclusion: This method of closure is simple and effective for patients with pliable neck skin, who require permanent closure of the tracheoesophageal fistula.
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Axillary breast: Navigating uncharted terrain p. 283
Medha A Bhave
DOI:10.4103/0970-0358.173126  PMID:26933282
Introduction: Axillary breast is a common condition that leads to discomfort and cosmetic problems. Liposuction alone and open excision are two techniques used for treatment. Materials and Methods: This study assesses the results of treatment in 24 consecutive patients, operated between 2005 and 2015.All patients had Kajava class IV masses. Three were treated by liposuction alone, while 21 were treated by open axillaplasty with limited liposuction. Results: One patient treated by liposuction alone had to be re-operated for a residual lump, while with axillaplasty, no major complications were observed and the results were uniformly good. Discussion: Certain points of technique emerged as major determinants in obtaining the best results. In brief, these are: a) limited skin excision; b) placing elliptical incisions within the most lax, apical axillary skin, irrespective of the location of the lump; c) raising skin flaps at the level of superficial fascia; d)meticulous dissection and preservation of the nerves, especially the second intercostobrachial; f) judicious liposuction for eliminating dog ears and axillary sculpting only; g) avoiding drains. Conclusion: Open axillaplasty with limited liposuction is the best way to minimise complications and produce good results.
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Hypothenar island flap: A safe and excellent choice for little finger defects p. 288
Mehmet Tapan, Murat Igde, Ali Riza Yildirim, Yagmur Yaprak Bali, Sedat Yilanci, Ramazan Erkin Unlu
DOI:10.4103/0970-0358.173127  PMID:26933283
Soft-tissue defects of the little finger are challenging especially when bone, tendon or vascular pedicle is exposed because of trauma. The hypothenar island flap is easy to harvest and has a good colour and texture match to the little finger pulp. We present nine clinical cases of soft tissue defects of the little finger covered using the reversed hypothenar fasciocutaneous island flap. This article intends to highlight the ease of elevation and good clinical results of the hypothenar flap which is rarely used.
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Simple device to determine the pressure applied by pressure clips for the treatment of earlobe keloids p. 293
Aashish Sasidharan, Ann David, Amish Gohil, Ashish Kumar Gupta
DOI:10.4103/0970-0358.173128  PMID:26933284
Background: Keloids of the ear are common problems. Various treatment modalities are available for the treatment of ear keloids. Surgical excision with intralesional steroid injection along with compression therapy has the least recurrence rate. Various types of devices are available for pressure therapy. Pressure applied by these devices is uncontrolled and is associated with the risk of pressure necrosis. We describe here a simple and easy to use device to measure pressure applied by these clips for better outcome. Objectives: To devise a simple method to measure the pressure applied by various pressure clips used in ear keloid pressure therapy. Materials and Methods: By using a force sensitive resistor (FSR), the pressure applied gets converted into voltage using electrical wires, resistors, capacitors, converter, amplifier, diode, nine-volt (9V) cadmium battery and the voltage is measured using a multimeter. The measured voltage is then converted into pressure using pressure voltage graph that depicts the actual pressure applied by the pressure clip. Results: The pressure applied by different clips was variable. The spring clips were adjustable by slight variation in the design whereas the pressure applied by binder clips and magnet discs was not adjustable. Conclusion: The uncontrolled/suboptimal pressure applied by certain pressure clips can be monitored to provide optimal pressure therapy in ear keloid for better outcome.
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A report of 2 patients with transient blindness following Le Fort I osteotomy and a review of past reported cases p. 297
Philip Mathew, Hirji Sorab Adenwalla, Puthucode V Narayanan, Emily Nyamu
DOI:10.4103/0970-0358.173129  PMID:26933285
Blindness following a LeFort I osteotomy is a rare but extremely serious complication. Ten cases have been reported to date. None of these patients recovered vision. Optic neuropathy is believed to be the cause but the exact mechanism has not been settled. We report the first, and the only two, documented cases of complete loss of vision that recovered subsequently. The first patient was a 19-year-old male with repaired bilateral cleft lip and palate. He developed loss of vision in the right eye on the second postoperative day. The second patient was a 22-year-old male with repaired unilateral cleft lip and palate. He developed complete loss of vision in the left eye on the day of surgery. Both these patients underwent ongoing studies, which did not show any abnormalities. Both were treated with methylprednisolone. Both the patients gradually showed improvement in their vision. The first patient recovered normal vision several months postoperatively. The second patient's vision improved to 4/60 by 4 months postoperatively. We discuss the probable mechanisms of optic nerve injury and also the possible reasons why sight was restored in these patients. This is a rare but serious complication following a fairly common procedure. Through this article we wish to create an awareness of this complication and also a possible way of avoiding such a disaster.
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Pentafid tongue: A new entity p. 301
Manesh Senan, Varun P Menon
DOI:10.4103/0970-0358.173130  PMID:26933286
Tongue plays a pivotal role in both physiological and functional life of human beings. Structural and developmental abnormalities of the tongue in various forms have been reported in isolation or in combination with various syndromes. Though cases of bifid tongues have been mentioned in literature, no reports of pentafid tongue have been reported till date. Here we describe a unique case of congenital pentafid tongue along with bilateral polydactyly and its surgical management.
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Severe iatrogenic nostril stenosis p. 305
Ali Ebrahimi, Amin Shams
DOI:10.4103/0970-0358.173131  PMID:26933287
Nostril stenosis (narrowing of the nasal inlet) is an uncommon deformity which results in aesthetic and breathing discomfort in patients. The literature review shows that trauma, infection, iatrogenic insults and congenital lesions are major causes of stenosis. Nowadays, rhinoplasty is one of most popular aesthetic surgeries which may have complications such as bleeding, swelling, bruising, asymmetry, obstruction of nasal airways. We present a 30-year-old female patient, who complained about breathing and aesthetic difficulties due to external nasal valve obstruction and nasal deformity. Past medical history showed that the patient had undergone three unsuccessful rhinoplasty surgeries with aesthetic goals.
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A simple external tissue expansion technique based on viscoelastic properties of skin to attain direct closure of a large scalp defect: A case report p. 309
Bandikatla Venkata Ratnam
DOI:10.4103/0970-0358.173137  PMID:26933288
Background: Direct closure of large scalp defects is not an easy task. Complicated flap designs or staged surgeries over a period of 6 months are often required. A case of a large scalp defect that was closed directly in 3 months by applying a simple external tissue expansion technique is presented in this report. Patient Profile: A 28-year-old male patient presented with a painful swelling of about 13 cm × 14 cm, on frontoparietal scalp. A biopsy done elsewhere reported it to be a neurofibroma. He sought tumour excision and scalp defect coverage by hair-bearing scalp in a period of less than 5 months. Materials and Methods: The tumour was excised and the adjacent scalp was gradually expanded with the help of an external fixator. The patient had immediate pain relief after excision. The goal of repairing scalp defect and replacing it with hairy scalp was achieved in 3 months. Conclusion: The mechanical device required for this technique is relatively easily accessible. It is not difficult to achieve desirable outcomes, and the same can be applied to large wounds on other areas.
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A simplified modification of a reconstruction plate into a mandibular transport distraction device: A technical note p. 313
Sujata Mohanty, Jitender Dabas, Rekha Gupta
DOI:10.4103/0970-0358.173138  PMID:26933289
Transport distraction is nowadays gaining enormous popularity and is becoming a promising option for reconstruction of mandibular defects. However, the vast number of distraction device designs create huge confusion in the clinician's mind to choose the right one. Considering these complex and costly designs, the authors decided to find a simplified way of combining a modified conventional reconstruction plate and monofocal distraction device that can act as a transport distraction device for bridging of bony defects. A case performed by this technique and device has been presented along with the description of device design.
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Management of asymptomatic silicone-injected breast with reduction mammoplasty p. 317
Theddeus Octavianus Hari Prasetyono, Patricia Marcellina Sadikin
DOI:10.4103/0970-0358.173139  PMID:26933290
Even though Silicone injection for breast augmentation has been related to disastrous long-term effects and complications, some patients do not develop significant symptoms at all (asymptomatic). Unfortunately, the management of asymptomatic Silicone-injected breast is still unclear and has never been reported exclusively. We present two cases of asymptomatic patients with a history of liquid Silicone injections who refused to have a mastectomy. They were concerned with the breast ptosis and chose to undergo reduction mammoplasty to improve the appearance of the breasts. Magnetic resonance imaging may be useful as an additional screening tool to confirm the diagnosis and exclude the presence of malignancy in breasts with injected Silicone. We believe that breast reduction may be the alternative option for women with a history of liquid Silicone injection who have no symptoms but desire to preserve their breasts and improve their aesthetics.
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A simple technique of marking the perforator of a free flap for postoperative monitoring p. 321
Hari Venkatramani, Gururaj Hosahalli, S Raja Sabapathy
DOI:10.4103/0970-0358.173140  PMID:26933291
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The pivotal role of pedicled perforator flaps amidst irradiation p. 322
Leena Jain, Samir M Kumta, Shrirang K Purohit, Manik Menezes, Mehul Bhansali
DOI:10.4103/0970-0358.173141  PMID:26933292
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Surgical revirgination: Four vaginal mucosal flaps for reconstruction of a hymen p. 324
SS Shirol, Mahesh Prabhu, Jaideep Ratkal
DOI:10.4103/0970-0358.173142  PMID:26933293
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Authors' Reply p. 325
Hemant A Saraiya
DOI:10.4103/0970-0358.173143  PMID:26933294
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Anticoagulation therapy and hand surgery: Do we worry too much? p. 326
Mark Twoon, Marc-James Hallam
DOI:10.4103/0970-0358.173144  PMID:26933295
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Ossified costal cartilage during rhinoplasty: A surgical dilemma p. 327
Kapil S Agrawal, Raghav Shrotriya
DOI:10.4103/0970-0358.173146  PMID:26933296
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A simple method to facilitate oral surgery in patients with orthodontic appliances p. 328
Janarthanan Ramu, Abhijeet Wakure, Mohit Sharma
DOI:10.4103/0970-0358.173162  PMID:26933297
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Dr. Behman Minoo Daver 1939-2015 p. 330
Mukund R Thatte
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