Indian Journal of Plastic Surgery
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   Table of Contents - Current issue
Coverpage
January-April 2017
Volume 50 | Issue 1
Page Nos. 1-123

Online since Monday, June 5, 2017

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EDITORIAL  

Publish or perish? p. 1
Mukund Jagannathan
DOI:10.4103/ijps.IJPS_83_17  PMID:28615802
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ICON OF THE ISSUE Top

Dr. Behman Minoo Daver (1939–2015) p. 3
Mukund R Thatte
DOI:10.4103/ijps.IJPS_65_17  PMID:28615803
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PROF. MIRA SEN (BANERJEE) CME ARTICLE Top

The neurochemistry of peripheral nerve regeneration p. 5
Andreea Benga, Fatih Zor, Ahmet Korkmaz, Bogdan Marinescu, Vijay Gorantla
DOI:10.4103/ijps.IJPS_14_17  PMID:28615804
Peripheral nerve injuries (PNIs) can be most disabling, resulting in the loss of sensitivity, motor function and autonomic control in the involved anatomical segment. Although injured peripheral nerves are capable of regeneration, sub-optimal recovery of function is seen even with the best reconstruction. Distal axonal degeneration is an unavoidable consequence of PNI. There are currently few strategies aimed to maintain the distal pathway and/or target fidelity during regeneration across the zone of injury. The current state of the art approaches have been focussed on the site of nerve injury and not on their distal muscular targets or representative proximal cell bodies or central cortical regions. This is a comprehensive literature review of the neurochemistry of peripheral nerve regeneration and a state of the art analysis of experimental compounds (inorganic and organic agents) with demonstrated neurotherapeutic efficacy in improving cell body and neuron survival, reducing scar formation and maximising overall nerve regeneration.
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ORIGINAL ARTICLES Top

Free anteromedial thigh perforator flap: Complementing and completing the anterolateral thigh flap p. 16
Dushyant Jaiswal, Amol Ghalme, Prabha Yadav, Vinaykant Shankhdhar, Akshay Deshpande
DOI:10.4103/ijps.IJPS_161_16  PMID:28615805
Objective: Theobjective of this study was to determine the indications, utility, advantages and surgical approach for the anteromedial thigh (AMT) flap. Materials and Methods: We reviewed the records of the patients in whom the AMT flap was used for head and neck reconstruction. We use an anterior approach to harvest the anterolateral thigh (ALT) flap with a non-committal straight line incision. This preserves both ALT and AMT flap territories intact, and further decision is based on the intraoperative anatomy of perforator and pedicle. The ALT flap was usually used as the first choice when available and suitable. Results: Free AMT skin flaps were harvested in 24 patients. All flaps were used for the head and neck reconstruction. Two flaps had marginal flap necrosis. One flap was lost due to venous thrombosis. Discussion: The thigh is an excellent donor site as it has large available skin territory, expendable lateral circumflex femoral artery system and low donorsite morbidity. The ALT flap is the most commonly used flap for reconstruction of soft-tissue defects. However, it is characterised by variable vascular pedicle and perforator anatomy. The AMT flap is an excellent alternative when the ALT flap is not available due to variable perforator anatomy, injury to perforator, when an intermediate thickness is needed between distal and proximal thigh or a chimeric flap is needed. Conclusion: The AMT flap offers all the advantages of the ALT flap without increasing donor-site morbidity. The anterior non-committal approach keeps both the ALT and the AMT flap options viable.
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Proposal of a new classification scheme for periocular injuries p. 21
Devi Prasad Mohapatra, Friji Meethale Thiruvoth, Ravi Kumar Chittoria, S Dinesh Kumar, Sudhanva Hemant Kumar, Senthil Kumar, Preethitha Babu, Elan Kumar
DOI:10.4103/ijps.IJPS_207_16  PMID:28615806
Background: Eyelids are important structures and play a role in protecting the globe from trauma, brightness, in maintaining the integrity of tear films and moving the tears towards the lacrimal drainage system and contribute to aesthetic appearance of the face. Ophthalmic trauma is an important cause of morbidity among individuals and has also been responsible for additional cost of healthcare. Periocular trauma involving eyelids and adjacent structures has been found to have increased recently probably due to increased pace of life and increased dependence on machinery. A comprehensive classification of periocular trauma would help in stratifying these injuries as well as study outcomes. Material and Methods: This study was carried out at our institute from June 2015 to Dec 2015. We searched multiple English language databases for existing classification systems for periocular trauma. We designed a system of classification of periocular soft tissue injuries based on clinico-anatomical presentations. This classification was applied prospectively to patients presenting with periocular soft tissue injuries to our department. Results: A comprehensive classification scheme was designed consisting of five types of periocular injuries. A total of 38 eyelid injuries in 34 patients were evaluated in this study. According to the System for Peri-Ocular Trauma (SPOT) classification, Type V injuries were most common. SPOT Type II injuries were more common isolated injuries among all zones. Discussion: Classification systems are necessary in order to provide a framework in which to scientifically study the etiology, pathogenesis, and treatment of diseases in an orderly fashion. The SPOT classification has taken into account the periocular soft tissue injuries i.e., upper eyelid, lower eyelid, medial and lateral canthus injuries., based on observed clinico-anatomical patterns of eyelid injuries. Conclusion: The SPOT classification seems to be a reliable system to address eyelid injuries. This classification scheme would guide the ophthalmic and facial reconstructive surgeons to provide optimal outcomes in eyelid injuries.Based on the classification scheme and review of existing literature, an algorithm is presented to facilitate repair and reconstruction.
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Soft embalming of cadavers for training purposes: Optimising for long-term use in tropical weather p. 29
Raghuveer Reddy, Subramania Iyer, Minnie Pillay, Krishnakumar Thankappan, Janarthanan Ramu
DOI:10.4103/ijps.IJPS_219_16  PMID:28615807
Background: Surgical and anatomical training has been found to be most optimally simulated in a cadaver than any other available methods. Soft embalming methods have made the bodies more 'lifelike' and better suited for training. The widely accepted soft embalming techniques, including Thiel embalming, are designed for temperate climates. Their use in tropical locations has been found to be associated with poor short-term and long-term preservation of the bodies. In fact, adequate reports from tropical countries on effective methods for soft embalming are lacking. Materials and Methods: This article details the modifications made in the Thiel embalming technique over a period of 2 years which has enabled us to preserve the anatomical features of bodies in an optimal way for longer periods in tropical conditions. This study was carried out in a tertiary care referral centre located in a tropical climate zone. A total of 13 frozen and thawed cadavers were used over a period of 2 years for developing such soft embalming technique. The efficacy of the technique was tested using these cadavers for varying types of surgical exercises on multiple occasions. Results: The conventionally described technique of Thiel embalming did not provide desired results. Hence, various modifications to this technique were instituted which helped us to get superior quality of soft-embalmed cadavers. In the final year, these cadavers were used successfully for workshops in flap dissection. Head and neck access surgery, arthroscopic and laparoscopic procedures as well as mock face and hand transplant dissections. Conclusions: The Theil embalming technique for obtaining soft embalmed cadavers, even though found to be best in many centres in the world, has not been found to be suitable to tropical weather. By modifying it, we have succeeded in developing a technique suitable to the tropical weather. This technique yields cadavers suitable for various surgical simulation exercises. This technique also allows the body to be optimally used over several months in multiple occasions. These modifications are very simple and have been described in detail enabling it to be adopted by any surgical skill laboratory in the tropical countries.
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Triceps to biceps transfer for restoration of elbow flexion following upper brachial plexus injury p. 35
Pothula Durga Prasada Rao, Rayidi Venkata Koteswara Rao, R Srikanth
DOI:10.4103/ijps.IJPS_225_16  PMID:28615808
Introduction: Upper brachial plexus injury in adults causes loss of elbow fl exion; when the primary nerve surgery has failed or the patient seeks treatment after 12 months of injury and pedicled muscle transfers are required. Most commonly, the latissimus dorsi or the Steindler flexorplasty is used. Material and Methods: We have transferred one of the heads of triceps muscle to restore the elbow flexion in such cases. In addition to return of elbow flexion, extension of elbow following surgery is retained. Ten patients suffering from upper brachial plexus injuries underwent transfer of one head of triceps to biceps tendon between December 2011 and August 2015. Results: The recovery of elbow flexion was Grade 5 in 1, Grade 4 in 4 and Grade 3 in 2; only three of the ten patients had no functionally useful elbow flexion. Seven of the ten patients had an adequate elbow extension following the procedure.
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Role of customised negative-pressure wound therapy in the integration of split-thickness skin grafts: A randomised control study p. 43
Mir Mohsin, Haroon Rashid Zargar, Adil Hafeez Wani, Mohammad Inam Zaroo, Peerzada Umar Farooq Baba, Sheikh Adil Bashir, Altaf Rasool, Akram Hussain Bijli
DOI:10.4103/ijps.IJPS_196_16  PMID:28615809
Background: Split-thickness skin grafting (STSG) is a time-tested technique in wound cover, but many factors lead to suboptimal graft take. Role of custom-made negative-pressure wound therapy (NPWT) is compared with conventional dress in the integration of STSG and its cost is compared with widely used commercially available NPWT. Materials and Methods: This is a parallel group randomised control study. Block randomisation of 100 patients into one of the two groups (NPWT vs. non-NPWT; 50 patients each) was done. Graft take/loss, length of hospital stay post-grafting, need for regrafting and cost of custom-made negative pressure wound therapy (NPWT) dressings as compared to widely used commercially available NPWT were assessed. Results: Mean graft take in the NPWT group was 99.74% ± 0.73% compared to 88.52% ± 9.47% in the non-NPWT group (P = 0.004). None of the patients in the NPWT group required second coverage procedure as opposed to six cases in the non-NPWT group (P = 0.035). All the patients in the NPWT group were discharged within 4–9 days from the day of grafting. No major complication was encountered with the use of custom-made NPWT. Custom-made NPWT dressings were found to be 22 times cheaper than the widely used commercially available NPWT. Conclusions: Custom-made NPWT is a safe, simple and effective technique in the integration of STSG as compared to the conventional dressings. We have been able to reduce the financial burden on the patients as well as the hospital significantly while achieving results at par with other studies which have used commercially available NPWT.
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Computed tomography angiographic study of internal mammary perforators and their use as recipient vessels for free tissue transfer in breast reconstruction p. 50
Aditya V Kanoi, Karnav B Panchal, Saugata Sen, Gautam Biswas
DOI:10.4103/ijps.IJPS_168_16  PMID:28615810
Context: The internal mammary artery perforator vessels (IMPV) as a recipient in free flap breast reconstruction offer advantages over the more commonly used thoracodorsal vessels and the internal mammary vessels (IMV). Aims: This study was designed to assess the anatomical consistency of the IMPV and the suitability of these vessels for use as recipients in free flap breast reconstruction. Patients and Methods: Data from ten randomly selected female patients who did not have any chest wall or breast pathology but had undergone a computed tomography angiography (CTA) for unrelated diagnostic reasons from April 2013 to October 2013 were analysed. Retrospective data of seven patients who had undergone mastectomy for breast cancer and had been primarily reconstructed with a deep inferior epigastric artery perforator free flap transfer using the IMPV as recipient vessels were studied. Results: The CTA findings showed that the internal mammary perforator was consistently present in all cases bilaterally. In all cases, the dominant perforator arose from the upper four intercostal spaces (ICS) with the majority (55%) arising from the 2nd ICS. The mean distance of the perforators from the sternal border at the level of pectoralis muscle surface on the right side was 1.86 cm (range: 0.9–2.5 cm) with a mode value of 1.9 cm. On the left side, a mean of 1.77 cm (range: 1.5–2.1 cm) and a mode value of 1.7 cm were observed. Mean perforator artery diameters on the right and left sides were 2.2 mm and 2.4 mm, respectively. Conclusions: Though the internal mammary perforators are anatomically consistent, their use as recipients in free tissue transfer for breast reconstruction eventually rests on multiple variables.
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Adipokine concentrations in lipoaspirates may have a role in wound healing p. 56
Christian Herold, Stefan Engeli, Bibiana Beckmann, Peter M Vogt, Hans-Oliver Rennekampff
DOI:10.4103/ijps.IJPS_103_16  PMID:28615811
Objectives: In addition to its use as a volume filler, fat grafting may have a potential role in wound healing based on the concentration of growth factors in the lipoaspirate. In this study, we compare the quantitative and qualitative concentration of the various growth factors and adipokines using the Shippert or the Coleman techniques to prepare the lipoaspirate. Methods: We measured leptin, adiponectin and the growth factors, i.e., acidic fibroblast growth factor (aFGF), basic FGF (bFGF), keratinocyte growth factor (KGF), bone morphogenetic protein-2 (BMP-2) and vascular endothelial growth factor (VEGF) by ELISA in solid and liquid fractions obtained with both techniques in human fat obtained with Coleman technique and Shippert technique. Results: All of these peptides, except BMP-2, were detected in relevant quantities in the solid fraction. The Coleman but not the Shippert technique resulted in statistically higher adiponectin concentrations in the solid tissue fraction. The other four growth factors occurred in significantly higher concentrations in the solid fractions compared to the liquid fractions, independent of the processing technique. Conclusion: In summary, we demonstrated that KGF, aFGF, bFGF and VEGF, as well as leptin and adiponectin, are contained in fat suspensions obtained by liposuction and in the supernatant. Only the concentration of adiponectin was in the range reported to contribute to wound healing.
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Optimising aesthetic outcome after nipple-areola complex-sparing mastectomy and immediate one-stage prosthetic reconstruction: A simple surgical trick to fix nipple-areola complex position p. 64
Luca Maione, Andrea Lisa, Federico Barbera, Mattia Siliprandi, Valeriano Vinci, Francesco Klinger, Marco Klinger
DOI:10.4103/ijps.IJPS_210_16  PMID:28615812
Background: Nipple-areola complex (NAC) sparing mastectomy (NSM) is mostly indicated in patients with small-/medium-sized and non-ptotic breasts, while skin-reducing mastectomy is used in patients with medium or large breasts with severe ptosis. NAC location on the reconstructed breast is one of the major factors in determining the final aesthetic result and patients' satisfaction. An optimum result obtained at the end of surgical procedure may be altered and compromised by skin redistribution and consequently NAC depositioning during the post-operative period in patients with medium-sized breasts and a moderate degree of ptosis. Aims: In the present study, we propose a simple surgical trick to fix the NAC in the desired position with a long-lasting result. Methods: We selected 35 patients undergoing NAC sparing mastectomy for breast cancer and immediate one-stage prosthetic reconstruction and we performed a single suture to fix NAC in the desired position before closing the skin envelope. We evaluated NAC complex position stability overtime comparing pre-operative standard photographs with early (3 weeks after surgery) and late (1 year after surgery). Results: In all patients, we were able to place the NAC complex on the desired position, and the result was stable at 1 year follow-up. The aesthetic outcome was satisfactory in all patients with no change in the complication rate. Conclusions: This simple surgical trick has been shown to be safe and effective in optimising the aesthetic outcome in a patient undergoing NAC sparing mastectomy and immediate one-stage prosthetic reconstruction. Level IV: evidence obtained from multiple time series with or without the intervention, such as case studies. Dramatic results in uncontrolled trials might also be regarded as this type of evidence.
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Modified cantwell–ransley repair for isolated continent epispadias in adult: Our experience p. 68
Venkat Arjunrao Gite, Hitesh Mahendra Jain, Sachin M Bote, Jayant Vijay Nikose
DOI:10.4103/ijps.IJPS_243_16  PMID:28615813
Purpose: We evaluate here our experience with modified Cantwell–Ransley technique described by Gearhart for correction of isolated continent epispadias in adults with respect to its long-term functional outcome and complications. Introduction: Isolated male epispadias is a rare anomaly with a reported incidence of 1 in 11,700 males. Many surgical techniques with various modifications described to correct epispadias as treatment are debatable and challenging. The majority of the cases are treated at childhood as clinical presentation is striking at birth; hence, presentation in adulthood is extremely rare. Materials and Methods: During the past 5 years, modified Cantwell–Ransley technique described by Gearhart was performed in five cases of isolated continent epispadias which includes two cases of proximal penile, two distal penile and one penopubic. All cases were fresh except one had prior failed repair. Corporal rotation was done by delayed absorbable sutures without incision and anastomosis and suprapubic diversions placed in all the cases. Results: All cases followed up ranging from 6 months to 5 years and were having horizontal and downwards angled penis. No case had urethrocutaneous fistula or stricture. One case had superficial skin infection which healed by secondary intention did not require any secondary procedure. All cases maintained erection post-operatively too. Catheterisation with soft tube revealed easily negotiable channel in all cases on follow-up. Conclusion: Modified Cantwell–Ransley repair described by Gearhart has excellent cosmetic, functional and anatomical results in isolated continent epispadias in the adult.
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An anatomical study for localisation of zygomatic branch of facial nerve and masseteric nerve – an aid to nerve coaptation for facial reanimation surgery: A cadaver based study in Eastern India p. 74
Ratnadeep Poddar, Alipta Bhattacharya, Iman Sinha, Asis Kumar Ghosal
DOI:10.4103/ijps.IJPS_128_16  PMID:28615814
Context: In cases of chronic facial palsy, where direct neurotisation is possible, ipsilateral masseteric nerve is a very suitable motor donor. We have tried to specifically locate the masseteric nerve for this purpose. Aims: Describing an approach of localisation and exposure of both the zygomatic branch of Facial nerve and the nerve to masseter, with respect to a soft tissue reference point over face. Settings and Design: Observational cross sectional study, conducted on 12 fresh cadavers. Subjects and Methods: A curved incision was given, passing about 0.5cms in front of the tragal cartilage. A reference point “R” was pointed out. The zygomatic branch of facial nerve and masseteric nerve were dissected out and their specific locations were recorded from fixed reference points with help of copper wire and slide callipers. Statistical Analysis Used: Central Tendency measurements and Unpaired “t” test. Results: Zygomatic branch of the Facial nerve was located within a small circular area of radius 1 cm, the centre of which lies at a distance of 1.1 cms (±0.4cm) in males and 0.2cm (±0.1cm) in females from the point, 'R', in a vertical (coronal) plane. The nerve to masseter was noted to lie within a circular area of 1 cm radius, the centre of which was at a distance of 2.5cms (±0.4cm) and 1.7cms (±0.2cm) from R, in male and female cadavers, respectively. Finally, Masseteric nerve's depth, from the masseteric surface was found to be 1cm (±0.1cm; male) and 0.8cm (±0.1cm; female). Conclusions: This novel approach can reduce the post operative cosmetic morbidity and per-operative complications of facial reanimation surgery.
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IDEAS AND INNOVATIONS Top

Harvesting split thickness costal cartilage graft p. 79
Sunil Gaba, Richa Gupta, Bharat Mishra, Daisy Sahni
DOI:10.4103/ijps.IJPS_124_16  PMID:28615815
Aim: There are few complications associated with harvesting of full thickness coastal cartilage grafts i.e., pneumothorax (0.9%), contour deformities and prolonged post-operative pain. To address these issues, authors devised special scalpel to harvest split-thickness costal cartilage grafts. Materials and Methods: Standard inframammary incision was used for harvesting rib. Incision was made directly over the desired rib. Specially designed scalpel was used to cut through the rib cartilage to the half of the thickness. The study was conducted in two parts – cadaveric and clinical. Results: There was significantly less pain and no pneumothorax in the patients in whom the split thickness graft was harvested. Wounds healed without any complication. Discussion: Thus, newly devised angulated scalpel used in the current study, showed the potential to supply the reconstructive surgeon with split thickness rib graft without risk of complications such as pneumothorax or warping contour deformities and post-operative pain.
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Use of selfie sticks and iPhones to record operative photos and videos in plastic surgery p. 82
Ashok Basur Chandrappa, Pradeep Kumar Nagaraj, Srikanth Vasudevan, Anantheswar Yelampalli Nagaraj, Krithika Jagadish, Ankit Shah
DOI:10.4103/ijps.IJPS_26_17  PMID:28615816
Use of smartphone has become ubiquitous. With smartphone cameras becoming powerful, they are replacing digital cameras and digital SLRs as primary instruments to take photos and record videos. It is natural even for plastic surgeons that smartphones are handy to take still photographs and even record high-definition or 4K videos. Another invention which has become popular with smartphone photography is a selfie stick. We explain the possibility and methodology of using an iPhone and selfie stick to take operative photographs and high-quality videos.
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REFLECTIONS Top

Advocacy and mass education in plastic surgery: Efforts and outcomes p. 85
Nikhil Shrikrishna Panse
DOI:10.4103/ijps.IJPS_19_16  PMID:28615817
Background: Awareness of plastic surgery is lacking. Be it reconstructive surgery, or aesthetic surgery, public education and awareness regarding the spectrum is the need of the hour. Materials and Methods: We undertook a string of activities for patient awareness and education for burn prevention, occupational hand injuries prevention, skin banking awareness and various other conditions relevant to us as plastic surgeons. Use of social media helped us for increasing the reach of our projects. Observation and Results: Some of the projects we started, we are still pursuing with sincerity, and some never really picked up. A wide range and spectrum of activities were undertaken, and we would like to think that we have made some impact towards advocacy of plastic surgery; however, the measurable impact of these initiatives is questionable. Conclusion: Collective efforts for promotion of the speciality using innovative methods, use of celebrities for awareness and social media amongst other things must be undertaken to make a sustained and demonstrable impact towards advocacy of plastic surgery.
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CASE REPORTS Top

Minimising the donor area morbidity of radial forearm phalloplasty using prefabricated thigh flap: A new technique p. 91
Aditya Aggarwal, Hardeep Singh, Sanjay Mahendru, Vimalendu Brajesh, Sukhdeep Singh, Nitin Ghag, Rakesh kumar Khazanchi
DOI:10.4103/ijps.IJPS_158_16  PMID:28615818
Phalloplasty is indicated in various conditions of penile loss or absence. There are numerous techniques for phalloplasty including the pedicle and free flaps with the ultimate goal of micturition in standing position, attaining adequate size, aesthesis and sensations for sexual intercourse. Radial forearm phalloplasty is the gold standard flap to achieve above results but gives a very bad scar on the forearm. We present a technique of using prefabricated thigh flap to reduce the morbidity of donor area. The descending branch of lateral circumflex femoral pedicle was placed in a subcutaneous plane over tissue expander. After attaining an adequate size of flap with tissue expansion, it was delayed 3 weeks before phalloplasty. Prefabricated flap was thin and of large size replicating the radial forearm flap used for phalloplasty. Whole forearm defect was covered with the thigh flap, and the thigh could be closed primarily. This new technique of using prefabricated thigh flap has significantly reduced the donor site morbidity both aesthetically and functionally without the use of skin grafting in the whole procedure.
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Columella reconstruction with an inferiorly-based philtral advancement flap in a cocaine abuser p. 96
Davide Di Santo, Matteo Trimarchi, Andrea Galli, Mario Bussi
DOI:10.4103/ijps.IJPS_163_16  PMID:28615819
Nasal columella defects can significantly impair aesthetic appearance. Columella reconstruction can be very challenging for surgeons, especially if due to cocaine abuse. The case of a 32-year-old male patient with subtotal columellar necrosis secondary to cocaine abuse is presented. An inferiorly based philtral advancement flap was performed to cover the defect. Aesthetic outcome was the primary goal of surgery. Reconstruction led to good aesthetic and functional results.
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From wheelchair to walking: First case report of post-electrical burn destruction of patellar ligament with its one-stage reconstruction and restoration of function p. 100
Sandip Kanti Basu, Jayanta Bain, Bijay Kumar Majumdar, Debarati Chattopadhyay, Debasis Baitalik, Yatindra Kumar Dewangan, Debtanu Bhattacharya, Pritha Rakshit, Vivek Gupta, Ashwani Kumar, Rathindra Nath Haldar
DOI:10.4103/ijps.IJPS_200_16  PMID:28615820
Electrical burn injury causing bilateral patellar ligament destruction leading to complete loss of knee extension is a very rare injury. In such situation, surgical repair or reconstruction of the patellar ligament becomes necessary to restore knee functions. Here, we present such a case of an 8-year-old boy, whose both patellar ligaments were destroyed throughout its length due to high-voltage electrical injury. His left knee joint cavity was exposed and grossly infected, but the right knee joint cavity was apparently intact. The right-sided patellar ligament was reconstructed with an ipsilateral and looped semitendinosus tendon graft and covered with a medial gastrocnemius musculocutaneous flap. The patient had an uneventful recovery, and full range of motion in the right knee joint along with good bipedal locomotion was achieved successfully.
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Pyogenic granuloma-like lesion in children: Should we wait? p. 104
Lai Kuan Chooi, Arman Zaharil Mat Saad, Shamala Durairajanayagam
DOI:10.4103/ijps.IJPS_25_17  PMID:28615821
Malignant melanoma is a potentially lethal cutaneous malignancy. Melanoma in paediatrics is rare as compared to adult melanoma. The clinicopathological characteristics of paediatric melanoma are different from adult melanoma, and the presence of melanoma mimics which occurs frequently in children (Spitz naevi) resulted in diagnosis uncertainty. We reported a 9-year-old girl who presented with a slow-growing, pyogenic granuloma-like lesion which was diagnosed with melanoma. It is important to have a high index of suspicion in paediatric skin lesion that would usually be deemed benign. Early tissue biopsy in a suspicious lesion prevents delayed diagnosis and treatment.
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LETTERS TO EDITOR Top

A new method of salvaging nipple projection after secondary nipple reconstruction using locoregional flap p. 107
Fabrizio De Biasio, Nicola Zingaretti, Sebastiano Mura, Alessandra Fin, Michele Riccio, Pier Camillo Parodi
DOI:10.4103/ijps.IJPS_47_17  PMID:28615822
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Bilateral superficial brachioulnar artery in a cadaver along with bilateral absence of palmaris longus p. 108
Doris George Yohannan, Komalavallyamma Chandrakumari
DOI:10.4103/ijps.IJPS_228_16  PMID:28615823
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Absence of flexor carpi radialis: A rare anatomical variation with clinical significance p. 111
Vigneswaran Varadharajan, Praveen Bhardwaj, S Raja Sabapathy
DOI:10.4103/ijps.IJPS_178_16  PMID:28615824
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Novel use of preputial flap p. 112
Ankit Gupta, Shyam Gupta, Akhil Kumar, Manoj Kumar Jha, Sameek Bhattacharaya, Vinay Kumar Tiwari
DOI:10.4103/ijps.IJPS_2_16  PMID:28615825
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Mnemonics for gillies principles of plastic surgery and it importance in residency training programme p. 114
Sandhya Pandey, Ravi Kumar Chittoria, Devi Prasad Mohapatra, MT Friji, Dinesh Kumar Sivakumar
DOI:10.4103/ijps.IJPS_93_16  PMID:28615826
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Selfie stick: An extension of the photographer's hand in operation room conditions p. 115
Ayse Sencan, Mehmet Baydar, Kahraman Ozturk, Osman Orman
DOI:10.4103/ijps.IJPS_187_16  PMID:28615827
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Simple way of splinting the arm following vascular anastomosis in the axilla p. 116
Pravin H. P. Kumar, Vijay Dattatrya Kadam, Sushil Nahar, Rahul Krishnarao Patil, Ashok Raj Koul
DOI:10.4103/ijps.IJPS_34_15  PMID:28615828
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Primary management of post-burn contracture neck with tracheostomy: A surgeon and an anaesthetist's perspective p. 117
Madhubari Vathulya, Seema Shukla, Navin Shukla
DOI:10.4103/ijps.IJPS_154_15  PMID:28615829
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Pedicled transverse rectus abdominis myocutaneous flap: A method for tunnelling with Dilson Luz vascular dilation wands for breast reconstruction p. 119
Christopher Tam Song, Joshua Perrett, Terence Goh, Bien Keem Tan
DOI:10.4103/ijps.IJPS_21_16  PMID:28615830
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Ashok Raj Koul p. 122
GS Satish Kumar, Rahul Krishnarao Patil
DOI:10.4103/ijps.IJPS_89_17  
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